The Cat Lady Really Is Crazy

In the March issue of Atlantic magazine there is a must-read story entitled "How Your Cat is Making You Crazy", an interview with neuroscience researcher Jaroslav Flegr. Flegr has been studying the effects of the parasite toxoplasma gondii upon humans. Toxoplasmosis is a parasite endemic to outdoor cats, and the reason why pregnant women are always counseled to avoid the litter box.

I had heard about this line of research before through casual reading, but until now I hadn't realized how strong some of the data actually were or the more subtle and far-reaching effects infection with toxo could have.

Flegr became curious about toxo after incidentally discovering he carried the parasite himself. He wondered if infection with toxo could explain some of his own quirks, specifically his lack of fear and irrational calmness in the face of danger. He knew that in rats toxoplasmosis caused confrontational and overtly dangerous behavior: a rat with toxo will completely lose it's natural fear of cats and will seek out interactions with them.

So he set out to study toxoplasmosis infected people. He discovered that there were subtle but significant differences in the personalities of people who carried the parasite, but the differences were based upon gender. Infected men were cautious and suspicious, socially withdrawn sloppy dressers. Women with toxo were more extroverted, meticulous dressers. Infected humans as a group were also more than two and a half times more likely to get into car accidents---a difference that might be due to both fearlessness and slower reaction times seen in infected people.

Then there was the relationship to psychiatric disorders, the aspect I had already read about. Some neuroimaging studies have shown that people with schizophrenia who show reduced grey matter volume are almost all also positive for toxoplasmosis. This is particularly striking given that toxoplasmosis has two genes which can increase the production of dopamine.

So now when I read articles purporting that psych meds shrink the brain I'll know what question to ask first: "Did they control for the cat?"

Guest Blogger Dr. David Hellerstein on Trauma and Resilience, Ten Years after 9/11

All New Yorkers have vivid memories of the events of 9/11/2011; and for New York-based health care workers our memories are generally mixed with feelings of frustration and helplessness. We recall how we emptied out hospital beds that day, how we were prepared in emergency rooms and clinics, and how we waited hour after hour—in expectation of a flood of patients that never came.  And we recall how in the ensuing days, weeks, and months, survivors finally entered our offices, clinics and hospitals, seared by memories and nightmares and visions they could not erase.

Patients working on Wall Street, living in Battery Park City or in lower Manhattan, those who were evacuated by boats from apartments located close by the base of the towers, people who happened to be shopping or walking in Lower Manhattan that Tuesday morning, firemen who rushed to the site of the rubble, parents who were scheduled for meetings at Windows on the World restaurant, but had to drop their kids off at school first, people who heard the first impact, and—remembering the prior attack on the WTC—immediately  left the buildings and headed North, people whose apartments were destroyed or cars were crushed or jobs were eliminated…or people who waited in the suburbs for a spouse to return on the MetroNorth commuter train, and finally concluded they would never return.  They all came, looking for help.

We remember equally vividly how many months and years it took for recovery to begin. We worked intensely to enhance the process of recovery, whether through medical treatments or psychotherapy.  All of us, patients and doctors alike, were haunted by the memories of those who never emerged from the rubble, and by the randomness of survival.  And yet we patients and doctors had a unique cameraderie as well—a feeling that we were all in this together, united against a common, though perhaps unseen, enemy.  Surely this helped with recovery, along with the expectation that life would eventually return to normal. 

For neuroscience researchers, the events of 9/11 were a sort of natural experiment, similar to the events of war.  Over the past decade, there has been significant progress in understanding the brain’s responses to trauma and what causes PTSD, and as well as understanding what may help people to recover from such cataclysmic events. It has become abundantly clear that the brain’s fear systems, commonly associated with the center called the amygdala, have incredibly tenacious memories for trauma that are extremely difficult to dislodge.

New research has brought illumination and hope to these issues.  NYU researcher Elizabeth Phelps is doing research on the neurological processes involved in the consolidation of traumatic memories, which indicates that there may be a window of time during which the deposition of such memories can be interrupted. Will this eventually provide a way to prevent PTSD, either by new types of psychotherapy or by the development of new medications that can block the deposition of such memories?

On a broader level, the events of 9/11/2001 have underlined the importance of resilience.  Some survivors of 9/11 quickly returned to their usual level of functioning, yet many others, a decade later, are still haunted by those events.  Resilience, or the ability to survive or even thrive under stress, is being studied as a neuroscience-based process. Researchers such as Avram Caspi have determined that there are genes related to resilience. Other researchers have described behavioral characteristics that are related to higher levels of resilience, such as Charles Nemeroff and Dennis Charney in their book The Peace of Mind Prescription.  (Resilience is one of the 6 key New Neuropsychiatry principles described in my book Heal Your Brain and in my blog at Psychologytoday.com).

