Beliefs that Create Madness (Kindle)

 Beliefs that Create Madness (Kindle)

Beliefs about madness have evolved long before the emergence of science. From the ancient Egyptians, who believed that the heart controls the mind, to the Middle Ages, when it was thought that evil spirits took over the mind, these beliefs had consequences for how the patient was treated. There was no science in any of these treatments, just beliefs that we held about the behavior of others that did not fit with the norm. We always tried to understand it or explain it. What is important is that these beliefs are always tied to treatment. How we attribute a cause determines how we deal with it. If we believe that the reason why we are fat is because of our genes, then we have limited options. But if we attribute to cause to food intake, then our options become clearer. 

The Egyptians practiced trepanation (drilling into the skull), but also relaxation, sleep, and other soothing therapies to relax the heart. In the Middle Ages, with their belief in evil spirits invading the body, the treatment was predetermined. You cannot reason with bad spirits; they only react to violence, and hence we get the draconian treatment of madness of the Middle Ages. Looking from the safety of our modern time, their treatment of chaining, beating,  and restraining patients looks sadomasochistic, but they had their reasons; they had their beliefs. Their beliefs in what caused the dis-order, not only determined the treatment, but these beliefs also determined what theories were developed. 

With the rise of science and the eminence of theory, a new set of beliefs was adopted. The Enlightenment in the middle of the 16th century ushered in a new set of scientific theories, energized by the discovery of electricity in the body, and a new understanding of chemistry and biology. In the shadow of this newfound knowledge emerged new lay beliefs about madness. Madness was believed to be due to excess nervous energy, and since the business of pharmacology was still nascent and still morphing from apothecary, their option for lessening this excess energy was to provide a peaceful and nurturing environment that reduces stress and trauma. The way they believed that they could cure madness was by providing “moral” treatment (a mistranslation from the French meaning ‘psychological’ care). Hospitals for the insane became the du jure cure for madness. During the mid-to-late 19th century in the United States, it was the Kirkbride Buildings that took hold of the imagination at the time. They were magnificent buildings that were a testament to the glory of science over madness. Built to the specification of a physician and Quaker, Thomas Story Kirkbride, each ward had expansive windows, wide corridors, fresh hot and cold water, gardens, and recreational outdoor areas. Kirkbrides were more of retreats than hospitals. Instead of punishment to drive the evil spirits out, now there was psychotherapy to diffuse the trauma within the individual. Dorothea Lynde Dix, a retired nurse, went around the country promoting these Kirkbrides as a panacea. An inspired fervent frenzy ensued, believing that civilized societies were bringing mental health science to the unfortunates. Cities clamored to build these symbols of scientific superiority over madness. At its apex, 78 Kirkbride Buildings crowned the landscape across the United States, mostly in the Northeast, half of which have been repurposed and still stand today.  They were described as the “cult of curability” as everyone believed that they worked. Designed to accommodate 200-250 patients, these buildings soon became a panacea. As a result, they ended up becoming a warehouse for all sorts of unwanted. When they became too expensive, and the promise of cheaper, more effective drugs came on the market, they were abandoned. By the first half of the 20th century, Kirkbrides and the majority of insane hospitals devolved into dystopian tragedies. Increasingly, invasive treatments replaced “moral” care. Psychiatry, taken over by the much more powerful pharmaceutical industry, started to reel in random grasps for relevance. 

The eventual failure of the 19th-century asylums led to the dead-end intervention of pharmacy (insulin coma therapy), biological (bloodletting, organ excising, and purging), chemical (toxification), skeletal (trephination), electrical (electroconvulsive therapy), physical manipulation (rotational therapy), neurological surgeries (lobotomies), and behavioral constraints (straightjackets) all these therapies had dubious efficacy and definitive harm. All based on lay beliefs with a whiff of scientific method. All eventually shown to be sham, all. 

In the 1900s, when psychiatry divorced from psychology and psychoanalysis, it became the turf keeper of biology and chemistry. With the eventual dominance of the pharmaceutical industry, psychiatry became subsumed as a pusher of drugs. With this new overlord came a change in attributions, a new paradigm, and a new meaning of mental illness emerged.

First came the anti-psychiatrists. The infamous Thomas Szasz and R.D. Laing, who became famous because they were not too radical and they were intellectual enough to make it through the filter of public decorum. Their criticisms were sanitized, discussing issues of ontology such as the meaning of madness,  and they broadcast that they wanted to modify psychiatry to help change it to become more humane and more sensitive to the social context. In contrast to this pragmatic and acceptable (by the institution) approach, there are the less famous anti-psychiatrists, the radical Franco Basaglia and Frantz Fanon. These psychiatrists realized that you cannot modify psychiatry; you must revolutionize it, you have to abolish it. These factions helped to bring psychiatry into public focus. But it was only when the patients themselves started to speak out that radical change became possible. With Mad Studies, which aims to reclaim humanity for patients, patients started to lobby for a new perspective to look at enhancing their well-being rather than pathologizing their behavior. Their criterion of outcome was different; they wanted to feel accepted, they wanted to feel better, and not necessarily to be cured, if that was even possible.

