It can be hard to make it through the next hour, if you are feeling desperately unhappy, agitated, empty, worthless, or isolated, especially if you also feel disconnected from love, meaning, community, "belongingness," or relationships with others.
Such desperate places of mind can yet be familiar places, and a certain set of coping tactics may evolve. Sometimes social isolation or sleep can help the time pass; other times there can be addictive or compulsive behaviours of different sorts. These tactics may either be distractions from pain or distress, or may serve to anesthetize the symptoms in some way, to help the time pass.
Time can become an oppressive force to be battled continuously, one minute after the next.
I'd like to work on a set of ideas to help with situations like this. I realize a lot of these ideas may be things that are already very familiar, or that may seem trite or irrelevant. Maybe things that are much easier said than done. But I'd like to just sort of brainstorm here for a moment:
1) One of the most important things, I think, is to be able to hold onto something positive or good (large or small), in your mind, to focus on it, to rehearse it, to nurture its mental image, even if that good thing is not immediately present. The "good thing" could be anything -- a friend or loved one, a song, a place, a memory, a sensation, a dream, a goal, an idea. In the darkest of moments we are swept into the immediacy of suffering, and may lose touch with the internalized anchors which might help us to hold on, or to help us direct our behaviour safely through the next 24 hours.
In order to practice "holding on" I guess one would have to get over the skepticism many would have that such a tactic could actually help.
In order to address that, I would say that "covert imagery" is a well-established technique, with an evidence base in such areas as the treatment of phobias, learning new physical activities, practicing skills, even athletic training (imagining doing reps will actually strengthen muscles). The pianist Glenn Gould used covert imagery to practice the piano, and preferred to do much of his practice and rehearsal away from any keyboard; he preferred to learn new pieces entirely away from the piano. There is nothing mystical about the technique -- it is just a different way of exercising your brain, and therefore your body (which is an extension of your brain).
In order for covert imagery to work, it really does help to believe in it though (skepticism is highly demotivating).
Relationships can be "covertly imagined" as well -- and I think this is a great insight from the psychoanalysts. An internalized positive relationship can stay with us, consciously or unconsciously, even when we are physically alone. If you have not had many positive relationships, or your relationships have not been trustworthy, safe, or stable, then you may not have a positive internalized relationship to comfort you when you are in distress. You may feel comforted in the moment, if the situation is right, but when alone, you may be right back to a state of loneliness or torment.
The more trust and closeness that develops in your relationship life, the easier it will be to self-soothe, as you "internalize" these relationships.
Here are some ways to develop these ideas in practical ways:
-journaling, not just about distress, but about any healthy relationship or force in your life which helps soothe you and comfort you
-using healthy "transitional objects" which symbolize things which are soothing or comforting, without those things literally being present. These objects may serve to cue your memory, and help interrupt a cycle of depressive thinking or action.
-if there is a healthy, positive, or soothing relationship with someone in your life, imagine what that person might say to comfort or guide you in the present moment; and "save up" or "put aside" some of your immediate distress to discuss with that person when you next meet.
2) Healthy distraction.
e.g. music (listening or performing); reading (silently or aloud, or being read to); exercise (in healthy moderation); hobbies (e.g. crafts, knitting, art); baking
-consider starting a new hobby (e.g. photography)
3) Planning healthy structured activities
e.g. with community centres, organized hikes, volunteering, deliberately and consciously phoning friends
4) Creating healthy comforts
e.g. hot baths, aromatherapy, getting a massage, preparing or going out for a nice meal
5) Recognizing and blocking addictive behaviours
-there may be a lot of ambivalence about this, as the addictive behaviours may have a powerful or important role in your life; but freeing oneself from an addiction, or from recurrent harmful behaviour patterns, can be one of the most satisfying and liberating of therapeutic life changes.
An addictive process often "convinces" one that its presence is necessary and helpful, and that its absence would cause even worse distress.
6) Humour
-can anyone or anything make you laugh?
-can you make someone laugh?
7) Meditation
-takes a lot of practice, but can be a powerful tool for dealing safely with extreme pain
-could start with a few Kabat-Zinn books & tapes, or consider taking a class or seminar (might need to be patient to find a variety of meditation which suits you)
8) Being with animals (dogs, cats, horses, etc.). If you don't or can't have a pet, then volunteering with animals (e.g. at the SPCA) could be an option.
9) Caring for other living things (e.g. pets, plants, gardens)
10) Arranging for someone else to take care of you for a while (e.g. by friends, family, or in hospital if necessary)
11) Visiting psychiatry blogs
-(in moderation)
...I'm just writing this on the spur of the moment, I'll have to do some editing later, feel free to comment...
Friday, September 11, 2009
Tuesday, September 8, 2009
When your therapist makes a mistake
Sometimes your therapist will make a mistake:
- an insensitive or clumsy comment
- an intrusive line of questioning
- a failure to notice, attend to, or take seriously, something important in the session
- unwelcome or way-off-base advice.
If such problems are recurrent and severe, it may be a sign that you don't have a very good therapist, and that it is important to seek a referral to someone else.
Some problems could be forms of malpractice (e.g. being given dangerous medications inappropriately), and could be pursued through legal channels.
I think that a healthy therapy frame is one in which the therapist will be open to discussing any problems or mistakes.
The therapist should sincerely apologize for all mistakes, and be open to making a plan to prevent similar mistakes from happening again.
You deserve to feel safe, respected and cared for in therapy.
There are other types of conflicts that can arise in therapy, when one person or the other feels hurt, frustrated, or misunderstood. I can think of situations over the past ten years in which there have been tense conflicts, and in which my patient chose not to continue seeing me. In some of these cases, I have felt that there was a conflict--a problem in the relationship--which needed to be resolved. Sometimes these conflicts were made more likely by my own character style or behavioral quirks; other times I think these conflicts were at least partly "transferential," in that my actions triggered memories associated with conflicts from previous relationships (such as with parents growing up). In a few cases, I think the conflict was influenced by active mood symptoms (e.g. severe irritability). I think many conflicts have a mixture of different causes, and are not necessarily caused by just one thing.
In any case, I do strongly believe that resolving conflict in therapy is very important. And I believe a therapist must gently and empathically invite a dialog about conflicts, in a manner which is open, non-defensive, and "non-pushy." Such a moment of conflict-resolution, if it occurs, could be one of the most valuable parts of a therapy experience, a source of peace and freedom.
- an insensitive or clumsy comment
- an intrusive line of questioning
- a failure to notice, attend to, or take seriously, something important in the session
- unwelcome or way-off-base advice.
If such problems are recurrent and severe, it may be a sign that you don't have a very good therapist, and that it is important to seek a referral to someone else.
Some problems could be forms of malpractice (e.g. being given dangerous medications inappropriately), and could be pursued through legal channels.
I think that a healthy therapy frame is one in which the therapist will be open to discussing any problems or mistakes.
The therapist should sincerely apologize for all mistakes, and be open to making a plan to prevent similar mistakes from happening again.
You deserve to feel safe, respected and cared for in therapy.
There are other types of conflicts that can arise in therapy, when one person or the other feels hurt, frustrated, or misunderstood. I can think of situations over the past ten years in which there have been tense conflicts, and in which my patient chose not to continue seeing me. In some of these cases, I have felt that there was a conflict--a problem in the relationship--which needed to be resolved. Sometimes these conflicts were made more likely by my own character style or behavioral quirks; other times I think these conflicts were at least partly "transferential," in that my actions triggered memories associated with conflicts from previous relationships (such as with parents growing up). In a few cases, I think the conflict was influenced by active mood symptoms (e.g. severe irritability). I think many conflicts have a mixture of different causes, and are not necessarily caused by just one thing.
In any case, I do strongly believe that resolving conflict in therapy is very important. And I believe a therapist must gently and empathically invite a dialog about conflicts, in a manner which is open, non-defensive, and "non-pushy." Such a moment of conflict-resolution, if it occurs, could be one of the most valuable parts of a therapy experience, a source of peace and freedom.
Monday, August 31, 2009
Language Learning Metaphor
I have often compared psychological change to language learning.
This could be appreciated on a metaphorical level, but I think that neurologically the processes are similar.
Many people approach psychological change as they would approach something like learning Spanish. Reasons for learning Spanish could be very practical (e.g. benefits at work, moving to a Spanish-speaking country, etc.), or could be more whimsical or esthetic (e.g. always enjoying Spanish music or movies). There is a curiosity and desire to learn and change, and steps are taken to begin changing. A Spanish language book would be acquired. An initial vigorous burst of energy would be spent learning some Spanish vocabulary.
This process often might last a few weeks or months. There might be a familiarity with certain phrases, an intellectual appreciation of the grammatical structure, and perhaps the ability to ask for something in a coffee shop.
Then the Spanish book would sit on the shelf, and never be opened again.
Another pathway could be like the French classes I remember during elementary school. We must have had some French lessons every week for eight years. I did well academically, and had high grades in French.
But I never learned to speak French.
And most people don't learn to speak Spanish either, despite their acquisition of instructional books.
So, there is a problem here: motivation exists to change or learn something new. There is a reasonable plan for change. Effort is invested into changing. But change doesn't really happen. Or the change only happens in a very superficial way.
Here is what I think is required to really learn a language:
1) Immersion is the optimal process. That is, you have to use only the new language, constantly, for weeks, months, or years at a time. This constrains one's mind to function in the new language. Without such a constraint, the mind shifts back automatically to the old language most of the time, and the process of change is much slower, or doesn't happen at all.
2) Even without immersion, there must be daily participation in the learning task, for long periods of time.
3) The process must include active participation. It is helpful to listen quietly, to read, to understand grammar intellectually -- but the most powerful acts of language learning require you to participate actively in conversation using the new language.
4) Perhaps 1000 hours of active practice are required for fluency. 100 hours of practice will help you to get by on a very basic level. 6-10 hours of work per week is a reasonable minimum.
5) Along the way, you have to be willing to function at what you believe is an infantile level of communication, and stumble through, making lots of mistakes, possibly being willing to embarrass yourself. It will feel awkward and slow at first.
6) It is probably necessary to have fellow speakers of the new language around you, to converse with during your "immersion" experience.
7) Part of the good news is that once you get started, even with a few hours' practice, there will be others around you to help you along enthusiastically.
I think that psychological change requires a similar approach. The brain is likely to change in a similar way. I am reminded of Taub's descriptions of constraint-induced rehabilitation from strokes: recovery of function, and neuroplastic brain change, can take place much more effectively if the person is in a state of physiologic "immersion."
Many people acquire books about psychological change (e.g. self-help books, CBT manuals, etc.) in the same way one might acquire a book about learning Spanish. People might read them through, learn a few things, then the books would sit unopened for the next five years.
Or many people might participate in psychotherapy similar to a weekly language lesson: it might be familiar, educational--if there was an exam to write, people might get high grades--but often the "new language" fluency never really develops.
So I encourage the idea of finding ways to create an "immersion" experience, with respect to psychological change. This requires daily work, preferably in an environment where you can set the "old language" aside completely. This work may feel artificial, slow, contrived, or superficial. But this is just like practicing phrases in a new language for the first time. Eventually, the work will feel more natural, spontaneous, and easy.
I think the greatest strength of cognitive-behavioural therapy is its emphasis on "homework," which calls upon people to focus every day on constructive psychological change. And the different columns of a CBT-style homework page remind me of the "columns" one might use to translate phrases from one language into another. In both cases, in order for this homework to work, it has to be practiced, not just on paper, but spoken out loud, or spoken inside your mind, with sincerity and repetition, and preferably also with other people in dialogs.
