Richard G. Petty, MD

Evaluating Sense of Coherence

Yesterday we began to look at Aaron Antonovsky's concept of Sense of Coherence.

Here is one of the most widely used sets of questions to determine an individual’s Sense of Coherence, derived from Antonovsky's The Sense of Coherence Quest.

The questions concern a number of aspects of our lives.

Each question has seven possible answers. The person doing the evaluation marks one number from 1 to 7 for whichever one most closely corresponds to their beliefs or  feelings.

1. When you talk to people, do you have the feeling that they don’t understand you?
    Never     1 2 3 4 5 6 7     Always have this feeling

2 In the past, when you had to do something that depended upon cooperation with others, did you have the feeling that it:
    Surely wouldn't get done     1 2 3 4 5 6 7     Surely would get done

3. Think of the people with whom you come into contact daily, aside from the ones to whom you feel closest. How well do you know most of them?
    You feel that they're strangers     1 2 3 4 5 6 7     You know them very well

4. Do have the feeling that you don't really care about what goes on around you?
    Very seldom or never     1 2 3 4 5 6 7    Very often

5. Have you in the past ever been surprised by the behavior of people whom you thought you knew well?
    Never happened     1 2 3 4 5 6 7     Always happened

6. Have you ever had people that you counted on, ended up disappointing you?
    Never happened     1 2 3 4 5 6 7     Always happened

7. Life is:
    Full of interest     1 2 3 4 5 6 7     Completely routine

8. Until now your life has had:
    No clear goals or purpose at all     1 2 3 4 5 6 7     Very clear goals and purpose

9. Do you have the feeling that you're being treated unfairly?
    Very often     1 2 3 4 5 6 7     Very seldom or never

10. In the past ten years your life has been:
    Full of changes without your knowing what will happen next     1 2 3 4 5 6 7     Completely consistent and clear

11. Most of the things you do in the future will probably be:
    Completely fascinating     1 2 3 4 5 6 7     Deadly boring

12. Do you have the feeling that you are in an unfamiliar situation and don't know what to do?
    Very often     1 2 3 4 5 6 7     Very seldom or never

13. What best describes how you see life:
    One can always find a solution to painful things in life     1 2 3 4 5 6 7     There is no solution to painful things in life

14. When you think about your life, you very often:
    Feel how good it is to be alive     1 2 3 4 5 6 7     Ask yourself why you exist at all

15. When you face a difficult problem, the choice of a solution is:
    Always confusing and hard to find     1 2 3 4 5 6 7     Always completely clear

16. Doing the things you do every day is:
    A source of deep pleasure and satisfaction     1 2 3 4 5 6 7     A source of pain and boredom

17. Your life in the future will probably be:
    Full of changes without your knowing what will happen next     1 2 3 4 5 6 7     Completely consistent and clear

18. When something unpleasant happened in the past your tendency was:
    "To beat yourself up" about it     1 2 3 4 5 6 7 to say,     "Ok that’s that, I have to live with it " and go on

19. Do you have very mixed-up feelings and ideas?
    Very often     1 2 3 4 5 6 7     Very seldom or never

20. When you do something that gives you a good feeling:
    It’s certain that you'll go on feeling good     1 2 3 4 5 6 7     It's certain that something will happen to spoil the feeling

21. Does you have feelings inside you would rather not feel?
    Very often     1 2 3 4 5 6 7     Very seldom or never

22. You anticipate that your personal life in the future will be:
    Totally without meaning or purpose     1 2 3 4 5 6 7     Full of meaning and purpose

23. Do you think that there will always be people whom you'll be able to count on in the future?
    You're certain there will be     1 2 3 4 5 6 7     You doubt there will be

24. Does it happen that you have the feeling that you don't know exactly what's about to happen?
    Very often     1 2 3 4 5 6 7     Very seldom or never

25. Many people - even those with a strong character - sometimes feel like sad sacks (losers) in certain situations. How often have you felt this way in the past?
    Never     1 2 3 4 5 6 7     Very often

26. When something happened, have you generally found that:
    You overestimated or underestimated its importance     1 2 3 4 5 6 7             You saw things in the right proportion

27. When you think of the difficulties you are likely to face in important aspects of your life, do you have the feeling that:
    You will always succeed in overcoming the difficulties     1 2 3 4 5 6 7             You won't succeed in overcoming the difficulties

28. How often do you have the feeling that there's little meaning in the things you do in your daily life?
    Very often     1 2 3 4 5 6 7    Very seldom or never

29. How often do you have feelings that you're not sure you can keep under control?
    Very often     1 2 3 4 5 6 7     Very seldom or never

There are no right or wrong answers, but the overall pattern of your scores will give you some useful insights. There is a large research literature in which scores on this scale have been related to everything from career choices to the risk of getting PTSD.

A Sense of Coherence

One of the central concepts of Integrated Health and Integrated Medicine is the idea of coherence. This is not a new idea, but was developed in new ways and formalized by the American/Israeli sociologist Aaron Antonovsky. It is such an important concept that I have mentioned something about it before

Antonovsky developed his theory of health and illness, which he termed Salutogenesis. This model was described in his 1979 book "Health, Stress and Coping", followed by "Unraveling the Mystery of Health" in 1987. I remember its publication, and the strong feeling amongst many of us interested in Integrated Health that it was a most important contribution to understanding the relationship between health and illness. A key concept in Antonovsky's salutogenic theory concerns the way in which specific personal dispositions serve to make us more resilient to the stressors that we encounter in daily life.

Antonovsky identified these characteristics, which he said helped a person better cope and remain healthy by providing "a sense of coherence" (SOC) about life and the challenges we all face. Measures of Sense of Coherence have been developed and tested in more than 30 countries.

The SOC is defined as: “The extent to which one has a pervasive, enduring though dynamic, feeling of confidence that one’s environment is predictable and that things will work out as well as can reasonably be expected.”

So it tries to capture our sense of optimism and control.

SOC has three components:

• Comprehensibility
• Manageability
• Meaningfulness

Comprehensibility is the extent to which events are perceived as making logical sense, that they are ordered, consistent, and structured. Manageability is the extent to which a person feels they can cope. Meaningfulness is how much one feels that life makes sense, and challenges are worthy of commitment.

