Are you conscious? 29 September, 2012Posted by Queen of Spades in Uncategorized.
Tags: consciousness, reality, selfhood, thoughts
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You know how sometimes it feels like your thoughts are simmering in a big cauldron, that you keep adding ingredients to, until the mixture really starts to bubble and froth, and turns an interesting colour? (Maybe that’s just me.) A few things have recently come together for me, making my thought-mixture very restless.
My research, in a nutshell, has been looking at things that shift controlled, purposeful action to behaviour that is not under executive control. Add to this a good dash of reading (The Neurology of Consciousness, and Saks’ The Man Who Mistook His Wife for a Hat never far from my mind), an elective I’ve been doing this year, which looks at and takes apart the raw processes that construct what we view as completely endogenous, intact and fully-formed thoughts and beliefs, and a pinch of All in the Mind (especially this episode: Are You Conscious?) and you get some serious bubbling action.
I’ve been thinking a lot about the nature of consciousness and choice. If you are completely disengaged withy your surroundings, and on auto-pilot, are you actually conscious? If there are things you can do that make you much more likely to perform certain other behaviours either without wanting to, or without engaging with the outcomes or consequences, what does that mean for the theory of free will? Does personhood exist when behaviour is automatic? Are “we” really more than disparate processes that have somehow been brought together under the guise of cohesion and seamlessness?
In a concrete, every-day sense, these questions don’t matter, I suppose. Life goes on, regardless of whether or not we are actually conscious at every moment; the illusion (if it is, indeed, an illusion) is so pervasive that we live and breathe (and die) in the Matrix. But engaging with these concepts and thought experiments definitely feels unsettling, and I wonder if we’ll ever understand ourselves. If there truly is no “self” to understand though, who is asking the questions?
What I’ve learned this year 17 August, 2012Posted by Queen of Spades in Uncategorized.
Tags: neuropharmacology, neuroscience, random
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Fun: drug stuff, behavioural addictions/compulsions, how to program operant conditioning chambers, that I can write things that get accepted for presentation, multivariate stats (yes – nerdy), seekrit psychology stuff (assessment), and that I am medium-hypnotisable (like 70% of the population).
Not-so-fun: that I actually have to do a conference presentation in the near future, 60+ hour weeks are crap, having to be somewhere every day including public holidays, weekends etc without a break for weeks and without getting paid sucks, that published papers lie about their methods, that results are sometimes really odd, and that, in general, 4th year is brutal.
Random: how to pH stuff, that I really like powder-free gloves and drawing-up needles (perhaps mostly because it’s harder – though not impossible – to hurt myself with these), that male fruit flies are jerks, that research facilities are kind of creepy when you’re the only one working late, that there are bunnies outside said research facility when you’re working late, that brain cupcakes are a thing.
The most important lesson, and a take-home for us all:
Do not drink the blue liquid.
Nicotine Valium Vicodin Marijuana Ecstasy and Alcohol 21 December, 2011Posted by Queen of Spades in Uncategorized.
Tags: access, neuropharmacology
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Next year is the fourth year of my degree, which is part coursework, part research. I recently found out that I’ll be doing the research project in the neuropharmacology lab. At first I was a bit unsure about this, as addiction (the main focus of the neuropharma lab) is not my main area of interest, but then again, I realised it’s all about the brain, which makes it ok in my book (receptors! pathways! downregulation! agonists/antagonists! etc).
The things I’m excited about:
1. Getting a good grasp on brain chemistry and the action of substances of abuse (as well as psychiatric medication).
2. Working in a real lab – with all sorts of instruments and beakers and weird contraptions invented by the people in this centre. And maybe getting to use a mass spectrometer! (What can I say…Abby Sciuto is my geek girl hero.)
3. Being able to wear casual clothes and runners (very different to my job, which has clinical contact!). Shallow, I know, but I like being comfortable.