Just to mention one key element of resilience: appraisal.  Appraisal means the way in which we interpret events.  If an event is interpreted as a threat, it evokes fear responses, including activation of the amgdala, and a series of physical responses including release of cortisol and stress hormones. Yet if an event is interpreted as a challenge, it evokes a different series of responses, including interest, calm, relaxation, and adaptive coping. And as Nemeroff and Charney note, “The hormones released by an appraisal of challenge include growth factors, insulin, and other compounds that promote cell repair, trigger relaxation responses, and stimulate efficient energy use.”

The components of resilience include:

·      Physical resilience, physical ‘toughening’ and ‘tempering’

·      Psychological resilience “situations are viewed as challenges, not threats”:

·      Activating social networks, including confiding relationships

·      Adequate external supports

·      Challenging one’s self

·      Looking for meaning through involvement

·      Learning

Now, a decade after 9/11/2001, it is possible to have almost a strange nostalgia for that moment, since we live in a world with increasingly huge problems but without clear solutions, in which day-to-day stresses seem to be continually increasing, with worsening financial and political instability, and increased polarization between incompatible world-views.  In attempting to cope with all of these ongoing and much less clearly defined stressors, the question is, what can help?

In my view, resilience is key.

*    *    *

Shock Value

Electroconvulsive therapy, or ECT, is considered to be a highly effective treatment for depression. The story goes that roughly 90% of patients respond. The down-side is that it requires general anesthesia with all it's attendant risks, and patients may suffer from headaches, and memory loss. The memory loss is often mild, but there are cases where it is profound and very, very troubling. As with any psychiatric treatment ---or so it seems-- there are those who say it saved them and those who say it destroyed them. Because the risks aren't minor, the procedure is expensive and often done on an inpatient unit, and people generally don't like the idea of having an IV line placed, being put under, then shocked through their brain until they seize, only to wake up groggy and perhaps disoriented with a head ached, it's often considered to be the treatment of last resort, when all else has failed. This makes the 90% response rate even more powerful.

I'm no expert on ECT. I haven't administered it since I was a resident and I don't work on inpatients where I see people before and after. I've rarely recommended it, and then I've been met with a resounding, "NO." My memory of it was that it worked, and that most people didn't complain of problems. One woman read a novel during her inpatient stay. I asked if she had trouble following the plot (ECT in the morning, novel reading in the afternoon) and she said no.

The FDA has been looking at the safety and efficacy of the machines used to perform ECT. It's a fairly complex story where the FDA advisory panel was considering whether to keep ECT machines categorized as "Class III" machines which would now require machine manufacturers to prove their efficacy and safety. A reclassification as Class II (and therefore lower risk) would not require this stringent proof.

On Medscape, Fran Lowry writes:

If the FDA decides to follow the advice of its Neurological Devices Committee, it means that the 2 companies that currently manufacture ECT machines would have 30 months to submit a premarket approval to show that the devices are safe and effective.

ECT has been in use since before the FDA enacted new, more stringent laws for device approval, and psychiatrists fear that the logistics of conducting new trials will pose insurmountable problems for the manufacturers.

They also doubt whether data from any new trial would be sufficient to convince a subsequent advisory panel of the efficacy and safety of the devices, long considered by the APA to be life-saving.

"It hasn't been yanked from the market right now," said Sarah H. Lisanby, MD, head of psychiatry, Duke University, Durham, North Carolina, and chair of the APA Task Force to Revise the Practice of Electroconvulsive Therapy.

"But the continued availability of this life-saving treatment in the long term lies in the hands of the FDA right now. We're pleased it wasn't taken off the market instantly, but if new trials are going to be required, it's not clear who will fund them and whether they will in fact even be done. This is the concern," she told Medscape Medical News.

David Brown has an excellent article in the Washington Post-- see "FDA panel advises more testing of 'shock therapy' devices."

(As an unrelated aside, since Roy claims that "everyone" is my neighbor , I'll mention that David Brown is also my neighbor. )

In surfing, I found a strong anti-ECT sentiment on many blogs. There were also those who said it helped them, but theirs was a quieter rant. I particularly enjoyed Electroboy's rendition of his treatment for mania.

If you have thoughts or stories, by all means....

Thanks to Bob Roca for the heads up on the FDA hearings.

Lots And Lots Of Questions

One of our blog and podcast followers wrote to us with a few questions. I'm not going to mention the person's name without permission, but they're a pre-med student with an interest in psychiatry. I thought I'd take a stab at some of the answers. Dinah and Roy can chime in with their own thoughts on the subjects. Here we go:
Dinah: I'll chime in in green. Roy? Roy? Where are you Roy?

