The area of personality disorders is a sensitive one. Many people find this type of diagnostic labeling pejorative, judgmental, or insulting. And there are examples I have seen where professionals have applied such labels to patients in a pejorative, judgmental, or insulting manner.
Some of the professional literature on this subject is almost impossibly pedantic or arcane.
Yet on the other hand, personality disorder categories do describe the experiences of life many people have been through, or are continuing to go through.
Some of my patients readily accept the idea of having a "personality disorder", and have worked earnestly and successfully with their symptoms, using this type of diagnostic framework.
I am cautious myself about using "personality disorder" terminology. Yet I acknowledge that sometimes understanding, and speaking frankly about, these issues, permits opportunities for things to get better more efficiently and quickly.
In general I would say that "personality disorders" could be understood as collections of chronic symptoms and behaviours which have had strong, recurrent, entrenched feedback cycles involving a person's experience of relationships with other people, with society, with work, and with lifestyle. The intersection of symptoms with these relationships tends to lead to negative results, then tends to perpetuate the pattern. And this dynamic persists irrespective of whether there are prominent mood or anxiety symptoms.
In chronic psychological conditions of any type, whether it be depression, anxiety, psychosis, etc., there are similar intersections between symptoms and relationships, but my sense of the dynamic in personality disorders is that the relationship and lifestyle disruption persists independent of other psychological symptoms.
In some cases, chronic primary symptoms such as anxiety, depression, irritability, or mood lability, could cause "personality disorders" to arise, particularly if such symptoms have been present since early childhood.
Another frequently-observed or theorized cause for "personality disorder" phenomena is childhood adversity or trauma. The adversities or traumas may differ, but in most cases recurrent or ongoing trauma is most strongly associated. Different types of adversity may affect people with different inherited temperaments in different ways -- the same type of trauma may severely affect one person, while causing few lasting symptoms in another.
It is clear that, just as with most any other set of psychiatric symptoms or diagnoses, there is a significant inherited predisposition to have a "personality disorder" diagnosis. Heritability estimates are typically in the 40-50% range. To some degree these types of findings have always seemed obvious to me, it confirms that most anything that happens in life is jointly a product of genes and environment, and the proportional split of causality is often about 50/50.
Advancing understanding of this issue has led to a conceptual shift: "personality disorders" need not be considered lifelong ailments or "defects of character". It is clear that all types of psychological symptoms may change or improve with time, under the right conditions.
There are numerous categories of "personality disorder" as described in the DSM-IV and other diagnostic schemes, and in future posts I would like to discuss each of them in turn. Also there are different theoretical schemes about what "personality" even means--and I think the best research in this area shows that personality itself is better-described using categories quite different from those in the DSM-IV. Yet, I find the DSM-IV categories do describe a common variety of problems and experiences which many of my patients have been through, and so I do think that they have relevance and validity.
Wednesday, January 7, 2009
Monday, January 5, 2009
Transcendental Meditation for ADHD
Today I encountered an interesting article in the journal
Current Issues in Education, Volume 10, No. 2, 2008
It is about teaching a meditation technique ("transcendental meditation") to children with ADHD, and measuring changes in their symptoms over time. The study shows a significant beneficial effect in numerous symptom clusters, including anxiety and mood.
Some of the authors appear to have good backgrounds in research and scholarship.
Looking up a different author, and checking out some of the other stuff on the internet about TM made me concerned about the level of religious dogma in this area, bolstered by numerous claims (many of which I think are overvalued) about "scientific evidence", also with many claims about TM being part of something morally advanced, yet I note various registered trademarks among the jargon used, together with an insistence that one has to learn the technique from a specially-trained instructor, and an insistence that one cannot learn the technique in other ways. One would think that a purely altruistic set of motives would lead to such ideas being shared more freely and humbly.
The study is substantially weakened by the fact that there is no "placebo control group", hence the findings likely exaggerate the specific benefit of TM (it may be possible, for example, that any other quiet technique taught to children for 10 minutes twice a day, might have led to symptom improvements).
But it is my hunch that meditative techniques can be helpful to improve contentment, and to reduce negative symptoms, for many people. Also, I do agree with the authors' point in this article, that there are different types of meditation, and that some types suit people better than others. Some of my patients have tried meditating, and found it unhelpful. It may be worthwhile in these cases to give a different style of meditating a try. TM apparently does not aim for "mental control"--and therefore it may be more suited for people whose minds and thoughts are hard to "control". "Control" as a meditative goal may just lead to frustration.
