Archive for the ‘intuitive notions’ Category

I didn’t realize this until I’d spent a summer around dogs, but they’re like people in some very relevant ways.  They get enthusiastic, they get angry, they feel down and icky, they misbehave and know it, they understand a small English vocabulary, and they look up at you adoringly whenever you have control over who gets chicken scraps and who doesn’t.

Let’s say you have a dog (let’s make him a mutt) named Barky (your six-year-old named him, not you).  You’ve had him for five years, you love him and your kid does too, and you know quite well that lying in one place, resisting going out into the sunshine for walks, and eating very little is not at all normal behavior for rambunctious, cheerful Barky.  He’s more than unhappy and you know him well enough to know that this is well outside the normal.  You take him to the vet and nothing’s physically wrong, but the vet suggests that he’s depressed and might benefit from Reconcile, the Prozac for dogs.

What do you do?  Your options include (this is not a complete set): reject the option because he’s a dog, not a human, and only humans feel real emotional pain and/or deserve treatment; reject the option because you ask about the side effects and decide they would be worse for Barky than how he appears to feel now; or accept the suggestion because you think that reducing pain, even animal pain, is desirable, and can be helped by medication. You can also go home and make fun of it. I know what I’d choose to do for someone I cared about, even if they weren’t human, or weren’t adults, or whatever we choose as the boundary line between living beings whose pain matters, and those whose pain we don’t consider real enough to matter.  It wouldn’t necessarily be to give them psych meds (that really would depend on the expected benefit and side effects), but I wouldn’t reject it based on the notion that dogs cannot have serious problems or painful emotional experiences.

The availability of Prozac for dogs is unquestionably an attempt for Eli Lilly to expand their market.  This is not different from other companies.  When you see an ad for life-saving drugs, it’s because they want more people to get those drugs.  When you see an ad for a new sports drink, it’s because they’re trying to get more people to buy it.  And so on.

The question here isn’t whether drug companies are exploitative – we already know they are, so that’s not really a question – but whether we want to use their products to reduce suffering.

Some therapists do not “get” the difference between having life problems, and having mental illness (plus, often, life problems).  My suggestions for dealing with this, if you are mentally ill and seeking therapy, are:

1) Look for therapists affiliated with hospitals, they tend to have more experience with psych patients.

2) Be leery of anyone who makes a big deal out of “situational” versus “chemical” depression.  It’s all chemical; it all happens in your brain and body.  Peter Kramer, a psychiatrist who is pro-therapy and writes books about therapy and books about medication, argues that research shows that depression triggered by repeated situational events comes to look no different from depression with a heavier genetic component.  It’s just that some people start higher or lower down the slope.

Those who start further down the slope – who some people would say have “chemical” depression – can still be helped by therapy.  For example, people who are more prone to depression following negative life events can learn to better anticipate and/or avert those events, and cognitive therapy can help people interpret those events in ways that are less damaging.  It’s not always enough, but it can be very helpful.

Continue reading ‘Situational versus chemical depression, and what it (doesn’t) mean for treatment’ »

I looked up celiac disease and autism on pubmed the other day.  My mother’s secretary has a daughter recently diagnosed with autism, and diagnosed several years with celiac disease.  So we were sitting in the dining room and I’m snacking and looking up stuff on pubmed.

“There’s not much research, but the two studies I’ve found on autism and celiac did not find a link, except for this one quack guy,” I say, meaning Andrew Wakefield.

“Okay,” my mom says.  “So they haven’t done the research confirming it yet.”

“No,” I say.  “There are two existing studies that have looked, and they did not find evidence of a link.  I’m looking on pubmed, so if there were more studies they would very likely be there.”

“Ah,” my mom says. “So all we’ve got now to go on is anecdotal evidence.”

“No,” I say again.  “Studies looked.  They looked for a link, and they didn’t find a link, suggesting there’s not a link.”

I think at that point we detected mutually incompatible approaches to uncovering truth, and dropped the conversation.

——–

It’s a normal human thing to figure out what you believe is true (often by assuming anecdotes are representative of overall reality), and then seek out social back-up to help convince others of it.  In this approach to truth (which drives scientists up the wall), if science is used, it is used to support one’s own truth claims to others.  If someone is not trying to make truth claims to others, then there is no need for science; it doesn’t tell you anything you don’t already know.

In contrast, the role of science as-generally-agreed-upon is to test what we believe to be true to see whether it really is true. In this approach to science, science can disconfirm anecdotes, and its role is to drive what people believe, not just to back what they already do believe.  So it’s much less useful for normal human goals.

Frustrating, that.   Also frustrating that we don’t have much research on a lot of things.  It could be true that the two studies on autism and celiac disease didn’t pick up on an actual connection…but the point is, two studies that show no connection are a lot more meaningful than no studies that show no connection.

