Nostalgia is a Muse

“Let others praise ancient times. I am glad that I was born in these.”

                                                                                                – Ovid in “Ars Amatoria”

When I struggle with scientist’s block, I play 1980s music with the hope that the music will inspire me. This blast from the past often works for me. After listening to the songs, I can sometimes perceive patterns between our various pieces of cell biology and molecular biology data that had previously eluded me and design new biological experiments. But I have to admit that I have never performed the proper music control studies. Before attributing inspirational power to songs such as “99 Luftballons“, “Bruttosozialprodukt” or “Billie Jean“, I ought to spend equal time listening to music from other decades and then compare the impact of these listening sessions. I have always assumed that there is nothing intrinsically superior or inspirational about these songs, they simply evoke memories of my childhood. Eating comfort foods or seeing images of Munich and Lagos that remind me of my childhood also seem to work their muse magic.

Camera nostalgia

My personal interpretation has been that indulging nostalgia somehow liberates us from everyday issues and worries – some trivial, some more burdensome – which in turn allows us to approach our world with a fresh, creative perspective. It is difficult to make such general sweeping statements based on my own anecdotal experiences and I have always felt a bit of apprehension about discussing this with others. My nostalgia makes me feel like an old fogey who is stuck in an ossified past. Nostalgia does not have a good reputation. The German expression “Früher war alles besser!” (Back then, everything used to be better!) is used in contemporary culture to mock those who always speak of the romanticized past with whimsical fondness. In fact, the expression nostalgia was coined in 1688 by the Swiss medical student Johannes Hofer. In his dissertation “Dissertatio Medica de Nostalgia oder Heimweh“, Hofer used nostalgia as an equivalent of the German word Heimweh (“home-ache”), combining the Greek words nostos(homecoming) and algos (ache or pain), to describe a medical illness characterized by a “melancholy that originates from the desire to return to one’s homeland“. This view of nostalgia as an illness did not change much during the subsequent centuries where it was viewed as a neurological or psychiatric disorder.

This view has been challenged by the University of Southampton researchers Constantine Sedikides and Tim Wildschut, who have spent the past decade studying the benefits of nostalgia. Not only do they disavow its disease status, they have conducted numerous studies which suggest that nostalgia can make us more creative, open-minded and charitable. The definition of nostalgia used by Sedikides and Wildschut as a “sentimental longing for one’s past” is based on the contemporary usage by laypersons across many cultures. This time-based definition of nostalgia also represents a departure from its original geographical or cultural coinage by Hofer who viewed it as a longing for the homeland and not one’s personal past.

In one of their most recent experiments, Sedikides and Wildschut investigate nostalgia as a “mnemonic muse“. The researchers first evoked nostalgic memories in participants with the following prompt:

“Please think of a nostalgic event in your life. Specifically, try to think of a past event that makes you feel most nostalgic. Bring this nostalgic experience to mind. Immerse yourself in the nostalgic experience. How does it make you feel?”

Importantly, each experiment also involved a control group of participants who were given a very different prompt:

“Please bring to mind an ordinary event in your life. Specifically, try to think of a past event that is ordinary. Bring this ordinary experience to mind. Immerse yourself in the ordinary experience. How does it make you feel?”

This allowed the researchers to compare whether specifically activating nostalgia had a distinct effect from merely activating a general memory.

After these interventions, participants in the nostalgia group and in the control group were asked to write a short story involving a princess, a cat and a race car. In an additional experiment, participants finished a story starting with the sentence: “One cold winter evening, a man and a woman were alarmed by a sound coming from a nearby house“. After 30 minutes, of writing, the stories were collected and scored for the level of creativity by independent evaluators who had no knowledge of the experimental design or group that the participants belonged to. Participants who had experienced more nostalgia wrote more creative prose!

This is just one example of the dozens of studies conducted by Sedikides and Wildschut which show the benefits of nostalgia, such as providing inspiration, increasing trust towards outsiders and enhancing the willingness to donate to charities. What is the underlying mechanism for these benefits? Sedikides and Wildschut believe that our nostalgic memories provide a sense of belonging and support, which in turn helps our self-confidence and self-esteem. The comfort of our past gives us strength for our future.

Does this mean that this longing for the past is always a good thing? Not every form of nostalgia centers on personal childhood memories. For example, there is a form of ideological nostalgia expressed by groups who feel disenfranchised by the recent progress and long for days of former power and privilege. The South African sociologists van der Waal and Robbins recently described the popularity of a song about the Anglo-Boer waramong white Afrikaans-speakers in the post-Apartheid era which may have been rooted in a nostalgic affirmation of white Afrikaner identity. It is conceivable that similar forms of ideological nostalgia could be found in other cultures and states where privileged classes and races are losing ground to increased empowerment of the general population.

It is important that we distinguish between these two forms of nostalgia – personal childhood nostalgia and ideological group nostalgia – before “rehabilitating” nostalgia’s reputation. The research by Sedikides and Wildschut clearly demonstrates that nostalgia can be a powerful tool to inspire us but we have to ensure that it is not misused as am ideological or political tool to manipulate us.

