Saturday, October 23, 2010

Celebrity Neurostigma



Celebrity SPECT scan from rehab patient


Celebrity Rehab is an American TV reality show on VH1 that exploits the addictions of the rich and C- or D-List famous.
“I thought REAL doctors talked to patients in offices behind closed doors.”
-Lindsay Lohan [who reportedly turned down six figures to appear on the show]
Privacy? Confidentiality? Those rights don't apply to the alcoholic and drug-addicted characters who appear on television and other public media outlets as a form of entertainment. How many of you professional psychology and mental health and cog neuro and pharmaceutical types have taken training courses such as the CITI Course in The Protection of Human Research Subjects? All of you?

Medical Ethics do not apply to Dr. Drew, the star and chief physician of the Celebrity Addiction franchise:
In 2009 [Dr. Drew] Pinsky drew criticism from experts for publicly offering professional opinions of celebrities he has never met or personally examined, based on media accounts, and has also drawn the ire of some of those celebrities.
In contradistinction, proper clinicians who make media appearances take great pains to avoid such unethical outbursts. As explained by Dr Petra Boynton:
They tried to make me talk about rehab but I said ‘no, no, no’

Yesterday I had over 25 emails and phone messages from journalists wanting me to comment on the mental state of several celebrities currently in the press with various drug/relationships problems.

And I’ve said no to all of them.

At the risk of sounding like a broken record here’s why psychologists (and other experts working with the media) can’t talk about celebrities.

If we know the celeb in person (for example as their therapist or healthcare provider) we are breaking their confidence if we speak about them in public. If we do not know them personally we’re simply speculating about them if we were to comment.

The same applies to case studies based on people who are not famous.

In Season 3 Episode #6, ('Triggers') Dr. Drew takes former NBA star Dennis Rodman to see our favorite neurohuckster, Dr. Daniel G. Amen, for a SPECT scan. Amen claims he can diagnose all sorts of psychiatric and neurological ailments using SPECT (single photon emission computed tomography)1 procedures performed at his clinics.

Drew Pinsky exacerbates the unprofessional circus-like atmosphere by making all sorts of unfounded dire predictions about the state of Rodman's brain.

Dr. Drew voiceover: It's day 13, and despite nearly 2 weeks of intense treatment, Dennis has rigidly refused to identify as an alcoholic. It's clear to me there's much more going on here. Probably on an organic basis, both in terms of his personality functioning and possibly damage caused by the alcohol itself. I've arranged for Dennis to receive a brain scan to show him objective evidence of what I suspect is going on.

Van arrives at the Amen Clinics in Newport Beach, CA and Rodman is placed in the scanner.



Cue colorful images of Mr. Rodman's brain appearing on the monitor. All very scientific. Then Dr. Drew introduces him to Dr. Amen.

Amen: "So, we did a study called SPECT that looks at how your brain works. And what we see on your scan here, there's some evidence of alcohol damage. When we see this bumpy appearance, I don't like that. I would worry that you could get something like Alzheimer's disease if you don't do a better job of taking care of your brain. Alcoholic dementia is the second most common cause of dementia in the country. The exciting thing is it can be better but without taking good care of it this is going to deteriorate and get worse."

Rodman: "Uh... it doesn't matter. All right." (Gets up and leaves).

Amen made some rather outrageous statements here. Even though he used the qualifying words something like, there is absolutely no evidence that alcoholism causes the amyloid plaques and neurofibrillary tangles of Alzheimer's disease. In fact, the pathologies are produced by entirely different mechanisms (Aho et al., 2009):
In the present study, no statistically significant influence was observed for alcohol consumption on the extent of neuropathological lesions encountered in the three most common degenerative disorders. Our results indicate that alcohol-related dementia differs from VCI [vascular cognitive impairment], AD [Alzheimer's disease], and DLB [dementia with Lewy bodies]; i.e., it has a different etiology and pathogenesis.
One meta-analysis even found that heavy drinkers did not have an increased risk of dementia of any kind,2 and regular drinkers had a reduced risk (Anstey et al., 2009).

Then brain imaging non-expert Dr. Drew narrates...

Dr. Drew voiceover: Dennis's scans were quite dramatic. In addition to there being an unusual pattern of temporal lobe dysfunction, which confirms my feelings about his personality, he also clearly has damage from alcohol.

Dr. Drew (to Amen): "It makes me sad thinking about it... if he doesn't change."

I see...

Where in the temporal lobe did Dr. Drew find the confirmatory evidence of personality disorder? Anterior temporal lobes (semantic memory)? Posterior/inferior temporal regions, such as the fusiform gyrus (high-level vision)? Superior temporal plane (audition)? Region of the left posterior superior temporal gyrus (Wernicke's area for language comprehension)? Area MT/V5 (perception of motion)? The medial temporal lobe memory system? The amygdala and other portions of the limbic system? Yeah, maybe that, but Amen's "bumpy appearance" was located in ventral visual areas.


Dramatic Brain of Dennis Rodman, age 48

(which looks a lot better than this 38 yr old with 17 years of heavy weekend use).


