Thursday, December 22, 2011

Mental health issues in the workplace

A frequent source of unhappiness I see has to do with a psychologically unhealthy work environment.  I am interested to survey the research literature on this subject, but for starters here are a few thoughts:

1) many businesses simply do not seem to value the idea of simply treating employees well.  Instead, a short-sighted view is taken, of attempting to maximize the work output or efficiency of the workers, while minimizing costs.   On a short term basis (perhaps confirmed by mathematical models composed by the recent business or commerce graduate who is now in a managerial position), this leads to more profit for the business with fewer expenses.  On a longer-term basis, however, this pattern leads to poor morale, loss of good or talented employees, higher rates of absenteeism, lower productivity, lower worker loyalty, which in turn must undoubtedly be perceived or intuited by customers, all of which would severely dampen the prosperity of the business.

2) counter-examples exist, of particular businesses which treat employees very well, allowing them more autonomy, healthy scheduling, security, non-authoritarian leadership, even paid time to attend fitness activities, etc.  I can think of a few examples like this in which the business and the employees are prospering together, with a very positive public image as well.

3) I have to wonder if the current educational system biases the business world to perpetuate these types of problems.  University programs in commerce, economics, or business may have a variety of biases:  a money or wealth-acquisition-oriented value system may be very frequent in students drawn to these areas.  The programs themselves, I observe, may be dealing with subject matter that involves very interesting, complex, and subtle interactions between human motivations, emotions, and behaviours.  Yet the programs tend to have very little instruction or requirement for students to study the obviously related fields of psychology, sociology, ethics, history, political science, etc.  Unfortunately this may equip graduates, who may be involved in group leadership and policy-making decisions affecting thousands of people, with strong profit-optimization skills, but very little wisdom or education about human nature or a foundation in altruistic values. 

4) In any case, I think many employer-employee interactions are like a dysfunctional family:  the "parents" either too authoritarian or enmeshed, or too detached and uninvolved.  Usually there are problems with communication.   Unfortunately,  it is usually very difficult for this type of "family" to come for group therapy:  it seems more common for these types of group problems to become more entrenched with time.

The field of "corporate psychology" seems to address some of these issues.  I will be interested to survey this literature in the coming months, and hopefully add to this post in a helpful way. Aside from therapeutic ideas to make beneficial changes in business group dynamics, I wonder if it could be a useful trend in the future to allow free economic forces to help things along:  if one is considering being a customer or an investor in a business, how about checking out how happy the employees are?  It would be a service to the community, in the name of public and individual mental health,  to support businesses which provide a healthy community not only to the public, but to their own employees.

Antidepressants = Psychotherapy = Placebo ?

Jacques Barber et al. have recently published the results of a randomized, controlled study conducted between 2001 and 2007, comparing antidepressant therapy, short-term dynamic psychotherapy, and placebo in a 16-week course of treatment for 156 depressed adults.  Here is a link to the abstract:

The bottom line in the study was that there was no significant difference between antidepressants, psychotherapy, or placebo. Response rates were 31% for medication,   28% for psychotherapy, and  24% for placebo -- which has a low probability of being statistically different.  Remission rates were 26% for medication, 22% for psychotherapy, and 20% for placebo. 

Critics trying to explain these findings might attempt to argue that the psychotherapy or the medication regime was not sufficient, etc. -- but I do not see this to be true.  The medications (venlafaxine or sertraline) were given at quite sufficient doses for good lengths of time.  The psychotherapy was not CBT (which has a larger research evidence base) but there is little reason, in my opinion, to believe that the therapy style was inferior.

The authors attempt to do some secondary analyses looking for explanations, but their conclusions seem quite weak to me (e.g. regarding race or gender).   The fact that they spin these conclusions into a prominently framed set of "clinical points" seems quite inappropriate to me -- this is a negative study, there are no "clinical points" to be found here, unless they recommend placebos and cessation of other therapies!

There are a number of issues from this study that I do find very important to discuss:

1) despite a massive amount of data showing that various therapies (e.g. antidepressants or psychotherapy) are effective for various problems, there are examples of carefully-conducted negative studies, such as this one.  These results cannot simply be explained away as statistical aberration:  there must be a reason why one group of people responds to a treatment, while another does not.  Many of these reasons are poorly understood.  It may be that the diagnostic category of "major depressive disorder" is inadequate, in that it correlates poorly on its own with treatment responsiveness.

2) the subjects in this study had a high degree of comorbidity (e.g. substance abuse problems, anxiety disorders, and axis II problems).  While the severity and chronicity of depression was not found to actually correlate with treatment responsiveness, I suspect that the comorbidities would substantially affect response to a relatively short-term course of therapy. 

3) the subjects in this study were socioeconomically disadvantaged; while the effect of SES was also not found to "influence the initial findings,"  I believe that low SES is not necessarily a direct negative influence upon mental health; rather it is an indirect factor which for many people increases the likelihood of some profound mental health negatives (e.g. unemployment, lack of meaningful or satisfying employment, lack of healthy or safe community, lack of availability to do healthy or meaningful leisure activities, not enough money to eat healthily, etc.).  I believe that the environmental adversities need to be looked at very closely in a study of this type.

This leads to what I believe is an obvious explanation for the findings here:  there is no therapy for depression that is likely to help unless ALL contributing factors (including obvious environmental contributing factors) are addressed.   By way of analogy, I believe it is pointless to treat insomnia using a powerful sedative if a person is sleeping in a room which is continuously noisy, cold, and prone to break-ins by violent intruders.  The environmental issues need to be addressed first!  Another analogy I have often used is of trying to repair a water supply system for a city:  it is a waste of effort to pipe in more water from rivers, or to dig a deeper reservoir, if the walls of the reservoir and the pipes are leaking or bursting because of structural defects.   In order for a therapeutic strategy to work, the "leaks" have to be repaired first.  For a person with anemia, it is not an appropriate strategy to simply give a blood transfusion:  while a transfusion may be necessary, it will not be sufficient--and could even make matters worse-- if the underlying cause of blood loss is not addressed and treated.

In the case of medications or psychotherapy, I believe these can be very helpful, but only if environmental adversity is also remedied.  In some instances, of course,  relief of a psychiatric symptom could help a person to improve the environmental circumstances.  But in most other cases, I think the issue is broader, and could be considered a political or social policy matter.

Another related issue is that I do not believe "depression" can be treated on its own without addressing all psychiatric and medical comorbidities at the same time.  Ongoing substance abuse, in my opinion, is often a powerful enough factor--psychologically as well as neurophysiologically--to completely dominate and dissolve the positive influences of psychotherapy or effective medication.  In this study, 30-40% of the cohort reported substance use problems. 

As a final thought, I think the "5 axis" model of diagnosis in the DSM system deserves some affirmation; many times, however, we only pay attention to Axis I (diagnoses such as depression or schizophrenia, etc.) or Axis II (personality disorder).  I think that studies such as this one highlight the necessity to look closely at Axes III (medical illnesses) and IV (social, community, financial, and relational problems).  It is likely that issues on these latter two axes can prevent any resolution of problems on the first two.

Saturday, December 10, 2011


Here's a good site that has many links to free therapy worksheets:

Spending some focused time with a worksheet can be a healthy, useful, structured component of therapy or self-help.  Worksheets can be especially useful if you want to build up healthy therapeutic habits, both in terms of inner reflection and external action, but find yourself in need of more clear structure to get started or to continue guiding you.  I find this can be analogous to learning a subject at school, or a musical instrument, etc. :  practicing is obviously important, but it can certainly help guide and discipline your practice efficiently to have a good textbook to work through. 

