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The Magic of Science
Dr. Oliver Sacks
New York, NY
Oliver Sacks is a real-life Harry Potter, all grown-up. His fascination with science began in London in the late 1940s around the time he discovered the periodic table in the local museum’s chemistry gallery. Dr. Sacks likened that discovery to “seeing God” and has compared Mendeleev to Moses.1 These revelations lend insight to the intensity of Dr. Sacks’ fascination with science and learning. There is nothing blasé about this scientist—he is passionate, daring, and he has an uncanny ability to sprinkle medicine with a bit of magic by treating “untreatable” patients and explicating the most esoteric disorders of the brain.
Raised by physician parents, Dr. Sacks grew up running from the library to the lab, falling in love with the noble gases and gobbling up books about his scientist heroes. He maintained his zeal for biology and chemistry into adulthood, receiving his medical training at Oxford. He came to the United States in 1960 and finished his residency in neurology and neuropathology at the University of California, Los Angeles. In 1965 he migrated to the Bronx, NY, where he met the patients who would inspire him to explore unfamiliar and long-forgotten medical terrain and begin his writing career
Specifically, a group of 1,000 migraine patients at Montefiore Hospital—who had disturbances of speech, hearing, taste, touch, and vision—peaked his interest in how aberrations in the brain’s system of perception change the nature of reality. Dr. Sacks also became interested in how the brain adapts to these challenges.
Many of the patients at Montefiore described migraine-associated auras, but the neurology texts of the time contained no references to “aura.” It was only when Dr. Sacks began to dig through the rare bookshelves in the college library that he found extensive references to auras in the works of a Victorian physician named Edward Liveing. This research and the ideas it spawned eventually became the basis for his first book, Migraine.
Dr. Sacks found inspiration for another book at Beth Abraham Hospital, also in New York, where he became involved with an abandoned group of patients: people who had contracted encephalitis lethargica, otherwise known as “sleepy sickness,” in the global encephalitis epidemic of the 1920s. For more than 40 years, no known treatment could restore movement and language to these patients. Dr. Sacks’ work with this group and his unorthodox use of a new drug, L-dopa, which seemed to magically bring these “frozen” patients back to life for a short period of time, was chronicled in his book Awakenings. A British documentary based on the book followed, as did a play by Harold Pinter and an Oscar-nominated film starring Robin Williams and Robert DeNiro.
Dr. Sacks is now the author of nine published books, including the well-known The Man Who Mistook His Wife for a Hat, which includes intriguing case reports on a variety of neurological disorders, including Tourette’s syndrome and autism. He has also written about color blindness and deafness. His recent books include Oaxaca Journal, an account of a trip to Oaxaca, Mexico, with a group of fern enthusiasts, and Uncle Tungsten, which describes his childhood in wartime England and his early fascination with light, matter, and energy.
Throughout his work, Dr. Sacks reveals himself to be an intensely curious risk-taker. He takes an interest in things others have dismissed—oftentimes rare behaviors such as those seen in Tourette’s syndrome and autism—and his curiosity sends him on an intellectual escapade. He combs through libraries and devours long-forgotten medical literature, jumping into the worlds of bygone physicians, philosophers, and poets.
Unlike most other contemporary physicians,
Dr. Sacks is able to integrate medicine and the arts, and uses this skill to hone his understanding of how the brain works, what happens when things go wrong, and what this means for human beings.
In our evidence-based age, it is statistics and outcomes that get respect. But Dr. Sacks has given back power and validity to the observational prowess of the physician.
In his work, Dr. Sacks also elevates the role of the patient to that of the hero. He is keenly aware of the human individuals at the heart of his chronicles; his interest in their neurological symptoms is matched by sincere compassion. That is part of what makes his writing so interesting—it is as inspiring as it is intellectually stimulating.
When Dr. Sacks is not writing, he is busy working as a clinical professor of neurology at the Albert Einstein College of Medicine, an adjunct professor of neurology at the New York University School of Medicine, and a consultant neurologist to the Little Sisters of the Poor and to Beth Abraham Hospital, all in New York City.
Whether writing, consulting, exploring, or theorizing, Dr. Sacks finds and creates magic in life and then shares it with the world. For Dr. Sacks, everything the world encompasses is cause for interest and exploration, if not pure love. In the course of his career he has made discoveries, recreated a literary genre, treated patients, and kept a large portion of the thinking population educated and deeply moved at the same time. It is quite a legacy. �
News from the Field
Trauma Victims Find Solace in Telling Their Stories
A psychiatrist who works with refugees of political violence urges a multidisciplinary approach to understanding and structuring victims’ testimonies. Stevan Weine, MD, associate professor of psychiatry at the University of Illinois, Chicago (UIC), recognizes the power of testimony for victims of serious trauma. After listening to Bosnian refugees’ stories of having survived ethnic cleansing in the 1990s, he wanted to offer an alternative to the prevailing cognitive approach to treating trauma-related stress. He says, “The cognitivist approach pays too little attention to context, to collective dimensions, and the survivors’ desire to find meaning from the experience of trauma.” In a pilot study of eight female and 12 male adult refugees and survivors of ethnic cleansing who resettled in Chicago, Weine was able to determine whether giving testimony helps the survivor recover. He defines testimony psychotherapy as “a brief individual method for working with survivors of state-sponsored violence. The survivor and therapist establish a working alliance to enable the survivor’s story to be told and documented. The therapist is informed about the state’s political, social, and cultural history to put the story in the appropriate context and ensure its truthfulness.” In this way, the therapist helps the survivor to express his or her struggles with meaning and morality without imposing judgment.
Weine used this method in his pilot study and found the rate of Post Traumatic Stress Disorder among subjects to be significantly decreased from 100% to just 53% at six months after treatment. Severity of symptoms such as nightmares and flashbacks and symptoms of depression also decreased significantly, with a substantial improvement in overall functioning.
