The other Kenny Rogers (Texas Ranger pitcher) with arguably the best first half of the season in the American league lost his composure if not his mind before a game in Arlington, Texas on Wednesday, June 29, 2005. Footage of him pushing away TV cameras, knocking down a cameraman and kicking the camera dominated the national news today. One of the cameramen was evaluated at a local hospital and is reporting injuries to his neck and back.

What pushed the most valuable player on the Rangers to join the ranks of Bobby Knight, Ron Artest, and other notorious athletes with violent tempers? Is it the intense competition that has driven their success since childhood? Is it the constant media pressure and scrutiny? Is it the fault of a social system that elevates our sports heroes to positions loftier than us mere mortals with their multi-million dollar a year salaries? Is it the fact that if they don’t continue to perform they are history? Is it the fact that they are really just commodities that can be traded away? Is it because overnight they can lose a team mate who has been traded? Yes, to all of the above plus sometimes you can add in performance enhancing substances including but not just steroids.

The biggest problem is that we are not learning from experience. The Indiana Pacers of the National Basketball Association lost their star player, Ron Artest, for the season after he charged into the stands during a game with the Detroit Pistons in the fall of 2004. The Texas Rangers were aware of Kenny Roger’s temper and his progressive loss of control during the prior month but they apparently took no action.

What causes this behavior from a biological, psychological and cultural perspective?

Related Article: Violence in Sports …

Your interview with Tom Cruise is an evocative tour de force. You were criticized, admonished and belittled. Is it possible for someone to be condescending squared? You maintained total composure and continued to elicit additional information and opinion. You aroused in him the passion he feels about this subject. You weren’t critical but you shared from your experience enough to hopefully leave the viewer with the idea - Matt seems reasonable and Tom seems over the top.

Imagine yourself sitting in an emergency room as part of your training to be a psychiatrist. Tom Cruise is brought in by two sheriff’s deputies. His family has gone to a mental illness court and convinced a judge that there is sufficient evidence of a mental disorder and that he could be potentially dangerous to self or others. As a psychiatric resident in training it is your job to evaluate his mental status and decide whether he needs to be committed. During the interview he tells you that you are "glib". He says, "you don’t understand, I do". He tells you he doesn’t agree with psychiatry and never has. He generalizes that antidepressants and stimulants are antipsychotics. He says, "you don’t know the history, I do and there’s no such thing as a chemical imbalance". He tells you that you are irresponsible when you say that some people have been helped by these types of medication.

You, of course know that religion is based on faith. You accept it or you don’t. Philosophy is based on logic - it invites argument and discussion. Science is based on hypotheses/theories and invites data. If new data comes out that doesn’t support the hypotheses/theory further careful research confirms the new data - you modify the theory. An example of science is the blood pressure range that is considered normal. When new data found that systolic pressure of 130-140, or diastolic of 80-90 was associated with increased heart disease the standard for blood pressure was lowered.

Covey talks about principles that are timeless and unassailable. He compares these principles to the direction north. If you and I are lost and we disagree as to which way is north - one of us may be more persuasive or passionate, or we could take a vote but that wouldn’t change the fact that north is north.

An example of an unarguable principle is that prejudice and racism is wrong. Harming someone because of their color, religion, or sexual preference has always been and will always be wrong. Is it possible that I’m wrong? No, I feel passionate about that - not because it’s science but because it is an ethical principle. Tom Cruise treats religion, philosophy, and science as though they all follow the same rules.

Cruise says that psychiatry is pseudoscience, that medication "masks the problem" and that postpartum depression and other mental health problems can be better solved with vitamins and exercise.

Go back to our emergency room scene. You ask Mr. Cruise, "is it possible that you’re wrong?" He would of course reply in an agitated voice, "absolutely not"! An opinion or belief that is adamantly defended as a fact is a delusion.

Now you have a patient who is agitated and delusional. Your next question, "is he likely to do harm to himself or others?" He’s a celebrity. He has a huge fan base. He seems knowledgeable and speaks with authority. There may be many people who might think, "he’s right", and stop their medication. The consequences could be harmful or even deadly.

