Uncategorized

Social Cognitive Neuroscience Goes Hollywood. Thanks to wood s lot for pointing to the American Psychological Association’s coverage of the recent first Social Cognitive Neuroscience conference in Hollywood; these are the people grappling with how minds and social environments are linked. Let me take this one step further, and recommend that you scroll down until you find the section called Mirror Neurons, which IMHO is the heart of the matter. First discovered in the ventral premotor cortex of macaques, these neurons fire both when the monkey does something and when she sees another doing it; as the reporter cunningly says, they are “monkey see” and “monkey do” neurons. Human analogues have been found in both visual and vocal areas and are hypothesized to exist in other cortical areas as well. If, as speculated, they form the neural basis for understanding others’ actions, experiences, intentions and emotions, then they may be the neural underpinning for a host of social phenomena such as imitation, social learning, empathy, sympathy, ‘theory of mind’ ( a hot topic in cognitive philosophy to explain how we understand anyone else), altruism and guilt; indeed, cultural transmission as a whole. I wrote long ago about mirror neurons, pointing to a long commentary about their significance by V.S. Ramachandran which appeared at The Edge (with subsequent discussion here), but all this is worth repeating as, perhaps, the most significant development in cognitive neuroscience in a long time. In my earlier blink, I called it an “intriguing but overreaching theory.” Since I’m in a more speculative mood today, I’m not as bothered by the stretch.

wood s lot also points you to Prescription For Scandal: Biological Psychiatry’s Faustian Pact by Athony (sic) Black, without further comment. Allow me. This is one more in a series of pieces decrying biological psychiatry and drug treatment, all of which seem to be emanating from the dawning realization of the degree to which the pharmaceutical industry and psychiatry are in bed with each other, Make no mistake about it (as George W. likes to say), I decry this trend too from my vantage point practicing and teaching psychiatry. But this piece also sets up a reductionistic straw man rendition of what modern psychiatry is in order to savage it as — ironically — reductionistic and “riven with pseudo-scientific claims and evidential suppression.” It is not clear what the author’s scientific credentials are, but on the basis of some of his reasoning they do not appear to be very robust. Some specifics:

