By now you have probably heard of the middle and high school children in LeRoy, NY who have come down with what some reports are calling a “mystery” illness. Of course it is almost obligatory to note in such stories that doctors or experts are “baffled.” There are several features of this story that are interesting from a science-based medicine and also just a critical thinking point of view – the media response, how such ailments are diagnosed, the publicity around a private medical condition, and the speculation from many camps that appears ideologically motivated.
To first review the facts of the case, there are now 15 children affected with involuntary tics, which are sudden “jerk-like” motor movements. They all attend the same junior-senior high school and so range in age from 12-18, with onset of symptoms from October to January of the current school year. All but one of them are girls. All of the children have been examined by pediatric neurologists, 12 of the 15 at the Dent neurological institute by the same two neurologists, including Dr. Lazlo Mechtler.
Dr. Mechtler, and in fact all of the pediatric neurologists who have examined any of the children, have come to the same diagnosis: conversion disorder and mass psychogenic illness. A conversion disorder occurs when psychological stress manifests as physical symptoms. We take this for granted to some degree – when people feel anxious they may get sweaty, nauseated, short of breath, and have palpitations. People with panic attacks can have these symptoms and also difficulty swallowing, and episodes that may resemble certain types of seizures with feelings of being separate from reality or from themselves. These are physical symptoms resulting from pure emotional stress. But in some cases psychological stress can also lead to neurological symptoms – pretty much any neurological symptoms, such as weakness, difficulty speaking, loss of vision, and involuntary movements.
Steven Novella recently wrote about so-called “chiropractic neurology” and its most outspoken proponent, Ted Carrick. In 2005 I published an article in The Scientific Review of Alternative Medicine (Vol 9, No 1, p. 11-15) entitled “Blind-Spot Mapping, Cortical Function, and Chiropractic Manipulation.” It was an analysis of a study Carrick had published.
Carrick read a shorter, popularized version of my critique in Skeptical Inquirer and responded with a diatribe that was inaccurate, distorted what I had said, and accused me of fraud, deception, and mis-representation. He failed to offer a credible rebuttal of my specific criticisms; and, in my opinion, showed that he failed to understand some of my points. He referred to me as “Ms. Hall” and suggested that I was psychotic. He characterized my e-mail correspondence with him as “bizarre, rude, and offensive.” It was none of those, and I have copies of the e-mails to prove it. Carrick says he “forwarded it to the legal council for the American Chiropractic Association for review.” Now that strikes me as bizarre.
I am re-publishing the entire text of my article here as an instructive example of what passes for science in the chiropractic neurology community. Readers can judge for themselves whether my critique amounts to fraud and whether I am showing signs of psychosis, whether Carrick is a good scientist and whether his reply to my critique was appropriate. (more…)
Chiropractic is a diverse collection of beliefs and practices occurring under a broad regulatory label. The differences among various chiropractics are so stark that it is difficult to make general statements about chiropractic practice. At one end of the spectrum, however, are so-called “straight” chiropractors who adhere to the original philosophy of D.D. Palmer – that a vital force they call innate intelligence is response for health, and blockages in the flow of this magical force through the nerves are what cause illness. Such chiropractors believe they can influence non-neuromuscular conditions by restoring the flow of innate blocked by mysterious “subluxations” in the spine.
From chiropractors.org we have this definition of “straight” chiropractors:
Because straight chiropractors believe that nearly all diseases are caused by issues with the spine, they don’t believe they need any diagnostic tools. Traditional testing done by medical doctors and hospitals is not even considered by a straight chiropractor as being necessary. Diagnosis is done by finding the subluxations in the spine so that those can be corrected.
This particular version of chiropractic (by some estimates about a third of chiropractors follow this philosophy) is pure pseudoscience. It is, as indicated by the quote above, hostile to science-based medicine. After a century of such belief there isn’t a bit of evidence to support the notion of innate intelligence, chiropractic subluxations, or health benefits from this approach.
Scientific medicine is not easy. By this point we have largely picked the low hanging fruit, and continued improvements are mostly incremental and hard won. In order to get the most out of our limited research dollars, and optimize medical practice with the safest and most effective treatments, we need to use all available scientific evidence in the proper way. That is the essence of SBM.
