What the pot and pain pill overdose study teaches us about ecological fallacies

I am delighted to offer Mind the Brain readers a guest blog written by Keith Humphreys, Ph.D., John Finney, Ph.D., Alex Sox-Harris, Ph.D., and Daniel Kivlahan, Ph.D. Drs. Humphreys, Sox-Harris, and Finney are at the Palo Alto VA and Stanford University. Dr. Kivlahan is at the Seattle VA and the University of Washington.

Follow Professor Humphreys on Twitter @KeithNHumphreys.

 

Image Credit: Bogdan, Wikimedia Commons
Image Credit: Bogdan, Wikimedia Commons

A team of scientists recently reported that states with laws permitting medical marijuana had lower rates of opioid overdose than states without such laws. In a New York Times essay, two members of the team suggested this state-level association between medical marijuana access and deaths reflects the behavior of individuals in pain:

 

If enough people opt to treat pain with medical marijuana instead of prescription painkillers in states where this is legal, it stands to reason that states with medical marijuana laws might experience an overall decrease in opioid painkiller overdoses and deaths.

 

At first blush, saying it “stands to reason” seems, well, reasonable. But in the current issue of the journal in which the study appeared, we point out that the assumption that associations based on aggregations of people (e.g., counties, cities and states) must reflect parallel relationships for individuals is a seductive logical error known as the “ecological fallacy.”

 

Once you understand the ecological fallacy, you will recognize it in many interpretations of and media reports about science.   Here are some examples that have been reported over the years:

 

 

Such differences are counter-intuitive and therefore a bit baffling. If individuals having heart attacks who receive high quality care are far more likely to survive, doesn’t it follow that hospitals that provide higher quality care to larger percentages of their heart attack patients would have substantially lower mortality rates? (Answer: No, their results are barely better). Why don’t patterns we see in the aggregate always replicate themselves with individuals, and vice versa?

 

The mathematical basis for the ecological fallacy has multiple and complex aspects (our detailed explanation here), but most people find it easiest to understand when presented with a simple example. Imagine two states with 100 people each residing in them, with each state population including a comparable proportion of people in pain. Potsylvania has a loosely regulated medical marijuana system that 25% of residents access. Alabstentia, in contrast, limits access to medical marijuana so only 15% of residents can obtain it.

 

Potsylvania

Medical Marijuana User Medical Marijuana Non-User Totals
Died of Opioid Overdose 2 3 5
Did Not Die of Overdose 23 72 95
Totals 25 75 100

 

Alabstentia

 

Medical Marijuana User Medical Marijuana Non-User Totals
Died of Opioid Overdose 4 6 10
Did NotDie of Overdose 11 79 90
Totals 15 85 100

 

Ganja-loving Potsylvania has a lower opioid overdose death rate (5%) than more temperate Alabstentia (10%).   Does this prove that individuals in those states who use medical marijuana lower their risk of opioid overdose death? Nope. In both states, medical marijuana-users are more likely to die of a pain medication overdose than are non-users: 2 of 25 (8%) of marijuana users dying versus 3 of 75 (4%) marijuana non-users dying in Potsylvania; 4 of 15 (26.6%) of marijuana users dying versus 6 of 85 (7.1%) of non-users dying in Alabstentia!

 

Embracing the ecological fallacy is tempting, even to very bright people, but it must be resisted if we want to better understand the world around us. So, the next time you see a study saying, for example, that politically conservative states have higher rates of searching for sex and pornography on line and want to immediately speculate about why conservative individuals are so hypocritical, pause and remember that what applies at the aggregate level does not necessarily apply to individuals. For all we know, alienated liberals in red states may just be feeling lonely and frustrated.

Repost: Claire Underwood From Netflix’s House of Cards: Narcissistic Personality Disorder?

Last month, Netflix released Season 3 of House of Cards. In light of this, I am reposting a blog I wrote about the second season of the series last year: “Claire Underwood From Netflix’s House of Cards: Narcissistic Personality Disorder?”

 

Last month I used the character of Frank Underwood as a “case study” to illustrate the misunderstood psychiatric diagnosis of Antisocial Personality Disorder, and many of you asked: Well, what about his wife, Claire?

Good question!  You asked, and so today I will do my best to  answer.

 

SPOILER ALERT: For those of you who have not yet watched all of Season 2 yet, consider yourself warned. 

 

Image: Netflix
Image: Netflix

Clinical lore would certainly support that Claire, herself, must have a personality disorder of some kind – a sort of fatal attraction, where a couple is drawn to each other because there is something in their personality patterns which is complementary and reciprocal.

She does appear to have mastered the art of turning a blind eye to Frank’s more antisocial exploits.  She is a highly intelligent woman, and she must have some inkling that her husband may be involved in the death of Zoe Barnes and Peter Russo.  But if she has an inkling, she does not show it.

