Sunday, September 17, 2017

Book review: "The Noonday Demon" by Andrew Solomon

As an undergraduate, I had dreamed of being a writer so accomplished that students there would study my work. But when I hatched that fantasy, I didn't envision the work as a memoir assigned in an Abnormal Psych course. (From the Epilogue, p. 445)

Andrew Solomon, resembling a cross between Tobey Maguire and Sheldon from bad sitcom The Big Bang Theory, is a tremendous public speaker and storyteller. He is somewhat of a regular on the Ted talk circuit. You can hearing him holding forth on adversity and identity, as well as parenthood. One of his most interesting talks concerns depression. This talk is a primer for his much more in-depth treatment of this topic in "The Noonday Demon", a modern classic on the subject.

Solomon discusses his own experience of depression in depth, giving a sometimes poetic description of the phenomenology of his depression, and describing clearly how his level of activity was drastically reduced. He gives a warts-and-all account, describing not only his suicidal ideation but also how distorted thoughts led to self-destructive behaviour that must have seemed illogical to Solomon himself with hindsight. A memorable aspect of these accounts is his fear of relapse, and how he seemed to predict one relapse following a physically painful accident (whether it was a self-fulfilling prophecy, we cannot say).

In discussing depression, Solomon highlights the confusion in how we discuss body and mind (e.g. how a "chemical depression" can make some patients feel that it's not their fault, as if it would be their fault were it more "purely" psychological). He follows this controversy and confusion over the mind-body problem back to the days of Ancient Greece, when the more medical model of Hippocrates contrasted with the views of Plato and Socrates, with Aristotle taking the view of a closer interaction between the body and mind.

In a similar vein, when Solomon moves on to the subject of treatment, he wastes no time in attacking a duality between talk therapy "versus" pharmacological treatment. He touches on this in his own continuing use of pharmacological treatment to avoid relapse, where he feels that there is some pressure to come off medication now that he is better. Although no simple cheerleader for dualism himself, to some extent Solomon needs to find some way of distancing from his own experience of severe clinical depression, initially describing it as something outside of himself; indeed, his cross-cultural experiences of depression lead him to praise traditional approaches to treatment that externalise  depression by linking it to spirits. Nonetheless, he also harks back to days when it felt the depression may have always been there in the background, waiting to be triggered

The mind-body relationship appears again in Solomon's investigation into the politics of mental health. From meetings in the USA's halls of power, he notes the bipartisan support for funding in mental health. However, as the book was originally published just a few years after the 1996 Mental Health Parity Act, he points the history of differing health insurance policy with regard to mental compared to physical health. Politics again rears its heads in the issue of poverty and depression. Solomon does not shy away from the role that poverty can play in precipitating depression (and childhood abuse, though hardly unique to poorer people, seems to be a recurring theme on this point). Nonetheless, Solomon is also a champion of individual treatment of depression in poorer patients (although what treatments they can/will afford is another issue...)

In discussing suicide within a book about depression, it is positive that Solomon highlights that many suicidal people do not have depression and vice versa. It is on this topic that he is perhaps at his most confessional, outlining how he helped his mother in assisted suicide. Suicide throws up thorny ethical questions about self-determination (as does the question of involuntary institutionalisation), and although Solomon offers an even-handed view he is not afraid to grasp some of these nettles.

Although this book is authoritative in its research and brave in its exposition, it is flawed. Some aphorisms don't come off quite so strong: Solomon prefaces some statistics with " is a mistake to confuse numbers with truth" (mind = blown, man). Notwithstanding that the book was written over 15 years ago, it seems a bit off that exercise is listed as an "alternative" treatment for depression when religion is in the same chapter (on mainstream treatment) as psychotherapy and psychopharmacology. As for listing homeopathy as a "serious" alternative-Jesus wept. Nonetheless, Solomon is at pains not make empty promises about relief from depression. He is clear that every treatment out there will work for some people but not others, and he warns that relapse is always a possibility.

