Sunday, May 31, 2020

The COVID Stress Scales



Danger. Deprivation. Xenophobia. Contamination. These are some of the fears related to COVID-19. Scores of COVID questionnaires have popped up recently to assess fear, anxiety, stress, and depression related to the novel coronavirus and its massive disruption to daily life. Most are freely available for use as research tools, but few have been validated and peer reviewed.

The COVID Stress Scales (CSS) developed by Taylor and colleagues (2020) were recently published in the Journal of Anxiety Disorders. The authors propose a new COVID Stress Syndrome, and present evidence that the CSS subscales are intercorrelated (which is suggestive of a “coherent” condition).

To develop the CSS, representative samples of people in Canada (n=3,479) and the US (n=3,375) completed a 58-item survey on Qualtrics. Factor analysis identified five subscales...
  1. COVID danger and contamination fears
  2. COVID fears about economic consequences
  3. COVID xenophobia
  4. COVID compulsive checking and reassurance seeking
  5. COVID traumatic stress symptoms

...and limited the questionnaire to 36 items. I'll note that “fears about economic consequences” were restricted to a lack of supplies at grocery stores and pharmacies, rather than fears of crushing debt, eviction, hunger, and homelessness because of unemployment.

One can view this new syndrome as a context-related extension of OCD contamination fears, compulsive checking, and health anxiety (preoccupation with the possibility of serious illness). Indeed, convergent validity was confirmed by showing correlations with established measures of those conditions. Unique aspects of COVID Stress Syndrome not seen in other diagnoses include fears that grocery stores would run out of toilet paper,1 and especially a fear of foreigners (xenophobia). Xenophobia is promulgated by politicians and amplified by bad actors on social media and IRL. I don't think xenophobia (specifically, anti-Asian sentiment) is on the list of symptoms for any DSM diagnosis.

Basically, it seems that a coherent condition called COVID Stress Syndrome would require racist beliefs and a fear of people who are Chinese, Chinese-American, or Chinese-Canadian.2 The prevalence of COVID Stress Syndrome in their Canadian and American samples was not specified, nor was the cut-off point for such a diagnosis. Plenty of Americans are xenophobic, but they don't have bad dreams about coronavirus.

In an editorial, Taylor and Asmundson (2020) said:
It appears that people who develop COVID Stress Syndrome have pre-existing psychopathology, particularly pre-existing high levels of health anxiety and obsessive-compulsive checking and contamination symptoms. It remains to be seen whether the COVID Stress Syndrome is simply an adjustment disorder, abating once the pandemic is over, or whether it will become chronic for some individuals.

So much about COVID-19 “remains to be seen”, and this level of uncertainly is a major source of anxiety on its own.


Footnotes

1 The toilet paper question just missed the cut...included were worries about water, cleaning supplies, medications, etc. The original version also included “worry about looting & rioting.”

2 One could really say East Asian people more broadly. Or actually, anyone considered “Other”.


References

Taylor S, Asmundson GJG. (2020). Life in a post-pandemic world: What to expect of anxiety-related conditions and their treatment. J Anxiety Disord. 2020; 72:102231.

Taylor S, Landry CA, Paluszek MM, Fergus TA, McKay D, Asmundson GJG. Development and initial validation of the COVID Stress Scales. J Anxiety Disord. 2020; 72:102232.


Additional Scales (from a compendium of COVID questionnaires on Google docs)

Epidemic-Pandemic Impacts Inventory Racial/Ethic Discrimination Addendum (15 items).

COVID-19 Stressful events (13 items)

COVID-19 Concerns (9 items)

Coronavirus Stressor Survey (9 items)

CRISIS (The CoRonavIruS Health Impact Survey V0.3) - more here

Covid-19 Staff Needs and Concerns Survey (18 items)

COVID-19 Family Stress Screener (10 items)


ADDENDUM (June 1, 2020): MORE!

UCLA Brief COVID-19 Screen for Child/Adolescent PTSD

Fear of COVID-19 Scale (10 items)
Ahorsu DK, Lin CY, Imani V, Saffari M, Griffiths MD, Pakpour AH. The Fear of COVID-19 Scale: Development and Initial Validation. International Journal of Mental Health and Addiction. 2020 Mar 27:1-9.
Coronavirus Anxiety Scale (5 items)
Lee SA. Coronavirus Anxiety Scale: A brief mental health screener for COVID-19 related anxiety. Death Studies. 2020 Apr 16:1-9.




