"Outlier": The causes of high achievement

Outlier by Malcolm Gladwell, is a brilliant book about the causes of success, outstanding achievement, and personal greatness.

Gladwell describes a variety of interesting life stories, of people with outstanding ability or outstanding achievement, then looks carefully at the factors leading to these successes.

He does not claim that "inborn traits" or hereditary factors are unimportant.  But he shows quite convincingly that inborn talents correlate with achievement only to a certain point.  Individuals with extreme talents tend not to achieve more than those with merely "sufficient" talents. A recurring theme in this book, shown through one example after the next, is that the simple stories many people might have, to account for a person's great achievements, are often appealing and believable, but are in fact often inaccurate or at the very least incomplete.

He shows that various situational biases can have a profound, snowballing effect on the course of successfulness in a person's life.  A trite detail such as birthdate can lead to a cascade of advantages or disadvantages for athletes, which then accumulate over many years (his example is of successful hockey players being much more likely to have an early birthday--if you're born in December, this is an instant disadvantage, as you will be a little bit smaller and weaker on average compared to your teammates, therefore the older players will tend to outperform you, leading to a smaller chance of  you being noticed or advanced to a more challenging team, or to be deemed "gifted" and given more ice time, etc.)  

He emphasizes the role of thousands of hours of intensive practice being required to master a skill.  Those who have 10 000 hours of practice under their belt early on in their lives--particularly if some serendipitous quirk of fortune allowed them to be one of the only individuals, or one of the first, to gain this experience-- have a strong chance of succeeding spectacularly in their fields.  He gives examples such as Bill Gates, or the Beatles, or some of the most successful New York lawyers doing a particular type of law. 

One of the psychologists cited in this book,  who has studied the area of "exceptional achievement" is AK Ericsson, who generally argues that "extended, intense practice"  is the primary determinant of elite performance, as opposed to inborn talent.  The ability to do this type of practice, of course, requires or is greatly facilitated by, motivational resources as well as environmental opportunity, parental support, a culture which favours such as endeavour, etc.) Here are some references to articles of his:
http://www.ncbi.nlm.nih.gov/pubmed/17905932
http://www.ncbi.nlm.nih.gov/pubmed/17642130
I suspect that heredity is quite relevant, but may manifest itself in many ways aside from what many people might assume.  Factors that could be considered at first glance to be a disadvantage, either hereditarily or environmentally, may, in the world of successfulness, end up being compelling advantages.

Guillermo Campitelli is another excellent researcher in this field; here's a reference to one of his recent papers: http://www.ncbi.nlm.nih.gov/pubmed/17201516.  The evidence here, looking specifically at chess players as a model of acquiring expertise, affirms the extreme importance of thousands of hours of  practice, but also recognizes that some players improve much more than others with the same amount of practice.  This is probably the influence of inherited talent.  Maybe there could be other hidden variables, including family or cultural factors.   He suggests that the age at which the practice begins is another important variable.  

It should be noted that, in this literature, "deliberate practice" refers to a type of activity which is specifically directed towards performance improvement, is adequately difficult, has feedback about performance, and which has opportunity to correct errors.  This differs from "ordinary" work experience, which may be quite a bit less intense and much less geared towards improving skills.  I suspect that the quality of "deliberate practice" may vary quite a bit, depending on the degree of immersion, concentration, energy, engagement, and meaningfulness there is in the action.  I wonder if enjoyment of the practice is a major variable too, I would be interested to see if some of these researchers would look at this.  If someone finds their 100 hours of practice meaningful and enjoyable, I have to wonder if they might advance much more than someone whose 100 hours were a drudgery.    

Another excellent angle of discussion in Gladwell's book has to do with understanding a person's cultural background and childhood developmental history, as extremely important determinants of success.   This leads to discussions about opportunity, pedagogical technique and policy, etc.  Sometimes cultural or developmental factors cause individuals to lack a certain skill necessary to succeed, or put individuals at risk of recurrent severe problems or frustrations.  Good examples are given, including the story of a profoundly gifted intellect who was never able to share his talents; and of highly trained pilots who were too quietly respectful of authority to be able to proactively use strong assertive social skills to prevent an aviation disaster.

I'll add to this post later on, to expand some thoughts about achievement and success.  In the meantime, I think Outlier is a worthwhile and entertaining read.

Writing about worries can ease exam anxiety

Here's another simple research finding, published recently in Science by Sian Beilock:  students who spent ten minutes--immediately before a test--writing down their thoughts about what was causing them fear, performed substantially better on the test.


http://www.ncbi.nlm.nih.gov/pubmed/21233387


I'll have to review this paper in more detail to comment further, but I think it is another simple anxiety-management tactic for exam or performance preparation.  A frantic review or a frantic bout of anxious rumination right before an exam is unlikely to help -- an anxiety-management exercise such as expressive writing is very much more likely to help, and a study like this is strong evidence of this.

The article shows that the effective action was specifically to write about negative thoughts and feelings during the ten minutes before the beginning of a stressful exam.  A control activity--of writing about anything that comes to mind--was not effective.   So the effectiveness of this technique was not simply due to distraction. 

I would be interested to see the authors' opinions and/or research about whether specific journaling techniques could work particularly well, or less well, in various anxiety scenarios.  Sometimes, purely "negative" journaling can end up being a somewhat ruminative activity which entrenches negative emotional states and attitudes (e.g. one can get worked up in a cynical, pessimistic rant, which could increase or magnify one's following cynicism or pessimism, or increase one's filtered attention to negative events in the day).
See the following references:
http://www.ncbi.nlm.nih.gov/pubmed/12173682 
http://www.ncbi.nlm.nih.gov/pubmed/17120515
   A "balanced" journaling style, which includes room for free discussion of thoughts and feelings, but also room for positively-focused or constructive discussion may prevent this risk of snowballing rumination or negativity from a journaling activity.   One simple aspect of this experiment was that the journaling was immediately before a performance, and was very time-limited (10 minutes); these factors may reduce the potential for the journaling to be a negative or ruminative behaviour, and may increase the chance of the activity serving to process anxious emotion effectively.

Testing improves learning

Here's another recent bit of research, published in Science, demonstrating the value of doing a test ("retrieval practice"), immediately after learning something.  Those who did the tests, instead of other study techniques, had much better retention 1 week after learning something.

http://www.sciencemag.org/content/early/2011/01/19/science.1199327.abstract
This finding is consistent with my believe that a lot of study time is inefficient, because it encourages the studier to push forward to "get more reading done", before the reading which was just done has been consolidated well or reviewed.  Even though "pushing forward" may seemingly cover more pages of text, it accomplishes less long-term learning.  A much more efficient use of time is to pause, review, and do a test on the material at just the right interval.  If the interval is too short, the tests will be too easy, and the review will also be an inefficient use of time.  If the interval is too long, too much will have been forgotten already, the tests will be too hard, and it will make you have to go over the same material again, another inefficiency.

I don't believe findings such as this one necessarily contradict ideas about  flexible or "constructivist" approaches to education.  Nor do I believe it has anything to do with the controversial area of standardized tests for children or professional schools, etc.  Standardized tests are not a mechanism for education, they are assessment tools (how good they are as assessment tools would be a subject for a good debate).

There are some instances in which pausing frequently to review could disrupt a larger thematic appreciation of a subject or experience--it would be like pausing a movie every ten minutes to answer questions about the plot or characters--so, of course, sometimes this technique would have to be set aside.

I think that flexible, personalized educational approaches are extremely important--but this evidence about the merits of retrieval practice testing can be applied to any such style.  Its immediate value is in helping people use their time more efficiently for many study tasks.

A previous post also deals with the subject of study efficiency, and actually cites a more densely technical analysis showing more or less the same result, though it adds information about the frequency with which one should optimally pause to test oneself: http://garthkroeker.blogspot.com/2010/04/optimal-learning-training-schedules.html

Reading Exercises

A common problem I find among university students is difficulty reading quickly or efficiently.  Reading problems can also occur in conjunction with depression.

The best thing to do to improve reading skills is, of course, to read more.  But a phenomenon which often happens when reading any text, but especially longer texts, such as novels, is that you can lose track of what you have just been reading.  Whole sections of the text may end up being skimmed superficially, as part of your attention lapses or wanders, while still maintaining a basic pace of absent-minded reading.  This leads to a lack of enjoyment or feeling of mastery with reading, dampened morale, sapped motivation, contributing further to any depression which had been present, and deterring further reading efforts. 

An approach to this type of problem requires you to stop to reflect or answer questions frequently about what you have just read.  Whenever you test yourself regularly, your learning and retention are greatly increased.  Most good introductory university textbooks are set up this way.  But not very much in the line of non-textbook reading.  

So, I have been trying to find resources to help with reading skill, for adults.  Elementary-school language textbooks or readers seemed like a reasonable thing to check.   I certainly recommend that adults at least periodically read books which have been written for children or adolescents.  The best things I've found online are from ESL (English as a second language) programs.  Even if you are an advanced reader, or have spoken English all your life, I think that ESL exercises could be good for improving reading skill. 

