Cognition and Evolution

Consciousness and how it got to be that way

Sunday, November 3, 2019

Editorial Clickbait about Psychiatry in the New England Journal of Medicine

I'm really disappointed in NEJM for publishing this piece by Gardner and Kleinman (G&K.) Overall this article is not helpful or useful. There is a cottage industry of psychiatrists writing hit pieces on our own specialty, and often they make coherent and actionable points that improve the specialty and ultimately patient outcomes. But of many valid criticisms of psychiatry, this article bizarrely focuses on two problems that pervade most of medicine, and implies that they are uniquely problems for psychiatry. The thesis seems to be that psychiatry has been damaged by reliance on a biological approach, which has stunted its ability to treat patients, and damaged our interactions with them by decreasing the quantity and quality of our interaction.

First: these two have apparently not been talking to many of their colleagues, inside and outside of psychiatry. How many physicians do you know, especially in cognitive specialties with lots of patient contact, who say "No, I don't have inappropriate time pressures on my patient interactions, and what pressures there are, are not worse than they were thirty years ago"? Most psychiatrists would love to spend more time with patients. When we don't, it's not because we've already gone through the checklist so we don't want to waste time forming rapport - it's due to the moral hazard introduced by the financial and administrative structure of modern medicine. The same argument obviously applies to many specialties outside of psychiatry.

The second part of their argument is that over-reliance on a biological approach is what has distorted psychiatry and prevented us from adequately treating patients. In case they haven't noticed, we do have psychiatric medications which work, that we didn't have a few decades ago. (They somehow fail to comment on the existence of SSRIs and second-generation antipsychotics, for example.) How is this the failure of a biological approach? It is trivially true that biological approaches to psychiatry have not yet been as fruitful as we would all like. The genomics revolution (for example) has also not benefited most branches of medicine to the degree hyped - yet. It's a bit premature to say that therefore, biological approaches like genomics have not yet benefited psychiatry and therefore will never benefit psychiatry. They have essentially not benefited any other branch of clinical medicine besides hem/onc - because it's easier to kill or poison certain cells than it is to make them work better, especially ones that are suspended structurelessly in fluid, rather than connected in a specific network, neural or otherwise. We should expect that oncology would have been the first to benefit. In this G&K are rather like engineers in 1900 saying "we haven't achieved powered flight yet, therefore it can't be achieved ever." (Which, by the way, some engineers did.)

It's unclear what G&K's solution is. Perhaps most tellingly, the voices I've seen online defending this article seem to have great difficulty understanding the definition of "syndrome", or the idea of treating empirically before the biology of a specific case or even the disease itself is clear is quite often the best approach (and again, this is not specific to psychiatry.) For instance, many psychotherapies have an impressive evidence base at this point, and if we don't understand psychopharmacology as well as we would like at the biological level, we certainly don't have anything like a fully articulated biological theory of psychotherapy either. If you have a treatments that can help - pharmacologically or otherwise - it's immoral to withhold it just because the science behind the treatment mechanism or pathophysiology is not settled. And as near as I can tell, that's exactly what G&K are proposing.

Saturday, May 4, 2019

All Perching Birds Descend From an Australian Ancestor

When I visited Australia, I remember walking around my first day seeing lorikeets and other very tropical-looking birds and thinking "Huh, I guess I'm in Gondwanaland now." Little did I did I know, all perching birds even including my own North American ones are actually Australian! This, from a new PNAS study showing that the last common ancestor was 47 MA ago in Australia. Immediate evolutionary just-so thoughts: Australia has a strange and (relative to other continents) low mammal population, which may have allowed for such a radiation within Australia. Neighboring New Zealand had no mammals at all until seven centuries ago, and is famous for its (sadly threatened) bird diversity, as well as its birds filling many roles usually taken by mammals (hence, now being threatened.) As the Earth went through pulses of cooling and drying and Australia moved north and became drier, less forested, and less hospitable for perching birds, this may have given an opportunity and incentive for a diverse bird population to spread to other continents where they hadn't had similar opportunities to get a head-start on mammals. The paper focuses more on known global climactic shifts, such as the cooling in the Oligocene-Miocene transition: "Three rate shifts [i.e. in rate of diversification] appear to have occurred almost simultaneously during the Oligocene-Miocene transition in three different oscine clades on three different continents...[obviously, after the most recent common ancestor had left Australia.]"

