Tuesday, September 29, 2009

Astronomical Photographs

For something completely different--

Have a look at NASA's "astronomy picture of the day" site: http://apod.nasa.gov/apod/

It's interesting, awe-inspiring--and I hope therapeutic--to be reminded of things much larger than ourselves.

Here are some of my favourite pictures from the NASA site:

the sun:



N-Acetylcysteine for treatment of compulsive disorders

N-acetylcysteine is an antioxidant which modulates the glutamate system in the brain. Glutamate is actually the most prevalent neurotransmitter in the brain, and generally has strongly activating effects on nerve cells.

A recent study in Archives of General Psychiatry described groups of individuals with compulsive hair-pulling behavior (trichotillomania), randomized to receive either placebo, or N-acetylcysteine 1200 mg/day, then up to 2400 mg/day, over 12 weeks:

The N-acetylcysteine group had about 50% reduction in hair-pulling behaviour, with no change in the placebo group. Those in the N-acetylcysteine group did not report any side effects. In fact, the only side effects were among those in the placebo group.

The same author published a study in 2008 showing a substantial improvement in compulsive gambling behavior in a group given NAC at an average dose of about 1500 mg/d:

A very preliminary study showed that NAC may have some promise in treating cocaine addiction:

NAC has shown some promise as an adjunctive treatment for chronic schizophrenia; in this study the dose was 1000 mg twice daily, over 24 weeks. Once again, there were no side-effects. As I look at the body of the paper, I see that there was a definite favorable effect from the NAC compared to placebo, in several domains, but the size of the effect seemed clinically modest:

So NAC appears to be an appealing therapy for a variety of frequent, and often difficult-to-treat psychiatric symptoms. There do not appear to be side effect problems.

At this point, NAC can be obtained from health food stores in Canada, as a nutritional supplement.  It is also on the prescription formulary in an injectable form for treating acetaminophen toxicity. 

Friday, September 25, 2009

Randomized Controlled Trials in psychiatry

There is a good debate presented in the September 2009 issue of the Canadian Journal of Psychiatry (pp. 637-643), about the importance of randomized controlled trials in psychiatric research and clinical practice.

Steven Hollon presents a strong case supporting the philosophical foundations of RCT research, while Bruce Wampold presents many good points about the present limitations and weaknesses prevalent in current psychiatric RCT research studies. In particular, Wampold points out that much evidence exists regarding the relevance of the individual therapist (and, I might add, of the individual sense of patient-therapist alliance or connection) in determining therapeutic outcomes, and that this very individual factor may have a stronger influence on outcome than the particular "treatment" being offered (whether it be CBT, psychoanalysis, a medication combination, etc.).

My own view of a lot of the evidence resonates with these ideas. I strongly support the importance of randomized controlled trials in medicine and psychiatry. Yet it often seems to me that many variables are not accounted for. The impact of the individual therapist is one specific factor. If the patient is more comfortable with one therapist than another, than this factor alone may greatly outweigh the effect of the particular style of therapy being offered. Interestingly, this factor may not necessarily depend on the length of experience of the therapist -- sometimes a trainee may have a more positive therapeutic impact than a therapist who has decades of experience. This fact is not surprising to me: a lot of psychotherapy can have a lot to do with the capacity for the therapeutic relationship to grow and be healthy, which may depend substantially on very personal factors in the therapist. This may be humbling to those of us who revere the notion of psychotherapeutic theory being of paramount importance.

The whole of psychiatric theory may, at least in some cases, be less important than the goodness of a single interpersonal connection.

But I do also believe that certain therapeutic techniques are more effective than others. I think that strategies which promote daily long-term psychological work just have to be more effective (along the lines of language learning again). Also I think that strategies which encourage and help a person to face their fears or to move away from destructive habits are more likely to be helpful than strategies which do not look at these issues.

Many other factors are often not controlled (or examined at all) in present psychiatric RCTs, including nutrition, exercise, other self-care activities, supportive relationship involvement, community involvement, altruistic activity, etc.

