Dr Caroline Leaf and the Me-Too approach to mental health

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Since her recent less-than-successful attempt at portraying herself as a mental health expert, Dr Leaf has been laying low on social media, sticking to bland, innocuous quotes or passages of scripture.

Today, she thought it was safe enough to pop her head up from the trenches to fire off another opinionated volley on mental well-being, with a quote from one of her favourite authors, Peter Kinderman:

“It’s our framework of understanding the world, not our brains and not even the events that happen to us – not nature and not nurture – that determines our thoughts, emotions, behaviours and, therefore, our mental health.”

Dr Leaf is a communication pathologist and self-titled cognitive neuroscientist. Without any training or professional experience in mental illness, she has also taken it upon herself to act as an expert on mental health within the Christian church.

Unfortunately, posting quotes like today’s offering only further destroys her flagging credibility among those with professional psychiatric experience, and adds to the confusion of the rest of the Christian church when it comes to understanding mental illness.

There are two main problems with Dr Leaf’s meme: the quote itself and it’s source.

The quote itself is wafer-thin, unable to stand up to even the most basic interrogation. For example, we know through basic common sense that the brain changes how we think, our moods, our emotions and our behaviours. We change our mood, our emotions and our alertness every time we have a cup of coffee, or a glass of wine. Hallucinogenic medications like LSD definitely change our framework of understanding the world. Coffee, alcohol, and illicit substances like LSD all change the mood or experience of the person using them because they all temporarily alter the function of the users brain.

Though it’s not just external substances that change how we experience our external and internal worlds, but our own internal hormonal ecosystem changes our emotions, our moods, our thoughts and our behaviours. This isn’t so obvious for most men as our hormones are fairly constant, though testicular failure is known to result in reduced energy, vitality, or stamina; depressed mood or diminished sense of well-being; increased irritability; and difficulty concentrating and other cognitive problems. For the female gender, monthly hormonal changes can sometimes result in sudden, marked changes in emotions, moods, thoughts and behaviours.

There are a lot of other reasons why the brain controls the mind, and our mental health, which I’ve also discussed numerous times in other blogs (here, here and here)

If you aren’t satisfied with a common sense approach, then consider the scientific evidence that personality, the name that we give to our inbuilt ‘framework of understanding the world’ is largely genetic, and dependent on the function of various neurotransmitter systems [1-4].

So to suggest that the brain is not responsible for our moods, our emotions, our thoughts and our behaviours isn’t supported by the weight of scientific evidence.

The quote by Kinderman doesn’t stop there, but suggests that “not even the events that happen to us … determines our thoughts, emotions, behaviours”, something that also flies in the face of current scientific evidence. For example, the other forty percent of personality is determined by our environment (specifically the ‘non-shared’ environment, the environment outside of our parental influence) [5, 6]. And common psychiatric illnesses are associated with early childhood adversity, such as schizophrenia [7] and ADHD [8]. So again, the quote is unscientific.

Who then is this Kinderman guy, and why does he disagree with the scientific literature?

Peter Kinderman is a Professor of Psychology at University of Liverpool, and the President-elect of the British Psychological Society. He’s a highly outspoken critic of modern psychiatry and what he perceives to be the medicalisation of normal moods and emotions and overuse of medications to treat these non-existent diagnoses. Kinderman believes that it’s our learning history that shapes the paths that our lives take, and so if we simply understand our personal models of the world and how they were shaped by the events and experiences to which we’ve been exposed, we can simply think our way out of any disease process [9].

Kinderman has come out in favour of talking treatments for psychosis in schizophrenia instead of medication, when there’s no scientific proof of benefit for psychosocial therapies in schizophrenia [10, 11] (and here).

This, and his staunch opposition of the DSM5 as invalid, makes me concerned about his bias against modern psychiatry, despite it’s many advances, scientifically and clinically.

However, I’m surprised that Kinderman would make such a statement because it’s such an asinine argument, I find it hard to believe that it came from a professor of psychology. Kinderman would surely recognise the role of biology in our mental health and wellbeing, even if he doesn’t agree with how it’s managed. Perhaps there’s an alternative explanation. Perhaps Kinderman didn’t say what Dr Leaf has claimed?

The answer is, he does, and he doesn’t.

Dr Leaf has quoted Kinderman correctly. Today’s quote is taken directly out of Kindermans 2014 book, “The New Laws of Psychology” [9], on the penultimate page of his introduction. So he does say that our brains and our experiences aren’t relevant for our mental health. But then again, in a blog on the militant anti-psychiatry blog ‘Mad in America’, Kinderman wrote this:

“I’ve spent much of my professional life studying psychological aspects of mental health problems. Inevitably, this has also meant discussing the role of biology. I hope I’ve made some progress in understanding these issues, in working out how the two relate to each other, and the implications for services. That’s my academic day-job. But it’s not just academic for me. I’m probably not untypical of most people reading this; I can see clear examples of how my experiences may have affected my own mental health, but I can also see reasons to suspect biological, heritable, traits. As in all aspects of human behaviour, both nature and nurture are involved and they have been intimately entwined in a complex interactive dance throughout my childhood and adult life.” http://www.madinamerica.com/2015/03/brain-baked-beans/

So he seems confused, both recognising that biological traits influence psychiatric illness, then denying it.

Personally, I disagree with the quote from his book, although I’m just a suburban GP from Australia, so what would I know, right? Though I think the evidence I’ve cited is on my side, and Kinderman is not without his critics who are more than his academic equal.

It also concerns me because the logical conclusion of this line of thinking is that psychiatric illnesses have no biological basis, and therefore psychiatric medications have no place in treatment of them. But as I outlined previously, there is good evidence for the beneficial effects of medications for schizophrenia and ADHD amongst other mental health disorders.

Dr Leaf continues to ignore the scientific evidence for the biological basis for mental ill-health, medications for their treatment, and even the most basic of all that our mind is a product of our brain. Instead, she’s nailed her colours to her mast and aligned herself with outspoken authors on the fringe of modern neuroscience. Rather than addressing the science behind her opposition to modern psychiatry and neuroscience, she has resorted to hiding behind their quotes, a ‘me-too’ commentator, rather than an actual expert.

Of more importance is the confusion that this brings to the vulnerable Christians who follow her social media “fan sites”. The more Dr Leaf criticises psychiatric medications and condemns their prescription and usage, the more likely it is that someone will come to serious harm when they inappropriately cease their medications. And if Dr Leaf won’t come to her senses, our church leaders are going to have to take action, before it’s too late.


