Inflammatory stuff

You know what it's like - some days everything just seems to go awry. The boiler starts leaking, your child gets sick and has to be picked up from school, and when you step out to get into the car you realise you've had a flat tyre.

These are the sorts of daily stressors that can seriously impede our serenity, and how we react to them over time may significantly impact on our long-term physical health, a recent study finds.

The investigators, reporting their results in Health Psychology, took a group of 872 adults from the US National Study of Daily Experiences and asked them to report daily stressors and emotional 'affect' over the course of eight consecutive days. Blood samples were taken on those days and assayed for inflammatory markers interleukin 6 (IL-6) and C-reactive protein (CRP).

The results showed that people who experienced greater suppression of positive affect on stressful days had elevated inflammatory biomarkers, especially IL-6. Heightened negative affect and reactivity was also associated with higher CRP, among women in particular.

According to the authors, this is the first study to link biomarkers of inflammation with emotional reactivity to stressors of everyday life. It highlights the important, yet sometimes overlooked, contribution of a positive mindset to keeping biological stress reactions under control.

That's all well and good but, as anyone who suffers from Post Traumatic Stress Disorder (PTSD) and/or anyone who treats it will tell you, keeping emotions right-sized can be difficult when the triggering stressor has the 'flavour' of a stressor from the past, especially one from a troubled childhood. Indeed the size of the reaction is often a tell-tale sign that the real-time stressor is not being treated simply for what it is, but rather, is being 'projected onto', possibly as a means of addressing the original trauma.

The key with stressful events in daily life, then, is to use them to effect greater self-knowledge and greater awareness of the past - and to harness this over time to intervene on reflexive over-reactions. In this way, daily stressors can even become a sort of friend; a means of integrating past traumas and cultivating the ability to 'keep calm and carry on'.

It seems highly likely that intense reactions to everyday stressors over time might conceivably affect our biochemistry and it's not too great a leap to imagine the harmful long-term health effects.

But the good news is that when the light is shone on such reactions and they can be chipped away at over time, the emotional fruits can be transformational.


Written by Jacqui Hogan

What happens when even our mental health provision is depressed?

From 'Addressing the Deterioration in Public Psychotherapy Provision' (UKCP/BPC)

A recent report published by the United Kingdom Council for Psychotherapy (UKCP) and the British Psychoanalytic Council (BPC) entitled 'Addressing the deterioration in public psychotherapy provision' leaves us in no doubt as to the state of government provision of mental health services.

Some of the more impressive statistics from this survey, last conducted in 2012, give a disturbing insight into what psychotherapists are seeing on the ground. For example:

• Over three-quarters ((77%) of psychotherapists report an increase in the number of cases of patients with complex needs 
• Despite this, coming up for half (44%) report a reduction in the clinical experience and qualifications of psychotherapy practitioners
• In line with this finding, over two-thirds (67%) report a cut in higher band posts and an increase in the use of honorary staff or volunteers delivering services
• Over half (52%) report a fall in the number of psychotherapy services being commissioned

Given this situation, it is not surprising that patients are increasingly being forced out of the public system and into the private sector. What is repeatedly being heard by therapists is that patients are coming for private treatment having been let down by the NHS, which could not provide the type or length of treatment they needed. For those who have eyes to see, this amounts to the effective privatisation of mental health in the United Kingdom.

This development is having serious knock-on effects. We are now seeing the growth of a third party sector in mental health; private contractors brokering such individuals as 'Psychological Wellbeing Practitioners' (PWPs) to support services like the NHS's Increasing Access to Psychological Therapies (IAPT) programme.

These services are based on a watered-down version of Cognitive Behavioural Therapy (CBT), and can by no means be considered as bona fide psychotherapy. The interventions are entirely scripted and there is one compulsory outcome - that everybody feels well. Veering off script on the part of the practitioner is considered a breach of contract.

Such labour agencies and contractors are now buying up burgeoning NHS mental health waiting lists and replacing already inadequate provision with even more impotent alternatives.

With NHS services now being frankly undermined, the UKCP/BCP report observes:

"The [survey] responses paint a picture of public sector therapists taking on more complex cases, of experienced therapists being laid off and clients turning to the private sector for help they cannot get on the NHS."

