The Talking Cure !

The best way to classify psychotherapy is the way Wollberg (who has authored a 2 volume text book on the subject) has done it. He divides psychotherapies into 3 - Reconstructive, Re educative and Supportive.

1) Reconstructive: These are the highly ambitious approaches claiming to completely reconstruct the personality of a person after understanding everything about him including long forgotten (or buried within unconscious) childhood memories. The gold standard came from the master - Sigmund Freud himself. But there are many variants.
The problem with these kind is that they are time consuming and costly (how many can afford a 50 minute, five days a week therapy for months or even years) and have poor empirical evidence for efficacy.

2) The re educative therapies: Their claims are modest - helping individuals to lead a better life by changing certain maladaptive behaviors and attitudes. Behaviorism, C B T and the Humanistic- existential therapies come under this. Behaviorism emerged as a reaction to the emphasis of the former on 'unconscious processes' of dubious nature. But John B Watson certainly went overboard with his claims that he can make a genius or a criminal out of any individual infant given to him.
Cognitive therapies appear to bridge the gap between the extreme emphasis on 'unconscious only' of the first group and the other extreme of 'looking at overt behavior only' style of behaviorism.
Though C B T uses cognitive terms - negative automatic thoughts, cognitive errors etc - its concepts can also understood using concepts of psychoanalysis. Both agree that behavior and mood states have underlying causes within the psyche of the person, more than the external events. They also agree that an individual is not always fully able to explain his behaviors at all times. In other words we are not always our own masters. For psychoanalysts the culprit is the hidden conflict in the unconscious. For C B T experts it is the hidden biases and cognitive errors. Both agree that the origins of these may be past experiences.
Both C B T and behaviorism exponents have garnered objective evidence for the efficacy of their approaches. C B T has been found to be equal in efficacy to drugs in the treatment of moderate depression, with lesser chances of recurrence.
But the fundamental question raised in the 'Guardian' article - whether we need to try to change the subjective world of another human being, even as part of therapy - is still valid.

Cognitive behavior therapy - Is it superficial and driven by the philosophy of market economy ?

An interesting article has appeared in The Guardian. "A quick fix for the soul" by Darian Leader, Tuesday September 9 2008, The Guardian
http://www.guardian.co.uk/science/2008/sep/09/psychology.humanbehaviour
The writer argues that the highly successful form of psychotherapy called C B T is ideologically justified by the prevailing philosophy of market economy. Everything including the human psyche is viewed as commodities. Symptoms of mental illness like anxiety and depression are viewed as the result of 'faulty thinking patterns' which can be corrected using appropriate techniques rather than as expression of deep underlying conflicts.
He argues that such superficial skin deep approaches will only lead to cosmetic correction and symptoms may reappear in another form. This particular argument has been voiced by the predominant psychoanalytic school against Cognitive and Behavior therapy schools since the beginning of the latter. I think there is nothing inherently wrong in going by evidence base which favors C B T. The psychoanalytic and related therapists were unable to deliver results, despite their claims of addressing deep rooted issues. Any way, the article makes interesting reading and merits serious consideration of all mental health professionals, philosophers and public policy makers.

(s)HAPPY (p)ONAM

sHAPPY malayalis resting after earnestly contributing to the state's exchequer. High highness King Maveli will be proud of these patriotic souls.

During the Onam season this year, from 10th to 13th of September, the sale of alcohol by the BevCo (the government monopoly selling alcohol in retail in Kerala) recorded significant increase in the sale of alcohol. This has been a consistent trend. In Calicut district alone, compared to the corresponding period last year, they had excess sale of Rs. 75 lakhs. The total sale during these 4 days was for Rs 6 crores in Calicut district alone!

A very Happy Onam indeed !

(Photos are from my friend Ajeesh)

Serotonin and behavior

Seoronin has no relationship to IQ. It definitely plays a role in pathological fears, anxiety etc. But it will be too simplistic to manipulate just one variable (level of a neurotransmitter) alone to modify man's behavior. The underlying reasons for any specific behavior will be more complex.

We are mostly talking of association when we speak of neurotransmitter levels etc to specific behaviors. It will not be correct to assign causative role to every phenomena associated with a specific behavior. We need to find out the definite cause that is both the 'necessary and sufficient' condition for the behavior in question. For this we need more precise tools. I happily share the optimism of Sashi. I thank Sashi and Ajeesh for their comments.

