Still 'Profiteering From Anxiety'

Late last year, the excellent Neurobonkers blog covered a case of 'Profiteering from anxiety'.

It seems one Nader Amir has applied for a patent on the psychological technique of 'Attentional Retraining', a method designed to treat anxiety and other emotional problems by conditioning the mind to unconsciously pay more attention to positive things and ignore unpleasant stuff.

For just $139.99, you can have a crack at modifying your unconscious with the help of Amir's Cognitive Retraining Technologies.

It's a clever idea... but hardly a new one. As Neurobonkers said, research on these kinds of methods had been going on for years before Amir came on the scene. In a comment, Prof. Colin MacLeod (who's been researching this stuff for over 20 years) argued that "I do not believe that a US patent granted to Prof Amir for the attentional bias modification approach would withstand challenge."

Well, in an interesting turn of events, Amir has issued just Corrections (1,2) to two of his papers. Both of the articles reported that retraining was an effective treatment for anxiety; but in both cases he now reveals that there was

an error...in the article a disclosure should have been noted that Nader Amir is the co-founder of a company that markets anxiety relief products.

Omitting to declare a conflict of interest... how unfortunate.

Still, it's an easy mistake to make: when you're focused on doing unbiased, objective, original research, as Amir doubtless was, such mundane matters are the last thing you tend to pay attention to.

Amir, N., and Taylor, C. (2013). Correction to Amir and Taylor (2012). Journal of Consulting and Clinical Psychology, 81 (1), 74-74 DOI: 10.1037/a0031156

Amir, N., Taylor, C., and Donohue, M. (2013). Correction to Amir et al. (2011). Journal of Consulting and Clinical Psychology, 81 (1), 112-112 DOI: 10.1037/a0031157

Language That Is Person-First

An editorial in the Canadian Medical Association Journal by Roger Collier highlights the problem of Person-first language: Laudable cause, horrible prose

Person-first language (or language that is person-first, as it prefers to be known) is the nice idea that rather than calling someone, say, "blind", we should call them "a person who is blind", so as to remind everyone that they're not defined by their blindness but are a person first... clever, eh?

No. For one thing, it's just bad English. As Collier puts it: "There’s a reason Ernest Hemingway didn’t call his novel The Person Who Was Male and Advanced in Years and the Sea."

He goes on to quote linguist Helena Halmari who highlights a number of problems with the approach:

In English, emphasis naturally occurs at the end of sentences... so by pushing mention of a disability or disease deeper into a sentence, adherents to person-first language may actually be adding stress to those words. “What you have at the end of a sentence is the new information that gets the most attention,” says Halmari.

Worse yet...

Tucking the disability behind the noun may contribute to stigma rather than reduce it. After all, most adjectives with positive connotations precede nouns. We do not typically say a “person who is beautiful,” for instance, or a “person who is intelligent.” Sticking a word in the shadow of a noun can create the impression that there is something inherently wrong with it - that it should be hidden.

As a 'person with mental illness', I entirely agree. I am a man, a neuroscientist, a blogger; I'm not ashamed of those things, so I don't feel the need to erect linguistic fences between them and my person. I am also a psychiatric patient, a depressive, mentally ill; I'm not ashamed of that, either, and I resent the implication - however well-intentioned - that I should.

To me that's the really troubling part of this: the should aspect. The only reason you should not call someone something, is because they ask you not to.

Person-first advocates claim to be speaking on behalf of the 'group' who are harmed and offended by the current use of language - but who gave them that right? They don't speak for me, or anyone but themselves. I don't see 'the mentally ill' as a group at all, but even if it is one, they're certainly not our  elected representatives.

So non-person-first language doesn't offend me. In fact, I'm more worried by the idea that people will assume that, because I'm mentally ill, I want them to use person-first language. Now that's offensive.

Drunk Rats Could Overturn Neurological Orthodoxy

A form of brain abnormality long regarded as permanent is, in fact, sometimes reversible, according to an unassuming little paper with big implications.

Here's the key data: some rats were given a lot of alcohol for four days (the "binge"), and then allowed to sober up for a week. Before, during and after their rodent Spring Break, they had brain scans. And these revealed something remarkable - the size of the rats' lateral ventricles increased during the binge, but later returned to normal.

Control rats, given lots of sugar instead of alcohol, did not show these changes.

This is really pretty surprising. The ventricles are simply fluid-filled holes in the brain. Increased ventricular size is generally regarded as a sign that the brain is shrinking - less brain, bigger holes - and if the brain is shrinking that must be because cells are dying or at least getting smaller. So bigger ventricles is bad.

Or so we thought... but this study shows that it might not always be true: alcohol reversibly increases ventricular volume over a timescale of days. It does so, the authors say, essentially by drying brain tissue out; like most things, if you dry the brain out, it gets smaller (and the ventricles get bigger) but when the water comes back to the tissues, it expands again.

As you can see here in Figure 2...

Maybe. I admit that just eyeballing this, it looks more like the ventricles are getting brighter, rather than bigger, but I'm not familiar with the details of water scanning. Maybe some readers will know more about it.

If it's true, this is big - maybe it's not just high doses of alcohol that does this. Maybe other drugs or factors can shrink or expand, the ventricles, or even other areas, purely by acting on tissue water regulation, rather than by anything more 'interesting'.

Take the various claims that some psychiatric drugs boost brain volume while others decrease it, just for starters...could they be headed for a watery grave?