There's some interesting academic work out there on language acquisition--but for a start, here's a reference from a language-learning website (particularly the summary on the bottom half of this webpage):
http://www.200words-a-day.com/language-learning-reviews.html
Monday, August 17, 2009
ADHD questions
Here are some great questions about ADHD, submitted by a reader:
I don't know the answers to a lot of these, but I am interested to keep trying to learn more. Here's my best response I can come up with for now:
1) First of all, the bottom line of whether something is helpful or not may not be some specific thing, like academic performance. Perhaps "well-being" in a broad, general sense is a more reasonable goal. Yet, things like academic performance are important in life. Perhaps stimulants or other treatments for ADHD are "necessary but not sufficient" to help with ADHD-related academic problems over the longer term. It appears to me from the data that stimulants are actually helpful for academic problems, it's just that the size of the effect is much smaller than what most people would hope for.
2) I wrote a post about zinc supplementation before. Also adequate iron stores are probably important. A generally healthy diet is probably important. I've encountered some people with ADHD who have reduced tolerance for irritation or frustration, and may be particularly bothered or distracted by hunger; yet they may not be organized to have meals prepared regularly through the day. So it can help them manage their ADHD to make sure they always have snacks with them, so that they are never in a hungry state. Other than that, I think there are a lot of nutritional claims out there which have a poor evidence base. The link between sugar intake and hyperactivity is poorly substantiated--I've written a post about that.
Food additives or dyes could play a role in exacerbating ADHD symptoms. Based on this evidence, it makes sense to me to limit food dyes and sodium benzoate in the diet, since such changes do not compromise quality of life in any way, and may lead to improved symptoms. Here are a few references:
http://www.ncbi.nlm.nih.gov/pubmed/17825405
(this is the best of the references: it is from Lancet in 2007)
http://www.ncbi.nlm.nih.gov/pubmed/15613992
http://www.ncbi.nlm.nih.gov/pubmed/15155391
I once attended a presentation on EEG biofeedback. I think it is a promising modality. Harmless to give it a try, but probably expensive. It will be interesting once the technology is available to use EEG biofeedback in front of your own home computer, at low cost.
A few of the self-help books about ADHD are worth reading. There are a lot of practical suggestions about managing symptoms. Some of the books may contain a strongly biased agenda for or against things like stimulants or dietary changes, so you need to be prepared for that possibility.
3)The ADHD label is an artificial, semantic creation, a representation of symptoms or traits which exist on a continuum. Even for those who do not officially satisfy symptom checklist criteria for ADHD, they could benefit substantially from ADHD treatments if there is some component of these symptoms at play neurologically. Many people with apparent disorders of mood, personality, learning, conduct, etc. may have some component of ADHD as well: in some cases ADHD treatments are remarkably helpful for the other problems. So I think careful trials of stimulants could be helpful diagnostically for some people, provided there are no significant contraindications.
4) I've always thought about the ADHD label as just a semantic updating of the previous ADD label. Subtypes of ADHD which are predominantly inattentive rather than hyperactive may differ in terms of comorbidities and prognosis.
5) Hard to say. Many people think of bupropion as a "dopaminergic" drug, whereas bupropion and its relevant metabolites probably act mainly on the norepinephrine system in humans (its dopaminergic activity is more significant in dogs). But perhaps bupropion response could correlate with stimulant response. I haven't seen a good study to show this, nor do I have a case series myself to comment one way or the other based on personal experience.
6) I don't know about that. Comorbidities (e.g. substance use, relationship, or conduct problems) may have accumulated in adults who have not had help during childhood. Yet I have often found it to be the case that the core symptoms of most anything can improve with treatment, at any age.
7) Patients with psychotic disorders (i.e. having a history of hallucinations, delusions, or severely disorganized thinking) often seem to do poorly on stimulants. Patients who are using stimulants primarily to increase energy or motivation often are disappointed with stimulants after a few months, since tolerance develops for effects on energy. Patients with eating disorders could do poorly, since stimulant use may become yet another dysfunctional eating behaviour used to control appetite. And individuals who are trying to use stimulants as part of thrill-seeking behaviour, who are using more than prescribed doses, or who are selling their medication, are worse off for receiving stimulant prescriptions.
1) You write here that long-term use of stimulants has NOT been shown to improve long-term academic outcomes. Why do you think this is, given that symptoms of ADHD improve on medication? (It actually really depresses me to think that individual symptoms can improve, yet no real change takes place...though I know that this might not apply to all patients.
2) What are some effective non-drug treatments for ADHD? I am particularly interested in dietary measures, and also EEG biofeedback.
3) I have read about prescribing psychostimulants as a way of basically diagnosing ADHD...i.e., the diagnosis is based on your response to the medication. I am just wondering how precise this would be, given that stimulants would probably (?) impove most people's concentration, etc. Or is there any role for neuropsychological testing in trying to establish a diagnosis? Is there any way of definitively establishing this kind of diagnosis?
4) I have read that there are many differences between ADD and ADHD, i.e. not just in symptom presentation but in the underlying brain pathology. Is that true? I'm not sure how to phrase it, it seemed like the suggestion was that ADD was more "organic", although maybe that doesn't make sense. Does that have implications for prognosis or treatment strategies?
5) I have read that one red flag that suggests ADD in the context of MDD treatment is a good response to bupropion. If a patient did not have a really good response to bupropion-- or if the response was only partial-- does this usually mean that treatments with psychostimulants like Ritalin, Adderall, etc. will be ineffective (or only partially effective) also?
6) If ADD is not diagnosed/treated until adulthood, is it usually more difficult to treat than if it is diagnosed/ treated in early childhood? Is the response to stimulant treatment just as good? I guess I am wondering if there are certain structural changes that occur in the brain that result from untreated ADD-- kind of like long-term depression and hippocampal atrophy?
7) Is there a certain type of patient who usually does poorly on psychostimulants, or who experiences severe side effects on psychostimulants?
I don't know the answers to a lot of these, but I am interested to keep trying to learn more. Here's my best response I can come up with for now:
1) First of all, the bottom line of whether something is helpful or not may not be some specific thing, like academic performance. Perhaps "well-being" in a broad, general sense is a more reasonable goal. Yet, things like academic performance are important in life. Perhaps stimulants or other treatments for ADHD are "necessary but not sufficient" to help with ADHD-related academic problems over the longer term. It appears to me from the data that stimulants are actually helpful for academic problems, it's just that the size of the effect is much smaller than what most people would hope for.
2) I wrote a post about zinc supplementation before. Also adequate iron stores are probably important. A generally healthy diet is probably important. I've encountered some people with ADHD who have reduced tolerance for irritation or frustration, and may be particularly bothered or distracted by hunger; yet they may not be organized to have meals prepared regularly through the day. So it can help them manage their ADHD to make sure they always have snacks with them, so that they are never in a hungry state. Other than that, I think there are a lot of nutritional claims out there which have a poor evidence base. The link between sugar intake and hyperactivity is poorly substantiated--I've written a post about that.
Food additives or dyes could play a role in exacerbating ADHD symptoms. Based on this evidence, it makes sense to me to limit food dyes and sodium benzoate in the diet, since such changes do not compromise quality of life in any way, and may lead to improved symptoms. Here are a few references:
http://www.ncbi.nlm.nih.gov/pubmed/17825405
(this is the best of the references: it is from Lancet in 2007)
http://www.ncbi.nlm.nih.gov/pubmed/15613992
http://www.ncbi.nlm.nih.gov/pubmed/15155391
I once attended a presentation on EEG biofeedback. I think it is a promising modality. Harmless to give it a try, but probably expensive. It will be interesting once the technology is available to use EEG biofeedback in front of your own home computer, at low cost.
A few of the self-help books about ADHD are worth reading. There are a lot of practical suggestions about managing symptoms. Some of the books may contain a strongly biased agenda for or against things like stimulants or dietary changes, so you need to be prepared for that possibility.
3)The ADHD label is an artificial, semantic creation, a representation of symptoms or traits which exist on a continuum. Even for those who do not officially satisfy symptom checklist criteria for ADHD, they could benefit substantially from ADHD treatments if there is some component of these symptoms at play neurologically. Many people with apparent disorders of mood, personality, learning, conduct, etc. may have some component of ADHD as well: in some cases ADHD treatments are remarkably helpful for the other problems. So I think careful trials of stimulants could be helpful diagnostically for some people, provided there are no significant contraindications.
4) I've always thought about the ADHD label as just a semantic updating of the previous ADD label. Subtypes of ADHD which are predominantly inattentive rather than hyperactive may differ in terms of comorbidities and prognosis.
5) Hard to say. Many people think of bupropion as a "dopaminergic" drug, whereas bupropion and its relevant metabolites probably act mainly on the norepinephrine system in humans (its dopaminergic activity is more significant in dogs). But perhaps bupropion response could correlate with stimulant response. I haven't seen a good study to show this, nor do I have a case series myself to comment one way or the other based on personal experience.
6) I don't know about that. Comorbidities (e.g. substance use, relationship, or conduct problems) may have accumulated in adults who have not had help during childhood. Yet I have often found it to be the case that the core symptoms of most anything can improve with treatment, at any age.
7) Patients with psychotic disorders (i.e. having a history of hallucinations, delusions, or severely disorganized thinking) often seem to do poorly on stimulants. Patients who are using stimulants primarily to increase energy or motivation often are disappointed with stimulants after a few months, since tolerance develops for effects on energy. Patients with eating disorders could do poorly, since stimulant use may become yet another dysfunctional eating behaviour used to control appetite. And individuals who are trying to use stimulants as part of thrill-seeking behaviour, who are using more than prescribed doses, or who are selling their medication, are worse off for receiving stimulant prescriptions.
Wednesday, July 29, 2009
Twin Studies & Behavioral Genetics
The field of behavioral genetics is of great interest to me.
A lot of very good research has been done in this area for over 50 years.
One of the strongest methods of research in behavioral genetics is the "twin study", in which pairs of identical twins are compared with pairs of non-identical twins, looking at symptoms, traits, behaviors, disease frequencies, etc.
I would like to explore this subject in much greater detail in the future, but my very brief summary of the data is this:
1) most human traits, behaviors, and disease frequencies are strongly affected by hereditary (genetic) factors. Typically, about 50% of the variability in these measures is caused by variability of inherited genes. That is, the "heritability" is typically 50%, sometimes much higher.
2) The remaining variability is mostly due to so-called "non-shared environmental factors". This fact is jarring to those of us who have believed that the character of one's family home (a "shared environmental variable") is a major determinant of future character traits, etc.
3) Hereditary factors tend to become more prominent, rather than less prominent, with advancing age. One might have thought that, as one grows older, environmental events would play an ever-increasing role in "sculpting" our personalities or other traits. This is not the case.
4) Some of the "environmental variation" may in fact be random. Basically, good or bad luck. Getting struck by lightning, or winning the lottery, or not. Such "luck-based" events are mostly (though not entirely) outside our control.
5) All of these facts may lead to a kind of fatalism, a resignation about our traits being determined by factors outside our control. (mind, you, being "lucky" or "unlucky" may be more determined by attitudinal factors such as openness than just by random events: see the following article--http://www.scientificamerican.com/article.cfm?id=as-luck-would-have-it)
Here is some of my critical response to the above statements:
1) Statements about heritability are in fact dependent upon the average environmental conditions experienced by the population being studied. For example, if we were to measure the heritability of becoming the leader of a large country, we would find heritabilities of nearly 100% in times or places where there are hereditary monarchies, and much lower heritabilities for democracies (mind you, the case of the Bush family shows that the heritability has been non-zero in the U.S.).
2) Non-shared environmental factors are extremely important. This does not mean that the family environment is unimportant. Part of an individual's non-shared environmental experience is that person's unique experience of the family environment. The lesson in this is that families need to pay close attention to how each individual family member is adapting to the family situation, and to also pay close attention to a child's peer and school environment.
3) The influence of shared environmental factors is small, but rarely zero. Usually there is some small percentage of variability accounted for by shared factors. Often this percentage is larger in childhood, and declines towards zero during adult maturation. But it is not zero. Just because an influence is small does not mean that it is unimportant. We have limited control over our genetics, after all, but we do have more substantial control over shared and non-shared environmental variables.