As a responsible physician your only choice is to hospitalize him. He would obviously refuse medication - especially antipsychotics. He accuses you of being part of a plot to control the world with medication (Brave New World). You know medication would help him. You also know that he will sue you if you force him to take it. You don’t know what to do. A nurse approaches you - "Dr. Lauer, there is a mob of people surrounding the hospital. They have come to set Tom free. They are threatening to break in. They are threatening you".

You decide, "this is not worth it!" He won’t let me treat him anyway. You write the order to let him go. His fans cheer. The crowd dissipates. Fortunately they didn’t know which car was yours so it’s still in one piece. You sit quietly pondering your day. Suddenly you have an epiphany. You go to the director of training. You say, "I am resigning from my psychiatry residency. I’ve decided to become a television news show anchorman!"

P.S. I don’t think he’s really psychotic, but too much narcissism where intelligence and accurate information would serve him better.

When I first heard that Michael Jackson was found innocent I was glad. But didn’t he get away with pedophilia? Not really. He is not a slippery sociopath who manipulates his way out of being responsible for his actions. He is clearly a tortured soul. The ordeal of public shame, humiliation, facing criminal charges and going through this long painful trial didn’t kill him but took years off his life.

Michael Jackson will never again be a super star loved by all. He will always be looked at with different eyes and will always feel he’s being judged if not scorned by many. The evidence for him being a pedophile is too strong to be ignored. But he seems so immature. His sexual interests are probably much more voyeuristic and possibly tactile - I bet any kind of penetration to him would be disgusting.

I don’t feel that he will be a danger to society - those around him will help keep him paranoid enough about aberrant behavior - "sharing his bed" with young boys.

I am also relieved we don’t have to hear every day about how he’s coping with prison. The shower was cold, the towel was rough and gray, his jammies were scratchy, his eggs were staring at him and on and on and on.

The prosecution chose the wrong case and presented it poorly. Money buys the best attorneys. The best attorneys usually win. What else is new?

Thank God it’s over!

Is the "runaway bride", Jennifer Wilbanks, still running? She’s nowhere to be found. When she was having her fifteen minutes of fame I received several email questions as to what was up with her. I kept waiting for more information and explanation but very little has come out. She somehow has escaped the pack of media dogs - so far. My best guess as to an explanation is that she has some kind of bipolar spectrum disorder.

In general the best way to understand behavior is to look at its outcome. She got world wide attention but that was not her intention since she covered her head with a blanket going through the airport and then disappeared from media scrutiny. Is she in treatment or writing a book or both? Will we have to wait until next fall’s rating week when she’s featured in the TV movie of the week?

But back to the question, "what was her motive"? She obviously avoided the wedding. We did learn that she had backed out of another engagement with little explanation some time in the past. We also learned that she had been arrested on occasions for shoplifting. In my clinical experience shoplifting is often associated with bipolar disorder. It is a way of stimulating excitement to either help fight depression or fan the flames of hypomania.

The fact that she purchased her bus ticket days before she took off shows that her leaving was not totally impulsive. But it also wasn’t rational. The pain she caused her family and friends defies any logical explanation.

The ultimate evidence is the story she concocted about being abducted. Again in my clinical experience fabrication of wild tales is frequently associated with bipolar disorder. The excitement generated by these extraordinary stories is greater than anything grounded in reality - even a wedding with 14 attendants - a somewhat grandiose fact in itself.

Then finally the pictures of her that have been published - does she look wired or what? The only explanation given to the media has been that she wasn’t running away from her fiancé or the wedding and that she is sorry and seeking help.

Should she be held responsible for the tax payer dollars spent in searching for her? I think yes. I believe it is another example of "guilty by reason of insanity". Unfortunately this concept has not been incorporated into our legal system. We still force jurors and the theater of public opinion to decide between "guilty", i.e., criminal, or "not guilty by reason of insanity", absolving the individual of responsibility. Neither does real justice. No wonder she’s still running.