Of course, this is in mice - and it might not translate to humans... we need to find out, and I for one am keen to apply for a grant. Here's my draft:

Participants: 8 healthy-livered neuroscientists.
Materials: 1 MRI scanner, 1 crate Jack Daniels.
Methods: Subjects will confer to pick a Designated Operator, who will remain sober. If no volunteers for this role are forthcoming, selection will be randomized by Bottle Spinning. All other participants will consume Jack Daniels ad libitum, and take turns being scanned. Once all Jack Daniels is depleted, participants will continue to be scanned until fully sobered up (defined as when they can successfully spell "amygdalohippocampal").
Instructions to Participants: i) what happens in the magnet, stays in the magnet. ii) If you 'dirty' the scanner, you clean it up. iii) Bottle caps are not MRI safe!

Er... seriously though, someone should check.

Zahr NM, Mayer D, Rohlfing T, Orduna J, Luong R, Sullivan EV, and Pfefferbaum A (2013). A mechanism of rapidly reversible cerebral ventricular enlargement independent of tissue atrophy. Neuropsychopharmacology  PMID: 23306181

DSM-5: A Ruse By Any Other Name...

In psychiatry, "a rose is a rose is a rose" as Gertrude Stein put it. That's according to an editorial in the American Journal of Psychiatry called: The Initial Field Trials of DSM-5: New Blooms and Old Thorns.

Like the authors, I was searching for some petal-based puns to start this piece off, but then I found this "flower with an uncanny resemblance to a MONKEY" which I think does the job quite nicely:

Anyway, the editorial is about the upcoming, controversial fifth revision to the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association (APA).

A great deal has been written about the DSM-5 over the past few years, as "the rough beast, its hour come round at last / Slouches towards Bethlehem to be born" (see, I can reference early-20th-century poetry too).

But now the talk has moved into a new phase, because the results of the DSM-5 'field trials' are finally out. In these studies, the reliability of the new diagnostic criteria for different psychiatric disorders was measured. The new editorial is a summary and discussion of the field trial data.

Two different psychiatrists assessed each patient, and the agreement between their diagnoses was calculated, as the kappa statistic, where 0 indicates no correlation at all and 1 is perfect.

It turns out that the reliabilities of most DSM-5 disorders were not very good. The majority were around 0.5, which is at best mediocre. These included such pillars of psychiatric diagnosis like schizophrenia, bipolar disorder, and alcoholism.

Others were worse. Depression, had a frankly crap kappa of 0.28, and the new 'Mixed Anxiety-Depressive Disorder' came in at -0.004 (sic). It was completely meaningless.

The American Journal editorial was written by a group of senior DSM-5 team members. I'm sure they wanted to write a triumphant presentation of their work, but in fact the tone is subdued, even apologetic in places:

As for most new endeavours, the end results are mixed, with both positive and disappointing findings...Experienced clinicians have severe reservations about the proposed research diagnostic scheme for personality disorder...like its predecessors, DSM-5 does not accomplish all that it intended, but it marks continued progress for many patients for whom the benefits of diagnoses and treatment were previously unrealized.

Remember: this is the journal published by the organization responsible for the DSM and even they don't much like it.

But the real story is even worse. The previous editions of the DSM also conducted field trials. These trials had a system to describe different kappa values: for example, 0.6-0.8 was 'satisfactory'.

However, the new DSM-5 studies used a different, lower threshold. They simply moved the goalposts, deeming lower kappa values to be good. At one point, they wrote that values of above 0.8 would be 'miraculous' and above 0.6 a 'cause for celebration', yet this wasn't the view of previous DSM developers.

The indispensable 1boringoldman blog has a nice graphic showing the results of the DSM-5 trials, with the kappas graded according to the old vs. the new criteria. As you can see, the grass is greener on the new side.

The fact is that the DSM-5 field trial results are worse than the results from DSM-III, the 1980 version that's served mostly unchanged for 30 years (DSM-IV made fairly modest changes.) The reliabilities have got worse - despite the editorial's claims of 'continued progress'. It's true that the DSM-5 field trials were a lot bigger and conducted rather differently, but still, it's a serious warning sign.

Finally, there was great variability in the results between different hospitals - in other words the reliability scores were not, themselves, reliable. Some institutions achieved much higher kappa values than others, but it's anyone's guess how they managed to do so.

Still, there's great news: the DSM-5 is just a piece of paper (well, a big stack of them). Any psychiatrist is free to ignore it - as the creator of the more reliable DSM-IV (not III, oops) is now urging them to do.

Freedman R, Lewis DA, Michels R, Pine DS, Schultz SK, Tamminga CA, Gabbard GO, Gau SS, Javitt DC, Oquendo MA, Shrout PE, Vieta E, and Yager J (2013). The Initial Field Trials of DSM-5: New Blooms and Old Thorns. The American Journal of Psychiatry, 170 (1), 1-5 PMID: 23288382

Smart People Say They're Less Depressed

The questionable validity of self-report measures in psychiatry has been the topic of a few recent  posts here at Neuroskeptic.

Now an interesting new study looks at the question in issue from a new angle, asking: what kind of people report feeling more or less depressed? Korean researchers Kim and colleagues found that intelligence and personality variables were both linked to the tendency to self-rate depression more severely.

The study involved 100 patients who'd previously suffered from an episode of depression or mania and who, according to their psychiatrist, had now recovered and were back to normal. Kim et al looked to see what the patient thought about their mood, by getting them to complete the Beck Depression Inventory (BDI) self-report questionnaire.

This was compared to the clinican-administered HAMD scale (another Neuroskeptic favourite) which is meant to be independent of self report.

It turns out that the BDI and HAMD scores were only weakly correlated - with a coefficient of just r=0.32. That's really not very good considering that, in theory, they both measure the same thing: 'depression'. Many people reported being considerably depressed when their clinicians rated them as fine.

