Seasonal Affective Disorder? Or a Bad Winter?

In Eastern Ontario, this has been a winter for the record books: long periods of deep cold alternating with difficult periods of precipitation and very few days of temperatures that make for a pleasant walk. Just this past week the temperature fell 30 degrees within 12 hours and the precipitation turned from rain, to freezing rain to snow. I find that whenever there is a difficult period of winter weather, more patients will ask, “Do you think I have Seasonal Affective Disorder?” Because of the weather, there are many more people asking that question this year so a brief primer and some references might be helpful for some of you.

Norman Rosenthal is the psychiatrist who, with his research team, first described Seasonal Affective Disorder (SAD) and his book, Winter Blues: Everything You Need To Know To Beat Seasonal Affective Disorder, is still one of the best references on the condition. It is available now in its fourth edition. The book is easy to read and still provides some of the most authoritative information with respect to SAD. He even has a blog and short video about what you need to know about SAD.

Since I see youth and young adults in my practice, I should point out that this group has a higher rate of Seasonal Affective Disorder. It is interesting that, in his blog about SAD in college students, Rosenthal suggests that parents can have a protective effect on youth vulnerable to SAD since they will remind them to get enough sleep and to care for themselves. When one is away from home for the first time, it takes awhile to learn selfcare and so these students might be more vulnerable to a condition that causes decreased energy and a sleep disturbance. This is Rosenthal’s contention so it follows from this that if you, or a family member, suffers from Seasonal Affective Disorder, a good way to support them is by helping them to maintain a reasonable schedule, especially with respect to getting enough sleep.

The symptoms of Seasonal Affective Disorder include:
1. Difficulty waking
2. Decreased energy
3. Difficulty concentrating
4. Increased appetite especially for sweets and starches
5. Weight gain
6. Anxiety
7. Decreased interest in socializing

These symptoms can interfere with a person’s capacity to manage their regular work or academic schedule and if you’re experiencing these, there are some things you can do that may be able to help.

First, look up the material I’ve included and consider whether you might have Seasonal Affective Disorder. Even if you’re not certain, there are some health measures you can take that have no risk and that could be helpful. Start with getting more light: go for a walk, especially a morning walk and find ways to let the sunshine into your home or workspace. You can use a timer or a dawn light at your bedside table to “start” the daylight a bit earlier. You can also get a specific light for Seasonal Affective Disorder. These are available in medical supply stores and some insurance plans even cover the cost.

You can also develop some basic Cognitive Behaviour Therapy techniques. Learn to recognize and manage negative thoughts and find some things to do that always help you to feel better. This last suggestion seems to be very hard for many people for whom depressed mood can be problematic. When there is a depressed young person on the inpatient unit, one of the most enjoyable and rewarding things to do is to help them find activities that always help them to feel better.

Finally, when should you see a doctor if you think you might have SAD? If your functioning at work or in school becomes affected, it’s time to discuss with your family doctor whether more treatment is required. Some cases of Seasonal Affective Disorder can be so severe that antidepressant medication will be needed.

All of this does not address whether a winter such as we’re having in Central Canada results in more cases of Seasonal Affective Disorder. Well, this does not seem to be supported by research. I cannot quite believe it myself. When I get ready to leave for work in the morning and I can’t quite face the 10-minute walk because it’s -30 degrees centigrade and there’s a wind chill factor on top, it would be great to feel justified in worrying about an increased risk of SAD. But it’s not the case. In fact, the short walk in the bright morning is likely just what I need to prevent the condition.

Book Review: The One Memory of Flora Banks

I read The One Memory of Flora Banks (Author: Emily Barr at  last weekend when I was on call at the Children’s Hospital of Eastern Ontario. On a day when I was providing service to a busy emergency room, it grounded me to be considering the plight of a young person who had suffered considerable trauma and had lost her memory because of it.

This is the adventure of a 17 year old girl named Flora Banks who has anterograde amnesia, which means that she cannot remember anything that happened after the event which caused the amnesia. To help her manage her life, Flora writes down every important thing that she must remember. Many, many things she wants to remember are written into notebooks, but the most important things are written on her hands. Of the important messages, one is prominent and it is a tattoo that says: Flora be brave.