Oliveros CH, Field DJ, Ksepka DT, Barker K, Aleixo A, Andersen MJ, Alström P, Benz BW, Braun EL, Braun MJ, Bravo GA, Brumfield RT, Chesser RT, Claramunt S, Cracraft J, Cuervo AM, Derryberry EP, Glenn TC, Harvey MG, Hosner PA, Joseph L, Kimball RT, Mack AL, Miskelly CM, Peterson AT, Robbins MB, Sheldon FH, Silveira LF, Smith BT, White ND, Moyle RG, Faircloth BC. Earth history and the passerine superradiation. PNAS April 16, 2019 116 (16) 7916-7925

Friday, March 22, 2019

How Delusions in the Real World Disappointed My Expectations

Delusions have long been of interest to me and they're fascinating for many people. Why do people see the same thing as everyone else, but arrive a very different conclusion, and become unable to change their mind about it? I've been fortunate to be able to do basic research into this phenomenon, and in my daily practice I see and treat them frequently.

(You should note that delusions represent a small, pathologic subset of false beliefs, really a disturbed belief process distorted by different anatomy. We all have false beliefs, but hopefully we can update them when we get new information. Even when people don't update their beliefs based on relevant information - they're usually identity-forming or socially important beliefs - and frustrating though that is, that is still different than a delusion. So, no, your most un-favorite religion or political party adherents are not delusional, even if they're wrong.)

There are a number of misconceptions, or more accurately, misexpectations, that I had about delusions when I went into this business, which will be glaringly basic and obvious to any psychiatrist, but will probably not be so obvious to other people. In no particular order:
  • If and when delusions resolve, there is only rarely a "eureka" moment where the patient realizes the belief is false, or has even a significant enough increase in insight to gradually look back and sheepishly say "Yeah, I guess that wasn't true." Rather than updating the belief, people just stop being so motivated by it. That is to say, in the large majority of people, rather than the belief changing, the centrality of the belief changes. I find this very unsatisfying. "Yeah, I still think drones are probably following me everywhere but I don't worry about it that much." This isn't all that much different from belief in health - confirmation bias is all-pervasive, and recall that science advances one funeral at a time.
  • Related: you can't talk someone out of a delusion. Ever. (As the rationalist proverb goes, you can't reason someone out of a position that they didn't reason themselves into.) At best, you will waste your and their time, and at worst, you will anger them and damage your therapeutic alliance. And if the psychiatrist who gives into this urge is completely honest, it's partly informed by a need to "win" the discussion. Even if you know this intellectually, early in your career it's very difficult to avoid engaging a delusional patient in this way (partly because the patient will not infrequently challenge you to do exactly that.) At this point I'm proud to say I can mostly resist the temptation.
  • Though delusions sometimes do appear in isolation, they rarely occur without other neuropsychiatric symptoms. Even delusional disorder (where the patient has ONLY delusions) is often a misdiagnosis that evolves to something else - like dementia, especially when appearing in middle age or later, with the delusion merely as the earliest symptom. So very often, the person with a delusion is quite psychiatrically ill in many ways that make having a coherent discussion about the delusion (to hear a coherent set of delusional beliefs) very unlikely; e.g., severe paranoia that keeps them from talking to you about the details of the delusion, and/or constant hallucinations which distract them and to which they respond, or merely an inability to speak in a way that makes sense at all.
  • This one was most disappointing to me: delusions are rarely coherent, in contrast to how they are often presented in the lay media - for example, K-PAX, or the analysand in the essay The Jet-Propelled Couch (who supposedly was in reality the science fiction writer Cordwainer Smith.) They are sometimes completely bizarre and incomprehensible, and even after giving the patient a chance to explain, you still have no idea what they mean. (This is one subtle feature of thought and speech in psychosis: though the sentences might be grammatical and seem to be meaningful, strung together, you can't make sense of what they're saying or even clearly remember it ten minutes later - much like, I think not coincidentally, we struggle to remember an early morning dream even until lunchtime.) Even when delusions are "about" something comprehensive, they are only peripherally about discrete objective facts, delusions are based on affect and "primitive" themes of the sort that color nightmares[1] - pursuit, certain people being morally bad, looming organizations with sinister intent, an overwhelming sense of contamination, etc.
  • It is often striking how incurious delusional people are about their predicament - after years of, say, harassment by a sinister government agency, when one asks "Do you know why they're doing this? And where they get all these resources? And how their technology operates?" people often do little more than shrug.[2] They are also usually obviously and badly internally inconsistent, again unlike the cleverly constructed delusions in fiction. If the psychiatrist in the Terminator thought the future-warrior's tale was a delusion, he was right to be impressed by it. People will tell you (for example) that they were victimized for many years by their persecutors, until they developed their special powers at age 23 that made them immune; then in the next sentence, tell you how they were victimized at 26. Rather than becoming upset when such continuity problems are pointed out, they generally just wave it off as irrelevant and keep going.

