Wednesday, October 21, 2009

Internet, Video Games, and TV: Addictions or Cognitive Enhancers?

I'll introduce this post with my opinion on this issue:

Almost any human activity can be addictive, in a harmful way. That is, the activity could provide a mental reward which leads to the following pattern:
- the activity happens more frequently
- tolerance develops
- increased absorption with the activity develops, in order to achieve the same or greater reward
- other activities feel more boring or unrewarding
- other activities & relationships are neglected
- physical harm may result from sleep deprivation, sedentary behaviour, repetitive strain, reduced self-care, etc.
- social harm may result from relationship neglect or isolation, but also from associating with a cohort of fellow "addicts" who do the same behaviours
- the "mental reward" could probably correlate with functional brain imaging demonstrating increased activity of central dopaminergic reward circuits

Many "good" activities could lead to an addictive pattern. Here's a list of possible activities that can potentially become addictive in this sense:
1) work
2) earning money
3) studying
4) hobbies
5) house chores
6) talking or texting on phones or other electronic devices
7) being in the company of people, or of a particular person
8) sports (playing or watching)
9) reading
10) pursuing excellence


Sometimes, behaviours or thoughts associated with depression or low self-esteem can be "addictive", in that some people may feel a type of masochistic reward from them.

Individuals may not recognize the unhealthy or addictive components of their behaviours. For a person wanting to earn more money, or pursue more excellence, it may seem absurd, and contrary to that person's values, to consider backing away from these pursuits.

For the person "pursuing excellence," it may be true that pouring more time and energy into training might increase achievement in a short-term sense. But this is the addictive trap. In order to pursue excellence in the most effective way, a balanced lifestyle is necessary. In order to achieve that balanced lifestyle, that person may paradoxically need to back away from their immediate pursuit.

I think that all types of modern technology have the potential to be addictive.

Technology and technological culture are changing at an unprecedented pace. And the technologies have ever more powerful and subtle ways to capture our interest, attention, and to stimulate neural reward.

All technological inventions have become addictive for some people. Yet most of these inventions have also contributed to an evolution of modern culture, which has been positive in many ways.

The internet, TV, and video games can all be stimulating, educational activities, which could enhance brain function, intelligence, and could lead to improved social relationships. They could be devices which improve relatedness rather than foster alienation.

Some of these technologies may permit an individual with problems such as a social skills difficulty to explore social connectedness in a different way. In this way, the internet can be an expansion of human connectedness and community. It is a technology which continues the trend of increased potential connectedness through human history. Thousands of years ago, it would have been hard to meet anyone who lived any farther away than the next village. While many individuals would have thrived socially in isolated village culture, some individuals would have been alienated.

Yet technological devices can be easily addictive. And the huge availability of choice in modern technology may permit an individual to find a particular thing that absorbs attention, and disappear into that activity while general physical, social, and mental health deteriorates. There is also a lot of choice available that has violent content, or which creates only an illusion of connection, while none really exists. Facebook or other social connection applications can become preoccupations for many people. While such sites could facilitate social connection, they could also be such a preoccupation that actual social relationships are neglected. The "network" itself could become a meaningless connection of distant acquaintances, yet the preoccupied individual may believe that expanding the network further is a valid solution to this problem. This is not unlike various neurotic social behaviours that exist outside of modern technology: people have always had collections of social behaviours which they believed to be useful, but in fact caused increased social distance & loneliness (e.g. vain behaviours, talking a lot without listening, etc.).

The thing that I believe distinguishes addictions to modern technology from other types of addiction is that many individuals are unquestioningly adopting the technologies as major parts of their daily lives, without being aware of the addictive potential, and without maintaining balance in other parts of life. While everything in life can be addictive, we have a greater understanding of non-technological addiction, since these phenomena have developed more slowly over past decades or centuries. New technology is changing personal culture so rapidly that we may have little chance to understand the risks before the addictiveness is quite entrenched in many people.