Exciting! But, at the same time, major changes are afoot in the future of my training/profession, changes that I don’t know a whole lot about yet, but that make me wary. On one hand, there is a (wholly justifiable) push to better regulate the profession, and to require a higher level of qualifications, in line with other countries. On the other, the federal government has recently and dramatically cut the number of sessions available to patients under Medicare (from 18 to 10), which doesn’t comply with evidence-based treatment for a lot of psychological disorders/severity (a good summary here). So on the one hand, lengthier and more stringent training is required, and on the other, you are somewhat thwarted once you finish the training. More changes may be coming up too. Anyway, all I can do is take it one step at a time and hope for the best.
Cultural competence 15 April, 2011Posted by Queen of Spades in assessment, clinical, culture.
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It’s been a full-on few weeks/months, not leaving me with much time to post, even though I’ve been doing lots of psychology- and neuroscience-related things.
I recently attended some talks on mental health in refugees, people from CALD1 backgrounds, and Indigenous people. Really interesting and important stuff. How appropriate is it to assess someone with these backgrounds using established “mainstream” tools? How do mental illness symptoms manifest themselves differently in different cultures? What are some of the signs to look out for in terms of trauma, torture, domestic violence? And what are the risk factors for developing a mental illness in these populations? These are some of the points raised in the talks, and things I’ve been thinking about lately.
It all comes under the umbrella of culturally-competent practice, which in a nutshell, is not imposing assumptions, and being open to information that may conflict with your beliefs/stereotypes/established norms, etc to be able to treat people from cultural backgrounds different to your own. The main point I took away regarding culturally-competent practice is that it’s not necessarily “how much” you know, but how open you are to receiving information. I would add to this the need to be aware of your own context, and of biases and beliefs that influence you – no one is a blank slate and I think the only way to deal with this is to be mindful of your own position and what you’re bringing to the table.
Here are some points I picked up:
1. Being an immigrant does not inherently boost the risk of developing a mental illness. Pre- and post-migration factors play a big part. Pre-migration factors may be political turmoil in the country of origin, trauma/torture/persecution of yourself or family, having to leave family behind. Post-migration factors include not having a good support network, not being able to find employment, language and cultural barriers to receiving appropriate care, and discrimination.
2. In many cultures, it is perfectly appropriate to have experiences that would normally put you in the “severe, possibly psychotic mental illness” category quite squarely – such as hearing voices. This is quite usual for many Indigenous people, who may hear family members and friends who’ve passed away talking to them.
3. It’s important to look at methods of healing traditionally endorsed by the client’s/patient’s culture. Normally healthcare in Australia stays away (or tries to) from anything to do with spirituality or religion,
but in some cases it would be appropriate to ask a spiritual leader for a prayer, or wearing a holy talisman, having a house blessed, etc.
4. Advocacy is important, especially for people who’ve left family behind – producing supporting documentation to help reunite the family, for example, or that shows that certain types of work are not appropriate, or to help secure disability services as needed.
5. Respect for boundaries is very important, for example choosing age- and gender- appropriate health providers for people from cultures that emphasise a separation of values between such groups.
6. Body language may not always be read correctly. For example, avoiding eye contact may be a way of showing respect. Also, short “yes/no” answers may be a way of avoiding real issues in an attempt to make an assessment/interview/session come to an end quickly, so these are to be avoided. Open-ended questions and plenty of time for answers are best (although it’s frustrating that the health system in general really doesn’t encourage spending a lot of time with each individual).
7. This is really basic but also really important: explaining every procedure, therapy, medication, etc in a way that can be easily understood and making the treatment process collaborative, rather than something being ordered “from above” by an authority figure (which, let’s face it, would make many of the people in the above groups quite uneasy, frightened or non-compliant, and with really good reason – or, on the flipside, some people may comply too easily and not ask enough questions, without fully understanding a procedure). It’s best to have an interpreter or a cultural consultant present, rather than family members (although interpreters can be hard to find with languages that are not common community languages).
These are the things that come to mind – I may add more if I remember other points later.
And some links:
- NSW Multicultural Health Communication Service
1. CALD = culturally and linguistically diverse
World Suicide Prevention Day 2010 10 September, 2010Posted by Queen of Spades in clinical.
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Today is World Suicide Prevention Day. The International Association for Suicide Prevention has a lot of good information on suicide and prevention and a list of activities happening throughout the world, including Australia. There’s also a downloadable activity sheet.
