New Autism Theory: "The boy whose brain could unlock autism"

The article "The boy whose brain could unlock autism" from https://medium.com/ is beautiful. It is beautifully written. It is hosted on a beautifully designed site. And most importantly, the non-judgmental theory of autism presented is beautiful.  This theory is also pretty brilliant.

The article presents a theory that reconceptualizes autism as an "intense world syndrome."  This theory suggests that autism is not best thought of as a disorder characterized by a lack of empathy or intelligence, but by the existence of an overload of emotion plus a great capacity to learn.  Further, intense world syndrome suggests that people with autism experience sensations differently.  What an awe-inspiring idea.

There are so many different issues to discuss now!

Let's start with empathy.  Just because it may appear that people with autism lack empathy, doesn't mean this interpretation is correct.  It could be that a person's mind with autism is so overloaded that focusing on someone else is next to impossible.  Over time, this could result in lacking empathy for others.  Further, if people with autism are constantly bombarded with not only intense emotions (e.g. anxiety), but aversive sensory experiences as well (e.g. the act of brushing your teeth produces the internal sensations that nails on a chalkboard would typically evoke), certain consequences can be expected.  We know that spikes in anxiety result in increased calcium release and the encoding of memories.  This process could result in really rigid thinking.  Not to mention, one's focus is really narrowed in those moments.  So if there is constant anxiety, the brain is in a state of rapid-fire learning...on one hand.  On the other hand, it may be difficult to focus on anything but a particular target.  This combination of increased anxiety and rapid fire learning may carve out some pretty "strange" observable behavior patterns over time.  For instance, perhaps a hyper focus on learning calendar dates could result.  Also, the manner of brain processing could leave very little left over for attention on others, hence our current/previous perception of lack of empathy in people on the spectrum.

Speaking of the "spectrum," as a field we are very comfortable examining autism on this spectrum.  But it seems to me that there is still the perception of a dichotomous cutoff whereby some people have autism and others don't.  Right now, once a diagnosis of autism is made, then you are examined on the spectrum as compared to others with this diagnosis.  But what if we viewed every single person as representing a different degree of autism on a full spectrum?  What if the spectrum was thought to encompass all humans?  Well, I think that'd do us a huge service when conceptualizing cases.

Eating disorders, OCD, and self-injury are all jumping into my mind as relevant to this new theory of autism.

Let's take eating disorders for starters.  I'm too invested in writing this blog post right now to look it up, but I remember learning at this year's International Conference on Eating Disorders in Montreal that autism and eating disorders are related.  This was an internal hypothesis of mine for ages.  When I saw the data, I literally scribbled "I knew it!!!" in my notes.  [P.S. Even though I'm not going to look up the exact presentation I saw, here's a Medical News Today article on the relationship between eating disorders and autism from August 2013.]

Similar to what this new theory of autism posits, people with eating disorders are also in a state of anxiety, which results in rigid thoughts (e.g. "fat is bad"), compulsive behaviors (e.g. calorie counting), and a self-centered focus.  There's also usually an increased level of intelligence in people with eating disorders... or perhaps it's better conceptualized as "fast learners."   Sounds a bit like high-functioning autism, huh?  

Unlike autism though, many times people with eating disorders report desperately wanting the approval of others.  So, even if the behavior is seemingly self-centered (e.g. wanting to look good), I maintain that the function of the behavior is not completely egocentric.  But reconciling this seemingly self-centered focus and a desire to please others is usually not easy for family members of people with eating disorders.  The idea is difficult to grasp that intense anxiety about other's approval ironically results in a "self-centered" disorder. In short, I think it could be really useful to use intense world syndrome concepts in fostering understanding about eating disorders. 

Here are a few last notes before I move on with my Sunday: I think eating disorders relate to autism in the same way OCD is related to autism.  In fact, I conceptualize eating disorders as a specific subtype of OCD.  It appears to me that the process is the same in both disorders, but the content of the worry differs.  And as such, slightly different treatments are needed... but not too different.  I'll publish more on what I've written about this in the future.

And lastly, there is the example of how self-injury may relate to autism.  I've blogged here before about my hypothesis on self-injury's relation to sensory integration issues.  To read, click this link.  The idea that intense emotions can create perceptual disturbances (auditory hallucinations such as hearing voices) is not new in psychology.  But the idea that intense emotions can also lead to sensory disturbances remains an area where we need work.  Taking that a step further, exploring exactly how emotions are moderated with sensory acts like self-injury (or even doing things like soothing oneself with lavender hand lotion) is worth researching.

