Lindsay Myers, MBA, MPH – Brain Blogger Health and Science Blog Covering Brain Topics Wed, 30 May 2018 15:00:03 +0000 en-US hourly 1 Fighting Mental and Physical Illness by Reshaping Cities Fri, 19 Sep 2014 11:00:42 +0000 A recently published study in The Lancet estimated that 40 percent of Americans will develop diabetes in their lifetime – a trend which is largely due to obesity and inactivity. Since the 1990s, some public health professionals have turned their attention to the potential offered by environmental modifications to fight obesity and improve population health. The same environmental modifications might positively impact another public health problem: depression.

“Obesity is a multicomponent disease arising from a complex interaction between genetic and environmental factors. However, the dramatic increase in obesity prevalence observed in the last decade seems attributable mainly to environmental changes promoting the intake of energy-dense foods, and/or reduced physical activity due to the high number of sedentary jobs, different transportation systems, and increasing urbanization,” observe Grave et al.

Mackenbach et al. echo this opinion, noting that “although genetic factors may underlie the propensity of individuals to become obese, the pace at which obesity prevalence has grown at the population level during recent decades points to social and environmental causes.”

Several studies have linked urban sprawl to obesity. Food advertising and rising stress levels have also been implicated. Other studies have shown that individuals eat 35 percent more when eating socially as opposed to eating alone, that fast paced music has the effect of encouraging people to eat more, and that lighting, hard surfaces, and colors are associated with greater food consumption. Environmental cues influence caloric consumption in addition to physical activity, which has led public health professions to consider the role of transportation infrastructure, sports facility placement, land use, green spaces, and other environmental factors in promoting population health.

Modifying individual behavior is often an uphill battle. Relapse can unravel previous efforts at any point in time. Grave et al. describe two factors required for behavior change: discrepancy and self efficacy.

The former refers to a perceived gap between current self image and an ideal or value-driven image. The latter, common to many models including the transtheoretical model, social cognitive theory, and protection motivation theory, refers to the “belief in one’s capacity to organize and execute the courses of action required to produce given attainments,” meaning individuals must feel adequately equipped to effect change. Self efficacy has been shown to predict the adoption and maintenance of healthy physical activity behaviors among adults. 

Promoting the adoption of new healthy behaviors often requires reinforcement. However, changes to infrastructure, such as increasing the price of parking and providing ample walking and biking paths can shape behaviors in ways that promote health.

The city of Montreal provides over 5,000 public use bicycles at 405 docking stations throughout the city, with clearly marked bicycle lanes and traffic signals for cyclists. Researchers conducted an impact evaluation based on the idea that “studies show associations between high levels of cycling for transportation or utilitarian cycling, and reduced traffic congestion, noise and air pollution, and obesity as well as an increase in physical activity,” and found that, once adjusted for rain and snow conditions, physical activity had increased as a result of the program. As many as 17.8 percent of survey respondents had used the bikes in the previous 7 days.

Another analysis based on a similar program in Barcelona estimated an impact of 0.03 incremental traffic deaths, 0.13 incremental deaths associated with air pollution, and 12.46 deaths avoided as a result of the increased physical activity.

Just as changing environment to counter the social isolation of cars and lack of physical activity can fight obesity, it also has the potential to address depression, which the WHO has indicated affects 350 million people. Globally, the prevalence of child and adolescent mental health disorders is an estimated 20 percent, led by depression. Brown et al. note that while pharmacological interventions and psychotherapy are common, they are often reported to be ineffective. Research has demonstrated that physical activity can have a protective effect against the onset of depressive symptoms as well as benefiting those with current symptoms.

Consequently, environments which promote good nutrition and encourage physical activity may fight depression in addition to diabetes, certain cancers, and cardiovascular disease. There is also a social dimension to walking, cycling, and other more physical forms of transportation, which has been shown to have a protective effect.

Diabetes and other obesity-related illness and depression are poised to consume a staggering amount of resources while resulting in significant loss of quality of life. Thoughtful urban planning with economic incentives offers the potential to modify behavior at the population level while offsetting some of the need for constant, ongoing intervention by providers at the individual level.


Brown, H., Pearson, N., Braithwaite, R., Brown, W., & Biddle, S. (2013). Physical Activity Interventions and Depression in Children and Adolescents Sports Medicine, 43 (3), 195-206 DOI: 10.1007/s40279-012-0015-8

Carlson, S. (2012). America’s Health Threat: Poor Urban Design. The Chronicle of Higher Education.

Freudenberg, N., Libman, K., & O’Keefe, E. (2010). A Tale of Two ObesCities: The Role of Municipal Governance in Reducing Childhood Obesity in New York City and London Journal of Urban Health, 87 (5), 755-770 DOI: 10.1007/s11524-010-9493-x

Fuller D, Gauvin L, Kestens Y, Daniel M, Fournier M, Morency P, & Drouin L (2013). Impact evaluation of a public bicycle share program on cycling: a case example of BIXI in Montreal, Quebec. American journal of public health, 103 (3) PMID: 23327280

Galea, S. (2005). Urban built environment and depression: a multilevel analysis Journal of Epidemiology & Community Health, 59 (10), 822-827 DOI: 10.1136/jech.2005.033084

Dalle Grave R, Centis E, Marzocchi R, El Ghoch M, & Marchesini G (2013). Major factors for facilitating change in behavioral strategies to reduce obesity. Psychology research and behavior management, 6, 101-10 PMID: 24124398

Gregg EW, Zhuo X, Cheng YJ, Albright AL, Narayan KM, & Thompson TJ (2014). Trends in lifetime risk and years of life lost due to diabetes in the USA, 1985-2011: a modelling study. The lancet. Diabetes & endocrinology PMID: 25128274

Mackenbach JD, Rutter H, Compernolle S, Glonti K, Oppert JM, Charreire H, De Bourdeaudhuij I, Brug J, Nijpels G, & Lakerveld J (2014). Obesogenic environments: a systematic review of the association between the physical environment and adult weight status, the SPOTLIGHT project. BMC public health, 14 PMID: 24602291

Image via Rawpixel / Shutterstock.

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Is Anorexia a Modern, Culture-Bound Disorder? Wed, 03 Sep 2014 11:00:17 +0000 The universality and the origins of anorexia nervosa have been the subject of years of debate. Some argue that the eating disorder is a culture-bound syndrome specific to the Western, industrialized world, while others maintain that there is evidence that the disease is not confined to more recent times or one part of the world.

While acknowledging “symptomatic continuities” which extend back in time prior to the mid-1800s, others maintain that certain elements essential to the classification of anorexia nervosa were absent prior to the latter half of the 19th century.

Whether or not anorexia nervosa (AN) and bulimia nervosa (BN) existed before this time hinges on a crucial factor, argues Tilmann Habermas: “The clinical feature that renders both disorders distinctly modern and Western is the overvalued idea of being too big when at normal body weight, which serves as the primary conscious motivation for restricting food intake.”

Self-starvation is by no means modern, however the components of distorted body image and fat-phobia as principal motivators may not have emerged until more recently. This is consistent with the DSM-IV criteria for AN, which includes “refusal to maintain body weight at or above a minimally normal weight”, and “intense fear of gaining weight or becoming fat even though underweight,” along with “disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight.”  

We should not, therefore, include cases of self-starvation throughout the ages which stemmed from other motivations, such as depression or grief, digestive issues, obsessive disgust with food or eating that does not have a weight-loss motivation, or fear of poisoning.

Cases Prior to the 19th Century
Klump and Keel go as far back as the case of a 9th century Bavarian serf named Friderada whose inability to eat was described as part of a monk’s attestation to a miracle peformed by Walburgis. The fasting medieval saints have been part of the discussion surrounding whether AN emerged more recently or has been present throughout the centuries.

While self-starvation criteria is met, fat-phobia is often missing in these cases. Habermas distinguished cases of inedia among fasting religious ascetics from AN as we know it in modern times: “Being underweight was not a necessary or even a typical condition for claiming inedia.”

He also points out that anorexics tend to hide their food avoidance, while the religious ascetics tended to exhibit their abstinence as miraculous. “The miraculous fasting girls from the 16th to the 19th century,” says Habermas, “remained in their families, were ill or handicapped, and claimed not to be eating anything, although most of them were not emaciated. Girls with AN, in contrast, try to make believe they are eating normally, and provide a variety of medical, somatic, or aesthetic reasons not to eat.”

Consequently, he concluded that neurotic asceticism accompanied by weight loss had similarities with AN, but was “probably still more similar to neurotic asceticism without weight loss.”

When AN Coincides with Religious Asceticism
Later studies have looked at anorexia and religiosity, finding that religiosity was associated with lower minimum body mass index achieved, and that religiosity tended to increase as AN progressed. Another study found that anorexics modified their religious practices after the onset of AN, with decreased participation in communion or feasts and increased religious fasting.

The element of self-disgust with one’s body is not recorded in many older and religious cases, however one French catholic named Renata, documented by Schnyder in 1912, did exhibit a loathing of her shape, with a religious bend. She felt that weight contributed to sensuality and did not want to be “an object of desire,” and expressed feeling “ashamed to feel that I was looked at.”

The time of onset, at about age 16, as well as Renata’s obsession with biking 40 kilometers, self-induced vomiting, and self-starvation, point to anorexia and bulimia framed in religious terms. Habermas therefore suggests that intense religiosity and AN need not be mutually exclusive, however many of the religious ascetics did not meet the DSM-IV criteria for AN.

Change in Incidence, or Change in Documentation?
The late 19th century produced abundant medical literature on AN cases, leading to the question of whether the incidence of AN actually increased at that time, or whether the clinical documentation that accompanied the emergence of psychiatry in France led to increased notice of cases in conjunction with what was otherwise a stable incidence rate.