[1]        Vinkhuyzen AA, Pedersen NL, Yang J, et al. Common SNPs explain some of the variation in the personality dimensions of neuroticism and extraversion. Translational psychiatry 2012;2:e102.
[2]        Chen C, Chen C, Moyzis R, et al. Contributions of dopamine-related genes and environmental factors to highly sensitive personality: a multi-step neuronal system-level approach. PloS one 2011;6(7):e21636.
[3]        Caspi A, Hariri AR, Holmes A, Uher R, Moffitt TE. Genetic sensitivity to the environment: the case of the serotonin transporter gene and its implications for studying complex diseases and traits. The American journal of psychiatry 2010 May;167(5):509-27.
[4]        Felten A, Montag C, Markett S, Walter NT, Reuter M. Genetically determined dopamine availability predicts disposition for depression. Brain and behavior 2011 Nov;1(2):109-18.
[5]        Krueger RF, South S, Johnson W, Iacono W. The heritability of personality is not always 50%: gene-environment interactions and correlations between personality and parenting. Journal of personality 2008 Dec;76(6):1485-522.
[6]        Johnson W, Turkheimer E, Gottesman, II, Bouchard TJ, Jr. Beyond Heritability: Twin Studies in Behavioral Research. Current directions in psychological science 2010 Aug 1;18(4):217-20.
[7]        Howes OD, Murray RM. Schizophrenia: an integrated sociodevelopmental-cognitive model. Lancet 2014 May 10;383(9929):1677-87.
[8]        Thapar A, Cooper M, Eyre O, Langley K. What have we learnt about the causes of ADHD? Journal of child psychology and psychiatry, and allied disciplines 2013 Jan;54(1):3-16.
[9]        Kinderman P. The New Laws of Psychology: Why Nature and Nurture Alone Can’t Explain Human Behaviour: Robinson, 2014.
[10]      Buckley LA, Maayan N, Soares-Weiser K, Adams CE. Supportive therapy for schizophrenia. The Cochrane database of systematic reviews 2015;4:CD004716.
[11]      Jones C, Hacker D, Cormac I, Meaden A, Irving CB. Cognitive behaviour therapy versus other psychosocial treatments for schizophrenia. The Cochrane database of systematic reviews 2012;4:CD008712.

Dr Caroline Leaf and the Myth of the Chemical Imbalance Myth

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There are lots of medical myths that people believe.

“I have acne because I eat too much chocolate, or my face isn’t clean enough”

“Stomach ulcers are because of stress”

“I coughed up some yellow phlegm, so I must need antibiotics right?”

“My baby’s fevers are because of teething.”

Is the “chemical imbalance” theory one of them?

Dr Leaf is a communication pathologist and self-titled cognitive neuroscientist. A couple of weeks ago she opened a proverbial can of worms by quoting the out-spoken Peter Gøtzsche, claiming that psychiatric drugs are the third leading cause of death after heart disease and cancer. This did not go down well, and Dr Leaf had to issue three separate statements on social media to try and justify herself and attempt to rescue her rapidly deteriorating credibility.

Not that she issued an apology, mind you, or retracted her statement.

Today, Dr Leaf published a blog on psychiatric medications … but again, not to apologise but to further justify why she is right, and nearly every other doctor and scientist in the world is not. Worse than that, she went so far as to accuse doctors of deliberately prescribing clearly dangerous drugs, which have no therapeutic effects, just because of some overcooked drug-company sponsored dinner and a few pens. More on that later.

Her post is a defiant deflection, a logically flawed and factually inaccurate criticism of modern psychiatry and psychopharmacology – not fueled by research, but largely based on the books of disgruntled fringe psychiatrists and researchers with an axe to grind.

Dr Leaf doesn’t discuss the actual science of the medications that she’s so against, but simply tries to create a smokescreen of distrust.

A good example of all that is wrong with this post is contained in the opening paragraph.

Today, it has become commonplace to say that people have chemical imbalances in their brain, most notably a disruption in the proper production of dopamine (for “diseases” like ADHD) and serotonin (for “diseases” like depression). These people, it is supposed, need drugs to “cure” these chemical imbalances, hence the terms “antipsychotics” or “antidepressants”.

The first thing to note is how Dr Leaf uses the term “cure”. No doctor ever uses the word “cure”, especially when talking about complex diseases. This is a pejorative term which is used to set up the implication that modern medicine is only interested in permanently fixing things. But it’s a straw man fallacy, a false premise that Dr Leaf then uses to cast the medical model as impotent and futile. Nice try, but no one in medicine ever promises cure, and no doctor in their right mind would ever be so narrow-minded as to suggest that drugs are the only treatment for every condition. This doesn’t mean that drugs are not useful, nor that the medical model is broken. As we’ll discuss soon, medications are extremely helpful for certain conditions, when used carefully, as are non-drug treatments like CBT.

Dr Leaf also puts inverted commas around the word “diseases” as if to suggest that ADHD and depression aren’t diseases, an act which smacks of petulance and willful ignorance, and is insulting to those who have or who have ever suffered from ADHD and depression.   Last week, Dr Leaf was happy to share that her eldest daughter suffered from bulimia and depression, but now she’s suggesting that depression isn’t really a disease. So what is it then? Malingering? Just personal weakness? Bad parenting?

It’s really surprising that someone claiming to be a cognitive neuroscientist would ignore strong scientific evidence.  For example, ADHD is associated with dopamine dysfunction as well as the dysfunction a number of other neurotransmitters [1-3]. And depression is associated with a decrease in the growth factor BDNF, (known as the neurotrophic hypothesis of depression) [4-6]. Schizophrenia, which Dr Leaf conveniently failed to mention, is clearly related to dopamine dysfunction in nerve cells of the pre-frontal cortex and the striatum, two parts of the brain that are incredibly important for how your brain processed incoming and outgoing signals [7-9].

So there is nothing to suppose here. There is ample evidence that psychiatric diseases are related to dysfunction within the brain, commonly with the function of neurotransmitters among other things. Call it whatever you like, the truth doesn’t change. “Chemical imbalance” is just an easy phrase for the general public to remember.

Dr Leaf then tries to suggest that psychiatric drugs don’t fix chemical imbalances but create them, citing the 1950’s observations of French researchers Deniker and Delay who noted that the first anti-psychotic, chlorpromazine, caused symptoms of Parkinson’s Disease. And indeed it did, but this wasn’t a new disease, just evidence that it worked.