Scientifically Unfounded Claims in Diagnosing and Treating Patients

That's the title of a Letter to the Editor of the American Journal of Psychiatry by Adinoff and Devous (2010). They responded positively to a critical review (Leuchter, 2009) of none other than Daniel Amen's book, Healing the Hardware of the Soul: Enhance Your Brain to Improve Your Work, Love, and Spiritual Life. The letter goes even further in critiquing Amen's methods:
Several years ago, following conversations with Dr. Amen on how to address such concerns, the Brain Imaging Council of the Society of Nuclear Medicine offered Dr. Amen the opportunity to submit his analyses of a blinded set of SPECT scans (to have been prepared by the Brain Imaging Council) to determine how effective his technique is at correctly diagnosing subjects. Although this proposed study could have provided support for his approach, the offer was declined. Nevertheless, for more than two decades, Dr. Amen has persisted in using scientifically unfounded claims to diagnose and treat patients (over 45,000 by his own count).

There are several dangers to patients that can accrue from this approach: 1) patients (including children) are administered a radioactive isotope without sound clinical rationale; 2) patients pursue treatments contingent upon an interpretation of a SPECT image that lacks empirical support; and 3) based on a presumed diagnosis provided by Dr. Amen's clinics, patients are guided toward treatment that may detract them from clinically sound treatments.

Amen published a rebuttal letter, Brain SPECT Imaging in Clinical Practice (Amen, 2010). Here, he portrays himself as an early adopter -- ahead of his time, persecuted by the unenlightened -- and highly ethical:
The Society of Nuclear Medicine has never formally approached me to perform a study. Plus, I would never engage in a charade where I was expected to give a diagnosis from a scan. That is not how imaging is or should be practiced. The notion of Adinoff and Devous that SPECT is dangerous is disingenuous.
Really? An appearance on Celebrity Rehab and a proclamation that Dennis Rodman is in danger of getting "something like Alzheimer's disease" (based on reading his scan) is NOT a charade?


Public Medical Disclosure

Why is that so inappropriate?
The HIPAA Privacy Rule provides federal protections for personal health information held by covered entities and gives patients an array of rights with respect to that information. At the same time, the Privacy Rule is balanced so that it permits the disclosure of personal health information needed for patient care and other important purposes.
Did Rodman understand all the medical procedures that would be performed on him? Did he sign a consent form in advance to allow the release of a stigmatizing diagnosis for public consumption? Did the fine doctors and television producers consider that if they wanted to portray Rodman as brain damaged, such a compromised mental status could potentially limit his capacity to give informed consent?

But it's only entertainment, after all.

So back to the scientifically unfounded claims... Without mentioning Celebrity Rehab and its diagnostic disclosure issues (perhaps he didn't watch this particular episode), the Editor of AJP felt strongly enough to publish his own Note, appended to the letter of Adinoff and Devous, which concludes:
We have published this exchange of letters as part of our responsibility to readers to point out when a procedure may lack sufficient evidence to justify its widespread clinical use.

For more on Amen and his practices, see The Neuroshrink.

ADDED BONUS! Watch the video for Dr. Drew's neuroanatomy lesson: Celebrity Rehab 3: Dennis's Brain Scan and read the follow-up post: Dennis Rodman-Mindy McCready Mind Meld.


Footnotes

1 SPECT (single photon emission computed tomography) is a less expensive cousin of PET scanning (positron emission tomography) with low spatial resolution. In case you're interested in learning more about it as a valid imaging method, read this from the experts (Committee on the Mathematics and Physics of Emerging Dynamic Biomedical Imaging, National Research Council).

2 The authors noted there could have been a sampling bias.

References

Adinoff, B., & Devous, M. (2010). Scientifically Unfounded Claims in Diagnosing and Treating Patients. American Journal of Psychiatry, 167 (5), 598-598 DOI: 10.1176/appi.ajp.2010.10020157

Aho L, Karkola K, Juusela J, Alafuzoff I. (2009). Heavy alcohol consumption and neuropathological lesions: a post-mortem human study. J Neurosci Res. 87:2786-92.

Amen D. (2010). Brain SPECT Imaging in Clinical Practice. Am J Psychiatry 167: 1125.

Anstey KJ, Mack HA, Cherbuin N. (2009). Alcohol consumption as a risk factor for dementia and cognitive decline: meta-analysis of prospective studies. Am J Geriatr Psychiatry 17:542-55.

Leuchter AF (2009): Healing the hardware of the soul: enhance your brain to improve your work, love, and spiritual life, by Daniel Amen (book review). Am J Psychiatry 166:625.

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10 Comments:

At October 23, 2010 8:33 PM, Blogger SustainableFamilies said...

Ugh. Dr. Drew drives me crazy! Thank you so much for writing this. It drives me nuts when therapists pretend to understand neurology but only if it fits EXACTLY what they want it to be.

Alcoholics anonymous has horrible success rates and yet it's supposed to be "if you aren't going to AA you aren't trying"

AA doesn't work for some people. It's really an obnoxious system, although it is free and it is something which makes it.... well free and something.

