Foolproof, by Sander van der Linden: a recommendation, review, and analogy with psychotherapy

I strongly recommend a new book by Cambridge psychologist Sander van der Linden, entitled Foolproof: why misinformation infects our minds and how to build immunity.

I have followed van der Linden's research for several years, alongside other experts who are studying the psychology of persuasion, misinformation, and propaganda.    This area has been an interest of mine for many years, after discovering psychologists such as Cialdini and Kahneman.  

This is a subject that everyone needs to learn about!  Persuasive techniques (for good and for bad) have always been with us through history; the power and influence of these techniques will only continue to escalate, thanks to the internet era, and now the era of artificial intelligence (AI).  

I have discussed these issues in other posts, such as:

 Garth Kroeker: How Minds Change by David McRaney: a book review and discussion (August 18, 2022)

and 

Garth Kroeker: Political polarization, propaganda, conspiracy theories, misinformation, and vaccine hesitancy: a psychiatric approach to understanding and management).  (September 1, 2021) 

and 

Garth Kroeker: "GroupThink" (October 6, 2016) 

Van der Linden reviews the history and scope of misinformation.  Among the many current examples are conspiracy theorists impacting public opinion and policy, political influencers attempting to sway elections, propagandists from other countries defending violent or oppressive policies or sowing discord among their opponents, and of course the anti-vaccine community.  

There are a couple of acronyms he introduces: the word CONSPIRE can help us to recognize some of the common features of conspiracy theories:  

C = contradictory.  Most conspiracy theories feature contradictions.  For example, there could be a belief that some awful event is a hoax, but then also a belief that the awful event is real but was caused by evil conspirators.  

O = over-riding suspicion.    A sense of general distrust that goes beyond the topic of the conspiracy theory, particularly a distrust of official or mainstream explanations.  

N = nefarious plot.  A belief that there is a shadowy group of evildoers, such as government officials, corporations, or (at worst) a particular racial or ethnic group, who behind the scenes have caused some bad thing, perhaps with a motive to advance themselves.  

S = "something's wrong."  The belief that regardless of any acknowledged or corrected fact about an event, there's something going on that isn't right.  

P = persecuted individual.  The belief that someone is being deliberately harmed (most commonly, the believers in the conspiracy theory).  

I = immune to evidence.  Presentations of evidence often have little or no effect to change the opinion of people having conspiracy theory beliefs, in fact evidence could even "backfire" and cause the conspiracy theorist to become even more entrenched, or to believe that you or your sources of evidence are all biased or part of the conspiracy.   Such immunity to evidence is common among people who have limited expertise or knowledge about science, but could also be present in some highly educated people.  A conspiracy theorist who does have more scholarly expertise may understandably deploy statistical or psychological terminology to defend their beliefs; for example, by accusing other scholars of having psychological biases (such as confirmation bias).

Re = reinterpreting randomness.  This is creating a false causal story about random, unrelated events.   Humans in general are prone to doing this.   

It's interesting as a psychiatrist to reflect on the "CONSPIRE" factors above.  They are very often present in frank psychotic states, or in milder variants such as paranoid personality.  The tendency to have paranoid thoughts exists as a trait on a continuum in the population.  This trait has various environmental causes, but also has a high heritability.   It is a typical psychotic symptom to believe that there is a special, often ominous explanation behind pseudorandom events.    

Of course, sometimes there are explanations for events which differ from the mainstream understanding.  Through history there have always been maverick scientists,  who demonstrated something new and important, despite the objections or condemnation of their peers.  One example that has always bothered me was Alfred Wegener, who in 1912 was the first to propose the theory of continental drift; he was ridiculed and dismissed by his peers, who couldn't believe that entire continents could move across the face of the earth; Wegener tragically died before his theory was proved correct.   We have to be open to consider alternative theories.  However, maverick scientists, unlike conspiracy theorists, have clear evidence to support their claims; their reasoning does not contain contradictions; they are not immune to evidence, do not reinterpret randomness, and do not have ominous, over-riding suspicious beliefs about persecution.  

Van der Linden's next acronym is "DEPICT", to help remember features of manipulative communication:

  

D - discrediting.  The manipulative communicator will portray experts who disagree with them (such as scientific leaders, or even entire communities such as leading scientific journals), as biased, poorly qualified, incompetent, or having some nefarious agenda.  It is frustrating to have a scientific debate with someone who is engaging in such discrediting, since any sound evidence you raise with them will be dismissed as invalid.  

E - emotional.  Using strong emotional language to induce fear, anger, or disgust as a persuasive tool.  

P - polarization.  Framing issues, and people who have positions on these issues, in a "black or white" fashion, rather than as shades of grey.  This leads to a false sense of dichotomy, and encourages the formation of teams of opponents holding increasingly extreme positions, and increasing disrespect for those who disagree. 

I - impersonation.  Using fake experts to bolster a claim.   A variant of this is using an actual expert, but whose expertise has nothing to do with the issue at hand.  

C - conspiracy theories.  Encouraging conspiracy theory beliefs. 

T - trolling.  Attacking, insulting, or threatening opponents, usually in an online environment, such as on social media.  Such harassment has at times been so intense that scientists or policy experts (including in public health) have been afraid to speak out, fearing for their safety.  

Van der Linden's work focuses on how we can best deal with misinformation.  He concludes with an analogy:  misinformation must be dealt with by "immunizing" ourselves against it.  

In order to build immunity against an infectious disease, it is necessary to be exposed to a weakened version of the pathogen, in order to train the immune system, such that future doses of pathogens would be dealt with quickly.  

Infectious diseases are much easier to manage, with much less risk of harm or spread, by building immunity, rather than by only relying on treatment after infection.   

Similarly, it is much harder to "treat" misinformation after the fact.  Tactics to "treat" misinformation would be debate, education, and careful review of evidence.  But many people who have fallen into a misinformation "rabbit hole" are difficult to reach or persuade using reasoned debate.  Such debate may even cause the misinformed person to become even more angry or stubbornly adherent to their ideas.    

It is better to prevent people from falling into the rabbit hole in the first place--not by eliminating rabbit holes (which is impossible) but by teaching people how to identify and manage rabbit holes if they encounter them.  

The idea of "vaccination" is presented as an analogy throughout the book.  But beliefs and persuasion are not exactly like the body's immune system.  It's a very good analogy, but not perfect.  Much of the phenomenon van der Linden is talking about is explainable through learning theory:   we learn much better if we actually practice "hands on" with things, rather than just passively absorbing theory.  If you want to learn mathematics, you actually have to work through a lot of problems, not just read about how to do them.  If you want to learn how to ride a bike or drive a car, you have to practice cycling and driving, not just read about those things in a book!  As part of the practice, it is best to face challenging situations, and learn through experience how to overcome them.  

Similarly, to deal with emergencies, it is imperative to do behavioural practice many times as a preparation.  We have to do fire drills to prepare for a potential fire.  Pilots need to practice many times in a simulator how to manage engine failure.  If you only read about something, or learn about something, without practicing, you can't possibly become proficient, especially under pressure.  

To deal with misinformation, we have to practice, hands-on, dealing with misinformation, at first with "easy" examples, then more and more difficult ones.  

