Introducing: Petri Dish Talk

I was delighted to stumble across a neuroscience blog that I hadn't seen before. Petri Dish Talk is run by Mohammed Rahman, a neurobiology researcher who now works in biotech, and who has also worked with drugs that affect the CNS such as Carbidopa and Divalproex, which are used to treat Parkinson's and Bi-polar disorder respectively.

Among the few posts currently published, Rahman discusses the tension between research and industrialisation in his first offering. He suggests that departmentalising projects will allow errors to slip through the net in spite of well-intentioned lab researchers, and that biotech industries should do more to ensure research and experimental integrity instead of following a business model that tends to be blinkered and short-sighted in regard to such concerns.

After a very brief and informative post on BOLD fMRI that excellently serves as an expanded definition of the term, he launches into a more detailed post about dendritic pruning within the wider issue of neuroplasticity. With decent illustrations, Rahman talks about how Long-Term Potentiation (LTP) is one of the many theories advanced to explain this adaptability of the brain and the mechanism by which the dendrites are pruned. He ends with looking forward to a future in which neuroplasticity will be vigorously studied and what it will have to say about our minds as a physical structure (and rightly so).

In the last two posts we are treated to a double-whammy that explains how meditation can bring about neurophysiological changes, by virtue of a 2007 PNAS paper on the neural correlates of attentional expertise in long-time meditation practitioners, that long-time (focused) experts tend to have specialised attentional networks with a simultaneous decrease in "chatter". In the second part, Rahman discusses a 2008 paper that discusses these changes: larger volumes of grey matter in the hippocampus and frontal cortex. On the face of it,this seems as natural as a professional athlete gaining muscle mass due to exercise, so in the same way an experienced meditator gains greater "strength" in certain neural circuits due to focus and concentration-oriented meditating.

Overall I think this is a good start for a blog and I was impressed with the quality of the information as well as the easily readable presentation. I'll definitely be looking forward to more contributions.

Foot Discovered In Baby Brain

Ok guys, for the first time I have something that's

NSFW!

Pity that isn't my own work, I'm lazy right now and nicked this via Joanne Manaster and KevinMD.com. Still, you gotta admit this story treads the fine line between Whoa and Pass-Me-That-Buckettttt. The Denver Channel is running a story about a medical first - a foot found growing inside a newborn's brain. I have nothing to add so I'm just gonna post the entire article here. Graphic image ahead, you have been warned:

COLORADO SPRINGS, Colo. -- A Colorado Springs family is part of one of the strangest cases in medical history.

Dr. Paul Grabb, a pediatric brain surgeon, said he was surprised when he discovered a small foot growing inside the brain of 3-day-old Sam Esquibel. "The foot literally popped out of the brain," Grabb told TheDenverChannel Wednesday.

The appendage threatened the newborn's life.

When Grabb performed the life-saving surgery at Memorial Hospital for Children in Colorado Springs, he was in for another surprise: he also found what appeared to be parts of an intestine in the folds of the infant's tiny brain, in addition to another developing foot, hand and thigh. "I've never seen anything like it before," Grabb told the Colorado Springs Gazette. "It looked like the breach delivery of a baby coming out of the brain."


Sam was delivered on Oct. 1, within hours of an ultrasound that showed what appeared to be a tumor developing in the brain of the fetus. Three days later, Grabb performed the surgery to remove it. The reason for the strange growth was not clear at first. It was thought to be a teratoma -- a congenital brain tumor composed of foreign tissue such as muscle, hair or teeth -- or a fetus in fetu, which is a developmental abnormality in which a fetal twin begins to form within the other.

Grabb, the only pediatric brain surgeon in southern Colorado, said that the formal pathology report identified the mass as a teratoma because of how perfectly formed the structure was but there is a fine line between that and the fetus in fetu. "So it's unclear if a fetal twin began to form within another," Grabb said.

Grabb said he sees a teratoma once every few years but it doesn't compare to Sam's. Teratoma tumors do not usually grow as complex as a foot. "You show those pictures to the most experienced pediatric neurosurgeons in the world, and they've never seen anything like it," Grabb told the Gazette. "This is completely abnormal."

Grabb said neurologically, Sam is expected to do well. Sam's brain tumor can come back so he will be monitoring that in the months and years to come.