Fast forward to today. Now we have a new set of beliefs dictated by the industry. With the Diagnostic & Statistical Manual (DSM) defining psychiatric disorders as a “broken brain”, a “chemical imbalance, ” or a “neurological mis-wire,” it is evident that patients need help correcting their abnormality. The DSM is perhaps the most obvious approach for reliability in defining madness, at the expense of validity. It categorizes different aspects of madness by willfully discounting the main cause of all these variances—our context in a social environment. Even if madness were somehow chemically or neurological determined, the behaviors are socially expressed and defined. Being aware of someone’s living conditions can help place the behavior in context. The social aspect of madness is crucial to understanding the behavior. How we see the cause of madness, our beliefs, dictate how we treat patients. Clinicians are less likely to see this social influence. There is an attribution bias with clinicians as they are biased to diagnose a patient‘s dysfunction as internal, stable, and uncontrollable. In reality, most dysfunctions are periodic and cyclical and therefore unstable, and through behavioral therapy, most are controllable. Most madness is not the dramatic but the mundane. The emergence of ADHD among children and adults is but one instance where psychiatrists are pathologizing greater swaths of behavior, and even if these definitions are valid, then we have to ask how to make it less stressful and disturbing for those experiencing these conditions.

A new belief is emerging that accepts the role of sociology in creating and expressing dysfunction. Only by understanding how beliefs create madness can we predict the future of psychiatric treatment. By exposing the assumptions made about dysfunctional behaviors, treatment options can be better understood. Belief in the cause of a disorder determines what is done to alleviate it. With the social context gaining importance, social prescribing has become a more effective way of treating madness. Social prescribing is providing social services, housing work, respite, drug treatment, physical therapy, all services that are usually in the realm of social work, psychology, or social services.

With Mad Studies promoting the perspective of the patients who use the mental health care system, the attribution of disease changes again, and a greater emphasis is placed on the external, unstable, and controllable aspects of madness. According to the theory of Power Threat Meaning Framework, ‘madness is a mental strategy that has become mismatched with its current context.’ The context determines the expression of dysfunction. While this approach argues that future treatment requires a population-based approach that offers social prescribing, short-term respite programs, and broad community-based cognitive-behavioral therapies, psychiatry remains stuck on “curing” the “diseases” with medication. A more pragmatic objective would be to focus on alleviating the anxiety and distress experienced by the individual and to aim for personal and functional recovery rather than to aim for a purely clinical recovery. A cure is possible if we redefine what a cure looks like.

With public awareness, the tide is changing, slowly but surely. The seeds are here already, as with the early inklings of Moral Treatment in the late 1700s; it takes time for them to grow. However, change is coming as our beliefs have already changed. Most of us have family members, friends, or personal experience with madness. We know that it is not simply a chemical imbalance or a broken brain. We know how the context plays a large role in how we behave. History has taught us that beliefs change first, and the rest follows. Perhaps the cult of curability, a derogatory slight for those who had the vision to believe in a cure, might materialize in this new ecological age.

This book is a detailed account of this story and covers several topics in detail, some of the more interesting are: The current mental health crisis, unforeseen consequences of medication, crisis of confidence, Classification of dysfunctions, the DSM and other nosologies, reliability versus validity, history of nosology, Kirkbride’s story, Beliefs of Moral Treatment, silting-up of moral treatment, culture, superorganic concept, outcome paradox, seasonality and periodicity, madness as strategy, developmental mismatch, and evolutionary mismatch. Each chapter has a summary at the end. The narrative is referenced in detail and offers both a theory of madness that predicts an epidemic of madness and also highlights workable solutions.

Exceptionalism

Exceptionalism

I am writing a book about disruptive science. This is science that overturns how we think about the world. Such scientists as Galileo, Newton, Einstein, Freud, Tesla, and many others. I am researching this to understand why there is a lack of disruptive science nowadays. We seem to have career scientists who do not disrupt science but affirm it. This is not how science progresses. Science progresses through ‘revolutions’ that turn what we believe upside down. The book focuses on similarities between these scientists. As a psychologist, I am interested not just in their personality but also in the conditions that allowed them to be disruptive. Interestingly, for example, most of these scientists were accused of plagiarism early on. Most had influential friends, and most spent time in obscurity and isolation. With this frame of thought, I was trying to explain what is happening politically here in the US and, it seems, across Europe, too. We are going through disruptive politics. But unlike science, which only seems to move forward, politics is more of a pendulum confined by human desires. The pendulum swings right and, after some time, returns to center and swings left. Right now, we have swung out to the right as much as we have ever done. I speak with a lot of this administration’s supporters, as most are older adults. They want things to be more stable and more consistent They are afraid of ambiguity: transgender, gay, foreigners, disabled, poor, homeless. Their view of the world, where the US is the paramount of virtue, does not fit with having these “types” of people. There is also a strong belief in exceptionalism. That we are uniquely different. I find exceptionalism in every country. I was brought up on a small island of Malta. We had no resources, could hardly feed ourselves throughout history, and it was one of the poorest places on earth. We had a coin, a ‘habba,’ that was the lowest denomination in the world (‘Habba’ a third of a farthing-farthing a quarter of a penny-penny one-twelfth of a shilling, shilling one-twentieth of a pound). Despite this poverty, I was brought up to believe we are special. Everyone believes this about their country growing up. The difference is when you impose this view on others, either by enslaving them or declaring war on them, then you create an injustice. In the US, we are now again imposing war on ‘others.’ It seems we exported this to other countries and waged war on the poor. However, there is another angle to this conflict, both at home and abroad. The inequity also affects those who are doing well. There is a feeling that they do not deserve their condition, they have not earned it. This feeling makes them more protective of what they have, an unsettling feeling that it can all be taken away. This is the new conservatism we are seeing. People are so unsettled that they feel they must protect themselves from others, even if they are doing well.