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Monday, April 27, 2020

The Noble Prize for a Life Well-Lived

In honor of a beautiful and affectionate cat.



RIP, beloved Max
April 19, 2003 April 24, 2020


So much acrimony and confusion and death...


In the true meaning of the word, Max lived a noble life.

“But he was just a cat,” you say. Yes, that's true. But he was loving and kind and selfless until the very end. He was a wonderful companion, and a great source of comfort to me (especially after my partner died in October 2018).



Max and Sandra
Feb. 2, 2017


He was cherished by previous caretakers and human friends, who showered him with gifts.



Christmas Eve, 2017




Christmas Day, 2018


But now he's gone and life continues, filled with acrimony and confusion and death.


The Very Real Threat of Trump’s Deepfake by David Frum

While reading this article in The Atlantic, I was immediately struck by how a cat could hold human values and respect human life to a greater extent than the President of the United States. Sounds absurd, doesn't it? But not really. Not any more. Here's David Frum:
April 26, 2020, was an especially manic day in the presidency of Donald Trump.  ...  something was gnawing at him. Perhaps his business troubles were weighing on him.  ...  Or perhaps Trump was still seething at the widespread ridicule of his press conference of April 23, when he suggested using disinfectant “by injection.” Or perhaps something else had shifted his mood from its usual setting of seething aggrievement to frothing fury.

Whatever the cause, between early afternoon and near 9 o’clock eastern time, Trump fired off a sequence of crazy-even-for-him tweets and retweets. He demanded that reporters be stripped of the “Noble prizes” they had supposedly been awarded for their reporting on Trump scandals, apparently conflating them with the Pulitzers—and then pretended that his misspelling of Nobel had been intentional.  ...  He retweeted an increasingly wild and weird range of supporters’ Twitter accounts.

Trump shows no compassion for the suffering around him, no sympathy for the families devastated by the loss of their loved ones, and only hollow praise for the health care workers, the bus drivers, the home delivery drivers, the grocery store clerks, and the sanitation workers who put their lives on the line every day.

Eternal optimists say “we're all in this together” while sitting at home on Zoom meetings, placing endless orders on Amazon, and fretting about their sourdough starter. I'm only marginally better, but I realize I'm privileged. {I've tried to help financially contributing to homeless organizations, a fund for unemployed hourly workers, bookstores, museums, etc.}

And obviously I'm way more pessimistic.

How does this rant honor my cat??


Case History

Max was diagnosed with intestinal lymphoma in August 2019 at the age of 16. He also had a murky ailment that made it difficult for him to eat (“his tongue is inflamed” or later, “he has a mass at the base of his tongue”), but the true cause was never confirmed. He was prescribed oral chemotherapy pills three times a week and an oral steroid (prednisolone syrup) twice daily. I declined the chemo pills, opting for quality of life for both of us. Max's oral steroid became unworkable after four doses.

This was not fair, especially after my wife suffered through Stage 4 cancer for a year.

Another vet started bimonthly / monthly injections of Depo-Medrol (methyl prednisolone) to reduce the inflammation in his mouth, and as a partial treatment for his lymphoma. It worked wonders (for a while). He ran up and down stairs, played with his toys, and jumped over the red chair!

He started getting worse in January. His weight was down to 9.5 lbs (4.3 kg), a 2 lb loss in two months. He was prescribed buprenorphine as needed for pain and transdermal mirtazapine as an appetite stimulant. My quest for palatable foods became more and more challenging. I spent hours walking the aisles of pet superstores.




ADDENDUM (April 28, 2020): How could I forget his stint on an all-chicken diet (KFC no skin of course or grocery store roasted chicken), which he enjoyed for a few weeks until he could no longer eat chicken...

His last regular appointment was March 9. And then the shelter-in-place orders were issued.


