Fingers

How many fingers do you have?

10, obviously, unless you've been the victim of an accident or a birth defect. Everyone knows that. You count up to ten on your fingers, for one thing.

But look at your left hand - how many fingers are on it? Little finger, ring finger, middle finger, first finger... thumb. So that's 4. But then we'd only have 8 fingers, and we all know we have 10. Unless the thumb is a finger, but is it?

Hmm. Hard to say. Wikipedia has some interesting facts about this question, and on Google if you start to type in "is the thumb", the top suggested search terms are all about this issue. It's a tricky one. People don't seem to know for sure.

But does that mean there's any real mystery about the thumb? No - we understand it as well as any other part of the body. We know all about the bones and muscles and joints and nerves of the thumb, we know how it works, what it does, even its evolutionary history (see The Panda's Thumb by Steven J Gould, still one of the greatest popular science books ever.) Science has got thumbs covered.

The mystery is in the English language, which isn't quite clear on whether the word "finger" encompasses the human thumb; for some purposes it does, i.e. we have 10 fingers, but for other purposes it probably doesn't, although even English speakers seem to be in two minds about the details (see Google, above).

Notice that although the messiness seems to focus on the thumb, the word "thumb" is perfectly clear. The ambiguity is rather in the word "finger", which can mean either any of the digits of the hand, or, the digits of the hand with three joints. Take a look at your hand again and you'll notice that your thumb lacks a joint compared to the fingers; something I must admit I'd forgotten until Wikipedia reminded me.

Yet it would be very easy to blame the thumb for the confusion. After all, the other 4 fingers are definitely fingers. The fingers are playing by the rules. Only the thumb is a troublemaker. So it comes as somewhat of a surprise to realize that it's the fingers, not the thumb, that are the problem.

*

So words or phrases can be ambiguous, and when they are, they can lead to confusion, but not always in the places you'd expect. Specifically, the confusion seems to occur at the borderlines, the edge cases, of the ambiguous terminology, but the ambiguity is really in the terminology itself, not the edge cases. To resolve the confusion you need to clarify the terminology, and not get bogged down in wondering whether this or that thing is or isn't covered by the term.

It's important to bear in this in mind when thinking about psychiatry, because psychiatry has an awful lot of confusion, and a lot of it can be traced back to ambiguous terms. Take, for example, the question of whether X "is a mental illness". Is addiction a mental illness, or a choice? Is mild depression a mental illness, or a normal part of life? Is PTSD a mental illness, or a normal reaction to extreme events? Is... I could go on all day.

The point is that you will never be able to answer these questions until you stop focussing on the particular case and first ask, what do I mean by mental illness? If you can come up with a single, satisfactory definition of mental illness, all the edge cases will become obvious. But at present, I don't think anyone really knows what they mean by this term. I know I don't, which is why I try to avoid using it, but often I do still use it because it seems to be the most fitting phrase.

It might seem paradoxical to use a word without really knowing what it means, but it isn't, because being able to use a word is procedural knowledge, like riding a bike. The problem is that many of our words have confusion built-in, because they're ambiguous. We can all use them, but that means we're all risking confusing each other, and ourselves. When this gets serious enough the only solution is to stop using the offending word and create new, unambiguous ones. With "finger", it's hardly a matter of life or death. With "mental illness", however, it is.

Fingers

How many fingers do you have?

10, obviously, unless you've been the victim of an accident or a birth defect. Everyone knows that. You count up to ten on your fingers, for one thing.

But look at your left hand - how many fingers are on it? Little finger, ring finger, middle finger, first finger... thumb. So that's 4. But then we'd only have 8 fingers, and we all know we have 10. Unless the thumb is a finger, but is it?

Hmm. Hard to say. Wikipedia has some interesting facts about this question, and on Google if you start to type in "is the thumb", the top suggested search terms are all about this issue. It's a tricky one. People don't seem to know for sure.

But does that mean there's any real mystery about the thumb? No - we understand it as well as any other part of the body. We know all about the bones and muscles and joints and nerves of the thumb, we know how it works, what it does, even its evolutionary history (see The Panda's Thumb by Steven J Gould, still one of the greatest popular science books ever.) Science has got thumbs covered.

The mystery is in the English language, which isn't quite clear on whether the word "finger" encompasses the human thumb; for some purposes it does, i.e. we have 10 fingers, but for other purposes it probably doesn't, although even English speakers seem to be in two minds about the details (see Google, above).

Notice that although the messiness seems to focus on the thumb, the word "thumb" is perfectly clear. The ambiguity is rather in the word "finger", which can mean either any of the digits of the hand, or, the digits of the hand with three joints. Take a look at your hand again and you'll notice that your thumb lacks a joint compared to the fingers; something I must admit I'd forgotten until Wikipedia reminded me.

Yet it would be very easy to blame the thumb for the confusion. After all, the other 4 fingers are definitely fingers. The fingers are playing by the rules. Only the thumb is a troublemaker. So it comes as somewhat of a surprise to realize that it's the fingers, not the thumb, that are the problem.

*

So words or phrases can be ambiguous, and when they are, they can lead to confusion, but not always in the places you'd expect. Specifically, the confusion seems to occur at the borderlines, the edge cases, of the ambiguous terminology, but the ambiguity is really in the terminology itself, not the edge cases. To resolve the confusion you need to clarify the terminology, and not get bogged down in wondering whether this or that thing is or isn't covered by the term.

It's important to bear in this in mind when thinking about psychiatry, because psychiatry has an awful lot of confusion, and a lot of it can be traced back to ambiguous terms. Take, for example, the question of whether X "is a mental illness". Is addiction a mental illness, or a choice? Is mild depression a mental illness, or a normal part of life? Is PTSD a mental illness, or a normal reaction to extreme events? Is... I could go on all day.

The point is that you will never be able to answer these questions until you stop focussing on the particular case and first ask, what do I mean by mental illness? If you can come up with a single, satisfactory definition of mental illness, all the edge cases will become obvious. But at present, I don't think anyone really knows what they mean by this term. I know I don't, which is why I try to avoid using it, but often I do still use it because it seems to be the most fitting phrase.

