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ACT on Drugs Functional Contextual Behavioral Pharmacology

ACT on Drugs Functional Contextual Behavioral Pharmacology. Dr Robert Purssey MBBS FRANZCP Psychiatrist and ACT therapist Clinical Senior Lecturer, Uni of Qld www.mindfulpsychiatry.com.au. ACT on Drugs. Functional Contextual Behavioral Pharmacology :

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ACT on Drugs Functional Contextual Behavioral Pharmacology

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  1. ACT on DrugsFunctional Contextual Behavioral Pharmacology Dr Robert Purssey MBBS FRANZCP Psychiatrist and ACT therapist Clinical Senior Lecturer, Uni of Qld www.mindfulpsychiatry.com.au

  2. ACT on Drugs Functional Contextual Behavioral Pharmacology: Transform understanding of psychiatric drugs Empower rational and truly informed consent Enable the workable use of medications The things that you’re liable To read in the (psychiatric ) bible It ain’t necessarily so…

  3. Introduction – Rob Purssey’s background Formal training in medicine, conventional psychiatry 1982 – 2004 Clinical psychiatry work in all fields and settings 1992 – 2010 Since 2005 trained in ACT, from 2007/8 – a Functional Contextualist Member ACBS, Healthy Skepticism, and Auspsyc email Listserves eTOC’s of all major psychiatric / psychopharmacology journals University of Qld and American Psychiatric Assoc library access Sees 3-8 new patients weekly, 1:1 private rooms, and detox and rehab setting, previously acute, perinatal, forensic, etc etc Prescribes psychiatric medication every day in clinical practice

  4. TAKE HOME MESSAGE 1. Change and improve your clients use of & response to medications - Workability, Values, Acceptance

  5. TAKE HOME MESSAGE 2. Grow the FC behavioral pharmacology evidence to better help your clients and others taking meds

  6. TAKE HOME MESSAGE 3. Stand with science in your own and clients’ meds understanding and use – and access this science. •  www.mindfulpsychiatry.com.au

  7. TAKE HOME MESSAGES 1. Change and improve your clients use of & response to medications - Workability, Values, Acceptance 2. Grow the FC behavioral pharmacology evidence to better help your clients and others taking meds 3. Stand with science in your own and clients’ meds understanding and use – and access this science. •  www.mindfulpsychiatry.com.au

  8. Change and improve your clients use of and response to medications • Psychiatric medications change neurochemistry • Nothing wrong with neurochemistry to start with • Real concern about longterm change in neurochemistry NO evidence of chemical imbalance in anxiety, depression, schizophrenia, bipolar, ADHD, PTSD, etc Medications change neurotransmitters NO evidence that drug induced imbalances are how they help, when they do. Medication effectiveness exaggerated , hazards minimised. Long-term outcomes steadily worsened in 40 years medications widely used depression, anxiety, schizophrenia, and esp. bipolar disorder and all behavioral disorders in children.

  9. Change and improve your clients use of and response to medications • Hazardous to rapidly stop any psychiatric medication • Significant hazards of long term use – outcomes / side-effects • New knowledge will contradict usual received wisdoms • Short term - may struggle more with feelings and thoughts • Guidelines carefully manipulatedregarding medications • General Practitionerscan’t know/accessthe real evidence base • Psychiatrists can’t know/accessthe real evidence base without hard work, forgoing peer acceptance, refusing perks and luxuries • You / your clients should hold lightly, and tread softly, in this area

  10. OUTLINE OF TALK • History of behavioral pharmacology – very briefly • Philosophical foundations of conventional psychopharmacology • Outcomes of conv’l psychopharmacology - scientific and clinical • Philosophical foundations of behavioral pharmacology (and implications for a functional contextual neuroscience) • Outcomes of behavioral pharmacology - scientific and clinical • Verbal behavior - ACBS Research (Clinical Practice Collaborative) • Clinician responsibilities: clients and others – ethical, scientific • Clinical talk - hexaflex oriented middle level and other terms • Take home messages – and further research items if time… 

  11. Hexaflex processes, useful drug effects? Beta blockers ?less “palpit’n, shakiness” Heart’s desires vs Head’s discomfort Benzodiazepines “relaxing warmth” Hazardous Vs necessary Serotonin - SSRI “serene/sanguine” “takes edge off” “sort of peek over the wall” Bodily health Gradual wean “a little more distance” SNRI ?also “energy/drive” Increase adherence In service of values Antipsychotics “who cares” “detachment” Stimulants “focus, calming” “tired, buzzing” Lithium, “mood” “stabilisers”???

