I also served temporary duty (TDY) at Lackland AFB working with airman stationed in Vietnam, presenting with PTSD and substance abuse disorder (SUD).  As a clinician in Behavioral Health Care, I dealt with folks presenting with multiple psychosocial trauma, including combat Vets from Vietnam.

I’ve not witnessed directly the ghosts of combat. Those who have repeatedly are haunted by those of comrades killed (KIA) and by those who they killed, especially those who are civilians. Thus, they experience what I refer to as “compacted grief”. During war, there is little room and energy to grieve.

I completely agree with Lt. Col. Grossman that most of us possess a natural inclination to not kill other humans. No amount of combat training can prepare soldiers for the realities of war and combat. I see war as an extreme expression of insanity, even when war is deemed by some to be necessary and the participants are “voluntary”. War and combat sear us at the limbic level, a necessary encounter which I refer to as “Dark Beast”. The Vets I have treated and my many clients in BHC have taught me so much about this Beast. The following account here centers on my running commentary as I read “Shooting Ghosts”, using my observing clinical ego.

When I embarked on reading their candid descriptions of encountering repeated episodes of violent death, At times I felt guilty for not having served in Vietnam. I joined the Air Force after my college deferment lapsed once I graduated. I did not really support our endeavor there. I never felt this Conflict to be an urgent and immediate threat to our nation’s integrity. I became a medic so that I would not have to kill anyone, nor would anyone would be killing me. I did therapy with some of the field medics who were confronted with killing. Killing is counterintuitive to our ethical oath to: above all else, do no harm.

From Chapter One, I disagree that “Misfits Go to War”. We join the military for a number of reasons. For the most part, the Armed Forces want servicemen with integrity who join for a higher purpose like serving our country and protecting others. The bonds forged with comrades begin during advanced training and intensifies early in deployment. Individual survival is directly associated within this group that we refer to as our squad. It is this commitment that soldiers go into battle and come back as a group which I refer to as “affiliative aggression”. Soldiers are protecting one another!

The second disagreement is that war and journalism do mix in order to inform the rest of us about the horrors and terrors of war, and the tremendous cost borne by those who directly experience it. And none of us are “fearless and invincible”. In fact, my professional experiences assure me that life is quite precious and tenuous at the same time; so we dearly need to hold onto it! And guns and cameras are valuable tools of the respective trades.

Chapter Three: Ambushed

Now it is kill or be killed by the enemy. Affiliative and defensive aggression is rising. They sustain some injuries and every squad member returns to their outpost. No time for “mental casualties”; the BB is really present for the first time! An RPG creates a concussion suffered by the squad leader.  Back at the outpost “Air Force medics” come to the rescue. Everyone is alive, but are they really? Concussions are quite serious. Each skirmish does not change the outcome of the war; yet indeed changes those who participate!

Chapter Four: Walking Wounded

The human brain consists of about One Trillion nerve cells, and about ½ of our genome is dedicated to the form and function of this organ. Sounds like a lot and many that can be spared. Indeed, the brain is well known for its neuroplasticity! I’m uncertain as well if God has or has not allowed us to contemplate going to war let alone engage in it. Traumatic Brain Injury (TBI) also occurred in Vietnam, not just in our more recent conflicts. Perhaps it is garnering more clinical attention? We know that it is also intimately related to Clinical Depression and PTSD. I agree that repeated combat encounters result in a “kinship and loyalty” that many of us will never know!

Chapter Five: The in-between

The brain and all of our human senses process all of our internal and external experiences. I refer to the brain as a “master accountant”. Much of what we process occurs beneath our conscious awareness.

In fact, there are at least seven streams of awareness. Some are deeply embedded suggesting that we better remember certain experiences more than others to ensure our survival.

Those in combat continue to experience the traumas once confronted repeatedly by the DB! Being back “home” and away from the front lines does not matter. We are genetically primed by our “threat alarm” in responding to perceived and/or real threats by fighting, fleeing, or freezing. Our primary cognitive processes regarding threats pertain to harm, loss, and challenge. We must not ignore them!

Even photographers and journalists are not immune to being harmed or killed! Immunity from stress and trauma is indeed an “illusion”. During adolescence, males exhibit an increase of invincibility (probably due to the significant infusion of testosterone). And there is no “magical cure” for real trauma. And life is more important than what each of us do for a living.

Chapter Six: Human Triggers

Another death of a platoon member, who is very experienced in combat; and he is survived by a wife and children, gets a lot of attention. His loss impacts more than this soldiers. And indeed death is all around as the “Dark Beast” possesses an insatiable appetite for “kills and body counts”.

The effects of TBI on the squad leader are apparent. And there is no room for complacency and lapses of concentration! They are becoming human targets and increasingly aware of this reality. The sights, smells, and sounds of violent death are deeply etched in the collective minds of these soldiers. Home for them seems a long way off! The platoon leader earns a Purple Heart. And he feels he doesn’t deserve it. So far, he and his men are alive.

Chapter Seven: Lost Limbs and Skull Tattoos

Another photographer is severely injured having stepped on an IED. It is natural to “dread” the “damaged cargo” carried by the MEDEVAC choppers. Some photojournalists become resigned to this possible occupational fate. There is a growing sense that these soldiers may not ever win the “hearts and minds” of the Afghan civilians despite their best efforts to do so.

Some of the violence and deaths of comrades that these soldiers experience are etched on the largest sense organ—the skin. No time to deal with any of this in a combat zone, no time to grieve! Suppression of trauma from previous combat excursions does not work either! And the photojournalist embedded with this squad begins to question his witness position and “feels predatory, repulsive, and a betrayal of human decency”.

Chapter Fourteen: Coming Undone

The home front is becoming undone. Interpersonal relationships are becoming frazzled. The natural regression after repeated exposure to the “Dark Beast” is taking its toll. All the prescribed psychotropics (chemical cocktails) in the world won’t make that much difference. BTW suicide among combat vets is rising despite priority efforts to prevent them.

Chapter Sixteen: Echoes of Iraq

The Boston Marathon bombing reawakens images of the “DB” on US soil for the second time since the attack on 9-11. Surely there is no safety and security now! Understandably, cemeteries and headstones serve as triggers. For soldiers converting back to civilian life, there exists a natural disconnect between military culture and the civilian role; clinicians refer to this as cognitive dissonance, and it penetrates much deeper than just our thinking!

Advanced combat training does not really train soldiers to kill the designated enemy, only the illusion of them. And the military certainly does not prepare them to kill civilians such as children, women, and the aged. Yet, this happens in actual combat. For example, during the Vietnam Conflict, it is estimated that more civilians were killed than enemy combatants on both sides. This distinction gets lost in the insanity of combat. Yet the civilian-soldier has to come to terms with this reality; and based on having conducted psychotherapy with Vietnam combat Vets, the grief and regret become almost unbearable! I refer to this state as psychosocial death. Sociologist, Erving Goffman, refers to this as “mortification”. Killing the innocent does not reflect affiliative or defensive aggression. To me, it is an adverse consequence of encounters with the “Dark Beast”.

Final Thoughts and Observations

First of all, I express my sincere gratitude to all those who have, do now, and will serve in the Armed Forces; and my gratitude to all the loved ones who endure this journey with them. I want you all to know, that in my clinical view, soldiers do what they do out of affiliative and defensive aggression; they are not predators!

Those who send humans to war need to examine much more closely the human damage done to the participants and family members for whatever gains are earned in doing so.

And it is my clinical observation that group counseling/therapy could be more efficacious in treating those who are haunted by the ghosts of combat. Group therapy can recapitulate the crucial military unit- the squad. This offers a better opportunity for some healing from the repeated exposure to the “Dark Beast”.

Richard G Kensinger, MSW

Image via DasWortgewand/Pixabay.

In 2017, Mental Health America reported that one in five adults with mental illness say that they are not receiving the mental health care that they need. (Mental Health America, 2017) The reasons for this are the following:

There is one mental health care provider for every 529 individuals in the US. This gap widens significantly for specialized mental health care. Only 20% of children with mental health problems receive some form of mental health services. The reason is that there are only about 8000 child and adolescent psychiatrists practicing in the US. In San Francisco alone, the Center for Disease Controls and Prevention (CDC) reports that there are about 32 child psychiatrists and 88 child psychologists per 10,000 children ages 0 to 17 years old.

There is a need for re-imagining the delivery of mental health care. One such method is known as the Friendship Bench Intervention (see video). The friendship bench has been undergoing development for more than 20 years in Harare, Zimbabwe where the Harare City Health Department in collaboration with the University of Zimbabwe Medical School sought to solve a major cause of disability from non-communicable diseases in the region, mostly common mental disorders such as depression and suicidal ideation.

The Friendship Bench is a task-shifted brief intervention and problem-solving therapy for common mental disorders which is provided by female lay health workers trained in specific aspects of cognitive behavioral therapy, particularly in problem-solving therapy and behavior scheduling. 

