Family Dynamics and the Brain: Implications for Psychotherapy

IMO, the most important contribution of neurobiology to psychotherapy is our understanding, albeit quite partial and preliminary, of the mechanisms by which we are programmed to respond to attachment figures. This understanding is sort of what is meant by sociobiology, if I may use a politically incorrect term. 

I found early on in treating personality disorders in therapy that I was no match for a patient’s parents in triggering or reinforcing their problematic (or even their positive) behavior patterns in the long term. I could coach them on how to be assertive with difficult family members ‘til the cows came home, and this might even work for a time, but after a while the old patterns of self-defeating behavior almost invariably re-emerged unless something was done about this.

Even so-called “oppositional” behavior follows this path: oppositional children think and later automatically respond to their family as if the family wants or needs them to be a black sheep for various reasons.

Therapy outcome studies seldom follow patients with self-destructive or self-defeating behavior patterns for more than a year after therapy ends, but the few studies I’ve seen that do are consistent with this clinical experience. So I had to figure out a way to help patients to make changes in their long term repetitive dysfunctional interactions with attachment figures.

When mothers and their babies interact, huge numbers of synaptic connections in the brain are made every second (see https://developingchild.harvard.edu/science/key-concepts/serve-and-return/). These large numbers are “pruned” significantly during adolescence. We don’t know exactly how or why certain synapses are retained, but I suspect it is those that keep us aligned with the social behavior of our kin group and tribe. There is preliminary evidence that the pruning is dependent, much like the strength of many brain neural connections, on how often a particular neural pathway is stimulated.

Another factor involved is something called the myelination of neurons in existing neural pathways. This is the process of coating the body of each neuron with a fatty coating called myelin, which protects the neuron and helps it conduct signals more efficiently. This process does not become complete until an individual reaches late adolescence.

With these two processes, we lose some flexibility in the brain, but the proficiency of signal transmission improves. Since we are talking in particular about those that form during interactions in infancy, it is reasonable to suspect that these interactions continue to do this. In particular, behaviors that occur in response to social cues may become more automatic in order to preserve higher thinking ability for novel situations.

In addition to this, fear tracks formed early in life in particular are not as plastic as are other tracks in the brain. They never really go away, although they can be overridden by newly formed neural pathways. (Lott, D. A. [2003]. Unlearning fear: calcium channel blockers and the process of extinction. Psychiatric Times, May, 9-12).

According to Neuroscientist David Eagleman on his PBS show, The Brain, about 80% of our behavior is done automatically in response to environmental cues (especially social cues, I might add) without any conscious deliberation. In a sense they are subconscious.

This does not mean that we lack the capacity to decide to think about and break the social rules we are usually bound by. We certainly can – this is where the family systems theorists have been wrong. But when we do, we are often faced with massive invalidation by our families, which is extremely powerful in delivering the message, “You’re wrong, change back.” When we distance ourselves from our social alliances, our level of the attachment hormone oxytocin dips and we start to feel unsafe.

The negative feelings generated by this invalidation is probably the biological price we pay if we don’t: the highly disturbing feeling of groundlessness described so eloquently by Irvin Yalom. This is nature’s way of telling us to behave ourselves for the good of our kin group. This has survival value for the group.

The implications for therapy are clear. In order to prevent problematic automatic behavior patterns that have been and that are continually reinforced through this powerful process, neither insight into which behaviors are performed automatically, nor which automatic belief systems keep us on the straight and narrow for our kin group, is usually enough. These patterns need to be interrupted at their source in order to help patients extinguish bad habits of thinking (or, more often, not thinking) and behavior. 

Book Review: "Behave" by Robert M. Sapolsky

For anyone who wants to understand all of the huge number of factors that influence human behavior, as well as counter overly pat, simple, or downright mythological explanations for it, I cannot recommend a book more highly than this one. Every page – and there are almost 700 of them - is just packed with enlightening information on the role of almost everything you can think of. 

