The Neurocritic will be gone for a two week stint in a rapid detox program at an undisclosed European location. Semi-regular posting will commence shortly thereafter.
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Deconstructing the most sensationalistic recent findings in Human Brain Imaging, Cognitive Neuroscience, and Psychopharmacology
There appear to be three main patterns of hallucinogenic drug use. First, there are the people who are primarily and preferentially narcotic drug addicts who have used the hallucinogenic agents on one or several occasions mainly for "kicks" or "curiosity." They seldom seek these drugs and tend to use them infrequently, as for example when these agents come their way through a friend or at a party. Rarely do they take the hallucinogenic agent alone but tend to take it after a "fix" with heroin, hydromorphone hydrochloride, morphine, or some other narcotic drug to which they are addicted at the time.The next group sounds like your everyday 1960s hippie stereotype:
Second, there are the group of people, aptly described by one of the informants as the "professional potheads," who have had extensive experience with various drugs. The most commonly used drug by this group of people is marijuana (hence the name "potheads"), but amphetamines and barbiturates are also popular. Many have had some experience with the narcotic drugs, but on the whole they tend to avoid the opiates. "Creative" and "arty" people, such as struggling actors, musicians, artists, writers, as well as the Greenwich Village type of "beatnik," tend to fall in this category. The "frustrated," "curious," "free thinkers," "nonconformists," and "young rebels," who are seeking a temporary escape also comprise this class of hallucinogenic users, according to our informants. Although the "professional potheads" enjoy the euphoric effects produced by smoking marijuana, they also tend to relish and seek out the feelings of greater insight, inspiration, and sensory stimulation and distortions which the hallucinogens may produce. They are in constant search of agents to rouse them from their apathy, to make life more meaningful, to overcome social inhibitions, and to facilitate meaningful conversations and interpersonal relationships.
Hallucinogenic agents are used by these people mainly on weekends (often "four-day weekends") or on special occasions, such as parties. It is rare for users to take drugs alone. They are mainly taken with friends or at intimate gatherings of people. The parties are of all varieties. Frequently, little conversation takes place while people are under the influence of these drugs, but they claim to experience a greater closeness and rapport with the other members of the group. One patient described having attended "basket weaving" and "lampshade making" parties where all members, under the influence of these drugs, squatted on the floor and silently attended to their tasks. At another type of party, overt sexual activities were carried out. Folk singing was also common. To quote another patient, "Mostly the people sit around trying to dig each other . . . everybody is sitting around and waiting, like on New Year's Eve, for something to happen."
Third, there are a small number of people who take the hallucinogenic agents repeatedly over a sustained period of time to the exclusion of all other drugs. The frequency of drug use during these periods of time is variable. One patient took peyote four times a day over a two-year period, while another patient took it two out of every three days over a three-month period. One patient took mescaline every day for two separate 15-day periods, while another took mescaline every two to three days over a six-month period...Generally, these patients seemed different from those in the second group, who primarily smoke marijuana. They did not take these drugs in a group for social purposes but used them mainly as a means of attaining some personal, esoteric goal. One patient talked of having achieved an increased sensitivity to nature and a greater insight into himself after prolonged peyote usage. While living by himself on Big Sur in California, he claimed to have achieved a "Christ-like state of mind" and a greater feeling of altruism. Another patient stated that as he kept taking mescaline, he was able to control his experience and attained a state of mind in which "every little thing is projected large," where he was able to see the negative and positive aspects of everything, and where "everything is real." A third patient, of Mexican extraction, kept taking peyote to "find God."
