Robert A. Yourell, MA – Brain Blogger Health and Science Blog Covering Brain Topics Wed, 30 May 2018 15:00:03 +0000 en-US hourly 1 A Gateway to Weight Loss? Thu, 17 May 2012 14:44:20 +0000 Judging from those hoaky commercials, some products will transform you from a jellyfish into a superhero in a jiffy. But what about the mantra we’re hearing that aggressive weight loss is hopeless, because it results in rebound weight gain? Our brain’s reward centers, our hormones, and our psyches simply can’t resist the evolutionary forces unleashed by artificial famine conditions, they say.

Some research is telling us that people can lose weight fast and that this speedy start bodes well for sustained improvement: More weight loss, and no more rebound than slower dieters that lose less weight. This has been a recurring outcome, even recently. Posts online make the claim more boldly than the researchers. A look past the headlines tells us a more nuanced story.

In a study by Nackers and colleagues, three groups were identified: fast, medium, and slow. The fast group lost more weigh up front, and kept it off just as successfully as the other groups. But this does not mean that an aggressive calory restriction diet is the answer. Here are some points to consider.

The fast group did not consume a drastically lower number of calories than the slow one (1,366.4 vs 1,486.8).

The fast group did not lose a drastic amount of weight, compared to the slow group (13.5 vs. 5.1 kg). Yes, it’s more than double, but it’s over six months.

We should ask what distinguished the slow group from the rest. The slow group attended less meetings, exercised less, and ate more calories. Were they more stressed? Was there a higher rate of depression? Where there other conditions that made them less active? Something was going on. Since the slow group was not as successful at maintaining weight loss, it’s a good guess that the conditions continued throughout the study period. The fast group was 5.1 times more likely to have maintained at least a 10% weight loss at 18 months than the slow group.

There are countless factors that might interfere. One is ADD. There is speculation that people with ADD have higher rates of obesity because their reward system is especially in need of a dopamine fix, and because of less consistent self-discipline. Medication appears to remedy this for many folks.

If there’s a take away, it seems that it would be for us to ask ourselves what might keep us from fully participating in a weight loss program. Those factors are probably the gateway to significant, sustained weight loss.


Odent, M. (2010). Attention deficit hyperactivity disorder (ADHD) and obesity: Two facets of the same disease? Medical Hypotheses, 74 (1), 139-141 DOI: 10.1016/j.mehy.2009.07.020

Nackers, L., Ross, K., & Perri, M. (2010). The Association Between Rate of Initial Weight Loss and Long-Term Success in Obesity Treatment: Does Slow and Steady Win the Race? International Journal of Behavioral Medicine, 17 (3), 161-167 DOI: 10.1007/s12529-010-9092-y

Neiberg, R., Wing, R., Bray, G., Reboussin, D., Rickman, A., Johnson, K., Kitabchi, A., Faulconbridge, L., Kitzman, D., & Espeland, M. (2012). Patterns of Weight Change Associated With Long-Term Weight Change and Cardiovascular Disease Risk Factors in the Look AHEAD Study Obesity DOI: 10.1038/oby.2012.33

Image via AGorohov / Shutterstock.

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Memory Ain’t What It Used to Be – And That’s Good for Psychotherapy Mon, 07 May 2012 11:59:58 +0000 New insights into memory are helping to explain treatments for serious problems, and guide us to making them better. Many psychotherapies use the one-two punch of targeting (focusing on a memory or other source of anxiety, flash backs, or related symptoms) and state change (the best-known being relaxation, as in systematic desensitization, and bilateral stimulation in EMDR). Now, researchers are exploring other ways to accomplish this, and they are being guided by new insights into how memory works.

The theory in play is that memories are more vulnerable to change when they are brought to mind, and they can be connected with different feelings most readily at that time. There is a window of time, perhaps 10 hours, for this, but in psychotherapy, the work is done at the same time. Thus, if a veteran’s flashbacks are depriving them of sleep, the understanding is that those flashbacks are encoded with intense emotion that can be changed. The memories can go from stormy and tormentous to significant and meaningful. For trauma therapists, this is a very familiar process, and they are very intuitive about doing this work.

There hasn’t been a popular word for this experience, so I coined the term “shimmering” for it. I teach people a version of this targeting/state change under that generic term. The professional terms related to this include desensitization and reprocessing, and memory reconsolidation.

It’s becoming more obvious why there are so many variations of this process, and why they can be found in numerous approaches to therapy, and countless processes and rituals found in cults, personal growth programs, and religions. The difference is that, instead of intuitively stumbling into it, we can continue to improve upon this through research and application. Joseph Wolpe, MD, really got the ball rolling in 1955, and now, 57 years later, this is headed for a new level.

Essentially, we’re talking about altering memories while they are volatile so they can be reconsolidated in long-term memory without disturbing emotions or destructive unconscious beliefs attached. There is reason to believe that matching the stimulus with the main sense modality that is disturbing will be an improvement on existing protocols. So, if the person has intrusive visual memories, using a visual stimulus while the person recalls the memory would be more effective than a sound.

I think it’s sad that, with such a great need for continued improvement in PTSD treatment, there are studies with veterans being published that still use longer, more arduous treatments such as prolonged exposure (where there is no sophistication regarding using state change such as relaxation in order to make the treatment less traumatic and prolonged — they even use the word prolonged in the name of the therapy. How’s that for being stuck in a paradigm?)

Now, researchers are even exploring Tetris as a stimulus.


Holmes EA, James EL, Kilford EJ, & Deeprose C (2010). Key steps in developing a cognitive vaccine against traumatic flashbacks: visuospatial Tetris versus verbal Pub Quiz. PloS one, 5 (11) PMID: 21085661

Below are the citations form that article that appear to be the most interesting, if you would like to learn more about this subject:

Andrade J, Kavanagh D, & Baddeley A (1997). Eye-movements and visual imagery: a working memory approach to the treatment of post-traumatic stress disorder. The British journal of clinical psychology / the British Psychological Society, 36 ( Pt 2), 209-23 PMID: 9167862

Kavanagh, D., Freese, S., Andrade, J., & May, J. (2001). Effects of visuospatial tasks on desensitization to emotive memories British Journal of Clinical Psychology, 40 (3), 267-280 DOI: 10.1348/014466501163689

van den Hout M, Muris P, Salemink E, & Kindt M (2001). Autobiographical memories become less vivid and emotional after eye movements. The British journal of clinical psychology / the British Psychological Society, 40 (Pt 2), 121-30 PMID: 11446234

Walker MP, Brakefield T, Hobson JA, & Stickgold R (2003). Dissociable stages of human memory consolidation and reconsolidation. Nature, 425 (6958), 616-20 PMID: 14534587

Bourne C, Frasquilho F, Roth AD, & Holmes EA (2010). Is it mere distraction? Peri-traumatic verbal tasks can increase analogue flashbacks but reduce voluntary memory performance. Journal of behavior therapy and experimental psychiatry, 41 (3), 316-24 PMID: 20359691

Vallar, G., & Baddeley, A. (1982). Short-term forgetting and the articulatory loop The Quarterly Journal of Experimental Psychology Section A, 34 (1), 53-60 DOI: 10.1080/14640748208400857

Gunter RW, & Bodner GE (2008). How eye movements affect unpleasant memories: support for a working-memory account. Behaviour research and therapy, 46 (8), 913-31 PMID: 18565493

Kemps E, & Tiggemann M (2007). Reducing the vividness and emotional impact of distressing autobiographical memories: the importance of modality-specific interference. Memory (Hove, England), 15 (4), 412-22 PMID: 17469020

Kemps, E., Tiggemann, M., Woods, D., & Soekov, B. (2004). Reduction of food cravings through concurrent visuospatial processing International Journal of Eating Disorders, 36 (1), 31-40 DOI: 10.1002/eat.20005

Engelhard IM, van den Hout MA, Janssen WC, & van der Beek J (2010). Eye movements reduce vividness and emotionality of “flashforwards”. Behaviour research and therapy, 48 (5), 442-7 PMID: 20129601

Krans J, Naring G, & Becker ES (2009). Count out your intrusions: effects of verbal encoding on intrusive memories. Memory (Hove, England), 17 (8), 809-15 PMID: 19657961

May, J., Andrade, J., Panabokke, N., & Kavanagh, D. (2010). Visuospatial tasks suppress craving for cigarettes Behaviour Research and Therapy, 48 (6), 476-485 DOI: 10.1016/j.brat.2010.02.001

Hagenaars MA, Brewin CR, van Minnen A, Holmes EA, & Hoogduin KA (2010). Intrusive images and intrusive thoughts as different phenomena: two experimental studies. Memory (Hove, England), 18 (1), 76-84 PMID: 20391178

Pearson, D., & Sawyer, T. (2011). Effects of Dual Task Interference on Memory Intrusions for Affective Images International Journal of Cognitive Therapy, 4 (2), 122-133 DOI: 10.1521/ijct.2011.4.2.122

Kindt M, Soeter M, & Vervliet B (2009). Beyond extinction: erasing human fear responses and preventing the return of fear. Nature neuroscience, 12 (3), 256-8 PMID: 19219038

Schiller D, Monfils MH, Raio CM, Johnson DC, Ledoux JE, & Phelps EA (2010). Preventing the return of fear in humans using reconsolidation update mechanisms. Nature, 463 (7277), 49-53 PMID: 20010606

Pitman RK, Sanders KM, Zusman RM, Healy AR, Cheema F, Lasko NB, Cahill L, & Orr SP (2002). Pilot study of secondary prevention of posttraumatic stress disorder with propranolol. Biological psychiatry, 51 (2), 189-92 PMID: 11822998

Liao, S., & Sandberg, A. (2008). The Normativity of Memory Modification Neuroethics, 1 (2), 85-99 DOI: 10.1007/s12152-008-9009-5

Henry M, Fishman JR, & Youngner SJ (2007). Response to open commentaries for “Propranolol and the prevention of post-traumatic stress disorder: is it wrong to erase the ‘sting’ of bad memories?”. The American journal of bioethics : AJOB, 7 (9) PMID: 17849329

Depue, B., Curran, T., & Banich, M. (2007). Prefrontal Regions Orchestrate Suppression of Emotional Memories via a Two-Phase Process Science, 317 (5835), 215-219 DOI: 10.1126/science.1139560

Anderson MC, & Green C (2001). Suppressing unwanted memories by executive control. Nature, 410 (6826), 366-9 PMID: 11268212