Checklists are often simple and straightforward, and very short checklists can carry the unfortunate implication that the person using the checklist can’t remember to do simple things. But sometimes they can’t. Or don’t. The NY Times has an article discussing the rewards – in lives saved – of medical professionals using checklists, sometimes very simple one, to ensure that they don’t forget – or skip out on (do you wash your hands every single time you go to the bathroom?) – important steps under pressure, particularly those that may not seem as important as others.

The practice of medicine gets a little more scientific here , and rewards clinical intuition a little less, by reducing the human element involved in medicine. I’d bet you money that most patients would think that a doctor who uses a checklist is less competent than one that doesn’t, because they’re following delineated steps set up by someone else.

And that’s the dilemma: you can get the best healthcare available, or you can get healthcare that feels intuitively right.

If we keep going, healthcare may wind up being executed by health professionals but determined by information professionals. Good news for us science of info people…although I could just be expecting this potential from based on personal bias…
Using checklists (NYT article).

A book review with a lot of commentary.

Most doctors do not like decision aids. They rob them of much of their power and prestige. Why go through medical school and accrue a six-figure debt if you’re simply going to use a computer to make diagnoses? [….] It is no secret many doctors despise evidence-based medicine. It is impersonal “cookbook medicine.” It is “dehumanizing,” treating people like statistics. Patients do not like it either. They think less of doctors’ abilities who rely on such aids.

The problem is that it is usually in patients’ best interest to be treated like a “statistic.”

And he talks about why.

It’s unfortunate that getting good healthcare can be at odds with doctors and patients thinking about things in normal human ways.  It does take the humanity out of it; it’s not “normal”.  But seriously: is it worth it to have an intuitively comfortable visit, and make your doctor feel better, at the cost of your getting better healthcare?

I feel a bit cheap when I write about how researchers have located a brain area for something or other. It’s unremarkable that every aspect of cognition occurs in the brain; that’s where it all goes on. Except most people still find it really interesting to hear that people perceive faces with a specific part of the brain, or inhibit their behavior with a specific part of the brain. (I heard once that if you’re at a teaching/education conference and really want to drive your point home, you say that your learning technique leads to changes in the brain zomg.) The aspect most relevant here is that convincing people that mental illnesses are brain disorders tends to carry a lot of weight. (Although actually, they tend to involve the body too, and that’s pretty important.)

My guess is a lot of it is due to our having different mental systems for handling people’s thoughts/beliefs/intentions and for handling people as biological bodies, so it’s counterintuitive and mentally catchy to find out that something you’d thought was part of the person is actually part of their body. Reality doesn’t have a boundary between biological and mental, but the distinction we have between the two in our minds tends to influence things in odd ways.

Anyhow, here’s the link that inspired this. I think this is interesting beyond the “omg it’s in the brain” aspect, because it lifts out “remembering visual information in order” as a thing in itself and suggests that it might be impaired in ADD (and my guess would be other mental disorders as well since bipolar also involves the prefrontal cortex, depression involves the prefrontal cortex, autism involves the prefrontal cortex, etcetera). I’d love to see some investigations on whether/how this is an issue in daily life.

I’m going to be away all day tomorrow, so here’s Friday’s entry.

This is the fourth general take I’ve seen on the notion of what makes ideas memorable and makes them spread. The first is a paper by freelance philosopher Murray Davis, on what makes ideas interesting. He says it is when they are surprising, and contain relevance for our behavior. The second is meme theory, Dawkins and all those, and this unfortunately is often poorly spelled out. The third is cultural epidemiology, which is my “home” in terms of thinking about culture – I’ll write more on that later. I like this one too, because it seems to be both broader and more specific than Davis or Dawkins, and more accessible than cultural epidemiology, which requires some cognitive science briefing.

A friend asks: do you know if there’s been any progress informing the public about the difference between “psychopathy,” “psychosis,” and “psychotic axe-murder?” which should probably be “psychopathic axe-murderer,” now that I think about it.

I don’t know, but it’s probably similar to when other terms have been adopted by the public and used pejoratively (like “idiot,” “imbecile,” and “moron,” originally specific technical designations). Then we switch to different terms like “mentally retarded” which the public then starts using as an insult, and move on to “developmental delay,” “developmental disability,” “intellectual disability,” etc.

All of these terms have been used to refer to very similar things, which interested parties want to destigmatize, some people merely wish to describe accurately, and many people want to mock and insult. Linguist Steven Pinker calls this the euphemism treadmill.

I think it’s virtually certain that words for mental illnesses and symptoms will continue to be turned into words that mean “completely unresponsive to social norms, and violent” or “SUPERDANGEROUSWILLKILLYOU”.

So what if instead we gave them a word or phrase to name the kind of person they’re trying to name: the kind of person everyone is afraid of, someone who is not merely malevolent and physically dangerous, but so mentally unbound from laws and rules and social demands that nothing you can do will stop them?

Such as “horror movie killers”. Or “Jasophrenics” (after Jason of the various horror movies, but with “phrenic” (“minded”) added because most people named “Jason” are not horror movie killers. Or “berserkers” (though I think that’s kind of mean to the originals. I wonder if they had to go around after battle explaining to people that they weren’t the equivalent of horror movie killers?). I also came up with the idea of “Voldemorts” since everybody loves Harry Potter, but I’m told that he’s not violent enough.

