25

It’s a gratitude day. 25 years clean and sober.  I take my cake this coming week at my home group Burnaby Men’s with George insisting he’ll bring the cake.  I joke and say we celebrate the sacraments of cake and coffee of Bill and Bob.  It’s a long fast.  Thankfully the hang over goes in weeks to months though we clean up the ‘wreckage of the past’ for sometimes years’, making amends and just living sober.  

I was a binge drinker . Much of my life was intensely dedicated but I was attracted to the ‘chaos’.  I married women who shared my pleasures.  My family was orderly by comparison.  So much alcohol and mental illness with those I was attracted to or what I attracted.  I wasn’t called ‘Wild Bill’ because I was tame.  Always the first to dance on tables and do anything on a dare.  

I remember at Homewood Treatment Centre, Graeme Cunningham saying to me ‘some people run with the cheetah’s and some people run with the turkeys, you’ve been running with the turkeys’.  My dad called them ‘fair weather friends’.  He was what men called a ‘straight shooter’.  I regret that I didn’t listen more to him.  He transformed from the stupidest man I knew as a genius to the greatest man I knew as an adult.

When I stopped drinking, smoking tobacco and cannabis, so much of that life paled. We joke and say an alcoholic 10 is a  4 with a 6 pack.  Just so much of what people do when they’re drinking has no appeal sober. Like staying up late. I love the dawn now.  I love waking refreshed and alert. I can’t imagine why I would suffer a hangover and then go back and do it again.  

I can’t imagine today ‘not living life on life’s terms’.  I don’t want to be ‘dope dumb’ on marijuana joking about how stupid we talk even if it is like taking valium and relaxing. I don’t want to knee jerk emotions of alcohol and I never want the lack of peace of mind or the ability to appreciate a natural high.  Jesus said we must be like children again to enter heaven.  I remember thinking pot was coming out of my fat cells when I regained the natural love of life and joy de vivre. 

 Do you now remember the joyful times of childhood? a celebrity friend in recovery said to me.  

Suddenly I remembered myself playing baseball in a radiant green park with happy people and a glorious sun.  When we are depressed we remember depression because we are in the valley of our minds. Only on the peaks can we see all the joy of the truly high places as well as the lows and valleys of life.  Drugs and alcohol are depressing.

Asked to remember all the things in life I was proud of and would like to be remembered for I realized that the vast majority of them occurred sober, family and church and childhood, hunting and fishing, the great romances, provincial gymnastic and volleyball competitions,  dance training and competitions, theatre performances,  cycling across Europe, study of history and literature, studying  chemistry and anatomy, medical school training, working as a country gp, delivering babies, flying doctor through the sub arctic, residency training in community medicine and psychiatry. Then psychiatry and another divorce and alcohol abuse. Then work continued but my recreation increasingly was associated cigarettes, reefers and wine.  I’d gone camping to tent and fish but now looked forward to drinking a bottle of wine and smoking a joint around the fire. There was a shift.

At first it’s fun , then it’s fun and trouble, then it’s trouble..  I remember it being trouble sailing down to Mexico and then in Mexico, Instead of sailing around the world my partner and I stayed in margaritaville.  There were good times.  Sailing was spectacular.  Playing blues in the band was fun. Spear fishing and snorkelling and sun was great but it was going nowhere . When we came home she wouldn’t get help.  I didn’t want to be around her friends or my friends that drank and drugged. I’d liked her because she had her own group of dealers and prayers . Her’s tended to have university degrees but were no less ‘friends in high places and low places’ while I had friends who were interesting the sober ones in high place and the ones who crank and did dope professionals and bikers and rural.  

She would get so impaired she couldn’t work. I’d party on the weekend but I’d go to work and I was seeking help seeing professionals and told that my problems wasn’t the joint or wine I drank but the impaired wife doing cocaine. The lying and destruction increased . My unforgettable line was , “I can go to work and help. a hundred people or stay home and help one person. I can’t do both.”  I’d been years of covering for her.  I was so tired of being told a man would handle his wife. She was not a pretty site drunk and stoned though we’d both been younger. We were passed the magic forty year old place where you’re expect to be able to get your act together.  She lied and lied and lied.  It was impossible.  I never liked cocaine but she sure did.  I didn’t like the people around cocaine either. I’d liked the hippy wine and reefer world but this cocaine crowd was mean. My former friends who had fallen to cocaine were the same.  We joke that an alcoholic will steal your wallet but an addict will not only steal your wallet they’re help you look for it.

I just couldn’t carry on. I was working harder than I’d ever trying to cover for her when she suddenly refused to get out of bed forever or see a doctor. I knew this couldn’t go on.  She’d had a grow operation and with friends of her. She’d moved all the money I made into her accounts except for what required my signature.  In the end it was apparent that she’d been financially scheming for a year.  I remember thinking I’m trying to make this work and she’s been stabbing me in the back.  Separation and divorce.  The times she almost killed me and the times drunk when she almost killed us both. I saved our lives so many times, the worst being when I went off the bow wave of a tanker coming out of San Francisco harbour in the fog having again messed up the radar and lied when I asked if she’d touched it.  

I don’t want to ever be back in a relationship with someone drunk and stoned. I don’t want to ever be drunk and stoned again. I can see her behaviour clearly but only know that I was a mirror. I loved in AA the ‘restore us to saniety’ clause. I never realized how insane I was but I certainly saw how insane she was, yet I was with her and our friends were too. It was a bad sit com, something out of a Kardasian bizarro world.

I remember thinking that my life had gone wrong when I was sexually abused by my professor, when I was a psychiatry resident, when I committed adultery when I saw so much learning to understand the insane.  I thought when was my life right and remembered church and prayer and meditation. I was going to return to Winnipeg to talk to the people there I knew and trusted.  I was going to leave psychiatry and maybe go back to being a country doctor or just get out of medicine all together.  The psychiatrists I knew were drunks and addicts and as I learned the depths of my wife’s deceit and even the deceit of my therapist and authorities in general I became paranoid.  My fair weather friends stole from me as did my ex wife. Manly I’d taken nothing of hers and we’d lived on my income as most of our times she’d been a student and took her own income.  I remember thinking that as a man I was powerless and that maybe I could become a woman because I was really tired of having all the responsibility and accountability, all the blame and none of the praise.  I was utterly confused too. I’d spent 20 years with women to have a family but after marriage I learned they didn’t want children.  They wanted a daddy.  Their fathers were alcoholic or absent.  But God were they beautiful, brilliant and fun. I forfeited joy and peace for fun and drama. Not a bad trade when young but time marches on.  

