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Mental Health

Mental Health, Podcasts

My descent into madness – a conversation with author Susannah Cahalan

My descent into madness - a conversation with author Susannah Cahalan

Cahalan illustrationWhen you talk to Susannah Cahalan on the phone, you’d never imagine that this is a woman who has been to hell and back. Without warning 5 years ago, she descended into a nightmare of paranoia, hallucinations, catatonia and near death. One moment she’s a journalist living the high wire life in the New York media world and the next, her brain is swimming in a world of severe mental illness without any diagnosis.

With the precision of an investigative journalist, Cahalan recreates what happened to her in the New York Times-bestselling memoir, Brain on Fire, My Month of Madness. There she describes the terror of what it’s like to be a patient without a medical diagnosis. A human being lost in a sea of clinical maybes. Violent, psychotic and considered a flight risk, she was all but a shadow of her former self.

Luckily, she did eventually find clinical clarity. The diagnosis: anti-NMDA receptor autoimmune encephalitis - a disease only discovered in 2007.

Cahalan’s back at work now at the New York Post. She’s writing book reviews, science and health articles, all with a new perspective. In this 1:2:1 podcast and Stanford Medicine magazine piece, I asked her if she was a different person now, and she told me you can’t go through something like this and not be. “It has changed everything.”

Previously: Stanford Medicine magazine traverses the immune system
Illustration by Joe Ciardiello

Behavioral Science, Mental Health, Public Health, Stanford News

"Every life is touched by suicide:" Stanford psychiatrist on the importance of prevention

in-a-lonely-place-fa873a88-0c57-4b11-8f84-58c09aab94acMost people shy away from talking about suicide. Me too – I have some personal ties to the topic that still stab every time the s-word comes up. Yet after the initial reluctance wears off, that pain from grief and anger and fear turns into a motivational jab. Let’s talk about suicide nonstop. Let’s talk to make it stop.

Laura Roberts, MD, who leads Stanford’s psychiatry department, had the opportunity as editor-in-chief of the journal Academic Psychiatry to focus attention on suicide prevention. And she took it – partnering with the Wisconsin-based Charles E. Kubly Foundation to produce a special package of articles to inform clinicians about the latest efforts to prevent suicide.

Roberts and I spoke recently about the special issue and about suicide prevention:

Why did you want to publish this issue?

Suicide is such an under-recognized phenomenon, and it is an urgent threat to public health. Mental illness affects one in five people. Each year, more than 36,000 people commit suicide in the U.S. That is one person every fifteen minutes. In rough numbers, that’s twice the number of people who die from a violent injury in this country. Really, every life is touched by suicide.

Despite their serious public-health impact and life-threatening nature, illnesses and conditions associated with suicide have received little attention in society. These conditions are poorly understood and so greatly stigmatized. Learning to understand and evaluate people at risk for self-harm is an important element of medical student and resident education — we really wanted to emphasize these topics in this special collection.

New evidence-based models for prevention of suicide are emerging and inspire optimism. Integrating these new models is an exciting challenge for medical educators. Papers in this collection also document the impact of suicide and suicidal behavior among medical students and graduate students. About 350 physicians commit suicide each year in the U.S., and recently two interns in New York City ended their lives shortly after entering residency training. This is devastating.

In our special issue, a systematic review highlights the observation that psychiatry residents commonly experience the death of a patient by suicide, and three articles address coping with suicide professionally. Several articles focus on the development of educational programs that help strengthen suicide prevention, including screening skills and suicide awareness and management. Two articles address the resources and experience of from the Department of Veterans Affairs.

The journal special issue underscores there is much we can do in medical education to foster understanding and strengthen our responses to the phenomenon of suicide. Taken together, the papers also show how important it is that academic leaders better educate other about the prevention and impact of suicide.

What have we learned about preventing suicide?

We have learned a great deal about the prevention of suicide. Population data have shown that certain subgroups are especially vulnerable to suicide, including, for example, older white men who are ill and live alone, Native American youth as they make the transition to adulthood, and people living with serious illnesses that cause great physical and emotional pain. Understanding these larger population patterns has done a lot to help raise awareness of suicide and has allowed for creative interventions to address this problem.

