The ethical psychiatrist

ABC Radio National’s The Philosopher’s Zone had a fascinating discussion recently on the ethics of psychiatry, tackling some of the challenges of this unique medical speciality.

Perhaps the most obvious aspect of psychiatry which distinguishes it from other medical specialities is that it more commonly involves treating people against their will.

The laws on involuntary treatment vary, but most include the principle that someone who is judged to have their lost their insight into their own condition because of mental illness, is at risk to themselves or others, and who refuses voluntary treatment can be treated against their will.

Of course, this relies on a huge amount of other assumptions, such as the ability to distinguish between normal and abnormal mental states, and an idea of what constitutes insight.

It also relies on a presumption that psychiatrists can distinguish between potentially foolish but reasoned refusal of treatment, and a refusal driven by pathological thinking.

The programme tackles many of these issues and discusses how these decisions are affected by cultural norms and political influence, as well as how they fit in with the wider ethical approach of medicine.

Link to the Philosopher’s Zone on the ethics of psychiatry.

Cerebral blood sweets

It looks like a pipette full of cerebral blood, but actually it’s a fun and harmless candy product for children. Bless!

But if you’re concerned that this might be a bit too disturbing for your sweet-toothed young ones, another product by the same company will do nothing to dispell your worries.

Because they also makes a plastic brain from which you can squeeze the liquified neural mush straight into your mouth.

After which, the gummy brains and chocolate brains just seem a bit passé really.

Link to disturbing brain candy.

Reflections on the brain of an idiot

I’ve just discovered that the Journal of Anatomy and Physiology have all their past issues freely available online all the way back to 1867. I came across a curious article entitled ‘Description of the Brain of an Idiot’ in the 1871 issue and it made me think about how names for brain disorders have been rejected and changed throughout history.

Back in 1871, the term ‘idiot’ was a proper medical term. It referred to someone we would now describe as having learning disabilities or intellectual impairment.

As the word became used as an everyday form of abuse, it left the realms of medicine because it was deemed inappropriate, and has been replaced by seemingly more appropriate terms. There is a long history of this process and it continues to this day.

For example, wildly abnormal or problematic sexual behaviours used to be called sexual deviancy. ‘Sexual deviancy’ described something beyond the presumed normal range, but it was thought to be inappropriate because it branded people as outsiders.

Now we use the term ‘paraphillia’ which means, well, exactly the same – someone who has desires outside the norm – but because it’s Greek, everyone is much happier.

It’s also interesting when the terminology differs between countries. In America, ‘mentally retarded’ is a common description in medicine, but in Europe it’s considered an outdated insult – similar to the previously official words imbecile and idiot.

However, it’s always struck me as a little curious why our words for intellectual disabilities have changed so much throughout history, but the word for epilepsy (despite there being many commonly used nicknames) has been maintained since the time of Ancient Greece.

Presumably, there’s something about the Greek language which just makes us feel better about our difficulties.

Link to 1871 article ‘Description of the Brain of an Idiot’.

A pain in the neck, mind, brain and society

Technology Review has an article that looks at recent work on the neuroscience of chronic pain. While understanding the problem in terms of neurobiology is essential, understanding the psychology and social influences on pain is equally important.

Chronic pain is an interesting condition because it can continue even when the original tissue damage has healed.

The article talks about chronic pain purely in terms of its neurobiology, but there is now a great deal of evidence that we can explain how pain is maintained through social and psychological explanations.

This is remarkably hard for some people to take on board, as there is still the attitude that explaining something in psychological terms somehow implies the pain isn’t “real” or is somehow a figment of their imagination.

As he recounted in a recent article for the British Medical Journal, Ben Goldacre came across exactly this when he recently discussed the psychosocial aspects of pain on the radio and got a number of outraged listeners contact the programme to say they were offended by the implication that their suffering was imaginary.

This is exactly the opposite of what the standard scientific approach aims to do though. It accepts that pain is experienced, but attempts to work out the biological, psychological and social factors that can increase or decrease pain.