That’s certainly the implication of the headline appearing yesterday on the popular Drudge Report website. It read, "School Killer was on Prozac …" The story then goes on to describe a very disturbed and isolated teen who had tragically lost both parents. The only information available about Prozac was in paragraph seven and just comments that he was on it.

But was he really taking it - likely not. We won’t know until we get the final coroner’s report. Many questions need to be answered before we can speculate about what role, if any, Prozac played.

So, why would a headline want to jump so quickly to insinuate that Prozac was the real killer? Because this is America, and the main purpose of our dominant news sources is to build as large an audience as possible - it’s all about the money.

Recently a 15 year-old was found guilty of maliciously murdering his grandparents. The jury rejected the defense that his behavior was caused by Zoloft, a medication similar to Prozac. The evidence was overwhelming that in his case a long history of pathologic violence and absence of normal guilt and remorse had long preceded his taking the medication.

So what about the case in Minnesota? He had a long history of deviant behavior and fascination with violence. He had been in a psychiatric hospital because he was suicidal.

When was he put on Prozac? Did it precede his deviant behavior? We don’t know. But hey, let’s not wait for the facts. Let’s exploit the possibility. How else are we going to get over 9 million hits per day?

Besides, we need to move on to planning the made-for-T.V. movie. I can see it now … ratings week … Slaughter in Minnesota goes head to head with Terry Schiavo.

Recently it was reported that a common anti-inflammatory medication (Aleve) caused an increase in heart problems or stroke in patients being studied to see if it helped Alzheimer’s risk. Another common medication, Vioxx, was taken off the market after studies showed that long term use increased risk of heart problems. A major problem is that the FDA over emphasizes short term studies and the wealth of clinical experience is not systematically monitored. The media contributes to the problem. Medications that help people feel better or raise their quality of life don’t make news. That wouldn’t increase ratings. It’s the juicy stories that get the press.

Last year, a report on a study of hormone treatment in menopausal women claimed that hormone therapy causes increased heart problems, strokes, and cancer. On the Today Show an author was interviewed saying basically that pharmaceutical companies have misled doctors and the public. The author further stated that they have profited by misrepresenting the benefits of hormones and failed to report dangerous complications. The interviewer’s response was "a lot of us women are mad that we have been so deceived." The truth of the matter is that less than half of menopausal women were on hormones at the time and up to half of the ones that were on hormones stopped them after the report came out. Insurance companies fearing an avalanche of law suits, put pressure on physicians. Some insurance companies told gynecologists they wouldn’t cover complications of hormone treatment other than short term use. For this and other reasons many doctors advise their patients to get off hormones. My knowledge of the limitations of studies and more importantly my clinical experience all lead me to believe at this time the benefits both short term and long term (especially for the brain) outweigh the risks for most menopausal women taking hormones.

Another example of media impact is that of Michael Moore. He is currently working on an expose of the pharmaceutical industry. He is allegedly paying physicians, pharmaceutical reps and others to provide the "inside scoop" on the workings of the pharmaceutical industry. On a recent Today Show he described the pharmaceutical industry as evil. Katie Couric’s attempt to get him to admit that the industry does provide us with new and better treatment was met with sarcasm and contempt. He gave an example that Eli Lilly had known for years but kept secret that Prozac, a popular treatment for depression and anxiety, increased the risk of suicide 12 times. My reply to this is, "do you think it would still be on the market if it was that dangerous?" He made his statement as if it were fact. A lot of people see him as a folk hero. I like that in America we are free to say what we believe. I’m exercising the right of free speech now. What I don’t believe in is the right to present opinions and distorted information out of context, and quote uninformed sources as though they are well researched fact. Satire should not be presented as a documentary. It does a lot of harm. But it gets the ratings and makes the money, and after all this is America.

What role has managed care (more honestly, managed cost), played in changing the way medical care is provided? The idea of a system that improves the quality of medical care is a good one. But over the past two decades I believe the result has been more the opposite. When I first started treating patients in the private sector, (early 70’s), decisions about medical tests, hospitalization, and treatment were made between the patient and doctor. Insurance would help with the cost depending upon the specifics of the policy or health care program. Medications were mostly generic. As health care costs escalated, insurance company profits began to shrink and the cost to employers was increasing at an alarming rate. Thus, the managed care system was born.

Managed care now monitors care and has the right to approve or not approve tests, hospitalization, or treatment. The decisions about care were gradually taken away from the patient and the doctor. Of course, the patient is always free to pay for healthcare themselves, but the costs are usually prohibitive.

The managed care companies became a fourth player in this process. They justified their existence by reducing the amount of dollars insurance companies had to pay - the managed care company would then get part of the savings for their profit and cost of doing business. So, in effect, the insurance companies would sometimes save 30% (20% of which would go to the management company). The insurance companies were happy, the employers were happier because they had more cost containment, the management companies were happy they had a job, BUT the poor patient now has about 30% less help with care and mainly has been out of the loop. In addition, the management companies contract with certain physicians who help "contain costs". This would insure that the physician gets a certain volume of patients with guaranteed but reduced payment for their services.

So how does this change the way physicians provide care? Almost always it means less time for the patient. The visit is shorter, and maybe less frequent, and tests are harder to get approved. Certain medications (cheaper generics) are more likely to get approved. Although I stopped accepting insurance (control) for my services a few years ago, I must still get involved frequently with having to request approval for medications that I feel are the best for the patient. Recently, I asked an insurance company to approve Provigil, a medication that increases alertness, and is also used for narcolepsy, shift work, and many other causes of excessive sleepiness. This was the only medication that I could find that one of my patients could take that would allow her to stay awake at work and not cause any side effects. After two letters pleading our case we were still denied. Why? COST. The insurance company felt that the drug was too expensive so the patient was "out of luck".

Please, somebody wake me up and tell me I’ve been having a bad dream. I didn’t just read that the District Attorney in Collin County has charged a Plano woman, Dena Schlosser, with capital murder. She can be put to death for taking a phrase in the Bible literally and cutting off her baby’s arms. It couldn’t also be true that Child Protective Services is not letting her husband have his other two traumatized, confused kids for just the opposite reason. He didn’t take his wife literally when she told him the night before the incident that she was giving the baby to God. He is being punished because he didn’t know his wife was insane before she carried out an obviously psychotic act. But the district attorney hasn’t figured it out, even after the act.

The reason I know that I’m dreaming is that this is 2004. Our government officials couldn’t be that obtuse. How could they expect the husband to take his wife literally? Even in the Bible, when Samuel’s mother said she was giving her son to God, she meant she was dedicating his life to God’s work. I guess if the CPS officials came to a fork in the road - they would eat with it.

Our officials need to make up their minds. They can’t have it both ways. You can’t expect the wife to think metaphorically and the husband to think literally. As a New York newspaper chief editor (and crusty Texan) told his fence riding journalist, "Don’t pee down both legs at the same time." So what’s the problem? The problem is the law is out of touch with reality. I guess you could say the law is not sane. According to the law, there are two options - guilty OR not guilty by reason of insanity. But she IS guilty. She is guilty by reason of insanity.

Scott Peterson is a totally different story. He is obviously guilty by reason of severe narcissism and sociopathy. He has no conscience. Mrs. Schlosser, Andrea Yates, plus another woman in East Texas last year were all suffering from postpartum psychosis. 

The percent of women who become clinically depressed in the few weeks after having a baby is ironically higher than at any time in a woman’s life. Fortunately, psychosis during this period is not common. It only occurs in about 1 in 1000 deliveries. Most of the time, women who develop postpartum psychosis turn out to be bipolar. This is a serious mood disorder that requires continuous treatment, just as does diabetes.

Most women who develop postpartum psychosis don’t murder their babies, but it is a well known possible complication. Most of the time, women who murder their babies lack adequate family network, have husbands who don’t provide enough emotional comforting, and they are usually involved in a fundamentalist church.

One classic symptom of psychosis is concrete thinking (i.e. taking everything literally). Have you ever had a really crazy dream? That’s the way the psychotic mind works when they are awake - and to them it seems real.

