Chapter 1: Introduction PDF

C H A P T E R O N E Introduction Learning Objectives complex organ known to humanity—the human...

C H A P T E R Introduction Learning Objectives Be able to conceptualize the and how it relates to the brain sciences. Be able to describe pharmacodynamics and pharmacokinetics. Be able to articulate the benefits approach to psychopharmacology. ENCOURAGEMENT TO THE READER Some of you may begin this book with some anxi- ety because this is a new area for you. You may imagine that psychopharmacology is exclusively a “hard science,” and perhaps you don’t think of yourself as a “hard science” kind of person. You may even feel uncertain about your ter basic psychopharmacological concepts. us assure you one more time that our goal is to make this topic accessible to readers who are prac- ticing as or studying to be mental health profes- sionals, many of whom may not have a background in the physical or organic sciences. Sec- ond, we recommend to those teaching a course in psychopharmacology that, because of the rapid nature of change in the field, teaching styles that rely on memorization are of limited use in this area. We recommend helping students master basic concepts and then applying these concepts to cases. To facilitate that process, we supply cases and objectives/review questions for main sections of the book. Finally, we invite you students to join us in an incredible journey centering on the most Copyright 201 Cengage Learning. All Rights Editorial review has deemed that any suppressed 4 PART ONE The primary audience for this book is mental health clinicians who may not have had much train- ing in biology, neurology, and psychopharmacology. This includes counselors, psychologists, clinical social workers, marriage and family therapists, and sub- stance abuse counselors. We will refer specifically to these different mental health professionals throughout the book as well as including all of them in the phrase “mental health professionals.” Although there are significant differences in the training models of these different professionals, they all draw on the same knowledge base when treating clients in school or clinical settings. We also want to add that there are several labels used to describe the therapeutic relationships clients have with mental health professionals. These labels include “counsel- ing,” “therapy,” “talk therapy,” “psychosocial inter- ventions,” and “psychotherapy.” There is great debate across the mental health professions about whether and how these labels differ, but in this book we use them synonymously for the sake of simplicity. While reading this book, you will notice technical terms highlighted with bold print the first time they appear. These terms are defined in the Glossary at the end of the book. Although not all key terms are highlighted, those that nonmedical mental health professionals are less likely to have been exposed to are defined in the Glossary. We encourage you to keep a dictionary handy for other terms that may be new to you. If you come across a word you do not understand, stop reading and check the definition in the glossary or a dictio- nary. Many readers skip over unfamiliar words assuming the meaning will become clear in a later sentence. Clarifying unfamiliar words when they occur adds to the enjoyment of reading the book and facilitates a better understanding of the topic. SCIENTIFIC TRUTH AND THE ACCELERATION OF KNOWLEDGE It is no secret that knowledge accumulation is accel- erating. We are familiar with the label “information explosion” to describe this phenomenon. In the early 1970s, the French economist Georges Anderla Copyright 201 Cengage Learning. All Rights Editorial review has deemed that any suppressed matter in red blood corpuscles that carry oxygen to tissues) and by tracing changes in blood oxygen levels in the brain. Like the PET scan, MRI images of the brain can be used for diagnostic or research purposes. DTI is a type of MRI that can highlight microstructural changes in the white matter of the brain or glial cells (Emsell & McDonald, 2009). This is becoming more important because we discovered that, far from being only glue or insulation for neuronal axons (glia comes from the Greek word for glue), glial cells actually send neurotransmission and communicate with other cells (Fields, 2009, 2010; Sasaki, Matuski, & Ikegaya, 2011). Magnetoencephalography measures the mag- netic field associated with electrical currents in the brain to trace activity levels across brain structures when subjects are engaged in a particular task (Bloom, Nelson, & Lazerson, 2001). There are also multiple techniques for extracting information from MRI scans. The most common quantitative techniques are “region of interest” (ROI) and computational morphometry studies. In ROI analysis, a trained rater manually traces a brain region of interest using “boundary rules” to compare sizes between different brains scanned. Computational morphometry is an automated method of comparing brain structures between different populations in a study. The most common variation is called voxel-based morphometry (VBM), which allows viewing of gray matter, white matter, and cerebrospinal fluid (Emsell & McDonald, 2009).1 Voxel-based morphometry is neuroimaging analysis technique that uses a type of mapping (statistical parametric mapping) to identify regions of interest in the brain and calculate their volume. Finally, there are also deformation-based morphometry (DBM) and tensor-based morphometry (TBM). Both techniques are used to compare brain struc- tures, but they rest upon different theoretical assumptions. 