These factors include genes, gene regulation, epigenetics, neurotransmitters, hormones, brain structures, neural networks, unconscious cuing and sensory triggers, stress responses and protective factors, neural plasticity, peers and social acceptance, attachment figures, brain development in childhood and adolescence, socioeconomic and hierarchical status, collectivist vs. individualistic cultures, gender, reactions to “them” vs. “us,” heritibility  vs. inheritance of traits, gene/environmental interactions,  population density, evolution (individual, kin, and group selection), reciprocal and pathological altruism, obedience vs. resistance, cooperation vs. competition, and empathy. And a whole lot more.

Can one book really be that encyclopedic?? Yes! I have no idea how he accomplished writing this. 

If you do not understand some of the scientific concepts that are under discussion, he conveniently includes three appendices in the book to help explain them. Not that the main body of the book is dry and overly technical. It is laced throughout with witty jokes, stories, and ironic observations that kept me thoroughly entertained.

Does he leave anything out? Well, yes, he does not seem to know about the effects of rapid cultural change on families which may create shared intrapsychic conflicts leading to parents giving mixed messages to their children which then trigger and reinforce their repetitive self destructive behavior. But I haven’t yet seen anyone else write about that besides me – at least not in the way I have conceptualized the process - so I wouldn’t expect that. He also doesn’t discuss the effects of chaos theory on the amazingly multi-factorial “causes” of behavior he goes into - a minor quibble.

Sapolsky shoots down behavioral and neuroscientific myths believed by health care professionals, some scientists, and the lay public alike (what mirror neurons actually do, for example) with the abandon of someone armed with an Uzi facing off against people armed with swords. Amazing.

Some of his important points: 

1.       Brains and cultures co-evolve.

2.       We haven’t evolved to be selfish or altruistic, but to behave in particular ways in particular settings. Context is everything.

3.       Genes are not about inevitabilities, but about potentials and vulnerabilities, and they do not determine any behavior on their own.

4.       Evolution has been most consequential when altering regulation of genes, not the genes themselves.

5.       Saying a biological system works well is not a value judgment – it can function equally well for those who do something wonderful or in those who do something horrific.

6.       Nothing seems to cause anything - everything just modulates something else within a specific environmental context. And changing one thing often changes ten other things as a byproduct.

7.       Any causative factor within any specified population of individuals within any specific environmental context has an average effect on behavior that may or may not apply to any given individual. There are always exceptions.

What an accomplishment.

Genetic Programming Makes Nurture the Most Important Factor in our Behavior: Another Paradox

Claudia Gold, on a post on her Child in Mind blog, mentioned in passing that 700 new connections per second are made in the brains of newborns within the context of caregiving relationships. 700 per second! 

One of the basic theories behind my psychotherapy treatment method (unified therapy) for repetitive self destructive or self-defeating behavior patterns is that the behavior of primary attachment figures - in most cases, the parents - are, from a cognitive-behavioral standpoint, simply the most important environmental factor in triggering and reinforcing the problematic patterns. And not only when we our children, but throughout life. Certainly more powerful than a therapist could ever be.

I argue that babies come into the world completely helpless and with absolutely no knowledge about how the universe operates. We remain helpless far longer than the young of most species. Therefore, evolution likely proceeded in a way that resulted in our being biologically programmed to wire our automatic and repetitive  behavioral responses in most environmental contests - in particular social contexts - in accordance with what we learn from our interactions with those attachment figures. 

There is much evidence from neuroscience that the brain wiring that develops in this context and remains in the brain is particularly resistant to change through the normal process of neural plasticity. While it is true that later in childhood and adolescence the number of these connections is greatly reduced through a process called pruning, I suspect the ones that are lost are those that are not continually reinforced by the attachment figures.

In the nature-nurture debate about psychological behavior problems, for most of them I come down on the side of nurture being far more important than nature. Nature just provides us with a range of possible behaviors and reactions, while both nurture (and thinking - don't forget about that) allow us to choose where in that range we would prefer to reside.

But our nature as determined by our genes apparently does have one all-important function. Interestingly, it is the same influence no matter what the rest of our individual genome (assuming we have intact neural functioning) contains: it dictates that we are highly likely to respond to our nurture in accordance with the feedback provided to us by our parents. Paradoxically, it is nature that makes nurture so damned important in determining our behavior.