Money and Science

Galileo sold telescopes; Einstein sold patents for a refrigerator (among other patents), Edison commercialized many of his 1,000 patents, Tesla sold many appliances and inventions to the public, while Watt improved and sold steam engines. In fact, science is expensive, but science is not only about money, but it seems like it is. 

Science as it relates to old people is all about geriatrics, about their health. The biggest worry is, of course, dementia. In the United States, dementia receives the third most funding money, after heart problems and cancer. After more than five decades of this funding, there are the traditional medications that were supposed to slow the disease. These Acetylcholinesterase Inhibitors are ineffective. Although they seem to reduce death, they do not improve behavior. In the last few years, a new class of anti-amyloid drugs was introduced that clean the disease (amyloid) from the brain. Two main drugs are now approved by the Food and Drug Administration (FDA) for dementia: donanemab (Kisunla) and lecanemab-irmb (Leqembi). A third anti-amyloid drug, aducanumab (Aduhelm), was fast-tracked for approval in 2021, but Biogen, the drugmaker, took it off the market in early 2024, possibly to reduce the risk of liability. In all these injectable drugs, there is a serious risk of brain bleeds that have caused death in the past. Statistically, these drugs make little positive changes, but money has a way of interfering with science. What is surprising is that non-drug therapies have much better improvement and yet receive little research funding. These non-drug alternatives also have the advantage of not causing your brain to bleed.

Brainfitness, from Posit Science, is the oldest and most established of such programs in the US. However, Japan has its own homegrown and established programs. One of these is a computer-based program developed by Namco Bandai and tested by Dr. Kawashima, known for his Nintendo DS games Brain Age: Train Your Brain in Minutes a Day! and Brain Age 2: More Training in Minutes a Day! Japan sold 3.3 million already. The other with more than 20 years of legacy, is NeU Corporation. They fused the science of Tohoku University’s Institute of Development, Aging and Cancer, with the “portable brain measurement technology” of Hitachi’s High Technology Division. All of these are effective, and although they cost a little bit of money, it is an investment in the future. Science does not have to be free, only affordable.

Sarcopenia

There is an “Obesity paradox” among older Americans. This describes the unexpected finding that slightly overweight older people with a particular disease have better outcomes than their normal-weight or underweight peers.  Overweight is measured by a formula called the Body Mass Index (BMI), which measures height, weight, and age. A recent review in 2023 by Moustapha Dramé confirmed this observation that being a little overweight for older adults is beneficial. Even though obese people are more vulnerable to diseases, including an increased risk of infections, cancer, and heart disease. However, once you get a disease, having greater functional reserves might come in use. But there is a more interesting story to tell rather than simply weight.

BMI is not a good way to measure healthy body weight, especially for older adults. Once you reach 30 years of age, muscle begins to reduce. By the time we reach 70, we may have only half the muscle we had in our 20s. This is not only a function of age but a function of poor nutrition, inactivity, and a general difficulty in building muscle. Women’s menopause might also make things worse. Physicians call this Sarcopenia, the common tendency to lose muscle mass due to aging, but it does not have to be like this.

Loss of muscle mass is a serious threat to health.  It contributes to disability and frailty. In addition, studies show that there may be an association between sarcopenia and rheumatoid arthritis, falls, and even dementia. Building muscle in older age is difficult but possible. A person can only build muscle through resistance training, not just walking. We can use our own body weight (e.g., by doing push-ups and squats) and lifting household items such as soup cans. One of the few areas that is easy to change is diet. Older adults don't eat enough protein. 

Rei Otsuka and his colleagues have shown that greater protein intake improved muscle mass for men but not for women, which might have to do with menopause and the role of estrogen (especially estradiol). Women have it worse, since the loss of estradiol increases fat, decreases bone density, as well as muscle mass and muscle strength. All of these factors significantly contribute to the development of a condition termed “sarcopenic obesity.” It is that much harder for women to retain their muscles. But diet and exercise still seem to help, and increasing protein intake seems to help.

Keisuke Sakurai and his team compared a high-carbohydrate (HC) diet mainly composed of cereal against a protein-balanced (PB) diet with high intake of legumes, vegetables, seafood, meat, and eggs. Cognitive function was significantly higher in the PB group than in the HC group in a Japanese group. 

