Brain Fog

 

“Brain fog” or “brain-fog” is a popular term that has penetrated the medical literature fairly recently.  In talking with hundreds of patients who have used the term in my evaluations most of them mean an actual fogginess to their mentation.  That typically occurs in two ways. The first is an underwater feeling and noticing that both the speed and content of thought is not quite up to par.  The second is more of a problem in concentration and focus where it takes a noticeable effort to sustain both.  I have personally had these experiences during illness and probably on a developmental basis.  In the case of the illness, I was running my usual team meeting at about 8AM, and suddenly realized my thoughts were clouded. I developed chills and knew that there was a mini-epidemic of influenza in my staff. I told my team members that I had to stop due to illness and went home.  It took about 48 hours for that to clear.  Since that time, I have been very interested in how infectious diseases and diseases in general have that effect on the brain.

The closest term that I could think of that might approximate brain fog is “clouding of consciousness”.  This term from descriptive psychiatry and psychopathology is commonly associated with neurocognitive disorders. It is typically a criterion for delirium but in most texts, it is also associated with other anatomical and functional brain disorders.  The best review of the psychopathology and phenomenology of clouding of consciousness is from Lipowki’s text (1).  Lipowski reviews the 2500 year history of delirium and how confusion and clouding of consciousness became critical concepts in advancing research in this area.

A lot of the current psychopathology texts have very little to say about clouding of consciousness and symptoms of delirium.  There are a few exceptions.  Sims discusses it in a chapter “Consciousness and Disturbed Consciousness”.  He starts with defining consciousness by three components an inner awareness of experience, intentional reaction to objects, and knowledge of the conscious self.  He also has an excellent diagram (Fig 3.1 p. 40) that ties together the medical use of the term, clinical context, and changes that can occur in that context.  Since I cannot get permission to post the diagram I will describe it.  Normal consciousness is the central component and it is transitioned to reduced wakefulness, sleep, and stages of sleep and deep sleep.  There is another transition to the unconscious mind (via preconsciousness).  The final transition is to clouding of consciousness, drowsiness, stupor, and coma. The latter transition is obviously the only pathological one, but in terns of psychopathology there is obvious overlap between reduced wakefulness transitioning to normal sleep and drowsiness that may be a prelude to neurocognitive disorders.  That is also a critical decision point in thinking about brain fog.  Is the underlying mechanism one of reduced wakefulness or a focal or global decrease in brain metabolism seen in neurocognitive disorders?  Sims also defines clouding of consciousness as: “most intellectual functions are impaired including attention and concentration, comprehension and recognition, understanding, forming associations, logical judgement, communication by speech and purposeful action”. (p. 41).  Sims definition is most consistent with an early delirious state but not “brain fog” described by a person who is going to work every day and subjectively feels that their work performance could be better.

I have followed the evolution of Neuropsychiatric Systemic Lupus Erythematosus (NPSLE) across the last 3 versions of Lahita’s text on SLE.  There are generally 2 chapters dedicated to this topic in each text.   Over the years, there has been much more specificity in terms of the biological mechanisms involved in NPSLE.  There are 19 separate neuropsychiatric syndromes involving neurocognitive symptoms and constellations of more pure psychiatric symptoms like anxiety and depression.  From a purely cognitive standpoint, an interesting concept is that many of the mechanisms that are thought to moderate cognitive function like long term potentiation (LTP), synaptic plasticity, and neurogenesis are immune cells and inflammatory molecules.  The diagram below illustrates some upstream perturbations in the cytokine system that can result in impaired learning and memory.  There are additional immune systems affecting neurogenesis.

     

In the review that I constructed this diagram from, the author states: “‘‘Lupus brain fog’’ is an extremely common patient complaint that refers to periods of forgetfulness and confusion that are related to impaired cognition.”  She cites the range of 21-80% of SLE patients having some degree of cognitive impairment leading to some degree of disability or impaired quality of life.  NPSLE and the associated studies of how inflammation and immune function impair learning and memory is an excellent example of how various disease processes can have effects on cognition. It is also a good example of how the term “brain fog” has developed recently in this clinical population with clear CNS pathology.  It also suggests a lack of specificity for the term given the range of impairment.

At this point – a few clinical vignettes of “brain fog” can be considered as additional examples:

Vignette 1:  60-year-old man referred for assessment and treatment of mania and possible bipolar disorder.  He gives a history of drinking 750 ml/day of alcohol and appears intoxicated at the time of the evaluation.  As part of the initial evaluation, he is given a standard cognitive exam and scores a perfect 30/30 points indicating no deficits in orientation, attention span, short term memory or language skills (comprehension, repetition, or naming).  He has no subjective cognitive symptoms.  He returns a week later for reassessment and does not recall meeting the same physician or doing any cognitive testing. He does not believe he was ever at the clinic in the past.

This patient essentially blacked out or was amnestic for the initial interview with the psychiatrist.  Like many heavy drinkers he has a sustained mood disturbance at times that resembles manic episodes, but these symptoms resolve after detoxification and abstinence from alcohol. Patient with these problems are likely to described brain fog during episodes of intoxication, withdrawal, detoxification, sleep deprivation from the effects of alcohol, decreased attention span and concentration that is probably multifactorial and during mood changes that are alcohol induced.  Heavy alcohol consumption can lead to profound and persistent cognitive changes, most notable from untreated Wernicke encephalopathy the result of Vitamin B1 deficiency that can accompany persistent alcohol use.

Vignette 2: 40 yr old woman referred for assessment of severe anxiety and panic. She attributes both symptoms to “chronic Lyme disease” despite extended course of antibiotic treatment by experts and extended treatment by non-medical personnel using more atypical types of treatment.  She was previously very vigorous and physically active but that is no longer the case.  She describes fatigue, hypersomnia, and “brain fog” that puts her job at risk because of decreasing productivity and performance. She is being treated with benzodiazepines for anxiety and z-drugs for sleep.

This is a familiar scenario for psychiatrists. In this case the patient is diagnosed with a controversial illness and has not recovered despite very aggressive treatment.  She is anxious because of the decrease in her level of functioning and describes fatigue, hypersomnia, and brain fog.  It is often difficult to determine the progression of symptoms without detailed records – depending only on the patient’s recollection of what happened over a number of years.  In these cases I have found that it is best to track all of these symptoms and see how they fluctuate with logical changes based on the patients current clinical status. In these cases I would typically proceed with tapering and discontinuing the benzodiazepines and z-drugs and monitoring the fatigue, hypersomnia, and brain fog while simultaneously providing psychotherapy that I thought would be most effective for the target symptoms.

Vignette 3: 50 yr old man being seen for severe alcohol use disorder, persistent depression disorder, major depression, chronic insomnia, and possible attention- deficit/hyperactivity disorder. He has had lifelong insomnia, onset of chronic depression at age 18, and heavy daily drinking for the past 15 years. He describes inattentiveness, distractibility, procrastination, and “brain fog”.  He is requesting that treatment for the “brain fog” be prioritized since it is currently his most significant problem.

Very common scenario in treatment settings.  The ADHD diagnosis is more controversial lately based on the idea that some people may develop it as an adult.  I always ask adults about childhood sleep problems and it is a very common finding.  Childhood sleep disturbance also results in erroneous diagnoses of ADHD, but it is often difficult to establish that diagnosis in generations where it was not emphasized on school.  The diagnosis of alcohol use disorder is a complicating factor. In the case of heavy drinkers, they are often drinking all day long, in a state of intoxication or withdrawal, and typically wake up in the middle of the night and need to decide whether to drink in order to fall back asleep or tolerate withdrawal until the morning and then drink to reduce more severe withdrawal symptoms.  Clearly, every one of those transitional states is associated with some cognitive impairment and some have described it as “brain fog”.  An additional patient-based bias is wish that a medication can correct all of this cognitive impairment.  That wish is complicated by the fact that many heavy drinkers have used cocaine or amphetamines to drink more and improve their concentration and attention.  They have also used benzodiazepines as a way to treat insomnia and withdrawal symptoms, especially withdrawal symptoms in the morning that could otherwise lead driving to work with high blood alcohol levels and risking legal problems.  In all of these cases, the patient needs to be followed and serially reassessed up to the 60-day mark.  In my experience, the transient cognitive symptoms should be clear at that point and the baseline symptoms and their severity can be determined.

