Psychiatry needs a user's manual

Psychiatry may be a nice tool, but only if you know how to use it, and whether it is the right tool for your tasks. Unfortunately, modern psychiatry is usually sold to the customers without a user's manual; the patients have to figure everything out by themselves.

As with any powerful tool, such approach is bound to be dangerous. Many a patient have suffered a great deal from psychiatric enterprise, only because they didn't know what to expect from it. Everybody knows how to behave if you're stopped by the police, but very few people seem to have any idea what they ought to do in a psychiatrist's office or a mental hospital.

Will the gene of schizophrenia help you?

So why am I not being too enthusiastic about psychiatric genetics? Why am I not excited by the prospect of uncovering the genetic basis of mental disorders, despite the proponents' claims that it should make diagnosis more reliable and eventually provide avenues for effective treatment?

Because these promises do not sound realistic to me. I have to admit that the question of psychiatric genetics is very interesting academically, and it is also readily funded by both drug companies seeking profit and the government seeking some kind of solution to the overwhelming quantities of mentally disturbed citizens. Still, I find it difficult to buy that genetic advances will benefit the real-world patients, and here is why.

First of all, the genetics of mental disorders is subtle and multifactorial. Therefore, even if some genetic predisposition could be statistically proven, in any concrete individual the environment plays a dominant role in determining whether the disorder will appear. In other words, regardless of whether a particular person possesses the wrong genes or not, his being sick or normal will largely depend on his life situation (which is exactly what we've known for a hundred years).

Let's take an example from oncology. There is a gene called BRCA1 that, if mutant, has been recognized as carrying much higher risk of breast cancer development. Now, in oncology the diagnosis can be made much more accurately than in psychiatry; the genetic association with BRCA1 gene is also simple and straightforward. Nonetheless, oncologists do not usually make predictions about any particular patient; even though the risk may be significantly increased, we still cannot say to the carrier or the mutant gene: "You will have breast cancer", or to the carrier of the normal gene: "You're cool, go home."

Whatever gene associations are found in mental disorders, they will not be enough to make predictions, because the environment plays a major role in the fate of any organism. Hence, we can only afford hunting for genes after we've done everything possible to fix the environment. Talking genetics when there are major problems in people's psychological well-being (look around!) is like cleaning the carburetor when the car's wheels are missing. It could help, but it's not the biggest concern right now.

The second reason why genetics is unlikely to benefit the patients is that psychiatry has a tendency of rushing things into practice as soon as they are discovered (if it can be profitable, of course). It is theoretically possible that genetic discoveries will lead to the creation of the effective treatment for psychiatric disorders, but most likely this simply won't have time to happen. What will happen much sooner is that some type of genetic analysis will be implemented, and people who are at risk will be recommended to take the medications preventively.

This will be catastrophic, because the drugs can make a healthy person sick; so there will be no way of disproving that they were really needed. This will reinforce the sense of scientific correctness, and promote further treatment and propaganda efforts, supported by the drug manufacturers. The tradition of giving drugs to healthy people, mandatory genetic testing of children and adults, and the arising legal battles will change the whole landscape of psychiatry into something entirely different from what we know today.

In the resulting confusion the original goal of the genetic research (to develop treatment) will be postponed, as scientists of the day will concentrate on getting out of the current crisis. And everything will repeat again - only the counter of the innocent victims of psychiatric help will advance by a few tens of millions... but who counts them?

Gene of Schizophrenia?

A recent advance in studying the genetics of schizophrenia is reported in this Nature article.

There are reasons why scientists keep looking vigorously for the genetic basis of psychiatric disorders despite decades of unsuccessful efforts. With such persistence it is likely that some kind of genetic association will finally be found, or at least claimed to be found. Given the computational complexity and sample sizes of the modern genetic studies, many years could pass before the results of any given study could be verified or disproved.

What worries me is that psychiatry has a tradition of trumpeting the first promising results of a new study and rushing them into practice before the results are verified. And the nature of the specialty is such that once something new is implemented, it confuses the picture so much that it becomes impossible to say if the new method was even helpful.

In practice, as soon as some believable hint is received that psychiatric disorders are genetic in nature, and some genetic testing procedures become available, it will make the case for preventive use of psychotropic drugs on people who are "at risk". This makes no scientific sense (I'll explain this point next time, otherwise I'll be late for my train), but this most definitely will be done.

When You See What You Like You Want It - Science Has Proved

"Strong cravings for alcohol can be sparked by the mere sight, smell and taste of a person’s favorite drink,"

- say scientists, who are about to publish their findings in Biological Psychiatry, a prestigious psychiatric journal, as reported by Science Daily article today.

This revolutionary scientific finding has opened our eyes on one of the most interesting aspects of human behavior: when we see something that we like, we start to want it. Turns out, alcoholics can abstain from drinking for a long time, but as soon as they see their favorite drink in an engaging environment (such as their neighborhood bar), their desire to consume the drink increases dramatically.

To discover this curious fact the scientists used the help of the rat behavioral model. They first trained the rats to drink alcohol in a special "bar cage". It isn't mentioned what types of drinks were served, which is one of the shortcomings of the study: after all, the rats' behavior would probably differ if they were offered vodka versus martini or beer (in which case domestic or imported could also make a difference). It was reasonably clear, however, that the rats enjoyed their drinking experience. Then the animals were put into a different cage, and deprived from alcohol. After a certain period of abstinence they were allowed to go back to the bar, and before the scientists knew it they were drinking again like there was no tomorrow.