Indeed, in a new epilogue, included in the 2015 edition, Solomon maintains that a relapse could always be on the horizon for him, though he seems arguably more accepting about it now, feeling that recovery will follow relapse. Solomon updates his account of treatment with an outline of the grandchildren of electroconvulsive therapy, including more precise methods such as transcranial magnetic stimulation and even more precise (though highly invasive) methods such as deep brain stimulation-the development of which (including setbacks and ongoing uncertainty) is laid out with great narrative drive. He also follows up people he interviewed for the main text of the book, and discusses whether stigma surrounding depression (and the treatment thereof) has changed; well-known reactionary Irish journalist John Waters comes in for a (less than glowing) mention here.

This is a sprawling overview of a deeply complex topic, that goes some way towards conveying how depression is different for everyone it touches, yet still places it within a broader social and political context. I would highly recommend it to anyone looking for a reasonably accessible book on this subject, as long as they are willing to sit with this subject for some time.

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I felt a funeral in my brain
Stigma "goes meta"

Saturday, August 19, 2017

Days of future past: Autobiographical memory and thinking about the future

"For the older writer, memory and the imagination begin to seem less and less distinguishable. This is not because the imagined world is really much closer to the writer's life than he or she cares to admit (a common error among those who anatomise fiction) but for exactly the opposite reason: that memory itself comes to seem much closer to an act of the imagination than ever before."

Julian Barnes (2008), Nothing To Be Frightened Of  (p. 238, paperback edition)

Think of the last time someone annoyed you. If you're like me you might replay the scene over in your mind. You might think of different things you might have said, how you could have got your own back on the person, or conversely how you could have responded with a greater level of calm. This kind of counterfactual thinking is useful in that it can prepare us to respond better if/when such events re-occur. Memories from our past can thus be tied up with how we think about our future.

As I'm planning a new project examining autobiographical memory, I recently picked up a really interesting book on Understanding Autobiographical Memory. One chapter in particular (see reference below) takes a rather interesting perspective on the connections between memory and future thinking. D'Argembeau highlights an interesting case study of a patient who lost not only his ability to remember past episodes from his life, but also to imagine his future; he described his attempts to engage in either form of thinking as leading to a mental blankness.

This is a rather extreme case that may be difficult for the average person to imagine, but in general both autobiographical memory and thinking about the future can be described as forms of "mental time travel" (imagining oneself in a different time, offering oneself the possibility to experience now what one is not experiencing directly from the present moment). They can both draw upon similar knowledge structures in the mind such as episodic detail or social scripts. For example, your knowledge of what happens in a job interview helps both to delineate what did and did not occur during a past job interview (e.g. bumping into one of the interviewers beforehand was not part of the interview, or so you hope) and to think of how to be more successful in similar situations in future (e.g. by responding to a type of question differently). A difference between the two forms of thinking is that spontaneous thoughts about the future tend to be more generic than their remembered counterparts. However, people may draw upon autobiographical memory in order to "flesh out" more generic thoughts of the future with episodic detail.

An interesting meta-analysis has suggested that a network of brain regions is activated during both autobiographical memory and thinking about the future, in addition to other forms of complex cognition such as theory of mind. Perhaps there is some connection here with creative thought; even though autobiographical memory does not and future thinking about oneself typically should not concern fictional events, both could be described as a forms of imagination. As Ruth Byrne has suggested, counterfactual thinking can be a form of creativity, and when this is applied to our own autobiography, the work of fiction can be how our own pasts may have played out.

D'Argembeau, A., 2012. Autobiographical memory and future thinking. In D. Berntsen & D.C. Rubin (Eds.)Understanding autobiographical memory: Theories and approaches, pp.311-330. Cambridge: Cambridge University Press. 

Sunday, August 6, 2017

Psychology of the brain-gut-microbiome axis

"Excretion is a universal part of the human experience, but it is veiled in taboo. Psychologists have torn the veil off other taboos, such as sex and death, but they have largely ignored elimination. Nevertheless, it is linked to a rich assortment of intense emotions, mental disorders, personality traits, social attitudes and linguistic practices. From psychoanalysis to neurogastroenterology...the psychology of the toilet offers surprising insights into mind–body connections, culture and gender."

