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Category: Mind & Brain
Psychiatry’s Identity Crisis, and How to Start Fixing It
Andres Barkil-Oteo is an assistant professor of psychiatry at Yale University School of Medicine, with research interests in systems thinking, global mental health, and experiential learning in medical education. Find him on Google+ here.
Last spring, the American Psychiatric Association (APA) sent out a press release [pdf] noting that the number of U.S. medical students choosing to go into psychiatry has been declining for the past six years, even as the nation faces a notable dearth of psychiatrists. The Lancet, a leading medical journal, wrote that the field had an “identity crisis” related to the fact that it doesn’t seem “scientific enough” to physicians who deal with more tangible problems that afflict the rest of the body. Psychiatry has recently attempted to cope with its identity problem mainly by assuming an evidence-based approach favored throughout medicine. Evidence-based, however, became largely synonymous with medication, with relative disregard for other evidence-based treatments, like some forms of psychotherapy. In the push to become more medically respected, psychiatrists may be forsaking some of the important parts of their unique role in maintaining people’s health.
Over the last 15 years, use of psychotropic medication has increased in all kinds of ways, including off-label use and prescription of multiple drugs in combination. While overall rates of psychotherapy use remained constant during the 1990s, the proportion of the U.S. population using a psychotropic drug increased from 3.4 percent in 1987 to 8.1 percent by 2001. Antidepressants are now the second-most prescribed class of medication in the U.S., preceded only by lipid regulators, a class of heart drugs that includes statins like Lipitor. Several factors have contributed to this increase: direct-to-consumer advertising; development of effective drugs with fewer side effects (e.g., SSRIs); expansion in health coverage for mental illness made possible through the Mental Health Parity Act; and an increase in prescriptions from non-psychiatric physicians.
Unfortunately, not all of these psychiatric drugs are going to good use. Antidepressive drugs are widely used to treat people with mild or even sub-clinical depression, even though drugs tend to be less cost-effective for those people. It may sound paradoxical, but to get more benefit of antidepressants, we need to use them less, and only when needed, for moderate to severe clinically depressed patients. Patients with milder forms should be encouraged to try time-limited, evidence-based psychotherapies; several APA-endorsed clinical guidelines center on psychotherapies (e.g., cognitive behavioral therapy or behavior activation) as a first-line treatment for moderate depression, anxiety, and eating disorders, and as a secondary treatment to go with medication for schizophrenia and bipolar disorder.
Are Warnings About Drug Side Effects Actually Making Us Sick?
Steve Silberman (@stevesilberman on Twitter) is a journalist whose articles and interviews have appeared in Wired, Nature, The New Yorker, and other national publications; have been featured on The Colbert Report; and have been nominated for National Magazine Awards and included in many anthologies. Steve is currently working on a book on autism and neurodiversity called NeuroTribes: Thinking Smarter About People Who Think Differently (Avery Books 2013). This post originally appeared on his blog, NeuroTribes.
Photo by Flickr user Noodles and Beef
Your doctor doesn’t like what’s going on with your blood pressure. You’ve been taking medication for it, but he wants to put you on a new drug, and you’re fine with that. Then he leans in close and says in his most reassuring, man-to-man voice, “I should tell you that a small number of my patients have experienced some minor sexual dysfunction on this drug. It’s nothing to be ashamed of, and the good news is that this side effect is totally reversible. If you have any ‘issues’ in the bedroom, don’t hesitate to call, and we’ll switch you to another type of drug called an ACE inhibitor.” OK, you say, you’ll keep that in mind.
Three months later, your spouse is on edge. She wants to know if there’s anything she can “do” (wink, wink) to reignite the spark in your marriage. She’s been checking out websites advertising romantic getaways. No, no, you reassure her, it’s not you! It’s that new drug the doctor put me on, and I hate it. When you finally make the call, your doctor switches you over to a widely prescribed ACE inhibitor called Ramipril.