Mom Says Baby A Miracle

Sam's mom, Tiffnie, told TheDenverChannel on Wednesday that her son is doing well but that she didn't want to appear on camera because she doesn't want to exploit her child and make him appear like a freak in the eyes of the world.

"This is our baby," Tiffnie explained, in tears.

She said when she first talked to the Gazette, she thought the story would only appear in the small-town paper. But it has circled the globe and she is getting calls from national and international media outlets. "I am so overwhelmed right now ... We've been bombarded with calls," Tiffnie said.

DenverChannel.com Reporter Jane Slater held the infant with the baby blue eyes and round face and said "he is the cutest baby I've ever seen." Sam's at a healthy weight -- as evidenced by his pudgy arms and legs -- which explains why family members call him the "Michelin Man," Slater said.

He was alert and happy, with a barely visible inch-long scar which stretched from his hairline to the top of his cheek. Sam is still recovering from the surgery and shows weakness on one side of his body and some trouble with higher-level eye functions. He is already undergoing rehabilitation.

Tiffnie had said that her pregnancy was easy and there were no signs of complications until the ultrasound on Oct. 1. She and her husband had given up on the idea of having any children after years of trying and then Sam was conceived. Tiffnie said she doesn't mind driving to the hospital every week or month for Sam's MRI and blood checks, considering that he is healthy and happy.

"It's a miracle," she said.

In the meantime, Grabb wonders about the possibilities for medical science. "How does the body form complete extremities? Who is to say we can't grow a heart, leg or foot?" Grabb asked the Denver Post earlier. "This could show a window of what's possible."

"It's always impressive to see these sorts of things but it's not as unsual as you would think," said Dr. Rich Gustafson, with Cherry Creek Pediatrics. "Teratomas can be found in abdomens or other parts of the body ... what made this case so unusual is how perfectly formed the foot was and being in the skull as well. Usually, it's a totally safe and benign tumor. Often, it gets picked up in adulthood but now with ultrasound, you're actually picking more up as they are getting fetal ultrasounds."

700-year-old Brain Found Preserved!

Evolutionary psychology tends to receive harsh criticism, and often rightly so. One of the main reasons for this is the severe lack of evidence for many of it's proposals given that the paucity of fossilised brains fails to bolster many a case. And it isn't even anyone's fault. That's just the way it goes sometimes, that the brain is a jelly-like substance that is subject to decay after death, and there's no way we can objectively analyse or verify any differences in brains of long ago with brains of today.

This isn't set to change anytime soon, but the remarkable discovery of a medieval child's brain was the subject of a Neuroimage paper published recently. This is extremely exciting on many counts: the brain has been so fantastically preserved that it is possible to identify the frontal, temporal and occipital lobes, and even the sulci and gyri, the grooves and furrows channeled into brains.



However it is only the left-hemisphere that survived and not the entire brain, which had also shrunk to about 80% of it's original weight due to the (natural) mummification process. Although it was first discovered in 1998 and preserved all this time in a formalin solution, it was found in the skull of a 13th Century infant that was exhumed at an archaeological dig in north-west France. The body of the 18-month-old child was wrapped in leather and kept in a wooden coffin with a pillow underneath the head.

The presence of acidic clay soil and fresh briny water around the burial site is believed to have contributed towards the excellent preservation of the brain. To a certain degree, even the innate cellular structure had been preserved, so much so that intact neurons and dendrites - branched fibres that extend from the cell body of a neuron - had survived for observation in the 21st Century. It was also possible to identify grey and white matter. Apart from the external burial conditions, the toughness of the neuronal myelin sheath and collagen fibres are said to be the reasons for why the brain tissue had been nicely preserved.

It cannot be said for sure how the infant died, but the presence of an unhealed circular head fracture may have been the likeliest cause. High levels of hemosiderin suggested that the infant had heavy bleeding for several days prior to death. Poor little mite.
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Papageorgopoulou, C., Rentsch, K., Raghavan, M., Hofmann, M., Colacicco, G., Gallien, V., Bianucci, R., & Rühli, F. (2010). Preservation of cell structures in a medieval infant brain: A paleohistological, paleogenetic, radiological and physico-chemical study NeuroImage, 50 (3), 893-901 DOI: 10.1016/j.neuroimage.2010.01.029

What is "Self Transcendence"?