4) Most studies look at the general effect of genetic & environmental factors in populations. Compelling examples are frequently cited of individual twins, separated at birth: perhaps one twin is adopted into a wealthy, privileged home with access to multiple educational resources, while the other grows up in a more impoverished setting. The story typically is that the twins both end up with similar funds of knowledge or intelligence: the first twin reads books available at home, while the other twin develops her inherited interest in knowledge by going out of her way to acquire a library card, and spending all day reading at the local library. Such case examples illustrate how inherited factors can prevail despite environmental differences.
But I'm interested to see counterexamples: examples in which differences in environment between twins did lead to substantial differences in traits later on. It is this type of example that has the most practical value, in my opinion.
5) I have considered the following idea:
For any trait or characteristic having any heritability, there may be environmental variables that can change the outcome of the trait for a given individual. Even for highly, obviously heritable traits. Consider eye color, for example. This seems obviously purely genetic. But suppose there was a medication that could change eye color. This would be a purely environmental factor (though, of course, perhaps the tendency to use a drug to change eye color would be partially inherited). Most people would not use such a drug. Measures of heritability for eye color would remain very high. But, despite this high heritability, there may well be simple, direct environmental changes which, for a given individual, could completely change the trait. Such environmental changes would have to be very different from average environmental conditions. The higher the heritability, the farther would the environmental change have to be from average, in order to effect a change in the trait.
We could say that the tendency to kill and devour wildebeest is heritable, among the different wild creatures of the African savanna. The genetic differences between lions and giraffes would completely determine the likelihood of such creatures devouring a wildebeest or not. We could say that lions inherit a tendency to eat wildebeest, while giraffes do not. Yet, I suppose that it is true that we could train and/or medicate lions (and also keep them well-fed with a vegetarian diet!) so that wildebeest are totally safe around them. In this way, we would be introducing a set of environmental changes which would cause a radical change in lion behavior. This does not change the fact that the heritability for lions' killing wildebeest is extremely high, it just means that the environmental change necessary to change the trait must have to be something radically different from the environmental experience of the average lion (most lions are not trained to be non-predatory!).
The clinical applications I have based on these observations are the following:
1) Many psychological phenomena are highly heritable. This does not mean that these phenomena are unchangeable though. It does mean that, in order to change the trait or behavior, an environmental change needs to occur which is substantially different from the environmental experiences of most people, or of the "average person". This may help us to use our efforts most efficiently. So, for example, it would be inefficient to merely provide everybody with a typical, average, 2-parent family living in a bungalo. The evidence shows that such "average" environmental changes have minimal impact on psychological or behavioral traits. It would be important to make sure each individual is not deprived or harmed, and has access to those basic environmental elements that are required for them to realize their potential. If there are problems, then the means of addressing those problems may require a substantial, unique, or radical environmental change.
2) The most influential environmental variables are those which are unique to the individual, not the ones which are shared in a family. This does not mean that family experiences are unimportant, but that a child's unique experience of his or her own family environment, is much more important than the overall atmosphere of the home. A chaotic household may be a pleasure, a source of boisterous social stimulation, for one child, but an injurious, disruptive, irritating source of stress for another. A calm household may allow one child to grow and develop, while it may cause another child to become bored or restless.
3) The higher the heritability, the more pronounced the environmental (or therapeutic) change is required to change the trait, compared to the average environment in the population.
4) The motivation to have a certain style of home, or parenting, etc. should logically not primarily be to "sculpt" the personality of your child, but to allow for joyous long-term memories, to be shared and recounted as stories by parent and child, and to pay attention to the unique nature of each individual child, providing for any healthy needs along the way.
Some references:
Segal, Nancy L. (2000). Entwined Lives: Twins and what they tell us about human behavior. New York: Plume.
http://www.ncbi.nlm.nih.gov/pubmed/19378334
{a 2009 review including a look at "epigenetics", the notion that one's genes are changeable, therefore identical twins are not truly "identical" in a genetic sense}
http://www.ncbi.nlm.nih.gov/pubmed/18412098
{genetics of PTSD}
http://www.ncbi.nlm.nih.gov/pubmed/17176502
{a look at how genetic factors influence environmental experience}
http://www.ncbi.nlm.nih.gov/pubmed/17679640
{a look at how choice of peers is influenced by heredity, moreso as a child grows up}
http://www.ncbi.nlm.nih.gov/pubmed/18391130
{some of the research showing different genetic influences coming "on line" during different stages of childhood and young adult development}
http://www.ncbi.nlm.nih.gov/pubmed/19634053
{a recent article by TJ Bouchard, one of the world's leading experts in twin studies}
A lot of very good research has been done in this area for over 50 years.
One of the strongest methods of research in behavioral genetics is the "twin study", in which pairs of identical twins are compared with pairs of non-identical twins, looking at symptoms, traits, behaviors, disease frequencies, etc.
I would like to explore this subject in much greater detail in the future, but my very brief summary of the data is this:
1) most human traits, behaviors, and disease frequencies are strongly affected by hereditary (genetic) factors. Typically, about 50% of the variability in these measures is caused by variability of inherited genes. That is, the "heritability" is typically 50%, sometimes much higher.
2) The remaining variability is mostly due to so-called "non-shared environmental factors". This fact is jarring to those of us who have believed that the character of one's family home (a "shared environmental variable") is a major determinant of future character traits, etc.
3) Hereditary factors tend to become more prominent, rather than less prominent, with advancing age. One might have thought that, as one grows older, environmental events would play an ever-increasing role in "sculpting" our personalities or other traits. This is not the case.
4) Some of the "environmental variation" may in fact be random. Basically, good or bad luck. Getting struck by lightning, or winning the lottery, or not. Such "luck-based" events are mostly (though not entirely) outside our control.
5) All of these facts may lead to a kind of fatalism, a resignation about our traits being determined by factors outside our control. (mind, you, being "lucky" or "unlucky" may be more determined by attitudinal factors such as openness than just by random events: see the following article--http://www.scientificamerican.com/article.cfm?id=as-luck-would-have-it)
Here is some of my critical response to the above statements:
1) Statements about heritability are in fact dependent upon the average environmental conditions experienced by the population being studied. For example, if we were to measure the heritability of becoming the leader of a large country, we would find heritabilities of nearly 100% in times or places where there are hereditary monarchies, and much lower heritabilities for democracies (mind you, the case of the Bush family shows that the heritability has been non-zero in the U.S.).
2) Non-shared environmental factors are extremely important. This does not mean that the family environment is unimportant. Part of an individual's non-shared environmental experience is that person's unique experience of the family environment. The lesson in this is that families need to pay close attention to how each individual family member is adapting to the family situation, and to also pay close attention to a child's peer and school environment.
3) The influence of shared environmental factors is small, but rarely zero. Usually there is some small percentage of variability accounted for by shared factors. Often this percentage is larger in childhood, and declines towards zero during adult maturation. But it is not zero. Just because an influence is small does not mean that it is unimportant. We have limited control over our genetics, after all, but we do have more substantial control over shared and non-shared environmental variables.
4) Most studies look at the general effect of genetic & environmental factors in populations. Compelling examples are frequently cited of individual twins, separated at birth: perhaps one twin is adopted into a wealthy, privileged home with access to multiple educational resources, while the other grows up in a more impoverished setting. The story typically is that the twins both end up with similar funds of knowledge or intelligence: the first twin reads books available at home, while the other twin develops her inherited interest in knowledge by going out of her way to acquire a library card, and spending all day reading at the local library. Such case examples illustrate how inherited factors can prevail despite environmental differences.
But I'm interested to see counterexamples: examples in which differences in environment between twins did lead to substantial differences in traits later on. It is this type of example that has the most practical value, in my opinion.
5) I have considered the following idea:
For any trait or characteristic having any heritability, there may be environmental variables that can change the outcome of the trait for a given individual. Even for highly, obviously heritable traits. Consider eye color, for example. This seems obviously purely genetic. But suppose there was a medication that could change eye color. This would be a purely environmental factor (though, of course, perhaps the tendency to use a drug to change eye color would be partially inherited). Most people would not use such a drug. Measures of heritability for eye color would remain very high. But, despite this high heritability, there may well be simple, direct environmental changes which, for a given individual, could completely change the trait. Such environmental changes would have to be very different from average environmental conditions. The higher the heritability, the farther would the environmental change have to be from average, in order to effect a change in the trait.
We could say that the tendency to kill and devour wildebeest is heritable, among the different wild creatures of the African savanna. The genetic differences between lions and giraffes would completely determine the likelihood of such creatures devouring a wildebeest or not. We could say that lions inherit a tendency to eat wildebeest, while giraffes do not. Yet, I suppose that it is true that we could train and/or medicate lions (and also keep them well-fed with a vegetarian diet!) so that wildebeest are totally safe around them. In this way, we would be introducing a set of environmental changes which would cause a radical change in lion behavior. This does not change the fact that the heritability for lions' killing wildebeest is extremely high, it just means that the environmental change necessary to change the trait must have to be something radically different from the environmental experience of the average lion (most lions are not trained to be non-predatory!).
The clinical applications I have based on these observations are the following:
1) Many psychological phenomena are highly heritable. This does not mean that these phenomena are unchangeable though. It does mean that, in order to change the trait or behavior, an environmental change needs to occur which is substantially different from the environmental experiences of most people, or of the "average person". This may help us to use our efforts most efficiently. So, for example, it would be inefficient to merely provide everybody with a typical, average, 2-parent family living in a bungalo. The evidence shows that such "average" environmental changes have minimal impact on psychological or behavioral traits. It would be important to make sure each individual is not deprived or harmed, and has access to those basic environmental elements that are required for them to realize their potential. If there are problems, then the means of addressing those problems may require a substantial, unique, or radical environmental change.
2) The most influential environmental variables are those which are unique to the individual, not the ones which are shared in a family. This does not mean that family experiences are unimportant, but that a child's unique experience of his or her own family environment, is much more important than the overall atmosphere of the home. A chaotic household may be a pleasure, a source of boisterous social stimulation, for one child, but an injurious, disruptive, irritating source of stress for another. A calm household may allow one child to grow and develop, while it may cause another child to become bored or restless.
3) The higher the heritability, the more pronounced the environmental (or therapeutic) change is required to change the trait, compared to the average environment in the population.
4) The motivation to have a certain style of home, or parenting, etc. should logically not primarily be to "sculpt" the personality of your child, but to allow for joyous long-term memories, to be shared and recounted as stories by parent and child, and to pay attention to the unique nature of each individual child, providing for any healthy needs along the way.
Some references:
Segal, Nancy L. (2000). Entwined Lives: Twins and what they tell us about human behavior. New York: Plume.
http://www.ncbi.nlm.nih.gov/pubmed/19378334
{a 2009 review including a look at "epigenetics", the notion that one's genes are changeable, therefore identical twins are not truly "identical" in a genetic sense}
http://www.ncbi.nlm.nih.gov/pubmed/18412098
{genetics of PTSD}
http://www.ncbi.nlm.nih.gov/pubmed/17176502
{a look at how genetic factors influence environmental experience}
http://www.ncbi.nlm.nih.gov/pubmed/17679640
{a look at how choice of peers is influenced by heredity, moreso as a child grows up}
http://www.ncbi.nlm.nih.gov/pubmed/18391130
{some of the research showing different genetic influences coming "on line" during different stages of childhood and young adult development}
http://www.ncbi.nlm.nih.gov/pubmed/19634053
{a recent article by TJ Bouchard, one of the world's leading experts in twin studies}
Low-dose atypical antipsychotics for treating non-psychotic anxiety or mood symptoms
Atypical antipsychotics are frequently prescribed to treat symptoms of anxiety and depression. They can be used in the treatment of generalized anxiety, panic disorder, OCD, major depressive disorder, PTSD, bipolar disorder, personality disorders, etc. At this point, such use could be considered "off-label", since the primary use of antipsychotics is treating schizophrenia or major mood disorders with psychotic features.