“Now, Ramipril is just a great drug,” he tells you, “but a very few patients who react badly to it find they develop a persistent cough…” Your throat starts to itch even before you fetch the new prescription. Later in the week, you’re telling your buddy at the office that you “must have swallowed wrong” — for the second day in a row. When you type the words ACE inhibitor cough into Google, the text string auto-completes, because so many other people have run the same search, desperately sucking on herbal lozenges between breathless sips of water.
In other words, you’re doomed. Cough, cough!
Is Autism an “Epidemic” or Are We Just Noticing More People Who Have It?
Emily Willingham (Twitter, Google+, blog) is a science writer and compulsive biologist whose work has appeared at Slate, Grist, Scientific American Guest Blog, and Double X Science, among others. She is science editor at the Thinking Person’s Guide to Autism and author of The Complete Idiot’s Guide to College Biology.
In March the US Centers for Disease Control and Prevention (CDC) the newly measured autism prevalences for 8-year-olds in the United States, and headlines roared about a “1 in 88 autism epidemic.” The fear-mongering has led some enterprising folk to latch onto our nation’s growing chemophobia and link the rise in autism to “toxins” or other alleged insults, and some to sell their research, books, and “cures.” On the other hand, some researchers say that what we’re really seeing is likely the upshot of more awareness about autism and ever-shifting diagnostic categories and criteria.
Even though autism is now widely discussed in the media and society at large, the public and some experts alike are still stymied be a couple of the big, basic questions about the disorder: What is autism, and how do we identify—and count—it? A close look shows that the unknowns involved in both of these questions suffice to explain the reported autism boom. The disorder hasn’t actually become much more common—we’ve just developed better and more accurate ways of looking for it.
Leo Kanner first described autism almost 70 years ago, in 1944. Before that, autism didn’t exist as far as clinicians were concerned, and its official prevalence was, therefore, zero. There were, obviously, people with autism, but they were simply considered insane. Kanner himself noted in a 1965 paper that after he identified this entity, “almost overnight, the country seemed to be populated by a multitude of autistic children,” a trend that became noticeable in other countries, too, he said.
In 1951, Kanner wrote, the “great question” became whether or not to continue to roll autism into schizophrenia diagnoses, where it had been previously tucked away, or to consider it as a separate entity. But by 1953, one autism expert was warning about the “abuse of the diagnosis of autism” because it “threatens to become a fashion.” Sixty years later, plenty of people are still asserting that autism is just a popular diagnosis du jour (along with ADHD), that parents and doctors use to explain plain-old bad behavior.
Asperger’s syndrome, a form of autism sometimes known as “little professor syndrome,” is in the same we-didn’t-see-it-before-and-now-we-do situation. In 1981, noted autism researcher Lorna Wing translated and revivified Hans Asperger’s 1944 paper describing this syndrome as separate from Kanner’s autistic disorder, although Wing herself argued that the two were part of a borderless continuum. Thus, prior to 1981, Asperger’s wasn’t a diagnosis, in spite of having been identified almost 40 years earlier. Again, the official prevalence was zero before its adoption by the medical community.
And so, here we are today, with two diagnoses that didn’t exist 70 years ago (plus a third, even newer one: PDD-NOS) even though the people with the conditions did. The CDC’s new data say that in the United States, 1 in 88 eight-year-olds fits the criteria for one of these three, up from 1 in 110 for its 2006 estimate. Is that change the result of an increase in some dastardly environmental “toxin,” as some argue? Or is it because of diagnostic changes and reassignments, as happened when autism left the schizophrenia umbrella?
War Has Deep Roots in Human Nature, But It’s Not Inevitable
Thomas Malthus
In the June 2012 issue of Discover, E. O. Wilson authored a piece with the provocative title, “Is War Inevitable?” Derived from his recent book The Social Conquest of Earth, the narrative has a rather simple answer to the question implied in the title: war is inevitable, because it is part of human nature, and, perhaps more provocatively, it shaped human nature. John Horgan, who recently penned The End of War, rebuts Wilson’s argument in a point-by-point fashion in a companion article, “No, War Is Not Inevitable.” I find myself in a curious position: I agree with John Horgan in terms of the conclusion—that war is not inevitable—but not for the same reasons. While Horgan is right that Wilson relies on a particular, controversial group of ethologists to make the assertion that chimps have frequent inter-group conflicts and humans have always had wars, so Horgan leans upon his own preferred group of scholars to make the opposite points. But both of them, I think, miss the crucial part of the answer: the tricky interplay between nature and nurture.