Professor Antonovsky believed that a person with a strong SOC is more likely to feel less stress and tension, and to have confidence that he or she can meet the demand placed upon them. The SOC was developed to apply across cultures, and versions of the questionnaire have been used in over 30 countries.

The SOC is not the only factor in a predicting outcomes in a person’s life: it interacts with a person’s natural coping style, upbringing, financial assets, mood and social support. The strength and availability of each is a major determinant in the development of a strong or weak SOC.

Research in the growing field of psychoneuroimmunology has supported many of the basic assertions of the relationship between emotions and health contained in Antonovsky's theory of Salutogenesis.

I saw some research (NR691) at the 2007 Annual Meeting of the American Psychiatric Association in San Diego, California last month that was based on a sample of 976 working people in Denmark, found that people with a high sense of coherence perceive less stress and experience less psychological disturbance in the work place.

This all makes very good sense, and it also gives us yet another line of approach for helping people deal with the stresses of life and gain personal mastery.

I shall talk about using this information in the future.

Enlightenment

Regular readers will know that I have been collecting wise words from around the globe for many years, and I now have almost 40,000 of them broken down into more than 500 topics. It has taken years not just to collect them, but to try to check the sources and wording. But if you find errors, please let me know!

Here are 23 of my favorites comments about enlightenment.

I do hope that you find them as useful and inspiring as I have.



“One does not become enlightened by imagining figures of light, but by making the darkness conscious.”   
--Carl G. Jung (Swiss Psychologist and Psychiatrist, 1875-1961)

“Be a lamp unto your own feet; do not seek outside yourself.”   
--Buddha (a.k.a. “The Awakened”, a.k.a. Siddhartha Gautama, Indian Religious Figure and Founder of Buddhism, c.563 B.C.E. – c.483 B.C.E.)

“When the divine vision is attained, all appear equal; and there remains no distinction of good and bad, or of high and low.”   
--Sri Ramakrishna (a.k.a. Sri Ramakrishna Paramahansa, Indian Hindu Mystic and Promoter of Universal Religion, 1836-1886)

“We loosely talk of Self-realization, for lack of a better term.  But how can one realize or make real that which alone is real? All we need to do is to give up our habit of regarding as real that which is unreal. All religious practices are meant solely to help us do this. When we stop regarding the unreal as real, then reality alone will remain, and we will be that.”   
--Ramana Maharshi (Indian Hindu Mystic and Spiritual Teacher, 1879-1950)

“We attain enlightenment when we love truth for the sake of truth, and not for the sake of self-promotion or worldly gain.”   
--Emanuel Swedenborg (Swedish Scientist, Mystic and Philosopher, 1688-1772)

“Once and for all, dedicate yourself to the service of a high ideal, to the coming of the kingdom of God, and do not be concerned with what will become of you. This ideal will bring you everything."
--Omraam Mikhaël Aïvanhov (Bulgarian Spiritual Master, 1900-1986)

“The holy instant is the recognition that all minds are in communication. Every thought you would keep hidden shuts off communication.”
--A Course in Miracles (Book of Spiritual Principles Scribed by Dr. Helen Schucman between 1965 and 1975, and First Published in 1976)

“If you are enlightened, you are not free, as some people say, but you are freedom itself. Not like a bird in the sky, but like the sky itself.”
--Wolter A. Keers (Dutch Advaita Teacher and Editor, 1923-1985)

“The reason why so few people find enlightenment is because they have free will and punish themselves by making wrong choices. Constantly, enlightenment is being offered to them, but they refuse to accept it. Therefore they refuse to accept it. Therefore they are being taught problems that are set before them, since they refuse to make choices voluntarily.”
--“Peace Pilgrim” (a.k.a. Mildred Norman, American Peace Activist, 1908-1981)

“All the riches of this world are too less a price for a single word which enlightens the soul.”    
--Hazrat Inayat Khan (Founder of the Sufi Order of the West, 1882-1927)

“To the dull mind all nature is leaden. To the enlightened mind the whole world sparkles and burns”   
--Ralph Waldo Emerson (American Poet and Essayist, 1803-1882)

“Enlightenment must come little by little, otherwise it would overwhelm.”   
--Idries Shah (Afghan-born Sufi Philosopher and Writer, 1924-1996)

“Out of compassion I destroy the darkness of their ignorance. From within them I light the lamp of wisdom and dispel all darkness from their lives.”   
--Bhagavad Gita (Ancient and Sacred Sanskrit Poem Incorporated into the Mahabharata)

“If these little sparks of holy fire which I have thus heaped together do not give life to your prepared and already enkindled spirit, yet they will sometimes help to entertain a thought, to actuate a passion, to employ and hallow a fancy.”
--Jeremy Taylor (English Anglican Clergyman, Writer and Bishop, 1613-1667)

“The great beacon light God sets in all, the conscience of each bosom.”
--Robert Browning (English Poet, 1812-1889)

“God reveals himself unfailingly to the thoughtful seeker.”
--Honoré de Balzac (French Novelist, 1799-1850)

“There is no difference between an enlightened man and an ignorant one. What makes the difference is that the one realizes it, while the other is kept in ignorance of it.”
--Hui-Neng (a.k.a. Daikan Eno, Chinese Chan Monk, A.D. 638-713)

“You may have expected that enlightenment would come Zap! Instantaneous and permanent. This is unlikely. After the first "ah ha" experience, it can be thought of as the thinning of a layer of clouds...”   
--Ram Dass (a.k.a. Richard Alpert, American Spiritual Teacher, Author and Lecturer, 1931-)

“God realization does not begin in a cave high atop the Himalayas. It begins in the pots and pans of the kitchen. Treat all your tasks, however small, as opportunities to see God and serve him.”
Sri Swami Sivananda (Indian Physician and Spiritual Teacher, 1887-1963)

“Enlightenment is not an attainment: it is a realization. When you wake up, everything changes and nothing changes. If a blind man realizes that he can see, has the world changed?”   
--Dan Millman (American Writer, Philosopher and Former World Class Trampolinist, 1947-)

“Enlightenment is the highest good. Once you have it, nobody can take it away from you.”   
--Siddharameshwar Maharaj (Indian Spiritual Teacher, 1888-1936)

“Is enlightenment really possible for the average person? Yes. Big Yes. Enlightenment is very possible for the ordinary individual. Actually it is easier than for some one who thinks that they are special.... whenever someone is ordinary, simple, innocent and natural, that is enlightenment.”   
--Sri Sri Ravishankar (Indian Spiritual Teacher and Founder of the Art of Living Foundation and the International Association for Human Values, 1956-)

Brain Training and the Paradox of Aging

For centuries, people in cultures throughout the world have believed that increasing age is associated with increasing wisdom. Not just knowledge and experience, but wisdom. Is this an old wives' tale, or is there something to it?

