Pleh, I say. And also bah.

First red flag: this is not yet published, but Professor Crowe is giving press releases and interviews to the general media. Not an especially auspicious sign.

So, I can’t check out the details of what was done, including any statistics. I can however comment on what they’ve said in their press release about the experiment:

“The participants were assigned to either a high or a low stress condition and a high or a low caffeine condition on the basis of self-report.”

It gets worse. They didn’t administer caffeine, or even measure intake or serum caffeine levels. Perhaps they asked how many coffees the participants drank, but different types of coffee (brewed, espresso, instant…) differ in their caffeine content, and even with the same sort of coffee, different baristas will give different results (for example, I’d lay good odds there’s a lot more caffeine in one shot from me than in a double shot from almost any cafe in which I’ve observed the barista). There are no details about how they determined whether the person was subject to a high or low stress condition – so we can basically almost discount the stated difference between the groups in the “study”, before we even really begin.

“The participants were then asked to listen to white noise and to report each time they heard Bing Crosby’s rendition of “White Christmas” during the white noise. The song was never played. The results indicated that the interaction of stress and caffeine had a significant effect on the reported frequency of hearing “White Christmas”. The participants with high levels of stress or consumed high levels of caffeine were more likely to hear the song.”

So. Maybe interesting. Not hallucinations though. Not without a lot more detail. At most I suppose we could call them secondary hallucinations (an hallucination triggered by a real perception), but my money’s on illusions/misperceptions. This was done under the guise of a hearing test, and the subjects were led to think White Christmas would be played. Therefore they were listening for it. It is perhaps interesting that (possibly) more highly stressed or caffeinated individuals were more likely to think they heard something, but it expressly does not mean…

“This study also helped to explain the mechanism by which stress may facilitate the symptoms of schizophrenia in non-clinical samples. Caffeine has only recently been reported to increase proneness to hallucinate. ‘The results also support both the diathesis-stress model and the continuum theory of schizophrenia in that stress plays a role in the symptoms of schizophrenia and that everyone, to some degree, can experience these symptoms. This was demonstrated by a significant effect of stress on the occurrence of hallucinatory experiences, or hearing the song.”

Absolute. Rot.

There is no basis – from what has been reported (and only in their press release and news media) – on which to extrapolate illusions when primed to expect a particular experience, to schizophrenia. None. Zip. Nada.

Certainly, stress plays a part in psychotic illness. Certainly it’s plausible to think stimulating the brain might not be the best thing in the world to do, especially if that brain is vulnerable. This wretched (or at best, wretchedly reported) excuse for a study takes us no further than those two basically common-sense statements.

So, go forth and sup your coffee.

*coughbullshitcough*

I’m kind of sick of it though, after reading and calculating and re-reading and re-calculating. They did a screening tool, and then two diagnostic instruments on the kids whose parents consented. with the number of cases they identified, out of their whole initial sample, their raw prevalence figure was 0.38%. After a couple of paragraphs comparing proportions of autism, aspergers and other ASDs, came the kicker: after “statistical adjustment for non-participants” the prevalence of ASDs was 2.64%

LOLWUT??

It’s ok, they’ll explain how they got from 0.38% to 2.64% … right?

……….

Riiiiiiiiighhhht?!??!

Nup. They just point the reader to “Table 3″ which doesn’t explain anything; it simply displays their final figures. Total crap, unless they (just like maths class in school) show their working.

Edit: ok, looking again I see that they did – before the results section – go through the way in which they calculated the adjusted prevalence. Starting (to me incomprehensibly) with:

“We hypothesized that each child’s parents have an unobservable score on a latent variable representing willingness to participate in diagnostic evaluations. Probabilities for consent and evaluation after screening positive, likely indicators of this latent construct, were modeled with logistic regression, using parent-rated ASSQ score and child’s sex and age as predictors.”

And ending up with:

“Therefore, it is reasonable to infer that the probability of ASD diagnoses among children who were not definitively evaluated is no different from that for children who had full assessments. Hence, a simple proportional weigh-back procedure was used to compute prevalence estimates for the regular schools.”