I had been in church as a boy with my brother and mother and father and that was the oasis I aimed for. A Christian friend asked if he could help and offered to rent me his trailer . He didn’t smoke dope and rarely drank.  I returned to church.  She’d refused to go. In psyhiatriy the psychoanalytic professors hearing I meditated as a disciple of Paramahansa Yogananda and a follower of Christian Dr. Carl Ridd I was summarily told that meditation was harmful and must stop and that if I wished to continue my training with these two psychiatrists I had to leave community medicine and stop taking Christian studies courses while in residency.  I had left surgery and family medicine and now was told if I wanted to be a psychiatrist I needed to be a devotee of the megalomaniac analyst I who I frankly admired.  Psychiatrists then were a weird mix, mensch’s and devils.  All were charming and highly skilled. We learned from the psychopaths , narcissists and borderlines. We walk miles in their moccasins and they get under our skin. We are as much artists of the mind as scientists. I was naive and vulnerble.  I was also obedient.  Thise who rise high in systems much have this trait of obedience as the rebels get pruned.  Systems are like military organizations.  They’re like religious organizations.  The abuse of power is ubiquitous.  

I was willing to stay a doctor sober and clean. I was encouraged to go to AA and asked my friend, Kirk, who I trusted if he trusted AA. Kirk and I and been spiritual disciples our whole live, he a follower of Prem and me a Christian doctor who’d taken a detour in better living with chemistry, the tantra yoga,Daost path.  

“I think AA is a good group. I know people who belong and they’ve done well.  I think it’s good that you’ve stopped drugs and alcohol.  I didn’t think that was making you happy. I’m sorry that you and your wife have separated but I never thought she and you were that compatible.  But yes I think AA is a good thing.”  

I’d stopped drinking and left the drug crowd and was detoxing on a hillside with my Bible and my shotgun. The bikers I’d been staying with who stole my money, possessions and vehicle were threatening to come by one night and kill me for the registration.  They never came by but I saw they’d sold my vehicle without registration. I learned that I obeyed laws but so many didn’t .I was so naive. I’d also have all these ‘god’ moments. Events were constantly synchronistic.  Good came to me. I was free of the baggage and suddenly out of the dark I was in the light and it was uncanny how my relationship with God restored. I’d actually thought I was beyond God’s love.  

Bernie showed up in his new truck, the ex wife had destroyed my truck, I was riding a bicycle American Express wanted to claim, my ex wife having with her lawyer and her millions used up all my money on lawyers who said ‘she and her lawyer are refusing to meet so they’re using seige techniques to destroy you and ruin you financially.’  I’d given the last of my money to the lawyer to free my accounts to pay the rent. I was getting charity and food from the church and Christian friends. I went to welfare and the woman screamed at me saying that a ‘doctor can’t get welfare…welfare is for the poor people…you rich men can’t expect poor people to pay you….get out of my office…you’ll get nothing here.”  Every day was humiliation. I’m still hoarding food as again I was hungry like when I left my father’s home.

So i went to church and I went to AA and I trusted Christians .  I trusted godly people. I was lied to by the College of Physicians and Surgeons. I was lied to by psychiatrists but I’d been a family physician , a member of the family physician of canada before becoming a specialist in medicine and psychiatry. I found myself trusting family physicians and Godly psychiatrists. I’d extend my trust to Sam Sussman , an Orthodox Jew. I had named the psychiatrist who raped me drunk and stoned out of the blue and left field this powerful connected man ‘made me his woman’ and ‘bred me’ as my engineer friend liked to put it.  He was a misogynist.  I am still confused.  I was the wife in my marriages to female doctors doing the cooking and cleaning as well as working each day. My colleagues most had wive ‘s and mothers of their children and they went home to the traditional division of labour but I was married to female doctors and never had any support. They did school , I did the wifely duties, and worked two jobs for their ‘desires’ and maintained us while they brought in stipends.  I realized that the guy who said marriage was institutionalize prostitution was talking to me. I was destitute after divorce and they were wealthy yet I’d spent the marriage helping them academically literally dragging them to the library to study and sitting beside them as a study coach, I was ahead of them. But women repeatedly put me down projecting their anger at their husbands and boyfriends who somehow got ‘served’. I never got served’.  I cooked and cleaned and worked.  As a psychiatrist I was most interested in the escorts and their pimps. I was fascinated having pimps as patients and learning how they trained ‘their bitches’.  Exact opposite to all I did.

I read Gottman of Love Lab fame and learned that I was a master at verbally winning battles but lost the war because my wives held onto resentments.  They had horrendous relationships with their alcoholic families and their horendously abusive mothers and I’d had this straight arrow ex military engineer who supervised hundreds of men and a religious Baptist loving mother who had wanted a daughter but had me and couldn’t have more children. I failed her because while I was apparently the prefect child I left home. I preferred running with the pack and had this spiritual path that took me away from the safety and love of home. I truly was the prodigal son.  I came home after I left and then left again. My parents were always there for me. I feel sorry for so many who haven’t had that. The trouble was always my pride.  

Pride is the original sin.  Alcohol and addiction create the mental state of ‘egomania wth inferiority comp;lexes’.

I’m thankful to day because of all the people who helped me to surrender to God and let go of self. The Swami song say ‘mother father have I none I am he, I am he, blessed spirit I am he’.  In my training in theology I learned that there is God and me and if I wanted to know God more fully I must let go of ‘me’.  I had to learn to trust God. The last 25 years have been good. Better and better.

Sober I went to AA with the former head of UBC psychiatry. I continued to see Christian Psyvhiatrists who helped me deal with the addicts and alcoholics in government who abused their power rather frequently. I was blessed to know the lawyer Jonathan Meadows and lived in this great psychodrama of my life.  I was often not the centre state. The play was called William Hay but there were all these bad actors trying to make it all about them. Meanwhile I was listening to the big black Milton who in AA said he pasted a message on his mirror ‘you’re looking at the problems’ to remind him it’s his perception that is the problem.  AA taught me that alcoholism was first a ‘thinking disease’. I had thought I had thought I was spiritual but I’d worshiped the demon drink and demon pot and demon tobacco.  Now I thank God for the early deep breaths I take in the morning. Now I’m writing gratitude lists each morning thanking the Lord for my dog Madigan, my long term friend and lover Laura and all the precious people in my life. I also thank God for the ‘enemies’. The College of Physicians and Surgeons resident pervert was a trial as is the PM today. I was so thankful for the fourth step in AA and Bernie, Hank and Father John who helped me work thought my resentments and fears. I was so hurt and angry and frightened and betrayed. I really wasn’t a good man or a good husband. I probably was a pretty good doctor. I joke and say I fear a class action suit from the 100 babies I delivered who get together and find they share a thumb printed on their forehead because I held too tight guiding them into life. I also think that any day the thousands of people I convinced not to suicide will sue me for false promise.  Yet I did my best and thanks to the amazing teachers and those who went before me and the College of Physiccians and Surgeons, and the Royal College of Physiians and Surgeons and the Canadian Medical Protective Associations and the Society of Addiction Medicien and Christianity and AA and frankly and friends and dogs and cats I’ve done okay.