Another factor that I have considered is the heterogeneity of many studied psychiatric populations. Different individuals with so-called "major depressive disorder" may in fact have different underlying causes for their symptoms; some of these individuals may respond well to one type of treatment, others may respond to something else. I suppose the RCT design remains appropriate in this situation, yet a powerful focus in research, in my opinion, needs to be to examine why some people respond to something, while others don't.

This erratic pattern of response doesn't just happen with individuals in a particular study. There are whole studies in which a well-proven psychiatric treatment (such as an antidepressant) doesn't end up differing from placebo. I don't think such studies show that antidepressants (or other treatments) are ineffective, but I do think it strongly suggests that the current criteria for psychiatric diagnoses are insufficient to predict treatment response as consistently as we need.
Often times, these negative studies are dismissed automatically. In many cases, such studies have been poorly designed, and that is the main problem. But in other cases, I think we need to very carefully examine such negative studies, to understand why they were negative.

This is consistent with another type of scientific rigor (different from the RCT empirical approach): in mathematics, a single counterexample is sufficient to disprove a theorem. If such a counterexample is found, it can be extremely fruitful to examine why it occurred--in this way a new and more valuable theorem can be conceived. The process of generating the disproven theorem was not a waste of time, but could be understood as part of a process to find the accurate theorem. Such examples abound in other fields, such as computer programming--a program or algorithm may work quite well, but generate errors or break down in certain situations. Careful examination of why the errors are taking place is the only way to improve the program, and perhaps also to more deeply understand the problem the program was supposed to solve.

Wednesday, September 16, 2009

Perils of Positive Thinking?

Joanne Wood et al. had an article published in Psychological Science in June 2009. It was a study in which subjects with low self-esteem felt worse after doing various "positive thinking" exercises. Subjects with higher self-esteem felt better with self-affirming statements.

Here is a link to the abstract: http://www.ncbi.nlm.nih.gov/pubmed/19493324

So the study seems to suggest that it could be detrimental to engage in "positive thinking" if you are already having depressive thoughts, or negative thoughts about yourself or your situation. The authors theorize that if you if have a negative view of yourself, then it may simply draw more attention in your mind to your own negative self-view, if you force yourself to make a positive statement about yourself. The positive statement may simply seem ridiculous, unrealistic, unattainable, perhaps a reminder of something you don't have or feel that you cannot ever have.

However, the study is weak, and demonstrates something that most of us could see to be obviously true. The study is cross-sectional, and looks at the effect of a single episode of forced "positive thinking." This is like measuring the effect of marathon training after one single workout, and finding that those already in good shape really enjoyed their workout, while those who hadn't run before felt awful afterward.

Any exercise to change one's mind has to be practiced and repeated over a period of months or years. A single bout of exercise will usually accomplish very little. In fact, it will probably lead to soreness or injury, especially if the exercise is too far away from your current fitness level. I suppose if the initial "exercise" is a gentle and encouraging introduction, without overdoing it, then much more could be accomplished, as it could get one started into a new habit, and encourage hope.

"Positive thinking" exercises would, in my opinion, have to feel realistic and honest in order to be helpful. They may feel somewhat contrived, but I think this is also normal, just as phrases in a new language may initially feel contrived as you practice them.

And, following a sort of language-learning or athletic metaphor again, I think that "positive thinking" exercises cannot simply be repeating trite phrases such as "I am a good person!" Rather, they need to be dialogs in your mind, or with other people -- in which you challenge yourself to generate self-affirming statements, perhaps then listen to your mind rail against them, then generate a new affirming response. It becomes an active conversation in your mind rather than bland repetition of statements you don't find meaningful. This is just like how learning a language requires active conversation.

