“Stop Whining!”: The Operant Approach to Pain Behavior

When reading my health psychology textbook, I came across something called the operant approach to treating pain. Well, more correctly, the operant approach treats pain behaviors. It utilizes a system of rewards and extinction (ignoring unwanted behavior) to lessen a patient’s pain behaviors, such as complaining of pain, refusing to perform physical activity, etc.

In some ways, I can see how the operant approach is useful, for example when someone’s pain behaviors interfere with physical rehabilitation. The example given in the textbook involved a young girl who refused to put on a splint by displaying pain behavior and was “rewarded” for this behavior by attention from the nurses. The refusing to put on a splint of course interfered with her recovery. In this sense, I can see how ignoring pain behaviors and rewarding appropriate behavior, such as putting on the splint, can be helpful.

However, the operant approach has a risk that wasn’t mentioned in my textbook, in that pain behavior has a function other than getting secondary gains such as attention or getting out of unpleasant activities. Pain behavior, especially in people who have limited abilities – the patient in the example was three-years-old -, can signal to other people that the expectations set for them are too high. After all, initially at least, someone exhibits pain behavior because they are, oh duh, in pain, not because they want to get out of unpleasant activities or get attention. And, unlike cognitive or other behavioral approaches such as relaxation, it was not said that the operant approach actually reduces pain, which may however be assumed if the person stops communicating that they are in pain.

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Is Sleep Apnea a Mental Disorder?

In the current DSM-IV, breathing-related sleep disorder is diagnosed on axis I, clinical disorders. This already surprised me, but I was assuming that the evidence for obstructive and central sleep apnea as medical disorders was not yet established by 1994. Now, however, both central and obstructive sleep apnea are proposed as separate conditions in DSM-V. There is no rationale for their inclusion as mental disorders.

To me, obstructive and central sleep apnea are medical disorders, not mental ones. Central sleep apnea is a neurological condition, and I don’t know what about obstructuve sleep apnea. But they are, in my opinion, most certainly not psychiatic disorders. So what do they do on axis I of the DSM? Their coding as separate disorders, rather than both as breathing-related sleep disorder, is rationalized by harmonization with the ICD, but when something is simply not a psychiatric disorder, is it not enough that it be included in the ICD?

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Zolpidem Increases Risk of Falls, Cognitive Impairment

In the department of “Oh duh!” inducing news, research from the University of Colorado-Boulder found that zolpidem increases the risk of falls and grogginess-induced cognitive impairment. Zolpidem is the most commonly used sleep medication in the U.S. It is not a benzodiazepine, but a similar drug.

The study had 25 healthy adults, both older and younger, first take placebo and then take zolpidem. The adults were tested on balance using a tandem walk on a beam. They were also tested for cognitive function using a computerized test. There was also a control condition during wakefulness.

After taking zolpidem, many more subjects had balance problems and were cognitively impaired than after taking placebo. The placebo was used to control for sleep inertia (grogginess). Surprisingly, younger adults suffered more grogginess-induced cognitive impairment after taking placebo than did older adults.

The implications of this study are that non-benzo sleep meds are not as safe as previously thought. This does not surprise me, given how similar the effects of these drugs are to those of benzodiazepines. It is important to take caution when prescribing any sleep med, because falls are an important risk factor for hip fractures and other injuries, and both cognitive impairment and balance problems can contribute to falls.

Reference

Frey DJ, Ortega JD, Wiseman C, Farley CT, Wright KP (2011), Influence of Zolpidem and Sleep Inertia on Balance and Cognition During Nighttime Awakening: A Randomized Placebo-Controlled Trial. Journal of the American Geriatrics Society, 59(1):73-81. DOI: 10.1111/j.1532-5415.2010.03229.x.

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This Is News?: Antipsychotics Cause Weight Gain In Children

For the sake of eliciting an “Oh, duh!” with most of my readers, research just found that antipsychotics cause weight gain in children. In fact, all four drugs tested – Risperdal, Seroquel, Zyprexa and Abilify – cause significant weight gain within the first three months of use, sometimes up to 15% of the child’s former weight.

