"Junk" Neuroscience?

A recent comment on my observation that normal function of human memory could explain what he considered to be obvious lies prompted a reading suggestion.  The author suggested that I should read a book called "Junk Neuroscience" by Satel. The only book I could find with a similar title was  Brainwashed: The Seductive Appeal of Mindless Neuroscience.   I am reluctant to spend good money on a polemics when I can get as much polemic as I want by reading it for free on the internet.  It turns out I am familiar with the author's work from a Frontiers in Psychiatry series that I reviewed last year before presenting a CME course lecture on the neurobiology of addiction.  There are currently 19 papers collected there including Satel and Lilienfeld's.  It is somewhat ironic that the entire series is based on a what I would see as assumptions that have a faulty historical, medical and certainly neurobiological premise and that is:

"For much of the 20th Century, theories of addictive behavior and motivation were polarized between two models. The first model viewed addiction as a moral failure for which addicts are rightly held responsible and judged accordingly. The second model, in contrast, viewed addiction as a specific brain disease caused by neurobiological adaptations occurring in response to chronic drug or alcohol use, and over which addicts have no choice or control....."

The first few lines captures the main problem with debates about any topic but it is particularly pernicious when it comes to addiction and neuroscience.  It leads to a number of false observations that seem to be cropping up in the popular press at an increased frequency.  The observation that most addictions spontaneously remit is taken as evidence that they do not require treatment or that neurobiological factors do not need to be considered.  There is the idea that you can be a "heavy drinker" without being an alcoholic suggesting that "heavy drinking" is protective against the factors leading excessive mortality and morbidity in alcoholism.  Those same arguments lead back to the idea that addiction is either a choice or a bad habit.  Both are gross oversimplifications of how complex decision-making is affected in addictions.  One of the main diagnostic systems for addiction from the American Society of Addiction Medicine (ASAM) describes addiction as:  "Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry".  It does not however suggest that addicts "have no choice or control".  In fact, much treatment of addiction depends on a 12-step recovery model that is designed to help learn new controls, improve social affiliation, and re-engineer living environments to remove triggers for relapse.  The learning, affiliation, cravings and relapse triggers all have neurobiological substrates.  Against that backdrop there are 19 papers offered and Satel and Lilienfeld's is one of them.

I happen to be fortunate enough to work at a residential center that specializes in treating addictions.  In addition to the clinical work I present a number of lectures to graduate students, physicians, and residents.  The residents are in primary care and psychiatry.  The two slides that follow are right out of my PowerPoint on the neurobiology of addiction.  The Theories of Addiction slide is intended as a rapid survey of addiction theories.  I put it out there as a warm up and free associate to the theories on the slide.  As an an example, I will look at the nutritional deficiency theory of alcohol or look at alcohol being considered a medicine by itself and how that correlates with per capita alcohol consumption in the US.  I can build on that point by looking at the cultural factors that affect per capita alcohol consumption int he US and the UK.  I might ask groups of physicians if Self Medication is a legitimate theory of addiction.  Practically all physicians have heard: "Listen doc, if you can't do something about my (pain, depression, anxiety, insomnia) - I know what I can do to make it go away for a few hours."  Everybody in the room also knows that in the long run, none of those symptoms/syndromes/disorders can be treated and in fact many become considerably worse as a result of the drug or alcohol use.  Even the example of availability proneness that I typically use only partially accounts for addiction.

Any approach to neurobiology has to account for pathways to recovery as well as pathways to addiction.  In treatment centers most of those pathways are based on learning interventions.  I digress to talk about the how learning occurs both in the addiction process and in the recovery process.  I start out with Kandel's example from his classic New England Journal of Medicine article on plasticity.  His original example talks about two people in a room during a psychotherapy session, and the brain changes that occur in both as a result of that session.  Both people leave the room and their brains have been changed by the discussion.  Experience dependent changes in the brain.  That brief introduction brings me to the four considerations of the neurobiology lecture.  They are listed in the second slide below.  

I think that these are all fairly basic starting points for a lectures on neurobiology and proceed to talk about a number of systems and structures that are thought to be important from a neurobiological standpoint.  I bring in the concept that nobody knows how it all works together by a brief discussion of Chalmers hard problem or the fact that we don't know how anyone's unique conscious state comes about and what that implies.  I am evolving to a new lecture that looks at complex decision making and its roots in the neuroanatomical structures that I discuss in this lecture.  Studying this field is what I consider to be fun.  It brings together a number of concepts from my previous scientific studies.  I would probably be focused on this if I was practicing clinical psychiatry or retired.  I will be the first to admit that I am not a trained neuroscientist, but I have been trained in science and worked in scientific research.

That brings me to Satel and Lilienfeld's paper.  I don't know either author.  If you read the paper it is definitely well written and it has 121 references.  There is a bolded statement before the text begins saying that this paper is excerpted from the book Brainwashed: The Seductive Appeal of Mindless Neuroscience.  As far as I know that is the book that would apparently straighten out my views about neuroscience.  The author's begin with: "The brain-disease model implies erroneously that the brain is necessarily the most important and useful level of analysis for understanding and treating addiction." and build rapidly to a second: "In short, the brain-disease model obscures the dimension of choice in addiction, the capacity to respond to incentives, and also the essential fact people use drugs for reasons (as consistent with a self-medication hypothesis)."