But more interestingly, certain characteristics of the patients were correlated with their self-report/clinician-rating discrepancy. Specifically, patients with a lower IQ, who were more impulsive, and less conscientious, tended to self-report more severe depression.

Now, the uncharitable interpretation of these people is that they were just too sloppy to complete the form properly... the uncharitable interpretation of the psychiatrists is that it's their fault for underestimating depression in people less inclined to express themselves in 'the right way'. There's no way to know.

Either way, it's a serious problem because it shows that self-report and observer-report measures of depression aren't just poorly correlated, they're actually measuring different things for different people.

It could be even worse than it appears because the HAMD, although supposedly not a self-report measure, does in fact heavily rely on the patient's cooperation. So a 100% clinician-rated scale might be even further removed from self-report.

Kim EY, Hwang SS, Lee NY, Kim SH, Lee HJ, Kim YS, and Ahn YM (2012). Intelligence, temperament, and personality are related to over- or under-reporting of affective symptoms by patients with euthymic mood disorder. Journal of affective disorders PMID: 23270973

Artwork During Recovery From Encephalitis

I recently wrote about anti-NMDA receptor encephalitis, a neurological disorder that often manifests with psychiatric symptoms, such as depression and hallucinations.

The latest American Journal of Psychiatry features a strange series of four drawings made by a 15 year old girl during an episode of the disease, which presented as psychotic symptoms but later progressed to severe insomnia and epilepsy before it was diagnosed and treated.

"As she gradually recovered we asked her to draw something. She did not know what to draw, so we suggested an animal, such as a dog, but she did not know how to start.

When we told her that a dog has four legs, a tail, two ears, two eyes, and a mouth, she drew an abstract figure that consisted of a head with four legs (A). Her next drawing, of a cat, looked exactly the same, apparently since they share the same basic features.

Two weeks later the dog now looked more recognizable but like a human, standing upright, with two arms and four legs...All body parts were listed beneath the figure in the same color as they were drawn (B).

Two months after the patient was transferred to a local rehabilitation center, the cat was catlike for the first time; it had four legs, was normally proportioned, and was correctly positioned. Colors were used adequately. However, this drawing still looked like one by a primary school child instead of a 15- year-old girl (C).

Finally, after 5 months of rehabilitation her drawing had a normal composition. She still had the urge to write down what she drew, she did not encircle the figures anymore (D)."

Esseveld MM, van de Riet EH, Cuypers L, and Schieveld JN (2013). Drawings During Neuropsychiatric Recovery From Anti-NMDA Receptor Encephalitis. The American journal of psychiatry, 170 (1), 21-2 PMID: 23288386

Finally, Hard Evidence Against The "Autism Epidemic"?

The idea of an 'autism epidemic' has a lot of people very worried.

No-one disputes that diagnosed rates of autism have increased enormously over the past 15 years or so, around the world. However, other people write it off as essentially a cultural phenomenon: we're getting better at detecting the disorder and more willing to label kids as having it.

I subscribe to the latter view, but there's very little hard evidence for it. To prove that diagnostic changes have occurred, rather than a true increase in autism, you'd have to know what would have happened to today's kids, say, 20 years ago. Would they have been diagnosed? We have no way of knowing. At least not until someone invents a time machine.

However, a new study just out offers a valuable new perspective on the debate: Spatial clusters of autism births and diagnoses point to contextual drivers of increased prevalence.

According to authors Soumya Mazumdar and colleagues, there's a zone of high autism prevalence in California, areas where kids aged 0-4 years old are more likely to be diagnosed with the condition. The epicentre is L.A.; there's actually three overlapping hotspots centred on Santa Monica, Alhambra and North Hollywood.

In these clusters, autism rates are between 2 and 6 times higher than the rest of the state.

Now an interesting thing about these areas was that they're rich in paediatricians, autism advocacy organizations, and money. In other words, there's better access to health services and probably more awareness of autism. This is suggestive evidence that the reason lots of kids get diagnosed here is about diagnosis, not autism per se.

But the blockbuster result is that children born outside the cluster, who later moved home into one, had a higher chance of getting a diagnosis than those who stayed out. The effect was smaller than for kids born inside the hot zone, but it was significant.

That's also consistent with the idea that the clusters are clusters of diagnosis, not autism.

It's not proof. You could argue that there's some toxic chemical, say, present in the rich parts of L.A. that causes autism, even if you move into the toxic area only at age 3 or 4, and that's been getting worse recently, leading to rising rates.

But it seems a stretch. What's the chemical? And why hypothesize one, when the diagnostic services hypothesis nicely accounts for these findings? As the authors say:

The findings reported in this article do not fully reject the possibility that environmental toxicants drive some of the risk of autism ... since there are a plethora of possible toxicants, it is impossible to falsify all hypotheses that researchers have started to explore.

 Mazumdar S, Winter A, Liu KY, and Bearman P (2012). Spatial clusters of autism births and diagnoses point to contextual drivers of increased prevalence. Social Science And Medicine PMID: 23267775

Mental Illness and Crime, Yet Again

As if on cue, a major study about the relationship (if any) between mental disorder and crime has appeared just when everyone's talking about that.

Although having said that, people seem to be interested in that issue most of the time nowadays, in the UK at any rate, with schizophrenia topping the list of supposedly scary syndromes.

So - should we be worried?

The new research, from Australian team Morgan et al, surveyed everyone born in the state of Western Australia between 1955 and 1969. About 1.6 million people lived there over the course of the study so this was a big project.

By linking local records of arrests over the period 1985 to 1996 to the database of psychiatric diagnosis, the researchers were able to examine disorder-crime correlations in the entire population - meaning that there was no possibility of bias.

