The lost art of joy – Music

Posted on December 20, 2017 by cedwardpitt

With only five days to go before Christmas, most people are rushing into the shops to purchase those last minute items.

The average shopping centre in the pre-Christmas week is an auditory and visual cacophony. Not only are there people EVERYWHERE, there are fairy lights, baubles, and tinsel everywhere! Then there are those Christmas carols, the auditory froth of tinny Christmas melody bubbling incessantly in the background. It’s all enough to make you want to shop on-line.

It’s such a shame the way Christmas carols have been subjugated and exploited for commercial gain. So many of the old Christmas carols are euphonious in their own right, with a lyrical profundity that encapsulates the deeper meaning of Christmas in just a few words.

In fact, music in general is fundamental to us as a language of emotion. The linguist Steven Pinker once said that music was “auditory cheesecake,” a purposeless byproduct of language development. But music is deeper than language. Neuroscience suggests that we’re hardwired to interpret and react emotionally to music from before we’re able to crawl, and well and truly before we develop language. Music activates most of our brain, from our frontal lobe and temporal lobe to process the sounds across both sides of the brain. Music also activates our visual cortex, our motor cortex, our memory centres and, not surprisingly, our deep emotional brain centres. It’s only if the song has lyrics that our language processing areas are activated.

Music has been shown to affect our physical bodies and our minds. Music helped to reduce blood pressure, heart rate and anxiety in heart disease patients, while upbeat music can have a very positive effect on our emotional wellbeing, so long as the music was happy and upbeat. Music that we expect to be happy also results in an increase of dopamine, the neurotransmitter of pleasure.

So the emotional connection that music carries is very important for our overall joy.

Listening to music can increase our joy. While the research supports the improvement in mood that comes from listening to happy, upbeat music, there’s a place for ‘sad’ or ‘angry’ songs too, which can connect directly to our souls and provide a type of catharsis that goes beyond trying to express our emotions through the clunky limitation of speech.

Music can help to scaffold memories, especially emotional memories. Remember the music playing when you had your first kiss? Or the song that they played at a friends funeral? Playing those songs related to happy times in your life can help you to recall and re-experience those uplifting emotions if you’re feeling down.

Music creates opportunities for healing. Hospitalised children were happier during music therapy (in which all the children were involved and could play with simple musical instruments like maracas and bells while a leader played the guitar) than they were in standard play therapy when their options puzzles and toys.

But more than anything, music increases joy through the power of human connection. Music is emotionally deeper than language and the social bond that music can create between people is much stronger than any intellectual or verbal connection. There have been numerous studies that demonstrate this – people who go to concerts and who go dancing report higher levels of subjective wellbeing than those people who listen to music on their own. People who create music together have higher levels of happiness and find other activities more pleasurable overall, an effect which has been demonstrated in groups of both adults and school children.

So if you want to increase your joy, engage with music, and use music to engage with other people … even if it is singing Christmas carols.

The lost art of joy – Learning

Posted on December 19, 2017 by cedwardpitt

Solomon wrote: “Of the making of many books there is no end, and much study is a weariness unto the flesh”.

I loved that verse when I was at school. It was utilised more than once when my teachers wanted to give us more homework – “But, sir, the Bible says that too much homework is bad for you.” Not that my teachers cared, they just gave me more homework anyway.

Much study may be a weariness unto the flesh, but some study is actually very beneficial. Learning helps to promote joy, and joy helps to promote learning.

It’s been shown that learning is much easier when there’s joy involved. Co-founder of the NeuroLeadership Institute, Dr David Rock said,

“Engagement is a state of being willing to do difficult things, to take risks, to think deeply about issues and develop new solutions … Interest, happiness, joy, and desire are approach emotions. This state is one of increased dopamine levels, important for interest and learning.”

and

“There is a large and growing body of research which indicates that people experiencing positive emotions perceive more options when trying to solve problems, solve more non-linear problems that require insight, [and they] collaborate better and generally perform better overall.”

This makes sense. According to the classical psychology principle of the Yerkes-Dodson law, optimal task performance occurs at an intermediate level of arousal, with relatively poorer performance at both lower and higher arousal levels. Too much stress (anxiety) or not enough stress (boredom) results in reduced performance. When someone is happy and engaged, their learning is at its optimum level.

But while it’s true that happiness and engagement create the optimal conditions for learning, it’s also true that learning created a sense of joy.

Learning new things is stimulating. Exposure to new information makes the brain work harder. We are very predictive creatures, and our brain has adapted to be predictive because it’s the most efficient way of processing the vast amount of information that we come across each day. After a while of being exposed to the same stimuli, our brains get a bit lazy. There’s no need to grow new branches and our brains become a bit stagnant. There’s no stimulation, so there’s no dopamine rush. We just get into our rut. But being exposed to new experiences, to new stimuli, is invigorating. Our brain can not longer rely on the same old predictive pathways, and new parts of the brain need to be engaged to process all of the different things we’re being exposed to. The dopamine cloud that comes from all of the novel stimuli is quite euphoric.

Learning something new helps our brain to stay supple. The brain is like a muscle – the only way to keep it flexible and strong is to exercise it. By constantly providing stimulation, our brain can better cope when unexpected events occur, because we’re already used to novel challenges. It helps us stay resilient by improving our psychological flexibility.

Learning something new can also give us a sense of accomplishment which is always good for our self-esteem and self-confidence.

There are many ways to learn new things – read new books, or if you’re not the reading type, find some interesting, factual documentaries. A great way of stimulating your brain is to learn a second language, which also gives you a great excuse to do the other thing that helps to grow your brain and your joy, which is to travel to a different country. Trying to speak a new language in a foreign country will really give your brain a workout, which may seem very daunting at first, but will help you grow immensely. You can also learn a new skill like craft, or a musical instrument. Your learning doesn’t just have to be about yourself – learn to juggle or make balloon animals, and use those skills to entertain people, or put a smile on a child’s face. That way the joy is shared through learning and giving.

Just remember your values when deciding what you would like to learn so that your learning is in step with your authentic self and enriches your life. And make sure you keep your work and life in balance as you carve out time to learn something new, all that study doesn’t become a weariness unto the flesh.

The lost art of joy – Laughter

Posted on December 18, 2017 by cedwardpitt

(and part 2 – https://youtu.be/cZ4R4e_f3-c)
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

I was lectured by Patch Adams once. He took his pants off.

When I was in medical school in the early 1990’s at the University of Queensland, Patch Adams gave a guest lecture. He was originally booked on a speaking tour and sadly, his other engagements cancelled, but he was extremely generous with his time, and visited our humble university anyway, to share his life story and his less-than-conventional views on practicing medicine. This was before the movie based his life was released (it came out in 1998), where he was portrayed by none other than the great Robin Williams.

It took a little while for the audience of young, idealistic, somewhat naive medical students to warm up, and in order to engage us, Patch took off his pants.

Everybody laughed!

It had the desired effect. He had everyone’s attention and it broke down the pretence and barriers. He later put on a pair of clown pants and continued to use humour to communicate his message of laughter, advocacy and social justice.

For the record, I have never taken my pants off to enable better communication with my patients, just so you (and anyone from the medical board who’s reading this) knows. It was the first and only time in my whole seven years of medical school that anyone ever delivered a lecture in their boxer shorts, and it’s not a customary way of engaging with one’s audience. Still, he made us laugh, and it was once of the most memorable lectures I have ever been to.

Laughter connects us. It certainly helped Patch Adams engage with people from all walks of life. Laughter equalises, because it is one of the most ubiquitous and natural of all human emotions.

And laughter is the best medicine, as the saying goes. According to the Mayo Clinic, laughter can lighten your load mentally and induce physical changes in your body. Laughing increases your intake of oxygen-rich air and stimulates your heart, lungs and other muscles. Laughter increases the endorphins that are released by your brain.

A good belly-laugh can also stimulate circulation and aid muscle relaxation which can help reduce physical symptoms of stress. Over the longer term, laughter can improve your immune system. Humour can actually release neuropeptides that help fight stress and potentially more-serious illnesses.

Laughter may even help to relieve pain by stimulating the body’s production of endorphins. Laughter can also make it easier to cope with difficult situations – like the saying goes, you either laugh or you cry. Laughter is also thought to lessen depression and anxiety.

Laughter is even thought to improve your cognitive function. As cognitive neuroscientist, Dr Scott Weems says, “Comedy is like mental exercise, and just as physical exercise strengthens the body, comedy pumps up the mind.”

It sort of goes without saying that laughter increases our joy levels. But it’s worth mentioning, because sometimes in the serious business of adulting, we can start taking things too seriously, and sometimes we just need a good laugh.

As always, it comes down to balance. There are times when we need to be serious, but we can’t be serious all the time. There are times when we just need to (metaphorically) take our pants off.

The lost art of joy – Move!

Posted on December 17, 2017 by cedwardpitt

What’s your vision of bliss? Massage? Sitting by the beach with a pina colada? Enjoying a sumptuous dinner with friends?

Most relaxation fantasies don’t involve sweat.

So it’s almost a bit counter-intuitive that exercise is one of the most frequently associated habits of happy people. Although maybe it’s not so counter-intuitive, as there is strong anecdotal evidence of the “runner’s high” – the feeling of euphoria that some people feel after a session of vigorous exercise, the “endorphin buzz” that ironically doesn’t have anything to do with endorphins!

Endorphin buzz or no, exercise is certainly one way of enhancing the joy in your life. I previously wrote about the work of George MacKerron from the University of Sussex, who used an app he created to map the correlation of happiness to activity and location. Using the hundreds of thousands of data points from the tens of thousands of users, he found that the times that people recorded the highest levels of happiness and life satisfaction were during sexually intimate moments (on a date, kissing, or having sex). Number two was during exercise.

Physical fitness is good for us. I’ve never seen a study that shows exercise to be a bad thing. Ultimately, it’s not how fat you are that’s important for your longevity, it’s how fit you are, and the way to get fit is to exercise. Physical exercise isn’t just good for the body but good for the brain as well. While the exact pathways are still being determined, there’s good evidence that moderate regular physical activity improves the balance of pro- and anti-inflammatory mediators in the body and in the brain. In the brain, this improves the overall function of our brain cells. Exercise is also thought to increase the production of a growth factor called BDNF which helps the brain cells grow new branches and improves their ability to form new pathways, which in turn, has been shown to improve mood disorders like anxiety and depression.

Exercise is great, but not everyone is ready to suddenly get up and run a half-marathon, me included. These days, I’m like a walrus on tranquillisers. I’m certainly not about to jump up and go for a jog. Some people have physical injuries or conditions that limit their capacity for physical exercise.

So how do you find the balance between maximising the joy-enhancing effects of exercise while not pushing yourself so far and causing yourself some unhappiness?

Simply, move more.

Where are you at with you’re level of exercise right now? If you could turn it into a scale from 1 to 10 (where 1 is completely sedentary, and 10 is your ideal version of regular exercise), what would you rate? The next question is, what’s one thing you could do to go one point closer to 10? So let’s just say that you walk 200m from your house to the bus stop in the morning, and the same on the way home at night. For you, that might be a 3/10. What else could you do to make that 3 turn into a 4?

You don’t have to go for vigorous two-hour walks or run up every set of stairs you come across to be happy. Just move, and move that little bit more. That will help build joy in your life.

The lost art of joy – Friendship

Posted on December 10, 2017 by cedwardpitt

Last night, my family and I had dinner with an old friend.

I should clarify … by ‘old’, I don’t mean ‘geriatric’. I mean that I have known this friend for a long time. She is the person I have been friends with the longest, having first met her in early medical school nearly a quarter of a century ago. It’s a friendship that survives despite geographical, logistical and theological differences, because it’s built on the deepest mutual respect and care. I don’t have many friends, but this friend is definitely a keeper.

Friendships mean different things to different people. Some friends are gregarious, a source of instant joy, that person that always makes you laugh even when life makes you want to cry. Then there are those friends who enkindle that deeper sense of joy, because they are steadfast through the tough times.

In the 21st century, our concept of friendship has undergone some pretty radical changes. Before 2004, ‘social networks’ were the people you physically hung out with. Now when you talk about ‘social networks’, people assume you’re referring to Facebook.

Is physical social networking better than virtual? Everyone has their own opinion. We know that humans are wired for social interaction, with specific areas of the brain devoted to social behaviour, such as the orbitofrontal cortex. There are also neurotransmitters and hormones that are strongly associated with bonding and maintenance of social relationships, like oxytocin and β-endorphins. Research has shown that both humans and other primates find social stimuli intrinsically rewarding—babies look longer at faces than at non-face stimuli.

We also know that people who engage in social relationships are more likely to live longer, and that loneliness predicts depressive symptoms, impaired sleep and daytime dysfunction, reductions in physical activity, and impaired mental health and cognition. At the biological level, loneliness is associated with altered blood pressure, increased stress hormone secretion, a shift in the balance of cytokines towards inflammation and altered immunity. Loneliness may predict a shortened life-span.

It’s important to understand what loneliness is, and conversely, what defines good social relationships? Fundamentally, good or bad social relationships are related to the quality of the social interaction. This rule applies equally to real social networks and their on-line equivalents. So quality is fundamentally more important than quantity in terms of friendships, with that quality strongly determined by the connection within those social relationships. For example, loneliness “can be thought of as perceived isolation and is more accurately defined as the distressing feeling that accompanies discrepancies between one’s desired and actual social relationships”.

The corollary is that friendship can be thought of as perceived connection within social relationships, or the comforting feeling that accompanies the match between one’s desired and actual social relationships.

So healthy social relationships aren’t defined by the size of your network, but by the strength of the connections that your network contains, relative to what’s important to you. Just because you’re not a vivacious extrovert who is friends with everyone doesn’t mean that your social network is lacking. It also means that you can have meaningful connections to friends through social media, just as much as you can have meaningful connections through face-to-face interactions. It’s not the way you interact, but the quality of the connection that counts.

One way to increase the quality of your social connections is to enjoy your friendships mindfully. Mindfulness is being fully engaged in the present moment. So mindful friendships is to be fully engaged with the other people around you, to use all your senses to connect with those around you. To ignore the other social networks around you on your phone or tablet, keeping them out of sight and out of mind until afterwards.

Try it. At the next Christmas party, or when you’re with your loved ones on Christmas Day, turn off the phone and engage with the people around you as mindfully as you can, and see if you experience a new and improved form of Christmas joy.

ASD and GP

Posted on September 9, 2017 by cedwardpitt

“You see, but you do not observe. The distinction is clear.” ~ Sherlock Holmes (A Scandal in Bohemia)

Autism. It’s a condition that we see weekly as general practitioners. The question is, do we observe it? And if we do, what do we see it as, a series of deficits, or as a set of different strengths that can be celebrated?

For the last few days, I’ve enjoyed being a delegate at the Asia-Pacific Autism Conference in Sydney, a series of some cognitively stimulating discussions covering the full spectrum of being on the spectrum.

There’s always so much that can be gleaned from conferences like these, but for me, the take-home messages as a GP came at the book-ends of the first session and the last.

One of the first keynote presentations came from researchers at the Olga Tennison Autism Research Centre (http://www.latrobe.edu.au/otarc). Prof Cherl Dissanayake and Dr Josephine Barbaro presented their research on a tool they developed called SACS-R, an early detection tool to screen for infants at higher risk for developmental disorders.

Early detection of children on the autism spectrum is very important, something recognised by the AMA in their position statement late last year (https://ama.com.au/position-statement/autism-spectrum-disorder-2016). Despite being important, early detection can also be tricky, and many children on the autism spectrum who are relatively high functioning are often missed in general practice.

Barbaro and Dissanayake have previously tested this tool, training community child health nurses to use it as part of the standard infant health checks. The results of their work showed that the tool was robust (Estimated sensitivity ranged from 69% to 83.8%, and estimated specificity ranged from 99.8% to 99.9% for babies between 12 and 24 months – Barbaro and Dissanayake, 2010).

Barbaro and Dissanayake have continued to develop the tool, but more importantly, they have refined the tool to utilise only the factors that had the highest sensitivity, and then turned the tool into a free app, untethering the initial assessment process from the domain of professionals and potentially putting it in the hands of every parent anywhere in the world via a smart phone. The results of their study are still being finalised, but they claim that the SACS-R tool on the app has a positive predictive value of 82%, a negative predictive value of 97%, a specificity of 99.58% and a sensitivity of 72%.

The power shift that an app like this brings is important for us as GP’s. In time, parents will be doing their own assessments at home and coming in to their GP with a recommendation to have a further assessment, and we need to be prepared for this and take the recommendation seriously. But there’s also a prime opportunity here, to use the app to enhance early screening for developmental disorders in general practice, by sending a link to the parents booking in for their baby’s 12 and 18-month immunisations and discussing the results of the assessment with them when they come in. This could also be in addition to the professional version of the program that Barbaro and Dissanayake are in the process of developing.

Given the preliminary results of their longitudinal study (not yet published but in its final stages) showing a prevalence of up to 1 in 43 children, it’s likely that we will be picking up several new cases a year.

If you want to review the app yourself or consider recommending it to your patients, it’s called ASDetect and it’s available from the App Store or Google Play.

At the other end of the conference, Dr Barry Prizant presented a keynote address on “Uniquely Human: a different way of seeing autism”, based on his book of the same name and his decades of work with people on the autism spectrum.

His theme was that most people see autism as a negative. In times gone by, children on the autism spectrum were seen as profoundly deficient, to the point that they weren’t considered a person. Even today, some pundits have said that “autism is a lost, hellish world” while others have likened having autism to being a victim of the holocaust.

On the other hand, self-advocacy is growing amongst those with autism, who are working to try and change the social view that autism is a series of weaknesses to overcome, but differences to be celebrated. Not only that, but more people on the spectrum are designing research projects to understand the condition better and to translate those advances into tangible benefits, taking self-advocacy to a whole new level.

Prizant not only promoted autism self-advocacy, but also discussed the concept of neuroharmony – that there is no such thing as autistic behaviour, but only human behaviour; that so many people with autism have succeeded in their chosen fields and have made lasting contributions to the benefit of our society. He championed the notion that rather than expecting autistic people to be ‘normal’, ‘normal’ society should be embracing the differences that those on the spectrum have. As one father of a child on the spectrum told him, “You don’t grow out of autism, you grow into autism.” As John Elder Robison wrote, “Asperger’s is not a disease. It’s a way of being. There is no cure, nor is there a need for one. There is, however, a need for knowledge.”

As GP’s, when we see those children on the spectrum picked up by the enhanced early screening tools, we need to ensure we give their parents the balanced view. It’s easy to look at the negatives and the weaknesses inherent in a diagnosis of ASD. I’m not suggesting that we sugar-coat things and tell only the positive side of the story, but we need to balance out any concerns the parents have with a generous serving of hope. As one father put it, “The people who have been the most helpful to us have are those who do not take away our hope. We have learned to keep away from the ‘doom and gloom’ crowd”, while one mother wrote, “Some call it autism, others call it despair and sorrow. I happen to call it hope, beauty and fascination.”

For ASD and the average GP, change is coming – good change that will empower parents to get an earlier diagnosis, and for those with ASD to get the early intervention that will benefit their weaknesses, complement their strengths and accept who they are as people. As GP’s, we need to be flexible and accepting, observing the strengths that autism can bring to our patients, not just seeing the weaknesses.

References

Barbaro J. and Dissanayake C., “Prospective identification of autism spectrum disorders in infancy and toddlerhood using developmental surveillance: the social attention and communication study.” J Dev Behav Pediatr. 2010 Jun;31(5):376-85

Post-script, 21 September 2017

I received an e-mail from Erin from La Trobe today:

“My name is Erin and I am a Research Assistant at La Trobe University. Currently, I am working with Dr. Josephine Barbaro on the ASDetect project.
We would also like you and your readers to know that we’re currently seeking parents/caregivers of young children aged 11-30 months for our research study looking at how ASDetect identifies early signs of Autism (Australia only). You can register at asdetect.org/app or SMS 0409 758 602. You must register via this website to be eligible for study, so just downloading the app won’t enrol you.”

If you can, please get involved. This is important research that has the potential to have profound benefits for some of our most vulnerable patients ~ CEP

Dr Caroline Leaf – stop spreading ADHD stigma and ignorance

Posted on August 30, 2017 by cedwardpitt

“Nothing in all the world is more dangerous than sincere ignorance and conscientious stupidity.” ~ Martin Luther King Jnr.

Sincere ignorance … conscientious stupidity – I’m struggling to know which category to put Dr Leaf’s latest e-mail newsletter into.

Dr Caroline Leaf is a communication pathologist and self-titled cognitive neuroscientist and self-titled mental health expert. She is not a doctor. She is not a psychologist. She does not work for a university. She hasn’t published any peer reviewed medical papers for two decades. She is not accountable to any peak professional body.

Yet the Christian church gives her unfettered access to their pulpits despite the ignorance and stigma she enthusiastically promotes.

Take the “Mental Health News” e-mail that she posted today for example. Dr Leaf seamlessly moves from one misrepresentation to another, weaving a narrative that unfairly undermines scientifically proven treatments for mental illness, eroding confidence and destroying hope.

She starts with the story of Michelle and Carter, although it wasn’t Michelle and Carter as her e-mail newsletter stated. It was Michelle Carter and Conrad Roy, something which Dr Leaf got right in her blog post dated 1 August 2017 (see the image at the bottom of the page), but then got wrong in her e-mail newsletter on 30 August 2017. Dr Leaf says that Michelle texted Conrad to kill himself, and he did. Michelle and Conrad were on “brain-disabling” (psychiatric) drugs. Therefore, psychiatric drugs killed Michelle and Conrad. In my opinion, that Dr Leaf would stoop so low as to use the suicide of a teenager to try and push her own ideological barrow says much about her character, but then I shouldn’t be surprised as she did the same thing when Carrie Fisher died earlier this year. It’s sick, and it’s low, and it’s something that Dr Leaf should apologise for.

It’s also incredibly disingenuous, drawing a conclusion from incomplete evidence. Dr Leaf has no experience with the case. Instead, the source of this information is Dr Peter Breggin, himself an outspoken and discredited critic of psychiatric medication with a penchant for cherry picking and bias. Dr Leaf has used the story of Michelle and Conrad based on the tainted recall of half a story. She has no idea what really contributed to Michelle and Conrad’s tragedy. Her statement, “Yet, as is often the case, there is a large and dreadful disparity between what actually happened and what we are told happened” is therefore sadly ironic.

Dr Leaf then moves on to ADHD and drugs. Dr Leaf treats the concepts of ADHD and its treatment with the same respect as she gave Michelle and Conrad. She makes statement after misleading statement which do nothing but demonstrate her myopic bias.

Let’s just take one sentence: “These drugs create, rather than cure, chemical imbalances in the brain, are difficult to come off and can have terrible side-effects that last for years, including suicide and homicide.”

ADHD is often misunderstood and almost always stigmatised. ADHD is more than just being an active child who likes to play. ADHD is a dysfunctional lack of control that’s abnormal compared to other children the same stage of development, is long standing and affects their entire lives.

ADHD is caused by an abnormal pattern of genes, the expression of which are triggered by environmental conditions in pregnancy and early childhood, resulting in slower maturation of the brain and an uncoordinated network of “connectomes”, which disrupts the attention and planning processes of the brain.

We know that children with ADHD have slower maturation of the grey matter [1] and structural changes in the frontal regions and deeper parts of the brain [2]. In more recent times, modern brain imaging techniques have been able to show differences in the way that the regions of the brain link together to form networks.

Think of the brain networks as a tug-o-war team. When all the members of a tug-o-war team work in unison, they increase their collective strength, but if the different team members don’t co-ordinate their efforts properly, the strength is lost. The same goes for the brain. Modern neuroscientists have discovered that the function of the brain relies on physical networks within the brain, called “connectomes” and how these connectomes co-ordinate with each other.

In the ADHD brain, the connections between the different connectomes are immature [3]. These immature connections weaken the collective strength of the network, because they aren’t synchronously “pulling” together.

What’s better understood is that the neurotransmitter called dopamine is crucial to the ADHD disease process [4]. Medications such as Ritalin which enhance the dopamine signals in the brain significantly reduce the symptoms of ADHD [5].

So Ritalin and other drugs like it actually balance the neurotransmitters in the brain. Dr Leaf’s argument that they “create … chemical imbalances in the brain” is as misleading as trying to argue that diabetic treatments are creating an “insulin imbalance”.

“These drugs … are difficult to come off” is also misleading. Once the brain eventually matures as it does in most children with ADHD, the drug is simply weaned. Dr Leaf doesn’t seem to understand that some children with ADHD will grow into adults with ADHD who will still need medication. This isn’t because the drugs are hard to come off, they are simply treating an ongoing condition.

“These drugs … can have terrible side-effects that last for years, including suicide and homicide.” Actually, the effects of Ritalin last less than a day because the drug is rapidly metabolised, and ‘homicide’ is not listed anywhere in the official product information. Suicide has been reported in patients taking the Ritalin although the official product information notes that, “Adverse events reported since market introduction in patients taking methylphenidate include suicide, suicide attempt and suicidal ideation. No causal relationship between methylphenidate and these events has been established.” Even so, medications like Ritalin are not meant to be given to people who have severe depression, anorexia, psychotic symptoms or suicidal tendency, just in case Ritalin might worsen these conditions.

Indeed, a Cochrane Review as recently as November 2015 said, “The evidence in this review of RCTs suggests that methylphenidate does not increase the risk of serious (life threatening) harms when used for periods of up to six months. However, taking methylphenidate is associated with an increased risk of non-serious harms such as sleeping problems and decreased appetite.” [6]

So “these drugs” don’t have side effects for years, don’t make people homicidal, don’t make people addicted and don’t unbalance their brain chemicals. It’s amazing how much profound mistruth Dr Leaf was able to pack into one littlesentence.

Then Dr Leaf goes on to attack the concept of ADHD itself – “Unfortunately, there is little scientific evidence for these labels … the very idea of ADHD, which includes vague operational definitions such as ‘often fidgets with hands or feet or squirms in seat,’ is subjective and defined by what society currently deems as ‘normal’ or ‘abnormal’”.

Denying the existence of ADHD is an old trick used by medication critics and the ignoranti for decades, but it’s like denying the existence of rain so you don’t have to buy an umbrella. Dr Leaf’s assertion that the diagnosis of ADHD includes ‘vague operational definitions’ is just a strawman, because ADHD diagnosis is rigorous and relies on more than just a single characteristic like fidgeting. I have listed the diagnostic criteria for ADHD at the end of this post, or you can look it up here: http://www.cdc.gov/ncbddd/adhd/diagnosis.html

In all of Dr Leaf’s railing against medications for ADHD, she fails to cite the evidence that shows that medications for ADHD improves the lives of those with ADHD [6], more than restrictive diets or cognitive retraining or neurofeedback [7].

Dr Leaf may like to think of herself as an expert, but her claims on ADHD and it’s treatment do not hold up under scrutiny. She may think she’s acting benevolently but the promotion of her Dunning-Kruger style ignorance erodes the enormous hope that medications like Ritalin give to people who, without it, are held back by the mental and physical chaos that ADHD causes.

Dr Leaf, please, stop spreading the ADHD stigma and ignorance. We already have to put up with enough suffering from the disease itself and the social stigma without you adding to it.

References

[1]       Shaw P, Lerch J, Greenstein D, et al. Longitudinal mapping of cortical thickness and clinical outcome in children and adolescents with attention-deficit/hyperactivity disorder. Archives of general psychiatry 2006 May;63(5):540-9.
[2]       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.
[3]       Cao M, Shu N, Cao Q, Wang Y, He Y. Imaging functional and structural brain connectomics in attention-deficit/hyperactivity disorder. Mol Neurobiol 2014 Dec;50(3):1111-23.
[4]       Wu J, Xiao H, Sun H, Zou L, Zhu LQ. Role of dopamine receptors in ADHD: a systematic meta-analysis. Mol Neurobiol 2012 Jun;45(3):605-20.
[5]       Reichow B, Volkmar FR, Bloch MH. Systematic review and meta-analysis of pharmacological treatment of the symptoms of attention-deficit/hyperactivity disorder in children with pervasive developmental disorders. Journal of autism and developmental disorders 2013 Oct;43(10):2435-41.
[6]       Storebo OJ, Ramstad E, Krogh HB, et al. Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD). The Cochrane database of systematic reviews 2015 Nov 25;11:CD009885.
[7]       Sonuga-Barke EJ, Brandeis D, Cortese S, et al. Nonpharmacological interventions for ADHD: systematic review and meta-analyses of randomized controlled trials of dietary and psychological treatments. The American journal of psychiatry 2013 Mar 1;170(3):275-89.

ADHD Diagnostic Criteria

The current criteria that must be matched to qualify for a diagnosis of ADHD is:

(1) Inattention: Six or more symptoms of inattention for children up to age 16, or five or more for adolescents 17 and older and adults; symptoms of inattention have been present for at least 6 months, and they are inappropriate for developmental level:
* Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities.
* Often has trouble holding attention on tasks or play activities.
* Often does not seem to listen when spoken to directly.
* Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., loses focus, side-tracked).
* Often has trouble organizing tasks and activities.
* Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework).
* Often loses things necessary for tasks and activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).
* Is often easily distracted
* Is often forgetful in daily activities.

(2) Hyperactivity and Impulsivity: Six or more symptoms of hyperactivity-impulsivity for children up to age 16, or five or more for adolescents 17 and older and adults; symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for the person’s developmental level:
* Often fidgets with or taps hands or feet, or squirms in seat.
* Often leaves seat in situations when remaining seated is expected.
* Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless).
* Often unable to play or take part in leisure activities quietly.
* Is often “on the go” acting as if “driven by a motor”.
* Often talks excessively.
* Often blurts out an answer before a question has been completed.
* Often has trouble waiting his/her turn.
* Often interrupts or intrudes on others (e.g., butts into conversations or games)

In addition, the following conditions must be met:
– Several inattentive or hyperactive-impulsive symptoms were present before age 12 years.
– Several symptoms are present in two or more setting, (e.g., at home, school or work; with friends or relatives; in other activities).
– There is clear evidence that the symptoms interfere with, or reduce the quality of, social, school, or work functioning.
– The symptoms do not happen only during the course of schizophrenia or another psychotic disorder.
– The symptoms are not better explained by another mental disorder (e.g. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).
(http://www.cdc.gov/ncbddd/adhd/diagnosis.html)

But I’m normally a rational person …

Posted on July 24, 2017 by cedwardpitt

She shifted uncomfortably in her seat, her uneasy hands fidgeting together, her eyes flitting around as she tried to focus on the wall across from her, unable to find a target for her empty gaze.

“But … I’m normally a rational person,” she said, finally putting words to the thought that had been evading her for half a minute.

She was a woman in her mid thirties, with a comfortable job, a family and a mortgage in the suburbs. We were halfway through a standard GP consult, and we had already discussed and resolved something trivial before she finally plucked up the courage to change tack and reveal the hidden agenda she’d hoped to discuss all along.

“I’m anxious all the time. I try so hard, but I can’t seem to stop thinking about all the things that could go wrong.”

I empathised. I’ve been there too – I’ve lived through times when my anxiety disorder was so debilitating that I wouldn’t call someone on the phone for fear of dialling the wrong number. Or when I was so depressed that I couldn’t see anything positive for the future, when nearly every thought I had was saturated with moribund darkness.

I was anxious as a teenager, but I was depressed as an adult. I’d been through medical school and I had attained by GP fellowship when my depression took hold. During the four years or so that I spent with the black dog, I was constantly haunted by the same narrative that now haunted my patient … “I’m a rational person, why am I thinking like this?”

The fact I had fellowship level medical training intensified my mental self-flagellation, “I know all about depression. I understand CBT. I know I’m ruminating on catastrophic thoughts. So why can’t I stop them? If only I could think more positively, I’d be so much better.”

I found myself in a self-defeating spiral, often called the struggle switch, where I thought I knew how to climb out of my psychological mire, but all I achieved in trying to climb out was to sink further in, making me feel more defeated, even more of a failure. It was a very difficult time which I thought would never end.

Eventually it lifted, like a heavy fog thinning in the morning sunlight, but it certainly wasn’t the result of anything clever I did. So why did my rational brain keep filling my mind with irrational thoughts?

The answer lay in a paradigm shift away from the long held beliefs that we were taught at medical school and in our general practice training. We’ve been lead to believe for so many years that our thoughts were the key driver of our behaviour, but it turns out that it’s actually the other way around, our behaviour is but one of a number of key driver of our thoughts.

The foundation of CBT is the notion that challenging maladaptive thoughts helps to empower behavioural change. Except that research suggests that cognitive therapy specifically targeting problem thoughts offers no extra improvement over behavioural therapy alone.

Herbert and Forman confirm this when they point out that, “proponents of behavioral activation point to the results of component control studies of CT, in which behavioral activation or exposure alone is compared to behavioral activation (or exposure) plus cognitive restructuring. The majority of these studies have failed to demonstrate incremental effects of cognitive restructuring strategies.” [1]

This fact has been further confirmed by a number of meta-analyses [2] and by a large randomised controlled trial comparing behavioural therapy and cognitive therapy side by side with medication for depression [3].

So therapies aimed at fixing thinking works equally as well as therapies aimed only at promoting therapeutic action. However, when thinking therapies are added to behaviour therapies, they add no extra benefit over and above the behaviour therapies alone [2]. This suggests that action is the driver of the therapeutic effects of psychological therapy. If thinking were the driving force of psychological change, the addition of cognitive therapy to behaviour therapy should have an incremental effect.

That cognitive therapy works equally well as behavioural therapy may be related to their fundamental similarities. Dobson et al explains, “Behavioural Activation is implemented in a manner that is intended to both teach coping skills and to reduce future risk. The same is true for Cognitive Therapy, which adds an emphasis on cognitive change, but otherwise takes a similar skills-training approach.” [3] In other words, cognitive behavioural therapy is just behavioural therapy with bling.

Herbert and Forman summarise it nicely, “The ideas that thoughts and beliefs lead directly to feelings and behavior, and that to change one’s maladaptive behavior and subjective sense of well-being one must first change one’s cognitions, are central themes of Western folk psychology. We encourage friends to ‘look on the bright side’ of difficult situations in order to improve their distress. We seek to cultivate ‘positive attitudes’ in our children in the belief that this will lead to better academic or athletic performance. Traditional cognitively-oriented models of CBT (e.g., CT, stress inoculation training, and rational emotive behavior therapy) build on these culturally sanctioned ideas by describing causal effects of cognitions on affect and behavior, and by interventions targeting distorted, dysfunctional, or otherwise maladaptive cognitions.” [1]

I understand this is going to ruffle some feathers, and not everyone is going to be keen to dispense with CBT just yet, but I hope this gets us thinking about thinking at the very least.

For me, coming to an understanding that my thoughts were just the dashboard and not the engine helped me to pay less attention to them and to focus my healing energies on what was really important, taking values based action rather than just fighting with my stream of thoughts.

And it’s helped me to empathise differently with my patients and reassure them that you can still be a rational person even if your thoughts don’t always seem to follow suit.

References
[1]       Herbert JD, Forman EM. The Evolution of Cognitive Behavior Therapy: The Rise of Psychological Acceptance and Mindfulness. Acceptance and Mindfulness in Cognitive Behavior Therapy: John Wiley & Sons, Inc., 2011;1-25.
[2]       Longmore RJ, Worrell M. Do we need to challenge thoughts in cognitive behavior therapy? Clinical psychology review 2007 Mar;27(2):173-87.
[3]       Dobson KS, Hollon SD, Dimidjian S, et al. Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the prevention of relapse and recurrence in major depression. Journal of consulting and clinical psychology 2008 Jun;76(3):468-77.

KINTSUKUROI CHRISTIANS – Available at Koorong, Amazon, iBooks and other good book retailers

Where are all the shepherds?

Posted on July 21, 2017 by cedwardpitt

In “The Myth of Icarus”, Icarus, full of the folly that comes with pride, flew too high and the sun melted his wings.

Dr Caroline Leaf is the modern day Christian version of Icarus, foolishly flying higher and higher, deluded by her self-importance and unaware of the weakness and fissuring of her presumed competence.

But unlike the myth of Icarus where only Icarus himself paid the ultimate price, Dr Leaf isn’t the only person flying too close to the sun, but she is encouraging the church to follow her lead.

Dr Caroline Leaf is a communication pathologist and self-titled cognitive neuroscientist. Unfortunately, despite no training or experience whatsoever in psychiatry, psychology or even basic counselling, Dr Leaf has assumed the role of a mental health expert for the church.

Having the untrained Dr Leaf lecture Christian congregations on mental illness is an absolutely absurd proposition – it’s like having a plumber give a public lecture about coronary bypass surgery. Yet the uncredentialed Dr Leaf continues to speak at church after church after church about mental health and illness, given a free license as if she were a psychiatrist with decades of experience.

And my question is “Why”?

Why do pastors and church leaders give Dr Leaf a free pass to speak from their platforms on a subject that she is objectively unqualified to speak on? Where is the public process of due diligence? Where is public demonstration of accountability that undergirds the reverence, the sacred gravitas, of the church pulpit? Why do our church leaders stay silent when unqualified preachers poison their congregations with saccharine subterfuge?

Where are all the shepherds? Why aren’t they shepherding?

Dr Leaf’s latest e-mail newsletter aptly demonstrates what the church needs protecting from – an entire e-mail encouraging people to withdraw from psychiatric medications. Her bias is clear – psychiatric medications are harmful and you can withdraw from them if you want to. If you do, you’ll feel better.

This might as well be unsolicited, unlicensed medical advice. There’s no discussion about the nuances of psychotropic medication, or the proven benefits. She then encourages people to look for more information by reading books or visiting websites that are known to be unhinged or, at best, clearly biased against medications for mental ill-health.

In the past, Dr Leaf has clearly shown her ignorance when it comes to psychiatric medications. She has accused them of everything from being poisonous to being unspiritual. Never once has she acknowledged the scores of research papers that confirm the judicious use of psychiatric medications saves lives and extends the lifespan of those who take them.

Now, she has advised people that they can stop their medications and promotes unscrupulous and biased sources of information to help. This isn’t just ignorant, this is dangerous. [1]

Will it take the untimely death of one of their congregation before our church leaders say ‘enough is enough’? It will be all too late then.

It’s time for our church leaders to stand up for the congregations they lead and denounce the teaching of Dr Caroline Leaf. Her ignorance and her arrogance are becoming a dangerous mix. Our pastors can’t wait until blood is on their hands before they’re forced into action – they need to act now, before it’s too late.

~ ~
If you are concerned about the medications you’re taking or you think you don’t need them any more, for heaven’s sake don’t just stop taking them or try and wean yourself. Go see your doctor for advice specific to your medication and your situation.

Don’t believe me? https://psychcentral.com/lib/discontinuing-psychiatric-medications-what-you-need-to-know

DISCLAIMER: Just in case anyone was wondering about my motives, 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.

References and bibliography

[1] Valuck RJ, Orton HD, Libby AM. Antidepressant discontinuation and risk of suicide attempt: a retrospective, nested case-control study. J Clin Psychiatry 2009 Aug;70(8):1069-77.

For good number twos, lift your shoes, say some moos

Posted on July 10, 2017 by cedwardpitt

What I’m about to tell you will change your life, forever.

In my job, I help people overcome some of life’s greatest challenges. When I was a medical student, fuelled by my strong sense of idealism and too many episodes of ER, I thought those challenges would be thumping on someone’s chest to save them from the clutches of death, or removing a gangrenous appendix with just a butter knife and some twine, or delivering a baby whilst upside down in some plane wreckage. You know, something heroic.

But from my first day as an intern, I learnt something … nothing is as life changing as a good poo.

You might be thinking something smells a little funny here … “one moment you’re talking about delivering babies and the next minute you’re talking about delivering Mr Hankey. How is that suddenly heroic?”

Sure, talking to people about their time on the porcelain throne isn’t particularly glamorous but the daily download, exorcising a demon, pressing towards the bowl … it’s vital. Not enjoying a regular Trump dump leads to stagnation in the literal and economic sense – chronic constipation costs the US over $18 billion dollars in additional health care costs, not to mention lost productivity.

So how does one regularly clean the pipes to ensure the health of our bowels and our budgets? Well, we’ve all heard that “fibre is your friend”, and that remains true, though most people don’t realise that fibre works better when you drink lots of water with it. So more veggies, and more water.

Though the main push of this particular post is a look at the production side of the Captain’s log. This was inspired by a blog I came across as I click-grazed across the internet the other night – http://www.evidentlycochrane.net/feet-up-constipation/

So apparently if you want your bowels to move efficiently, assume the crash position … “Lean forwards and rest elbows on knees, almost like the crash position on an aeroplane. The anal sphincter should relax …” Yep, the anal sphincter would definitely relax if one were really sitting in the crash position on an aeroplane, though I dare say it’s not the position that’s the key variable!

But, ok, the author of the blog does have a point – sitting with our hips flexed naturally reduces the otherwise convoluted path of our sigmoid colon to an efficiently straight rectal super-highway. One way to do that is to squat, but if you’re old, inflexible, or like me, no longer have a great sense of balance (or you’re trying to defecate whilst drunk) then squatting is probably not a good idea – you and your poo are likely to end up on the floor.

The alternative is the ‘crash position’, leaning forward slightly with your elbows on your thighs and putting your feet up on a small stool (the ‘stool stool’ and she called it!).

The other thing to do, although perhaps not in a public toilet or at a dinner party, is to moo. As the author said: “Leaning on the elbows and making a “moo” (or other) sound reduces the urge to strain” … Well, it works for cows I guess.

So, the bottom line: you need to lift your shoe and moo on the loo to poo.

See … life changing!

Dr C. Edward Pitt

Faith, Hope, Love, Science.

Category Archives: Biological