Chmielewski et al. have published an article in the September 2011 edition of the Canadian Journal of Psychiatry in which they show that borderline personality is better described as having several separate symptom dimensions.
The benefit of having several dimensions instead of one could be illustrated by way of analogy: suppose we are talking about heart disease. One could simply describe all patients suffering a "heart attack" according to a single severity scale, perhaps including information of the amount of pain, degree of disability afterwards, etc. This scale could be quite useful, but it would obscure a great deal of information about the group, and reduce the efficiency of treatment. A multi-dimensional scale would instead look at several domains separately, such as perfusion abnormalities, rhythm abnormalities, and structural abnormalities. Abnormal perfusion might be treated specifically with bypass surgery, rhythm problems with a pacemaker, and structural problems with a valve replacement etc. Thus the management could become more meaningfully specific.
The authors of this paper about borderline personality show that a 3-factor model fit well to describe symptoms in borderline patients; a 1-dimensional model fit much more poorly. The 3 factors are "affective dysregulation," "behavioural dysregulation," and "disturbed relations." Affective dysregulation would refer to high intensity and lability of negative emotion, inappropriate anger, etc. Behavioural dysregulation would refer to self-injurious behaviour, excessive or out-of-control behaviours such as binge eating, or I might add any sort of chemical or behavioural addiction. Disturbed relations of course refers to interpersonal relationship problems. One could see that these three domains would each influence the others, but part of a theoretical model is to consider to what degree problems in each domain could be considered primary. (similarly, a blocked coronary artery would be a primary perfusion problem, but could in turn cause a secondary rhythm and structural problem in the heart).
A particularly relevant remark from the authors comes in the discussion: "...the current pattern of associations suggests that the glue that holds the BPD construct together may largely represent the general dysfunction or misery common across all forms of psychopathology and not just BPD." So, the authors are hinting that we could perhaps do away with the BPD construct altogether, without any loss of insight, and instead simply describe in succinct terms what the core symptoms are. This makes sense to me. I do believe that some of these core symptoms are extremely important to examine and address directly. "Affective dysregulation" would be almost automatically addressed in any therapy environment, and "relationship dysfunction" is perhaps the most frequent topic of discussion (and perhaps transferential work) done in therapy. But the "behavioural dysregulation"domain I think is not quite so well-addressed in much therapeutic work. I see this domain as the most common severe problem relatively more unique to those who fit into a "borderline personality" spectrum. It is my own view to consider this domain through a type of addiction-medicine lens, as a set of problems which are highly destructive and addictive behavioural habits, often engaged in to cope with other symptoms, but which become independent problems with time. This is similar to any other addiction; alcoholism, for example, may begin as alcohol consumption intended to calm nerves, deal with boredom, or to facilitate socialization, but in time becomes more and more a separate, self-contained behavioural and physiological addiction.
In my browsing through the literature as I was writing this post just now, I encountered a psychology master's thesis published online (by Edward Selby, M.Sc. 2007). Here's a link:
http://etd.lib.fsu.edu/theses/available/etd-07092007-164107/unrestricted/SelbyMastersThesisFinal.pdf
Selby makes the case well that negative emotional cascades leading to behavioural dyregulation are strongly fuelled by rumination. The events of behavioural dysregulation, such as self-injury, serve to distract one from the intense discomfort of rumination. Here is a quote from the conclusion:
"the findings of this study provide preliminary evidence for an
emotional cascade model of dysregulated behavior. In this model high levels of rumination may cause extremely intense states of negative affect, which result in dysregulated behaviors that distract from rumination and reduce that state of negative affect. This study specifically linked rumination to drinking to cope, binge-eating behaviors, reassurance seeking, and urgency, and it is likely that rumination is linked to a variety of other deregulated behaviors. "
Rumination, of course, is another phenomenon common to much "general dysfunction or misery." I am reminded how important it can be, as a practical therapeutic project with patients, to work on ways to move away from, or to let go of, rumination. (see my previous post on rumination: http://garthkroeker.blogspot.com/2011/08/chronic-pain-rumination.html)
Thursday, September 29, 2011
Thursday, August 18, 2011
"Anti-psychiatry"
I'm just bumping up this post, originally from July 2008, because there have been some new comments.
There are a lot of strong opinions out there about psychiatry.
Some people are concerned that the practice of psychiatry has caused harm, perhaps by "over-medicalizing" issues that should be considered matters of personal challenge, character, individual choice & responsibility, spirituality, or normal human experience. Other concerns are that psychiatry is overly influenced by large pharmaceutical companies, whose agenda is to earn larger profits by selling more medication. Critics holding these concerns often consider the results of research studies to be biased, since they have often been sponsored by drug companies.
I think these concerns need to be heard and respected. There are specific examples about some of the concerns having some validity to them. In the history of psychiatry, as in the history of all other human endeavour, mistakes have been made. Small mistakes and large mistakes. On a systemic level, I think some of the core theories about psychiatry over the past hundred years have been laden with huge inaccuracies, despite the many nuggets of wisdom contained within them (Freud's ideas are one example). Many times, attempts at treatment have not helped, or perhaps have reduced a symptom at a very great expense to other aspects of the patient's life. There have been trends and fashions in treatment, such as the widespread use of anxiolytic drugs in past decades--while only later do we discover that these treatments can cause entrenched problems with addiction.
Conversely, there are some testimonial accounts of individuals who have had long histories of conventional psychiatric therapies, who have gone on to thrive once leaving all of these behind (perhaps pursuing alternative or naturopathic medicine, or making some other lifestyle change).
I think it is important to step back and examine the evidence closely, with a critical eye (in future posts I will refer to some of the evidence). I hold that there is a vast body of evidence about psychiatry to look at. And the evidence shows that the treatments are truly helpful. The evidence also shows that the treatments are not perfect, and that typically 30% of people do not have a good response from a given psychiatric treatment. The evidence also shows that up to 30% of patients respond to "placebo treatments". These facts lead to several criticisms about psychiatric treatment: first, there are many (perhaps in the first group of 30%) who have tried "conventional psychiatry" and have found that it hasn't worked for them. Second, there are those who have tried "non-psychiatric" treatments, and found that these HAVE worked for them (perhaps these people are in the 30% "placebo" group). Both of these groups may have a tendency to criticize psychiatry; yet there is another 40% -- a group whose ailments have resolved as a direct result of their psychiatric treatments.
This has always reminded me a bit of other areas of medicine, such as cardiology or oncology: the treatments in these specialties can be remarkably curative for some, only palliative for others, and may not work at all for others still.
I do agree that we must never "over-medicalize" any human ailment. It is rare for a problem to be truly cured by a pill. Usually, for any human concern or challenge, any therapy that helps has to be accompanied by holistic changes in lifestyle & behaviour. For the cardiac patient, this means rehabilitative exercise, healthy diet, no smoking, etc. For the mind, just as for the heart, there are many lifestyle habits that are healthy, restorative, and protective against recurrent illness.
Yet, very often people are too ill to be able to institute the "healthy lifestyle habits". The cardiac patient may require medication to control blood pressure and angina before being able to safely or comfortably exercise. Similarly, there are medical treatments in psychiatry that can hopefully provide enough symptom relief to allow the patient to energetically change their life for the better.
I have observed that the "anti-psychiatry" group can be very vocal. I could understand that the individuals among this group could have good reasons to hold such strong, forceful opinions. But I don't want this site to be a forum to spend a lot of time on this debate, I would rather focus on my own beliefs about ways to manage the mind's symptoms in the healthiest possible ways.
There are a lot of strong opinions out there about psychiatry.
Some people are concerned that the practice of psychiatry has caused harm, perhaps by "over-medicalizing" issues that should be considered matters of personal challenge, character, individual choice & responsibility, spirituality, or normal human experience. Other concerns are that psychiatry is overly influenced by large pharmaceutical companies, whose agenda is to earn larger profits by selling more medication. Critics holding these concerns often consider the results of research studies to be biased, since they have often been sponsored by drug companies.
I think these concerns need to be heard and respected. There are specific examples about some of the concerns having some validity to them. In the history of psychiatry, as in the history of all other human endeavour, mistakes have been made. Small mistakes and large mistakes. On a systemic level, I think some of the core theories about psychiatry over the past hundred years have been laden with huge inaccuracies, despite the many nuggets of wisdom contained within them (Freud's ideas are one example). Many times, attempts at treatment have not helped, or perhaps have reduced a symptom at a very great expense to other aspects of the patient's life. There have been trends and fashions in treatment, such as the widespread use of anxiolytic drugs in past decades--while only later do we discover that these treatments can cause entrenched problems with addiction.
Conversely, there are some testimonial accounts of individuals who have had long histories of conventional psychiatric therapies, who have gone on to thrive once leaving all of these behind (perhaps pursuing alternative or naturopathic medicine, or making some other lifestyle change).
I think it is important to step back and examine the evidence closely, with a critical eye (in future posts I will refer to some of the evidence). I hold that there is a vast body of evidence about psychiatry to look at. And the evidence shows that the treatments are truly helpful. The evidence also shows that the treatments are not perfect, and that typically 30% of people do not have a good response from a given psychiatric treatment. The evidence also shows that up to 30% of patients respond to "placebo treatments". These facts lead to several criticisms about psychiatric treatment: first, there are many (perhaps in the first group of 30%) who have tried "conventional psychiatry" and have found that it hasn't worked for them. Second, there are those who have tried "non-psychiatric" treatments, and found that these HAVE worked for them (perhaps these people are in the 30% "placebo" group). Both of these groups may have a tendency to criticize psychiatry; yet there is another 40% -- a group whose ailments have resolved as a direct result of their psychiatric treatments.
This has always reminded me a bit of other areas of medicine, such as cardiology or oncology: the treatments in these specialties can be remarkably curative for some, only palliative for others, and may not work at all for others still.
I do agree that we must never "over-medicalize" any human ailment. It is rare for a problem to be truly cured by a pill. Usually, for any human concern or challenge, any therapy that helps has to be accompanied by holistic changes in lifestyle & behaviour. For the cardiac patient, this means rehabilitative exercise, healthy diet, no smoking, etc. For the mind, just as for the heart, there are many lifestyle habits that are healthy, restorative, and protective against recurrent illness.
Yet, very often people are too ill to be able to institute the "healthy lifestyle habits". The cardiac patient may require medication to control blood pressure and angina before being able to safely or comfortably exercise. Similarly, there are medical treatments in psychiatry that can hopefully provide enough symptom relief to allow the patient to energetically change their life for the better.
I have observed that the "anti-psychiatry" group can be very vocal. I could understand that the individuals among this group could have good reasons to hold such strong, forceful opinions. But I don't want this site to be a forum to spend a lot of time on this debate, I would rather focus on my own beliefs about ways to manage the mind's symptoms in the healthiest possible ways.
Wednesday, August 10, 2011
Chronic Pain & Rumination
I was planning to write separate posts on chronic pain and on rumination; but I have found that these subjects are related to each other, so I thought I would combine them.
In this article, I am defining "rumination" as frequent, repetitive thoughts about symptoms or problems. Such recurrent thinking can consume so much time and energy, that little is left in the mind to permit quality of life. And the ruminations, while understandable in the context of troubling symptoms or problems, do not help to resolve the problems at all. Rumination can also refer to a gastrointestinal problem, which I am not discussing here.
Chronic physical pain obviously has a huge negative impact on quality of life. The presence of physical pain symptoms is a strong risk factor for suicide. (references: http://www.ncbi.nlm.nih.gov/pubmed/21668756 ; http://www.ncbi.nlm.nih.gov/pubmed/16420727 )
If physical pain and depression are combined, the severity of both problems is substantially elevated.
Treatment of chronic pain requires good comprehensive medical care. Investigation and treatment of underlying medical causes is obviously important. Coordinated involvement of a mutlidisciplinary team is ideal, though often lacking in many people's experience.
In the psychiatric realm, a variety of therapies can help:
1) mindfulness meditation. Jon Kabat-Zinn developed much of his work on mindfulness meditation with patients suffering from physical pain. In my opinion, meditation is extremely important, since it carries no risk, has a variety of possible and probable benefits, and is likely to help with both emotional and physical symptoms.
This study shows similar reductions in pain from a mindfulness program vs. a multidisciplinary pain program without a meditation focus:
http://www.ncbi.nlm.nih.gov/pubmed/21753729
This study shows improvements in various types of chronic pain conditions, with greater improvements in symptoms when subjects practiced more at home:
http://www.ncbi.nlm.nih.gov/pubmed/20004298
This study showed that mindfulness strategies probably work best for those who already have higher levels of mindfulness to begin with, as a type of character trait:
http://www.ncbi.nlm.nih.gov/pubmed/21254055
This study shows a slight advantage for a mindfulness meditation program to treat back pain:
http://www.ncbi.nlm.nih.gov/pubmed/17544212
An interesting study showing improvement in distressing intrusive thoughts and images following a meditation program. This shows that mindfulness exercises can substantially improve symptoms of rumination and even psychosis. In chronic pain, ruminations and intrusive thoughts about the pain itself are a very common feature, and an element of the vicious cycle of pain perpetuation and reduced quality of life. The study was of good quality, and the effect was quite substantial and robust:
http://www.ncbi.nlm.nih.gov/pubmed/19545481
Similarly, a study showing the mindfulness training specifically increases ability to "let go" (in this case, of OCD thoughts). "Letting go" of ruminations about pain is very helpful in managing chronic pain conditions:
http://www.ncbi.nlm.nih.gov/pubmed/18852623
Here's another study once again showing that mindfulness is specifically helpful to reduce rumination:
http://www.ncbi.nlm.nih.gov/pubmed/17291166
2) Cognitive-behavioural therapy
There is a significant research literature showing the effectiveness of CBT for managing pain conditions. Here are some research examples:
non-cardiac chest pain: http://www.ncbi.nlm.nih.gov/pubmed/21262413
chronic TMJ (jaw) pain: http://www.ncbi.nlm.nih.gov/pubmed/20655662
fibromyalgia: http://www.ncbi.nlm.nih.gov/pubmed/20521308
severe back pain: http://www.ncbi.nlm.nih.gov/pubmed/19967572
vulvodynia: http://www.ncbi.nlm.nih.gov/pubmed/19022580
back pain (here, active behavioural/physical therapy was necessary for optimal improvement in performance, as expected): http://www.ncbi.nlm.nih.gov/pubmed/16426449
chronic headaches: http://www.ncbi.nlm.nih.gov/pubmed/17690017
3) Medications
a) antidepressants:
Several antidepressant types could help with chronic pain: tricyclics such as amitriptyline have been used in this way for decades, with reasonable evidence-based support. Cymbalta (duloxetine) has been marketed for this, and is reasonable to try. However, venlafaxine (Effexor) is probably just as effective for pain symptoms.
There have been no studies comparing venlafaxine with duloxetine in pain patients; I suspect that there would be little difference. Currently, duloxetine is more expensive, so I do not believe it should be a first-line agent. SSRI antidepressants or bupropion appear not to be consistently helpful for treating physical pain.
Here`s an animal study showing a difference favoring a tricyclic over an SSRI or bupropion for pain management: http://www.ncbi.nlm.nih.gov/pubmed/20689938
Here`s a negative study on moclobemide for physical pain: http://www.ncbi.nlm.nih.gov/pubmed/7549169
This study shows equivalent benefits from amitriptyline and duloxetine, with over 50% of patients having good pain relief in diabetic neuropathy: http://www.ncbi.nlm.nih.gov/pubmed/21355098
This study shows benefits from duloxetine in fibromyalgia; again with over 50% of patients feeling much better, compared to about 30% with placebo: http://www.ncbi.nlm.nih.gov/pubmed/20843911
This study shows significant benefit in treating osteoarthritis pain with duloxetine; the pain relief was not related to any change in depression scores (which, in this population, were quite low and did not change very much with either duloxetine or placebo). I find this study quite significant, in that it is looking at a different variety of pain than most of the other research: http://www.ncbi.nlm.nih.gov/pubmed/19625125
This study shows relief attributable to duloxetine in depressed patients with idiopathic pain symptoms: http://www.ncbi.nlm.nih.gov/pubmed/18052564
Here, venlafaxine is shown to be an effective agent to prevent migraine headaches: http://www.ncbi.nlm.nih.gov/pubmed/15705120
Venlafaxine shown to be effective in treating functional chest pain:
http://www.ncbi.nlm.nih.gov/pubmed/20332772
A 2007 Cochrane review concluding that venlafaxine and tricyclics are effective for chronic pain:
http://www.ncbi.nlm.nih.gov/pubmed/17943857
b) anticonvulsants, e.g. gabapentin, pregabalin, carbamazapine, topiramate
A comparison of gabapentin, pregabalin, and amitriptyline in treating neuropathic cancer pain. All of these drugs clearly helped, with pregabalin probably the best. Aside from direct relief, these drugs resulted in lower doses of opiates being needed: http://www.ncbi.nlm.nih.gov/pubmed/21745832
A review of gabapentin treatment for neuropathic pain, affirming its usefulness, particularly at higher doses of 1800-3600 mg per day: http://www.ncbi.nlm.nih.gov/pubmed/12637113
This is a negative review article, showing that lamotrigine is unfortunately not likely to be useful in treating chronic pain: http://www.ncbi.nlm.nih.gov/pubmed/21328280
An interesting study showing that pregabalin can reduce postoperative morphine requirement acutely: http://www.ncbi.nlm.nih.gov/pubmed/21786524
This is an example, and a review article, part of the large literature showing that topiramate is an agent of choice to prevent or treat recurrent or chronic migraine. There is preliminary evidence at a case-report level that topiramate could help with other types of pain: http://www.ncbi.nlm.nih.gov/pubmed/19838625
c) opiates, such as codeine or morphine -- outside of the scope of this posting. These may have a role in managing non-malignant chronic pain, but supervision is needed from someone with experience prescribing opiates, a pain clinic, etc. Long-acting opiates such as methadone are being used more often in acute or chronic non-malignant pain conditions. Of course, there is a balance here between pain relief and addictive risk.
