Friday, April 3, 2009

OCD - Why Science Has Rendered Antipsychiatry Irrelevant

Antipsychiatry dogma contends that because science has failed to show any link between underlying brain dysfunction and psychiatric symptoms that mental illness is a myth and psychiatry is a fraud.

Antipsychiatrists have been getting away with this for years. Mental illness, after all, is highly complex, which doesn't lend itself to gift-wrapped causes and effects the way a simpler brain illness - say Huntington's - does.

Wait - I take that back. Last night, at my local NAMI here in San Diego, I heard Neal Swerdlow MD, PhD of UCSD talk about obsessive-compulsive disorder (OCD).

OCD is a failure in the brain to screen out certain thoughts. People with OCD, for instance, may drive themselves (and others) crazy obsessing over whether one's pet poodle has succeeded in picking three sets of door locks and is now being carved up for lab experiments.

The thought is ridiculous, but the consequence is deadly serious. Literally, the victim cannot stop the thought. The thought takes over to the point where the victim may feel compelled to leave work and drive home. Should that happen enough times, the victim becomes both unemployable and a social leper.

Dr Swerdlow opened with a short clip of a Huntington's patient. Individuals with Huntington's experience uncontrollable movement. The brain, literally, fails to screen out certain movement impulses. The area of the brain responsible, the cingulate, is the same area of the brain most implicated in OCD.

With Huntington's, of course, the symptoms are obvious (uncontrollable movements). Of course something mechanical in the brain has to be wrong. Uncontrollable thoughts and inner torment, on the other hand, are invisible. Of course psychiatry is at fault for creating a mythical illness out of thin air in order that Big Pharma can sell more drugs.

Forget about the victim.

The problem with OCD, Dr Swerdlow explained, lies in "gating." I have discussed gating on this blog numerous times in relation to schizophrenia. The victim is overwhelmed - too much sensory input, too much thought, too much emotion. The brain can't filter out the irrelevant stuff, cannot focus, cannot function, cannot cope.

In a normal brain, on a cellular level, the neuron essentially makes a "yes-no"decision in response to a neurotransmitter message from another neuron. Air conditioner noise? "No." Not relevant. Tune it out. Instructions from your doctor? "Yes." Very relevant. Pay attention.

On a systems level, the thinking and reacting areas of the brain - and areas in between - are organized around processing and prioritizing all the "incoming." These circuits are referred to as "cortico-striatal-thalamic-cortical loops" and similar-sounding names. Self-correcting feedback is both top-down and bottom up and exists in interdependent relationships with parallel loops.

Neurons that specialize in gating tend to exist in the mid-brain regions, such as the cingulate. In a famous set of experiments performed two decades or so ago, OCD subjects (ones obsessed with cleanliness) shared a brain scan machine with a "dirty" sweat sock. Their respective brain loops lit up like a Christmas tree (much like the image on the right). When exposed to a "clean" sock, their brains quieted down (much like the image on the left).

We know that with Huntington's the neurons in the cingulate die off. There is no gating function to regulate excess dopamine signaling related to movement, and the brain fails to compensate by recruiting gating neurons from other areas of the brain.

Similarly, with OCD, we know that the cingulate is operating below capacity, with about 15 percent less neurons. In some cases, serotonin antidepressants may enhance cingulate function. Or the brain may be successful in recruiting gating neurons from other areas of the brain. This is why CBT and other talking therapies can work so well for OCD and other mental illnesses - often, we can literally train our brains to lay down new roadwork.

Because of our knowledge of cause and effect and our ability to pinpoint an exact location, brain surgery to treat OCD is not only feasible, it is being performed, albeit very rarely and only as a last resort for severe cases on treatment-refractory individuals. Capsulotomies and cingulotomies essentially compensate for lack of gating by surgically turning off the flow of certain brain circuits.

In February this year, the FDA approved deep brain stimulation (DBS) for OCD. DBS has a history of use in Parkinson's and is showing promise for depression. A lead is inserted near the affected brain area. Electrical pulses travel up wiring from a pacemaker device implanted below the brain. For OCD, the signaling from the lead has the effect of interrupting the thoughts that the cingulate is supposed to be screening out.

Brain surgery for psychiatric illness, of course, raises a whole host of ethical and other issues, and you can expect antipsychiatry to add its unmodulated voice to this conversation. But in the context of this blog piece, think of surgery for OCD as the icing on the cake.

Mental illness is indeed, unequivocally real. We can point to the brain systems. We can link breakdowns in these systems to behavior. We have treatments based on this knowledge.

