Author: James Vornov

I'm an MD, PhD Neurologist who left a successful academic career on the Faculty of The Johns Hopkins Medical School to develop new treatments in Biotech and Pharma. I became fascinated with how people actually make decisions based on the science of decision theory and emerging understanding of how the brain works to make decisions. My passion now is this deep explanation of what has been the realm of philosophy, psychology and self help but is now understood as brain function. By understanding our brains, I believe we can become happier, more successful people.

Practicing in Public

Ivy Aside

Joel Meyerowitz, now 75, is becoming the voice of photography, the voice of the artist for me. Here’s a remarkable sit down video of him describing the lifelong journey of an artist. At about 7 minutes in he talks about moving from phase to phase as an artist. I’m taken by the idea that at some point one reaches a competency and understanding of an artistic problem followed by a choice of whether to pursue the next artistic question at hand. Meyerowitz likens it very aptly to the process of a scientist, experimenting and exploring questions- sometimes with great results and sometimes for long periods down blind alleys.

I thought about the companints I’ve heard from fine artists about how the internet has changed expectations of the speed of output. Traditionally, an artist might spend years on a project, exploring out of the public eye, generating a new body of work. The work would then be revealed as complete just like a script or musical composition would be performed when done. Now we post a photo a day to Flickr, write about process and technique in our artists blogs and otherwise experiment in public.

The truth is that artists have rarely been successful working in isolation. We have circles of friends, families, gallery owners, mentors and trusted critics who get to see the work being done and provide some outside, independent opinion on the work as it forms. While being able to edit one’s own work is a necessary skill for success, being coachable is an equally valuable skill.

oel Meyerowitz spent months on the streets shooting with Garry Winogrand and Tod Papageorge. He’d show proofs to John Szarkowski at the Museum of Modern Art for feedback

When I’m actively working, I have Flickr and this weblog to serve a similar purpose with a virtual circle of artists who appreciate what I’ve been trying to do over the years. When things work well, we don’t just give each other animated GIF awards, but we point out what works in some photos and ignore the ones that don’t connect. I seek inspiration from mentors who directly teach on the web or like Meyerowitz and David Allen Harvey act as mentors to broader audiences. I’ve developed as a photographer in these online communities lacking a local photo salon and access to museum curators.

Ivy Again

Ivy Again

Funny how things fall apart.

I took a few minutes on Thanksgiving day to try the 105mm Nikon Micro lens on the D800. The camera was still in Monochrome display mode, shooting raw, so I saw Black and White images on the LCD as I reviewed the shots. Immediately, I reacted against the loss of color from the fall palate around the yard, so switched it back to Standard color mode.

Reviewing images in Aperture this morning for the first time, I liked the image that I took just before this one- a pretty similar framing of the ivy on the tree bark. But it was horribly out of focus and blurred. This one was better, but if you look at the EXIF of the image, it was shot handheld at 1/10 of a second. Even with the stabilization build into the 105mm, it’s technically a poor capture.

As I started processing the color image, I was fighting the lack of subject in the photo, what Vincent Versace calls in his books a primary isolate from CJ Elfont’s Isolate Theory. I find myself in this situation way too often and it comes from the lack of mindfulness that I have all too often behind the camera. It starts with an emotional connection to something seen but requires technical expertise to capture the most usable image file to express what was seen. Creating it afterward is nice practice, but in my experience never as successful.

At some point, I bail out. Back in black and white, the image works as a texture study. Having deliberately to work in color, I’ve taken it back to monochrome. There’s a little bit of light and a little bit of structure in it, but not worth much more than a glance for me in this final state. In my darkroom days, this would have gone into the reject box. Now I write about it and show it to dozens on Flickr and here on the blog.

Just Missed



Just Missed, originally uploaded by jjvornov.

Another factor in my return to photography is setting up a fixed workstation. Since I now spend workdays at an office, I no longer have a multi-computer work setup. My 13″ Macbook Air was the perfect tool for my decentralized work habits, sharing the desk with a docked Windows laptop for corporate use.

I’ve set up a nicely spec’ed Mac Mini as a workstation, providing me speed and storage. I can sit down and quickly enter the photographic workflow that I’m rebuilding based on the new Versace books.

The Nikon D800 is the perfect tool in town with the large travel zoom on the shelf and a small prime mounted. I think the waterfront and the historic streets of Canton will serve for subjects during these short late fall days.