Recently, researchers have been pursuing neurobiological markers that may signal when an individual is most at-risk for attempting suicide. Other studies are connecting other aspects of health — such as healthy sleep and exercise — to protective factors that may help diminish the likelihood of suicide. Such innovative work is very much needed because it will help us understand when a person with latent risk factors for suicide may act on this impulse, or, alternatively, how we can better support and intervene.

Other recent work has focused on psychological and situational factors that may contribute to suicidality among young veterans, and again, this line of inquiry may give us greater understanding on how best to reduce suicide deaths. As you may know, the number of veteran deaths due to suicide have been devastating. The VA has shown immense concern for members of the military and young veterans returning from conflicts around the world. In the course of studying suicide in this population, we have begun to have greater insight into when and whether an individual will act on an impulse to end his life. Three factors appear to be in play: first, a predisposition or vulnerability, for example, the presence of depression or anxiety that increases the general risk of suicide; second, access to a way to end one’s life, such as a gun; and, third an experience or set of experiences that make the individual feel like he is out of place, isn’t part of things, and doesn’t belong — what’s referred to as “thwarted belongingness.”

We are getting parts of the problem figured out, but so much more scientific investigation is needed. Ironically, suicide has been understudied because of concerns that the population is too vulnerable to be included in human research studies and because of the stigma associated with suicide. There have been so many barriers to these studies, and it strikes me as doubly tragic that suicide takes so many lives and yet has been relatively neglected by society and by science. In the Department of Psychiatry and Behavioral Sciences at Stanford, we are working to turn this around.

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Immunology, Mental Health, Stanford News

Stanford Medicine magazine traverses the immune system

Stanford Medicine magazine traverses the immune system

cover_fall2014_2If you want to understand the human immune system, try studying humans – not mice. That’s what Mark Davis, PhD, urges in a special report on the immune system in the new issue of Stanford Medicine magazine.

For decades, most research on the immune system has used mice. Davis, director of Stanford’s Institute for Immunology, Transplantation and Infection, launched Stanford’s Human Immune Monitoring Center a few years ago to change the immunology research paradigm.

“Inbred mice have not, in most cases, been a reliable guide for developing treatments for human immunological diseases,” Davis says in the special report, titled “Balancing act: The immune system.”

As the editor of the magazine, I wanted to feature a story that showed how human-focused immunology research plays out. So I was glad to learn that the center is in the midst of its largest study so far – one to figure out the cause of chronic fatigue syndrome. A team led by Stanford professor of infectious diseases José Montoya, MD, is looking for meaningful patterns in the components of blood samples gathered from 200 patients with chronic fatigue syndrome and 400 healthy subjects.

“It’s like dumping a hundred different puzzles on the floor and trying to find two pieces that fit,” Davis says in our story. We also have a video about a patient’s seven-year battle with chronic fatigue, from despair to recovery.

Also covered in this issue:

  • “I can eat it”: on a revolutionary treatment for food allergies
  • “Brain attack”: on the struggle to help children with psychiatric illness caused by a malfunctioning immune system – a condition known as PANS or PANDAS
  • “When bones collide”: on a new view on the cause of osteoarthritis: autoinflammation
  • “My rendezvous with insanity”: a Q&A with Susannah Cahalan, author of Brain on Fire: My Month of Madness, her memoir of surviving an autoimmune attack on her brain
  • “The swashbuckler”: on look back to the early days of molecular biology when Mark Davis cracked one of the greatest mysteries of the immune system

The issue also includes an article on efforts at the VA Palo Alto Health Care System to use peer-support services to help veterans with post-traumatic stress disorder, and a story on the growing concern that biomedical research results are often erroneous and efforts being made to solve the problem.

The issue was funded in part by the Institute for Immunology, Transplantation and Infection.

Previously: Stanford Medicine magazine opens up the world of surgery, Mysteries of the heart: Stanford Medicine magazine answers cardiovascular questions and From womb to world: Stanford Medicine Magazine explores new work on having a baby.
Illustration by Jeffrey Decoster

Cardiovascular Medicine, Men's Health, Mental Health, Research, Women's Health

Examining how mental stress on the heart affects men and women differently

Examining how mental stress on the heart affects men and women differently

stress_womanPast research has shown that stress, anger and depression can increase a person’s risk for stroke and heart attacks. Now new findings published in the Journal of the American College of Cardiology show that cardiovascular and psychological reactions to mental stress vary based on gender.

