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PROFESSOR: Good afternoon.
 

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When we parted last time, I
was -- you just did that demo

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with Sam, who was either
collecting stamps or lady's

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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 abnormal

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in some meaningful sense, maybe
even pathological in some

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sense, but that the border
between what is normal and what

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is abnormal is going to be
necessarily ambiguous.

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

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be 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 look

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quite different from the normal
state and less like that

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it's on a continuum.
 

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You will notice on your handout
that it says Lecture 20.

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And those of you who are
particularly observant

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will 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

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or 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

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to bring the real
Lecture 20 handout.

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

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

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bin of schizophrenia.
 

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And one reasonable
question to ask is, well,

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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 about

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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

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more 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 one

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of a pair of identical twins
becomes schizophrenic, there's

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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 you look

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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 genetic

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component there, and second of
all, 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,
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 all

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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,

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to 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

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than 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 -- twins reared

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apart -- 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 look

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for this is that 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 family

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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 chromosome

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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,

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but not in this family.
 

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Clearly schizophrenic but not
clearly 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 than

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one genetic insult.
 

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That's jargon -- 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 in a

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secondary source.
 

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I have been unsuccessful
in tracking down

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the primary source.
 

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But I'll tell you anyway -- is
a study -- it turns out that

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there are two types
of 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

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the other twin and so on.
 

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And the curious finding
reported in this one relatively

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small study, I think, is that
the concordance rates for

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identical identical twins, the
right hand, right hand

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identical twins, very high in
this 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 groups

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different, if indeed that turns
out to be a reliable result.

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I went hunting in the
databases, and I think I

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found 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 for

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a genetic component.
 

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And then there's pretty
strong evidence that that

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by itself 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

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to have 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 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 you

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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
-- this raises interesting

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problems for public policy.
 

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

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OK 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 -- should I
go and suggest to the head of

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admissions that we really
should get little tubes

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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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And we know where -- we don't
know exactly which loci are

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critical, but we know a bunch
of loci that seem to be

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related to family histories
of schizophrenia.

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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 of

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applicants and systematically
decide not to admit people who

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had the genetic marker for
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 environment?

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All right.
 

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Short of Guantanamo Bay
or something, you know,

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it's right up there.
 

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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

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illnesses, 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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Isn't it our responsibility to
prevent that from happening?

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Well, now, typically the -- I
won't take a poll, but the

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typical answer is, no,
that doesn't sound right.

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You know, that somehow
that sounds a little too

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paternalistic, too invasive for
me to be screening your genes.

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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 never passing 18.03.

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You know, what would we ever do
with information like that?

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But the disease case,
it doesn't feel right

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typically to people.
 

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But on the other hand, we
spend a lot of time worrying,

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believe it or not, about
your mental health.

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The dean's office has
substantial branches devoted to

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mental health issues as does
the medical department.

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We know that university
environments kick up a certain

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amount of psychiatric problems.
 

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And we know that that can
be catastrophically bad

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for the person and for
people around them.

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Wouldn't it be our
responsibility to do

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something about that?
 

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Well, look, I'm not going to
give you an answer to that, and

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I promise not to ask on the
exam, you know, should we get

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blood samples from everybody
and, you know, the choices are

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yes, no, all of the above
or something like that.

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I raise that as an
issue to think about.

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When you take a look at the
brains of schizophrenics, by

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the way, they don't look like
the brains of healthy,

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normal individuals.
 

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So you get things like
shrinkage of grey matter.

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You get enlargement
of the ventricles.

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The ventricles are those
nice, empty fluid-filled

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spaces in your brain.
 

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Great answer for a -- if you're
looking at the multiple-choice

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question on the final, and
you're thinking, I'm going to

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go for, you know, the third
ventricle as the answer,

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you're probably getting
suckered here, right?

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Because the ventricles are
empty fluid-filled spaces.

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It's not where any of the more
important mental functions are

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thought to be localized, at
least not since the Middle

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Ages, where people did think
that memories were stored in

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the ventricles, because
after all they looked

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like store rooms.
 

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Anyway, the ventricles
get bigger.

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That's presumably not a good
thing because it's reflecting

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loss of brain tissue.
 

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What's not absolutely clear is
whether or not abnormalities

276
00:15:37 --> 00:15:42
in brain structure
precede disease.

277
00:15:42 --> 00:15:44
You know, are they there
somehow from birth?

278
00:15:44 --> 00:15:47
Is part of what the gene is
doing somehow changing the

279
00:15:47 --> 00:15:50
structure of the brain in
such a way that it makes it

280
00:15:50 --> 00:15:53
vulnerable, or is it that
having the disease itself

281
00:15:53 --> 00:15:57
is bad for the brain?
 

282
00:15:57 --> 00:16:04
In any case, the point to take
away here is there are lots of

283
00:16:04 --> 00:16:10
different routes into the
kingdom of schizophrenia.

284
00:16:10 --> 00:16:13
It's not a nice, clean simple
diagnosis where you say, you

285
00:16:13 --> 00:16:18
get this bacterium, you get
this disease, we give you this

286
00:16:18 --> 00:16:20
antibiotic, and you're OK.
 

287
00:16:20 --> 00:16:25
Multiple routes in and
treatment options are,

288
00:16:25 --> 00:16:30
you know, getting better
but remain difficult.

289
00:16:30 --> 00:16:30
Let's see here.
 

290
00:16:30 --> 00:16:31
Oh yes.
 

291
00:16:31 --> 00:16:36
What I think I will do is
switch gears and talk a

292
00:16:36 --> 00:16:38
bit about depression.
 

293
00:16:38 --> 00:16:42
But in order to talk about
depression, what I want you to

294
00:16:42 --> 00:16:47
do is to decide how you want to
treat my three invented

295
00:16:47 --> 00:16:50
patients on the handout.
 

296
00:16:50 --> 00:16:53
The third one is on
the back of the page.

297
00:16:53 --> 00:16:54
So play with that for a second.
 

298
00:16:54 --> 00:16:58
Kristen, can you do me a favor?
 

299
00:16:58 --> 00:16:59
Go find me a bottle of water.
 

300
00:16:59 --> 00:17:01
I'm going to expire
today otherwise.

301
00:17:01 --> 00:17:02
AUDIENCE: I have some.
 

302
00:17:02 --> 00:17:03
Do you want some?
 

303
00:17:03 --> 00:17:03
PROFESSOR: I don't know.
 

304
00:17:03 --> 00:17:04
Do you got any
interesting diseases?

305
00:17:04 --> 00:17:06
AUDIENCE: No.
 

306
00:17:06 --> 00:17:10
PROFESSOR: I don't
want to steal yours.

307
00:17:10 --> 00:17:11
Find me something somewhere.
 

308
00:17:11 --> 00:17:12
Thank you.
 

309
00:17:12 --> 00:17:17
 
 

310
00:17:17 --> 00:17:21
I'm recovering from a cold
still, and I can feel that I'm

311
00:17:21 --> 00:17:24
going to run out of moisture.
 

312
00:17:24 --> 00:17:26
And my tongue is going to
get all big and like a

313
00:17:26 --> 00:17:26
parrot or something.
 

314
00:17:26 --> 00:17:28
I won't be able to talk.
 

315
00:17:28 --> 00:17:31
All right, have you
managed to do this?

316
00:17:31 --> 00:17:31
Still working on it.
 

317
00:17:31 --> 00:17:32
All right.
 

318
00:17:32 --> 00:17:34
Don't cheat off your neighbors.
 

319
00:17:34 --> 00:17:38
But I promise you this time,
none of these guys are dealing

320
00:17:38 --> 00:17:38
in lady's undergarments.
 

321
00:17:38 --> 00:17:42
 
 

322
00:17:42 --> 00:17:42
Here.
 

323
00:17:42 --> 00:17:44
Let's collect some.
 

324
00:17:44 --> 00:17:51
 
 

325
00:17:51 --> 00:17:51
All right.
 

326
00:17:51 --> 00:17:57
Let's collect us some data.
 

327
00:17:57 --> 00:18:03
 
 

328
00:18:03 --> 00:18:05
OK.
 

329
00:18:05 --> 00:18:09
Everybody pretty
much done here?

330
00:18:09 --> 00:18:12
Make assenting noises
or something.

331
00:18:12 --> 00:18:13
OK, that's good.
 

332
00:18:13 --> 00:18:15
That sounded very assenting.
 

333
00:18:15 --> 00:18:19
OK, so Sarah had a bad day.
 

334
00:18:19 --> 00:18:25
How many people would, let's
see, so that -- slow numbers

335
00:18:25 --> 00:18:28
are the "no way, we're not
going to medicate this

336
00:18:28 --> 00:18:31
depression." How many people
-- oh, that was quick.

337
00:18:31 --> 00:18:32
That was good.
 

338
00:18:32 --> 00:18:34
Thank you.
 

339
00:18:34 --> 00:18:37
How many people are going
to give her no meds?

340
00:18:37 --> 00:18:38
Oh, OK.
 

341
00:18:38 --> 00:18:43
So the answer is
everybody, more or less.

342
00:18:43 --> 00:18:45
Don't worry if you said, I'll
give her a little bit of med.

343
00:18:45 --> 00:18:46
That's OK, too.
 

344
00:18:46 --> 00:18:49
But I won't bother
asking about it.

345
00:18:49 --> 00:18:51
These really are all
the same, by the way.

346
00:18:51 --> 00:18:53
There's no fifty-fifty split.
 

347
00:18:53 --> 00:18:55
This is just straight
up, normal.

348
00:18:55 --> 00:18:57
I'm not tricking you this time.
 

349
00:18:57 --> 00:19:00
OK.
 

350
00:19:00 --> 00:19:04
And by contrast if we look at
Sam, Sam's depressed, no

351
00:19:04 --> 00:19:06
particular reason,
just happens.

352
00:19:06 --> 00:19:10
And he oscillates between
manic and depressed states.

353
00:19:10 --> 00:19:15
How many people think no
treatment or unlikely

354
00:19:15 --> 00:19:18
to medicate?
 

355
00:19:18 --> 00:19:20
How many moderately like,
you know, somewhere in the

356
00:19:20 --> 00:19:21
four to seven department?
 

357
00:19:21 --> 00:19:24
Well, a few people in there.
 

358
00:19:24 --> 00:19:27
And you have all embodied
the ethos of the

359
00:19:27 --> 00:19:29
yeah, yeah, OK, good.
 

360
00:19:29 --> 00:19:34
I mean, I don't know if it's
good or not, but it's clearly

361
00:19:34 --> 00:19:39
where medical science, I
suppose, is these days, which

362
00:19:39 --> 00:19:42
is that he would be a candidate
for an antidepressant in

363
00:19:42 --> 00:19:44
a way that she wouldn't.
 

364
00:19:44 --> 00:19:45
Why not?
 

365
00:19:45 --> 00:19:47
Why wouldn't you give
her an antidepressant?

366
00:19:47 --> 00:19:48
She's depressed.
 

367
00:19:48 --> 00:19:53
 
 

368
00:19:53 --> 00:19:56
AUDIENCE: It's normal for
her to be depressed.

369
00:19:56 --> 00:19:59
Like, anyone could be depressed
in that situation, but if

370
00:19:59 --> 00:20:04
you're depressed for no reason,
then that [UNINTELLIGIBLE]

371
00:20:04 --> 00:20:08
problem in the brain that could
be solved by medication,

372
00:20:08 --> 00:20:11
whereas with her thing, all
that needs to happen is the

373
00:20:11 --> 00:20:12
problem's [? cured. ?]
 

374
00:20:12 --> 00:20:15
PROFESSOR: There's a couple
of things that are worth

375
00:20:15 --> 00:20:17
picking up on here.
 

376
00:20:17 --> 00:20:23
One is, I mentioned last time
that the exact mapping between

377
00:20:23 --> 00:20:28
cause and treatment shouldn't
be seen as one to one.