Similarly, writing and visual art are powerful vehicles for communicating individual and collective experiences of trauma. The process is often therapeutic for the survivor and the work can educate the public. Migael Scherer, a woman who was raped 15 years ago, says it was important to her to continue to write. Her struggle to recover is chronicled in a journal titled Still Loved by the Sun. Many readers wrote Scherer about their reactions to the book. She says, “Survivors of rape said that I expressed what they felt. People with relatives who had been raped said they now understood why life was so hard for them.”
According to Stevan Weine, “the challenge for practitioners and scientists is to learn from art and literature born from trauma to counter the tendencies to construct trauma as an object and healing as a mechanism.”
Source: Psychiatric News
Board Game to Help Parkinson’s Disease Patients
The European Parkinson’s Disease (PD) Association has introduced an interactive education resource which uses a board game format online to engage patient interest and improve understanding about PD and strengthen recall. The board game, named Parkinsonpoly, is modeled after Monopoly and will help doctors communicate information to patients regarding their illness. The game consists of various educational tools including the website, booklets, and other materials using visual imagery to help patients recall and grasp the
information. Much of the information on PD can be confusing and overwhelming for someone with PD to understand. Parkinsonpoly is designed to give people with PD a concise, reliable resource to visual information to help them improve their quality of life. Parkinsonpoly can be accessed at www.parkinsonpoly.com.
Source: PR Newswire.
Brain Senses Pain of Others
According to a recent British study, seeing a loved one endure pain activates the brain region which processes pain, indicating a possible neurological explanation for empathy. The research bolsters separate findings which show that the way people understand the experiences of others is by simulating the same emotions in their own mind.
In the study, sixteen couples were hooked up to MRI machines and placed next to each other. However, each couple could view only the other’s hand, which was hooked up to an electrode delivering short bursts of electricity. A computer screen showed whose hand would be zapped and how intense the shock would be.
When the women were shocked, brain scans showed activity in various regions, including the anterior insula and anterior cingulate cortex (areas which control
the emotional experience of pain) as well as the somatosensory cortex (where touch is perceived).
When the women’s significant others were shocked, the somatosensory cortex remained inactive. However, the emotional areas of the brain were mobilized, pointing to the conclusion that they had recreated the neurological experience of pain without physical stimulation. The recreation of emotional pain in the women’s brains effectively allowed them to “feel” their partner’s pain.
“It’s rather surprising that we tune into the experiences of others so quickly and with an emotional response, not just with a cognitive personality,” said
Dr. Tania Singer, a research fellow at the University College of London and the lead author of the study. However, whether empathy is genetically programmed remains unclear due to the fact that the subjects showed empathy towards their partners, but not strangers.
Future Not Hopeless For Violence-Prone Youth
More and more research shows certain psychosocial approaches and psychoactive drugs to reduce relapse rates among violent youth and even save taxpayers money in the long run. At the annual meeting of the American Academy of Psychiatry and the Law, the organization’s president, Roy O’Shaughnessy, MD emphasized that current government policies advocating a “tough on crime” approach can do more harm than good. He also stressed the importance of forensic psychiatrists, who are in a prime position to shape US policy on the management of violent youth due to their unique ability to bridge the gap between medicine and the law.
O’Shaughnessy noted that violent adolescents have high rates of mental illness, and so the increasing numbers of juvenile offenders being tried as adults is resulting in detrimental ramifications. Such consequences include longer periods of incarceration, during which these youth are more likely to be victimized and have higher suicide rates, and a higher probability of committing violent crimes once the sentence has been served. One study by Linda Teplin, PhD and colleagues, found that 60% of males and 67% of females in juvenile detention met DSM-IV criteria for at least one psychiatric disorder, excluding conduct disorder.
Of course, psychiatric illness alone does not predict violence in youth. However, if combined with environmental or psychosocial factors-low socioeconomic status, poor parenting, and/or association with gangs-the chances a young person will become a violent offender are significantly increased. In light of this, O’Shaughnessy claims early detection of psychopathology in children can provide the impetus for interventions which can help clinicians “reduce exposure to other risk factors and prevent some of the reinforcement of antisocial values,” thus preventing further violence.
Source: Psychiatric News
“Abide with Me” Tops the Charts as Number One Musical Hallucination
In a study of people who experience musical hallucinations, the hymn “Abide with Me” was found to be the melody most commonly heard by such patients.
Nick Warner, from the St. Cadocs Hospital in Caerleon, South Wales, presented his findings at the Royal College of Psychiatrists’ Faculty of the Psychiatry of Old Age Meeting in Liverpool, UK. Warner said that Christmas carols were also frequently heard.
Hearing Christmas carols may be more a result of the repetitive volume of such songs over a lifetime of Christmases, whereas “Abide with Me” may be popular for giving a subconscious sense of hope to patients. The hymn alludes to personal struggle and religious guidance. Written by Harry F. Lyte, the first verse of the song begins:
Abide with me,
Fast falls the eventide,
The darkness deepens,
Lord, with me abide.
Warner and co-workers recorded and analyzed the musical hallucinations experienced by 30 people whose average age was 78 years. The majority of the participants were women living alone and one-third had significant hearing impairment.
Seventy-percent of these participants were able to name the tune they hear during their hallucinations. Overall, 60% of patients hear religious music, usually sung by a choir. Secular melodies, although heard by only one individual each, included “Show Me the Way to Go Home,” “The Red Flag,” and “Don’t Cry for Me, Argentina.”
Five people heard mainly Christmas carols, including “Silent Night” and “Hark the Herald Angels Sing.” Out of 30 individuals, six heard the hymn, “Abide with Me.”
Warner was quick to note that age, musical taste, and religious affiliation may play a factor in subconscious song selection. “I think it is going to change because we are becoming more secular. We are not so religious these days and there is much pop music played,” he noted.
Source: MF news services.
Ecstasy Approved for Medical Study
A South Carolina psychiatrist has won recent FDA and DEA approval to conduct the first study testing methylenedioxymethamphetamine (MDMA), or ecstasy, as a therapeutic tool. The FDA approved the study in 2001, but it has taken two years to find an institutional review board who would sanction the study.