We need to know the following: is there a dose response relationship between intense anxiety/emotion and 1) sensory disturbances, 2) learning, 3) rigid thinking, 4) compulsive/repetitive behaviors, and 5) a self-centered focus?  If not, is there some relationship?  What mediates/moderates that relationship?

This new idea of conceptualizing autism as "intense world syndrome" clicked a few pieces into place of an enormous puzzle that I have been kicking around in my brain for years.  I very much look forward to learning from research on this theory in the coming years. 

The French Paradox

The French Paradox:

Why The French Eat Fatty Food & Are Skinnier Than Us

It is official.  The French enjoy food more than Americans. And they are thinner with less health issues.  Awesome.

As it turns out, this phenomenon is so well documented,  even has a name - The French Paradox.

But what if it wasn't actually a paradox?  Maybe it all makes perfect sense.

Studies have shown that the French stop eating when they're full.  Americans stop eating when their plate is empty (Wansink,  2006).  Interestingly, the larger a person is, the more likely they were to rely on external cues to stop eating (e.g. portion size).

Frankly, this isn't too surprising.   We all understand that the plate sizes in the States are big, some of us have an inclination to eat everything on the plate, and subsequently, we gain weight.  But this begs a more interesting million dollar question:  If relying on external cues like plate size can cause weight gain, what is the answer to weight stablization?

Well, the answer is resoundingly NOT self-control, restraint, effort, pressuring yourself, and/or punishing yourself.  These methods also rely on external cues or rules that you set for yourself.  These types of eating guidelines are largely ineffective in practice too.  Consider how many times you've tried to restrain your eating, only to eat a ton.  You may even binge after trying to restrict.

I would go so far as to say that restricting food intake with any type of diet may actually be just as much a part of long-term weight gain as overeating.  For so many people, restricting food intake is simply just the first step in a sequence that eventually leads to unstoppable eating.

Take a moment to chew on that concept a bit: restricting is the opening act for a grande finale binge.  If this cycle repeats over time, the overall effect could actually be weight gain.  Shortening the message, restricting may = weight gain for some.

[Turns out there is this whole psychological component to dieting practically no one has been considering!  But I digress.]

Now, returning to the million dollar question.  The correct answer is this: the opposite of relying on external cues to stop eating is relying on internal cues of hunger and fullness.  In short, if you go by external cues like your plate size, you could be heavier over time.  Conversely, if you go by internal cues, your weight is likely to be more stable over time (e.g. Augustus-Hovarth & Tylka, 2011)

Interestingly, Rozin et al (1999) found that American's associated "chocolate cake" with guilt, while the French associated it with "celebration."  The French can actually enjoy cake and they're still thinner.

After all of that dieting, could it be that thinking more like a hedonist shrinks your waistline?  Tell me what you think with a comment below.

P.S. As usual, this post is only a sliver of my thoughts on the matter.  More generally, not only does one need to start paying attention to hunger/satiety cues, but also 1) decrease fear about weight gain, 2) try to curb the desperate desire to be thin, 3) stop mentally obsesses over calories, 4) curb efforts to compensate for calories, and 5) very importantly, being "thin" doesn't equal good health in the same way being "overweight" doesn't equal bad health.  But these issues are fodder for another post!  We'll get there.

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References

Augustus-Hovarth, C. & Tylka. T.  (2011). The Acceptance Model of Intuitive Eating: A Comparison of Women in emerging adulthood, early adulthood, and middle adulthood. The Journal of Counseling Psychology, 58, 110-125.

Rozin, P., Fischler, C., Imada, S., Sarubin, A., & Wrzesniewski, A. (1999). Attitudes to Food and the Role of Food in Life in the U.S.A., Japan., Flemish Belgium, and France: Possible Implications for the Diet-Health Debate.  Appetite, 1999, 33, 163-180.

Wansink,  B. (2006).  Mindless Eating: Why We Eat More Than We Think.  New York: Bantam Books.

You can read more about The French Paradox here: http://en.wikipedia.org/wiki/French_paradox

Psychosis in Mania

by Tara Deliberto

Here are some quick late night thoughts on psychosis and mania:

There's some fantastic brand new research showing that beta amyloid, a toxic substance, gets cleared from the brain while its sleeping (article).  Just fyi, beta amyloid is the stuff that is thought to cause dementia and Alzheimer's disease.

So, when people who are manic don't sleep for days, perhaps some of the psychotic symptoms are triggered from amyloid and other toxins building up in the brain.  In other words, perhaps the bipolar swings result from one mechanism, while the psychosis secondarily results from a lack of brain cleaning.  Further, maybe those who are more susceptible to these psychotic symptoms have a less efficient cleaning mechanisms more generally.