And I do--with some reservation--agree that having a meditation teacher or class may be necessary to learn the technique optimally, just like learning to swim or play the violin may require a teacher or class. Yet, I think it is fair to make use of other resources, including books and the internet. I am always wary of salesmanship or charlatanism in these areas, where people are charging a substantial fee while using various elements of persuasion to get you to sign up for something.
Another big area in meditation for treating psychiatric or medical problems is so-called "mindfulness-based meditation". There is an accumulating evidence base for this, and I encourage people to learn more about it. Interestingly, one of the pioneers in using these techniques in medicine first used it for successfully treating chronic physical pain.
I will be on the lookout for other pieces of objective evidence on this issue, as I find meditation interesting, probably beneficial, and at least harmless, provided the practice doesn't lead someone to be swept into some kind of cult-like subculture. I would agree with the statement that if everyone quietly meditated daily in some way, we would probably have a fair bit less violence and conflict in the world.
Current Issues in Education, Volume 10, No. 2, 2008
It is about teaching a meditation technique ("transcendental meditation") to children with ADHD, and measuring changes in their symptoms over time. The study shows a significant beneficial effect in numerous symptom clusters, including anxiety and mood.
Some of the authors appear to have good backgrounds in research and scholarship.
Looking up a different author, and checking out some of the other stuff on the internet about TM made me concerned about the level of religious dogma in this area, bolstered by numerous claims (many of which I think are overvalued) about "scientific evidence", also with many claims about TM being part of something morally advanced, yet I note various registered trademarks among the jargon used, together with an insistence that one has to learn the technique from a specially-trained instructor, and an insistence that one cannot learn the technique in other ways. One would think that a purely altruistic set of motives would lead to such ideas being shared more freely and humbly.
The study is substantially weakened by the fact that there is no "placebo control group", hence the findings likely exaggerate the specific benefit of TM (it may be possible, for example, that any other quiet technique taught to children for 10 minutes twice a day, might have led to symptom improvements).
But it is my hunch that meditative techniques can be helpful to improve contentment, and to reduce negative symptoms, for many people. Also, I do agree with the authors' point in this article, that there are different types of meditation, and that some types suit people better than others. Some of my patients have tried meditating, and found it unhelpful. It may be worthwhile in these cases to give a different style of meditating a try. TM apparently does not aim for "mental control"--and therefore it may be more suited for people whose minds and thoughts are hard to "control". "Control" as a meditative goal may just lead to frustration.
And I do--with some reservation--agree that having a meditation teacher or class may be necessary to learn the technique optimally, just like learning to swim or play the violin may require a teacher or class. Yet, I think it is fair to make use of other resources, including books and the internet. I am always wary of salesmanship or charlatanism in these areas, where people are charging a substantial fee while using various elements of persuasion to get you to sign up for something.
Another big area in meditation for treating psychiatric or medical problems is so-called "mindfulness-based meditation". There is an accumulating evidence base for this, and I encourage people to learn more about it. Interestingly, one of the pioneers in using these techniques in medicine first used it for successfully treating chronic physical pain.
I will be on the lookout for other pieces of objective evidence on this issue, as I find meditation interesting, probably beneficial, and at least harmless, provided the practice doesn't lead someone to be swept into some kind of cult-like subculture. I would agree with the statement that if everyone quietly meditated daily in some way, we would probably have a fair bit less violence and conflict in the world.
Wednesday, December 17, 2008
Social Learning Therapy
Here's another style of therapy probably under-utilized:
This is based on Bandura's work on social learning theory and self-efficacy.
The best examples along this line involve the treatment of phobias. Many approaches to phobias involve graded exposure (i.e. practicing the feared activities), cognitive therapy (examining and challenging thoughts which are associated with the fears), relaxation training, and medication (sedatives and antidepressants).
A neglected but extremely important component of therapy for phobias includes a social learning, or social modeling approach.
For example, a person afraid to swim would simply watch others swim, as a component of treating the fear. But, of course, this could just lead to the frightened person feeling left out, and heighten the sense of alienation or futility. A more effective social modeling experience would be for the person with the phobia to watch OTHER people with the same phobias learning successfully to swim. This could start off with watching videos, and move on to working directly with other people. It may not be convincing evidence that swimming phobia can be overcome just by watching a bunch of swimmers; but it may well be much more convincing evidence to watch other FEARFUL swimmers successfully learn.