If brain fog exists can it be phenomenologically separated from other psychiatric diagnostic terms?  Sedation or excess somnolence is a common form of clouding of consciousness.  There is a temporal aspect to both related to a combination of both alerting mechanisms and circadian rhythms and the biological basis of both has been grossly determined (6).  I would anticipate that sedation or somnolence would fluctuate over the course of the day, with the exception excessive sleep deprivation or external sources of sedation like a sleeping agent.  Most people tend to describe brain fog as unrelenting.

In the final analysis, is brain fog a useful term?  Is it a colloquialism rather than a technical term that should be used in medicine? My argument suggests that it may be a useful descriptor of a sub delirious state or very early clouding of consciousness.  There are multiple associated etiologies and conditions including some that are just a temporary disruption in normal physiology.  Based on my clinical experience it is clearly a word that patients frequently use. From the PubMed search, it is also being used more frequently in the medical literature, just over the past 20 years. 

 

A word of caution is needed before it is adopted on any widespread basis. Lipowski points out how 19^th century psychopathologists advanced the field by specifying a class of disorders based on clouding of consciousness and confusion arising in the context of acute brain dysfunction.  What followed was a proliferation of terms that set back further research for decades (p. 27).  Time will tell if the term becomes more widely adapted or it is fitted into existing nomenclature.  Based on the recent tightening of the nomenclature for delirium (7) it is not likely.  Since most people seem to be using it to cover both mild and moderate subjective cognitive impairment - it does not add much precision. On the other hand psychiatrists are focused on the patient’s subjective state and use of language so it is undoubtedly useful for beginning the early exploration of the problem that led to the consultation.

 

George Dawson, MD, DFAPA

 

References:

1:  Lipowski ZJ.  Delirium: Acute Confusional States.  New York: Oxford University Press, Inc; 1990.

2:  Sims A.  Symptoms in the Mind: An Introduction to Descriptive Psychopathology. 3^rd ed. Amsterdam: Elsevier Limited; 2003.

3:  Mackay M, Ulug AM, Volpe BT.  Neuropsychiatric Systemic Lupus Erythematosus: Mechanisms of Injury.   In:  Lahita RG, Tsokos G, Buyon J, Kolke T.  Systemic Lupus Erythematosus. 5^th ed. London: Academic Press; 2011. p. 491- 512.

4:  Hanley J.  The Nervous System and Lupus. In:  Lahita RG, Tsokos G, Buyon J, Kolke T.  Systemic Lupus Erythematosus. 5^th ed. London: Academic Press; 2011. p. 727-746.

5:  Mackay M. Lupus brain fog: a biologic perspective on cognitive impairment, depression, and fatigue in systemic lupus erythematosus. Immunol Res. 2015 Dec;63(1-3):26-37. doi: 10.1007/s12026-015-8716-3. PMID: 26481913.

-Reference 5 is an excellent open access review of the relationship between inflammation, immune systems, and cognition (especially memory and learning).

6:  Valentino RJ, Volkow ND. Drugs, sleep, and the addicted brain. Neuropsychopharmacology. 2020 Jan;45(1):3-5. doi: 10.1038/s41386-019-0465-x. Epub 2019 Jul 16. PMID: 31311031; PMCID: PMC6879727.

7:  Slooter AJC, Otte WM, Devlin JW, Arora RC, Bleck TP, Claassen J, Duprey MS, Ely EW, Kaplan PW, Latronico N, Morandi A, Neufeld KJ, Sharshar T, MacLullich AMJ, Stevens RD. Updated nomenclature of delirium and acute encephalopathy: statement of ten Societies. Intensive Care Med. 2020 May;46(5):1020-1022. doi: 10.1007/s00134-019-05907-4. Epub 2020 Feb 13. PMID: 32055887; PMCID: PMC7210231.

8:  Servick K. COVID-19 ‘brain fog’ inspires search for causes and treatments.  Science. 2021 Apr 27;372(6540):329. doi:10.1126/science.abj2105. 

Graphic Credit:

Graphic was downloaded from Shutterstock per their standard agreement.  The artist in this case had many similar brain fog graphics and these depictions are probably an indication of how common this term has become.

Here is an additional graphic that I complied as I did the literature search for this post:

 

Another Round of Addiction As A Brain Disease

 

A new open access article looking at the issue of addiction as a brain disease was recently published by Neuropsychopharmacology.  The authors point out that since this original claim as made 20 years ago (7) and subsequently reinforced (8) there have been a flurry of critical articles. On this blog I have examined several of these articles in the past. They parallel typical arguments that are used against psychiatric diagnoses, particularly the concept of psychiatric disorders as diseases.  Interestingly, in this paper that entire issue was summarily addressed:

“Few, if any healthcare professionals continue to maintain that schizophrenia, rather than being a disease, is a normal response to societal conditions. Why, then, do people continue to question if addiction is a disease, but not whether schizophrenia, major depressive disorder or posttraumatic stress disorder are diseases?”  (p. 3)

Any casual observer of the constant arguments on this issue will note a constant flux of how psychiatric disorders are described.  Disorders, conditions, and constructs come to mind.  I always like to point out that actual surveys of both the general public and health care professionals finds that both groups typically classify severe mental illnesses and substance use disorders as diseases, but to varying degrees.  The best surveys of this problem have been done in Finland (4,5) with large sample of doctors, nurses, psychiatrists, laypersons, and politicians included.  In two separate studies the authors asked respondents to consider 60 general conditions and 20 psychiatric conditions.  Respondents were asked to rank the disorders according to which were more similar to disease conditions and different cut offs were used for both samples. In the larger survey of 60 medical and psychiatric conditions – schizophrenia and autism met the survey requirements for disease.  In the second survey, 75% of the respondents considered schizophrenia and autism as diseases and 50% considered Depression, Anorexia, Panic disorder, Generalized Anxiety Disorder, Bulimia, Attention deficit hyperactivity disorder, and Personality disorder to be diseases.  There was more disagreement on Alcoholism and Drug Addiction but 64% of physicians and 74% of psychiatrists considered alcoholism to be a disease.  On the issue of drug addiction 50% of physicians and 65% of psychiatrists considered that condition to be a disease. The authors generally discuss the implications of these opinions from a practical and public policy perspective rather than a medical or philosophical one. The common arguments that persist is that disease status confers social legitimacy on a disorder leading to more treatment resources and hopefully decreasing stigma.  In the case of addictions there are longstanding moral defect or choice theories that essentially equate addiction to willful misconduct. Since large corporations have taken over the healthcare systems in the United States many of these biases are less visible since proprietary rules determine who gets treatment resources and how they are treated. A recent court ruling details how these rules are seriously flawed (6).  An important perspective from the discussion and that is personal experience with the illness by the patient, family members, friends, and employers– a subject I will elaborate on further.