Habermas also points to “an interest in nutrition, which, combined with an interest in the psychology of their patients, made German physicians of internal medicine sensitive to motives for not eating.”

German doctors, he also noted, attributed cases of AN to Simmonds’ Disease between 1914 and 1945. Cases of AN motivated by fear of weight gain were recorded in Russia in the late 1800s, as well as in Italy. However, a change in primary sources around this time also occurred, with cases recorded by physicians in the context of medicine rather than by religious sources.

The medical literature of the latter half of the 19th century describes French school girls drinking vinegar and limiting food intake for aesthetic purposes, an emaciated Queen Elizabeth of Austria, obsessed with exercise and food restriction, motivated by a fear of growing fat. Habermas recounts that “in the second half of the 19th century, medicine began to label as pathological even moderate degrees of overweight, which were increasingly judged by reference to statistical tables such as those by Quetelet (1835) and Worthington (1875).” Interestingly, concern about excess weight first emerged among men, in contrast to today’s typical anorexic, the adolescent girl. In the early 1900s, some physicians associated corseting with AN.

Universality vs. the Globalization of Eating Disorders
Whether AN is a Western phenomenon, or found throughout the world has also been debated. Isaac cites research in which Keel and Klump concluded that AN was not a culture-bound syndrome, but bulimia was, suggesting that nonwestern bulimics had  been exposed to Western culture.

Smink et al. performed a meta-analysis of 125 studies and point to “cultural transition and globalization” as mechanisms by which eating disorders which were historically characterized as culture-bound started appearing in non-western countries and among minorities. They note a study on the Caribbean island Curacao in which no cases were found among the black population, while incidence rates among white and mixed-race residents where comparable to those found in the U.S. and the Netherlands. Other eating disorders, such as binge eating, have been associated with migration from Mexico to the U.S.

As Haberman stated, “whether AN and BN are universal or restricted to specific historical phases (and cultures) has been shown to depend on two main factors, namely, on the methodology of historical research and on the diagnostic criteria chosen.” In this context, some evidence suggests that although abnormal eating habits and fasting can be found throughout the ages, the motives and body image distortion that accompany what we currently know as AN may not have been present prior to the mid or late 1800s. Alternately, AN may have been present, but cultural context and the nature of sources, both of which shifted in the 1800s, may have simply obscured its presence.

Habermas, T. (1992). Further Evidence on Early Case Descriptions of Anorexia Nervosa and Bulimia Nervosa. International Journal of Eating Disorders, 11(4) 351-359.

Habermas T (2005). On the uses of history in psychiatry: diagnostic implications for anorexia nervosa. The International journal of eating disorders, 38 (2), 167-82 PMID: 16134113

Isaac D (2013). Culture-bound syndromes in mental health: a discussion paper. Journal of psychiatric and mental health nursing, 20 (4), 355-61 PMID: 23495975

Smink FR, van Hoeken D, & Hoek HW (2012). Epidemiology of eating disorders: incidence, prevalence and mortality rates. Current psychiatry reports, 14 (4), 406-14 PMID: 22644309

Image via Keith A Frith / Shutterstock.

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The Relationship Between Depression and Arthritis Fri, 08 Aug 2014 11:00:35 +0000 Both arthritis and depression are common in the United States, with age and obesity trends likely to increase the number of people who suffer from both conditions simultaneously.

Studies have repeatedly demonstrated an association between arthritis symptoms and major depression. Of concern, research has shown that among patients with both conditions, the result is not merely the sum of the suffering and disability associated with each independent illness; when depression coincides with arthritis, studies have found that the conditions are multiplicative rather than additive, amplifying each other.

Arthritis and depression are but one example of the increasingly frequent overlap between medical and behavioral health, and evidence suggests that treating depression reduces arthritis-related healthcare expenditures, increases compliance with arthritis treatment plans, and alleviates physical symptoms.

The Arthritis Problem
According to the CDC’s 2013 Morbidity and Mortality Weekly Report, one in five adults in the United States has physician-diagnosed arthritis. For the past 15 years, arthritis has been the most common cause of disability among U.S. adults. Ten years ago, just under 10 percent of U.S. adults, approximately 19 million people, said their activities of daily living were limited by this chronic condition. The number is projected to reach 25 million by 2030.

In older populations, arthritis is widespread: by age 65, at least a third of people in the U.S. have osteoarthritis, and the majority, approximately 80 percent, experience degenerative changes or joint disease. The costs associated with this are enormous: The American Academy of Orthopedic Surgeons (AAOS) reported an estimated annual cost for medical care to treat arthritis and joint pain of $281.5 billion in 2004. Prescription drugs accounted for 23 percent of the expenditures.

The Depression Problem
The Morbidity and Mortality Weekly Report also notes that depression is more common among people with chronic diseases such as diabetes, asthma, cancer, and arthritis. Citing the Behavioral Risk Factor Surveillance System (BRFSS) survey conducted from 2006 to 2008, 9 percent of U.S. adults, of any health status, met the criteria for depression.

Depressive symptoms have been identified as an independent risk factor for all-cause mortality. A study by Wells et al. found an association between depression and disability where the effects of depression were comparable to several major medical conditions.

When Arthritis and Depression Overlap
When arthritis and depression overlap, studies have shown a synergism resulting in worse suffering and disability than that which would be associated with each condition independently. A 1998 study found that osteoarthritis-related knee pain was associated with depression. Other studies demonstrate worse outcomes, lack of adherence to treatment plans, and increased cost of care in patients suffering from both illnesses.

In addition to increased use of pain medication, a bidirectional relationship exists between the two conditions: Yohannes and Canton describe how the fatigue that accompanies depression results in activity avoidance, which decreases muscle conditioning, resulting in increasing arthritis pain while also leading to social isolation, thereby perpetuating depression. They also note that “a previous history of depression is a better predictor of utilizing healthcare than the severity of osteoarthritis symptoms,” which implies that the financial burdens of arthritis could be mitigated to some extent by addressing coinciding depression.

While osteoarthritis is the most common form of arthritis, another form, rheumatoid arthritis, shows an even more significant link with depression. The National Institute of Mental Health (NIMH) Catchment Area program reports that the lifetime prevalence of psychiatric disorders among patients with rheumatoid arthritis is 63 percent. “Indeed,” state the researchers, “approximately 20 percent of patients with RA are found to have current major depression with potential impact on RA symptoms.”

Devellis and Devellis summarize the implications of these studies, stating that “helping arthritis patients obtain relief from their depression promises both to mitigate the added risk associated with depression and to enable the patient and physician to manage the arthritis itself more effectively. A first step to optimal treatment may simply be an awareness of the role that depression can play in the course of arthritis and its treatment.” Primary care physicians could screen arthritis patients for depression and refer them for treatment.

The long term effects of medication, as well as interactions between medications, should be cause for concern among patients afflicted with multiple conditions. Non-steroidal anti-inflammatory and other drugs for arthritis are associated with gastrointestinal issues, renal toxicity, and other side effects.

Breedveld notes that among American adults over the age of 35 with osteoarthritis, 41 percent were also receiving pharmacotherapy for hypertension. As other chronic diseases join the mix of arthritis and depression, the potential for activity-limiting, undesirable medication side effects increases. According to the CDC, 57 percent of those with heart disease also have arthritis, and 52 percent of diabetics have arthritis.

The CDC’s Arthritis Program recommends self-management education and physical activity programs, noting that some of the barriers to self-management through physical activity include lack of time, competing responsibilities, lack of motivation, difficulty finding an enjoyable activity, and fear of exacerbating pain or further damaging joints. Barriers to treating depression often include cost of drugs, side effects, stigma, and the patient-provider relationship.

Studies have shown that older people with osteoarthritis could benefit from combination therapy utilizing medication and cognitive behavioral therapy, however copays are frequently a barrier to treatment for elderly patients on a fixed income. Consistent with the CDC’s recommendations, Yohannes and Canton concluded that self management techniques, medical information, assistance with pain coping skills, and exercise would be beneficial. Cognitive behavioral therapy has been used to cultivate the belief that the patient is equipped to effectively cope with the condition, resulting in increased activity and improvement in depressive symptoms. Aerobic exercise programs have decreased depression in adults with arthritis.

Depression exacerbates the manifestations of joint disease. Recognition of this relationship by family members and providers can lead to better support for the increasing number of people suffering from overlapping medical and behavioral health issues. Counseling, education, and exercise programs have shown the potential to mitigate symptoms and reduce health care spending while improving quality of life and daily functioning.


Agarwal P, Pan X, & Sambamoorthi U (2013). Depression treatment patterns among individuals with osteoarthritis: a cross sectional study. BMC psychiatry, 13 (1) PMID: 23607696

Behnam, B. (2013). The Frequency and Major Determinants of Depression in Patients with Rheumatoid Arthritis Turkish Journal of Rheumatology, 28 (1), 32-37 DOI: 10.5606/tjr.2013.2599

Breedveld, F. (2004). Osteoarthritis–the impact of a serious disease Rheumatology, 43 (90001), 4-8 DOI: 10.1093/rheumatology/keh102

Current Depression Among Adults, 2006-2008. (2010). Morbidity and Mortality Weekly Report

Parmelee PA, Harralson TL, McPherron JA, & Schumacher HR (2013). The structure of affective symptomatology in older adults with osteoarthritis. International journal of geriatric psychiatry, 28 (4), 393-401 PMID: 22653754

Prevalence of Doctor-Diagnosed Arthritis and Arthritis-Attributable Activity Limitation – United States, 2007-2009. Morbidity and Mortality Weekly Review, 59(139).

Yohannes AM, & Caton S (2010). Management of depression in older people with osteoarthritis: A systematic review. Aging & mental health, 14 (6), 637-51 PMID: 20686976

Image via Image Point Fr / Shutterstock.