So learning about those 700 connections per second seemed to me to be good evidence for this point of view. So I looked up the source and found an article published by  Harvard's Center on the Developing Child. It said that those neural connections "...are formed through the interaction of genes and a baby’s environment and experiences, especially “serve and return” interaction with adults, or what developmental researchers call contingent reciprocity. These are the connections that build brain architecture – the foundation upon which all later learning, behavior, and health depend."

Serve and return was further explained as interactions that shape brain architecture: "When an infant or young child babbles, gestures, or cries, and an adult responds appropriately with eye contact, words, or a hug, neural connections are built and strengthened in the child’s brain that support the development of communication and social skills. Much like a lively game of tennis, volleyball, or Ping-Pong, this back-and-forth is both fun and capacity-building. When caregivers are sensitive and responsive to a young child’s signals and needs, they provide an environment rich in serve and return experiences."

If Free Will Does Exist, How Often Do We Employ it in Our Daily Lives?

In my post of 7/31/10 I discussed a somewhat widely-publicized study published in 2008 in Nature Neuroscience, in which researchers using brain scanners could predict people's very simple decisions seven seconds before the test subjects were even aware of what their decision was. 

The concern raised at that time was whether some totalitarian government might start arresting people based on a determination of what they were going to do at some time in the future, like the precrime unit in the movie Minority Report.

This study still comes up in philosophical discussions of a different issue - whether people even really have free will at all, or if we are more like pre-programmed robots.

The decision studied in the experiment — whether to hit a button with one's left or right hand —may not be representative of complicated choices that are more integrally tied to our sense of self-direction. Regardless, the findings raise interesting questions about the nature of self and autonomy: How free is our will? Is conscious choice just an illusion?

"Your decisions are strongly prepared by brain activity. By the time consciousness kicks in, most of the work has already been done," said study co-author John-Dylan Haynes, a neuroscientist who was at the Max Planck Institute. Haynes updated a classic experiment by Benjamin Libet, who showed that a brain region involved in coordinating motor activity fired a fraction of a second before test subjects chose to push a button. Hayne's study showed a much large time gap between a decision and the experience of making it.

In the seven seconds before Haynes' test subjects chose to push a button, activity shifted in their frontopolar cortex, a brain region associated with high-level planning. Soon afterwards, activity moved to the parietal cortex, a region of sensory integration. Haynes' team monitored these shifting neural patterns using a functional MRI machine.

Taken together, the patterns consistently predicted whether test subjects eventually pushed a button with their left or right hand -- a choice that, to them, felt like the outcome of conscious deliberation. In fact, their decision seems to have been made before they were aware of having made a choice.

So does this mean the feeling and belief we have that we have free will is just an illusion?

Well possibly, but probably not. For one thing, as mentioned, the experiment may not reflect the mental dynamics of much more complicated and/or emotionally meaningful decisions. Also, the predictions were not 100% accurate. Might free will enter at the last moment, allowing a person to override a subconscious decision?

But there is a much bigger problem with drawing conclusions about free will from this type of experiment. We usually do not employ free will in the sense of making conscious choices when we engage in the vast majority of our usual daily activities. If individuals had to weigh the pro's and con's of their every move as they negotiated their lives, or if they had to stop and think about how to behave before doing the most routine activities, so much time would be spent on that that they would be nearly paralyzed. 

Most of our "decisions" are based on environmental cues which are processed subconsicously and which then trigger habitual behavior without requiring any thought on our parts at all. 

Through our life experiences, we all build mental models of our environment called schemas which then, when cued by environmental triggers, automatically kick in. Cues elicit a certain well-rehearsed repertoire of responses.

To understand this, think of your daily drive to work. Most drivers, while negotiating a familiar route, have at one time or another come to the realization that they had not been paying the least attention to what they had been doing for several minutes. Nonetheless, they arrived at their destination, with almost no recollection of any of the landmarks that they had passed.

Surely, we have the option to choose to make a turn that would take us away from our intended destination, but, under most circumstances, why would we waste our time even considering something like that?

A lot of predictable situations like this are handled on "automatic pilot." Gregory Bateson observed that ordinary situations and "constant truths" are assimilated and stored in deep brain structures, while conscious deliberation is reserved for changeable, novel, and unpredictable situations.