378
00:20:28 --> 00:20:35
So even if we take as correct
for present purposes that Sam's

379
00:20:35 --> 00:20:38
got something biochemical wrong
with him, it wouldn't

380
00:20:38 --> 00:20:41
necessarily be the case that
the only way to deal with this

381
00:20:41 --> 00:20:45
would be by a biochemical
kind of treatment.

382
00:20:45 --> 00:20:47
There isn't that necessary
one-to-one mapping.

383
00:20:47 --> 00:20:50
But it's not an
unreasonable thought.

384
00:20:50 --> 00:20:53
And the other part of that
thought was, you know, she's

385
00:20:53 --> 00:20:55
depressed for a reason.
 

386
00:20:55 --> 00:21:01
And we don't want to shield
her necessarily from

387
00:21:01 --> 00:21:02
that depression.
 

388
00:21:02 --> 00:21:09
Though this gets raised
as an issue too now.

389
00:21:09 --> 00:21:12
I talked last time about
treatments for post-traumatic

390
00:21:12 --> 00:21:14
stress disorder.
 

391
00:21:14 --> 00:21:22
One of the notions is that you
could give people medications

392
00:21:22 --> 00:21:26
that would in a sense prevent
them from feeling as bad about

393
00:21:26 --> 00:21:32
something horrible as
they normally would.

394
00:21:32 --> 00:21:34
I mean, this is a real
something horrible

395
00:21:34 --> 00:21:35
now, you understand.
 

396
00:21:35 --> 00:21:38
But we're going to get you --
something horrible has happened

397
00:21:38 --> 00:21:43
-- we're going to give you a
pill that is going to decrease,

398
00:21:43 --> 00:21:45
we hope, the chance of you
having a post-traumatic stress

399
00:21:45 --> 00:21:48
disorder, but it's going to
do that by blunting your

400
00:21:48 --> 00:21:54
emotional response and your
memory for that event.

401
00:21:54 --> 00:21:57
Is that something that
we want to get into?

402
00:21:57 --> 00:22:06
Now, Sam I described as having
this -- if this is now, oh,

403
00:22:06 --> 00:22:10
I suppose, mood -- Sam I
described as having one of

404
00:22:10 --> 00:22:14
these oscillatory or bipolar
conditions where he bounces

405
00:22:14 --> 00:22:18
back and forth between -- well,
let's see, which end is this?

406
00:22:18 --> 00:22:26
This can be the manic end
and the depressed end.

407
00:22:26 --> 00:22:32
 
 

408
00:22:32 --> 00:22:36
You sometimes think that it
might kind of be worth it,

409
00:22:36 --> 00:22:40
right, because you have to put
up with the depression, but the

410
00:22:40 --> 00:22:42
manic energy thing
would be good.

411
00:22:42 --> 00:22:45
Well, the manic energy thing
is kind of good here, maybe.

412
00:22:45 --> 00:22:48
You know, you get all your
problem sets done in ten

413
00:22:48 --> 00:22:50
minutes or something.
 

414
00:22:50 --> 00:22:56
But by the time you get out
here, you are just as abnormal,

415
00:22:56 --> 00:22:59
if you like, or just as crazy
if we want to be colloquial

416
00:22:59 --> 00:23:04
about this, out here
as you are down here.

417
00:23:04 --> 00:23:07
And you can be pretty hard on
your friends and neighbors

418
00:23:07 --> 00:23:11
and yourself, in fact.
 

419
00:23:11 --> 00:23:13
I don't need -- I mean, this
is very MIT, right -- I

420
00:23:13 --> 00:23:14
don't need to sleep anymore.
 

421
00:23:14 --> 00:23:17
I can talk all night.
 

422
00:23:17 --> 00:23:18
You don't want to listen to me?
 

423
00:23:18 --> 00:23:19
Well, I'll talk anyway.
 

424
00:23:19 --> 00:23:22
 
 

425
00:23:22 --> 00:23:28
I remember reading a memoir by
the child of a manic depressive

426
00:23:28 --> 00:23:33
mother, who as I recall comes
home -- the child comes home

427
00:23:33 --> 00:23:36
from school one day, discovers
mom has decided we're going to

428
00:23:36 --> 00:23:40
have a great old-fashioned
Christmas this year.

429
00:23:40 --> 00:23:44
So she went out and bought like
thirty-five Christmas trees.

430
00:23:44 --> 00:23:47
And you walk into the living
room and it's just, you

431
00:23:47 --> 00:23:48
know, forest in there.
 

432
00:23:48 --> 00:23:51
She's stuffed the Christmas
trees all over the -- and, you

433
00:23:51 --> 00:23:54
know, this is, I'm sorry, I'm
glad you're feeling really

434
00:23:54 --> 00:23:58
up, but this is nuts too.
 

435
00:23:58 --> 00:23:59
It's not working.
 

436
00:23:59 --> 00:24:05
 
 

437
00:24:05 --> 00:24:09
It's an interesting
observation.

438
00:24:09 --> 00:24:14
There are interesting data
suggesting that this sort of

439
00:24:14 --> 00:24:17
bipolar disorder, this
oscillation between deep

440
00:24:17 --> 00:24:24
depression and this wild mania,
that that's overrepresented in

441
00:24:24 --> 00:24:27
at least some creative
populations.

442
00:24:27 --> 00:24:31
The notable one is poets.
 

443
00:24:31 --> 00:24:35
It's notable because a woman
named -- what is her full name?

444
00:24:35 --> 00:24:38
-- well, anyway, Jamison
is her last name.

445
00:24:38 --> 00:24:41
 
 

446
00:24:41 --> 00:24:43
I think it's spelled like this.
 

447
00:24:43 --> 00:24:46
Anyway, she wrote a book called
Touched by Fire where what she

448
00:24:46 --> 00:24:49
did was she went and looked
at the biographies of, in

449
00:24:49 --> 00:24:53
particular, sort of the run
of famous English poets.

450
00:24:53 --> 00:24:56
And over and over in their
biographies you get these

451
00:24:56 --> 00:25:00
descriptions that -- you know,
they didn't have the diagnosis

452
00:25:00 --> 00:25:04
in 18th century England, but it
sure sounds like a manic

453
00:25:04 --> 00:25:05
depressive disorder.
 

454
00:25:05 --> 00:25:08
You know, Shelley or Keats or
somebody writes eight million

455
00:25:08 --> 00:25:13
poems and then lies
in bed for a month.

456
00:25:13 --> 00:25:14
It's that sort of thing.
 

457
00:25:14 --> 00:25:16
Now, great, you know.
 

458
00:25:16 --> 00:25:17
I can be a famous poet.
 

459
00:25:17 --> 00:25:18
All I have to do is
put up with this.

460
00:25:18 --> 00:25:21
The problem -- well, there are
a number of problems with this.

461
00:25:21 --> 00:25:24
First of all, you become a
little intolerable to your

462
00:25:24 --> 00:25:25
immediate surroundings.
 

463
00:25:25 --> 00:25:29
The other thing is that a
very serious consequence

464
00:25:29 --> 00:25:33
of deep depression is
the threat of suicide.

465
00:25:33 --> 00:25:38
Interestingly, you would think
that this was a continuum

466
00:25:38 --> 00:25:41
thing, right, that you go way,
way down here and if you get

467
00:25:41 --> 00:25:45
this far down into depression,
that's when people

468
00:25:45 --> 00:25:46
commit suicide.
 

469
00:25:46 --> 00:25:48
Turns out not to be the case.
 

470
00:25:48 --> 00:25:50
When people describe their
really deep -- there's

471
00:25:50 --> 00:25:52
a huge genre here.
 

472
00:25:52 --> 00:25:54
It's a very popular
genre at the moment.

473
00:25:54 --> 00:25:59
If you're into depression,
your, you know, Christmas

474
00:25:59 --> 00:26:01
reading list can be all set
out because there's all

475
00:26:01 --> 00:26:04
sorts of people who
are happy to describe

476
00:26:04 --> 00:26:08
-- happy to describe their
depression? -- anyway, more

477
00:26:08 --> 00:26:12
than willing to describe
their depression in

478
00:26:12 --> 00:26:14
volumes thin or thick.
 

479
00:26:14 --> 00:26:16
Jamison actually has a volume
of her -- she got interested in

480
00:26:16 --> 00:26:21
this because she was a manic
depressive and trained

481
00:26:21 --> 00:26:22
in psychiatry.
 

482
00:26:22 --> 00:26:24
So she's coming at it
from every which way.

483
00:26:24 --> 00:26:28
Anyway, she has a memoir -- I
don't remember the title of it

484
00:26:28 --> 00:26:34
-- about her own depression
that's actually nice and slim.

485
00:26:34 --> 00:26:36
It's not a bad read.
 

486
00:26:36 --> 00:26:40
But what the descriptions sound
like is that when you're

487
00:26:40 --> 00:26:43
really, really deeply
depressed, you just

488
00:26:43 --> 00:26:44
don't do anything.
 

489
00:26:44 --> 00:26:48
You might in some sense want
to be dead, but that's just

490
00:26:48 --> 00:26:53
too much effort to do
anything about that.

491
00:26:53 --> 00:26:59
The danger for suicide in
bipolar disorders turns out to

492
00:26:59 --> 00:27:03
be -- well, let's get rid of
this -- turns out to be when

493
00:27:03 --> 00:27:06
you're on your way back out.
 

494
00:27:06 --> 00:27:12
Still depressed, but now you're
activated enough that you can

495
00:27:12 --> 00:27:14
do stuff, but you're not
convinced you're ever really

496
00:27:14 --> 00:27:16
going to get better.
 

497
00:27:16 --> 00:27:19
I mean, look, most of us have
not been really clinically

498
00:27:19 --> 00:27:25
depressed, but many of us can
tap into this, into this aspect

499
00:27:25 --> 00:27:30
in the sense of have you had
the flu or some, you know,

500
00:27:30 --> 00:27:33
relatively disgusting disorder
of some variety where you're

501
00:27:33 --> 00:27:37
sitting there thinking, "I know
rationally that I'm going to

502
00:27:37 --> 00:27:41
get better, but am I really
going to get better, or am I

503
00:27:41 --> 00:27:47
just going to be barfing
forever?" So you're coming on

504
00:27:47 --> 00:27:51
your way out, and that's where
the suicide risk is high.

505
00:27:51 --> 00:27:57
Now, that phenomenon may be
related to something that hit

506
00:27:57 --> 00:28:05
the news a lot this year, which
was concerns about giving

507
00:28:05 --> 00:28:10
antidepressants to
children and adolescents.

508
00:28:10 --> 00:28:13
Because there are data out
there that say that the suicide

509
00:28:13 --> 00:28:18
risk in depressed adolescents
taking antidepressants

510
00:28:18 --> 00:28:19
is elevated.
 

511
00:28:19 --> 00:28:21
Exactly what you don't want
to have happen, right?

512
00:28:21 --> 00:28:24
What you really want to not
have happen is people

513
00:28:24 --> 00:28:26
committing suicide when
they're depressed.

514
00:28:26 --> 00:28:28
What is the cause of this?
 

515
00:28:28 --> 00:28:30
Well, we don't actually
know, I don't think.

516
00:28:30 --> 00:28:31
At least I haven't seen
anything definitive.

517
00:28:31 --> 00:28:35
But there are a number -- one
theory is that antidepressants

518
00:28:35 --> 00:28:38
work differently in young
brains than in older brains.

519
00:28:38 --> 00:28:39
That's one possibility.
 

520
00:28:39 --> 00:28:42
But the other possibility is
that what the antidepressant

521
00:28:42 --> 00:28:49
did was it moved the patient
along to a point where they

522
00:28:49 --> 00:28:51
weren't so paralyzed by the
depression that suicide

523
00:28:51 --> 00:28:53
became an option.
 

524
00:28:53 --> 00:28:57
It sounds weird and disturbing,
but that is one possibility for

525
00:28:57 --> 00:29:03
where this elevated rate of
suicide in antidepressant

526
00:29:03 --> 00:29:07
treated young
patients came from.