Applying these ideas to psychotherapy: CBT (cognitive-behavioural therapy) is very important and useful, but at worst it can be too passive.  Many people engaging in CBT do a lot of passive learning, they do written exercises in a workbook, but do not really practice deliberate exposure to uncomfortable stimuli.  The "vaccine" analogy could be useful to incorporate into CBT for treating depression or anxiety.   This is something that I have advocated for many years, mainly an emphasis on the "B" part of CBT.  To deal with panic attacks, it is most helpful to actually practice having panic attacks, in safe, controlled conditions!   To deal with depressive thoughts, it could be a useful exercise to invent simulated depressive thoughts, at first mild ones, then more challenging ones, to understand the mechanism by which they are created, and to practice facing them without being negatively affected.   This exposure therapy is like van der Linden's "vaccine."  But most therapists don't emphasize this enough, they only try to teach people to relax or cope with symptoms after they have occurred.  One of the purposes of talking about past emotional trauma is to recreate the painful events in the mind, but in a limited, controlled, "virtual" form, within the safe context of a therapy office.  In this way talking therapy has a vaccine-like effect.  

Linden's book is a must-read, not only for those interested in propaganda or misinformation, but also for anyone wanting a better understanding of the mind itself, with ideas that touch upon managing almost any life adversity, including mental illnesses.  

References: 

Linden, S. V. D. (2023). Foolproof: Why Misinformation Infects Our Minds and How to Build Immunity. WW Norton.

Review: Shrinking Violets: The Secret Life of Shyness, by Joe Moran

 Joe Moran's book is a nice exploration of various historical figures (such as authors, poets, and musicians) who had what he calls "shyness."  Moran alludes to his own shyness as well.  

A thematic goal of the book is to understand shyness as a part of the tapestry and variety of human life, as opposed to a pathology that requires treatment, or that is even treatable at all.  

Moran is a good writer--he's an English professor, and it is always a delight to read a book in this type of genre written by someone with a mastery of the language.  

This book is interesting as a historical or biographical journey, but I found it quite limited as a serious study of shyness from a psychiatric point of view.  First of all, "shyness" is a very limited term to describe the many varieties of anxiety, introversion, personality styles, and autistic traits likely present in some of his case studies.  

Near the end of the book, Moran encourages a position of gentle acceptance of shyness, but this acceptance seems to disparage the potential value of attempting to help people manage or change their social anxiety or avoidance using therapeutic techniques.  One chapter is even called "The War Against Shyness," which is a pretty strong condemnation of the therapeutic culture.    

There are many shy people, who have what might be considered social anxiety or autistic traits, who might find therapy helpful, to improve social skills, to find ways of facing fears more comfortably, or even to reduce anxiety a notch (including with the help of medication).   We should always have modest or limited expectations of therapy; also we need to take care to affirm an accepting rather than a pathologizing stance, particularly when social behaviour and experience always exists on a spectrum.  Yet the best of modern therapy is affirming and accepting; it just helps people to suffer a little bit less, to help people have a little bit more freedom in their lives to do things they might find meaningful, enjoyable, or essential for survival or prosperity.  

Audio and Video recordings of Positive Affirmations

In my last post, I was discussing a technique of practicing exposure to recordings of upsetting thoughts.

This same idea can be applied to positive thoughts too!

I encourage you to collect ideas, quotations, and encouragements.  Write them down, and then make an audio or video recording, using your own voice.

Choose a time when you are feeling calm and comfortable.  Make your recording a type of message to yourself, a message of support and encouragement.

Your encouragements could be quotations from a cognitive therapy exercise, in which you were reasoning or problem solving in response to negative thoughts.  Or they could be passages from a gratitude journal, in which you express thanks for any positives in your life.  Or they could be things you might say to someone else who has struggled or suffered in the same way that you did.  Or they could simply be simple, kind encouragements directed towards yourself.  For example, you could record something like "You are a beautiful person, full of kindness, love, and potential.  The world needs you. Take care of yourself...whatever hard times you are having now will pass..."   If you make a video, smile at yourself, and gaze at yourself with loving, compassionate eyes.

After you make your recording, it would be something to listen to or watch frequently.

Unlike the exposure therapy exercise, the goal here would not be to face a fear and strengthen yourself against it, but rather the goal would be to practice absorbing and accepting the positive messages.  If you listen to a piece of music frequently, the tune will eventually "play itself" in your mind, and your memory for this music will become more and more effortless.  Similarly, these positive recorded messages could become more naturally integrated into your memory.

I think that hearing your own voice, and seeing your own image, are more powerful influences on your mind and your thinking, compared to only working with your ideas using written text.  Hearing yourself speak is much more like experiencing your own thoughts, compared to reading your own written words.

Exposure Therapy for Worries, Intrusive Thoughts, Ruminations, and Obsessions

Worries, ruminations, intrusive thoughts, and obsessional thoughts can be a terrible source of suffering.  If they are mild or infrequent, they can be part of a healthy, balanced life.  But when they are occurring frequently, they interfere with all of our activities.  They make it hard to enjoy anything.  A beautiful walk in the forest is interrupted by upsetting thoughts about daily stresses, or about painful events that happened long ago.  Attempts to work or study are interrupted constantly, preventing you from getting things done, and certainly preventing you from enjoying what you are doing.  If the intrusive thoughts have to do with past traumatic events, it is as if these terrible events are happening to you all over again.

In this post, I am exploring a challenging approach to this.  But I know that in many cases upsetting thoughts cause extreme pain and suffering, and therefore any therapeutic approach must be considered with very great care.  The approach I am proposing may not be right for you, unless you feel very well-prepared for work that could be difficult.   With any therapeutic approach, you must feel entirely in control of the therapeutic process.  You must never be pushed into any sort of therapy, even by a well-meaning therapist whom you trust entirely.  Sometimes the framework of therapy implies that you should be doing certain types of work.  Just coming to a therapy appointment can implicitly push you into engaging with certain therapeutic tasks, such as sharing a painful story about your past.  

But I believe it is of the greatest importance to be guided entirely by your own will, with any therapeutic task.   

Upsetting thoughts are problems in which an event is happening outside of your own will.  Past traumatic events also have happened against your will.  So it would be wrong to engage in a therapeutic effort, unless you are very clearly in agreement with it, and you are engaging in each step with the full force of your will and consent.

I am also aware that many therapeutic ideas can seem too focused on some particular "technique."  Sometimes we can focus too much on "technique" in such a way that we are distracted from the larger picture.  In the big picture, I believe that healing forces include gentle self-care, empathy, healthy lifestyle, and loving relationships.  So, regardless of whatever "techniques" you try, be careful to remember that the "big picture" factors are the most important of all.

But let's get started on looking at some "techniques," with these limitations in mind:

What strategies or techniques can help to manage anxious thoughts, worries, or ruminations?


The Problem with Relaxation Techniques

Most people, including therapists, focus on techniques to help calm the mind.  These could include relaxation or meditation techniques.  Most of us would also encourage healthy distraction techniques, such as trying to read a book, listen to music, "breathe," go for a walk, talk to a friend, have a bath, etc.  Many medication treatments also focus on relaxation.  Benzodiazepines, including lorazepam (Ativan), clonazepam (Clonopin), alprazolam (Xanax), or diazepam (Valium), often literally calm the mind, slow down racing thoughts, and reduce the distress caused by rumination or worry.