With a strong background in ecology, Wilson assumes a Malthusian paradigm when it comes to human numbers and human resources. In other words, we are subject to a carrying capacity. When there is a surplus of resources population size increase, and “catches up” to the resource base. After a time an equilibrium develops between population and resources. How? The reality is that for solid evolutionary reasons, individuals do not reduce their own reproductive output altruistically. Rather, the population “self-regulates.” In the jargon there is “intra-species competition,” as individuals and groups scramble for finite resources. (There are also, of course, inter-species factors, like predator, prey, and parasites.) The losers die, while the winners reproduce. Each generation is witness to conflicts which check the population and maintain the equilibrium.
How Doctors Can Ethically Harness the Placebo Effect
Howard Brody, MD, PhD, is the John P. McGovern Centennial Chair in Family Medicine and Director of the Institute for the Medical Humanities at the University of Texas Medical Branch, Galveston.
For years, doctors thought that placebos like sugar pills were totally inert, just something to be given out to mollify a demanding patient without any expected health benefits. Gradually, both physicians and medical researchers came to realize that such treatments can sometimes cause substantial improvement of symptoms, even when there’s no chemical or other biomedical explanation for what occurs—a phenomenon called the placebo effect. In a recent commentary in the Journal of Medical Ethics, Cory Harris and Amir Raz of McGill summarize the data from recent surveys of physician use of placebos in clinical practice in several nations.
They find that prescribing drugs like antibiotics or supplements like vitamins as placebos is now a widespread practice. This is happening without any public guidelines or regulations for placebos’ use, which raises an important question: How, exactly, should physicians be using the placebo effect to help patients?
This discussion is necessary because the understanding of the placebo effect is changing, and fast. In the past decade, scientists have used brain-scanning to see just which parts of the brain, and in what order, become active when a patient takes a placebo pill for various conditions. Other investigators have looked more closely at the treatment environment and sorted out what parts of that environment rev up a placebo response. For example, seeing a nurse inject a painkiller into your IV line gives you roughly twice as much pain relief as having the same dose of medicine administered by a hidden pump. Getting acupuncture treatment from a warm and friendly practitioner works better than the same treatment from a cold, distant one. There’s even some preliminary evidence to suggest that patients experience positive placebo effects even when told frankly that the pills they are taking are placebos, with no active chemical ingredients.
This research—and perhaps personal experience—has changed the way doctors view the importance of their patients’ mental states. Surveys from 20–30 years ago found a general belief among physicians that placebos were completely inert and powerless, and that if any good effect occurred, it was only in the patient’s imagination. The newer surveys, one of which I participated in, show a small revolution in physician thinking about mind-body relations. Physicians today generally agree that placebos can actually have a positive effect on the patient’s body, and that mind-body medicine “works.” That’s important, and has not been sufficiently noted.
Don’t Call a 9-Year-Old a “Psychopath”
Emily Willingham (Twitter, Google+, blog) is a science writer and compulsive biologist whose work has appeared at Slate, Grist, Scientific American Guest Blog, and Double X Science, among others. She is science editor at the Thinking Person’s Guide to Autism and author of The Complete Idiot’s Guide to College Biology.
In May, the New York Times Magazine published a piece by Jennifer Kahn entitled, “Can you call a 9-year-old a psychopath?” The online version generated a great deal of discussion, including 631 comments and a column from Amanda Marcotte at Slate comparing psychopathy and autism. Marcotte’s point seemed to be that if we accept autism as another variant of human neurology rather than as a moral failing, should we not also apply that perspective to the neurobiological condition we call “psychopathy”? Some autistic people to umbrage at the association with psychopathy, a touchy comparison in the autism community in particular. Who would want to be compared to a psychopath, especially if you’ve been the target of one?