The study, which will be conducted by Micheal Mithoefer, MD, will involve 20 women who suffer from posttraumatic stress disorder (PTSD) as a result of sexual assaults or other violence, and who have not responded to previous treatments. Twelve women will be given MDMA prior to psychotherapy sessions with Mithoefer, while the other eight will be given a placebo.
MDMA, a Schedule I drug, has (along with heroin, cocaine, and LSD) previously been considered to have no medical usage.
“We owe it to them,” said Mithoefer, referring to patients suffering from PTSD. “It would be irresponsible of the medical community not to investigate something like this.”
All participants will undergo psychiatric screening and a physical exam to screen for risk factors, such as high blood pressure. MDMA is also known to cause overheating. The subjects will be given the drug only once or twice during the study and will be under supervision for the period of influence.
In the late 1970s, psychiatrists experimented with prescribing MDMA to patients with PTSD and others suffering from anxiety. While MDMA is stimulating, it also decreases anxiety, possibly helping people to feel calm and comfortable enough to talk about painful subjects.
Some doctors imagine this treatment to be a sort of psychotherapeutic anesthesia, allowing full recall of a traumatic event while remaining calm and comfortable enough to explore it. Julie Holland, MD, of New York University, and author of “Esctacy: A Complete Guide,” said “because you can anesthesize the patient to some extent you can get to that malignant core in one or two sessions instead of three to four years.”
There is some opposition to this approach, however, claiming effective treatment of PTSD requires head on confrontation of their trauma. “If you are calm, you are not getting to the root of the problem,” said Scott Lilienfeld, PhD, a psychiatrist at Emory University who has done extensive research on PTSD
Postnatal Depression May Trigger Adolescent Violence
According to a recent study reported in Developmental Psychology, depression in mothers after delivery increases the risk of violence in the child later in life.
Dale Hay, PhD, and colleagues from Cardiff University, in Wales, surveyed 122 families in south London, tracking their children extensively from infancy up until age 11. Mothers were assessed for postnatal depression when the child reached the age of three months, and 1, 4, and 11 years. At age 11, the mother, child, and his or her teachers were interviewed about any violent behavior of the child.
Results showed that boys whose mothers were depressed postnatally were at an increased risk of becoming aggressive and violent as they matured. Findings of the study also showed violence to be associated with symptoms of attention deficit/hyperactivity disorder and problems with anger management.
Additionally, compared to other intervals, maternal depression when the child was three months old seemed to have the greatest influence. Researchers reported the most violence was detected in children born to mothers who had been depressed at three months after delivery and at least once thereafter. However, while there was a significant influence of maternal depression on boys, girls seemed surprisingly less vulnerable.
From these findings researchers postulate that attention and emotional problems displayed by depressed mothers have a biological, possibly hormonal, effect on the child. However, there can be another explanation of this phenomenon from a different angle. Researchers also find it possible that babies of inherently difficult temperament may provoke depression in mothers, and rather the child’s behaviors are affecting the depressive state of the parent.
Source: Dev Psychol
FDA Gains Long-Sought Power To Order Pediatric Drug Testing
After years of frustration, the FDA finally has the authority to require the study of drugs’ safety and efficacy in children.
After nearly ten years of fruitless efforts, the FDA has gained the authority to force drug-makers to prove their medications safe and effective in children and adolescents.
Since 1997, when Congress first required the agency to “promote research into pediatric use of adult medications,” the FDA has struggled to gather data on the safety and efficacy of medications which are prescribed everyday for children without the evidence base to support this use.
The agency first developed the concept of “pediatric exclusivity”—voluntary submission by drug manufacturers of minimal data on the safety of their medications in children in exchange for extended patent protection. When the exclusivity program proved not to be very productive, the agency formulated the “pediatric rule” requiring submission of the data included with any new drug application. In October 2000, however, the pediatric rule was struck down in federal court when justices agreed with industry claims that the FDA lacked the statutory authority to require the research (Psychiatric News, September 19, 2003).
The law grants the FDA the authority to require the submission of data on safety and effectiveness, as well as on dosing and administration, as part of any submission of an application for approval of a new active ingredient, new indication, new dosage forms, new dosing regimen, or new route of administration.
If the course of a disease and the effects of the drug treating it are “sufficiently similar in adults and pediatric patients,” the FDA may waive the requirement. Essentially, if it can be concluded that “pediatric effectiveness can be extrapolated from the adequate and well-controlled studies in adults,” then the requirement is less needed.
Also, if adult studies are completed significantly in advance of pediatric studies, a drug may be approved for adult use, with a date set for subsequent submission of pediatric data.
The new law should significantly boost the study of psychotropic safety and efficacy in child and adolescent populations. To date, only two such medications have indications for pediatric use: Fluoxetine (Prozac), for major depressive disorder in patients aged 7 years and older and obsessive-compulsive disorder in patients aged 8 years and older; and atomoxetine (Strattera), for treatment of ADHD in patients aged 6 years and older. Fluvoxamine (Luvox) has pediatric safety dosing information for patients with obsessive-compulsive disorder aged 8 years and older included in its approved labeling, but does not carry a pediatric indication.
The Right Brain/Left Brain No-Brainer
by Dr. John Ratey, MD, and Dr. Catherine Johnson, PhD
Drs. Ratey and Johnson are coauthors of Shadow Syndromes now in paperback (Bantam).
Which Side Are You On?
In his discovery of the unconscious mind, Freud articulated the vague sense most of us have that we harbor another being within. Whether we are speaking of conscious versus unconscious, parent versus inner child, or Dr. Jekyll versus Mr. Hyde, human beings have long sensed the possibility that within each skull there exists two different souls: one public and one hidden from view.
No doubt this ancient perception—which can be traced back to the ancient Greece philisophes—accounts for the tremendous popularity of Roger Sperry’s split-brain studies in the 1960s. He observed individuals who had the corpus callosum of their brains severed to control severe epilepsy. The corpus callosum is a thick bundle of nerves which connects the hemispheres; in these people, the two sides of the brain now function independently.
The right side of the brain controls the left side of the body, and the left side of the brain controls the right side of the body. When Sperry and his team tested split-brain patients in a variety of tasks, they produced some very strange results. When split-brained patients held a familiar object, such as a pencil, out of sight in their left hands, they could not say what it was. When the same patients held the pencil out of sight in their right hands, they could name it easily.
