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PROFESSOR: Good afternoon.

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When we parted last
time, I was --

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you just did that demo with Sam,
who was either collecting

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stamps or lady's undergarments,
depending.

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And the point there was to
describe the fact that any

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behavior is going to be
distributed across the

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population in some fashion.

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It may well be that the extreme
of the population is

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abnormal in some meaningful
sense, maybe even pathological

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in some sense, but that the
border between what is normal

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and what is abnormal is going
to be necessarily ambiguous.

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There's not going to be some
nice, neat line that can be

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drawn in all cases.

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I was arguing that something
like schizophrenia is a bit

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more like that, where the
abnormal state really does

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look quite different from the
normal state and less like

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that it's on a continuum.

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You will notice on your
handout that it

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says Lecture 20.

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And those of you who are
particularly observant will

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say, last one was called
Lecture 20.

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And that's true.

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I just liked 20.

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No, this is really 21.

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And with a bit of luck, I'll
label the next one 22.

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Otherwise it'll just turn out
that there's 20A and 20B or

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something like that.

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Anyway, it really is
the right handout.

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You'll discover that it is
closely related to the later

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pages of the last handout that
we didn't get to last time.

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Yeah, it's kind of the same
is what people are noting.

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But I didn't have any faith that
people would remember to

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bring the real Lecture
20 handout.

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Anyway, what I want to talk
about, at least initially

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here, is to talk a bit about how
you would end up in this

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abnormal bin of schizophrenia.

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And one reasonable question
to ask is,

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well, it's on the handout.

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It says, is there evidence
for a genetic component?

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And the answer is yes.

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And the way you get one of the
important sources of that

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information is similar to the
data that we were talking

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about in intelligence testing.

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Take a look at people who vary
in the amount that they are

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genetically related
to each other.

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Notably here, MZ stands for
monozygotic or identical

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single-egg twins.

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And DZ stands for dizygotic
two-egg twins who are no more

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similar than siblings.

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Concordance means what the
chance is of Twin Two having

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the disease if Twin
One has it.

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And so what you can see is that
for monozygotic twins, if

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one of a pair of identical twins
becomes schizophrenic,

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there's a 50% chance that
the other one will, too.

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That tells you two things.

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Well, it only tells
you two things if

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you look at the dizygotic.

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The dizygotic twins have a
much lower concordance

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rate of about 15%.

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So that tells you first of all
that there's a probable

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genetic component there,
and second of all,

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that it's not absolute.

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If you have the genetic mutation
that makes you

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color-blind or color anomalous,

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you'll be color anomalous.

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There's no big mystery at
this point about that.

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If you have whatever the genetic
predisposition is for

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schizophrenia, something else
has to happen before you would

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end up showing the disorder.

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Now, these twin studies run into
the same problem that the

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intelligence testing twin
studies did, which is that

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monozygotic twins are simply
more similar on

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all sorts of things.

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You know, they're treated more
similarly and so on.

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One way to look at whether or
not there is a, you know, to

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try parceling this out, is
this third line here.

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This was a population of
dizygotic twins who thought

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they were identical.

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You know, they looked alike.

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Presumably they're the same
sex and stuff like that.

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Thought they were identical.

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You'll see that their
concordance rate was less than

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the 50% that the true
monozygotic twins had.

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So there does seem to be
something to being really

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genetically identical.

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You can also do twins
reared apart things.

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But look, if you have
a set of --

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twins reared apart --

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not common.

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But all those twins have IQs.

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You can always measure
their IQs.

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If you take twins reared apart
and then take the cases where

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one of them has schizophrenia
and ask what the concordance

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rate is, the answer is
it's quite elevated.

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But, you know, it's a really
small population of people.

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You know, twin reared apart
and schizophrenic,

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it's not a big crowd.

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Now, when you go look for the
genetic marker, since the late

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'80s, there have been a slew of
papers on genetic markers

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for schizophrenia.

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The way you look for this --
one of the typical ways to

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look for this is that

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schizophrenia runs in families.

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And if you go and analyze the
genetics of families, you can

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find specific loci that seem
to be abnormal in the

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schizophrenic members
of the family.

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The difficulty or the
interesting aspect of this

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genetic story is that the story
that works for this

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family doesn't necessarily
work for this family.

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In the early days of this,
there'd be some big article in

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Science or Nature or something
saying gene locus on

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chromosome eight for
schizophrenia or whatever.

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I'm making it up.

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And then, you know, either in
the same issue or in the, you

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know, next week, there'd be
another thing saying, but not

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in this family.

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Clearly schizophrenic
but not clearly

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having the same defect.

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It suggests that there are
multiple roots, genetic

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predispositions, to
schizophrenia.

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It's also possible that
you need more

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than one genetic insult.

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That's jargon --

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you don't say, you
got an ugly gene.

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You need to have perhaps more
than one defect in order to

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have the susceptibility
to schizophrenia.

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One of the curious little
wrinkles that I dug up in my

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reading on this -- and
I've only read this

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in a secondary source.

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I have been unsuccessful
in tracking

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down the primary source.

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But I'll tell you anyway --

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is a study -- it turns out that
there are two types of

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identical twins.

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There are, sort of, plain
vanilla identical twins.

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You know, Twin One
is right-handed.

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Twin Two is right-handed
and so on.

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And then there are so-called
mirror twins.

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They're genetically identical,
but the phenotype, the actual

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organism, is mirrored rather
than identical or

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something like that.

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So if one's right-handed, the
other is left-handed.

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You know, swirl on the top of
your head, if it swirls

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clockwise for one twin, it
swirls the other way for the

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other twin and so on.

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And the curious finding
reported in this one

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relatively small study, I think,
is that the concordance

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rates for identical identical
twins, the right hand, right

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hand identical twins,
very high in this

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study, like over 90%.

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If one twin was schizophrenic,
the other was schizophrenic.

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The mirrored twins, the left,
right ones, were concordance

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rate down at about 25%.

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Both of these are genetically
identical pairs of twins.

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It's abundantly unclear what
it is that makes these two

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groups different, if indeed
that turns out to be a

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reliable result.

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I went hunting in the databases,
and I think I found

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the guy who did it.

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So I sent him an email, but he
didn't get back to me in time.

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Oh, that reminds me.

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It's a little late in the day
to tell you this, but if you

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discover that something that
you're looking for in primary

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source land, you know, you're
looking for the Journal of

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Hoozy Phoozy Results or
whatever, and oh my god, MIT

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doesn't carry it so you don't
have access to it, it's often

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very useful to go and see if you
can find the website for

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the lab where the
work was done.

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Because many, many of us post
all of our publications, or as

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many as we have PDFs for, on the
website to be downloaded.

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And so you can dig things up.

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You can dig things
up that way.

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So anyway, there's pretty
strong evidence

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for a genetic component.

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And then there's pretty strong
evidence that that by itself

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is not enough.

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Unlike a variety of other
neurological disorders, there

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are plenty of neurological
disorders where if you've got

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this problem with your genome,
it's going to munch up your

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brain in the following fashion,
you're going to have

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this problem.

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And fortunately most of
these are very rare.

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But they're straightforward
genetic stories.

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In schizophrenia, something
about the environment seems to

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be important to trip it off.

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The leading notion is stress.

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So, actually, does
anybody remember?

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The book used to go on at vast
lengths about the stress

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diathesis model of
schizophrenia.

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Does this sound familiar
to anybody?

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Has anybody looked
at the relevant

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parts of the book yet?

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Nobody knows.

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All right, well anyway, one of
the leading notions about what

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it is that actually produces
the florid disease, is that

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you need to have some genetic
predisposition and then you

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need something like stress to
drop-kick you into pathology.

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Now, this is an interesting --

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this raises interesting problems
for public policy.

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I think we talked last time
about, you know, when is it OK

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to force somebody to be
medicated, right?

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This is a similar
sort of problem.

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Suppose you are applying
to MIT this year.

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Should I be able to --

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00:11:30,840 --> 00:11:34,550
should I go and suggest to the
head of admissions that we

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really should get little tubes
of blood from everybody?

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Because if we got little tubes
blood from everybody, we could

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genetically screen them.

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00:11:42,340 --> 00:11:45,220
And we know where --

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we don't know exactly which loci
are critical, but we know

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00:11:48,370 --> 00:11:51,620
a bunch of loci that seem to be
related to family histories

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of schizophrenia.

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00:11:53,420 --> 00:11:55,220
And anyway, there's all sorts
of other interesting genetic

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markers out there
at this point.

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We could screen the incoming
population or the population

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of applicants and systematically
decide not to

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00:12:06,210 --> 00:12:09,920
admit people who had the
genetic marker for

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00:12:09,920 --> 00:12:11,670
schizophrenia or for
some other --

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well, schizophrenia
is a good example.

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Why in the world would
we do this?

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Well, is there anybody currently
present who believes

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that MIT is a at least
modestly stressful

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environment?

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00:12:23,580 --> 00:12:24,830
All right.

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00:12:26,630 --> 00:12:29,300
Short of Guantanamo Bay or
something, you know, it's

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right up there.

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00:12:33,250 --> 00:12:35,830
All right.

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The state of the art is that
we know that stress is a

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contributing factor to a variety
of mental illnesses,

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notably in this example
schizophrenia.

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If we admit people to an
environment that we know is

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highly stressful, we are asking
for a certain number of

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psychiatric problems.

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00:13:01,250 --> 00:13:06,750
Isn't it our responsibility to
prevent that from happening?

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00:13:06,750 --> 00:13:09,090
Well, now, typically the --

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00:13:09,090 --> 00:13:11,820
I won't take a poll, but the
typical answer is, no, that

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00:13:11,820 --> 00:13:13,860
doesn't sound right.

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00:13:13,860 --> 00:13:17,280
You know, that somehow that
sounds a little too

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00:13:17,280 --> 00:13:19,860
paternalistic, too invasive
for me to be

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screening your genes.

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00:13:21,050 --> 00:13:21,910
And, you know, who knows?

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Down the line, we take a look at
this hunk of the genome and

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we say, you know, sorry,
you're just

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never passing 18.03.

249
00:13:30,630 --> 00:13:34,710
You know, what would we ever do
with information like that?

250
00:13:34,710 --> 00:13:38,320
But the disease case, it
doesn't feel right

251
00:13:38,320 --> 00:13:40,710
typically to people.

252
00:13:40,710 --> 00:13:44,410
But on the other hand, we spend
a lot of time worrying,

253
00:13:44,410 --> 00:13:48,140
believe it or not, about
your mental health.

254
00:13:48,140 --> 00:13:53,070
The dean's office has
substantial branches devoted

255
00:13:53,070 --> 00:13:57,130
to mental health issues as does
the medical department.

256
00:13:57,130 --> 00:14:00,700
We know that university
environments kick up a certain

257
00:14:00,700 --> 00:14:04,720
amount of psychiatric
problems.

258
00:14:04,720 --> 00:14:08,640
And we know that that can be
catastrophically bad for the

259
00:14:08,640 --> 00:14:11,020
person and for people
around them.

260
00:14:11,020 --> 00:14:13,750
Wouldn't it be our
responsibility to do something

261
00:14:13,750 --> 00:14:14,190
about that?

262
00:14:14,190 --> 00:14:15,990
Well, look, I'm not going to
give you an answer to that,

263
00:14:15,990 --> 00:14:19,140
and I promise not to ask on the
exam, you know, should we

264
00:14:19,140 --> 00:14:21,700
get blood samples from everybody
and, you know, the

265
00:14:21,700 --> 00:14:25,940
choices are yes, no,
all of the above or

266
00:14:25,940 --> 00:14:28,150
something like that.

267
00:14:28,150 --> 00:14:34,970
I raise that as an issue
to think about.

268
00:14:34,970 --> 00:14:37,560
When you take a look at the
brains of schizophrenics, by

269
00:14:37,560 --> 00:14:44,680
the way, they don't look like
the brains of healthy, normal

270
00:14:44,680 --> 00:14:45,480
individuals.

271
00:14:45,480 --> 00:14:49,570
So you get things like shrinkage
of grey matter.

272
00:14:49,570 --> 00:14:53,020
You get enlargement
of the ventricles.

273
00:14:53,020 --> 00:14:56,330
The ventricles are those nice,
empty fluid-filled spaces in

274
00:14:56,330 --> 00:14:57,000
your brain.

275
00:14:57,000 --> 00:14:59,730
Great answer for a --

276
00:14:59,730 --> 00:15:01,510
if you're looking at the
multiple-choice question on

277
00:15:01,510 --> 00:15:06,080
the final, and you're thinking,
I'm going to go for,

278
00:15:06,080 --> 00:15:09,660
you know, the third ventricle as
the answer, you're probably

279
00:15:09,660 --> 00:15:11,530
getting suckered here, right?

280
00:15:11,530 --> 00:15:14,320
Because the ventricles are empty
fluid-filled spaces.

281
00:15:14,320 --> 00:15:19,630
It's not where any of the more
important mental functions are

282
00:15:19,630 --> 00:15:22,480
thought to be localized, at
least not since the Middle

283
00:15:22,480 --> 00:15:25,170
Ages, where people did think
that memories were stored in

284
00:15:25,170 --> 00:15:26,360
the ventricles, because
after all they

285
00:15:26,360 --> 00:15:28,180
looked like store rooms.

286
00:15:28,180 --> 00:15:29,490
Anyway, the ventricles
get bigger.

287
00:15:29,490 --> 00:15:31,510
That's presumably not a good
thing because it's reflecting

288
00:15:31,510 --> 00:15:33,680
loss of brain tissue.

289
00:15:33,680 --> 00:15:37,980
What's not absolutely clear is
whether or not abnormalities

290
00:15:37,980 --> 00:15:42,300
in brain structure
precede disease.

291
00:15:42,300 --> 00:15:44,170
You know, are they there
somehow from birth?

292
00:15:44,170 --> 00:15:47,170
Is part of what the gene is
doing somehow changing the

293
00:15:47,170 --> 00:15:50,330
structure of the brain in such
a way that it makes it

294
00:15:50,330 --> 00:15:55,560
vulnerable, or is it that having
the disease itself is

295
00:15:55,560 --> 00:15:57,970
bad for the brain?

296
00:15:57,970 --> 00:16:04,540
In any case, the point to take
away here is there are lots of

297
00:16:04,540 --> 00:16:10,080
different routes into the
kingdom of schizophrenia.