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Psychological Factors Predict Soccer Injuries Sat, 12 Jul 2014 11:00:00 +0000 As the World Cup continues in Brazil, several star players have been left out due to injuries: French winger Franck Ribery due to a back problem, Colombia’s striker Radamel Falcao out with a torn ACL, Germany’s Marco Reus’ ankle injury, Italy’s midfielder Riccardo Montolivo’s broken tibia, and Theo Walcott of England as the result of a knee issue. Awareness of psychological variables can be useful to health professions and coaches who work with players of various levels.

An estimated 65 to 95 percent of elite players sustain a performance-limiting injury in a single season, and research has repeatedly demonstrated that psychological variables such as perfectionism, Type A behaviors, and trait anxiety lead to increased frequency and severity of injuries. The realm of sports psychology lends insight into states of mind which can be predictive of injury.

“Interest in the pathogenesis of sport injuries has led to the general conclusion that two major factors influence injury vulnerability: external factors (e.g. type of sport and weather conditions) and internal factors (e.g. physiological and psychological factors),” note Johnson and Ivarsson, researchers who have focused on psychological predictors of soccer injuries.

Jean Williams’ and Mark Andersen’s stress injury model has been frequently cited in subsequent research. Williams and Andersen proposed that certain psychological traits exacerbate the stress response, which in turn has physiological manifestations making injury more probable. The specific mechanisms by which researchers have suggested that injury occurrences and severity increase as a result of psychological factors include distraction, the narrowing of peripheral vision, muscle tension, and impaired coordination.

Ivarsson et al. also cite Rogers and Landers, whose research found that “peripheral narrowing mediated the relationship between major stressors (i.e. negative life-event stress) and injury occurrence.”

Ivarsson et al. note that “in addition to having to cope with the physical stresses of injury (e.g. pain, discomfort, the rigors of rehabilitation), athletes must contend with the psychosocial stresses of injury such as threats to self-esteem, threats to athletic career involvement, and isolation from peers. Given the profound physical and psychosocial burden of injury, prediction efforts aimed at minimizing injury risk are important.” 

The element of celebrity that accompanies the World Cup introduces a new level of potential stressors in the form of media scrutiny. Recall the frenzy surrounding charges that star French players had relations with an underage prostitute, or the players from Ghana who last month threatened to boycott the game over money concerns. Marital problems and career uncertainty are just some of the sources of stress potentially affecting professional athletes’ performance and therefore safety.

In their own prospective study involving 56 professional Swedish Premier League soccer players, both male and female, Ivarsson et al. used a “Hassle and Uplift Scale” to delve into the players’ perceptions of their “daily hassles,” such as family issues and work relationships, and how these might impact the risk of injury.

They found that “negative life event stress had an indirect effect on injury occurrence through daily hassle,” and that “trait anxiety was indirectly related to injury risk through negative life event stress and daily hassles.” To explain the indirect nature of the injury effect of personality traits, they point to a study by Perna et al., who found that negative emotions were associated with physiological responses, and concluded that “attempts to decrease injury risk should address both the cognitive-affective component of stress and the somatic responses that are likely the causal mechanism behind injury occurrence.”

Similar findings apply to other types of players, such as high school age soccer players and rugby players. With FIFA reporting that more than 270 million people are involved in soccer worldwide, athletes of varying levels could benefit from using the information to better prevent injury. Stressors are ubiquitous, but how athletes perceive and react to them affects their risk of getting hurt while participating in sports. Interventions by coaches and health care professionals, particularly with regard to stress management, could potentially decrease the incidence or severity of injuries.


Devantier, C. (2011). Psychological Predictors of Injury among Professional Soccer Players Sport Science Review, XX (5-6) DOI: 10.2478/v10237-011-0062-3

Ivarsson A, Johnson U, & Podlog L (2013). Psychological predictors of injury occurrence: a prospective investigation of professional Swedish soccer players. Journal of sport rehabilitation, 22 (1), 19-26 PMID: 23404909

Johnson U, & Ivarsson A (2011). Psychological predictors of sport injuries among junior soccer players. Scandinavian journal of medicine & science in sports, 21 (1), 129-36 PMID: 20136759

Williams, J., & Andersen, M. (1998). Psychosocial antecedents of sport injury: Review and critique of the stress and injury model’ Journal of Applied Sport Psychology, 10 (1), 5-25 DOI: 10.1080/10413209808406375

Image via dotshock / Shutterstock.

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Facebook “Likes” and Twitter Followers Predict Personality Traits and More Tue, 17 Jun 2014 22:47:10 +0000 Social networking sites display multiple facets of life: social, professional, and romantic. Self-regulated presentations of self on Facebook, Twitter, dating sites, and other newer forms of communication have led to an unprecedented amount of individual data which can be used by corporations, governments, and other interested parties.

Recent research has repeatedly demonstrated how seemingly innocuous public information such as number of Twitter followers or Facebook “likes” can accurately predict very personal information the user thinks is private, such as personality traits, sexual preference, or health status.

While research on this topic is typically used for marketing purposes, such as targeted ads and recommender systems, it has implications for healthcare providers as well. Kosinski et al. were able to use general Facebook “likes” of photos, friends, and products to identify substance abuse and relationship status with accuracy of around 65 to 73 percent, race and sexual preference with between 75 to 95 percent accuracy, and also cited the example of a U.S. retailer mining shopping records to predict pregnancies among female customers. They point out that “an unexpected flood of vouchers for prenatal vitamins and maternity clothing may be welcome, but it could lead to a tragic outcome, e.g. by revealing (or incorrectly suggesting) a pregnancy of an unmarried woman to her family in a culture where this is unacceptable.”

How does the real person compare to the profile?

Social networking sites provide a wealth of data for research, since a clear log of behavior and interactions is available for mining. Ivcevic and Ambady’s Face to (Face)Book: the Two Faces of Social Behavior? examined whether there were significant differences in Facebook users’ perception of their online behavior compared to their actual online behavior, and how their Facebook behavior compared to their offline behavior, as reported by informants. The researchers found “substantial similarity between online and everyday traits and social behavior,” and that “impressions of personality based on Facebook pages seem to reflect the actual and not the ideal self.” Similarly, they found that Facebook users’ perceptions of their own behavior on Facebook were consistent with their actual behavior. Public social networking sites are a more meaningful source of data for making predictions about individuals when the virtual and actual self are so similar.

Facebook and personality

Facebook has over 1 billion users worldwide, and is almost ubiquitous among younger age brackets. One of the interesting characteristics of Facebook discussed by Caci et al. in their 2014 study Personality Variables as Predictors of Facebook Users is “nonymity,” the opposite of anonymity, or the tendency of Facebook users to post under their real names and use their actual photos rather than anonymous handles and avatars.

Caci et al. looked at personality variables which included openness, conscientiousness, extraversion, agreeableness, and neuroticism, finding that high neuroticism was associated with frequent, longer daily use. They speculate that a “surveillance function tendency” may explain why “nervous and emotionally unstable individuals might try to control what is going on online as often as they can,” also suggesting that impulsivity or boredom may play a role. Conscientiousness was found to correspond to fewer, shorter sessions, with the researchers theorizing that “discipline in daily activities and devotion to work or family” could account for the more minimal involvement in social networking sites. Openness was associated with early adoption and larger groups of friends, echoing previous research with similar findings.

Three basic Twitter counts predict personality

Twitter is fundamentally different from Facebook in that it tends to be more public and open, while Facebook users typically “friend” people that they already know. A study by Quercia et al. classified four types of Twitter users:

  • “Listeners” who follow many users
  • “Popular” users who are followed by many
  • “Influencers”, and the
  • “Highly read” who are listed in multiple tweets

Popular users and Influencers tended to be extroverted and emotionally stable, while Influencers scored high on “conscientious” traits like organization. Three counts of basic public information were all that was needed to predict personality with a surprising degree of accuracy: the number the user is following, the number of followers, and listed counts (number of times the user has been listed in others’ reading lists).

Privacy implications

The authors of the Twitter study liken the privacy implications of their discovery to, a site devoted to “raising awareness about over-sharing” which demonstrates the dark side of seemingly harmless information: By posting Foursquare and Twitter updates with one’s whereabouts, one (unintentionally) implies that one is away from home, a piece of information which could be advantageous to potential burglars.

Similarly, regarding the predictive power of Facebook “likes”, Kosinski et al. reported that the Colbert Report and “science” were among the best predictors of high intelligence, while liking Sephora, “I love being a mom”, Harley Davidson, and Lady Antebellum were predictive of low intelligence. Likes of Wicked the musical and MAC cosmetics were associated with male homosexuality, whereas Wu-Tang Clan, Shaq, and “Being Confused After Waking Up from Naps” were predictive of male heterosexuality. The Twitter or Facebook user may think they are guarding more personal information when they like a product or “check in” to a place, yet the systematic collection and use of this data can often accurately predict user intelligence, sexual orientation, race, addictions, and other personal information.

Narcissism and social networking sites

It has been observed that social media has certain features which may be particularly appealing to narcissists. For example, Facebook “likes” and other features can serve as a frequent source of the affirmation narcissists seek. Sanja Kapidzic points out that “Narcissism, especially, is linked to prominent aspects of self-presentation such as the frequency of status updates, or the amount of self-promoting content displayed.” Social networking sites “provide narcissists with both an audience and a stage for highly-controlled self-presentation.”

A recent rash of Kim Kardashian Instagram “selfies” of her navel framed by beaches in Mexico appears to suggest to us anecdotally what Kapidzic’s research on Narcissism as a Predictor of Motivations Behind Facebook Profile Picture Selection concluded: that narcissism is a predictor of the motivations behind choices of profile pictures intended to emphasize the attractiveness and personality of the user.