Anderson MC, Ochsner KN, Kuhl B, Cooper J, Robertson E, Gabrieli SW, Glover GH, & Gabrieli JD (2004). Neural systems underlying the suppression of unwanted memories. Science (New York, N.Y.), 303 (5655), 232-5 PMID: 14716015

Anderson, M., & Levy, B. (2009). Suppressing Unwanted Memories Current Directions in Psychological Science, 18 (4), 189-194 DOI: 10.1111/j.1467-8721.2009.01634.x

Holmes, E., Moulds, M., Kavanagh;, D., Depue, B., Curran, T., & Banich, M. (2007). Memory Suppression in PTSD Treatment? Science, 318 (5857), 1722-1722 DOI: 10.1126/science.318.5857.1722a

Bolger, N., Davis, A., & Rafaeli, E. (2003). Diary Methods: Capturing Life as it is Lived Annual Review of Psychology, 54 (1), 579-616 DOI: 10.1146/annurev.psych.54.101601.145030

Dalgleish, T. (2004). Cognitive Approaches to Posttraumatic Stress Disorder: The Evolution of Multirepresentational Theorizing. Psychological Bulletin, 130 (2), 228-260 DOI: 10.1037/0033-2909.130.2.228

Dewar, M., Cowan, N., & Sala, S. (2007). Forgetting Due to Retroactive Interference: A Fusion of Müller and Pilzecker’s (1900) Early Insights into Everyday Forgetting and Recent Research on Anterograde Amnesia Cortex, 43 (5), 616-634 DOI: 10.1016/S0010-9452(08)70492-1

Wixted, J. (2005). A Theory About Why We Forget What We Once Knew Current Directions in Psychological Science, 14 (1), 6-9 DOI: 10.1111/j.0963-7214.2005.00324.x

Foa EB (1995) The posttraumatic diagnostic scale (PDS) manual. Minneapolis, MN: National Computer Systems.

Lee, J. (2009). Reconsolidation: maintaining memory relevance Trends in Neurosciences, 32 (8), 413-420 DOI: 10.1016/j.tins.2009.05.002

Riccio, D., Millin, P., & Bogart, A. (2006). Reconsolidation: A brief history, a retrieval view, and some recent issues Learning & Memory, 13 (5), 536-544 DOI: 10.1101/lm.290706

Stuart, A., Holmes, E., & Brewin, C. (2006). The influence of a visuospatial grounding task on intrusive images of a traumatic film Behaviour Research and Therapy, 44 (4), 611-619 DOI: 10.1016/j.brat.2005.04.004

Image via Vlue / Shutterstock.

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The Empathy and the Irony – Plastic Disc to Teach Empathy to Doctors Tue, 15 Nov 2011 04:15:59 +0000 When one of my duties was handling complaints about clinicians in our managed care network, I got the most complaints about psychiatrists. Sorry, docs, but it wasn’t because they thought you were projecting thoughts into their toasters. The biggest piece of the pie was problems with appropriate communication. These tended to boil down to neglect of what most folks would consider to be the basic stuff of humanity.

This is not a dig at psychiatrists, but a call for action — and a shout out to irony. We know that a lot of our really bright folks tend to have some autistic traits. This can lead to a lot of communication problems. On the other hand, this population can learn a lot of communication skills when things are systematized for them.

But can you analyse empathy enough to actually train on it? Can someone be a better clinician by learning how to act empathic, even if they don’t personally change their sentiments? Wait. That last question might come to mind easily, but it might be missing the point. After all, most doctors, including the poor communicators, are committed to improving their patient’s lives. Inside, they care. So the question isn’t whether they should change on the inside, but how to train them to get better outcomes through objectives such as compliance with the agreed-upon treatment regimine, improved mood, improved relationship support, and improved motivation.

Even the most analytical, poor-eye-contact, forget-to-discuss-side-effects, don’t-discuss-feelings-like-a-normal-person doctor can be motivated by the above outcome objectives and the vision of empathy revealed as a set of finite, reproducable skills.

OK, I know this isn’t a new idea, but now there’s a DVD for that. Duke University researchers have been taking a multi-dimensional approach with a software tutorial plus feedback on recorded sessions with actual patients. The program takes a page from expensive courses that involve role play with actors taking on the role of patient.

So far, the research was with 48 cancer doctors. One of the striking outcomes of the promising study was that patients expressed more trust in the physicians that had used the program.

Now Teach the Patients

But what about reversing the training? Have a course for patients and their support people on how to deal with doctors on the autism spectrum. I think this could be huge. I nominate Temple Grandin to help develop such a course, called, You Doctor isn’t Erie, Just Gifted in Other Ways. OK, scratch that title.

Temple Grandin, the famously autistic engineer has already made a cause of helping people understand how to relate to everyone from developmentally disabled people with autism, to professionals with some autistic traits. She says many are engineers like her. NPR did a wonderful piece on her as well. Excellent, relevant YouTube vids: My Experience with Autism and the TED presentation: Temple Grandin: The World Needs All Kinds of Minds.

One of the things therapists have to do is to help their clients understand and benefit from their psychiatrists. Often, it’s as simple as telling them things the psychiatrist neglected to explain. Sometimes it’s about helping them cope with unusual behavior or actually get a different doc. In many geographic areas, there is a shortage of psychiatrists, so I’m actually more serious about the need than you might think.


The materials didn’t bring up autism, and there are plenty of reasons other than autism that could lead to communication problems.


Tulsky JA, Arnold RM, Alexander SC, Olsen MK, Jeffreys AS, Rodriguez KL, Skinner CS, Farrell D, Abernethy AP, & Pollak KI (2011). Enhancing communication between oncologists and patients with a computer-based training program: a randomized trial. Annals of internal medicine, 155 (9), 593-601 PMID: 22041948

Image via jetsetmodels / Shutterstock.

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Politics of Persuasion, Persuasion in Healing Mon, 22 Aug 2011 12:00:23 +0000 If there is anything I know a lot about, it’s persuasion. I don’t mean to say that I am a genius sales person or politician, but I had a big lesson about psychotherapy some years ago. I edited a book about persuasion and did a lot of literature research in the process. I realized just how many persuasion techniques I was using as a therapist—in addition to those that I (and many other therapists) were aware of (e.g., Ericksonian hypnotic language and motivational interviewing in particular). Of the previously unconscious (on my part) techniques, one of the most important is priming, which means activating implicit (unconscious, basically) memory, so that the person is more likely to experience a particular state, or evince a particular kind of behavior.

Hand-in-hand with other techniques, you can really help lubricate the channel to a new chapter in a person’s life. Or, if you are a sales person, “help” the person buy something they don’t really need. I say this, not as an assault on sales people, but to point out that, if you must use such techniques to sell something, I must raise the ethical questions, “Why is such psychological firepower necessary to sell someone what they need? Are they resisting the truth? If so, who are you to have a higher truth?” Of course, those questions are merely red herrings. The answer is: follow the money.

And it is in this spirit that I raise another question, “Why is so much psychological firepower needed on American political TV?” As a student of persuasion, I am observing very sophisticated techniques used very consistently; so consistently, that I have no doubt that there is training and networking toward perfecting them. I’m also sure that, just as I am finding with psychotherapy, many of these political media types are more intuitive than studied in their skills. But why? Again, follow the money.

Here one of my favorite (in a bad way) skills. Watch for them when you see people debating politics on TV or elsewhere.

Targeted interruption: This is an amazing ability to know exactly when to interrupt the other party so they will not effectively get their points across. After years of watching this, I finally saw someone confronted on this behavior. But Noam Chomsky, a famous intellectual and linguist no less, was effectively undermined at the hands of an expert interrupter, William F. Buckley. Buckley was so talented, he almost made apartheid sound like it was a boon to civilization.

An ethical use of interruption (and priming): A therapist may use forms of interruption to prevent a client from getting into a state of mind that would block them from succeeding at a task in therapy. For example, consider a couple that is on the verge of having a constructive dialog. They begin to fall into their characteristic conflict pattern. The man begins to feel rage. Family therapist Virginia Satir might put her maternal hand on his belly and say that she could feel the hurt in his voice. Not only did this interrupt the rage state, but it also primed the husband for vulnerable feelings. This created an opening for dialog, with constructive results.

Would you like more examples? I could go like this all day! Comment, please.

One of my reasons for wanting people to reflect on these techniques, is that much of the American public appears to be adopting the unethical and illogical methods of debating and presenting that they see on TV. As far as I’m concerned, this is one of the signs of the apocalypse (figuratively speaking, of course). Let’s all work to turn this trend around. Educate! Develop compelling ways to highlight and dispense with unethical moves! If anyone should pick up this mantle, I should think it would by psychologically-minded people, because you can see the meta-level communication such as manipulation of implicit memory.

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Domestic Violence – Understanding is Getting More Nuanced Sun, 05 Jun 2011 12:00:30 +0000 A few years ago I brain blogged about domestic violence (DV), focusing on how ideology, politics, and stereotypes were interfering with an effective social response. It got a big response, almost entirely supportive. At that time, the tide was turning because of lawsuits and a preponderance of research that were beginning to overwhelm the dominance of old-school DV responses.

For example, it was becoming clear that roughly half of DV comes from women, there is a wide range of perpetrators, the majority of DV is mutual fighting, and current “treatment” (the Duluth model) is not effective, unless more modern intervention is sneaked into the mix. (Or maybe patriarchal conspirators are sneaking into lesbian households, starting a fight, and then sneaking back out before the police arrive.) Various dynamics were beginning to humanize violent people, including a huge spike in arrests of women for domestic violence. It was easier to demonize perps when the archetype was all hetero male.

Let’s look at the latest insights that have been building beyond the key points that men’s advocates have been pressing. This post is about antisocial personality and genetics in intimate partner violence.

Antisocial personalities (sociopaths) are the people that best match the stereotype of the DV perpetrator: violent and controlling. They have become the perp poster child because they elicit the most sympathy (and funding) for women, they create the strongest need for abused women to seek shelter, and they constitute the most dangerous and invasive profile. However, there are some inconvenient differences between the antisocial men and the patriarchal stereotype. They are not an expression of the patriarchy that feminists have blamed DV on, even though they may blurt out some patriarchal ideas as they grasp for some way to justify their behavior. Sociopaths have a limitless capacity to rationalize and blame; and they don’t suffer from the burden of being consistent or rational.

