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 ...

Breaking Down Personality

The story so far: We all want happiness and love and meaning in our lives. The people who have this tend to have positive emotions, an integrated personality, life satisfaction, and virtues (such as courage and wisdom). But to get there, we need to have a strong sense of self-awareness, we need to "know thyself."

Personality is adaptive and non-linear, and evolved from three basic systems: 1) Habit (non-rational, tied to basic emotions such as fear), 2) Propositions (rational, tied to secondary emotions such as empathy) 3) Narratives (rational and also self-aware, allows us to change).

The above is from a lecture last week at the American Psychiatric Association's annual meeting by leading personality expert Robert Cloninger MD, detailed in two blog posts (here and here).

Okay, let's break down personality. The slide you see below dates from Dr Cloninger's work in 1993. It breaks personality into two separate but interconnecting branches, temperament and character.













Temperament is about our habit systems (which roughly equates to the ancient Greek concept of the "four humors") namely:

1. Harm avoidance - The fear system that mediates responding to punishment and pain.
2. Novelty seeking - Looking for pleasure, which leads to rage when frustrated.
3. Reward dependence - Allows us to be sensitive to social cues that in turn allows social intimacy.
4. Persistence - Allows us to deal with expectations about whether we will get rewarded or not. We see it in very conscientious people.

But these traits don't stand alone. They're always interacting with the person's character, namely their view of who they are and how they relate to the rest of the world. You can describe these in terms of three cognitive sets: 1) Self-directedness, 2) cooperation, and 3) self-transcendence.

It's the communication between all these that allows us to say whether someone is healthy and in a state of well-being. This in turn influences your overall sense of who you are, which in turn allows you to shape the rest of your personality.

Thus, we have a model of mental self-government that allows us to regulate the competing urges from our basic biological drives.

Fine, but if our mental self-governance is closer to anarchy, can we impose order? If it's closer to autocracy, can we loosen the reins? In short, can we change?

Let's back up. Below is Dr Cloninger's "temperament cube," that he developed in 1987.















Don't worry. We will compassionately spare you the details. The gist of the model is the interplay between three of the four temperaments: novelty seeking (high and low), harm avoidance (high and low), and reward dependence (high and low).

Thus, someone with low harm avoidance tends to be carefree and risk-taking while those with high harm avoidance are characterized as anxious and pessimistic. Combine high harm avoidance with low novelty seeking and worlds collide.

Note, on the corners of the top we see the four Cluster B Axis II personality disorders, together with their prime descriptors, thus: histrionic (passionate), antisocial (adventurous), narcissistic (sensitive), and borderline (explosive).

The bottom corners produce another set of (opposite) extremes. Thus, the antithesis to someone with explosive borderline traits would be a methodical and obsessional individual. Fortunately, most of us don't cluster into the corners.

But life isn't that simple. This is where mental self-government and its three branches come in:

1. Self-directedness equates to the executive branch that implements the rules and allows you to be responsible, purposeful, and resourceful.
2. Cooperation equates to the legislative branch that gives you the rules to allow you to get along with other people, so you can be flexible, helpful, and compassionate.
3. Self-transcendence (judiciary) gives you the flexibility to figure out when the rules apply and don't apply.

Voila, the "character cube."














The ones who seek help, Dr Cloninger said, tend to be schizotypal or depressed. Thus, if we look to the bottom corner of the cube, in Dr Cloninger's words: "I had a patient of mine describe this as, 'Life is hard, people are mean, and then you die.'"

This contrasts with those who hit the character trifecta with the Jungian prize of enlightenment and all the goodies that go with it. Those with the Freudian prize of being organized can take comfort in the fact that they can at least love and work.

Thus we see a spectrum from transcendence to psychopathology, with a lot of room in the middle, meaning there is no true separation between normal and abnormal personality.

In the slide below, the upper case letters (S,C,T) stand for high self-directedness, cooperation, and transcendence, while the lower case letters (s,c,t) stand for their polar opposites. Red is happiness, blue is sadness.














Take a look. If you're low in all three, you're really going to be depressed. And seeing that personality is fairly stable, you are likely to stay depressed. Not good.

But here's the good news: We can change, and change can occur fairly rapidly. Stay tuned ...

Who the Hell Are We and What Does That Have To Do With Our Recovery?

Picking up from where we left off:

It turns out the most consistent way of recognizing that someone is in a state of well-being is how well they've been able to express self-directedness, cooperation, and self-transcendence in their lives.

This translates into meaningful work, mutually caring relationships, and a sense of what's really important beyond out individual needs.

