Psychiatry’s Mission Impossible

Mission Impossible

Most of my work is aimed at discrediting the current biological model of psychiatric treatment—which is supported by bad science, and corrupted by financial interests. But the sad truth is that psychiatry has always been inherently prone to such corruption—simply because its scientific challenges are so very daunting, and the public desire for successful intervention in psychiatric disorders is so desperate. So, before we begin to ponder psychiatry’s many sins against science, let’s first give full consideration to the peculiar challenges it faces as a medical specialty.

Psychiatry’s main anatomical focus is the brain—an organ entirely encased in bone.  Underneath the bone are layers of fibrous tissue and fluid that cushion the brain, all of which are vulnerable to infection if intruded upon.  The brain itself is a fabulously complex array of about a hundred billion nerve cells (neurons), each with numerous junctions connecting it to its neighboring cells.  Cells communicate between each other across these nerve junctions (synapses) through the secretion of chemical messengers known as neurotransmitters. Each neuron has an average of about 7,000 synapses. There are over 100 different neurotransmitter agents identified in the human brain–each of which may have either an excitatory or inhibitory effect on the postsynaptic cell, depending on what kind of receptor protein it contacts in the cell membrane.  The location of this intercellular communication is in the synaptic cleft, the microscopic space within the junction which is crossed by the neurotransmitters. Here the balance of neurotransmitters is constantly adjusted by the two cells through the processes of release, metabolism, and reuptake—which in turn are regulated by an elaborate feedback network incorporating input from other neurons as well. 

In short, the raw circuitry of the brain is microscopic, profuse, and unimaginably complex. And every brain is unique!  

The physiological tasks of brain cells are largely determined by their location within the brain—and the higher functions associated with thoughts and feelings are particularly inscrutable, since they occur within a microscopic assemblage of neurons acting in a meticulously coordinated fashion. Hence studies of brain cells in vitro (i.e. outside of the body in a laboratory medium) tell us little about their psychiatric function. This leaves us with the necessity of studying brain cells in vivo (in the living organism) to gain an accurate understanding of their function.  But doing so would require passing a needle past the skull and through the surrounding nerve tissue, causing irreparable damage to the brain since neurons have little if any capacity for regeneration.  This makes direct observation of living brain tissue ethically unacceptable—and even if it wasn’t, how many people would give informed consent to participate in such a study? 

The other medical specialties (besides neurology, of course) focus on organ systems that are infinitely less complicated than the brain, more physically accessible, and able to withstand a needle biopsy without irreparable loss of function.  Chemical markers associated with these systems are typically measurable in the peripheral blood, unlike those of the brain. Other intrusive diagnostic procedures such as endoscopy are available as well.  Access to this sort of information allows physicians to be reasonably certain what’s going on inside the patient—a feeling dreadfully unfamiliar to any prudent psychiatrist.

Before one even contemplates these anatomical and physiological complexities, there is the conundrum of its duality—the brain in the corporeal world, the mind in the ethereal.  Like astrophysics, neuroscience is an area of study that raises philosophical and spiritual questions, provoking the sort of controversies that are attendant to such concerns. In the realm of medical science, the brain-mind stands out as a uniquely remote wonder, a bottomless enigma that we’ve barely begun to crack.  In point of fact, the secrets of the brain-mind constitute a last frontier far more scientifically daunting than astrophysics—which, after all, is just the study of a bunch of dumb particles that happen to be very far away.  It’s only fair to acknowledge the onerous scientific challenges that psychiatric researchers confront in trying to penetrate this ironic, existential mystery.