There is growing evidence that as we age our brains actually become stronger. Everyone missed it, because the emphasis was on memory, concentration and thinking speed, and those may all deteriorate with age. What changes is that as we age we become more efficient at making associations rather than thinking linearly. we also recruit regions of the brain that may have lain dormant for years. At the same time, different types of mental training, including meditation, can improve many aspects of our cognitive abilities, and may also enrich and even grow appropriate regions of the brain.

Some new data from a study being conducted at Wake Forest University Baptist Medical Center in North Carolina suggests that it is possible to use a fitness program for your brain that can improve thinking skills, attention and concentration as reliably as lifting weights can increase muscle strength.

Preliminary findings from the study, which used functional magnetic resonance imaging (fMRI) to record brain activity, were presented last week at the Organization for Human Brain Mapping conference in Chicago.

As we age, we do experience changes in how we perceive the information that our senses gather from the environment. As I mentioned older adults combine information from the different senses more readily than do younger adults. This is known as sensory integration, and the down side is that it can lead to difficulties in blocking out distracting sights and sounds while still maintaining focus on important information. You are probably familiar with the "Cocktail Party Phenomenon." You are in a loud room, but because someone is saying something interesting, you are able to block out uninteresting information. This technical term for this is cortricofugal inhibition. As we get older it gets more difficult to do the inhibiting.

The Brain Fitness in Older Adults (B-fit) study has been designed to establish whether eight hours of brain exercise can improve the ability of healthy older adults, ages 65 to 75 years, to filter out unwanted sights and sounds.

The B-fit study uses fMRI to visualize blood flow and brain activity to determine how attention training affects brain function. The training involves either a structured one-on-one mental work-out program or a group brain exercise program. During the one-on-one sessions, the volunteers were asked to ignore distracting information and tasks get harder as the eight-week training progresses. For the group sessions, participants learn new information relevant to healthy aging and are then tested on their ability to apply the new information.

All participants had an fMRI scan during a distraction task. They had to look for target words or numbers while ignoring distracting sounds. The scans showed brain activity in areas related to both sight and sound. Follow-up fMRIs showed that in the group receiving the one-on-one training, activity related to sight was increased, while activity related to sound was decreased. In addition, performance on the task was improved.

So the data do indeed suggest that attention training is a way to reduce older adults' susceptibility to distracting stimuli and therefore help improve concentration.

And what about wisdom?

I have written in Healing, Meaning and Purpose that "Wisdom is the integration of understanding:" making more new associations and drawing conclusions based on a new perspective is a gift of aging. The training enables us to make sense of and communicate our conclusions.

When it comes to the brain, use it or lose!

Aggressive Bullies, Sleep and Breathing

Here is yet another possible problem associated with poor quality sleep and breathing problems during sleep.

Research from the University of Michigan that was presented at SLEEP 2007, the 21st Annual Meeting of the Associated Professional Sleep Societies in Minneapolis this week, suggests a link with aggression.

Aggressive behavior and bullying are common amongst schoolchildren and are likely to have multiple causes. But a new one, and one which may be an undiagnosed, is sleep-related breathing disorder (SRBD).

The study focused on children in the second through fifth grades who attended school in an urban public school district. Parents completed two well-validated rating instruments: the Conners' Parent Rating ScalePediatric Sleep Questionnaire SDB Scale. Teachers completed the Conners' Teacher Rating Scale (CPRS) the  (CTRS). The numbers of discipline referrals in the previous 12 months were obtained from the six elementary schools.

A total of 345 CPRS's and 245 corresponding CTRS's were completed. The main finding was that schoolchildren who bully may be more likely to have an SRBD than their peers.

An SRBD may be a problem in more than 10 percent of children. It occurs when the airway is partially blocked during sleep. The most common example is snoring. The most severe form of an SRBD is obstructive sleep apnea. It occurs in about one percent to two percent of children.

If you suspect that your child or grandchild might be suffering from an SRBD or, for that matter, any type of sleep disorder, it is a really good idea to consult with your child's pediatrician, who can see of he or she needs to be referred to a sleep specialist.

We already know that treatment of an SRBD may improve other mood, attention and behaviors in children. We do not know if treatment might reduce aggression and bullying, and that will be the next research project.

More Data on Guanfacine for Attention Deficit Disorder

Several months ago I mentioned that there is growing interest in a medicine called guanfacine for attention-deficit /hyperactivity disorder (ADHD).

Though it is not yet approved for this indication by the Food and Drug Administration, there were a number of papers about it at the Annual Meeting of the American Psychiatric Association in San Diego last month.

The first (NR656) from Cincinnati and Massachusetts General Hospital looked at guanfacine extended release for the treatment of children aged 6 to 17 with ADHD. The study showed that the medicine wa both effective and well tolerated.

The second (NR657), also from Cincinnati looked at children who had been treated for 23 months, and it looks as if the efficacy is maintained. Thirteen out of 259 patients had serious side effects, which is actually quite a low number.

There were two more from Massachusetts General Hospital (NR658 and NR659) that produce very similar results: good efficacy and tolerability for up to two years.

Now we shall have to wait and see what the regulatory authorities in Europe and the United Sates have to say. There has been so much concern about the safety of medicines that the FDA in particular is being etxra cautious these days.

I shall let you know if and when I hear something more about guanfacine.

Burnout and the Adrenal Glands

I have talked about burnout and the myth that it is caused by “adrenal fatigue.”