A recent study by Italian researchers uncovered the fact that neurosurgery involving certain brain structures can effect personality changes that make one feel more "spiritual". 88 patients underwent pre- and post-surgical personality assessments while treated for tumours, and the results were combined with lesion mapping procedures (to precisely locate lesions) after surgery to measure changes in a personality construct called Self-Transcendence (ST). It was found that patients with posterior lesions experienced a considerable increase in 'spirituality' after the surgical removal of their tumours than those with anterior lesions, and that those with more aggressive types of tumour were most likely to describe themselves as religious. For a fuller report and discussion of this fascinating study, please see Mo Costandi's Neurophilosophy.

As I read through various articles detailing this announcement, I became intrigued at the constant mention of ST as a measure of personality. In his paper, Cosimo Urgesi describes ST as reflecting "the enduring tendency to transcend contingent sensorimotor representations and to identify the self as an integral part of the universe as a whole." ST is among several other personality dimensions in the psychobiological Temperament and Character Inventory (TCI) that was devised by C. R. Cloninger and colleagues in 1994. The TCI has been used in genetics to show ST as a heritable trait, and in molecular neurosciences to show ST related to the functioning of the serotoninergic system. According to Cloninger et al. (1993) their model followed on from previous research that confirmed four dimensions of temperament; novelty-seeking, harm avoidance, reward dependence, and persistence, and added three more dimensions that mature in adulthood; self-directedness, cooperativeness and self-transcendence.

In their discussion of ST, Cloninger et al. begin with the amusing sentence: "Most people meditate or pray daily, which is more frequent than sexual intercourse according to population surveys". They go on to note the lack of spirituality-related traits from personality inventories including the well-known Five Factor Model, which is odd considering that spirituality is an integral aspect of people's lives and mental activity. In describing their definition of spirituality, they say:

"Self-transcendence refers generally to identification with everything conceived as essential and consequential parts of a unified whole. This involves a state of 'unitive consciousness' in which everything is part of one totality. In unitive consciousness, there is no individual self because there is no meaningful distinction between self and other—the person is simply aware of being an integral part of the evolution of the cosmos. This unitive perspective may be described as acceptance, identification, or spiritual union with nature and its source ... The person may identify (or feel a sense of spiritual union) with anything or everything. They may experience the feeling that they are part of or being guided by a wonderful intelligence, which is possibly the divine source of all phenomena. Ultimately, there may be loss of all distinctions between self and other by identifying with the concept of an immanent God as one-in-all."

So it all sounds rather New-Agey (the paper mentions Buddhism and nirvana, Taoism and Advaita Vedanta), but I was still curious about the actual questions themselves. In formulating questions to measure personality dimensions, care is taken to ensure that they accurately represent the concepts they try to measure. Moreover, statistics such as Cronbach's Alpha are employed to ensure that the measure has a high level of internal consistency; the higher, the better it is at measuring a personality construct. In this context ST consisted of three sub-scales; Self-forgetfulness vs. self-consciousness, transpersonal identification, and spiritual acceptance vs. materialism, all three exhibiting a Cronbach Alpha of above 0.7. This indicates that each of the three sub-scales were reliable in excess of 70% in measuring what they claimed to measure.

PsychMaven kindly helped me aquire a copy of the TCI. Bearing in mind that the "questions" are actually statements that one ought to rate on a 5-point scale (1 = Definitely false, 5 = Definitely true), here is the complete list (in order of appearance) that purport to contribute to the ST dimension of personality:

12. I often feel a strong sense of unity with all the things around me.

25. Often I have unexpected flashes of insight or understanding while relaxing.

29. I sometimes feel so connected to nature that everything seems to be part of one living process.

32. I think that most things that are called miracles are just chance.

42. Sometimes I have felt like I was part of something with no limits or boundaries in time and space.

43. I sometimes feel a spiritual connection to other people that I cannot explain in words.

52. Sometimes I have felt my life was being directed by a spiritual force greater than any human being.

56. I have had moments of great joy in which I suddenly had a clear, deep feeling of oneness with all that exists.

68. I often become so fascinated with what I’m doing that I get lost in the moment – like I’m detached from time and place.

73. I often feel a strong spiritual or emotional connection with all the people around me.

91. I have made real personal sacrifices in order to make the world a better place – like trying to prevent war, poverty and injustice.

95. It often seems to other people like I am in another world because I am so completely unaware of things going on around me.

99.I often feel like I am a part of the spiritual force on which all life depends.

