APA Annual Meeting 2013

Many months ago, psychiatrist extraordinairre Drew Ramsey, MD of Columbia University asked if I would be part of a group to present information in a workshop format at the American Psychiatric Association annual meeting in San Francisco. He submitted an abstract, rounded up a reputable mentor on the scientific advisory board and collected not only myself but also Mala Nimalasuriya, MS and Roger McIntyre, MD to present.

Leagues: Spotlight

I must admit I've been a very bad academic up until this point. I keep the tip of my little finger in the academic world by teaching the clinical section of the introduction to psychiatry course at Harvard Medical School and have given a few Grand Rounds and other CME talks around town, but I haven't published or done any research besides serving as a psychiatrist for a project in the first couple years after residency. So for me, the opportunity to present at the largest annual meeting of psychiatrists in the world seemed, well, amazing. I do try for the blog to be honest and based on common sense and evidence and practicality, but at the end of the day, it is just a blog, and there are probably 10,000 new blogs on the Internet every single day.

Writing articles for the blog entertains me, helps me to learn, and is a lot more fun than toning it down for the interminable language of scientific papers, which tend to be interesting yet hideous unless written by the best (such as Gabbard or Rook). I do admire those who do publish, like Dr. McIntyre, whose resume is about 80 times as long as mine.

But I never look a gift horse in the mouth, and if they wanted me to present at the APA, I would help deliver…

Drew began the presentation with a brief overview of some important brain nutrients and the concept of whole foods versus the ubiquitous bastardization of wholesome living food we call "processed food." Drew's example: "I went to the store to buy some ham, and it was advertised as 'gluten-free.' When did gluten get into my ham?" He also reviewed some of the dietary pattern studies and elimination diet studies I've mentioned on my blog from time to time. Drew is both an expert at the various nutrients in whole foods, but also anti-"nutritionism," highlighting the importance of combinations of nutrients and their availability in whole foods that is quite different from the stripped down nutrients replenished with salt, industrial fats, and synthetic vitamins so prevalent in processed foods. Drew is the author of The Happiness Diet and the upcoming 50 Shades of Kale (he did indeed order the kale salad at the Split Bread in San Francisco).  I'm going to review The Happiness Diet soon, once I get a minute…

Maya continued the talk with information from her master's thesis on nutrition, the brain, and brain derived neurotrophic factor (BDNF). BDNF is brain fertilizer that helps with neurogenesis and repair, and good nutrition is associated with goodly amounts of BDNF.

Roger followed up with his vast body of work on obesity and mood disorders, noting the effects of weight loss, obesity, and active mood disorders on particular inflammatory cytokines. He highlights the point that the success I see with some of my folks on a paleo-style diet may be a result from an anti-inflammatory state that comes along with weight loss rather than from any particular diet per se.

I was the closer for the presentation with a very brief overview of the evolutionary medicine hypothesis, its pluses and pitfalls, the commonalities of a paleo-style diet and some evidence (including the evidence on fructose malabsoprtion) linking modern diets to poor mental health. I gave a few case studies and my clinical pearls for helping introduce a whole foods diet to people as part of a holistic model for health care in addition to more traditional therapies. I also discussed the theoretical applications of ketogenic diets in psychiatric disorders, the available evidence (almost nil: all pilot trials or case studies), and advised folks to keep an eye out for more research.

We had a number of questions and interest in the ideas of celiac disease masking as major mental illness, coconut and MCT oil, tofu and the poor performance of so called "modern diets" in the dietary pattern studies and depression, and interesting tracks for research and some practical questions about implementing recommendations. At the end we were approached by a number of psychiatrists wanting more information.

Did I mention our room was completely packed with people sitting in the front and aisles and lined up out the door?

All in all, a great success.

The remainder of the APA was, as always, interesting. 15,000 psychiatrists and the launch of the DSMV meant a continuous Scientology protest outside, plus a number of men with bushy eyebrows and bow ties. I attended a number of lectures, the most notable being a 4 hour seminar on giving better lectures. The APA attracts psychiatrists from all over the world, and I would estimate the number of international attendees at 1/5-1/4 in the lectures I attended.

I happen to be friends with the son of a former president of the APA, and as such was able to finagle my way into the APA Presidential Reception at the Palace hotel, which was great fun. My friend's father and his wife very kindly introduced me to everyone, and I can't express my appreciation enough.

