Thursday, December 27, 2012

Consciousness and Reality

Speculative Flights of Fancy about the Nature of Reality, Part II 

In part I of this post, which explored the relationship between individual consciousness and the collective, I promised to offer some more bizarre and hopefully fascinating speculation about the relationship between consciousness and what it is that people are conscious of – that is, what they perceive to be external reality. I posed the question, is reality something that is wholly constructed by each of us and not really independent of our perception of it, or is there an external reality independent of consciousness?

Again my disclaimer:  In this post, I am going to go on a flight of fancy. Nothing in the post is an assertion that anything I am talking about is true, or that it should be construed as proof of anything. It is all speculation and conjecture. Just fun stuff to think about.

In philosophy, a debate has raged for centuries about the nature of reality and its relationship to personal perception.  To greatly over-simplify, and at risk of making a caricature of the positions, we have on one side those who are sometimes referred to as naïve realists, who believe that reality is, well, real, and totally independent of our perceptions of it. While individuals may have a highly distorted view of it, it exists as immutable facts regardless of the observer's bias.

On the other side are the constructivists, who point out that we cannot really “know” what is real except as we perceive and process the universe through our own central nervous systems, which are incapable of reproducing reality exactly as it might be.  In this view, all of our knowledge is distorted somewhat.  Then we have the radical constructivists, who believe that outside reality is completely a product of our own minds – sort of a delusion, if you will.

Clearly, we all live our lives as naïve realists even if we claim to be radical constructivists. Any attempts to deny this would indeed be laughable. We accept much of what we experience as being factual. We have to in order to survive. Some facts do seem rather immutable. Take dead people for instance. Whatever we may think or perceive, dead people do seem to remain dead, and except in the case of Elvis, there doesn't seem to be much disagreement about that.

But then came quantum physics, and the whole debate was rekindled - this time among physicists.  It started with Heisenberg’s uncertainty principle. He showed that it impossible to observe anything at the atomic level without changing that which we are observing, because whatever energy we used for purposes of observing affects and changes the item observed.

Then we discovered what is referred to as the wave/particle duality, wherein electromagnetic energy behaves like a wave if we use certain methods of observation, while it acts like a particle (and has completely different and contradictory properties) if we use other methods.  And we have also found that particles can appear to us to be in two places at once!  Chalk up one for constructivists.

Nobody has won this debate.  Descartes thought he settled it a long time ago.  He thought, therefore he was, and since he believed in God, he believed God would not fool us about the universe outside of ourselves.  Therefore, it must be real.

However, some physicists have even found evidence that they believe proves that nothing can exist in nature without an observer.  Again, with subatomic particles, this seems to have some validity.  But what about the proverbial tree falling in the forest?  Doesn’t it make sound waves regardless of whether anyone is around to hear them?

And of course, the universe existed for literally billions of years before consciousness evolved to perceive it.  Didn’t it?

OK, now for some of my bizarre speculations. I will start with the question I just raised.  I find a possible solution to this issue by asking the question, how fast does an hour go by?  I submit that the answer to this question is entirely a matter of consciousness. Surely, as we grow older, hours seem to race by faster than they did when we were young. We can stand next to a kid, with both of us agreeing that an hour went by, but for the kid it felt like a much longer time than for the older adult right there with him.

But this is just a matter of perception, one might argue.  An hour is an hour.  How fast it seems to go by has absolutely no effect on the physical universe.

Oh yeah?  Well, the theory of relativity predicts, and experiments have proven, that the faster an observers moves, the more time slows down for the observer relative to an observer who is not moving as fast. The closer you get to the speed of light, the more pronounced is this effect. 

If someone took off from earth in a very fast spaceship and stayed away for several years, when he returned to earth, he would be much younger than a friend who was originally the same age but who was left back on the home planet. Interestingly, psychologically the rate of the passage of time would not seem to have been affected for either either of them.

So what does this have to do with the question about whether or not the universe existed before the advent of consciousness?  This: when we are born, could it be that both our consciousness and the universe came to exist almost simultaneously.  The universe, in this scenario, would pop into its existence with its entire history. The billions of years would take place, in the experience of the newly formed consciousness, in what would seem to him to be a fraction of a second relative to him.