What is good for muscles is also good for the brain. A healthy body means a balanced diet and staying as active as you can.  Addressing sarcopenia might also prevent falling. Improving balance and flexibility by strengthening core muscles (chest, back, belly, hips, glutes, and thighs) and careful stretching can help prevent falls, a major cause of disability and death. Avoiding falls can be as simple as wearing stable shoes and having well-lit paths, to maintaining strength and flexibility. However active you are, don’t use ladders and perform other risky actions.

Sleep

We are only aware when we are conscious, and the obverse is also true, that we are unaware of our unconscious life. As a result of this skewed perception, we assume that we are primarily conscious beings. But this fallacy is the result of conscious bias. This self-awareness is what is known as the “hard problem.” First introduced by David Chalmers, the hard problem is why and how we have consciousness. This contrasts with the “easy problems” of explaining the ability to discriminate, integrate information, report mental states, focus attention, and problems of cognition in general, since we will eventually specify a mechanism that can perform these functions. But the problem of experiencing consciousness is distinct from these questions and will persist. Although consciousness is a hard question, we might learn about what it means by defining the unconscious in our daily lives.

One of the longest period of unconsciousness is sleep. Most animals sleep. Birds, mammals, and reptiles have some form of daily sleep varying from around 3 hours in a horse to over 20 hours in the pocket mouse. This variation can be due to conserving energy, reflecting predation risks and energy conservation (Elgar, Pagel & Harvey, 1988). Since lack of sleep is detrimental to health, it is therefore assumed that sleep is a necessary and adaptive feature. In a review of the literature that looked at the global practice of changing the clock by an hour to accommodate seasonal changes in sunlight, Till Roenneberg and his colleagues reported that the first days after summer time change results in an increase in general accidents and visits to the emergency room increase (Ferrazzi et al., 2018),  incidence of myocardial infarctions (Manfredini et al., 2018), ischemic stroke (Sipilä et al., 2016), the risk of in vitro fertilized mothers losing their babies (Liu et al., 2017), and suffering from negative mood changes (Monk & Aplin, 1980). Interference in our sleep patterns have serious harmful effects.

With humans there is also the need for sleep to consolidate our isomorphic representation and therefore our memories. All theories of sleep involve some aspect that involves memory consolidation. Everything that we have experienced for that day is assimilated with our general model of the world (Bucci & Grasso, 2017). Since sleep-deprived humans and animals perform poorly in learning tasks when compared to individuals that are well rested, there is some evidence for the function of sleep and dreaming as a consolidation of memory (Smith, 1995). Dreaming has also been functionally linked with amygdala growth providing some biological evidence that sleep and dreaming are involved with memory processing (Capellini  et al, 2009). This is especially true for humans as we spend almost one-third of our life sleeping, and a good portion of that time is spent dreaming (Bucci & Grasso, 2017).

Continually evolving theories all support the idea that sleeping and dreaming contribute to memory consolidation. But this consolidation is not simply through rote repetition until memorization takes hold, but it is a much more complex development of scaffolding. Building different scenarios where our experiences becomes integrated together until it forms a virtual edifice that eventually morphs  into one overall model of the world.  Humans use sleep and dreaming to test the integrity of this  scaffolding, a model built on real experiences, by conjecturing different scenarios. Our isomorphic model of the world becomes predictive. In sleep, while dreaming, we replay and predict different scenarios on the basis of our past experiences. The consolidation of memory is one artifact of this intricate process of learning.

There are many theories of the neural explanation of dreaming. Each of these theories provide one part of the puzzle that contribute to an understanding of how we consolidate our experiences into a model of the world, our isomorphic representation. These theories, that will be explained later, include: activation-synthesis hypothesis (ASH; Hobson & Mc Carley, 1977); reciprocal-interaction model (RIM; Vogel, 1978); hippocampo-neocortical dialogue (Buzsáki, 1996); Activation level, Input source and Information-processing Mode (AIM; Hobson et al. 2000); neuropsychoanalytic model (Solms, 2000); cognitive-functional approaches (Domhoff 2001); Reverse Learning theory (Crick and Mitchison 1983); Synaptic Pruning hypothesis/ Synaptic Homoeostasis hypotheses (SHY; Tononi & Cirelli 2014); memory consolidation (Stickgold et al. 2001; Perogamvros and Schwartz 2012); Threat Simulation theory (Revonsuo 2000; Valli & Revonsuo 2009); Social Simulation theory (Revonsuo et al. 2015); and, neurocognitive theory (Domhoff, 2011). 

