I just finished reading an excellent book called Happiness: Lessons from a New Science, by Richard Layard (Penguin, 2005).
His main points are in synchrony with ideas that I have alluded to in previous posts:
-Economic growth is a numerical measure which does not correlate consistently with well-being or health. Except for people who are living in poverty. $100 to relieve one person's poverty goes much, much, much farther to improve well-being (for both the individual and for the world) than $100 to increase a wealthy person's leisure budget.
-Despite large increases in wealth in many parts of the world, people are not any happier (in fact, they are often less so, particularly in the U.S.)
-Pursuit of wealth has an addictive quality: it produces short-term satisfaction, but the mind habituates to any short-term external satisfaction. The mind is more satisfied with stability, and is more averse to perceived loss than it is satisfied with material gain.
-If economic growth is optimized, it leads to "pollution" of various sorts. Literal, environmental pollution is one type (actually Layard could do well to include more ideas about environmental care in his thesis). Most economists do not measure this "pollution" in their calculations. But there is other "pollution" as well: a culture which values accumulation of financial wealth as the main priority may do so while "polluting" its social fabric. For example, optimal financial output may require longer workweeks and more worker mobility, which then becomes a social norm, leading to everyone spending less time with family & friends & culture, leading to declining morale and a declining sense of community, increased crime, etc. Once again, this type of social "pollution" from maximizing financial performance in society is often not included in economists' calculations.
The wisdom of his book lies in his attempt to combine the field of economics with psychology and the other social sciences, a combination which I think is badly needed. He encourages economists' calculations to be "weighted" by consideration of emotional well-being, not simply by optimization of simple financial measures.
Some of his specific ideas could be challenged (e.g. see the following paper: http://bpp.wharton.upenn.edu/jwolfers/Papers/EasterlinParadox.pdf). He advocates increased taxation as a deterrent to over-work, as a cost to pay for "pollution". I think the idea deserves attention, but it has certainly been challenged as a specific policy (the "cost" of feeling more burdened by the state may be a different psychological factor to include; furthermore, I think one of his stronger points is that motivations should be best drawn from inner sources, rather than from external incentives or disincentives).
However, the spirit of his ideas encourages us to do the following, as individuals, and as a society, for the sake of improving our lives & happiness:
1) avoid the "rat race" -- i.e. be wary of choosing a lifestyle in which you have to do more and more, to get more and more stuff, in the name of supposedly improving your life, when in fact you are sacrificing not only your own personal, family, social, and cultural life, but also participating in establishing a competitive social norm which others will want to follow, at their own expense, and at the expense of society itself. Let hard work be done for its intrinsic satisfaction, and as a satisfying way of life, rather than as a means to "get ahead" or to "get rich".
2) Pay close attention to nourishing aspects of personal culture which improve personal and collective happiness:
-be involved in helping others & be involved in your community
-avoid making choices just to keep up with someone else
-avoid criticizing or judging yourself in comparison to someone else; the modern world is set up to make you feel needlessly bad about yourself, or needlessly competitive to change something about yourself that needs affirmation rather than change
-educate oneself, and participate in the education of others, about emotional self-care
3) Watch less TV. The TV is a specific device which has clearly been shown to reduce happiness, through a similar process by which wealth itself can reduce happiness: it is an external source of pleasure, to which we become habituated, at the expense of relationships, community, physical fitness, and personal culture. Also it desensitizes us to violence, which is a further factor leading to increased aggression. Also it feeds, through advertising, the rat-race mentality of acquiring more and more stuff; much of this advertising is directed at children. He quotes an interesting study which supports his view: http://jcc.sagepub.com/cgi/content/refs/16/3/263). I might add the internet is another example of something similar.
Addendum: actually, as with many things, I think modern technology can have positive influences too. I remember many experiences of joy, humour, and togetherness watching movies or good TV series. Sometimes the TV can enhance education about the world, history, nature, current events, etc. And TV can introduce us to new aspects of personal culture, and therefore be a cultural enhancement. But I do think that TV can become an addictive and isolative habit; I guess the key is moderation, choosing wisely when and what you watch, and considering carefully why you're watching it.
I especially agree with Layard's ideas about encouraging children to learn from an early age about ways to manage and understand emotion, to practice compassion and empathy (yes, compassion and empathy can be "practiced" and "learned"), and to be involved in community-building. It often concerns me that many supposed community-building activities involving children (e.g. sports, academics, or even music lessons) end up being subverted into yet another rat-race or competition. Ideas from cognitive therapy could be introduced in elementary school, and I'm pretty sure that this could help prevent, or lessen the severity of, many cases of mood and anxiety disorder.
