Rating Scales: limitations & ideas for change

A visitor's comment from one of my previous posts reminded me of an issue I'd thought about before.

In mental health research, symptom scales are often used to measure therapeutic improvement. In depression, the most common scales are the Hamilton Depression Rating Scale (HDRS), the Montgomery-Ashberg Depression Rating Scale (MADRS), or sometimes the Beck Depression Inventory (BDI). The first two examples involve an interviewer assigning a score to a variety of different symptoms or signs. The last example is a scale which is filled out by a patient.

Here are examples of questions from the HDRS, with associated ranges of scoring:
depressed mood (0-4); decreased work & activities (0-4); social withdrawal (0-4); sexual symptoms (0-2); GI symptoms (0-2); weight loss (0-2); weight gain (0-2); appetite increase (0-3); increased eating (0-3); carbohydrate craving (0-3); insomnia (0-6); hypersomnia (0-4); general somatic symptoms (0-2); fatigue (0-4); guilt (0-4); suicidal thoughts/behaviours (0-4); psychological manifestations of anxiety (0-4); somatic manifestations of anxiety (0-4); hypochondriasis (0-4); insight (0-2); motor slowing (0-4); agitation (0-4); diurnal variation (0-2); reverse diurnal variation (0-3); depersonalization (0-4); paranoia (0-3); OCD symptoms (0-2)

One can see from this list that depressive syndromes which have many physical manifestations will obviously score much higher. The highest possible score on the 29-item HDRS is 89. It is likely that physical manifestations of acute depression resolve more quickly, particularly in response to medications. Therefore, the finding that more severe depressions have better response to medication could be simply an artifact of the fact that physical symptoms respond better and more quickly to physical treatments.

A person who is eating and sleeping poorly, is tired, feels and looks physically ill, who is not working, who is not seeing friends as much, and whose symptoms fluctuate in the day, would already get an HDRS score of up to 30 -- without actually feeling depressed or anxious at all! A person feeling very depressed, struggling through life with little pleasure, meaning, satisfaction, or joy -- but sleeping ok, eating ok, and forcing self through daily routines such as work, social relationships, etc. -- might only get a score of 4-6 on this scale.

I acknowledge that the many questions on the HDRS cover a variety of important symptom areas, and improvement in any one of these domains can be very significant.

But -- a big problem of the scale, for me, is that the relative significance of the different symptoms is arbitrarily fixed by the structure of the questionnaire. So, for example, are the 4 points for fatigue of equivalent importance to the 4 points for guilt, or social withdrawal, or depressed mood? Would different individuals rate the relative importance of these symptoms differently? Maybe some people might prefer to sleep better, rather than socialize with greater ease. Also, perhaps some of the symptom questions deserve to be "non-linear," or context-dependent. So, for example, perhaps mild or intermittent depressed mood might deserve a score of only "1". Moderately depressed mood might warrant a score of "5". Severe depressive mood might warrant a score of "20". Or, relentless moderate symptoms over a period of years might warrant a score of "20", while only short-term or episodic moderate symptoms might warrant a score of "5".

It would be interesting to change the weighting of these symptom scores, on an individualized basis.

Also, it would be interesting to see the results of depression treatment studies portrayed with all the separate symptom categories broken down (i.e. to see how the treatment changed each item on the HDRS). Many researchers or statisticians would complain that to portray, or make conclusions, about so many results at once, would reduce the statistical significance. Statistically, a so-called "Bonferroni correction" is necessary if multiple hypotheses are being made simultaneously: if n hypotheses are made, the statistical significance is reduced by a factor of 1/n. Based on this statistical idea, most researchers prefer to analyze just a single quantity, such as the HDRS score, instead of looking at each component of the score separately.

But, this analysis dilutes the data from any study, in the same way that the analysis of artworks in a museum would be diluted if each piece were summarized only by its mass or area.

A more complete analysis would portray every category at once. A graphical presentation would be reasonable, perhaps taking the form of a 3-d surface (once again). The x-axis could represent the different symptom areas (or scores on each item on the HDRS); the y-axis could represent time; and the z-axis could represent the severity. With this analysis, we could say that we are not actually making n hypotheses--we are making a single hypothesis, that the multifactorial pattern of symptom results, manifest as a 3-d surface, is changing over time. Each individual patient's symptom changes, in every symptom category, could be represented on the graph. In this way, no data, or analytic possibility, would be lost or diluted. The reader would be able to inspect every part of the data from the study, and perhaps notice interesting relationships which the original researchers had not considered.

Some patterns of change with different treatment could present in the following ways, as shown in such as 3-d surface:
1) some symptoms improve dramatically with time, while others are much slower to change, or don't change at all. In depression treatment studies, sleep or appetite might change very quickly with a potent antihistaminic drug...this would immediately lead to pronounced improvement on the overall HDRS score, but might not be associated with any significant improvement in mood, energy, concentration, etc.
2) some symptoms might improve immediately, but deteriorate right back to baseline or worse after a few weeks or months. Benzodiazepine treatment would produce such as pattern, in terms of sleep or anxiety improvement. A medication which is sedating but addictive might cause rapid HDRS improvement, but only a careful look at individual category changes over a long period of time would allow us to see the addiction/tolerance pattern. Some people drink alcohol to treat their anxiety symptoms -- such a behaviour might rapidly improve their HDRS scores! But of course, the scores would return to worse than baseline within a few weeks or months. And the person would probably have new symptoms and problems on top of their original ones. So, we must be cautious about getting too excited about claims of rapid HDRS change!
3) some treatments might cause a global change in most or all symptoms...this would be the goal of most treatment strategies. Such a pattern would imply that the multi-symptom syndrome (in this case, the "major depressive disorder" construct) is in fact valid, all components of which improving together with a single treatment.
4) some combined treatments might work well together...for example, a treatment which helps substantially with energy or concentration (such as a stimulant), together with a treatment which helps with mood, socialization, optimism, or anxiety (such as psychotherapy, or an antidepressant). These treatments on their own might appear to be equivalent if only the total HDRS score is considered (since each would reduce symptom points overall); the synergistic effect would only be apparent by looking at each symptom domain separately.