All these theories contribute to a part of the story of how we develop our model of the world. ASH posits that dreams automatically synthesizes experiences by comparing information generated in specific brain stem circuits with information stored in memory. There is an exchange across the brain to merge different types of information. Reciprocal Interaction Model (RIM) proposes that waking and Rapid Eye Movement (REM) sleep are at opposite extremes of a state continuum with Non-Rapid Eye Movement (NREM) sleep intermediate between them. Suggesting that processing continues while sleeping at different dream cycles. The hippocampo-neocortical dialogue posits a transfer of data from neocortex to hippocampus in active awake, and consolidation of information within the hippocampus along with its transfer back to the neocortex for longer-term storage during quiet waking and NREM. In the AIM theory we see again this exchange across different processes with a two-stage hypothesis of sleep enhancement of plasticity with Rapid Eye Movement sleep (REM) at one end of this continuum and Non-Rapid Eye Movement sleep (NREM) at the other end that allow a two-stage process of memory consolidation. In AIM the excitation of the neurons determine the level of processing (Activation level) while the level of input into the system can be high when awake or low when sleeping and there is little external input (Input source) and the type of neuronal activity shift from noradrenergic and serotonergic activity when awake to aminergic activity with NREM (Information-processing Mode). Again, we see this processing of information during dreaming that is both qualitatively and quantitatively different. An interesting developing was with the neuropsychoanalytic model since it argues that what happens in sleep reflects what happens in conscious life. By applying neurobiological knowledge this model places disorders of dreaming as equal to other higher mental functions such as the aphasias, apraxias, and agnosias that are associated with specific localization (focal) cerebral pathology. Disorders of dreaming are part of the continuum of neural processing.  In contrast, the Threat Simulation Theory predicts that dreams contain more frequent and more severe threats than waking life does, and because these threats are realistic, they elicit defensive response. Dreams are a way of teaching us about threat in the environment the options we have at our disposal to deal with them. While Social Simulation theory proposed that we enact dreams that simulate social situation that we have experienced. Dreaming is a rehearsal for waking social perceptions and interactions, and therefore has adaptive value. Antti Revonsuo recently developed these Threat and Social stimulation further into the “world-simulation” (Revonsuo, Tuominen & Valli, 2015),  that require an “obvious avatar” (Dresler, 2015). World simulation is another term for isomorphic representation and is as close as we get to a theory of dreaming that supports an isomorphic explanation. Waking consciousness and dreaming are manifestations of the same natural biological phenomenon in the brain. The theory stipulates that there are three mechanisms; downward-, backward- and upward-looking that refers to excitation of the brain, the focus on past experiences and the influence that our dreams have on our conscious cognition. While an intensified form of mind-wandering that makes use of embodied simulation, primarily to enact the dreamer's major conceptions and personal concerns, is a byproduct of human cognitive developments important in waking life. The difference is that the neurocognitive model argues that dreaming has no adaptive value (Domhoff, 2018). Since there is evidence that dreaming can be largely or completely absent without any obvious ill effects (e.g., Pagel, 2003) it therefore is not an adaptive feature of our life. Despite variation in emphasis and approaches, there is an incredible consistency in these theories. While not discounting the importance of nuanced criticism—the process that will eventually refine these theories—there are overwhelming consistencies in all of these theories that require recognition, especially since this convergence promotes an obvious convergence.

As can be seen, all these theories of dreaming suggest that we are revisiting our model of the world. The embodied nature of dreams represent our real-life experiences in a virtual world that correspond to waking life. For example the content of dreams reflects our engagement in the word with the following activities: Movement (66%), Verbal (62%), Physical (61%), Sight/visual (44%), Location (29%), Cognitive (18%), Expressive (12%), and Auditory (7%) (Domhoff & Schneider, 2018). Dreams are mainly reported to involve social simulation (94%) and very rarely are dreams exclusively just about the dreamer (4%) (Domhoff & Schneider, 2018). Most of the processing in dreams related to negative elements, as we would expect since the squeaky wheel gets the most attention. Aggressions, misfortunes, failures, and negative emotions accounted for 80% of men's dreams and 77% of women's dreams. In contrast, 53% of dreams for both men and women had at least one of several positive elements, including friendly interactions, good fortune, success, and positive emotions (Domhoff, 2007). Dreams are about the world around us, one that we have experienced when interacting in the world. These dreams are enactment for consolidation of our model of the world that results in a consolidation of our memories, streamline learned material that integrates new experiences into our predictive model. We act upon this process in virtual reality, “dreams are weakly functionally embodied states” (Windt 2015, p. 383). As Bucci & Grasso (2017) have proposed, dreaming is not only a way of running scenarios so that we can predict the future—using the theory of Predictive Processing (Clark 2013)—it also allows for synaptic organization and restore energetic equilibrium (homoeostasis) in the brain (SHY (Tononi & Cirelli 2014). Even in dream however, the brain is designed to narrate, to tell a story. For example, when there is the introduction of external sensation while sleeping (a blood pressure cuff fitted above the knee) people incorporate the pressure into their dream as a story, however bizarre that story might get (Sauvageau et al, 1998). The model of the world we develop is a temporal and spatial story, based on a time and a place, an embodiment.

Eventually even sleep and dream research leads to the study of consciousness. The integrated information theory, one attempt at explaining consciousness (Oizumi et al. 2014; Tononi et al. 2016) falls short of descriptive potential. The theory starts by identifying the properties of conscious experience as five “axioms” and are based on properties of the physical world “postulates”. These axioms are more general rules that are assumed to exist and difficult to substantiate empirically. However, the theory argues that learning and sleep is where these axioms are modified to reflect postulates. Why this process is best done while sleeping under dreams is not explained. The hard question of why we have consciousness, and why sleep is so important remains impenetrable to our feeble attempts.