So says personality and well-being expert Robert Cloninger MD of Washington University (St Louis). Dr Cloninger was addressing a packed house at the American Psychiatric Association's annual meeting last week in San Francisco. I was in the audience as a journalist.

Medications are useful in getting us to stable, Dr Cloninger advised, and in putting us in a position to get started. Then the real journey begins. It all starts with knowing ourselves, having a sense of growth and self-awareness.

So who the hell are we?

Well, before we answer that question, we might first ask ourselves to define personality. Dr Cloninger's simple explanation: "It's the way we learn and adapt." Let's amplify that: "It's the self plus the internal and external forces that pull on the self."

Key features of personality, Dr Cloninger said, include:

• It's dynamic, and non-linear. "Get over the idea that it's fixed and written in stone."
• It is psychobiological, which includes the body, the analytical mind, and the intuitive and creative mind.
• It is organized. There is a basic design in all human beings that allow us understand and to communicate with each other.
• It is personal. Adaptive processes occur within the individual. We tend to get sidetracked comparing the differences between people, which is wrong. If we want to motivate someone, we need to figure out what is going on within them, what counts to them.
• It is idiographic. We are each unique.

Here's a key fact we tend to overlook: We have evolved over millions of years, and with it three major systems of learning and memory.

1. Habits and skills learning: Reptiles have this nailed. This is based on the quantitative strength of our synaptic connections. It is prelogical, not rational, and subjectively linked to basic emotions such as fear and anger and ambition. These habit systems demand instant gratification and tend to get in conflict with each other.
2. Semantic learning of facts and propositions: Mammals rule in this department. It is contingently logical and rational in a hierarchical sense, and is associated with secondary emotions such as empathy. Propositions bring order to the chaos of the demands of our basic emotions, but is not self-aware.
3. Intuitions and narratives: A uniquely human trait, the recognition that we are writing our own story. At once, we talking about pre-verbal and intuitive, rational and self-aware, modular rather than hierarchical. Here's the pay-off: "It gives us flexibility about the future. We can change. We can have hope. We can be creative and do things we've never done in the past and surprise everybody."

Ah, now we're getting somewhere. We've just gotten past the Table of Contents. Now we can begin to check out our Owner's Manual in earnest. Think of the slide below as a sneak preview.













Trust me, "Know Thyself" is where recovery starts, and Dr Cloninger is the leading authority. Much more to come ...

What the Hell is Well-being, Anyway, and Why Is It So GD Important?

Good title for a talk? Psychiatry tends to veer toward wonky titles, such as: "Developing a Positive Psychiatry of the Person."

Okay, let's go with that. Last week in San Francisco, at the American Psychiatric Association's annual meeting, I heard Robert Cloninger MD of Washington University (St Louis) deliver the type of lecture that justifies his reputation as a pioneer in that strange field that we simultaneously know everything and nothing about: personality and well-being.

"Well-being is the universal wish of human beings," Dr Cloninger opened. "We all want happiness, love, and a meaning of life that is greater than our individual self."

Obviously, this is something that you can't get in a pill, and therein lies the problem with our treatments. Response to acute (initial phase) treatment, whether with meds or talking therapy, is only moderate, and drop-outs, relapses, and recurrences are high.

But if clinicians are smart, Dr Cloninger went on to say, they will attend to what people want in life and build therapeutic alliances around that. On the other hand: "Getting people to do things they don't want to do doesn't work well."

There are four converging ways to measure well-being, Dr Cloninger told his audience:

1. Emotions: Namely positive ones, ie being happy.
2. Personality: It turns out that positive emotions relates to maturity in character. People who have a well-integrated personality also turn out to be happy.
3. Life satisfaction: People who are content with their lives don't have a lot of complaints.
4. Virtues: People who have them (courage, justice, moderation, honor, wisdom, patience, love, hope, and faith) also tend to be happy, mature, and satisfied with life. Reframing a goal to work on developing courage, for instance, may produce a better outcome than figuring out what to do with an anxiety disorder.

Well-being has little to do with income. Rather, there is an association with heritable personality traits, plus with meaningful work, mutually caring friendships, and spiritual values. Dr Cloninger cited Ed Diener's pioneering work that showed while personal income in the US has dramatically increased from the 1930s to the present, life satisfaction has remained static.

Over this time period, we have seen the introduction of all our psych meds and all our manualized therapies. We know these things are helpful, Dr Cloninger said, but "why isn't it making a dent" in these statistics?

So what's the key to well-being? It all starts with self-awareness, Dr Cloninger advised.

Check out the name of this blog. Much more on Dr Cloninger to come ...