In short, the Friendship Bench mitigates common mental disorders such as depression by utilizing female lay health workers who are trained and supervised by clinical psychologists and psychiatrists to perform problem-solving therapy in a primary care setting.

The problem-solving approach starts with the patient identifying the cause of his mental illness. For example, unemployment. Interestingly, this approach deviates from the conventional where experts aim at diagnosing the patient from the symptoms that they present. Problem-solving therapy aims to provide a positive orientation of the patient towards resolving these identified problems. This makes them realize that they can have control in overcoming their mental illness.

The lay workers follow a script and conduct 6 sessions lasting from 30 to 45 minutes for each patient. The first session involves three components: (1) Opening the Mind or kuvhura pfungwa, (2) Uplifting or kusimudzira, and (3) Strengthening or kusimbisa. The first session aims to let the patient open their mind and identify their problems. They would then be allowed to choose only one to work on. The lay worker and the patient will then identify how to solve this problem realistically and formulate an action plan. This is an iterative process where the subsequent sessions will develop based on the first session.

Common mental health disorders that the Friendship Bench aims to treat are the following: depression, anxiety, panic disorder, post-traumatic stress disorder, cognitive disorders, and substance abuse.

Hiring and training lay workers from the community can significantly increase the mental health workforce. The requirement for the adult female trainees in this program is an educational background with at least 8 years of formal schooling (secondary schooling may suffice). The average age of the trainees is 58-years old. The training can be easily implemented, and it is cost-efficient at only $200 per health worker.

Figure 1. An Example of a Theory of Change Framework Output. LHW = Lay Health Workers

Community engagement is a key process in the development of the Friendship Bench. The goal is to bring community members, experts, researchers, and other key stakeholders together and become equal partners in the program. They engage in a workshop to develop a theory-driven framework known as the Theory of Change. Members hypothesize the best treatment initiative plan for the community’s patients and form a theory of “how and why an initiative works?”. Variables are identified and constantly measured for every cause and effect pathway. This illustrates proof that an initiative has a positive or negative impact. The theories are continuously measured, challenged, and changed until the desired impact is formulated (see Figure 1).

The success of the program is heavily reliant on the training method, the translation of the manual to the local language, and the integration of the program with the culture of the community. Lay workers must also learn how to translate and utilize tools used in common mental disorders such as the 20 item Self-Reporting Questionnaire (SRQ-20), General Health Questionnaire (GHQ-12), Hospital Anxiety and Depression Scale (HADS-D), and Patient Health Questionnaire – 9 Depression Test (PHQ-9). These are the basic metrics used to determine if the therapies are working.

Adding to the workforce, competent lay mental health workers in the primary care setting can offset the gap in mental healthcare delivery in communities. Its success in first-world countries is more likely because its growth can be sustained by leveraging readily accessible financial resources allocated each year by public health organizations. Its robust infrastructure, particularly in primary care clinics and information technology such as telehealth services, can boost the Friendship Bench programs. A limitation of the Friendship Bench is that it is designed to treat adult common mental disorders. To emulate this program so that it can suit the need for pediatric mental health disorders is of importance.

References

Abas, M., Broadhead, J. C., Mbape, P., & Khumalo-Sakatukwa, G. (1994). Defeating Depression in the Developing World: A Zimbabwean Model. Brittish Journal of Psychiatry, 293-296. doi:10.1192/bjp.164.3.293

American Academy of Child and Adolescent Psychiatry. (n.d.). Workforce Issues. Retrieved May 15, 2018, from American Academy of Child and Adolescent Psychiatry: https://www.aacap.org/aacap/resources_for_primary_care/Workforce_Issues.aspx

Blakely, T. (2003). Unemployment and suicide. Evidence for causal association? J Epidemiol Community Health, 57, 594-600. doi:10.1136/jech.57.8.594

Center for Disease Controls. (2015). Behavioral Health Services Providers by County. Retrieved May 15, 2018, from Centers for Disease Control and Prevention: https://www.cdc.gov/ncbddd/adhd/stateprofiles-providers/california/index.html

Chibanda, D., Mesu, P., Kajawu, L., Cowan, F., Araya, R., & Abas, M. A. (2011, October 26). Problem-solving therapy for depression and common mental disorders in Zimbabwe: piloting a task-shifting primary mental health care intervention in a population with a high prevalence of people living with HIV. DMC Public Health, 11, 828. doi:10.1186/1471-2458-11-828

de Silva, M. J., Breuer, E., Lee, L., Asher, L., Chowdhary, N., Lund, C., & Patel, V. (2014, July 5). Theory of Change: a theory-driven approach to enhance the Medical Research Council’s framework for complex interventions. BioMed Central, 15, 267. doi:10.1186/1745-6215-15-267

Mental Health America. (2017). 2017 State of Mental Health in America – Access to Care Data. Retrieved May 5, 2018, from Mental Health America: http://www.mentalhealthamerica.net/issues/2017-state-mental-health-america-access-care-data

Munets, E., Simms, V., Dzapasi, L., Chapoterera, G., Nyaradzo, G., Gumunyu, T., . . . Chibanda, D. (2018, February 8). Trained lay health workers reduce common mental disorder symptoms of adults with suicidal ideation in Zimbabwe: a cohort study. BMC Public Health, 18, 227. doi:10.1186/s12889-018-5117-2

Shamu, S., Zarowsky, C., Roelens, K., Temmerman, M., & Abrahams, N. (2016). High-frequency intimate partner violence during pregnancy, postnatal depression and suicidal tendencies in Harare, Zimbabwe. Gen Hosp Psychiatry, 38, 109-114. doi:10.1016/j.genhosppsych.2015.10.005

van Ginneken, N., Tharyan, P., Lewin, S., Rao, G., Meera, S., & Pian, J. (2013). Non-specialist health worker interventions for the care of mental, neurological and substance-abuse disorders in low- and middle-income countries. Cochrane Database Syst Rev, 11, CD009149. doi:10.3109/01612840.2015.1128299

Image via Pexels/Pixabay.

With the prevalence of mental health problems, it is clear why. Mental health issues are one of the leading causes of the overall disease burden globally, according to the World Health Organisation. One study reported that mental health is the primary source of disability worldwide, causing over 40 million years of disability in 20 to 29-year-olds.

Compared to previous generations, mental illness is now said to surpass the effects of the Black Death. The root causes of the unprecedented rise in people directly affected by mental illness, and the cost of this, can be considered across at least three levels of analysis.

If we don’t have time to be sick, then we have to make time to be healthy.

Colleen Patrick Goudreau

At the first level of analysis, the root cause of mental illness is an amalgamation of heredity, biology, environmental stressors, and psychological trauma.

Notions of specific genes being responsible for illness have been supplanted by those of genetic complexity, where various genes operate in concert with non-genetic factors to affect mental illness. That is, health-relevant biology and mental health impact each other in a complex interplay, which is inherently social.

Despite the importance of understanding the social underpinnings of biological risk factors for mental illness, there is a relative paucity of research investigating this topic. Research that does exist, is nevertheless engrossing. For example, one study, of many, found that social isolation leads to increased risk of coronary heart disease. Since low levels of social integration are related to higher levels of C-reactive protein, a marker of inflammation related to coronary heart disease, social integration is posited to be a biological link between social isolation and coronary heart disease.

Moreover, social support affects physical perception. In a landmark study, researchers demonstrated that people accompanied by a supportive friend or those who imagined a supportive friend, estimated a hill to be less steep when compared to people who were alone.

Mental health, like physical health, is more than the sum of functioning or malfunctioning parts.

At the second level of analysis, the complex bio-social interplay scaffolding mental illness points to the fundamentally chemical underpinnings of human thinking and emotion.

With recent advances in neuroscience like Clarity, we are now able to make the brain optically transparent, without having to section or reconstruct it, in order to examine the neuronal networks, subcellular structures, and more. In short, we can examine mental illness from a biological perspective.

The depth and complexity of the bio-social root of mental illness, however, paints a more nuanced picture than discussed thus far. With such pioneering work, there is an increasingly popular assumption that the brain is the most important level at which to analyze human behavior.

In this vein, mental illness perpetuates itself by virtue of the fact that people often consider it to be biologically determined. In turn, a ‘trait-like’ view of mental illness establishes a status quo of mental health stigma by reducing empathy. Such explanations overemphasize constant factors such as biology and underemphasize modulating factors such as the environment.

At the third level of analysis, the obsession with seeing mental health in terms of mental illness reveals the fallible assumption that mental health is simply the absence of mental disorder. However, the problematic landscape of mental health draws on a far wider set of working assumptions. That is, mental health, like physical health, is more than the sum of the functioning or malfunctioning parts. It is an overall well-being that must be considered in light of unique differences between physical health, cognition, and emotions, which can be lost in a solely global evaluation.