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I Shrunk

 I shrunk. I went to get my annual physical check-up, and I came out 6 centimeters shorter than I thought I was going in. From 188 cm to 182cc! I might lose another 6 centimeters if I am lucky enough to continue to age. It’s mainly in my torso, as what has shrunk is the soft tissue in between my vertebrae in my spine. There are 33 of them, all stacked one on top of the other. In humans, the 24 upper vertebrae are separated by discs that allow movement, while the 9 lower vertebrae are fused. Usually, these discs shrink because of osteoporosis, but in my case, it is pure aging. The discs lose some of their moisture and shrink as we age. We become drier. A human embryo is about 90 percent water, a newborn child about 80 percent, a mature adult about 70 percent, and an older adult about 60 percent water, while those between 70-80 years of age are only 50 percent water. I wonder what water percentage a 100-year-old would have.

Driving home from the clinic, as I was thinking how lucky I am to be able to enjoy aging, despite shrinking, I remembered the Aristotelian view of aging. I use this example with my students. Aristotle defined aging as a natural, inevitable process of becoming cold and dry, characterizing it as a "natural disease" and the gradual extinction of innate heat. He believed life requires warmth and moisture, but over time, the body’s "innate heat" diminishes due to the consumption of "radical moisture" or fuel. If you believe that you get old because you are drying out and losing heat, then the therapy that would reverse this is a sauna. Which is why hot baths were so popular in the gymnasiums during Roman times. They believed that this method of moisturizing rejuvenated the lost moisture and heat. 

Romans followed a ritualized sequence: beginning in the tepidarium (warm room), moving to the caldarium (hot, steamy room), using the laconicum (hottest dry room), and finishing in the frigidarium (cold plunge). Recent studies have supported these beliefs. In a 2017 study on a Finnish male population, Tanjaniina Laukkanen and his colleagues reported that moderate to high frequency of sauna bathing was associated with lowered risks of dementia and Alzheimer's disease. In a review, the same researcher reported that saunas are linked to several health benefits. These include a reduction in the risk of heart diseases such as high blood pressure, cardiovascular disease, and pulmonary diseases, as well as less arthritis, headache, and flu. Maybe Aristotle was onto something when he identified water as the giver of life. But as we get older, we do not feel as thirsty as we did when younger and therefore drink less. This results in less water around our cells and points to an increased risk for dehydration. 

Japanese culture is also centered around the bath, more so than just cleanliness. So, we expect to see this advantage reflected in life expectancy. Finnish life expectancy at around 81-82 is less than Japan’s 84-85. Although moisture might be a contributing factor to long life, there are other things that promote long life. While we all ponder this, remember that we are still shrinking, and although some might also experience reduced spinal mobility because of this dryness, it does not have to restrict mobility. There are things we can do to remain active, stay hydrated, and enjoy our shrinking lives.

Growing up in Malta

Walk through any Mediterranean city and the fast food on sale has nothing to compare with the ideal diet that academics think we eat. 

Fast foods are accessible to everyone:  kebabs, burgers, butter and lard pastries, sweets, ice cream, donuts, fried chicken, and sodas are all the opposite of traditional diets. But the world is changing again. The growth of traditional food, inspired by our neighbors the Italians' "slow food" movement has brought back some of the local dishes, mostly from the Arabs. Food based on legumes cooked with garlic and chilies, roasted vegetables, and lean rabbit cooked in garlic and red wine. We ate fish pie nearly twice a week in summer when the fishermen came back to shore with their boats brimming with the local catch of Mahi Mahi (Lampuki). Before the popularity of fridges, everything had to be eaten fresh. The Mahi Mahi were so cheap that we had fish for a month and the housewives got creative in how to cook it. Fried, roasted, or in soup with lemon and rice ("aliota"). But the pie won favor as it included fish, spinach, and ricotta in a flour pastry shell. 

Then came the sweet pastries made without baking using leftover cake and biscuits mixed with nuts and candied fruits and drenched in evaporated condensed milk.  Some fruits that only grow in Malta are also making a comeback. A small sweet pear called a "Bambinella" (from the Italian meaning a small girl) is still a popular indigenous fruit. We had lots of healthy soups, such as minestrone made with squash that had been harvested and then left on top of the roofs of the farms to mature in the sun. When cut open and a slice is purchased it gives the soup a mellow rich body with that traditional orange color. But the absolute favorite foods have never left the island. The local "pastizzi" of filo pastry filled with ricotta or peas. And there is always the local bread baked in a traditional wood-fired oven that is rare to find nowadays, but you can still find it. 

Our memories of the past are tied to the foods we ate at the time. When I visit my parents, which I try and do every year, I go and look for these wonderful foods. Some restaurants cater to this new demographic. Food has become a time portal for me as it is the best way to transport myself to the past. I have a secret pleasure of going away on my own to the city and in some of the local shops that still make traditional "pastizzi" I order 6 and walk to the garden overlooking the harbor and watch the ships as I devour these small pastries. Such fleeting escapades remind me of who I am and where I came from. It anchors me to my culture and my foundation. Food has a way of transporting me across time and mostly good times.

