07/21/17

Blind Spots with Antipsychotics, Part 2

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The American Journal of Psychiatry published an article by Goff et al. that addressed concerns that antipsychotic medications can adversely effect long-term outcomes of people with schizophrenia. Their conclusion was that there was little evidence to support “a negative long-term effect of initial or maintenance antipsychotic treatment on outcomes,” when compared to withholding medication treatment. Additionally, the researchers said while a subgroup of patients may benefit from “nonpharmacological treatment approaches,” they warned of the potential for an “incremental risk of relapse” and recommended the need for further research into the question. But did these researchers have a blind spot in how they evaluated their evidence?

In part one of this article, I reviewed some of the research evidence that supported concerns with long-term antipsychotic treatment. There was evidence supporting a link between long-term antipsychotic use and adverse cardiovascular events, brain shrinkage, and dopamine supersensitivity, as well as questions regarding the efficacy of antipsychotic maintenance treatment. There also seemed to be a disregard in Goff et al. of the evidence for the risk of metabolic syndrome with long-term antipsychotic use in their risk-benefit analysis of antipsychotic use. Yet health concerns from metabolic syndrome have been connected to the glaring difference in a shortened life expectancy, with persons suffering with serious mental illness dying 25 years earlier than the general population.

My previous encounters with Dr. Jeffrey Lieberman, who was the lead researcher for Goff et al., have led me to be cautious of his assertions without further investigation. I believe he has a serious blind spot when it comes to assessing and interpreting information counter to his position. See (“A Censored Story of Psychiatry, “Part 1, Part 2;  “Psychiatry, Diagnose Thyself!” Part 1, Part 2) for more on my concerns with Dr. Lieberman. So if there was a blind spot in Goff et al., what do other experts have to say about their conclusions?

Joanna Moncrieff wrote a response to Goff et al. on the Mad in America website, which can be accessed here. Moncrieff is a practicing psychiatrist, academic and author. She is one of the founding members and current co-chair person for the Critical Psychiatry Network, “a group of psychiatrists from around the world who are sceptical of the idea that mental disorders are simply brain diseases and of the dominance of the pharmaceutical industry.” She has written extensively on this issue, including a recent book on the troubling story of antipsychotic drugs entitled: The Bitterest Pill. You can read more about her thinking and her background on her website. She said she was shocked by how Goff et al. dismissed the concerns with long-term antipsychotic treatment and the evidence of brain impacts.

It is riddled with distortion, ignores the most pressing criticisms, and is shot through with the unexamined presumption that the multitude of problems currently labelled as schizophrenia or psychosis will one day be revealed to be due to a specific brain abnormality that is targeted by antipsychotics.

She doesn’t dispute the usefulness of antipsychotics for treating acute psychosis, what Goff et al. called initial antipsychotic treatment. Yet she noted where “decades of research into early intervention has not demonstrated that early antipsychotic treatment improves long-term outcomes.” She pointed out where Goff et al. stated the effectiveness of maintenance treatment has been well established, but then failed to acknowledge that randomised trials of maintenance treatment were typically maintenance treatment versus sudden withdrawal. “Thus they completely fail to address concerns that effects of withdrawal of long-term treatment inevitably confound such studies.”

The most worrying thing about the Goff et al. paper to Moncrieff was the minimization of the evidence that antipsychotics produce brain shrinkage. They claim that shrinkage of brain grey matter has been shown to be part of schizophrenia, claiming that brain differences were detected long before the introduction of antipsychotics. The paper they cited was a 1985 study by Bogerts and Schonfeldt-Bausch, which was a post mortem study done long after antipsychotics had been introduced.

The presence of differences between the brains of people with schizophrenia and controls does not establish that there is progression of brain volume loss, which is what has been clearly demonstrated in people and animals taking antipsychotics. There are no studies that show progressive brain changes in people diagnosed with schizophrenia or psychosis in the absence of antipsychotic treatment.

Dr. Moncrieff concluded her article by saying:

I still think antipsychotics can be useful, and that the benefits of treatment can sometimes outweigh the disadvantages, even in the long-term for some people. However, it does no one any service to pretend that they are innocuous substances that somehow magically transform (hypothetically) abnormal schizophrenic brains back to normal. Psychiatrists need to be fully aware of the detrimental effects of antipsychotics on the brain and body. They also need to acknowledge the way these drugs make life so miserable for many people, even for some who might have been even more distressed were they to be without them… Psychiatrists need to support people to evaluate the pros and cons of antipsychotic treatment for themselves and to keep doing this as they progress through different stages of their problems. To do this they need to be able to acknowledge the real nature of these drugs, and not sweep inconvenient truths under the carpet!

Miram Larsen-Barr also wrote a response to Goff et al. that appeared on Mad in America, which can be accessed here. She is a clinical psychologist with the University of Auckland, New Zealand. Larsen-Barr created and is the Service Director for Engage Aotearoa, an initiative that aims to make recovery information more easily accessible to the general public. She has “lived experience” of recovery from trauma, depression and suicidality. Her doctoral research explored experiences of taking, and attempting to stop, antipsychotic medication.

For her doctoral research she talked to 144 people who take or have taken antipsychotics. One-third thought antipsychotics had relieved their symptoms and given them back their lives—but another third said quite the opposite. She said the claim that the benefits of antipsychotic medications conclusively outweigh the adverse effects is just not true. It is true for some; entirely the opposite for others; and a mixed bag for the remaining individuals. You can access a copy of her thesis research here.

In my study, overall subjective experiences ranged on a continuum from life-saver” to hell” and every point between (Larsen-Barr, 2016). Around a third reported overall positive experiences such as A major relief from the monsters […] for me they have saved my life” and Helped me get through an unstable period of my life. And around a third of the participants reported mixed experiences such as, A short term help when needed then a burden” and A double edged sword. They help me with my bad experiences but they also take away the wind in my sails.”Another third reported wholly negative experiences such as, The worst experience of my life […] affected every aspect of my health and wellbeing. The therapeutic benefits certainly did not outweigh the costs for those who described the overall experience of taking antipsychotics as The ruin of my life or said they were Helpful to a point but […] robbed me of everything I value in myself as a person.

Larsen-Barr reported that few people in her study reported being well-informed of the potential benefits and risks before antipsychotic treatment. While about one-third reported beneficial results, 79% overall did contemplate stopping their medication, with 73% making at least one attempt. She said her study suggested the desire to stop antipsychotic medications was not just because of negative experiences. These decisions were primarily based upon whether or not taking AMs helped the person to “function in daily life.”

