Thursday, July 9, 2015

Deconstructing "Quick Fixes" for Psychiatric and Mood Disorders

I don't mean to be a wet blanket. I don't like to be a wet blanket. But I have to be. 

I've suffered from "mood disorders" all my life. In my case, bipolar disorder and bipolar depression with some good ol' unipolar major depressive episodes thrown in for good measure (along with Borderline Personality Disorder, at times major anxiety disorder (according to DSM clinical criteria, which isn't the best source for diagnosing anything but for whatever it's worth I did meet all diagnostic criteria), schizophrenic like psychosis and some other fun stuff). And I can tell you unequivocally that depression "sucks". No, I don't mean the popular slang use of the term "it/that sucks", I mean it literally sucks the very life out of you. It sucks all the light out of you. It sucks all the hope out of you. It sucks any sense of pleasure out of you. It sucks happiness out of you. It sucks your very soul out of you (readers and fans of the Harry Potter series will recognize the results and symptoms of a Dementor's Kiss, a fate in that series considered worse than death). 

But what I found even worse than all that in all my years of dealing with all my various "mood disorders" (a useless and understated euphemism if I ever saw one) was getting built up and run around by false hopes; the false hopes of promises of "cures" and "treatments". 

After a number of years of getting jerked around by psychiatrists and merry-go-round, roulette wheel, blind shots in the dark, yo-yo pharmaceutical "treatments", a couple of years ago I got really pissed off (a massive understatement but we don't need to go there) and I thought "fuck this, I'll learn what's going on myself and figure it all out from there". And so I took up neuroscience and in a massive manic rush (which I briefly touched on in The Mother of All Manic Depressive Cycles) I dug into every treatment there was and everything to do with the brain, what goes on in there and what may be involved in psychiatric (bipolar, schizophrenia) and mood disorders (depressions of various kinds, anxiety disorders, etc). 

And to sum it all up extremely briefly, I just realized that a) there are an enormous amount of factors flung all over the brain involved in any disorder, b) almost invariably there will be numerous complicated chronic or acute external factors such as socioeconomic conditions, family, work or social circle dynamics, etc and c) there is absolutely no way any "quick fix"  treatment could possibly or realistically untangle all that, be it drugs, electroconvulsive therapy (a "lite" version of the barbaric old electro shock therapy of One Flew Over the Cuckoo's Nest fame, but essentially the same thing) and the relatively new kids on the block, transcranial magnetic stimulation therapy and deep brain stimulation therapy. There's just no way, I could easily see, that these relatively simplistic "treatments" are going to untangle everything that's going on in any given patient's brain and body and external life factors that are giving rise to the condition they are suffering from. 

So it came as no surprise to me today see the headline Much-touted Deep-Brain-Stimulation Treatment for Depression Fails Another Trial in Scientific American's online edition. As has been the case with all so called "treatments", it failed to outperform a placebo in double blind studies. 

A team led by Darin Dougherty of Massachusetts General Hospital tested 30 subjects with treatment-resistant depression. Half of the patients received DBS, and half received a “sham” treatment. Last December, the team reported in Biological Psychiatry finding “no significant difference in response rates” between the treated and untreated subjects.
“The bottom line is that we can’t separate out active treatment from placebo,” Dougherty, the trial leader, told Neurology Today. “Whether that is a dulled active or an overactive placebo, or a combination, it’s bad news.” He added: “Given the investments in these pivotal trials, the manufacturers would have to have some awfully compelling reason” to continue sponsoring research.

Which may appear rather depressing (yes, just sorting through all the so-called treatments for depression and the seeming hopelessness of it all can itself be depressing) but I don't think so. We can't find what will work, my thinking goes, if we don't eliminate what doesn't work. Plus, there's nothing worse, in my opinion, than being jerked around and our hopes falsely built up by "treatments" that don't actually treat anything. 

But let's dig a little deeper to understand why treatments such as these and pharmaceutical drugs don't work either long term nor can outperform placebos (I really must get to soon a post dedicated to understanding the extremely powerful placebo and nocebo phenomenon in the brain). 

My whole education in neuroscience came as a result of simply asking the question "why?". I asked and searched for the answers to that one word question literally hundreds of times (and I've yet to stop. I'll never stop until I find satisfactory answers ... should keep me busy for a while). And I mean I ruthlessly searched. And I mean I ruthlessly culled out bullshit claims and science. I didn't just look at studies, I wanted to know who conducted them, who wrote them and why they wrote them. I wanted to know where their funding came from and why. I wanted to know how and why they selected their test subjects (massive errors, bad science and outright corruption takes place in this one aspect of clinical trials alone). I cross checked and referenced everything I found (yes, this was a staggering amount of work, but hey, I was enormously motivated and very manic (at one point I went a mind blowing 864 hours straight with no sleep other than occasional cat naps - I kid you not)). 