Now, living in the United States, the food tastes like plastic. I try to capture the taste by buying organic and local produce, which is an improvement, but I cannot capture the same flavor of my past. Only when I travel back to Europe, especially Turkey and Sicily do I  taste some of those flavors again. Perhaps that is why I like traveling so much. But it is more than food. It is how I felt as a young boy. That feeling of hope, of having a whole world to explore. The hunger was not just for food but for the excitement of all those opportunities that I believed existed for me, all I had to do was be adventurous. Perhaps by trying to capture the foods of my past, I am trying to capture that feeling of hope, that the world is full of opportunities. 

Perhaps that is the secret, being able to meditate and enjoy the world around us, and food certainly helps.

It is that feeling of belonging that we are trying to capture. As a child, I felt close to my family. I used to rush home from school and I knew that I had a safe place and that mum would be cooking and we get to eat together and maybe dad would tell us stories about his work. There were always the vendors that came pulling their carts selling "bigilla" (bean chili paste) or just fresh stalks of chickpeas still on their branch. 

My favorite was the vendor who sold romance novels. Mum who never went to school could read in Maltese, English, and Italian. I used to go and buy the sheet from the vendor. It measured something like 4 by 4 feet. I will take it to the kitchen table fold it and very carefully, using the only knife we had, a serrated bread knife, cut the paper into individual pages. Mum would then sew the pages together to make a book. She used to follow these romance novels religiously, and every month another chapter was added and I had my job, cutting the pages. 

There was always something happening and I belonged with this family. Sharing the food was not so much about sharing, as we devoured our food like stray cats. Sharing meant being together. We cannot recapture that now as we rarely see each other as a family. Like most of us, we have our own families now. My mum has severe dementia and my dad is angry at the world. He did not expect his life to end like this. We, the children are lost, despite having our own families our parents still remain our foundation and how we knew we belonged. Now we offer this belonging to our children even though we seem to have lost it for ourselves.

Medicine and Long Life

Why do we have medicine?

The answer is obvious that a child can answer. It is to help people. To help them live long and healthy lives.

 

But does medicine help us live long?

Some medicines do, like some vaccines, and most interventions help people live slightly longer.

 

But people still die. In the last hundred years, we have only improved life expectancy at older age by 6 years. The great improvement in medicine has been in helping children survive childhood. And this was not just medicine it was because of public health. We made great progress in getting clean fresh water to communities and an efficient sewage system. Laws that protect the air we breathe, the hours worked, and age restrictions. It is these factors that have improved life the most rather than medicine.

 

For older people medicine performs invasive treatment like heart operations, setting bone fractures, and through medication like controlling blood pressure, cholesterol, and diabetes. These help some older people live slightly longer and in better health. But only slightly.

 

Two researchers examined what happens if we completely cure some chronic diseases.

Like a magician with their magic wand, they eliminate all diseases. This can only be done statistically. Kenneth Manton eliminated one disease at a time. By eliminating all of these killer diseases at 87 years of age, people live an additional 5.7 years for males and 6.5 years for females.

 

Another researcher eliminated one disease at a time and saw the effect this had on people’s lives. Again, they did this using statistics. Douglas G. Manuel reported that by eliminating cancer they predicted that one fifth of the years of life gained would be spent in poor health—and increased cost. This is because living longer results in these people getting dementia or other chronic disease such as atherosclerosis. On the other hand, eliminating musculoskeletal conditions would result in a year of good health for women and under half a year for men.

 

Many diseases are waiting for us in older age. The healthiest people on earth, like the Blue Zone people, one of which is in Okinawa, tend to live a long life. They only get sick for a few days before they die. There is no long period of sickness. In the end, it is best to be healthy as death comes quickly and our bodies seem to know how to shut down effectively when we are healthy.

 

We need to understand why our bodies are designed to shut down. We need to study aging not just specific diseases.

 

Then I return the question. Does medicine help people live long and healthy lives?

 

The answer might be that medicine allows us to believe we can change our nature. But as yet we do not understand “aging” enough to be able to change very much, but we all take what we can get right now.

 

Don’t Blame the Chickens or the Foxes

I have been teaching a university course on programs for older people for ten years. Every year I get some of my bright students come back to tell me that the program does not run as it was intended. The program that they interned in (clinical experience) operated differently from how it should have operated. Most reduced their services to make a larger profit. At first, I thought that this was an anomaly, infrequent events. But it happened with many of my students across a broad range of services. At one time one of my students, an ex-military intelligence in his previous life, wrote a critique of hospice services. I thought it was intriguing so I followed up and did my own research. What I found was that not only was he right, but there were other ways that he missed that hospices use to increase their profit and unfortunately reduce their care to older adults that are dying. How can this be?