But there is an expanding evidence base showing that atypicals can be useful in "off-label" situations. Here is a brief review of some of the studies:
http://www.ncbi.nlm.nih.gov/pubmed/19470174
{this is a good recent study comparing low-dose risperidone -- about 0.5 mg -- with paroxetine, for treating panic disorder over 8 weeks. The risperidone group did well, with equal or better symptom relief, also possibly faster onset. But 8 weeks is very brief -- it would be important to look at results over a year or more, and to assess the possibility of withdrawal or rebound symptoms if the medication is stopped. Also is would be important to determine if the medication is synergistic with psychological therapies, or whether it could undermine psychological therapy (there is some evidence that benzodiazepines may undermine the effectiveness of psychological therapies) }
http://www.ncbi.nlm.nih.gov/pubmed/16649823
{an open study from 2006 showing significant improvements in anxiety when low doses of risperidone, of about 1 mg, were added to an antidepressant, over an 8 week trial}
http://www.ncbi.nlm.nih.gov/pubmed/18455360
{this 2008 study shows significant improvement in generalized anxiety with 12 weeks of adjunctive quetiapine. It was not "low-dose" though -- the average dose was almost 400 mg per day. There is potential bias in this study due to conflict-of-interest, also there was no adjunctive placebo group}
http://www.ncbi.nlm.nih.gov/pubmed/16889446
{in this 2006 study. patients with a borderline personality diagnosis were given quetiapine 200-400 mg daily, for a 12 week trial. As I look at the results in the article itself, I see that the most substantial improvement was in anxiety symptoms, without much change in other symptom areas. The authors state that patients with prominent impulsive or aggressive symptoms responded best}
http://www.ncbi.nlm.nih.gov/pubmed/17110817
{in this large 2006 study (the BOLDER II study), quetiapine alone was used to treat bipolar depression. Doses were 300 mg/d, 600 mg/d, or placebo. There was significant, clinically relevant improvement in the quetiapine groups, with the 300 mg group doing best. Improvements were in anxiety symptoms, depressive symptoms, suicidal ideation, sleep, and overall quality of life.}
Here's a reference to a lengthy and detailed report from the FDA about quetiapine safety when used to treat depression or anxiety:
http://www.fda.gov/ohrms/dockets/ac/09/briefing/2009-4424b2-01-FDA.pdf
In summary, I support the use of atypical antipsychotics as adjuncts for treating various symptoms including anxiety, irritability, etc. But as with any treatment (or non-treatment), there needs to be a close review of benefits vs. risks. The risks of using antipsychotics for treating anxiety are probably underestimated, because the existing studies are of such short duration. Also the benefits over long-term use are not clearly established either.
For risk data, it would be relevant to look at groups who have taken antipsychotics for long periods of time. In this group, antipsychotic use is associated with reduced mortality rates (see the following 2009 reference from Lancet: http://www.ncbi.nlm.nih.gov/pubmed/19595447, which looks at a cohort of over 60 000 schizophrenic patients, showing reduced mortality rates in those who took antipsychotics long-term, compared to those taking shorter courses of antipsychotics, or none at all--the mortality rate was most dramatically reduced in those taking clozapine. Overall, the life expectancy of schizophrenic patients was shown to have increased over a 10-year period, alongside substantial increases in atypical antipsychotic use)
It is certainly clear to me that all other treatments for anxiety (especially behavioural therapies, lifestyle changes, other forms of psychotherapy) be optimized, in an individualized way, before medication adjuncts be used.
But I recognize that suffering from anxiety or other psychiatric symptoms can be severely debilitating, can delay or obstruct progress in relationships, work, school, quality of life, etc. The risks of non-treatment should be taken very seriously. My view of the existing evidence is that adjunctive low-dose antipsychotics can have significant benefits, which can outweigh risks for many patients with non-psychotic disorders. As with any medical treatment decision, it is important for you and your physician to regularly monitor or discuss risks vs. benefits of ongoing medication therapies, and be open to discuss new evidence which is coming out.
But there is an expanding evidence base showing that atypicals can be useful in "off-label" situations. Here is a brief review of some of the studies:
http://www.ncbi.nlm.nih.gov/pubmed/19470174
{this is a good recent study comparing low-dose risperidone -- about 0.5 mg -- with paroxetine, for treating panic disorder over 8 weeks. The risperidone group did well, with equal or better symptom relief, also possibly faster onset. But 8 weeks is very brief -- it would be important to look at results over a year or more, and to assess the possibility of withdrawal or rebound symptoms if the medication is stopped. Also is would be important to determine if the medication is synergistic with psychological therapies, or whether it could undermine psychological therapy (there is some evidence that benzodiazepines may undermine the effectiveness of psychological therapies) }
http://www.ncbi.nlm.nih.gov/pubmed/16649823
{an open study from 2006 showing significant improvements in anxiety when low doses of risperidone, of about 1 mg, were added to an antidepressant, over an 8 week trial}
http://www.ncbi.nlm.nih.gov/pubmed/18455360
{this 2008 study shows significant improvement in generalized anxiety with 12 weeks of adjunctive quetiapine. It was not "low-dose" though -- the average dose was almost 400 mg per day. There is potential bias in this study due to conflict-of-interest, also there was no adjunctive placebo group}
http://www.ncbi.nlm.nih.gov/pubmed/16889446
{in this 2006 study. patients with a borderline personality diagnosis were given quetiapine 200-400 mg daily, for a 12 week trial. As I look at the results in the article itself, I see that the most substantial improvement was in anxiety symptoms, without much change in other symptom areas. The authors state that patients with prominent impulsive or aggressive symptoms responded best}
http://www.ncbi.nlm.nih.gov/pubmed/17110817
{in this large 2006 study (the BOLDER II study), quetiapine alone was used to treat bipolar depression. Doses were 300 mg/d, 600 mg/d, or placebo. There was significant, clinically relevant improvement in the quetiapine groups, with the 300 mg group doing best. Improvements were in anxiety symptoms, depressive symptoms, suicidal ideation, sleep, and overall quality of life.}
Here's a reference to a lengthy and detailed report from the FDA about quetiapine safety when used to treat depression or anxiety:
http://www.fda.gov/ohrms/dockets/ac/09/briefing/2009-4424b2-01-FDA.pdf
In summary, I support the use of atypical antipsychotics as adjuncts for treating various symptoms including anxiety, irritability, etc. But as with any treatment (or non-treatment), there needs to be a close review of benefits vs. risks. The risks of using antipsychotics for treating anxiety are probably underestimated, because the existing studies are of such short duration. Also the benefits over long-term use are not clearly established either.
For risk data, it would be relevant to look at groups who have taken antipsychotics for long periods of time. In this group, antipsychotic use is associated with reduced mortality rates (see the following 2009 reference from Lancet: http://www.ncbi.nlm.nih.gov/pubmed/19595447, which looks at a cohort of over 60 000 schizophrenic patients, showing reduced mortality rates in those who took antipsychotics long-term, compared to those taking shorter courses of antipsychotics, or none at all--the mortality rate was most dramatically reduced in those taking clozapine. Overall, the life expectancy of schizophrenic patients was shown to have increased over a 10-year period, alongside substantial increases in atypical antipsychotic use)
It is certainly clear to me that all other treatments for anxiety (especially behavioural therapies, lifestyle changes, other forms of psychotherapy) be optimized, in an individualized way, before medication adjuncts be used.
But I recognize that suffering from anxiety or other psychiatric symptoms can be severely debilitating, can delay or obstruct progress in relationships, work, school, quality of life, etc. The risks of non-treatment should be taken very seriously. My view of the existing evidence is that adjunctive low-dose antipsychotics can have significant benefits, which can outweigh risks for many patients with non-psychotic disorders. As with any medical treatment decision, it is important for you and your physician to regularly monitor or discuss risks vs. benefits of ongoing medication therapies, and be open to discuss new evidence which is coming out.
Wednesday, July 15, 2009
Benefits and Risks of Zinc Supplementation in Eating Disorders, ADHD, and Depression
Zinc supplementation may help treat anorexia nervosa, ADHD, and treatment-resistant depression.
Zinc is a metallic element involved in multiple aspects of human cellular function, metabolism, growth, and immune function. It is required for the function of about 100 human enzymes. The human body contains about 2000-3000 mg of zinc, of which about 2-3 mg are lost daily through kidneys, bowel, and sweat glands. The biologic half-life of zinc in the body is about 9 months, so it can take months or years for changes in dietary habits to substantially change zinc status, unless the intake is very high for short periods.
Red meat is a particularly rich source of zinc. Vegetarians may have a harder time getting an adequate amount from the diet. The prevalence of zinc deficiency may be as high as 40% worldwide.
When referring to zinc dosage, it is best to refer to "elemental zinc". Different types of zinc preparations (e.g. zinc gluconate or zinc sulphate) have different amounts of elemental zinc. For example, 100 mg of zinc gluconate contains about 14 mg of elemental zinc. 110 mg of zinc sulphate contains about 25 mg of elemental zinc.
Here are references to articles written by a Vancouver eating disorders specialist between 1994 and 2006, advising supplementation of 14 mg elemental zinc daily (corresponding to 100 mg zinc gluconate daily) for 2 months in all anorexic patients:
http://www.ncbi.nlm.nih.gov/pubmed/17272939
http://www.ncbi.nlm.nih.gov/pubmed/11930982
http://www.ncbi.nlm.nih.gov/pubmed/8199605
Here's a 1987 article from a pediatrics journal, showing improvement in depression and anxiety following 50 mg/d elemental zinc supplementation in anorexic adolescents:
http://www.ncbi.nlm.nih.gov/pubmed/3312133
In this 1990 open study, anorexic patients were treated with 45-90 mg elemental zinc daily, most of whom had significant improvement in their eating disorder symptoms over 2 years of follow-up.
http://www.ncbi.nlm.nih.gov/pubmed/2291418
Here's a 1992 case report of substantial improvement in severe anorexia following zinc supplementation:
http://www.ncbi.nlm.nih.gov/pubmed/1526438
Zinc depletion may lead to an abnormal sense of taste (hypogeusia or dysgeusia). This sensory abnormality improves with zinc supplementation. Here's a reference:
http://www.ncbi.nlm.nih.gov/pubmed/8835055
Here's a randomized , controlled 2009 Turkish study showing that 10 weeks of 15 mg/day zinc supplementation led to improvement in ADHD symptoms in children. However, a close look at the study shows a bizarre lack of statistical analysis comparing the supplemented group directly with the placebo group. When you look at the data from the article, both groups improved to a modest degree on most measures, with perhaps a little bit more improvement in the zinc group. The analysis here was insufficient, I'm surprised a journal would accept this.
http://www.ncbi.nlm.nih.gov/pubmed/19133873
Here's a 2004 reference to a study showing that 6 weeks of 15 mg elemental zinc daily as an adjunct to stimulant therapy improved ADHD symptoms in children, compared to stimulant therapy plus placebo. In this case, there was a valid statistical analysis:
http://www.ncbi.nlm.nih.gov/pubmed/15070418
Here's a 2009 study showing that zinc supplementation improves the response to antidepressants in treatment-resistant depression. The dose they used was 25 mg elemental zinc daily, over 12 weeks.
http://www.ncbi.nlm.nih.gov/pubmed/19278731
Here's an excellent 2008 review article about zinc deficiency, and about the potential role of zinc supplementation in a wide variety of diseases (e.g. infections ranging from the common cold, to TB, to warts; arthritis; diarrhea; mouth ulcers). The review shows that zinc may have benefit for some of these conditions, but the evidence is a bit inconsistent:
http://www.ncbi.nlm.nih.gov/pubmed/18221847
Here is a warning about zinc toxicity:
http://www.ncbi.nlm.nih.gov/pubmed/12368702 {hematological toxicity from taking 50-300 mg zinc daily for 6-7 months. The toxicity was thought to be due to zinc-induced copper malabsorption leading to sideroblastic anemia}
Here is a nice website from NIH summarizing the role of zinc in the diet, in the body, some of the research about health effects, and about toxicity. It sticks to a recommended daily intake of 10-15 mg elemental zinc for adults, or about 5 mg for young children. It states that the maximum tolerable daily intake levels are about 5-10 mg for young children, 20-30 mg for adolescents, and 40 mg daily for adults:
http://ods.od.nih.gov/FactSheets/Zinc.asp
Here is a reference to another excellent review of zinc requirements, benefits, and risks. It makes more cautious recommendations about zinc supplementation, advising no more than 20 mg/day of zinc intake in adults. In order to prevent copper deficiency, it also advises that that the ratio between zinc intake and copper intake does not exceed 10.
http://www.ncbi.nlm.nih.gov/pubmed/16632171
So, were I to make a recommendation about a zinc supplementation trial, I would advise sticking to amounts under 20 mg (elemental) per day for adults, and to ensure that you are getting 2 mg of copper per day with that.