It might seem paradoxical to use a word without really knowing what it means, but it isn't, because being able to use a word is procedural knowledge, like riding a bike. The problem is that many of our words have confusion built-in, because they're ambiguous. We can all use them, but that means we're all risking confusing each other, and ourselves. When this gets serious enough the only solution is to stop using the offending word and create new, unambiguous ones. With "finger", it's hardly a matter of life or death. With "mental illness", however, it is.

Password

A few days ago, a friend of mine had her GMail account compromised, resulting in much stress for all concerned. This prompted me to change my passwords.

That was three days ago. Since then, I've logged into GMail maybe ten or fifteen times, and every single time I've initially typed the old password. Sometimes, I catch myself and change it before hitting "enter", but usually not. Access denied. Oops. It's getting slightly better, but I think it'll be a good few days before I'm entering the new password as automatically as I did the old one.

It's not hard to see why this kind of thing happens: I'd typed in the old password hundreds, probably thousands, of times over the course of at least a year. It had become completely automatic. That kind of habit takes a long time to learn, so it's no surprise that it takes quite a while to unlearn (though hopefully not quite as long).

Psychologists will recognize the distinction between declarative memory, my concious knowledge of what my new password is, and procedural memory, my ability to unconsciously type it. It's also commonly known as "muscle memory": this is misleading because it's stored in the brain, like all knowledge, but it nicely expresses the feeling that it's your body that has the memory, rather than "you".

Damage to the hippocampus can leave people unable to remember what happened ten minutes ago, but perfectly capable of learning new skills: they just don't remember how they learned them. But you don't have to suffer brain damage to experience procedural knowledge in the absence of declarative recall. I've sometimes found myself unable to remember my password and only reminded myself by going to the login page and successfully typing it. I knew it all along - but only procedurally.

The thing about procedural knowledge is that when it works, you don't notice it's there. So we almost certainly underestimate its contribution to our lives. If you asked me what happens when I log in to GMail, I'd probably say "I type in my username and my password". But maybe it would be more accurate to say: "I go to the login screen, and my brain types my username and password."

Can I take the credit, given that sometimes I - my conciousness - don't even know the password until my brain's helpfully typed it for me? And while in this case I do know it some of the time, much of our procedural knowledge has no declarative equivalent. I can ride a bike, but if you asked me to tell you how I do it, to spell out the complex velocity-weight-momentum calculations that lie behind the adjustments that my muscles constantly make to keep me upright, I'd be stumped.

"I just sit down and pedal." But if I literally did that and nothing more, I'd fall flat on my face. There's a lot more to cycling than that, but I have no idea what it is. So can I ride a bike, or do I just happen to inhabit a brain that can? Isn't saying that I can ride a bike like saying that I can drive just because I have a chauffeur?


Take this train of thought far enough and you reach some disturbing conclusions. Maybe it's not so hard to accept that various skills lie outside the reach of our concious self, but surely the decisions to use those skills are ours alone. Sure, my brain types my username and password for me, but I'm the one who decided to login to GMail - I could have decided to turn the computer off and go for a walk instead. I have Free Will! Like George W. Bush, I'm the Decider. My brain just handles the boring details.

But isn't deciding a skill too? And willing, remembering, thinking, judging, feeling, concluding - I can do all those things, but if I knew how I do them, I'd win the the Nobel Prize in Physiology or Medicine because I'd just have solved the hardest questions of neuroscience. So can I take credit for doing them, or is it my brain?

Ultimately, every concious act must be constructed from unconscious processes; otherwise there would be an infinite regress of conciousness. If the world rested on the back of a giant turtle, what would the turtle stand on? Turtles all the way down?

Link: The Concept of Mind (1949) is a book by the British philosopher Gilbert Ryle, from which I "borrowed" the ideas in this post, and which was probably the one book that most inspired me to study neuroscience.

Password

A few days ago, a friend of mine had her GMail account compromised, resulting in much stress for all concerned. This prompted me to change my passwords.

That was three days ago. Since then, I've logged into GMail maybe ten or fifteen times, and every single time I've initially typed the old password. Sometimes, I catch myself and change it before hitting "enter", but usually not. Access denied. Oops. It's getting slightly better, but I think it'll be a good few days before I'm entering the new password as automatically as I did the old one.

It's not hard to see why this kind of thing happens: I'd typed in the old password hundreds, probably thousands, of times over the course of at least a year. It had become completely automatic. That kind of habit takes a long time to learn, so it's no surprise that it takes quite a while to unlearn (though hopefully not quite as long).

Psychologists will recognize the distinction between declarative memory, my concious knowledge of what my new password is, and procedural memory, my ability to unconsciously type it. It's also commonly known as "muscle memory": this is misleading because it's stored in the brain, like all knowledge, but it nicely expresses the feeling that it's your body that has the memory, rather than "you".

Damage to the hippocampus can leave people unable to remember what happened ten minutes ago, but perfectly capable of learning new skills: they just don't remember how they learned them. But you don't have to suffer brain damage to experience procedural knowledge in the absence of declarative recall. I've sometimes found myself unable to remember my password and only reminded myself by going to the login page and successfully typing it. I knew it all along - but only procedurally.

The thing about procedural knowledge is that when it works, you don't notice it's there. So we almost certainly underestimate its contribution to our lives. If you asked me what happens when I log in to GMail, I'd probably say "I type in my username and my password". But maybe it would be more accurate to say: "I go to the login screen, and my brain types my username and password."

Can I take the credit, given that sometimes I - my conciousness - don't even know the password until my brain's helpfully typed it for me? And while in this case I do know it some of the time, much of our procedural knowledge has no declarative equivalent. I can ride a bike, but if you asked me to tell you how I do it, to spell out the complex velocity-weight-momentum calculations that lie behind the adjustments that my muscles constantly make to keep me upright, I'd be stumped.

"I just sit down and pedal." But if I literally did that and nothing more, I'd fall flat on my face. There's a lot more to cycling than that, but I have no idea what it is. So can I ride a bike, or do I just happen to inhabit a brain that can? Isn't saying that I can ride a bike like saying that I can drive just because I have a chauffeur?