527
00:29:07 --> 00:29:10
 
 

528
00:29:10 --> 00:29:20
Let's see, what else do I want
to say about Sam and Emma here?

529
00:29:20 --> 00:29:22
Oh, Emma's the one on the back.
 

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

531
00:29:24 --> 00:29:30
We need to collect
some data on Emma.

532
00:29:30 --> 00:29:32
Did I describe Emma
as dysphoric?

533
00:29:32 --> 00:29:32
Yes.
 

534
00:29:32 --> 00:29:34
Emma is a dysphoric.
 

535
00:29:34 --> 00:29:36
That's the opposite
of euphoric.

536
00:29:36 --> 00:29:38
So it's not depressed.
 

537
00:29:38 --> 00:29:41
It would be sort of lying
around here somewhere.

538
00:29:41 --> 00:29:43
Just kind of flat.
 

539
00:29:43 --> 00:29:45
All right.
 

540
00:29:45 --> 00:29:55
So how many people voted
that we'll leave her be?

541
00:29:55 --> 00:29:55
OK.
 

542
00:29:55 --> 00:29:59
How many people voted maybe?
 

543
00:29:59 --> 00:30:02
And how many people voted sure?
 

544
00:30:02 --> 00:30:05
Well, OK, we got a normal
curve out of that.

545
00:30:05 --> 00:30:10
Well, I could have gone -- it
looked sort of like this to me.

546
00:30:10 --> 00:30:14
 
 

547
00:30:14 --> 00:30:17
So people are sort of
unsure about -- oops.

548
00:30:17 --> 00:30:19
Well, I guess it's
going over there now.

549
00:30:19 --> 00:30:22
People are sort of
unsure about it.

550
00:30:22 --> 00:30:24
So what are the issues here?
 

551
00:30:24 --> 00:30:27
Why wouldn't you
give it to her?

552
00:30:27 --> 00:30:27
Yeah?
 

553
00:30:27 --> 00:30:29
AUDIENCE: If she
doesn't want it.

554
00:30:29 --> 00:30:30
PROFESSOR: Oh, yes, yes.
 

555
00:30:30 --> 00:30:30
Well, that's a separate issue.
 

556
00:30:30 --> 00:30:34
Did I say anything about it?
 

557
00:30:34 --> 00:30:36
No, no, no, this is just
-- well, actually, we'll

558
00:30:36 --> 00:30:37
come back to that.
 

559
00:30:37 --> 00:30:39
That's an interesting problem.
 

560
00:30:39 --> 00:30:42
But yes, I was not suggesting
that we jam it down her throat,

561
00:30:42 --> 00:30:46
which is by the way not
the problem with Prozac.

562
00:30:46 --> 00:30:50
 
 

563
00:30:50 --> 00:30:54
Let's imagine that the
antidepressant is Prozac here,

564
00:30:54 --> 00:30:57
or one of its newer friends.
 

565
00:30:57 --> 00:31:05
Prozac gets a lot of play
in the public sphere.

566
00:31:05 --> 00:31:06
Whoops.
 

567
00:31:06 --> 00:31:09
Well, I'll put a P there now.
 

568
00:31:09 --> 00:31:09
Uh oh.
 

569
00:31:09 --> 00:31:11
C or K?
 

570
00:31:11 --> 00:31:12
AUDIENCE: C.
 

571
00:31:12 --> 00:31:12
PROFESSOR: C.
 

572
00:31:12 --> 00:31:12
Yes.
 

573
00:31:12 --> 00:31:13
Thank you.
 

574
00:31:13 --> 00:31:14
OK.
 

575
00:31:14 --> 00:31:25
Prozac is a serotonin -- that's
a neurotransmitter -- selective

576
00:31:25 --> 00:31:27
-- thank you, where
was that coming --

577
00:31:27 --> 00:31:27
AUDIENCE: It's first.
 

578
00:31:27 --> 00:31:29
PROFESSOR: Oh, it's a
selective serotonin, not

579
00:31:29 --> 00:31:30
serotonin selective.
 

580
00:31:30 --> 00:31:31
It's SS.
 

581
00:31:31 --> 00:31:33
All right.
 

582
00:31:33 --> 00:31:33
All right.
 

583
00:31:33 --> 00:31:41
It's a serotonin selective --
reverse -- uptake, reuptake

584
00:31:41 --> 00:31:43
-- can I do reuptake?
 

585
00:31:43 --> 00:31:44
AUDIENCE: [INAUDIBLE]
 

586
00:31:44 --> 00:31:44
PROFESSOR: Yeah.
 

587
00:31:44 --> 00:31:44
Yeah.
 

588
00:31:44 --> 00:31:46
OK.
 

589
00:31:46 --> 00:31:54
Reuptake inhibitor.
 

590
00:31:54 --> 00:31:58
 
 

591
00:31:58 --> 00:32:02
Or an SSRI, which makes it
understandable how I would have

592
00:32:02 --> 00:32:06
thought it might have been
an SSRI rather than an SSRI.

593
00:32:06 --> 00:32:09
 
 

594
00:32:09 --> 00:32:14
But let me explain what
this is doing actually.

595
00:32:14 --> 00:32:18
So remember that in
schizophrenia, the first big

596
00:32:18 --> 00:32:21
psychopharmacological
breakthrough was the discovery

597
00:32:21 --> 00:32:22
there's too much dopamine
in bits of the brain.

598
00:32:22 --> 00:32:29
If we block some dopamine
receptors, we reduce

599
00:32:29 --> 00:32:30
the symptoms.
 

600
00:32:30 --> 00:32:35
In the case of at least some
forms of depression, the

601
00:32:35 --> 00:32:38
problem seems to be too little
serotonin -- or a problem.

602
00:32:38 --> 00:32:40
Seems to be too little
serotonin in some

603
00:32:40 --> 00:32:42
parts of the brain.
 

604
00:32:42 --> 00:32:45
And so you've got a synapse.
 

605
00:32:45 --> 00:32:50
 
 

606
00:32:50 --> 00:32:54
And serotonin is being
released here and binding

607
00:32:54 --> 00:32:57
to the other side.
 

608
00:32:57 --> 00:33:02
But now, in order to have this
synapse be reusable, once

609
00:33:02 --> 00:33:05
you've released some serotonin,
you've got to get rid of it.

610
00:33:05 --> 00:33:07
You've got to get it out of
the synapse so you can do it

611
00:33:07 --> 00:33:08
again and again and again.
 

612
00:33:08 --> 00:33:12
One of the techniques is
to take the molecules and

613
00:33:12 --> 00:33:18
suck them back into the
originating neuron.

614
00:33:18 --> 00:33:20
That's called reuptake.
 

615
00:33:20 --> 00:33:23
Now, if you don't have enough
serotonin here to do the job,

616
00:33:23 --> 00:33:28
one thing to do is to slow
down this reuptake so that

617
00:33:28 --> 00:33:30
the serotonin hangs
around here longer.

618
00:33:30 --> 00:33:36
And that way you get more bang
for your molecular buck.

619
00:33:36 --> 00:33:40
And so that's what
Prozac is doing.

620
00:33:40 --> 00:33:45
The reason I put Emma on here
is that Prozac seemed to do

621
00:33:45 --> 00:33:50
good things for dysphoric
patients, patients who did not

622
00:33:50 --> 00:33:57
meet a clinical criterion for
depression but who found -- I

623
00:33:57 --> 00:34:03
think in part because the drug
manufacturer gave the docs

624
00:34:03 --> 00:34:05
piles of free Prozac.
 

625
00:34:05 --> 00:34:08
You know, patient comes through
and says, "I feel kind

626
00:34:08 --> 00:34:10
of down." So, "Oh yeah.
 

627
00:34:10 --> 00:34:11
Try this.
 

628
00:34:11 --> 00:34:14
This is new." You
know, "All right.

629
00:34:14 --> 00:34:14
Hey!
 

630
00:34:14 --> 00:34:16
I feel better.
 

631
00:34:16 --> 00:34:17
I feel a bunch better.
 

632
00:34:17 --> 00:34:22
I'm not clinically depressed,
but I really like this stuff.

633
00:34:22 --> 00:34:24
 
 

634
00:34:24 --> 00:34:28
And not only that, if I
go off it, I go back

635
00:34:28 --> 00:34:30
to my dysphoric state.
 

636
00:34:30 --> 00:34:32
I go back to -- "
 

637
00:34:32 --> 00:34:34
The example says something
to the effect of, that's

638
00:34:34 --> 00:34:37
just the way she is.
 

639
00:34:37 --> 00:34:43
If she goes off Prozac, there
are lots of reports even in the

640
00:34:43 --> 00:34:46
popular literature of this, of
people who said, you know, if

641
00:34:46 --> 00:34:48
I'm off Prozac, I'm just, ughh.
 

642
00:34:48 --> 00:34:52
But if I'm on Prozac,
I'm just a better me.

643
00:34:52 --> 00:34:54
Well, do you give
them the drug?

644
00:34:54 --> 00:34:55
Do you give them the drug?
 

645
00:34:55 --> 00:34:57
Do you allow them to continue
taking the drug for the rest

646
00:34:57 --> 00:35:00
of their natural born days,
particularly since we have no

647
00:35:00 --> 00:35:03
idea since it's a new drug --
well, now it's over

648
00:35:03 --> 00:35:04
a decade old.
 

649
00:35:04 --> 00:35:05
But, you know, we don't know
what happens if you take this

650
00:35:05 --> 00:35:08
for twenty, thirty,
forty years.

651
00:35:08 --> 00:35:10
Who should pay for it?
 

652
00:35:10 --> 00:35:14
You know, if you think that
this drug makes you feel

653
00:35:14 --> 00:35:16
better, that's lovely.
 

654
00:35:16 --> 00:35:19
Should your insurance
company pay for it on

655
00:35:19 --> 00:35:24
a continuing basis?
 

656
00:35:24 --> 00:35:28
So those are the
Emma issues here.

657
00:35:28 --> 00:35:34
The issues about whether or not
it's OK to make somebody better

658
00:35:34 --> 00:35:38
than they, in some sense,
better than they were.

659
00:35:38 --> 00:35:41
Are you the same person?
 

660
00:35:41 --> 00:35:44
Is this, you know, is this
the real Emma, or is this

661
00:35:44 --> 00:35:47
some medicated Emma?
 

662
00:35:47 --> 00:35:52
And, well, all right, now let's
look back to the comment

663
00:35:52 --> 00:35:54
about forcing them.
 

664
00:35:54 --> 00:35:55
Well, you know what?
 

665
00:35:55 --> 00:35:59
It works on kids, too.
 

666
00:35:59 --> 00:36:06
And you know that there's a
fairly substantial industry in

667
00:36:06 --> 00:36:11
feeding psychiatric drugs to
kids for various and

668
00:36:11 --> 00:36:13
sundry problems.
 

669
00:36:13 --> 00:36:18
Suppose, well, we know
that shy -- how did I

670
00:36:18 --> 00:36:20
describe old Emma here?
 

671
00:36:20 --> 00:36:22
Is she shy and withdrawn?
 

672
00:36:22 --> 00:36:23
No, that was what's his
name collecting the

673
00:36:23 --> 00:36:25
underwear, wasn't it?
 

674
00:36:25 --> 00:36:26
Oh well.
 

675
00:36:26 --> 00:36:30
 
 

676
00:36:30 --> 00:36:33
I could have described
Emma as shy and quiet.

677
00:36:33 --> 00:36:37
We know that the kid who's shy
and quiet in first grade

678
00:36:37 --> 00:36:40
doesn't get the same amount
of attention that the

679
00:36:40 --> 00:36:43
bouncy, active kid gets.
 

680
00:36:43 --> 00:36:49
And in fact, there's some
evidence that if you feed

681
00:36:49 --> 00:36:55
something like Prozac to this
kid, the kid will move from

682
00:36:55 --> 00:36:59
here in the -- well, we've got
to change the axis again.