This is an important read for anyone working in mental health. The UKCP and BCP say that they are 'deeply concerned' about the lack of provision for the army of people who are now slipping through the net, unable to access genuine help on the NHS and unable to afford private treatment. As they acknowledge, their registrants are providing an invaluable service, often themselves volunteering and supporting low cost treatment programmes. They are picking up the pieces for patients caught in the revolving door of the NHS system.

What's your experience of the provision of public mental health services, either as a patient, from the inside as an NHS therapist or as a therapist working in private practice? What do you see happening that is fostering the breakdown? Is the system redeemable? Are there any signs of hope? Do your experiences corroborate the findings of the UKCP/BCP report? We'd love to hear your thoughts.


Written by Jacqui Hogan

Pesticides go incognito

At no other time in world history have we been exposed to such a heady cocktail of chemicals which, while supposedly making our lives easier, also put us at risk. From the fumes we inhale in traffic-choked cities to the plastic residues we ingest on cling-filmed foods, we are arguably being bombarded.

Pyrethroid insecticides are commonly found in household insect sprays, flea treatments for pets, medicinal shampoos and gardening products. Their mode of action is to block the neurotransmission of their unfortunate targets, who generally succumb to paralysis and death.

Which is why the researchers reported here were interested to test the hypothesis that the same chemicals might be influencing human neurotransmission, especially in children, who are biologically most vulnerable. They proposed that six year-olds exposed to pyrethroids, might exhibit negative cognitive effects.

The PELAGIE mother-child cohort was established to monitor 3,500 mother-child pairs between 2002 and 2006 in France. One of the parameters monitored was exposure to pyrethroids in utero and in childhood. A total of 287 women were randomly selected from this cohort and were followed up when their children were six years old.

Level of exposure to pyrethroids was assessed by measuring metabolites in the mothers' urine between the sixth and nineteenth weeks of pregnancy, and then later, on the children's sixth birthdays.

On that birthday, the children were also assessed for neuro-cognitive performance, particularly verbal comprehension and working memory. Family environment and other factors which might affect intellectual development were also taken into account.

The results showed that higher concentrations of pyrethroid metabolites in the urine of children (3PBA and cis-DBCA) were associated with a significant decrease in their cognitive performance. By contrast, metabolite concentrations in the mothers' urine during pregnancy showed no correlation with their children's cognitive performance.

Cecile Chevrier, lead author of the study, commenting on the results, said:

"Although these observations must be reproduced in further studies in order to draw definite conclusions, they indicate the potential responsibility of low doses of deltamethrine in particular [a precursor of cis-DBCA] and pyrethroid insecticides in general [for the decrease in cognitive performance observed among six year olds]."

Children are frequently exposed to pyrethroid neurotoxins, since they are closer to ground-level dust, engage in frequent hand-to-mouth contact and delight in handling pets who are often covered in toxic flea treatments. If pyrethroids work well on insects, it seems reasonable to assume they might also be working 'well' to reduce cognitive function in our children.

Given the number of pressures already facing the upcoming generation, it would seem prudent to consider at least reading the labels on insecticide packs, gardening products and lice shampoos to identify the presence of pyrethroids. And perhaps allowing Fido to have a few more scratching fits, instead of dousing him in toxic flea treatment, is a price that may be well worth paying.


Written by Jacqui Hogan

CBT forty years on

Albert Ellis (1913-2007)

Last year, the World Health Organization ranked depressive disorders as the third highest cause of disease burden in the world. You don't have to look very far to verify this claim.

Psychotherapy has been rightly identified as a fundamental approach to its treatment and Cognitive Behavioural Therapy (CBT) has enjoyed pride of place in the official psychotherapeutic armamentarium.

CBT was introduced more than forty years ago. Its founding fathers were Albert Ellis (pictured above) and Aaron Beck, who essentially put forward the hypothesis that emotional distress and dysfunctional behaviour were a product of maladaptive thoughts, with 'thoughts' being the critical word. In their world, all one needed to do to return to emotional wellness was to realise this and change ones' thoughts. Such change, they maintained, could be accomplished in a small number of sessions.

Studies since its inception have generally shown CBT to be a helpful intervention - so much so, that it has been adopted as the treatment of choice by Big Government - for example, patients in the UK have been able to receive CBT free of charge on the NHS; likewise patients within the public health system in Australia. The consensus has been that CBT is the way to go and there has been plenty of money thrown in its direction.

What hasn't been looked at, until now, is how the efficacy of CBT has evolved over time, a fact which two Norwegian researchers (Johnsen and Friborg) sought to rectify.