1. Firstly why did each of you choose to go into psychiatry?
Clinkshrink: There were many reasons. I loved neuroanatomy and did well in it. I was a big fan of the "popular science" brain books as a med student--Andreasen's "The Broken Brain" and anything by Michael Gazzaniga. I enjoyed mysteries and "black box" kind of puzzles, and the human mind is the biggest "black box" puzzle in medicine.
Dinah: I was intrinsically interested in why people do what they do and feel how they feel. I'd planned to get a Ph.D. in psychology and do research, and then realized that if I became a psychiatrist, I'd have the option to do both research and clinical work. So why didn't ClinkShrink become a neurologist???
Clink redux: I didn't become a neurologist because gross neurological impairment wasn't interesting but mind-brain issues were. Neurologists don't deal with hallucinations and delusions, usually. There's a big difference between psychiatry and neurology.
Roy:  Please also take a look at this 2007 post, where we also addressed this question in more detail in Who Wants to be a Psychiatrist.  I grew up watching several family members develop hallucinations and behavior changes, questioning how this could happen to someone's mind.  I started out wanting to go into neuroscience research, deciding to go to medical school only to learn more about how the brain and body work together.  I later learned how much I enjoyed helping people with these problems that I decided to go into psychiatry.


2. How do you cope with some of the stupid and strange stuff people say to you? How long does it take to learn to keep a straight face?
Clinkshrink: The "strange stuff" is what psychiatrists enjoy hearing about. Complicated delusional systems can be bizarre and fascinating and I enjoy listening to that. It's not hard to keep a straight face when you know the person actually believes what's happening to them and it's frightening or bothering them. If you put yourself in their mind set and think about what it would be like if your food really WERE being poisoned, or you really did have something implanted in your teeth that controlled your mind, well, that wouldn't be very fun.

Dinah: There were a few times as a medical student when I did want to laugh. I haven't found that anyone says anything I feel is stupid. Sometimes I have have trouble empathizing with peoples' ideas, especially if they are paranoid or are offensive to me. This is unusual, though, and mostly I enjoy listening to stories about people's lives, and nothing about their pain feels stupid or strange. Some of it feels desperately sad.

Roy:  It doesn't feel like coping, it feels like trying to learn how to speak someone else's language, and understanding how they see the world differently from how I see it.


3. Do SSRI's make non-depressed people relatively happy? Do TCAs have any mood altering affect on non-depressed people as well?
Clinkshrink: Antidepressants are mood-correcting rather than mood elevating. There is some research to suggest that SSRI's may make non-depressed introverts more outgoing, and I have direct experience with non-depressed antisocial patients who like SSRI's because it makes them more apathetic and less reactive to minor slights. Dinah and Roy may have other experiences.
Dinah: Many people take SSRI's for anxiety and find them very helpful, even if they aren't depressed. I guess what Clink said. Also, they can induce mania, so theoretically, if someone with no mood disorder takes an SSRI, they could unmask bipolar disorder.

Roy:  While antidepressants can result in a flattening of affect for some (more so for SSRIs than TCAs), at least one study found that nondepressed subjects had a more positive outlook.


3. What is the neurological basis behind the symptomatology in disorders such as depression, bipolar and schizophrenia? Does it explain all the various subcategories assigned to depression and bipolar?
Clinkshrink: This one is easy. We just don't know. In spite of all the research being done in neuroimaging with PET scans and fMRI, we still don't know for sure what goes awry in these disorders, and we can't use these technologies to diagnose or subtype psychiatric diseases.
Dinah: As per Clink: We don't know.
Roy:  I spent three years doing postmortem brain research in schizophrenia.  There are quite a few replicable findings, such as reductions in markers of synaptic connections and fewer numbers of certain kinds of brain cells.  However, we don't know what they mean or how they are associated with symptoms of the disease.  Like Dinah said, we don't know for certain, but there are many good theories.

4. Why and how do some people with depression suffer from psychotic symptoms?
Clinkshrink: See answer #3. There's still a lot we don't know. Some people are genetically predisposed, some people have vascular or traumatic brain injuries that predispose them, some people have overwhelming life events that trigger an event. For me a better question is what makes people so resilient---able to survive horrible childhoods or natural disasters and "bounce back", while others can't handle routine life events without checking in to a hospital.

Dinah: Regarding the question: Great question. We don't know.

Regarding Clink's answer: I agree that their are some amazingly resilient peeps out there. I don't, however, know of people who end up in the hospital because of inability to handle "routine life events." Seems to me that people have episodes of illness....sometimes they identify a precipitant, often they don't, and sometimes I think the search for a triggering event is just a human nature way of trying to explain what may, at this point, be the unexplainable.
Clink redux: Some of my patients with severe ASPD seek admission to hospitals for, by their own report, being "unable to handle life". In other words, having no place to live, no friends or family to help them, and not being able to keep a job. They lack the resilience and ability to maintain the basic necessities of life. Or a girlfriend breaks up with them and they end up in the hospital.



5. What are your views on prevention for psych related problems? How do you think they should fit in a model of public health?
Clinkshrink: This is the next phase of psychiatry---primary prevention. We already have national depression screening day in October, and primary care providers are starting to use simple screening instruments for various psych disorders. All of this is well and good, but it means nothing if everyone can't afford a doctor. Finding the problem is one thing, doing something to solve it is even better.

Dinah: Prevention? We're a long way from knowing how to prevent mental illness. World peace and drug prevention would go a long way towards helping some people to not develop problems.