Cognitive-skills training websites tend not to offer very much in terms of language learning or improving reading fluency or retention.  I wish that the cognitive skills website people could develop more along these lines: reading-oriented games don't seem very difficult to imagine or design, compared to other types of games.

Here's a list of a few sites I've found, where you can practice English reading skills:

http://web2.uvcs.uvic.ca/courses/elc/studyzone/
This is an excellent free resource from the University of Victoria (in BC).  For the reading exercises, choose an "English language level"  (beginner to advanced), then follow the links about reading. 

Houghton Mifflin College
This site also offers timed readings with questions afterwards. 


Quizzes Based On VOA Programs (ESL/EFL)

This link goes to a site where you have to read a text a sentence at a time, and fill in the blanks from a list of options, according to what makes sense or is grammatically correct.  While some might find this type of exercise too easy, I think it is a nice way to remain more interactive with the text.  If you do find it easy, you can just try to do it faster, and make it into a game. 

Another useful thing to look for is an online book club which has discussion questions about the book you're reading.  Some sites have questions for each chapter, which is the type of thing I'm recommending, so that you can pause frequently to review what you have just been reading.   I haven't found a single site which has chapter-by-chapter questions for a wide variety of books, but here's an example of a specific site, giving questions about Great Expectations by Charles Dickens (a great book, by the way):
http://www.victorianweb.org/authors/dickens/ge/pva107.html

Tetris or sleep deprivation to treat or prevent PTSD?

Here's a reference to an interesting 2009 study showing that playing tetris for 30 minutes can interfere with memory consolidation of upsetting visual imagery:
http://www.ncbi.nlm.nih.gov/pubmed/19127289

This is an example of evolving evidence that an important period for consolidation of  memories occurs in the first 24 hours after an experience.  A consolidated implicit association between the factual components of memory and strong negative emotions may also form most strongly during this initial post-exposure period.

The same group published a 2010 study showing that a game like tetris was more effective than a quiz-type game activity for reducing visual flashbacks following exposure to upsetting imagery:
http://www.ncbi.nlm.nih.gov/pubmed/21085661

I think the message here is not that tetris in particular has some kind of unique medicinal properties, but that a non-passive activity which requires continuous, intense visual attention is most effective at reducing consolidation of intrusive visual memory.  A distracting activity lacking strong visual involvement may be less likely to interfere with this consolidation mechanism. 

Other research has suggested that propranolol, a beta-blocking drug, can reduce post-traumatic memory consolidation, particularly the troubling implicit or emotional component responsible for psychological symptoms of PTSD.  (see my other post, http://garthkroeker.blogspot.com/2009/02/beta-blockers.html)

Some of the standard psychological treatments in the immediate post-trauma period may be harmful, such as critical incident stress debriefing.  If individuals are compelled to revisit details of their trauma in a group setting,  during the sensitive 24-hour post-incident window,  this may increase rather than decrease memory consolidation.  I think this tactic is especially problematic if there is social pressure or overt prescriptive advice from professionals to do this, when the individual may not wish to talk about the trauma.   This type of pressure may feel coercive rather than freely consensual, a dynamic which could be re-traumatizing. 

In another recent study (http://www.ncbi.nlm.nih.gov/pubmed/20889142 ),  sleep deprivation following exposure to upsetting visual stimuli was shown to reduce aspects of implicit memory consolidation.  This is consistent with other evidence showing that sleeping facilitates learning, by helping to consolidate recently acquired memories.

In conclusion, I think it is useful to know some simple techniques which could reduce the harm which traumatic experience can immediately impose upon the brain's memory systems.  Immediate distraction with an absorbing visual activity, such as tetris, could be helpful.  Sleeping right away may not be helpful, and may actually increase consolidation of traumatic memory.

For consolidated symptoms of PTSD, and for longstanding troubling thoughts, memories, images, and emotions, etc.  it is clear that therapeutic dialog can be very helpful, provided the setting is safe, non-pressured, comfortable, with a strong sense of trust.    Such gentle dialog could begin the process of weakening the strong negative emotional grip that the traumatic experiences may have in daily life.  The evidence mentioned above has to do with reducing the incidence of PTSD in the first place, through specific tactics to be undertaken immediately after the trauma. 

We could infer, conversely,  that engaging in distracting activities, such as video games, after doing an activity that you would want to remember vividly (such as studying, or some other pleasurable or meaningful event), could lessen retention of these positive experiences  (so, you shouldn't distract yourself with an absorbing visual activity right after studying).  Also, having a good sleep after a pleasurable event, or after studying, would be expected to make these experiences more permanent in your factual and emotional memory. So, it's important to be conscious of what you do, during, but also after, events of significance.

"The King's Speech"

I recently watched this movie ("The King's Speech"), which I thoroughly enjoyed.

I found it to be a nice story about the potential benefits of therapeutic change, and about the ingredients required to achieve this.

The literal facts of the story were interesting, but like a plot of a play, are not important in themselves to appreciate the theme or message.  

The story has to do with the relationship between Prince Albert--who would become King George VI--and a seemingly unconventional speech therapist he met to deal with his stuttering problem.

I see the stuttering/speech therapy angle of the story (and its implied psychodynamic underpinnings) to be more of a metaphor for psychological symptoms.   The facts about the causation of stuttering do not include a prominent role for psychodynamic factors or childhood trauma, etc.   But the therapy for any problem, irrespective of its cause, is often helped greatly through psychodynamic insights and focus, particularly if the context of the problem has affected relationships and sense of self. 

The compelling message I found about therapy in general, was that symptoms in the mind can obstruct the attainment of greatness or satisfaction in achievement or character.    I see this often -- that there is tremendous potential in an individual, almost a sense that there is a special place or purpose for the person in the world, but this potential is obstructed and trapped because of symptoms, psychological injury, or illness.    For a therapeutic endeavour to be helpful, it requires trust, a safe and balanced therapeutic frame, and a good rapport.  I like the idea that playfulness, spontaneity,   physical activity,  and humour are essential elements of therapeutic benefit in this story.  The other ingredient for therapeutic change--often under-emphasized in many stories--is that the work required needs to be very intense and disciplined.  A good therapist can have the role of trusted confidante, listener, teacher, or advisor, but also of a behavioural coach, to help and encourage the long and difficult daily work involved to effect behavioural and psychological change.

Another great thing about this movie is the soundtrack, which includes some of my very favourite, wonderful and thematically relevant pieces by Mozart and Beethoven.

Psychiatry & Dentistry

There could obviously be psychiatric issues in dentistry, such as phobias.  A good dentist could be quite therapeutic in this regard.

But there are a other dental issues that have to do with psychiatry.

For example, having unhealthy gums probably causes increased transient bacteremia each time one eats; this is caused by the mechanical stimulation of gums with a high bacterial load leading to leakage of bacteria into the blood circulation.  This would not be expected to cause a systemic infection, but it would stimulate an immune response.  Some research suggests that this type of recurrent phenomenon causes heightened systemic inflammation, which in turn stresses the brain.  
Here are some references which show a relationship between gum disease and systemic inflammation; this causative relationship is further associated with increases in the risk of various systemic diseases, and overall mortality. 
http://www.ncbi.nlm.nih.gov/pubmed/20306866
http://www.ncbi.nlm.nih.gov/pubmed/20502435
http://www.ncbi.nlm.nih.gov/pubmed/18052701
http://www.ncbi.nlm.nih.gov/pubmed/19909639
 http://www.ncbi.nlm.nih.gov/pubmed/17559634
http://www.ncbi.nlm.nih.gov/pubmed/20960226
http://www.ncbi.nlm.nih.gov/pubmed/19774803
 http://www.ncbi.nlm.nih.gov/pubmed/20509364

The existing research shows a link between oral disease and increased risk for various other diseases, such as cardiovascular disease.  We can hypothesize that any factor increasing risk for cardiovascular disease would also be deleterious to the brain, as it would affect the brain's very sensitive vascular system.  Not much research clearly proves this risk.  Here is a reference which starts a discussion on the subject:
http://www.ncbi.nlm.nih.gov/pubmed/19864654
Here's another, suggesting that controlling or preventing gum disease is a preventable risk factor for Alzheimer's Disease:
http://www.ncbi.nlm.nih.gov/pubmed/18631974

So, it is a relevant part of preventative mental health care to take good care of your teeth, including regular dental visits!