Fortunately, we have excellent medications to treat this disorder. Unfortunately, these medications are expensive and our "managed cost" medical system often only provides less expensive, less effective medication. 

Let’s wake up from the dark ages. I believe the United States is the only country that treats infanticide during postpartum psychosis as a crime. Scott Peterson murdered his wife and unborn child because he didn’t want to be bothered by a child or child support. He planned it out carefully and tried to hide the fact from everyone. Dena Schlosser and Andrea Yates murdered their babies to send them to heaven. They immediately called someone to tell them what they had done. Am I crazy or do these two scenarios seem different?

Guilty by reason of insanity!

On 9-14-04 I made a diary entry after the baseball incident where a pitcher threw a chair into the stands. In the baseball incident, I was most perplexed by the lack of any commentary about the fans’ roles in the problem or their inappropriate behavior. Now this weekend we had the Detroit incident where players went into the stands and players and fans were punching each other. What is up with all this insanity?

On Sunday following the incident, NBA commissioner David Stern made a comment. Punishments were quick and harsh. What impressed me the most about his comments was that he included the fact that the league will make changes that also regulate the fans’ behavior. 

A previous incident where a basketball player went into the stands was provoked by a fan taunting him about the death of his child. I hope that the public will get behind the NBA in mandating civilized behavior by the fans. Earl Warren is reported to have said - "I can’t give you an exact definition of pornography, but I know it when I see it."

We know when a fan has crossed the line and become abusive, and we all need to help security promptly and effectively deal with these individuals. Some of the fans in Detroit should face criminal charges and suspensions from attending games for the season.

I was disappointed when USA Today came out Monday morning - Page 1 Headline - "Pacer Suspended for Season", "Is Game Out of Control?" The story takes up 1/2 of page 1 and 1/2 of page 2, but the article fails to mention the need for standards to regulate fan behavior.

I will do an article soon about the physiology and treatment options for inappropriate aggression.

Did you know that testosterone increases aggression? 

And did you know that athletes on the winning team and their fans have an increase in testosterone after the game? 

Did this contribute to Ron Artest going up into the stands? 

The corollary to the testosterone increase is that the losing team and their fans have a decrease in their testosterone. I have been a Cubs fan for over 50 years - no wonder I’m not a fighter.

Related Article: Violence in Sports …

In 1999, the National Institute of Mental Health sponsored the most comprehensive study of ADHD children that had ever been done. They wanted to find out how various treatment approaches compared in outcome. It was called the Multimodal Treatment Study of ADHD (MTA). 579 children ages 7-9 with ADHD combined type were studied for 14 months. Patients were randomly assigned to one of 4 groups: A) Referred to doctors in the community for treatment as usual B) Treated with stimulants or placebo* according to strict dosing guidelines and frequent dose adjustments during the first four weeks. They also had daily feedback from the child’s parents and teachers. The children were first given methylphenidate (generic Ritalin) and then if not doing well changed to Dexedrine or one of 2 other medicines. After the first 4 weeks they were followed monthly. C) Comprehensive cognitive/behavioral treatment that included individual, group, and family therapy, aides in the classroom and summer camps. D) Combination of B and C *stimulants or placebo under blinded conditions Response rates were positive in 77% of the patients on medication. Cognitive behavioral treatment (CBT) added to medication did not provide any additional benefits to the medication alone. Benefits were noted even more in school than at home. Benefits continued throughout the 14 months but quickly reverted back to initial ADHD symptoms when medication stopped. Side effects were mild or none in 86%, moderate in 11%, and only a significant problem in 3%. (Irritability was worse in kids on placebo than medication). CBT did not significantly improve core ADHD symptoms, but did help with anxiety. Patients also on anxiety medication required slightly lower doses of ADHD medication. The MTA study very effectively demonstrated several principles about the treatment of ADHD: 1) Medication works well. Cognitive behavioral therapy alone doesn’t. 2) Patients respond well to the "right medication" at the "right dose." Most reports of bad reactions to stimulants were kids taking the wrong stimulant or the wrong dose. In this study only 3% had significantly negative reactions. 3) Benefits of medication were confirmed throughout 14 months (longer in other studies) without tolerance or sensitization. Three other long duration studies, two in the U.S., and one in Canada, had the same outcome. Other studies have shown continued benefit up to 10 years. Behavioral modification studies have shown some temporary benefit to some symptoms, but as soon as the treatment stops the symptoms return. ADHD is NOT the result of bad parenting. An observational study by Russell Barkley, a leading researcher and expert on ADHD, found that in ADHD families parents are more critical and controlling and less supportive than non ADHD families. However, when medication is given to the ADHD kids the parent’s behavior normalizes. In conclusion, ADHD is a disorder associated with different genetics, differences in brain structures and differences in brain chemistry. Abusive/traumatic childhoods can make it worse, as can excessive exposure to TV or computer games especially at an early age. In my clinical experience of over 30 years when I explain the medical basis of ADHD to kids, teens, and adults and we find the right medication and the right dose of medication, they like taking it. It makes their life easier. They are able to be normal - to pay attention in class, complete reading assignments and other homework, and get along with friends, teachers and family. As a consequence their self-esteem and self-confidence improve. The diagnostic tests and treatments recommended on the Dr. Phil Show by Dr. Phil and Dr. Lawlis are not based on scientific evidence. The treatments they criticize are supported by more scientific evidence than most illnesses in all of medicine. The worst thing is that potentially millions of people who have faith in Dr. Phil may rule out the use of medication for their kids and risk adverse outcomes not just to their academics but social skills and self-esteem……but the ratings are good. See ADHD Newsletter