106. I have had personal experiences in which I felt in contact with a divine and wonderful spiritual power.

112. Often when I look at an ordinary thing, something wonderful happens – I get the feeling that I am seeing it fresh for the first time.

118. Religious experiences have helped me to understand the real purpose of my life.

143. I believe that all life depends on some spiritual order or power that cannot be completely explained.

148. I often feel so connected to the people around me that it is like there is no separation between us.

151. I am often called “absent-minded” because I get so wrapped up in what I am doing that I lose track of everything else.

157. I often do things to help protect animals and plants from extinction.

175. I have a vivid imagination.

190. I would gladly risk my own life to make the world a better place.

206. I think it is unwise to believe in things that cannot be explained scientifically.

212. Often I become so involved in what I am doing that I forget where I am for a while.

223. I have had experiences that made my role in life so clear to me that I felt very excited and happy.

232. Reports of mystical experiences are probably just wishful thinking.

It could be argued that statements such as these are anything but 'transcendent'. As Costandi eloquently put it in his report, Urgesi et al. fall short in their study of truly defining spirituality because it is likely that different patients will hold different ideas of spirituality and how it affects their lives. Furthermore, spirituality is an area that consists of many ideas apart from 'transcendence' which, by all accounts, is generally taken to refer to a state of being philosophically and affectively 'above and beyond' this world and all forms of mundane issues. Although many items deal with experiencing spiritual connections and having a sense of oneness with the universe, items that attempt to measure patients' attempts to save plants and animals from extinction hardly qualify as being transcendent and neither does gladly risking one's life for any purpose do the same. Having a "vivid imagination", however, is certainly a questionable inclusion which is bound to draw some sarcastic remarks.

We may quibble about the exactness of ST items and whether they accurately measure spirituality, the neurological findings nevertheless support the dependence of religious beliefs on brain function and even further increases evidence that religious beliefs can be experimentally studied. Urgesi et al. even go as far as to say that "dysfunctional parietal neural activity may underpin altered spiritual and religious attitudes and behaviours".
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Urgesi, C., Aglioti, S., Skrap, M., & Fabbro, F. (2010). The Spiritual Brain: Selective Cortical Lesions Modulate Human Self-Transcendence Neuron, 65 (3), 309-319 DOI: 10.1016/j.neuron.2010.01.026

Cloninger CR, Svrakic DM, & Przybeck TR (1993). A psychobiological model of temperament and character. Archives of General Psychiatry, 50 (12), 975-90 PMID: 8250684

We've Been Nominated!

The team at ResearchBlogging.Org and Seed Media Group are honouring the best bloggers who discuss peer-reviewed research in the first Research Blogging Awards. Over 400 nominations were made, and an expert panel of judges have whittled them down to 5-10 blogs per category which are deemed to be the "best of the best".

I feel very honoured to have my blog nominated under the category of Best Blog - Psychology, and would like to thank the judges for this. I would also like to give a very heartfelt thank you to all my readers.

To view a record of my peer-reviewed research posts, please see a list of all my research posts or my user page at ResearchBlogging. Voting is underway as registered bloggers have been sent invitation by ResearchBlogging.Org. If you're not registered (and blog about peer-reviewed research) but would like to vote, register here.

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UPDATE 23 March 2010: The award for Best Blog-Psychology went to Christian Jarrett of the BPS Research Digest. And I wish him a hearty congratulations on the achievement.

Mr. Crowley's Suicide Solution

Wine is fine,
But whiskey's quicker.
Suicide is slow with liquor.
Take a bottle, drown your sorrows,
THEN IT FLOODS AWAY TOMMORROW!!

So goes the first verse of 'Suicide Solution', an infamous song of Ozzy Osbourne's that deals with the dangers of alcohol abuse, and which was the central feature in two legal cases against him where he was charged with inciting the suicides of heavy metal fans after they listened to the song. In fact, controversy has dogged Osbourne since the beginning of his career with the founding of the influential heavy metal group Black Sabbath, who are credited with having invented the genre. Although Osbourne was found not guilty in those cases, other related matters referred to the issues of including satanic imagery in song lyrics, stage performances and album covers, as well as allegations of surreptitious backmasking of satanic messages in said albums, all things that were said to be bad infuences on young adults. Osbourne has claimed he harbours no satanic beliefs and that the inclusion of such imagery in his musical corpus was purely for reasons of showmanship.