Of course, this isn't my main area of research.  I just felt compelled to encode my responses to this exciting new work on the internet before my beta amyloid levels become too high.

What I Wish I Knew Before Becoming a Doctoral Student in ClinicalPsychology: So Much More Than I Did.

As I am (hopefully) nearing the end of my graduate school training, there are many things I wish I would've know prior to starting. Getting a Ph.D. isn't as easy as it seems - and not for the reasons you may have guessed.

While much of this post is specific to my experience, it still may prove helpful. So without further ado, here's a list of what I wish I knew before going for a doctorate in clinical psychology:

1. The training isn't as hard as having the financial burden. If you're considering going for an academic degree like a Ph.D., chances are you've been pretty good at school. You can go to class, learn, and use the info you've picked up.  That being said, managing to pay the bills can become very difficult. While programs differ, doctoral students generally have to complete three externships, which are 20 hour / week training positions at clinics or hospitals outside of your program. While some externships are paid, I was only accepted to unpaid externships for my first two years. I am extremely grateful to have trained where I did, but I needed to pick up extra work on the side. It was exhausting.

2. Unpaid externships tend to offer better training than paid ones. Because I was running myself into a financial hole, I just figured I would get paid positions. Interestingly, the less competitive positions tend to be paid. Conversely, the most competitive positions tend to be unpaid.  Your supervisors at the unpaid externships are likely to take more time to really educate you rather than just quickly putting you to work. At my unpaid externships, I had about four to five hours a week of supervision, CBT classes, seminars, etc. Conversely, although I really learned a ton at my paid position from my wonderful direct supervisor, I was treated as more of a work horse by the other hospital staff.   While I did my best to have learning experiences at the paid position, much more of my day was spent doing paperwork that (much more) falls under the job description of other members of the hospital staff.  Anyhow, I thought for sure with my publication record I would be able to make a bit more money training. Wrong!  As it turned out, I wasn't offered interviews at paid positions for my first two externship years. The whole process is kind of backwards.

3. Most clinical positions don't care about research experience and publications. Again, I thought for sure that my publication record would help me get clinical jobs. In fact, I was told that I wasn't offered some paid clinical positions because I was "too research-y." People are split into two stereotypes: clinical folks and research folks. Broadly speaking, the clinician is viewed as valuing human connection above science. In turn, the scientist is viewed as valuing data that may be helpful to the masses over helping a smaller number of people via direct human interaction.  Even though I consider myself a good balance between clinical and research, my CV shows a bunch of research conference presentations and papers. It appears I was pigeon-holed.

4. The current APA-accredited internships are not the internships of your professors. Internships are the last year of your training. They are very typically completely clinical in nature (meaning you won't be doing research). It is extremely hard to get an APA-accredited internship nowadays. Something like 67% of people match to accredited sites. Because of financial problems, many internships - especially in the NYC area - were closed. While most of the great unpaid externships are worth it in the long-run, the ones I was accepted to were located in clinics, not hospitals. Getting a hospital externship puts you in a much better place for an APA-accredited internship. They may also pay. Even if you think you "know" you never want to work in hospitals, be prepared to give it a shot as part of your clinical training. Don't try to avoid it.

5. Get experience in a bunch of different type of settings. It doesn't matter if you're afraid of working on an inpatient unit. Use all of your CBT, DBT, and ACT skills. Also, it may not be a bad idea to take a self-defense course. Inpatient units aren't exactly dangerous, but they're not exactly not dangerous. I am lucky enough to have worked at places that require self-defense classes aimed at keeping yourself safe without hurting patients.  Anyhow, work on being willing to have the experience of working on an inpatient unit. And if you can find them, try emergency department experiences too.

6. It is unclear if getting an APA-accredited internship matters long-term.  It's common knowledge in psychology that you will be unable to work at a VA and are unlikely to ever be hired by a state hospital if you don't have an accredited internship.  Beyond that, no one seems to know how not having an accredited internship will impact your career.  I can say though, that if you just want to do research, it likely won't impact you at all since internships are clinical positions.

Also, because universities typically didn't offer stellar insurance policies for students with preexisting medical problems at the time and since I was 26 (the age at which you can no longer be on your parents' plan), I needed private insurance. Because unaccredited internships often don't offer health insurance, I fervently sought out an accredited internship so that I can stop paying through the nose for private insurance.

 By the way, for positions and internships at state-run hospitals, you do not get health benefits until six months after you have been employed. Because internships are one-year, you will not be provided coverage for half of the year.

7. If your program does not teach the Rorschach because it is not considered research-validated, seek outside training. While many consider the Rorschach to be outdated, many APA-accredited internships require it as part of your training. They will not accept you application without it.