298
00:16:10,080 --> 00:16:13,130
It's not a nice, clean simple
diagnosis where you say, you

299
00:16:13,130 --> 00:16:18,610
get this bacterium, you get this
disease, we give you this

300
00:16:18,610 --> 00:16:20,450
antibiotic, and you're OK.

301
00:16:20,450 --> 00:16:26,030
Multiple routes in and treatment
options are, you

302
00:16:26,030 --> 00:16:30,090
know, getting better but
remain difficult.

303
00:16:30,090 --> 00:16:30,920
Let's see here.

304
00:16:30,920 --> 00:16:31,430
Oh yes.

305
00:16:31,430 --> 00:16:36,390
What I think I will do is switch
gears and talk a bit

306
00:16:36,390 --> 00:16:38,550
about depression.

307
00:16:38,550 --> 00:16:42,510
But in order to talk about
depression, what I want you to

308
00:16:42,510 --> 00:16:47,510
do is to decide how you want
to treat my three invented

309
00:16:47,510 --> 00:16:50,430
patients on the handout.

310
00:16:50,430 --> 00:16:53,120
The third one is on the
back of the page.

311
00:16:53,120 --> 00:16:54,840
So play with that
for a second.

312
00:16:54,840 --> 00:16:58,570
Kristen, can you
do me a favor?

313
00:16:58,570 --> 00:16:59,850
Go find me a bottle of water.

314
00:16:59,850 --> 00:17:01,810
I'm going to expire
today otherwise.

315
00:17:01,810 --> 00:17:02,610
AUDIENCE: I have some.

316
00:17:02,610 --> 00:17:03,600
Do you want some?

317
00:17:03,600 --> 00:17:03,860
PROFESSOR: I don't know.

318
00:17:03,860 --> 00:17:04,750
Do you got any interesting
diseases?

319
00:17:04,750 --> 00:17:06,790
AUDIENCE: No.

320
00:17:06,790 --> 00:17:10,540
PROFESSOR: I don't want
to steal yours.

321
00:17:10,540 --> 00:17:11,790
Find me something somewhere.

322
00:17:11,790 --> 00:17:13,040
Thank you.

323
00:17:17,350 --> 00:17:21,183
I'm recovering from a cold
still, and I can feel that I'm

324
00:17:21,183 --> 00:17:24,720
going to run out of moisture.

325
00:17:24,720 --> 00:17:25,890
And my tongue is going
to get all big and

326
00:17:25,890 --> 00:17:26,900
like a parrot or something.

327
00:17:26,900 --> 00:17:28,040
I won't be able to talk.

328
00:17:28,040 --> 00:17:31,210
All right, have you managed
to do this?

329
00:17:31,210 --> 00:17:31,920
Still working on it.

330
00:17:31,920 --> 00:17:32,860
All right.

331
00:17:32,860 --> 00:17:34,330
Don't cheat off your
neighbors.

332
00:17:34,330 --> 00:17:38,350
But I promise you this time,
none of these guys are dealing

333
00:17:38,350 --> 00:17:39,600
in lady's undergarments.

334
00:17:42,570 --> 00:17:42,830
Here.

335
00:17:42,830 --> 00:17:44,150
Let's collect some.

336
00:17:51,030 --> 00:17:51,510
All right.

337
00:17:51,510 --> 00:17:57,230
Let's collect us some data.

338
00:18:03,990 --> 00:18:05,230
OK.

339
00:18:05,230 --> 00:18:09,080
Everybody pretty
much done here?

340
00:18:09,080 --> 00:18:12,630
Make assenting noises
or something.

341
00:18:12,630 --> 00:18:13,740
OK, that's good.

342
00:18:13,740 --> 00:18:15,510
That sounded very assenting.

343
00:18:15,510 --> 00:18:19,090
OK, so Sarah had a bad day.

344
00:18:19,090 --> 00:18:24,950
How many people would,
let's see, so that --

345
00:18:24,950 --> 00:18:28,050
slow numbers are the "no way,
we're not going to medicate

346
00:18:28,050 --> 00:18:31,610
this depression." How many
people -- oh, that was quick.

347
00:18:31,610 --> 00:18:32,460
That was good.

348
00:18:32,460 --> 00:18:34,110
Thank you.

349
00:18:34,110 --> 00:18:37,660
How many people are going
to give her no meds?

350
00:18:37,660 --> 00:18:38,510
Oh, OK.

351
00:18:38,510 --> 00:18:43,660
So the answer is everybody,
more or less.

352
00:18:43,660 --> 00:18:45,510
Don't worry if you said, I'll
give her a little bit of med.

353
00:18:45,510 --> 00:18:46,360
That's OK, too.

354
00:18:46,360 --> 00:18:49,560
But I won't bother
asking about it.

355
00:18:49,560 --> 00:18:51,800
These really are all the
same, by the way.

356
00:18:51,800 --> 00:18:53,370
There's no fifty-fifty split.

357
00:18:53,370 --> 00:18:55,870
This is just straight
up, normal.

358
00:18:55,870 --> 00:18:57,830
I'm not tricking
you this time.

359
00:18:57,830 --> 00:19:00,420
OK.

360
00:19:00,420 --> 00:19:04,520
And by contrast if we look at
Sam, Sam's depressed, no

361
00:19:04,520 --> 00:19:06,180
particular reason,
just happens.

362
00:19:06,180 --> 00:19:10,560
And he oscillates between manic
and depressed states.

363
00:19:10,560 --> 00:19:14,180
How many people think
no treatment

364
00:19:14,180 --> 00:19:18,190
or unlikely to medicate?

365
00:19:18,190 --> 00:19:20,730
How many moderately like, you
know, somewhere in the four to

366
00:19:20,730 --> 00:19:21,850
seven department?

367
00:19:21,850 --> 00:19:24,410
Well, a few people in there.

368
00:19:24,410 --> 00:19:27,280
And you have all embodied
the ethos of the

369
00:19:27,280 --> 00:19:29,760
yeah, yeah, OK, good.

370
00:19:29,760 --> 00:19:34,010
I mean, I don't know if it's
good or not, but it's clearly

371
00:19:34,010 --> 00:19:39,690
where medical science, I
suppose, is these days, which

372
00:19:39,690 --> 00:19:41,630
is that he would be
a candidate for an

373
00:19:41,630 --> 00:19:44,150
antidepressant in a way
that she wouldn't.

374
00:19:44,150 --> 00:19:45,330
Why not?

375
00:19:45,330 --> 00:19:47,720
Why wouldn't you give her
an antidepressant?

376
00:19:47,720 --> 00:19:48,970
She's depressed.

377
00:19:53,978 --> 00:19:56,955
AUDIENCE: It's normal for
her to be depressed.

378
00:19:56,955 --> 00:19:59,436
Like, anyone could be depressed
in that situation,

379
00:19:59,436 --> 00:20:02,910
but if you're depressed for
no reason, then that

380
00:20:02,910 --> 00:20:04,624
[UNINTELLIGIBLE]

381
00:20:04,624 --> 00:20:08,068
problem in the brain that could
be solved by medication,

382
00:20:08,068 --> 00:20:11,020
whereas with her thing, all that
needs to happen is the

383
00:20:11,020 --> 00:20:12,988
problem's [? cured. ?]

384
00:20:12,988 --> 00:20:16,250
PROFESSOR: There's a couple of
things that are worth picking

385
00:20:16,250 --> 00:20:17,310
up on here.

386
00:20:17,310 --> 00:20:23,110
One is, I mentioned last time
that the exact mapping between

387
00:20:23,110 --> 00:20:28,130
cause and treatment shouldn't
be seen as one to one.

388
00:20:28,130 --> 00:20:35,050
So even if we take as correct
for present purposes that

389
00:20:35,050 --> 00:20:38,120
Sam's got something biochemical
wrong with him, it

390
00:20:38,120 --> 00:20:40,520
wouldn't necessarily be the case
that the only way to deal

391
00:20:40,520 --> 00:20:45,160
with this would be by a
biochemical kind of treatment.

392
00:20:45,160 --> 00:20:47,490
There isn't that necessary
one-to-one mapping.

393
00:20:47,490 --> 00:20:50,410
But it's not an unreasonable
thought.

394
00:20:50,410 --> 00:20:53,060
And the other part of that
thought was, you know, she's

395
00:20:53,060 --> 00:20:55,290
depressed for a reason.

396
00:20:55,290 --> 00:21:02,100
And we don't want to shield
her necessarily from that

397
00:21:02,100 --> 00:21:02,900
depression.

398
00:21:02,900 --> 00:21:09,670
Though this gets raised
as an issue too now.

399
00:21:09,670 --> 00:21:12,390
I talked last time about
treatments for post-traumatic

400
00:21:12,390 --> 00:21:14,690
stress disorder.

401
00:21:14,690 --> 00:21:22,550
One of the notions is that you
could give people medications

402
00:21:22,550 --> 00:21:26,850
that would in a sense prevent
them from feeling as bad about

403
00:21:26,850 --> 00:21:32,740
something horrible as
they normally would.

404
00:21:32,740 --> 00:21:34,770
I mean, this is a real something
horrible now, you

405
00:21:34,770 --> 00:21:35,710
understand.

406
00:21:35,710 --> 00:21:37,750
But we're going to get you --

407
00:21:37,750 --> 00:21:39,340
something horrible has happened
-- we're going to

408
00:21:39,340 --> 00:21:43,670
give you a pill that is going
to decrease, we hope, the

409
00:21:43,670 --> 00:21:45,300
chance of you having a
post-traumatic stress

410
00:21:45,300 --> 00:21:48,360
disorder, but it's going to
do that by blunting your

411
00:21:48,360 --> 00:21:54,450
emotional response and your
memory for that event.

412
00:21:54,450 --> 00:21:57,700
Is that something that
we want to get into?

413
00:21:57,700 --> 00:22:04,090
Now, Sam I described
as having this --

414
00:22:04,090 --> 00:22:08,710
if this is now, oh,
I suppose, mood --

415
00:22:08,710 --> 00:22:12,270
Sam I described as having one
of these oscillatory or

416
00:22:12,270 --> 00:22:16,340
bipolar conditions where he
bounces back and forth between

417
00:22:16,340 --> 00:22:18,020
-- well, let's see,
which end is this?

418
00:22:18,020 --> 00:22:26,730
This can be the manic end
and the depressed end.

419
00:22:32,290 --> 00:22:36,090
You sometimes think that it
might kind of be worth it,

420
00:22:36,090 --> 00:22:39,570
right, because you have to put
up with the depression, but

421
00:22:39,570 --> 00:22:42,150
the manic energy thing
would be good.

422
00:22:42,150 --> 00:22:45,870
Well, the manic energy thing is
kind of good here, maybe.

423
00:22:45,870 --> 00:22:48,650
You know, you get all your
problem sets done in ten

424
00:22:48,650 --> 00:22:50,920
minutes or something.

425
00:22:50,920 --> 00:22:55,640
But by the time you get out
here, you are just as

426
00:22:55,640 --> 00:22:58,880
abnormal, if you like, or just
as crazy if we want to be

427
00:22:58,880 --> 00:23:04,590
colloquial about this, out here
as you are down here.

428
00:23:04,590 --> 00:23:08,450
And you can be pretty hard on
your friends and neighbors and

429
00:23:08,450 --> 00:23:11,140
yourself, in fact.

430
00:23:11,140 --> 00:23:11,860
I don't need --

431
00:23:11,860 --> 00:23:13,290
I mean, this is very
MIT, right --

432
00:23:13,290 --> 00:23:14,610
I don't need to sleep anymore.

433
00:23:14,610 --> 00:23:17,920
I can talk all night.

434
00:23:17,920 --> 00:23:18,730
You don't want to
listen to me?

435
00:23:18,730 --> 00:23:19,980
Well, I'll talk anyway.

436
00:23:22,900 --> 00:23:28,150
I remember reading a memoir
by the child of a manic

437
00:23:28,150 --> 00:23:32,940
depressive mother, who as
I recall comes home --

438
00:23:32,940 --> 00:23:35,500
the child comes home from school
one day, discovers mom

439
00:23:35,500 --> 00:23:38,840
has decided we're going to have
a great old-fashioned

440
00:23:38,840 --> 00:23:40,600
Christmas this year.

441
00:23:40,600 --> 00:23:41,760
So she went out and bought like

442
00:23:41,760 --> 00:23:44,060
thirty-five Christmas trees.

443
00:23:44,060 --> 00:23:47,240
And you walk into the living
room and it's just, you know,

444
00:23:47,240 --> 00:23:48,630
forest in there.

445
00:23:48,630 --> 00:23:51,270
She's stuffed the Christmas
trees all over the --

446
00:23:51,270 --> 00:23:53,850
and, you know, this is, I'm
sorry, I'm glad you're feeling

447
00:23:53,850 --> 00:23:58,340
really up, but this
is nuts too.

448
00:23:58,340 --> 00:23:59,590
It's not working.

449
00:24:05,960 --> 00:24:09,060
It's an interesting
observation.

450
00:24:09,060 --> 00:24:14,370
There are interesting data
suggesting that this sort of

451
00:24:14,370 --> 00:24:17,880
bipolar disorder, this
oscillation between deep

452
00:24:17,880 --> 00:24:23,150
depression and this wild
mania, that that's

453
00:24:23,150 --> 00:24:27,910
overrepresented in at least
some creative populations.

454
00:24:27,910 --> 00:24:31,700
The notable one is poets.

455
00:24:31,700 --> 00:24:34,740
It's notable because a woman
named -- what is

456
00:24:34,740 --> 00:24:36,170
her full name? --

457
00:24:36,170 --> 00:24:38,680
well, anyway, Jamison
is her last name.

458
00:24:41,790 --> 00:24:43,150
I think it's spelled
like this.

459
00:24:43,150 --> 00:24:46,060
Anyway, she wrote a book called
Touched by Fire where

460
00:24:46,060 --> 00:24:49,010
what she did was she went and
looked at the biographies of,

461
00:24:49,010 --> 00:24:53,460
in particular, sort of the run
of famous English poets.

462
00:24:53,460 --> 00:24:56,720
And over and over in their
biographies you get these

463
00:24:56,720 --> 00:24:58,800
descriptions that --

464
00:24:58,800 --> 00:25:01,890
you know, they didn't have the
diagnosis in 18th century

465
00:25:01,890 --> 00:25:03,780
England, but it sure
sounds like a

466
00:25:03,780 --> 00:25:05,570
manic depressive disorder.