Other than the convenience of taking Marxist theory and substituting patriarchy for capitalism, there isn’t a lot of support for the idea of pervasive patriarchy in western societies. These antisocial types are not only violent with their partners; they tend to have a history of violence and criminal behavior outside of their domicile. Alcohol and other drugs often contribute to the violence, crime, and other chaos. But then, boozy households are more likely to have violence, including mutual violence, regardless of whether there’s a sociopath in the house.

Much has been made of research connecting childhood exposure to violence with later violent behavior in adulthood. The connection is there, but not as strong as people think. Old school feminist ideologues are highly motivated to ignore genetics and stress learning, childhood abuse, and patriarchy (while stressing that childhood abuse is no excuse), but genetics researchers point to a very strong genetic basis for antisocial personality. A meta-analysis published last year concluded that 56% of variance in antisocial personality was accounted for by genetic influences. We also know that childhood events trigger genetic change in individuals (epigenetic change) that can dramatically alter the course of their mental health over the lifespan.

So when we say that violence in childhood causes violent adults, we should also point out that violence in childhood (from biological parents) is an indication that the child may have violent genetics. At this point, it appears that the genetics takes the lion’s share of the credit. However, genetics as triggered by childhood stressors (epigenetics) may turn out to be the more powerful blend, because we are realizing that we have to think in terms of vulnerability profiles, rather than think species wide in assessing the effects of stress.

Perhaps we will be able to get a genetic test one day that will tell us what stresses are most important for each of us to avoid. We also know that it’s getting more complicated, in that genetic vulnerabilities appear to come in combinations. In other words, there are numerous illnesses (including psychiatric problems) that appear in heightened quantities in vulnerable families. Only certain problems are the result of passing on a single genetic vulnerability. Science is tasked with nailing down the difference (or spectrum) between these two types of problems: The specific disorder that is passed down (such as sickle cell anemia), versus the vulnerability to a variety of problems.

According to Ferguson, geneticists’ desire not to be contaminated by controversial and hard-to-substantiate theories of evolutionary psychology has slowed the integration of genetic and evolutionary theory regarding human behavior. At the same time, evolutionary psychologists have not used genetics to its potential because of a desire to focus on natural selection rather than more proximal effects on behavior, as well as to focus on more general (species-wide) traits at the expense of looking at genetic differences. And then, there is a general allergy to anything that might be conflated with racism or eugenics. Be as objective as you want, but touch certain topics and suddenly your a woman-hating KKK Nazi. After all, people tend to think in stereotypes, and stereotypes are easily triggered.


Ferguson, C. (2010). Genetic Contributions to Antisocial Personality and Behavior: A Meta-Analytic Review From an Evolutionary Perspective The Journal of Social Psychology, 150 (2), 160-180 DOI: 10.1080/00224540903366503

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Is Trauma Victim Becoming the New N-Word? Sat, 09 Apr 2011 15:58:58 +0000 A prevalant stereotype of trauma victims is the person transformed into a serial killer or other threat to society. The Oakland Tribune has gone over the top in reinforcing this stereotype with some truly awful journalism. They dramatically misinterpreted a highly-regarded researcher, Bessel van der Kolk, MD, in their article Scientists Seek to Treat Chronically Traumatized Brains.

The article makes rash statements that could help make “trauma victim” into the new N-word, and attributes them to the good doctor. It’s too bad, because Dr. van der Kolk has maintained important roles in trauma research as well as awareness of EMDR, the trauma treatment. I helped bring him to Denver for a conference (a long time ago).

Perhaps the most bizarre fear-mongering tactic in the article was posting a list of local murder victims in the middle of the article, strongly implying that they were all killed by people who were, like a new version of the zombie flick, transformed into murders by trauma.

You’ve seen that the press has been conditioned to point out that mentally ill people are not normally killers. They point this out when a mentally ill person kills. Why couldn’t the paper afford trauma victims the same courtesy?

The article makes it sound as though Dr. van der Kolk is talking about trauma victims. Actually, he is referring to children with serious symptoms that are difficult to save from lives of crime and violence. The newspaper author quotes him as saying, “I think the 50 kids we have are no longer the future rapists and killers of America,” (as a result of treatment).

Excuse me!… are NO LONGER? They WERE? It’s destiny? Although my main beef is with the Oakland Tribune, I have to take issue with Dr. van der Kolk in his phrasing either the pathological behavior or the cure as faits accomplis. I really hope that Dr. van der Kolk is correct about his ability to save these children (and, by extention, their victims), but it will be a long time before there is enough verification of his treatment approach to produce a scientific consensus.

We know that trauma is not destiny, and we know that not all people who experience potentially traumatizing events actually evince trauma symptoms. We need to distinguish between trauma as injury and “traumatic event” as something that, in some percentage of people, causes trauma. These events have been referred to as traumatogenic, to get across the idea that the events do not induce trauma in everyone, much less destin them to rape and kill.

Now tell me, what percentage of elevation of rape and murder is actually caused by PTSD? And if you think you have a percentage, how controversial and defensible would it really be in a scientific debate?

And add to this the matter of acculturation. The kids he is referring to are in areas where there is a strong gang influence; where there are powerful economic and cultural incentives to join a gang. How much of the elevation in crime in that population is the result of acculturation and under-privilege, and how much is trauma? Are the middle and upper class kids that are insulated from such influences also destined to become rapists and murderers when traumatized?

Of course not. Neither group is destined. But the question brings up the matter of race. The areas (Compton and Richmond, California) have high minority populations. You already know how the media and society in the USA and elsewhere paint with a broad brush. This kind of superficial talk reinforces racial and victim stereotypes.

Don’t hire an African-American, they were probably traumatized and will rape and kill.

Don’t hire that person that posted to their Facebook page that they experienced a trauma, they will rape and kill.

Here’s more from the article:

Trauma also muddies the connections between the left and right sides of the brain, affecting speech and cognitive abilities. ‘These things change the brain to become chronically fearful, or to not fear at all, or think the best thing to do before someone hurts you is to hurt them,’ van der Kolk said. ‘It’s bad news.’

‘Trauma is the residue of what those experiences leave in your body,’ van der Kolk said. ‘People’s brains change because of trauma.’ The effects of this are well-known: anti-social behavior, emotional numbness, aggression, violence and physical and mental dissociation — the hallmarks, in other words, of the emotional states of many traumatized youth in cities like Oakland and Richmond.

(At least the author bothered to throw in the word “many.” But to the average reader, what does “many” mean?)

And how dare the author say that it is “well-known” that trauma equates to “anti-social behavior” and so forth. It doesn’t. And it’s well-known that it doesn’t. It may, but in what percentage? Not a high percentage.

And there are bits about smaller brains, lower IQs, and not knowing where you are in physical space.

“Scientists and therapists now believe the long-term effects of childhood trauma are more far-reaching and worrisome than previously thought.” We weren’t worried enough a few years ago? It’s worse than we thought? Really? I haven’t seen any shortage of such concern among clinicians.

I think the new brain science will yield important clinical tools in coming years, but at this point, much of it is telling us what we already know. (As in, “You know that phenomenon we’ve been observing and commenting on and treating for so many years? Now we can point to a place in the brain where there’s less oxygen consumption!”) By over-hyping the science and making poorly-considered statements, we could easily do more harm than good.

I wrote Dr. van der Kolk about my concerns. He said he didn’t have time to post a response, but said I could quote him. Here is the bulk of his response:

I am talking (about) the 500,000 children and adolescents in residential treatment and juvenile detention settings in the US, who are there because of their violence and extreme impulsive behavior. Furthermore I am talking about the urgent need to help these kids to achieve a state of mindful self-possession and executive functioning so that they can grow up to become relatively healthy contributing members of society. Right now most of these kids are medicated to such a degree that it severely impairs their capacity to learn and to develop into well-functioning adults.  This issue goes well-beyond ‘trauma processing’ — it requires our finding out how we can help their brains develop in a way that they can play, understand other people’s intentions, anticipate the future, and experience the joy of work and love.

These children now are at extreme risk to grow up to have both miserable lives and to also inflict enormous damage on those around them. I am warning people that, unless effective  treatments are developed and implemented, these children will not only pay with very unhappy lives, but society will pay with staggering costs of incarceration, medial illnesses and other socially expensive consequences.

Feel free to argue about the political correctness of these statements, but I would prefer it if the energy went into the development and implementation of effective treatments.

I think he is underestimating the power of the media to exact harm through stereotyping. I think the social class and racial implications of some of his comments deserve more consideration. But the way the Oakland Tribune ran with the idea that trauma equals destiny was really over the top, and not his responsibility.

But this is just an extreme example of a trend of depicting traumatized individuals as becoming killers because of PTSD without providing the message that such conversion is rare and generally involves other aspects of mental illness and social dynamics. I hope that trauma victims can receive the same consideration that persons with other mental illnesses do when it comes to media representations of violent behavior, fictional or actual.

For an example of the complexity of PTSD and how numerous other factors determine the outcomes, have a look at a very touching and sad documentary on the fates of Iraq veterans by Frontline, called A Company of Soldiers. Here is a related program and ample additional materials called The Soldier’s Heart.

We know trauma is a matter of degree, and that Iraq veterans have experienced higher rates of PTSD becuase of matters such as multiple deployments and being coerced to commit (or to witness) war crimes. I point this out to remind readers that there is no poster child for PTSD; there are many manifestations and combinations.


Johnson, S. (2011). Scientists seek to treat chronically traumatized brains. Oakland Tribune, 3/30/2011..

Resources for Persons with PTSD

There are numerous resources that could be found at PTSD Forum.

Resources for Professionals

The PsychIN Directory has numerous professional PTSD resources. There is also an anxiety disorders section.

A Company of Soldiers, Frontline.

The Soldier’s Heart, Frontline.

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Preventing Schizophrenia, Part 1 – Overview Mon, 28 Mar 2011 12:00:50 +0000 Is it too soon to talk about preventing schizophrenia? Is medicine, social policy, or insurance ready to tackle it? What about individuals and families? According to The Schizophrenia Bulletin, “The stage is now set for the ‘implausible’ — the primary prevention of schizophrenia.” The journal recently published a volume addressing this question, and Medscape turned the lead article into a continuing education piece.

These posts distil key information from the journal issue, and input from some additional articles that I pulled in so I could add comments for personal action (not just professional or organizational).

