09/30/15

Psychiatry, Diagnose Thyself! Part 1

© lightwise | 123rf.com

© lightwise | 123rf.com

Wow. I can hardly believe he said the things he did. Dr. Jeffery Lieberman, a former president of the American Psychiatric Association and the Chairman of the Department of Psychiatry at the Columbia University College of Physicians and Surgeons, took umbrage at an op-ed article written in The New York Times on January 17, 2015 by Stanford anthropologist T.M. Luhrmann, “Redefining Mental Illness.”  Luhrmann referred in her article to a report by the British Psychological Society, “Understanding Psychosis and Schizophrenia,” that suggested interpreting paranoid feelings and hearing voices as symptoms of mental illness was only one way of thinking about them. She indicated the report said antipsychotic medications were sometimes helpful, but “there is no evidence that it corrects an underlying biological abnormality.” It went on to warn about the risks of taking these medications over the long term.

In a Medscape video “What Does The New York Times Have Against Psychiatry?” Lieberman referred to the NYT publication of her article as “journalistic opportunism.” He chided the editors for thinking that “providing a platform for this would be useful.” With regard to Luhrmann, he cited the title of her books, whose subject areas dealt with religion and God, witches, and psychiatry. Yes, they were eclectic topics, but how does that then lead him to this comment:

The equating of psychiatry with these other topics suggests that she thinks of psychiatry not as a hard science but as something that is either a philosophical or religious discipline, has a supernatural or religious dimension, or is in the realm of the supernatural.

I’ve read two of her books, Of Two Minds and When God Talks Back, and for the life of me I cannot follow how he can make that connection. There was not association of psychiatry with witchcraft or religion on Luhrmann’s part in her NYT article; I can only conclude the association was somehow in Lieberman’s mind, not Luhrmann’s article.

But she did comment how there was plenty of scientific evidence for the report’s claims. She then had the audacity to mention that the National Institute of Mental Health (NIMH) announced in 2013 that it would no longer pursue diagnosis-driven research. Under a program called Research Domain Criteria (RDoC), all research would begin from a matrix of “functional dimensions, grouped into broad domains such as cognition and reward-related systems.” One example she gave from the RDoC site was how psychiatric researchers would no longer study people with anxiety. Rather they would study fear circuitry.

Lieberman went on to name some additional publications by Lurhmann, and said: “This hearkens back to the days when psychiatry had only fanciful theories about the mind and what caused mental illness in people.” Thankfully, he said we are well past that.  Articles like Luhrmann’s, according to Lieberman, are a throwback to the days of ignorance and fear; and they spread stigma.

Why would The New York Times do this? It is very disturbing that we still live in an age when the stigma of mental illness and the lack of interest in trying to present medical science as it deserves and needs to be for an informed public, is still preyed upon by this kind of journalistic opportunism.

Then Lieberman was interviewed on CBC radio podcast, “The Sunday Edition” on April 26, 2015. He was there to promote his new book, Shrinks, a history of psychiatry for the general public. After playing an excerpt of an interview he did over a year ago with Robert Whitaker, the host asked Lieberman to comment on what Whitaker had said in the excerpt. Lieberman said: “What he says is preposterous. He’s a menace to society because he’s basically fomenting misinformation and misunderstanding about mental illness and the nature of treatment.”

But he wasn’t finished. Lieberman went on to say how Whitaker “ostensibly considers himself to have been a journalist.” Whitaker has won awards for his journalism and was even a finalist for a Pulitzer in Public Service. But Lieberman lamented: “God help the publication that employed him.” Lieberman also thought Whitaker’s comments that some unmedicated patients did better than medicated ones were absolutely wrong. If you did a randomized, controlled study of any of the various psychiatric illnesses, using whatever is state of the art in psychiatry, including medication, Lieberman said: “the outcomes will be extraordinarily superior in the treated group.”

This led to “A Challenge to Dr. Lieberman” by Whitaker on his website for Lieberman to provide a list of randomized studies that show how medicated patients have a much better long-term outcome than unmedicated patients. He noted how he had posted the abstracts of the studies he cited in his book, Anatomy of an Epidemic on his website, madinamerica.com. “So here is you chance to point to the studies I left out.”

1 Boring Old Man commented on this outburst by Dr. Lieberman and Whitaker’s reply, observing how Lieberman sees himself as the spokesman and champion for “Psychiatry.” His article also described the Lieberman rant against Lurhmann and also cited several articles written by Lieberman over the past few years with the same theme. I’d just finished reading Lieberman’s book and was struck in reading 1 Boring Old Man’s article by how it seemed Lieberman was casting himself in a role similar to the one he gave Robert Spitzer in Shrinks. Spitzer was portrayed there as an unlikely hero and a psychiatric revolutionary who, in effect, saved psychiatry from imploding during the 1970s. Psychiatry today seems to be in similar situation, with questions being raised about the current validity and reliability of DSM diagnosis, and the credibility of psychiatry itself.

So if Lieberman sees himself as a modern psychiatric hero, then Robert Whitaker would be a natural pick by Lieberman as an antipsychiatry foil, replacing David Rosenhan, who was a “foe” of psychiatry in the 1970s. In Shrinks, Lieberman discussed the controversies over the DSM-5, saying the APA hadn’t experienced that kind of public pressure since the early 1970s, “when the Rosenhan study, the homosexual controversy, and the antipsychiatry movement compelled the APA to move away from psychoanalysis and endorse a radically new paradigm for psychiatric diagnosis. See “A Censored Story of Psychiatry, Part 1, Part 2” and “The Quest for Psychiatric Dragons, Part 1, Part 2” for more on Spitzer, Rosenhan and these issues.

In his role as a “foe of psychiatry,” Whitaker has published three well-received books by both the general public and individuals within the mental health profession that are critical of the current state of psychiatry and mental healthcare. His most recent book, Psychiatry Under the Influence, was just released on April 23, 2015.

So we have these successive actions: Lurhmann’s article published in the NYT on January 17th. Three days later Lieberman recorded his Medscape response, which was published online on February 18, 2015. The release date for Lieberman’s book, Shrinks, was on March 10, 2015. Whitaker’s review of Shrinks appeared on his website, Mad in America on March 19th. The release date for Whitaker’s book, Psychiatry Under the Influence, was on April 23rd. Lieberman’s CBC interview was on April 26, 2015. Whitaker’s invitation to Lieberman was on April 26th as well.

I don’t think he’ll take Whitaker up on his challenge. He can’t. The science doesn’t support his position. Go to madinamerica.com and read through the abstracts mentioned above by Whitaker to confirm this. But why would one of the top psychiatrists of our time write and say such obvious drivel?

It’s all PR. In his review of Shrinks, Whitaker noted how Shrinks doesn’t tell a previously unknown tale. Rather, it “relates a story that the American Psychiatric Association has been telling the American public ever since it published DSM III in 1980.” Whitaker and Cosgrove noted in Psychiatry Under the Influence that by adopting a disease model and insisting psychiatric disorders were discrete illnesses in the 1970s, the APA simultaneously responded to its antipsychiatry critics and addressed its image problem by presenting itself to the public as a medical specialty. “Metaphorically speaking, psychiatry had donned a white coat.” Whitaker pointed out in his review how Lieberman wore a doctor’s white coat for a promotional video he did on YouTube, where he discusses his book. I noticed that he did the same thing for his Medscape video critique of Lurhmann and the NYT.

Whitaker said Shrinks provided a revealing self-portrait of psychiatry as an institution. Lieberman repeats the same story the APA has been telling the public since the publication of the DSM-III. “And it is this narrative, quite unmoored from science and history, that drives our societal understanding of mental disorders and how best to treat them.” He observed that Lieberman diagnosed the Freudians as extravagant, grandiose and having irrational faith in its world-changing powers. The same symptoms seemed to be present in Shrinks.

09/28/15

The End of Alcoholism? Part 2

© Katarzyna Białasiewicz | 123rf.com

© Katarzyna Białasiewicz | 123rf.com

Within an introductory “Note to the Reader,” to his book, The End of My Addiction, Olivier Ameisen said: “By completely suppressing my addiction, baclofen saved my life. I believe it can save and improve the lives of many others by completely suppressing their addictions, and I have written this book to that end.” He ended his note with a caution that his book was not a self-help manual or a guide to self-treatment. Baclofen, a prescription drug, “should be taken only as prescribed … and closely monitored by a licensed physician.” Yet his book is a detailed discussion of how he did exactly the opposite of everything he had just cautioned others not to do.

There had been some ongoing research into the potential of baclofen as a treatment for alcohol use disorders (see the References for Ameisen’s Alcohol and Alcoholism article) before Ameisen wrote his book. But Ameisen’s personal experimentation and its description in his book brought it to the attention of the public and sparked further interest in researching the potential of baclofen to treat addiction. “The End of Alcoholism? Part 1” looks in more detail at that story. Here I want to explore some of the research supportive of using baclofen in treating alcohol use disorders.