So let's take just one disorder - depression - and have a brief look at what's going on there. All or some of the following will be involved in any one case. Today this is just off the top of my head (sorry, I'm not in my monster mood of writing a huge scholarly piece but I will get to all of this in more detail with proper citations, etc at some point soon. I did have some of this in a post, but I took that post down in a fit of fury last winter and now I can't find it). 

As follows, we have (not necessarily in this order):

The Limbic Region

This is the main (though not only) emotional processing center of the brain. Here we'll find the amygdala and the hippocampus duo (one of each in each hemisphere). The amygdala is responsible for both "tasting" incoming sensory information (via all five senses) for emotional content and assigning emotional content (fear, for example if the sensory data happens to be visual input of a tiger about to jump on you and eat you). The hippocampus is a sort of a "filing lady" that files stuff away in your short and long term memory areas (flung all over the brain). Many, many studies will show that just these two nodules alone will determine to a great degree how you experience your environment and react to it. 

There are massive communication trunks tying these two regions to other parts of the limbic region (thalamus, hippothalamus, etc) and how these communication trunks are formed are going to affect how one experiences and processes sensory data and reacts to it. There are massive (in relative size to the brain) communication trunks tying these nodules to other important areas of the brain, such as our vaunted human frontal lobes. How these are formed, how thick they are and so on are going to affect how one experiences and processes sensory data (the world around us, in short) and their reactions. 

And if you are experiencing chronic depression, anxiety, overwhelm and so on, I would bet the farm that key parts of this major brain region are formed in important ways differently than that of people who don't so suffer, not to mention the aforementioned communication trunks. There is now tremendous amounts of evidence for this. 

There is a good amount of evidence (which I'll get to presenting when I get to all of this in more detail) that the Anterior Cingulate Gyrus may be heavily involved. This is a brain region that is between the limbic region and our neocortex (and in evolutionary terms it would have evolved somewhere in between those two as well). Numerous thought processes are believed to arise here, including those associated with self-rumination, and new research is showing a heavy role in mediating attention and focus that could be disrupted during depressive phases or episodes. This includes evidence that both glia cell density and neuronal size may be reduced in major depressive disorder.

Speaking of self-rumination, all kinds of distorted thoughts are going to be involved with any case of depression, many of them negative, self-ruminating, highly irrational, self-critical thoughts (AKA: "beating ourselves to a pulp" thoughts) and these are going to arise in, be consolidated by and routed to our consciousness (that weird, undefinable feature of the human brain where we experience what our brain produces) via all kinds of brain regions and wiring spread all over the brain and in turn our very thoughts are going to have incredible brain changing effects (hunting all this down and learning it all was quite exciting and fun, I can tell you, all serious implications of it all aside). I'll be getting to the effects our own thoughts have on our very neurobiology and brain anatomy at some future point (I swear, I really will).

How all this is formed and works is, as I explained in Genetic and Environmental Factors in Brain Development, vastly complex and takes place over years from our very conception through to early adulthood. A tremendous amount of "who we are" is going to be determined during our "formative years" (yes, Virginia, the term "formative years" is not just an out of date expression, it actually does work a great deal that way). 

The Stress Response System:

For reasons that are entirely unclear to me, psychiatry, psychology and medical clinicians all almost completely overlook the stress response system and all its wild and wacky machinations and "downstream" effects on the mind and body biology in their "attempts" to treat psychiatric and mood disorders (and I do not use the word "attempt" at all flatteringly). The SRS will alter vast amounts of our neuorobiology, it will switch genes on and off, the stress hormone glucocorticoid will almost literally melt your brain down (it will cause neuronal death in the hippocampus as just one example) in chronic doses and all kinds of other fun stuff (top fifteen neuroscientist in the world Robert Sapolsky is my go-to source on most of the SRS and long term implications of its chronic over-activation). 

If you are suffering any mood or psychiatric disorder, I would bet the house that you are in some way (and there are numerous, numerous possible ways) living under or with all kinds of identifiable and unidentifiable stressors that are keeping your SRS locked on or in a constant state of "high alert". 

Phew, what else?

The Brain-Gut Axis

Only recently have researchers begun to start to unravel (and even discover in the first place) the importance of this axis and the role our intestinal tract has on our brains and brain functions. It turns out that the trillions of microbes that are in residence there and how they're balanced - or out of balance - can have enormous effects on our brain functions, cognitive abilities and - tra-la! - moods. 

And yes, Virginia, it really does matter what you eat (and not eat). For it also turns out that all the shit we shovel indiscriminately down our throats has a) a huge effect on our gut microbial ecosystem (yes, it is an ecosystem down there) and - AND - that this in turn can - pardon my French - fuck with our heads (I know, I know, I really am a wet blanket).  

Environmental Factors One:

This is very simple and straight forward and I'm not going to get into much detail because there is so much detail to get into. In our modern environment we are almost completely surrounded by toxic materials. A list of these and their ubiquitous presence all over most of our daily living environments alone would fill a large book. It wasn't long after I started looking into environmental toxins and their effects on the brain (and thus human behaviours, mental states, abilities and so on) that I had to stop because a) it was too overwhelming and b) it was too depressing. I simply concluded that to give myself the best shot at living/feeling better, I had to minimize environmental toxins as best I could (for one, see above about the shit we shovel down our throats indiscriminately). 