Angel and Stars



Angel and Stars, originally uploaded by jjvornov.

I’m finding I can push these black and white images further from reality because the color doesn’t provide such a clear reference to the real.

In the city, a 50 mm prime is sufficient for this kind of image capture. It isolates detail in way that’s similar to noticing part of the world.

Next to the Water



Next to the Water, originally uploaded by jjvornov.

I’m dipping into Vincent Versace’s “From Oz to Kansas” just because of the potential of monochrome images. With a D800 and “almost every black and white conversion technique know to man” who needs Tri-X?

Cups and Trays in Harbor



Cups and Trays in Harbor, originally uploaded by jjvornov.

I think more that a few photographers have begun to realize that we finally have some digital cameras with enough dynamic range to begin to replicate a more classic black and white look. Film, with its slow fade to pure white and pure black captured tonality with ease. This D800 is about there. With a 50mm prime, it’s not much bigger than the film cameras I started with, although it is a good bit heavier.

Oregon Ridge, MD



_DSC0788cc, originally uploaded by jjvornov.

Having made a major life transition in moving to a new job, perhaps it’s not surprising that I’m feeling a need for some simple visual work. Vince Versace’s two new books have been waiting for me. My first goal will be to catch up on the updated technique in Welcome to Oz 2.0. So far, I find my new conversions a bit more naturalistic, a bit less dramatic.

Mind In The Cloud

“Technology changes ”how“ not ”what.“ Expands in space, compresses in time. The results are sometimes breathtaking.”

Notebooks as Extended Mind

In 1998, Andy Clark and David Chalmers made the radical suggestion that the mind might not stop at the borders of the brain. In their paper, The Extended Mind, they suggested that the activity of the brain that we experience as consciousness is dependent not only on brain but also on input from the rest of the world. Clark’s later book, Supersizing the Mind clarifies and expands on the idea. Taken to its logical conclusion, this extended mind hypothesis locates mind in the interactions between the brain and the external world. The physical basis of consciousness includes the brain, the body and nearby office products.

I mean to say that your mind is, in part, in your notebook. In the original paper, Clark and Chalmers use the hypothetical case of Otto. Otto has Alzheimer’s Disease and compensates for his memory deficit by carrying a notebook around with him at all times. They argue for externalism- that Otto’s new memories are in the notebook, not in his brain. The system that constitutes Otto’s mind, his cognitive activities depends not only on his brain, but on the the notebook. If he were to lose the notebook those memories would disappear just as if removed from his brain by psychosurgery. It should make no difference whether memory is stored as physical traces in neuronal circuitry or as ink marks on paper since the use is the same in the end.

The paper actually opens with more extreme cases like neural implants that blur completely whether information is coming from the brain or outside. We have brain mechanisms to separate what is internally generated and what is external. The point is that these external aids are extensions. In medical school I learned to use index cards and a pocket notebook reference, commonly referred to as one’s “peripheral brain”. Those of us who think well but remember poorly succeed only with these kinds of external knowledge systems.

In 1998, when The Extended Mind was published, we used mostly paper notebooks and computer screens. The Apple Newton was launched August, 1993. The first Palm Pilot device, which I think was the first ubiquitous pocket computing device , in March, 1997.

The Organized Extended Mind

When David Allen published Getting Things Done in 2001, index cards and paper notebooks were rapidly being left behind as the world accelerated toward our current age of email and internet. I’ll always think of Getting Things Done system as a PDA system because of the lists I created my system that lived on mobile devices. First it was the Palm, then Blackberry and most recently, iPhone. @Actions, @WaitingFor, @Projects were edited on the PC and synced to a device that needed daily connection to the computer. I had a nice collection of reference files, particularly for travel called “When in London”, “When in Paris”, etc.

My information flow moved to the PC as it became connected to the global network. Two communication functions really: conversations and read/write publishing. Email and message boards provided two way interaction that was generally one to one or among a small community. Wider publishing was to the web. Both of these migrated seamlessly to hand held devices that replicated email apps or the browser on the PC. Eventually the mobile device became combined with phone. Even though capabilities have grown with faster data rates, touch interfaces, bigger screens and large amounts of solid state data storage, The first iPhones and iPads showed their PDA roots as a tethered PC device in the way they backed up and synced information. That world is rapidly fading as the internet becomes a ubiquitous wireless connection.