1 As with any approach, VBM has received tions on which it is based. See Ashburner (2001). Copyright 201 Cengage Learning. All Rights Editorial review has deemed that any suppressed 6 PART ONE As recently as 30 years ago, psychopharmacology was a medical subspecialty for psychiatrists in par- ticular. At that time, nonmedical mental health pro- viders could ethically practice with little knowledge of psychotropic medications. As long as they had a medical professional to whom they could refer cli- ents, their knowledge of psychotropic medications could be minimal. This is no longer the case. Most (if not all) mental health professionals work with clients taking psychotropic medications and need to be knowledgeable about the drugs their clients are taking. The integrative perspective we empha- size in this book provides a template that, when applied properly, suggests that understanding the physiological properties of psychotropic medica- tions is merely the beginning of the journey. We use the integrative Model to address many pressing issues rarely discussed in books on psychopharma- cology. For example, most psychopharmacology books simply discuss what medications are used for particular symptoms but do not address how to deal with cultural issues that may influence a client’s resistance to taking a prescribed medication. Another example is the place of direct-to- consumer advertising. Although mental health professionals may know that changes in federal law in the 1980s allowed pharmaceutical companies to advertise directly to consumers via television ads and other media, they may not know that there is a fierce debate over whether such advertising for psy- chotropic medications is ethical. Pharmacologists working in controlled conditions in laboratories may have the luxury of limiting their focus to interactions between drug molecules and neurotransmitters. But mental health professionals in the field must understand clients’ perceptions and subjective experiences of taking medications, cultural views of psychotropic medications, group differences in response to the medications (according to sex, age, race, etc.), developmental considerations, socioeco- nomic institutions that mediate access to medications, and competing worldviews and theories on what causes mental health symptoms. The four perspec- tives of our integrative framework requires consider- ation of these topics and sets this book apart from other books on psychopharmacology. Although this Copyright 201 Cengage Learning. All Rights Editorial review has deemed that any suppressed psychological disorders are really that can be alleviated with a particular medication, much as antibiotics can alleviate If psychological disorders were like medical disorders, then studying the brain, brain chemistry, and scien- tific method would suffice. Even the International Classification of Diseases, tenth separate volume for mental and behavioral disorders (WHO, 1992). So although the medical model pro- vides an important perspective, we also need to study the mind, the sociocultural contexts in which mind and brain function, and the consciousness underlying mind and brain. The entire truth of psychopharmacology cannot be explored solely through scientific method. Like a diamond, truth has many facets, which are comple- mentary (but not necessarily competing). As philos- opher Ken Wilber (2003) notes, no mind is capable of 100% error, so everyone is right about something but not everyone is equally right about everything. Given that insight, exploring the different perspec- tives of psychopharmacology need not produce warring factions championing mutually exclusive theories of etiology and treatment. Taking differ- ent perspectives in exploring psychopharmacology reveals different truths about it. Lest you think we are lapsing into some type of radical constructivism or relativism (we are not), consider these questions: What sort of blood test would you use to determine your political phi- losophy? How might exploring your feelings about your mother help diagnose a streptococcus infec- tion? How can a firsthand understanding of a per- son’s religion be used to tell you how much money he or she earns? How could data about your yearly income be used as an indicator of your sexual ori- entation? These questions are meaningless, because each proposes an incorrect tool for finding the answer. Because different perspectives reveal differ- ent faces of truth, they require tools matched to the task. There are different forms of truth and knowl- edge and different tools are employed in exploring them. We emphasize this point because many peo- ple believe that medical science (or science in gen- eral) is the only tool and that it can solve any problem. Copyright 201 Cengage Learning. All Rights Editorial review has deemed that any suppressed 8 PART ONE medications, as well as how our clients’ place in society affects their ability to get the drugs they may need. The Psychological Perspective Other perspectives complement the medical model and help mental health professionals build a well- rounded understanding of psychopharmacology. These other perspectives reveal other faces of truth that the medical model is not equipped to explore but that are equally important for mental health professionals. As Wilber (1997) noted, the techniques of the medical model perspective can trace the electrical currents in a subject’s brain but can only give scientific verification about the elec- trical activity in that brain—they cannot tell whether the person is thinking about opening a homeless shelter or robbing a liquor store. Further, there is no evidence that the experience of con- sciousness is caused solely by electrical activity in our brains (Chalmers, 1995). Information about what other people (including our clients) are thinking can only be obtained through truthful dialogue with them. This intro- duces the second perspective we use in this book, the psychological perspective. Psychology’s name is derived from the goal of studying the mind or soul. Despite that origin, it has evolved into the scientific study of mind and behavior and has come to greatly resemble the medical model. Schwartz and Begley (2002) assert that psychologists have become overly attached to a version of the medical model that dismisses conscious experience and focuses only on what is observable or measur- able. They conclude, “Surely there is something deeply wrong, both morally and scientifically, with a school of psychology whose central tenet is that people’s conscious life experience … is irrele- vant” (p. 6). It is that conscious experience that we are referring to when we use the phrase “psycho- logical perspective” or what consciousness feels like from the inside. We include the psychological per- spective because clients’ phenomenological experiences of the world cannot be dismissed as irrelevant and are often a key ingredient in their growth. Copyright 201 Cengage Learning. All Rights Editorial review has deemed that any suppressed The psychological perspective also includes peo- ple’s unconscious life experience. The many tools we use to explore the psychological perspective include introspection, dialogue about that intro- spection, interpreting dialogue, and sharing our interpretation to assess its accuracy. Although we can only be aware of those things that are con- scious, by definition, the tools of the psychological perspective can help clients bring to awareness things that were