But the problem with these approaches is that they are primarily avoidance-based, rather than strength-based.

Analogously, if you are very fearful about swimming, it will absolutely relieve your anxiety if you distract yourself, meditate, read a book, or take a sedative, whenever you are close to a swimming pool--but, of course, these techniques will not help you to cure your anxiety!  The only cure must involve deliberately approaching the water, and gradually facing your fear!

In many cases, relaxation therapy (especially if it is the only approach used) can make underlying anxiety worse, because it consolidates the notion that the anxiety is intolerable and must be avoided.

Exposure-Based Techniques

Over the years, I have become more and more a fan of behavioural therapy ideas, for approaching a wide variety of psychological symptoms.  I believe that this approach is strength-based, and is similar to having a physical fitness regime, or a structured program of learning a new skill (such as speaking a new language, playing a new sport, enjoying a new hobby, or playing a new musical instrument).

To treat a phobia about swimming, it is easy to prescribe a behavioural therapy program.  The first step might be to just watch people swim, while you sit in the bleachers.  The next step could be sitting at the side of the pool, with your feet in the water.  Eventually you might walk in the shallow end of the pool.  This could build up to putting your head under the water, learning to float, etc.  Eventually, with practice, you could be swimming laps in the deep end (maybe with the help of a swim teacher).

But how could we devise a plan to treat anxious thoughts or ruminations, using this type of approach?

An idea I have been working with is to encourage patients to make a detailed record of anxious thoughts or ruminations.  Try to "catch" the thoughts verbatim -- as though you are taking dictation, or using quotation marks.  Then make an audio or video recording, of yourself reading these thoughts aloud, in a way which mimics as closely as possible the way in which the thoughts occur in your mind.    The recording then becomes something to practice listening to...the task is to sit calmly with your thoughts.  If anxiety comes as you listen, let it come.  Consider it a type of "workout" to face a difficult task.

As with other types of workouts, it is important to plan the duration and intensity so that it is challenging but not overwhelming.  It can't be too easy -- otherwise there would be no training or strengthening effect.  But it can't be too hard -- otherwise you could injure yourself, or just have an unpleasant experience that would discourage you from working out again.

With exposure to recordings of anxiety thoughts, you can adjust the intensity in a number of ways (this is analogous to adjusting the weights in the gym).  Here are three ways to adjust the intensity or difficulty:
1) just turn the volume of the recording down.
2) listen to the recording for very short periods of time, and gradually increase the duration as tolerated.
3) listen to recordings of thoughts which are less upsetting.  As you feel able, you can introduce more difficult or challenging thoughts.  
   

There are various phenomena that can happen which reduce the effectiveness of this technique.  The mind has strong reflexes to manage anxiety using avoidance.  When dealing with worries or intrusive thoughts, it is very common to want to respond to these thoughts by trying to reason with them, reassure yourself, problem-solve, or distract yourself in various ways.  With this technique, it is important to simply let the thoughts come, let the ensuing anxiety happen, without trying trying to reassure, problem-solve, or distract.

I am not saying that problem-solving is unhealthy!  Of course, problem-solving and reassurance are very important!  But not if they occur during this type of exercise!  Analogously, if you are lifting weights in the gym, you could roll the weight upwards using a ramp, instead of lifting it directly!  This would be using clever problem-solving to bring the weight to a higher point!  But you would not get stronger if you used the ramp!  Or you could use a flotation device in the pool...this would be a good solution to help you float safely.  But it would not help you to swim better, or to master your anxiety of deep water!

Another type of technique used commonly for managing worrying and rumination is "thought stopping."  There has been some research supporting it.  This would appear to be an avoidant technique.  But according to one analysis, the reason that thought stopping can sometimes appear to work is because the exercise often first calls for people to deliberately induce anxious thoughts!  Only after a period of exposure to the anxious thoughts do people then use a thought-stopping technique.  At this point, often the thoughts which are "stopped" are not the anxious thoughts themselves, but rather the compulsive self-reassurances or problem-solving attempts.  Therefore the thought-stopping is actually favouring a better anxiety exposure exercise!

Summary of the Technique

1) make a detailed list of anxious thoughts, to replicate as closely as possible how they occur in your mind
2) make a recording, in which you read these thoughts out loud
3) listen to the recording, as a type of psychological "workout"
4) adjust the volume, duration, and content of the recordings, so that it is moderately difficult for you, but not overwhelming.  Aim for an experience of "mastery" just as you would when you are lifting weights successfully at the gym, or when you are doing some other type of exercise
5) While you are listening, you could attempt to do other tasks that you normally would like to do, such as studying.  But work hard not to engage in "avoidance" behaviours such as distraction, reassurance, or even relaxation techniques
6) You could aim for about 20 minutes at a time...but you might need to start with much shorter durations, such as a few seconds, if you are very sensitive.  Once again, it is like starting to do a new exercise such as running...you may need to begin with running just a few steps, and then building up to longer distances as you get stronger.
7) After each exercise, you could then do some relaxation or other pleasant activities...just like soaking in the hot tub after a workout at the pool or gym...
8) Pay attention to how you feel in the next few days.  Just like workouts at the gym, you might feel "sore" in some ways.  Sometimes you might have more upsetting thoughts or nightmares, and feel worse.  If this is the case, you may need to make the next "workout" easier.
9) You may need to have a guide (such as a trusted therapist) to help you with this.  The role of the therapist, with respect to this technique, would be like a "personal trainer" at the gym--the therapist would be there to support you, encourage you, and help you with any problems along the way.
10) Sometimes a particular technique, such as this one,  may not be right for you.  If this is the case for you, remind yourself that it is not a sign of "failure."  It is just a sign that a different strategy is needed for now.  You might come back to a technique like this at a later time, or you may find other techniques that suit you better.


Is there still a role for Relaxation Techniques? 

To carry the fitness analogy further, I think most of us like to relax during part of our physical workouts.  Before or after our exercise, we might like to stretch, warm up, cool down, or relax in a hot-tub or sauna.  This could add to the enjoyment of the workout, and possibly even reduce the chance of injuries.

With an exposure-based anxiety management technique, perhaps some relaxation-oriented ideas could be used before or afterwards, in the same way.  It could help make your work a little bit more enjoyable, part of a pleasant routine.  It would just be important that your relaxation technique does not cause you to indulge in some kind of compulsive pattern that could contradict the work you were doing.

How other techniques already use this idea

In mindfulness-style meditation, the strategy is not to "empty your mind" or to prevent anxious thoughts.  The goal in mindfulness is acceptance and practicing attention without excessive reaction to sensations, feelings, or thoughts.   Worries or intrusive thoughts are viewed as clouds drifting through the sky of your consciousness, rather than attackers which need to be confronted.  Therefore, a person practicing mindfulness is also practicing being with the upsetting thoughts, rather than avoiding them.

In EMDR, various upsetting thoughts or memories can be contemplated while doing a physical activity.  In this way, arguably, the eye movements have a catalytic role to allow exposure practice to occur in a framework which feels therapeutic and well-boundaried.  A weakness in this technique, and possibly a reason that EMDR may work better with some therapists or clients than others, is that the eye movement activity could in some cases be an excessive distraction, and therefore dilute the effectiveness of the other therapeutic work.  But I think that provided this potential problem could be addressed, EMDR techniques could help a client and therapist adjust the intensity of a therapeutic session, analogous to adjusting the difficulty of a physical workout.