References

1. de Diego, F. F., & Ots, C. V. (2014). Nostalgia: a conceptual history. History of psychiatry, 25(4), 404-411.

2. Sedikides, C., & Wildschut, T. (2016). Past Forward: Nostalgia as a Motivational Force. Trends in cognitive sciences (published online Feb 18, 2016)

3. van Tilburg, W. A., Sedikides, C., & Wildschut, T. (2015). The mnemonic muse: Nostalgia fosters creativity through openness to experience.Journal of Experimental Social Psychology, 59, 1-7.

4. Van der Waal, K., & Robins, S. (2011). ‘De la Rey’and the Revival of ‘Boer Heritage’: Nostalgia in the Post-apartheid Afrikaner Culture Industry. Journal of Southern African Studies, 37(4), 763-779.

 

Note: An earlier version of this article was first published on 3Quarksdaily.

 

ResearchBlogging.org

van Tilburg, W., Sedikides, C., & Wildschut, T. (2015). The mnemonic muse: Nostalgia fosters creativity through openness to experience Journal of Experimental Social Psychology, 59, 1-7 DOI: 10.1016/j.jesp.2015.02.002

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We Have Become Exhausted Slaves in a Culture of Positivity

We live in an era of exhaustion and fatigue, caused by an incessant compulsion to perform. This is one of the central tenets of the book “Müdigkeitsgesellschaft” (translatable as “The Fatigue Society” or “The Tiredness Society“) by the German philosopher Byung-Chul Han. Han is a professor at the Berlin Universität der Künste (University of the Arts) and one of the most widely read contemporary philosophers in Germany. He was born in Seoul where he studied metallurgy before he moved to Germany in the 1980s to pursue a career in philosophy. His doctoral thesis and some of his initial work in the 1990s focused on Heidegger but during the past decade, Han has written about broad range of topics regarding contemporary culture and society. “Müdigkeitsgesellschaft” was first published in 2010 and helped him attain a bit of a rock-star status in Germany despite his desire to avoid too much public attention – unlike some of his celebrity philosopher colleagues.

Fatigue

The book starts out with two biomedical metaphors to describe the 20th century and the emerging 21st century. For Han, the 20th century was an “immunological” era. He uses this expression because infections with viruses and bacteria which provoked immune responses were among the leading causes of disease and death and because the emergence of vaccinations and antibiotics helped conquer these threats. He then extends the “immunological” metaphor to political and societal events. Just like the immune system recognizes bacteria and viruses as “foreign” that needs to be eliminated to protect the “self”, the World Wars and the Cold War were also characterized by a clear delineation of “Us” versus “Them”. The 21stcentury, on the other hand, is a “neuronal” era characterized by neuropsychiatric diseases such as depression, attention deficit hyperactivity disorder (ADHD), burnout syndrome and borderline personality disorder. Unlike the diseases in the immunological era, where there was a clear distinction between the foreign enemy microbes that needed to be eliminated and the self, these “neuronal” diseases make it difficult to assign an enemy status. Who are the “enemies” in burnout syndrome or depression? Our environment? Our employers? Our own life decisions and choices? Are we at war with ourselves in these “neuronal” conditions? According to Han, this biomedical shift in diseases is mirrored by a political shift in a globalized world where it becomes increasingly difficult to define the “self” and the “foreign”. We may try to assign a “good guy” and “bad guy” status to navigate our 21st century but we also realize that we are so interconnected that these 20th century approaches are no longer applicable.

The cell biologist in me cringed when I read Han’s immunologic and neuronal metaphors. Yes, it is true that successfully combatting infectious diseases constituted major biomedical victories in the 20th century but these battles are far from over. The recent Ebola virus scare, the persistence of malaria resistance, the under-treatment of HIV and the emergence of multi-drug resistant bacteria all indicate that immunology and infectious disease will play central roles in the biomedical enterprise of the 21st century. The view that the immune system clearly distinguishes between “self” and “foreign” is also overly simplistic because it ignores that autoimmune diseases, many of which are on the rise and for which we still have very limited treatment options, are immunological examples of where the “self” destroys itself. Even though I agree that neuroscience will likely be the focus of biomedical research, it seems like an odd choice to select a handful of psychiatric illnesses as representing the 21st century while ignoring major neuronal disorders such as Alzheimer’s dementia, stroke or Parkinson’s disease. He also conflates specific psychiatric illnesses with the generalized increase in perceived fatigue and exhaustion.

Once we move past these ill- chosen biomedical examples, Han’s ideas become quite fascinating. He suggests that the reason why we so often feel exhausted and fatigued is because we are surrounded by a culture of positivity. At work, watching TV at home or surfing the web, we are inundated by not-so-subtle messages of what we can do. Han quotes the example of the “Yes We Can” slogan from the Obama campaign. “Yes We Can” exudes positivity by suggesting that all we need to do is try harder and that there may be no limits to what we could achieve. The same applies to the Nike “Just Do It” slogan and the thousands of self-help books published each year which reinforce the imperative of positive thinking and positive actions.