There are other overlaps between psychiatry and dentistry.  Many people, when depressed, neglect daily dental care.   Psychotic symptoms can arise over dental issues (e.g. believing there is a transmitter implanted in a filling).  Various overvalued ideas can persuade people to seek arguably unnecessary dental procedures (e.g. regarding mercury amalgam filling removals).  While mercury is likely to be of some risk, e.g. regarding the development of autoimmune reactions, it is likely that many people overestimate the degree of risk, or falsely attribute symptoms to the type of dental fillings they have.  Therefore, a business may arise of expensive filling replacements which are medically unnecessary.   Here are a few articles about this: http://www.ncbi.nlm.nih.gov/pubmed/16042501
http://www.ncbi.nlm.nih.gov/pubmed/16393137
http://www.ncbi.nlm.nih.gov/pubmed/18517065
http://www.ncbi.nlm.nih.gov/pubmed/16448848
Another dentistry/psychiatry intersection has to do with cosmetic dentistry, and orthodontics.  Orthodontic treatment is associated with at least a temporary increase in self-esteem, and possibly even an improvement in motivation. (reference: Karen Korabik, "Self Concept Changes during Orthodontic Treatment",  Journal of Applied Social Psychology, 1994, 24, 11, pp. 1022-1034).   Korabik's earlier work showed that orthodontic treatment led to individuals being perceived in a more positive way by others, with regard to impressions of personality, intelligence, as well as appearance (even, for example, based on pictures in which teeth were not visible). (Basic and Applied Social Psychology 2, 59-66, 1981).   This phenomenon illustrates a problem with human nature, that we would infer things about one another based on superficial factors.   The power of such superficial phenomena, relationally,  is usually also short-lived and superficial, yet I do think that simple esthetic practices, if available, could be at least a small positive in affecting interpersonal dynamics, and therefore be a small positive influence in maintaining a healthy mood.  

Psychiatry and Linguistics

The history of spoken and written language is a very interesting field of study.  The manner in which languages evolve over time is similar, literally, to the way in which species evolve (languages do evolve much more rapidly than species).  It is interesting to look at a kind of linguistic evolutionary tree, to see the parallels and differences alongside a genetic evolutionary tree, say of Indo-European languages in comparison to mitochondrial or Y-chromosome haplotype analysis in Eurasian groups.

Styles of language, and of word choice, etc. are certainly influenced by the culture of the day.  It would be interesting to consider the degree to which word choices affect individual psychology.  Some modern feminist thinking has certainly looked at the issue of language issues having important elements of psychological effects, particularly if the language itself is biased towards being sexist.  This is a big area, one which I'd be interested to learn more about.

Another aspect of linguistics has to do with the multi-sensory nature of language perception.  I find this very interesting, in expanding our understanding of the way the mind works in general:  words on their own may be perceived or understood in different ways intellectually (this is an issue often discussed by literary scholars), but the manner in which words are perceived is also influenced very directly by core neurologic processes.

For example, I recently discovered the existence of a very powerful perceptual phenomenon called the "McGurk Effect."   Here are a few examples from YouTube:
http://www.youtube.com/watch?v=DsdyE491KcM&feature=related
http://www.youtube.com/watch?v=aFPtc8BVdJk&feature=related
If you watch the video while listening to the speaker pronounce a syllable, it sounds completely different from when you close your eyes and just listen without watching.  The phenomenon demonstrates how powerfully visual input changes how we perceive an auditory stimulus.  I was surprised to find how overpoweringly strong the effect was, how difficult it is to somehow "over-ride" it.

Other linguistics research demonstrates that other sensory modalities, including tactile, also have strong effects on language perception.

As an extension to psychiatry, and to the general workings of the mind, I think it is true that many different perceptual and psychological inputs have very strong effects on the way we perceive other stimuli.  In social exchanges, there may be a wide variety of inputs which we are not consciously aware of, which could be substantially affecting our experiences.  In most cases, these other inputs assist us in understanding better.  The purpose of having one sensory modality influence another is to bolster the input from both, so as to facilitate understanding.  This is the foundation for how lip-reading works, for example.   But if one input is, without our knowledge, giving opposing information compared to another input, then this could lead to a very problematic behavioural cycle.

I think such phenomena are likely to happen in many anxiety disorders, for example, in which the anticipatory anxiety, and resultant physical and emotional tension, are likely to cause one's perceptions of benign social stimuli to become exaggeratedly negative.  This is happening not just on an intellectual level, but arguably on a core perceptual level, akin to the McGurk effect.  Similar perceptual distortions are likely to happen in other psychological states, such as depression.  The cognitive theory of depression centres around so-called "cognitive distortions," but I think it is important to expand this concept to admit that the phenomena could be powerful "cognitive-perceptual" distortions, which could require a lot of disciplined work to overcome.  Without acknowledging the strength of this phenomenon, frustration could quickly set in, just as it would if you were to simply practice hearing McGurk-style syllables without knowledge of the McGurk effect.

Psychiatry and Economics

I've alluded to the field of "behavioural economics" in other posts.  I think this is a very interesting extension of social and motivational psychology.

I think that a broad analogy can be made between economics and psychiatry:
the phenomenon of an economy is similar to the mind, or to one's life, in a variety of ways:
1) there are engines which drive the economy, in the form of productivity.  Economic productivity may be measured by goods or services generated by the population.  Life productivity includes various tasks of developmental "work".
2) There is a relationship between "supply" and "demand" which changes the valuation and flow of productivity.
3) Currencies become symbolic short-cuts to exchange goods or services; emotional or behavioural "currencies" can be short-cuts in to obtain needs in the community or in relationships.
4) Problems in an economy could occur at many different levels in the system:  productivity failure due to a technical, external problem (e.g. a natural disaster), a failure to exchange or trade freely, a symbolic or regulatory system which goes out of control despite integrity in the rest of the system (e.g. stock market crashes).  In the economics of mind, there could be core external problems (e.g. a neurological disorder), but there could certainly also be problems "trading freely."  Heightened neurotic defenses could be compared to a lack of "free trade," where healthy inner resources cannot be shared, not with other parts of oneself, nor with others.  Such phenomena stunt an economy, even if the core capacity for productivity is strong.  A "stock market" crash, similarly, could occur in the mind, if regulatory mechanisms in one's mind run wild, while losing touch with a moment-to-moment sense of self or present. 
5) Borrowing could, one the one hand, be a powerful means to accomplish tasks that would otherwise be impossible (e.g. buying a house).  Refusal to borrow limits capacity for growth.  But if debt cannot be managed, it leads to an economic instability, reduced autonomy, and ultimate failure (bankruptcy).  Similarly, in one's mind, risks need to be taken to grow, and one needs to borrow from others and from the community in order to develop oneself.  Refusal to borrow limits what is possible.  However, over-borrowing, and accumulation of social & emotional debts, leads to a cascade of chaotic effects. 
6) Investing is a means of taking a risk of giving one's resources away, with the hope that the community will prosper as a result, and return the investment prosperously.  Emotional and social investments are risks taken which, on the one hand, are immediately depleting, and which may cause permanent losses (e.g. with unfruitful actions are relationships) but which permit the possibility of substantial growth in one's own life, while also allowing resources for the community to grow (emotionally or socially) around you. 

Much in the field of economics include sophisticated mathematical analysis of the energy dynamics in an economic system, accounting for the many variables at play.  It would be interesting to apply some of this analysis to psychological dynamics.  Behavioural economics is more psychology than economics, at this point.  It would be curious to have more of the leaders in the study of mathematical economics apply some of their ideas to "psychological economics."  

Psychiatry & Architecture

This is the first in a series of posts in which I'd like to discuss figurative or literal comparisons and overlaps between psychiatry and other fields of study. 

Architecture could be considered a science and an art--a field with many technical elements, but with an over-riding importance given to esthetics, expressiveness, and community relationships.

Ideas in psychiatry could be considered "architectural" in the sense that it is important to have an overall sense of a plan, with a clear sense of purpose.  Even with good technical skills (e.g. to relieve a symptom),  work in psychiatry, or in life progress, may be unsatisfying if there is no attendance to the larger sense of purpose in the life's structure.  Part of the purpose is "esthetic," but part has to do with identity, interaction with community, originality, and expressiveness.  This is similar to the architectural considerations involved in planning and developing a new physical structure. 

As in architecture, many very good ideas could be generated to develop one's life, but the ideas must also be technically sound, and supported by good engineering.  Many life plans have dangerous weaknesses in the foundation, so to speak, or may be hindered by untreated symptoms.  So, a sound architectural plan in psychiatry or in life management must include both esthetic or artistic elements, as well as good structural support.  

Making tasks fun improves motivation & self-control

Juliano Laran and Chris Janiszewski recently published a study in Journal of Consumer Research (Vol. 37, electronically published Aug. 24, 2010, entitled "Work or Fun?  How Task Construal and Completion Influence Regulatory Behavior."

It is an example of a simple research study in an evolving literature about self-control.

A prevailing notion is that the work involved in any self-controlling action is depleting; therefore, repeated difficult acts of self-control, even if successful, increase the chance of self-control failure shortly thereafter, because of the depletion of inner self-control resources.

The authors in this study hypothesize that there are several variables which affect the dynamics here:
1) individuals vary in their capacity for self-control
2) individuals who engage in actions which are inherently satisfying (fun) are not depleted by these actions, and do not experience a decrement in self-control afterwards
3) individuals for whom these same actions are merely work, and not fun, are depleted by their actions,  and have less self-control afterwards
4) Activities which are incomplete have a neutral effect on subsequent self-control
5) Activities can be "reframed" as work, or as fun, and this reframing affects whether the activity is depleting or not. 

