Wednesday, June 28, 2006

Advice for Other Psychologists

If you're like me, you dread telling people what you do for a living. You tell them you're a psychologist, and somebody always says, "We better watch out what we're saying!" A real original comment. I finally came up with the perfect response:

"Don't worry. Your secrets are safe with me."

If I'm feeling particularly sadistic, I can add, "You know that sexual issue you have? Don't worry, I won't say a word."

Friday, June 23, 2006

Who was Freud?

Over at Frontal Cortex on the newly expanded ScienceBlogs, Jonah Lehrer compares Malcolm Gladwell (author of Blink, in which he discusses rapid, unconscious, "snap" decision-making) to Sigmund Freud:

Sigmund Freud was also a master prose stylist, wasn't particularly interested in the neurological foundations of his theories, and loved theorizing about the all powerful unconscious. (Like Gladwell, he also loomed large in mass culture and had a talent for giving his books pithy names, although I'm pretty sure Freud never made the rounds of the corporate lecture circuit...) Blink could have been a great book. It could have really explored the modern science of unconscious thinking.

I haven't read Blink yet, so this post isn't about the book. Instead, I am concerned about the trivialize of Freud. Freud was a brilliant man. (No, he wasn't obsessed with sex.) Much of psychoanalysis has been put aside, but it was Freud who recognized that there can be pathology in thought. He recognized that there is value in introspection. He created the idea of the therapeutic relationship, and these ideas have woven their way into the fabric of our lives.

Freud was a visionary. His power came, not from being a literary stylist (he didn't even write in English), but because he presented a compelling new vision of humanity. Today, that vision is dated. Popular conceptions of psychoanalysis inevitably simplify it, and those simplifications seem very trite.

Nevertheless, Freud's vision of the human psyche changed the way we think about ourselves so fundamentally, we take it for granted. For some people, no argument with our spouse is complete unless we have introspected about our motives. Did I really tell here what I was angry about? Is there another issue I'm not facing? The idea that our motives can be hidden from ourselves came from Freud.

As parents, we worry how our parenting will affect our children when they grow up. That came from Freud.

As I've said before, I'm not a psychoanalyst. But I have to respect Freud's vision, his creation of a whole new way to help people, and his contribution to our current culture.

Wednesday, June 14, 2006

Psychological Effects of Day Care

The New York Times has a summary of an extensive study on daycare, conducted in Quebec. In 1997, Quebec began subsidizing daycare for all 4 year olds, regardless of income. By 2000, the program was expanded to include all children not in kindergarten. The program was very popular, and resulted in significant economic expansion in Quebec. Three economists, Michael Baker, Kevin Milligan, and Jonathan Gruber collected data on the well-being of the children going through daycare.

They compared those results with children in the rest of Canada during that same period. Unfortunately, they found that the children in daycare did not fare so well. The Times reports:

Young children in Quebec are more anxious and aggressive than they were a decade ago, even though children elsewhere in Canada did not show big changes. Quebec children also learn to use a toilet, climb stairs and count to three at later ages, on average, than they once did. The effects weren't so great for parents, either. More of them reported being depressed, and they were less satisfied with their marriages — which also didn't happen in other provinces.

I can hear the pontificating now. Mothers should stop trying to work and just stay home with the children. Enough of this liberal working mother stuff and be good, pro-family conservatives!


David Leonhardt, the author of the Times article, makes the following comment:
The big lesson from Quebec is that parents really do need more support, but they need the kind of support that allows them to choose what is best for their family. Mothers and fathers should get paid time off after a baby is born, and the money should come from a government insurance program, as it does in Canada, England and other countries. Companies need to be given incentives to create more part-time jobs that don't derail careers — and then find some up-and-coming men who want those jobs. High-quality preschool programs should be available for every low-income child and perhaps universally.

Wouldn't that really be pro-family?

Monday, June 12, 2006

Intermittent Explosive Disorder: The New Rage?

Sorry, I couldn't resist the title.

Apparently, intermittent explosive disorder (IED) has hit the popular press. I've seen about 3 or 4 different references to it in the last week. The stories have been confusing it with road rage, but it's not. IED has been a diagnosis for years.

The whole thing follows a predictable arc:

1. An obscure diagnosis sits in the current Diagnostic and Statistical Manual.
2. Someone finds a way to use it to sell drugs. psychotherapy, or self-help books.
3. It catches the attention of the press.
3. It gets initials (e.g., IED) and becomes overdiagnosed and overtreated.
4. Warnings are issued about overdiagnosis.
5. Clinicians who benefit from the diagnosis argue that in the past it was underdiagnosed.
6. It continues to be overdiagnosed.
7. In some cases, associations get formed, and the diagnosis starts getting used as an excuse for underachievement or misbehavior.

We saw this with attention deficit disorder. Now Ritalin is rampant, and people with ADD get longer to take tests. A few years ago, oppositional defiant disorder followed the same arc, as did autism. Now, intermittent explosive disorder is hitting the same arc.