“This effect is highly detrimental to humans who are trying to abstain from drinking,”

- says lead author Nadia Chaudhri, Ph. D., with the Ernest Gallo Clinic and Research Center at UCSF.

These humans, as her words imply, are hopelessly trapped inside the control centers of their essentially animal bodies that divert them from their chosen path and towards their favorite drink.

To help such unfortunate individuals, the scientists propose to broaden the context of the exposure-based therapies. The experiment has shown that when the drinks were no longer available even at the bar cage, the rats would gradually lose their interest to alcohol, and start to engage in other activities like mating and generally scratching around. Therefore, the alcoholics should, as part of their therapy, visit their favorite bars with the therapist, but - and here the ingenious scientific thought unveils itself - they shouldn't drink anything there.

"These contexts could be real, i.e., visiting bars or liquor stores, could be created using virtual reality techniques, or could simply be recreated by patients as they imagined visiting places that triggered their urges to drink,”

- says John H. Krystal, M.D., Editor of Biological Psychiatry and affiliated with both Yale University School of Medicine and the VA Connecticut Healthcare System.

It is easy to imagine how much this study can change the lives of alcoholics once its results are put into practice. And those of you who are not yet alcoholics (at least not the ones treated by psychiatrists) could also take a lot out of this study. If you know you want something, but shouldn't have it - you must never allow yourself to see it, smell it, or, perish the thought, taste it. Otherwise, your desire may increase. You've been warned!

Behavioral Therapy Doesn't Work Because People Are Not Stupid Enough

Behavioral therapy comes in many flavors, but they all more or less share the same outcome: either the therapy doesn't work, or it works but in such a way that it better didn't.

The reason for this is the basic error of assuming that people are stupid enough. I am not talking about the kind of stupidity that is the opposite of being a Nobel prize winner; but in order for behavioral therapy to work people must be so stupid as to not understand what is going on around them. Otherwise they quickly figure out the rules of the game, and refuse to participate if it gives them too much trouble.

Behavioral therapy is based on clever application of positive and negative stimuli in order to support or eliminate certain types of behavior. A textbook example: if the room is too cold (negative stimulus), the subject will set the thermostat up (desired behavior); thus, without any complicated analysis or dream interpretation business we have achieved the change in behavior, which is all we need after all (right?).

The problems start when we try to reproduce the situation in the real world. In the real world someone needs to go and set that thermostat down first, so as to create the negative stimulus. At this moment the subject, who is not stupid enough, says: "Wait a minute! Why are you doing this? Are you trying to manipulate me?" - and the whole ingenious plan goes down the drain.

Glance through any book on dog training, and then any behavioral therapy manual. You will notice a lot of similarities in approach; sometimes you will find it difficult to remember which book is which. But even being as stupid as a dog is still not enough! Anyone who attempted to train a dog knows that he will play along while he finds it funny; but at some point he will look at you suspiciously: "I thought we were playing, and turns out you're trying your silly methods on me?" From then on, if you persist in your attempts, you will only make the dog angry and put your relationship at risk.

To successfully train a dog, one must somehow convince him that being a good dog can be a lot of fun. You cannot explain it, or manipulate a dog into thinking so. The ability to convey the message is a matter of talent. All good trainers incorporate the principles of behavioral science in their work, but they do it "from within" - unobtrusively and naturally. Simply following a set of rules and methods does not work even with dogs, not to mention human beings.

Sometimes, however, the human beings are smart enough to realize that they have to go through therapy and follow the trainer's instructions. They will not get angry, but instead will play a double game, convincing everybody and themselves that they really don't see the person who enters the room and sets the thermostat down. They trick themselves into being genuinely surprised when the room becomes cold, and allow themselves to act upon the urge to get rid of the negative stimulus and reach the desired behavior. In so doing, they become persuaded that they really improve.

The situation thus grows worse than if there was no therapy at all. The patient now thinks that he is prepared for the life's misfortunes, but it is only an illusion; therefore his vulnerability actually increases. Besides, the long-term consequences of playing an idiot are not well-studied.

Drug Therapy: Does The Easiest Mean The Best?

From a conversation with a psychiatrist one typically gets the impression that the medications are the most powerful tool for treating mental disorders. Yes, you can try therapy, or lifestyle modifications, but if you are dealing with anything serious, the drug treatment is the only thing that has the real power to help.

At least partly, this conviction is based on the practical difficulty to use alternative treatments. For example, good psychotherapy exists but is hard to find and expensive; life style is possible to modify, but it requires significant time and energy invested into patient education and follow-up. Some patients cannot use these treatments even if they want to, because their mental disturbances result in the inability to understand and follow complex directions. The lifestyle modifications may be unattainable for economic or social reasons: someone whose entire family of nine lives in a one-bedroom apartment might want to modify his lifestyle, but be unable to do so.

A pill is certainly the easiest means of treatment, whether or not the most helpful. It can be used in any circumstances and by people of any economic, educational or social background. It is therefore true that medication therapy may be usable in cases when other types of treatment may not; however, any further implications about efficacy are much harder to prove.

Taking Medication Is Voluntary

Taking a psychiatric medication is a voluntary act. Unless you are brought to a psychiatric hospital by ambulance, or suspected of being a possible danger to yourself or others, or not obeying the directions of hospital personnel, or hallucinating, or not agreeing to take the drugs voluntarily for too long when the doctor deems it necessary, you cannot be given a medication against your will.