So instead of comparing their positive diagnostic results against the total population (much like an intent-to-treat-analysis) they have gone through some contortions to arrive at the position that “it is reasonable to infer” that the non-participants were the same as the participants in terms of prevalence of ASD – and therefore they can just look at their positive diagnostic results as a proportion of the participant group. This is despite saying:

“ASSQ score was significantly positively associated with parental consent and with participation in the assessment…”

So higher screening scores for ASD are correlated with participation in further assessment, but it’s reasonable to infer there’s no difference between participant and non-participant groups. Que? And it appears all their fancy statistical jiggery-pokery was based on their “hypothesis” that “each child’s parents have an unobservable score on a latent variable representing willingness to participate in diagnostic evaluations.” … ‘K …

Also, to nitpick, it’s not an hypothesis, as they didn’t test/attempt to disprove it. So it’s a guess.

The other point, is that even if the 2.64% is right, it’s wrong. If a developmental disorder is present in 1 of every 38 people, then It. Is. Not. A. Disorder. How can it be? At what point will we stop and say “ya know, maybe we’ve got this a bit wrong. Let’s have another look at the category.”?

Steve Novella has blogged very thoughtfully about this (with a less dismissive take on it than me). One of the points he makes is that:

“…many of the undiagnosed children would likely not require or even benefit from special services.”

So remind me why the frak it’s called a disorder?

And why we need to identify these kids?

Dr Novella points out that 2.64% is almost exactly 2 standard deviations on the left side of the social ability bell curve, and also correctly points out that being at the tail of a bell curve does not equate with having a disorder.

I think this study is bad science, and bad medicine. Too much getting caught up in statistical tests and figures before actually applying basic logic and common sense. Both are necessary if we are to approach the truth of anything, and thereby help people properly. Psychiatry has been described as lurching between brainlessness and mindlessness. This is generally in discussions of how much the biological or psychological are eschewed in favour of the other, but another aspect is seen in psychiatric research: whereas in years past there was insufficient scientific rigour, and our literature was somewhat brainless, now the pendulum has swung to the point that I’ve heard of psychiatrists or psychiatric research being described as “desperately in search of a p value less than 0.05″.

Mindless.

As I’ve written recently (well, not that recently; I have been slack and haven’t written much at all recently…), the efficacy of antidepressants has been called ini to question by a few meta-analyses – and while there are real problems with those studies, I do think there might be some truth to what they say. I’ve also written often about psychiatry’s lamentable role in social control or engineering, and being thrown at all of society’s ills, when people might not be actually ill, but just distressed by their life situations.

So why would I now be extolling the virtues of antidepressants?

Because I’ve had a wee cluster of patients suffering major life stressors (job stuff, marriage stuff, children stuff, losing a home stuff… Yu know: the real biggies), who have also presented with serious depression. In such situations I generally tell people my aim is not to make them happy, as I think that would be unrealistic – and in fact diminishes the importance of the stressors – but rather to treat that part that is illness, and thus allow them to function. (That distinction was somewhat more clear in these recent cases I’m thinking of, by virtue of pre-existing diagnoses.)

Anyhow, so I set about treating the illness part of their problems, and on review, despite no change in circumstances (in some cases a worsening) the illness is resolving (not just because I think so; not just because the patient thinks so; because we both agree AND a well-validated rating scale says so). Again, I wouldn’t say any of them are exactly happy, but they’re physically and functionally improved.

That’s what I want to do. That’s what I’m here to do. I can’t fix the vicissitudes of people’s lives, but I can treat the illnesses that stop my patients from addressing them (or just coping with them) adequately.

So: FUCKYEAHANTIDEPRESSANTS! (And mood stabilisers and antipsychotics, of course – for exactly the same reasons.)