467
00:25:05,570 --> 00:25:08,210
You know, Shelley or Keats or
somebody writes eight million

468
00:25:08,210 --> 00:25:13,170
poems and then lies in
bed for a month.

469
00:25:13,170 --> 00:25:14,640
It's that sort of thing.

470
00:25:14,640 --> 00:25:16,480
Now, great, you know.

471
00:25:16,480 --> 00:25:17,690
I can be a famous poet.

472
00:25:17,690 --> 00:25:18,980
All I have to do is
put up with this.

473
00:25:18,980 --> 00:25:20,390
The problem -- well, there
are a number of

474
00:25:20,390 --> 00:25:21,190
problems with this.

475
00:25:21,190 --> 00:25:24,090
First of all, you become a
little intolerable to your

476
00:25:24,090 --> 00:25:25,830
immediate surroundings.

477
00:25:25,830 --> 00:25:29,410
The other thing is that a very
serious consequence of deep

478
00:25:29,410 --> 00:25:33,410
depression is the threat
of suicide.

479
00:25:33,410 --> 00:25:38,080
Interestingly, you would think
that this was a continuum

480
00:25:38,080 --> 00:25:41,530
thing, right, that you go way,
way down here and if you get

481
00:25:41,530 --> 00:25:44,820
this far down into depression,
that's when

482
00:25:44,820 --> 00:25:46,240
people commit suicide.

483
00:25:46,240 --> 00:25:48,160
Turns out not to be the case.

484
00:25:48,160 --> 00:25:50,450
When people describe their
really deep --

485
00:25:50,450 --> 00:25:52,030
there's a huge genre here.

486
00:25:52,030 --> 00:25:54,540
It's a very popular genre
at the moment.

487
00:25:54,540 --> 00:25:59,100
If you're into depression,
your, you know, Christmas

488
00:25:59,100 --> 00:26:01,980
reading list can be all set out
because there's all sorts

489
00:26:01,980 --> 00:26:05,470
of people who are happy to
describe -- happy to describe

490
00:26:05,470 --> 00:26:06,140
their depression? --

491
00:26:06,140 --> 00:26:12,240
anyway, more than willing to
describe their depression in

492
00:26:12,240 --> 00:26:14,320
volumes thin or thick.

493
00:26:14,320 --> 00:26:15,860
Jamison actually has
a volume of her --

494
00:26:15,860 --> 00:26:18,190
she got interested in this
because she was a manic

495
00:26:18,190 --> 00:26:22,130
depressive and trained
in psychiatry.

496
00:26:22,130 --> 00:26:24,550
So she's coming at it from
every which way.

497
00:26:24,550 --> 00:26:27,610
Anyway, she has a memoir --

498
00:26:27,610 --> 00:26:29,440
I don't remember the
title of it --

499
00:26:29,440 --> 00:26:34,840
about her own depression that's
actually nice and slim.

500
00:26:34,840 --> 00:26:36,630
It's not a bad read.

501
00:26:36,630 --> 00:26:40,020
But what the descriptions sound
like is that when you're

502
00:26:40,020 --> 00:26:43,540
really, really deeply
depressed, you

503
00:26:43,540 --> 00:26:44,990
just don't do anything.

504
00:26:44,990 --> 00:26:48,860
You might in some sense want
to be dead, but that's just

505
00:26:48,860 --> 00:26:53,040
too much effort to do
anything about that.

506
00:26:53,040 --> 00:26:59,780
The danger for suicide in
bipolar disorders turns out to

507
00:26:59,780 --> 00:27:03,280
be -- well, let's get rid of
this -- turns out to be when

508
00:27:03,280 --> 00:27:06,350
you're on your way back out.

509
00:27:06,350 --> 00:27:12,280
Still depressed, but now you're
activated enough that

510
00:27:12,280 --> 00:27:14,600
you can do stuff, but you're
not convinced you're ever

511
00:27:14,600 --> 00:27:16,160
really going to get better.

512
00:27:16,160 --> 00:27:19,560
I mean, look, most of us have
not been really clinically

513
00:27:19,560 --> 00:27:24,570
depressed, but many of us can
tap into this, into this

514
00:27:24,570 --> 00:27:30,220
aspect in the sense of have you
had the flu or some, you

515
00:27:30,220 --> 00:27:33,570
know, relatively disgusting
disorder of some variety where

516
00:27:33,570 --> 00:27:37,640
you're sitting there thinking,
"I know rationally that I'm

517
00:27:37,640 --> 00:27:40,980
going to get better, but am I
really going to get better, or

518
00:27:40,980 --> 00:27:47,840
am I just going to be barfing
forever?" So you're coming on

519
00:27:47,840 --> 00:27:51,720
your way out, and that's where
the suicide risk is high.

520
00:27:51,720 --> 00:27:57,900
Now, that phenomenon may be
related to something that hit

521
00:27:57,900 --> 00:28:05,430
the news a lot this year,
which was concerns about

522
00:28:05,430 --> 00:28:10,030
giving antidepressants to
children and adolescents.

523
00:28:10,030 --> 00:28:12,710
Because there are data out
there that say that the

524
00:28:12,710 --> 00:28:17,660
suicide risk in depressed
adolescents taking

525
00:28:17,660 --> 00:28:19,520
antidepressants is elevated.

526
00:28:19,520 --> 00:28:21,530
Exactly what you don't want
to have happen, right?

527
00:28:21,530 --> 00:28:24,740
What you really want to not
have happen is people

528
00:28:24,740 --> 00:28:26,540
committing suicide when
they're depressed.

529
00:28:26,540 --> 00:28:28,440
What is the cause of this?

530
00:28:28,440 --> 00:28:30,520
Well, we don't actually
know, I don't think.

531
00:28:30,520 --> 00:28:31,870
At least I haven't seen
anything definitive.

532
00:28:31,870 --> 00:28:32,980
But there are a number --

533
00:28:32,980 --> 00:28:35,800
one theory is that
antidepressants work

534
00:28:35,800 --> 00:28:38,360
differently in young brains
than in older brains.

535
00:28:38,360 --> 00:28:39,690
That's one possibility.

536
00:28:39,690 --> 00:28:42,310
But the other possibility is
that what the antidepressant

537
00:28:42,310 --> 00:28:49,420
did was it moved the patient
along to a point where they

538
00:28:49,420 --> 00:28:51,400
weren't so paralyzed by
the depression that

539
00:28:51,400 --> 00:28:53,070
suicide became an option.

540
00:28:53,070 --> 00:28:55,680
It sounds weird and disturbing,
but that is one

541
00:28:55,680 --> 00:29:02,210
possibility for where this
elevated rate of suicide in

542
00:29:02,210 --> 00:29:07,820
antidepressant treated young
patients came from.

543
00:29:10,850 --> 00:29:13,060
Let's see, what else do
I want to say about

544
00:29:13,060 --> 00:29:20,090
Sam and Emma here?

545
00:29:20,090 --> 00:29:22,530
Oh, Emma's the one
on the back.

546
00:29:22,530 --> 00:29:24,850
All right, so how about Emma?

547
00:29:24,850 --> 00:29:30,140
We need to collect some
data on Emma.

548
00:29:30,140 --> 00:29:32,390
Did I describe Emma
as dysphoric?

549
00:29:32,390 --> 00:29:32,740
Yes.

550
00:29:32,740 --> 00:29:34,140
Emma is a dysphoric.

551
00:29:34,140 --> 00:29:36,460
That's the opposite
of euphoric.

552
00:29:36,460 --> 00:29:38,400
So it's not depressed.

553
00:29:38,400 --> 00:29:41,050
It would be sort of lying
around here somewhere.

554
00:29:41,050 --> 00:29:43,740
Just kind of flat.

555
00:29:43,740 --> 00:29:45,870
All right.

556
00:29:45,870 --> 00:29:55,500
So how many people voted that
we'll leave her be?

557
00:29:55,500 --> 00:29:55,850
OK.

558
00:29:55,850 --> 00:29:59,690
How many people voted maybe?

559
00:29:59,690 --> 00:30:02,850
And how many people
voted sure?

560
00:30:02,850 --> 00:30:05,750
Well, OK, we got a normal
curve out of that.

561
00:30:05,750 --> 00:30:07,040
Well, I could have gone --

562
00:30:07,040 --> 00:30:10,040
it looked sort of
like this to me.

563
00:30:14,520 --> 00:30:17,670
So people are sort of unsure
about -- oops.

564
00:30:17,670 --> 00:30:19,250
Well, I guess it's going
over there now.

565
00:30:19,250 --> 00:30:22,850
People are sort of
unsure about it.

566
00:30:22,850 --> 00:30:24,680
So what are the issues here?

567
00:30:24,680 --> 00:30:27,500
Why wouldn't you
give it to her?

568
00:30:27,500 --> 00:30:27,830
Yeah?

569
00:30:27,830 --> 00:30:29,510
AUDIENCE: If she doesn't
want it.

570
00:30:29,510 --> 00:30:30,080
PROFESSOR: Oh, yes, yes.

571
00:30:30,080 --> 00:30:30,930
Well, that's a separate issue.

572
00:30:30,930 --> 00:30:34,280
Did I say anything about it?

573
00:30:34,280 --> 00:30:36,850
No, no, no, this is just --
well, actually, we'll come

574
00:30:36,850 --> 00:30:37,330
back to that.

575
00:30:37,330 --> 00:30:39,310
That's an interesting problem.

576
00:30:39,310 --> 00:30:41,710
But yes, I was not suggesting
that we jam it down her

577
00:30:41,710 --> 00:30:46,340
throat, which is by the way not
the problem with Prozac.

578
00:30:50,260 --> 00:30:54,030
Let's imagine that the
antidepressant is Prozac here,

579
00:30:54,030 --> 00:30:57,170
or one of its newer friends.

580
00:30:57,170 --> 00:31:05,550
Prozac gets a lot of play
in the public sphere.

581
00:31:05,550 --> 00:31:06,090
Whoops.

582
00:31:06,090 --> 00:31:09,580
Well, I'll put a P there now.

583
00:31:09,580 --> 00:31:09,940
Uh oh.

584
00:31:09,940 --> 00:31:11,590
C or K?

585
00:31:11,590 --> 00:31:12,050
AUDIENCE: C.

586
00:31:12,050 --> 00:31:12,360
PROFESSOR: C. Yes.

587
00:31:12,360 --> 00:31:13,340
Thank you.

588
00:31:13,340 --> 00:31:14,020
OK.

589
00:31:14,020 --> 00:31:20,290
Prozac is a serotonin --

590
00:31:20,290 --> 00:31:21,540
that's a neurotransmitter --

591
00:31:24,570 --> 00:31:27,030
selective -- thank you, where
was that coming --

592
00:31:27,030 --> 00:31:27,720
AUDIENCE: It's first.

593
00:31:27,720 --> 00:31:29,350
PROFESSOR: Oh, it's a selective
serotonin, not

594
00:31:29,350 --> 00:31:30,290
serotonin selective.

595
00:31:30,290 --> 00:31:31,250
It's SS.

596
00:31:31,250 --> 00:31:33,000
All right.

597
00:31:33,000 --> 00:31:33,350
All right.

598
00:31:33,350 --> 00:31:40,860
It's a serotonin selective
-- reverse --

599
00:31:40,860 --> 00:31:42,420
uptake, reuptake --

600
00:31:42,420 --> 00:31:43,920
can I do reuptake?

601
00:31:43,920 --> 00:31:44,040
AUDIENCE: [INAUDIBLE]

602
00:31:44,040 --> 00:31:44,230
PROFESSOR: Yeah.

603
00:31:44,230 --> 00:31:44,930
Yeah.

604
00:31:44,930 --> 00:31:46,830
OK.

605
00:31:46,830 --> 00:31:54,430
Reuptake inhibitor.

606
00:31:58,710 --> 00:32:02,760
Or an SSRI, which makes it
understandable how I would

607
00:32:02,760 --> 00:32:05,210
have thought it might
have been an SSRI

608
00:32:05,210 --> 00:32:06,460
rather than an SSRI.

609
00:32:09,550 --> 00:32:14,580
But let me explain what this
is doing actually.

610
00:32:14,580 --> 00:32:18,890
So remember that in
schizophrenia, the first big

611
00:32:18,890 --> 00:32:21,030
psychopharmacological
breakthrough was the discovery

612
00:32:21,030 --> 00:32:22,970
there's too much dopamine
in bits of the brain.

613
00:32:22,970 --> 00:32:28,730
If we block some dopamine
receptors,

614
00:32:28,730 --> 00:32:30,310
we reduce the symptoms.

615
00:32:30,310 --> 00:32:35,070
In the case of at least some
forms of depression, the

616
00:32:35,070 --> 00:32:37,710
problem seems to be too
little serotonin --

617
00:32:37,710 --> 00:32:38,420
or a problem.

618
00:32:38,420 --> 00:32:40,530
Seems to be too little
serotonin in some

619
00:32:40,530 --> 00:32:42,380
parts of the brain.

620
00:32:42,380 --> 00:32:45,680
And so you've got a synapse.

621
00:32:50,540 --> 00:32:54,360
And serotonin is being released
here and binding to

622
00:32:54,360 --> 00:32:57,460
the other side.

623
00:32:57,460 --> 00:33:02,710
But now, in order to have this
synapse be reusable, once

624
00:33:02,710 --> 00:33:04,785
you've released some serotonin,
you've got

625
00:33:04,785 --> 00:33:05,530
to get rid of it.

626
00:33:05,530 --> 00:33:07,210
You've got to get it out of the
synapse so you can do it

627
00:33:07,210 --> 00:33:08,700
again and again and again.

628
00:33:08,700 --> 00:33:12,205
One of the techniques is to take
the molecules and suck

629
00:33:12,205 --> 00:33:18,410
them back into the originating
neuron.

630
00:33:18,410 --> 00:33:20,550
That's called reuptake.

631
00:33:20,550 --> 00:33:23,980
Now, if you don't have enough
serotonin here to do the job,

632
00:33:23,980 --> 00:33:28,110
one thing to do is to slow down
this reuptake so that the

633
00:33:28,110 --> 00:33:30,660
serotonin hangs around
here longer.

