Author Archives: jamesmarroquin.com

The pediatrician Margaret Morhman tells the story of caring for a young girl in the ICU who developed a devastating case of meningitis.  One day when she came to check on her patient, the girl’s mother asked Morhman why her daughter had become sick.  As Morhman began to explain what meningitis is and how it is transmitted, it quickly became clear to her she was missing the meaning of the mother’s question.  Like Job, the mother was struggling to make sense of why her daughter was being made to suffer.

Whether we realize it or not, each of us operates with beliefs about causality and meaning.  Who or what controls the course of events in our lives and the world?   Do blind physical forces alone determine our destiny?  Is God or some other force like karma in control?  These basic beliefs often come into play when we get sick and seek to make sense of our suffering.

For instance, some people may interpret their disease as a kind of punishment for bad health decisions like smoking or alcohol abuse.  Others may find a spiritual purpose in being ill.  Still others may believe they became sick due to sheer bad luck.

The meaning we attribute to a symptom such as pain can influence how we experience it.  This is because our perception of pain is mediated through our central nervous system, through our brain, through our mind.  For example, if I had a headache right now, I would experience it in a radically different way depending on if I attributed it to stress or if I feared it was due to a life-threatening brain tumor.

Our emotional and spiritual state of being can also influence how physical ailments feel.  In my work in hospice, I have cared for patients with severe pain that did not respond to higher and higher doses of potent analgesics.  Only after somebody identified and addressed a spiritual crisis, such as a fear of dying or an agonizing regret, did the suffering person find relief.  

I turned 36 almost a week ago and for some reason, this birthday prompted me to reflect on the scarcity of time.  When we are young, it seems like the days will go on forever.  The reality of an ending, of death, hardly enters our mind.  I adore this care-free innocence I witness in the life of my 5 year old son.

But as we enter adulthood, there is value in clearly seeing that our days are numbered.  It can motivate us to contemplate what really matters and how we want to spend the rest of their lives.

The psychology professor Mihaly Csikszentmihalyi has carefully studied how people spend their time.  He points out that what we do during an average day can be divided into three major kinds of activities.

The first way we spend our time is producing, or generating the resources such as money that ensure our survival and comfort.  The amount of time we spend working in this way differs across time and places.  Csikszentmihalyi writes that “according to some anthropologists, among certain societies, such as the tribesman of Brazilian jungles or the African deserts, grown men rarely spend more than four hours a day providing for their livelihood–the rest of the time they spend resting, chatting, singing, and dancing.  On the other hand, during the hundred years or so of industrialization in the West, before unions were to regulate working time, it was not unusual for workers to spend twelve or more hours a day in the factory.  So the eight-hour workday, which is currently the norm, is about halfway between the two extremes.”

The second way we spend our time is preserving the body and its possessions.  Csikszentmihalyi calls eating, resting, grooming, cooking, shopping, housework, and driving maintenance activities.  Traditionally women have taken on a greater portion of the maintenance work, while men spent more time on productive roles.  But, of course, this division of labor has changed over time and will continue to evolve.  

The time left over from production and maintenance is free time or leisure.  Csikszentmihalyi notes that our free time is divided into three major sorts of activities.  The first is media consumption, consisting mostly of watching television and surfing the internet.  The second is conversation.  The third is hobbies such as making music or art, engaging in sports and exercise, and reading.  Interestingly, Csikszentmihalyi does not specify how he would categorize service and volunteer work or being involved in a spiritual community.  Is this work or leisure? 

I think Csikszentmihalyi’s poetic summary of how we spend our days is worth sharing.

These three main functions–production, maintenance, and leisure–absorb our psychic energy.  They provide the information that goes through the mind day after day, from birth to the end of life.  Thus, in essence, what our life is consists in experiences related to work, to keeping things we already have from falling apart, and to whatever else we do in our free time.  It is within these parameters that life unfolds, and it is how we choose what we do, and how we approach it, that will determine whether the sum of our days adds up to a formless blur, or to something resembling a work of art.

 

I love that last thought: Will the sum of our days add up to a formless blur, or to something resembling a work of art?

One of the common symptoms of depression is difficulty sleeping.  Now a new study suggests that curing insomnia in people with depression could double their chance of full recovery.  The New York Times reports that the trial conducted at Ryerson University “found that 87% of patients who resolved their insomnia in four biweekly talk therapy sessions saw their depression symptoms dissolve after eight weeks of treatment, either with an antidepressant drug or a placebo pill–almost twice the rate those who could not shake insomnia.”