A full third of her survey sample had discontinued medications at the time of the study, which was similar to the stable discontinuation rate found in Harrow’s long-term study. Larsen-Barr found half of 105 survey participants who attempted to stop remained AM-free for one year or more; some over five years ago. Her research showed “withdrawal often entails a lack of information, poor support, and a range of physical, emotional, cognitive, social and functional disruptions that can be difficult to cope with, and which may include exacerbation of symptoms to the point of relapse.” For more on the Harrow study and concerns with antipsychotics, see “The Case Against Antipsychotics” by Robert Whitaker and “Worse Results with Psych Meds” on this website.

In part 1 of this article there was a discussion of how Carrie Fisher’s sudden cardiac death may have been associated with her use of psychiatric medications. Yet the possibility of her medications being a contributing factor to her death seemed to be overlooked in many articles about her unexpected death. For example, writing for Scientific American, Tori Rodriguez raised the possibility that Fisher’s bipolar disorder played a role in her death. Not the medication used to treat her bipolar disorder, but the disorder itself.

Did Carrie Fisher’s Bipolar Disorder Contribute to Her Death?” noted several possible connections to her bipolar disorder, but only made an oblique comment about how the medications may cause adverse effects like weight gain, diabetes higher triglycerides and even sudden cardiac death. Rodriguez noted how Fisher’s earlier substance abuse and struggles with her weight have been speculatively raised as contributing factors to her death. But she said one possibility that has been overlooked was the connection between bipolar disorder and cardiovascular disease and mortality. Individuals with bipolar disorder are twice as likely to develop or die from cardiovascular disease. The onset of cardiovascular disease occurs up to 17 years earlier in persons with bipolar disorder than in the general population. But as we’ve seen, that connection seems to be with the medications and not the disorder itself.

Rodriguez said Carrie Fisher “fit the bill” for several of the risk factors for sudden cardiac death at different points in her life. Then she said: ‘There is no definitive way to know whether her bipolar disorder or addiction history contributed to her death.” Yet there does seem to be a strong likelihood that not only did her use of antipsychotic medications help her be a better mother, friend and daughter, it may have contributed to her sudden cardiac death as well.

07/11/17

Blind Spots with Antipsychotics, Part 1

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Carrie Fisher was flying back to her home in Los Angeles on December 23, 2016 when she went into cardiac arrest. She was removed from the plane and later died in the hospital. Her daughter, Billie Lourd, said: ““She was loved by the world and she will be missed profoundly.” She was a well-known actress, writer and humorist. She wrote six books, some of which described her life, loves and adventures, which included drug addiction and bipolar disorder. A series of articles lamented that she was taken too soon, but there wasn’t anything said about a possible connection between her sudden cardiac death (SCD) and the medication she took for her bipolar disorder.

Fisher was a vocal mental health advocate and talked freely about her bipolar disorder and over the years. An article contained the following statements made by Fisher about her mental health and use of medication. In an interview with Diane Sawyer in December of 2000, she said: “I am mentally ill. I can say that. I am not ashamed of that. I survived that, I’m still surviving it, but bring it on. Better me than you.” At a February 2001 rally in Indianapolis for increased state funding for mental health and addiction treatment, she said: “Without medication I would not be able to function in this world. Medication has made me a good mother, a good friend, a good daughter.”

Writing for Mad in America, Corinna West raised the question of whether Fisher’s too soon passing was related to her use of psych meds. West referred to an article in the European Heart Journal by Honkola et al. that concluded: “The use of psychotropic drugs, especially combined use of antipsychotic and antidepressant drugs, is strongly associated with an increased risk of SCD at the time of an acute coronary event.”

This study confirms that combining antidepressants and old school [first generation] antipsychotics causes an 18-fold increase in death during a cardiac event. Combining antidepressants with any antipsychotic causes an over 5-fold increase in relative risk of death during a cardiac incident.

To put this into some context, West noted: “Vioxx was pulled from the market for a 2-fold increase in relative risk factor of strokes and heart attacks.” It may have led to the death of 50,000 to 70,000 people while it was on the market. She then did some speculative calculations and suggested psych meds may contribute to 74,191 additional heart attacks annually and 33,386 deaths from SCD per year.

She also noted how people with serious mental illness have a 25-year lower life expectancy than others and a significantly greater risk of myocardial infarction. The NASMHPD “Morbidity and Mortality Report” said that it has been known for several years that people with serious mental illness die younger than the general population. “In fact, persons with serous mental illness (SMI) are now dying 25 years earlier than the general population.” The report also said people with SMI also suffer from a greater percentage of modifiable risk factors associated with cardiovascular disease, such as obesity, smoking, diabetes, hypertension and dyslipidema (high cholesterol). Corrine West noted the data from the “Morbidity and Mortality Report” showed that psychiatric drugs increased 4 of the top 5 normal risk factors for cardiac disease. Smoking was included as a risk factor because many individuals using psych meds find the nicotine helps relieve some of the numbness caused by the meds. See the following chart from the report.

There is increasing evidence of multiple adverse effects from the long-term use of antipsychotics in addition to the risk of SCD. Murray et al. concluded there was a lack of evidence for the long-term effectiveness of prophylactic (maintenance) antipsychotic use; and a growing concern with the cumulative effects of antipsychotics on physical health and brain structure. “There is enough evidence concerning the adverse effects of antipsychotics on physical health to compel psychiatrists to act.”

Murray et al. said long-tem maintenance treatment with antipsychotics was “based on hope rather than evidence.” They pointed to two serious methodological problems. First, studies claiming that antipsychotic maintenance treatment substantially reduced the risk of relapse were often limited to two years of follow-up. Second, the studies compared schizophrenic patients continuing on antipsychotics with those who stopped taking antipsychotics, not individuals who never used the drugs. So the withdrawal effect from antipsychotics in the discontinuation group influenced the higher relapse rates, making it a confounding variable to the supposed positive results with antipsychotic maintenance treatment.

The Murray et al. researchers did think there was no clear link between antipsychotic-associated changes in brain structure and cognitive decline or functional impairment. However, studies like that of Ho et al. suggested antipsychotics can “have a subtle but measurable influence on brain tissue loss over time.” Ho et al. said there was also a problem with dopamine receptor supersensitivity in some antipsychotic users. This supersensitivity could be a factor in the decreased efficacy of antipsychotics with continued prescription; and it may contribute to relapse when an individuals stops using antipsychotics. “There is an urgent need for neurochemical imaging studies addressing the question of dopamine supersensitivity in patients.”  In their conclusion, the researchers gave the following recommendations.

[The wise psychiatrist] will treat acute psychosis with the minimum necessary dose of antipsychotics, employing weight sparing antipsychotics wherever possible; dopamine partial agonists have this property and may also be less likely to induce dopamine supersensitivity. Following recovery, the psychiatrist should work with each patient to decrease the dose to the lowest level compatible with freedom from troublesome psychotic symptoms; in a minority of patients, this level will be zero.

You can read a summary review of the study by Justin Karter on Mad in America here.