The experiments described in this paper are, like many brief psychological studies of this sort, somewhat amusing to read about, and could certainly be criticized as somewhat shallow, cross-sectional portraits of a complex behavioural dynamic, with quite limited generalizability.    The measure of "self-control," for example, involves measuring how much candy the subjects eat following a written exercise. 

Yet, the results did support the hypotheses, allowing the following conclusions:

1) One's attitude towards a task has a very strong influence upon how the completed task will affect you afterwards.  If tasks are perceived and experienced as work, as tedious, as unenjoyable, then they will leave you "depleted," and substantially more prone to unhealthy behaviours afterwards.  If an attitude can be nurtured of tasks being enjoyable or fun, then the completion of these tasks leads to an increased sense of vitality, without any experience of depletion.  .  

2) While there may be mood or personality states or traits which influence these attitudes towards tasks, it is possible to reframe the activities in a beneficial way.

3) If some tasks cannot be reframed as "fun," than a neutral alternative could be to frame the activity as ongoing, and therefore never complete.  Incompleted tasks, according to this study, have a more neutral effect upon self-control depletion.   In the management of obesity, for example, nutrition management tactics, even if not subjectively enjoyable, would best be framed as a permanent lifestyle change, rather than a temporary "diet."  An unpleasant "diet" is much more likely to cause regulatory failure after completion; this is certainly the almost invariable experience of all those who have managed their weight using spartan "diets."   Yet, I would emphasize that something better than neutrality should be sought after, which, in the case of nutrition management, means that one's permanent nutritional habits should also be enjoyable, rather than simply a self-care chore.

Medications for ADHD: newspaper headline

I have just looked at a front-page newspaper article by Carolyn Abraham in The Globe and Mail (Tuesday, October 19, 2010).

The article attempts to discuss the issue of whether medications are prescribed too often, for treating supposed attention deficit disorder, particularly in male children.

This is a very serious, important question.  It warrants careful analysis of the issues, and a balanced evaluation of evidence.

Unfortunately, the article bothered me greatly, because of its bias.  Here are some quotes from the article:

Boys: Fixing with a pill is easier than counselling  [this was a heading]

There's a desire for the quick fix...the idea that - 'oh, we'll fix this with a pill' - rather than spend a few months in counselling, is pretty appealing. [this was a quote attributed to Gordon Floyd, the CEO of Children's Mental Health Ontario]

What are we drugging?  Female teachers who don't understand boys like to run and jump and shout - that's what boys do. [this was a quote attributed to Jon Bradley, an education professor at McGill University]

Prescription rates for ADHD drugs, which like cocaine, are psycho-stimulants...

Mr. Floyd feels counselling stands a better chance of getting to the root of the problem with children, rather than using drugs for years to dull symptoms.  Research shows, he says, that talk therapy can be very successful for kids with ADHD.

stimulant drugs may be dangerous for those with underlying heart problems - and those who do not actually have ADHD.

I have often wondered why no real connection has been made between the over-medicalization of our children and the increasing prevalence of illicit drug use in our society.  When we give kids the message that they can be 'fixed' by popping a pill, it hardly seems surprising to me that they would later seek to solve their problems by using other available substances. [a quote attributed to Judy McGuire, a "Globe Catalyst"]

The article mentions important issues of concern, including the role of pharmaceutical marketing in changing medication prescription patterns.  The diagnosis of ADHD, and the use of medications, appears to vary substantially from one locale to the next.  The phenomenon of teachers coercing parents to seek medication treatment for their children is certainly problematic.

But the article did not give a balanced presentation of evidence.

It is more common, in my experience, to encounter young adults who have struggled with ADHD symptoms, without any medication treatment,  all their lives.   Often times, they, or their parents, have been strongly opposed to the idea of taking medications.  Many of these young adults are very intelligent, but often have been unable to sit through the intellectual tasks required to develop their intelligence.  Therefore, they have often not been able to achieve the goals which are reasonably available to them.  There is really no way around the fact that reading, for example, is necessary to develop one's mind in the modern world; reading requires one to sit still and focus for extended periods of time.  A great deal of the discipline required to develop one's intellect requires prolonged focus, often with tasks that are initially perceived to be uninteresting (with discipline, intelligence, and imagination, any so-called "boring" subject can become interesting--but if individuals are unable to focus during the initial "boring" introduction to a subject, this deep interest and engagement may never be found).

Treating ADHD with medication does not increase substance abuse.  Rates of substance use in an untreated ADHD population are substantially higher.  Here is a reference to a research article demonstrating this: http://www.ncbi.nlm.nih.gov/pubmed/18838643  It is certainly my clinical experience, that subjects with untreated ADHD have much higher rates of substance use, including cigarettes, alcohol, cannabis, and harder drugs.  The belief that treating ADHD with medications somehow increases risk for substance abuse, is simply unfounded--the opposite effect has been clearly shown.  Exceptions exist, of course, in individual cases where adolescents may be abusing their medication, selling it, etc. Also, in many cases "ADHD" is not the only issue or problem; there may be antisocial behaviour, mood disorders, severe family or psychosocial problems, etc. which also obviously affect risks. 

In terms of dangers or risks, it is of course important to examine negative side-effects or toxicity from stimulants.  Such an analysis would fairly establish that risks are present, but of low incidence.  For example, the risk of stimulants causing heart problems.

But a fair assessment of risk must include consideration of the risks of non-treatment!  The obvious risks in an ADHD population are  higher risks of accidental injuries, car accidents, sequelae from substance abuse, and reckless interpersonal behaviour.  The risk pertains not only to those with untreated ADHD, but also to peers (for example, passengers in a vehicle).  Here are a few references evidence about this:
http://www.ncbi.nlm.nih.gov/pubmed/19739058
http://www.ncbi.nlm.nih.gov/pubmed/18815438
http://www.ncbi.nlm.nih.gov/pubmed/10790000

 It is also, of course, very important to consider whether counseling or other types of therapy could be helpful for ADHD symptoms.  The prevailing evidence shows that there can be small effects with existing therapy styles--this is certainly worth pursuing--but counseling often doesn't work very well.  In cases where there are multiple other problems going on (e.g. anxiety, mood, family conflicts, etc.) then of course some type of external counseling support would be preferable to simply obtaining a stimulant prescription. The notion that "a few months of counseling" would make much of a difference for most kids with ADHD symptoms is absurd, and entirely unsupported by any evidence. 

The idea of accepting that "that's what boys do," etc. is important to consider.  But imagine, as an adult reader, that you are transported to elementary school again.  Would it be a pleasant and rewarding situation for you to be in a classroom where the attitude "that's what boys do" prevails?    Similar philosophies, in the adult world, have been used to justify various types of antisocial behaviour.  The issue is not just about the individuals with so-called ADHD, but also about peers and community.  Rambunctiousness need not be pathologized, but a desire for sustained attentiveness need not be pathologized either.  Most people with ADHD histories have had serious difficulties not just in classroom settings, but in all spheres of life:  home, friendships, community, work, etc.  This issue is not just about artificially forcing people into the constraints of a boring, quiet classroom, although admittedly a sedate classroom environment could be a very unhelpful factor for some. 

The article seems to suggest that male teachers would be preferable.  What does this have to do with anything?  Where is the evidence?! Is this claim not an insult to female teachers?  And, in my memory, I don't remember male teachers being any better at managing a classroom of rambunctious kids, compared to female teachers.  In fact, I can think of counterexamples, in which female teachers could have a gentle, maternal effect on hyperactive kids helping them to enjoy their day, so that their experience of a classroom could be more positive.  

I do agree that there are learning or educational styles which could suit some individuals much better.  And I agree that having opportunities to be physically active is extremely important--for everyone, not just for "ADHD kids."  One of the authors in this article suggests that the decline of opportunities such as "wood shop" (the implication is, that these are mainly for boys) is part of the problem.   But, imagine as a wood shop teacher -- where you are in charge of a band saw, a lathe,  and a few power nail guns -- that you have a few kids who are easily bored, highly rambunctious, and have difficulty paying attention.  Band saw + ADHD!   Do you see any problems there? 

Some "alternative learning styles" could already begin to produce an unnecessary tier, sending kids with more ADHD symptoms away from a more scholarly focus, towards developing a more physical trade.  I don't think there's anything wrong with this per se, unless the child with ADHD symptoms actually wants to develop scholarly pursuits, and/or has an undeveloped talent for the type of scholarship which requires intense focus, and doesn't really want to be "tiered" in this way.

I recognize that this is an important issue, and everyone's point of view needs to be considered to work out the best solutions for health policy and for helping individuals.  But this article, in one of Canada's leading newspapers, was disturbingly one-sided, and in my opinion could contribute to many individuals feeling stigmatized or rejecting the possibility of medication therapy without a balanced understanding of the evidence. 

