Category Archives: Psychology

How Science Tries to Understand Mental Processes

By Dr David Laing Dawson

When science tries to understand human behaviour it can develop methodologies to look at multiple levels of our organization. These levels could range from subatomic particles to the behaviour of tribes, nations, the population of the entire world.

Within the medical sciences we are interested in the behaviour of cells, of neurochemistry, and, at the other end of this chain, the experiences and behaviour of individual humans.

Behaviour can be observed, and observed within different contexts, and under specified situations. Internal experiences require self reporting within a social context, and self reporting is notoriously unreliable. (Imagine asking Donald Trump what he is thinking and feeling, and why he is having these thoughts and feelings, and whether he has written many books.)

Until quite recently the behaviour of brain cells, of neurochemistry, could only be studied by measuring the rise and fall of various metabolites in blood and urine.

And between these extremes (human behaviour and the rise and fall of metabolites in blood and urine) there existed an enormous black box containing the interaction of chemistry, cells, neurons, organs within the brain, systems of arousal and perception, systems of neural organization, complex biochemical and electrical feedback systems….

With EEGs, CT Scans, MRI’s, Pet scans, molecular biology, genome mapping, our new ability to at least see which parts of the brain are active (metabolizing, using glucose and oxygen) and which are dormant when we talk, listen to music and/or hallucinate, that Black Box has shrunk. But it is still there.

Behaviour is a visible product of a long complex chain of events from cell activity, neurohormone production, arousal and filtering systems, inhibiting and stimulating feedback loops.

Ritalin is a stimulant. Yet when given to a boy with ADHD it usually slows him down. So my best guess here is that with ADHD our stimulant is stimulating an inhibitory mechanism.

Like many medications, the power of Chlorpromazine (Largactil) to quell psychosis was discovered by accident. This time in France. Heinz Lehmann brought it to Canada to use in a trial at The Douglas Hospital. It worked dramatically, but why and how it worked is another question. Following the methodologies mentioned above it was first determined that chlorpromazine and drugs developed within the same family affected the neurochemical, neurotransmitter, dopamine. From this arose the dopamine hypothesis of schizophrenia.

But we have since learned that each mental illness is the product of long, complicated pathways from neuron to dendrite to neuron to behaviour (sometimes through long chains and multiple pathways), and that different medications can affect the final behavioural outcome by affecting different parts of that chain, sometimes by stimulating production of a neurohormone, sometimes by emulating a neurohormone, sometimes by inhibiting a neurohormone, sometimes by blocking the transmission of a neurohormone, and sometimes by inhibiting the degradation of a neurohormone (hence the SSRI’s – Selective Serotonin Reuptake Inhibitors)

With the modern technologies we can describe with accuracy what exactly each drug does at a neuronal, biochemical level. But there remains a black box between that level and the actual observed behaviour. Though it is getting smaller and smaller and easily bridged with hypotheses.

But psychosis is not simply too much dopamine, nor depression inadequate serotonin. Although medically altering those two neurochemicals (neurotransmitters) does affect (usually) the chain of electrical/molecular events that leads to psychosis and depression.

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The Failure in Police Reactions to Emergencies – Amended After Toronto

By Dr David Laing Dawson

Within the span of a few days the Hamilton Police demonstrated good judgment and remarkable restraint keeping two unruly mobs apart on Locke Street, saved a little girl’s life with quick compassionate action, and killed a teenager, a boy obviously in the throes of some kind of psychotic episode.

Why do they perform so well, even heroically, in some circumstances, and so poorly, tragically, in others?

I am not asking the question rhetorically, for the question may be worth serious consideration.

The first of these three situations was the most dangerous. It could easily have erupted into violence followed by five years of lawsuits.

The second required quick, focused action despite the horrifying sight of a child being caught under a moving train.

The third required a calm assessment of imminent danger (there was none) and then a calm slow approach.

