06/30/17

Rooting for the Underdog

© konstantynov | 123rf.com

In July of 2010, a 57-year-old partner at the law firm Reed Smith jumped in front of a subway train in Chicago and died. His widow, Wendy Dolin, sued the pharmaceutical companies GlaxoSmithKline (who originally manufactured Paxil) and Mylan (the drug company who manufactured paroxetine, the generic version that Stewart Dolin took), charging that the drug caused akathisia, which led to his suicide. GSK attorneys dismissed the testimony of the plaintiff’s expert witness as “junk science,” which argued for a link between the drug and suicide. However it seems the jury disagreed, since on April 20th, 2017 they awarded a $3 million verdict for the plaintiff.

Mylan was released from the suit by the trial judge, who ruled they had no control over the drug’s label. GSK continues to maintain the company wasn’t responsible since it hadn’t manufactured the drug taken by Dolin. A Chicago Tribune article quoted Wendy Dolin as saying the ruling was “a great day for consumers.” The trial was not just about the money for her. It was about awareness to a health issue. But this isn’t the end. “Officials from the pharmaceutical company said the verdict was disappointing and that they plan to appeal.” GSK continues to assert they weren’t responsible because they didn’t manufacture the drug taken by Dolin.

Writing for Mad in America, attorney and activist Jim Gottstein noted the legal significance of the case, as it established GSK did not inform the FDA or doctors that Paxil could cause people to commit suicide—a conclusion GSK continues to deny. A second legal hurdle overcome by the ruling is a Catch-22 dilemma since SSRIs, like Paxil, are now usually prescribed as generics. “The generic drug manufacturer [Mylan} isn’t liable because it was prohibited from giving any additional information and the original manufacturer [GSK] isn’t liable because it didn’t sell the drug.” You can read Jim Gottstein’s article for an explanation of how these legal hurdles were overcome.

Bob Fiddaman interviewed Wendy Dolin after the verdict and she described some disturbing tactics used by GSK attorneys. She said depositions that should have been a few hours long became eight hours, “in an attempt to wear people down.” She said GSK asked the same question over and over again, hoping to confuse or manipulate people. She alleged they also called her friends, trying to get them to say something negative about her relationship with her deceased husband.

As a therapist, as a mother and a compassionate human being, I am aware there was no purpose to have done such. I have talked to therapists, physicians and pharmaceutical lawyers and all agree there was nothing gained by this other than to show me that GSK would stop at nothing to intimidate me.

During the trial it came to light that 22 individuals had died in Paxil clinical trials, 20 by suicide; two other deaths were suspected to be suicide. “All 22 victims were taking Paxil at the time, and 80% of these patients were over the age of 30.” GSK tried to argue their “illness” caused their deaths and not Paxil. Wendy Dolin said the lawsuit showed that “akathisia is a real, legitimate adverse drug reaction.” The public needs to be aware of its signs and symptoms.

Wendy said she knew even before they went to trial, that GSK would appeal the ruling if they lost. She thought there was a GSK lawyer in the courtroom during the trial gathering information for the appeal process. She said it had been suggested this case could go all the way to the Supreme Court, because GSK is afraid of the legal ramifications of a guilty verdict. The process could take 5-7 years. She said: “Clearly this case has never been about money. For me, it has always been about awareness, highlighting akathisia and ultimately changing the black box warning to include all ages.”

Writing for STAT News, Ed Silverman suggested the new head of the FDA, Scott Gottlieb, should require a stronger warning label for Paxil. “For the past decade, Paxil’s label has not carried any information indicating the drug poses a statistically significant risk of suicidal behavior for anyone over 25.” Yet there is scientific evidence of such a risk. See Table 16 in the linked “Exhibit 40” document of his article (I assume it’s from the Dolin trial). Silverman said: “For public health reasons, the FDA should pursue a warning.”  A former FDA commissioner was quoted as saying it was hard for him to understand why the warning of increased suicidal risk was not in the label.

But sucidality is not just a risk with Paxil (paroxetine). A meta-analysis done by Peter Gotzsche of the Cochrane Collaboration concluded that antidepressants doubled the risk of suicidality and aggression in children and adolescents. Gotzsche and his team of researchers reviewed the clinical study reports for duloxetine (Cymbalta), fluoxetine (Prozac and Sarafem), paroxetine (Paxil), sertraline (Zoloft), and venlafaxine (Effexor). Estimates of harm could not be accurately done because the quality of the clinical study reports varied drastically, limiting their ability to detect the harms. The true risk for serious harms was uncertain, they said, as the low incidence of these events and the poor design and reporting of the trials made it difficult to get accurate estimates.

A main limitation of our review was that the quality of the clinical study reports differed vastly and ranged from summary reports to full reports with appendices, which limited our ability to detect the harms. Our study also showed that the standard risk of bias assessment tool was insufficient when harms from antidepressants were being assessed in clinical study reports. Most of the trials excluded patients with suicidal risk and so our numbers of suicidality might be underestimates compared with what we would expect in clinical practice.

In April of 2016, the CDC released data indicating the suicide rate in the U.S. increased by 24% from 1999 to 2014. Overall, the age-adjusted suicide rate increased from 10.5 per 100,000 in 1999, to 13.0 per 100,000 in 2014. The rates increased for both males and females and for all ages from 10 to 74. The age-adjusted rates for males (20.7 per 100,000 population), was over three times that of females (5.8 per 100,000). Males preferred firearms as a method (55.4%), while poisoning was the most frequent method for females (34.1%). However, this was a lower percentage for both sexes than in 1999. See the following figure from the CDC Report noting suicide deaths by method and sex for 1999 and 2014.

This reverses a trend from 1985 to 2000, where the U.S. suicide rate was dropping. See the following chart taken from an NPR report on the same data.  The president-elect of the American Psychiatric Association (APA), Maria Oquendo, said she thought the late 1980s drop was probably due to the fact that new antidepressants (SSRIs) were more effective and had fewer side effects.

Karter noted how Oquendo and Christine Moutier (from the American Foundation for Suicide Prevention) both saw the addition of black box warnings of the potential for suicide in teenagers and young adults as contributing the rise in suicide rates. Moutier was more direct, stating the progress in depression treatment in the 80s and the 90s “was undone in recent years because of concerns that antidepressants could increase suicide risk.” Oquendo thought the increase of suicide deaths in younger populations was potentially due to the understandable reluctance of physicians to prescribe antidepressants to these individuals, “even when they’re aware the individual is suffering from depression.” She added how research showed the benefits outweigh the risks of prescribing antidepressants to children and adolescents.

But Justin Karter indicated this suggestion, that the warning labels led to a decreased number of antidepressant prescriptions for teenagers and adults, was inaccurate. Although several media outlets reported the increase in the suicide rate, they didn’t report the corresponding increase of Americans taking antidepressants, a rate that has nearly doubled.

There was a report published in the British Medical Journal in June of 2014 that indicated black box warnings on SSRIs had a paradoxical effect, with an increase in suicide attempts among youths. Mad in America cited 12 critics of the study and noted its multiple flaws. The unwarranted conclusion, namely lead to increasing the prescription of antidepressants to teenagers and youths, had the potential to do considerable harm. Mad in America concluded that it should never have been published. Among the problems with the study were the following:

The researchers’ stated conclusion, which was that a decrease in antidepressant prescribing in youth following the black box warning led to an increase in suicide attempts, isn’t supported by their own data. (1) There was not a significant decrease in SSRI prescriptions to teenagers and young adults following the black box warning. (2) Psychotropic drug poisonings are not a good proxy for suicide attempts. (3) This coding category actually tells of poisonings due to the use of psychiatric drugs, as opposed to their non-use. (4) Finally, there was no significant increase in the number of poisonings.

Additionally, Kantor et al., in “Trends in Prescription Drug Use Among Adults in the US” reported data from the National Health and Nutrition Examination Survey (NHANES) indicated that the use of antidepressants increased from 6.8% to 13% between 1999 and 2012. Yet, as Justin Karter reported, “The American Psychiatric Association guidelines continue to suggest medications as the preferred treatment for moderate to severe depression.”

If you’re still not convinced, take some time to read through a series of scientific articles submitted by Peter Breggin in his affidavit for another Paxil-related suicide trial. The topics covered included exhibits of Paxil causing suicidal behavior as well as SSRIs and SSRI withdrawal causing suicidality. There is another section on Dr. Breggin’s website that is an “Antidepressant Drug Resource & Information Center” with even more relevant articles.

Given the above discussion on antidepressants, the recent court ruling in Illinois awarding $3 million to Wendy Dolin has the potential to lead to an unknown number of future lawsuits, if it is upheld upon appeal. This could end up costing the pharmaceutical companies that brought now off patent SSRIs and SNRIs to market untold millions and possibly billions of dollars in further awards. So you can bet that GlaxoSmithKline has plenty of pharma companies (and their legal representatives) rooting for GSK to overturn the ruling in the Dolin case. Me, I’m rooting for the underdog here—the 13% of Americans who are taking antidepressant medications without clearly knowing the potential they have to make their depression and its consequences worse.