So, why do we as a society ponder solving mental illness, which should have been targeted long ago, far more than we consider improving mental health? In part, because when we think of mental health, we think of raising the mean positive mental health of a population, more than closing the implementation gap between prevention, promotion, and treatment.

Cumulatively, social environments are the lubricating oil to biological predispositions, which influence mental health, such that mental health and physical health should be considered holistically. In this vein, national mental health policies should not be solely concerned with mental disorders, to the detriment of mental health promotion.

It is worth considering how mental health issues can be targeted using proactive behavioral programs. To achieve this, it is pivotal to involve all relevant government sectors such as education, labor, justice, and welfare sectors.

In a diverse range of existing players, many nonprofits’, educational institutions’, and research groups’ efforts contribute to the solution landscape of mental health promotion. In Ireland, for example, schools have mental health promotional activities such as breathing exercises and anger management programs. Nonprofits around the world are increasingly seeing the value of community development programmes and capacity building (strengthening the skills of communities in so they can overcome the causes of their isolation). In addition, businesses are incorporating stress management into their office culture.

We think of raising the mean positive mental health of a population, more than closing the implementation gap between prevention, promotion and treatment.

The pursuit to empower people to help themselves joins up these social ventures to teach us that promoting mental health is optimized when it is preventative, occurring before mental illness emerges, and when it is linked to practical skills within a community. Furthermore, these social ventures exemplify how different types of efforts (government, nonprofit, business etc.) cater to different populations, from children to corporates.

While these social ventures bring hope to the future and underscore the importance of sustainable change, there are still too few programs effectively targeting people, who want to maximize already existent positive mental health not just to resolve or cope with mental health issues. If we continue to take such pride in our successful problem finding and solving of mental illness that we ignore mental illness prevention and mental health promotion, we are at risk of increasing the problem we are trying to solve.

References

Heffner, K., Waring, M., Roberts, M., Eaton, C., & Gramling, R. (2011). Social isolation, C-reactive protein, and coronary heart disease mortality among community-dwelling adults. Social Science & Medicine, 72(9), 1482-1488. doi: 10.1016/j.socscimed.2011.03.016

Lozano, R., Naghavi, M., Foreman, K., Lim, S., Shibuya, K., & Aboyans, V. et al. (2012). Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. The Lancet, 380(9859), 2095-2128. doi: 10.1016/s0140-6736(12)61728-0

Schnall, S., Harber, K., Stefanucci, J., & Proffitt, D. (2008). Social support and the perception of geographical slant. Journal Of Experimental Social Psychology, 44(5), 1246-1255. doi: 10.1016/j.jesp.2008.04.011

Image via Wokandapix/Pixabay.

You don’t need to be a die-hard Ellen DeGeneres fan to appreciate the value of that motto. And while we’re reminded how kindness goes a long way in our everyday interactions with others, we often forget to apply it to those who need it most: ourselves.

Whether it’s setting a personal weight-loss goal, or believing that we can ace a final exam—all of us are familiar with the experience of setting high standards. We’re even more familiar with the inevitable let-down that comes from not living up to those very standards.

Enter, the life of a perfectionist.

But, importantly, not all perfectionists operate the same. There are different types that are associated with different psychological outcomes.

On the one hand, if you strive to attain your ambitious goals and prevent yourself from being overly self-critical, you might be a personal strivings perfectionist. This isn’t so bad. In fact, this type of perfectionism is more likely to lead to relatively higher levels of self-esteem and decreased levels of negative affect.

On the other hand, if you constantly believe that you are not good enough, if you judge yourself by your shortcomings, and if you are constantly worried that other people won’t approve of you, then you might be more on the side of maladaptive perfectionism. This form of perfectionism has been linked to depressive symptoms in both adolescents and adults.

It’s no wonder then that researchers are curious to know more about interventions that help buffer against this maladaptive perfectionism. In one recent study, researchers examined the possibility that self-compassion can protect us against the negative effects of maladaptive perfectionism. The questions is, can self-directed kindness increase our chances of living a full, healthy life? Can it combat the symptoms of depression that come from this less ideal version of perfectionism?

Understanding self-compassion

You may ask, “What exactly is self-compassion? And is it something that can be cultivated by anyone, or is a skill that is only available to some of us?” To shed some light on these questions, researchers have broken down self-compassion into three main components: self-kindness, common humanity, and mindfulness.

While the first component is self-explanatory, the other two require careful consideration. When something terrible happens to us, often the initial reaction is to sit and wallow in our grief and self-pity. We convince ourselves that no one else is going through similar problems in their lives. But that is simply not true. Statistically speaking, it’s an erroneous judgment.

In order to be more accepting of ourselves, we need to realize that we are never as alone and isolated as we think we are. This is at the heart of common humanity.

At the same time, many of us are prone to over-analyzing painful experiences, or trying to avoid negative feelings altogether. Mindfulness then, is about acknowledging our thoughts, feelings, and emotions without judgement, and accepting them as part of the common human experience.

Back to our study. Taking into account these three sub-components, the researchers in the present investigation set out to predict that self-compassion would weaken the relationship between perfectionism and depression in both adolescent and adult populations.

The study

541 adolescents from grades 7 to 10 were recruited for the first study. Participants were asked to complete three online questionnaires during school hours, as part of a larger well-being intervention study. The questionnaires tapped into perfectionism, mood/feelings, self-worth and self-esteem, as well as reported self-compassion.

As predicted, self-compassion was found to moderate, or weaken, the relationship between maladaptive perfectionism and depression in this sample of adolescents. Next, the researchers wanted to see if the results would hold for adults.

515 adults from the general population were recruited through online advertisements. Again, participants were asked to complete the same questionnaires. Once again in line with the researchers’ predictions, self-compassion was found to weaken the relationship between perfectionism and depression in the adult sample. What was true for teens was also true for adults later on in life.

Why it matters

It seems that more than anything, today’s culture values perfection. Parents and teachers may push us towards excellence at school, our friends may judge us by how we dress and act in their company, and perhaps worst of all, our social media accounts constantly fool us into thinking that there are people out there who actually have perfect lives.

Good news, bad news. The bad news is that we can’t completely eradicate perfectionistic thoughts. Good news is that we can try to change our relationship to those thoughts through self-compassion. If we learn to cultivate self-kindness, connection, and mindfulness as we strive toward achieving our goals, any setback we face along the way will be met with greater resilience and mental strength. As a result, we are less likely to fall victim to the debilitating effects of depression, and more likely to live a happy, balanced life.

So, as Ellen DeGeneres reminds us, always be kind to others. But before you do, be sure to look after yourself first. In this case, it’s okay to be a little selfish.

References

Ferrari, M., Yap, K., Scott, N., Einstein, D., & Ciarrochi, J. (2018). Self-compassion moderates the perfectionism and depression link in both adolescence and adulthood. PLOS ONE, 13(2), e0192022. doi: 10.1371/journal.pone.0192022

Hill, R., Huelsman, T., & Araujo, G. (2010). Perfectionistic concerns suppress associations between perfectionistic strivings and positive life outcomes. Personality And Individual Differences, 48(5), 584-589. doi: 10.1016/j.paid.2009.12.011

NEFF, K. (2003). The Development and Validation of a Scale to Measure Self-Compassion. Self And Identity, 2(3), 223-250. doi: 10.1080/15298860309027

Stoeber, J., & Otto, K. (2006). Positive Conceptions of Perfectionism: Approaches, Evidence, Challenges. Personality And Social Psychology Review, 10(4), 295-319. doi: 10.1207/s15327957pspr1004_2

Image via nandhukumar/Pixabay.

As everyone gathers in the room, you’re suddenly flooded with a hit of adrenaline. The bad kind. In a flash you become acutely aware of what your body is doing: beads of sweat forming on your brow, a dry mouth that no amount of water can fix, and a steadily increasing heart rate thumping inside your chest.

This ability to perceive the signals of your body is known as interoceptive accuracy (IAc). There are, as the example demonstrated, different psychosomatic cues that you pick up within yourself during states of anxiety. But above all, a beating heart is the hardest one to ignore.

It’s for this reason that heartbeat perception, as brain scientists call it, is a direct proxy for measuring people’s IAc and reported anxiety and stress levels.

IAc and a beating heart

Having the ability to accurately detect your own heartbeat is critical for reappraising your anxiety on a moment to moment basis. We know that anxiety is as much in the body as it is in the mind, and that a (mis)perception of a fast heart rate can easily contribute to the catastrophization of a panicked state.

It’s why some of the most effective anxiety-related therapies, like progressive muscle relaxation and deep breathing, tend to focus on muting a physiological response followed by a cognitive reappraisal technique.