Setting the Stage: Some Background

No single intervention will eliminate schizophrenia because there are numerous causes and vulnerabilities. There are many ways to develop schizophrenia. There are physical vulnerabilities such as genetic risks, and environmental factors that trigger those vulnerabilities, such as certain nutritional deficiencies.

The case for pursuing prevention strategies includes two favored outcomes: 1) The results will probably produce benefits for a wide variety of disorders, and 2) Some strategies are especially favored from a public health perspective because, they are expected to produce a lot of bang for the buck. These tend to be those that produce “nonspecific benefits,” that is, improved health in many people and prevention of a variety of problems that are costly to society.

Strategies for prevention may target high-risk groups, low-risk (but larger) groups, or people with “risk syndrome” (a candidate for being an official psychiatric diagnosis, this diagnosis means that there are early signs that constitute current clinical need; these individuals are at risk for schizophrenia or other kinds of psychotic disorders such as depression that generates psychosis). There are many issues in deciding how to dedicate resources to these groups, such as the risk of false positives, stigma, or low bang-for-the-buck programs. Some argue that the focus should be on “universal prevention” targeting the population in general, because of the difficulty in accurately identifying at-risk individuals, and the desirability of improving well-being and knowledge in the population at large.

High-risk people may be a small group that is difficult to identify and target, while medium-risk people may be so well distributed through the population, that a lower cost-benefit “universal prevention” effort may have more impact with less resources.

The prevention paradox means many people making a sacrifice so that those at risk or who unpredictably come into contact with an environmental risk factor can be helped. But the burden to society is reduced, thereby making the intervention an investment that pays back not only in terms of less suffering, but also in dollars.

In part II, I’ll share prevention strategies (both personal and social) that are promising and some that are not. In part III, I’ll cover approaches that are firmly planted in reality.


McGrath, J., Brown, A., & St Clair, D. (2010). Prevention and Schizophrenia–The Role of Dietary Factors Schizophrenia Bulletin, 37 (2), 272-283 DOI: 10.1093/schbul/sbq121

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Willpower and the Unconscious on Automatic Pilot Sun, 13 Mar 2011 12:00:37 +0000 What is the practical value of research delving into our sense of self? Willpower is one answer. In the course of putting the pieces of my consciousness back together after assaults to my brain, I came to see my conscious self as being the size of a person navigating on the high seas. There was me taking wind, currents, and sea-worthiness into account, and there was the vast ocean and atmosphere offering up enough detectable patterns that I could navigate toward a destination.

Most of my dear readers experience their conscious minds as a complete self. The countless reminders and ideas that pop out our their subconscious “oceans” are taken for granted, not even given the credit for being convenient. That’s because their ocean never evaporated. They were never faced with hoisting a ship on their shoulders and carrying it the thousand miles to their destination port, all the while praying for rain — a lot of rain.

I mention this difference because many of my readers may have to stretch a bit to really appreciate how research into the unconscious and the sense of self pertain to willpower. In essence, I’m going to tell you how the captain, so insignificant in that ocean, can talk to the ocean and show it some symbols, so that the currents align to make the journey much easier.

There is a diverse and extensive literature showing that our behavior is often directed by unconscious goals that can be primed by various influences ranging from subliminal flashes of text to symbolic objects in our environment. This affects things ranging from our persistence to what unconsciously pay attention to. (Yes, attention can be unconscious.)

Dijksterhuis and Aarts provide a detailed overview of research pertaining to “automaticity,” that is, unconscious behaviors that operate, well, automatically. Being of a practical mindset, I look to such experiments with an eye to how they might help people succeed. Reviewing it with an eye to willpower and focus on goals, I kept hearing echoes of motivational speakers. It seems that most of what the research tells us is what we already know. (Please comment if you think I missed anything.) But if you’ve heard motivational speakers, did you just chalk it up to being somebody else’s Kool-Aid? If you didn’t take it seriously, then at least this mountain of research can serve as a powerful nudge in the right direction.

Prime, Baby, Prime!

One of the most important points, and maybe least used, is priming. We know that our mental state is very influenced by subliminals, even words flashed too briefly for us to see (consciously). The early excitement over subliminal commands about eating popcorn turned out to be generated by a hoax, but priming of “state” and even goals is another matter. We can be primed for success. Success-related words, provided subliminally, have been shown to improve performance. People improved their persistence and level of effort.

Have an environment that is rich with things that trigger associations in your unconscious mind related to your goals, especially when you most need them. Pictures of people you want to impress, music related to your goals, words and phrases posted in various spots, regular listening to motivational recordings, are all examples.

The smell of a commercial cleaning product caused people to clean up more crumbs after they ate cookies than people not exposed to the smell. They didn’t know it, but their subconscious minds were primed to clean just by the odor. See what I mean about using symbols?

Connect your short-term goals with long-term goals. This way you can get more oomph out of priming. The significance of the long-term goal will help drive the short-term goal. Connect in your mind the A in Calculus with having that pet dinosaur you always wanted to clone (or would you prefer a cape-style home for summering in the Hamptons?)

Examples: When I write down the tasks and when I plan, I jot down a few priming words that are related to what I want to do and, more generically, the state of mind I need to be in; usually just a few individual words. Remember that you don’t just prime your unconscious to orient to your goals. You also prime states. When my son was small, we played a lot of Barney songs. This is the uplifting and bouncy music of a purple dinosaur. I noticed that during the harsh winter, my mood improved a great deal as a result of having that music on. Now I listen to bouncy grown up music, but I select it for the emotional energy needed. But you already do that, don’t you?

Now it’s your turn.

What can you do to prime your subconscious for success, achievement, excellence, confidence, poise, inner peace, leadership?


Dijksterhuis, A., & Aarts, H. (2010). Goals, Attention, and (Un)Consciousness Annual Review of Psychology, 61 (1), 467-490 DOI: 10.1146/annurev.psych.093008.100445

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Plan a Cognitive and Memory Enhancement Program Mon, 07 Mar 2011 12:00:43 +0000 In my last post about memory training (that spilled into cognitive training issues), the experts quoted pointed to limitations in the research as well as existing programs tested. The indication was that programs were no better than normal activities that use cognitive abilities, such as discussion and learning. Many older people play word games online to charge up their brains. I have long suspected that much of the draw to American TV shows like The Price is Right (with Bob Barker talking so slowly and directing people so carefully) and Jeopardy (with constant memory testing) was for older folks wanting to challenge their minds even though they were home during the day. Now the older demographic is flooding onto the Internet for even more variety in games and intellectual stimulation.

Since there is such a loud collective “maybe” concerning the use of commercial brain games and clinical programs as preferred alternatives to what we might call “natural” activities, I’ll post some suggestions for enhancing such programs. This is based on the research and articles as well as my own experience with recovery and in working with clients. These are directed to full-blown programs with clinical abilities, but website designers for brain programs, therapists, and regular citizens concerned about their own brain health can use these items to trigger some brainstorming. How about posting what you do for your brain in the comments?

Of course, developers are already brainstorming. A brain-stimulation website called has augmented it’s games with articles containing tips for enhancing brain health through means such as exercise and nutrition. But then, such articles are ubiquitous.

The Recommendations

1. Providers must get better at targeting specific functions that they determine to be most important to shore up each individual’s overall functioning. And for people without impairments, designer programs might prepare people for improved performance for other reasons. What about a waiter that is having difficulty remembering who ordered what, not because he or she is impaired, but because the waiter wants to excel or keep up with other staff that are better at it? Skills that are more sophisticated than brute force memory can be offered by such designer programs. There is already evidence that “reasoning” group training can have a good impact on daily living in the elderly.

Of the three types of training in the individual study cited in the first post, only reasoning training improved functioning in everyday activities (IADLs or instrumental activities of daily living). The other two trainings, speed of processing and memory, did not.

How about a staff person that wants to be more indispensable at work, and feels it will require better logical and synthetic analysis of problems that are discussed in staff meetings? I had a personal experience along these lines after brain injury. I spent roughly a year intensely studying hundreds clinical problems provided by a test-preparation organization (so the answers were actually available) and observed my ability to draw conclusions about subtle differences between viable clinical judgments improve markedly over that period). Note that the answers involved selecting from several groupings drawn from sixteen answer components (unique to each question). This meant that two or more answers would often be very close calls as to which was best. Further, the test for which I was preparing had a nearly 50% failure rate. (I passed.)

In exploring ways to improve effectiveness, says Medscape, Dr. Martin (from the previous post) is developing training that activates multiple skills through “goal-related cognitive activities” that include motor and cognitive tasks of diverse kinds. They measure “individual needs and goals for improvement” to customize their approach.

2. Providers should draw from real life to produce training activities as much as possible. I think this would help with motivation (choosing from various enjoyable activities would probably produce better compliance and engagement than being given something that seems artificial). But for many folks, the real kicker would be that they would be using their time productively in additional areas of life such as language learning, building social support, and cultivating artistic or musical skills. If there is resistance to this idea among any professionals, they should take inventory as to their motives. The subconscious can be very tricky in biasing us, and I’ve seen good professionals interfere with good ideas because of turf issues, all the while convinced of their purity.

3. Providers should think in terms of active ingredients, with a prime example being the social dimension. Research has been very supportive of social activity. If the training activities parallel (or actually are) normal life activities, many would be social, or could be converted into social activities. Since reasoning training is proving helpful, discussion is probably very helpful. In fact, it was one of the types of activities of the active controls (non-trained group that had improvement). Among the activities was an art discussion group.

4. Programs should address more variables, such as mood, psychosocial support and psychosocial problems. Many clinicians fall too easily into the “brain in a jar” syndrome of thinking that their job is done because they conformed to a limited definition of the outcome or job they are performing. It is very important that programs addressing cognitive impairment look at the other issues that often arise. For example, even a “small” level of cognitive impairment makes many people experience difficulties managing their lives. The resulting stress can be part of a spiral affecting mood, finances, and relationships. Conversely, mood problems such as depression can contribute to cognitive problems. Assessment should include financial difficulties and whether the person is being conned or manipulated by anyone, including family members. Finances are among the first areas to go out of whack with mounting cognitive issues because of mismanagement, forgetting, or being manipulated. Many con artists specialize in manipulating elderly people or anyone they size up as having cognitive problems. Even the Readers Digest Sweepstakes has been accused of being manipulative of this demographic. For example, they have sent money requests that look like bills. I reported them to the authorities for this. I feel very protective of our elders. I hope you do, too.