I’m alive and 25 years ago I so suffered indescribable and utter ‘incomprehensible demoralization.  I had such anxiety and was told by an old internist in a late night meeting of International Doctors in AA, “anxiety is a measure of your distance from God and a measure of your humanity.’  I know God is an experience and not an idea. I used to say I knew Christ and Christ consciousness but today I know Jesus as a friend. God is good all of the time.  

I continued to hunt big game with my friend Bill Mewhort shooting moose and deer and bear with him. I continued to sail and sailed solo on the SV GIRI San Francisco to Hawaii in winter through a hurricane. Thanks to Dr. Willie Gutowski I worked a couple of years in Saipan in sobriety so enjoying meetings on the beach with Frank beneath palm trees watching the sunset.  I loved learning from Phillip another sailor doctor and wise man.  I still struggled with the inclusivity of Christian churches caught between the LGBT include church of Peter and the exclusive church of my evangelical friends. I loved studying theology with the purest deepest Catholic psychiatrist John whose paraplegia he may as well have called his ‘glad gethseame’ like the catholic priest friend of Bill Wilson.  All the Christians I knew and admired were living inspirations as they were persecuted in Canada like the disciples of Jesus were.  I was blessed to go to Israel and make so many trips to conferences all over the US and be with the finest of men like Nady and Art and Carroll and Dick and men and women who are now dying or dead. I loved my friend George in recovery , another physician who would go for dinner with me before an AA meeting as we’d talk about baseball and life and love.  I’ve been truly blessed despite being a kafetch and having the worst tendency to slip into rabbit holes and whine with self pity. My military friend who told me ‘you’ve got one foot in the future and one foot in the past and you’re pissing on your day, get your head in the same room as your ass’ also said ‘get down off the cross we can use the wood’.  

Recovery is ancient healing journey. Just for today was a profound awakening for me as I felt that God , omniscient, omnipotent, omnipresent was here and now and for me to be with god I had to be present. The journey I ‘d begun as a child and later continued in church and school and temple and love came to this point of intersection in the cloud of unknowing at the point of Stellate reality and Interdimensional experience with each day a beginning. I pray to know God more and to know God’s will more. I have quiet time.  I meditate. I do right livelihood . I listen to the spiritual teaching of the Bible and the Big Book of AA and Kurtz book, Spirituality of Imperfection, the great teachings of the world. Paramahansa Yolanda taught “I bow to the saints of all religions’.  I never thought of a hell and didn’t believe in the tribalism religions that said ‘our little group wins and your group loses’ but I liked Pascal’s wager and Eben Alexander the neurosurgeons ‘proof of heaven’.  I’ve known sacred and supernatural.

I would love more. I would learn to be more loving not in that sentimental way but in the way of the God of Gods.  God is all. God made the devil and free will and fate are central We like to choose free will when we do something good and blame the other guy but refuse to accept fate when ‘shit happens’.  It’s all ego.  God is good all of the time. The people like the man who abused me or the ex wife who lied and stole or the college administrator whose perversion obscured her vision , all of these people were bicycle lessons like the soldier who held me hostage threatening to kill me, or the native who shot at me and all those antagonists in my play of life with me as the protagonist.  

I’m so thankful to be sober so that I have been able to live this good life with knowing people like I do,  I struggle now with gender, sexuality and aging. At the point when I’m Shakespearean with desire greater than performance no longer a consequence of alcohol but rather a product of physically hurting and slowing. I struggle to stay fit when I was always active and climbing mountains to experience the joy above the clouds with a sober friends revelling in the beauty of existence.  I loved seeing the great works of arts and museums in Edinburg Oxford and London and Paris this spring taking Laura as a companion but missing Madigan yet knowing Karen and Belinda people I could trust with my puppy while I was away.  I can trust today and people don’t lie and betray me. I know that expectations are preformed resentments and I don’t have the unrealistic expectations I had younger.  I’m more mature. Who would have guessed. But I do miss the theatre and dance world and find so many older people still pretentious and tedious.  

I’m becoming ornery with age.  I’m happy alone.  I’m less afraid.  I worry I might drink or smoke dope again and fall into the psychosis of believing the false is true.  

It’s 25 years. A quarter century, much longer than the entire time I smoked or drank. I still don’t know what I will do when I grow up.  Right now I have to go have my hair done and the biggest challenge is whether to wear a skirt or slacks.  I’m having a lot of first world problems and very few third world problems .  I’m full of gratitude and know grace.  I really am blessed but often don’t know what next. I miss the Sturges expedition.  I knew I wanted to ride my Harley there and back like I knew I wanted to visit the church’s of Ethiopian and see the black Jesus.  I knew I wanted to go to Athens and the Vatican and Mexico City pyramids ,  I’ve known what it is I have to do but now I’m able to plan the day but don’t have any real idea for much into the future. I felt last winter I was kedging my life off the sand bars of Covid and the WHO . I’m aware that Trudeau is the devil incarnate and that I’m at best a hobbit in the spiritual warfare of today but it’s hard to see.  I’m in the cloud of unknowing and just keep walking forward with Jesus.  

I need to be sober because the world is so crazy I need all my wits about me. I don’t want to be an ostrich that puts it’s head in the sand and doesn’t know who kicked it. The Donovan song, season of the witch and beatniks are out to make it rich makes me ware of my vulnerability.  I am learning to trust God more in old age. 

I’m thankful for sobriety and don’t believe I’d have achieved the long term sobriety that Vaillant of Harvard fame wrote so eloquently about without AA.  

I’ve a doctors in AA meeting tomorrow. So I know I’m looking forward to that. I’m continuing to work. I’m here. I’’m muddling along. I have a principle responsibility to Madigan who is dependent on me.  He’s a messy room mate.  

Thank you.  25 years. Thank you, Thank you God and as I learned in AA God works through people. Thank you.

