Your Mind Thinks its an Expert (or Calling Dr. Rutherford)

You’ve probably noticed this already, but our minds have something to say on most topics. Some of this is pretty minor: “That iced tea looks refreshing!” In other cases our minds dole out expert opinions. We become:

  • Critics of modern art: “My three-year-old could draw that!”
  • Experts on gastronomy (i.e., food): “Why would anyone pay high prices for small portions in that fancy-pants place?”
  • Amateur meteorologists: “Looks like it’s gonna rain today.”

Most of the time, our running commentary is pretty harmless. It’s also built into us. As human beings, we seek patterns in our environment in order to understand our world and keep ourselves safe. This tendency has helped us survive.

But it can also create a lot of problems.

A common way I see this tendency go awry in my practice is when our minds become medical experts. Some degree of monitoring our health is important in deciding when to take a sick day, see a doctor, or get some rest. But sometimes our minds jump to worst case scenarios. The Internet tends to escalate these problems. Here’s an important equation to consider:

Ambiguous physical symptom + worry/anxiety + Internet search = “I might be dying!”

In researching that small brown spot that you recently noticed on your face, you’ll learn it’s probably just a harmless freckle—OR IT MIGHT BE SKIN CANCER!

Dr. Rutherford

The people with whom I work often come with clever and interesting images, metaphors, and ideas for working with their problem—far most interesting than anything I come think of—and I’ve learned a lot from clients over the years. I wanted to share one of those ideas in this post. The client gave full permission, and I changed the details to maintain confidentiality.

We had discussed his tendency to interpret physical symptoms—usually symptoms of anxiety—as signs he was dying. At one point I asked him in session, “Does your mind have a medical degree that you yourself don’t possess? It sounds like your mind thinks it’s an expert in areas that you yourself are not.”

I didn’t think much of my comments at the time, but for this individual it planted a seed.

He and his partner named his worry mind after a sketchy-looking educational institution they saw located in a retail area. For the sake of confidentiality, I’ve changed the name and key details. I’ll call the worry mind “Dr. Rutherford,” even though the actual name has a nicer ring to it. According to the client, Dr. Rutherford became certified in different specialties during one-day certification programs in areas such as:

  • Neuroscience
  • Veterinary medicine
  • Infectious Diseases
  • Relationships
  • Dentistry
  • Food allergist
  • “Sudden death prediction analyst”

Dr. Rutherford became a way to talk about excessive worry. When he’d begin to worry, his partner might say to him, “Looks like Dr. Rutherford is here,” and the two could light-heartedly laugh about it. Over time, this tendency towards worry became something funny rather than something frustrating.

He even wrote down a series of Dr. Rutherford’s sayings or mottos in order to identify when he was worrying.  Again, for the sake of confidentiality, I won’t give them word-for-word, but they reflected ideas such as, “Sure it’s rare, but if you get it, YOU’RE DEAD!”

Some concluding thoughts about the ubiquitous Dr. Rutherford

In conclusion, it’s generally pretty harmless when your mind has strong opinions about Wagnerian opera in the absence of a musicology degree. However, you might hold your mind’s views with some skepticism on topics such as interpreting vague physical symptoms or contamination risks that no one else seems worried about. That might just be your own version of Dr. Rutherford talking.

And finally, I just wanted to say thanks to the individual who gave me permission to share this fantastic idea!

Are Antipsychotic Medications a Helpful Adjunct for Treating Obsessive-Compulsive Disorder?

Among people with whom I work, a practice that’s grown more common in the last few years but with iffy research support is the addition of an antipsychotic medication when an antidepressant medication doesn’t seem to be working. This is done in an attempt to augment the effect of the antidepressant. The practice concerns me because there’s a lot of research evidence showing that the side effects of antipsychotics can be pretty awful (e.g., weight gain, high blood pressure). It concerned me enough that I wrote an editorial about it that the Oregonian published in 2012.

Now new data has been published that clearly suggests antipsychotics should not be added to antidepressants for people with OCD.

Another study showing that CBT does the best with OCD

As I’ve written before, the most effective treatment for OCD is cognitive behavioral therapy (CBT) with exposure and response (or ritual) prevention (ERP).

A 2013 study examined a group of people with moderate to severe OCD who were already taking an antidepressant. They were divided into three groups.