There are those, however, that misuse or abuse the scientific evidence — whether to promote an ideology, out of innocent ignorance, or for nefarious purposes. In order to be truly science-based a medical intervention should be plausible, or at least not implausible, based upon basic science evidence, and it should actually be safe and effective when tested in people. Therefore, medical practices can fail to be scientific for one of two broad reasons: they can be scientifically implausible, or they can lack proper clinical evidence for safety and efficacy (or even have evidence for lack of efficacy). Some modalities (like homeopathy) fail on both counts.
The more pernicious medical claims are those that seem highly plausible, that can be extrapolated from basic science, but simply lack adequate clinical evidence. Stem cell clinics are an example — they can easily dazzle desperate patients with scientific descriptions of how stem cells work, and even cite published basic-science papers showing the potential of this technology. But what they cannot do is provide clinical evidence that the specific intervention they are offering is safe and effective for the specific disease or condition they are treating.
Last week, in part 1, I covered Steven Fowkes’ “cures” for Alzheimer’s and herpes. In part 2, I will cover a video where he goes further afield. It is titled “Nutrients for Better Mental Performance,” but he also discusses sleep, depression, hangovers, and a lot of other topics.
Some of what he says are simple truisms: mental performance is affected by everything related to health such as sleep, food, vitamins, minerals, detoxification, nutrients, amino acids, hormone replacement, pharmaceuticals and herbs. Metabolism is the key to brain function: 3% of the body uses 20% of the energy. Macronutrients, micronutrients, exercise, water, and breathing are important too.
We knew that.
Which nutrients promote optimal brain function? All of them: any deficiency will affect the brain. Fowkes goes beyond the evidence to claim that some nutrients are needed at super-physiological levels; Mother Nature is not optimal. Some supplements appear to work but the effects are not sustainable. It’s not about parts, but about how things work together. (more…)
A correspondent asked me to review a video presentation by Steven Fowkes, “Nutrients for Better Mental Performance,” one segment of a 9-part series on preventing and curing Alzheimer’s that was mentioned recently by an SBM commenter. Fowkes is an organic chemist without a PhD; he says this means:
I am not institutionalized [This begs for a joke, but I will refrain.] and see the world differently. Everything I know I learned outside the system.
He is associated with CERI, the Cognitive Enhancement Research Institute and has written extensively on nutrition and health. I’ll comment on his claims for Alzheimer’s and herpes first, and then return to the “Nutrients for Better Mental Performance” video next week.
He says he can prevent Alzheimer’s disease and cure it in the early stages, although later damage will not be reversible. And yet he doesn’t actually specify the details of how he accomplishes that miracle: apparently it’s complicated (I would imagine so) and varies with the individual. Science doesn’t know what causes Alzheimer’s, but Fowkes does. The current thinking of scientists is that it is due to genetic factors interacting with environmental factors, and it might be a natural consequence of the aging process that would eventually affect anyone who lives long enough. Fowkes says it involves a complicated domino cascade of effects, but the cause boils down to loss of glutathione cycling and failure of sulfhydryl enzymes, which interferes with the detoxification of mercury in the brains of Alzheimer’s patients. (more…)
While we frequently on SBM target the worst abuses of science in medicine, it’s important to recognize that doing rigorous science is complex and mainstream scientists often fall short of the ideal. In fact, one of the advantages of exploring pseudoscience in medicine is developing a sensitive detector for errors in logic, method, and analysis. Many of the errors we point out in so-called “alternative” medicine also crop up elsewhere in medicine – although usually to a much less degree.
It is not uncommon, for example, for a paper to fail to adjust for multiple analysis – if you compare many variables you have to take that into consideration when doing the statistical analysis otherwise the probability of a chance correlation will be increased.
I discussed just yesterday on NeuroLogica the misapplication of meta-analysis – in this case to the question of whether or not CCSVI correlates with multiple sclerosis. I find this very common in the literature, essentially a failure to appreciate the limits of this particular analysis tool.
Another example comes recently from the journal Nature Neuroscience (an article I learned about from Ben Goldacre over at the Bad Science blog). Erroneous analyses of interactions in neuroscience: a problem of significance investigates the frequency of a subtle but important statistical error in high profile neuroscience journals.
There has been an ongoing debate about placebos on SBM, both in the articles and in the comments. What does it mean that a treatment has been shown to be “no better than placebo?” If our goal is for patients to feel better and they feel better with placebos, why not prescribe them? Do placebos actually do anything useful? What can science tell us about why a patient might report diminished pain after taking an inert sugar pill? The subject is complex and prone to misconceptions. A recent podcast interview offers a breakthrough in understanding.
