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.
Friday, May 13, 2011
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.
Thursday, October 28, 2010
Psychiatry & Dentistry
There could obviously be psychiatric issues in dentistry, such as phobias. A good dentist could be quite therapeutic in this regard.
But there are a other dental issues that have to do with psychiatry.
For example, having unhealthy gums probably causes increased transient bacteremia each time one eats; this is caused by the mechanical stimulation of gums with a high bacterial load leading to leakage of bacteria into the blood circulation. This would not be expected to cause a systemic infection, but it would stimulate an immune response. Some research suggests that this type of recurrent phenomenon causes heightened systemic inflammation, which in turn stresses the brain.
Here are some references which show a relationship between gum disease and systemic inflammation; this causative relationship is further associated with increases in the risk of various systemic diseases, and overall mortality.
http://www.ncbi.nlm.nih.gov/pubmed/20306866
http://www.ncbi.nlm.nih.gov/pubmed/20502435
http://www.ncbi.nlm.nih.gov/pubmed/18052701
http://www.ncbi.nlm.nih.gov/pubmed/19909639
http://www.ncbi.nlm.nih.gov/pubmed/17559634
http://www.ncbi.nlm.nih.gov/pubmed/20960226
http://www.ncbi.nlm.nih.gov/pubmed/19774803
http://www.ncbi.nlm.nih.gov/pubmed/20509364
The existing research shows a link between oral disease and increased risk for various other diseases, such as cardiovascular disease. We can hypothesize that any factor increasing risk for cardiovascular disease would also be deleterious to the brain, as it would affect the brain's very sensitive vascular system. Not much research clearly proves this risk. Here is a reference which starts a discussion on the subject:
http://www.ncbi.nlm.nih.gov/pubmed/19864654
Here's another, suggesting that controlling or preventing gum disease is a preventable risk factor for Alzheimer's Disease:
http://www.ncbi.nlm.nih.gov/pubmed/18631974
So, it is a relevant part of preventative mental health care to take good care of your teeth, including regular dental visits!
There are other overlaps between psychiatry and dentistry. Many people, when depressed, neglect daily dental care. Psychotic symptoms can arise over dental issues (e.g. believing there is a transmitter implanted in a filling). Various overvalued ideas can persuade people to seek arguably unnecessary dental procedures (e.g. regarding mercury amalgam filling removals). While mercury is likely to be of some risk, e.g. regarding the development of autoimmune reactions, it is likely that many people overestimate the degree of risk, or falsely attribute symptoms to the type of dental fillings they have. Therefore, a business may arise of expensive filling replacements which are medically unnecessary. Here are a few articles about this: http://www.ncbi.nlm.nih.gov/pubmed/16042501
http://www.ncbi.nlm.nih.gov/pubmed/16393137
http://www.ncbi.nlm.nih.gov/pubmed/18517065
http://www.ncbi.nlm.nih.gov/pubmed/16448848
Another dentistry/psychiatry intersection has to do with cosmetic dentistry, and orthodontics. Orthodontic treatment is associated with at least a temporary increase in self-esteem, and possibly even an improvement in motivation. (reference: Karen Korabik, "Self Concept Changes during Orthodontic Treatment", Journal of Applied Social Psychology, 1994, 24, 11, pp. 1022-1034). Korabik's earlier work showed that orthodontic treatment led to individuals being perceived in a more positive way by others, with regard to impressions of personality, intelligence, as well as appearance (even, for example, based on pictures in which teeth were not visible). (Basic and Applied Social Psychology 2, 59-66, 1981). This phenomenon illustrates a problem with human nature, that we would infer things about one another based on superficial factors. The power of such superficial phenomena, relationally, is usually also short-lived and superficial, yet I do think that simple esthetic practices, if available, could be at least a small positive in affecting interpersonal dynamics, and therefore be a small positive influence in maintaining a healthy mood.
But there are a other dental issues that have to do with psychiatry.
For example, having unhealthy gums probably causes increased transient bacteremia each time one eats; this is caused by the mechanical stimulation of gums with a high bacterial load leading to leakage of bacteria into the blood circulation. This would not be expected to cause a systemic infection, but it would stimulate an immune response. Some research suggests that this type of recurrent phenomenon causes heightened systemic inflammation, which in turn stresses the brain.
Here are some references which show a relationship between gum disease and systemic inflammation; this causative relationship is further associated with increases in the risk of various systemic diseases, and overall mortality.
http://www.ncbi.nlm.nih.gov/pubmed/20306866
http://www.ncbi.nlm.nih.gov/pubmed/20502435
http://www.ncbi.nlm.nih.gov/pubmed/18052701
http://www.ncbi.nlm.nih.gov/pubmed/19909639
http://www.ncbi.nlm.nih.gov/pubmed/17559634
http://www.ncbi.nlm.nih.gov/pubmed/20960226
http://www.ncbi.nlm.nih.gov/pubmed/19774803
http://www.ncbi.nlm.nih.gov/pubmed/20509364
The existing research shows a link between oral disease and increased risk for various other diseases, such as cardiovascular disease. We can hypothesize that any factor increasing risk for cardiovascular disease would also be deleterious to the brain, as it would affect the brain's very sensitive vascular system. Not much research clearly proves this risk. Here is a reference which starts a discussion on the subject:
http://www.ncbi.nlm.nih.gov/pubmed/19864654
Here's another, suggesting that controlling or preventing gum disease is a preventable risk factor for Alzheimer's Disease:
http://www.ncbi.nlm.nih.gov/pubmed/18631974
So, it is a relevant part of preventative mental health care to take good care of your teeth, including regular dental visits!
There are other overlaps between psychiatry and dentistry. Many people, when depressed, neglect daily dental care. Psychotic symptoms can arise over dental issues (e.g. believing there is a transmitter implanted in a filling). Various overvalued ideas can persuade people to seek arguably unnecessary dental procedures (e.g. regarding mercury amalgam filling removals). While mercury is likely to be of some risk, e.g. regarding the development of autoimmune reactions, it is likely that many people overestimate the degree of risk, or falsely attribute symptoms to the type of dental fillings they have. Therefore, a business may arise of expensive filling replacements which are medically unnecessary. Here are a few articles about this: http://www.ncbi.nlm.nih.gov/pubmed/16042501
http://www.ncbi.nlm.nih.gov/pubmed/16393137
http://www.ncbi.nlm.nih.gov/pubmed/18517065
http://www.ncbi.nlm.nih.gov/pubmed/16448848
Another dentistry/psychiatry intersection has to do with cosmetic dentistry, and orthodontics. Orthodontic treatment is associated with at least a temporary increase in self-esteem, and possibly even an improvement in motivation. (reference: Karen Korabik, "Self Concept Changes during Orthodontic Treatment", Journal of Applied Social Psychology, 1994, 24, 11, pp. 1022-1034). Korabik's earlier work showed that orthodontic treatment led to individuals being perceived in a more positive way by others, with regard to impressions of personality, intelligence, as well as appearance (even, for example, based on pictures in which teeth were not visible). (Basic and Applied Social Psychology 2, 59-66, 1981). This phenomenon illustrates a problem with human nature, that we would infer things about one another based on superficial factors. The power of such superficial phenomena, relationally, is usually also short-lived and superficial, yet I do think that simple esthetic practices, if available, could be at least a small positive in affecting interpersonal dynamics, and therefore be a small positive influence in maintaining a healthy mood.
Wednesday, October 27, 2010
Psychiatry and Linguistics
The history of spoken and written language is a very interesting field of study. The manner in which languages evolve over time is similar, literally, to the way in which species evolve (languages do evolve much more rapidly than species). It is interesting to look at a kind of linguistic evolutionary tree, to see the parallels and differences alongside a genetic evolutionary tree, say of Indo-European languages in comparison to mitochondrial or Y-chromosome haplotype analysis in Eurasian groups.