In conventional CBT, the initial phase of paying attention to upsetting thoughts, and recording them, is already a type of "exposure."  The act of writing something down can often require a strong act of will, and carry powerful symbolic value.  But a problem with cognitive therapy can sometimes be that the thought records become distractions, foster rumination, or lead to excessive debate or intellectual argument about thoughts.  

In psychodynamic styles of therapy, the experience of freely discussing painful thoughts and memories also involves exposure to the strong emotions associated with them.  Sometimes, in this style, the therapist's quiet presence is not directly "reassuring."  Rather, the therapist has a quiet role of facilitating exploration without a need for direct reassurance or problem-solving.  But a problem with psychodynamic styles has to do with its passivity--there is a lot of focus on exploration and "interpretation" but often not enough focus on strength and practical, immediate, active mastery of symptoms.   The preoccupation, in psychodynamic therapies, of searching for remote causation of symptoms, can distract clients or patients from working on strategies to master their anxiety in the present moment.  

Limitations

For many people, intrusive thoughts are occurring so frequently and intensely that it is hard to recommend deliberate exposure to even more upsetting thoughts.  It would be like recommending a demanding physical workout to someone who is exhausted or injured from a grueling daily routine of hard labour.    In these situations, it may be important to look at other techniques, including more of a focus on relaxation, or on medication, to help reach a state of calm restfulness, before beginning an exposure-based strategy.

If there is a history of psychosis or mania, then there would have to be a lot of caution about using this type of technique.  But I would not rule it out entirely...there is more and more evidence about CBT-style ideas being useful in managing psychosis.

If negative thoughts are part of a volatile pattern leading to dangerous behaviours, including suicide attempts, self-injury, destructive bouts of anger, or severe dissociation, then very great care would have to be taken to make sure that this type of technique was used in an especially slow, cautious manner if at all.  There might have to be some preparatory steps to make sure that the situation was safe and stable enough to proceed.  This is again similar to recommending a physical exercise routine to someone:  it is important to make sure that a person does not have joint problems, heart disease, etc. which could make the exercise dangerous.

In some types of depression, a person can feel self-destructive.  With this technique, excessive exposure to the content of upsetting thoughts could be self-injurious.  Self-destructive behaviour would need to be addressed first, in order to allow a technique such as this one to be safe and helpful.  
One of the most important things, with any type of therapy, but especially with a process such as this, is to frequently emphasize that it is completely up to the client or patient to engage with the technique or not.  The therapist must never push this.  The client must feel completely free to stop the technique at any time, without any concern that the therapist would somehow be disappointed or disapproving.


The Role of Medication

A goal of medications is usually to reduce anxiety directly.  But I think it is important to think of effective medication as a "catalyst" rather than a direct "cure."   Medication may reduce the severity of the underlying problem, so that other types of therapeutic work could take place more effectively. The effect of medication could be analogous to reducing the weights in the gym, or to using a flotation device to help you practice kicking in the swimming pool.    Without medication, sometimes the symptoms could be so severe that it is much more difficult or painful to do the therapeutic work.  It would be like going to a gym where the only barbells available had 200 pounds or more on them!

Some medication can also theoretically improve sleep or restfulness, and therefore allow you to do better and more enjoyable therapeutic work the next day, when you will feel more rested.  In other cases, medication could help with energy, allowing you to become more actively involved in all therapeutic tasks.  

Another dynamic in PTSD can be that uncomfortable experience is too quickly assimilated--perhaps via the amygdala--into a strong, aversive "emotional memory."  Past trauma, in combination with inherited factors, can make this type of neural pathway hypersensitive.  Arguably, some medications, including beta-blockers and other adrenergic antagonists,  could reduce the intensity of this reflex.   This would be analogous to a person with arthritis using an anti-inflammatory medication before doing physical exercise--the medication would allow the exercise to occur more comfortably, and with a lower chance of injury.     But I have to admit that it can be hard to find medications that are consistently helpful for this type of problem...I do think it is good to have an open mind about trying different approaches.


Conclusion

Upsetting thoughts can be a difficult problem, but I encourage patient, gentle persistence in a search for relief.  Remember the big picture, of patient, gentle self-care, healthy lifestyle, and nurturing loving relationships.

I do invite you to consider the possibility of finding ways to approach upsetting thoughts in a way which seems paradoxical--by finding a way to face them directly, and to practice having the thoughts rather than practicing ways to get rid of them.  This practice is not meant to be masochistic, but rather is meant to build a strength inside of you, so that the bully-like emotional effect of upsetting thoughts is gradually weakened as your strength improves.

References

There are not enough research studies done regarding approaches to rumination, primary obsessions, and other intrusive thoughts...but a similar exposure-based idea is described by  Salkovskis & Westbrook (1989).  I will look for other articles to expand my list of references later.

Salkovskis, P. M., & Westbrook, D. (1989). Behaviour therapy and obsessional ruminations: can failure be turned into success?. Behaviour research and therapy, 27(2), 149-160.

Quetiapine for non-psychotic depression and anxiety

I read a recent review last week which warned against the use of quetiapine for treating non-psychotic mood disorders.

Yet, I believe there are a number of reasons to consider quetiapine and similar medications for non-psychotic states:

1) there is a much lower risk of the medication causing mania or psychosis.  With antidepressants, there is always the risk of mania induction.  Quetiapine not only would not cause mania, it could protect against it.

2) the use of quetiapine could reduce the likelihood of other sedatives, such as benzodiazepines, being used as often.  Benzodiazepine dependence is very common.  Quetiapine is less "addictive."

3) the doses of quetiapine in non-psychotic states can often be very low (under 100 mg) causing a much lower risk of metabolic side-effects than full doses of 400-600 mg per day or more.

What about research evidence?

Mezhebovsky et al (2013) published results of a multi-centre study involving about 450 elderly patients, showing that quetiapine 50-300 mg (mean = 168 mg) daily for 11 weeks, led to significant improvements in generalized anxiety symptoms, compared to placebo.
( http://www.ncbi.nlm.nih.gov/pubmed/23070803  )
 As with most effective treatments, the medication group had about twice as much improvement as the placebo group.  It is true that sleep improvement could account for a significant proportion of the overall symptom score improvement, but there was also improvement in the other symptom domains.   There were no major metabolic side effect problems in the quetiapine group.  The most common side effect was somnolence (sleepiness).

A 2012 review by Sanford and Keating ( http://www.ncbi.nlm.nih.gov/pubmed/22519923 ) showed an abundance of evidence that quetiapine is beneficial for treating bipolar depression (typically at doses of 300 mg/day) and for preventing recurrences of any mood episode.  For those who benefit acutely from quetiapine, there is evidence that it is a more effective mood stabilizer--on its own--than lithium. 


In unipolar depression, quetiapine would be most commonly used when a standard treatment such as an antidepressant was not working well.  In a study by El-Khalili et al (2010), quetiapine up to 300 mg per day was added as an adjunct to previous therapy for non-remitting depression:
( http://www.ncbi.nlm.nih.gov/pubmed/20175941).  They showed a modest benefit of adding the quetiapine, particularly at a higher dose of 300 mg/d.    A nice component of this article is the inclusion of symptom subtypes.   Many critics would argue that quetiapine might simply be sedating, and improve sleep, leading to most of its benefit over placebo.  These results confirm that quetiapine improves sleep symptoms.  But there were also symptom improvements in other categories, such as pessimism, inner tension,  and concentration impairment.

In conclusion, I think that quetiapine deserves to be considered as a medication option for non-psychotic conditions.   In many cases, there are comorbidities or diagnostic uncertainties, in cases of depression.  Many studies exclude patients who have comorbidities, or who do not neatly fit into diagnostic categories.   Quetiapine is unlikely to worsen comorbid conditions, and may be beneficial for many.  This makes it a safe option to think about if there is uncertainty or complexity in the diagnosis.  Standard antidepressants in this situation may carry a higher risk of causing new problems, including agitation or a manic state.

 The risks of metabolic side effects, etc. need to be watched for carefully, with consideration of stopping or changing the plan if problems of this type arise. 

N-acetylcysteine for OCD

I've written a post about N-acetylcysteine before (http://garthkroeker.blogspot.ca/2009/09/n-acetylcysteine-for-treatment-of.html), which suggested that it could be useful in treating compulsive behaviour disorders such as skin-picking. 

A recent 2012 study by Afshar et al. has shown that NAC is useful for treating obsessive-compulsive disorder (OCD).  Here's the reference: http://www.ncbi.nlm.nih.gov/pubmed/23131885

In this study, 48 patients with OCD who had not responded to an SSRI were given NAC up to 2400 mg/day or placebo, in addition to a continued dose of the same SSRI, for 12 weeks. 

The NAC group had about a 40% reduction in YBOCS score (a quantitative measure of OCD symptoms) after 12 weeks, compared to a 20% reduction in the placebo group.  This is a good, clinically relevant symptom change especially for a treatment-resistant group. 

Mild gastrointestinal complaints were more common in the NAC group, but there was not a big difference in drop-out rates between placebo and NAC. 

NAC works as as a glutamate-modulating agent, with possible anti-inflammatory effects.  It is metabolized to the amino acid cystine after entering the brain. 

So it appears that NAC could be a simple, low-risk, effective adjunct, or even a primary treatment modality, for obsessive-compulsive disorder. 

I would be curious to see more research looking at NAC for other anxiety disorders, or for ruminative depression. 

Long-term clonazepam for panic disorder

The treatment of anxiety disorders, particularly panic disorder, should emphasize behavioural and cognitive therapy, exercise, lifestyle factors, etc. 

But medication treatments can often be very helpful if these other therapies are not helping.  The trend of thinking on this matter over the past few decades has been to preferentially use SSRI antidepressants, and to minimize the use of benzodiazepines such as clonazepam, due to concerns about side effects and dependence. 

This study challenges that notion:  http://www.ncbi.nlm.nih.gov/pubmed/22198456   It is a 3 year followup study (an excellent duration for a psychiatric study!) -- and compares paroxetine 40 mg/d with clonazepam 2 mg/d (all doses taken at bedtime) for treatment of panic disorder. 

The clonazepam alone group did very similarly well to the paroxetine group, with even a slight edge of superiority over paroxetine.  And there were fewer side effect complaints in the clonazepam group compared to paroxetine.  There was no advantage to combined therapy (clonazepam + paroxetine). 

While I still remain concerned about dependency and abuse problems with benzodiazepines, this type of study affirms that long-term benzodiazepine use may be helpful--and possibly superior to antidepressants--for some patients. 

How long does it take for psychotherapy to work?

There are various research articles done in the past which describe rates of change in psychotherapy patients, some studies for example describing a plateau after about 25 sessions or so.  I find these studies very weak, because of the multitude of confounding factors:  severity and chronicity are obvious variables, also the type of follow-up assessments done.

In the CBT literature, a typical trial of therapy is perhaps 16-20 sessions.

In light of our evolving knowledge of neuroplasticity, and our breadth of understanding about education & learning, it seems to me that the most important variable of all is the amount of focused, deliberate practice time spent in a therapeutic activity.  Oddly, most psychotherapy studies--even CBT studies--do not look at how many hours of practice patients have done in-between therapy appointments.  This would be like looking at the progress of music students based on how many lessons they get, without taking into account how much they practice during the week. 

I have often compared psychological symptom change to the changes which occur, for example, with language learning or with learning a musical instrument.

So, I believe that a reasonable estimate of the amount of time required in psychotherapy depends on what one is trying to accomplish:

-Some types of therapeutic problems might be resolved with a few hours of work, or with a single feedback session with a therapist.  This would be akin to a musician with some kind of technical problem who needs just some clear instruction about a few techniques or exercises to practice.  Or it might be akin to a person who is already fluent in a foreign language, but needs a few tips from a local speaker about idioms, or perhaps some help with editing or grammar in a written text.

-Many more therapeutic problems could improve with perhaps 100 hours of work.  This would be like learning to swim or skate competently if you have never done these activities before.  Regular lessons ("therapy") would most likely speed up your rate of progress substantially.   But most of those 100 hours would be practice on your own, unless you're okay with the progress taking place over a year or more.   With the language analogy, think of how fluent you might become in a foreign language with 100 hours of focused, deliberate practice.  For most of us, this would lead to an ability to have a very simple conversational exchange, perhaps to get around in the most basic way in another country.  

-A much larger change is possible with 1000 hours of work:  with music, one could become quite fluent but probably not an expert.  With a foreign language, comfortable fluency would probably be possible, though probably still with an accent and a preference for the old language.
 
-With 5000-10000 hours of work (this is several hours per day over a decade or more) one could become an expert at a skill or a language in most cases.  

In psychotherapy, another confound though is whether the times in-between "practice sessions" lead to a regression of learning.  An educational analogy would be of practicing math exercises an hour per day with a good teacher, but then practicing another 8 hours a day with another teacher whose methods contradict the first.  Often times, learning will still take place with this paradigm, but it might be much less efficient.    Persistent mental habits, in the context of mental illnesses, can be akin to the "second teacher" in this metaphor, and unfortunately they do tend to plague people for many hours per day.

This reminds me of the evolving evidence about stroke rehabilitation & neuroplasticity:  substantial brain change can happen in as short a time as 16 days--but it requires very strict inhibition or constraint of the pathways which obstruct rehabilitation. (note: 16 days of continuous "immersion" = 16*24 = 384 hours!)  In stroke rehabilitation, the neuroplasticity effect is much more pronounced if the unaffected limb is restrained, compelling the brain to optimize improvement in function of the afflicted limb.  Here is a recent reference showing rapid brain changes following limb immobilization: http://www.ncbi.nlm.nih.gov/pubmed/22249495

In conclusion, I believe that it is important to have a clear idea about how much time and deliberate, focused effort are needed to change psychological symptoms or problems through therapeutic activities.  A little bit of meaningful change could happen with just a few hours of work.  In most cases, 100 hours is needed simply to get started with a new skill.  1000 hours is needed to become fluent.  And 5000-10000 hours is needed to master something.  These times would be much longer still if the periods between practice sessions are regressive.  In the case of addictions, eating disorders, self-harm,  or OCD, for example, relapses or even fantasies about relapse will substantially prolong the time it takes for any therapeutic effort to help.  Of course, it is the nature of these problems to have relapses, or fantasies about relapse--so one should let go of the temptation to feel guilty if there are relapses.   But if one is struggling with an addictive problem of this sort, it may help to remind oneself that the brain can change very substantially if one can hold onto to quite a strict behavioural pattern for the hundreds or thousands of hours which are needed.

As a visual reminder of this process, start with an empty transparent bottle, which can hold 250-500 mLof liquid (1-2 cups), and which can be tightly sealed with a small cap.  Add one drop of water every time you invest one hour of focused, deliberate therapeutic work.   The amount of time you need to spend in therapy depends on your goal.  If the goal is total mastery--then you must fill the entire bottle.  If simple competence in a new skill is an adequate goal, then you must fill just the cap of the bottle.  If there are activities in your day which contradict the therapeutic work, it would be like a little bit of water leaking out of your bottle.  So you must also attend to repairing any "leaks."  But every hour of your effort counts towards your growth.

Piracetam

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:


http://www.ncbi.nlm.nih.gov/pubmed/16007238  -- a 2005 review

http://www.ncbi.nlm.nih.gov/pubmed/1794001  -- a 1991 review looking specifically at its use  in treating  dementia; the data is really not impressive at all for dementia treatment.  

http://www.ncbi.nlm.nih.gov/pubmed/11084917  -- 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). 


http://www.ncbi.nlm.nih.gov/pubmed/8914096  -- 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). 


http://www.ncbi.nlm.nih.gov/pubmed/11346373 -- 2001 study from Archives of Neurology again affirming that piracetam is effective over 12 months of follow-up for treating myoclonic epilepsy. 

http://www.ncbi.nlm.nih.gov/pubmed/10796585 -- this 2000 Cochrane review stated that the data on piracetam are inconclusive, with studies not being of good quality


http://www.ncbi.nlm.nih.gov/pubmed/10338110 - 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. 

http://www.ncbi.nlm.nih.gov/pubmed/17685739  -- 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.


http://www.ncbi.nlm.nih.gov/pubmed/10338108  -- 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.


http://www.ncbi.nlm.nih.gov/pubmed/8061686  -- this is a broad review of nootropics, published in 1994.


http://www.ncbi.nlm.nih.gov/pubmed/3305591  -- 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.

http://www.ncbi.nlm.nih.gov/pubmed/12394531
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. 


http://www.ncbi.nlm.nih.gov/pubmed/16878489
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. 

http://www.ncbi.nlm.nih.gov/pubmed/12809069
a Hungarian study describing successful use of piracetam to treat alcohol withdrawal delirium

http://www.ncbi.nlm.nih.gov/pubmed/7906672
a 1993 Indian study showing that piracetam has anti-anxiety effects when administered on a longer-term basis in rats.  


http://www.ncbi.nlm.nih.gov/pubmed/95599
a 1979 article from Journal of Affective Disorders describing anti-anxiety effects from piracetam similar to a benzodiazepine, but without sedation.


http://www.ncbi.nlm.nih.gov/pubmed/6415738
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.

http://www.ncbi.nlm.nih.gov/pubmed/360232
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.

http://www.ncbi.nlm.nih.gov/pubmed/11687079
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. 

http://www.ncbi.nlm.nih.gov/pubmed/6128331
this 1982 study shows that 40 g of IV piracetam caused greater reduction than placebo in antipsychotic-induced Parkinsonian side-effects.



http://www.ncbi.nlm.nih.gov/pubmed/488520
a small 1979 study which showed that refractory depressed patients improved with the addition  of 2.4 g piracetam. 



http://www.ncbi.nlm.nih.gov/pubmed/10338106
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: http://garthkroeker.blogspot.com/2011/08/chronic-pain-rumination.html).  Here's another link about this: http://www.ncbi.nlm.nih.gov/pubmed/21742932)

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.

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.

Writing about worries can ease exam anxiety

Here's another simple research finding, published recently in Science by Sian Beilock:  students who spent ten minutes--immediately before a test--writing down their thoughts about what was causing them fear, performed substantially better on the test.


http://www.ncbi.nlm.nih.gov/pubmed/21233387


I'll have to review this paper in more detail to comment further, but I think it is another simple anxiety-management tactic for exam or performance preparation.  A frantic review or a frantic bout of anxious rumination right before an exam is unlikely to help -- an anxiety-management exercise such as expressive writing is very much more likely to help, and a study like this is strong evidence of this.

The article shows that the effective action was specifically to write about negative thoughts and feelings during the ten minutes before the beginning of a stressful exam.  A control activity--of writing about anything that comes to mind--was not effective.   So the effectiveness of this technique was not simply due to distraction. 

I would be interested to see the authors' opinions and/or research about whether specific journaling techniques could work particularly well, or less well, in various anxiety scenarios.  Sometimes, purely "negative" journaling can end up being a somewhat ruminative activity which entrenches negative emotional states and attitudes (e.g. one can get worked up in a cynical, pessimistic rant, which could increase or magnify one's following cynicism or pessimism, or increase one's filtered attention to negative events in the day).
See the following references:
http://www.ncbi.nlm.nih.gov/pubmed/12173682 
http://www.ncbi.nlm.nih.gov/pubmed/17120515
   A "balanced" journaling style, which includes room for free discussion of thoughts and feelings, but also room for positively-focused or constructive discussion may prevent this risk of snowballing rumination or negativity from a journaling activity.   One simple aspect of this experiment was that the journaling was immediately before a performance, and was very time-limited (10 minutes); these factors may reduce the potential for the journaling to be a negative or ruminative behaviour, and may increase the chance of the activity serving to process anxious emotion effectively.

Antidepressant + CBT superior to either treatment alone for treating social anxiety

Blanco et al. published this study in the March 2010 issue of Archives of General Psychiatry.  Here's a link to the abstract:
http://www.ncbi.nlm.nih.gov/pubmed/20194829 

Patients with social anxiety were divided into four groups in this randomized prospective 24-week study:  placebo; cognitive behavioural group therapy; phenelzine medication; combined CBT + phenelzine.

CBT was modestly effective, phenelzine only slight more effective, but the combination of CBT + medication was substantially more effective, more or less additively so, particularly in terms of total remission rates.  There was a very low placebo response.

Findings of this type are not surprising.   An interesting aspect to this particular study is that it makes use of phenelzine, an old MAO inhibitor.  This shows that sometimes these old drugs can still be quite useful.

This study does not necessarily demonstrate that CBT is the only form of psychotherapy which would work adjunctively to help social anxiety.  I do think that components of CBT, such as emphasizing exposure to anxiety-provoking situations, and practicing social initiatives in a systematic way, are necessary.  But, other forms of psychotherapy might adjunctively help the CBT to work better!  

Swine Flu Anxiety

While in the midst of an epidemic, a great deal of anxiety arises in the population.

Anxiety can lead to an exaggerated or inaccurate perception of risk, particularly when the mass anxiety is spread in the media, such as via front-page accounts of unexpected deaths.

In approaching any type of anxiety, I think it is important to know exactly what the risks are.