I saw some research (NR620) at the 2007 Annual Meeting of the American Psychiatric Association in San Diego, California last month that further nails the idea.

The investigators were from Ege University in Izmir, Turkey, and they looked at 37 people with burnout and did a battery of psychological and endocrine investigations.

The burnout group had:

• Higher levels of emotional exhaustion and depersonalization
• Higher depression and anxiety scores on the Beck depression and Beck anxiety inventories
• Higher scores on the global symptom index

The people with burnout did not have any differences in cortisol levels either at rest or after the investigators did a standard test to stimulate the adrenal glands. They reported exhaustion, but it was NOT caused by a problem with their adrenal glands.

I know that there are still plenty of people promoting the idea of adrenal fatigue, and there are many who sell their services online. The evidence that we have so far indicates that the adrenal glands of most people with burnout seem to be just fine.

Acupuncture for Temporomandibular Joint Pain

I was pleased to see that a group of researchers from Manchester in England (that's its skyline, above!) did a double-bind randomized controlled study of twenty seven people suffering from temporomandibular joint myofascial pain (TMJ/MP), to see if acupuncture would help them.

The people in the trial either had acupuncture or something called "sham" acupuncture, using a device that was created to create a "placebo control." The piece of equipment is called the Park Sham Device, and there has been a lot of discussion about whether it is really feasible to do "pretend" acupuncture. This study showed that it is.

The acupuncture was shown to have a greater influence on pain and movement than the "sham" treatment.

This is important: TMJ can be very difficult to treat. Last year there was a report, also from the UK, that acupuncture seemed to be effective, based on an audit of dental practices, and this study just adds to the evidence that we are accumulating.

Sleep Deprivation

When I was a young doctor we used to work absurdly long hours: for more than three years I worked every other night and every other weekend. It was not uncommon to be on your feet for three at a time. It is a wonder that we didn’t die or make more mistakes.

We know that sleep deprivation is not healthy, but we are only now beginning to find out just how damaging it can be. One of the biggest problems is that sleep deprivation interferes with the normal functioning of the immune system.

I saw an interesting paper (NR619) at the 2007 Annual Meeting of the American Psychiatric Association in San Diego last month.

A team from Korea took sixteen healthy volunteers and made them stay awake for 48 hours. They found that even this relatively short period of sleep deprivation produced some impressive effects on the body and the mind:

• Thyroid hormone levels rose
• The speed and accuracy of reaction times fell
• Blood glucose and protein levels rose, and there were disturbances in several liver function tests
• White blood counts increased
• There was a slight fall in immunoglobulin levels

We already know that insufficient sleep is associated with insulin resistance and weight gain, and it is likely that these are mediated by a rise in inflammatory mediators in the blood.

It is remarkable how quickly the effects occur.

And how pleased I am that young doctors no longer have to tolerate those incredibly long shifts.

Some things have changed for the better!

Sleep and Memory

When I was a child and I had to learn something, I was always encouraged to read things one last time before I went to sleep. Now there is some research to indicate that this was excellent advice.

We have known for decades that sleep helps improve memory for procedural tasks, such as learning a new piece on the piano. But nobody has known for sure whether sleep helps other types of memory.

A study that presented at the 59th Annual Meeting of the American Academy of Neurology (AAN) in Boston, Massachusetts showed that declarative memories — memories for facts and events in time — become more resistant to interference during sleep.

To test whether sleep strengthens declarative memory in the face of interference, a research team led by Dr. Jeffrey Ellenbogen from Harvard conducted a study in which 48 people between the ages of 18 and 30 were divided into 4 groups:

• A wake group without interference
• A wake group with interference
• A sleep group without interference
• A sleep group with interference

Each group was taught the same 20 pairs of words in the initial training session. The wake groups were taught the word pairings at 9 AM and then tested on them at 9 PM, after 12 hours of being awake. The sleep groups were taught the word pairs at 9 PM and tested on them at 9 AM, after a night of sleep.

Just before testing, the interference groups were given a second list of word pairs to remember. The first word in each pair was the same on both lists, but the second word was different. The idea was that this would test the brain's ability to handle interference. The interference groups were then tested on both lists.

The investigators found that subjects in the sleep groups had superior recall, when compared to those in the wake groups. The difference between the sleep and wake groups was greatest when the subjects were tested after interference (76% vs 32% of words recalled correctly in the sleep group vs the wake group. This result was statistically impressive: P < .0001).

This is important research: not only does it help us advise people on how and when to study, but it will likely have important implications for our understanding about how memories are laid down and encoded in the brain.

Yoga Improves Concentration and Motivation

We know that hatha yoga can improve balance and flexibility, and there has been evidence that it can have more profound effects on the body and mind.

Now some new research confirms something else that we have suspected: it can also lessen anxiety and improve concentration and motivation in as little as eight weeks.

The research was presented in New Orleans at the 54th Annual Meeting of the American College of Sports Medicine. Researchers from California State University in San Bernardino wanted to quantify the benefits of yoga beyond just strength and flexibility.

The investigators tested 84 students during the second and eighth weeks of four, 10-week hatha yoga classes at the University. 93% of the participants were female, 45 percent were Hispanic, 35 percent “Caucasian,” seven percent African-American, and two percent Asian. The students averaged 24 years of age; most had at least three months of consistent yoga experience prior to the class. (Why the quotes around “Caucasian?” I just don’t like the term. I am white and not from the Caucasus. I am also a nit picky Virgo…)

Two weeks and again nine weeks into the class, participants completed three standard assessments to measure their concentration, motivation and anxiety level. The results were dramatic. In just eight weeks of practice they measured significant increases in all three areas.

The research will be expanded to include more men, and also to see how these findings can be applied to sports and clinical treatment.

The researchers have opened up a fascinating field for further study, and I shall continue to report on the data as it comes out.

Acupuncture for Itch

Acupuncture has been used for every conceivable type of problem, and I have often been surprised how well it can help some skin problems. I was particularly impressed by its effectiveness in treating shingles, but I have sometimes also found that it can be very helpful in treating chronic itching.

So I was interested to see a study from Bochum in Germany in which 32 healthy volunteers had histamine applied to both forearms. Histamine is the chemical that normally causes a red wheal and a flare after being bitten by a mosquito or other bug.

