Tag: psychiatry

05/29/15

Ancient Healing Rituals

© Peter Hermes Furian | 123RF.com
© Peter Hermes Furian | 123RF.com

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.

03/4/15

Chasing Ghosts

© : Vera Kuttelvaserova Stuchelova | 123RF.com
© : Vera Kuttelvaserova Stuchelova | 123RF.com

Jay Joseph, a licensed psychologist, has written extensively on the failure of researchers to find scientific evidence that even one psychiatric condition has a genetic basis. In “The Crumbling Pillars of Behavioral Genetics,” he followed the history of failed predictions by Robert Plomin, a genetics researcher, who claimed repeatedly that we were “at the dawn of a new era” in molecular genetics; that “genes associated with behavioral dimensions and disorder are beginning to be identified;” that “within a few years psychology will be awash with genes associated with behavioral disorders.” So far, Plomin and other researchers have got nothing.

Despite the hope that the Human Genome Sequencing Project would “revolutionize the understanding, diagnosis and treatment of most human disorders,” acknowledged polymorphisms (common gene variants) for psychiatric conditions are still nonexistent. In “Still Chasing Ghosts,” Evan Charney said: “Not a single polymorphism has been reliably associated with any psychiatric conditions nor any aspect of human behavior within the ‘normal’ range.” Instead, researchers in psychiatry see schizophrenia and other psychiatric conditions as “multifactorial complex disorders,” meaning that they are caused by a complex interaction of multiple genes and environmental risk factors.

Within an editorial announcing that changes to the journal Neuropsychiatric Genetics, S.S. Farone et al. proudly announced that their journal “has become a leading venue for the publication of high quality research on the genetic basis of neuropsychiatric phenotypes.” But they also acknowledged: “It is no secret that our field has published thousands of candidate gene association studies but few replicated findings.” Joseph commented that in a practical sense, these results are a secret. After the initial results are hyped in the media, the replication failures rarely receive the same media attention. See “The Reproducibility Problem.”

The public has been misled by sensationalized reporting in the popular press, often in concert with leading researchers, to believe that genes for the major psychiatric disorders have been found.

Reluctant to believe the foundational heritability estimates were wrong, genetic researchers have instead hypothesized there is “missing heritability.” Proponents of this position argue that genes (heritability) are present, but cannot be identified (are “missing”) because each gene has such a small effect. So small in fact, that its effect cannot be identified by standard genome-wide association studies (GWAS). Joseph noted that by the summer of 2011 this failure to discover genes underlying psychiatric disorders led 96 of the leading psychiatric researchers to publically plead for potential funding sources to not “give up” on GWAS.

As Joseph pointed out in “Five Decades of Gene Finding Failures in Psychiatry,” the belief in “missing heritability” ignores the possibility that previous conclusions from family, twin and adoption studies could be wrong, all the while assuming that the genes have to exist. Despite evidence that many people diagnosed with “schizophrenia and other psychotic disorders are impacted by trauma, abuse, and other adverse experiences,” there continues to be an almost exclusive focus on “the genetic and biological bases of psychosis.” He suggested that although some researchers claim that several genes for the major psychiatric disorders have now been discovered, “these claims are likely to suffer the same fate as similar non-replicated claims we have heard for decades.” He then quoted John Horgan, a science journalist, who said that since 1990:

Researchers have announced the discovery of ‘genes for’ attention-deficit disorder, obsessive-compulsive disorder, manic depression, schizophrenia, autism, dyslexia, alcoholism, heroin addiction, high IQ, male homosexuality, sadness, extroversion, introversion, novelty seeking, impulsivity, violent aggression, anxiety, anorexia, seasonal affective disorder, and pathological gambling. So far, not one of those claims has been confirmed.

Evan Charney and Jay Joseph (Twin Studies and the “Nonreplication Curse”) described a new methodology, the genome-wide complex trait analysis (GCTA), which has been developed to replace the problems with GWAS. Like a typical GWAS, GCTA scans hundreds of thousands of polymorphisms of thousands of persons. But it does not identify which SNPs [single-nucleotide polymorphisms, common types of genetic variation] are responsible for a trait. Rather, it estimates the total genetic variance by comparing the genetic profiles of a large group of unrelated people. “In other words, it can produce a ‘finding’ of genes even when no specific genes are identified.”

Joseph indicated the GCTA method, like the GWA studies, is based upon two faulty assumptions: 1) the validity of heritability estimates for human behavioral traits and 2) that twin studies and adoption studies have established the genetic basis of psychiatric disorders.

Charney noted that the twin study methodology has been critiqued for making faulty assumptions, like assuming that the environments of MZ (identical) twins were no different than those of DZ (fraternal) twins. In fact, several studies have shown that MZ twins have more similar environments than DZ twins. The equal environment assumption was shown to be false. This environmental difference means that: “trait similarities ascribed to the greater genetic similarity of MZ twins might in fact be due to greater environmental similarity, significantly inflating heritability estimates.” In The Journal of Mind and Behavior, Joseph commented that:

Conclusions in favor of genetics based on twin studies (as well as family studies) were confounded by environmental factors, suggesting that the twin method should have been discarded as an instrument for the detection of genetic influence.