Self-affirmation may initially be yet another tool which at times helps you get through the hour or the day. But I believe that self-affirming language will gradually become incorporated deeply into your identity, as you practice daily, over a period of years. Actually, I think the "language" itself is not entirely the source of identity change; I think such language acts as a catalyst which resonates with a core of positive identity which already exists within you, and allows it to develop and grow with greater ease. This core of positivity may have been suppressed due to years of depression, environmental adversity, or other stresses.

Monday, September 14, 2009

A list of individuals who developed talents later in life

This is a follow-up to my language-learning metaphor entry.

One comment was about the unlikelihood of mastering a "new language" (literally or metaphorically) if you only start learning beyond childhood or adolescence.

This seems to be a common view.

I always like to look for counterexamples (it's my mathematical way coming out in me):

1) the first one that leapt to my mind is Joseph Conrad, one of the greatest authors in the history of the Engish language. Conrad did not speak a word of English until he was 21. He began writing in English at age 32. His first published works came out when he was about 37. In order to learn English, he did not attend language classes or read grammar books, but chose to live and work in an English-speaking environment (immersion!).

2) I don't know much about rock musicians, but my research led me to a biography of Tom Scholz, from the group Boston. He started playing musical instruments at 21.

3) Here's a link to someone else's list:

4) Here's another list, which is part of a review of a book called Defying Gravity: A Celebration of Late-Blooming Women:

5) Another link with good examples:
(I'm the one who added Joseph Conrad to this list).

...I invite other suggestions to expand my list!

Friday, September 11, 2009

Making it through a difficult day or night

It can be hard to make it through the next hour, if you are feeling desperately unhappy, agitated, empty, worthless, or isolated, especially if you also feel disconnected from love, meaning, community, "belongingness," or relationships with others.

Such desperate places of mind can yet be familiar places, and a certain set of coping tactics may evolve. Sometimes social isolation or sleep can help the time pass; other times there can be addictive or compulsive behaviours of different sorts. These tactics may either be distractions from pain or distress, or may serve to anesthetize the symptoms in some way, to help the time pass.

Time can become an oppressive force to be battled continuously, one minute after the next.

I'd like to work on a set of ideas to help with situations like this. I realize a lot of these ideas may be things that are already very familiar, or that may seem trite or irrelevant. Maybe things that are much easier said than done. But I'd like to just sort of brainstorm here for a moment:

1) One of the most important things, I think, is to be able to hold onto something positive or good (large or small), in your mind, to focus on it, to rehearse it, to nurture its mental image, even if that good thing is not immediately present. The "good thing" could be anything -- a friend or loved one, a song, a place, a memory, a sensation, a dream, a goal, an idea. In the darkest of moments we are swept into the immediacy of suffering, and may lose touch with the internalized anchors which might help us to hold on, or to help us direct our behaviour safely through the next 24 hours.

In order to practice "holding on" I guess one would have to get over the skepticism many would have that such a tactic could actually help.

In order to address that, I would say that "covert imagery" is a well-established technique, with an evidence base in such areas as the treatment of phobias, learning new physical activities, practicing skills, even athletic training (imagining doing reps will actually strengthen muscles). The pianist Glenn Gould used covert imagery to practice the piano, and preferred to do much of his practice and rehearsal away from any keyboard; he preferred to learn new pieces entirely away from the piano. There is nothing mystical about the technique -- it is just a different way of exercising your brain, and therefore your body (which is an extension of your brain).

In order for covert imagery to work, it really does help to believe in it though (skepticism is highly demotivating).

Relationships can be "covertly imagined" as well -- and I think this is a great insight from the psychoanalysts. An internalized positive relationship can stay with us, consciously or unconsciously, even when we are physically alone. If you have not had many positive relationships, or your relationships have not been trustworthy, safe, or stable, then you may not have a positive internalized relationship to comfort you when you are in distress. You may feel comforted in the moment, if the situation is right, but when alone, you may be right back to a state of loneliness or torment.

The more trust and closeness that develops in your relationship life, the easier it will be to self-soothe, as you "internalize" these relationships.