Through these experiments, Sperry and his colleagues demonstrated that the two hemispheres of the brain are dominant for different types of tasks and thinking. Left equaled language, math, and verbal intelligence; right equaled body language, music, creativity, and visual-spatial processing. Only when patients used their right hands (connecting to the talking left hemisphere) could they find words to describe what was in them. To the extent that these researchers considered emotion at all, they assigned it entirely to the right. The right brain was emotion, the left reason.
The Better Side?
Although neuroscientists of the 19th century already knew there were significant differences between the two hemispheres, in the second half of the 20th century the public became mesmerized by this fact. In short order, popularizers began to describe people as being either “left brained” or “right brained.” It being the 1960s—the right brain came out as “better” than the left. The whole problem with the West, people said, was that we are left-brain dominant. The Western preoccupation with reading, writing, and coolly reasoning things through had isolated us from our dreaming, impressionistic, nonlinear right selves.
By the 1970s, right-brain enthusiasts had spawned political and ideological movements advocating right-brain teaching in the classroom, right-brain visualizing at work, and right-brain emoting at home. Entire groups of people—invariably non-Western, non-white, or non-male—were said to be right-brain dominant and applauded as models of the intuitive life.
Of course other thinkers in other times have argued exactly the opposite. Robert Louis Stevenson’s Dr. Jekyll and Mr. Hyde was based upon his understanding of the right brain as brutish and animal, the left as the locus of language and civilization. Dr. Jekyll was left, Mr. Hyde was right.
Interestingly, 20th-century science tells us there is something to be said for this view. In The Right Mind: Making Sense of the Hemispheres, Robert Ornstein, PhD, reported the real-life case of a split-brained man who threatened his wife with his left hand while his right hand tried to push the left away. Since the right brain controls the left hand, it was the patient’s right brain that wanted to hurt his wife, while the sensible left sought to protect her.
Down on the Right
Further evidence for a “dark side” notion of the right hemisphere has emerged from brain scan studies of depression. When Sperry’s followers consigned all emotion to the right brain, they got it wrong. The right brain is filled with emotions but only the unhappy ones: depression, fear, anger, disgust—precisely the kinds of feelings that might make a man want to strangle his wife. The left brain, in sharp contrast, is a sunny land; it is the realm of happy thoughts and round smiley faces. People who are depressed have significantly higher activity on the right side of the brain than on the left; fussy babies show the same pattern. But good-natured, “easy” infants come into the world with a left brain that is positively humming with activity, as psychiatric researchers Mark George and Richard Davidson have found.
“Cool” reason, it seems, is not so cool after all. At least in the geography of the brain, reason is associated with a happy nature, though no one knows whether “reasonable” people are also happy people as a rule. By the same token, intuition, metaphor, and creative thinking—all functions of the right—are geographically associated with emotions most of us would prefer to avoid. Does being more creative mean being less happy? Conventional wisdom would hold that it does, and it is possible that brain-scan data will end up supporting the image of the tortured artist. Preliminary studies show that when one function of a hemisphere becomes aroused, other nearby functions may speed up as well. Perhaps when artists arouse the negative emotions of the right hemisphere, they arouse the artistic faculties of the right as well. It is purely speculation at this point, but nonetheless not impossible.
No one knew anything about a link between the right brain and depression back in the 1970s. However, the writers and educators proselytizing on behalf of right-brain “values”—creativity, emotion, and intuition—may have made their own intuitive leap without quite realizing what they had stumbled upon. As research into the two hemispheres progressed, neuroscientists began to realize that there is a profound connection between right-brain ways of approaching the world and what we now call social intelligence. Studies of patients with selective brain damage show that when the right brain is damaged, they lose vitally important elements of social comprehension. They lose the ability to understand jokes or metaphors or body language; they veer off on unrelated topics in the middle of conversations; many have been reported to lose all sense of how to dress and groom themselves appropriately to a time and place.
They also lose context, the ability to see the forest for the trees. Those with damage to the left brain can no longer locate individual words or numbers; in effect, they lose sight of the individual trees. Even so, they get the big picture. When early researchers (correctly) located language on the left side of the brain, they did not realize that the capacity to use context to grasp the many different meanings of the same words was in the right hemisphere. Without the right brain up and running, language turns into the speech patterns of the high-functioning autistic. Like Dustin Hoffman’s character in “Rain Man,” right-brain damaged people speak fluently and literally but to the point of being comically inaccurate.
Social intelligence is intrinsically linked to the ability to see beyond the immediacy of a word to gesture, metaphor, humor, irony, and tone of voice, to the social intent behind the words. In the annals of communication studies, there is a famous calculation showing that only 10% of the meaning in any human exchange comes from the actual words. The remaining 90%, which the right brain grasps, is nonverbal.
Dreamers Need Logicians,
Who Need Dreamers
It is easy to see why the right brain has provoked the hoopla that it has. But we should give the workaday magic of the left its due. It is the left brain, with its logic and reason, math and grammar, which forces us to reason things through. A world filled with right-brain dreamers will not produce cities or cars or computers. When it comes to turning dreams into reality, it is
the left brain which does the heavy lifting. (The right-brained Albert Einstein, who suffered a severe language delay as a child, found it taxing in the extreme to work out the necessary proofs for his grand theorems. To the end of his life, he had trouble performing simple arithmetic.)
Thus, dreamers need logicians and logicians need dreamers. It is the logic- and proof-driven bench scientists, not the complexity theorists, who will cure AIDS. “Natural healing” is not going to save us either, not without a strong infusion of the testing and retesting performed by dogged left-brainers bending over their microscopes at the National Institutes of Health in Bethesda, MD.