Access to email and internet through smartphones has served to further “expand time”“ and ”compress space" as Dave put it. I adopted a text file based approach so that I could switch at will between my iPhone, iPad and MacBook Air and have my external thoughts available. The synced plain text files seems transformational, but feels like my old Palm set of lists.

The age of the cloud is one of information flakes. Much of what we know is now latent and external requiring reference to a small device. Is it any wonder that our streets and cafes are filled with people peering down into a screen rather than out into the world?

It was a rapid transition. One that continues to evolve and that demands frequent reconsideration of the means and methods for constructing the extended mind.

A Mind Released

The SimpleNote and Notational Velocity and DropBox ecosystem was the enabling technology for me. Suddenly there was seamless syncing between the iPad or iPhone and the Mac. The rapid adoption of Dropbox as the defacto file system for iOS broke the game wide open so that standard formats could be edited anywhere- Mac, Windows, iPhone, iPad, Unix shell. This was a stable fast data store available whenever a network was available.

Editing data on a server is also not a new idea. Shell accounts used for editing text with vi or Emacs on a remote machine from anywhere is as old as computer networking. I started this website in late 1999 on Dave Winer’s Edit This Page service where a text editor in the browser allowed simple website publishing for the first time.

Incremental searching of text files eliminates the need for databases or hierarchical structure. Text editors like Notational Velocity, nvAlt, SimpleNote or Notesy make searching multiple files as effortless as brain recall from long term memory. Just start typing associations or, for wider browsing, tags embedded in metadata, and unorganized large collections become useful. Just like brain free recall of red objects or words that begin with the letter F. Incremental searching itself is not a new idea for text editors. What’s new is that we’re not seeing just a line of text, but rather multiline previews and instant access to each file found. But together incremental searching with ubiquitous access and the extended mind is enabled across time and space.

What seems to have happened is that the data recorded as external memory has finally broken free from its home in notebooks or on the PC and is resident on the net where it can be accessed by many devices. My pocket notebook and set of GTD text lists is now a set of text files in the cloud. Instantly usable across platforms , small text files have once again become the unit of knowledge. Instant access to personal notebook knowledge via sync and search.

Thoughts On The Raw Shark Texts

“Why do you speak to me of the stones? It is only the arch that matters to me.”
Polo answers: “Without stones there is no arch.”
-Italo Calvino
Invisible Cities (1972)

As Steven Hall’s The Raw Shark Texts begins, a man awakes without memory of his life or of his personal identity. He finds instructions to visit a therapist who will explain his situation. The therapist tells him he has a dissociative disorder- he’s blocked his memory because of a traumatic event. This is more or less a conventional explanation for global amnesia, a loss of the past and personal identity.

An alternative explanation soon presents itself. Mysterious letters and packages arrive at the apartment. These have somehow been sent by his previous self, the first Eric Sanderson. His past self warns him that he is pursued by a conceptual shark that seeks to consume whats left of his mind and sense of self. The novel is the story of his quest to understand his situation and somehow defeat or evade the abstract menace that threatens his tenuous existence.

What to make of this abstract threat to mental and possibly physical life? In the opening scenes of the novel, Eric is completely uncertain whether he is crazy or really threatened by the abstract world. Which is real, the outside world or the interior world of mind? The reader is just as confused.

The philosopher recognizes this conflict as having its roots going back to Rene Descartes. Descartes famously asserted that mind and the world “out there” are separate. As thinking beings, people live on the side of mind, entirely without access to physical reality. That is, if the real world can be said to exist at all if it is so far out of reach. The apparent entry of the abstract into the real world. The breach of mind into world breaks the Cartesian divide wide creating the central suspense of the novel.

How can a neuroscientist approach a book like this? I come to the book with a certainty that the central conflict doesn’t exist. There is no abstract world of mind, only physically based activity of the brain. It couldn’t be more clear that Eric’s conceptual shark and his the loss of personal identity are occurring in his brain. Electrical patterns of neuronal discharge can’t leave the brain and pursue the body though the world. So I can’t bring myself to a suspension of disbelief and accept the premise that a conceptual shark might be real and a physical threat.

And yet once I settled into the book I was swept up in the quest and invested in the outcome. It was a great and clever read, full of suspense and action even though I knew the events were occurring in Eric’s brain with no external referent even if he perceived it to be so.