06/27/17

More Equal Therapies than Others, Part 1

© Allan Swart | 123rf.com

In the classic novella, Animal Farm, by George Orwell, the animals of Manor Farm revolted and drove the drunken and irresponsible farmer Mr. Jones from the farm. They renamed it “Animal Farm” and adopted the Seven Commandments of Animalism, the most important of which was the seventh: “All animals are equal.” Eventually the pigs cemented their role as the leaders of Animal Farm, and this commandment was modified to say: “All animals are equal, but some animals are more equal than others.”  Barry Duncan adroitly applied this example of double-speak in his discussion of those who apply the medical model of “diagnosis plus prescriptive treatment equals symptom amelioration” to declare that some psychotherapies were more equal than others.

Two other articles, “The Dodo Bird Effect” and “Another Brick in the Wall” explored Duncan’s argument for the power of common factors in psychotherapy and the dodo bird effect, an alternate way of understanding the process of therapeutic change from the dominant medical model of therapeutic change described above. He developed this position in: “The Legacy of Saul Rosenzweig: The Profundity of the Dodo Bird” and a book he coauthored: The Heart & Soul of Change.” Here I want to explore how the Orwellian sense that some therapies are more or less equal than others runs wild in addiction treatment.

The National Institute on Drug Abuse (NIDA) defined addiction as “a chronic, relapsing brain disease” because drugs changed the brain—its structure and how it worked. Here is a short YouTube video of the Director of NIDA, Nora Volkow, discussing this view of addiction. This definition was purely a physiological, biomedical understanding of addiction. Philosophically, it also seems Volkow assumed there is no mind; that human traits like “free will” were products of the biology of the brain. Note where she said “free will” was a product of the biology of the brain.

As in medical practice, addiction treatments are quantified according to an evidence-base of effectiveness. Here, the buzzword is “evidence-based treatment.” NIDA has a listing of  “Evidence-Based Approaches to Drug Addiction Treatment,” which it categorized as “Pharmacotherapies” and “Behavioral Therapies.” The NIDA introduction said the section “presents examples of treatment approaches and components that have an evidence base supporting their use.” One of the behavioral therapies NIDA listed as “effective in addressing substance abuse,” was “12-Step Facilitation Therapy” (TSF).

This 12-Step-based treatment approach was developed by Joseph Nowinski, a clinical psychologist as part of the Project MATCH study into the effectiveness of three different perspectives on how to treat alcohol use disorders (then described as alcohol abuse and alcohol dependence in the DSM, the psychiatric Diagnostic and Statistical Manual). In his book, If You Work It, It Works!, Nowinski said many academic researchers were highly skeptical that TSF would work at all, as A.A. and the Twelve Step approach was poorly understood. “Many academic researchers inclined to think of it more as a cult or quasi-religion than a serious programmatic approach to recovery from addiction.”

The two other interventions, Cognitive Behavioral Therapy (CBT) and Motivational Enhancement Therapy (MET) had been extensively studied. But Twelve-Step interventions had not been the subject of significant, rigorous research. So Nowinski developed TSF, a psychosocial treatment manual based on engaging the individual in 12 Step support groups such as Alcoholics Anonymous (A.A.).

In 1997 published results from the MATCH Research Group showed that all three interventions (CBT, MET and TSF) were effective in reducing drinking and increasing abstinence after treatment. One year after completing treatment those who were in the outpatient section of MATCH were sober over 80% of the time. And TSF was found to be equally effective for individuals who had been diagnosed as an alcohol abuser rather than as alcohol dependent.

These findings were so unexpected that some long-standing critics of AA and its Twelve Step program went so far as to question whether the MATCH data were somehow falsified. Of course, nothing could be further from the truth. The reality, rather, was what some skeptics could not abide: the idea that the Twelve Step approach works.

Nowinski said his goal in writing If You Work It, It Works was to make information on the effectiveness of Twelve Step recovery, now documented in academic journals, available to the general public. His goal was “to stand for the Twelve Step model in the face of long-standing and unchallenged criticism and skepticism, much of which is not based in fact.” Equally important, he hoped that people on the fence about going to an A.A. meeting “will benefit from learning about the science (as opposed to the myths) of Twelve Step recovery.”

Nowinski referred to a long-standing bias against the Twelve Step approach to recovery. He said it was regularly portrayed as a quasi-religious approach, and then rejected because it is not a structured treatment approach. Therefore it lacked a clear demonstration of its scientific, evidence-based effectiveness. If an addiction treatment approach, like TSF, used the 12 Steps or actively encouraged clients to participate in 12 Step groups like Alcoholics Anonymous (A.A.) or Narcotics Anonymous (N.A.), it was often judged to be “a less equal treatment” than others. An article by Laurel Sindewald for The Fix, “AA Is not Evidence-Based Treatment,” illustrates this bias.

The author said she had previously done a literature review that found insufficient evidence to support the use of 12-step groups as treatment, so she was surprised the Surgeon General included TSF as an evidence-based behavioral treatment for addiction in Facing Addiction in America. She admitted to a personal bias, which apparently was against the spirituality of 12-step groups and what she referred to as “12-step philosophy.” It seems that since TSF encouraged participation in 12-Step self-help groups, it was suspect as a “less equal” treatment approach, because it retained “ the spiritual emphasis of 12-step philosophy.” However, she would “set aside her bias” in her assessment of TSF, in order to give it a scientific, objective assessment. But that does not seem to have been the case.

Sindewald noted where the Surgeon General’s Report classified TSF as a “professional behavioral treatment,” but then immediately asked: “How could a professional medical treatment be based on a definition of addiction as a spiritual disease?” She stated (without any supportive citation) that Twelve-Step philosophy stipulated that addiction was a spiritual disease born of defects of character; and that 12-step groups were the only cure. She later compared Twelve-Step literature to religious literature like the Bible and the Qur’an and contrasted Twelve-Step philosophy with medical science. She gave an extended quote from the A.A. “Big Book” of Alcoholics Anonymous, which she said represented Twelve-Step philosophy saying it can never be wrong. Her bias against spiritual/religious philosophy was all through her critique.

The AA pamphlet “How AA Members Cooperate with Professionals,” stated that A.A. is not in competition with anyone. “Our ability to help other alcoholics is not based on scientific or professional expertise.” Unpacking principles articulated in AA’s Twelve Traditions, the pamphlet also said: “A.A. is not allied with any sect, denomination, politics, organization or institution; does not wish to engage in any controversy; neither endorses nor opposes any causes.” In his essay on Tradition Six in Twelve Steps and Twelve Traditions, Bill W. gave a brief history of early A.A.including attempts to institute A.A. hospitals and get involved in education. He noted where these activities raised confusion. “Did A.A. fix drunks or was it an educational project? Was A.A. spiritual or was it medical? Was it a reform movement?”

These adventures implanted a deep-rooted conviction that in no circumstances could we endorse any related enterprise, no matter how good. We of Alcoholics Anonymous could not be all things to all men, nor should we try.

In the same chapter of the A.A. Big Book, which Sindewald cited and linked, “How It Works,” there is a discussion of resentment being the “number one” offender, destroying more alcoholics than anything else. “From it stem all forms of spiritual disease, for we have been not only mentally and physically ill, we have been spiritually sick. When the spiritual malady is overcome, we straighten out mentally and physically.” So there is an understanding of alcoholism as a spiritual, mental and physical illness/disease.

Also in that chapter you will find the 12 Steps described as a suggested program of recovery. “The principles we have set down are guides to progress. We claim spiritual progress rather than spiritual progression.” So it seems that AA does not present itself as the only cure; nor does it describe alcoholism merely as “a spiritual disease born of defects of character.”

A clear distinction by the author between TSF, A.A., and rehab programs using the 12-Steps isn’t maintained in her critique. In her article for The Fix, she said she used “12-step approaches” to refer to all 12-step self help groups, all 12-step-based rehab programs and TSF. However, in another article she wrote previously for Handshake Media (linked as her literature review), she said: “TSF is distinct from AA and other 12-step support groups.” Yet in her conclusion for “AA Is not Evidence-Based Treatment” Sindewald said “after exhaustive research” she could assert with confidence that 12-step approaches—including TSF—were not evidence-based treatments. She called for the reallocation of funds away from these approaches to those “that can be studied rigorously and without such crippling methodological limitations.”

