Announcement

1. Historical Approaches toAbnormal Behavior, Part IIJanuary 27, 2014PSYC 2340: Abnormal PsychologyBrett Deacon, Ph.D.

2. Announcement • Sona systems mass testing has begun

3. From Last Class • The biological tradition • History • Assumptions • Contemporary popularity (e.g., medication use)

4. Classifying Psychotropic Medications • An example of the popularity of the biological approach in psychiatry: terms we use to describe classes of psychotropic medications

5. Classifying Psychotropic Medications • Xanax (a benzodiazepine, like Valium): • What class of medication is this?

6. Classifying Psychotropic Medications • What are the major classes of psychotropic medications?

7. Classifying Psychotropic Medications • Current taxonomy of psychotropic medications (National Institute of Mental Health): • Antipsychotics • Mood stabilizers • Antidepressants • Anti-anxiety drugs • Stimulants • What does this taxonomy suggest about the nature of these medications?

8. Classifying Psychotropic Medications • Older taxonomy: • Major tranquilizers • Minor tranquilizers • The same drugs that used to be major tranquilizers are now antipsychotics • The same drugs that used to be minor tranquilizers are now anti-anxiety agents • What’s in a name? What implications do these different terms have for how we think about the nature of psychotropic medications?

9. Classifying Psychotropic Medications • “One day we may look back and marvel at the stroke of marketing genius that led to calling these medications antidepressants in the first place” (Antonuccio, Burns, & Danton, 2002).

10. Understanding Drug Action • Disease centered vs. drug centered model of drug action (Moncrieff, 2008) • Disease centered model: Antipsychotics act on the underlying biological cause of schizophrenia • Drug-centered model: Major tranquilizers produce an altered brain state that, among other things, reduces the symptoms of schizophrenia

11. Drug-Centered Drug Ad, 1956 http://www.bonkersinstitute.org/medicineshow.html

12. Drug-Centered Drug Ad, 1969 http://www.bonkersinstitute.org/medicineshow.html

13. Disease-Centered Drug Ad “While the cause is unknown, depression may be related to an imbalance of natural chemicals between nerve cells in the brain. Prescription Zoloft works to correct this imbalance.” -Zoloft commercial

14. Disease-Centered Drug Ad, 2008 “When activity of key brain chemicals is too high, Abilifylowers it. When activity of key brain chemicals is too low, Abilifyraises it.” http://www.bonkersinstitute.org/medicineshow.html

15. Understanding Drug Action • Implications of disease-centered model • Drugs correct an abnormal brain state • Drug have no effect on healthy people • Drugs have “therapeutic effects” and “side effects” (regarded as a nuisance or irrelevant unless they are severe) • Prototype: insulin for diabetes, antibiotic for bacterial infection • Is this how psychotropic medications work?

16. Understanding Drug Action • Implications of drug-centered model • Drugs produce an abnormal brain state that improves symptoms of the disorder • Drug have similar effects in people with or without the disorder • Drugs have effects, period, not “therapeutic effects” and “side effects” • Prototype: alcohol for social anxiety • Is this how psychotropic medications work?

17. Understanding Drug Action • Are these “anti-ADHD” medications?

18. Understanding Drug Action • Are these “anti-anxiety” medications?

19. A Thought Experiment • Using alcohol to manage one’s social phobia http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.0030240 • Imagine conducting a clinical trial examining the effectiveness of alcohol in treating social anxiety… • What would the findings be?

20. A Thought Experiment • How should we interpret the findings? • Can we reason backward and assume that social anxiety is caused by an alcohol deficiency? • Can we assume that alcohol works by correcting this alcohol deficiency? or… • Does alcohol produce an abnormal brain state that, among other things, reduces the symptoms of social phobia? • Does it make sense to divide the effects of alcohol into “therapeutic effects” (reduction of social phobia symptoms) and “side effects” (slowed reaction time, cognitive impairment, sedation, impaired motor control, increased frequency of urination)?

21. Understanding Drug Action • Thought questions • How should we think about psychotropic medications? • Are they disease-specific magic bullets? Whose interests are served by promoting this notion? • Do they normalize brain abnormalities, or produce abnormal brain states that improve symptoms of mental disorders? • Should we divide their effects into therapeutic effects and side effects?

22. Biomedical Model: Tenets • The primary goal of research is identification of biological mechanisms and magic bullets • Psychological phenomena can be fully reduced to their biological causes • Psychology is a “placeholder science” awaiting replacement by neuroscience and molecular biology (Gold, 2009)

23. Biomedical Model: History • A brief history lesson • Psychoanalysts vs. pharmacologists • DSM-III • APA and drug industry partnership • The quartet • “We need to be more medical to be taken seriously.” – APA President Alan Schatzberg (2010)

24. Biomedical Model vs. Reality • Mental disorders are brain diseases caused by neurotransmitter dysregulation, genetic anomalies, and defects in brain structure and function. • Yet, scientists have not identified a biological cause of, or even a reliable biomarker for, any mental disorder.

25. Biomedical Model vs. Reality • Psychotropic medications work by correcting the neurotransmitter imbalances that cause mental disorders. • However, there is no credible evidence that mental disorders are caused by chemical imbalances, or that medicines work by correcting such imbalances.

