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.

04/7/17

Souless Psychiatry

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A psychiatric resident at Stanford University School of Medicine wrote an essay on the crisis with psychiatry that appeared in a Scientific American blog. The author said the field was in decline as fewer medical students sought to specialize in psychiatry. He stated psychiatry was looked down upon by nearly every segment of society; and patients avoided treatment because of the stigma related to the field. His solution was to change the name of the field—call it something else.

The crisis, in his view, stems largely from a misunderstanding of what psychiatry is. He said it was “the medical field where doctors incorporate neuroscience and medical research to treat patients with diagnosable mental disorders.” But his friends seem to think he interprets dreams and administers Rorschach tests. Administering Rorschach tests and interpreting dreams are activities associated with psychoanalytic practice that dominated psychiatry up until the 1970s. While “mental health” has made great strides raising awareness (i.e., May is now National Mental Health Awareness Month), “psychiatry has been left behind as its anachronistic forebear.” So he asked, “Would renaming the field help?”

The word psychiatry evokes thoughts of dated medical practices, like Freudian analysis and ice-pick lobotomies. Its sordid history turns away patients, providers, and the public from the progress of mental health care today.

He acknowledged where relabeling could be seen as a Band-Aid. A mere name change ignores the root causes of the problem, which from his perspective is the stigma attached to psychiatry and mental illness. However, citing studies of name changes within the U.S. and other countries, he suggested these language shifts helped psychiatry sound more reputable. He imagined most people would rather have a mental health disorder than a psychiatric disorder, “even if it were the same thing.”

“Mental Health Care” would be a simpler name for the field instead of psychiatry. Psychiatrists would then become “mental health physicians.” Medical centers could create departments of mental health, combining specialties such as internal medicine, psychiatry, psychology and social work. “By uniting these fractured disciplines under one roof, clinicians could provide more comprehensive care to patients without the stigma associated with aging terminology.” Mental health units were said by the author to be far less frightening than psychiatric wards.

In conclusion, he noted how the term psychiatry meant: “healing of the psyche,” drawn from the Greek goddess of the soul—Psyche. “It’s a romantic notion, but we don’t treat patients’ souls. We treat diagnosable diseases of the brain. Perhaps it’s time to rename the field.”

In reading this essay, I was reminded of what psychiatrist Jeffrey Lieberman wrote in his book, Shrinks about psychiatry. He commented that in the 1970s, “the majority of psychiatric institutions were clouded by ideology and dubious science,” mired in a pseudomedical Freudian landscape. But now in the twenty-first century, psychiatry offered scientific, humane and effective treatments. “Psychiatry is finally taking its rightful place in the medical community after a long sojourn in the scientific wilderness.” You can read about the fallacies of “Freudian analysis and ice pick lobotomies” in Shrinks, but you won’t hear the complete and unvarnished truth about psychiatry.

Robert Whitaker astutely commented that Shrinks is more of a story of how psychiatry sees itself as an institution, than it is an accurate history of psychiatry. And I see the same approach here. I wonder if the Stanford psychiatric resident who wrote “Maybe We Should Call Psychiatry Something Else” is simply rehashing the received view of psychiatric history.

If you want a truly unvarnished look at psychiatry, read Whitaker: Mad in America, Anatomy of an Epidemic, and Psychiatry Under the Influence. You can read more about Lieberman and Shrinks on this website. Do a search for “Lieberman.”

The term “psychiatry” was originally coined by Johann Reil—a German physician—in 1808. And it does literally mean the medical treatment of the soul. Another German physician, Johann Heinroth was the first person to hold a chair of psychiatry. He also staked out working with the mentally ill as medical territory. Since there was little or no knowledge within the medical tradition to equip doctors to deal with mental disturbances, he proposed the creation of a new branch of medicine—psychiatry.

In his 1818 Textbook of Mental Disturbances, Heinroth said: “Since we are speaking of medical art and science, we should think that nobody but a doctor should have a right to make mental disturbance the object of his studies and treatment.” In The Myth of Psychotherapy, Thomas Szasz said of this time:

The birth of psychiatry occurs when the study of the human soul is transferred from religion to medicine, when the “cure of souls” becomes the “treatment of mental diseases,” and, most importantly, when the repression of the heretic-madman ceases to be within the jurisdiction of the priest and becomes the province of the psychiatrist.