  1. One group received psychotherapy—cognitive behavioral therapy with ERP.
  2. One group was prescribed an antipsychotic—Risperidone—in addition to the antidepressant.
  3. One group was prescribed a placebo (i.e., inactive) pill.

What did they find?—CBT was much more effective

The results are pretty striking. For those that were given an antipsychotic, only 23% of people showed improvement. This might suggest there is some benefit to adding an antipsychotic; however, this finding is not very impressive because those given the placebo (e.g., sugar pill) showed a 15% improvement. Moreover, the researcher found no statistically significant different between the effectiveness of the antipsychotic and that of the placebo. What this means is that, statistically speaking, the antipsychotic was no better than the placebo; that is, the 23% improvement (i.e., antipsychotic) is not more meaningful than the 15% improvement (i.e., placebo).

By contrast to those who received a pill, 80% of people who received cognitive behavioral therapy with ERP showed improvement! This is 3-4x the rate of improvement compared to those taking an antipsychotic—and without the extensive side effects that are common with antipsychotics.

Antipsychotic medication should not be considered for people with OCD

I think this is an important study because it makes it clear that adding antipsychotic medication is unlikely to really benefit someone with OCD. However, that cognitive behavioral therapy with ERP is more effective than medication for OCD is not a new finding

There’s already a solid base of research that suggests the ERP is superior to antidepressant medication for OCD. Giving an antidepressant to someone receiving EX/RP for OCD neither helps nor hinders treatment. This study is evidence that antipsychotics should not be considered for people with OCD.

Anxiety Treatment at Portland Psychotherapy

Psychotherapy vs. Medication for OCD – Which is More Effective?

Obsessive-Compulsive Disorder (OCD) is a serious and disabling problem for many people. Understandably, many people seek out medication to help with this problem, and research is shown that medication can be helpful some people. However, research is also very clear that particular proven forms of psychotherapy work much better than medication for OCD. A newly published review paper provides further evidence that psychotherapy outperforms medication for OCD.

Some background about the paper

Published in 2013 in World Psychiatry, Cuijpers and colleagues collected 67 studies where medication and psychotherapy were directly compared against each other for depression and anxiety-related problems. The researchers conducted what is called a meta-analysis, a way of converting the data from separate studies into a computation that allow for a direct comparison across studies.

The researchers determined that for OCD, psychotherapy is “clearly more efficacious” than medication. Specifically, psychotherapy was found to be more effective than antidepressants, the most well-research pharmacological treatment for OCD

One caveat

One point I’d like to make clear is that we’re not talking about generic talk therapy but some form of OCD-specific cognitive-behavior therapy (CBT), typically with what is called exposure and response (or ritual) prevention (ERP). Although mild to moderate anxiety and depression may respond to generic talk therapy, OCD generally does not, and usually requires a structured approach such as CBT with ERP.

What this research adds to what we currently know

This study contributes to a body of literature suggesting that psychotherapy is the treatment of choice for OCD. Previous research has found that medication does not interfere with evidence-based psychotherapy for OCD, but neither does it enhance treatment. In sum, although some people with OCD may benefit from medication, particularly if they are also depressed, medication alone for OCD is a substandard treatment. Cognitive behavior therapy with exposure and response/ritual prevention is the gold standard. There is also newer evidence that Acceptance and Commitment Therapy (ACT), even without ERP, is an effective treatment for OCD.

Don’t take my word for it, though: you can read the Cuijpers and colleagues study yourself here.

A Call for More Services for Families with Loved Ones with Serious Mental Illness

With all the talk about healthcare reform and budget cuts to healthcare programs, my colleague, Jerome Yoman, PhD, and I were inspired to write an editorial about the need for more family services for The Oregonian, our local newspaper. We just found out that the editorial was published in the April 10, 2012 edition!

You can read the editorial by clicking on the linked title below:

Plans for Treating Mental Illness Should Encourage Family Involvement

-By Christeine Terry, Ph.D.

Research graveyard may come to life

“If enough data is collected, anything may be proven by statistical methods”

Williams and Holland’s Law

It’s an amazing day for scientific research! Hold on, don’t leave me yet. I know I typically try to post things here that are inspiring or at the very least interesting and directly applicable to your everyday life. And the behind-the-scenes politics and procedures of conducting scientific research generally wouldn’t be thought to fall into the “inspiring” category. But trust me, this matters to you!