Kapidzic reiterates that “studies analyzing self-presentation in various online environments have found that users strategically manipulate visual cues to reflect an ideal, rather than their actual, self, also citing the widely acknowledged tendency of many online dating service subscribers to choose more favorable representations of themselves to appear younger, thinner, or more attractive. Other research found that content with an overt mission to persuade readers of the user’s positive traits are also associated with narcissism.

Some of the takeaways from these studies are that seemingly nonspecific or impersonal data can often be used to draw fairly accurate conclusions of a very personal nature. Also, healthcare providers, who are increasingly interacting with patients via nontraditional channels, should be aware of the insight that can be gleaned from social media use, which is no longer just for marketing professionals. While certainly no substitute for face to face interaction, physicians and adolescent counselors should be aware that social media can serve as a window for information regarding social support systems, substance abuse, and other individual behavior.


Caci B, Cardaci M, Tabacchi ME, & Scrima F (2014). Personality variables as predictors of Facebook usage. Psychological reports, 114 (2), 528-39 PMID: 24897905

Ivcevic Z, & Ambady N (2013). Face to (face)book: the two faces of social behavior? Journal of personality, 81 (3), 290-301 PMID: 22812602

Kapidzic S (2013). Narcissism as a predictor of motivations behind Facebook profile picture selection. Cyberpsychology, behavior and social networking, 16 (1), 14-9 PMID: 23249240

Kosinski, M., Stillwell, D., & Graepel, T. (2013). Private traits and attributes are predictable from digital records of human behavior Proceedings of the National Academy of Sciences, 110 (15), 5802-5805 DOI: 10.1073/pnas.1218772110

Quercia D, Kosinski M, Stillwell DJ, Crowcroft J (2011.) Our Twitter profiles, our selves: Predicting personality with Twitter. IEEE International Conference on Social Computing. Proceedings of the 2011 IEEE International Conference on Privacy, Security, Risk, and Trust, and IEEE International Conference on Social Computing, pp 180–185.

Image via Nopporn / Shutterstock.

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Who Uses Complementary and Alternative Medicine? Mon, 09 Jun 2014 11:00:42 +0000 The most recent National Health Interview Survey reports that in the preceding 12 months, 38% of Americans used complementary and alternative medicine (CAM); defined as “a group of diverse medical and health care systems, practices, and products that are not generally considered part of conventional medicine.” So why is interest in alternative therapies increasing?

In general, complementary medicine refers to the use of unconventional medical therapies in conjunction with conventional medical treatment, while alternative medicine implies substitution for conventional medical therapies. More often, CAM is used in addition to conventional Western medicine.

While definitions of CAM vary, they frequently include, but are not limited to, massage, acupuncture, deep breathing, chiropractic adjustment, meditation, yoga, qi gong, vitamins and supplements, and guided imagery. In the Journal of Clinical Psychology, Crystal Park points out that “demographics associated with CAM use are fairly well established, but less is known about their psychological characteristics.” Other studies suggest that CAM use is associated with positive health behaviors and behavioral change. Consequently, the psychology of CAM users has implications as healthcare reform and other industry shifts move conventional providers towards integrated, outcome-focused care where they are expected to exert greater influence on patient behavior.

Increasing use of CAM in the United States

Out of pocket expenditures on CAM for the preceding 12 months, based on the CDC’s 2007 National Health Interview Survey, were almost $34 billion. Park reports that: “In the United States in 2007, the most commonly used CAM modalities were nonvitamin, nonmineral, natural products (17.7%), deep breathing exercises (12.7%), meditation (9.4%), chiropractic and osteopathic manipulation (8.6%), massage (8.3%), and yoga (6.1%).”

There was a precipitous drop in the government’s report of CAM use by Americans between 2002 and 2010. The 2002 National Health Interview Survey reported that 62 percent of Americans used CAM in the past 12 months. Due to the subsequent decision to reclassify prayer, which was previously included as a CAM modality and is no longer included in the definition, the number declined to 38.3 percent, still a substantial portion of the population. Prayer remains on the survey, but is no longer part of the CAM definition.

Contemporary research has attempted to quantify CAM use by the population, identify demographic predictors of use, and assess perceived CAM effectiveness related to specific conditions. The National Health Interview Survey collects substantial information on CAM use, perceived efficacy, as well as a multitude of conditions for which CAM is used. Other data sources specific to certain conditions, such as arthritis, have been used to examine both the efficacy of treatments and demographic characteristics of patients. Park suggests that increasing interest in CAM in the U.S. may be due to “greater awareness of the critical role that psychological distress plays in many medical conditions and health outcomes along with increased acceptance of the biopsychosocial model.”

Several studies suggest that women and middle-aged people are more inclined to use CAM. While women in general tend to seek healthcare more often than men, Park cites studies which find an “amplified” tendency for CAM use among women relative to overall use of health services.

While much research has focused on minorities and CAM use, the findings have been mixed. CAM use has been shown to increase with education and income, with more consistent results supporting the association with increased education. Explanations offered have included the idea that more educated patients are more capable of identifying and researching possible alternative treatments.

Studies have found an inverse relationship between health status and CAM use, which is consistent with other studies finding that increases in CAM use accompany multiple chronic conditions. Willison et al. found that chronically ill people use CAM two to five times as much as those who are not chronically ill. Interestingly, in the NHIS, only 30 percent of users of mind-body types of CAM used it for a specific condition; general wellness is a frequent aim of patients utilizing CAM.

Psychological traits of users

Parks reports that “psychological characteristics associated with higher mind-body CAM use include higher levels of openness, extraversion, social support, and goal persistence,” and that “considering one’s illness as having more severe consequences and beliefs that one has control over one’s health are related to greater use of mind-body CAM. Study participants who have used CAM have voiced motivations including wanting greater control over one’s health and dissatisfaction with conventional medicine. Greater awareness and practice of healthy behaviors has been associated with CAM use.

In a study of 243 British adults, Furnham sought to determine whether certain “big 5” personality traits, “modern health worries”, and attitudes towards science predicted attitudes and beliefs about CAM, wondering whether CAM was associated with neuroticism, skepticism towards science, or high levels of modern health worries. Furnham found that regular and occasional CAM users have higher modern health worries relative to non-users. Young males with a positive attitude toward science were the least likely to turn to CAM, and positive attitudes towards science were associated with skepticism towards CAM. The personality traits measured in the study were not predictive of CAM use.

Another aspect of the behavior of CAM users which has been the subject of research is whether or not they tell their conventional medical providers that they are using complementary or alternative therapies.

One study looked at potential adverse reactions between commonly used conventional treatments and CAM treatments. A study of urban, under-served minority patients with rheumatoid arthritis determined that 71.6 percent of research participants were using CAM, and that 59 percent shared this information with their provider. This same study found that women were more likely to disclose their use of CAM to their providers, while Hispanics were less likely to mention their CAM use.

Other research has found that many patients do not discuss their CAM treatments with their doctors. The National Center on Complementary and Alternative Medicine (NCCAM) and AARP identified common reasons that patients withhold this information: 42 percent said their provider never asks, and 30 percent said they didn’t know if they should raise the issue. As a result, the NCCAM started an educational campaign to promote discussions between providers and patients about CAM use: “Considering this and other campaigns addressing patient-provider relations it is of interest that an individual’s self-efficacy and their level of participation in health decision making are both potent.”

CAM use in other parts of the world

CAM is popular throughout the world. A study of South Koreans found that nearly 75 percent of those surveyed had used CAM in the last 12 months. A large Australian study found that 52 percent were current CAM patients and that 85 percent had used CAM treatments in their lifetime. The lifetime CAM use estimate from one UK survey was nearly half of those surveyed.

However, motivations differ among cultures. For instance, Koreans indicated that disease prevention and health promotion were the principal motive for CAM, with 45.8 percent seeking increased energy, 9.1% hoping to prevent disease, and 12.7 percent seeking anti-aging effects or beauty. Treatment of medical problems was the reported as the motive for only 20.3 percent of Korean survey participants, whereas in America people suffering from chronic conditions, particularly musculoskeletal problems, most often seek CAM.

Research gaps

Despite the quantity of research on the subject, there are relatively few definitive findings. This is due to the high degree of variability in CAM definitions, as well as variability in application. Park notes that “the specific definition of CAM used in any particular study strongly shapes the results of its prevalence statistics,” citing the earlier example of prayer. CAM treatments are also characterized by a great degree of heterogeneity. Many are self-administered, while others involve various practitioners.

Yoga and meditation methods vary considerably, for example. With so many CAM users using it for overall health rather than specific conditions, it is difficult to draw conclusions from the NHIS and other surveys. Efficacy measures often rely on subjective scales and self-reporting. Further convoluting the matter is the fact that so many CAM users have multiple, coinciding conditions for which they may be using CAM. Park also notes that CAM modalities “differ in historical precedent, cultural acceptability, cost, safety, extent to which they are systematic and rooted in traditional or new age approaches and purported mechanism of effect and the plausibility of that mechanism.”

Implications for health professions

CAM use has significant implications for various healthcare stakeholders. Since most CAM expenditures represent out of pocket costs to patients, insurers stand to gain where patients opt for non-covered services they deem more effective that prescriptions or conventional treatments which tend to be covered. Many conventional providers, such as primary care physicians, have integrated certain types of CAM into their business models, as a source of cash business and in response to patient demand.

As CAM gains traction as a socially acceptable means of treating chronic conditions, research efforts will continue to expand. Crystal Park duly noted that: “Knowledge about CAM modalities and their integration into clinical health psychology can be useful for researchers interested in taking a broader perspective on stress and coping processes, health maintenance and illness behaviors, and culture, and for practitioners seeking to incorporate CAM perspectives and techniques into their work. The increasingly expanding and officially recognized use of CAM warrants greater attention by conventional health care practitioners, decision makers, and researchers.”


National Health Interview Survey (2010). National Center for Health Statistics, Centers for Disease Control and Prevention.