Finally, I think it is important to look at very broad, simple indicators of quality of life, or of general improvement. The "CGI" scale is one example, although it is awkward and imprecise in design, and most likely prone to bias.

Quality of life scales are important as well, in my opinion, since they look at overall satisfaction with life, rather than merely a collection of symptoms.

In practice, only a discussion with the person receiving the treatment can really assess whether it is worthwhile to continue the treatment or not. In such a discussion, the subjective pros and cons of the treatment can be weighed. Even if the treatment has had a minimal impact on a rating score, it might be subjectively beneficial to the person receiving it. And even if the treatment has produced large rating score changes, it might not be the person's preference to continue. I suppose the role of a prescriber is mainly to facilitate such a dialog, and contradict the patient's wishes only if the treatment is objectively causing harm.

Health benefits of dietary nut intake

Dietary nut intake is strongly associated with a variety of health benefits, particularly a lower risk of developing cardiovascular disease. Here is a link to a recent review of the subject:
http://www.ncbi.nlm.nih.gov/pubmed/19321572

This 2009 article describes a carefully controlled, inpatient, 4-day randomized study in which subjects were given a breakfast containing walnuts; or a "placebo" breakfast containing the same number of calories, and the same amount of carbs & fat, but no walnuts. The results showed that a breakfast containing walnuts leads to a significantly greater feeling of satiation (contentment and satisfaction with respect to food), at lunchtime:
http://www.ncbi.nlm.nih.gov/pubmed/19910942

Therefore, eating walnuts, as part of a balanced diet, is likely to maintain a feeling of satiation, and therefore reduce some of the physiological drives which can contribute to unhealthy eating behaviours.

This is a reference to a large prospective study of over 50 000 women followed over 8 years. The results included a multivariate analysis controlling for many other factors, such as physical activity, smoking, other dietary habits, etc. There was a slight reduction in weight gain or obesity in those who included more nuts in their diet, and in fact the more frequent the nut intake, the lower the risk of obesity:
http://www.ncbi.nlm.nih.gov/pubmed/19403639

With respect to mental health, I think that a balanced, healthy diet is important. Lifestyle habits, including nutritional choices, which reduce risk of cardiovascular disease, are likely also to reduce risk of degenerative brain disease. Walnuts are a source of omega-3 fatty acids, for which there is modest evidence of beneficial effects on mood.

Treatment of eating disorders requires deliberate attention to healthy, regular nutritional habits. Many individuals with eating disorders exclude certain types of food from their diets, based on an unfounded belief that the exclusion would lead to improved control of appetite or caloric intake.

Nuts in particular clearly deserve to be part of a healthy diet, unless there are issues such as food allergy.

Antidepressants only effective in severest depression?

A recent article in JAMA by Fournier et al. is a meta-analysis of antidepressant treatment effects assessed in relation to depression severity. Here's the reference:
http://www.ncbi.nlm.nih.gov/pubmed/20051569

The results show that antidepressants work significantly well, compared to placebo, only for very severe depression (corresponding to Hamilton Depression Rating Scale scores of at least 25).

The analysis is quite well-done, and the results are also presented in a graphical form clearly showing a linear increase in antidepressant effect as baseline depression scores increase.

The authors observe that antidepressants are most commonly prescribed to people who have milder depressions--a population in which they show that medications arguably do not work.

Here are a few of my criticisms of this study:

1) the duration of each trial included in the meta-analysis was between 6 and 11 weeks. In my opinion, depressive disorders are long-term, highly recurrent problems, which have a natural period over at least 6-11 months, not 6-11 weeks. Treatments to address mood disorders of any severity require much longer durations. The short duration could cause a significant under-estimation of treatment effects.

2) the study, like many, looks at "depression alone." In most real-life situations, outside of a research study, individuals have several different problems, such as mild depression + social anxiety, or mild depression + panic attacks, etc. The presence of other symptoms, particularly anxiety symptoms, most likely would increase the likelihood of antidepressants helping.

3) Milder depressions, just like more severe depressions, may actually improve more consistently with a "second step" such as combination with psychotherapy, or combining two different antidepressants. The mildness of a medical syndrome does not necessarily mean that the effective treatments need only to be "mild."

4) Milder depressive syndromes may be more prone to misdiagnosis.

5) current "resolution" to measure treatment effects in depression is quite poor. "Depression" is a very broad category. An analogy could be considering "abdominal pain" to be a diagnostic category. If "abdominal pain" is the only category, and is simply rated on a severity scale (rather than subcategorized to obtain a precise diagnosis), and the treatment offered for "abdominal pain" is appendectomy, then we would probably see no difference in treatment effectiveness between appendectomy and placebo. This is because appendectomy is only effective to treat appendicitis (a subset of the abdominal pain population), and is either ineffective or harmful in treating abdominal pain patients without appendicitis (except, perhaps, for those patients who have a placebo improvement of psychosomatic or factitious abdominal pain, an improvement which they attribute to having surgery).

We currently do not have the science to subcategorize depression in a more clinically meaningful way (there are subcategorization schemes, but they don't have much relevance in terms of treatment).

But we do have a research method which could improve "resolution":
-instead of comparing two populations of depressed individuals, one group receiving antidepressant (or some other treatment), and the other receiving placebo (or some other alternative), the study design could instead be to offer every individual courses of placebo, alternating with antidepressant (or "treatment one" alternating with "treatment two"). Each course of treatment would have to last an adequate length of time. The analysis would aim to show whether there is a subset of individuals who respond to the antidepressant, or a subset of individuals who do better with placebo. The averaged results over the whole group might show that antidepressant effects do not differ from placebo (just like appendectomy might not differ from placebo in treating "abdominal pain"), but the individualized result could show that some individuals improve substantially with the antidepressant (just like appendectomy would save the lives of the small group of "abdominal pain" patients who have appendicitis).