Zinc is a metallic element involved in multiple aspects of human cellular function, metabolism, growth, and immune function. It is required for the function of about 100 human enzymes. The human body contains about 2000-3000 mg of zinc, of which about 2-3 mg are lost daily through kidneys, bowel, and sweat glands. The biologic half-life of zinc in the body is about 9 months, so it can take months or years for changes in dietary habits to substantially change zinc status, unless the intake is very high for short periods.
Red meat is a particularly rich source of zinc. Vegetarians may have a harder time getting an adequate amount from the diet. The prevalence of zinc deficiency may be as high as 40% worldwide.
When referring to zinc dosage, it is best to refer to "elemental zinc". Different types of zinc preparations (e.g. zinc gluconate or zinc sulphate) have different amounts of elemental zinc. For example, 100 mg of zinc gluconate contains about 14 mg of elemental zinc. 110 mg of zinc sulphate contains about 25 mg of elemental zinc.
Here are references to articles written by a Vancouver eating disorders specialist between 1994 and 2006, advising supplementation of 14 mg elemental zinc daily (corresponding to 100 mg zinc gluconate daily) for 2 months in all anorexic patients:
http://www.ncbi.nlm.nih.gov/pubmed/17272939
http://www.ncbi.nlm.nih.gov/pubmed/11930982
http://www.ncbi.nlm.nih.gov/pubmed/8199605
Here's a 1987 article from a pediatrics journal, showing improvement in depression and anxiety following 50 mg/d elemental zinc supplementation in anorexic adolescents:
http://www.ncbi.nlm.nih.gov/pubmed/3312133
In this 1990 open study, anorexic patients were treated with 45-90 mg elemental zinc daily, most of whom had significant improvement in their eating disorder symptoms over 2 years of follow-up.
http://www.ncbi.nlm.nih.gov/pubmed/2291418
Here's a 1992 case report of substantial improvement in severe anorexia following zinc supplementation:
http://www.ncbi.nlm.nih.gov/pubmed/1526438
Zinc depletion may lead to an abnormal sense of taste (hypogeusia or dysgeusia). This sensory abnormality improves with zinc supplementation. Here's a reference:
http://www.ncbi.nlm.nih.gov/pubmed/8835055
Here's a randomized , controlled 2009 Turkish study showing that 10 weeks of 15 mg/day zinc supplementation led to improvement in ADHD symptoms in children. However, a close look at the study shows a bizarre lack of statistical analysis comparing the supplemented group directly with the placebo group. When you look at the data from the article, both groups improved to a modest degree on most measures, with perhaps a little bit more improvement in the zinc group. The analysis here was insufficient, I'm surprised a journal would accept this.
http://www.ncbi.nlm.nih.gov/pubmed/19133873
Here's a 2004 reference to a study showing that 6 weeks of 15 mg elemental zinc daily as an adjunct to stimulant therapy improved ADHD symptoms in children, compared to stimulant therapy plus placebo. In this case, there was a valid statistical analysis:
http://www.ncbi.nlm.nih.gov/pubmed/15070418
Here's a 2009 study showing that zinc supplementation improves the response to antidepressants in treatment-resistant depression. The dose they used was 25 mg elemental zinc daily, over 12 weeks.
http://www.ncbi.nlm.nih.gov/pubmed/19278731
Here's an excellent 2008 review article about zinc deficiency, and about the potential role of zinc supplementation in a wide variety of diseases (e.g. infections ranging from the common cold, to TB, to warts; arthritis; diarrhea; mouth ulcers). The review shows that zinc may have benefit for some of these conditions, but the evidence is a bit inconsistent:
http://www.ncbi.nlm.nih.gov/pubmed/18221847
Here is a warning about zinc toxicity:
http://www.ncbi.nlm.nih.gov/pubmed/12368702 {hematological toxicity from taking 50-300 mg zinc daily for 6-7 months. The toxicity was thought to be due to zinc-induced copper malabsorption leading to sideroblastic anemia}
Here is a nice website from NIH summarizing the role of zinc in the diet, in the body, some of the research about health effects, and about toxicity. It sticks to a recommended daily intake of 10-15 mg elemental zinc for adults, or about 5 mg for young children. It states that the maximum tolerable daily intake levels are about 5-10 mg for young children, 20-30 mg for adolescents, and 40 mg daily for adults:
http://ods.od.nih.gov/FactSheets/Zinc.asp
Here is a reference to another excellent review of zinc requirements, benefits, and risks. It makes more cautious recommendations about zinc supplementation, advising no more than 20 mg/day of zinc intake in adults. In order to prevent copper deficiency, it also advises that that the ratio between zinc intake and copper intake does not exceed 10.
http://www.ncbi.nlm.nih.gov/pubmed/16632171
So, were I to make a recommendation about a zinc supplementation trial, I would advise sticking to amounts under 20 mg (elemental) per day for adults, and to ensure that you are getting 2 mg of copper per day with that.
Wednesday, July 8, 2009
Prazosin and other treatments for PTSD-related nightmares
Nightmares are a common symptom of post-traumatic stress disorder (PTSD).
Various psychotherapeutic approaches can help people to deal with nightmares, both to be more psychologically prepared for them, and to be able to let them pass with a smaller amount of distress. Techniques include simply keeping a written record of the nightmares, with or without doing some cognitive therapy exercises based on this record; practicing relaxation techniques; exposure therapy during the daytime (by evoking the imagery of the nightmares, possibly "rescripting" the sequence of events); or by planning for a "rescripting" of the nightmare during the nightmare itself. Here is a reference to a review article about psychotherapy for nightmares: http://www.ncbi.nlm.nih.gov/pubmed/18853707
Sedative drugs can change dreaming activity, but often times these medications are problematic: tolerance or oversedation may develop, or sometimes the nightmares continue despite other types of sleep improvement.
Prazosin is a cardiovascular drug which blocks alpha-receptors, and is commonly used to treat high blood pressure. Alpha receptors are stimulated by adrenaline, which causes constriction of blood vessels, therefore increased blood pressure. In the brain, increased stimulation of alpha-receptors may be one of the mechanisms driving PTSD-related sleep disturbances such as nightmares. Prazosin has been shown to help reduce PTSD-related nightmares. Here are a few references:
http://www.ncbi.nlm.nih.gov/pubmed/18447662 {a good review article}
http://www.ncbi.nlm.nih.gov/pubmed/17069768 {a 2007 randomized, controlled, crossover study published in Biological Psychiatry, showing pronounced reduction in PTSD-related nightmares with 10-15 mg bedtime doses of prazosin}
http://www.ncbi.nlm.nih.gov/pubmed/12562588 {a 2003 randomized study published in The American Journal of Psychiatry showing substantial benefit in PTSD-related sleep symptoms with prazosin at an average of 10 mg/d}
There is the suggestion in these studies that prazosin, if dosed in the daytime as well, could help treat other PTSD symptoms.
Prazosin has been used for over 35 years in the treatment of hypertension. Interestingly, it is also one of the treatments of choice in the medical management of severe scorpion stings. It may also be a promising option in the treatment of alcoholism (reference: http://www.ncbi.nlm.nih.gov/pubmed/18945226).
Prazosin is well-tolerated by the majority of people taking it. It appears to have minimal psychiatric side-effects. Sedation does not seem to be common. If the dose is too high, too soon, it can cause excessive postural blood pressure drops, with dizziness and a risk of fainting (syncope). It may cause nasal congestion or headache. Priapism (a medically dangerous sexual side-effect) is possible but very rare.
Various psychotherapeutic approaches can help people to deal with nightmares, both to be more psychologically prepared for them, and to be able to let them pass with a smaller amount of distress. Techniques include simply keeping a written record of the nightmares, with or without doing some cognitive therapy exercises based on this record; practicing relaxation techniques; exposure therapy during the daytime (by evoking the imagery of the nightmares, possibly "rescripting" the sequence of events); or by planning for a "rescripting" of the nightmare during the nightmare itself. Here is a reference to a review article about psychotherapy for nightmares: http://www.ncbi.nlm.nih.gov/pubmed/18853707
Sedative drugs can change dreaming activity, but often times these medications are problematic: tolerance or oversedation may develop, or sometimes the nightmares continue despite other types of sleep improvement.
Prazosin is a cardiovascular drug which blocks alpha-receptors, and is commonly used to treat high blood pressure. Alpha receptors are stimulated by adrenaline, which causes constriction of blood vessels, therefore increased blood pressure. In the brain, increased stimulation of alpha-receptors may be one of the mechanisms driving PTSD-related sleep disturbances such as nightmares. Prazosin has been shown to help reduce PTSD-related nightmares. Here are a few references:
http://www.ncbi.nlm.nih.gov/pubmed/18447662 {a good review article}
http://www.ncbi.nlm.nih.gov/pubmed/17069768 {a 2007 randomized, controlled, crossover study published in Biological Psychiatry, showing pronounced reduction in PTSD-related nightmares with 10-15 mg bedtime doses of prazosin}
http://www.ncbi.nlm.nih.gov/pubmed/12562588 {a 2003 randomized study published in The American Journal of Psychiatry showing substantial benefit in PTSD-related sleep symptoms with prazosin at an average of 10 mg/d}
There is the suggestion in these studies that prazosin, if dosed in the daytime as well, could help treat other PTSD symptoms.
Prazosin has been used for over 35 years in the treatment of hypertension. Interestingly, it is also one of the treatments of choice in the medical management of severe scorpion stings. It may also be a promising option in the treatment of alcoholism (reference: http://www.ncbi.nlm.nih.gov/pubmed/18945226).
Prazosin is well-tolerated by the majority of people taking it. It appears to have minimal psychiatric side-effects. Sedation does not seem to be common. If the dose is too high, too soon, it can cause excessive postural blood pressure drops, with dizziness and a risk of fainting (syncope). It may cause nasal congestion or headache. Priapism (a medically dangerous sexual side-effect) is possible but very rare.
Monday, July 6, 2009
Melatonin: benefits and risks
Melatonin is a hormone synthesized in the pineal gland, and is thought to be important in the regulation of circadian (day-night) rhythms.
It has been used to treat insomnia and sleep-phase abnormalities.
The most interesting study I found regarding long-term use of melatonin was published in JAMA in 2008: http://www.ncbi.nlm.nih.gov/pubmed/18544724
In this prospective, blinded study, elderly patients with dementia were given 2.5 mg melatonin near bedtime, over an average of 15 months of follow-up. Patients in another group were exposed to bright light during the day (approximately 1000 Lux indoors, from 10:00 AM to 6:00 PM). A third group received both melatonin at night and bright light in the day. Placebo groups received no melatonin, or were exposed to typical indoor office lighting, of about 300 Lux.* Interestingly, caregivers were not able to tell whether their site had the ordinary lighting or the bright light (the increased light intensity was measurable with a meter, but was not noticeable subjectively).
It has been used to treat insomnia and sleep-phase abnormalities.