Nick Haslam (2012), The Psychologist magazine

"And I first memory...I was four years old, and I was standing in front of my parents' house and I was shitting in my pants. I was just shitting a massive, terribly painful shit...the centre of this shit was so wide that I actually came online as a result of the anal pain that I was experiencing. It actually awakened me into AAAAAAAA this stream of consciousness I am now living"

Louis C.K., stand-up comedian

Those interested in the human mind have been interested in how it interacts with our guts since at least the days of Freud and colleagues, although as Haslam implies, interest in this area may have waned with the decline of psychoanalysis within academic and research-driven psychology. However, with an increasing interest in the body within psychology and cognitive neuroscience, research is starting to address how gastrointestinal factors may play a role in human psychology.

The nature of this interaction likely goes well beyond the psychology of elimination habits. Although our central nervous systems may do the cognitive heavy lifting available to consciousness, we have an enteric nervous system within our gastrointestinal tracts. Bacteria can produce neurochemicals that impact upon receptors within this nervous system. Ted Dinan, professor of psychiatry and mentor of mine at UCC, refers to it as a form of "collective unconscious". Although the Human Genome Project has mapped out the genes of human cells, there are a huge host of bacterial cells within us; furthermore, different types of bacteria will appear in different people, so this area is opening up a whole industry of gene sequencing of our microbial tenants. The whole area of gene X environment interactions just became more complex.

A major topic in this area is stress; intuitively, you may have noticed changes in your bowel habit while going through periods of heightened stress. One of the major research findings in this area is evidence of alteration in the gut microbiota in stress-related psychological disorder. Irritable bowel syndrome is the most obvious example, but studies from Ireland, China and Norway have indicated alteration of the microbiota in major depression. However, although these studies use healthy adults as controls, it is still too early to comment on what "the" healthy human microbiome looks like. A greater level of diversity is generally seen as a good thing, but as I mentioned above there is likely to be considerable variation in microbiota between different individuals who are generally healthy, so what "the right mix" is is still up for debate.

Despite this interesting evidence in stress-related disorder, there has generally been a lack of research looking at how chronic levels of stress per se can alter the microbiota. This is regrettable when one considers that following the same individuals over periods of greater or lesser stress could get around the issue of how much difference there is between different individuals.

Conversely, could tweaking the microbiota affect stress? A small study I was working on indicated that administration of a probiotic over four weeks could reduce reported daily stress as well as an acute stress response in healthy volunteers. This would suggest that manipulation of the microbiota can potentially affect psychological outcomes. These effects did not occur using the same assessments with a different probiotic; one would expect that different strains will have different effects, but even trying to combine research on a given strain can be fraught, as pointed out in a recent editorial.

Perhaps one of the more tractable questions in this area is how changes in dietary behaviour may impact upon our microbiota at a relatively broad level. There have been studies that compare a contemporary Western diet to groups of people relatively untouched by such dietary trends, such as the Hazda of Tanzania and children from rural Burkina Faso. Although one might think the easy availability of foods from around the world might increase the Westerner's microbial diversity, some findings suggest that it's actually the other way round. We could, of course, speculate that differences in levels of stress in different populations could also have some impact upon microbial differences (and indeed, our diets may become somewhat more processed during stressful times!).

Needless to say, issues such as diet and stress play out in a broader cultural context. It would be interesting to see more research being done on the social psychology surroundings the taboos and neuroses of our toilet habits and the kind of mishaps described by Louis C.K. However, unravelling the question of just how, and to what extent, the microbiota interact with an embodied psychology is going to be keeping people busy for some time.

Allen, A. P., Dinan, T. G., Clarke, G., & Cryan, J. F. (2017). A psychology of the human brain–gut–microbiome axis. Social and Personality Psychology Compass, 11(4).

Image is a detail adapted from Fig. 1 of the paper cited above. See full text here.

Related articles
Irritable bowel syndrome
From the depths came the form
Probiotics and stress

Sunday, July 9, 2017

Book review: "The Art of Losing Control" by Jules Evans

We were guided through intense emotions, like buttons on a TV remote. And the strange thing is, I felt each emotion. Are we so easily manipulated?
(p. 143)

I've won via a book thanks to a competition at The Psychologist magazine. It's a thesis on ecstatic experiences by Jules Evans, philosopher and bon vivant (in a broad sense of the term). Although the term "ecstasy" is used to describe religious or sexual experience, Evans highlights that many different forms of activity can be associated with this type of experience, which is not just about extreme happiness or pleasure but a loss of the sense of self.