Now in terms of IAc, the longstanding view was that it is an inherited trait, similar to eye color or height. Your IAc is immutable, unchanging. But now there’s new evidence suggesting that the situation matters just as much as the person: While some people may have inherently bad interoceptive ability, we can’t ignore the influence of the broader context. And this, if it turns out to be true, is a definite win for anyone looking to reverse a certain anxiety-based predisposition.

The study and findings

A team of researchers led by Martin F. Whittkamp out of the University of Luxembourg  set out to investigate just how much of a role the environment plays in determining our ability to self-reflect on accurate biofeedback.

The researchers relied on two methods to measure IAc via heartbeat perception. The first, called the counting task is simply a comparison between actual measures of your heartbeat with your self-reported measures. Another method, called the heartbeat discrimination task, measures how accurately you can rate whether or not your heartbeat is in sync with an external stimulus such as a blinking light on a computer screen.

The team in this newest study compared the results of both a heartbeat counting task and discrimination task in two conditions: a resting state and a stress state. Mental stress was induced by having participants match the color of a flashing light bulb with a corresponding button as fast and accurately as possible. If this wasn’t stressful enough, the experimenter also chimed in with a few verbal cues urging the participant to perform better so as to not ruin the entire experiment.

In addition to comparing stress state IAc with resting state IAc, the researchers also designed a number of computational models. These models aimed to measure how much of one’s interoceptive accuracy is owed to individual ability versus the situation.

The results found that about 40% of a person’s IAc can be explained by his/her individual traits, while around 30% can be explained by the changing situation, leaving the remaining 30% to measurement error.

What this says is that your ability to detect and therefore modulate your bodily responses during an anxious state is not fixed. These signals are amenable to change. You can learn to more accurately perceive your beating heart in a high-stress environment. You can apply reappraisal techniques in mitigating your anxiety.

The findings of this study have the potential to inform research on stress and anxiety management. For example, having a general idea of how much your IAc is dependent on biological predisposition could provide leeway to pharmaceutical interventions to help combat debilitating responses to stressful situations.

For now there’s therapeutic power in knowing you can improve your IAc and work towards minimizing your anxiety.

References

Feldman, G., Greeson, J., & Senville, J. (2010). Differential effects of mindful breathing, progressive muscle relaxation, and loving-kindness meditation on decentering and negative reactions to repetitive thoughts. Behaviour Research And Therapy, 48(10), 1002-1011. doi: 10.1016/j.brat.2010.06.006

Knoll, J., & Hodapp, V. (1992). A Comparison between Two Methods for Assessing Heartbeat Perception. Psychophysiology, 29(2), 218-222. doi: 10.1111/j.1469-8986.1992.tb01689.x

Richter, D., Manzke, T., Wilken, B., & Ponimaskin, E. (2003). Serotonin receptors: guardians of stable breathing. Trends In Molecular Medicine, 9(12), 542-548. doi: 10.1016/j.molmed.2003.10.010

Wittkamp, M., Bertsch, K., Vögele, C., & Schulz, A. (2018). A latent state-trait analysis of interoceptive accuracy. Psychophysiology, 55(6), e13055. doi: 10.1111/psyp.13055

Image via mohamed_hassan/Pixabay.

But a new Australian study published in the Journal of Psychopharmacology reveals some unexpected problems with the nasal spray method. In particular, the study shows the unpredictable nature of intranasal ketamine tolerance from one person to the next.

Lead author Professor Colleen Loo at the University of New South Wales (UNSW), who is based at Black Dog Institute, states:

It’s clear that the intranasal method of ketamine delivery is not as simple as it first seemed. Many factors are at play when it comes to nasal spray ketamine treatments. Absorption will vary between people and can fluctuate on any given day within an individual based on such things as mucous levels in the nose and the specific application technique used.

The pilot trial aimed to analyze the effectiveness of repeated doses of ketamine through an intranasal device amongst 10 volunteers with severe depression, ahead of a larger randomized controlled trial.

First, the participants were given extensive training in proper self-administration techniques before receiving either a course of eight ketamine treatments or an active control over a period of four weeks, under supervision at the study center.

Following the observation of each patients’ initial reaction to the nasal spray, the dosages were adjusted to include longer time intervals between sprays.

However, the trial had to be put on hold after testing with five participants resulted in unexpected problems with tolerability. Side effects included high blood pressure, psychotic-like effects, and motor incoordination which left some participants unable to continue to self-administer the spray.

Professor Colleen Loo commented:

Intranasal ketamine delivery is very potent as it bypasses metabolic pathways, and ketamine is rapidly absorbed into the bloodstream. But as our findings show, this can lead to problems with high peak levels of ketamine in some people causing problematic side effects. Other recent studies have questioned whether changes to ketamine’s composition after being metabolised into derivative compounds may actually deliver useful therapeutic effects. It remains unclear whether ketamine nasal sprays can be safely relied upon as a treatment for patients with severe depression.

Previous research led by Loo last year revealed the success of ketamine’s antidepressant effects in elderly patients when delivered in repeated doses, which were adjusted on an individual basis and given by the subcutaneous method (injections under the skin):

Our prior research has shown that altering the dose on an individual patient basis was important. However, we wanted to see if a simpler approach using a set dose of ketamine for all people and administered by nasal spray could work just as well in this latest pilot. More research is needed to identify the optimal level of ketamine dosage for each specific application method before nasal sprays can be considered a feasible treatment option.

The researchers are now recruiting participants for the world’s largest independent trial of ketamine to treat depression, to determine the safety and effects of repeated dosing using subcutaneous injections.

This guest article appeared on PsychCentral.com: Ketamine Nasal Spray for Depression Runs Into Problems and was originally posted on Psych Central by Traci Pedersen.

References

Gálvez V, Li A, Huggins C et al. Repeated intranasal ketamine for treatment-resistant depression – the way to go? Results from a pilot randomised controlled trial. Journal of Psychopharmacology. 2018;32(4):397-407. doi:10.1177/0269881118760660.

Image via ThorstenF/Pixabay.

Unfortunately, many OCD patients tend to lack those adaptive coping skills while in the throes of the disorder, according to a new German study published in the journal Cognitive Therapy and Research.

OCD is a complex psychological condition in which the patient suffers from persistent unwanted thoughts and high levels of anxiety. The disorder can lead to a severe reduction in one’s quality of life.

For the study, the researchers compared the behavior of 60 patients with OCD to a group of 110 people with depression as well as a control group of 1,050 adults. All participants completed anonymous online surveys in which they reported their medical and psychological histories, along with their levels of compulsivity and abilities to cope in specific situations.

Participants also answered a questionnaire that covered different adaptive and maladaptive coping styles that one might use to deal with difficult situations.

The participants also completed the Maladaptive and Adaptive Coping Styles Questionnaire (MAX) that had been recently developed by the researchers. This questionnaire measures coping styles using three dimensions: maladaptive coping (thought suppression, rumination), adaptive coping (problem-solving, acceptance), and avoidance.

Participants gave information about the coping strategies they use against their OCD symptoms such as problem-solving and rumination, as well as other coping styles that have recently been adopted in therapy, such as acceptance and suppression.

People with OCD were found to possess more maladaptive coping skills than all of the other participants, including those suffering from depression. They also possessed fewer functional skills to help them cope and adapt. Those who lacked adaptive coping skills were more likely to have poor insight into their condition and a resistance to symptoms.

As put by the study leader, Dr. Steffen Moritz from the University Hospital Hamburg in Germany:

Patients with OCD are characterized by both more maladaptive coping and less adaptive coping relative to controls. Coping skills are important for many aspects of daily life beyond mental health.

Teaching children skills such as how to cope with bullying at school, poor performance or problems with their parents, for example, in the framework of general cognitive preventative treatment and resilience training in school, may help children to better deal with emotional turmoil and challenging situations during adolescence.

It may also prevent the progression of a vulnerability to later obsessive-compulsive disorder or depression as well as other disorders.

Although the findings highlight some of the skills that patients with OCD lack, Moritz says further research is needed to find out to what extent improving such coping skills during childhood and adolescence through cognitive behavioral therapy (CBT) or similar interventions may indeed improve an OCD patient’s quality of life.

This guest article appeared on PsychCentral.com: Many OCD Patients Tend to Use Poor Coping Strategies and was originally posted on Psych Central by Traci Pedersen.

Reference

Moritz, S., Fink, J., Miegel, F., Nitsche, K., Kraft, V., Tonn, P., & Jelinek, L. (2018). Obsessive–Compulsive Disorder is Characterized by a Lack of Adaptive Coping Rather than an Excess of Maladaptive Coping. Cognitive Therapy And Research, 1–11. doi:10.1007/s10608-018-9902-0

Image via aleksandra85foto/Pixabay.