Roy:  Prevention is the holy grail.  (Insert Monty Python quote here.)


So those are my answers to lots of questions.
And mine, too!

Memorial For A Brain

When I was in medical school I was fascinated by neuroanatomy and neuroscience. I enjoyed reading popular science books like Broca's Brain and The Three Pound Universe. I liked reading about the classic clinical cases studies that taught us a lot about how the brain works---cases like Phineas Gage, the Nineteenth Century railroad foreman whose brain injury revealed the purpose of frontal lobes, or the case of H.M., the man whose temporal lobectomy taught us about the how memory works.

Patient H.M. had parts of both his temporal lobes removed in order to treat a seizure disorder. After the surgery he was unable to form new memories at all, and he became one of the most-studied subjects in the field of neuropsychology. From H.M. we learned that there are two types of memory, declarative and procedural memory. Declarative memory is the what we use when we learned facts. Procedural memory is what we use when we learn how to do things, like brush our teeth or ride a bike. H.M's temporal lobectomy destroyed his declarative memory, but his procedural memory was left intact.

I'm bringing this up now because of an article in Wednesday's New York Times, "Dissection Begins on Famous Brain". Patient H.M., whose name we now know is Henry Molaison, died last year and donated his brain to a neuroscience project at M.I.T. They are in the process of sectioning his brain to learn more about what went wrong with it. There is even a web site, the Brain Observatory, where you can watch the sectioning as it happens.

I read the story and checked out the sectioning web site, but my reactions are mixed. As a psychiatrist it's fascinating to see that we can study a lesion from an individual patient all the way down to the microscopic level, but as a human being it leaves me feeling rather sad for this guy. It was noble of him to donate his brain, and years of his life, to science but on the other hand I can't help wondering if he ever just wished people would leave him alone.

Are You Chemically Unbalanced?

This will be quick; I'm actually headed off to work.

In his "In Practice" blog, Peter Kramer discusses the issue of whether the concept of a chemical imbalance is still a useful one and he looks at the evidence for and against such a theory, concluding that the concept met a premature death.
"Since 1993, other biochemical contributors to depression have claimed their roles, especially “stress hormones” and factors that influence nerve cell growth. The new overarching biological model of depression (I outline it in Against Depression) integrates all three factors—monoamines, stress, and cell growth—but serotonin dysregulation remains very much on the table as a contributor to depression."

Dr. Kramer talks about PET scans and genes and differential rates of monoamine metabolism, and the stupid little bouncing Zoloft mascot with the smiley face.

For the shrink in the field, so far it doesn't mean much. I can't order a test to find out if someone has too much of one enzyme breaking down any given neurotransmitter and thereby telling me what to prescribe. I'm waiting. In the meantime, what I do have is patients who come in wanting to know what they have. "Do I have a chemical imbalance?" Now what does that even mean? Do you have too much serotonin in some places in your brain and not enough in others? How would I know that? Too much (compared to what?) monamine oxidase breaking down your noradrenergic neurotransmitters? Should we inhibit them and this will make you better? Let me get my probe.

What I do know is that while I don't know what is meant by a "Chemical Imbalance," my patients do. For them it is a term that explains things, that writes the story, that has meaning. There's something socially acceptable about it. "I have poor coping skills" is pejorative and equally unprovable. "I have a chemical imbalance" is somehow explanatory, though still unprovable in a day-by-day psychiatric practice.

So, generally, if a patient with Major Depression asks, "Do I have a Chemical Imbalance?" I simply say "yes." It seems to work.

Interactive Brains

Neuroanatomy was my favorite class in medical school. I loved tracing out the brain pathways, figuring out which part did what, connecting up clinical syndromes to what I knew about brain structure and the nervous system. I learned all this back in the dark ages, back in the paleontologic age when whales had legs, before comets struck the earth and caused the last ice age. The World Wide Web didn't exist then either. I had to learn this stuff by examining the actual brains of dead people, by looking at stained microscope slides of brains and by pouring over books (the things with pages, covers and ink) rather than web sites.

So now the modern age is here and students get all kinds of cool high tech stuff to learn with. Just out of curiosity I scoured the web and put together a quick and dirty list of some web sites that provide interactive imaging of the human brain. Dang, I wish I had that when I was a med student.

Michigan State Brain Bank

Harvard's Whole Brain Atlas

University of Florida (takes a while to load, Flash-based, no labels)

University of Washington

Wayne State University

University of Utah (This one was my favorite atlas. It shows actual photographs of gross brain anatomy. You can click on the name of the structure and an arrow points to it. No neuroimaging to interpret, just identification of gross structures.)

University of Michigan

Columbia Brain Atlas

Neuroscience Funding Gets A Boost

Just a couple weeks ago the Justine and Catherine MacArthur Foundation awarded a $10 million dollar grant to twelve universities to study neuroimaging and the law. The purpose of the grant is to get a better understanding of the relationship between functional neuroimaging studies and forensic issues such as competence to make decisions, criminal responsibiity and disabiity. This grant has the potential to really change the nature of psychiatric expert testimony.