In the rush to arrive at an unfolding situation each officer will develop heightened arousal. Stress hormones, adrenalin, breathing pattern, heart rate, blood pressure will all be aroused. This is commonly called the fight / flight response, but it is a complex system of brain/body arousal that allows for increased awareness of danger, heightened ability to focus, increased startle response, decreased pain sensation, decreased attention to ‘unimportant’ internal and external stimuli (e.g. time, hunger, thirst, chirping birds, other people), and heightened reflexes.

For the little girl with the severed limb this served her well. The officer reacted quickly and with full focus and efficiency without external distraction.

For the containment of the two mobs there had been enough planning, preparation, structure, and organization that each officer was able to quell or override their fight/flight response and diffuse the potential for violence.

Not so in the third example. The officers arrived in fully aroused state and entered the situation with heightened reflexes and heightened fear. Guns were drawn, triggers pulled.

Each circumstance is different. But in all the unnecessary police shootings of the past few years there has been one consistency: Police arrive in a rush on a call labeled as dangerous in some way. They are in a state of heightened arousal. They do not pause. They do not collect their thoughts or information. They do not pause in safety to slow heart rate, breathing, to scan the environment. They are hyper focused. They push forward. There is no thought of backing up.

In this state a cell phone can be seen as a gun. Awkward movements and slow response to commands can feel dangerous and threatening. The fact that no third party is at imminent risk does not register.

In a recent police shooting in the U.S. you can hear the heightened arousal, the full fight/flight response in the voices and breathing of the officers.

I have to conclude that some things are missing from police training. The first would be a pause upon arrival at the scene to determine if there is indeed a truly imminent threat to a third party. (Not a suicide threat, refusals, waving of arms, bizarre behavior, bad language, verbal threats – but a truly imminent threat to a third party. Is there anyone else on the street car, in the back yard, nearby in the field, nearby in the park, in the arrival lounge?). The second is the option to hold, rest, backup, breathe, take the time to dampen the state of arousal one is in at that moment, and then and only then proceed in a sane, calm, safe fashion.

And all that I suggest was done by the Toronto police officer when he confronted the driver of the van that had just wreaked havoc on Yonge St killing 10 and injuring many others. When the officer arrived, no one was in imminent danger. He even had the presence of mind to return to his cruiser and turn off the siren as it was distracting and preventing the officer and the subject from hearing one another. That also gave  him time to calm his nerves. At times, he backed away and, presumably when he realized that he was not in danger himself, he advanced and the suspect gave up.

We can only hope that this incident will serve as a training tool for others who might find themselves in a similar situation.

Psychiatry, Eugenics and Mad in America Scare Tactics – Part II

By Dr David Laing Dawson

I am not shocked that we passed through a phase in our evolving civilization when we seriously considered Eugenics. Until we understood a little about genes and inherited traits, every serious abnormality must have been considered an accident or an act of God, perhaps a punishment for some immoral thought or deed. Certainly a stigma and something for a family to hide, if it could. And, at the time, the tribe or village would feel no collective responsibility to look after the impaired child, the disabled adult. This infant and child would be a burden on the family alone until she died, usually very young.

But coinciding with a time our tribes, our villages, our city-states, and then our countries developed a social conscience, a new social contract, and accepted the collective burden to care for these disabled members, we began to learn of their genetic origins. It would be entirely logical to then consider the possibility of prevention.

When medicine discovers a good thing, it always takes it too far, and then pulls back. When men and institutions have power we always, or some of us at least, abuse it, until we put in some safeguards. And there is always at least one psychopathic charismatic leader lurking nearby willing to bend both science and pseudo science to his own purposes.

But we have, here in the western world, passed through those phases (and hope to not repeat them). Now every year we find genetics is more complicated, that there are more factors involved. And every year we pinpoint at least one more detectable genetic arrangement (combinations, additions, deletions, modifiers, absences) that cause specific and serious abnormalities.