I remember being tormented after I stopped drinking and smoking. I think the tobacco was as bad as the pot. I was in withdrawal for weeks to months, hiking all day and visiting a Christian psychiatrist, going to church, praying, meditating, writing, doing odd jobs to pay 

Positive Memory and a Broken Mind

I have to be active to retrieve positive memories.  My mind’s broken.  Left to it’s own devices it will tend to replay past trauma, old wars, resentments, failures.  It’s not surprising because those were by their nature times of threat and times that my mind had to focus most. In danger we are most alert. After danger passes my mind will tend to be scanning for future threats and reminding me of past dangers. I’ll also sometimes play scenarios again in search of whatever I might think I did that had I done differently would have resulted in a more positive outcome.
Meanwhile most of my life has been exceedingly positive. Every day I’m alive my life is 51% positive.  Yet trauma and failure have tendencies to blast aside the good days and the good experiences.
I had a Corolla. Amazing car. It was something I so enjoyed for it’s workmanship and maneuvering.  I loved the sound system. It was the days I played Steely Dan on the radio. Barbara Fromm was on CBC. Life was good. That little car had magnificent studded snow tires and for a year it carried me in summer and winter to and from my first country general practice.  It was a sweet car.  Yet a dangerous , horrible, incompetent, psychopathic driver hit that car passing in a lane, semi truck barreling towards us, I was doing the correct speed, the other fellow was speeding. The road conditions were black ice. He lost control of his car, hit the front end of mine causing me to barrel and burrow right into the ditch. The car flipped 360 degrees landing upright then rolling sideways 360 degrees and landing upright again.  The seat strap kept me in the car but because of the height of the car, made for Asian market I presumed, it didn’t keep me in my seat but allowed me to be crushed into the ceiling with my head tilted.  I had a cervical spine injury.  I gave the case to a friend to help him, a new lawyer, and he didn’t do so well, so that in the end, a year later, weeks of lost work and a life time of chronic pain and disability, I was severely punished by a psychopath speeding incompetent driver, a friend who was young like me, a tough insurance system. I got the replacement value of the brand new car and immediately bought a Ford Mustang which I truly loved.  But my life flashed before my eyes, It was a near death experience.  I was appalled at the price of the insurance and that in the end there was only punishment in the system for the victim. It changed my outlook on life and was a root cause in my changing my career, my marriage and might well have been an early root cause of the subsequent addiction year that really changed my life further a decade later.
So I don’t think of that car with the joy I can actively seek to remember.  With a little conscious probing I can remember the joy I had driving it. It would also be decades before I bought an Asian made car again.  I’m driving a Mini now, British,but with my head touching the ceiling. It’s got that same attention to detail the Toyota Corolla had. Marvelous workmanship.  But I could well have been driving it when the animal hit the front of my car and the criminal system didn’t castrate him there and then to insure his genetic strain was removed from the genome.
Being a civilized man I actually got out of my brutalized car which the insurance company subsequently insisted was just fine, no reason to be replaced,  never to be trustworthy in my mind again, a source of terror, a centre for ptsd images of life flashing before my eyes, but no , it drove so I should take it home as if nothing happened.  Assholes.  I’d love the ‘new car’ smell of that Corolla. I’d loved the faith I’d put in it. It was my first ‘new car’ as before that I’d only had second hand beaters.  So there was this insurance company insisting all was well and me remember every day for life that as I bounced off the ceiling of the car I thought that I knew no one who had survived a 360 forward turn and then when i rolled again over the ceiling my neck straining again, I thought I’ll never be the same because I don’t know people who survive such a crash.  It was a miracle. Everything about it was a miracle. But at the time I was surrounded by faithless friends who were caught up completely in their own life stories and were annoyed a bit by my ‘drama’.  “You crashed your car, what of it.” And some friend would then talk about a minor fender bender and the conversation would steer into a lot of oohing and aching about stuff people knew about , parking lot crashes and city bumps.  But even today I see that semi and feel that head over heels of the first smash on the roof the world coming round like a roller coaster and then the side ways rolling and the excruciating crunch of my body weight bent up against the ceiling, sustaining me because the strap didn’t hold me in the seat.
The other car was some young guys and girls , party animals in a big beater of an old boat , an Oldsmobile or something indestructible and it had just plowed me into the ditch and continued flat out across the prairie snow drifts.  Both cars would be a trial for tow trucks to get out. The deep snow cushioned the impact.
But when I see crashes on tv and watch the cars rolling, I rarely see something as intense as my own. It’s why I liked the Diesel XXX movies and Fast and Furious. The stunt men really owned their keep.  But I’m not a stunt driver. I was dressed in a suit and survived because the Toyota was such a strongly built car and the seat belt held me. If I was 2 inches shorter I’d not have crunched my neck.  But I survived.  I lived .
My mind is like that.  I was married a few times.  I sometimes have whisps of memories of those glorious days of love and roses, the ultimate romances, the extraorinary, love and lust, the close talks at dusk and dawn, the hours of fun together, the years of best friend relationships, the pride of having a partner so extraordinary in so many ways, beautiful, accomplished, brilliant, confident, successful, admired, and to have them with you, to be able to trust them, to do things together and be so intimate.  Years of that connection. The separation and divorces in my cases seemed to happen over the last year. The negative outweighed the positives. We part and then the courts and the lawyers and the government and friends and counselors and society just makes it all so much uglier.  And the loss is like an explosion dropped into the memory bank. It wipes out the whole amazing love story of two people who felt no other was the ‘one’, who felt they’d found their ‘soul mate’ and lived with love and carefree for years, amazingly, only to find that the indestructible thing of perfection wasn’t up to the task.
Now passively the wounds come back.  I can see the one judge who was as disgusting pig of a man studying my ex’s exposed cleavage and black lace hooker stockings that day of the divorce when her own lawyer looked more like a whore with her buttons undone and cleavage exposed.  I remember that and how later when I talked to other lawyers they told me she would have jockeyed for just that judge because he was such a perverted pig and a real disgusting womanizer in his personal life, a mommy’s boy, with a little dick and a need to win women and a history of consecutively finding against men in all divorce and custody cases because he’s such a loser.  Backstabbing psychopath.  That little weasel jumps right into my passive memory.  Especially learning about him from the lawyers and learning that there’s still a pedophile judge missing and me thinking it’s got to be him because he was such a type, but really, was he.  Yes, he was a 13 year old boy who had a big position and abused it and feared men and treated women as whores but.....and here’s the but...I’ve been divorced three times, 23 years of marriage, two decades of loving the enemy, providing and protecting for all that time and 90% of it was really good for ‘us’ but I left.  I walked out on two while she walked out on one. But the important thing was there three judges and only one was a smegma. The other two were saints. Amazing considerate gentlemen with genius and wisdom and love and care who ended the marriages with the least fan fare. True I was never one to ask for anything except my life back so I walked out without anything essentially, dividing the assets of one house and giving another away but the key is that I don’t dwell on these ‘gentlemen’.  They didn’t look at the women like they were meat and they didn’t talk to me like I was a fool. They were mensch.  They were Skookum men.
My mind passively drifts to the ugly little piece of stinky dog tourd. There is if I am ‘active’ about my memory these two great men who made a bad situation less bad. These two great men did their tough job with kindness and care.
I used to have a resentment against my mother for a thing she did when I was a teen. It wasn’t anything really but I was pimple faced and awkward and tended to be ‘sensitive’ in adolescence. I expect I’m the only such teen of that kind. I had attitude and Mom wasn’t always ‘tolerant’ and ‘enlightened’ about how she should talk to an asshole kid. So we had words and I held this resentment against her.  My mom is a saint. I can go on and on about the accomplishments of my parents which include not killing me but my mind used to go to that argument instead of to the times she held me as a child when I came to her afraid. I remember that now. The adolescent ‘bomb’ memory concealed the feeling of her taking me in her arms and holding me when I was hurt child. I can feel that today.  It was the work of therapy and doing a 12th step that brought home the insanity of the mind and how ‘selective bias’ worked in the brain.
My mind is broken.  I can fix it by remember that it’s going to lie to me about my life and the relationships I had and the people I knew.  I’m blessed and I have to actively remember the truth about my life.  The Toyota Corolla is an awesome car.  I’ve driven more than a half century on on kinds of roads with all kinds of other drivers around, in cars, trucks and on motorcycles.  I drive a lot. I’ve driven desserts and freeways, and across tundra and off road and on road.  So 99.9% of the time the other drivers are incredible. I’ve had a few accidents but statistically I drive about 10x as much as every one I know and I’ve driven in worse conditions and in different countries with a whole lot of my own and rental equipment.  So statistically, and in reality, other drivers are by and large amazing, and the very vast majority actually do have the intelligence to have figured out how to use the ‘turn’ signal for changing lanes.
But I have a broken mind and most people would know my descriptors of the one driver in the morning commute whose causing the traffic jam that day, one driver out of thousands.
Just saying.
I have to be ‘active’ and make my memory remember ‘truly’ and avoid the ‘emotional memory’ of ‘selective bias’ that suffers from such inaccuracy and causes me to have a skewed view of reality.  My life is blessed. I’m really thankful for all the people I’ve known and all the machines I’ve driven.
Thank you.