It was also great to hang out with Drew Ramsey; food-minded and sensible psychiatrists are always a pleasure to talk to, crossing fingers we'll be invited to the next APA, and I'm going to get his 50 Shades of Kale to help me cope with the mountains of kale I get from my CSA, which starts up next week.

A Bit of Hiatus

Hi there. Yes, it has been a while. I am spending several hours each day working on the book, so other writing has taken a back seat for the moment. In addition, I am preparing for the upcoming American Psychiatric Association Annual Meeting in San Francisco, where I will be presenting as part of a group on food and the brain (on Sunday afternoon, before the Clinton speech, for anyone who will be there). My next talk after that will be in Arlington, VA, as I have graciously been asked to be a (far less glamorous and much shorter) speaking substitute for the Melissa half of Whole9Life for the summer of Melissa's maternity leave. You can get tickets for the talk here. I'll be adding a bit on the psychology of change and sleep cycles to the general Whole9 information.

Sometime in the next week or so I will have a new (or new-ish) post on Psychology Today. And you never know what will happen if a white-hot paper comes to my attention.

In the meantime, have a lovely spring. Keep checking back, and as always I'm still far too talkative on twitter.

Marathon Monday

I've always worked on Marathon Monday until this year, when we went to California to visit my sister for the week. Otherwise, since my oldest is now in school and had the day off, we may well have been downtown to see the festivities. For four years I lived about a half mile from where the bombings took place. I've walked down Boylston Street hundreds of times.

Two things folks who have not spent time in Boston may not understand about the events in Boston and Watertown this week: Marathon Monday, Patriot's Day, is a family event. I personally knew hundreds of people who went down to the race, because nearly everyone seems to go. My niece and nephew had watched a bit just down the block, though they had left by the time of the bombing. My sister-in-law knew a woman, a nurse, and her new husband who both lost limbs from the bomb, but so far I've not heard from other friends, family, or patients who were hurt. The "could have been" is sobering.

The second thing to understand is that Boston proper is a very small city. One could walk across it in a few hours. It is just a bit of a walk across the river to Cambridge, more of a hike over to Watertown. Closing down the city to do a confined manhunt in Watertown might seem unimaginable in Manhattan or Dallas or Los Angeles, but it is not so terribly far-fetched in Boston.

I mostly know the medical community, and some people in the law enforcement community. Atul Gawande wrote a good post for The New Yorker online about why so many survived the initial blast despite critical injuries. Today there are more than 50 people still hospitalized. And of course the five who died (including the MIT officer who was shot by the alleged bombers on Thursday night/Friday morning and the older bombing suspect himself). We will go back to work tomorrow and see how people are handling what happened, though I was on call for the practice and spoke with a few people who were very shaken up, particularly on Friday.

It was a good week to have been away, but I am glad to be home. My family is safe and sound, and it is so terrible that so many families were maimed and wounded this week. Thank you to those who reached out to me via social media and email, concerned about us.

Source

Sunlight, ADHD, and Current Events

First off, a brand new post is up on Psychology Today (one never before seen on this blog):

Sunlight and ADHD

Secondly, the blog has been a bit quiet of late because I am busy trying to get some real work done on the book. The deadline for a solid first draft is fast approaching.

In light of some shake-up in the blogosphere and the recent paleo debunking fad, I do plan a little post about what I think of the "paleo-style" diet (though long-time readers probably know my opinion already).

Also, for any of you who speak Polish, many of my articles have been translated…here is the link from Joanna Satula-McGirr: http://mojapsychologia.pl/eksperci/13,emily_deans_m_d/

Stay tuned!

PaleoFx13 and BA Training

Last weekend I went down to Austin for the PaleoFx13 conference. While I enjoyed PaleoFx12, I had a bit of trepidation at the idea of going back, mostly because the science talks were exceptionally fringe. However, I really enjoyed the people, and since I’m originally from Austin, it’s a nice excuse to get down for a few days and see my family and old friends and escape the horrendous early spring in the Northeast.