previously unconscious. As Wilber (2003) noted, psychotherapy is always about increasing awareness and this increase in awareness is experienced through the psychological perspec- tive. These tools are familiar to anyone trained in the mental health professions, but it is amazing how easily we forget their importance. The Cultural Perspective A third perspective or type of truth people should treat one another as well as the beliefs and worldviews people may share. These shared beliefs constitute aspects of culture. Culture, ways of living that groups of humans transmit from one generation to another, includes the shared beliefs and worldviews that different groups develop to understand the world and their place in it. Because shared worldviews are so important to culture, we refer to this third perspective as the cultural per- spective. The word culture may refer to a subgroup of people who share similar genetic and social histo- ries, as in “African-American culture” that comes about for other reasons, such as a business or industry, as in the culture of a pharmaceutical company. Again, no number of PET or MRI scans of brains can show what worldview a person holds, which ways of relating or worldviews are bet- ter than others, or whether a person time” or “on time.” As Wilber tific knowledge can never tell us why compassion is better than murder, why social service is better than genocide. Michael Polanyi (1958) also articulated this insight. Polanyi was a Nobel Prize–winning chemist who realized during the communist revolu- tions in Europe that the revolutionaries were trying to build a culture and a society on scientific princi- ples (the Lenin-Trotsky five-year plan) and that Copyright 201 Cengage Learning. All Rights Editorial review has deemed that any suppressed 10 PART ONE Most books on psychopharmacology focus on scientific or medical model perspectives of what medications seem to do, how they correlate with symptom relief, how much of the medication is needed, and so on. Although we cover these issues in detail, we also discuss the other perspectives that are pertinent to mental health professionals. For example, what does it mean to a client to take a psychotropic medication (psychological perspec- tive)? What does it mean that a significant number of children in this society are referred for medica- tion instead of for counseling (social perspective)? How should we interpret and interact with a family that believes psychotropic medication is spiritually damaging (cultural perspective)? It is time for humanity to integrate the various types of knowl- edge people have access to, and a study of psycho- pharmacology can benefit by such integration. We have mentioned the power of the pharma- ceutical industry particularly in the United States. Like all power it can be used well or misused. One of the most striking things since the publica- tion of the first edition of this book is the increase in lawsuits prosecuting pharmaceutical companies for illegal practices related to psychotropic medica- tion. Some examples: In 2011, Massachusetts filed a lawsuit against Janssen for “deceptive” marketing of the chotic resperidone (Mental Health Weekly, 2011) and settled for $158 million. Since 2004, the United States has collected nearly $8 billion from fraud enforcement actions against pharmaceutical companies for illegally promoting drugs for off-label uses (Avorn & Kesselheim, 2011). In 2009, Eli Lilly Company pled guilty to illegal marketing of the antipsychotic olanzapine and paid a $1.42 billion fine (Associated Press, 2009). In 2010, AstraZeneca was fined $520 million for illegal marketing of the antipsychotic quetiapine (Wilson, 2010). What seems to be happening is that the culture of the pharmaceutical industry is being more closely monitored by government agencies due to a history of ethically questionable actions. This definitely Copyright 201 Cengage Learning. All Rights Editorial review has deemed that any suppressed current “war on drugs” (which is really a war on drug users) in the United States (revisited in Chapter Ten). How does this relate to psychopharmacology? When various professionals, groups, or companies use words to convey pharmacological certainty where little certainty exists, they are engaging in word magic and in some cases trying to increase their own power. An example of this is the flawed idea that mental illness is caused by a chemical imbalance in the brain. As noted this “hypothesis” has been falsified multiple times. This can result in what Charles Tart (1997) refers to as scientism: “a dogmatic, psychological hardening of materialistic belief systems with emotional attachments, rather than authentic science” (p. 22). Frequently this hardening of belief systems with emotional attach- ments takes the form of proclaiming something to be much simpler than it is in reality. An example is when pharmaceutical companies, in ads for antide- pressants, state, “Depression is a serious medical disease.” The payoff for pharmaceutical companies in framing depression this way is that if the general public thinks of depression first and foremost as a medical disease, their first response if feeling depressed will be to go to a medical doctor for a prescription rather than to a mental health profes- sional for counseling. As we will show, depression is an overdetermined set of symptoms that may be biological, psychological, or spiritual in etiology. Just because depression is described in the ICD-10 (the diagnostic manual for physicians) does not mean it is a medical disease in the same sense that influenza is a disease. Tart goes on to explain that we are conditioned to assume people in lab coats are dealing with certainty and that sometimes peo- ple in lab coats perpetuate that misunderst MOVING ON: WHAT WE KNOW, WHAT WE DO NOT KNOW To avoid falling into word magic, people must be willing to admit what they do not know. Studying the mind and brain moves us all to the knowledge frontier of the 21st century. Consider this: Despite Copyright 201 Cengage Learning. All Rights Editorial review has deemed that any suppressed 12 PART ONE right, not like the other boys. His father would always reply with the same phrase, “Just move on, son.” Lawrence always believed that no one got him, not even his new stepmom. Both at home and in school he was a loner. He was very bright and got more than acceptable grades. He grew very anxious whenever he had to interact with others. His father had no patience for his isolation. Lawr- ence gradually developed what seemed to be a social