The All Trials Campaign has organized experts from around the world who are demanding that all unpublished data from clinical medication trials be published and all misreported data be formally corrected. Just this month, the British Medical Journal (BMJ) and PLOS Medicine have taken up the call of the “Restoring Invisible and Abandoned Trials” initiative (RIAT), endorsing the proposal that sponsors and researchers begin publishing the results of their previously confidential clinical trial documents within one year. If they fail to take these actions, RIAT would call for independent scientists to publish those previously confidential trial documents.

To understand why this is such a potentially momentous move, it’s helpful to first understand a bit about how the world of scientific publishing works. At the heart of the problem is the fact that, in general, only studies that find “significant” results get published, and here the word “significant” means that the study found that the particular drug/intervention/treatment being tested was effective. On the surface this practice seems to make sense. I mean, would you sit down to read a newspaper that had a bunch of titles like “Nothing at all happened in Portland last night” and “Nobody did anything of significance in Congress yesterday” (ok, well, maybe that one doesn’t seem like a stretch!). Those of us who read journal articles to get our news about the latest developments in our field want to spend what little time we have reading articles about treatments that actually seem to work. We’re generally less interested in studies that fail to find that a particular treatment works. The result is that studies showing that a treatment doesn’t work, or worse, caused harm, are often unpublished.

However, the problem with state of affairs is that it gives health care providers and the public very skewed information. For every study we hear about that shows a particular drug or treatment supposedly works, we never know about the potentially countless other studies that showed that it didn’t work, or even that it caused harm. And the picture gets even more worrisome when you take into account how most research is funded in the first place.

The vast majority of scientific researchers are only able to do their work through grant funding (though we have a different model here at Portland Psychotherapy for funding our research which you can read more about here). One way this happens is that a researcher, who is very interested in a particular treatment, spends months writing and rewriting a grant application to ask some institution, such as the National Institutes of Health (NIH), essentially asking them for money to study their idea. But even more frequently, it isn’t the NIH or some other arguably unbiased institution that is funding research. As funding from places like the NIH have dropped drastically in recent years, “industry funded research” (e.g. research paid for by a company that is highly invested in its outcome) has soared, with industry-funded research in universities increasing 250% from 1985 to 2005. Increasingly, researchers are paid by a particular company, often a big pharmaceutical company, who has a vested interest in showing that their product (e.g., their drug) is effective.

Now let’s return to the problem of only publishing “significant” findings. If only those studies that show a “significant” result (e.g. that the drug “Y” was more effective than placebo) are going to be published, the company has every incentive in the world to just keep funding study after study until they finally get one that shows the result they want, not because it is a real result, but because of the natural variation and error that is part of research.  And these companies have the deep pockets to do that. So theoretically, they could fund 100 clinical trials and even if they only found a “significant” result in 1 out of 100 studies they ran, that one “significant” finding gets published in a journal, health care providers read about it, the press picks up on it, there are ads in magazines touting the positive findings, and now it’s the new wonder drug. However, the 99 other studies showed that drug “Y” was ineffective were never published.

From a consumer standpoint, would you purchase something if the advertisers told you that 99 times out of 100 it was shown to be completely ineffective? No, we’re more likely to buy (or in the case of health care providers, prescribe them to our patients) products when they are backed by claims like “Clinical studies prove that drug “Y” significantly reduced symptoms of X”. What the RIAT initiative will do is give us a more complete picture so that we can know about the studies that showed that a drug or other product was harmful or ineffective, versus only hearing about the studies that happen to work out.

Unfortunately, the RIAT initiative doesn’t have the ability to force drug companies or researchers to publish their negative findings. However, it does shine light on this incredibly important issue and, if the public demands it, will put new pressure on researchers and the industries to commit to making ALL their data available. This will allow researchers do what they are meant to do, be scientists, rather than being PR machines for companies with very deep pockets.

If I’ve convinced you here that this issue really does impact you and you’d like to read more about this problem of only publishing “significant” findings, you can read this great, in-depth article on the topic published in Scientific America.

You can also sign the petition to support the All Trial Registry here.

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