Styles of language, and of word choice, etc. are certainly influenced by the culture of the day. It would be interesting to consider the degree to which word choices affect individual psychology. Some modern feminist thinking has certainly looked at the issue of language issues having important elements of psychological effects, particularly if the language itself is biased towards being sexist. This is a big area, one which I'd be interested to learn more about.
Another aspect of linguistics has to do with the multi-sensory nature of language perception. I find this very interesting, in expanding our understanding of the way the mind works in general: words on their own may be perceived or understood in different ways intellectually (this is an issue often discussed by literary scholars), but the manner in which words are perceived is also influenced very directly by core neurologic processes.
For example, I recently discovered the existence of a very powerful perceptual phenomenon called the "McGurk Effect." Here are a few examples from YouTube:
http://www.youtube.com/watch?v=DsdyE491KcM&feature=related
http://www.youtube.com/watch?v=aFPtc8BVdJk&feature=related
If you watch the video while listening to the speaker pronounce a syllable, it sounds completely different from when you close your eyes and just listen without watching. The phenomenon demonstrates how powerfully visual input changes how we perceive an auditory stimulus. I was surprised to find how overpoweringly strong the effect was, how difficult it is to somehow "over-ride" it.
Other linguistics research demonstrates that other sensory modalities, including tactile, also have strong effects on language perception.
As an extension to psychiatry, and to the general workings of the mind, I think it is true that many different perceptual and psychological inputs have very strong effects on the way we perceive other stimuli. In social exchanges, there may be a wide variety of inputs which we are not consciously aware of, which could be substantially affecting our experiences. In most cases, these other inputs assist us in understanding better. The purpose of having one sensory modality influence another is to bolster the input from both, so as to facilitate understanding. This is the foundation for how lip-reading works, for example. But if one input is, without our knowledge, giving opposing information compared to another input, then this could lead to a very problematic behavioural cycle.
I think such phenomena are likely to happen in many anxiety disorders, for example, in which the anticipatory anxiety, and resultant physical and emotional tension, are likely to cause one's perceptions of benign social stimuli to become exaggeratedly negative. This is happening not just on an intellectual level, but arguably on a core perceptual level, akin to the McGurk effect. Similar perceptual distortions are likely to happen in other psychological states, such as depression. The cognitive theory of depression centres around so-called "cognitive distortions," but I think it is important to expand this concept to admit that the phenomena could be powerful "cognitive-perceptual" distortions, which could require a lot of disciplined work to overcome. Without acknowledging the strength of this phenomenon, frustration could quickly set in, just as it would if you were to simply practice hearing McGurk-style syllables without knowledge of the McGurk effect.
Styles of language, and of word choice, etc. are certainly influenced by the culture of the day. It would be interesting to consider the degree to which word choices affect individual psychology. Some modern feminist thinking has certainly looked at the issue of language issues having important elements of psychological effects, particularly if the language itself is biased towards being sexist. This is a big area, one which I'd be interested to learn more about.
Another aspect of linguistics has to do with the multi-sensory nature of language perception. I find this very interesting, in expanding our understanding of the way the mind works in general: words on their own may be perceived or understood in different ways intellectually (this is an issue often discussed by literary scholars), but the manner in which words are perceived is also influenced very directly by core neurologic processes.
For example, I recently discovered the existence of a very powerful perceptual phenomenon called the "McGurk Effect." Here are a few examples from YouTube:
http://www.youtube.com/watch?v=DsdyE491KcM&feature=related
http://www.youtube.com/watch?v=aFPtc8BVdJk&feature=related
If you watch the video while listening to the speaker pronounce a syllable, it sounds completely different from when you close your eyes and just listen without watching. The phenomenon demonstrates how powerfully visual input changes how we perceive an auditory stimulus. I was surprised to find how overpoweringly strong the effect was, how difficult it is to somehow "over-ride" it.
Other linguistics research demonstrates that other sensory modalities, including tactile, also have strong effects on language perception.
As an extension to psychiatry, and to the general workings of the mind, I think it is true that many different perceptual and psychological inputs have very strong effects on the way we perceive other stimuli. In social exchanges, there may be a wide variety of inputs which we are not consciously aware of, which could be substantially affecting our experiences. In most cases, these other inputs assist us in understanding better. The purpose of having one sensory modality influence another is to bolster the input from both, so as to facilitate understanding. This is the foundation for how lip-reading works, for example. But if one input is, without our knowledge, giving opposing information compared to another input, then this could lead to a very problematic behavioural cycle.
I think such phenomena are likely to happen in many anxiety disorders, for example, in which the anticipatory anxiety, and resultant physical and emotional tension, are likely to cause one's perceptions of benign social stimuli to become exaggeratedly negative. This is happening not just on an intellectual level, but arguably on a core perceptual level, akin to the McGurk effect. Similar perceptual distortions are likely to happen in other psychological states, such as depression. The cognitive theory of depression centres around so-called "cognitive distortions," but I think it is important to expand this concept to admit that the phenomena could be powerful "cognitive-perceptual" distortions, which could require a lot of disciplined work to overcome. Without acknowledging the strength of this phenomenon, frustration could quickly set in, just as it would if you were to simply practice hearing McGurk-style syllables without knowledge of the McGurk effect.
Psychiatry and Economics
I've alluded to the field of "behavioural economics" in other posts. I think this is a very interesting extension of social and motivational psychology.
I think that a broad analogy can be made between economics and psychiatry:
the phenomenon of an economy is similar to the mind, or to one's life, in a variety of ways:
1) there are engines which drive the economy, in the form of productivity. Economic productivity may be measured by goods or services generated by the population. Life productivity includes various tasks of developmental "work".
2) There is a relationship between "supply" and "demand" which changes the valuation and flow of productivity.
3) Currencies become symbolic short-cuts to exchange goods or services; emotional or behavioural "currencies" can be short-cuts in to obtain needs in the community or in relationships.
4) Problems in an economy could occur at many different levels in the system: productivity failure due to a technical, external problem (e.g. a natural disaster), a failure to exchange or trade freely, a symbolic or regulatory system which goes out of control despite integrity in the rest of the system (e.g. stock market crashes). In the economics of mind, there could be core external problems (e.g. a neurological disorder), but there could certainly also be problems "trading freely." Heightened neurotic defenses could be compared to a lack of "free trade," where healthy inner resources cannot be shared, not with other parts of oneself, nor with others. Such phenomena stunt an economy, even if the core capacity for productivity is strong. A "stock market" crash, similarly, could occur in the mind, if regulatory mechanisms in one's mind run wild, while losing touch with a moment-to-moment sense of self or present.
5) Borrowing could, one the one hand, be a powerful means to accomplish tasks that would otherwise be impossible (e.g. buying a house). Refusal to borrow limits capacity for growth. But if debt cannot be managed, it leads to an economic instability, reduced autonomy, and ultimate failure (bankruptcy). Similarly, in one's mind, risks need to be taken to grow, and one needs to borrow from others and from the community in order to develop oneself. Refusal to borrow limits what is possible. However, over-borrowing, and accumulation of social & emotional debts, leads to a cascade of chaotic effects.
6) Investing is a means of taking a risk of giving one's resources away, with the hope that the community will prosper as a result, and return the investment prosperously. Emotional and social investments are risks taken which, on the one hand, are immediately depleting, and which may cause permanent losses (e.g. with unfruitful actions are relationships) but which permit the possibility of substantial growth in one's own life, while also allowing resources for the community to grow (emotionally or socially) around you.
Much in the field of economics include sophisticated mathematical analysis of the energy dynamics in an economic system, accounting for the many variables at play. It would be interesting to apply some of this analysis to psychological dynamics. Behavioural economics is more psychology than economics, at this point. It would be curious to have more of the leaders in the study of mathematical economics apply some of their ideas to "psychological economics."