Take this train of thought far enough and you reach some disturbing conclusions. Maybe it's not so hard to accept that various skills lie outside the reach of our concious self, but surely the decisions to use those skills are ours alone. Sure, my brain types my username and password for me, but I'm the one who decided to login to GMail - I could have decided to turn the computer off and go for a walk instead. I have Free Will! Like George W. Bush, I'm the Decider. My brain just handles the boring details.

But isn't deciding a skill too? And willing, remembering, thinking, judging, feeling, concluding - I can do all those things, but if I knew how I do them, I'd win the the Nobel Prize in Physiology or Medicine because I'd just have solved the hardest questions of neuroscience. So can I take credit for doing them, or is it my brain?

Ultimately, every concious act must be constructed from unconscious processes; otherwise there would be an infinite regress of conciousness. If the world rested on the back of a giant turtle, what would the turtle stand on? Turtles all the way down?

Link: The Concept of Mind (1949) is a book by the British philosopher Gilbert Ryle, from which I "borrowed" the ideas in this post, and which was probably the one book that most inspired me to study neuroscience.

Carlat's Unhinged

Well he's not. Actually, I haven't met him, so it's always possible. But what he certainly has done is written a book called Unhinged: The Trouble with Psychiatry.

Daniel Carlat's best known online for the Carlat Psychiatry Blog and in the real world for the Carlat Psychiatry Report. Unhinged is his first book for a general audience, though he's previously written several technical works aimed at doctors. It comes hot on the heels of a number of other recent books offering more or less critical perspectives on modern psychiatry, notably these ones.

Unhinged offers a sweeping overview of the whole field. If you're looking for a detailed examination of the problems around, say, psychiatric diagnosis, you'd do well to read Crazy Like Us as well. But as an overview it's a very readable and comprehensive one, and Carlat covers many topics that readers of his blog, or indeed of this one, would expect: the medicalization of normal behaviour, to over-diagnosis, the controversy over pediatric psychopharmacology, brain imaging and the scientific state of biological psychiatry, etc.

Carlat is unique amongst authors of this mini-genre, however, in that he is himself a practising psychiatrist, and moreover, an American one. This is important, because almost everyone agrees that to the extent that there is a problem with psychiatry, American psychiatry has it worst of all: it's the country that gave us the notorious DSM-IV, where drugs are advertised direct-to-the-consumer, where children are diagnosed with bipolar and given antipsychotics, etc.

So Carlat is well placed to report from the heart of darkness and he doesn't disappoint, as he vividly reveals how dizzying sums of drug company money sway prescribing decisions and even create diseases out of thin air. His confessional account of his own time as a paid "representative" for the antidepressant Effexor (also discussed in the NYT), and of his dealings with other reps - the Paxil guy, the Cymbalta woman - have to be read to be believed. We're left with the inescapable conclusion that psychiatry, at least in America, is institutionally corrupt.

Conflict of interest is a tricky thing though. Everyone in academia and medicine has mentors, collaborators, people who work in the office next door. The social pressure against saying or publishing anything that explicitly or implicitly criticizes someone else is powerful. Of course, there are rivalries and controversies, but they're firmly the exception.

The rule is: don't rock the boat. And given that in psychiatry, all but a few of the leading figures have at least some links to industry, that means everyone's in the same boat with Pharma, even the people who don't, personally, accept drug company money. I think this is often overlooked in all the excitement over individual scandals.

For all this, Carlat is fairly conservative in his view of psychiatric drugs. They work, he says, a lot of the time, but they're rarely the whole answer. Most people need therapy, too. His conclusion is that psychiatrists need to spend more time getting to know their patients, instead of just handing out pills and then doing a 15 minute "med check" - a great way of making money when you're getting paid per patient (4 patients per hour: ker-ching!), but probably not a great way of treating people.

In other words, psychiatrists need to be psychotherapists as well as psychopharmacologists. It's not enough to just refer people to someone else for the therapy: in order to treat mental illness you need one person with the skills to address both the biological and the psychological aspects of the patient's problems. Plus, patients often find it frustrating being bounced back and forth between professionals, and it's a recipe for confusion ("My psychiatrist says this but my therapist says...")

This leads Carlat to the controversial conclusion that psychiatrists should no longer have a monopoly on prescribing medications. He supports the idea of (appropriately trained) prescribing psychologists, an idea which has taken off in a few US states but which is hotly debated.

As he puts it, for a psychiatrist, the years in medical school spent delivering babies and dissecting kidneys are rarely useful. So there's no reason why a therapist can't learn the necessary elements of psychopharmacology - which drugs do what, how to avoid dangerous drug interactions - in say one or two years.

Such a person would be at least as good as a psychiatrist at providing integrated pills-and-therapy care. In fact, he says, an even better option would be to design an entirely new type of training program to create such "integrated" mental health professionals from the ground up - neither doctors nor therapists but something combining the best aspects of both.

There does seem to be a paradox here, however: Carlat has just spent 200 pages explaining how drug companies distort the evidence and bribe doctors in order to push their latest pills at people, many of whom either don't need medication or would do equally well with older, much cheaper drugs. Now he's saying that more people should be licensed to prescribe the same pills? Whose side is he on?

In fact, Carlat's position is perfectly coherent: his concern is to give patients the best possible care, which is, he thinks, combined medication and therapy. So he is not "anti" or "pro-medication" in any simple sense. But still, if psychiatry has been corrupted by drug company money, what's to stop the exact same thing happening to psychologists as soon as they got the ability to prescribe?

I think the answer to this can only be that we must first cut the problem off at its source by legislation. We simply shouldn't allow drug companies the freedom to manipulate opinion in the way that they do. It's not inevitable: we can regulate them. The US leads the world in some areas: since 2007, all clinical trials conducted in the country must be pre-registered, and the results made available on a public website, clinicaltrials.gov.

The benefits, in terms of keeping drug manufacturer's honest, are far too many to explain here. Other places, like the European Union, are just starting to follow suit. But America suffers from a split personality in this regard. It's also one of the only countries to allow direct-to-consumer drug advertising, for example. Until the US gets serious about restraining Pharma influence in all its forms, giving more people prescribing rights might only aggravate the problem.