The grant has three components: brain abnormalities, substance abuse and decision-making. There will be some overlap between these areas, but the general idea is to start bridging the gap between what is seen on a functional MRI and the ultimate legal questions of criminal culpability and competence. This can be a life or death question---in Roper v Simmons neuroimaging was used as evidence that juveniles should not be given the death penalty. Hopefully the MacArthur grant will shed some light on whether the degree of brain myelination in juveniles is, in fact, relevant at all to criminal responsibility. Right now the legal opinions based on neuroimaging have tended to leap a bit beyond what science has shown in my opinion.

What I Learned Part 3

The final installment in my conference series. Tomorrow I come home to my fellow bloggers! I miss them.

• In France they are doing an interesting project to look at the effects of incarceration. They are asking prisoners to spontaneously describe their incarceration experience and how they think it has affected them, then they are using computerized lexicographical analysis to define common domains of concern.

• There was a poster looking at the neuroanatomical basis of empathy, sympathy and moral reasoning. Highly theoretical and completely lacking in data, unfortunately.

• In 1895 Bridget Cleary was burned to death by her husband, who believed that she had been kidnapped by fairies and a changeling left in her place. It is possible that Michael Cleary suffered from a form of Capgras delusion.

• Someone tried to do a study looking at treatment compliance and motivation for change in sex offenders, but there weren't enough sex offenders motivated to participate in the research.

• Very few states have laws requiring mandatory reporting of impaired drivers to the MVA.

• One Russian psychiatrist proposed that the term "dependent behavior disorder" be used as a diagnosis for a broad range of compulsive behaviors.

• The first documented use of telepsychiatry was in 1959. In the U.K. a criminal justice statute required the installation of teleconferencing equipment throughout the courts and correctional facilities in the country. This is now being used to perform clinical and court-ordered psychiatric assessments. Free society studies have shown patient satisfaction to be similar between telepsychiatry evaluations and face-to-face interviews. In the U.S. there are a number of undefined legal issues with regard to telepsychiatry and computer-assisted treatment. These including licensing issues for practice across state lines, informed consent for remote clients/patients and malpractice coverage across state lines.

• Directors of forensic fellowship training are working to create measurement tools and procedures to meet the core competency requirements of the American Council for Graduate Medical Education (ACGME). There was a very nice workshop that presented a "toolbox" of techniques for documenting residents' competency as well as a discussion regarding how to prepare for an accreditation visit. The workshop also discussed the challenges of funding a forensic fellowship program.

THE END

Thank you for reading

What I Learned Part 2

Here's the second installment in my conference ramblings:

• The Supreme Court decided in Sutton vs. United Airlines that for the purposes of the Americans with Disabilites Act the disability must be assessed only after attempts have been made to correct the impairment.
  

• Liability in medication-related tort claims is best reduced by well-documented informed consent (Duh. But that came up a lot this year so I mention it.)

• In states that allow for outpatient commitment, only 20% of pretrial detainees who are referred for commitment actually end up getting commitment orders. This is because most of them are either sent to prison prior to a commitment hearing or because they are committed to a hospital for restoration to competence prior to an outpatient commitment hearing.

• Death Penalty

In 2006 there were 53 people executed, 32 were white and 21 were black. In 2005 there were 1805 whites and 1372 blacks on death row. One out of 12 death row inmates had committed previous homicides. Death penalty aggravating and mitigating factors are set by state statute. Aggravating factors include victim characteristics (law enforcement or firefighting personnel, children, pregnant women), defendant characteristics (previous violent offenses), and offense characteristics (murder committed during the course of a felony, contract killings). By law all possible mitigating evidence is allowed to be heard during the sentencing phase of a death penalty proceeding. Although mental health issues are statutory mitigating factors, sentencing juries actually consider them as aggravators and they are more likely to result in a death sentence. The main purpose of expert mental health testimony in a death penalty hearing is to humanize the defendant and to change the focus of the hearing from the crime to the defendant. It also serves to give the defendant an opportunity to communicate to the jury through the expert. Surveyed death penalty defense attorneys usually prefer psychiatrist rather than psychologist expert testimony. They prefer forensically trained experts with an area of expertise that is relevant to the case, with good testifying skills.

• Risk Assessment in the U.K.

The U.K. has a relatively new law that allows for the indefinite detention and/or community supervision of violent offenders. This led to the creation of the Risk Management Authority, an administrative body that trains, supervises and regulates official risk management assessors. The assessments are quite exhaustive and includes a minimum 6 hour interview over three days. It is primarily a clinical assessment although it does require the use of at least one "official" approved actuarial tool. There were only 7 orders for assessments filed in 2006. Some offenders refuse to cooperate since they know it could result in a lifetime of supervision and mandatory treatment.