Claire, from what we know, does not engage in outright antisocial behavior.  Unlike Frank, she has not murdered anyone and we have not seen her engage in very reckless or impulsive outbursts.

However, she rarely shows emotion—her smiles seem fake, her laugh empty, and her expressions are bland.  She is more restrained and guarded than Frank, and she does not reveal her inner thoughts to the viewer the way Frank does so it is much harder to know what could be going on in her mind.

Still, I think I have seen enough to venture forth with an assertion that she may have a Narcissistic Personality Disorder.

 

What is Narcissistic Personality Disorder?

 

A pervasive pattern of grandiosity, need for admiration, and lack of empathy beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of 9 criteria.

 

Below are the five criteria that I think apply to Claire:

 

1) Has a sense of entitlement (i.e. unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations)

 

Image: Netflix
Image: Netflix

She expected Galloway to take the blame for the photos that were leaked and eventually claim it was all a “publicity stunt,” thus ruining his own reputation and image.  She expressed no regret that her ex-lover was cornered into having to do this, on her behalf, and no remorse that it almost ruined his life and his relationship with his fiancé. She was entitled to this act because she is “special” and expects that people will “fall on their swords” for her.

 

2) Is interpersonally exploitative (i.e. takes advantage of others to achieve his or her own ends)

 

Claire manipulates the first lady, Tricia Walker, into believing Christina (a White House aide) is interested in the president. She pretends to be a friend, wangles her way into becoming the first lady’s confidant, and persuades her to enter couples therapy with the president.  All of this is actually part of an elaborate plan to help Frank take the President down so that he can become president and she (Claire) can usurp Tricia as first lady.

Another example: Claire is pressured by the media into revealing that she once had an abortion, but she lies and states that the unborn child was a result of rape (presumably to save political face).  Again, she shows no remorse about her lie and instead profits from it, gaining much sympathy and public support.

 

3) Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others

 

Image: Netflix
Image: Netflix

This was best seen in the way Claire deals with her former employee Gillian Cole’s threat of a lawsuit –  she pulls a few strings and threatens the life of Gillian’s unborn baby.  In fact, in addition to the obvious lack of empathy was the simmering rage she had toward Gillian for daring to cross her.  Again, entitlement, narcissistic rage, and a lack of empathy would explain that evil threat she made, to Gillian’s face, about the baby.

 

4) Is often envious of others or believes that others are envious of him or her

 

I think part of the reason Claire was so angry at Gillian was because, deep down, she was envious of her pregnancy.  We know that, in parallel, Claire is consulting a doctor about becoming pregnant and is told that her chances are slim.  This is such a narcissistic injury to Claire that she directs her rage at Gillian.  I don’t think she was even consciously aware of how envious she is of Gillian for being pregnant.

Another example would be the look on her face when Galloway indicates he is madly in love with his fiancé and wishes to make a life with her.  For a second her face darkens – a flash of jealous rage – which then translates to indifference and almost pleasure at his eventual public humiliation.

 

5) Shows arrogant, haughty behaviors or attitudes 

 

Image: Netflix
Image: Netflix

Correct me if I am wrong, but Claire just does not appear to be that warm or genuine and has an almost untouchable air about her. Furthermore, we only ever see her with people who work for her (i.e. have less power than her) or with people more powerful than her (i.e. whose power she wants for herself). Other than Frank, where are her equals? Her oldest friends and colleagues? Her family? People who might not be influenced by her title or power?

 

One last comment – in Season 2 Claire certainly comes across as more ruthless and power hungry than the Claire in Season 1—whether she is now showing her true colors and is dropping her facade or just becoming more lost in Frank’s world and hence looking more like him is unclear to me…

 

I suppose we will find out in Season 3!

 

Repost: Francis “Frank” J. Underwood From Netflix’s House of Cards: A Textbook Case of Antisocial Personality Disorder

Last week, Netflix released Season 3 of House of Cards. In light of this, I am reposting a blog I wrote about the second season of the series last year: “Frank” J. Underwood From Netflix’s House of Cards: A Textbook Case of Antisocial Personality Disorder.” 

 

I always like to take the opportunity to explain misunderstood psychiatric concepts or diagnoses, and to clarify when a psychiatric term is used incorrectly or prone to misinterpretation.  In today’s blog, I aim to do both of these things.

 

First, I’ll use the character of Frank Underwood as a “case study” to illustrate the misunderstood psychiatric diagnosis of Antisocial Personality Disorder.