Then, five minutes later, they had electroacupuncture of either the right or left ear. There are specific points on the ear that are said to be good for treating itching. They then re-tested the volunteers four weeks later, but this time without the acupuncture.

Acupuncture was found to significantly reduce  - and in some cases completely prevent – the areas of itchy redness, but only on the same side that had the acupuncture. So if the right ear was treated, the itch and redness was less on the right side, but not of the left.

This is an impressive demonstration of something that we have seen in clinical practice, but until now have never proven.

Insulin Resistance and Cognition

I have talked a lot about insulin resistance and the problems that it can cause. It is one of the biggest threats facing the human population, with at least a third of Americans now being insulin resistant. It looks as there may be another complication of insulin resistance that we need to add to the list.

Researchers from Canada presented some interesting data (NR385) at the 2007 Annual Meeting of the American Psychiatric Association in San Diego last month.

There has been a great deal of concern that some newer antipsychotics may cause insulin resistance and perhaps diabetes, and the FDA has required all the newer antipsychotics to carry a warning about this potential problem. We also know that although these medicines can be very effective in treating some symptoms, they do not usually help cognition very much.

The researchers recruited 37 people with chronic schizophrenia and did neurocognitive tests on them while also measuring their insulin resistance.

They found a significant correlation between insulin resistance and neurocognitive functioning. It looks as if insulin signaling is important for processing information in the brain and insulin resistance interferes with the process.

Though this study look at a highly specialized group: people with chronic schizophrenia – there is some recent evidence to suggest that insulin resistance may be a factor in Alzheimer’s disease, and that people may develop cognitive impairments if they go on to develop insulin resistance syndrome or impaired fasting glucose.

Yet another good reason for using diet, exercise and sleep to try and present insulin resistance and maintain healthy glucose levels.

Regular readers will recall that there are five pillars of healthy aging and the prevention of cognitive decline:

1. Blood pressure
2. Physical activity
3. Mental activity
4. Supplements and moderate alcohol
5. Social engagement and level mood

We should now add avoidance of insulin resistance to the list. Taken together, the evidence suggests that we can dramatically reduce our risk of cognitive decline as we get older.

A New Treatment for Parkinson’s Disease?

It is remarkable how often we find that a treatment for one problem may turn out to help something completely different.

Parkinson’s disease is caused by a loss of dopamine neurons in specific circuits in the brain. Dopamine has a great many actions, but I these particular circuits it is involved in the control of movement. Once it starts, the process usually continues on inexorably. The mystery has been why the neurons die in the first place.

There is a very promising article that was published online today in the journal Nature.

Investigators from the Department of Physiology in the Feinberg School of Medicine at Northwestern University in Chicago and the Department of Cellular and Molecular Pharmacology at the Chicago Medical School, Rosalind Franklin University of Medicine and Science have looked at a medicine that is usually used for treating hypertension, and found that it may protect dopaminergic neurons.

Their studies have suggested that the dopaminergic neurons involved are unusually reliant on a type of calcium channel that maintains their rhythmic activity. If the pacemaker is damaged, the neurons become more vulnerable to stressors such as neurotoxins. As we age, calcium ions begin to enter the neurons and change their behavior. They showed that mice that had been engineered to develop a progressive Parkinson's-type disease did not become ill when their condition was treated with the calcium channel blocker  israpidine. Their dopamine neurons appeared to revert back to their original, youthful form.

It is much to early to think about using isradipine for treatment. We do not, for example, know whether it works in humans and we have any idea how much of the drug would be needed. But this research does suggest a whole new line of research and possibilities for treatment.

That is exciting, though when I read about research like this I always wish that researchers did not use animals in their experiments. But since the animals have made the sacrifice to help us, we need to acknowledge their help.

Solar Cycles and Human Disease

We have all heard about the supposed association between full moon and mental illness, though most of the research has failed to find an association between phases of the moon and mood disorders or psychosis.

But something that we have not heard so much about is the possible association between solar activity and human problems.

Investigators from Chile presented some interesting data (NR308) at the 2007 Annual Meeting of the American Psychiatric Association in San Diego last month.

They used a measure of solar activity called the Wolf number that is based on the number of sunspots. The sunspot cycles are usually between 9.5 and 11 years. They examined the clinical records of 1862 individuals who had been seen at a psychiatric clinic in Santiago over a sixteen-year period, which corresponded to one and a half solar cycles. They found that there was a big rise in admission for severe depression during years with low solar activity and a slight increase in the number of admission for mania during years of high solar activity.

This is not the first time that a connection has been found between the sun and human affairs.

The same authors published a paper in Spanish two years ago in which they also found that depression is more common when there is less solar activity and mania increases when there is more activity. They cannot say whether it is just light that is causing this or some other form of radiation.

Two researchers used the Maine Medicaid database to look at the relationship between solar cycles and human disease, and found that that radiation peaks in solar cycles and particularly in chaotic solar cycles (CSCs) are associated with a higher incidence of mental disorders. The same researchers had previously used the same database to suggest that CSCs produce more ultraviolet radiation and it is this that limits human longevity by causing chromosomal damage.

Interestingly, in 1993 two researchers also suggested a relationship between solar activity and longevity. They looked at the mean longevity of birth cohorts from 1740 to 1900 for United States of America (U.S.) Congressional Representatives exhibited oscillations that coincided with the 9- to 12-year sunspot cycle. They found that the mean longevities of these cohorts were 2-3 years longer during times of low sunspot activity than at peak activity. This phenomenon was confirmed in data from members of the House of Commons of the United Kingdom Parliament and from University of Cambridge alumni.

Researchers in Slovakia have suggested that there may be an association between solar radiation and cerebral strokes, though their data is a little difficult to interpret.

It is clear that the Heavens have more of an impact upon us than many scientists realized, and need to be factored into studies of human mood and behavior.

Red Meat and Breast Cancer

There is an important study that was published in the April issue of the British Journal of Cancer, but which I haven't seen reported in the United States.