Psychosis, a pathological state involving hallucinations and delusions, is because of an excess of the neurotransmitter called dopamine. Dopamine is the neurotransmitter that’s used by the nerve cells deep in the brain in a part called the basal ganglia, which acts like a central mail delivery centre for incoming and outgoing signals from other parts of the brain. The function of the nerves in one part of the basal ganglia are responsible for sending sensory signals to the frontal lobes of the brain. In another part, the signals are important for smooth movements of our muscles. Proper function depends on just the right amount of dopamine – too much and you get psychosis. Not enough and you get Parkinson’s disease symptoms.

All the French researchers were noting were the side-effects of too much medication blocking the action of dopamine in the basal ganglia – the psychosis had improved, but the blockade of dopamine was just too much in some patients, who had the opposite symptoms.

Again, Dr Leaf’s position is diametrically opposed to the published science [10, 11], and if anything, her claim contradicts her fundamental argument. After all, if chemical imbalances are myths, then how can chlorpromazine create a “new neurological syndrome” because of a chemical imbalance?

Dr Leaf then launches into a discussion on the history of the DSM and psychiatric medications. This is just the first in her ad hominem attacks on the medical profession –  playing the man, not the ball if you will. If she can discredit the doctors that prescribe the medication, then she indirectly discredits the medications.  This appears desperate and ultimately serves to weaken her case.

“It was just assumed that since these drugs affected brain chemistry in a certain way, the opposite reaction must be the result of the disease, notwithstanding the fact that this has never been adequately proven.”

The history of medicine is littered with cures being found without the disease being fully understood. Take Edward Jenner, for example, who is the founder of the modern technique of vaccination. He didn’t know why his smallpox vaccine worked, only that it did. Electron microscopes and a modern understanding of the immune system were centuries away, but Jenner saved billions of lives through his observation that prior vaccination with a small sample of cowpox virus would protect against smallpox [12].

When amphetamines, known to increase dopamine concentrations in the brain, caused psychotic symptoms and reserpine, a dopamine blocker, improved psychosis, it stood to reason that dopamine was a good candidate as a cause of psychosis and schizophrenia. Decades of research have gone on to further confirm and delineate the link [7]. Again, this is not “an overly simplistic explanation of chemical imbalances”. It is well proven, and rather complex.

Dr Leaf also makes the astounding accusation that psychiatrists inflicted suffering and caused “a public health disaster” by creating the DSM. The DSM, the ‘Diagnostic and Statistical Manual’ is an agreed-upon standard classification for psychiatric diagnoses. It is nothing more than a system of classification. It allows psychiatrists and researchers to speak a common language and attempt some coherence among their diagnoses.

Dr Leaf wrote, “… institutions like the American Psychiatric Association and the DSM would define what is normal, in turn telling us what it means to suffer and, essentially, what it means to be human. They medicalized misery, and today millions are suffering because of their actions, creating a public health disaster.”

That’s like saying that classifying the different types of cancer causes cancer. And that millions of people are suffering from cancer because doctors know to call it ‘cancer’. People have been suffering long before the DSM came along. The DSM doesn’t tell people they’re suffering, and it certainly doesn’t define what it is to be human. Such statements are disingenuous and melodramatic.

But wait, there’s more. “Today a psychiatrist can be praised for drugging a depressed person with mind-altering substances and, if these do not work, institutionalizing them and shocking their brain with ECT (electroconvulsive therapy). It is even an acceptable and commonplace practice to imprison mentally ill persons, drug them and lock them in solitary confinement, compelling them to live their days marinating in their own excrement.”

Dr Leaf is again playing to the fears of the public who have watched too many movies and only think of ‘One Flew Over the Cuckoo’s Nest’, ‘Shutter Island’ or scenes from ’12 Monkeys’. There are more oversight boards and lawyers than there are psychiatric patients, and the only people who are institutionalised are those who are clearly a danger to themselves or others. And while institutionalised, they are not subjected to random bouts of electrical shock as if some doctor is wandering around with a medical grade cattle prod, zapping people and laughing maniacally. Nor is anyone locked in solitary confinement and forced “to live their days marinating in their own excrement”.

The paranoid accusations continue some more. Dr Leaf accuses all psychiatrists of ignorance, and then accuses primary care physicians of negligence, by claiming that we prescribe medications that we do not understand because of the bribes and a pretty smile from a pharmaceutical rep.

Again, Dr Leaf contradicts her own argument:

Despite the recognition amongst many psychiatrists and medical health professionals that the chemical imbalance theory is not valid, drug companies like Eli Lilly still claim that ‘antipsychotic medicines are believed to work by balancing the chemical found naturally in the brain’.

Except that antipsychotic medications DO balance the naturally occurring chemical in the brain (dopamine) as we discussed earlier. What the … a drug company telling doctors how their drug works! How dare they tell the truth!

I find it disturbing that Dr Leaf would stoop so low as to insult the entire medical profession, especially every GP and family physician the world over.

Hey, I’m not above criticism. It’s important to have a good long look at ourselves from time to time, to review our practice, and make sure we’re treating our patients in the best possible way. The RACGP, the peak body of Australian GP’s, invited Prof Gøtzsche to present his opinions on anti-depressant medications so that GP’s could decide for themselves if they should adjust their prescribing.

But to suggest that primary care physicians are stupid, ignorant, incompetent and money hungry, that we would sell our soul for a drug company branded pen, is insulting. Though the irony of her statement, “we do not ask ourselves if these doctors really understand all the implications of using these substances. Not even the psychiatrists understand these drugs” is clearly lost on Dr Leaf.  It’s clear from the rest of her essay that Dr Leaf has no idea how these medications work or what benefits they have for those who suffer from mental ill-health.

There’s a lot more to discuss in response to Dr Leaf’s diatribe, but for the sake of brevity, I’ll try and discuss just a couple of other important themes.

Dr Leaf continues to try to make the medications sound useless and poisonous. She has several paragraphs on the placebo effect, making the false argument that the effect of the medications is just because someone tells you it will work. Of course, the placebo effect is part of the therapeutic effect, but that’s the same for all treatments, even Dr Leaf’s programs … “So, if the pastor or cell-group leader says that these programs are safe and will fix your toxic thinking, even though they get most of their information from the author, we believe wholeheartedly in what he or she may say and are more inclined to believe the program will work for us. These beliefs, which ignore actual scientific results, are buttressed by a flood of distorted and biased news reports, press releases and scientific journal articles on supposed toxic thoughts, and have transformed the theory into church dogma. So, obviously, if we experience negative side effects and do not feel the program is working, it must be something wrong with us, not the program.” Is that a fair statement?