The therapy used to treat insomnia was cognitive behavioral therapy (CBT).  The therapist works with clients to help them establish optimal sleep habits.  Below are some specific behavioral changes that CBT promotes:

Keep a consistent bedtime and wake-time.  Our bodies get used to going to bed and getting up at certain times.  Disrupting this internal rhythm, by excessive napping, staying up late, or sleeping in is a recipe for insomnia.

Avoid caffeine after noon.  The stimulatory effects of caffeine stay in your system several hours after intake.

Get regular exercise. Studies show that exercise improves sleep quality.

Keep your bedroom cool.  Our bodies’ temperature decreases when we sleep.  A cool sleep environment mimics this activity.

Take time to calm your mind before bed.  Dedicate 30-60 minutes before bedtime to something that relaxes you.  A warm bath, a pleasurable novel, meditation, etc. Doing this will not only help you get to sleep, but improve your sleep quality.  Avoid bright lights from your computer, phone, or television since this simulates the activating effect of the sun.

Don’t clock-watch.  If you get up during the night, avoid looking at what time it is.  This will likely cause anxiety about how much time you have left to get the sleep you need.  Revving up your system with such thoughts will make it even harder to get back to sleep.  So hide your alarm clock in a drawer or cover it with a book.

Limit alcohol before bedtime. Although alcohol may help you get to sleep, it impairs sleep quality and makes you more likely to wake up during the night.

Keep your bedroom dark and quiet.  

Use your bed only for sleep and sex.  You want to condition your mind to associate your bed with sleep, not reading, thinking, talking, and other activities.

If you wake up during the night and can’t go back to sleep, get up and do something relaxing.  Don’t try to fight your way back into unconsciousness.

Keep a Sleep Journal. Write down what time you go to bed every night, what time you tried to fall asleep, how long it took, how many awakenings you had, and what time you woke up.  Keeping track of this information will allow you to monitor your progress and understand what factors help you get the sleep you need.

Many robust studies show that cholesterol-lowering medicines called statins decrease the risk of having a heart attack or stroke.  Indeed, the widespread use of statins in people with or at risk for heart disease is at least partially responsible for the decreasing mortality from heart disease over the past few decades.

But almost nothing good in life or medicine comes without a cost.   With statins, the most common problem is muscle aches.  Some studies have estimated that as many as 20% of people on statins experience this symptom, which usually goes away when the medicine is stopped.  This issue can also be effectively addressed by lowering the dose or changing to a different statin.

A more recent concern about statins is the announcement last year by the FDA that a small number of people on statins report experiencing memory loss, forgetfulness and confusion.  The FDA reported that “in general, the symptoms were not serious and were reversible within a few weeks after the patient stopped using the statin.”  Today the Annals of Internal Medicine published a systematic review of available evidence on the relationship between statins and cognitive impairment.   

Researchers searched PubMed, Embase, and the Cochrane Library through October 2012 for randomized, controlled trials (RCTs) and cohort, case-control and cross-sectional studies that assessed cognition in patients taking statins. They also searched FDA databases from January 1986 through March 2012 to identify reports of adverse events related to statins.

Based on this extensive analysis, the study authors concluded that the currently available evidence does not support the theory that statins have negative cognitive effects.  They did note, however, that no randomized controlled trials have yet been conducted to investigate this issue.  Thus, they concluded that “larger and better-designed studies are needed to draw unequivocal conclusions about the effect of statins on cognition.”  

Here is a link to the review which received no industry funding.  And here is a Medscape article on the study.

About two weeks ago, my wife looked over at me in disgust as I spit a large volume of saliva into a plastic test tube just before we went to bed.  I had recently received a testing kit from a company called 23andMe, which for $99, conducts a comprehensive analysis of your DNA. 

I first learned about this kind of thing a few years ago reading Francis Collins’ book The Language of Life:  DNA and the Revolution of Personalized Medicine.  In the introduction, Collins describes how he submitted his DNA to 23andMe and two other companies offering complex DNA analysis.  Learning he had a higher than average risk of developing type 2 diabetes, he resolved to “go ahead with a long-postponed plan to contact a personal trainer and work harder at a diet and exercise program.”  He was also relieved to learn that he had a low risk of developing Alzheimer’s disease. 