683
00:36:59 --> 00:37:00
You know, I don't know,
what's the axis here?

684
00:37:00 --> 00:37:02
Bounciness?
 

685
00:37:02 --> 00:37:05
Technical term.
 

686
00:37:05 --> 00:37:05
You know.
 

687
00:37:05 --> 00:37:10
So the kid's going to move from
being unbouncy to, you know,

688
00:37:10 --> 00:37:12
Tigger is up here somewhere.
 

689
00:37:12 --> 00:37:17
 
 

690
00:37:17 --> 00:37:21
As are several -- couple of
people out there halfway up the

691
00:37:21 --> 00:37:28
-- so there's Tigger, I guess.
 

692
00:37:28 --> 00:37:30
But, you know, move them
up here, let's say.

693
00:37:30 --> 00:37:32
Get them above average and
the teacher's going to pay

694
00:37:32 --> 00:37:34
more attention to them.
 

695
00:37:34 --> 00:37:35
Is it OK to medicate your kid?
 

696
00:37:35 --> 00:37:37
AUDIENCE: No.
 

697
00:37:37 --> 00:37:40
PROFESSOR: If it's -- all
right, it's not OK to

698
00:37:40 --> 00:37:40
medicate your kid.
 

699
00:37:40 --> 00:37:42
I'm not going to
medicate my kid.

700
00:37:42 --> 00:37:44
Uh oh.
 

701
00:37:44 --> 00:37:46
The neighbors.
 

702
00:37:46 --> 00:37:49
They're medicating their kids.
 

703
00:37:49 --> 00:37:51
So what they've done --
my kid was right here.

704
00:37:51 --> 00:37:54
He was average, right.
 

705
00:37:54 --> 00:37:57
All right, now what the
neighbors and the population as

706
00:37:57 --> 00:38:01
a whole has done is they moved
the whole distribution over.

707
00:38:01 --> 00:38:06
Because they're all handing
out Prozac in the lunch box.

708
00:38:06 --> 00:38:10
Now is it fair to my kid --
this is a hypothetical my kid.

709
00:38:10 --> 00:38:12
This is not a real issue
on my street in case

710
00:38:12 --> 00:38:13
you're wondering.
 

711
00:38:13 --> 00:38:17
But is it fair to my kid
to not medicate him?

712
00:38:17 --> 00:38:20
He's going to fall behind.
 

713
00:38:20 --> 00:38:24
Is this systematically
different, you know, is this

714
00:38:24 --> 00:38:30
sort of morally or ethically
different than the Kaplan

715
00:38:30 --> 00:38:34
or Princeton Review
approach to SAT tests?

716
00:38:34 --> 00:38:37
 
 

717
00:38:37 --> 00:38:41
What Princeton Review and stuff
does is it takes the population

718
00:38:41 --> 00:38:44
and it shoves it on --
everybody gets to gain those

719
00:38:44 --> 00:38:46
hundred points or whatever.
 

720
00:38:46 --> 00:38:50
So is it OK for you to say, "My
kid doesn't need to do that.

721
00:38:50 --> 00:38:55
I didn't do that when I was a
kid, and no kid of mine's going

722
00:38:55 --> 00:38:56
to go off and get tutored.
 

723
00:38:56 --> 00:38:58
He'll do it on his own brains.
 

724
00:38:58 --> 00:39:01
It's an aptitude test
after all." Right.

725
00:39:01 --> 00:39:05
You know, is there a difference
between everybody being signed

726
00:39:05 --> 00:39:10
up for Princeton Review versus
everybody being signed up, you

727
00:39:10 --> 00:39:11
know, going down to the
nurse's office for the

728
00:39:11 --> 00:39:14
daily Prozac dose?
 

729
00:39:14 --> 00:39:16
Or is there a difference
between just sitting there

730
00:39:16 --> 00:39:19
saying, "I'm not going to go
and make myself into a better

731
00:39:19 --> 00:39:26
me by popping Prozac
all the time.

732
00:39:26 --> 00:39:30
I'll stick with --" What
is that, Mountain Dew?

733
00:39:30 --> 00:39:34
You know, twice the caffeine
of whatever, right?

734
00:39:34 --> 00:39:35
AUDIENCE: Late
night last night.

735
00:39:35 --> 00:39:36
PROFESSOR: Yeah.
 

736
00:39:36 --> 00:39:37
OK, well, that's good.
 

737
00:39:37 --> 00:39:38
You're vertical.
 

738
00:39:38 --> 00:39:40
That's encouraging.
 

739
00:39:40 --> 00:39:41
Give some to the guy
next to you there.

740
00:39:41 --> 00:39:42
He's gone.
 

741
00:39:42 --> 00:39:45
[LAUGHTER FROM AUDIENCE]
 

742
00:39:45 --> 00:39:46
I shouldn't have said that.
 

743
00:39:46 --> 00:39:49
 
 

744
00:39:49 --> 00:39:52
Anyway, we do this
all the time, right?

745
00:39:52 --> 00:39:55
We self-medicate.
 

746
00:39:55 --> 00:39:59
We self-medicate,
particularly with caffeine.

747
00:39:59 --> 00:40:01
But perhaps with a
variety of other things.

748
00:40:01 --> 00:40:04
The use of alcohol as an
antidepressant is probably a

749
00:40:04 --> 00:40:09
mistake, but is not uncommon.
 

750
00:40:09 --> 00:40:17
So when is this a sort of an
unwarranted medicalization of

751
00:40:17 --> 00:40:21
your life, and when is it, you
know, a lifestyle choice?

752
00:40:21 --> 00:40:24
And again, there's not going to
be a question on the final that

753
00:40:24 --> 00:40:30
says, "It's OK to drink
Mountain Dew: yes, no, only if

754
00:40:30 --> 00:40:37
it was a late night." But
you can see that there are

755
00:40:37 --> 00:40:39
issues to wrestle with.
 

756
00:40:39 --> 00:40:45
And the doctors ended up with
or have ended up with a serious

757
00:40:45 --> 00:40:48
problem, which is what do you
do with these patients who you

758
00:40:48 --> 00:40:54
cannot in good conscience give
a clinical diagnosis of

759
00:40:54 --> 00:40:58
clinical depression to, but who
say, you know, if you don't

760
00:40:58 --> 00:41:03
give me my Prozac, I'm just
going to be so depressed, who

761
00:41:03 --> 00:41:07
really need that or who think
that they really need that.

762
00:41:07 --> 00:41:12
Oh, by the way,
OK, what's this?

763
00:41:12 --> 00:41:15
Want to make sure that
I do what it says.

764
00:41:15 --> 00:41:15
Oh.
 

765
00:41:15 --> 00:41:15
Well, OK.
 

766
00:41:15 --> 00:41:19
Let's say something about
how antidepressants work.

767
00:41:19 --> 00:41:24
 
 

768
00:41:24 --> 00:41:28
Here's a mystery for you.
 

769
00:41:28 --> 00:41:30
Take Prozac.
 

770
00:41:30 --> 00:41:36
It blocks the reuptake
pathway within hours.

771
00:41:36 --> 00:41:38
It doesn't take
much time at all.

772
00:41:38 --> 00:41:38
OK.
 

773
00:41:38 --> 00:41:44
So you are down here,
clinically depressed.

774
00:41:44 --> 00:41:45
You come into the
doctor's office.

775
00:41:45 --> 00:41:47
He says, here's your Prozac.
 

776
00:41:47 --> 00:41:48
You take the Prozac.
 

777
00:41:48 --> 00:41:52
A few hours later,
more serotonin at

778
00:41:52 --> 00:41:53
all those synapses.
 

779
00:41:53 --> 00:41:55
How do you feel?
 

780
00:41:55 --> 00:41:58
Well, you feel
depressed, actually.

781
00:41:58 --> 00:42:04
It takes typically at least
days, more like several weeks,

782
00:42:04 --> 00:42:10
before an antidepressant of
this sort has an effect, beyond

783
00:42:10 --> 00:42:11
perhaps placebo effects.
 

784
00:42:11 --> 00:42:14
There are placebo effects where
you can take any old damn thing

785
00:42:14 --> 00:42:16
and you feel a little better if
you're convinced that

786
00:42:16 --> 00:42:17
it's going to work.
 

787
00:42:17 --> 00:42:21
But the main effect of
antidepressants seems

788
00:42:21 --> 00:42:23
to take a long time.
 

789
00:42:23 --> 00:42:24
That's a mystery.
 

790
00:42:24 --> 00:42:27
At least as far as I know,
there's no neat, clean answer

791
00:42:27 --> 00:42:33
to why it should be the case
that the pharmacological effect

792
00:42:33 --> 00:42:37
is there instantly almost
and the psychological effect

793
00:42:37 --> 00:42:40
takes a vastly longer time.
 

794
00:42:40 --> 00:42:43
The reference that I put on
the handout is a theory.

795
00:42:43 --> 00:42:44
It's not proven.
 

796
00:42:44 --> 00:42:48
But it's an interesting theory
about what might be going on.

797
00:42:48 --> 00:42:51
As I think I mentioned earlier
in the course, one of the

798
00:42:51 --> 00:42:55
interesting new findings in
neuroscience is that

799
00:42:55 --> 00:42:56
we grow new neurons.
 

800
00:42:56 --> 00:42:58
We didn't used to think
we grew new neurons.

801
00:42:58 --> 00:43:04
But now it's pretty clear
that you grow new neurons.

802
00:43:04 --> 00:43:08
And there's a pretty strong
suggestion that this

803
00:43:08 --> 00:43:13
neurogenesis, as it's called,
is depressed in depression.

804
00:43:13 --> 00:43:15
You're not making
those new neurons.

805
00:43:15 --> 00:43:21
And one theory is that what an
antidepressant is doing is

806
00:43:21 --> 00:43:24
jump-starting the neurogenesis,
that this is the beginning of a

807
00:43:24 --> 00:43:29
cascade of events that leads
eventually to the birth of

808
00:43:29 --> 00:43:31
new cells, new neurons.
 

809
00:43:31 --> 00:43:33
And only when you manage to
sort of grow yourself a new bit

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

811
00:43:40 --> 00:43:44
of the depression.
 

812
00:43:44 --> 00:43:46
The data on how well these
things work is a little

813
00:43:46 --> 00:43:47
depressing in its own right.
 

814
00:43:47 --> 00:43:52
 
 

815
00:43:52 --> 00:43:55
Antidepressants, like a lot
of these -- antidepressants

816
00:43:55 --> 00:43:58
don't work as well once
they go off patent.

817
00:43:58 --> 00:44:02
It's a mysterious thing.
 

818
00:44:02 --> 00:44:04
You want to worry about this.
 

819
00:44:04 --> 00:44:07
Over and over again you get
some cool new drug like Prozac.

820
00:44:07 --> 00:44:09
It's got no after effects.
 

821
00:44:09 --> 00:44:11
It cures the disease like that.
 

822
00:44:11 --> 00:44:16
And everybody is better,
and it's a miracle drug.

823
00:44:16 --> 00:44:19
Amazingly, by the time, you
know, Eli Lilly or whoever's

824
00:44:19 --> 00:44:22
patent has worn off, it now has
side effects, doesn't work all

825
00:44:22 --> 00:44:27
that well, but you want to try
my new amazing wonder drug.

826
00:44:27 --> 00:44:30
So the last few reviews I've
read of the effectiveness of

827
00:44:30 --> 00:44:33
antidepressants have been,
well, they've been sort of

828
00:44:33 --> 00:44:38
depressing, actually, that
they're not magic bullets.

829
00:44:38 --> 00:44:41
Now, there are several
ways to treat depression.

830
00:44:41 --> 00:44:45
And how you treat it depends
-- there are also several

831
00:44:45 --> 00:44:48
flavors of depression.
 

832
00:44:48 --> 00:44:51
Not all depressions -- well,
certainly not all are bipolar.