I think that a broad analogy can be made between economics and psychiatry:
the phenomenon of an economy is similar to the mind, or to one's life, in a variety of ways:
1) there are engines which drive the economy, in the form of productivity. Economic productivity may be measured by goods or services generated by the population. Life productivity includes various tasks of developmental "work".
2) There is a relationship between "supply" and "demand" which changes the valuation and flow of productivity.
3) Currencies become symbolic short-cuts to exchange goods or services; emotional or behavioural "currencies" can be short-cuts in to obtain needs in the community or in relationships.
4) Problems in an economy could occur at many different levels in the system: productivity failure due to a technical, external problem (e.g. a natural disaster), a failure to exchange or trade freely, a symbolic or regulatory system which goes out of control despite integrity in the rest of the system (e.g. stock market crashes). In the economics of mind, there could be core external problems (e.g. a neurological disorder), but there could certainly also be problems "trading freely." Heightened neurotic defenses could be compared to a lack of "free trade," where healthy inner resources cannot be shared, not with other parts of oneself, nor with others. Such phenomena stunt an economy, even if the core capacity for productivity is strong. A "stock market" crash, similarly, could occur in the mind, if regulatory mechanisms in one's mind run wild, while losing touch with a moment-to-moment sense of self or present.
5) Borrowing could, one the one hand, be a powerful means to accomplish tasks that would otherwise be impossible (e.g. buying a house). Refusal to borrow limits capacity for growth. But if debt cannot be managed, it leads to an economic instability, reduced autonomy, and ultimate failure (bankruptcy). Similarly, in one's mind, risks need to be taken to grow, and one needs to borrow from others and from the community in order to develop oneself. Refusal to borrow limits what is possible. However, over-borrowing, and accumulation of social & emotional debts, leads to a cascade of chaotic effects.
6) Investing is a means of taking a risk of giving one's resources away, with the hope that the community will prosper as a result, and return the investment prosperously. Emotional and social investments are risks taken which, on the one hand, are immediately depleting, and which may cause permanent losses (e.g. with unfruitful actions are relationships) but which permit the possibility of substantial growth in one's own life, while also allowing resources for the community to grow (emotionally or socially) around you.
Much in the field of economics include sophisticated mathematical analysis of the energy dynamics in an economic system, accounting for the many variables at play. It would be interesting to apply some of this analysis to psychological dynamics. Behavioural economics is more psychology than economics, at this point. It would be curious to have more of the leaders in the study of mathematical economics apply some of their ideas to "psychological economics."
Psychiatry & Architecture
This is the first in a series of posts in which I'd like to discuss figurative or literal comparisons and overlaps between psychiatry and other fields of study.
Architecture could be considered a science and an art--a field with many technical elements, but with an over-riding importance given to esthetics, expressiveness, and community relationships.
Ideas in psychiatry could be considered "architectural" in the sense that it is important to have an overall sense of a plan, with a clear sense of purpose. Even with good technical skills (e.g. to relieve a symptom), work in psychiatry, or in life progress, may be unsatisfying if there is no attendance to the larger sense of purpose in the life's structure. Part of the purpose is "esthetic," but part has to do with identity, interaction with community, originality, and expressiveness. This is similar to the architectural considerations involved in planning and developing a new physical structure.
As in architecture, many very good ideas could be generated to develop one's life, but the ideas must also be technically sound, and supported by good engineering. Many life plans have dangerous weaknesses in the foundation, so to speak, or may be hindered by untreated symptoms. So, a sound architectural plan in psychiatry or in life management must include both esthetic or artistic elements, as well as good structural support.
Architecture could be considered a science and an art--a field with many technical elements, but with an over-riding importance given to esthetics, expressiveness, and community relationships.
Ideas in psychiatry could be considered "architectural" in the sense that it is important to have an overall sense of a plan, with a clear sense of purpose. Even with good technical skills (e.g. to relieve a symptom), work in psychiatry, or in life progress, may be unsatisfying if there is no attendance to the larger sense of purpose in the life's structure. Part of the purpose is "esthetic," but part has to do with identity, interaction with community, originality, and expressiveness. This is similar to the architectural considerations involved in planning and developing a new physical structure.
As in architecture, many very good ideas could be generated to develop one's life, but the ideas must also be technically sound, and supported by good engineering. Many life plans have dangerous weaknesses in the foundation, so to speak, or may be hindered by untreated symptoms. So, a sound architectural plan in psychiatry or in life management must include both esthetic or artistic elements, as well as good structural support.
Making tasks fun improves motivation & self-control
Juliano Laran and Chris Janiszewski recently published a study in Journal of Consumer Research (Vol. 37, electronically published Aug. 24, 2010, entitled "Work or Fun? How Task Construal and Completion Influence Regulatory Behavior."
It is an example of a simple research study in an evolving literature about self-control.
A prevailing notion is that the work involved in any self-controlling action is depleting; therefore, repeated difficult acts of self-control, even if successful, increase the chance of self-control failure shortly thereafter, because of the depletion of inner self-control resources.
The authors in this study hypothesize that there are several variables which affect the dynamics here:
1) individuals vary in their capacity for self-control
2) individuals who engage in actions which are inherently satisfying (fun) are not depleted by these actions, and do not experience a decrement in self-control afterwards
3) individuals for whom these same actions are merely work, and not fun, are depleted by their actions, and have less self-control afterwards
4) Activities which are incomplete have a neutral effect on subsequent self-control
5) Activities can be "reframed" as work, or as fun, and this reframing affects whether the activity is depleting or not.
The experiments described in this paper are, like many brief psychological studies of this sort, somewhat amusing to read about, and could certainly be criticized as somewhat shallow, cross-sectional portraits of a complex behavioural dynamic, with quite limited generalizability. The measure of "self-control," for example, involves measuring how much candy the subjects eat following a written exercise.
Yet, the results did support the hypotheses, allowing the following conclusions:
1) One's attitude towards a task has a very strong influence upon how the completed task will affect you afterwards. If tasks are perceived and experienced as work, as tedious, as unenjoyable, then they will leave you "depleted," and substantially more prone to unhealthy behaviours afterwards. If an attitude can be nurtured of tasks being enjoyable or fun, then the completion of these tasks leads to an increased sense of vitality, without any experience of depletion. .
2) While there may be mood or personality states or traits which influence these attitudes towards tasks, it is possible to reframe the activities in a beneficial way.
3) If some tasks cannot be reframed as "fun," than a neutral alternative could be to frame the activity as ongoing, and therefore never complete. Incompleted tasks, according to this study, have a more neutral effect upon self-control depletion. In the management of obesity, for example, nutrition management tactics, even if not subjectively enjoyable, would best be framed as a permanent lifestyle change, rather than a temporary "diet." An unpleasant "diet" is much more likely to cause regulatory failure after completion; this is certainly the almost invariable experience of all those who have managed their weight using spartan "diets." Yet, I would emphasize that something better than neutrality should be sought after, which, in the case of nutrition management, means that one's permanent nutritional habits should also be enjoyable, rather than simply a self-care chore.
It is an example of a simple research study in an evolving literature about self-control.
A prevailing notion is that the work involved in any self-controlling action is depleting; therefore, repeated difficult acts of self-control, even if successful, increase the chance of self-control failure shortly thereafter, because of the depletion of inner self-control resources.
The authors in this study hypothesize that there are several variables which affect the dynamics here:
1) individuals vary in their capacity for self-control
2) individuals who engage in actions which are inherently satisfying (fun) are not depleted by these actions, and do not experience a decrement in self-control afterwards
3) individuals for whom these same actions are merely work, and not fun, are depleted by their actions, and have less self-control afterwards
4) Activities which are incomplete have a neutral effect on subsequent self-control
5) Activities can be "reframed" as work, or as fun, and this reframing affects whether the activity is depleting or not.