In the study (subscription required), participants with heart disease completed three mentally stressful tasks. Researchers monitored changes in their heart using echocardiography, measured blood pressure and heart rate, and took blood samples during the test and rest periods. According to a journal release:

Researchers from the Duke Heart Center found that while men had more changes in blood pressure and heart rate in response to the mental stress, more women experienced myocardial ischemia, decreased blood flow to the heart. Women also experienced increased platelet aggregation, which is the start of the formation of blood clots, more than men. The women compared with men also expressed a greater increase in negative emotions and a greater decrease in positive emotions during the mental stress tests.

“The relationship between mental stress and cardiovascular disease is well known,” said the study lead author Zainab Samad, M.D., M.H.S., assistant professor of medicine at Duke University Medical Center, Durham, North Carolina. “This study revealed that mental stress affects the cardiovascular health of men and women differently. We need to recognize this difference when evaluating and treating patients for cardiovascular disease.”

Previously: Study shows link between traffic noise, heart attack, Ask Stanford Med: Cardiologist Jennifer Tremmel responds to questions on women’s heart health and Study offers insights into how depression may harm the heart
Photo by anna gutermuth

Mental Health, Research, Technology

How social media can affect your mood

How social media can affect your mood

Facebook_10314A close friend engages in a yearly media detox, where for a period of time he limits his time and activity spent on the Internet. He only answers e-mails requiring an immediate response, spends few minutes reading current news and avoids engaging in social media, shopping online or perusing gossip and entertainment sites. Another friend goes on annual eight-day meditation retreats and turns off her phone for her entire stay. Both report that these periodic breaks significantly improve their moods.

Past research supports their personal experience and shows that while many of use social media to feel connected to others, it can also leave us feeling frustrated, lonely and depressed.

A study (subscription required) recently published online in the journal Computers in Human Behavior offers context to these earlier findings and suggests that when we are feeling blue we use social media sites, such as Facebook, to find friends that are also having a bad day, suffered a setback or going through a tough time in their lives.

During the experiment, researchers gave participants a facial emotion recognition test and randomly told them their performance was “terrible” or “excellent” to put them in positive or negative moods. The individuals were than asked to review profiles on a new social networking site. The profiles used dollar sign or heart icons to make users appear successful and attractive or unattractive and unsuccessful. All profile photos were blurred and the status updates were relatively mundane and similar in tone. PsychCentral reports:

Overall, the researchers found that people tended to spend more time on the profiles of people who were rated as successful and attractive.

But participants who had been put in a negative mood spent significantly more time than others browsing the profiles of people who had been rated as unsuccessful and unattractive.

“If you need a self-esteem boost, you’re going to look at people worse off than you,” [Silvia Knobloch-Westerwick, PhD, co-author of the study] said.

“You’re probably not going to be looking at the people who just got a great new job or just got married.

“One of the great appeals of social network sites is that they allow people to manage their moods by choosing who they want to compare themselves to.”

Previously: Ask Stanford Med: Answers to your questions on the psychological effects of Internet use and Elderly adults turn to social media to stay connected, stave off loneliness
Photo by Paul Walsh

Behavioral Science, Events, Mental Health

Learning to forgive with Fred Luskin, PhD

283888330_71b4084e22The long, wooden conference table was surrounded by 12 women, including me. We giggled a bit: Where were the men?

“All over the world, it’s almost always women,” said the first and only man to enter the room, Fred Luskin, PhD, the instructor of a four-week “Forgive for Good” class (presented by the Stanford Health Improvement Program) and founder of a movement to forgive – for your own health. He looked every bit the professor — gangly, with disheveled hair and a shirt sporting an equation.

“Even in northern Ireland?,” one woman asked.

“Even in northern Ireland,” Luskin responded.

I came to watch, to record as an observer, just as I have covered hundreds of events in the past. But in Luskin’s class, everyone must forgive. Even journalists.

It hurt to darken my laptop and separate my fingers from its well-worn keys. I bristled during the initial relaxation session, where we were directed to focus on our breathing. He’s saying things and I’m missing them! Grrrrrr. My heart raced.