833
00:44:51 --> 00:44:56
And there's evidence that they
differ both in their symptoms

834
00:44:56 --> 00:44:59
and in their neurochemistry.
 

835
00:44:59 --> 00:45:02
So for instance, say, I think
it says on the handout --

836
00:45:02 --> 00:45:05
yeah, typical versus
atypical depression.

837
00:45:05 --> 00:45:09
I'm sure if I rummaged around
I'd remember which was which.

838
00:45:09 --> 00:45:15
But in some forms of
depression, people sleep

839
00:45:15 --> 00:45:17
too much and eat too much.
 

840
00:45:17 --> 00:45:19
In other forms of depression,
they sleep too little

841
00:45:19 --> 00:45:22
and eat too little.
 

842
00:45:22 --> 00:45:27
They're both depressions in
terms of the mood, but they

843
00:45:27 --> 00:45:31
are clinically distinct and
psychopharmacologically

844
00:45:31 --> 00:45:32
distinct.
 

845
00:45:32 --> 00:45:42
Actually, bipolar disorders,
the treatment of choice for

846
00:45:42 --> 00:45:45
long before Prozac came
on the scene was of all

847
00:45:45 --> 00:45:46
things lithium chloride.
 

848
00:45:46 --> 00:45:49
It's just the salt of lithium.
 

849
00:45:49 --> 00:45:51
You know, just move right
up from sodium chloride.

850
00:45:51 --> 00:45:54
 
 

851
00:45:54 --> 00:45:58
Jamison credits lithium with
keeping her alive, that if she

852
00:45:58 --> 00:46:03
had not been put on lithium as
a treatment for her bipolar

853
00:46:03 --> 00:46:05
disorder, that she thinks she
probably would have ended

854
00:46:05 --> 00:46:07
up committing suicide.
 

855
00:46:07 --> 00:46:11
Anybody an expert on
how lithium works?

856
00:46:11 --> 00:46:11
No.
 

857
00:46:11 --> 00:46:13
I think I don't know
the answer to this.

858
00:46:13 --> 00:46:14
I'm not sure it's known.
 

859
00:46:14 --> 00:46:16
The last time I checked on it,
we didn't know how it worked.

860
00:46:16 --> 00:46:19
It was -- how was
it discovered?

861
00:46:19 --> 00:46:22
It was discovered in
some bizarro fashion.

862
00:46:22 --> 00:46:26
You know, where do
you find lithium?

863
00:46:26 --> 00:46:30
Like a salt -- I'm
remembering some odd

864
00:46:30 --> 00:46:31
story about, you know --
 

865
00:46:31 --> 00:46:32
AUDIENCE: Batteries?
 

866
00:46:32 --> 00:46:32
PROFESSOR: Fine.
 

867
00:46:32 --> 00:46:34
Batteries?
 

868
00:46:34 --> 00:46:36
That people -- that's --
 

869
00:46:36 --> 00:46:38
AUDIENCE: 7 Up.
 

870
00:46:38 --> 00:46:39
PROFESSOR: 7 Up.
 

871
00:46:39 --> 00:46:43
OK, if you dissolve your
battery in 7 Up, I don't know

872
00:46:43 --> 00:46:45
what happens but I don't
imagine it's good because the

873
00:46:45 --> 00:46:46
mercury and the rest of it
probably isn't really

874
00:46:46 --> 00:46:47
good for you.
 

875
00:46:47 --> 00:46:50
 
 

876
00:46:50 --> 00:47:00
The other treatment for -- now,
sadly not all depressions are

877
00:47:00 --> 00:47:02
amenable to pharmacology.
 

878
00:47:02 --> 00:47:09
Oh, first of all, the big
mistake, which I think the

879
00:47:09 --> 00:47:14
insurance people are growing
out of, was the notion, OK, now

880
00:47:14 --> 00:47:17
that we've got these cool
pills, we'll pay for the

881
00:47:17 --> 00:47:19
pills, but that's it.
 

882
00:47:19 --> 00:47:26
So if it's going to take you
several weeks for the medicine

883
00:47:26 --> 00:47:29
to work, it turns out to be
very helpful if you're actually

884
00:47:29 --> 00:47:32
talking to somebody during this
time, if there's some

885
00:47:32 --> 00:47:36
psychotherapy of
some sort going on.

886
00:47:36 --> 00:47:38
Because if you are down here in
the depths of the depression

887
00:47:38 --> 00:47:41
and some genius hands you a
pill and says, "Go away.

888
00:47:41 --> 00:47:45
Don't bother me no more." You
know, if it's true that as

889
00:47:45 --> 00:47:47
you're slowly coming out of the
depression, that's when the

890
00:47:47 --> 00:47:51
suicides take place, you know,
this is a recipe for disaster.

891
00:47:51 --> 00:47:54
And if it takes a long time to
work -- you know, if you take a

892
00:47:54 --> 00:47:57
medicine and nothing happens
for weeks, what do you do?

893
00:47:57 --> 00:47:59
You stop taking the medicine.
 

894
00:47:59 --> 00:48:04
And so what you really need
typically as part of a sensible

895
00:48:04 --> 00:48:08
treatment for a depression is
not only somebody who will give

896
00:48:08 --> 00:48:09
you the medicine, but
somebody who will talk

897
00:48:09 --> 00:48:11
to you about it too.
 

898
00:48:11 --> 00:48:14
But even so there are
depressions that are not

899
00:48:14 --> 00:48:18
amenable -- or don't seem
to respond well to any

900
00:48:18 --> 00:48:20
of the medicines that
we have at the moment.

901
00:48:20 --> 00:48:24
And under the heading of even
more unlikely treatments that

902
00:48:24 --> 00:48:29
really turn out to work, more
unlikely than feeding them

903
00:48:29 --> 00:48:33
lithium salts, is what's
known as ECT for

904
00:48:33 --> 00:48:35
electroconvulsive therapy.
 

905
00:48:35 --> 00:48:38
I talked about this a bit when
we were talking about memory.

906
00:48:38 --> 00:48:40
Remember this is little rats.
 

907
00:48:40 --> 00:48:41
They step down.
 

908
00:48:41 --> 00:48:44
You run electrical current
through their heads.

909
00:48:44 --> 00:48:45
You shock their little feet.
 

910
00:48:45 --> 00:48:47
You run electrical current
through their brains.

911
00:48:47 --> 00:48:48
They don't remember that you
shocked their feet, so they

912
00:48:48 --> 00:48:50
step down again, you know.
 

913
00:48:50 --> 00:48:51
Sound familiar?
 

914
00:48:51 --> 00:48:54
OK, good.
 

915
00:48:54 --> 00:48:57
Well, this is a treatment
for depression.

916
00:48:57 --> 00:49:04
Not abundantly clear why it
works, but in my circle of

917
00:49:04 --> 00:49:11
friends, I have a friend who
actually went back to --

918
00:49:11 --> 00:49:13
graduated college, went off,
did a whole bunch of stuff,

919
00:49:13 --> 00:49:18
then went back to med school,
then became desperately

920
00:49:18 --> 00:49:23
clinically depressed and
had to be hospitalized.

921
00:49:23 --> 00:49:29
And what got her through it was
electroconvulsive therapy.

922
00:49:29 --> 00:49:33
Not an entirely
benign procedure.

923
00:49:33 --> 00:49:36
It does have memory
side effects.

924
00:49:36 --> 00:49:39
But it used to be that nobody
in an intro psych class thought

925
00:49:39 --> 00:49:41
this was a good idea at all
because everybody had seen One

926
00:49:41 --> 00:49:43
Flew Over the Cuckoo's Nest.
 

927
00:49:43 --> 00:49:45
How many people have
seen that movie?

928
00:49:45 --> 00:49:47
Oh, so still a fair number
people have seen it.

929
00:49:47 --> 00:49:49
That's a movie that does
nothing good for the reputation

930
00:49:49 --> 00:49:51
of electroconvulsive therapy.
 

931
00:49:51 --> 00:49:55
Electroconvulsive therapy
these days is, you know, you

932
00:49:55 --> 00:49:56
give somebody a sedative.
 

933
00:49:56 --> 00:49:58
They don't thrash around.
 

934
00:49:58 --> 00:49:59
They don't hurt themselves.
 

935
00:49:59 --> 00:50:02
It still has memory
consequences, consolidation of

936
00:50:02 --> 00:50:04
memory consequences, but it
really does seem to

937
00:50:04 --> 00:50:09
mysteriously break
up depressions.

938
00:50:09 --> 00:50:14
Now the latest wrinkle on this,
you know, what boils down

939
00:50:14 --> 00:50:17
to smack-them-up-th
e-side-of-the-head treatments

940
00:50:17 --> 00:50:21
of depression is the use of,
very new, is the use of

941
00:50:21 --> 00:50:25
transcranial magnetic
stimulation, which I think I

942
00:50:25 --> 00:50:26
also talked about earlier.
 

943
00:50:26 --> 00:50:29
But basically what you do is
you put a giant electromagnet

944
00:50:29 --> 00:50:32
or strong electromagnet
next to the skull.

945
00:50:32 --> 00:50:37
You fire a big pulse of -- a
big magnetic field that induces

946
00:50:37 --> 00:50:44
an electrical field locally and
knocks out neural

947
00:50:44 --> 00:50:47
activity locally.
 

948
00:50:47 --> 00:50:50
And there's some evidence that
properly applied, that this is

949
00:50:50 --> 00:50:56
a sort of a kinder, gentler
version of ECT, that it acts

950
00:50:56 --> 00:50:57
to break up depressions.
 

951
00:50:57 --> 00:50:59
I don't -- anybody know if
there's a brilliant theory

952
00:50:59 --> 00:51:01
for how that works?
 

953
00:51:01 --> 00:51:02
Uh, who knows?
 

954
00:51:02 --> 00:51:06
But it's very new.
 

955
00:51:06 --> 00:51:10
But I expect that in a few
years, I'll be lecturing

956
00:51:10 --> 00:51:11
more about that.
 

957
00:51:11 --> 00:51:18
Because it, at least initially,
sounds rather promising.

958
00:51:18 --> 00:51:18
All right.
 

959
00:51:18 --> 00:51:26
I think this would be a
good time to take a break.

960
00:51:26 --> 00:51:30
Let's take -- unless you're
too depressed to get

961
00:51:30 --> 00:51:31
up, take a break.
 

962
00:51:31 --> 00:51:42
 
 

963
00:51:42 --> 00:51:47
AUDIENCE: I read
Jamison's book.

964
00:51:47 --> 00:51:47
PROFESSOR: Uh huh.
 

965
00:51:47 --> 00:51:48
Which one?
 

966
00:51:48 --> 00:51:49
AUDIENCE: Prozac Nation.
 

967
00:51:49 --> 00:51:50
PROFESSOR: No.
 

968
00:51:50 --> 00:51:51
Prozac Nation is
somebody else's book.

969
00:51:51 --> 00:51:52
AUDIENCE: Not Jamison?
 

970
00:51:52 --> 00:51:53
PROFESSOR: No, that's
somebody else.

971
00:51:53 --> 00:51:56
I can't remember who wrote
it, but yes, that's

972
00:51:56 --> 00:51:57
a cool book, too.
 

973
00:51:57 --> 00:51:57
AUDIENCE: Yes.
 

974
00:51:57 --> 00:51:58
That's what I thought
you were talking about.

975
00:51:58 --> 00:51:59
PROFESSOR: Nope.
 

976
00:51:59 --> 00:52:00
Nope.
 

977
00:52:00 --> 00:52:02
But you'll come back and
tell me who wrote it.

978
00:52:02 --> 00:52:05
Because we're both
forgetting who wrote it.