Furnham A (2007). Are modern health worries, personality and attitudes to science associated with the use of complementary and alternative medicine? British journal of health psychology, 12 (Pt 2), 229-43 PMID: 17456283

Park C (2013). Mind-body CAM interventions: current status and considerations for integration into clinical health psychology. Journal of clinical psychology, 69 (1), 45-63 PMID: 22936306

Wallen GR, & Brooks AT (2012). To Tell or Not to Tell: Shared Decision Making, CAM Use and Disclosure Among Underserved Patients with Rheumatic Diseases. Integrative medicine insights, 7, 15-22 PMID: 23071389

Image via Andrey Popov / Shutterstock.

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The Self-Help Industry Helps Itself to Billions of Dollars Fri, 23 May 2014 11:00:22 +0000 Self-improvement represents a $10 billion per year industry in the U.S. alone. In addition to high revenues, self-help also has a high recidivism rate, with the most likely purchaser of a self-help book being the same person who purchased one already in the last 18 months. This begs the question of how much good these self-help books and seminars are doing for consumers. If they are so effective at solving our problems, why do they usually result in a continuing stream of self-help purchases?

Self-help books are frequently followed by a train of formulaic subsequent manuals for happiness, weight loss, success, money, or spirituality by the very same authors, fueling the 6.1% average annual growth rate projected by Marketdata Enterprise Inc. The New Statesman’s Barbara Gunnell forecasts a secure future for positive psychology, noting that “never has an age been so certain that it deserves not just freedom from distress, but positive well-being” and that “the worried well with a belief in their right to feel good are a lucrative market.” Furthermore, the credentials of self-help authors are uneven, and research has documented the noticeable absence of empirical evidence supporting the advice so copiously pumped out to the masses.

The origins of the self-help genre have been attributed to Victorian phrenologist George Combe’s The Constitution of Man (1828), followed by Ralph Waldo Emerson’s Compensation. Dale Carnegie, famous for his books How To Win Friends and Influence People (1936) and How to Stop Worrying and Start Living still holds a top-ranking spot on to this day.

In the 1950s and 60s, Abraham Maslow “proclaimed the supremacy of the self-actualizing person, who realizes the fullness of his or her nature – without doing harm to others, or course – and lives as happily as one can on earth,” notes Algis Valiunas. Among the more modern offerings, Tony Robbins has raked in $80 million in a year and John Gray’s New York Times best-seller Men Are From Mars, Women Are From Venus “outsold almost every other book in the known universe except the Bible” claims Valiunas in The New Atlantis. In his particularly eloquent and scathing commentary, “The Science of Self-Help,” Valiunas points out that “this is the scientific fruit of those who consider themselves not only the wisest of our time but evidently the wisest of all time,” with teaching that is “sensible, unexceptional. It is also obvious and insipid. Accept imperfection and pain. Do some jogging. Slow down and count your breaths.”

Credentials of Self-Help Authors and Recurring Themes Among Best-Sellers

Norah Dunbar and Gordon Abra conducted a survey of current self-help literature, with 2 aims: first, to determine whether the people advising the masses had the appropriate credentials to do so, and second, to identify common themes among top selling self-help books.

Using to identify the most popular self-help authors by searching terms including “marriage”, “relationships”, and “communication,” the researchers identified 31 authors. Among them, two were medical doctors and 19 held doctorates, mostly PhDs in psychology, with two in linguistics or education. Seven held a master’s degree in social work, counseling psychology/family therapy, or theology, with one in film studies. Two authors had no formal education, and one had a bachelor’s degree in Home Economics. “All degrees were from accredited institutions except one. Gray’s degree is from the unaccredited and now defunct Columbia Pacific University,” state Dunbar and Abra.

Another component of this query was whether the authors of popular self-help books used research published in academic journals to support their advice. The majority did not, relying solely or primarily on anecdotal evidence: “Few of the popular authors are basing their opinions about communications on empirically-tested research findings. Fewer than 20% had based their findings on a sustained program of research and less than half had published even one article in peer-reviewed journals or books.”

With regard to overarching themes, the researchers identified five. The first was the use of banking or financial metaphors and analogies, such as “love bank”, “account balances”, “relationship bank account,” and other references amounting to debits and credits to relationship satisfaction. Chapman, author of The Five Love Languages (and all the subsequent variations thereof, such as the singles edition, men’s edition, and so on), is quoted: “I am convinced that keeping the emotional love tank full is as important to a marriage as maintaining the proper oil level is to an automobile. Running your marriage on an empty ‘love tank’ may cost you even more than trying to drive your car without oil.”

A second theme dealt with creating buckets or types in which to neatly categorize people, where the reader is supposed to find their category and follow the advice tied to that category or type. For example, dichotomous types were found in Gray’s Men Are From Mars, Women Are From Venus (male and female) and in Lerner’s book, which the researchers say “places women into two types: ‘bitches’ and ‘nice ladies.’” A third commonality was the step format, where the authors offered simple steps to implement solutions. They note that seven seems to be the “magic number” of steps, with The Seven Principles for Making Marriage Work, The Proven 7-Step Program for Saving Your Marriage, and The 7 Habits of Highly Effective People.

A fourth common element was emphasis on childhood for past models, where childhood experiences were major determinants of current relationship behavior. The fifth theme involved offering the reader exercises to complete.

A Lack of Evidence

Bibliotherapy is clearly cheaper than counseling. There is minimal risk to the consumer who invests in one book. Financially, self-help books are accessible to a greater number of people than life coaches and counselors, and there is arguably more anonymity in a book purchase than a relationship with a local therapist. This can be especially appealing to people with stigmatizing problems.

However, it’s difficult to test the effectiveness of these books. Researchers Norah Dunbar and Gordon Abra cite Rosen, stating that two main conclusions that can be drawn from bibliotherapy literature: “First, techniques applied successfully by a therapist are not always self-administered successfully,” and “second, the therapeutic value of a self-help book can only be determined by testing the specific instructions to be published under the conditions in which they are to be given. The fact that people are free to read all or only part of a particular book, and follow the book’s advice to varying degrees makes it difficult to evaluate the effectiveness of self-help books for their therapeutic value.”

Corporate Self-Help

In addition to the typical female, middle-class, educated consumer buying the majority of self-help products, the corporate wallet has opened up to the happiness and success industry. In recent Securities and Exchange Commission filings, publicly traded Franklin Covey, whose mission is “enabling greatness in people and organizations everywhere,” warns shareholders of the risks of an “intensely competitive” industry with easy entry by new competitors. Franklin Covey sells training and consultancy on topics including leadership, execution, productivity, sales performance, customer loyalty, and educational improvement. In the New Statesman’s article, “The Happiness Industry,” a psychologist challenges whether the best interests of workers are served where corporations are paying the bills of coaches and consultants.

Egalitarianism versus Reality

In additional to the presumption of autonomy, there seems to be a certain egalitarian assumption underlying the demand for self-help: that the end result being sought is attainable to virtually all. Counters Valiunas: “Beauty, size, strength, health, energy, disposition, verbal or spatial or mathematical or emotional intelligence, ability in music or painting or oratory simply are not parceled out equally- and in any chosen activity, not even a single-minded devotion or expert training and wholesome diet can ensure that all will come out even in the end. Natural inequalities will always make for differences between one person and the next, and these differences will always be cause for unhappiness.”

However, Valiunas praises Malcolm Gladwell’s Outliers, which instead of offering quick five or seven step fixes or dropping people into buckets such as genius and non-genius, suggests that years of hard work and deliberate practice can lead to self-improvement. “That does not mean everyone will be above average, as the old joke goes. It does mean that the average should rise, and everyone willing to put in the work be able more fully to realize his potential, if not necessarily his dreams.” However dreams of the perfect relationship, the perfect career, and the perfect weight continue to sell off the shelves.


Dunbar, N. and Abra, Gordon (2006). Popular Self-Help Books on Communications in Relationships: Who’s Writing them and What Advice Are They Giving? Paper presented at the annual meeting of the International Communication Association, Dresden International Congress Centre, Dresden, Germany, Jun 16, 2006.

Gunnell, B. (6 September 2004). The Happiness Industry. New Statesman.

Valiunas, A. (2010). The Science of Self-Help. The New Atlantis: A Journal of Technology and Society.

Van Wyhe, J. George Combe Phrenologist and Natural Philosopher (1788-1858). The Victorian Web.

Image via maxriesgo / Shutterstock.

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Jury Still Out On After Effects of Concussion Wed, 14 May 2014 15:50:04 +0000 Controversy surrounding Postconcussion Syndrome (PCS) dates back to the 1800s. 150 years on, contention still surrounds the lingering symptoms of insomnia, dizziness, irritability, depression, cognitive impairment and so on that affect between 30 and 80 percent of Americans following a mild traumatic brain injury (mTBI), or concussion.

The present day billboards of personal injury attorneys seeking auto accident victims as clients hark back to the late 19th century, when railways became a popular means of travel. During that time, railway accidents, and the number of physicians reporting on conditions such as “Railway Spine”, increased dramatically. Present day conditions of PCS and whiplash present similar symptoms, with etiology that is still the subject of debate. With billions of dollars of claims at stake, courtroom adversaries can pick and choose from a range of conflicting studies and theories.


In his book Post-Traumatic Neurosis, physician Michael Trimble notes that:

“In the nineteenth century and before, legal cases involved with personal injury were mainly to do with material injuries, such as loss of a limb or an eye, where objective evidence was unmistakable and quantifiable. With the advent of ‘concussion of the spine’ the situation changed, and the concept that the injured were victims of at best ‘shock’ and at worst spinal anaemia or meningitis became prevalent.”

