Youth's Social Problems Contribute To Anxiety And Depression

ScienceDaily (Mar. 25, 2008) — Socially successful children tend to have fewer symptoms of anxiety or depression, while children with problems such as anxiety and depression tend to have difficulties forming relationships and being accepted by friends. However, it is difficult to determine whether the anxiety and depression lead to the social problems, or vice versa. New research suggests that social problems are more likely to contribute to anxiety and depression than the reverse. The research also shows that this is particularly likely during the transition from adolescence into young adulthood.

Using data from Project Competence, which has followed a group of 205 individuals from middle childhood (ages 8 to 12) over 20 years into young adulthood, the researchers used detailed interviews with participants and reports from their parents, teachers, and classmates to create measures of so-called internalizing problems (anxiety, depressed mood, being withdrawn) and social competence (how well one functions in relation to other people, particularly with respect to getting along with others and forming close relationships). They then examined how these measures related to each other over time, taking into account the stability of each (in other words, that children who have social problems at the start of the study may continue to have them over time).

The researchers found that young people who had more internalizing problems (such as anxiety and depression) at the start of the study were more likely to have those problems in adolescence and young adulthood. Those who were socially competent at the start of the study were socially competent as they grew up. However, in addition to this evidence of continuity, the study found evidence of spillover effects, where social problems contributed to increasing internalizing symptoms over time.

Children who were less socially competent in childhood were more likely to have symptoms of anxious or depressed mood in adolescence. Similarly, young people who were less socially competent in adolescence were at greater risk for symptoms of anxiety and depression in young adulthood. The findings remained the same when the researchers took into account some other possible explanations, such as intellectual functioning, the quality of parenting, social class, and such problems as fighting, lying, and stealing. And the results were generally the same for both males and females.

"Overall, our research suggests that social competence, such as acceptance by peers and developing healthy relationships, is a key influence in the development of future internalizing problems such as anxiety and depressed mood, especially over the transition years from adolescence into young adulthood," explains Keith Burt, assistant professor of psychology at the University of Vermont and the study's lead author. "These results suggest that although internalizing problems have some stability across time, there is also room for intervention and change. More specifically, youth at risk for internalizing problems might benefit from interventions focused on building healthy relationships with peers."

Summarized from Child Development, Vol. 79, Issue 2, The Interplay of Social Competence and Psychopathology Over 20 Years: Testing Transactional and Cascade Models by Burt, KB (University of Vermont), Obradoviæ, J, Long, JD, and Masten, AS (University of Minnesota). The study was funded, in part, by the National Science Foundation and the National Institute of Mental Health.

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Tuesday, August 4, 2009

Is Exposing the Rorschach Killing the Rorschach?

The Rorschach has been exposed. Is it dying?

The New York Times recently staged the Wikipedia-Rorschach debate that's been going on at least since June, when emergency room doctor James Heilman posted all 10 ink blots on Wikipedia, along with the most frequent form responses. Heilman says that restricting this information from the public domain would be akin to "the Chinese government's attempt to control information about the Tiananmen massacre," according to The Times.

Technically, Heilman has a point. The Rorschach material is no longer protected under copyright law, because the copyright has expired. And, Heilman is not bound by the APA code of ethics, which requires that psychologists "make reasonable efforts to maintain the integrity and security of test materials." After all, he is not a psychologist (I don't think), just a person, like many of us, who can buy a set of the inkblots from one of its distributors for $100 to $200. (Some restrictions do apply. Western Psychological Services, for instance, requires that people who buy the test from them have a Masters degree in psychology or a related field, but not necessarily a license to practice.)

There are other reasons to cool the hysteria we might feel about the disclosure of a reliable psychological tool. On the scary side, of course, Wikipedia does give away a couple "clues" that might help test-takers skew or at least invalidate their scores. For instance, Wikipedia reports that psychologists monitor for an appropriate number of responses to each ink blot, for the organization of responses, for complexity, and for references to the human figure. But "organization" and "complexity" are technical words to people who score the test, and vague descriptions to people reading the Wikipedia entry. Indeed, it takes years of training to learn the nuance of scoring a Rorschach. If the "answers" to receiving a certain score were so simple that they could be listed in a Wikipedia entry, psychologists would not need years of testing classes before they earned their degrees.