I also especially agree with certain other public policy points: for example, I think it is unconscionable that governments encourage gambling as a form of revenue. To encourage, and advertise, an addictive behaviour which takes individuals away from their families, loved ones, and communities, and leaves some in a miserable state of addiction, just because it is an efficient source of revenue, is extremely poor public policy. It is poor economic policy too, since more people spending more time gambling surely does not lead to increased economic success for individuals or communities, except for the people running the casinos.
I think his ideas about limiting commercial advertising directed at children warrants serious attention. Apparently Sweden has banned such advertising; the Scandinavian countries appear to be a good example to follow in terms of public policy which considers well-being above mere economic optimization.
Thursday, January 8, 2009
Borderline Personality, addendum:
I continue to feel this whole subject--of borderline personality-- is a dicey one to wade into, but I didn't want to be avoiding it either.
Part of a problem I've observed is that many extremely important and valid concerns or complaints can be dismissively pathologized as part of a "personality disorder trait".
For example, negative experiences of physicians or the hospital system need not be considered part of an individual's "pathology".
In fact, I think it is more uncommon than common for anyone to have a smooth journey through any medical care system--it tends to be laden with frustration, despite hopefully encountering some good people along the way.
Negative experiences of individual caregivers or relationships within a system need not be dismissed as so-called "splitting" (a "borderline" phenomenon)--they may be accurate and insightful accounts of having encountered a negative relationship.
The experiences may be a product of having encountered poor medical care, a poor medical system, or an unhealthy set of social structures which provide inadequate help. Sometimes an individual's complaints about these negative experiences may actually be a sign of courage, a character strength, rather than of a "borderline trait".
I think a larger view of so-called "borderline phenomena" has to do with group dynamics, as opposed to individual dynamics. If expressions of concern or frustration are met with hostile, judgmental, or inconsistent reactions, this may magnify the initial concerns or frustrations, leading to a vicious cycle. Each individual in such a dynamic may be behaving "healthily", but the relationship is not working. The relationship failure may be due to an inadequate structure, a lack of mutual understanding, communicative failure, a long history of relationship problems which biases the present point of view, tiredness or frustration on either side, or an insurmountable cultural gap. This reminds me of some of the conflicts between nations that go on today, in which each nation's "point of view" is understandable and valid, but the relationship fails, sometimes in a very destructive way, sometimes leading to an "arms race." Ironically, in psychiatry, such borderline relationship dynamics may occur involving the very individuals who are trying to be relationship mediators. My point here is that sometimes it is not the individual who has a "borderline personality disorder", but the relationship, or the system, which is suffering from "borderline dynamics".
An author on the subject of borderline personality I consider important is David Dawson. Title: Relationship Management of the Borderline Patient, Brunner/Mazel, 1993
I do find him wise and frank. He challenges some of the the professionally self-indulgent dogmas about psychotherapy, psychiatric hospitalization, and psychiatric medication, dogmas which may not apply to every situation, dogmas which may well, in some cases, aggrandize the "healing power" of the system or the therapeutic process, dogmas which deserve a generous dose of humility in order to more soundly be helpful. He describes numerous dramatic "case vignettes", with much needed attention given to the consideration of process and relationship dynamics. Many of his ideas about the vignettes I disagree with, but the book could open a forum for debate and discussion.
But-- I find his style at times too cynical and lacking in gentle warmth, to affirm it strongly. In fact, Dawson's ideas I think at times have been misapplied in the medical system, used as part of a tactic to prematurely discharge some patients from hospital or from other follow-up care. Yet, I think Dawson's views are important to hear, at least as the starting point for a debate.
Part of a problem I've observed is that many extremely important and valid concerns or complaints can be dismissively pathologized as part of a "personality disorder trait".
For example, negative experiences of physicians or the hospital system need not be considered part of an individual's "pathology".
In fact, I think it is more uncommon than common for anyone to have a smooth journey through any medical care system--it tends to be laden with frustration, despite hopefully encountering some good people along the way.
Negative experiences of individual caregivers or relationships within a system need not be dismissed as so-called "splitting" (a "borderline" phenomenon)--they may be accurate and insightful accounts of having encountered a negative relationship.
The experiences may be a product of having encountered poor medical care, a poor medical system, or an unhealthy set of social structures which provide inadequate help. Sometimes an individual's complaints about these negative experiences may actually be a sign of courage, a character strength, rather than of a "borderline trait".