"Congressman Weiner departed this morning to seek professional treatment to focus on becoming a better husband and healthier person," Weiner's spokeswoman, Risa Heller, tells Us Weekly in a statement. "In light of that, he will request a short leave of absence from the House of Representatives so that he can get evaluated and map out a course of treatment to make himself well.This was, of course, before his resignation. The New York Times went on to state:
Ms. Heller would not identify the facility or the precise kind of counseling Mr. Weiner, who has admitted having explicit communications with six women he met online, would receive... . . .Ms. Pelosi had hoped that the congressman would reach the decision on his own to go. In addition to her concerns about the political distraction Mr. Weiner had become, Ms. Pelosi concluded that his behavior required medical intervention. “When you are this self-destructive, there is obviously something deeper going on with you,” said a Pelosi adviser who spoke on condition of anonymity for fear of being seen as betraying her confidence.This brings us to the issue of "sexual addiction", or compulsive sexuality, or hypersexuality. Establishing an agreed-upon definition and proper diagnostic critieria for this condition is a minefield (compare Kafka 2010a, 2010b and Levine, 2010). For the present blog post, I will present the view of Reid et al. (2011) from their paper on A Surprising Finding Related to Executive Control in a Patient Sample of Hypersexual Men:
The proposed diagnostic criteria for the DSM-V characterize hypersexual disorder (HD) as a repetitive and intense preoccupation with sexual fantasies, urges, and behaviors, leading to adverse consequences and clinically significant distress or impairment in social, occupational, or other important areas of functioning. One defining feature of this proposed disorder includes multiple unsuccessful attempts to control or diminish the amount of time the individual engages in sexual fantasies, urges, and behavior in response to dysphoric mood states or stressful life events. Despite a constellation of studies investigating characteristics of HD (usually defined in the literature as sexual addiction, sexual compulsivity, or hypersexual behavior), little is known about the neuropsychological correlates of this phenomenon, including possible associations with executive functioning.Executive functions are a series of high-level cognitive processes that allow for the flexible control of thought and adaptive behavior. They include processes such as planning, decision making, multitasking, task switching, and impulse control. One might expect that executive functions (or at least some of them) would be impaired in those who show problematic hypersexual behavior. For example, although Weiner may be witty and reasonably intelligent, his apparent narcissism, poor impulse control, and terrible decision making abilities in the sexting realm proved to be his downfall.
BLUETrail Making version B is an attention switching task where the participant connects the dots on the sheet below by alternating between letters and numbers: 1-A-2-B-3-C, etc.
In the clinical interview, participants were asked about the degree to which they use sex to cope with stress or uncomfortable emotions, consequences they have experienced as a result of their sexual choices, and ways in which they may have felt unable to control their sexual behavior. For patients referred for the hypersexual group, classification as such was verified based on elevated scores on the hypersexuality measures and (i) a reported pattern of hypersexual behavior that persisted for at least 6 months; (ii) reported preoccupation with sexual thoughts, urges, and the pursuit of sexual activities that interfered with at least two aspects of their daily life (e.g., academic or scholastic goals, work, parenting); and (iii) reported experiencing at least one significant consequence (e.g., contraction of a sexually transmitted disease [STD], loss of employment, debt, arrest, relational discord) as a result of their sexual behavior.
There are a number of potential explanations as to why executive deficits did not emerge among the patient sample in this study despite a pattern of impulsive and risky sexual behavior. First, difficulties in executive functioning of a magnitude that would show up on performance-based measures may be present in only a subset of hypersexual patients... Second, it is possible that the neuropsychological tests of executive functions were not sensitive to detect subtle deficits that may have existed in the patient sample. Third, it may be that hypersexual men may exhibit impaired judgment, difficulty with impulse control, and cognitive rigidity but only in situations where they encounter opportunities for sex. ... In other words, hypersexual men may indeed exhibit impaired judgment, difficulty with impulse control, cognitive rigidity, and so forth only in situations where they encounter opportunities for sex or are exposed to specific cues that have been paired with sex.In other words, the hypersexual participants might have had more difficulty on the Sex Stroop task:
TITSPerhaps I can go into the business of designing customized neuropsychological tests of executive functions for use on VH1 reality shows like Sex Rehab with Dr. Drew...