With regard to A.A .and other 12 Step groups, she was right when she said they were not treatment approaches to addiction recovery. A.A. is not developed as a treatment approach and doesn’t claim to be a treatment approach. The A.A. website said: “Alcoholics Anonymous is an international fellowship of men and women who have had a drinking problem.” It is also self consciously nonprofessional, stating in Tradition Eight, “Alcoholics Anonymous should remain nonprofessional.” As fellowship organizations, A.A. and other 12-Step self-help groups are not structured in ways that can be easily studied by researchers who want to assess their effectiveness within a structured medical model of therapeutic change.

But Twelve Step Facilitation is considered to be a treatment approach. According to the NIDA description of “12-Step Facilitation Therapy,” TSF is a manual-based, structured treatment approach. It is “designed to increase the likelihood of a substance abuser becoming affiliated with and actively involved in 12-step self-help groups, thereby promoting abstinence.” And TSF is listed by NIDA as an evidence-based treatment approach, the same organization, by the way, that Sindewald referenced as defining addiction as a brain disease. Apparently NIDA doesn’t agree with her that TSF is not an evidence-based treatment approach.

It seems Sindewald’s failure to acknowledge the difference of A.A. and other 12-Step groups from the various addiction treatment approaches that apply “Twelve-Step philosophy” was intentional. It sets up a straw man argument that illegitimately transfers a critique of the TSF treatment approach onto 12-Step groups. It also seems that Sindewald’s claim to have set aside her bias while she examined Twelve Step treatment philosophy and TSF was not true.

06/23/17

Total War Against Sin

Christian fighting against Apollyon; Wiki image of stained glass in Robin Chapel

The sense of total war, and the carnage it generates, was graphically portrayed by Mel Gibson in the movie Hacksaw Ridge. And yet the movie’s hero was a man who did not fire a shot against his enemy. He trusted in God to deliver him. Puritan writers regularly used the imagery of warfare to describe our battle against the indwelling sin of our flesh. But John Owen intensified that imagery in his work Indwelling Sin, when he clearly portrayed our fight against sin as total war against the indwelling sin of our flesh.

In chapter four of Indwelling Sin, Owen said he would limit his reflections on the nature of indwelling sin to what Paul said in Romans 8:7, namely that the carnal mind (or the mind that is set on the flesh, as in the ESV) is hostile to God. After quoting the Greek phrase for “carnal mind”, Owen said this fleshly wisdom was the same as “the law of sin.”  More than just an enemy of God, this mindset is hostile to God. It does not submit to God’s law, because it cannot.  Owen said this enmity signifies there is no possibility for reconciliation.

There can be reconciliation with an enemy of God, as Paul wrote in Romans 5:10: “while we were enemies we were reconciled to God by the death of his Son.” But where there is enmity, there can be no reconciliation. As Owen said: “There is no way to deal with any enmity whatever but by its abolition or destruction.” The only way to reconcile enemies is to first destroy the enmity that exists between them, which Christ did by his death (Ephesians 2:15).  And if even the smallest amount remains, it is still enmity; it is still poison.

Every spark of fire is still fire, and it will burn. The apostle Paul, who may have made as great a progress in subduing his flesh as any one on earth, still cried out for deliverance: “Who will deliver me from this body of death?” (Romans 7:24) Mortification of the flesh will abate its force, but cannot change its nature. While grace changes the nature of a person, nothing can change the nature of sin. “Whatever effect be wrought upon it, there is no effect wrought in it, but that it is enmity still, sin still.”

God is love (1 John 4:8) and against this God we carry enmity all out days—an enmity that is incapable of cure or reconciliation. “Destroyed it may be, it shall be, but cured it cannot be.” When it is enmity against which a person struggles, nothing can be expected but continual fighting until one or the other is destroyed. “If it be not overcome and destroyed, it will overcome and destroy the soul.”

Here lies its power: there is never a truce or true peace. “It is never quiet, conquering nor conquered.” Some people try to quiet their corruptions by trying to satisfy them—to make provisions for their flesh by gratifying its desires (Romans 13:14). Yet this is but adding fuel to the fire. All the fuel in the world, everything that is combustible will not satisfy it, but will only increase it. So it is with trying to satisfy sin by sinning. You cannot bargain with a fire to only burn so much; you have to quench it.

It is so with this indwelling sin: whether it violently tumultuate [create great emotional or mental agitation], as it will do on provocations and temptations, it will be outrageous in the soul; or whether it seem to be pleased and contented, to be satisfied, all is one, there is no peace, no rest to be had with it or by it. Had it, then, been of any other nature, some other way might have been fixed on; but seeing it consists in enmity, all the relief the soul hath must lie in its ruin.

Although Scripture variously portrays this enmity as our enemy, it is ultimately “enmity against God.” Peter urged us to abstain from the passions of the flesh that war against our soul (1 Peter 2:11). Paul said the desires of the flesh and Spirit are opposed to one another to keep us from doing what we want to do in the flesh (Galatians 5:17). “It fights against the Spirit, or the spiritual principle that is in us, to conquer it; it fights against our souls, to destroy them.” Its nature and ultimate aim is to oppose God.

This is our state and condition: All the opposition that ariseth in us unto any thing that is spiritually good, whether it be from darkness in the mind, or aversation in the will, or sloth in the affections, all the secret arguings and reasonings that are in the soul in pursuit of them, the direct object of them is God himself. The enmity lies against him; which consideration surely should influence us to a perpetual, constant watchfulness over ourselves.

Every sin is opposition to God—an attempt to cast off His yoke. It is an attempt to break off the dependence the creature should have on the Creator. So here we may reflect back on the Genesis account of the Fall, where humankind sought to be like God, independently knowing what was good and what was evil (Genesis 3:5). The carnal mind is hostile to God because it will not subject itself to the will of God. “The soul wherein it is may be subject to the law of God; but this law of sin sets up in contrariety unto it, and will not be in subjection.” It is absolute and universal to all of God and all of the soul.

If there were anything of God that sin was not in enmity against, the soul could have a shelter and retreat there. But enmity lies against God himself. It is against everything that is of God—his nature, properties, mind or will, his law or gospel. The nearer anything is to God, the greater is enmity against it. “That which hath most of God hath most of its opposition.” The more spirituality and holiness is in a thing, the greater is the enmity against it.

Enmity is also universally against the soul. If this law of sin had been content to subdue one faculty of the soul, but leave another at liberty, “it might possibly have been with more ease opposed or subdued.” But when Christ comes with his spiritual power to the soul, he can find no quiet landing place. “He can set foot on no ground but what he must fight for and conquer.”

Everything is secured against him—the mind, the will and emotions. And when grace had made it’s landing, yet sin is entrenched from coast to coast. Had there been anything in the soul at perfect freedom and liberty, perhaps a stand to drive enmity out could be made. But it is universal and makes war throughout the soul.

The mind hath its own darkness and vanity to wrestle with,—the will its own stubbornness, obstinacy, and perverseness; every affection its own frowardness and aversation from God, and its sensuality, to deal withal: so that one cannot yield relief unto another as they ought; they have, as it were, their hands full at home. Hence it is that our knowledge is imperfect, our obedience weak, love not unmixed, fear not pure, delight not free and noble.

In Pilgrim’s Progress there is a battle between the pilgrim Christian and Apollyon that captured this sense of total war described by Owen. The narrator, who “dreamed the dream” of Christian’s journey had this to say:

In this combat no man can imagine, unless he had seen and heard as I did, what yelling and hideous roaring Apollyon made all the time of the fight—he spake life a dragon; and on the other side, what sighs and groans burst from Christian’s heart. I never saw him all the while give so much as one pleasant look, till he perceived he had wounded Apollyon with his two-edged sword; then, indeed, he did smile, and look upward; but it was the dreadfullest sight that ever I saw.

A digital copy of Owen’s work, Indwelling Sin in Believers, is available here.

06/20/17

Freud’s Nanny

© Michal Bednarek | 123rf.com

Sigmund Freud is widely known to have been an atheist or agnostic. Ernest Jones, his biographer, friend and close colleague said he went through life from beginning to end as an atheist: “One who saw no reason for believing in the existence of any supernatural Being and who felt no need for such a belief.” His daughter Anna, herself a psychoanalyst, said her father was a “lifelong agnostic.”  He regularly described religion as “a universal, obsessional neurosis.” In The Future of an Illusion (1927), he said religious doctrines were also illusions—wish fulfillments of the oldest, strongest and most urgent desires of mankind. But what would you think if, as a child, Sigmund Freud had been taken regularly to Catholic Mass and quite possibly had been secretly baptized?

Paul Vitz supported these claims in his book: Sigmund Freud’s Christian Unconscious. He said Freud had “a strong, life-long, positive identification with and attraction to Christianity.” According to Vitz, this was offset by a concurrent and unconscious hostility to Christianity, reflected in his preoccupation with the Devil, Hell, and the Anti-Christ. He thought this substantial Christian and anti-Christian part of Freud provided an understanding of his adult ambivalence towards religion; and should suggest a re-evaluation of Freud’s psychology of religion.

