This post complements I’ve Come to Praise SSRIs not to Bury Them as well as Interoception or Neuroplasticity.
Ghosts
In 1832 the discovery of spinal reflexes initiated a journey that led to a realization that incoming sensations could trigger motor reflexes that could account for ever greater amounts of our behaviour. This was the start of a journey to a nervous systems that can function without a soul, without a ghost in the machine. The meaning of the word Reflex turned inside out – it had been applied to wise actions like removing a foot from the flame which showed our soul had reflected on what to do. Now it mean an action without any reflection.
Ironically, in this case, no reflection meant no ghost. This removed a stumbling block in the way of seeing ourselves as machines. See Madness, Normality and Antidepressant Dysregulation
But there is another stumbling block – the puzzle of our Subjectivity and our consciousness. It was our subjectivity and consciousness, which we assumed animals do not have, that gave rise to the idea of a soul and a mind, in the first instance, along with notions of responsibility as well as religions. Our Subjectivity still feels like a Ghost somehow hidden in our machinery. We ask if AI systems are ever likely to be conscious and we worry that they may not be responsible
From birth, visual, auditory, tactile and balance sensory inputs enable us to grapple with and give shape to the blooming buzzing confusion inside and outside us. Sensation drives the development of our nervous systems, including our brains. Sensory systems embody the knowledge of how to walk, how to read a mother’s mood, the time to go to sleep, how long to stay asleep. Sensory systems drive the dreams we have when asleep. From birth, unlike motor systems, sensory systems don’t lie still – even when we are asleep.
Just as the image below shows the new normal:
This post replaces the ghostly message from the movie Inception:
Your Mind is the Scene of a Crime, the Dream is Real
With a new sensory message about Interoception:
Your Mind is the Scene of a Crime, Your Senses are Real
Embodied Knowledge
Unlike machines, which are programmed from outside, from birth onwards our sensory systems learn from scratch and scratches as we fall over and by blunt repetition they embody this learning. A lot of embodiment goes into keeping us upright, helping us balance on tightropes, and playing pianos.
We think of sensory systems as ‘just’ registering touch, taste, smell, sight, balance, hearing and pain and imagine a Ghost who assembles the units of information into something meaningful.
We are more like Octopi than machines. The bits of us that experience, learn and think fast are in our limbs and tentacles rather than in our bulbous heads, which might look important but are less so than we think.
Our Boundary
Our senses sit on a boundary between our insides and outsides not just sensing what is going on within and without but ‘thinking fast’ about what is happening and able to trigger or block reflexes that may be critical for survival. Our senses keep us upright and awake. The sensory shaping of our reflexes over years creates our habits, what we are and are not aware of – our consciousness and subconscious – along with our personalities.
Our senses rather than our Id, Ego or Superego are the boundary between us and the world
The explorations of our nervous systems progressed astonishingly in the twentieth century. Who would have thought we could visualize brain functioning as we now can. We have elegant diagnostic tests to assess the integrity of our peripheral motor system.
But neurologists, no less, have side-stepped our sensory nervous system. Why? Because it’s too subjective. What? Is this our soul creeping back into the picture?
Compared to tests on motor systems, sensory system tests do not give reliable, reproducible figures. The data can vary dramatically by sex, personality type, time of day, emotional state – along with host of internal factors affecting our motivation like hunger, bladder issues or a palpitation. The influence of internal factors is not surprising – our vigilance centers are more geared to monitoring our internal milieu than the external environment.
Subjectivity and Objectivity
The subjectivity (variability) of our sensory systems does not make them scientifically irrelevant. It does not mean we cannot establish objective facts based on sensory information. Quite the contrary, we cannot have objectivity without subjectivity.
We have the impression that science developed by harnessing chance through statistics to achieve objectivity but this is completely at odds with the history of Science. Our history shows that Science developed when we harnessed bias (subjectivity) to achieve objectivity. See God Does not Roll Dice.
Scientific objectivity hinges on observers reaching a consensus about observables. This parallels the task facing jurors, who, bringing their biases to the task, are challenged to come to a consensus on what they have observed in examination and cross-examination. Objectivity arises in this process. The best and most objective consensus does not guarantee validity or truth. Jurors and scientists reserve the right to change their verdict or diagnosis if further observables come to light – and resist or should resist being told by an outsider what their verdicts have to be.
Observables do not include scientific articles or claims about figures in these articles. Medical and other figures are invariably abstractions, which get modelled and coded and sometime fraudulently eliminated.
When Science began in the Royal Society it had a jury looking at observables right in front of them. They could interrogate the observables by adjusting a dose for instance and if appropriate by asking questions. As applied to medical events, this remained the case for nearly 300 years. The most astonishing decade for drug development was the 1950s. This happened without a single randomized controlled trial or statistical modelling.