This does not mean, however, that rigid behavior cannot be overcome by conscious deliberation. In neurologically intact individuals, the more evolutionarily-advanced part of the human brain, the cerebral cortex, can override even the most reflexive of gross motor behavior.

So perhaps the brain processes described in this study are the ones that determine whether or not an individual goes on automatic pilot, or has to stop and think about potential unanticipated consequences. React in the usual habitual way, or re-assess? When it comes to pushing an inert button in a lab, the consequences for the subject are pretty predictable: there will not be any.

Unless the subject were purposely trying to foul up the experimenter's protocol, which would be a strange thing to want to do in an experiment with no social consequences to the subject, why would they extend brain energy in making a choice? They would not. They would just "go with their gut."

Therefore, from the data in this study alone, it is not possible to know which interpretation is correct: the experimenter's, or the one I just suggested.

Maybe you don't have free will, maybe you do. As I said in the earlier post, I am pretty sure I do.

The Woeful State of Our Knowledge of the Brain, and the Director of the National Institute of Mental Health

The major theme of this blog is how family systems issues have been denigrated in psychiatry and even psychology in favor of a disease model for everything.  

For this reason, you might think that I would be highly critical of the National Institute of Mental Health and its director, Dr. Thomas Insel. He has led the agency to focus almost entirely on neuroscience to the exclusion of research into family dynamics and other types of social psychological phenomena. Without an understanding of those latter factors, I believe it is impossible to really understand even the neuroscience, let alone human behavior in general.

Dr. Thomas Insel

Insel has been particularly supportive of President Obama’s BRAIN initiative (Brain Research Through Advancing Innovative Neurotechnologies), with its emphasis on such things as bio materials, engineering and nanoscience. He has been critical of the field’s diagnostic manual, the DSM 5, because it is limited to just observable signs and symptoms rather than the causes (etiology) of the various mental disorders.

While I certainly am critical of his neglect of handing out research dollars for social psychological and other such issues in mental disorders, I certainly have nothing against studying the brain in more detail.

I was pleasantly surprised by a recent article about Insel in Clinical Psychiatric News (August, 2014) that showed that he was at least realistic about both the current state of our knowledge about the brain as well as the prospects for our ever really understanding it.

I was particularly pleased about the following facts he emphasized to the newspaper:

“We can get cells to turn into neurons, but getting cells to turn into circuits is still a challenge. We don’t even know what a neural circuit is. We don’t know where it begins, where it ends; we don’t know how big it has to be; we don’t know exactly what the dynamics are.”

“…it may turn out that our brains simply aren’t smart enough to figure out how they work…It may be just a cosmic joke that we’re evolved enough to ask these questions, but not evolved enough to answer them. We’ll have to see.”

And then there’s his comments about the whole issue of emergent properties that characterize anything as complicated as the human brain. As an analogy, think of a car. Is it just a collection of bolts, screws, gears and metal shafts? Well, yes and no. 

It is definitely comprised of those things, but if you just look at those things alone (reductionism), you’d be hard pressed to understand a vehicle which can transport humans and other cargo over long distances. Other properties of the car emerge from the interactions of the parts.

So for the brain:

“…there is this whole body of work now that says, ‘Don’t worry about those hundred cells, or even those individual cells, and don’t even worry about looking at the circuitry because the key activity in the brain that is associated with attention, and thought, and consciousness is very slow oscillatory activity…

…these oscillations that go in and out of the cortex create the dynamic of the cortex – some people call these cortical avalanches – seem to be pretty important for the way the mind works.

It would be like saying we want to know what’s on a television screen, and that you actually do better if you step back and get the whole picture, but don’t worry about any given pixel, because the emergent property of that television show is actually the whole thing together.’”

You can say that again!

Neural Plasticity and Error Management Theory

One of the ongoing themes of this blog is the nonsensical practice of some researchers in psychiatry of routinely labeling differences seen on brain scans between various diagnostic groups and control subjects as abnormalities. 

Just because there is more blood flow to one area of the brain during the performance of certain tasks or a difference in size between various subsections of the more primitive part of the brain, the limbic system, in a group of people who show similar behaviors and symptoms does not automatically mean that this demonstrates a disease process.

We know now that the neural structure of the brain is extremely plastic, and many of these differences merely reflect the fact that people who have certain habitual behavior patterns routinely show these differences. Disease processes can also certainly account for differences, but just the mere presence of a difference does not tell us which of the two possibilities - abnormality or normal difference – is the accurate explanation for the finding

As I pointed out on my post Neural Plasticity on March 14, 2010, after just three months of a vigorous exercise program in one study, the size of a brain structure called the hippocampus increased an average of 16% in normal people.

So how do we determine whether a difference is or is not an abnormality? Well, one line of evidence that may help tip the balance of evidence and help us to decide is the use of something called Error Management Theory (EM). This is an extensive theory of perception and cognitive biases that was created by David Buss and Martie Haselton (Haselton, M. G., & Buss, D. M.  Error management theory: A new perspective on biases in cross-sex mind reading. Journal of Personality and Social Psychology, 2000; 78:81-91) and expanded upon in another article (Haselton MG, Nettle D. The paranoid optimist: an integrative evolutionary model of cognitive biases. Personality and Social Psychology Review. 2006; 10(1):47-66).

Martie Haselton, Ph.D.

The human species is highly adaptive to its environment, particularly its social environment. The survival of we human beings, and our ability to live long enough to have children and pass along our genes, depends on how well we can read and react to that environment. In particular, we need the ability to read the motives of other members of our species to determine whether or not we may be being deceived or endangered by them.

It making a determination about whether the environment is dangerous or friendly, it is often true that it is far better for long-term survival and procreation to err on one side or the other in making this judgment. A friendly situation might be misinterpreted as a dangerous one while a dangerous situation might be misinterpreted as a friendly one. 

Depending on the environment, a false negative or a false positive interpretation might prove fatal; hence, it is often best to err consistently in one of these directions.

The best illustration of this is the "unidentified animal in the woods" problem. If you are walking in a forrest and mistake a raccoon for a bear and run away, all you have lost is some needless expenditure of energy. If, on the other hand, you mistake a bear for a raccoon and don’t run away, you are dead.  So all other things being equal, if you cannot identify the animal for sure, it is always better to run.

So what does this have to do with neural plasticity? To illustrate, allow me return to the issue of my favorite “diagnostic” group, the patients who exhibit traits of borderline personality disorder (BPD). These folks can be extremely reactive to stress in the social environment. They tend to get more agitated that the average person in response to any perceived slight, and it takes them much longer to calm down. Their behavioral reactions tend to be sort of "shoot first and ask questions later, if at all."

It is also true that some but not all fMRI studies show that, on average, patients with BPD have slightly reduced volumes compared with normal controls in several brain areas including the frontal lobe, bilateral hippocampus, left orbito-frontal cortex, right anterior cingulated cortex, and right parietal cortex.  

Another recent study (Ruocco et. al., Biol Psychiatry, 2013;73:153–160) showed that BPD patients demonstrated greater activation within the insula and posterior cingulate cortex. Conversely, they showed less activation than control subjects in a network of regions that extended from the amygdala to the subgenual anterior cingulate and dorsolateral prefrontal cortex. 

Abnormalities, or just differences?

Well, these brain areas are involved in the body’s threat assessment as well as fight, flight or freeze reactions in response to potentially dangerous environmental situations.  Panic attacks and rage attacks, common in these patients, are also created in some of these brain areas.

Many studies have shown that the childhood family environment of patients who go on to develop BPD is often highly chaotic and unpredictable. Therefore, “normal” inhibition of fear and rage responses might be extremely maladaptive. The size and activity level of the amygdala and other limbic system structures might be gradually shaped through ongoing environmental interaction, so that on average they look different than "normal" control subjects.

Voila. If prospective (studies in which babies are followed for many years) studies showed this hypothesis to be true, this would be potential evidence that these differences are normal differences, not abnormalities. 

The borderline trait of hyper-reactivity often becomes maladaptive in non-family adult social situations because most other people do not react like the family members that produce offspring that show borderline traits.

Unfortunately, for reasons discussed elsewhere in this blog, patients with BPD usually look for people to hang out with that do in fact act like their family members, and, if the others do not act like that, often go out of their way to try to provoke them to react in these ways.