 
At October 24, 2010 10:54 AM, OpenID Sanjay Srivastava said...

Brain images lend a false air of scientific heft to this kind of stuff. But Dr. Drew seems perfectly happy to make unfounded diagnoses of behavior too -- often accompanied by plugs for his TV shows. I put up a short blog post juxtaposing Dr. Drew's unsolicited diagnosis of Joaquin Phoenix (Dr. Drew didn't think he was faking because he showed symptoms that are "difficult if not impossible to mimic") with Phoenix's reaction after he ended his hoax. Phoenix took it in good humor, he could have embarrassed Dr. Drew a lot more.
http://hardsci.wordpress.com/2010/09/23/nice-try-doctor-firstname/

 
At October 24, 2010 6:26 PM, Blogger Bradley Voytek said...

This is an excellent post. Very well done.

 
At October 24, 2010 7:47 PM, Blogger The Neurocritic said...

Thanks for the comments. I read a lengthy piece in the NYT Magazine, Hitting Bottom, because of the title page: "Is Dr. Drew Pinsky's Show Therapy or Tabloid Voyeurism?" So I wanted to see how much criticism was included. Very very little, actually. I thought it was a puff piece. The end of the article is very disturbing, but the appalling nature of his exploitative behavior goes unmentioned. He almost breaks a cardinal rule by disclosing confidential (and traumatic) information in a group therapy session:

“Do you want to share your life experiences?” Pinsky asked.

“Not today,” Sizemore said.

“May I just say that Tom’s experience, Tom’s childhood experience?” Pinsky told the group. “Common to many experiences here. He actually told a story once that stayed with me.” Pinsky looked at Sizemore with obvious sympathy, then tried to prompt him. “You know?” he said. “About the crib?”

As Pinsky tried to draw him out, Sizemore looked back at Dr. Drew with a soft, tired smile. Finally he said, “Not on TV.”

I can't quite come up with the correct term: emotional vampire? addiction pimp? trauma junky? celebrity cannibal? User (of course), but I was going for something more descriptive, more sinister.


Sanjay - Your post on the Joaquin Phoenix diagnosis is hilarious! The link to the Letterman show isn't valid anymore, but this one should work:

Joaquin Phoenix Return visit on David Letterman show

 
At October 25, 2010 8:01 AM, OpenID Sanjay Srivastava said...

Thanks for the new link -- I've updated my site.

 
At October 26, 2010 1:54 AM, Blogger Justin Grace said...

I think when Amen said "... something like Alzheimer's" he was referring to Korsakoff's dementia - which is clinically similar to fronto-temporal dimentia but shares some clinical criteria with Alzheimer's (basically poor memory function) which is far more common and better understood by the population at large.

There are many levels of similarity - not just aetiology (which you have assumed here). To the (lay) patient the most sensible criteria to use is behavioural - Rodman can imagine what it may be like to have something like Alzheimer's behaviourally. He is not going to imagine the neurofibrillary tangles and plaques.

Aetiology is not always the most relevant dimension - Alzheimer's, progressive supranuclear palsy and corticobasal degeneration all share aeitiological similarities (plaques and tangles) but the pathology affects very different brain regions and so has very different effects on cognitive systems and bahaviour.

 
At October 30, 2010 10:02 AM, Anonymous Anonymous said...

I've always found it it disturbing that in the US it is impossible to do a scientific experiment on situations that are routinely used for entertainment. Most of the situations shown on many reality TV shows would not be approved by standard IRBs.

 
At October 30, 2010 11:42 AM, Blogger AnnaZed said...

Hi Neuroccritic, I have just found your blog and am reading every single post. You are very interesting and brilliant.

I can't see a place to contact you directly (and I certainly don't blame you for that) so thinking that it's not entirely off topic I'll just post a question here.

Does anything in this blog make any scientific sense?:

http://newrecovery.blogspot.com/2010/10/stiffness-of-mind.html

thanks.

 
At October 31, 2010 12:35 PM, Blogger The Neurocritic said...

AnnaZed - Thanks for the kind words. Other than the stilted "Stiffness of the Mind" metaphor, that blog post seems fairly accurate. He brought up the under-utilized, valid argument that rats who become addicted to cocaine self-administration...

"...probably don't suffer from spiritual maladjustment. Quite a few theories blame the person's emotional and spiritual deficiencies for the onset of addiction. The animal experiments teach that there's a neurobiological process at work."

Anonymous - I totally agree that most reality shows would never pass an IRB.

Justin - I think Amen could have made his point without misleading Rodman and the general public. And Korsakoff's syndrome is actually considered a rare disease by NIH, and is quite different from fronto-temporal dementia.

 
At December 17, 2010 6:13 PM, Anonymous Anonymous said...

So much for Dr. Amen and diagnosis via Spect scans or should I say Spect scams?
I say Amen for your info on the dangers of diagnosing Mental Illness based on unproven methodology.
I am a mental health advocate.
My site is http://disabilityinfo.hostcell.net/index.htm

 

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