Physicians and other researchers operated on the basis of what was observable and Evident. In English the word Evidence is a False Friend.
Roughly 333 years after the Royal Society revolution established the Scientific process, this process was eclipsed within medicine. There was a reversion to something closer to a religion with the people in the Room told to follow the authorities – where in this case the authorities were pharmaceutical companies and bureaucrats (medicines regulators).
Since 1992, those running the experiment of giving a pill to someone and attempting to come to a consensus with that person about what is happening them have had to instead deny whatever the person says and insist that the Science shows quite the opposite – that Bad trips on an antidepressant are a normal part of an eventually good response to the pill even if the person taking an SSRI figured it was driving them mad and might have a grim outcome.
It’s time to adopt and adapt the No Taxation without Representation slogan that led to democratic government and prepare to fight under a new banner
- No Objectivity without Subjectivity
- Strong Objectivity needs Strong Subjectivity
- No Prescription without Experimentation
And to recognize that Science Uses Subjectivity (Bias) to control chance not chance (statistics) to control bias
SSRIs and Subjectivity
The SSRI group of drugs offer an extraordinary instrument to explore our subjectivity. They also illustrate in scenarios that everyone can understand the extent to which we are deviating from science.
We can attend to what we are sensing and the variability in what we sense and we can also report on what is going on. We can’t read our brains or motor systems in this way. One of us on our own may not be accurate when it comes to establishing sensory observables, but we can read our internal states and correct our perceptions – often with the help of others. We can read their body language for instance and make them aware of what they might be feeling especially when our feedback contrasts with what they think they are feeling.
We cannot be instructed on how to embody knowledge but mimicking others and paying heed to their feedback shapes us profoundly and what we can do. Sensory processing is intensely social.
Observables, even if highly variable, are what count in science, not opinions. But the opinions of others (social factors) can shape our ability to observe or read our senses/feelings. In addition to the capacities of others to read our body language and vice versa, a mismatch is possible between what we are actually sensing and what our socially determined persona, the ‘we’ that we imagine we present or want to present to others, expects us to be feeling. Our social image may be so important to us that we do not register inconvenient observations – inconvenient truths.
The fact that our first impression about the observables or interpretation of the observables may be wrong is evidence for the James-Lange Theory of the Emotions. In the 1880s, stemming in part from the developing understanding of our nervous systems, William James in Boston and Carl Lange in Copenhagen shocked many when they unbelievably located our feelings (senses) in our bodies rather than our minds or souls. These feelings, they said, get interpreted or misinterpreted through the filter of our persona and the context in which they arise.
Misinterpretations can get passed off as our true feelings, our emotions, even to the point of triggering acts that may be at odds our reflexes. This, however, does not have to land us back in a subjective morass – in part because we have new tools.
The SSRIs are a tool that acts on sensory systems and can help us generate observables and in so doing help us to probe ourselves like never before. Acting on sensory receptors in our peripheral nervous system, SSRIs reduce emotional reactivity which has effects on our hunch-generating or thinking fast systems.
The SSRIs came from observations with older serotonin reuptake inhibitors when doctors spotted that they made some of us less emotionally reactive, more mellow, more serene.
Almost all of our serotonin is in our sensory nervous system. Both SSRIs and LSD act on serotonin receptors, closing the gates to sensation in the case of SSRIs and opening them in the case of LSD.
Within 30 minutes of a first low dose SSRI erotic sensation in genitals is muted in most of us as is touch around our body. This correlates closely with what we call reduced emotional reactivity.
Dizziness is the most common effects healthy volunteers report on starting or stopping an SSRI. (They might notice genital numbing but are slower to report it). Depending on the dose, vertigo or balance problems may be better words than dizziness. Balance is far more complex than we usually think. Sensory input from receptors in our muscles, bones and joints create a map of where our body is and the movements of our limbs. With input from our eyes and the vestibules in our inner ears we can balance. All of these systems have serotonergic input and judging by reports to FDA millions of us have balance problems when taking SSRIs – See Lonesome Heroes.
We regularly refer to our emotional balance – with good reason. If you try squatting or balancing on one foot and then imagine an emotional scene that perhaps involves you being angry and gesticulating at or shouting at someone, the images you generate prime actions, which direct blood to the muscles needed to gesticulate or shout. This alters your balance and you may topple over. Maintaining balance is not just a simple matter of staying physically upright. We spend our Lives on a tightrope, constantly juggling our balance.
Vision and thinking operate in a similar fashion to balance and emotions. Vision is normally 3-dimensional. SSRIs may flatten it so that what we are seeing looks more like a videogame, and hand in hand with that they affect thinking in the same way, as this quote shows.
