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.

Related posts

*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.

Related articles 

Saturday, April 29, 2017

The Loved Ones

As someone who tries to use language precisely, I dislike it when terms stray into inaccuracy. For example, the phrase “making love” has tended to annoy me for years, as it is sometimes used as an all-purpose stand-in term to describe any sexual intercourse. Although I’m sure such inaccuracy isn’t the intention (people just want a euphemism), the term nonetheless seems to imply that sexual activity is somehow inherently loving. However, this pet peeve is a bit flippant compared to a somewhat similar example I’ve noticed more recently.

In my recent work on dementia caregivers, one can end up thinking quite a bit about the best way to use language in describing patients and those who care for them. The majority of dementia carers who aren’t professional carers are either children or spouses of the patient. However, you do see siblings, sometimes nephews/nieces, or even friends or neighbours. “Carer” or “caregiver” (as opposed to “family member”) works fine, as it describes what they do.

What then is the best single collective term to use for those being cared for? “Patient” or “person with dementia” is fine, but doesn’t capture who they are with relation to the carer. “Family members” covers most, but not all, patients with unpaid carers. “Loved ones” looks like a good one -the patient doesn’t have to be a family member of their carer for us to call the patient a “loved one”. And does it not capture the idea of care as loving? I recall seeing a video of an elderly man caring for his wife with a caption along the lines of “If this isn’t true love, what is?”

One afternoon, while speaking with a carer, she took the opportunity to share some of her thoughts and feelings. She had been caring for her husband with dementia for a number of years. After speaking more broadly about caring for her husband, she came to the topic of love and marriage: “You know, sometimes I ask myself whether after x years of marriage, do I still love this man?…And really, the answer is no. Well, you’re a young man-I suppose it’s something you’ll understand when you’re older…”

Another carer (again caring for her spouse) spoke of how she no longer loved her husband at a gathering of carers. She added that it’s not something she felt she could say to her (adult) children. Maybe she just wanted to get it off her chest when speaking to other carers, or perhaps she wanted to see if she wasn’t the only one who felt this way. On hearing what she had said, another carer (caring for a parent) suggested that maybe the first carer didn’t like her spouse any more, but she did love him. The first carer who had spoken of her feelings restated them.

I can see how people might identify with the carer who made the “not liking, but still loving” suggestion. Perhaps there is a temptation not to take these statements about an end of love at face value. We could be suggesting that carers perform love, even if they don’t feel it, if we say things like “If this isn’t true love, what is?” But if we try to downplay these feelings (or lack of feelings), are we not also downplaying how, in some cases, there is great social pressure to stay in the full-time carer role? (Particularly if society at large is not giving them enough help). And are we not more generally downplaying the level of altruism such carers are showing?

If caring for someone you love is heroic, caring for someone you no longer love is more so.

Related posts

Saturday, April 8, 2017

A brief guide to accusing someone of hypocrisy

A man who moralises is usually a hypocrite.
Oscar Wilde

"I consider myself a vegetarian because there is no meat in here." A tongue-in-cheek comment in the 2am queue in McDonald's from some woman I had met an hour or two previously. In an argumentative train of thought and taking her comment a bit too seriously, I nonetheless refrained from voicing aloud the idea that she was doubly hypocritical; firstly for describing herself as a veggie when she eats meat and secondly for dissing McDonald's when clearly about to buy their stuff.

But when is it best to accuse someone of being a hypocrite? It's something I've thought a bit over the past while. Here are some questions to consider:

1. Is the person really a hypocrite?

1a. Do their actions contradict their current stance, or is it just their previous stance/opinion that contradicts their current stance?

To state the obvious, being a hypocrite involves saying/doing something and then doing/saying something else that contradicts that. It's worth thinking clearly about whether the person has really done anything or is just giving one opinion and then opining differently later on. (This may be harder in the case of politicians or more powerful people, where speech acts may have quite tangible consequences).

1b. Do they just have a short memory about something they previously said?

People are notoriously inconsistent about their preferences and opinions, including those about hypocrisy itself, and may at different times believe that something is THE most important aim. "You must respect others' religious views" and "the rights of women should be upheld" may strike the same person as very highly important principles, but depending on the situation one particular view may be more salient than the other. As a result, they may segue from suggesting that westerners should leave religious minorities alone to advocating (or maybe even engaging in) strong intervention if women's rights are in some way compromised by a religious minority.

1c. A question of extent

If a person is vocally against a strong instance of a crime, are they a hypocrite if they commit a much milder version of the same (or very similar) crime? Unfortunately, we all have to live in a physical and practical world. It would be nice to always live up to the standards of a particular view, but this may not always be very practical...