When time is seen to be limited, every moment can take on a weight that has never before been experienced. Some of these expectations come from within and some externally, but regardless of their origin they can be paralyzing for the young person facing their mortality, particularly when unwell. Culturally, there are multiple references as to what ‘dying young’ is meant to mean and most refer to extraordinary and often unobtainable expectations. For instance, members of the ‘27 club’ (celebrities who die on or before their 27th birthday) and notable cancer-related concepts around ‘bucket lists’ and works of fiction (e.g., The Fault in Our Stars). Most young people, particularly those who are dying, do not have the capacity or the options to engage in an extraordinary feat, they can become overwhelmed and paralyzed by what they are ‘meant to be doing’.

I think I have well and truly missed my opportunity for greatness, I now just want enough energy to spend time with my friends. Maybe even go to the pub.

~18-year-old male

Often, as is the case with many things in life, simple and small are the gestures and moments which are the most meaningful, with huge projects and adventures feeling too overwhelming and out of the grasp of someone with limited energy and resources. As such, the fantasy of what something may have looked and felt like, had they have been well, is a much more satisfying space for them to sit with. Similarly, relationships become much more meaningful, as do the simple things that are taken away through the treatment process, like being able to sit in the sun or go to the pub with a friend.

‘I had been playing online games with him for years, and I thought that I would never meet him now. He made it happen though.’

~19-year-old male

Young patients can be bombarded with well-intentioned suggestions about what they ‘need’ to do, including making future legacy-based activities, such as leaving cards for each of their younger sibling’s birthdays, video journals of their death, or chronicling how they feel about all the people in their world. Although these are good ideas, they are emotionally and physically difficult to manage with limited resources. Patients need to be feeling very resilient and well before attempting any of these things with most being abandoned due to the confronting nature of conceptualizing the world without them present in it. It is a difficult ask for anyone to be able to take the relatively abstract idea of the world continuing following your own death; this does not change for young people and, in some ways, it is even more challenging due to their pervasive sense of self, even in the face of very real threats to their mortality.

‘I could clean out my room, and all of my stuff. But then I think, well I don’t want to do it really, and it’s not like it’s going to be my problem.’

~23-year-old male

The way that young people respond to being presented with a very limited life expectancy can vary tremendously. Some may stick their head firmly in the sand and refuse to discuss or conceptualize anything about what may happen in the lead-up to their death, or following. Others will organize everything about the end of their lives, including where they want to die, how alert they want to be, as well as what will happen following their death—such as where their belongings go and how they want to be remembered. For most people in this situation, in an existential sense, almost everything is out of control, the disease will do what it does, the pain is what it is, and they are an observer to the things happening in their bodies. The things that people can control is what they talk about, how much they talk about it, and who they talk about it too.

Just because death, dying, and legacy are not being talked about, does not mean that it is not in the consciousness and thoughts of the person pondering their own end. Instead, it may be that they have done as much thinking and talking about it as they need to do; it is often these patients that have very well-considered plans about what they want to happen as they deteriorate and the decisions that must be made about their care.

References

Chochinov, H., Kristjanson, L., Breitbart. W., et al. (2011). Effect of Dignity Therapy on Distress and End-of-Life Experience in Terminally Ill Patients: A Randomised Controlled Trial. The lancet oncology. 12. 753-62. DOI:10.1016/S1470-2045(11)70153-X

Hack, T., Mcclement, S., & Chochinov, H., et al. (2010). Learning from dying patients during their final days: Life reflections gleaned from dignity therapy. Palliative medicine. 24. 715-23. DOI:10.1177/0269216310373164

Hedkte, L., (2014). Creating stories of hope: A narrative approach to illness, death and grief. Australian New Zealand Journal of Family Therapy. 35. 4-19. DOI:10.1002/anzf.1040

Kehl, K., (2006). Moving Toward Peace: An Analysis of the Concept of a Good Death.. American Journal of Hospice and Palliative Medicine. 23. 277-286. DOI:10.1177/1049909106290380

Smith, R. (2000). A good death: an important aim for health services and for us all. BMJ. 2000;320:129-130.

Steinhauser, K. E., Clipp, E. C., McNeilly, M., et al. (2000). In search of a good death: observations of patients, families, and providers. Ann Intern Med. 2000;132:825-832

Steinhauser, K. E., Alexander, S. C., Bycock, I., et al. (2008). Do preparation and life completion discussions improve functioning and quality of life in seriously ill patients? Pilot randomized control trial. Journal of Palliative Medicine. 11. 1234 – 1240. DOI:10.1089/jpm.2008.0078

If you go to Netflix’s online subscription platform, you are quickly invited to “Choose the plan you like best. The first month is free”.

But which subscription should you go for?

With this question, the budding psychologist in you has just tapped into prospect theory (PT), one of the most discussed psychological theories of this century.

Prospect theory and loss aversion

PT is a theory of decision making, stating that people estimate the perceived likelihood of available options by overweighting small subjective probabilities and underweighting large subjective probabilities.

In PT, loss aversion (LA) refers to the tendency to prefer avoiding losses than obtaining equivalent gains. LA operates as a function of a dual processing system where effortless thought is the norm and where thought monitoring is lax, allowing the expression of intuitive judgments, including erroneous ones.

Netflix Marketing and Loss Aversion

When choosing your Netflix subscription, LA first influences your decision making through the framing effect: when irrelevant features unjustifiably influence decision-making. By placing “premium” as the default subscription option, and comparing this plan with two other less inclusive alternatives, Netflix gives the you a negative choice frame, as though by not choosing “premium” you miss out.

Secondly, this loss frame can also invoke fear of omission (not buying the ‘right’ (optimal) subscription) and commission errors (buying the ‘wrong’ (suboptimal) subscription), which induce regret in hindsight.

Indeed, people feel mistakes of commission more poignantly than those of omission (omission bias). It follows, that when you, the customer, use subscription plan features as the key attribute for choosing a Netflix plan, you are more likely to concern yourself with not making the ‘wrong’ (less inclusive but also less expensive) rather than the ‘right’ (more inclusive but also more expensive) choice. This is because, according to Hsee’s evaluability hypothesis, framing effects work particularly well in joint evaluation.

In one classic experiment, researchers asked participants to read the descriptions of two dictionaries. Dictionary B had 10,000 more entries than Dictionary A, but its front cover was torn while Dictionary A was completely new. When the dictionaries were presented in a single evaluation, participants chose Dictionary A. In joint evaluation this preference was reversed. The number of entries bore little weight on single evaluation but in joint evaluation, it was evident that Dictionary B was superior on this attribute and the number of entries was more important than the cover’s condition.

The study exemplifies how joint evaluation increases discrepancies between which alternatives preclude the most loss. Preferences, subsequently, reverse in favor of the least loss aversive option (salient reference attribute).

Netflix Marketing, the Pain of Paying, and Zero Cost

The ‘pain of paying’ operates in a similar way. For example, paying with cash elicits greater loss than paying with credit card. Companies like Netflix, therefore, promote one free month’s subscription. This technique implicitly encourages you to overreact to the free month of subscription by unconsciously treating it as zero cost, which attenuates LA experienced after prepaying full subscription.

To illustrate zero cost, experimenters placed a booth in an MIT student center where a passer-by could buy Hershey’s kisses for one penny or Lindt truffles for fifteen cents. Most people chose the truffles over the kisses. In a second condition, in which Lindt truffles cost fourteen cents and Hershey’s kisses cost nothing, most people chose the kisses over the truffles.

If people operate on purely mathematical logic they should have behaved the same in both conditions because the price difference between the sweets was constant. Instead, people calculated the difference between cost and reward. When both items cost money, they focused primarily on the quality of the products but when one product was free they focused primarily on the cost of the products.

In this light, Netflix’s free month of services potentially dampens LA and, consequently, the tendency to weigh pros and cons with the equal focus deployed when factoring in potential losses.

Netflix Marketing and the Sunk Cost Fallacy

Even when people factor in losses they are, nevertheless, still exposed to errors. One such error is the sunk cost fallacy: when people persevere in a fruitless activity because of hitherto invested resources (time, money, or effort).

In another classic experiment, Tversky and Kahneman asked participants to imagine that they are going to see a play which costs $10 per ticket. As they enter the theater, they discover that their ticket is missing. When participants were asked whether they would still buy a ticket, 46% confirmed they would. In a similar experiment, other participants were told to imagine that they have decided to go see a play which costs $10 per ticket. As they enter the theater, participants discover that they have lost a $10 bill. In this scenario, however, 88% of participants confirmed they would still buy a ticket. Tversky and Kahneman explain this sunk cost fallacy by describing how LA mediates mental accounting.

According to mental accounting, if costs outweigh benefits, incurred extra costs (inconvenience, time, or money) are contained in different mental accounts. Going to the theatre is, thus, a transaction: the cost of a ticket is exchanged for the experience of the play such that buying a second ticket increases the cost in the ‘theatre’ account to an unacceptable level. Loss of cash, however, is not deducted from the ‘theatre’ account and only affects the purchase by making participants feel less wealthy.