Many thanks to the person who recommended this site to me!

Thursday, November 3, 2011


Piracetam is a so-called "nootropic" drug, a substance which supposedly helps improve cognitive functioning.  It is available without prescription as a sort of supplement in many parts of the world.  In Canada it is not illegal, but must be imported (such as by ordering over the internet from U.S. suppliers).

The mechanism of action is not clear.   There is no obvious single receptor-mediated mechanism.  There may be various effects on ion channels, cell membrane characteristics, etc. but of course such statements are quite vague.

It is quite clear that there are few side-effect problems or toxicity risks with this agent.  Doses are typically 2-5 grams per day.

I became interested in this agent after encountering a case example of someone who reported quite a dramatic improvement in mood and overall functioning attributed to piracetam supplementation.

Here are the results of my survey through the research literature:  -- a 2005 review  -- a 1991 review looking specifically at its use  in treating  dementia; the data is really not impressive at all for dementia treatment.  -- a 2000 Japanese study affirming the effectiveness of piracetam combined with clonazepam  for treating myoclonus  (myoclonus is a neurological problem in which muscles are twitching involuntarily).  -- a 1996 study from Japan also showing benefit in treating myoclonus;  there were also improvements in motivation, attention, sleep, and mood (possibly secondary to improvement in the movement disorder). -- 2001 study from Archives of Neurology again affirming that piracetam is effective over 12 months of follow-up for treating myoclonic epilepsy. -- this 2000 Cochrane review stated that the data on piracetam are inconclusive, with studies not being of good quality - this 1999 article reviewed studies of piracetam for treating vertigo, concluding that it was useful for reducing frequency of recurrence, at doses of 2-5 grams per day.  -- this is a 2007 randomized placebo-controlled study from The Journal of Clinical Psychiatry,  in which piracetam 4800 mg/d for 9 weeks led to substantial improvements in tardive dyskinesia, with large differences from placebo.  -- piracetam has some antiplatelet function, which could be used in managing or preventing recurrences of vascular disorders.  This is a 1999 review of this subject.  -- this is a broad review of nootropics, published in 1994.  -- this 1987 study from The Journal of Clinical Psychopharmacology shows that children treated with piracetam may show improvements in dyslexia.
Doses were 3.3 grams daily x 36 weeks (dosed twice per day).  However, as I look at the results, I see that there is a statistical difference, but the numbers really look very similar between placebo and piracetam.    The placebo group improved substantially; the piracetam group improved only slightly more.  For example, the raw scores in the Grey Oral Reading Test increased from 17.1 to 22.5 in the placebo group; in the piracetam group it increased from 14.8 to 22.9.   It is true that the piracetam was well-tolerated, with minimal side-effect problems.
this is a 2002 study which attempted to show whether piracetam could prevent ECT-induced cognitive problems.   The dose was 7.2 g/day for a 2-week loading phase, then 4.8 g daily for the remaining 2 weeks.  They concluded that piracetam had no effect on cognition in this group; but the piracetam group did slightly better than the placebo group in terms of overall clinical improvement.
this 2006 study described anxiolytic effects of piracetam which were blocked by flumazenil (a benzodiazepine receptor blocker), suggesting that piracetam has some GABA-like activity.
a Hungarian study describing successful use of piracetam to treat alcohol withdrawal delirium
a 1993 Indian study showing that piracetam has anti-anxiety effects when administered on a longer-term basis in rats.
a 1979 article from Journal of Affective Disorders describing anti-anxiety effects from piracetam similar to a benzodiazepine, but without sedation.
in this 1983 study, piracetam 2.4 g/day or 4.8 g/day was compared with placebo in treating 60 elderly psychiatric patients; the 2.4 g/day group showed increased socialization, altertness, and cooperation, and had some improvement on memory and IQ tests, compared to the placebo group.
in this 1977 study, elderly psychiatric patients were given 2.4 g/day of piracetam or placebo, for 2 months.  The piracetam group did not improve in any cognitive tests or mood symptom scores compared to placebo, but interestingly 52% of subjects in the piracetam group showed overall improvement (CGI) compared to only 25% in the placebo group.
a Cochrane review from 2001 concluding that there is evidence that piracetam may improve the course of aphasia after stroke; however, the evidence was found to be weak.
this 1982 study shows that 40 g of IV piracetam caused greater reduction than placebo in antipsychotic-induced Parkinsonian side-effects.
a small 1979 study which showed that refractory depressed patients improved with the addition  of 2.4 g piracetam.
a look at toxicity risk due to piracetam, when given in higher doses (12 g/day) for 12 weeks, to stroke patients.  The paper concludes that there is no significant toxicity risk at this dose for this population.

In conclusion, piracetam appears to be clearly effective for a few uncommon conditions, such as myoclonus.  There is possible effectiveness for some other problems such as tardive dyskinesia.  The evidence for effectiveness as a "cognitive enhancer" appears to be quite shaky, but not absent.

I am particularly interested in some of the evidence which suggests that it could be useful as a safe, well-tolerated adjunct to treat depression or anxiety.  Some of the studies quoted above appear to support this possibility.  This theme also intersects with my recent thoughts about considering cognitive function in chronic mood, anxiety, ADHD, or personality disorders. A weakness in working memory capacity or executive functioning could substantially interfere with recovery from psychiatric illness; I suspect that a treatment which could specifically help with cognitive function could be a unique angle to augment treatments for these other psychiatric problems.  (see my previous post, which discusses an association between rumination & working memory dysfunction:  Here's another link about this:

I do think it would be worthwhile for research groups to consider doing some new, careful, large trials of piracetam as an augmentation for managing depression, anxiety disorders, etc.

Wednesday, October 26, 2011

Therapeutic approaches to irritability

Irritability can be a challenging symptom, often present in a wide range of different clinical settings.  Unipolar depression can present with irritable mood, as can the manic states of bipolar disorder.  Irritability is also a common problem in borderline personality disorder, as well as in various other populations, such as in those with autism, dementias, brain injury, conduct or oppositional disorders, and addiction disorders.  In some cases, arguably, irritability could be considered the primary problem for some people, which either exists on its own as a solitary symptom, or is the direct single cause of the person's other life problems (e.g. in relationships, employment, conflicts with the law, ability to work or study, etc.)

A variety of simple factors usually make irritability worse:
1) sleep problems.  Insomnia or deliberate reduction of sleep hours will magnify irritability.
2) hunger.  For some individuals especially, allowing a hungry state without eating healthily will magnify irritability.

In both cases above, a vicious cycle can arise, as greater irritability may prevent sleep or cause a further lack of appetite.   

3) multiple environmental or medical irritants which are not improving:  for example, crowding, noise, poor air quality, physical pains or discomforts

Therefore, in approaching irritability, it is essential to take steps to improve sleep, nutrition, pain, and environmental stimuli.

Further therapy for irritability should of course involve healthy lifestyle practices, such as exercise, relaxation, and meditative activity (if not formal "meditation" then something which accomplishes something similar, such as music listening or performance, biofeedback, hot baths, massage, etc.)  Reduction of caffeine intake, etc. could be important to try. Developing healthy philosophical practices can be very useful; for example, some type of calm or peace-oriented religious or other community involvement may add to one`s ability to manage irritability, especially since there could be group-based support and healthy cultural activities. 