The issue of suicide is very personal to me. Like many of us, I’ve lost a loved one to suicide. Looking back on it, I realise there were little to no resources for him to access at the time, and that his issues were not understood, or were ignored. His death has left a trail of destruction in the lives of those who were close to him.
For WSPD this year I wanted to post some information about suicide and where to get help.
National Crisis Services
Lifeline (telephone crisis counselling): 13 11 14
Suicide Callback Service: 1300 659 467
Please see the bottom of this post for state-specific resources and for national information lines.
Risk factors for suicide in Australian youth
Being male, living rurally, being Indigenous, non-heterosexual, having a mood disorder, a history of suicide attempts, substance abuse, stressful or traumatic life events, family problems, family history of suicide, easy access to means of suicide, social disengagement, unemployment.
1. Talking about suicide will cause suicide. False: Talking openly about suicide can save a life. Sometimes people don’t want to die, but don’t feel they have a choice.
2. People who threaten to commit suicide won’t do it. False: Threatening to commit suicide is not just attention-seeking. It needs to be taken seriously as a cry for help.
3. After an unsuccessful attempt, the danger has passed. False: The danger period is not over. The person needs to be monitored for at least 90 days.
4. Suicide is an impulsive act. False: Not always – sometimes it’s planned for a long time and/or in detail.
5. “Truly” suicidal people have already made up their mind to die. False: some people don’t want to continue living in their current situation but don’t necessarily want to die. Suicide may be seen as the lesser of two evils.
6. A suicide attempt is not serious and the person is just “seeking attention”. False: Take every suicide attempt seriously.
7. If a previously depressed person suddenly seems happy, relieved or upbeat it means that they feel better. False: sometimes the person may seem “happy” or “content” because they’ve made the decision to take their own life as an option to get out of current pain and suffering. Watch for any sudden swings in mood. Also watch for the person giving away personal belongings and putting affairs in order.
8. Suicide is a cowardly act. False: It’s often a desperate act for people who are overwhelmed by their circumstances, who are sometimes not thinking clearly, and who need help.
National Information Services
Beyondblue Info Line: 1300 224 636
MensLine Australia: 1300 789 978
Australian Psychological Society Referral Line: 1800 333 497
SANE Australia: 1800 187 263
Relationships Australia: 1300 364 277
Carers Australia: 1800 242 636
Crisis Assessment and Treatment Team: 1800 629 354
Gay and Lesbian Telephone Help, Referral and Outreach Bureau (THROB): (02) 6247 2726
Suicide Prevention and Support: 1300 133 911
Salvation Army Prevention & Crisis Line: 02 9331 2000 (Metro) and 1300 363 622 (Rural)
Gay and Lesbian Counselling Service of NSW: 1800 184 527 or (02) 8594 9596
Mental Health on Call Team: Top End (08) 8999 4988
Mental Health on Call Team: Central Australia (08) 8951 7777
Gay & Bisexual Mens Line Telephone Service: 1800 181 888
Salvo Crisis Counselling Service: Metro (07) 3831 9016 & Rural 1300 363 622
Gay and Lesbian Welfare Association: 1 800 184 527 or (07) 3017 1717
Mental Health Assessment and Crisis Intervention Service: 13 14 65
Gay and Lesbian Counselling Service of SA: 1 800 182 233 or (08) 8334 1623
Mental Health Services Helpline: 1800 332 388
Working It Out: http://www.workingitout.org.au/contact.html
Mental Health Advice Line: 1300 280 737
SuicideLine: 1300 651 251
Gay and Lesbian Switchboard: 1 800 184 527 or (03) 9827 8544
Mental Health Emergency Response Line (Metro): 1300 555 788
Rural Link (Rural): 1800 552 002
Gay and Lesbian Community Services of Western Australia: 1 800 184 527 or (08) 9420 7201
Samaritans Crisis Line: 1800 198 313
DSM-V: outline of proposed changes 15 February, 2010Posted by Queen of Spades in assessment, clinical.
Tags: diagnosis, dsm, psychopathology
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Here is a short summary of the proposed changes in the DSM-V draft, from The Medical News: APA releases proposed draft diagnostic criteria for DSM-5 and from Medscape Medical News (you have to register to access Medscape, but registration is free).