Similarly, the music of Marilyn Manson is said to have contributed to at least one fan's suicide. But more seriously the students who carried out the Columbine High School massacre and the SuccessTech Academy shootings were said to have been heavily influenced by Manson's music. Around 50 churches were also burned down between 1992 and 1996 in Norway, for which many fans of the developing black metal scene claimed responsibility.

It isn't just the fans who are supposedly influenced adversely. Mayhem vocalist Per Yngve Ohlin, better known by his stage name 'Dead', was notorious for mutilating himself on stage with hunting knives and broken glass. Finally in 1991, and almost as a fitting homage to his nom de plume, he sat down among his bandmates and calmly slashed his wrists and neck with small cuts before inserting a shotgun into his mouth and blowing his brains everywhere. Other bandmates were famous for regular conflicts, culminating in the brutal murder of guitarist Øystein Aarseth by bassist Varg Vikernes.

If one looks deeper in the issue, one is sure to find many more horror stories of murders and depressive suicides with the common denominator of metal music. Indeed, one wouldn't be blamed for automatically assuming that individuals attracted to such music may tend to be prone to depression and/or exhibit anti-social behaviour of other kinds. But is there any actual data to substantiate this?

Vaughan Bell of mindhacks.com was kind enough to alert and send me a paper published late last year that attempts to analyse if there is a link between mental health and the enjoyment of such music. The main research questions that the study sought to answer were:

• Do metal music fans in France exhibit great levels of anxiety and depression?
• What variables mediate the levels of anxiety and depression for metal music fans?

Recours et al. (2009) surveyed 333 French metal fans by administering the Hospital Anxiety and Depression Scale (HADS), a simple test that aims to detect, obviously, notable anxiety and depression. Among other things, they analysed differences in gender, age, status, education, motivation and level of participation in metal culture. This included intimate items such as the behaviour of participants at metal concerts and whether they had body modifications such as piercings and tattoos.

Summary of the very interesting results: Out of 333 participants, 282 were male (87.8%) and 39 were female (12.15%), the mean age of which was 22.6 years old. (age range: 13-44 years). Half of them were students, 41.7% of the rest being employed and the remainder being both students and employed. Average years immersed in metal music culture was 9.22 years with average concerts attended per year was 16. Slightly over one-third had a tattoo or piercing while just 5.3 had a combination of both. The most popular subgenres of metal music indulged in were death metal (37.7%), black metal (22.7%) and thrash metal (18%). Motivations for attending concerts included the expectedly high 95.9% to enjoy the music, followed by 84.6% attending for the "ambience". Only 33.9% cited drinking as a reason to attend, and very small percentages of people attended in order to sample drugs (4.98%), sell drugs (2.72%), and to fight (0.91%).

Factor analyses revealed a three-dimensional structure, and an orthagonal rotation was performed to analyse how pertinent the depression and anxiety factors were. These two factors ended up explaining 38.71% of the variance (27.55% = anxiety, 11.17% depression), with reliability factors using Cronbach's Alpha being 0.70 and 0.67 respectively. In plain language, this means that - based on the answers provided - the HADS test was 70% and 67% reliable in detecting anxiety and depression respectively.

All in all, the results showed that the respondents exhibited low levels of anxiety and depression. The HADS instrument can be used to determine an arbitrary cutoff point as there is no generally accepted cutoff. The creators of the instrument, Zigmond & Snaith (1994), recommended a cutoff of 7/8 for possible and 10/11 for probable anxiety or depression. Following previous research Recours et al. chose 11 as a cutoff score for each dimension of anxiety and depression, implying that respondents exhibiting a score greater than 11 would be considered to have a serious level of anxiety or depression. The results found the average scores to be 7.26 and 3.76 for anxiety and depression respectively, far below the chosen cutoff levels. However, as in all populations there were some individuals scoring above the cutoff (15.6% anxiety, 3.4% depression) but these cannot be said to be due to the influence of metal music.

Multiple regression analyses revealed that none of the other variables (age, gender, concert attendance, etc.) had a link to mental health in terms of either anxiety or depression, but surprisingly the same analyses revealed a relationship between mental health and writing song lyrics, drinking at concerts, and having scarifications. Also, links were revealed between mental health, education level and employment status. However, these relationships were still nowhere near the 'danger' cutoff point of 11.