So, in conclusion, I do not believe that modern technology, including internet, TV, or video games, are necessarily "bad." They may in fact be wonderful, life-enhancing joys which improve happiness, culture, relationships, and connectedness. Yet they have a high risk to be addictive. I do not believe most people understand the degree of risk involved. I encourage people, in the meantime, to choose wisely when using technology, or when doing supposedly "good" activities such as those listed above, perhaps using the following questions:

1) am I doing this just out of a habit, because of boredom, or as part of procrastinating?
2) is this activity enhancing my life, or is it just gobbling up some of my time and attention?
3) is this activity improving my community, or is it distracting energy away from healthy community?
4) is this activity causing me physical harm, due to lack of exercise, or physical overuse?
5) is this activity consistent with my core values?
6) if it is consistent, is it really helping realize those core values?
7) is the activity itself causing my core values to change in an unwelcome way?
8) is the activity distracting energy or time away from other activities (such as learning, developing a talent, practicing a creative art, developing social relationships) which are important to personal culture?
9) do I have boundaries around this activity, in terms of time & energy, that protect my health?

References & Further Reading:

http://www.ncbi.nlm.nih.gov/pubmed/19818048
{this is a 2009 study by Kira Bailey et al., giving a good review of data concerning video gaming & cognitive variables; they discuss their own study, which leads to the following conclusion:
"these data may indicate that the video game experience is associated with a decrease in the efficiency of proactive cognitive control that supports one’s ability to maintain goal-directed action when the environment is not intrinsically engaging." In other words, video gaming may lead to an ADHD-like phenomenon}

http://www.ncbi.nlm.nih.gov/pubmed/18506602
{a useful review of the subject of technological advancements, in this case specifically regarding gambling technology, looking at whether these advancements constitute increased addictive risk, and if technology to reduce addictive risk is effective. The promise is that the technology itself could evolve--if it is the will of individuals and manufacturers to permit this evolution--to become safer, healthier, and less prone to foster addictive behaviour}

http://www.ncbi.nlm.nih.gov/pubmed/19805713
{this 2-year prospective study of adolescents shows that ADHD, depression, social phobia & hostility symptoms are risk factors for developing internet addiction}

http://www.ncbi.nlm.nih.gov/pubmed/19701792
{one of many associational studies correlating negative mood & internet/gaming addiction; unfortunately, associational studies are very weak, and do not really answer the question for us of how internet/gaming affects people, since we do not see the directions or strengths of causation}

http://www.ncbi.nlm.nih.gov/pubmed/19490510

{a study showing a strong association between addictive internet use and excessive daytime sleepiness}

http://www.ncbi.nlm.nih.gov/pubmed/16634979
{a study associating TV & computer use with sedentary behavior in 5-year-olds}

http://www.ncbi.nlm.nih.gov/pubmed/19428410
{one of the studies showing enhanced visual attentional skills in video gamers. But I find this a severely limited study which should not be over-interpreted--basically it shows that if you play video games, you become more skilled at a visual attention test that resembles the video games you've been playing. It says nothing about general intelligence, social skills, verbal aptitude, etc. which may well have atrophied in the video gamers}

http://www.ncbi.nlm.nih.gov/pubmed/18929349

{a more extensive analysis of cognitive skills in relation to video game playing. But, astonishingly, no cognitive tests were given to assess verbal skills, social skills, etc.; rather the tests were all related to things that seemed to me quite similar to video game tasks--so it is no surprise that the video gamers performed modestly better on some of these! No surprise that playing 1000 hours of Tetris probably will help you mentally rotate 3-d shapes more easily! But at what cost to other social, emotional, and intellectual skills? We need to have prospective studies that do very broad cognitive and psychological evaluations following prolonged exposure to different types of video games. The evaluations must include assessments of emotional state, verbal & non-verbal attention, memory, and reasoning; and they should include assessments of "social intelligence" such as establishing appropriate social communication, empathy, recognition of emotions, etc.}

http://www.ncbi.nlm.nih.gov/pubmed/19016226

{a 30-month longitudinal study showing increased aggression and hostile attribution bias in those exposed to violent video games}

http://www.ncbi.nlm.nih.gov/pubmed/19127289

{here's a description of an interesting psychotherapeutic application for a video game: in this study, those who played Tetris after watching a disturbing film had fewer flashback symptoms afterwards; it may encourage a tactic of treating those who have recently experienced a traumatic event with cognitive distraction, in order to reduce involuntary intrusive emotional memory of the trauma, and therefore to reduce the chance of developing PTSD. The deliberate, voluntary memory of the traumatic scene was unaffected.}

http://www.ncbi.nlm.nih.gov/pubmed/16972829
{an example of using video games to reduce pre-operative anxiety in young children. This sounds like a great idea, which could improve comfort while minimizing medication use in this type of situation.}

http://www.liebertpub.com/products/product.aspx?pid=10
{this is a link to a fairly new journal called "CyberPsychology & Behavior", which looks interesting and pertinent}