Muse: Panic Station (really digging the 21st century Stevie Wonder vibe of this song)

PaleoFx13 was a blast. The venue at the Palmer event center was terrific. Keith and Michelle Norris and all their help (including Corben Thomas among others) organized things very well, and the focus was drawn away from the sketchy science of yesteryear and more towards functional fitness and practical applications. For all the recent acrimony and problems in the paleoblogosphere, PaleoFx manages to make ancestral health a lot of fun. And we definitely needed the fun.

My contribution as a presenter was not fringe at all, but rather the evidenced-based application of behavior theory and stages of change and motivational interviewing on lifestyle changes in general. I use these techniques pretty much every day in my clinical practice in coping with addiction and other lifestyle changes, so it was both straightforward for me and rewarding. Several physicians came up to me after the presentation and spoke to me about their need to really tailor interventions to the particular stage of change of the patient to reduce frustration and prevent wasted energy. My friend, Jacob Egbert DO used the second half of our presentation to talk about his interventions in the gym, his success stories, and the idea of a gym (or any community) as a primary care center for wellness and prevention of chronic disease. He has struggled a great deal with the paradigm of modern medicine and the push for more procedures, more billing, and less holistic care.

I spent a lot of time with my online coach, Clifton Harski of BA training and his amazing girlfriend, Amy. She is a gymnast and he a kinesiology major and former MovNat master trainer along with a ton of experience with other forms of functional fitness. 

The term “functional” merely refers to full body, useful movement, such as getting up from the floor or climbing trees or Olympic weightlifting. I’ve been doing a program designed by Clif for about two months, and my general strength and movement has increased a great deal, even after two years of CrossFit. His BA training “Bootycamp” uses a lot of bodyweight movement and kettlebells to increase lower body stength. It’s high volume and intense, and beneficial, though he backed off and lightened my workouts when I was having a stressful week. Despite an injured shoulder, I’ve been able to do some legit chin-ups since I started his program. Between that and the heavy deadlifts, I can draw a lot of eyes in the globogym.

In person training (with an excellent trainer)  is always best, but with my time constraints and boredom with the standard fare (and the fact that I am just a psychiatrist who can do chin-ups rather than some sort of athlete), the online training keeps things interesting as well as challenges me in a way that local trainers probably wouldn’t. In person, Clif helped me perfect my two-kettlebell swing while Amy helped me achieve the one-armed handstand (against the wall!). Clif, like many of the folks I admired at PaleoFx loves perfecting human movement. It turns out I have an issue with my hip adductors, which my CrossFit trainer had noticed, and kept ordering me to keep my knees out on squats, but that wasn’t enough to fix the problem. 

Clif’s programming of one-legged deadlifts helped me to isolate the problem and start to work on it. He also respected the limitations of my shoulder and programmed specific strength exercises with that in mind. He is thoughtful about movement and functional training, but also recognizes that fitness should not be so deadly serious that we can’t enjoy it (just like paleo food…fun healthy delicious food as opposed to quinoa and textured soy protein? Sign me up!)

At PaleoFx I was fortunate enough to hang out with all the folks who goof off and do stupid human tricks between conference sessions, including Amy, Skyler Tanner (my favorite efficient exercise trainer) and Jacob Egbert. (Photo taken from A Jolly's twitter stream.)

I won’t be able to post before and after pictures of my bootycamp derriere, but rest assured I’m stronger and more shapely after the introduction to Clifton’s program. His brilliant tagline is “turn that applesauce into apples.” I’m going to hire him to give me some extra workouts in the future along with 2X  a week CrossFit training (nothing like the social crew at CrossFit to keep me motivated and coming back for more early morning gym time). 

Hopefully I will be able to attend PaleoFx14 and beyond! Life is becoming incredibly busy…today I presented at Psychiatry Grand Rounds at a hospital in Cambridge and it was very well received. Last week I presented at UT Austin, and flubbed the talk a bit as I am used to presenting a lower-level talk, or to clinical medical audiences. All the criticism and experience is very welcome. My wish is that a medical student and his or her eager mentor will latch hold of the idea of studying fructose malabsorption and depression. And if it is fecal transplants and depression instead, or magnesium and depression, or whatever, I will be a happy camper. 

The Heart is a Lonely Hunter

Respighi: Fountains of Rome

Carson McCullers wrote The Heart is a Lonely Hunter when she was 23. It became a literary sensation, though she was already suffering from rheumatic fever and would live most of her remaining life handicapped by a series of strokes. She wrote most often of love, loneliness, and empathy for the human condition.