1d. To what extent can they freely choose their actions?

Without wanting to get bogged down in a debate about free will, someone may be pressurised into selling out their views. If someone is threatened with job loss, blackmail, or even harm to their family they may be pushed into actions that contradict their genuinely-held values.

1e. Are their actions as an individual inconsistent with their views on broader societal issues?

The anarchist drawing the dole, the climate change warrior driving their petrol-burning car...If the person is vocally advocating for societal change, do their actions as an individual really have to stand up to what they are advocating for society at large? If someone speaks out against violence against women (a societal issue) but is controlling his wife with threats of violence, that's pretty damn hypocritical. However, the climate change warrior is probably only making a negligible contribution to the problem (whereas one battered wife is in itself a clear wrong). Furthermore, the advocate for societal change still has to exist in a society which may not allow them to function without contributing in some way to climate change (see also 1d above).

2. What's in it for you?

It's worth pausing to think why you want to accuse someone of hypocrisy.

2a. Is your key aim to prove your own point?

Are you using the person's hypocrisy about a matter as a way of "proving" that their stance on an issue is wrong? This is a logical fallacy. Maybe there are better examples, but a topical example in Ireland is that many pro-choice advocates seem to point out the (sometimes glaring) hypocrisy of various pro-life individuals or institutions and just leave it at that, without going on to make their own case for why the freedom to choose to have an abortion/bodily integrity outweighs the preservation of the fetus/embyro/zygote etc.* This can be self-sabotaging, as one misses out on the opportunity to showcase why your point of view makes sense in its own right.

2b. Are you trying to discredit the person, or their argument?

Pointing out hypocrisy may go some way towards undermining your opponent's argument/actions, or at least their rationale for speaking/acting this way. However, is the real agenda here to actually undermine people's perception of your opponent's character?

Given some of the issues raised above, most people with an opinion may come off as a bit hypocritical at some point. In this sense I wonder how much of a character assassination an accusation of hypocrisy really is (unless the really damning thing is some awful act they committed that they're now being a hypocrite about).

In any case, deciding what your key aim really is will help in making a more cogent case.

2c. Do you actually want to get through to the person?

If so...

3. How can you get through to the person?

Perhaps you really feel this is a moment where you can show someone the error of their ways, or at least a contradiction in their thought patterns. But consider...

3a. Do they actually care?

The expressed opinion of the person may simply be telling people what they want to hear, before pounding out business-as-usual in their actions.

It can be surprising how often one is fighting a lost cause.

3b. Will they think that you are just trying to discredit them as a person or just using their hypocrisy as a "proof" of your own point-of-view, or defence of your own actions?

If they think you're falling into some of the positions mention above, then they are unlikely to think that they're going to actually pick up anything worth learning by listening to you.

3c. If you're outlining their opinion, are you giving a fair account of what they've said?

As argued by Daniel Dennett and others, one should try and develop the best account of what your opponent is really trying to argue, or what the aims of their actions are, before you start criticising them. Going after a straw man is not really the best use of one's time.

Obviously these suggestions are easier to make than to follow. Just earlier I saw an argument online that seemed somewhat contradictory, and I nearly went off on a train of thought whereby I speculated that the person would engage in a number of other hypocritical arguments (that were purely imagined by me at this point). Had I put anything down in writing I'm sure I would be failing to heed a number of points here.

What a hypocrite, ay?

Related posts
Daniel Dennett book review
Being right wing and doing the right thing

*This is just an example of how someone might frame the debate on this issue; I realise people may have more/less utilitarian stances on this.

Saturday, March 18, 2017

Conference Review: American Psychosomatic Society Meeting 2017

There's a film-making legend that Michael Caine accepted a role in a particular movie immediately after reading the opening line "EXT. South of France. Day". When one sees "Seville, Spain" for a conference, this in itself could be sufficient reason to go. A beautiful city, bike-friendly but not so veggie-friendly (one menu helpfully lists a dish with eggs and fish under "vegetables"). But I'm here for the American Psychosomatic Society's Annual conference. Thanks to the generosity of their Young Investigator Program, I had registration fees written off this year, so with so many interesting talks on it was an offer I couldn't refuse!