Mental fitness for all is going to require the talents and insights of both right and left. Right-brained types (Einstein aside) must learn to appreciate left hemisphere reason; the left-brained among us should try to be more right. Everything counts. It is left and right together that will usher in an era when we’ll use the unfolding knowledge of neuroscience to understand our own mixes of capacity and deficit—to better grasp who we are today, and who we can hope to become. �
Avoiding Food Traps and Other Strategies for Dieting While Traveling
Staff Reporters, MedWorksMedia
While it can be challenging to monitor calorie consumption even in the controlled environment of one’s home, when away on a vacation or business trip it is particularly tempting to relinquish responsibility for what one eats because of the reliance on restaurants, airlines, and the hospitality of others for the selection of foods available. In these situations, the implementation of specific food-trap avoidance stratregies can help people to maintain their momentum and avoid undoing their hard earned weight loss. The following are some helpful strategies for dieting while away from home.
Losing weight and maintaining weight loss are very difficult. The discovery of hormone-like compounds such as leptin that regulate appetite and weight only reinforces what many overweight persons already know: they are biologically programmed to overeat. It also presages a time when obesity will be treated with agents that act on its underlying endocrine basis. There are many agents on the market to help people lose and subsequently maintain their weight loss. Some patients resort to gastrointestinal.
Whatever the underlying cause, the problem of obesity must still be managed through will power, education, and strategizing. Adherence to certain dieting basics is essential to success in any setting.
Keep a daily food diary—even when traveling. Studies confirm that most overweight people dramatically underestimate the amount of food they actually consume. Before beginning a diet, keep a daily log of what you eat. This process alone will often result in weight loss. It also serves as an external source of reality testing. After a while, keeping a written diary can become tiresome. Try to internalize the process, keeping a mental note of what you have eaten during the day.
Learn the size and calorie content of commonly used portions. Since you also need to limit the amount of food you eat, it is helpful to have an idea of about how many calories are contained in a given portion of food. Use a scale and measuring cup to determine how much you actually are consuming.
Limit the fat content of your diet. All diets ultimately are based on reduction in caloric intake. There are two ways to accomplish this end: Reduce the quantity of food you eat or reduce the caloric content of what you eat. Since most people stray from diets because they feel deprived of food (not to mention being hungry), it is generally easier to eat filling foods that are lower in calorie count. On an ounce-per-ounce basis, fat has twice as many calories as protein or carbohydrates, so the most efficient way to lose weight is to minimize the daily amount of fat you consume.
Learn to love spices. Most people agree that fat enhances the flavor of many foods (although people who have been on low fat diets for extended periods of time feel that heavy use of oil masks the true flavors of many foods). While people often fear that low-fat foods are bland and unsatisfying, the liberal use of spices and herbs can produce remarkably satisfying meals without the addition of oil, butter, margarine, or cream. If you request low-fat meals, let the waiter know that spices and herbs are welcome.
Specific Strategies for the Traveler
Avoid big breakfasts. Breakfasts in hotels and restaurants usually confront the guest with a larger than usual choice of foods. Beginning the day in good control sets the tone for the rest of the day.
Plan ahead. Develop a mental image of the day as it will evolve so that you can avoid temptations that may arise. It is easier to resist pastries during a meeting coffee break if you can visualize a satisfying lunch an hour or two later. Ask for or bring fruit or another low calorie snack if you feel deprived (or bored) watching others eat. This may be the most important element in weight control during travel away from home.
Anticipate food traps. These include situations where you will have little or no control over menu selection such as dinner parties, catered affairs, and long airplane flights. If you are friends with the host or hostess giving a dinner party, it is acceptable to let them know of your dietary needs. Another strategy in such situations is to minimize damage by avoiding high calorie foods. When going to catered affairs at hotels, call ahead and speak to the banquet manager. Explain your needs and you will usually be told to identify yourself to the captain when you arrive. On long flights, bring food with you. Don’t rely on airline food to be either satisfying or diet-sensitive. You can always request special low-fat or low calorie meals, but these are usually not satisfying.
Making specific dietary requests while in a foreign country can represent a major problem, especially in locations where English is not spoken. It can be helpful to have the concierge at your hotel write a note on your behalf, explaining your dietary preferences. (It can also prove amusing to watch the expressions on the face of the person trying to fathom why in the world you would want to eat that way!)
Seek out and patronize restaurants that can accommodate your diet needs. Seafood restaurants, Japanese restaurants, and especially French and Italian restaurants, generally have a variety of healthy, low-fat foods available for preparation. For instance, pasta can be prepared with an oil-free tomato sauce,; chicken can be broiled; fish can be poached, baked, or broiled. Prepared this way, the foods are dramatically less caloric than if they were marinated in oil, fried, or sauteed. Request sauce on the side. Bear in mind that not all chefs understand this approach to eating. While many chefs are willing to please, some temperamental chefs actually resent requests to make special dietary orders. Avoid embarrassing situations by calling ahead to see if a given restaurant is willing to prepare dishes that meet your dietary needs.
Avoid grabbing a bite on the run or eating standing up; this is a sure-fire way to overeat.
Eat food that you enjoy eating. Part of any diet is the need to renounce or at least markedly restrict certain foods because of their high fat and/or calorie content. This does not mean that you need to eat foods you dislike. Once you overcome the sense of deprivation of food restriction, you begin to discover the very wide range of foods which do not promote weight gain, but are very satisfying.
Never eat while reading or watching television. At home, in a restaurant, or in a hotel room, being focused on another activity during a meal tends to reduce your awareness of the food. An important part of the gratification that should come with eating becomes absent and the food tends to be eaten more quickly. In order to maintain weight loss over time, it is helpful for the experience of eating to be more qualitative. Take the time to focus on what you are eating so the experience of eating is in itself a source of gratification. The Japanese tea ceremony and the rituals and sensibilities which surround it, for instance, amplify the overall gratification
Do not eat food left on another diner’s plate. While it may seem a shame to let good food go to waste, picking remnants off the plate of others (especially your children, whose food is probably high in both fat and calories) is both poor manners and a quick way to sabotage a diet.
Once you have successfully navigated the many dietary hazards of travel and returned home without having gained weight, there is a tremendous sense of satisfaction. More importantly, you will have reinforced your sense of being in control of your food consumption. Vacations, business trips, catered functions, and working lunches no longer need to be dreaded. These situations should be viewed as challenges which require strategies. By overcoming food traps, you can maintain the momentum of a weight loss diet and avoid undoing the success already achieved. Remember that each morning represents a new day and an opportunity to go back to your diet.