634
00:33:30,660 --> 00:33:36,330
And that way you get more bang
for your molecular buck.

635
00:33:36,330 --> 00:33:40,670
And so that's what
Prozac is doing.

636
00:33:40,670 --> 00:33:45,430
The reason I put Emma on here
is that Prozac seemed to do

637
00:33:45,430 --> 00:33:50,020
good things for dysphoric
patients, patients who did not

638
00:33:50,020 --> 00:33:55,120
meet a clinical criterion for
depression but who found --

639
00:33:57,670 --> 00:34:03,040
I think in part because the
drug manufacturer gave the

640
00:34:03,040 --> 00:34:05,810
docs piles of free Prozac.

641
00:34:05,810 --> 00:34:08,550
You know, patient comes through
and says, "I feel kind

642
00:34:08,550 --> 00:34:10,770
of down." So, "Oh yeah.

643
00:34:10,770 --> 00:34:11,260
Try this.

644
00:34:11,260 --> 00:34:14,150
This is new." You know,
"All right.

645
00:34:14,150 --> 00:34:14,460
Hey!

646
00:34:14,460 --> 00:34:16,290
I feel better.

647
00:34:16,290 --> 00:34:17,870
I feel a bunch better.

648
00:34:17,870 --> 00:34:22,050
I'm not clinically depressed,
but I really like this stuff.

649
00:34:24,840 --> 00:34:28,720
And not only that, if I go
off it, I go back to

650
00:34:28,720 --> 00:34:30,430
my dysphoric state.

651
00:34:30,430 --> 00:34:32,830
I go back to -- "

652
00:34:32,830 --> 00:34:35,220
The example says something to
the effect of, that's just the

653
00:34:35,220 --> 00:34:37,240
way she is.

654
00:34:37,240 --> 00:34:43,170
If she goes off Prozac, there
are lots of reports even in

655
00:34:43,170 --> 00:34:45,830
the popular literature of this,
of people who said, you

656
00:34:45,830 --> 00:34:48,030
know, if I'm off Prozac,
I'm just, ughh.

657
00:34:48,030 --> 00:34:52,120
But if I'm on Prozac, I'm
just a better me.

658
00:34:52,120 --> 00:34:54,290
Well, do you give
them the drug?

659
00:34:54,290 --> 00:34:55,380
Do you give them the drug?

660
00:34:55,380 --> 00:34:57,730
Do you allow them to continue
taking the drug for the rest

661
00:34:57,730 --> 00:35:00,690
of their natural born days,
particularly since we have no

662
00:35:00,690 --> 00:35:03,260
idea since it's a new drug
-- well, now it's

663
00:35:03,260 --> 00:35:04,120
over a decade old.

664
00:35:04,120 --> 00:35:05,880
But, you know, we don't know
what happens if you take this

665
00:35:05,880 --> 00:35:08,630
for twenty, thirty,
forty years.

666
00:35:08,630 --> 00:35:10,920
Who should pay for it?

667
00:35:10,920 --> 00:35:14,370
You know, if you think that
this drug makes you feel

668
00:35:14,370 --> 00:35:16,560
better, that's lovely.

669
00:35:16,560 --> 00:35:19,150
Should your insurance company
pay for it on

670
00:35:19,150 --> 00:35:24,160
a continuing basis?

671
00:35:24,160 --> 00:35:28,560
So those are the Emma
issues here.

672
00:35:28,560 --> 00:35:33,610
The issues about whether or not
it's OK to make somebody

673
00:35:33,610 --> 00:35:38,620
better than they, in some sense,
better than they were.

674
00:35:38,620 --> 00:35:41,860
Are you the same person?

675
00:35:41,860 --> 00:35:45,230
Is this, you know, is this the
real Emma, or is this some

676
00:35:45,230 --> 00:35:47,280
medicated Emma?

677
00:35:47,280 --> 00:35:52,990
And, well, all right, now let's
look back to the comment

678
00:35:52,990 --> 00:35:54,350
about forcing them.

679
00:35:54,350 --> 00:35:55,670
Well, you know what?

680
00:35:55,670 --> 00:35:59,220
It works on kids, too.

681
00:35:59,220 --> 00:36:06,580
And you know that there's a
fairly substantial industry in

682
00:36:06,580 --> 00:36:10,760
feeding psychiatric
drugs to kids for

683
00:36:10,760 --> 00:36:13,490
various and sundry problems.

684
00:36:13,490 --> 00:36:18,510
Suppose, well, we
know that shy --

685
00:36:18,510 --> 00:36:20,200
how did I describe
old Emma here?

686
00:36:20,200 --> 00:36:22,180
Is she shy and withdrawn?

687
00:36:22,180 --> 00:36:23,570
No, that was what's his
name collecting the

688
00:36:23,570 --> 00:36:25,130
underwear, wasn't it?

689
00:36:25,130 --> 00:36:26,580
Oh well.

690
00:36:30,850 --> 00:36:33,880
I could have described Emma
as shy and quiet.

691
00:36:33,880 --> 00:36:37,520
We know that the kid who's shy
and quiet in first grade

692
00:36:37,520 --> 00:36:41,140
doesn't get the same amount of
attention that the bouncy,

693
00:36:41,140 --> 00:36:43,000
active kid gets.

694
00:36:43,000 --> 00:36:49,310
And in fact, there's some
evidence that if you feed

695
00:36:49,310 --> 00:36:55,970
something like Prozac to this
kid, the kid will move from

696
00:36:55,970 --> 00:36:59,220
here in the -- well, we've got
to change the axis again.

697
00:36:59,220 --> 00:37:00,730
You know, I don't know,
what's the axis here?

698
00:37:00,730 --> 00:37:02,840
Bounciness?

699
00:37:02,840 --> 00:37:05,330
Technical term.

700
00:37:05,330 --> 00:37:05,660
You know.

701
00:37:05,660 --> 00:37:10,630
So the kid's going to move from
being unbouncy to, you

702
00:37:10,630 --> 00:37:12,310
know, Tigger is up
here somewhere.

703
00:37:17,850 --> 00:37:20,750
As are several -- couple
of people out there

704
00:37:20,750 --> 00:37:22,000
halfway up the --

705
00:37:24,750 --> 00:37:28,590
so there's Tigger, I guess.

706
00:37:28,590 --> 00:37:30,990
But, you know, move them
up here, let's say.

707
00:37:30,990 --> 00:37:33,030
Get them above average and the
teacher's going to pay more

708
00:37:33,030 --> 00:37:34,220
attention to them.

709
00:37:34,220 --> 00:37:35,740
Is it OK to medicate your kid?

710
00:37:35,740 --> 00:37:37,930
AUDIENCE: No.

711
00:37:37,930 --> 00:37:40,425
PROFESSOR: If it's -- all
right, it's not OK to

712
00:37:40,425 --> 00:37:40,760
medicate your kid.

713
00:37:40,760 --> 00:37:42,300
I'm not going to medicate
my kid.

714
00:37:42,300 --> 00:37:44,640
Uh oh.

715
00:37:44,640 --> 00:37:46,030
The neighbors.

716
00:37:46,030 --> 00:37:49,340
They're medicating their kids.

717
00:37:49,340 --> 00:37:51,890
So what they've done --
my kid was right here.

718
00:37:51,890 --> 00:37:54,840
He was average, right.

719
00:37:54,840 --> 00:37:57,850
All right, now what the
neighbors and the population

720
00:37:57,850 --> 00:38:00,300
as a whole has done is
they moved the whole

721
00:38:00,300 --> 00:38:01,260
distribution over.

722
00:38:01,260 --> 00:38:06,620
Because they're all handing out
Prozac in the lunch box.

723
00:38:06,620 --> 00:38:10,280
Now is it fair to my kid -- this
is a hypothetical my kid.

724
00:38:10,280 --> 00:38:11,960
This is not a real issue
on my street

725
00:38:11,960 --> 00:38:13,140
in case you're wondering.

726
00:38:13,140 --> 00:38:17,950
But is it fair to my kid
to not medicate him?

727
00:38:17,950 --> 00:38:20,610
He's going to fall behind.

728
00:38:20,610 --> 00:38:24,580
Is this systematically
different, you know, is this

729
00:38:24,580 --> 00:38:31,010
sort of morally or ethically
different than the Kaplan or

730
00:38:31,010 --> 00:38:34,230
Princeton Review approach
to SAT tests?

731
00:38:37,740 --> 00:38:40,310
What Princeton Review and stuff
does is it takes the

732
00:38:40,310 --> 00:38:43,540
population and it
shoves it on --

733
00:38:43,540 --> 00:38:46,790
everybody gets to gain those
hundred points or whatever.

734
00:38:46,790 --> 00:38:49,770
So is it OK for you
to say, "My kid

735
00:38:49,770 --> 00:38:50,960
doesn't need to do that.

736
00:38:50,960 --> 00:38:54,980
I didn't do that when I was a
kid, and no kid of mine's

737
00:38:54,980 --> 00:38:56,450
going to go off and
get tutored.

738
00:38:56,450 --> 00:38:58,120
He'll do it on his own brains.

739
00:38:58,120 --> 00:39:01,430
It's an aptitude test
after all." Right.

740
00:39:01,430 --> 00:39:04,570
You know, is there a difference
between everybody

741
00:39:04,570 --> 00:39:09,380
being signed up for Princeton
Review versus everybody being

742
00:39:09,380 --> 00:39:11,770
signed up, you know, going down
to the nurse's office for

743
00:39:11,770 --> 00:39:14,220
the daily Prozac dose?

744
00:39:14,220 --> 00:39:16,930
Or is there a difference between
just sitting there

745
00:39:16,930 --> 00:39:19,870
saying, "I'm not going to go and
make myself into a better

746
00:39:19,870 --> 00:39:26,250
me by popping Prozac
all the time.

747
00:39:26,250 --> 00:39:30,110
I'll stick with --" What
is that, Mountain Dew?

748
00:39:30,110 --> 00:39:34,050
You know, twice the caffeine
of whatever, right?

749
00:39:34,050 --> 00:39:35,890
AUDIENCE: Late night
last night.

750
00:39:35,890 --> 00:39:36,170
PROFESSOR: Yeah.

751
00:39:36,170 --> 00:39:37,710
OK, well, that's good.

752
00:39:37,710 --> 00:39:38,570
You're vertical.

753
00:39:38,570 --> 00:39:40,440
That's encouraging.

754
00:39:40,440 --> 00:39:41,720
Give some to the guy
next to you there.

755
00:39:41,720 --> 00:39:42,510
He's gone.

756
00:39:42,510 --> 00:39:45,320
[LAUGHTER FROM AUDIENCE]

757
00:39:45,320 --> 00:39:46,570
I shouldn't have said that.

758
00:39:49,820 --> 00:39:52,620
Anyway, we do this all
the time, right?

759
00:39:52,620 --> 00:39:55,480
We self-medicate.

760
00:39:55,480 --> 00:39:59,010
We self-medicate, particularly
with caffeine.

761
00:39:59,010 --> 00:40:01,760
But perhaps with a variety
of other things.

762
00:40:01,760 --> 00:40:04,920
The use of alcohol as an
antidepressant is probably a

763
00:40:04,920 --> 00:40:09,240
mistake, but is not uncommon.

764
00:40:09,240 --> 00:40:17,010
So when is this a sort of an
unwarranted medicalization of

765
00:40:17,010 --> 00:40:21,210
your life, and when is it, you
know, a lifestyle choice?

766
00:40:21,210 --> 00:40:24,360
And again, there's not going to
be a question on the final

767
00:40:24,360 --> 00:40:30,620
that says, "It's OK to drink
Mountain Dew: yes, no, only if

768
00:40:30,620 --> 00:40:38,470
it was a late night." But you
can see that there are issues

769
00:40:38,470 --> 00:40:39,110
to wrestle with.

770
00:40:39,110 --> 00:40:44,710
And the doctors ended up with
or have ended up with a

771
00:40:44,710 --> 00:40:48,180
serious problem, which is what
do you do with these patients

772
00:40:48,180 --> 00:40:52,190
who you cannot in good
conscience give a clinical

773
00:40:52,190 --> 00:40:57,610
diagnosis of clinical depression
to, but who say,

774
00:40:57,610 --> 00:41:00,590
you know, if you don't give me
my Prozac, I'm just going to

775
00:41:00,590 --> 00:41:04,950
be so depressed, who really need
that or who think that

776
00:41:04,950 --> 00:41:07,710
they really need that.

777
00:41:07,710 --> 00:41:12,510
Oh, by the way, OK,
what's this?

778
00:41:12,510 --> 00:41:15,030
Want to make sure that
I do what it says.

779
00:41:15,030 --> 00:41:15,360
Oh.

780
00:41:15,360 --> 00:41:15,560
Well, OK.

781
00:41:15,560 --> 00:41:19,260
Let's say something about how
antidepressants work.

782
00:41:24,690 --> 00:41:28,620
Here's a mystery for you.

783
00:41:28,620 --> 00:41:30,330
Take Prozac.

784
00:41:30,330 --> 00:41:36,450
It blocks the reuptake
pathway within hours.

785
00:41:36,450 --> 00:41:38,250
It doesn't take much
time at all.

786
00:41:38,250 --> 00:41:38,620
OK.

787
00:41:38,620 --> 00:41:44,090
So you are down here, clinically
depressed.

788
00:41:44,090 --> 00:41:45,740
You come into the
doctor's office.

789
00:41:45,740 --> 00:41:47,670
He says, here's your Prozac.

790
00:41:47,670 --> 00:41:48,980
You take the Prozac.

791
00:41:48,980 --> 00:41:51,980
A few hours later,
more serotonin

792
00:41:51,980 --> 00:41:53,070
at all those synapses.

793
00:41:53,070 --> 00:41:55,260
How do you feel?

794
00:41:55,260 --> 00:41:58,280
Well, you feel depressed,
actually.

795
00:41:58,280 --> 00:42:04,960
It takes typically at least
days, more like several weeks,

796
00:42:04,960 --> 00:42:10,260
before an antidepressant of
this sort has an effect,

797
00:42:10,260 --> 00:42:11,920
beyond perhaps placebo
effects.

798
00:42:11,920 --> 00:42:14,210
There are placebo effects where
you can take any old

799
00:42:14,210 --> 00:42:16,030
damn thing and you feel a
little better if you're

800
00:42:16,030 --> 00:42:17,140
convinced that it's
going to work.