So what happened? Here's some highlights:

• 32% of psychiatric patients had been arrested at least once. Unfortunately, it's not clear what the rate was in the general population, but that falls into the range of overall arrest rates in most countries.
• 11% of those arrested had a psychiatric diagnosis. This rose to 20% of arrests for violent offences.
• 0.8% of suspects had schizophrenia, rising to 1.7% for violent offences.
• The number of arrests in people without a disorder fell over the period 1985-1996, reflecting the well-known fact that people commit fewer crimes as they get older. However, in psychiatric patients, there was no change over time.
• For murder, 30% of suspects had a psychiatric history while 3% had a diagnosis of schizophrenia.
• Both substance abuse and personality disorders were associated with higher arrest rates than schizophrenia, but schizophrenia in turn was higher than depression, anxiety, and other miscellaneous disorders.
• Although only 1.7% of violent offenders had schizophrenia, those with the disorder were somewhat more likely to involve strangers, and to take place in public places, and less likely to target family and partners.

Overall this confirms that the great majority of crimes, including violent ones, are not committed by people with mental illness, and that your chance of getting 'murdered by a lunatic' is incredibly low. This strikes me as the only statistic that matters to most people.

There's a long-standing debate over whether people with various disorders are more likely to commit crimes than they would be if they didn't have one, the relative risk. While interesting, this is a purely academic question. What the rest of us need to know is the absolute risk, and this is low.

Morgan VA, Morgan F, Valuri G, Ferrante A, Castle D, and Jablensky A (2012). A whole-of-population study of the prevalence and patterns of criminal offending in people with schizophrenia and other mental illness. Psychological medicine, 1-12 PMID: 23234722

Religion Rises After Disaster Strikes

People turn to religion after natural disasters - but it doesn't actually provide much solace.

So say researchers Sibley and Bulbulia, who examined the population of Christchurch, New Zealand, before and after the 2011 earthquake. 185 died and many city landmarks were damaged in the disaster.

The paper, Faith after an Earthquake, opens with a Biblical quote.

Sibley and Bulbulia took advantage of the fact that a longitudinal study of the 'health and values' of the New Zealanders was already underway when the quake struck, and the survey included questionnaires about religious beliefs.

They found that, compared to before the event, residents of the affected Canterbury region were more likely to report becoming religious (8.6%) than of losing their faith (5.3%); in the rest of the country religion declined from 2009 to 2011, so the earthquake-hit area was exceptional.

The authors say:

Philosophers have plausibly argued that natural disasters such as the Christchurch earthquake are rationally incompatible with the existence of an all-powerful, all-loving God, because natural disasters cause pointless suffering to innocents... though faith eroded elsewhere in New Zealand, there was a significant upturn in religious faith among those who experienced the misery of New Zealand's most lethal natural disaster in eighty years.

But did faith help people cope with the disaster?

No - believers reported no better subjective well-being compared to the non-religious, either before or after the earthquake, although those who both lost their faith (apostates) during the period and were personally affected suffered a decline.

What's rather odd about this, however, is that other results showed that apart from the apostates, well-being wasn't affected by the earthquake at all. So it's no surprise that the religious coped no better: the irreligious already coped very well, so there was no room for improvement.

Sibley, C., and Bulbulia, J. (2012).Faith after an Earthquake: A Longitudinal Study of Religion and Perceived Health before and after the 2011 Christchurch New Zealand Earthquake PLoS ONE, 7 (12) DOI: 10.1371/journal.pone.0049648

When "Mental" Illness Isn't

 

There's a theory that 'psychiatric diseases' like depression and schizophrenia aren't diseases because they're not diagnosed on the basis of any kind of biological abnormality, but purely on symptoms - unlike 'real' diseases like cancer and AIDS.

Now, in my view there's quite a bit of truth in that - but there's also a serious flaw in the argument. Sometimes, disorders diagnosed on the basis of psychiatric symptoms do turn out to have had a clear biological cause. So the original diagnosis of a psychiatric disease was correct: there was indeed a disease.

This is happening more and more often now because of biomedical advances.

A group of German neurologists and psychiatrists recently wrote about a case of a man diagnosed with bipolar disorder:

In February 2009, a 28-year-old presented to our clinic with a first episode of depression. He reported depressed mood, anhedonia, decreased drive, reduced alertness and concentration. The symptoms responded well to quetiapine 100 mg.

Fourteen months later, a first manic episode with logorrhea [excessive speech], aggressive and disinhibited behavior occurred... it completely remitted after treatment with quetiapine 1000mg. A diagnosis of bipolar I disorder was made.

Two months later, the patient presented with another depressive episode... Despite treatment with quetiapine, aripiprazole, lithium, valproate and escitalopram, the patient did not improve...

So far, seems like a fairly typical case of bipolar. However, it turned out that...

Neurological examination was remarkable for extrapyramidal symptoms with left-sided rigor and bradykinesia [slowed movements]. On initial and concurrent magnetic resonance imaging (MRI), numerous subcortical lesions in the frontal lobes were detected... Screening for autoimmune antibodies detected NMDAR antibodies.

It turned out the guy had autoimmune encephalitis: his body was generating antibodies that blocked the brain's key NMDA receptors; the drug ketamine does that too. Treatment with immunosuppressant drugs was started and he recovered fairly quickly. For a first-hand account of the disease, in which it was also diagnosed as a psychiatric disorder initially, see the recent book Brain On Fire.

Now, let's imagine that this had happened in 1960. What would the guy's story have been then?

He'd have been seen by a psychiatrist and diagnosed with bipolar, just as he was today. Depending on how severe the depression was, and whether or not he had any more episodes, he might well have ended up in a psychiatric hospital.