Evans does not simply wish to sit at the sidelines but rather engage in some of the kinds of experience he discusses in the book. Sometimes he draws on past personal experiences, at other times he engages in new activities as research for the book (his attempts to dip his toes back into organised religion veer between endearingly awkward and slightly off-putting, as congregants and preachers hungry for young blood latch on to him or try to use him as a mouthpiece). Unsurprisingly, when dabbling in these various activities Evans often fails to become ecstatic. However, he draws on characters from the past who have abandoned themselves to ecstasy more than Evans himself, from sexualised cult leaders to preachers who found ecstasy in the natural world.

Indeed, like many philosophers, Evans has a healthy interest in history. He traces much of the reaction against ecstatic experience (or most ways of seeking ecstasy) to the Enlightenment. He posits that at this time an increasingly materialist worldview was increasingly hostile towards ecstatic experiences where sense of self (and therefore self-control) is lost.  I mention "most ways of seeking ecstasy" above, as the ecstatic appreciation of the natural world may be a form of ecstasy less antagonistic to Enlightenment values; people from Dawkins to Tim Michin have highlighted how we shouldn't need God when we could be happy and in awe of the wonder of the Natural World. Evans himself insists that he remains agnostic about religion, although he does seem to want the skeptical reader to consider the spiritual realm.

In delving into the world of ecstasy, a recurring theme is the danger underlying the loss of self. Besides the hazards of dangerous drugs, Evans highlights the negative reaction some people have to meditation. He even suggests there is a dark side to the seemingly innocuous ecstatic appreciation of the natural world; there is a risk of reading an excessively benevolent intention into Nature. However, Evans also suggests a further risk is that ecstasy in nature could distract from a higher power/transcendence (his nudging the reader towards the spiritual again?) This counterbalance serves as a useful rejoinder for the tendency of many self-help types to give an uncomplicated view of phenomena from romantic love to peak experience and flow.

Perhaps the boldest chapter is that which highlights war as a means for searching for ecstasy. Evans mentions Malthusian philosopher John Gray's reference to war as being a major part of the human psyche. Evans does not go as far as Gray in suggesting war as a universal drive, but he does delve deeper into suggesting a number of different reasons why war and violence can be a means to annihilate the self, such as a loss of self to a "greater cause". Of course, with war, unlike most other ecstatic pursuits, when the pleasure fades, you have not just temporarily annihilated the self, but permanently destroyed the other.

This book will raise more questions than answers, which is almost inevitable for a book that deals with a relatively under-explored phenomenon from such a wide-ranging perspective. Is there anything wrong with a life of modest happiness, rather than overwhelming ecstasy? Why is it that ecstatic experience can be turned on/off for many people engaging in quite diverse activities? Why, for so many people, is the self a burden that needs to be shed?

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Sunday, July 2, 2017

Honeymoon diary: Karpathos, Greece

Today this supremely beautiful landscape seemed to me to be almost unreal in its perfection. It produces a tonic effect on me…I felt a kind of aesthetic exhilaration, a mental exuberance and keenness of perception, a complete environmental euphoria. (John Fowles, “The Journals: Volume 1” p. 168)

The knot is tied. Daniela and I are honeymooning on a Greek island-KarpathosI am reading the journals of a favourite writer (I had just recently picked these up in Cardiff, having previously planned to re-read his famous novel with a Greek island setting, The Magus). In his early twenties, John Fowles’s initial resentment and self-absorption in England change to a more outward focus on the extravagant characters he encounters when he takes up a teaching job on the Greek island of Spetsai-possibly the most extravagant of which is the landscape of the island itself. 

From visiting the in-laws in Italy, I am by now used to the fairly urban Verona and Bergamo airports. Landing in Karpathos airport, one is struck by the almost alien landscape. It is a little bit like a grey/deep green version of Red Rocks in Denver. Although the sun takes the temperature into the high twenties, the island is windy, with enough of a breeze to make it feel like low twenties much of the time.