801
00:42:17,140 --> 00:42:21,770
But the main effect of
antidepressants seems to take

802
00:42:21,770 --> 00:42:23,390
a long time.

803
00:42:23,390 --> 00:42:24,440
That's a mystery.

804
00:42:24,440 --> 00:42:27,900
At least as far as I know,
there's no neat, clean answer

805
00:42:27,900 --> 00:42:33,230
to why it should be the case
that the pharmacological

806
00:42:33,230 --> 00:42:37,560
effect is there instantly almost
and the psychological

807
00:42:37,560 --> 00:42:40,090
effect takes a vastly
longer time.

808
00:42:40,090 --> 00:42:43,360
The reference that I put on
the handout is a theory.

809
00:42:43,360 --> 00:42:44,270
It's not proven.

810
00:42:44,270 --> 00:42:48,240
But it's an interesting theory
about what might be going on.

811
00:42:48,240 --> 00:42:51,530
As I think I mentioned earlier
in the course, one of the

812
00:42:51,530 --> 00:42:55,520
interesting new findings in
neuroscience is that we grow

813
00:42:55,520 --> 00:42:56,370
new neurons.

814
00:42:56,370 --> 00:42:58,080
We didn't used to think
we grew new neurons.

815
00:42:58,080 --> 00:43:04,790
But now it's pretty clear that
you grow new neurons.

816
00:43:04,790 --> 00:43:08,960
And there's a pretty strong
suggestion that this

817
00:43:08,960 --> 00:43:13,450
neurogenesis, as it's called,
is depressed in depression.

818
00:43:13,450 --> 00:43:15,780
You're not making those
new neurons.

819
00:43:15,780 --> 00:43:21,630
And one theory is that what an
antidepressant is doing is

820
00:43:21,630 --> 00:43:24,310
jump-starting the neurogenesis,
that this is the

821
00:43:24,310 --> 00:43:28,030
beginning of a cascade of events
that leads eventually

822
00:43:28,030 --> 00:43:31,110
to the birth of new cells,
new neurons.

823
00:43:31,110 --> 00:43:33,750
And only when you manage to sort
of grow yourself a new

824
00:43:33,750 --> 00:43:40,810
bit of brain, in a sense, does
it help you to break out of

825
00:43:40,810 --> 00:43:44,240
the depression.

826
00:43:44,240 --> 00:43:46,560
The data on how well these
things work is a little

827
00:43:46,560 --> 00:43:47,960
depressing in its own right.

828
00:43:52,460 --> 00:43:54,890
Antidepressants, like
a lot of these --

829
00:43:54,890 --> 00:43:58,940
antidepressants don't work as
well once they go off patent.

830
00:43:58,940 --> 00:44:02,160
It's a mysterious thing.

831
00:44:02,160 --> 00:44:04,560
You want to worry about this.

832
00:44:04,560 --> 00:44:06,290
Over and over again
you get some cool

833
00:44:06,290 --> 00:44:07,710
new drug like Prozac.

834
00:44:07,710 --> 00:44:09,650
It's got no after effects.

835
00:44:09,650 --> 00:44:11,730
It cures the disease
like that.

836
00:44:11,730 --> 00:44:16,130
And everybody is better, and
it's a miracle drug.

837
00:44:16,130 --> 00:44:19,650
Amazingly, by the time, you
know, Eli Lilly or whoever's

838
00:44:19,650 --> 00:44:22,300
patent has worn off, it now has
side effects, doesn't work

839
00:44:22,300 --> 00:44:24,590
all that well, but you
want to try my new

840
00:44:24,590 --> 00:44:27,090
amazing wonder drug.

841
00:44:27,090 --> 00:44:30,900
So the last few reviews I've
read of the effectiveness of

842
00:44:30,900 --> 00:44:33,130
antidepressants have been, well,
they've been sort of

843
00:44:33,130 --> 00:44:38,580
depressing, actually, that
they're not magic bullets.

844
00:44:38,580 --> 00:44:41,970
Now, there are several ways
to treat depression.

845
00:44:41,970 --> 00:44:44,660
And how you treat
it depends --

846
00:44:44,660 --> 00:44:48,200
there are also several flavors
of depression.

847
00:44:48,200 --> 00:44:51,580
Not all depressions -- well,
certainly not all are bipolar.

848
00:44:51,580 --> 00:44:56,660
And there's evidence that they
differ both in their symptoms

849
00:44:56,660 --> 00:44:59,790
and in their neurochemistry.

850
00:44:59,790 --> 00:45:02,840
So for instance, say, I think
it says on the handout --

851
00:45:02,840 --> 00:45:05,150
yeah, typical versus atypical
depression.

852
00:45:05,150 --> 00:45:09,240
I'm sure if I rummaged around
I'd remember which was which.

853
00:45:09,240 --> 00:45:15,250
But in some forms of depression,
people sleep too

854
00:45:15,250 --> 00:45:17,290
much and eat too much.

855
00:45:17,290 --> 00:45:20,200
In other forms of depression,
they sleep too little and eat

856
00:45:20,200 --> 00:45:22,120
too little.

857
00:45:22,120 --> 00:45:27,590
They're both depressions in
terms of the mood, but they

858
00:45:27,590 --> 00:45:29,690
are clinically distinct and

859
00:45:29,690 --> 00:45:32,540
psychopharmacologically distinct.

860
00:45:32,540 --> 00:45:42,190
Actually, bipolar disorders,
the treatment of choice for

861
00:45:42,190 --> 00:45:45,480
long before Prozac came on the
scene was of all things

862
00:45:45,480 --> 00:45:46,600
lithium chloride.

863
00:45:46,600 --> 00:45:49,320
It's just the salt of lithium.

864
00:45:49,320 --> 00:45:51,580
You know, just move right
up from sodium chloride.

865
00:45:54,100 --> 00:45:58,580
Jamison credits lithium with
keeping her alive, that if she

866
00:45:58,580 --> 00:46:03,260
had not been put on lithium as
a treatment for her bipolar

867
00:46:03,260 --> 00:46:06,630
disorder, that she thinks she
probably would have ended up

868
00:46:06,630 --> 00:46:07,810
committing suicide.

869
00:46:07,810 --> 00:46:11,010
Anybody an expert on
how lithium works?

870
00:46:11,010 --> 00:46:11,270
No.

871
00:46:11,270 --> 00:46:13,090
I think I don't know
the answer to this.

872
00:46:13,090 --> 00:46:14,080
I'm not sure it's known.

873
00:46:14,080 --> 00:46:16,890
The last time I checked on it,
we didn't know how it worked.

874
00:46:16,890 --> 00:46:19,080
It was -- how was
it discovered?

875
00:46:19,080 --> 00:46:22,780
It was discovered in some
bizarro fashion.

876
00:46:22,780 --> 00:46:26,980
You know, where do
you find lithium?

877
00:46:26,980 --> 00:46:29,060
Like a salt --

878
00:46:29,060 --> 00:46:31,250
I'm remembering some odd story
about, you know --

879
00:46:31,250 --> 00:46:32,370
AUDIENCE: Batteries?

880
00:46:32,370 --> 00:46:32,820
PROFESSOR: Fine.

881
00:46:32,820 --> 00:46:34,220
Batteries?

882
00:46:34,220 --> 00:46:36,980
That people -- that's --

883
00:46:36,980 --> 00:46:38,410
AUDIENCE: 7 Up.

884
00:46:38,410 --> 00:46:39,520
PROFESSOR: 7 Up.

885
00:46:39,520 --> 00:46:43,420
OK, if you dissolve your battery
in 7 Up, I don't know

886
00:46:43,420 --> 00:46:45,240
what happens but I don't imagine
it's good because the

887
00:46:45,240 --> 00:46:46,720
mercury and the rest of
it probably isn't

888
00:46:46,720 --> 00:46:47,970
really good for you.

889
00:46:50,670 --> 00:46:53,710
The other treatment for --

890
00:46:53,710 --> 00:47:02,810
now, sadly not all depressions
are amenable to pharmacology.

891
00:47:02,810 --> 00:47:09,020
Oh, first of all, the big
mistake, which I think the

892
00:47:09,020 --> 00:47:13,970
insurance people are growing
out of, was the notion, OK,

893
00:47:13,970 --> 00:47:17,150
now that we've got these cool
pills, we'll pay for the

894
00:47:17,150 --> 00:47:19,390
pills, but that's it.

895
00:47:19,390 --> 00:47:26,040
So if it's going to take you
several weeks for the medicine

896
00:47:26,040 --> 00:47:29,530
to work, it turns out to be
very helpful if you're

897
00:47:29,530 --> 00:47:32,750
actually talking to somebody
during this time, if there's

898
00:47:32,750 --> 00:47:36,160
some psychotherapy of
some sort going on.

899
00:47:36,160 --> 00:47:38,555
Because if you are down here
in the depths of the

900
00:47:38,555 --> 00:47:40,720
depression and some genius
hands you a pill

901
00:47:40,720 --> 00:47:41,550
and says, "Go away.

902
00:47:41,550 --> 00:47:45,320
Don't bother me no more." You
know, if it's true that as

903
00:47:45,320 --> 00:47:47,720
you're slowly coming out of the
depression, that's when

904
00:47:47,720 --> 00:47:49,860
the suicides take place,
you know, this is

905
00:47:49,860 --> 00:47:51,570
a recipe for disaster.

906
00:47:51,570 --> 00:47:54,335
And if it takes a long time to
work -- you know, if you take

907
00:47:54,335 --> 00:47:57,340
a medicine and nothing happens
for weeks, what do you do?

908
00:47:57,340 --> 00:47:59,710
You stop taking the medicine.

909
00:47:59,710 --> 00:48:04,480
And so what you really need
typically as part of a

910
00:48:04,480 --> 00:48:07,480
sensible treatment for a
depression is not only

911
00:48:07,480 --> 00:48:09,255
somebody who will give you the
medicine, but somebody who

912
00:48:09,255 --> 00:48:11,670
will talk to you about it too.

913
00:48:11,670 --> 00:48:14,570
But even so there are
depressions that are not

914
00:48:14,570 --> 00:48:15,760
amenable --

915
00:48:15,760 --> 00:48:18,730
or don't seem to respond well
to any of the medicines that

916
00:48:18,730 --> 00:48:20,070
we have at the moment.

917
00:48:20,070 --> 00:48:24,870
And under the heading of even
more unlikely treatments that

918
00:48:24,870 --> 00:48:29,650
really turn out to work, more
unlikely than feeding them

919
00:48:29,650 --> 00:48:33,290
lithium salts, is what's
known as ECT for

920
00:48:33,290 --> 00:48:35,660
electroconvulsive therapy.

921
00:48:35,660 --> 00:48:38,330
I talked about this a bit when
we were talking about memory.

922
00:48:38,330 --> 00:48:40,240
Remember this is little rats.

923
00:48:40,240 --> 00:48:41,330
They step down.

924
00:48:41,330 --> 00:48:44,050
You run electrical current
through their heads.

925
00:48:44,050 --> 00:48:45,730
You shock their little feet.

926
00:48:45,730 --> 00:48:47,330
You run electrical current
through their brains.

927
00:48:47,330 --> 00:48:48,940
They don't remember that you
shocked their feet, so they

928
00:48:48,940 --> 00:48:50,270
step down again, you know.

929
00:48:50,270 --> 00:48:51,950
Sound familiar?

930
00:48:51,950 --> 00:48:54,260
OK, good.

931
00:48:54,260 --> 00:48:57,930
Well, this is a treatment
for depression.

932
00:48:57,930 --> 00:49:04,900
Not abundantly clear why it
works, but in my circle of

933
00:49:04,900 --> 00:49:11,120
friends, I have a friend who
actually went back to --

934
00:49:11,120 --> 00:49:13,870
graduated college, went off,
did a whole bunch of stuff,

935
00:49:13,870 --> 00:49:18,120
then went back to med school,
then became desperately

936
00:49:18,120 --> 00:49:23,420
clinically depressed and
had to be hospitalized.

937
00:49:23,420 --> 00:49:29,720
And what got her through it was
electroconvulsive therapy.

938
00:49:29,720 --> 00:49:33,550
Not an entirely benign
procedure.

939
00:49:33,550 --> 00:49:36,440
It does have memory
side effects.

940
00:49:36,440 --> 00:49:39,210
But it used to be that nobody
in an intro psych class

941
00:49:39,210 --> 00:49:41,270
thought this was a good idea at
all because everybody had

942
00:49:41,270 --> 00:49:43,370
seen One Flew Over the
Cuckoo's Nest.

943
00:49:43,370 --> 00:49:45,350
How many people have
seen that movie?

944
00:49:45,350 --> 00:49:47,540
Oh, so still a fair number
people have seen it.

945
00:49:47,540 --> 00:49:49,230
That's a movie that does
nothing good for the

946
00:49:49,230 --> 00:49:51,680
reputation of electroconvulsive
therapy.

947
00:49:51,680 --> 00:49:55,760
Electroconvulsive therapy these
days is, you know, you

948
00:49:55,760 --> 00:49:56,890
give somebody a sedative.

949
00:49:56,890 --> 00:49:58,110
They don't thrash around.

950
00:49:58,110 --> 00:49:59,240
They don't hurt themselves.

951
00:49:59,240 --> 00:50:02,550
It still has memory
consequences, consolidation of

952
00:50:02,550 --> 00:50:04,760
memory consequences, but
it really does seem to

953
00:50:04,760 --> 00:50:09,730
mysteriously break
up depressions.

954
00:50:09,730 --> 00:50:14,760
Now the latest wrinkle on this,
you know, what boils

955
00:50:14,760 --> 00:50:17,420
down to smack-them-up-th
e-side-of-the-head treatments

956
00:50:17,420 --> 00:50:21,920
of depression is the use of,
very new, is the use of

957
00:50:21,920 --> 00:50:25,290
transcranial magnetic
stimulation, which I think I

958
00:50:25,290 --> 00:50:26,560
also talked about earlier.

959
00:50:26,560 --> 00:50:29,410
But basically what you do is you
put a giant electromagnet

960
00:50:29,410 --> 00:50:32,790
or strong electromagnet
next to the skull.