So, for example, it would be dishonest to tell an airplane-phobic person that air travel is perfectly safe. It isn't: there is about a 1 in 1 million chance of the plane crashing. (In a future post, I'd like to present my analysis of the statistics, and also show that the average spontaneous death rate in the population, for a person beyond young adulthood, exceeds the death rate from flying in an airplane--therefore I could claim--flippantly--that flying is statistically a "life-prolonging activity" for most travelers).


The current flu epidemic is clearly a serious matter. There definitely is a risk of death for those infected.

Estimates I've seen of the mortality rate vary, but the prevailing opinion seems to be that it is less than 0.1% (1 in 1000) for those infected.

This is not particularly different from the mortality rate of ordinary seasonal flu.

HOWEVER, the significant difference in this epidemic is the mortality rate by age. It is clearly true that swine flu has a higher mortality rate for healthy young adults--probably at least triple-- compared to seasonal flu.

Therefore, we are seeing more young, healthy adults die of flu this year. The total numbers are very low, but are much higher than in other years. The reason the overall mortality rate is the same is that fewer elderly individuals are dying of swine flu, most likely because of heightened immunity in that population due to exposure to a similar virus decades ago.

The CDC site shows that in a cohort of 268 people who died from swine flu early in the epidemic, 39% were in the 25-49 age group, and 25% were in the 50-64 age group. This is very different from seasonal influenza, in which about 90% of the deaths are in the over 65 age group. Here's a link to a pertinent page from their site:
http://www.cdc.gov/H1N1FLU/surveillanceqa.htm

Here's another important page from the CDC:
http://www.cdc.gov/h1n1flu/estimates_2009_h1n1.htm

Based on the table shown on this page, here are estimated risks of death for individuals infected with H1N1, stratified by age:
0-17 age group: between 1 in 10 000 and 1 in 20 000.
18-64 age group: between 1 in 2400 and 1 in 6000.
65+ age group: between 1 in 2300 and 1 in 6800.

I found a table of age-standardized "excess deaths" due to pneumonia and influenza in Italy between 1969-2001. (http://www.cdc.gov/eid/content/13/5/694-T2.htm) Based on this table, and assuming that only 10% of the population is infected during typical seasonal flu years, here is a very rough estimate of the risks of death by age for seasonal flu:
0-44 age group: 1 in 100 000
45-64 age group: 1 in 20 000
65+ age group: 1 in 750

The above data show that H1N1 influenza has a substantially higher death rate for those under 65 compared to seasonal flu, but as you can see the chances of dying if you catch the flu are still quite low, regardless of your age.


The risk of flu vaccines appears to be extremely low.
There is a substantial risk of contracting flu without the vaccine.
There is a low but non-zero risk of severe illness or death if you contract the flu.
The risk of a severe adverse reaction to the vaccine is much lower than the risk of a severe adverse effect from the flu itself.
The vaccine is likely to reduce the risk of contracting the flu by at least 90%.
Therefore, the benefit:risk ratio regarding the flu vaccine is very favourable. Here are references:
http://www.cdc.gov/h1n1flu/vaccination/safety_planning.htm
http://www.who.int/csr/disease/swineflu/frequently_asked_questions/vaccine_preparedness/safety_approval/en/index.html

So, my recommendations regarding swine flu anxiety are to be informed about the most accurate facts available:

1) the risk of death or severe illness remains low, for anyone infected

2) but the risk of a healthy young adult becoming severely ill or dying is relatively higher compared to seasonal flu

3) public health measures, such as very careful hygiene and mass vaccinations, are likely to save many lives (this is true of seasonal flu as well). Statistically, you as an individual are unlikely to contract severe flu illness. Hygiene and vaccine recommendations are more likely to be part of reducing the spread of flu in the population: therefore such recommendations, if you follow them, are statistically more likely to spare severe disease in someone else, rather than yourself. That is, if you receive a vaccination, that vaccination is more likely to save someone else's life rather than your own, since the average active case of flu is likely to spread to about 2 other people, even if the case is mild.

4) Therefore, I encourage following hygiene protocols and receiving the vaccine when it becomes available. It may spare you severe illness, and it has an even higher likelihood of being an altruistic act, which spares other people severe illness. Prompt use of anti-influenza medications such as Tamiflu are likely to further reduce the risk of severe complications, and most likely will further reduce the risk of contagion.


Altruistic acts, such as getting vaccinated or washing your hands, are psychologically healthy (this is my justification for posting something about influenza in a psychiatry blog!).


*It may be important to keep in mind, for the sake of perspective, that automobile accidents, for example, claim about 600 000 lives per year among young, healthy adults. In Canada alone, there are about 1000 deaths of young, healthy adults per year due to car accidents. (reference:http://www.statcan.gc.ca/pub/82-003-x/2008003/article/10648-eng.pdf) Another altruistic act of very practical importance is to slow down on the road!

Addendum:
A good article in the November 10, 2009 edition of CMAJ (p. 667-668) presents evidence that handwashing is not actually likely to be very effective in reducing the spread of influenza. Microbiologist Dr. Donald Low argues that hand hygiene has not been proven to reduce influenza spread, and that the influenza virus is primarily spread by fine droplets from coughing, which then have to be inhaled deeply. He points out that receptors for the influenza virus are located farther back in the respiratory tract, hence cannot be easily infected by touching mouth or eyes with hands, etc.
Here is an excellent article on the subject:
http://www.scienceadvice.ca/documents/%282007-12-19%29_Influenza_PPRE_Final_Report.pdf

His evidence-based position is that the N95 mask is the best mechanical way to prevent infection if you are near an infected person. Other than that, the best practice to prevent contagion would be to contain any coughing or sneezing, to stay away from other people if you are coughing, and to avoid close proximity with those who are infected, if possible.

Meanwhile, it is undoubtedly true that good handwashing practices do reduce the spread of the common cold and other infectious diseases. So all the handwashing and hand-sanitizing stations you see all over the place remain a good idea -- it's just that handwashing might not actually protect you very much from contracting influenza, compared to other measures.

Mindfulness actually works

So-called "mindfulness" techniques have been recommended in the treatment of a variety of problems, including chronic physical pain, emotional lability, anxiety, borderline personality symptoms, etc.

I do not think mindfulness training is a complete answer to any of these complex problems, but it could be an extremely valuable, essential component in therapy and growth.

I think now of a metaphor of a growing seedling, or a baby bird: these creatures require stable environments in order to grow. Internal and external environments may not always be stable, though. This instability may be caused by many internal and external biological, environmental, social, or psychological factors. In an unstable environment, growth cannot occur--it gets disrupted, uprooted, or drowned, over and over again, by painful waves of symptoms. Mindfulness techniques can be a way to deal with this type of pain, by taking away from the pain its power to disrupt, uproot, or drown. In itself it may not lead to psychological health, but it may permit a stable ground on which to start growing and building health.

Mindfulness on its own may not always stop pain, but it may lay the groundwork for an environment in which the causes of the pain may finally be dealt with and relieved. In this way mindfulness can be more a catalyst for change than a force of change.

Here is some research evidence:

http://www.ncbi.nlm.nih.gov/pubmed/1609875
http://www.ncbi.nlm.nih.gov/pubmed/7649463
This is a link to two of Kabat-Zinn's papers: the first describes the results of an 8-week mindfulness meditation course on anxiety symptoms in a cohort of 22 patients, and the second describes a 3-year follow-up on these same patients. The results show persistent, substantial reductions in all anxiety symptoms. The studies are weakened by the lack of placebo groups and randomization. But the initial cohort had quite chronic and severe anxiety symptoms (of average duration 6.8 years). Symptom scores declined by about 50%, which is very significant for chronic anxiety disorder patients, and represent a radical improvement in quality of life.

These papers suggest that mindfulness does not merely "increase acceptance of pain"--they suggest that mindfulness also leads to direct reduction of symptoms.

http://www.ncbi.nlm.nih.gov/pubmed/3897551
This is a link to one of Kabat-Zinn's original papers showing substantial symptom improvement and quality-of-life improvement in 90 chronic pain patients who did a 10-week mindfulness meditation course.

http://www.ncbi.nlm.nih.gov/pubmed/15256293
This is a 2004 meta-analysis concluding that mindfulness training, for a variety of different syndromes of emotional or physical pain, has an average effect size of about 0.5, which strongly suggests a very significant clinical benefit. It does come from a potentially biased source, "the Freiburg Institute for Mindfulness Research." But the study itself appears to be well put-together.


http://www.ncbi.nlm.nih.gov/pubmed/17544212
This randomized, controlled 8 week study showed slight improvements in various symptoms among elderly subjects with chronic low back pain. Pain scores (i.e. quantified measures of subjective pain) did not actually change significantly. And quality of life scores didn't change very much either. So I think the results of this study should not be overstated.

I do think that 8 weeks is too short. Also the degree of "immersion" for a technique like this is likely to be an extremely important factor. I think 8 weeks of 6 hours per day would be much more effective. Or a 1-year study of 1-hour per day. Techniques such as meditation are similar to learning languages or musical skills, and these types of abilities require much more lengthy, immersive practice in order to develop.

In the meantime, I encourage people to inform themselves about mindfulness techniques, and consider reserving some time to develop mindfulness skills.

The Importance of Two-Sided Arguments

This is a topic I was meaning to write a post about for some time. I encountered this topic while doing some social psychology reading last year, and it touches upon a lot of other posts I've written, having to do with decision-making and persuasion. It touches on the huge issue of bias which appears in so much of the medical and health literature.

Here is what some of the social psychology research has to say on this:

1) If someone already agrees on an issue, then a one-sided appeal is most effective. So, for example, if I happen to recommend a particular brand of toothpaste, or a particular political candidate, and I simply give a list of reasons why my particular recommendation is best, then I am usually "preaching to the converted." Perhaps more people will go out to buy that toothpaste brand, or vote for that candidate, but they would mostly be people who would have made those choices anyway. The only others who would be most persuaded by my advice would be those who do not have a strong personal investment or attachment to the issue.

2) If people are already aware of opposing arguments, a two-sided presentation is more persuasive and enduring. And if people disagree with a certain issue, a two-sided presentation is more persuasive to change their minds. People are likely to dismiss as biased a one-sided presentation which disagrees with their point of view, even if the presentation contains accurate and well-organized information. This is one of my complaints about various types of media and documentary styles: sometimes there is an overt left-wing or right-wing political bias that is immediately apparent, particularly to a person holding the opposing stance. I can think of numerous examples in local and international newspapers and television. The information from such media or documentary presentations would therefore have little educational or persuasive impact except with individuals who probably agree with the information and the point of view in advance. The strongest documentary or journalistic style has to be one which presents both sides of a debate, otherwise it is probably almost worthless to effect meaningful change--in fact it could entrench the points of view of opposing camps.


It has also been found that if people are already committed to a certain belief or position, than a mild attack or challenge of this position causes people to strengthen their initial position. Ineffective persuasion may "inoculate" people attitudinally, causing them to be more committed to their initial positions. In an educational sense, children could be "inoculated" against negative persuasion, such as from television ads or peer pressure to smoke, etc. by exploring, analyzing, and discussing such persuasive tactics, with parents or teachers.

However, such "inoculation" may be an instrument of attitudinal entrenchment and stubbornness: a person who has anticipated arguments against his or her committed position is more likely to hold that position more tenaciously. Or an individual who has been taught a delusional belief system may have been taught the various challenges to the belief system to expect: this may "inoculate" the person against challenging this belief system, and cause the delusions to become more entrenched.

An adversarial justice system reminds me to some degree of an efficient process, from a psychological point of view, to seek the least biased truth. However, the problem here is that both sides "inoculate" themselves against the evidence presented by the other. The opposing camps do not seek "resolution"--they seek to win, which is quite different. Also, the prosecution and the defense do not EACH present a balanced analysis of pro & con regarding their cases. There is information possibly withheld--the defense may truly know the guilt of the accused, yet this may not be shared openly in court. Presumably the prosecution would not prosecute if the innocence of the accused was known for sure.

Here are some applications of these ideas, which I think are relevant in psychiatry:

1) Depression, anxiety, and other types of mental illness, tend to feature entrenched thinking. Thoughts which are very negative, hostile, or pessimistic--about self, world, or future--may have been consolidated over a period of years or decades, often reinforced by negative experiences. In this setting, one-sided optimistic advice--even if accurate-- could be very counterproductive. It could further entrench the depressive cognitive stance. Standard "Burns style" cognitive therapy can also be excessively "rosy", in my opinion, and may be very ineffective for similar reasons. I think of the smiling picture of the author on the cover of a cognitive therapy workbook as an instant turn-off (for many) which would understandably strengthen the consolidation of many chronic depressive thoughts.

But I do think that a cognitive therapy approach could be very helpful, provided it includes the depressive or negative thinking in an honest, thorough, systematic debate or dialectic. That is, the work has to involve "two-sided argument".

2) In medical literature, there is a great deal of bias going on. Many of my previous postings have been about this. On other internet sites, there are various points of view, some of which are quite extreme. Those sites which are invariably about "pharmaceutical industry bias", etc. I think are actually quite ineffectual, if they merely are covering the same theme, over and over again. They are likely to be sites which are "preaching to the converted", and are likely to be viewed as themselves biased or extreme by someone looking for balanced advice. They may cause individuals with an already biased point of view to unreasonably entrench their positions further.

Also, I suspect the authors of sites like this, may themselves have become quite biased. If their site has repeatedly criticized the inadequacy of the research data about some drug intended to treat depression or bipolar disorder, etc., they may be less likely to consider or publish contrary evidence that the drug actually works. Once we commit ourselves to a position, we all have a tendency to cling to that position, even when evidence should sway us.

On the other hand, if there is a site which consistently gives medication advice of one sort or the other, I think it is unlikely to change very many opinions on this issue, except among those who are already trying out different medications.

So, in my opinion, it is a healthy practice when analyzing issues, including health care decisions, to carefully consider both sides of an argument. If the issue has to do with a treatment, including a medication, a style of psychotherapy, an alternative health care modality, or of doing nothing at all, then I encourage the habit of analyzing the evidence in two ways:
1) gather all evidence which supports the modality
2) gather all evidence which opposes it

Then I encourage a weighing, and a synthesis, of these points of view, before making a decision.
I think that this is the most reliable way to minimize biases. If such a system is applied to one's own attitudes, thoughts, values, and behaviours, I think it is the most effective to promote change and growth.



References:
Myers, David. Social Psychology, fourth edition. New York: McGraw-Hill; 1993. p. 275; 294-297.