One of the most important findings in the last few decades is that psychological and social factors have a huge influence.

A recent review article, published in Psychological Bulletin [pdf], examined all of the factors and recounted some fascinating studies that have found that people’s beliefs about pain have a huge impact both on how unpleasant they rate the pain to be, and on how disabled they are in everyday life.

This is just a sample from the huge amount of research done on the psychology of pain:

Appraisal and beliefs about pain can have a strong impact on an individual’s affective and behavioral response to pain. If a pain signal is interpreted as harmful (threat appraisal) and is believed to be associated with actual or potential tissue damage, it may be perceived as more intense and unpleasant and may evoke more escape or avoidance behavior. For instance, pain associated with cancer is rated as more unpleasant than labor pain, even when the intensity is rated as equivalent (Price, Harkins, & Baker, 1987). Similarly, Smith, Gracely, and Safer (1998) demonstrated that cancer patients, who attributed pain sensations after physiotherapy directly to cancer, reported more intense pain than patients who attributed this pain to other causes… These studies demonstrate the important role of people’s interpretations regarding the meaning of pain.

Pain appraisal and pain beliefs are also prominent determinants of adjustment to chronic pain (Jensen, Romano, Turner, Good, & Wald, 1999; Turner, Jensen, & Romano, 2000). The following pain beliefs have been identified as particularly maladaptive in dealing with pain: Pain is a signal of damage, activity should be avoided when one has pain, pain leads to disability, pain is uncontrollable, and pain is a permanent condition (Jensen, Turner, Romano, & Lawler, 1994; Turner et al., 2000). The belief that pain is a signal of damage and the belief that activity should be avoided in order to recover from pain appear to be widespread (Balderson, Lin, & Von Korff, 2004; Ihlebaek & Eriksen, 2003).

Because of the importance of our beliefs about pain on the experience of pain itself, we know that psychological therapy can lead to significant improvement.

A key 1999 study [pdf] gathered evidence from all the relevant clinical trials to date and found that cognitive behaviour therapy was a useful and powerful treatment.

Although we typically associate pain with physical damage to the body, thinking only in terms of physical damage is counter-productive. We also need to tackle the psychology and neuroscience of pain both to fully understand it and to help people affected by it.

Link to TechReview article on the neuroscience of chronic pain.
Link to Ben Goldacre on the challenges of communicating psychosocial factors.
pdf of scientific article on psychology and neuroscience of pain.
pdf of scientific article on effectiveness of CBT for pain.

2007-11-16 Spike activity

Quick links from the past week in mind and brain news:

NPR has a radio programme exploring the significance of dreams and nightmares.

The first version of chocolate is discovered to be 500 years older than previously thought

The Washington Post has an article on ways of optimising your brain function.

An artificial speech implant is looked at by Neurophilosophy.

The Neurocritic rounds up the group smack-down to the nonsense election brain scanning ‘study’ we reported on earlier.

Japan suffers an average of 90 suicides a day, spurring the government into action, according to a report by The Times.

The New York Times has an article by an economist doing the maths on the process of dating and dating success.

Men talk more than women overall, but not in all circumstances, according to a new study covered by Science Daily.

A forthcoming science series called Curious has launched their website with video clips of some interesting neuroscience stuff.

BBC Radio 4’s Case Notes has a special on chronic fatigue syndrome.

BBC News report on more evidence that a healthy diet cuts Alzheimer’s risk.

PLoS One has an interesting paper on how gene expression in the human hippocampus differs in cocaine users compared to others.

Dr Petra analyses the Sex Addiction Screening Test and discovers it’s not been validated despite being widely used.

Teaching children philosophy brings persistent, long-term cognitive benefits, according to a study reported by the BPS Research Digest.

Does stress turn your hair grey?