Here is a recent review, which basically affirms that the use of opiates for chronic non-cancer pain is an "iffy" practice, yet I do affirm that in some cases it may be necessary. In any case I think that experienced and specialized prescribers, such as those at a pain clinic, would be highly preferred:
http://www.ncbi.nlm.nih.gov/pubmed/21412367
d) Atypical opiate: tramadol. This is an interesting drug, for various reasons, including that it has antidepressant activity as well as being a physical analgesic. It is an opiate, but a significant portion of its analgesic properties come from non-opioid mechanisms, such as neurotransmitter reuptake inhibition. It does a potential for addictive problems, but the risk is clearly less than other opiates. For this reason, I think it is reasonable to think of using tramadol before using other opiates (such as codeine or morphine) in treating pain syndromes.
Chronic CNS effects of tramadol differ from those of morphine, supporting the evidence that tramadol has a smaller risk of inducing opiate dependence/addiction:
http://www.ncbi.nlm.nih.gov/pubmed/17401159
Tramadol can be identified subjectively as having opiate-like effects, but mainly at higher doses:
http://www.ncbi.nlm.nih.gov/pubmed/21467190
Here are animal studies using a mouse model of depression, suggesting effectiveness of tramadol.. However, I would want to see longer-term studies of this sort, as the acute beneficial action of any therapy does not necessarily prove that the benefits will last, in fact many acutely beneficial things can become harmful if used long-term (e.g. benzodiazepines):
http://www.ncbi.nlm.nih.gov/pubmed/9749830
http://www.ncbi.nlm.nih.gov/pubmed/12417248
An animal study suggesting that tramadol and anticonvulsants (in this case, specifically topiramate) can work synergestically (cooperatively) in relieving neuropathic pain: http://www.ncbi.nlm.nih.gov/pubmed/17532139
Treatment of refractory major depression with tramadol monotherapy: http://www.ncbi.nlm.nih.gov/pubmed/11305709
Rapid remission of ocd with tramadol:
http://www.ncbi.nlm.nih.gov/pubmed/10200754
http://www.ncbi.nlm.nih.gov/pubmed/9559288
Restless legs treatment with tramadol:
http://www.ncbi.nlm.nih.gov/pubmed/10221285
Treating catalepsy with tramadol:
http://www.ncbi.nlm.nih.gov/pubmed/14504345
Tramadol dependence : in general these articles show that tramadol dependence occurs, but is significantly less likely than with stronger opiates:
http://www.ncbi.nlm.nih.gov/pubmed/19827010
http://www.ncbi.nlm.nih.gov/pubmed/21467190
http://www.ncbi.nlm.nih.gov/pubmed/20589494
http://www.ncbi.nlm.nih.gov/pubmed/16716877
There is a risk of serotonin syndrome with tramadol, particularly if combined with other serotonergic drugs, such as SSRI antidepressants:
http://www.ncbi.nlm.nih.gov/pubmed/21147393
Other direct approaches to treat rumination:
Here is a study showing effectiveness using a modified form of cognitive therapy called competitive memory training. It basically involves teaching techniques to either accept, or become indifferent to, the themes of the rumination:
http://www.ncbi.nlm.nih.gov/pubmed/21784413
Here`s a similar recent study showing improved relief in chronic depression with a CBT style modified to target rumination:
http://www.ncbi.nlm.nih.gov/pubmed/21778171
An interesting study from the psychology literature which shows that rumination is associated with a type of cognitive deficit involving reduced ability to manage negative material in working memory. This suggests to me that cognitive exercises, ones which train working memory, could have a role in treating depression and rumination. Conversely, it suggests to me that practicing ways of "letting go" such as via CBT or meditation, could improve working memory (by freeing working memory space of irrelevant, ruminative, or intrusive negative material), and therefore improve intellectual functioning, academic performance, etc. http://www.ncbi.nlm.nih.gov/pubmed/21742932
Here's one of many articles discussing rumination as a risk factor for depressive relapse or chronicity. Clearly, tactics to help manage or prevent rumination are very important in both acute treatment and in prevention:
http://www.ncbi.nlm.nih.gov/pubmed/19899844
Another article discussing the role of rumination as a sort of emotional amplifier, which causes "impaired down-regulation of negative feelings" -- thus preventing the maintenance of positivity or relationship health after a stressor. Such a dynamic would be a recipe for life disappointments to consistently derail one's emotional life. Once again, practicing ways to manage rumination directly could therefore help with emotional resilience, and prevent a recurrent depressive cycle:
http://www.ncbi.nlm.nih.gov/pubmed/21432690
In summary, there are a variety of ways to treat or manage chronic pain and rumination. Rumination itself may be an important perpetuating factor in pain syndromes. Due to the presence of many symptoms in such syndromes, affecting both physical and emotional domains, it is important to have a cohesive, integrated treatment plan. There is a risk of having multiple sources of therapy, each of which targeting only part of the symptom complex, which potentially could complicate or confound efficient treatment efforts. In physical pain, emotional pain, or rumination, it can be extremely valuable to practice ways of "letting go."
In this article, I am defining "rumination" as frequent, repetitive thoughts about symptoms or problems. Such recurrent thinking can consume so much time and energy, that little is left in the mind to permit quality of life. And the ruminations, while understandable in the context of troubling symptoms or problems, do not help to resolve the problems at all. Rumination can also refer to a gastrointestinal problem, which I am not discussing here.
Chronic physical pain obviously has a huge negative impact on quality of life. The presence of physical pain symptoms is a strong risk factor for suicide. (references: http://www.ncbi.nlm.nih.gov/pubmed/21668756 ; http://www.ncbi.nlm.nih.gov/pubmed/16420727 )
If physical pain and depression are combined, the severity of both problems is substantially elevated.
Treatment of chronic pain requires good comprehensive medical care. Investigation and treatment of underlying medical causes is obviously important. Coordinated involvement of a mutlidisciplinary team is ideal, though often lacking in many people's experience.
In the psychiatric realm, a variety of therapies can help:
1) mindfulness meditation. Jon Kabat-Zinn developed much of his work on mindfulness meditation with patients suffering from physical pain. In my opinion, meditation is extremely important, since it carries no risk, has a variety of possible and probable benefits, and is likely to help with both emotional and physical symptoms.
This study shows similar reductions in pain from a mindfulness program vs. a multidisciplinary pain program without a meditation focus:
http://www.ncbi.nlm.nih.gov/pubmed/21753729
This study shows improvements in various types of chronic pain conditions, with greater improvements in symptoms when subjects practiced more at home:
http://www.ncbi.nlm.nih.gov/pubmed/20004298
This study showed that mindfulness strategies probably work best for those who already have higher levels of mindfulness to begin with, as a type of character trait:
http://www.ncbi.nlm.nih.gov/pubmed/21254055
This study shows a slight advantage for a mindfulness meditation program to treat back pain:
http://www.ncbi.nlm.nih.gov/pubmed/17544212
An interesting study showing improvement in distressing intrusive thoughts and images following a meditation program. This shows that mindfulness exercises can substantially improve symptoms of rumination and even psychosis. In chronic pain, ruminations and intrusive thoughts about the pain itself are a very common feature, and an element of the vicious cycle of pain perpetuation and reduced quality of life. The study was of good quality, and the effect was quite substantial and robust:
http://www.ncbi.nlm.nih.gov/pubmed/19545481
Similarly, a study showing the mindfulness training specifically increases ability to "let go" (in this case, of OCD thoughts). "Letting go" of ruminations about pain is very helpful in managing chronic pain conditions:
http://www.ncbi.nlm.nih.gov/pubmed/18852623
Here's another study once again showing that mindfulness is specifically helpful to reduce rumination:
http://www.ncbi.nlm.nih.gov/pubmed/17291166
2) Cognitive-behavioural therapy
There is a significant research literature showing the effectiveness of CBT for managing pain conditions. Here are some research examples:
non-cardiac chest pain: http://www.ncbi.nlm.nih.gov/pubmed/21262413
chronic TMJ (jaw) pain: http://www.ncbi.nlm.nih.gov/pubmed/20655662
fibromyalgia: http://www.ncbi.nlm.nih.gov/pubmed/20521308
severe back pain: http://www.ncbi.nlm.nih.gov/pubmed/19967572
vulvodynia: http://www.ncbi.nlm.nih.gov/pubmed/19022580
back pain (here, active behavioural/physical therapy was necessary for optimal improvement in performance, as expected): http://www.ncbi.nlm.nih.gov/pubmed/16426449
chronic headaches: http://www.ncbi.nlm.nih.gov/pubmed/17690017
3) Medications
a) antidepressants:
Several antidepressant types could help with chronic pain: tricyclics such as amitriptyline have been used in this way for decades, with reasonable evidence-based support. Cymbalta (duloxetine) has been marketed for this, and is reasonable to try. However, venlafaxine (Effexor) is probably just as effective for pain symptoms.
There have been no studies comparing venlafaxine with duloxetine in pain patients; I suspect that there would be little difference. Currently, duloxetine is more expensive, so I do not believe it should be a first-line agent. SSRI antidepressants or bupropion appear not to be consistently helpful for treating physical pain.
Here`s an animal study showing a difference favoring a tricyclic over an SSRI or bupropion for pain management: http://www.ncbi.nlm.nih.gov/pubmed/20689938
Here`s a negative study on moclobemide for physical pain: http://www.ncbi.nlm.nih.gov/pubmed/7549169
This study shows equivalent benefits from amitriptyline and duloxetine, with over 50% of patients having good pain relief in diabetic neuropathy: http://www.ncbi.nlm.nih.gov/pubmed/21355098
This study shows benefits from duloxetine in fibromyalgia; again with over 50% of patients feeling much better, compared to about 30% with placebo: http://www.ncbi.nlm.nih.gov/pubmed/20843911
This study shows significant benefit in treating osteoarthritis pain with duloxetine; the pain relief was not related to any change in depression scores (which, in this population, were quite low and did not change very much with either duloxetine or placebo). I find this study quite significant, in that it is looking at a different variety of pain than most of the other research: http://www.ncbi.nlm.nih.gov/pubmed/19625125
This study shows relief attributable to duloxetine in depressed patients with idiopathic pain symptoms: http://www.ncbi.nlm.nih.gov/pubmed/18052564
Here, venlafaxine is shown to be an effective agent to prevent migraine headaches: http://www.ncbi.nlm.nih.gov/pubmed/15705120
Venlafaxine shown to be effective in treating functional chest pain:
http://www.ncbi.nlm.nih.gov/pubmed/20332772
A 2007 Cochrane review concluding that venlafaxine and tricyclics are effective for chronic pain:
http://www.ncbi.nlm.nih.gov/pubmed/17943857
b) anticonvulsants, e.g. gabapentin, pregabalin, carbamazapine, topiramate
A comparison of gabapentin, pregabalin, and amitriptyline in treating neuropathic cancer pain. All of these drugs clearly helped, with pregabalin probably the best. Aside from direct relief, these drugs resulted in lower doses of opiates being needed: http://www.ncbi.nlm.nih.gov/pubmed/21745832
A review of gabapentin treatment for neuropathic pain, affirming its usefulness, particularly at higher doses of 1800-3600 mg per day: http://www.ncbi.nlm.nih.gov/pubmed/12637113
This is a negative review article, showing that lamotrigine is unfortunately not likely to be useful in treating chronic pain: http://www.ncbi.nlm.nih.gov/pubmed/21328280
An interesting study showing that pregabalin can reduce postoperative morphine requirement acutely: http://www.ncbi.nlm.nih.gov/pubmed/21786524
This is an example, and a review article, part of the large literature showing that topiramate is an agent of choice to prevent or treat recurrent or chronic migraine. There is preliminary evidence at a case-report level that topiramate could help with other types of pain: http://www.ncbi.nlm.nih.gov/pubmed/19838625
c) opiates, such as codeine or morphine -- outside of the scope of this posting. These may have a role in managing non-malignant chronic pain, but supervision is needed from someone with experience prescribing opiates, a pain clinic, etc. Long-acting opiates such as methadone are being used more often in acute or chronic non-malignant pain conditions. Of course, there is a balance here between pain relief and addictive risk.
Here is a recent review, which basically affirms that the use of opiates for chronic non-cancer pain is an "iffy" practice, yet I do affirm that in some cases it may be necessary. In any case I think that experienced and specialized prescribers, such as those at a pain clinic, would be highly preferred:
http://www.ncbi.nlm.nih.gov/pubmed/21412367
d) Atypical opiate: tramadol. This is an interesting drug, for various reasons, including that it has antidepressant activity as well as being a physical analgesic. It is an opiate, but a significant portion of its analgesic properties come from non-opioid mechanisms, such as neurotransmitter reuptake inhibition. It does a potential for addictive problems, but the risk is clearly less than other opiates. For this reason, I think it is reasonable to think of using tramadol before using other opiates (such as codeine or morphine) in treating pain syndromes.
Chronic CNS effects of tramadol differ from those of morphine, supporting the evidence that tramadol has a smaller risk of inducing opiate dependence/addiction:
http://www.ncbi.nlm.nih.gov/pubmed/17401159
Tramadol can be identified subjectively as having opiate-like effects, but mainly at higher doses:
http://www.ncbi.nlm.nih.gov/pubmed/21467190
Here are animal studies using a mouse model of depression, suggesting effectiveness of tramadol.. However, I would want to see longer-term studies of this sort, as the acute beneficial action of any therapy does not necessarily prove that the benefits will last, in fact many acutely beneficial things can become harmful if used long-term (e.g. benzodiazepines):
http://www.ncbi.nlm.nih.gov/pubmed/9749830
http://www.ncbi.nlm.nih.gov/pubmed/12417248
An animal study suggesting that tramadol and anticonvulsants (in this case, specifically topiramate) can work synergestically (cooperatively) in relieving neuropathic pain: http://www.ncbi.nlm.nih.gov/pubmed/17532139
Treatment of refractory major depression with tramadol monotherapy: http://www.ncbi.nlm.nih.gov/pubmed/11305709
Rapid remission of ocd with tramadol:
http://www.ncbi.nlm.nih.gov/pubmed/10200754
http://www.ncbi.nlm.nih.gov/pubmed/9559288
Restless legs treatment with tramadol:
http://www.ncbi.nlm.nih.gov/pubmed/10221285
Treating catalepsy with tramadol:
http://www.ncbi.nlm.nih.gov/pubmed/14504345
Tramadol dependence : in general these articles show that tramadol dependence occurs, but is significantly less likely than with stronger opiates:
http://www.ncbi.nlm.nih.gov/pubmed/19827010
http://www.ncbi.nlm.nih.gov/pubmed/21467190
http://www.ncbi.nlm.nih.gov/pubmed/20589494
http://www.ncbi.nlm.nih.gov/pubmed/16716877
There is a risk of serotonin syndrome with tramadol, particularly if combined with other serotonergic drugs, such as SSRI antidepressants:
http://www.ncbi.nlm.nih.gov/pubmed/21147393
Other direct approaches to treat rumination:
Here is a study showing effectiveness using a modified form of cognitive therapy called competitive memory training. It basically involves teaching techniques to either accept, or become indifferent to, the themes of the rumination:
http://www.ncbi.nlm.nih.gov/pubmed/21784413
Here`s a similar recent study showing improved relief in chronic depression with a CBT style modified to target rumination:
http://www.ncbi.nlm.nih.gov/pubmed/21778171
An interesting study from the psychology literature which shows that rumination is associated with a type of cognitive deficit involving reduced ability to manage negative material in working memory. This suggests to me that cognitive exercises, ones which train working memory, could have a role in treating depression and rumination. Conversely, it suggests to me that practicing ways of "letting go" such as via CBT or meditation, could improve working memory (by freeing working memory space of irrelevant, ruminative, or intrusive negative material), and therefore improve intellectual functioning, academic performance, etc. http://www.ncbi.nlm.nih.gov/pubmed/21742932
Here's one of many articles discussing rumination as a risk factor for depressive relapse or chronicity. Clearly, tactics to help manage or prevent rumination are very important in both acute treatment and in prevention:
http://www.ncbi.nlm.nih.gov/pubmed/19899844
Another article discussing the role of rumination as a sort of emotional amplifier, which causes "impaired down-regulation of negative feelings" -- thus preventing the maintenance of positivity or relationship health after a stressor. Such a dynamic would be a recipe for life disappointments to consistently derail one's emotional life. Once again, practicing ways to manage rumination directly could therefore help with emotional resilience, and prevent a recurrent depressive cycle:
http://www.ncbi.nlm.nih.gov/pubmed/21432690
In summary, there are a variety of ways to treat or manage chronic pain and rumination. Rumination itself may be an important perpetuating factor in pain syndromes. Due to the presence of many symptoms in such syndromes, affecting both physical and emotional domains, it is important to have a cohesive, integrated treatment plan. There is a risk of having multiple sources of therapy, each of which targeting only part of the symptom complex, which potentially could complicate or confound efficient treatment efforts. In physical pain, emotional pain, or rumination, it can be extremely valuable to practice ways of "letting go."
Wednesday, July 27, 2011
Optimal Sleep Duration
The best study which examines the relationship between sleep duration and mortality risk was published in 2007 by Hublin et al in the journal Sleep. Here's a link to the abstract:
http://www.ncbi.nlm.nih.gov/pubmed/17969458
It is part of the Finnish twin study, which followed over 20 000 twins over a 22 year period. This is an extremely large cohort, and the study had very high response rates. The analysis was thoughtful and comprehensive.
They showed that mortality rates were lowest for those who sleep between 7 and 8 hours per day. For those sleeping less than 7 hours per day, or more than 8, the mortality rates were about 20-25% higher. The results were adjusted for the covariates of education, marital status, age, working status, BMI, social class, drinking behavior, physical activity, smoking, and life satisfaction. Interestingly, and unexpectedly, sleep quality was not shown to be associated with differences in mortality risk.
The argument could be made that average sleep duration has a non-causal association with lower mortality. That is, people who happen to be healthier in the first place are more likely to have average sleep length. But another part of this analysis suggests that this is more than a non-causal association: subjects who changed their sleep duration during the course of this 22 year follow-up also changed their mortality rate, after controlling for the measured confounding factors. I suppose it could still be true that some other mortality-increasing factor was the cause of the sleep duration change, and not the other way around.
In conclusion, this data supports the commonly held belief that 7-8 hours of sleep per night is a desirable goal. It may be that particular individuals have a different "set point" for optimal sleep, and for those individuals optimal health might result from more or less hours than this average. Yet I do not actually see firm evidence of this in the research I've seen.
A 2010 meta-analysis supports the same conclusion: http://www.ncbi.nlm.nih.gov/pubmed/20469800 but I think the authors understate their findings. In particular, while a lot of the data showing increased mortality in short sleepers defined short sleep to be under 7 hours, the authors state in their discussion that "consistently sleeping 6 to 8 h per night may therefore be optimal for health." I think there is a significant difference between 6 and 7 hours, particularly due to pressures in the culture where many people are sleeping only 6 hours because of a busy schedule, while really needing 7 or 8.
Knutson in 2007 published a good article showing that sleep deprivation causes impairments in glucose tolerance (similar to the changes which occur in the development of type II diabetes), and impairments in the hormones associated with appetite regulation: http://www.ncbi.nlm.nih.gov/pubmed/185162
Here's one of the articles in the literature showing that sleep deprivation leads to an increase in proinflammatory cytokines and abnormal immune activation: http://www.ncbi.nlm.nih.gov/pubmed/19240794
I think it is especially true that if one has signs or symptoms related to sleep duration (e.g. feeling sleepy in the daytime after sleeping only 6 hours per night) then this could be taken as strong evidence that sleep duration should be increased up to the average (7-8 hours), if circumstances permit.
Patterns of sleeping long hours (above average) could be approached similarly, but of course if the reason for the long sleeping duration is medical illness or medication effects, etc. it would not be healthy to force oneself into a shorter (average) sleep regimen.
http://www.ncbi.nlm.nih.gov/pubmed/17969458
It is part of the Finnish twin study, which followed over 20 000 twins over a 22 year period. This is an extremely large cohort, and the study had very high response rates. The analysis was thoughtful and comprehensive.
They showed that mortality rates were lowest for those who sleep between 7 and 8 hours per day. For those sleeping less than 7 hours per day, or more than 8, the mortality rates were about 20-25% higher. The results were adjusted for the covariates of education, marital status, age, working status, BMI, social class, drinking behavior, physical activity, smoking, and life satisfaction. Interestingly, and unexpectedly, sleep quality was not shown to be associated with differences in mortality risk.
The argument could be made that average sleep duration has a non-causal association with lower mortality. That is, people who happen to be healthier in the first place are more likely to have average sleep length. But another part of this analysis suggests that this is more than a non-causal association: subjects who changed their sleep duration during the course of this 22 year follow-up also changed their mortality rate, after controlling for the measured confounding factors. I suppose it could still be true that some other mortality-increasing factor was the cause of the sleep duration change, and not the other way around.
In conclusion, this data supports the commonly held belief that 7-8 hours of sleep per night is a desirable goal. It may be that particular individuals have a different "set point" for optimal sleep, and for those individuals optimal health might result from more or less hours than this average. Yet I do not actually see firm evidence of this in the research I've seen.
A 2010 meta-analysis supports the same conclusion: http://www.ncbi.nlm.nih.gov/pubmed/20469800 but I think the authors understate their findings. In particular, while a lot of the data showing increased mortality in short sleepers defined short sleep to be under 7 hours, the authors state in their discussion that "consistently sleeping 6 to 8 h per night may therefore be optimal for health." I think there is a significant difference between 6 and 7 hours, particularly due to pressures in the culture where many people are sleeping only 6 hours because of a busy schedule, while really needing 7 or 8.
Knutson in 2007 published a good article showing that sleep deprivation causes impairments in glucose tolerance (similar to the changes which occur in the development of type II diabetes), and impairments in the hormones associated with appetite regulation: http://www.ncbi.nlm.nih.gov/pubmed/185162
Here's one of the articles in the literature showing that sleep deprivation leads to an increase in proinflammatory cytokines and abnormal immune activation: http://www.ncbi.nlm.nih.gov/pubmed/19240794
I think it is especially true that if one has signs or symptoms related to sleep duration (e.g. feeling sleepy in the daytime after sleeping only 6 hours per night) then this could be taken as strong evidence that sleep duration should be increased up to the average (7-8 hours), if circumstances permit.
Patterns of sleeping long hours (above average) could be approached similarly, but of course if the reason for the long sleeping duration is medical illness or medication effects, etc. it would not be healthy to force oneself into a shorter (average) sleep regimen.
Monday, June 27, 2011
Somatoform Disorders & CFS : a discussion
Somatoform disorders could be considered clusters or syndromes of physical symptoms which have a psychological cause.
Here are some examples:
1) somatization disorder -- a syndrome of multiple physical symptoms--typically pain symptoms-- which have a psychological cause
2) conversion disorder -- typically there is a complaint of paralysis or loss of sensation (including blindness) despite an absence of neurological signs; the symptoms may be generated without conscious intent, but may be profoundly disabling. With modern examination techniques and tests, these symptoms are easily demonstrated to be of non-neurological origin.
3) somatic delusions, in the context of psychotic depression or schizophreniform disorders. These have a wide variety of manifestations, though are most commonly bizarre in nature. Arguably, cases of somatization or conversion could be treated as somatic delusions.
4) somatic manifestations of anxiety -- this is extremely familiar to us all: tremor, sweating, bowel problems, etc. can all occur as a direct obvious consequence of anxiety. At times this physical component becomes the dominant feature, leading to behaviours intended to relieve the physical complaint, leading in turn to worsened avoidance, withdrawal, and exacerbation of the underlying problem.
This whole subject requires a lot of care, in my opinion. I believe that somatization is very common, and exists in a wide range of extremity--from minor symptoms to syndromes that can be almost totally disabling--yet it is also true that undiagnosed medical ailments of non-psychological origin can often be misdiagnosed as psychosomatic or somatoform. Therefore, thorough physical medical assessment and care is needed as a multidisciplinary strategy to manage these problems. These types of problems do indeed tend to be handled poorly by the conventional medical system--either through excessive and harmful medical interventions (e.g. in Munchausen's Syndrome), or through the dismissive neglect of a frustrated caregiver.
I think it is fair to say--and an observation I certainly find consistently in my experience--that physical symptoms of any cause ALWAYS have a psychological component as well. Often times, the psychological component is simple and direct: recurrent migraine headaches, malignant chronic pain, recurrent seizures, etc. (among hundreds of different causes of physical symptoms) cause a disruption to daily life & function, and their unpredictable patterns can leave one in a nearly constant state of anxiety. It can be hard to plan activities, time for relationships, work schedules, etc. when symptoms may come at any moment. So there is obvious direct psychological stress. This stress understandably can cause a feedback loop which may exacerbate the underlying medical condition.
Other times, I believe that the psychological effects of medical conditions can be more subtle or indirect. Chronic conditions can come to have a lot of power to redefine one's sense of self, often in a way which pronounces one to be more disabled than the medical problems necessitate. Some types of symptom clusters may be sufficiently common as to allow a community of fellow sufferers to form. While this may permit the supportive care of a community, it may also consolidate or entrench the aspects of the phenomenon which have to do with identity. The relief that one may find in a group of people experiencing something similar may sometimes be so compelling that entrenched factitious beliefs about disability are deepened, at the expense of therapeutic growth.
Some currently unexplained diagnostic entities, such as chronic fatigue syndrome (CFS), may in some cases be examples of complex somatoform illness. I acknowledge that in other cases--perhaps even in the majority--there may well be some as yet unexplained physical pathology driving the symptoms. A physiologic disposition towards fatigue may cause a cascade of behavioural changes (including withdrawal from activities), leading to a further cascade of cognitions about illness, mood change (which can often present itself, for many people, in a further somatized set of symptoms), and perpetuating of underlying symptoms. The worldwide network of fellow sufferers may lead to perpetuation of symptoms, rather than relief, because the group consolidates some of the beliefs and identity formation which individuals may have about the condition, and also may agitate against what is seen as a dismissive or ineffectual medical system. The group dynamics may also foster the spread of various spurious alternative therapies, whose evidence base would often consist of glowing testimonial accounts rather than careful randomized data. Factitious therapies could sometimes be quite effective for factitious illnesses, since the therapeutic effort would permit the sufferer a psychological opportunity to move away from the illness symptoms, and attribute the improvement to something external, rather than to psychological change. Such is, in my opinion, the basis for most stories of so-called "faith healing" which have been around for millenia.
It is helpful to have observed extreme examples of somatoform illness. Case examples include individuals who have had recurrent factitious seizures (pseudoseizures), often leading to dangerous and harmfully inappropriate medical interventions. Many persons with a history of pseudoseizures also have neurologically-based epilepsy as well: somatized, factitious, or conversion symptoms often co-exist with their non-psychiatric counterparts. Other case examples include situations where individuals are delusionally convinced that they are paralyzed (due to a conversion disorder) causing them to have lived in a wheelchair for years. Such individuals often have networks of people in their lives who support them in their paralyzed role; such supporters often include physicians and other caregivers. Yet, it has been an amazing experience for me to witness cases of this type--cases where there has never been any objective sign of neurologic disease, but where the impact of the problem has been extreme; if a very careful neuropsychiatric evaluation is done, with strongly structured psychiatric and rehabilitative therapy, I have seen situations where a person experiencing paralysis is able to walk home after a hospital stay.
But cases like these are inevitably complex. If a person has lived in a certain way for years, the behaviours themselves, and the associated thoughts, become integrated into identity. If you live as a paralyzed person for many years, it will not be so easy to get up and walk, even if you are neurologically healthy. There are physical barriers, but obvious psychological and social ones as well.
I believe this is a theme which epitomizes our understanding of brain function: repeated behaviour entrenches neural pathways. If "illness behaviour" exists despite "no illness", the brain learns to function "as if" a physical injury were present. It is just like language learning--with immersive experience over a course of months or years, the brain will speak the new language with ever greater fluency. It is a difficult task for the brain to "unlearn" such experience.
But this suggests a therapeutic imperative: for all cases of this type, immersive physical rehabilitation is necessary. In every single case I have ever seen of severe conversion, for example, the cure required intensive, prolonged, structured involvement of physiotherapists, in addition to whatever medications (typically antidepressants and antipsychotics) and psychotherapeutic work the person needed.
I believe this theme crosses over into the realm of ALL chronic disease, regardless of cause. Management of chronic disability or chronic diseases is greatly assisted by physical rehabilitation. In the language of narrative therapy, if we consider the illness or symptom to be like a negative character in our lives, that character is constantly telling us to do less and less--part of the therapy to challenge this is to find a structured and safe manner in which to do more and more, or to optimize our fitness so that we can do the most despite the limitations imposed by the disease.
Another interesting modality of therapy for conversion, one which can illustrate very compellingly the existence of a structure of drives and defenses first suggested by Freud, is the so-called "amytal interview." In the version I have seen, a patient with a conversion syndrome (following informed consent, of course) is given a dose of ritalin (which allows more amytal to be given without loss of consciousness), followed by intravenous sodium amytal (a barbiturate), with the supervision of an anesthetist in a well-equipped medical setting. The dose is titrated just to the point before the patient loses consciousness. The effect of the medication is to cause disinhibition. In this condition, the psychological forces necessary to continue the conversion symptom are weakened, so for example a person describing paralysis of an arm can be guided to raise the paralyzed arm in the air, and flex it, etc. This event can be videotaped. When the effects of the drug wear off, the person may not remember the scene, but when presented with the video footage (of the non-paralyzed limb in action), the person's psychological defense of conversion will be substantially weakened. As a result, often times a strong emotional reaction takes place, usually the overt emotions or affects consistent with a severe underlying depression which had previously shown itself through "paralysis." In this way, "conversion" operates as a psychological defense, a way in which the brain deals emotionally or behaviourally with a painful symptom. These defenses can be vital ways to survive in the world, but sometimes--as in conversion disorders--the defense system goes awry, and becomes the core problem.
Here are some examples:
1) somatization disorder -- a syndrome of multiple physical symptoms--typically pain symptoms-- which have a psychological cause
2) conversion disorder -- typically there is a complaint of paralysis or loss of sensation (including blindness) despite an absence of neurological signs; the symptoms may be generated without conscious intent, but may be profoundly disabling. With modern examination techniques and tests, these symptoms are easily demonstrated to be of non-neurological origin.
3) somatic delusions, in the context of psychotic depression or schizophreniform disorders. These have a wide variety of manifestations, though are most commonly bizarre in nature. Arguably, cases of somatization or conversion could be treated as somatic delusions.
4) somatic manifestations of anxiety -- this is extremely familiar to us all: tremor, sweating, bowel problems, etc. can all occur as a direct obvious consequence of anxiety. At times this physical component becomes the dominant feature, leading to behaviours intended to relieve the physical complaint, leading in turn to worsened avoidance, withdrawal, and exacerbation of the underlying problem.
This whole subject requires a lot of care, in my opinion. I believe that somatization is very common, and exists in a wide range of extremity--from minor symptoms to syndromes that can be almost totally disabling--yet it is also true that undiagnosed medical ailments of non-psychological origin can often be misdiagnosed as psychosomatic or somatoform. Therefore, thorough physical medical assessment and care is needed as a multidisciplinary strategy to manage these problems. These types of problems do indeed tend to be handled poorly by the conventional medical system--either through excessive and harmful medical interventions (e.g. in Munchausen's Syndrome), or through the dismissive neglect of a frustrated caregiver.
I think it is fair to say--and an observation I certainly find consistently in my experience--that physical symptoms of any cause ALWAYS have a psychological component as well. Often times, the psychological component is simple and direct: recurrent migraine headaches, malignant chronic pain, recurrent seizures, etc. (among hundreds of different causes of physical symptoms) cause a disruption to daily life & function, and their unpredictable patterns can leave one in a nearly constant state of anxiety. It can be hard to plan activities, time for relationships, work schedules, etc. when symptoms may come at any moment. So there is obvious direct psychological stress. This stress understandably can cause a feedback loop which may exacerbate the underlying medical condition.
Other times, I believe that the psychological effects of medical conditions can be more subtle or indirect. Chronic conditions can come to have a lot of power to redefine one's sense of self, often in a way which pronounces one to be more disabled than the medical problems necessitate. Some types of symptom clusters may be sufficiently common as to allow a community of fellow sufferers to form. While this may permit the supportive care of a community, it may also consolidate or entrench the aspects of the phenomenon which have to do with identity. The relief that one may find in a group of people experiencing something similar may sometimes be so compelling that entrenched factitious beliefs about disability are deepened, at the expense of therapeutic growth.
Some currently unexplained diagnostic entities, such as chronic fatigue syndrome (CFS), may in some cases be examples of complex somatoform illness. I acknowledge that in other cases--perhaps even in the majority--there may well be some as yet unexplained physical pathology driving the symptoms. A physiologic disposition towards fatigue may cause a cascade of behavioural changes (including withdrawal from activities), leading to a further cascade of cognitions about illness, mood change (which can often present itself, for many people, in a further somatized set of symptoms), and perpetuating of underlying symptoms. The worldwide network of fellow sufferers may lead to perpetuation of symptoms, rather than relief, because the group consolidates some of the beliefs and identity formation which individuals may have about the condition, and also may agitate against what is seen as a dismissive or ineffectual medical system. The group dynamics may also foster the spread of various spurious alternative therapies, whose evidence base would often consist of glowing testimonial accounts rather than careful randomized data. Factitious therapies could sometimes be quite effective for factitious illnesses, since the therapeutic effort would permit the sufferer a psychological opportunity to move away from the illness symptoms, and attribute the improvement to something external, rather than to psychological change. Such is, in my opinion, the basis for most stories of so-called "faith healing" which have been around for millenia.
It is helpful to have observed extreme examples of somatoform illness. Case examples include individuals who have had recurrent factitious seizures (pseudoseizures), often leading to dangerous and harmfully inappropriate medical interventions. Many persons with a history of pseudoseizures also have neurologically-based epilepsy as well: somatized, factitious, or conversion symptoms often co-exist with their non-psychiatric counterparts. Other case examples include situations where individuals are delusionally convinced that they are paralyzed (due to a conversion disorder) causing them to have lived in a wheelchair for years. Such individuals often have networks of people in their lives who support them in their paralyzed role; such supporters often include physicians and other caregivers. Yet, it has been an amazing experience for me to witness cases of this type--cases where there has never been any objective sign of neurologic disease, but where the impact of the problem has been extreme; if a very careful neuropsychiatric evaluation is done, with strongly structured psychiatric and rehabilitative therapy, I have seen situations where a person experiencing paralysis is able to walk home after a hospital stay.
But cases like these are inevitably complex. If a person has lived in a certain way for years, the behaviours themselves, and the associated thoughts, become integrated into identity. If you live as a paralyzed person for many years, it will not be so easy to get up and walk, even if you are neurologically healthy. There are physical barriers, but obvious psychological and social ones as well.
I believe this is a theme which epitomizes our understanding of brain function: repeated behaviour entrenches neural pathways. If "illness behaviour" exists despite "no illness", the brain learns to function "as if" a physical injury were present. It is just like language learning--with immersive experience over a course of months or years, the brain will speak the new language with ever greater fluency. It is a difficult task for the brain to "unlearn" such experience.
But this suggests a therapeutic imperative: for all cases of this type, immersive physical rehabilitation is necessary. In every single case I have ever seen of severe conversion, for example, the cure required intensive, prolonged, structured involvement of physiotherapists, in addition to whatever medications (typically antidepressants and antipsychotics) and psychotherapeutic work the person needed.
I believe this theme crosses over into the realm of ALL chronic disease, regardless of cause. Management of chronic disability or chronic diseases is greatly assisted by physical rehabilitation. In the language of narrative therapy, if we consider the illness or symptom to be like a negative character in our lives, that character is constantly telling us to do less and less--part of the therapy to challenge this is to find a structured and safe manner in which to do more and more, or to optimize our fitness so that we can do the most despite the limitations imposed by the disease.
Another interesting modality of therapy for conversion, one which can illustrate very compellingly the existence of a structure of drives and defenses first suggested by Freud, is the so-called "amytal interview." In the version I have seen, a patient with a conversion syndrome (following informed consent, of course) is given a dose of ritalin (which allows more amytal to be given without loss of consciousness), followed by intravenous sodium amytal (a barbiturate), with the supervision of an anesthetist in a well-equipped medical setting. The dose is titrated just to the point before the patient loses consciousness. The effect of the medication is to cause disinhibition. In this condition, the psychological forces necessary to continue the conversion symptom are weakened, so for example a person describing paralysis of an arm can be guided to raise the paralyzed arm in the air, and flex it, etc. This event can be videotaped. When the effects of the drug wear off, the person may not remember the scene, but when presented with the video footage (of the non-paralyzed limb in action), the person's psychological defense of conversion will be substantially weakened. As a result, often times a strong emotional reaction takes place, usually the overt emotions or affects consistent with a severe underlying depression which had previously shown itself through "paralysis." In this way, "conversion" operates as a psychological defense, a way in which the brain deals emotionally or behaviourally with a painful symptom. These defenses can be vital ways to survive in the world, but sometimes--as in conversion disorders--the defense system goes awry, and becomes the core problem.
A negative study on vitamin d supplementation
http://www.ncbi.nlm.nih.gov/pubmed/21525520
this 2011 randomized, controlled, prospective study from the British Journal of Psychiatry shows that vitamin d supplementation did not improve well-being in a group of over 1000 elderly women compared to a similar-sized control group.
This is a good study, with negative results. I don't think it means that vitamin d is of no use, but rather that it cannot be assumed to have obvious positive effects for everyone. Some of the effects measured in other vitamin d studies may be the result of non-causative associations (e.g. those with various healthier habits and health paramaters may be more likely to have higher vitamin d levels, but the vitamin d is not the cause of this healthiness, it results from it)
However, the data on this issue continues to evolve. There is some good positive data on vitamin d as well, though not enough in terms of randomized, prospective studies. It will be important, for example, to look at whether vitamin d could obviously be an effective adjunct to other therapies for treating depression. Or whether vitamin d alone has little effect, unless combined with other positive factors.
Meanwhile, I still believe that the standard recommended daily dose of 400 IU for vitamin D is too low, and that 1000-2000 IU per day is better.
See my previous post on vitamin d, http://garthkroeker.blogspot.com/2009/02/vitamin-d-other-vitamins.html
this 2011 randomized, controlled, prospective study from the British Journal of Psychiatry shows that vitamin d supplementation did not improve well-being in a group of over 1000 elderly women compared to a similar-sized control group.
This is a good study, with negative results. I don't think it means that vitamin d is of no use, but rather that it cannot be assumed to have obvious positive effects for everyone. Some of the effects measured in other vitamin d studies may be the result of non-causative associations (e.g. those with various healthier habits and health paramaters may be more likely to have higher vitamin d levels, but the vitamin d is not the cause of this healthiness, it results from it)
However, the data on this issue continues to evolve. There is some good positive data on vitamin d as well, though not enough in terms of randomized, prospective studies. It will be important, for example, to look at whether vitamin d could obviously be an effective adjunct to other therapies for treating depression. Or whether vitamin d alone has little effect, unless combined with other positive factors.
Meanwhile, I still believe that the standard recommended daily dose of 400 IU for vitamin D is too low, and that 1000-2000 IU per day is better.
See my previous post on vitamin d, http://garthkroeker.blogspot.com/2009/02/vitamin-d-other-vitamins.html
Friday, May 13, 2011
Music Therapy
I believe that many creative modalities can be usefully included in a therapeutic relationship. There are times when spoken dialog can be more difficult, unwelcome, inhibited, or even frankly unhelpful. Other types of activities can be part of a therapeutic milieu, and work on non-verbal forms of communication, as well as other forms of positive experience in the therapeutic frame.
The use of music in therapy is well-established. Music therapy is a recognized profession, with a substantial academic literature behind it. I believe that music is under-utilized in therapy generally, perhaps considered outside the scope of experience or training of most therapists. Even therapists with a background interest in music may not share this with patients, for a variety of reasons. The predominantly oral tradition of psychotherapy can be so dominant sometimes as to view non-verbal activities as eccentricity.
Music -- listening, performing, learning, and coordinating -- can touch upon the following therapeutic themes:
1) emotional expression
2) performance anxiety / communicative inhibition
3) perfectionism
4) assumptions about capacity or incapacity to learn something new
5) focusing on an activity which is sufficiently engaging as to calm anxiety or agitation, or at least distract attention away from negative emotions or unwelcome thoughts
6) enjoyment
7) a sense of achievement
8) patterning the same learning schedule which leads to psychological change or skill acquisition of any sort -- some immediate progress in the moment--which needs to be enjoyable in itself-- but part of a process which can include thousands of hours of experience to grow substantially
9) a sense of trust and "harmony" with the therapist; possibility a modality which makes the therapeutic relationship stronger
10) on a sort of psychodynamic or developmental level, music could be understood as one of the individual's first experiences of emotional soothing (from the mother humming or singing to her infant), a modality which precedes verbal language. There might be deprivations or problems associated with this dynamic for some individuals, which could become a therapeutic theme if music was part of the frame of activities and discussion.
11) music preferences and interests are, of course, an element of identity expression. I believe that questions about music preference and experience are a useful part of a psychiatric history; often an understanding about this part of a person immediately deepens understanding, and offers a chance to connect in different ways, to build rapport and interested collaboration.
Many types of music therapy involve having the patient improvise on a simple instrument, etc., or perhaps listen to music. I think that doing cooperative musical exercises can be a valuable element, in which the therapist can act partly as collaborator or music teacher. The technical skill level is not relevant, in my opinion, and in fact could be considered a type of neutral transferential theme to be worked with in the therapy. Simply practicing a simple technical exercise on an instrument--even during a conversation--could be a tactic to help attain calm and relaxation, in the same way that many other physical skills can be relaxing (e.g. knitting, swimming, yoga).
Here is a review of some of the research literature on music therapy:
http://www.ncbi.nlm.nih.gov/pubmed/19269725
2009 meta-analytic review showing music therapy robustly effective for a wide range of problems in severe mental illness, including overall function, well-being, and symptom control. More sessions are more effective; 16-51 sessions associated with large effect sizes.
http://www.ncbi.nlm.nih.gov/pubmed/21474494
a 2011 article from the British Journal of Psychiatry, showing robust effects of music therapy in the treatment of depression. There was a "control group", but in this case the control group received "standard care" (medications + a few sessions of psychotherapy), while the active group received this same standard care plus up to 20 sessions of music therapy. So, in my opinion, the study did not control for the effect of simply spending time with the patients for 20 extra sessions. There should have been a control group which had 20 sessions of the same length of time as the music therapy group, but doing a "placebo" activity. Nevertheless, this does show that, at the very least, doing music activities with patients during therapy sessions is a supportable practice.
http://www.ncbi.nlm.nih.gov/pubmed/15846692
2005 Cochrane review showing that music therapy is an effective component of therapy for schizophrenia, leading to improved global state, as well as probable positive changes in various symptom clusters.
http://www.ncbi.nlm.nih.gov/pubmed/18254052
2008 Cochrane review showing that music therapy may be effective in the treatment of depression. 4 of 5 studies showed greater improvements in depressive symptoms in the music therapy group compared to standard care.
http://www.ncbi.nlm.nih.gov/pubmed/20614449
music therapy shown to be helpful to improve the rate of rehabilitation in brain injury or stroke
http://www.ncbi.nlm.nih.gov/pubmed/21292560
this is quite a cute study, showing that listening to Mozart's K.448 (sonata for 2 pianos) once nightly for 6 months leads to substantial reductions in seizures in children with refractory epilepsy. It's a weak study, of course, since there is no control group.
http://www.ncbi.nlm.nih.gov/pubmed/20129759
a similar study, but a bit stronger, since it shows that Mozart's K. 448 leads to an immediate change in EEG patterns, as long as the recording does not have prominent higher harmonics. I've noticed this myself, that tones with very strong higher-order harmonics above the fundamental tone can prevent focus on music performance, particularly for those with very strong ear skills, or could even be strident and unpleasant. Mozart himself was apparently very sensitive to this as a child. This leads to another issue, about sound level: the modern habit of listening to music at very high sound levels could sabotage not only one's hearing, but also the psychological benefits of the music.
http://www.ncbi.nlm.nih.gov/pubmed/21290852
a discussion of the role of music in non-suicidal self-injury.
I think some music may itself be self-injurious, or at least a consistent cue associated with self-injury; but clearly there is therapeutic potential, for music to be helpful in affect regulation or as a healthy substitute behaviour instead of self-injuring.
I'm curious as to the manner in which musical lyrics or the emotional tone in music affects "self-talk" or inner emotional tone. In a "Rogersian" sense, music with very depressive or hostile lyrical or tonal content may help a person to feel less alone--a type of empathic bond with the music--which may be therapeutic. But I believe that such a bond is much more therapeutic if it leads to a sense of resolution of the underlying problems, or offers a consistent message of hope or joy despite whatever empathic connections are made with sadness, anger, emptiness, etc. I think the greatest songs (present in all genres and eras) are those which suggest a resolution for problems of suffering or emotional pain, rather than simply evoking the negative emotion.
The use of music in therapy is well-established. Music therapy is a recognized profession, with a substantial academic literature behind it. I believe that music is under-utilized in therapy generally, perhaps considered outside the scope of experience or training of most therapists. Even therapists with a background interest in music may not share this with patients, for a variety of reasons. The predominantly oral tradition of psychotherapy can be so dominant sometimes as to view non-verbal activities as eccentricity.
Music -- listening, performing, learning, and coordinating -- can touch upon the following therapeutic themes:
1) emotional expression
2) performance anxiety / communicative inhibition
3) perfectionism
4) assumptions about capacity or incapacity to learn something new
5) focusing on an activity which is sufficiently engaging as to calm anxiety or agitation, or at least distract attention away from negative emotions or unwelcome thoughts
6) enjoyment
7) a sense of achievement
8) patterning the same learning schedule which leads to psychological change or skill acquisition of any sort -- some immediate progress in the moment--which needs to be enjoyable in itself-- but part of a process which can include thousands of hours of experience to grow substantially
9) a sense of trust and "harmony" with the therapist; possibility a modality which makes the therapeutic relationship stronger
10) on a sort of psychodynamic or developmental level, music could be understood as one of the individual's first experiences of emotional soothing (from the mother humming or singing to her infant), a modality which precedes verbal language. There might be deprivations or problems associated with this dynamic for some individuals, which could become a therapeutic theme if music was part of the frame of activities and discussion.
11) music preferences and interests are, of course, an element of identity expression. I believe that questions about music preference and experience are a useful part of a psychiatric history; often an understanding about this part of a person immediately deepens understanding, and offers a chance to connect in different ways, to build rapport and interested collaboration.
Many types of music therapy involve having the patient improvise on a simple instrument, etc., or perhaps listen to music. I think that doing cooperative musical exercises can be a valuable element, in which the therapist can act partly as collaborator or music teacher. The technical skill level is not relevant, in my opinion, and in fact could be considered a type of neutral transferential theme to be worked with in the therapy. Simply practicing a simple technical exercise on an instrument--even during a conversation--could be a tactic to help attain calm and relaxation, in the same way that many other physical skills can be relaxing (e.g. knitting, swimming, yoga).