The experiments described in this paper are, like many brief psychological studies of this sort, somewhat amusing to read about, and could certainly be criticized as somewhat shallow, cross-sectional portraits of a complex behavioural dynamic, with quite limited generalizability. The measure of "self-control," for example, involves measuring how much candy the subjects eat following a written exercise.
Yet, the results did support the hypotheses, allowing the following conclusions:
1) One's attitude towards a task has a very strong influence upon how the completed task will affect you afterwards. If tasks are perceived and experienced as work, as tedious, as unenjoyable, then they will leave you "depleted," and substantially more prone to unhealthy behaviours afterwards. If an attitude can be nurtured of tasks being enjoyable or fun, then the completion of these tasks leads to an increased sense of vitality, without any experience of depletion. .
2) While there may be mood or personality states or traits which influence these attitudes towards tasks, it is possible to reframe the activities in a beneficial way.
3) If some tasks cannot be reframed as "fun," than a neutral alternative could be to frame the activity as ongoing, and therefore never complete. Incompleted tasks, according to this study, have a more neutral effect upon self-control depletion. In the management of obesity, for example, nutrition management tactics, even if not subjectively enjoyable, would best be framed as a permanent lifestyle change, rather than a temporary "diet." An unpleasant "diet" is much more likely to cause regulatory failure after completion; this is certainly the almost invariable experience of all those who have managed their weight using spartan "diets." Yet, I would emphasize that something better than neutrality should be sought after, which, in the case of nutrition management, means that one's permanent nutritional habits should also be enjoyable, rather than simply a self-care chore.
Friday, October 22, 2010
Medications for ADHD: newspaper headline
I have just looked at a front-page newspaper article by Carolyn Abraham in The Globe and Mail (Tuesday, October 19, 2010).
The article attempts to discuss the issue of whether medications are prescribed too often, for treating supposed attention deficit disorder, particularly in male children.
This is a very serious, important question. It warrants careful analysis of the issues, and a balanced evaluation of evidence.
Unfortunately, the article bothered me greatly, because of its bias. Here are some quotes from the article:
The article mentions important issues of concern, including the role of pharmaceutical marketing in changing medication prescription patterns. The diagnosis of ADHD, and the use of medications, appears to vary substantially from one locale to the next. The phenomenon of teachers coercing parents to seek medication treatment for their children is certainly problematic.
But the article did not give a balanced presentation of evidence.
It is more common, in my experience, to encounter young adults who have struggled with ADHD symptoms, without any medication treatment, all their lives. Often times, they, or their parents, have been strongly opposed to the idea of taking medications. Many of these young adults are very intelligent, but often have been unable to sit through the intellectual tasks required to develop their intelligence. Therefore, they have often not been able to achieve the goals which are reasonably available to them. There is really no way around the fact that reading, for example, is necessary to develop one's mind in the modern world; reading requires one to sit still and focus for extended periods of time. A great deal of the discipline required to develop one's intellect requires prolonged focus, often with tasks that are initially perceived to be uninteresting (with discipline, intelligence, and imagination, any so-called "boring" subject can become interesting--but if individuals are unable to focus during the initial "boring" introduction to a subject, this deep interest and engagement may never be found).
Treating ADHD with medication does not increase substance abuse. Rates of substance use in an untreated ADHD population are substantially higher. Here is a reference to a research article demonstrating this: http://www.ncbi.nlm.nih.gov/pubmed/18838643 It is certainly my clinical experience, that subjects with untreated ADHD have much higher rates of substance use, including cigarettes, alcohol, cannabis, and harder drugs. The belief that treating ADHD with medications somehow increases risk for substance abuse, is simply unfounded--the opposite effect has been clearly shown. Exceptions exist, of course, in individual cases where adolescents may be abusing their medication, selling it, etc. Also, in many cases "ADHD" is not the only issue or problem; there may be antisocial behaviour, mood disorders, severe family or psychosocial problems, etc. which also obviously affect risks.
In terms of dangers or risks, it is of course important to examine negative side-effects or toxicity from stimulants. Such an analysis would fairly establish that risks are present, but of low incidence. For example, the risk of stimulants causing heart problems.
But a fair assessment of risk must include consideration of the risks of non-treatment! The obvious risks in an ADHD population are higher risks of accidental injuries, car accidents, sequelae from substance abuse, and reckless interpersonal behaviour. The risk pertains not only to those with untreated ADHD, but also to peers (for example, passengers in a vehicle). Here are a few references evidence about this:
http://www.ncbi.nlm.nih.gov/pubmed/19739058
http://www.ncbi.nlm.nih.gov/pubmed/18815438
http://www.ncbi.nlm.nih.gov/pubmed/10790000
It is also, of course, very important to consider whether counseling or other types of therapy could be helpful for ADHD symptoms. The prevailing evidence shows that there can be small effects with existing therapy styles--this is certainly worth pursuing--but counseling often doesn't work very well. In cases where there are multiple other problems going on (e.g. anxiety, mood, family conflicts, etc.) then of course some type of external counseling support would be preferable to simply obtaining a stimulant prescription. The notion that "a few months of counseling" would make much of a difference for most kids with ADHD symptoms is absurd, and entirely unsupported by any evidence.
The idea of accepting that "that's what boys do," etc. is important to consider. But imagine, as an adult reader, that you are transported to elementary school again. Would it be a pleasant and rewarding situation for you to be in a classroom where the attitude "that's what boys do" prevails? Similar philosophies, in the adult world, have been used to justify various types of antisocial behaviour. The issue is not just about the individuals with so-called ADHD, but also about peers and community. Rambunctiousness need not be pathologized, but a desire for sustained attentiveness need not be pathologized either. Most people with ADHD histories have had serious difficulties not just in classroom settings, but in all spheres of life: home, friendships, community, work, etc. This issue is not just about artificially forcing people into the constraints of a boring, quiet classroom, although admittedly a sedate classroom environment could be a very unhelpful factor for some.
The article seems to suggest that male teachers would be preferable. What does this have to do with anything? Where is the evidence?! Is this claim not an insult to female teachers? And, in my memory, I don't remember male teachers being any better at managing a classroom of rambunctious kids, compared to female teachers. In fact, I can think of counterexamples, in which female teachers could have a gentle, maternal effect on hyperactive kids helping them to enjoy their day, so that their experience of a classroom could be more positive.
I do agree that there are learning or educational styles which could suit some individuals much better. And I agree that having opportunities to be physically active is extremely important--for everyone, not just for "ADHD kids." One of the authors in this article suggests that the decline of opportunities such as "wood shop" (the implication is, that these are mainly for boys) is part of the problem. But, imagine as a wood shop teacher -- where you are in charge of a band saw, a lathe, and a few power nail guns -- that you have a few kids who are easily bored, highly rambunctious, and have difficulty paying attention. Band saw + ADHD! Do you see any problems there?
Some "alternative learning styles" could already begin to produce an unnecessary tier, sending kids with more ADHD symptoms away from a more scholarly focus, towards developing a more physical trade. I don't think there's anything wrong with this per se, unless the child with ADHD symptoms actually wants to develop scholarly pursuits, and/or has an undeveloped talent for the type of scholarship which requires intense focus, and doesn't really want to be "tiered" in this way.
I recognize that this is an important issue, and everyone's point of view needs to be considered to work out the best solutions for health policy and for helping individuals. But this article, in one of Canada's leading newspapers, was disturbingly one-sided, and in my opinion could contribute to many individuals feeling stigmatized or rejecting the possibility of medication therapy without a balanced understanding of the evidence.