In the late 1800s, the dominant theory involved organic lesions of the spine and brain. London surgeon John Eric Erichsen gave famous lectures in 1866, later republished in book format in 1875 as On Concussion of the Spine: nervous shock and other obscure injuries of the nervous system in their clinical and medico-legal aspects, in which he opined:

“The primary effects of these concussions or commotions of the spinal cord are probably due to changes in its structure. The secondary are mostly of an inflammatory character, or are dependent on retrogressive organic changes, such as softening, etc., consequent on interference with its nutrition.”

This view was challenged in the 1880s by London and Northwest Railway surgeon Herbert Page, who asserted that one of Erichsen’s spinal concussion cases was potentially suffering the effects of syphilis instead, and pointed to a lack of post-mortem data in the majority of spinal concussion cases. Dr. Page proposed that fear and shock played a role, suggesting psychological rather than organic causes in the large number of people who had been in relatively minor accidents yet remained symptomatic afterwards.

Among the many train crash victims was Charles Dickens, famous author of A Tale of Two Cities, A Christmas Carol, and Great Expectations. Dickens’ carriage did not go over the bridge, but was too close for comfort, dangling. He described “two or three hours work afterwards around the dead and dying surrounded by terrific sights”. Dickens suffered from symptoms including weakness and anxiety and being “not quite right within,” which he attributed to “the railway shaking.”

Later, Oppenheimer moved from the theory of “Railway Spine” to “Railway Brain”, like Erichsen attributing symptoms to an organic cause. Pioneering French neurologist Charcot suggested manifestations of hysteria instead. After World War II, as cars became popular, whiplash injuries multiplied, resulting in similar clusters of symptoms.

The Present Problem

According to the CDC, there were 2.5 million emergency room visits, hospitalizations, or deaths associated with traumatic brain injury, the majority of which were concussions, or “mild TBI”, in 2010. These numbers are understated, as they do not include those head injuries which did not involve a trip to the hospital. While causes vary and include falls, auto accidents, assault, occupational accidents, and sports, some of these, such as auto or occupational accidents, result in litigation.

Injury claims in the U.S. cost billions of dollars each year. Veronique de Rugy, a senior research fellow at George Mason University’s Mercatus Center indicated that despite medical advances which allow people to remain on the job, the number of Americans claiming disability has increased more than 6 fold.

Her report points to the fact that changing standards put more weight on self-reported pain and discomfort. Auto accidents follow a similar trend where the cost of claims is rising while the overall severity of injuries is declining.  

The Coalition Against Insurance Fraud estimates that fraudulent claims cost $80 billion per year in the U.S. In a litigious society with so much money at stake, plaintiffs are often portrayed negatively by the media. In particular, those who are injured in ways that are not obviously disfiguring frequently are subject to great scrutiny and accusations of fraud. Types of fraud can include malingering, falsely assigning real symptoms to a compensable cause, or misrepresentation of diminished capacity following injury.

Diagnosis of PCS depends largely on self reporting. An observed loss of consciousness is not necessary,  and common symptoms such as headache, irritability, loss of memory and the ability to concentrate, dizziness, and sensitivity to noise or alcohol do not lend themselves to objective, verifiable measurement. Some of these complaints are also highly prevalent in the general population.

Some explanations allow for the legitimacy of reported symptoms, while largely dismissing organic causes. Instead, other theories offered include psychogenic causes. Symptoms such as insomnia, dizziness, headache, and cognitive impairment can overlap with depression, anxiety, and post-traumatic stress disorder (PTSD). Studies have found premorbid depression common to almost half of those who develop PCS. Another study found that mild TBI was not a risk factor for PCS after adjusting for PTSD and depression. PTSD was found in other research to be the strongest predictor of PCS. (PTSD could also offer an explanation for what Dickens described following the train wreck).

Studies have found a link between persistent PCS and potential financial compensation. Evans reports that “on neuropsychological testing, there is a dose-response relationship between an increasing amount of potential compensation and an increasing rate of failure on malingering indicators, particularly in those who have suffered only mild TBI.”

Lithuania served as a testing ground, chosen for the fact that compensation for post-traumatic headache is unlikely there, and because the general population has fewer “expectations of persisting symptoms than in a Western society.” Among emergency room patients with mild headache injuries and loss of consciousness not exceeding 15 minutes, headaches disappeared within a month for the overwhelming majority of Lithuanian subjects- 96 percent of respondents. However this does not necessarily prove that American plaintiffs with PCS are faking.

Litigation Response Syndrome

While prospective studies of emergency room patients in other countries on the surface appear to support non-organic etiology, it is worth noting that studies of neurasthenia have found that cultural factors can influence the manifestation of clinical symptoms. Additionally, a group of stress problems known as Litigation Response Syndrome have been described, the symptoms of which mirror PCS.

People can become “so terrified and emotionally traumatized by the litigation that they appear to have mental disorders,” explains expert Paul Lees-Haley. When plaintiffs are followed by insurance investigators, subjected to intrusive depositions and compulsory medical exams conducted by strangers, must hand over their private medical records to insurance company employees, and are constantly bombarded with medical bills and legal documents, symptoms such as stress, insomnia, anxiety, and dizziness may ensue, but not be attributable to the actual injury.

However, since the litigation, and therefore the symptoms, did not occur prior to the injury, patients could reasonably believe that the injury caused the symptoms. This is also a plausible explanation for why these symptoms are so persistent in U.S., but not in places like Lithuania where litigation is less common.

Due to the subjective nature of the symptoms associated with PCS, and the substantial overlap with highly prevalent psychiatric and medical conditions such as headaches and depression, it is unlikely that the debate will be fully resolved in the near future. Research has increased as a result of the return of veterans with brain injuries and PTSD as well as increased awareness of sports related concussions, which should result in more refined studies of specific subsets of the population with PCS symptoms.


De Rugy, V. (August 7 2013). Social Security Disability Costs are Exploding. The Washington Examiner.

Evans RW (2010). Persistent post-traumatic headache, postconcussion syndrome, and whiplash injuries: the evidence for a non-traumatic basis with an historical review. Headache, 50 (4), 716-24 PMID: 20456159

Lees-Haley, P.(1989). Litigation Response Syndrome: How Stress Confuses the Issues. Defense Counsel Journal, 110.

Rogers R, & Payne JW (2006). Damages and rewards: assessment of malingered disorders in compensation cases. Behavioral sciences & the law, 24 (5), 645-58 PMID: 17016811

Styrke, J. (2012). Traumatic Brain Injuries and Whiplash Injuries. Umea University Department of Surgical and Perioperative Sciences.

Trimble, M. R. (1981). Post Traumatic Neurosis. New York: John Wiley and Sons.

Image via Riccardo Piccinini / Shutterstock.

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Executive Pathologies – The Relationship Between CEO Narcissism and Fraud Wed, 16 Apr 2014 15:19:18 +0000 Research suggests an association between CEO personality traits and fraudulent behavior. Narcissism has been linked to manipulation of financial results, which has implications for the executive selection process, board oversight, and the structuring of executive compensation packages.

The celebration of financial misconduct in movies like The Wolf of Wall Street tends to focus on the enthralling aspects of the perpetrator’s personality, rather than the economic woe that ensues for other, less glamorous stakeholders such as the average investor or the employee who loses his or her job in the wake of a scandal.

The Committee of Sponsoring Organizations report Fraudulent Financial Reporting 1998-2007: An Analysis of U.S. Public Companies analyzed 347 fraudulent financial reporting occurrences investigated by the SEC from 1998 to 2007, and found CEO and/or CFO involvement in 89 percent of the cases, with the CEO specifically implicated in 72 percent of those cases.

The report also found that the magnitude of losses from financial misstatement and misappropriation has been on the rise: 300 of the cases together resulted in over $120 billion in losses.

Fraud Behavior

Allegedly, one of the first instances of financial statement fraud at a publicly traded company occurred in the 1600s at the British East India Company. Economist Adam Smith, in his 1776 Inquiry into the Nature and Causes of the Wealth of Nations, mentioned shareholders suffering from the effects of fraud as well. Fraud is everywhere. More than 80 percent of respondents to a 2012 FINRA national survey on Financial Fraud and Fraud Susceptibility in the United States indicated that they had been solicited to participate in a potentially fraudulent offer. Of concern, many Americans appear to be unable to discern signals of potential fraud, such as unreasonable rates of return or “fully guaranteed” investments. Accounting scandals also show the failure of auditors to detect or report financial results fraud by executives.

Models explaining factors contributing to fraud behavior have evolved from the fraud triangle, consisting of three points that criminologist Cressey proposed must be present at the same time: pressure, opportunity, and rationalization. Wolf and Henderson later stretched Cressey’s fraud triangle into a fraud diamond by adding a fourth element: capability, suggesting that capability is what allows the fraudster to identify and take advantage of deficiencies in internal controls and effectively cover up misconduct.

Studies and surveys demonstrate that financial fraud is a slippery slope, with “accidental fraudsters” transitioning into “predators.”  When pressure, opportunity, and rationalization combine, Cressey’s fraud triangle explains unethical behavior by a seemingly normal person, the “accidental fraudster”. However, once the criminal mindset takes hold, pressure and rationalization fade into the background, and the remaining condition of opportunity is all that is required for the predatory fraudster. The desensitization that occurs after committing fraud and which leads to more fraudulent behavior has been noted in fraud literature.

“Managing earnings” is often a euphemistic way of referring to deliberate or fraudulent manipulation of financial results to change the picture of a company’s financial position prior to presentation to board members or shareholders by exploiting gray areas in accounting on how and when revenue and expenses are recognized. It’s relatively easy to turn losses into a profit on the books by estimating and recording more revenue in a particular time period.

Researchers have proposed that “financial statement fraud perpetrators often appear to start as accidental fraudsters by managing earnings, trying to buy time for their organization until conditions improve. But sooner or later, managing earnings gives way to financial reporting fraud, and the accidental fraudster becomes a predator.”