This is quite a disturbing finding, because unhealthful weight gain is at least as dangerous for children as it is for adults. You don’t want to put children at significantly increased risk of diabetes and heart disease.

Of course, however, I am not opposed to the use of antipsychotics. I’m also not opposed by definition to their use in children. However, extreme caution should be taken when prescribing these powerful drugs, and I’m a little worried that too many children are prescribed antipsychotics for convenience rather than as genuine treatment for their mental illness.

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Support Site Used for Drug Marketing

Natasha Singer at the New York Times writes an interesting article on patient social networking sites like PatientsLikeMe, and the way they’re used to collect individual health data fro direct-to-consumer drug marketing.

PatientsLikeMe is a community for people with neurological diseases such as epilepsy and multiple sclerosis, where they can share their experiences with various drug treatments with othrs. People can create extensive profiles, which are useful for finding people with similar characteristics, so that you can compare notes on what works and what doesn’t. However, this same information can be analyzed by pharmaceutal companies, and PatientsLikeMe actually actively promotes this. It is not its intention that pharma companies will market to individual patients, since their goal is that companies learn from patients rather than the other way around, but of course direct-to-patient marketing does happen as a result.

Of course, one’d say, if you read the privacy policy, you’d know what happens to your information when shared on PatientsLikeMe. PatientsLikeMe, after all, is very honest about its sharing with third parties. This is one more reminder to always read privacy policies, but I know that many people don’t. That way, medical information could be distributed to third parties and used for marketing purposes without informed consent, when all the patients thought they were doing, is sharing support with other patients.

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Psychological Factors Affecting Physical Health Are Not Mental Disorders

In the DSM-V, the effect of psychological factors on physical health, will be acknowledged and reflected in a conditoin tentatively labeled psychological factors affecting medical condition. A number of subdiagnoses are considered, but for now, they will not be included as specific subtypes in the DSM.

Now of course it is a fact that psychological factors impact physical health. Health psychology and behavioral medicine emerged for a reason: the biomedical model of disease simply doesn’t work. Psychiatrists make up a large portion of those involved in behavioral medicine, and this is not in itself bad, since there is a possible link between mental and physical illness.

However, that emphatically does not turn psychological factors that impact physical health, into psychiatric disorders. The category of psychological factors being included, is rather broad – including maladaptive health behaviors, stress, personality traits, psychological symptoms, etc. -, so everyone probably has one of them. The proposed ways in which these psychological factors can impact the medical condition, are also rather diverse:

1. The factors have influenced the course of the general medical condition as shown by a close temporal association between the psychological factors and the development or exacerbation of, or delayed recovery from, the general medical condition;
2. The factors (e.g. poor adherence) interfere with the treatment of the general medical condition;
3. the factors constitute additional health risks for the individual;
4. the factors influence physiology to precipitate or exacerbate symptoms of the general medical condition.

The proposed severity rating includes at the mild end the situation where the psychological factors only increase the risk of the condition. Does this mean any smoker, fat person, or person under high stress will get a diagnosis of mental illness the day they get a heart attack?

Again, I am not saying that smoking, obesity and high stress do not increase the risk of physical illness. I am also not saying that the impact personality, psychological symptoms, and health behaviors have on physical disease, should not be studied. Neither am I saying that counseling should not be offered to those who wish to overcome the psychological issues that affect their medical condition. However, a psychologist or counselor would just be fine for that, and a consumer of counseling services should not have to be in a psychiatric handbook. Inclusion in the DSM of the psychological factors influencing medical illnesses will likely just increase the shame and blame associated with a large number of medical conditions. People whose illnesses are possibly influenced by psychological factors, people who engage in unhealthful behaviors, and people with certain characteristics, such as obesity, regardless of health or behavior, bear enough stigma already.