Flora’s memory problems, we are told at the beginning, are the result of a brain tumour that was removed at age 10. The book is written in Flora’s voice and so the reader can experience what it is like to live inside Flora’s brain. To an observer, it would seem as though Flora has lost a lot of her capacity. But from inside Flora’s brain, the reader realizes that this is not the case. One of the most important messages of this book is never to underestimate a person’s abilities.

Even though Flora is capable of more than is evident, she is very hopeless about what she has lost and worries about what her life holds. One evening this changes when a boy kisses her and Flora remembers this kiss for longer than her usual several hours. Immediately, Flora is hopeful that this boy, or his love, holds the answer to her regaining a functional memory. She sets off to find him, despite the limitations of her memory and without anyone supporting her.

There are many days in my work as a psychiatrist for youth that I see young people coping with having a chronic medical condition that could limit what they might achieve. Like Flora, they have periods of hopelessness when they sadly wonder what their lives will bring. But many of them, like Flora, refuse to be defeated by despair. I don’t care if they disagree with me about their medications, or their symptoms or their diagnosis. I hope that I am true to the spirit of hope that lives in them, and I work to be worthy of that positivity.

This is an important book because we can all benefit by knowing Flora. Not all of the people who love Flora trust her hope any longer, but she meets a lot of new people in her voyage to find love and her memory and they do trust Flora’s hope. Please read about Flora and resolve to help at least one person stay hopeful.

(Note: I read the 2017 Penguin Random House edition of The One Memory of Flora Banks. The photo is the cover of that edition.)

Is there someone else Narcissus?

Narcissism is a word that gets used a lot these days, mostly because of the American election, but I am absolutely going to say nothing else about that because I want to focus on the central message of Craig Malkin’s 2015 book Rethinking Narcissism: The Bad – and Surprisingly Good – About Feeling Special.

This book started off perfectly for me since, right after the introduction, Malkin retold the myth of Narcissus, making it unnecessary for me to find my university copy of Bullfinch’s Mythology.

From the myth about the beautiful young man, admired by many and convinced that the many were correct, the term “narcissism” was first considered in a psychological sense by Sigmund Freud in his paper: On Narcissism: An Introduction. Malkin tells us that Freud’s introductory consideration of narcissism was developed in the 1960’s and 1970’s by Heinz Kohut and Otto Kernbergbut, but via Kohut’s self-psychology movement, the term narcissism and the concept of unhealthy narcissism moved into the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association, a manual in wide use and, for most psychologists and psychiatrists, the standard of care.

Dr. Malkin’s goal in writing this book, he tells us, is “…to help you not only understand and cope with the people around you…but also to better understand yourself.” To do this, Malkin takes the reader on a consideration of both healthy and unhealthy narcissism.

The book has a number of features that would make it popular, but here’s the key: Early in the book, he introduces the Narcissism Spectrum Scale, developed by Malkin and two colleagues, Dr. Stuart Quick and Shannon Martin. Using the scale, the reader can determine their own place on the “Narcissism Spectrum” and then go on to read about how narcissism develops, the advantages of healthy narcissism and how to develop a healthier attitude towards one’s own narcissism.  This does provide some very valuable tools for dealing with the people in your own life whose narcissistic traits are difficult to negotiate in day-to-day situations. There are also good suggestions for parents trying to raise a child who has a healthy degree of narcissism. There is really not especially good advice for a person who has gotten into trouble because of narcissism and who is contemplating self-improvement. Perhaps, there are not enough people in this category to make this worthwhile??

One chapter worth reading all on its own is the chapter on social media. It has advice about Facebook and Twitter in particular, but also summarizes some of the studies exploring the psychological impact of social media on self-esteem and mental health in general. If you’re wondering about joining Facebook or Twitter, or what the attraction is, this is certainly worth reading.

Rethinking Narcissism also has all the hallmarks of a well-written, well-researched nonfiction book. It has an index, references for the factual information provided and even a small section listing further resources for any who might want these. Finally, if you happen to be from Ottawa, Canada, Dr. Malkin references the work of well-known Ottawa psychologist, Dr. Sue Johnson. This is worth the investment of time to learn a bit more about “narcissism”, and, as a special bonus, you get to see one of my favourite New Yorker cartoons.

(Note: I read the 2015 Hardcover edition published by Harper Collins, which I borrowed from the Ottawa Public Library.)