961
00:50:32,790 --> 00:50:35,400
You fire a big pulse of --

962
00:50:35,400 --> 00:50:39,390
a big magnetic field that
induces an electrical field

963
00:50:39,390 --> 00:50:47,130
locally and knocks out neural
activity locally.

964
00:50:47,130 --> 00:50:50,940
And there's some evidence that
properly applied, that this is

965
00:50:50,940 --> 00:50:56,140
a sort of a kinder, gentler
version of ECT, that it acts

966
00:50:56,140 --> 00:50:57,750
to break up depressions.

967
00:50:57,750 --> 00:50:59,840
I don't -- anybody know if
there's a brilliant theory for

968
00:50:59,840 --> 00:51:01,000
how that works?

969
00:51:01,000 --> 00:51:02,440
Uh, who knows?

970
00:51:02,440 --> 00:51:06,230
But it's very new.

971
00:51:06,230 --> 00:51:10,450
But I expect that in a few
years, I'll be lecturing more

972
00:51:10,450 --> 00:51:11,020
about that.

973
00:51:11,020 --> 00:51:15,280
Because it, at least initially,

974
00:51:15,280 --> 00:51:18,350
sounds rather promising.

975
00:51:18,350 --> 00:51:18,960
All right.

976
00:51:18,960 --> 00:51:26,560
I think this would be a good
time to take a break.

977
00:51:26,560 --> 00:51:28,600
Let's take --

978
00:51:28,600 --> 00:51:31,820
unless you're too depressed
to get up, take a break.

979
00:51:42,870 --> 00:51:47,400
AUDIENCE: I read
Jamison's book.

980
00:51:47,400 --> 00:51:47,590
PROFESSOR: Uh huh.

981
00:51:47,590 --> 00:51:48,110
Which one?

982
00:51:48,110 --> 00:51:49,590
AUDIENCE: Prozac Nation.

983
00:51:49,590 --> 00:51:50,440
PROFESSOR: No.

984
00:51:50,440 --> 00:51:51,830
Prozac Nation is somebody
else's book.

985
00:51:51,830 --> 00:51:52,650
AUDIENCE: Not Jamison?

986
00:51:52,650 --> 00:51:53,660
PROFESSOR: No, that's
somebody else.

987
00:51:53,660 --> 00:51:56,010
I can't remember who wrote
it, but yes, that's

988
00:51:56,010 --> 00:51:57,230
a cool book, too.

989
00:51:57,230 --> 00:51:57,470
AUDIENCE: Yes.

990
00:51:57,470 --> 00:51:58,910
That's what I thought you
were talking about.

991
00:51:58,910 --> 00:51:59,320
PROFESSOR: Nope.

992
00:51:59,320 --> 00:52:00,040
Nope.

993
00:52:00,040 --> 00:52:02,790
But you'll come back and
tell me who wrote it.

994
00:52:02,790 --> 00:52:05,070
Because we're both forgetting
who wrote it.

995
00:52:05,070 --> 00:52:08,020
AUDIENCE: Have they ever done,
what is it, using sugar pill

996
00:52:08,020 --> 00:52:10,982
and Prozac and hand them out to
patients and just seeing if

997
00:52:10,982 --> 00:52:11,640
the sugar pill --

998
00:52:11,640 --> 00:52:16,360
PROFESSOR: It's a big problem
in mental illness in general

999
00:52:16,360 --> 00:52:19,550
and certainly in depression,
which is, particularly if

1000
00:52:19,550 --> 00:52:21,300
you've got a cycling
depression, who's

1001
00:52:21,300 --> 00:52:22,590
going to get better?

1002
00:52:22,590 --> 00:52:22,910
Right?

1003
00:52:22,910 --> 00:52:29,920
And, yeah, the difference
between placebos and Prozac

1004
00:52:29,920 --> 00:52:32,970
is, at least in some of the
studies that I've read, a lot

1005
00:52:32,970 --> 00:52:36,000
less dramatic than
you would think.

1006
00:52:36,000 --> 00:52:41,480
And the problem with a
population like us is that

1007
00:52:41,480 --> 00:52:44,640
we're too well informed.

1008
00:52:44,640 --> 00:52:45,920
Placebos are great.

1009
00:52:45,920 --> 00:52:48,530
The side effects are
really limited.

1010
00:52:48,530 --> 00:52:51,170
In the good old days, your
doctor would come around, have

1011
00:52:51,170 --> 00:52:55,620
no clue, you know, how to treat
you, but give you, you

1012
00:52:55,620 --> 00:53:01,180
know, Dr. Hoozy's magic elixir,
and you'd feel better.

1013
00:53:01,180 --> 00:53:04,450
And it's a great pity that now
if I fed you Dr. Hoozy's

1014
00:53:04,450 --> 00:53:07,220
elixir, the first thing you'd
do is Google it and discover

1015
00:53:07,220 --> 00:53:10,430
that it's snake oil, and
feel worse and sue me.

1016
00:53:10,430 --> 00:53:16,840
So, yeah, if you turn out to
be particularly interested,

1017
00:53:16,840 --> 00:53:19,590
send me an email and I can
send you a couple of the

1018
00:53:19,590 --> 00:53:22,620
references of things that
depressed me when I read them.

1019
00:53:22,620 --> 00:53:25,310
Because they weren't
that much good.

1020
00:53:25,310 --> 00:53:28,290
On the other hand, my
mother absolutely

1021
00:53:28,290 --> 00:53:31,350
swears by this stuff.

1022
00:53:31,350 --> 00:53:35,010
She's had her own issues with
depression and thinks that

1023
00:53:35,010 --> 00:53:35,917
Prozac is wonderful.

1024
00:53:35,917 --> 00:55:33,790
[PRIVATE CONVERSATION]

1025
00:55:33,790 --> 00:55:37,190
PROFESSOR: I want to talk
about a couple of other

1026
00:55:37,190 --> 00:55:42,840
disease, you know, mental
illness states, in part as a

1027
00:55:42,840 --> 00:55:47,580
way of illustrating --

1028
00:55:47,580 --> 00:55:50,240
I guess what I really want to
illustrate in the last bit of

1029
00:55:50,240 --> 00:55:55,800
this lecture is the, sort of,
mind and brain links.

1030
00:55:55,800 --> 00:55:59,220
We tend to like to make
up theories that

1031
00:55:59,220 --> 00:56:00,570
are one or the other.

1032
00:56:00,570 --> 00:56:04,540
And the current popular trend is
towards brain explanations.

1033
00:56:04,540 --> 00:56:08,650
Oh, you're depressed because
you don't have enough

1034
00:56:08,650 --> 00:56:10,810
serotonin happening for you.

1035
00:56:10,810 --> 00:56:11,970
We'll boost up your serotonin.

1036
00:56:11,970 --> 00:56:12,580
You'll be fine.

1037
00:56:12,580 --> 00:56:14,550
It's a very brain
kind of thing.

1038
00:56:14,550 --> 00:56:17,280
Freudian theories were very
mind kinds of things.

1039
00:56:17,280 --> 00:56:22,430
But there's a number of cases
that really illustrate, I

1040
00:56:22,430 --> 00:56:28,260
think, well, what you sort of
know intuitively, right?

1041
00:56:28,260 --> 00:56:31,670
The brain isn't here and
the mind is here.

1042
00:56:31,670 --> 00:56:33,340
It's, you know, waves
and particles.

1043
00:56:33,340 --> 00:56:36,470
They're two manifestations
of the same thing.

1044
00:56:36,470 --> 00:56:40,200
And brain stuff and mind stuff
bounce back and forth

1045
00:56:40,200 --> 00:56:41,150
here all the time.

1046
00:56:41,150 --> 00:56:46,710
So let's think, for example,
of panic attacks.

1047
00:56:46,710 --> 00:56:49,980
Which I didn't put on the
handout at all, I see, but I

1048
00:56:49,980 --> 00:56:52,750
suddenly developed a need to
talk about because I was

1049
00:56:52,750 --> 00:56:56,000
feeling really anxious and --

1050
00:56:56,000 --> 00:56:58,310
no.

1051
00:56:58,310 --> 00:57:01,850
So panic attack is
this feeling of

1052
00:57:01,850 --> 00:57:04,780
anxiety out of the blue.

1053
00:57:08,310 --> 00:57:11,180
People report that they just
suddenly feel very, very, very

1054
00:57:11,180 --> 00:57:13,710
fearful and anxious.

1055
00:57:13,710 --> 00:57:17,820
And it's scary and it's
unpleasant and so on.

1056
00:57:17,820 --> 00:57:21,700
You may recall that Freud and
his followers had a perfectly

1057
00:57:21,700 --> 00:57:25,030
nice notion about this, which
was that anxiety was warning

1058
00:57:25,030 --> 00:57:30,540
you that you were about to
tread on the super ego.

1059
00:57:30,540 --> 00:57:34,430
And it was the warning sign of
the ego that was saying, don't

1060
00:57:34,430 --> 00:57:35,170
go and do that.

1061
00:57:35,170 --> 00:57:39,060
But that hasn't worked
that well.

1062
00:57:39,060 --> 00:57:44,660
More modern notions tend to
focus on the idea that it's

1063
00:57:44,660 --> 00:57:46,130
essentially neurochemical.

1064
00:57:49,530 --> 00:57:54,930
You get too much of some juice,
some neurotransmitter.

1065
00:57:54,930 --> 00:57:57,920
It fires off the bits of your
brain that are responsible for

1066
00:57:57,920 --> 00:57:59,300
the experience of anxiety.

1067
00:57:59,300 --> 00:58:02,270
And you feel this anxiety.

1068
00:58:02,270 --> 00:58:09,020
And this is a lovely case of
looping back to a prior mode

1069
00:58:09,020 --> 00:58:10,540
of understanding.

1070
00:58:10,540 --> 00:58:13,560
The notion that you feel too
anxious because you have too

1071
00:58:13,560 --> 00:58:16,870
much of this fluid, it's an
awful lot like the notion that

1072
00:58:16,870 --> 00:58:20,230
you feel melancholic because you
have too much black bile.

1073
00:58:20,230 --> 00:58:22,140
The difference of course is
that we think we've got a

1074
00:58:22,140 --> 00:58:23,940
better scientific grounding
than we had.

1075
00:58:23,940 --> 00:58:29,710
But the form of the argument
is rather similar.

1076
00:58:29,710 --> 00:58:33,610
So is it the case that panic
attacks, the clinical

1077
00:58:33,610 --> 00:58:37,580
condition of a panic
attack, is just too

1078
00:58:37,580 --> 00:58:39,050
much of some juice.

1079
00:58:39,050 --> 00:58:43,170
It's possible to think about
it as being somewhat more

1080
00:58:43,170 --> 00:58:45,020
complicated than that.

1081
00:58:45,020 --> 00:58:47,610
And, well, I didn't put that
reference on the handout,

1082
00:58:47,610 --> 00:58:48,610
because I didn't.

1083
00:58:48,610 --> 00:58:52,800
But I'm stealing
a story from --

1084
00:58:52,800 --> 00:58:54,810
who am I stealing it from?

1085
00:58:54,810 --> 00:59:00,130
Oh, Dave Barlow, who's
over at BU.

1086
00:59:00,130 --> 00:59:05,730
This is a three-step route
into panic attack.

1087
00:59:05,730 --> 00:59:12,020
And the first part of it is
that you feel the visible

1088
00:59:12,020 --> 00:59:15,640
symptoms of anxiety.

1089
00:59:15,640 --> 00:59:17,890
Your heart starts --

1090
00:59:17,890 --> 00:59:22,580
remember the shaky bridge
experiment all about

1091
00:59:22,580 --> 00:59:25,590
misattribution of arousal?

1092
00:59:25,590 --> 00:59:28,850
You're feeling "ooh-ooh-ooh" and
you see her, and you just

1093
00:59:28,850 --> 00:59:31,480
think you're feeling
"aah." Right?

1094
00:59:31,480 --> 00:59:34,210
So that can work in
all sorts of ways.

1095
00:59:34,210 --> 00:59:38,100
Suppose that your heart is going
through -- there are a

1096
00:59:38,100 --> 00:59:41,450
variety of things that cause
your heart to go pitter-pat.

1097
00:59:41,450 --> 00:59:46,000
Suppose that you get these sort
of symptoms and you don't

1098
00:59:46,000 --> 00:59:50,120
interpret it as love, you
interpret it as "I feel

1099
00:59:50,120 --> 00:59:52,550
nervous about something.

1100
00:59:52,550 --> 00:59:55,840
I can't quite tell exactly
what it is.

1101
00:59:55,840 --> 00:59:56,420
But I don't --"

1102
00:59:56,420 --> 00:59:58,810
People don't have panic
attacks, by the way,

1103
00:59:58,810 --> 01:00:02,350
typically, when they're
exercising vigorously.

1104
01:00:02,350 --> 01:00:04,910
Because they've got a good
account of where that symptom

1105
01:00:04,910 --> 01:00:05,770
is coming from.

1106
01:00:05,770 --> 01:00:08,090
Your heart's pounding, you're
sweating, and stuff like that.

1107
01:00:08,090 --> 01:00:09,350
Yeah, all right, fine.

1108
01:00:09,350 --> 01:00:11,440
If you're walking down the
street and your heart is

1109
01:00:11,440 --> 01:00:15,170
pounding and you're sweating,
you need a different

1110
01:00:15,170 --> 01:00:16,550
interpretation.

1111
01:00:16,550 --> 01:00:19,450
Now, this is unpleasant.

1112
01:00:19,450 --> 01:00:23,540
So you develop, flipping back
to an earlier piece of the

1113
01:00:23,540 --> 01:00:25,420
course, you develop
a conditioned

1114
01:00:25,420 --> 01:00:29,160
fear of these symptoms.

1115
01:00:29,160 --> 01:00:38,670
So you start avoiding situations
that would produce

1116
01:00:38,670 --> 01:00:40,910
the symptoms, or that
you think might

1117
01:00:40,910 --> 01:00:43,390
produce these symptoms.

1118
01:00:43,390 --> 01:00:46,040
And this can be quite
unconscious, right?

1119
01:00:46,040 --> 01:00:49,850
This is good classical
association learning or

1120
01:00:49,850 --> 01:00:52,350
something of that sort.