Freud was born on May 6, 1856, in Freiberg Moravia—a town now part of the Czech Republic. At the time, Moravia was a predominantly Catholic region, with a particular devotion to the Virgin Mary. The main church in Freiberg was called “The Nativity of Our Lady.” The town had a population of about 4500, over 90% of whom were Roman Catholic. About 3% of the city were Jewish. Freud lived there with his family until he was three years old. After a brief time in Leipzig, the family moved to Vienna, where Freud lived all but the last fifteen months of his life. Vienna was also predominantly Roman Catholic. “As a result, Freud spent almost his entire life as a Jew in a society dominated by Roman Catholic culture.”

Birthplace of Sigmund Freud

Resi (short for Theresa) Wettik was in the employ of the Freud family by June of 1857 at the latest. Freud himself wrote that he was in her charge from some time “during early infancy.” Family matters support the likelihood that Resi assumed a major maternal role with young Sigmund from an early date. Sigmund had a younger brother, Julius, who was born when Freud was fifteen months old (August of 1857). Julius was sickly and died on April 15, 1858, just before Sigmund was two. Seven and a half months later, his mother gave birth to his sister, Anna.

So when Freud was between the ages of one and three, his mother Amalia went through two pregnancies and births, and was caring for the sickly Julius, who died when he was eight months old. Vitz observed that Freud must have found his mother relatively unavailable from around the age of one until he was close to three years old. “There is, then, every reason to believe that the nanny filled the maternal vacuum during this important period, and that Freud experienced her as a second mother—or even … as his primary mother.”

Amalia Freud was 21 at the time she gave birth to Sigmund. During the first 32 months of his life, she was pregnant for a total of 18 months. Since during pregnancy, a mother’s milk supply diminishes, there is a strong possibility that she did not breast-feed, or at least did not fully breast-feed very long after her children’s births. Vitz explained that it is rare for a woman to get pregnant while nursing her baby regularly the first six months after giving birth. “In any case, it is unlikely that Sigmund was nursed by his mother for more than a brief period.”

While not definitive, this and others evidence suggests that Resi was also a wet nurse to young Sigmund. A biographer of Freud’s indicated the Freud women frequently worked together in a “garment district” warehouse, while the children were cared for by a maid, presumably Resi. “If so, Sigmund would have been almost exclusively with the nanny for many weeks during his earliest years.” Freud himself seems to have acknowledged this in letters he wrote to his friend, Wilhelm Fliess. This was during the time he was in the midst of his own self-analysis when he was in his forties.

Vitz quoted from a letter Freud wrote to Fliess on October 3, 1897. He said there had been something interesting things with his self-analysis over the previous four days. He referred to his nanny as the “prime originator” figure of his dream, meaning she was a parent (an originator) to him. “The ‘prime originator’ was an ugly, elderly, but clever woman, who told me a great deal about God Almighty and hell and who instilled in me a high opinion of my own capacities.” Resi may have only been in her later thirties or early forties. “Elderly” here could then be the perspective of Freud as a child in the dream or his mother, who was herself only in her early twenties at the time.

I have not yet grasped anything at all of the scenes themselves, which lie at the bottom of the story. If they come [to light] and I succeed in resolving my own hysteria, then I shall be grateful to the memory of the old woman who provided me at such an early age with the means for living and going on living.

In The Interpretation of Dreams, Freud wrote that he had a vague memory of his nanny. He added that: “it is reasonable to suppose that the child [Freud] loved the old woman.” Vitz commented that Freud didn’t make such claims about the early importance of his own mother. “Indeed, this lack of evidence further supports the present view that the nanny was the primary mother.” In an October 15, 1897 letter to Fliess, Freud said he’d asked his mother if she remembered his nurse. “’Of course,’ she said, ‘an elderly person, very clever, she was always carrying you off to some church; when you returned home you preached and told us all about God Almighty.’”

Paul Vitz said while it would have been unusual in most Christian homes at the time to attend Mass several times a week, it would not have been unusual for a pious woman of the time to do so.  However, for it to occur “within a Jewish home would have been quite striking.” There was no synagogue in Freiburg, so Freud would not have had the opportunity to be exposed to any Jewish religious experience in these early years.  Nor is there any evidence that the Freuds celebrated the Jewish holidays, or kept the Jewish dietary laws while living in Freiberg. Additionally, “There is no reason to believe that Freud’s mother gave him religious instruction; she is known to have been uninterested in religion.”

 In any case, the nanny, this functional mother, this primitive Czech woman who was the “primary originator” of Freud, was his first instructor in religion. These first lessons were of a simple, no doubt often simple-minded, Catholic Christianity.

Vitz said that given the likelihood of a close relationship between the nanny and young Sigmund, there is a distinct possibility that she may have secretly baptized him. With the death of his sickly, infant brother, the nanny may have even baptized Julius. Or his death without baptism would have been a disturbing tragedy to her. Either possibility would arouse her fears and concern for Sigmund. “Such a possible covert baptism, in church or otherwise, may have had a lasting effect on Freud’s memory; if the nanny had talked about the meaning of baptism, it would have left permanent traces.”

Freud’s mother related a story that his nanny was abruptly dismissed by the Freuds, supposedly because she was discovered to have been stealing. Reportedly, Amalia told her son this happened while she was still bed ridden after the birth of Anna in December of 1858. Vitz questioned both the timing of the dismissal, suggesting it occurred in late May or early June of 1859, and the circumstances of the nanny’s dismissal. He noted Amalia’s recollection of the event was almost forty years after it occurred. Also the alleged circumstances were odd. The nanny was said by Freud’s mother to have been found with coins and toys that had been given to Sigmund. Why, asked Paul Vitz would such a clever woman keep the toys with the coins and not hide them in a safe place?

All this is most odd, especially given the extreme likelihood that Freud’s mother must have looked on the nanny with increasing jealousy and dismay. Here was this peasant woman who was in many ways taking over the role of a mother in the life of her lively and attractive first-born son. Not only was the nanny coming to be extremely important to her son’s affections, but she was also taking him to church and instructing him in Christianity. Amalia Freud was never very serious about her own Judiasm; still, there is certainly no reason to think she was benevolently disposed towards Christianity. Possibly, her young son’s early training in Christianity roused real concern. If so, this was a reason why the Freuds, in particular Amalia, would have wished to get rid of the nanny.

So soon after Sigmund turned three, he was suddenly separated from his nanny; his mother “prime originator.” Again in the letter to Fliess on October 15, 1897, Freud wrote that if he was suddenly parted from her, “it must be possible to demonstrate the impression this made on me.” He then described to Fliess what he believed to be a childhood memory that had emerged repeatedly into his conscious memory over the years (without understanding it). The memory was of a time when he couldn’t find his mother, and he was crying uncontrollably for her. “When I missed my mother, I was afraid she had vanished from me, just as the old woman had a short time before.”

The significance of these events is striking when they are seen in the light of Freudian theory. Ernest Jones said in his biography of Freud that he taught: “The essential foundations of character are laid down by the age of three and that later event can modify, but not alter the traits then established.” Paul Vitz observed that you don’t have to believe this theory of character is universally true “to accept that it was most certainly true of its originator.”

Quotes used in this article are from Sigmund Freud’s Christian Unconscious, by Paul C. Vitz, and The Complete Letters of Sigmund Freud to Wilhelm Fliess 1887-1904, translated and edited by Jeffrey Moussaieff Masson.

06/16/17

Something Old is New

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Police in Reynoldsburg Ohio, a suburban community in the Columbus Ohio metropolitan area, were called to the local high school when some students were acting dazed and disoriented. This kind of news is not unusual these days, but what they were using was—betel nut. Several news outlets picked up the story, including The News Herald, the CBS affiliate Cleveland 19, and The Fix. Although betel nut or areca nut is not well known in the U.S., it is the fourth most commonly used “social” drug worldwide, after nicotine, ethanol, and caffeine. Over 600 million people—10 percent of the world’s population—presently use some form of areca/betel nut.

Technically the areca nut is the seed of the areca palm, which grows in the tropical Pacific, parts of Africa, Southeast and South Asia. It’s not a true nut, but rather a berry. It is commercially available in dried, cured and fresh forms. Usually chewed, a few slices of areca nut are wrapped in a betel leaf containing calcium hydroxide (slaked lime) and mixed with clove, cinnamon or other spices. It gives the users a warming sensation and a heightened sense of alertness, but the effects vary from person to person. A BBC news report said it gives a buzz equivalent to about six cups of coffee.

Its use dates back thousands of years in the above noted areas of Asia and the Pacific. It isn’t known how or when the psychoactive properties of combining the areca nut and the betel leaf were discovered. However, archaeological evidence in Thailand, Indonesia and the Philippines suggests they have been used together for at least 4,000 years. A Report by the World Health Organization (WHO) noted there is evidence of betel nut use in Guam and the Northern Mariana Islands for 2,000 years and the Solomon Islands for at least 1,000 years.