Here is the crux of Han’s thesis. “Yes We Can” sounds like an empowering slogan, indicating our freedom and limitless potential. But according to Han, this is an illusory freedom because the message enclosed within “Yes We Can” is “Yes We Should”. Instead of living in a Disziplinargesellschaft(disciplinary society) of the past where our behavior was clearly regulated by societal prohibitions and commandments, we now live in a Leistungsgesellschaft (achievement society) in which we voluntarily succumb to the pressure of achieving. The Leistungsgesellschaft is no less restrictive than the Disziplinargesellschaft. We are no longer subject to exogenous prohibitions but we have internalized the mandates of achievement, always striving to do more. We have become slaves to the culture of positivity, subjugated by the imperative “Yes, We Should”. Instead of carefully contemplating whether or not to pursue a goal, the mere knowledge that we could achieve it forces us to strive towards that goal. Buying into the “Yes We Can” culture chains us to a life of self-exploitation and we are blinded by passion and determination until we collapse. Han uses the sad German alliteration “Erschöpfung, Ermüdung und Erstickung” (“exhaustion, fatigue and suffocation”) to describe the impact that an excess of positivity has once we forgo our ability to say “No!” to the demands of the achievement society. We keep on going until our minds and bodies shut down and this is why we live in a continuous state of exhaustion and fatigue. Han does not view multitasking as a sign of civilizational progress. Multitasking is an indicator of regression because it results in a broad but rather superficial state of attention and thus prevents true contemplation

It is quite easy for us to relate to Han’s ideas at our workplace. Employees with a “can-do” attitude are praised but you will rarely see a plaque awarded to commemorate an employee’s “can-contemplate” attitude. In an achievement society, employers no longer have to exploit us because we willingly take on more and more tasks to prove our own self-worth.

While reading Han’s book, I was reminded of a passage in Bertrand Russell’s essay “In Praise of Idleness” in which he extols the virtues of reducing our workload to just four hours a day:

In a world where no one is compelled to work more than four hours a day, every person possessed of scientific curiosity will be able to indulge it, and every painter will be able to paint without starving, however excellent his pictures may be. Young writers will not be obliged to draw attention to themselves by sensational pot-boilers, with a view to acquiring the economic independence needed for monumental works, for which, when the time at last comes, they will have lost the taste and capacity. Men who, in their professional work, have become interested in some phase of economics or government, will be able to develop their ideas without the academic detachment that makes the work of university economists often seem lacking in reality. Medical men will have the time to learn about the progress of medicine, teachers will not be exasperatedly struggling to teach by routine methods things which they learnt in their youth, which may, in the interval, have been proved to be untrue.

Above all, there will be happiness and joy of life, instead of frayed nerves, weariness, and dyspepsia. The work exacted will be enough to make leisure delightful, but not enough to produce exhaustion. Since men will not be tired in their spare time, they will not demand only such amusements as are passive and vapid. At least one per cent will probably devote the time not spent in professional work to pursuits of some public importance, and, since they will not depend upon these pursuits for their livelihood, their originality will be unhampered, and there will be no need to conform to the standards set by elderly pundits. But it is not only in these exceptional cases that the advantages of leisure will appear. Ordinary men and women, having the opportunity of a happy life, will become more kindly and less persecuting and less inclined to view others with suspicion.

While Russell’s essay proposes reduction of work hours as a solution, Han’s critique of the achievement society and its impact on generalized fatigue and malaise is not limited to our workplace. By accepting the mandate of continuous achievement and hyperactivity, we apply this approach even to our leisure time. Whether it is counting the steps we walk with our fitness activity trackers or competitively racking up museum visits as a tourist, our obsession with achievement permeates all aspects of our lives. Is there a way out of this vicious cycle of excess positivity and persistent exhaustion? We need to be mindful of our right to refuse. Instead of piling on tasks for ourselves during work and leisure we need to recognize the value and strength of saying “No”. Han introduces the concept of “heilende Müdigkeit” (healing tiredness), suggesting that there is a form of tiredness that we should welcome because it is an opportunity for rest and regeneration. Weekend days are often viewed as days reserved for chores and leisure tasks that we are unable to pursue during regular workdays. By resurrecting the weekend as the time for actual rest, idleness and contemplation we can escape from the cycle of exhaustion. We have to learn not-doing in a world obsessed with doing.

Notes: An earlier version of this article was first published on the 3Quarksdaily Blog. Müdigkeitsgesellschaft was translated into English in 2015 and is available as “The Burnout Society” by Stanford University Press.

ResearchBlogging.org

Byung-Chul Han (2015). The Burnout Society Stanford University Press

When can you have sex after a heart attack? Most doctors do not talk about it.

Each year in the United States about 720,000 people have heart attacks and about 124,000 people in the UK and 55,000 people in Australia will have them as well. Since the 1980s, survival rates from heart attacks have improved – a lot of people get them, but more and more people are surviving. A recent study of patients in Denmark showed that in 1984-1988 31.4% of patients died within a month of having a heart attack. From 2004-2008 this was down to 14.8%.

Once a patient has made it through a heart attack and begins to recover, they get advice from their doctors on what to do to stay healthy and get back to normal. That includes a lot of things – when to go back to work, when they can start traveling again and what to eat. But there is an important item that a lot of doctors don’t talk about: sex.