Error management theory may also explain something that psychologists call the fundamental attribution error. When observing the behavior of strangers, we are all more likely to attribute their behavior to the person’s underlying dispositions to a greater extent than is logically warranted. We all err on the side of thinking that their behavior is due to their innate tendencies rather than it being a reasonable reaction to the particular environmental situation in which they find themselves. This social judgment, wrong though it often is, helps us to avoid connecting with poor social partners.

So, is it better to be paranoid or to be optimistic? It all depends on our experiences over a lifetime. Due to natural selection, the truth of any particular judgment is far less important to us than its potential effects on our survival and reproductive success.

ADHD: More Misleading Propaganda

In the never ending effort to con the world in general, and physicians in particular, into thinking that most inattentive and rambunctious children and adults have a neurobiological disease, a Dr. Samuele Cortese and his colleagues presented yet another MRI study that they allege shows that children and adults who have been diagnosed with ADHD have abnormalities in their brains. 

Dr. Cortese is listed as a consultant for Shire Pharmacueticals, a major manufacturer of stimulant drugs for “ADHD.” Or as some might say in ordinary language, Shire is a drug dealing syndicate. One of the most egregious examples of same, at that. Shire’s interests are served by having the largest number of people taking their “legal” amphetamines as possible, while also spreading the word that their competition, “illegal” amphetamines, are dangerous and highly abused drugs.

I use the word “diagnosed” with ADHD in the first paragraph above rather than “have” ADHD because, as I have demonstrated in previous posts, the evaluation of patients who seem to have these problems leaves out an entire and absolutely essential part of their lives – the behavior of their families that provides a context for the child’s “symptoms.” 

No effort, or only a half-baked one, is made in these studies to differentiate acting out from other possible causes for the patient’s hyperactive behavior or difficulties in maintaining focus.

The new study, published in the issue of the American Journal of Psychiatry, proves the following point beyond a shadow of a doubt: people who are not paying good attention to a particular task in which they are engaged exhibit less activity in those brain centers involved in paying attention to tasks than people who are paying strong attention.  Wow. Who’d’a thunk it?

And as we all know, any difference simply must be an abnormality.

In fact, the study says absolutely nothing about whether these research subjects cannot pay attention or simply are not paying attention.

The study in question (Cortese et al, “Toward Systems Neuroscience of ADHD: A Meta-Analysis of 55 fMRI Studies,” Am J Psychiatry 2012; 169:1038-1055) combines statistics from 55 different studies of ADHD, many of which use very different diagnostic “tests” which are merely symptom report lists and pay little attention to the pervasiveness of the symptoms, let alone the psychosocial context in which the symptoms take place.

Here are the results. Hypoactivation is a term meaning that the affected part of the brain is less active, on average, than it might be in a comparison subject. Of course, how active such a brain part might depends strongly on the motivations of the particular subjects. (This is analogous to the results of IQ tests, which are biased against those people who don’t give a damn about how well they do on the test).  Hyperactivation means the opposite.  

Surely, whether more or less activity in a region of the brain is pathological is entirely pre-supposed by the authors without any valid justification. It is basically a value judgment.

“Fifty-five studies were included (39 for children and 16 for adults). In children, hypoactivation in ADHD relative to comparison subjects was observed mostly in systems involved in executive function (frontoparietal network) and at­tention (ventral attentional network). Sig­nificant hyperactivation in ADHD relative to comparison subjects was observed predominantly in the default, ventral at­tention, and somatomotor networks. In adults, ADHD-related hypoactivation was predominant in the frontoparietal system, while ADHD-related hyperactivation was present in the visual, dorsal attention, and default networks. SignificantADHD-related dysfunction largely reflected task features and was detected even in the absence of comorbid mental disorders or a history of stimulant treatment.

Conclusions: A growing literature pro­vides evidence of ADHD-related dysfunc­tion in multiple neuronal systems involved in higher-level cognitive functions but also in sensorimotor processes, including the visual system, and in the default net­work. This meta-analytic evidence extends early models of ADHD pathophysiology that were focused on prefrontal-striatal circuits.”

The studies being "meta-analyzed" are designed on purpose to make it appear that normal differences mean something other than their just being normal differences.

Let us look at the distribution of how strongly people “pay attention” to boring tasks to which they have no particular motivation to do well (other than their desire to be co-operative with an experimenter). Most of the tasks during which brain activity is measured are, let’s face it, at least somewhat uninteresting.

This distribution, like almost everything else in nature, will look like a bell-shaped curve, or what is called normal distribution. We don’t even have to invoke the fact that some people may habitually pay less attention to most activities because they might be compulsively and habitually playing a role ["unambitious"] within their family of origin that allows them to get labeled as having ADHD.

The self report instruments and diagnostic interviews through which a diagnosis of ADHD is made will, in effect, sort the patients so that those labeled with ADHD will fall, on average, at point A on the bell shaped curve in the figure above. Since those individuals will then be taken out of the pool of study subjects, those that remain will have an above average tendency to pay attention to boring tasks – their average will be at point B in the diagram.

Everything else being equal, the “ADHD” subjects and the control control subjects could all be completely normal, and the study result would be identical to a study in which a real disease were being studied! The authors have no way of knowing which of these possibilities their study is demonstrating. They do not clearly acknowledge the above considerations as a weakness of the study, although they do concede, “fMRI data cannot define an absolute or quantitative baseline of activation…” (p. 1053).

That disclaimer is added to give the authors plausible deniability, and will of course be completely ignored by readers if it is noticed at all.

The authors start their discussion of their results with the sentence, “ADHD is increasingly being conceived of as a disorder underpinned by dysfunctions in multiple large scale brain networks.” Yeah, because of pseudo-scientific conclusions made from a multiplicity of studies done the way this one was.

The False Theory That Refuses to Die

"The great tragedy of Science — the slaying of a beautiful hypothesis by an ugly fact."  ~ Thomas Huxley

The presence in the brain of a "chemical imbalance" is one theory about the cause of certain mental illnesses. Specifically, the basic concept is that neurotransmitters -  the different chemicals that are released from the ends of brain cells into the space between two neurons (synapses) and are the means by which two neurons communicate - are out of balance within the brains of patients suffering with clinical depression or schizophrenia. Therefore, medication which helps these conditions must surely correct these "imbalances."

In the case of clinical depression, two neurotransmitters are thought to be the primary culprits. Because antidepressants increase the amount of serotonin and norepinephrine in synapses, these monoamines or catecholamines - different name for the class of chemicals in which they are classified - this was presumed to be the mechanism of action through which the drugs helped depressive symptoms.


Zoloft Ad



Research into other mental illnesses such as schizophrenia also found that too much activity of certain neurotransmitters such as dopamine was correlated with these disorders.  The basic problem with this theory is that it is wrong. There is no evidence that a "chemical imbalance" is behind serious clinical depression. 

A few problems with this idea: 

First, the effect of antidepressants on serotonin and norepinephrine in the brain is immediate, but the therapeutic effects do not begin to appear until after about a week and a half pass by, and the full effect takes 3-6 weeks.

Second, all of the drugs affect the monoamine neurotransmitters, but some people respond to one but not another, while others do not respond to the first but do to the second.

For a third point, I quote neuroscientist John J. Medina, author of the wonderful Molecules of the Mind column in the Psychiatric Times.   From his April column: 

"When we consider the molecular mechanisms of SSRI interactions, it is easy to resort to commonly taught ideas about interactions that involve a single synapse.  Nothing could be further from the truth. 

The most comprehensive neurological view of SSRI actions must take into account the participation of thousands of individual neurons strung together in coordinated, complex neural networks.

And not just serotonergic neurons.  The cells are in contact with many other central nervous denizens, from adjacent glial cells to the extracelular matarix into which the cells are embedded."

And yet, the monoamine theory refuses to die!  "Biological" psychiatrists have become obsessed with monoamine neurotranmitters and the parts of the neurons which snap them up and react to them - the neurotransmitter receptors. I think that horse has been beaten to death.  Studying receptor physiology will, I predict, not lead to any new drugs with a different mechanism of action from the ones we have now.



The propaganda coming from Big Pharma continues to push the importance of the neurotransmitters and their receptors, even when the significance of many findings of receptor differences is completely unknown.  A recent ad that does this is discussed in Dan Carlat's blog.