Some neuroscientists take the rejection of Cartesian dualism too far, denying that mind matters at all. After all, it makes no sense to say that mind can control anything since only brain circuits can do anything. Mind is what brain does and so is not able to cause or create anything in a real sense, all metaphor aside. Subjective experience, in the most extreme version of this view, is of no importance. They would, I presume, find the entire book of no interest. Mental states are not something to be taken seriously. We know that scientists and philosophers who espouse this view don’t act this way. Typically when the subject turns to mental events they often act Cartesians, treating mind as existing in a separate world that somehow influences the brain. Like abstract sharks stalking vulnerable people.

A novel like The Raw Shark Texts actually helps demonstrate how important the content of thought really is. Mind matters because it is the only window we have onto reality. It is not reality itself. It is a simplified approximation of the world represented in brain maps that we experience with this marvelous subjective sense of sight, sound, smell and meaning everywhere.

The brain needs the sensory input to be anchored in reality. Without the input, the reproduction of the world continues on, just without as much relevance. Deprived of sensation to anchor it, the brain runs independently and disconnected. Sensory deprivation, for example, results in vivid hallucinations. Dreams are likely to be similar brain network activation patterns untethered to external input.

The fact is that I can close my eyes at will and bring sights and sounds to mind that exist only in memory. Imagination is a mechanism by which new reality can be constructed from bits and pieces of the known and remembered.

After all, the brain is an amazing realtime engine that uses a simplified model of the world to reconstruct a guessed at reality and predict outcomes based on imperfect knowledge. There is nothing more important than the battles that occur inside, the self-referential arguments to decide what is real and what is right.

The Raw Shark Texts puts this idea in a literary frame and dramatically portrays the struggle as a fantasy thriller. The genre we call magical realism gets much its power from projecting the interior imagination out into a story that seems to be about the real world. It’s more dramatic to read about the clash of swords than the clash of ideas. It’s a bigger problem to have your life threatened than to have your ideological underpinnings or emotional stability attacked.

The life of mind is important. It’s our most important experience in life because it’s our only experience in life. What you perceive becomes what is. Your perception of me, my motivations, my character is what I am to you. Who I really am or what I really think is entirely inaccessible to you. Even as you read this you are assembling a model of me that may be wildly different from the view I hold of myself. Who’s understanding of me is more accurate?

To awaken completely isolated from oneself, from one’s memories is a dangerous situation for Eric Sanderson. His journey to save himself is no less epic if it only happens in his mind. It makes my own daily interior struggle to be better seem more important, more noble.

It would be depressing to judge myself only based on my position in the world. Material success as measured by the bank account or the rank and esteem bestowed by others seem empty because they are external. Perceptions of the perceptions of others are mere shadows of shadows. It’s bad enough that we have to live in the illusion we’ve created for ourselves. What a greater pity to live that fragile illusion reflected from the shifting and conflicted illusions of others.

We know or at least imagine who we want to be. Success is best measured by the distance between who we are now and that goal of thinking, knowing and acting well.

Eric Sanderson awakes completely missing his memories, disconnected from what he has been and what he’s learned. He’s as far away from who he wants to be as possible. He doesn’t know who he was, who he is or who he wants to be. That conceptual shark has taken away most of his life and now threatens to wipe him out completely. I can’t think of anything more real than that.

Do ADHD Drugs Work Longterm?

“Illness is the doctor to whom we pay most heed; to kindness, to knowledge, we make promise only; pain we obey.”
― Marcel Proust

An essay on ADHD in the New York Times launched an interesting Twitter exchange with Steve Silberman and a medical blogger PalMD on how well we understand psychiatric disorders and treatment.

In the article, Dr. Sroufe concludes that since there is no evidence for longterm use of ADHD medication, their use should be abandoned. He is right that the evidence of efficacy is all short term. Over the long term, no benefit has been shown. Of course almost no one dealing with the issue on a day to day basis would agree. Parents, teachers and physicians all agree that these medications have a use to improve the lives of these children. Count me among those who believe it is highly probable that treatment over the course of months and years has utility, but is hard to prove.

As a problem in decision making, this is a good example of the difference between believing and knowing.

There is a difference between the practice of science and an absolutist approach to truth. In decision making, we must be practical. As Williams James said, “Truth is what works.” He believed that science was a pragmatic search for useful models of the world, including mind. Those that look for abstract, absolute truth in clinical research will be confused, misguided and as often as not, wrong in their decisions. Truth is something that happens to a belief over time as evidence is accumulated, not something that is established by a single positive experiment.