One of the main issues to contemplate, and really the main helpful theme in this article, in my opinion, has to do with degree or magnitude:  ADHD symptoms exist on a continuum, with everyone in the population having some measurable quantity of attentional capacity, physical restlessness, or impulsivity.  These could be considered traits, and each of these traits could be considered useful, positive, and "normal"  in some ways, as well as negative or deleterious in others.  Medications or other therapies have the capacity to change the degree of symptoms or traits somewhat, for anyone (it is a myth that stimulants improve attention only in those with ADHD).  The degree of environmental change required to help an individual escalates rapidly as the degree of symptoms increases.  So, there will always be a gray area, of individuals who have more "ADHD symptoms" than the population average, but fewer than those with extreme and highly disabling symptoms.   Determining how to help these individuals may be highly influenced by the whims of the local educational or medical culture, combined with the attitudes of the individuals and their families.  There may be no absolute, fixed standard possible, to determine exactly when to use a particular form of therapy.  

I believe that such decisions should be influenced by the following factors:
1) clear informed consent on the part of individuals and families considering medications or other therapies.   This involves having a balanced understanding of evidence, of the risks and benefits of treating and of not treating. 
2) thorough assessment with careful attendance to family and psychosocial stresses--never an impulsive prescription of stimulants after a single 5-minute appointment!
3) Follow-up in all cases, with opportunities for talking therapies and behavioural therapy if desired.
4) A reasonable set of nationalized, standardized guidelines for assessment and treatment, to reduce the possibility that a person's geographic location, or the whims of teachers, doctors, journalists, etc. would be strong determinants of whether or not treatment of any kind is offered.

Atomoxetine for ADHD

 Atomoxetine (Strattera) is one of the pharmacological options for treating ADHD symptoms (attention or concentration problems, hyperactivity, impulsivity) in children and adults.  I think it is a good drug, quite safe, quite effective.  It is not likely to help with mood or anxiety symptoms.  Its effect is probably not quite as robust, for most people, compared to stimulants, but it has the compelling advantage of working continuously throughout the day, instead of wearing off (as the stimulants do) after a few hours.  It takes at least 2 weeks of daily dosing for it to work, which differs from the immediate effect of stimulants. 

While it has only a 5-hour half-life in the body, it probably works just as well if dosed once-daily compared to twice-daily.  Side-effects are usually quite mild, including possible dry mouth and reduced appetite.  

It is quite expensive, and is not covered well by medication funding plans in BC.

Here is a brief survey of some of the research literature about atomoxetine that I found interesting:

http://www.ncbi.nlm.nih.gov/pubmed/20665133
This 2010 article demonstrates that once-daily atomoxetine is superior to placebo for treating adult ADHD symptoms, over a 6-month follow-up period.   Treated patients typically had about a 30% reduction in their symptom scores.  Doses were about 80 mg/day.

http://www.ncbi.nlm.nih.gov/pubmed/18448861
This is an important study, with 4 years of follow-up, treating adult ADHD patients on an open-label basis.  The medication was tolerated well, again with ADHD symptom reductions of about 30%.  Depression and anxiety symptoms were not affected.  I tried unsuccessfully to find a clear statement about average doses used in the study; the dosing regime was similar to other studies, with a maximum of 160 mg/day.   From the authors' previous paper on the interim results of this study, the mean dose was about 100 mg/day, the median about 120 mg/day.  So these are higher doses than in some of the other studies, which typically had 80 mg/day dosing.  

http://www.ncbi.nlm.nih.gov/pubmed/20070786
This was a 6-week open study, showing that adults with "atypical ADHD" showed improvement with atomoxetine treatment, doses averaging about 80 mg/day.


http://www.ncbi.nlm.nih.gov/pubmed/20051220
This is an important 2008 meta-analysis, comparing effect sizes of different therapies for adult ADHD.  Short-acting stimulants were best; long-acting stimulants similar (no advantage--if anything, not quite as high an effect size compared to short-acting stimulants); non-stimulants such as atomoxetine significantly helpful, but not quite as large an effect size as stimulants.


http://www.ncbi.nlm.nih.gov/pubmed/17110824This study shows modest but significant improvement in quality-of-life ratings for adult ADHD patients treated with atomoxetine 80 mg/day for 6 weeks.  

http://www.ncbi.nlm.nih.gov/pubmed/20642391
This study shows reduction in high-risk behaviours in adolescents treated with atomoxetine over a 40-week period.  Looking quickly at the results, I see significant differences between atomoxetine and placebo, but the absolute differences were quite modest in size (typically about a 10% change).  Also the study design has a variety of weaknesses. 


http://www.ncbi.nlm.nih.gov/pubmed/17474814
This is one of many studies showing that atomoxetine does not help with depressive symptoms.  In this case, it was used as an adjunct to an SSRI.

http://www.ncbi.nlm.nih.gov/pubmed/19358788
This study showed no improvement in cognitive function in patients with schizophrenia treated with atomoxetine over 8 weeks.  There were no adverse psychiatric effects, however.   This is an important area to study, to determine if ADHD treatments such as atomoxetine are psychiatrically safe for those with other major mental illnesses, such as schizophrenia or bipolar disorder. 

http://www.ncbi.nlm.nih.gov/pubmed/20679638
This 2010 article from Neurology shows that atomoxetine is not useful for treating depression in Parkinson Disease patients.  I find this type of study useful, to look at psychiatric symptoms in medical illnesses.  In such situations, the biological impact of the treatment often seems more clear to me, perhaps with fewer confounding psychological factors.    The study did find that patients treated with atomoxetine (target dose 80 mg/day) had significantly less daytime sleepiness, and significant improvement in "global cognitive function."

http://www.ncbi.nlm.nih.gov/pubmed/19025777
This similar study shows a possible improvement due to atomoxetine treatment--averaging about 90 mg/day--of executive dysfunction in Parkinson Disease patients.  I note also that there was a reduction in other symptom domains, such as apathy and emotional lability; these problems can be difficult to address in those with mood disorders. 


http://www.ncbi.nlm.nih.gov/pubmed/17900980
Here's another interesting study, using atomoxetine to treat sleep apnea patients, averaging about 80 mg/day over 4 weeks.  The atomoxetine did not help reduce apnea, but it did significantly reduce subjective sleepiness.   There are only a couple of fragmentary mentionings of atomoxetine in treating narcolepsy, another disorder of excessive sleepiness; here is one case report: http://www.ncbi.nlm.nih.gov/pubmed/16268387 Excessive sleepiness is another challenging symptom I see a lot of in young adult depression; antidepressants often don't help with the sleepiness, and tolerance tends to develop for stimulants.  So atomoxetine may be another useful option. 

"Vitamin Water" and "Energy Drinks"

Here's another exploitative marketing scheme going on, in the middle of university campuses:

A sugary drink, consisting of water with 23 grams (about 5 teaspoons) of sugar per 500 mL, sold in large, colourful bottles of 300 - 500 mL each  -- is being aggressively marketed to young people, with many implied claims about healthfulness.  There are funny, witty, ironic statements printed on the bottles, which I think would appeal to young adults, and consolidate the notion that these are actually healthy. 

A similar drink, which also contains caffeine and a bizarre mixture of added chemicals,  is also being aggressively marketed, with free samples being given out by smiling, athletic young people in decorated sports cars.  Today I noticed the energy drink people occupying one of the university's athletic fields with three large garishly decorated vehicles, hip musical accompaniment blaring out as they handed out samples.  It was a bothersome irony that an athletic field (another health-associated prop) had to be the setting for this.   


It is not a healthy practice to consume sugary drinks.  Aside from the risk of tooth decay, and the exposure to metabolically harmful simple carbohydrates, the habit of consuming these drinks conditions people to expect sweetness while they hydrate themselves.  Ordinary, pure, free drinking water becomes bland and undesirable.  Though the direct health effects of having a glass of sweetened water are not catastrophic, there are a variety of indirect harmful effects:

-because you are quenching your thirst, and hunger, with a solution containing glucose or fructose, you will have a smaller appetite, and less money,  to obtain or consume a healthy meal.

-because of the advertising involved, you will become conditioned to believe that you are engaging in a healthy behaviour.

-you will be financially supporting one of the largest junk food manufacturers in the world; the magnitude of harm done to the world's population (directly and indirectly) by such companies would be staggering to calculate.

-by purchasing these products, you are contributing to the phenomenon of  retailers stocking their shelves with "vitamin water" instead of with healthier choices.  In one of my favourite local cafes, my favourite healthy, locally-made fruit juice is gone, replaced by rows of multi-coloured "vitamin water."  The reason was economic -- the bright colours and the sugar make for a rapidly-selling product.


The presence of vitamins, minerals, amino acids, etc. in these products is, in my opinion, irrelevant.  It is pure marketing.  If you need extra vitamins in your day, you can take a daily supplement, or have a piece of fresh fruit.   The other ingredients are largely placebo as well, just like the colouring.

The case is made by some that there is less sugar in these drinks, compared to other familiar soft drinks.  The difference is actually not very substantial, it reminds me of cigarette companies manufacturing "light" cigarettes, to try to sell people on the idea that this is "healthier."  

I consider this type of marketing to have little ethical difference from a hypothetical example of cigarette companies hiring athletic, charming young people to hand out free samples from a flashy new car.

What bothers me most about this issue is the use of healthy-sounding nutrition talk ("vitamins," etc.) to persuade people to buy an unhealthy product.