Pharmacological treatment of irritability, if necessary, would  depend on obvious underlying causes.  In substance withdrawal states, for example, temporary appropriate sedation (e.g. with benzodiazepines, clonidine, or anticonvulsants such as gabapentin) could ease the irritability.    In manic states, mood stabilizers, antipsychotics, and benzodiazepines which ease the manic symptoms, would be expected to ease the irritability.  In major depression, an antidepressant of any sort, if it works for the individual, could dramatically improve the irritability.  ADHD can be a cause of irritability, which--seemingly paradoxically--could improve with stimulant therapy. 

In this post, I am particularly interested in looking at specific pharmacological treatments for idiopathic irritability, or irritability which has existed as a long-term emotional dynamic such as in those with borderline personality traits or disorder.

Here are a few pertinent links to abstracts in the research literature:
this 12 week randomized study shows modest benefits from divalproex to treat irritability in autistic children (ages 5-17)  gabapentin useful for borderline patients over a 6 month period (this is a good article, but it's in German)--  review of anticonvulsant effectiveness in personality disorders.  There is evidence in this paper to support trials of valproate, topiramate, and possibility also lamotrigine.  They describe some data on carbamazepine as well.  The level of evidence is such that I think these medications could be worth trying cautiously on an individual basis, particularly to target symptom domains such as irritability.  However, I think expectations should be modest, due to there most likely being a lot of variability in an individual's response. 

I am interested in the use of clonidine for irritability.  This drug is effective for treating withdrawal states (including one of the most unbearable withdrawal states possible, from opiates), but has also been used for many years to treat ADHD.  It can help with tic disorders as well, so could be a good choice for managing ADHD + tic comorbidity, a difficult problem often made worse by stimulants.  Clonidine was originally developed as a treatment for high blood pressure.  My main concern about clonidine is about how well its effects persist if taken continuously for more than a few months.  Here is an article about treating borderline personality patients with clonidine:

Here's a study looking at treating children with conduct or oppositional problems with stimulants and/or clonidine:

In conclusion, there are various options to try in the treatment of irritability from most causes.  While the evidence base is limited, there is support for attempting a variety of different pharmacological treatments for idiopathic irritability, particularly anticonvulsant medications.

Monday, October 3, 2011

Parental behaviours associated with offspring personality traits

Johnson et al. have published an interesting article in the August 2011 edition of The Canadian Journal of Psychiatry (pp. 447-456) in which they describe a nice longitudinal study of 669 families, correlating parenting behaviour with future personality traits in the offspring.

To some degree, studies of this type might seem to be re-examinations of the obvious -- that is, children of friendly, gentle, stable, involved parents are more likely to be healthy and stable themselves.  The thing is, much of this effect is arguably due to heredity rather than parenting.  The genetic factors which influence temperament, mood, personality, etc. are likely to be present in both parents and children--the impact of parenting behaviours themselves are therefore likely to be overestimated.

A good method to tease out these factors would be to study  families with adopted children, provided there is good data about psychological characteristics of the birth parents.  In general studies of this sort have led to the surprising conclusion that genetic factors are quite a bit higher than expected, and parenting factors quite a bit lower.

But this particular study is quite good.  It was longitudinal, following parents and offspring  at various ages during the offspring's childhood years (ages 6, 14, and 16), then following up in the offspring's young adulthood years (ages 22 and 33).  Most importantly, the study carefully assessed parental psychological traits and symptoms, which in my opinion would help control for inherited traits confounding the results.

This article has some problems with lack of clarity in the writing.  It was not exactly clear when the interviews were done (particularly the data from when the children were 6 years old).  Also, in the tables, various items (such as "high praise and encouragement" in Table 2) are listed twice, with different numbers!  I'm surprised that the writers and editors didn't address these things before publication.  

In any case, the results show that various positive parental behaviours led to substantially reduced risk of future psychological problems in the offspring ("reduced aggregate offspring personality disorder symptoms levels" and "elevated aggregate offspring personality resiliency").  Here are a few examples (some of these things may seem like obvious truths -- but it is important to be reminded about just how important these are):
1) speaking kindly to child
2) being calm, not reactive with child
3) attention and dedication to child
4) raised child without reliance on punishment
5) lots of time spent with child
6) shared enjoyable activities with child
7) high affection toward child
8) good communication with child
9) high praise and encouragement

A few findings might be surprising to some.  For example, "encouragement of offspring autonomy" from fathers actually was associated with a higher risk of offspring psychological problems.

Studies about parenting may seem to have limited relevance to those of us who are not parents, or who are not currently being parented.  But I believe these findings can be generalized:  in a psychodynamic sense, all relationships have at least a partial "parental" quality to them.  We all also have a "parenting role" with ourselves!  This role, and the behaviours or stance we take in this role, are undoubtedly coloured by the type of parenting we have experienced in our childhoods.

Findings of this type encourage us to change our "self-parenting":

1) Speak kindly to self!
2) Be calm and not reactive to self!
3) Be attentive and dedicated with yourself!
4) Be with yourself without reliance on punishment!
5) Spend lots of time with yourself! 
6) Share enjoyable activities with yourself!
7) Have high affection toward self!
8) Communicate well with self!
9) And give self praise and encouragement!

10) If you are accustomed to "encourage autonomy in yourself" a lot, maybe you can give this one a rest.

Friday, September 30, 2011

Pregabalin for generalized anxiety

There have been a variety of studies in the literature showing that pregabalin is effective for treating generalized anxiety.

The latest of such studies I have seen is published by Mark Boschen in the September 2011 issue of The Canadian Journal of Psychiatry (p.558-565).  

This article is a meta-analysis, and shows generally that pregabalin is effective compared to placebo, and has similar, if not greater, effectiveness than other medication options for treating generalized anxiety, such as SSRIs, venlafaxine, and benzodiazepines.

The most common doses have been in the 600 mg/day range, which I consider quite high, particularly since a reasonable dose range for pregabalin could be around 75-300 mg/day.  

The "limitations" admitted by the author include issues about dosing, and the fact that Pfizer has funded every published randomized study quoted in the article.

I believe that pregabalin could be a very useful option to try, if a medication trial is being considered for generalized anxiety treatment (of course, the first lines of therapy for generalized anxiety are CBT, relaxation-oriented therapies, meditation, exercise, etc.--but for many people these approaches are not sufficiently helpful).  Pregabalin has the advantage of having a quite different--and generally mild--side effect profile compared to other medications, and a what appears to be a fairly low (but I do not think zero) risk of addictiveness/dependence problems, particularly compared to benzodiazepines.

However -- the most obvious limitation of the literature findings is only mentioned briefly in passing by the author in the discussion:  it is hard to make a good conclusion about a treatment for anxiety when the duration of follow-up is only 4-8 weeks!  I believe that a study for this problem needs to extend for a year or more.  First of all, many treatments for anxiety can be acutely helpful, but then wear off substantially over time.  Arguably, having a beer every 4 hours could reduce GAD scores over a 4-week trial--but obviously this is not an acceptable long-term treatment!  (not only would there be multiple physical harms caused by this over a period of many months or years, but there would be substantial tolerance to anxiety reduction effects, which might only become apparent over many months; furthermore,there would be new psychiatric symptoms induced over a period of months and beyond).

It is not clear from the literature whether the acute benefits over 4-8 weeks from pregabalin would persist over a year or more, whether there would be tolerance, whether there would be longer-term emergent physical or psychiatric side-effects, dependence phenomena, trouble with withdrawal or discontinuation, etc.