1121
01:00:52,350 --> 01:00:55,850
And that in turn -- that's sort
of step two, is sort of a

1122
01:00:55,850 --> 01:01:04,350
learning story that is going
to cause you to start --

1123
01:01:04,350 --> 01:01:07,170
you're going to act to
avoid situations that

1124
01:01:07,170 --> 01:01:10,750
make you feel nervous.

1125
01:01:10,750 --> 01:01:15,030
But, all right, remember
Pavlov?

1126
01:01:15,030 --> 01:01:16,370
Bell, tone.

1127
01:01:16,370 --> 01:01:17,290
Bell, tone.

1128
01:01:17,290 --> 01:01:18,440
Bell, tone.

1129
01:01:18,440 --> 01:01:19,940
Now I ring the bell by itself.

1130
01:01:19,940 --> 01:01:20,170
No.

1131
01:01:20,170 --> 01:01:20,750
Bell, tone.

1132
01:01:20,750 --> 01:01:23,950
That's stupid.

1133
01:01:23,950 --> 01:01:26,450
I'm not supposed to be the one
who notices that first, guys.

1134
01:01:26,450 --> 01:01:28,400
You're supposed to -- "What's
he talking about?" Anyway,

1135
01:01:28,400 --> 01:01:28,990
bell, food.

1136
01:01:28,990 --> 01:01:29,840
Bell, food.

1137
01:01:29,840 --> 01:01:30,290
Bell, food.

1138
01:01:30,290 --> 01:01:32,910
Eventually the bell by itself
produces salivation.

1139
01:01:32,910 --> 01:01:37,200
So you make this association
in your own mind.

1140
01:01:37,200 --> 01:01:40,980
So when did this happen to me?

1141
01:01:40,980 --> 01:01:42,880
I was outside.

1142
01:01:42,880 --> 01:01:43,630
OK.

1143
01:01:43,630 --> 01:01:47,500
So now I'm outside, it
doesn't happen to me.

1144
01:01:47,500 --> 01:01:48,950
But I feel --

1145
01:01:48,950 --> 01:01:51,770
I get the conditioned
response in effect.

1146
01:01:51,770 --> 01:01:55,140
So now something else acts as
a trigger for the panic.

1147
01:01:55,140 --> 01:01:59,010
The initial feeling of panic
might have been, I don't know,

1148
01:01:59,010 --> 01:02:03,870
too many bottles of Mountain
Dew, right.

1149
01:02:03,870 --> 01:02:06,300
You drink enough caffeine,
and you'll get b-b-b-b.

1150
01:02:06,300 --> 01:02:07,920
Forget that you drank --

1151
01:02:07,920 --> 01:02:08,920
your brain doesn't remember the

1152
01:02:08,920 --> 01:02:10,600
caffeine part of the story.

1153
01:02:10,600 --> 01:02:11,720
And you're going b-b-b-b.

1154
01:02:11,720 --> 01:02:12,700
And you say, "Oh!

1155
01:02:12,700 --> 01:02:17,740
I'm having a panic attack." Then
you don't want that --

1156
01:02:17,740 --> 01:02:20,040
this is an aversive event.

1157
01:02:20,040 --> 01:02:23,480
It's just like the business of
the rat stepping down, right?

1158
01:02:23,480 --> 01:02:25,920
The rat steps down --

1159
01:02:25,920 --> 01:02:27,290
oh, all right.

1160
01:02:27,290 --> 01:02:31,870
Rat's up here, rat steps down,
gets his little feet shocked.

1161
01:02:31,870 --> 01:02:32,940
That's unpleasant.

1162
01:02:32,940 --> 01:02:34,230
Rat's put back up here.

1163
01:02:34,230 --> 01:02:35,650
Does the rat step down again?

1164
01:02:35,650 --> 01:02:36,200
No.

1165
01:02:36,200 --> 01:02:36,900
Why?

1166
01:02:36,900 --> 01:02:38,920
Because he's got this
anticipatory fear.

1167
01:02:38,920 --> 01:02:41,650
You can actually measure the
fear physiologically.

1168
01:02:41,650 --> 01:02:45,170
All right, so you caffeine
overdose or whatever.

1169
01:02:45,170 --> 01:02:47,170
You have this unpleasant
experience.

1170
01:02:47,170 --> 01:02:50,990
Now you're in that environment
again sometime later and you

1171
01:02:50,990 --> 01:02:53,200
have the experience again
because it's a conditioned

1172
01:02:53,200 --> 01:02:56,780
response now, no caffeine
involved.

1173
01:02:56,780 --> 01:03:00,110
You come to the reasonable,
if perhaps unconscious,

1174
01:03:00,110 --> 01:03:06,590
conclusion that what makes me
nervous is being outside in

1175
01:03:06,590 --> 01:03:10,750
public or being on shaky
bridges or whatever.

1176
01:03:10,750 --> 01:03:13,500
Then you get step three, which
is again learning theory kind

1177
01:03:13,500 --> 01:03:15,660
of stuff like Thorndike's
Law of Effect.

1178
01:03:15,660 --> 01:03:22,900
You start doing things to avoid
this punishment, right.

1179
01:03:22,900 --> 01:03:25,180
You're going to avoid the
aversive stimulus.

1180
01:03:25,180 --> 01:03:29,940
So you can get secondary
symptoms to the panic, like a

1181
01:03:29,940 --> 01:03:35,900
fear of open spaces, let's
say, because you've now,

1182
01:03:35,900 --> 01:03:38,960
perhaps completely
unconsciously, concluded, "If

1183
01:03:38,960 --> 01:03:41,490
I go out in public,
the sky is so big.

1184
01:03:41,490 --> 01:03:42,500
I feel so small.

1185
01:03:42,500 --> 01:03:44,180
I get panicky.

1186
01:03:44,180 --> 01:03:46,000
And so now I'm not going
to go outside."

1187
01:03:46,000 --> 01:03:50,260
And so what you end up with is
the possibility that the

1188
01:03:50,260 --> 01:03:53,770
clinical thing that you see,
what you get in your office if

1189
01:03:53,770 --> 01:03:57,010
you're the clinician, is
somebody who says, "I have,

1190
01:03:57,010 --> 01:03:58,980
you know, I have uncontrollable

1191
01:03:58,980 --> 01:04:00,980
panic when I'm outdoors.

1192
01:04:00,980 --> 01:04:03,060
This is crippling my life
because I don't go out

1193
01:04:03,060 --> 01:04:07,550
anymore." And what this may be
is a cascade of events coming

1194
01:04:07,550 --> 01:04:11,250
from some sort of an initial
physiological issue that you

1195
01:04:11,250 --> 01:04:15,820
then learned about, if you like,
using the laws of animal

1196
01:04:15,820 --> 01:04:20,160
learning, in ways that
that don't work well.

1197
01:04:20,160 --> 01:04:22,190
Well, what are you going
to do about it?

1198
01:04:22,190 --> 01:04:24,770
Well, one thing you might do
about it if you believed that

1199
01:04:24,770 --> 01:04:28,880
there was a significant learning
component here is to

1200
01:04:28,880 --> 01:04:32,950
use learning theory kinds
of things to treat it.

1201
01:04:32,950 --> 01:04:36,020
Now if it turns out that there
really is a chemical imbalance

1202
01:04:36,020 --> 01:04:39,870
and every time the chemicals
go out of whack, you feel

1203
01:04:39,870 --> 01:04:41,890
panicked, you might want to do
something about the chemicals.

1204
01:04:41,890 --> 01:04:44,450
But if you've got one of these
situations where the person

1205
01:04:44,450 --> 01:04:48,760
has basically scared themselves
into maladaptive

1206
01:04:48,760 --> 01:04:52,100
behavior, you've now got
to un-scare them.

1207
01:04:52,100 --> 01:04:53,310
So what are you going to do?

1208
01:04:53,310 --> 01:04:56,170
One of the standard techniques
for these sort of disorders

1209
01:04:56,170 --> 01:04:59,920
would be desensitization
methods.

1210
01:04:59,920 --> 01:05:01,750
Is it Barlow who
was doing this?

1211
01:05:04,370 --> 01:05:06,770
So one of the versions
-- you can imagine --

1212
01:05:06,770 --> 01:05:09,320
I did a version where you became
scared of the outside.

1213
01:05:09,320 --> 01:05:13,020
Another version is you have a
panic attack in an enclosed

1214
01:05:13,020 --> 01:05:15,730
space and you become very
nervous about enclosed spaces.

1215
01:05:15,730 --> 01:05:18,760
You won't go into elevators
and stuff like that.

1216
01:05:18,760 --> 01:05:21,950
I can't remember if
it was Barlow --

1217
01:05:21,950 --> 01:05:25,300
I got a feeling it was --
whose technique for --

1218
01:05:25,300 --> 01:05:29,620
there are a variety of ways of
using learning theory to get

1219
01:05:29,620 --> 01:05:30,090
around this.

1220
01:05:30,090 --> 01:05:32,880
One is the kinder,
gentler one.

1221
01:05:32,880 --> 01:05:34,480
So you come to me.

1222
01:05:34,480 --> 01:05:37,900
You say, "I'm really afraid of
being in enclosed spaces."

1223
01:05:37,900 --> 01:05:40,510
You say, "OK" --

1224
01:05:40,510 --> 01:05:44,560
the first cure out in this field
that you've come to,

1225
01:05:44,560 --> 01:05:47,280
that I'm using for my doctor's
office at the moment --

1226
01:05:47,280 --> 01:05:49,170
"Imagine that you're
in a space.

1227
01:05:49,170 --> 01:05:50,610
Can you deal with that?"

1228
01:05:50,610 --> 01:05:53,260
"Oh, it's making me nervous,
but, yeah, OK, I can deal with

1229
01:05:53,260 --> 01:05:53,410
that."

1230
01:05:53,410 --> 01:05:55,890
"OK, now we'll go to 10-250.

1231
01:05:55,890 --> 01:05:57,430
It's a big enclosed space.

1232
01:05:57,430 --> 01:05:59,740
And then we'll go to a smaller
room and a smaller room.

1233
01:05:59,740 --> 01:06:04,310
And eventually we'll put you
in a closet for a while.

1234
01:06:04,310 --> 01:06:07,030
And you'll discover -- what
you'll do is un-learn the

1235
01:06:07,030 --> 01:06:08,550
response, in effect.

1236
01:06:08,550 --> 01:06:12,990
You'll learn nothing bad
happened to me."

1237
01:06:12,990 --> 01:06:18,160
And this behaviorist sort of
therapy does work to break up

1238
01:06:18,160 --> 01:06:21,310
these sorts of behaviors
in many cases.

1239
01:06:21,310 --> 01:06:25,340
I think it's Barlow who has been
advocating a much less

1240
01:06:25,340 --> 01:06:27,890
kinder, gentler version,
which is to shut

1241
01:06:27,890 --> 01:06:29,200
people in car trunks.

1242
01:06:32,030 --> 01:06:34,850
So none of this business
of doing it gradually.

1243
01:06:34,850 --> 01:06:37,330
This is known in the
trade as flooding.

1244
01:06:37,330 --> 01:06:38,530
You just take the --

1245
01:06:38,530 --> 01:06:42,730
the guy says, "You know, I think
if I'm in an enclosed

1246
01:06:42,730 --> 01:06:45,020
space, I'm going to die."

1247
01:06:45,020 --> 01:06:46,220
"All right.

1248
01:06:46,220 --> 01:06:46,670
Boom.

1249
01:06:46,670 --> 01:06:48,330
You dead yet?

1250
01:06:48,330 --> 01:06:48,960
No.

1251
01:06:48,960 --> 01:06:49,490
OK.

1252
01:06:49,490 --> 01:06:50,070
You're cured.

1253
01:06:50,070 --> 01:06:50,330
Good.

1254
01:06:50,330 --> 01:06:50,580
Out."

1255
01:06:50,580 --> 01:06:53,650
Well, it's not quite that
simple, but the basic idea is

1256
01:06:53,650 --> 01:06:58,280
that if you have a patient who
can actually deal with this,

1257
01:06:58,280 --> 01:07:01,830
that you can basically speed
up the therapy rather

1258
01:07:01,830 --> 01:07:05,960
dramatically by not moving
gradually to --

1259
01:07:05,960 --> 01:07:08,550
this is used for all
sorts of phobias.

1260
01:07:08,550 --> 01:07:13,400
So, scared of snakes, you know,
you're pathologically

1261
01:07:13,400 --> 01:07:14,800
scared of snakes.

1262
01:07:14,800 --> 01:07:18,650
OK, what we'll do is first
we'll show you --

1263
01:07:18,650 --> 01:07:21,520
so the two versions are
desensitization and flooding.

1264
01:07:21,520 --> 01:07:24,280
The desensitization
story would be:

1265
01:07:24,280 --> 01:07:25,490
"We'll show you pictures
of snakes."

1266
01:07:25,490 --> 01:07:27,100
"Ooh, I hate it.

1267
01:07:27,100 --> 01:07:27,180
I hate it."

1268
01:07:27,180 --> 01:07:27,540
"Are you dead?"

1269
01:07:27,540 --> 01:07:27,770
"No."

1270
01:07:27,770 --> 01:07:33,230
"Oh, OK." So now we'll go to the
zoo. "And see that snake

1271
01:07:33,230 --> 01:07:34,130
cage way over there?

1272
01:07:34,130 --> 01:07:34,740
Are you dead yet?"

1273
01:07:34,740 --> 01:07:35,080
"No."

1274
01:07:35,080 --> 01:07:36,050
"OK, let's get closer.

1275
01:07:36,050 --> 01:07:37,490
OK, that's a snake, right.

1276
01:07:37,490 --> 01:07:38,770
OK, now you're going
to get in with him.

1277
01:07:38,770 --> 01:07:39,190
Yeah."

1278
01:07:39,190 --> 01:07:39,910
"Aah."

1279
01:07:39,910 --> 01:07:40,340
All right.

1280
01:07:40,340 --> 01:07:42,070
"But I'm not dead."

1281
01:07:42,070 --> 01:07:45,080
And the flooding technique is
"You're afraid of snakes?

1282
01:07:45,080 --> 01:07:47,750
Boom.

1283
01:07:47,750 --> 01:07:49,210
See those boas?

1284
01:07:49,210 --> 01:07:49,931
Are you dead?"

1285
01:07:49,931 --> 01:07:50,894
"Yes, actually."