“You can’t forgive if you don’t relax,” Luskin said. “You have to quiet down and open.”

I tried to pretend I was in yoga class. I took in a breath. Open. Breathe. Then, the relaxation session was over and I relaxed, once again reunited with my trusty Mac.

But then, as Luskin was mentioning that many women had taken his classes to forgive their ex-husbands – “There’s lots of terrible ex-husbands running around,” he joked – I looked around the table. Here were 11 women, driven to spend four evenings letting go of a hurt that was tearing them up inside. Instantly, my aggravation slipped away. My teensy anger was nothing compared to the real wrongs of the world.

“It’s quick and difficult to be a human being,” Luskin said. “You don’t get a do-over.”

Grieving and suffering are normal, he said. Yet make sure the harm doesn’t dampen the rest of your life. A jerk cuts you off on the freeway? Fume for a second, but one exit later it should be forgotten, Luskin said. A drunk driver leaves you crippled? That takes a bit longer, maybe five years. Dreadful childhood? No one in their 50s should still be stewing about their harsh lot.

“Life is very challenging,” Luskin said. “Do you want to spend years holding on to your part of that challenge? Or can you accept your portion of portion of pain?”

Once the grieving is done, stop talking about the hurt, Luskin said. “We used to call this shut-up therapy…  Just shut up and stop driving yourself nuts.”

Then, he said, you can love again, without hiding your heart. That’s a message worth parting from my computer.

Previously: Practicing forgiveness to sustain healthy relationships, A conversation with Stanford psychologist Fred Luskin on forgiveness and its health benefits and Teaching children the importance of forgiveness
Image by Ian Burt

Addiction, Bioengineering, Mental Health, Neuroscience, Stanford News, Stroke

Neuroscientists dream big, come up with ideas for prosthetics, mental health, stroke and more

Neuroscientists dream big, come up with ideas for prosthetics, mental health, stroke and more

lightbulbs

So there you are, surrounded by some of the smartest neuroscientists (and associated engineers, biologists, physicists, economists and lawyers) in the world, and you ask them to dream their biggest dreams. What could they achieve if money and time were no object?

That’s the question William Newsome, PhD, asked last year when he became director of the new Stanford Neurosciences Institute. The result is what he calls the Big Ideas in Neuroscience. Today the institute announced seven Big Ideas that will become a focus for the institute, each of which includes faculty from across Stanford schools and departments.

In my story about the Big Ideas,I quote Newsome:

The Big Ideas program scales up Stanford’s excellence in interdisciplinary collaboration and has resulted in genuinely new collaborations among faculty who in many cases didn’t even know each other prior to this process. I was extremely pleased with the energy and creativity that bubbled up from faculty during the Big Ideas proposal process. Now we want to empower these new teams to do breakthrough research at important interdisciplinary boundaries that are critical to neuroscience.

The Big Ideas are all pretty cool, but I find a few to be particularly fascinating.

One that I focus on in my story is a broad collaboration intended to extend what people like psychiatrist Robert Malenka, MD, PhD, and psychologist Brian Knutson, PhD, are learning about how the brain makes choices to improve policies for addiction and economics. Keith Humphreys, PhD, a psychiatry professor who has worked in addiction policy and is a frequent contributor to this blog, is working with this group to help them translate their basic research into policy.

Another group led by bioengineer Kwabena Boahen, PhD, and ophthalmologist E.J. Chichilnisky, PhD, are working to develop smarter prosthetics that interface with the brain. I spoke with Chichilnisky today, and he said his work develop a prosthetic retina is just the beginning. He envisions a world where we as people interface much more readily with machines.

Other groups are teaming up to take on stroke, degenerative diseases, and mental health disorders.

One thing that’s fun about working at Stanford is being able to talk with really smart people. It’s even more fun to see what happens when those smart people dream big. Now, they face the hard work of turning those dreams into reality.

Previously: This is your brain on a computer chip, Dinners spark neuroscience conversation, collaboration and Brain’s gain: Stanford neuroscientist discusses two major new initiatives
Photo by Sergey Nivens/Shutterstock

Mental Health, Neuroscience, Technology

What email does to your brain

What email does to your brain

man yellingUpdated 10-2-14: A follow-up post, with tips on how to manage your inbox, can be found here.

