05/29/15

Ancient Healing Rituals

I find it ironic that the rod of Asclepius is associated with the healing rituals of asclepions as well as modern medicine. Within the claims of psychiatry, the connection is certainly appropriate. While modern medicine as a whole has come a long way since then, it seems psychiatry still has a lot in common with the cultic healing rituals the apostle Paul saw practiced in Corinth.

Soon after he declared the unknown god at the Areopagus. (Acts 17:22ff), Paul left Athens for Corinth. He may have become impatient waiting for Timothy and Silas to return from Thessalonica, and just continued on with the next leg of their mission trip. They would catch up to him in Corinth, because Paul ended up staying there for eighteen months.

Corinth was about fifty miles southwest of Athens, so it is likely Paul entered the city from the north on the Lechaeum road. Just inside the northern city wall Paul would have passed by a temple to Asclepius, the Greek god of healing. The cult of Asclepius began around 350 bc and his temples, called acelepions, became popular sites for pilgrimages and training in healing throughout the Mediterranean. Both Hippocrates and Galen were said to have studied medicine at asclepions.

Asclepius was the son of the Greek god Apollo and the woman Coronis. After Apollo killed Coronis for her infidelity, he gave the infant Asclepius to the centaur Chiron, who raised him and taught him the art of medicine. Alternately, Greek mythology says that as a result of a kindness he rendered to a snake, the snake taught Asclepius the secret knowledge of healing. Ancient Greeks believed snakes were sacred beings of wisdom, healing and resurrection. The rod of Asclepius, a snake-entwined staff, remains the symbol of medicine today.

Asclepius became famous for his skill as a healer, surpassing even Chiron and Apollo. He was so proficient with his healing arts, that he was said to be able to bring his patients back to life from the brink of death—and beyond. This led Zeus to kill Asclepius for reasons that ranged from population control (too many humans), to complaints from Hades about not having enough spirits in the underworld. Zeus then raised Asclepius from the dead and made him immortal, extracting a promise from him to never raise another human from the dead without getting permission from Zeus first. This is Greek mythology at its dysfunctional finest.

As Paul passed by the asclepion, he would have seen the sick and infirm coming and going from the temple. They slept there overnight, believing that Asclepius would come to them in a dream to provide healing or prescribe medication for their illness. Once worshipers experienced their healing, they would commission votive offerings representative of the body part that was healed and present these offerings to the temple. So the Asclepius cult provided the apostle with rich, local imagery to illustrate the unity of Christians that Paul would later argue was needed in his letter to the Corinthians.

Some scholars said that early Christians saw Asclepius as “their strongest enemy,” and “the most dangerous antagonist” to Christ. Justin Martyr pointed to a connection between Jesus and Asclepius when he wrote that there were analogies to the works attributed to the Christ in Greek mythology, including those of healing by Asclepius. “And in that we say that He made whole the lame, the paralytic, and those born blind, we seem to say what is very similar to the deeds said to have been done by Aesculapius.” So it’s not hard to imagine Paul using the customs of this cult for his initial presentation of the Christian gospel to the Corinthians, just as he used the example of an altar to an unknown god in Athens (Acts 17:23). J. D. Charles, in the Dictionary of New Testament Background, said:

Imagery abounds from Corinthian life as mirrored in Paul’s letters to the church in Corinth. Polished bronze mirrors, the theater, the proconsul’s judgment seat, agriculture, architecture and building, the Isthmian Games and local temples all add color to Pauline correspondence. Given the apostle’s emphasis on unity and diversity among different members of Christ’s body, it would be natural for him to conceive of unity and diversity in terms of the local Asclepius temple in Corinth. In 1 Corinthians 12:12–31 Paul mentions ears, eyes, hands and more honorable and less honorable parts of the body. It is plausible that he is alluding to the huge number of clay figurines of dismembered body parts scattered throughout the Asclepion that represented afflicted members cured by the deity. In Paul’s day, these terra cotta offerings consisted of heads, hands and feet, arms and legs, breasts and genitals, eyes and ears. Against the background of the Asclepion the Corinthian believers would have been reminded in the most vivid of terms of what they should not be—divided, dead, unconnected members of the body.

Charles went on to illustrate the wealth of cultural images and allusions used by Paul in his first letter to the Corinthians. Paul used the metaphor of the temple in 1 Corinthians 3:16-17 and 6:19-20. He used a building metaphor in 1 Corinthians 3:10 ff (see “The Architektōns of God)”. He quoted Menander in 15:33, saying: “Bad company corrupts good morals.” He toyed with the sense of knowledge or gnōsis in 8:1-13. There were others as well. But the one of our particular interest here is the body metaphor in 12:12-27, most likely borrowed in part from the religious practices of the Asclepius cult.

In the Dictionary of Paul and His Letters, Ronald Fung indicated how the body metaphor was unique to Paul in the New Testament writings. Rather than attributing it just to the votive offerings at the Corinthian asclepion, he thought it was the result of the interplay of several sources. Fung suggested Paul combined the Stoic comparison of the state to a body of interdependent members (see “Ancient Star Wars Philosophy”) with the Hebrew concept of “corporate personality.” Here he referenced the notion of all men and women being born “in Adam” and all believers having new birth “in Christ” (Romans 5:12-21; 1 Corinthians 15:22, 45).

A third idea behind Paul’s use of the body metaphor, according to Fung, was that of the solidarity between Christ and his people (see Mark 9:37; Matthew 18:5; 25:40 and Acts 9:4). Certainly the use of the body metaphor with Paul’s discussion of the Lord’s Supper in First Corinthians 11:17 ff ties in with this third idea. An intriguing fact of the Corinthian asclepion is that when it was renovated in the first century, three dining rooms were added to the east side of the temple courtyard. Like parish halls in modern churches, these dining rooms were used for social events as well as religious ones. Could they have been the space used by the church in Corinth for its celebration of the Lord’s Supper? Or perhaps Paul’s description of the excesses at Christian celebrations of the Lord’s Supper were being compared to the eating behavior at religious and social gatherings in the asclepion dining rooms.

If so, he would have been saying that even if you avoid using the asclepion for your gatherings, your behavior is just as bad. Just as a devotee of the asclepion must perform their ritual properly for healing, when you eat and drink the Lord’s Supper in an unworthy manner, you eat and drink judgment upon yourself (1 Cor. 11:29). I think that in addition to the ideas favored by Ronald Fung, Paul had the cult of Asclepius in mind when he spoke of the body metaphor in First Corinthians. Just as he used an Athenian altar to an unknown god as an illustration in his address at the Areopagus, Paul would have seen how the Asclepius cult practices could be used to speak of how “we who are many are one body” (1 Corinthians 10:17).

I had intended to just reflect on Paul’s use of the body metaphor in his first letter to the Corinthians, but the association of Asclepius and modern psychiatry intruded into my thoughts. In the asclepions medical healing rites were administered as cultic healing rituals. Modern psychiatry often dispenses its own healing rituals as medical healing rites.

05/27/15

Pseudoscience with Vyvanase?

