While in the midst of an epidemic, a great deal of anxiety arises in the population.
Anxiety can lead to an exaggerated or inaccurate perception of risk, particularly when the mass anxiety is spread in the media, such as via front-page accounts of unexpected deaths.
In approaching any type of anxiety, I think it is important to know exactly what the risks are.
So, for example, it would be dishonest to tell an airplane-phobic person that air travel is perfectly safe. It isn't: there is about a 1 in 1 million chance of the plane crashing. (In a future post, I'd like to present my analysis of the statistics, and also show that the average spontaneous death rate in the population, for a person beyond young adulthood, exceeds the death rate from flying in an airplane--therefore I could claim--flippantly--that flying is statistically a "life-prolonging activity" for most travelers).
The current flu epidemic is clearly a serious matter. There definitely is a risk of death for those infected.
Estimates I've seen of the mortality rate vary, but the prevailing opinion seems to be that it is less than 0.1% (1 in 1000) for those infected.
This is not particularly different from the mortality rate of ordinary seasonal flu.
HOWEVER, the significant difference in this epidemic is the mortality rate by age. It is clearly true that swine flu has a higher mortality rate for healthy young adults--probably at least triple-- compared to seasonal flu.
Therefore, we are seeing more young, healthy adults die of flu this year. The total numbers are very low, but are much higher than in other years. The reason the overall mortality rate is the same is that fewer elderly individuals are dying of swine flu, most likely because of heightened immunity in that population due to exposure to a similar virus decades ago.
The CDC site shows that in a cohort of 268 people who died from swine flu early in the epidemic, 39% were in the 25-49 age group, and 25% were in the 50-64 age group. This is very different from seasonal influenza, in which about 90% of the deaths are in the over 65 age group. Here's a link to a pertinent page from their site:
http://www.cdc.gov/H1N1FLU/surveillanceqa.htm
Here's another important page from the CDC:
http://www.cdc.gov/h1n1flu/estimates_2009_h1n1.htm
Based on the table shown on this page, here are estimated risks of death for individuals infected with H1N1, stratified by age:
0-17 age group: between 1 in 10 000 and 1 in 20 000.
18-64 age group: between 1 in 2400 and 1 in 6000.
65+ age group: between 1 in 2300 and 1 in 6800.
I found a table of age-standardized "excess deaths" due to pneumonia and influenza in Italy between 1969-2001. (http://www.cdc.gov/eid/content/13/5/694-T2.htm) Based on this table, and assuming that only 10% of the population is infected during typical seasonal flu years, here is a very rough estimate of the risks of death by age for seasonal flu:
0-44 age group: 1 in 100 000
45-64 age group: 1 in 20 000
65+ age group: 1 in 750
The above data show that H1N1 influenza has a substantially higher death rate for those under 65 compared to seasonal flu, but as you can see the chances of dying if you catch the flu are still quite low, regardless of your age.
The risk of flu vaccines appears to be extremely low.
There is a substantial risk of contracting flu without the vaccine.
There is a low but non-zero risk of severe illness or death if you contract the flu.
The risk of a severe adverse reaction to the vaccine is much lower than the risk of a severe adverse effect from the flu itself.
The vaccine is likely to reduce the risk of contracting the flu by at least 90%.
Therefore, the benefit:risk ratio regarding the flu vaccine is very favourable. Here are references:
http://www.cdc.gov/h1n1flu/vaccination/safety_planning.htm
http://www.who.int/csr/disease/swineflu/frequently_asked_questions/vaccine_preparedness/safety_approval/en/index.html
So, my recommendations regarding swine flu anxiety are to be informed about the most accurate facts available:
1) the risk of death or severe illness remains low, for anyone infected
2) but the risk of a healthy young adult becoming severely ill or dying is relatively higher compared to seasonal flu
3) public health measures, such as very careful hygiene and mass vaccinations, are likely to save many lives (this is true of seasonal flu as well). Statistically, you as an individual are unlikely to contract severe flu illness. Hygiene and vaccine recommendations are more likely to be part of reducing the spread of flu in the population: therefore such recommendations, if you follow them, are statistically more likely to spare severe disease in someone else, rather than yourself. That is, if you receive a vaccination, that vaccination is more likely to save someone else's life rather than your own, since the average active case of flu is likely to spread to about 2 other people, even if the case is mild.
4) Therefore, I encourage following hygiene protocols and receiving the vaccine when it becomes available. It may spare you severe illness, and it has an even higher likelihood of being an altruistic act, which spares other people severe illness. Prompt use of anti-influenza medications such as Tamiflu are likely to further reduce the risk of severe complications, and most likely will further reduce the risk of contagion.
Altruistic acts, such as getting vaccinated or washing your hands, are psychologically healthy (this is my justification for posting something about influenza in a psychiatry blog!).
*It may be important to keep in mind, for the sake of perspective, that automobile accidents, for example, claim about 600 000 lives per year among young, healthy adults. In Canada alone, there are about 1000 deaths of young, healthy adults per year due to car accidents. (reference:http://www.statcan.gc.ca/pub/82-003-x/2008003/article/10648-eng.pdf) Another altruistic act of very practical importance is to slow down on the road!
Addendum:
A good article in the November 10, 2009 edition of CMAJ (p. 667-668) presents evidence that handwashing is not actually likely to be very effective in reducing the spread of influenza. Microbiologist Dr. Donald Low argues that hand hygiene has not been proven to reduce influenza spread, and that the influenza virus is primarily spread by fine droplets from coughing, which then have to be inhaled deeply. He points out that receptors for the influenza virus are located farther back in the respiratory tract, hence cannot be easily infected by touching mouth or eyes with hands, etc.
Here is an excellent article on the subject:
http://www.scienceadvice.ca/documents/%282007-12-19%29_Influenza_PPRE_Final_Report.pdf
His evidence-based position is that the N95 mask is the best mechanical way to prevent infection if you are near an infected person. Other than that, the best practice to prevent contagion would be to contain any coughing or sneezing, to stay away from other people if you are coughing, and to avoid close proximity with those who are infected, if possible.