But here is where we are now medically and socially in the Western World: We can test the parents’ genetic makeup, we can test the amniotic fluid, if indicated we can test the fetal cells, we can offer parents a choice to abort or not; we can tell them of projected difficulties, available treatment or lack thereof, likely outcome, and possible future improvements in treatment and cure. We have also socially evolved sufficiently (and are rich enough) for the state to assume some, or, if necessary, all of the burden of care.

That is where we are, notwithstanding the difficulties of providing this care, and the antiabortion crowd: Some genetic certainties, some intrauterine tests, some blood tests for carriers, some absolute and some statistical predictions, and parental choice.

Now we come to genetics and mental illness. We have no certainties; we have some statistics; we have no intrauterine tests, no blood tests, and we have parental choice.

For science to not continue to pursue a genetic line of inquiry for serious mental illness would be a travesty.

Nature/Nurture. I think I entered psychiatry at the height of this academic debate. On one hand the psychoanalysts dominated US psychiatry, while biological psychiatry (Kraepelian psychiatry) dominated British psychiatry. (R.D. Laing was an outlier). Meanwhile psychology figured if you could train a dog to salivate at a bell you could train any kid to do anything. At the same time many poets, essayists, and not a few Marxist sociologists were telling us that the insane were not insane. It was the world around them that was insane. From Biological Determinism to parental cause to the Tabula Rasa and back to Social Determinism.

Other psychiatrists worked hard to find a way of including all possible factors: the bio/psycho/social model. (Which I would like to see redefined as the bio/socio/psychological model, for it is clear to me that our behaviors are driven first by our biology, secondly by our social nature, by social imperatives, and thirdly by our actual psychology, our cognitive processes. (Just watch Donald Trump)

How much of our nature is determined genetically, or epigenetically in the womb, and how much by our experiences as infants and children and teens and adults? When it comes to human behavior it is clearly all of the above, to different degrees and proportions.

The studies show that the risk of developing schizophrenia is 50% if your identical twin has schizophrenia, whether raised together or apart. This was often touted to show that 50% of the causative factors for schizophrenia must be environmental. But we now know that identical twins are not really genetically identical. And the interplay of genes, genome, brain development and environment is time sensitive. (Despite her fluent English my wife still stumbles on some English sounds. They were just not the sounds her brain was hearing at age 3.)

On the other hand identical twins reared apart are later found to have developed surprisingly similar traits, speech patterns, skills, and interests. And on every visit with my daughter in Australia she complains about the knees I bequeathed her.

As I mentioned before, genetics gets more complicated the more we are able to study it. Some DNA sequences seem to predict a mental illness in adolescence or adulthood but not the exact one.

Of course that finding may reflect not so much on environmental influences as on the vagaries of our definitions, our current diagnostic system.

An old colleague once remarked that our criteria for the diagnosis of schizophrenia are at the stage of the diagnosis of Dropsy in about 1880. I think he exaggerated. They are closer today to a diagnosis of Pneumonia in 1940. (Note that we can now distinguish a pneumonia that is bacterial caused, from viral, or autoimmune, or inhalational, and which bacteria, but our antibiotics help only one form of pneumonia, and each of these forms of pneumonia may have one of numerous underlying problems (biological and social) causing the vulnerability to developing pneumonia.)

For mental illness the development of drugs (1960’s on) that actually work much of the time threw a monkey wrench into this ongoing debate and inquiry. It tipped the balance to biological thinking for many of us. But it is a logical fallacy to assume a treatment that works reveals the original cause. The treatment is disrupting the chain of pathogenesis at some point but not necessarily at the origin of the chain.

We will continue to argue nature/nurture, and science will continue to investigate. And doctors will continue to treat with the best tools they have available.

If Dr. Berezin is correct (which he is not) and serious mental illnesses like schizophrenia, manic depressive illness, autism, and debilitating depression, OCD, and anxiety are all caused by “trauma”, much hope is lost and we will not find good treatments and cures for centuries. For today, despite what Donald Trump and Fox News tell us, in our childhoods in Europe and North America we experience far less trauma, strife, deprivation and loss than every generation before us. Yet mental illness persists in surprisingly persistent numbers.