979
00:52:05 --> 00:52:08
AUDIENCE: Have they ever done,
what is it, using sugar pill

980
00:52:08 --> 00:52:10
and Prozac and hand them out to
patients and just seeing

981
00:52:10 --> 00:52:11
if the sugar pill --
 

982
00:52:11 --> 00:52:16
PROFESSOR: It's a big problem
in mental illness in general

983
00:52:16 --> 00:52:19
and certainly in depression,
which is, particularly if

984
00:52:19 --> 00:52:21
you've got a cycling
depression, who's

985
00:52:21 --> 00:52:22
going to get better?
 

986
00:52:22 --> 00:52:22
Right?
 

987
00:52:22 --> 00:52:30
And, yeah, the difference
between placebos and Prozac is,

988
00:52:30 --> 00:52:33
at least in some of the studies
that I've read, a lot less

989
00:52:33 --> 00:52:36
dramatic than you would think.
 

990
00:52:36 --> 00:52:41
And the problem with a
population like us is that

991
00:52:41 --> 00:52:44
we're too well informed.
 

992
00:52:44 --> 00:52:45
Placebos are great.
 

993
00:52:45 --> 00:52:48
The side effects are
really limited.

994
00:52:48 --> 00:52:51
In the good old days, your
doctor would come around, have

995
00:52:51 --> 00:52:55
no clue, you know, how to treat
you, but give you, you know,

996
00:52:55 --> 00:53:01
Dr. Hoozy's magic elixir,
and you'd feel better.

997
00:53:01 --> 00:53:04
And it's a great pity that now
if I fed you Dr. Hoozy's

998
00:53:04 --> 00:53:07
elixir, the first thing you'd
do is Google it and discover

999
00:53:07 --> 00:53:10
that it's snake oil, and
feel worse and sue me.

1000
00:53:10 --> 00:53:17
So, yeah, if you turn out to be
particularly interested, send

1001
00:53:17 --> 00:53:20
me an email and I can send you
a couple of the references of

1002
00:53:20 --> 00:53:22
things that depressed
me when I read them.

1003
00:53:22 --> 00:53:25
Because they weren't
that much good.

1004
00:53:25 --> 00:53:28
On the other hand, my
mother absolutely

1005
00:53:28 --> 00:53:31
swears by this stuff.
 

1006
00:53:31 --> 00:53:34
She's had her own issues
with depression and thinks

1007
00:53:34 --> 00:53:35
that Prozac is wonderful.
 

1008
00:53:35 --> 00:55:33
[PRIVATE CONVERSATION]
 

1009
00:55:33 --> 00:55:38
PROFESSOR: I want to talk about
a couple of other disease, you

1010
00:55:38 --> 00:55:46
know, mental illness states, in
part as a way of illustrating

1011
00:55:46 --> 00:55:50
-- I guess what I really want
to illustrate in the last bit

1012
00:55:50 --> 00:55:55
of this lecture is the, sort
of, mind and brain links.

1013
00:55:55 --> 00:55:59
We tend to like to make
up theories that are

1014
00:55:59 --> 00:56:00
one or the other.
 

1015
00:56:00 --> 00:56:04
And the current popular trend
is towards brain explanations.

1016
00:56:04 --> 00:56:08
Oh, you're depressed because
you don't have enough

1017
00:56:08 --> 00:56:10
serotonin happening for you.
 

1018
00:56:10 --> 00:56:11
We'll boost up your serotonin.
 

1019
00:56:11 --> 00:56:12
You'll be fine.
 

1020
00:56:12 --> 00:56:14
It's a very brain
kind of thing.

1021
00:56:14 --> 00:56:17
Freudian theories were very
mind kinds of things.

1022
00:56:17 --> 00:56:22
But there's a number of cases
that really illustrate, I

1023
00:56:22 --> 00:56:28
think, well, what you sort
of know intuitively, right?

1024
00:56:28 --> 00:56:31
The brain isn't here
and the mind is here.

1025
00:56:31 --> 00:56:33
It's, you know, waves
and particles.

1026
00:56:33 --> 00:56:36
They're two manifestations
of the same thing.

1027
00:56:36 --> 00:56:39
And brain stuff and mind
stuff bounce back and

1028
00:56:39 --> 00:56:41
forth here all the time.
 

1029
00:56:41 --> 00:56:46
So let's think, for
example, of panic attacks.

1030
00:56:46 --> 00:56:49
Which I didn't put on the
handout at all, I see, but I

1031
00:56:49 --> 00:56:52
suddenly developed a need to
talk about because I

1032
00:56:52 --> 00:56:58
was feeling really
anxious and -- no.

1033
00:56:58 --> 00:57:04
So panic attack is this feeling
of anxiety out of the blue.

1034
00:57:04 --> 00:57:08
 
 

1035
00:57:08 --> 00:57:10
People report that they just
suddenly feel very, very,

1036
00:57:10 --> 00:57:13
very fearful and anxious.
 

1037
00:57:13 --> 00:57:17
And it's scary and it's
unpleasant and so on.

1038
00:57:17 --> 00:57:21
You may recall that Freud and
his followers had a perfectly

1039
00:57:21 --> 00:57:25
nice notion about this, which
was that anxiety was warning

1040
00:57:25 --> 00:57:30
you that you were about to
tread on the super ego.

1041
00:57:30 --> 00:57:34
And it was the warning sign
of the ego that was saying,

1042
00:57:34 --> 00:57:35
don't go and do that.
 

1043
00:57:35 --> 00:57:39
But that hasn't
worked that well.

1044
00:57:39 --> 00:57:44
More modern notions tend to
focus on the idea that it's

1045
00:57:44 --> 00:57:46
essentially neurochemical.
 

1046
00:57:46 --> 00:57:49
 
 

1047
00:57:49 --> 00:57:54
You get too much of some
juice, some neurotransmitter.

1048
00:57:54 --> 00:57:57
It fires off the bits of your
brain that are responsible for

1049
00:57:57 --> 00:57:59
the experience of anxiety.
 

1050
00:57:59 --> 00:58:02
And you feel this anxiety.
 

1051
00:58:02 --> 00:58:07
And this is a lovely case
of looping back to a prior

1052
00:58:07 --> 00:58:10
mode of understanding.
 

1053
00:58:10 --> 00:58:13
The notion that you feel too
anxious because you have too

1054
00:58:13 --> 00:58:16
much of this fluid, it's an
awful lot like the notion that

1055
00:58:16 --> 00:58:20
you feel melancholic because
you have too much black bile.

1056
00:58:20 --> 00:58:22
The difference of course is
that we think we've got

1057
00:58:22 --> 00:58:23
a better scientific
grounding than we had.

1058
00:58:23 --> 00:58:29
But the form of the argument
is rather similar.

1059
00:58:29 --> 00:58:33
So is it the case that panic
attacks, the clinical condition

1060
00:58:33 --> 00:58:39
of a panic attack, is just
too much of some juice.

1061
00:58:39 --> 00:58:43
It's possible to think about
it as being somewhat more

1062
00:58:43 --> 00:58:45
complicated than that.
 

1063
00:58:45 --> 00:58:47
And, well, I didn't put that
reference on the handout,

1064
00:58:47 --> 00:58:48
because I didn't.
 

1065
00:58:48 --> 00:58:54
But I'm stealing a story from
-- who am I stealing it from?

1066
00:58:54 --> 00:59:00
Oh, Dave Barlow,
who's over at BU.

1067
00:59:00 --> 00:59:05
This is a three-step
route into panic attack.

1068
00:59:05 --> 00:59:12
And the first part of it is
that you feel the visible

1069
00:59:12 --> 00:59:15
symptoms of anxiety.
 

1070
00:59:15 --> 00:59:22
Your heart starts -- remember
the shaky bridge experiment

1071
00:59:22 --> 00:59:25
all about misattribution
of arousal?

1072
00:59:25 --> 00:59:28
You're feeling "ooh-ooh-ooh"
and you see her, and you just

1073
00:59:28 --> 00:59:31
think you're feeling
"aah." Right?

1074
00:59:31 --> 00:59:34
So that can work in
all sorts of ways.

1075
00:59:34 --> 00:59:38
Suppose that your heart is
going through -- there are a

1076
00:59:38 --> 00:59:41
variety of things that cause
your heart to go pitter-pat.

1077
00:59:41 --> 00:59:46
Suppose that you get these sort
of symptoms and you don't

1078
00:59:46 --> 00:59:50
interpret it as love, you
interpret it as "I feel

1079
00:59:50 --> 00:59:52
nervous about something.
 

1080
00:59:52 --> 00:59:55
I can't quite tell
exactly what it is.

1081
00:59:55 --> 00:59:56
But I don't --"
 

1082
00:59:56 --> 00:59:58
People don't have panic
attacks, by the way,

1083
00:59:58 --> 01:00:02
typically, when they're
exercising vigorously.

1084
01:00:02 --> 01:00:04
Because they've got a good
account of where that

1085
01:00:04 --> 01:00:05
symptom is coming from.
 

1086
01:00:05 --> 01:00:08
Your heart's pounding, you're
sweating, and stuff like that.

1087
01:00:08 --> 01:00:09
Yeah, all right, fine.
 

1088
01:00:09 --> 01:00:11
If you're walking down the
street and your heart is

1089
01:00:11 --> 01:00:15
pounding and you're sweating,
you need a different

1090
01:00:15 --> 01:00:16
interpretation.
 

1091
01:00:16 --> 01:00:19
Now, this is unpleasant.
 

1092
01:00:19 --> 01:00:23
So you develop, flipping back
to an earlier piece of the

1093
01:00:23 --> 01:00:27
course, you develop a
conditioned fear of

1094
01:00:27 --> 01:00:29
these symptoms.
 

1095
01:00:29 --> 01:00:38
So you start avoiding
situations that would produce

1096
01:00:38 --> 01:00:43
the symptoms, or that you think
might produce these symptoms.

1097
01:00:43 --> 01:00:46
And this can be quite
unconscious, right?

1098
01:00:46 --> 01:00:49
This is good classical
association learning or

1099
01:00:49 --> 01:00:52
something of that sort.
 

1100
01:00:52 --> 01:00:55
And that in turn -- that's sort
of step two, is sort of a

1101
01:00:55 --> 01:01:04
learning story that is going to
cause you to start -- you're

1102
01:01:04 --> 01:01:07
going to act to avoid
situations that make

1103
01:01:07 --> 01:01:10
you feel nervous.
 

1104
01:01:10 --> 01:01:15
But, all right,
remember Pavlov?

1105
01:01:15 --> 01:01:16
Bell, tone.
 

1106
01:01:16 --> 01:01:17
Bell, tone.
 

1107
01:01:17 --> 01:01:18
Bell, tone.
 

1108
01:01:18 --> 01:01:19
Now I ring the bell by itself.
 

1109
01:01:19 --> 01:01:20
No.
 

1110
01:01:20 --> 01:01:20
Bell, tone.
 

1111
01:01:20 --> 01:01:23
That's stupid.
 

1112
01:01:23 --> 01:01:26
I'm not supposed to be the one
who notices that first, guys.

1113
01:01:26 --> 01:01:27
You're supposed to --
"What's he talking about?"

1114
01:01:27 --> 01:01:28
Anyway, bell, food.
 

1115
01:01:28 --> 01:01:29
Bell, food.
 

1116
01:01:29 --> 01:01:30
Bell, food.
 

1117
01:01:30 --> 01:01:32
Eventually the bell by
itself produces salivation.

1118
01:01:32 --> 01:01:37
So you make this association
in your own mind.

1119
01:01:37 --> 01:01:40
So when did this happen to me?
 

1120
01:01:40 --> 01:01:42
I was outside.
 

1121
01:01:42 --> 01:01:43
OK.
 

1122
01:01:43 --> 01:01:47
So now I'm outside, it
doesn't happen to me.

1123
01:01:47 --> 01:01:51
But I feel -- I get the
conditioned response in effect.

1124
01:01:51 --> 01:01:55
So now something else acts
as a trigger for the panic.

1125
01:01:55 --> 01:01:58
The initial feeling of panic
might have been, I don't

1126
01:01:58 --> 01:02:03
know, too many bottles
of Mountain Dew, right.