Research of this type could be used --spuriously--to justify giving GAD patients benzodiazepines on a routine basis as well, despite the frequent and obvious problem of tolerance, dependence, cognitive problems, etc.  Most benzodiazepine studies are of similarly short duration, hence have very limited value to guide us for the long-term treatment decisions which are most important.

Yet, I do think that pregabalin is promising, and could be worth a cautious try, particularly if other approaches are not working well.

Thursday, September 29, 2011

Multi-dimensional nature of borderline personality symptom structure

Chmielewski et al. have published an article in the September 2011 edition of the Canadian Journal of Psychiatry in which they show that borderline personality is better described as having several separate symptom dimensions.

The benefit of having several dimensions instead of one could be illustrated by way of analogy:  suppose we are talking about heart disease.   One could simply describe all patients suffering a "heart attack" according to a single severity scale, perhaps including information of the amount of pain, degree of disability afterwards, etc.  This scale could be quite useful, but it would obscure a great deal of information about the group, and reduce the efficiency of treatment.   A multi-dimensional scale would instead look at several domains separately, such as perfusion abnormalities, rhythm abnormalities, and structural abnormalities.  Abnormal perfusion might be treated specifically with bypass surgery, rhythm problems with a pacemaker, and structural problems with a valve replacement etc.   Thus the management could become more meaningfully specific.

The authors of this paper about borderline personality show that a 3-factor model fit well to describe symptoms in borderline patients; a 1-dimensional model fit much more poorly.  The 3 factors are "affective dysregulation," "behavioural dysregulation," and "disturbed relations."    Affective dysregulation would refer to high intensity and lability of negative emotion, inappropriate anger, etc.   Behavioural dysregulation would refer to self-injurious behaviour, excessive or out-of-control behaviours such as binge eating, or I might add any sort of chemical or behavioural addiction.  Disturbed relations of course refers to interpersonal relationship problems.   One could see that these three domains would each influence the others, but part of a theoretical model is to consider to what degree problems in each domain could be considered primary.  (similarly, a blocked coronary artery would be a primary perfusion problem, but could in turn cause a secondary rhythm and structural problem in the heart). 

A particularly relevant remark from the authors comes in the discussion:  "...the current pattern of associations suggests that the glue that holds the BPD construct together may largely represent the general dysfunction or misery common across all forms of psychopathology and not just BPD."  So, the authors are hinting that we could perhaps do away with the BPD construct altogether, without any loss of insight,  and instead simply describe in succinct terms what the core symptoms are.  This makes sense to me.   I do believe that some of these core symptoms are extremely important to examine and address directly.  "Affective dysregulation" would be almost automatically addressed in any therapy environment, and "relationship dysfunction" is perhaps the most frequent topic of discussion (and perhaps transferential work) done in therapy.  But the "behavioural dysregulation"domain  I think is not quite so well-addressed in much therapeutic work.  I see this domain as the most common severe problem relatively more unique to those who fit into a "borderline personality" spectrum.  It is my own view to consider this domain through a type of addiction-medicine lens, as a set of problems which are highly destructive and addictive behavioural habits, often engaged in to cope with other symptoms, but which become independent problems with time.  This is similar to any other addiction;  alcoholism, for example,  may begin as alcohol consumption intended to calm nerves, deal with boredom, or to facilitate socialization, but in time becomes more and more a separate, self-contained behavioural and physiological addiction.

In my browsing through the literature as I was writing this post just now, I encountered a psychology master's thesis published online (by Edward Selby, M.Sc. 2007).  Here's a link:
Selby makes the case well that negative emotional cascades leading to behavioural dyregulation are strongly fuelled by rumination.  The events of behavioural dysregulation, such as self-injury, serve to distract one from the intense discomfort of rumination.  Here is a quote from the conclusion:
"the findings of this study provide preliminary evidence for an
emotional cascade model of dysregulated behavior. In this model high levels of rumination may cause extremely intense states of negative affect, which result in dysregulated behaviors that distract from rumination and reduce that state of negative affect. This study specifically linked rumination to drinking to cope, binge-eating behaviors, reassurance seeking, and urgency, and it is likely that rumination is linked to a variety of other deregulated behaviors. "

Rumination, of course, is another phenomenon common to much "general dysfunction or misery."  I am reminded how important it can be, as a practical therapeutic project with patients, to work on ways to move away from, or to let go of, rumination.  (see my previous post on rumination:  

Thursday, August 18, 2011


I'm just bumping up this post, originally from July 2008, because there have been some new comments.  

There are a lot of strong opinions out there about psychiatry.

Some people are concerned that the practice of psychiatry has caused harm, perhaps by "over-medicalizing" issues that should be considered matters of personal challenge, character, individual choice & responsibility, spirituality, or normal human experience. Other concerns are that psychiatry is overly influenced by large pharmaceutical companies, whose agenda is to earn larger profits by selling more medication. Critics holding these concerns often consider the results of research studies to be biased, since they have often been sponsored by drug companies.

I think these concerns need to be heard and respected. There are specific examples about some of the concerns having some validity to them. In the history of psychiatry, as in the history of all other human endeavour, mistakes have been made. Small mistakes and large mistakes. On a systemic level, I think some of the core theories about psychiatry over the past hundred years have been laden with huge inaccuracies, despite the many nuggets of wisdom contained within them (Freud's ideas are one example). Many times, attempts at treatment have not helped, or perhaps have reduced a symptom at a very great expense to other aspects of the patient's life. There have been trends and fashions in treatment, such as the widespread use of anxiolytic drugs in past decades--while only later do we discover that these treatments can cause entrenched problems with addiction.

Conversely, there are some testimonial accounts of individuals who have had long histories of conventional psychiatric therapies, who have gone on to thrive once leaving all of these behind (perhaps pursuing alternative or naturopathic medicine, or making some other lifestyle change).
I think it is important to step back and examine the evidence closely, with a critical eye (in future posts I will refer to some of the evidence). I hold that there is a vast body of evidence about psychiatry to look at. And the evidence shows that the treatments are truly helpful. The evidence also shows that the treatments are not perfect, and that typically 30% of people do not have a good response from a given psychiatric treatment. The evidence also shows that up to 30% of patients respond to "placebo treatments". These facts lead to several criticisms about psychiatric treatment: first, there are many (perhaps in the first group of 30%) who have tried "conventional psychiatry" and have found that it hasn't worked for them. Second, there are those who have tried "non-psychiatric" treatments, and found that these HAVE worked for them (perhaps these people are in the 30% "placebo" group). Both of these groups may have a tendency to criticize psychiatry; yet there is another 40% -- a group whose ailments have resolved as a direct result of their psychiatric treatments.

This has always reminded me a bit of other areas of medicine, such as cardiology or oncology: the treatments in these specialties can be remarkably curative for some, only palliative for others, and may not work at all for others still.

I do agree that we must never "over-medicalize" any human ailment. It is rare for a problem to be truly cured by a pill. Usually, for any human concern or challenge, any therapy that helps has to be accompanied by holistic changes in lifestyle & behaviour. For the cardiac patient, this means rehabilitative exercise, healthy diet, no smoking, etc. For the mind, just as for the heart, there are many lifestyle habits that are healthy, restorative, and protective against recurrent illness.

Yet, very often people are too ill to be able to institute the "healthy lifestyle habits". The cardiac patient may require medication to control blood pressure and angina before being able to safely or comfortably exercise. Similarly, there are medical treatments in psychiatry that can hopefully provide enough symptom relief to allow the patient to energetically change their life for the better.