Today when I received an email telling me my results were back I felt apprehensive about that component of what I would find.  As Collins writes in his book, the test for Alzheimer’s disease is “one of the strongest genetic risk factors yet identified, capable of increasing one’s risk by as much as eightfold.  And at the present state of medical research, there is nothing you can do about it, other than use the information to plan for the future.”  Ultimately, the desire to know quickly overcame any qualms I had about what I’d do with the information.  So when I pulled up to Jack  Brown Cleaners to pick up my clothes, I logged in to my 23andMe account through my iPhone.  Before receiving the results of my risk for developing Alzheimer’s and Parkinson’s disease, I was required to read a lengthy, informative warning about the implications of learning this information.  While appreciating the company’s attempt to act responsibly, I quickly scrolled down the page looking for the results, holding my breath as I did so.  Then I saw it:  My risk for getting Alzheimer’s between the ages of 50-79 was 4.3% compared the 7.2% average. I felt like I’d just received a good grade on my report card, except that I had done nothing to deserve it.

I did find that I have a higher than average risk of developing certain health problems.  Thankfully, most of these are conditions that can be screened for and treated.

I also learned that my ancestry is pretty homogeneous:  96.6 percent European, with 2.7 percent East Asian and Native American thrown in just to spice things up a little bit.

Perhaps because the tests did not reveal any very concerning abnormalities, I have a feeling that this report on my DNA is something that I will soon largely forget.  Nonetheless, it was an enlightening preview of the kind of personalized, gene-based analysis that will likely become a common component of health care in coming years.

Allie Brosh is a writer whose skillful storytelling and wonderful comic art have earned her blog, Hyperbole and a Half, an enormous following.  In a moving interview on NPR’s Fresh Air, she provides a revealing portrait of depression by sharing her own experience with this condition.  When asked to describe her depression, she says:

The first part was all sorts of feelings and a lot of self-loathing. … And then slowly it transitioned to feeling nothing and feeling very detached and bored with everything because I couldn’t connect in a meaningful way to the things I enjoyed or the things around me. …

 

I’ve always sort of secretly thought of feelings as a weakness. I think growing up I always wanted to be someone tougher than I am, and so when I first started not having feelings anymore I thought, “I’m finally this person who doesn’t react. I’m not sensitive anymore.” I enjoyed that for a short time, especially when I hadn’t lost my feelings completely, where I just felt like I was emotionally very strong. And then once all of my emotions disappeared, I very quickly realized that emotions are the only thing that provide variation in your life.

 

I think there’s a common misconception that depression is about something or depression is sadness or some form of negativity. It can represent a sadness or a self-loathing, as the first half of my depression did. It sort of circled back on itself and made me dislike myself more because I was so sad, and I didn’t know why, and I felt like I needed a reason. … It took me a long time to figure out that something was broken on a fundamental level. There was no reason behind it; it was just the way things were.

 

One of Brosh’s most beloved blog posts is one she wrote about her experience with depression and Here is a link to it.

I have an instinct to be a kind of good-read evangelist, compelled to share whatever I’ve read that’s been interesting, inspiring, and/or enriching.  Here’s some of the best stuff I’ve come across lately.  

In the journal Nature, a young neuroscientist writes about being diagnosed with Parkinson’s Disease.  He recalls when he first knew that something was wrong.  He was only 36 years old when 

I was filling out a mountain of order forms for new lab equipment. After a few pages, my hand became a quaking lump of flesh and bone, locked uselessly in a tense rigor. A few days later, I noticed my walk was changing: rather than swinging my arm at my side, I held it in front of me rigidly, even grabbing the bottom edge of my shirt.

 

He writes that ever since his diagnosis, 

I have had a different relationship with the brain — my scientific focus for the past 20 years. I now know what it is like to have a brain disorder and can explore its manifestations first hand. Take the very peculiar symptom known as ‘freezing’. Occasionally, when I attempt to lift my hand it well … won’t. Notice that I didn’t say can’t. There is nothing wrong with my arm. It is still strong and capable of moving, but I have to put effort, even focus, into getting it to move — frequently to such a degree that I have to pause whatever else my brain is doing (including talking or thinking). Sometimes, when no one else is around, I use my other hand to move it.