F.A.T.

F.A.T. - Food Addiction Treatment
Obesity is at epidemic proportions in North America.  Obesity is certainly not good for morbidity or mortality. The fat we see on the outside is also surrounding and clogging all our internal organs. The heart is constricted with fat. The weight of the body is destroying joints.  The weight of the chest is obstructing breathing.
All manner of illness is more prominent among fat people.  Obesity is roughly 50 lbs over what one’s projected normal weight to height should be.  In the past this was done with routine height and weight charts. I still prefer this to fancier (Body Mass Index) but more complicated methods of assessing how fat one is.
The worst indicated is the pear shape at the middle. This is associated most with development of disease.  Diabetes, hypertension, just another couple of examples.  Success is reducing waist size.  Being tall I hide that I really 'should' be 4 to 6 inches less at the middle.  I love to kid myself, that it's posture. I can 'suck it' in the belt is supposed to be 'straight' not curved at the front.
Obviously it’s a black box equation.  Too much food in and not enough exercise out.  There are those who say they have ‘slow metabolism’. Maybe, rarely. There are countless excuses.  The fact remains, obesity is unhealthy. Fat is unhealthy.
See your family physician and get a complete physical to make sure you're not fat because you're suffering from some disease like hypothyroidism.
I recommend Overeaters Anonymous. There are a variety of self help 12 step programs. They are all beneficial.  Mostly they focus one on being ‘honest’ and ‘accountable’.  They recognize that food addiction, overeating, is done for emotional reasons, to stuff emotions, such as fear or resentment.  Expectations are pre formed resentments. Fat people are commonly passive aggressive, angry on the inside, smiling on the outside, people pleasers.
The most common mental illness associated with fat is depression.  Unfortunately a lot of antidepressants cause increased weight.  Wellbutrin and Cymbalta are neutral medications that are least likely to cause weight gain. If you do gain weight with an antidepressant this can be counteracted by the addition of dexedrine to treat the 'side effect' of therapy. Other psychiatrists would add synthroid to counteract the weight gain effect of those antidepressants that cause weight gain in susceptible populations.
Often fat people are bipolar too.  They've not uncommonly had a lot of trauma.  More often than not a lot of it's been sexual.  Since sex is an athletic activity fat people aren't very good at it.  They don't like being on top and might crush their partner if they were.  They can be loving but are often hurt and hurtful lovers.
There are very important ways to reevaluate one’s life and ambition and look for more positive ways to achieve realistic goals without becoming the Michelin Man in the process and having an early death.
I recommend Fat is a Family Affair by Judy Hollis.  Excellent book. Good ideas and tools.  There are other good books out there.  Therapeutic reading is helpful
Fasting at least a day a week or by missing meals with good education and therapeutic plan is a great diet approach.  If one is on medication discuss it with a doctor knowledgeable of fasting. The principle problem is that people don't drink enough fluids when fasting. It's amazing how much fluid one gets in food so this has to be compensated for by literally forcing down a couple more glasses of liquid than one feels they wants.
There are a variety of diets. None of them is good enough alone. They must be coupled with a whole change of life and lifestyle.  People usually diet like drunks change from drinking vodka to beer without really addressing the problem.  Fat and obesity are life long problems.  The failure of diets is that one doesn’t follow them or returns to previous behaviour the first stress one encounters.
I recommend 500 calorie diets. In my obesity clinic, everyone lost 50 lbs or more in a matter of months to a year.  However, though I recommended 500 calories everyone cheated . When I had a sweet little silly headed nutritionist come in and recommend 2500 calorie diet all my big boys and girls took that to mean 5000 calories. People lie and cheat with diets.  Best recommend 500 and be done with it.  Aim for perfection and be thankful you hit the target even if you’re way off the bull’s eye.
To understand the principles of what is 'good nutrition' understand the Mediterranean Diet and the Zone Diet. All the rest is gooblygook and confusing.  There are no obese people over 100 and the diets of longevity are in the long run the best diet. If you are rich you can be a vegetarian. Rich vegetarians live long but poor vegetarians die young.  Being rich is more associated with longevity than diet. But fat rich people die the same horrible deaths that fat poor people do.
I knock 'fad' diets but there are good people out there like the Jenny Craig folk and others. Check them out and do something.
Obviously seeing a psychiatrist is a good idea.  I’m a psychiatrist and a whole lot of my obese patients had underlying ‘issues’ which had to be  addressed for the various other tactics and strategies to work.  I don't think seeing a slim counsellor is that helpful unless the slim counsellor used to have a problem with fat and now is and remains slim. Ask to see their fat pictures.  Given counsellors have the least education it's best if they have the most experience. I've got the most education and it helps that I have a little of my own experience.  I've seen too many people talking about things which never came hard for them and what they're saying only works for others like them. It doesn't work for the obese.  Obese people are resistant to learning. They're not stupid. They 'know' what's good for them. They just have difficulty 'doing' what's good.
Exercise and coaches and physiotherapists are all very helpful.  Aquafit exercise program is the best program for the really obese.  Obviously jogging is great exercise but if you're five hundred pounds and start jogging you're going to cripple yourself.  Start slow , go slow and don't hurt yourself with whatever exercises you under take.  I like martial arts. Tai Chi is great. Yoga is good for flexibility but not that good for losing weight.  Group therapy, some kind of group exercise program, is the least expensive but also the most effective long term.
An american military study showed that once a certain level of exercise was achieved, a few hours  on the military obstacle course for instance, then force feeding wasn’t associated with weight gain. This study showed that diet came second to exercise.  Most people are too fat to exercise or like exercise hence the benefit of personal coaches and beginning in the safety of ones home only to progress to the group experience.
When you lose weight, 10 lbs or 20 lbs, a size or two, then buy new clothes and burn the old ones, or at least give them to the Sally Ann.
Now having done all this there are medications which help.
First and foremost consider what medications you are taking that might be adding to the problem. High dose antipsychotics, like seroquel, often used for sleep  or anxiety often increase appetite and put on weight.  Discuss medications with the doctor and make sure if possible you’re not on anything that will be complicating matters if possible. Don’t stop medications just because they can cause weight gain by affecting appetite.  The worst medication for obesity is so called 'medical marijuana'.
