193 The anecdote of the weepy man is in Grethe Andersen, “Treatment of Uncontrolled Crying after Stroke,” Drugs & Aging 6, no. 2 (1995).
193 For the anecdote of the man who returned belatedly to work, see Ibid.
194 The quotation from Mad Travelers is taken from the book’s introduction, pages 1–5.
195 The quotation from Willow Weep for Me is on pages 18–19.
200 The Singapore magazine is Brave, and the article is by Shawn Tan and appeared in the 1999 final edition.
202 The passages on gay depression draw heavily from the work of Richard C. Friedman and Jennifer Downey, especially from their “Internalized Homophobia and the Negative Therapeutic Reaction,” Journal of the American Academy of Psychoanalysis 23, no. 1 (1995), and their “Internal Homophobia and Gender-Valued Self-Esteem in the Psychoanalysis of Gay Patients,” Psychoanalytic Review 86, no. 3 (1999). This work will ultimately be combined and augmented and published as a book to be called Psychoanalysis and Sexual Orientation: Sexual Science and Clinical Practice. I consulted with Richard Friedman at some length and he provided some supplementary information in anticipation of that book, and my quotations in several instances bridge the two articles with language approved by Friedman and Downey.
202 The 1999 study of male twins is in R. Herrel et al., “Sexual Orientation and Suicidality: A Co-Twin Control Study in Adult Men,” Archives of General Psychiatry 56 (1999). They used a registry that had been set up during the Vietnam War and compared those who were exclusively heterosexual to those who had had same-sex partners. In addition to the shocking rates of suicide attempts, the study indicated that while straight men had a 25.5 percent rate of suicidal ideation, among gay people the proportion was 55.3 percent.
202 The 2000 study of suicide attempts in men between the ages of seventeen and thirty-nine was conducted by Cochran and Mays, and actually considered 3,648 randomly selected cohorts. It was published as “Lifetime Prevalence of Suicide Symptoms and Affective Disorders among Men Reporting Same-Sex Sexual Partners: Results from NHANES III,” American Journal of Public Health 90, no. 4 (2000). The same researchers using a different database of 9,908 cohorts considered panic disorders in people who had had sex only with members of the opposite sex and those who had had same-sex partners during the previous year. This work was published as “Relation between Psychiatric Syndromes and Behaviorally Defined Sexual Orientation in a Sample of the U.S. Population,” American Journal of Epidemiology 151, no. 5 (2000). Of those considered for the latter study, 2,479 had to be turned away because they (rather depressingly, I think) had had no sexual partners during the previous year.
202 The New Zealand longitudinal study, which asked cohorts to comment on their sexual orientation and their sexual relationships from age sixteen onward, and showed risk factors for many complaints, was published by D. M. Fergusson, et al., “Is Sexual Orientation Related to Mental Health Problems and Suicidality in Young People?” Archives of General Psychiatry 56, no. 10 (1999).
202 The Dutch study conducted in 1999 had 5,998 cohorts, and in it both homosexual men and women were seen to have at least one DSM-III-R psychiatric diagnosis more frequently than heterosexuals. Gay men had increased rates of present and lifetime depression and anxiety; gay women had higher prevalence of major depression and alcohol drug dependence. See the study by T. G. Sandfort, et al., “Same-Sex Sexual Behavior and Psychiatric Disorders: Findings from the Netherlands Mental Health Survey and Incidence Study (NEMESIS),” Archives of General Psychiatry 58, no. 1 (2001).
202 The study of youth in Minnesota included 36,254 students from seventh to twelfth grades and was published by G. Remafedi, et al., “The Relationship between Suicide Risk and Sexual Orientation: Results of a Population-Based Study,” American Journal of Public Health 88, no. 1 (1998). It indicated no variation for suicidal ideation between lesbians and straight women, but showed that while straight men had a 4.2 percent rate of suicidal ideation, gay males came in at 28.1 percent.
202 The study showing that homosexual males were 6.5 times as likely to make a suicide attempt as heterosexual males had 3,365 cohorts, and is found in R. Garofalo, et al., “Sexual Orientation and Risk of Suicide Attempts among a Representative Sample of Youth,” Archives of Pediatrics and Adolescent Medicine 153 (1999).