© Pavel Parmenov | Abstraction. Pseudoscience 123RF.com

There was an intriguing study done by Cosgrove et al. in 2014 that looked at the existence of financial conflicts of interest (FCOI) among individuals on the work groups of the DSM-5 approving new diagnoses. They found that among the 13 registered clinical trials testing drugs for a new DSM-5 disorder, 61% of the DSM Task Force members and 27% of the Work Group members had FCOI with the trial drug manufacturers. Principal investigators (PI) of these clinical trails were found to have ties other than funding to the drug manufacturer. Three PIs (23%) had financial ties to the drug manufacturer AND were DSM panel members with decision-making authority over the DSM revision process.

These findings suggest that increased transparency (e.g., registration on ClinicalTrials.gov) and mandatory disclosure policies (e.g., the American Psychiatric Association’s disclosure policy for DSM-5 panel members) alone may not be robust enough strategies to prevent the appearance of bias in both the DSM revision process as well as clinical decisions about appropriate interventions for DSM disorders.

One of these new diagnoses was Binge Eating Disorder (BED). In another article, “A Drug in Search of a Disorder,” I looked at how Vyvanase was fast tracked as a “treatment” by the FDA and immediately promoted in a marketing campaign by Shire, its manufacturer. One of the two clinical trials used for the approval of Vyvanase was just published in a JAMA Psychiatry article by McElroy et al. in March of 2015. It bears a closer examination because of the concerns raised by several experts on eating disorders regarding the approval of an amphetamine to treat BED.

Roy Posey, MD of Health Care Renewal reported that the McElroy et al. study randomized participants into one of four groups: individuals receiving the drug at doses of 30, 50, or 70 mg daily, and placebo. The participants were then followed for 11 weeks. The main outcome variable was the number of weekly binge eating days. At the beginning of the study, participants were binge eating an average of 4.5 days per week. “At 11 weeks, the average number of binge eating days/ week declined in all groups, dropping 3.3 days/ week for the placebo group, 3.5 for the 30 mg group, 4.1 for the 50 mg group, and 4.1 for the 70 mg group.” The difference between the placebo group and the maximum strength was .8 binge-eating days a week. So, “it seems that the drug had only a small effect on binge eating compared to placebo.”

The study did not permit its participants to get any additional treatment besides the drug or placebo, again reinforcing the finding that the drug was not much better than the placebo. In addition, neither the study’s abstract nor the clinical trial data mentioned if the placebo was inert or not. If it was inert, which I’d guess it was, as most clinical trials still use inert placebos, then the nominal findings are even more concerting. The study’s participants could have guessed whether they were in a treatment group or the placebo group by the presence or lack of a drug effect. This would have broken the double-blind methodology and called the reported results into question as a result.

Posey pointed out that the reported reduction with placebo had several suggestions to be considered. First, merely calling attention to binge eating (by placing yourself in a trial) could lead to a marked decrease in binge eating. Second, people in binge eating trials may tend to report improvement regardless of which intervention they received. Third, binge eating may not be a stable phenomenon; its frequency and intensity could vary over time. Fourth, making a reliable diagnosis of binge eating could be difficult. Doctor Posey noted several additional problems with the study, which you can read in his article linked above. He also gave a short, helpful history of the problems with attempting to use amphetamines to treat obesity, “which can be, of course, a consequence of eating too much.”

In summary, at best, the trial showed that Vyvanse only caused small reductions in binge eating, and that binge eating may decrease spontaneously, or at least when patients are given more attention or scrutiny. Thus, even putting the best face on the evidence from a trial done by the maker of Vyvanse does not greatly support the benefits of this drug.

Both Posey and Katie Thomas, writing for The New York Times, reported that Shire received a warning letter for improperly promoting Adderall, another of its ADHD stimulants besides Vyvanase. The warning letter indicated that a video and webpage overstated the efficacy of Adderall XR and omitted information about the risks associated with Adderall XR. “The webpage and video raise significant public health and safety concerns through their overstatement of efficacy and omission of important safety information.” Shire has sold its commercial rights to the Adderall name.

They also reported that Shire was ordered by the Department of Justice to pay $56.5 million to resolve civil allegations that it violated the False Claims Act as a result of marketing and promoting several of its drugs, including Adderall and Vyvanase. The false claims about Adderal XR included that it was clinically superior to other ADHD drugs; that it would “prevent poor academic performance, loss of employment, criminal behavior, traffic accidents and sexually transmitted disease.” The settlement also resolved claims that Shire sales reps “allegedly” made false and misleading statements about the efficacy and abusability of Vyvanase, concerns noted in the warning letter from the FDA.

Sandra Steingard, MD, also critiqued the McElroy et al. study in: “Stimulants and Food.” She commented how historically, physicians knew amphetamines were dangerous drugs and that their effects in dampening appetite tended to wear off over time. She warned that we should not lose sight that this study was not only sponsored by a drug company, but used the assistance of professional writers in its composition. She commented on the unreliability of it being a multi-center study with no site having more than 10 subjects. She also gave a long citation of the conflict of interest disclosures from the article. Dr. McElroy was noted to be a consultant to or member of the scientific boards of nine pharmaceutical companies (including Shire); and had received grant support from twelve pharmaceutical companies (including Shire).

She voiced concern that in the real clinical world, that Vyvanase will be used much longer than the time of the 11-week study; perhaps indefinitely. Pointing out the existing diversion problem with stimulants, she also said: “We already have a diversion problem with stimulants; widening their approved indications will only exacerbate that problem.” Steingard then pointed out how amphetamines has been long used to create animal models for psychosis and was stupefied that her colleagues seemed to downplay this risk in humans. “I see at least one student a year who developed psychosis after using stimulants; sometimes after convincing a doctor (often at their college health service) that they have ADHD.”

05/25/15

Spiritual, Not Religious Experience

The Varieties of Religious Experience (VRE) by William James had an important influence on Bill W. and Alcoholics Anonymous. There is a free edition of VRE available here. Within VRE are several notions common to the A.A. sense of spiritual, not religious, experience. The first is the distinction between spiritual and religious. William James distinguished between institutional and personal within the broader field of religion. Worship, sacrifice, ritual, theology, ceremony, and ecclesiastical organization were the essentials of what he referred to as institutional religion. Limited to such a view, he said religion could be viewed as an external art of winning the favor of the gods.

James said that within the personal dimension of religion, the inner dispositions of human conscience, helplessness and incompleteness were of central importance. Here the external structures for winning divine favor took a secondary place to a heart-to-heart encounter between the individual and his maker. He proposed to confine himself, as much as possible within VRE, to discuss pure and simple personal religion.

If someone felt that the term religion should be reserved for the fully organized system of feeling, thought, and institution typically called the church, then James was willing to accept almost any name for what he called personal religion. He suggested two: conscience or morality. Alcoholics Anonymous and Twelve Step recovery have called it spirituality.

Personal religion/spirituality for his purposes was defined as “the feelings, acts, and experiences of [the] individual . . . in their solitude, so far as they apprehend themselves to stand in relation to whatever they may consider the divine.” In the broadest sense possible, this spirituality consisted of the belief that there was an unseen order to existence, and supreme good lay in harmoniously adjusting to that order.