There are no universal guidelines for getting back to ‘normal’

Providing advice about lifestyle can be more challenging than prescribing standardized medications or smoking cessation because “normal” life differs widely among patients and requires individualized counseling.

For instance, scientific evidence from large-scale clinical trials isn’t always available to help the cardiologist decide the ideal time for when an individual patient should return to work. A software engineer might get different advice than a butcher or construction worker who has to lift heavy objects all day long. Physicians have to carefully estimate the patient’s capacity for physical activity as well as the physical demands of the job and be pragmatic about how long a patient can take time off from work.

Sex also requires this kind individualized counseling. New research shows that patients want to talk about sexual activity with their doctors, but that all too often that conversation never takes place.

Time for a heart-to-heart with your doctor.
Heart via Syda Productions/Shutterstock

 

Let’s talk about sex

A recent study conducted in 127 hospitals in the United States and Spain suggests that doctors are not very good at broaching the topic of sexual activity after a heart attack.

Researchers studied 2,349 women and 1,152 men who had suffered from a myocardial infarction (the medical term for a heart attack). This study focused on younger heart attack patients (ages 18-55) and asked them whether they had discussed sexual activity with their doctors. With younger patients talking about life after a heart attack is especially important. The loss of sexual activity or function is a major quality of life issue, and can affect intimate relationships, reproduction and lead to depression.

In the month following the heart attack, only 12% of women and 19% of men had some discussion with a doctor about sex. In the US, most patients reported that they initiated the discussion, whereas in Spain, most discussions were initiated by the doctor. This means that more than 85% of patients received no advice from their doctors regarding if and when they could resume sexual activity.

The study found that the vast majority of patients were sexually active in the year before their heart attacks, and they valued sexuality as an important part of life. They also felt it was appropriate for physicians to initiate the discussion about having sex again.

It is interesting that in the US, patients were more likely to bring up sex and men were given more restrictive advice, while in Spain, physicians were more likely to bring up the topic and more restrictive recommendations were given to women.

The study did not specifically study the motivations of the physicians but these differences suggest that cultural differences and gender affect the counseling in regards to sexual activity. Future research could potentially also study the physicians and help uncover how culture and gender influence the counseling process.

This lack of communication between doctors and patients was not due to the patients’ unease: 84% of women and 91% of men said that they would feel comfortable talking to their doctors about sex. What is even more concerning is that the 15% or so of patients who received counseling often got inaccurate recommendations.

Sex is exercise. But doctors don’t talk about it that way

Two-thirds of those who talked about sex with their doctors were told that they could resume sexual activity with restrictions like limiting sex, taking a “passive role” or keeping their heart rate down during sex. But here’s the thing: sex is exercise. And after a heart attack doctors routinely ask patients whether they can tolerate mild to moderate physical activity such as mowing the lawn or climbing up two flights of stairs without chest pain or other major symptoms.

The Scientific Statement of the American Heart Association (AHA) on sexual activity states that it is reasonable to resume sexual activity as early as one week after an uncomplicated heart attack. If there are complications after the heart attack such as feeling out of breath or experiencing persistent chest pain then these problems need to be addressed first. And in the AHA guidelines there is no mention of “passive roles” or keeping heart rates down during sex. These restrictions are also quite impractical. How are patients supposed to monitor their heart rates and keep them down during sex?

The kind of restrictions recommended by doctors in the study – and presumably by medical practitioners who weren’t polled – are not backed up by science and place an unnecessary burden on a patient’s personal life. Hopefully, after reading the results of this study, doctors will take a more pro-active role and address the topic of sex with their heart attack patients with proper recommendations instead of leaving patients in a state of uncertainty. If a patient can handle moderate exercise, they can probably handle sex.

The Conversation

This article was originally published on The Conversation.
Read the original article.

 

The Link Between Using Pro-Social Media and Empathy

Does watching TV and playing video games affect our empathy and willingness to engage in pro-social behavior? A team of international psychology researchers studied over 2,000 adolescents (mean age 21 years, 60% female and 40% male) in seven countries (Australia, China, Croatia, Germany, Japan, Romania and the United States) to determine whether there is a link between the media they consume and their levels of empathy and pro-social behavior. Using either online surveys or face-to-face interviews, participants were asked to rate their favorite TV shows, movies and video games for pro-social and violent content. The question “How often do characters help each other?” was used to assess the pro-social content of TV shows and movies, whereas the question “How often do characters try to physically injure each other?” was used to measure the violent content. To account for the interactive nature of video games, the researchers used two items to measure the pro-social content in each game: “How often do characters help each other in this game?” and “How often do you help others in this game?”. Similarly, two questions were asked to measure the violent content in each video game: “How often do characters try to physically injure each other in this game?” and “How often do you try to physically injure players in this game?” The empathy and pro-social behavior of the participants was assessed by asking them to complete personality questionnaires in which they used scaled responses to lists of questions such as “Before criticizing somebody, I try to imagine how I would feel if I were in their place” (one out of 14 questions from the empathy questionnaire) or “I try to be helpful to people even if I don’t expect to see them ever again.” (one out of the ten items on the pro-social behavior questionnaire).

