Thinking Our Way to Well

This is my fourth post that reports on a lecture on personality and wellness by Robert Cloninger MD two weeks ago at the American Psychiatric Association's annual meeting in San Francisco.

The first three pieces:

What the Hell is Well-being, Anyway?
Who the Hell Are We?
Breaking Down Personality

We left off with the proposition that although personality is heritable and stable, we can change. To pick up ...

Change is a very nonlinear dynamic process. We tend to maximize our strengths to move in more positive directions. By contrast, if we deteriorate we tend to maximize all our weaknesses.

We are shaped by the interactions between our genes and environment, and our self-awareness (a uniquely human trait) allows us to modify our environment. So what happens when we grow up in a hostile home environment?

Dr Cloninger cited a Finish study that followed 3,600 kids from birth to adulthood. Among other things, the findings showed the effects of growing up with parents who were either overly strict (tending to bring out anger and novelty-seeking) or overly neglectful (tending to bring out anxiety).

An angry or anxious individual is going to be restricted in reacting to his environment. This is because if you get the limbic system, the emotional brain, all charged up and defensive "you shut off reasoning."

(Have you ever tried to reason with someone who is angry or anxious?)

Brain imaging studies amply demonstrate the over-reactive limbic system at work, but the same body of research also shows activity in the prefrontal cortex (PFC). A 2001 study that Dr Cloninger was involved in demonstrated a correlation between heightened left dorsal medial PFC activity and and those with high "self-directedness."

Translation: The thinking parts of the brain can transcend the emotional brain. Instead of blindly reacting or engaging in avoidant behavior, well-adjusted individuals evaluate what is going on inside them.

So - how to engage these recently-evolved rational parts of the brain to mobilize change? Okay, take a guess: How many thoughts do we have per second?

Answer: Ten, as in ten thoughts a second. Try snapping your fingers as fast as you can - your thoughts are going way faster. What's remarkable is that when a person has a new thought or looks at something from a new point of view, "ALL the connections in the brain shift just like that."

So we're not sending messages by neurotransmitters down highways. Rather, we are going from Point A to Point Z in the brain. (Think quantum change.)

Below is a diagram of how the internet was connected in 1999. We are looking at long tracks that connect local networks.














There is another property. Complex adaptive systems operate like nonlinear thermodynamic systems. "Stable State A," for instance, may be okay, as everything nearby is worse. But "Stable State B" (that manifests a gain in potential energy) is where you want to be. But activating the energy to get from A to B tends to involve perturbations that initially makes one feel worse.

"You have to go through this valley of tears to get there, and that's painful."

Psychiatry tends to be focused on "keeping people close to their local optimum," in other words at Stable State A.

Development is a spiral, Dr Cloninger told his audience. You can spiral up or spiral down. You need to seize on your strengths to get through your pain.

Hold that thought. More later ...

Blueprint for Recovery - YOU Are the Authority

Last week, I spent three days at a schizophrenia conference listening to some of the smartest people in the world, and I have the autograph of a Nobel Laureate (Arvid Carlsson) to prove it.

But the people I learn from the most is you - patients and loved ones - and I have this month's latest survey to prove it.

"What is holding you back most in your recovery?" I asked you over the month of March. Readers were free to check off as many of the nine answers as they wished. (169 respondents accounted for 490 answers, averaging 2.9 answers per person.) You could have knocked me over with a feather with the results:

Only 35 percent of you checked off, "Unresolved illness symptoms." In other words, a full 65 percent of you felt that your illness no longer posed an obstacle to your recovery.

Does this mean psychiatry has a high success rate? Um ... not exactly. In my January survey, only 14 percent of you told me that you "were back to where [you] wanted to be or better than [you] ever could have imagined."

What is going on here? Could it be that we have other stuff we need to deal with? This is where it gets interesting:

Fifty percent of you (representing by far the largest total) responded that the thing holding you back the most is "fears/difficulties in dealing with people." Very closely related (at 35 percent) is "bad living/work/etc" situation.

Clearly, we have major interpersonal issues that need addressing. Without doubt, our respective illnesses play havoc with our ability to get along with people. But you are telling me that people problems have taken on a life of their own, and it's not hard to imagine why.

Often, we can't go back to our old relationships or work. As we become isolated and cut off, our social skills atrophy. We lose confidence. We are overwhelmed.

Half of you are telling me that you see the world as a threatening and hostile place, and this does not bode well for recovery. We tend to judge personal success by how well we get along with others. Unfortunately, there is no magic pill to help us. But there exists a lot of therapeutic and social help. You have identified this issue as your top priority. Please do not hesitate to act.

Also related to this (at 32 percent) is "inability to manage fears, impulses, etc apparently unrelated to your illness." Maybe you don't attribute, say, anger, to your illness. Maybe you talk too much or are afraid to speak up. Maybe going with an irrational thought makes you feel good. These are common problems that the general population also experiences, but you have added this twist - your sense of lack of control is holding as many of you back in your recovery as unresolved illness symptoms.

Your clinician may have overlooked all this, but clearly you haven't. You know what you need to do.

We all have "bad personal habits" (even those with good personal habits), but 36 percent of you felt they were impeding your progress. Likewise, 30 percent of you report that "making excuses" constitutes a major problem.

Congratulations at setting out a recovery agenda: You need to change; no excuses. But do keep in mind: Change does not come easy. Set modest goals, forgive yourself when you mess up, and make full use of peer and professional support.

Finally: Meds side effects (24 percent), addictions (21 percent), and physical ailments (21 percent).