A second notion from VRE important to A.A. was that a higher power could be anything that was other than and larger than the person’s conscious self. Towards that end, James said that spiritual experience could only testify unequivocally to two things: the possible union with something larger than oneself and the great peace that was found within that union. Spiritual encounters could not unconditionally confirm a traditional belief in the one and only infinite God. James suggested that the practical needs and occasions of religion were sufficiently met by the belief that beyond each person, a larger power existed that was friendly to him and his ideals. All that was required was that the power should be both other than and larger than a personal conscious self.

“Anything larger will do, if only it be large enough to trust for the next step. It need not be infinite; it need not be solitary. It might conceivably be only a larger and more godlike self.” There was something—a sense of reality or perhaps a feeling of objective presence—that was a deeper and more general perception of actuality than science supposed was possible with any of the particular human senses. This supreme reality was what Christianity called God.

According to James, humanity had an instinctive belief regarding this supreme reality of the universe that could be stated simply as: “God is real since he produces real effects.” Yet most religious/spiritual people spontaneously embraced a wider sphere than this immediate subjective religious episode. Based upon the perception of godly order in existence and the supreme good found in adjusting to that order, they took a further step of faith concerning God. James said religious people formulated a hypothesis that the existence of God was a guarantee that an ideal order would be permanently preserved, even beyond the probable destruction of this world. Only with this further step of faith, in which remote objective consequences were predicted, did religion become free of its immediate subjective experience.

The third place where James influenced AA’s understanding of spiritual experience was in his view of conversion. In VRE, James stated that in general terms, conversion signified the gradual or sudden process by which a person became unified and consciously right, superior, and happy as a result of a firmer hold upon religious/spiritual realities. To be converted, to be regenerated, to receive grace, to experience religion, to gain assurance, all referred to the same process.

Taken at face value, James equated religious or spiritual experience with conversion. Before this “conversion” process, the person was initially divided, consciously wrong, inferior, and unhappy. This was true whether or not the person believed that a direct divine operation was needed to bring about such a moral transformation. After an extensive discussion of the psychology of conversion, James noted that as long as the religious life was spiritual, and not a consequence of outer works, ritual, or sacraments, the self-surrender element of conversion was always the vital turning point of the religious life. The Jamesean conversion and surrender process became formalized in the first three Steps of AA.

In 1949, Bill Wilson said that conversion, as broadly described by James, was the basic process of AA. Everything else was but the foundation to this process. He declared that by 1949, AA spoke little of its recovery process as a conversion because so many people were afraid of being God-bitten. Nonetheless, it was the basic process of AA. One alcoholic working with another could only consolidate that process of conversion, built upon a foundational faith in God as we understand Him. (William Wilson, “The Society of Alcoholics Anonymous,” American Journal of Psychiatry, 106 [Nov. 1949], 370-375)

This is the second of three related articles (What Does Religious Mean?, Spiritual not Religious Experience, The God of the Preachers) that will more fully describe some of the influences I believe helped to shape the spiritual, but not religious distinction of 12 Step recovery.

05/20/15

Jump Starting Your Brain

Of course, there is research into using low dose electrical stimulation of the brain, a technique called transcranial direct current stimulation (tDCS). Dan Hurley published an article in the online magazine for The New York Times, Jumper Cables for the Mind, where he described the science and history of tDCS as well as his personal experience with it. It uses less than 1 percent of the electricity necessary for electroconvulsive therapy and can be powered by an ordinary nine-volt battery. Papers published in peer-reviewed scientific journals have claimed tDCS can improve:

Everything from working memory to long-term memory, math calculations, reading ability, solving difficult problems, piano playing, complex verbal thought, planning, visual memory, the ability to categorize, the capacity for insight, post-stroke paralysis and aphasia, chronic pain and even depression. Effects have been shown to last for weeks or months.

Felipe Fregni, the physician and neurophysiologist where Hurley received tDCS, said that it won’t make you superhuman, “but it may allow you to work at your maximum capacity.” He said the strongest evidence for its effectiveness was for depression. By itself, he said tDCS was as effective as Zoloft at relieving depression. “But when you combine the two, you have a synergistic effect, larger than either alone. That’s how I see the effects of tDCS, enhancing something else.” Looking at the JAMA Psychiatry abstract for Fregni’s published article, the researchers also found that out of 125 participants in the study, there were 7 cases of treatment-emergent mania or hypomania—5 of which were in the combined treatment group. So one the things enhanced by combining the use of Zoloft and tDCS was mania and hypomania.

Hypomania is a mood state that is less intense than mania. The individual is impulsive, shows a lack of restraint in social situations and is a poor judge of risky activities. Motor, emotional and cognitive abilities could be effected. The person may be euphoric or irritable, but typically to a lesser intensity than in mania. Their characteristic behaviors are being very energetic and talkative. They are quite confident while verbalizing a flight of creative ideas.

Because of the inexpensiveness and easy application of tDCS, people are treating themselves with kits and homemade devices. Hurley indicated that YouTube videos showing individuals experimenting on their own brains are available. They look more foolhardy than the cast of “Jackass,” he said. “What they fail to realize is that applying too much current, for too long, or to the wrong spot on the skull, could be extremely dangerous.” Here seems to be one example of what he meant: “Still Zapping My Brain.” Yet there is a good bit of serious research a well: tDCS for Cogntive Enhancement or Centre for Brain Science: Transcranial Direct Current Stimulation (tDCS).

So-called DIY head zappers ignore the caution from scientists that tDCS is not ready for home use. The research is preliminary and stimulation could be dangerous. Home use is only as good as the person who built and operated the system. Some people have posted online images of scalp burns from improper current. There have been some rare reports of manic episodes and even temporary paralysis.

“We are in such a fog of ignorance,” says neuroethicist Hank Greely of Stanford Law School, who studies how brain research intersects with society. “We really need to know more about how this works.”

Caroline Williams at NewScientist.com reported that Jared Horvath and others at the University of Melbourne reviewed more than 100 studies of tDCS and only found one that was convincing. He said there didn’t seem to be any significant or reliable effect of tDCS on blood flow, electrical, or evoked activity within the brain. tDCS supporters dispute the findings. Horvath and his research team are finalizing another analysis that looks at the evidence for cognitive and behavioral change after tDCS. Vincent Walsh, a cognitive neuroscientist at University College London is not convinced there will be any supportive results.

In terms of cognition, which is the other aspect that people make claims about, tDCS is massively hyped. The danger is that people have been promised better memories, better reading, better maths, increased intelligence… you name it. The effects are small, short lasting, and no substantial claims have been replicated across laboratories. This paper [Horvath’s] is hopefully the beginning of a counterweight to all the bullshit.

Horvath has recently published his further research into the efficacy of tDCS, claiming he found no evidence of cognitive effects from a single-session of tDCS. What was unique about this study is that Horvath and his colleagues only included independently replicated studies. This means an originally published study that another research group had repeated. “Our quantitative review does not support the idea that tDCS generates a reliable effect on cognition in healthy adults.” Of the 59 analyses conducted, no significant effect for tDCS was found—regardless of the inclusion laxity of the studies.

Neuroskeptic, a British neuroscientist, pointed out the exclusion of non-replicated studies was an unusual restriction. However, it seems to me that the intent was to correct for the research problems with publication bias (see “Open Access Could ‘KO’ Publication Bias”). He quoted Nick Davis, who has published several papers about tDCS, who said Horvath’s review was useful, helping researchers think about the way they talk about the effects of tDCS. Davis remains optimistic about the future of tDCS.

tDCS is still a developing technology. I think that with more principled methods of targeting the current flow to the desired brain area, we will see tDCS become one of the standard tools of cognitive neuroscience, just as EEG and fMRI have become.