phobia. From an intrapsychic perspective, this client suf- fered a serious loss of the mothering one at a critical time in development. Just as he began to enter the latency age of child development, he loses his pri- mary relationship with whom he can share insights and changes that he is experiencing. This aspect of his development was delayed or foreclosed while his father expected him to accelerate his develop- ment to an advanced stage of caretaker of his sisters. In both roles he became very passive. By the time he reached high school he was in a suicidal depres- sion and had to be hospitalized for attempting sui- cide. Each day of his life was a burden. The attending physicians at the hospital tried to get him to take an antidepressant. He refused. Lawrence graduated from college, served in the army, and married. Eventually, he attended law school with very little alteration of his mood or self-efficacy. He failed the law boards and his wife threatened to divorce him if he did not pass them the second time. He was distraught and angry. He felt betrayed by his wife who had almost forced him to attend law school. He sought out therapy and consultation with a psychiatrist. The therapist recommended twice-a-week psychotherapy and the psychiatrist put him on 100 mg of sertraline (brand name Zoloft). Lawrence tried the sertraline for three months and indicated that he felt no improvement. The psychiatrist added 250 mg of bupropion (brand name Wellbutrin) to be taken along with the sertraline. Lawrence expressed his concern about being over medicated, but the psy- chiatrist encouraged him to try both medications. After four months, Lawrence spoke to both his therapist and psychiatrist that he believed the med- ications were not really helping him. After much Copyright 201 Cengage Learning. All Rights Editorial review has deemed that any suppressed what the mind is. To say you adhere to a particular theory of the mind–brain problem is fine; to claim a particular theory is ultimately true at this point in history is scientism, not science. Generally, the mind–brain problem has been explored through two hypotheses, the epiphenomenon hypothesis and the dual-substance hypothesis, discussed as follows. The Epiphenomenon Hypothesis The first hypothesis is called the epiphenomenon hypothesis (sometimes called the “side effect” hypothesis—the mind is a side effect of the brain). The theory underlying this is what might be called radical materialism. The basis of radical materialism is that all things, including the mind, derive from other things that can be objectively observed and measured. This hypothesis states that the mind derives from the brain. In other words, the mind is an epiphenomenon of the brain. In a sense, this theory claims that your mind, including your sense of self, of having a developed brain. The 19th-century biologist Thomas Huxley (known as “Darwin’s Bulldog” for his fervent support of Darwin’s the- ory of evolution) popularized this hypothesis. More recently Damasio (2000), Dennett (1991), and Churchland (1995, 1999) have set forth varie- ties of the theory. Sometimes the theory is not stated outright but implied, as if this were the only acceptable theory on mind and brain. Richard Thompson (2000) gave one example when he wrote, “What is consciousness and how does it arise from the brain?” (p. 481). His impli- cation that it does arise from the brain is a theo- retical assumption, not an indisputable fact even though he presents it as such. This is another example of word magic—using words to create an illusion of certainty where there is none. Advocates of the epiphenomenon hypothesis sup- port it by first noting a brain structure a particular function (such as the relationship of Broca’s area to speech, for example). Next they point out that, for example, if Broca’s area is dam- aged, speech is impaired. The reasoning is that one’s sense of self (one’s mind) is a consequence of brain Copyright 201 Cengage Learning. All Rights Editorial review has deemed that any suppressed 14 PART ONE process, you introduce an agent (such as a drug) that acts in a manner opposite to the disease process you are trying to treat or cure. Although it is often assumed that if scientists know a disease process they also know its etiology (cause), this is far from true. Thus, there is no foundation for the allopathic assumption that identifying a disease process (depressive symptoms for example) and decreasing or stopping that process means that the process had a physical origin. Strict adherence to the medical model leads to unfounded assumptions that all mental or emotional disorders derive from faulty functioning in the brain or nervous system. Many follow this strict adherence despite strong evidence that the mind (at least the thought processes and emotions of the mind) influences the body as much as any organ like the brain and particularly disorders like depression and anxiety. Although we would agree that severe mental disorders like Schizophrenia will almost certainly turn out to be primarily physiological in their etiology, others like depression are overdetermined (meaning there are many ways one may develop depression). The Dual-Substance Hypothesis The dual-substance hypothesis is often dated back to the philosopher René Descartes who lived in the early 17th century, although it certainly predates Descartes, because it exists to some extent in both Hindu and Buddhist philosophy. Descartes pro- posed both that a divine being exists and that this divine being created thinking things (res cogitans) and material things (such as bodies) that extend into the material realm (res extensa). He thought thinking things do not actually exist in time and space and cannot be externally observed. The extended beings do exist in time and space and can be externally observed. Although Gabbard (2001) believes that substance dualism has fallen out of favor, there is still ample support for varia- tions on the hypothesis. Most variations equate “mind” with “consciousness.” Those holding a spiritual worldview often accept the dual-substance argument (in various formulations). Such a worldview may endorse a Copyright 201 Cengage Learning. All Rights Editorial review has deemed that any suppressed with word magic (such as asserting that all depression is caused by a “chemical imbalance”). THE LAYOUT OF THIS BOOK Part One The first part of this book covers introductory O N E complex organ known to humanity—the human mind and brain. We hope you can revel in the com- “information explosion” plexity