 

Kevin Spacey in House of Cards, Image: Netflix
Kevin Spacey in House of Cards, Image: Netflix

While enjoying the second season of House of Cards, I could not help but notice how Kevin Spacey’s character, Frank Underwood, meets a textbook definition of Antisocial Personality Disorder (ASPD).  Inspired by Spacey’s tremendous performance, I thought I would venture forth and use this example of a central character in a drama to illustrate this misunderstood and, often, underestimated psychiatric disorder.

Individuals with antisocial personality disorder (or sociopaths) are difficult and dangerous; they deny, lie, and contribute to all manner of mayhem in our communities and societies. They know full well what is going on around them and know the difference between right and wrong (and hence are fully responsible for their own behaviors) yet are simply unconcerned about such moral dilemmas.

Below is the “textbook” definition of ASPD interspersed with examples from the life of Frank Underwood, which perfectly illustrate the elements of this disorder.

 

SPOILER ALERT: For those of you who have not watched all of Season 2 yet, consider yourself warned.

 

Antisocial Personality Disorder 301.7 (From the DSM V): 

A) A pervasive pattern of disregard for and violation of the rights of others,  occurring since age 15 years, as indicated by three (or more) of the following

1) Failure to conform to social norms with respect to lawful behaviors, as indicated by repeatedly performing acts that are grounds for arrest.

 

Image: Netflix
Image: Netflix

Murder. Not once, but at least two times (that we know of).  He swiftly pushed Zoe Barnes into the path of an oncoming metro train. Let’s not forget this was a woman with whom he had had a physical relationship with and a (sort of) emotional intimacy.  No doubt, this personal history contributed to Barnes’ poor judgment and her letting down her guard; she suspected he was a murderer but still underestimated what he was truly capable of. Frank leveraged her miscalculation to his favor.

In addition to murder, let’s not forget the unlawful behaviors carried out, on his orders, by those who work for him – e.g. vanquishing the remaining reporters who tried to expose him for what he truly is.

 

2)  Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure

 

Image: Netflix
Image: Netflix

Honestly, I found it hard to keep track of the web of lies Frank wove during Season 2. What was notable was the sincerity with which he told many of these lies, almost as though in the moment he believed them himself. He repeatedly lied so he could drive a wedge in the previously tight relationship between the Billionaire, Raymond Tusk, and the President – a wedge he created, on purpose (and at much cost and hassle to the American tax payer!) to further his own goal of becoming President. 

 Then there was the web of lies told to cover the fact that his wife Claire’s (played by Robin Wright) abortion had nothing to do with her alleged rape by General McGinnis, but more to do with the inconvenience of Underwood’s political campaign timings.

A final example is the strategic drama he created (along with Claire) to cover her affair with Galloway.  Again, there was no inkling of any remorse or feelings that they should be held accountable for their actions.  Instead there was only a rigid entitlement:  How dare anyone get in the way of me becoming president?

 

3)  Impulsivity or failure to plan ahead

 

Underwood has a degree of impulse control.  In fact, his ability to plot, scheme, and plan has served him well with regards to his political posturing and career.  This is not the case for many with ASPD.  Those without means, education, or status can be dangerously impulsive, and this behavior often leaves them in jail, prison, or dead.

 

4)  Irritability and aggressiveness, as indicated by repeated physical fights or assaults

 

Image: Netflix
Image: Netflix

See point #3.  He is aggressive and violent but has probably learnt, over time, to become more measured in his actions.  Repeated irritable outbursts and acts of physical aggression are not compatible with life in political office.

 

5)  Reckless disregard for safety of self or others

 

 See point #1.

 

6)  Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations

 

 Did Frank Underwood honor any of his obligations or duties associated with being the Vice President of the United States of America?  Did he use his powers to be of service to the American people or to his country?  No.  His days and nights appeared to be utterly consumed with one goal…to become president of the United States.  At any cost.

 

7)  Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated or stolen from another.

 

Image: Netflix
Image: Netflix

This was best illustrated in his reaction to the murder of  Zoe Barnes.  It was business as usual.  Not a hair out of place, no loss of appetite or sleep.  No remorse, no guilt or angst. She was getting in his way as he tried to forge a path to the presidency, so he got rid of her and never thought about it again. Her murder was no more of an incident than flicking lint from his jacket lapel.  In fact, he was so cool after the event that it makes me wonder about his psychopathic tendencies, but that would be a whole other blog for another day.

 

B) Individual is at least 18 years old

 

C) There is evidence of conduct disorder with onset before age 15 years

 

Who knows what skeletons lie in the Frank Underwood closet?

 

D) The occurrence of antisocial behavior is not exclusively during the course of schizophrenia or bipolar disorder.

 

One final point that is not done justice in the brief description above (more details can be found here) – those with ASPD are able to be utterly charismatic, charming, and almost bewitching. This characteristic is one Spacey has down to a tee in his performance.