At lunch the day before the conference proper began, one researcher was voicing a scepticism with findings from psychological research in general, at least in terms of their ability to translate into tangible outcomes for people in everyday life. Hey presto, here's a slide from the first morning session:

Not that the society hasn't concerned itself with the major issues of the day-the major addresses of this conference acknowledge the anti-intellectual spectre of the Trump administration, a source of anxiety for US researchers hoping to fund (and disseminate) their work. This breadth of focus of the society goes back to its beginnings. This being the 75th birthday of the APS, the opening plenary by Joel Dimsdale delved into the Society's history. Formed during World War II, there was a heavy focus on military psychology and the impact of combat. During the Nuremburg trials, a number of APS figures were involved in psychological profiling of Nazi war criminals, including a brain postmortem. Although the methods may have been outdated (an unblinded evaluation of Rorschach), it remains the only psychological study of cabinet-level war criminals. It'd be a difficult study to replicate!

On that note, perhaps some of the difficulty in getting research applied comes down to the replication crisis within psychology and other disciplines. If the research can't be replicated, it's unlikely to be applied, and statistical analysis that leads to false positives may confound the problem. A session on statistics in the post p < .05 era began with some fairly basic 101 on p-values (a tad dull to wade through, although a show-of-hands at the beginning did suggest a lack of understanding of p-values even in a professional audience). More interesting were the suggestions of tips on what to do next, such as using effect sizes rather than p-values for our benchmark for replication.

Larger sample sizes are one way of avoiding replication issues, and a session on the genomics era certainly delved into big data. From my own perspective a talk by Brenda W. Penninx was particularly interesting, as she focused on the genetics of depression. Her work had the interesting approach of both identifying genetic similarities between depression and other conditions, but also delving into the differences within depressive phenotypes (e.g. some people have lower appetite and sleep less, other sleep more and have a higher appetite). It will be interesting if she can show genes that are predictive of treatment response in future analyses.

A talk by David Clark on Friday really brought a focus to a national level, describing Improving Access to Psychological Therapies (IAPT) in the United Kingdom. Although IAPT targets depression as well as a variety of anxiety disorders, Clark grounded things by giving the specific example of social anxiety, and how cognitive therapy can address the thoughts and behaviours that can exacerbate anxiety in people with social anxiety. They've collected a lot of data from IAPT, which has been shown to be cost effective. It made me wonder why we can't do something similar in Ireland.

At the poster sessions, in keeping with trying to gain more replicable and generalisable results, a number of posters on various topics tapped into large cohort/prospective studies. It was also good to see other people covering caregiver research, with researchers from Madrid finding that psychological therapies could reduce blood pressure in dementia caregivers, and a systematic review from researchers in Bath, UK indicating that problem-focused coping in particular was associated with better outcomes in younger carers (aged under 18). Belgian researcher Natalie Michels presented a poster on microbiome research-this is another area of investigation that will be generating large datasets and will again challenge us to avoid false positives. With regard to false positives in abstract screening, my own poster on dementia caregiving was somewhat upstaged by a truly "interesting" poster beside it, manned by 5 or 6 Japanese researchers, which indicated in its rationale that different deities emit different forms of light. Provocative stuff...

In terms of "walking the talk", at least in our own lives, the conference had well-being sessions every day. Mindfulness sessions included mindful walking (which I attended; good fun) as well as loving kindness meditation and T'ai Chi. Un/fortunately, although the Society also strive to have healthy options at their conferences, the venue was rather keen to keep the pastries and treats flowing at the coffee breaks-as well as showing the Sevilla fondness for meat I mentioned above!

All in all this was a forward-thinking meeting, with researchers, clinicians and thinkers who weren't going to let the sunny weather stop them from focusing how to ensure our discipline remain relevant to life outside the academy.

Related posts
Conference Review: APS 2016
APS 2016: Young Investigator Colloquium

Sunday, February 26, 2017

Theatre review: Mic Drop

Gareth Stack, writer/director; Me, critic; Adam Tyrell, actor

Enter Perry Pardo. Successful entrepreneur; envied, rich, a go-getter. He had to work his way to top to become the man he is today, and if you're not willing to come with him, then fine, stay part of the 99.9%. Think of Tom Cruise's character in Magnolia, but instead of women, his conquest (or perhaps his enemy) is everyone else. 

Mic Drop, a new play from Gareth Stack, comprises a motivational talk by Perry Pardo, who must contend with indifferent AV staff, an audience that can never be as engaged as he wants, and his own demons to deliver his message of crawling your way to the top by any means necessary. But for all his go-out-there-and-get bravado, Perry is well aware that Ireland, and the world, are not meritocracies.