Scientific American has a short article which examines whether there’s any truth to the common theory that stress makes your hair go grey. It’s turns out there’s some circumstantial evidence that stress may have an effect, but no definite causal link has been found.

Apparently, the gradual loss of melanocyte stem cells, ones that are key for hair colouring, lead to the loss of pigment.

Does stress accelerate this demise of the melanocyte population? “It is not so simple,” Fisher says, noting that the process of graying is a multivariable equation. Stress hormones may impact the survival and / or activity of melanocytes, but no clear link has been found between stress and gray hair. Suspicions ‚Äî and hypotheses ‚Äî abound, however.

“Graying could be a result of chronic free radical damage,” says Ralf Paus, professor of dermatology at the University Hospital Schleswig-Holstein in L√ºbeck, Germany. Stress hormones produced either systemically or locally (by cells in the follicle) could produce inflammation that drives the production of free radicals ‚Äî unstable molecules that damage cells ‚Äî and “it is possible that these free radicals could influence melanin production or induce bleaching of melanin,” Paus says.

“There is evidence that local expression of stress hormones mediate the signals instructing melanocytes to deliver melanin to keratinocytes,” notes Jennifer Lin, a dermatologist who conducts molecular biology research at the Dana-Farber / Harvard Cancer Center in Boston. “Conceivably, if that signal is disrupted, melanin will not deliver pigment to your hair.”

And general practice physicians have observed accelerated graying among patients under stress, says Tyler Cymet, head of family medicine at Sinai Hospital in Baltimore, who conducted a small retrospective study on hair graying among patients at Sinai. “We’ve seen that people who are stressed two to three years report that they turn gray sooner,” he says.

Link to SciAm article ‘Fact or Fiction?: Stress Causes Gray Hair’ (via 3Q).

Uh-oh, little girl, psychotic reaction

It’s an age old story. Boy meets girl, boys loses girl, boy suffers psychotic reaction, boy forms band to sing about his experience on live TV.

I feel depressed, I feel so bad
‘Cause you’re the best girl that I ever had
I can’t get your love, I can’t get a fraction
Uh-oh, little girl, psychotic reaction

The group is Count Five singing ‘Psychotic Reaction’ and as well as being a 1960s rock n’ roll classic, it also helpfully informs us that depression is one of the most common signs of impending relapse in psychosis.

In fact, the song preceded Herz and Melville’s pioneering study, the first to report this association in the scientific literature, by at least 15 years.

Did the two psychosis researchers lead an earlier life as garage band pioneers? I think we should be told.

Link to Count Five singing ‘Psychotic Reaction’ (actually very good).
Link to abstract of Herz and Melville study (still rocks).

Seeing red can really affect performance

Cognitive Daily discusses the findings of two interesting studies that suggest that simply seeing the colour red makes us perform worse on tests.

The articles discuss a couple of elegant studies by a research team, led by psychologist Andrew Elliot, which confirmed that seeing red makes us tend to do worse on tests. They then set about trying to understand why.

In a second study, students were given test booklets with the title in one of several possible colours. Interestingly, those who had booklets with red titles tended to choose easier questions, which led to a direct test of a neuropsychological idea about brain symmetry and avoidance:

Students who saw the red test cover chose significantly more easy test questions than either those who saw green or gray test covers. There was no significant difference between the students who saw green and gray.

So it seems that the color red in this context may cause people to avoid challenging or difficult situations. In their final experiment, the researchers took advantage of a robust experimental finding about avoidance. For more than two decades, nearly a hundred studies have found a characteristic brain activity associated with avoidance — asymmetrical activity in the right frontal cortex. This is easily measured using non-invasive EEG equipment.

The research team used exactly this technique and found that relatively greater right hemisphere was found for red material, but not other colours, suggesting red triggers part of the avoidance system.

As Cognitive Daily note, we can’t tell from these experiments whether the red and avoidance link is with us from birth, or whether we’ve just learnt it through cultural exposure.

It’s a really elegant couple of studies though, and as always, they’re wonderfully explained by the CogDaily team.