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In the meantime, though, I think it is reasonable to recognize that antidepressants are less consistently helpful when symptoms are less severe.

A Gene-Environment-Phenotype Surface

I've been thinking of a way to describe the interaction between genes, environment, and phenotype qualitatively as a mathematical surface.

In this model, the x-axis would represent the range of genetic variation relevant to a given trait. If it was a single gene, the x-axis could represent all existing gene variants in the population. Or, the idea could be extended such that the x-axis could represent all possible variants of the gene (including the absence of the gene, represented as "negative infinity" on the x-axis). The middle of the x-axis (x=0) would represent the average expression of the relevant gene in the population.

The y-axis would represent the range of environmental variation relevant to a given trait. y=0 would represent the average environmental history in the population. y="negative infinity" would represent the most extreme possible environmental adversity. y="positive infinity" would represent the most extreme possible environmental enrichment.

The z-axis would represent the phenotype. For example, it could represent height, IQ, extroversion, conscientiousness, etc.

In my opinion, current expressions of "heritability" represent something like the partial derivative dz/dx at x=0 and y=0; or perhaps, since the calculation is based on a population sample, heritability would be the average of derivatives dz/dx over various sampled (x,y) points near x=0 and y=0.

Conventional heritability calculations give a severely limited portrait of the role of genes on phenotype, since it condenses the information from what is really a 3-dimensional surface into a single number (the heritability). This is like looking at a sculpture, then being told that the sculpture can be represented by a single number such as "0.6", based on the average tilt on the top centre of the artwork.

A more comprehensive idea of heritability would be to consider that it is the gradient, a component of which is dz/dx. This gradient would not be a fixed quantity, but could be considered a function of x and y.

It is particularly interesting to me to consider other properties of this surface, such as what is the derivative dz/dy at different values of y and x? This would determine the ease with which environmental change could change a phenotype regardless of genotype.

A variety of different shapes for this surface could occur:

1) z could plateau (asymptotically) as y approaches infinity. This implies that the phenotype could not be changed beyond a certain point, regardless of the degree of environmental enrichment.
2) z could appear to plateau as y increases, but this is only because we do not yet have existing environments y>p, where p is the best current enriched environment. It may be that z could increase substantially at some point y>j, where j>p. I believe this is the case for most medical and psychiatric problems. It implies that we must develop better environments. Furthermore, it may be that for some genotypes (values of x), z plateaus as y increases, but for other genotypes z changes more dynamically. This implies that some people may inherit greater or lesser sensitivity to environmental change.
3) dz/dx could be very high near the origin (x,y)=(0,0), leading to a high conventional estimate of heritability; but at different values of (x,y), dz/dx could be much smaller. Therefore, it may be that for some individual genomes or environmental histories, genetic effects may be much less relevant, despite what appears to be "high heritability" in a trait.
4) dz/dx could be very low near the origin, but much higher at other values of (x,y). Therefore, despite conventional calculations of heritability being low, there could be substantial genetic effects on phenotype for individuals with genotypes or environmental histories which are farther from the population mean.

The idea of x itself being fixed in an individual may also not be entirely accurate, since we now know of epigenetic effects. Also, evolving technology may allow us to change x therapeutically.

In order to describe such a "surface", many more data points would need to be analyzed, and some of these might be impossible to obtain in the current population.

But I think this idea might qualitatively improve our understanding of gene-environment interaction, in ways that could have practical applications (current heritability estimates are typically 0.5 for almost anything you can think of--this fact seems intuitively obvious, but is not very helpful to inspire therapy or change, can sometimes increase a person's sense of resignation about the possibility of therapeutic change, and can distort understanding about the relative impacts of genes and non-genetic environment).

Non-human Primate Models of Psychiatric Treatment Effects

Before starting the main body of my post, here's a little introduction:

I've been doing quite a bit of reading lately about the history of psychiatry (in particular, an excellent book by Lisa Appignanesi; I'll write a post about it when I've finished, which could be in a while, since the book is 5 cm thick!). Also I've been reading about cultural psychology (another very interesting field), after finding a free set of university lecture notes published online. I'd like to write another post about this subject as well, when I get around to it.

What does this have to do with "non-human primate models of psychiatric treatment effects?" Well, I'm becoming more strongly aware of the powerful effects of culture upon the manifestations of psychological (and, possibly, physical) health and distress. The book I'm reading deals with cultural change through history; these changes have influenced the presentation, management, and course of many psychiatric phenomena. Even terms like "psychiatric phenomena" or "symptoms," etc. are culturally influenced jargon. The cultural psychology subject also deals, of course, with cultural differences, but in this case mainly with the way different groups of people in the present era around the world experience or perceive emotions, psychological distress, social interactions, or cognitive processes. I suspect that cultural differences may exist between families as well, within the same geographical area.

These factors complicate the study of psychiatric therapies, perhaps in many ways that could be subtle but powerful.

I've been interested in finding more evidence about the effect of physical and psychological treatments for psychiatric symptoms in non-human primates. In this case, cultural or personal history biases could be much more carefully controlled.

There are a lot of studies done in rodents, of behavioural therapies and of medication, including a very questionable rodent "model" of antidepressant effectiveness. I think that possible conclusions are much more limited, about human therapies based on research done in mice, etc.

Monkeys or apes are much closer to humans, in terms of genetic similarity and brain structure. They may exhibit behavioural problems that are much more closely analogous to psychiatric symptoms in humans. So, I have been looking for good research about medication and "psychotherapy" effects in primates. Here's a start:

http://www.ncbi.nlm.nih.gov/pubmed/19383215

This 2009 article describes self-injurious behaviour in rhesus macaques. These animals may bite themselves severely; this is thought to be due to an underlying vulnerability combined with social deprivation in infancy or being isolated in captivity. About one-third of macaques experiencing solitary captivity exhibit self-directed stereotypic behaviour. The behaviour is exacerbated by separation from the social group, by disruption of daily routines, or by exposure to a fear-provoking stimulus (for animals, this could be an unfamiliar person trying to interact with them closely). It is interesting to consider that analogous behaviours in humans are probably related to similar vulnerabilities, deprivations, or triggers.