Charney suggested that chasing these “polymorphisms of tiny effect,” in ever-larger studies involving hundreds of thousands of persons, “is the last gasp of a failed paradigm.” It is like chasing ghosts. “Do we really want to squander our time and resources chasing ghosts?”

11/19/14

Evidence-Based Treatment … Lacks Evidence

21828750_sEvidence-based medicine (EDM) began in the early 1990s and was seen as a revolutionary movement that would improve patient care. It grew to become the buzz-word for all medical and behavioral health care—make sure treatment is evidence-based! And yet, there is little evidence that EDM has achieved its aim. Health care costs have soared and there is a distinct lack of “high-quality evidence suggesting that EBM has resulted in substantial population-level health gains.”

Given that EBM firmly favours an empirical approach over expert opinion and mechanistic rationale, it is ironic that its widespread acceptance has been based on expert opinion and mechanistic reasoning, rather than EBM ‘evidence’ that it actually works.

The article from which the above critique was taken suggested that the lack of evidence for the overall benefit of EBM was a consequence of it not being implemented effectively. A cornerstone of EBM methodology—the randomized trial—has been corrupted by vested interests.  The authors, Every-Palmer and Howick, defined EBM as “the conscientious and judicious use of current best evidence in conjunction with clinical expertise and patient values to guide health care decisions.” They singled out the field of psychiatry for specific concern, where “the problems with corruption of randomized trials are dramatic.”

Most of the medical psychiatric evidence base has been funded by the pharmaceutical industry, often without the relationships being disclosed. “Between two-thirds and three-quarters of all randomized trials in major journals have been shown to be industry funded.” One of the consequences of this has been publication bias: positive results are published; negative results are not. The best current estimate is that half of all completed clinical trials have never been published in academic journals. Some trials are never registered.

There is also evidence that industry-funded studies exaggerate the treatment effects in favor of the product preferred by their sponsor. One study reviewed industry-funded studies of atypical antipsychotics and found that 90% of the trials showed superiority of the sponsor’s drug. The studies had been designed “in a way that would virtually guarantee the favoured drug would ‘win.’”

Among their recommendations, Every-Palmer and Howick suggested that all clinical trials should be registered and reported. There needs to be more investment in independent research. Evidence-ranking schemes also need to be modified to account for industry bias. These suggestions would be helpful corrections for the corruption of the randomized trial methodology, but what if there are additional problems? For example, merely correcting problems with the misuse of randomized trials would not address concerns related to clinical expertise or patient values.

If current medical science is reaching its limits with some complex illnesses, as Every-Palmer and Howick said was one possibility for the lack of progress with EBM, then further gains will be hard to come by. This would seem to be true with mental illness and addiction, which are diagnosed with the Diagnostic and Statistical Manual (DSM), 5th edition. DSM diagnoses are consensus-based decisions about clusters of symptoms and do not have any objective laboratory measure. Thomas Insel, the Director of the National Institute of Mental Health (NIMH), said that diagnosis with the DSM was equivalent to “creating diagnostic systems based on the nature of chest pain or the quality of fever.”

A further compounding error could be when the role of clinical judgment is neutralized as a result of an overreliance upon the trump of scientific—real or imagined—evidence. Kiene and Kiene noted how the reputation of clinical judgment in medicine has undergone a “substantial transformation” over the last century with the rise of modern research methodology.  “A primary mission [in medical progress] therefore became ‘to guard against any use of judgement’, and it was executed through clinical trials.”

Giovanni Fava pointed to the increasing crisis in psychiatric research and practice because “Psychopathology and clinical judgment are often discarded as non-scientific and obsolete methods.” He noted how the concept of evidence-based medicine has achieved widespread endorsement in all areas of clinical medicine, including psychiatry. But randomized trials were not intended to answer questions about the treatment of individual patients. “The results may show comparative efficacy of treatment for an average randomized patient, but not for pertinent subgroups formed by characteristics such as severity of symptoms, comorbidity and other clinical nuances.”

An aura of authority is given to collections of “best available evidence”, which can in turn lead to major abuses that produce “inappropriate guidelines” for clinical practice. The risk is especially serious as a result of the substantial financial conflicts of interest in medical societies and with the authors of the medical guidelines for clinical practice within those societies.

Special interest groups are thus using evidence-based medicine to enforce treatment through guidelines, advocating what can be subsumed under the German language term of “ Leitkultur ”, which connotes the cultural superiority of a culture, with policies of compulsory cultural assimilation. In psychiatry, such process has achieved strong prescribing connotations, with a resulting neglect of psychosocial treatments.

Given the existing crisis within psychiatry, especially with the questionable validity and reliability of diagnosis within the DSM, evidence-based treatment guidelines that were developed and disseminated within such a culture require radical revision or should be used with extreme caution. The evidence for their efficacy is lacking.