Don’t drink or smoke dope.  Face it, alcohol is empty calories, leads to poor judgement and marijuana, especially ‘medical marijuania’ causes the munchies.  We used it with AIDS patients to improve their appetite and increase their weight,  for that reason.
Xenical is an interesting and relatively safe medication. It works by reducing the absorption of fats. Several of my patients swear by it. The only side effect they noticed was a little bit of loose stool and they had to be more careful about farting in public, not because of leakage but the smell was noticeable or something like that, as I remember. Didn’t stop them from using it.  There’s a whole list of side effects but compared to obesity they’re all minor.
Dexedrine and other appetite suppressants are what the models and such use. These are essentially ‘prescription’ speed.  They are excellent for appetite suppression however they are also highly addictive. When I ran an obesity clinic I used them for 6 week bursts , when people on a regular exercise and diet program got ‘stuck’. Weight loss tends to go in steps and sometimes the use of an appetite suppressant helped one over that ‘hump’.  The critical factor here is that the doctor be working closely with you and also be monitoring your weight. No sense taking these if there’s not significant weight lost. The cost of addiction then outweighs any benefit. Further the risk is that people will continue them and want increased amounts. That’s a danger sign. Further they shouldn’t be continued if they cause sleep problems.  However if a person is already on sleep aids they can be tried because they won’t necessarily be making a sleep disorder worse if taken early in the day.
I don't think it's a coincidence that a whole lot of people who got fat suddenly got 'adult attention deficit disorder and got their hands on medical speed for appetite suppression.  The tragedy of this approach is that it means the doctor isn't working with you on the obesity problem and merrily going along with the idea that you can't concentrate.  Which might be true, given how distracted you are by the munches.
Revia is a novel medication with great promise. I’ve had success with this and really should use it more. It’s not a cheap medication and I’ve thought about cost prescribing it however when I consider the fortunes that people use on unproven alternative health aids and silly fad diets, Revia is far superior. It was found that it reduced craving in alcoholics and addicts. From that it followed that it might reduce food craving. And that’s what it does. Reduces craving for foods by 50% .  It’s a relatively safe drug with great benefit .It’s really worth a trial with any obese people where the safety is assured.  It’s benefit is seen in a 3 month trial for instance and the potential of negative side effects aren’t as bad as the hazards of obesity in general.  My patients haven't had negative side effects to date.  Everyone knows about 'negative side effects' these days because it's a lawyer thing and it's out there for the ambulance chasers and as a medical disclaimer for the manufacturer. In a lot of cases these long lists are about as useful as coffee cups which say on the side ,be careful ,cup may be hot.
If these don't help really consider boot camp and a 1-4 week treatment spa where one goes for the sake of losing weight and getting healthy.  Alcoholics have embraced Betty Ford so I don't know why the fat church ladies aren't getting on the wagon too. There are many out there and they do work.  So if one remains obese for a year or two, think of the drunk husband who keeps falling off the wagon, then consider the fat farms.
It's easy to treat obesity earlier than later.  That's the case with all diseases.  Nipping them in the bud is what one does before consider nip and tuck.
After one has failed with exercise and diet and programs  one really should consider surgery though. 30 years ago I was assisting a surgeon doing stomach stapling.  It was relatively experimental back then but today it’s fairly routine with the safety of the surgery pretty much overall established compared to the risks of gross obesity.  The first step is to talk to your family physician about surgery and get a consult to a surgeon who does surgery for obesity.  You don't get the surgery that visit. He tells you about and assesses your risks and lets you know if surgery would be for you.  You don't have to decide then.  But now you know. If you're grossly obese and have been for awhile then you're kidding yourself if you haven't talked to a surgeon. It's like a person who complains about having to walk to the bus who has never even talked to a car dealer to see if there might well be a car they can buy.
I’m a little overweight. I wouldn’t mind a little liposuction but I’m not planning on stomach stapling. But if I was a couple of hundred pounds overweight and had failed at a variety of approaches I’d certainly give it a go. Several of my patients have had long term benefits from it and I’ve seen them and been surprised to hear they once were grossly obese. Their lives are going well today only they can’t gorge on food. Regular servings is as much as they can take.
The key is to get a ‘plan’ and go with it. Don’t do it alone. Work with your doctor and better still surround yourself with a ‘team’ of people including family and friends who are on board with your plans and know your goals.  Imagine how stupid the world would be still if we didn’t have schools and take a regimented approach to learning.  Stupidity can be ‘cured’ . Education even treats arrogance because the more you learn the more you realize how much more there is to learn.  Sloth and gluttony are treatable.  You don’t have to be ashamed.  It’s a life long process with no easy quick cure. Plans involve life style changes that occur for years even after making the ideal weights. My patients commonly tell me of ‘relapses’ that occurred after five or ten years of maintaining a healthy weight.  Then they go back to basics and progress through to advanced weight maintenance learning all over again.  Success is normal if you follow the steps.
With an aging population and the improvement in the comfort of the couch and the advent of the tv channel changer we’ve got more to face than the previous generations that had to chop wood for their heat and use a pump to get water.  We’re adapting as a civilization to the digital age.  And yes, just like we know that Goldman Sachs were developmentally challenged as human beings so are the folk that produce those disgusting fast food vending machines for schools.  We collectively dealt with the tobacco companies and the psychopathic CEO and their vampire disgusting children and collectively we’ll have to eventually deal with the folks ‘pushing’ sugar salt fake food substances on us and their degenerate young.  That comes later.
Before we can kick ass we've  got to deal with our own lard asses,  get out and exercise, ask for help, network, plan, strategise, and lose weight and get healthy.
What use are you going to be to the rest of us when the zombie wars start. We’ll be dragging your ass and the zombies will be charging for the greatest mass of flesh which is you.   If you want help then start helping yourself now.