The experiment described in the article is about treating these self-injuring monkeys. Each group started off with 4 weeks of baseline observation, followed by 4 weeks of placebo, before randomization to fluoxetine, venlafaxine, or placebo for the final 4 weeks.

The individuals in the fluoxetine groups, at higher doses in particular, had substantial reductions in self-injurious behaviour (at least 50-75% less self-injury than the placebo group). The venlafaxine group did not improve as much.

There were no changes in "general behaviour" aside from a reduction in "aggressive displays." In particular, there were no signs of sedation or reduced engagement, etc.

I don't mean to make too much of results of this type, but I do think that this is strong evidence that the effect of an SSRI is not simply of an elaborate active placebo, influenced by cultural expectation. Also, just because a symptom is reduced doesn't necessarily mean a problem is solved...however, reducing a problematic behaviour such as self-injury may be a necessary prerequisite to resolving other types of psychological problems.

This type of study would be strengthened if it was extended for a year or more, and if it was to include data about other "quality of life" indicators, such as social integration, longevity, physical health, etc.

Here's another study, showing that tryptophan administration over a 4-week period substantially decreased self-injurious behaviour (again, by 50-75%) in small monkeys. There was also a decrease in previously high levels of cortisol. The dose of tryptophan was over 100 mg/kg per day, which would be a bit inconvenient to administer to humans:
http://www.ncbi.nlm.nih.gov/pubmed/19383216

Here's another study of self-injury in macaques. In this case, housing the animals outdoors led to significant reductions in self-injury. I think the message here could be that a healthy environment which optimizes freedom of movement, space, and natural sensory cues (e.g. of light, sound, and temperature), leads to diminished stress and and diminished symptoms of psychological distress. We could confidently generalize this statement to humans, I think.
http://www.ncbi.nlm.nih.gov/pubmed/16995645

Here is a relevant review on the subject of self-injury in human vs. non-human primates:
http://www.ncbi.nlm.nih.gov/pubmed/16713051

Here's an amusing (and, unfortunately, not very strong) study showing that hearing music leads to increased affiliative behaviour and decreased aggressive behaviour in chimpanzees. There were different degrees of responsiveness to different types of music:
http://www.ncbi.nlm.nih.gov/pubmed/17203919


I'll try to add to this post later. In the "psychotherapy" realm, some of the first important animal studies in primates were done by Harlow. I'm interested to find some more recent stuff in the research literature. I guess there won't be much on cognitive therapy in monkeys, since there is a bit of a problem encouraging non-human primates to keep written diaries with thought records...similarly, psychoanalytic studies are probably in short supply (!) Yet, in all seriousness, I suspect that the key elements for successful therapy in non-human primates involve positive, gentle, consistent relationships; and gentle, non-punitive behavioural education & modeling.

Authoritative, Authoritarian, and Permissive Self-Parenting

Here's a nice summary of different parenting styles:
http://en.wikipedia.org/wiki/Parenting_styles

The authoritarian style is strict and dictatorial, with no dialog between parent & child.

The permissive or indulgent style is lenient, with little discipline or rules.

The authoritative style is balanced: there are clear rules, clear boundaries, which are consistently enforced, but lots of empathy, understanding, dialog, and flexibility. Strong consideration is given to the child's point of view.

I think these different styles could be applied to one's own individual mind -- I encourage aiming for a healthy, balanced, authoritative style.

Authoritarian styles will be oppressive, and foster resentment, unhappiness, anger, and rebellion within oneself (sometimes an "underground" rebellion manifesting itself as depressive self- harm).

Permissive styles could feel liberating, but could lead to an experience of drifting, with a lack of direction, without a feeling of growing or developing one's potential.

An authoritative style would lead to a healthy balance between freedom and self-discipline, allowing for growth, challenge, and happiness. It could also tame the wilder forces within your mind, not by suppressing them, but by hearing them and guiding them in a well-boundaried, safe context.

Becoming a "Self Whisperer"

Well, you may accuse me of having sentimental tastes in film, but I really did enjoy the 1998 movie with Robert Redford, called The Horse Whisperer. It's about a reclusive Montana rancher who has an almost mystical ability to gently connect with and rehabilitate horses (and humans?) who are wild, traumatized, or out-of-control.

Since 2002, a dog trainer named Cesar Millan has called himself "the dog whisperer," and has a TV show, website, and has sold millions of books. His approach is basically one of gentle, calm authority: maintaining clear and consistent boundaries without losing one's cool or becoming excessively punitive. Mind you, I see that there is a little bit of debate about some of his techniques. And it's a bit dicey to apply animal training ideas to humans.

Recently, however, people have been trying to generalize these ideas a little bit, to the subject of parenting. Hence the idea of becoming a "child whisperer." Many parents have unhelpful interactions with their children: perhaps there are behavioural or discipline problems, but often times the parents are losing their cool, the parents are resorting to excessive and ineffective punishments, or the parents are giving a lot of praise but without any discipline. Sometimes the timing of praise or discipline is out of synch with the child's behaviour. Some methods of discipline may be harmful to both child and parent. Sometimes misbehaving children seem to be ruling the house, leaving the parents frustrated and exhausted. An exhausted parent in this situation may end up just spending less and less time parenting, in order to find distractions from the problems, or in order to escape. While respite is necessary, this tactic would of course make the parent-child dynamics even worse.

Here's an article from the New York Times on this:
http://www.nytimes.com/2009/11/22/fashion/22dog.html

I would like to generalize this idea one step further, to consider ways to become a "self whisperer."