I do not support a puritanical view of food & eating though.  I think there are many sweet, wonderful, decadent foods to be savoured (in moderation of course!)   Generally, dessert vendors do not market their tastiest pastries by emphasizing their vitamin content!  In any case, such foods can be enjoyed more richly, in smaller, healthier portions, if one is less conditioned to expect sweetness frequently through the day, such as in drinking water.  


Here are a few references to some pertinent review articles:
http://www.ncbi.nlm.nih.gov/pubmed/20631477
http://www.ncbi.nlm.nih.gov/pubmed/20682226
http://www.ncbi.nlm.nih.gov/pubmed/18809264

One exception, in which a case could be made to supplement drinks with vitamins, could be in the management of chronic, severe alcoholism.  There is a syndrome called "Wernicke-Korsakoff encephalopathy", in which severely malnourished alcoholics develop irreversible, catastrophic brain damage due to metabolism of carbohydrates without adequate vitamin B1.  Adding vitamin B1 (thiamine) to hard liquor, could conceivably prevent some cases of irreversible brain damage in malnourished alcoholics who keep drinking.  I'm not sure if thiamine would be chemically stable in an ethanol solution though--if anyone knows the answer to this one, please let me know.   Anyway, I don't believe this consideration is relevant to health management on university campuses (!)

Conclusion:  if you're thirsty, drink water!

Personality Tests

Here's a site which has a good selection of  free personality questionnaires:

http://similarminds.com/personality_tests.html

I find that questionnaires of this type rarely give any novel information that you wouldn't know about yourself already, and be able to describe in a short self-descriptive paragraph.  Many such questionnaires are actually copyrighted, and one needs to pay a fee just to have a copy. I've always had a bit of a problem with this, as I think it exaggerates the importance of what is usually a simple set of questions, which in my opinion should usually be in the public domain.  It is annoying to read a journal article about questionnaires (which are often referred to, in a somewhat aggrandizing way, as "instruments," as though we are talking about some kind of highly sophisticated engineering technology), where the copyrighted questionnaire is referred to in the article, but you can't actually see the questions! 

But spending some time with these things can have a few positives:


1) a framework for reflection -- sometimes questionnaires can deal with questions or phenomena which are relevant, but rarely thought about or discussed.  The questions can be a cue or a framework to contemplate issues.  Some of these issues could be addressed in a therapeutic discussion. 

2) entertainment  -- it can be an interesting or possibly enjoyable activity to fill out questionnaires, and compare your results with others in the population.

It would be important to resist any tendency to be self-critical about your results; everyone will have a unique set of responses,  some of which may change over time, or be mood-dependent, as well.  Questionnaires are an imperfect way to measure any sort of characteristic anyway.  But in any case, a questionnaire is a bit like a lens or a camera--it  produces data which can be informative.  Sometimes the information can be unique or interesting, like a clever snapshot of yourself from a camera; but other times the information may not be very unique or interesting at all (like a poorly-lit or blurry snapshot of yourself).  Even if you may have issues with the way a particular questionnaire is constructed, it can be interesting to see how your responses compare on a percentile basis with others.  You may find certain phenomena about yourself that you previously thought were quite extreme, are in fact really quite close to the population average.  Or you might discover there are other phenomena which are farther from the mean.  Any of these findings might be a subject of future therapeutic dialog. 

Health Tips for the new school year

Here are some suggestions for maintaining your health during the new school year:

1) Have a healthy study schedule.  You will learn much more efficiently and enjoyably if you study regularly, in a disciplined schedule.  I don't believe it is possible to master any subject, much less build up an enjoyment of it, by procrastinating or cramming.  Each full-year course probably deserves about 200 hours of study, to be spread out as evenly as possible.   Mastery of a specific field of study probably requires about 10 000 hours of work, which would be full-time for 5 years.   Even if you can get good grades without working hard, I would emphasize to you that doing the bare minimum is an extremely harmful habit--the consequence is that your potential will remain unrealized, also your enjoyment and respect for your subject will never be fully developed.   
2) Have a healthy leisure schedule.  Time must be reserved for pleasure (outside of the hoped-for intrinsic pleasure of studying or working).  A type of "meta-subject" at university is learning to have a pleasurable and healthy lifestyle, with a sense of friendship and community, in the midst of working hard.
3) Be physically active.  Exercise & sports will help you maintain your strength, sharpen your mind, relieve stress, and offer potential sources of community & friendship.  A common problem, however, is excessive exercise, which drains time and energy away from other activities, and which can cause an addictive pattern leading to a psychological dependence on fitness activities alongside a diminished capacity to manage stress in other ways.
4) Don't binge drink.  There is an illusion that binge drinking is an essential part of university social culture.  While it may be a common phenomenon, I think many people minimize its extremely negative health impact.  Anything more than 2 drinks per 24 hours is, from an epidemiologic point of view, harmful to health.    For those dealing with anxiety, depression, trouble fitting in, etc., alcohol can lead to an illusory sense of relief or social belonging while insidiously deepening and entrenching the problems.
5) Eat well.  It's easy to neglect this one, particularly if you're living on your own for the first time.  Basic nutritional advice is not hard to find.  Unfortunately, I think that unhealthy food choices are too easy to find on university campuses.  I think that university cafeterias should not sell junk food, soft drinks, etc. (I also think such items should be taxed heavily, in the same way that cigarettes are).   It's always disappointing to see soft drink companies or fast food restaurants as major food sponsors, with vending machines all over the place, including in hospitals and gyms, etc.   Two simple changes for most people would be to increase vegetables in the diet, and to eliminate junk food.   Allowing oneself to go hungry, or to be carbohydrate-deprived, is likely to substantially impair academic performance, attention, and mood.
6) Make cultural choices with care.  Developing personal culture is very important, and deserves time and energy.   I don't think it is healthy to make a particular cultural choice (e.g. "let's go clubbing!") just because everyone else seems to be doing it. I see a lack of personal culture, with an ensuing lack of a sense of meaningful community, to be one of the leading problems driving loneliness and perpetuating depression on university campuses.
7) Seek medical help if you have symptoms.  There are treatments and supports to be connected with, which can help address anxiety, mood problems, physical symptoms, etc.  It can be better to connect with resources early, rather than wait for things to get worse.
8) Be wary of viral contagion.  A single banal respiratory infection could substantially reduce your enjoyment and learning for a week or more at a time.  The best preventative strategy is to wash your hands frequently, especially if handling objects which thousands of other people have handled or coughed on.  It's important not to go overboard with this--which could be an obsessive-compulsive symptom-- but basic infection control techniques could save you a lot of headache.
9) If you tend to get tired or depressed in the winter months, consider trying a light box.  This is an easy, safe physical treatment which can help with seasonal depression.  Daylight is diminishing rapidly in September, so this is probably a good time to get out your light box.
10) Nutritional supplements.  Women should have ferritin levels checked, and in general should take iron supplements if ferritin is below 50 ug/L.  A daily multivitamin/mineral supplement is a good idea, especially if having abundant fruits and vegetables in the daily diet is not happening consistently.   Harmless at worst.  Extra vitamin D is indicated, I'd suggest 2000 IU extra per day.  DHA/EPA supplements could be useful (omega-3 fatty acids, typically from fish oils). I have some references about this in other entries.  
11) Addiction inventory.  I'd encourage everyone to take an inventory of all addictive or compulsive behaviours, and take steps to stop or moderate them all.  Alcohol or drug use are obvious examples, but other activities could include internet use, gambling, exercise, self-injury, phoning or texting, etc.  Many habits consume so much time and attention, that there is much less time, energy, or enthusiasm left for other things that may be more deeply important to you.

Dopamine Agonists in Psychiatry

The dopamine agonists pramipexole and ropinirole are drugs used in the treatment of Parkinson Disease.

These drugs are now well-established in treating restless legs syndrome (RLS) and periodic limb movement disorder of sleep (PLMS), which are frequent problems afflicting about 10% of the population, and which can negatively impact quality of life & mood symptoms.

There is a small body of evidence showing possible benefits of dopamine agonists in the treatment of depression.

Unfortunately, dopamine agonists can exacerbate addictive/compulsive behaviour: http://www.ncbi.nlm.nih.gov/pubmed/20484726 

Here are some references about the role of dopamine agonists in RLS and PLMS:

http://www.ncbi.nlm.nih.gov/pubmed/20120624

Here's a good review article on the use of ropinirole to treat these conditions: http://www.ncbi.nlm.nih.gov/pubmed/20421915
Here's a recent review of dopamine agonists in general to treat RLS: http://www.ncbi.nlm.nih.gov/pubmed/20206780
Here's a 2008 meta-analysis comparing ropinirole with pramipexole for treating RLS.  Pramipexole is shown to be slightly superior:
http://www.ncbi.nlm.nih.gov/pubmed/18226947

In this 2010 study, gabapentin was compared to ropinirole for treating RLS.  While ropinirole was superior in reducing objective measures of periodic limb movements, subjects taking gabapentin had a higher subjective benefit:
http://www.ncbi.nlm.nih.gov/pubmed/20049491


Here's a case study showing remission of depressive symptoms with ropinirole used as an augmenting agent:
http://www.ncbi.nlm.nih.gov/pubmed/20188777 

Here's a 2005 study looking at ropinirole augmentation in treating depression:
http://www.ncbi.nlm.nih.gov/pubmed/15999953
This 2010 review in Lancet showed a direct antidepressant effect of pramipexole in Parkinson Disease patients:  http://www.ncbi.nlm.nih.gov/pubmed/20452823
Here's a rather weak but positive 2010 paper describing a group of patients with bipolar depression who appeared to benefit from longer-term pramipexole treatment; doses averaged about 1 mg/d:  http://www.ncbi.nlm.nih.gov/pubmed/20425143


The side effects from these drugs include frequent nausea and dizziness, possibly some daytime sleepiness.  Psychiatric adverse effects can include hallucinations, and increased compulsive or impulse-control problems.