The most interesting study I found regarding long-term use of melatonin was published in JAMA in 2008: http://www.ncbi.nlm.nih.gov/pubmed/18544724
In this prospective, blinded study, elderly patients with dementia were given 2.5 mg melatonin near bedtime, over an average of 15 months of follow-up. Patients in another group were exposed to bright light during the day (approximately 1000 Lux indoors, from 10:00 AM to 6:00 PM). A third group received both melatonin at night and bright light in the day. Placebo groups received no melatonin, or were exposed to typical indoor office lighting, of about 300 Lux.* Interestingly, caregivers were not able to tell whether their site had the ordinary lighting or the bright light (the increased light intensity was measurable with a meter, but was not noticeable subjectively).
The results showed that melatonin consistently improved sleep, particularly helping reduce the time required to fall asleep, and increasing total sleep time.
However, the group receiving melatonin alone showed worsening mood (less positive affect & more negative affect).
The group exposed to bright light in the day, plus melatonin at night, did not show worsened mood.
The authors conclude that bright light in the day helps with mood, cognition, and function in elderly dementia patients. Melatonin alone helps with sleep but has a negative impact on mood. Bright light plus melatonin had a positive impact on all the symptoms studied.
Based on this study, I would encourage anyone using melatonin at night to ensure that they get plenty of bright light during the daytime. It also suggests that any study looking at melatonin treatments should also consider daytime bright light exposure as an important variable which could affect response to melatonin.
Here's a reference to a study showing that 2 mg of sustained-release melatonin improves sleep:
http://www.ncbi.nlm.nih.gov/pubmed/18036082
In this study, children with intellectual disabilities experienced relief of their insomnia (including reduced time to fall asleep, reduced time awake, and increased total sleep time) with 5 mg melatonin supplementation over a 4-week period:
http://www.ncbi.nlm.nih.gov/pubmed/18261024
Here's a study showing improved sleep, with no adverse effects, due to melatonin administration to autistic children:
http://www.ncbi.nlm.nih.gov/pubmed/18182647
Here's a study showing improved sleep in children with epilepsy who were treated with adjunctive melatonin (6-9 mg). There were no significant side-effects:
http://www.ncbi.nlm.nih.gov/pubmed/15794175
However, the group receiving melatonin alone showed worsening mood (less positive affect & more negative affect).
The group exposed to bright light in the day, plus melatonin at night, did not show worsened mood.
The authors conclude that bright light in the day helps with mood, cognition, and function in elderly dementia patients. Melatonin alone helps with sleep but has a negative impact on mood. Bright light plus melatonin had a positive impact on all the symptoms studied.
Based on this study, I would encourage anyone using melatonin at night to ensure that they get plenty of bright light during the daytime. It also suggests that any study looking at melatonin treatments should also consider daytime bright light exposure as an important variable which could affect response to melatonin.
Here's a reference to a study showing that 2 mg of sustained-release melatonin improves sleep:
http://www.ncbi.nlm.nih.gov/pubmed/18036082
In this study, children with intellectual disabilities experienced relief of their insomnia (including reduced time to fall asleep, reduced time awake, and increased total sleep time) with 5 mg melatonin supplementation over a 4-week period:
http://www.ncbi.nlm.nih.gov/pubmed/18261024
Here's a study showing improved sleep, with no adverse effects, due to melatonin administration to autistic children:
http://www.ncbi.nlm.nih.gov/pubmed/18182647
Here's a study showing improved sleep in children with epilepsy who were treated with adjunctive melatonin (6-9 mg). There were no significant side-effects:
http://www.ncbi.nlm.nih.gov/pubmed/15794175
High-dose melatonin (1 mg/kg body weight) has been used experimentally to treat intractable epilepsy, but more research is needed to evaluate effectiveness & safety. Here is one reference:
This study showed improved sleep in adolescents with ADHD, when they were given 5 mg melatonin over a 30-day trial. However there was no improvement in ADHD symptoms:
http://www.ncbi.nlm.nih.gov/pubmed/16670647
Melatonin has been associated with autoimmune conditions. Here is a case report associating melatonin use with autoimmune liver disease:
http://www.ncbi.nlm.nih.gov/pubmed/9412927
Here is an article about melatonin possibly exacerbating rheumatoid arthritis (various reports show increased melatonin levels in rheumatoid arthritis patients):
http://www.ncbi.nlm.nih.gov/pubmed/19069959
Yet, in various other reports, melatonin has been shown in animals to protect the liver from various forms of artificially-induced toxicity. (e.g. http://www.ncbi.nlm.nih.gov/pubmed/15386534)
In conclusion, melatonin appears to be have a reasonable safety profile, and is a potentially effective treatment for insomnia, particularly "initial insomnia" in which there is difficulty falling asleep at the beginning of the night. Typical doses of melatonin range from about 2 mg - 6 mg.
The one main concern about adverse effects concerns possible exacerbation of autoimmune diseases such as rheumatoid arthritis, although the evidence is not clear on this point. Other types of toxicity, while possible, appear to be rare. Melatonin may even protect cells from a variety of different types of harm. But it is important to recognize the possibility that there could be other unknown adverse effects over long periods of time.
As with any treatment, we have to balance risks against benefits: insomnia itself clearly has a variety of negative long-term health effects (ranging from increased risk of physical and psychiatric illness, to increased risk of accidents). Other treatments for insomnia have their own risk/benefit profiles.
Cognitive-behavioural therapies for insomnia are clearly the safest and most beneficial, and should be optimized before any other medical therapy. But it appears to me that melatonin ought to have a place in the medical treatment of insomnia, alongside other established therapies.
*here are some measures of light intensity in different settings, to help give you some reference points to compare:
50 Lux -- family living room
100 Lux -- very dark overcast day
300-500 Lux -- recommended office lighting
400 Lux -- sunrise or sunset on a clear day
1000 Lux -- overcast day
10 000 Lux -- clear day (not direct sun)
100 000 Lux -- direct sun
Wednesday, June 17, 2009
Increasing Anxiety in Recent Decades
Another question from a visitor:
Here's the reference:
http://www.ncbi.nlm.nih.gov/pubmed/11138751
This is a good and important article by Twenge, showing that anxiety and neuroticism (the tendency to experience negative emotion) have increased substantially in the past 5 decades, such that, for example, normal children in the 90's had similar scores on anxiety tests as child psychiatric patients from the 50's. The author finds that economic factors are not associated with this change, but that decreased social connectedness, and an increased sense of environmental danger or threat, are associated.
Here's a related comment:
I guess this is a failure of psychiatry/psychology. Not because the therapies don't work, but because the issue is one of public health and culture. I think this type of evidence emphasizes the importance of encouraging social connectedness and community involvement--to whatever degree is possible--as essentials in a therapeutic prescription for treating anxiety or depression.
In this regard, I encourage involvement in volunteering, community organizations, churches, sports teams, activity clubs, etc. It may be necessary to change one's personal culture in order to change anxiety or depression. You must be wary about being swept up in the prevailing culture, and must instead make active choices about what is healthy and meaningful for you.
*As an addendum here, I have to say that research data of this type may be biased by a variety of factors which differ between one time period and another, including use of language, cultural acceptance of symptoms, etc. Therefore, the children in the 50's may have had lower anxiety scores because they were less familiar with the language associated with anxiety symptoms, were less likely to admit such symptoms on a questionnaire, were more likely to deal with the underlying cause of such symptoms in a different way, etc. We now realize many terrible problems which were going on in the 50's (such as abuse), but which people did not talk about as openly back then. A questionnaire on these issues done at that time might have underestimated the degree of such problems.
**Here's another article, showing increasing life satisfaction over the past decades:
http://www.ncbi.nlm.nih.gov/pubmed/19227700
Shifts towards higher anxiety and neuroticism: Twenge** has noted an increase in anxiety and neuroticism in recent decades. Is this the failure of psychiatry/psychology?
Here's the reference:
http://www.ncbi.nlm.nih.gov/pubmed/11138751
This is a good and important article by Twenge, showing that anxiety and neuroticism (the tendency to experience negative emotion) have increased substantially in the past 5 decades, such that, for example, normal children in the 90's had similar scores on anxiety tests as child psychiatric patients from the 50's. The author finds that economic factors are not associated with this change, but that decreased social connectedness, and an increased sense of environmental danger or threat, are associated.
Here's a related comment:
Baumeister* suggests that purpose, values, sense of efficacy, and self-worth are needed for a meaningful life. Religions and spiritual belief-systems have long provided meaning and more. Nietzsche has supposedly said: "He who has a why to live for can bear almost any how". How do you think one can live a meaningful life? *Baumeister, R. F., & Vohs, K. D. (2002). The pursuit of meaningfulness in life. In C. R. Snyder& S. J. Lopez (Eds.), Handbook of positive psychology (pp. 608-618). Oxford: OxfordUniversity Press.I have always felt that a strong sense of belonging, safety, meaningfulness, and community is necessary for mental health. Modern culture supports independence. Perhaps modernity also encourages the solitary pursuit of wealth, educational success, etc., in an increasingly competitive and busy culture. People are less likely to join community organizations or visit friends. People are more likely to remain single or live alone for longer periods of their lifetime (in their 20's and beyond). There are more activities that can absorb time and attention while alone (e.g. video games, recreational drugs). Even music--an aspect of life that was previously associated strongly with social connection--has become a medium in which a person can disappear alone, disconnected from the social milieu, thanks to portable music players. A cost of sexual or relationship freedom, particularly in the internet age, can be a tendency for people to have brief, less committed relationships, in the quest for variety, or in the quest for an "ideal mate." Intellectual freedom and advanced knowledge, while possibly allowing for heightened meaningfulness and enlightenment, may also shatter previous bastions of meaningfulness (such as religious dogmas), and may finally cause one to confront the absurdity and seeming empty arbitrariness of the universe. Owen Barfield, in his book Saving the Appearances, described modernity as a "shattering of idols", leaving a spiritual emptiness which science cannot fill.
I guess this is a failure of psychiatry/psychology. Not because the therapies don't work, but because the issue is one of public health and culture. I think this type of evidence emphasizes the importance of encouraging social connectedness and community involvement--to whatever degree is possible--as essentials in a therapeutic prescription for treating anxiety or depression.
In this regard, I encourage involvement in volunteering, community organizations, churches, sports teams, activity clubs, etc. It may be necessary to change one's personal culture in order to change anxiety or depression. You must be wary about being swept up in the prevailing culture, and must instead make active choices about what is healthy and meaningful for you.
*As an addendum here, I have to say that research data of this type may be biased by a variety of factors which differ between one time period and another, including use of language, cultural acceptance of symptoms, etc. Therefore, the children in the 50's may have had lower anxiety scores because they were less familiar with the language associated with anxiety symptoms, were less likely to admit such symptoms on a questionnaire, were more likely to deal with the underlying cause of such symptoms in a different way, etc. We now realize many terrible problems which were going on in the 50's (such as abuse), but which people did not talk about as openly back then. A questionnaire on these issues done at that time might have underestimated the degree of such problems.
**Here's another article, showing increasing life satisfaction over the past decades:
http://www.ncbi.nlm.nih.gov/pubmed/19227700
Intuition in Psychiatric Practice
Another question from a visitor:
Good question. I think the crucial point here is "what constitutes evidence?"
Years of positive personal experience with something is itself a strong type of evidence. A negative study is another type of evidence. In all logical assessments of treatments, we must weigh the positive evidence against the negative.
If there was such a strong negative study, particularly if it was done with scientific and statistical rigour, it should lead to a critical re-appraisal of one's own practice, to examine reasons why one's own experience was so different from what another study shows. We should always be prepared to change our ways if strong evidence challenges the status quo.
I don't think "intuition" need be placed in opposition to "logic" or "evidence." I like to think that healthy intuition is a way to incorporate logic and evidence in a way which is flexible and open-minded, and which allows room for creativity.