Book Review: Stir

Stir: My Broken Brain and The Meals That Brought Me Home is a cross between a memoir and a cookbook. The theme, however, is not one that many can relate to, although the book will help the reader understand what it’s like to live recovering from a brain injury. At age 28, Jessica Fechtor was on a treadmill when an aneurysm in her brain burst. This is her account of how her favourite recipes helped her to recover.

As a physician, I was particularly struck by Ms. Fechtor’s accounts of her encounters with the health care system. These were certainly a stark reminder that, even in the United States, care is not always what it could be. Consider this description of an occupational therapy assessment:

‘ “How did you bathe before you got sick?” The healthy, unterrified version of myself would have realized that all of this “before you got sick” business was just standard language. The therapist had probably been taught to ask the same things in exactly the same way of each of her patients, many of whom – unlike me – had limited mobility before whatever had landed them in the hospital, orhad suffered debilitating physical or cognitive deficits. But hadn’t she read my file? And if she had, and she still thought these questions applied, was I worse off than I knew? Panic crept along the back of my neck.

‘ “I got into the shower. I washed my hair.” My throat was so tight that it hurt to talk. Why was I speaking in the past tense?

‘ “Can you show me how?” she asked. I lifted both my hands and wiggled my fingers around. She scribbled another something down. Silent tears had begun to squeeze out from the corners of my eyes. I wiped at them with the back of my hand.’ (Page 143)

As well as this interaction, the account of a hospitalization when Ms. Fechtor develops a fever after surgery would leave anyone with concerns about health care. In other words, this is not a book for the fainthearted. Having said this, the book also describes how the health care system comes back after a worrisome encounter and goes on to deliver topnotch care. It is this kind of honesty that characterizes the best memoirs.

Leaving the health memoir to consider the recipes, their integration into the text is extremely powerful. As one reads why certain recipes are chosen, the reader realizes in no uncertain terms that food facilitates health and healing. Ms. Fechtor traces the origins of some recipes to her childhood, others to her travels, but all of the recipes are linked to her own life. It is because of this connection that the food becomes an elixir for her.

Think about this for a moment. Think of the foods that you want when you’re not well. Food, preparing food, sharing a meal are linked to healing and comfort in all cultures. Fechtor’s memoir reminds us of this, and tells us in particular how the recipes she cooked, and that others cooked for her, helped her to recover. Food is not just about nourishing the body; it is about nourishing the spirit and this nourishment is linked inextricably to recovery.

An example to illustrate this idea could be chicken soup. Many people have a chicken soup recipe in their family that is felt to be almost a magic remedy. This book does have a recipe for chicken soup – and its history in Ms. Fechtor’s family. She also provides the secret to producing a clear broth, but I’ll let you discover that for yourself. If you’d like to get a feeling for Ms. Fechtor’s writing, you can find it on her blog. You can also find some of the recipes there. Why not find one and think about the food you like when you’re not feeling well? I made the pumpkin bread.

(Note: I read the first hardcover edition of the book published in 2015 by Penguin.)


Book Review: A Memoir About MS

How would you cope if you or a loved one were suddenly struck with a condition that would affect the rest of your life? That would probably not get better and that would likely get worse? That is what happened to Richard Cohen at the age of 25 when he learned that he had Multiple Sclerosis. His memoir Blindsided: Lifting a Life Above Illness, A Reluctant Memoir tells us how he lived with this progressive disease for 30 years of his life. The span of his life that it covers is one of the ways in which this book is remarkable. You will really learn what it is like to live with Multiple Sclerosis.

Another important aspect of his account is that Cohen is not always “good” at dealing with his condition and the title of the book tells us how he felt when he learned about his condition. He also situates the reader into the paradigm of a privileged man of his generation:

“The trouble with men is that we cannot forget that once we were boys. And boys see their lives   as cinemas until we are forced to grow up, to walk away from the theatres in our heads and go home to reality.” (pp. 30-31)

As Cohen discusses the period in which he first accepted his illness, what he stated crystallized for me what a patient’s role is in the treatment of their illness:

“Attitude is not to be easily dismissed as a source of power and influence governing the course of a disease.” (p.141)

This one sentence says a great deal about what a patient must strive for when they learn they have a chronic illness. That attitude is likely best fostered by empowerment – hence the success of Cognitive Therapy models in treating mental illnesses. This statement also supports the view that education, support for patients and families and other resources likely also help patients develop the best attitude to treatment.