I have observed that the "anti-psychiatry" group can be very vocal. I could understand that the individuals among this group could have good reasons to hold such strong, forceful opinions. But I don't want this site to be a forum to spend a lot of time on this debate, I would rather focus on my own beliefs about ways to manage the mind's symptoms in the healthiest possible ways.

Wednesday, August 10, 2011

Chronic Pain & Rumination

I was planning to write separate posts on chronic pain and on rumination; but I have found that these subjects are related to each other, so I thought I would combine them.

In this article, I am defining "rumination" as frequent, repetitive thoughts about symptoms or problems.  Such recurrent thinking can consume so much time and energy, that little is left in the mind to permit quality of life.  And the ruminations, while understandable in the context of troubling symptoms or problems, do not help to resolve the problems at all.  Rumination can also refer to a gastrointestinal problem, which I am not discussing here.  

Chronic physical pain obviously has a huge negative impact on quality of life.  The presence of physical pain symptoms is a strong risk factor for suicide. (references: ; )

If physical pain and depression are combined, the severity of both problems is substantially elevated.

Treatment of chronic pain requires good comprehensive medical care.  Investigation and treatment of underlying medical causes is obviously important.  Coordinated involvement of a mutlidisciplinary team is ideal, though often lacking in many people's experience. 

In the psychiatric realm, a variety of therapies can help:

1) mindfulness meditation.  Jon Kabat-Zinn developed much of his work on mindfulness meditation with patients suffering from physical pain.  In my opinion, meditation is extremely important, since it carries no risk, has a variety of possible and probable benefits, and is likely to help with both emotional and physical symptoms.

This study shows similar reductions in pain from a mindfulness program vs. a multidisciplinary pain program without a meditation focus: 

This study shows improvements in various types of chronic pain conditions, with greater improvements in symptoms when subjects practiced more at home:

This study showed that mindfulness strategies probably work best for those who already have higher levels of mindfulness to begin with, as a type of character trait: 

This study shows a slight advantage for a mindfulness meditation program to treat back pain:

An interesting study showing improvement in distressing intrusive thoughts and images following a meditation program.  This shows that mindfulness exercises can substantially improve symptoms of rumination and even psychosis.  In chronic pain, ruminations and intrusive thoughts about the pain itself are a very common feature, and an element of the vicious cycle of pain perpetuation and reduced quality of life.  The study was of good quality, and the effect was quite substantial and robust:

Similarly, a study showing the mindfulness training specifically increases ability to "let go" (in this case, of OCD thoughts).  "Letting go" of ruminations about pain is very helpful in managing chronic pain conditions: 

Here's another study once again showing that mindfulness is specifically helpful to reduce rumination:

2) Cognitive-behavioural therapy
There is a significant research literature showing the effectiveness of CBT for managing pain conditions.  Here are some research examples:
non-cardiac chest pain:
chronic TMJ (jaw) pain:
severe back pain:
back pain (here, active behavioural/physical therapy was necessary for optimal improvement in performance, as expected):
chronic headaches:

3) Medications
 a) antidepressants:

Several antidepressant types could help with chronic pain:  tricyclics such as amitriptyline have been used in this way for decades, with reasonable evidence-based support.  Cymbalta (duloxetine) has been marketed for this, and is reasonable to try.  However, venlafaxine (Effexor) is probably just as effective for pain symptoms.
There have been no studies comparing venlafaxine with duloxetine in pain patients; I suspect that there would be little difference.  Currently, duloxetine is more expensive, so I do not believe it should be a first-line agent.  SSRI antidepressants or bupropion appear not to be consistently helpful for treating physical pain.

Here`s an animal study showing a difference favoring a tricyclic over an SSRI or bupropion for pain management:   

Here`s a negative study on moclobemide for physical pain:

This study shows equivalent benefits from amitriptyline and duloxetine, with over 50% of patients having good pain relief in diabetic neuropathy:

This study shows benefits from duloxetine in fibromyalgia; again with over 50% of patients feeling much better, compared to about 30% with placebo:

This study shows significant benefit in treating osteoarthritis pain with duloxetine; the pain relief was not related to any change in depression scores (which, in this population, were quite low and did not change very much with either duloxetine or placebo).  I find this study quite significant, in that it is looking at a different variety of pain than most of the other research:

This study shows relief attributable to duloxetine in depressed patients with idiopathic pain symptoms:

Here, venlafaxine is shown to be an effective agent to prevent migraine headaches:

Venlafaxine shown to be effective in treating functional chest pain: 

A 2007 Cochrane review concluding that venlafaxine and tricyclics are effective for chronic pain: 

b) anticonvulsants, e.g. gabapentin, pregabalin, carbamazapine, topiramate

A comparison of gabapentin, pregabalin, and amitriptyline in treating neuropathic cancer pain.  All of these drugs clearly helped, with pregabalin probably the best. Aside from direct relief, these drugs resulted in lower doses of opiates being needed:

A review of gabapentin treatment for neuropathic pain, affirming its usefulness, particularly at higher doses of 1800-3600 mg per day: 

This is a negative review article, showing that lamotrigine is unfortunately not likely to be useful in treating chronic pain:

An interesting study showing that pregabalin can reduce postoperative morphine requirement acutely:

This is an example, and a review article, part of the large literature showing that topiramate is an agent of choice to prevent or treat recurrent or chronic migraine.  There is preliminary evidence at a case-report level that topiramate could help with other types of pain:

c) opiates, such as codeine or morphine -- outside of the scope of this posting.  These  may have a role in managing non-malignant chronic pain, but supervision is needed from someone with experience prescribing opiates, a pain clinic, etc. Long-acting opiates such as methadone are being used more often in acute or chronic non-malignant pain conditions.  Of course, there is a balance here between pain relief and addictive risk.

Here is a recent review, which basically affirms that the use of opiates for chronic non-cancer pain is an "iffy" practice, yet I do affirm that in some cases it may be necessary.  In any case I think that experienced and specialized prescribers, such as those at a pain clinic, would be highly preferred:

d) Atypical opiate:  tramadol.  This is an interesting drug, for various reasons, including that it has antidepressant activity as well as being a physical analgesic.  It is an opiate, but a significant portion of its analgesic properties come from non-opioid mechanisms, such as neurotransmitter reuptake inhibition.  It does a potential for addictive problems, but the risk is clearly less than other opiates.  For this reason, I think it is reasonable to think of using tramadol before using other opiates (such as codeine or morphine) in treating pain syndromes.   

Chronic CNS effects of tramadol differ from those of morphine, supporting the evidence that tramadol has a smaller risk of inducing opiate dependence/addiction:

Tramadol can be identified subjectively as having opiate-like effects, but mainly at higher doses:

Here are animal studies using a mouse model of depression, suggesting effectiveness of tramadol..  However, I would want to see longer-term studies of this sort, as the acute beneficial action of any therapy does not necessarily prove that the benefits will last, in fact many acutely beneficial things can become harmful if used long-term (e.g. benzodiazepines):

An animal study suggesting that tramadol and anticonvulsants (in this case, specifically topiramate) can work synergestically (cooperatively) in relieving neuropathic pain:

Treatment of refractory major depression with tramadol monotherapy:

Rapid remission of ocd with tramadol:

Restless legs treatment with tramadol:

Treating catalepsy with tramadol:

Tramadol dependence :  in general these articles show that tramadol dependence occurs, but is significantly less likely than with stronger opiates:

There is a risk of serotonin syndrome with tramadol, particularly if combined with other serotonergic drugs, such as SSRI antidepressants:

Other direct approaches to treat rumination:

Here is a study showing effectiveness using a modified form of cognitive therapy called  competitive memory training.  It basically involves teaching techniques to either accept, or become indifferent to, the themes of the rumination:

Here`s a similar recent study showing improved relief in chronic depression with a CBT style modified to target rumination: 

An interesting study from the psychology literature which shows that rumination is associated with a type of cognitive deficit involving reduced ability to manage negative material in working memory.  This suggests to me that cognitive exercises, ones which train working memory, could have a role in treating depression and rumination.  Conversely, it suggests to me that practicing ways of "letting go" such as via CBT or meditation, could improve working memory (by freeing working memory space of irrelevant, ruminative, or intrusive negative material), and therefore improve intellectual functioning, academic performance, etc.