Psychiatry’s sense of futility is further aggravated by the likelihood that once a psychiatric disorder does become treatable, it will be reclassified as a non-psychiatric disease.  In the 19th Century a large proportion of asylum inmates were diagnosed with general paralysis of the insane (GPI)—a psychiatric disease characterized by manic symptoms or other behavioral problems, followed thereafter by the onset of dementia and progressive paralysis.  It was noted that this presentation was more frequent in men, especially those with “debauched” lifestyles.  Eventually this problem was identified as neurosyphilis, an advanced stage of syphilis that takes ten years or more to manifest itself in infected individuals.  Once antibiotic treatments were developed it became a “medical” illness, and thus no longer the concern of psychiatrists.  Similar paths were followed by epilepsy, the thiamine deficiency and hepatic encephalopathy associated with alcoholism, Parkinson’s disease, Huntington’s chorea, and other neurodegenerative diseases.  It would seem that we are in part defined as a specialty by our ineffectuality, since any disease that can be readily treated becomes someone else’s responsibility.  This sequence pretty much dooms us to persistent clinical failure–a reality of psychiatric practice that at times can be quite demoralizing.  

With so much to prove to our patients and peers, and a dearth of reliable scientific information, psychiatry has time and again compensated for the deficiency of its knowledge base by simply making shit up.  The unfathomable nature of our calling conveniently lends itself to grand fabrications—and when patients bring us uneasy questions about what we’re doing and how it works, almost any answer seems more satisfactory than yet another “I don’t know.” Consequently, psychiatry has been prone to spasms of radical reinvention over its history, as one brand of pseudoscience is replaced by another in a desperate attempt to cover up our gaping ignorance. These “breakthroughs” have generally swung between two opposing modes of characterizing psychopathology—either a biological orientation focusing on the brain, or a psychological orientation preoccupied with the mind.

At this time in psychiatric history, our understanding of the brain certainly exceeds our physiological understanding of the mind—which is nil. I’m completely forgiving of our ignorance in this regard. What I can’t forgive, however, is our refusal to acknowledge that ignorance in our clinical practice–and our vain, corrupt promotion of biological half-measures, as if they were clinically and ethically sufficient.

My contention is that in order to improve our success in psychiatric treatment, and to minimize the unintended harm we are inflicting, we need at last develop an eclectic array of interventions that address the eclectic nature of psychiatric disorders. Treatments that incorporate not only what we know about the brain, but what we know about the mind. We may not understand the underlying physiology of how the mind works, but we do have plenty of knowledge about how human beings work—and it’s foolish and inhumane to not make that sort of knowledge a necessary part of psychiatric intervention.

For thousands of years, people have been overcoming anxiety and depression by pursuing emotional growth. In my opinion, no psychiatric patient should be deprived of assistance in exploiting that innate capacity for meaningful, lasting improvement in the course of their treatment. I see nothing in our current model of care that acknowledges that capacity, much less utilizes it. I think it should be our duty to do so, if patient health is in fact our goal.

But there’s one major sticking point in my proposition—yet another quandary, one that impedes the aggressive funding of research to develop new models of psychotherapy for common psychiatric disorders:                  

How the hell are corporations going to monetize it???

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Artificial Afterglow: SSRI’s Exposed!!!

Artificial Afterglow:
How SSRIs Might Actually Work

Many of the most popular antidepressants—like Prozac, Zoloft, and Celexa—are classified as selective serotonin reuptake inhibitors, or SSRIs. In the nerve junctions of the brain where the neurotransmitter serotonin is released, it’s typically reabsorbed by nerve cells as a sort of feedback mechanism to regulate the amount present in the synaptic cleft—the space between two neurons. SSRIs act by decreasing this reabsorption of serotonin, which results in a net increase in the amount of serotonin in the cleft.

SSRIs aren’t just used to treat depression. They’re also prescribed for chronic anxiety, and to treat obsessive-compulsive disorder. However, they have significant side effects, the most frequently annoying of which are their sexual side effects. SSRIs typically decrease sexual desire, inhibit sexual arousal—and most frustrating of all, can stop you from being able to attain orgasm. All SSRIs seem to be equally problematic—these sexual effects seem to be tightly bound to their therapeutic benefits.

Over 20 years ago it occurred to me that this might not just be a coincidence, but rather a clue as to the therapeutic mechanism of these antidepressants. I’ve always been intrigued by the mechanism in which birth control pills work. For those of you who don’t know, the reason we don’t have a birth control pill for men is not because of sexism in the health industry—but rather because women happen to have a natural state of infertility, and men don’t. This state of infertility is pregnancy—when ovulation is suppressed by the body in order to preserve the endometrium of the uterus to nourish the fertilized egg that’s implanted there. Birth control pills contain the hormone that promotes gestation, i.e. progesterone—thus imitating the state of pregnancy.

