Weed be better off smoking our parents' pot

We've all heard our parents say it*: "Back in my day, dope was much better than it is now. It wasn't nearly as strong as what you kids smoke today."

Like much of the advice our parents give us (like always take out your contacts before you go to bed), this one is also true. The THC (tetrahydrocannabinol - the primary psychoactive compound in cannabis) concentration in marijuana has increased by as much as 12% over the last 30 years. This rise in THC levels is related to increases in the subjective 'high' feelings associated with smoking cannabis, like changes in perceptual sensations, contentedness, and increased appetite. However, THC is also linked to many of the negative consequences of cannabis use, including risk for dependence, attentional bias or distraction, impaired memory and cognition, and the potential emergence of psychotic symptoms.

A proposed shift in drug policy: From prevention to harm reduction

I recently finished Professor David Nutt's new book, Drugs Without the Hot Air, on minimizing the harms of drug use, both legal and illegal. Professor Nutt's tone is light and his writing is accessible to readers of all scientific backgrounds, but his message is an important one. He explores the history and culture surrounding many drugs of abuse, ranging from the popularization of caffeine and nicotine, to the original medicinal purposes for cocaine and heroin, to the widespread use of prescription stimulant drugs today. He also discusses previous governmental endeavors, both successful and unsuccessful, on limiting drug abuse. This includes the floundering War on Drugs waged by the United States since the Nixon administration, as well as the more effective reduction in tobacco use seen in the U.S. and U.K through smoking bans, higher taxation and tighter restrictions on marketing campaigns.

Psychiatry and psychedelia

Timothy Leary, the influential psychologist who popularized the use of LSD in the 1960s, is a polarizing figure in the debate on psychiatry and psychedelic drugs. While revered by some as the father of psychedelic research, he is reviled by others for his unconventional research methods, which culminated in Leary's lab, the Harvard Psiloybin Project, being shut down by the University in 1963. Following this set back, Leary established a private laboratory in a mansion in upstate New York where he continued conducting studies on his friends and followers. Leary's previously unseen recordings and notes from this period have recently been purchased and published by the New York Public Library, for the first time allowing us insight into the ground-breaking work done with these then novel substances. The backlash to Leary and his colleagues' extremist views regarding drug use, religion and politics (Richard Nixon at one point called Leary "the most dangerous man in America") potentially discredited any real benefits psychedelics may have in therapy for over 40 years. Experimentation and research with LSD, psilocybin (commonly known as hallucinogenic or "magic" mushrooms) and other psychedelic substances has been highly stigmatized and virtually impossible to conduct in a responsible laboratory setting. However, the restrictions against such research have gradually been lifted, and new studies are cautiously popping up heralding the clinical benefits of drugs like psilocybin and MDMA, or ecstasy.  These drugs are thought to help individuals who suffer from severe anxiety, post-traumatic stress disorder (PTSD), obsessive compulsive disorder (OCD) and depression when paired with talk therapy methods. The effectiveness of these drugs is thought to lie in their ability to engender feelings of empathy, love and connectedness, fostering a sense of unity and compassion for oneself and fellow man. These feelings may potentially create an easier, more open environment for patients to discuss their concerns in, while safely being guided by clinicians on a therapeutic trip.

Some of the most notable research coming out of this renaissance is being conducted at John's Hopkins University, led by Dr. Roland Griffiths. Griffiths has shown that psilocybin can be used to effectively reduce levels of depression and anxiety in terminally ill cancer patients, anecdotally helping some patients to accept and come to terms with their approaching mortality.

Another influential use for this type of research is in patients with PTSD. With the recent announcement that antipsychotic drugs, frequently prescribed to help treat PTSD in combat veterans, are no more successful than placebos at improving symptoms, it seems that a new method is needed to help those suffering from severe trauma. Antidepressants are already known to be ineffective at treating PTSD, and doctors were hoping that antipsychotic medication, a stronger mood affecter, would be more successful at treating the associated symptoms, such as flashbacks, memory suppression, outbursts of anger, anxiety, anhedonia and depression. However, after six months of treatment only 5% of patients who received the drug had recovered, a number that was statistically negligible and not significantly different from those who had received a placebo.

Some researchers are now looking at more unconventional methods, such as psychedelics, as potential treatments for PTSD. Clinical researchers both in the US and in the Netherlands have shown that MDMA can be effective at reducing PTSD symptoms in survivors of rape or other traumatic events. Neurologically, MDMA stimulates serotonin in the brain, a neurochemical linked to feelings of  happiness and whose depletion is commonly attributed to depression. This activation takes place throughout the brain, but much of it is focused in the dorsal lateral prefrontal cortex (dlPFC), a region involved in higher order cognition, memory and associative learning. Simultaneously, there seems to be a decrease in amygdala activity, an area involved in fear and emotion. Taken together, these two changes in neural activity are thought to increase memory and rational, cognitive coping of the traumatic event, while down-playing the aversive negative emotions connected to it. Therefore, an individual would be able to replay the more painful details of a memory and rationally analyze and come to terms with them, facilitated by a boost in mood from serotonin and disconnected from the typical painful affective responses. This could potentially help a patient "relearn" their associations with this memory, thus allowing them to lose the negative and recreate positive affective associations for these recalled experiences.