I haven’t written a philosophical post in a while. Maybe because I’d done enough public searching for meaning in the first years. Maybe because so many read the blog now. And sometimes when I am busy, meaning is lost in the day to day of clinical medicine. In pain, addiction, success, coping, transcendence…but mostly pain, loss, and suffering. That is what people bring to me on a daily basis. And of all my elixirs to offer the most powerful is empathy.

Maybe when people longed for a thing that bad the longing made them trust in anything that might give it to them.

A psychiatrist’s job is a strange one. I sit with people as they cry. I try to sort out the influences of biological and psychologic pathology. I attempt to buttress the strengths and soothe and repair the weaknesses. And I never know what will happen, though I may have seen a similar patient walk through my door a hundred times, say a middle aged man drinking twelve beers a day. One of them gets worse, loses his family, the next one finds his path, quits drinking, and yet another sticks with six beers a day from here on out. Ten thousand variables walk in with every patient and we try to predict the possibilities.

It was funny, too, how lonesome a person could be in a crowded house.

I hate people, sometimes, their selfishness and my own. Our weakness and blindness. The mistakes we make over and over. And I love people, as they push through. It is a great gift that they will share with me all these daily despairs and victories. Sometimes I wish I could be more specific, but another part of my job is the vault of secrets, whether they are fantastic or heart wrenching.

One of the things I struggled with, initially, was a great sense of loneliness. Here I was with so many psychiatrists dismayed by my elixirs and not entirely sure the answer could be found by reading enough Kohut, Winnicot, or Freud. But the blogosphere is plentiful, the world of interested people almost limitless, despite the limitations of the medium and the egos and the foolishness.

I do not have any home. So why should I be homesick?

Our brittle weaknesses almost always come from places of pain. If someone is arrogant, outrageous, narcissistic, or lost, or too easily hurt…at the heart of it is insecurity and the ever-present pain. And where does the wish for finding some truth in the evolutionary medicine come from but dismay and pain? How many people have I seen die from heart disease or complications of diabetes? How many disabled from multiple sclerosis or lupus? And then the daily complaints of fatigue, depression, or constipation. I have few cures and far more questions to ask. 

The modern human race is a dysfunctional, limping family with awesome powers of energy and information. Here on the interweb we strike out and rant and rave and post pictures of our cats.

It was like they waited to tell each other things that had never been told before. What she had to say was terrible and afraid. But what he would tell her was so true that it would make everything all right.

When I sit with people who are dying, they tell me of their families. Their children and lives, and the people they meet on the street, and the color of the air at their favorite summer place. And when I sit with people who are living, they speak of the same, but hardly ever mention the color of the air.

Pain is the currency of my profession. For all doctors, perhaps, and all nurses. The rants, always, the raves, sometimes, and rarely, we hear about the cat pictures, which are, of course, the most important things. When you go out tomorrow try to remember to notice the colors in the sky and the crispness of the wind, because within those small details are serenity. The past is gone, the future is not here. The present is all we will ever hold and experience.

I’m a stranger in a strange land.

I am filled with stories, with sorrows and secrets. Carson McCullers knew these things at 23, and I am much older yet am still figuring them out. When do you call out the brutes, the proud, and the misguided? When do you succor their misery? What is the greater good? Is it silence and a smiling face, or a bitter cut, or perhaps manipulating a character weakness to serve a common end.

Some will benefit from the succor, others the cut. Some won’t learn, ever, and can only serve the good with the benign manipulation. All the terrible and glorious people and their ten thousand variables.

The most fatal thing a man can do is try to stand alone.

It seems like a long time ago that I wrote The Glorious Cause. And I still believe in it, that we have to move forward with open minds, honest skepticism, and a common respect for each other, for science, and for human health. But there are no seekers without flaws, no truths without pain, and no consensus without compromises. The question is are the compromises we make and the new friends we keep worth the cost? Each day those variables change, and the question differs, and the air carries a new scent and a new hue.

We learn so much when we go to those places that cause us pain, yet it sticks to us like glue, and we cannot be free, and we make the same foolish mistakes when we are beset by pain. I hope we can transcend and write and learn and move forward and break through. I hope we can do such a thing together, brute, nerd, narcissist, seeker, mother, warrior, and all the elements of the human family.