In the face of such overwhelming evidence, why would antipsychiatry think otherwise? Hmm ... defective thought gating?


Lizabeth said...

Wow--that is one impressive MRI. Somehow it makes everything more real--which for those of us dealing with BP is a good thing.

As for the antis--don't people always deny what they fear the most in/for themselves. The problem is they are so LOUD they may result in delays in funding or new treatments and researches for those of us that need them.

John McManamy said...

Hi, Lizabeth. Bingo! I'm not a big fan of loud ignorant people, be they blabbing heads on Fox News or anti-intellectual, anti-science nihilsts who don't do their homework.

Funding is a HUGE issue. Heart disease, cancer, AIDS, etc get the big bucks funding. We're left with the crumbs. Funding is no accident - it comes from the advocacy efforts of patients and families, and we simply do not have our act together.

Part of the reason is antipsychiatry, which sends a completely contradictory message to those who make decisions. Part of it lies with psychiatry, which does not respect us enough to form alliances with us. But we also have ourselves to blame.

I have great faith in the younger generation. They have been out of the closet from an early age and will be far less timid in making demands than our generation. Here's to looking at the glass half full ...

Anonymous said...

I'm not sure where you got the information that antipsychiatry resolves around the idea that "mental illness is a myth and psychiatry is a fraud."

I am a psychotherapy student and have personal experience with "mental illness" and antipsychiatry concepts are very close to my heart. I have seen many people including myself got much better using non-intrusive, non-medical techniques (diet, being taken care of by loving people, medical herbs, acupuncture, breathwork, etc.). You yourself I belive are a great proponent of stress-free living are you not? Wouldn't you say that is kind of antipsychiatric too?

Also IMO the brain scans show only a part of the picture. Would you be able to understand how the television works if you took it apart? Probably yes. But would you understand where the program is coming from?

John McManamy said...

Hi, Anonymous. You raise some valid points. Very quickly:

1. "The Myth of Mental Illness," by Thomas Szasz. Their words. The classic antipsychiatry work and a seminal book, very relevant to its time but an anachronism now, but this generation of antipsychiatrists refuses to acknowledge that.

2. The "psychiatry movement" from the great reform era of the early-mid 1800s was based on "stress-free living." Check out the inaugural issue (1844) of the American Journal of Psychiatry if you don't believe me. I'm a strong advocate of back to basics.

3. My own recovery is based largely on many of the smart living practices you mention. That does not mean I am "anti" anything. Today's brain science supports ancient recovery principles, including mindfulness and managing stress. Neuroplasticity means we can be pro-active in our own recovery.

4. I've witnessed many people do well living smart. In fact, I have learned from them.

5. But I have also witnessed many people who need medications to perform the tasks most of us take for granted. (I am one of these individuals, as well.) I honor their choice. I also unambiguously condemn those who would take away that choice or who spread false information that would put this population in danger.

6. Psychiatry has specialized in offering a particular service - namely meds. It is not the complete answer, but for many of us it is an important building block in our treatment/recovery.

7. Likewise the psychotherapy you are a student of presents only a partial answer. It is a great tool, but obviously not the total answer.

8. In my experience, no one thing gets the job done. Anyone who claims otherwise, in my opinion, is a fraud.

9. Yes, brain scans only show part of the picture. That's why today's research is a collaboration across numerous disciplines ranging from anthropology to psychiatry to pscyhology to genetics to cellular biology to neuro-biology - and, oh, yes, brain imaging. That's why we're getting a pretty good picture of both the wiring and mechanics AND the programming.

10. My guess is you are confusing antipsychiatry with pro-recovery. We see a lot of pro-recovery people carelessly referring to the "medical model" vs the "recovery model" as if the two were separate and in opposition. On the surface, that may sound antipsychiatry. Trust me, antipsychiatrists don't give a crap about our recovery.

11. Trust me, you are nothing close to antipsychiatry. You come across as a thoughtful person willing to both challenge, learn, and contribute. Welcome to "Knowledge is Necessity," and by all means keep commenting.

Louise Woo, CABF L.A. area support group coordinator said...

I just want to add one more thing to this thread. I think part of the success of the antipsychiatry movement in this country is created to the structure of our unflinchingly capitalist healthcare system.

We clearly have four levels of health care in the U.S.

1. No insurance, which means no ongoing, regular physician to watch your overall health.

2. Medicare if you're poor enough. This means you get to go to a public clinic where you never see the same doctor twice and only get a minimum of attention and service.

3. Private health insurance through your employer. HMOs, PPOs, etc. with a limited list of providers, most of whom are overloaded with the insurance companies required caseload. You get some continuity of care but be prepared to fight for every specialist you need.