  • He is disturbed by the demographic trends for ECT; “over two thirds of these patients are women, and almost half are the elderly.” Well, duh, more than two thirds of patients seeking treatment for depression are women. And ECT is more readily an option for the elderly because they are particularly responsive to and tolerant of it and less responsive to and tolerant of antidepressant medication.
  • In cataloguing the risks of psychiatric medications, he calls tardive dyskinesia (a neurological complication of antipsychotic medication) “Parkinsonian-like” (not true) and “indicative of permanent brain damage” (not true). He cites discredited overblown prevalence estimates and does not seem to understand that “tardive akathisia” is not a new, different syndrome but included within the spectrum of tardive dyskinesia.
  • He claims that patients exposed to this risk of antipsychotic medication are not informed of the risks they face. In fact, sensitivity to the requirement for informed consent is deeply ingrained in modern psychiatric practice. Someone may be too psychotic to understand the issues and not capable of consenting; in this case, a special court proceeding to obtain permission to give antipsychotics is required.
  • “…these drugs are routinely employed in institutional settings on clients that are patently not psychotic.” First of all, one would like to know if Mr. Black’s understanding of what constitutes psychoticism, and of the range of indications for antipsychotic medication, is sophisticated enough to make this assertion. Secondly, he conflates the old, risky antipsychotics, for which the risk-benefit ratio did largely restrict them to severely psychotic patients, with the newer, so-called atypical antipsychotic medications. The development of the newest generation of ‘atypical’ antipsychotic medications has been the greatest advance in my profession since Prozac and the post-Prozac new generation of antidepressants (although one about which you hear alot less, as their constituency is far narrower). These newer antipsychotics work through a different neural mechanism than the older drugs, one which makes them largely free of the insinuation of alarming neurological side effects. It is for this reason that they can be more broadly applied, and they have demonstrated safe effectiveness in ‘borderline’ psychotic and quasi-psychotic presentations, severe character pathology, extreme mood instability, uncontrollable aggression and rage, treatment-resistant anxiety disorders and aspects of dementia.
  • He claims that antidepressants and “minor tranquilizers” (an outmoded term that shows he has not read any psychiatric literature, if ever, that is less than a decade or more old) have a “shadowy reputation” because of the potential for severe side effects. This straw man argument ignores the fact that therapeutic measures throughout medicine have dangers and untoward consequences if not managed properly. It is part of what physicians do.
  • Tricyclic antidepressants do not produce “severe withdrawal symptoms” ; an ignorant and highly inaccurate mistake.
  • He falsely represents claims for the popularity of SSRI antidepressants (Prozac etc.) as based on “the theory, widely embraced by the general public, that depression involves a well defined point source, or sources, in the brain upon which anti-depressant drugs act like magic bullets surgically targeting the offending region(s).” Perhaps embraced by the public, but I don’t know of any psychiatric source that claims anything vaguely as reductionistic as this. And, if there was any doubt about his neurophysiological ignorance, the following statement — “They act, in other words, non-specifically to block emotional (limbic system) and higher cognitive (frontal lobe) connection. They don’t ‘target’ anything other than a generalized splitting of psychic functioning” — is pseudo-scientific mumbo-jumbo. He appears to have just enough of the jargon, dangerously as the saying goes, to appear to know what he is saying. He next asserts that their mechanism of action is analogous to that of cocaine and amphetamine, which is utterly absurd. Disingenuous and scurrilous, this comment can be designed for no scientific purpose but only propagandistically, to alarm prospective users. This author bbegins to sound more and more like a Scientologist.
  • “…in light of the widespread concern about biochemical imbalances in the brain, the only known such imbalances … are those caused by the drugs themselves.” The author chooses to reshape his reality by ignoring an enormous body of rigorous scientific knowledge which establishes alterations in neurochemical balance and function in psychiatric illness. How disingenuous and selective is it to emphasize the supposed neurochemical mechanisms in the adverse effects he attributes to the medications but leave no room for neurochemical mechanisms in the symptoms of the illnesses?
  • Condemning the pre-approval studies of new drugs: “It is natural to ask at this point, why, given their potential danger, we haven’t witnessed an epidemic of adverse reactions and brain damage related to these new generation drugs.” Uh, maybe because the pre-marketing research often does adequately assess safety and efficacy? The FDA approval process is indeed often criticized as more complicated than it needs to be, needlessly delaying the introduction of potentially useful medications in comparison with European standards. In the last decade alone, in fact, marketing plans for several potential new antidepressants and antipsychotics (whose introduction I and many other psychiatrists familiar with new-drug development were anticipating eagerly) have been killed because of FDA nonapproval due to adverse safety findings.
  • As is usually the case, the author is stuck in an “us-vs.-them” paradigm which is outmoded in modern psychiatry. He views with alarm choosing medication instead of psychotherapy and “giving up on personal growth”, “substituting helplessness for mastery,” etc. No responsible psychiatrist I know believes that medication is a substitute for psychotherapy; personal growth and mastery are facilitated by helping a person too distressed to otherwise grapple with the emotional issues in their life. If he wants to point a finger, it should be at the primary care doctors who have never, in contrast to psychiatrists, been trained in or understood the psychotherapeutic process, assuming from their own experience that it is just an extended version of the supportive and sympathetic ear they lend to their patients’ complaints and are impatient to be done with to get to the ‘real’ practice of medicine. With the development of safer medications in the last two decades, the pharmaceutical industry has hit upon the ingenious marketing strategy of convincing primary care physicians (PCPs) that they can easily prescribe these medications without recourse to psychiatric referrals, a trend that my readers know I decry as the true greatest disaster in the modern care of the psychiatrically ill. I’m convinced, for example, that behind the controversial assertion of increased suicides among Prozac-treated patients, and other similar claims is the fact that PCPs do not have the time, the training, or the expertise to adequately assess the mental state of their patients — not so much the drug as the gift wrap it’s coming in these days.
  • “Thus, there is hardly a shred of experimental evidence to buttress such trendy childhood ‘disease’ entities as Minimal Brain Dysfunction, Learning Disorder, or Attention-Deficit Hyperactivity Disorder. No underlying local organic malformation, physiological malfunction or chemical basis has ever been clearly demonstrated for these syndromes and no well controlled clinical studies have ever unequivocally supported them either.” To start with, does he realize that MBD and ADHD are the same thing; the former is the previous psychiatric generation’s term for the latter? Moving on, this assertion is simply untrue, as anyone familiar with functional MRI studies will understand.
  • “Culturally, the notion that we should conceive ourselves primarily as biochemical mechanisms is not only dangerously dehumanizing and spiritually stunting, it leads inevitably to both a dismissive and escapist attitude towards many genuinely psychological and social problems.” Of course, the answer to this is not to stick our heads in the sand and avoid a sophisticated model of the human being that properly embraces its complexity by including the neurobiological dimension. Many of the most thoughtful psychiatrists — who as a profession have always been interested in grappling philosophically with the complexities of human nature — have struggled in their writing and teaching with the balance between promise and danger in sharing a biological notion, as well as a psychosocial one, with our patients, with the sensitivity necessary to approach that complicated issue adequately, far from being “inevitably … dismissive.” See, for example, the writings of Gerald Klerman MD.
  • “In having suborned, in other words, a substantial proportion of the population into believing their behaviours are dictated principally by their genes and their biochemistry, biological psychiatry has not only set back the psychological paradigm a hundred years, it has also fanned the flames of a simplistic, reductionist view of human nature and of human society.” It is a reductionistic straw man of a biological psychiatry that he sets up for ridicule and, in so doing, demonstrates that he is the real reductionist.
  • Neither the “mind-ers” or the “brain-ers” will be the winners in this type of tortured debate based on specious reasoning and a dearth of facts — I’m rooting for the “brain-mind-ers” myself. Read this article, if you must, with a massive grain of salt. I’m serious in suggesting that the author might be a Scientologist, by the way… Disputing articles like this which pass for thoughtful criticism of modern psychiatry makes me sound embarrassingly like an uncritical booster (either defensive about maintaining my livelihood or perhaps brainwashed by the pharmaceutical industry?), which I am by no stretch of the imagination. Remind me to try to blink some worthy, credible critiques of the predominant psychiatric paradigm for you, if I haven’t in awhile. Your comments are welcome.