5. Programs should have more hours and longer duration. At least this is one factor that researchers speculate may make the difference. Most research has involved rather limited time periods for intervention. The fact that they have demonstrated effectiveness parallel to related life activities despite this limitation is a very good reason to include a “more is better” hypothesis. However, in some conditions, booster sessions were not helpful, so we clearly have a lot to learn.

6. Programs should incorporate the forms of training that have been proven to be effective, even if they are mainly gung-ho about training that has yet to be proven. However, note that a complaint about the available data was that there was not enough diversity in the programs to be very enlightening. (Too much “heterogeneity.”)

7. Programs should include lifestyle factors as programmed activities (or at least as activities promoted through education). Exercise has a great deal of support in cognitive enhancement and maintenance. Safe practices for exercise should be included. I’m a big fan of myofascial conditioning (such as through trigger point therapy and massage, which can be self-applied with body tools). Nutritional factors such as avoiding trans-fatty acids are coming to the fore as well.

8. It can be very helpful to desensitize and reprocess losses and other issues associated with cognitive decline, such as stigma. Cognitive abilities comprise a tremendous share of what people feel makes them “who” they are, even how human they are. The stigma associated with cognitive issues is harsh and unconscious. People apply it to themselves unconsciously. Treatments such as coherence therapy and eye movement desensitization and reprocessing (EMDR) should be available or at least recommended and explained. In the spirit of draining the swamp to find out where the alligators are, using a treatment like EMDR for desensitization may remove some symptoms of cognitive decline that were based in trauma. With this handled, it is clearer what cognitive problems need to be addressed in their own right.

9. Programs should help to identify and habituate self-management behaviors that will aid people in staying safe and organized. People with cognitive problems are very dependent on external structure and input for success. I have seen people make the same mistake over and over (like not being able to find their medication) until someone helped them focus and establish a special place for it. Even for someone still living at home, input that helps them see the importance of adapting to their changing needs as they age can be very valuable. I have helped families hire “success coaches” to drop in on people who had such difficulties. They helped the person structure their lives. I got this idea from working with developmentally disabled people as an independent living skills training about a million years ago, give or take.


Johnson, K. (2011). Cognitive training to improve memory just as effective as other intellectual activities. Medscape Medical News, January 25.

Martin M, Clare L, Altgassen AM, Cameron MH, & Zehnder F (2011). Cognition-based interventions for healthy older people and people with mild cognitive impairment. Cochrane database of systematic reviews (Online), 1 PMID: 21249675

Willis, S., Tennstedt, S., Marsiske, M., Ball, K., Elias, J., Koepke, K., Morris, J., Rebok, G., Unverzagt, F., Stoddard, A., Wright, E., & , . (2006). Long-term Effects of Cognitive Training on Everyday Functional Outcomes in Older Adults JAMA: The Journal of the American Medical Association, 296 (23), 2805-2814 DOI: 10.1001/jama.296.23.2805

Example Programs (This does not constitute any kind of endorsement)

UCSF Memory and Aging Center: Emphasizing evaluation, treatment and research.

Memory Training Centers of America: A commercial/clinical program that integrates into living situations for the elderly.

CSEP: Vocational rehab for cognitively impaired (example of a type of program that contracts with states).

PACE: Example of a program for children.

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Willpower and Reward Myopia Sat, 26 Feb 2011 12:00:27 +0000 Don’t let the immediate rewards of a bad behavior wash away your better knowledge and values. Prevent your imagination from being hijacked by myopic temptations — eliminate “reward myopia.”

For the sake of research and for developing good theories, researchers work with ideas that are boiled down. But what about real life? As we’ve seen from the my prior posts on the subject of willpower, we can take some very useful measures, and they aren’t all the kinds of obvious things that you didn’t need research to know.

But let’s kick the accountability factor up a notch: what if we look at willpower in a more expanded way? Anyone who has struggled with self-control knows that the idea that the self regulates bottom up impulses is not all that satisfying. There are many issues where it’s a matter of the self struggling with the self, or so it seems.

Consider the phenomenon of swearing off of big desserts for the sake of losing weight. Have you ever noticed how much less important that value is (or how it does a disappearing act) when it’s time for dessert? This happens in the early phase of commitment, when the idea is not so strong. When dieters build more resolve, and are conscious of the agenda when exposed to temptation, they experience the frustration of struggling with themselves. At least they do if their prefrontal cortex is humming along.

You could say that this is no different; that it is the self trying to regulate a bottom-up drive that is so strong that it causes rationalization. Thus, there is the illusion of self struggling with self. But this leads one to ask, “What is the self, then, if bottom-up drives can masquerade as the self?” “How do we know it isn’t all a masquerade?” This kind of question has vexed philosophers throughout history, with some abdicating to an “everything is an illusion” position.

For the practical purposes of a psychotherapist, or anyone concerned with self-help (or, more to the point, self-mastery), I suggest we bounce out of the either-or thinking and look at self as a spectrum that goes from:

a) Primitive drives evoked by various stimuli and internal processes, to

b) Values and goals that are well-orchestrated and articulated (using conscious, verbal mental processes that we identify with as the self).

Notes for nerds:

That definition of self is, as I mentioned, a practical tool. It doesn’t pretend to be a complete definition. But bear in mind that people do not identify with everything in consciousness, so is can be misleading to simply say that “consciousness” is self. I say this knowing that there are altered states of consciousness in which we can experience an expanded sense of consciousness that we experience as self plus a higher self or universal consciousness. It’s a very pleasant experience. Careful, though, as it can come with strings attached: Spiritualists can use that experience to “prove” their belief systems or extract a lot of time and money out of hopeful spiritual travelers.

The constructivist movement in psychotherapy is quite concerned with helping us align our behavior with our values in order to extricate us from various emotional maladies, so this “spectrum” perspective can help us digest constructivist thinking and make use of related approaches such as coherence therapy and acceptance and commitment therapy.

With this in mind, let’s have a look at an example of what we can apply to willpower by looking beyond the convenient definition of my previous recent blogs (top-down self-regulation fueled by glucose or other nutrients).

Consider the capacity to think ahead. People will difficulty in this area tend to get into trouble in various ways. They can make bad financial decisions or fall prey to addictions. Most of the folks in jail have trouble thinking ahead.

A recent study offers hope that this can be remediated, with life-changing results. Training to improve awareness and valuing of future rewards has been used in addiction treatment research.

In terms of the big picture, this is another step in our understanding of neuroplasticity: our ability to expand the functioning of our minds by beefing up our brains.

Notes for nerds:

The researchers call the problem “delay discounting,” that is, devaluing future rewards and punishments. The research was conducted with adults addicted to stimulants. The result was an improvement of 50% in reducing this problem, simply through neurocognitive training, that is, memory exercises. The researchers say this is the first study to show that this can be done.

This is part of a larger field of neurocognitive rehabilitation that holds the key to great progress in many areas such as recovery from severe mental illnesses.

Executive functioning is key to our sense of self-mastery, and this research targets an important aspect of executive functioning: short-tem memory. This shows that in one population of persons with addictions, short-term memory can be improved a great deal. Future research will need to look at other addictions. Can heroin addicts or glue sniffers get such improvements. Also, they’ll be looking to the bottom line: do they have lower relapse rates?

This research does not guarantee that we can get actual treatment outcomes such as preventing relapse from this approach; it did not go as far as to measure treatment outcomes. However, given the strong results of neurocognitive rehabilitation-informed approaches in severe mental illness, I think this research is a notable step in expanding our appreciation and acceptance of this as clinically viable.

I wrote about the value of willpower training (practicing self control) as demonstrated in research, where participants made improvements in various behaviors, not just the ones the training focused on. There was overall improvement; the training generalized. Have you added it, or some of the other gudelines, to your lifestyle?

I suggest you add this idea to your bouts of self-training: exercise your working memory. This scratchpad of the brain is an important part of your power to delay gratification in service of more valuable, but longer-term, objectives.

But how? Don’t we exercise it enough in managing our lives? Not if your goal is to get a “training effect” (strengthening above normal demands–remember, this is to help a weak area become stronger than normal life can achieve). Also, this will help build awareness of your short-term memory and opportunities to exercise it. You probably have a collection of tricks you use to extend short-term memory with external aids, such as notes, or doing something immediately, before you forget.

When the results would not be disastrous if you forget, spend some time each day putting yourself in a position where you have to juggle several things, but without the help of notes or other aids. You might wear yourself out if you tried this all day–and who knows what you might screw up if you dared–but there’s no harm in this exercise so long as you use a little common sense.

You may find you can do more than you thought, and you may become more aware of your limits so that you can exercise them in a more targeted way. More importantly, you will be extending your ability for forethought in ways that can serve you in mastering the behaviors that you want to change.


Bickel, W., Yi, R., Landes, R., Hill, P., & Baxter, C. (2011). Remember the Future: Working Memory Training Decreases Delay Discounting Among Stimulant Addicts Biological Psychiatry, 69 (3), 260-265 DOI: 10.1016/j.biopsych.2010.08.017

In this study, 27 adults in treatment for stimulant use were randomly assigned to receive either working memory training or control training according to a yoked experimental design. Measures of delay discounting and several other cognitive behaviors were assessed pre- and posttraining.

Rates of discounting of delayed rewards were significantly reduced among those who received memory training… Discount rates were positively correlated with memory training performance measures.

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Itching to Evolve Thu, 17 Feb 2011 12:00:26 +0000 I hope you had a very special Darwin Day on February 12. My honey and I spent it as a romantic evening watching some special videos. They gave me the urge to write about an intimate subject. The vids were about the current state of evolutionary theory, especially regarding us humans. And now I can’t resist my desire to write about itching.

Creationists talk about the amazing balance of physical laws that hold the universe together. Similarly, I would like to spread the Good News about the amazing balance that evolution has produced in our itching. Have you considered how natural selection would sculpt the perfect amount and distribution of itching? Itch too much and you could forage too little; maybe damage your skin. Itch too little, and who knows what kind of pestilence might hang on, partaking of your blood supply. You might even overlook a superficial infection that would be reduced by some abrasion; especially if you don’t have any knowledge of health or, for that matter, much of a conscious mind.

Speaking of consciousness, since the part of my brain that can talk is writing to yours, I’d like you to think for a moment of how you can feed data into a formula and turn it into a chart, or a shape. You have a visual representation of numbers. Now think of the statistical nature of natural selection. You could say that, in a sense, every animal is a representation of the statistics of selection pressures, and of the genes as being a handy data management program that comes replete with current data. Have an earthquake and a seismograph provides an analog and statistical readout. Have billions of years of natural selection and you get the latest animals — complete with survival-computed itching.