of the brain and the sheer magnitude of its power. We hope you can resist the temptation to want simple and concrete answers to many of the questions this journey will raise. We also hope you of an integrative learn to appreciate the ambiguous nature of “mind” and its relationship to the brain. As authors and researchers who have traveled this path before us will attest, there are no simple or even known answers to many of the questions that arise (Grilly & Salmone, 2011; Schatzberg & Nemeroff, 1998). We encour- age a mixture of trying to comprehend the informa- tion while dwelling in the mystery that is the context for the information. Before moving on, we offer a mantra to help you implement this recommendation. ability to mas- First, let A MANTRA Even though psychopharmacology is in its embry- onic stage, it is a vast and complex topic. Several years ago I (Ingersoll) engaged in some multicul- tural counseling training with Paul Pederson. In that training, Dr. Pederson commented, “Culture is complex, and complexity is our friend.” We offer a paraphrase as a mantra for psychopharmacol- ogy students: “Reality is complex, and complexity is our friend.” We remind the reader of this mantra throughout the book. You might try saying it aloud right now: “Reality is complex, and complexity is our friend.” If you reach a passage in this book that is challenging for you or that arouses anxiety, stop, take a deep breath, and practice the mantra. 3 Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. An Overview of the New Edition (1973, 1974) prepared a statistical estimate of how quickly knowledge has been growing, based on a variety of indicators. According to Anderla, if you begin in the year 1 C.E. (which stands for Current or Common, Era) it took 1500 years for knowledge to double. The second doubling took only 250 years (1750). The third doubling took only 150 years (1900), the fourth 50 years (1950), and the fifth dou- bling only 10 years (1960). If there is any accuracy in Anderla’s model, knowledge began doubling almost monthly in the late 20th century (Wilson, 1992). Increase in knowledge about the human brain is particularly pronounced. The final decades of the 20th century unearthed more knowledge about the human brain than all prior centuries combined. One of the most exciting fields benefiting from these developments is psychopharmacology. Pharmacology is the science of the preparation, uses, and effects of drugs. Psycho- pharmacology is the branch of pharmacology related to the psychological effects of drugs and the use of drugs to treat symptoms of mental and emotional disorders. These drugs are called psychotropic medica- tions. “Psyche” colloquially refers to “mind,” and “tropic” means “acting on” or “moving toward” but many in the field would say these medications act on the brain and this affects the mind. Developing neuroscience technologies have helped accelerate brain research and change in the field of psychopharmacology by letting scien- tists peer more deeply into the brain and nervous system. The latest technological advances include positron emission tomography (PET) scans, magnetic resonance imaging (MRI), Diffusion Tensor Imaging (DTI), Voxel-Based Morphome- try, and magneto-encephalography. PET scans for brain functions work thus: The technician injects a radioactive form of oxygen into a person and then asks the person to perform a particular task under a PET scanner. Because the brain area most active during the task requires more oxygen, the PET scanner can trace the radioactive oxygen to those sites in the brain used in the task. The computer scanner then generates a picture that maps the brain activity. MRI scans generate images by mag- netizing hemoglobin (the iron-containing colored Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. CHAPTER ONE Introduction 5 Computer technology has also enabled pharma- ceutical researchers to generate three-dimensional models of brain cell receptors and the drug mole- cules that bind to them. Brain-scanning technolo- gies have allowed us to see how the drugs act on the nervous system (pharmacodynamics covered in Chapter Two) and how the body metabolizes and eliminates drugs (pharmacokinetics covered more extensively in Chapter Three). These are only some of the advances that have contributed to the exponential increase in the number of drugs devel- oped annually. Despite the explosion of advances in psychophar- macology in the last 30 years, the field can still be thought of as in an embryonic stage (Advokat, Comaty, & Julien, 2014). Although scientists know a lot about the physiological mechanisms of many psychotropic medications, we know little about how they actually change mood. Researchers are just now beginning to explore how the effects of psychotropic medication differ depending on the age, sex, and race of the person taking them (Heinrich & Gibbons, 2001). Although Western society is emerging from a postmodern era where multiculturalism was heavily emphasized, little research has been done on differing cultural world- views regarding psychotropic agents, let alone how such agents differentially affect people of various racial and ethnic backgrounds. In addition, people are now rethinking whether current diagnostic cat- egories for mental and emotional disorders apply to younger children (Ingersoll & Marquis, 2014; McClure, Kubiszyn, & Kaslow, 2002a) and how medications affect the dozens of developmental variables in this age group. Although the Human Genome Project has initiated efforts to understand human DNA, in the late 20th century scientists were still unclear about the role of over 90% of human DNA (Suurkula, 1996). In 2012, teams of scientists agreed that much of the DNA previously thought to be “junk” are actually “switches” that regulate how genes work or turn “off” and “on” (Doolittle, 2013). Efforts to describe the human genetic code and mechanisms of gene expression criticism because of the assump- and Friston (2001) and Bookstein hold great promise for drug development, but there is still a great deal to be learned. Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. An Overview of the New Edition consideration requires more effort, it contributes to a well-rounded knowledge of psychopharmacology that translates into better clinical practice. Review Questions What is meant by “information explosion” and how is it reflected in psychopharmacology? Describe pharmacodynamics and pharmacokinetics. What are the benefits of an integrative approach to psychopharmacology? CHAPTER ONE: SECTION TWO Learning Objectives Be able to describe why therapists need more than just a physiological or medical understanding of psy- chotropic medications. Discuss the differences between what is commonly thought of as “mind” and what is thought of as “brain.” Everybody Is Right (About Something): The Many Faces of Truth History shows that extremists, despite the strength of their convictions, are rarely correct (Radin, 1997, p. 205). In this book, we consider multiple dimensions of and perspectives on psychopharmacology. Although it would be convenient to state that all mental and emotional symptoms derive from some malfunction of brain chemistry, there is no evidence to support this statement. Many people are surprised to hear this, so it is important to restate: There is no evidence that all mental and emotional symptoms derive from some malfunction or imbalance of brain chemistry. Today pharmaceutical companies advertise directly to consumers and often give the impression that Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. CHAPTER ONE Introduction 7 “medical disorders” The Medical Model Perspective The perspective of medical science (and science in a bacterial infection. general) clearly reflects one type of truth, and we draw amply from it in this book. Whereas a relativ- ist would say that one perspective or type of truth is just as good as another for any job, we maintain that edition (ICD-10) has a some perspectives and tools are better than others for particular tasks. Everyone knows that no blood test can determine a person’s political philosophy. Does this mean one’s preference for a political phi- losophy does not exist? No. It simply means a blood test is not a good tool to use to explore the issue. In this case, dialogue is far better than a blood test. To find out a person’s political philosophy, you talk with the person to learn what his or her political philosophy is. Regarding the diagnosis of strepto- coccus infection, a throat culture is a far better test than discussing feelings about one’s mother. Scientific truth is objective truth that can be ver- ified by some observable measurement. This is the type of truth emphasized by the tools of scientific method, the medical model, and most psychophar- macology books. The perspective of scientific truth is an important cornerstone of psychopharmacol- ogy. This is what we are referring to as the medical model perspective. It is characterized by its focus on objective, measurable data related to individuals. Although labeled “medical model” for the purposes of this book, this perspective also includes schools of psychology that rely heavily on objective mea- surement (such as behaviorism). In psychopharma- cology, the medical model perspective helps us understand parts of the brain that seem correlated with symptoms of mental or emotional disorders and things such as the molecular structure of drugs. But mental health professionals are con- cerned with more than the correlations of symp- toms with brain functions or the molecular structures of drugs. As professionals, we are also concerned with how clients feel about taking medica- tions, how and whether psychotropic medications alter their consciousness, relevant cultural issues that may affect their attitudes or increase their prefer- ence for alternatives to psychotropic medications, aspects of group membership (race, sex) that may predict differential responses to psychotropic Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. An Overview of the New Edition Our psychological perspective deals with con- sciousness. Although one of the most ambitious pursuits of scientific knowledge is the Human Genome Project, there exists an equally ambitious (even if less well known) human consciousness project. The psychological perspective as revealed by the consciousness project is summarizing millen- nia of knowledge about the human mind, the sub- jective human experience, consciousness, the domain of the unconscious, and the farther reaches of human nature (be they existential or spiritual). For more on the human consciousness project go to http://www.nourfoundation.com/events/Beyond- the-Mind-Body-Problem/The-Human-Consciousness- Project.html. This knowledge is different from knowledge generated by the medical model per- spective, but is no less important for mental health professionals who deal with the whole person. The subjective knowledge about oneself that counsel- ing, psychotherapy, or meditation explore is differ- ent from the type of knowledge that science produces to tell us about how nerve cells fire in our brain. It is truly odd that although psychotropic medications are actually supposed to modify expe- rienced consciousness, very few books on the topic actually address that and instead prefer just to discuss how drug molecules bind to neuronal receptors. Suppose, for example, that you experience an insight about yourself that leads to more effective ways of living. For the sake of the example, assume the insight is that you fear emotionally depending on others, so you tend to push them away and isolate yourself. When you experience this insight, certainly nerve cells will fire in your brain, but no one can prove the cells are “causing” the insight—in some cases they accompany it and in others they fire slightly before your conscious knowledge of the insight. Further, others cannot learn about the insight by reading a PET scan of your brain taken when you had the insight. You must truthfully share the insight in order for others to learn about it—no physical measurement of any type (brain cells firing, heart rate, blood pressure, and so forth) will reveal the insight—you must share it. This is an important type of knowledge of the sort commonly shared and explored in counseling sessions. Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. CHAPTER ONE Introduction 9 those principles were the wrong tools for the task. Polanyi understood that the tools of science could never help these revolutionaries build a culture or a society worth living in. History has validated his judgment. Although the design of the Soviet Union tried to account for and control all the mea- surable aspects of society, it severely underestimated the cultural/ethnic differences that, since its dissolu- tion, have erupted between former member nations. Scientific truth can tell us which psychotropic med- ication has the greatest probability of easing a client’s suffering. But the scientific truth and the medication cannot erase nonbiological sources of suffering nor address what this suffering means to the client. For example, if the client shares a worldview that is highly suspicious of taking psychotropic medi- cation, the client is unlikely to comply with the prescription. concerns how The Social Perspective A fourth type of truth, which concerns the structure and impact of social institutions, we call the social perspective. Social institutions are based in shared beliefs, policies, and laws that affect people in observ- able, measurable ways. Whereas the medical model perspective deals with measurable, observable data about individuals, the social perspective deals with measurable, observable data about groups and partic- ularly institutions. One good example in psycho- pharmacology is the ongoing debate about whether or a subgroup a person can and should be medicated against his or her will (Gelman, 1999). Although the legal system is ideally based on the public’s shared understanding of how we need to be regulated with laws, laws prohibiting or permitting forced pharmacological treatment have profound impact on individuals. prefers to be “in Besides the legal institutions of our society, other (1995) puts it, scien- institutions relevant to psychopharmacology include the government (e.g., the Food and Drug Adminis- tration, the Drug Enforcement Agency) and the pharmaceutical industry in general. Issues such as whether people in the United States should be able to import medications from Canada are the domain of the social perspective. (Again, imagine the absur- dity of trying to resolve this import question through the medical model perspective.) Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. An Overview of the New Edition affects clinicians and clients. For example, what if one of your clients was taking a drug that is not FDA approved for a serious disorder like Bipolar I Disorder and that has no documented efficacy? Certainly the client’s welfare is at stake and this is where clinicians advocating for clients and maintaining healthy relationships with prescribing professionals is important. PSYCHOPHARMACOLOGY AND MAGICAL THINKING R. Stivers, in his book Technology as Magic (2001) suggests that as different technologies “disenchant” our sense of the world, people may respond with magical thinking by endowing those technologies with magical attributes. “Today our expectations for technology are magical” (p. 7). You can see this change particularly in psychopharmacology. We have had clients who thought that if they took antidepressant medication prescribed for their symptoms it would (almost magically) erase all suf- fering from their lives. We agree with Stivers that this society has almost magical expectations of phar- maceutical companies, their products, and the med- ical professionals who prescribe those products. One practice tied to this expectation is what we antipsy- call “word magic.” “Word magic” is the use of words in such a way so as to create the illusion of certainty where cer- tainty does not exist. Word magic is used to increase one’s control over the world (and other people), to artificially reduce the complexity of reality, and to help one deal with the insecurity experienced in the face of complexity. Particularly in the service of control, word magic can be used to trigger strong emotions in a reader or listener for the purpose of increasing the speaker’s own power. Former U.S. Attorney General A. Mitchell Palmer and Senator Joseph McCarthy engaged in word magic, wielding the key term “communist” to increase their political power during “red scares” in the early- and mid-20th century. The same type of word magic was used in the witch hunts, in the Inquisition, and is still being used in the Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. CHAPTER ONE Introduction 11 considerable success in developing medications that ease the symptoms of mental and emotional disor- ders, scientists have little understanding of how most of these medications work. Researchers are learning more about how psychotropic agents act on the brain and body (pharmacodynamics) and how the body disposes of them (pharmacokinetics), but scientists still know very little about why certain drugs decrease certain symptoms and contribute to emotional and behavioral changes. Even more interesting (although less publicized) is that in a great number of studies (and with particular symp- toms like depression), as many participants respond to placebos as respond to the actual medications being investigated (Fisher & Greenberg, 1997; Khan, Leventhal, Khan, & Brown, 2002). There are many unanswered questions about the brain, the mind, and the relationship between the two. All together now: “Reality is complex, and com- plexity is our friend.” An example of this complexity is the case of Louise. Throughout the book, we provide cases that illustrate good responses to medications, treatment-resistant symptoms, side effects, client psychological issues related to medications, and cul- tural and social considerations. The cases illustrate the complementary types of truths we have summa- rized as the medical model, psychological, cultural, and social. Although it would be much simpler only to use cases where clients have symptoms, take medications, then get better, this has seldom been our experience. Lawrence’s case illustrates many of the perspectives we have introduced in this chapter. It does not lend itself to a single inter- pretation that relies solely on one perspective. Read the case, and consider the questions following it. anding. The Case of Lawrence Lawrence is a 35-year-old lawyer who anguishes with a very poor self-image, terrible anxiety, depression, and lability of mood. He is the oldest of three and his mother left the family permanently when he was five. At that time, his father expected him to be the little man of the house and take care of his younger sisters. Lawrence remembers that he always complained to his father that he didn’t feel Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. An Overview of the New Edition consultation and discussion with Lawrence, the psy- chiatrist decided to titrate him off the buproprion and to add 2 mg of aripiprazole (brand name Abilify a newer antipsychotic used at very low doses in the treatment of depression). Within a week, Lawrence was unable to sleep, was very agitated, and could not focus on his work. The psychiatrist, although puzzled, was not totally baffled by this development in Lawrence. He expanded his clinical interview, consulted in-depth with the therapist, and con- cluded that Lawrence had been masking