4. Fee for service. The best care available for people who have enough cash. You will have the state of the art, fast service, optimal care. Only a small percentage of the population can afford this.

Now since most people fall into categories 1, 2 or 3, they are unlikely to get a "good" doctor caring for them. By "good" I don't mean competent or intelligent. There are lots and lots and lots of competent, intelligent "bad" doctors.

By "good" I mean a physician who actually has the time and energy to care about YOU as their patient, who WANTS to see you improve and recover, and isn't just interested in getting through their caseload today so they can go home and collapse from the overwork.

By this definition, I'd say the majority of doctors I've met in our HMO list are "bad." Bad means they didn't care, didn't return calls, didn't have time to answer my questions. And I'm not just talking about HMO psychiatrists. I also mean pediatricians, internists, neurologists, dentists and other specialists.

As an HMO user for years, I have fired 3 psychiatrists, 2 pediatricians, one dentist and one neurologist over the last 15 years. In the end, we have gone "out of network" for our psychiatric care. It's worth paying cash for this one specialist to keep my family in good health.

I would bet that our experience isn't unique. But many people are too overwhelmed or exhausted to shop for better doctors, so they stick with their "bad" one and are convinced that the problem is not the doctor but the whole medical specialty!

FALSE. So false. But the antipsychiatry people like to capitalize on this general climate of lousy healthcare. It's easy to rag on psychiatry when there are SO many mediocre, uncaring psychiatrists in practice. Just as there are crappy doctors in every specialty. And don't even get me started on DENTISTS. I had one dentist who tried to convince me that one of my teeth was "dead" and another dying and should be removed and replaced by dental implants.

I left him, went to another dentist (10 years ago) and my new dentist never mentioned those teeth had any problems. Still have 'em.

But do we see an AntiDentistry movement? No. But we do see an antivaccination movement by parents of young children. So we can see it's easy for loud, ignorant paranoid conspiracy theorists to get media attention and taint everything if they want to.

And it's easy for the public to believe it, because how many of you out there will tell me YOUR doctor, dentist, fill-in-the-blank specialist is "excellent?" Not many, I'll bet. It takes work to find a good one who accepts insurance.

Otherwise, it just takes wealth.

John McManamy said...

Hey, Louise. AntiDentristy - love it. This is a classic example of one word being worth a thousand words. It says it all.

Also, remember that Seinfeld episode where he was accused of being "antidendite" for telling a dentist joke?

You hit the nail on the head. Incidentally, I'm paying for my own pdoc out of pocket. I, too, have dealt with bad pdocs. The answer to encountering a bad pdoc is to find a good one, not become an antipsychiatrist.

But I do appreciate that good pdocs are in short supply. Even bad pdocs are in short supply, particularly if you're living in a rural area and/or money is a real problem.

Looking forward to hearing from more of you on the points Louise raised. Certainly, we need to keep this topic going ...

Louise Woo said...

I think many of our "bad" doctors could be "good" doctors if they didn't have such a heavy caseload from the insurance companies. I had a great primary care physician once. About five years ago, she opted out to go "Concierge Medicine."

That means it would've cost me a $2000 annual "membership fee" to be one her patients as covered by insurance. Sorry, I need that money to pay for our out-of-network psychiatrist...

Too many "good" doctors do opt out now. They can't stand practicing bad medicine under the insurance company rules. How terrible is this? We are literally RUNNING the good docs out of insurance company lists because insurance insists that they practice bad medicine!

Then there are the simply "bad" doctors who don't care how big the caseload is because they just don't care.

I forgot to mention the Ob/gyn I had for my first son. That jerk gave me an unnecessary C-section and then lied on my records to justify it.

He later had his license revoked completely for drug and alcohol abuse.

So I hope everyone remembers that it's NOT Psychiatry or Gynecology of Dentistry that is the PROBLEM. It's the American Healthcare system that cares more about profits than wellness.

The solution? God knows. Let's all move to Europe.

John McManamy said...

Hey, Louise. Or New Zealand. My absolutely fantastic son-in-law is a neurosurgeon there. Every system has its strengths and weaknesses, but there is a lot to like about the strengths of Europe, Canada, New Zealand, and Australia.

I have no doubt that the best medicine in the world is practiced in the US, but it is only available to the privileged few. If US healthcare were a restaurant, there would be only two items on the menu - fillet mignon and dog food. No one could afford the fillet, of course, and you are told that you are lucky to have dog food in the best country on earth.

We really believe that crap.