Executive Involvement

Studies show little correlation between income level and fraud. The tendency to compare one’s social status to that of other people, as well as a culture of competition, have been cited in surveys as potential motives for financial fraud committed by otherwise affluent CEOs. Coleman offered that wealth and success, rather than being goals, become entrenched in the individual’s sense of identity.

The “pressure” component of Cressey’s fraud triangle, therefore, may come in the form of internal pressure to preserve one’s image rather than external financial pressure.  Among high profile cases, often the CEOs who committed fraud did so for payoffs which seem trivial relative to their very generous legitimate compensation packages. This seems to suggest that personality and other factors contribute to financial fraud behavior by CEOs.

The role of CEO Narcissism

The DSM-IV definition of narcissism encompasses “a pervasive pattern of grandiosity (in fantasy or behavior), need for admiration and a lack of empathy, beginning by early adulthood and present in a variety of contexts.” While Kets de Vries notes that “a solid dose of narcissism is a prerequisite for anyone who hopes to rise to the top of an organization”, and others have suggested that all leadership is inherently narcissistic to some degree, narcissism can be viewed on a sliding scale. Certain levels of narcissistic traits in leadership have been categorized as constructive, having a positive effect on an organization, whereas other more extreme forms of narcissism have had destructive effects on companies and their stakeholders. Dysfunctional, high levels are categorized as Narcissistic Personality Disorder, the prevalence of which is estimated to be between 0.7 to 1 percent of the population.

The “narcissistic paradox” refers to the seeming contradiction where narcissists lack self-confidence and self-esteem and overcompensate by representing themselves as superior to other people. According to Rijsenbilt and Commandeur, “In order to protect themselves from being criticized, narcissistic people constantly look for affirmation and tend to ignore the feelings, words, and behaviors of others and therefore cultivate underdeveloped feelings of empathy.” Investigators of CEO narcissism have expressed the idea that financial reporting, due to its frequent and periodic nature, serves as a regular source of affirmation of the CEO’s greatness.

A study by Chatterjee and Hambrick found a “strong indication” of an association between “large annual fluctuations in accounting returns” and CEO narcissism. In Accounting as a Facilitator of Extreme Narcissism, Amernic and Craig propose that accounting is a choice tool for narcissistic CEOs, allowing them to “construct a narrative about the corporation and themselves using financial accounting measures.” Pointing out that the general public perceives accounting to be rigid, objective, and scientific, when in fact accounting rules are often subjective and malleable, they “suggest that many narcissistic CEOs make accounting policy choices and earnings management decisions to maintain a positive sense of self, defend their egos, and preserve self-esteem.”

Measures of CEO performance often reside in the accounting world, namely financial metrics such as earnings per share (EPS), return on investment (ROI), and net income. Since narcissistic CEOs view these as a reflection of self and personal accomplishment, they are inclined to manipulate them by exercising their power over accounting policies and procedures. These same metrics also serve as a basis for compensation for many CEOs, so there are significant monetary rewards to be reaped from artificially rosy financial ratios.

Several aspects of accounting which appeal to narcissistic CEOs have been described by Amernic and Craig: financial reports regarded as personal report cards, the fact that accounting measures are “amenable to refraction and distortion by them,” and that a company’s financial reporting, “which can produce unflattering self-images, can be tailored easily to reflect a picture of financial performance that is more flattering and ego-satisfying for a CEO.” The perception of accounting by the general public as something more objective and neutral than it really is, as well as the “social patina of presumed external auditor independence” are also cited as reasons accounting manipulation appeals to narcissist CEOS.

A 2013 study by Rijsenbilt and Commandeur followed up on previous research suggesting that narcissists have a propensity to set unrealistic or unattainable goals as a result of the constant “intense need to have their superiority continually reaffirmed.” Using a sample of 953 S&P 500 CEOs from all industries, they found a positive relationship confirming the influence of CEO narcissism on fraud. The researchers used proxies for narcissism, such as the size of the CEOs’ photos in annual reports (2 pages of photos of the CEO alone, rather than with a team, were worth a maximum of 12 points), number of biography lines in the Marquis Who’s Who database, the “Idi Amin phenomenon” of holding multiple titles signaling a consolidation of power, whether the CEO was also chairman of the board, and perquisites. The resulting narcissism score was used in conjunction with the SEC’s Accounting and Auditing Enforcement Releases which name CEOs and their involvement in financial misstatement or fraud.


Narcissistic CEOs, largely ignoring the long term interests of shareholders and employees, may engage in high risk and unethical behaviors which jeopardize organizations.

Studies have linked aggressive merger and acquisition behavior with the propensity to commit financial fraud, and found that executives at high growth firms are more likely to engage in such behavior. The destructive effects of their behavior include tremendous economic damage to multiple stakeholders, including employee job loss and loss of investor money and confidence. Firms with fraud activity are more likely to declare bankruptcy.

The body of literature surrounding narcissism and accounting fraud has implications for the executive screening process, board oversight, auditors, and the design of executive compensation packages. Amernic and Craig propose that understanding narcissism offers insight into CEO involvement in unethical financial reporting practices. Boards and audit committees should pay attention to CEO personality traits and power consolidation. CEO involvement in the auditor selection process also warrants scrutiny. Research demonstrates that the personalities and pathologies of leadership have the capacity to greatly impact various stakeholders.


Amernic, J., & Craig, R. (2010). Accounting as a Facilitator of Extreme Narcissism Journal of Business Ethics, 96 (1), 79-93 DOI: 10.1007/s10551-010-0450-0

Boyle, D., Carpenter, B., and  Hermanson, D. (2012). CEOs, CFOs, and Accounting Fraud. The CPA Journal.

Dorminey, J., Fleming, A., Kranacher, M., & Riley, R. (2012). The Evolution of Fraud Theory Issues in Accounting Education, 27 (2), 555-579 DOI: 10.2308/iace-50131

Financial Fraud and Fraud Susceptibility in the United States: Research Report from a 2012 National Survey. FINRA Investor Education Foundation.

Fraudulent Financial Reporting 1998-2007: An Analysis of U.S. Public Companies. (2010). Committee of Sponsoring Organizations of the Treadway Commission

Rijsenbilt, A., & Commandeur, H. (2012). Narcissus Enters the Courtroom: CEO Narcissism and Fraud Journal of Business Ethics, 117 (2), 413-429 DOI: 10.1007/s10551-012-1528-7

Zona, F., Minoja, M., & Coda, V. (2012). Antecedents of Corporate Scandals: CEOs’ Personal Traits, Stakeholders’ Cohesion, Managerial Fraud, and Imbalanced Corporate Strategy Journal of Business Ethics, 113 (2), 265-283 DOI: 10.1007/s10551-012-1294-6

Image via Gajus / Shutterstock.

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Dental Anxiety’s Past and Its Lucrative Future Sat, 05 Apr 2014 11:30:40 +0000 Dental horrors abound in literature, artwork, and dental museum exhibits. Throughout most of the world’s history, dentistry, like childbirth, has been associated with intense pain. Yet in our modern era of preventive maintenance, restoration, and local anesthesia, the prevalence of dental anxiety remains persistently high. This widespread dental angst has created a ripe market for profitable sedation dentistry.

As the authors of a 2011 study point out, “consternation in dentistry” has been classified as dental fear, dental anxiety, and dental phobia. They propose that dental fear is the result of “a real, immediate, present and specific stimulus, such as needles or drilling,” whereas dental anxiety is characterized by a threat “ambiguous, unclear, and not immediately present.”

Other researchers have suggested that “dental phobia” is a misnomer, and that most dental anxiety is closer to a form of post-traumatic stress disorder, recommending that it be conceptualized as “Posttraumatic Dental-Care Anxiety” (PTDA) and classified as part of the PTSD spectrum. Bracha et al., (2006) state: “In our experience, most individuals with dental “phobia” do not recognize their symptoms as ‘excessive or unreasonable,’ and in that sense resemble individuals with PTSD. Our review of the dental-care literature suggests that true (innate) dental phobias (akin to unreasonable fear at the sight of blood or a syringe) probably account for a smaller percentage of cases, and that the vast majority of dental-care anxiety cases stem from aversive dental experiences.”

Tools commonly employed by researchers to identify dental anxiety include the Modified Dental Anxiety Scale and Corah’s Dental Anxiety Scale. Patients are asked questions such as “When you are waiting in the dentist’s office for your turn in the chair, how do you feel?” or “While you are waiting and the dentist is getting out the instruments which he or she will use to scrape your teeth around the gums, how do you feel?”

Dental anxiety is not merely the fear of pain. Nineteenth century literature paints a picture of what modern researchers delving into dental anxiety have categorized as a feeling of  “existential threat.” During the same year that Carl Koller first used cocaine as a local anesthetic for dental procedures, and about twenty years prior to German chemist Alfred Einhorn’s creation of what became widely known as Novocaine, French author Joris-Karl Huysmans described in his famous novel A Rebours an intrusive and anxiety-provoking memory of a molar extraction at the hands of “a mechanic who called himself a dentist of the people and who lived down near the quays.” Gatonax, The People’s Dentist, operated on the third floor, accessible from a “darkened stairway” stained with “large gobbets of blood-red spittle.”

Huysmans’ protagonist, Des Esseintes, recounts the procedure:”A cracking sound was heard, the molar was breaking as it came out; then it seemed to him that his head was being torn off, that his skull was being shattered; he lost all self control, had shouted at the top of his voice, furiously trying to defend himself against the man, who threw himself afresh on him, as if he wanted to force his arm into the very depths off Des Esseintes’ bowels, then he suddenly took a step back, and, lifting up the body that was still attached to the jaw, had brutally let it fall back down on is backside into the chair as, standing upright and filling the window frame, he panted, brandishing a blue tooth dripping with blood at the end of his forceps.”