One of the main issues to contemplate, and really the main helpful theme in this article, in my opinion, has to do with degree or magnitude: ADHD symptoms exist on a continuum, with everyone in the population having some measurable quantity of attentional capacity, physical restlessness, or impulsivity. These could be considered traits, and each of these traits could be considered useful, positive, and "normal" in some ways, as well as negative or deleterious in others. Medications or other therapies have the capacity to change the degree of symptoms or traits somewhat, for anyone (it is a myth that stimulants improve attention only in those with ADHD). The degree of environmental change required to help an individual escalates rapidly as the degree of symptoms increases. So, there will always be a gray area, of individuals who have more "ADHD symptoms" than the population average, but fewer than those with extreme and highly disabling symptoms. Determining how to help these individuals may be highly influenced by the whims of the local educational or medical culture, combined with the attitudes of the individuals and their families. There may be no absolute, fixed standard possible, to determine exactly when to use a particular form of therapy.
I believe that such decisions should be influenced by the following factors:
1) clear informed consent on the part of individuals and families considering medications or other therapies. This involves having a balanced understanding of evidence, of the risks and benefits of treating and of not treating.
2) thorough assessment with careful attendance to family and psychosocial stresses--never an impulsive prescription of stimulants after a single 5-minute appointment!
3) Follow-up in all cases, with opportunities for talking therapies and behavioural therapy if desired.
4) A reasonable set of nationalized, standardized guidelines for assessment and treatment, to reduce the possibility that a person's geographic location, or the whims of teachers, doctors, journalists, etc. would be strong determinants of whether or not treatment of any kind is offered.
The article attempts to discuss the issue of whether medications are prescribed too often, for treating supposed attention deficit disorder, particularly in male children.
This is a very serious, important question. It warrants careful analysis of the issues, and a balanced evaluation of evidence.
Unfortunately, the article bothered me greatly, because of its bias. Here are some quotes from the article:
Boys: Fixing with a pill is easier than counselling [this was a heading]
There's a desire for the quick fix...the idea that - 'oh, we'll fix this with a pill' - rather than spend a few months in counselling, is pretty appealing. [this was a quote attributed to Gordon Floyd, the CEO of Children's Mental Health Ontario]
What are we drugging? Female teachers who don't understand boys like to run and jump and shout - that's what boys do. [this was a quote attributed to Jon Bradley, an education professor at McGill University]
Prescription rates for ADHD drugs, which like cocaine, are psycho-stimulants...
Mr. Floyd feels counselling stands a better chance of getting to the root of the problem with children, rather than using drugs for years to dull symptoms. Research shows, he says, that talk therapy can be very successful for kids with ADHD.
stimulant drugs may be dangerous for those with underlying heart problems - and those who do not actually have ADHD.
I have often wondered why no real connection has been made between the over-medicalization of our children and the increasing prevalence of illicit drug use in our society. When we give kids the message that they can be 'fixed' by popping a pill, it hardly seems surprising to me that they would later seek to solve their problems by using other available substances. [a quote attributed to Judy McGuire, a "Globe Catalyst"]
The article mentions important issues of concern, including the role of pharmaceutical marketing in changing medication prescription patterns. The diagnosis of ADHD, and the use of medications, appears to vary substantially from one locale to the next. The phenomenon of teachers coercing parents to seek medication treatment for their children is certainly problematic.
But the article did not give a balanced presentation of evidence.
It is more common, in my experience, to encounter young adults who have struggled with ADHD symptoms, without any medication treatment, all their lives. Often times, they, or their parents, have been strongly opposed to the idea of taking medications. Many of these young adults are very intelligent, but often have been unable to sit through the intellectual tasks required to develop their intelligence. Therefore, they have often not been able to achieve the goals which are reasonably available to them. There is really no way around the fact that reading, for example, is necessary to develop one's mind in the modern world; reading requires one to sit still and focus for extended periods of time. A great deal of the discipline required to develop one's intellect requires prolonged focus, often with tasks that are initially perceived to be uninteresting (with discipline, intelligence, and imagination, any so-called "boring" subject can become interesting--but if individuals are unable to focus during the initial "boring" introduction to a subject, this deep interest and engagement may never be found).
Treating ADHD with medication does not increase substance abuse. Rates of substance use in an untreated ADHD population are substantially higher. Here is a reference to a research article demonstrating this: http://www.ncbi.nlm.nih.gov/pubmed/18838643 It is certainly my clinical experience, that subjects with untreated ADHD have much higher rates of substance use, including cigarettes, alcohol, cannabis, and harder drugs. The belief that treating ADHD with medications somehow increases risk for substance abuse, is simply unfounded--the opposite effect has been clearly shown. Exceptions exist, of course, in individual cases where adolescents may be abusing their medication, selling it, etc. Also, in many cases "ADHD" is not the only issue or problem; there may be antisocial behaviour, mood disorders, severe family or psychosocial problems, etc. which also obviously affect risks.
In terms of dangers or risks, it is of course important to examine negative side-effects or toxicity from stimulants. Such an analysis would fairly establish that risks are present, but of low incidence. For example, the risk of stimulants causing heart problems.
But a fair assessment of risk must include consideration of the risks of non-treatment! The obvious risks in an ADHD population are higher risks of accidental injuries, car accidents, sequelae from substance abuse, and reckless interpersonal behaviour. The risk pertains not only to those with untreated ADHD, but also to peers (for example, passengers in a vehicle). Here are a few references evidence about this:
http://www.ncbi.nlm.nih.gov/pubmed/19739058
http://www.ncbi.nlm.nih.gov/pubmed/18815438
http://www.ncbi.nlm.nih.gov/pubmed/10790000
It is also, of course, very important to consider whether counseling or other types of therapy could be helpful for ADHD symptoms. The prevailing evidence shows that there can be small effects with existing therapy styles--this is certainly worth pursuing--but counseling often doesn't work very well. In cases where there are multiple other problems going on (e.g. anxiety, mood, family conflicts, etc.) then of course some type of external counseling support would be preferable to simply obtaining a stimulant prescription. The notion that "a few months of counseling" would make much of a difference for most kids with ADHD symptoms is absurd, and entirely unsupported by any evidence.
The idea of accepting that "that's what boys do," etc. is important to consider. But imagine, as an adult reader, that you are transported to elementary school again. Would it be a pleasant and rewarding situation for you to be in a classroom where the attitude "that's what boys do" prevails? Similar philosophies, in the adult world, have been used to justify various types of antisocial behaviour. The issue is not just about the individuals with so-called ADHD, but also about peers and community. Rambunctiousness need not be pathologized, but a desire for sustained attentiveness need not be pathologized either. Most people with ADHD histories have had serious difficulties not just in classroom settings, but in all spheres of life: home, friendships, community, work, etc. This issue is not just about artificially forcing people into the constraints of a boring, quiet classroom, although admittedly a sedate classroom environment could be a very unhelpful factor for some.
The article seems to suggest that male teachers would be preferable. What does this have to do with anything? Where is the evidence?! Is this claim not an insult to female teachers? And, in my memory, I don't remember male teachers being any better at managing a classroom of rambunctious kids, compared to female teachers. In fact, I can think of counterexamples, in which female teachers could have a gentle, maternal effect on hyperactive kids helping them to enjoy their day, so that their experience of a classroom could be more positive.
I do agree that there are learning or educational styles which could suit some individuals much better. And I agree that having opportunities to be physically active is extremely important--for everyone, not just for "ADHD kids." One of the authors in this article suggests that the decline of opportunities such as "wood shop" (the implication is, that these are mainly for boys) is part of the problem. But, imagine as a wood shop teacher -- where you are in charge of a band saw, a lathe, and a few power nail guns -- that you have a few kids who are easily bored, highly rambunctious, and have difficulty paying attention. Band saw + ADHD! Do you see any problems there?