In conclusion, the authors discuss the huge gender bias towards males among other things, and suggest it as being 'very' representative of the culture of metal music. Maybe so, but let's get to discussing the drawbacks of this study:

The study was carried out over the Internet. The HADS instrument is effectively a questionnaire that was administered over a non-personal medium, but even with personal contact there is no way to certify the replies as genuine. In this way Internet-administered tests contain an extra layer of uncertainty. The authors state that they considered 'personal' measures such as approaching "morbidly dressed" metal fans on the street, but this would isolate metal fans who do not attire themselves in such an "obvious" way. But at least they entered 10 different Internet forums dedicated to metal music in order to have a realistic possibility of contacting individuals with an almost certain interest in metal music and culture. However, another category of isolation occurs here as genuinely depressed people are least likely to complete a questionnaire.

Also, by the authors' admission, France happens to be a country where the growth of cults are strictly controlled, and where "French officials are particularly concerned about Satanic cults related to metal music". Apparently a Govt. ministry has warned parents to limit their children's exposure to metal music and also to monitor their access to metal-oriented websites. Could it be possible that the majority of the French metaller population aren't exposed to the most extreme of metal subgenres? After all, throughout the entire paper scant mention is made of any specific group and metal music is referred to in categorical format; black, death, and thrash. Passing mentions are made of Slayer, Black Sabbath, Megadeth and Metallica, bands that have a certain notoriety but are also decidedly mainstream. Aren't French teenagers aware of bands like Arch Enemy, Goatwhore, Amon Amarth, Dimmu Borgir, Extol, Kult ov Azazel, and others? These are things to consider.

It was also interesting to observe how the results pointed to an unnoted third factor before orthogonal rotation enabled relevance to the anxiety and depression factors. So I agree with the authors that further research needs to be undertaken in order to determine which factor(s) can aptly describe the 61.3% of the variance that wasn't accounted for by anxiety and depression.

In closing, the authors offer reasons for why the general conclusions point to lower levels of anxiety and depression among metal lovers. It is proposed that the predominant themes of satanism, gloom and death give airing to subjects infrequently discussed in society and which are treated in a somewhat taboo manner. Although metal music is classed as entertainment in contrast to real images of death, it presents such themes as "typical occurrences that are not outside the norm" and I interpret that as a desensitising factor of sorts. So metal music lovers who frequently indulge in this pastime are more often exposed to morbid themes that have the effect of eventually desensitising them and enabling them to treat it more of the entertainment that it is supposed to be.

But then, what of all the horror stories referred to earlier? What about Dead's suicide? What about the terrible Marilyn Manson-inspired school shootings? Ozzy Osbourne's "satanism"? A tentative proposal is that metal music has a malevolent effect on individuals with certain vulnerabilities, and this is precisely why further research is needed in order to uncover these details. It is for this reason that I do not heartily share the confident assertions of the authors that their "representative" sample (from one country!) indicates low levels of anxiety and depression among metal lovers. Typical quote:

"The results indicate that fans of metal music are in good health with respect to anxiety and depression ... [and] indicate that, contrary to critics who suggest that images of death and destruction in metal music have harmful consequences, the mental health of fans of this type of music is generally good."

Hmmm, when they put it that way it's hard not to agree, but only tentatively. A more accurate representation of this study is that it simply provides an indicative snapshot rather than a comprehensive description.

Speaking of which, it's been ages since I've been to a Motörhead concert...


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Recours, R., Aussaguel, F., & Trujillo, N. (2009). Metal Music and Mental Health in France Culture, Medicine, and Psychiatry, 33 (3), 473-488 DOI: 10.1007/s11013-009-9138-2

Snaith, R. Philip, and Anthony S. Zigmond (1994). HADS: Hospital Anxiety and Depression Scale. Windsor: NFER Nelson.

Junkie On The Phone

Kirsten Emott is an MD from British Columbia who also writes poetry. The March 2010 issue of the British Journal of Psychiatry has published a poem of hers that was originally printed in The Naked Physician: Poems About the Lives of Patients and Doctors by R. Charach.

Junkie On The Phone

You don’t have a headache.

The GP you named doesn’t know you.

The pharmacist recognizes your name.

You even called me before.

I won’t prescribe the drugs.

Play the game elsewhere.

Call up some other doctor.

Set out your lies:

"Doctor, here is my lie.

I want you to join me in my lying.

Pretend I am sick.

Give me what will make me sicker.

Give me a stick

with which to beat myself.

Help me to die."