  12. Behavioral Pharmacology Two fundamental principles unite the field: 1. effects of drugs are lawful and subject to scientific analysis. 2. behavioral effects of drugs merit attention in and of themselves. Behavioral pharmacologists assume that: • drugs are environmental events (stimuli -response relations), • drugs and their effects, like those of other stimuli -response relations, can be understood (i.e., predicted and controlled with precision, scope, depth) • without recourse to reductionistic, biologistic or mentalistic explanations. From this perspective, the study of drug effects should focus upon: • determination of behavioral loci of drug action, • determination of behavioral mechanisms of drug action, • determination of variables that modulate a drug’s behavioral effects

  13. Behavioral Pharmacology – a history J. R. Pappenheimer, B. F. Skinner, and P. B. Dews.

  14. The historical context The foundation and initial directions of behavioral pharmacology  1950s - the Psychobiology Laboratory at Harvard began  behavioral context found to be a very significant influence indeed on the behavioral effects of drug action. The 1950’s - “Golden Age of Psychopharmacology”  In ten years, drugs discovered, clinically introduced and helped with schizophrenia, depression, and anxiety. Chlorpromazine, imipramine, and diazepam influence on treatment was tremendous

  15. Effects of drugs on emotional statesversus the influence of context…  1950s research effects of drugs on emotional states, the theoretical reduction of drive states – i.e. mentalism, or cognitivism • how drugs affect presumed underlying emotional states 1955 Peter Dews - 1st major finding of Psychobiology Lab published in TheJournal of Pharmacology and Experimental Therapeutics “hungry pigeons” – same underlying emotional state… and … Pentobarbital affected behavior under a fixed-interval (FI) schedule differently from behavior controlled by a fixed-ratio (FR) schedule • pentobarbital increased pecking rates under FR schedule • same dose decreased or eliminated responding under FI schedule.

  16. Dews, P.B. Studies on behavior. I. Differential sensitivity to pentobarbital of pecking performance in pigeons depending on the schedule of reward. 1955 Effects depend not only on drug, dose, and behavior, but also on the circumstances under which the behavior is occurring: Hungry pigeons pecking disc “to earn food” • Fixed Ratio of pecks – i.e. 50 pecks – to earn food. • Fixed Interval of time - i.e. 10 minutes – to earn food (lots of pecks) Effects of Pentobarbital tested – and with intermediate doses • Fixed Ratio subjects  enormous increase in pecking • Fixed Interval subjects  almost complete elimination of pecking In FR a stimulant, in FI a depressant, depending on behavioral history NOT just drug, dose, kind of subject, and “why” doing it, but b/h history

  17. B. F. Skinner and P. B. Dews

  18. Implications and extensions of Dews’s work Evaluation and interpretation of drug effects on behavior shifted from speculation about ephemeral emotional states to quantitative and observable aspects of behavior  manipulable directly and testable experimentally These effects are demonstrated quite graphically in individual pigeons, with the effects of pentobarbital shifting rapidly dependent on context Effects of Amphetamine also differed under FR, as opposed to FI, schedules in a direction opposite that of pentobarbital. Schedule-controlled behavioral research in pharmacological studies provided insight into behavioral and pharmacological principles Implications and extensions of Dews’s work profound – guided nature / direction of research in behavioral pharmacology over four decades.

  19. Classic Harvard Psychobiology Lab demonstration – the influence of context 2 pigeons trained under Fixed Ratio 30 1 in apparatus other in holding cage Peck peck peck in apparatus, other just sitting there Inject each with pentobarbital dose nearly enough to cause sleep 1 in apparatus pecks even more quickly than normal, 1 in holding cage almost asleep. Switch pigeons, and behaviors switch. Shows effect of drugs depends not only on drug, dose, behavior, but the environment and history IN that environment of that behavior This visually shown dramatically with contexts so apparently close

  20. Techniques for the Study of the Behavioral Effects of DrugsNew York Academy of Sciences Chaired by Skinner and Dews (Annals, 1956) EAB methods for analyzing the behavioral effects of drugs. Impetus for a science of behavioral pharmacology resulted from: • treatment of behavioral problems (i.e., psychotropic drugs) and • the ubiquity and seriousness of drug abuse problems. • Concern re: effects of environmental chemical contamination.

  21. Experiential / contextual factors have a huge influence on drug effects on behavior Effects HIGHLY INFLUENCED by historical and present context NO GREAT ADVANCES in exactly what about historical / present contexts make drug effectsso very different in individuals. A few general rules, which drugs do follow, but not much… (Marc Branch podcast, www.behaviortherapist.com ) Behavioral pharmacology in many areas synonymous with psychopharmacology  mechanism and biologism Biological differences exist, but… although individual neuron function understood somewhat clearly, but… 1 Voxel in each fMRI comprise at least ½ million neurons… ?

  22. Rule-Governed Behavior and Human Behavioral Pharmacology AlanPoling’s plea, 1992  RGB, help us! Verbal behavior and the theoretical and experimental analysis of drug-related human behaviors. Behavior analysts in 1980’s began exploring variables controlling rule generation and rule following (e.g., Hayes, 1989). Noticing that rule-governed behavior is operant behavior, and hence… … varies within / across people as function of historical + current variables, which are in the environment, hence measurable and manipulable  Role of ACBS / RFT / ACT in furthering Behavioral Pharmacology

  23. Assumptions, coherence, effectiveness Behavioral Pharmacology Mentalistic/Cognitivistic Psychopharmacology

  24. Philosophy of science – why bother? Pre-analytic assumptions explicit  owning them Attempting to eliminate incoherence in assumptions Rules of evidence (or criteria for truth) • used to create, assess, and evaluate knowledge claims and theories • how otherwise to proceed effectively in science? Coherence, less misunderstanding & pointless debate, productive comparisons / theory evaluations PROGRESSIVITY OF SCIENCE, BUILDING THE WORK

  25. DIFFERENT MOUNTAINS- assumptions

  26. DIFFERENT MOUNTAINS – strategies

  27. Pragmatism or “Realism” – a choice

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