Inkwell: Authors and Artists

    
Great thread. Thanks for being here, Gary.

In your research, have you come across drugs or treatments outside the
psychological realm that exibit the same sorts of problems as things
like Ritalin where conditions are over-diagnosed and the science is
vague? Things like Lipitor maybe (I mention it just to pull something
out of the hat).
  

    
Sorry to have fallen behind here but <97> was brilliant.

"The problem with AA is that it has been acquired by medicine and so
what is being "treated" at the meetings is a disease."

There are longtime members of AA who are working to undo this on a
local basis, because it is detrimental to the true core of the program,
but there really isn't any medium to spread messages throughout AA
(and there shouldn't be), it is disorganized and parochial by design.
  

    
re: 125, "scientific" means there are reproducible results.  But there
are many forms of healing that haven't been scientifically proven yet.
  

    
Exactly right. If science is the search for the laws that can predict
and control outcomes, we may never be able to use it to account for the
kind of healing STeve mentioned above, the kind that takes place in
narrative. I would say that narrative medicine, or at least therapy, is
always something you can "retrodict," i.e., account for by a
historical reading, but rarely if ever something you can predict. Or to
put this another way, trying to use science to account fore the kind
of healing that shows up in placebo effects or psychotherapy may be
like looking for feathers with a magnet.

Thesea are all such good questions. But I'm bushed after a whole day
of being a therapist, so I'm going to get to them tomorrow.
  

    
That's not to say that science as organized and systematic knowledge
can't be used to understand phenomena like the placebo effect. EVen as
scientific medicine was gearing up at the end of the nineteenth
century, some philosophers and psychologists were on a parallel
path--trying to develop the "human sciences." If the model for the
doctors was Newtonian physics, the model for the phenomenologists was
Biblical hermeneutics, and other methods of systematic interpretation.
From Dilthey and Husserl, through Heidegger and GAdamer, and to Ricoeur
and Habermas and even Rorty, these guys and their followers tried to
specify how human behavior could be read like a text, how there could
be constraints on the interpretation, how it could be done
systematically, and, above all else, how you could account for the fact
that both observer and observed were living, breathing beings who had
histories, which meant that all interpretation was necessarily
tentative and contingent. But while some of this work continues in
fields like psychology--in its most common if most watered down form,
in a method known as content analysis--most of it goes on in
literature. 

Freud straddled both of these worlds--without meaning to, I think. He
wanted to be a scientist in the narrow sense, but his contribution was
one of the most highly developed interpretive schemes ever invented.
  

    
>In your research, have you come across drugs or treatments outside
the psychological realm that exibit the same sorts of problems as
things like Ritalin where conditions are over-diagnosed and the science
is vague? Things like Lipitor maybe (I mention it just to pull
something out of the hat).

In a question like this, it's easy to see how this narrow definition
of science leads to a narrow definition of disease, into which
enterprising doctors then hurry to shoehorn their favorite diagnosis. 

That narrow disease definition, by the way, is a recent event, more
recent even than the development of modern science. It's a little older
than waht STeve says--the pharmaceutical industry emerged in the early
twentieth century, modern medicine about fifty years earlier. That was
when the discovery of microbial agents that caused certain
illnesses--smallpox, cholera, syphilis, etc.--made it possible to
identify and cure suffering. 

The first two were discovered empirically--smallpox through the
vaccine and cholera through John Snow's famous discovery of the
contaminated pump in London, both of which had cures before anyone
actually saw the little bugs. But the last one, syphilis, was
discovered because they were looking for the bug, and the resulting
cure was invented specifically to kill that bug. That's when Pharma
began its rise, a story that you'll have to wait for my depression book
to read in all its delicious details.

But the point is that when those discoveries were made, it made for a
classic paradigm shift. The old paradigm--the idea that disease was the
result of humoral imbalances that could be caused by things like
miasmas (bad air)--had been around for a couple thousand years, and had
yielded some really bad medicine. Some of those treatments were
biochemically effective--quinine, willow bark (aspirin), leeches--but
that was purely accidnetal, and many were downright harmful--mercury,
for instance, which was the favorite cure for syphilis. Which is why
Oliver Wendell Holmes said in the 1860s, if the entire pharmacoepia
were thrown into the sea, it would be all the better for mankind and
all the worse for the fishes. But mjost of them were pharmacologically
inert, and if they worked it was by placebo effects (or by bad
logic--natural course of most diseases is that they get better). 

So the new discoveries gave a huge boost to the power andstatus of the
doctor, who suddenly could specify a target and send in a magic
bullet. And in turn, they discovered al sorts of pathogens and invented
all sorts of effective drugs--antibiotics, corticosteroids, insulin.
So it's no wonder why the bacteriological model has generalized, and
that today when we think of "disease," we think of  suffering that has
a single cause, some internal pathogen that can be found and destroyed.
  

    
But as to the question, Lipitor is ag reat example. Is high
cholesterol really a disease? Of course not. It's not even a syndrome
or any other form of suffering. It's a risk factor. It's something that
is associated with other diseases, although it's always been clear
that people with high cholesterol do not by any means always have
strokes or heart attacks, that it is not the pathogen in those
diseases. But the marketing opportunity is irresistible, so high
cholesterol is sold as a disease unto itself, and when your doctor
tells you that it will lead to disaster, you that's irresistible too.
Cholesterol in cardiovascualr disease is sort of like serotonin in
depression, Lipitor like Prozac.
  

    
Fascinating stuff, Gary.

Do you feel like talking about where you're going with your next book, 
Manufacturing Depression?
  

    

After reading that paragraph about high cholesterol as a risk factor and 
not a disease and that people who have it don't always have strokes or 
heart attacks, I wonder if it's really necessary for me to take Lipitor. 

And while I'm at it, maybe I should stop taking the antidepressants, too, 
because how do I know that they aren't really placebos?  I do feel better, 
but maybe I'm fooling myself.

And maybe my ulcerative colitis medication is a placebo, too.

How does one know, really, unless one stops taking them?  

Is it better to not take the medication and just live with the symptoms, 
because there's no telling what the long-term auxiliary effect of the 
medication will be?  

What about medication with measurable results, like diabetes, where one
can test one's blood sugar?  Are those the only diseases where the
efficacy of the medication can be believed?
  

    
An old girfriend of mine was constantly having her meds "calibrated", but
was still depressed and edgy at the same time.   Finally she shed the
husband of 8 years, and quit ALL the meds.   She feels much better now that
she's not trying to medicate a losing marriage back to health.
  

    
One of div's laws is that if you have to take medication to tolerate a
situation (or another person), it's time to run off with the circus.

Which is not, of course, to say that people with real maladies don't
need real medicine. 
  

    
(remembering a patient I saw during medical school who refused to
consider that her daily evening headaches were perhaps not due to a
terrible brain condition, but symptoms of a failing marriage, because
it was literally painful to her to go home after a day at work.  She
preferred antidepressants to considering that maybe the problem was the
relationship.)
  

    
>After reading that paragraph about high cholesterol as a risk >factor
and  not a disease and that people who have it don't always >have
strokes or heart attacks, I wonder if it's really necessary >for me to
take Lipitor. 

Well, of course I'm not giving medical advice here, but there are many
people who don't take cholesterol drugs because they don't like the
side effects. FRiend of mine told me the other day that he'd just
stopped and he never felt better. Many docs will tell you that
cholesterol alone doesn't tell you much. The other risk factors--high
blood pressure, family history of cardiovascular diseases, etc.--need
to be taken into account. 

Shannon Brownlee's book, Overtreated, talks about risk factors as one
of the elements in our overpriced, undereffective health care system.
She's also right on the money about colonoscopies,etc. Worth reading.


>And while I'm at it, maybe I should stop taking the >antidepressants,
too, because how do I know that they aren't really >placebos?  I do
feel better, but maybe I'm fooling myself.

This is perhaps the trickiest part of antidepressants, and the most
infuriating. Whether or not they're working psychologically, they are
definitely working neurochemically. At first, when you take an SSRI (or
any neurotransmitter-reuptake-blocking drug), the neurons that send
out the neurotransmitter in question keep working at their normal pace.
But after a short time, they adjust to the fact that the chemical is
in the synapse longer and they down-regulate. So when you stop taking
the drug, ther are neurochemical consequences: regardless of what your
brain metabolism was like before you started, you now have a
"deficiency" of serotonin. And there may be psychological consequences
of this--if the theory is anywhere near right, you will get anxious and
depressed. And there are other problems--seizure, severe headache,
sleep disturbance, and strange neurological symptoms, the famous of
which is the feeling of electric shocks in your head, among others. The
cure for this is either to beast it out for a few weeks, or, more
likely, to go back on the drug, convinced that you have a lifelong
chronic illness called depression.

Sound familiar? Well, that's because with other drugs, notably illicit
drugs, that's called a withdrawal syndrome. But of course the SSRIs
have a monopoly on legalized consciousness alteration, so by definition
they can't be addictive, which means they can't cause a withdrawal
syndrome. 



>And maybe my ulcerative colitis medication is a placebo, too.
>How does one know, really, unless one stops taking them?  

>Is it better to not take the medication and just live with the
>symptoms, because there's no telling what the long-term auxiliary
>effect of the medication will be?  

>What about medication with measurable results, like diabetes, where
>one can test one's blood sugar?  Are those the only diseases where
>the efficacy of the medication can be believed?

I think that while placebo effects are present in nearly every
treatment, not every treatment is *dependent* on them. YOu can give
antibiotics to an unconscious person and it will clear up his or her
infection. If you stop taking insulin and your pancreas isn't working,
you will very quickly die. In both of these cases, you can know exactly
why the medication is working, you can replicate that effect in
animals and test tubes, and it's safe to say that consciousness is only
minimally involved. Which doesn't mean it can't be, only that no one
has figured out how to harness consciousness to cure infection or
diabetes. Right now, there's no need for that. It's much more efficient
to do it with anitbiotics or insulin. (In the former case, the day may
be coming when we can't say that anymore; bacteria seem to be winning
the arms race.)

But the more consciousness is implicated in suffering, the more
important placebo effects become--and, not coincidentally, the less
straightforward cure by medication is. Pain, depression, chronic
fatigue, even some autoimmune conditions (including perhaps ulcerative
colitis and Crohn's disease) are all examples of conditions in which
etiology is unknown, medication is a crapshoot (and, again not
coincidentally, drug effects can't be fully accounted for; the package
insert for antidepressants and other psychiatric drugs invariably says
something like "the mechanism of action is not understood"), and
psychological life is in play. Which is, of course, why the placebo
effect is more of a factor when it comes to evaluating drugs for those
conditions.

This means to me that because every drug has side effects, which
include not only chemical side effects but also economic and political
side effects  (as in <rik>'s and <debunix>'s stories about people for
whom the drugs only obscured the more obvious, and treatable, problem
in their outer world, to take a drug for an illness is often to exclude
the possibility that your suffering is the result of material, and
changeable, conditions of your life), the more these characteristics
are present--unknown origin, inconsistent cure, drugs whose mechanism
is not understood--the more important it is to look for alternatives.
Or to put it another way, the more the power of the placebo effect
needs to be harnessed.
  

    
Gary, I think about the superiority of the placebo effect a lot. It's the
powerful medicine we really want to take first, but it seems to me 
that in our culture, paying a lot or going through grueling sequences 
of treatments like an epic quest -- or even suffering those side 
effects -- may be part of what gives a placebo its kick, even as 
part of the operation of chemical medicines, where it may exist in 
overlap with the chemical actions.  A sugar pill is too easy, it 
doesn't fit our belief systems.

I don't know if I'm expressing that clearly, but it's part of the paradox 
of placebos not being able to be labeled as such.  Maybe our brains 
and belief systems whan them to be difficult, expensive, hard to 
obtain, even a little painful.  More placebo research is clearly required!
  

    
I may have already said this here, but the crowning irony is that
virtually every clinical trial of every new drug approved since 1972,
and of most between 1962 and 1972 (before 1962, believe it or not, the
FDA did not require drug makers to prove that their drugs actually
worked before they were approved) is also a study of placebo, because
all those trials were placebo controlled. But the people with the money
aren't interested, and when they do get interested, it's for the
purpose of figuring out how to get rid of placebo responders or
otherwise to eliminate, statistically speaking, the placebo effect from
trials. 

But the real challenge would be to figure out how to study it in a way
that would be recognizable as science, that would yield the kind of
results that are replicable and useful for prediction nand control I
tend to doubt that this is possible, but I could easily be wrong. 
  

    

I'd love to read about a double blind test with two placebos, one of which
had a minor irritating side effect -- even just a very bitter taste -- and
one of which was painless.

Just musing about it.
  

    

Gary, thank you so much for these thoughtful and very interesting 
responses to my questions.  I'm sending my therapist a link to this 
discussion.  I told her about the book, and a little about what you said, 
and how it got me thinking about my anti-depressants and whether or not I 
should quit taking them, and she is recommending that I meet with a 
pharmacologist to begin to examine that.
  

    <scribbled by digaman Fri 5 Dec 08 17:27>
  

    
(Sorry, typos.)

That would be fascinating, Gail. Just yesterday, I came across references 
 in the medical journals to cases of *addiction* to placebos, which is 
 provocative, and has relevance to Gary's thoughts about antidepressants.
 Really interesting stuff, Gary.
  

    
Addiction to placebos? I love that. Myself, I'm addicted to oxygen. In
fact, I once tried, unsucessfully, to sell a book called Oxygen was my
Gateway Drug, which was going to be about the drug war and popular
culture. 

Addiction comes from teh Latin ad + dictum, toward the edict, and in
early English usage, it carried the meaning of signing yourself over as
an apprentice, as in addicting yourself to a master. (You could look
it up in the OED.) It seems that as our idea of what it means to be
human has changed to become more atomistic, there has been less room
for turning yourself over to soemthing or someone outside of yourself.
Competent selfhood, maturity we might call it, has come to be the
equivalent of individualism, and, conversely, to the extent that you
aren't self-contained, you are considered deficient, immature, sick, a
failure. For all its virtues, the Enlightenment leaves us mighty
confused about losing ourselves.

I think proliferation of addiction is related to this development. I
don't mean this epidemiologically, i.e., that the reason more people
are "addicted" is the difficulty of living with this concept of
selfhood, although that's probably true as well (and certainly
underlies the AA emphasis on turning your life over to a Higher Power).
I mean it conceptually, i.e., that more and more behaviors and
experiences are considered addictive because of the increasing
suspicion of signing your life over that is inherent to a
hyperindividualistic culture. 

Many addictions are certainly debased forms of surrender. But not all
surrender is addiction.

Linda--Good luck with your experiment. There's lots of information on
the net about getting off antidepressants. LIke everything else on the
INternet, it's all true. No, seriously, I'll try to dig up some links
for you.
  

    

> Competent selfhood, maturity we might call it, has come to be the equiv-
> alent of individualism, and, conversely, to the extent that you aren't self-
> contained, you are considered deficient, immature, sick, a failure.

Except, of course, to those for whom addiction to God is the way to live.
  

    
addiction to being not-god, manifested by paying tithes to self-proclaimed
agents of god.

when the gas stations started charging for air, the state stopped them.

oxygen, god for less.
  

    
"addiction to being not-god"

Pretty common in the Abrahamic traditions.
  

    
Some people's hunger for a father figure does not stop at humans.
  

    
There are a couple of touching/unsettling tales in the brain-death section
of Gary's book about relatives who tend to loved ones in coma for years or
even decades.  Here's a sad story from today's news.  It blew my mind that
the cost of maintaining "Sunny" Von Bulow in her unconscious state had
risen to nearly a million dollars a year by the 1990s, with private
nursing.

http://online.wsj.com/article/SB122859113427285587.html?mod=googlenews_wsj