Pet Care During the COVID-19 Pandemic

Max's condition was getting worse. Depo-Medrol was less and less effective, and he needed injections every two weeks. The veterinary practice enacted stringent measures to protect its essential workers. In-person appointments were reserved for animals showing signs of extreme pain and suffering. Virtual Vet was used for consults and for recommending treatment plans. We had an appointment on March 27. Max was prescribed his usual meds. I picked them up curbside (calling upon arrival) and paid via contactless transaction. I watched a helpful YouTube video and then administered his subcutaneous injection of Depo-Medrol.

By April 16, I had grown desperate. The poor fellow was having a severe bout of diarrhea that lasted for days. I tried scheduling a Virtual Vet appointment and called for a refill of buprenorphine. Finally I got through and picked up more meds the next day. These included oral metronidazole, a hideously bitter and distressing medication that made his mouth foam.

He improved slightly. I was up for hours in the middle of the night, trying to coax him to eat. Some "meaty morsels" and "flaked' varieties were palatable for their gravy. I got out the food processor and whirled them into a very soft format, which he mostly rejected. “But you were just licking the gravy off these meaty morsels!” I told him. Finally I came up with a winning concoction. But this was only a palliative interlude before the inevitable.

Then I realized I'd established a Palliative Care Unit for my cat.

On April 23, I could no longer care for him myself. I brought him to the ER for severe dehydration. He had blood work and an "incidental" ultrasound, neither of which he'd had since his initial diagnosis. The results were devastating. Anemia due to suspected blood loss from his GI tract. Elevated white blood cell count (no surprise). Emerging diabetes mellitus (e.g., glucose in his urine), a known side-effect of steroid treatment. He weighed only 3.8 kg (8.4 lbs).

Most concerning was “free fluid in the abdomen and what looks like masses, possibly lymph nodes and fluid distended bowel loops.”  /  “If he does not improve in the next few days to a week, humane euthanasia should be considered given what we know.”

I picked him up and brought him home. He hated car rides much more than actual visits to the vet or treatments of any sort. Veterinary staff all loved him. The report from his ER doc even said, “Max is a very good cat.”

He was withdrawn for several hours. Then he got over it and sat on my lap in the red chair, purring. Here he is, as beautiful as ever.




The change in Max from that day to the next was astounding. He couldn't hold his head up any more. He tried to drink some water but couldn't manage to do it. I don't think any additional intervention would have improved his condition. I didn't want to wait any longer and had to act quickly.

I was fortunate to find a caring and compassionate vet who made house calls, and wasn't ridiculously overboard on COVID-19 restrictions. Some said they wouldn't enter the main living area — it had to take place outside or in the garage or in their mobile van. But Max was in a comfortable and familiar environment, at least. And then he didn't have to suffer any longer.


Max was such a sweet, loving, affectionate cat. He sought me out until the end, until his very last day when he was too weak to do so.




This is another story of love, and of loss. How we care for the most helpless among us is an enduring sign of our humanity.



MORE CAT PHOTOS below.

Read more »

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Friday, March 27, 2020

The "Six Feet Away" Rule is Woefully Inadequate

“...the rapid international spread of COVID-19 suggests that using arbitrary droplet size cutoffs may not accurately reflect what actually occurs with respiratory emissions, possibly contributing to the ineffectiveness of some procedures used to limit the spread of respiratory disease” (Bourouiba, 2020).

Dr. Lydia Bourouiba has published an important paper that updates 1930s-era models of respiratory infectious disease transmission based on the size of droplets emitted when a person breathes or talks or coughs or sneezes. Large droplets were thought to contaminate the area immediately surrounding an infected individual, because they settle before evaporating. In contrast, small droplets evaporate quickly and form residual particulates, or aerosols. However, the classification of droplet size (and therefore the mode of transmission) is not based on modern science. Yet this scheme still informs public health policy to this day.

The figure above shows a Multiphase Turbulent Gas Cloud From a Human Sneeze (Bourouiba, 2020). The puff trapped droplets of many sizes and carried them quite a long distance (23-26 feet!) while evading evaporation. Droplets that settle can contaminate surfaces. Aerosols may persist in the air for hours, depending on ambient temperature and humidity, as well as prevailing winds or airflow of indoor ventilation systems.1

Watch the educational video showing Respiratory Pathogen Emission Dynamics and you will be truly horrified!!

This newer understanding of respiratory emission dynamics has implications for mask and respiratory design, social distancing recommendations, and other public health interventions during and after the COVID-19 pandemic.”