Some "alternative learning styles" could already begin to produce an unnecessary tier, sending kids with more ADHD symptoms away from a more scholarly focus, towards developing a more physical trade. I don't think there's anything wrong with this per se, unless the child with ADHD symptoms actually wants to develop scholarly pursuits, and/or has an undeveloped talent for the type of scholarship which requires intense focus, and doesn't really want to be "tiered" in this way.
I recognize that this is an important issue, and everyone's point of view needs to be considered to work out the best solutions for health policy and for helping individuals. But this article, in one of Canada's leading newspapers, was disturbingly one-sided, and in my opinion could contribute to many individuals feeling stigmatized or rejecting the possibility of medication therapy without a balanced understanding of the evidence.
One of the main issues to contemplate, and really the main helpful theme in this article, in my opinion, has to do with degree or magnitude: ADHD symptoms exist on a continuum, with everyone in the population having some measurable quantity of attentional capacity, physical restlessness, or impulsivity. These could be considered traits, and each of these traits could be considered useful, positive, and "normal" in some ways, as well as negative or deleterious in others. Medications or other therapies have the capacity to change the degree of symptoms or traits somewhat, for anyone (it is a myth that stimulants improve attention only in those with ADHD). The degree of environmental change required to help an individual escalates rapidly as the degree of symptoms increases. So, there will always be a gray area, of individuals who have more "ADHD symptoms" than the population average, but fewer than those with extreme and highly disabling symptoms. Determining how to help these individuals may be highly influenced by the whims of the local educational or medical culture, combined with the attitudes of the individuals and their families. There may be no absolute, fixed standard possible, to determine exactly when to use a particular form of therapy.
I believe that such decisions should be influenced by the following factors:
1) clear informed consent on the part of individuals and families considering medications or other therapies. This involves having a balanced understanding of evidence, of the risks and benefits of treating and of not treating.
2) thorough assessment with careful attendance to family and psychosocial stresses--never an impulsive prescription of stimulants after a single 5-minute appointment!
3) Follow-up in all cases, with opportunities for talking therapies and behavioural therapy if desired.
4) A reasonable set of nationalized, standardized guidelines for assessment and treatment, to reduce the possibility that a person's geographic location, or the whims of teachers, doctors, journalists, etc. would be strong determinants of whether or not treatment of any kind is offered.
Wednesday, September 29, 2010
Atomoxetine for ADHD
Atomoxetine (Strattera) is one of the pharmacological options for treating ADHD symptoms (attention or concentration problems, hyperactivity, impulsivity) in children and adults. I think it is a good drug, quite safe, quite effective. It is not likely to help with mood or anxiety symptoms. Its effect is probably not quite as robust, for most people, compared to stimulants, but it has the compelling advantage of working continuously throughout the day, instead of wearing off (as the stimulants do) after a few hours. It takes at least 2 weeks of daily dosing for it to work, which differs from the immediate effect of stimulants.
While it has only a 5-hour half-life in the body, it probably works just as well if dosed once-daily compared to twice-daily. Side-effects are usually quite mild, including possible dry mouth and reduced appetite.
It is quite expensive, and is not covered well by medication funding plans in BC.
Here is a brief survey of some of the research literature about atomoxetine that I found interesting:
http://www.ncbi.nlm.nih.gov/pubmed/20665133
This 2010 article demonstrates that once-daily atomoxetine is superior to placebo for treating adult ADHD symptoms, over a 6-month follow-up period. Treated patients typically had about a 30% reduction in their symptom scores. Doses were about 80 mg/day.
http://www.ncbi.nlm.nih.gov/pubmed/18448861
This is an important study, with 4 years of follow-up, treating adult ADHD patients on an open-label basis. The medication was tolerated well, again with ADHD symptom reductions of about 30%. Depression and anxiety symptoms were not affected. I tried unsuccessfully to find a clear statement about average doses used in the study; the dosing regime was similar to other studies, with a maximum of 160 mg/day. From the authors' previous paper on the interim results of this study, the mean dose was about 100 mg/day, the median about 120 mg/day. So these are higher doses than in some of the other studies, which typically had 80 mg/day dosing.
http://www.ncbi.nlm.nih.gov/pubmed/20070786
This was a 6-week open study, showing that adults with "atypical ADHD" showed improvement with atomoxetine treatment, doses averaging about 80 mg/day.
http://www.ncbi.nlm.nih.gov/pubmed/20051220
This is an important 2008 meta-analysis, comparing effect sizes of different therapies for adult ADHD. Short-acting stimulants were best; long-acting stimulants similar (no advantage--if anything, not quite as high an effect size compared to short-acting stimulants); non-stimulants such as atomoxetine significantly helpful, but not quite as large an effect size as stimulants.
http://www.ncbi.nlm.nih.gov/pubmed/17110824This study shows modest but significant improvement in quality-of-life ratings for adult ADHD patients treated with atomoxetine 80 mg/day for 6 weeks.
http://www.ncbi.nlm.nih.gov/pubmed/20642391
This study shows reduction in high-risk behaviours in adolescents treated with atomoxetine over a 40-week period. Looking quickly at the results, I see significant differences between atomoxetine and placebo, but the absolute differences were quite modest in size (typically about a 10% change). Also the study design has a variety of weaknesses.
http://www.ncbi.nlm.nih.gov/pubmed/17474814
This is one of many studies showing that atomoxetine does not help with depressive symptoms. In this case, it was used as an adjunct to an SSRI.
http://www.ncbi.nlm.nih.gov/pubmed/19358788
This study showed no improvement in cognitive function in patients with schizophrenia treated with atomoxetine over 8 weeks. There were no adverse psychiatric effects, however. This is an important area to study, to determine if ADHD treatments such as atomoxetine are psychiatrically safe for those with other major mental illnesses, such as schizophrenia or bipolar disorder.
http://www.ncbi.nlm.nih.gov/pubmed/20679638
This 2010 article from Neurology shows that atomoxetine is not useful for treating depression in Parkinson Disease patients. I find this type of study useful, to look at psychiatric symptoms in medical illnesses. In such situations, the biological impact of the treatment often seems more clear to me, perhaps with fewer confounding psychological factors. The study did find that patients treated with atomoxetine (target dose 80 mg/day) had significantly less daytime sleepiness, and significant improvement in "global cognitive function."
http://www.ncbi.nlm.nih.gov/pubmed/19025777
This similar study shows a possible improvement due to atomoxetine treatment--averaging about 90 mg/day--of executive dysfunction in Parkinson Disease patients. I note also that there was a reduction in other symptom domains, such as apathy and emotional lability; these problems can be difficult to address in those with mood disorders.
http://www.ncbi.nlm.nih.gov/pubmed/17900980
Here's another interesting study, using atomoxetine to treat sleep apnea patients, averaging about 80 mg/day over 4 weeks. The atomoxetine did not help reduce apnea, but it did significantly reduce subjective sleepiness. There are only a couple of fragmentary mentionings of atomoxetine in treating narcolepsy, another disorder of excessive sleepiness; here is one case report: http://www.ncbi.nlm.nih.gov/pubmed/16268387 Excessive sleepiness is another challenging symptom I see a lot of in young adult depression; antidepressants often don't help with the sleepiness, and tolerance tends to develop for stimulants. So atomoxetine may be another useful option.
While it has only a 5-hour half-life in the body, it probably works just as well if dosed once-daily compared to twice-daily. Side-effects are usually quite mild, including possible dry mouth and reduced appetite.
It is quite expensive, and is not covered well by medication funding plans in BC.