Hence, when people attach labels to money (e.g., disposable cash can be “theatre money” but “theatre money” is not simply disposable cash) they make decisions by considering each mental account separately, missing the big picture of opportunity costs (trade-offs).

The Status Quo Bias

In addition, LA contributes to sunk cost fallacy by referencing the status quo bias (i.e., the preference for the current state of things). In one study, participants had to imagine they had inherited some investments and gave them alternative investments they could switch into. Compared to the control group, who were asked to imagine having the cash equivalent of the inherited investments, the experimental group was unlikely to shift from the original inherited investments.

The study results intimate that the status quo bias functions as a reference point, where aspects of alternative choices are evaluated as advantages or disadvantages relative to the current situation, such that disadvantages of alternatives are felt more strongly than corresponding advantages.

In this vein, the status quo bias predicts that you will not unsubscribe from Netflix after the free month, even if you do not use Netflix.

The prospect of loss (paying for Netflix but not using it) can motivate you to watch TV just to ‘get your money’s worth’. Unsubscribing would also produce negative changes to the status quo by eliminating choice: the fact that you could potentially watch Netflix even if you actually do not.

Time spent on Netflix because of the sunk cost fallacy, can, nevertheless, help you derive increasing post purchase satisfaction through increased personal connection with the product.

Also, when you watch Netflix, despite a lack of interest, you are more likely to justify your subscription. This is because the cognitive dissonance you experience between your attitude and behavior is likely to make you feel uncomfortable at the thought of having wasted time and money, so you aim to reduce it. Since justifying your behavior is easier than changing your attitude, you are more likely to continue paying for and watching Netflix than to change your attitude and face your mislead investment.

How Netflix Takes Your Money In Sum

So there it is, Netflix subscriptions demystified.

While not without its limitations, PT robustly shows how, that in the human search for coherence and security there seems to be the seed of compulsion, the sort of addiction to stability and continuity that transforms into LA when threatened.

The impact of LA on framing effects, through omission bias, joint (vs single) evaluation and zero cost offers, and the impact of LA on sunk-cost fallacy through status quo bias, cognitive dissonance and mental accounting, is evident.

Cumulatively, LA amply explains a wide range of decision making phenomena by invoking bounded rationality, which reflects an exclusively human proclivity to evaluate outcomes in terms of loss and gain, where loss is felt more powerfully than gain.

In this sense, when we confess that some efforts are in vain and some losses enduring, we admit that one of the only certainties in life is uncertainty. In the end, knowing about what errors we are susceptible to, does not make us more likely to commit them, but urges us to correct ourselves.

Should you subscribe to ‘premium’ Netflix?

You decide.

References

Hsee, C. K., & Leclerc, F. (1998). Will products look more attractive when evaluated jointly or when evaluated separately? Journal of Consumer Research, 25, 175-186. DOI:

Samuelson, W., & Zeckhauser, R. J. (1988). Status quo bias in decision making. Journal of Risk and Uncertainty, 1, 7-59. DOI: 10.1007/BF00055564

Shampanier, K., Mazar, N., & Ariely, D. (2007). Zero as a special price: The true value of free products. Marketing Science, 26(6), 742-757. DOI: 10.1287/mksc.1060.0254

Tversky, A., & Kahneman, D. (1981). The framing of decisions and the psychology of choice. Science, 211(4481), 453-458. DOI: 10.1126/science.7455683

Image via jgryntysz/Pixabay.

Pfau’s goal with Your Behavior is to synthesize work from various fields including psychology, sociology, anthropology, and biology into a coherent explanation of why we do the things we do, and to do so in a way that is accessible to both laypeople and professionals. Throughout the book, he draws from perceptual control theory (PCT) to help readers understand their own behavior and how to change it.

Pfau does an excellent job of ordering and organizing his work. He begins with establishing the reader as an “autopoietic being,” which includes the assertion that we are wired to survive. As such, he asserts that most of our behaviors are done to ensure survival and often occur without conscious thought.

Pfau examines the origins of behavior from the cellular level up to all possible environmental levels and discusses how the different levels interact with each other in a system that is not strictly linear.

In life, most of us have “references,” or things like goals, plans, or how we think things ought to be. We change our behaviors based on our perceptions of how congruent they are with our references. A basic example could be something as simple as putting on a jacket when it is cold. Our body’s reference is to maintain its optimum temperature and homeostasis. But it can also be much more complicated. For instance, the references a person may have in his or her political or religious beliefs may lead to behaviors to bring the references for those beliefs into being.

We behave in such a way that our perceptions give us feedback to ensure we are in congruence with our references, whether our behavior is or is not a conscious thing. At times, we may mistakenly attribute a behavior to one level when it is a result of a different level. We are in constant interaction with our environment in terms of our perceptions of our references. Pfau offers a truly intriguing look at human behavior.

The first ten chapters offer a comprehensive overview of perceptual control theory (PCT) and why people behave the way they do, which includes a look at both ourselves and others. Pfau has organized the book in a way so that the reader can delve as deeply as they want.

Each chapter begins with a brief overview and contains multiple boxed highlights that give examples of topics in the chapter, or more in-depth information about concepts. These were very helpful as refreshers of what concepts mean throughout the book. I do not recall ever coming across PCT or autopoiesis before reading Your Behavior.

Each chapter ends with a preview of the following chapter, which gives a sense of the intentional continuity of the educational process of this book. There is an extensive list of references for further reading at the end of each chapter, as well as endnotes that give further information on the covered material. The organization and presentation are very straightforward, well thought out, and excellently presented.

I am still debating Pfau’s critique of current behavioral theory. He says that the term “culture” is abstract, and therefore a statement such as “culture causes behavior” is meaningless or misleading, and cannot be verified. But just as humans evolve in the interplay with their environment to survive, cultures also evolve, and generally due to the shortness of our lives, cultures (our interplay with our environment in a systems way) evolve outside of our awareness.

I think it may come down to “abstract” versus “construct.” There are arguments that the self is a construct, which I don’t think is addressed in this work. While reading this, I became curious as to how PCT would address the self, and perhaps culture, as a construct.

After providing a very thorough understanding of PCT and why we and others behave the way we do, the final two chapters guide us through analyzing our own behaviors, and how to systematically change them.

Pfau calls upon the works of several individuals for this, but one that stood out to me was John Norcross, who has been involved in the transtheoretical model of change over the years. (Curiously, I didn’t find any reference to the model here.)

There are very useful appendices including checklists and forms with cues to help readers analyze and develop a way to change their own behavior. Pfau even discusses his own change process with weight and smoking.

This is a very comprehensive work that is clearly presented. Your Behavior is a good book for anyone interested in behavioral change with a theory backing it that encompasses a comprehensive system from the cellular level up.

This guest article appeared on PsychCentral.com: Your Behavior: Understanding & Changing the Things You Do and was originally posted on Psych Central by Richard H. Pfau and reviewed by Stan Rockwell, PsyD.

References

Richard H. Pfau (2017) Your Behavior: Understanding and Changing the Things You Do. Paragon House.

Image via aleksandra85foto/Pixabay.

Craving can be defined as an intense, conscious desire, usually to consume a specific drug or food. There is also a significant body of research that suggests it is causally linked to behavior.

Investigators reviewed experimental studies that addressed the effects of different types of mindfulness strategies on cravings. They discovered that in many instances these strategies brought about an immediate reduction in craving.

For example, craving predicts relapse episodes in substance use, and food cravings predict both eating and weight gain. As such, cravings are often considered an appropriate target for intervention.

Researchers from City, University of London believe the mindfulness techniques work by occupying short-term memory which in turn lead to clinically relevant changes in behavior. Their findings appear in the journal Clinical Psychology Review.

Mindfulness meditation has a long tradition of being used to address cravings. According to ancient Buddhist texts, craving leads to suffering but can be avoided through meditation practice.

Mindfulness interventions typically employ a range of strategies. Some techniques include exercises designed to promote greater awareness of bodily sensations, while others help to develop an attitude of acceptance toward uncomfortable feelings.

Additionally, a mindfulness objective may be to help individuals see themselves as separate from their thoughts and emotions.

However, there is currently a limited understanding of the ways in which these different types of strategy may influence craving-related outcomes, either independently, or in combination.

As a result, the review aimed to address these limitations by reviewing studies that have examined the independent effects of mindfulness on craving.

Looking at 30 studies which met the criteria, it was found that some of the beneficial effects seen for mindfulness strategies in relation to craving are likely to stem from interrupting cravings by loading working memory. Working memory is a part of short-term memory concerned with immediate conscious perceptual and linguistic processing.

In addition, it was also seen that mindfulness reduced craving over the medium term, most likely due to “extinction processes,” essentially strategies that result in the individual inhibiting craving-related responses and behaviors which eventually lead to reduced cravings.