Giovanni Addolorato of the Catholic University of Rome was one of the initial baclofen researchers Ameisen read. Eventually they began to correspond and shared their interest its potential to treat alcoholism. A sampling of Addolorato’s published research studies looks at the ability of baclofen to reduce cravings and alcohol intake (2000); the suppression of alcohol withdrawal syndrome with baclofen (2002); a comparison of baclofen to diazepam in treating alcohol withdrawal (2006); the effectiveness of baclofen in maintaining abstinence with patients with cirrhosis of the liver (2007). Addolorato found baclofen to be effective in reducing craving and alcohol intake; it was comparable to diazepam in treating withdrawal; and it promoted abstinence—even in alcohol-dependent patients with cirrhosis of the liver.

Colombo et al. (2002) found that baclofen inhibited the drinking behavior of selectively bred alcohol-preferring rats. Baclofen is a known GABA(B) receptor and the results suggested that the GABA(B) receptor was involved in the disclosure and experience of the psychopharmacological effects of alcohol.

William Bucknam published a case study in 2007 to investigate whether baclofen-induced suppression to consume alcohol in animals could be transposed to humans. The patient, Mr. A., wanted to be able to control his drinking not establish and maintain abstinence. He “experienced a satisfactory response to high-dose baclofen that [was] sustained over ten months without significant side-effect.”

Lorenzo Leggio (2009) suggested that baclofen “represents a promising medication in the treatment of alcohol-dependent subjects.” It demonstrated an ability to reduce alcohol craving and intake. So it could be useful for promoting abstinence “as well as relieving alcohol withdrawal syndromes.”

In 2012 Renaud de Beaurepaire published a 2-year observational study of 100 individuals using baclofen. Initially 132 individuals were included in the study, but 32 were excluded for various reasons. These reasons included: not providing feedback after their first visit, stopping their use of baclofen because of adverse drug effects, and not being motivated to stop drinking. The effects of baclofen in the first three months were not included in the study, “because the effect of the treatment during this period does not represent the full potential of the drug.” (So what was going on in the initial three months that might give an unfavorable view of baclofen, I wonder?) The participants were evaluated before treatment with baclofen and then at 3, 6, 12 and 24 months to fit into three categories: low risk, medium risk and high risk.

In the “at low risk” category, patients experienced a suppression of craving, and their complete control over drinking was effortless. In the “at medium risk” category, patients experienced a clear decrease in craving but, for various reasons (in general, too strong an attachment to their drinking habits associated with an incomplete motivation to cease drinking), they were not able to control completely their drinking compulsions. In the “at high risk” category, patients either experienced an insufficient reduction of craving, or, although they experienced a significant decrease in craving, after a period of decrease in drinking, relapsed in their addiction. The risk category was defined according to the control over drinking during the last 4 weeks [before the evaluation].

Fifty-nine percent of the participants had one or more concomitant psychiatric disorders, including: 53% with anxiety disorder, 34% with depression, 18% with bipolar disorder, 42% with a sleep disorder, 11% with another addiction (mostly cannabis), 8% with psychosis, and 5% with an eating disorder.

At the end of the first visit, participants were told they could drink as usual. Using baclofen was expected to suppress the motivation to drink. No additional therapeutic intervention other than baclofen was given or suggested.

The doses ranged from 20 mg to 330 mg, with an average dose of 147 mg. Eighty-eight percent of the participants reported at least one undesirable side effect. The five most frequently reported were: fatigue or sleepiness (64%); insomnia (31%); dizziness (21%); tingling or abnormal sensations (18%); nausea or vomiting (17%).  There were several others, including: weight loss, memory loss, mental confusion, hypomania, dysphoria (a state of profound unease or dissatisfaction). De Beaurepaire assessed these side effects as “always benign.” However, eleven individuals discontinued treatment because they could not tolerate the side effects. And 20 participants did not reach an optimum dose because of the worsening of side effects.

The study reported that 92% reported a decrease in their motivation to drink at one time or another during the follow up time period. About half reported that at sufficient doses of baclofen, they had “a complete and effortless control” of alcohol craving. All participants were rated “at high risk” initially, but about half were rated “at low risk” at 3, 6, 12, and 24 months of follow up.

De Beaurepaire concluded that baclofen was very effective in treating alcohol dependence, particularly in reducing the motivation to drink. High doses were often necessary to obtain an optimum effect. The principle limitations seemed to be the side effects, the absence of a strong willingness in some to stop drinking, and co-occurring psychiatric illness—with the possibility that the concomitant use of psychotropic medications was a factor. “Baclofen should be considered a major help for drinking cessation, but other factors (psychological and environmental) are likely to play an important role with many patients.”

Ameisen sees baclofen as essentially a miracle cure for alcoholism. “So far it seems to work in all types except for one … and that’s people who turn up once and don’t come again.” He admits that no medication works effectively for everyone, and that includes baclofen. It’s not one size fits all; “you have to refine it.” There is a parallel here to methadone maintenance for opioid addiction. Ameisen’s “threshold dose,” refining the dosage until it’s high enough to eliminate cravings, sounds like raising a person’s methadone dose until they don’t want to get high anymore.

But the miracle cure claims of his treatment have provoked skepticism. Dr. Nicholas Pace, a clinical professor of medicine at New York University said: “I have studied alcoholism for the past 40 years, and there is no single magic bullet. This is a complex disease, and you can’t just flip one switch. The idea that an alcoholic can drink socially is simply a lot of bull.”

Ameisen said this kind of reaction from addiction professionals is because they feel threatened. “If baclofen works, then their specialism is going to fall apart.” But James Medd, writing for The Guardian suggested there could be another reason. This isn’t the first time someone claimed they found a cure for alcoholism. Barbiturates, benzodiazepines like Valium and antidepressants such as Prozac were hyped at one time as an end to addiction. Naltrexone has also been proposed as a “cure” for alcoholism in the Sinclair Method (See A “Cure” for Alcoholism).

At least for Ameisen, baclofen seems to have turned his life around. He reportedly had over nine years without drinking compulsively. There are several studies being done to investigate the treatment potential of baclofen. Here is sample a of some of those listed on clinicaltrials.gov. Assistance Publique – Hôpitaux de Paris (study 8) is completing a study to show the effectiveness of a year of baclofen treatment to that of a placebo. It was planned to increase the dose to a maximum of 300mg daily. In case of intolerance, the dosage would be decreased.  Essentia Health (study 9) is investingating the use of baclofen to prevent the symptoms of Alcohol Withdrawal Syndrome. The University of North Carolina at Chapel Hill (study 14) is investigating whether a 90mg dose of baclofen is effective and safe with individuals with alcohol dependence.

While there are some potential benefits with baclofen in treating alcohol use disorders, there are some clear adverse effects as well. We will look closer at those side effects in Part 3. Amiesen did not describe or dwell on the adverse effects with baclofen. Perhaps this was because he came to it when his own fight against alcoholism was at the point that he thought he was going to die from it. He had a blind spot to its negative effects because baclofen became the miracle drug that saved his life. As a physician writing a book on baclofen he cautioned his readers to not self-treat with baclofen. As an active binge drinker he was desperate to find something—anything—that would put an end to his addiction and did it anyway.

09/25/15

Tree of Life

photo credit: The British Museum

photo credit: The British Museum

Besides its presence in the books of Genesis and Revelation in the Bible, the idea of a tree of life is present in various religions and mythologies. It existed in Persian mythology, as the Gaokerena world tree, which had healing properties when eaten and gave immortality to the resurrected bodies of the dead. To ancient Egyptians, the Tree of Life represented the chain of events that brought creation into existence. In Chinese mythology, a carved Tree of Life depicts a phoenix or a dragon—which represented immortality. In the Book of Mormon, the tree of life symbolizes the love of God. In the Norse religion the tree of life is Yggdrasil, the world tree.

There is a sacred tree motif in ancient Near East art, but no literature of the time that clearly links it with the tree of life. The Assyrian relief in the above photo was originally in the throne room of the Palace of Ashurnasirpal II, who reigned from 883-859 BC. His reign over Assyria would have been concurrent to that of Ahab in Israel (873-853 BC) and Jehoshaphat in Judah (873-853 BC). Ashurnasirpal is pictured twice, on each side of a Sacred Tree. The figure of the king on the left is gesturing to the Sacred Tree, a symbol of fertility and abundance given by the gods. The figure of the king on the right gestures to a god within a winged disk above the Tree, possibly Shamash, the god of sun and justice or Ashur, the national god. For more information on this stone relief, try the link here to the British Museum.

So what makes the Bible’s use of the sacred tree, the tree of life unique? In Genesis, it was in the midst of Eden, the garden where humanity had fellowship with God (Genesis 3:8). Adam and Eve sinned by disregarding God’s command to not eat from another tree, the tree of the knowledge of good and evil. They wanted to be like God, knowing good and evil independent of His counsel and command. This rebellion ruptured their fellowship with God and He banished them from Eden. Banishment also prevented them from eating from the tree of life and becoming immortal (Genesis 3:22). So death and separation from God became consequences of their sin.