Meanwhile, it is undoubtedly true that good handwashing practices do reduce the spread of the common cold and other infectious diseases. So all the handwashing and hand-sanitizing stations you see all over the place remain a good idea -- it's just that handwashing might not actually protect you very much from contracting influenza, compared to other measures.
Monday, November 2, 2009
Thursday, October 29, 2009
Spread of psychological phenomena in social networks
Here is a link to the abstract of an interesting article by Fowler & Christakis, published in the British Medical Journal in December 2008:
http://www.ncbi.nlm.nih.gov/pubmed/19056788
I think it is a delightful statistical analysis of social networks, based on a cohort of about 5000 people from the Framingham Heart Study, followed over 20 years. This article should really be read in its entirety, in order to appreciate the sophistication of the techniques.
They showed that happiness "spreads" in a manner analogous to contagion. Having happy same-sex friends or neighbours who live nearby, increases one's likelihood of being, or becoming, happy. Interestingly, spouses and coworkers did not have a pronounced effect.
Also, the findings show that having "unhappy" friends does not cause a similar increase in likelihood of being or becoming "unhappy" -- it is happiness, not unhappiness, in the social network, which appears to "spread."
So the message here is not that people should avoid unhappy friends: in fact the message can be that befriending an unhappy person can be helpful not only to that unhappy individual, but to that unhappy person's social network.
There has been some criticism of the authors' techniques, but overall I find the analysis to be very thorough, imaginative, and fascinating.
Here are some practical applications suggested by these findings:
1) sharing positive emotions can have a substantial positive, lasting emotional impact on people near you, including friends and neighbours.
2) nurturing friendships with happier people who live close to you may help to improve subjective happiness
3) this does not mean that friendships with unhappy people have a negative emotional impact, unless all of your friendships are with unhappy people.
4) in the treatment of depression, consideration of the health of social networks can be very important. Here, the "quantity" of the extended social network is not relevant (so the number of "facebook friends" doesn't matter). Rather, the relevant effects are due to the characteristics of the close social network, of 2-6 people or so, particularly those who have close geographic proximity. As I look at the data, I see that having two "happy friends" has a significantly larger positive effect than having only one, but there was not much further effect from having more than two.
5) I have to wonder whether the value of group therapy for depression is diminished if all members of the group are severely depressed. I could see group therapy being much more effective if some of the members were in a recovered, or recovering, state. This reminds me of some of the research about social learning theory (see my previous post: http://garthkroeker.blogspot.com/2008/12/social-learning-therapy.html)
6) on a public health level, the expense involved in treating individual cases of depression should be considered not only on the basis of considering that individual's improved health, function, and well-being, but also on the basis of considering that individual's positive health impact on his or her social network.
7) There is individual variability in social extroversion, or social need. Some individuals prefer a very active social life, others prefer relative social isolation. Others desire social activity, but are isolated or socially anxious. Those who live in relative social isolation might still have a positive reciprocal experience of this social network effect, provided that relationships with people living nearby (such as next-door neighbours or family) are positive.
I should conclude that, despite the strength of the authors' analysis, involving a very large epidemiological cohort, my inferences and proposed applications mentioned above could only really be proven definitively through randomized prospective studies. Yet, such studies would be virtually impossible to do! I think some of the social psychology literature attempts to address this, but I think manages to do so only in a more limited and cross-sectional manner.
http://www.ncbi.nlm.nih.gov/pubmed/19056788
I think it is a delightful statistical analysis of social networks, based on a cohort of about 5000 people from the Framingham Heart Study, followed over 20 years. This article should really be read in its entirety, in order to appreciate the sophistication of the techniques.
They showed that happiness "spreads" in a manner analogous to contagion. Having happy same-sex friends or neighbours who live nearby, increases one's likelihood of being, or becoming, happy. Interestingly, spouses and coworkers did not have a pronounced effect.
Also, the findings show that having "unhappy" friends does not cause a similar increase in likelihood of being or becoming "unhappy" -- it is happiness, not unhappiness, in the social network, which appears to "spread."
So the message here is not that people should avoid unhappy friends: in fact the message can be that befriending an unhappy person can be helpful not only to that unhappy individual, but to that unhappy person's social network.
There has been some criticism of the authors' techniques, but overall I find the analysis to be very thorough, imaginative, and fascinating.
Here are some practical applications suggested by these findings:
1) sharing positive emotions can have a substantial positive, lasting emotional impact on people near you, including friends and neighbours.
2) nurturing friendships with happier people who live close to you may help to improve subjective happiness
3) this does not mean that friendships with unhappy people have a negative emotional impact, unless all of your friendships are with unhappy people.
4) in the treatment of depression, consideration of the health of social networks can be very important. Here, the "quantity" of the extended social network is not relevant (so the number of "facebook friends" doesn't matter). Rather, the relevant effects are due to the characteristics of the close social network, of 2-6 people or so, particularly those who have close geographic proximity. As I look at the data, I see that having two "happy friends" has a significantly larger positive effect than having only one, but there was not much further effect from having more than two.
5) I have to wonder whether the value of group therapy for depression is diminished if all members of the group are severely depressed. I could see group therapy being much more effective if some of the members were in a recovered, or recovering, state. This reminds me of some of the research about social learning theory (see my previous post: http://garthkroeker.blogspot.com/2008/12/social-learning-therapy.html)
6) on a public health level, the expense involved in treating individual cases of depression should be considered not only on the basis of considering that individual's improved health, function, and well-being, but also on the basis of considering that individual's positive health impact on his or her social network.
7) There is individual variability in social extroversion, or social need. Some individuals prefer a very active social life, others prefer relative social isolation. Others desire social activity, but are isolated or socially anxious. Those who live in relative social isolation might still have a positive reciprocal experience of this social network effect, provided that relationships with people living nearby (such as next-door neighbours or family) are positive.