An Update on the Treatment and Mistreatment of Attention-Deficit/Hyperactivity Disorder
Following the American Psychiatric Association’s 1994 publication of revised attention-deficit/hyperactivity disorder (ADHD) criteria in The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), mass media in the United States took on ADHD with an almost faddish fascination. It would be the beginning of a very public and ongoing discussion of what qualifies as ADHD and what is effective as treatment.
While the general public came to commonly refer to the disorder as “ADD,” the official clinical diagnosis is “attention-deficit/hyperactivity disorder.” ADHD is a lifelong neurobiological condition affecting both children and adults. Although it is a common misconception that only children have ADHD, the truth is that ADHD can continue through adulthood. Studies are still inconclusive, but follow-up studies have shown that many children with ADHD experience symptoms of the disorder into their adult lives. According to the Attention Deficit Disorder Association (ADDA), approximately 4 to 6% of the U.S. population has ADHD.
The ADDA asserts that the most common symptoms of ADHD include failure to pay close attention to details, difficulty sustaining attention, losing or forgetting important things, and constant physical restlessness. While these symptoms may suggest inconclusive childhood behavior, that idea is an unlikely justification for such behavior in adults. In addition, the ADDA explains there are important distinctions that qualify these symptoms for ADHD diagnosis; in order to meet diagnostic criteria, symptoms must appear before the age of 7 and continue for at least 6 months. Also, these behaviors must be excessive, long-term, and pervasive. Lastly, a major component of diagnosis is whether the behavior creates a real handicap in at least two areas of a person’s life such as school, work, or home life.
ADHD often runs in families and there appears to be a strong genetic component. For example, it is much more common for identical twins to have ADHD than fraternal twins.
Treatment of ADHD has evolved over the past decade as doctors and patients try to reconcile drug and drug-free therapy. One of the first, and perhaps most notorious drugs prescribed for ADHD, was methylphenidate (Ritalin). Methylphenidate, manufactured by Ciba-Geigy, is a central nervous system stimulant with effects more potent than caffeine, but less so than amphetamines. Benefits include a “focusing” effect, while the side effects may include sleeplessness and loss of appetite. Presently, it is estimated that between 4 and 6 million children in America are medicated with methylphenidate.
Another option for ADHD treatment ventures into the use of amphetamines. Dextroamphetamine (Adderall) is a medication manufactured by Shire US, Inc. Often prescribed as a “plan B” to methylphenidate, dextroamphetamine is a mixture of different amphetamine salts which last twice as long as methylphenidate. For many people, it is a major benefit to have to administer dextroamphetamine half as frequently, particularly for children who are attending school or other activities outside the home.
Side effects of dextroamphetamine include anorexia, insomnia, abdominal pain, emotional lability, and nervousness. These effects are usually mild and are not completely different from those of methylphenidate. Yet, amphetamines also elevate mood and create feelings of superiority and confidence similar to the effects of cocaine. Some studies suggest that amphetamines used in patients suffering from psychosis may intensify symptoms of behavior and thought disorder. Another concern is stunted growth, but there has yet to be a proven direct link between the two.
In our new age of direct to consumer advertisements, the release of many psychiatric drugs is now christened by breezy, friendly commercials on television and in print ads in magazines. This type of customer education provides for a wide audience for ADHD drugs. Atomoxetine HCl (Strattera), for example, is a new drug offered by Eli Lilly for the treatment of ADHD. Atomoxetine HCl is not only an alternative to methylphenidate, but also a different type of treatment; Lilly claims that unlike methylphenidate or dexedrine, it is a non-stimulant. Atomoxetine HCl is also a non-controlled prescription making it possible for doctors to dole out samples and refill prescriptions over the phone. In complete truth, the Federal Drug Administration (FDA) has not classified atomoxetine HCl as a stimulant, but it still may cause similar side effects as stimulant treatment.
Of course, there is another popular opinion on the drug treatment of ADHD: lose the drugs and opt for alternative therapy. The biggest controversy over ADHD drugs may simply be whether or not to take them at all. While many critics of ADHD drugs claim patients have been “cured” without drugs, psychiatrists may argue that, therefore, those “sufferers” did not truly have ADHD. Also, some people suffering from ADHD may not necessarily need medication. On the flip side, we must consider the confusion over what constitutes symptoms versus normal ‘acting out’ which most children, and even adults, experience.
The extended predicament is that symptoms of ADHD may appear all too similar to normal childish episodes, such as someone who won’t pay attention in class or a child who is constantly running and climbing. Teachers and family members may not recognize these behaviors as beyond their control. Often, ADHD sufferers are mistakenly labeled disobedient or lazy. An important difference which marks ADHD is that sufferers’ symptoms are ongoing and tend to occur confoundedly. It is not a bad day at work, but a bad year; not a rebellious child, but an over-stimulated child.
Alternatively, ADHD is one of the few diseases in which personality or temperament may incorrectly suggest the disease. For example, a rowdy child may be quickly marked as an ADHD candidate when in fact, the cause may be ineffective parenting, an environment with loose boundaries, or even the natural temperament of the child. These subtleties continue to cause confusion and debate over ADHD treatment.
Of course, there is no simple test for ADHD. The only way to accurately diagnose is to carefully evaluate the appearance of symptoms and their persistence. Treatment should be recommended as is fit for each individual child or adult; at least all agree that what works for some, may not work for others.
Some leaders in American child psychiatry say the overall increase in the use of psychiatric medication comes because of greater public awareness and improved diagnosis of children’s mental illness. Others insist that the motivation for prescribing these drugs is mainly financial, with doctors receiving more cash or promotional goods for dishing out prescriptions. In either case, ADHD has reached the height of cultural and public awareness and doctors will now have to work with patients in deciding the best treatment—be it drug or alternative therapy.