Cohen’s profession was also a hindrance to his treatment. The chapters that describe his life as a journalist, specifically a television news producer in the 70’s and 80’s reveal the true biases of that world at that time. Also, journalism certainly did not help Cohen develop the attitude that he came to realize was necessary for him to have to best manage his illness in the context of a very full life. Cohen lied to remain at work and to advance. In fact, he was advised to do so by the few friends who knew he has MS:

“So much of what I had learned about journalism had to do with basic honesty and full disclosure. Yet there I was, about to perform a dishonest act to inaugurate my relationship with an institution built around honesty.” (pp. 63-64)

We follow Cohen through the life stages of moving into a committed relationship, having children, moving out of Manhattan – all in the context of ever worsening Multiple Sclerosis. In case you’re thinking, “Well, now it gets boring,” Cohen’s life takes another twist when he learns he has cancer. In final chapters, Cohen considers how his children and his wife have managed his worsening and developing illnesses. His account of these life struggles is nuanced for the reader by the fact that Cohen and his wife, Meredith Vieira, are giants in the United States world of journalism and so much of their coping is ultimately in the public domain. Cohen emphasizes that it is only after many years that he finally realizes that resilience is fostered by an active role in his own treatment:

“The moment was sobering. A new era had to begin. Coping evolves. It was time to take charge and stop making a monkey of myself. There is work to be done. Trying to sneak away from the truth worked for a long time but now seemed foolish. Adulthood must be learned anew from time to time.” (p.233)

(The page numbers are taken from the Harper Collins first edition of this book, published in 2004, New York.)cropped-cropped-photo-3.jpg

A book that rethinks cancer

Book: Malignant Metaphor: Confronting Cancer Myths by Alanna Mitchell (Toronto: ECW Press, 2015)

Cancer is one of the mythological illnesses and in this spare, riveting book Alanna Mitchell confronts the myths that surround cancer diagnosis, treatment and living with cancer as few writers have done. To do this she uses the premise provided by Susan Sontag in Illness as Metaphor (New York: Farrar, Strauss and Giroux, 1978.) Sontag’s premise is that we build mythologies around illnesses we don’t understand. Cancer is one of these illnesses.

This book is personal. Mitchell follows her brother-in-law’s and her daughter’s journeys with cancer. With dignity and an open mind, she examines the fictions that persist around the diagnosis of cancer and, in particular, that nagging view that, if you have cancer, then you’ve done something wrong. Most poignant was Mitchell’s account of her daughter’s brush with cancer and the myths she immediately encountered:

“Above all, I felt guilt. That it ought to have been me…That I ought to have been able to forestall this somehow…I replayed every second of her childhood that I could remember, wondering what I had done to fail her in this way.” (p. 155)

What is most important about Mitchell’s book is that the science is so thoroughly explored. She does a very credible job of examining what science exists around the homeopathic and naturopathic treatments of cancer. However, she also examines the most prevalent metaphor that health care systems and providers use in relation to treatments: the metaphor in which treatment is likened to conflict or a war. We have all heard those metaphors, even use them – fight cancer, combat heart disease, an arsenal of treatments.

How does the war metaphor benefit the treatment of cancer? Does it give us the energy to cope with the rounds of investigations, treatments, hospitalizations? Perhaps it does. What this metaphor does not do, however, is help us to understand the randomness of cancer in many cases. Cancer sometimes strikes out of the blue. We all know people who have no family history of cancer, who live healthy lives, eat organic food, exercise, and still get cancer. Do you notice how we seek reasons for these anomalies? Do you see how strongly we believe the myth that science will find all the answers – even when we know there are questions we haven’t even considered?

For the question Does science have the answers? Mitchell makes this point:

“The point is that if you think you can pinpoint the cause, then you can fool yourself into thinking that you can avert the cause. It’s deeply egotistical. It’s life played as a grand insurance policy. Our myth-making around cancer stems from the same impulse. Because we don’t know exactly why most of it happens, we weave a makeshift wisdom around it, a false prophet, which seeps into the common story and feeds our hunger to understand why. The guilt is a byproduct, a way to assign blame and seek absolution. It’s a lesser evil than the forces of randomness. And it gives us the illusion of control.” (p.163)

Mitchell posits that other metaphors might serve us better in our quest to understand our lives in the context of cancer. To me, this may be where other knowledge: literature, philosophy, faith may serve us better in managing disease. We speak of “random acts of kindness” but aspects of all illnesses are random, too.