1127
01:02:03 --> 01:02:06
You drink enough caffeine,
and you'll get b-b-b-b.

1128
01:02:06 --> 01:02:08
Forget that you drank -- your
brain doesn't remember the

1129
01:02:08 --> 01:02:10
caffeine part of the story.
 

1130
01:02:10 --> 01:02:11
And you're going b-b-b-b.
 

1131
01:02:11 --> 01:02:12
And you say, "Oh!
 

1132
01:02:12 --> 01:02:17
I'm having a panic attack."
Then you don't want that --

1133
01:02:17 --> 01:02:20
this is an aversive event.
 

1134
01:02:20 --> 01:02:23
It's just like the business of
the rat stepping down, right?

1135
01:02:23 --> 01:02:27
The rat steps down
-- oh, all right.

1136
01:02:27 --> 01:02:31
Rat's up here, rat steps down,
gets his little feet shocked.

1137
01:02:31 --> 01:02:32
That's unpleasant.
 

1138
01:02:32 --> 01:02:34
Rat's put back up here.
 

1139
01:02:34 --> 01:02:35
Does the rat step down again?
 

1140
01:02:35 --> 01:02:36
No.
 

1141
01:02:36 --> 01:02:36
Why?
 

1142
01:02:36 --> 01:02:38
Because he's got this
anticipatory fear.

1143
01:02:38 --> 01:02:41
You can actually measure
the fear physiologically.

1144
01:02:41 --> 01:02:45
All right, so you caffeine
overdose or whatever.

1145
01:02:45 --> 01:02:47
You have this
unpleasant experience.

1146
01:02:47 --> 01:02:50
Now you're in that environment
again sometime later and you

1147
01:02:50 --> 01:02:53
have the experience again
because it's a conditioned

1148
01:02:53 --> 01:02:56
response now, no
caffeine involved.

1149
01:02:56 --> 01:03:01
You come to the reasonable, if
perhaps unconscious, conclusion

1150
01:03:01 --> 01:03:08
that what makes me nervous is
being outside in public

1151
01:03:08 --> 01:03:10
or being on shaky
bridges or whatever.

1152
01:03:10 --> 01:03:13
Then you get step three, which
is again learning theory kind

1153
01:03:13 --> 01:03:15
of stuff like Thorndike's
Law of Effect.

1154
01:03:15 --> 01:03:22
You start doing things to
avoid this punishment, right.

1155
01:03:22 --> 01:03:25
You're going to avoid
the aversive stimulus.

1156
01:03:25 --> 01:03:29
So you can get secondary
symptoms to the panic, like a

1157
01:03:29 --> 01:03:36
fear of open spaces, let's say,
because you've now, perhaps

1158
01:03:36 --> 01:03:39
completely unconsciously,
concluded, "If I go out in

1159
01:03:39 --> 01:03:41
public, the sky is so big.
 

1160
01:03:41 --> 01:03:42
I feel so small.
 

1161
01:03:42 --> 01:03:44
I get panicky.
 

1162
01:03:44 --> 01:03:46
And so now I'm not
going to go outside."

1163
01:03:46 --> 01:03:50
And so what you end up with is
the possibility that the

1164
01:03:50 --> 01:03:53
clinical thing that you see,
what you get in your office if

1165
01:03:53 --> 01:03:57
you're the clinician, is
somebody who says, "I have, you

1166
01:03:57 --> 01:04:00
know, I have uncontrollable
panic when I'm outdoors.

1167
01:04:00 --> 01:04:03
This is crippling my life
because I don't go out

1168
01:04:03 --> 01:04:07
anymore." And what this may be
is a cascade of events coming

1169
01:04:07 --> 01:04:11
from some sort of an initial
physiological issue that you

1170
01:04:11 --> 01:04:15
then learned about, if you
like, using the laws of animal

1171
01:04:15 --> 01:04:20
learning, in ways that
that don't work well.

1172
01:04:20 --> 01:04:22
Well, what are you
going to do about it?

1173
01:04:22 --> 01:04:24
Well, one thing you might do
about it if you believed that

1174
01:04:24 --> 01:04:28
there was a significant
learning component here is to

1175
01:04:28 --> 01:04:32
use learning theory kinds
of things to treat it.

1176
01:04:32 --> 01:04:36
Now if it turns out that there
really is a chemical imbalance

1177
01:04:36 --> 01:04:39
and every time the chemicals
go out of whack, you feel

1178
01:04:39 --> 01:04:41
panicked, you might want to do
something about the chemicals.

1179
01:04:41 --> 01:04:44
But if you've got one of these
situations where the person has

1180
01:04:44 --> 01:04:49
basically scared themselves
into maladaptive behavior,

1181
01:04:49 --> 01:04:52
you've now got to
un-scare them.

1182
01:04:52 --> 01:04:53
So what are you going to do?
 

1183
01:04:53 --> 01:04:56
One of the standard techniques
for these sort of disorders

1184
01:04:56 --> 01:04:59
would be desensitization
methods.

1185
01:04:59 --> 01:05:01
Is it Barlow who
was doing this?

1186
01:05:01 --> 01:05:04
 
 

1187
01:05:04 --> 01:05:07
So one of the versions --
you can imagine -- I did a

1188
01:05:07 --> 01:05:09
version where you became
scared of the outside.

1189
01:05:09 --> 01:05:13
Another version is you have a
panic attack in an enclosed

1190
01:05:13 --> 01:05:15
space and you become very
nervous about enclosed spaces.

1191
01:05:15 --> 01:05:18
You won't go into elevators
and stuff like that.

1192
01:05:18 --> 01:05:22
I can't remember if it was
Barlow -- I got a feeling it

1193
01:05:22 --> 01:05:27
was -- whose technique for --
there are a variety of ways of

1194
01:05:27 --> 01:05:30
using learning theory
to get around this.

1195
01:05:30 --> 01:05:32
One is the kinder, gentler one.
 

1196
01:05:32 --> 01:05:34
So you come to me.
 

1197
01:05:34 --> 01:05:37
You say, "I'm really afraid of
being in enclosed spaces."

1198
01:05:37 --> 01:05:43
You say, "OK" -- the first cure
out in this field that you've

1199
01:05:43 --> 01:05:46
come to, that I'm using for my
doctor's office at the

1200
01:05:46 --> 01:05:49
moment -- "Imagine that
you're in a space.

1201
01:05:49 --> 01:05:50
Can you deal with that?"
 

1202
01:05:50 --> 01:05:52
"Oh, it's making me nervous,
but, yeah, OK, I can

1203
01:05:52 --> 01:05:53
deal with that."
 

1204
01:05:53 --> 01:05:55
"OK, now we'll go to 10-250.
 

1205
01:05:55 --> 01:05:57
It's a big enclosed space.
 

1206
01:05:57 --> 01:05:59
And then we'll go to a smaller
room and a smaller room.

1207
01:05:59 --> 01:06:04
And eventually we'll put you
in a closet for a while.

1208
01:06:04 --> 01:06:06
And you'll discover -- what
you'll do is un-learn

1209
01:06:06 --> 01:06:08
the response, in effect.
 

1210
01:06:08 --> 01:06:12
You'll learn nothing
bad happened to me."

1211
01:06:12 --> 01:06:18
And this behaviorist sort of
therapy does work to break up

1212
01:06:18 --> 01:06:21
these sorts of behaviors
in many cases.

1213
01:06:21 --> 01:06:25
I think it's Barlow who has
been advocating a much less

1214
01:06:25 --> 01:06:27
kinder, gentler version,
which is to shut

1215
01:06:27 --> 01:06:29
people in car trunks.
 

1216
01:06:29 --> 01:06:32
 
 

1217
01:06:32 --> 01:06:34
So none of this business
of doing it gradually.

1218
01:06:34 --> 01:06:37
This is known in the
trade as flooding.

1219
01:06:37 --> 01:06:41
You just take the -- the guy
says, "You know, I think if

1220
01:06:41 --> 01:06:45
I'm in an enclosed space,
I'm going to die."

1221
01:06:45 --> 01:06:46
"All right.
 

1222
01:06:46 --> 01:06:46
Boom.
 

1223
01:06:46 --> 01:06:48
You dead yet?
 

1224
01:06:48 --> 01:06:48
No.
 

1225
01:06:48 --> 01:06:49
OK.
 

1226
01:06:49 --> 01:06:50
You're cured.
 

1227
01:06:50 --> 01:06:50
Good.
 

1228
01:06:50 --> 01:06:50
Out."
 

1229
01:06:50 --> 01:06:53
Well, it's not quite that
simple, but the basic idea is

1230
01:06:53 --> 01:06:58
that if you have a patient who
can actually deal with this,

1231
01:06:58 --> 01:07:02
that you can basically speed up
the therapy rather dramatically

1232
01:07:02 --> 01:07:06
by not moving gradually to --
this is used for all

1233
01:07:06 --> 01:07:08
sorts of phobias.
 

1234
01:07:08 --> 01:07:13
So, scared of snakes, you
know, you're pathologically

1235
01:07:13 --> 01:07:14
scared of snakes.
 

1236
01:07:14 --> 01:07:19
OK, what we'll do is first
we'll show you -- so the two

1237
01:07:19 --> 01:07:21
versions are desensitization
and flooding.

1238
01:07:21 --> 01:07:24
The desensitization
story would be:

1239
01:07:24 --> 01:07:25
"We'll show you
pictures of snakes."

1240
01:07:25 --> 01:07:27
"Ooh, I hate it.
 

1241
01:07:27 --> 01:07:27
I hate it."
 

1242
01:07:27 --> 01:07:27
"Are you dead?"
 

1243
01:07:27 --> 01:07:27
"No."
 

1244
01:07:27 --> 01:07:33
"Oh, OK." So now we'll go
to the zoo. "And see that

1245
01:07:33 --> 01:07:34
snake cage way over there?
 

1246
01:07:34 --> 01:07:34
Are you dead yet?"
 

1247
01:07:34 --> 01:07:35
"No."
 

1248
01:07:35 --> 01:07:36
"OK, let's get closer.
 

1249
01:07:36 --> 01:07:37
OK, that's a snake, right.
 

1250
01:07:37 --> 01:07:38
OK, now you're going
to get in with him.

1251
01:07:38 --> 01:07:39
Yeah."
 

1252
01:07:39 --> 01:07:39
"Aah."
 

1253
01:07:39 --> 01:07:40
All right.
 

1254
01:07:40 --> 01:07:42
"But I'm not dead."
 

1255
01:07:42 --> 01:07:45
And the flooding technique is
"You're afraid of snakes?

1256
01:07:45 --> 01:07:47
Boom.
 

1257
01:07:47 --> 01:07:49
See those boas?
 

1258
01:07:49 --> 01:07:49
Are you dead?"
 

1259
01:07:49 --> 01:07:50
"Yes, actually."
 

1260
01:07:50 --> 01:07:54
[LAUGHTER FROM AUDIENCE]
 

1261
01:07:54 --> 01:08:02
So, anyway, the point from the
panic attack example is that

1262
01:08:02 --> 01:08:06
it's possible that what you're
seeing as the clinical entity

1263
01:08:06 --> 01:08:13
is a dance between physiology
and learning, in effect, and

1264
01:08:13 --> 01:08:16
that what you learn -- and
that a mode of treatment

1265
01:08:16 --> 01:08:19
would be to unlearn.
 

1266
01:08:19 --> 01:08:22
Now, let's take another example
which I did put on the

1267
01:08:22 --> 01:08:24
handout, which is obsessive
compulsive disorders.

1268
01:08:24 --> 01:08:27
 
 

1269
01:08:27 --> 01:08:32
Obsessive compulsive disorders
are, well, there's the

1270
01:08:32 --> 01:08:37
obsessive part and there's
the compulsive part.

1271
01:08:37 --> 01:08:42
The obsessive part refers
to obsessive thoughts.

1272
01:08:42 --> 01:08:48
What gets you into treatment
is not some sort of obsessive

1273
01:08:48 --> 01:08:51
thought that "I love him.
 