And then we would have the word “Jasophrenic” to describe something that probably doesn’t exist as a discrete clinical entity, just as a catchy mental concept, and we might make more headway in explaining that “psychotic” covers a great deal of ground that doesn’t involve it, and so does “schizophrenic” and “crazy” and “mentally ill,” and even “psychopathic” does too. That might be a lot of education gained for a pretty cheap memehack.

There is an undergraduate research assistant doing research-for-credit for a friend of mine. The research assistant asked me about research on averting mania by changing your emotional coping style. This is the email I drafted after he didn’t like what I sent him (on cognitive-behavioral therapy helping to recognize impending mania and avoid triggers), in response to his explaining to me that actually he was looking for information more relevant to his theory, and that he’d developed the theory because of his ex-girlfriend and her family.

The actual email I sent was kinder than this, but I like this one better. (If anyone thinks any of post would be useful in explaining mental illness stuff to someone else, take all you like; I release this email into the wild for the purposes of education. Take/rephrase/whatever.)

Hi [undergraduate research assistant’s name],

I sent you the most relevant information I’m aware of. I try to stay pretty on top of things, so although it may not be ideal, it’s unlikely there’s anything more related. There’s a reason for that:

We all have intuitions about how peoples’ emotions work, and those tend to work pretty well most of the time, when we’re thinking about most people. So it’s completely accurate that dealing with stress helps (most) people manage emotions quite well. Unfortunately, because people with bipolar disorder have emotion regulation systems that are broken, our intuitions give us faulty predictions about what will fix their problems.

To make an overly simplified analogy, practice well help most people learn to ride a bike – but practice just won’t do it for someone with a missing leg, because they do not have the standard physical setup that people with two legs have. They need a different kind of support before practice will make any difference. A prosthetic leg will let practice come into play, and the prosthetic leg plus practice will let that person bike – but practice alone won’t cut it.

There are definitely therapeutic interventions that help people with bipolar disorder when they are well – and they are very important in helping avoid triggers (like lack of sleep, etc.) that can bring on mood episodes. And cognitive therapy also makes a big difference in training people to recognize when they’re in the early stages of a mood episode so they can seek help before it gets too bad.

People have tried, and continue to try, unsuccessfully, to use *just* therapy (or yoga, meditation, fish oil, supplements, etc) to manage bipolar disorder, instead of using medication. Everyone I know who has bipolar disorder would love to find something that would work without the side effects and stigma of taking medication! As would many mental health practitioners, social workers, etc, who could do a lot of good work by successfully treating a devastating illness.

Unfortunately, no one has come up with a way to do so, despite many of the best minds in research and practice have doing their best for years (you may want to consider that very smart people with years of accumulated knowledge of bipolar disorder have been working on the problem for decades; it has not proved amenable to simple answers, despite many hopes and bold theories).

No reputable mental health provider would consider attempting to treat someone with bipolar disorder entirely without medication, unless they are considering ECT as a last-ditch resort following many medication trials. It is dangerous and unethical to do so because of the consequences that are much more likely to follow off medication than on (consequences like death, debt, ruined relationships, property damage, jail sentences, sexually transmitted diseases, and kindling leading to worsened future episodes, to name a few).

I realize you didn’t say this, but it’s a dangerous idea that a lot of people fall into and I want you to understand this very clearly: It is similarly dangerous and ignorant for friends, family members, etc., to encourage people to go off their medication in favor of alternative treatments. It would be hubris to for a layperson to think they know more than people with years of medical and/or research training and extensive knowledge of what treatment is effective and what is not – unless (until) they have had extensive training in the same.

It can be easy to think you can solve a difficult problem like bipolar disorder with undergrad psych classes and a good idea, but trust me that if that were the case it would have been solved by another brilliant young psych undergrad long before you (as would many, many other problems that we’re still stuck with). Teachers give you the simplified versions of reality in undergrad because no one can learn the difficult complicated crap without first learning the building blocks – but the building blocks aren’t the answer to the real-world problems, they’re just the foundation for starting to understand what the real-world problems actually are.

We do know that there are therapeutic techniques that are indispensable parts of treatment for bipolar disorder, even if they cannot be the only treatment. It’s an important area, and there’s certainly room for some research first on whether coping style really is related to bipolar disorder (it could be that the people you’ve spoken with just happen to have both) and second on whether it provides a useful adjunct to medication (which it may or may not; you do research on techniques to find out whether they work or do not work, not to prove that they do work).

If you would like to learn more about the real-world problem and the scope of its complexity, I recommend:

http://www.mcmanweb.com for high-quality essays and information

“Manic-Depression: Bipolar Disorder and Recurrent Depression” (I think that’s the title) by Goodwin and Jamison (the SECOND edition, which just came out; the first is over ten years old). This is really expensive so you probably want to get it through ILL, but it is the absolute definitive work, it is very current, and it is fantastic.

Good luck.