 

As a neuroscientist, it is simultaneously fascinating and terrifying to be directly confronted with the intersection of the neurophysiological and philosophical constructs of ‘will’. The way my mind and body do battle forces me to reconsider the homunculus, a typically pejorative (among neuroscientists) caricature of a little man pulling levers inside our heads, reading the input and dispatching the output. Virtually all that we know about how the brain is organized belies this image, and yet there is a dualism to my daily experience.

 

I keep coming across the subject of music and the brain lately.  For my younger son with autism, a music class has brought to life hitherto hidden parts of his precious mind.  And a study from George Mason University “found that nursing home patients with dementia who sang along with show tunes did better on cognitive tests than counterparts who just listened to the music.”  

Over a four-month study, the mental performance of patients who took part in regular group singing sessions improved compared with others who just listened.

In the sessions, patients were led through familiar songs from The Sound of Music, Oklahoma, The Wizard of Oz and Pinocchio.

The sessions appeared to have the most striking effect on people with moderate to severe dementia, with patients scoring higher on cognitive and drawing tests, and also on a satisfaction-with-life questionnaire at the end of the study.

All of this makes me want to read Oliver Sacks’ Musicophilia, his book exploring the relationship between music and the brain.  

These days many people seem to love to hate Malcolm Gladwell.  But I’m reading his new book David and Goliath and finding it so very fun and thought-provoking.  Its theme is that sometimes what seem like weaknesses and disadvantages can become great strengths.  He wrote a great essay in the New Yorker in 2009 exploring this idea.

Tonight my 5 year old son chased me around the house for a very long time.  We circled tables, climbed over couches, and tumbled across beds.  As he ran after me with all of his energy, he laughed with rapturous delight.  And I got to thinking about the emotions of children.  Their feelings are like bright colors, while those of us adults are so subtle we often hardly realize their presence.  

Why do adults stop having fun?  Is it because we have responsibilities to which care-free kids are oblivious?  Perhaps.  But I live near some tennis courts and when I watch people play, they look deadly serious, as if their lives are hanging in the balance.  In those moments, these adults are not working for their livelihood or engaged in some other activity essential to their survival.  They are playing a game and yet it takes hitting a spectacular shot to bring a smile to one of their faces.  And I am probably the same way when I play.

Is children’s ability to more easily delight in life due to its freshness and novelty?  Do adults get bored with what we’ve become used to?  I think that is part of the answer.   

There are also the expectations we adults place upon ourselves and each other.  In childhood you are supposed to discover and be surprised by what you find.  In contrast, we adults take pride in not being caught off guard.  We are wise to the world.  Our humor is that of wry irony.   

Does being an adult require leaving the frivolous fun of childhood behind?  Or should we cultivate a space in our days to do nothing but delight in the miracle of our existence?

As many of you know, about 1 year ago my younger son was diagnosed with autism.  Before that time, I had brief encounters with children on the autism spectrum during my pediatric rotations of medical school.  But my first sustained exposure to it was with Jack Robbins, the son of my wife’s cousins Brent and Carla.  We lived in the same neighborhood with them when they received Jack’s diagnosis.  Since then we have witnessed how they’ve given all of themselves to provide him with the best life possible.  Their courage and love serve as an inspiring example for us in our experience with our son.  

In recent days, Jack has become a bit of a celebrity. His family realized that what they thought were meaningless sounds were actually Jack singing Katy Perry’s song “Roar.”  This was the first time he had meaningfully put words together on his own.  Carla and Brent put the video on YouTube and it’s become a viral hit with features on Yahoo and Huff Post.  Here is a link to Carla and Jack being interviewed on their local TV station.  

You will consider it time well spent if you listen to Terry Gross’ interview with astronaut Chris Hadfield.  Here is a link to the NPR website with the full interview, key excerpts, and a beautiful video of Hadfield singing his own version of David Bowie’s “Space Oddity” from outer space.  

He describes what it is like to be in space outside of the shuttle or space station. 

The contrast of your body and your mind inside … essentially a one-person spaceship, which is your spacesuit, where you’re holding on for dear life to the shuttle or the station with one hand, and you are inexplicably in between what is just a pouring glory of the world roaring by, silently next to you — just the kaleidoscope of it, it takes up your whole mind. It’s like the most beautiful thing you’ve ever seen just screaming at you on the right side, and when you look left, it’s the whole bottomless black of the universe and it goes in all directions. It’s like a huge yawning endlessness on your left side and you’re in between those two things and trying to rationalize it to yourself and trying to get some work done.