I think a larger view of so-called "borderline phenomena" has to do with group dynamics, as opposed to individual dynamics. If expressions of concern or frustration are met with hostile, judgmental, or inconsistent reactions, this may magnify the initial concerns or frustrations, leading to a vicious cycle. Each individual in such a dynamic may be behaving "healthily", but the relationship is not working. The relationship failure may be due to an inadequate structure, a lack of mutual understanding, communicative failure, a long history of relationship problems which biases the present point of view, tiredness or frustration on either side, or an insurmountable cultural gap. This reminds me of some of the conflicts between nations that go on today, in which each nation's "point of view" is understandable and valid, but the relationship fails, sometimes in a very destructive way, sometimes leading to an "arms race." Ironically, in psychiatry, such borderline relationship dynamics may occur involving the very individuals who are trying to be relationship mediators. My point here is that sometimes it is not the individual who has a "borderline personality disorder", but the relationship, or the system, which is suffering from "borderline dynamics".
An author on the subject of borderline personality I consider important is David Dawson. Title: Relationship Management of the Borderline Patient, Brunner/Mazel, 1993
I do find him wise and frank. He challenges some of the the professionally self-indulgent dogmas about psychotherapy, psychiatric hospitalization, and psychiatric medication, dogmas which may not apply to every situation, dogmas which may well, in some cases, aggrandize the "healing power" of the system or the therapeutic process, dogmas which deserve a generous dose of humility in order to more soundly be helpful. He describes numerous dramatic "case vignettes", with much needed attention given to the consideration of process and relationship dynamics. Many of his ideas about the vignettes I disagree with, but the book could open a forum for debate and discussion.
But-- I find his style at times too cynical and lacking in gentle warmth, to affirm it strongly. In fact, Dawson's ideas I think at times have been misapplied in the medical system, used as part of a tactic to prematurely discharge some patients from hospital or from other follow-up care. Yet, I think Dawson's views are important to hear, at least as the starting point for a debate.
Wednesday, January 7, 2009
Borderline Personality
There are many patients I have seen who have had some mixture of the following symptoms or experiences:
1) sudden, intense shifts of mood, often towards extreme sadness, emptiness, or rage. Often times, these sudden shifts occur in the context of a relationship event (a disappointment with someone, a conflictual conversation, a breakup, etc.)
2) very chaotic interpersonal relationships -- lots of conflict, sometimes a lot of aggression, sometimes frequent break-ups, reconciliations, break-ups, reconciliations, etc. Sometimes this is a product of the person having chosen a partner with a chaotic relationship style, but sometimes this relationship chaos occurs even with a partner who is calm
3) prominent, longstanding thoughts about suicide, even when mood is better
4) frequent self-injurious behaviour (most frequently, cutting skin with a razor), which is often done to relieve extreme emotional tension. Sometimes self-injury or suicide attempts occur as a form of non-verbal interpersonal communication or protest.
5) prominent, longstanding self-hatred
6) symptoms which "seem psychotic", such as hallucinations, paranoia, or thought disorganization of various types, but which do not have the characteristic qualities or patterns found in psychotic illness such as schizophrenia
7) pronounced confusion about identity, often with respect to gender, sexuality, or "sense of self"
8) difficulty with relationship boundaries
9) a chaotic and often very negative set of experiences with doctors, the health care system, etc.
10) hospital stays in which symptoms got worse rather than better
I have seen many for whom these symptoms were their manifestation of depression, or part of a type of bipolar disorder, and for whom these issues improved following standard treatments for mood disorder.
For others, some of these symptoms are part of a post-traumatic syndrome.
I have seen many others for whom these symptoms seemed to be part of a developmental struggle, arising with adolescence or earlier, and resolving with time, support, work, development of purpose, meaning, community, autonomy, etc. Often a fairly short-term experience of therapy has helped.
For others, these symptoms become more lasting phenomena, and may in fact become more and more entrenched with time. It is as though the person has a chaotic relationship with time itself, which feeds the symptoms, rather than relieving them.
Some of the symptoms, such as self-injury, seem to have strong addictive components. Other types of addictive behaviours (such as substance abuse) are common in this population as well.
For many of my patients, there is so much overlap between "depression" and so-called "borderline personality traits" that I don't find that there is much point being concerned with "labeling" at all, since the same things help with both.