There have been some radical shifts in how psychiatrists function since the early 1800s. Initially they were administrators of large institutions for the insane. Under Freud’s influence, psychiatrists began to consult with individuals living in society rather than working solely with those within institutions. Then in 1909, Freud was invited to give a series of lectures on psychoanalysis by Stanley Hall, the president of Clark University.

The cover photo for “Maybe We Should Call Psychiatry Something Else” shows seven men from the time of that conference, but only identified Sigmund Freud and Carl Jung. At the time, Jung was still friendly with Freud. The photo credit said the others were “pioneers in psychiatry,” but that is not entirely accurate. The photo shows Sigmund Freud and Carl Jung on either side of Stanley Hall in the front row. In the back row from left to right are Abraham Brill, Ernest Jones and Sandor Ferenczi.

Stanley Hall was a well-known American psychologist in addition to the then president of Clark University. He had an interest in Freud’s psychoanalytic theories and invited him to be part of a “galaxy of intellectual talent” to celebrate the twentieth anniversary of the founding of Clark University. Jung and Ferenczi were invited as the leading European disciples of Freud. Ernest Jones, another protégé of Freud, was then in Toronto Canada, building a private psychoanalytic practice and teaching at the University of Toronto. Jones would later become a biographer of Freud. Brill was the first psychoanalyst to practice in the U.S. and the first translator of Freud into English. In 1911 he founded the New York Psychoanalytic Society.

So these individuals are better seen as pioneers of Freudian psychoanalytic practice —the approach dismissed by the author of  “Maybe We Should Call Psychiatry Something Else” as a dated medical practice, which he placed alongside ice pick lobotomies.

By the 1940s, psychoanalytic theory had not only taken over American psychiatry, it had become part of our cultural psyche. Alfred Hitchcock’s 1945 film, Spellbound is an example of how influential psychoanalytic thinking was. The opening credits of the film announce that it wanted to highlight the virtues of psychoanalysis in banishing mental illness and restoring reason. Look for the Freud look-a-like character as Ingrid Bergman’s psychoanalyst and mentor.

Psychoanalytic thought dominated the field until the 1970s when the birth of biological psychiatry was ushered in by Robert Spitzer and his reformulation of psychiatric diagnosis. After Spitzer was appointed to do the revisions for the 3rd edition of the DSM in 1974, he was able to appoint whomever he wanted to the committees. He made himself the chair of all 25 committees and appointed individuals who he referred to as the “young mavericks” psychiatry. In other words, they weren’t interested in Freudian analysis. Spitzer said: “The feeling was that the same techniques that were useful in medicine, which is you describe something, you do laboratory studies; that those same kind of studies were appropriate for psychiatry.” Except it didn’t happen because in the 1970s, there just wasn’t a lot of psychiatric research. So the decisions of the committees were based on the expertise of the committee members.

David Chaffer was part of the process back then. He said committee members would gather together into a small room. Spitzer would sit with a mid 1970s “portable” computer and raise a provocative question. “And people would shout out their opinions from all sides of the room. And whoever shouted loudest tended to be heard. My own impression was … it was more like a tobacco auction than a sort of conference.” So much for using the same techniques as those used in medicine. Listen to the NPR story, “The Man Behind Psychiatry’s Diagnostic Manual” for the above information on Spitzer and the DSM.

But the real driving force behind the revisions made by Spitzer and others was because a “psychopharmacological revolution” couldn’t begin with the diagnostic process that existed before Spitzer and the DSM-III. Allen Frances, the chair of the next revision, the DSM-IV, acknowledged as much in his comments before the American College of Neuropsychopharmacology in 2000. Frances said the DSM-III was an innovative system that focused on descriptive diagnosis and provided explicit diagnostic criteria. “In many ways this aided, and was aided by, the knowledge derived from psychopharmacology. . . . The diagnostic system and psychopharmacology will continue to mature with one another.”

The psychopharmacological revolution required that there be a method of more systematic and reliable psychiatric diagnosis. This provided the major impetus for the development of the structured assessments and the research diagnostic criteria that were the immediate forerunners of DSM-III. In turn, the availability of well-defined psychiatric diagnoses stimulated the development of specific treatments and increasingly sophisticated psychopharmacological studies.