There is a Vietnamese myth about the betel leaf and areca nut that goes like this. There were twin brothers, Tan and Lang who were benig tutored by a Taoist named Chu Chu. The tutor had a beautiful daughter, who he gave in marriage to Tan. The two of them were very happy together. But Tan grew apart from Lang after he was married. So Lang decided to go away and wander around the country.

Finally he reached a large river, but could not cross it. There was no boat to transfer him to the other side. Lang was so sad that he kept crying until he died. Then he was transformed into a lime-stone by the river. Troubled by Lang’s absence, Tan went looking for him. When he reached the river, Tan sat on the lime-stone and died from exhaustion and weariness. “He was transformed into an areca tree.” The young woman in turn went looking for her husband when he did not return. When she reached the place where the areca tree grew, she leaned against the tree and died. And she was transformed into the betel vine.

The local inhabitants set up a temple to their memory, commemorating this tragic love story. One day, King Hung went to the temple and heard this tragic love story. He ordered his men to ground together a leaf of betel, an areca nut and a piece of lime. A juice, as red as human blood, was formed out of the mixture. He tasted it, found that it was delicious, Then the king recommended the mixture be used at every marriage ceremony from then on.

The leaves and juices are used in Vietnamese weddings, symbolizing the idealized married couple. Guests to a Malay house are offered a try of areca nuts and betel leaves like drinks are offered in other cultures. See the following link for more information on the variety of cultures using the areca nut.

So what’s not to like? WebMD reported that eating 8 to 30 grams of betel nut could cause death. Your mouth, lips and stool can turn red. It can cause diarrhea, vomiting, gum problems, chest pain, abnormal heartbeats, low blood pressure, shortness of breath, rapid breathing, heart attack and coma. Interactions with some medications can be problematic, decreasing the effectiveness of antidepressants and antihistamines. It can interact with medications used for glaucoma and Alzheimer’s disease. “Stay on the safe side and avoid using betel nut if you are pregnant or breast-feeding.”

Gang et al. did a systematic review of the adverse effects of betel nut. The authors said it affects almost all the organs of the human body, “including the brain, heart, lungs, gastrointestinal tract and reproductive organs.” It causes or aggravates several medical conditions including asthma, type II diabetes, infertility, and heart problems such as myocardial infarction and cardiac arrhythmias. It affects the immune system leading to suppression of T-cell activity and decreased release of cytokines. See the following link to Table 1 in the article for a summary of the systematic effects.  “Thus, areca nut is not a harmless substance as often perceived and proclaimed by the manufacturers of areca nut products such as Pan Masala, Supari Mix, Betel quid, etc.”

The effects of areca nut are mainly on the central and autonomic nervous systems from the alkaloid arecoline. There is a dependency syndrome associated with the use of areca nut that includes increased concentration, mild euphoria, relaxation and withdrawal. The withdrawal syndrome is associated with insomnia, mood swings, irritability and anxiety. The severity is comparable to that of amphetamine use. “Areca nut leads to palpitation, increased blood pressure, increased body temperature, flushing and sweating within minutes of consumption.” And there is substantial evidence that it is a carcinogen, contributing to cancers of the mouth, esophagus, liver and uterus.

A 2010 study by Bhat et al. (reload link) looked specifically at areca nut dependency among a South Indian community. Fifty-nine daily chewers from Karanatka State in southwest India were surveyed. Questionnaires assessed their chewing history, pattern of use and adapted measures developed for assessing nicotine/tobacco dependence to assess areca dependence. There were low levels of dependency observed, but about 44% of chewers endorsed at least one of the following items: continued use despite illness or wounds, difficulty refraining from chewing in forbidden places, or craving during periods of abstinence.

At least 15% of respondents had intentionally made a quit attempt [ an attempt to quit]. During periods of abstinence for any reason, 27% reported feelings of discomfort or craving. Many of these participants were those who scored high on the dependence measures and/or reported a high frequency of use. Of the 13 informants who reported the highest number of nuts chewed/day (i.e., 5), nine had scores ≥ 16 on the CDS-5. These individuals also reported the greatest number of use episodes/day, with 6–15 chews daily.

Many chewers started as adolescents of young adults; 52.5% started before the age of 30. Reasons for starting to chew areca nut included boredom (39.0%) and as an aid in socialization (28.8%). Many respondents also said it helped them at work. “Chewing helps me to think what to do next, or how to do other work.”  They also reported using areca nut as a mouth and breath freshener.

At this point in time, betel/areca nut use is not a drug of concern outside of the Western Pacific Region, highlighted in the above graphic. In the US, betel nut is not a controlled substance and can even be found in some Asian grocery stores. The Reynoldsburg Police Chief, Jim O’Neill, said they would like to keep this out of the hands of students, which may be difficult. Although it’s illegal to import, betel nut is readily available online—“a loophole law enforcement agencies want to see shut.” Health inspectors in Ohio are searching markets to remove betel nuts from shelves; and the FDA was said to be investigating into betel nut use.

In writing this article, particularly in light of the Vietnamese legend described above, I thought of the bridal rhyme that goes “Something old, something new, something borrowed, something blue.” Well, at least the first half of it. Betel nut use has an old, long history; and yet, is being investigated as a new, potentially harmful substance by the FDA. It seems that betel nut use and misuse is something old that became something new in the ongoing American cultural wars against mind altering-mood changing substances.

06/13/17

What Does God Look Like?

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A neuroimaging study published in the journal Nature demonstrated that when a well-recognized face was shown to an individual, a single neuron in the person’s brain would fire. The researchers were able to show that a single unit in the left posterior hippocampus would fire “to all pictures of the actress Jennifer Aniston.” But the neuron did not respond to pictures of Jennifer Aniston together with Brad Pitt. In a previous study, the researchers found that individual neurons would fire selectively to various images—like animals or buildings. So it is possible that some people could have a single neuron that would fire when they see a familiar picture of Jesus—or Buddha. “That neuron could represent the cornerstone of their religious training and belief.” This adds a whole new way of looking at God as you understand Him.

The study mentioned above was “Invariant Visual Representation by Single Neurons in the Human Brain.” Here are links to the abstract and the full article. The above speculation of the possibility of a “God neuron” in your brain was by Andrew Newberg in his book, How God Changes Your Brain. Newberg wondered if it was possible that people could have a neuron or specific set of neurons that fired when they were asked to envision God. “As brain-scan technology becomes more refined, I suspect we will see that each human being has a unique neural fingerprint that represents his or her image of God.”

Newberg described how we are born with a neurological mechanism to identify objects. The first objects an infant learned to identify were family members and caretakers. We see this when a stranger looks at an infant and gets a frowned response. The child’s brain labels each new object it learns to recognize; the first of many steps that turn an image into a concept or a word. The simplest kind of word for a child to learn is a concrete noun, “because it refers to something the child can see, touch, or taste.” The neurological capacity of young children to comprehend abstract objects won’t fully develop until adolescence, so they can only readily understand the simplest concepts.

A young child’s brain has no choice but to visualize God as a face that is located somewhere in the seeable physical world, and that is what we find when we analyze the pictures drawn by children younger than ten.

Brain-scan studies show that nouns are linked to visual-object-processing regions of the brain. Each time a novel idea is introduced, there is increased activity in specific areas of the right hemisphere of the brain—“the same areas that construct our visual representations of reality.” So when a child is introduced to a spiritual concept, their brain will automatically give it a sense of realness and personal meaning. The brains of children who continue in religious education will modify their “spiritual map” as they are introduced to new ways of conceptualizing God. “So its not surprising to see children’s pictures becoming more complex as they mature.”

A German professor of religious education, Helmut Hanisch, did a study where he compared drawings of God from West German children, who attended Christian-oriented schools, to those of children who attended school in East Germany, where an official antireligious doctrine had been in place.

In the religious group, children between the ages of seven and nine represented God as a face or a person around 90% of the time. By the time they reached the age of sixteen, only 20% drew pictures of faces or people. Instead, they preferred symbolic representations of God. But this did not happen with the East German, nonreligious students. By sixteen, “80% of the nonreligious children still used people to symbolize God.” The following chart illustrates the findings of Hanisch, as they were shown in Greenberg’s book. The vertical axis reflects the percentage of images that were abstract. The horizontal axis reflects the age of the children.

There were also differences in their comments about God. The older religious children described a loving sense of God, while the nonreligious children saw God as powerless and weak. They often referred to war, misery, suffering and poverty. One 12-year old girl said: “I don’t understand why God is allowing all this. Therefore I don’t believe in God.”