To put it another way, there's a richness to every Rorschach response that's akin to the richness of any sentence someone speaks in a therapist's office. It's our job as clinicians to interpret and not just score the thing. As Alvin Burstein from the University of Tennessee says in the NYT article, "The process of making sense of one's experience is gratifying. To take Rorschach's test is to make sense of ambiguity in the context of someone who is interested in how you do that."

Also, there's the issue that projective responses are pretty hard to fake. It's hard, for instance, for an anxious woman to "act convincingly calm" during a test. (I use that example to obscure what I want to say, to give a more specific example of how one could or could not "cheat" the test. I feel bound by the code of ethics!) But it's certainly hard for a psychotic person to decide not to give psychotic answers.

That said, I am surprised the ink blots haven't been so widely exposed until now. And I do think it's very sad--that the thrill of exposure here threatens to render a helpful tool, which took years to build, less helpful. I feel like someone's spat graffiti on the Mona Lisa, or crapped on the Museum steps.

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More on Emotional Intelligence and Bombs

My latest post, a discussion and review of "The Hurt Locker" spotlighted emotional intelligence, specifically the psychological ability to mind-read others known as empathy and its deceivingly high importance in successful foxhole behavior. Coincidently, today's NY Times health section features an article that reiterates and expands upon much of what I wrote. As this article contains more in-depth information about a wider body of research on the human mind and bomb detection, I wanted to disseminate the link as well as some thoughts.

Here is the link: http://www.nytimes.com/2009/07/28/health/research/28brain.html

What is becoming increasingly clear with recent research findings is that some soldiers (like James in The Hurt Locker) are much better than most other individuals at detecting danger. Some confluence of cognitive and psychological abilities allows these super mind-readers of detection to constantly hone on an above-average, invisible mental radar. This radar comes in the form of a gut instinct or subtle physical sensation that hits the body a few seconds/minutes before it hits the conscious mind. Benedict Carey, author of the abovementioned article, likens this "moment" to when you pause as you are leaving your house but only well after the pause do you realize you've forgotten your wallet.

If you are a U.S. soldier patrolling an Iraqi marketplace, empathy can become a mildly prophetic power in identifying buried bombs. Empathy is so widely discussed in the literature that many fields have tweaked its definition to accommodate the purpose of study. Here, the purpose is things that are central to avoiding imminent threats, and empathy is discussed as the speed with which the brain reads and interprets sensations like the feelings in one's own body and emotions in the body language of others.

In my blog post, I discussed how the world of intelligence testing embraces rational processes like memory and all but discards emotional processes like empathy, despite the potentially high value this skill has in a military-specific context. This article notes the turning-of-the-tide. Yes, emotions are still viewed as the perpetrators of reckless, rebellious behavior (as James was accused of in "The Hurt Locker") but now emotions are also being seen as the key elements of the most sensitive detection equipment available, the human mind. "We understand emotions as practical action programs that work to solve problems, often before we're conscious of it. These processes are at work continually, in pilots, leaders of expeditions, parents, all of us," says Dr. Antonio Damasio, director of the Brain and Creativity Institute at the University of Southern California.

Another important point that the article notes but does not sufficiently analyze is the buffering effects that empathy and emotional intelligence exerts on PTSD. Without explicitly saying so, the article builds a persuasive case that bomb detection is a much too perfect occupation for developing PTSD. This is due to the genealizability of uncertainty.

The soldiers interviewed in the Times article describe the search for buried bombs as never routine, and never obvious. Bombs might be ticking away in an innocent looking divot in or a pile of discarded cans. In fact, one story tells of real bombs buried in fake rocks and fake bombs in plain view. Our brains are designed in such as to learn the association between life threatening danger and a pile of discarded cans in as quickly as one-trial. Walk past an explosion of this sort and when you return home taking out the garbage may feel like a life-or-death chore. Essentially, PTSD is learning in a new and dangerous environment that sticks even after a return to the old, safe environment. Due to such deceitful bomb burying tactics soldiers are unconsciously learning to fear that which is routine, mundane, and seemingly safe from all sides.