202 The study that showed that 7.3 percent of homosexuals had made four or more suicide attempts as opposed to 1 percent of heterosexuals included 1,563 cohorts. Homosexual/bisexual students in this study showed greater incidence of suicidal ideation than straight students; 12 percent of homosexuals had attempted suicide as opposed to 2.3 percent of heterosexuals, and 7.7 percent of homosexuals had made a suicide attempt requiring medical attention in the previous twelve months as opposed to 1.3 percent of heterosexual youth. See the study by A. H. Faulkner and K. Cranston, “Correlates of Same-Sex Sexual Behavior in a Random Sample of Massachusetts High School Students,” American Journal of Public Health 88, no. 2 (1998). The study showed that gay students were at elevated risk of injury, disease, death from violence, substance abuse, and suicidal behavior.
202 The finding that 10 percent of suicides in San Diego County were committed by gay men is in C. L. Rich et al., “San Diego Suicide Study I: Young vs. Old Subjects,” Archives of General Psychiatry 43, no. 6 (1986). This was an uncontrolled study. D. Shaffer, et al., attempted to reproduce these results in the New York City area in 1995 in the article “Sexual Orientation in Adolescents Who Commit Suicide,” Suicide and Life Threatening Behaviors 25, supp. 4 (1995), and were not able to do so, but these researchers were working on youth suicide only and took information about sexual orientation from family members and peers who are in many instances unlikely to know and in other instances unwilling to admit even to themselves the details of their children’s sexual orientation.
202 The work on the socialization of gay men and children’s upbringing in homophobic environments and the early incorporation of homophobic attitudes is in A. K. Maylon, “Biphasic aspects of homosexual identity formation,” Psychotherapy: Theory, Research and Practice 19 (1982).
204 The study showing that gay students were likely to have their property stolen or deliberately damaged is in R. Garofalo et al., “The Association between Health Risk Behaviors and Sexual Orientation among a School-Based Sample of Adolescents,” Pediatrics 101 (1998). The authors found that the homosexuals in the group were also more likely to engage in multiple drug abuse, high-risk sexual behavior, and other high-risk behaviors.
204 The fact that suicide rates were particularly high among Jews in Berlin between the wars is published in Charlotte Salomon: Life? Or Theatre? on page 10, though it is given more ample exposition in text panels that were mounted as part of the exhibition of Salomon’s remarkable work at The Jewish Museum in early 2001. I thank Jennie Livingston for steering me toward this material, and for proposing the link between this Jewish suicidality in pre–Nazi Germany and gay suicidality in modern America.
205 The New Yorker questionnaire about parents’ preferring unhappy straight-identified children to happy gay-identified children is in Hendrik Hertzberg, “The Narcissus Survey,” The New Yorker, January 5, 1998.
208 Jean Malaurie’s The Last Kings of Thule, though much maligned in recent years, gives a particularly stirring and passionate account of traditional Inuit life in Greenland.
208 The suicide rate in Greenland was published in Tine Curtis and Peter Bjerregaard’s Health Research in Greenland, page 31.
213 The descriptions of polar hysteria, mountain wanderer syndrome, and kayak anxiety come from Inge Lynge, “Mental Disorders in Greenland,” Man & Society 21 (1997). I must thank John Hart for providing the parallel to “running amok.”
213 Malaurie’s quote here is from The Last Kings of Thule, page 109.
CHAPTER VI: ADDICTION
217 That there are about twenty-five common substances of abuse was taken from the National Institute of Drug Abuse’s Web site at www.nida.nih.gov/DrugsofAbuse.
217 The three-stag
e mechanism of substances of abuse is described in David McDowell and Henry Spitz’s Substance Abuse, page 19.
217 Peter Whybrow provides a concise summary of the interactions between cocaine and dopamine in A Mood Apart, page 213. A more in-depth analysis is provided by Marc Galanter and Herbert Kleber’s Textbook of Substance Abuse Treatment, pages 21–31.
217 Work on morphine and dopamine may be found in Marc Galanter and Herbert Kleber’s Textbook of Substance Abuse Treatment, pages 11–19.