Young people do not have the cognitive skills to articulate abstract concepts of God, but they can use their visual imagination to comprehend spiritual realms. Even in the adult brain, ideas appear to be associated with internal visual processes, and mathematicians often think in pictures when they describe the invisible forces of the universe. Even when we imagine the distant past or future events, we activate the visual-spatial circuits of the brain. In fact, if you cannot see, hear, touch, taste, or smell something, the brain’s first impulse is to assume that it doesn’t exist. Thus, for anyone, the brain’s first response is to assign an image to the concept of God.

Newberg said without this capacity for visual imagination, we would be barely able to think. Even when we sleep and dream, this capacity for visual imagination remains active. But children do not have the neural capacity to easily separate fantasy from fact, so they form beliefs that blur the boundaries of reality. Think here of the child who insists there are monsters under their bed. Children readily believe their nightmares are real, “while adults have advanced neural processes to help them analyze perceptual discrepancies.”

© Bill Watterson

If you tell a child that God can see you, or listen to your prayers, then the child’s imagination will associate those qualities with the eyes and ears of a face. If you tell the same child that God gets angry, the brain will generate images of frowns, gritted teeth, or perhaps fists banging against a wall—visual constructions that represent how a child perceives anger in other human beings. If you tell your child that God performs miracles, then the internal imagery takes on superhuman traits. For example, one boy drew God with a cape and a large S on his chest.

Newberg said that based upon his research, he thought the more a person examined their spiritual beliefs, the more their experience of God would change. And if you could not or would not change your image of God, you might have problems tolerating people who held to different images of God. He said if you clung to your childhood image of God, you limited your perception of truth. He thought this was a drawback for any religion that insisted upon a literal, biblical image of God. “If you limit your vision, you might feel threatened by those who are driven to explore new [or different] spiritual values and truths.”

For both the secular individual and the biblical Christian, there is validity in what Newberg says. The reality of radical Islamists and Westerners who reflexively oppose all Islamists as a result, clearly illustrates Newberg’s observation. The growing criticism of conservative Christian beliefs with regard to changing social and political mores is another example. Even within Christianity we find infighting and disputes over how to interpret the first 11 chapters of Genesis, the authority and inerrancy of the Bible, the form of church government, what happens during the sacrament of communion, and so on.

However for the biblical Christian, there is a potential confusion, and perhaps a danger of slipping into postmodern or theological relativism, in what Newberg said as well. In order to avoid this, clearly make a distinction between God and how you image (view) God. What remains the same yesterday, today and tomorrow is God, and not how you imagine Him to be. Greenberg used the sense of the “image of God” because he was describing how children and adults visualize complex abstractions like God.

But when applied theologically to human beings, the term “image of God” has the sense that they were created (not visualized) in the image of God. Here “image” is used metaphysically and not visually. All humans are images of God in a metaphysical sense. So regardless of the differences in how they understand or view God (how they imagine Him), all people should be given the same toleration and respect as human beings created in the image of God.

Secondly, be aware that as a Bible-believing Christian, authority and power lies with God and His revealed Word, not your understanding (your image) of Him. Regularly Christians impute onto their views (images) of God the authority and power properly owed only to Him and his Word. And if there is any questioning of that personal image, they react as if the person questioned God, and not just their understanding of Him. I’d suggest such a Christian has implicitly violated the second commandment (found in Exodus 20), which forbids making an image of God. We see this more explicitly stated in the Westminster Larger Catechism, where it says the second commandment forbids the making of any kind of image of God, “either inwardly in our mind, or outwardly in any kind of image of likeness.”

So what does God look like to you? If you want, you can replicate an experiment Newberg has done with different groups of religious and nonreligious people—get a pencil or pen and a piece of paper and draw a picture of God. He suggested that you be spontaneous and draw whatever comes to your mind. Don’t worry about the quality of your art, but complete the drawing in two minutes. When you finish, write a brief description of its meaning below the picture.

Nearly everyone pauses for a long time—even longer than when we asked, “What does God feel like?”—which tells us there is increased activity occurring in many parts of the brain, especially in the visual, motor, association, cognitive, and emotional centers. Indeed, the question appears to be so neurologically challenging and psychological provocative that some people simply refuse to draw anything. Children, however, have no difficulty with the request, and delight in drawing their impressions of God.

06/9/17

Worse Results with Psych Meds

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Psych meds are popular. One in six U.S. adults (16.7% of 242 million) reported filing at least one prescription for a psychiatric medication in 2013. That increased with adults between the ages of 60 and 85, where one in four (25.1%) reported using psych meds. Only 9% of adults between the ages of 18 and 39 reported using one or more psych drugs. Most psychiatric drug use was long-term, meaning patients reported taking these meds for two years or more; 82.9% reported filling 3 or more prescriptions in 2013. “Moreover, use may have been underestimated because prescriptions were self-reported, and our estimates of long-term use were limited to a single year.”

The above findings were reported in a research letter written by Thomas Moore and Donald Mattison in JAMA Internal Medicine. Their findings got a fair amount of media attention, including articles in Live Science (here), The New York Times (here), Mad in America (here), Psychology Today (here) and even Medscape (here).

Moore said the biggest surprise was that 84.3% of all adults using psychiatric medication (34.1 million) reported using these meds long-term, meaning over two years. He said the high rates of long-term use of psych meds raises the need for closer monitoring and a greater awareness of the potential risks.

Both patients and physicians need to periodically reevaluate the continued need for psychiatric drugs. . . This is a safety concern, because 8 of the 10 most widely used drugs have warnings about withdrawal/rebound symptoms, are DEA Schedule IV, or both.

The ten most commonly used psychiatric drugs in ranked order were:

  1. Sertraline (Zoloft, an SSRI antidepressant)
  2. Citalopram (Celexa, an SSRI antidepressant)
  3. Alprazolam (Xanax, a benzodiazepine for anxiety)
  4. Zolpidem tartrate (Ambien, a hypnotic prescribed for sleep)
  5. Fluoxetine (Prozac, an SSRI antidepressant)
  6. Trazodone (an antidepressant often prescribed for sleep)
  7. Clonazepam (Klonopin, a benzodiazepine for anxiety)
  8. Lorazepam (Ativan, a benzodiazepine for anxiety)
  9. Escitalopram (Lexapro, an SSRI antidepressant)
  10. Duloxetine (Cymbalta, an SNRI antidepressant)

Drawing on data from a different source in “Drugs on the Mind” for Psychology Today, Hara Estroff Marano said the Institute for Healthcare Informatics (IMS) reported there were 4.4 billion prescriptions dispensed in 2015, with total spending on medicines reaching $310 billion. “Over a million of the prescriptions written for a psychiatric drug were to children 5 years of age or younger.” There were 78.7 million people in the U.S. using psychiatric meds. Within this group, 41.2 million were prescribed one or more antidepressants; 36.6 million were given anti-anxiety medications; and 6.8 million were given antipsychotics.

These figures were different than the percentages reported above from the Moore and Mattison study. Moore and Mattison found that 12% (29 million) reported using antidepressants; 8.3% (20 million) reported using anxiolytics and 1.6% (3.9 million) reported using antipsychotics. Their 1 in 6 (16.7%) figure would then be 40.4 million people using at least one psychiatric medication. Regardless of which data source you use, there are millions of U.S. citizens taking at least one psychiatric drug and therefore at risk of experiencing the adverse effects associated with these drug classes.

Anatomy of an Epidemic by Robert Whitaker described how psychiatric drugs seem to be contributing to the rise of disabling mental illness rather than treating those who suffer from it. What follows is a sampling of comments from Anatomy that he made about benzodiazepines (anxiolytics), which are widely used to treat anxiety and insomnia. Whitaker said long-term benzodiazepine use can worsen the very symptoms they are supposed to treat. He cited a French study where 75 percent of long-term benzodiazepine users  “. . . had significant symptomatology, in particular major depressive episodes and generalized anxiety disorder, often with marked severity and disability.”

In addition to causing emotional distress, long-term benzodiazepines usage also leads to cognitive impairment (137). Although it was thirty years ago that governmental review panels in the United States and the United Kingdom concluded that the benzodiazepines shouldn’t be prescribed long-term … the prescribing of benzodiazepines for continual use goes on (147).

In her article for Medscape, Nancy Melville pointed out the CDC found zolpidem (a so-called “Z” drug) was the number one psychiatric linked to emergency department visits. As many as 68% of patients used it long-term, while the drug is only recommended for short-term use. Up to 22% of zolpidem users were also sustained users of opioids.

Among the concerns with antidepressants are that they are not more effective than placebos (see discussions of the research of Irving Kirsch, starting here: “Do No Harm with Antidepressants”). In some cases they contribute to suicidality and violence (see “Psych Drugs and Violence” and “Iatrogenic Gun Violence”) and they have a risk of withdrawal symptoms upon discontinuation.

In a systematic review of the literature, Fava et al. concluded that withdrawal symptoms might occur with any SSRI. The duration of treatment could be as short as 2 months. The prevalence of withdrawal was varied; and there was a wide range of symptoms, encompassing both physical and psychological symptoms. The table below, taken from the Fava et al. article, noted various signs and symptoms of SSRI withdrawal.