tree-200795_640

The results of this study were recently published in the article “Long-Term Relations Among Prosocial-Media Use, Empathy, and Prosocial Behavior“. As expected, empathy was strongly correlated with pro-social behavior. The more likely we empathize with fellow humans, the more likely we are to help them. The key finding of this study was that pro-social media content (TV, movies or video games) was significantly associated with greater empathy scores, and thus also with greater pro-social behavior. What makes this study quite innovative is that it surveyed participants from many different countries and cultures, all of whom showed a similar trend. This means that no matter what countries the participants grew up in, there was a correlation between watching helpful characters on TV screens or in video games and being able to empathize with fellow humans in real life. Importantly, there was no significant correlation between watching violent characters on screen and their empathy or pro-social behavior. This is an important finding because we often hear clichés about violent movies and video games turning us into psychopaths, but this international study of 2,000 adolescents could not find any evidence to support this notion. Despite the importance of this negative data, the authors do not really discuss the absence of the correlation in their paper. Lastly, there was also a significant inverse correlation between total screen-time and empathy or pro-social behavior. This means that the more time participants spent watching TV and movies or playing video games, the less likely they were to feel empathy towards others.

There are important limitations to this study. First and foremost, this was a correlational study conducted at a single time point which only offered a snapshot view and did not prove any cause-and-effect relationship. Just because watching pro-social behavior on screen is correlated with more empathy does not mean that pro-social media can convert us into empathic people. It is quite possible that people who are already predisposed towards feeling empathy and behaving in a more pro-social manner are more likely to seek out TV shows or video games with pro-social content. Furthermore, “pro-social behavior” was assessed by self-report and are not necessarily reflect the actual engagement in pro-social behavior.

To try to get to the bottom of the cause-effect relationship, the researchers then conducted a second study in which they tracked over 3,000 school-children (mean age 11 years, 73% male and 27% female) in Singapore over time. They measured video game playing, empathy and pro-social behavior annually at three different time points. They found that pro-social video game content was statistically at time point 1 was significantly correlated with greater empathy and pro-social behavior at time points 2 and 3, thus suggesting that perhaps exposing children to pro-social video games could increase the empathy of the children. However, the correlation coefficients were quite small (even though they were statistically significant). In fact, the best predictor of future empathy and pro-social behavior was already exhibiting pro-social behavior and empathy at a younger age.

The take home message from these two studies is that although there are significant correlations between pro-social media use and empathy or pro-social behavior, there is little evidence to support the idea that one can engender empathy by exposing children to pro-social content.

ResearchBlogging.org
Sara Prot, Douglas A. Gentile, Craig A. Anderson, Kanae Suzuki, Edward Swing, Kam Ming Lim, Yukiko Horiuchi, Margareta Jelic, Barbara Krahé, Wei Liuqing, Albert K. Liau, Angeline Khoo, Poesis Diana Petrescu, Akira Sakamoto, Sachi Tajima, Roxana Andreea Toma, Wayne Warburton, Xuemin Zhang, & Ben Chun Pan Lam (2013). Long-Term Relations Among Prosocial-Media Use, Empathy, and Prosocial Behavior Psychological Science DOI: 10.1177/0956797613503854

Should Doctors ‘Google’ Their Patients?

Here is an excerpt from my latest post on the 3Quarksdaily blog:

 

Beware of what you share. Employers now routinely utilize internet search engines or social network searches to obtain information about job applicants. A survey of 2,184 hiring managers and human resource professionals conducted by the online employment website CareerBuilder.com revealed that 39% use social networking sites to research job candidates. Of the group who used social networks to evaluate job applicants, 43% found content on a social networking site that caused them to not hire a candidate, whereas only 19% found information that that has caused them to hire a candidate. The top reasons for rejecting a candidate based on information gleaned from social networking sites were provocative or inappropriate photos/information, including information about the job applicants’ history of substance abuse. This should not come as a surprise to job applicants in the US. After all, it is not uncommon for employers to invade the privacy of job applicants by conducting extensive background searches, ranging from the applicant’s employment history and credit rating to checking up on any history of lawsuits or run-ins with law enforcement agencies. Some employers also require drug testing of job applicants. The internet and social networking websites merely offer employers an additional array of tools to scrutinize their applicants. But how do we feel about digital sleuthing when it comes to relationship that is very different than the employer-applicant relationship – one which is characterized by profound trust, intimacy and respect, such as the relationship between healthcare providers and their patients?


The Hastings Center Report is a peer-reviewed academic bioethics journal which discusses the ethics of “Googling a Patient” in its most recent issue. It first describes a specific case of a twenty-six year old patient who sees a surgeon and requests a prophylactic mastectomy of both breasts. She says that she does not have breast cancer yet, but that her family is at very high risk for cancer. Her mother, sister, aunts, and a cousin have all had breast cancer; a teenage cousin had ovarian cancer at the age of nineteen; and that her brother was treated for esophageal cancer at the age of fifteen. She also says that she herself has suffered from a form of skin cancer (melanoma) at the age of twenty-five and that she wants to undergo the removal of her breasts without further workup because she wants to avoid developing breast cancer. She says that her prior mammogram had already shown abnormalities and she had been told by another surgeon that she needed the mastectomy.