Here is a review of some of the research literature on music therapy:
http://www.ncbi.nlm.nih.gov/pubmed/19269725
2009 meta-analytic review showing music therapy robustly effective for a wide range of problems in severe mental illness, including overall function, well-being, and symptom control. More sessions are more effective; 16-51 sessions associated with large effect sizes.
http://www.ncbi.nlm.nih.gov/pubmed/21474494
a 2011 article from the British Journal of Psychiatry, showing robust effects of music therapy in the treatment of depression. There was a "control group", but in this case the control group received "standard care" (medications + a few sessions of psychotherapy), while the active group received this same standard care plus up to 20 sessions of music therapy. So, in my opinion, the study did not control for the effect of simply spending time with the patients for 20 extra sessions. There should have been a control group which had 20 sessions of the same length of time as the music therapy group, but doing a "placebo" activity. Nevertheless, this does show that, at the very least, doing music activities with patients during therapy sessions is a supportable practice.
http://www.ncbi.nlm.nih.gov/pubmed/15846692
2005 Cochrane review showing that music therapy is an effective component of therapy for schizophrenia, leading to improved global state, as well as probable positive changes in various symptom clusters.
http://www.ncbi.nlm.nih.gov/pubmed/18254052
2008 Cochrane review showing that music therapy may be effective in the treatment of depression. 4 of 5 studies showed greater improvements in depressive symptoms in the music therapy group compared to standard care.
http://www.ncbi.nlm.nih.gov/pubmed/20614449
music therapy shown to be helpful to improve the rate of rehabilitation in brain injury or stroke
http://www.ncbi.nlm.nih.gov/pubmed/21292560
this is quite a cute study, showing that listening to Mozart's K.448 (sonata for 2 pianos) once nightly for 6 months leads to substantial reductions in seizures in children with refractory epilepsy. It's a weak study, of course, since there is no control group.
http://www.ncbi.nlm.nih.gov/pubmed/20129759
a similar study, but a bit stronger, since it shows that Mozart's K. 448 leads to an immediate change in EEG patterns, as long as the recording does not have prominent higher harmonics. I've noticed this myself, that tones with very strong higher-order harmonics above the fundamental tone can prevent focus on music performance, particularly for those with very strong ear skills, or could even be strident and unpleasant. Mozart himself was apparently very sensitive to this as a child. This leads to another issue, about sound level: the modern habit of listening to music at very high sound levels could sabotage not only one's hearing, but also the psychological benefits of the music.
http://www.ncbi.nlm.nih.gov/pubmed/21290852
a discussion of the role of music in non-suicidal self-injury.
I think some music may itself be self-injurious, or at least a consistent cue associated with self-injury; but clearly there is therapeutic potential, for music to be helpful in affect regulation or as a healthy substitute behaviour instead of self-injuring.
I'm curious as to the manner in which musical lyrics or the emotional tone in music affects "self-talk" or inner emotional tone. In a "Rogersian" sense, music with very depressive or hostile lyrical or tonal content may help a person to feel less alone--a type of empathic bond with the music--which may be therapeutic. But I believe that such a bond is much more therapeutic if it leads to a sense of resolution of the underlying problems, or offers a consistent message of hope or joy despite whatever empathic connections are made with sadness, anger, emptiness, etc. I think the greatest songs (present in all genres and eras) are those which suggest a resolution for problems of suffering or emotional pain, rather than simply evoking the negative emotion.
Tuesday, May 3, 2011
Alternative conceptions of "IQ"
Standard IQ tests measure a particular set of intellectual skills. But this leads to a big question about what exactly is being measured. The notion of "IQ" implies that the test is measuring an innate, relatively fixed intellectual capacity.
But consider the following analogies:
-Suppose reading skill in English was being tested. Obviously, we could see that those who score very well in a test of rapid reading and comprehension would most likely be classified as more "intelligent." Yet, the test would have massive potential sources of bias or inaccuracy. Many people with excellent language skills would do poorly on an English reading test simply because of their lack of knowledge or experience with English. Others with excellent minds might not have had much reading education or experience of any sort, therefore they would not have acquired the skill to read or comprehend written language quickly.
-If "athleticism" was being measured, suppose the test involved having subjects shoot free throws on a basketball court. People who would score very highly on this test would most likely fit reasonably into a "high athleticism" category. But many very athletic people would score poorly on this test, simply because they had very little experience shooting basketballs. If a skill that was brand-new to all subjects was being tested one time (e.g. archery target practice), those who performed very well might well be more "athletic" but perhaps they had more experience in a similar type of skill in the past, or they just happen to be more calm with novel activities.
Acquisition of skills is a process that grows over a period of hundreds or thousands of hours of experience. If a test is measuring a skill, it may simply be measuring how many hours of experience that person has with a similar activity. Of course, an intrinsic strength in something is more likely to lead to a person spending more time developing the strength -- talent leads to passionate commitment; it facilitates and makes enjoyable the thousands of hours of work
So, an IQ test may be measuring--to a significant degree--the number of hours of experience the subjects have with similar types of activities (e.g. memory tasks, logic puzzles, arithmetic, etc.).
On a related note, recent findings have suggested that doing cognitive exercises such as brain-training video games does not really improve intellectual function significantly. But--the manner in which this conclusion was reached was testing subjects before and after using tests that did not directly relate to the cognitive games which were being played. Therefore, I believe the findings are spurious.
Here is my thesis on this issue:
"Intelligence" could be understood not as an absolute quantity of a skill (since this quantity would depend mainly on how many hours of practice or experience the person has had, which arguably should be viewed independently from the concept of "intelligence" as an innate trait). Rather, "intelligence" could be viewed as the RATE at which brand-new skills improve with a given period of practice. For example, the amount of improvement after 10 hours of practice of a brand-new activity would be a much better measure of "athleticism" than simply measuring the absolute performance one time. Even this type of measure would be influenced by a person's past experience: for example, a person with thousands of hours of experience learning different languages would probably be able to learn a completely new language more quickly with 10 hours of practice, compared to someone with very little past experience of this sort. The proviso that this be a "brand new" activity is important, because if a person has a very high level of expertise in a particular skill, then their rate of further improvement will be very low (since there is not much further improvement humanly possible).
So, for example, with athletic tests, it would seem a reasonable measure of "innate athleticism" to introduce a completely new sport or fitness activity, and to measure how quickly subjects could improve or master it with limited practice time.
Another complicating angle on this theme is that intellectual experience and focus in ANY area is likely to improve "innate intelligence." If you have practiced music for 10 000 hours, you will probably have strengthened a variety of other "innate" intellectual capacities. But this strengthening effect would not be obvious if measured conventionally.
Similarly, I suspect that "brain training" video games could have a significant effect of strengthening various intellectual capacities. But this positive effect would not be captured well by simply repeating single "before" and "after" skills tests. A much better measure would be the following:
1) "pre" test: subjects would have to put in 10 hours of practice learning a game having to do with verbal memory. The absolute scores, and the rate of improvement over the 10 hours, would be recorded.
2) Subjects would put in 100 hours of practice doing either a battery of memory-focused brain training games, or a "placebo" set of games not focusing on memory.
3) "post" test: subjects would put in 10 hours of practice learning a completely new game having to do with verbal memory. Once again, the absolute scores, and the rate of improvement, would be noted.
Here is my hypothesis about the findings of such an experiment:
1) The absolute scores at the beginning of the "pre" and "post" tests would be quite similar. This would be like testing the basketball skills of a group of volleyball players before and after volleyball training season. You would not expect any difference. This is the conventional type of assessment, which is bound to lead to the conclusion that there is no beneficial training effect.
2) What I would expect to be different is that the subjects who had done 100 hours of memory games would be able to much more rapidly IMPROVE their scores in the "post" test. In the athletic analogy, a group of people who have spent the summer in volleyball training would be able to much more rapidly learn soccer skills, compared to a group who spent the summer watching TV, even though both groups might have very similar soccer skills at the beginning of a 10-hour training period.
I believe my hypothesis is supported by observations of individuals acquiring expert skills, such as playing chess. While the absolute number of hours practicing chess correlates directly with performance, there are some individuals who advance more rapidly with the same number of hours of practice.
(see the following reference: http://www.ncbi.nlm.nih.gov/pubmed/17201516)
I believe it is this "rate of change" that is the most reasonable measure of "innate" cognitive ability. Even this "innateness" could be more malleable than the term implies, since I suspect that there could be a type of "meta-training" which could improve one's rate of skill learning or acquisition. This would involve practicing ways to use time more efficiently, and, most importantly, practicing ways to bring devotion, joy, and energetic attention to one's learning experiences.
But consider the following analogies:
-Suppose reading skill in English was being tested. Obviously, we could see that those who score very well in a test of rapid reading and comprehension would most likely be classified as more "intelligent." Yet, the test would have massive potential sources of bias or inaccuracy. Many people with excellent language skills would do poorly on an English reading test simply because of their lack of knowledge or experience with English. Others with excellent minds might not have had much reading education or experience of any sort, therefore they would not have acquired the skill to read or comprehend written language quickly.
-If "athleticism" was being measured, suppose the test involved having subjects shoot free throws on a basketball court. People who would score very highly on this test would most likely fit reasonably into a "high athleticism" category. But many very athletic people would score poorly on this test, simply because they had very little experience shooting basketballs. If a skill that was brand-new to all subjects was being tested one time (e.g. archery target practice), those who performed very well might well be more "athletic" but perhaps they had more experience in a similar type of skill in the past, or they just happen to be more calm with novel activities.
Acquisition of skills is a process that grows over a period of hundreds or thousands of hours of experience. If a test is measuring a skill, it may simply be measuring how many hours of experience that person has with a similar activity. Of course, an intrinsic strength in something is more likely to lead to a person spending more time developing the strength -- talent leads to passionate commitment; it facilitates and makes enjoyable the thousands of hours of work
So, an IQ test may be measuring--to a significant degree--the number of hours of experience the subjects have with similar types of activities (e.g. memory tasks, logic puzzles, arithmetic, etc.).
On a related note, recent findings have suggested that doing cognitive exercises such as brain-training video games does not really improve intellectual function significantly. But--the manner in which this conclusion was reached was testing subjects before and after using tests that did not directly relate to the cognitive games which were being played. Therefore, I believe the findings are spurious.
Here is my thesis on this issue:
"Intelligence" could be understood not as an absolute quantity of a skill (since this quantity would depend mainly on how many hours of practice or experience the person has had, which arguably should be viewed independently from the concept of "intelligence" as an innate trait). Rather, "intelligence" could be viewed as the RATE at which brand-new skills improve with a given period of practice. For example, the amount of improvement after 10 hours of practice of a brand-new activity would be a much better measure of "athleticism" than simply measuring the absolute performance one time. Even this type of measure would be influenced by a person's past experience: for example, a person with thousands of hours of experience learning different languages would probably be able to learn a completely new language more quickly with 10 hours of practice, compared to someone with very little past experience of this sort. The proviso that this be a "brand new" activity is important, because if a person has a very high level of expertise in a particular skill, then their rate of further improvement will be very low (since there is not much further improvement humanly possible).
So, for example, with athletic tests, it would seem a reasonable measure of "innate athleticism" to introduce a completely new sport or fitness activity, and to measure how quickly subjects could improve or master it with limited practice time.
Another complicating angle on this theme is that intellectual experience and focus in ANY area is likely to improve "innate intelligence." If you have practiced music for 10 000 hours, you will probably have strengthened a variety of other "innate" intellectual capacities. But this strengthening effect would not be obvious if measured conventionally.
Similarly, I suspect that "brain training" video games could have a significant effect of strengthening various intellectual capacities. But this positive effect would not be captured well by simply repeating single "before" and "after" skills tests. A much better measure would be the following:
1) "pre" test: subjects would have to put in 10 hours of practice learning a game having to do with verbal memory. The absolute scores, and the rate of improvement over the 10 hours, would be recorded.
2) Subjects would put in 100 hours of practice doing either a battery of memory-focused brain training games, or a "placebo" set of games not focusing on memory.
3) "post" test: subjects would put in 10 hours of practice learning a completely new game having to do with verbal memory. Once again, the absolute scores, and the rate of improvement, would be noted.
Here is my hypothesis about the findings of such an experiment:
1) The absolute scores at the beginning of the "pre" and "post" tests would be quite similar. This would be like testing the basketball skills of a group of volleyball players before and after volleyball training season. You would not expect any difference. This is the conventional type of assessment, which is bound to lead to the conclusion that there is no beneficial training effect.
2) What I would expect to be different is that the subjects who had done 100 hours of memory games would be able to much more rapidly IMPROVE their scores in the "post" test. In the athletic analogy, a group of people who have spent the summer in volleyball training would be able to much more rapidly learn soccer skills, compared to a group who spent the summer watching TV, even though both groups might have very similar soccer skills at the beginning of a 10-hour training period.
I believe my hypothesis is supported by observations of individuals acquiring expert skills, such as playing chess. While the absolute number of hours practicing chess correlates directly with performance, there are some individuals who advance more rapidly with the same number of hours of practice.
(see the following reference: http://www.ncbi.nlm.nih.gov/pubmed/17201516)
I believe it is this "rate of change" that is the most reasonable measure of "innate" cognitive ability. Even this "innateness" could be more malleable than the term implies, since I suspect that there could be a type of "meta-training" which could improve one's rate of skill learning or acquisition. This would involve practicing ways to use time more efficiently, and, most importantly, practicing ways to bring devotion, joy, and energetic attention to one's learning experiences.
Monday, May 2, 2011
Health effects of binge drinking
In Canada, a "drink" or a "standard drink", as a unit of alcohol consumption, refers to a drink containing 13.6 grams of ethanol. This amount is present in a 12-ounce (355 mL) beer, or a 5-ounce (146 mL) glass of wine, or a 1.5 ounce (44 mL) shot of hard liquor such as whiskey or vodka. Reference: *
Binge drinking is defined as having 5 or more drinks on one occasion for men; or 4 or more drinks on one occasion for women. This pattern of consuming alcohol is a common cultural habit, with historic roots going back thousands of years.
There are various sources of epidemiologic evidence that light drinking may have health benefits. My review of the evidence suggests that the cut-off point for this would be no more than 2 drinks per 24 hours, with any episodes of greater alcohol consumption conferring a substantial health risk (both physical and psychiatric).
When it comes to binge drinking, I believe the health risks are very high. The immediate risks have to do with accidents & injuries, which are much more likely during a binge drinking episode. This risk also affects other people, such as passengers in a car or other drivers on the road.
In my opinion, the psychiatric risks of binge drinking can be divided into several categories:
1) Simple addiction. If heavy intoxication is associated with pleasure or relief, this may easily become an addictive process, such that relief or pleasure may only come with intoxication. As a result, other activities not involving intoxication become more subjectively boring and more prone to induce dysphoria rather than pleasure. I call this the "greying of the sky" phenomenon. The sky becomes less and less blue--figuratively speaking-- the more one repeats an addictive behaviour. It is so gradual as to often be unnoticable, until years later one may have the realization that the simple pleasure of gazing at the blue sky is no longer available.
2) Subcultural effect. In conjunction with simple addiction, binge drinking is likely to affect one's social network, such that one's friends will more likely also be binge drinkers. This makes it more difficult to leave the behaviour behind, since it would involve leaving one's social network. Also the subcultural effect tends to cause a subjective normalization of the behaviour, such that people could actually feel abnormal if they cut back or stopped binge drinking. Heavy drinking and its associated behaviour are a regular source of humour in our culture, which unfortunately may be another normalizing influence for those who are addicted.
3) Direct pharmacological effects during intoxication and withdrawal. Aside from the obvious effects during intoxication, I observe that binge drinking often leads to "mini-withdrawals" afterwards. While many people may normalize their once-weekly alcohol binge, they may not realize that the withdrawal effects during the rest of the week cause impaired sleep quality and heightened anxiety. Many young people are very resilient, so this may not be a problem, but if there is already a progressing problem with anxiety, depression, or other causes for insomnia, then binge drinking will make these problems much more difficult to treat. I believe that the presence of binge-drinking behaviour makes antidepressant treatment much less likely to be successful.
My recommendation is never to binge drink. More than 2 drinks per 24 hours is harmful, causing adverse short-term and long-term health effects in all cases. If binge drinking is a significant part of recreational culture for any individual, then therapeutic work needs to be done not only to cut back on alcohol consumption, but to build a healthier cultural life, and probably a healthier social network.