I should conclude that, despite the strength of the authors' analysis, involving a very large epidemiological cohort, my inferences and proposed applications mentioned above could only really be proven definitively through randomized prospective studies. Yet, such studies would be virtually impossible to do! I think some of the social psychology literature attempts to address this, but I think manages to do so only in a more limited and cross-sectional manner.
Tuesday, October 27, 2009
Positive Psychology (continued)
This is a response to a reader's comment on my post about positive psychology:
http://garthkroeker.blogspot.com/2009/10/positive-psychotherapy-ppt-for.html
Here's a brief response to some of your points:
1) I don't think there's anything wrong with focusing on pathology or weaknesses. In fact, I consider this type of focus to be essential. Imagine an engineering project in which structural weaknesses or failures were ignored, with a great big smile or a belief that "everything will be fine." Many a disaster has resulted from this kind of approach. I think of the space shuttle disaster, for example.
The insight from positive psychology though, in my opinion, has to do with re-evaluating the balance between a focus on "positivity" vs. pathology.
In depressive states, the cognitive stance is often overwhelmingly critical, about self, world, and future. Even if these views are accurate, they tend to prevent any solution of the problem they describe. It is like an engineering project where the supervisor is so focused on mistakes and criticism that no one can move on, all the workers are tired and demoralized, and perhaps the immediate, relentless focus on errors prevents a different perspective, and a healthy collaboration, which might actually definitively solve the problem.
2) I believe that pronouncements of the "right or wrong" of an emotional or intellectual position are finally up to the individual. It is not for me, or our culture, to judge. There will be all sorts of points of view about the morality or acceptability of any emotional or social stance: some of these points of view will be very critical or judgmental to a given person, some won't. I suppose there are elements of the culture that would harshly judge or criticize someone who appears too "happy": perhaps such a person would be deemed shallow, delusional, uncritical, vain, etc. I prefer to view ideas such as those in "positive psychology" as possible instruments of change, to be tried if a person wishes to try them. CBT, medications, psychoanalysis, surgery, having "negative friends" or "ditching them", etc. are all choices, change behaviours, or ways of managing life, which I think individuals should be free to consider if available, and if legal, but also free to reject if they feel it is not right for them.
In terms of the "gimmicky" nature of positive psychology, I agree. But I think most of the ideas are very simple, and are reflected in other very basic, widely accepted research in biology & behaviour. In widely disparate fields, such as the study of child-rearing, education, coaching, or animal training, it is clear that recognition and criticism of "faults" or "pathologies" is necessary in order for problems to be resolved. Yet the mechanism by which change most optimally occurs is by instilling an atmosphere of warmth, reward, comfort, and joy, with a minority of feedback having to do with criticism. The natural instinct with problematic situations, however, is often to punish. Punishing a child for misbehaviour may at times be necessary, but most times child punishments are excessive and ineffectual, often are more about the emotional state of the punisher rather than the behavioural state of the child, and ironically may reinforce the problems the child is being punished for. Punishing a biting dog through physical injury will teach the dog to be even more aggressive. I find this type of cycle prominent in depressive states: there may be a lot of internal self-criticism (some of which may be accurate), but it leads to harsh self-punishment which ends up perpetuating the depressive state. I find the best insights of "positive psychology" have to do with stepping out of this type of punitive cycle, not by ignoring the negative, but by deliberately trying to nurture and reward the positive as well.
3) The research about so-called "depressive realism" has always seemed quite suspect to me. In a person with PTSD (a disorder which I consider highly analogous to depression and other mental illnesses), very often there is a high degree of sensitivity to various stimuli, that may, for example, cause that person to be able to have better vigilance regarding the potential dangers associated with the sound of footsteps in the distance, or of the smell of smoke, etc. Often times, though, this heightened vigilance comes at great expense to that person's ability to function in life: a pleasant walk, a work environment, or a hug, may instead become a terrifying journey or a place of constant fear of attack.
Similarly, in depressive states, there may be beliefs that are, on one level, accurate, but on another level are causing a profound impairment in life function (e.g. regarding socializing, learning, work, simple life pleasures, spirituality, etc.).
With regard to science, I do not find any need to say that "positive psychology" etc. is about a biased interpretation of data. Instead, my analogy would be along the lines of how one would solve a complex mathematical equation:
-a small minority of mathematical problems have a straightforward answer. If one was to look only at precedents in data, one might conclude that there is no definable answer for many problems. A cynical and depressive approach would be to abandon the problem.
-but most complex problems today require what is called a "numerical analysis" approach. This necessitates basically guessing at the solution, then applying an algorithm that will "sculpt" the guess closer to the true answer. Sometimes the algorithm doesn't work, and the attempted solutions "diverge." But the convergence to a solution through numerical analytical methods is the most powerful phenomenon in modern science. It has permitted most every single major advance in science and engineering in the past hundred years. It is basically analogous to positive behavioural shaping in psychology. It is not about biased interpretation of data, it is about using a set of "positive" tools to solve a problem (in the mathematical case, to get numerical solutions; in the psychological case, to relieve symptoms, to increase freedom of choice, and to expand the realm of possible life functions available).
4) Some of the experiments are weak, no doubt about that. I don't consider experiments evaluating superficial cross-sectional affect to be relevant to therapy research. Experiments which evaluate the change in symptoms and subjective quality of life measures over long periods of time, are most relevant to me. I consider "positive psychology" to be just one more set of ideas that may help to improve quality of life, and overall life function, as subjectively defined by a patient.
In my discussion of this subject, I am not meaning to suggest that so-called "positive psychology" is my favoured therapeutic system. Some of the ideas may be quite off-putting to individuals who may need to deal with a lot of negative symptoms directly before doing "positivity exercises." But I do think that some of the ideas from positive psychology are important and relevant, and deserve to be adopted as part of an eclectic therapy model.
http://garthkroeker.blogspot.com/2009/10/positive-psychotherapy-ppt-for.html
Here's a brief response to some of your points:
1) I don't think there's anything wrong with focusing on pathology or weaknesses. In fact, I consider this type of focus to be essential. Imagine an engineering project in which structural weaknesses or failures were ignored, with a great big smile or a belief that "everything will be fine." Many a disaster has resulted from this kind of approach. I think of the space shuttle disaster, for example.