Link to ‘Does the color red really impair performance on tests?’.
Link to ‘Why does seeing red make test-takers choke?’

Ten of the best in social psychology

PsyBlog has just concluded a great series of articles, each of which tackled a classic experiment in social psychology that demonstrated something counter-intuitive, curious or even shocking about ourselves.

You may recognise some of them, as they’ve become various shades of legendary to notorious, even to people without a special interest in psychology.

Others are well known within the field but have yet to filter out to the general consciousness.

To my mind, one of the best is the theory of cognitive dissonance. Perhaps one of the most important findings in social psychology – explaining how we are motivated to reconcile conflicting beliefs and actions.

The rest of the experiments have been equally as influential and the whole series makes for a great overview of some of the foundation stones of the modern science of mind.

Link to “Why We do Dumb or Irrational Things: 10 Brilliant Social Psychology Studies”.

The absinthe minded green fairy

The New York Times has a brief but wonderfully illustrated article on the cultural history of absinthe, the highly alcoholic spirit that was adopted by numerous famous artists.

Wikipedia also has a fantastic article on absinthe which looks at the history of its creation, popularity, prohibition and revival.

It also exposes the myth that wormwood, a key flavouring ingredient, causes hallucinations. A scientific article looked at the evidence for this and found that the effects of the drink are almost entirely due to its alcohol content.

While thujone, an active ingredient in wormwood, can causes seizures in high enough quantities, there isn’t enough in absinthe to have a significant effect.

However, erroneous concerns about the drink leading to dangerous forms of ‘madness’ led it to be banned in most European countries in the early 1900s, giving it an instant notoriety and cultural impact that far goes beyond its pharmacological influence.

Link to NYT on ‘Absinthe Returns in a Glass Half Full of Mystique…’
Link to Wikipedia article on absinthe.
Link to scientific article ‘Absinthism: a fictitious 19th century syndrome…’

Election brain scan nonsense

Neuropsychologist Martha Farah has written a highly critical commentary on a recent New York Times op-ed piece where neuroscientist Marco Iacoboni and colleagues used brain scans of people who viewed videos of US presidential candidates in an attempt to reveal voter reactions “on which this election may well turn”.

Farah quite rightly calls it “junk science” as it is a barely controlled study that relies on stereotypes and generalisation to infer that activation in one particular brain area means the viewers are experiencing a certain reaction.

So why do I doubt the conclusions reported in today’s Op Ed piece? The problems I see have less to do with brain imaging per se than with the human tendency to make up “just so” stories and then believe them. The scattered spots of activation in a brain image can be like tea leaves in the bottom of a cup – ambiguous and accommodating of a large number of possible interpretations.

For example, the story reports that “When we showed subjects the words ‚ÄúDemocrat,‚Äù ‚ÄúRepublican‚Äù and ‚Äúindependent,‚Äù they exhibited high levels of activity in the part of the brain called the amygdala, indicating anxiety”.

In brain-scanning studies, the amygdala is regularly found to be active in people who experience fear. But you can’t make the reverse inference, that amygdala activation equals fear, because it can be equally as active when people experience happiness or joy.

There’s plenty more where that came from, but what is most shocking is not that this junk made The New York Times but that it made it again, and again.

In fact, Iacoaboni’s team were on the front page of the NYT in 2004 with almost exactly the same stunt – attempting to use brain scans to predict responses when viewing political campaign ads.

The ‘study’ details have mysteriously gone from the web but are still archived if you want to see history repeating itself.

And as we reported in 2006, similar nonsense was repeated with the Super Bowl ads, by (guess who) the same team.

None of these studies have ever been published in scientific journals so why does Iacoboni, who does lots of respectable cognitive neuroscience, keep running these essentially meaningless studies?

All of these stunts are essentially PR for FKF Applied Research, a ‘neuromarketing company’ who will carry out bespoke brain scan marketing studies for a price.