Speaking of masks, droplets are visible after sneezing into a surgical mask (Granville-Chapman & Dunn, 2007). Although the paper was a light-hearted study appearing in the Christmas issue of BMJ, the spread of respiratory droplets is no longer a joke.




Footnote

1 A recent report by investigators in Singapore suggested the possibility of significant environmental contamination (including air vents) in the hospital rooms of SARS-CoV-2 patients (Sean Wei Xiang Ong et al., 2020). The air samples themselves were negative, however. And standard cleaning  procedures effectively decontaminated surfaces.


ADDENDUM (March 28, 2020): @SamWangPhD rightfully pointed out that sneezing is not a symptom of coronavirus-19 infection. My initial reply was that an asymptomatic individual could be strolling through a park and sneeze due to allergies. On a more scientific note, it's true that the COVID-19 symptom of coughing isn't as violent as sneezing. However:

"droplets of diameter 30 µm can have a horizontal range of up 2.5 m away from the cougher due to cloud dynamics."






References

Bourouiba L (2020). Turbulent Gas Clouds and Respiratory Pathogen Emissions: Potential Implications for Reducing Transmission of COVID-19. JAMA March 26.

Granville-Chapman J, Dunn RL. (2007). Excuse me! BMJ 335:1293.

Ong SW, Tan YK, Chia PY, Lee TH, Ng OT, Wong MS, Marimuthu K. (2020). Air, surface environmental, and personal protective equipment contamination by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) from a symptomatic patient. JAMA March 4.


Thanks to @midendian and @perrymetzger for alerting me to this article.

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Sunday, March 15, 2020

Coping with COVID-19: Resources for Managing Mental Health



  • Don't shake hands. 
  • Maintain a distance of 6 feet. 
  • Don't touch surfaces that could contain respiratory droplets. 
  • Don't touch your face. [It's very hard to not touch your face.]

When your leaders fail to follow the most basic guidelines for preventing the spread of COVID-19, trust and confidence are eroded.





The coronavirus pandemic has raised (nearly) everyone's level of anxiety and stress. Rampant panic buying, superstore shelves emptied of toilet paper, selfish people hoarding hand sanitizer. Worries about elderly relatives, jobs, money, health care costs.

If you already have a serious anxiety disorder, how can you possibly cope in the current climate of fear and uncertainty? What if one of the core recommendations to help prevent disease transmission is the very pathology you've worked so hard to overcome?


Obsessive-Compulsive Disorder

Contamination fears cause many individuals with OCD to compulsively wash their hands. Meanwhile, the directive to frequently wash your hands with soap & water for 20 seconds could be quite triggering for some. The International OCD Foundation has provided helpful resources:

Resources for the OCD and related disorders community during the COVID-19 outbreak
In times like these, what the experts are recommending temporarily becomes our new normal. This may mean that you need to make some changes to your treatment, including which exposures you do, when you do them, how frequently, etc. What might normally be considered a “baseline” for people with OCD to aspire to should shift to match the recommended guidelines for as long as those guidelines are in place. A good suggestion would be to talk about the guidelines with your treatment team at your next session and go over how, if at all, your plan might change for the near future.

It is important for all of us in the OCD and related disorders community to remember that this is temporary, and understand that it may feel uncomfortable. You are not going backwards in your recovery journey because the baseline changes. These troubled times will end, and you will keep doing your best in the meantime.
They also provide recommendations for what you should and should NOT do.

Examples of What to do:
  • set a time limit of 5 minutes per day for reading news and updates from trusted sources
  • take breaks and allow yourself to do things you enjoy
  • consult your treatment team
Examples of What NOT to do:
  • avoid the temptation to learn “everything” about COVID-19
  • do not excessively wash your hands
  • don’t let “social distancing” rob you of your support networks seek online connections

Generalized Anxiety Disorder

Tips from Health Canada:

What to do if you’re anxious or worried about coronavirus (COVID-19)
  • Be self-compassionate
  • Limit the news & unplug from social media
  • Stop talking about coronavirus
  • Protect yourself
...and more


Health Anxiety
The constant new barrage of developments regarding the current outbreak of COVID-19 can cause particular challenges for people living with anxiety, stress and/or anxiety-based depression especially those that have health anxiety and/or OCD.
Suggestions from Anxiety UK:

Health and other forms of anxiety and coronavirus
  • Firstly, try to limit your exposure to news sources which are covering the coronavirus issue as this only serves to feed fear.
[an ongoing theme]


COVID-19 and anxiety – part 2
  • For those that have anxiety disorders such as claustrophobia, agoraphobia and panic disorder, some of the potential management strategies that are being discussed in relation to COVID-19 might give rise to specific challenges and thoughts of ‘feeling trapped’.
  • Fearing being ‘out of control’ and ‘being unable to tolerate uncertainty’ are actually common characteristics of many anxiety disorders and therefore it stands to reason why so many individuals with pre-existing anxiety may now be seemingly experiencing an exacerbation of their anxiety as a result of COVID-19.
[see Intolerance of uncertainty, appraisals, coping, and anxiety: The case of the 2009 H1N1 pandemic]


Post-Traumatic Stress Disorder

Suggestions from the National Center for PTSD:

Managing Stress Associated with the COVID-19 Virus Outbreak
  • Increase Sense of Safety 
  • Stay Connected
  • Cultivate Ways to be More Calm
  • Improve Your Sense of Control and Ability to Endure
Those who have been faced with life-threatening situations recommended the following strategies:
  • Quickly recognize, acknowledge, and accept the reality of the situation.
  • Make a plan for dealing with feelings of being overwhelmed or overly distressed.
  • Combat unhelpful emotions by using distraction or staying busy—both mentally and physically.
  • Avoid impulsive behavior.
  • Increase positive coping behaviors that have worked in the past.
  • Shift negative self-statements to statements that allow you to function with less distress.
...and more


Managing Healthcare Workers' Stress Associated with the COVID-19 Virus Outbreak
A strong service-orientation, a lack of time, difficulties in acknowledging or recognizing their own needs, stigma, and fear of being removed from their duties during a crisis may prevent staff from requesting support if they are experiencing stress reactions. Given this, employers should be proactive in encouraging supportive care in an atmosphere free of stigma, coercion, and fear of negative consequences.
[...this link has guidelines for a crucial segment of the population Heath Care Workers  — who may neglect their own self-care.]


Of Interest to Mental Health Professionals

Mental Health Concerns Arise Amid COVID-19 Epidemic
Experts studying the spread of novel coronavirus disease (COVID-19) are increasingly concerned about the psychological ramifications of the epidemic, particularly for older adults and medical staff working on the ground. The issue has been raised in several correspondence pieces published in Lancet Psychiatry.

Coronavirus on the inpatient unit: A new challenge for psychiatry

by Dr. Dinah Miller (contributor to the iconic and now-retired Shrink Rap blog)
. . .

COVID-19 represents a new challenge for the inpatient psychiatry unit. Some patients on an acute psychiatric unit may be agitated, uncooperative, or even violent, and it’s not hard to imagine the distress of anyone who has a patient spit on them as we’re all trying to remember not to shake hands. Inevitably, there will be patients who present for psychiatric admission with no respiratory symptoms, who are admitted and then become ill and are diagnosed with COVID-19. In the meantime, the potential is there for contagion to other patients on the unit, the hospital staff, and visitors to the unit.

Readers if you have any suggestions for helpful resources or personal coping strategies, feel free to comment here or on Twitter.

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Saturday, February 22, 2020

The City of Lost Engrams



I was travelling back in time to an unreal place when The City appeared again after a long absence. It had been 16 months since we’d been together, and The City was not pleased. A vivid image of the security lines at the airport ushered me out of town to continue my journey to The Place That Doesn’t Exist.

A diabolical entanglement known as time has stolen memories from their homes in the dentate gyrus, lateral amygdala, precuneus, and elsewhere. These engrams hold the key to the past and the future. Without them – and their mysteriously stored representations – “we are condemned to an eternal present.”

Dwelling in the present is the path to enlightenment – “…the only moment to be alive is the present moment.”1  There is no past and no future. The amnesiac icon H.M. was the perfect being.

And yet, avoiding the past makes everything seem unreal. So does avoidance of an unlivable present. Perhaps I am preoccupied with a future of Other Deaths. That, I am not ready for.