This may involve nurturing a sense of calm, gentle understanding and authority over the various forces within your own mind:

-in this sense exercises to relax or meditate need not be considered exercises in tolerating an unhealthy state, but rather exercises to produce a stance of calm, loving, gentle authority, which is ideal in "self-whispering."

-part of the process may involve setting very clear boundaries within your own mind, without becoming excessively punitive, bossy, critical, or authoritarian towards aspects of yourself or others. Various therapy styles can help in this sense, including cognitive-behavioural ideas. Methods of non-harmful self-discipline may need to be learned and practiced.

-it can be important to have "respite", but it will be important "to do activities together" with the more challenging aspects of your mind, to be an effective "self whisperer." There needs to be time for reflective, empathic dialog with self, provided there is a benevolent structure, healthy boundaries, and clear safety rules.

--I'll have to edit this posting a bit, I think it's in a formative stage right now, but I thought I'd put it up here as the start of an idea I found enchanting in the moment--

Physical Warmth promotes Interpersonal Warmth

In an amusing study by LE Williams and JA Bargh, published in Science in 2008, subjects exposed to warm objects behaved in a manner which was more interpersonally warm. Here is the reference:
http://www.ncbi.nlm.nih.gov/pubmed/18948544

In the first experiment described by the authors, subjects in the elevator on the way to the study lab were asked to hold an experimenter's drink cup for a moment, while the experimenter wrote some identifying information down on a clipboard. The experimenter in the elevator did not have knowledge of the study's hypotheses. In the study lab afterward, the subjects were given a brief written description of a person (the same description given to all subjects), and were asked to rate that person in terms of a variety of personality dimensions. The subjects who briefly had held a cup of hot coffee gave personality ratings that were significantly "warmer," compared to the subjects who had held a cup of iced coffee. The ratings for warmth were 4.71 out of 7 for the "hot coffee" group, compared to 4.25 out of 7 for the "iced coffee" group; these differed with a p value of 0.05. "Warmth" in this sense refers to traits such as friendliness, helpfulness, and trustworthiness.

The second experiment was more blinded, in that the experimenters did not know whether the subjects were handling a warm or cold object. This time, subjects were offered a choice of two types of gifts after the experiment: the first type would be for personal use, the second would be a gift for a friend. Those who had handled a warm object were substantially more likely to choose a gift for a friend, rather than for themselves.
Those who had handled a cold object chose a "selfish" gift 75% of the time.
Those who had handled a warm object chose the "selfish" gift 46% of the time.

The authors discuss attachment theory, and suggest that one explanation for these findings, on a neurobiological level, is that the insular cortex in the brain is responsible for processing information about both physical and psychological warmth, therefore the two types of warmth perception may influence each other.

I find this type of cross-sectional social-psychological research fun and a bit lighthearted, but often containing kernels of wisdom.

It would be interesting to do similar studies of this sort, but with different groups of subjects who are stratified according to interpersonal style, depressive symptoms, etc. Perhaps there are subjects who are most sensitive to these environmental effects.

I'm amused and delighted, in any case, that figurative or "metaphorical" warmth seems to match up with literal or physical warmth. A nice meeting of the metaphorical with the literal. Perhaps this is typical of what the brain does.

In any case, this little piece of evidence further supports the recommendation to do sensually pleasing, "warmth-oriented" activities, as part of a regimen for maintaining psychosocial health. There may be something in particular about heat which could be therapeutic. Hot baths are anecdotally helpful for relaxation, pain relief, and to promote deeper sleep. I've encountered a few examples in which people found saunas quite helpful for seasonal depressive symptoms. Maybe a very warm, cozy sweater can be helpful for your mental health, and even have positive effects on others!

Here are references to a few studies showing improvement in insomnia following hot baths:
http://www.ncbi.nlm.nih.gov/pubmed/10566907 {a 1999 study from the journal Sleep, showing improvements in sleep continuity and more slow-wave sleep earlier in the night, in older females with insomnia who had 40-40.5 °C baths 1.5-2 hours before bedtime}
http://www.ncbi.nlm.nih.gov/pubmed/15879585 {a 2005 study in the American Journal of Geriatric Psychiatry showing improved sleep in elderly people with vascular dementia, following 30 minute baths in 40°C water, 2 hours before bedtime}

A precipitant of some seasonal depression, at least in Canada, may be not only the darkness but the cold. The cold may lead not only to a disinclination to go outside, but also to a less generous or a "colder" interpersonal stance, which would further perpetuate a depressive cycle. This is another reason to heed that advice mothers often give young children, to dress warmly in the winter.

Here is a link to the abstract of a study from Japan, published in Psychosomatic Medicine in 2005: http://www.ncbi.nlm.nih.gov/pubmed/16046381

In this study, mildly depressed subjects were randomized to receive one of two treatments, 5 days per week, for 4 weeks, in addition to daily physical and occupational therapy:
1) "thermal therapy" in a 60 °C sauna for 15 minutes, followed by 30 minutes wrapped in a blanket, in a 28 °C room.
2) "non-thermal therapy" of 45 minutes in a 24°C room

The thermal therapy group had a 33% reduction in psychological symptoms, compared to a 14% reduction in the non-thermal therapy group.
The thermal group had a 42% reduction in somatic complaints, compared to an 8% reduction in the non-thermal group.

The research literature on this subject is quite limited, but there is some evidence that warmth--physical and psychological--is therapeutic!

Chocolate & Stress

This is a sequel to one of my previous posts:
http://garthkroeker.blogspot.com/2008/10/chocolate.html

A recent study looked at various hormonal and metabolic changes associated with consuming chocolate. In this case, 30 people were given 40 g of dark chocolate daily for 2 weeks. The authors conclude that the chocolate consumption was responsible for reducing metabolic changes associated with stress, including cortisol and catecholamine excretion.