05/18/15

Cross Addiction Isn’t a Myth

Last year there was a study published in JAMA Psychiatry that concluded there was a lower risk of developing a new SUD (substance use disorder, the new DSM-5 lingo) if the individual had “remitted” from a SUD in the past. The results indicated that remitters had “less than half the risk of developing a new SUD.” So contrary to “clinical lore,” achieving remission does not lead to drug substitution, but rather to a lower risk of new SUDs.

There was a Reuters article, “Former Addicts May be at Lower Risk of New Addictions,” that discussed the study’s results. Mark Olfson, the senior author of the study, was quoted by Reuters as saying the results “cut against conventional clinical lore” that suggests people who stop one addiction are at risk of starting a new one. “The results challenge the old stereotype that people switch or substitute addictions but never truly overcome them.” He went on to say:

While it would be foolish to assume that people who quit one drug have no risk of becoming addicted to another drug, the new results should give encouragement to people who succeed in overcoming an addiction.

Commenting on the study to Reuters, Olaya García-Rodríguez, who was not one of the study’s researchers, said: “To achieve remission, most individuals need to make changes in their lifestyle and learn strategies to avoid substance use that will eventually protect against the onset of new addictions.” They learn to avoid substance-related people, place and things. They develop more behavioral coping strategies. Improved family relationships, better health and financial stability can also contributed to their ability to maintain abstinence. She suggested that we should rethink the perception that SUDs are chronic illnesses as the study indicated that remission was possible.

There was also an article on The Fix, titled: “New Study Disproves So-Called ‘Cross-Addiction’ Myth. The author began her article by saying that it is often believed that people who have a substance use disorder are at increased risk for developing another. However, the JAMA Psychiatry study debunked this so-called “cross-addiction” myth. When comparing the two articles, it seemed to me that they both reported much of the same information. Both even quoted the above block quote by Mark Olfson. And yet The Fix article concluded the study had debunked the cross-addiction myth, while the Reuters article was suggesting that there was little support for the hypothesis that conquering one addiction leaves you vulnerable to substituting another substance.

It does seem that Mark Olfson sees his work as challenging the notion of switching or substituting addictions, but even he said it would be foolish to assume people who quit one drug have no risk of becoming addicted to another drug. Not only would it be foolish to conclude the study disproved cross-addiction, but to simply stop where The Fix author did with her understanding of its implications would be dangerous for some people with a SUD. So I decided to look at the study myself, “Testing the Drug Substitution Switching-Addictions Hypothesis.” You can review the article abstract here.

There were two “waves” to the data gathering that occurred an average of 36 months apart. Individuals were considered to have remitted from an SUD (abuse or dependence) if by the wave 2 assessment they did not meet the DSM-IV criteria for that disorder in wave 2, but had met the criteria in wave 1.

Individuals who met the criteria for abuse at wave 1, but later met the criteria for dependence (a more serious diagnosis) at wave 2, were seen as having a new-onset SUD. Individuals who met the criteria for dependence at wave 1 (which meant they also met the criteria for the less serious diagnosis of abuse), were not counted as in remission at wave 2 if they still met the abuse criteria, but no longer met the dependence criteria.

Having a new SUD was defined as having an SUD at wave 2, but no lifetime history of that SUD at wave 1. Relapse was a new episode of an SUD at wave 2 among individuals with a lifetime history of the SUD that was in remission at wave 1. So far, so good. The diagnostic distinctions and operational definitions for remission, relapse and a new SUD made sense. Now let’s look at the results. Remember that there was a 36-month average time period between wave 1 and wave 2.

Individuals who did not remit an SUD were more likely to have a new SUD at wave 2 than individuals who did remit (43.3% for non-remitters versus 8.7% for remitters). This makes sense. People with an SUD who continued active substance use had a greater likelihood of “catching” a second one in 3 years. Remitters with only one SUD at wave 1 were less likely to have a new SUD at wave 2 than non-remitters (10.0% versus 24.3%). Remitters with two or more SUDs at wave 1 were also less likely to have a new SUD at wave 2 than non-remitters (21.4% versus 46.3%).

It seemed the presence of multiple SUDs at wave 1 was a significant factor in remission. The proportion of individuals with 1 SUD at wave 1 who remitted was 41.1%. “Among individuals with 2 or more SUDs, 17.1% remitted from all of them, 46.9% from at least 1 of them, and 36.6% did not remit from any of them.”

Taken together, our findings indicate that remission of an SUD is not associated with an increase but rather with a dramatic decrease in the risk of a new-onset SUD or relapse onto a previously remitted SUD.

Some observations need to be made about the study. First, as the study noted, there were several likely mechanisms that contributed to “the protective effects of SUD remission from new-onset SUDs.” The avoidance of drug-related cues and drug-using peers (avoiding people, places and things associated with addiction) would not only assist in blocking SUD remission, but also in inhibiting new-onset SUDs. The lifestyle changes made by successful remitters would make it less likely they could “catch” a new SUD.

The study also did not include any information on whether other substances were used during the time of remission. For example, someone with an opioid SUD remission in the study could have used and even been drunk on alcohol off and on during their remission time without meeting the criteria for an alcohol use disorder diagnosis. Alcohol use disorders will typically take a longer period of time to progress from initial use to meeting the criteria for an SUD diagnosis.

In addition, the assessment of what the researchers referred to in their study title as “switching-addictions hypothesis” was limited to assessing the risk of developing another SUD. “Adults who recover from an SUD are often thought to be at increased risk for developing another SUD.” Ironically, the study cited in support of this statement, “Substitute Addiction: A Concern for Researchers and Practitioners,” had a broader understanding of what a substitute addiction could be. In addition to substance addictions, they also looked at how process addictions and food could become “substitute addictions.”

Sussman and Black, the authors of the study, described process addictions as “a series of pathological behaviors that exposes one to ‘mood-altering events’ on which one achieves pleasure and becomes dependent.” They said process addictions involved a relatively indirect manipulation of pleasure through situational and physical activity. Examples of process addictions they said were identified in the literature included: video game playing, gambling, Internet use, sex, work, exercise, compulsive spending, and religion.

That there may be a wide variety of behaviors that one can become dependent on, repeat excessively, and suffer consequences from, suggests the opportunity for someone to participate in these behaviors sequentially; one replacing functions of the other. In the recovery movement, substitute addictions have been addressed as an issue about which persons in recovery should be vigilant.

So I don’t think the study goes against conventional clinical lore that people who stop one addiction are at risk to develop a new one. It does not debunk the so-called “cross-addiction” myth. It does indicate that individuals who successfully establish a lifestyle that is not full of drug-related cues and drug-using peers will have a decreased chance of developing a new SUD.

In closing, I thought the following results, while not directly related to the purpose of the study, were particularly interesting. Individuals who sought treatment between wave 1 and wave 2 “were significantly more likely to remit than those who did not (36.8% versus 19.2%).” After adjusting for remission status (remission versus non-remission), individuals who sought treatment had the lower odds of a new-onset SUD at wave 2. “The probability of a new-onset SUD was lowest for abstinent remitters (12.4%), intermediate for nonabstinent remitters (15.2%), and highest for nonremitters (27.2%).”

I’d say the “cross-addiction myth” is very much alive and well. And it isn’t just a myth.

05/15/15

More Evidence for Heaven

The anonymous female author of Evidence for Heaven (see another article titled: Evidence for Heaven) began her treatise with a catechism-like question: “How can I come to be truly, and infallibly assured of my salvation?” Her simple answer was by knowing you are united with Christ: “There is therefore no condemnation for those who are in Christ Jesus” (Romans 8:1). The follow up question, again mirroring a catechism, was how could you be certain? Her answer was to diligently examine yourself to see whether or not you have the Spirit of Christ. “Anyone who does not have the Spirit of Christ does not belong to him” (Romans 8:9).

To be assured of your union with Christ, the author said you must diligently search and examine yourself for the operation of the Holy Spirit in your soul. He would be evident in the special sanctifying graces working in the hearts of the Elect. Among those special graces is faith—justifying faith. “Faith is the grace, and the only grace, whereby we are justified before God, by it we eat of the Tree of Life, (Jesus Christ) and live for ever.”

Satan knows this and would flatter the person to Hell by persuading them that their faith is good and true when actually it is what Christ described in the Parable of the Sower (Matthew 13:1-8; 18-23). Conversely, when Satan seeks to overthrow all hope of Heaven, he seeks to convince the person that their faith is a counterfeit, pretended one. Therefore, it concerns all persons to thoroughly try their faith to see if it is a feigned or unfeigned faith, a temporary or justifying faith.

And when searching your soul for this grace of faith, value the truth of it more than the strength of it. Christ absolutely requires the truth of belief, but not the strength of belief. “He will not suffer that soul that hath but the least grain of true faith to miscarry.” But, what is this faith and how is it different from a temporary faith?

Justifying faith is a special work of the Spirit of God upon the Soul, causing a man to lay hold on the special promises of Mercy, and Salvation by Christ, and all other promises, which are, in him, yea, and in him, Amen, and rest upon him that hath promised, for the accomplishment of his word.

This Faith may be distinguished from other kinds of faith by the following properties. It is bred, fed, and nourished by the word preached. It is grounded on the written Word. It gives firm, absolute and unlimited assent to the whole Word of God. This Faith is seated in the heart. It is not merely head-assenting, it is heart-consenting. It is unfeigned, where a hypocrite’s faith is feigned. “This Faith is a Christ-receiving faith.” It embraces Christ as Savior and Lord—in all his offices as Prophet, Priest and King.

This Faith is a working Faith. As James says, Faith without works is dead (James 2:17). It purifies and cleanses, not only the outer person, but the heart as well. It spurs you on to obedience—active, passive, sincere, universal and constant. It makes you wait patiently on God, for Him to accomplish all the good he promised in his Word—by whatever means he has ordained.

It makes the person open-hearted and open-handed towards others—ready to do good to all in misery, but especially to the Godly. They do this not for their own glory, but for the honor of Christ and the Gospel. It makes a person industrious, laboring to keep a good conscience in all things; to walk inoffensively towards God and towards others in all things. This Faith is always accompanied by true repentance. “He that truly believes, unfeignedly repents.” It is always accompanied with new obedience.

This Faith is a world overcoming Faith. It is a flesh overcoming and a Devil-overcoming Faith. Although a true believer, “may be put to the worse” many times, and foiled by one or another of these enemies, in the end they overcome them all: “In all these things we are more than conquerors through him who loved us” (Romans 8:37). It is permanent and persevering. It holds on to death, and it is never totally lost. “A true believer, as he lives in the faith, so he dyes in the faith.”

These words plainly evidence, that justifying faith is persevering faith, it holds out unto the death and ends in fruition, it can never be totally nor finally lost; and this indeed is it’s distinguishing property, and it is the property of every renewing grace; every renewing grace holds out unto the end; that grace which weares the Crown of Glory is persevereing (Revelations 2:10).

Sadly, it is not always so in appearance, but it is in truth. A true believer may at times seem both to himself and to others to have lost his faith and his other graces. However, as Job said: “The root of the matter is found in him”; it is found in his inward parts (Job 19:28; 38:36). A true believer may, for a time, lose his or her comfort of their grace and the power of acting on their grace. Yet they never totally lose the habit of renewing grace. “These gifts of God are without repentance.”

Wouldest thou then know, whether thy faith be sound and saving, and such as consequently demonstrates the holy Spirits saving habitation in thy soule; try and examine thy saith, by these properties and Scripture-Characters of a true justifying faith, and if it hold correspondency with them, know for thy comfort, that it is such as really demonstrates the holy Spirits saving habitation, and special operation in thy soul, thy Union with Christ, and eternal salvation by him, whatsoever Satan or thine own conscience abused by Satan, may at any time hereafter say to the contrary, and give the Lord the praise.

This anonymous author then goes on to speak of even more graces that demonstrate the assurance of your salvation. There is love, repentance, obedience, poverty of spirit, death to sin, being a new creature in Christ, being chastised by the Father, suffering as a Christian, and more.

As she concluded her treatise, she said she had traveled through the Holy Scriptures and searched to see what she might find therein that might entitle her to “the inheritance of the Saints of Light.” She noticed a variety of places in Scripture that were helpful for this purpose. Some of these she studied industriously, according to her poor ability and as God helped her. She committed what she found to writing for her present and future benefit and as a legacy to her children. Having done so, she committed this work and its reader “to the blessing of God, through Christ.”

If you or someone you know struggles with the assurance of their salvation, I’d encourage you to spend some time reading through and studying what she has shared in Evidence for Heaven.

05/13/15

Sedating Seniors

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In September of 2014, the British Medical Journal published an article titled: “Benzodiazepine use and risk of Alzheimer’s disease.” It received a good bit of public attention because of its conclusion that there was an increased risk of up to 51% of Alzheimer’s disease with the use of benzodiazepines —for as short a period of time as three months. There was concern expressed by Psychiatric News, which quoted Davangeere Devanand, the director of the geriatric psychiatry program at Columbia, who said: “These findings emphasize the importance of restricting the use of benzodiazepines in the elderly population.”

Philip Hickey reviewed the article and noted where the study’s authors commented there findings were congruent with five previous studies. The authors also said their findings were of major importance for public health, particularly considering the widespread chronic use of benzodiazepines with older people. Guy Goodwin, a professor of psychiatry at Oxford, voiced a common assessment of the study, namely that it was more likely that the drugs were being given to people who were already ill. I’ve heard similar comments made by pharmaceutical researchers. This dismissal of the study’s results was despite the fact that the researchers specifically attempted to control for this factor. They said:

Our study was designed specifically to reduce the possibility of reverse causation bias and to provide additional arguments linking benzodiazepine use with Alzheimer’s disease, such as a dose-effect relation.

To a certain extent, this is a rehashing of old news, as I’ve previously addressed the BMJ study in “What a Drag It Is Getting Old.” But the concern over the use of benzos with older people hasn’t gone away. There was an article published in the February 2015 issue of JAMA Psychiatry that looked at “Benzodiazepine Use in the United States.” The article first appeared online in December of 2014. You can watch a short YouTube video by the lead author summarizing the study’s results here.

The study found that about 1 in 20 (5%) people between the ages of 18 and 80 received a benzodiazepine prescription in 2008. However, the percentage increased with age, rising to 8.7% among individuals 65 to 80. Women were twice as likely as men to receive prescriptions in all age groups. Most of the prescriptions—two thirds—were written by non-psychiatrists. For adults 65 to 80, this was 9 out of 10. Thomas Insel, the director of the National Institute of Mental Health (NIMH), voiced the following concerns with the NIMH-funded study’s results:

These new data reveal worrisome patterns in the prescribing of benzodiazepines for older adults, and women in particular. . . . This analysis suggests that prescriptions for benzodiazepines in older Americans exceed what research suggests is appropriate and safe.

In a Psychiatric News Alert, one of the study’s authors was quoted as saying that it was alarming to find the highest rates of benzodiazepine use among the groups with the highest risks. “Given that safer, effective options are available for anxiety and insomnia, it’s hard to make a clinical argument for these results.” In an editorial written about the study in JAMA Psychiatry, the authors commented that there seems to be a societal addiction to using benzodiazepines with the elderly. They said these drugs should only be used for very short periods of time. With individuals susceptible to cognitive impairment or to falls and fractures, benzodiazepines should be avoided altogether.

The editorial authors also suggested that prescribing benzodiazepines should be restricted to psychiatrists. Their recommendation was based upon the perception that psychiatrists seemed prescribe them properly in the JAMA Psychiatry study. They further recommended that benzodiazepines be reclassified as a Schedule II Controlled Substance with limited-duration prescriptions and no refills. “Such barriers could help the public and prescribers think more about these risks before prescribing or using benzodiazepines.”

I don’t think limiting the prescription of benzodiazepines to psychiatrists is either practical or realistic. Despite the dangers reviewed here, restricting benzodiazepines, while permitting antidepressants, neuroleptics and mood stabilizers to be prescribed by all medical doctors is nonsensical. All these additional classes of drugs have their own serous side effects. Some are arguably more problematic than benzodiazepines. If only psychiatrists were permitted to prescribe benzos, then pharmaceutical companies would adjust their marketing strategies to concentrate on psychiatrists.

Reclassifying benzodiazepines as Schedule II Controlled Substance has more merit, but will be hard to accomplish. The process to reclassify any prescription drugs is complicated and difficult.

I’m also not convinced that all psychiatrists would be better monitors of benzodiazepine use/abuse. I know of one person whose primary care physician was reluctant to continue a long-term benzodiazepine prescription, but a psychiatrist wasn’t. I know of another individual who has been prescribed daily benzodiazepine use for sleep by a psychiatrist for over two years. My thought is that the more entrenched any medical doctor is within a biological view of psychiatric disorders, the more willing they are to prescribe benzodiazepines long-term.

Sadly, all these concerns with the use of benzodiazepines with the elderly were voiced and know twenty-five years ago. The journal Drug Safety published “Problems and Pitfalls in the Use of Benzodiazepines in the Elderly” by Wolfgang Kruse in its September issue for 1990. Dr. Kruse noted benzodiazepines were frequently prescribed for elderly patients; and that their use was more common with women. Prolonged use was likely for treating not only insomnia and anxiety in the elderly, but also a wide range of nonspecific symptoms. “Long term users are likely to have multiple concomitant physical and psychological health problems.”

He noted that long-term studies on unwanted effects were scarce, but there was some evidence that benzodiazepines were implicated in drug-associated hospital admissions. “There is suggestive evidence that benzodiazepines, especially compounds with long half-lives, may contribute to the falls which are a major health problem in old age.” Prophetically, he stated:

Problems in the use of benzodiazepines will arise if the available knowledge on altered pharmacokinetics and pharmacodynamics and principal guidelines for drug prescribing in the elderly are neglected. Poor prescribing habits are related mainly to inadequate clinical assessment, excessive prescribing and inadequate supervision of treatment. Unlimited repeat prescribing, particularly for the treatment of sleep disturbances, is seldom justified.

05/11/15

Flack from Flakka

There’s a new drug in town—Flakka! A news report in January of 2015 from Broward County Florida’s WPBF 25 reported a disturbance call at a local nightclub that led to an arrest of an individual who was in possession of a bag of flakka. It looks like a cross between crack cocaine and meth. It can be snorted, smoked, ingested or shot up. And, “It has a strong odor like a sweaty sock.” Sounds inviting.

On March 13, 2015, there was a report by NBC South Florida that a fifty year-old man was trying the BREAK INTO the Fort Lauderdale Police Department because he thought 25 cars were chasing him down Broward Boulevard. He was kicking the hurricane glass with enough force that both the glass and the door were shaking. Again, he was high on flakka. Here is a security video of the man in the act of trying to break into the locked door of the department.

A thirty-four year-old man wearing only sneakers and socks was running on Broward Boulevard (again). He thought that people had stolen his clothes and were trying to kill him. He said he’d rather die than be caught by these people. He told police he was running down the middle of the street because if he was hit by a car, they would stop chasing him. You guessed it: high on flakka. Here is a video and report on the streaker.

In addition to these incidents, there was a naked man with a loaded gun on the roof of a building in Lake Worth shouting that someone was trying to kill him. When he saw the responding police officers approaching, he placed the pistol to his head and pulled the trigger. He misfired. Again, he’d smoked (vaped) flakka. And a twenty-six year-old man faces attempted murder charges after attacking an 86-year-old woman when he was high on flakka. You can access reports and videos on these two incidents here.

Now this flakka story is just too weird. Police in Melbourne Florida responded to a burglary call and discovered a naked man (of course) who claimed he was God before he got into a “tussle” with a police officer. This was after the officer hit the man TWICE with a taser. But he pulled out the probes and attacked the officer with his fists. Aleksander Chan for Gawker quoted a report by WKMG saying: “The officer punched Crowder in the face and a scrum ensued, with Crowder saying that he was Thor and trying to stab the officer with the officer’s badge, police said.”

Flakka is a new psychoactive substance (NSP) typically made from alpha-PVP, a synthetic cathinone. Cathinones are chemicals from the khat plant grown in the Middle East and Somalia. Effective February 27, 2014, the DEA listed alpha-PVP and 9 other synthetic cathinones as Schedule I controlled substances with a temporary ban. How it works (pharmacologically) is not known. It is believed to be similar to MDPV, which acts as a norepinephrine-dopamine reuptake inhibitor (NDRI). But no substantive research has been conducted yet on alpha-PVP.

In 2012, an Australian man died after injecting alpha-PVP. He stripped off his clothes, jumped a barbed wire fence into a shipping yard and smashed a window in a psychotic fit. He was restrained by several security guards inside the shipping yard and went into cardiac arrest. His girlfriend, also high on alpha-PVP, was covered in blood as she fell from their truck. She then took her top off and ran away, yelling, “Help me, help me.”