Not all of the above-cited researchers agreed with the conclusions of each other. But collectively they pointed to evidence of a link between antipsychotics and adverse cardio vascular events, brain shrinkage, and dopamine supersensitivity.  Murray et al. also suggested that studies of long-tem antipsychotic maintenance treatment unfairly stacked their results in favor of antipsychotic maintenance by using patients who were withdrawn/discontinued from using antipsychotics as their control group. So when the recent press release from Columbia Medical Center regarding Goff et al. concluded the benefits of antipsychotics outweigh the risks was disconcerting and confusing at first. The Goff et al. abstract asserted: “Little evidence was found to support a negative long-term effect of initial or maintenance antipsychotic treatment on outcomes, compared with withholding treatment.”

The press release acknowledged the above concerns that antipsychotic medications have been said to have toxic effects and negatively impact long-term outcomes. However it went on to say that if this view was not justified by data, it had the potential to “mislead some patients (and their families) to refuse or discontinue antipsychotic treatment.” Therefore a team of researchers led by Jeffrey Lieberman, the Lawrence C. Kolb Professor and Chairman of Psychiatry at Columbia University College of Physicians and Surgeon, undertook “a comprehensive examination of clinical and basic research studies that examined the effects of antipsychotic drug treatment on the clinical outcomes of patients and changes in brain structure.” Lieberman was liberally quoted in the Columbia press release with regard to their findings supporting how the benefits of antipsychotics outweigh the risks. He said:

The evidence from randomized clinical trials and neuroimaging studies overwhelmingly suggests that the majority of patients with schizophrenia benefit from antipsychotic treatment, both in the initial presentation of the disease and for longer-term maintenance to prevent relapse. . . . Anyone who doubts this conclusion should talk with people whose symptoms have been relieved by treatment and literally given back their lives.

Lieberman went on to suggest that only a very small number of individuals recover from an initial psychotic episode without the use of antipsychotic maintenance treatment. “Consequentially, withholding treatment could be detrimental for most patients with schizophrenia.” He acknowledged where rodent studies suggested antipsychotics can sensitize dopamine receptors, but “there is no evidence that antipsychotic treatment increases the risk of relapse.” Further, although antipsychotic medications can increase the risk of metabolic syndrome, which is linked to heart disease, diabetes and stroke, their study did not include a risk benefit analysis of this concern.

Wait a minute. Why didn’t their study include a risk benefit analysis for metabolic syndrome? It seems to be one of the most reliably documented adverse effects, as noted above. Could it be that the intended message of the research—namely how strong evidence supports the benefits of antipsychotic medications—would not have been as clearly communicated if the risk benefit analysis concluded there was a substantial risk of metabolic syndrome? By the way, according to the Mayo Clinic,

Metabolic syndrome is a cluster of conditions — increased blood pressure, high blood sugar, excess body fat around the waist, and abnormal cholesterol or triglyceride levels — that occur together, increasing your risk of heart disease, stroke and diabetes. Having just one of these conditions doesn’t mean you have metabolic syndrome. However, any of these conditions increase your risk of serious disease. Having more than one of these might increase your risk even more. If you have metabolic syndrome or any of its components, aggressive lifestyle changes can delay or even prevent the development of serious health problems.

Dr. Lieberman has been a vocal advocate of modern psychiatry and equally critical of those who question many of its claims, as with those documented here. My previous encounters with his presentation of evidence and data, like his discussion of the conclusions of Goff et al. above, have led me to be skeptical of his conclusions without further investigation. I believe his fervent desire to defend modern psychiatry and current psychiatric methods has distorted how he interprets and presents conflicting evidence. He seems to have a blind spot when assessing and interpreting evidence counter to his position. The above question about the failure to include a risk benefit analysis of metabolic syndrome is one illustration of what I mean.

So what do others have to say with regard to the Goff et al. study? We’ll look at some of those critiques in part 2 of this article.

06/30/17

Rooting for the Underdog

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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.

06/20/17

Freud’s Nanny

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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.

06/9/17

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.

05/30/17

Psychoanalysis Without Freud

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An article in STAT News on Freud and psychoanalysis, “Saving Sigmund,” caught my attention. It described how psychoanalysis is trying to “reinvigorate” itself. In the process, psychoanalysts are trying not to be “unduly fixated” on Freud’s stages of psychosexual development or his tripartite psyche of the id, ego and superego. One psychoanalyst said assuming she was Freudian was “like asking a modern-day nuclear physicist whether he’s Copernican.” While much of what Copernicus said was not true, it was a helpful foundation.

The analogy is a bit over the top and seems to be an attempt to distance current psychoanalysis from the rejection of many of Freud’s ideas. Writing for STAT, Carter Maness pointed to what may be the foundation of the need to reconceptualize psychoanalysis: only 15% of the members of the American Psychoanalytic Association (APA) are under 50. Traditional Freudian analysis is a dying art. “Lying on a couch, talking about your childhood, day after day for years — is widely seen as a musty relic, far too expensive and intensive to fit into modern life.”

The 1945 film Spellbound, directed by Alfred Hitchcock, captured Freudian psychoanalysis at the zenith of its popularity. The movie’s producer, David O. Selznick wanted Hitchcock to make a movie reflecting his own positive experience with psychoanalysis. Selznick even brought in his own analyst as a technical advisor for the film. The advisor clashed frequently with Hitchcock. Of course in a pro-Freudian movie like Spellbound, there was a dream sequence, which was designed by the artist Salvador Dali. In it, the Freud look-a-like character encouraged Gregory Peck to continue recalling the details of his dream—“the more cock-eyed, the better for the scientific side of it.”

Freud saw himself as a pioneering scientist and repeatedly asserted psychoanalysis was a new science. In his work, An Outline of Psycho-Analysis, Freud said conceiving mental life as a function of the psychical apparatus of id, ego and super-ego was “a scientific novelty.”

We assume that mental life is the function of an apparatus to which we ascribe the characteristics of being extended in space and being made up of several portions—which we imagine, that is, as resembling a telescope. . . . we have arrived at our knowledge of this apparatus by studying the individual development of human beings.

However, Freud’s claim that psychoanalysis was a science of the mind is the subject of continuing debate. As was pointed out in the article on Sigmund Freud in the Internet Encyclopedia of Philosophy, the scientific status of psychoanalysis is undermined since it cannot be falsified. Karl Popper’s criterion of demarcation between the scientific and the unscientific is that for something to be scientific it must be testable and therefore falsifiable.

 It is argued that nothing of the kind is possible with respect to Freud’s theory–it is not falsifiable. If the question is asked: “What does this theory imply which, if false, would show the whole theory to be false?,” the answer is “Nothing” because the theory is compatible with every possible state of affairs. Hence it is concluded that the theory is not scientific, and while this does not, as some critics claim, rob it of all value, it certainly diminishes its intellectual status as projected by its strongest advocates, including Freud himself.

Psychoanalytic thought finally lost its stranglehold on psychiatry in the 1980s with the reformulation of the Diagnostic and Statistical Manual (DSM). That was also the beginning of the rise of biological psychiatry. The heroic figures of psychoanalytic therapists in movies like Spellbound, The Snake Pit (1948), and The Three Faces of Eve (1957) changed. Psychiatric treatment began to be seen through the lens of movies like One Flew Over the Cuckoo’s Nest (1975) and Frances (1982).

Modern popular thinking on Freudian thought is satirically captured in the 1991 comedy, What About Bob? Bill Murray plays Bob Wiley, the unstable patient of an egotistical psychiatrist, Leo Marvin, played by Richard Dreyfuss. Unable to cope on his own, Bob Wiley follows and befriends Dr. Marvin’s family when the family leaves for a month-long vacation. Ultimately this pushes the good doctor over the edge and there is a role-reversal of sorts. Look for the appearance of a bust of Sigmund Freud in several scenes throughout the movie. By the way, Dr. Marvin’s son is named Sigmund. Here is a clip of the therapy session at the beginning of the film.

In order to reinvigorate their profession, psychoanalysts are repackaging the concepts underlying analysis and introducing them to school kids. A past president of the APA said: “We’ve started applying psychoanalytic ideas outside of our offices—in schools, in agencies, in business . . . . We’ve made social issues much more on the minds of our membership.” Project Realize, an alternative school for at-risk teenagers in Cicero Illinois, has treated more than 400 students expelled from regular school for aggressive and dysfunctional behavior. Now in its 12th year, it is said to have lowered rates of violence and improved graduation.

Training requirements have been altered somewhat. In the past, would-be analysts had to first earn an MD, a PhD, or an LCSW (a license to practice social work). Then they had to complete four years of coursework in psychoanalysis AND 200 hours of clinical training. In addition, they had to undergo analysis (four sessions per week) for at least two years.

One psychoanalyst in private practice remarked those requirements fit the 1950s, when every psychologist wanted to be an analyst. “If you’re doing a MD or a PhD or an LCSW, the conditions of starting a private practice and having a job don’t fit with analytic training anymore. Candidates find their analytic voice at 50. That’s nuts.” When Mark Smaller became the president-elect of the APA at 62, he said he could have been considered “a Young Turk.”

Freud has been dethroned as the king of psychotherapy and classic psychoanalysis is increasingly seen as a dying art. Now there is a two-year training for “psychoanalytic psychotherapy” offered by some training centers. It incorporates Freudian ideas about motivation and the unconscious and offers an easier and cheaper way to train as an analyst. And recent studies of Freud have suggested new, and intriguing perspectives into the man and the development of his theories.

In The Freudian Fallacy, E.M. Thornton said Freud’s personal use of cocaine was not just limited to his late twenties and early thirties, between 1884 and 1887.  She presented evidence that Freud resumed using cocaine in the latter half of 1892, “the year coinciding with the emergence of his revolutionary new theories, and asserts that these theories were the direct outcome of this usage [of cocaine].”

The false prophet of the drug world can propagate his message with as much conviction and authority as the true and his manner will have the same burning fervor and sincerity. In common with other victims of brain pathology, Freud would still have been able to reason skillfully from his false premises and so hide his psychotic traits from his followers. And yet, over the years, one by one, most of Freud’s inner circle of early disciples left him.

Paul Vitz developed a fascinating thesis that Freud had a strong, life-long positive identification and attraction to Christianity in Sigmund Freud’s Christian Unconscious. Vitz said there was also a concurrent secondary influence of unconscious hostility to Christianity seen in his preoccupation with the Devil, Hell, and the Anti-Christ.

All of this very substantial Christian (and anti-Christian) part of Freud should provide an understanding of his ambivalence about religion. It should also furnish a new framework for understanding major aspects of Freud’s personality, and allow us … to re-evaluate Freud’s psychology of religion.

As a young child, Sigmund had a Catholic nanny from around the age of one until he was two years and eight months old, maybe longer. It is likely that given that his mother had two pregnancies and births, and took care of a sick child who died during this time, that the nanny was also his wet nurse. Freud himself admitted that his nanny told him a great deal about God and hell. In a letter to his friend Wilhelm Fiess, he said:

I asked my mother whether she remembered my nurse. “Of course,” she said, “an elderly woman [Freud’s mother was 21 at the time of his birth], very shrewd indeed. She was always taking you to church. When you came home you used to preach, and tell us all about how God conducted His affairs.

In “Reassessing Freud’s Case Histories,” science historian Frank Sulloway said the intellectual quicksand upon which Freud built his theories and assembled his “empirical” observations was extensive. “His controversial clinical methods only served to magnify the conceptual problems already inherent in his dubious theoretical assumptions.” The training methods he supported were “highly influential” in removing psychoanalysis from academic science and medicine. “As a result, the discipline of psychoanalysis, which has always tapped considerable religious fervor among its adherents, has increasingly come to resemble a religion in its social organization.”

In “Why Freud Still Isn’t Dead,” John Horgan pointed out how there has been a recent trend in trying to find common ground between neuroscience and psychoanalysis. From one perspective, this fits as Freud originally trained as a neurologist and tried to base his theory of the psyche on an evolutionary sense of brain development. Here he followed the thought of Ernst Haeckel, who theorized the soul/psyche evolved biologically. In his classic 1892 work, Monism as Connecting Religion and Science, Haeckel said:

What we briefly designate as the “human soul,” is only the sum of our feeling, willing, and thinking—the sum of those physiological functions whose elementary organs are constituted by the microscopic ganglion-cells of our brain. Comparative anatomy and ontogeny show us how the wonderful structure of this last, the organ of our human soul, has in the course of millions of years been gradually built up from the brains of higher and lower vertebrates.

Horgan observed that science has failed to produce “a theory/therapy potent enough to render psychoanalysis obsolete once and for all.” Neither Freudians nor proponents of “more modern treatments” can point to any unambiguous evidence that psychoanalysis works or doesn’t work. “Until science yields an indisputably superior theory/therapy for the mind, psychoanalysis–and Freud–will endure.” Here’s the rub. When psychoanalysis asks “fundamental questions” like, “Why do people do the things they do,” it goes beyond the limits of what can legitimately be investigated by science. So science will never be able to develop unambiguous evidence for ANY theory/therapy for the mind.

Psychoanalysis may not be dead as a therapy, but it is not the science Freud thought it was. In a world dominated by the DSM, neurotransmitter dysregulation, and the search for the biomarkers of mental disorders, there is increasingly less room for Freudian constructs like psychosexual development and the id, ego and super ego. We might even say that Freudian thought is in danger of being overcome by its own death instinct.

05/19/17

Another Brick in the Wall

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A Task Force for the American Psychological Association said that if clinical psychology was to survive in the heyday of biological psychiatry, it had to emphasize the strength of what it had to offer, namely “a variety of psychotherapies of proven efficacy.” So it proceeded to develop criteria to identify empirically validated treatments. Yet outcome research has regularly shown over the past forty years that “when treatments intended to be therapeutic are compared, the true difference between all such treatments is zero.” This has been referred to as the “dodo bird effect,” reflecting the observation made in 1936 by Saul Rosenzweig that common factors were responsible for the efficacy of various psychotherapies. Barry Duncan remarked: “the task force not unlike the pigs in George Orwell’s Animal Farm, continues to assert that some therapies are more equal than others.”

The APA Task Force on Promotion and Dissemination of Psychological Procedures noted that treatment manuals have become a required element of psychosocial treatment research. The standardization in treatment manuals reduces the methodological problems caused by “variable therapist outcomes.” Since no treatment will work for all problems, “it is essential to verify which treatments work for which types of problems.” Following this rationale, the Task Force suggested criteria for Empirically Validated Treatments (EVT) for two categories: Well-Established Treatments and Probably Efficacious Treatments.” You can see the criteria for each in Tables 1 and 2 in the above link.

In “The Legacy of Saul Rosenzweig: The Profundity of the Dodo Bird,” Duncan commented that although the APA had good intentions in trying to preserve a section of the therapy market for the psychology profession, “declaring an approach to be an EVT and suggesting that it should therefore be the prescribed treatment of choice is empirical bankruptcy.” The EVT approach equates the client with the problem and describes the treatment as if it is isolated from what has been shown to be the most powerful factors that contribute to therapeutic change—the client’s resources and the therapeutic relationship of client and therapist.

The EVT position virtually ignores 40 years of outcome data about common factors and the veracity of the dodo bird verdict. Model factors are pale in comparison with client and relationship factors; efficacy over placebo is not differential efficacy over other approaches.

Duncan said the EVT “house of cards” was built on the medical model of “diagnosis plus prescriptive treatment equals symptom amelioration.” He pointed back to a 1949 conference in Boulder when psychology’s training guidelines was framed with medical language and concept of mental disease. Later, when the National Institute of Mental Health (NIMH) decided to apply the same methodology it used in drug research to evaluate psychotherapy—randomized clinical trials (RCT)—it had profound effects. This methodology meant a study had to include manualized therapies (to approximate drug protocols) and DSM defined disorders to be eligible for an NIMH-sponsored research grant.

The result was that funding for studies not related to specific disorders dropped nearly 200% from the late 1980s to 1990. “Force fitting the RCT on psychotherapy research is empirical tyranny and bereft of scientific reasoning.” It takes what is a human relational method of change and tries to cram it into a series of operationally defined behavior modifications.

The RCT compares the effects of a drug (an active compound) with a placebo (a therapeutically inert or inactive substance) for a specific illness. The basic assumption of the RCT is that the active (unique) ingredients of different drugs (or psychotherapies) will produce different effects with different disorders. The field has already been there and done that—the dodo bird verdict is a reality, and the active ingredients model (or drug metaphor) borrowed from medicine does not fit.

Among the problems when the RCT methodology is used for psychotherapeutic research is that the findings are profoundly limited because they do not generalize to the way psychotherapy is conducted in the real world. “Efficacy in RCTs does not equate to effectiveness in clinical settings; internal validity does not ensure external validity. . . . Experienced therapists know psychotherapy requires the unique tailoring of any approach to a particular client and circumstance.” When therapists do psychotherapy by the book, it doesn’t go very well. Duncan said doing therapy by manual was like having sex by a manual.

The EVT position is not only selective science at its worst, it is another brick in the wall of medical model privilege in psychotherapy. The end result of our Faustian deal with the medical model: Psychotherapy is now almost exclusively described, researched, taught, and practiced in terms of pathology and prescriptive treatments and is firmly entrenched in our professional associations, licensing boards, and academic institutions. It is so taken for granted that it is like the old story about a fish in water. You ask a fish, “How’s the water?” and the fish replies, “What water?”

Then the more structured a therapeutic relationship is (as with manualized therapy), the less room there is for a real relationship to develop between the client and the clinician. This structure inevitably leads to the client being viewed as the problem, rather than part of the solution. And it implicitly applies a medical model to psychotherapy: “diagnosis plus prescriptive treatment equals symptom amelioration.” It ignores a 40-year body of empirical evidence that indicates how common factors of various therapies, centered on the client and the therapeutic relationship, are far more indicative of therapeutic efficacy than whether or not a particular psychotherapy is an empirically validated treatment.

For more information on therapeutic power of common factors and the dodo bird effect, see “The Legacy of Saul Rosenzweig: The Profundity of the Dodo Bird,” by Barry Duncan, which is linked above. Also read the Wampold et al. article, “A Meta-analysis of Outcome Studies Comparing Bona Fide Psychotherapies: Empirically, ‘All Must Have Prizes’”, or “The Dodo Bird Effect” on this website.

05/9/17

The Dodo Bird Effect

The original art work and the reproduction here are in the public domain

In order to get dry after a swim, the Dodo in Alice in Wonderland proposed that everyone run a race. He said the participants could run anyway they want. They could even start and stop whenever they wanted. When the race was completed and the Dodo bird was asked who won, and he said: “Everybody has won, and all must have prizes.” Intriguingly, the Dodo’s announcement has been used as a metaphor when discussing the outcome research of psychotherapeutic approaches.

The metaphoric application of the dodo bird effect to describe the equivalence of effectiveness when comparing psychotherapies first occurred in a classic paper written by Saul Rosenzweig in 1936: “Some Implicit Common Factors in Diverse Methods of Psychotherapy.” The article was republished in the July 2010 issue of the American Journal of Orthopsychiatry, which you can read if you pay APA PsycNET $11.95. An alternative approach would be to read an article by Barry Duncan, “The Legacy of Saul Rosenzweig: The Profundity of the Dodo Bird” available for free under the link.

Duncan saw Rosenweig’s article as having a clairvoyant ability to predict the intervening years of research that underlies the argument for the common factors perspective of psychotherapeutic approaches. Essentially Rosenweig (and the common factors approach) attributed the positive outcomes of these approaches to factors common to the various therapies and not necessarily to the particular therapeutic approach itself. Michael Lambert made a significant contribution to the modern sense of the common factors perspective, according to Duncan, when he identified four therapeutic factors as the principle elements accounting for improvement in psychotherapy. Based upon Lambert’s work, Scott Miller and a team of researchers expanded the use of the term “common factors” from its traditional sense of nonspecific relational factors to include four specific factors: client, relationship, expectancy and placebo, and technique.

Clients have been typically portrayed as passive targets or recipients for the all-important technical intervention of a therapy. However, research by Tallman and Bohart demonstrated “that the client is actually the single, most potent contributor to outcome in psychotherapy—the resources clients bring into the therapy room and what influences their lives outside it.” Client attributes like persistence, openness, faith, optimism, supportive family members, or membership in a religious community might be important factors operative in the individual’s life before they enter therapy. “Assay and Lambert ascribed 40% of improvement during psychotherapy to client factors.” This is a departure from the conventional emphasis on the contribution of the therapist, the therapeutic model or technique.

Clients are the main characters, the heroes and heroines of therapeutic stage, and they are the most potent contributor to psychotherapeutic change. This common factor suggests that therapists eschew the five Ds of client desecration (diagnosis, deficits, disorders, diseases, and dysfunction) and instead find ways to enlist the client in service of client goals. Whatever path the psychotherapist takes, it is important to remember that the purpose is to identify not what clients need but what they already have that can be put to use in reaching their goals.

Regardless of the therapist’s theoretical approach, relationship variables account for 30% of successful outcome variance in therapy. “Next to what the client brings to therapy, the therapeutic relationship is responsible for most of the gains resulting from therapy.” Related to this, the client’s perception of the relationship is the most consistent predictor of therapeutic improvement.

The core conditions identified by Carl Rogers as “necessary and sufficient” conditions for personal change in therapy are accepted as important factors by most schools of therapy. These core conditions, accurate empathy, positive regard, nonpossessive warmth and genuineness, have been empirically supported. They are also consistently reported in client reports of successful therapy.

“Placebo, hope and expectancy” is estimated to contribute 15% to the outcome of psychotherapy. In part, the client’s assessment of the credibility of the healing rituals of the therapy’s rationale and related techniques play a role here. These curative effects come from the positive and hopeful expectations that accompany the use and the implementation of the therapeutic method. “Rituals are a shared characteristic of healing procedures in most cultures.” The procedures are not the causal agents of change. “What does matter is that the participants have a structure, concrete method for mobilizing the placebo factors. From this perspective, any technique from any model may be viewed as a healing ritual.”

In Persuasion and Healing, Jerome Frank said the therapeutic enterprise has a strong expectation that the client will be helped. He suggested that an underlying factor to all the different approaches to psychotherapy, like the placebo in medicine, is that people are offered hope that something can be done to help them. Sometime merely the name of a therapeutic procedure mobilizes a person’s hope of relief. “For therapy to be effective, patients must link hope for improvement to specific processes of therapy as well as to outcome.” Frank said:

Despite differences in specific content, all therapeutic myths and rituals have functions in common. They combat demoralization by strengthening the therapeutic relationship, inspiring expectations of help, providing new learning experiences, arousing the patient emotionally, enhancing a sense mastery or self-efficacy, and affording opportunities for rehearsal and practice.

Therapeutic models and techniques account for 15% of improvement in therapy. Conceived broadly, model/technique factors can be understood as therapeutic or healing rituals. From this perspective, even therapies like EMDR, eye-movement desensitization response, offer nothing new. When a therapist tells a client “to lie on a couch, talk to an empty chair, or chart negative self-talk,” they are engaging in healing rituals.

Because comparisons of therapy techniques have found little differential efficacy, they may all be understood as healing rituals—technically inert, but nonetheless powerful, organized methods for enhancing the effects of placebo factors.

Rosenzweig said it mattered little whether the therapist talked in terms of psychoanalysis or Christian Science. What counted was “the formal consistency with which the doctrine used is adhered to, thereby offering a systematic basis for change and an alternative formulation to the client.”

And yet, the therapy field continues to be “model maniacal,” according to Duncan. He quoted Arthur Bohart as saying the dodo bird effect is ignored because it is so threatening to special theories. “The data call for a change in how we view therapy, but the field continues to stick to the old technique-focused paradigm.” Another reason is the ongoing search for the GUT—the Grand Unified Theory—of therapy that cures all or most suffering individuals. But the cure always seems just around the corner or just out of reach.

Self-proclaimed experts present mysterious scans of brains showing incontrovertible truth that “mental illness” exists and medical science is on the verge of conquering it. But when reality sets in, therapists know that they can never produce the epic transformations witnessed on videos or reported in edited transcripts. Psychotherapists painfully recognize that colorized brain images will not help when they are alone in their offices facing the pain of people in dire circumstances.

The final reason the dodo bird effect is ignored is because clinicians are too invested in the privilege model perpetuated by graduate schools, professional organizations and managed care companies. Psychiatrists are one example, particularly with their hegemony of targeting particular drugs as treatments for specific disorders. Drawing from the medical example of evidence-based practice, there are a growing number of evidence-based or evidence-verified treatments. But the EVT position essentially ignores the 40 years of outcome data about common factors and the truth of the dodo bird effect.

The dodo bird effect means that the client and what they bring to the therapeutic encounter is the most important factor for its effectiveness, rather than the therapist or the therapy. The next most important factor is the therapeutic relationship of client and clinician. Consequently, relationship skills such as acceptance, warmth and empathy are fundamental for establishing a good therapist-client relationship. A therapist with these skills will ensure their practice doesn’t go the way of the dodo bird, which went extinct in the 1600s.

04/28/17

Psychiatric Huffing and Puffing

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For awhile now I’ve been aware of the ongoing dispute between mainline psychiatry and what is disparagingly referred to as the “anti-psychiatry” movement instead of the critical psychiatry movement.  Over time I have come to identify with the “anti-psychiatric” types. The term sets up a false dichotomy, implying you can only be “for” or “against” psychiatry. Critiques of psychiatric diagnosis or the use of psychiatric medications are regularly dismissed out-of-hand by mainline psychiatry. One of the ongoing dialogues of dispute occurs between the author and journalist Robert Whitaker and the eminent psychiatrist Ronald Pies.

Robert Whitaker is the author of three books that relentlessly drive their readers to question the narrative for mental illness and psychiatry verbalized by mainline psychiatrists like Ronald Pies. These books are: Mad in America, Anatomy of an Epidemic and Psychiatry Under the Influence.  His articles on the mentally ill and the drug industry have won several awards. A series he wrote for The Boston Globe was a finalist for the Pulitzer in 1998. Anatomy was the 2010 winner for best investigative journalism by Investigative Reporters and Editors, Inc. Mad in America is also the name of a nonprofit organization and webzine, madinamerica.com, whose mission is “to serve as a catalyst for rethinking psychiatric care in the United States (and abroad).”