For one thing, these monoamines make up only about 5% of all neurotransmitters in the brain.  For another, all the other ones, most notably glutamate and GABA, all regulate each other in a cascade of two-directional influences among thousands or even millions of cells. Last, all neurotransmitters are widespread throughout the entire brain.

Now do not get me wrong.  Just because one theory about how antidepressants work is wrong, this does not mean that the drugs do not work.  Clinically, in properly diagnosed patients, they work fabulously.  I have personally witnessed their dramatic positive effects in literally thousands of patients.

There are other reasons why recent studies seem to show that antidepressants do not work in moderate to mild depression (NO honest study says they do not work in severe depression). Not the least of these reasons is that the drugs have mostly gone generic and Big PhARMA has a vested interest in seeing other, less effective drugs being used.  See my 8/31/10 post, SSRI Tales.  The drug company marketing departments are so sophisticated that they use the anti-psychiatry zealots to help them sell more (and more dangerous) brand named drugs!

To those that think antidepressants never work, I have one word for you:  Bullsh*t!

For ages, we did not know how aspirin works.  I am not sure that we really do now.  But it relieves an awful lot of headaches for sure.

The Heritability Fraud

As I also discuss in detail in my upcoming book, another way that some "biological" psychiatrists twist the truth in order to justify their belief that certain behavioral problems are due to brain disorders is to try and make a case that they have their origins in genetics. Never mind that there is barely a legitimate neuroscientist alive that believes that any gene or any group of genes specifically codes for any complex behavior pattern in humans that varies widely from person to person.

Most of the "experts" who mislead the field by exaggerating genetic influences do concede that both genetic and enviromental factors play a part in creating behavioral syndromes. They have to, since the rate at which genetically identical twins both show the syndromes is almost never anywhere close to 100%. (Everyone seems to ignore a very important third factor: people's ability to anticipate upcoming events and their consequences and plan accordingly).

What they have done is to come up with a way to apportion these supposed causative factors into genetic and enviromental factors using a statistic called heritability.

Using studies of identical twins that were raised together versus those who were raised apart, they purport to estimate the "variance," or how much each of the various causative factors contributes to a certain disorder. The variance is expressed as a percentage of the total package. Variances are thusly assigned to genetic factors, "shared" environmental factors such as growing up in the same household, and "unshared" environmental factors.

In actuality, a determination of which parts of an environment are shared by siblings and which are unshared has a lot in common with finding water with a divining rod. Anyone foolish enough to think that both parents treat all of their children in anything remotely close to an identical manner must have no siblings and no more than one child.

The even more misleading tactic is to use the twin study statistic called heritability as a synonym for genetic. It is not. The statistic derived from twin studies is not a measure of genotype but of phenotype. Genotype refers to the actual sequence of molecule pairs in the DNA of which an individual’s genes are made. Phenotype, on the other hand, is the final result of the interaction between genes and the environment.

Most of the genes in a cell, even the ones that are at times active in a given type of cell such as a neuron, are in the “off position” most of the time. What turns them on or off are environmental influences. In regards to behavior issues, the social environment is especially important. One of the main purposes of the brain is in fact to interact with other brains.

Heritability is actually a mix of purely genetic influences and gene-environment interactional influences. There is no way to tell how much of each is present in the statistic. The determination of heritability can also be manipulated in a number of ways, such as by setting the bar for saying that a syndrome is present or absent. How much and how often does one have to drink to be an alcoholic, after all?

All human behavior, normal or abnormal, has a genetic component. That's because genes determine what the brain is capable of or incapable of, what it has a tendency to do and a tendency not to do, etc. They provide a range of options. They do not specify what behavior within that range will occur in a given environmental context. To say that genes play a role in creating a behavioral syndrome is a tautology.

In this post I will not go into more detail about what this all means. However, the absurdity of using heritability as a synonym for genetic is illustrated by a recent study published in the Journal of Adolescent Health (V.45 [6]:579-86, Dec. 2009) by van der Aa et. al. They looked at the heritability of high school truancy. The study pegged the "genetic" influence on this behavior at 45%!! Does anyone seriously believe that ditching school is determined by heredity?