Here is a review of some of the research literature on the subject:
http://www.ncbi.nlm.nih.gov/pubmed/21345624
binge drinkers have double the rates of depression; reductions of drinking subsequently associated with reduced depressive symptoms.
http://www.ncbi.nlm.nih.gov/pubmed/20858964
This is a very strong 2010 prospective twin study, showing that binge drinkers have double the risk of cognitive impairment (dementia); light drinkers have the lowest risk; abstainers in the middle. High alcohol intake is clearly a strong risk factor for dementia; binge drinking is a risk factor independent of total alcohol intake. That is, even if you don't drink a large volume of alcohol in a month, if you ever binge drink you will still be in a high risk group.
http://www.ncbi.nlm.nih.gov/pubmed/19556525
prospective study showing increased strokes and overall mortality in binge drinkers
http://www.ncbi.nlm.nih.gov/pubmed/19438420
Current binge drinking associated with increased depression 5 years later. This was strong data with a good effort to control for confounding factors. Heavy intoxications at least once a month, especially with associated phenomena (e.g. blackouts, hangovers), were associated with double to fourfold increases in hospitalizations due to depression.
http://www.ncbi.nlm.nih.gov/pubmed/19144978
binge drinking a stronger predictor of social harms (e.g. violence, loss of relationships) than total alcohol volume
http://www.ncbi.nlm.nih.gov/pubmed/21294995
2011, large epidemiologic study. 16% of men over 50 met criteria for binge drinking, 6% of women over 50. Binge drinking behaviour strongly correlated with alcohol dependence (alcoholism).
http://www.ncbi.nlm.nih.gov/pubmed/20930706?dopt=Abstract
another major prevalence study
http://www.cdc.gov/mmwr/preview/mmwrhtml/su6001a22.htm
a concise review from the Centers for Disease Control and Prevention. Prevalence of binge drinking at least 20% for men, 10% for women; rates were higher still for young adults.
http://www.ncbi.nlm.nih.gov/pubmed/19538908
this study shows even higher binge drinking prevalences for college students; 40% of this population engaging in binge drinking in a one month period.
http://www.ncbi.nlm.nih.gov/pubmed/20407040
This is a very nice 2010 review article and discussion from JAMA , about the health impacts of alcohol consumption, particularly the question of whether light drinking might protect against cardiovascular disease. In the particular case discussion, it is concluded that light drinking could have a small but insignificant positive health impact, and it would be more a lifestyle choice than one rationally motivated by health variables. For other individuals, any drinking at all could confer substantial health risks (e.g. those with severe addictive disorders, high sensitivity to negative side-effects of alcohol, various medical diseases). Reasonable warnings are included, such as never to drink while pregnant, before driving, etc.
Binge drinking is defined as having 5 or more drinks on one occasion for men; or 4 or more drinks on one occasion for women. This pattern of consuming alcohol is a common cultural habit, with historic roots going back thousands of years.
There are various sources of epidemiologic evidence that light drinking may have health benefits. My review of the evidence suggests that the cut-off point for this would be no more than 2 drinks per 24 hours, with any episodes of greater alcohol consumption conferring a substantial health risk (both physical and psychiatric).
When it comes to binge drinking, I believe the health risks are very high. The immediate risks have to do with accidents & injuries, which are much more likely during a binge drinking episode. This risk also affects other people, such as passengers in a car or other drivers on the road.
In my opinion, the psychiatric risks of binge drinking can be divided into several categories:
1) Simple addiction. If heavy intoxication is associated with pleasure or relief, this may easily become an addictive process, such that relief or pleasure may only come with intoxication. As a result, other activities not involving intoxication become more subjectively boring and more prone to induce dysphoria rather than pleasure. I call this the "greying of the sky" phenomenon. The sky becomes less and less blue--figuratively speaking-- the more one repeats an addictive behaviour. It is so gradual as to often be unnoticable, until years later one may have the realization that the simple pleasure of gazing at the blue sky is no longer available.
2) Subcultural effect. In conjunction with simple addiction, binge drinking is likely to affect one's social network, such that one's friends will more likely also be binge drinkers. This makes it more difficult to leave the behaviour behind, since it would involve leaving one's social network. Also the subcultural effect tends to cause a subjective normalization of the behaviour, such that people could actually feel abnormal if they cut back or stopped binge drinking. Heavy drinking and its associated behaviour are a regular source of humour in our culture, which unfortunately may be another normalizing influence for those who are addicted.
3) Direct pharmacological effects during intoxication and withdrawal. Aside from the obvious effects during intoxication, I observe that binge drinking often leads to "mini-withdrawals" afterwards. While many people may normalize their once-weekly alcohol binge, they may not realize that the withdrawal effects during the rest of the week cause impaired sleep quality and heightened anxiety. Many young people are very resilient, so this may not be a problem, but if there is already a progressing problem with anxiety, depression, or other causes for insomnia, then binge drinking will make these problems much more difficult to treat. I believe that the presence of binge-drinking behaviour makes antidepressant treatment much less likely to be successful.
My recommendation is never to binge drink. More than 2 drinks per 24 hours is harmful, causing adverse short-term and long-term health effects in all cases. If binge drinking is a significant part of recreational culture for any individual, then therapeutic work needs to be done not only to cut back on alcohol consumption, but to build a healthier cultural life, and probably a healthier social network.
Here is a review of some of the research literature on the subject:
http://www.ncbi.nlm.nih.gov/pubmed/21345624
binge drinkers have double the rates of depression; reductions of drinking subsequently associated with reduced depressive symptoms.
http://www.ncbi.nlm.nih.gov/pubmed/20858964
This is a very strong 2010 prospective twin study, showing that binge drinkers have double the risk of cognitive impairment (dementia); light drinkers have the lowest risk; abstainers in the middle. High alcohol intake is clearly a strong risk factor for dementia; binge drinking is a risk factor independent of total alcohol intake. That is, even if you don't drink a large volume of alcohol in a month, if you ever binge drink you will still be in a high risk group.
http://www.ncbi.nlm.nih.gov/pubmed/19556525
prospective study showing increased strokes and overall mortality in binge drinkers
http://www.ncbi.nlm.nih.gov/pubmed/19438420
Current binge drinking associated with increased depression 5 years later. This was strong data with a good effort to control for confounding factors. Heavy intoxications at least once a month, especially with associated phenomena (e.g. blackouts, hangovers), were associated with double to fourfold increases in hospitalizations due to depression.
http://www.ncbi.nlm.nih.gov/pubmed/19144978
binge drinking a stronger predictor of social harms (e.g. violence, loss of relationships) than total alcohol volume
http://www.ncbi.nlm.nih.gov/pubmed/21294995
2011, large epidemiologic study. 16% of men over 50 met criteria for binge drinking, 6% of women over 50. Binge drinking behaviour strongly correlated with alcohol dependence (alcoholism).
http://www.ncbi.nlm.nih.gov/pubmed/20930706?dopt=Abstract
another major prevalence study
http://www.cdc.gov/mmwr/preview/mmwrhtml/su6001a22.htm
a concise review from the Centers for Disease Control and Prevention. Prevalence of binge drinking at least 20% for men, 10% for women; rates were higher still for young adults.
http://www.ncbi.nlm.nih.gov/pubmed/19538908
this study shows even higher binge drinking prevalences for college students; 40% of this population engaging in binge drinking in a one month period.
http://www.ncbi.nlm.nih.gov/pubmed/20407040
This is a very nice 2010 review article and discussion from JAMA , about the health impacts of alcohol consumption, particularly the question of whether light drinking might protect against cardiovascular disease. In the particular case discussion, it is concluded that light drinking could have a small but insignificant positive health impact, and it would be more a lifestyle choice than one rationally motivated by health variables. For other individuals, any drinking at all could confer substantial health risks (e.g. those with severe addictive disorders, high sensitivity to negative side-effects of alcohol, various medical diseases). Reasonable warnings are included, such as never to drink while pregnant, before driving, etc.
Wednesday, April 13, 2011
Vitamin B12
A reader recently sent in a comment wondering about the possible role of vitamin B12 supplementation in psychiatry.
Here's a brief review of the literature:
http://www.ncbi.nlm.nih.gov/pubmed/21191533 --a small case report of b12-deficient individuals responding better to antidepressants after b12 supplementation.
http://www.ncbi.nlm.nih.gov/pubmed/20976769
--survivors of stroke who took folic acid 2mg/d, b6 25 mg/d, and b12 0.5 mg/d had slightly lower rates of depression; there was an impressive 7 year follow-up period
http://www.ncbi.nlm.nih.gov/pubmed/20716710
this cross-sectional study using a diet questionnaire found an association between dietary folate & b6 and lower rates of depression in a sample of over 6000 adolescents; no association was found regarding b12.
http://www.ncbi.nlm.nih.gov/pubmed/20519557
a study from the American Journal of Clinical Nutrition, which showed a relationship between higher folate and b12 levels, and lower rates of depression, over 7 years of follow-up.
http://www.ncbi.nlm.nih.gov/pubmed/19175490
another study finding an association between low b12 & folate levels and higher rates of depression. Here, the b12 association was specifically for women. Looking more closely at the data, I find that the results are not overwhelmingly strong or convincing; I suspect there could be many confounding factors influencing the association.
http://www.ncbi.nlm.nih.gov/pubmed/18854539
this is an important study from JAMA showing that high dose folate, b6, and b12 supplements did not improve the course of dementia. Furthermore, 28% of the vitamin group experienced depression, compared to 18% of the placebo group.
http://www.ncbi.nlm.nih.gov/pubmed/18557664this study from the Journal of Clinical Psychiatry showed very little protective effect of vitamin b6, b12, and folate supplementation to prevent depression in older men. However, I see the vitamin group did slightly better than the placebo group, but not well enough to meet criteria for statistical significance.
In summary, there is a little bit of evidence of benefits from b12 in psychiatry, but the results are not overwhelmingly strong unless there is evidence of deficiency. It is worthwhile to have B12 levels checked. It appears not to be dangerous to take supplements; I suppose it is reasonable to aim for the higher part of the recommended serum levels, and to adjust any supplementation accordingly. Having said that, I acknowledge the possibility that some individuals may have a more beneficial effect from b12 supplementation, perhaps there could be selected cases in which this could act synergistically or as an augmentation with other treatments for depression, or perhaps there could be cases of subtle deficiency.
B12 deficiency is not uncommon; this can occur due to malabsorption (as in pernicious anemia or bowel disease), or due to dietary deficiency (e.g. in vegans). If the cause of low b12 is malabsorption, is may be necessary to have b12 injections. Once again, it is important to have b12 levels checked, and make decisions about supplementation if the level is low.
Here's a brief review of the literature:
http://www.ncbi.nlm.nih.gov/pubmed/21191533 --a small case report of b12-deficient individuals responding better to antidepressants after b12 supplementation.
http://www.ncbi.nlm.nih.gov/pubmed/20976769
--survivors of stroke who took folic acid 2mg/d, b6 25 mg/d, and b12 0.5 mg/d had slightly lower rates of depression; there was an impressive 7 year follow-up period
http://www.ncbi.nlm.nih.gov/pubmed/20716710
this cross-sectional study using a diet questionnaire found an association between dietary folate & b6 and lower rates of depression in a sample of over 6000 adolescents; no association was found regarding b12.
http://www.ncbi.nlm.nih.gov/pubmed/20519557
a study from the American Journal of Clinical Nutrition, which showed a relationship between higher folate and b12 levels, and lower rates of depression, over 7 years of follow-up.
http://www.ncbi.nlm.nih.gov/pubmed/19175490
another study finding an association between low b12 & folate levels and higher rates of depression. Here, the b12 association was specifically for women. Looking more closely at the data, I find that the results are not overwhelmingly strong or convincing; I suspect there could be many confounding factors influencing the association.
http://www.ncbi.nlm.nih.gov/pubmed/18854539
this is an important study from JAMA showing that high dose folate, b6, and b12 supplements did not improve the course of dementia. Furthermore, 28% of the vitamin group experienced depression, compared to 18% of the placebo group.
http://www.ncbi.nlm.nih.gov/pubmed/18557664this study from the Journal of Clinical Psychiatry showed very little protective effect of vitamin b6, b12, and folate supplementation to prevent depression in older men. However, I see the vitamin group did slightly better than the placebo group, but not well enough to meet criteria for statistical significance.
In summary, there is a little bit of evidence of benefits from b12 in psychiatry, but the results are not overwhelmingly strong unless there is evidence of deficiency. It is worthwhile to have B12 levels checked. It appears not to be dangerous to take supplements; I suppose it is reasonable to aim for the higher part of the recommended serum levels, and to adjust any supplementation accordingly. Having said that, I acknowledge the possibility that some individuals may have a more beneficial effect from b12 supplementation, perhaps there could be selected cases in which this could act synergistically or as an augmentation with other treatments for depression, or perhaps there could be cases of subtle deficiency.
B12 deficiency is not uncommon; this can occur due to malabsorption (as in pernicious anemia or bowel disease), or due to dietary deficiency (e.g. in vegans). If the cause of low b12 is malabsorption, is may be necessary to have b12 injections. Once again, it is important to have b12 levels checked, and make decisions about supplementation if the level is low.
Tuesday, February 15, 2011
Looking at affected body parts reduces pain
Here's an interesting little study showing that acute physical pain is diminished in intensity when one is looking at the affected body part; if this body part is artificially made to look larger, then the subjective pain is reduced even further.
http://www.ncbi.nlm.nih.gov/pubmed/21303990
In applying this type of idea to psychological pain, I guess one could say that "looking at the affected body part" could translate to discussing the problem in a therapeutic dialog.
A limitation of the study, and with pain studies in general, is that a brief intervention for an acute pain may not necessarily be equivalently helpful as a prolonged intervention for a chronic pain. In fact, some effective physical treatments for acute pain potentially exacerbate a chronic or recurrent pain disorder (e.g. using opiates to treat mechanical back pain or migraine).
However, I believe that studies of this type do illustrate that simple, brief psychological techniques can be surprisingly powerful in modulating perceptions or sensation.
http://www.ncbi.nlm.nih.gov/pubmed/21303990
In applying this type of idea to psychological pain, I guess one could say that "looking at the affected body part" could translate to discussing the problem in a therapeutic dialog.
A limitation of the study, and with pain studies in general, is that a brief intervention for an acute pain may not necessarily be equivalently helpful as a prolonged intervention for a chronic pain. In fact, some effective physical treatments for acute pain potentially exacerbate a chronic or recurrent pain disorder (e.g. using opiates to treat mechanical back pain or migraine).
However, I believe that studies of this type do illustrate that simple, brief psychological techniques can be surprisingly powerful in modulating perceptions or sensation.
Working memory exercises for treating addictions?
Here's a link to an interesting article from Biological Psychiatry this month:
http://www.ncbi.nlm.nih.gov/pubmed/20965498
It is based on the notion that the decision to engage in an addiction is often made based on a short-term, possibly impulsive, analysis of benefits and risks; consequently, longer-term risks or benefits associated with the behaviour are undervalued. This phenomenon is termed "delay discounting." Resistance to delay discounting could be considered a cognitive faculty that would help, on an intellectual level, with making a healthy decision in the face of strong impulses in the moment.
The authors note a relationship between addictive disorders and increased delay discounting. They also note a previously described relationship between delay discounting and reduced working memory function.
Based on these relationships, they did a controlled study of persons with stimulant addiction, in which the active group did a set of memory training exercises for 1-2 months. They found that the memory exercises led to improved (reduced) delay discounting.
This study does not show that memory exercises directly improve the course of addictive disorders; but it does present a promising therapeutic idea which I think is currently underutilized in the therapeutic community, not only for addictions but for other types of problems.
Cognitive exercises could have a variety of benefits for various psychological problems:
1) the improvement one would see with practice could help with self-esteem
2) arguably, the exercises would favourably alter the balance between executive function and visceral, limbic emotional drives (which could often be turbulent or disruptive)
3) the exercises could be an introduction to the various mental and physical disciplines required to effect psychological or behavioural change
In terms of the specific exercises used in this study, I do think that the number of practice sessions was far too small. I believe that most psychologically beneficial activities start to show substantial results after 50-100 hours of practice. This study used only a maximum of 15 training sessions. The memory practice itself could have been organized in a more engaging, game-like manner. I think of some quite unique working memory games from the lumosity.com website, which tap into a type of activity most people would rarely work on directly, but yet are quite entertaining and allow gradual progress.
In summary, this was an interesting article looking at the promising theme of using cognitive training exercises as part of the treatment of a psychological problem. This is a relatively new idea, showing up only a few other times so far in the research literature.
http://www.ncbi.nlm.nih.gov/pubmed/20965498
It is based on the notion that the decision to engage in an addiction is often made based on a short-term, possibly impulsive, analysis of benefits and risks; consequently, longer-term risks or benefits associated with the behaviour are undervalued. This phenomenon is termed "delay discounting." Resistance to delay discounting could be considered a cognitive faculty that would help, on an intellectual level, with making a healthy decision in the face of strong impulses in the moment.
The authors note a relationship between addictive disorders and increased delay discounting. They also note a previously described relationship between delay discounting and reduced working memory function.
Based on these relationships, they did a controlled study of persons with stimulant addiction, in which the active group did a set of memory training exercises for 1-2 months. They found that the memory exercises led to improved (reduced) delay discounting.
This study does not show that memory exercises directly improve the course of addictive disorders; but it does present a promising therapeutic idea which I think is currently underutilized in the therapeutic community, not only for addictions but for other types of problems.
Cognitive exercises could have a variety of benefits for various psychological problems:
1) the improvement one would see with practice could help with self-esteem
2) arguably, the exercises would favourably alter the balance between executive function and visceral, limbic emotional drives (which could often be turbulent or disruptive)
3) the exercises could be an introduction to the various mental and physical disciplines required to effect psychological or behavioural change
In terms of the specific exercises used in this study, I do think that the number of practice sessions was far too small. I believe that most psychologically beneficial activities start to show substantial results after 50-100 hours of practice. This study used only a maximum of 15 training sessions. The memory practice itself could have been organized in a more engaging, game-like manner. I think of some quite unique working memory games from the lumosity.com website, which tap into a type of activity most people would rarely work on directly, but yet are quite entertaining and allow gradual progress.