If we see someone we feel is similar to ourselves do a difficult task successfully, we are more likely to be able to try or do that task.
I think this is one of the advantages of group therapy, provided there are abundant examples of individuals in the group who are beginning to cope well with their problem. Social modeling of this sort is a particular strength of 12-step groups, where individuals can see others struggling, sometimes slipping back, but finally succeeding, in a way that they can relate to and see themselves in.
Here are a few links to some sites dealing with Bandura's theories:
http://www.stanford.edu/dept/bingschool/rsrchart/bandura.htm
(this link summarizes some of Bandura's opinions about the influence of media violence, etc. on children's behaviour -- an important subject which could be generalized in many ways)
http://www.des.emory.edu/mfp/bandurabio.html
(a nice biographical sketch of Bandura and his ideas)
An introductory experience to something like a social learning therapy approach could involve looking at videos or documentaries showing individuals struggling with and resolving longstanding mental illnesses. This could be a source of inspiration, motivation, and hope. I would like to find some examples of documentaries of this type; if any readers are aware of good examples, please let me know.
I've just found one site that has a few videos (actually the site seems pretty mediocre to me, but I can't find a lot of other better stuff right now); I think the most pertinent videos to look at from here are in the "programmes" section and would be the case studies on page 3 about phobias (you have to log in to this site as a guest to get into the videos):
http://www.mentalhealth.tv/index.php?mod=page&page=Home
This is based on Bandura's work on social learning theory and self-efficacy.
The best examples along this line involve the treatment of phobias. Many approaches to phobias involve graded exposure (i.e. practicing the feared activities), cognitive therapy (examining and challenging thoughts which are associated with the fears), relaxation training, and medication (sedatives and antidepressants).
A neglected but extremely important component of therapy for phobias includes a social learning, or social modeling approach.
For example, a person afraid to swim would simply watch others swim, as a component of treating the fear. But, of course, this could just lead to the frightened person feeling left out, and heighten the sense of alienation or futility. A more effective social modeling experience would be for the person with the phobia to watch OTHER people with the same phobias learning successfully to swim. This could start off with watching videos, and move on to working directly with other people. It may not be convincing evidence that swimming phobia can be overcome just by watching a bunch of swimmers; but it may well be much more convincing evidence to watch other FEARFUL swimmers successfully learn.
If we see someone we feel is similar to ourselves do a difficult task successfully, we are more likely to be able to try or do that task.
I think this is one of the advantages of group therapy, provided there are abundant examples of individuals in the group who are beginning to cope well with their problem. Social modeling of this sort is a particular strength of 12-step groups, where individuals can see others struggling, sometimes slipping back, but finally succeeding, in a way that they can relate to and see themselves in.
Here are a few links to some sites dealing with Bandura's theories:
http://www.stanford.edu/dept/bingschool/rsrchart/bandura.htm
(this link summarizes some of Bandura's opinions about the influence of media violence, etc. on children's behaviour -- an important subject which could be generalized in many ways)
http://www.des.emory.edu/mfp/bandurabio.html
(a nice biographical sketch of Bandura and his ideas)
An introductory experience to something like a social learning therapy approach could involve looking at videos or documentaries showing individuals struggling with and resolving longstanding mental illnesses. This could be a source of inspiration, motivation, and hope. I would like to find some examples of documentaries of this type; if any readers are aware of good examples, please let me know.
I've just found one site that has a few videos (actually the site seems pretty mediocre to me, but I can't find a lot of other better stuff right now); I think the most pertinent videos to look at from here are in the "programmes" section and would be the case studies on page 3 about phobias (you have to log in to this site as a guest to get into the videos):
http://www.mentalhealth.tv/index.php?mod=page&page=Home
Relaxation Training
Here's another example of a therapy style that is probably under-emphasized.
Relaxation techniques are simple, straightforward, and intuitive. There is evidence that they work; here is a reference to a Cochrane review on relaxation techniques for treating depression:
http://www.ncbi.nlm.nih.gov/pubmed/18843744
As with most any other strategy to deal with psychological symptoms, I do believe that a lot of practice is required.