Perhaps we cannot get along. Perhaps the compromises we make are not honorable or worthy enough. Perhaps we are too small, too vulnerable, to make it work. That is the human condition, and it is not shameful.

I will not be hurried…kindly allow me to sit in peace a moment.

Every day we are dying. And every moment we live. Every moment there is an opportunity for weakness or triumph or love or serenity. Everything risks pain except perhaps serenity, and that may be why it is the nirvana of choice in lieu of happiness for the wise. The heart is a lonely hunter. We know so little, and expect so much.

Malnourishment in Infancy and Adult Personality Traits

I could have sworn I’d written about the Barbados long-term malnutrition follow-up study before, but I could not for the life of me remember the context or the name of the article. That’s the problem with having over 350 articles since 2010…I tried looking for the similarly-designed Mauritius study and found it at the bottom of this breezy post from last summer, Mainstreaming. In that study, poor nutrition in early childhood correlated with low IQ at age 12 and schizotypal personality traits at age 23. (Schizotypal traits in the Five Factor model include low self-directedness, introversion, and some distorted perceptions of reality, though an increased openness to new ideas).  It was felt the malnutrition resulted in poor development and functioning of the frontal lobes.

This week a new study came out from Barbados (1). 77 children who were admitted to the hospital at age 7 months for malnutrition were matched with 57 controls. All the malnourished children were subsequently enrolled in an interventional program from infancy until age 12. All 77 malnourished infants were otherwise healthy and achieved complete catch-up of growth by the end of puberty. The children and their matched classmates with no hospital admissions have been followed pretty much ever since. What is interesting about the original cohort is that malnutrition was a “reportable” disease in Barbados, so every child on the island who presented with malnutrition was subsequently enrolled in the same program. That means there is not extra "selection bias" in the malnourished cohort, besides the obvious that they were malnourished in the first place. In addition, on Barbados, education is compulsory until age 16, and 99% of the population is literate.

New Politics: Harlem

As children, the malnourished cohort had impaired IQ and poorer grades than their peers. They also had poorer attention and behavior, even after controlling for socioeconomics and family background. These problems persisted through adolescence, along with a greater tendency to be depressed. At age 40 years, both groups were given personality testing, measuring the tendency of the person to be open or withdrawn, altruistic or suspicious, angry, depressed, hopeful, and other measures such as whether the person tends to have irrational ideas, poor planning abilities, or brittle coping skills. All adults with IQ less than or equal to 70 were taken out of the sample, and a number of other measures that had been taken over the years, including questionnaires completed by their parents, were used to sort out other factors that might cause certain personality traits in mid-adulthood.

After all the data-crunching, the personality testing showed some significant differences between the previously malnourished cohort and their classmates. The malnourished cohort was more likely to have more negative feelings such as anxiety, anger and depression, seemed more vulnerable to stress, were less warm and gregarious, less trusting and less altruistic. They were less likely to consider new ideas and try to experience new things, and they also reported being less able to carry out plans, less punctuality and reliability. These significant differences remained after controlling for IQ and socioeconomic status in adulthood and childhood.

The malnourishment itself could have affected the brain, of course, particularly the frontal lobe and hippocampus, where it is known that early protein malnutrition can cause changes. In addition, maternal depression is associated with malnourishment in children, and maternal depression is known to affect childhood behavior and coping. Also, it is clear the early malnutrition was associated with other problems in childhood (behavioral issues, less ability to achieve in school) and these childhood experiences could have contributed to the adult personality differences as well.

Children born during the Dutch Famine in WWII were found to have an increased prevalence of antisocial and schizoid personality traits (which would include some of the traits studied here, such as decreased trust of others). In a Finnish study, children with slow growth in the first 6 months of life were more likely to be hospitalized later for personality disorders, particularly borderline and antisocial personality (2). No study had examined the personality particular traits in a Five Factor Personality questionnaire after 40 years of follow-up as was done in the Barbados cohort.

These are interesting studies and fascinating cohorts, and I think it is very plausible that early malnutrition would affect personality development and coping skills. It is also plausible that other kinds of maltreatment in early infancy could be factors as well.