In clinical practice, a manifestation of "intuition" may at times be a product of a great deal of experience or mastery in something (with the acquisition of "formal operations" in one's area of specialty, in a Piagetian sense), such that pattern recognition and responses can happen very quickly. We can see this in chess players, musicians, auto mechanics...any type of acquired expertise. Things appear to happen effortlessly, seemingly without a thought--certainly without the laborious calculations or stilted rumination which a beginner might apply to the task. These "formal operations" though, represent a great efficiency of weighing evidence and decision-making, not an absence of reason. Those who reject formal evidence in favour of their supposed "intuition" are in a different camp. This would be like the chess player or musician who does not pay attention to his or her weaknesses of technique, or like the auto mechanic who doesn't bother to check the oil. I consider this practice to be inefficient and potentially quite dangerous. There are studies which show that "intuitive" diagnostic impressions in psychiatry are often inaccurate (I'll have to find some references); yet I return to my claim that intuition can be a manifestation of our ability to process information quickly, efficiently, even subconsciously, and often with a natural grace and ease which can be a joy of life to practice or witness.
But intuition cannot be used recklessly or with disregard for other types of evidence.
Conversely, over-reliance on non-intuitive evidence can also be stilted and inefficient. The musician who has note-perfect technique, without grace, is uninteresting. A physician who goes through a symptom checklist meticulously, but fails to attend to alarming non-verbal cues, may entirely miss the underlying problem--a problem which is not detectable by a checklist, because checklist data may not be valid or relevant in cases where process is not attended to.
Evidence-Based Medicine: Do you find that intuition has its place in practice of clinical psychiatry? Despite years of positive experience with a certain technique or medicine, would you decide against it if the only study done on it finds it harmful or useless? If not, how do you go about qualifying your sense of intuition and personal experience?
Good question. I think the crucial point here is "what constitutes evidence?"
Years of positive personal experience with something is itself a strong type of evidence. A negative study is another type of evidence. In all logical assessments of treatments, we must weigh the positive evidence against the negative.
If there was such a strong negative study, particularly if it was done with scientific and statistical rigour, it should lead to a critical re-appraisal of one's own practice, to examine reasons why one's own experience was so different from what another study shows. We should always be prepared to change our ways if strong evidence challenges the status quo.
I don't think "intuition" need be placed in opposition to "logic" or "evidence." I like to think that healthy intuition is a way to incorporate logic and evidence in a way which is flexible and open-minded, and which allows room for creativity.
In clinical practice, a manifestation of "intuition" may at times be a product of a great deal of experience or mastery in something (with the acquisition of "formal operations" in one's area of specialty, in a Piagetian sense), such that pattern recognition and responses can happen very quickly. We can see this in chess players, musicians, auto mechanics...any type of acquired expertise. Things appear to happen effortlessly, seemingly without a thought--certainly without the laborious calculations or stilted rumination which a beginner might apply to the task. These "formal operations" though, represent a great efficiency of weighing evidence and decision-making, not an absence of reason. Those who reject formal evidence in favour of their supposed "intuition" are in a different camp. This would be like the chess player or musician who does not pay attention to his or her weaknesses of technique, or like the auto mechanic who doesn't bother to check the oil. I consider this practice to be inefficient and potentially quite dangerous. There are studies which show that "intuitive" diagnostic impressions in psychiatry are often inaccurate (I'll have to find some references); yet I return to my claim that intuition can be a manifestation of our ability to process information quickly, efficiently, even subconsciously, and often with a natural grace and ease which can be a joy of life to practice or witness.
But intuition cannot be used recklessly or with disregard for other types of evidence.
Conversely, over-reliance on non-intuitive evidence can also be stilted and inefficient. The musician who has note-perfect technique, without grace, is uninteresting. A physician who goes through a symptom checklist meticulously, but fails to attend to alarming non-verbal cues, may entirely miss the underlying problem--a problem which is not detectable by a checklist, because checklist data may not be valid or relevant in cases where process is not attended to.
Metaphors
Here's another question from a visitor:
Theoretically, it has been part of a larger world-view of mine, that a great deal of wisdom is couched in metaphorical language, yet this language is often taken literally by dogmatic adherents. The dogmatism intensely suppresses the wisdom. This happens frequently in religion, politics, and even in science and medicine. Joseph Campbell was one of my influences: I think he had a great balance of wisdom, humour, and story-telling ability--these are qualities of a good physician, thinker, or healer. Campbell himself was influenced by psychoanalytic thinkers such as Freud, and particularly Jung, but in my opinion his writing never had the annoyingly dogmatic and preachy tone characteristic of these psychoanalysts. Yet, Campbell's ideas are intellectually limited, and I think one should be wary of going too far with them (I find many styles of therapy which are overtly about "exploring myths", etc. to be tiresome, ignorant of modern scientific evidence, and overburdened with jargon). But I liked Joseph Campbell's style, and maybe this is one of the reasons I like "indulging in metaphor" at times as part of my work.
You note that you like using metaphors in psychotherapy. Can you elaborate more on the use of metaphor. I personally find that using metaphors can have its downside. Some metaphors, once useful--or helpful to those who never heard of them--can become quite trite and cliché. They may even take on negative connotations if associated with unpleasant memory or a disagreeable person from the client's past.To some degree it is a personal indulgence on my part to attempt to use metaphors. I think you're quite right that this could be unhelpful or annoying to others, and at the very least trite or cliché. I would need to keep this tendency of mine healthily reigned in when necessary. It is, however, very characteristic of me, and a pleasure of mine, to seek out a new metaphor, and therefore an aspect of genuineness that I would attempt to share with patients at times.
Theoretically, it has been part of a larger world-view of mine, that a great deal of wisdom is couched in metaphorical language, yet this language is often taken literally by dogmatic adherents. The dogmatism intensely suppresses the wisdom. This happens frequently in religion, politics, and even in science and medicine. Joseph Campbell was one of my influences: I think he had a great balance of wisdom, humour, and story-telling ability--these are qualities of a good physician, thinker, or healer. Campbell himself was influenced by psychoanalytic thinkers such as Freud, and particularly Jung, but in my opinion his writing never had the annoyingly dogmatic and preachy tone characteristic of these psychoanalysts. Yet, Campbell's ideas are intellectually limited, and I think one should be wary of going too far with them (I find many styles of therapy which are overtly about "exploring myths", etc. to be tiresome, ignorant of modern scientific evidence, and overburdened with jargon). But I liked Joseph Campbell's style, and maybe this is one of the reasons I like "indulging in metaphor" at times as part of my work.
Psychologists Prescribing Antidepressants?
Here's another question from a visitor:
Your views on psychologists' obtaining the right to administer antidepressant.
I don't have any problem with this. If psychologists, or anyone else, were to have prescribing privileges, I do think there should be an educational program with a licensing exam, with continuing education requirements for maintaining licensure, etc., to ensure that the prescribers are up-to-date and knowledgable about the medications and risks, etc. At that point, it could be up to an informed patient to decide whether to trust and accept a prescription from a psychologist. As far as I'm concerned, this is a fair balance between regulation and individual rights in a freedom-oriented society.
I think some psychiatrists' opposition to psychologist prescribing has a lot to do with wanting to hold on to more influence, authority, power, or perhaps a greater sense of importance or exclusivity. There may be elements of narcissism and insecurity which underlie this position. It reminds me of the history of modern medical opposition to midwifery.
While many patients need complicated regimes of medication, may have complex comorbid medical problems, and may therefore require a highly specialized expert in psychopharmacology to prescribe for them (actually, the level of expertise in this area among psychiatrists is very inconsistent), the majority of patients who might benefit from antidepressants require a very simple regimen. Such a regimen does not require many years of advanced education to competently administer. It seems a waste of time and health-care expense for those individuals to have to seek out an MD for their prescriptions.
Furthermore, many antidepressant prescriptions are currently written by a gp who may have only seen the patient for a few minutes--if psychologists were prescribing, this would most likely be in the context of knowing the patient very well, with hour-long appointments, and offering very good follow-up care.
There are risks associated with prescription antidepressants, and there are bound to be patients who run into problems after being prescribed antidepressants from a psychologist. But I am doubtful that these risks would be higher than if antidepressants were only available from an MD, particularly if prescribing privileges required passing a licensing exam, etc.
Future of personalized antidepressants
Another question from a visitor:
Advances in psychiatrist medications: Holsboer has recently elaborated on the future of personalized antidepressants designed using genotype and biomarkers. Where do you think psychiatry is headed, in terms of ideology, but also medications and treatments?
Here's the reference:
http://www.ncbi.nlm.nih.gov/pubmed/18628772
It's an interesting and important subject. In current practice, it can be hard to find medications or other types of therapy which are helpful. It would relieve a great deal of suffering much more quickly to have some way of determining, in advance, which particular treatment for psychiatric illnesses might help best.
Also, the article emphasizes the need to search for treatments outside of the current pharmacological paradigms; we probably have enough medication choices affecting serotonin uptake, etc. It will probably be important to search for pharmacological treatments which affect other systems in the brain.
I don't feel very well-informed about the cutting edge of this science (translating genetic research into pharmacological treatments), but I can see this being a huge advance in the coming decades.
Are Psychiatrists Professionals, Friends, or Healers?
Another question from a visitor:
The standard of practice in psychiatry, and in other areas of medicine, is for the therapeutic relationship to be "well-boundaried." Mind you, this seems like an obvious truth; furthermore, any healthy friendship also needs to be "well-boundaried." Many unhealthy friendships or family dynamics are problematic due to unhealthy or absent boundaries. But in psychiatry, there are formal legal and professionally-mandated restrictions around the type of relationships permitted between therapist and patient, or between therapists and former patients. In general, I would say the rule is that any interaction between psychiatrist and patient (or between psychiatrist and former patient) needs to be considered a "therapeutic action," or at least an attempt to be a "therapeutic action," and if this interaction cannot be justified as such, it would be considered outside a healthy boundary. These rules protect patients from unethical practioners.
But I do consider any type of healthy human interaction to be a manifestation of a type of friendship. And I consider it a healthy way to live, to consider that all of one's interactions in the world are "friendship-building" activities. To experience the very personal relationship of psychotherapy as strictly bereft of "friendship" seems wrong to me.
Different individuals will have different needs or wishes in this regard. For many people, they prefer to interact with a psychiatrist or other professional in a polite but formal and distant way. Many people would not want to have a friendship with their psychiatrist or physician.
For many others, closeness and trust in a therapy relationship is extremely important to nurture.
One thing I strongly feel to be true is that the therapy relationship needs to be a setting in which growth of healthy relationships outside of the therapy relationship can be encouraged.
I am reminded of some of the psychiatric theory from the previous century about "object relations." This theory generally considers that relationships become "internalized" as abstract mental models, during the course of development. Relationships with parents during early childhood become the first internalized models. Recent evidence establishes that early peer relationships are extremely important in psychological development, perhaps having an equal or larger effect than parental relationships in many cases. Included in these internalized relationships are a sense of "other," a sense of "self," and a sense of expected dynamics between "self" and "other." Future relationships then develop which tend to be in synchrony, or in a type of resonance, with the internalized models. If these internalized models are disturbed by unhealthy relationships, absent or neglectful caregivers, abuse, environmental adversity, or inherent neuropsychiatric symptoms (such as innate tendencies to be anxious, irritable, depressed, etc.), then future relationships are likely also to be disturbed. This leads to a vicious cycle of unhealthy relationships and escalating symptoms.
In a therapeutic relationship, I think this "object relations" idea is important. The therapeutic relationship should aim to be one in which previous vicious cycles are not allowed to repeat. Over time, if the therapeutic relationship is healthy, it could perhaps become "internalized" as well, hopefully as a model of comfort, stability, nurturance, respect, trust, and healthy boundaries. In this way, I think the role of therapist is a bit more like the role of a parent, in that there is an element of friendship, a strong expectation of nurturance, a benevolent "paternalism" to some degree (some desire this element more or less than others), but also the observation that the "parent" becomes less and less necessary for meeting personal needs as the relationship develops over time.