Empathy and emotional intelligence can become a bullet-proof vest against PTSD because it fights off one of its top predictors - peri-trauma dissociation. This occurs when you become so freaked out during a traumatic event that you curl up into the fetal position, psychologically, tune out and simply hope that danger will be averted. You fail to manage your emotions enough stay grounded and collected, accept the unfairness of it all and escape danger with speed and skill and, subsequently, self-efficacy (the knowledge that you can keep yourself alive). Walking around with a perpetually firm grasp on what you and others are feeling (empathy) and managing intense feelings and converting negative emotions to positive ones (all skills under the rubric of emotional intelligence), prevents this sort of mental fleeing.

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OCD Treatment: As Good As It Gets?

For OCD, medication not necessarily "as good as it gets."

I got a call from a psychiatrist colleague of mine a while back. He was an old-school Freudian psychoanalyst who had his patients come in twice a week to lie on a couch, talk about their dreams, free-associate about childhood experiences, and so on. Although this type of treatment might be useful for some patients - especially those who wish to better understand and change troublesome personality patterns - it has not always been strongly supported by research.

As it turned out, the psychiatrist was calling to ask if I would take on one of his patients who suffered from obsessive-compulsive disorder (OCD) - a debilitating mental illness that afflicts about 2% of the population - wonderfully depicted by Jack Nicholson in the film, As Good As It Gets. The psychiatrist had already been treating this distraught young man for over 4 years, but his OCD symptoms actually worsened over that span of time. Since there's no good scientific evidence that Freudian psychoanalysis is an effective treatment for OCD, I wasn't terribly surprised.

Fortunately, during my grad school training at Duke, our instructors and supervisors emphasized the importance of asking, for each form of mental illness: which of the hundreds of possible treatments are most strongly supported by the research evidence?

For OCD, this is a no-brainer: a form of behavior therapy called exposure and response prevention (sometimes called exposure and ritual prevention) has outperformed other treatments (including meds) in the clear majority of relevant outcome trials.

To get some idea of the potency of behavior therapy for OCD, consider the results of the largest OCD comparative outcome study to date, sponsored by the National Institutes of Mental Health. The study pitted behavior therapy against a drug called Anafranil (clomiprimine), arguably the most effective OCD medication currently on the market. Here were the observed rates of favorable treatment response:

Behavior Therapy: 86%
Anafranil: 48%
Placebo: 10%

Notice that OCD is such a severe disorder that it has a minimal placebo response . . . it takes much more than placebo-induced positive expectancies to cure this particular illness. And even though Anafranil certainly outperformed the placebo in this study (48% to 10%), behavior therapy was considerably more effective (with a whopping 86% response rate). In fact, it wasn't even a close call.

There's a genuine tragedy, though, embedded in these numbers: many OCD patients will never even know that behavior therapy exists. While some will waste their time and money on ineffective forms of psychotherapy, most OCD patients will simply be told that they have a 'chemical imbalance', handed a prescription of Anafranil or a similar medication, and told in effect, "this is as good as it gets".

Sadly, it's hard to get the word out about behavior therapy for OCD. Few mental health reporters understand the field well enough to do the story. Drug companies have multimillion dollar budgets to promote their products - for better and for worse - whereas psychotherapists skilled in behavior therapy for OCD are small in both numbers and financial resources. (To find such a therapist near you, try contacting the Center for Anxiety and Related Disorders.)

In case you're wondering . . . within 4 months of my taking on the aforementioned OCD patient and treating him with standard behavior therapy, his symptoms were in remission. I've seen it repeatedly over the course of my career, and I'm not a particularly gifted psychotherapist (clinical research is my main gig), nor is OCD my area of specialty.