The previous posts on this blog addressed a New England Journal of Medicine article suggesting that addiction was a problem in learning rather than a disease in two separate posts.  Before that I addressed a 2015 article that listed 10 reasons why addictions were not a disease. Responding to these articles highlighted their rhetorical aspect.  Many of the arguments against a disease model of addiction have three basic flaws.  First, they consider the concept of disease to be clearly defined and it is not. Second, they use their more precise definitions for comparison and as a way to prove addiction is not a disease.  And third, they suggest that psychosocial variables are relevant only if the condition in question is not a true disease.  They suggest that real diseases are self-contained and self-perpetuating and that interpersonal relationships and environmental factors cannot modify diseases.  By extension only a medication or a surgical intervention can modify or cure a real disease.  There are many examples of diseases that illustrate why that premise is not true.  In my practice over the past 30 years the most common examples have been diabetes mellitus Type 2, hypercholesterolemia, and hypertension. I have seen many people with extreme cholesterol elevations who were “cured” by a simple dietary change and starting to exercise.  My two previous articles discuss these lines of argumentation.

Another disease feature of substance use disorders is that they can occur in discrete epidemics.  Although epidemics are typically thought of as being associated with infectious diseases, the CDC description is careful to point out that they can also occur as a result of non-infectious diseases like obesity and diabetes mellitus. They also describe 5 conditions that lead to epidemics including an increase in exposure in terms of total amount or increased virulence, introduction of a novel agent, enhanced transmission, a change in host response, or increased host exposure that can occur by new portals of entry.  All 5 of these factors are relevant in drug epidemics.  Substance use disorder epidemics have these features as evidenced by the 20-year opioid epidemic that started with excessive availability of prescriptions opioids and transitioned to more potent illicit opioids. The widespread availability of these compounds come from illicit importation and supply chain proliferation often by opioid users selling these compounds in order to assure that they have an adequate supply.  Over the past 25 years there have been a clear pattern of increased geographic availability of multiple drug classes – leading to increased morbidity and mortality from substance use disorders in these areas.  

Does the current paper add anything to the argument for addiction as a brain disease?  The authors review the history of the more public airing of the concept – an original article by Leshner (7) asserting “addiction is a brain disease” and a follow up article by McClellan (8). The fact that both of these declarations are only about 20 years old should not be lost on anyone. The authors get derailed from the basic concept of disease in the very next paragraph by suggesting “To promote patient access to treatments, scientists need to argue that there is a biological basis beneath challenging behaviors of individuals suffering from addiction.”  The social utility of a diagnosis is separate from its medical and scientific utility. All three are conflated at times (even to the point of suggesting that laypersons should have input into what is a diagnosis), but in my opinion without medical and scientific utility – there is not social utility.

They review the definition of disease – starting with Jellinek’s “The Disease Concept of Alcoholism”.  Jellinek made the argument that diseases were not self-contained “entities” but it is more of an agreed upon label “to describe a cluster of substantial deteriorating changes in the structure or function of the human body and the accompanying deterioration in biopsychosocial functioning”.  That definition is very close to the one I came up with reviewing the work of philosophers Munson and Resnick who defined disease as a “failure of normal functioning”. The main difference is that these two philosophers predicated the definition on the premise that biological systems were programmed processes and those processes failing is what causes the disease.  Adaptive reward based learning can certainly be considered a programmed process in brain biology.  

They take a close look at the idea that any definition of addiction should account for spontaneous remission and non-relapsing states. One of the typical arguments against addiction as a disease is that a significant number of heavy drinkers (and probably cannabis smokers) stop after they graduate from college.  In many ways, excessive alcohol and drug use in college is considered a rite of passage by many Americans.  That rite of passage has a considerable mortality and morbidity on its own that is usually not considered by the addiction as disease critics.  The vast majority of these people are not the people seen by addiction specialists later in life. The people seen in their 40s or 50s will typically give a history of knowing that their pattern of drinking was problematic.  As an example: “I knew from the very first time that I drank a lot more and I drank faster than anyone else. I drank more in college and I did not stop after I graduated”.  And they elaborate on the consequences of excessive alcohol use at every life stage.  Binge use or even fairly continuous use of drugs or alcohol in college is not the same as an addiction.  

The authors point out that some of the epidemiological data used to justify the remission argument is dependent on methodology and population.  For example, a population recruited from a residential treatment facility and interviewed with a standardized interview will yield much different results than a community sample. The diagnosis of addiction (or severe alcohol use disorder) will be stable in the former case but not the latter.  They reference NESARC (National Epidemiological Survey on Alcohol and Related Conditions) as the community sample and using that methodology the baseline lifetime prevalence of non-remitting alcohol dependence was 10% (p. 9).  They also point out that opioid use disorder when observed for 10-30 years has a stable abstinence rate of < 30%.  The fact that some people stop using excessive amounts of drugs or alcohol is not an argument that there is not a large population of people who clearly have a chronic relapsing course and incur significant mortality and morbidity along the way.

The authors proceed to the genetic argument and point out that family and adoption studies point to a heritability of ~50% for addictive disorders. They highlight typical misunderstandings of genetics, specifically the concept of polygenic risk and that fact that some polygenic disorders lead to pathological states – addiction being one of them.  An additional argument is that although the first 20 years of human genome study have been very productive for Mendelian disorders, it has been far less productive for more complex disorders (11). Understanding the human genome is far from complete at this point and some research groups are just beginning to understand the relationships between genetics, addiction, and medication effects (12, 13, 14).

The lesion argument is the next disease straw man to fall. It should be obvious to anyone that diseases do not necessarily produce a discrete lesion either on imaging studies or autopsy.  An yet it remains a favorite to anyone who claims that addictions or psychiatric disorders are not diseases.  They review how imaging is currently used clinically.  This is a reality that most of the critics seem to miss.  If I see brain imaging consistent with small vessel ischemic disease – that alone is insufficient to make the diagnosis. It also requires an adequate history and examination of the patient. The critics apparently have not see radiology reports that point out “clinical correlation is necessary”.  The authors briefly review the functional imaging of alcohol and stimulant use disorders that point to problems with frontal-striatal circuitry, structural changes with alcohol, and demonstrable and expected changes in dopamine signaling. Brain imaging in addiction at this point (apart from the necessary clinical imaging) is useful from a heuristic standpoint – looking for relevant mechanism and treatments, but there is no imaging of addictive disorders per se. 

A popular viewpoint these days is that there is not enough of an investment in psychosocial factors in funded research. Many of those critics make the argument that the trade off should be reduced funding for biological research and those funds should be diverted to psychosocial research. The authors here acknowledge the importance of social factors, their incorporation in more complex research designs, and the fact that a view of addiction as a brain disease in no way negates the importance of other environmental factors. 

The authors address the issue of reductionism.  They use the term determinism instead. Over the past two decades molecular biologists have moved firmly away for the idea that all complex biological systems can be reduced to the basic laws of chemistry and physics. The does not mean that with the appropriate tools biological complexity can not be understood and explained.  Many physicists see the brain as deterministic.  In other words because the brain is made up of particles and those particles must follow the laws of physics, the future (or past state) of any brain can be determined by the right differential equation. Deterministic states can be chaotic and in that situation they are not predictable.  If you believe the brain is deterministic based on physical laws – it follows that there is no free will and that free will is an illusion.  The real limiting factors with describing the brain as deterministic include the following problems:

1.  There are known stochastic factors that introduce random events – some of which are relevant for the addiction.

2.  Complexity – as noted above.  There is so much structure and so many particles that must be considered in these complex systems that there is a clear measurement problem and the most difficult problems are solved by computer modeling approximations rather than mathematically.  I have not seen it discussed but whenever I consider the complexity of biological systems, I see them as an almost infinite set of microenvironments - each with their own physical and chemical parameters. If there was an equation to describe all of those microenvironments acting at one - it would be exceedingly complex.

3.  Brain changes occurring during the addiction process (a large number of which are unknown at this time) alter the deterministic nature of the system.  I suppose the response by the physical determinists would be that the new altered system would be determined by the laws of physics and chemistry. That does not alter the fact that it is a new system with different physical and chemical componenets.

The authors contend that the system is indeterministic because of these factors and therefore free will is allowed.  An associated physics and philosophical question is whether it is really deterministic but unpredictable and why.  Overall, these philosophical arguments do not really seem to add much to the debate.  The critical piece is whether either deterministic or reductionist is used in a pejorative manner.  That use is typically coupled with arguments that other social or psychological theories is what is really happening.  Scientists and physicians are generally interested in knowing all of the details and mechanisms of action. The is the real driver of knowing what is happening at the molecular level.  This paper does a good job of explaining why people who use that approach do not exclude everything else that is going on in the environment.

They end on the issue of compulsivity (or more accurately uncontrolled use) in addiction. It is not the case that this does not happen, but the degree at which it happens.  In the people who I work with practically all of the negative outcomes are associated with uncontrolled use/compulsivity.   That does not mean that people with addictions are automatons. The major treatment modality anywhere is some form of group therapy.  Those groups would not exist if there was an assumptions that people with substance use disorders could not choose to change their thought patterns and behavior.  They continue to have some flexibility, but the probabilities during an active addiction is that the substance use will continue despite negative and in many cases life threatening outcomes. Intact decision making in other areas or even in the focal area of continued substance use with episodes of abstinence does not mean that normal decision making occurs in all areas of life.

In their conclusion, the authors suggest that progress can occur from integrating a number of scientific perspectives including those outside the field of neuroscience.  They advocate for consilience and input from a plurality of disciplines. They also suggest that no single discipline has exclusive ownership of the field.

As a clinician who is used to constant criticism of psychiatry from people who don’t know anything about it – I have a different position.   First, we need to acknowledge the severity of addictions specifically that they kill and disable large numbers of people.  Family members trying to help an afflicted persons know that as well as the difficulty in trying to help them stop.  Second, in rankings of disability compared with other disease states – addictions are consistently in the top 10.  When combined with psychiatric diseases they are ranked second.  There are few other diseases as disabling or lethal.  Third, there have been treatments that are based on the underlying biological factors that are thought to be relevant to addiction that have worked.  Four, it is very clear that individuals with addictions are no longer functioning normally – defined as their normal baseline.  That can start at any point in the life cycle – and at some point most people are aware that they have a severe problem and cannot stop.

All of those factors point to a disease state and it is good to see a paper supporting that opinion.   But even beyond this opinion, consider the people you have known with addictions and make up your own mind based on that experience.  Carefully consider how you interact with people if you consider addiction to be a disease or intentional decision-making.

 

 George Dawson, MD

 

References:

1:  Heilig M, MacKillop J, Martinez D, Rehm J, Leggio L, Vanderschuren LJMJ. Addiction as a brain disease revised: why it still matters, and the need for consilience. Neuropsychopharmacology. 2021 Feb 22. doi: 10.1038/s41386-020-00950-y. Epub ahead of print. PMID: 33619327.

2:  Heilig M, Augier E, Pfarr S, Sommer WH. Developing neuroscience-based treatments for alcohol addiction: A matter of choice? Transl Psychiatry. 2019 Oct 8;9(1):255. doi: 10.1038/s41398-019-0591-6. PMID: 31594920; PMCID: PMC6783461.

3:  Venniro M, Banks ML, Heilig M, Epstein DH, Shaham Y. Improving translation of animal models of addiction and relapse by reverse translation. Nat Rev Neurosci. 2020 Nov;21(11):625-643. doi: 10.1038/s41583-020-0378-z. Epub 2020 Oct 6. PMID: 33024318.

4:  Tikkinen KA, Leinonen JS, Guyatt GH, Ebrahim S, Järvinen TL. What is a disease? Perspectives of the public, health professionals and legislators. BMJ Open. 2012 Dec 2;2(6):e001632. doi: 10.1136/bmjopen-2012-001632. PMID: 23204142; PMCID: PMC3533011.

5:  Tikkinen KAO, Rutanen J, Frances A, Perry BL, Dennis BB, Agarwal A, Maqbool A, Ebrahim S, Leinonen JS, Järvinen TLN, Guyatt GH. Public, health professional and legislator perspectives on the concept of psychiatric disease: a population-based survey. BMJ Open. 2019 Jun 4;9(6):e024265. doi: 10.1136/bmjopen-2018-024265. PMID: 31167856; PMCID: PMC6561450.

6:  Wit v. United Behavioral Health.  Full text of ruling.

7:  Leshner AI. Addiction is a brain disease, and it matters. Science. 1997 Oct 3;278(5335):45-7. doi: 10.1126/science.278.5335.45. PMID: 9311924.

8:  McLellan AT, Lewis DC, O'Brien CP, Kleber HD. Drug dependence, a chronic medical illness: implications for treatment, insurance, and outcomes evaluation. JAMA. 2000 Oct 4;284(13):1689-95. doi: 10.1001/jama.284.13.1689. PMID: 11015800.

9:  Koob GF, Volkow ND. Neurobiology of addiction: a neurocircuitry analysis. Lancet Psychiatry. 2016 Aug;3(8):760-773. doi: 10.1016/S2215-0366(16)00104-8. PMID: 27475769; PMCID: PMC6135092.

10:  Volkow ND, Morales M. The Brain on Drugs: From Reward to Addiction. Cell. 2015 Aug 13;162(4):712-25. doi: 10.1016/j.cell.2015.07.046. PMID: 26276628.

11:  Koob GF, Powell P, White A. Addiction as a Coping Response: Hyperkatifeia, Deaths of Despair, and COVID-19. Am J Psychiatry. 2020 Nov 1;177(11):1031-1037. doi: 10.1176/appi.ajp.2020.20091375. PMID: 33135468.

12.  Miga KH. Breaking through the unknowns of the human reference genome. Nature. 2021 Feb;590(7845):217-218. doi: 10.1038/d41586-021-00293-8. PMID: 33568817.

13:  Ho MF, Zhang C, Zhang L, Wei L, Zhou Y, Moon I, Geske JR, Choi DS, Biernacka J, Frye M, Wen Z, Karpyak VM, Li H, Weinshilboum R. TSPAN5 influences serotonin and kynurenine: pharmacogenomic mechanisms related to alcohol use disorder and acamprosate treatment response. Mol Psychiatry. 2020 Aug 4:10.1038/s41380-020-0855-9. doi: 10.1038/s41380-020-0855-9. Epub ahead of print. PMID: 32753686; PMCID: PMC7858703.

14:   Nguyen TTL, Liu D, Ho MF, Athreya AP, Weinshilboum R. Selective Serotonin Reuptake Inhibitor Pharmaco-Omics: Mechanisms and Prediction. Front Pharmacol. 2021 Jan 11;11:614048. doi: 10.3389/fphar.2020.614048. PMID: 33510640; PMCID: PMC7836019.

 

 

Fluorinated Medications - Revisited

I wrote a post a few years ago on the issue of fluorinated medications.  It was based on and investigation of the Fathead minnow (Pimephales promelas) and the possible induction of autism like illness from increasing amounts of fluoxetine in the water system.  The authors of this article looked at concentrations about 10 times what they currently are in wastewater. Medications of all kinds can be detected ins wastewater with the primary sources being ingested medications and excreted medications and metabolites and wasted medications.  There has been a suggestion that “wasted medications” – like full prescriptions that were either never used or only a few tablets were used should be incinerated in a plasma furnace.  That type of incineration destroys the chemical structure of medications and any chance that they could have unexpected secondary effects. 

The first fluorinated compound was the mineralocorticoid fludrocortisone or Florinef in 1955. I recall prescribing it for people with autonomic disorders (Shy-Drager Syndrome) and orthostatic hypotension from tricyclic antidepressants before the era of SSRI-type antidepressants.  Recently 45% of all FDA approved small molecule drugs (2018-2019) were fluorinated (3).  On the illicit side, in South Korea the percentage of seized synthetic cannabinoids that were fluorinated went from 0% in 2010 to 90% in 2013 (6).  Agricultural chemicals have had a similar increase in fluorinated compounds.  The medications at the top of this post are from my collection of standard psychiatric medications.  That list currently contains 144 medications across all therapeutic classes. After looking at all of the chemical structures only the 15 at the top were fluorinated and most of them have been around for a long time.

The FDA’s current position on medications in general is that there are no demonstrated problems with medications in wastewater.  They encourage the use of safe disposal sites.  They provide details on medications that should not be added to wastewater (No Flush List) that is basically a default based on the Flush List. Consumers are instructed to mix the no flush medications with inert substances that would render them unusable and dispose of them in the trash.  That typically would mean a landfill and the possibility of groundwater contamination. The issue of pharmaceuticals in freshwater is loosely regulated at this time.  There is existing research that some of these compounds can be measured, persist, and in some cases can damage aquatic life.  There is also the case of what can happen if bioaccumulating pharmaceuticals are detected in tap water as well as illegal drugs.  The total number of compounds detected are at the highest levels in the United States and Europe (see graphic on page 2 of this OECD document).

The organic chemistry of fluorinated compounds is detailed in the Science review (1). The authors of that review do a good job of looking at the advantaged of fluorination – specifically how it affects the physical properties of fluorinated molecules and their activity in biological systems. There is probably a lot more detail in that review than most people unfamiliar with organic chemistry need to know. The basic concept is that fluorination can alter the physicochemical properties of a molecule based on its electronegativity and that can later metabolism and how a drug interacts with the site of action.  As an example, fluorinated compounds tend to be more lipophilic or fat soluble than their non-fluorinated counterparts.  The authors of the Science article also take a look at how common fluorinated compounds like atorvastatin bind to an active site in 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase to inhibit cholesterol biosynthesis.

A more recent review (3) suggests that fluoride is used to block the metabolism of molecules and that the number of fluorinated compounds continues to increase.   They also describe more widespread use of fluorine in pesticides, herbicides, and fungicides that incorporate anywhere from 2.5 to 4 halogen atoms per molecule.  These authors also describe fluorine toxicity and make the following relevant points.  First, that fluorine can accumulate in bone and teeth and if it occurs in excess can cause fluorosis.  A case report in the New England Journal of Medicine (4) describes a woman who developed fluorosis from excessive tea consumption (100-150 tea bags per day or an estimated >20 mg/day of fluoride). Radiographs showed spinal changes consistent with fluorosis (forearm and spine). She also had brittle teeth to the point they were all extracted. Fluorine toxicity can also occur at the level of metabolism specifically the Krebs cycle when fluorinated small molecules like fluoracetic acid can block metabolism.  Fluorine toxicity at this level is potentially lethal.  The LD 50 of fluoracetic acid is listed as 10 mg/kg and the toxic intake of fluoride is estimated to be > 10 mg/day.

An important consideration by these authors is that some fluorinated compounds can be metabolized freeing up fluoride in toxic levels.  They describe reactions including oxidation, nucleophilic substitution, and glutathione displacement (5) as reactions that can result in liberating fluorine from some of these compounds. Their example of toxicity is voriconazole – a tri-fluorinated antifungal compound that can undergo metabolism over time and lead to excess fluorine levels.  400 mg doses were estimated to liberate 17.5 mg/day of fluoride.  That leads the authors to conclude that fluoride metabolism of many of the new compounds needs investigation to reduce the risk of toxicity.  Pan has also stressed the importance of follow-up studies of these compounds to investigate how they are metabolized.

As an addiction psychiatrist, there is an additional group of fluorinated compounds that are less likely to be investigated and they are street drugs in this case fluorinated JWH compounds or synthetic cannabinoids (see Figure 1 below for the location of fluorination).  Bannister, et al noted that a design trend in these synthetic cannabinoids was to incorporate a terminal fluorine into these compounds.  Potency at the CB1 receptor was enhanced by this process. The authors describe concern over fluorine toxicity since it can be mobilized in these molecules by thermolytic defluorination by smoking as well as metabolic oxidative defluorination. 

At present time, the fate of fluorine in human metabolism and the ecosystem seems to be in a state of flux.  The trend in producing fluorinated human medications, pesticides, herbicides, fungicides, and synthetic cannabis compounds seems to be increasing at an unprecedented rate.  Understanding the toxicology of these compounds does not seem to have kept pace and that may be because many of them have been around for a long time and have not caused any significant problems. There was also a lot of theoretical reasons to think that the carbon-fluoride bond was very stable and difficult to break.  Now that we have plausible chemical paths for the metabolism of these compounds – physicians probably need to be more aware of fluorosis as a side effect and hopefully there will be more studies focused on metabolites and their possible toxicities.  Fluorination of street drugs is a real wild card because of the different paths of administration and potential impurities in these compounds some of which may contain fluorine precursors.

 

George Dawson, MD, DFAPA

 

References:

1:  Müller K, Faeh C, Diederich F. Fluorine in pharmaceuticals: looking beyond intuition. Science. 2007 Sep 28;317(5846):1881-6. doi: 10.1126/science.1131943. PMID: 17901324.

2:  Benotti MJ, Trenholm RA, Vanderford BJ, Holady JC, Stanford BD, Snyder SA. Pharmaceuticals and endocrine disrupting compounds in U.S. drinking water. Environ Sci Technol. 2009 Feb 1;43(3):597-603. doi: 10.1021/es801845a. PMID: 19244989.

3:  Kyzer JL, Martens M. Metabolism and Toxicity of Fluorine Compounds. Chem Res Toxicol. 2021 Jan 29. doi: 10.1021/acs.chemrestox.0c00439. Epub ahead of print. PMID: 33513303.

4:  Kakumanu N, Rao SD. Images in clinical medicine. Skeletal fluorosis due to excessive tea drinking. N Engl J Med. 2013 Mar 21;368(12):1140. doi: 10.1056/NEJMicm1200995. PMID: 23514291.

5:  Pan Y. The Dark Side of Fluorine. ACS Med Chem Lett. 2019 Jun 20;10(7):1016-1019. doi: 10.1021/acsmedchemlett.9b00235. PMID: 31312400; PMCID: PMC6627733.

6:  Banister SD, Stuart J, Kevin RC, Edington A, Longworth M, Wilkinson SM, Beinat C, Buchanan AS, Hibbs DE, Glass M, Connor M, McGregor IS, Kassiou M. Effects of bioisosteric fluorine in synthetic cannabinoid designer drugs JWH-018, AM-2201, UR-144, XLR-11, PB-22, 5F-PB-22, APICA, and STS-135. ACS Chem Neurosci. 2015 Aug 19;6(8):1445-58. doi: 10.1021/acschemneuro.5b00107. Epub 2015 May 8. PMID: 25921407.

 

Permissions:

Table 1 is reprinted with permission from Banister SD, Stuart J, Kevin RC, Edington A, Longworth M, Wilkinson SM, Beinat C, Buchanan AS, Hibbs DE, Glass M, Connor M, McGregor IS, Kassiou M. Effects of bioisosteric fluorine in synthetic cannabinoid designer drugs JWH-018, AM-2201, UR-144, XLR-11, PB-22, 5F-PB-22, APICA, and STS-135. ACS Chem Neurosci. 2015 Aug 19;6(8):1445-58. doi: 10.1021/acschemneuro.5b00107. Epub 2015 May 8. PMID: 25921407. Copyright 2015 American Chemical Society."