The insight from positive psychology though, in my opinion, has to do with re-evaluating the balance between a focus on "positivity" vs. pathology.
In depressive states, the cognitive stance is often overwhelmingly critical, about self, world, and future. Even if these views are accurate, they tend to prevent any solution of the problem they describe. It is like an engineering project where the supervisor is so focused on mistakes and criticism that no one can move on, all the workers are tired and demoralized, and perhaps the immediate, relentless focus on errors prevents a different perspective, and a healthy collaboration, which might actually definitively solve the problem.
2) I believe that pronouncements of the "right or wrong" of an emotional or intellectual position are finally up to the individual. It is not for me, or our culture, to judge. There will be all sorts of points of view about the morality or acceptability of any emotional or social stance: some of these points of view will be very critical or judgmental to a given person, some won't. I suppose there are elements of the culture that would harshly judge or criticize someone who appears too "happy": perhaps such a person would be deemed shallow, delusional, uncritical, vain, etc. I prefer to view ideas such as those in "positive psychology" as possible instruments of change, to be tried if a person wishes to try them. CBT, medications, psychoanalysis, surgery, having "negative friends" or "ditching them", etc. are all choices, change behaviours, or ways of managing life, which I think individuals should be free to consider if available, and if legal, but also free to reject if they feel it is not right for them.
In terms of the "gimmicky" nature of positive psychology, I agree. But I think most of the ideas are very simple, and are reflected in other very basic, widely accepted research in biology & behaviour. In widely disparate fields, such as the study of child-rearing, education, coaching, or animal training, it is clear that recognition and criticism of "faults" or "pathologies" is necessary in order for problems to be resolved. Yet the mechanism by which change most optimally occurs is by instilling an atmosphere of warmth, reward, comfort, and joy, with a minority of feedback having to do with criticism. The natural instinct with problematic situations, however, is often to punish. Punishing a child for misbehaviour may at times be necessary, but most times child punishments are excessive and ineffectual, often are more about the emotional state of the punisher rather than the behavioural state of the child, and ironically may reinforce the problems the child is being punished for. Punishing a biting dog through physical injury will teach the dog to be even more aggressive. I find this type of cycle prominent in depressive states: there may be a lot of internal self-criticism (some of which may be accurate), but it leads to harsh self-punishment which ends up perpetuating the depressive state. I find the best insights of "positive psychology" have to do with stepping out of this type of punitive cycle, not by ignoring the negative, but by deliberately trying to nurture and reward the positive as well.
3) The research about so-called "depressive realism" has always seemed quite suspect to me. In a person with PTSD (a disorder which I consider highly analogous to depression and other mental illnesses), very often there is a high degree of sensitivity to various stimuli, that may, for example, cause that person to be able to have better vigilance regarding the potential dangers associated with the sound of footsteps in the distance, or of the smell of smoke, etc. Often times, though, this heightened vigilance comes at great expense to that person's ability to function in life: a pleasant walk, a work environment, or a hug, may instead become a terrifying journey or a place of constant fear of attack.
Similarly, in depressive states, there may be beliefs that are, on one level, accurate, but on another level are causing a profound impairment in life function (e.g. regarding socializing, learning, work, simple life pleasures, spirituality, etc.).
With regard to science, I do not find any need to say that "positive psychology" etc. is about a biased interpretation of data. Instead, my analogy would be along the lines of how one would solve a complex mathematical equation:
-a small minority of mathematical problems have a straightforward answer. If one was to look only at precedents in data, one might conclude that there is no definable answer for many problems. A cynical and depressive approach would be to abandon the problem.
-but most complex problems today require what is called a "numerical analysis" approach. This necessitates basically guessing at the solution, then applying an algorithm that will "sculpt" the guess closer to the true answer. Sometimes the algorithm doesn't work, and the attempted solutions "diverge." But the convergence to a solution through numerical analytical methods is the most powerful phenomenon in modern science. It has permitted most every single major advance in science and engineering in the past hundred years. It is basically analogous to positive behavioural shaping in psychology. It is not about biased interpretation of data, it is about using a set of "positive" tools to solve a problem (in the mathematical case, to get numerical solutions; in the psychological case, to relieve symptoms, to increase freedom of choice, and to expand the realm of possible life functions available).
4) Some of the experiments are weak, no doubt about that. I don't consider experiments evaluating superficial cross-sectional affect to be relevant to therapy research. Experiments which evaluate the change in symptoms and subjective quality of life measures over long periods of time, are most relevant to me. I consider "positive psychology" to be just one more set of ideas that may help to improve quality of life, and overall life function, as subjectively defined by a patient.
In my discussion of this subject, I am not meaning to suggest that so-called "positive psychology" is my favoured therapeutic system. Some of the ideas may be quite off-putting to individuals who may need to deal with a lot of negative symptoms directly before doing "positivity exercises." But I do think that some of the ideas from positive psychology are important and relevant, and deserve to be adopted as part of an eclectic therapy model.
Wednesday, October 21, 2009
Internet, Video Games, and TV: Addictions or Cognitive Enhancers?
I'll introduce this post with my opinion on this issue:
Almost any human activity can be addictive, in a harmful way. That is, the activity could provide a mental reward which leads to the following pattern:
- the activity happens more frequently
- tolerance develops
- increased absorption with the activity develops, in order to achieve the same or greater reward
- other activities feel more boring or unrewarding
- other activities & relationships are neglected
- physical harm may result from sleep deprivation, sedentary behaviour, repetitive strain, reduced self-care, etc.