So lately, whenever I see an antidepressant commercial, I find myself thinking, "If only someone had the money for a series of slick commercials about behavior therapy! We've got to find a way to tell the 6 million OCD sufferers that there's a potentially more efficacious treatment out there - one (alas) that many have never even heard of."

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Saturday, July 25, 2009

Food Inc.: The Psychological Weapons of Protest

Why we don't care about the things that kill us

Food Inc. is a case in point of powerful activism. Its mission is to crystallize two things about food in America: a. what we eat is disturbingly unsafe b. the system in charge of what we eat is disturbingly corrupt. There is anecdotal evidence and statistics. The presentation is accessible and thorough. This is as moving and well done a documentary as any since Al Gore's Inconvenient Truth. The weapons used in this intellectual war against Big Business of food are vast and effective. The problem, however, is that the villain this documentary wages war on is psychologically difficult to stay mad at for very long.

For instance, I left the theater a little too cognizant of the candy and soda I'd just ingested, I wondered just how many minutes it was going to take for the sense of outrage and disgust I currently felt to dissolve back into indifference?

One of the reasons I am not ashamed to admit this is because of research by Daniel Gilbert, a social psychologist from Harvard.

He has studied our psychological response to such large and abstract threats as global warming and concluded that the human brain is naturally designed to respond in a manner that is far from ideal. When it comes to certain evolutionarily relevant threats like snakes and darkness, Gilbert maintains that our alarm systems are sleek, smooth and dependable. And yet for certain other threats this same alarm system goes haywire, producing an emotional baseline of apathy and acceptance that is challenging to change.

So, where does Big Agriculture lie on the "response to threat" spectrum and does the documentary effectively battle these psychological barriers?

According to Gilbert there are four key elements of a threat without which we will not act instantaneously and decisively:

a. The threat must have a face. We are highly social beings and our wiring is triggered by the aggressive action of other people, as opposed to something invisible or unhuman. This is why the Big Business CEO's of the agricultural industry were so wise in refusing to interview. Consequently, Food Inc.'s list of villains is long and vague: the greedy private enterprises, the corrupt government, the apathetic consumers etc. Here, too little is done in establishing a face to put on the dartboard.

b. The threat must incite a moral sensibility. When we are confronted with something repugnant, our minds generate such powerful emotions as disgust, which compel us to action as much as anything. On this barometer Food Inc. lands not too far behind puppy killing. In providing extending home footage of little Kevin, a three year-old victim of E-coli, Food Inc. activates our moral centers. Additional images of pigs that are too fat to move, cows that are knee-deep in their own feces and chickens with heads bigger than Barry Bonds provide an exclamation point.

c. The threat must represent a clear and present danger. Gilbert says that global warming is not happening fast enough in that sense that our brains best respond in milliseconds to flying baseball bats, not incremental recessions in icebergs. The documentary highlights the what-have-you-done-for-me-lately elements of threat by highlighting the various outbreaks and recalls that have soiled America's clean bill of health.

d. The threat must cause absolute, not relative changes. We respond to threats that can be current and observed in real-time. The documentary does focus on such current crises as the obesity and diabetes II epidemics, but these disorders do not develop overnight.

Food Inc. tackles an issue that bats two-for-four leaving me to conclude that food impurity, as a villain that incites activism, ranks a little better than global warming but worse than terrorism. Incidentally, a terrorist is an extremely gratifying enemy, psychological speaking. Fuse Osama Ben Laden with the 9/11 attacks and bat a thousand on Gilbert's categorical system.

This documentary shows the industrial food industry to be a small group of greedy, clever business figures (probably old white and male, too) who abuse animals, workers and the welfare of just about everyone all so their respective pockets can be lined with yet another billion dollars. The veil has been lifted to reveal supermarkets that are barely a step removed from the grease and slime of McDonalds. Food Inc. convicts Big Agriculture of terrorizing a fair and healthy way of life. Indeed, this documentary will need to link the industrial food system with terrorism to incite the sort of feverish protest that is needed.

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