The dead are neglected and forgotten by other people because their windows of tolerance are closed to further mourning. Their lack of reinforcement negates my grief. The opportunities for systems consolidation2 are waning.

Time. Avoidance. Neglect. They all silence my memories of The City.

I've had hundreds of involuntary visual images appear in my mind's eye like photographs, and I've documented all of them.




The images visit me rarely these days. They must be forcefully shaken from their torpor.

My passport expired 6 months ago. I finally noticed this recently.



I used to be able to cry, but now I can’t cry even though I want to.


Engram Cells

This meditation on memory, loss, and memory loss was inspired by a recent review article on memory engrams (Josselyn & Tonegawa, 2020). An “engram” is the neural substrate for storing and recalling memories. Futuristic “Inception-like” experiments in mice have shown that conditioned fear memories (tone-shock or context-shock associations) can be deleted or “inserted” by manipulating a functionally-defined class of neurons known as engram cells.



A pink engram cell alongside a white nonengram cell (modified from Josselyn & Tonegawa, 2020). Within the hippocampus, dentate gyrus cells were filled with a tracer to examine cellular anatomy (white). Engram cells active during fear conditioning were engineered to express the red fluorescent protein mCherry, which appears pink (because of overlap with the white tracer).


A primary truism of neuroscience is that memory storage is mediated by structural and synaptic plasticity. If engram cells are dedicated to preserving specific memories, the next question is: how do you define “a memory”? Most rodent studies search for engram cells associated with memories like “this location = bad”. But what about engrams formed after learning a list of words? Memories of Tomato, Attic, PliersMotorcycle, etc. are presumably represented by overlapping/distinctive groups of engrams distributed across multiple brain regions. What about complex autobiographical memories, like what you did on your 21st birthday? The full day (and night) of festivities consisted of many different events tied together by their temporal proximity and autobiographical significance. Studies of event perception and segmentation (Zacks, 2020) are informative in this regard:
What is the relationship between event structure in perception and that in memory? There is strong evidence that the segments that are identified during event perception correspond to the representational units in subsequent memory. First, the boundaries themselves are remembered exceptionally well. ... Second, event boundaries tended to occur at points in time when many features were changing, and the participants remembered those points better.

Life Beyond Engrams

The development of an appropriate animal model to allow selective manipulation of the whole-brain engram associated with one “birthday event” (but not the others) seems remote. Likewise, the often-involuntary nature of autobiographical memory retrieval (Bernsten, 2010) — in my case, the spontaneous appearance of visual images associated with loss and grief — is not illuminated by current engram research. Nor is the feeling of self-alienation that occurs when those memories start to fade.


Footnotes

1 “Dwelling in the present moment
    I know this is a wonderful moment.”

   –Thich Nhat Hanh, Being Peace [PDF]

But the Present Moment usually isn't all that great,” I say.

2 Or contextual binding, depending on your degree of hippocampal dependence.


References

Berntsen D. (2010). The unbidden past: Involuntary autobiographical memories as a basic mode of remembering. Current Directions in Psychological Science 19(3):138-42.

Josselyn SA, Tonegawa S. (2020). Memory engrams: Recalling the past and imagining the future. Science 367(6473).

Zacks JM. (2020). Event Perception and Memory. Annu Rev Psychol. 71:165-191.


The Place that Doesn't Exist







I can’t remember the last time I was there. It seems like I was just there. I am always here.




All my lovers were there with me
All my past and futures
And we all went to heaven in a little row boat
There was nothing to fear and nothing to doubt

--Radiohead, Pyramid Song

(I can cry now)

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Thursday, February 20, 2020

02202020



New and exciting content will be available for you this weekend. Until then, please enjoy Lena Lovich and my four part series on money, religion, and numerology from 2008.


080808 (god is a number part 1)

01 1 01 1 01 (god is a number part 2)

3.14159265 (god is a number part 3)

7 (god is a number part 4)





You certainly do have a strange effect on me
I never thought that I could feel the way I feel
There's something in your eyes gives me a wild idea
I never want to be apart from you my dear
I guess it must be true
My lucky number's two

--Lena Lovich, Lucky Number

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Sunday, February 02, 2020

Netflix Neurology: Inside the Brain of Aaron Hernandez (for a few seconds)


from Dr. Ann McKee / Boston University


A recent addition to the Netflix “making a murderer” franchise is Killer Inside: The Mind of Aaron Hernandez. At the end of any such story, there is no single answer as to what “made” the murderer.