Dr Leaf that plays the fear card again by listing all of the potential side effects from psychiatric medications. Dr Leaf is right in saying that psychiatric medications have serious proven long term side effects, and we should be careful.

For instance, if you knew that thrombocytopenia, anaphylaxis, cutaneous hypersensitivity reactions including skin rashes, angioedema and Stevens Johnson syndrome, bronchospasm and hepatic dysfunction were the potential side effects for a medication, would you take it? Most people wouldn’t.   Reading the list makes that drug sound really dangerous, and is it any wonder that we should be up in arms about such a dangerous drug … except that this list of side effects isn’t a psychiatric drug at all, and is actually the side effect profile of paracetamol (acetaminophen in the US). People take paracetamol all the time without even thinking about it.

Saying that we shouldn’t take medications because of potential side effects is a scarecrow argument, a scary sounding straw man fallacy. All drugs have serious proven long term side effects. Licencing and prescribing a medication depends on the overall balance of the good and the harm that a medication does. And no one has ever hidden these side effects from the public as if there is a giant conspiracy from the doctors and the pharmaceutical companies. They’re right there in the product information (here is the product information for fluoxetine. See for yourself).

Whilst it’s true that these side effects do happen, we know that they happen infrequently, just like we know that people win lotteries infrequently. Even so, the medications are not just doled out like sweets at a candy store. You require a minimum of ten years of university level education to be able to prescribe them.

Patients ALWAYS have a right to ask questions about possible benefits and side effects, and in my practice, I tell my patients the pros and the cons before prescribing, and I give them the choice of whether they want them or not. No one is ever forced into taking them.

Finally, Dr Leaf makes a number of irrational statements and flawed arguments in her final page of ranting. Let me quickly go through some of the honourable mentions:

* “Most people recover from depression without antidepressants” – true, because most cases of depression are mild. That doesn’t mean to say that antidepressants shouldn’t be used for severe depression, just like most people recover from upper respiratory infections without antibiotics, but that doesn’t mean that we shouldn’t use antibiotics for severe tonsillitis or pneumonia.
* “Antidepressants are no better than placebos” – It’s a controversial topic right now. There are many pushing the barrow that SSRI medications are no better than a sugar pill. But Dr Leaf has conveniently ignored several Cochrane reviews (the best of medical evidence) that shows anti-depressants work for a variety of disorders [13-15], but that psychological therapy might not [16].
* Equating antidepressants and antipsychotics with illicit drugs, and claiming that “more people die from overdoses of psychiatric drugs than illicit drugs” – This is Reductio ad absurdum – the logical conclusion from this argument is that illicit drugs are safer than psychiatric drugs. And therefore we should not give people psychiatric drugs since we don’t give people the ‘safer’ illicit drugs. But that conclusion is absurd, and when you think about it, the whole thing is based on hidden false premises – people rarely die of illicit drug overdoses because they’re illegal and are hard to come by. And also, people who use illicit drugs are not usually suicidal, whereas those given psychiatric medications sometimes are suicidal, and sometimes use them to try and commit suicide. But modern psychiatric drugs are much less dangerous in overdose than their old counterparts.  It should also be noted here that more overdose suicide attempts are with paracetamol or ibuprofen than with psychiatric medications [19], but I don’t see paracetamol or ibuprofen being demonised.
* Psychiatric medications are part of a neo-liberal capitalist plot to keep the rich, richer and the poor, poorer – To me, this looks like Dr Leaf clutching at straws. Her statement, “By emphasizing that the problem lies within an individual’s biology, we are less inclined to look at their experiences and the social context of why they are feeling the way they feel. We look at the mythical chemical imbalance instead of economic exploitation, violence and inept political structures” is false.   Schizophrenia is often seriously discussed in terms of neurodevelopment and not just ‘chemical imbalances’ [17, 18]. So it’s just plain wrong to suggest that researchers don’t look at the “economic exploitation, violence and inept political structures”. Oh, and Dr Leaf suggests that foster children are abused because they’re all forced to take psychiatric medication, and implies that ADHD children are abused by being force-fed Ritalin because they “move a lot in class”. Again, these are emotional over-generalisations that have no basis in reality.

And this was only part one.  If Dr Leaf’s promised second part is anything like the first, we’re in for a real treat.

Dr Leaf seems lost.  She’s ignored solid published medical and scientific evidence in coming to an opinion based on the discontented rumblings of a few vocal but outspoken critics. In order to make her arguments, she has had to resort to borderline-slanderous ad hominem attacks on scientists and the medical profession, and purely emotional arguments based on fear and mistrust.

Though as if that wasn’t enough, by suggesting that psychiatric drugs cause changes in your brain, cause chemical imbalances, and cause that slew of negative side effects, Dr Leaf is admitting that it’s your brain that changes your thought life, which directly contradicts her most recent teachings. After all, if thought was the dominant force in your neurology and your mind controlled your brain, then the medications would have no effect since they’re physical and aren’t connected to our mind, so there would be no need for Dr Leaf to worry us about these medications.

So which is it? Because if the brain controls our mind, then her best-seller needs to be pulped and refunds offered to the hundred of thousands of people who bought it. But on the other hand, if the mind really does control the brain, then you’re wrong to tell people that these drugs will change your thoughts.

Dr Leaf has painted herself into a corner and there’s still part two to come.