Tuesday, October 20, 2009

"Positive Psychotherapy" (PPT) for depression

This post is a continuation of my earlier post on the psychology of happiness. I'm trying to look at each of the references in more detail.

PPT (positive psychotherapy) is a technique described in a paper by Seligman et al. Here's a reference, from American Psychologist in 2006:
http://www.ncbi.nlm.nih.gov/pubmed/17115810

In this paper the technique was tested on two groups. The more important finding concerns the application of PPT with severely depressed adults. PPT was compared with "treatment as usual" (mainly supportive therapy), and "treatment as usual plus antidepressant". The trial lasted 12 weeks, and there was follow-up over 1 year.

The PPT group showed significant improvement in depression scores, and significantly increased happiness, compared to the two control groups.

More controlled studies need to be done on the technique, but in the meantime, the ideas are simple, valuable, potentially enjoyable, and easily incorporated into other therapy styles such as CBT. Here are some of the exercises recommended in PPT, as described in the paper mentioned above:

1) Write a 300-word positive autobiographical introduction, which includes a concrete story illustrating character strengths
2) Identify "signature strengths" based on exercise (1), and discuss situations in which these have helped. Consider ways to use these strengths more in daily life
3) Write a journal describing 3 good things (large or small) that happen each day
4) Describe 3 bad memories, associated anger, and their impact on maintaining depression (this exercise to be done just once or a few times, not every day)
5) Write a letter of forgiveness describing a transgression from the past, with a pledge to forgive (the letter need not be actually sent)
6) Write a letter of gratitude to someone who was never properly thanked
7) Avoiding an attitude of "maximizing" as a goal, rather focusing on meaningfully engaging with what is enough (i.e. avoiding addictive hedonism, in terms of materialism or achievement). The authors use the term "satisficing", which led me to look this word up--here's a good article I found: http://en.wikipedia.org/wiki/Satisficing). I think this idea is really important for those of us who are very perfectionistic or who have very specific, fixed standards for the way they believe life should be, and who therefore feel that real life is always lagging behind these expectations or requirements, or that real life could at any moment crash into a state of failure.
8) Identification of 3 negative life events ("doors closed") which led to 3 positives ("doors opened").
9) Identification of the "signature strengths" of a significant other.
10) Give enthusiastic positive feedback to positive events reported by others, at least once per day
11) Arrange a date to celebrate the strengths of oneself and of a significant other
12) Analyze "signature strengths" among family members
13) Plan and engage with a "savoring" activity, in which something pleasurable is done, with conscious attention given to how pleasurable it is, and with plenty of time reserved to do it
14) "Giving a gift of time" by contributing to another person, or to the community, a substantial amount of time, using one of your signature strengths. This could include volunteering.

Here's a link to a blog devoted to positive psychology techniques:
http://blog.happier.com/
This blog is connected to a site in which they want you to sign up and pay for a membership. I'm always a bit jarred when an altruistic psychotherapeutic system is marketed for financial profit. Would it not be more satisfying to everyone to offer this for free? Also I think the photograph of an ecstatic woman in a flowery meadow is a bit over-the-top as advertising for the site. I find the marketing excessively aggressive, it looks like an infomercial. Some of this stuff could really be off-putting to weary, understandably cynical individuals with chronic depression who have tried many other types of therapy already. And there can be a sort of religious fervor among enthusiastic adherents of a new technique, which can skew reason.

Yet, these ideas are worth looking at. And I certainly agree that in psychiatry, and in therapy, we often focus excessively on the negative side of things, and do not attend enough to nurturing the positive.

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.

Monday, October 19, 2009

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.

Friday, October 16, 2009

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.