New Zealand and other countries are more like a good local diner or steak house. Good affordable food, lots of choice, but overcrowded (part of the price of making good medicine available to all).

Right-wing propaganda here would have us believe that New Zelanders and others would trade in their health care system any day of the week for ours.

I can assure you that is a load of garbage.

One reason we are witnessing the rise of the recovery movement and alternative medicine is the unavailability in this country of quality western medicine, including quality psychiatry and quality talking therapy.

In essence, we need to make do with what is available to us. Mindfulness and stress reduction - both of which I am a big fan of - are FREE. So is adopting a regular sleep schedule and healthy diet and exercise.

Back to the restaurant example - in essence we are growing our own vegetables and raising our own chickens. But it is stupid to think we can sustain ourselves in this fashion forever. Even the most "anti" of us needs competent medical care.

Let's move Europe here.

Erika said...

This post illustrates a very typical confusion, one at the heart of the misunderstanding between biological and non-biological approaches to dealing with mental illness. When looking at pictures like the ones at the beginning of your post showing a difference in brain activity, it makes sense to conclude that the illness is biologically based and should be treated using physical and chemical means. What follows is not a rejection of this statement but a different way of looking at the same data.

The mind and the brain are one-- all mental states have their basis in the brain. Philosophers may quibble over exactly how this relationship works but it becomes clearer and clearer with the progress of neuroscience that loss of brain function leads to loss of mental function, and that subtle changes in mental function can be observed using fMRI and other neuroscientific instruments.

So the idea that the mind is something disconnected from biology might be argued in some circles, but it really can't be taken seriously from a scientific perspective. But the connection goes both ways. Mental activity and behavior can change the brain. For instance, musical expertise has been shown to cause measurable brain differences. This should be completely unsurprising of course. According to the theory all mental activity and behavior will cause brain differences.

I suspect you will readily agree to this on principle. But when you say "Mental illness is indeed, unequivocally real. We can point to the brain systems. We can link breakdowns in these systems to behavior. We have treatments based on this knowledge." you seem to imply that real means biologically based, and biologically based means amenable to understanding and treatment solely or primarily through physical or chemical means. This seems to miss the fact that all behavior is biologically based. My reaction to Bach's St. Matthew's Passion is biologically based, very literally so and in complex ways (have just read Oliver Sack's Musicophilia which details the connections between brain and music). But it would be absurd to educate people about music through drug treatments (even though it might actually be possible!).

So the question of whether an illness is real, and how to pursue knowledge about it and what treatment options to consider does not actually rest on whether a connection to the brain can be demonstrated. I'm not saying we shouldn't study the brain, or try to discover the neural correlates of mental illnesses, of course we should! But brain research needs to be grounded in a humanistic understanding that does not leave out our collected and everyday wisdom about how to understand ourselves as people or somehow compartmentalize some aspects of behavior and emotion as brain-related and some as just plain human.

Sorry for going on at such length. I hope it's clear that I don't mean to simply disagree, nor to quibble on some small point. What I am trying to address is subtle but quite important, and I haven't found that it is often well addressed in neuroscience or psychiatry.
Really it needs to be addressed more broadly, but I saw a version of the problem here and thought, well maybe that's a place to start. I'm not saying I have a full grasp of it myself, or have the answers to how this understanding could have been applied better in your post or in general, but I do think there's a lot of work to be done in somehow creating a better understanding of mind and brain which might reduce the acrimony and misunderstandings between different camps in the mental health world. So, using this post as my guinea pig. What do you think? Does what I'm saying make sense, seem fair?

John McManamy said...

Hi, Erika. This absolutely makes sense. For context, I suggest reading some of my immediately preceding posts from the schizophrenia conference. The experts don't see a conflict between biology and the environment - it's connected. We literally create our own brains. Also, the brain science validates ancient recovery techniques - think neuroplasticity. A lot of new therapies for those with schizophrenia are based on neuroplasticity - literally training the brain to perform tasks most of us take for granted, and it appears to be working.

Or, look at it this way - our genes are about how we respond to the environment. So if we're born with poor thought gating function, then we're inclined to react to certain stimuli in a certain way. But we can often train the brain to compensate for our bad biology.

I think Oliver Saks has the science-humanity equation down right, and I think a lot of the brain scientists do too. They don't see the brain as just mechanical, and human thought and emotion as reducible to mere mechanics. You can't be a credible brain researcher today without appreciating the vast interplay between all the different dynamics that influence how we think and feel.

The point of this blog piece is the biology is real. But it is connected to a vast set of other dynamics.

Many thanks for your comments. Hope this clears up things ...