Dr. Berezin is taking a leaf from the Donald J Trump book. He is trying to frighten you with images of violence, abuse, regression, lawlessness for his own purposes. He is waving Eugenics and Hitler at you in much the same way Donald conjures images of rapists, criminals, illegals, and terrorists streaming across the American border.

But lets get real:

Serious mental illness (schizophrenia, manic depressive illness, debilitating anxiety and OCD, true medical, clinical depression) are little helped with non-pharmacological treatments alone. The reason we do not see today, mute and stuporous men and women lying in hospital beds refusing to eat and wasting away is because we have the pharmacological means (and ECT) to treat depression. The reason we do not have four Queen Victorias and six Christs residing in every hospital is because we now have drugs that control Psychotic Illness. The reason we don’t see thin elated starving naked men standing on hills screaming at the moon until they die of exhaustion is because we now  have drugs that control mania. The reason we don’t have as many eccentrics living in squalor collecting their own finger nail clippings and urine is because we now have very effective pharmacology to treat serious OCD.

All of these people also need social help and someone in their corner, but without the actual pharmacological treatment it will get us nowhere.

(Though, I must admit, today, you may be able to see untreated catatonia, untreated stuporous and agitated depression, untreated mania and untreated schizophrenia in some of our correctional facilities).

But lets look at the less serious mental problems as well for a minute. A patient tells me she is afraid of flying, and always avoided it. But her father is dying in another province and she needs to fly there to see him one last time. She is terrified of getting on that plane. She imagines having a panic attack and disrupting the flight.

A fear of flying. A phobia of flying. Those of us who have such a phobia can usually manage by avoiding travel by plane.

But my patient. She needs to make this trip. Now perhaps I should send her to a trauma therapist who might uncover the fact a school friend was lost over Lockerbie and have her grieve about this, and still be afraid of flying; or perhaps to a cognitive behavioural therapist who might try to convince her that her fears are unfounded, pointing out how air travel is safer than car travel; or perhaps a desensitization approach in which the counselor uses relaxation techniques and has her imagine being at the airport, boarding the plane, and perhaps accompanying her to the airport on the day of travel; or perhaps I should find out if the fear is based on sitting so close to 300 strangers for 5 hours, or riding in a 20 ton contraption at the speed of sound two miles in the air; or spending 5 hours locked in a cigar shaped coffin with 300 strangers…..

Or I might simply prescribe for her five dollars worth of Lorazepam and offer a few encouraging words to get her through the trip.

Then lets look at something in between, like ADHD, one of the diagnoses mentioned by Dr. Berezin.

It is not a difficult equation for me. The child can’t sit still in class, he is too easily distracted, lacks focus, can’t concentrate, always being reprimanded by the teacher, socially ostracized because he intrudes, he pokes, he speaks out of turn, he angers too easily.

To become a successful adult he needs to succeed in at least one thing, if not more than one thing, in his childhood. If, with accommodation at school, and some parental strategies, some adaptational strategies, such as being allowed to wear earphones and take an exercise break every 20 minutes, have one-on-one instruction, good diet, better sleep – if these work, then he may not need medication.

If they don’t work it means he will fail socially and academically and maybe at home as well. He will be in trouble all the time. He will become surly, or give up, or become more aggressive, or depressed. In his teens he will self-medicate.

If the difference between a child failing or succeeding socially and academically is a single pill taken with breakfast it would be, to use that word again, a travesty to not prescribe that pill. And that is true whether the ultimate or necessary causative factor is inherited or acquired, or some complex combination of biological vulnerability, epigenetics, infantile and toddler experience, parenting styles, pedagogic methods, diet, and video game addiction.

 

 

Is There a Professional Turf War in the Mental Health Field?

