Psychological Research 
___ 
By Malou Albertsen 

 
 
 
Introduction  
These articles are either relevant to the upcoming topics in the AQA Psychology A-level course 
or general topics that interest me within the boundaries of psychology. While searching on the 
internet, I was recommended the website ​www.psychologytoday.com​ which has a vast selection 
of articles, blogs and advice. Throughout the summer holiday, i collected these articles directly 
from the site and into this research document. 
 
 
 

 
  

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Mental Illness and Welfare 

Schizophrenia Doesn’t Exist!? 
Joe Pierre M.D. 
A month prior to Joe Pierre M.D.’s article being released, another article written by a 
psychiatrist at Maastricht University (Netherlands), Dr. Jim van Os appeared in a popular 
science press with the headline, “‘Schizophrenia’ does not exist, argues expert.” Although not 
widely published it was named by various online commenters as proof that “there’s no such 
thing as schizophrenia” and therefore by association “there’s no such thing as mental illness.” 
However, before these dramatic conclusions are drawn, it is advisable to look further into the 
meaning of Dr. van Os statement, that schizophrenia doesn’t exist, but also that it does. 
Firstly, Dr van Os is a respected psychiatric researcher and expert on psychosis, his work 
focuses on the presence of psychotic experiences, including voice-hearing or delusional 
thinking of those not undergoing psychiatric treatment or diagnosed with a mental illness. 
Therefore his research has contributed greatly to the notion that psychosis exists on a 
spectrum, distributed ​along a continuum of severity, impairment, clinical concern, and need for intervention. 
Consequently, when Dr. van Os writes that “’schizophrenia’ does not exist,” taking care to place quotation marks 
around “schizophrenia,” what he’s mainly saying is that the term “schizophrenia” doesn’t represent a single disease 
entity and should therefore be replaced with “something like ‘psychosis spectrum syndrome.’” 
In fact, that’s neither a radical nor a novel proposition. The psychiatrist who originally coined the term 
“schizophrenia”, Eugen Bleuler, said the very same thing more than a century ago. Bleuler, a dedicated clinician, 
spent countless hours with his patients and in recognition of the diversity of their experiences, proposed that 
schizophrenia wasn’t a single disease, but a “whole group” of schizophrenias. His classic text on the subject was even 
titled,​ ​Dementia Praecox or The Group of Schizophrenias​. This heterogeneity has been built into the criteria for 
schizophrenia outlined in the ​Diagnostic and Statistical Manual of Mental Disorders (DSM-5)​, which based on the need 
for only a few psychotic symptoms for diagnosis, allows that two individuals with schizophrenia could look very 
different. 
But saying that “schizophrenia” represents a variety of distinct disorders with different causes doesn’t mean that it 
doesn’t exist at all. To understand why, let’s break down what we mean when we talk about a “psychosis (or any 
other disease) spectrum.” First, let’s consider a more familiar example of a spectrum from science, the visible light 
spectrum. Electromagnetic radiation exists on a continuum that varies in frequency and wavelength, with the visible 
light spectrum representing radiation whose wavelengths comprise a more narrow range of roughly 400-700 
nanometers. The different wavelengths within this range are perceived by the human eye and​ brain​ as different 
colors like red, orange, yellow, green, blue, and indigo. Likewise, individual colors themselves – like green, can be 
characterized as dark green, light green, or blue/green (turquoise). 
By way of analogy, we can then think of electromagnetic radiation as the continuum of mental​ health​ and mental 
illness, the visible light spectrum as psychosis, and the color green as schizophrenia. So, when psychiatrists talk 
about a “spectrum of psychosis,” we mean that psychosis is a kind of identifiable brain experience that can span a 
continuum of quantifiable severity, ranging from the distressing and functionally impairing symptoms of a mental 
disorder to the unusual but potentially normal experiences of people without mental illness. When we talk about a 
disorder like schizophrenia, we’re talking about a recognizable form of psychosis that, like the color green, exists 
within the psychosis continuum and can itself span a continuum of severity. To say that schizophrenia isn’t any one 
  