More on serotonin and violence

This is in response to Sashi's comments on the post - Serotonin, mood and violence.
Serotonin is widely present in the other tissues like gastro intestinal tract, blood etc. There is poor correlation between its concentration in the peripheral blood and within the brain. Hence there is no point in correlating these two. Further, serotonin from peripheral blood does not cross the blood brain barrier to enter the brain.
But tryptophan, the amino acid precursor of serotonin does cross the blood brain barrier to enter the brain. May of us have a habit of drinking milk at bed time. Milk is a rich source of amino acids including tryptophan. Could this practice help to improve our sleep ? I am not aware of any studies that have tried to influence our mood states using dietary modification.
Suicide bombers are indoctrinated into certain beliefs that justify their acts. Such indoctrinations can change the personality of a person and make him perform the crime. Without evidence it is difficult to say whether suicide bombers have low serotonin in their brains, but it is a likely possibility. But we have not reached a stage where we can use the serotonin levels or any other biological markers to accurately identify people who are likely to commit suicide, violent crimes etc. This may be possible in future with further advances in our understanding of the causes of human behavior and the development of refined techniques to measure neural correlates of such behaviors.

A bit more on Post Traumatic Stress disorder

Sashi had commented that all elephants do not develop PTSD, though subjected to violence as part of training. There is nothing unusual here. This is true for humans as well. All the parties involved in traumatising people (both perpetrators and victims - isn't it poetic justice: both victims and perpetrators developing the same disorder?) do not go on to develop PTSD. In fact this is true for all diseases. All exposed to pathogens - TB bacillus or other bacteria - do not develop the disease.
Another point is the role of serotonin in PTSD. Serotonin dysfunction has been found in patients suffering from PTSD.
In clinical practice the number of PTSD cases is not very large. This may be because the severe trauma needed for its development does not occur in usual social life. PTSD is more common in victims of severe riots, people trapped in combat zones, severe natural disasters, torture etc.
But it is also true that many psychiatric assessments miss out this condition because the interviewers fail to ask appropriate questions.

Many of my colleagues and myself have had occasions to see cases being treated as mild anxiety/phobia or depression turning out to be true PTSD on detailed evaluations. Usually the victims have suffered from sexual assaults, or tortures. Some were innocent victims of violent assaults on others. I have treated a person who developed PTSD after he witnessed the execution of a convict in Saudi Arabia. He walked into a junction crowded with people unknowingly. The traffic was in stand still. A man was kneeling on the road with head stooped. The executors cut his neck in broad daylight in front of several people. My patient developed PTSD symptoms within a few days. He had to come down to Kerala for treatment.

Serotonin, mood and violence.

Serotonin (5 hydroxy tryptamine) is a derivative of the amino acid tryptophan. It is present in high concentration in certain areas of brain called median and dorsal raphe nucleus. From the neurons in this area fibers project diffusely to all the major brain areas. Serotonin is implicated in sleep, regulation of mood, appetite and sexual behavior.
Low levels of serotonin are found in victims who die of suicide. Still lower levels are found in the brains of victims who choose more violent methods to kill themselves. Low level is linked to propensity to show violent behaviors.
Reduced serotonin transmission is implicated in anxiety disorders, depression and the negative symptoms of schizophrenia.

Reply to Sashikumar's comment on Violent elephants

Thanks for the comment, Sashi. The PTSD theory is only one of the many theories to explain violence in captive elephants. The fact that male elephants are prone points to a role of the male sex hormones. It is well known that male hormones are implicated in violent behaviors. Hence female elephants may be expressing their 'feelings' in non violent ways.
Violence has been linked to low level of serotonin in brain. There is also evidence to show that people exposed to violence are more prone to violent behavior. Children disciplined using corporeal punishments inflict the same as parents later.
Both these factors - low serotonin and exposure to violence - may be responsible for some elephants becoming more aggressive.

Like us, animals also can vary in their propensity to become violent. It is true that a few such 'rogue elephants' are implicated in majority of violent incidents. Whether majority of such rogues have past history of exposure to violence has to be studied. Similarly the role of neurotransmitter levels and history of violent behavior in elephants.
It is curious to observe that psychiatry is the only branch of medicine without an equivalent in veterinary science, though animal psychology exists.