We are honeymooning with an Italian tour operator (Irish tourists are a novelty on the island) who take us from the airport to the Aegean Hotel, Amoopi. A polite yet brilliantly deadpan Serbian waiter attends to us at dinner. We dine a few times at a taverna down the road. The highly extroverted husband & wife proprietors engage their patrons/audience not only with cuisine that often incorporates their mini-farm by the taverna, but also with anecdotes and conversation, the hijinks of their dog, a chance to hold newly-born chicklets etc. They also do a mean Greek coffee. 

Our first excursion with the tour operator is to Olimbus. The various shops sell bespoke items, and the keepers call to the tourists as they stroll past to check their wares. (I look the archetypal tourist in shorts, T-shirt and a Karpathos baseball cap). In one place we pick up a necklace made up butterfly eggs. Another shopkeeper, who sells us a mug she made herself, is as comfortable discussing her life as an architect in Athens outside of the tourist season as she is asking us what age we are.

We hire a small car. I have never driven on the right before, and by force of habit I frequently reach left for the gearbox. In comparing our relative levels of stress when I am driving versus when Daniela is driving, I decide that I should stick to acting as navigator more often than driver. The car is used to travel to various beaches around Karpathos. Starting from the beach outwards, the water starts transparent, then aquamarine, then azure, then a deep blue. Most of the beaches are enclosed by cliffs or hills reaching down to the outskirts of the water. When swimming I tread water to admire the landscape, feeling a touch of Fowles's "aesthetic exhilaration".  

Our second excursion with the tour operator is to the island of Saria, the tiniest bit North of Karpathos. Although some people travel out on a semi-regular basis, when the boat pulls in the island it is quite deserted apart from three mules observing us from the rocky beach. We then walk up a steepish ascent under direct midday sunlight (some of the people on the tour are older-I have to wonder how everyone manages). On the descent we take slight divergence from the way up; there is a dead sheep lying on the path. I was reminded about a reference to travel research I made in an Irish Indo piece highlighting how satisfaction tends not be higher during the initial part of travelling, when one is actually doing the travelling to the place you want to get to! 

Towards the initial high point of Saria we encounter a beautiful small church. There seem to be very numerous Orthodox churches dotted all over the island, although they also tend to be either small or very small (a few of them would struggle to accommodate a full family, were they Catholic churches of yesteryear). The churches usually have a similar style in terms of the icons depicted. One less small church we visit elsewhere is besides a large floor mosaic, much of which has been lost in time.  

Following Karpathos, we return to Verona, Italy for a few days, for some quieter time in Italy post-wedding excitement, when we can settle some debts and run around with the niece and nephew. Then the return to Ireland and relative normalcy-assembling a wardrobe for our apartment and gearing up for more research at work. The honeymoon is not just another holiday. There's an expectation of creating memories that one holds on to for good. I don't think I'll forget the sunset view from the Aegean Hotel at dinner, overlooking the footpath to the hills that stretched to the sea.

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Monday, May 29, 2017

Stigma "goes meta"

When Irish voters were about to go the polls for a referendum on gay marriage, something interesting happened. There were certainly people out there who were willing to express their opposition to such marriages, but within the mainstream Irish media, there seemed at times to be less debate about the referendum question itself, and more debate about whether you could voice a “No” opinion without being “labelled a homophobe”. In short:

The foregone conclusion*: full gay marriage should be legal

The controversy: Pfff, just because someone is opposed to this specific issue they are being labelled as prejudiced. Surprise surprise, here come the stereotypes about Catholics… 

I wonder if something slightly similar is happening with disclosure of mental disorder.

I daresay most people would voice their opposition to stigma of people with mental disorder (especially when phrased in such general terms as that). And yet…there is a fatigue setting in about certain things. One is famous people disclosing mental disorder. If there’s something about the person that may challenge stereotypes around mental disorder it might get a bit more attention (e.g. Bruce Springsteen is an energetic, strong and successful man of an older generation but has depression; rappers often project a tough exterior but, hey, they can have mental vulnerability as well). However, if A.N. Other Montrose kid with a trendy haircut cries on RTÉ as they disclose that they have suffered from depression, you can bet that some viewers are rolling their eyes.