And if you think itching is always because of something actually going on at the site of the itch, think again. Stimulate the itch gene in the spinal chord of a mouse, and he starts scratching, which in turn inhibits the firing of itch neurons in the spinal cord. The itch gives you a glimpse into your most primitive origins. You have no idea how much you itch. It’s managed by primitive programming that has little use for your conscious mind. Just because you can pay attention to it is no reason to give your conscious mind credit for it or think you really know how much you scratch.

Of course, you can suppress it, but notice how intensely the demand commands you to satisfy that itch! What is that demand? Think of birds preening. What commands them to do that? If they had the will and tried to resist it, what overwhelming discomfort might well up? When people with obsessive-compulsive disorder try to resist their compulsions, they tell us they feel intense, irresistible anxiety and are driven to act on the compulsions. Theorists suspect that they have poor regulation of primitive impulses related to preening behavior. But they often have a conscious basis for their behavior; they justify it. Of course — people tend to justify unconsciously-driven behavior. They need to conform to social pressures.

Still need some proof regarding the unconscious nature of such urges? Obsessive-compulsive traits can be genetically loaded into animals. Researchers do this so we can better understand them. Stress sometimes causes obsessive-compulsive traits to emerge in humans and other animals, and this lends support to the idea that some kind of regulation has become unhinged, releasing instinctual forces.

To round out these ideas, I’d like you to notice how every area of you body needs a certain amount of vitamin S (scratch) every day. Then forget about it and let your unconscious continue to manage the affair, as it has all along.

As for the betterment of humanity, perhaps one day, we will be able to satisfy the itch without scratching. The motive: medical conditions that cause excessive, unnecessary itching.

Notes for Nerds

A study by Berkman and Plutzer found that only about 25 percent of high school biology teachers polled teach evolution in an adequate manner, as recommended by the National Research Council. They also found that roughly 13 percent of the teachers teach creationism or intelligent design.

Here are some details on evolution I’m throwing in from various sources just for fun (my way of saying no references from this point on).

The earliest human-like creatures emerged about 5 or 6 million years ago.

Most animals appeared as marine creatures around 542 million years ago, unless you believe some researchers that favor up to a billion years ago, but they have flimsy evidence.

Their ancestors were complicated cells with mullets, well, actually, flagella in the back. They did not bowl or have trailers.

Chimps and humans branched apart about 7 million years ago. But we have about the same number of genes. A number we also have in common with corn; about 25,000. Humans still like chimps and corn, but only name chimps, not cobs.

Different human species co-existed for a long time, dying out and leaving only Homo sapiens. Not all previous human species are our ancestors. They are separate branches on the evolutionary tree. The last was the Neanderthal, disappearing about 20,000 years ago. They and we branched off of a common ancestor about 400,000 years ago. Genetic data tell us that there probably was no interbreeding.

Our modern behavior has existed for only a small fraction of our existence. Most of our past casts us as stone-age folks with only the vaguest sense as to how to improve our lives (as in creating very primitive fireplaces in our caves, but we didn’t even fish). We didn’t shift into cultural overdrive until about 11,000 years ago, starting in Africa. This culminated in knockoff designer handbags.

There’s a theory that our brains are so big because a defect in our muscle genes gave us weaker jaw muscles, affecting how early our skulls fuse during development. I’m not joking. I saw it on PBS.

No one has determined the year of the first itch or scratch. But I’ll wager spontaneous itching (that does not stem from a parasite or other stimuli) came after we emerged from marine life and selection had plenty of time to develop it. The reason: fish only glance (dart against an object) or dive and roll (touching the floor) when there is a problem such as parasites. This is fortunate, as they have no arms.


Davidson, S., Zhang, X., Khasabov, S., Simone, D., & Giesler, G. (2009). Relief of itch by scratching: state-dependent inhibition of primate spinothalamic tract neurons Nature Neuroscience, 12 (5), 544-546 DOI: 10.1038/nn.2292

Berkman, M., & Plutzer, E. (2011). Defeating Creationism in the Courtroom, But Not in the Classroom Science, 331 (6016), 404-405 DOI: 10.1126/science.1198902

Sun, Y., & Chen, Z. (2007). A gastrin-releasing peptide receptor mediates the itch sensation in the spinal cord Nature, 448 (7154), 700-703 DOI: 10.1038/nature06029

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Would You Prefer Memory Training, or a Life? Fri, 11 Feb 2011 19:31:13 +0000 By life, I mean things like normal activities, intellectual pursuits, games or events with friends (or by yourself, for that matter), and the like. A Cochrane review (of 24 trials over 37 years that had 2,229 subjects), found that there was “surprisingly little evidence” supporting the use of cognitive training programs for memory improvement compared to other activities for people age 60 or older, with or without mild cognitive impairment (MCI).

And while the interventions were as good as other stimulating activities, the review only found two types of trainings that were proven effective. This means that we can’t assume that any given commercial or non-commercial program being promoted is necessarily effective. But you knew that.

This is why I chose the title for this post. I’m asking,

Would you prefer to do or learn something that is truly meaningful to you (for example, learn a language) or engage in a training program designed without that consideration (as most are, especially the commercial ones)?

If you learn the language, your brain will work better (nonspecific training effects are shown in research) AND you’ll gain the language skills. If you join a discussion group, your brain will work better, and you’ll enhance your social skills, build and maintain friendships and support, and expand your awareness of whatever you’re discussing. But if you take the program, you only get the better brain function.

Providers of training programs take heed: there is no reason for your programs to be insulated from the desire to learn information and skills that your customers find meaningful. And there is no reason that your programs have to insulate people from each other; they can be social. And we haven’t even gotten into the matter of longevity being improved in those with social engagement and support.

Look on the Bright Side

The good news is that stimulating your brain for cognitive improvement really does make a difference, whether you use a professional (training) program or natural activities that stimulate the brain. A good deal of research has looked at the question of natural activities that improve or maintain cognitive abilities in older persons, and the results encourage us to be engaged in life, especially social activities. Research on involvement in religion suggests that it is primarily the social aspect that improves longevity. This is probably true for cognition and memory as well.

And science is not standing still, cognitive and memory programs are being enhanced with new knowledge for new experiments. Medscape interviewed expert Gary Small, MD, who pointed out that the review did not sufficiently emphasize the fact that the programs were shown to be helpful. Point taken. They were helpful. He also wondered if the programs might not be more effective if some improvements were made. Dr. Small pointed out that programs can target specific mental functions. He is developing programming with improvements like this in mind. Likewise, Dr. Martin, an author of the Cochrane review, is developing programming targeting common age-related complaints.

Extra Details

From the review:

[B]ut none of the effects observed could be attributable specifically to cognitive training, as the improvements observed did not exceed the improvement in active control conditions. This does not mean that longer, more intense or different interventions might not be effective, but that those which have been reported thus far have only limited effect.

The authors defined cognitive training as “an intervention providing structured practice on tasks relevant to aspects of cognitive functioning, such as memory, attention, language, or executive function.” The settings can be group or individual. The interventions were categorized into cognitive domains such as memory, executive function, attention, and processing speed.

The control group that had the stimulating activities (called the “active controls”) received “non-cognitive activities” or “unspecific cognitive stimulation, such as art discussion.”

Medscape quoted one of the authors, Dr. Martin, as saying,

The conclusion is based on the fact that we have looked at 37 years of memory training research and shown that only 2 types of training are effective. We consider this ‘little’ evidence.

Outcome measures for persons with MCI included, “rates of conversion to dementia, and rates of institutionalization. Incidence and severity of adverse effects were also considered.” For those without MCI, outcomes included “immediate and delayed recall of face-name associations; visuospatial memory; short-term memory; paired associates; and immediate and delayed recall of words, paragraphs, and stories.” Immediate and delayed verbal recall significantly improved in persons without MCI.

Of the various training targets, only the memory training had enough comparable data to be pooled.

Be cautious in interpreting the results for persons with MCI, because only three studies addressed that population and the data were “scarce.”


Johnson, K. (2011). Cognitive training to improve memory just as effective as other intellectual activities. Medscape Medical News, January 25.

Martin M, Clare L, Altgassen AM, Cameron MH, & Zehnder F (2011). Cognition-based interventions for healthy older people and people with mild cognitive impairment. Cochrane database of systematic reviews (Online), 1 PMID: 21249675

Continuing Medical Education

You can take a CME course from Medscape.

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Willpower, Glucose, and Belief Wed, 02 Feb 2011 12:00:14 +0000 It looks like journalists are short on willpower. They give into the temptation to jump to conclusions. At least they do when they report on willpower research. Read one article, and we have a limited supply of willpower. If we use it up, then we simply can’t be held accountable for how much junk food we eat while dithering away the evening watching television.

Contrary to that, a spate of articles about a recent study tells us that it’s all in our minds; it depends on what we believe. This gives new traction to the Henry Ford quote, “If you think you can do it, or you think you can’t do it, You are right.”

However, I think the research tells us that the first step to more willpower is a step away from simple nostrums. The art of willpower looks more like a busy box than a one-step instruction.

Willpower is in Limited Supply?

We should start with asking what it is that researchers are researching when they research willpower. First, they may not even use the word. Instead, they might call it self-regulation or self-control. Sometimes self-regulation means something like homeostasis, as when our bodies keep us at the right temperature, but both self-regulation and self-control can also refer to willpower, the force with which one can, “exercise of control over oneself” according to a standard or goal.

When we seek willpower, we are seeking one (or a combination) of the following three things (it gets more complicated, but we’ll save the additional details for another time):

  1. Restraint against impulses (as in resisting the ice cream)
  2. Force against resistance (as in staying on task)
  3. Force over limitations or weakness (as in persisting despite getting cold, tired, or hungry)

This is starting to look a lot like Ohm’s law, for those of you that are into electricity (as in force divided by resistance equals current).

This three-factor view raises some questions. If you are trying to run five miles, how much of the effort is in running, and how much is in resisting the urge to turn right and get a cold one at the Plan B Bar? If you’re working on a term paper, how much of the challenge lies in managing your blood sugar (glucose), and how much lies in your self concept?

