Tuesday, June 25, 2013


Recently, as if I don't have enough problems, I realized I had to make another psychiatric diagnosis on myself. Like several of my others, this newest one has not yet been described. You may remember that Freud, father of not so modern Psychiatry, was also a Neurologist. In the movie The Cameleon , a character played by Woody Allen, imitates a number of people. At one point, he was in Vienna, early 20th century, and was imitating Sigmund Freud. The character, in classic Woody Allen style states:  "The major difference between Freud and myself, is that Freud felt that 'penis envy' was a condition affecting only women"   The major difference between Freud and yours truly, who both enjoy inventing psychiatric disorders, is that he astutely noted these problems in other people, while I have consistently identified all of these previously unrecognized disorders in myself. Now, you may ask: how can someone with so many psychiatric conditions still function? The answer, I suspect, is some of these disorders may neutralize others, another novel psychiatric theory someone, with more time on their hands, should look into.

The Greeks and their phobias. I was always baffled by how such an advanced culture eventually collapsed. Given the number of phobias attributed to them, I think I figured it out. Googling  'phobias', one discovers there are almost 60 beginning with the letter (A). All are of Greek origin. If you multiply by 26 letters in the alphabet, and then by 50 or 100, likely the minimum number of people needed, to warrant naming the condition, you are approaching  the order of magnitude of a Greek city. Eventually EVERYONE must have been afflicted with an incapacitating phobia- and this I think adequately explains the end of Greek civilization.

For 30 years plus I have regularly dealt with patients who have a problem known as "ptosis". This refers to having a droopy eyelid, partially, sometimes totally, covering the pupil. It can be on one eye or both. It is a problem because it impairs vision, but additionally it is very often is a sign of a more serious disorder, such as an impending cerebral artery aneurysm rupture, or myasthenia gravis, a muscle problem that can affect the breathing muscles in short order, or lung cancer, or dissection (torn) carotid artery, which can imminently occlude and cause a big stroke. There are subtle characteristic differences of the 'ptosis' in each of these conditions and it is my job to figure it out before the catastrophe occurs. For decades I assumed the Greek origin of the word translated to "droopy". Recently I learned the correct translation is "falling". I love this clarification, the eyelid is not "drooping", it is "falling".

Last weekend I made my first return to the mountains. It has been almost a year since 'The Fall' and I was curious to see if I was able to descend the mountains at the usual speeds. I knew I was in adequate condition to do the 6 or so climbs we typically make. In preparation, I have been riding up and down the few nearly one mile descents with greater than 5% grade, we are lucky enough to have in our area. It was during these practice runs I discovered I have 'ptosiphobia', fear of falling, a previously unrecognized condition I believe needs to be added to the Handbook of Psychiatric disorders.

In the last several weeks, whenever I have made these relatively short descents, I have had a massively intense internal butterfly feeling in my gut, the likes of which I have not experienced since I was a kid. The peculiar aspect of this feeling was that it was not altogether unpleasant. While descending on these preparatory rides, I was very concerned the bike, or the rider, would fail. This  'ptosiphobia', as it has now been labeled, is distinctly different than acrophobia, the mundane fear of heights any amateur might experience. But why was this butterfly feeling not unpleasant?

I had this feeling often as a very young person. It may have been on the playground slide or swing, climbing a tree, or jumping out of window in a partially constructed house my friends and I were trespassing upon, before landing on a pile of leaves. It was the same intense abdominal butterfly sensation. I kinda liked it when I was young because I was always sure everything would  turn out OK.  As previously discussed in an earlier entry to the blog (see Purgatory) I did not buy into many of the proclamations in the Baltimore Catechism, (manifesto of Catholic training we were forced to memorize in elementary school) but I did like the concept of Purgatory and also " the Guardian Angel". I was sure I had a guardian angel, given the number of tight spots I had survived in our totally unsupervised play. That butterfly feeling was never associated with a bad consequence, thanks to my angel. Over time these feelings became a pleasurable part of my adventures. Now having rekindled that exact sensation, ptosiphobia, I intermittently feel like a kid again

On the day of the ride, the weather prediction was 0% chance of rain. We lathered up with sunscreen at the base of Blood Mountain (bad name all factors considered) but before we were half way up the 7 1 /2 mile climb it began to rain. My two friends, Andy and Chuck (see future entry on the NYC Century involving these guys) and I, had planned to ride at a slow warm up speed on the first climb. Soon we were wet. Of course we brought NO foul weather gear. Just  before the halfway mark, some guys passed us up. I was feeling great and felt I needed to pick.up the pace to keep warm as well as the other obvious shallow reason: Say you are 30 or so years old and riders pass you on a climb while you are warming up. If you then decide to catch and drop them, you are an asshole. But if you are over 60 and those same competitive juices still flow, with like reaction, it is my view, you're not! I know it seems like a double standard, but that's why we need and indeed have this good standard.

When we made it to the top,(after passing the other guys) we went into the small store for supplies Enough time elapsed to really cool off. When we started down the mountain I did not feel cold. As it turns out this was identical to the situation on the Grand Teton Pass 11 month ago, just prior to 'The Fall'. Major effort up, long wait, cool down, then descent. So what  happened?

I sat up to wind brake as much as possible and reached very conservative descending speeds of less than 40 mph. It did not take long for the ptosiphobia to kick in and this time I did not care for it. At just over 3 miles down, the same distance as on the Teton Pass incident, the bike started to wobble. I had recently convinced myself  the original  high speed death wobble before the Fall was a technical problem, something to do with the new bike fork or the front wheel slightly out of true. Last weekend I was on different bike. Luckily I had started to slow for the hard left turn to Wolf Pen Gap and I was able to pull off the road. Only when I was off the bike did I realize there was nothing wrong with the machine. The bike was wobbling on the descent because I was shivering, with no other sensation of feeling cold.

The physiological explanation for this is complicated but the short version is, when one is working hard climbing a mountain for 45 minutes, there is a tremendous amount of heat production in the body, dealt with by dilating the skin blood vessels, which releases heat. You have likely heard of marathon runners experiencing hypothermia a short time after their race. During the race, their core body temperature is 105 degrees ( As a med student, I did an experiment with Dr Robert Cade, inventor of Gator Aid, on marathon runners and this was discovered). After the race, the hormones and neurotransmitters responsible for the vasodilation are still circulating and the runner continues to lose heat. Since he/she is no longer creating heat, hypothermia ensues. The runner never feels cold, because coldness is sensed by the skin, which remains warm. Similarly, when one has an adult beverage or 3, and sits on a bench in Central Park in the middle of winter, the alcohol dilates the skin vessels and there is a nice sensation of warmth, occasionally accompanied by hypothermia and death!

The rest of the day went well, though I was never able to shake my fear of falling. A bike rider who fears speed is like a gourmand who fears truffles. This a problem that needs to be solved. My instinct is to hit it hard pharmocolgically with extra espressos. Drugs are the modern day solution to all pysch problems and may only be a weak patch. This time I might stick with my buddy Freud and look into psychotherapy. In the meantime at least I learned a skinny guy needs to immediately descend, once the mountain has been conquered