I like the collapse into “substance use disorders” of “substance dependence”/”abuse” – for example, Alcohol-Use Disorder, as opposed to Alcohol Abuse and Alcohol Dependence (click on the “DSM-IV” tab for details).
There will also be new suicide risk scales, adult and adolescent, chronic and acute. I’d be interested to look at the details, but can’t find these on the website at the moment.
DSM-V: hope and controversy 9 February, 2010Posted by Queen of Spades in assessment, clinical.
Tags: diagnosis, dsm, psychopathology
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The draft DSM-V will be released tomorrow, 10 Feb 2010. Its website, DSM5.org (which launches tomorrow) will include proposed revisions and draft diagnostic criteria. The final version of the DSM-V is scheduled for release in May 2013.
The new edition is generating a lot of discussion, which is A Good Thing. The significant levels of unrest in the mental health field are because the DSM is seen to at least partly control the psychiatric diagnosis process, which in turn regulates treatment (pharma and non-pharma), as well as insurance pay-outs and allowances for psych care items.
The APA is framing the new edition as nothing short of revolutionary and at the same time, as usual, it runs an extremely tight ship regarding input and output. There have been calls for greater transparency into the process of creating the DSM-V, including from Dr. Allen Frances, the head of the APA taskforce that produced the last edition of the DSM.
Some of the problems that Dr. Frances has with DSM-V production process and taskforce are:
1. The very idea of a “paradigm shift” in the new edition. Psychiatric diagnosis is still descriptive, pretty much. Even as we have seen great advances in neuroscience, molecular biology, and brain imaging since the release of the last DSM edition, causality has not been proved to a level where biological tests can be a part of the DSM, and the findings of neuroscientific research are not yet suitable for clinical practice, and won’t be for quite a while.
2. The creation of new instruments, which is slow and resource-intensive, was not necessary.
3. Indirect involvement of pharma companies. To promote drug sales, pharma companies may sponsor selective “education” campaigns focusing on the diagnostic changes that increase the rate of diagnosis for disorders that will lead to the increased writing of prescriptions.
4. The inclusion of many new categories to capture subthreshold versions of disorders (for example, “pre-psychotic”, for those considered at risk for developing psychotic disorders). The intended purpose is to reduce the occurrence of false negatives (missed cases), hence boosting early detection and preventive treatment. However, this could also have the negative consequence of increasing false positives and, in Dr. Frances’s words, the “wholesale imperial medicalization of normality that will trivialize mental disorder and lead to a deluge of unneeded medication treatments.” (Eeek!)
5. Ditto for a new series of behavioural addictions (to sex, the internet, etc.) which may cause a medicalisation of behavioural problems.
6. A failure to specify the level of empirical support needed to approve any changes to the information contained in the previous edition.
7. A lack of openness to constructive criticism.
These are all very important concerns and I’d like to see the APA address them – especially no. 4, 5 and 6. Regarding no. 7, the APA is inviting feedback and opinions on the draft, and the fact that the release date is more than 3 years from now could mean that they will have the time to consider suggestions and criticism received.
My own thinking on the DSM is that it’s not perfect, and it should not be a “bible” for psychiatry and psychology. No psych*ist I know only uses the DSM for diagnosis. It’s a tool to be used by qualified and experienced clinicians in conjunction with a thorough interview and history-taking. However, indirect influences such as selective education could play a part in even the most thorough diagnostic process.
Also, many instruments are based on DSM criteria, so while the DSM itself may not be specifically used for diagnosis or for research, it has a wide reach.
I see disorders as cultural constructs. By this I don’t mean to imply that they are “made up”, or that their effects are not extremely serious, but that a certain grouping of symptoms into a coherent disorder is arrived at in a culturally-grounded way. I don’t think there will ever be conclusive scientific proof that shows that a certain cluster of symptoms should always be grouped together to form a certain disorder (not that scientific research is not culturally-grounded and -driven itself). This can be seen in the significant changes that DSM disorders have gone through from one edition of the DSM to the next. Then, even symptoms can vary culturally. For example, in certain Middle Eastern populations mood disorders present more somatic symptoms than in Western populations. And then you have culture-bound syndromes as well.