Such prophylactic mastectomies, i.e. removal of both breasts, are indeed performed if young women are considered to be at very high risk for breast cancer based on their genetic profile and family history. The patient’s family history – her mother, sister and aunts being diagnosed with breast cancer – are indicative of a very high risk, but other aspects of the history such as her brother developing esophageal cancer at the age of fifteen are rather unusual. The surgeon confers with the patient’s primary care physician prior to performing the mastectomy and is puzzled by the fact that the primary care physician cannot confirm many of the claims made by the patient regarding her prior medical history or her family history. The physicians find no evidence of the patient ever having been diagnosed with a melanoma and they also cannot find documentation of the prior workup. The surgeon then asks a genetic counselor to meet with the patient and help resolve the discrepancies. During the evaluation process, the genetic counselor decides to ‘google’ the patient.

The genetic counselor finds two Facebook pages that are linked to the patient. One page appears to be a personal profile of the patient, stating that in addition to battling stage four melanoma (a very advanced stage of skin cancer with very low survival rates), she has recently been diagnosed with breast cancer. She also provides a link to a website soliciting donations to attend a summit for young cancer patients. The other Facebook page shows multiple pictures of the patient with a bald head, suggesting that she is undergoing chemotherapy, which is obviously not true according to what the genetic counselor and the surgeon have observed. Once this information is forwarded to the surgeon, he decides to cancel the planned surgery. It is not clear why the patient was intent on having the mastectomy and what she would gain from it, but the obtained information from the Facebook pages and the previously noted discrepancies are reason enough for the surgeon to rebuff the patient’s request for the surgery.

 

If you want to learn more about how ethics experts analyzed the situation and how common it is for psychologists enrolled in doctoral programs to use search engines or social networking sites in order to obtain more information about their patients/clients, please read the complete article at 3Quarksdaily.com.  

Armchair Psychiatry and Violence

Following tragic mass shootings such as the one that unfolded in Newtown, Connecticut, it is natural to try to “make sense” of the events. The process of “making sense” and understanding the underlying causes is part of the healing process. It also gives hope to society that if we were able to address the causes of the tragedy, we could prevent future tragedies. It is not unexpected that mental illness is often invoked as a possible reason for mass shootings. After all, the slaying of fellow human beings seems so far removed from what we consider normal human behavior. Since mental illness directly affects human behavior, it seems like the most straightforward explanation for a mass shooting. It is surmised that the mental illness severely impairs the decision-making capacity and perceptions of the afflicted person so that he or she is prone to acting out in a violent manner and causing great harm to others. Once evidence for “mental illness” in a shooter is found, one may also be tempted to stop looking for other factors that may have caused the tragedy. The nebulous expression “mental illness” can appear like a convenient catch-all explanation that requires no further investigation, because the behavior of a “mentally ill” person might be beyond comprehension.

The problem with this convenient explanation is that “mental illness” is not a homogeneous entity. There are many different types of mental illness, and specific psychiatric disorders, such as major depression, anxiety disorder or schizophrenia represent a broad spectrum of disease. These illnesses do not only vary in their severity from patient to patient, but even within a single patient, mental illnesses vary over time in severity. Just because someone carries the diagnosis of schizophrenia does not mean that the patient will continuously have severe manifestations of the disease. Some patients may show signs of withdrawal and introversion, others may act out with aggressive behavior. Making a direct causal link between a person’s diagnosis of mental illness and their violent behavior requires a careful psychiatric examination of that individual patient, as well as other circumstances, such as recent events in their lives or possible substance abuse.

When shooters kill themselves after the murders they commit, it is impossible to perform such a psychiatric examination and all that one can go by are prior medical records, but it becomes extremely difficult to retrospectively construct cause-effect relationships. In the case of Adam Lanza, the media and the public do not have access to his medical records. However, soon after the shooting, there was frequent mention in the media that Lanza had been diagnosed with either Asperger syndrome, autism or a personality disorder and potential links between these diagnoses and the shooting were implied. Without carefully perusing his medical records, it is difficult to assess whether these diagnoses were accurate, how severe his symptoms were and how they were being treated. To make matters worse, some newspapers and websites have resorted to generating narratives about Adam Lanza’s behavior and mental health based on subjective and anecdotal experiences of class-mates, family friends and in perhaps the most ridiculous case, Lanza’s hair stylist. Snippets of subjective information regarding odd behaviors exhibited by Lanza have been offered to readers and viewers so that they can perform an armchair evaluation of Lanza’s mental health from afar and search for potential clues in his past that might point to why he went on a shooting rampage. Needless to say, this form of armchair analysis is fraught with error.

It is difficult enough to diagnose a patient during a face-to-face evaluation and then try to make causal links between the symptoms and the observed pathology. In the setting of cardiovascular disease, for example, the healthcare professional has access to blood tests which accurately measure cholesterol levels or biomarkers of heart disease, angiograms that generate images of the coronary arteries and even ultrasound images of the heart (echocardiograms) that can rather accurately assess the strength of the heart. Despite all of these objective measurements, it requires a careful and extensive discussion with the patient to understand whether his shortness of breath is truly linked to his heart disease or whether it might be related to other factors. Someone might have mild heart disease by objective testing, but the shortness of breath he experiences when trying to walk up the stairs may be due to months of physical inactivity and not due to his mild heart disease.

