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.