In summary, this was an interesting article looking at the promising theme of using cognitive training exercises as part of the treatment of a psychological problem. This is a relatively new idea, showing up only a few other times so far in the research literature.
Monday, January 31, 2011
Omega-3 deficiency and low dietary omega-3 to omega-6 ratio may exacerbate depression and reduce neuroplasticity
Here's an interesting update on the dietary fatty acid issue, as it pertains to mood disorders and neuroplasticity:
http://www.nature.com/neuro/journal/vaop/ncurrent/full/nn.2736.html
This article, published in Nature Neuroscience (January 30, 2011), is an example of some good research being done by a group at the University of Bordeaux in France. They demonstrate substantial negative neurophysiological changes in mice as a result of an omega-3 deficient diet. It is interesting to note that the brain's endocanniboid system is specifically affected by omega-3 deficiency, according to this research.
This is further evidence supporting the importance of attending to a healthy diet, in maintaining optimal mental health. Omega-3 fatty acids are one element of a healthy diet. While omega-6 fatty acids are also needed in the diet, these lipids behave to some degree competitively with omega-3. Therefore, the ratio of dietary omega-3 to omega-6 is is very important. Western diets tend to have an unhealthy ratio of these lipids, due to excessive omega-6.
An ongoing issue of debate has to do with whether plant sources of omega-3 (primarily ALA) are as useful as fish sources (DHA and EPA). Existing evidence shows that DHA and EPA are more important. ALA can be converted in the body to DHA and EPA, but the efficiency of this may vary from person to person.
Wikipedia has a nice review of this subject: http://en.wikipedia.org/wiki/Omega-3_fatty_acid
but some of the sources are less than ideal.
It is interesting to consider that the DHA/EPA issue is not a "micronutrient" issue. They could be considered "macronutrients." The solid mass of the brain consists mostly of lipids (60-80 % of the non-aqueous mass); DHA and EPA make up over 10% of this lipid mass, which is a very high concentration.
Here's a link to a paper which quantifies the high fractions of omega-3 lipids in brain mass:
http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=921064 --this paper also showed that dietary changes substantially altered the proportion of omega-3 lipids in brain tissue
http://www.nature.com/neuro/journal/vaop/ncurrent/full/nn.2736.html
This article, published in Nature Neuroscience (January 30, 2011), is an example of some good research being done by a group at the University of Bordeaux in France. They demonstrate substantial negative neurophysiological changes in mice as a result of an omega-3 deficient diet. It is interesting to note that the brain's endocanniboid system is specifically affected by omega-3 deficiency, according to this research.
This is further evidence supporting the importance of attending to a healthy diet, in maintaining optimal mental health. Omega-3 fatty acids are one element of a healthy diet. While omega-6 fatty acids are also needed in the diet, these lipids behave to some degree competitively with omega-3. Therefore, the ratio of dietary omega-3 to omega-6 is is very important. Western diets tend to have an unhealthy ratio of these lipids, due to excessive omega-6.
An ongoing issue of debate has to do with whether plant sources of omega-3 (primarily ALA) are as useful as fish sources (DHA and EPA). Existing evidence shows that DHA and EPA are more important. ALA can be converted in the body to DHA and EPA, but the efficiency of this may vary from person to person.
Wikipedia has a nice review of this subject: http://en.wikipedia.org/wiki/Omega-3_fatty_acid
but some of the sources are less than ideal.
It is interesting to consider that the DHA/EPA issue is not a "micronutrient" issue. They could be considered "macronutrients." The solid mass of the brain consists mostly of lipids (60-80 % of the non-aqueous mass); DHA and EPA make up over 10% of this lipid mass, which is a very high concentration.
Here's a link to a paper which quantifies the high fractions of omega-3 lipids in brain mass:
http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=921064 --this paper also showed that dietary changes substantially altered the proportion of omega-3 lipids in brain tissue
Monday, January 24, 2011
"Outlier": The causes of high achievement
Outlier by Malcolm Gladwell, is a brilliant book about the causes of success, outstanding achievement, and personal greatness.
Gladwell describes a variety of interesting life stories, of people with outstanding ability or outstanding achievement, then looks carefully at the factors leading to these successes.
He does not claim that "inborn traits" or hereditary factors are unimportant. But he shows quite convincingly that inborn talents correlate with achievement only to a certain point. Individuals with extreme talents tend not to achieve more than those with merely "sufficient" talents. A recurring theme in this book, shown through one example after the next, is that the simple stories many people might have, to account for a person's great achievements, are often appealing and believable, but are in fact often inaccurate or at the very least incomplete.
He shows that various situational biases can have a profound, snowballing effect on the course of successfulness in a person's life. A trite detail such as birthdate can lead to a cascade of advantages or disadvantages for athletes, which then accumulate over many years (his example is of successful hockey players being much more likely to have an early birthday--if you're born in December, this is an instant disadvantage, as you will be a little bit smaller and weaker on average compared to your teammates, therefore the older players will tend to outperform you, leading to a smaller chance of you being noticed or advanced to a more challenging team, or to be deemed "gifted" and given more ice time, etc.)
He emphasizes the role of thousands of hours of intensive practice being required to master a skill. Those who have 10 000 hours of practice under their belt early on in their lives--particularly if some serendipitous quirk of fortune allowed them to be one of the only individuals, or one of the first, to gain this experience-- have a strong chance of succeeding spectacularly in their fields. He gives examples such as Bill Gates, or the Beatles, or some of the most successful New York lawyers doing a particular type of law.
One of the psychologists cited in this book, who has studied the area of "exceptional achievement" is AK Ericsson, who generally argues that "extended, intense practice" is the primary determinant of elite performance, as opposed to inborn talent. The ability to do this type of practice, of course, requires or is greatly facilitated by, motivational resources as well as environmental opportunity, parental support, a culture which favours such as endeavour, etc.) Here are some references to articles of his:
http://www.ncbi.nlm.nih.gov/pubmed/17905932
http://www.ncbi.nlm.nih.gov/pubmed/17642130
I suspect that heredity is quite relevant, but may manifest itself in many ways aside from what many people might assume. Factors that could be considered at first glance to be a disadvantage, either hereditarily or environmentally, may, in the world of successfulness, end up being compelling advantages.
Guillermo Campitelli is another excellent researcher in this field; here's a reference to one of his recent papers: http://www.ncbi.nlm.nih.gov/pubmed/17201516. The evidence here, looking specifically at chess players as a model of acquiring expertise, affirms the extreme importance of thousands of hours of practice, but also recognizes that some players improve much more than others with the same amount of practice. This is probably the influence of inherited talent. Maybe there could be other hidden variables, including family or cultural factors. He suggests that the age at which the practice begins is another important variable.
It should be noted that, in this literature, "deliberate practice" refers to a type of activity which is specifically directed towards performance improvement, is adequately difficult, has feedback about performance, and which has opportunity to correct errors. This differs from "ordinary" work experience, which may be quite a bit less intense and much less geared towards improving skills. I suspect that the quality of "deliberate practice" may vary quite a bit, depending on the degree of immersion, concentration, energy, engagement, and meaningfulness there is in the action. I wonder if enjoyment of the practice is a major variable too, I would be interested to see if some of these researchers would look at this. If someone finds their 100 hours of practice meaningful and enjoyable, I have to wonder if they might advance much more than someone whose 100 hours were a drudgery.
Another excellent angle of discussion in Gladwell's book has to do with understanding a person's cultural background and childhood developmental history, as extremely important determinants of success. This leads to discussions about opportunity, pedagogical technique and policy, etc. Sometimes cultural or developmental factors cause individuals to lack a certain skill necessary to succeed, or put individuals at risk of recurrent severe problems or frustrations. Good examples are given, including the story of a profoundly gifted intellect who was never able to share his talents; and of highly trained pilots who were too quietly respectful of authority to be able to proactively use strong assertive social skills to prevent an aviation disaster.
I'll add to this post later on, to expand some thoughts about achievement and success. In the meantime, I think Outlier is a worthwhile and entertaining read.
Gladwell describes a variety of interesting life stories, of people with outstanding ability or outstanding achievement, then looks carefully at the factors leading to these successes.
He does not claim that "inborn traits" or hereditary factors are unimportant. But he shows quite convincingly that inborn talents correlate with achievement only to a certain point. Individuals with extreme talents tend not to achieve more than those with merely "sufficient" talents. A recurring theme in this book, shown through one example after the next, is that the simple stories many people might have, to account for a person's great achievements, are often appealing and believable, but are in fact often inaccurate or at the very least incomplete.
He shows that various situational biases can have a profound, snowballing effect on the course of successfulness in a person's life. A trite detail such as birthdate can lead to a cascade of advantages or disadvantages for athletes, which then accumulate over many years (his example is of successful hockey players being much more likely to have an early birthday--if you're born in December, this is an instant disadvantage, as you will be a little bit smaller and weaker on average compared to your teammates, therefore the older players will tend to outperform you, leading to a smaller chance of you being noticed or advanced to a more challenging team, or to be deemed "gifted" and given more ice time, etc.)
He emphasizes the role of thousands of hours of intensive practice being required to master a skill. Those who have 10 000 hours of practice under their belt early on in their lives--particularly if some serendipitous quirk of fortune allowed them to be one of the only individuals, or one of the first, to gain this experience-- have a strong chance of succeeding spectacularly in their fields. He gives examples such as Bill Gates, or the Beatles, or some of the most successful New York lawyers doing a particular type of law.
One of the psychologists cited in this book, who has studied the area of "exceptional achievement" is AK Ericsson, who generally argues that "extended, intense practice" is the primary determinant of elite performance, as opposed to inborn talent. The ability to do this type of practice, of course, requires or is greatly facilitated by, motivational resources as well as environmental opportunity, parental support, a culture which favours such as endeavour, etc.) Here are some references to articles of his:
http://www.ncbi.nlm.nih.gov/pubmed/17905932
http://www.ncbi.nlm.nih.gov/pubmed/17642130
I suspect that heredity is quite relevant, but may manifest itself in many ways aside from what many people might assume. Factors that could be considered at first glance to be a disadvantage, either hereditarily or environmentally, may, in the world of successfulness, end up being compelling advantages.
Guillermo Campitelli is another excellent researcher in this field; here's a reference to one of his recent papers: http://www.ncbi.nlm.nih.gov/pubmed/17201516. The evidence here, looking specifically at chess players as a model of acquiring expertise, affirms the extreme importance of thousands of hours of practice, but also recognizes that some players improve much more than others with the same amount of practice. This is probably the influence of inherited talent. Maybe there could be other hidden variables, including family or cultural factors. He suggests that the age at which the practice begins is another important variable.
It should be noted that, in this literature, "deliberate practice" refers to a type of activity which is specifically directed towards performance improvement, is adequately difficult, has feedback about performance, and which has opportunity to correct errors. This differs from "ordinary" work experience, which may be quite a bit less intense and much less geared towards improving skills. I suspect that the quality of "deliberate practice" may vary quite a bit, depending on the degree of immersion, concentration, energy, engagement, and meaningfulness there is in the action. I wonder if enjoyment of the practice is a major variable too, I would be interested to see if some of these researchers would look at this. If someone finds their 100 hours of practice meaningful and enjoyable, I have to wonder if they might advance much more than someone whose 100 hours were a drudgery.
Another excellent angle of discussion in Gladwell's book has to do with understanding a person's cultural background and childhood developmental history, as extremely important determinants of success. This leads to discussions about opportunity, pedagogical technique and policy, etc. Sometimes cultural or developmental factors cause individuals to lack a certain skill necessary to succeed, or put individuals at risk of recurrent severe problems or frustrations. Good examples are given, including the story of a profoundly gifted intellect who was never able to share his talents; and of highly trained pilots who were too quietly respectful of authority to be able to proactively use strong assertive social skills to prevent an aviation disaster.
I'll add to this post later on, to expand some thoughts about achievement and success. In the meantime, I think Outlier is a worthwhile and entertaining read.
Friday, January 21, 2011
Writing about worries can ease exam anxiety
Here's another simple research finding, published recently in Science by Sian Beilock: students who spent ten minutes--immediately before a test--writing down their thoughts about what was causing them fear, performed substantially better on the test.
http://www.ncbi.nlm.nih.gov/pubmed/21233387
I'll have to review this paper in more detail to comment further, but I think it is another simple anxiety-management tactic for exam or performance preparation. A frantic review or a frantic bout of anxious rumination right before an exam is unlikely to help -- an anxiety-management exercise such as expressive writing is very much more likely to help, and a study like this is strong evidence of this.
The article shows that the effective action was specifically to write about negative thoughts and feelings during the ten minutes before the beginning of a stressful exam. A control activity--of writing about anything that comes to mind--was not effective. So the effectiveness of this technique was not simply due to distraction.
I would be interested to see the authors' opinions and/or research about whether specific journaling techniques could work particularly well, or less well, in various anxiety scenarios. Sometimes, purely "negative" journaling can end up being a somewhat ruminative activity which entrenches negative emotional states and attitudes (e.g. one can get worked up in a cynical, pessimistic rant, which could increase or magnify one's following cynicism or pessimism, or increase one's filtered attention to negative events in the day).
See the following references:
http://www.ncbi.nlm.nih.gov/pubmed/12173682
http://www.ncbi.nlm.nih.gov/pubmed/17120515
A "balanced" journaling style, which includes room for free discussion of thoughts and feelings, but also room for positively-focused or constructive discussion may prevent this risk of snowballing rumination or negativity from a journaling activity. One simple aspect of this experiment was that the journaling was immediately before a performance, and was very time-limited (10 minutes); these factors may reduce the potential for the journaling to be a negative or ruminative behaviour, and may increase the chance of the activity serving to process anxious emotion effectively.
http://www.ncbi.nlm.nih.gov/pubmed/21233387
I'll have to review this paper in more detail to comment further, but I think it is another simple anxiety-management tactic for exam or performance preparation. A frantic review or a frantic bout of anxious rumination right before an exam is unlikely to help -- an anxiety-management exercise such as expressive writing is very much more likely to help, and a study like this is strong evidence of this.
The article shows that the effective action was specifically to write about negative thoughts and feelings during the ten minutes before the beginning of a stressful exam. A control activity--of writing about anything that comes to mind--was not effective. So the effectiveness of this technique was not simply due to distraction.
I would be interested to see the authors' opinions and/or research about whether specific journaling techniques could work particularly well, or less well, in various anxiety scenarios. Sometimes, purely "negative" journaling can end up being a somewhat ruminative activity which entrenches negative emotional states and attitudes (e.g. one can get worked up in a cynical, pessimistic rant, which could increase or magnify one's following cynicism or pessimism, or increase one's filtered attention to negative events in the day).
See the following references:
http://www.ncbi.nlm.nih.gov/pubmed/12173682
http://www.ncbi.nlm.nih.gov/pubmed/17120515
A "balanced" journaling style, which includes room for free discussion of thoughts and feelings, but also room for positively-focused or constructive discussion may prevent this risk of snowballing rumination or negativity from a journaling activity. One simple aspect of this experiment was that the journaling was immediately before a performance, and was very time-limited (10 minutes); these factors may reduce the potential for the journaling to be a negative or ruminative behaviour, and may increase the chance of the activity serving to process anxious emotion effectively.
Testing improves learning
Here's another recent bit of research, published in Science, demonstrating the value of doing a test ("retrieval practice"), immediately after learning something. Those who did the tests, instead of other study techniques, had much better retention 1 week after learning something.
http://www.sciencemag.org/content/early/2011/01/19/science.1199327.abstract
This finding is consistent with my believe that a lot of study time is inefficient, because it encourages the studier to push forward to "get more reading done", before the reading which was just done has been consolidated well or reviewed. Even though "pushing forward" may seemingly cover more pages of text, it accomplishes less long-term learning. A much more efficient use of time is to pause, review, and do a test on the material at just the right interval. If the interval is too short, the tests will be too easy, and the review will also be an inefficient use of time. If the interval is too long, too much will have been forgotten already, the tests will be too hard, and it will make you have to go over the same material again, another inefficiency.
I don't believe findings such as this one necessarily contradict ideas about flexible or "constructivist" approaches to education. Nor do I believe it has anything to do with the controversial area of standardized tests for children or professional schools, etc. Standardized tests are not a mechanism for education, they are assessment tools (how good they are as assessment tools would be a subject for a good debate).