My registrars and I have been reading about and discussing phenomenology, in preparation for a presentation (which we did today, but I was most disappointed that the video clips I had embedded – and that worked fine on other computers – didn’t play on the laptop we had for the presentation, so I had to recite Morpheus’ lines from the clips below). We focused on delusions to illustrate many of the aspects of phenomenology – as opposed to (relatively) simple descriptive psychopathology. The standard definition of a delusion is along the lines of “a fixed false belief, not understandable within the patient’s culture/social group, that is not amenable to reason” – or some variation. The essential points being that it is false, it isn’t shared with others, and it’s fixed/can’t be reasoned away.

Karl Jaspers, a psychiatrist and philosopher, wrote about phenomenology, and found that standard definition wanting. Rather than the content of the belief (that is, that it is false, and not shared with others), he wrote that the form was what defines the phenomenon: in particular the characteristic way the belief arises.

Jaspers described a primary delusional process – kind of the archetype of a delusion; not all will be like this, but it’s like an underlying template. First there is often what is termed a “delusional mood” or delusional atmosphere. Anyone who’s seen The Matrix should recognise this: it is a state of heightened sensitivity, where everything around has increased meaning and seems to refer to the self. There is a sense of perplexity, that something is wrong but they do not know what.

Here’s one of the best descriptions of that state I have heard:

Out of that state crystallises the primary delusion, in a fashion quite different from ordinary belief: it is instantly known, fully-formed (sometimes in response to a perception that becomes imbued with delusional significance – and is termed a delusional perception). The delusion “explains” the preceding unpleasant dysphoric perplexed and anxious state, and thereby allows the person to feel again that everything makes sense.

This delusion is then held to with extraordinary conviction. The person is unable to even subject it to logic, as it becomes bound so closely with their sense of self that for the delusion to go would mean complete collapse of how they now see themselves and the world. Rather than misapplying logic, it appears the deluded person parcels off the delusion and logic is simply not applied to it at all.

In contrast to secondary delusions (for example: forming a delusional belief about one’s hallucinatory voices), the primary delusion process is seen as irreducible: we cannot break it down into anything more basic. It is also said to be ultimately un-understandable, as it is so qualitatively different from normal human experience. As I was thinking about this however, I began to relate it to the notion of epiphany. The more I thought about it, the more I thought that phenomenologically it is in fact analogous to the primary delusional process. I’ll illustrate with my own experience of an epiphany.

One evening in my late teens I was walking home from my crappy supermarket job. I recall feeling somewhat odd or different, and that everything was a bit more “real” and meaningful than usual. It was dark, and as I walked I looked up and saw the stars. Suddenly – and instantly – I was struck by a realisation of the vastness of the universe, my own cosmic insignificance, and yet my connectedness to that unfathomably vast universe.

The parallels are, I hope, clear. Another thing about my experience which appears to be shared with the delusional process is that it was not simply the idea that sprang into my mind; it was accompanied by its own quite intense affect. That seems to be the case with delusions: it’s not “just” a belief; there is a feeling (an affective state) associated with that belief.

Both the idea/belief and its associated affect have remained with me, unchanged, for 2 decades now. It has become a very important part of how I see myself and the world – and if I really think about it, it’s not something I do, or want to, apply logic to. The fact that the universe is in actuality unfathomably vast, and I am indeed cosmically insignificant (though made from elements forged in supernovae) is irrelevant. Just because it is true doesn’t mean there’s any logic in it, and it does feel somehow odd if I try to aim logic toward it: to even begin trying to formulate a course of logical enquiry is uncomfortable.

It’s also interesting that this happened for me in my late teens – around when schizophrenia often has its onset in males. I wonder if there’s any pattern to the ages at which prophets have their revelations….

So. The point of that?

Simply that I think the apparently un-understandable primary delusional process might not be as qualitatively different and alien as we generally think, and perhaps there is some scope for empathic understanding of the deluded person’s experience.

I’ll finish with another clip from the Matrix with relevance to psychiatry, philosophy and phenomenology. Why? Because I got it all set for our presentation and it failed, and so I might as well use it here. The connection is that a delusionary belief does not exist in isolation: it occurs within the person’s experience of reality … so what is real?