...limitations of the DSM-IV nosology may impede the diagnosis of BD, because the DSM-IV has rather broad criteria for MDD and narrow criteria for BD.According to Akiskal and Pinto, the evolving bipolar spectrum (circa 1999) includes:
BIPOLAR I: FULL-BLOWN MANIAEach of the diagnostic categories was illustrated by a clinical case report. Cyclothymia is included in DSM-IV: "A history of hypomanic episodes with periods of depression that do not meet criteria for major depressive episodes. There is a low-grade cycling of mood which appears to the observer as a personality trait, and interferes with functioning." Hyperthymia, however, is not a diagnosis but an affective temperament "characterized by exuberant, upbeat, overenergetic, and overconfident lifelong traits." More specifically (Akiskal & Pinto, 1999):
BIPOLAR I½: DEPRESSION WITH PROTRACTED HYPOMANIA
BIPOLAR II: DEPRESSION WITH HYPOMANIA
BIPOLAR II½: CYCLOTHYMIC DEPRESSIONS [often labeled as borderline personality disorder]
BIPOLAR III: ANTIDEPRESSANT-ASSOCIATED HYPOMANIA
BIPOLAR III½: BIPOLARITY MASKED—AND UNMASKED—BY STIMULANT ABUSE
BIPOLAR IV: HYPERTHYMIC DEPRESSION - "patients with clinical depression that occurs later in life and superimposed on a lifelong hyperthymic temperament."
The attributes of a hyperthymic temperament are not episode-bound and constitute part of the habitual long-term functioning of the individual. Patients are typically men in their 50s whose lifelong drive, ambition, high energy, confidence, and extroverted interpersonal skills helped them to advance in life, to achieve successes in a variety of business domains or political life.Arnold Schwarzenegger comes to mind [if he had started having depressive episodes several years ago]. In fact, the case study of bipolar IV was presented as a highly successful, 53 year old married lawyer with three other families in different countries.
Having hallucinations, arguments, striking out, and violent behavior
Having delusions, depression, agitation
We present our perspective as an alternative to the more commonly held clinical–neurological view that agitation, impulsivity and related mood instability in Alzheimer's and other dementia patients merely represents frontal lobe dysfunction (Senanarong et al., 2004). A more sophisticated view in the literature argues that behavioral–cognitive syndrome in Alzheimer's disease is a prodromal stage, whereas in fronto-temperal dementia the behavioral disorder appears when the cognitive deficit is relatively mild (Jenner et al., 2006). Our perspective, while ostensibly recognizing the dementia setting postulates the possible contribution of pre-existing familial and/or temperamental diathesis for bipolarity in patients presenting with dementia-like clinical pictures with marked mood and behavioral disturbances.Are they grasping at straws to justify prescribing mood stabilizers and atypical antipsychotics to these patients, perhaps? Let's look at the declared Conflicts of Interest of the senior author on this paper:
Dr. Akiskal is on the US GSK Advisory Board, Abbott's Latin American Bipolar Advisory Board, and International Advisor to Sanofi-Aventis. He has received honoraria for lectures from these companies, as well as from Lilly.Branded formulations of generic valproic acid, one of the most common mood stabilizers, include:
Dr. Akiskal has served on speakers or advisory boards for Abbott, AstraZeneca, Bristol-Myers Squibb, Eli Lilly, GlaxoSmithKline, and Janssen.AstraZeneca makes Seroquel (quetiapine), an atypical prescribed to five patients, Bristol-Myers Squibb makes Abilify (aripiprazole), an atypical that was not given to any of the patients, and Janssen's products include Risperdal (risperidone), an atypical prescribed to one patient.
In nursing homes, 14% of residents have been given at least one prescription for a second-generation antipsychotic, according to a government investigation. A full 88% of these prescriptions are given to people with dementia, despite the fact that these drugs may double the risk of death in these patients (there is a black box warning on the drug to this effect). The investigation estimated that $116 million Medicare dollars have been spent filling antipsychotic prescriptions that never should have been written.If these elderly patients were diagnosed with the official label of Bipolar Disorder Type VI, then the prescriptions could potentially be justified, and an old discredited market becomes new once again.