In her Times piece, Kahn noted that although no tests exist to diagnose psychopathy in children, many in the mental health professions “believe that psychopathy, like autism, is a distinct neurological condition (that) can be identified in children as young as 5.” Marcotte likely saw this juxtaposition with autism and based her Slate commentary on the comparison. But a better way to make this point (and to avoid a minefield), I’d argue, is to stop mentioning autism at all and to say that any person’s neurological make-up isn’t a matter of morality but of biology. If we argue for acceptance of you and your brain, regardless how it works, we should argue for acceptance of people who are psychopaths. They are no more to blame for how they developed than people with other disabilities.
If being compared with a psychopath elicits a whiplash-inducing mental recoil, then you probably have a good understanding of why the autism community responded to Marcotte’s piece (and accompanying tweets) so defensively, even though her point was a good one. At its core, the argument is a logical, even humanistic one. When it comes to psychopathy, our cultural tendencies are to graft moral judgment onto people who exhibit symptoms of psychopathy, a condition once designated as “moral insanity.” We tend collectively to view the psychopath as a cold-hearted, amoral entity walking around in a human’s body, a literal embodiment of evil.
But those grown people whom we think of as being psychopaths were once children. What were our most infamous psychopaths like when they were very young? Was there ever a time when human intervention could have deflected the trajectory they took, turned the path away from the horror, devastation, and tragedy they caused, one that not all psychopaths ultimately follow? Can we look to childhood as a place to identify the traits of psychopathy and, once known, apply early intervention?
Can Mindfulness Meditation Make You Smarter?
Dan Hurley is writing a book about new research into how people can increase their intelligence. His latest article for DISCOVER, published in April, was about how the brain forms memories.
Can you consciously increase your intelligence? That question was the title of an article I wrote in April for the New York Times Magazine, examining studies showing that people who train their working memory with specially designed games show increases in their fluid intelligence, the ability to solve novel problems and identify patterns. In particular, the article focused on a game called the N-back task, in which a participant is challenged to keep track of spoken words or locations on a grid as they continuously pile up.
While some skeptics doubt that anything as profound as intelligence can be increased in as little as a month by playing a silly game, far stranger methods are also being tested. And the results keep getting published in respectable journals, showing significant effects.
Perhaps the most seemingly absurd approach is the use of “first-person shooter” video games, like Call of Duty. Studies by Daphne Bavelier at the University of Rochester have found that practicing the games improved performance on an array of untrained sensory, perceptual, and attentional tasks. Notably, the transfer is broad enough to improve trainees’ ability to distinguish an auditory signal from white noise, despite the fact that no auditory training was involved in the games, and that two distinct brain areas are involved in auditory and visual processing.
“This is not the first kind of activity you’d think is good for the mind,” Bavelier told me. “But there is a whole field of research showing that executive control and the ability to decide whether to attend to something or not is a main determinant of intelligence. In that sense the games are making you smarter. Whether they will make you do better on an exam, I cannot say.”
Does Speaking in a Second Language Make You Think More, or Feel Less?
Julie Sedivy is the lead author of Sold on Language: How Advertisers Talk to You And What This Says About You. She contributes regularly to Psychology Today and Language Log. She is an adjunct professor at the University of Calgary, and can be found at juliesedivy.com and on Twitter/soldonlanguage.
Should homosexuals should be allowed to serve in the military? Let me rephrase that: Should gay men or lesbians be allowed to serve in the military?
You may have detected within yourself a subtle emotional shift between these two questions. For many Americans, according to a 2010 poll by CBS and The New York Times, those subtly different gut reactions actually led to different responses depending on how the question was worded; people were more receptive to having “gay men and lesbians” than “homosexuals” in the military.
The poll reflects one of the weirder aspects of human cognition: that for all of our capacity for rational, analytical thought, we can have different feelings about the same thing—even make different decisions about it—depending on the language used to talk about it. This phenomenon, known as the framing effect, creates some brisk business for marketers and political communications experts. For example, Frank Luntz, a high-profile consultant for Republican candidates, earns his keep by testing the emotional vibrations set off by language, and keeps lists of words that work, and words that don’t. In advancing a conservative agenda, for example, you should never use phrases like public health care, drilling for oil, or tax cuts; you should instead say government-run health care, energy exploration, and tax relief. (You can find a brief video profile of Luntz and his techniques here, taken from the 2004 PBS documentary The Persuaders.)