.

DSMV

Hoorah!
I just received my new American Psychiatric Assocation, Diagnostic and Statistical Manual of Mental Disorders - DSM5 - 5th edition.  It's been a long awaited highly controversial text. I've just done the overview and really it's looking overall very good. The devil's in the details but first glance this is a great book.  A whole lot of terrific work.  Well done! 
July3, 2013
I got to read some more of DSM5
PTSD criteria has been broadened over all but has some more specific subcategories. I think it is more in line with the way it has been used clinically though I can see problems arising. Overall it's clear that some serious thinking has gone into this area of trauma related illness and it's well reflected in the clinical thinking inherrent in the changes since DSMIV. This is an area I work alot with and can see myself enjoying using the DSM5 without any overt concerns.
Bipolar Disorder II - the Bipolar Disorder I has remained much the same and hasn't had any controversy attached to it over the years.  Mania is a pretty drastic presentation so it's not one that gets overly misdiagnosed.  Bipolar II however has had serious flaws in diagnostic thinking lacking any real 'exclusion' criteria surrounding the term hypomania.  The idea that 'hypomania is irritability' is where the major crux is. If you're 'irritable' for 4 days now you can be diagnosed with a 'major' mental illness which can reflect on you 'freedom', 'work', 'income' and reputation.  However, a psychiatrist can safely prescribe a wide variety of medications that are likely to improve your mood.  Bipolar II and Bipolar Spectrum Disorders has been where drug companies have had their recent greatest influence as well reported in the book Unhinged, among other sources. That said there's really clear evidence that while the DSM folk might have still been overly influenced by the industry in this regard, there's an attempt to tighten up the diagnosis in specific areas. Therefore I'd say that the prescription pad psychiatrist won't be changed by this but a more concerned clinician with some diagnostic conscience will find this a better diagnosis than was available previously. 
Cyclothymia is well detailed in DSMV.
Substance Abuse - this was a very controversial area and it leaves a lot to be desired.  But it's far from as bad as some of us Addiction Psychiatry/Addiction Medicine sort thought.  It's only about 10years outdated in conceptualization but it's not 50 years out of date or on another planet like some feared.  It's really not changed much from DSMIV on first sight . Again the details will count.  There's some improvement in language. What I do like is that substance use depression is under depression. There was obviously a need for the Substance Use Disorder like this to be categorized under the headings and this has been done with Substance Use Psychotic disorder listed in the grouping for
Schizophrenia and Psychotic Disorders.  When all the chameleon colours of substance abuse disorders was listed separately novice practitioners and especially counsellors routinely misdiagnosed substance abuse psychosis and mood disorder and anxiety disorders because they were not listed under psychosis, mood or anxiety.  This is an improvement I think. The category of substance abuse itself in he desk reference is just fine, broad and specific as needed. Consistent with ICD9and 10 and not much different from DSMIV and probably easier to use clinically in the desk reference because the presentations of this category are often messy and overlapping. The specificity of the previous DSMIV was fairly academic and there's evidence this is more user friendly
The specific substance abuse areas are well documented too
Obviously I'll have more to say about this category when I go through the big book in detail but really it's not as crazy as people feared. I think everyone can work with it but appreciate that Addiction folk feel short changed as the opportunity for DSM5 to reflect the scientific advances in the field, as evidence by MRI, PET, blood urine, end organ damage etc and all the advanced knowleded now available in genetics and neurochemistry isn't clearly evidenced but that's possibly not the job of DSMV. 
Schizophrenia and Psychosis - I think this section is pretty damn good.  It's really well described schizophrenia, brief psychotic episodes, schizophreniform illness, schizoaffective disorder and substance induced psychosis. Can't see anything with first overview I'd disagree with.
 Personality Disorders- I'm really pleased that  the original Jungian categories of essentially odd, extrovert and introvert have been maintained.  There's been major advances in this field which are represented by more dimentionality but frankly I was concerned with clinically having to learn a whole new way of thinking about personality even if it's more scientific. I can see doctors working in this field being very disappointed but again I'm kind of happy it's not going to change the whole Axis II thinking radically. I suspect others that don't work in my areas of interest will like the conservative elements that have influenced DSM5 because while I individually as an addiction psychiatrist who works with trauma have specific concerns I'm pleased when I see that others broad areas have retained their overall basis.  DSM5 is a major undertaiking as much political as scientific, just getting all the doctors with competing agendas to sit at the table.
And this is looking overall like a really worthwhile undertaking.  An amazing contribution like a new encyclopedia Britanica.
The Neurocognitive Domains is a great section that really is an advance and reflects much of the new knowledge in traumatic and degenerative brain changes. Well done DSM5
The Sexual Dysfunction section in DSMIV was really well established and there's more of the same good thinking and work in this DSM5.
Eating disorders seems good too. No surprises, nothing off the wall. Just what we're concerned about clinically.
The Dissociative disorders were highly controversy but seem to be here in a very usable form. 
Somatic Sympton and related disorders seems on first glance to be better conceptualized overall and a very useful set of categories laid out the way clinicians think./
The sleep disorders are well established also with clear definitions and criteria. 

I''m going to say that again with first and second go round at this book, the DSM5 is a truly great work overall with naturally some areas of controversy. It's been a long time coming and a whole lot of very dedicated folk have done an overall amazing job at categorizing mental illness in a way that is clearly going to be useful to clinicians.  Having seen some 10 thousand psychiatric cases over a quarter century or so I think this new DSM5 is going to serve me well.  I'm looking forward to to the courses and controversy and discussions that will flow from this book and result in development of a likely even better DSMV.  It's only too bad that DSMV doesn't have a 'spiritual psychiatry" section.  A V code would have been nice. That would be asking the APA to raise the bar higher than it's usually used too though. Other V codes have been improved on in a major way with the addition of 'suspected and confirmed categories" in the case of 'abuse' which previously was 'assumed true' when indeed it's turned out that there's a real place in the world for the legal term 'alleged' and it's apparent that psychiatric diagnosis are demanding some 'boundaries' in this regard. 

There's a lot of little category changes and additions which will need specific review but again overall it's really an admirable work.

 I know DSMIII is a whole other animal than this DSMV. I'm looking at the advances in my life time a bit like the Star Trek series of enterprises over the centuries of that show and this is only in a matter of decades. The advances made in science and the clinical progression is truly amazing. 

The American Psychiatric Association deserves to be highly applauded for this major and extraordinary contribution to our collective medical knowledge.  Thank you to all involved in the production of DSM5. 