If this were true, it would then be possible for “reality” not to exist without someone there to perceive it, at least time-wise. But what about space-wise? Is there not a reality that exists independently of each one of us in space?  Well, I for one believe this to be the case.  But perhaps it does not exist independently of all of us collectively.

This brings us back to the idea of collective consciousness that I talked about in Part I of this post. To understand my crazy speculations about this, I must first raise two questions: 1. Which is a closer representation of reality, a photograph that is in focus or one that is out of focus.  2.  What is the significance of the uncanny but ubiquitous normal distribution (I will define that after I focus on the first question, pun intended).

Which is more accurate: the in-focus face of the pony in the picture below, or the out-of-focus items in the rest of the picture?

Answer: the out of focus part. We know from physics that the electrons which make up the outer shells of every physical object we see can be anywhere – even miles away.  Probabalistically, however, they tend to hang around certain orbits in close proximity to the nuclei of their atoms. But they aren’t there all the time. 

It is our eyes, and therefore our consciousness, which “focuses” them at their most probable location.  If it were not for our consciousness, they might be anywhere at any given moment of time.  At the subatomic  level, without our consciousness, the universe is nothing but an endless sea of subatomic particles that come into and out of existence continually - and nothing more.

This brings us to normal distributions, the proverbial bell shaped curve.  It seems that the vast majority of any measurable quality of items in the universe comes in a variety of sizes and shapes, whose frequency of occurrence follows the pattern in the picture below:

From dice throws to human height and weight to atomic motions in matter to psychological and social events such as how much alcohol people consume, it seems like almost all quantities in nature are distributed in this pattern.  Each flip of a fair coin, even if you’ve already thrown fifty heads in a row, has a fifty percent chance of coming up heads again, but the odds of throwing fifty-one heads in a row at the beginning of your coin-tossing experiment are astronomical.

As physicist Heinz Pagels points out, individual chaos leads to collective determinism.  It seems that the only way you can get distributions of measurements or events to have a skewed distribution, as pictured below, is by introducing a non random event.

In his fascinating book, The Cosmic Code, Pagels gives the example of the number of dog bites in a city with a stable population.  In one city, the yearly number of bites over succeeding years was 68, 70, 64, 66 and 71.  Why so stable?  Why is there not a year with 5 bites and another year with 500?  It is almost as if there is an invisible hand (a god?) which produces the normal distribution with the about the same average number coming up year after year after year.

The only way to change things, as mentioned, is to introduce a non-random event, like the sudden passage of a law requiring city inhabitants to limit their dog ownership to non-aggressive breeds.

So let’s apply this reasoning to the distribution of people’s perceptions of reality.  If the same principle applies, most people will perceive reality at or near a specific average point, with a few outlying people perceiving it to be somewhat different, and a very few people perceiving it as extremely different, in one of two possible ways, but with similar frequency.

So, if I may offer a crazy conclusion, actual reality could be determined by the average perception of a collective of individual consciousnesses. The "average" perception becomes an immutable external reality, regardless of what the outliers think or perceive. Once again, individual chaos leads to collective determinism.

Tuesday, December 18, 2012

Cognitive Behaviorists and Big Pharma Demonize Tranquilizers for PTSD

A medical society called the International Society for Traumatic Stress Studies (ISTSS) publishes a set of guidelines for treating those people suffering from post traumatic stress disorder (PTSD), such as soldiers returning from war zones or victims of natural disasters.

Treatments for PTSD generally involve both psychotherapy and psychiatric medications. No psychiatric medication controls two of the primary symptoms of post traumatic stress disorder:  re-experiencing the trauma as flashbacks, and becoming episodically numb or zoned out.  We do, however,  have a medicine that effectively controls the nightmares, believe it or not – an old blood pressure medication called prazocin. I will talk more about medication a little later in the post, but first let me discuss the psychotherapy of PTSD. 

Many types of psychotherapy have been employed for PTSD, with widely varying results. 

In my clinical experience, many chronic PTSD patients have been given group therapy, in which they meet with other PTSD sufferers who have had similar experiences. I have found that this sort of treatment has been next to worthless for a significant percentage of such patients, particularly those patients who have been severely disabled by their disorder and who have been unable to work for years or even decades.