The script is finger-licking for any actor, and in the words of Pardo, Tyrell takes it and eats it with his f(ck)ng mouth. It's perhaps the most intense one-man performance I've seen since Jonathan Capdevielle's role as a serial killer (and his victims) in Gisele Vienne's production of Dennis Cooper's Jerk. Tyrell struts and frets his half hour on the stage like his life depends on it (no doubt Pardo believes that it does). Modafinilled out of his box, Pardo is itching for confrontation but has to content himself with feeding off the nervous quiet of the audience.

Mic Drop has its final performance tonight as part of the Smock Alley Scene and Heard festival. It is a 30 minute, abridged version of a longer play, but manages to pack more into those 30 minutes than most do in 90.  The unabridged version will be worth looking out for.

Related posts
Theatre Review: Autumn Royal

Saturday, February 11, 2017

HRB Seminar on Stress: Part II

Thanks to generous funding from the Health Research Board, we at UCC Dept. Psychiatry & Neurobehavioural Science and the APC Microbiome Institute were able to host an international research seminar. This was a chance for some leading researchers in the areas of caregiving stress to discuss their research and ideas.

Shireen Sindi of the Karolinska Institute in Sweden set the scene for our discussion of stress. She touched on classic work from the late sixties by Mason, highlighting key factors for producing a stress response, such as a stressor's unpredictability, its unfamiliarity and a person’s sense of control (or lack thereof). This work has since been borne out in a large review by Dickerson & Kemeny, who found that release of cortisol tended to be most clearly associated with such aspects of stress.

Dr Sindi made the interesting point that people may often lack insight into their own chronic stress levels, particularly in the case of physiological stress. This raises the question of whether self-report and physiological measures may show less concordance when tapping into more long-term stress. Speaking of long-term stress, she pointed out evidence that chronic stress in childhood may lead to very difficult-to-reverse changes in the amygdala (a region of the brain associated with processing emotion such as fear).

Brent Mausbach from the University of California at San Diego opened by highlighting a classic finding from Schulz and colleagues, indicating that caregivers were at increased risk for mortality at follow-up, specifically those with high levels of caregiver strain. He then discussed some of his own findings, looking at caregivers and whether they had depression and/or distress with challenging behaviours in the patient, with cardiovascular disease (CVD) as the outcome. Those who suffered from both depression and high distress in their caring role had an increased risk for CVD-a rather startling result.

Professor Mausbach went on to discuss some really interesting results from his group following caregivers over time in terms of measures of inflammation and clotting; interleukin-6 and D-dimer were higher in dementia caregivers compared to controls, and also increased at a sharper rate. These biological markers are associated with heightened risk of CVD, so these findings neatly suggest a biological mechanism as to how psychosocial stress can lead to negative health effects over time.

It wasn’t all bad news; he also highlighted promising preliminary data on treatment. The team at San Diego used behavioural activation (getting people to engage more in activities they enjoyed) as a way to treat depression in caregivers, thereby treating CVD risk. This behavioural activation approach, which allowed carers to develop their own tailored intervention, led to greater improvement than a typical intervention (education and support).

Kathryn Lord brought things back to basics, challenging assumptions underlying work in the area of caregiver stress, particularly the concept of “challenging behaviour”. Lord suggested that the classification of a given behaviour as challenging risks ignoring the perspective of the patient, who may act as they have genuine grievances with how they are being cared for. Dr Lord posited that a person-centred approach to care should inquire into the meaning of a patient’s behaviour, and whether they are trying to communicate something about their environment.

Dr Lord also warned of being too ready to attribute any behaviour that causes others difficulty to dementia. Patients with dementia can have pre-existing issues with others that can pre-date the dementia that can nonetheless be missed by care workers (or indeed family caregivers). 

Like Brent Mausbach, Dr Lord had some very nice intervention data from a randomised clinical trial for family carers using the START program. This program was developed by the Livingston team at UCL in the US, and Dr Lord’s team adapted this program for a UK population. Although it only lasted 8 weeks, START reduced the risk of depression at follow-up years later in the carers who completed it. It was also cost-effective; interestingly carer’s health costs actually went up in START group (perhaps due to increased health-seeking behaviour), but the patients’ health costs went down by more than the increase seen in the carers.

Noted intellectual-about-town Andrew P. Allen wrapped things up, highlighting similar themes in his own research that chimed with previous speakers, including immune data suggesting increased inflammatory cytokines in carers compared to controls, as well as a positive impact of psychosocial interventions for carers (with cognitive performance as the outcome). He also tied this area in with the brain-gut axis, mentioning evidence of altered microbiota in major depression, evidence from France of increased prevalence of IBS in carers as well as the potential for probiotic supplementation to attenuate stress.

Related posts:
HRB seminar on carer stress
He ain't heavy, he's my carer