I think it’s important to keep disorders (and symptoms) -as-constructs in mind when looking at DSM debates; however, since the biomedical model of illness, including mental illness, requires the clinician to draw a line – what does and doesn’t require treatment, what requires one particular treatment or another, a particular intervention, a particular dosage, what is and isn’t relevant in a court of law, what is and isn’t worthy of compensation, awareness of disorders as cultural constructs may not be very useful in a practical clinical way.
However – I think one of the biggest steps forward that the DSM has made over time, which gives heed to the idea of subjectivity of classification and diagnosis, is the fact that many disorders in the DSM have as one of their inclusion/exclusion criteria the degree of impairment (physical, psychological, social) that the symptoms are causing the individual. In other words, even considering the subclinical categories which will be introduced in DSM-V, one of the determining factors for treatment will still be the answer to the question: “how affected by these symptoms is your life?”. After all, unpleasant or painful symptoms that affect quality of life don’t need to be part of some greater and well-defined disorder, nor do they need to be universal in manifestation, to be taken seriously and treated in other branches of healthcare, so I don’t see why they should be disregarded in mental health. Of course, it’s also of utmost importance to heed Dr. Frances’s warnings of overmedication and overpathologisation.
Overall, I’m both excited and anxious about DSM-V and I will be taking the time to go through the information on DSM5.org tomorrow.
Ceci n’est pas un chapeau 27 December, 2009Posted by Queen of Spades in books.
Tags: neurology, sacks
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Charcot and his pupils, who included Freud and Babinski as well as Tourette, were among the last of their profession with a combined vision of body and soul, ‘It’ and ‘I’, neurology and psychiatry. By the turn of the century, a split had occurred, into a soulless neurology and a bodiless psychology…
Oliver Sacks, renown New York neurologist and author of The Man Who Mistook His Wife for a Hat, attempts to reconcile this split, both in his practice and through his writing. And this is the very reason I find his work so compelling – without losing sight of the chemical imbalances and neural damage underlying the disorders described in his writing, he treats his patients holistically – as a system of flesh, bones, electricity and chemistry, beliefs, values and fears, family and community members, loved ones, history, symbols and wonder.
In one of the chapters of The Man Who Mistook His Wife for a Hat, Sacks describes how he spent 3 months analysing all the implications – psychological, social, economical – of treatment with haloperidol (a dopamine antagonist) for a patient with Tourette’s syndrome, “Witty Ticcy Ray”. He did this in weekly sessions with Ray and in the end they came up with an unconventional but satisfactory solution that was best for Ray (controlling Tourette’s during the week with medication, and letting it run its course on weekends). I find this so inspiring – this process of working with each individual patient, recognising the unique ways in which a disorder might affect them, and tailoring treatment to suit them, rather than making them fit a rigid and generic treatment regimen.
I also find fascinating the way in which disorders can become more or less accommodated or integrated within an individual’s personality and life – especially with chronic disorders. They become part of the person, altering who they are – which is why, in cases like Ray’s, simply “taking the disorder away” was impossible and disastrous for Ray’s sense of self, which was partly based on Tourette’s.
Sacks never loses a sense of wonder in what he encounters; disorders don’t only cause deficits, but can also cause excesses (of energy, mood, movement, reflexes, thought) and can be productive in a Foucauldian sense, contributing to identity (subjectivity) production. However, Sacks also always preserves empathy for his patients – they never become mere “subjects” or “curios”.
Sometimes I feel this is a lost art (at least in the Western biomedical model) – treating the disorder (symptoms and underlying causes), but also treating the patient – as a complete person enmeshed in a larger network, where both the internal and external workings rely on delicate and complex sets of balances. Homeostasis needs to be maintained, or restored, both inside and outside the body. Sacks seems to have an intuitive understanding of this, and I think anyone who works in any sort of healthcare profession (especially mental health!) would get a lot out of his writing.
Sacks, O. (1986). The Man Who Mistook His Wife for a Hat. London: Picador