The researchers did a survival analysis to assess the effect of meat consumption and meat type on the risk of breast cancer in the UK Women's Cohort Study. Between 1995 and 1998 a cohort of 35,372 women was recruited, aged between 35 and 69 years with a wide range of dietary intakes, assessed by a 217-item food frequency questionnaire. The researchers also took into account smoking, weight, fruit and vegetable intake, class, education and use of hormone replacement therapy.

The results showed that eating even small amounts of red meat daily can increase the risk of breast cancer by 56 per cent in older women.

As little as 2oz (57g) of beef, lamb or pork a day showed an effect. Post-menopausal woman who ate larger amounts, 3.6oz (103g), of processed meats such as sausage, bacon or ham had an increased risk of 64 per cent.

Even younger, pre-menopausal women had a slightly raised risk if they ate red meat daily.

Earlier analysis from the study found that pre-menopausal women who had the greatest intake of fibre cut their breast cancer risk by half.

The Leeds work supports other studies. In November, a study from the United States found that women who ate the largest amounts of red meat had a rising risk of breast cancer. But different studies have presented conflicting views.

One reason why red meat may contribute to a raised risk of breast cancer is that it is a rich source of saturated fat. The women who ate the most meat were also more likely to be fatter.

The publication of the study in the United Kingdom generated a great many negative comments from the meat industry.

One spokesperson, on hearing that as little as two ounces may be enough to increse the cancer risk said,

"Two ounces is absolutely tiny. I have never heard such rubbish. It's a tiny amount. This is ridiculous, it's silly."

I doubt very much that it is "silly," though it is a surprise that the study has not attracted more attention.

The best way to look at this data is not to say that everyone should become vegetarian, but to recommend that women should:

• Eat a balanced diet
• Limit alcohol consumption
• Exercise regularly
• Keep and maintain a healthy weight
• Try to maintain a regular sleep schedule

Negative Ions to Help Treat Mania

Last year I talked about some of the nasty problems that can be caused by the hot dry winds that blow in many parts of the planet.

I have just seen that a paper that I was asked to look at a few months ago has just appeared in print, though according to the journal it came out in February!

The investigators used a negative ionizer to augment the treatment of 20 acutely manic people. It was a standard double-blind crossover study with raters who did not know who had received what treatment.

The negative ions did indeed produce a significant improvement in manic symptoms. We already know that atmospheric ions can have an impact on serotonin levels in some parts of the brain, and that could be the mechanism of action.

It is surprising that there has been so little research into such a simple intervention, though it is important to note that the patients were also receiving medications. But it would be valuable to see if such a simple environmental change could modulate serious mood problems before they get to the level of needing hospitalization.

Acupuncture and Acupressure for Morning Sickness

Although I am most definitely of the male persuasion, I know that morning sickness can be an awful problem, though there is some evidence that it is an attempt by the body to rid itself of toxins that could otherwise harm the baby.

I have had a longstanding interest in the use of acupuncture and acupressure for the treatment of nausea and vomiting, whether pregnancy related or caused by infections, anesthesia or chemotherapy. Over twenty years ago my committee at the Research Council for Complementary Medicine helped fund research on the topic at the University of Belfast, and I have used both acupuncture and acupressure to treat many hundreds of people with nausea and vomiting. Before I left England, we were planning to do a clinical trial of acupuncture on morning sickness at Queen Charlotte’s hospital in London.

So I was delighted to see a meta-analysis published in the journal Explore.

The authors identified 14 eligible trials that had been completed over the last sixteen years, involving a total of 1615 women who had been treated with either acupressure, acupuncture or electrical stimulation at acupuncture points.

The conclusions were that these methods may reduce nausea by more than 50% compared with controls and vomiting by around 40%. These figures look about right, though acupuncture and acupuncture are very “operator-dependent:” some therapists get better results than others. What was interesting was that the effect was all due to acupressure: acupuncture was not shown to be effective, but acupressure was.

The analysis also points out a potential weakness in other meta-analyses. It is not wise to lump all acupuncture and acupressure together, since each may work somewhat differently.

As a sidebar, when we use acupuncture or acupressure, we always tailor the treatment to the individual, but the most commonly used points are Liver-3 on the top of the foot between the big toe and second toe, and Pericardium-6, which lies on the inside of the forearm, about two inches above the wrist.

Larks, Owls and Depression

It is well known that mood disorders are associated with the disruption of many of the circadian rhythms of the body including sleep, temperature and thyroid function. These links are so well known that many experts believe that depression may be a consequence of disturbances in circadian rhythms.

Although circadian rhythms tend to be fairly consistent across individuals, but there are significant differences in these rhythms in different people: we call this the "morningness-eveningness” dimension (MED).

As part of a larger project, researchers from Providence, Rhode Island last month presented a most interesting study (NR293) at the 2007 Annual Meeting of the American Psychiatric Association in San Diego.

People with psychiatric problems tend to be owls: evening types who don't like mornings, and this was particularly striking in people with depression.

This suggests that “eveningness” may be reflecting a risk factor or vulnerability to psychopathology, in particular depression. It may actually be that if you are a “morning person,” you may have some protection against developing depression.

I remember seeing a study from Stanford in April that suggested that people labeled a “night owls” report more pathological symptoms related to insomnia, despite many having the opportunity to compensate for their nocturnal sleeplessness by extending their time in bed and being able to gain more total sleep time. So this may be the link with depression.

Neurological Complications of Gastric Bypass Surgery

Our bodies are highly complex systems. They are not just bags of randomly assorted organs. So tinkering with one part of the system can have an impact in an entirely different part of the body. Many of us have worried for some time about the long-term consequences of gastric bypass surgery for weight loss. We know that some people who have had the surgery develop “substitution addictions.” If they had a real addiction to food before the surgery, after it they may begin to develop an addiction to something else, such as drugs or alcohol.

Now neurologists at the University of Arkansas for Medical Sciences (UAMS) in Little Rock have reported the results of a ten-year study found a link between gastric bypass surgery and several serious neurological conditions.

The study was published online May 22 in the medical journal Neurology and concludes that patients who undergo gastric bypass surgery, also known as bariatric surgery, are at risk for long-term vitamin and mineral deficiencies and as a result may develop a variety of neurological symptoms.