There can sometimes be experiences of very great personal need. The experience of therapy can partially meet this need. The boundaries of the therapy can feel tremendously frustrating for a patient if this need is only partially met. Yet I feel that part of the growth experience in therapy can be to come to terms with this frustration, i.e. that the therapist is a positive, caring figure, but also that the therapist is limited and unable to meet any need completely or perfectly. If the therapy is to be truly effective or "healing," then the more complete or "perfect" satisfaction of needs eventually could occur outside of the therapy, during daily life.
Here's a light-hearted poem about this theme. It's by Hal Sirowitz, from the collection My Therapist Said.
* I like this poem but it's okay with me if you tell people you're in therapy!
**Thank you to the reader who found the author's name & info for me.
Are psychiatrists professionals, friends, or healers? I personally believe that healing occurs in a time and place beyond professional rules and regulations. Even friendships can be healing. I wonder if professionalization of medicine is antithetical to a healing process that is dependent on...deep human connection.This is a good question, one I've often thought about.
The standard of practice in psychiatry, and in other areas of medicine, is for the therapeutic relationship to be "well-boundaried." Mind you, this seems like an obvious truth; furthermore, any healthy friendship also needs to be "well-boundaried." Many unhealthy friendships or family dynamics are problematic due to unhealthy or absent boundaries. But in psychiatry, there are formal legal and professionally-mandated restrictions around the type of relationships permitted between therapist and patient, or between therapists and former patients. In general, I would say the rule is that any interaction between psychiatrist and patient (or between psychiatrist and former patient) needs to be considered a "therapeutic action," or at least an attempt to be a "therapeutic action," and if this interaction cannot be justified as such, it would be considered outside a healthy boundary. These rules protect patients from unethical practioners.
But I do consider any type of healthy human interaction to be a manifestation of a type of friendship. And I consider it a healthy way to live, to consider that all of one's interactions in the world are "friendship-building" activities. To experience the very personal relationship of psychotherapy as strictly bereft of "friendship" seems wrong to me.
Different individuals will have different needs or wishes in this regard. For many people, they prefer to interact with a psychiatrist or other professional in a polite but formal and distant way. Many people would not want to have a friendship with their psychiatrist or physician.
For many others, closeness and trust in a therapy relationship is extremely important to nurture.
One thing I strongly feel to be true is that the therapy relationship needs to be a setting in which growth of healthy relationships outside of the therapy relationship can be encouraged.
I am reminded of some of the psychiatric theory from the previous century about "object relations." This theory generally considers that relationships become "internalized" as abstract mental models, during the course of development. Relationships with parents during early childhood become the first internalized models. Recent evidence establishes that early peer relationships are extremely important in psychological development, perhaps having an equal or larger effect than parental relationships in many cases. Included in these internalized relationships are a sense of "other," a sense of "self," and a sense of expected dynamics between "self" and "other." Future relationships then develop which tend to be in synchrony, or in a type of resonance, with the internalized models. If these internalized models are disturbed by unhealthy relationships, absent or neglectful caregivers, abuse, environmental adversity, or inherent neuropsychiatric symptoms (such as innate tendencies to be anxious, irritable, depressed, etc.), then future relationships are likely also to be disturbed. This leads to a vicious cycle of unhealthy relationships and escalating symptoms.
In a therapeutic relationship, I think this "object relations" idea is important. The therapeutic relationship should aim to be one in which previous vicious cycles are not allowed to repeat. Over time, if the therapeutic relationship is healthy, it could perhaps become "internalized" as well, hopefully as a model of comfort, stability, nurturance, respect, trust, and healthy boundaries. In this way, I think the role of therapist is a bit more like the role of a parent, in that there is an element of friendship, a strong expectation of nurturance, a benevolent "paternalism" to some degree (some desire this element more or less than others), but also the observation that the "parent" becomes less and less necessary for meeting personal needs as the relationship develops over time.
There can sometimes be experiences of very great personal need. The experience of therapy can partially meet this need. The boundaries of the therapy can feel tremendously frustrating for a patient if this need is only partially met. Yet I feel that part of the growth experience in therapy can be to come to terms with this frustration, i.e. that the therapist is a positive, caring figure, but also that the therapist is limited and unable to meet any need completely or perfectly. If the therapy is to be truly effective or "healing," then the more complete or "perfect" satisfaction of needs eventually could occur outside of the therapy, during daily life.
Here's a light-hearted poem about this theme. It's by Hal Sirowitz, from the collection My Therapist Said.
BETTER THAN A FRIEND
You shouldn't tell everyone that you're
in therapy, my therapist said. Some people
might think you're crazy. If
someone asks why you go to the city
at the same time each week, you should
just tell him that you have an appointment
with a friend, which is not really a lie,
because I'm your friend. But I'm also
so much more. You can insult me, & I'll
never get mad. I'll just say that you're
transferring again. I'll never leave you,
but you can leave me. One day you'll
tell me that you don't need to see me anymore,
& instead of being mad, I'll be happy,
because that'll mean you're cured. But
I wouldn't advise you to do that
in the near future. You still have problems.
* I like this poem but it's okay with me if you tell people you're in therapy!
**Thank you to the reader who found the author's name & info for me.
Tuesday, June 16, 2009
Political Involvement of Psychiatrists
Here's another excellent question from a visitor to the site:
I've often thought of the ideal role of psychiatrist (politically) as some kind of monastic figure ("Jedi-like", if I could indulge in a popular culture metaphor): serenely outside the political machine, possessing wisdom but healthily setting aside the need to exert power or control at all. This type of paradigm is in conflict with the competitive and ambitious world of politics or administration.
I do agree that we all need to be more active in informing ourselves about political concerns, and attempting to help not only individuals, but also groups, communities, or nations. And psychiatry as an organized group most definitely needs to be aware of large-scale social effects of treatments such as psychotherapy and medications.
In very dark and troubled times, or in dark and troubled parts of the world, very bad things can happen politically. The institution of psychiatry has sometimes been involved in these events. At other times, psychiatrists or therapists are themselves persecuted. It is a luxury to live in a peaceful and free nation, and we need to be vigilant to maintain social and political freedom.
Here are a few articles about this:
http://www.atypon-link.com/GPI/doi/pdf/10.1521/prev.88.2.295.17677 (an essay about psychiatry in Nazi Germany)
http://www.nybooks.com/articles/16082 (an 2003 excerpt published in the New York Review of Books about psychiatry in China)
Political involvement of psychiatrists: We live in a "therapeutic culture". [There] are changing sociocultural norms for what is considered normal and acceptable. Are--and should--psychiatrists be aware of the sociological and political changes occurring as a result of the millions taking antidepressants or receiving psychotherapy? Should psychiatrists take a more active role in managing forces that influence communities, given the positive therapeutic effects of unconditional positive regard, hope, trust, interpersonal connection, and belonging (some of the common factors)?Psychiatrists as a group are extremely heterogeneous, in terms of personality style, intellectual background, and political beliefs. Those who involve themselves in administration or politics may do so in a loving attempt to help their community, but may also do so due to a need to have more influence, control, money, or self-aggrandizement (to be fair, I suppose most people would be motivated by all of these factors, to some degree). There are a lot of big egos in psychiatry, just like everywhere else.
I've often thought of the ideal role of psychiatrist (politically) as some kind of monastic figure ("Jedi-like", if I could indulge in a popular culture metaphor): serenely outside the political machine, possessing wisdom but healthily setting aside the need to exert power or control at all. This type of paradigm is in conflict with the competitive and ambitious world of politics or administration.
I do agree that we all need to be more active in informing ourselves about political concerns, and attempting to help not only individuals, but also groups, communities, or nations. And psychiatry as an organized group most definitely needs to be aware of large-scale social effects of treatments such as psychotherapy and medications.
In very dark and troubled times, or in dark and troubled parts of the world, very bad things can happen politically. The institution of psychiatry has sometimes been involved in these events. At other times, psychiatrists or therapists are themselves persecuted. It is a luxury to live in a peaceful and free nation, and we need to be vigilant to maintain social and political freedom.
Here are a few articles about this:
http://www.atypon-link.com/GPI/doi/pdf/10.1521/prev.88.2.295.17677 (an essay about psychiatry in Nazi Germany)
http://www.nybooks.com/articles/16082 (an 2003 excerpt published in the New York Review of Books about psychiatry in China)
Neurology & Psychiatry
Here's another question from a visitor to the site:
"Neurology and Psychiatry: ...I continue to read the scientific literature and I find it somewhat arbitrary how different fields are divided up. What do you think of joining psychiatry and neurology?"
The field of "neuropsychiatry" is extremely interesting. At UBC there is a specialized ward devoted to helping patients who suffer from a combination of neurological diseases (such as epilepsy, head injuries, etc.) and psychiatric illnesses. Some "neuropsychiatrists" have completed specialty training in both neurology and psychiatry. At UBC a particular focus in neuropsychiatry has been the treatment of severe somatization and conversion disorders: these are psychiatric illnesses which present with severe physical or neurological symptoms (such as paralysis, blindness, or seizures). In conversion disorders, symptoms such as paralysis, blindness, or seizures, are not caused by neurologic problems such as stroke or epilepsy, but by severe, complicated depression in most cases. Treatment of the underlying psychiatric illness causes the neurological symptoms to disappear.
So, neurology and psychiatry do have an intersection in current practice. However, many neurologists may not be predisposed to dealing with psychiatric problems, or may not be willing to offer the type of regular follow-up which I believe is a healthy standard of care in psychiatry (unfortunately, the same could be said of some psychiatrists). Conversely, most psychiatrists would be uncomfortable dealing with acute or esoteric neurological problems.
So, in practice, while neurology and psychiatry have an overlap, the areas outside of the overlap are sufficiently large for the specialties to exist separately.
"Neurology and Psychiatry: ...I continue to read the scientific literature and I find it somewhat arbitrary how different fields are divided up. What do you think of joining psychiatry and neurology?"
The field of "neuropsychiatry" is extremely interesting. At UBC there is a specialized ward devoted to helping patients who suffer from a combination of neurological diseases (such as epilepsy, head injuries, etc.) and psychiatric illnesses. Some "neuropsychiatrists" have completed specialty training in both neurology and psychiatry. At UBC a particular focus in neuropsychiatry has been the treatment of severe somatization and conversion disorders: these are psychiatric illnesses which present with severe physical or neurological symptoms (such as paralysis, blindness, or seizures). In conversion disorders, symptoms such as paralysis, blindness, or seizures, are not caused by neurologic problems such as stroke or epilepsy, but by severe, complicated depression in most cases. Treatment of the underlying psychiatric illness causes the neurological symptoms to disappear.
So, neurology and psychiatry do have an intersection in current practice. However, many neurologists may not be predisposed to dealing with psychiatric problems, or may not be willing to offer the type of regular follow-up which I believe is a healthy standard of care in psychiatry (unfortunately, the same could be said of some psychiatrists). Conversely, most psychiatrists would be uncomfortable dealing with acute or esoteric neurological problems.
So, in practice, while neurology and psychiatry have an overlap, the areas outside of the overlap are sufficiently large for the specialties to exist separately.
Passion Flower
There's not a lot of research information about passion flower's medical effects.
It's a beautiful flower though! I would encourage having some in your garden if possible.
Here's a reference to a 2007 Cochrane review:
http://www.ncbi.nlm.nih.gov/pubmed/17253512
Passion flower is mentioned in a good 2006 review article on complementary medicines in psychiatry, from The British Journal of Psychiatry:
http://www.ncbi.nlm.nih.gov/pubmed/16449696
Here's a reference to a 2001 study from Iran, showing that passionflower relieved anxiety to a similar degree as oxazepam (a benzodiazepine), over a 4 week trial.
http://www.ncbi.nlm.nih.gov/pubmed/11679026
The same author published a study suggesting that passionflower could help with opiate withdrawal symptoms:
http://www.ncbi.nlm.nih.gov/pubmed/11679027
In conclusion, not a lot of evidence. The existing studies are only of short duration. But passionflower extract does look like an interesting substance to research further.
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