However, just as there are side effects with any drug, so there are too with MDMA. The most notable and potentially harmful one is a resulting decrease in serotonin after the high has worn off. When the brain is flooded with a neurochemical it regulates itself to become less receptive to this neurotransmitter, adapting to re-obtain homeostasis in the chemical levels in the brain. The brain therefore becomes relatively depleted of serotonin over the next few days after taking MDMA, and after multiple uses (or abuses) of the drug this effect can become pervasive and long-lasting. While the amounts of depletion are not particularly severe after minimal use, in a patient who is already struggling with depression or anxiety this temporary loss could be potentially devastating.

Banning potentially valuable clinical research because of social concerns and constraints only hurts scientific progression and the community at large. However it is important to keep in mind that these psychedelic substances are powerful drugs with potentially very severe consequences. They should be investigated as their benefits to clinical populations could be immense, but they should still be used carefully as much is still unknown (just as much as unknown about most drugs, prescription or otherwise) about their mechanisms and effects. Responsible research is the best way to investigate the therapeutic possibilities of these drugs, and the existence of methodical record taking like Leary's can only help us in our quest to understand these substances and their effects on the mind.

Leadership skills?

In our hyper-driven and competitive culture, gaining access to the elite "C-suite" of a corporation, and the money and power that engenders, is highly coveted. Ambition, drive, hard work, and a certain degree of ruthlessness are regarded as essential qualities in an aspiring leader and traits necessary for someone working his or her way to the top. However, two interesting commentaries on leadership and advancement in the professional world have recently questioned these qualities and brought to light their similarities to two seemingly very different life paths. In the first, journalist Jon Ronson makes the claim that top business leaders are four times more likely to have psychopathic tendencies than the normal population. In his new book The Psychopath Test, also brilliantly re-told on This American Life, he claims that 4% of business leaders demonstrate psychopathic tendencies, as compared to 1% of the normal population. He attributes this to a significantly less active amygdala, the region of the brain associated with fear and emotion. In psychopaths, or potentially CEOs, fear and empathy are diminished, enabling them to act selfishly or in the spirit of Machiavelli, if you will. Abnormal amygdala responses allow them to take risks and ruthless measures to get ahead and leave them disinhibited from the feelings of guilt, apprehension, or remorse that most of us would feel after firing employees or conning someone out of their money.

In his book he interviews Al Dunlap, the CEO of Sunbeam toasters and a man known for his cut-throatness and proclivity for firing people with glee. Ronson informally administers the classic PCL-R (Psychopath Checklist-Revised) to Dunlap, on which he scores higher than normal, though not high enough to register as a true psychopath. However, Dunlap does manages to turn nearly every item he answers affirmatively to into a positive quality for business. For instance, reinterpreting "a grandiose sense of self-worth" as "believing in yourself", and "lack of remorse" as "freeing yourself up to move forward and achieve more".

While the claim that most CEOs are secret psychopaths may not hold true, a second theory does carry more weight. Originally raised in neuroscientist Dr. David Linden's new book on pleasure, The Compass of Pleasure: How Our Brains Make Fatty Foods, Orgasm, Exercise, Marijuana, Generosity, Vodka, Learning, and Gambling Feel So Good, and reiterated recently in an opinion piece for the New York Times, Linden makes the comparison between addictive personality traits and leadership skills. He cites compulsivity, risk taking, and a depletion in pleasure as tendencies that could be utilized to facilitate perfectionism, a push towards new financial ventures, and an unwillingness to settle in business. However these traits can easily manifest disadvantageously in society's leaders, the most obvious example being the poor risky decisions made in the financial and political sectors that resulted in the global recession.

Additionally, it is not only these personality traits that drug users and innovative leaders have in common. Paradoxically, many of the creative geniuses and political and financial authorities of our time have struggled with drug or alcohol abuse at some point in their careers. Indeed, it would be surprising for these men and women to apply their sensation seeking tendencies towards only one aspect of their lives, and thus it is not uncommon for influential leaders and those in power to abuse drugs or alcohol. A new book on cocaine use, The Anatomy of Addiction by Dr. Howard Markel, has brought these tendencies to light using Sigmund Freud, the father of psychoanalysis, as a prime example. In addition to Freud, Linden also lists Winston Churchill, Aldous Huxley, and Alexander the Great, as well as countless others, as examples of leaders who have struggled with addiction. However, it is important to note that most of these writers, CEOs, dignitaries, and geniuses were not on drugs at the moment of their breakthroughs.

I am not one to criticize drug taking or experimentation, but I am against the romanticization of these habits that can so easily become dangerous compulsions (compulsivity is clinically referred to as the persistence of a behavior despite negative consequences). Light experimentation with mind-altering substances is often cited as having provided inspiration and cognitive expansion perhaps not otherwise possible in our daily world. However, truly addictive drugs such as cocaine or opiates rarely provide these experiences without some potentially devastating long-term consequences. It is possible to maintain a recreational relationship with some of these substances, however it is a slippery slope that should be rappelled with extreme caution. The personality traits of curiosity and the desire for exploration, both personal and intellectual, do seem to foster innovation and creativity, and compulsivity can be analogous to perfectionism or a relentless drive for success. However, compulsivity can also lead an individual from exploratory recreational use to drug abuse and dependence, and it is important to keep in mind that those individuals who created corporate, creative or intellectual masterpieces while on drugs may have done so in spite of, not because of their addictions.