But he probably wouldn't have been diagnosed with a neurological disorder. He'd have tested negative for all the neurological diseases known at the time. No-one tested for NMDA antibodies back then, because NMDA receptors weren't even discovered until 1981.

It's true that his neurological exam showed a movement disorder (left-sided rigor and bradykinesia)  but this might well have been written off as a side effect of the high dose antipsychotics he was taking, which cause similar movement disorders.

50 years ago this guy, and many others like him, could well have ended up committed to an asylum. 100 years ago, I think it would have been almost certain he'd have been deemed 'insane' and locked up at some point.

If so, some of the people in psychiatric hospitals 50 or 100 years ago will have had this disease - or others. And if we didn't know about anti-NMDA encephalitis until recently, who's to say what we'll discover next?

Choe CU, Karamatskos E, Schattling B, Leypoldt F, Liuzzi G, Gerloff C, Friese MA, and Mulert C (2012). A clinical and neurobiological case of IgM NMDA receptor antibody associated encephalitis mimicking bipolar disorder. Psychiatry research PMID: 23246244

Neither Drugs Nor Therapy Prevent Psychosis

Neither medication nor psychotherapy is effective in improving the prognosis for youngsters considered to be at high risk of developing psychosis, according to a major study just published.

The idea of identifying and treating young people at risk of becoming psychotic - because of a family history of schizophrenia, or because they're showing some mild symptoms - has become very fashionable lately. But can we really do anything to pre-empt the disorder?

In this trial, 115 "ultra-high risk" Australian subjects were randomized to three different treatment conditions, or if they didn't agree to treatment, they were just followed up to see what happened.

The treatments didn't work. Here's the smoking gun, showing the proportion who didn't go psychotic over time:

This shows all four of the subject groups did pretty much the same in terms of their likelihood of becoming psychotic. Neither cognitive therapy, nor the antipsychotic drug risperidone (at a low dose) had any effect: those given 'supportive therapy' (basically: sympathetic chats) and a placebo pill did just as well.

There probably wasn't even a placebo effect: none of the three treatment groups did better than people who got no treatment at all (monitoring group), although people weren't randomly assigned to that group, so that's a little less clear.

Is this a surprise? Yes, if you believed the early studies to examine this question which claimed great things for drugs and therapy. But the current findings are no shock if you've been following the (much larger) recent trials - for example the British one from earlier in the year, which found zero benefit of cognitive therapy.

Early small trials have a nasty habit of not working out in the long run.

The other lesson here is that even "ultra-high risk" folks usually don't get psychotic: only about 10-20% of them, in fact, became ill in the first two years of this study; the British results I mentioned are very similar.

So is this really "ultra high"? Relatively, yes it is; even a 10% risk is far higher than the chance that a random person on the street would have. But in absolute terms, perhaps not.

A concern here is that rounding these folks up, labelling and 'treating' them might make their lives worse, or even increase the risk of psychosis. That's not just my opinion: that's what the very cognitive therapists who eagerly run these trials believe (or ought to, if they're being consistent with their own theories).

One of the key ideas in cognitive accounts of psychosis is that the belief and fear that one is 'going crazy', or that you're otherwise abnormal, is itself a major source of stress that actually leads to worsening of symptoms.

What could be scarier than being told you're at "ultra high risk"?

Preventing psychosis is a great idea in theory. But most bad ideas are.

McGorry, P., Nelson, B., Phillips, L., Yuen, H., Francey, S., Thampi, A., Berger, G., Amminger, G., Simmons, M., Kelly, D., Thompson, A., and Yung, A. (2012). Randomized Controlled Trial of Interventions for Young People at Ultra-High Risk of Psychosis The Journal of Clinical Psychiatry DOI: 10.4088/JCP.12m07785

Search Trends Reveal The Most Suicidal States

US states with more Google searches for suicide-related things actually have a higher suicide rate, according to a study just out.

Researchers Gunn and Lester write that, across the 50 US states,

The association between suicide rates and the search volume for ‘‘commit suicide’’ was significant and positive[r=0.31, p=0.01]... ‘‘how to suicide’’ was marginally significant and positive [r=0.21, p=0.07]... Finally, ‘‘suicide prevention’’ was significant and positive [r=0.61, p=0.001].

This seems pretty convincing although it's hard to know whether this represents suicidal people making the searches, as opposed to people searching in response to local suicides that already happened.

The fact that "suicide prevention" was the closest correlated with suicides while "how to suicide" was weakest makes the latter seem more plausible to me.

Previous suicide-search research has given mixed findings:

Sueki (2011) looked at variations in the volume of Google searches about suicide and depression in Japan by month from 2004–2012 and found that the monthly search volume for‘‘suicide’’and‘‘suicide method’’was not significantly correlated with the monthly suicide rate. However, searches for‘‘depression’’ were positively associated with the monthly suicide rate especially with a time lag of 1–3 months.

Over the past couple of years there's been a flurry of studies based on analyzing Google and Twitter trends. What's interesting to me is that we're really in the early days of this, when you think about likely future technologies. What will happen when everyone's wearing a computer 24/7 that records their every word and move, and even what they see?

Eventually, psychology and sociology might evolve (or degenerate) into no more than the analysis of such data...

Gunn III, J., & Lester, D. (2012). Using google searches on the internet to monitor suicidal behavior Journal of Affective Disorders DOI: 10.1016/j.jad.2012.11.004

The Case Of The Missing Parasites

Collembola or "Springtails" are a common group of bugs - they're technically not insects although much like them - found all over the world.

There's no evidence that these critters are parasites for humans - except for one strange scientific report claiming to have found Collembola body parts in skin scrapings from people diagnosed with delusional parasitosis - a psychiatric disorder characterised by the belief that one is infested with parasites.