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Having a Miscarriage Now a Crime in Utah

According to a post on RHRealityCheck.org, a pro-choice commentary site, Utah passed a bill to criminalize miscarriage. To be exact, a woman can be charged with homicide for any “reckless” behavior that possibly led to a miscarriage. This is not limited to seeking an illegal abortion or even to risky behavior with the intention of inducing a miscarriage, such as when a teenage girl paid someone to assault her in order to induce a miscarriage. Really, there is no mention that the intent of the woman’s behavior should be to terminate the pregnancy. Even if a woman engages in behavior that could endanger the unborn child, but she has absolutely no intention of actually killing the baby, she can still be held legally responsible if she has a miscarriage. Since I did not read the original text of the bill, I do not know how it defiens “reckless” behavior. What about a woman who drinks or smokes during pregnancy, both of which increase the risk of miscarriage? What about a woman who is unable or unwilling to follow doctor’s orders to take bedrest, such as the woman in Florida a few months ago who was detained in hospital for this very reason? What, in fact, about women who have miscarriages for an unknown reason? Will they be subject to criminal investigations while mourning the loss of their unborn child? It really seems that this bill is grounded in the belief that all women go around trying to end pregnancies all the time, rather than the fact that most women who miscarriage, even if they engaged in some “reckless” behavior – as most pregnant women will have done at some point -, had absolutely no intention of killing their unborn babies.

Besides, doesn’t the Utah police have anything better to do than investigating miscarriages? Miscarriages are pretty common, unfortunately. So is behavior among pregnant women that could put the unborn baby at risk. Whether the two are connected, is not always easy to tell, which means a pretty thorough investigation is needed in order to gain substantial evidence that the woman’s miscarriage was illegal. I do not think the tiny chance of saving an unborn baby’s life weighs up to the huge risk to many women’s human and civil rights and their wellbeing. Indeed, this bill does not look like a sensible pro-life measure at all. Rather, it is a draconian effort to police the way pregnant women take care of themselves and their unborn babies and, beyond that, a state-sponsored blame game of every woman (whether she is eventually charged or not) who has a miscarriage.

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“Real Age” Tests and the Presumption of Health as a Choice

You know those online tests you can take to determine your “real age”, the age your health is supposed to reflect. These tests usually promise you that you can make yourself “younger” by adjusting your lifestyle, hereby populating the idea that health is something you choose. Now of course it is true that lifestyle has an impact on health, especially in western cultures, but there are a number of factors influencing someone’s health that are entirely or largely beyond that person’s control. These factors may be considered in “real age” tests, too, and, if these tests really aim at any form of accuracy, they should. However, since these tests also populate the idea that you have your health in your own hands, there is some risk of blaming and shaming of people with less-than-optimal health, even if there is nothing within their lifestyle that contributes to their conditions.

For example, the main Dutch “real age” test includes questions about your family history or present illnesses. For example, females are asked whether ovarian cancer runs in their family. Since family history is the biggest risk factor for ovarian cancer, and people cannot choose their genetic family, there is little a woman can do about acquiring this disease. Nonetheless, the presence of ovarian cancer in your family, raises your “real age” considerably. The same goes, by the way, if you suffer from depression, migraine, arthritis or even nearsightedness. I always say that I don’t wear glasses, so my visual impairment is negatively correlated with my “real age”.

The number of prescription and over-the-counter drugs you take, is also presumed to be a factor in your “real age”: the more drugs you take, the higher your “real age”, regardless of the fact that you usually take drugs in order to preserve as much health as possible. Of course, drugs have health risks, and sometimes these health risks may be worse than the health risks if one doesn’t take the drug. However, this should be an individual choice. The simple fact that you take prescription or over-the-counter drugs, should not be an indication of poor health, let alone that it should be even remotely suggested that you can lower your “real age” by quitting a drug you need to stay healthy.