I then decided to research all services to older adults. The results were devastating but informative. In the United States, every service that is provided for older adults is designed to increase profit generation. Every single one and it did not matter if they were “for-profit”, or “not-for-profit.” There are only two ways to increase your profit, you either increase prices for your services, reduce the number of services, and/or reduce their costs. What I found is that across a broad range of services, the preferred method was to reduce services. This had the direct effect of causing harm to the older client. It is predictable institutional abuse at a level that is difficult to comprehend in a developed and rich country. But my task was not simply to document these abuses, but to find a solution. That is when I came up with a parable.

A farmer has a brood of hens, he sells their eggs. Next to the farm there were a couple of foxes with their own small family to feed. They often got into the chicken coop and helped themselves to some of the chickens. This continued to happen year after year. I ask my students, who is at fault? Are the chickens at fault as they remain defenseless? Are the foxes at fault since they attempt to feed themselves and their families? Or is it the farmer who is incompetent at protecting the chickens? You cannot blame the chickens or the foxes which is what the media does. They blame people for not doing their homework and checking up on nursing homes, or hospices when they are at their most vulnerable stage in their life. Others blame the medical and pharmaceutical companies for their greedy behavior as they need to make a profit to survive. No one seems to blame the farmer, the government. We have regulatory agencies that are designed to safeguard our citizens, but they are not doing their job. Like the farmer they are incompetent, but unlike the farmer who loses the sale of his eggs, these administrators still get a hefty paycheck every month. When I figured that the solution was to enhance and strengthen government regulatory agencies, I formulated a theory that explains all of this and predicts that these abuses will continue to increase unless we enhance oversight. The book was published as Critical Age Theory on Kindle an Amazon company. It was generating some interest, but not a blockbuster, but then one day my account on Kindle was deleted. No explanation was given and no apology for deleting more than 12 books I had online.

I remember a friend of mine Allen Smith, a Professor of Economics at Eastern Illinois University, who published about similar institutional abuse this time on social security. He published The Alleged Budget Surplus, Social Security, and Voodoo Economics and in 2000, The Looting of Social Security. All of these books were critical of what the government was doing. Strangely, the last of these books was stopped from being published. Someone bought the rights and stopped printing it. At the end of his life Professor Smith bought the rights back and made it public again. I distribute it free to my students.

Basically, he is saying the same thing, don’t blame the chickens or the foxes.

We must hold our government to a higher standard as their only job, their sole reason for existing, is to better the lives of its constituents, the chickens. If they are not doing that then they have relinquished their right to govern. Most radical governments now, the populists, want to overthrow all our institutions and start again. But that is wrong; these institutions developed for a reason. Just because they are not functioning properly does not mean that they cannot be fixed. Look at the motive for their inception and you will find the answer of how to fix them. Perhaps we can regain a system of care that promotes health and dignity in our last stages of life.

Many Dementias

My mother, of 86 years of age, has dementia. But we do not really know what that means. At first, she was slow and fragile; her short-term memory was shot. The doctors found high calcium in her blood and diagnosed a benign tumor in the hyperthyroid. They operated and she came back energetic, hyperactive, and hallucinating and talking with her dead mother and sister. Then she stopped eating and only drank when directed. She shrank in weight and became nearly catatonic. I met with the family as I predicted a quick death. I made the family take uncomfortable decisions.  We admitted her to a nursing home, and when my sister visited her four hours later and saw how anxious she was, mum came back home. She had an infection, ended up in hospital, and came back with a bloody nose. This abuse further solidified the primary caregiver, my younger brother's determination to protect mum by keeping her home. Then she started independently eating and drinking and while still looking for her dead relatives, she was getting more exercise than anyone else. She was physically getting stronger. She is in constant motion and repeats nonsensical words as though she is praying. From the moment she wakes up to the last breath at night she is in motion and vocal.

It seems there are layers of diseases, one waiting for the other to emerge and take priority, or both acting at the same time. Our categorization of diseases is not designed for older people with multiple diseases. Especially in psychiatric nosology, the idea of identifying specific diseases as distinct and independent diseases is nonsensical. As we get older the body ages across the board. A weaker heart, lung, muscles, skeleton, joints,  everything is diminished, some more than others. An emerging disease is not independent but can be an expression of all of these small deteriorations. My mother had a hyperthyroid tumor that created a calcium imbalance that slowed her cognition and body down, and she also had Lewy Bodies Dementia that created the hallucinations, and ontop of these she also must have Vascular dementia or Alzheimer’s disease that destroyed her memory. All of these were acting upon her at the same time. Then there are other neurological diseases that we still have not identified. Her improved eating habits cannot be explained by the dementia diagnosis alone. There are other changes that are hidden from us. Among 90-year-olds half of the cause of their dementia is unknown as there are so many other biological changes happening. When there are neurological deficits you can be certain that other diseases will emerge at the same time. Aging might be the most obvious factor, but that does not inform us on how to prevent or delay dementias as we cannot stop aging, but we can improve how we age.  Psychiatric nosology will eventually be dragged kicking and screaming through this terrain of older patients’ maladies until we finally admit that unless we start looking at the whole person, studying aging and not just diseases, we will never get a handle on dementia.