In the Foreword to his book, The Anatomy of an Epidemic, Robert Whitaker explained how he first wandered into the “minefield” of psychiatry by writing in the mid 1990s about research practices such as rapidly tapering schizophrenic patients off of their antipsychotic medications and then giving them a drug to exacerbate their symptoms. This “research” was done in the name of studying the biology of psychosis. Jeffery Lieberman took part in some of those studies, using methylphenidate (Ritalin, Concerta) to deliberately provoke psychotic symptoms in schizophrenic patients. Read “Psychiatry, Diagnose Thyself! Part 2” for more information on Whitaker’s articles and Lieberman. Incidentally, the series of articles Whitaker co-wrote for the Boston Globe was a finalist for the Pulitzer Prize for Public Service. Whitaker said in the Foreword to Anatomy of an Epidemic:

I began this long intellectual journey as a believer in the conventional wisdom. I believed that psychiatric researchers were discovering drugs that helped “balance” brain chemistry. These medications were like “insulin for diabetes.” I believed that to be true because that is what I had been told by psychiatrists while writing for newspapers. But then I tumbled upon the Harvard study and the WHO findings, and that set me off on an intellectual quest that ultimately grew into this book, The Anatomy of an Epidemic.

Maybe there is a stigma against psychiatry for more than just the past use of ice pick lobotomies or insulin comas or ice baths or the electroshock treatment shown in One Flew Over the Cuckoo’s Nest. But simply changing the name of what we now call psychiatry will not change the opposition against a medical specialty that no longer treats patients’ souls. And perhaps that is really why the field is in decline.

03/28/17

Reproducibility in Science

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In 2011 a University of Virginia psychologist named Brian Nosek began the Reproducibility Project. He simply wanted to see if the reported problem with reproducing the scientific findings of published research studies in psychology was true. Nosek and his team recruited 250 research psychologists, many of whom volunteered their time to double-check what they considered to be the important works in their field. They identified 100 studies published in 2008 and rigorously repeated the experiments while in close consultation with the original authors. There was no evidence of fraud or falsification, but “the evidence for most published findings was not nearly as strong as originally claimed.”

Their results were published in the journal Science:Estimating the Reproducibility of Psychological Science.” In a New York Times article about the study, Brian Nosek said: “We see this is a call to action, both to the research community to do more replication, and to funders and journals to address the dysfunctional incentives.” The authors of the journal article said they conducted the project because they care deeply about the health of psychology and believe it has the potential to accumulate knowledge about human behavior that can advance the quality of human life. And the reproducibility of studies that further that goal is central to that aim. “Accumulating evidence is the scientific community’s method of self-correction and is the best available option for achieving that ultimate goal: truth.”

The present results suggest that there is room to improve reproducibility in psychology. Any temptation to interpret these results as a defeat for psychology, or science more generally, must contend with the fact that this project demonstrates science behaving as it should. Hypotheses abound that the present culture in science may be negatively affecting the reproducibility of findings. An ideological response would discount the arguments, discredit the sources, and proceed merrily along. The scientific process is not ideological. Science does not always provide comfort for what we wish to be; it confronts us with what is.

The editor in chief of Science said: ““I caution that this study should not be regarded as the last word on reproducibility but rather a beginning.” Reproducibility and replication of scientific studies has been a growing concern. John Ioannidis of Stanford has been particularly vocal on this issue. His best-known paper on the subject, “Why Most Published Research Findings Are False,” was published in 2005. A copy of one of his latest works, “Empirical assessment of published effect sizes and power in the recent cognitive neuroscience and psychology literature,” can be found here.  Szucs and Ioannidis concluded that false report probability was likely to exceed 50% for the whole literature. “In light of our findings the recently reported low replication success in psychology is realistic and worse performance may be expected for cognitive neuroscience. “

A recent survey conducted by the journal Nature found that more than 70% of researchers have tried and failed to reproduce another scientist’s experiments. More than half failed to reproduce their own experiments.  In response to the question, “Is there a reproducibility crisis?” 52% said there was a significant crisis; another 38% said there was a slight crisis. More than 60% of respondents thought that two factors always or often contributed to problems with reproducibility—pressure to publish and selective reporting. More than half also pointed to poor oversight, low statistical power and insufficient replication in the lab. See the Nature article for additional factors.

There were several suggestions for improving reproducibility in science. The three most likely were: a better understanding of statistics, better mentoring/supervision, and a more robust experimental design. Almost 90% thought these three factors would improve reproducibility. But even the lowest-ranked item had a 69% endorsement. See the Nature article for additional approaches for improving reproducibility.