Carlat's Unhinged

Well he's not. Actually, I haven't met him, so it's always possible. But what he certainly has done is written a book called Unhinged: The Trouble with Psychiatry.

Daniel Carlat's best known online for the Carlat Psychiatry Blog and in the real world for the Carlat Psychiatry Report. Unhinged is his first book for a general audience, though he's previously written several technical works aimed at doctors. It comes hot on the heels of a number of other recent books offering more or less critical perspectives on modern psychiatry, notably these ones.

Unhinged offers a sweeping overview of the whole field. If you're looking for a detailed examination of the problems around, say, psychiatric diagnosis, you'd do well to read Crazy Like Us as well. But as an overview it's a very readable and comprehensive one, and Carlat covers many topics that readers of his blog, or indeed of this one, would expect: the medicalization of normal behaviour, to over-diagnosis, the controversy over pediatric psychopharmacology, brain imaging and the scientific state of biological psychiatry, etc.

Carlat is unique amongst authors of this mini-genre, however, in that he is himself a practising psychiatrist, and moreover, an American one. This is important, because almost everyone agrees that to the extent that there is a problem with psychiatry, American psychiatry has it worst of all: it's the country that gave us the notorious DSM-IV, where drugs are advertised direct-to-the-consumer, where children are diagnosed with bipolar and given antipsychotics, etc.

So Carlat is well placed to report from the heart of darkness and he doesn't disappoint, as he vividly reveals how dizzying sums of drug company money sway prescribing decisions and even create diseases out of thin air. His confessional account of his own time as a paid "representative" for the antidepressant Effexor (also discussed in the NYT), and of his dealings with other reps - the Paxil guy, the Cymbalta woman - have to be read to be believed. We're left with the inescapable conclusion that psychiatry, at least in America, is institutionally corrupt.

Conflict of interest is a tricky thing though. Everyone in academia and medicine has mentors, collaborators, people who work in the office next door. The social pressure against saying or publishing anything that explicitly or implicitly criticizes someone else is powerful. Of course, there are rivalries and controversies, but they're firmly the exception.

The rule is: don't rock the boat. And given that in psychiatry, all but a few of the leading figures have at least some links to industry, that means everyone's in the same boat with Pharma, even the people who don't, personally, accept drug company money. I think this is often overlooked in all the excitement over individual scandals.

For all this, Carlat is fairly conservative in his view of psychiatric drugs. They work, he says, a lot of the time, but they're rarely the whole answer. Most people need therapy, too. His conclusion is that psychiatrists need to spend more time getting to know their patients, instead of just handing out pills and then doing a 15 minute "med check" - a great way of making money when you're getting paid per patient (4 patients per hour: ker-ching!), but probably not a great way of treating people.

In other words, psychiatrists need to be psychotherapists as well as psychopharmacologists. It's not enough to just refer people to someone else for the therapy: in order to treat mental illness you need one person with the skills to address both the biological and the psychological aspects of the patient's problems. Plus, patients often find it frustrating being bounced back and forth between professionals, and it's a recipe for confusion ("My psychiatrist says this but my therapist says...")

This leads Carlat to the controversial conclusion that psychiatrists should no longer have a monopoly on prescribing medications. He supports the idea of (appropriately trained) prescribing psychologists, an idea which has taken off in a few US states but which is hotly debated.

As he puts it, for a psychiatrist, the years in medical school spent delivering babies and dissecting kidneys are rarely useful. So there's no reason why a therapist can't learn the necessary elements of psychopharmacology - which drugs do what, how to avoid dangerous drug interactions - in say one or two years.

Such a person would be at least as good as a psychiatrist at providing integrated pills-and-therapy care. In fact, he says, an even better option would be to design an entirely new type of training program to create such "integrated" mental health professionals from the ground up - neither doctors nor therapists but something combining the best aspects of both.

There does seem to be a paradox here, however: Carlat has just spent 200 pages explaining how drug companies distort the evidence and bribe doctors in order to push their latest pills at people, many of whom either don't need medication or would do equally well with older, much cheaper drugs. Now he's saying that more people should be licensed to prescribe the same pills? Whose side is he on?

In fact, Carlat's position is perfectly coherent: his concern is to give patients the best possible care, which is, he thinks, combined medication and therapy. So he is not "anti" or "pro-medication" in any simple sense. But still, if psychiatry has been corrupted by drug company money, what's to stop the exact same thing happening to psychologists as soon as they got the ability to prescribe?

I think the answer to this can only be that we must first cut the problem off at its source by legislation. We simply shouldn't allow drug companies the freedom to manipulate opinion in the way that they do. It's not inevitable: we can regulate them. The US leads the world in some areas: since 2007, all clinical trials conducted in the country must be pre-registered, and the results made available on a public website, clinicaltrials.gov.

The benefits, in terms of keeping drug manufacturer's honest, are far too many to explain here. Other places, like the European Union, are just starting to follow suit. But America suffers from a split personality in this regard. It's also one of the only countries to allow direct-to-consumer drug advertising, for example. Until the US gets serious about restraining Pharma influence in all its forms, giving more people prescribing rights might only aggravate the problem.

Head Trip

A quick post to recommend the 2007 book Head Trip, by Jeff Warren.

Head Trip is about "24 hours in the life of your brain": sleeping, waking, and everything in-between, from lucid dreaming to daydreams and hypnosis.

Warren gives a nice overview of current research and theory along with the story of his personal quest to experience the full spectrum of conciousness.

The book's most interesting chapter is called "The Watch". It's about that hour or two of wakefulness which occurs in the middle of the night, between the first sleep and the second sleep. You know the one...right? Neither did I, but apparently, this makes us a bit weird, historically speaking.

Warren says that until the era of artificial lighting and alarm clocks, sleep was segmented. It was common for people to sleep twice each night, with a bout of awakeness in the middle. This nocturnal alertness wasn't quite like daytime waking, though: it was more relaxed, less focussed, carefree. Our modern sleep pattern, then, is kind of compressed, with the two sleeps pushed together until they merge into one.

There are two lines of evidence for this. Writings from the pre-modern era routinely make reference to "first sleep" and "second sleep", and in many languages, although not modern English, there were special words for these periods and the wakefulness between. This is according to historian A. Roger Ekirch in his history of night-time, At Day's Close (review, Wiki), a book I really want to read now.