- social harm may result from relationship neglect or isolation, but also from associating with a cohort of fellow "addicts" who do the same behaviours
- the "mental reward" could probably correlate with functional brain imaging demonstrating increased activity of central dopaminergic reward circuits
Many "good" activities could lead to an addictive pattern. Here's a list of possible activities that can potentially become addictive in this sense:
1) work
2) earning money
3) studying
4) hobbies
5) house chores
6) talking or texting on phones or other electronic devices
7) being in the company of people, or of a particular person
8) sports (playing or watching)
9) reading
10) pursuing excellence
Sometimes, behaviours or thoughts associated with depression or low self-esteem can be "addictive", in that some people may feel a type of masochistic reward from them.
Individuals may not recognize the unhealthy or addictive components of their behaviours. For a person wanting to earn more money, or pursue more excellence, it may seem absurd, and contrary to that person's values, to consider backing away from these pursuits.
For the person "pursuing excellence," it may be true that pouring more time and energy into training might increase achievement in a short-term sense. But this is the addictive trap. In order to pursue excellence in the most effective way, a balanced lifestyle is necessary. In order to achieve that balanced lifestyle, that person may paradoxically need to back away from their immediate pursuit.
I think that all types of modern technology have the potential to be addictive.
Technology and technological culture are changing at an unprecedented pace. And the technologies have ever more powerful and subtle ways to capture our interest, attention, and to stimulate neural reward.
All technological inventions have become addictive for some people. Yet most of these inventions have also contributed to an evolution of modern culture, which has been positive in many ways.
The internet, TV, and video games can all be stimulating, educational activities, which could enhance brain function, intelligence, and could lead to improved social relationships. They could be devices which improve relatedness rather than foster alienation.
Some of these technologies may permit an individual with problems such as a social skills difficulty to explore social connectedness in a different way. In this way, the internet can be an expansion of human connectedness and community. It is a technology which continues the trend of increased potential connectedness through human history. Thousands of years ago, it would have been hard to meet anyone who lived any farther away than the next village. While many individuals would have thrived socially in isolated village culture, some individuals would have been alienated.
Yet technological devices can be easily addictive. And the huge availability of choice in modern technology may permit an individual to find a particular thing that absorbs attention, and disappear into that activity while general physical, social, and mental health deteriorates. There is also a lot of choice available that has violent content, or which creates only an illusion of connection, while none really exists. Facebook or other social connection applications can become preoccupations for many people. While such sites could facilitate social connection, they could also be such a preoccupation that actual social relationships are neglected. The "network" itself could become a meaningless connection of distant acquaintances, yet the preoccupied individual may believe that expanding the network further is a valid solution to this problem. This is not unlike various neurotic social behaviours that exist outside of modern technology: people have always had collections of social behaviours which they believed to be useful, but in fact caused increased social distance & loneliness (e.g. vain behaviours, talking a lot without listening, etc.).
The thing that I believe distinguishes addictions to modern technology from other types of addiction is that many individuals are unquestioningly adopting the technologies as major parts of their daily lives, without being aware of the addictive potential, and without maintaining balance in other parts of life. While everything in life can be addictive, we have a greater understanding of non-technological addiction, since these phenomena have developed more slowly over past decades or centuries. New technology is changing personal culture so rapidly that we may have little chance to understand the risks before the addictiveness is quite entrenched in many people.
So, in conclusion, I do not believe that modern technology, including internet, TV, or video games, are necessarily "bad." They may in fact be wonderful, life-enhancing joys which improve happiness, culture, relationships, and connectedness. Yet they have a high risk to be addictive. I do not believe most people understand the degree of risk involved. I encourage people, in the meantime, to choose wisely when using technology, or when doing supposedly "good" activities such as those listed above, perhaps using the following questions:
1) am I doing this just out of a habit, because of boredom, or as part of procrastinating?
2) is this activity enhancing my life, or is it just gobbling up some of my time and attention?
3) is this activity improving my community, or is it distracting energy away from healthy community?
4) is this activity causing me physical harm, due to lack of exercise, or physical overuse?
5) is this activity consistent with my core values?
6) if it is consistent, is it really helping realize those core values?
7) is the activity itself causing my core values to change in an unwelcome way?
8) is the activity distracting energy or time away from other activities (such as learning, developing a talent, practicing a creative art, developing social relationships) which are important to personal culture?
9) do I have boundaries around this activity, in terms of time & energy, that protect my health?