Another development was the creation of a Dangerous and Severe Personality Disorder Service, which essentially is a tool for civil commitment of psychopaths. This has led to 150 referrals a month and an increased number of non-mentally ill sociopaths in forensic hospitals. (One presenter's quote: "The system is swamped.") They are treated with cognitive-behavioral therapy at a cost of $500,000 per inmate per year. Remarkably, there have only been three minor inpatient assaults involving these patients over five years.

• Liability and risk management in forensic practice

Case law is still defining areas of liability for forensic clinicians. Most liability seems to arise as a result of independent medical evaluations (IME's). The 2006 case Harris v. Kreutzer determined that there was a limited physician-patient relationship created during the IME. The three duties created as a result of this are: 1) to cause no injury during the evaluation (read the Harris case), 2) disclose significant findings to the evaluee (eg. an orthopedic surgeon doing an IME who incidentally discovers a tumor), 3) maintain confidentiality (eg HIPAA compliance)

Most states have limited civil immunity for expert testimony but this is not absolute & varies with jurisdiction. Experts appointed by medical boards for peer review have been sued with varying degrees of success by their evaluees. A forensic expert could face discipline from the AMA, the state medical board, or a specialty organization. In general psychiatric practice most liability comes from suicide or from medication-related injuries.

• Ethics of Forensic Psychiatry

In 1982 Harvard professor Dr. Alan Stone gave an address in which he suggested that it was unethical for psychiatrists to be involved in expert testimony. The last panel today was an update by Dr. Stone on his position and a response from a number of illustrious colleagues. I can only give this topic pitiful recapitulation here. Stone argued that psychiatry has no absolute truths to offer and that professional consensus is dangerously misleading. Panelists Ezra Griffith, Stephen Morse and Paul Appelbaum responded that it is ethical for professionals to aid the court's search for truth and to promote justice. While acknowledging potential ethical pitfalls, there was a consensus that evolving standards of science provide something to offer.

(Incidentally, in Podcast #14 (No April Fool) I talked about the New York Times article, Brain On The Stand, which quotes Dr. Morse's views on the use of neuroimaging in forensics. Now that I've had a chance to listen to this guy speak it is clear that he is someone to keep an eye on. Interesting things are going to be coming out of U. Penn, particularly with his involvement in the recent $10 million MacArthur grant for neuroscience and the law. This is probably worth a blog post all on its own, when I get the chance. Right now I'm off to dinner.)

What I Learned Part 1

This is my second annual blog post that summarizes my experiences at the forensic conference I attend every year. Last year I put up a three part "What I Learned" series, which I occasionally go back to when questions come up and I know I heard something about it once but can't remember the details.

So here goes:

• The Atlantic ocean is surprisingly warm for October.
• There are approximately 5000 women murdered every year in honor killings. Syria and Jordan still have laws on the books for men to kill their wives without consequences if they are caught in the act of adultery.
• There is evidence that the Slater method may be effective for restoring developmentally disabled defendants to competence to stand trial.
• Only two states in the country (Connecticut and Indiana) have laws that allow police to seize legally owned weapons from dangerous individuals.
• Violence predictions instruments, even the PCL-R, has not been validated for use with women and it is not recommended to use them as a predictive tool for female defendants or prisoners.
• Vaginal plethysmography exists but has not been validated for use in evaluating female sex offenders.
• In recent years the number of women found Not Guilty By Reason of Insanity (NGBRI) has increased. This may be due to increased awareness of post-partum psychiatric illness.
• Culture-bound syndromes can be seen in immigrant populations and it is necessary to understand these phenomena in order to distinguish them from delusions. Ashanti witchcraft, "root workers" and others may lead to commonly held cultural beliefs.
• A woman named Marti Ripoli was an infamous serial killer in the nineteenth century. She was thought to be responsible for the deaths of 25 children, whose blood she used to make magical remedies that she sold on the streets. Belle Gunness had nothing on this lady.
• Alan Felthous gave an amazing Presidential Address in which he reviewed the religious and philosophical underpinnings of free will from Aristotle up to the neuroanatomy of decision-making as shown by functional MRI's. All in less than an hour. Wow.
• There was a great panel presentation about cults. They discussed the difference between a religion, a sect and a cult. They described characteristics of cult leaders and followers and cult dynamics including recruitment, retention and deprogramming. They presented case law regarding deprogramming practices and risk management issues for psychiatrists. Finally, they presented the satanic cult abuse issues of the 1980's and the lessons learned from this. (I enjoyed the tutorial about the Church of Satan and what to ask your Goth patients. Also the Church of Satan tattoos. Personally, if I saw a 'Satan Rules' tattoo I don't think I'd need to ask too many more questions.)
• In Germany forensic experts are always the agents of the court rather than agents of an adversarial attorney. The goal is a neutral and impartial evaluation. (We could learn something from that here in the States. I bet their malpractice costs are significantly lower.)
• The concealed information test is the most commonly used experimental deception paradigm. It has been used in functional MRI lie detection studies, the first one of which was published in 2001. The number of fMRI lie detection studies has increased quickly since then, but a number of the authors are partners in two companies that do commercial fMRI lie detection, Cephos and No Lie MRI. (We discussed this topic in Podcast 5: Sex, Lies and Neuroeconomics.) Functional MRI's cost about $1800.
  