We know that ever more of these operations are being done every year, and so long as people are motivated they are usually successful in reducing weight. But they are not without risk, and we always have to balance that risk against the risk of being morbidly obese. This work is important because it suggests that there is an extra risk about which we previously knew very little.  Many of the complications that patients experience affect the nervous system, and they are often disabling and irreversible.

More than 150 patients who came to the UAMS Neurology Clinic following gastric bypass were included in the report. In 26 of these patients a link between the surgery and their neurological condition was found.

All of the patients involved in the study had previously undergone what is known as the Roux-en-Y gastric bypass procedure in which a small stomach pouch is created by stapling part of the stomach together and bypassing part of the small bowel, resulting in reduced food intake and a decreased ability to absorb the nutrients in food. The interval between surgery and onset of neurological symptoms ranged from 4 weeks to 18 years.

The neurological problems involved many different parts of the nervous system, and the symptoms included confusion, auditory hallucinations, optic neuropathy, weakness and loss of sensation in the legs, and pain in the feet, among other conditions. None of the patients had prior neurological symptoms.

Many of the patients also experienced multiple nutritional abnormalities, especially low serum copper, vitamin B12, vitamin D, iron and calcium.

This study underlines something very important. Many heavy people are actually malnourished, because they eat the wrong things and an excess of fat in the diet can create problems in the absorption of some vitamins and minerals. In addition, surgery like this can cause a form of malabsorption.

It is therefore essential to make sure that people who have this kind of surgery have an adequate long-term intake of vitamin and mineral supplements to prevent these neurological complications. It is important for everyone to know about these potential problems and to be on the lookout for neurological symptoms.

Personal Mastery and the Wellness of Caregivers

Looking after aging relatives can be incredibly difficult, particularly if they have a chronic illness such as Alzheimer’s disease.

There is also evidence that the caregivers of people with Alzheimer’s disease have increased rates of cardiovascular disease and they die prematurely. It has been assumed that the cardiovascular problems are a result of stress causing overdrive of the sympathetic nervous system.

There was some interesting research (NR241) presented last month at the 2007 Annual Meeting of the American Psychiatric Association in San Diego. The investigators did not have to come far: they are from the University of California in San Diego.

The investigators looked at 70 spousal caregivers of people with Alzheimer’s disease and used an experimental task to measure the activity of their sympathetic nervous systems. They also measured the caregiver’s levels of “Mastery:” the belief that one is capable of handing one’s problems. Mastery is one of the components of resilience, a key characteristic of a person who can handle stress well.

What they found make very good sense: the caregivers with the highest levels of personal mastery had the lowest levels of sympathetic activity, suggesting that a sense of mastery may protect against the physiological effects of acute stress.

This provides us with yet more evidence that psychosocial interventions that increase mastery may reduce the risk of cardiovascular disease amongst the caregivers of people with dementia.

The Seeker Academy

Regular readers know that I occasionally review worthy books at Amazon.com. Though I read a lot, I only review those that I think will be of interest to other people or help them in some way. I belong to the old school: "If you can't say something nice, say nothing." The exception is if someone writes something false or misleading.

I would like to tell you about a book that I was asked to review, and that I think deserves a wide readership. Yet because it is being published independently, it could fall below your radar.

It is called The Seeker Academy and is by someone whom I have not met, called L.D. Gussin. There is also a blog to support and supplement the book.

I think that my review of the book speaks for itself, but as I say at the end of it,

"If you are interested in some of the big questions in life, or if you feel that (Emotional and spiritual) hunger that I described above, this is an excellent, well-written and engaging book."

I do not know if the author is male or female, young or old, and in a way I am glad, in that it enabled me to read the book without preconceptions.

It is an enjoyable work, and I can guarantee that it is a book that will make you think.

The Development of Color Vision

Last year we looked at the research suggesting that the reason why primates developed color visions was so that they could pick up color changes on the faces and posteriors of other apes.

Now researchers at Ohio University have found that after primates evolved the ability to see red, they began to develop red and orange skin and hair.

As we discussed last year, humans, apes and Old World monkeys, such as macaques and leaf monkeys, all have trichromatic vision, allowing them to distinguish between blue, green and red colors. Primatologists have disagreed about whether this type of color vision initially evolved to help early primates forage for ripe fruit and young, to be able to red leaves among green foliage, or to tell the state of anger or arousal in other apes or to help them select mates.

Now a new study published online this week in American Naturalist by Ohio University researchers Andre´Fernandez and Molly Morris suggests that red-color vision evolved for non-social purposes, possibly foraging. But once developed, trichromaticism - i.e. three color vision - drove the evolution of red skin and hair through sexual selection.

Andre´Fernandez first began to question the strict correlation of food choice and color vision while studying howler monkeys in Costa Rica. He recently compiled data on the color vision, social and sexual habits and red skin and pelage (hair, fur and wool) of 203 different primate species.

The researchers then used a phylogenetic tree representing the evolutionary relationships among all the primate species under study to test hypotheses about the order in which the traits of red color vision, gregariousness (highly social behavior) and red coloring evolved. By comparing the traits of individual species in this evolutionary context, Fernandez and Morris could use statistical methods to deduce the probability of their ancestors having the same traits. They could also see if any of the traits were correlated with one another.

They found that the species that could discern red and orange hues were more likely to develop red and orange skin and hair, as well as highly social habits that make it easier to visually compare mates. In fact, the more social the three-color vision apes are, the more red coloring they show.

Fernandez said,

“Neuroscience research has found some evidence of a perceptual bias for more brilliant colors, so it is reasonable for primates with trichromatic color vision to respond more when they see bright colors."

Molly Morris, the co-author on the paper is a fish biologist who studies how physical traits such as coloring evolve through sexual selection.

She said,

"It looks like red skin and hair became a sexual preference, so while the benefits in terms of eating may not apply anymore, the (red-color) vision in some groups is now relevant in social terms."

So while foraging may have initially sparked red color vision, the new ability was likely "recruited" for social purposes.

This is not just an interesting little evolutionary tidbit. There are plenty of systems in the human brain that evolved to do one thing, and are now used for something quite different. And sometimes these new uses conflict with some of the other programs running in the brain. This is likely to be one of the causes for some types of psychological problems. when the brain is trying to do too many things at once, and there is an imbalance between the older limbic regions of the brain and the cerebral cortex.