Their paper, entitled 'The effects of Cognitive Behavioural Therapy as an anti-depressive treatment is falling: a meta-analysis' leaves little to the imagination.

They examined outcome data from seventy clinical trials from the mid-1970s up until 2014, encompassing data from almost 2,500 patients diagnosed with depression. Almost 70% of subjects were women and the average age was 41 (in itself an interesting finding).

As part of the protocol, the authors focused only on studies which used the Hamilton Depression Rating Scale and Beck's own Depression Inventory, two popular ratings scales that involve either therapist or patient objectively scoring the efficacy of the CBT intervention.

The results showed that CBT has diminished in efficacy since the 1970s, a finding that holds true across different exclusion criteria.

So what's going on here? Is the psychotherapy model funded by governments around the world proving itself to be progressively less effective? The authors speculate:

"In the initial phase of the cognitive era, CBT was frequently portrayed as the gold standard for the treatment of many disorders. In recent times, however, an increasing number of studies... have not found this method to be superior to other techniques. Coupled with the increasing availability of such information to the public, including the internet, it is not inconceivable that patients' hope and faith in the efficacy of CBT has decreased…"

In other words, CBT appears not to have lived up to the hype and people are finding out.

Many therapists would argue that this finding is a formality, knowing that in practice, there is rarely one technique or remedy which 'does the trick'. One obvious short-coming of CBT is that it fails to recognise the psychodynamic - that is, the role of unconscious material in creating emotional distress and dysfunctional behaviour.

Mining the depths of a soul is rarely a rapid undertaking and so the notion that a sharp burst of six sessions could reliably unscramble thinking was always going to fall short of the mark. The emotions are, arguably, driving the thinking, so dealing with them must be top priority.

That's not to say there is no place for CBT in psychotherapy - far from it. As part of an integrated programme of change, it can be an invaluable tool. But it's not the only one, nor necessarily the optimal way.


Written by Jacqui Hogan

Are you anxious to make a decision?

How many of us can genuinely say we find decision-making easy? Sure, when the question is tea or coffee, spots or stripes, wine or mineral water, it's no big deal. But what about when the stakes are higher, like 'should I take that job that pays less but is less stressful' or 'should we leave our friends and move to a new area for a better quality of life'?

MIT researchers have identified a neural circuit that seems to underlie decision-making in situations which combine this positive-negative element, otherwise known as approach-avoidance conflict.

Striosomes are clusters of cells found in the striatum of the brain, a region thought to be involved with anxiety. The researchers tested the hypothesis that these cells are also involved with approach-avoidance decision-making by studying mice.

The mice were placed in a maze and compelled to choose between either strong chocolate and bright light or weaker chocolate and dimmer light. Mice like chocolate and do not like bright light (not so silly) and so the first option was deemed to be 'high cost, high reward' and the second 'low cost, low reward'. Using a technique called optogenetics the researchers were also able to turn cortical input to striosomes on or off.

When the striosome circuit was switched off, the mice began choosing the 'high cost, high reward' option as much as 20% more often than when it was switched on. This suggests that the striosomes may be acting as gatekeepers that limit anxiety, thereby helping in the formation of a decision.

It is hoped that these findings will ultimately help researchers identify new ways to treat psychiatric disorders that often feature anxiety and impaired decision making, such as schizophrenia, depression and bipolar disorder. Commenting on this, Ann Graybiel, an MIT Institute Professor and the paper's senior author said:

"We would so like to find a way to use these findings to relieve anxiety disorder and other disorders in which mood and emotion are affected. That kind of work is a real priority."

I would like them to find a way, too. If diminishing the anxiety associated with decision-making is just a matter of tinkering with my striosomes, then bring it on - it would undoubtedly save me years of procrastination. But perhaps the picture is not quite so simple.

Some would say that decision-making is not an easy thing to do, especially when the stakes are high. Effective decision-making arguably demands a sophisticated interplay between memory, will and intellect, coupled with the ability to 'hold' potent feelings of anxiety, so that conflicting realities may be adequately processed.

This work may be helpful in identifying part of the mechanism involved with decision-making, but meanwhile, I'm going to work on developing my emotional maturity and see how that goes. This seems to me the obvious challenge in 'high cost, high reward' decision-making scenarios. What do you think?


Written by Jacqui Hogan

How much do you love me?