According to E. B. Smick in The International Standard Bible Encyclopedia, the tree of life can symbolize Adam and Eve’s continued relationship with God. Access to it is contingent upon their maintaining obedience to God’s commands. “The most significant thing about the tree of life theologically is that when our first parents broke their relationship with God through disobedience they were driven from the Garden ‘lest he put forth his hand and take also of the tree of life, and eat, and live for ever’” (Genesis 3:22).

Adam and Eve were on probation in the Garden. They were not yet permanent (regenerated) spiritual children of God. The tree of life from this perspective is a type of Christ, through whom eternal life is possible. The uniqueness of how the tree of life is portrayed in Scripture signifies how the person and work of Christ restores access to it.

Partaking of the tree of life implies not only continued probation (negative obedience) but also a positive commitment analogous to what believers do in the Lord’s Supper and what the OT saints did at the sacrifices.

In his commentary on Genesis, Gordon Wenham noted how trees as a symbol of life corresponded to items in or near the center of Israelite worship throughout the Old Testament. Genesis 3:22 of course noted that this tree conferred life on those who ate it. Proverbs described wisdom (3:18), the fruit of the righteous (11:30), a desire fulfilled (13:12), and a gentle tongue as a tree of life. In other words, they gave fullness of life to their owners.

Trees, because they remain green throughout the summer drought, are seen as symbolic of the life of God (e.g., Psalm 1:3; Jeremiah 17:8). In Genesis 21:33 Abraham prayed by a tamarisk tree he planted. It seems likely that the golden candlestick in the tabernacle was a stylized tree of life (Exodus 25:31-40). The Dictionary of Biblical Imagery also affirmed this symbolism: “It is very likely that this lamp symbolized the tree of life in the garden of Eden.”  Lamps in general also had a symbolic connection to the tree of life. The lamp in the shrine at Shiloh is called “the lamp of God” in 1 Samuel 3:3. In Psalm 119 the Word of God is exalted as “a lamp to my feet and a light to my path.”

This imagery continues into the New Testament, where Jesus said in John 8:12 that he was the light of the world; that whoever followed him would not walk in darkness, but would have “the light of life”—eternal life. When the New Jerusalem comes down from heaven in Revelation 21, lamps are no longer needed, because “its lamp is the Lamb” (Revelation 21:23).

The gift of life offered by the Tree of Life in the Garden of Eden is now offered in the person of the Word incarnate. By believing in Jesus, humans partake of the eternal life he offers (John 3:16). Or, more vividly, by eating the flesh and drinking the blood of Christ, they gain eternal life and will be raised on the last day (John 6:54).

In Revelation, humanity is granted access once again to the tree of life and may freely eat of it (Revelation 2:7; 22:2). So Revelation depicts a reversal of the damage done at the beginning by the sin of Adam and Eve. Fellowship and relationship with God is restored. Revelation 22:2 also suggests the leaves of the tree of life have a sacramental role or purpose in that they are for “the healing of the nations.” The Dictionary of Biblical Imagery commented how “The Bible’s story of salvation history begins and ends with references to symbolic trees.”

The tree of life in Genesis then represents the relationship humanity initially had with God, but lost through their rebellion. This loss was not to be a permanent one, as it was also a type of Christ—a representation of the planned restoration of relationship with God through the finished work of Christ. It is not until this side of the completed of the work of Christ that we could see how he restored relationship with God, in effect becoming the lamp and light of life.

220px-YggdrasilThe biblical tree of life is then much more than a world tree that supports the heavens, upholds the world, and connects both with the underworld, as in the Yggdrasil of Germanic and Norse mythology. It is greater than just being a symbol of fertility and abundance given by the gods in Assyrian mythology; or a plant easily stolen from the King of Uruk by a snake at the end of his quest in the Epic of Gilgamesh. Gilgamesh learned that: “Life, which you look for, you will never find. For when the gods created man, they let death be his share, and life withheld in their own hands.” The Christian quest for the tree of life is one that has the promise of fulfillment one day in Christ. As an anonymous female Puritan wrote:

Faith is the grace, and the only grace, whereby we are justified before God, by it we eate of the Tree of Life, (Jesus Christ) and live forever: It is therefore the fittest grace of all, to satisfie Conscience in this weighty matter, and to make up conclusions from, about our eternall estate. This Satan knows full well, and therefore when he would flatter a man to Hell, he perswades him, that his faith is right good, when indeed there is no such matter; and when he would overthrow all hope of Heaven in a man, and drag him into despaire, he perswades him, that his faith, though never so good, is but a feigned and counterfeit thing, and the poore soul, is ready to say, Amen.

This is the fourth reflection I’ve done on excerpts from Evidence for Heaven, written by an anonymous Puritan female author. Edward Calamy was credited as the author, but he himself acknowledged it was actually written by a female member of his church.

09/23/15

Psychiatry Is Not Neurology

© Lightsource |stockfresh.com

© Lightsource |stockfresh.com

Psychiatry is not neurology; it is not a medicine of the brain. Although mental health problems undoubtedly have a biological dimension, in their very nature they reach beyond the brain to involve social, cultural and psychological dimensions. These cannot always be grasped through the epistemology of biomedicine. The mental life of humans is discursive in nature.

Wow. I want to get in contact with a psychiatrist in the Pittsburgh area who believes and practices their profession consistent with this position. The article from which I took the opening quote, “Psychiatry beyond the current paradigm,” is reminiscent of Thomas Szasz, who presented his argument that mental illness was a myth in his seminal book, The Myth of Mental Illness. His original article of the same title, “The Myth of Mental Illness,” is available on the website, Classics in the History of Psychology.

Szasz said that the notion of mental illness assumed that there was some neurological defect, “perhaps a very subtle one,” behind all disorders of thinking and behavior. “The crux of the matter is that a disease of the brain, analogous to a disease of the skin or bone, is a neurological defect, and not a problem in living.” Pat Bracken et al., who wrote “Psychiatry beyond the current paradigm” for The British Journal of Psychiatry, were more nuanced. They acknowledged the undoubted biological dimension in mental health problems, but also admitted the reality of other dimensions beyond the grasp of “the epistemology of biomedicine.” They believe the biomedical dimension should be a secondary—not the primary—consideration in psychiatry.

A “biomedical idiom” has guided psychiatry’s understanding of mental health problems. Problems with feelings, thoughts, and behaviors were thought to be capable of exploration and understanding just like our livers and lungs. The scientific tools and methods used to investigate problems with biological life would help unlock the secrets of mental life. In recent decades, even models of cognitive psychology have been developed to work within this “technological paradigm.” Its main assumptions made are:

  • The problem to be addressed is that of a faulty mechanism in the individual.
  • The mechanism or process can be modeled in causal terms; it can be described in a universal way that works regardless of the context.
  • Technological interventions are instrumental.

In the technological paradigm, mental health problems can be mapped and categorized with the same causal logic used in the rest of medicine, and our interventions can be understood as a series of discrete treatments targeted at specific syndromes or symptoms. Relationships, meanings, values, cultural beliefs and practices are not ignored but become secondary in importance. This order of priorities is reflected in our understanding of the training needs of future psychiatrists, what gets published in journals, what topics are selected for analysis at conferences, [and] the types of research that are promoted.

Bracken et al. said the overall evidence did not support the idea that mental health problems were best understood through this technical paradigm. While medical knowledge was relevant, “the problems we grapple with cry out for a more nuanced form of medical understanding and practice.” Psychiatrists need to develop an approach to mental health problems that is genuinely sensitive to the interplay of forces (biological, psychological, social and cultural) that underlie them.

Pat Bracken said in a lecture he gave at the University of Copenhagen in 2012, that: “The realm of mental health is one area of human life that cannot be grasped in a purely technical way.” He argued that psychiatry is very much a product of the cultural shift brought on by the Enlightenment. Without the Enlightenment, Bracken believes we would not have the discipline of psychiatry as it exists today. The attention to unreason, came as a byproduct of the Enlightenment emphasis on rationality or reason. It also gave rise to the isolation and confinement of the “mentally ill.”

As a result, they became the subject matter for the new discipline to study, theorize and treat. There could now be a “science” of madness and distress, with its own experts and authorities. The new medical specialty sought to frame all its problems within a modernist, scientific and technical idiom. This grew to become the technological paradigm of psychiatry. Now it’s the dominant paradigm of psychiatry and mental health. “It underscores not just the medical model in psychiatry, but many of the alternatives being argued for at present.”

This technological approach is the foundation of the medical model of psychiatric “disease,” some of the psychological approaches to mental health, and positivist forms of social science. The only questions asked by this approach are: does it work; is it efficient; and is it cost effective. The technological paradigm shapes the classification systems of mental health problems (the DSM-5 and the ICD-10), the research into mental health problems, and the delivery system of clinical care. This is particularly true in the concept of “evidence-based medicine,” which has become the standard for many aspects of clinical care. Looking for a specific technical “fix” for a condition pushes the less technical issues to the periphery. They are still acknowledged, but are seen as secondary issues or causes.