On the other hand, there's the findings of sleep psychiatrist Thomas Wehr, in particular his classic 1992 study called In short photoperiods, human sleep is biphasic. Wehr took healthy American volunteers and put them in an artificial environment with a controlled light cycle, such that there were only 10 hours of brightness per day. (That's 6 hours less than we get on average, even in winter, due to artificial light.) Within a few weeks "their sleep episodes expanded and usually divided into two symmetrical bouts, several hours in duration, with a 1-3 h waking interval between them."

This is pretty freaky. Sleeping all night seems natural, normal and healthy: if we wake up before we need to get up, we're dismayed and we call it insomnia. Maybe this is a modern invention like electric lighting. There's something amazing and also a bit disturbing about this idea. As Warren says, it's like finding out that your house "is really the exposed bell-tower of a vast underground cathedral".

Head Trip

A quick post to recommend the 2007 book Head Trip, by Jeff Warren.

Head Trip is about "24 hours in the life of your brain": sleeping, waking, and everything in-between, from lucid dreaming to daydreams and hypnosis.

Warren gives a nice overview of current research and theory along with the story of his personal quest to experience the full spectrum of conciousness.

The book's most interesting chapter is called "The Watch". It's about that hour or two of wakefulness which occurs in the middle of the night, between the first sleep and the second sleep. You know the one...right? Neither did I, but apparently, this makes us a bit weird, historically speaking.

Warren says that until the era of artificial lighting and alarm clocks, sleep was segmented. It was common for people to sleep twice each night, with a bout of awakeness in the middle. This nocturnal alertness wasn't quite like daytime waking, though: it was more relaxed, less focussed, carefree. Our modern sleep pattern, then, is kind of compressed, with the two sleeps pushed together until they merge into one.

There are two lines of evidence for this. Writings from the pre-modern era routinely make reference to "first sleep" and "second sleep", and in many languages, although not modern English, there were special words for these periods and the wakefulness between. This is according to historian A. Roger Ekirch in his history of night-time, At Day's Close (review, Wiki), a book I really want to read now.

On the other hand, there's the findings of sleep psychiatrist Thomas Wehr, in particular his classic 1992 study called In short photoperiods, human sleep is biphasic. Wehr took healthy American volunteers and put them in an artificial environment with a controlled light cycle, such that there were only 10 hours of brightness per day. (That's 6 hours less than we get on average, even in winter, due to artificial light.) Within a few weeks "their sleep episodes expanded and usually divided into two symmetrical bouts, several hours in duration, with a 1-3 h waking interval between them."

This is pretty freaky. Sleeping all night seems natural, normal and healthy: if we wake up before we need to get up, we're dismayed and we call it insomnia. Maybe this is a modern invention like electric lighting. There's something amazing and also a bit disturbing about this idea. As Warren says, it's like finding out that your house "is really the exposed bell-tower of a vast underground cathedral".

DSM-V, a Prenatal Health Check

Last month the proposed draft of the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) came out.

In my post at the time I was pretty critical of several aspects of the new DSM. Many many other blogs have discussed DSM-V, as have older media. As you'd expect with such a complex and controversial issue as psychiatric diagnosis, opinions have varied widely, but one thing stands out: people are debating this. Everyone's got something to say about it, professionals and laypeople.

Debate is usually thought to be healthy, but I think in this case, it's a very bad sign for DSM-V. The previous editions, like DSM-IV, were presented to the world as a big list of mental disorders carrying the authority of the American Psychiatric Association. That's why people called the DSM the Bible of psychiatry - it was supposedly revealed truth as handed down by a consensus group of experts. If not infallible, it was at least something to take note of. There have always been critics of the DSM, but until recently, they were the underdogs, chipping away at an imposing edifice.

But DSM-V won't be imposing. People are criticizing it before it's been finalized, and even bystanders can see that there's really no consensus on many important issues. The very fact that everyone's discussing the proposed changes to the Manual is also telling: if the DSM is a Bible, why does it need to be revised so often?

My prediction is that when DSM-V does arrive (May 2013 is the current expected birth date) , it will be a non-event. By then the debates will have happened. I suspect that few researchers are going to end up deciding to invest their time, money and reputation in the new disorders added in DSM-V. Why study "temper regulation disorder with dysphoria" (TDDD) when it was controversial before it even officially existed? Despite the shiny new edition, we may be using DSM-IV for all intents and purposes for a long time to come.

DSM-V, a Prenatal Health Check

Last month the proposed draft of the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) came out.

In my post at the time I was pretty critical of several aspects of the new DSM. Many many other blogs have discussed DSM-V, as have older media. As you'd expect with such a complex and controversial issue as psychiatric diagnosis, opinions have varied widely, but one thing stands out: people are debating this. Everyone's got something to say about it, professionals and laypeople.

Debate is usually thought to be healthy, but I think in this case, it's a very bad sign for DSM-V. The previous editions, like DSM-IV, were presented to the world as a big list of mental disorders carrying the authority of the American Psychiatric Association. That's why people called the DSM the Bible of psychiatry - it was supposedly revealed truth as handed down by a consensus group of experts. If not infallible, it was at least something to take note of. There have always been critics of the DSM, but until recently, they were the underdogs, chipping away at an imposing edifice.

But DSM-V won't be imposing. People are criticizing it before it's been finalized, and even bystanders can see that there's really no consensus on many important issues. The very fact that everyone's discussing the proposed changes to the Manual is also telling: if the DSM is a Bible, why does it need to be revised so often?

My prediction is that when DSM-V does arrive (May 2013 is the current expected birth date) , it will be a non-event. By then the debates will have happened. I suspect that few researchers are going to end up deciding to invest their time, money and reputation in the new disorders added in DSM-V. Why study "temper regulation disorder with dysphoria" (TDDD) when it was controversial before it even officially existed? Despite the shiny new edition, we may be using DSM-IV for all intents and purposes for a long time to come.