For the record, clinicians have been treating anger for many years. I recall diagnosing intermittent explosive disorder a few years ago, and having the insurance company kick the claim back saying they don't cover it. When this happens, clinicians always fall back on the same strategy. You avoid diagnoses that you don't get paid for.

That's not quite as dishonest as it sounds. A quick perusal of the Fourth Edition of the Diagnostic and Statistical Manual (DSM-IV) will show that multiple disorders manifest the same behavioral symptoms. For example, irritability and rage are the prime symptoms of intermittent explosive disorder, but, they are also associated with unipolar depression, bipolar disorder, attention deficit disorder, conduct disorder, and various personality disorders.

So, in the past, to assure payment, we treated anger as a symptom of another diagnosis. IED wasn't very common because no one was diagnosing it. I could be wrong here, but it's my recollection that when the Columbine School shootings occurred, more attention was brought to the problems associated with anger. We started to hear about "anger management," and I suspect this led to more diagnosis of intermittent explosive disorder.

So, two takeaways from this. First, diagnosis in mental health is not the same as in physical health. Despite all the huffing and puffing about biochemical imbalance, we have no clear understanding of the underlying mechanisms of depression or other mental illnesses. This means that ultimately "diagnosis" involves just summarizing what particular symptoms are being treated. It says nothing about etiology.

Second, diagnoses are influenced by social and economic factors. After Columbine, we stopped thinking that anger was just a matter of rudeness and immaturity. Now we think it's something serious that should be addressed, and our patterns of diagnosis have changed as a result. Let us not forget, however, that from spousal abuse to school shootings to office shootings to road rage, anger is a real problem.

I don't want to see it trivialized, either. I'm sure we'll soon hear, "I shouldn't be found guilty for running that man off the road because I have intermittent explosive disorder." That doesn't fly. IED is a serious problem and a treatable one, but it's not an excuse.

Sunday, June 04, 2006

Early Infant-Mother Attachment

The latest issue of Current Directions in Psychological Science contains an interesting article on early infant-mother attachment, by Myron Hofer. His work is based on research with rats, but nevertheless, there is much interesting data that is relevant to humans.

The term, attachment, as Hofer uses it, refers to “the processes that maintain and regulate sustained social relationships” (p. 84). Attachment between mother and infant is the first bond that occurs. Much clinical and social experience over the last 50 years has shown that inhibiting this process has long and severe consequences for the infant. The current thinking is that both reactive attachment disorder and antisocial personality disorder stem from impaired attachments during infancy and childhood. There are also suggestions that borderline personality disorder is also related to disrupted attachment.

Hofer addresses three issues. First, he presents data suggesting the attachment bond is created through the interaction of mother and infant through a complex pairing of stimuli. Apparently, there is an early period, immediately after birth, when the infant rapidly learns to associate smells, sounds, taste, and touch with the mother. It happens quite rapidly, enabling the infant to discriminate the mother from other parents and probably from other objects in the infant's environment.

Interestingly, Hofer mentions some data that indicates that aversive stimulation may intensify the bonding. He links this finding with the intense bond between a child and an abusive parent, and why this occurs needs to be clarified. Rapid bonding between the infant and the mother makes good sense from an evolutionary point of view. The mother provides all of the infants needs for survival, so the sooner the infant can recognize the mother the better. But the reason for increased attachment in the face of pain makes no sense to me.

The second issue involves the question of why maternal separation is stressful. Hofer says that basic biological processes are initially regulated by the mother in subtle ways. In describing an experiment with rats, he commented, “We concluded from these surprising results that warmth provided by the mother normally maintained the pup's activity level and that her milk maintained her pup's heart rate. Maternal separation withdrew these regulatory influences that were hidden within the ordinary mother–infant interactions, resulting in slowed behavior and low heart rate.” (p. 86).

The final issue Hofer addresses is why disruption of the early maternal-infant relationship can have lasting effects. Hofer argues, “when all maternal regulators are withdrawn early, a number of physiological and behavioral systems are altered in their developmental paths and in their relation to each other, creating a complex, changing pattern of vulnerability over the life span.” (p. 86). Interestingly, not all those changes are negative, which is consistent with what humans will tell you.

People who have gone through arduous childhood experiences often comment that they take away some positives from it. For example, some of my clients have said that because of the abuse they suffered as child, they have learned to manage stress better than their friends. They do not minimize the experience or deny how bad it was. They simply recognize that they did manage to take something positive from it.

Finally, it's always a pleasure to read a basic science article that has implications for practice. There's an awful lot of stuff out there that will never be of any real use to anyone beyond a line on a vita.

Hofer, Myron A. (2006). Psychobiological Roots of Early Attachment. Current Directions in Psychological Science 15 (2), 84-88. doi: 10.1111/j.0963-7214.2006.00412.x

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