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thing or that its definitional boundaries are fuzzy doesn’t mean that it doesn’t exist, anymore than we could credibly 
claim that “green” doesn’t exist. The same could be said of “planets,” “cars,” or “pain.” 
This is a subject I’ve addressed in my own academic work: 
“Although it is practical and perhaps reassuring to think of mental disorders as discrete entities or “natural kinds,” 
existing evidence supports a continuum between mental illness and mental health with indistinct borders. Even the DSM-IV 
concedes that ‘there is no assumption that each category of mental disorder is a completely discrete entity with absolute 
boundaries dividing it from other mental disorders or from no mental disorder.’ However, this lack of discrete boundaries 
does not mean that there is no such thing as mental illness ​[or schizophrenia]​, or that the boundaries are completely 
arbitrary.” 
I’ve likewise written about the apparent conflict between categorical approaches to psychiatric diagnosis (the idea 
that psychiatric disorders are discrete entities) and the kind of “spectral” or “dimensional” approach for which Dr. 
van Os advocates, arguing that the two need not be mutually exclusive: 
“While seemingly contradictory, [the] duality between category and continuum is present throughout medicine, whether in 
hypertension (where there is now “prehypertension”), cancer (where there is carcinoma in situ), and even debates about 
what constitutes life and death. In fact, while human perception is particularly adept at contriving patterns and boundaries 
in “things,” the reality is that most “things” can be conceptualized along both categorical and dimensional terms, as with 
the “particle” and “wave” duality of light.” 
"Incorporation of a dimensional model, “based on quantification of attributes rather than the assignment to categories” 
was considered for DSM-IV, but the idea was eventually abandoned due to “serious limitations,” including the belief that 
categorical boundaries are vital to clinical​ decision-making.​ ” 
In other words, there are relative advantages and disadvantages to thinking of psychiatric disorders as either 
categories or continua. Categorical classification systems or “nosologies” are often favored for ease of 
communication and to guide decisions that require threshold definitions (e.g. when to treat or not treat a disorder), 
while continuous approaches better account for diversity and variation within a given category. The utility of one 
approach doesn’t invalidate the other. 
Beyond the idea that schizophrenia probably represents one word but many disorders, Dr. van Os also argues that the 
term “schizophrenia” should be dropped because the term is equated with a “devastating” and “hopeless chronic 
brain disease” with a much poorer prognosis than the more subtler or milder forms of psychosis detected in his own 
research.1 Here again, the assertion that the natural course of schizophrenia is variable would be best credited to 
Bleuler a hundred years ago. In coining the term “schizophrenia” (loosely translated as “split mind/soul/spirit”), he 
intended to move beyond the previously-used term “​dementia​ praecox” (literally, “precocious dementia”) that 
emphasized a more deteriorative course of illness in favor of a “less static and stigmatizing” term that highlighted 
the fractioning of different psychological functions and aspects of​ personality​. 
That’s not to say that the term “schizophrenia” isn’t stigmatizing. It is. But inventing a new name for something 
that’s stigmatized runs the risk of turning into what psychologist Stephen Pinker calls a “euphemism treadmill.” As I 
wrote in a previous blogpost called “Rebranding Psychiatry: Euphemisms, Stigma, and Progress:” 
“…changing the name for schizophrenia would probably not fix its association with stigma because “the stigma associated 
with schizophrenia arises mainly because of our inability to treat it effectively” rather than because of the name itself. In 
other words, the best remedy to erase stigma associated with a mental illness is to improve its treatment and in doing so 
remove associations with poor functioning and low prospects of recovery. Inasmuch as that is possible, it would go a much 
longer way towards combating stigma than changing names ever could. 
Nonetheless, some countries have forged ahead in abandoning the term “schizophrenia” in an attempt to combat stigma. 
For example, in Japan, after much debate, the Japanese Society of Psychiatry and Neurology replaced the old term for 
schizophrenia, “​ seishin-buretsu-byo”​ (“mind-split-disease”) with a new term ​“togo-shitcho-sho”​ (“integration 
disorder”). While preliminary surveys suggested that name changes like this can indeed reduce stigma, it may be that any 
such benefits reflect only temporary ignorance about a new term, with old stigma becoming associated with the new name 
  