• SPECT scans are very sensitive but completely nonspecific. They are abnormal in a broad variety of conditions but there is a lot of overlap between conditions. When using SPECT to evaluate mild traumatic brain injury, it is important to first rule out the confounding variable of clinical depression.
• Problematic Internet use covers a broad range of behaviors: cyberstalking, cyberbullying, excessive surfing, excessive online gaming and inappropriate work behavior.
• When evaluating a building for Sick Building Syndrome it is important to do a visual inspection first, then take samples if necessary. Sampling includes measurements of wall and room humidity, temperature, carbon monoxide and carbon dioxide levels and surface swabs. A normal carbon dioxide level is 1000 parts per million. Normal building temperature is from 68-72 degrees in the wintertime with less than 60% humidity. Some plaintiffs alleging sick building syndrome are actually suffering from somatization disorder so it may be necessary to involve forensic psychiatrists in these evaluations.

PHEW. And that's only the first day. Here's the other thing that I learned:

I love eating lobster while watching the ocean. Beats the heck out of working in prison.

Because It Feels Good

See other Savage Chicken cartoons here

The Psychology Of Altruism

I saw a story in our local newspaper recently that summarized the results of a Johns Hopkins survey of people who volunteer for research projects. The projects they were looking at were Phase I clinical drug trials, in other words studies that are done using drugs on humans (as opposed to animal) subjects for the first time.

It led to the obvious question: Who the heck would do something like that?

Now, I knew a couple people who volunteered for studies when I was an intern. They were both rather adventurous, young, and somewhat in need of money. Looking back on it I could say that they were trusting people who believed that the researchers wouldn't do anything to seriously put them in harm's way and that they were also fully armed with the youthful denial of any possibility of death, disability or adverse consequences to many things they did.

Some of the subjects in the survey reported that they essentially became professional guinea pigs, even travelling from state to state to make a relatively lucrative living (lying to the investigator in the meantime about their extracurricular research activities). However, about half the volunteers were employed at the institutions where the research was being done. They reported that volunteering made them feel good that they were helping people.

That got me thinking about altruism in general. We have many examples of altruists in our society: parents, volunteer firefighters, soldiers, people who sign organ donor cards or send money to charitable organizations. What leads people to give up something when there is no immediate benefit to the giver? Or worse yet, when there are always people ready to take the benefit without ever making a sacrifice in return?

There are religious motivations for altruism, but this being a psychiatry blog I thought it would be more relevant to look at the psychology and evolutionary biology of altruistic behavior. (Don't worry, I'll keep it short to avoid being snooze-worthy.)

In The Ego And The Mechanisms Of Defense Anna Freud described the concept of "atruistic surrender". I'm admittedly nowhere near being an analyst, so if any reader out there has a better handle on this than I do feel free to enlighten me. As best as I can figure it out, altruistic surrender takes place when a patient's unconscious conflicts are triggered by superego suppression of impulses. To manage the resultant anxiety the patient projects the forbidden impulse onto someone else, identifies with that person, then works to help that person satisfy the impulse. For example: someone feels the urge to eat lots of gourmet food but this impulse triggers an unconscious conflict. The impulse is attributed externally: "I am not hungry. They are hungry," and the person throws herself into feeding the hungry or cooking extravagant meals for friends and family.

Whew. This must be why analytic training takes years.

The evolutionary perspective is much more simple-minded (lucky for me). A behavior survives for one of a few reasons: it's good for your relatives, it helps you have more kids or it improves your standing in the community. The weird thing about altruism is that it doesn't seem to do any of those things, yet you see the behavior in non-human species as well as insects. And if altruism didn't do something to enhance survival then all altruists would be extinct by now. What gives?

This is where I get to refer to an economist---probably the only time we've mentioned economists on the blog even though the few I've known have been pretty terrific people. Robert Aumann and Thomas Schelling developed game theory in order to understand economic cooperation and conflict, but they ended up enlightening human behavior. They used mathematical models to prove that given enough time and enough opportunities for strangers to interact the altruists come out ahead economically the majority of the time. Later researchers showed that the "cheaters" (people who don't sacrifice) eventually get punished by the group by being denied opportunities to interact---no one wants to do business with them.

And finally, now that we have this gee-whiz cool fMRI technique you can pretty much count on the fact that someone somewhere has taken a picture of an altruistic brain in action. One study showed that increased activity in the posterior superior temporal sulcus strongly predicted a person's likelihood for altruistic behavior. (And now that I've volunteered my time to write this summary I can practically feel my posterior superior temporal sulcus glowing.)

So now when someone asks you why you volunteered for that activity that everyone else in the neighborhood is hiding in the attic to avoid, you can say: "Because given X number of trials involving Y individuals there's approximately Z percentage likelihood that I'll come out ahead by doing it." Or you can keep it simple: because it feels good.