According to said 2004 paper by Altschuler et al, these patients are not delusional after all. This paper has been popular in the delusional parasitosis community.

However, insect expert Matan Shelomi says that Altschuler et al's best photo of the so-called Springtails was probably Photoshopped. He explains that in the only pic to clearly show anything resembling a 'bug' (there were many others, but none look convincing), the raw microscope image shows nothing but a blurry blob.

Altschuler et al claimed to have enhanced the contrast, but when Matan did that, there was still no visible critter. However, in the published image, a rather sinister bug is clearly seen. How did it get there?

Either the image contrast was somehow selectively enhanced just for the 'bug' part - which, of course, presumes that the bug was there, and is quite invalid - or more likely,

The level of detail present in Altschuler et al.’s enhanced image, particularly in the areas of the legs and a very odd pair of stripes along the abdomen, does not appear when contrast is applied equally. Such detail, however, can easily be created using functions such as Burn, Dodge, and Colorize on Photoshop®,when applied to select portions of the image manually as if via paintbrush.

However, Shelomi says, even if such fraud is proven, there may be nothing anyone can do: the journal the original paper was published in has since folded, so it would be impossible to retract it, and the author runs an independent non-profit and is hence not subject to scientific misconduct regulations.

Thanks very much to @benmeg for sending me a copy of this paper.

Shelomi M (2012). Evidence of Photo Manipulation in a Delusional Parasitosis Paper. The Journal of parasitology PMID: 23198757

The Onion Makes Mental Illness Ridiculous

Despite being entirely fictional, The Onion offer some of the most perceptive political analysis anywhere.

Less well known, but likewise brilliant, is its coverage of mental health. The Onion's approach is to satirize the beliefs and perceptions that characterize psychiatric illness. The result is hilarious, but also insightful and, in a weird way, empathetic:

Local Anorexic Still Way Too Fat

Despite years of intense dieting and vigorous exercise, local anorexic Lisa Kimmel is still way too fat, it was reported Monday... Though Kimmel could stand to lose a few pounds in nearly every area of her body, worst of all are her arms. "I've got this totally disgusting flab on the back of my arms that swings back and forth when I move," said Kimmel, wearing an oversized Champion sweatshirt to conceal her obesity. "My arms totally look like my grandmother's."

Making matters worse is the fact that Kimmel's mother wants her to be overweight, constantly trying to get her to eat fatty foods like ravioli, mashed potatoes and broiled chicken with the skin still on. Other family members, as well as Kimmel's friends and doctors, also entreat her to eat because they want her to be fat, repulsive and unliked.

Pharmaceutical Company Says Its New Anti-Depressant Is 'Worthless And Dumb'

At a press conference Monday, Peter Cafazzo, CEO of Brunley-Hunt Pharmaceuticals (BHP), introduced his company's latest anti-depressant, Cyntrex, a product he described as "a totally stupid waste of time that probably nobody will ever want ever." ...

According to reports, top BHP researchers began having doubts about the drug during the early development stages, when they realized they couldn't do anything right ever ever ever, and that none of the pharmaceutical-industry leaders cared whether they lived or died. But work on the project continued, despite BHP's growing conviction that Cyntrex would be the worst product in pharmaceutical history.

Is The Government Spying On Paranoid Schizophrenics Enough?

Panelists discuss ways to care for the nation's paranoid schizophrenics, such as hiding cameras in their homes or audio transmitters in their ears. e.g. "We need to hide cameras everywhere they go, in the street, in their homes, in the eyes of people at the stores where they shop."

Some people might see this as making fun of the mentally ill, but I don't: it's making fun of the illness.

Suffering from a psychiatric disorder is a tragedy, but the disorder itself, and the distorted cognitions associated with it are, well, ridiculous. It's ridiculous to see yourself as fat when you're dangerously underweight. It's laughable to think you're worthless when you're successful and respected.

Coming to realize the absurdity of such beliefs is an important part of recovery, and an explicit goal of cognitive behavioural therapy although therapists don't tend to emphasize the funny side, it is certainly there.

Ritalin, The Ultimate Crimefighter?

There's been lots of interest in the idea that ADHD meds reduce crime rates.

No doubt that, even as we speak, worried pundits are writing of how this is a worrying Orwellian scenario and yadda yadda. But what's really going on?

The research is from Sweden and published in the New England Journal of Medicine: Medication for Attention Deficit–Hyperactivity Disorder and Criminality. The first thing to note is that the study is not about giving medication in order to prevent crime; it was purely looking at what happened to people given ADHD treatment for their ADHD.

In a nutshell, the authors found that people diagnosed with ADHD were about 10% less likely to be convicted of a crime during periods when they were on medication for the disorder. This was true of both men and women, and the effect was greater for the more serious offences.

It was a huge study with over 25,000 ADHD patients and the data comprise pretty much everyone in Sweden over the relevant period so in that respect it's a very good study - although speaking of Orwellian, these studies are only possible because of the Scandinavian tendency to make national registers of everything.

Now the big criticism here is that it's just a correlation, it doesn't prove that the meds were what prevented crime. It might be that ADHD meds have no effect on crime, but that people are less likely to commit crimes at periods when they have their lives sorted out (when they're 'on the rails'), one marker of which is that they're seeking treatment for their ADHD.

However, the authors found that periods of use of SSRI antidepressants were not associated with changes in conviction rates. This is quite good evidence against the 'on the rails' critique, assuming that being prescribed SSRIs is as much a marker of being on the rails as being prescribed Ritalin is.

So, in my view, this is pretty good work, as good as any observational non-randomized study. However, remember: this is just about treating ADHD. Not drugging criminals to stop crime.