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in time. Simply finding a new name for the same thing may have limited utility in changing people’s negative attitudes, with 
new euphemisms inevitably becoming dysphemisms in an endless cycle.” 
Stigma aside, Dr. van Os also argues that we should also abandon the term “schizophrenia” because it detracts from 
attention to other psychotic disorders that represent “70% of psychosis morbidity,” yet are less well-recognized “as if 
they don’t exist.”1 But this is a puzzling argument. While he suggests that “only 30% of people with psychotic 
disorder have symptoms that meet the criteria for schizophrenia,” his claim that other psychotic disorders including 
delusional disorder​,​ schizophreniform​ disorder, and brief psychotic disorder “constitute 70% of psychotic illness 
morbidity” misses the mark. Schizophrenia,​ lying​ at the more severe end of the psychosis spectrum, warrants the 
attention it receives because it’s responsible for a disproportionate amount of morbidity in the form of functional 
impairment and need for care. As the most easily recognizable and debilitating form of psychosis, schizophrenia 
deserves its own name. In contrast, some of the other disorders that Dr. van Os thinks deserve more attention are 
self-limited (e.g. schizophreniform disorder and brief psychotic disorder), while the kind of psychotic symptoms that 
his research has detected “in the community” often don’t represent mental disorder at all. 
One of the disadvantages of conceptualizing psychosis as a spectrum is that it can encourage the very thing that Dr. 
van Os seems to want to avoid – lumping psychosis together with a kind of “one size fits all” mentality. This has the 
potential to go awry in different directions, by inappropriately conflating severe disorders with those that are more 
mild and mild disorders with those that are severe. Dr. van Os wants to get rid of “schizophrenia” because he doesn’t 
want to see the term inappropriately applied those with milder forms of psychosis. I couldn’t agree more and have 
said so – properly used, schizophrenia shouldn’t be applied as lazy and loose label for all forms of psychosis, just as 
treatments like anti-psychotic medications that are effective for schizophrenia shouldn’t be assumed to be the best 
intervention for other psychotic conditions for which they haven’t been well-studied. 
But keeping schizophrenia as a categorical diagnosis could help to preserve milder disorders as distinct in real and 
meaningful ways. When DSM-5 eliminated the term “​Asperger​’s Disorder” in favor of “Autistic Spectrum Disorder,” 
advocacy groups were up in arms because “Aspies” had suddenly lost their special status as an example of 
“neurodiversity” as opposed to merely part of a large spectrum of more clearly pathological autism. Adopting a 
“psychosis spectrum syndrome” could do the same to those with milder forms of psychosis. 
In practice, a spectral view of psychosis could end up being far more likely to pathologize than to destigmatize, with 
a greater potential for inappropriate diagnosis and treatment. It has been argued for example that this is exactly 
what has happened with bipolar spectrum disorders,7 where wanton antipsychotic treatment of irritable depressions 
has now become the rule. If you’re the kind of person that wants to argue that mental illness doesn’t exist and that 
psychiatrists are guilty of overdiagnosis and overtreatment, citing Dr. van Os’ headline that “’schizophrenia’ does 
not exist” is therefore precisely the wrong way to go about doing it. 
At the same time, adopting a spectrum view of psychosis just as easily risks inappropriately applying assumptions 
about mild psychotic symptoms – like that treatment isn’t needed or that it might just go away – to severe 
conditions like schizophrenia. This is a serious concern that has recently arisen in response to efforts to "romanticize 
psychosis" that I addressed in a previous blogpost called “Psychosis Sucks!” 
Finally, let’s take a quick, parting look at Dr. van Os’ complaint that schizophrenia is described by the American 
Psychiatric Association as a “chronic brain disorder” that is “highly heritable” with “predominantly genetic risk 
factors.” He doesn’t quite go so far as to say that this is wrong, though certainly other naysayers have done so, 
pointing a finger at the outdated fiction of a “chemical imbalance” being the cause of schizophrenia. Still, despite the 
idea of schizophrenia as a group of different disorders, it does appear to be highly heritable, with the greatest 
predictor of schizophrenia having an identical twin or a 1st-degree relative with the disorder (50% and 10% risk 
respectively). In 2015, a research group re-examined genetic data from existing genome-wide association studies, 
operating on the assumption that if schizophrenia is indeed a group of disorders, then clusters of small genetic 
differences called single-nucleotide polymorphisms (SNPs) might be associated with different subsets of psychotic 
symptoms that themselves cluster in certain people with schizophrenia.8 The authors reported that 42 different sets 
  

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of SNPs sets accounted for 70% or more of the risk of schizophrenia, with certain genetic variations conferring as 
much as a 100% risk of schizophrenia among those with specific types of psychotic symptoms. 
In a similar vein, another paper published earlier this year that was carried widely in the popular press revealed how 
there could be many possible genetic pathways culminating in a common biological mechanism for schizophrenia 
called excessive synaptic pruning in which too many connections between brain cells are pruned away during 
adolescence​.9Although the synaptic pruning hypothesis isn’t new, the study revealed how multiple SNPs that are 
associated with schizophrenia can affect the structure of​ genes​ in mice encoding a protein called complement 
component 4 that activates pruning in mice. This offers an attractive model for how multiple genetic abnormalities 
might converge on a common explanation for schizophrenia. Taken together, these two studies suggest that for all 
the shortcomings of modeling schizophrenia as a single disease entity, psychiatric research may indeed be hot on the 
trail of biological explanations that can account for both the heterogeneity of the “group of schizophrenias” as well 
as unifying symptoms and causal explanations. 
In the end then, the argument that “schizophrenia” doesn’t exist is far from compelling. Schizophrenia is a word we 
use in medicine to describe a familiar set of co-occurring psychotic symptoms, with potentially different causes, just 
like “anemia,” or “hypertension,” or “headache.” In some cases, it can be useful to think of it as a categorical 
disorder, distinct from other forms of psychosis. In others, it can be best thought of as a spectrum condition, lumping 
it together with other psychotic disorders. A more enlightened view of schizophrenia acknowledges that both can be 
true. 