In psychiatry, making diagnoses and causally linking symptoms and signs to mental illness is even more difficult, because there are fewer objective tests available. There are, as of now, no CT-Scans or blood tests that can accurately and consistently diagnose a mental illness such as depression. There are numerous reports of documented abnormalities of brain imaging observed in patients with mental illness, but their reliability and their ability to predict specific outcomes of the respective diseases remains unclear. The mental health professional has to primarily rely on subjective reports of the patient and the patient’s caregivers or family members in order to arrive at a diagnosis. In the case of Adam Lanza, who killed himself as well as his mother, all one can go by are his most recent mental health evaluations, which could provide a diagnosis, but may still not reliably explain his killing spree. Retrospective evaluations of his mental health by former class-mates, hair stylists or family members are of little help. Comments on the past behavior of a mass shooter will invariably present a biased and subjective view of the past, colored by the knowledge of the terrible shooting. Incidents of “odd behaviors” will be remembered, without objectively assessing how common these behaviors were in other people who did not go on to become mass shooters.

An article written by Liza Long with the sensationalist title “I Am Adam Lanza’s Mother” was widely circulated after the shooting. Long was obviously not the mother of Adam Lanza, and merely took advantage of the opportunity to describe her frustration with the mental health care system and her heart-wrenching struggles with the mental health of her son who was prone to violent outbursts. In addition to violating the privacy of her son and making him a likely target of future prejudice and humiliation, Long implied that the observed violent outbursts she had seen in her son indicated that he might become a mass shooter like Adam Lanza. Long, like the rest of the public, had no access to Lanza’s medical records, did not know whether Lanza had been diagnosed with the same illnesses as her own son and whether Lanza had exhibited the same behaviors. Nevertheless, Long’s emotional story and the sensationalist title of her article caught on, and many readers may have accepted her story as a proof of the link between certain forms of mental illness and predisposition to becoming a mass shooter.

Instead of relying on retrospective analyses and anecdotes, it may be more helpful to review the scientific literature on the purported link between mental illness and violence.

 

The link between mental illness and violence

There is a widespread notion that mental illness causes violent behavior, but the scientific evidence for this presumed link is not that solid.  “Mental illness” is a very heterogeneous term, comprising a wide range of disorders and degrees of severity for each disorder, so many studies that have tried to establish a link between “mental illness” and violence have focused on the more severe manifestations of mental illness. The 1998 land-mark study “Violence by People Discharged From Acute Psychiatric Inpatient Facilities and by Others in the Same Neighborhoods” by Henry Steadman and colleagues was published in the highly cited psychiatry journal Archives of General Psychiatry and focused on patients whose mental illness was severe enough to require hospitalization. The study followed patients for one year after they were released from the acute psychiatric inpatient units, and assessed how likely they were to engage in violence. At one of the sites (Pittsburgh), the researchers also compared the likelihood of the psychiatric patients to engage in violence with that of other residents of the same neighborhood.  Steadman and colleagues found that there was a higher rate of violence observed in psychiatric patients, this was associated with the higher rate of substance abuse. Psychiatric patients without substance abuse had the same rate of violence as other residents of the neighborhood without substance abuse.

The recent large-scale study “The Intricate Link Between Violence and Mental Disorder” was published in the Archives of General Psychiatry by Elbogen and Johnson in 2009 and also found that severe mental illness by itself was not a strong predictor of violence. Instead, future violence was more closely associated with a history of past violence, substance abuse or contextual factors, such as unemployment or a recent divorce. A 2009 meta-analysis by Fazel and colleagues was published in PLOS Medicine and reviewed major studies that had investigated the potential link between schizophrenia and violence. The authors found an increased risk of violence and homicide in patients with schizophrenia, but this was again primarily due to the higher rates of substance abuse in the patient population. The risk of homicide in individuals with schizophrenia was 0.3%, and the risk of homicide was also 0.3% in people with a history of substance abuse. All of the studies noted a great degree of variability in terms of violence, again reminding us that mental illnesses are very heterogeneous diseases. An individual diagnosed with “schizophrenia” is not necessarily at higher risk for engaging in violent behavior. One also has to assess their specific context, their past history of violence, their social circumstances and especially their degree of substance abuse, which can refer to alcohol abuse or alcohol dependence as well as the abuse of illegal substances such as cocaine. The data on whether Asperger syndrome, one of the conditions that Adam Lanza is said to have been diagnosed with, is far sparser. Stål Bjørkly recently reviewed the studies in this area and found that there has been no systematic research in this field. The hypothesized link between Asperger syndrome and violence is based on just a few studies, mostly dealing with case reports of selected incidents.