***

10-1-14: Have you ever been in a situation in which you were feeling great until you received an email out of the blue that completely upset your day? How does it feel to receive 30 such emails first thing in the morning? There’s a reason why: Research shows that just looking through your inbox can significantly increase your stress levels (see research described here).

Why is this? Let’s start by defining stress. Stress is the experience of having too great a task to accomplish with too few resources to meet the demand. In the past, for our ancestors, this stress might have looked like meeting a hungry wild animal in the jungle. Today, however, it takes on a much more simple, yet equally powerful form: an inbox. Email overload is just another way in which we experience that there is too great a task (the huge list of to-dos) to handle. In the study mentioned above, email overload had a lot to do with the stress response as measured psychologically and physiologically through heart rate, blood pressure and a measure of cortisol (the “stress hormone”).

Is it just the amount of emails that lead to stress though? There’s another element that we are forgetting. The emotional impact of each email. Think about it: Usually, in our email-less past, we would experience maybe one highly emotional event a day or maybe two or three at the most, e.g. a confrontation with a colleague, perhaps a spat with a spouse, and/or a phone call from an angry neighbor. Our stress response is evolved to handle and recover from a small number of stressful situations but not a whole host of them. Unless we live in unusually extreme situations such as warzones, for example, our life usually doesn’t have frequent and sequential stressors thrown at us.

Today, however, just sitting down at our desk to check our email with a cup of coffee can bring on a deluge of emotional assailants. Between 30-300 different emotional stimuli are delivered to you within the span of minutes. From an email from your boss asking you to complete a task urgently, to a passive-aggressive message from a family-member, to news from a colleague that he’s out sick and you have to take over his workload. One hour of email can take you through a huge range of emotions and stressors. Sure, you can get happy emails too – photos of your nephews, someone’s marriage announcement – but unfortunately, research on the negativity bias shows that our brain clings more to the negative and they don’t always balance out.

That’s when our emotional intelligence is impacted. We know that when our stress response is activated, the parts of our brain that respond with fear of anxiety tend to take over, weakening our ability to make rational choices and to reason logically this study). You may be stressed; what’s more, your own ability to respond appropriately is impacted. We know that our emotions impact the way we act. You’re going to reply with a different tone if you’re upset (even at someone other than your email recipient) than if you’re not.

Have you ever pressed “send” only to regret it moments later? Don’t blame yourself. Research shows that getting depleted because you have too much on your plate reduces your self-control. For example, it can make you take more risks when maybe you should be more cautious (e.g. this study). It’s harder to have a say over our impulses when there’s just too much going on. As in too many emails, with too many different messages leading to increased stress and emotional overload.

When you’re doing a million emails – all about different topics and requesting you for different things, you are, by definition in a situation of overwhelmed multitasking. And multitasking, research shows, leads to lower productivity and makes you lose a lot of time out of our day!

So what’s the answer to the assailment of email on our lives?

Before you contemplate moving to a farm, selling your smartphone on Ebay, raising chickens and goats and cutting technology out of your life forever despite your love of selfies – WAIT, there’s a solution. Think about it – email didn’t exist 10 years ago! That means that there is a way to undo the madness. I’ll share a number of tips in my next post… Stay tuned.

Emma Seppala, PhD, is associate director of Stanford’s Center for Compassion and Altruism Research and Education and a research psychologist at the School of Medicine. She is also a certified yoga, pilates, breath work and meditation instructor. A version of this piece originally appeared on her website.

Photo by bark

Medical Education, Medical Schools, Mental Health, Stanford News, Surgery

New surgeons take time out for mental health

New surgeons take time out for mental health

rope webI spent a recent morning watching about 30 Stanford surgical residents take time off from their operating rooms to participate in a series of team-building games out on the alumni lawn on campus. These are busy, dedicated professionals who are passionate about their work, so getting them to take time off is hard. “I can tell you a surgical resident would rather be in the operating room than anywhere else on earth,” Ralph Greco, MD, a professor of surgery, told me as he sat on a nearby bench watching the residents play games.