Here is a brief survey of some of the research literature about atomoxetine that I found interesting:
http://www.ncbi.nlm.nih.gov/pubmed/20665133
This 2010 article demonstrates that once-daily atomoxetine is superior to placebo for treating adult ADHD symptoms, over a 6-month follow-up period. Treated patients typically had about a 30% reduction in their symptom scores. Doses were about 80 mg/day.
http://www.ncbi.nlm.nih.gov/pubmed/18448861
This is an important study, with 4 years of follow-up, treating adult ADHD patients on an open-label basis. The medication was tolerated well, again with ADHD symptom reductions of about 30%. Depression and anxiety symptoms were not affected. I tried unsuccessfully to find a clear statement about average doses used in the study; the dosing regime was similar to other studies, with a maximum of 160 mg/day. From the authors' previous paper on the interim results of this study, the mean dose was about 100 mg/day, the median about 120 mg/day. So these are higher doses than in some of the other studies, which typically had 80 mg/day dosing.
http://www.ncbi.nlm.nih.gov/pubmed/20070786
This was a 6-week open study, showing that adults with "atypical ADHD" showed improvement with atomoxetine treatment, doses averaging about 80 mg/day.
http://www.ncbi.nlm.nih.gov/pubmed/20051220
This is an important 2008 meta-analysis, comparing effect sizes of different therapies for adult ADHD. Short-acting stimulants were best; long-acting stimulants similar (no advantage--if anything, not quite as high an effect size compared to short-acting stimulants); non-stimulants such as atomoxetine significantly helpful, but not quite as large an effect size as stimulants.
http://www.ncbi.nlm.nih.gov/pubmed/17110824This study shows modest but significant improvement in quality-of-life ratings for adult ADHD patients treated with atomoxetine 80 mg/day for 6 weeks.
http://www.ncbi.nlm.nih.gov/pubmed/20642391
This study shows reduction in high-risk behaviours in adolescents treated with atomoxetine over a 40-week period. Looking quickly at the results, I see significant differences between atomoxetine and placebo, but the absolute differences were quite modest in size (typically about a 10% change). Also the study design has a variety of weaknesses.
http://www.ncbi.nlm.nih.gov/pubmed/17474814
This is one of many studies showing that atomoxetine does not help with depressive symptoms. In this case, it was used as an adjunct to an SSRI.
http://www.ncbi.nlm.nih.gov/pubmed/19358788
This study showed no improvement in cognitive function in patients with schizophrenia treated with atomoxetine over 8 weeks. There were no adverse psychiatric effects, however. This is an important area to study, to determine if ADHD treatments such as atomoxetine are psychiatrically safe for those with other major mental illnesses, such as schizophrenia or bipolar disorder.
http://www.ncbi.nlm.nih.gov/pubmed/20679638
This 2010 article from Neurology shows that atomoxetine is not useful for treating depression in Parkinson Disease patients. I find this type of study useful, to look at psychiatric symptoms in medical illnesses. In such situations, the biological impact of the treatment often seems more clear to me, perhaps with fewer confounding psychological factors. The study did find that patients treated with atomoxetine (target dose 80 mg/day) had significantly less daytime sleepiness, and significant improvement in "global cognitive function."
http://www.ncbi.nlm.nih.gov/pubmed/19025777
This similar study shows a possible improvement due to atomoxetine treatment--averaging about 90 mg/day--of executive dysfunction in Parkinson Disease patients. I note also that there was a reduction in other symptom domains, such as apathy and emotional lability; these problems can be difficult to address in those with mood disorders.
http://www.ncbi.nlm.nih.gov/pubmed/17900980
Here's another interesting study, using atomoxetine to treat sleep apnea patients, averaging about 80 mg/day over 4 weeks. The atomoxetine did not help reduce apnea, but it did significantly reduce subjective sleepiness. There are only a couple of fragmentary mentionings of atomoxetine in treating narcolepsy, another disorder of excessive sleepiness; here is one case report: http://www.ncbi.nlm.nih.gov/pubmed/16268387 Excessive sleepiness is another challenging symptom I see a lot of in young adult depression; antidepressants often don't help with the sleepiness, and tolerance tends to develop for stimulants. So atomoxetine may be another useful option.
Thursday, September 16, 2010
"Vitamin Water" and "Energy Drinks"
Here's another exploitative marketing scheme going on, in the middle of university campuses:
A sugary drink, consisting of water with 23 grams (about 5 teaspoons) of sugar per 500 mL, sold in large, colourful bottles of 300 - 500 mL each -- is being aggressively marketed to young people, with many implied claims about healthfulness. There are funny, witty, ironic statements printed on the bottles, which I think would appeal to young adults, and consolidate the notion that these are actually healthy.
A similar drink, which also contains caffeine and a bizarre mixture of added chemicals, is also being aggressively marketed, with free samples being given out by smiling, athletic young people in decorated sports cars. Today I noticed the energy drink people occupying one of the university's athletic fields with three large garishly decorated vehicles, hip musical accompaniment blaring out as they handed out samples. It was a bothersome irony that an athletic field (another health-associated prop) had to be the setting for this.
It is not a healthy practice to consume sugary drinks. Aside from the risk of tooth decay, and the exposure to metabolically harmful simple carbohydrates, the habit of consuming these drinks conditions people to expect sweetness while they hydrate themselves. Ordinary, pure, free drinking water becomes bland and undesirable. Though the direct health effects of having a glass of sweetened water are not catastrophic, there are a variety of indirect harmful effects:
-because you are quenching your thirst, and hunger, with a solution containing glucose or fructose, you will have a smaller appetite, and less money, to obtain or consume a healthy meal.
-because of the advertising involved, you will become conditioned to believe that you are engaging in a healthy behaviour.
-you will be financially supporting one of the largest junk food manufacturers in the world; the magnitude of harm done to the world's population (directly and indirectly) by such companies would be staggering to calculate.
-by purchasing these products, you are contributing to the phenomenon of retailers stocking their shelves with "vitamin water" instead of with healthier choices. In one of my favourite local cafes, my favourite healthy, locally-made fruit juice is gone, replaced by rows of multi-coloured "vitamin water." The reason was economic -- the bright colours and the sugar make for a rapidly-selling product.
The presence of vitamins, minerals, amino acids, etc. in these products is, in my opinion, irrelevant. It is pure marketing. If you need extra vitamins in your day, you can take a daily supplement, or have a piece of fresh fruit. The other ingredients are largely placebo as well, just like the colouring.
The case is made by some that there is less sugar in these drinks, compared to other familiar soft drinks. The difference is actually not very substantial, it reminds me of cigarette companies manufacturing "light" cigarettes, to try to sell people on the idea that this is "healthier."
I consider this type of marketing to have little ethical difference from a hypothetical example of cigarette companies hiring athletic, charming young people to hand out free samples from a flashy new car.
What bothers me most about this issue is the use of healthy-sounding nutrition talk ("vitamins," etc.) to persuade people to buy an unhealthy product.
I do not support a puritanical view of food & eating though. I think there are many sweet, wonderful, decadent foods to be savoured (in moderation of course!) Generally, dessert vendors do not market their tastiest pastries by emphasizing their vitamin content! In any case, such foods can be enjoyed more richly, in smaller, healthier portions, if one is less conditioned to expect sweetness frequently through the day, such as in drinking water.
Here are a few references to some pertinent review articles:
http://www.ncbi.nlm.nih.gov/pubmed/20631477
http://www.ncbi.nlm.nih.gov/pubmed/20682226
http://www.ncbi.nlm.nih.gov/pubmed/18809264
One exception, in which a case could be made to supplement drinks with vitamins, could be in the management of chronic, severe alcoholism. There is a syndrome called "Wernicke-Korsakoff encephalopathy", in which severely malnourished alcoholics develop irreversible, catastrophic brain damage due to metabolism of carbohydrates without adequate vitamin B1. Adding vitamin B1 (thiamine) to hard liquor, could conceivably prevent some cases of irreversible brain damage in malnourished alcoholics who keep drinking. I'm not sure if thiamine would be chemically stable in an ethanol solution though--if anyone knows the answer to this one, please let me know. Anyway, I don't believe this consideration is relevant to health management on university campuses (!)