The story of Aaron Fernandez is still in the public eye because of his fame as a professional football player for the New England Patriots (2010-2012). He was so successful that he signed a 5 year, $40 million contract with the team in August 2012. His alleged involvement in a July 2012 double homicide came to light in 2014, after he had been charged with the June 2013 murder of his friend, Odin Lloyd. For the latter crime, he was found guilty and sentenced to life without parole. He was acquitted of the double homicide, but two days later he hanged himself with a bed sheet in his jail cell.

His brain was donated to the Boston University CTE Center. From extensive coverage in the New York Times and elsewhere, we already knew that the autopsy revealed extensive chronic traumatic encephalopathy (CTE).

If you hope to gain insight into repetitive head injury, brain pathology, and violent behavior from watching this documentary, you'll be disappointed. The 3-part series spent 5 minutes on CTE and 3 hours 15 minutes on everything else his childhood, violent father, hurtful mother, immense athletic talent, football career, ex-con friends, girlfriend and daughter, heavy drug use, street life, weapons collection, paranoia, alleged shootings, alleged same-sex relationships, arrests, murder trials, conviction, appeal, recorded jailhouse telephone conversations, outwardly professed homophobia, death by suicide, and numerous interviews with friends and former players.

Much of this material was pruient and unnecessary, especially the speculations about his hidden sexual orientation and how this might have fueled his anger.


Prosecution Considered a “Fear of Outing” Motive

This argument was preposterous and a rarity in the history of violence involving the LGBTQ community: Hernandez supposedly feared that his friend would reveal his secret life as a bisexual man, so he killed Lloyd to preserve his image as a hyper-masculine heterosexual man. This baffling obsession with sexuality is distracting and dangerous, as aptly explained by D. Watkins:
There's no evidence proving that Hernandez's sexuality made him a killer. So why is the newly resurfaced Hernandez conversation centered around his sex life? Probably because sex is juicy, forbidden and learning that Hernandez may have been gay provides the consumers with content for endless hours of gossip about what public figures do in their personal lives.
Fortunately, this argument was not allowed at trial.


The Potential Role of CTE Was an Afterthought

A Rolling Stone interview with director Geno McDermott revealed the project began as a 90 minute documentary initially presented at DOC NYC in 2018. Netflix was interested in expanding the doc into a multi-part series. The gay angle emerged when high school friend/lover Dennis SanSoucie agreed to an on-camera interview. Other additions included newly available recordings of prison phone calls, and a coda about CTE, the neurodegenerative disease that may be associated with repeated concussions in high-impact sports (in concert with other poorly delineated factors).

At the very end of Killer Inside, self-serving celebrity defense attorney Jose Baez spoke about the family's decision to donate Aaron's brain to the CTE Center at Boston University.



Dr. Ann McKee with the brain of Aaron Fernandez


Dr. McKee said Hernandez had very advanced disease for a 27 year old:
...and not only was it advanced microscopically, especially in the frontal lobes which are very important for decision-making, judgment and cognition, this would be the first case we've ever seen of that kind of damage in such a young individual.

I can say this is substantial damage that undoubtedly took years to develop. This is not something that is developed acutely or just in the last several years. I imagine these changes had been evolving over maybe even as long as a decade.



Then we see interviews with non-experts, who make causal connections between Aaron's CTE and his erratic, violent, tragic behavior. Worst of all is sleazy lawyer Jose Baez, who drummed up business for other players to sue the NFL under false pretenses (there is currently no way to accurately diagnose CTE in living persons).

Why didn't Aaron's brother, who grew up with the same abusive father and played football for many years, become a murderer? I'll let former NFL player Jermaine Wiggins have the last word:
My thoughts to people who think that CTE was somehow involved, I think that's an absolute cop out. There are thousands of former NFL players out there that might have dealt with concussions, I've dealt with them. So to use that as a cop out? I'm not... no, no. C'mon, we're smarter than that, people.”

Further Reading

Is CTE Detectable in Living NFL Players?
this 2013 post is still true today

Brief Guide to the CTE Brains in the News. Part 1: Aaron Hernandez

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