Anne of Green Gables

My Nana and I have been talking. And I really want these books for my birthday. It's the set of Anne of Green Gables books. My Nana was telling me about a set that she had when she was little. She really liked them! After we watched some of the show from PBS, now I really want to read these books! :) C

Little Women

My Dad and I went to Barnes and Noble yesterday. I've been wanting a new book. It's been really cold around here. I like to read when it gets cold like this.

I looked and looked through all the books. My Dad was having coffee and a cookie. I picked the book Little Women. My Nana and I had been talking about it. She likes to read a lot like me. I stayed up late last night reading. I got up early today to read too! I'm already halfway through my new book. But it's a really good book. :) C

DSM-V: Change We Can Believe In?

So the draft of DSM-V is out.

If, as everyone says, the Diagnostic and Statistical Manual is the Bible of Psychiatry, I'm not sure why it gets heavily edited once every ten years or so. Perhaps the previous versions are a kind of Old Testament, and only the current one represents the New Revelation from the gods of the mind?

Mind Hacks has an excellent summary of the proposed changes. Bear in mind that the book won't be released until 2013. Some of the headlines:

• Asperger's Syndrome is out - everyone's going to have an "autistic spectrum disorder" now.
  
• Personality Disorders are out - kind of. In their place, there's 5 Personality Disorder Types, each of which you can have to varying degrees, and also 6 Personality Traits, each of which you can have to varying degrees.
• Hypoactive Sexual Desire Disorder - the disease which failed-antidepressant-turned-aphrodisiac flibanserin is supposed to treat - is out, to be replaced by Sexual Interest and Arousal Disorder.
• Binge Eating Disorder, Hypersexuality Disorder, and Gambling Addiction are in. Having Fun is not a disorder yet, but that's on the agenda for DSM-VI.

More important, at least in theory, are the Structural, Cross-Cutting, and General Classification Issues. This is where the grand changes to the whole diagnostic approach happen. But it turns out they're pretty modest. First up, the Axis system, by which most disorders were "Axis I", personality disorders which were "Axis II", and other medical illnesses "Axis III", is to be abolished - everything will be on a single Axis from now on. This will have little, if any, practical effect, but will presumably make it easier on whoever it is that has to draw up the contents page of the book.

Excitingly, "dimensional assessments" have been added... but only in a limited way. Some people have long argued that having categorical diagnoses - "schizophrenia", "bipolar disorder", "major depression" etc. - is a mistake, since it forces psychiatrists to pigeon-hole people, and that we should stop thinking in terms of diagnoses and just focus on symptoms: if someone's depressed, say, then treat them for depression, but don't diagnose them with "major depressive disorder".

DSM-V hasn't gone this far - the categorical diagnoses remain in most cases (the exception is Personality Disorders, see above). However, new dimensional assessments have been proposed, which are intended to complement the diagnoses, and some of them will be "cross-cutting" i.e. not tied to one particular diagnosis. See for example here for a cross-cutting questionnaire designed to assess common anxiety, depression and substance abuse symptoms.

Finally, the concept of "mental disorder" is being redefined. In DSM-V a mental disorder is (drumroll)...

A. A behavioral or psychological syndrome or pattern that occurs in an individual

B. The consequences of which are clinically significant distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning)

C. Must not be merely an expectable response to common stressors and losses...

D. That reflects an underlying psychobiological dysfunction

E. That is not primarily a result of social deviance or conflicts with society

The main change here is that now it's all about "psychobiological dysfunction", whereas in DSM-IV, it was about "behavioral, psychological, or biological dysfunction". Hmm. I am not sure what this means, if anything.

But read on, and we find something rather remarkable...

J. When considering whether to add a mental/psychiatric condition to the nomenclature, or delete a mental/psychiatric condition from the nomenclature, potential benefits (for example, provide better patient care, stimulate new research) should outweigh potential harms (for example, hurt particular individuals, be subject to misuse)

This all sounds very nice and sensible. Diagnoses should be helpful, not harmful, right?

No. Diagnoses should be true. The whole point of the DSM is that it's supposed to be an accurate list of the mental diseases that people can suffer from. The diagnoses are in there because they are, in some sense, real, objectively-existing disorders, or at least because the American Psychiatric Association thinks that they are.

This seemingly-innocuous paragraph seems to be an admission that, in fact, disorders are added or subtracted for reasons which have little to do with whether they really, objectively exist or not. This is what's apparently happened in the case of Temper Dysregulation Disorder with Dysphoria (TDDD), a new childhood disorder.

TDDD has been proposed in order to reduce the number of children being diagnosed with pediatric bipolar disorder. The LA Times quote a psychiatrist on the DSM-V team:

The diagnosis of bipolar [in children] "is being given, we believe, too frequently," said Dr. David Shaffer, a member of the work group on disorders in childhood and adolescence. In reality, when such children are tracked into adulthood, very few of them turn out to be bipolar, he said.

And the DSM-V website has a lengthy rationale for TDDD, to the same effect.

Now, many people agree that pediatric bipolar is being over-diagnosed. As I've written before, pediatric bipolar was considered to be a vanishingly rare disease until about 10 years ago, it still is pretty much everywhere outside the USA.

So we can all sympathize with the sentiment behind TDDD - but this is fighting fire with fire. Is the only way to stop kids getting one diagnosis, to give them another one? Should we really be creating diagnoses for more or less "strategic" purposes? When the time comes for DSM-VI, and the fashion for "pediatric bipolar" has receded, will TDDD get deleted as no longer necessary? What will happen to all the "TDDD" kids then?

Can't we just decide to diagnose people less? Apparently, that would be a rather too radical change...

DSM-V: Change We Can Believe In?

So the draft of DSM-V is out.

If, as everyone says, the Diagnostic and Statistical Manual is the Bible of Psychiatry, I'm not sure why it gets heavily edited once every ten years or so. Perhaps the previous versions are a kind of Old Testament, and only the current one represents the New Revelation from the gods of the mind?

Mind Hacks has an excellent summary of the proposed changes. Bear in mind that the book won't be released until 2013. Some of the headlines:

• Asperger's Syndrome is out - everyone's going to have an "autistic spectrum disorder" now.
  