Many people abandon relaxation techniques because they do not work when they try them. I encourage persistence--it could take months of daily practice for these skills to become more effective, effortless, and automatic.
There are different styles of relaxation training out there, and I encourage people to do a bit of research, and try a few different types. There are self-help books on the subject, as well as audio CDs and videos. Joining a group or taking a course can be a good way to learn and practice as well.
The beauty of relaxation therapy is that there is no risk of harm, it is side-effect free. However, some people with panic or psychotic symptoms can feel uncomfortable with certain types of relaxation experiences. If this happens, I think it is a technical problem to work around, rather than necessarily a reason to abandon the technique altogether.
Relaxation techniques are simple, straightforward, and intuitive. There is evidence that they work; here is a reference to a Cochrane review on relaxation techniques for treating depression:
http://www.ncbi.nlm.nih.gov/pubmed/18843744
As with most any other strategy to deal with psychological symptoms, I do believe that a lot of practice is required.
Many people abandon relaxation techniques because they do not work when they try them. I encourage persistence--it could take months of daily practice for these skills to become more effective, effortless, and automatic.
There are different styles of relaxation training out there, and I encourage people to do a bit of research, and try a few different types. There are self-help books on the subject, as well as audio CDs and videos. Joining a group or taking a course can be a good way to learn and practice as well.
The beauty of relaxation therapy is that there is no risk of harm, it is side-effect free. However, some people with panic or psychotic symptoms can feel uncomfortable with certain types of relaxation experiences. If this happens, I think it is a technical problem to work around, rather than necessarily a reason to abandon the technique altogether.
Neuroimaging Research
I think modern technology is wonderful.
We now have machines which can image the living brain and measure activity in different parts of the brain as events are happening.
Whenever there are interesting new measuring devices, there will be many research scientists who will compete for time on the machines, to conduct experiments.
In psychiatry, brain imaging has been an active area of research. Most every week there is something in newspaper headlines about brain imaging findings pertaining to human emotion, perception, personality, or behaviour.
I think such studies will eventually help guide us to understand and help a greater variety of problems, perhaps in a more proactive and specific way.
But, in my opinion, we are not nearly there yet. Functional imaging has few practical applications. And, in the excitement about seeing something light up on a computer screen, people are suspending common sense at times.
For example, the other day I was reading an article in the paper, which was citing an imaging study apparently showing that people had less empathy for those struggling with addiction, compared to those with other problems.
I would not doubt that many people truly do have less empathy for addicted indididuals. But in the article, the "proof" that people had less empathy was that some area of their brains, when scanned, showed less activity, when contemplating scenes depicting individuals with addiction problems. This imaging finding was used as a rhetorical device in the article.
This reminds me of trying to determine if people outside believe it is daytime or night-time, by making them wear hats that have solar panels on top, and measuring the intensity of light picked up by the solar panels during the day.
--i.e. such measurements are indirect, imperfectly correlated, and absurdly unnecessary--
People may certainly believe it is daytime when the solar panel is picking up the strongest signal. But does that mean that this evidence from the solar panel data is somehow more intellectually superior to simply asking the person what they think? The most direct measure is to ask the person outside "do you think it is day or night"? The solar hat is just silly. However, it might at times pick up a situation in which someone is lying or unaware. Even then, such a finding would merely warrant further investigation, and would hardly constitute proof of anything.
--
It is an obvious truth that changes in thought, emotion, and behaviour, will correlate with, or be the result of, changes in brain activity. Yet it is NOT an obvious truth that a change in regional brain activity--particularly with the relatively crude spacial and temporal resolution permitted by today's technology-- proves that there is a particular change in thought, emotion, or behaviour, or that such measures of brain activity have higher levels of validity than simply having a conversation with someone.
I worry that findings from machine-generated data may so dazzle the audience that it causes unwarranted persuasion to occur, despite the findings being vague or associative. People tend to be impressed by colourful pictures made by expensive machines. We can't let this kind of phenomenon cause us to suspend critical judgment.