Developmental Psychology 
The Trouble with Daycare 
Heidi Lang 
It could be the greatest social experiment of our time, in which millions of​ parents​ are unwitting participants. 
So says Stanley Greenspan, George Washington University child psychiatrist, about the current state of day care. In 
just 25 years, American families have been radically restructured as the number of women in the workforce has 
nearly doubled. Instead of parents providing early child care, it is outsourced to virtual strangers. An estimated 12 
million American infants, toddlers and preschoolers—more than half of children in this age group—attend day care. 
The majority of these kids spend close to 40 hours per week in day care; many start when they are only weeks old. 
The raging debates around maternal guilt, work/family balance, money and childrearing often drown out scientific 
insights into the developmental impact of day care. But the latest findings, from a huge, long-term​ government 
study, are worrisome. They show that kids who spend long hours in day care have behavior problems that persist well 
into elementary school. About 26 percent of children who spend more than 45 hours per week in day care go on to 
have serious behavior problems at kindergarten age. In contrast, only 10 percent of kids who spend less than 10 
hours per week have equivalent problems. 
Developmental psychologists are sweeping this information under the rug, hoping studies will churn out better data 
soon, argues Jay Belsky, a​ child development​ researcher at London's Birbeck College and a longtime critic of his 
fellow scientists. He contends that the field of developmental psychology is monopolized by women with a "liberal 
progressive feminist"​ bias​. "Their concern is to not make mothers feel bad," he says. 
Belsky's fellow researchers—many of them women—take a different view. They emphasize that research findings 
about day care's effects are a complicated mixture of good and bad news, and that it's too early to judge whether too 
many hours in child care is inherently dangerous. 
Few parents have heard about the National Institute of Child​ Health​ and Human Development (NICHD) Study of 
Early Child Care, an ongoing $100 million survey of 1,100 children. It's the largest and most rigorous examination of 
day care in history, taking into account family income and the quality of day care. Evidence from the study shows 
that the total number of hours a child is without a parent, from birth through preschool, matters. The more time in 
  

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child care of any kind or quality, the more aggressive the child, according to results published in ​Child Development​. 
Children in full-time day care were close to three times more likely to show behavior problems than those cared for 
by their mothers at home. 
Belsky contends that the current results clearly show children benefit from fewer hours in child care, especially at a 
very young age, and parents should be advised to limit the hours their young children spend there. NICHD researcher 
Sarah Friedman—who, along with Belsky and many other scientists, works on the NICHD study—emphasizes that 83 
percent of children who spend 10 to 30 hours in day care did not show higher levels of aggression. Friedman says the 
study results so far don't tell her anything. 
"It's so obvious that this is the worst of politically correct rhetoric," counters Belsky, adding that if researchers were 
studying the amount of time spent in poverty and they got the same results, no one would dare put a neutral spin on 
the data. 
Belsky has been outspoken on the issue for decades. In the 1980s, his studies showed that children spending long 
hours in day care had higher levels of aggression than those raised by their mothers. Detractors excoriated him then 
for using bad science to criticize working women. 
Belsky argues that other NICHD scientists gloss over the finding that the aggressive children in the study were more 
than just a little defiant. They were in the "at risk" range, meaning their behavior was close to the threshold requiring 
therapy​. The children with problematic behavior were regularly observed being disobedient. Parents and caregivers 
noted frequent hitting of other children and caregivers, arguing, cheating, destruction of objects and demands for 
excessive attention. 
Although Belsky's harsh words haven't won him many friends, some researchers think he has a point. Kathy 
McCartney, an​ education​ professor at Harvard and another NICHD day care researcher, concedes the aggression 
results are significant, but won't offer cautionary advice without more research. "So far it is looking like he's right," 
says McCartney, who criticized Belsky's claims in the past. "Long hours in child care are associated with behavior 
problems." 
Still, McCartney questions what parents and policy makers should do with the information since solutions aren't 
obvious. "I don't think there is a simple answer to the question 'Does child care pose a risk?' because it clearly does 
for some children, but not all children," she says. 
The real question is whether parents can afford to wait years for more answers. What if, Belsky asks, "kids 
experiencing long hours in day care are more likely to use​ drugs​, are less ambitious and have trouble with 
relationships? Parents will say, 'How come no one warned me?' It is our scientific responsibility to tell people what 
they may not want to know." 
Bad Behavior 
Data from a government study show a strong link between the total hours per week a child spends in day care and 
behavior problems at age 5. The 113 behaviors surveyed include frequent arguing, temper tantrums,​ lying​, hitting 
and unpredictable conduct. 
Number of hours in day care equals a percentage of bad behavior* 
Less than 10: 10 percent. 
10 to 30: 17 percent. 
More than 45: then 26 percent. 
*As reported by mothers. Source: NICHD. 