Take home message: There is no such thing as "just depression," "just bipolar," "just anxiety," and so on. A lot of other stuff is going on. Whether wrapped in your illness or independent of it, it all needs to be addressed, because if it isn't - recovery is simply not going to happen

I can say this with great authority, because this is what you - my valued readers - have told me. Be smart. Live well ...

Previous survey results:

Have Our Treatments and Therapies Failed Us?

Meds and Wellness: Like Rolling a Rock Uphill?

Meds and Wellness: Like Rolling a Rock Uphill?

"How do you rate your meds in managing your illness?" I asked my readers here in survey that ran through the month of February. The results, quite frankly, astonished me.

Fifty percent responded that meds were their single most important tool and another 32 percent that their meds were "important, but no more so than their other tools." In other words, four in five patients put meds at the top of their list, either as a solo act or with a dance partner.

As for the one in five: A mere three percent said meds were less important than their other tools, just five percent said their other tools were way more important, and another five percent assigned no importance to meds (or were not on meds).

Why am I surprised? In the 10 years that I have immersed myself full-time in researching my illness and listening to patients and loved ones, never once have I come across an "end-user" who has told me of writing a letter of appreciation to Eli Lilly or some other manufacturer or talked about starting up, say, a Seroquel fan club.

To the contrary, all I hear is complaints. Meanwhile, over the same 10-year period, I have witnessed the rise of the recovery movement, which acknowledges the role of meds in our getting better but takes a dim view in their ability to get us well.

What gives? Has everything I've heard all these years been wrong? Have meds been given a bad rap? Are they really much better than patients have been letting on, way decidedly better?

Not exactly. No, in fact. Make that unequivocally no. The month before, I polled my readers on how well they are doing. One in four replied they were "in crisis or close to crisis." Four in ten reported they were "stable but not well." Just one in five said they were on the way to recovery, and only 14 percent responded that they were back to where they wanted to be or better than they ever could have imagined.

Granted, neither poll was scientific. My readership may not reflect the patient population at large. Moreover, those who answered my second poll may not be the same people who responded to my first. But even taking all that into account, we are looking at numbers that boggle the mind, namely:

82 percent who rate their meds as their number one management tool vs 14 percent who are actually well.

Holy crap!

Four years ago, I came across a far more scientific survey conducted by Melbourne researcher Sarah Russell PhD. Dr Russell recruited a hundred bipolar patients who were doing well (either symptom-free and behaving normally or having a sense of control over their illness) and asked them what they did to stay well. Meds figured in the equation, but they were way down low on their list of priorities.

Instead, the people Dr Russell talked to emphasized various mindfulness and stress reduction techniques, rigorous sleep management, smart life decisions, and so on.

Dr Russell's findings are more in accord with my own experiences and those of "well" patients I have encountered, namely:

When we're new to our diagnosis, or in crisis or heading into crisis, our meds loom large. "Snapping out of it" and "getting a grip" are simply not options. Our brains are overwhelmed. We don't know what hit us. We need our meds to do the heavy lifting.

That changes further into the game. Our brains start to boot up. Our thinking comes back on line. We start finding out everything we can. Over time, we acquire much greater wisdom and insight. We pick up a vast range of coping and management skills.

As we become more adept, our meds assume far less importance. We may still be taking them (generally in reduced doses or on an as-needed basis), but we're simply not thinking about them as much. We are thinking far more, instead, about the things that have an impact in the here and now, such as stress and sleep.

For instance, for many of us, missing a good night's sleep is far more likely to result in personal disaster than missing a meds dose. Paradoxically, the key to getting a good night's sleep may be taking a sleeping pill.

The "well" patient understands this. Unfortunately, if my two polls are anything to go by, way too many of us are not there yet.

Much more on Dr Russell's study and related issues in future blogs ...

From mcmanweb:

Staying Well

The patients informed Dr Russell that they were extremely mindful of their diagnosis and “how they were responding to their mental, emotional, social, and physical environment.” Rather than simply taking their meds and forgetting about their illness (an impression created by their doctors), patients would “move swiftly to intercept a mood swing.” Moving swiftly often meant a decent night’s sleep and other strategic stop and smell the roses moments.

Have Our Treatments and Therapies Failed Us?

"What best describes your condition in the past 30 days?" I asked my visitors, here at "Knowledge is Necessity." Nearly 200 people replied over late Dec and Jan. The results were not exactly encouraging:

Nearly one in four (24 percent) replied they were in crisis or close to crisis. Four in ten (42 percent) reported that they were stable but not well. Thus, a full six in ten of those who responded to my poll indicated that they are in pretty bad shape.

Contrast these results to the mere 14 percent who were evenly divided in being back where they wanted to be or better than they ever could have imagined.

In the middle, one in five (18 percent) reported they were on the way to recovery. Hopeful or false hope? Who knows? Perhaps we can split the difference.

No matter which way you parse the totals, the results are not encouraging. Granted, the poll is unscientific. Granted, the results could be totally skewed. But even accounting for all the distortions in the world we have clear evidence that our treatments are failing us, our therapies are failing us, and - let's apportion blame responsibly, here - we are failing us.

One advantage of this simple poll over far more sophisticated surveys is that those who responded were the judges of their condition. Patients, themselves, defined success or failure by their own criteria. In clinical trials and other studies, doctors typically fill out a symptom checklist (with patient input) and interpret the results. Having few illness symptoms typically means you are well, even though you may not feel well.

The world we live in is far different. For a lot of us, we have other things to deal with besides just our illness symptoms. On the flip side, a lot of us have learned to lead very enviable lives, despite a huge panoply of symptoms.

"Well" is how we define well, not how others define it for us. Even accounting for the fact that people who go online to find out more about their illness may be worse off than those who don't, we are dealing with an astronomical 86 percent who reported feeling well short of well.

Something is clearly wrong.