It is quite noteworthy that multiple large-scale studies investigating the association between mental illness and violence have come up with the same conclusion: Patients with mental illnesses may be at greater risk for engaging in violence, but this appears to be primarily linked to concomitant substance abuse. In the absence of substance abuse, mental illness by itself does not significantly increase the likelihood of engaging in violence. Richard Friedman summarized it best in an article for the New England Journal of Medicine:

The challenge for medical practitioners is to remain aware that some of their psychiatric patients do in fact pose a small risk of violence, while not losing sight of the larger perspective — that most people who are violent are not mentally ill, and most people who are mentally ill are not violent.

Human behavior and mental illness

One rarely encounters armchair diagnoses in cardiovascular disease, neurologic disease or cancer. Journalists do not usually interview relatives or friends of cancer patients to ascertain whether there had been early signs of the cancer that had been missed before the definitive diagnosis was made or a patient died of cancer. If medical details about public persona are disclosed, such as for example the heart disease in the case of former vice-president Cheney, journalists and TV viewers or readers without medical expertise rarely offer their own opinion whether the diagnosis of cardiovascular disease was correct and how the patient should be treated. There were no interviews with other cardiovascular patients regarding their own personal history of heart disease and they were also not asked to comment on how they felt Cheney was being treated. In the case of the 2012 US meningitis outbreak, which resulted in the death of at least 35 people, many questions were raised in the media regarding the underlying causes and there was understandable concern about how to contain the outbreak and address underlying causes, but the advice was usually sought from experts in infectious disease.

When it comes to mental illness, on the other hand, nearly everyone with access to the media seems to think they are an expert on mental health and one finds a multitude of opinions on the efficacy of psychoactive medications, whether or not psychiatric patients should be institutionalized and warning signs that lead up to violent behavior. There are many potential reasons for why non-experts feel justified in commenting on mental illness, but remain reticent to offer their opinion on cardiovascular disease, cancer or infectious disease.  One reason is the subject matter of psychiatry. As humans, we often define ourselves by our thoughts, emotions and behaviors – and psychiatry primarily concerns itself with thoughts, emotions and behaviors. Our personal experiences may embolden us to offer our opinions on mental health, even though we have not had any formal training in mental health.

The psychiatric profession itself may have also contributed to this phenomenon by blurring the boundaries between true mental illness and the broad spectrum of human behavior. The criteria for mental illness have been broadened to such an extent that according to recent studies, nearly half of all Americans will meet the criteria for a mental illness by the time they have reached the age of 75. There is considerable debate among psychiatrists about the potential for over-diagnosis of mental illness and what the consequences of such over-diagnoses might be. The labeling of mildly “abnormal” behaviors as mental illnesses not only results in the over-prescription of psychoactive medications, but it may also take away mental health resources from patients with truly disabling forms of mental illness. For example, the upcoming edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM – which establishes the diagnostic criteria for each mental disorder) will remove the bereavement exemption for the diagnosis of depression. This means that people suffering from severe grief after the death of their loved ones, such as the parents of the children that were murdered in Newtown, could conceivably be diagnosed with the mental disorder “Major Depression”. 

Romanticizing and vilifying mental illness

The topic of mental illness also lends itself to sensationalism. Occasionally, mental illness is romanticized, such as the idea that mental illness somehow fosters creativity for which there is little scientific evidence. More often, however, patients with mental illness are vilified. Broad generalizations are made and violent tendencies or criminal behaviors are ascribed to patients, without taking into account the heterogeneity of mental illness. Wayne LaPierre of the National Rifle Association (NRA) recently called for the creation of an “active national database of the mentally ill” and on a subsequent event, LaPierre referred to mentally ill patients as “monsters” and “lunatics”. Such sensationalist rants may make for good publicity, but they also help further undermine an objective discussion about mental health. Especially the call for a national database of mentally ill people comes seems somewhat counter-intuitive since the NRA has often portrayed itself as a defender of personal liberty and privacy. Are organizations such as the NRA aware of the fact that nearly half of all Americans will at some point in their life qualify for mental illness diagnoses and would have to be registered in such a database? Who would have access to such a database? For what purposes would the database be used? Would everyone listed in the database be barred from buying guns? How about household members living with a patient who has been diagnosed with a mental illness? Would these household members also be barred from buying guns?  If indeed all patients with at least one psychiatric diagnosis were registered in a national database and if they and their household members were barred from owning guns, nearly all US households would probably become gun-free. If one were to follow along the logic of the NRA, one might even have to generate a national database of people with a history of substance abuse or a past history of violence, since the above-mentioned research showed that substance abuse and past history of violence may be even stronger predictors of future violence than mental illness.

When it comes to reporting about mental illness it is especially important to avoid the pitfalls of sensationalism. Mental illness should be neither romanticized nor vilified. Potential links between mental illness and behaviors such as violence should always be made in the context of the existing medical and scientific literature and one should avoid generalizations and pronouncements based on occasional anecdotes. Journalists and mental health professionals need to help ensure the accuracy and objectivity of analyses regarding the mental health of individuals as well as specific mental illnesses. It never hurts to have a discussion about mental health. There is clearly a need for the improvement of the mental health infrastructure and for the development of better therapies for psychiatric disease, but this discussion should be based on facts and not on myths.

 

Image Credit: Brain of MRI scan data for child onset schizophrenia showing areas of brain growth and loss of tissue via NIMH