The foregone conclusion: we do not stigmatise mental disorder

The controversy: here we go, another person “opening up” about how they feel a bit down sometimes and they got prescribed an SSRI by a lazy GP. You should feel a bit down, you’re a vacuous Irish sleb model! Here come the stereotypes about…

Does the analogy become a bit strained here? In the case of mental disorder, who are the perceived stigmatisers who are being stereotyped? Older people?  Some ethnic minority group? Of course, I couldn’t be stigmatising people with mental disorder-stigma is bad!

The Diagnostic and Statistical Manual of Mental Disorders generally indicates that the symptoms of mental disorder only become a disorder when it is associated with significant impairment, such as social or occupational functioning. Are we being “labelled as a stigmatiser” because we can’t work around the person who can’t come to work as they have depression? But the fact is, that person with depression is the only person on our current team who can do this specific task, and it needs to be done…

But, sorry, we were talking about public disclosure of mental disorder, not mental disorder itself. Or are we?

“Look, we know now that disorders like depression and anxiety disorders are really quite prevalent. Why do we still need to hear about how some celebrity has it?”

Perhaps we don’t need to hear them say it. But we should let them say it. Because we can’t be sure that the real issue here is freedom of speech, but rather that society has a problem with a certain group of people.

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*I realise it was actually not that much of a landslide, the “foregone conclusion” is just the vibe of a foregone conclusion coming from the mainstream media

Tuesday, May 23, 2017

Conference review: Dementia and fMRI

I am back where I did my PhD studies: Cardiff University. The research project I am newly involved in examines memory, dementia and brain imaging employing fMRI. I have come for a trip back to Cardiff for a focused meeting on fMRI and dementia, bringing together researchers and clinicians in the field from the UK and further abroad.

The talks open with some quite technical discussion of brain imaging acquisition and analysis. Although the mathematics and physics are generally beyond my level of comprehension (I’d need to learn more about the applications of complex numbers for a start), it does draw attention to how different algorithms can be used at various stages of the research process.

A big focus of the talks is on predicting who is at greater risk for developing dementia. An interesting talk by Tony Bayer discusses subjective cognitive decline as a precursor of mild cognitive impairment (which in turn precedes dementia). There is a surprising plethora of approaches in this area, although people working in this area have recently got together to try and create some consistency in how this area is investigated.

In terms of work addressing dementia directly, there is much discussion of Alzheimer’s Disease (the most prevalent form of dementia), but it’s also encouraging to see a lot of research in other forms of dementia (e.g. frontotemporal dementia, Lewy Body Dementia and rarer conditions such as posterior cortical atrophy). It’s also nice to see someone venture outside the hippocampus (a classic target for brain imaging in this area) to look at the cerebellum; Michael Hornberger highlighted that he has had trouble convincing reviewers of his research on the role of the cerebellum in dementia, although he did show interesting results from a meta-analysis in this area as well as his own data.

At lunchtime I take a tour of CUBRIC 2; a new brain imaging centre at Cardiff that builds on the success of the first phase of CUBRIC (Cardiff University Brain Research Imaging Centre). In addition to a high-resolution 7 Tesla fMRI scanner, it boasts a rare 3 Tesla connectome scanner, as well as TMS, MEG, EEG and sleep laboratories. It seems to be one of a number of new buildings coming online in Cardiff University, along with a new Innovation Centre nearby (I believe this will be more geared towards humanities and social sciences). One can only hope the Brexit fallout does not hold neuroimaging at Cardiff back from attracting the talent and research funding needed to keep a centre like this operating.

Back at the talks, it was great to see Dennis Chan (who has worked with Nobel Laureate John O’Keefe) outline some of the novel assessments of memory he has been using, including applications of virtual reality. The conference was grounded by a patient who spoke about her own experience of taking part in research. As someone who had been active in writing and teaching as a younger person, she had a great sense of loss of agency when she developed cognitive impairment. She described how taking part in research gave her the sense that she could in some way help others in the future.

The poster section is very small but very focussed and lively. Quite a few posters highlight new developments in methodology.

Next year’s meeting will be held at Cambridge. Given the level of focus, and the potential to meet researchers in the field at a relatively “intimate” meeting, it’s worth going if this is your area.

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