In patients with chronic PTSD (who do not also have severe personality disorders or majorly dysfunctional families), it is generally believed that the most effective type of psychotherapy is something called prolonged exposure therapy (PE), which is an intense form of what cognitive behavioral therapists (CBT) refer to as systematic  desensitization.  

It is a difficult process in which - and I am grossly simplifying it in order to be brief (and since I do not do this sort of work myself) -  the traumatic experiences suffered by the patient are relived under controlled conditions so that the anxiety and other symptoms generated by the memories can gradually be extinguished.  I have read that doctors have even experimented with recreating the traumatic events using virtual reality through computers, projected images, and earphones, to enhance the desensitization process.

In a PTSD treatment facility I know of, I was told that if a patient were taking a benzodiazepine tranquilizer like Klonopin or Xanax, then they would not be a candidate for PE and would therefore be referred to the aforementioned group therapy.  I was told this was the case because, CBT folks believed, that tranquilizers somehow affect the learning process so that the PE therapy was not effective if the patient were on the meds.  I had heard this idea before from other CBT therapists. 

However, since people who take benzodiazepines are almost never intoxicated, I had always thought this idea a bit strange. So I asked the head of the clinic for a reference. He did not know of one.  Interesting, I thought.  So I did my own literature search. 

Well guess what?  I found exactly one study that showed that benzodiazepines might affect learning in rats.  But in people?  All of the studies showed they had absolutely no effect whatsoever. 

Yet another urban CBT psychotherapy myth.

But then things got even stranger. I was also told that I should check out the treatment guidelines from ISSTS, which said that benzo’s were not indicated for the treatment of PTSD, and that  this clinic followed ISSTS guidelines.  On advice from the clinic leader, I looked up said treatment guidelines, which turned out to be pretty amazing.

Here’s what they said:

 “Although [benzos] are effective anxiolytics [anti-anxiety] and anti-panic agents, they are contraindicated [italics mine] for PTSD treatment.  They don’t reduce re-experiencing or avoiding/numbing behavior.  They should not be prescribed in patients with past or present alcohol/drug abuse or dependence.  Finally, they may produce psychomotor slowing or exacerbate depression. [Benzo’s] do not have any advantage over other classes of medications; therefore they cannot be recommended as monotherapy [again, my italics] in PTSD at this time.”

Being the cynical critic that I am, I should not have been shocked how a supposedly scientific document could be filled with so many half truths. (I’ll enumerate them shortly). But I was. And then I remembered that the pharmaceutical companies had been demonizing benzo’s ever since they all went generic and therefore became far less profitable for the companies (See my earlier post). 

The Cognitive Behavioral Mafia folks also has a vested interest in demonizing benzodiazepines, it seems to me, since the drugs are so effective for some symptoms. This leads to a situation in which  patients would rather just take drugs than go to a CBT therapist to go through systematic desensitization, which can be a long, involved process that is sometimes itself quite traumatic in the short run. 

This preference is unfortunately common even though it is probably better to treat chronic anxiety with psychotherapy than with medication alone, because when the therapy is successful, the patient might be  more or less cured. Not so with the medication.  If you stop them, the symptoms often return.  (And no, not because the medications cause the symptoms, but because they stop but do not cure the symptoms).

Of course, it is also a perfectly good idea to treat anxiety issues with medicine for the quick relief and therapy for the eventual cure. You might then be able to stop the drugs after therapy is completed.  Remember, there is no evidence that medications interfere with systematic desensitization. Still, the CBT folks (and many psychiatrists as well) seem to think of drugs versus therapy as some sort of competition or zero sum game, so their prejudices just happen to coincide with the interests of drug companies: demonizing benzodiazepines. 

It is well documented by several news organizations that drug companies have insinuated themselves into scientific committees that draw up treatment  guidelines to make sure that their interest in making higher profits from their brand-named medication is advanced.  I do not have any proof, of course, but might this have been what happened with the ISSTS treatment guidelines for PTSD?

So let us return to the subject of the half truths in the ISSTS guidelines.  Most of the misleading ideas in the paragraph reproduced above have to do with the misconception implied in the guidelines that PTSD generally exists in some sort of psychiatric vacuum in which PTSD patients show no other symptoms of any other psychiatric disorders as well (Comorbid conditions). In fact, comorbidity is the rule rather than the exception.

