Self-Assured Destruction

\"CYS020\" OK, it is time to put on your nostalgia caps and remember back to the cold war.  Those were the days, weren\’t they?  \”Nuclear Winter\” was being thrown around like \”Global Warming\” is now.  Life went on like normal, but life was always lived with an underlying dis-ease that the end of everything was just a button-push away.
One term frequently used at that time was \”Mutually-Assured Destruction\” (MAD) which described the stalemate of two huge stockpiles of nuclear weapons that could destroy the world many times over.   The thing that kept the fingers off of the button was the surety that the destruction of one side would result in the end of life for both sides.  It wasn\’t a comforting thing to have to trust the rationality of two sides that had created the stockpiles in the first place, but perhaps there was some truth to the idea of MAD causing restraint to occur even in the least rational of all people: our leaders.  Who knows?  We\’re not really out of those woods yet.

But this is not a post about nuclear weapons.

I was listening to the NPR Science Friday podcast, and there was a very interesting story about a journalist who had studied and befriended people with Lesch-Nyhan syndrome, a condition where people have a single nucleotide substituted in their DNA that causes them to engage in grotesque self-mutilation.  The degree to which people with this disease harm themselves is quite disturbing (don\’t look at pictures of it unless you are prepared), even resulting in these patients chewing off their fingers.  Very disturbing.

On the podcast (I highly recommend it), the journalist makes the statement: \”There\’s a little of Lesch-Nyhan in all of us.\”  Some people chew their fingernails and others bite their cuticles, even when they know they shouldn\’t.  Lesch-Nyhan is just the extreme of this type of behavior.

\"smoking\" Yes, there is a little of Lesch-Nyhan in all of us.  Smokers smoke despite their emphysema, alcoholics would do anything to get away from the destruction of drinking but keep drinking to their own harm, compulsive gamblers gamble away all of their money, and people with credit cards spent to the limit somehow find a way to keep spending.  Last week I picked at a callus on my foot so much that it hurt to walk.  I kept telling myself to stop, but my hand would somehow end up on my heel without before I could think to pull it away.

My job depends on this irrationality.  I once posed the question: what impacts my income more, human frailty or human stupidity?  Self-destructive behavior causes a significant percentage of my visits – whether it be subtle: noncompliance with medications or tests ordered; obvious: alcohol, smoking, or overeating; or overt; anorexia nervosa, people staying in abusive relationships, or people \”cutting\” themselves.  Is this stupidity?  It certainly is irrational – people feel like they can\’t stop themselves in this kind of behavior and sometimes even feel a pleasure in the self-harm.  Yet there is also a degree of rationality to it, as it puts pain in our own control rather than in the hands of others.  The draw to it is moth/flame-like.  The more irrational the behavior seems, the stronger the gravity of the need it is filling.


This is a mystery to me.  I see it every day in my patients and I see it in myself.  I sometimes tell my patients that one of the best parts of being a doctor is that you get to see that everyone is as screwed up as you are.  If I could push a button or prescribe a drug to help with this behavior, I would.  I doubt there will be a button or drug to fix this, however, as history tells us that this kind of self-assured destruction (SAD) is not new to our time and culture.

This is probably the main reason I don\’t feel I can judge my patients for their self-destructive behavior.  It is too common.  I see it in the mirror every morning.  That is not to say that the behavior itself is not wrong or bad, but to make the jump to say that I wouldn\’t do the same in their shoes belies the fact that I engage in my own form of SAD.

Too many people see SAD as inevitable and too many physicians just treat the consequences of this behavior.  My hope for both myself and my patients is that somehow this cycle can be broken and the legacy of self-destruction can be interrupted.  As any recovering alcoholic can tell you, this is not easy at all.  But life would be a lot happier for all of us without that dis-ease of the finger close to the button.

As one of my favorite musicians once put it:

The man who twirled with rose in teeth
Has his tongue tied up in thorns
His once expanded sense of time and
Space all shot and torn
See him wander hat in hand –
\”Look at me, I\’m so forlorn –
Ask anyone who can recall
It\’s horrible to be born!\”

Life is hard.  But it is far harder when we forget that, despite the appearances, we are all human.

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