Gender 
Testosterone v. Oxytocin : Bridging the Gene-Behaviour Gap 
One problem with theories which start with​ genes​ and then go on to try to explain complex mental outcomes such as 
psychosis or​ autism​ in the way in which the imprinted​ brain​ theory does is that they leave you asking what, if 
anything, fills the explanatory gap between the two?   
  

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The answer, of course, is the​ ​epigenesis​ of the central nervous system, which builds brains according to instructions 
written in DNA. One major way in which DNA does this is to code for neuro-transmitters, growth factors, and other 
agents that control and regulate the expression of genes in the development of the brain. A striking example of the 
latter is the subject of​ ​a recent paper​ by my colleague, Bernard Crespi. Writing with Peter Hurd, he shows that ​GTF2I,​  
a gene which codes for General Transcription Factor IIi, is strongly expressed in the brain and that variations in its 
expression provide a neurogenetic basis for social communication and​ social anxiety​, both among individuals in 
healthy populations and in Williams syndrome (where you find a striking lack of fear of strangers, coupled with 
indiscriminate friendliness and extreme volubility). 
Hormones are another example of biological factors which bridge the DNA-to-behaviour gap, but are widely 
misunderstood. People think of them as magic potions, with intrinsic power to masculinize, for example, in the case 
of androgens such as​ testosterone​, which has far-reaching effects on the body, brain, and behaviour. But testosterone 
is a very simple molecule that differs from its feminizing alternative, oestrogen, by only one atom. Could a single 
atom change the magic potion that much? 
The truth is that hormones are chemical messages, which, like any message, need to be received to have any effect. 
The classic example of this is androgen insensitivity syndrome, which results in a person seeming to be female, but 
in fact being chromosomally male and having male levels of testosterone way above anything found in females, and 
all thanks to a complete lack of testosterone receptors. Such receptors, like the hormones to which they respond, are 
coded in DNA, and their number and characteristics are crucial to the way in which hormonal messages are received 
and interpreted. For example, variations in ​V1aR,​ a gene for a vasopressin hormone receptor, explain why prairie 
voles are life-long monogamists but meadow voles are promiscuous. 
This means that natural selection gets two bites at the cherry, so to speak, where hormones are concerned. Selection 
can​ act​ on the genes involved in forming the hormone (several in the case of testosterone, for which there is no 
single gene as such but rather a number of enzymes that synthesize it from cholesterol). But selection can also act on 
the genes that code for receptors (in the case of the androgen receptor, the number of glutamine units specified 
inversely determines sensitivity to testosterone: rodents have 1, gorillas 6-17, chimps 8-14, humans are most 
insensitive with 11-31, averaging 21). 
Another important consideration that people overlook—especially where​ sex​hormones such as testosterone are 
concerned—is that chemical messages, just like any other kind of message, can be mixed, or even conflicting. As 
Bernard Crespi points out in a paper soon to appear in ​Biological Reviews​,* in humans,​ oxytocin​—a hormone similar 
to vasopressin—“motivates, mediates and rewards the cognitive and behavioural processes that underlie the 
formation and dynamics of a more or less stable social group, and promotes a relationship between two or more 
individuals.” 
Indeed, he notes that “oxytocin is also apparently represented culturally by specific words (e.g. ‘hygge’ in Danish and 
‘gemütlichkeit’ in German) whose meanings correspond closely to its documented​ endocrine​ effects” 
(coziness/friendliness, according to Google Translate). Enhanced monitoring of gaze and increased​ empathy​ have 
been reported after oxytocin administration, and along with intensification of existing pro-social tendencies, 
oxytocin facilitates​ memory​ of faces. Variations in the oxytocin receptor gene, OXTR, are associated with measures 
of social recognition, co-operation and empathy. 
Where brain development is concerned, three recent studies have demonstrated strong oxytocin-induced increases 
in activation of specific cortical brain areas, especially in regions of the medial prefrontal cortex that regulate 
processes related to​ ​mentalism​ (or theory of mind). Oxytocin administration also leads to increased functional 
connectivity between the amygdalas (key parts of the emotional or limbic brain) and the orbitofrontal cortex which, 
as Crespi puts it, “may serve to foster the controlled mentalization that leads to enhanced, more-deliberative social 
decision-making​.” 
Testosterone, on the other hand, “exhibits opposite effects from oxytocin on diverse aspects of​ cognition​ and 
behaviour, most generally by favouring self-oriented, asocial and antisocial behaviours.” By direct contrast to 
  