Do you have a penchant for a certain brand of perfume or aftershave? Would you camp out overnight to lay your hands on the latest piece of Apple kit?

One group of researchers has set out to discover whether people feel the same kind of love for brands as they do for people, in a study which says as much about the times we live in, as about the nature of love.

Tobias Langner and his colleagues, writing in Psychology & Marketing in a paper entitled 'Is it really love: a comparative investigation of the emotional nature of brand and interpersonal love', recruited 20 participants on the basis of two criteria:

1. They had to have a consumer brand they felt they 'could not live without'
2. They had to be in a romantic relationship

All were asked to look at images of their beloved brand logo, followed by images of their partner and then images of their closest friend. Their reactions were assessed, first subjectively, using a visual rating tool and then physiologically, using a skin test to detect levels of arousal.

Thankfully, sanity prevailed, and on both the subjective and physiological ratings scales, the participants' love for partners was significantly more intense than for their favourite brand. When probed on the findings in interview, participants maintained that their love of brands was about the tangible benefits imparted (i.e. what they got from the brand), while romantic love was much more altruistic in nature.

We can all breathe a sigh of relief then.

Um, not quite. The study also showed that the level of physiological arousal was equally strong when subjects were shown images of their favourite brand as their favourite friend. And on the subjective rating scale, the brand actually scored higher. You know who your friends are!

Perhaps that's why it's not so uncommon to see people glued to their iPhone or proudly strolling arm in strap with a Prada handbag. Maybe these items are standing in as some kind of partner substitute.

It's difficult to tell with such a small sample size, but if these results are anything to go by, it's a sad indictment of our culture. The day an inanimate object can usurp a human being one calls a friend is a sad day indeed. In truth, relationships with objects have nothing whatever to do with love and everything to do with attachment. Only when we can make the distinction between the two, do we have any hope of truly loving.

Do you, in your daily practice, see certain objects becoming misguided targets for feelings? Or, conversely, do you see human beings becoming the target of behaviours that rightly belong to objects? If so, let us know.


Written by Jacqui Hogan

Let them eat Prozac

The neurotransmitter theory, despite being a theory, has become hard-wired into our understanding of the way depression works. A shortfall in the neurotransmitter serotonin in the synapses between neurones represents a 'chemical imbalance' which leads to the symptoms of depression, right?

Professor David Healy, author of a book published in 2004 entitled 'Let them eat Prozac: the unhealthy relationship between the pharmaceutical industry and depression', challenges this understanding.

He argues in editorial in the latest edition of the British Medical Journal, that the notion that low levels of serotonin are responsible for depression was created by drug companies in the 1980s in response to concerns about patients developing dependence on tranquilisers. To quote from his paper:

"The serotonin reuptake inhibiting (SSRI) group of drugs came on stream in the late 1980s, nearly two decades after first being mooted. The delay centred on finding an indication. They did not have the hoped for lucrative antihypertensive or anti obesity profiles. A 1960s idea that serotonin concentrations might be lowered in depression had been rejected and in clinical trials the SSRIs had lost out to the older tricyclic antidepressants."

According to Healy, the marketing of SSRIs for depression was pursued to solve two problems - the lack of a satisfactory indication and the emerging problem of dependence on tricyclic antidepressants. Launching SSRIs as a viable treatment for depression gave the marketers an indication and the doctors a prescription alternative.

The BMJ article, while challenging 'the received wisdom' on SSRIs, also stresses that serotonin is not irrelevant.

Rather, it focuses on the marketing history of SSRIs and raises general questions about the weight the medical establishment sometimes places on theory over empirical evidence for lives saved or restored function. Professor Healy goes on to say:

"In other areas of life the products we use, from computers to microwaves, improve year on year, but this is not the case for medicines where this year's treatments may achieve blockbuster sales despite being less effective and less safe than yesterday's models."

It's an indisputable fact that, anecdotally at least, many mental health practitioners and patients have observed and experienced clinical benefits with SSRI treatment. And, in a way, perhaps that is the most important point here, notwithstanding the placebo effect.

Nonetheless, it behooves us to understand the historical context for all pharmacological medications, especially in the mental health arena, given the psychosocial implications, reality of side effects and increasing dominance of business interests.

What is your experience of SSRIs, either as a prescriber, witness or patient? We'd love to hear your informed reflections on this vitally important topic.


Written by Jacqui Hogan