Lichtenstein P, Halldner L, Zetterqvist J, Sjölander A, Serlachius E, Fazel S, Långström N, and Larsson H (2012). Medication for attention deficit-hyperactivity disorder and criminality. The New England journal of medicine, 367 (21), 2006-14 PMID: 23171097

Are Porn Stars Happier?

Women who appear in porn are happier than other women, enjoy sex more - and have lots more of it.

So says a new paper with the pulls-no-punches title of Pornography Actresses: An Assessment of the Damaged Goods Hypothesis

Researchers James Griffith and colleagues sampled 177 American adult actresses, and an equal number of other women of the same age, gender and relationship status. The results were pretty clear: the actresses said they started having sex earlier; had far more partners with an average of 75 vs. 5 in their lifetime (and that's not including on camera).

They were a lot more likely to be bisexual (67% vs 7%!), enjoyed sex more, and reported slightly higher levels of sexual satisfaction, happiness and self-esteem.

On the other hand, they were more worried about STDs and took more drugs (50% had tried ecstasy, 40% cocaine and 27% methamphetamine.)

Finally - and the authors emphasize this - they were no more likely than other women to have suffered childhood sexual abuse. They're not 'damaged goods' as that horrible phrase has it.

So. Well. This study is clearly going to become a hot potato, or rather a political football in The Great Porn Debate, so let's take a calm look at it.

In any survey the fundamental question is - are the respondents representative examples? Or were the porn actresses who filled out the questionnaire atypically happy? Were the comparison women unusually miserable?

We really have no way of knowing. The controls were recruited from a university and an airport, which is pretty sensible although it might introduce some bias. The actresses came via adverts placed in an L.A. clinic specifically for the adult movie industry, the now-defunct AIMHF. That seems like a selective sample - but the clinic reportedly catered to most, if not all, stars in LA because all performers had to get monthly HIV tests there.

Ultimately, though, we don't know how representative they were.

Next up, it was all self-report. So the reports might have been wrong. However, that's a feature of all survey studies, especially those about such things as happiness. It's hard to see a way around this. It's also not clear what bias it would introduce into the results. It could be that the porn actresses were motivated to exaggerate their happiness in a bid to defend their industry, which I suspect will be a common criticism - but that assumes they're happy enough with it to want to defend it, so it's somewhat circular.

Finally, and most importantly in my view, L.A. porn stars are not your average pornstars. The American professional adult movie industry is the biggest, most regulated, and most 'mainstream' in the world. Sadly elsewhere the degree of exploitation, coercion, poverty and abuse among people who end up in porn is a lot higher.

Basically, I can't see anything obviously wrong with this study as far as it goes, but all it shows is that American porn actresses are in fairly good shape. Most women in porn, however, are not American.

Griffith JD, Mitchell S, Hart CL, Adams LT, and Gu LL (2012). Pornography Actresses: An Assessment of the Damaged Goods Hypothesis. Journal of sex research PMID: 23167939

The New "Mood Disorder" That Isn't One

The storied history of "Disruptive Mood Dysregulation Disorder (DMDD)", a controversial new child psychiatric disorder proposed for inclusion in the new DSM-5 manual, continues.

If DSM-5 is officially published (it's due in 2013), kids will be deemed DMDD if they show

severe recurrent temper outbursts that are grossly out of proportion in intensity or duration to the situation.

At least three times a week. Would giving that label be helpful?

Pittsburg psychiatrists David Axelson and colleagues have just shown that the DMDD concept is deeply flawed. They took a large sample of kids assessed for emotional or behavior problems, and compared those who would meet the new DMDD criteria, to those who wouldn't.

"DMDD" turned out not to be correlated with anxiety or mood symptoms in either the child or their parents - rather unusual for a so-called 'Mood Dysregulation Disorder' which is found in the 'Depressive Disorder' section of the DSM-5.

However, DMDD was correlated with - and in fact "could not be delimited from" - two existing disorders, "Conduct Disorder" and "Oppositional Defiant Disorder". It wasn't even a more severe form of those disorders, it was pretty much the same thing.

So, DMDD seems to be nothing to do with mood, but instead covers a pattern of misbehavior which is already covered by not one but two labels already. Why add a misleadingly-named third?

Well, the back-story is that in the past ten years, many American kids and even toddlers have got  diagnosed with 'child bipolar disorder'  - a disease considered extremely rare everywhere else. To stop this, the DSM-5 committee want to introduce DMDD as a replacement. This is the officially stated reason for introducing it. On the evidence of this paper and others it wouldn't even achieve this dubious goal.

The possibility of just going to back to the days when psychiatrists didn't diagnose prepubescent children with bipolar (except in very rare cases) seems to not be on the table.

Axelson D, et al (2012). Examining the proposed disruptive mood dysregulation disorder diagnosis in children in the Longitudinal Assessment of Manic Symptoms study. The Journal of Clinical Psychiatry, 73 (10), 1342-50 PMID: 23140653

Beware Small Positive Studies

A Letter in the prestigious American Journal of Psychiatry offers a skeptical response to a paper published there recently.

The original article claimed amazing benefits of a safe and cheap brain stimulation technique in treating schizophrenia. But Dutch letter-writers Sommer et al aren't convinced.

It's a short piece and worth quoting:

We read with interest the article by Brunelin et al. in the July issue, which described the application of transcranial direct-current stimulation (tDCS) in the treatment of both auditory hallucinations and negative symptoms simultaneously... An effect size of 1.58 was reported for refractory hallucinations, which is remarkably large when compared with the effect sizes of antipsychotic medication (0.4–0.6).