First, consider the truism that willpower comes in a limited daily supply. Willpower is usually compared to a muscle, and there is an apt comparison here, because your supply of strength depends on whether you have consumed proper fuel, restored the fuel when it is depleted, and used the work-rest-work principle to get the most out of your strength. This is hardly a specified daily supply. Like muscular strength, our strength of will varies with our nutritional status. This includes our blood sugar level, according to fairly recent research. But please don’t use that as an excuse to surrender to too much sweet temptation. After all, rationalization is really just a way to sabotage our will power when we still have some left.

Imagine how many other health and nutritional factors would weigh in if researched in this regard? And then there are sleep and exercise, which might as well be nutrients, since they are mission-critical when it comes to willpower.

Willpower is in the Mind?

But what about the idea that willpower is all in the mind. Set aside for now the question of where the mind is. Should I find mine, I’ll venture an opinion at a later time. Suffice it to say that recent research has shown that willpower is greatly affected by what we believe about how much we have. The researchers point out, however that this does not deny that other factors also affect willpower.

What is notable about the recent study on this question is this: people who were led to believe that willpower is not in limited supply took shorter breaks and ate less junk food. This suggests that, when it comes to the muscle of will, the work-rest-work principle demands only moderate rest and carbohydrates in order to serve you quite well.

Thus, you needn’t bulk up on carbs to win the willpower battle, but you must wean yourself from indulgent beliefs about it. Gandhi said, “Strength does not come from physical capacity. It comes from an indomitable will.” But where, exactly does this indomitable will come from? Apparently a good measure of it really does come from believing in it.


Baumeister, R. F. and Vohs, K. D. (2004). Understanding self-regulation: An Introduction, in Handbook of self-regulation: Research and theory. The Guilford Press.

Gailliot, M., & Baumeister, R. (2007). The Physiology of Willpower: Linking Blood Glucose to Self-Control Personality and Social Psychology Review, 11 (4), 303-327 DOI: 10.1177/1088868307303030

Job, V., Dweck, C., & Walton, G. (2010). Ego Depletion–Is It All in Your Head?: Implicit Theories About Willpower Affect Self-Regulation Psychological Science, 21 (11), 1686-1693 DOI: 10.1177/0956797610384745

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Woman Comparable to Men in Domestic Violence: Stereotypes and their Consequences Sun, 08 Jun 2008 14:07:39 +0000 Anti-Stigmatization CategoryIt’s very common to hear about violence against women and about male batterers rather than about violence against men and about female batterers. Like it or not, experts that do not cherry pick their data find a fairly even split when the general public is polled in various ways.

Domestic Violence expert John Hamel, LCSW recently addressed this, with abundant research citations, for a book chapter. I will provide, with his permission, his annotations. But why? First, derogatory stereotypes are bad in principle. Second, the stereotypes cause people to downplay or ignore domestic violence and related behaviors by women. Third, funding for shelters and other services for men who are victims of domestic violence is affected. Fourth, men may end up as victims of the justice system when it turns against them because of the stereotypes.

PoliceConsider these two examples:

A volunteer who presents about male victims was presenting to a police department. She had 200 law enforcement personnel present. At the end, she got a police officer to volunteer a call to a shelter, posing as a male victim. He called a hotline for a battered womens program and asked about services for men, explaining that he was experiencing violence at the hands of a female. The hotline worker said, “You should be in jail.” The officer restated that he needed help because his wife was violent. The hotline worker hung up on him.

In a recent article in the San Diego Metro Weekly domestic violence was mentioned in the context of the California Supreme Court ruling in favor of gay marriage, regarding gay divorce. It says,

And, if any violence has preceded the divorce discussions and say… the local gendarmerie is called in, our boys are subject to domestic violence laws, which are stickier by far than if they were single and decided to box each other on the ears.

This not only assumes there is no violence in lesbian relationships, and there certainly is, I’ve seen it, but it also diminishes the seriousness of it by referring to it as boxing the ears.

Hamel’s Review of Research

Now here is a taste of Hamel’s review of the data. Thank you, John!

Straus et al. (1980); Straus & Gelles (1990). Both National Family Violence Surveys, with a combined sample of more than 8,000 respondents, reported comparable gender rates for not only physical assaults, but verbal abuse as well.

Rouse, Breen and Howell (1988). This survey of 130 dating and 130 married students found that women are more likely than men to engage in isolation behaviors, such as “monitors time,” “discourages same-sex friends” and “discourages opposite sex friends.”

Stets (1991). The male and female respondents in this study of dating students reported equivalent rates of controlling behaviors (e.g., “I keep my partner in line,” “I am successful in imposing my will onto my partner”), as well as psychological abuse (e.g., “Said mean things,” “Degraded him/her”).

Kasian & Painter (1992). The authors surveyed a large sample (1,625) university students. Male respondents reported higher rates of received abuse, as measured by a modified version of the Psychological Maltreatment of Women Inventory, for control, jealousy/isolation, verbal abuse and withdrawal of affection. There were no gender differences in rates of received emotional abuse (“diminishment of self-esteem”).

Feder and Henning (2005). In this study of 317 couples dually arrested for IPV (interpersonal violence), most of them African-American, criminal justice data revealed no differences between the partners in injuries inflicted or weapons use. Interview data revealed no differences in physical assault; women were more likely to use a weapon, but to suffer slightly higher rates of injuries (19.6% vs. 15.0%). There were no gender differences in overall psychological abuse or coercive control tactics.

Stacey, Hazelwood & Shupe (1994). Higher rates of victimization than perpetration were reported by the male subjects in this Texas study of men in batterer treatment on four of the thirteen items from the CSR Abuse Index: “deny rights to privacy,” “deny access to family,” “withdraw emotions to punish,” and “withhold sex to punish.” Although the men reported lower rates of victimization than females on the other items, the differences were usually not large (e.g., “deny freedom of activities” was cited by 71% of men and 72% of women; “deny access to friends” was cited by 57% of men and 63% of women, and “censor phone calls” was reported by 53% of men and 60% of women.) One would have expected much larger differences from this population, considering that the men had been arrested and deemed “batterers,” while their female partners were deemed the “victims.”

Tjaden & Thoennes (2000). The National Violence Against Women Survey (NVAWS), drawing on a sample of 16,000 men and women, reported that 0.2% of men are stalked each year by a current or former intimate, and 0.5% of women, a ratio of 2.5 women for each man victimized. In addition, .038% of the men reported to having been raped the previous year. Five times as many women (0.2%) said that this had happened to them.

Spitzberg & Rhea (1999). The authors examined a variety of stalking subtypes, collectively known as obsessive relational intrusion (ORI). Results from their sample of college students in Texas revealed a 54% rate of male-perpetrated ORI’s, versus 46% for females.

Langhinrichsen-Rohling, Palarea, Cohen & Rohling (2000). In this college survey, respondents were asked to report on their own ORI behavior, as well as incidents of victimization. There were no overall gender differences in stalking rates. However, men made more unwanted visits to homes and apartments, whereas women left the greater share of unwanted phone messages. Women were also four times as likely to report having been physically threatened.

Meloy & Boyd (2003). The authors reported on 82 female cases from mental health clinics and some who came to the attention of law enforcement. The women were similar to male stalkers in having a history of failed intimate relationships and having cluster “B” DSM IV personality disorders (not antisocial). They were also similar in that 50% — 75% threatened and 50% — 55% assaulted their victim. But they were different in that they more often carried out threats and caused property damage.

Busby & Compton (1997). A large survey of 3,034 engaged couples reported that 6.1% men and 13.0% women had been sexually pressured by their partner.

O’Sullivan et al. (1998). In this survey of 433 dating university students, 18.5% of the men and 42.5% of women reported to having been sexually coerced by their partner.

Muehlenhard & Cook (1988). This college study revealed that men more often than women engaged in unwanted sexual intercourse, at rates of 63% versus 46%. Being taken advantage of when intoxicated was reported by 30.8% of the men, and 21.0% of the women. Among the men, 13.4% had been verbally coerced, and 11.5% of the women said that this had happened to them. The rates were 5.7% for men subjected to nonviolent coercion (e.g., blocking the door, holding the person down), compared with 5.4% for the women. Coercion involving physical assaults was experienced by 1.4% of the men and 2.7% of the women.

Waldner-Haugrud & Magruder (1995). The authors asked a dating population about a range of coercive sexual behaviors. In the previous year, the men had an average of 2.26 incidents perpetrated upon them, and the women 2.86. Persistent touching was reported by 51% of males and 70% of females. Men were twice as likely to report blackmail (8.5% versus 4.2%); women reported a higher incidence of manipulative guilt (30.1% versus 22.5%). The women were twice as likely as men to be restrained or detained, and more threatened with physical force (6.9% to 6.0%); but three times more men had weapons used against th em (4.5% versus 1.4%).

Coker, Davis, Arias, Desai, Sanderson, Brandt & Smith (2002). A re-examination of data of 16,000 respondents from the National Violence Against Women Survey found lifetime male victimization rates of 10.5% for experienced verbal abuse and jealousy/possessiveness, and 6.8% for power/control, compared to rates of 5.2% and 6.9% for women.

Riggs, O’Leary & Breslin (1990). Found a strong correlation between having a dominant and aggressive personality and IPV for both men and women.

Cano, Avery-Leaf, Cascardi & O’Leary (1998). Found a significant correlation in high school dating study for boys and girls between the use of jealousy and dominance tactics and physical assaults.

Hines & Saudino (2003). Using the Revised Conflict Tactics Scale, this survey of 481 university students found comparable levels of physical aggression between the genders. Women were found to have engaged in higher levels of psychological aggression, and the two types of abuse tended to co-exist.

Graham-Kevan & Archer (2005). Drawing upon a community sample of university students and faculty in Lancashire, England, the authors found rates of 13% for female intimate terrorists and 9% for male intimate terrorists, based upon the same criteria as used by Michael Johnson (a combination of physical violence, control, and psychological abuse).