When I first heard that Dr. Phil devoted a program to ADHD (Sept. 28 ‘04) called "Parenting with Pills" in which he sharply criticized the overuse of medication to "control behavior," instead of using good parenting skills, my response was "if all you have is a hammer, you treat everything as a nail." How ironic that when I went on his website, the first thing I read was a comment from Dr. Frank Lawlis, who has written a book, The ADD Answer, in which he criticizes doctors by using the same comment about treating everything as a nail (He credits Maslow as being the source on this quote.).

He implies all doctors have is a prescription pad for medication. The fact is the opposite. We physicians can prescribe meds or use education or therapy, but psychologists/counselors can only use talk therapy. For them to criticize meds has a stench of "sour grapes."

But it gets worse. In lieu of medication (they prefer to call them drugs), they recommend "snake oil," specifically diets and biofeedback. These are treatments with no scientific validity or endorsement by any of the reputable organizations, including the National Institute of Mental Health.

What exactly is "snake oil"?

Snake oil is anything that is highly recommended and especially endorsed by a person who has credentials or position of influence. The confusing thing is that due to the placebo effect, "snake oil" has some benefit.

What is the placebo effect?

Placebo is not a sugar pill. It is everything involved in treatment except the active treatment to which it’s being compared. It is the commitment and optimism of the patient, the interaction with staff, especially the doctor, the monitoring of symptoms, etc.

Sometimes the placebo effect alone accounts for over 50% improvement. The more a patient feels understood and cared about by the treater and the more confidence they have in the treater’s experience, the greater the placebo effect. For a treatment to be considered scientifically helpful, it has to add significant benefit above and beyond the placebo effect.

So what’s the problem?

There are several. First, the more charismatic the treater, the greater the placebo effect and more success they will have with "snake oil." To be fair, they may not know it’s snake oil because they see benefit.

A second problem is that the "snake oil" may not just be useless, it may actually make the condition worse. Two recent examples are Neurontin for bipolar disorder and progesterone for PMS. Both had been found to be helpful in open (not placebo controlled) studies. But when the controlled studies were subsequently done, the placebo group actually did better. The Neurontin and the progesterone had actually taken away from the placebo benefit.

Many pseudo treatments for ADHD result in delay of effective treatment at best and possibly worsen their symptoms. Ironically, one of the most comprehensive studies ever, the Multimodal Treatment Study of ADHD in 1999 (MTA) showed conclusively the overwhelming superiority of medication in treating this condition. I will describe this study next, but suffice it to say, "snake oil" won’t cut it.
See ADHD Newsletter