[1]        Prince J. Catecholamine dysfunction in attention-deficit/hyperactivity disorder: an update. J Clin Psychopharmacol 2008 Jun;28(3 Suppl 2):S39-45.
[2]        Del Campo N, Chamberlain SR, Sahakian BJ, Robbins TW. The roles of dopamine and noradrenaline in the pathophysiology and treatment of attention-deficit/hyperactivity disorder. Biological psychiatry 2011 Jun 15;69(12):e145-57.
[3]        Cortese S. The neurobiology and genetics of Attention-Deficit/Hyperactivity Disorder (ADHD): what every clinician should know. European journal of paediatric neurology : EJPN : official journal of the European Paediatric Neurology Society 2012 Sep;16(5):422-33.
[4]        Haase J, Brown E. Integrating the monoamine, neurotrophin and cytokine hypotheses of depression–a central role for the serotonin transporter? Pharmacol Ther 2015 Mar;147:1-11.
[5]        Bus BA, Molendijk ML, Tendolkar I, et al. Chronic depression is associated with a pronounced decrease in serum brain-derived neurotrophic factor over time. Molecular psychiatry 2015 May;20(5):602-8.
[6]        Sousa CN, Meneses LN, Vasconcelos GS, et al. Reversal of corticosterone-induced BDNF alterations by the natural antioxidant alpha-lipoic acid alone and combined with desvenlafaxine: Emphasis on the neurotrophic hypothesis of depression. Psychiatry research 2015 Sep 1.
[7]        Howes OD, Fusar-Poli P, Bloomfield M, Selvaraj S, McGuire P. From the prodrome to chronic schizophrenia: the neurobiology underlying psychotic symptoms and cognitive impairments. Curr Pharm Des 2012;18(4):459-65.
[8]        Williams GV, Castner SA. Under the curve: critical issues for elucidating D1 receptor function in working memory. Neuroscience 2006 Apr 28;139(1):263-76.
[9]        Der-Avakian A, Markou A. The neurobiology of anhedonia and other reward-related deficits. Trends Neurosci 2012 Jan;35(1):68-77.
[10]      Leucht S, Tardy M, Komossa K, et al. Antipsychotic drugs versus placebo for relapse prevention in schizophrenia: a systematic review and meta-analysis. Lancet 2012 Jun 2;379(9831):2063-71.
[11]      Torniainen M, Mittendorfer-Rutz E, Tanskanen A, et al. Antipsychotic treatment and mortality in schizophrenia. Schizophrenia bulletin 2015 May;41(3):656-63.
[12]      Riedel S. Edward Jenner and the history of smallpox and vaccination. Proc (Bayl Univ Med Cent) 2005 Jan;18(1):21-5.
[13]      Arroll B, Elley CR, Fishman T, et al. Antidepressants versus placebo for depression in primary care. The Cochrane database of systematic reviews 2009(3):CD007954.
[14]      Soomro GM, Altman D, Rajagopal S, Oakley-Browne M. Selective serotonin re-uptake inhibitors (SSRIs) versus placebo for obsessive compulsive disorder (OCD). The Cochrane database of systematic reviews 2008(1):CD001765.
[15]      Kapczinski F, Lima MS, Souza JS, Schmitt R. Antidepressants for generalized anxiety disorder. The Cochrane database of systematic reviews 2003(2):CD003592.
[16]      Jakobsen JC, Lindschou Hansen J, Storebo OJ, Simonsen E, Gluud C. The effects of cognitive therapy versus ‘treatment as usual’ in patients with major depressive disorder. PloS one 2011;6(8):e22890.
[17]      van Os J, Linscott RJ, Myin-Germeys I, Delespaul P, Krabbendam L. A systematic review and meta-analysis of the psychosis continuum: evidence for a psychosis proneness-persistence-impairment model of psychotic disorder. Psychological medicine 2009 Feb;39(2):179-95.
[18]      Howes OD, Murray RM. Schizophrenia: an integrated sociodevelopmental-cognitive model. Lancet 2014 May 10;383(9929):1677-87.
[19]     Prescott K, Stratton R, Freyer A, Hall I, Le Jeune I. Detailed analyses of self-poisoning episodes presenting to a large regional teaching hospital in the UK. Br J Clin Pharmacol 2009 Aug;68(2):260-8.


  1. Do not abruptly stop any medications that you are taking. Talk to your licenced physician first. They’re not all money-hungry, imbecilic drug-company bitches. Most of them actually know what they’re talking about.
  2. For the record, I declare that I have no connection with any pharmaceutical company. I do not accept gratuities of any form from any sales representative. I don’t eat their food, I don’t take their pens, and I don’t listen to their sales pitches

The significance of thoughts

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A few days ago, I posted a rebuttal to one of Dr Leaf’s favourite memes, “Thoughts are real and occupy mental real estate.”

In short, I wrote that thoughts are real, but the issue hasn’t ever been whether thoughts are real, but what thoughts really are. The conclusion was that thoughts are just a projection, a function of the brain. They are not independent of the brain and they do not control the brain.

Dr Caroline Leaf is a communication pathologist and a self-titled cognitive neuroscientist. Dr Leaf tried to refine her meme today, saying:

“Your thoughts produce proteins, which form real structures that change the landscape of your brain.”

So, is that true? Do thoughts produce proteins which change the structure of the brain? To answer that, we need to have a look at some basic neurobiology.

The brain is made of nerve cells. Nerve cells have three unique structures that help them do their job. First are dendrites, which are spiny branches that protrude from the main cell body, which receive the signals from other nerve cells. Leading away from the cell body is a long thin tube called an axon which helps carry electrical signal from the dendrites, down to the some tentacle-like processes that end in little pods. These pods, called the terminal buttons of the axon, and then convey the electrical signal to another nerve cell by directing a burst of chemicals towards the dendrites of the next nerve cell in the chain.

In order for the signal to be successfully passed from the first nerve cell to the second, it must successfully traverse a small space called the synapse.

Despite being very close to each other, no nerve cell touches another. Instead, the spray of chemicals that’s released from the terminal button of the axon floats across a space of about 20-40nM (a nanometre is one billionth of a metre).

Combining nerve cells and synapses together creates a nerve pathway, where the input signal is received by specialised nerve endings and is transmitted down the nerve cell across a synapse to the next nerve cell, across the next synapse to the next nerve cell, and on and on until the signal has reached the destination for the output of that signal.

And that’s it. The entire nervous system is just a combination of nerve cells and the synapses between them.

What gives the nervous system and brain the near-infinite flexibility, and air of mystery, is that there are eighty-six billion nerve cells in the average adult (male) brain. Each nerve cell has hundreds to thousands of synapses. It’s estimated that there are about 0.15 quadrillion (that’s 150,000,000,000,000) synapses throughout the average brain [1]. Each of these cells and synapses connect in multiple directions and levels, and transmit signals through the sum of the exciting or inhibiting influences they receive from, and pass on to, other nerve cells.