We seem now to look at rugby players.

Who all seem to have bipolar disorder.

I understand it. It’s a nice intellectual exercise – kind of detective work: not like a real-life police detective actually finding out facts, but sitting Holmes-like and declaiming on what one has seen. There’s also the appeal of possibly helping to de-stigmatise psychiatric illness – or even to “normalise” it (though surely “normalising” a serious illness is a bit of a funny idea…). It’d be nice to be able to point to some well-known and successful people with the illness you’ve just diagnosed a young person with, and perhaps give them some hope (justified or not is a different question).

The thing that occurs to me (in addition to the question of whether or not being a publicly-known figure makes it ok for all and sundry to speculate about your health, psychiatric or otherwise) is that it can be hard enough to be definitive about the diagnosis of the person sitting right in front of you, when you’ve asked the questions you want, and observed the person directly. To read second and third hand accounts of behaviour, and see footage of them in non-interview settings and so on, and try to extract a diagnosis from that, is a seriously fraught endeavour.

…

I’ve just deleted a paragraph that included a couple of names, because even saying overtly that it’s speculation and using them as examples of why we shouldn’t so speculate, it seems wrong to me. It would imbue the notion that these people have or had psychiatric illnesses with a semblance of authority, when in fact it is nothing more than somewhat idle speculation.

I’m not sure that it is all that good for psychiatry – or psychiatric patients – either. Well-known people are well-known. Or at least we all think they are. We think we know about them. We have our own ideas about them – so when a shrink comes along and is seen to excuse some bad behaviour by saying it’s psychiatric illness, if it doesn’t gel with our conception of them, we see it as just that: an excuse. The reality and impact of psychiatric illness is potentially then downgraded. Perhaps thereby psychiatric illness is somewhat “normalised” … but I don’t think we want to “normalise it”.

It is not normal to be so depressed you stand in a corner not moving, eating or drinking – not eating because you believe your insides have rotted away. It is not normal to sleep only an hour at night (if you really can’t keep your eyes open) because you’re too busy being the new prophet of god and satan working to bring peace to the Middle-East by sending thought messages to Oprah Winfrey. It is not normal to be unable to leave the house for fear of crippling panic attacks that leave you drenched in sweat, with your heart pounding out of your chest, sure you’re about to have a heart attack, drop dead and go crazy. It is not normal to be unable to function because you spend 18 hours a day showering, and washing your hands, or to take 2 hours to get down the road because you have to keep doubling back to check you locked the door – even though you know absolutely that you are clean, or did lock the door, and that your thought and behaviour are irrational. It is not normal to believe that you have an implant in your brain by which the FBI are tracking you, because you said something negative about George Bush in a FaceBook status update.

I don’t see that this sort of thing addresses the stigma – or more properly the discrimination suffered by people with psychiatric illnesses. The stigma is real: some illnesses (thinking particularly psychotic illness) do mark a person as different. The treatments can do that pretty well too: blunted affect, worsened negative symptoms, movement disorders – these are all stigmata of psychiatric illness. Anecdotes about people living well with psychiatric illness don’t change the stigma. The discrimination is related but different. We discriminate against those who are different from us – hence the importance of the stigmata.

But really, I don’t see that saying this or that famous person has this or that psychiatric illness has much of a show of reducing discrimination against people with psychiatric illness in general. What? Are we all going to think when we see someone obviously psychotic “oh, that famous rugby player was diagnosed with bipolar disorder; I won’t discriminate against this person”? Like so much elsegood and important in life, I think it comes down to empathy. We don’t want to normalise psychiatric illness, we want to encourage an empathic response. Some education about what happens in psychiatric illness is needed, and trying to help people to think “how would I be feeling if that were happening to me? How would I hope people would react to me?”

… Instead of “omg lock up the crazy person!” – which I see far too often.

postscript, as though it needs saying: the above descriptions are not of any actual people’s symptoms. They’re more  like archetypes off the top of my head, if you like