Think about how so many good events in our lives are seen as serendipitous: falling in love, meeting a best friend, finding the “perfect house”. We don’t seem to agonize over why these things happened. We have a view that the best things are often random. Why can the worst things never be random?

In medicine, our excessive reliance on science (e.g. double blind trials, evidence-based practice) blinds us to the realities that we might confront illness more effectively if we remembered that the root of science is not just science. As Mitchell states: “…dream, experiment, fail and then dream again.” (p. 184)

Trying to understand cancer, or any illness, scientifically fails to help most of us live well with illness. The only thing certain about our lives is death. As the illnesses that will kill us develop, we need metaphors that feed our souls as well as sustain our physical comfort. Death is not our fault.

“Balance” or Bias: My Favourite Vaccine Book

The book The Panic Virus by Seth Mnookin inspired my blogging project for the summer, which was vaccines. The author explores why the myth that vaccines cause developmental disorders persists despite extensive research that demonstrates just the opposite.

Mnookin follows the course of a theory by a now discredited British gastroenterologist, Andrew Wakefield, that the measles-mumps-rubella vaccine causes autism. How Wakefield’s theory found fertile ground in the minds of parents struggling with an autistic child and with their search for answers is well-developed in the book and exposes two problematic aspects of science and science reporting.

In reviewing the meeting of a group of 51 specialists who had reviewed HMO patient records via the Vaccine Safety Datalink at the request of the Centers for Disease Control, Mnookin considered both how science works and the importance of accurate scientific reporting.

Mnookin reminds us that the central distinction between science and ideology is through the theory of “falsifiability”. This theory asserts that, in order for a subject to be a legitimate topic for scientific study, it must have a single, corresponding null hypothesis that can be disproven. This is fundamental to the scientific process in that, since it would be impossible to prove a negative, the closes one can come to proof for any theory is through a thorough effort to prove the null hypothesis.

There is a complexity in the null hypothesis that means that scientific reporters have to understand science sufficiently to be able to communicate this. Also the “debate” on vaccine safety has suffered by the journalist’s ethic to provide “balanced” reporting. This has meant, in some circumstances that the “balance” has been a false. To illustrate this, Mnookin cites a study from Cardiff University in Wales. Towards a Better Map: Science, the Public and the Media by Ian Hargreaves, Justin Lewis and Tammy Spears: This study examined how the media affects the public’s understanding of science, using studies on a link between MMR vaccine and autism. The study found that 70% of media stories related to MMR vaccine mentioned a link with autism in contrast to 11% that reported on the vaccine’s safety record. “Balance” for the overwhelming safety record of the vaccine was provided by the “junk scientists” whose research was poor, if not unethical. The result of this “balanced” reporting was that most people began to believe that the MMR vaccine, and vaccines in general, were not safe.

Mnookin outlines some of the tragedies caused when the safety of vaccines is questioned and the public health benefit they provide is disregarded:

  • In 2009, six unvaccinated children in Pennsylvania were infected with Hib, a disease previously eliminated in the United States. Two of these children died.
  • In October 2010, the California Department of Public Health reported 5500 cases of whooping cough. This was the highest number of cases in California since the pertussis vaccine had been introduced in the 1950’s.

Physicians, as well as the public, are now aware of more and more outbreaks of diseases across North America that are known to be prevented by vaccines. Mnookin accounts for this by the platform journalists have provided to “junk science” in the name of “balance”. He also noted that several states have introduced laws mandating education on “both sides” of previously proven scientific tenets, e.g. evolution or global warming or vaccine safety. This is not education and it’s not “balance” either.

Why does the “balance” of journalism trump the truth? I would say because tragic stories sensationally told sell the news. Mnookin tells the story of how the use of vaccines as an important public health measure have been undermined by the media. His book gave me the tools to further advocate for vaccine use and I recommend to anyone for whom vaccine safety is at all in question.