In an article published in the journal World Psychiatry, Bracken detailed how psychiatry is currently going through a crisis of confidence. He argued the need for a hermeneutical shift in psychiatry. And if it is to be truly “evidence-based,” psychiatry needs to radically rethink its guiding epistemology, namely that of the technological paradigm. “We need a radical rethinking of our guiding epistemology: a move from reductionism to hermeneutics.” He rejected the heralded Research Domain Criteria (RDoC) project (see “Psychiatry Has No Clothes;” or “Psychiatry’s Mythical Phoenix;” or “The Quest for the Holy Grail of Psychiatry”) as a “quintessentially technological view of the future” that conceptualizes mental illnesses as brain disorders. He believes such an approach is simply inadequate.

Good psychiatry, he contends, involves a “primary focus on meanings, values and relationships,” both in terms of how patients are helped and where their problems come from. When the word “mental” is put in front of the word “illness,” it demarks “a territory of human suffering that has issues of meaning at its core. This simply demands an interpretive [hermeneutical] response.”

I do not believe that we will ever be able to explain the meaningful world of human thought, emotion and behaviour reductively, using the “tools of clinical neuroscience”.  This world is simply not located inside the brain. Neuroscience offers us powerful insights, but it will never be able to GROUND a psychiatry that is focused on interpretation and meaning. Indeed, it is clear that there is a major hermeneutic dimension to neuroscience itself. A mature psychiatry will embrace neuroscience but it will also accept that “the neurobiological project in psychiatry finds its limit in the simple and often repeated fact: mental disorders are problems of persons, not of brains. Mental disorders are not problems of brains in labs, but of human beings in time, space, culture, and history.”

Pat Bracken has an intriguing background. Not only is he a clinical psychiatrist, he also has a Ph.D. in philosophy. His thoughts can be found in various places online. Here is a link for “Bracken” on Mad in America. He helped found the UK division of the International Critical Psychiatry Network (ICPN). He’s co-written Postpsychiatry: A New Direction for Mental Health. Currently he is the Clinical Director of the Mental Health Service in West Cork, Ireland. Sadly he lives too far away to consult on cases in the Pittsburgh area.

09/21/15

The End of Alcoholism? Part 1

© Katarzyna Białasiewicz | 123rf.com

© Katarzyna Białasiewicz | 123rf.com

There is an existing generic medication called baclofen, a muscle relaxant, which has been primarily used to treat spasticity and multiple sclerosis. Now it is in the early research stages as a treatment for alcoholism. Olivier Ameisen, a French-American cardiologist used himself as guinea pig in testing baclofen to treat his own alcoholism. He said that baclofen saved his life by freeing him of all cravings for alcohol and suppressing his addiction. He’s written several journal articles and a book, The End of My Addiction, describing his active drinking and how baclofen helped him stop. Ameisen died of a heart attack on July 18, 2013, but his “discovery” lives on. Let’s see if it is a miracle treatment; or not.

First we will summarize his experiences by looking at The End of My Addiction and an article he wrote for the journal, Alcohol and Alcoholism about nine months after his “complete liberation from symptoms of alcohol dependence.” Afterwards, we will look at some of what the research literature has to say about baclofen.

Ameisen said he began to struggle with symptoms of alcohol dependence in the 1990s. In his struggles to stop drinking, he had numerous emergency hospitalizations, emergency room visits, detoxifications, and years of both inpatient and outpatient rehabilitation services. Because of his persistent and strong cravings for alcohol he tried disulfiram (Antabuse), but drank on it. He tried Naltrexone and acamprosate, which didn’t stop his cravings or his relapses. He achieved periods of prolonged abstinence, but always struggled with cravings and a preoccupation with alcohol.

He attended Alcoholics Anonymous—sometimes as often as two, three or four meetings a day. He had a sponsor and a home group. Twice he did a “90 in 90,” attending ninety meetings in ninety days. He achieved prolonged periods of abstinence, but continued to relapse. By his estimate, he attended roughly 700 meetings a year, over a period of 7 years between 1997 and 2004. But until he began using baclofen to treat himself, he was unable to maintain abstinence.

Ameisen noted that physicians are notoriously bad patients “who often inhibit their recovery by trying to run their own cases.” And he seems to have been one of the worst. Long before he experimented with baclofen, he preferred to administer his own detox at home after his binges. He objected to CPH (the Committee for Physician Health of the New York Medical Society) refusal for him to continue using benzodiazepines for his anxiety. “Being denied a standard medication for severe anxiety, the condition that triggered and fueled my craving for alcohol, was at best counterproductive and at worst callous and cruel.”

He moved back to France in 1999, where he continued to drink off and on; and continued to seek help to stop his drinking. His binge cycles became shorter and shorter. A treating psychiatrist told him he was afraid he would not live much longer. In the midst of a binge, a friend from New York sent him an article on baclofen treatment for cocaine craving she saw in the New York Times. He was in the midst of a binge and misplaced it. A year later in November 2001 he remembered the article and had the friend track it down and send him another copy. Thus began his investigation and growing belief that baclofen could be a treatment for his alcoholism.

He contacted the doctor mentioned in the New York Times article. In February of 2002 he bought a PC and began to search the internet for information on “baclofen and panic.” He added “baclofen anxiety;” and finally baclofen alcohol.” This led him to a 2000 research article written by an Italian researcher, Giovanni Addolorato on the ability of baclofen to reduce alcohol craving and intake. Ameisen checked with a neurologist friend who told him it was a safe drug; not addictive (Baclofen is not a controlled substance, but can impair thinking or reactions. Withdrawal can result in seizures and hallucinations in some long term users). He decided to order some baclofen and try it on himself. In The End of My Addiction, Ameisen wrote:

Until this point, I had steadfastly tried to be a good patient and had avoided benig my own physician, but it seemed to me that in order to save my life from alcoholism, I had no choice but to risk walking out onto a tightrope without the normal safety net of another physician’s supervision.

This seems to be an inconsistent memory by Ameisen. He had been acting as his own doctor from the time of preferring his own detox at home. Nevertheless, he started using baclofen on March 22, 2002 and gradually increased his dose to 180 mg daily. He found some immediate relief of his muscular tension. He slept better and felt calmer. But he continued to binge drink and he continued to do research into baclofen. Eventually he saw an animal study that suggested even higher doses of baclofen could suppress cocaine intake in rats addicted to cocaine. “The more I learned, the more I came to believe that at a high enough dose of baclofen, I too could reach a point where I would lose the motivation to consume alcohol.”

Then on January 8, 2004, he decided it was now or never. “If I continued to follow my doctor’s advice and the conventional treatments for alcoholism, I was going to keep lapsing into binges and eventually die from drinking. I had to take my treatment into my own hands.”

From the first day, he reported his anxiety was substantially reduced and his sleep became restful. By the 37th day on 270 mg of baclofen, “I experienced no craving or desire for alcohol for the first time in my alcoholic life.” He reported that even in a restaurant with friends, he was indifferent to people drinking. Drowsiness became an inconvenient side effect, so he tapered his dose down to 120 mg per day from days 49-63 of his abstinence from alcohol. He stabilized at that dose, with occasional additions of 40 mg as needed in stressful situations.

At first he avoided situations and places where alcohol was present. But then believed he did not have to be concerned about this. Even when socializing with friends who were drinking, he had no cravings for alcohol. He realized he was “completely and effortlessly indifferent” to alcohol. He was encouraged by a friend and physician to write a paper of his self experiment, which was eventually published in the journal Alcohol and Alcoholism. In the article he said:

At the end of my ninth month of complete liberation from symptoms of alcohol dependence, I remain indifferent to alcohol. Abstinence has become natural to me. I no longer plan my life around alcohol. Alcohol thoughts no longer occur. . . . I no longer suffer anticipatory anxiety of relapse, of embarrassing or dangerous alcohol-related situations. I am no longer depressed about having an incurable stigmatizing disease.

Eventually he wondered if he was vulnerable to relapse. “Would one drink plunge me back into the hell of alcoholism?” So in May of 2005, sixteen months after his abstinence with baclofen, he decided to put his recovery to the test with three successive challenges.

First, while continuing his maintenance dose of 120 mg of baclofen, he had three standard drinks over a few hours at a social gathering. He didn’t guzzle his first drink. He also didn’t finish his third drink. The second test was increasing his alcohol intake to five standard drinks over a six-hour span. Again, he had no urge to drink rapidly and experienced only a mild euphoria. But the following afternoon, he had a serious craving that he said an additional dose of 40 mg of baclofen suppressed within an hour.

His final test was to consume a massive amount of alcohol; similar to that he ingested during active relapse. Over an evening, he drank about 600 milliliters of Scotch. The next day he had a mild hangover, but no cravings. “It was good to discover that with baclofen I could drink in a nondependent way.” On occasions he said he would have a glass or two of champagne or a mixed drink. But he preferred to not drink. In a 2010 article for The Guardian, James Medd, reported Ameisen can now even drink socially. “I became disease free-free,” he said.