Retirement By Default or Transitional Year?

 

As noted in a previous post, I stopped working on January 19, 2021. That is one month and two days ago. Since then I have been exercising on a daily basis, reading, outlining papers, and preparing posts for this blog. I have also been actively looking for positions in adult psychiatry or addiction psychiatry. The positions that have come up have all been fairly standard managed-care positions. In other words I would be using the standard electronic health record in Minnesota and I would have productivity expectations based on relative value units or RVUs.  Casual readers of this blog know that I have worked under those systems and would not do it again.

The second option is private practice. I greatly appreciate recommendations from a number of colleagues including some that were highly specific. There is no doubt at all that if I was just completing my residency and know what I know today about the practice environment that I would go into private practice. That option at this point is more complicated. I realize that a clinic infrastructure and all that entails is not really necessary now that everyone is doing telemedicine and telepsychiatry. On the other hand, I am very aware of the necessary medical basis of psychiatry and know that the farther you practice away from medical settings - the less likely you are to be able to attend to medical problems and medical monitoring. I also base this opinion on seeing three presentations by a physician I would consider to be the top telepsychiatry practitioner in this state if not the country. In all those presentations he emphasized the need for clinical monitoring on the receiving end. That would typically include vital signs, lab testing, arranging the necessary medical testing and referrals to medical practitioners. He also made it a policy to drive out to meet all of the individual patients at least once a year in the 5 county area that he covered. That would preclude me from setting up a telepsychiatry practice focused on seeing people in their homes.

I have a lot of concern about the boundary issue that occurs with telepsychiatry outside of clinical settings. I would have no difficulty assuring confidentiality on my end from my home office. I would be very concerned about confidentiality on the other end if I was seeing someone in their home. There is also the question of medical records and how they would be handled whether my private practice was established for two years or another 10 or 15 years.

After this month off, and the above considerations the practical question is whether or not I am on the glide path to retirement. A significant part of my time has been used to complete all the necessary Social Security and Medicare paperwork. A lot of that paperwork has been redundant and poorly thought out. I have been planning for retirement for at least 30 years and strongly considered it 10 years ago, but nothing prepared me for the rules, forms, and surveys from federal agencies. As just one example, I was not aware of the fact that Medicare Part B (and in some cases by default Part D) premiums were indexed against earned income from the previous year. A related problem is that no two people give you the same answers to questions about Medicare or Social Security. After two months, I think the paperwork is all finally complete.

I anticipate that retirement will be a relatively easy process for me. My life is structured around exercise, academics, and art. I have more than enough to keep me interested. During a recent conversation with a retired biochemist who is a good friend of mine - he pointed out that those are the things that keep him going.  I agree with that philosophy. That does not mean that I will be conflict free. When you have been talking with people for decades for most of the day in a very specific way and you are good at it -  there will always be the nagging question about how many more people you could have helped. That is also the time during my day when I am the calmest and most focused. Sitting alone in my library is certainly relaxing but there are times when it has the opposite effect on my focus. I have too many things to focus on and very few of them are as important as talking to a patient. 

The social aspect of work will be another more subtle loss. I am fortunate enough to have worked with excellent colleagues that I actively dialogue with and expect that to continue. But there are colleagues from other disciplines where that kind of work-related dialogue will just disappear. A lot of people seem to focus on whether or not they will maintain their relevance when retired. My work has always led me to the conclusion that the only people I was relevant to in the workplace were the patients I was treating. I don’t consider myself to be an opinion leader in the field. I am regularly consulted and expect that will fade away over time if I am not actively practicing.  Ageism is prevalent and younger generations will generally consider older practitioners to be less relevant - even if they may know a lot less than the older person.

The most significant aspect of psychiatry that I will miss is research. I was very fortunate to be involved in a research project with the Mayo Clinic over the past three years. That research team, their conceptual depth, intelligence, technical expertise and productivity was absolutely stunning compared with research efforts I have been affiliated with in the past. That is a significant loss both in terms of the knowledge I was acquiring but also because I expect this research team to have the best shot at determining relevant biomarkers for psychiatric  disorders and associated personalized medicine approaches for these disorders. My personal past research included both plant tissue culture (somatic embryogenesis of Douglas Fir (Pseudotsuga menziesii) and Loblolly Pine (Pinus taeda), and clinical drug trials of antidepressants, antipsychotics, anxiolytics, and pharmacotherapy of Alzheimer’s disease as well as neuroendocrinology studies of depression. I also studied quantitative EEG of psychiatric disorders and more specifically the effect of Alzheimer’s disease on quantitative EEG.  I am still interested in research work and that includes bench type research if those positions are available. I am also available for literature research, editing, and writing papers. My friend the biochemist has continued to do that in retirement and I plan to try it with or without collaborators.

That is my current status - not retired and actively looking for work. But the work can’t be just any job and after carefully considering - it won’t be private practice. My current job requirements are fairly high relative to other employed psychiatrists but not in the salary sense. I have very specific practice environment requirements in mind and the tradeoff is that I know as much neuropsychiatry and medical psychiatry as anyone and practiced it in high acuity environments. I am hopeful that the right job will materialize, and at this point will give it up to one more year.

Either way I will still be plugging away at this blog.

 

George Dawson, MD, DFAPA

Supplemental 1:

I thought I would add this thought after the fact.  My guess is that there are a significant number of psychiatrists in my current transitional phase.  The pandemic has highlighted a couple of issues that apply.  The first is the widespread use of telemedicine and telepsychiatry - specifically its successful implementation. The second is the levels of distress experienced by front line caregivers from various professions.  Apart from the usual avenues of assistance there have been informal programs set up to assist these workers and refer them to appropriate resources. I can think of no better use of my abilities than to assist in this area, but exactly how to assist is the problem.  All of the documentation, hardware, software, medical resource availability, and malpractice issues that I described in the main post still apply.  No single person has enough resources to provide this service unless they set up a private practice.

With the advent of telemedicine, it is possible to have a centralized administration that can provide all of the necessary services and coordination to get psychiatric services out to the people who need them.  I think it would be relatively easy to find psychiatrists to staff that service.  A uniform administrative structure could be used similar to other government-civilian service organizations like the Peace Corps.  At the humanistic level it would serve the dual purpose of providing services and matching that with a resource in search of a home and that is skilled psychiatrists. 

Supplemental 2:

I was reminded today of the success that I have had treating patients with conversion disorders, fibromyalgia, and seronegative (also known as "chronic") Lyme disease.  That reminder was a reference to how to approach people with chronic post  COVID-19 symptoms. I would be very interested in clinical trials or direct clinical service is any setting that specialized in seeing this patient population. Brain fog has become a term of interest as well as a pejorative term with the politcalization of the SARS-CoV-2 pandemic.  I have discussed that symptom with hundreds of patients and again would welcome a clinical setting or research setting where I could do more.  To me this has been a significant problem in primary care clinics that has been unaddressed by most of psychiatry and neurology.  

Graphics credit:  Aircraft on final approach image was downloaded from Shutterstock per their standard user agreement.  It symbolizes a glide path the retirement.

Does the Insurrection End the Debate on the Goldwater Rule?

 

I think it does and both sides lose.

As a refresher take a look at my earlier comments on the Goldwater Rule at this link.  More briefly, the Goldwater Rule was implemented by the American Psychiatric Association (APA) as ethical guidance to its members following an incident where a 1964 magazine survey of psychiatrists concluded that the Republican candidate Barry Goldwater was “psychologically unfit” to be President of the United States.  As you can see from the ad in this previous post, there was a strong implication by the Lyndon Johnson campaign that a Goldwater presidency would put the country on a path to nuclear war.  Goldwater subsequently sued the magazine and was awarded damages – three years after he lost the election.