Dr. Katy Tapper, author of the review and a Senior Lecturer in the Department of Psychology at City, University of London, said:

The research suggests that certain mindfulness-based strategies may help prevent or interrupt cravings by occupying a part of our mind that contributes to the development of cravings. Whether mindfulness strategies are more effective than alternative strategies, such as engaging in visual imagery, has yet to be established.

However, there is also some evidence to suggest that engaging in regular mindfulness practice may reduce the extent to which people feel the need to react to their cravings, though further research is needed to confirm such an effect.

This guest article appeared on PsychCentral.com: Using Mindfulness Strategies to Curb Cravings and was originally posted on Psych Central by Rick Nauert PhD.

References

Tapper, K. (2017). Mindfulness and craving: effects and mechanisms. Clinical Psychology Review, 59, pp. 101-117. doi: 10.1016/j.cpr.2017.11.003

Image via aleksandra85foto/Pixabay.

Research on these annually age-grouped cohorts reveal relative age effects (RAEs) that convey the greater achievements accrued by the relatively old (RO) students compared to the relatively young (RY) students. RAEs are pervasive. Across OECD countries, in fourth grade, RY students scored 4–12% lower than RO students, while in eight grade the difference was 2–9% lower. RAEs are most evident in early formal education and can diminish as children mature. In 2016 for instance, Thoren, Heinig, and Brunner published a study on three grades attending public school in Berlin, Germany, and showed that the RAE in disappeared for reading by grade 8 and was reversed for math in favor of RY students.

Investigating the mechanisms involved is important because RAEs can remain evident in high-stakes exams taken at the end of compulsory education. RAEs may impact educational attainment, which is defined as an individual’s highest educational qualification (i.e., compulsory schooling, apprenticeship, or university education). For example, research by Sykes, Bell, and Rodeiro found that 5% less August-born GCSE students than September-born GCSE students chose at least one A level. Likewise, August-born students were 20% less likely to progress to university than September-born students. RO students also outperformed RY students on college admission tests to a university in Brazil, which significantly impacted the probability of being accepted to that university. Moreover, in Japan the percentage of graduates (aged 19–22 and 23–25) was two points greater for those born in April than those born in March. Collectively, these findings indicate that RAEs impact educational attainment because of their direct link to students’ acceptance to higher education. Since much of children’s development occurs within compulsory education, a natural question is whether educators act to alleviate or exacerbate RAE.

RAEs emerge primarily because of within-group maturity differences among RO and RY children (age-at-school-entry effect). RO children, have a one-year developmental advantage over RY children when they sit exams (age-at-test effect). Based on these advantaged test scores and maturation, RO children receive special opportunities from educators to excel in school. Using attainment, program participation, and attendance data from 657 students aged 11–14 from a secondary school in North England, a study by Cobley, McKenna, Baker and Wattie found that RO students were more likely than RY students achieve high scores across various subjects and be admitted to gifted programs. Even if RO students accepted to gifted programs are not actually gifted, the prestige of attending such programs would help them to foster strong positive self-esteem, which can persist over time. In turn, RO students may experience enhanced learning and praise long after small age differences are important in and of themselves.

Conversely, teachers lower their expectations of RY students because RY students appear less developed and intelligent than RO students. Interestingly, having RO classmates can prompt a spillover effect that boosts RY students’ grades, but also increases the probability that RY students will to be pathologized. This research suggests that RAEs emerge as a consequence of maturity differences but are maintained by the magnitude and persistence of social factors, such as educator-student interaction. Another study also reported RAEs in the diagnosis and treatment of ADHD in children aged 6–12 in British Columbia. Incorrect diagnosis can unnecessarily limit RY students’ academic performance by diminishing their self-esteem and task involvement, which are school achievement predictors.

If these inequalities decline over time, the influence of RAE on educational attainment is arguably minimal. However, if relative advantages such as skill accumulation persist in favor of RO students throughout formal education, RAEs translate into academic disadvantages for RY students. For instance, RY students’ negative self-perceptions of academic competence and learning disability can mediate the relationship between depressive symptoms and school dropout in adolescence. In turn, lack of formal education or poor academic performance makes entry to higher education arduous. Research illustrates with 16-year-old RY students scoring 0.13 standard deviations lower than RO students. This test score predicted that RY students would have a 5.8% higher potential dropout rate from high school and a consequently 1.5% lower college admission rate than RO students. Initial gains for RO students partly explain why they have a 10% greater probability of attending top-ranking universities and why they are more likely to graduate from university than RY students.

Research on the impact of RAE on educational attainment is not as straightforward as discussed thus far. Cascio and Schanzenbach used experimental variation by randomly assigning students to classrooms. Results showed improved test scores for RY students up to eight years after kindergarten and an increased probability of taking a college-entry exam. These positive spillover effects are evident when RY students, in a relatively mature peer environment, strive to catch up with higher-achieving RO students and end up surpassing them. Since RO students may strain under the expectations placed on them to be top of the class, RY students have an opportunity to catch up. Alternatively, RO students may not have the same incentive as RY students to work hard for academic success because RAEs already work in their favor. To overcome RAEs and succeed academically, RY students need greater persistence and attention than RO students in their schoolwork, which helps them gain a motivated mindset that benefits lifelong learning. For example, RY students in high school are more likely than RO students to study and compensate for poor academic achievement in middle school.

At a university in Italy, RY students obtained better grades than RO students. This reversal effect was also reported at university in the UK. The researchers postulated that due to RAEs, the RY students developed social skills more slowly. Therefore, RY students had less active social lives and more time to concentrate on educational attainment. The impact of RAEs on educational attainment is, subsequently, probabilistic not deterministic. Although research by Abel, Sokol, Kruger, and Yargeau indicated that RAEs do not affect the success of either RO or RY students’ university applications, they reported that more RO than RY students applied to medical school. In addition, Kniffin and Hank’s study did not find RAEs that influence whether a university student obtains a PhD. These two studies suggest that RAEs do not have such an important influence on college acceptance or educational attainment once in college. Instead, RAEs are a salient influence in so far as students in compulsory education obtain the necessary grades to apply to university in the first place.

The acquisition of higher mental functions and schooling over time helps normalize the student population by minimizing the attainment gap between RO and RY students, which helps explain why RAEs lessen in university. In addition, universities are often learning environments with great diversity in age (i.e., mature and repeat students), culture (i.e., international students), and academic achievement (i.e., doctorate/master’s students). Perceived developmental parities are inherently less important in university because classroom composition becomes heterogeneous, mitigating and masking the remaining relative age differences. Given this knowledge, greater classroom heterogeneity could be applied to compulsory education to minimize RAEs. Students in mixed-grade classrooms in Norwegian junior high schools, for example, outperformed students in single-grade classrooms on high-stakes school finishing exams. With this classroom composition, it is not disproportionately skewed in favor of younger/older students, the losses for RO students following class mixing would not outweigh the gains of the RO students. With more heterogenous classes, educational attainment could subsequently become less influenced by RAEs and a more equalized pursuit.

Since mitigating the impact of RAE on educational attainment depends partly on the strength of compensating investments such as classroom environments, streaming remains controversial. Academic streaming involves separating students according to innate ability. In reality, streaming is based on students’ prior academic performance, which is an imperfect measure of ability that can lead to misallocations. Streaming in early education can be particularly unfair because RY students do not get the opportunity to more closely approximate older classmates’ mental and physical development when sitting exams. In Germany for instance, being relatively old increased test scores by 0.40 standard deviations, increasing the probability of attending the highest secondary school track (gymnasium) by 12%. RY students are also at risk of being unfairly streamed into lower-ability classes because they are more likely than RO students to be diagnosed with behavioral problems and learning disabilities. Streaming thereby provides students with unequally differentiated educational experiences of teaching, competition, and opportunity that limit their academic exposure. Therefore, postponing streaming can reduce the impact of RAEs on educational attainment by ensuring that any developmental gaps have time to narrow.

Unequal educational experiences can limit RY students’ educational attainment. In 2015, the average number of 25–64-year-olds with tertiary education was greater for countries who exhibit almost no streaming, such as Ireland (42.8%), compared to the OECD average (35%). Is it the case that streaming at multiple stages can rectify initial misallocations while still enhancing academic achievement? In Austria, children are streamed in grade five (aged ten) and in grade nine (aged fourteen). In one study, RY students in grade five were 40% less likely to be streamed into higher classes, but the second streaming, in grade nine, helped mitigate RAEs by giving students the opportunity to upgrade to a higher stream. In a complex interplay, streaming and RAEs can reinforce and be reinforced by existing socioeconomic inequalities. In this vein, the researchers concluded that RAEs only disappeared for students with favorable parental backgrounds in the second streaming. In contrast, RY students with unfavorable parental backgrounds were 21% less likely than RO students to move to a high-ranking school. As previously mentioned, learning at the wrong academic level can strain academic achievement and reduce the chances of continuing to higher education.