After his “self-case report” was published in Alcohol and Alcoholism, it didn’t cause much professional excitement. “But he found that potential patients were much more interested.” After two unsuccessful years of trying to work up interest within the medical system, Ameisen decided to write The End of My Addiction, published in France as Le Dernier Verre (The Last Glass). Small groups using high-dose baclofen sprung up around doctors who adopted Ameisen’s ideas and who were willing to prescribe baclofen off-label. Interest in researching the potential treatment benefits of baclofen also began to occur.

Ameisen did begin to gather some research and media interest in his treatment method with baclofen. Here is a 2009 video of Diane Sawyer interviewing him after the publication of his book.  Ameisen began to correspond with George Koob in 2005, who would become the Director of the NIAAA, the National Institute on Alcohol and Alcoholism in January of 2014. He reported agreeing to act as a consultant to a prospective study Koob planned to do on baclofen. There was a mention in a report by the Committee on the Neurobiology of Addictive Disorders (where Koob was the Committee Chair before moving to the NIAAA) that baclofen could block alcohol self-administration in rats. Here is a link to Koob’s 2007 published study.

Ameisen was not the first person to theorize baclofen could be useful in the treatment of alcoholism. But his self-experimentation and the publication of his results spurred an interest in baclofen. His theories may or may not be ultimately demonstrated as valid. But what is clear is that while he claimed baclofen ended his cravings for and addiction to alcohol, it didn’t end his drinking. Ameisen believes that “In addiction the symptoms ARE the disease.” So he sees suppressing his symptoms as “curing” his alcoholism. Since he doesn’t have cravings and doesn’t obsess over alcohol and drinking, he’s “cured.”

But what are the long-term consequences of high-dose baclofen treatment for alcoholism? It isn’t listed as a controlled substance, but there is a baclofen withdrawal syndrome and high dose users are discouraged from rapid tapering or withdrawal. So is there a slow developing physical dependency or dysregulation of the GABA system in the brain from long term use of baclofen? Is taking a dose of a drug daily to not drink alcohol really a cure for alcoholism? Ameisen asserted that he has yet to find a patient where it hasn’t been a success. But is that the whole story? Ameisen’s death came before there was an answer to these questions.

09/18/15

Obedience is Better than Sacrifice

14969291_sIn what seemed to be more of parody of a news story that you’d find on The Onion, a Jim Beam warehouse in Kentucky was struck by lightning. This released 800,000 gallons of bourbon into a nearby pond, which was itself struck by lightning, lighting the bourbon on fire. A small tornado passed over the scene, sucked up the flaming alcohol and created a firenado. Yes, you heard right—a firenado. I think this is what the insurance company would refer to as an act of God. Here is a short video of that scene.

The book of Leviticus has its own story of an act of God with fire, when the two eldest sons of Aaron were consumed by fire because they impulsively offered up unauthorized fire before the Lord. The literal meaning of the Hebrew word here is alien or strange, but the final phrase of Leviticus 10:1 helps us see where the sense of unauthorized is best:

Now Nadab and Abihu, the sons of Aaron, each took his censer and put fire in it and laid incense on it and offered unauthorized fire before the Lord, which he had not commanded them. And fire came out from before the Lord and consumed them, and they died before the Lord. (Leviticus 10:1-2)

The explanation of why Nadah and Abihu were consumed by fire is quite abbreviated in the text—they put fire and incense in their censers and offered unauthorized fire before the Lord. Period. For that, they died. What’s more, immediately before this in Leviticus 9:24, fire came out from before the Lord and consumed the burnt offering on the altar. In an act of approval, God consumes the sacrifice prepared for him. But then strikes down two of his priests for not following protocol. What is going on here? The brief description may be meant to elicit just such a response by the reader. So let’s look deeper.

Fire from heaven is equally used in a beneficial way and as judgment in Scripture, just it is here in Leviticus. Mark Rooker pointed out in his commentary on Leviticus that fire from heaven occurred twelve times in the Old Testament, six times in a beneficial way (Lev 9:24; Judges 6:21; 13:20; 1 Chronicles 21:26; 1 Kings 18:38; and 2 Chronicles 7:1) and six times in judgment (Leviticus 10:1; Numbers 11:1; 16:35; 2 Kings 1:10, 12; and Job 1:16).

Another lesson evident here is the importance of proper worship. John Calvin points us back to the ordination ceremony beginning in Leviticus chapter 8. In his commentary on Leviticus, Calvin said:

If we reflect how holy a thing God’s worship is, the enormity of the punishment will by no means offend us. Besides, it was necessary that their religion should be sanctioned at its very commencement; for if God had suffered the sons of Aaron to transgress with impunity, they would have afterwards carelessly neglected the whole Law.

Both Aaron and his four sons were installed as priests before the Lord. As the high priest, Aaron was singled out for special preparation in his consecration and then in his actual duties. In the ritual, Moses said: “This is the thing that the Lord has commanded to be done” (Leviticus 8:5). The consecration and preparatory sacrifices had to be just so, “for today the Lord will appear to you” (Leviticus 9:4). Aaron and his sons were careful to do all the things that God has commanded through Moses (Leviticus 8:36). And when all these things had been done in accordance with the commandment of the Lord, God fulfilled His promise:

Fire came out from before the Lord and consumed the burnt offering and the pieces of fat on the altar, and when all the people saw it, they shouted and fell on their faces. (Leviticus 9:24)

At this precise moment, Nadab and Abihu stepped forward with their own censors and offered up incense before the Lord. And for their impulsiveness, they died. Their illicit fire was met with divine fire. Up to this point in the ritual, all of Aaron’s sons had played a secondary role in the consecration and the sacrifices. Here they took matters in their own hands. The reply given by Moses to Aaron in Leviticus 10:3 suggests that this unsanctioned behavior had been a violation of acceptable behavior in the presence of the Lord. Moses told Aaron the Lord had said: “Among those who are near me I will be sanctified, and before all the people I will be glorified.”

John Hartley said: “By sanctifying themselves and by mediating between Yahweh and the people in the way that Yahweh has instructed, the priests honor him before the people.” But according to Numbers 18:1-7, if any priest violated the sanctity of the sanctuary, the whole community would come under God’s wrath until those in the wrong were removed. By His swift action against Nadab and Abihu, God spared the people of Israel from his wrath.

Still, it seems that God was being too harsh for a mere failure to comply with religious ritual. At the end of Leviticus 10, Moses and Aaron have words over Aaron’s failure to comply with the requirement that the priests eat the sin offering in the sanctuary (Leviticus 6:24-30). No one died from fire then and Moses was satisfied with Aaron’s reasons not to eat the sacrifice as required. What was the big deal with Aaron’s sons?

There is a suggestion to what was going on with Nadan and Abihu in what the Lord spoke to Aaron in Leviticus 10:8-11. The heading in 10:8, “And the Lord spoke to Aaron,” is the only time in Leviticus where the Lord addressed Aaron by himself. All the other instances read “Moses and Aaron” (11:1; 13:1; 14:33; 15:1). According to Hartley, “This means that the following words have tremendous importance for the priests. It also means that Yahweh continues to recognize Aaron as high priest despite the transgression of his two eldest sons.”

Then God said Aaron and his sons should not drink alcoholic beverages when they go into the tent of meeting, “lest you die.” They are to distinguish between the holy and the common, between the clean and the unclean. And they are to teach the people of Israel all the statutes the Lord has spoken to them by Moses.

Placing the decree to not drink alcohol at Leviticus 10:9 could be implying that alcohol was a contributing factor in the sin of Nadab and Abihu. Inebriated, they were unclean while attempting to fulfill an act of worship in the presence of the living God. By their example, they were teaching the people of Israel to disregard the statutes of the Lord. Hartley mentioned this as a possibility, but was quick to point out there is nothing in the actual text of Scripture to support this interpretation. Nevertheless, Mark Rooker said: “This warning was surely received with undivided attentiveness coming on the heels of the transportation of Nadab and Abihu from the tabernacle.”

The possibility that drunkenness was a factor in their destruction is intriguing. Drunkenness is condemned in several Scriptures, such as Proverbs 20:1; 23:29-35; Hosea 4:11; and Isaiah 5:11-12). Within a judgment oracle found in Isaiah 28:7-13, priests and prophets who fail in their spiritual responsibilities are portrayed as drunkards. They reel in vision and stumble in giving judgment. Their tables are covered in vomit. Who will they teach? Infants just weaned from their mothers’ breasts? Their words will be nonsense. Pronouncing the phrase in verse 28:10 and 13, “precept upon precept, precept upon precept, line upon line, line upon line, here a little, there a little,” has a distinctive drunken slurring when recited in Hebrew.