Delusions are hard to treat; even so, medications can and do help people. But if you get into this business to hear fully elaborated, articulate, consistent delusions about time travel, space empires, or sinister (but interesting) experiments that shadowy government agencies are doing on us - you're going to be disappointed.


[1] Even in delusional "shadow syndromes" like physics crackpots or various denialists that do seem to be focused on external objective cold facts, invariably there is ranting against the Establishment and paranoia about people stealing their work, and this takes up much of the time that might otherwise in a more rational person be devoted to research or making their case.

[2] Regarding this incuriosity: delusions are not the only neuropsychiatric symptom where this feature appears. I'm agnostic as to whether this incuriosity is actually part of these diseases, or is just (unfortunately) the natural state of most humans. For example, hemi-neglect is a symptom usually seen after strokes, where the patient loses one half of space. I don't mean that they can't sense what's going on one side of them; they literally can't understand that that side of the universe exists, exactly like you or I can't perceive the fourth dimension.

To illustrate: these people lose not only the use of one half of their bodies, but the awareness that they exist. So they will deny that they have a left arm. And if you hold their (genuinely paralyzed) left arm up in front of them, they often confabulate ridiculously: "That's my sister's arm. She's hiding under the table." Now, if my doctor told me I had four arms, I would tell her she was a goof. But if she could consistently could keep holding two extra arms up in front of me that had roughly the shape and skin tone of my other arms and in the middle of a room where there was no chance of a trick, I would eventually have to concede that I was having perceptual difficulties and that I indeed had four arms, even if I couldn't tell how they attached to me. Probably a more common situation is that a hospitalized patient will demand to speak to the doctor at dinner, and as the doc enters their room, says angrily "They keep telling me this is a full-sized dinner, but look at this thing!" And they gesture to their plate, exactly one half of which is eaten. So, you turn the plate 180 degrees, and they grunt, and finish the other half of their dinner, now that it exists. Now, if tonight I complain to my wife that she only gave me half a serving of dinner, and she glared at me and reached over and did something I didn't understand and suddenly my plate was full again as if it had passed partway through my dimension like a sphere in Flatland, I think I would say "Whoa! You just magically produced food out of the fourth dimension! I don't understand how you did it, but could you do it again?" But that's not how people usually react, which implies there's a loss of insight or ability to update associated with this condition. It should not be missed that most neglect is left neglect (meaning, a right-sided lesion), and that one theory of delusion holds that somatic delusions can be caused by right frontal lesions, and that some sort of functional right hypofrontality is required for the lack of insight inherent to all delusions, somatic or otherwise.

Monday, March 11, 2019

In Medicine, Rounding Works

Rounding is a time-honored tradition where doctors meet to talk about cases, either in a meeting room (the "rounding room" was named after a specific room at Hopkins) or at/near the bedside. Most often associated with inpatient medicine teams especially in training environments, the treating physician will present the case and discuss it with her colleagues. Not only is it thought that in this way, medical decision-making benefits from collective intelligence, but the anxiety provoked by immediate criticism (especially in trainees) sharpens one's thinking. A study in JAMA Network Open supports this. Teams here were internal medicine teams composed of multiple levels of training, from med students up to attendings. I don't think the findings would be too domain specific, but at a guess, I imagine the benefit would be even greater for psychiatry than for internal medicine, as psychiatry's diagnoses are fuzzier and more subjective.

Groups don't always arrive at better decisions than individuals - especially groups of non-expert individuals with no feedback - but teams with people who are experts, and who do get feedback benefit from collective intelligence, do better than individuals alone. So qualitatively this isn't surprising, but a problem in medicine is lack of quantitative thinking; especially in my specialty, psychiatry, where studies are constantly coming out showing that medical or psychiatric illness X increases the risk of psychiatric illness Y. No kidding! By how much is what we want to know. So what's the actual benefit of rounding?

For groups of 9, on average you need to treat about 4 people before you make a diagnosis that an individual would have missed (i.e. NNT is about 4.)

For groups of 5, NNT = 6.

For groups of 2, NNT = 8.

The simple plot below shows the % accuracy improvement per person based on group size, and again not surprisingly, there's a diminishing marginal return for adding more people. (Where does it go to zero? Nine is already on the big size for a rounding team.)


This of course doesn't take into account rounding time, which is a real consideration, and big teams are slow. Maybe the % improvement per minute drops at a certain point.

Therefore, don't hesitate to curbside-consult your colleague, because just by talking to one other person, every eight patients you're making a more accurate diagnosis.