The brain is a highly plastic organ. When biologists talk about plasticity, they aren’t talking about the chemical plastic that we make everything out of, like plastic cups or bottles, but the ability for the cells, tissues or organs to change or adapt. And the brain does this all of the time. Every stimulus changes one or more of the billions of branches and synapses that the brain has. Branches can be pruned back, or new ones grown. Existing branches can be strengthened or weakened. Each change to the branches of the nerve cells helps the brain to adapt to the ever-changing internal and external stream of signals that the brain is required to process.

So returning to Dr Leaf’s statement: The key part of the meme is, “Your thoughts produce proteins”. This is where Dr Leaf’s statement is wrong. The error is deceptively subtle, but it’s still wrong. When changes are required, new branches are formed, which do indeed require new proteins. But most brain function, including our thoughts, is simply electrical current running along the pathways already formed by the branches of our nerve cells.

Even then, our stream of conscious thought is only a tiny fragment of the billions of nerve impulses our brains produce each and every second of our lives. As I described in my previous post, thought is not dominant. Our thoughts do not control our brains, it’s our brains that control our thoughts. Thoughts are real, but they’re real like an image on a screen is real, but isn’t the real thing.

Thoughts are only significant when they are considered for what they truly are. Our stream of consciousness is simply a selective place of refinement for highly salient parts of our non-conscious information that need further processing before further action is taken with that information. They are like the dials on your dashboard, which give selective important information about the car but they don’t control the car. Thoughts do not control our brains growth, or alter our brains architecture.

Dr Leaf should have said something along the lines of, “The landscape of the brain is created by real structures called neurons and synapses, which have many functions including our thoughts.”

As it is, Dr Leaf’s meme creates a false impression that our thoughts are the critical factor in determining our brains structure and function, when the reality is the exact opposite.


[1]        Sukel K. The Synapse – A Primer. 2013 [cited 2013 28/06/2013]; Available from: http://www.dana.org/media/detail.aspx?id=31294

Dr Caroline Leaf – Better graphics, same content

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In the world of marketing, visual media is king. Humans are sight based creatures. About thirty percent of our brains cortex is dedicated to vision , compared to 8 percent for touch and 2 percent for hearing http://channel.nationalgeographic.com/brain-games/articles/brain-games-watch-this-perception-facts/)

It’s no wonder then that sites like Pinterest and Instagram have so rapidly become such dominant sites on the social media landscape. And why billions of dollars are invested in visual advertising on TV and billboards.

Dr Caroline Leaf is a communication pathologist and self titled cognitive neuroscientist. In the last few weeks, she’s gone for a new look for her Instagram and Facebook posts – gone are the simple lines, plain text and stand alone logo. Her posts have gone glam, with backgrounds of her photo treated with coloured layering and shading, overlaid with Dr Leafs favourite text. Sometimes the text is pretty easy to read. Other times it looks like a 4th grade class got to take turns picking the font and text size for each different word. But hey, it’s edgy, it’s happening, it’s so hot right now.

It’s a real shame that she only chose to update the look and not the actual content of her social media memes. Take today’s offering as an example: “The mind processes. The brain reflects this processing.” (The unsaid conclusion being that, “The mind controls the brain.”)

I’ve written about this meme a few times (here, here, here and here, as a small sample). But let’s relook at it again, since Dr Leaf is unwilling to reconsider the statements lack of validity.

Does the mind really control the brain, or does the brain control the mind? Well, if the mind was separate from the brain and controlled the brain, then the mind would be able to function independently of the brain. And also, if the mind was separate to the brain, then changes to the brain would not influence the function of the mind.

It’s difficult to show that a person has a mind without a brain. You can’t really remove someone’s brain and then put it back again, so not many people are keen to volunteer for that study. But anecdotally, have you ever heard of a person who has woken from a coma having spend all that time in deep thought?

What IS much easier to study, and has been proven over the course of centuries, is the change to our cognitive function when our brain is changed, physically or functionally.

The mind changes when the function of the brain is changed by medications.
The mind changes when the function of the brain is changed by illicit drugs.
The mind changes when the function of the brain is changed by electrical stimulation.
The mind changes then the structure of the brain is changed by tumours or injuries.

In 1848, a man named Phineas Gage was packing gunpowder in some rock when an accidental detonation blasted a foot-long iron rod through the left face and forehead, severely damaging the left frontal lobe of his brain. History records that his personality changed from polite, well mannered, and well spoken to fitful, irreverent, impatient of restraint or advice, obstinate and capricious [1].

Whilst Phineas Gage was is most famous, other brain injuries can also change the way in which someone thinks. For example, lesions of the parietal lobe of the brain changes the way people see their own bodies. Baars writes, “Patients suffering from right parietal neglect can have disturbing alien experiences of their own bodies, especially of the left arm and leg. Such patients sometimes believe that their left leg belongs to someone else (often a relative), and can desperately try to throw it out of bed. Thus, parietal regions seem to shape contextually both the experience of the visual world and of one’s own body.” [2]

Some might argue that the mechanism of injury might be the variable that could change someone’s personality. After all, if an iron rod was blasted through my skull, I might be a little antsy too. But other structural change to the brain, not associated with a sudden traumatic event, can also result in personality changes – it’s well recognised that personality changes can be the first presenting symptom of brain tumours, for example.

Though the brain doesn’t have to be horribly distorted for the mind to change. In the last couple of decades, a tool has been developed called TMS – short for transcranial magnetic stimulation. A magnetic pulse is delivered over a part of the skull, passing through the bone to reach the brain, causing changes to the electrical current running through the nerve cells. Stimulation of different intensities can either turn off the nerve cells or excite them. TMS has become a great tool for studying cognitive neuroscience because it directly changes the function of the brain in a well localised and temporary manner. It’s also easy for scientists to blind the subjects to whether they’re receiving the treatment or a sham treatment, so the results are reliable. Research shows that when the frontal lobes of the brain are changed by the electrical signals, their executive function also changes [3].

Changes to the function of the brain are known to change the function of the mind and have been known to do so for centuries. From religious hallucinogens to Woodstock hippies, drugs of various forms have been used to alter mood, thought, and perceptions of reality. But there’s a drug that’s much more common, that’s known for its ability to alter our brains thinking ability the world over, and even Dr Leaf enjoys it.

Like most people, my morning doesn’t really start until after my first cup of coffee. Sure, I’m functional, but barely. Fifteen minutes after the first short black is in my system, I find that I’m much more alert and my thinking is clearer.