• Personality Disorders are out - kind of. In their place, there's 5 Personality Disorder Types, each of which you can have to varying degrees, and also 6 Personality Traits, each of which you can have to varying degrees.
• Hypoactive Sexual Desire Disorder - the disease which failed-antidepressant-turned-aphrodisiac flibanserin is supposed to treat - is out, to be replaced by Sexual Interest and Arousal Disorder.
• Binge Eating Disorder, Hypersexuality Disorder, and Gambling Addiction are in. Having Fun is not a disorder yet, but that's on the agenda for DSM-VI.

More important, at least in theory, are the Structural, Cross-Cutting, and General Classification Issues. This is where the grand changes to the whole diagnostic approach happen. But it turns out they're pretty modest. First up, the Axis system, by which most disorders were "Axis I", personality disorders which were "Axis II", and other medical illnesses "Axis III", is to be abolished - everything will be on a single Axis from now on. This will have little, if any, practical effect, but will presumably make it easier on whoever it is that has to draw up the contents page of the book.

Excitingly, "dimensional assessments" have been added... but only in a limited way. Some people have long argued that having categorical diagnoses - "schizophrenia", "bipolar disorder", "major depression" etc. - is a mistake, since it forces psychiatrists to pigeon-hole people, and that we should stop thinking in terms of diagnoses and just focus on symptoms: if someone's depressed, say, then treat them for depression, but don't diagnose them with "major depressive disorder".

DSM-V hasn't gone this far - the categorical diagnoses remain in most cases (the exception is Personality Disorders, see above). However, new dimensional assessments have been proposed, which are intended to complement the diagnoses, and some of them will be "cross-cutting" i.e. not tied to one particular diagnosis. See for example here for a cross-cutting questionnaire designed to assess common anxiety, depression and substance abuse symptoms.

Finally, the concept of "mental disorder" is being redefined. In DSM-V a mental disorder is (drumroll)...

A. A behavioral or psychological syndrome or pattern that occurs in an individual

B. The consequences of which are clinically significant distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning)

C. Must not be merely an expectable response to common stressors and losses...

D. That reflects an underlying psychobiological dysfunction

E. That is not primarily a result of social deviance or conflicts with society

The main change here is that now it's all about "psychobiological dysfunction", whereas in DSM-IV, it was about "behavioral, psychological, or biological dysfunction". Hmm. I am not sure what this means, if anything.

But read on, and we find something rather remarkable...

J. When considering whether to add a mental/psychiatric condition to the nomenclature, or delete a mental/psychiatric condition from the nomenclature, potential benefits (for example, provide better patient care, stimulate new research) should outweigh potential harms (for example, hurt particular individuals, be subject to misuse)

This all sounds very nice and sensible. Diagnoses should be helpful, not harmful, right?

No. Diagnoses should be true. The whole point of the DSM is that it's supposed to be an accurate list of the mental diseases that people can suffer from. The diagnoses are in there because they are, in some sense, real, objectively-existing disorders, or at least because the American Psychiatric Association thinks that they are.

This seemingly-innocuous paragraph seems to be an admission that, in fact, disorders are added or subtracted for reasons which have little to do with whether they really, objectively exist or not. This is what's apparently happened in the case of Temper Dysregulation Disorder with Dysphoria (TDDD), a new childhood disorder.

TDDD has been proposed in order to reduce the number of children being diagnosed with pediatric bipolar disorder. The LA Times quote a psychiatrist on the DSM-V team:

The diagnosis of bipolar [in children] "is being given, we believe, too frequently," said Dr. David Shaffer, a member of the work group on disorders in childhood and adolescence. In reality, when such children are tracked into adulthood, very few of them turn out to be bipolar, he said.

And the DSM-V website has a lengthy rationale for TDDD, to the same effect.

Now, many people agree that pediatric bipolar is being over-diagnosed. As I've written before, pediatric bipolar was considered to be a vanishingly rare disease until about 10 years ago, it still is pretty much everywhere outside the USA.

So we can all sympathize with the sentiment behind TDDD - but this is fighting fire with fire. Is the only way to stop kids getting one diagnosis, to give them another one? Should we really be creating diagnoses for more or less "strategic" purposes? When the time comes for DSM-VI, and the fashion for "pediatric bipolar" has receded, will TDDD get deleted as no longer necessary? What will happen to all the "TDDD" kids then?

Can't we just decide to diagnose people less? Apparently, that would be a rather too radical change...

Dope, Dope, Dopamine

When you smoke pot, you get stoned.
Simple. But it's not really, because stoned can involve many different effects, depending upon the user's mental state, the situation, the variety and strength of the marijuana, and so forth. It can be pleasurable, or unpleasant. It can lead to relaxed contentment, or anxiety and panic. And it can feature hallucinations and alterations of thinking, some of which resemble psychotic symptoms.

In Central nervous system effects of haloperidol on THC in healthy male volunteers, Liem-Moolenaar et al tested whether an antipsychotic drug would modify the psychoactive effects of Δ9-THC, the main active ingredient in marijuana. They took healthy male volunteers, who had moderate experience of smoking marijuana, and gave them inhaled THC. They were pretreated with 3 mg haloperidol, or placebo.

They found that haloperidol reduced the "psychosis-like" aspects of the marijuana intoxication. However, it didn't reverse the effects of THC of cognitive performance, the sedative effects, or the user's feelings of "being high".

This makes sense, if you agree with the theory that the psychosis-like effects of THC are related to dopamine. Like all antipsychotics, haloperidol blocks dopamine D2 receptors, and increased dopamine transmission has long been implicated in psychosis; some studies have found that THC causes increased dopamine release in humans (although others have not.)

Heavy marijuana use probably raises the risk of psychotic illnesses, like schizophrenia, although this is still a bit controversial, but it's accepted that some people do experience psychotic-type symptoms while stoned. So Liem-Moolenaar et al's conclusion that "psychotic-like effects induced by THC are mediated by dopaminergic systems" while the other aspects of being stoned are mediated by other brain systems, is not unreasonable, and this study is a nice example of the 'pharmacological dissection' of drug effects.