8. Read the newest edition of the APA's Publication Manual before you write anything. It will save you loads of time and embarrassment if you read the newest version of the manual before writing your thesis or dissertation. The manual not only tells you how to format things correctly, but offers excellent writing tips you'll want to know.

9. Try to make your master's thesis the precursor / pilot study to your dissertation. This will save you a lot of time in doing a literature review and will make the putting together a plan for your dissertation easily. Before you finish your dissertation, you need to defend a proposal. Knowing the literature well and having piloted your study's method will make the proposal defense go much more smoothly. You'll be able to answer questions based on previous experience.

10. Even after learning all of that, I'm so happy I'm doing what I love. Did the process of going through graduate school leave me unscathed? No. Yet, I would do it all over again. If you're willing to do it, try. Even when I'm doing the paperwork of overburdened hospital staff instead of seeing patients, I'm still part of a solution to a larger problem. Every day has meaning.

And that's all for now! I'll probably continue to add to this over the coming weeks/months/years, as I tend to do with all of these posts.

Comments welcome!

Best,
Tara

Is Multiple Personality Disorder Real? - The Response

In April 2011, I wrote a post called "Is Multiple Personality Disorder Real?"   It is the third most popular post I've written here and certainly generates the most polarized comments / emails.   While I encourage you to read the original if you're interested in the following response, the gist is that Dissociative Identity Disorder (DID) - which was once called Multiple Personality Disorder (MPD) -  could potentially be Borderline Personality Disorder peppered with some delusional qualities. 

One very interesting & thought-provoking comment from 9/25/2012 inspired me to write this (belated) response.

Comment:
This blog post reads like it was written by someone who's never read a book or an article on DID, who's never worked with people with DID, who's just making wild assumptions. There are people dx'ed with both DID and BPD. There are also people dx'ed with BPD who don't have BPD at all, but have DID. You also make no mention of PTSD which all DID patients have, but not all BPD patients have. Look at somewhere that actually treats DID and PTSD specifically like the trauma Ward at Sheppard Pratt. But your theories seem a little half cocked.

This is my response:
Fair enough - I've admittedly not had much experience with DID - however; allow me a belated response (apologies for the delay).

First, I was generally very impressed when visiting Sheppard Pratt in May 2012.  My impression was that they offer top-of-the-line treatment.

As for DID though, I have read a bit about it.  For a summary, I would see Prof. Rich McNally's book "What is Mental Illness?" from 2011, copyright, President and Fellows at Harvard College.

In short, the book explains right after the book Sybil was published, "from near-nonexistence, MPD spread throughout North America, with the number of diagnosed cases soaring to 50,0000."  And then the "epidemic of MPD ended abruptly" because a study showing that asking leading questions is more likely to "create false memories than to recover them" (Ceci & Loftus, 1994).

The book also reads "MPD therapists inadvertently undermined the credibility of their own field when they began helping patients recall alleged memories of satanic ritual abuse" (McNally, Remembering Trauma). And that the FBI failed to uncover any physical evidence of these types of abuses (Lanning, 1992).

Interestingly enough, stories about abuse and trauma Sybil herself endured were also unfounded.  What seems to be the (even more disturbing) truth is that Sybil sought treatment with Dr. Cornelia Wilbur, who appears to have implanted false memories with the (unwitting) use of leading questions and social positive reinforcement.  When treatment tapes of the sessions between Wilbur and Sybil were researched, convincing evidence of this was revealed.  The book also states "indeed, Sybil admitted in writing to Wilbur that she had manufactured her MPD symptoms."

As such, while the symptoms of DID are in the DSM-IV, this does not mean that the disorder is not socially constructed, at least for the vast majority of cases.

[By the way, I'm not saying that there was never an organic (non-socially constructed) case of DID out there.  Saying that 100% of DID cases are socially constructed is a bit like meeting 50,000 Elvis impersonators in the year 2013 and then concluding Elvis Presley never existed. It stands though, that the ratio of hypothetical Elvis impersonators to Elvis Presley himself is still 50,000:1.] 

If someone presents with a case of DID, undoubtedly the situation is severe; however, I would argue that give the citations provided above, the idea  that the etiology (or cause) of the disorder is organic seems dubious at best.  Of course, understanding etiology is extremely important for treatment - especially if the treatment itself is indicated as a possible cause of the disorder, as was in the case of Dr. Cornelia Wilbur and Sybil.

For the cases that are not organic, but socially-constructed - which the evidence seems to suggest is most of them - perhaps a BPD identity disturbance / delusional quality may be present.  That's all.