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oxytocin, testosterone reduces connectivity between regions involved in mentalism “and is thereby expected to 
reduce controlled mentalization, in contexts where aggressive behaviour is favoured over affiliation or​ cooperation​.” 
As far as mental illness is concerned, 
Reduced oxytocin and higher testosterone levels have been associated with under-developed social cognition, 
especially in autism. By contrast, some combination of oxytocin increased above normal levels, and lower 
testosterone, has been reported in a notable number of studies of​ schizophrenia​,​ bipolar disorder​ and​ depression​, 
and, in some cases, higher oxytocin involves 
maladaptively ‘hyper-developed’ social cognition in 
these conditions. This pattern of findings suggests 
that human social cognition and behaviour are 
structured, in part, by joint and opposing effects of 
oxytocin and testosterone, and that extremes of such 
joint effects partially mediate risks and phenotypes of 
autism and​ psychotic​-affective conditions. 
 
Crespi goes on to argue that the model illustrated in 
his diagrams (above and below) suggests in 
particular that higher oxytocin, and lower 
testosterone, should be associated with 
increased levels of hyper-developed, 
dysregulated, or affectively​ biased 
mentalistic cognition in schizophrenia and 
depression, as well as other 
psychotic-affective conditions. For example, 
a paradigmatic hyper-mentalistic symptom 
of schizophrenia,​ paranoia​, explicitly 
involves an exaggerated ‘me and them’ social 
relationship, and so might be expected to 
involve unresolved, oxytocin-associated 
stress​ and anxiety given the central role of 
this hormone in mediating both positive, and 
negative, social connections, and its apparent 
role in shifting cognition from self to other 
orientation (…). 
Finally, writing with Mikael Mokkonen in ​Evolutionary Applications,​ Crespi reviews the genetic and evolutionary basis 
of the testosterone v oxytocin model, specifically “two major forms of genomic conflicts, genomic imprinting, and 
sexual antagonism, with regard to their impacts on hormonally mediated,​ health​-related human phenotypes.”** 
Clearly, where the imprinted brain theory is concerned, the gene-behaviour gap is beginning to be bridged! 

Eating Behaviour 
Eating Disorders 
1. What Are Eating Disorders? 
Eating disorders​ are psychological conditions with both emotional and physical symptoms. The disorders include 
anorexia nervosa​ (voluntary starvation),​ bulimia nervosa​ (binge-eating followed by purging), binge-eating disorder 
(binge-eating without purging) and unspecified eating disorders (disordered eating that does not fit into another 
  

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category). Eating disorders occur frequently—but not exclusively—in affluent cultures. A disproportionate number of 
those diagnosed are young women in their teens and 20s but anyone, including young men and older adults, can 
develop an eating disorder at any age. Among the most baffling of conditions, eating disorders take on a life of their 
own so that eating, or not eating, becomes the focus of everyday existence. 
Biological factors, social pressure, and family history and dynamics are some of the factors associated with eating 
disorders. Culturally mediated body-image concerns and​ personality​ traits like​ perfectionism​ and obsessiveness also 
play a large role in eating disorders, which are often accompanied by​ depression​ and/or anxiety. 
Treatment is never simple for these conditions which, in many cases, can cause multiple medical problems and even 
be acutely life-threatening, requiring hospitalization and forced nourishment. It can take a multi-disciplinary​ team 
of of​ health​ professional, including a psychotherapist, medical doctor and a specialized dietitian or nutritionist to 
bring someone with an eating disorder to full recovery. 
2. Symptoms of Eating Disorders 
 
A disturbed relationship to food marks all​ eating disorders​, as does emotional fragility. Since eating is a normal part 
of life, these are conditions marked by extremes. All eating disorders may start out unnoticed––a person eats a little 
more or a little less food than usual. The urge to eat more or less becomes increasingly compelling until it can 
become the focus of a person's existence. 
 