Laroche (2005), and Graham-Kevan (2007). Laroche analyzed a massive Canadian study, the 1999 GSS, involving 25,876 respondents. Respondents were asked about their victimization by a current or previous spouse in the past 5 years. In addition to questions on physical assaults, the survey also asked respondents about victimization from the following psychologically abusive and controlling behaviors by their partner, similar to those in the Duluth Power and Control Wheel: “Limits your contact with family or friends,” “puts you down or calls you names to make you feel bad,” “is jealous and doesn’t want you to talk to other men/women,” “harms or threatens to harm someone close to you,” demands to know who you are with and where you are at all times,” “damages or destroys your possessions or property,” and “prevents you from knowing about or having access to the family income, even if you ask.” For the five year period prior to the study, approximately 3% of the surveyed women, and 2% of the men, were counted as victims of severe intimate terrorism (IT) – defined as having experienced severe and frequent physical violence and high levels of psychological abuse and control, and who would fit Ehrensaft et al.’s “clinical abuse cases” from injuries sustained, fear expressed, and use of police and other services. Graham-Kevan analyzed the results of the same survey, except that she focused on abuse reported for the past year only, and found very comparable rates of intimate terrorism between the genders. This is a remarkable finding, considering the study’s methodology (akin to the NVAWS in t hat its questionnaire framed IPV in terms of personal safety rather than conflict, thus suppressing male victimization rates) and “the inadequate assessment of controlling behaviors suffered by men” (Laroche, 2005, p. 11).

Felson & Outlaw (2007). An analysis of data originally obtained through the NVAWS with a sample of over 15,000 currently married or formerly married adults found that: (1) women are just as controlling and jealous towards their male partners as other way around; (2) the relationship between use of control/jealousy and physical violence exists equally for both male and female respondents; (3) “Intimate terrorists” can be either male or female. (Controlling/ jealous behaviors defined as: “Prevents you from knowing about or having access to family income even when you ask”; “Prevents you from working outside the home”; “Insists on knowing who you are with at all times”; Insists on changing residences even when you don’t want or need to”; “Tries to limit your contact with family and friends.”) Regarding the extent to which men and women engage in “intimate terrorism,” the authors write: “Both husbands and wives who are controlling are more likely to produce injury and engage in repeated violence. Similar effects are observed for jealousy, although not all are statistically significant. The seriousness of the violence is apparently associated with motive, although the relationship does not depend on gender” (p. 404). It should be pointed out that the National Violence Against Women Survey was designed, conducted and analyzed by feminist researchers, who sought to prove that violence against female intimate partners is much more serious than violence against male intimate partners.

Straus (2006). 7.6% of the male respondents and 10.6% of the female respondents interviewed in the International Dating Violence Survey (sample of 13,601 university students in 32 countries) reported having perpetrated severe assaults, and both partners were found to be violent in 68.6% of the cases. Based on 9 items related to dominance on the PRP (e.g., “my partner needs to remember that I am in charge”), the survey found overall dominance scores to be equal across gender, although higher dominance scores were found for women in 24 of 32 countries. It was also found that dominance by either partner increases the probability of severe violence, and that dominance by females increases risk of severe female-only or mutual IPV more than does male dominance.

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The Score at Medscape: Meds 9 and the Rest of the Universe 1 Mon, 26 May 2008 17:16:35 +0000 Drugs and Clinical Trials CategoryI’m never surprised at the power big pharma has over the media, especially media directed at physicians. For once, I’d like to talk back. Here’s a perfect opportunity! I’m going to talk back at an article recently posted to — a source of very informative, thoughtful, brainwashing, and useful information for physicians. This article is about individualizing adult ADD treatment:

To review the latest clinical thinking in this field, Medscape’s Randall F. White, MD, spoke with Richard H. Weisler, MD. Dr. Weisler, a busy clinician and researcher, is adjunct professor of psychiatry at the University of North Carolina at Chapel Hill, and adjunct associate professor of psychiatry at Duke University Medical Center in Durham, North Carolina.

ADHD… so long as the “latest clinical thinking” gives short shrift to anything but medication.

… some in the general public worry that ADHD may be overdiagnosed. When you look at the diagnostic criteria, they require impairment in multiple areas, such as school or work, and also in relationships or at home. If significant impairment exists in these areas, I believe that treatment is indicated.

But we won’t address the fact that there are regions where ADD diagnosis is at extremely high levels, and how diagnostic and systemic biases cause this. And don’t get me started on how we have abandoned the educational system and it’s need for adequate integrated counseling and mental health staffing.

Medscape: In your opinion, who are the 10.9% of adults with ADHD receiving treatment, and why are they getting treatment whereas the others are not?

Dr. Weisler: Some selection bias exists related to resources that people have, such as insurance coverage and maybe access to care in some regions. Certain places have a shortage of mental health professionals, and although primary care physicians may be comfortable in making a diagnosis of major depression or generalized anxiety disorder, almost half feel uncomfortable making a diagnosis of adult ADHD. They likely will refer the person to a psychiatrist for evaluation, if possible.

So only 10.9% of adults have adequate insurance or income and access to a psychiatrist or other mental health professional who would guide them properly? That’s the explanation? What about the extreme drop out rate among those who get medication for ADD? How about actually thinking this through? No. That would spoil the bias!

Medscape: Once the diagnosis is established and a decision is made to proceed with treatment, how should the clinician and patient arrive at the treatment goals? And what’s the best way to monitor progress?

At this point in the article, something good happens. Dr. Weisler talks about tracking real-life symptoms in order to monitor progress, and talking to people in the person’s life to get a more balanced and realistic view of what’s going on.

But he mentions something akin to denial:

If a person has somehow managed for 15, 20, or 30 years, he or she thinks that’s just the way it is.

Sometimes, but sometimes they have a lifestyle that does not challenge them in their symptom areas, and they are functioning well enough that they would rather not take the risks that are involved in taking medication. All medical decisions are, after all, a tradeoff involving risk, even if it’s relatively small. Or, perhaps the person is in a safety-sensitive job, such as being a pilot, and they don’t want to destroy their careers after performing safely and effectively for years.

At this point, Weisler takes the position that you should treat affective symptoms of problems such as depression before ADHD, but leaves room for individuality and points out that control of ADHD symptoms can improve abstinence by increasing life stability.

Then he recognizes the world outside of his office, which I wish more clinicians would do. He says that, since the most impaired people with ADHD are also the least likely to comply with medication, that people in the person’s life should be involved in their treatment. It would be nice if he had emphasized what kind of problem solving and problems with the medication take place. When medication has good odds of working, I agree that spouses should ask, “Are you taking your medication today?” even though it sounds like an unbalanced relationship. Even if it is, it’s still a relationship. He also points out advantages to once-a-day versions of stimulant medication.

He comes to a naive conclusion about a study on compliance. He mentions a study in which a medication management system showed that persons with cocaine dependence tended to take out their stimulant medication just before coming in to see the doctor, and lie about it, saying that they took the medication. He makes it sound like they were just disorganized and need a helpful spouse to remind them. But if they’re lying and addicted to cocaine, they are probably selling. After all, you have to take special measures to offset the cost of cocaine! But let’s not think this though, it would spoil the bias!

Here’s where I have the biggest problem, verging on disgust. Catch this:

More directly relevant to ADHD is a study by Capone and colleagues that examined monthly persistence on medication. They found that even after just a few months, half the people weren’t taking their medication. Adherence dropped to 20% after a year or so. Unfortunately, it’s not all that different from what we see with bipolar disorder, depression, or other psychiatric disorders.

How does he address this critical issue? He wanders off, briefly, into how children’s stimulant use goes down in the summer, and then veers into the awful things that are likely to happen to people with ADHD, such as job loss, divorce, and traffic violations.

In other words, he doesn’t answer the question, and distracts us with some fear mongering intended to emphasize the importance of medication. No solution is in sight, other than the clinician becoming more strident with the patient.

Or, as Medscape puts it, without alluding to any direct evidence:

So poor adherence could have deadly consequences.

Could be. More likely, the greatest threats to well-being are from developmental issues that medication cannot treat in adults. At best, medication might make an adult more successful in treatment directed at those developmental issues. But, in this case, the medication would be adjunctive. But let’s stick with the illusion of things being more clear-cut, don’t spoil the bias!

Weisler also points out that regular treatment (he always says treatment instead of stimulant medication treatment, as you would say if you were acknowledging the importance of other treatment modalities) reduces the initial side effects that can reduce medication compliance. In my experience, people who complain about side effects, whether they are taking stimulant medication or have discontinued it, complain about enduring side effects. I rarely hear of complaints about the initial effects.

Medscape: Aside from extended-action medications, what other pharmacologic characteristics affect treatment adherence?

Dr. Weisler: With ADHD, just as with other diseases, people will have idiosyncrasies as to what effects are unacceptable.

They have “idiosyncrasies,” because calling them personal preferences (like being upset about losing their appetite or sleep difficulties) is too, well, personal!

Oh boy, now we’re going to hear about something besides medication!

Medscape: What role do psychotherapy or other psychosocial interventions play in treatment of adult ADHD and promoting medication adherence?

Dr. Weisler: I think that psychotherapy can play a significant role. If you’ve lived with undiagnosed ADHD for many years, your self-esteem is likely to be low. You may well have some depression or be anxious in certain situations because you are worried about what people think of you. I think that cognitive therapy can make a big difference for both depression and anxiety.

Why are some people so good at diminishing a topic down to a token, and sounding as though they’re really talking about it? And how about the value of having a more specialized approach? It that too managed care unfriendly?

Dr. Weisler: Patients can learn techniques that will help them cope with their limitations better. Professional coaches can assist people, and simple techniques such as wearing sound-canceling headphones while they’re trying to work in a noisy environment can make a difference.

Sure, ADD people just need a few simple techniques. They are vulnerable to deadly things like traffic accidents, drug use and fights (well, the article says so), but this is because of impulsiveness (well, the article says so), and that’s taken care of by the meds (well, the article says so), so a couple simple techniques from a coach, and some counseling for self esteem and mood will take care of the rest. I’m starting to like the Weisler Universe. It’s so much tidier and simpler than the one with developmental issues and numerous reasons for medication noncompliance (such as the serious limitations of the medications themselves) that you have to deal with in the Unprocessed Universe.

Dr. Weisler: In my experience, adherence is clearly improved with psychotherapy. It doesn’t necessarily get people better faster, but it makes them more likely to stick with treatment, and it’s another way of addressing difficult issues.

Ugh. No comment. I’m done.

1,606 words about meds, and 156 about everything else. That’s just under 10%. It doesn’t take Noam Chomsky to see the pattern at Medscape.

Mind you, I’m not anti-medication. I’m just anti-brainwashing.


Weisler, R.H., White, R.F. (2008). Managing Expectations and Individualizing Treatment for Adults With ADHD: An Expert Interview With Richard H. Weisler, MD. Medscape Psychiatry & Mental Health.

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