I pondered the array of therapeutic benefits that SSRIs offered—improved mood, decreased anxiety, diminished obsession—and their peculiar sexual side effects, particularly inhibition of orgasm—and it seemed to me that this confluence of effects was more than coincidental. Then it dawned on me that there is in fact a natural state in which we humans exhibit all these phenomena—the refractory stage of sexual response, aka “afterglow.” You know what I mean (or I certainly hope you do)—that time after the act when we probably feel more relaxed, happy, and at peace with the world than any other time in our life. And I wondered if indeed serotonin might just mediate that phase of sexual response. But since that time I haven’t since heard that connection suggested in any psychiatric literature.

As you might expect, SSRIs have been found to exert their influence where serotonin is most prevalent in the brain—which is the raphe nuclei of the pons. This is located in the brainstem just north of the spinal cord—which is nowhere near the higher cognitive centers of the brain. The brainstem is the home of the limbic system, commonly referred to as “the lizard brain”—the seat of our primitive emotions, directing us to choose among any one of the “five F’s” of emotional response: “fight, flee, freeze, feed, or f**k.” And sure enough—along with the hormone prolactin, serotonin has indeed been implicated in mediating the refractory phase of sexual response.

The oldest citation I could find postulating this role of serotonin in sexual response was an archival article that’s currently posted on the website of the National Institute of Health. It’s an article that was first published in the British journal Behavioural Brain Research in 1984—3 years before the release of Prozac, the first SSRI, in 1987. It’s intriguing to me that Prozac was vigorously promoted, by Big Pharma and clinicians, using the unsubstantiated assumption that it was correcting some mythical “chemical imbalance” that was causing depression. For many years we psychiatrists held out hope for the development of an SSRI that didn’t cause these sexual side effects—when the evidence against this possibility was right before our eyes! Nowadays there’s a consensus among sexual response researchers that serotonin functions as a sort of hormonal “brake” applied to the process of orgasm, and that it may trigger release of the hormone prolactin. There is precious little evidence that serotonin has any other role in the control of mood—and numerous studies aimed at identifying any serotonin deficiency in the brains of chronically depressed individuals have failed to do so.

It’s worth noting that only 5% of the body’s serotonin is in the brain—the remaining 95% is in the gastrointestinal tract, where it is involved in the neurological regulation of digestion. This not only accounts for the GI side effects of SSRIs, but is also postulated to explain how we tend to feel our emotions in our guts, and how emotions affect GI function. Anyone who’s ever had a pet cat and moved from one residence to another can testify that this is not a peculiarly human phenomenon. This connection confirms the primitive origins of serotonergic responses, disengaged from the higher cognitive functions that almost certainly have a role in depression.

All this leads me to the conclusion that rather than correcting any underlying chemical imbalance in the brain, SSRIs probably act by creating a chemical imbalance that masks psychiatric symptoms, by triggering the instinctual psychological effects associated with postcoital afterglow—not unlike the way birth control pills trick the female reproductive system into thinking it’s pregnant. Unfortunately, these effects are not experienced with the intensity associated with actual post-orgasmic bliss—perhaps because of the endorphins that are released in intercourse during the plateau period prior to orgasm, and/or the prolactin that is released along with serotonin during the refractory period.

I can’t help but suspect that a whole lot of smart people have been playing dumb about the true nature of serotonin’s role in the brain for many, many years. The evidence of serotonin’s role in sexual response was in plain sight prior to their marketing campaign—so it seems to me that Big Pharma and academic psychiatry chose to pretend that they were fixing something that was broken, rather than acknowledging the likelihood that the efficacy of SSRIs was based on a cheap neurophysiological gimmick. Pursuit of a “healthy balance” is so much more marketable than manufacturing some instinctual delusion of wellbeing. I still prescribe these medications, but I don’t bullshit my patients into thinking that there’s any chemical imbalance to fix.