On her Brain Science Podcast Dr. Ginger Campbell interviewed Dr. Fabrizio Benedetti, a physician and clinical neurophysiologist who is one of the world’s leading researchers on the neurobiology of placebos. A transcript of the interview [PDF] is available on her website for those who prefer reading to listening. The information Dr. Benedetti presents and the expanded remarks by Dr. Campbell after the interview go a long way towards explaining the placebo phenomenon and its consequences for clinical medicine. Dr. Campbell also includes a handy list of references. I’ll try to provide a summary of the main points, but I recommend reading or listening to the original.
A common misconception is that the response to placebos is a purely subjective psychological response involving only the cortical level of the brain; but evidence is accumulating that real, measurable, objective subcortical neurophysiologic phenomena are involved. One of the first hints was a 1978 study showing that the placebo response to pain could be blocked by naloxone, a narcotic antagonist drug, indicating that the placebo must have actually caused an increase in endogenous opioids. (more…)
When Scientific American first announced that they would publish Scientific American Mind, I hurried to subscribe, thinking it would keep me informed about new developments in a field I am passionately interested in. I have enjoyed the magazine, particularly the regular columns, the news items about research findings, the reviews that alert me to books I will want to read, the “Ask the Brains” Q and A, the challenging “Head Games” quiz, and the presentation of many intriguing ideas. The board of advisers is impressive, and the columns by Christof Koch, Scott Lilienfeld, Hal Arkowitz, the Ramachandrans and others have been consistently excellent. Unfortunately, some of the other articles have descended into pop psychology, speculation, poor science and even pseudoscience. Contributing editor Robert Epstein’s articles have particularly raised my blood pressure.
In December 2009 I was annoyed enough to write this letter to the editor:
After reading Robert Epstein’s article in the last issue, I had to go back to the cover and verify that the word “scientific” was indeed part of the title of your magazine. The Love Building Exercises he recommends are more appropriate to a magazine of fantasy and science fiction.
Two as One — feeling that the two of you have merged?
Soul Gazing — looking into the very core of your beings?
A Mind-Reading Game — wordlessly trying to broadcast a thought to another person?
Love Aura — feeling “eerie kinds of sparks” when your palm is close to another’s?
Thought transfer? Auras? Come on! Shame on you for publishing such metaphysical pseudoscientific psychobabble!
They published my letter to the editor with the heading “Hating ‘Love’.” There was no response from the author.
About three weeks ago, ironically enough, right around the time of TAM 9, the New England Journal of Medicine (NEJM) inadvertently provided us in the form of a new study on asthma and placebo effects not only material for our discussion panel on placebo effects but material for multiple posts, including one by me, one by Kimball Atwood, and one by Peter Lipson, the latter two of whom tried to point out that the sorts of uses of these results could result in patients dying. Meanwhile, Mark Crislip, in his ever-inimitable fashion, discussed the study as well, using it to liken complementary and alternative medicine (CAM) as the “beer goggles of medicine,” a line I totally plan on stealing. The study itself, we all agreed, was actually pretty well done. What it showed is that in asthma a patient’s subjective assessment of how well he’s doing is a poor guide to how well his lungs are actually doing from an objective, functional standpoint. For the most part, the authors came to this conclusion as well, although their hedging and hawing over their results made almost palpable their disappointment that their chosen placebos utterly failed to produce anything resembling an objective response improving lung function as measured by changes (or lack thereof) in FEV1.
In actuality, where most of our criticism landed, and landed hard—deservedly, in my opinion—was on the accompanying editorial, written by Dr. Daniel Moerman, an emeritus professor of anthropology at the University of Michigan-Dearborn. There was a time when I thought that anthropologists might have a lot to tell us about how we practice medicine, and maybe they actually do. Unfortunately, my opinion in this matter has been considerably soured by much of what I’ve read when anthropologists try to dabble in medicine. Recently, I became aware that Moerman appeared on the Clinical Conversations podcast around the time his editorial was published, and, even though the podcast is less than 18 minutes long, Moerman’s appearance in the podcast provides a rich vein of material to mine regarding what, exactly, placebo effects are or are not, not to mention evidence that Dr. Moerman appears to like to make like Humpty-Dumpty in this passage: