Why Psychotherapy?

http://www.apsa.org/

Check out the animated video on the home page of APSA (link above), which I think is a great explanation of why psychotherapy is so important to build quality of life, in ways that medication management is severely limited. With the movement of psychiatry away from psychotherapy, we are limiting ourselves to a limited treatment, and hence we are leaving to non-MDs the treatment of very complicated mental states with means other than medication. I hope, with some technical assistance to be able to embed that video into my post, but for now, this will be a two step process. I think Dr. Norman Kohn did an excellent job illustrating why the narrative is critical to healing. In the second video, the one that I could embed in my post, there is a tutorial on Freud’s model of the mind. The illustration that we have behaviors which we are ashamed of, or not proud of, or that make us feel guilt, helps us to understand that guilt is the point of inquiry into the recesses of our minds. Understanding this guilt, in addition to minimizing the anxiety which arouses around the guilt, is key to promoting mature and sophisticated human beings. Psychopharmacology, although useful, does not take away guilt and it is this guilt, which is often the key to understanding inconsistent, or neurotic, behavior. More than any other reason, promoting this cause, psychiatrists doing psychotherapy along with psychopharmacology, is a major motivation for this blog. For reasons that seem to be unconscious, at the moment, I felt like I  just had to write this today.

Brain Stimulation: Literally Speaking

 

Deep Brain Stimulation (DBS), Transcranial Magnetic Stimulation (TMS), Electroconvulsive Therapy (ECT), and Vagus Nerve Stimulation (VNS) are all FDA approved treatments for neuropsychiatric disorders, heralding the new modality of treatment for psychiatric diagnoses. Darin Dougherty MD from the Division of Neurotherapeutics at a Harvard-affiliated hospital, presented his studies, demonstrating that when subjects were given active treatment, versus sham treatments, there was a high placebo response. To date, he has not been able to show the effectiveness of Deep Brain Stimulation, but he believes, that is because he has not determined where to place the electrode in the brain. Nevertheless, whereas drug companies used to sponsor most of the psychiatric research, now there is a lot of research sponsored by those who make these machines, such as Medtronics. Procedure-based psychiatry is the frontier, with hope of targeting a more specific area of the brain, moving us forward from ECT in which the entire brain has to seize in order to achieve the desired results. If we could localize the emotional brain, we could tickle it, and make folks feel better, or so the hope goes, for our future. In this way, this is an exciting time to be a psychiatrist, with the hope that like our medical colleagues, we hope to be able to offer our patients both pharmaceuticals and medical procedures which “fix” the underlying problem. Do I think this will put psychotherapists out of business? On the one hand, I would welcome the immediate relief that these procedures promise. On the other hand, I cannot imagine a substitute for working through difficult life decisions in a way in which one approaches junctures with thought and deep appreciation for the gravity of the decision. As always, I imagine these procedures could enhance psychotherapy by giving folks who are paralyzed by life’s traumas a way to move forward in psychotherapy so that they can navigate their world in a deeply conscious way. My work dovetails the work of those like Dr. Dougherty and so I welcome his neurotherapeutic  innovations.

Neuroscience Comes Alive!

 

http://www.latimes.com/news/science/la-sci-transparent-brain-20130411,0,313957.story

Space Sharing: Herd Animals-Confirmed!

So, now we have technology which places an office in a pocket. The calendar, the phone, the email and the fax are all being filtered through a hand-held device. Now, I know I am late in the game, but I am coming to understand portability. I could be anywhere in the world and return phone calls, have a phone session, renew prescriptions and stay in touch with the day to day struggles in my local news. So, I think to myself, this brings a new-found freedom of not being tethered to an office. Duh, my readers are saying. Yes, I am slowly coming to understand that, but at the same time, I also understand that young creative types are searching out work spaces which they can share, and yet work independently. The water cooler returns. How do I understand the need for freedom, while there also seems to be a need to gather and work with the energy of other working folks. As with most things that I right about, this is another push/pull experience. There is both a need to break out of the mold and lie on a beach while getting work done, and at the same time, there seems to be a need to be around others, in order to work in parallel. I attribute the latter to the social nature of the human condition. We are the people we surround ourselves with. We compete, we strive, we grow, based on the bar that our friends set for themselves. We are comparative beings. We measure success against others whom we care about. Positive growth stems from surrounding yourself with others who are striving for what you want for yourself. Intuitively, those seeking out a shared work space know that. They will be more creative if they can find the right energy, the right environment, the right people to work alongside. New technology does not change human nature, although it might change some aspects of the human brain. The part of human nature that needs others for growth and development does not change with the smart phone. We are herd animals, after all.

Brain Plasticity

Schizophrenia is a problem with brain mapping, so says Sophia Vinogradov MD, a psychiatrist from UC San Francisco. As such, cognitive enhancing programs might, and she said might at least twenty times during this one hour Grand Rounds, improve the outcome of this dreaded disease. She reminded the audience, filled with psychiatrists, that it was only twenty years ago that we were all taught that the brain stopped changing somewhere around age fifteen. Now, we know that the brain changes throughout one’s lifetime, albeit at different rates of change as we age. Learning, she reminded us takes place with repetition. I think we all know that! More specifically, she taught us that the first time we learn a new skill, we are tentative, but with intensive repetition, that skill, like playing scales on a piano, becomes automatic. I think we all know that too. This automatic quality to a new skill is evidence that we have created a new “brain map”. As such, we can train our brain, if we apply intense repetition, to form new neural connections, and hence new skill sets. Little children, it seems to me, need less repetition to develop new brain maps, and hence their brains are more plastic. Aging, in other words, demands from us that we have to work harder to acquire new ways of thinking, but the good news, is that we can expand our brain, literally. Phew!

 

http://www.psychiatrygrandrounds.com/namedlectures/may.html

Genes and Politics: We Knew That

http://www.latimes.com/news/science/sciencenow/la-sci-sn-politics-genes-republicans-tampa-20120827,0,6578432.story

 

The nature/nurture argument never ends, but as we come upon a presidential election, there is support for the notion that our poltics are genetic. Interesting that the article mentions that children tend to think like their parents until they leave the nest. Of course, as with all nature/nurture arguments, most kids are biological children, so one would assume they share genes which make them think in similar ways. The most interesting part of the article is the following:

“‘Modern questions about immigration are similar to the primal need to recognize and deal with out-groups,’ they wrote. Attitudes about welfare reflect age-old questions about               sharing  resources, while views on foreign policy are the modern-day equivalent of concerns about protecting one’s tribe.”

Once again, aspects of personality, generosity versus frugality, for instance, are largely genetically determined. Does this mean we can’t get mad at our spouse for genetic differences? Hmmm…

White Matter, Matters

http://www.latimes.com/news/science/la-sci-orphan-brains-20120724,0,1723553.story

“What they found was striking: Brains of children who had remained in institutions had less white matter — the type of tissue that connects different regions of the brain — than orphans who were placed in foster care or children living with their own families.

Reductions in white matter have been found in numerous neurological and psychiatric conditions, including autism, schizophrenia and attention deficit hyperactivity disorder, or ADHD.”

Children need families. This is news, seriously. The LA Times reported today of a randomized studies in which orphans were either sent to foster care or institutions. Those sent to institutions had less white matter in their brains, thanks to imaging studies. Now, we finally have proof that nurture, the factor that I struggle with in some of my posts, is critical to the developing brain. Brains need stimulation. To paraphrase Winnicott,  a baby is nothing without a mother.  Now, we can say with more certainty that intimate connections help a baby develop security by helping the brain develop white matter. The more white matter that develops, the less likely the child will suffer from numerous mental disorders including childhood anxiety. The attachment theorists are having a good day. This study supports the notion that a primary attachment is critical for development. This small window of time, infancy, is key to having the brain grow properly. Now, does this mean that if one misses out on a good attachment, and hence has less white matter, that he/she is bound to have psychiatric disorders? Maybe. Is it harder to compensate for this deficiency as one ages? Always. Still, understanding is still critical to our personal enhancement and empowerment. We now know that as a society, we should try to strengthen families, and not provide alternative ways of raising children. We also know that given an inadequate early childhood experience, mental disorders are more likely, and hence there might be a role for medication to attempt to compensate, however slightly, for these deficits. As a Child Psychiatrist, I feel excited to have data to support what children need from the moment they leave the womb until they are able to enter school. Now, we can have a public relations campaign……White Matter, Matters! You heard it here first!

 

Nature or Nurture: Will The Debate Ever End?

   Daniel http://shirahvollmermd.wordpress.com/2012/02/07/the-aggressive-child/ is out of control in that he throws chairs when he gets frustrated with his video games. He punches his mother when she asks him to do homework. Is the problem a parenting issue or a mental health problem or both? Although seemingly complex, the issues become straightforward. All children, especially aggressive children, need to have very clear limits: a “holding environment” as Winnicott has taught us. By clear limits, I mean that Daniel has to be told that hitting is not acceptable. He needs help to use his words when he gets frustrated. He needs to be exposed to video games which are age-appropriate. He needs to have guidance with self-regulation when it comes to eating and sleeping. The parents need to make sure that he eats well and has a regular bedtime. They also need to make sure that the school is attending to his academic and emotional needs. Finally, they need to make sure that Daniel is exposed to playdates so that he has the opportunity to learn social behaviors from his peers. When all of this is in place, and Daniel still has problems with frustration and aggression, then the discussion about diagnosis and medication management needs to begin. It is not that Daniel’s parents are responsible for Daniel’s aggression, it is that Daniel’s parents can provide the basic nurturing environment such that we can see that even with a clear “holding environment” whether Daniel can control his impulses. It is hard to know if Daniel can control his impulses when the environment is chaotic and unpredictable. In this latter circumstance, many kids, with or without a mental illness, become anxious and physical. I think I am stating the obvious, and yet controversy ensues. What am I missing?

Mirror Neurons

Marello Dapretto PhD http://faculty.bri.ucla.edu/institution/personnel?personnel%5fid=46838 spoke today about how mirror neurons are abnormal in those with ASD-autism spectrum disorder. It was one of those lectures where I felt like I already knew this, and so I was not learning anything, but at the same time, she was demonstrating with pretty fMRI pictures that what I/we have suspected for years, is finally being proven with our imaging technology. That is, we now can demonstrate that those individuals with ASD have a defective wiring in their ability to imagine what others are thinking or imagining. In other words, their “theory of mind” is impaired, and the level of their impairment matches the level of defect in their mirror neurons. In other words, this is a continuum of damage, resulting in the “S” or the spectrum concept. Sure, there are workarounds to the mirror neuron system. Children can learn to understand human behavior and they can learn empathy, but they will have to bring in another neurological system since their mirror neurons do not fire properly. For years, in my training from 1986-1991, we told families of those with ASD that there was a “wiring problem” without any specific knowledge about what that wiring problem might be. We felt certain that parents should not blame themselves for the social awkwardness of their children, but at the same time, parents can help fix the problem. Listening to Dr. Dapretto today, confirmed what we told parents, back in the day. Phew!

Taste Buds and Sensitivity Buds: A Hypothesis

This blog is part of my series on the Neurobiology of Behavior.

With Thanksgiving here, I am interested in the work of Linda Bartoshuk PhD, a Presidential Endowed Professor of Community Dentistry and Behavioral Science at the University of Florida. Her research, spanning three decades, has focused on the genetic variations in the perception of taste. Through studies of the disposition and the density of taste buds on the tongues of test subjects, Bartoshuk has divided people into three categories: supertasters, tasters and non-tasters. Supertasters, despite their name, are oversensitive to flavor and so prefer bland foods. Tasters are people who can develop a sophisticated palate, some of whom will become food critics. Non-tasters do not appear to care too much about food.

Bartoshuk’s work makes me wonder if people can be divided into three categories of feeling sensitivity. There is the supersensitive, those who are so vulnerable to feeling that they cope in the world by being emotionally flat. There are the sensitive types, who like food critics, can parse out different kinds of feelings in any given situation. Finally, there are the non-feeling types, who although they have feelings, they only feel feelings which are hammered in. They miss the subtlety.

Adding on, I wonder if  matching sensitivity types could help one predict the longevity of a marriage. The non-feeler would do well with the sensitive type, since they could help each other manage feelings to enhance their lives, but at the same time,  they could manage their feelings so that they do not get overwhelmed. Sensitive types would do well marrying each other also, but they would not do well with the supersensitive type who needs to maintain equanimity by denying his feeling state.

Looking at feeling states, as we look at taste, we could imagine that we come into this world with certain sensitivities and certain insensitivities. Understanding those innate sensitivities and insensitivities could help us make good decisions for ourselves and our loved ones. Many people learn about themselves intuitively, or from their family and friends. However, there are times when a person can no longer help themselves, and their family and friends are at a loss as well. At those times, the individual can reach out to a therapist, gain insight into their wiring and thereby reclaim their lives.