What’s changed? Is it my mind changing the function of my brain, or is it the coffee, specifically the caffeine in it, that’s changing my brain which is in turn is making my mind clearer and sharper? I think the answer is obvious. Caffeine is the most commonly used recreational drug in the history of mankind, and every cup of java (real coffee that is, not the travesty that is decaf) is more proof against Dr Leaf’s dogmatic misrepresentation of basic science.

So, if the mind is changed by alterations to the structure and/or function of our physical brain, it follows that our mind must be a function of our brain. Therefore, the mind does not process, while the brain simply hangs on for the ride. Rather, the brain processes, and our mind reflects this processing.

Dr Leaf can tart up her memes all she likes, but until she changes the content of her memes to match some actual science, it’s all just smoke and mirrors. The truth doesn’t need visual pimping. It is simply the truth.


[1]        Fumagalli M, Priori A. Functional and clinical neuroanatomy of morality. Brain : a journal of neurology 2012 Jul;135(Pt 7):2006-21.
[2]        Baars BJ. Global workspace theory of consciousness: toward a cognitive neuroscience of human experience. Progress in brain research 2005;150:45-53.
[3]        Guse B, Falkai P, Wobrock T. Cognitive effects of high-frequency repetitive transcranial magnetic stimulation: a systematic review. J Neural Transm 2010 Jan;117(1):105-22.

Dr Caroline Leaf and the tongues trivia tall tales trifecta

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I saw a Facebook factoid from Caroline Leaf today that said, “When we speak in tongues, research shows that the areas involved in discernment in the brain increase in activity, which means we increase in wisdom.”

Dr Caroline Leaf is a communication pathologist and a self-titled cognitive neuroscientist. She has also proclaimed herself as an expert on science and the Bible.

In the opening of her “Scientific Philosophy”, for example, Dr Leaf says that, “God is the Creator of the Universe and is the Author of Science. Since God is the Author of the Bible, the Bible is therefore the ultimate authority in any scientific matters. The study of Science is therefore the study of God’s handiwork and is a way of admiring His Creation. God, the Creator, is the One to be worshipped, not the Creation. The Creation, however, reflects the Glory of God and points to His Divine attributes.”

In order to prove that the Bible is the ultimate scientific authority, Dr Leaf attempts to find scientific studies which support Biblical concepts. One example of this is her teaching on Glossolalia, the scientific term for the Biblical concept ‘speaking in tongues’.

Dr Leaf’s Facebook factoid on the neuroscience of speaking in tongues is at least the second time she has posted it. In November when I first saw Dr Leaf’s proclamation on the science of speaking in tongues, I was fascinated. I went to find the research for myself to see if the areas involved in discernment in the brain really increase in activity when speaking in tongues. As it turns out, there isn’t any.

The only study that I could find about brain functioning during speaking in tongues was by Newberg [1]. As I wrote in my previous blog, the study by Newberg showed the part of the brain that’s involved in both speaking in tongues and discernment, the ventromedial prefrontal cortex, decreases in activity when praying in tongues, not increases, in direct contradiction to Dr Leaf’s meme.

In November, I concluded, “there are really only two reasonable explanations as to why the research contradicts Dr Leaf; either there is another piece of research which supports Dr Leaf’s assertion, or Dr Leaf is simply wrong.”

Today on Facebook, Dr Leaf demonstrated that she can not be swayed from her entrenched idea that speaking in tongues increases discernment … or can she? Her meme and her discussion on glossolalia in her ‘Scientific Philosophy’ seem contradictory.

For example, she writes in her scientific philosophy manifesto, “In 2006 Dr. Andrew Newberg at the University of Pennsylvania, using single-photon emission computerized tomography (SPECT), found that the frontal lobe of individuals who spoke in tongues was less active. This brain profile was in contrast to Franciscan nuns in contemplative prayer and Buddhist monks in meditation, in which frontal lobe activity is increased. Since the frontal lobe activity is increased when we are focused on what we are saying, this finding confirms self-reports of what people who spoke in tongues experienced, implying that the words spoken in glossolalia originate from a source other than the mind of the individual speaking in tongues.”

In this paragraph, Dr Leaf confirms that frontal lobe activity decreases when speaking in tongues, in keeping with her anecdotal evidence of “self-reports of what people who spoke in tongues experienced, implying that the words spoken in glossolalia originate from a source other than the mind of the individual speaking in tongues.” But this is in direct contrast with her social media meme, which suggests that speaking in tongues increases frontal lobe activity – the area of the brain common to glossolalia and discernment is the vmPFC, which decreases with glossolalia and increases with discernment.

Dr Leaf is a confusing enigma. She posts social media memes that are clearly wrong, even disagreeing with the scientific papers she has written about and her own conclusions in her own manifesto.

This only discounts her legitimacy. You can’t continue to contradict your own evidence. It’s like shooting yourself in the foot, or digging your own grave. What’s worse, Dr Leaf teaches this from real pulpits, not just on social media. How is her audience supposed to feel when they hear what she has to say and find it disagrees with her own scientific philosophy?

I sound like a broken record, but Dr Leaf desperately needs to review her teaching and social media memes. It’s bad enough to be contradicted by scientific evidence, but to be in disagreement with your own teaching is embarrassing, and does nothing to preserve trust with your audience.


[1]        Newberg AB, Wintering NA, Morgan D, Waldman MR. The measurement of regional cerebral blood flow during glossolalia: a preliminary SPECT study. Psychiatry research 2006 Nov 22;148(1):67-71.

Dr Caroline Leaf – Manhandling scriptures again

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I recently heard a great quote, “If you take the text out of context, all you’re left with is a con.” It’s a quote that seems to describe Dr Leaf’s social media pings quite nicely over the last twenty-four hours.

Dr Caroline Leaf is a communication pathologist and a self-titled cognitive neuroscientist. She is also a self-titled theologian.

Today she posted, “3 John 2 = Mental Health ‘Beloved, I wish above all things that thou may prosper and be in health, even as your soul prospers.’ Everything relies on your soul, which is your mind, prospering” (original emphasis).

Except that her statement is blatantly false. The soul isn’t just the mind. A simple search of an on-line Bible dictionary reveals that there are a number of ways in which the word ‘soul’ is used, but more specifically to the meaning in 3 John 2, “the (human) soul in so far as it is constituted that by the right use of the aids offered it by God it can attain its highest end and secure eternal blessedness, the soul regarded as a moral being designed for everlasting life”. (http://goo.gl/AjhvNO)

It should also be noted that the two words used in ancient Greek that referred to our inner reality were pneuma (‘spirit’) and psyche (‘soul’). According to Thayer’s Greek Lexicon, the words pneuma (‘spirit’) and psyche (‘soul’) were often used indiscriminately. The Apostle Paul distinctly used the word pneuma separately to the word psyche in 1 Thessalonians 5:23, but nearly every other New Testament writer wasn’t so precise.