Conclusion: if you're thirsty, drink water!
A sugary drink, consisting of water with 23 grams (about 5 teaspoons) of sugar per 500 mL, sold in large, colourful bottles of 300 - 500 mL each -- is being aggressively marketed to young people, with many implied claims about healthfulness. There are funny, witty, ironic statements printed on the bottles, which I think would appeal to young adults, and consolidate the notion that these are actually healthy.
A similar drink, which also contains caffeine and a bizarre mixture of added chemicals, is also being aggressively marketed, with free samples being given out by smiling, athletic young people in decorated sports cars. Today I noticed the energy drink people occupying one of the university's athletic fields with three large garishly decorated vehicles, hip musical accompaniment blaring out as they handed out samples. It was a bothersome irony that an athletic field (another health-associated prop) had to be the setting for this.
It is not a healthy practice to consume sugary drinks. Aside from the risk of tooth decay, and the exposure to metabolically harmful simple carbohydrates, the habit of consuming these drinks conditions people to expect sweetness while they hydrate themselves. Ordinary, pure, free drinking water becomes bland and undesirable. Though the direct health effects of having a glass of sweetened water are not catastrophic, there are a variety of indirect harmful effects:
-because you are quenching your thirst, and hunger, with a solution containing glucose or fructose, you will have a smaller appetite, and less money, to obtain or consume a healthy meal.
-because of the advertising involved, you will become conditioned to believe that you are engaging in a healthy behaviour.
-you will be financially supporting one of the largest junk food manufacturers in the world; the magnitude of harm done to the world's population (directly and indirectly) by such companies would be staggering to calculate.
-by purchasing these products, you are contributing to the phenomenon of retailers stocking their shelves with "vitamin water" instead of with healthier choices. In one of my favourite local cafes, my favourite healthy, locally-made fruit juice is gone, replaced by rows of multi-coloured "vitamin water." The reason was economic -- the bright colours and the sugar make for a rapidly-selling product.
The presence of vitamins, minerals, amino acids, etc. in these products is, in my opinion, irrelevant. It is pure marketing. If you need extra vitamins in your day, you can take a daily supplement, or have a piece of fresh fruit. The other ingredients are largely placebo as well, just like the colouring.
The case is made by some that there is less sugar in these drinks, compared to other familiar soft drinks. The difference is actually not very substantial, it reminds me of cigarette companies manufacturing "light" cigarettes, to try to sell people on the idea that this is "healthier."
I consider this type of marketing to have little ethical difference from a hypothetical example of cigarette companies hiring athletic, charming young people to hand out free samples from a flashy new car.
What bothers me most about this issue is the use of healthy-sounding nutrition talk ("vitamins," etc.) to persuade people to buy an unhealthy product.
I do not support a puritanical view of food & eating though. I think there are many sweet, wonderful, decadent foods to be savoured (in moderation of course!) Generally, dessert vendors do not market their tastiest pastries by emphasizing their vitamin content! In any case, such foods can be enjoyed more richly, in smaller, healthier portions, if one is less conditioned to expect sweetness frequently through the day, such as in drinking water.
Here are a few references to some pertinent review articles:
http://www.ncbi.nlm.nih.gov/pubmed/20631477
http://www.ncbi.nlm.nih.gov/pubmed/20682226
http://www.ncbi.nlm.nih.gov/pubmed/18809264
One exception, in which a case could be made to supplement drinks with vitamins, could be in the management of chronic, severe alcoholism. There is a syndrome called "Wernicke-Korsakoff encephalopathy", in which severely malnourished alcoholics develop irreversible, catastrophic brain damage due to metabolism of carbohydrates without adequate vitamin B1. Adding vitamin B1 (thiamine) to hard liquor, could conceivably prevent some cases of irreversible brain damage in malnourished alcoholics who keep drinking. I'm not sure if thiamine would be chemically stable in an ethanol solution though--if anyone knows the answer to this one, please let me know. Anyway, I don't believe this consideration is relevant to health management on university campuses (!)
Conclusion: if you're thirsty, drink water!
Wednesday, September 15, 2010
Personality Tests
Here's a site which has a good selection of free personality questionnaires:
http://similarminds.com/personality_tests.html
I find that questionnaires of this type rarely give any novel information that you wouldn't know about yourself already, and be able to describe in a short self-descriptive paragraph. Many such questionnaires are actually copyrighted, and one needs to pay a fee just to have a copy. I've always had a bit of a problem with this, as I think it exaggerates the importance of what is usually a simple set of questions, which in my opinion should usually be in the public domain. It is annoying to read a journal article about questionnaires (which are often referred to, in a somewhat aggrandizing way, as "instruments," as though we are talking about some kind of highly sophisticated engineering technology), where the copyrighted questionnaire is referred to in the article, but you can't actually see the questions!
But spending some time with these things can have a few positives:
1) a framework for reflection -- sometimes questionnaires can deal with questions or phenomena which are relevant, but rarely thought about or discussed. The questions can be a cue or a framework to contemplate issues. Some of these issues could be addressed in a therapeutic discussion.
2) entertainment -- it can be an interesting or possibly enjoyable activity to fill out questionnaires, and compare your results with others in the population.
It would be important to resist any tendency to be self-critical about your results; everyone will have a unique set of responses, some of which may change over time, or be mood-dependent, as well. Questionnaires are an imperfect way to measure any sort of characteristic anyway. But in any case, a questionnaire is a bit like a lens or a camera--it produces data which can be informative. Sometimes the information can be unique or interesting, like a clever snapshot of yourself from a camera; but other times the information may not be very unique or interesting at all (like a poorly-lit or blurry snapshot of yourself). Even if you may have issues with the way a particular questionnaire is constructed, it can be interesting to see how your responses compare on a percentile basis with others. You may find certain phenomena about yourself that you previously thought were quite extreme, are in fact really quite close to the population average. Or you might discover there are other phenomena which are farther from the mean. Any of these findings might be a subject of future therapeutic dialog.
http://similarminds.com/personality_tests.html
I find that questionnaires of this type rarely give any novel information that you wouldn't know about yourself already, and be able to describe in a short self-descriptive paragraph. Many such questionnaires are actually copyrighted, and one needs to pay a fee just to have a copy. I've always had a bit of a problem with this, as I think it exaggerates the importance of what is usually a simple set of questions, which in my opinion should usually be in the public domain. It is annoying to read a journal article about questionnaires (which are often referred to, in a somewhat aggrandizing way, as "instruments," as though we are talking about some kind of highly sophisticated engineering technology), where the copyrighted questionnaire is referred to in the article, but you can't actually see the questions!
But spending some time with these things can have a few positives:
1) a framework for reflection -- sometimes questionnaires can deal with questions or phenomena which are relevant, but rarely thought about or discussed. The questions can be a cue or a framework to contemplate issues. Some of these issues could be addressed in a therapeutic discussion.
2) entertainment -- it can be an interesting or possibly enjoyable activity to fill out questionnaires, and compare your results with others in the population.
It would be important to resist any tendency to be self-critical about your results; everyone will have a unique set of responses, some of which may change over time, or be mood-dependent, as well. Questionnaires are an imperfect way to measure any sort of characteristic anyway. But in any case, a questionnaire is a bit like a lens or a camera--it produces data which can be informative. Sometimes the information can be unique or interesting, like a clever snapshot of yourself from a camera; but other times the information may not be very unique or interesting at all (like a poorly-lit or blurry snapshot of yourself). Even if you may have issues with the way a particular questionnaire is constructed, it can be interesting to see how your responses compare on a percentile basis with others. You may find certain phenomena about yourself that you previously thought were quite extreme, are in fact really quite close to the population average. Or you might discover there are other phenomena which are farther from the mean. Any of these findings might be a subject of future therapeutic dialog.
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