Iacoboni is not listed as a staff member but he’s been associated with most of their previous media stunts and four out of five FKF staff are co-authors on the NYT article. We can bet there’s some pretty strong connection there.

Unfortunately, these sorts of stunts play on the excitement surrounding high-tech science and distort the public’s understanding of the significance of brain imaging.

They’re are neither informative nor truly newsworthy but have enough of a sugar coating to make them attractive to a media beguiled by the bright lights of brain scanning.

Link to Farah article on the Neuroethics and Law Blog.

Music in dreams

From a footnote on p282 of Oliver Sacks Musicophilia:

There have been very few systematic studies of music in dreams, though one such [pdf], by Valeria Uga and her colleagues at the University of Florence in 2006, compared the dream logs of thirty-five professional musicians and thirty non-musicians. The researchers concluded that “musicians dreams of music more than twice as much as non-musicians [and] musical dream frequency is related to the age of commencement of musical instruction, but not to the daily load of musical activity. Nearly half of all recalled music was non-standard, suggesting that original music can be created in dreams.” While there have been many anecdotal stories of composers creating original compositions in dreams, this is the first study to lend support to the idea.

The finding has an interesting parallel with findings on the ‘age-of-acquisition effect’ in language research.

It was known for years that things like the ability to name objects or remember words was influenced by the how common the word is, and how ‘concrete’ it is. For example, concrete words like tree, apple and house tend to be more robust than abstract words like hope, love or like.

Largely due to the work Andy Ellis it’s been found that many of these effects are actually a function of at what age the word was first learnt, with earlier words being more robust in terms of being more easily processed or accessed during cognitive processing.

The Uga study hints that a similar process may be at work with music.

Link to PubMed entry for study on music and dreams.
pdf of full-text of music and dreams study.
Link to Google Scholar search for age-of-acquisition effect.

Hypnosis as a surgical tool

The editorial of the Journal of the National Cancer Institute discusses a recent study that found that hypnosis can be successfully used in breast cancer surgery to reduce pain, nausea, painkiller use, tiredness and emotional impact of the surgical procedure.

The study was a randomized controlled trial of patients who were undergoing breast surgery either to treat a cancer or to test a lump to see if it was cancerous.

Patients were randomly assigned to either a brief 15-minute hypnosis condition, or to another where the patient discussed their concerns with an empathic psychologist (to make sure the effects weren’t just due to having someone their to ‘calm their nerves’).

The study found that patients given hypnosis needed less painkilling medication, were less nauseous, less emotionally upset, and experienced less pain intensity than the patients in the ’empathic listening’ condition.

The editorial notes that the results suggest hypnosis is a powerful tool for helping patients, discusses why it isn’t being used more widely, and what we know about how it affects the brain:

Thus, the study in this issue contributes to an impressive body of research using randomized prospective methodology in sizeable patient populations to demonstrate that adjunctive hypnosis substantially reduces pain and anxiety during surgical procedures while decreasing medication use, procedure time, and cost. If a drug were to do that, everyone would by now be using it.

So why don’t they? For one thing, there is no mediating industry to sell the product‚Äîdangling watches are out of fashion for hypnotic inductions. Plus, there is still lingering suspicion that hypnosis reeks of stage show trickery. After all, the magic wand originated with Mesmer’s use of a magnetic stick to presumably alter magnetic fields in patients’ bodies. Yet hypnosis is the oldest Western form of psychotherapy. Hypnosis is a state of highly focused attention, with a constriction in peripheral awareness and a heightened responsiveness to social cues. It is most similar to the everyday state of becoming so absorbed in a good movie or a novel that one enters the imagined world and suspends awareness of the usual one, a condition playwrights refer to as the “suspension of disbelief.” This state can exert powerful influence on mind and body.