But I think there is a better, simpler explanation. They were disobeying the clear and specific command of God. They decided they could disregard the commands of God and worship the Lord as they saw fit. Such spiritual leadership was the antithesis of what Aaron and his sons had just completed in their installation as priests. In a similar situation, the prophet Samuel said to Saul, “to obey is better than sacrifice.”

Through Samuel, God commanded that Saul should “devote to destruction” every Amalekite and all their livestock. Instead, Saul spared the king, Agag and the best of the livestock. But “all that was despised and worthless they devoted to destruction.” Yet when confronted by Samuel with his disobedience, Saul claimed he had obeyed. Samuel said, “Then why do I hear the bleating of sheep and the lowing of oxen?” Saul then lied, saying the people saved the best of the livestock to sacrifice to the Lord. Then Samuel said: “Has the Lord as great delight in burnt offerings and sacrifices, as in obeying the voice of the Lord? Behold, to obey is better than sacrifice, and to listen than the fat of rams” (1Samuel 15:22).

Disregarding the command of God disqualified Saul as king. Samuel went on in 15:23 to say that rebellion was the same as divination, and presumption the same as idolatry. “Because you have rejected the word of the Lord, he has rejected you from being king.” Because Nadab and Abihu rejected the word of the Lord, he rejected them from being priests.

09/16/15

The Quest for Psychiatric Dragons, Part 2

© Olesia Sarycheva |123rf.com

© Olesia Sarycheva |123rf.com

The fallout from the Rosenhan study couldn’t have come at a worse time for psychiatry. Spitzer was in the midst of trying to put out one fire with the crisis brought about by gay activism against the APA. Then Rosenhan demonstrated that “psychiatrists could not distinguish the sane from the insane” from another angle.

Pseudopatients were admitted into psychiatric hospitals, but were not identified as such by hospital staff. The problem with the unreliability of psychiatric diagnosis was now front-page news, just as Spitzer and one of the coauthors of his 1967 article on the kappa statistic, Joseph Fleiss, were about to publish their own critique of psychiatric diagnosis. Their study, “A Reanalysis of the Reliability of Psychiatric Diagnosis,” became another classic article in the psychiatric literature.

The Spitzer and Fleiss study was received by the British Journal of Psychiatry on January 17, 1974, and published in the October 1974 issue of the BJP. The Spitzer and Fleiss article was received by the BJP about a month after the APA decision to remove homosexuality from the DSM-II and a year after the Rosenhan study was published.

Applying the kappa statistic in the re-analysis of five previous studies of diagnostic reliability, Spitzer and Fleiss said: “The reliability of psychiatric diagnosis as it has been practiced since at least the late 1950s is not good.” They were confident that developing structured interviews and specifying all diagnostic criteria “will result not only in improved reliability, but in improved validity, which is, after all our ultimate goal.” In The Selling of DSM, Stuart Kirk and Herb Kutchins said: “This article carefully and dramatically sets the stage for DSM-III. It reinterprets and denigrates the past, refers to innovations being currently developed by the authors and others, and predicts success in the future.”

The historical context suggests to me that the one-two punch of the gay activists and the Rosenhan study caught Spitzer and the other psychiatric researchers by surprise. These two events not only raised questions about the unreliability of psychiatric diagnosis, but they did it in a way that was easy to grasp by the public. They also publicly embarrassed psychiatry. How could trained psychiatrists not be able to tell whether someone was faking their symptoms? How could homosexuality be voted out of being a mental disorder? What implications do these two events have for diagnosing other so-called mental disorders?

Psychiatry now faced serious threats to its credibility, perhaps to its very existence. As Whitaker and Cosgrove noted in Psychiatry Under the Influence, the APA did recognize how the rampant criticism threatened their profession. “The public did not have a ‘strong conception of psychiatry as a medical specialty,’ and failed ‘to recognize a psychiatrist’s special competence in mental health care.’”

After his achievements in removing homosexuality from the DSM-II, and being appointed the chair for the DSM-III, Spitzer took on Rosenhan. Spitzer published his critique of Rosenhan’s study in the Journal of Abnormal Psychiatry in October of 1975, “On Pseudoscience in Science, Logic in Remission, and Psychiatric Diagnosis.” Spitzer’s article was originally received on November 1, 1974, less than a month after he and Fleiss published their article. He revised and resubmitted it on April 14, 1975. Several other articles on Rosenhan’s study were published in the same issue of the Journal of Abnormal Psychiatry. Spitzer now defended psychiatry and to a certain extent, diagnosis. Kirk and Kutchins noted that Spitzer was in the awkward position of defending psychiatric diagnosis, while he was in the process of restructuring it.

His rhetoric was clever and forceful. He characterized Rosenhan’s study as “pseudoscience,” playing to Rosenhan’s reference to his “pseudopatients.” Spitzer also referred to Rosenhan’s discussion of the pseudopatients discharge diagnosis as schizophrenia in remission as “logic in remission.” Kirk and Kutchins said:

Some of Spitzer’s criticisms of the design of the study were warranted, although his zeal to discredit Rosenhan sometimes led him simply to disregard or distort basic observations. . . . The importance of Spitzer’s comments are not what they tell us about Rosenhan’s study, but what they tell us about Spitzer’s new enterprise, the making of the DSM-III.

First he sought to invalidate Rosenhan’s basic point, namely the criticism of psychiatric practices that could not distinguish the sane from the insane. According to Spitzer, “A correct interpretation of [Rosenhan’s] own data contradicts his own conclusions. In the setting of a psychiatric hospital psychiatrists are remarkably able to distinguish the ‘sane’ from the ‘insane.’” Secondly, he used his article to redefine the problem of psychiatric diagnosis as one of reliability, and cited his own article, “A Reanalysis of the Reliability of Psychiatric Diagnosis,” and its recommendations in support of this conclusion. “Recognition of the serious problems of the reliability of psychiatric diagnosis has resulted in a new approach to psychiatric diagnosis.” In effect, Spitzer was saying to his audience of psychiatrists and other mental health professionals, “We already knew about the problem and have been working on a solution.”

Spitzer then reworked his article and published the revision in the Archives of General Psychiatry: “More on Pseudoscience in Science and the Case for Psychiatric Diagnosis.” The article was accepted for publication on December 12, 1975 and published in the April 1976 issue. In the introductory comments of his 1976 article, Spitzer observed that partly because of the prestige of Science, the journal in which it was published, and partly because it said what many others wanted to hear, “The [Rosenhan] study was widely acclaimed in the popular news media. . . . As a consequence, this single study is probably better known to the lay public than any other study in the area of psychiatry in the last decade.” And he was right.

In February of 1980, as the DSM-III was about to be published, Spitzer et al. published an article in The American Journal of Psychiatry that reviewed the achievements and changes in psychiatric diagnosis within the DSM-III. They also claimed the reliability problem had been significantly improved. “For most of the diagnostic classes the reliability was quite good, and in general it was much higher than that previously achieved with DSM I and DSM II.” As it turned, out this was not true. In their book, The Selling of DSM, and in an article, “The Myth of the Reliability of DSM,” Stuart Kirk and Herb Kutchins demonstrated how the standards for interpreting reliability were dramatically shifted in order to make it easier “to claim success with DSM-III, when in fact, the data were equivocal.”

David Rosenhan died on February 6, 2012 after a long illness. His obituary published in American Psychologist commented: “The lessons he cared most about offering, in the classroom as in his research, were about human dignity and the need to confront abuse of power and human frailties.” Robert Spitzer retired in December of 2010. According to Jeffrey Lieberman in Shrinks, it was because of a severe and debilitating form of Parkinson’s disease. But the fight over the legitimacy over psychiatric diagnosis continues and Robert Spitzer has been one of the critics of the recent revision process for the DSM-5. Joining him in this dispute is Allen Frances, the chair of the DSM-IV Task Force.

Writing for Wired, Gary Greenberg noted that the DSM-5 battle comes at a time when the authority of psychiatry “seems more tenuous than ever.” The director of the National Institute of Mental Health (NIMH), Thomas Insel, announced the NIMH wouldn’t be using the DSM to structure its research. “Some mental health researchers are convinced that the DSM might soon be completely revolutionized or even rendered obsolete.” Other psychiatrists privately fret that “the DSM-5 will create ‘monumental screwups’ that will turn the field into a ‘laughingstock.’” None of them were willing to go on record with their concerns for fear of retaliation. Reflecting on the ongoing debate over psychiatric diagnosis, Allen Frances was reminded of medieval maps that had notations such as “dragons live here” in places where their knowledge was lacking. “We have a dragon’s world here. But you wouldn’t want to be without that map.”

09/14/15

High on Flakka

P14296870603635738mFlakka continues to make the news and it seems to be spreading beyond its popularity in South Florida. A Fusion article showed that while 48% of the confirmed cases of flakka in the first half of 2014 were from Southern states, 27% were in the North East and 23% in the Midwest. “In 2015, individuals have been arrested for dealing Flakka in Illinois, Iowa, New York, and Minnesota.”