That’s probably no way to run a democracy. After all, the economic impact of reducing taxes is the same whether you call it cuts or relief. And it’s probably no way to make investment choices either, or a decision about medical treatment, or render a verdict in a murder trial. So one of the most useful questions that psychology can answer is what can be done to shift the mind away from an instinctive, gut-reaction mode to a more thoughtful and deliberative one.
In an intriguing study reported in the April 2012 issue of Psychological Science, Boaz Keysar and his colleagues found that bilinguals were immune to framing effects and other cognitive biases—but only when working through problems in their non-native language.
Turning Japanese, or, How to Change Your Self’s Ethnicity in Just 1 Week
Mark Changizi is an evolutionary neurobiologist and director of human cognition at 2AI Labs. He is the author of The Brain from 25000 Feet, The Vision Revolution, and his newest book, Harnessed: How Language and Music Mimicked Nature and Transformed Ape to Man.”
Tom Stafford, co-author of the excellent book Mind Hacks, recently wrote a piece for the BBC about one of the most fundamental principles in the brain’s arsenal. This principle is so important that it ought to have a super-excitingly electrifying name; alas, it’s misleadingly boring. The principle is “adaptation,” or otherwise called “tuning out” or “getting used to it.” In an effort to help further communicate the sorts of powers adaptation gives us, it struck me to relate a remarkable “adaptation encounter” I recently had.
In 2011 I had the pleasure of visiting Japan for the first time. In addition to fascinating neuroscience, priceless culture, wonderful food, and world-class skiing, during my week there I had the mind-blowing experience of…turning Japanese.
You don’t think it’s possible for a white person to turn Japanese? Well, you can…perceptually. In fact, although it is I who had turned Japanese during my stay, from my first-person perspective it seemed as if every Japanese person had turned Caucasian!
As Twilight Zone-ish as this may sound, this sort of transformation is well-known and commonplace. What made it so intriguing for me was the extent to which I was, by virtue of my research proclivities, consciously aware of what usually flies below radar.
What Is the “Bible of Psychiatry” Supposed to Do? The Peculiar Challenges of an Uncertain Science
The American Psychiatric Association have just published the latest update of the draft DSM-5 psychiatric diagnosis manual, which is due to be completed in 2013. The changes have provoked much comment, criticism, and heated debate, and many have used the opportunity to attack psychiatric diagnosis and the perceived failure to find “biological tests” to replace descriptions of mental phenomena. But to understand the strengths and weaknesses of psychiatric diagnosis, it’s important to know where the challenges lie.
Think of classifying mental illness like classifying literature. For the purposes of research and for the purposes of helping people with their reading, I want to be able to say whether a book falls within a certain genre—perhaps supernatural horror, romantic fiction, or historical biography. The problem is similar because both mental disorder and literature are largely defined at the level of meaning, which inevitably involves our subjective perceptions. For example, there is no objective way of defining whether a book is a love story or whether a person has a low mood. This fact is used by some to suggest that the diagnosis of mental illness is just “made up” or “purely subjective,” but this is clearly rubbish. Although the experience is partly subjective, we can often agree on classifications.
Speaking the same language
How well people can agree on a classification is known as inter-rater reliability and to have a diagnosis accepted, you should ideally demonstrate that different people can use the same definition to classify different cases in the same way. In other words, we want to be sure that we’re all speaking the same language—when one doctor says a patient has “depression,” another should agree. To do this, it’s important to have definitions that are easy to interpret and apply, and that rely on widely recognised features.
To return to our literature example, it’s possible to define romantic fiction in different ways, but if I want to make sure that other people can use my definition it’s important to choose criteria that are clear, concise, and easily applicable. It’s easier to decide whether the book has “a romantic relationship between two of the main characters” than whether the book involves “an exploration of love, loss and the yearning of the heart.” Similarly, “low mood” is easier to detect than a “melancholic temperament.”
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