In “What does research reproducibility mean? John Ioannidis and his coauthors pointed out how one of the problems with examining and enhancing the reliability of research is that its basic terms—reproducibility, replicability, reliability, robustness and generalizability—aren’t standardized.  Rather than suggesting new technical meanings for these nearly identical terms, they suggested using the term reproducibility with qualifying descriptions for the underlying construct. The three terms they suggested were: methods reproducibility, results reproducibility, and inferential reproducibility.

Methods reproducibility is meant to capture the original meaning of reproducibility, that is, the ability to implement, as exactly as possible, the experimental and computational procedures, with the same data and tools, to obtain the same results. Results reproducibility refers to what was previously described as “replication,” that is, the production of corroborating results in a new study, having followed the same experimental methods. Inferential reproducibility, not often recognized as a separate concept, is the making of knowledge claims of similar strength from a study replication or reanalysis. This is not identical to results reproducibility, because not all investigators will draw the same conclusions from the same results, or they might make different analytical choices that lead to different inferences from the same data.

They said what was clear is that none of these types of reproducibility can be assessed without a complete reporting of all relevant aspects of scientific design.

Such transparency will allow scientists to evaluate the weight of evidence provided by any given study more quickly and reliably and design a higher proportion of future studies to address actual knowledge gaps or to effectively strengthen cumulative evidence, rather than explore blind alleys suggested by research inadequately conducted or reported.

In “Estimating the Reproducibility of Psychological Science,” Nosek and his coauthors said it is too easy to conclude that successful replication means the original theoretical understanding is correct. “Direct replication mainly provides evidence for the reliability of a result.” Alternative explanations of the original finding may also account for the replication. Understanding come from multiple, diverse investigations giving converging support for a certain explanation, while ruling out others.

It is also too easy to conclude a failure to replicate means the original evidence was a false positive. “Replications can fail if the replication methodology differs from the original in ways that interfere with observing the data.” Unanticipated factors in the sample, setting, or procedure could alter the observed effect. So we return to need for multiple, diverse investigations.

Nosek et al. concluded that their results suggested there was room for improvement with reproducibility in psychology. Yet the Reproducibility Project demonstrates “science behaving as it should.” It doesn’t always confirm what we wish it to be; “it confronts us with what is.”

For more on reproducibility in science, also look at: “The Reproducibility Problem” and “’Political’ Science?” on this website.

03/17/17

Broken Promises with Abilify

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Based upon sales data for the world’s 15 top selling drugs, Abilify was ranked fourth, with $9.3 billion of sales in 2014. Reflect for a moment what this means; an antipsychotic drug had greater worldwide sales than Nexium (for acid reflux) and Crestor (for high cholesterol). While it is an approved medication in the US for bipolar 1 and schizophrenia, it is likely these sales figures reflect it use as an adjunct medication for major depression. Oh, and along with other antipsychotics, it is used off label to treat several other behavioral disorders such as Tourette’s and irritability associated with autism. This popularity is despite the reality that antipsychotics have a high incidence of negative side effects—greater than antidepressants and anti-anxiety medications.

The problems with antipsychotics have been known for a few years. As far back as 2010, Robert Field wrote: “Antipsychotic Medications Are Spelling Legal Trouble for Drugmakers” for the journal Pharmacy and Therapeutics. In 2007, Bristol-Myers Squibb paid $515 million to settle charges of illegally marketing Abilify for children and the elderly, “In contravention of FDA-approved labeling.” But that hasn’t been the end of legal troubles regarding Abilify. On May 3, 2016, the FDA published a safety announcement warning that Abilify (aripiprazole) can trigger impulse-control problems such as “compulsive or uncontrollable urges to gamble, binge eat, shop, and have sex.” These urges reportedly stop when the drug is discontinued or the dose reduced.

These compulsive behaviors can affect anyone who is taking the medicine. As a result, we are adding new warnings about all of these compulsive behaviors to the drug labels and the patient Medication Guides for all aripiprazole products.

The mechanism of action for Abilify is not clearly understood, but researchers think it over-stimulates dopamine 3 (D3) reward receptors, which are mainly located in the limbic system. This in turn triggers the compulsive behaviors. Gaboriau et al. reviewed case reports in Addictive Behaviors and indicated that pathological gambling (PG) appeared as quickly as a few days after Abilify was started; sometimes after an increase in dosage with 7 of the 8 case reports. PG then decreased after Abilify treatment was stopped or decreased; again sometimes as soon as a few days afterwards.