Belief in the usefulness of therapy in medicine follows this model of accumulation of belief. The complexity and variability of human behavior demands a skeptical approach to evidence and a sifting through to discover what works.

Clinical trials for drugs to affect behavior are generally relatively small, short experiments that measure a change from baseline in some clinically meaningful variable. These trials are clinical pharmacology studies in the classic sense, studies in patients (clinical) of drug effect (pharmacology). No one is expecting cure or even modification of the disease. The benefit is short term symptom relief, so the trial examines short term symptom relief. In the case of a pain reliever, we ask whether patient’s self reports of pain are decreased by therapy compared to before therapy. In ADHD, we ask whether a group of target behaviors is changed by treatment compared to baseline.

This approach of measuring change from baseline has a host of pitfalls that limit the generalizability of clinical trials to real life medicine. First, baseline measures are subject to large amounts of bias. One of the worst sources of bias in these trials is the patient and physician’s joint desire to have the patient meet the severity required to be enrolled. The investigator is under pressure to contribute patients to the trial. The patient hopes to gain access to some new therapy, either during the trial or during some subsequent opportunity. Both of these factors pressure patients to maximize the severity of their complaint at baseline. How do you get into a trial? Exaggerate your problem! Even without conscious or unconscious bias from patients, any trial will enroll patients that happen to be worse than their average state. When measured repeatedly over time, the scores will tend to drop- a classic regression to the mean. If you select more severe outliers, they will tend to look more average over time.

Second, diseases are not stable over time. Without any intervention, measures of a disease will be most highly correlated when measured with a short duration between assessments. The longer you wait to measure again, the lower the correlation. Measuring a drug effect in a controlled trial accurately depends on a high level of correlation. All else being equal, the longer one treats, the harder it will be to measure the effect of the drug. This is the major pitfall of depression trials. Episodes are usually limited in duration, so most patients will get better over time without treatment.

So perhaps its not surprising that its very hard to measure the effect of ADHD drugs after months or years in chronic therapy trials. These kids get better over time both from regression to the mean and the natural history of the disease.

Another important issue in ADHD research is that these drugs have effects in healthy volunteers. As Dr. Sroufe points out, amphetamines help college students study for exams- no diagnosis of ADHD needed. This makes it easier to do pharmacology studies, but means that diagnosis in those studies doesn’t really matter- the pharmacology is largely independent of any real pathological state. One could never study a cancer drug in some one without cancer, but this is not true of a cognitive enhancing drug. Its probably most likely that the kids with ADHD don’t have a single pathophysiology, but rather a combination of being at one end of a normal spectrum of behavior plus stress or lack of coping mechanisms that create problems for them in the school environment where those behaviors are disruptive to their learning and that of others. The pharmacology of stimulants helps then all- after all it helps even neurotypic college students and computer programmers.

Treatment response does not confirm diagnosis in ADHD as it does in some other neurological diseases like Parkinson’s Disease. While we’d like to call ADHD a disease or at least abnormal brain state, we have no routine way of assessing the current state of a child’s brain. We have even less ability to predict the state of the brain in the future. Thus diagnosis, in the real meaning of the word- “dia” to separate and “gnosis” to know, is something we can’t do. We don’t know how to separate these kids from normal or into any useful categories. And we have no way of describing prognosis- predicting their course. So a trial that enrolls children on the basis of a behavior at a moment in time and tries to examine the effects of an intervention over the long term is probably doomed to failure. Many of those enrolled won’t need the intervention over time. Many of those who don’t get the intervention will seek other treatment methods over time.

With all of these methodological problems, we can’t accept lack of positive trials to be proof that drugs are ineffective long term. We can’t even prove that powerful opioid pain relievers have longterm efficacy. In fact, it was not too long ago that we struggled with a lack of evidence that opioids were effective even over time periods as short as 12 weeks.

Our short term data in ADHD provides convincing evidence of the symptomatic effects of treatment. Instead of abandoning their use, we should be looking at better ways to collect long term data and test which long term treatment algorithms lead to the best outcomes. And we should be using our powerful tools to look at brain function to understand both the spectrum of ADHD behaviors and the actions of drugs in specific brain regions.