Barnett ML, Boddupalli D, Nundy S, Bates DW, et al. Comparative Accuracy of Diagnosis by Collective Intelligence of Multiple Physicians vs Individual Physicians. JAMA Netw Open. 2019;2(3):e190096. doi:10.1001/jamanetworkopen.2019.0096

Friday, February 15, 2019

An Obvious Healthcare Cost-Savings Proposal, That Doctors and Patients Will Obviously Resist

Arnold Kling draws attention to a proposal by Karl Denninger, which includes the following:
No government funded program or government billed invoice will be paid for medical treatment where a lifestyle change will provide a substantially equivalent or superior benefit that the customer refuses to implement. The poster child for this is Type II diabetes, where cessation of eating carbohydrates and PUFA oils, with the exception of moderate amounts of whole green vegetables (such as broccoli) will immediately, in nearly all sufferers, return their blood sugar to near normal or normal levels...This one change alone will cut somewhere between $350 and $400 billion a year out of Federal Spending and, if implemented by private health plans as well, likely at least as much in the private sector.
The tone gets even more pointed, and more accurate, further on.

Denninger further points out the core values-disconnect that makes talking about healthcare so difficult. That disconnect is that we are trading dollars and human suffering back and forth, and there's no way around this brute fact, ever, except to hide it from both buyers and sellers. This makes the system nauseatingly inefficient, whether we're talking about centralized planning or a free market.
Americans, and especially health care providers, do not want to think of health care as a commodity. The providers want to be paid, but they do not want to think of themselves as selling their services, so the payment comes from third parties and the price is hidden to consumers...All surgical providers of any sort must publish de-identified procedure counts and account for all complications and outcomes, updated no less often than monthly. Consumers must be able to shop not only on price, but also on outcomes.
This will be unpopular as both patients and doctors want to avoid responsibility for bad choices - but now that we're all paying for people to keep eating McDonald's and performing poorly-evidence-supported surgeries so they can buy a vacation home - we will have to make some hard choices.

Monday, February 11, 2019

A Picture from a Recent Trip to Vienna I Somehow Forgot to Post

...before my residency's required psychoanalytic training ended and grades were in. This is the Freud Museum in Vienna, which used to be his flat and office, and is still a regular (nice) apartment building. (A hand-written sign taped to a current resident's door on the ground floor by the entrance explained in unsubtly annoyed German that the Freud Museum was upstairs.) I do have to admit a grudging admiration for Freud's self-promotion. At this point, I invite you to say pseudo-profound things in an Austrian accent about how my early life experiences led me to struggle against authority, I want to kill my father, etc. I loved Vienna and Central Europe generally, even including this museum. You will note I did grow a beard for the occasion, but at no point had a cigar.


The most interesting thing in the museum was the microtome on display, which he used to make brain sections. I imagine him thinking, "You can never get anywhere doing it this way...maybe I'll convince people I have the power to do the same thing by talking to people!" There was also a picture of him with fellow Viennese intellectual socialites, one of whom was an immediately striking and intense woman who turned out to be Ludwig Wittgenstein's sister. Also, in German the parts of the subconscious are just rendered in German (not Latin), as "Das Ich Und Das Es" ("The Ego and the Id") which somehow takes away some of the authoritative punch.

Sunday, February 10, 2019

American English: Examples of Within-Our-Lifetime Language Change

I once saw a translation of Beowulf from the early twentieth century, which used "throve" as the past tense of "thrive." Interestingly, this means that even the "modern" translation is now outdated, since during the twentieth century "thrived" replaced "throve." Language waits for no one.

I have noticed one particular shift in American English: "buck naked" has become "butt naked." No doubt readers younger than mid-30s will have never heard "buck naked" and wonder what I’m talking about. The explanation for the shift is that in some varieties of Black American English, the "k" sound at the end of buck becomes a glottal stop, which is then heard and reproduced as a t in most accents of American English. In conclusion - it’s BUCK, not butt, and you kids get off my lawn.

Also, many Californians pronounce the "-ing" verb suffix as "-een"; it's more prominent the further south you go in the state (Think Blink 182 - they’re from San Diego), which suggests it's from language contact with Spanish. When asked about this, people who clearly produce the morpheme this way, some people have insisted to me that they say it it the same as an -ing; this is common for people who speak non-received dialects that differ subtly, since they actually cannot hear the difference between the two phones. I once saw a young student learning to spell, write out a verb phonetically that way, ie "bildeen" for building. I mention this because as California becomes more prominent in American culture, I expect its dialect to become more prestigious, and people elsewhere will start imitating it - so by mid-century, people in e.g. the Midwest may be saying -een instead of -ing.