And that's all I could suggest for anyone.  

Environmental Factors Two:

By this environmental factor, I mean anyone and everyone you have to be in contact with and deal with on a regular basis in the real face to face world along with everything you take in via any and all media (hello, Facebook, TV, et al). 

Humans are highly social animals and social connections - or lack of them or quality of them - are going to have enormous and vast implications into how your particular brain works. 

And if you suffer from mood disorders, I can virtually one hundred percent guarantee you that you are a "highly sensitive" person. I do not in the least use the word "sensitive" to in any way implicate "weak" or "wimpy" or anything like that. What it means is that you not only taken in more sensory data from the world around you than the average person, but you process it much more intensely (see limbic region and stress response system above). 

What this means is that you have a high "emotional quotient" (not a term I'm particularly fond of, but for lack of a better one for now) and that people that aren't as "sensitive" have the EQ of a fence post (though I at times envy these emotional fence posts). It means that you see and experience far, far more of the world around you than the average person, plus you tend to feel the pain of all the world's injustices, PLUS you feel compelled to do something about all the pain and injustice and unfairness all around us PLUS you feel incredibly disempowered and/or inadequate to fight it all. This is also called our empathetic system, something which I briefly introduce and touch on in the post Bipolar in Focus - Empathy and Bipolar (which is actually more than just empathy in bipolar people). Talking about how our stress response system stays chronically activated, this is going to be a major factor as well.

I'd also bet dimes to donuts that you are experiencing intense feelings of isolation and that this factor alone could be deeply effecting your brain and how you experience the world (a vast topic I will cover in enormous detail at some point).  

In a future post I'll tie this into how our stress response system works and you'll easily see why many of us are in near constant states of overwhelm and meltdown. 

Also under this category are past environmental factors and by this I'm going to specifically mention childhood trauma. Evidence is pouring in from around the world for the enormous and vast effects on a person's brain (and thus mental functioning, emotional functioning and cognitive functioning and moral/reasoning abilities) child or early adulthood trauma will have. 

Lessee, what else? 

Oh yeah, as I outlined in a piece two years ago, how our memory functions and forms our inner world and perceptions of the world is going to have profound impacts on how we experience and react to the world, our mental models, our positive/negative perceptions and so on. How that works goes back to how our brains developed in the first place (see above link about Genetic and Environmental Factors in Brain Development). 

Phew, there's more but that's just roughly off the top of my head for now. 

Now all of this can change but that is through a process called neuroplasticity which is how the brain repairs itself when severely damaged (following a stroke, for example) or rearranges itself for more optimal and efficient functioning in response to a major change in our body or body structure (the loss of a limb, for example) or the loss of a sensory function (sight, for example). 

It changes synaptic connections, it changes brain regions, it can change enormous amounts and areas of how our brains (and thus us) work. 

But it is a very, very complex (and still somewhat mysterious) process. What is known is that be taught or learn a new habit or mental process and the brain will change itself in response to that. Give the brain a certain stimulation (musical training or intense music listening, for example) and it'll respond and rearrange itself in response to that. Give the brain a new task (a new dance step, for example) and it'll respond and rearrange itself to that. 

But whatever the new task, it has to be repeated regularly (like any training, like building a muscle). 

And when you understand all that is involved in any given mood or psychiatric disorder (and what I've mentioned here is breathtakingly brief), you cannot help but wonder (excuse my French again) how in the fuck simplistic quick fix "treatments" are a) going to target everything in the brain and body that may be going on and b) reverse what's going on. 

If this all sounds rather depressing and hope deflating, please, don't let it be. For I see all kinds of promising approaches to dealing with all of our messed up brain circuitry. 

I know I keep pimping my Positive Difference Making Fundamentals, but they really are solid and well founded fundamentals for changing how our brains (and thus us) work. And they're not "mine" at all, they are merely what I discovered when I went looking for answers as to what to do about our wacky brains and minds and mental states and moods. But there's more, much more, in terms of therapies and therapeutic approaches which I hope to start compiling and getting to at some point soon. 

In the meanwhile, I only ask you to approach with some healthy skepticism any "treatment" that promises a quick and easy fix to your depression. The world is full, I'm afraid, of charlatans trying to cash in on your misery (and mine). The professional ranks are, quite frankly, full of them. I suffered at their hands for years and so have many, many others (and yes, I am aware that there are those who believe professional psychiatry and pharmaceutical treatments have helped them or have helped hold them together). 

But since learning all I have about the brain, behaviours and what goes wrong and why in various disorders, I can vouch, with almost one hundred percent certainty, that if one doesn't on some level work on life issues, emotional issues, environmental issues and so on, no psychiatric or mood disorder is ever going to leave us alone. I'm not implying that we can make them completely go away either, but we can certainly learn to optimize our lives regardless (and I have, aside from myself, seen countless case stories of this happening, something else I hope to get to soon). 

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