Thus, John wasn’t referring to the mind at all, but probably our spirit, or at the very least, our generic soul, not specifically to our mental faculties or our thoughts. The scripture in 3 John 2 doesn’t have anything to do with our mental health.

Yesterday, Dr Leaf tried to merge one of her favourite authors views with scripture. She posted a quote from Dr Bruce Lipton, “Genes cannot turn themselves on or off. In more scientific terms, genes are not ‘self-emergent’. Something in the environment has to trigger gene activity.” Dr Leaf added, “That ‘something’ is your thoughts! Read Proverbs 23:7”.

So I did.   Proverbs 23:7 in the King James Version says, “For as he thinketh in his heart, so is he: Eat and drink, saith he to thee; but his heart is not with thee.”

So what is it with the second half of the verse? If this scripture is all about our thought life, then what’s the eating and drinking half of the verse got to do with our thought life?

The explanation is that this verse has nothing to do with our thought life at all. Dr Leaf has simply been misquoting it for years, and no one checked to see if she’s right. According to the Pulpit commentary found on the Bible Hub website, “The verb here used is שָׁעַר (shaar), ‘to estimate … to calculate’, and the clause is best rendered, ‘For as one that calculates with himself, so is he’. The meaning is that this niggardly host watches every morsel which his guest eats, and grudges what he appears to offer so liberally … He professes to make you welcome, and with seeming cordiality invites you to partake of the food upon his table. But his heart is not with thee. He is not glad to see you enjoy yourself, and his pressing invitation is empty verbiage with no heart in it.” (http://goo.gl/nvSYUh)

The other half of her meme comes from Dr Bruce Lipton, an agnostic pseudoscientist who was a cell biologist before he flamed out, and now teaches chiropractic in New Zealand. He believes that there is a metaphysical link between our thoughts and our cell function [1]. He’s ignored by real scientists (http://goo.gl/cX7Aeg).

As for his quote, it’s a misdirection. Sure, genes aren’t self-emergent – they don’t think for themselves. DNA is just a long chemical string which just carries a code, the biological equivalent to your DVD discs. Like a DVD, DNA isn’t worth anything if it doesn’t have a machine to read it. In every cell, there are hundreds of proteins that read and translate DNA. Those machines respond to the external environment, but they also respond to the cells internal environment, and to other genes themselves. Simply put, DNA is decoded by intracellular proteins, but intracellular proteins are only made by the expression of DNA, which happens all the time. A single-celled embryo becomes a baby because of DNA self-copying and expression that happens a trillion times over by the end of pregnancy. So while a single gene can’t turn itself on and off, the genome as a whole is essentially self-controlling, only being partly modulated by the external environment. Genes are turned on and off all the time by other genes through the proteins those genes make. Lipton’s assertion that “something in the environment has to trigger gene activity” is simply nonsense.

So Dr Leaf uses a flawed quote from a pseudoscientist to try and back up her specious interpretation of an out-of-context verse of scripture.

Somewhat poor from an “expert” theologian and cognitive neuroscientist really.

These memes speak to the issues of trust and legitimacy. Dr Leaf can call herself whatever she likes, but how can church leaders continue to endorse her to their congregations as an expert when she consistently misinterprets science and scripture? Can they honestly look their parishioners in the eye and say that Dr Leaf’s teaching is accurate? Can they stand at their pulpits and confidently support her book sales at their back of their churches?

Dr Leaf needs to re-evaluate. She needs to re-evaluate her claims to be an expert in cognitive neuroscience and the Bible. She needs to re-evaluate the quality of information that she relies on. She needs to re-evaluate what she’s trying to achieve in posting to social media, and re-evaluate the accuracy of her memes.

Because ultimately it’s the truth that sets people free, not errant opinions and misinterpretations.


[1]        Lipton BH. The biology of belief: Unleashing the power of consciousness, matter and miracles: Hay House, Inc, 2008.

Addit: Dr Leaf’s social media post in between the two memes mentioned above was also a doozy. A repeat offender, as it were, since she has posted it several times before, and I have blogged about it here.

Dr Caroline Leaf – It’s no joke

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So, stop me if you’ve heard this one … This guy walks into a bar, and says, “Owww, that bar is really hard.”

Ok, that was a bad joke. Hey, I’m no Robin Williams. Some people have the knack of being able to make people laugh in almost any situation. I can get a few laughs, but I’m not a naturally gifted comic.

Dr Caroline Leaf is a communication pathologist and a self-titled cognitive neuroscientist. She isn’t a comedian either.

Her post today was a light-hearted dig at giant lizards with a taste for organic free-range humans, or perhaps the fact that most people know being “all organic, gluten free” should be left to the sanctimonious foodies of San Francisco.

The other part of her post wasn’t meant to be funny, but certainly contained a healthy dose of irony. In trying to justify her bit of light comic relief, she posted another of her subtly erroneous factoids, this time claiming that, “Laughing 100-200 times a day is equal to 10 minutes of rowing or jogging!”

Not according to real scientists, who have worked out that laughing is actually the metabolic equivalent to sitting still at rest, while jogging or rowing burns between 6 to 23 times as much energy, depending on how fast you run or row [1].

That would mean that I would have to laugh for at least a whole hour a day (or about 700 times based on the average chortle) to be even close to the energy burnt by a light jog.

On the grand scale of things, this meme probably doesn’t really matter. These sort of factoids are thrown around on social media all the time, and it won’t make a big difference to the health and wellbeing of most people. But it does help establish a pattern. Dr Leaf habitually publishes memes and factoids that clearly deviate from the scientific truth, proving that Dr Leaf has become a cross between a science fiction author and life coach, not a credible scientific expert. From her social media memes to her TV shows, all of her teaching becomes tainted as untrustworthy.

While today’s meme may not be so serious, if Dr Leaf can’t get her facts straight, pretty soon the joke will be on her.


  1. Ainsworth, B.E., et al., 2011 Compendium of Physical Activities: a second update of codes and MET values. Med Sci Sports Exerc, 2011. 43(8): 1575-81 doi: 10.1249/MSS.0b013e31821ece12