The withdrawal syndrome will typically appears within a few days of drug discontinuation and last for a few weeks. Yet persistence disturbances as long as a year after discontinuation have been reported. “Such disturbances appear to be quite common on patients’ websites but await adequate exploration in clinical studies.”

Clinicians are familiar with the withdrawal phenomena that may occur from alcohol, benzodiazepines, barbiturates, opioids, and stimulants. The results of this review indicate that they need to add SSRI to the list of drugs potentially inducing withdrawal phenomena. The term ‘discontinuation syndrome’ minimizes the vulnerabilities induced by SSRI and should be replaced by ‘withdrawal syndrome’.

Updating his critique of the long-term use of antipsychotics in Anatomy of an Epidemic, Robert Whitaker made his finding available in a paper, “The Case Against Antipsychotics.” There are links to both a slide presentation and a video presentation of the information included in his paper. The breadth of material covered was difficult to summarize or select out some of the more important findings. Instead, we will look at what Whitaker said was the best long-term prospective study of schizophrenia and other psychotic disorders done in the U.S. The Harrow study assessed how well an original group of 200 patients were doing at various time intervals from 2 years up until 20 years after their initial hospitalization for schizophrenia. In his paper, Whitaker reviewed the outcome for these patients after 15 and 20 years of follow up.

Harrow discovered that patients not taking medication regularly recovered from their psychotic symptoms over time. Once this occured, “they had very low relapse rates.” Concurrently, patients who remained on medication, regularly remained psychotic—even those who did recover relapsed often. “Harrow’s results provide a clear picture of how antipsychotics worsen psychotic symptoms over the long term.” Medicated patients did worse on every domain that was measured. They were more likely to be anxious; they had worse cognitive functioning; they were less likely to be working; and they had worse global outcomes.

There is one other comparison that can be made. Throughout the study, there were, in essence, four major groups in Harrow’s study: schizophrenia on and off meds, and those with milder psychotic disorders on and off meds. Here is how their outcomes stacked up:

As Whitaker himself noted, his findings have been criticized from several individuals. However, he answered those critiques and demonstrated how they don’t really hold up. Read his paper for more information. But his conclusions about the use of antipsychotic medications are not unique. In the article abstract, for “Should Psychiatrists be More Cautious About the Long-Term Prophylactic Use of Antipsychotics?” Murray et al. said:

Patients who recover from an acute episode of psychosis are frequently prescribed prophylactic antipsychotics for many years, especially if they are diagnosed as having schizophrenia. However, there is a dearth of evidence concerning the long-term effectiveness of this practice, and growing concern over the cumulative effects of antipsychotics on physical health and brain structure. Although controversy remains concerning some of the data, the wise psychiatrist should regularly review the benefit to each patient of continuing prophylactic antipsychotics against the risk of side-effects and loss of effectiveness through the development of supersensitivity of the dopamine D2 receptor. Psychiatrists should work with their patients to slowly reduce the antipsychotic to the lowest dose that prevents the return of distressing symptoms. Up to 40% of those whose psychosis remits after a first episode should be able to achieve a good outcome in the long term either with no antipsychotic medication or with a very low dose.

All three classes of psychiatric medications reviewed here have serious adverse effects that occur with long-term use. In many cases, they lead to a worsening of the very symptoms they were supposed to “treat.” Increasingly, it is being shown that the psychiatric drug treatments are often worse than the “mental illness” they allegedly treat.

06/6/17

Preventing the Relapse Process, Part 2

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Recovery can be likened to walking up a down escalator. Imagine an escalator that stretches so far up that it disappears in the distance. As every child knows the trick to walking up one is to climb faster than the escalator is pulling you back. You could climb so far up this imaginary escalator, that you would no longer see the bottom. But the moment your climbing effort is less than the downward pull of the escalator, you begin moving back towards that bottom. That’s what relapse is like.

You might even be objectively climbing up the escalator, but if it isn’t enough to counter the downward pull, you have only delayed the inevitable. You have to be climbing as least as fast as the escalator is pulling you back to not lose ground. And that is what relapse prevention is like.

Relapse is a process, not an event. The last thing that happens in a relapse process is resuming alcohol or drug use. Depending on the effort you made to progress up the escalator of recovery, your relapse process could take a long time to play out. I’ve known people who identified patterns of relapse that stretched over years of their abstinent lives before they resumed active drinking or drugging. Perversely, this can be a message of hope and not hopelessness. If your relapse process takes months or years to lead you back to active drinking or drug use, then you have months or even years to recognize the problem and prevent it from getting any worse.

In the first part of this article we looked at coping with problems or stuck points in recovery and the high risk factors and trigger events that increase the likelihood of relapse if they are handled incorrectly.  This discussion on relapse applies the thinking of Terence Gorski on relapse and relapse prevention, particularly his use of the Relapse/Recovery Grid in Passages Through Recovery and the booklet, The Relapse/Recovery Grid.  There are also several articles using this material available on his blog, Terry Gorski’s Blog, including: “Understanding Relapse and Relapse Prevention.”

“The general direction towards relapse is from denial and evasion to high-risk lifestyle factors.” We left off a discussion of the relapse process in Part 1 with a description of high-risk situations and trigger events. High-risk factors make you vulnerable to trigger events, which can be “anything that causes sudden stress, pain, or discomfort.” They can be internal or external triggers. The interaction of high-risk situations and trigger events determines how the Relapse Process advances.

When there are relatively few high-risk factors in a person’s life, it will take a greater stressor to trigger the internal dysfunction of relapse. Conversely, with more high-risk factors, even a minor event can trigger internal dysfunction. “As internal dysfunction increases, the ability to manage reality gets worse, and more problems develop.” This internal dysfunction in early recovery is post acute withdrawal (PAW). See “Recognize Your PAWS” and “Manage Your PAWS.” Or you can read Gorski’s Comprehensive Guide to PAW here.

Internal Dysfunction

When under high stress, many recovering people begin to have difficulty thinking clearly, managing feelings and emotions, and remembering things. One of the main culprits leading to these problems appears to be a tendency to overreact to stressors. . . . Eventually the ability to sleep restfully is disrupted. This heightens stress and fatigue to the point where people become accident-prone.

Thinking problems can range from difficulty concentrating or thinking logically, to racing, repetitive thoughts. The person isn’t always clear about how things affect or relate to each other. “They have difficulty deciding what to do next to manage their lives and recovery.”

Feelings and emotions can range from being very sensitive to being numb. Strange or “crazy feelings” can occur for no apparent reason, leading the person to think they are going crazy. “These problems in managing feelings can cause recovering people to experience mood swings, depression, anxiety, and fear. Sometimes in this situation a mood disorder is diagnosed and treated with medication. Ironically, this could exacerbate the internal dysfunction of relapse. The person often doesn’t trust their emotions and seeks to ignore, stuff or forget them.

Memory problems interfere with learning new skills and retaining new information. Remembering what you just read can be difficult. “The new things they learn dissolve or evaporate from their mind within minutes.” Taking classes or learning a new job skill can be tough when this is happening.

Sleep-related problems can crop up. This could mean trouble falling asleep, trouble staying asleep, and even unusual or disturbing dreams. Restful sleep may be difficult to come by, leading to exhaustion or tiredness during the day.

Problems managing stress begin with a failure to recognize the minor signs of daily stress. So when stressors become evident, there is a tendency to overreact to them. “Stress sensitivity causes them to amplify, magnify, and intensify whatever feeling they are experiencing.” At times, they get so tense and the strain is so severe, they can’t function normally.

This internal dysfunction can lead to feelings of shame and guilt; feeling you are doing something wrong in recovery or not working a good program. This can lead to not talking honestly about what you are experiencing. These warning signs of relapse get stronger the longer they remain hidden. “Secrets keep you sick.” If you try and fail to manager them alone, you may begin to feel hopeless.

External Dysfunction

Problems in living emerge from a failure to manage the internal dysfunction issues of a relapse process. “Now problems arise at work, at home, with friends, and with fellow members of the program.” If there is a person (like a sponsor) or a situation (like a meeting) that might call on you to take an honest look at yourself, you begin to avoid them and isolate. If asked how you’re doing, you get defensive or lie. Impulsive actions, doing things without thinking them through can happen.

Confusion, overreaction and crisis building occur. “Here, people may begin to have problems cause by denying their feelings, isolating themselves, and neglecting their recovery.” You get upset with yourself and others. You can be irritable and overreact to little things. Relationships become strained; conflicts arise. Stress and anxiety increases. At this stage, denial locates the problems in others or outside situations.