Here are some ways to develop these ideas in practical ways:

-journaling, not just about distress, but about any healthy relationship or force in your life which helps soothe you and comfort you

-using healthy "transitional objects" which symbolize things which are soothing or comforting, without those things literally being present. These objects may serve to cue your memory, and help interrupt a cycle of depressive thinking or action.

-if there is a healthy, positive, or soothing relationship with someone in your life, imagine what that person might say to comfort or guide you in the present moment; and "save up" or "put aside" some of your immediate distress to discuss with that person when you next meet.

2) Healthy distraction.
e.g. music (listening or performing); reading (silently or aloud, or being read to); exercise (in healthy moderation); hobbies (e.g. crafts, knitting, art); baking
-consider starting a new hobby (e.g. photography)

3) Planning healthy structured activities
e.g. with community centres, organized hikes, volunteering, deliberately and consciously phoning friends

4) Creating healthy comforts
e.g. hot baths, aromatherapy, getting a massage, preparing or going out for a nice meal

5) Recognizing and blocking addictive behaviours
-there may be a lot of ambivalence about this, as the addictive behaviours may have a powerful or important role in your life; but freeing oneself from an addiction, or from recurrent harmful behaviour patterns, can be one of the most satisfying and liberating of therapeutic life changes.
An addictive process often "convinces" one that its presence is necessary and helpful, and that its absence would cause even worse distress.

6) Humour
-can anyone or anything make you laugh?
-can you make someone laugh?

7) Meditation
-takes a lot of practice, but can be a powerful tool for dealing safely with extreme pain
-could start with a few Kabat-Zinn books & tapes, or consider taking a class or seminar (might need to be patient to find a variety of meditation which suits you)

8) Being with animals (dogs, cats, horses, etc.). If you don't or can't have a pet, then volunteering with animals (e.g. at the SPCA) could be an option.

9) Caring for other living things (e.g. pets, plants, gardens)

10) Arranging for someone else to take care of you for a while (e.g. by friends, family, or in hospital if necessary)

11) Visiting psychiatry blogs
-(in moderation)

...I'm just writing this on the spur of the moment, I'll have to do some editing later, feel free to comment...

Tuesday, September 8, 2009

When your therapist makes a mistake

Sometimes your therapist will make a mistake:
- an insensitive or clumsy comment
- an intrusive line of questioning
- a failure to notice, attend to, or take seriously, something important in the session
- unwelcome or way-off-base advice.

If such problems are recurrent and severe, it may be a sign that you don't have a very good therapist, and that it is important to seek a referral to someone else.

Some problems could be forms of malpractice (e.g. being given dangerous medications inappropriately), and could be pursued through legal channels.

I think that a healthy therapy frame is one in which the therapist will be open to discussing any problems or mistakes.

The therapist should sincerely apologize for all mistakes, and be open to making a plan to prevent similar mistakes from happening again.

You deserve to feel safe, respected and cared for in therapy.

There are other types of conflicts that can arise in therapy, when one person or the other feels hurt, frustrated, or misunderstood. I can think of situations over the past ten years in which there have been tense conflicts, and in which my patient chose not to continue seeing me. In some of these cases, I have felt that there was a conflict--a problem in the relationship--which needed to be resolved. Sometimes these conflicts were made more likely by my own character style or behavioral quirks; other times I think these conflicts were at least partly "transferential," in that my actions triggered memories associated with conflicts from previous relationships (such as with parents growing up). In a few cases, I think the conflict was influenced by active mood symptoms (e.g. severe irritability). I think many conflicts have a mixture of different causes, and are not necessarily caused by just one thing.

In any case, I do strongly believe that resolving conflict in therapy is very important. And I believe a therapist must gently and empathically invite a dialog about conflicts, in a manner which is open, non-defensive, and "non-pushy." Such a moment of conflict-resolution, if it occurs, could be one of the most valuable parts of a therapy experience, a source of peace and freedom.