Here are some things that I have found to be helpful in all cases (in addition my standard advice about a healthy, happy lifestyle):
1) gentle, supportive, compassionate, friendly, consistent care in a setting with clear but non-rigid boundaries
2) treatment of specific symptoms pharmacologically (e.g. antidepressants may help with mood; anticonvulsants or antipsychotics may help with anxiety, irritability, insomnia, and lability; stimulants may help with inattention, hyperactivity, or distractability)
3) avoidance of harm (e.g. I would tend to avoid prescribing potentially addictive medications, or medications that are particularly dangerous in overdose; also some types of overly confrontational, reactive, over-medicalized, suggestive, dogmatic, or "digging into the past" styles of psychotherapy can probably be overtly harmful for some people, especially if the therapy style is engaged in without the patient's full understanding or consent).
4) gentle attention to the same kind of dynamics happening in the therapy as what happens in other relationships (e.g. intense conflicts, feelings of abandonment, "chaos"), and an attempt to gently work it out rather than let the symptoms threaten the relationship
5) cognitive-therapy techniques of various types can be particularly helpful; specifically Linehan's "Dialectical Behavioural Therapy" which is a type of cognitive therapy enriched by ideas from Buddhist mindfulness. Also Linehan's ideas emphasize the idea of "validation" which I consider extremely important -- symptoms need to be calmly understood, empathized with, rather than discounted or dismissed
6) long-term dynamically-oriented psychotherapy, 1-on-1 or group (or both). There is an expanding strong evidence base that this helps a lot
7) trying neither to over-react (e.g. push for an immediate hospital visit), nor to under-react (e.g. ignore or dismiss), regarding suicidal thoughts or self-injury; but to try to be understanding and helpful in any case
8) I do not tend to recommend hospitalization, especially through an emergency admission, as a cornerstone of therapy, except I do encourage people to use the emergency rooms if they cannot survive safely through the day and they do not feel they have other resources available. I believe it is much more therapeutic for people to choose themselves whether or not to use the emergency room.
9) a good day-program, if available, can be very helpful. These are harder to find nowadays
A few references:
http://www.ncbi.nlm.nih.gov/pubmed/16437534
(a Cochrane review of psychotherapy for borderline personality)
http://www.ncbi.nlm.nih.gov/pubmed/16437535
(a Cochrane review of medication for borderline personality; this shows, as I would expect, a modest and inconsistent evidence base, which I think supports the idea of being open-minded about using pharmacological therapies, but perhaps of having modest expectations of them, and being wary of relying too heavily on medication treatments alone)
http://www.ncbi.nlm.nih.gov/pubmed/17541052
(a randomized study showing broad, large effects from psychotherapy in patients having a borderline personality diagnosis, over a 1-year period)
http://www.ncbi.nlm.nih.gov/pubmed/18347003
(a study with an 8 year follow-up! --we need more such very long-term studies-- It shows that an intensive day program approach was very helpful)
http://www.ncbi.nlm.nih.gov/pubmed/17427099
(another longer-term study showing substantial benefits from psychotherapy)
It is important to note that many with so-called "borderline personality" may have depression or other problems at the same time, and each of these problems may improve with specific types of therapy. Many studies are not considering these "comorbid" conditions, and therefore underestimate the effectiveness of various types of therapy.
Here is a link to a dialectical-behavior therapy self-help site:
http://www.dbtselfhelp.com/index.html
1) sudden, intense shifts of mood, often towards extreme sadness, emptiness, or rage. Often times, these sudden shifts occur in the context of a relationship event (a disappointment with someone, a conflictual conversation, a breakup, etc.)
2) very chaotic interpersonal relationships -- lots of conflict, sometimes a lot of aggression, sometimes frequent break-ups, reconciliations, break-ups, reconciliations, etc. Sometimes this is a product of the person having chosen a partner with a chaotic relationship style, but sometimes this relationship chaos occurs even with a partner who is calm
3) prominent, longstanding thoughts about suicide, even when mood is better
4) frequent self-injurious behaviour (most frequently, cutting skin with a razor), which is often done to relieve extreme emotional tension. Sometimes self-injury or suicide attempts occur as a form of non-verbal interpersonal communication or protest.
5) prominent, longstanding self-hatred
6) symptoms which "seem psychotic", such as hallucinations, paranoia, or thought disorganization of various types, but which do not have the characteristic qualities or patterns found in psychotic illness such as schizophrenia
7) pronounced confusion about identity, often with respect to gender, sexuality, or "sense of self"
8) difficulty with relationship boundaries
9) a chaotic and often very negative set of experiences with doctors, the health care system, etc.