Loss of Control

Active addiction is often described as a loss of control. I find it helpful to distinguish between two kinds of loss of control: the loss of control over thinking, feeling or behavior; and the loss of control over drug or alcohol intake. Here the first sense of loss of control is activated. I describe this stage of the relapse process as feeling like a deer caught in the headlights. There is poor judgment; an inability to take action; an inability to resist destructive impulses.

Recovering people lose their ability to control their thinking and behavior. Judgment is impaired. They often know what they need to do but can’t do it. They begin to have cravings and self-destructive impulses and find the more and more difficult to resist. They consciously recognize the loss of control, but believe they can’t do anything about it.

Far too often, this is the first awareness the person has that they have slipped into “relapse mode.” They see how severe their problems have become; how unmanageable life has become and how little power they have to solve their problems. “By this time, they have become so isolated that it seems there is no one to turn to for help.” Feelings of powerlessness to resolve problems leads to believing you are useless and incompetent.

Feeling trapped by pain and inability to manage life, they feel their options are reduced to going insane, committing suicide or using drugs or alcohol. There is no sense that anyone or anything can help. Twelve Step meeting attendance stops, if it hasn’t already. Tension can lead to terminating a relationship with a sponsor of counselor that used to be helpful.

People can only live with debilitating stress for so long before they collapse. Some people collapse physically and develop stress-related illnesses such as ulcers, gastritis, back pain, hear disease, or cancer. Others collapse emotionally … [or] become suicidal.

Lapse/Relapse

“When faced with the limited alternatives of physical or emotional collapse, suicide or chemical use, using can seem like the sanest choice.” Assumed here is the person does know, or did know from experience when they were using in the past, that it’s likely they would again lose control over their use. Either they are so desperate that they convince themselves they will only use for a short while in a controlled way, or they impulsively act when an opportunity to use presents itself. This initial use will often produce intense feelings of guilt and shame for the individual.

Sometimes active using is a lapse—a short time period, perhaps even one night or a few drinks. Other times the active use spirals out of control and can go for months or years. Returning to a loss of control over use can be slow or rapid. Often the person quickly returns to using as much as they did before.

The goal of relapse prevention is to interrupt the above-described process as quickly as possible. The further the relapse process progresses, the more difficult it is to stop. Identifying and resolving stuck points (see part 1), avoiding as many high-risk factors as possible, and neutralizing trigger events are the best interventions. Next would be catching and addressing internal dysfunction, then external dysfunction and finally loss of control before the relapse into active chemical use. Remember that when you successfully intervene in a relapse process at the beginning, you need never risk actually picking up.

This is part 2 of my article, “Preventing the Relapse Process.” Part 1 describes stuck points, high-risk factors and trigger events connected to the relapse process and it can be found here.

I have read and used Terence Gorski’s material on relapse and recovery for most of my career as an addictions counselor. I’ve read several of his books and booklets; and I’ve completed many of his online training courses. He has a blog, “Terry Gorski’s Blog”, where he graciously shares much of what he has learned, researched and written over the years. This is one of a series of articles based upon the material available on his blog and websites.

06/2/17

Myth of the Medieval Science Gap

© Sergey Ishkov | 123rf.com

Carl Sagan and others described the Middle Ages as a time when scientific progress was thwarted by religion, specifically Christianity.  In his book Cosmos, Sagan has a timeline of science and technology with a gap from around 500 AD to 1500 AD. At the bottom of the timeline he commented: “The millennium gap in the middle of the diagram represents a poignant lost opportunity for the human species.” But this portrayal of the Middle Ages is as false as saying Columbus discovered American and proved the earth wasn’t flat.

In a BioLogos article, “Carl Sagan and the Myth of the Medieval Gap,” Stephen Snobelen said it was axiomatic for those who perceive a conflict between religion and science to hold to this belief. Namely, that while “science” existed in ancient Greece, during medieval times it faded away until Christianity’s influence started to subside. Snobelen said only with some significant qualifications can we say: “science existed in Ancient Greece.” And this Greek period of “science” was already in decline before Christianity came to power.

“It is true that the first half of the Middle Ages did not enjoy the intellectual vibrancy of the second half.” But this can be explained by historical contingencies such as “the impact of Barbarian invasions and political dislocations.” By the end of the medieval period, “science and technology had reached a state of sophistication and refinement that far surpassed that of the Greeks.” And yet, the term “medieval” has become a sneering way of referring to something that someone thinks is backward.

Among the technological advances of the Middle Ages are the horse collar, the rudder, eye glasses, buttons, the fork, trousers, windmills, the mechanical escapement clock, and the printing press. The invention of the Cyrillic script, which is the basis of several alphabets, also occurred during the Middle Ages. The myth also ignores the innovations to the practice and theory of science that occurred during that time. Roger Bacon (1220-1292), a Franciscan, is known as the first modern scientist. William of Ockham (1285-1347) conceived of the parsimony principle—Ockham’s Razor.

But, if we play the correlation-equals-causation game (which is a fallacy to begin with), then this argument proves more than advocates of the Medieval Gap want. For instance, there is a common assumption that Europe in the Middle Ages and the Early Modern Period was a cultural monolith dominated by the Church. This can hardly be said of the first half of the Middle Ages. Yet, it was only when the Catholic Church had consolidated its power in the second half of the period that there was a relative flourishing of science and technology. More spectacularly, it was precisely the period when Europe was at its most Christian—the sixteenth and seventeenth centuries—that science as we now know it emerged. (I am not saying that Christianity was in any simple way responsible for the emergence of modern science, only that the correlation argument can come back to bite its proponents)

In his essay on the myth “That the Medieval Christian Church Suppressed the Growth of Science,” in Galileo Goes to Jail, Michael Shank said the idea that the Middle Ages was a “millennium of stagnation” brought on by Christianity has largely disappeared among Medieval scholars. “But it remains vigorous among popularizers of the history of science” who uncritically repeat these false assertions made of those who went before them. For example, John William Draper, asserted in 1874 (History of the Conflict Between Religion and Science) that the Church of the Middle Ages “became a stumbling block in the intellectual advancement of Europe for more than a thousand years.” Carl Sagan, in his 1980 book Cosmos said: “For a long time the human instinct to understand was thwarted by facile religious explanations.”

Another factor in the growth of science during the Middle Ages was the spontaneous development of universities around famous teachers in towns like Paris, Oxford, and Bologna. “By 1500, about sixty universities were scattered throughout Europe.” About 30 percent of their curriculum covered subjects and texts about the natural world. Hundreds of thousands of students were exposed to science “in the Greco-Arabic tradition.”

If the medieval church had intended to discourage or suppress science, it certainly made a colossal mistake in tolerating—to say nothing of supporting—the university. . . . Dozens of universities introduced large numbers of students to Euclidean geometry, optics, the problems of generation and reproduction, the rudiments of astronomy, and arguments for the sphericity of the earth. Even students who did not complete their degrees gained an elementary familiarity with natural philosophy and the mathematical sciences and imbibed the naturalism of these disciplines.

The majority of students at these universities did not study theology. Most were not priests or monks. “They remained in the faculties of arts, where they studied only nonreligious subjects, including logic, natural philosophy, and the mathematical sciences.” The most popular advanced study was law, which promised lucrative careers in the bureaucracies of both church and state.

In another BioLogos article, “The Medieval Gap and New Atheists Today,” Stephen Snoblen said Carl Sagan isn’t the only modern author perpetuating the Myth of the Medieval Gap. He quoted the biologist Jerry Coyne who said Christianity was around for about 1,000 years without much science being done. “I maintain, though I can’t prove this, that had there been no Christianity, if after the fall of Rome atheism had pervaded the Western world, science would have developed earlier and be far more advanced than it is now.”  In a debate, physicist and philosopher Victor Stenger asserted civilization went through a period of “Dark Ages” during which science was lost. Christianity was the alleged cause. “And when Christianity finally began to be chipped away … we got it back.”

David Mills, the author of Atheist Universe, thought that if it weren’t for the religious persecution and oppression of science, humankind could have landed on the moon by 650 AD. Cancer could have been eradicated by 800 AD, and heart disease might be unknown today. He claimed the Christian Church operated torture chambers throughout Europe for 1500 years and yearly tortured “tens of thousands of people. Including children as young as two years old” to death. Snoblen noted estimates for the number of witches put to death range from 7,000 to 100,000. If the rhetoric of Mills was accepted here, then 20,000 yearly deaths (tens of thousands) over 1500 years would add up to 30,000,000 killed by torture. Richard Dawkins referred to the Atheist Universe as “an admirable work” and Carl Sagan’s son wrote the foreword.

Snoblen said that as a historian of science, he despaired when reading such nonsense. It depressed him to see the promotion of such ignorance. But he frequently encountered it among some undergraduates. He worried about the effect such vitriol had on secular attitudes towards Christians and Christianity. “This sort of rhetoric and misuse of history promotes intolerance and is simply inexcusable. It is the duty of historians to expose this for the mythology it is.”