(Thanks to Tanner Brown for the Sam Harris link)

Pathologizing the norm: Follow-up

For those of you who are interested in this debate, there's a great new two-part article in the New York Review of Books by Marcia Angell questioning "The Epidemic of Mental Illness". The articles summarize three new books concerned about the prescription frenzy we are in the midst of and how this reliance on psychoactive medication came about. She addresses the problem of dealing with psychiatric disorders as chemical imbalances and the dubious efficacy of these drugs at actually improving symptoms at all. I highly recommend this read, as well as the second part in the series on "The Illusions of Psychiatry", for anyone concerned about our mental health system. One of the most resounding points she makes in this second piece is the perpetual expansion of the diagnoses listed in the American Psychological Association's Diagnostics and Statistical Manual (DSM). With every publication of the DSM there are more and more "disorders" that we have pathologized and created, and with the upcoming publication of the DSM-V it is certain that there will be a slew of new problems we can claim for ourselves and put a name to. Angell succinctly describes this problem stating, "Unlike the conditions treated in most other branches of medicine, there are no objective signs or tests for mental illness—no lab data or MRI findings—and the boundaries between normal and abnormal are often unclear. That makes it possible to expand diagnostic boundaries or even create new diagnoses, in ways that would be impossible, say, in a field like cardiology."

Finally, she brings to task the drug companies who are more involved in psychiatric treatment than in any other medical field. This applies not only to clinicians or psychiatrists with private practices, but also the research institutions, hospitals, universities, policy makers, patient advocacy groups, educational organizations and the APA itself.

Angell's writing takes a good hard look at the system of mental health, and while at time she makes some uncomfortable points, these are important questions that need to be addressed.

(Thanks to Emily Barnet for the Angell articles.)

Pathologizing the norm

Going in to any introductory psychology course, students are warned that the basic education they are gaining does not make them experts in the field. They are cautioned against diagnosing friends and family members with their scant knowledge and are reminded that there are many nuances of both personality and personality disorders that they are far from privy to. A stirring op-ed piece in the New York Times recently highlighted the perils of the common citizen diagnosing themselves and their loved ones with Alzheimer’s disease or dementia. However, more and more it seems that clinicians and researchers in the field of psychology and psychiatry are at risk of making this same mistake by pathologizing natural neuropsychological slips and common cognitive errors. Neuropsychological assessments involve a series of challenging, and at times painstaking, tests of memory, decision-making and cognitive flexibility, among other executive functions. Standardized ranges are provided for these scores from the wider population, much as for an IQ test. These assessments are particularly useful in neurological patient populations (such as victims of a stroke or a brain tumor) and the elderly to assess cognitive decline, just as the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders) and MMPI (Minnesota Multiphasic Personality Inventory) are helpful in a therapist or clinician’s office. However, these tests, as well as “significant” real-life examples are now being used as evidence of disorder in normal individuals.

Nowadays, misplacing your car keys can be seen as a precursor to dementia, and blanking on an old acquaintance’s name is indicative of Alzheimer’s. Likewise, niche expertise is an example of savantism and social awkwardness a sign of long undiagnosed Asperger’s syndrome, which is just a short step away from autism on the spectrum.

But this is what we have to remember and what is getting lost in this dichotomous system of diagnoses: all of these disorders or impairments lie on a spectrum. And the ultimate litmus test for a disorder is not how poor one’s verbal recall is, but instead how much distress this impairment causes. The world of psychiatric and neuropsychological diagnoses is far from clear-cut and these classifications must be based on more than just behavior. The perception and attitude of the patient must be taken into account, including whether this person even considers themselves to be a patient in the first place.

Similarly, over the past twenty years the diagnosis of ADD/ADHD (attention deficit / attention deficit hyperactivity disorder) has risen dramatically, as has the subsequent backlash against over-diagnosing and over-medicating society’s children. Before running to the doctor's office or the prescription pad, it is important to remember that kids are squirmy, and that no one, college students and professors alike, can maintain disciplined attention during a tedious lecture.

Everyone experiences memory loss as they age, just as we all feel sadness over the course of our natural cycle of emotions. Unhappiness is a universal human feeling that everyone must go through from time to time, and is not indicative of the pervasive demoralizing morose of true depression. Emotion, attention and memory are all fluctuating human traits and must be remembered as just that, natural and transient. Our culture is so eager for a quick fix, to get rid of any feelings of discomfort and receive instant release. But sometimes it is important to experience these sentiments, to sit and work through our problems and wrestle with our shortcomings. This is in no way meant to minimize the tribulations that accompany these very real disorders, but to serve as a reminder that all of us are flawed, mentally, physically and emotionally, and if we pathologize these feelings, these struggles, then we may  miss out on the robustness of life.