Kids and Antidepressants: Finding Answers to Tough Questions
Staff Reporters, MedWorks Media
My friend Lila says she spent her entire childhood depressed.
“It started when I was very young,” she says. “I don’t remember ever feeling any way except bad.” Her parents suggested psychotherapy for her, and although it helped, as Lila says, “In my experience talking about it doesn’t make depression go away. It doesn’t keep you from not wanting to get out of bed in the morning or from spending a lot of time wondering why you should bother trying to do anything at all.” The psychotherapy did enable her to keep pushing ahead with her life despite her feelings and it helped protect her self-esteem from the attacks of guilt and self-loathing that went hand in hand with her mood disorder.
Lila describes her depression as “living under a cloud.” It didn’t lift until fourteen years ago, when her psychiatrist prescribed Prozac, then a brand-new type of antidepressant. Within a month, she says, she was a new person—and at age 35. “I’d never felt so good. I felt as though someone had taken a psychic vacuum cleaner to my head and sucked out all the fog.” Lila feels that Prozac changed her life dramatically for the better, and now she finds herself wondering how different her life might have been if she’d had the medication sooner. “What if it had been available to me as a child? What might I have accomplished if I hadn’t been constantly depressed, if I’d simply felt better? Would I have been a better student, a better partner, a better mother?”
When Lila was young, depression was infrequently recognized in children. Now it is known that an estimated 1 out of every 10 children in the United States are suffering from a severe emotional, behavioral, or mental disorder. Many types of psychotropic drugs (medications such as Prozac that act on the mind) are available or in development. But should they be given to children? There are many issues surrounding this current controversy including whether psychoactive drugs will make kids “high” or encourage the use of illicit drugs. Or, whether they’re simply a means for parents to control their kids. Or, whether their use will discourage learning how to cope with difficulty. Or, most importantly, whether they may cause suicidality. Some of these questions are easier to answer than others, as we shall see, but the dilemma of whether to offer suffering children access to these medications is perhaps most difficult for parents and physicians in light of the paucity of data on how such medications will affect children in the long run.
The SSRI Revolution
Prozac, the medication my friend Lila takes, belongs to the family of psychotropic drugs called selective serotonin reuptake inhibitors (SSRIs). These drugs work by helping to increase brain levels of serotonin, a neurotransmitter or message-carrying chemical that is linked to mood. Essentially, SSRIs correct a chemical imbalance if there is one. If there isn’t, the drugs have little if any positive effect—rather like taking aspirin in the absence of pain. Importantly, these are not drugs that create a “high” or feelings of euphoria; they generally take three to six weeks before they begin to have a mood-correcting effect at all.
SSRIs have in many ways revolutionized the treatment of depression. Although antidepressants in the so-called tricyclic class (TCAs) have long been available, many people have been unable to tolerate their side effects. Now, adults who in the past responded poorly or incompletely to psychotherapy and/or other types of medication often find they do well with one of the SSRIs. So it seems logical that these medications would find equal application in children for whom depression can be a serious and debilitating illness. In fact, according to a National Ambulatory Medical Care Evaluation Survey, in one year alone, physicians write about one million SSRI prescriptions for children under the age of 18.
Many child psychiatrists report that SSRIs seem to be very effective in treating childhood depression and anxiety disorders, and even pediatricians are prescribing them for children, which is not illegal (see “FDA Approval and Off-Label Prescribing—What They Mean,” page 73.) But these drugs were not designed for children. Every package insert or “label” for SSRIs clearly and unequivocally states: “Safety and effectiveness in children have not been established.” What’s more, in October 2003 the US Food and Drug Administration (FDA) issued a Public Health Advisory to alert physicians to reports of suicidal thinking and suicide attempts in clinical studies of various antidepressant drugs in pediatric patients with major depressive disorder (MDD). Adding to the controversy, the Wall Street Journal recently reported on the suicide of a 19-year-old college student in a clinical trial of an experimental antidepressant manufactured by Eli Lilly & Co., which led to an inquiry by federal regulators. While representatives from Eli Lilly assured the public that such an inquiry is standard when a person enrolled in a trial dies, the event sparked debate over whether SSRIs might cause suicidality, especially in children.
In March of this year, the FDA mandated the makers of ten antidepressant drugs to add suicide cautions to their labels, warning doctors and parents to be vigilant for signs of worsening depression or suicidal thoughts at the start of new antidepressant therapy or when switching antidepressant drugs. (See Bulletin on page 14.)
While the suicide rate in all of Elli Lilly’s antidepressant trials for depression was 4 out of approximately 4,000 patients, or .097%, that rate is actually lower than the rate of suicides by patients on placebos (sugar pills) in those trials, which was 1 of 777, or .129%. A study published in the American Journal of Psychiatry in April of 2003 showed similar suicide rates among people on medicines and in the placebo group suggesting no relevant evidence proving SSRIs cause suicidality.
No one knows for sure what the long-term effects of the drugs will be on a child’s physical, mental, and emotional development. Unlike adults, a child’s body, particularly the brain, is growing and developing very rapidly, especially in the early years. What will be the effect of tinkering with brain chemistry in the midst of all this development?
Right now, there are no solid answers to these questions. However, if a child is suffering and other treatments have failed, is it reasonable to withhold a treatment that may bring that child relief? As a parent responsible for the well being of your child, how do you balance concerns about long-term effects against the very real and very painful consequences of depression? We’re not talking about a temporary case of the blues or a period of grief following the death of a loved one, we are talking about clinical depression, a debilitating disorder that can persist for years and can recur throughout life.
In 2003, the Medicines and Healthcare products Regulatory Agency of England released a safety review of antidepressants used by children. The group of medical experts assembled to look at the safety of SSRIs found the risks of treating depressive illness in children under the age of 18 with certain SSRIs
to outweigh the benefits. The Safety Review states, “there is no, or insufficient, evidence from clinical trials that benefits outweigh the risks of side effects for sertraline (Lustral), citalopram (Cipramil), escitalopram (Cipralex) and fluvoxamine (Faverin).” They found only Prozac appearing to have a positive balance of risks and benefits in the treatment of depressive illness in children. The FDA also found data adequate to establish effectiveness in MDD for only Prozac. However, it states that failure to show effectiveness in any particular study in pediatric MDD is not definitive evidence the drug is not effective because trials may fail for many reasons.