But the largest epicenter outside of Florida may be southern Ohio around the town of Ironton. In January of 2015, two brothers, residents of Ironton, were arrested and charged with trafficking in alpha-PVP (flakka). Detective Joe Ross said they were having a lot of complaints from citizens about the sale of Alpha-PVP.  “It’s been a big problem here in the city and in the county.”

In Broward County, Florida, flakka accounted for 34% of their crime lab reports. In the ten months prior to August 2015, 33 people died from flakka-related overdoses in Broward County alone. Hospitals in Broward County reported seeing up to 20 flakka-related patients a day. Two men in Broward County pleaded guilty in August 2015 to importing more than 24 pounds of the main ingredient in flakka from China. Also see “Flack from Flakka” and this article by McCarton Ackerman on The Fix.

Flakka is more than just fodder for crazy news stories about naked people running around saying they are Satan, or trying to break into police stations to avoid get away from 20 cars chasing them and trying to kill them. It has also caught the attention of respected addiction professionals—Terence Gorski and researchers at The Scripps Research Institute.

Scientists at The Scripps Research Institute (TSRI) have found that flakka (alpha-PVP) seems to be equivalent to MDPV (bath salts). The study was a classic animal pressing a drug-delivery lever study; and the rats increased their lever pressing for the drug as the 20 daily sessions progressed. “When the researchers increased the number of lever presses required to get one dose, the animals kept pressing—for up to hundreds of presses per dose.” Those rats must have REALLY like their flakka. Head-to-head tests of flakka and bath salts showed an almost identical potency for inducing lever presses. This suggested to the researchers that the horror stories about flakka may have been overblown. An abstract for the 2015 study discussed by Aarde et al., is here.

They noted how a 2013 study, also by Aarde et al., found that bath salts induced far more drug-seeking lever presses among rats than crystal meth. In a TSRI News & Views report of the 2013 study, researchers said the rats worked more than ten times harder to get bath salts instead of crystal meth. “Animals will self-administer MDPV like no drug I have ever seen.” Where rats would emit about 60 presses on average for a dose of meth, they would emit around 600 for bath salts. “Some rats would emit 3,000 lever presses for a single hit of bath salts.”

Another study, Aarde et al. (2015b), found that bath salts could induce rats to forgo other rewarding behaviors. Rats will almost always respond more to food and tasty flavors than drugs. In this study, wheel running, a normally rewarding activity for rats, declined significantly as they self-administered more bath salts. A subset of the rats didn’t gradually increase their intake of bath salts. Rather, they went from occasional sampling to binging on as much as they could get during a session. “That was when they stopped using the wheel—that very day they binged.” An abstract of the Aarde et al. (2015b) binge study is here.

Terence Gorski wrote an informative summary about flakka on his blog: “Flakka: What You Need to Know.” He said it can cause extreme behavioral reactions and there have been reports of long-lasting neurological damage. “It is definitely a dangerous drug that is rapidly entering the drug-using culture.” Citing Jacob Sullim on reason.com, he suggested his readers read his blog to get a balanced view on flakka. Here is a link to Sullum’s article.

Gorski noted how flakka was a relatively new drug, initially available in South Florida in the spring of 2015. It’s a variation of bath salts (MDPV). The active ingredient, alpha-PVP, is a synthetic cathinone, the active ingredient in the khat shrub. Flakka is a stimulant and induces paranoia, psychosis and aggression. In high doses, it leads to “excited delirium,” with high body temperatures rising up to 107F. This leads to many users stripping off their clothes because they feel like they are on fire. When restrained, individuals on flakka scream, flail and struggle to free themselves. The struggling causes high core body temperatures, called hyperthermia, which needs immediate medical treatment to prevent disability and death. The struggling can also cause dehydration.

Flakka can be injected, swallowed, smoked or snorted. Especially when smoked or vaped, individuals can overdose on flakka. Remember the overdose deaths in Broward County noted above. It looks like a white or pink crystal; and smells like sweaty socks. Flakka users can become very agitated, making them verbally aggressive and irrational. Muscle tissue begins to break down, releasing proteins and other cellular products into the bloodstream, a condition referred to as rhabomolysis. It can lead to complications such as renal (kidney) failure and in rare cases, death. Gorski also provided this link to the Drudge Report Archives, which tracks news stories on flakka.

If understanding the danger from this drug hasn’t gone from your head to your gut yet, watch a few of these YouTube videos of people on flakka: “Flakka drug effects;” “High on Flakka;” Crazy! Woman High on “Flakka;” “Woman in Florida on Flakka.” Here is a 6 minute video from Fusion: “We spent 24 hours living through Florida’s flakka crisis.”

09/11/15

Practice What You Preach

© vepar5 | 123rf.com

© vepar5 | 123rf.com

One of the first things to know about Matthew 5:17-20 is that it is essentially unique to the gospel of Matthew. It seems to be an introduction to the topics Jesus addresses in verses 5:21 through 5:48. He reminds his audience in each of the following passages of what they have been previously taught as he introduces each issue: “You have heard it said.” But then he shows them the true spiritual depth of these commands: “But I say to you.”

But first, beginning in 5:17, Jesus used four full verses to be sure his audience clearly understood that what he was about to teach them was not abolishing or nullifying the Law and the Prophets. This was a typical way to refer the entire Hebrew Scriptures (the Old Testament for Christians). The Law referred to the Torah; or Pentateuch; the first five books of the Bible. Jesus did not intend to bring about an extreme makeover or a demolition of the teachings of the Old Testament. Rather, he wanted to fulfill them.

Do not think that I have come to abolish the Law or the Prophets; I have not come to abolish them but to fulfill them. (Matthew 5:17)

Leon Morris pointed out in his commentary on Matthew that by using the Greek word for fulfillment, Jesus was speaking of more than obedience to regulations here. There is a sense of continued obedience; or of completing; or bringing about its full meaning. Perhaps something from all three was within his use of the Greek word here. Morris also observed there are 613 commandments in the Old Testament, 248 positive ones and 365 negative ones. Using hyperbole, Jesus said that not even the smallest letter or even a part of a letter from any word in the Law would pass away before the entire creation (heaven and earth).

For truly, I say to you, until heaven and earth pass away, not an iota, not a dot, will pass from the Law until all is accomplished. (Matthew 5:18)

Therefore, anyone who relaxed or nullified one of the least of the commandments in the Scriptures and taught others to do the same would not be recognized for their efforts in heaven. But whoever did them and taught others to keep the commandments would be recognized in heaven for their efforts. Misunderstanding what Jesus was saying here would provide fertile ground for legalism to flourish. Legalists keep the letter of a commandment while nullifying its spirit.  To “fulfill” is not the same as to “keep.” And Jesus now was about to catch two of the most religious groups of his time off guard.

Therefore whoever relaxes one of the least of these commandments and teaches others to do the same will be called least in the kingdom of heaven, but whoever does them and teaches them will be called great in the kingdom of heaven. (Matthew 5:19)

The two religious groups widely recognized for their knowledge of the Law and their zeal for keeping the commandments of the Law at the time were the scribes and the Pharisees respectively. So up until verse 5:20, any scribe or Pharisee hearing what Jesus said would have been nodding his head in agreement. They knew and kept the commandments—and were proud of it.  They taught others what should be done to enter into heaven. Surely they were the ones who would be called “great” in the kingdom of heaven. But no—Jesus said to his audience, your righteousness must exceed that of the scribes and Pharisees!

Unless your righteousness exceeds that of the scribes and Pharisees, you will never enter the kingdom of heaven. (Matthew 5:20)

If you weren’t MORE righteous than the two highest status religious groups of that time, you couldn’t enter the kingdom of heaven. The message was that getting to heaven was more than knowing and keeping the commandments. The legalism and religiosity of the scribes and Pharisees won’t cut it. Your righteousness has to be better than theirs. Now Jesus had a captive audience. What could he possibly be about to say that would fulfill the Law and the Prophets? How would he apply the Law and the Prophets so differently from what the scribes and the Pharisees taught?

Broadly speaking, scribes were individuals who could read and write—talents that were not common to most individuals back then. These talents meant they would serve as secretaries or clerks—a higher status and function than we would think of today. Scribes in Jewish times were seen as men of wisdom, who studied the Law. They were teachers and legal experts with religious authority. The Dictionary of New Testament Background said Jewish scribes applied the general instructions of the Torah to daily living. They even extended the law to theoretical situations “To build a safety net against inadvertent breaches.”

The Pharisees seem to have been drawn more from the laity and not from the priestly or aristocratic classes. They too were experts and strict interpreters of the Mosaic Law. They developed a comprehensive set of oral extensions of the Law, which were to maintain their religious identity and purity. There are even some references to the scribes of the Pharisees (Mark 2:16 and Acts 23:9), possibly suggesting that scribes were a subgroup of Pharisees. Alternatively, the sect of Pharisees could have had individuals who could read and write and thus acted as scribes within the sect.