In the meantime, the APA included the following section in the Principles of Medical Ethics with Annotations Especially Applicable to Psychiatry.

Section 7.3

On occasion psychiatrists are asked for an opinion about an individual who is in the light of public attention or who has disclosed information about himself/herself through public media. In such circumstances, a psychiatrist may share with the public his or her expertise about psychiatric issues in general. However, it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement.

Since I wrote the original post, I have queried many colleagues who are also APA members and as far as I know no member has ever been sanctioned by the APA or any of its district branches for violating the Goldwater Rule.  There has been a lot of intense debate about it and that debate has never been as intense as during the recent Trump administration.  Beyond the debate there are unequivocal examples of psychiatrists ignoring the Goldwater Rule and, in some cases, criticizing the APA about it. The rhetoric extends to the point that the APA invented the rule because it was embarrassed about the original Goldwater incident and it was suppressing the free speech rights of its members who felt an ethical duty to use their skills to either warn or protect the United States from President Trump.  While some have found that rhetoric to be admirable, I do not. First, APA membership is completely voluntary and the obvious way to escape its long reach into First Amendment rights is to not be a member.  The predictable response to that suggestion is that all of the benefits of membership will be not be available and that might put non-members at a disadvantage.  Having been an APA member for over 30 years, I can attest to the fact that there are minimal advantages to being a member primarily as discounts to publications by the organization.  Even then, the American Medical Association (AMA) membership fee is much lower and includes free access to many more publications.

A second consideration is the context of what is happening.  In my previous post, I pointed out that psychiatrists are trained to assess problems in a particular context.  During years of training that comes down to a face-to-face discussion with the patient about problems that were either identified by the patient or someone else.  Collateral information is considered and that can be exhaustive. A diagnosis and problem formulation follows. Until the profiling of political leaders, criminals, and historical figures came into the scene in the past few decades there was no suggestion that psychiatrists could assess people at distance with any degree of accuracy. In fact, criminal profiling is generally done these days by trained law enforcement personnel suggesting that no psychiatric qualifications are necessary at all.  It all seems predicated on a folk psychology model that personality features and patterns of behavior are constant over time and dependent on past behavior. Some of the commentators on this issue have identified themselves as forensic psychiatrists. Forensic psychiatrists are paid to do even more exhaustive interviews and review of collateral information than clinical psychiatrists. They may take 15-20 hours to do an assessment compared with a clinical psychiatrist who probably has 60-90 minutes at the most. The idea that forensic psychiatrists endorse assessments at a distance seems even more incongruous to me.

Focusing only on the conclusory article (1) post insurrection it is clear why psychiatric opinion adds nothing to the political mix.  In the first paragraph, the authors conclude that Trump is “clearly mentally unbalanced and unable to grapple with a reality that threatens his inflated and fragile ego.”  They suggest that only reason that people would not believe their statement is that they ascribe his behavior to “puckish idiosyncrasy or creative disruption”.  That gives their statement way too much explanatory power. How about the obvious political considerations and Trump’s previous behavior as a businessman?  He is clearly a guy who is used to steamrolling over people and often uses the legal system to do it.  He demonstrated that in the primary and the debates.  He demonstrates it on a weekly basis toward anyone who he thinks is being disloyal – irrespective of their track record. He threw his Vice President under the bus for adhering to the Constitution that he was sworn to uphold. Who would describe that behavior as puckish?  Any objective observer would see that President Trump is a negative force and somebody that you do not want to deal with and hopefully would never be employed by. In political terms, he is an autocrat that deals in propaganda and he knows the power of propaganda. By definition, that is dangerous to any democratic republic but once again – it has nothing to do with psychiatry or the special training of psychiatrists.

The preamble in that conclusion: “clearly mentally unbalanced” is also rhetorical.  He has tens of millions of followers who all believe the propaganda. The authors themselves acknowledge that if Trump was a private citizen they would not be concerned and that their concern is only based on the fact that he was the President. This would be the first case of mental illness based on the condition of Presidency. The additional evidence in this article that Trump was “delusional”, “impulsive”, vengeance seeking, or “deranged” is non-existent and it can easily be argued that deficiency occurs as a direct result of not having personally examined him to ask him for direct explanations.   All of the examples cited are consistent with the behavior of a highly self-interested politician or businessman who will do anything to win. In the event that the authors have not noticed there are tens of thousands of these people walking around in American society. Possibly hundreds of thousands and none of them are being treated by psychiatrists.

The authors previous argument that they have an ethical responsibility to warn the public about Trump’s dangerousness based on a presumptive personality disorder falls apart under that scrutiny.  If there is no clear evidence of a diagnosis there seems to be no basis for the authors to base their actions on. Further Trump’s recent statement on the day of the insurrection and even since are no more radical than many of his colleagues or followers. Why are psychiatrists needed when there is nothing to base a professional opinion upon?

Early in the course of the Trump presidency, the issues arising with the Goldwater Rule were analyzed by Kroll and Pouncey (2).  After considering all of the variations their conclusion was that the Goldwater Rule was based on the need of the APA to prevent embarrassment to the profession by making statements similar to the statements made by psychiatrists during the original Goldwater controversy. That assumes that the APA as a guild is successful in preserving and promoting the interests of psychiatrists in the USA.  The track record there is very sketchy.  The APA and medicine in general has been completely unsuccessful in preserving a practice environment conducive to quality care.  At many levels it has facilitated that transition most notably by a near complete lack of opposition to managed care tactics and legislation and more recently collaborative care initiatives.  The APA has not been successful in advocating for patients with the most severe forms of mental illness. There has also not been any success in advocating for reasonable infrastructure to help the severely mentally ill avoid homelessness and incarceration. That string of failures is potentially more embarrassing than whether or not a few psychiatrists look foolish on the evening news.  I think there is an ethical basis for the Goldwater Rule that extends far beyond embarrassing the many by the few.

One of the key dimensions that I have not seen anyone comment one is that most psychiatrists are liberal Democrats. Psychiatry is the only medical specialty where that is true.  That is a clear bias when assessing a President from the opposite political party.

The insurrection itself clearly illustrates that psychiatric intervention in a Constitutional crisis is not possible or advisable.  I am basing that on the fact that for 25 years I participated in thousands of civil commitments, guardianships, and conservatorships.  I know all the legal requirements for these proceedings in both Minnesota and Wisconsin.  There is no court in any county in either state that would accept a legal proceeding against the President based on his current public behavior.  A typical argument against my position would say it is a utilitarian argument and therefore limited on those philosophical grounds. I don’t think it is at all.  If you are arguing that psychiatrists need to be involved, the question needs to be asked: “What for?”  The psychiatrists who have been the most vocal that President Trump is dangerous or irrational and, in some cases, claim that they are being stifled by the APA and the Goldwater Rule need to have an endpoint.  Every day psychiatric practice dictates that if you are seeing a dangerous individual you have to enact a plan to protect the patient and others. I don’t think that level of evidence exists – it certainly does not rise to the level of court intervention. The next step would be approaching members of Congress and asking for Impeachment or invoking the 25^th Amendment. They don’t need psychiatrists for that.  So what mysterious psychiatric intervention do the Goldwater Rule deniers want to see happen?  Should psychiatrists sitting in arm chairs call someone in the White House and tell them to remove the President based on his most recent outrageous statements?  That clearly would not work.  The concern that he has access to the nuclear briefcase also does not work. The evidence at this point is very clear, his cabinet had the opportunity to enact the 25^th Amendment and they declined.  Vice President Pence declined even after he was publicly berated by the President. Limits were set by the Department of Justice, the Joint Chiefs of Staff, social media companies, the National Guard and law enforcement on the ground.  President Trump had an unorthodox exit from the White House but he did leave.  Several days later the public was informed that he left a letter for President Biden.