For patients suffering from PTSD, I find clinically that the most important common co-morbid condition is panic disorder. In this disorder, sufferers experience severe anxiety attacks with physical symptoms that mimic those of a heart attack.  People who have been traumatized are especially vulnerable to developing panic attacks. 

I found it difficult to find information about exactly what percentage of chronic PTSD sufferers also have panic attacks, but in one study it was 35% and in those patients who sought treatment, 49%! (Cougle et. al., Anxiety Disorders 24(2), p. 183, 2010.)  In another study  (Falsetti & Resnick, Journal of Traumatic Stress 10, p. 683, 1997) the percentage was 69%. More than two thirds!

Yet another study (MacFarlane and Papay, Journal of Nervous and Mental Disorders 180 (8) p.498, 1992) showed that comorbid panic disorder is an important predictor of PTSD turning in to a chronic disorder.

People who have panic disorder also often develop agoraphobia - the fear of being out in crowded places.  Agorophobia is particularly likely to develop in combat veterans who have comorbid PTSD and panic disorder because of another symptom of PTSD: hyper-vigilence. It is as if these veterans have to remain constantly on guard for enemy soldiers, rocket propelled grenades, and improvised explosive devices – even though they are now back home in a safe environment. Being hyperalert in a crowd will often bring on panic attacks. 

This is probably one reason why patients with chronic PTSD and panic disorder may do not do well in group therapy. They are deathly afraid of groups.

Supposedly the first line treatment for panic disorder is an SSRI antidepressants like Paxil or Zoloft, but in my clinical experience benzodiazepines tend to be far more effective. The SSRI’s often only decrease the frequency and severity of panic attacks, but do not stop them completely as certain benzo’s often do. In fact, many victims of PTSD are already on SSRI’s when I first see them, and their panic symptoms and agoraphobia are not under any semblance of control whatsoever. 

So I add a benzo. The combination of an SSRI and a benzo is probably the most effective pharmacologic treatment of panic attacks of all, but you will never find a study that shows that.  In fact, you will never find a study using them in combination for the treatment of any disorder. The drug companies won’t fund such studies, because they don’t want doctors to think that benzo’s are good drugs.

Interestingly, the clinic I have been discussing allows patients who are on SSRI’s to get PE, whereas not so for those on benzo’s or the combination.

Back to the ISSTS guidelines.  They correctly point out that benzo’s do not help the PTSD symptoms of flashbacks and numbing - but no one has said that they do.  I agree that they should not be used as monotherapy for PTSD, as the guidelines say, for that very reason. But why would they be contraindicated (which means they should never ever be used under any condition)? The guidelines themselves start out by admitting that they are very effective for panic disorder, which as I have shown is highly comorbid with PTSD.

Well, maybe it’s because, “They should not be prescribed in patients with past or present alcohol/drug abuse or dependence. Finally, they may produce psychomotor slowing or exacerbate depression.” 

Well first of all, the first statement is not at all true for all patients, particularly those patients who have been sober for a significant period of time. Two different studies have shown that ex-alcoholics do not abuse benzo’s at a higher rate than anyone else. Also, some alcoholics are drinking only because they are, in fact, medicating themselves with alcohol for their panic attacks. They often STOP drinking when put on a benzo.

And even if a chronic PTSD sufferer becomes dependent on benzo’s, so what?  Is that somehow worse that being nearly housebound and completely disabled from work because of panic disorder with agoraphobia?  I think not. And the drugs have almost no side effects. The worst thing about being addicted to a benzo is that you are addicted to a benzo.

Ironically, a lot of the PTSD patients I see are never taken off SSRI’s. Essentially, they are dependent on them. But somehow that’s different. How?  Beats me.

What about benzo’s causing depression?  They sometimes do.  Rarely. The studies that led to FDA approval of the various benzo’s show that this happens in the range of 2-6% of cases. Not much different than placebo!  Sometimes one benzo will have this side effect on a given patient, while another will not. And if they all do in a given patient, they can be discontinued. Or an SSRI can be added for the very effective combination therapy, which prevents this side effect as well as the panic attacks.