There are some instances in which pausing frequently to review could disrupt a larger thematic appreciation of a subject or experience--it would be like pausing a movie every ten minutes to answer questions about the plot or characters--so, of course, sometimes this technique would have to be set aside.
I think that flexible, personalized educational approaches are extremely important--but this evidence about the merits of retrieval practice testing can be applied to any such style. Its immediate value is in helping people use their time more efficiently for many study tasks.
A previous post also deals with the subject of study efficiency, and actually cites a more densely technical analysis showing more or less the same result, though it adds information about the frequency with which one should optimally pause to test oneself: http://garthkroeker.blogspot.com/2010/04/optimal-learning-training-schedules.html
http://www.sciencemag.org/content/early/2011/01/19/science.1199327.abstract
This finding is consistent with my believe that a lot of study time is inefficient, because it encourages the studier to push forward to "get more reading done", before the reading which was just done has been consolidated well or reviewed. Even though "pushing forward" may seemingly cover more pages of text, it accomplishes less long-term learning. A much more efficient use of time is to pause, review, and do a test on the material at just the right interval. If the interval is too short, the tests will be too easy, and the review will also be an inefficient use of time. If the interval is too long, too much will have been forgotten already, the tests will be too hard, and it will make you have to go over the same material again, another inefficiency.
I don't believe findings such as this one necessarily contradict ideas about flexible or "constructivist" approaches to education. Nor do I believe it has anything to do with the controversial area of standardized tests for children or professional schools, etc. Standardized tests are not a mechanism for education, they are assessment tools (how good they are as assessment tools would be a subject for a good debate).
There are some instances in which pausing frequently to review could disrupt a larger thematic appreciation of a subject or experience--it would be like pausing a movie every ten minutes to answer questions about the plot or characters--so, of course, sometimes this technique would have to be set aside.
I think that flexible, personalized educational approaches are extremely important--but this evidence about the merits of retrieval practice testing can be applied to any such style. Its immediate value is in helping people use their time more efficiently for many study tasks.
A previous post also deals with the subject of study efficiency, and actually cites a more densely technical analysis showing more or less the same result, though it adds information about the frequency with which one should optimally pause to test oneself: http://garthkroeker.blogspot.com/2010/04/optimal-learning-training-schedules.html
Monday, January 10, 2011
Reading Exercises
A common problem I find among university students is difficulty reading quickly or efficiently. Reading problems can also occur in conjunction with depression.
The best thing to do to improve reading skills is, of course, to read more. But a phenomenon which often happens when reading any text, but especially longer texts, such as novels, is that you can lose track of what you have just been reading. Whole sections of the text may end up being skimmed superficially, as part of your attention lapses or wanders, while still maintaining a basic pace of absent-minded reading. This leads to a lack of enjoyment or feeling of mastery with reading, dampened morale, sapped motivation, contributing further to any depression which had been present, and deterring further reading efforts.
An approach to this type of problem requires you to stop to reflect or answer questions frequently about what you have just read. Whenever you test yourself regularly, your learning and retention are greatly increased. Most good introductory university textbooks are set up this way. But not very much in the line of non-textbook reading.
So, I have been trying to find resources to help with reading skill, for adults. Elementary-school language textbooks or readers seemed like a reasonable thing to check. I certainly recommend that adults at least periodically read books which have been written for children or adolescents. The best things I've found online are from ESL (English as a second language) programs. Even if you are an advanced reader, or have spoken English all your life, I think that ESL exercises could be good for improving reading skill.
Cognitive-skills training websites tend not to offer very much in terms of language learning or improving reading fluency or retention. I wish that the cognitive skills website people could develop more along these lines: reading-oriented games don't seem very difficult to imagine or design, compared to other types of games.
Here's a list of a few sites I've found, where you can practice English reading skills:
http://web2.uvcs.uvic.ca/courses/elc/studyzone/
This is an excellent free resource from the University of Victoria (in BC). For the reading exercises, choose an "English language level" (beginner to advanced), then follow the links about reading.
Houghton Mifflin College
This site also offers timed readings with questions afterwards.
Quizzes Based On VOA Programs (ESL/EFL)
This link goes to a site where you have to read a text a sentence at a time, and fill in the blanks from a list of options, according to what makes sense or is grammatically correct. While some might find this type of exercise too easy, I think it is a nice way to remain more interactive with the text. If you do find it easy, you can just try to do it faster, and make it into a game.
Another useful thing to look for is an online book club which has discussion questions about the book you're reading. Some sites have questions for each chapter, which is the type of thing I'm recommending, so that you can pause frequently to review what you have just been reading. I haven't found a single site which has chapter-by-chapter questions for a wide variety of books, but here's an example of a specific site, giving questions about Great Expectations by Charles Dickens (a great book, by the way):
http://www.victorianweb.org/authors/dickens/ge/pva107.html
The best thing to do to improve reading skills is, of course, to read more. But a phenomenon which often happens when reading any text, but especially longer texts, such as novels, is that you can lose track of what you have just been reading. Whole sections of the text may end up being skimmed superficially, as part of your attention lapses or wanders, while still maintaining a basic pace of absent-minded reading. This leads to a lack of enjoyment or feeling of mastery with reading, dampened morale, sapped motivation, contributing further to any depression which had been present, and deterring further reading efforts.
An approach to this type of problem requires you to stop to reflect or answer questions frequently about what you have just read. Whenever you test yourself regularly, your learning and retention are greatly increased. Most good introductory university textbooks are set up this way. But not very much in the line of non-textbook reading.
So, I have been trying to find resources to help with reading skill, for adults. Elementary-school language textbooks or readers seemed like a reasonable thing to check. I certainly recommend that adults at least periodically read books which have been written for children or adolescents. The best things I've found online are from ESL (English as a second language) programs. Even if you are an advanced reader, or have spoken English all your life, I think that ESL exercises could be good for improving reading skill.
Cognitive-skills training websites tend not to offer very much in terms of language learning or improving reading fluency or retention. I wish that the cognitive skills website people could develop more along these lines: reading-oriented games don't seem very difficult to imagine or design, compared to other types of games.
Here's a list of a few sites I've found, where you can practice English reading skills:
http://web2.uvcs.uvic.ca/courses/elc/studyzone/
This is an excellent free resource from the University of Victoria (in BC). For the reading exercises, choose an "English language level" (beginner to advanced), then follow the links about reading.
Houghton Mifflin College
This site also offers timed readings with questions afterwards.
Quizzes Based On VOA Programs (ESL/EFL)
This link goes to a site where you have to read a text a sentence at a time, and fill in the blanks from a list of options, according to what makes sense or is grammatically correct. While some might find this type of exercise too easy, I think it is a nice way to remain more interactive with the text. If you do find it easy, you can just try to do it faster, and make it into a game.
Another useful thing to look for is an online book club which has discussion questions about the book you're reading. Some sites have questions for each chapter, which is the type of thing I'm recommending, so that you can pause frequently to review what you have just been reading. I haven't found a single site which has chapter-by-chapter questions for a wide variety of books, but here's an example of a specific site, giving questions about Great Expectations by Charles Dickens (a great book, by the way):
http://www.victorianweb.org/authors/dickens/ge/pva107.html
Tuesday, January 4, 2011
Tetris or sleep deprivation to treat or prevent PTSD?
Here's a reference to an interesting 2009 study showing that playing tetris for 30 minutes can interfere with memory consolidation of upsetting visual imagery:
http://www.ncbi.nlm.nih.gov/pubmed/19127289
This is an example of evolving evidence that an important period for consolidation of memories occurs in the first 24 hours after an experience. A consolidated implicit association between the factual components of memory and strong negative emotions may also form most strongly during this initial post-exposure period.
The same group published a 2010 study showing that a game like tetris was more effective than a quiz-type game activity for reducing visual flashbacks following exposure to upsetting imagery:
http://www.ncbi.nlm.nih.gov/pubmed/21085661
I think the message here is not that tetris in particular has some kind of unique medicinal properties, but that a non-passive activity which requires continuous, intense visual attention is most effective at reducing consolidation of intrusive visual memory. A distracting activity lacking strong visual involvement may be less likely to interfere with this consolidation mechanism.
Other research has suggested that propranolol, a beta-blocking drug, can reduce post-traumatic memory consolidation, particularly the troubling implicit or emotional component responsible for psychological symptoms of PTSD. (see my other post, http://garthkroeker.blogspot.com/2009/02/beta-blockers.html)
Some of the standard psychological treatments in the immediate post-trauma period may be harmful, such as critical incident stress debriefing. If individuals are compelled to revisit details of their trauma in a group setting, during the sensitive 24-hour post-incident window, this may increase rather than decrease memory consolidation. I think this tactic is especially problematic if there is social pressure or overt prescriptive advice from professionals to do this, when the individual may not wish to talk about the trauma. This type of pressure may feel coercive rather than freely consensual, a dynamic which could be re-traumatizing.
In another recent study (http://www.ncbi.nlm.nih.gov/pubmed/20889142 ), sleep deprivation following exposure to upsetting visual stimuli was shown to reduce aspects of implicit memory consolidation. This is consistent with other evidence showing that sleeping facilitates learning, by helping to consolidate recently acquired memories.
In conclusion, I think it is useful to know some simple techniques which could reduce the harm which traumatic experience can immediately impose upon the brain's memory systems. Immediate distraction with an absorbing visual activity, such as tetris, could be helpful. Sleeping right away may not be helpful, and may actually increase consolidation of traumatic memory.
For consolidated symptoms of PTSD, and for longstanding troubling thoughts, memories, images, and emotions, etc. it is clear that therapeutic dialog can be very helpful, provided the setting is safe, non-pressured, comfortable, with a strong sense of trust. Such gentle dialog could begin the process of weakening the strong negative emotional grip that the traumatic experiences may have in daily life. The evidence mentioned above has to do with reducing the incidence of PTSD in the first place, through specific tactics to be undertaken immediately after the trauma.
We could infer, conversely, that engaging in distracting activities, such as video games, after doing an activity that you would want to remember vividly (such as studying, or some other pleasurable or meaningful event), could lessen retention of these positive experiences (so, you shouldn't distract yourself with an absorbing visual activity right after studying). Also, having a good sleep after a pleasurable event, or after studying, would be expected to make these experiences more permanent in your factual and emotional memory. So, it's important to be conscious of what you do, during, but also after, events of significance.
http://www.ncbi.nlm.nih.gov/pubmed/19127289
This is an example of evolving evidence that an important period for consolidation of memories occurs in the first 24 hours after an experience. A consolidated implicit association between the factual components of memory and strong negative emotions may also form most strongly during this initial post-exposure period.
The same group published a 2010 study showing that a game like tetris was more effective than a quiz-type game activity for reducing visual flashbacks following exposure to upsetting imagery:
http://www.ncbi.nlm.nih.gov/pubmed/21085661
I think the message here is not that tetris in particular has some kind of unique medicinal properties, but that a non-passive activity which requires continuous, intense visual attention is most effective at reducing consolidation of intrusive visual memory. A distracting activity lacking strong visual involvement may be less likely to interfere with this consolidation mechanism.
Other research has suggested that propranolol, a beta-blocking drug, can reduce post-traumatic memory consolidation, particularly the troubling implicit or emotional component responsible for psychological symptoms of PTSD. (see my other post, http://garthkroeker.blogspot.com/2009/02/beta-blockers.html)
Some of the standard psychological treatments in the immediate post-trauma period may be harmful, such as critical incident stress debriefing. If individuals are compelled to revisit details of their trauma in a group setting, during the sensitive 24-hour post-incident window, this may increase rather than decrease memory consolidation. I think this tactic is especially problematic if there is social pressure or overt prescriptive advice from professionals to do this, when the individual may not wish to talk about the trauma. This type of pressure may feel coercive rather than freely consensual, a dynamic which could be re-traumatizing.
In another recent study (http://www.ncbi.nlm.nih.gov/pubmed/20889142 ), sleep deprivation following exposure to upsetting visual stimuli was shown to reduce aspects of implicit memory consolidation. This is consistent with other evidence showing that sleeping facilitates learning, by helping to consolidate recently acquired memories.
In conclusion, I think it is useful to know some simple techniques which could reduce the harm which traumatic experience can immediately impose upon the brain's memory systems. Immediate distraction with an absorbing visual activity, such as tetris, could be helpful. Sleeping right away may not be helpful, and may actually increase consolidation of traumatic memory.
For consolidated symptoms of PTSD, and for longstanding troubling thoughts, memories, images, and emotions, etc. it is clear that therapeutic dialog can be very helpful, provided the setting is safe, non-pressured, comfortable, with a strong sense of trust. Such gentle dialog could begin the process of weakening the strong negative emotional grip that the traumatic experiences may have in daily life. The evidence mentioned above has to do with reducing the incidence of PTSD in the first place, through specific tactics to be undertaken immediately after the trauma.
We could infer, conversely, that engaging in distracting activities, such as video games, after doing an activity that you would want to remember vividly (such as studying, or some other pleasurable or meaningful event), could lessen retention of these positive experiences (so, you shouldn't distract yourself with an absorbing visual activity right after studying). Also, having a good sleep after a pleasurable event, or after studying, would be expected to make these experiences more permanent in your factual and emotional memory. So, it's important to be conscious of what you do, during, but also after, events of significance.
Saturday, January 1, 2011
"The King's Speech"
I recently watched this movie ("The King's Speech"), which I thoroughly enjoyed.
I found it to be a nice story about the potential benefits of therapeutic change, and about the ingredients required to achieve this.
The literal facts of the story were interesting, but like a plot of a play, are not important in themselves to appreciate the theme or message.
The story has to do with the relationship between Prince Albert--who would become King George VI--and a seemingly unconventional speech therapist he met to deal with his stuttering problem.
I see the stuttering/speech therapy angle of the story (and its implied psychodynamic underpinnings) to be more of a metaphor for psychological symptoms. The facts about the causation of stuttering do not include a prominent role for psychodynamic factors or childhood trauma, etc. But the therapy for any problem, irrespective of its cause, is often helped greatly through psychodynamic insights and focus, particularly if the context of the problem has affected relationships and sense of self.
The compelling message I found about therapy in general, was that symptoms in the mind can obstruct the attainment of greatness or satisfaction in achievement or character. I see this often -- that there is tremendous potential in an individual, almost a sense that there is a special place or purpose for the person in the world, but this potential is obstructed and trapped because of symptoms, psychological injury, or illness. For a therapeutic endeavour to be helpful, it requires trust, a safe and balanced therapeutic frame, and a good rapport. I like the idea that playfulness, spontaneity, physical activity, and humour are essential elements of therapeutic benefit in this story. The other ingredient for therapeutic change--often under-emphasized in many stories--is that the work required needs to be very intense and disciplined. A good therapist can have the role of trusted confidante, listener, teacher, or advisor, but also of a behavioural coach, to help and encourage the long and difficult daily work involved to effect behavioural and psychological change.
Another great thing about this movie is the soundtrack, which includes some of my very favourite, wonderful and thematically relevant pieces by Mozart and Beethoven.
I found it to be a nice story about the potential benefits of therapeutic change, and about the ingredients required to achieve this.
The literal facts of the story were interesting, but like a plot of a play, are not important in themselves to appreciate the theme or message.
The story has to do with the relationship between Prince Albert--who would become King George VI--and a seemingly unconventional speech therapist he met to deal with his stuttering problem.
I see the stuttering/speech therapy angle of the story (and its implied psychodynamic underpinnings) to be more of a metaphor for psychological symptoms. The facts about the causation of stuttering do not include a prominent role for psychodynamic factors or childhood trauma, etc. But the therapy for any problem, irrespective of its cause, is often helped greatly through psychodynamic insights and focus, particularly if the context of the problem has affected relationships and sense of self.
The compelling message I found about therapy in general, was that symptoms in the mind can obstruct the attainment of greatness or satisfaction in achievement or character. I see this often -- that there is tremendous potential in an individual, almost a sense that there is a special place or purpose for the person in the world, but this potential is obstructed and trapped because of symptoms, psychological injury, or illness. For a therapeutic endeavour to be helpful, it requires trust, a safe and balanced therapeutic frame, and a good rapport. I like the idea that playfulness, spontaneity, physical activity, and humour are essential elements of therapeutic benefit in this story. The other ingredient for therapeutic change--often under-emphasized in many stories--is that the work required needs to be very intense and disciplined. A good therapist can have the role of trusted confidante, listener, teacher, or advisor, but also of a behavioural coach, to help and encourage the long and difficult daily work involved to effect behavioural and psychological change.
Another great thing about this movie is the soundtrack, which includes some of my very favourite, wonderful and thematically relevant pieces by Mozart and Beethoven.
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