10) hospital stays in which symptoms got worse rather than better
I have seen many for whom these symptoms were their manifestation of depression, or part of a type of bipolar disorder, and for whom these issues improved following standard treatments for mood disorder.
For others, some of these symptoms are part of a post-traumatic syndrome.
I have seen many others for whom these symptoms seemed to be part of a developmental struggle, arising with adolescence or earlier, and resolving with time, support, work, development of purpose, meaning, community, autonomy, etc. Often a fairly short-term experience of therapy has helped.
For others, these symptoms become more lasting phenomena, and may in fact become more and more entrenched with time. It is as though the person has a chaotic relationship with time itself, which feeds the symptoms, rather than relieving them.
Some of the symptoms, such as self-injury, seem to have strong addictive components. Other types of addictive behaviours (such as substance abuse) are common in this population as well.
For many of my patients, there is so much overlap between "depression" and so-called "borderline personality traits" that I don't find that there is much point being concerned with "labeling" at all, since the same things help with both.
Here are some things that I have found to be helpful in all cases (in addition my standard advice about a healthy, happy lifestyle):
1) gentle, supportive, compassionate, friendly, consistent care in a setting with clear but non-rigid boundaries
2) treatment of specific symptoms pharmacologically (e.g. antidepressants may help with mood; anticonvulsants or antipsychotics may help with anxiety, irritability, insomnia, and lability; stimulants may help with inattention, hyperactivity, or distractability)
3) avoidance of harm (e.g. I would tend to avoid prescribing potentially addictive medications, or medications that are particularly dangerous in overdose; also some types of overly confrontational, reactive, over-medicalized, suggestive, dogmatic, or "digging into the past" styles of psychotherapy can probably be overtly harmful for some people, especially if the therapy style is engaged in without the patient's full understanding or consent).
4) gentle attention to the same kind of dynamics happening in the therapy as what happens in other relationships (e.g. intense conflicts, feelings of abandonment, "chaos"), and an attempt to gently work it out rather than let the symptoms threaten the relationship
5) cognitive-therapy techniques of various types can be particularly helpful; specifically Linehan's "Dialectical Behavioural Therapy" which is a type of cognitive therapy enriched by ideas from Buddhist mindfulness. Also Linehan's ideas emphasize the idea of "validation" which I consider extremely important -- symptoms need to be calmly understood, empathized with, rather than discounted or dismissed
6) long-term dynamically-oriented psychotherapy, 1-on-1 or group (or both). There is an expanding strong evidence base that this helps a lot
7) trying neither to over-react (e.g. push for an immediate hospital visit), nor to under-react (e.g. ignore or dismiss), regarding suicidal thoughts or self-injury; but to try to be understanding and helpful in any case
8) I do not tend to recommend hospitalization, especially through an emergency admission, as a cornerstone of therapy, except I do encourage people to use the emergency rooms if they cannot survive safely through the day and they do not feel they have other resources available. I believe it is much more therapeutic for people to choose themselves whether or not to use the emergency room.
9) a good day-program, if available, can be very helpful. These are harder to find nowadays
A few references:
http://www.ncbi.nlm.nih.gov/pubmed/16437534
(a Cochrane review of psychotherapy for borderline personality)
http://www.ncbi.nlm.nih.gov/pubmed/16437535
(a Cochrane review of medication for borderline personality; this shows, as I would expect, a modest and inconsistent evidence base, which I think supports the idea of being open-minded about using pharmacological therapies, but perhaps of having modest expectations of them, and being wary of relying too heavily on medication treatments alone)
http://www.ncbi.nlm.nih.gov/pubmed/17541052
(a randomized study showing broad, large effects from psychotherapy in patients having a borderline personality diagnosis, over a 1-year period)
http://www.ncbi.nlm.nih.gov/pubmed/18347003
(a study with an 8 year follow-up! --we need more such very long-term studies-- It shows that an intensive day program approach was very helpful)
http://www.ncbi.nlm.nih.gov/pubmed/17427099
(another longer-term study showing substantial benefits from psychotherapy)
It is important to note that many with so-called "borderline personality" may have depression or other problems at the same time, and each of these problems may improve with specific types of therapy. Many studies are not considering these "comorbid" conditions, and therefore underestimate the effectiveness of various types of therapy.
Here is a link to a dialectical-behavior therapy self-help site:
http://www.dbtselfhelp.com/index.html
Personality Disorders
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.
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.
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.
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