Ronald Pies is a noted psychiatrist, a Clinical Professor of Psychiatry at Tufts University and SUNY Upstate Medical University, Syracuse NY. He is also Editor in Chief Emeritus of Psychiatric Times. A bit of a Renaissance man, he’s published poetry: The Heart Broken Open, a novel: The Director of the Minor Tragedies, nonfiction: Becoming a Mensch: Timeless Talmudic Ethics for Everyone, as well as psychiatry: Psychiatry on the Edge, Handbook of Essential Psychopharmacology and psychotherapy: The Judaic Foundations of Cognitive-Behavioral Therapy.  He has authored or coauthored several other books as well.

Whitaker and Mad in America authors have disagreed with Pies on several issues. For example, they disagreed on whether psychiatrists widely promoted the chemical imbalance theory (see “Psychiatry DID Promote the Chemical Imbalance Theory” and “My Response to Dr. Pies” on madinamerica.com); or whether the long-term use of antipsychotics is helpful (see “Dr. Pies and Dr. Frances Make a Compelling Case that Their Profession is Doing Great Harm on madinamerica.com).

Into this mix Pies has written three articles for Psychiatric Times: “Is There Really an ‘Epidemic’ of Psychiatric Illness in the US?,” “The Bogus ‘Epidemic’ of Mental Illness in the US” and “The Astonishing Non-Epidemic of Mental Illness.” He’s clearly playing off of Whitaker’s book: Anatomy of an Epidemic. In his third article, “The Astonishing Non-Epidemic of Mental Illness,” Pies said that the epidemic of mental illness narrative is (with a few qualifications) “mostly fear-mongering drivel.” It sells books and makes for good online chatter, but “The so-called epidemic of mental illness among adults in the US proves largely illusory.”

He did some rhetorical sleight-of-hand, stating that by pulling out the bottom card of the epidemic narrative, the entire house of cards of the anti-psychiatry movement would collapse. In order to do this, he first quoted what he said was the CDC definition of epidemic: “ . . . an increase, often sudden, in the number of cases of a disease above what is normally expected in that population in that area . . .” Pies then said the CDC definition of epidemic applied to actual cases of disease; not to changing rates of diagnosis, which are subject to many socio-cultural variables. The distinction was critical,

Since psychiatry’s critics do not claim merely that there is more diagnosis of schizophrenia or major depression; rather, they claim there are actually more people sick with these illnesses, owing to misguided or harmful psychiatric treatment.

Remember that in psychiatric diagnosis, there are relatively few diagnoses that can be confirmed by medical tests. The vast majority of psychiatric disorders are assessed by a diagnostic process alone. If you demonstrate to a clinician that you meet the diagnostic criteria for a psychiatric disorder, you are treated as if you actually have the disorder. So Pies seems to be splitting hairs with his distinction between actual cases and diagnoses. And I don’t think he really hasn’t made as telling a point as he thought.

It would seem he is suggesting that psychiatric diagnostic rates for a disorder are overstated from the actual cases because of the influence of socio-cultural variables.  Yet how can you distinguish the actual cases from the false positives due to socio-culturally influenced diagnosis? The same diagnostic criteria are used. Is there an unstated assumption that diagnostic inflation is due to factors beyond psychiatry? Namely, that if a trained psychiatrist follows the structured clinical interview process, only actual cases of a psychiatric disorder will be identified?

Pies also said the “epidemic” claim was largely based on the increasing US rates of psychiatric disability over the past 50 years. Here he cited an article by Whitaker without mentioning Whitaker’s name. He dismissed the validity of using disability determinations, saying they cannot be used as “a legitimate index of disease incidence or prevalence.” He then shifts the focus to affirm there is a growing population of “persons with serious psychiatric illness who are not receiving adequate treatment.” Here he named two well-known psychiatrists who have written of their concerns with the “epidemic” of neglect with our most severely impaired citizens. But one of the persons he mentioned, Dr. Fuller Torrey, wrote The Invisible Plague about the rise of mental illness from 1750 to the present.

In the Introduction to The Invisible Plague Torrey described what he saw as “the epidemic of insanity.”  He said a major impediment to understanding the epidemic of insanity was that its onset occurred over so many years. Few people fully appreciated what was happening. “Those who did raise an alarm were largely ignored.” He said the suggestion today that we are living in the midst of an epidemic of insanity strikes most people as unbelievable.

Insanity is an invisible plague. There are no body counts with which one can compare the present with the past. In most countries, there are remarkably few statistics that can be used to assess insanity’s prevalence over time. Professional textbooks assume that insanity has always been present in approximately the same numbers as now.

Fuller Torrey is a believer in insanity as an epidemic of brain dysfunction. And he blames the likes of Michel Foucault, Thomas Szasz, Ronald Laing and others for emptying the insane asylums that have been “the mainstay for containing the epidemic for a century and a half,” without insuring these individuals received the treatment needed to control the symptoms of their illness.

When looking at the costs of this epidemic, Torrey said the combined costs in 1991 for the US were $110 billion. “And this included the single largest disease category for federal payments under the Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI) programs.” So in quantifying the cost of the epidemic of insanity, Torrey used the same statistic to make his point that Whitaker did. Pies either didn’t realize this, or ignored it in his critique of Whitaker. I wonder if Pies sees what Torrey said as fear-mongering drivel or one of the few qualifications?

Pies dismissively cited two articles written by Marcia Angell for The New York Review of Books in 2011 (“The Epidemic of Mental Illness: Why?” and “The Illusions of Psychiatry”) in all three of his articles as an example of the promotion of the false narrative of “the raging epidemic of mental illness.” Her articles discussed three books and their implications for psychiatry: The Emperor’s New Drugs, Anatomy of an Epidemic, and Unhinged: The Trouble with Psychiatry. Angell’s review of Whitaker’s book drew it to the attention of a wide audience; so it seems this may be at least partly why Pies is dismissive of it.

However, read her articles. They will give you a thumbnail sketch of issues Pies goes to great lengths to deny and minimize. Then read the books she discusses. Remember that Marcia Angell is a Senior Lecturer at Harvard Medical School and was the first woman to serve as editor-in-chief of the New England Journal of Medicine. Don’t be dismissive of what she has to say; she has great credibility.

There is one final point to be made with regard to Pies’ third article. In the conclusion, he references Thomas Kuhn’s idea of “paradigm,” saying it is misleading and unfair to suggest that psychiatry is laboring under a “failed paradigm.” This was, he said, because “there is no one paradigm the defines all of psychiatry or that dictates practice on the part of all psychiatrists.” But I wonder if he truly understood the implications to his comment. If you apply Kuhn’s notion of paradigm (“a paradigm is what members of a scientific community share”) with Pies’ application of the term to psychiatry, then you would have to conclude that psychiatry as it’s practiced, is NOT a science. Rather, it would either be what Kuhn called a “pseudoscience” or pre-scientific. He also seems to be oblivious to the possibility of an implicit paradigm generated in psychiatric practice with DSM diagnosis—that it classifies a real “illness” or “disease” of the brain.