By Marvin Ross – First published in the Huffington Post on March 9, 2015

One of my pet peeves is the use of the term “mental health problems and issues” to reflect mental illness. Some have told me that if we imply that people are mentally ill then we are stigmatizing them because we are saying that there is something wrong with their brain. Well, there is, and so what? With cancer, we don’t say someone has cell problems and issues but rather they have cancer and we are usually pretty specific because there are so many different forms of cancer each with its own unique outcomes.

And the same goes for mental illness. But, someone recently pointed out to me that the reason we use the vague term “mental health problems and issues” is that what we are seeing is a turf war amongst professionals. And I think that person is right.

When we think of an illness, we think medical doctor. When you are ill, you see an MD who uses diagnostic skills, tests, imaging — a methodology developed over time, to determine what the problem is. Once determined, the MD decides on a course of action (with the patient) which may include referral to another more appropriate health professional (dietitian, counsellor, medical specialist, hospitalization) or medication. The MD is at the apex of the pyramid and the gatekeeper for others.

Now as my cynical friend stated, there is only one relatively finite pot of money for services for the mentally ill and, if we call it an illness, then the medical docs are going to get most of it. Other professionals will get the crumbs. However, if we don’t call it an illness but a problem, then it becomes more appropriate for other professionals like psychologists, social workers and others to be the first line of assessment and treatment.

Last year, one of my blogs upset the Canadian Psychological Association because I pointed out that in 2006, they were concerned that the newly formed Mental Health Commission of Canada would focus on mental illness to the exclusion of mental disorders and behavioural health. That generated a reply from Karen Cohen, the CEO of the CPA.

In November of last year, the British Psychological Society issued a report called Understanding Psychosis and Schizophrenia where they conclude that “psychosis can be understood and treated in the same way as other psychological problems such as anxiety or shyness.” And that “Hearing voices or feeling paranoid are common experiences which can often be a reaction to trauma, abuse or deprivation. Calling them symptoms of mental illness, psychosis or schizophrenia is only one way of thinking about them, with advantages and disadvantages.” And they conclude that “Psychological therapies — talking treatments such as Cognitive Behaviour Therapy (CBT) — are very helpful for many people.”

What they have done is to trivialize schizophrenia and suggest that its treatment be shifted to themselves and that they can uncover the underlying trauma that is the cause over the course of many talk sessions and help.

To be fair, before they had any effective treatments, psychiatrists tried this as well, and it did not work.

First out of the gate to criticize this report were three bloggers on theMental Elf. Keith Laws, a Professor of Cognitive Neuropsychology, analyzed their claim on the efficacy of CBT and found that the research does not support the statement that it is as effective a treatment as medication. Alex Langford, a psychiatry trainee who also studied psychology, challenged their conclusions on medication and pointed out that there is “solid evidence for elevated presynaptic dopamine levels being a key abnormality in psychosis, and there is copious evidence that inhibiting the action of this excess dopamine using antipsychotics leads to clinical improvement in psychosis.” Samei Huda, a Consultant Psychiatrist, points out that the “reduction of psychosis to just hallucinations and delusions is flawed.” He points out that “Cognitive impairment and negative symptoms (depression, lack of enjoyment, lethargy) are important as they often have a bigger effect on social functioning than hallucinations or delusions.”

James Coyne, a psychologist himself and one who is very critical of his colleagues, pointed out that:

Key stakeholders were simply excluded — primary care physicians, social workers, psychiatrists, police and corrections personnel who must make decisions about how to deal with disturbed behavior, and — most importantly — the family members of persons with severe disturbance. There was no check on the psychologists simply slanting the document to conform to their own narrow professional self-interests, which we are asked to accept as ‘expertise’.