References & Further Reading:
http://www.ncbi.nlm.nih.gov/pubmed/19818048
{this is a 2009 study by Kira Bailey et al., giving a good review of data concerning video gaming & cognitive variables; they discuss their own study, which leads to the following conclusion:
"these data may indicate that the video game experience is associated with a decrease in the efficiency of proactive cognitive control that supports one’s ability to maintain goal-directed action when the environment is not intrinsically engaging." In other words, video gaming may lead to an ADHD-like phenomenon}
http://www.ncbi.nlm.nih.gov/pubmed/18506602
{a useful review of the subject of technological advancements, in this case specifically regarding gambling technology, looking at whether these advancements constitute increased addictive risk, and if technology to reduce addictive risk is effective. The promise is that the technology itself could evolve--if it is the will of individuals and manufacturers to permit this evolution--to become safer, healthier, and less prone to foster addictive behaviour}
http://www.ncbi.nlm.nih.gov/pubmed/19805713
{this 2-year prospective study of adolescents shows that ADHD, depression, social phobia & hostility symptoms are risk factors for developing internet addiction}
http://www.ncbi.nlm.nih.gov/pubmed/19701792
{one of many associational studies correlating negative mood & internet/gaming addiction; unfortunately, associational studies are very weak, and do not really answer the question for us of how internet/gaming affects people, since we do not see the directions or strengths of causation}
http://www.ncbi.nlm.nih.gov/pubmed/19490510
{a study showing a strong association between addictive internet use and excessive daytime sleepiness}
http://www.ncbi.nlm.nih.gov/pubmed/16634979
{a study associating TV & computer use with sedentary behavior in 5-year-olds}
http://www.ncbi.nlm.nih.gov/pubmed/19428410
{one of the studies showing enhanced visual attentional skills in video gamers. But I find this a severely limited study which should not be over-interpreted--basically it shows that if you play video games, you become more skilled at a visual attention test that resembles the video games you've been playing. It says nothing about general intelligence, social skills, verbal aptitude, etc. which may well have atrophied in the video gamers}
http://www.ncbi.nlm.nih.gov/pubmed/18929349
{a more extensive analysis of cognitive skills in relation to video game playing. But, astonishingly, no cognitive tests were given to assess verbal skills, social skills, etc.; rather the tests were all related to things that seemed to me quite similar to video game tasks--so it is no surprise that the video gamers performed modestly better on some of these! No surprise that playing 1000 hours of Tetris probably will help you mentally rotate 3-d shapes more easily! But at what cost to other social, emotional, and intellectual skills? We need to have prospective studies that do very broad cognitive and psychological evaluations following prolonged exposure to different types of video games. The evaluations must include assessments of emotional state, verbal & non-verbal attention, memory, and reasoning; and they should include assessments of "social intelligence" such as establishing appropriate social communication, empathy, recognition of emotions, etc.}
http://www.ncbi.nlm.nih.gov/pubmed/19016226
{a 30-month longitudinal study showing increased aggression and hostile attribution bias in those exposed to violent video games}
http://www.ncbi.nlm.nih.gov/pubmed/19127289
{here's a description of an interesting psychotherapeutic application for a video game: in this study, those who played Tetris after watching a disturbing film had fewer flashback symptoms afterwards; it may encourage a tactic of treating those who have recently experienced a traumatic event with cognitive distraction, in order to reduce involuntary intrusive emotional memory of the trauma, and therefore to reduce the chance of developing PTSD. The deliberate, voluntary memory of the traumatic scene was unaffected.}
http://www.ncbi.nlm.nih.gov/pubmed/16972829
{an example of using video games to reduce pre-operative anxiety in young children. This sounds like a great idea, which could improve comfort while minimizing medication use in this type of situation.}
http://www.liebertpub.com/products/product.aspx?pid=10
{this is a link to a fairly new journal called "CyberPsychology & Behavior", which looks interesting and pertinent}
Almost any human activity can be addictive, in a harmful way. That is, the activity could provide a mental reward which leads to the following pattern:
- the activity happens more frequently
- tolerance develops
- increased absorption with the activity develops, in order to achieve the same or greater reward
- other activities feel more boring or unrewarding
- other activities & relationships are neglected
- physical harm may result from sleep deprivation, sedentary behaviour, repetitive strain, reduced self-care, etc.
- social harm may result from relationship neglect or isolation, but also from associating with a cohort of fellow "addicts" who do the same behaviours
- the "mental reward" could probably correlate with functional brain imaging demonstrating increased activity of central dopaminergic reward circuits
Many "good" activities could lead to an addictive pattern. Here's a list of possible activities that can potentially become addictive in this sense:
1) work
2) earning money
3) studying
4) hobbies
5) house chores
6) talking or texting on phones or other electronic devices
7) being in the company of people, or of a particular person
8) sports (playing or watching)
9) reading
10) pursuing excellence
Sometimes, behaviours or thoughts associated with depression or low self-esteem can be "addictive", in that some people may feel a type of masochistic reward from them.
Individuals may not recognize the unhealthy or addictive components of their behaviours. For a person wanting to earn more money, or pursue more excellence, it may seem absurd, and contrary to that person's values, to consider backing away from these pursuits.
For the person "pursuing excellence," it may be true that pouring more time and energy into training might increase achievement in a short-term sense. But this is the addictive trap. In order to pursue excellence in the most effective way, a balanced lifestyle is necessary. In order to achieve that balanced lifestyle, that person may paradoxically need to back away from their immediate pursuit.
I think that all types of modern technology have the potential to be addictive.
Technology and technological culture are changing at an unprecedented pace. And the technologies have ever more powerful and subtle ways to capture our interest, attention, and to stimulate neural reward.
All technological inventions have become addictive for some people. Yet most of these inventions have also contributed to an evolution of modern culture, which has been positive in many ways.
The internet, TV, and video games can all be stimulating, educational activities, which could enhance brain function, intelligence, and could lead to improved social relationships. They could be devices which improve relatedness rather than foster alienation.
Some of these technologies may permit an individual with problems such as a social skills difficulty to explore social connectedness in a different way. In this way, the internet can be an expansion of human connectedness and community. It is a technology which continues the trend of increased potential connectedness through human history. Thousands of years ago, it would have been hard to meet anyone who lived any farther away than the next village. While many individuals would have thrived socially in isolated village culture, some individuals would have been alienated.
Yet technological devices can be easily addictive. And the huge availability of choice in modern technology may permit an individual to find a particular thing that absorbs attention, and disappear into that activity while general physical, social, and mental health deteriorates. There is also a lot of choice available that has violent content, or which creates only an illusion of connection, while none really exists. Facebook or other social connection applications can become preoccupations for many people. While such sites could facilitate social connection, they could also be such a preoccupation that actual social relationships are neglected. The "network" itself could become a meaningless connection of distant acquaintances, yet the preoccupied individual may believe that expanding the network further is a valid solution to this problem. This is not unlike various neurotic social behaviours that exist outside of modern technology: people have always had collections of social behaviours which they believed to be useful, but in fact caused increased social distance & loneliness (e.g. vain behaviours, talking a lot without listening, etc.).
The thing that I believe distinguishes addictions to modern technology from other types of addiction is that many individuals are unquestioningly adopting the technologies as major parts of their daily lives, without being aware of the addictive potential, and without maintaining balance in other parts of life. While everything in life can be addictive, we have a greater understanding of non-technological addiction, since these phenomena have developed more slowly over past decades or centuries. New technology is changing personal culture so rapidly that we may have little chance to understand the risks before the addictiveness is quite entrenched in many people.