Weaknesses of the study include its brief, non-randomized, non-blinded nature (mind you, many of us would not easily be fooled by a placebo chocolate substitute!). And I see that the study is associated with the "Nestle Research Centre" in Switzerland. While I am pleased to know that a large chocolate company has a "research centre," I do have to wonder if there could be a higher risk of bias at play.

Here's a link to the abstract:
http://www.ncbi.nlm.nih.gov/pubmed/19810704

In the meantime, there is a variety of evidence out there that chocolate consumption in moderation is good for your health, in a variety of ways.

However, one concerning issue I just learned about has to do with lead contamination in cocoa and chocolate products. Lead is a heavy metal poison which should not have any presence in the diet. It can have widespread toxicity, particularly affecting the nervous system, through either acute or chronic exposure. The issue of lead in chocolate is discussed in mainstream research, such as by Rankin & Flegal (references:http://www.ncbi.nlm.nih.gov/pubmed/16757407, http://www.ncbi.nlm.nih.gov/pubmed/16203244). Based on some of this research, it may be true that raw, unprocessed cocoa nibs have no significant lead contamination, rather the lead in some cocoa and chocolate products may be the result of industrial processing.

Hopefully, manufacturers can address this issue, so that we can be reassured about safety, and so that we can get on with the enjoyment of one of life's great pleasures, knowing that it, in moderation, may also be good for psychological and medical health.

Why Cats Paint

Why Cats Paint: A Theory of Feline Aesthetics by Heather Busch & Burton Silver.

I find this book a masterpiece of humour, a wonderful parody of art criticism, and also a simple entertainment for those of us who enjoy pets.

Have a look at the customer review comments from Amazon:
http://www.amazon.com/exec/obidos/ASIN/0898156122/qid=1005224759

More evidence about the impact of nutrition on mood

An important paper was just published by Akbaraly et al. in The British Journal of Psychiatry, in which 3486 people were followed prospectively for 5 years, with an analysis of nutritional habits and depression symptoms. Here's a link to the abstract:
http://www.ncbi.nlm.nih.gov/pubmed/19880930


The data showed that individuals consuming a diet rich in "processed foods" (such as sweetened desserts, fried food, processed meat, refined grains, and high-fat dairy products) had a much higher rate of depression compared to those consuming a diet heavily loaded with vegetables, fruits, and fish.

The analysis controlled for confounding factors such as gender, age, caloric intake, marital status, employment grade, education, smoking, physical activity, hypertension, diabetes, and cardiovascular disease. A component of the analysis also strongly suggests that the association is not due to reverse causation, of depression leading to worse nutrition. Rather, the analysis strongly suggests that poor diet is a component of causation: that is, poor diet directly increases the risk of becoming depressed, or of having worse depressive symptoms.

Those in the third of people with diets highest in processed foods had a 58% higher chance of having clinical depression compared to the third of people with the healthiest diets.

So, once again, more evidence-based advice to eat healthily in order to protect your mental health:
-more vegetables, fruits, and fish
-less sweets, fried foods, white flour, whole milk, ice cream, etc.

Memory Games

Here are a few links to some free memory games. They may be directed towards children, but I think people of any age could find them useful or fun exercises to improve attention & memory (or even better: you can devise your own memory games, to play with a friend, away from a computer screen):

http://faculty.washington.edu/chudler/chmemory.html
http://www.kidsmemory.com/memory_face_off/face_up_memory_game.php
http://www.kidsmemory.com/light_it_up/light_it_up_memory_game.php
http://www.kidsmemory.com/number_scrambler/index.php
http://users.netrover.com/~kingskids/memory.htm

Rhythm Practice

There's a lot out there about various exercises or games you can do to keep your brain sharp.

I would like to compile a list of things for sharpening your mind that I think are interesting, which you can do at little or no financial cost.

I think that music practice can take many forms, many of which are not only intellectually stimulating, but also possibly quite meditative: a way to let go of worries or agitation.

Here are a few sites where you can do some rhythm practice (i.e. reading rhythms or imitating them). The difficulty is quite variable, from beginner to advanced:

http/www.emusictheory.com/practice/rhythmPerf.html
http://www.tedvieira.com/onlinelessons/sightreading101/values/reading.html
http://www.rhythmpatterns.com/

Swine Flu Anxiety

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.

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.

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.

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}

"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.

Mindfulness actually works

So-called "mindfulness" techniques have been recommended in the treatment of a variety of problems, including chronic physical pain, emotional lability, anxiety, borderline personality symptoms, etc.

I do not think mindfulness training is a complete answer to any of these complex problems, but it could be an extremely valuable, essential component in therapy and growth.

I think now of a metaphor of a growing seedling, or a baby bird: these creatures require stable environments in order to grow. Internal and external environments may not always be stable, though. This instability may be caused by many internal and external biological, environmental, social, or psychological factors. In an unstable environment, growth cannot occur--it gets disrupted, uprooted, or drowned, over and over again, by painful waves of symptoms. Mindfulness techniques can be a way to deal with this type of pain, by taking away from the pain its power to disrupt, uproot, or drown. In itself it may not lead to psychological health, but it may permit a stable ground on which to start growing and building health.

Mindfulness on its own may not always stop pain, but it may lay the groundwork for an environment in which the causes of the pain may finally be dealt with and relieved. In this way mindfulness can be more a catalyst for change than a force of change.

Here is some research evidence:

http://www.ncbi.nlm.nih.gov/pubmed/1609875
http://www.ncbi.nlm.nih.gov/pubmed/7649463
This is a link to two of Kabat-Zinn's papers: the first describes the results of an 8-week mindfulness meditation course on anxiety symptoms in a cohort of 22 patients, and the second describes a 3-year follow-up on these same patients. The results show persistent, substantial reductions in all anxiety symptoms. The studies are weakened by the lack of placebo groups and randomization. But the initial cohort had quite chronic and severe anxiety symptoms (of average duration 6.8 years). Symptom scores declined by about 50%, which is very significant for chronic anxiety disorder patients, and represent a radical improvement in quality of life.