Working at an addiction treatment center and talking with thousands of people in my career with severe addictions leads me to have an explosion of associations whenever I see broad generalizations about the problem.  I don't know that the concept of disease means that an affected organ system is necessarily "the most important and useful level of analysis."  There seem to me to be many diseases where that is not true.  On the issue of "reasons to take drugs" it is seldom as rational as the author's suggest.  A classic example is one that I frequently use when lecturing about the current opioid epidemic.  A significant portion of the population is prone to get a hypomanic euphorigenic effect from taking opioids.  For nonpsychiatrists, that mean the person becomes extremely euphoric, energetic, productive, and socially outgoing.  On the initial night or two, they may engage in work or creative activities at a rate that surprises them.  Many will say: "I thought I had become the person I always wanted to be."  Carefully interviewing that person several months later will get the description that they developed a tolerance to that effect.  Now they were taking the opioid "just to stay well" or prevent withdrawal symptoms.  Koob has described this cycle as  "a chronic relapsing syndrome that moves from an impulse control disorder involving positive reinforcement to a compulsive disorder involving negative reinforcement."  Consistent with this definition is that the drug has both positive (euphoria) and negative (prevents withdrawal) reinforcing effects.  The reason to take the drug is an addiction or the specific match of drug effects on a specific nervous system.  Even in a case when addictive drugs are taken for other reasons (there is a long list) it often is due to the fact that the drug is perceived as having magical qualities or as a rationalization for continuing the addiction.

I could make similar arguments for all of the main points in this paper that I have laid out in the following table.  The authors provide ample details examples to support their contentions.  Part of the problem is that the concept of disease is complex.  When you try to dissect it the problems become apparent.  The other problem is that if this is a disease, it is a disease of complex decision making and very few people focus on that.  

What after all is considered a disease?  Any reader can come up with conditions that they consider diseases for many of the ten points above.  That is easiest for the points involving the clearest comparisons with disease (1, 2, 6, 10).  In other cases (4), their point seems to be somewhat arbitrary.  With any chronic illnesses it is usually possible to function with limited incapacity due to the illness until the late stages.   In some cases the critique has more to do with the unique capacity of the organ than anything else.  For example in point (3), emergent properties that are less obvious can be considered a property an any electrical tissue.  Cardiac tissue can produce electrical patterns of decreasing complexity as a heart ages or is affected by disease.  The brain can produce a very similar pattern (see Supplementary 1).  The only difference is that heart tissue is unable to produce a conscious state.  Two of the points (5, 9) minimize the role of a systems involved in complex decision-making.  This is no trivial matter because it is associated with addictive behaviors that lead most people to classify alcohol and drug use disorders as diseases.  Common examples include people who are unable to stop using drugs and alcohol despite life threatening illnesses, repeated pleas from family members, or repeated problems with relationships, employment or the law.  Deaths due to addiction are common and they impact on a large population.  You are much more likely to see a condition as a disease if you know it has killed somebody.  Point (7) is a curious argument.  In the past several years, I have attended seminars showing for example that in some trials of buprenorphine maintenance for opioid use disorders that the addition of counseling adds nothing to the outcome beyond the medication.   I don't personally believe that, but I am used to seeing people with severe addiction who cannot stop until they are taken out of their using environment.  In every residential treatment center that I am aware of, the main focus is on "personal agency" whether that is 12-step recovery (Alcoholics Anonymous, Narcotics Anonymous) or other methods for psychological change.  As part of that process there is often a focus on neurobiology not as an excuse but as an explanation for how people can become somebody that they never thought they could become and how that process can be reversed.  The other reason for a focus on neurobiology is medication assisted treatment and a discussion of how those medications might work as part of both informed consent and interest on the part of the patients.

I wonder if the best characterization of what is going on here has more to do with philosophy than neuroscience.  As I previously pointed out in a critique of a philosopher's attack on psychiatry - a straw man approach was used.  He suggested that something was true about the field and then proceeded with his attack as if it was true.  When confronted with that single fact and asked about any evidence to support the contention - the people supporting that contention drew an apparent blank.  To this day as far as I know there is no rational way to argue that the APA has an implicit position in the DSM-5 that teaches people how to live their lives.  Even as I write it on the page it is absurd and yet that was the form of the argument.   The current paper is much more sophisticated than that.   It points out the limitations of the disease concept and how that can be used rhetorically but then proceeds to eschew what they refer to as a "neurocentric view" of addiction.  I don't think that argument carries the day largely because there is very little evidence that the people who know neuroscience have the adverse effects that the authors suggest.  There is plenty of evidence that the neuroscientist-clinicians are focused on multiple levels of care.  I have a lot more to say about what is a disease and diseases of complex decision-making but I am going to stop here.  Look for those topics to be addressed in individual posts in the future.  In the meantime, read about the neuroscience of addiction.  The field has added more to brain neuroscience than just about any other discipline in the past three decades.  

I think an additional explanation of my intent in the reply is necessary.  I use the term "political" a lot when referring to editorials, rhetoric, and other polemics.  People who should know better seem to respond to a lot of these articles as though they are either the "truth" or the "facts" that happen to support their viewpoint.  I like my science very dry.  I ascribe to Pigliucci's observation that science is a process and if there is a truth it only occurs at the end of a very long process or a series of approximations.

Seeing it any other way shuts down that process and we are left with something that is ideologically based and no longer science.

George Dawson, MD, DFAPA

1: Satel S, Lilienfeld SO. Addiction and the brain-disease fallacy. Front Psychiatry. 2014 Mar 3;4:141. doi: 10.3389/fpsyt.2013.00141. eCollection 2013.   Review. PubMed PMID: 24624096


Supplementary 1:

I attached these graphics to illustrate that electrically active tissue can have emergent properties that are really unknown by either looking at the tissue or doing other kinds of biological analyses.  That is true for both the brain and the heart.  I don't have the heart graphs but could probably find them.  They are identical.  I do have the graphs of brain activity from a patient with Alzheimer's Disease and a normal control patient.  Recordings are from a single parietal electrode in the delta frequency and show the degree of variability over the same time interval.

Single Electrode EEG - Control

Single Electrode EEG - Alzheimer's Disease