So, in conclusion, I do not believe that modern technology, including internet, TV, or video games, are necessarily "bad." They may in fact be wonderful, life-enhancing joys which improve happiness, culture, relationships, and connectedness. Yet they have a high risk to be addictive. I do not believe most people understand the degree of risk involved. I encourage people, in the meantime, to choose wisely when using technology, or when doing supposedly "good" activities such as those listed above, perhaps using the following questions:
1) am I doing this just out of a habit, because of boredom, or as part of procrastinating?
2) is this activity enhancing my life, or is it just gobbling up some of my time and attention?
3) is this activity improving my community, or is it distracting energy away from healthy community?
4) is this activity causing me physical harm, due to lack of exercise, or physical overuse?
5) is this activity consistent with my core values?
6) if it is consistent, is it really helping realize those core values?
7) is the activity itself causing my core values to change in an unwelcome way?
8) is the activity distracting energy or time away from other activities (such as learning, developing a talent, practicing a creative art, developing social relationships) which are important to personal culture?
9) do I have boundaries around this activity, in terms of time & energy, that protect my health?
References & Further Reading:
http://www.ncbi.nlm.nih.gov/pubmed/19818048
{this is a 2009 study by Kira Bailey et al., giving a good review of data concerning video gaming & cognitive variables; they discuss their own study, which leads to the following conclusion:
"these data may indicate that the video game experience is associated with a decrease in the efficiency of proactive cognitive control that supports one’s ability to maintain goal-directed action when the environment is not intrinsically engaging." In other words, video gaming may lead to an ADHD-like phenomenon}
http://www.ncbi.nlm.nih.gov/pubmed/18506602
{a useful review of the subject of technological advancements, in this case specifically regarding gambling technology, looking at whether these advancements constitute increased addictive risk, and if technology to reduce addictive risk is effective. The promise is that the technology itself could evolve--if it is the will of individuals and manufacturers to permit this evolution--to become safer, healthier, and less prone to foster addictive behaviour}
http://www.ncbi.nlm.nih.gov/pubmed/19805713
{this 2-year prospective study of adolescents shows that ADHD, depression, social phobia & hostility symptoms are risk factors for developing internet addiction}
http://www.ncbi.nlm.nih.gov/pubmed/19701792
{one of many associational studies correlating negative mood & internet/gaming addiction; unfortunately, associational studies are very weak, and do not really answer the question for us of how internet/gaming affects people, since we do not see the directions or strengths of causation}
http://www.ncbi.nlm.nih.gov/pubmed/19490510
{a study showing a strong association between addictive internet use and excessive daytime sleepiness}
http://www.ncbi.nlm.nih.gov/pubmed/16634979
{a study associating TV & computer use with sedentary behavior in 5-year-olds}
http://www.ncbi.nlm.nih.gov/pubmed/19428410
{one of the studies showing enhanced visual attentional skills in video gamers. But I find this a severely limited study which should not be over-interpreted--basically it shows that if you play video games, you become more skilled at a visual attention test that resembles the video games you've been playing. It says nothing about general intelligence, social skills, verbal aptitude, etc. which may well have atrophied in the video gamers}
http://www.ncbi.nlm.nih.gov/pubmed/18929349
{a more extensive analysis of cognitive skills in relation to video game playing. But, astonishingly, no cognitive tests were given to assess verbal skills, social skills, etc.; rather the tests were all related to things that seemed to me quite similar to video game tasks--so it is no surprise that the video gamers performed modestly better on some of these! No surprise that playing 1000 hours of Tetris probably will help you mentally rotate 3-d shapes more easily! But at what cost to other social, emotional, and intellectual skills? We need to have prospective studies that do very broad cognitive and psychological evaluations following prolonged exposure to different types of video games. The evaluations must include assessments of emotional state, verbal & non-verbal attention, memory, and reasoning; and they should include assessments of "social intelligence" such as establishing appropriate social communication, empathy, recognition of emotions, etc.}
http://www.ncbi.nlm.nih.gov/pubmed/19016226
{a 30-month longitudinal study showing increased aggression and hostile attribution bias in those exposed to violent video games}
http://www.ncbi.nlm.nih.gov/pubmed/19127289
{here's a description of an interesting psychotherapeutic application for a video game: in this study, those who played Tetris after watching a disturbing film had fewer flashback symptoms afterwards; it may encourage a tactic of treating those who have recently experienced a traumatic event with cognitive distraction, in order to reduce involuntary intrusive emotional memory of the trauma, and therefore to reduce the chance of developing PTSD. The deliberate, voluntary memory of the traumatic scene was unaffected.}
http://www.ncbi.nlm.nih.gov/pubmed/16972829
{an example of using video games to reduce pre-operative anxiety in young children. This sounds like a great idea, which could improve comfort while minimizing medication use in this type of situation.}
http://www.liebertpub.com/products/product.aspx?pid=10
{this is a link to a fairly new journal called "CyberPsychology & Behavior", which looks interesting and pertinent}
Tuesday, October 20, 2009
"Positive Psychotherapy" (PPT) for depression
This post is a continuation of my earlier post on the psychology of happiness. I'm trying to look at each of the references in more detail.
PPT (positive psychotherapy) is a technique described in a paper by Seligman et al. Here's a reference, from American Psychologist in 2006:
http://www.ncbi.nlm.nih.gov/pubmed/17115810
In this paper the technique was tested on two groups. The more important finding concerns the application of PPT with severely depressed adults. PPT was compared with "treatment as usual" (mainly supportive therapy), and "treatment as usual plus antidepressant". The trial lasted 12 weeks, and there was follow-up over 1 year.
The PPT group showed significant improvement in depression scores, and significantly increased happiness, compared to the two control groups.