The treatment guidelines do not say that SSRI’s are contraindicated because some people might develop side effects, so why should benzo’s be? This is particularly nonsensical in light of the fact that one common side effect of SSRI medication is increased agitation. PTSD is an anxiety disorder!!  (This side effect can also be treated with – you guessed it – a benzo).

Tuesday, December 11, 2012

Is Marketing Drugs for Non-FDA Approved Uses Free Speech?

A recent ruling by a three-judge panel of the Court of Appeals for the Second Circuit in Manhattan threatens to legalize the marketing of snake oil without any restrictions. It maintains that the marketing  of pharmaceuticals by drug companies for conditions for which the FDA has not approved them is free speech!

Considering the ruling of the Supreme Court in the Citizens United case, many of us are highly concerned that if the lower court ruling is appealed and ends up there, that the current court will concur, and this will become the law of the land.

U.S. Supreme Court

As my colleague Ken Harvey says, only in America.

I have posted here several times about the huge fines levied against big Pharma drug companies for marketing psychiatric and other medical drugs for uses in conditions for which the FDA has not approved them as safe and effective. For a summary, see my last post on the subject.

Once a medication is FDA-approved for any indication, doctors are absolutely free to prescribed it for any other condition they see fit, but pharmaceutical companies are not allowed to market the drugs for these other conditions. This is important because pharmaceutical companies can run poorly-constructed studies that show that a drug might help this or that condition, and if there were no law against it, use their various marketing techniques and financial inducements to get doctors to prescribe the drug to larger and larger populations of patients.

Many of these powerful marketing techniques have been described by me in a series of previous posts (the last one being my post of August 7, 2012). The profits to be gained by so-called off-label marketing are enormous, and completely dwarf even the billion dollar plus fines levied by the U.S. Department of Justice. The fines are considered to be just a cost of doing business by Big Pharma.

This situation has also led to an explosion of disease mongering, in which the definitions of disorders like bipolar disorder for which certain drugs are FDA-approved are expanded beyond all reason (see my posts of 10/20/12 and 8/13/11).

The damage to patients, especially in the field of psychiatry, has been particularly horrendous. People with family and behavioral problems who are in desperate need of psychotherapy are instead given only drugs, many with potentially toxic side effects.  Patients unfortunately are all to eager to buy in to the proposition that their emotional problems or those of their children are merely the result of some brain dysfunction rather than their own behavioral difficulties.

(Disclaimer for the anti-medication lot: of course some psychiatric conditions do indeed result from brain dysfunction, and for those medication is the primary and most effective treatment, and psychotherapy is next to worthless. Which ones are those?  Read this blog! Also, medications can control anxiety and emotional reactivity so that psychotherapy becomes even more effective).

Just as an aside, readers may wonder if I think it should be illegal for doctors to prescribe medications for non-FDA approved indications. This is a complicated question, because of the crazy way the FDA in the U.S. works. For example, we know that if one SSRI antidepressant (Prozac, Paxil, Zoloft, Lexapro, Luvox, Viibrid) works for, say obsessive compulsive disorder, then they all do.

However, once one drug company does the studies that result in their getting an approval from the FDA for their product for this indication, the other drug companies have no financial incentives for doing studies with their own product. Doing the studies is expensive, and they know doctors know about the if one-then all idea, so they will use the other me-too drugs off label. I don't see anything wrong with doctors doing so in properly diagnosed patients (which, BTW, is unfortunately a big "if" nowadays).

Also, sometimes there is widespread clinical experience that shows that a given drug is effective for a certain indication for which studies have not led to FDA approval for that indication. For instance, many of us have successfully used SSRI antidepressants in patients with borderline personality disorder to decrease their emotional reactivity (neuroticism). The drugs do not stop the hyper-responsiveness that these patients show to problematic interactions, but they do raise the bar. It takes a higher level of stress to get them into a state of dysregulation than it would in an unmedicated state.  Hardly a cure, but still very useful.

There have been many studies to show that SSRI's do this, some performed by Emil Cocarro, a highly respected researcher. But so far, no drug company has, for a variety of reasons, made a petition to the FDA for this indication.

Dr. Emil F. Cocarro

I would be very much opposed to any action that would limit my ability to help my patients in this way. Unfortunately, many of my colleagues listen to drug company propaganda and use drugs in ways that are very inappropriate. I'm not sure what the solution to this quandary is, but of one thing I am certain: allowing Big Pharma to market drugs for unapproved indications ain't it.