Still, like most papers of this kind, this leaves me wanting to know more about the subjective effects experienced by the volunteers. What did it feel like to get stoned on haloperidol? The paper tells us that

THC caused a significant increase of 2.5 points in positive PANSS, which was significantly reduced by 1.1 points after pre-treatment with haloperidol... Haloperidol completely reversed THC-induced increases in ‘delusions’ and ‘conceptual disorganization’ and almost halved the increase in ‘hallucinatory behaviour’. Although not statistically significant, haloperidol seemed to increase the items ‘conceptual disorganization’, ‘suspiciousness/persecution’ and ‘hostility’ compared with placebo.

The PANSS being a scale used to rate someone's "psychotic symptoms". On the other hand haloperidol had no significant effect on the users' self-rated Visual Analogue Scales (VAS) scores for things like "altered external perception" and "feeling high".

But surely the haloperidol must have changed what it felt like in some way. It must have changed how people thought, felt, perceived, heard, and so forth. These kinds of rating scales are useful for doing statistics with, but they can no more capture the full depth of human experience than a score out of 5 stars substitutes for a full Roger Ebert movie review.

This matters, because it's not clear whether haloperidol really reduced "psychosis-like experiences", or whether it just sedated people to the extent that they were less likely to talk about them. In other words, its not clear whether the scores on the rating scales changed in "specific" or a "non-specific" way. This is no criticism of Liem-Moolenaar, though, because it's a general problem in psychopharmacology. For example, a sleeping pill could reduce your score on most depression rating scales, even if it had no effect on your mood, because insomnia is a symptom of depression.

There are various ways to try to work around these issues, but ultimately I suspect that there's no substitute for personal experience, with direct observation of other people taking the drugs coming second, and rating scales a distant third. Of course, direct observation is unsystematic, and prone to bias, and few would say it was practical for psychopharmacologists to go around drugging themselves and each other... but life is more than a series of numbers.

Link: On Being Stoned (1971) by Charles Tart is a classic book which used a very detailed questionnaire to investigate what it's like to be stoned, although the methodology was hardly rigorous.

Liem-Moolenaar, M., Te Beek, E., de Kam, M., Franson, K., Kahn, R., Hijman, R., Touw, D., & van Gerven, J. (2010). Central nervous system effects of haloperidol on THC in healthy male volunteers Journal of Psychopharmacology DOI: 10.1177/0269881109358200

Dope, Dope, Dopamine

When you smoke pot, you get stoned.
Simple. But it's not really, because stoned can involve many different effects, depending upon the user's mental state, the situation, the variety and strength of the marijuana, and so forth. It can be pleasurable, or unpleasant. It can lead to relaxed contentment, or anxiety and panic. And it can feature hallucinations and alterations of thinking, some of which resemble psychotic symptoms.

In Central nervous system effects of haloperidol on THC in healthy male volunteers, Liem-Moolenaar et al tested whether an antipsychotic drug would modify the psychoactive effects of Δ9-THC, the main active ingredient in marijuana. They took healthy male volunteers, who had moderate experience of smoking marijuana, and gave them inhaled THC. They were pretreated with 3 mg haloperidol, or placebo.

They found that haloperidol reduced the "psychosis-like" aspects of the marijuana intoxication. However, it didn't reverse the effects of THC of cognitive performance, the sedative effects, or the user's feelings of "being high".

This makes sense, if you agree with the theory that the psychosis-like effects of THC are related to dopamine. Like all antipsychotics, haloperidol blocks dopamine D2 receptors, and increased dopamine transmission has long been implicated in psychosis; some studies have found that THC causes increased dopamine release in humans (although others have not.)

Heavy marijuana use probably raises the risk of psychotic illnesses, like schizophrenia, although this is still a bit controversial, but it's accepted that some people do experience psychotic-type symptoms while stoned. So Liem-Moolenaar et al's conclusion that "psychotic-like effects induced by THC are mediated by dopaminergic systems" while the other aspects of being stoned are mediated by other brain systems, is not unreasonable, and this study is a nice example of the 'pharmacological dissection' of drug effects.

Still, like most papers of this kind, this leaves me wanting to know more about the subjective effects experienced by the volunteers. What did it feel like to get stoned on haloperidol? The paper tells us that

THC caused a significant increase of 2.5 points in positive PANSS, which was significantly reduced by 1.1 points after pre-treatment with haloperidol... Haloperidol completely reversed THC-induced increases in ‘delusions’ and ‘conceptual disorganization’ and almost halved the increase in ‘hallucinatory behaviour’. Although not statistically significant, haloperidol seemed to increase the items ‘conceptual disorganization’, ‘suspiciousness/persecution’ and ‘hostility’ compared with placebo.

The PANSS being a scale used to rate someone's "psychotic symptoms". On the other hand haloperidol had no significant effect on the users' self-rated Visual Analogue Scales (VAS) scores for things like "altered external perception" and "feeling high".

But surely the haloperidol must have changed what it felt like in some way. It must have changed how people thought, felt, perceived, heard, and so forth. These kinds of rating scales are useful for doing statistics with, but they can no more capture the full depth of human experience than a score out of 5 stars substitutes for a full Roger Ebert movie review.

This matters, because it's not clear whether haloperidol really reduced "psychosis-like experiences", or whether it just sedated people to the extent that they were less likely to talk about them. In other words, its not clear whether the scores on the rating scales changed in "specific" or a "non-specific" way. This is no criticism of Liem-Moolenaar, though, because it's a general problem in psychopharmacology. For example, a sleeping pill could reduce your score on most depression rating scales, even if it had no effect on your mood, because insomnia is a symptom of depression.

There are various ways to try to work around these issues, but ultimately I suspect that there's no substitute for personal experience, with direct observation of other people taking the drugs coming second, and rating scales a distant third. Of course, direct observation is unsystematic, and prone to bias, and few would say it was practical for psychopharmacologists to go around drugging themselves and each other... but life is more than a series of numbers.

Link: On Being Stoned (1971) by Charles Tart is a classic book which used a very detailed questionnaire to investigate what it's like to be stoned, although the methodology was hardly rigorous.

Liem-Moolenaar, M., Te Beek, E., de Kam, M., Franson, K., Kahn, R., Hijman, R., Touw, D., & van Gerven, J. (2010). Central nervous system effects of haloperidol on THC in healthy male volunteers Journal of Psychopharmacology DOI: 10.1177/0269881109358200