a bipolar presentation with some moderate drinking. He started Lawrence on a course of lithobid (Lithium) after discontinuing his other medications. This course of treatment served Lawrence well for sev- eral years and he periodically had his blood levels checked for lithium poisoning. The course of phar- macological treatment that Lawrence received is far more the norm for the patient of 2013. THE MIND–BRAIN PROBLEM If you were on a game show and the host asked you (for $1000) to clearly define mind, brain, and the difference between the two, how would you answer? How you answer is basically how you con- ceptualize the mind–brain problem. The mind– brain problem is an old philosophical issue that addresses whether or not the mind and brain are distinct entities and what their relationship is. Sci- entific knowledge of both the mind and the brain is incomplete. No one knows what the mind is, where it comes from, or how it interacts with the brain (Dossey, 2001). However, numerous scholars have noted that even if there were complete knowledge of the mind and brain, the problem might still be unsolvable (Koch, 2012). Consider being asked to define “the mind.” At first glance this might seem a simple task for a mental health counselor or a student training in one of the mental health professions. In fact, it is a rather vexing ques- tion with a multitude of answers depending on your theoretical orientation. As much as many hate to admit it, to “define” what “mind” means first requires a leap of faith in the theory or theories you believe most accurately reflect the reality of Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. CHAPTER ONE Introduction 13 functioning and if those parts of the brain responsible for the sense of self are damaged, the sense of self is either impaired or vanishes, just as speech becomes impaired if Broca’s area is damaged. Perhaps the most time-worn example used to support the epiphenomenon hypothesis is the 19th-century case of Phineas Gage. Gage was a rail- road construction worker who had a tamping iron driven through his skull as the result of an explosion. Although he miraculously survived the accident, the story used to be that his personality became so altered that those who knew him say Gage was a different person after the accident. Damasio (1995) hypothesized that from a materialist perspective Gage, the person, had changed because the areas of his brain that maintained and expressed personality had changed when damaged in the acci- dent. Of course, as in most things, there is now a difference of opinion on Gage. Kean (2014) wrote that descriptions of Gage’s personality change are greatly exaggerated. In fact, he noted that historical is a “side effect” documents show that Gage went to South America and worked as a stage coach driver. Even if the stories about his drinking and aggression after the accident are true, how much of that may have been related to pain or depression (the psychological perspective)? Our sense of self is somewhat more complicated than other functions that are traced to specific brain areas, so researchers do not yet know exactly which areas, and the relationships between them, result in the sense of self. Damasio (2010) and others have begun to tackle this problem, but science is far from an explanation. Thus to accept the radical material- ist position is a statement of faith that neuroscientists will be able to completely map out the brain and its functions (and that they are correct in thinking such knowledge would resolve the mind–brain problem). As you can imagine, those who adhere to the responsible for medical model of mental and emotional disorders often support the epiphenomenon hypothesis. This model is the basis of allopathic medicine. Allopathic medicine (as opposed to homeopathic or osteo- pathic) is the branch of medicine that adheres to the philosophy that to treat or cure a disease Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. An Overview of the New Edition belief in a God or Divinity of some sort and possi- bly some notion of an eternal soul. This is not necessary, however, because the Buddhist view, for example, refers to different types of conscious- ness. One such type is a nonmaterial, ever-present “subtle consciousness” that we are thought to be most in touch with in deep sleep, advanced medi- tation, sneezing, and orgasms (think about that next time you sneeze!). From the Tibetan Bud- dhist perspective, epiphenomenalism and radical materialism fall into the trap of reifying physical phenomena (Descartes’s res extensa) and denying the existence of mental phenomena (Descartes’s res cogitans) (Wallace, 1999). From this perspective, to say that consciousness depends on the brain for existence is akin to saying that food depends on a stomach for existence. Psychologist Dean Radin (1997) wrote, “The average neuron consists of about 80 percent water and about 100,000 mole- cules. The brain contains about 10 billion cells, hence about 1015 molecules. Each nerve cell in the brain receives an average of 10,000 connec- tions from other brain cells, and the molecules within each cell are renewed about 10,000 times in a lifetime” (p. 259). Radin then asked why, despite this continuous change, the patterns of our sense of self remain stable even though the physical material supporting that sense of self is in constant flux. The body you have while reading this (including your brain) is not at all the same body you had three years ago, but your sense of self is. In addition to these two perspectives on the mind–brain problem, there are also variations such as interactionism (mind and brain are different but mutually causal) and parallelism (mind and brain are totally separate and do not communicate). The mind–brain problem is an important context for the study of psychopharmacology. If this context is ignored, it is far easier to ignore things, such as the placebo effect, that hold important truths, as yet untapped, that may contribute to our knowledge of healing the symptoms of mental/emotional disor- ders. Ignoring the mind–brain problem also makes it easier to commit category errors and support them Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. CHAPTER ONE Introduction 15 discuss the relevance of powerful institutions such as the pharmaceutical industry and the Food and Drug Administration. Part Two The second part of the book contains four chapters covering classes of commonly prescribed psychotro- pic drugs used to treat depression, anx

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