These papers suggest that mindfulness does not merely "increase acceptance of pain"--they suggest that mindfulness also leads to direct reduction of symptoms.

http://www.ncbi.nlm.nih.gov/pubmed/3897551
This is a link to one of Kabat-Zinn's original papers showing substantial symptom improvement and quality-of-life improvement in 90 chronic pain patients who did a 10-week mindfulness meditation course.

http://www.ncbi.nlm.nih.gov/pubmed/15256293
This is a 2004 meta-analysis concluding that mindfulness training, for a variety of different syndromes of emotional or physical pain, has an average effect size of about 0.5, which strongly suggests a very significant clinical benefit. It does come from a potentially biased source, "the Freiburg Institute for Mindfulness Research." But the study itself appears to be well put-together.


http://www.ncbi.nlm.nih.gov/pubmed/17544212
This randomized, controlled 8 week study showed slight improvements in various symptoms among elderly subjects with chronic low back pain. Pain scores (i.e. quantified measures of subjective pain) did not actually change significantly. And quality of life scores didn't change very much either. So I think the results of this study should not be overstated.

I do think that 8 weeks is too short. Also the degree of "immersion" for a technique like this is likely to be an extremely important factor. I think 8 weeks of 6 hours per day would be much more effective. Or a 1-year study of 1-hour per day. Techniques such as meditation are similar to learning languages or musical skills, and these types of abilities require much more lengthy, immersive practice in order to develop.

In the meantime, I encourage people to inform themselves about mindfulness techniques, and consider reserving some time to develop mindfulness skills.

The Importance of Two-Sided Arguments

This is a topic I was meaning to write a post about for some time. I encountered this topic while doing some social psychology reading last year, and it touches upon a lot of other posts I've written, having to do with decision-making and persuasion. It touches on the huge issue of bias which appears in so much of the medical and health literature.

Here is what some of the social psychology research has to say on this:

1) If someone already agrees on an issue, then a one-sided appeal is most effective. So, for example, if I happen to recommend a particular brand of toothpaste, or a particular political candidate, and I simply give a list of reasons why my particular recommendation is best, then I am usually "preaching to the converted." Perhaps more people will go out to buy that toothpaste brand, or vote for that candidate, but they would mostly be people who would have made those choices anyway. The only others who would be most persuaded by my advice would be those who do not have a strong personal investment or attachment to the issue.

2) If people are already aware of opposing arguments, a two-sided presentation is more persuasive and enduring. And if people disagree with a certain issue, a two-sided presentation is more persuasive to change their minds. People are likely to dismiss as biased a one-sided presentation which disagrees with their point of view, even if the presentation contains accurate and well-organized information. This is one of my complaints about various types of media and documentary styles: sometimes there is an overt left-wing or right-wing political bias that is immediately apparent, particularly to a person holding the opposing stance. I can think of numerous examples in local and international newspapers and television. The information from such media or documentary presentations would therefore have little educational or persuasive impact except with individuals who probably agree with the information and the point of view in advance. The strongest documentary or journalistic style has to be one which presents both sides of a debate, otherwise it is probably almost worthless to effect meaningful change--in fact it could entrench the points of view of opposing camps.


It has also been found that if people are already committed to a certain belief or position, than a mild attack or challenge of this position causes people to strengthen their initial position. Ineffective persuasion may "inoculate" people attitudinally, causing them to be more committed to their initial positions. In an educational sense, children could be "inoculated" against negative persuasion, such as from television ads or peer pressure to smoke, etc. by exploring, analyzing, and discussing such persuasive tactics, with parents or teachers.

However, such "inoculation" may be an instrument of attitudinal entrenchment and stubbornness: a person who has anticipated arguments against his or her committed position is more likely to hold that position more tenaciously. Or an individual who has been taught a delusional belief system may have been taught the various challenges to the belief system to expect: this may "inoculate" the person against challenging this belief system, and cause the delusions to become more entrenched.

An adversarial justice system reminds me to some degree of an efficient process, from a psychological point of view, to seek the least biased truth. However, the problem here is that both sides "inoculate" themselves against the evidence presented by the other. The opposing camps do not seek "resolution"--they seek to win, which is quite different. Also, the prosecution and the defense do not EACH present a balanced analysis of pro & con regarding their cases. There is information possibly withheld--the defense may truly know the guilt of the accused, yet this may not be shared openly in court. Presumably the prosecution would not prosecute if the innocence of the accused was known for sure.

Here are some applications of these ideas, which I think are relevant in psychiatry:

1) Depression, anxiety, and other types of mental illness, tend to feature entrenched thinking. Thoughts which are very negative, hostile, or pessimistic--about self, world, or future--may have been consolidated over a period of years or decades, often reinforced by negative experiences. In this setting, one-sided optimistic advice--even if accurate-- could be very counterproductive. It could further entrench the depressive cognitive stance. Standard "Burns style" cognitive therapy can also be excessively "rosy", in my opinion, and may be very ineffective for similar reasons. I think of the smiling picture of the author on the cover of a cognitive therapy workbook as an instant turn-off (for many) which would understandably strengthen the consolidation of many chronic depressive thoughts.

But I do think that a cognitive therapy approach could be very helpful, provided it includes the depressive or negative thinking in an honest, thorough, systematic debate or dialectic. That is, the work has to involve "two-sided argument".

2) In medical literature, there is a great deal of bias going on. Many of my previous postings have been about this. On other internet sites, there are various points of view, some of which are quite extreme. Those sites which are invariably about "pharmaceutical industry bias", etc. I think are actually quite ineffectual, if they merely are covering the same theme, over and over again. They are likely to be sites which are "preaching to the converted", and are likely to be viewed as themselves biased or extreme by someone looking for balanced advice. They may cause individuals with an already biased point of view to unreasonably entrench their positions further.