I am, however, unequivocally concerned about the overuse of antidepressants today. I’m thoroughly convinced that they have undesirable effects that need to be studied further—especially in long term use, and when prescribed to young people. But my overarching concern about antidepressants is the manner in which they are oversold and overutilized as an alternative to actual exploration of feelings and psychosocial stressors—in a manner that ignores the holistic value of sadness, and is dehumanizing to both my profession and its patients. I believe that the thoughtless manner in which antidepressants are used today is a cheap, lazy, and ultimately ineffective way to address the complexities of human existence—the cumulative result of modern psychiatry’s economic and scientific corruption, and a spiritually empty worldview.

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How to Think Like a Scientist

How to Think Like a Scientist

(and Why Psychiatrists Don't)

Science is the study of nature—and perhaps the most challenging wonder of nature is our own brain-mind. It’s unimaginably complex, entirely surrounded by bone, terribly vulnerable to intrusion—and no two of them are alike! All these factors combine to make psychiatry’s task of understanding its subject far more difficult than that of other medical specialties. For centuries, in the face of our enormous gaps in knowledge, psychiatry has tended to grasp at slender reeds of evidence, and then play fast and loose with science—ambitiously concocting half-baked theories, in a vain effort to assert mastery of a scientifically impenetrable mystery.

In order to grasp just how far psychiatry’s brand of science has strayed from established scientific fact, you first need to understand the scientific method—which is how all scientific knowledge is obtained and verified. Physicist Jose Wudka describes the scientific method as “the best way yet discovered for winnowing the truth from lies and delusion”—in other words, a sort of intellectual filter specifically designed to eliminate all bullshit.

The birth of the scientific method is credited to the great Arab physicist and mathematician Ibn al-Haytham, who in the early 11th century performed rigorous experimentation while studying optics.  For a thousand years it has prevailed as the prescribed manner in which any working assumption is examined and validated.  The steps of the scientific method are as follows: 

  1. Observe and describe a phenomenon.
  2. Formulate a hypothesis to explain the phenomenon.
  3. Use the hypothesis to predict outcomes.
  4. Test the hypothesis through experimentation and/or further observation, and modify the hypothesis in light of the results.
  5. Repeat Steps 3 and 4 until there are no discrepancies between your hypothesis and the results.

When a hypothesis has been run through this mill over and over, demonstrating its validity to the point that it’s accepted as proven by a consensus of the scientific community, it is then called a theory—a conceptual framework that’s used to explain existing observations, and to predict new ones.  Such theories, like the theory of evolution and the theory of relativity, function as jumping off points for the creation of more hypotheses, further observation and experimentation, and the continued expansion of the body of scientific knowledge.   

Please note that this use of the word “theory” is very different from the way that we use it in everyday language, where it conveys significant doubt and speculation.  This common use of “theory” actually describes what we would call a “hypothesis” in scientific terms—an unverified idea based on speculation. This ambiguity has contributed significantly to the public’s confusion about science today. While in science no theory is unquestionable—because almost nothing in science is actually unquestionable—a theory is defined as a proposition that’s already been verified as true after extensive scientific testing, and is now used as a foundation for further study. Critics of science have exploited this ambiguity to cultivate disbelief.  After all, the theory of evolution is “just a theory”—and if your personal definition of “theory” is a dubious supposition rather than a generally accepted fact, then a scientist’s unqualified endorsement might seem imprudent. But it isn’t. Theories are NOT imprudent.

The single most ignorant and misleading claim spouted by science’s opponents is that science is a faith in itself—when nothing could be further from the truth. Properly done, science is the antithesis of faith—because its guiding purpose is to question perceived truth, rather than accept it. People of strongly held religious faith despise science for its rejection of faith –which is, by definition, belief in the absence of evidence. But there’s really no choice for scientists in this matter–because scientifically speaking, belief without evidence is nonsense.