How Doctors Think. Or Not.

I recently reviewed a fascinating book at the Amazon website. It is called “How Doctors Think,” and it was written by the ever-thoughtful Jerome Groopman from Harvard.

To save you having to look through all the reviews to find what I said, I thought that it would be useful to say something about the book and why I have some reservations about Jerome’s analysis.

Most doctors are highly educated, hard working people who most of the time try to do their best. Yet in our blame culture there are places in America where you can’t get a specialist to treat you: they have all been driven out of business by lawyers representing unhappy clients. The question of why this has come to pass has occupied the minds of the American medical profession for three decades.

Jerome believes that the key problem is that doctors make the same kind of errors in thinking that the rest of us do. We all – and not just doctors - jump to conclusions; believe what others tell us and trust the authority of “experts.” Clinicians bring a bundle of pre-conceived ideas to the table every time that they see a patient. If that have just seen someone with gastric reflux, they are more likely to think that the next patient with similar symptoms has the same thing, and miss his heart disease. And woe betides the person who has become the “authority” on a particular illness: everyone coming through his or her door will have some weird variant of the disease. As Abraham Maslow once said, “If the only tool you have is a hammer, you tend to see every problem as a nail.” To that we have to add that not all sets of symptoms fall neatly into a diagnostic box and that uncertainty can cause doctors and their patients to come unglued.

Up to this point the book is very good as far as it goes but I do not think that the analysis is complete.

I have taught medical students and doctors on five continents, and this book does not address some of the very marked geographic differences in medical practice and the book is “Americano-centric.”

The first point is that the evidence base in medicine is like an inverted pyramid: a huge amount of practice is still based on a fairly small amount of empirical data. As a result doctors often do not know want they do not know. They may have been shown how to do a procedure without being told that there is no evidence that it works. As an example, few surgical procedures have ever been subjected to a formal clinical trial. Although medical schools are trying to turn out medical scientists, many do not have the time or the inclination to be scientific in their offices. In day-to-day practice doctors often use fairly basic and sometimes flawed reasoning. A good example would be hormone replacement therapy. It seemed a thoroughly good idea. What could be better than re-establishing hormonal balance? In practice it may have caused a great many problems. Medicine is littered with examples of things that seemed like a good idea but were not. Therapeutic blood letting contributed to the death of George Washington, and the only psychiatrist ever to win a Nobel Prize in Medicine got his award for taking people with cerebral syphilis and infecting them with malaria. The structure of American medicine does not support the person who questions: consensus guidelines and “standards of care” make questioning, innovation and freedom very difficult. A strange irony in a country founded on all three.

The second major factor in the United States - far more than the rest of the world - is the practice of defensive medicine: doctors have to do a great many procedures to try and protect themselves against litigation. This is having a grievous effect not only on costs, but also on the ways in which doctors and patients can interact.

Third is the problem of demand for and entitlement to healthcare. We do not have enough money for anything: but what is enough if the demand for healthcare continues to grow as we expect? And if people are being told that it is their right to live to be a hundred in the body of a twenty year-old? Much of the money is directed in questionable directions. There are some quite well known statistics: twelve billion dollars a year spent on cosmetic surgery, at a time when almost 40 million people have no health insurance. There are some horrendous problems with socialized medicine, but most European countries have at least started the debate about what can be offered. Should someone aged 100 have a heart transplant? Everyone has his or her own view about that one, but it is a debate that we need to have in the United States.

Fourth is the impact of money on the directions chosen by medical students and doctors starting their careers. Most freshly minted doctors in the United States have spent a fortune on their education, so they are drawn to specialties in which they can make the most money to pay back their loans. In family medicine and psychiatry, even the best programs are having trouble filling their residency training programs. Many young doctors are interested in these fields, but they could die of old age before they pay off their loans.

Fifth is the problem of information. It is hard for most busy doctors in the United States to keep up to date on the latest research, and many are rusty on the mechanics of how to interpret data. So much of their information comes from pharmaceutical companies. Many of the most influential studies have been conducted by pharmaceutical companies, simply because they have the resources. But there have been times when data has therefore appeared suspect. Industry is not evil, but companies certainly hope that their studies will turn out a certain way, and the outcome of any study depends on the questions asked and the way in which the data is analyzed. And like any collection of people, it is easy to fall into a kind of groupthink. There are countless examples of highly intelligent individuals who all missed the wood for the leaves.

Another related problem is that many scientists are now also setting up companies to try and profit from the discoveries that they have made in academia. Most are working from the highest motives, but sometimes there are worries about impartiality. So once again, the unsuspecting physician may add data to the diagnostic mix without knowing its provenance. There have recently been a number of high profile examples of that.

I ended my review by saying that I hope that every doctor and patient in America should read it, and I stand by that, with the caveats and comments that I have added to the mix.

Yoga and the Brain

Depression and anxiety are increasingly common throughout the world, and although each may be a consequence of psychological and environmental stresses, there is also a genetic predisposition and an increasing number of reproducible disturbances in the brain.

In recent years, there has been increasing interest in the role of brain gamma-aminobutyric acid (GABA) levels, which is the brain's primary inhibitory neurotransmitter, in both depression and anxiety, following the finding that each may be associated with low levels of GABA in different regions of the brain.

There have also been reports that yoga may help stress and anxiety as well as depression.

Now colleagues from Boston University School of Medicine (BUSM) and McLean Hospital have found that practicing hatha yoga may elevate brain GABA levels.

This new research is published in last month’s issue of Journal of Alternative and Complementary Medicine.

The researchers used magnetic resonance spectroscopic imaging to compare the GABA levels of eight subjects before and after one hour of yoga. The control group consisted of 11 people who read a book or magazine instead of doing yoga. They found a twenty-seven percent increase in GABA levels in the yoga practitioner group after their session, but no change in the comparison subject group after an hour spent reading.

It is too early to start recommending yoga for the treatment of depression or anxiety, but it is fascinating that it will produce changes in brain chemistry that are very similar to those that we hope to achieve with other forms of therapy.