Clinical trials involving nonconvulsive brain stimulation in schizophrenia were first introduced in 1999. Initial effect sizes were very large while samples were small. Some years later, large negative studies were published. To date, 17 placebo controlled transcranial magnetic stimulation (TMS) studies on hallucinations have been published. The mean weighted effect size is now around 0.3. Yet, the negative correlation between effect size and year of publication suggests that over time, the mean effect size may become smaller.

When selective serotonin reuptake inhibitors (SSRIs) were introduced for depression, effect sizes greater than 1.0 were reported, which created their legacy as a wonder drug. Over the course of 20 years, the mean effect size of SSRIs decreased to around 0.3. A similar trend was demonstrated for cognitive-behavioral therapy.
 
This trend likely results from publication bias. A remarkably high effect size suggests the discovery of a new wonder treatment. Studies with such findings are therefore easily published in high-impact journals. In contrast, studies of similar sample size with marginally or nonsignificant findings are less likely to be accepted for publication. Usually, after some years, negative studies with large sample sizes become available. This is when meta-analyses start to detect a decrease in efficacy.

In this view, the Brunelin et al. study is exemplary of an initial placebo-controlled study applying a new technique: it included a small sample, found remarkably large effects, and is published in a high-impact journal.
 
We sincerely hope that tDCS is the exception to the rule— as a cheap, safe, and highly effective method to treat both refractory hallucinations and negative symptoms is most welcome. However, given the previous observations for other new treatments, it is realistic to expect that 10 years from now the mean weighted effect size of tDCS will be around 0.3.

Sommer et al are talking about the famous 'decline effect', in which the size of an effect mysteriously shrinks the more people study it, which I've written about before.

I suspect the authors are right in this case; playing science devil's advocate though, it's unfair and unscientific to assume that a new treatment that looks promising will eventually turn out to be mediocre, just because that's happened to other treatments before.

After all, some things look awesome because they are - penicillin, for example, was heralded as a new wonder drug... and it was.

I very much doubt that tDCS is the new penicillin. But I do think that this kind of speculation is ultimately not very useful. Rather than bemoaning the errors of the past and wondering whether they'll be repeated, we should reform science to make sure they don't.

Sommer IE, Aleman A, Slotema CM, and Schutter DJ (2012). Transcranial stimulation for psychosis: the relationship between effect size and published findings. The American Journal of Psychiatry, 169 (11) PMID: 23128925

Migraines On Twitter

People talk about migraines on Twitter more on weekdays than weekends and holidays - and the peak time of day for the horrible headaches is 7 in the morning.

The working-day effect on migraines has been reported before - perhaps a reflection of stress or, less charitably, people wanting a day off work... although some people suffer weekend migraines.

Of the working week, Tuesdays saw the most migraines, while Fridays were the least bad. About 80% of Twitter migraine mentions came from women - which matches the fact that women are at higher risk.

That's according to a little study just published that used a public database of tweets, timeu.se, that Neuroskeptic readers may remember.

In fact, an author of this study said in an email to me that it was actually inspired by one of my posts... but I'm aware that telling you that, combined with the previous post, means I'm in danger of blowing my own trumpet or 'disappearing up my own arse' as we say in the UK. So rest assured that this will be the last such self-referential piece for at least... a day or two.

Linnman, C., Maleki, N., Becerra, L., and Borsook, D. (2012). Migraine Tweets - What can online behavior tell us about disease? Cephalalgia DOI: 10.1177/0333102412465207

The Persistence of "Past-Life" Memories

Many children spontaneously report memories of 'past lives'. For believers, this is evidence for reincarnation; for others, it's a psychological oddity.

But what happens when they grow up?

Icelandic psychologists Haraldsson and Abu-Izzedin looked into it. They took 28 adults, members of the Druze community of Lebanon. All of the participants had been interviewed about their past life memories by the famous reincarnationist Professor Ian Stevenson in the 70s, back when they were just 3-9 years old.

Did they still 'remember'? Most of them thought they did:

Twelve of the 28 participants are sure that they still have clear memories of their past life, and an additional 12 believe that they still have some of their childhood memories, so 86% of our sample still report some memories of a past life... one man was not sure about the source of the memories, two remembered speaking of past life memories as a child, but do not have these memories now, and one thought she might only remember something of her past life because these memories were much talked about in her family.

However - it turned out that they weren't always the same memories they'd originally reported.

As children they reported on average 30 distinct memories of past lives. As adults they could only remember 8, but of those, only half matched the ones they'd talked about previously:

This indicates that half of the statements remembered today are either fictional or distortions of the original childhood memories, or that the old lists of statements might have been incomplete.

In other words, they probably suffered from a false memory of a false memory - the mind is weird. Despite this, past lives seemed more memorable than real early-childhood:

We asked our participants what they remembered from their preschool years. We were surprised how little they remembered, and some could not remember anything. Our general impression is that past-life memories are better remembered into adult life than are normal memories from preschool years.

There was no evidence that these people suffered from any particular psychological problems as a result of their experiences, but 21% did say that overall, they preferred their past lives to their real ones.

Personally, I have a very vivid memory, not of a past life per se but rather of a very early stage in my own: I remember lying in my cot, unable to get out, rather bored, and waiting for my parents to get me up for the day.

This may really be my earliest memory, but the more I've thought about it, the less likely it seems. Could I have known what time it was, and that my parents would eventually come, when I was unable to even stand up by myself?

Maybe. But maybe it was just a later childhood dream about being a baby that seemed real. At that age, the line between dreams and reality is blurry as parents who've had to comfort a child after a nightmare will attest. I suspect this accounts for many of these 'past lives'.

Haraldsson E, and Abu-Izzedin M (2012). Persistence of "past-life" memories in adults who, in their childhood, claimed memories of a past life. The Journal of nervous and mental disease, 200 (11), 985-9 PMID: 23124184