When religious opponents of evolution promote the concept of intelligent design—a feelgood hypothesis that maintains that there must be an engaged Creator because it sure seems like there is one—they start with an unobservable phenomenon, God, that is accepted without evidence—then scorn any effort to dismiss its existence. Their sole intention is to reaffirm faith, rather execute the skeptical work of science. In contrast, the theory of evolution is validated every time a drug-resistant strain of bacteria emerges, without us even looking for any more proof. 

But bogeymen of the culture wars are not the only enemies of science.  Like any other human enterprise, science is corruptible, especially when there’s big money is at stake. And in a time when psychiatry most lays claim to being based on science, it has done so by shrouding itself in pseudoscientific myths, to create the illusion of precision where there is none.

Ibn al-Haytham foresaw the corruptibility of the scientific process. As he put it, “Truth is sought for its own sake. And those who are engaged upon the quest for anything for its own sake are not interested in other things.” The sad truth is that most of psychiatry’s scientific knowledge today has been in a state of developmental arrest, stuck on a warped rendition of Step 3, which could be restated as: “Use the hypothesis to market psychiatry and its products.”  Like the advocates of intelligent design, most of psychiatry’s research institutions have been bent on producing data that supports a myth—specifically, the one that psychiatric disorders are caused by chemical imbalances, which are in turn resolved with psychiatric medications. Instead of scientifically scrutinizing this hypothesis, marginal findings are accepted as confirmatory and inflated in significance, so they can be used to generate pharmaceutical sales pitches.

One of the main reasons that psychiatry has abandoned this essential skepticism is because we have so little knowledge about how the brain-mind actually functions—and yet we need the illusion of knowledge in order to promote our products and services. The void in our scientific knowledge of the brain-mind is astounding. If you ever asked a cardiologist, “Physiologically speaking, what is a heartbeat?”, they could probably bore you to tears with details in explaining how it all works. But if you ask a psychiatrist this entirely pertinent question—“Physiologically speaking, what is a thought?”—the only honest answer would be, “We have no freaking clue”. Because we don’t. THAT is the most relevant measure of psychiatry’s scientific knowledge I can think of. We don’t know how the brain-mind executes any of the higher functions that are the actual focus of psychiatry, the generation of thought and behavior—and so the bulk of our psychiatric “science” to date is mucking around finding medications that cause desired effects in a brain-mind, when we really have no idea how it all works!

 With their embrace of technology—defined as “the application of science for practical purposes”—psychiatric researchers display the trappings of science, which is enough to impress much of the public with their efforts. But in fact, the modern myths of psychiatry are more thoroughly sustained by faith than by hard scientific proof.  Most of us use smart phones—a very advanced technology—regularly in our day-to-day lives, but I suspect very little of that time is spent doing hard science. Likewise, countless millions in research dollars have been spent amassing evidence to prop up psychiatry’s biological model and promote pharmaceutical products, rather than rigorously examining the scientific validity of its assumptions. This is a brazen neglect of the guiding precepts that have been at the foundation of scientific study for a millennium. In short, they’re baffling us with bullshit, more intent in generating pharmaceutical ad copy then establishing scientific fact.

You will find little in my work that attempts to assert any hard scientific truths—because the determination of scientific truth occurs through the exhaustive efforts of a community, rather than the musings of an individual.  I’m limited to exercising my scientifically driven skepticism—to doubt everything until all doubt is removed, shooting intellectual spitballs at institutions that may have less to do with real science than I do. Because they are no longer primarily engaged in the pursuit of truth, or driven by scientific skepticism. Ibn al-Haytham has provided me some cover for this mission, as he states:

The duty of the man who investigates the writings of scientists, if learning the truth is his goal, is to make himself an enemy of all that he reads, and to attack it from every side. He should also suspect himself as he performs his critical examination of it, so that he may avoid falling into either prejudice or leniency.

If you question this wisdom, remember that this is a guy who formulated an idea that is still with us a thousand years later. So, in that spirit, I invite you all to apply critical thinking anything that I might say in my videos or elsewhere—but to remember that doing so also requires a rigorous examination of your own beliefs. The scientific method demands a whole-hearted embrace of skepticism—because that’s the only way to establish that the truth you hold will be one that endures.   

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