In a story I wrote about the games, I describe how the Balance in Life program, which sponsored the day’s event, was founded following the suicide of a former surgical resident, Greg Feldman, MD. Greco, who helped build the program, was committed to doing whatever he could to prevent any future tragedies like Feldman’s, as I explain in the piece:

“The residency program was just rocked to its knees,” he said, remembering back to the death in 2010 of the much-loved mentor and role model for  many of the surgical residents and medical students at the time. Feldman died after completing his surgical residency at Stanford and just four months into his vascular surgery fellowship at another medical center. “It was a very frightening time,” Greco said. “Residents were questioning whether they’d made the right choices.”

Today, the Balance in Life program includes, among other thing, a mentorship program between junior and senior residents, group therapy time with a psychologist and a well-stocked refrigerator with free healthy snacks. Residents themselves, like Arghavan Salles, MD, who participated in the ropes course, plan and coordinate activities:

“Some people think this is kind of hokie,” said Salles, who was one of a group of residents who helped found the program along with Greco following Feldman’s death. “Surgery is a super critical field,” Salles said. She paused to instruct a blind-folded colleague: “Step left! Step left!” “You face constant judgment in everything you do and say,” she added. “Everyone is working at the fringes of their abilities. They’re stressed.”

While writing this story, my co-workers suggested I read a September editorial in the New York Times that brought the issue into sharp focus. Spurred by the suicides two weeks prior of two second-year medical residents who jumped to their deaths in separate incidents in New York City, Pranay Sinha, MD, a medical resident at Yale-New Haven Hospital wrote about the unique stresses of new physicians:

As medical students, while we felt compelled to work hard and excel, our shortfalls were met with reassurances: ‘It will all come in time.’ But as soon as that MD is appended to our names in May, our self-expectations skyrocket, as if the conferral of the degree were an enchantment of infallibility. The internal pressure to excel is tremendous. After all, we are real doctors now.

Pranay’s message was similar to the one promoted by Stanford residents during the games: The key to battling new physician stress is realizing that you are not alone, that your colleagues are there to support you. “It sounds touchy feely to say that we care,” Salles told me. “But at the end of the day, if we want to have better patient care, we need to take care of each other too.”

Previously: Using mindfulness interventions to help reduce physician burnout and A closer look at depression and distress among medical students
Photo by Norbert von der Groeben

Mental Health, Research, Stanford News

Study shows benefits of breathing meditation among veterans with PTSD

Study shows benefits of breathing meditation among veterans with PTSD

man meditating - smallEarlier this year, Emma Seppala, PhD, associate director of Stanford’s Center for Compassion and Altruism Research and Education and a research psychologist at the the medical school, wrote on Scope about her work using breathing meditation to help veterans with PTSD. One of her studies, involving 21 male veterans of the Afghanistan and Iraq wars who were taught a set of breathing techniques from the Sudarshan Kriya Yoga practice, has now been published.

A recent Stanford Report article provides more details on the research, which found that the breathing techniques “resulted in reduced PTSD symptoms, anxiety and respiration rate” among study participants. The piece also highlights Seppala’s surprise that the meditation appeared to have a lasting effect:

“It is unusual to find the benefits of a very short intervention – one-week, 21 hours total – lasting one year later,” she said. One year after the study, the participants’ PTSD scores still remained low, suggesting that there had been long-lasting improvement.

When the scientists asked the veterans whether they had continued practicing at home, a few had but most had not. The data showed that whether or not they had practiced at home, it did not hinder meditation’s long-term benefits.

One reason, Seppala suggested, is that Sudarshan Kriya yoga retrained the veterans’ memories.

Before the breathing meditation training, participants reported re-experiencing traumatic memories frequently and intensely, Seppala said. Afterward, they reported that the traumatic memories no longer affected them as strongly or frequently.

The study appears in the in the Journal of Traumatic Stress.

Previously: The remarkable impact of yoga breathing for trauma, The promise of yoga-based treatments to help veterans with PTSD, Using mindfulness therapies to treat veterans’ PTSD, As soldiers return home, demand for psychologists with military experience grows, Stanford and other medical schools to increase training and research for PTSD, combat injuries and Can training soldiers to meditate combat PTSD?
Photo by Sebastien Wiertz

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