In​ anorexia​, sufferers dramatically restrict what they eat and are markedly underweight. Symptoms include: 
• refusal to maintain body weight at or above a minimally normal weight for age and height 
• intense​ fear​ of gaining weight or becoming fat 
• extreme influence of body weight or shape on self-evaluation 
• infrequent or absent menstrual periods in those who have reached​ puberty 
• use of either food restriction or excessive exercising to limit body weight 
• feeling cold or lethargic, due to drop in body temperature as weight loss progresses 
• growth of hair all over the body 
• dry yellowish skin 
• brittle hair and nails 
• severe constipation. 
In bulimia, periods of food restriction are punctuated by bouts of binge-eating and some compensatory behavior, 
usually purging. As a result, sufferers may appear to be normal weight. Symptoms of​ bulimia​ include: 
• recurrent episodes of binge-eating, characterized by consuming in a short amount of time an amount of food larger 
than most people would eat 
• during those binge-eating bouts, a feeling that one cannot stop eating or control how much one eats 
• some compensatory behavior to prevent weight gain; purging is most common, but laxative use and excessive 
exercising are also widely used 
• extreme influence of body weight or shape on self-evaluation 
• chronically inflamed sore throat 
• swollen glands in the neck or jaw 
• wearing of tooth enamel and frank decay as a result of exposure to stomach acids 
• dehydration due to purging of fluids 
• kidney problems from diuretic​ abuse​. 
By contrast, binge-eating disorder is marked by recurrent episodes of extreme overeating not accompanied by 
compensatory behavior, so those with the disorder are usually overweight to obese. Symptoms include: 
• eating much more rapidly than normal 
• eating until feeling uncomfortably full 
  

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• eating large amounts of food even when not hungry 

• eating alone because of shame or​ embarrassment​ over eating behavior 
• binge-eating occurs at least two days a week for six months or more. 
3. Causes of Eating Disorders 
There is no single known cause of any​ eating disorder​, but they exist largely in affluent cultures where there is an 
abundance of food. No one knows why voluntary behaviors, such as eating smaller or larger amounts of food than 
usual, morph into an eating disorder for some people. 
Biology is a factor:​ Appetite​ control and the regulation of food intake is very complex, with many​ hormones​ in the 
brain​ and the body contributing to signals of hunger and satiety. 
Culture is thought to play a significant role, as women, especially, are pressured to fit an ideal of​ beauty​ that is 
increasingly defined by the sole criterion of body weight. Families contribute, to;​ parents​ who emphasize looks 
and/or​ dieting​ or criticize their children's bodies are more likely to raise a child who develops an eating disorder. 
Other circumstances figure in, too; the conditions can be triggered by​ stress​, social difficulty,​ loneliness​,​ depression 
and other unpleasant emotions, or dieting itself. 

Biological Rhythms and Sleep 

Biorhythms: Get in Step 
Hara Estroff Marano 
The average length of a movie is 90 minutes. And that doesn't seem to be an accident. If you ask the experts on these 
things, they'll tell you that many of the functions of your body and​ brain​ are set to operate in cycles of roughly 90 
minutes each. And going with the flow of biorhythms helps you maintain​ motivation​ and attention for whatever the 
task at hand. 
We humans, like all other animals, live in a world that is marked most basically and most invariably by cycles of day 
and night. This external fact of life has its counterpart in our bodies; somewhere in the dawn of time these 
fundamental rhythms were etched into our brains, so that we would be organized in synchrony with our 
environment​. 
How the brain does this is through an elaborate system of signals kicked off by light. Light strikes our eyes, certain 
nerve cells in our eyes detect the wavelengths of natural light, they signal the brain, and the brain sends messages to 
virtually every system of the body to rev up or ramp down. By virtue of this control center, among others, the 
performance of bodily systems is coordinated one with the other. 
Like the world around us, our biological clocks are set to tick in cycles of approximately 24 hours. We are designed to 
sleep​ and wake in cycles of roughly 24 hours, otherwise known as our basic​ circadian rhythm​. 
Study after study has shown that we function best physiologically and psychologically when our internal cycles are 
well-synchronized with those of the external world. If we mess up our sleep and wake patterns, for example, we feel 
out of sorts. Mood suffers. Alertness wanes and​ concentration​ falters.​ Memory​ gets shoddy. And performance on 
important tasks takes a dive. You don't feel coherent, may not even be able to speak coherently. 
Physical well being suffers too. The immune system is compromised, leading to higher likelihood of a cold or flu. 
Hormones​ are in disarray, stomach problems arise. These are common complaints among those doing shift work, 
experiencing jet lag and suffering​ insomnia​. 
Many of the body's major systems run on circadian rhythms. Cardiovascular activity has a circadian pattern, as does 
body temperature, metabolic functions and liver and kidney function. 
Yet, it is increasingly common for people to override basic biorhythms and ignore the biological signals for sleep. 
Stimulation is available around the clock in the form of the internet, to name just one attraction. 
  