He goes on to say that this paper is not evidence based and that “quotes are carefully selected to support the psychologists opinions expressed before the document was prepared — like 15 years ago in their Recent Advances in Understanding Mental Illness and Psychotic Experiences. ”

Dr Ronald Pies, a psychiatrist, writes that what is missing from the report “is any deep understanding of the psychic suffering occasioned by severe and enduring psychotic states, including but not limited to schizophrenia.” The psychologists see psychosis and schizophrenia simply as hearing voices that others do not and/or having fears or beliefs that those around us do not share. Pies points out that this is a shallow and superficial description of the psychotic experience and does scant justice to the nightmarish reality of severe psychotic states.

In fact, he finds that the psychologists responsible for this report do nothing but trivialize the profound suffering that is psychosis and schizophrenia.

It is well to remember that the prime directive for any physician, including psychiatrists, is not to “be clever”; not to “define abnormal,” not even “to diagnose,” but to reduce suffering.

And while the psychologists lobby for a greater piece of the treatment pie or, as Coyne says slanting to there own “narrow professional self-interests,” and debate with other professionals, the suffering of those with the most serious of mental health problems and issues — real illnesses — continues.

Are Psychologists Over Educated Bartenders?

Marvin Ross

By Marvin Ross

A rather provocative title but that is the gist of a new book called Psychology Gone Wrong: The Dark Side of Science and Therapy. The book is written by Tomasz Witkowski and Maciej Zatonski, two Polish scientists who argue that psychotherapy is a business and a kind of prostitution rather than an effective evidence-based medical treatment.

Witkowski is a psychologist, science writer, and founder of the Polish Skeptics Club while Zatonski is a surgeon and researcher who debunks unscientific therapies and claims. Their book was reviewed by Dr Harriet Hall on the blog Science Based Medicine.

I’m pleased to hear them call psychotherapy a business as that is a criticism that I’ve lodged against psychology in a couple of my earlier Huffington Post Blogs. In one, I quoted an internal paper I came across from the Canadian Psychology Association. They were concerned that an emphasis by government on treating serious mental illnesses would mean an exclusion of mental and behavioural health which is their domain.

In my second, I suggested that there is a turf war between psychology and psychiatry with psychology trying to gain more clients. If we don’t call psychiatric illnesses an illness but a mental health problem, then it becomes more appropriate for other professionals like psychologists to be the first line of assessment and treatment. Interestingly, psychologists are lobbying to prescribe medications and can do so in three US States. Likely, some of them seem to realize that their own theories may be deficient.

The authors point out that psychotherapy has been unsuccessful. Most of what psychologists do lacks proper evidence. Psychologists are still fixated on childhood trauma as the precursor to personality and as the cause of mental disorders. The only way to treat these mental disorders is with psychotherapy which depends on the reconstruction of childhood experiences. That is the concept underlying a great deal of their theories of problems like schizophrenia.

This concept, they argue, is dangerous and has led to the abuses of the recovered memory movement. In fact, the repressed memories are often the creation of the therapists themselves. Suggesting that schizophrenia is the result of childhood trauma and possible abuse serves no purpose other than to vilify the parents of offspring who are sick through no fault of anyone.

I made reference to bartenders earlier because the common perception that many have is of the wise and friendly bartender providing a sympathetic ear for the problems of his/her patrons and offering sympathy and support. The authors point out that conventional psychotherapy offers no additional benefits to that of a sympathetic friend. That is something we all need and those who are experiencing a serious illness need even more.

My own very special psychologist is Dr Bonnie Kaplan of the University of Calgary. For years, she has been pushing the use of vitamins for mental illness. She now begins her presentations with a warning to her audience with “Don’t Google My Name” as she did twice in this presentation in Syracuse.

Part of the reason she wants no googling is that two of my colleagues and I have been very critical of her vitamin research over the years. She went so far as to file a formal complaint against physician Dr Terry Polevoy with his regulatory body for unprofessional conduct arguing that he had no right to criticize her research. It was thrown out.

And what purpose does telling people not to google them have? We all know that human nature will only result in the opposite happening. Seems that she fails to understand basic human psychology.