Jim Hall, an epidemiologist, said in a CBS News report that cathinones like flakka are the next—and more potent—class of drugs taking over after MDMA. They are designed to flood the brain with dopamine, and then block the pre-synaptic neuron from removing the dopamine from synapse. The result is an intense feeling of euphoria. Hall said that “snacking,” taking more flakka or other drugs while high, often leads to serious health problems, such as rapid heart rate, agitation, extreme aggression and psychosis. He said they are starting to see cases of excited delirium with flakka, as noted in the above reports.

[Excited delirium] is where the body goes into hyperthermia, generally a temperature of 105 degrees. The individual becomes psychotic, they often rip off their clothes and run out into the street violently and have an adrenaline-like strength and police are called and it takes four or five officers to restrain them. Then once they are restrained, if they don’t receive immediate medical attention they can die.

The drug’s name has several meanings. The word flaca in Spanish means skinny. But flakka is also a Hispanic colloquial word that means a “beautiful, elegant woman who charms all she meets.” It has been reported in other parts of the country, such as Ohio and Houston. Outside of Florida it’s often sold under the street name of “gravel” because it looks like the grainy pebbles or gravel in an aquarium.

Flakka and other cathinone-based drugs are produced in China and sold online to individuals and drug gangs in the US. An investment of a few thousand dollars can make a dealer as much as $75,000. These drugs aren’t always pure, meaning neither the dealer nor the customer actually knows what is in them, or how strong the dose is. Hall said: “We’re referring to these as the guinea pig drugs. Often the dealer might not even know what they’re selling.” In 2013 there were 126 reported deaths due to synthetic cathinones in Florida.

Then on April 10, 2015 the Broward Sheriff’s office were called to the scene of what appears to have been an accidental fatal shooting. A 31 year-old man was on a three-day flakka and molly (MDMA) binge when his friend came over. They added vodka and more molly to the mix. After spending the rest of Friday morning selling heroin, they decided to go to the home of the one man’s sister. When one individual was trying to unload a shotgun, it accidentally fired, ripping through the side of a car and hitting the other man in the face. The shooter is in jail on manslaughter charges and possession of a firearm by a felon.

CBS News in Chicago did a story on April 24, 2015: “Scary new designer drug flakka hits Chicago.” And again, there was a naked man running around southwest Chicago. He had no memory of what he did while on flakka. “I went to jail, and I don’t remember anything until my third day in jail. I was completely out of my mind.” There is a whole new world of mind-altering substances and the problems associated with them out there. I don’t think we have not heard the end of flakka. And as long as there are willing guinea pigs, there are more NPSs to come.

05/8/15

The Deep Desire of True Ambition

Recently I watched the 1947 movie, Gentleman’s Agreement for the first time. Starring Gregory Peck and Dorothy McGuire, it told the story of a reporter, Phil Green (Gregory Peck), who poses as a Jew to uncover anti-Semitism in post World War II America. In a climatic scene, Phil’s fiancée, Kathy (Dorothy McGuire), realizes it’s not enough to privately abhor prejudice; you have to do something about it. In the context of Matthew 5:13-16, you have to be salt and light.

Further developing what he’d been teaching his disciples, Jesus said: “You are the salt of the earth. . . . You are the light of the world.” In verses 5:3-10, he described the blessings available to those who were his disciples. He warned them in 5:11-12 of the persecution they would face simply because they wanted to live righteous lives on his account. Here he said you can’t fly under the radar and avoid persecution. Theirs was not to be a life of quietism and retreat from the world. Rather, as Craig Blomberg said, they “must permeate society as agents of redemption.”

The first metaphor was a statement of fact—you are salt of the earth. In our time we think of salt as something that adds flavor—as a supplement—to what we eat. But up until the invention of refrigeration, salt was an essential preservative. That is the meaning of the salt metaphor here. Jesus is saying his disciples are to be a preserving influence on earth. According to Sinclair Ferguson in The Sermon on the Mount, “Christians whose lives exhibit the qualities of the ‘blessed’ will have a preserving impact” upon society.

Salt losing its taste is another saying that makes no sense to moderns, who get pure granulated salt from a Morton’s salt container at the grocery. But the salt used in first-century Palestine was most likely taken from the Dead Sea, where it would have been mixed with other minerals. If the sodium chloride somehow dissolved out of the mixture, it would leave “salt” that had lost its “saltiness” (sodium chloride). Good for nothing, it was tossed into the street, which was the garbage can of ancient cities.

Once again in Matthew 5:14 Jesus directly addresses the disciples, now saying they are (factually) the light of the world. It’s the same message as in the previous verse, but with a different image. In each case the target is broadly described—the earth and the world. It’s like saying, if you didn’t get it the first time, I’ll tell you again another way: “you are the light of the world.” You can’t hide; and you shouldn’t hide.

We lose some of the power of the metaphor today as we live with electricity in huge cities, where darkness is typically an annoyance or inconvenience, not something that stops human work and activity until the sun comes up the next day. Rural living or wilderness vacations get moderns closer to an understanding of the image. Until the widespread use of electricity, nightfall was DARK. A city on a hill, with its cooking fires and torches would have been an incredible contrast to the surrounding darkness. You could not hide it.

Conversely, it makes no sense to light an oil lamp and then put a basket over it. You put it on a lamp stand where it can illuminate the entire room. Now the light from an oil lamp doesn’t compete well with that from even a forty-watt light bulb. But recall how grateful you were to get that one candle lit when your electricity went out and the batteries in your flashlight were dead.

Notice also the contrast between the light of a city on a hill that can’t be hidden and that of an oil lamp that could be hidden. The disparity of the two images suggests that, whether your “light” is big or small, you shouldn’t try to hide it. It makes no sense and ultimately can’t be done. Rather, let it shine so others can see it.

The “light” is the light of righteousness in verse 5:10 that is ultimately from Jesus Christ. He is the great light who has dawned upon those dwelling in darkness (Matthew 4:16). He is the light of the world (John 8:12). His disciples, those who have been brought out of the kingdom of darkness into his kingdom of light (Colossians 1:12-13), are to now live as children of the light (Ephesians 5:8). Again turning to Sinclair Ferguson:

Jesus is underlining the challenge, which is stated so clearly in his Great Commission (Matt. 28:18-20): the whole world is to be our sphere of influence. To reduce it to anything less would be tantamount to restricting the power, authority, and grace of the Lord Jesus Christ.

This is not a Christianized “jihad,” calling for forced conversion or subjection. The light of Christ in the Sermon on the Mount is seen in his disciples as they are poor in spirit, mourning for sin, meek, hungering and thirsting for righteousness, merciful, pure in heart, and peacemakers in their daily lives with other “earth” people living in this world. “In the same way, let your light shine before others so that they may see your good works and give glory to your Father who is in heaven” (Mathew 5:16).

Parallel to the followers of Jesus living out the beatitudes as they are salt and light to the world, members of Alcoholics Anonymous (A.A.) put their program into action as well. Bill W. said repeatedly that “A.A. is more than a set of principles; it is a Society of alcoholics in action. We must carry the message, else we ourselves can wither and those who haven’t been given the truth will die.” You can find this statement in The Language of the Heart (p. 160), Alcoholics Anonymous Comes of Age (p. 139), and the pamphlet, A.A.’s Legacy of Service.