Also, I suspect the authors of sites like this, may themselves have become quite biased. If their site has repeatedly criticized the inadequacy of the research data about some drug intended to treat depression or bipolar disorder, etc., they may be less likely to consider or publish contrary evidence that the drug actually works. Once we commit ourselves to a position, we all have a tendency to cling to that position, even when evidence should sway us.

On the other hand, if there is a site which consistently gives medication advice of one sort or the other, I think it is unlikely to change very many opinions on this issue, except among those who are already trying out different medications.

So, in my opinion, it is a healthy practice when analyzing issues, including health care decisions, to carefully consider both sides of an argument. If the issue has to do with a treatment, including a medication, a style of psychotherapy, an alternative health care modality, or of doing nothing at all, then I encourage the habit of analyzing the evidence in two ways:
1) gather all evidence which supports the modality
2) gather all evidence which opposes it

Then I encourage a weighing, and a synthesis, of these points of view, before making a decision.
I think that this is the most reliable way to minimize biases. If such a system is applied to one's own attitudes, thoughts, values, and behaviours, I think it is the most effective to promote change and growth.



References:
Myers, David. Social Psychology, fourth edition. New York: McGraw-Hill; 1993. p. 275; 294-297.

Social Psychology

Social psychology is a wonderful, enchanting field.

It is full of delightful experiments which often reveal deeply illuminating facets of human nature.
The experiments are usually so well done that it is hard to argue with the results.

Many people in mental health fields, such as psychiatry, have not studied social psychology. I never took a course in it myself. I feel like signing up for one now.

Applications of social psychology research could apply to treating anxiety & depression; resolving conflict; improving morale; reducing violence on a personal or social level; improving family & parental relationships; building social relationships, etc.

My only slight criticism of typical social psychology research is that it tends to be quite cross-sectional, and the effects or conditions studied are most often short-term (i.e. results that could typically be obtained in a study lasting a single afternoon). My strongest interest is in applied psychology, and I believe that immediate psychological effects can be important, but long-term psychological effects are of greatest importance. The brain works this way, on many levels: the brain can habituate to immediate stimuli, if those same stimuli are repeated over weeks or months. Learning in the brain can start immediately, but deeply ingrained learning (akin to language or music learning) takes months or years. So some results from a day-long study may only be as deeply insightful as administering a medication for a single day -- the effects haven't had a chance to accumulate or be subject to habituation.

In any case, I strongly encourage those interested in mental health to read through a current social psychology textbook (examples of these tend to be very well-written, readable, and entertaining), and to consider following the latest social psychology research. The biggest journal in social psychology is the Journal of Personality and Social Psychology.

The Psychology of Happiness

So-called "positive psychology" is, in my opinion, a very important evolving field. Surprisingly, it is a relatively new field, in terms of formal academic study. Much of the past study of psychology, psychotherapy, and psychiatry has been focused on "pathology" or on treating symptoms of illness, rather than studying or understanding happiness.

Positive psychology need not be criticized as a discipline which defines normality as a continuous happy state. Rather, I think it is a different way of looking at, and nurturing, psychological health.

I'd like to discuss this subject further, but for now, here are a few authors to look at:
-Sonja Lyubomirsky
-Barbara Fredrickson
-Martin Seligman
-Richard Layard

Some insights from this field include the following:

- a "steady diet" of positive emotion increases a sense of meaning and purpose in life, and increases the likelihood of "flourishing" in life. * While this may seem like a truism, it really isn't: it is possible to make changes in lifestyle practices, and to practice skills, to increase positive emotion in daily life. Many people coast through their daily lives, lacking positive emotion, or a sense of meaning.

-Specific suggestions for increasing positive emotion include paying attention to kindness (giving and receiving); consciously increasing awareness in the present moment; simply going outside in good weather; or meditation techniques such as "loving kindness meditation."

-Also, a variety of research has suggested that a ratio of "positivity to negativity"-- in terms of dialog with others, personal emotional experience, and I would add, dialog within your own mind--should exceed 5 to 1. Some of this research comes from looking at dialog in marriages, and interactions in other groups. We all have a tendency to criticize too much--with others and with ourselves--which leads to the positive:negative ratio diminishing, often way below 5 to 1. This suggestion does not advocate suppressing criticism or negative dialog; rather it is about balancing the negative with a large abundance of positive. If you think of any teacher or guide who has ever helped you learn something or grow as a person, I'm pretty sure you'll find that the feedback given to you was mostly positive, with only occasional, concise, gentle, criticisms. I recommend this approach in dealing with negative thoughts within your own mind -- try to balance them, aim for that 5 to 1 ratio.



*see the article "Are you Happy Now?", interview of Barbara Fredrickson by Angela Winter, Utne Sep-Oct 09, p. 62-67.


Here are some more references, which I'll comment more on later:
http://www.ncbi.nlm.nih.gov/pubmed/17716102
http://www.ncbi.nlm.nih.gov/pubmed/17115810
http://www.ncbi.nlm.nih.gov/pubmed/16045394
http://www.ncbi.nlm.nih.gov/pubmed/11894851
http://www.ncbi.nlm.nih.gov/pubmed/19485613
http://www.ncbi.nlm.nih.gov/pubmed/18954193
http://www.ncbi.nlm.nih.gov/pubmed/17356687
http://www.ncbi.nlm.nih.gov/pubmed/11934003
http://www.ncbi.nlm.nih.gov/pubmed/19301241
http://www.ncbi.nlm.nih.gov/pubmed/11315250
http://www.ncbi.nlm.nih.gov/pubmed/19056790
http://www.ncbi.nlm.nih.gov/pubmed/19056788
http://www.ncbi.nlm.nih.gov/pubmed/19227700
http://www.ncbi.nlm.nih.gov/pubmed/18841581
http://www.ncbi.nlm.nih.gov/pubmed/18356530
http://www.ncbi.nlm.nih.gov/pubmed/17479628
http://www.ncbi.nlm.nih.gov/pubmed/17327862