217 For work on alcohol’s effect on serotonin, see Ibid., 6–7, 130–31.
218 That levels of the neurotransmitter enkephalin are affected by many of the substances of abuse is indicated in Craig Lambert, “Deep Cravings,” Harvard Magazine 102, no. 4 (2000).
218 The brain’s response to increased levels of dopamine is explicated in Nora Volkow, “Imaging studies on the role of dopamine in cocaine reinforcement and addiction in humans,” Journal of Psychopharmacology 13, no. 4 (1999).
218 The dynamics of addictive substances leading to addiction is discussed at some length in Nora Volkow et al., “Addiction, a Disease of Compulsion and Drive: Involvement of the Orbitofrontal Cortex,” Cerebral Cortex 10 (2000).
218 The statistics on proportions of addiction to specific substances are taken from James Anthony et al., “Comparative epidemiology of dependence on tobacco, alcohol, controlled substances, and inhalants: Basic findings from the National Comorbidity Survey,” Experimental and Clinical Psychopharmacology 2, no. 3 (1994).
218 Work on substances of abuse and the blood-brain barrier may be found in David McDowell and Henry Spitz’s Substance Abuse, pages 22–24.
218 The number of years it takes to develop dependence on alcohol and cocaine is described in H. D. Abraham et al., “Order of onset of substance abuse and depression in a sample of depressed outpatients,” Comprehensive Psychiatry 40, no. 1 (1999).
219 The work with PET scans showing limited recovery even at the three-month period has been done by Dr. Nora Volkow. See, for example, “Long-Term Frontal Brain Metabolic Changes in Cocaine Abusers,” Synapse 11 (1992). That chronic drug use has persistent neurological consequences is illustrated in Alvaro Pascual-Leone et al., “Cerebral atrophy in habitual cocaine abusers: A planimetric CT study,” Neurology 41 (1991), and Roy Mathew and William Wilson, “Substance Abuse and Cerebral Blood Flow,” American Journal of Psychiatry 148, no. 3 (1991). For information regarding cognitive impairment, including deficits in memory, attention, and abstraction, see Alfredo Ardila et al., “Neuropsychological Deficits in Chronic Cocaine Abusers,” International Journal of Neuroscience 57 (1991), and William Beatty et al., “Neuropsychological performance of recently abstinent alcoholics and cocaine abusers,” Drug and Alcohol Dependence 37 (1995).
220 A thorough review of the multiple causes of lesions in alcoholics is provided by Michael Charness, “Brain Lesions in Alcoholics,” Alcoholism: Clinical and Experimental Research 17, no. 1 (1993). For a more general and recent review of alcohol and brain damage, see Marcia Barinaga, “A New Clue to How Alcohol Damages Brains,” Science, February 11, 2000. That memory loss is a problem in this population is discussed in Andrey Ryabinin, “Role of Hippocampus in Alcohol-Induced Memory Impairment: Implications from Behavioral and Immediate Early Gene Studies,” Psychopharmacology 139 (1998).
220 A description of the use of SSRIs to bring alcoholics off alcohol is in David McDowell and Henry Spitz’s Substance Abuse, page 220. Mark Gold and Andrew Slaby, however, disagree with this position in their book Dual Diagnosis in Substance Abuse. They write, pages 210–11, “Antidepressant medication should not be prescribed for active alcoholics because the appropriate treatment is much more likely to be a period of sobriety.”
220 Increased REM latency has long been established as a hallmark sign of depression. See Francis Mondimore’s Depression: The Mood Disease, pages 174–78, for a good general discussion of depression and sleep. The work on REM sleep, alcoholism, and depression is taken from two studies: D. H. Overstreet et al., “Alcoholism and depressive disorder,” Alcohol & Alcoholism 24 (1989); and P. Shiromani et al., “Acetylcholine and the regulation of REM sleep,” Annual Review of Pharmacological Toxicology 27 (1987).
221 The statement on early-onset alcoholism and depression is taken from Mark Gold and Andrew Slaby’s Dual Diagnosis in Substance Abuse, pages 7–10.