Limitations on the Gaboriau et al. findings included that most of the patients were already gambling before starting with Abilify. Several patients also had a history of substance use disorders. However, the authors noted that the same D3 receptor was implicated in another study by J. E. Ahiskog of the dopamine agonist medications, pramipexole and ropinirole, which are commonly used to treat Parkinson’s disease.

This hyperstimulation would apparently be particularly enhanced in cases of a previous treatment by antipsychotics acting as a dopaminergic receptors antagonist, owing to the up-regulation and the dopaminergic receptor hypersensitivity processes. The partial agonist action of aripiprazole then causes stronger effects. Moreover, the intrinsic dopamine pharmacodynamic activity of aripiprazole imparts it less action agonist than a complete agonist, which could explain why the occurrence of PG is sometimes late or due to dosage increase.

The above concern with Abilify was also supported by the findings of a study by Moore, Glenmullen and Mattison reported in JAMA Internal Medicine. Adverse drug event reports received by the FDA from 2003 to 2012 were reviewed for the six dopamine receptor agonist drugs marketed in the U.S. The review identified 1580 reports of impulse control disorder events, including pathological gambling, hypersexuality, compulsive shopping and others. They also detected weaker signals for antidepressants and antipsychotics.

The Daily Beast reported on a massive tort lawsuit being filed against Otuska and Bristol-Myers Squibb charging that Abilify created a compulsion for sex and gambling. Moreover, the suit claims the drug makers knew of the serious side effects because of required changes in Canadian and European warning labels, but waited for years to warn U.S. consumers. Thomas Moore of the Institute for Safe Medication Practices explained the drug triggers an urge to gamble constantly, sometimes with people with no prior interest. “It might be people starting to spend $300 a week on lottery tickets, and in other cases people will gamble away tens of thousands of dollars.” Moore went on to say:

We live in a society whose rules and laws assume people are responsible for their actions, including running up a large gambling debt. . . But we have scientific evidence that sometimes a drug can trigger a pathological urge to gamble so severe it can ruin someone’s life.

A woman who began using Abilify to aid in treating her PTSD developed a compulsive gambling problem. She used up her unemployment checks, pawned her husband’s automotive tools, and lied about needing money for baby formula. “Nothing was off-limits when it came to getting the money I needed to keep up the ruse.” She’d stuff her bed at night in order to fool her husband into thinking she was asleep when she was actually at the casino playing the slot machines.

Another woman developed hypersexuality. She started with online chatting with men. She became obsessed with sexual fantasies and took sexualized pictures of herself and sent them to select ‘friends.’ “I just couldn’t stop with the pictures and fantasies.” She also went on shopping sprees. Then her husband caught her. “The drug has destroyed my life, my reputation, and the lives of those I love.”

The website RxISK has multiple reports on adverse events with Abilify. “Abilify from the Inside Out” described bouts of akathisia (a state of agitation, distress, and restlessness), unusual aggression or anger, first time episodes of psychosis, suicidality, at least three confirmed suicides, movement disorders such as tremors, and (of course) compulsive gambling. The author said the reports were hard for him to read. Since most of the patients were on several meds, some patients couldn’t be sure that Abilify alone caused the problem. Even stopping Abilify was related to adverse drug events.

The above noted 2007 lawsuit, where Bristol-Myers Squibb paid $525 million to settle charges of illegal marketing, unveiled some of the marketing records for Abilify. Remember, one of the concerns was that it was illegally marketed for use with the elderly. The sales reps for Abilify would invite nursing home staff to picture a new resident, hunched in their chair, staring off into space because of ‘depression.’ “’Who wants to see that when they come to visit Mom on a Saturday?’ the reps would ask. ‘Wouldn’t we like to see her up and about, looking lively?’” The sale pitch worked. One woman wrote the following to RxISK:

I have seen many commercials about how drugs like Abilify can perk people right up. . . So I was not only disappointed and frightened by the results, but felt once again tricked and exploited by the big promises that drug companies make but never seem to keep.

I wish the above concerns weren’t true. But I’ve known individuals whose experiences on Abilify are consistent with the above discussion of its adverse effects. Sadly, even when sanctions are in the millions of dollars, the profits are higher. And it seems the cards are stacked against pharmaceutical companies being held accountable financially. So consumers have to fight against this by refusing to use Abilify and telling others what you have read here. If you are interested in other articles on the problems with Abilify and the other antipsychotics, try: “Antipsychotic Big Bang” or “Abilify in Denial” on this website.