Altering perception using hypnosis results in brain changes that literally reduce pain perception [rather than merely altering the response to pain]. Indeed, simply changing the wording of the hypnotic instruction from “you will feel cool, tingling numbness more than pain” to “the pain will not bother you” alters the brain location of the analgesia from the somatosensory cortex to the anterior cingulate gyrus. Hypnotic alteration of color perception results in bidirectional changes in blood flow in the portions of the visual cortex that process color vision‚Äîblood flow in this region increases when color is imagined rather than seen and decreases when color is hypnotically drained from a colorful stimulus. Thus, there is good neurophysiologic reason to believe that hypnosis is potentially a powerful tool to alter perception of pain and associated anxiety.

If you’re interested in volunteering for research into the neuropsychology of hypnosis in London (which doesn’t involve anything painful!), we’re still recruiting participants for sessions at 2pm on Saturday 17th and 24th November.

There’s more information at our study web page.

Link to Journal of the National Cancer Institute editorial on hypnosis.
Link to abstract of RCT study.
Link to information on our neuropsychology of hypnosis study.

Antidote to TV drug ads

Consumer Reports have created a sort of video film review for a popular US television drug ad, where they update the commercial with scientific findings that aren’t mentioned.

The advert is for a drug that aims to treat ‘restless legs syndrome’, and both the condition and the drug are apparently being heavily marketed in the US at the moment.

Consumer Reports have their own take on the ad, noting that the side-effects of the drug can be worse than the condition itself, and highlighting that although trials showed the drug was effective in up to 73% of people, placebo was effective in up to 57% of people.

It’s great to see a counter-point to this sort of advertising, especially when it’s produced so well.

Link to Consumer Reports page with embedded video (via TWS).

‘Marlborough Marine’ fights post-war trauma, depression

The Los Angeles Times has a moving video and photo essay about Lance Corporal James Blake Miller, made famous by the iconic photo taken during the battle of Fallujah, and his post-war struggles with depression and post-traumatic stress disorder.

It’s somewhat ironic that the photo, which has become a symbol of the stoicism of the US Marine Corps, depicts Miller at a time when he was first struggling with the trauma of war.

The photo essay is by photographer Luis Sinco, who made the marine famous, and his been following Miller since he returned home from Iraq.

Sadly, Miller has suffered divorce, PTSD, depression and suicidal thoughts since his return owing to his experiences during the fighting.

It’s an incredibly powerful piece, with some quite poignant moments (e.g. being ignored by one politician who he had arranged to meet to discuss the effect of PTSD on troops), especially considering that mental illness in the US military is at an all time high.

Link to LA Times photo-essay on James Blake Miller (via MeFi).

Meditation for the nation

ABC Radio National’s All in the Mind just had a programme looking at both the neuroscience of meditation and its increasing use in evidence-based mental health treatments.

Key aspects of meditation are increasingly become adopted into well-researched mainstream cognitive therapies.

Essentially, it’s Buddhist mindfulness meditation, repackaged to make it sound more palatable to a wider audience, and often included alongside more traditional approaches.

The two big players in the psychological treatment field at the moment are Mindfulness-based CBT and Acceptance and Commitment Therapy.

Mindfulness approaches seem particularly useful for people with chronic or relapsing symptoms, such as severe relapsing depression, rather than for first-episode or acute conditions.

For example, a key study published in 2000 found that mindfulness-based CBT had a beneficial effect on people who had three or more relapse of depression, but not people who had experienced two relapses or less.

The idea is quite different from cognitive approaches, where clients are encouraged to identify, evaluate and retrain their problematic thoughts and behaviours.

Mindfulness instead encourages people to be fully aware of these troublesome thoughts or sensations, but not to engage with them.

In other words, clients are encouraged to develop a degree of separation from their thoughts and emotions, so they can experience them, but not feel that they are fully controlled by them.

Some research has suggested that this is because mindfulness (and indeed other approaches) improve our ability to monitor, evaluate and engage with our own thoughts – so-called metacognitive ability.

Link to AITM on ‘Dr Mindfulness: science and the meditation boom’.