This passage illustrates some of the qualitative aspects of dental anxiety found by Swedish researchers, such as feelings of powerlessness or the belief that the dentist has all the power, the presence of underlying neuroticism or general anxiety, and the dentist’s perceived lack of empathy. Perceived negative behavior by a dentist is common among sufferers of dental anxiety. One of the Swedish researchers’ subjects described a dentist from childhood who reeked of booze and had shaky hands. Studies have indicated that patients with anxiety often transfer negative sentiments about one dentist to all dentists they encounter subsequently.

Fear of suffocation as the mouth is filled with water, cotton, and dental instruments is another component of dental anxiety. Edgar Allan Poe’s short story, Berenice, published in 1835, invokes this fear as Berenice is buried prematurely and her thirty-two teeth, the object of her monomaniac cousin’s obsession, forcibly ripped out.

A survey of 1,882 individuals in the U.S. found an adult prevalence rate of “high dental fear” between 11.2 and 12.3 percent. Another 17.5 to 18.2 percent of respondents indicated moderate dental fear, and 15.5 percent avoided dental care out of dread. Outside of the U.S., a 2009 study in the Netherlands found that “the prevalence of dental fear was 24.3%, which is lower than for fear of snakes (34.8%), heights (30.8%), and physical injuries (27.2%). Among phobias, dental phobia was the most common (3.7%), followed by height phobia (3.1%) and spider phobia (2.7%). Scandinavian epidemiological studies found that 7 to 10 percent of population was highly anxious with regard to receiving dental care. Most research points to a higher prevalence rate among women compared to men. As to whether age and income are associated with dental anxiety, studies have shown mixed results, with some not finding any correlation with age, and others showing a curve where anxiety peaks in young adulthood and diminishes somewhat with age.

All this dental angst has fueled sedation dentistry’s growth and entrance into the mainstream. A survey of 1,101 Canadians found that the proportion of the population preferring sedation or general anesthesia was “7.2% for cleaning, 18% for fillings or crowns, 54.7% for endodontics, 68.2% for periodontal surgery, and 46.5% for extraction,” and that a greater proportion of respondents expressed an interest in sedation for dentistry than the proportion who had been sedated before. The researchers concluded that there was significant need and untapped demand.

Incidentally, The People’s Dentist charged 2 Francs for the extraction Huysmans so vividly described. Sedation dentistry is generally not covered by insurance, and prices can range from $50 for nitrous oxide to more than $1,000 for IV sedation. Fear is lucrative. The prospect of sedation has the ability to attract new dental patients to the market for general and cosmetic procedures- the patients who have avoided the dental market altogether as a result of their anxiety.

An analysis in Dental Economics showed that the highest profit in terms of dollars can be generated by IV sedation, but in terms of profit percentages, oral sedation such as Valium is the most lucrative. Also recognized was the collections advantage inherent in sedation dentistry: patients who plan to be sedated by oral or IV methods on the day of their procedure are usually required to pay up front.

Dental anxiety is a prolific problem affecting many people around the world, despite modern advances which have made dentistry dramatically more comfortable than it was historically. The avoidance of dental care due to dental anxiety can lead to deteriorating oral and general health, but also represents pent-up demand for sedation services and therefore incremental revenue for the 40 percent of U.S. dentists who are now offering some form of sedation dentistry.


Abrahamsson KH, Berggren U, Hallberg L, & Carlsson SG (2002). Dental phobic patients’ view of dental anxiety and experiences in dental care: a qualitative study. Scandinavian journal of caring sciences, 16 (2), 188-96 PMID: 12000673

Bracha HS, Vega EM, & Vega CB (2006). Posttraumatic dental-care anxiety (PTDA): Is “dental phobia” a misnomer? Hawaii dental journal, 37 (5), 17-9 PMID: 17152624

Chanpong B, Haas DA, & Locker D (2005). Need and demand for sedation or general anesthesia in dentistry: a national survey of the Canadian population. Anesthesia progress, 52 (1), 3-11 PMID: 15859442

Gatchel RJ, Ingersoll BD, Bowman L, Robertson MC, & Walker C (1983). The prevalence of dental fear and avoidance: a recent survey study. Journal of the American Dental Association (1939), 107 (4), 609-10 PMID: 6579095

Gatchel RJ (1989). The prevalence of dental fear and avoidance: expanded adult and recent adolescent surveys. Journal of the American Dental Association (1939), 118 (5), 591-3 PMID: 2785546

Oosterink FM, de Jongh A, & Hoogstraten J (2009). Prevalence of dental fear and phobia relative to other fear and phobia subtypes. European journal of oral sciences, 117 (2), 135-43 PMID: 19320722

Wong HM, Mak CM, & Xu YF (2011). A four-part setting on examining the anxiety-provoking capacity of the sound of dental equipment. Noise & health, 13 (55), 385-91 PMID: 22122954

Image via Zoya Kriminskaya / Shutterstock.

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Better Than Average – Are Prisoners Really So Different? Tue, 28 Jan 2014 12:00:00 +0000 In a study recently published in the British Journal of Social Psychology, University of Southampton researchers found that prisoners rated themselves equal to or better than non-incarcerated community members with respect to honesty, morality, self-control, and other attributes. These findings add to the substantial base of literature supporting the “better-than-average effect” (BTAE).

The BTAE refers to our tendency to consider ourselves better than our neighbors and colleagues, especially when it comes to more subjective traits like trustworthiness or compassion. Constantine Sedikides, Professor of Social and Personality Psychology and Director of the Centre for Research on Self and Identity at the University of Southampton, noted that:

“Virtually by definition, people who are incarcerated have shown a lack of respect for their peers and have violated a legal pact: to adhere to the laws of the community. Although non-incarcerated people do this also, it is highly likely that incarcerated people “cheat” their fellow community members more than the non-incarcerated do. To evaluate themselves more favourably than the non-incarcerated on virtually every social characteristic stretches reality to the breaking point.”

Based on decades of research on the BTAE in the population living outside the prison walls, we should be more surprised if the prisoners did not overinflate their own virtue relative to their peers. After all, our inclination to focus on the speck in our brother’s eye while a log obstructs our own eye was chronicled back in the time of the Apostles (Luke 7:1-5). Even if you never step foot inside a prison, the BTAE is all around you.

Instances of the BTAE you are more likely to encounter in your daily routine can be found in the 94% of professors who believe that they are better-than-average teachers. The effect has also been demonstrated in overly confident online investors, who rated their investment knowledge and past performance as above average, even when their actual past performance was verifiably not above average. Investors with unrealistically inflated assessments of themselves traded higher volume relative to more rational investors. If you are on the road, you can be assured that most of the drivers around you think their driving skills are superior to yours and the abilities of other drivers on the road.

In addition to assessing their own virtues relative to the average person, in another study Brown asked participants to rate each of several qualities in terms of importance. Honesty received the highest importance rating, and also showed the greatest BTAE. The attribute “outgoing”, was rated the least important by participants, and showed the smallest BTAE. The BTAE tends to be most pronounced among the qualities people value the most.

Americans are even more likely to view themselves as better-than-average with respect to pretty much any virtue you ask them about, compared to Asian cultures. In the United States, where the majority of people rate their honesty as above average, tax payers are estimated to report about $300 billion less per year than what they should, and some estimates of employee theft and fraud exceed $600 billion. The asymmetry between belief and reality resulting from self enhancement is very much alive outside of the prisons.

In their study The Dishonesty of Honest People: A Theory of Self-Concept Maintenance, Mazar, Amir, and Ariely theorized that “people who think highly of themselves in terms of honesty make use of various mechanisms that allow them to engage in a limited amount of dishonesty while retaining positive views of themselves.”

They describe a “band of acceptable dishonesty,” where the pursuit of positive material gains from a dishonest act may be mitigated by the potential deleterious effect the act could have on the individual’s concept of self. Lest we grow cynical, it’s worth noting that the “band of acceptable dishonesty” was shortened considerably when the participants were reminded of the Ten Commandments prior to being given an opportunity to cheat on a test.

The Southampton study not only calls into question the prisoners’ objectivity, it adds to the substantive body of literature suggesting that the rest of us fall prey to the same biases. How can we counteract this tendency? While our views related to ourselves are prone to distortion, our perceptions of others are generally more accurate. Conversely, others’ perceptions can be of value to us. We can look to objective measures and peer assessments of our performance to probe the validity of our own opinions about ourselves. When it comes to more subjective traits such as honesty and responsibility, general mindfulness of our standards — the ones we hold other people to — has a demonstrated countervailing effect on our inclination to stray from those standards.


Brown, J. (2012). Understanding the Better Than Average Effect: Motives (Still) Matter. Personality and Social Psychology Bulletin, 38: 209. doi:10.1177/0146167211432763

Glaser, M. and Weber, M. (2007). Overconfidence and Trading Volume. Geneva Risk Insurance Review, 32:1-36 doi: 10.1007/s10713-007-0003-3

Lee, J. (2012) Trait Desirability and Cultural Difference in the Better Than Average Effect. Asian Journal of Social Psychology, 15 261-272 doi: 10.1111/j.1467-839X.2012.01381.x

Mazar, N., Amir, O., and Ariely, D. (2008). The Dishonesty of Honest People: A Theory of Self-Concept Maintenance. Journal of Marketing Research, 45 633-644. Retrieved from EBSCOhost on January 15, 2014.

Sedikides C, Meek R, Alicke MD, & Taylor S (2013). Behind bars but above the bar: Prisoners consider themselves more prosocial than non-prisoners. The British journal of social psychology / the British Psychological Society PMID: 24359153

Zell, E. and Alicke, M. (2011). Age and the Better-Than-Average Effect. Journal of Applied Psychology, 41(5) 1175-1188. doi: 10.1111/j.1559-1816.2011.00752.x

Image via Bruno Passigatti / Shutterstock.

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