Socioeconomic status is the extent to which learning opportunities are disadvantaged as a result of low-income. Socioeconomic status can exacerbate the impact of RAEs on educational attainment. Huang and Invernizzi’s research examined a cohort of 405 students in a high poverty, low performing school from the beginning of kindergarten until the end of grade two. Results concluded that early-age literacy achievement gaps between RO and RY students narrowed over time but did not fully close by the end of grade two. Similarly, a Madagascar-based study by Galasso, Weber, and Fernald indicated that differences in home stimulation are dependent on the wealth gradient and accounted for 12–18% of the predicted gap in early outcomes between advantaged and disadvantaged children. At least in early education, these findings suggest that diminished academic performance and exacerbated RAEs are in direct proportion to socioeconomic status. Thus, greater flexibility regarding age at entry in compulsory schooling could help lessen the impact of RAE on academic performance.

Suziedelyte and Zhu published a “Longitudinal Study of Australian Children” and reported that starting school early benefits children from low-income families who, compared to children from high-income families, have limited access to learning resources at home and formal pre-school services. However, a three-month postponement of the cutoff enrollment date (increasing grade age) can increase both academic success and the likelihood of repeating a grade. Similarly, a one year delay in school enrollment (redshirting) can produce a 0.303 standard deviation decrease in test scores and lead to significantly lower math scores for students identified with a disability when compared to nonredshirted students with disability. These mixed findings suggest that equalizing educational attainment opportunities among RO and RY students, by implementing a flexible entry cutoff point, varies as a function of individual difference. Therefore, managing and mitigating RAEs requires greater sensitivity to confounds such as socioeconomic status.

The impact of starting school early on educational attainment is mediated by social factors, school policy, and socioeconomic factors, resulting in individual differences in learning outcomes. RAEs fade throughout formal schooling and can even reverse in higher education. The relative age phenomenon, nevertheless, caveats that ascribing merit to students based on relative age can lead to the provision of unequal learning opportunities and harmful pathologies. Unfortunately, the mechanisms that underpin the impact of RAEs on educational attainment are currently quite speculative and inconclusive. In this sense, existing findings warrant further empirical research and reveal the need for more comprehensive methods for determining an appropriate school entry cutoff point.

References

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Cascio, E., & Schanzenbach, D. (2016). First in the Class? Age and the Education Production Function. Education Finance And Policy, 11(3), 225-250. doi:10.1162/edfp_a_00191

Cobley, S., McKenna, J., Baker, J., & Wattie, N. (2009). How Pervasive are Relative Age Effects in Secondary School Education?. Journal Of Educational Psychology, 101(2), 520-528. doi:10.1037/a0013845

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Image via frolicsomepl/Pixabay.

Ketamine is best known as an illicit, psychedelic club drug. Often referred to as “Special K” or a “horse tranquilizer” by the media, it has been around since the 1960s and is a staple anesthetic in emergency rooms and burn centers. In the last 10 years, studies have shown that it can reverse — sometimes within hours or even minutes — the kind of severe, suicidal depression that traditional antidepressants can’t treat.

Researchers writing in the August 2010 issue of Archives of General Psychiatry reported that people in a small study who had treatment-resistant bipolar disorder experienced relief from depression symptoms in as little as 40 minutes after getting an intravenous dose of ketamine. Eighteen of these people had previously been unsuccessfully treated with at least one antidepressant medication and a mood stabilizer; the average number of medications they had tried unsuccessfully was seven. Within 40 minutes, 9 of 16 (56 percent) of the participants receiving ketamine had at least a 50 percent reduction in symptoms, and 2 of 16 (13 percent) had full remission and became symptom-free. The response lasted an average of about a week.

In a small 2006 NIMH study, one of the first to look at ketamine for depression, 18 treatment-resistant, depressed (unipolar) patients were randomly selected to receive either a single intravenous dose of ketamine or a placebo. Depression symptoms improved within one day in 71 percent of those who were given ketamine, and 29 percent of the patients became nearly symptom-free in a day. Thirty-five percent of patients who received ketamine still showed benefits seven days later.

In the most recent study published online in the journal Nature in May 2016, researchers discovered that a chemical byproduct, or metabolite, is created as the body breaks down ketamine. The metabolite reversed depression-like behaviors in mice without triggering any of the anesthetic, dissociative, or addictive side effects associated with ketamine.

As put by Carlos Zarate, MD, of the National Institute of Mental Health (NIMH), and a study coauthor and pioneer of research using ketamine to treat depression:

This discovery fundamentally changes our understanding of how this rapid antidepressant mechanism works, and holds promise for development of more robust and safer treatments. By using a team approach, researchers were able to reverse-engineer ketamine’s workings from the clinic to the lab to pinpoint what makes it so unique.”

In response to the Nature report, Sara Solovitch of The Washington Post wrote that:

experts are calling [ketamine] the most significant advance in mental health in more than half a century.

She reported that many academic medical centers, including Yale University, the University of California in San Diego, the Mayo Clinic, and the Cleveland Clinic, have all begun offering ketamine treatments off-label for severe depression.

It all sounds too good to be true, right?

The Drawbacks of Ketamine

The predominant drawback of ketamine is the lack of data.

There haven’t been enough clinical trials on the drug to assure its safety, and there’s a lack of information on the long-term effects of its use.

Ketamine’s effects are also short-lived. To be used as an effective antidepressant, it would need to be administered regularly, which leads to concerns about addiction, tolerance, and, again, long-term effects. The data that we do have on long-term use comes from people who have taken ketamine recreationally, as well as those who have used it to treat chronic pain.

One 2014 study published in the British Journal of Clinical Pharmacology included among possible side effects, psychedelic symptoms (hallucinations and panic attacks), nausea, cardiovascular stimulation, memory defects, and bladder and renal complications.

Still, the drug holds promise for uncovering new ways of treating depression and offers hope for the most severe and complicated mood disorders that baffle psychiatrists today.

Richard J. Hodes, MD, director of the National Institute on Aging, commented on the most recent NIH study and the importance of furthering the research:

Unraveling the mechanism mediating ketamine’s antidepressant activity is an important step in the process of drug development. New approaches are critical for the treatment of depression, especially for older adults and for patients who do not respond to current medications.

Join Project Hope & Beyond, the new depression community.

This guest article appeared on PsychCentral.com: Ketamine: A Miracle Drug for Depression? and was originally posted on Sanity Break at Everyday Health by Therese J. Borchard.

References

Diazgranados, N., Ibrahim, L., Brutsche, N., Newberg, A., Kronstein, P., & Khalife, S. et al. (2010). A Randomized Add-on Trial of an N-methyl-D-aspartate Antagonist in Treatment-Resistant Bipolar Depression. Archives Of General Psychiatry, 67(8), 793. DOI: archgenpsychiatry.2010.90.

Zanos, P., Moaddel, R., Morris, P., Georgiou, P., Fischell, J., & Elmer, G. et al. (2016). NMDAR inhibition-independent antidepressant actions of ketamine metabolites. Nature, 533(7604), 481-486. DOI: 10.1038/nature17998.

Zarate, C., Singh, J., Carlson, P., Brutsche, N., Ameli, R., & Luckenbaugh, D. et al. (2006). A Randomized Trial of an N-methyl-D-aspartate Antagonist in Treatment-Resistant Major Depression. Archives Of General Psychiatry, 63(8), 856. DOI: 10.1001/archpsyc.63.8.856.

Image via stevepb/Pixabay.

Clinically known as anti-social personality disorder in the DMS-V, some troublesome psychopathic traits include:

• an egocentric identity
• an absence of pro-social standards in goal-setting
• a lack of empathy
• an incapacity for mutually intimate relationships
• manipulativeness
• deceitfulness
• callousness
• irresponsibility, impulsivity and risk taking
• hostility

Although these characteristics may be unpleasant, not all psychopaths are dangerous or criminals, and not all dangerous criminals are psychopaths. Counter-intuitively there are pro-social psycopaths too. Nonetheless, some psychopaths do pose a genuine threat for the safety of others.

The real unsolved problem when it comes to psychopathy is how to treat the personality disorder. Although certainly not to be considered impossible with the malleable brains we have even as adults, Dr. Nigel Blackwood, a leading Forensic Psychiatrist at King’s College London, has stated that adult psychopaths can be treated or managed, but not cured. Curing adult psycopathy is considered a near-impossible challenge.

Therefore, understanding when and how psychopathy develops from child to adult is an important part of the research engine that will hopefully identify what parents, caregivers and governments can do to prevent an at risk child from growing up to be a dangerous psycopath.

Development of psycopathic personalities is mainly due to genes