221 On work with tests to diagnose primary versus secondary depression, see Ibid., 108–9.
221 The figures on the proportion of depressives who suffer from secondary alcoholism and vice versa I take from Barbara Powell et al., “Primary and Secondary Depression in Alcoholic Men: An Important Distinction?” Journal of Clinical Psychiatry 48, no. 3 (1987). For more on this complicated topic, see Bridget Grant et al., “The Relationship between DSM-IV Alcohol Use Disorders and DSM-IV Major Depression: Examination of the Primary-Secondary Distinction in a General Population Sample,” Journal of Affective Disorders 38 (1996).
221 That substance abuse often begins in adolescence is discussed in Boris Segal and Jacqueline Stewart, “Substance Use and Abuse in Adolescence: An Overview,” Child Psychiatry and Human Development 26, no. 4 (1996). They write lucidly: “Considering the epidemiological factors further, one must notice that adolescence is the primary risk period for the initiation of use of substances; those who have not experimented with licit or illicit drugs by age twenty-one are unlikely to do so after.” Page 196.
221 That substance abusers are more likely to relapse when depressed is indicated in Mark Gold and Andrew Slaby’s Dual Diagnosis in Substance Abuse: “Alcoholics reporting depression during periods of sobriety return to drinking more frequently than those with normal mood,” page 108.
221 R. E. Meyer’s views here quoted come from Psychopathology and Addictive Disorder, pages 3–16.
221 The remission of apparently schizophrenic symptoms (paranoia, delusions, hallucinations, etc.) in patients with depression and stimulant-abuse problems is related to the fact that mania can often be precipitated by excess dopamine. Abstinence from stimulant use may help to control such excesses. For more on the relationships among stimulants, mania, and psychosis, see Robert Post et al., “Cocaine, Kindling, and Psychosis,” American Journal of Psychiatry 133, no. 6 (1976), and John Griffith et al., “Dextroamphetamine: Evaluation of Psychomimetic Properties in Man,” Archives of General Psychiatry 26 (1972).
221 The severity of each illness in dual-diagnosis cases is reviewed in Mark Gold and Andrew Slaby’s Dual Diagnosis in Substance Abuse.
222 On the depression-engendering effects of withdrawal from cocaine, sedatives, hypnotics, and anxiolytics, see Ibid., 105–15.
222 Work on the capacity of substances, especially alcohol, to exacerbate suicidality is summarized in Ghadirian and Lehmann’s Environment and Psychopathology, page 112. Mark Gold and Andrew Slaby’s Dual Diagnosis in Substance Abuse says “rates of self-reported suicide attempts increase progressively with increased use of licit and illicit substances.” Page 14.
222 That depression often remits because of abstinence can be adduced from a number of studies. Mark Gold and Andrew Slaby’s Dual Diagnosis in Substance Abuse says, “For the majority of these primary alcoholics, secondary depressive symptoms tend to remit by the second week of treatment and continue to decrease more gradually with three to four weeks of abstinence,” pages 107–8.
222 Alcohol, in fact, causes all medications to be absorbed more rapidly; and it is a primary principle of antidepressant therapy that peaks of absorption exacerbate side effects.
222 Howard Shaffer’s pithy remark about addictive dice was published in Craig Lambert, “Deep Cravings,” Harvard Magazine 102, no. 4 (2000). Bertha Madras’s comments appear in the same article.
223 Work on endorphin levels and alcohol use has been published in J. C. Aguirre et al., “Plasma Beta-Endorphin Levels in Chronic Alcoholics,” Alcohol 7, no. 5 (1990).
224 The four origins of addiction I take from David McDowell and Henry Spitz’
s Substance Abuse.
224 The statistics on Irish and Israeli teetotalism were discussed in an oral interview with Dr. Herbert Kleber, March 9, 2000.
225 The quotation from Eliot appears in his poem “Gerontion,” in The Complete Poems and Plays, page 22.
225 These remarks on substitution come from Mark Gold and Andrew Slaby’s Dual Diagnosis in Substance Abuse, page 199.
225 The story of chili in the elephant’s eye I take from Sue Macartney-Snape, who has spent much time in Nepal and has interviewed numerous howdah drivers.
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