Of course, body mass is also an indication of “real age”. It doesn’t occur to the creators of these tests that people come in all sizes, and that fat does not by definition equal poor health. Along these lines, fat is also always assumed to be the result of a poor lifestyle, and can therefore always be gotten rid of. It is probably no coincidence that “real age” tests are usually sponsored by diet companies.

Lastly, social factors are presumed to play a role in one’s “real age”. I am consistently advised to make more friends, reduce stress and get a dog (why not a cat, by the way?). Of course, if there were fewer stressors in my life, that would be great. It would also be nice if I could actually make more friends, although quite likely that could actually raise my stress level. Getting a dog is not an option because of my living circumstances. So apparently I choose to be unhealthy because of my poor social life.

Of course, as I said, all of these factors do contribute to one’s health. In that sense, it is logical that “real age” tests include these risk factors. However, in that case it should not be populated that a high “real age” is an indication of poor choices, and this is exactly what these tests suggest.

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H.M. Brain Dissection

This week, neuroscientists started the dissection of the brain of Henry Molaison, a year after his death. Molaison, who was known as H.M. during his lifetime, had an operation to treat severe epilepsy in 1953. In this operation, both his medial temporal lobes, including the hippocampus, were removed. It was not yet known that these brain areas are esssential for forming new memories: this only became apparent when H.M., after his operation, suffered profound amnesia.

Of course, in a sense, it feels kind of strange to me that a disabled person is converted into a science puppet, described as a curious case in each psychology book – that’s how I learned about him. On the other hand, I’m also a psychology student and I know we wouldn’t have known what we know about neuropsychology now without him. I hope that he gave consent for being a study subject – he did give consent for his brain to be dissected.

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People May Starve

There’s a comment on this post, which raises an unrelated but valid concern – why is ASAN not campaigning actively against the bullying of autistics (or why do autism advocates not see it?)? -, that upset me to a significant degree. This is not meant as an attack on Stephanie Lynn Keril, who posted the comment, since the incorrect and potentially harmful belief stated here is pretty prevalent among autism advocates and, I think, also among certain subgroups of the neurodiversity moveement. Referring to autistics who (presumably!) can drive, work, have friends, and live in their own apartments but who forget to eat if they don’t have someone to remind them, she asks:

Which would you rather have: a job, a car, an apartment, friends and sometimes forget to eat and live in a messy apartment or live in an institution, self-mutilate, have trouble communicating but have shelter and food?

I will not go into the incorrect assumption that everyone who has a job, car, friends and apartment cannot possibly have trouble communicating or self-mutilate here. Suffice it to say that, just because Stephanie doesn’t know anyone who has all these and still self-mutilates and has problems with communication, or she dismisses the people she knows via the Internet who are like that, doesn’t mean these people don’t exist. But even if this assumption were correct, I still wouldn’t be able to go along with Stephanie’s obvious suggestion that going without food is better than being institutionalized. You know, starvation kills.

It isn’t like there is any reason to trivialize autistics’ problems remembering to eat. Going without food for a few days may not be a big problem, but going without food for a month or longer, certainly is. With fluid, you may die if you go a week without it (or sooner if you have pre-existing medical conditions). I know autistics who have almost starved, and at least one autistic who acquired severe kidney damage from forgetting to drink enough fluids. I don’t personally know autistics who have actually died of starvation or dehydration, but that is more likely due to the fact that I don’t know every autistic, than that they don’t exist. Does sereious damage or death only matter if it comes from self-harm?

And here is what angers me most: it is the incorrect assumption that an autistic who has a job (and you don’t know what accommodations that person gets for their communicative disabilities, cause you assume they can’t possibly have them) or lives in their own apartment, cannot possibly have trouble with nutrition or self-care, that allows these people to remain without services, sometimes even if they’re starving. It is the incorrect assumption that someone cannot forget to eat for more than a few days, that causes people to think it mustn’t really be this bad. How many so-called “high-functioning” autistics must die or acquire serious, permanent damage to their bodies before people stop assuming our cars, jobs or apartments (presuming we have them) mean we don’t have problems and therefore don’t need help?

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