1274
01:08:51 --> 01:08:52
I really love him.
 

1275
01:08:52 --> 01:08:53
Oh, I love him a lot.
 

1276
01:08:53 --> 01:08:54
Oh yeah, yeah, yeah.
 

1277
01:08:54 --> 01:08:56
I can't help but think about
him." Yeah, it's a little

1278
01:08:56 --> 01:08:58
obsessive, but tough.
 

1279
01:08:58 --> 01:09:03
It's "Every time I look at him,
I want to rip his guts out.

1280
01:09:03 --> 01:09:07
I'm imagining the knife."
You know, or something.

1281
01:09:07 --> 01:09:10
It's disturbing thoughts
that somehow won't get

1282
01:09:10 --> 01:09:11
out of your brain.
 

1283
01:09:11 --> 01:09:16
That's the sort of obsession
that people seek treatment for.

1284
01:09:16 --> 01:09:22
And compulsive behaviors are
behaviors where -- everybody

1285
01:09:22 --> 01:09:23
has some degree of this.
 

1286
01:09:23 --> 01:09:29
How many people here have left
their room, gotten halfway down

1287
01:09:29 --> 01:09:33
the hall, said "Did I really
lock it?", and gone

1288
01:09:33 --> 01:09:35
back to check?
 

1289
01:09:35 --> 01:09:37
Everybody does that sometime.
 

1290
01:09:37 --> 01:09:41
Or did I turn the stove off
or something like that.

1291
01:09:41 --> 01:09:45
That's normal on
compulsion land.

1292
01:09:45 --> 01:09:48
And almost always you
have locked it, right?

1293
01:09:48 --> 01:09:51
Because the time you didn't
lock it is the time you don't

1294
01:09:51 --> 01:09:55
go back to check, and somebody
steals all your stuff.

1295
01:09:55 --> 01:09:56
Very annoying.
 

1296
01:09:56 --> 01:09:59
I donated a laptop to
the criminal elements

1297
01:09:59 --> 01:10:00
doing exactly that.
 

1298
01:10:00 --> 01:10:01
Very annoying.
 

1299
01:10:01 --> 01:10:09
But anyway, if you have to
go and, you know, get down

1300
01:10:09 --> 01:10:12
the hall, "Did I lock it?
 

1301
01:10:12 --> 01:10:14
Yep, it's locked.
 

1302
01:10:14 --> 01:10:19
Did I lock it?" You've got to
do that forty or fifty times

1303
01:10:19 --> 01:10:22
and you can't get on with
your life, literally.

1304
01:10:22 --> 01:10:25
You can't get to the next
event in your life.

1305
01:10:25 --> 01:10:29
That's a compulsion that is
likely to lead you to want

1306
01:10:29 --> 01:10:31
to do something about it.
 

1307
01:10:31 --> 01:10:36
It's interesting that these are
compulsions -- rather like

1308
01:10:36 --> 01:10:39
there are similarities in
people's narrative dreams --

1309
01:10:39 --> 01:10:46
that compulsions seem to be
drawn from a limited vocabulary

1310
01:10:46 --> 01:10:47
of candidate compulsions.
 

1311
01:10:47 --> 01:10:49
I mean, I'm sure there's one
of everything out there,

1312
01:10:49 --> 01:10:54
but there's lots of
hand washers, right.

1313
01:10:54 --> 01:10:56
Actually, I can see my
hands are covered in

1314
01:10:56 --> 01:10:57
chalk at the moment.
 

1315
01:10:57 --> 01:10:58
I should go wash them.
 

1316
01:10:58 --> 01:10:59
But, you know, why do
you wash your hands?

1317
01:10:59 --> 01:11:03
 
 

1318
01:11:03 --> 01:11:05
Because your mother said
so, right, and because

1319
01:11:05 --> 01:11:06
there's germs on them.
 

1320
01:11:06 --> 01:11:09
Can you see the germs?
 

1321
01:11:09 --> 01:11:10
No.
 

1322
01:11:10 --> 01:11:13
So you got to do the act
and convince yourself

1323
01:11:13 --> 01:11:14
that you've done it.
 

1324
01:11:14 --> 01:11:17
 
 

1325
01:11:17 --> 01:11:18
OK, hands are clean.
 

1326
01:11:18 --> 01:11:21
Are they really clean?
 

1327
01:11:21 --> 01:11:24
I can't tell because there
might be germs there.

1328
01:11:24 --> 01:11:24
I'm going to get sick.
 

1329
01:11:24 --> 01:11:25
I'll wash them again.
 

1330
01:11:25 --> 01:11:28
If you have to do this so often
that your hands are getting

1331
01:11:28 --> 01:11:36
red and raw, that's a
compulsion of some sort.

1332
01:11:36 --> 01:11:41
Now, you can treat OCD, as
it's known in the trade, in

1333
01:11:41 --> 01:11:42
a number of different ways.
 

1334
01:11:42 --> 01:11:48
It turns out, for example,
that Prozac is good against

1335
01:11:48 --> 01:11:49
obsessive compulsive disorders.
 

1336
01:11:49 --> 01:11:53
It breaks up the obsession, you
know, the obsessive quality

1337
01:11:53 --> 01:11:57
here of this sort of thought
that doesn't quite

1338
01:11:57 --> 01:11:58
work for you.
 

1339
01:11:58 --> 01:12:01
You can imagine that you've got
some little circuit in the

1340
01:12:01 --> 01:12:05
brain somewhere that's
a little checker.

1341
01:12:05 --> 01:12:08
You know, did I do what
I was supposed to do?

1342
01:12:08 --> 01:12:11
And if that goes a little wacko
on you, that that's got too

1343
01:12:11 --> 01:12:14
much serotonin or too little
serotonin, I suppose, or

1344
01:12:14 --> 01:12:17
whatever, you know, you might
end up in a sort of an infinite

1345
01:12:17 --> 01:12:18
loop where, "Got to check.
 

1346
01:12:18 --> 01:12:19
Got to check.
 

1347
01:12:19 --> 01:12:20
Got to check.
 

1348
01:12:20 --> 01:12:23
Got to check." And something
chemical that gives

1349
01:12:23 --> 01:12:26
it a kick will help.
 

1350
01:12:26 --> 01:12:27
OK.
 

1351
01:12:27 --> 01:12:28
You can treat it that way.
 

1352
01:12:28 --> 01:12:32
You can also treat it using
the same sort of behavioral

1353
01:12:32 --> 01:12:35
techniques that I was just
talking about for phobias.

1354
01:12:35 --> 01:12:38
So let's do it for
hand washing.

1355
01:12:38 --> 01:12:41
All right, Patient So and So,
why do you have to wash? "Well,

1356
01:12:41 --> 01:12:45
I'm just really concerned
that my hands are dirty.

1357
01:12:45 --> 01:12:48
 
 

1358
01:12:48 --> 01:12:52
When I get dirt on my hands,
I get all excited and

1359
01:12:52 --> 01:12:54
[NERVOUS SOUND]." Right.
 

1360
01:12:54 --> 01:12:54
All right.
 

1361
01:12:54 --> 01:12:57
So we can do the densitization
business or we can do

1362
01:12:57 --> 01:12:58
the flooding business.
 

1363
01:12:58 --> 01:13:00
In the interests of time,
we'll do flooding.

1364
01:13:00 --> 01:13:01
"All right.
 

1365
01:13:01 --> 01:13:01
See this?
 

1366
01:13:01 --> 01:13:02
This is dirt.
 

1367
01:13:02 --> 01:13:06
Put your hands in it."
Right. "Are you dead yet?"

1368
01:13:06 --> 01:13:07
"No."
 

1369
01:13:07 --> 01:13:07
"All right.
 

1370
01:13:07 --> 01:13:11
How long can you
leave them there?"

1371
01:13:11 --> 01:13:15
And you can basically
desensitize this feeling

1372
01:13:15 --> 01:13:20
of deep anxiety about
not cleaning your hands.

1373
01:13:20 --> 01:13:20
All right.
 

1374
01:13:20 --> 01:13:23
So that's mildly interesting.
 

1375
01:13:23 --> 01:13:30
What's interesting, the reason
for raising this question or

1376
01:13:30 --> 01:13:35
this example, comes from this
nice article, now more than

1377
01:13:35 --> 01:13:37
a decade old, by Baxter.
 

1378
01:13:37 --> 01:13:44
You can see obsessive
compulsive states

1379
01:13:44 --> 01:13:47
in brain imaging.
 

1380
01:13:47 --> 01:13:50
There are little bits of brain
specifically in the caudate.

1381
01:13:50 --> 01:13:53
It doesn't particularly
matter for present purposes

1382
01:13:53 --> 01:13:54
where that might be.
 

1383
01:13:54 --> 01:13:57
But it's overactive.
 

1384
01:13:57 --> 01:14:00
You look at the brain of an
obsessive compulsive sort, and

1385
01:14:00 --> 01:14:03
this little chunk of brain
is busy, you know,

1386
01:14:03 --> 01:14:05
just going nuts.
 

1387
01:14:05 --> 01:14:10
If you give the patients
Prozac, that chunk of brain now

1388
01:14:10 --> 01:14:13
doesn't look weird anymore.
 

1389
01:14:13 --> 01:14:15
It comes into the normal range.
 

1390
01:14:15 --> 01:14:20
If you'd go and do behavioral
therapy on a patient with the

1391
01:14:20 --> 01:14:25
same story, the same piece of
brain comes to look normal.

1392
01:14:25 --> 01:14:29
The point here is that you can
reach this chunk of the brain,

1393
01:14:29 --> 01:14:32
if you like, either through the
brain sort of neurochemical

1394
01:14:32 --> 01:14:36
route, or through the
psych behavioral route.

1395
01:14:36 --> 01:14:40
They're not necessarily either
mutually exclusive or, you

1396
01:14:40 --> 01:14:44
know, one works and the other
doesn't or something like that.

1397
01:14:44 --> 01:14:47
This is a case where you can
get to the source of the

1398
01:14:47 --> 01:14:51
problem, at least in a
neurolocalization

1399
01:14:51 --> 01:14:52
kind of a way.
 

1400
01:14:52 --> 01:14:54
You can get to the source
of the problem through

1401
01:14:54 --> 01:14:57
either of these routes.
 

1402
01:14:57 --> 01:15:00
 
 

1403
01:15:00 --> 01:15:06
And I suppose the bottom line
here is that in disorder after

1404
01:15:06 --> 01:15:12
disorder, what you find is that
there isn't just one way of

1405
01:15:12 --> 01:15:17
treating -- one problem is
that in most mental illness

1406
01:15:17 --> 01:15:21
situations, there isn't one
magic bullet treatment that

1407
01:15:21 --> 01:15:23
automatically works for you.
 

1408
01:15:23 --> 01:15:27
And then in many of these
cases, there are both brain

1409
01:15:27 --> 01:15:31
and mind routes to therapy.
 

1410
01:15:31 --> 01:15:36
So when you're asking -- when
you have like these patients we

1411
01:15:36 --> 01:15:42
were cooking up, when you have
a particular patient, there's a

1412
01:15:42 --> 01:15:48
spectrum of choices that might
potentially be of some use.

1413
01:15:48 --> 01:15:51
It says on the handout, "What
happens when drugs make us

1414
01:15:51 --> 01:15:54
better than we ever were?" That
was the example I was talking

1415
01:15:54 --> 01:16:01
about before of Emma, who feels
better on Prozac even though

1416
01:16:01 --> 01:16:08
she wasn't technically --
didn't have a reasonable

1417
01:16:08 --> 01:16:11
diagnosis of something
being wrong with her.

1418
01:16:11 --> 01:16:13
So we've already
talked about that.

1419
01:16:13 --> 01:16:18
So I think I'll quit.
 

1420
01:16:18 --> 01:16:20
See you next week.
 

1421
01:16:20 --> 01:16:21