09/3/14

Psychiatry Has No Clothes

Copyright: pixelbrat / 123RF Stock Photo
Copyright: pixelbrat / 123RF Stock Photo

On April 29th of 2013, there was an astounding blog post by Thomas Insel, the Director of the National Institute of Mental Health (NIMH). He said that although the DSM-5 was due to be released in a few weeks, the NIMH would be “re-orienting its research away from DSM categories.” He noted that while the DSM has been referred to as a “Bible” for the field of mental health, “It is, at best, a dictionary, creating a set of labels and defining each.” Did you get that? The Director of the NIMH said the DSM was a “dictionary” that created “labels.” It was not, then functioning adequately, in his opinion, as its title suggests: as a Diagnostic and Statistical Manual of Mental Disorders! (emphasis added)

Insel said its strength had been “reliability”, meaning that it provided a way for clinicians to use the same terms in the same way. Its weakness was that it lacked validity. DSM diagnoses are based upon a consensus about clusters of symptoms and not any objective laboratory measure. “In the rest of medicine, that would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever.”

Insel was not using “reliability” in a statistical sense. In “The Myth of the Reliability of DSM,” Stuart Kirk and Herb Kutchins demonstrated conclusively that the DSM-III and DSM-IIIR were not statistically reliable. In fact, using the same statistic that Robert Spitzer used to justify the major changes to the DSM in the 1970s, they demonstrated that:

The reliability problem is much the same as it was 30 years ago [before the DSM-III]. Only now the current developers of the DSM-IV have de-emphasised the reliability problem and claim to be scientifically solving other problems.

Unfortunately, the tables in Figures 1 and 2 have been removed from the online version of their article. But the tables are still available in the original article found in the Journal of Mind and Behavior, 15 (1&2), 1994, p. 71-86. These tables plainly showed how the DSM statistical reliability was not what it was claimed to be. The Selling of the DSM (1992) by Stuart Kirk and Herb Kutchins has the tables. And there is a graphic comparison of the data within Mad Science (2013) by Stuart Kirk, Tomi Gomory, and David Cohen.

Insel went on in his blog to say that the NIMH will be supporting research projects that “look across current categories” or sub-divide them in order to begin to develop a better system. “We are committed to new and better treatments, but we feel this will only happen by developing a more precise diagnostic system.” In order to work towards that goal, the NIMH launched the Research Domain Criteria (RDoC). RDoC is only a research framework for now; a decade-long project that is just beginning. You can learn more about RDoC here (on the NIMH website).

Robert Whitaker, author of Anatomy of an Epidemic, said in a March 2014 interview that Insel stating that the DSM lacked validity was an acknowledgement the “disease model” has failed as a basis for making psychiatric diagnoses.

When Insel states that the disorders haven’t been validated, he is stating that the entire edifice that modern psychiatry is built upon is flawed, and unsupported by science. That is like the King of Psychiatry saying that the discipline has no clothes. If the public loses faith in the DSM and comes to see it as unscientific, then psychiatry has a real credibility problem on its hands.

Two weeks later on May 13, 2013, a joint press release was made by Thomas Insel and Jeffrey Liebermann, the President-elect of the American Psychiatric Association (APA). They said that the NIMH and the APA had a shared interest to ensure that patients and healthcare providers had “the best available tools and information” to identify and treat mental health issues.

Today, the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM), along with the International Classification of Diseases (ICD) represents the best information currently available for clinical diagnosis of mental disorders. . . . The National Institute of Mental Health (NIMH) has not changed its position on DSM-5. As NIMH’s Research Domain Criteria (RDoC) project website states: “The diagnostic categories represented in the DSM-IV and the International Classification of Diseases-10 (ICD-10, containing virtually identical disorder codes) remain the contemporary consensus standard for how mental disorders are diagnosed and treated.”

The DSM and RDoC were said to be complementary, not competing frameworks. As research findings emerge from RDoC, they may be incorporated into future DSM revisions. “But this is a long-term undertaking. It will take years to fulfill the promise that this research effort represents for transforming the diagnosis and treatment of mental disorders.”

Saul Levine, the CEO and Medical Director of the APA said on May 5, 2014 that the DSM and the RDoC will “begin to come together” as the research from NIMH is included into the way they diagnose mental illness. They know that mental illness and substance use disorders are a bio-psycho-social illness. “We work very well together with NIMH. And I think that the whole field is looking to the science coming out of NIMH to include it as a way to help get better treatment for patients in this country.”

So the APA and NIMH affirm they are working towards the same goals as complementary research frameworks. Someday the research findings of RDoC may even be included into the DSM. But until then, the NIMH will have to continue to “ooh and aah” at the APA’s DSM and ignore the nay-sayers crying: “Look at the DSM; look at the DSM!” Also see my blog post, “Psychiatry’s Mythical Phoenix.”