The Republic survived without psychiatric intervention and none was indicated. The Goldwater Rule did not prevent some psychiatrists from making rhetorical statements from both the right and the left.  Nobody was sanctioned because from a practical standpoint it is ethical guidance – and I think it is good ethical guidance.

Is there a role for psychiatrists in these situations apart from making a speculative guess about the mental status of the Commander-in-Chief?  I think there is and that is in an advisory capacity about some of the group dynamics and containment of violence that occurred. It is absolutely critical to notice when propaganda is being used to incite violence or in this case an insurrection. Propaganda is not a “shared delusion” it is emotionally charged speech that can lead to fixed irrational positions.  It has to be recognized and countered in order to prevent the mass level of dysfunction associated with the denial of systemic racism, pandemic denial, mask denial, climate change denial, and the denial that the Presidential election was free and fair.  All of those levels of denial associated with the Trump administration occur in the context of longstanding denial that there is a serious problem with firearms in this country.  If psychiatrists want to be politically involved – those are the hard problems that need to be addressed.

There is much to be said for psychiatrists’ experience with containing violence and aggression.  When I witnessed what happened on January 6, I had many concerns about Inauguration Day.  My primary concerns were whether there would be adequate force to stop a similar attack and minimize the risk of injury to the police or demonstrators.  As I saw the barriers erected my concern was whether they was a plan in place to keep large groups away from the fences and avoid a violent confrontation.  Was there intelligence about the possibility of foreign actors taking advantage of the situation? And most of all – did the police and National Guard have clear rules of engagement to contain escalating violence and aggression and avoid serious injuries.  It turns out that everything except the rules of engagement were handled well. 

My advice about the Goldwater Rule either way is straightforward.  Forget about debating the President’s mental status in public.  The standard for Presidential capacity is a lay standard and not specified by any statute.  Psychiatric opinion is and will be remain unnecessary.  And if an APA member decides they want to bring an ethics complaint based on a violation of the Goldwater Rule – that is a waste of time as well. Stay focused on your own medical professionalism and remember that being a psychiatrist does not necessarily make you immune to emotional reasoning, political rhetoric, or propaganda. There are probably many more friends, neighbors, and relatives that need to get back on track to carry on the more mundane work of democracy.  

 

George Dawson, MD, DFAPA

 

References:

1:  Leonard L. Glass,  Edwin B. Fisher, Bandy X. Lee.  Trump’s Danger is now Undeniable.  He is clearly mentally unbalanced and unable to grapple with a reality that threatens his inflated and fragile ego.  Boston Globe January 7, 2021.

2:  Kroll J, Pouncey C. The Ethics of APA's Goldwater Rule. J Am Acad Psychiatry Law. 2016 Jun;44(2):226-35. PMID: 27236179.

Graphics Credit:

1:  Donald J Trump official portrait By Shealah Craighead - White House, Public Domain, https://commons.wikimedia.org/w/index.php?curid=63769676  Downloaded from Wikimedia Commons on 1/29/2021

2:  Barry Goldwater 1960 portrait By United States Senate - https://www.senate.gov/artandhistory/history/common/generic/Featured_Bio_GoldwaterBarry.htm  Public Domain, https://commons.wikimedia.org/w/index.php?curid=79152516

Downloaded from Wikimedia Commons on 1/29/2021

 

Disclosure 1:

Jerome Kroll, MD was one of my professors when I was a resident at the University of Minnesota.  He is a brilliant psychiatrist and wrote one of the best books ever The Challenge of the Borderline Patient.  He was also one of many professors who taught me that you can argue with colleagues and nobody has to take it personally - a good lesson in politics as well. 

Disclosure 2:

In my previous post I pointed out that for the past several decades I have been a small "i" independent.  That has changed with recent events.  I would find it very difficult to vote for a Republican based on their collective behavior and inability to respond to President Trump for the good of the American people.  But I still  do not think that psychiatrists have anything to offer in that area.

Supplementary:

I decided to attach the next several paragraphs based on what I have encountered over the Goldwater Rule into arguments I have heard from deniers and supporters of the rule. The last section are my personal observations (from above) - admittedly not independent of the others

Goldwater Rule Deniers:

1: Psychiatric or mental health experience is necessary in the case where a President may be incapacitated and unable to perform their duties.

2: Psychiatrists are ethically bound to publicly speak out if the President is incapacitated and a potential danger to the country.

3: The only reason the Goldwater Rule exists is to prevent embarrassment of the psychiatric profession.

4:  There may be an element of financial conflict of interest if the Goldwater Rule was recently modified over concerns that the APA may receive less money/tax benefit because of criticism of the President.

4: The APA suppresses the free speech rights of psychiatrists who speak out on the basis of their public assessment of the President.

5.  At least some deniers of the Rule believe that there should be a lower standard for capacity or mental illness if it is applied to the President. In other words, psychiatric opinion is conditional on whether or not the person being observed is the elected President at the time.

6.  The personal interview is not reliable and all of the information necessary to make a diagnosis is already out there in the public domain.

7.  The President's personality or alleged mental illness is the primary problem in what appear to be poorly thought out decisions.

 

Goldwater Rule Supporters:

1:  The Rule is the rule and direct examination of the patient is required to get the assessment out of a purely speculative mode where observations potentially have multiple possible meanings.

2:  The politicization of psychiatry is inevitable with experts for either party.

3:  The politicization of psychiatry potentially impacts patients’ willingness to see psychiatrists for help.

4:  Competency versus capacity – competency requires legal definition, capacity may be informal but that is unlikely in a contested procedure.

5:  Scientific accuracy of predictions of dangerous behavior are not good (Estelle v. Barefoot and APA amicus brief)

6:  Psychiatrists are not immune to rhetoric, propaganda or emotionally charged speech. The original treatment of Goldwater is a good example.

7:  If the issue is dangerousness and we are talking about President Trump there were many more dangerous presidents based on total war casualties that occurred during their terms – including Lyndon Johnson who was elected in part on the alleged dangerousness of his opponent Barry Goldwater.

8:  The President's personality or alleged mental illness is difficult to separate from purely political tactics like intentional misinformation or propaganda that are designed to disrupt and manipulate the electorate. 

 

GD:

1:  The Rule is ethical guidance that has never been enforced.

2:   The Rule is obviously ignored – nobody has ever been sanctioned by the APA or a District Branch in the 50 years it has been in effect

3:   The Rule only applies to APA members so people outside of the APA should not be concerned about it.  If you are really concerned about it don’t be an APA member and comment as much as you like.

4:   Presidential capacity is a lay standard that is not specified in any legal statute. In other words, there are no judicial descriptions of a standard for Presidential incapacity, no standard of proof.

5:  There is no mechanism to remove the President from office based on psychiatric opinion.  There are however political and legal mechanisms (25^th Amendment, Impeachment) to remove the President based on the opinion of his cabinet and in the case of repeated impeachments disqualify from further election eligibility.  A non-psychiatric standard is defined in the 25^th Amendment.

6:  In retrospect, some of the original campaign against Goldwater was propaganda (see ad on nuclear war) and that was reflected in some of the psychiatric opinion at the time.

7:  Psychiatrists potentially have a more significant role at the level of the group dynamics of violence, aggression, misinformation, propaganda, and the containment of violence and aggression.

8:  Several polls have characterized psychiatry as the most liberal medical specialty and the only one where a majority of members are Democrats.  That conflict of interest should be disclosed when commenting on opposition party politicians.