In A.A. Comes of Age, Bill added that action was the magic word. “Action to carry A.A.’s message is therefore the heart of our Third Legacy of Service.” He defined A.A. service as “anything whatever that helps us to reach a fellow sufferer—ranging from the Twelfth Step itself to a ten-cent phone call and a cup of coffee. . . . The sum total of all these services is our Third Legacy of Service.” The Twelfth Step reads: “Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics, and practice these principles in all our affairs.” The linked pamphlet, A.A.’s Legacy of Service, goes on to tell some of the early history of A.A. More detail of that history, focusing on the Three Legacies, can be found in The Language of the Heart and Alcoholics Anonymous Comes of Age.

The life of service and recovery within A.A. is not identical to that described by Jesus within the Sermon on the Mount to his disciples. But I suspect they would all agree with this statement from Bill W.’s “Step Twelve” essay in Twelve Steps and Twelve Traditions: “True ambition in not what we thought it was. True ambition is the deep desire to live usefully and walk humbly under the grace of God.”

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

05/6/15

Parallel Psychiatric Universes

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“It is only really been in the last fifty years that psychiatry has established a scientific foundation for itself and developed treatments that truly work, beyond a shadow of a doubt, and are safe.”

I’m starting to think there is something to the belief in parallel universes. There just cannot be another explanation for how someone could believe what was said in the above quote. This person has to be from an alternative time line where An Anatomy of an Epidemic, Mad in America, Medication Madness, and The Myth of the Chemical Cure were never written. The story of psychiatry and “mad doctoring” contained in these and other books and articles I’ve read tell an entirely different story than what was stated above.

The opening quote is from an NPR interview with Doctor Jeffrey Lieberman, who wrote a new book, Shrinks: The Untold Story of Psychiatry. Dr. Lieberman is a past president of the American Psychiatric Association and is currently the Lawrence C. Kolb Professor and Chairman of Psychiatry at the Columbia University College of Physicians and Surgeons and Director of the New York State Psychiatric Institute. In other words, he has credibility within the field of psychiatry and he is a good choice to be the teller of a tale about the heroes of psychiatry. That is, if you believe the current state of psychiatry fits with the above statement. I don’t.

There is a suggestion in Lieberman’s interview that all is not sunshine and roses with the current state of psychiatry. At the end of the interview, he said that in order for psychiatrists to make a case for why psychiatry is a medical discipline that deserves “equal footing and respect as other medical specialties,” they needed to “fess up” to the unvarnished past. He asserted that things are different now, “and nobody should avoid seeking treatment if they think they need it because of uncertainty or fear.” I think that depends upon whether or not you believe in his version of psychiatry and its history.

I haven’t read Shrinks yet. Honestly, I’ll read Robert Whitaker’s new book on psychiatry before/if I ever get around to Shrinks. But Whitaker has read Lieberman’s book and shared his thoughts here. He suggested that his readers watch a promotional YouTube video of Lieberman discussing what is unique about Shrinks. Whitaker pointed out how Lieberman intentionally dressed for the video in a doctor’s white coat. Seems to be a not-so-subtle hint at wanting to assert the “equal footing and respect” he hopes to gain for psychiatry alongside other medical specialties.

In the YouTube video, Lieberman did say that his book was the first to tell the “complete and unvarnished truth” about the history of psychiatry. But he seems to have crossed over into that parallel universe when, according to Whitaker, he wrote how the intellectual seed from a small band of psychiatrists saved psychiatry and led to the development of the “book that changed everything.” This book was the third edition of the Diagnostic and Statistical Manual (DSM III). Whitaker astutely said Shrinks was more a story of how psychiatry as an institution saw itself, than it was an accurate history of psychiatry:

I think Shrinks ultimately provides a revealing self-portrait of psychiatry as an institution. Lieberman is a past president of the APA and he has reiterated the story that the APA has been telling to the public ever since DSM-III was published. And it is this narrative, quite unmoored from science and history, that drives our societal understanding of mental disorders and how best to treat them.

The history of the DSM described by Whitaker in his review article of Shrinks is one I’m already familiar with from reading Making Us Crazy and The Selling of DSM by Kirk and Kutchins. You can access an article written by them, “The Myth of the Reliability of DSM,” that elaborates on Whitaker’s description of the DSM III. Kirk, Gomory and Cohen have written Mad Science, which also tells the story of psychiatry and diagnosis from the perspective of Whitaker and the others.

Paula Caplan commented that as she listened to Lieberman’s NPR interview, she felt sad. She was glad Whitaker had written about Shrinks. She thought no one was in a better position to comment on its claims about the field of contemporary psychiatry.

I know that many people share my feelings of frustration and exhaustion about the ongoing misuses of the power, not only by some of the most powerful psychiatrists, but also some of the most powerful psychologists and members of other professions as they distort the facts and consistently close their ears to people whom their systems have harmed.

Whitaker closed his critique of Shrinks by pointing out that Lieberman took the Freudians to task, saying that if the psychoanalytic movement in psychiatry had itself diagnosed, it would have been found “all the classic symptoms of mania: extravagant behaviors, grandiose beliefs, and irrational faith in its world-changing powers.” Whitaker said the very same symptoms were present in Shrinks. He suggested there was also evidence of an institutional delusion too. Perhaps this is a better explanation for the radically different view psychiatry has of itself than saying it must be from a parallel universe. It is simply delusional.

Further illustration of the parallel universes (or delusions) regarding psychiatry was given when Dr. Lierberman was interviewed on the CBC radio program, The Sunday Edition on April 26, 2015. When asked by the interviewer if he was familiar with Robert Whitaker, he said “Unfortunately I am.” He proceeded to question (slander?) whether he is a journalist, saying: “God help the publication that employed him.” Lieberman asserted that Whitaker has “an ideological grudge against psychiatry.” In other words, Whitaker is one of those anti-psychiatry people. He dismissed Whitaker and his claims: “What he says is preposterous. He’s a menace to society because he’s basically fomenting misinformation and misunderstanding about mental illness and the nature of treatment.”

Lieberman went on to claim that there was no doubt in his mind that if randomized, controlled studies of various psychiatric illnesses, using the “state of the art” methods in psychiatry (including medication) “the outcomes will be extraordinarily superior in the treated group.” Whitaker responded to Lieberman’s claim by challenging him to provide “a list of randomized studies that show that medicated patients have a much better long-term outcome than unmedicated patients.”

We think this is important. This is the core issue for our society: Do these medications help people thrive over the long-term? Do they improve their lives over the long term? If there is such evidence, please let us know. I put up abstracts of the studies I cited in Anatomy of an Epidemic on madinamerica.com, which tell of worse outcomes for the medicated patients over the long term, and so here is your chance to point to the studies I left out.

Whitaker noted this wasn’t the first time Lieberman has denounced him as a “crappy” journalist. By the way, a series of articles Whitaker co-wrote on the abuses of psychiatric patients in research settings for the Boston Globe in the 1990s was a finalist for the Pulitzer Prize. He is a past winner of the George Polk Award for Medical Writing for the same series. One of the researchers he was critical of in that series was Lieberman. Whitaker said he took extra pride in being called a “menace to society” by Lieberman and thought he might just put that on his gravestone.

Faith Seeking Understanding

Charles Sigler, D.Phil.

Monthly Archives: May 2015