Dissociation in Psychiatry

Dissociation is a common experience.  At it's least, it's called 'day dreaming'. It refers to the experience of disconnecting our mental processes from the physical experience we are presently in.  At it's most severe expression there are multiple personality disorders, fugue states and flashbacks.
It's called a 'defence' or 'coping mechanism' and refers to an 'altered state of consciousness".
Hypnosis induces a 'dissociative state'.  It's also called 'compartmentalization of experience.
Normally a person is 'integrated' in regards to thoughts, emotion and bodily awareness.
In the dissociative state a person may not be aware of their objective reality but be solely focussed on their subjective reality.
In some dissociative experiences there is loss of memory associated with the altered state of consciousness. This is not necessary as a person experiencing a 'flashback' may have a complete memory of the point they experienced the 'derealization' , one of the terms used to describe the disociative experience, the experienced and the return to normal consciouness and awareness.
Dissociatiion is associated with trauma.  In early childhood trauma personality is not so coalesced. This is the explanation for the phenomena of mutliple personality now termed Dissociative Personality Disorder.  A person may develop an alter ego to cope with trauma.
In rape survivors they may experience flashbacks and react to normal person's as if they were a 'proto rapist'. Unfortunately the dissociative behaviour of people who have been traumatized can itself initiate recurrence of the truam.
Dissociative amnesia refers to the complete blocking out of a traumatic episode. This more commonly occurs with victims but can be a contributing factor in victimizers.
Conversion Disorders have been associated with dissociation.
Psychoactive drugs can also induced a dissociative state temporarily.

Whiplash Associated Disorders

"Whiplash" is defined as an acceleration-deceleration mechanism of energy transfer to the neck that results from rear-end or or side impact motor vehicle collisions. It can also derive from diving accidents or other similarly occurring impacts that result in bony or soft tissue injuries. These injuries can in turn lead to a variety of clinical manifestations. The collection of clinical manifestations has been called "Whiplash Associated Disorders" or WAD.

The Quebec Task Force WAD classification according to clinical presentation is as follows:

Grade Clinical Presentation

0 No neck complaints and no physical sign(s)

I Neck pain, stiffness or tenderness and no physical sign(s)

II Neck complaint and musculoskeletal sign(s)

III Neck complaint and neurologic sign (s)

IV Neck complaint and fracture or dislocation

The Gargan and Bannister classification of symptom severity is as follows:

Group Symptons

A Asymptomatic

B Mild Symptons not affecting work or leisure activities

C Intrussive symptons interfering with work or leisure. Frequent use of analgesics, orthosis, or physiotherapy.

D Severe problems: lost job, continual reliance on analgesics, orthosis. Repeated medical consultations.

The epidemiology of Whiplash Associated Disorders varies from country to country. The incidence has been reported as highest, 188/100,000 in the Netherlands to lowest, 39/100,000 in Australia.

Early ideal treatment involves the general rules of assessment for major trauma at the initial site and time of the accident. These involve preservation of life and prevention of further damage to the spine and cord and preservation of spinal function. This has been laid out in the US National Acute Spinal Cord Injury Study. The key is to assume spinal instability until proven otherwise.

In the Emergency Department Acute Traumatic Central Cord Syndrome (ATCCS) must be excluded. This is a complex spinal cord syndrome which presents with incomplete neurological deficits such as the ability to walk but not move hands, and sensory changes such as burning hands or urinary retention. MRI generally shows white matter involvement but no hemorrhage. The prognosis is generally good.

Fractures are ruled out by xrays.However if the xrays are normal but the patients persists in having severe pain special x ray views are indicated. If persisting severe pain without any abnormality being found then a hard collar is applied and an MRI is done within24-48 hours showing flexion/extension views to rule out ligamentous injury.These xrays and imaging are all however open to a variety of pitfalls requiring expert interpretation.

Once major injuries are ruled out the normal approach to WAD (Whiplash Associated Disorder) is reassurance and education, no soft collar, Non steroidal anti inflammatory medication such as ibuprofen or naproxens, and early mobilization. Rest and cervical collars can have a detrimental effect on the outcome.

This said nearly 75% of injured patients report immediate symptons such as cervical pain, painful neck movement, painful back, shoulder pain, disturbance of consciousness and dizziness. Examination may show paresthesias, ie unusual sensations, and weakness. Later patients may have visual disturbance, problems with concentration, fatigue, sleep impairment, as well as irritability and anxiety and depression. Interestingly studies show that the anxiety and depression are most directly related to the presence of symptons such as pain and disability. Anxiety and depression do not appear in contrast in those who are early asymptomatic.

While it is important to remember that approximately 10 to 30 % of the general population who have not had an injury report chronic neck symptons, studies show that 15 to 40 % of the WAD patients have chronic neck pain with 10% reporting this as severe. Studies have showed that there can be little alteration of in symptons by three months and stabilizing at 2 years. Authors in prospective study showed little alteration in sympton severity for the majority of patients (64%) between 3 months and 7.5 years . Between 3 months and 2 years the symptons fluctuated significantly and prognosis based on this were unreliable. Therapeutically the greatest benefit for influencing outcome was in those first three months. One interesting study showed that high dose methylprednisone resulted in earliest return to work.

There have been many issues raised relative to the prognosis or eventual outcome of the injury. This has been difficult because there is no clear definition of what is recovery. At best crude measures of symptons or disability have been used along with such matters as 'return to work', 'discontinuation of treatment', or 'conclusion of litigation' .

That said, a systematic review of prospective cohort studies done in Pain 2003 concluded that "strong evidence was found for high initial pain intensity, and strong evidence for no prognostic value for older age, female gender, high acute psychological response, angular deformity of the neck, rear-end collision and compensation". Limitted evidence was found for some physical, psychosocial, neuropsychological, crash related and treatment related factors in terms of prognosis.

References:

Initial assessment of whiplash patients, Dr. R Gunzburg, M. Szpalski, J. Van Goethem,Pain Res Manage Vol 8 No 1 Spring 2003

Fluctuation in recovery following whiplash injury, 7.5 year prospective review, P.J. Tomlinson, M.F. Gargan, G.C. Bannister, Injury, Int. J. Care Injured (2005) 36, 758-761

Sensory hypersensitivity occurs soon after whiplash injury and is associated with poor recovery, Michele Sterling, Gwendolen Jull, Bill Vicenzino, Justin Kenardy, Pain 104 (2003) 5009-517

Prognostic factors of whiplash-associated disorders: a systematic review of prospective cohort studies, Gwendolijne G.M. Scholten-Peeters, Arianne P. Verhagen, Geertruida E. Bekkering, Danielle A.W.M. van der Windt, Les Barnsley, Rob A.B. Oostendorp, Erik J.M. Hendriks, Pain (104 (2003)303-322