Image Credit: Melinda Sue Gordon
Image Credit: Melinda Sue Gordon

When Frank wants something or needs to manipulate someone, he is able to “switch on” the charm in an instant.  He conveys to others that he cares deeply about them by flashing an infectious smile and being gracious and attentive.

And, as season 2 showed, there were many who fell prey to his deceit…not least of all the President of the free world.  Perhaps nowhere is his charisma more evident that in the perverse loyalty of those in his inner circle; all turn a blind eye to what he is capable of and appear to be utterly captivated by his personality and presence.

 

My second point: The term “antisocial” is used incorrectly or prone to misinterpretation. 

 

The seriousness of ASPD leads me to my next point – the confusing usage of the term “antisocial.” Antisocial is often used in lay language to indicate someone who is shy and unwilling or unable to associate in a normal or friendly way with other people. While this is a legitimate definition of the word, I have never been a fan of how this one word can be used in such opposing ways. I would advocate that we reserve this word for individuals with personality disorders associated with the features described above. People who are described as “antisocial” because they are shy are (typically) not dangerous.  This is in sharp contrast to the definition of antisocial widely used in mental health terminology. In this context antisocial goes hand in hand with being “antisociety” and is a disorder associated with much more sinister and outright dangerous and reckless behavior.

 

At this point, many of you might be saying, well who cares about these individuals?  They are just evil, so why bother to make a psychiatric case about them?  Just lock them up and throw away the key!

 

But the situation is vastly more complicated than that.

 

ASPD is common.  For the reasons outlined above (their lies, deception, and charm) sociopaths are not always easy to detect, yet ASPD is associated with huge costs to our society that extend well beyond the individual who has the disorder. We have to stay curious about ASPD – about how the disorder develops, how to detect it, how to manage it – as our societies pay for its consequences on many levels, economically, socially, and emotionally.

And when someone with ASPD ends up in a position of unparalleled power? Well, who knows what the consequences could be.

 

The Top Eleven Ways to Tell that a Journal is Fake

I am delighted to offer Mind the Brain readers a guest blog written by my colleague, Eve Carlson, Ph.D.  Eve Carlson is a clinical psychologist and researcher with the National Center for PTSD and the U.S. Department of Veterans Affairs, VA Palo Alto Health Care System.  Her research focuses on assessment of trauma exposure and responses, and she has developed measures of PTSD, dissociation, trauma exposure, self-destructive behavior, affective lability, and risk for posttraumatic psychological disorder.  Her research has been funded by National Institute for Mental Health (U.S.) and the Dept. of Veterans Affairs (U.S.) and recognized by awards from the International Society for Traumatic Stress Studies and the International Society for the Study of Trauma and Dissociation.  Her publications include books on trauma assessment and trauma research methodology and numerous theoretical and research articles.  She has served as President and a member of the Board of Directors for the International Society for Traumatic Stress Studies and on the editorial boards of several journals.

 

The Top  Eleven Ways to Tell that a Journal is Fake

Eve Carlson, Ph.D.

Past President, International Society for Traumatic Stress Studies

If you have ever published a scholarly paper, your email inbox is probably peppered with invitations to submit papers to new journals with plausible-sounding names.  Many people dismiss these emails as spam, but with all one hears about the impending death of paper journals, who knows what is next in the wild, wild West of open source publishing?  And if you venture to click on a link to the journal, you may well see a web page boasting about a journal editor who is a prominent name in your field, an editorial board that includes several luminaries, instructions for authors, and legitimate-looking articles.  With the “publish or perish!” pressure still going strong, what’s an academic to do?

I recently stumbled into an “investigation” of a new, online, open source journal in the course of service as a leader of a professional society.  When I was president of an international professional society, a new journal began soliciting submissions that had a name that was very similar to our Society’s journal -“Journal of XXX”.  The Society feared that the new journal, called “Journal of XXX Disorders and Treatment”, would be mistaken for an offshoot of the original.  I saw the names of colleagues I knew on the editorial board and skimmed some of the opinion piece articles posted online and assumed it was a new experiment in open source publishing. But when I contacted the colleagues and began asking questions, it quickly became apparent that this journal had no editor, editorial board members were acquired via spam emails to authors of published articles, the journal appeared to follow no standard publishing practices, and most editorial board members had observed irregularities that made them suspicious that the journal was not legitimate.  Once informed of the problems observed and put in communication with one another, 16 of the 19 editorial members resigned en masse.

 

Based on actual experiences looking into three questionable open source journals, you can tell a journal is fake when…

 

1)  Searching in the box marked “Search this journal” on the journal web page for the name of an author of an article in a recent issue of the journal does not return any hits.