26. Biomedical Model vs. Reality • Educating the public that mental disorders are biologically-based brain diseases reduces stigma. • But despite the public’s increasing endorsement of biological causes and treatments, stigma has not improved and shows signs of worsening.

27. Biomedical Model vs. Reality • Advances in neuroscience have led to the development of safer and more effective pharmacological treatments. • Conversely, modern psychiatric drugs are generally no more safe or effective than those discovered by accident a half-century ago.

28. Biomedical Model vs. Reality • Biological psychiatry has transformed the treatment of mental disorder and ushered in an era of improved mental health outcomes. • However, mental disorders are becoming more chronic and severe, and the number of individuals disabled by their symptoms has skyrocketed in recent decades.

29. Biomedical Model vs. Reality • Increased investment in biomedical research will lead to a new era of personalized medicine characterized by neuroscience-based diagnosis and curative biological treatments. • The pharmaceutical industry has largely abandoned efforts to develop new psychiatric drugs due to the “absence of biomarkers, the lack of valid diagnostic categories, and our limited understanding of the biology of these illnesses.”

30. Biomedical Model: Thomas Insel, NIMH Director • “What we are missing is an understanding of the biology of the disorders and what is really going wrong.” • “In truth, we still do not know how to define a [brain] circuit… the metaphor of a circuit in the sense of flow of electricity may be woefully inadequate for describing how mental activity emerges from neuronal activity in the brain.” • “Despite high expectations, neither genomics nor imaging has yet impacted the diagnosis or treatment of the 45 million Americans with serious or moderate mental illness each year.”

31. Biomedical Model: Limitations • “The disorders contained [in the DSM] are heuristics that have proven extremely useful in clinical practice and research, especially by creating a common language that can be applied with reasonably good interrater reliability. Unfortunately, the disorders within these classifications are not generally treated as heuristic, but to a great degree have become reified. Disorders within the DSM-IV or ICD-10 are often treated as if they were natural kinds, real entities that exist independently of any particular rater.” – Steven Hyman, NIMH Director (1996-2001)

32. Biomedical Model: Limitations • “Although the past two decades have produced a great deal of progress in neurobiological investigations, the field has thus far failed to identify a single neurobiological phenotypic marker or gene that is useful in making a diagnosis of a major psychiatric disorder or for predicting response to psychopharmacological treatment.” – Michael First, Editor of DSM-IV

33. Biomedical Model: Limitations • “The incredible recent advances in neuroscience, molecular biology, and brain imaging . . . are still not relevant to the clinical practicalities of everyday psychiatric diagnosis. The clearest evidence supporting this disappointing fact is that not even one biological test is ready for inclusion in the criteria sets for DSM‐V.” – Allen Frances, Chair of DSM-IV Task Force

34. Biomedical Model: Limitations • “…brain science has not advanced to the point where scientists or clinicians can point to readily discernible pathologic lesions or genetic abnormalities that in and of themselves serve as reliable or predictive biomarkers of a given mental disorder or mental disorders as a group.” – American Psychiatric Association • “Few lesions or physiological abnormalities define the mental disorders, and for the most part their causes are unknown.” – Surgeon General’s Report on Mental Health

35. Biomedical Model: Limitations • “Chemical imbalance is sort of last-century thinking. It’s much more complicated than that. It's really an outmoded way of thinking.” – Joseph Coyle, editor of Archives of General Psychiatry • “In truth, the ‘chemical imbalance’ notion was always a kind of urban legend – never a theory seriously propounded by well-informed psychiatrists…In the past 30 years I don’t believe I have ever heard a knowledgeable, well-trained psychiatrist make such a preposterous claim, except perhaps to mock it.” – Ronald Pies, editor of Psychiatric Times

36. Biomedical Model: Limitations • “Psychopharmacology is in crisis. The data are in, and it is clear that a massive experiment has failed: despite decades of research and billions of dollars invested, not a single mechanistically novel drug has reached the psychiatric market in more than 30 years…nearly every major pharmaceutical company has either reduced greatly or abandoned research and development of mechanistically novel psychiatric drugs.” – H. Christian Fibiger, M.D., former vice president of neuroscience at Eli Lilly and Amgen

37. Mental Disorder vs. Disease • Scientific definition of disease: Departure from normal bodily structure and function. Includes: • Identifiable etiology • Identifiable pathophysiology • Identifiable signs and symptoms • Identifiable course • Are mental disorders diseases?

38. Chemical Imbalance Theory • There are established biological correlates and risk factors for depression, but…. • No test for measuring neurotransmitter levels in the brain of a living person • No basis for distinguishing a chemical “balance” from a chemical “imbalance”

39. Biomedical Model: Limitations • “Chemical imbalance is sort of last-century thinking. It’s much more complicated than that. It's really an outmoded way of thinking.” – Joseph Coyle, editor of Archives of General Psychiatry • “In truth, the ‘chemical imbalance’ notion was always a kind of urban legend – never a theory seriously propounded by well-informed psychiatrists…In the past 30 years I don’t believe I have ever heard a knowledgeable, well-trained psychiatrist make such a preposterous claim, except perhaps to mock it.” – Ronald Pies, editor of Psychiatric Times