In summary, I think dopamine agonists have a role in selected psychiatric conditions, particularly if there are restless-legs symptoms contributing to insomnia or nocturnal discomfort.  They may help treat refractory depression, but there is a risk of causing impulse control problems or hallucinations in predisposed individuals. 

Potential adverse effects of group therapy

I encountered an article today about a subject I've often thought about:  does group therapy actually have a risk of worsening underlying problems?

Here's a link to the article:
 http://www.time.com/time/health/article/0,8599,2003160,00.html

The mechanism could typically occur in the treatment of addictions, which is the subject of this article.  The same mechanism might operate in the treatment of behavioural problems, including conduct disorders, eating disorders, maybe even mood disorders.

Basically, the concern is that the individuals in the group might actually "teach" others in the group about tactics to engage more deeply in the problem behaviour.  The social bonds formed in the group might expand a person's network to engage in addictive behaviours.  If some members of an addiction treatment group are severely involved in the addiction, are perhaps ambivalently committed to therapy, and may be connected to convenient resources in the community to access their addiction, this may facilitate other less severely involved members of the group to broaden their access to addictions.

In eating disorders, members of the group might "compete" with each other to some degree with eating disorder behaviours.  If there are social leaders in the group who are still highly involved in the eating disorder, this may cause a negative peer pressure on others who are starting out.  

On the other hand, an opposing, positive force in group therapy is encountering others who have understanding and personal experience of similar problems.  This can be especially important for problems where a person often feels judged or misunderstood.  Also, members of the group can teach others tactics to deal with moment-to-moment manifestations of the addiction.  In order for these positive forces to be manifest, the group itself needs to be composed of individuals who are probably similar in terms of problem severity, and where there are individuals members of the group who are progressing.  This introduces a social learning effect, in which an individual can see and emulate another individual with similar problems who is starting to make progress.  The similar problem severity among members of the group would hopefully reduce the likelihood of mildly afflicted group members being drawn into more severe illness behaviours.

Since progress through problems is always a dynamic, individualized process, it may be that involvements with groups ideally need to change dynamically as well.  If  individuals are moving quickly away from addictive behaviours, they may ideally need to nurture group connections which are similarly healthy.

This poses another problem for many with long histories of addiction or other socially dynamic health problems:  relationships which have been strongly associated with the addiction may need to left behind, or at  least boundaried very carefully.

Naturalistic study comparing quetiapine, ziprasidone, olanzapine, and risperidone

This study caught my eye recently (here's a link to the abstract:)

http://www.ncbi.nlm.nih.gov/pubmed/20334680

It's a naturalistic study, published in BMC Psychiatry in 2010, prospectively following 213 patients with symptoms of psychosis, who were randomized to receive one of four antipsychotic medications (quetiapine, ziprasidone, olanzapine, or risperidone), then apparently followed for up to 2 years.  

My prediction with such a study would be that all four medications would have similar effectiveness, with a slight edge in favour of olanzapine.

In fact, the results showed a slight edge in favour of quetiapine.  There were no substantial differences in tolerability.

The problems with this study, though, include the following:

1) Most of the data was actually for patients who had only been followed up for 6 weeks (not 2 years!).  Only 8 of the 213 patients were followed up for 2 years.  Of these 8, 5 were taking olanzapine, 2 were taking ziprasidone, and 1 was taking risperidone.  Perhaps one might be tempted to conclude that olanzapine is the drug that has the highest chance of being acceptable for long-term use.

 2) The results were presented in a type of "refined" fashion, for example the changes in symptom scores for each drug over time were presented as graphs with a single straight line for each drug, plotted over a 300-day period.  This type of graph omits a tremendous amount of relevant data:  first of all, there were very few patients who were actually followed for 300 days, most of them were only followed for 6 weeks.  A graph like this implies that there are strong data points stretching out over the entire period.  Secondly, the linear plots do not show the degree of scatter in the data points.  There were no direct reports of the raw data in the study, only refined statistical distillations.  It would be much more informative to show all of the data points plotted out over time:  then one could see the times where most of the data were derived, the various courses of symptom change for each individual in the study, etc.  It would be a messier graph! -- but it would not mislead the viewer to immediately conclude that one medication is obviously better than the others.

In conclusion, the study really grabbed my attention when I first looked at it, but I found it to be much weaker than I thought, after reading it closely.

It does, however, provide a little bit of support for the idea that any one of these four antipsychotic medications are reasonable to try, in the treatment of psychotic symptoms.  I agree that quetiapine is a reasonable first choice, though the others could be reasonable also, depending on personal preference, past experience, side effect risks, etc.  I would still lean towards olanzapine for anticipated long-term treatment of severe symptoms.

A Learning Model of Psychological Change: the necessity of work & practice

It requires a great deal of work to bring about psychological change.

The brain is a dynamic organ, its development influenced by genetic predisposition combined with environmental experience.  Repeated environmental experience sculpts the brain, altering the strength of neuronal connections, neuronal activity, neurochemistry, and even neuronal growth or survival.

Various environmental adversities obviously predispose the brain to generate psychological symptoms, including specific incidents of trauma or neglect.

The manner in which adversity changes the brain is similar to the manner in which the brain changes in response to any other sort of experience:  sometimes there is sudden, intense change which can happen in an instant (e.g. a traumatic brain injury), but most often the brain changes gradually, after many repetitions of similar stimuli or similar inner processes.

Some environmental adversities are repetitive over months or years.  But often times the repetition which does further harm is generated by the brain itself:  in response to a problem, the brain's repetitious analysis and revisiting of the problem ends up causing consolidated change and ongoing symptoms. A great deal of the harm caused by specific instants of trauma is caused by the brain's reaction months or years after the trauma is over.  This reaction is akin to an autoimmune disease, in which the body's attempts to fight off disease end up causing inflammation, pain, and tissue damage. 

A symptom, such as anxiety or depressed mood, once generated from any cause, may lead to a cascade of brain changes which perpetuate and intensify the symptom.  The behavioural withdrawal which results from anxiety or depression changes the potential experiences the brain may incorporate in order to heal itself.  Even without overt behavioural withdrawal, an anxious or depressive state may cause the brain to perceive normal or pleasurable stimuli as dangerous, negative, boring, or unpleasant.   Each time this experience occurs, the brain changes further into a state of more deeply consolidated anxious or depressive disorder.  The theory of cognitive-behavioural therapy insightfully recognizes the role of thoughts as part of a cascade of phenomena perpetuating psychological illness.  Recurrent hostile, reflexively critical, cynical, pessimistic or negative thinking may at times have intellectual or philosophical validity; however, such thoughts, if highly recurrent, teach and sculpt the brain to make such a style of thinking an entrenched habit.  Such habits of thought are obvious causes for depression and diminished quality of life.    

My point here is to describe the brain as a "teachable" organ.  It is changed and sculpted by experience.  The source of this experience may be from the external environment or from the self-generated inner environment of the brain.   The degree to which the brain is sculpted by experience depends on the intensity of the experiences, multiplied by the time or frequency the experiences repeat themselves.

 In this regard, as I've stated before, the brain and its experiences are analogous to a growing garden, or a forest:  changes require time, care, knowledge about requirements, and energy.


Therapeutically, it is very clear to me that much work must be done in order to effect significant, lasting brain change. Likewise, a growing garden requires frequent care, particularly if there are adverse conditions caused from within (e.g. depleted soil, weeds) or from without (e.g. harsh weather, vandalism).  

The neurochemical environment can be an obstacle to brain change, in the same sense that abnormal soil chemistry may thwart the most earnest efforts of a gardener.  The "abnormal soil chemistry" may itself have been caused by an imbalanced garden ecology over many years, perhaps by genetic predispositions of the plants, and may conceivably be remediated and prevented in the long term by healthy gardening practices, yet an immediate external aid could be an immensely helpful catalyst to help these changes occur more easily and quickly.   Likewise, psychiatric medications can often be helpful catalysts for change.

But the key ingredient for brain change is experiential.  The type of experience capable of changing the brain substantially must be strong enough (i.e. it must employ a significant degree of the brain's capacity for attention, thought, feeling, and sensation, rather than simply being a passive or background activity), and must be frequent enough (i.e. it must occur regularly over a long period of time).

These requirements for experiential change are, as I've claimed before, similar to the requirements needed for learning a new language, or a musical instrument.

Without daily practice, therapy experiences which involve only one, or a few, appointments per week, are unlikely to cause significant psychological change, for the same reason that a language or music class once or twice a week will not lead to much language or music learning without doing daily homework.   The classes may be helpful or inspiring guides, but most of the change or learning will occur due to many hours of hard work, practicing, in-between classes.

Studies of different therapeutic strategies for treating psychological symptoms usually neglect to assess the most obvious and powerful source for change:  the amount and quality of the practice done.  It seems to me that most any style of therapy could work quite well (some slightly better than others, depending on the situation), provided that a great deal of disciplined work and practice takes place to learn new skills, and to effect change in the brain.

The analogy of musical practice leaps to mind again, in which quantity and repetition are important for learning, but also "quality."  To practice something passively, carelessly, or inattentively is often ineffectual, or sometimes even counterproductive, since one may be inculcating an unwanted habit.  Also, some types of practice may be excessively mechanical, or may be veering off a desired course too easily.

I am reminded of the "Suzuki" method of music education, which I think is wonderful, for the following reasons:
1) it encourages one to start young (i.e. at any age or level of ability)
2) it strongly encourages "playing by ear", listening frequently to recordings with strong attention to perceiving sound and tonal quality; this leads to a stronger and more rapidly developed appreciation for esthetics, as well as less dependency on external cues such as printed music.   The therapeutic analogy could be of  inviting frequent indirect involvement from a therapist or therapeutic system, rather than doing all "homework" completely on ones' own.
3) it strongly encourages group practice & performance, right from the beginning. This teaches not only solo musicianship, but also following and playing well with others, enjoying others, cooperation, being in a leadership role, having confidence with performance, and sharing one's gifts with others.   Also, practice is encouraged to be not just a solitary activity, but something which can be done with family or loved ones.  Therapeutically, I think it is strongly desirable to incorporate psychological work into group, family, and community settings.  
4) it emphasizes the importance of good posture.  Therapeutically, I think a fairly strict and disciplined framework to practice psychological techniques is healthy and reduces the likelihood of acquiring unhelpful habits.  On a literal level, I think a balanced exercise routine is psychologically healthy, including cardiovascular or strength training, sports, or a "postural" exercise such as yoga. 
5) it emphasizes the need for a lot of repetition.  Therapeutically, it may be necessary to practice techniques thousands of times, over a period of months or years, in order for them to become fluent.   Repetition should never be undertaken in a dull, mechanical way -- it needs to be infused with careful, reverent attention -- but it is absolutely needed in order to master anything. 

I challenge all those wishing to change longstanding psychological problems to frequently renew commitments to work hard, and to translate these commitments into a disciplined schedule of daily practice.  It may be that there are symptoms of  tiredness, amotivation, apathy, or a very negative or painful reaction to a broad variety of daily life experiences; these symptoms can prevent engagement with commitments, and can hinder the capacity to engage in disciplined work habits.  Also, the life stressors (work, money, relationship problems, etc) can take up so much time and energy that there is not much left to do regular psychological work.  Perhaps part of the therapeutic process at this stage is to problem-solve around ways to reduce stresses, reduce some of the symptoms, bolster energy, etc. as prerequisites to establishing a work plan.  Another view of this issue is that the "work" alluded to here could take place within any type of life stressor, it does not necessarily require a lot of extra time separate from other activities of daily living.

"Brain Training" ineffective?

Adrian Owen et al. published a letter in Nature this week, summarizing the results of a study examining the effects of playing "brain training" computer games.  Here is the link:
http://www.ncbi.nlm.nih.gov/pubmed/20407435


The format of the study is interesting, involving the BBC website, inviting mass public participation in ongoing on-line research projects (here's a link to that site, which has a variety of other entertaining surveys you can do: http://www.bbc.co.uk/science/humanbody/mind/index_surveys.shtml).

In this case, over 11 000 subjects did various types of computer games on-line, aimed at developing various cognitive skills.  The subjects had to practice for at least 10 minutes per day, at least 3 days per week, for 6 weeks.  Some subjects practiced much more than others. 

The results are not very surprising to me:  basically, they showed that the skills developed while practicing a computer game do not "transfer" : they do not lead to generalized improvement in cognitive ability.   Even the subjects who practiced much more than the minimum requirement did not end up improving in a set of generalized cognitive tests afterwords.

Subjects improved significantly only in the specific tasks which were practiced.  This is intuitively obvious.   If you practice Tetris, you will become much better at Tetris, but are not likely to improve your mastery of French vocabulary!  Practicing volleyball will not help your guitar skills very much -- in some cases, such practice may in fact interfere with other skills acquisition, because one is procrastinating or redirecting energy away from one skill while practicing another.    Certainly it is true that computer games can be quite addictive:  if someone is spending many hours per week playing computer chess, or some other game, instead of reading, then overall educational performance is likely to decline rather than improve.

For participants in this study, it may be true that benefits occurred in "process" which were not adequately measured by the benchmark tests administered before and after the 6-week trial.  For example, playing a game which improves reflexes or visual memory might not immediately or directly "transfer" or  lead to improved performance in another reflex-based or memory-based benchmark test--but it might cause improvement in the rate at which another reflex-based or memory-based test, task, or game would be learned or mastered.  Analogously, if you have played a lot of volleyball, you might not immediately perform well in soccer--but you might learn to play and master soccer more quickly.  Or, if you have learned French and Spanish, you might not immediately perform well in a German vocabulary test, but you might be able to learn German much more quickly.  These types of benefits would not be picked up by the testing administered in this study. 

Here are some further ideas:

1) Is it possible that some particular cognitive games are more useful or generalizable than others?

-I think this is very possible.  I think that one should consider what type of gain is desired from the exercise you are doing.

A game which helps you practice learning and remembering faces and names could be quite helpful if such memory issues are problematic in your daily life.  Such a game would be inherently generalizable, since the daily behaviour and experience outside of the game would be similar to the game challenges. Lumosity.com has examples of such games.

A game which helps you pay attention to reading texts closely, while monitoring and testing your speed, accuracy, memory, and comprehension of the text, could be very useful if you are having trouble reading or studying.

Games which teach and test general knowledge subjects could be obviously useful to gain general knowledge -- e.g. learning vocabulary, facts about nature, etc.

So, I think one should choose games carefully, with the knowledge that the game will train you to improve in a particular skill.  Is that particular skill likely to be useful or generalizable in your daily life?

2) Is it possible that some of the specific games used in this study could be generally useful to some particular individuals, even though they were not helpful to the group as a whole?

-I think this is very possible as well.  There are three main issues that leap to my mind about this:

First, the study looks at a large general population of volunteer subjects.  A great many of these subjects were probably already in pretty good shape cognitively, and were motivated and enthusiastic to participate in such a research project.  This would be like asking a bunch of fitness enthusiasts to do 10 minutes of calisthenics 3 times per week, and then checking to see if their overall fitness improved 6 weeks later.  It would not be surprising to see an absence of any effect.  However, if the participants were chosen because of having cognitive weaknesses, due to learning disabilities, dementia, other illnesses, or environmental deprivation, then perhaps there could have been a much more substantial and relevant improvement with such a regime.  People with a lower fitness level would be expected to benefit much more substantially from a simple calisthenic routine than those already in good shape.  Many people with depression might have low motivation or engagement with intellectual tasks -- in this case, games of this type might help people get their minds more active again, as a prelude to other types of learning or intellectual engagement. 

Second, I am reminded of some other requirements for change in the brain: an immersive or highly intensive environment can be required for the brain's plasticity to be harnessed.  This might require many hours per day, over many months.  These hundreds of hours of training would contrast with the total of 3 hours' minimum training which this study evaluated.   

Third, some of these game types could be useful, diagnostically, for evaluation or identification of particular cognitive or perceptual strengths and weaknesses.  If these problems are identified, then a specific recipe for improvement could be mapped out.

I do wish the authors of this study, given their interest in computer-based learning & cognitive testing, would invent some games which could help people develop ability in reading, comprehension, general knowledge, etc.  Also, there are game-like computerized exercises which can help people develop skills in recognizing emotions, empathizing, etc.  (examples can be found at the BBC site).   These exercises could be useful for dealing with social anxiety, relationship problems, Asperger's Syndrome, etc.

A good site for free cognitive training games

I found this free site which offers exercises which you can use to practice memory, concentration, and reasoning skills:

http://www.cambridgebrainsciences.com/ 

There are a variety of basic memory exercises, mainly testing visual/spatial immediate memory.  Many of the tests are on a timer, for 90 seconds to 3 minutes, so the exercises are designed to help develop speed and accuracy.  Unfortunately, there is not much at this site for practicing verbal memory skills, verbal comprehension, calculation, longer-term memory, or other practical cognitive skills such as remembering faces or names.  But for a free site, it is quite good.  It also shows you a graph of your score improvement over time, which can demonstrate to you that your skills are improving with practice.

The authors of the site are two British professors who do research into web-based assessment and development of cognitive skills.