More controlled studies need to be done on the technique, but in the meantime, the ideas are simple, valuable, potentially enjoyable, and easily incorporated into other therapy styles such as CBT. Here are some of the exercises recommended in PPT, as described in the paper mentioned above:
1) Write a 300-word positive autobiographical introduction, which includes a concrete story illustrating character strengths
2) Identify "signature strengths" based on exercise (1), and discuss situations in which these have helped. Consider ways to use these strengths more in daily life
3) Write a journal describing 3 good things (large or small) that happen each day
4) Describe 3 bad memories, associated anger, and their impact on maintaining depression (this exercise to be done just once or a few times, not every day)
5) Write a letter of forgiveness describing a transgression from the past, with a pledge to forgive (the letter need not be actually sent)
6) Write a letter of gratitude to someone who was never properly thanked
7) Avoiding an attitude of "maximizing" as a goal, rather focusing on meaningfully engaging with what is enough (i.e. avoiding addictive hedonism, in terms of materialism or achievement). The authors use the term "satisficing", which led me to look this word up--here's a good article I found: http://en.wikipedia.org/wiki/Satisficing). I think this idea is really important for those of us who are very perfectionistic or who have very specific, fixed standards for the way they believe life should be, and who therefore feel that real life is always lagging behind these expectations or requirements, or that real life could at any moment crash into a state of failure.
8) Identification of 3 negative life events ("doors closed") which led to 3 positives ("doors opened").
9) Identification of the "signature strengths" of a significant other.
10) Give enthusiastic positive feedback to positive events reported by others, at least once per day
11) Arrange a date to celebrate the strengths of oneself and of a significant other
12) Analyze "signature strengths" among family members
13) Plan and engage with a "savoring" activity, in which something pleasurable is done, with conscious attention given to how pleasurable it is, and with plenty of time reserved to do it
14) "Giving a gift of time" by contributing to another person, or to the community, a substantial amount of time, using one of your signature strengths. This could include volunteering.
Here's a link to a blog devoted to positive psychology techniques:
http://blog.happier.com/
This blog is connected to a site in which they want you to sign up and pay for a membership. I'm always a bit jarred when an altruistic psychotherapeutic system is marketed for financial profit. Would it not be more satisfying to everyone to offer this for free? Also I think the photograph of an ecstatic woman in a flowery meadow is a bit over-the-top as advertising for the site. I find the marketing excessively aggressive, it looks like an infomercial. Some of this stuff could really be off-putting to weary, understandably cynical individuals with chronic depression who have tried many other types of therapy already. And there can be a sort of religious fervor among enthusiastic adherents of a new technique, which can skew reason.
Yet, these ideas are worth looking at. And I certainly agree that in psychiatry, and in therapy, we often focus excessively on the negative side of things, and do not attend enough to nurturing the positive.
PPT (positive psychotherapy) is a technique described in a paper by Seligman et al. Here's a reference, from American Psychologist in 2006:
http://www.ncbi.nlm.nih.gov/pubmed/17115810
In this paper the technique was tested on two groups. The more important finding concerns the application of PPT with severely depressed adults. PPT was compared with "treatment as usual" (mainly supportive therapy), and "treatment as usual plus antidepressant". The trial lasted 12 weeks, and there was follow-up over 1 year.
The PPT group showed significant improvement in depression scores, and significantly increased happiness, compared to the two control groups.
More controlled studies need to be done on the technique, but in the meantime, the ideas are simple, valuable, potentially enjoyable, and easily incorporated into other therapy styles such as CBT. Here are some of the exercises recommended in PPT, as described in the paper mentioned above:
1) Write a 300-word positive autobiographical introduction, which includes a concrete story illustrating character strengths
2) Identify "signature strengths" based on exercise (1), and discuss situations in which these have helped. Consider ways to use these strengths more in daily life
3) Write a journal describing 3 good things (large or small) that happen each day
4) Describe 3 bad memories, associated anger, and their impact on maintaining depression (this exercise to be done just once or a few times, not every day)
5) Write a letter of forgiveness describing a transgression from the past, with a pledge to forgive (the letter need not be actually sent)
6) Write a letter of gratitude to someone who was never properly thanked
7) Avoiding an attitude of "maximizing" as a goal, rather focusing on meaningfully engaging with what is enough (i.e. avoiding addictive hedonism, in terms of materialism or achievement). The authors use the term "satisficing", which led me to look this word up--here's a good article I found: http://en.wikipedia.org/wiki/Satisficing). I think this idea is really important for those of us who are very perfectionistic or who have very specific, fixed standards for the way they believe life should be, and who therefore feel that real life is always lagging behind these expectations or requirements, or that real life could at any moment crash into a state of failure.
8) Identification of 3 negative life events ("doors closed") which led to 3 positives ("doors opened").
9) Identification of the "signature strengths" of a significant other.
10) Give enthusiastic positive feedback to positive events reported by others, at least once per day
11) Arrange a date to celebrate the strengths of oneself and of a significant other
12) Analyze "signature strengths" among family members
13) Plan and engage with a "savoring" activity, in which something pleasurable is done, with conscious attention given to how pleasurable it is, and with plenty of time reserved to do it
14) "Giving a gift of time" by contributing to another person, or to the community, a substantial amount of time, using one of your signature strengths. This could include volunteering.
Here's a link to a blog devoted to positive psychology techniques:
http://blog.happier.com/
This blog is connected to a site in which they want you to sign up and pay for a membership. I'm always a bit jarred when an altruistic psychotherapeutic system is marketed for financial profit. Would it not be more satisfying to everyone to offer this for free? Also I think the photograph of an ecstatic woman in a flowery meadow is a bit over-the-top as advertising for the site. I find the marketing excessively aggressive, it looks like an infomercial. Some of this stuff could really be off-putting to weary, understandably cynical individuals with chronic depression who have tried many other types of therapy already. And there can be a sort of religious fervor among enthusiastic adherents of a new technique, which can skew reason.
Yet, these ideas are worth looking at. And I certainly agree that in psychiatry, and in therapy, we often focus excessively on the negative side of things, and do not attend enough to nurturing the positive.
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