Tuesday, December 4, 2012

Words That Work

It’s not what you say, it’s what people hear

I coach my psychotherapy patients about techniques for empathically confronting close family-of-origin members about traumatizing repetitive, dysfunctional interactions. The goal is to devise a strategy to put a stop to them.  I use role playing as a technique. It is useful in accomplishing two goals: learning more about how the targeted Other is likely to react, and trying out various strategies for my patients to use that are likely to be effective in keeping the task (metacommunicationon track.  

I start with something called role reversal. The patient plays their significant other - the target of the metacommunication - and I try out various approaches to see what they are up against and to see what might work.  

After I find something that seems promising, we then trade places, and the patients play themselves (direct role play).  The patient practices the strategies we devised earlier, while I play the significant other.  I usually play the Other as a sort of worst case scenario, consistent with the prior behavior and sensitivities of that person.  

To get in character to play the targeted other, I can usually predict how they might behave from my patient’s description of them during the process of therapy, as well as from how they have been portrayed in the initial role reversal stage. Usually I am more difficult in the role play than the Other eventually turns out to be (although sometimes the Other does turn out to act as badly as I had), so that the patient finds it easier than they thought it would be to succeed at our goals (or, alternatively, is prepared for the worst). 

Almost invariably during the direct role play, when the patient first tries out the strategy we came up with, they immediately forget what I have shown them and revert to some of their usual ways of trying to solve their family problem – you know, the ones that have not worked because the Other becomes angry, abusive, defensive, or silent in response.  I then stop the role play and try to educate the patient about how what they have just said will torpedo metacommunication because of how it is likely to be heard by the other.

Often, the patient will at some point become somewhat exasperated and ask, “Do I have to be careful of every single word I say???

Well, yes, unfortunately you do.

In a book by Dr. Frank Luntz called Words That Work, the author goes into a great deal of detail as to how words with different connotations can lead to very different reactions from people.  He discusses mostly advertising and political speech.  

He repeatedly makes the point, “It’s not what you say, it’s what people hear.”  The world of advertising and political speech may seem to be a world away from the world of intimate family conversations, but the principles of effective opinion shaping are often the same.

Frank Luntz is a frequently-employed master political consultant. He was the one who turned the estate tax into the death tax and drilling for oil into exploring for energy. No matter how you feel about the author’s political beliefs, the book is a fascinating introduction to the power of using different words and phrases to get people to come over to your point of view.

He learned his trade by using focus groups as a research tool, in a way that most “evidenced-based psychology/psychiatry” advocates would label “unscientific.”  But the proof is in the pudding.

For example, take the issue of medical care for illegal immigrants. Luntz found that potential voters responded quite differently to whether a politician spoke about not giving them care versus denying them care, even though both phrases mean essentially the same thing. While only 38% of Americans would deny emergency care to these immigrants, fully 55% would not give it! 

The reason is that giving care conjures up images in people’s minds of freeloaders sponging off of the rest of us, while denying care conjures up images of unfortunate souls being coldly turned away like the character in Oliver Twist who dares to ask for more soup.

Likewise, inheritance tax conjures up images of Paris Hilton squandering away her famous family’s money on frivolous pursuits while death tax…well, you get the picture.

Luntz lists ten basic principles of word usage for maximum effect, some of which apply very much to making talks to recalcitrant relatives about sensitive topics more effective:  

1. Use small words. 
2. Be brief - the shorter what you say is, the better. 
3. Be credible.  If you sound defensive, repeat things you've said a million times already as if the person never heard you before, or ignore important aspects of whatever problem you are bringing up that the Other may feel to be important, you will not be believed.
4. Be consistent.  Stick to your point and do not go off on tangents. 
5. Offer a new way of looking at things. 
6. Sound and texture matter.
7.  Speak aspirationally. Say things in a way that elevates the person listening to you, not in a way that puts them down.  People will forget what you say, but remember how you made them feel.
8. Paint a vivid picture that people can visualize. 
9.  Ask rhetorical questions when possible rather than make statements. This allows the Other to interact with both you and your message. 
10. Provide a context and explain the relevance of your point of view.

Verrrrrry interesting. I recommend reading this fascinating book.