Just as there was a loss of depth to my vision – it was more like a 2-dimensional videogame – there was a loss of depth to my thinking. I was reacting to things on the surface rather than able to see through to the consequences.
If I had an impulse to drive, I would go rather than consider the time or whether I had work the next day. If I had an impulse to go out for a walk, I might simply go without my phone – or shoes.
By acting dramatically on our senses in very low doses, SSRIs have the potential to explore what we are made of and our subjectivity, in slow motion, as it were, compared to LSD, which opened the gates of sensation so wide that a flood of effects overpowered our gate control systems and our abilities to make sense of what it all means or even come to a consensus with others about what is happening much beyond saying there can be Good and Bad Trips.
SSRIs have just the opposite effects to LSD on sensory gates. The normal flow of imagery, which our gate control systems manage, slow to a trickle. This trickle can be difficult to manage. In the absence of competing sensory inputs, certain images can dominate, much as our actions can be controlled by a dominant image implanted by a hypnotist.
SSRIs, in addition, can modulate LSD effects. It may be possible to use the combination of these two drug principles to
Interoceptive Therapy
Given the potency of SSRI effects on sensory receptors, if this is the action treatment aims at, their use should go something like as follows.
- The starting dose should be less than a 5mg fluoxetine equivalent.
- Any later dose should rarely get to a 20 mg fluoxetine equivalent
- Before the first pill, an SSRI taker should be told the intention is to mute sensory receptors in order to help them – they are not going to get well by some other magical means.
- Ideally some work should be done before any pill perhaps using biofeedback to get them up to speed for what is coming.
- Their observations as to the degree of muting and its effects on them are key to the right dose for them or to continuing treatment.
- At best there is a 50:50 chance an SSRI will suit them. If it doesn’t suit early on, this will not change – it will not start ‘working’ later.
- If prior SSRI use has damaged a sensory system, paying heed to and working with the damage may lead to work-arounds.
Interoception and Neuroplasticity
There are major differences between Interoceptive Exposure Therapy and Neuroplastic approaches to treat SSRI problems. Just as Psychoanalysis is based loosely on the idea of an untestable libido, so Neuroplastic Therapies are based loosely on the idea of an untestable neuroplasticity.
Our sensory functioning is observable and with practice we can become skilled at it, using biofeedback and perhaps at some point neurofeedback. We may observe people getting well with neurofeedback or psychoanalysis without being able to link change to placebo effects, good interpersonal rapport or demonstrable and specific neuroplastic effects in one case or to effects on libido or transference reactions in the other.
In contrast, we are highly likely to be able to demonstrate that a group of patients who can manage the degree of sensory muting they get and find it suits them are likely to have a much higher Good Trip rate than the 1 in 6 Good Trips reported in company trials – See I come to Praise SSRIs.
The Science of Subjectivity
In addition to being therapeutically useful for some, SSRIs can also take us to many scientific frontiers.
Among the important medico-legal issues they can shed light on are the boundaries between voluntary and involuntary actions, between automatisms and actions for which we should be held responsible.
It is generally accepted that Hypnosis and related states like Sleepwalking and Catatonia can abolish the capacity to intend acts. No matter how willful an act that takes place while sleep-walking or catatonic might look, it is not intended. SSRIs create scenarios in which these states can be explored.
It seems clear that SSRIs can cause alcohol use disorders but we have no clear idea how. The answer may lie in what people on an SSRI report but who is paying any heed to this?
While the main action of an SSRI is to create a serenic reduction in emotional reactivity, in the case of sexual function, it became clear that one tenth of an antidepressant dose could mute genitals within 30 minutes of a first pill and this could be a therapeutic principle for premature ejaculation.
We are conditioned to think of this as a brain effect but long before SSRIs lidocaine gel was used for this purpose. Do we think lidocaine acts on the brain? And premature ejaculation can magically disappear with a change of partners. Do we know what is going on?
How many other tricky states are inappropriately dismissed as anxiety states or functional neurological disorders.
In a group of couples, try asking how many women think they could only marry a man with the right smell? Chances are half the women will endorse the idea with others looking flummoxed. What happens if she tells him your smell has changed since you began that drug? What happens if she develops parosmia on an SSRI – a sensory problems that like PSSD, PPPD, or VSS can endure for years after stopping? See Can Antidepressants Make You or Your Partner Less Attractive.
Women disabled by dyspareunia face all kinds of protracted therapies aimed at rooting out their problems. Changing partners can solve dyspareunia. We get told the improvement is because the new partner is more sensitive. Do we know for sure that’s the case?
How much do we know about Material Me or about Material Us?
SSRIs and mother and alcohol
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