 

2)  Clicking on a link like this medline on the journal web site leads to the spoof site www.Medline.com.

 

3)  No specific person is identified as the editor of the journal or the person who appears to be identified as the journal’s Editor on the web site says he is not the editor.

 

4)  Google Maps searches for the address of journal shows its headquarters is in a suburban bungalow.

googlemaps

 

5)  You cannot find articles from a bio-medical journal when you search PubMed.  [You can check by searching for the journal title here]

 

6)  The journal’s mission on its home page is described in vague, generic terms such as “To publish the most exciting research with respect to the subjects of XXXXXX.”

 

7)  When you call the local phone number for the journal office listed on the web page, any of these happen:  1. No one answers. 2. Someone answers “hello?” on what sounds like a cell phone and hangs up as soon as they hear you speaking.  3. The call is forwarded to the 800 phone bank for the publisher, and the person on the other end cannot tell you the name of the editor of the journal.

 

8)  PubMed Central refuses to accept content from a publisher’s bio-medical journals and DHHS sends a “cease and desist” letter to the publisher.

 

9)  The journal publisher’s posts online a legal notice warning a blogger who writes about the publisher that he is on a “perilous journey” and is exposing himself to “serious legal implications including criminal cases lunched (sic) again you in INDIA and USA” and directs him to pay the publisher $1 billion in damages.  Check out the legal notice here.

 

10)  The journal issues and posts online certificates with hearts around the border that certifies you as “the prestigious editorial board member of [name of journal here].”

certificate

 

11)  The journal posts “interviews” with members of its editorial board that appear to be electronic questionnaires with comical responses to interviewer questions such as:

interview1

interview3

CORRECTION: The site www.medline.com is real, not a spoof site.

 

 

Repost: The Latest and Greatest in Treatment for PTSD: Magic Bullets and Cutting Edge Innovation

June is PTSD awareness month.  In light of this, I am reposting a blog I wrote about “The Latest and Greatest in Treatment for PTSD.”  If you are interested in knowing more about PTSD please check out the NCPTSD website.

Also, below are links to other blog posts I have written about PTSD and related topics:

 

The Latest and Greatest in Treatment for PTSD: Magic Bullets and Cutting Edge Innovation

I am frequently asked to talk about PTSD to professional audiences and, without 2012-04-05-ptsd1exception, always get a post talk question asking about my experience with some experimental intervention that someone read about somewhere in a newsmagazine or heard about from the T.V.

Internally, I always groan.

Having just spent 60-90 minutes pouring over carefully crafted PowerPoint slides that contain information about the evidence base for the treatments of PTSD and what best practices consist of, why I am always confronted with a zealous audience member who is obsessed with the new, the innovative, or the magic bullet?

In the interest of full disclosure, I have to share my viewpoint as being that of a health services researcher.  I approach PTSD treatment with a basic belief that we already have pretty good treatments, and the issues with getting better outcomes for PTSD lie more in how we implement those treatments, the limitations of the systems that provide care, massive issues of access to care (i.e. those who need care the most simply can’t access it for a myriad of reasons), and healthcare disparities (that an individual’s outcomes for PTSD are more likely linked to their zip code as opposed to their genes/neurotransmitters).

In short, I usually have a healthy skepticism toward the experimental or magic bullets type of treatments for PTSD, which often get a lot of media attention and can be very seductive to the brain of a researcher or clinician who spends their days trying to help individuals who live with PTSD.

 

Still, today I am curbing my skepticism and with much enthusiasm am writing about some of the hottest ideas for innovation in the treatment of PTSD.

 

Please note: MANY of these approaches are still considered EXPERIMENTAL, and I am listing them in no particular order of importance.

1. Mind – Body Practices for PTSD

Image Credit: Cornelius383

Mind Body practices are increasingly used to offer symptom reduction for PTSD.  Approaches such as Yoga, Tai Chi, Mindfulness Based Stress Reduction, Meditation, and Deep breathing are some examples.  There are about 16 rigorous studies that have been done to date, most of which have small sample sizes.  Whilst early findings suggest such practices can have a beneficial impact on symptoms like intrusive memories, avoidance, and increased emotional arousal, there is insufficient evidence to support their use as standalone treatments, though they can be recommended as an adjunctive treatment.

 

2. Cervical Sympathetic Blockade and Stellate Ganglion Block for PTSD 

In 2008, reports started to emerge about a minimally invasive manipulation of sympathetic nerve tissue in patients with PTSD that relieved their anxiety.  The procedure consisted of injecting a local anesthetic into sympathetic cervical nerve tissue at the C6 level and was apparently accompanied by immediate relief by the patient.  In 2012, a case series was reported where treatment resistant veterans with PTSD were given a stellate ganglion block and also a pre and post intervention CAPS. After the intervention, 5/9 of the patients experienced significant improvement; these benefits diminished over time and the benefits were not universal.  Controlled trials are currently underway to investigate this intervention further.

 

3. Virtual Reality Exposure Therapy

Virtual Reality exposure therapy utilizes real time computer graphics, body tracking devices, visual displays, and other sensory input devices to give the patient the experience that they are immersed in a virtual environment. It is an enhanced version of the imaginal exposure typically utilized as a part of trauma-focused psychotherapies. In 2001 an open clinical trial of Virtual Reality exposure therapy yielded promising results. It is currently being studied under controlled conditions.

 

4. D-Cycloserinemanypills

D-Cycloserine is a partial agonist of the NMDA receptor (a brain receptor that plays an essential role in learning and memory). It has been used to treat social phobia and panic disorder and to enhance the effects of psychological therapies for those disorders.  Preliminary data suggests it can be a useful adjunct in addition to evidence-based psychotherapies for patients living with severe PTSD.

 

5. Ketamine

Ketamine is a non-barbiturate anesthetic and antagonist at the NMDA receptor that is typically administered intravenously.  It has been used for years for patients with severe burns and it was, in this use, that its dissociative properties became apparent.  Retrospective studies show that those who received Ketamine after a traumatic event were less likely to develop PTSD.  It has been postulated that Ketamine may disrupt the process via which traumatic memories are laid down. A 2014 JAMA study reported on a RCT which demonstrated a rapid reduction in symptom severity following Ketamine infusion in patients with chronic PTSD.

 

6. Increasing the Intensity of Treatments

In an experimentation with packaging, British researchers compressed versions of trauma-focused psychotherapies for PTSD into a seven day intensive treatment.  This was found to work as well as treatment as usual, which is the same treatment delivered once a week, over 12 weeks.  Such an approach was postulated to be more efficient and convenient and was associated with faster improvement in symptoms and lower dropout rates.

 

7. Memantine colorful-pills

Memantine is a non competitive NMDA antagonist that is thought to protect the glutamergic destruction of neurons and hence prevent the hypothesized neurodegeneration in the hypothalamus, which contributes to the memory issues related to PTSD.  In a 2007 open label small trial, Memantine was found to be associated with some encouraging outcomes.  Double blind placebo controlled trials are pending.

The Vital Importance of Integrating Primary Care and Mental Health Care: How the VA Does It

For the better part of the last two decades I have practiced psychiatry in a variety of different American healthcare systems, and over these years I have, on numerous occasions, heard psychiatric services referred to in manner that imply (often subtly) that such services are not medical care.  These references come not only from patients, but nurses and doctors (including myself) too.

 

“Yes Mr. Jones you need to follow up with your regular medical doctor about that issue.”

Or

“Dr. Jain, I went to see my medical doctor and he told me my blood pressure was high.”

 

Yes, I have been guilty of propagating this false dichotomy myself, and I too end up colluding with this societal misperception that somehow psychiatric care is NOT medical care, but something separate or distinct from other medical services. I think I did it because, on a day to day basis, when I am busy in clinic it is easier to collude than to get into a debate about semantics.

 

Still, in today’s blog I want to highlight the fact that this artificial distinction between physical and mental health perpetuates much of the stigma and misperception that, we as a society, have toward mental illness. But, most importantly, I want to convey my belief that when mental and physical well-being are separated, healthcare becomes poor in quality.

 

When I did my medical school training in Great Britain, every single medical school student was required to complete a 3 month (minimum) rotation in psychiatry and, furthermore, psychiatry was one of the specialties that had to be passed, in clinical exams, at finals before your MD would be granted.  Why, might you ask, should a ENT surgeon/dermatologist/ER physician to-be  need to spend so much time training in psychiatry?

Firstly, the majority of British medical students become primary care doctors.  The system is set up that way, so there are relatively few spots for specialty training (e.g. cardiology or plastic surgery) and there is much more emphasis for medical students to become primary care doctors.  This is based on the premise that that is what the country needs so that is what medical schools should provide.

colorful-pillsIt’s well known that a significant percentage of patients seen in primary care have a mental illness/disorder as a primary problem.  In fact, most prescriptions for psychotropic medications are written in primary care, hence it is logical that every British medical graduate be well versed and adept in diagnosing, treating, and managing psychiatric disorders.

Secondly, if one looks at mental illness from a sheer epidemiological point of view, no physician can afford to not be well trained in the fundamentals of psychiatric practice.  I, as a psychiatrist, may or may not, in my career, treat a patient who also develops a testicular tumor, needs bypass surgery, or has a fractured hip, but epidemiologically speaking, my colleagues in urology, cardiology, and orthopedics WILL treat patients who have comorbid depression/anxiety or even severe mental illness such as Bipolar Disorder or Psychosis.  For this reason, it makes sense that these providers have some awareness or understanding of such disorders.

My experience with US healthcare is different; the business side of US medicine has a tendency to favor medical specialties that are procedure-based or that generate flash technologies that can be promoted and attract more market share.  Unfortunately, psychiatry often fares poorly when it comes to such business strategies.  Mental illness can be chronic, take time to treat, and there is rarely a quick fix or magic cure.  Moreover, mental illness can be associated with a downward drift, e.g. someone becomes psychotic, they lose their job, and then their health insurance etc. etc.

 

In the U.S. healthcare business the specialty of psychiatry is often not given a seat at the table.

 

I think this, in part, explains this nonsensical divide between “medical” and “psychiatric” that we often have in healthcare.  Of course, it is a fallacy. Mental health and physical health are intricately link on every level, from a cellular level to a more macro perspective of how human beings navigate their day to day life.  In my view, a sophisticated healthcare system should reflect this intricate relationship and integrate primary and psychiatric care, i.e. get rid of this false distinction or separation by physically placing both services in one clinic, side by side.

soldier-294476_640One American healthcare system has been a leader in integrating primary care and mental health care. That system is the Veterans Health Administration (VA). Unlike many other U.S healthcare systems (which place more emphasis on treating individuals), the VA is charged with taking care of a population, i.e. veterans. This mission guides where the VA places emphasis, so whatever the prevalent issues are for this population becomes the area where the VA will place emphasis and resources.

 

The VA aims to meet the needs of the population it is serving, and hence gives psychiatry a seat at the table.

 

With more than 1,000 outpatient clinics, the VA is the largest health care system in the United States, and it has a very clear sense of its population. Over the past 15 years, the VA has not only participated in some of the biggest studies of integrated care, but has made a commitment to provide patient-centered integrated care to its population.

For the last two years I have been in the role of medical director of the Primary Care-Behavioral Health Team at the VA Palo Alto Health Care System, and I spend most of my days right here at the interface between physical well-being and mental health.  Contrary to some of my previous experiences in healthcare, the last two years have taught me the following:

 

  • Our colleagues in primary care place very high value on psychiatric and psychological consultation from colleagues.

 

  • The clinical work is very rewarding and in many ways bypasses a lot of the frustrations we often feel as physicians working in fragmented health care systems.

 

  • As a specialist, your experience and knowledge can add enormous benefit in making health care more streamlined and patient-centric. There are many opportunities for psychiatrists to act as educators to both colleagues and patients about common misperceptions surrounding mental disorders and mental health care.

 

  • Being a consultant for and working closely with a team of professionals from various specialty backgrounds helps your own career development. It prevents you from getting rusty in areas of medicine other than psychiatry and keeps you on the cutting edge of how health care systems are evolving to meet the needs and demands of all stakeholders.

 

Integrated care is the way of the future, and I feel fortunate that I work in a system that is at the cutting edge of such innovation.

 

For more information about the integrated model at the VA Palo alto Healthcare System please follow this link.

Using “Nashville” to Demonstrate The Truth about Flashbacks

I think it would be fair to say that most mental health professionals groan when watching how mental illness is represented on T.V shows. Too often popular culture portrays the lives of individuals living with mental illness (or the symptoms of psychiatric disorders) in a one dimensional way that lacks nuance or, worse, is outright misleading and only serves to perpetuate the many myths and misperceptions about psychiatric illness that already exist in our society.

 

Image Credit: ABC
Image Credit: ABC

Last month, whilst watching episode 19 of Season 2 of the hit TV show Nashville, I could not help but be pleasantly surprised at the show’s careful depiction of the psychiatric symptom known as a “flashback.” In this episode the musical prodigy, Scarlett O’Connor, (played by the Australian actress Claire Bowen) experiences a flashback of childhood trauma whilst performing live on stage in front of tens of thousands of people.

 

Whilst the term “flashback” is used loosely in everyday culture to describe casual recollections of memories from earlier on in life, mental health professionals have a different definition of the word flashback. When we use the word flashback, we use it to describe a phenomenon where an individual experiences involuntary recurrent memories.  The experience is often sudden and usually a powerful re-experiencing of a past experience or elements of a past experience.  The term is used particularly when the memory is so intense that the person “relives” the experience, and this reliving contributes to a serious disruption in the person’s life.

From my perspective, as a Posttraumatic Disorder (PTSD) expert, I find this psychiatric symptom particularly fascinating as it is commonly associated with the traumatic experiences associated with PTSD.

 

Definition of flashback

 

2012-04-05-ptsd1In the DSM V, references to flashbacks are to be found under the heading that describes PTSD, i.e. it is a symptom typically associated with PTSD.  A flashback is an example of a dissociative reaction – i.e. when the individual feels or acts as if the traumatic events were recurring. Such reactions occur on a continuum, with the most extreme expression being a complete loss of awareness of one’s present surroundings

A related quote from DSM V: (please note, this text refers to the definition of flashback as it pertains to adults)

 

“The individual may experience dissociative states that last from a few seconds to several hours or even days, during which components of the event are relived and the individual behaves as if the event were occurring at that moment. Such events occur on a continuum from brief visual or other sensory intrusions about part of the traumatic event without loss of reality orientation, to complete loss of awareness of present surroundings.  These episodes, often referred to as “flashbacks” are typically brief but can be associated with prolonged distress and heightened arousal”

 

There are surprisingly few empirical publications on flashbacks and even fewer articles on the phenomenology of flashbacks. Flashbacks are a defining feature of posttraumatic stress disorder (PTSD), but there have been few studies of their neural basis. But the study of flashbacks is becoming important, as they are given an increasingly prominent role in the diagnosis of posttraumatic stress disorder .

Indeed, the precise definition or clinical nature of a flashback remains a matter of debate, even amongst neuroscientists and mental health professionals, and this was part of the reason I was so impressed with the depiction in Nashville.

 

What does it feel like to have a flashback?

 

If you were experiencing a flashback of a traumatic experience it could be so realistic that it feels as though you are living through the experience all over again. You experience the flashback in your mind, but may also feel the emotions and physical sensations – fear, sweating, smells, sounds, and pain – associated with the original trauma.

Flashbacks are often triggered by some kind of reminder of the original trauma; it can be something as simple as a sensory experience associated with the original trauma e.g. the scent of a particular perfume, the feel of raindrops on a wet day, or a sudden loud street noise.

 

I have witnessed patients who are having a flashback of psychologically traumatic memories and the depiction in Nashville was pretty authentic.

 

The Nashville episode was classic not only for the scenes that depicted the actual flashback, as experienced by Scarlett O’Connor, but the narrative leading up to the terrible event was equally compelling and authentic.  The weeks and months leading up to the “meltdown” on stage shows a Scarlett who is working hard on a serious music album; she writes about her complicated, and often tortured, relationship with her mother.  Whilst her creative output is good, the process has been stressful and she has isolated herself from her closest friends and her maternal uncle—the key emotional supports in her life.  She starts to take illegally diverted prescription stimulants to help her stay awake so she can finish the album, this combined with the stresses and strains of an intensive tour schedule start to take its toll.

Photo by ABCNetwork/YouTube (screen capture)
Photo by ABCNetwork/YouTube (screen capture)

The “trigger” for Scarlett is the surprise arrival of her mother when she is on tour in San Francisco. Her mother, Beverly, is the main perpertrator of her childhood abuse.  Initially Beverly is civil but we soon start to see the side of her which is emotionally abusive and physically intimidating toward Scarlett. Scarlett starts to experience brief flashbacks of childhood physical abuse and neglect where she was locked in cupboards for hours at a time with no food, water, or access to a bathroom. Startled by the flashbacks and under pressure to perform on stage she starts to consume alcohol to “deal” with the flashbacks.

 

This is common amongst individuals experiencing symptoms of posttraumatic stress – they “self medicate” their symptoms with alcohol or illicit drugs.  Unfortunately, intoxication often contributes to an overall worsening of symptoms, and this is what happens to Scarlett.

 

The weeks of stress, lack of sleep, and abuse of prescription stimulants combined with the pressure of performing on stage and a grueling tour schedule make her susceptible to experiencing mental health distress. The arrival of her mother in “real life,” who is the perpetrator of the childhood abuse, combined with Scarlett’s alcohol intoxication triggers a horrifically intense flashback which, unfortunately, occurs whilst she is on stage.

The episode is particularly valuable as it shows the experience of a flashback from Scarlett’s perspective. She is no longer the country music star performing on stage for a live audience, she is a seven year old girl, locked in a closet, terrified for her life as she listens to her mother full of rage, ranting and raving outside the door.  As a result Scarlett behaves that way, retreating from light and noise and eventually curling up under her grand piano.

There are problems with the storyline – the episode is tactlessly titled, “Crazy” and Scarlett’s brief “hospitalization” where she is admitted to “get everything out of her system” returns the storytelling to the familiar levels of inaccurate and overly simplistic portrayals of mental illness that I am used to groaning and moaning about.  Nonetheless, when it comes to mental health issues in TV shows, Scarlett’s performance scene was a refreshingly truthful depiction of a flashback, and one that I had nothing to groan about.