But should parents keep their children from taking SSRIs when it may be the only effective solution? Take the case of Vanessa, a pretty, lovable ten-year-old who went almost overnight from being a straight-A student with lots of friends to being a sullen, withdrawn, and excessively irritable child who rarely left her room. “At first we thought it was a passing phase,” her mother said, “but after three months, it was breaking our hearts.” And the child’s condition got worse as she withdrew more and more. Her mother sought help when Vanessa told her at bedtime one night that she hoped she could sleep forever and never wake up. The family physician referred the parents to a child psychiatrist who after extensive evaluation diagnosed the condition as major depressive disorder. The psychiatrist prescribed an SSRI, “which definitely improved her condition,” says her mother, along with weekly psychotherapy sessions. Vanessa gets better every day and is “almost her old self,” as her mother puts it.
“It Means That We Don’t Know” Dr. Peter Jensen, associate director of child and adolescent research at the National Institutes of Mental Health (NIMH), acknowledges SSRIs can be lifesavers for some children, but that in young children, it is generally best to avoid any medication if possible. “Certainly I’d be somewhat more comfortable prescribing an SSRI to a 14-year-old than to a five-year-old. There is more development going on earlier in life,” he says. Jensen believes SSRIs should be used judiciously in children and only after other known and tested treatments, such as psychotherapy, have at least been tried. And if the physician makes the decision to use these drugs, Jensen advises they do so based on careful consideration and to be prepared to deal with any adverse effects that may occur.
Jensen has for some time called for extensive testing of SSRIs in children to determine what the long-term effects of these drugs will be. With the exception of one small clinical trial of fluoxetine (Prozac), he says, there has been no testing of SSRIs in scientifically designed trials with children to determine whether or not they are effective in treating depression. “This doesn’t mean that they don’t work or shouldn’t be used,” he says. “It means that we don’t know.”
The FDA also emphasizes the need for additional data, analyses, and a public discussion of available data. Because MDD is a serious illness, they stress the importance of a better understanding of how to use the products we already have in treating the disease.
Every Day Counts
Until data are in, child psychiatrist Marion Hart is among those who prefer to prescribe antidepressants only as a last resort. An assistant professor of psychiatry at Cornell University, Hart acknowledges that although she has seen some good results with SSRIs, in her experience depressed children generally respond quickly and very well to psychotherapy or a change in family environment.
Dr. Glenn Hirsch, deputy director of the New York University Child Study Center, says he would not wait to see if psychotherapy is effective before prescribing medication. “First of all, psychotherapy doesn’t always work,” he says. “And sometimes parents don’t follow through with it.” In a few rare instances, such as with a child who is unreachable with psychotherapy, Hirsch says he might treat them only with medication. “Every day counts,” he insists. “If a child is too depressed to participate in class work and social interactions, that child is not growing and is losing ground developmentally.”
Of course, there is no guarantee that the medication will work or that all the child’s symptoms will remit completely. However, those who prescribe antidepressants for children point out that although their long-term effects, whether positive or negative, are uncertain, the long-term effects of untreated depression are very well known—among them, poor academic performance, poor social development, low self-esteem, self-medication through substance abuse, and in some cases, suicide.
To Glenn Hirsch, the controversy over children taking antidepressants is less about the medication than about the very idea that children can and do get depressed. “Childhood is supposed to be a worry-free, happy time, and it’s hard for adults to think of children as depressed,” he says. Adults may consider depression in a child to be a temporary state of mind, so they think using medicine to treat
it is excessive. Also, parents often equate depression with their own failure to
give their child what the child wants or needs. “Depression is an illness just
like diabetes,” Hirsch asserts, adding, “SSRIs have been used by adults for around 15 years, and we have yet to see long-term adverse effects.”
As with adults, psychiatrists prescribe antidepressants to children for a period ranging from six months to a year, however this time frame can vary somewhat. At the end of that period, the child is reevaluated. “I would try not to discontinue the drug at the same time as a stressful situation”—such as school or exams starting—”is about to occur,” says Hirsch.
The reasonable approach for a parent of a child who appears to be suffering from depression would be to consult an expert—a child psychiatrist or psychologist. If that expert recommends treatment with an SSRI or evaluation for it (psychologists cannot themselves prescribe medication), then consider it.
But is this the way it usually happens? Although there is no specific data, it appears that family physicians and pediatricians write a large percentage of children’s SSRI prescriptions. “My approach to depression in children is first to make certain of the diagnosis,” Marion Hart says. Sometimes this is a long and difficult process, especially with young children who may not be able to articulate what is wrong. “If we are going to expect primary care physicians to make a differential diagnosis of depression, we are going to have to provide them with adequate time and information to make the diagnosis,” she says. “How is a busy pediatrician going to have time to determine if the child has a problem or if it’s the parent—or even if there is a problem?” It is also less likely that a primary care physician will recommend psychotherapy or counseling, an important first step to dealing with depressive illness.
The media have raised the specter of parents asking pediatricians to prescribe SSRIs out of some fantasy that they could be used to produce “super kids,” that is, children who excel, get better grades, behave better, and generally live up more closely to their parents’ expectations. But none of the experts I spoke to have ever had this experience. “The parents I see have a healthy approach to drugs. They don’t want to use them unless it’s absolutely necessary,” says Glenn Hirsch.
The parents of 10-year-old Vanessa feel that SSRIs may have saved her life. And that may well be true. The question that remains, and will remain for some time, is how will they and other parents whose children take these drugs feel ten years from now? The National Mental Health Association states that more scientific research is needed on the safety of all medications prescribed to children. However, they also maintain there is no doubt that SSRIs, like medications used to treat physical disease, are crucial in treating serious and potentially life-threatening illnesses. They believe we “must ensure that treatments for children are safe and effective through increased research and the sharing of all clinical findings. And we must be mindful of the many children with mental health needs who benefit greatly from these medications.”