When Terry Gross asks for him to relate an especially anxiety-provoking moment from his time in space, Hadfield recalls once suddenly becoming blind in one while working.  He realized some liquid had somehow entered his eye.  He tried to work through the pain, but rather than falling to the ground, the tears streaming from his eyes migrated to the other eye, leaving him temporarily blind.  This prompts him to describe what it feels like to close your eyes in space.

What does it feel like when you close your eyes when you’re weightless? Normally on Earth when you close your eyes you can feel your feet on the floor or your rear end on your chair or something and that gives you a sense of up. You can balance with your eyes closed, you can walk with your eyes closed because of all of the external references. When you’re weightless and you close your eyes it’s as if you just stepped off a cliff into complete blackness and you’re falling forever, so the perception of that is really odd. You can do it as like a thought experiment and instead of closing your eyes and thinking that you’re just floating, close your eyes and picture that you’ve just stepped off the Half Dome in Yosemite and are now falling into the blackness, and it’s interesting to see how your body reacts to it.

One of things that struck me in listening to the interview is that Hadfield never seemed to lose his awe for what he experienced in space.  Here he is talking about doing a spacewalk amid the Southern Lights.

I was coming across the Indian Ocean in the dark. I was riding on the end of the robot arm … [and] I thought, “I want to look at Australia in the dark,” because everyone lives along the coast, starting with Perth and across and it’s like a necklace of cities. So I shut off my lights, and I let my eyes completely adjust to the darkness, but as we came south under Australia instead of seeing just the lights of the cities of Australia we flew into the Southern Lights. Just like the Northern Lights they erupt out of the world and it’s almost as if someone has put on this huge fantastic laser light show for thousands of miles. The colors, of course, with your naked eye are so much more vivid than just a camera. There are greens and reds and yellows and oranges and they poured up under my feet, just the ribbons and curtains of it — it was surreal to look at, driving through the Southern Lights. …

To me it was taking time to notice something that is almost always there but that if you didn’t purposefully seek it out you would miss — and that is our planet and how it reacts with the energy from the sun and how our magnetic field works and how the upper atmosphere works — what it really is, is just beauty.

Hadfield also relates the effects of space and space travel on the astronauts’ bodies.  He developed osteoporosis, or thinning of the bones, a condition I often see and treat in my patients.  Thankfully, this condition at least partially reverses as an astronaut spends time back on Earth.  Scientists are seeking to understand how this happens and perhaps someday apply this knowledge to preventing hip and vertebral compression fractures in us regular, non-astronaut folks.  His description of the punishing collision astronauts endure when they land on Earth left me in awe of their bravery and toughness.

When Hadfield details how astronauts learn to cope with the many fears that their work evokes, it reminded me of cognitive behavioral therapy (CBT).  You confront your fears by thoughtfully planning for the realities you will face. 

Half of the risk of a six-month flight is in the first nine minutes, so as a crew, how do you stay focused? How do you not get paralyzed by the fear of it? The way we do it is to break down: What are the risks? And a nice way to keep reminding yourself is: What’s the next thing that’s going to kill me? And it might be five seconds away, it might be an inadvertent engine shutdown, or it might be staging of the solid rockets coming off. … We don’t just live with that, though. The thing that is really useful, I think out of all of this, is we dig into it so deeply and we look at, “OK, so this might kill us, this is something that would normally panic us, let’s get ready, let’s think about it.” And we go into every excruciating detail of why that might affect what we’re doing and what we can do to resolve it and have a plan, and be comfortable with it. …

It’s not like astronauts are braver than other people; we’re just meticulously prepared. We dissect what it is that’s going to scare us, and what it is that is a threat to us and then we practice over and over again so that the natural irrational fear is neutralized.

At the end of the interview, Terry Gross asks Hadfield about his own spirituality and how his experience in space has influenced it.  

The big pervasive feeling onboard looking at the Earth [from space] is one of tremendous exquisite privilege that it exists. … But I think what everyone would find if they could be in that position — if they could see the whole world every 90 minutes and look down on the places where we do things right, and look down where we’re doing stupid, brutal things to each other and the inevitable patience of the world that houses us — I think everybody would be reinforced in their faith, and maybe readdress the real true tenets of what’s good and what gives them strength.