Nevertheless, it seems that both groups were singled out as religious leaders who didn’t practice what they preached. In chapter 23 of Matthew, Jesus said: “The scribes and the Pharisees sit on Moses’ seat, so do and observe whatever they tell you, but not the works they do. For they preach, but do not practice” (Matthew 23:2-3). So here in chapter 5 of Matthew, Jesus is saying that you have to walk your talk—you have to practice what you preach—to get to heaven. Again, Leon Morris summarized the intent succinctly:

Jesus’ understanding of keeping the law meant a great deal more than making sure that the letter of the law was not infringed. For him it was important that the deeper implications of what God had commanded be understood and put into practice.

The application here for recovery is in the call to “walk your talk.” Just as Jesus said that those who both taught and did the commandments would be great in the kingdom of heaven, those who practice what they preach in recovery will stay sober and help others to stay sober at the same time. True spirituality in Christianity and in recovery is when someone lives out what they tell others. They don’t just know the Bible or the Big Book—they strive to live it.

There are parallels to “scribes” and “Pharisees” in 12 Step Recovery as well. When you see someone affirming the truth of a Step or a saying, but not truly living out the spirit of it’s meaning, then you are keeping rather than fulfilling it. Here is an example: individuals who only count abstinent time with their drug of choice. Someone could be in Alcoholics Anonymous and rationalize they aren’t drinking alcohol anymore, but they smoke marijuana. A heroin addict might say they never had a problem with alcohol, so its okay if they drink, as long as they don’t use heroin. I also don’t think that having a doctor diagnose you with an anxiety disorder means you can take benzodiazepines. Taking a mind-altering and mood changing substance to not use another mind-altering or mood changing substance is not walking your talk.

Recovery is not just knowing and “keeping” the Steps, but fulfilling them in your life—and then passing how to do that on to others.

This is part of a series of reflections dedicated to the memory of Audrey Conn, whose questions reminded me of my intention to look at the various ways the Sermon on the Mount applies to Alcoholics Anonymous and recovery. If you’re interested in more, look under the category link “Sermon on the Mount.”

09/9/15

The Quest for Psychiatric Dragons, Part 1

© dvarg | 123rf.com

© dvarg | 123rf.com

In her book, Opening Skinner’s Box, author Lauren Slater related a conversation she had with Robert Spitzer, one of the most important psychiatrists of the twentieth century. She told him of the personal struggles of another individual that Spitzer was historically linked to, David Rosenhan. Slater told Spitzer that Rosenhan’s wife had died of cancer, his daughter had died in a car crash and he was paralyzed from a disease that doctors couldn’t diagnose. She reported that Spitzer’s response was: “That’s what you get for conducting such an inquiry.”

There are questions regarding the truth of what Slater reported here. Spitzer himself said that he doesn’t remember saying that. And if he did, he meant it in a joking way. However, Slater’s observation that “Rosenhan’s study is still hated in the field [of psychiatry] after forty years” is very true. In his recently published book Shrinks, Jeffrey Lierberman, a former president of the American Psychiatric Association, described Rosenhan at the time of his infamous study as “a little-known Stanford-trained lawyer who had recently obtained a psychology degree but lacked any clinical experience.” He thought the 1973 Rosenhan study had fueled an “activist movement that sought to eliminate psychiatry entirely.” See “A Censored Story of Psychiatry” Parts 1 and 2 for more on Rosenhan’s study and Lieberman’s portrayal of it.

In 1973, the American Psychiatric Association (APA) was in crisis. Gay activists had actively protested at the annual APA meetings between 1970 and 1972, seeking to have the APA remove homosexuality as a mental disorder from the DSM. Robert Spitzer, the architect of the diagnostic revolution that was codified in the DSM-III, related in an interview that he was at a symposium on the treatment of homosexuality in 1972 that was disrupted by a group of gay activists. He recalled that in effect, the activists were saying they wanted the meeting to stop; because “You’re pathologizing us!” The media attention of the above protests created a very public embarrassment for psychiatry. Kirk et al., in Mad Science, commented:

An entire group of people labeled as mentally ill by the American Psychiatric Association was disputing its psychiatric diagnosis. At the core of their challenge was a simple, east-to-understand question: why was homosexuality a mental illness?

Spitzer approached one of the protesters after the symposium was cancelled and their conversation led to a meeting between some of the activists and an APA committee Spitzer was a member of, the APA Task Force on Nomenclature and Statistics. Spitzer recalled that the gist of the meeting was “the idea that the only way gays could overcome civil rights discrimination was if psychiatry would acknowledge that homosexuality was not a mental illness.” After the meeting with the Nomenclature and Statistics Task Force, Spitzer proposed the APA organize a symposium at the annual APA meeting in May of 1973. He continued to be active with this issue within the APA, and was responsible for the position statement (formulated on June 7, 1973 by Spitzer) that was approved by the APA Board of Trustees in December 1973 removing homosexuality as a diagnosis from the DSM.

Concurrent with this issue was the fallout from the publication of David Rosenhan’s article in the January 1973 issue of Science, “Being Sane in Insane Places.” Kirk et al. noted that the study was intriguing, easy to understand and had striking results. So it received a lot of media attention. The study reinforced the view that psychiatric judgments were inadequate, and even laughable. “Once again, the target of the joke was the scientific pretence of psychiatric diagnosis: Psychiatrists could not distinguish the sane from the insane.”

Jeffery Lieberman, a former president of the APA and author of the book Shrinks, said that an emergency meeting of the Board of Trustees was called in February of 1973 “to consider how to address the crisis and counter the rampant criticism.” Lieberman related how the APA Board of Trustees realized the best way to deflect the “tidal wave of reproof” was to make a fundamental change in how mental illness was conceptualized and diagnosed. They agreed that the most compelling means would be to transform the DSM. By the end of the emergency meeting, the trustees had authorized the creation of the third edition of the DSM.

Lieberman said Robert Spitzer wanted to be in charge of the revision process as soon as he heard it had been approved. Spitzer recalled,  “I spoke to the medical director at the APA and told him I would love to head this thing.”  In part because of the way he handled the quandary over homosexuality, Spitzer was appointed to chair the DSM-III Task Force in 1974. But he had already positioned himself as an expert on psychiatric diagnosis.

I think it is fair to say that Spitzer had been aiming towards this appointment for almost seven years. His association with the DSM began in 1966, when he agreed to take notes for the DSM-II committee. Then Spitzer et al. introduced use of the kappa statistic into the literature on psychiatric diagnosis in their 1967 study, “Quantification of Agreement in Psychiatric Diagnosis.” In The Selling of the DSM, Stuart Kirk and Herb Kutchins commented that the introduction of kappa appeared to provide a way to unify the comparison of reliability studies, while eliminating the statistical problem chance agreement at the same time. Joseph Fliess, who would later co-author with Spitzer their seminal 1974 study, was one of the authors here.

Before the Rosenhan study in 1973, Spitzer and others had already published several articles related to revising psychiatric diagnosis in the Archives of General Psychiatry: “Immediately Available Record of Mental Status Exam” (July, 1965);  “Mental Status Schedule” (April 1967); “Quantification of Agreement in Psychiatric Diagnosis: A New Approach” (July, 1967); “DIAGNO: A Computer Program for Psychiatric Diagnosis Utilizing the Differential Diagnostic Procedure” (June, 1968); “The Psychiatric Status Schedule” (July, 1970); “Quantification of Agreement in Multiple Psychiatric Diagnosis” (February, 1972). And these were just those published in the Archives.

In 1971 Spitzer was introduced to a group of psychiatric researchers from Washington University in St. Louis. They were working to develop diagnostic criteria for specific mental disorders. Spitzer was in heaven. Lieberman reported Spitzer said: “It was like I had finally awoken from a spell. Finally, a rational way to approach diagnosis other than the nebulous psychoanalytical definitions in the DSM-II.” According to Whitaker and Cosgrove in Psychiatry Under the Influence, more than half of the members Spitzer appointed to the DSM-III Task Force had an existing or past affiliation with Washington University.

Feighner et al., the group of researchers at Washington University in St. Louis, published “Diagnostic Criteria for Use in Psychiatric Research” in 1972. They proposed specific diagnostic criteria for 14 psychiatric disorders, along with the validating evidence for those criteria. Kirk and Kutchins said their work became known as the Feighner criteria, after its senior author. This study became a classic in the psychiatric literature, and has been cited over 4,000 times since its publication.

In 1978, Spitzer and others would use the Feighner criteria to produce the “Research Diagnostic Criteria”  (RDC), another significant step in the formation of the DSM-III. Kirk and Kutchins said: “These two articles … and the work on which they were based are among the most influential developments in psychiatry” since the late 1960s. An important fact in both the Feighner criteria and Spitzer’s RDC, was they were initially developed only for use in research. “Neither article proposed that the elaborate diagnostic systems be adopted by clinical psychiatrists.” That came later. But you can see the path that Spitzer had been walking since 1967. He wanted to radically change psychiatric diagnosis and had been methodically moving in that direction. And then the Rosenhan study, “Being Sane in Insane Places” was published in the journal Science.