1286
01:07:50,894 --> 01:07:54,180
[LAUGHTER FROM AUDIENCE]

1287
01:07:54,180 --> 01:08:02,480
So, anyway, the point from the
panic attack example is that

1288
01:08:02,480 --> 01:08:06,070
it's possible that what you're
seeing as the clinical entity

1289
01:08:06,070 --> 01:08:13,320
is a dance between physiology
and learning, in effect, and

1290
01:08:13,320 --> 01:08:14,990
that what you learn --

1291
01:08:14,990 --> 01:08:19,340
and that a mode of treatment
would be to unlearn.

1292
01:08:19,340 --> 01:08:22,560
Now, let's take another example
which I did put on the

1293
01:08:22,560 --> 01:08:24,740
handout, which is obsessive
compulsive disorders.

1294
01:08:27,420 --> 01:08:32,250
Obsessive compulsive disorders
are, well, there's the

1295
01:08:32,250 --> 01:08:37,250
obsessive part and there's
the compulsive part.

1296
01:08:37,250 --> 01:08:42,200
The obsessive part refers
to obsessive thoughts.

1297
01:08:42,200 --> 01:08:48,400
What gets you into treatment is
not some sort of obsessive

1298
01:08:48,400 --> 01:08:51,170
thought that "I love him.

1299
01:08:51,170 --> 01:08:52,060
I really love him.

1300
01:08:52,060 --> 01:08:53,230
Oh, I love him a lot.

1301
01:08:53,230 --> 01:08:54,430
Oh yeah, yeah, yeah.

1302
01:08:54,430 --> 01:08:56,390
I can't help but think about
him." Yeah, it's a little

1303
01:08:56,390 --> 01:08:58,410
obsessive, but tough.

1304
01:08:58,410 --> 01:09:01,950
It's "Every time I look
at him, I want to

1305
01:09:01,950 --> 01:09:03,670
rip his guts out.

1306
01:09:03,670 --> 01:09:07,580
I'm imagining the knife."
You know, or something.

1307
01:09:07,580 --> 01:09:10,170
It's disturbing thoughts
that somehow won't

1308
01:09:10,170 --> 01:09:11,730
get out of your brain.

1309
01:09:11,730 --> 01:09:15,520
That's the sort of obsession
that people

1310
01:09:15,520 --> 01:09:16,610
seek treatment for.

1311
01:09:16,610 --> 01:09:22,430
And compulsive behaviors are
behaviors where -- everybody

1312
01:09:22,430 --> 01:09:23,860
has some degree of this.

1313
01:09:23,860 --> 01:09:29,720
How many people here have left
their room, gotten halfway

1314
01:09:29,720 --> 01:09:33,620
down the hall, said "Did I
really lock it?", and gone

1315
01:09:33,620 --> 01:09:35,880
back to check?

1316
01:09:35,880 --> 01:09:37,670
Everybody does that sometime.

1317
01:09:37,670 --> 01:09:41,910
Or did I turn the stove off
or something like that.

1318
01:09:41,910 --> 01:09:45,330
That's normal on compulsion
land.

1319
01:09:45,330 --> 01:09:48,750
And almost always you have
locked it, right?

1320
01:09:48,750 --> 01:09:51,550
Because the time you didn't lock
it is the time you don't

1321
01:09:51,550 --> 01:09:55,250
go back to check, and somebody
steals all your stuff.

1322
01:09:55,250 --> 01:09:56,000
Very annoying.

1323
01:09:56,000 --> 01:09:59,690
I donated a laptop to the
criminal elements doing

1324
01:09:59,690 --> 01:10:00,660
exactly that.

1325
01:10:00,660 --> 01:10:01,860
Very annoying.

1326
01:10:01,860 --> 01:10:09,440
But anyway, if you have to go
and, you know, get down the

1327
01:10:09,440 --> 01:10:12,040
hall, "Did I lock it?

1328
01:10:12,040 --> 01:10:14,510
Yep, it's locked.

1329
01:10:14,510 --> 01:10:19,690
Did I lock it?" You've got to
do that forty or fifty times

1330
01:10:19,690 --> 01:10:22,940
and you can't get on with
your life, literally.

1331
01:10:22,940 --> 01:10:25,220
You can't get to the next
event in your life.

1332
01:10:25,220 --> 01:10:30,160
That's a compulsion that is
likely to lead you to want to

1333
01:10:30,160 --> 01:10:31,770
do something about it.

1334
01:10:31,770 --> 01:10:35,980
It's interesting that these
are compulsions --

1335
01:10:35,980 --> 01:10:38,360
rather like there are
similarities in people's

1336
01:10:38,360 --> 01:10:39,790
narrative dreams --

1337
01:10:39,790 --> 01:10:44,770
that compulsions seem to
be drawn from a limited

1338
01:10:44,770 --> 01:10:47,690
vocabulary of candidate
compulsions.

1339
01:10:47,690 --> 01:10:49,840
I mean, I'm sure there's one of
everything out there, but

1340
01:10:49,840 --> 01:10:54,770
there's lots of hand
washers, right.

1341
01:10:54,770 --> 01:10:56,730
Actually, I can see my
hands are covered in

1342
01:10:56,730 --> 01:10:57,450
chalk at the moment.

1343
01:10:57,450 --> 01:10:58,400
I should go wash them.

1344
01:10:58,400 --> 01:10:59,910
But, you know, why do
you wash your hands?

1345
01:11:03,180 --> 01:11:05,580
Because your mother said so,
right, and because there's

1346
01:11:05,580 --> 01:11:06,420
germs on them.

1347
01:11:06,420 --> 01:11:09,040
Can you see the germs?

1348
01:11:09,040 --> 01:11:10,090
No.

1349
01:11:10,090 --> 01:11:13,510
So you got to do the act
and convince yourself

1350
01:11:13,510 --> 01:11:14,790
that you've done it.

1351
01:11:17,300 --> 01:11:18,040
OK, hands are clean.

1352
01:11:18,040 --> 01:11:21,430
Are they really clean?

1353
01:11:21,430 --> 01:11:24,000
I can't tell because there
might be germs there.

1354
01:11:24,000 --> 01:11:24,860
I'm going to get sick.

1355
01:11:24,860 --> 01:11:25,920
I'll wash them again.

1356
01:11:25,920 --> 01:11:28,200
If you have to do this so often
that your hands are

1357
01:11:28,200 --> 01:11:36,460
getting red and raw, that's
a compulsion of some sort.

1358
01:11:36,460 --> 01:11:41,580
Now, you can treat OCD, as it's
known in the trade, in a

1359
01:11:41,580 --> 01:11:42,620
number of different ways.

1360
01:11:42,620 --> 01:11:48,410
It turns out, for example, that
Prozac is good against

1361
01:11:48,410 --> 01:11:49,750
obsessive compulsive
disorders.

1362
01:11:49,750 --> 01:11:53,150
It breaks up the obsession,
you know, the obsessive

1363
01:11:53,150 --> 01:11:57,690
quality here of this sort of
thought that doesn't quite

1364
01:11:57,690 --> 01:11:58,470
work for you.

1365
01:11:58,470 --> 01:12:01,270
You can imagine that you've got
some little circuit in the

1366
01:12:01,270 --> 01:12:05,960
brain somewhere that's
a little checker.

1367
01:12:05,960 --> 01:12:08,170
You know, did I do what
I was supposed to do?

1368
01:12:08,170 --> 01:12:11,570
And if that goes a little wacko
on you, that that's got

1369
01:12:11,570 --> 01:12:13,920
too much serotonin or too little
serotonin, I suppose,

1370
01:12:13,920 --> 01:12:16,550
or whatever, you know, you might
end up in a sort of an

1371
01:12:16,550 --> 01:12:18,880
infinite loop where,
"Got to check.

1372
01:12:18,880 --> 01:12:19,510
Got to check.

1373
01:12:19,510 --> 01:12:20,120
Got to check.

1374
01:12:20,120 --> 01:12:23,310
Got to check." And something
chemical that gives

1375
01:12:23,310 --> 01:12:26,810
it a kick will help.

1376
01:12:26,810 --> 01:12:27,300
OK.

1377
01:12:27,300 --> 01:12:28,480
You can treat it that way.

1378
01:12:28,480 --> 01:12:32,970
You can also treat it using the
same sort of behavioral

1379
01:12:32,970 --> 01:12:35,240
techniques that I was just
talking about for phobias.

1380
01:12:35,240 --> 01:12:38,220
So let's do it for
hand washing.

1381
01:12:38,220 --> 01:12:40,960
All right, Patient So and So,
why do you have to wash?

1382
01:12:40,960 --> 01:12:43,860
"Well, I'm just really
concerned that

1383
01:12:43,860 --> 01:12:45,510
my hands are dirty.

1384
01:12:48,970 --> 01:12:52,730
When I get dirt on my hands,
I get all excited and

1385
01:12:52,730 --> 01:12:54,060
[NERVOUS SOUND]." Right.

1386
01:12:54,060 --> 01:12:54,780
All right.

1387
01:12:54,780 --> 01:12:57,970
So we can do the densitization
business or we can do the

1388
01:12:57,970 --> 01:12:58,940
flooding business.

1389
01:12:58,940 --> 01:13:00,880
In the interests of time,
we'll do flooding.

1390
01:13:00,880 --> 01:13:01,330
"All right.

1391
01:13:01,330 --> 01:13:01,840
See this?

1392
01:13:01,840 --> 01:13:02,530
This is dirt.

1393
01:13:02,530 --> 01:13:06,590
Put your hands in it." Right.
"Are you dead yet?"

1394
01:13:06,590 --> 01:13:07,640
"No."

1395
01:13:07,640 --> 01:13:07,960
"All right.

1396
01:13:07,960 --> 01:13:11,680
How long can you leave
them there?"

1397
01:13:11,680 --> 01:13:15,790
And you can basically
desensitize this feeling of

1398
01:13:15,790 --> 01:13:20,320
deep anxiety about not
cleaning your hands.

1399
01:13:20,320 --> 01:13:20,630
All right.

1400
01:13:20,630 --> 01:13:23,340
So that's mildly interesting.

1401
01:13:23,340 --> 01:13:30,980
What's interesting, the reason
for raising this question or

1402
01:13:30,980 --> 01:13:35,190
this example, comes from this
nice article, now more than a

1403
01:13:35,190 --> 01:13:37,980
decade old, by Baxter.

1404
01:13:37,980 --> 01:13:42,030
You can see obsessive
compulsive

1405
01:13:42,030 --> 01:13:47,000
states in brain imaging.

1406
01:13:47,000 --> 01:13:50,990
There are little bits of brain
specifically in the caudate.

1407
01:13:50,990 --> 01:13:53,340
It doesn't particularly matter
for present purposes where

1408
01:13:53,340 --> 01:13:54,410
that might be.

1409
01:13:54,410 --> 01:13:57,270
But it's overactive.

1410
01:13:57,270 --> 01:14:00,260
You look at the brain of an
obsessive compulsive sort, and

1411
01:14:00,260 --> 01:14:03,620
this little chunk of
brain is busy, you

1412
01:14:03,620 --> 01:14:05,430
know, just going nuts.

1413
01:14:05,430 --> 01:14:10,490
If you give the patients Prozac,
that chunk of brain

1414
01:14:10,490 --> 01:14:13,370
now doesn't look
weird anymore.

1415
01:14:13,370 --> 01:14:15,630
It comes into the
normal range.

1416
01:14:15,630 --> 01:14:20,290
If you'd go and do behavioral
therapy on a patient with the

1417
01:14:20,290 --> 01:14:25,600
same story, the same piece of
brain comes to look normal.

1418
01:14:25,600 --> 01:14:29,460
The point here is that you can
reach this chunk of the brain,

1419
01:14:29,460 --> 01:14:31,950
if you like, either through
the brain sort of

1420
01:14:31,950 --> 01:14:34,100
neurochemical route,
or through the

1421
01:14:34,100 --> 01:14:36,330
psych behavioral route.

1422
01:14:36,330 --> 01:14:40,810
They're not necessarily either
mutually exclusive or, you

1423
01:14:40,810 --> 01:14:42,680
know, one works and the
other doesn't or

1424
01:14:42,680 --> 01:14:44,340
something like that.

1425
01:14:44,340 --> 01:14:47,290
This is a case where you can
get to the source of the

1426
01:14:47,290 --> 01:14:50,210
problem, at least in a

1427
01:14:50,210 --> 01:14:52,030
neurolocalization kind of a way.

1428
01:14:52,030 --> 01:14:55,890
You can get to the source of the
problem through either of

1429
01:14:55,890 --> 01:14:57,140
these routes.

1430
01:15:00,020 --> 01:15:06,830
And I suppose the bottom line
here is that in disorder after

1431
01:15:06,830 --> 01:15:12,880
disorder, what you find is that
there isn't just one way

1432
01:15:12,880 --> 01:15:14,150
of treating --

1433
01:15:14,150 --> 01:15:17,790
one problem is that in most
mental illness situations,

1434
01:15:17,790 --> 01:15:21,780
there isn't one magic bullet
treatment that automatically

1435
01:15:21,780 --> 01:15:23,660
works for you.

1436
01:15:23,660 --> 01:15:27,230
And then in many of these cases,
there are both brain

1437
01:15:27,230 --> 01:15:31,330
and mind routes to therapy.

1438
01:15:31,330 --> 01:15:34,260
So when you're asking --

1439
01:15:34,260 --> 01:15:36,890
when you have like these
patients we were cooking up,

1440
01:15:36,890 --> 01:15:44,140
when you have a particular
patient, there's a spectrum of

1441
01:15:44,140 --> 01:15:48,840
choices that might potentially
be of some use.

1442
01:15:48,840 --> 01:15:51,600
It says on the handout, "What
happens when drugs make us

1443
01:15:51,600 --> 01:15:53,750
better than we ever were?" That
was the example I was

1444
01:15:53,750 --> 01:16:01,390
talking about before of Emma,
who feels better on Prozac

1445
01:16:01,390 --> 01:16:03,280
even though she wasn't
technically --

1446
01:16:06,870 --> 01:16:10,490
didn't have a reasonable
diagnosis of something being

1447
01:16:10,490 --> 01:16:11,250
wrong with her.

1448
01:16:11,250 --> 01:16:13,000
So we've already talked
about that.

1449
01:16:13,000 --> 01:16:18,730
So I think I'll quit.

1450
01:16:18,730 --> 01:16:20,070
See you next week.