Here's one of many articles discussing rumination as a risk factor for depressive relapse or chronicity.  Clearly, tactics to help manage or prevent rumination are very important in both acute treatment and in prevention:

Another article discussing the role of rumination as a sort of emotional amplifier, which causes "impaired down-regulation of negative feelings" -- thus preventing the maintenance of positivity or relationship health after a stressor.  Such a dynamic would be a recipe for life disappointments to consistently derail one's emotional life.  Once again, practicing ways to manage rumination directly could therefore help with emotional resilience, and prevent a recurrent depressive cycle:

In summary, there are a variety of ways to treat or manage chronic pain and rumination.  Rumination itself may be an important perpetuating factor in pain syndromes.  Due to the presence of many symptoms in such syndromes, affecting both physical and emotional domains, it is important to have a cohesive, integrated treatment plan.   There is a risk of having multiple sources of therapy, each of which targeting only part of the symptom complex, which potentially could complicate or confound efficient treatment efforts.  In physical pain, emotional pain, or rumination, it can be extremely valuable to practice ways of "letting go." 

Wednesday, July 27, 2011

Optimal Sleep Duration

The best study which examines the relationship between sleep duration and mortality risk was published in 2007 by Hublin et al in the journal Sleep.  Here's a link to the abstract:

It is part of the Finnish twin study, which followed over 20 000 twins over a 22 year period.  This is an extremely large cohort, and the study had very high response rates.  The analysis was thoughtful and comprehensive.  

They showed that mortality rates were lowest for those who sleep between 7 and 8 hours per day.  For those sleeping less than 7 hours per day, or more than 8, the mortality rates were about 20-25% higher.  The results were adjusted for the covariates of education, marital status, age, working status, BMI, social class, drinking behavior, physical activity, smoking, and life satisfaction.  Interestingly, and unexpectedly,  sleep quality was not shown to be associated with differences in mortality risk. 

The argument could be made that average sleep duration has a non-causal association with lower mortality.   That is, people who happen to be healthier in the first place are more likely to have average sleep length.  But another part of this analysis suggests that this is more than a non-causal association:  subjects who changed their sleep duration during the course of this 22 year follow-up also changed their mortality rate, after controlling for the measured confounding factors.  I suppose it could still be true that some other mortality-increasing factor was the cause of the sleep duration change, and not the other way around.

In conclusion, this data supports the commonly held belief that 7-8 hours of sleep per night is a desirable goal.  It may be that particular individuals have a different "set point" for optimal sleep, and for those individuals optimal health might result from more or less hours than this average.  Yet I do not actually see firm evidence of this in the research I've seen.

A 2010 meta-analysis supports the same conclusion: but I think the authors understate their findings.  In particular, while a lot of the data showing increased mortality in short sleepers defined short sleep to be under 7 hours, the authors state in their discussion that "consistently sleeping 6 to 8 h per night may therefore be optimal for health."  I think there is a significant difference between 6 and 7 hours, particularly due to pressures in the culture where many people are sleeping only 6 hours because of a busy schedule, while really needing 7 or 8. 

Knutson in 2007 published a good article showing that sleep deprivation causes impairments in glucose tolerance (similar to the changes which occur in the development of type II diabetes), and impairments in the hormones associated with appetite regulation:

Here's one of the articles in the literature showing that sleep deprivation leads to an increase in proinflammatory cytokines and abnormal immune activation:

I think it is especially true that if one has signs or symptoms related to sleep duration (e.g. feeling sleepy in the daytime after sleeping only 6 hours per night) then this could be taken as strong evidence that sleep duration should be increased up to the average (7-8 hours), if circumstances permit.

Patterns of sleeping long hours (above average) could be approached similarly, but of course if the reason for the long sleeping duration is medical illness or medication effects, etc. it would not be healthy to force oneself into a shorter (average) sleep regimen.  

Monday, June 27, 2011

Somatoform Disorders & CFS : a discussion

Somatoform disorders could be considered clusters or syndromes of physical symptoms which have a psychological cause.

Here are some examples:
1) somatization disorder -- a syndrome of multiple physical symptoms--typically pain symptoms-- which have a psychological cause
2) conversion disorder -- typically there is a complaint of  paralysis or loss of sensation (including blindness) despite an absence of neurological signs; the symptoms may be generated without conscious intent, but may be profoundly disabling.  With modern examination techniques and tests, these symptoms are easily demonstrated to be of non-neurological origin.
3) somatic delusions, in the context of psychotic depression or schizophreniform disorders.  These have a wide variety of manifestations, though are most commonly bizarre in nature.  Arguably, cases of somatization or conversion could be treated as somatic delusions.
4) somatic manifestations of anxiety -- this is extremely familiar to us all:  tremor, sweating, bowel problems, etc. can all occur as a direct obvious consequence of anxiety.  At times this physical component becomes the dominant feature, leading to behaviours intended to relieve the physical complaint, leading in turn to worsened avoidance, withdrawal, and exacerbation of the underlying problem. 

This whole subject requires a lot of care, in my opinion.  I believe that somatization is very common, and exists in a wide range of extremity--from minor symptoms to syndromes that can be almost totally disabling--yet it is also true that undiagnosed medical ailments of non-psychological origin can often be misdiagnosed as psychosomatic or somatoform. Therefore, thorough physical medical assessment and care is needed as a multidisciplinary strategy to manage these problems.   These types of problems do indeed tend to be handled poorly by the conventional medical system--either through excessive and harmful medical interventions (e.g. in Munchausen's Syndrome), or through the dismissive neglect of a frustrated caregiver.

I think it is fair to say--and an observation I certainly find consistently in my experience--that physical symptoms of any cause ALWAYS have a psychological component as well.  Often times, the psychological component is simple and direct:  recurrent migraine headaches, malignant chronic pain, recurrent seizures, etc. (among hundreds of different causes of physical symptoms) cause a disruption to daily life & function, and their unpredictable patterns can leave one in a nearly constant state of anxiety.   It can be hard to plan activities, time for relationships, work schedules, etc. when symptoms may come at any moment.  So there is obvious direct psychological stress.  This stress understandably can cause a feedback loop which may exacerbate the underlying medical condition.

Other times, I believe that the psychological effects of medical conditions can be more subtle or indirect.  Chronic conditions can come to have a lot of power to redefine one's sense of self, often in a way which pronounces one to be more disabled than the medical problems necessitate.   Some types of symptom clusters may be sufficiently common as to allow a community of fellow sufferers to form.  While this may permit the supportive care of a community, it may also consolidate or entrench the aspects of the phenomenon which have to do with identity.   The relief that one may find in a group of people experiencing something similar may sometimes be so compelling that entrenched factitious beliefs about disability are deepened, at the expense of therapeutic growth.

Some currently unexplained diagnostic entities, such as chronic fatigue syndrome (CFS),  may in some cases be examples of complex somatoform illness.  I acknowledge that in other cases--perhaps even in the majority--there may well be some as yet unexplained physical pathology driving the symptoms.    A physiologic disposition towards fatigue may cause a cascade of behavioural changes  (including withdrawal from activities), leading to a further cascade of cognitions about illness,   mood change (which can often present itself, for many people, in a further somatized set of symptoms), and perpetuating of underlying symptoms.  The worldwide network of fellow sufferers may lead to perpetuation of symptoms, rather than relief, because the group consolidates some of the beliefs and identity formation which individuals may have about the condition, and also may agitate against what is seen as a dismissive or ineffectual medical system.  The group dynamics may also foster the spread of various spurious alternative therapies, whose evidence base would often consist of glowing testimonial accounts rather than careful randomized data.  Factitious therapies could sometimes be quite effective for factitious illnesses, since the therapeutic effort would permit the sufferer a psychological opportunity to move away from the illness symptoms, and attribute the improvement to something external, rather than to psychological change.  Such is, in my opinion, the basis for most stories of so-called "faith healing" which have been around for millenia. 

It is helpful to have observed extreme examples of somatoform illness.  Case examples include individuals who have had recurrent factitious seizures (pseudoseizures), often leading to dangerous and harmfully inappropriate medical interventions.  Many persons with a history of pseudoseizures also have neurologically-based epilepsy as well:  somatized, factitious, or conversion symptoms often co-exist with their non-psychiatric counterparts.  Other case examples include situations where individuals are delusionally convinced that they are paralyzed (due to a conversion disorder) causing them to have lived in a wheelchair for years.  Such individuals often have networks of people in their lives who support them in their paralyzed role; such supporters often include physicians and other caregivers.  Yet, it has been an amazing experience for me to witness cases of this type--cases where there has never been any objective sign of neurologic disease, but where the impact of the problem has been extreme; if a very careful neuropsychiatric evaluation is done, with strongly structured psychiatric  and rehabilitative therapy, I have seen situations where a person experiencing paralysis is able to walk home after a hospital stay. 

But cases like these are inevitably complex.  If a person has lived in a certain way for years, the behaviours themselves, and the associated thoughts, become integrated into identity.   If you live as a paralyzed person for many years, it will not be so easy to get up and walk, even if you are neurologically healthy.  There are physical barriers, but obvious psychological and social ones as well.

I believe this is a theme which epitomizes our understanding of brain function:  repeated behaviour entrenches neural pathways.  If "illness behaviour" exists despite "no illness", the brain learns to function "as if" a physical injury were present.  It is just like language learning--with immersive experience over a course of months or years, the brain will speak the new language with ever greater fluency.  It is a difficult task for the brain to "unlearn" such experience.

But this suggests a therapeutic imperative:  for all cases of this type, immersive physical rehabilitation is necessary.  In every single case I have ever seen of severe conversion, for example, the cure required intensive, prolonged, structured involvement of physiotherapists, in addition to whatever medications (typically antidepressants and antipsychotics)  and psychotherapeutic work the person needed.

I believe this theme crosses over into the realm of ALL chronic disease, regardless of cause.  Management of chronic disability or chronic diseases is greatly assisted by physical rehabilitation.  In the language of narrative therapy, if we consider the illness or symptom to be like a negative character in our lives, that character is constantly telling us to do less and less--part of the therapy to challenge this is to find a structured and safe manner in which to do more and more, or to optimize our fitness so that we can do the most despite the limitations imposed by the disease.   

Another interesting modality of therapy for conversion, one which can illustrate very compellingly the existence of a structure of drives and defenses first suggested by Freud, is the so-called "amytal interview."  In the version I have seen, a patient with a conversion syndrome (following informed consent, of course) is given a dose of ritalin (which allows more amytal to be given without loss of consciousness), followed by intravenous sodium amytal (a barbiturate), with the supervision of an anesthetist in a well-equipped medical setting.  The dose is titrated just to the point before the patient loses consciousness.  The effect of the medication is to cause disinhibition.  In this condition, the psychological forces necessary to continue the conversion symptom are weakened, so for example a person describing paralysis of an arm can be guided to raise the paralyzed arm in the air, and flex it, etc.  This event can be videotaped.  When the effects of the drug wear off, the person may not remember the scene, but when presented with the video footage (of the non-paralyzed limb in action), the person's psychological defense of conversion will be substantially weakened.  As a result, often times a strong emotional reaction takes place, usually the overt emotions or affects consistent with a severe underlying depression which had previously shown itself through "paralysis."   In this way, "conversion" operates as a psychological defense, a way in which the brain deals emotionally or behaviourally with a painful symptom.  These defenses can be vital ways to survive in the world, but sometimes--as in conversion disorders--the defense system goes awry, and becomes the core problem.

A negative study on vitamin d supplementation
this 2011 randomized, controlled, prospective study from the British Journal of Psychiatry shows that vitamin d supplementation did not improve well-being in a group of over 1000 elderly women compared to a similar-sized control group.

This is a good study, with negative results.  I don't think it means that vitamin d is of no use, but rather that it cannot be assumed to have obvious positive effects for everyone.  Some of the effects measured in other vitamin d studies may be the result of non-causative associations (e.g. those with various healthier habits and health paramaters may be more likely to have higher vitamin d levels, but the vitamin d is not the cause of this healthiness, it results from it)

However, the data on this issue continues to evolve.  There is some good positive data on vitamin d as well, though not enough in terms of randomized, prospective studies.  It will be important, for example, to look at whether vitamin d could obviously be an effective adjunct to other therapies for treating depression.  Or whether vitamin d alone has little effect, unless combined with other positive factors.

Meanwhile, I still believe that the standard recommended daily dose of 400 IU for vitamin D is too low, and that 1000-2000 IU per day is better.

See my previous post on vitamin d,

Friday, May 13, 2011

Music Therapy

I believe that many creative modalities can be usefully included in a therapeutic relationship.    There are times when spoken dialog can be more difficult, unwelcome, inhibited, or even frankly unhelpful.  Other types of activities can be part of a therapeutic milieu, and work on non-verbal forms of communication, as well as other forms of positive experience in the therapeutic frame.

The use of music in therapy is well-established.  Music therapy is a recognized profession, with a substantial academic literature behind it.  I believe that music is under-utilized in therapy generally,  perhaps considered outside the scope of experience or training of most therapists.  Even therapists with a background interest in music may not share this with patients, for a variety of reasons.  The predominantly oral tradition of psychotherapy can be so dominant sometimes as to view non-verbal activities as eccentricity.

Music -- listening, performing, learning, and coordinating -- can touch upon the following therapeutic themes:
1) emotional expression
2) performance anxiety / communicative inhibition
3) perfectionism
4) assumptions about capacity or incapacity to learn something new
5) focusing on an activity which is sufficiently engaging as to calm anxiety or agitation, or at least distract attention away from negative emotions or unwelcome thoughts
6) enjoyment
7) a sense of achievement
8) patterning the same learning schedule which leads to psychological change or skill acquisition of any sort -- some immediate progress in the moment--which needs to be enjoyable in itself-- but part of a process which can include thousands of hours of experience to grow substantially
9) a sense of trust and "harmony" with the therapist; possibility a modality which makes the therapeutic relationship stronger
10) on a sort of psychodynamic or developmental level, music could be understood as one of the individual's first experiences of emotional soothing (from the mother humming or singing to her infant), a modality which precedes verbal language.  There might be deprivations or problems associated with this dynamic for some individuals, which could become a therapeutic theme if music was part of the frame of activities and discussion.
11) music preferences and interests are, of course, an element of identity expression.  I believe that questions about music preference and experience are a useful part of a psychiatric history; often an understanding about this part of a person immediately deepens understanding, and offers a chance to connect in different ways, to build rapport and interested collaboration.  

Many types of music therapy involve having the patient improvise on a simple instrument, etc., or perhaps listen to music.  I think that doing cooperative musical exercises can be a valuable element, in which the therapist can act partly as collaborator or music teacher.  The technical skill level is not relevant, in my opinion, and in fact could be considered a type of neutral transferential theme to be worked with in the therapy.  Simply practicing a simple technical exercise on an instrument--even during a conversation--could be a tactic to help attain calm and relaxation, in the same way that many other physical skills can be relaxing (e.g. knitting, swimming, yoga). 

Here is a review of some of the research literature on music therapy:
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.
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.
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.
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.
music therapy shown to be helpful to improve the rate of rehabilitation in brain injury or stroke
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.
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.
a discussion of the role of music in non-suicidal self-injury.

I think some music may itself be self-injurious, or at least a consistent cue associated with self-injury; but clearly there is therapeutic potential, for music to be helpful in affect regulation or as a healthy substitute behaviour instead of self-injuring.

I'm curious as to the manner in which musical lyrics or the emotional tone in music affects "self-talk" or inner emotional tone.  In a "Rogersian" sense, music with very depressive or hostile lyrical or tonal content may help a person to feel less alone--a type of empathic bond with the music--which may be therapeutic.  But I believe that such a bond is much more therapeutic if it leads to a sense of resolution of the underlying problems, or offers a consistent message of hope or joy despite whatever empathic connections are made with sadness, anger, emptiness, etc.  I think the greatest songs (present in all genres and eras) are those which suggest a resolution for problems of suffering or emotional pain, rather than simply evoking the negative emotion.

Tuesday, May 3, 2011

Alternative conceptions of "IQ"

Standard IQ tests measure a particular set of intellectual skills.  But this leads to a big question about what exactly is being measured.  The notion of "IQ" implies that the test is measuring an innate, relatively fixed intellectual capacity.

But consider the following analogies:

-Suppose reading skill in English was being tested.  Obviously, we could see that those who score very well in a test of rapid reading and comprehension would most likely be classified as more "intelligent."  Yet, the test would have massive potential sources of bias or inaccuracy.  Many people with excellent language skills would do poorly on an English reading test simply because of their lack of knowledge or experience with English.  Others with excellent minds might not have had much reading education or experience of any sort, therefore they would not have acquired the skill to read or comprehend written language quickly.

-If "athleticism" was being measured, suppose the test involved having subjects shoot free throws on a basketball court.  People who would score very highly on this test would most likely fit reasonably into a "high athleticism" category.  But many very athletic people would score poorly on this test, simply because they had very little experience shooting basketballs. If a  skill that was brand-new to all subjects was being tested one time (e.g. archery target practice), those who performed very well might well be more "athletic" but perhaps they had more experience in a similar type of skill in the past, or they just happen to be more calm with novel activities. 

Acquisition of skills is a process that grows over a period of hundreds or thousands of hours of experience.  If a test is measuring a skill, it may simply be measuring how many hours of experience that person has with a similar activity.    Of course, an intrinsic strength in something is more likely to lead to a person spending more time developing the strength -- talent leads to passionate commitment; it facilitates and makes enjoyable the thousands of hours of work

So, an IQ test may be measuring--to a significant degree--the number of hours of experience the subjects have with similar types of activities (e.g. memory tasks, logic puzzles, arithmetic, etc.).

On a related note,  recent findings have suggested that doing cognitive exercises such as brain-training video games does not really improve intellectual function significantly.  But--the manner in which this conclusion was reached was testing subjects before and after using tests that did not directly relate to the cognitive games which were being played.  Therefore, I believe the findings are spurious. 

Here is my thesis on this issue:

"Intelligence" could be understood not as an absolute quantity of a skill (since this quantity would depend mainly on how many hours of practice or experience the person has had, which arguably should be viewed independently from the concept of "intelligence" as an innate trait).  Rather, "intelligence" could be viewed as the RATE at which brand-new skills improve with a given period of practice.  For example, the amount of improvement after 10 hours of practice of a brand-new activity would be a much better measure of "athleticism" than simply measuring the absolute performance one time.   Even this type of measure would be influenced by a person's past experience:  for example, a person with thousands of hours of experience learning different languages would probably be able to learn a completely new language more quickly with 10 hours of practice, compared to someone with very little past experience of this sort.   The proviso that this be a "brand new" activity is important, because if a person has a very high level of expertise in a particular skill, then their rate of further improvement will be very low (since there is not much further improvement humanly possible).

So, for example, with athletic tests, it would seem a reasonable measure of "innate athleticism" to introduce a completely new sport or fitness activity, and to measure how quickly subjects could improve or master it with limited practice time.

Another complicating angle on this theme is that intellectual experience and focus in ANY area is likely to improve "innate intelligence."  If you have practiced music for 10 000 hours, you will probably have strengthened a variety of other "innate" intellectual capacities.  But this strengthening effect would not be obvious if measured conventionally.

Similarly, I suspect that "brain training" video games could have a significant effect of strengthening various intellectual capacities.  But this positive effect would not be captured well by simply repeating single "before" and "after" skills tests.  A much better measure would be the following:
1) "pre" test:  subjects would have to put in 10 hours of practice learning a game having to do with verbal memory.  The absolute scores, and the rate of improvement over the 10 hours, would be recorded.

2) Subjects would put in 100 hours of practice doing either a battery of memory-focused brain training games, or a "placebo" set of games not focusing on memory.

3) "post" test:  subjects would put in 10 hours of practice learning a completely new game having to do with verbal memory.  Once again, the absolute scores, and the rate of improvement, would be noted.

Here is my hypothesis about the findings of such an experiment:

1) The absolute scores at the beginning of  the "pre" and "post" tests would be quite similar.  This would be like testing the basketball skills of a group of volleyball players before and after volleyball training season.  You would not expect any difference.  This is the conventional type of assessment, which is bound to lead to the conclusion that there is no beneficial training effect.

2) What I would expect to be different is that the subjects who had done 100 hours of memory games would be able to much more rapidly IMPROVE their scores in the "post" test.  In the athletic analogy, a group of people who have spent the summer in volleyball training would be able to much more rapidly learn soccer skills, compared to a group who spent the summer watching TV, even though both groups might have very similar soccer skills at the beginning of a 10-hour training period.  

I believe my hypothesis is supported by observations of individuals acquiring expert skills, such as playing chess.  While the absolute number of hours practicing chess correlates directly with performance, there are some individuals who advance more rapidly with the same number of hours of practice.
(see the following reference:
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:
binge drinkers have double the rates of depression; reductions of drinking subsequently associated with reduced depressive symptoms.
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.
prospective study showing increased strokes and overall mortality in binge drinkers
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.
binge drinking a stronger predictor of social harms (e.g. violence, loss of relationships) than total alcohol volume
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).
another major prevalence study
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.
this study shows even higher binge drinking prevalences for college students; 40% of this population engaging in binge drinking in a one month period.
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.