My Three Shrinks Podcast 14: No April Fool

[13] . . . [14] . . . [15] . . . [All]

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Hard to believe we went so long without a podcast. Sorry about that, folks, but life got too hectic for a spell. We didn't do anything special for April Fools Day (except some funny YouTube links), but we still think you'll like today's podcast.

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April 1, 2007:


Topics include:

• Q&A: Midwife with a Knife, an OB/GYN, asks us about whether pedophilia is a disease or something else, and what we think about civil (as opposed to criminal) commitment for it. Clink uses one of her 50-cent words on us (ephebophilia, a term that Clink says was coined by John Money in his book, Love Maps). See also The Last Psychiatrist's posts on this here and here.
  
• NYT article: "The Brain on the Stand", by Jeffrey Rosen. Clink talks about this article about brain diseases being put on trial to explain bad behavior.
• Q&A: Dr Anonymous wants us to say more about our recent posts (here and here) on humor and medicine. This whole discussion (and the numerous comments on the blog) was started by Roy's lyrics to "Walk Like a Psychiatrist."
  

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Find show notes with links at: http://mythreeshrinks.com. This podcast is available on iTunes (feel free to post a review) or as an RSS feed. You can also listen to or download the .mp3 or the MPEG-4 file from mythreeshrinks.com.

Thank you for listening.

Neurophilosophy lists psyc blogs

Here is a compilation of great psychiatry and neuroscience blogs that I wanted to share with you. Happy browsing.

Roy: Warrantless Brain Scans

This whole search for terrorist collaborators thing is getting a little ridiculous. Tapping into millions of domestic phone calls (and probably blogs and emails and IMs) in the name of terrorism? That's legal?

So, here's my nightmare scenario. If this is legal, the next step is to force functional MRIs on people to determine what they know (about terrorism, of course). The technology is there. Functional MRI (fMRI) measures minute changes in blood flow in the brain, comparing areas to see which ones have more blood flow, and thus are more active. It seems that one must use specific brain areas to make stuff up. This technology is being used for good purposes (eg, controlling chronic pain), but could certainly be applied to darker motives.

Talkleft asked:

"Would the Court view an involuntary brain scan as a nonintrusive gathering of information rather than a search governed by the Fourth Amendment? Would the Court view brain scans as forcing an involuntary disclosure of thoughts prohibited by the Fifth Amendment's requirement that individuals not be made to testify against their will?"

fMRI is not "invasive" in the classical sense. No needles. No tubes. Sorta like going through an airport scanner, but lying down (you can even keep your shoes on). So what's to stop them from using this technology on Gitmo detainees (or on us)?

The chronic pain link above is interesting, BTW. It makes me wonder if real-time fMRI scanning can be used to learn how to better control obsessive thoughts or auditory hallucinations or anxiety.

Freud set back Psychiatry 100 years

[Rant posted by Roy]

Okay, it was his birthday last week and all, but I think Sigmund Freud single-handedly stalled the progress of psychiatry for nearly a century.

Look at some of the thought leaders in psychiatry in the early 2oth century. Kraepelin. Bleuler. Alzheimer. It was around 1905 when it was found that syphilis could cause a type of psychotic illness, called general paresis of the insane. Most "psychiatrists" were actually neurologists then, and the field was decidedly heading in the what's-wrong-with-their-brain direction. Fifty years later, the first antipsychotic drug was introduced. What happened in those first 50 years, and in the 50 years since?

The locus of pathology switched from the brain to the mind, from the individual neuron to the individual person. We were just starting to realize that psychiatric illness could occur through no fault of one's own (okay, maybe unprotected sex, but you see where I'm going), and then Dr. Freud comes along and we start looking at the mother or the father or Uncle Pete as the source.

And the treatment? Lie on a couch and talk. About whatever comes to mind. Four times per week. For seven years.

The result? Worsening of stigma. Marginalization of Psychiatry from Medicine. Diversion of research interest and resources from the cell to the self. The "psychiatric reduction" and non-parity in health insurance coverage. (The "psychiatric reduction" was Medicare's discriminatory practice of requiring outpatients with psychiatric illnesses to pay 50% out-of-pocket, while all other illnesses cost you 20%. This sham is still on the books today, despite bipartisan efforts to end this anachronism.) Tom Cruise.

So now, with the Decade of the Brain a recent memory, we have now entered the Century of the Genome. We are discovering more and more about how the brain cell is put together, which protein does what, and what goes wrong when the blueprint goes awry. About time.

The damage is fading. People are getting more comfortable to talking about having an illness, less worried about folks wondering about the "dirty little secrets" which have tripped them up.

Don't get me wrong. We learned some things in the process about human psychosocial development... about transference... about id. After all, understanding psychiatric illness cannot be boiled down to neurons and receptors any more than diabetes can be boiled down to insulin and sugar. But we have had a long and winding detour. Time to blow out the candles and get this party started.