I’m reminded of what Robert Whitaker pointed out in his review of Jeffrey Lieberman’s book Shrinks, “The Untold Story of Psychiatry.” Whitaker noted how speeches given by the presidents of the American Psychiatric Association at their annual meetings regularly sounded the same theme: “Psychiatrists are true heroes.” He said it struck him that Shrinks served as an institutional self-portrait of psychiatry. “What you hear in this book [Shrinks] is the story that the APA and its leaders have been telling to themselves for some time.” Similarly, it seems Pies is preaching to the psychiatric choir—a message that there really isn’t an epidemic increase in mental illness; the argument of the anti-psychiatry movement is just a house of cards. Yet it seems to me that house is still standing despite the huffing and puffing of Pies and others.

04/18/17

Porn is a Public Health Hazard

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In a strange but true way, there was a study published in the Journal of Sex Research that found a correlation between some measures of religiosity and Google searchers for the term “porn.” In states with higher percentages of Evangelical Protestants, theists and biblical literalists—as well as states with higher church attendance rates—predict higher frequencies of searching for “porn.” Higher percentages of religiously unaffiliated persons in a state are related to lower frequencies of searching for porn. “Our findings support theories that more salient, traditional religious influences in a state may influence residents-whether religious or not-toward more covert sexual experiences.”

The above discussed study, “Unbuckling the Bible Belt: A State-Level Analysis of Religious Factors and Google Searches for Porn,” raised some questions when I saw graphics from the study on Twitter. Here is the link to the Twitter post. The linked study abstract and graphic on Twitter may be somewhat deceiving, as they plot and discuss searches done for the actual word “porn,” which could be done for a variety of reasons besides just wanting to view pornography. Yet the concern over the adverse social and spiritual effects of viewing pornography is a very real concern among a wider audience than just Evangelicals, theists and biblical literalists.

The state of Utah passed a resolution in March of 2016 declaring that pornography was a “public health hazard.” The resolution recognizes pornography leads to a broad spectrum of individual and public health concerns. It pointed to how young children are increasingly exposed to pornography, with the average age of exposure now 11 to 12 years of age. This early exposure leads to a multitude of personal and social problems, including: adolescents engaging in risky sexual behavior; an increase of sexual behavior at a younger age; depicting women and children as sex objects and rape and abuse as if they were harmless.

Writing for the Evangelical website The Gospel Coalition in May of 2016, Joe Carter described how pornography is increasingly being seen as a public health problem. Studies from the late 1960s to the mid-1980s concluded pornography had “no marked social effect.” But that was before the Internet. Since the late 1980s, there has been a wealth of social science research demonstrating the negative effect of porn on individuals, families, children and communities. Carter linked two meta-analyses that found sexual aggression among males and females was associated with the consumption of porn; and an overall positive association between pornography and attitudes supporting violence against women.

In “The Science of Pornography Addiction,” Gary Wilson described the effects of watching porn on the brain. He said that 25% of all Internet searches are for porn. It is the fourth most common reason people give for going online. In many ways, it acts like a drug. With prolonged exposure, it will lead to tolerance, loss of control and the compulsive desire to seek it out despite negative consequences. And there is “withdrawal” when it goes away. “The issue is that continued exposure can cause long term or even life-long neuroplastic change in the brain.”

There is a release of dopamine in our brains as a reward whenever we accomplish something, including sexual activity. “It alters and forms the brain cells to motivate certain actions. It rewires your brain.” The more time you spend doing a certain action, like viewing porn, the more dopamine is released—which then reinforces the behavior. As you begin to imagine the images away from the computer or while having sex, they become reinforced as well. “It’s a feedback loop that becomes harder to escape.”

The good news is this can be reversed or extinguished. Wilson said the brain is often described as “the use it or lose it system.” Like with muscles, the neural connections you use become stronger and want to be activated, while the ones you ignore become weakened. So the same neuroplastic system used to acquire these habits can be used to acquire healthier ones.

In another article on pornography and the brain, Joe Carter recommended “The Science of Pornography Addiction” video. He also summarized the thoughts of William Struther, an associated professor of psychology at Wheaton College. Commenting on the dopamine process described above, Struther said: “Pornography thus enslaves the viewer to an image, hijacking the biological response intended to bond a man to his wife and therefore inevitably loosening that bond.” Overstimulation of the reward circuitry, as when repeatedly viewing pornography, creates desensitization. “When dopamine receptors drop after too much stimulation, the brain doesn’t respond as much, and we feel less reward from pleasure.”

The psychological, behavioral, and emotional habits that form our sexual character will be based on the decisions we make. . . Whenever the sequence of arousal and response is activated, it forms a neurological memory that will influence future processing and response to sexual cues. As this pathway becomes activated and traveled, it becomes a preferred route—a mental journey—that is regularly trod. The consequences of this are far-reaching.

Internet porn is unique in a number of ways. First is its extreme novelty. Second, unlike food or drugs, there is almost no physical limit to its consumption. Third, a user can easily escalate to more novel “partners” and unusual genres. Fourth, unlike food or drugs, the brain’s natural aversion system is not activated. Like with drugs, the age users start using porn is a crucial factor. “A teen’s brain is at its peak of dopamine production and neuroplasticity, making it highly vulnerable to addiction and rewiring.”

A nonprofit organization called Fight the New Drug is trying to raise awareness on the harmful effects of porn and get this information to a wider audience. They use science, facts and personal accounts to bring the issue out in the open and get people talking about it. The organization’s website said not only are we the first generation to face the issue of pornography at this intensity and scale, “we’re also the first generation with a scientific fact-based understanding of the harm pornography can do.”

Then there is Elizabeth Smart. On June 5, 2002 when she was 14, Elizabeth was awakened by a strange male voice saying that he had a knife to her neck. She was told to get up without making a sound and come with him or he would kill her family. She remained a captive by this man and his wife for nine months, where she was repeatedly raped by the man. Sometimes he brought her hardcore porn, which he looked at and forced her to look at. Then he acted out with her what they had seen. Here is a short video of Elizabeth telling her story.

Looking at pornography wasn’t enough for him. Having sex with his wife after he looked at pornography, it wasn’t enough for him. Then it led to him finally going out and kidnapping me. He just always wanted more.  I can’t say that he would not have gone out and kidnapped me if he had not looked at pornography. All I know is that pornography made my living hell worse.

The morning following her rescue, her mother gave her a piece of advice that changed her life. She told Elizabeth the best punishment she could give to the people that did those things to her was to be happy. Elizabeth went on to become an advocate for abuse prevention and an advocate against pornography. She married in 2012 and gave birth to a daughter in February of 2015.

P.S. Elizabeth Smart lived in Utah when she was abducted.