A related example of this leaps to mind, in pharmaceutical marketing. There has been a lot of competition out there, in past decades, for companies selling antidepressants and antipsychotics. Typically, in a sales spiel, for a given drug, there would be information given such as:
"most receptor-specific"
or "dual mechanism of action"
or "highest potency"
These facts would certainly be true, and they would have the evidence to prove it. But -- the evidence does not actually exist that these facts are clinically relevant. Whether a drug is "receptor-specific" or not may not really matter at all in terms of how well the drug works. In fact, some drugs such as clozapine, are not "receptor specific" at all, yet work better than the others in its class. "Dual mechanism of action" actually refers to a drug affecting two different receptors (hence, actually it would be less "receptor-specific" yet the phrase is still used as a selling point). Venlafaxine is often marketed this way. Whether or not venlafaxine is a superior antidepressant because of its "duality" is hardly proven, yet the marketing catch-phrase can be compelling to many. And "highest potency" is almost always clinically irrelevant. A drug with smaller "potency" can simply be dosed differently, so that it produces the same effect as a "high potency" drug.
I wholeheartedly support ongoing imaging research, yet I think we need to be careful about inferring too much from the findings at this point.
We now have machines which can image the living brain and measure activity in different parts of the brain as events are happening.
Whenever there are interesting new measuring devices, there will be many research scientists who will compete for time on the machines, to conduct experiments.
In psychiatry, brain imaging has been an active area of research. Most every week there is something in newspaper headlines about brain imaging findings pertaining to human emotion, perception, personality, or behaviour.
I think such studies will eventually help guide us to understand and help a greater variety of problems, perhaps in a more proactive and specific way.
But, in my opinion, we are not nearly there yet. Functional imaging has few practical applications. And, in the excitement about seeing something light up on a computer screen, people are suspending common sense at times.
For example, the other day I was reading an article in the paper, which was citing an imaging study apparently showing that people had less empathy for those struggling with addiction, compared to those with other problems.
I would not doubt that many people truly do have less empathy for addicted indididuals. But in the article, the "proof" that people had less empathy was that some area of their brains, when scanned, showed less activity, when contemplating scenes depicting individuals with addiction problems. This imaging finding was used as a rhetorical device in the article.
This reminds me of trying to determine if people outside believe it is daytime or night-time, by making them wear hats that have solar panels on top, and measuring the intensity of light picked up by the solar panels during the day.
--i.e. such measurements are indirect, imperfectly correlated, and absurdly unnecessary--
People may certainly believe it is daytime when the solar panel is picking up the strongest signal. But does that mean that this evidence from the solar panel data is somehow more intellectually superior to simply asking the person what they think? The most direct measure is to ask the person outside "do you think it is day or night"? The solar hat is just silly. However, it might at times pick up a situation in which someone is lying or unaware. Even then, such a finding would merely warrant further investigation, and would hardly constitute proof of anything.
--
It is an obvious truth that changes in thought, emotion, and behaviour, will correlate with, or be the result of, changes in brain activity. Yet it is NOT an obvious truth that a change in regional brain activity--particularly with the relatively crude spacial and temporal resolution permitted by today's technology-- proves that there is a particular change in thought, emotion, or behaviour, or that such measures of brain activity have higher levels of validity than simply having a conversation with someone.
I worry that findings from machine-generated data may so dazzle the audience that it causes unwarranted persuasion to occur, despite the findings being vague or associative. People tend to be impressed by colourful pictures made by expensive machines. We can't let this kind of phenomenon cause us to suspend critical judgment.
A related example of this leaps to mind, in pharmaceutical marketing. There has been a lot of competition out there, in past decades, for companies selling antidepressants and antipsychotics. Typically, in a sales spiel, for a given drug, there would be information given such as:
"most receptor-specific"
or "dual mechanism of action"
or "highest potency"
These facts would certainly be true, and they would have the evidence to prove it. But -- the evidence does not actually exist that these facts are clinically relevant. Whether a drug is "receptor-specific" or not may not really matter at all in terms of how well the drug works. In fact, some drugs such as clozapine, are not "receptor specific" at all, yet work better than the others in its class. "Dual mechanism of action" actually refers to a drug affecting two different receptors (hence, actually it would be less "receptor-specific" yet the phrase is still used as a selling point). Venlafaxine is often marketed this way. Whether or not venlafaxine is a superior antidepressant because of its "duality" is hardly proven, yet the marketing catch-phrase can be compelling to many. And "highest potency" is almost always clinically irrelevant. A drug with smaller "potency" can simply be dosed differently, so that it produces the same effect as a "high potency" drug.
I wholeheartedly support ongoing imaging research, yet I think we need to be careful about inferring too much from the findings at this point.
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