  11 

According to Dr. Roseanne Armitage, an expert on sleep at the University of Michigan, the sleep patterns of 
Americans are getting worse, increasingly out of phase with the natural rhythm. People are staying up later than ever 
and it's happening at a progressively younger age. 
Interestingly, she points out, the less people sleep, the more they get depressed. And the worsening of sleep among 
Americans has been accompanied by real increases in the incidence of clinical​ depression​. 
In addition to the body rhythms set to the day, there are other body rhythms occurring in cycles of shorter duration, 
often multiple times during the day. These are known as ultradian rhythms. With these, too, biological and 
psychological alertness and performance are very strongly correlated to the synchronization of your actions with the 
body's natural patterns. 
Perhaps the best-known of the ultradian rhythms are the dream cycles of sleep. Researchers have long known that we 
cycle through deepening states of sleep until we fall into dream sleep, commonly known as​ REM​ sleep, for the rapid 
eye movements that occur as we dream. Within a night, we complete roughly five cycles of REM sleep. Disturbance of 
these sleep cycles interferes with mood regulation and leads to depression. 
According to Dr. Armitage, our bodies are similarly set for performance of most tasks in 90-minute cycles. Every 90 
minutes, she believes, we need to take a mental break because otherwise our concentration, memory and learning 
ability start fading. 
Staying in tune with your body's cycles puts you in line to achieve peak performance. Failure to synchronize your 
patterns of activity and stimulation with your body's natural circadian and ultradian rhythms puts a​ stress​ on the 
system. 
The most reliable way to set your body clock is to schedule exposure to natural light in the early morning. It allows 
you to fall asleep at night. The corollary is to avoid bright light at night. And avoid computer usage at night. 
Chasing Slumber 
Mark Wolverton 
It was supposed to be another routine trip for the venerable Staten Island Ferry. Instead, the afternoon crossing on 
October 15, 2003, led to one of the worst transportation disasters in New York City history. At about 3:30 p.m.,as the 
ferry Andrew J. Barberi came in for docking at the St. George terminal, it crashed into a concrete pier at full speed, 
killing 10 people and injuring 70 more. The subsequent investigation by the National Transportation Safety Board 
found that the main cause of the accident was the "unexplained incapacitation" of the assistant captain—exhausted, 
he'd passed out at the boat's controls. 
It was a tragic outcome for a common phenomenon: experiencing fatigue behind the wheel. In a recent AAA 
Foundation for Traffic Safety survey, over 40 percent of respondents reported having "fallen asleep or nodded off" 
while driving at least once; more than a quarter admitted to having driven while "so sleepy [they] had a hard time 
keeping [their] eyes open" within the past month. Studies by the Centers for Disease Control, NTSB, and other 
agencies estimate that drowsy driving may play a part in up to 6,000 fatal auto accidents annually. Those annoying 
"rumble strips" along the road's shoulder are there for good reason. 
A 2011 CDC analysis found that over 35 percent of adults routinely get less than seven hours of shuteye nightly. 
There's no magic number for the perfect amount of sleep, but research suggests that most of us require more—about 
eight hours—to perform optimally. (Still, a small percentage of people experience no adverse effects on performance 
with just five hours.) Unfortunately, societal exigencies such as overstuffed work schedules, family​ stress​, and our 
constantly pinging smart phones conspire against our getting enough sleep. 
Our need for sleep "is fairly inflexible,yet modern social and economic systems provoke it constantly," contends 
David Dinges, who heads the Sleep and Chronobiology laboratory at the University of Pennsylvania. Rest is too often 
treated as a disposable option: "It's a badge of courage to stay up all night to get the job done—we celebrate that in 
our society," says Mark R. Rosekind, who studies issues of fatigue and safety at the 
NTSB. 
  

  12 

As a result, everyday sleep deprivation causes​ cognitive​ impairments that lead to minor and major disasters in nearly 
every occupation: truckers falling asleep on highways, doctors making errors in treatment, nuclear power plant 
operators missing alarms. New research reveals that sleep loss affects the body on a systemic level as well, creating 
metabolic and immune disruptions that can cause​ obesity​, heart disease, reduced fertility—even cancer. 
Fortunately, while studies increasingly underscore the problematic​ nature​ of our national sleep debt, a new science 
of sleep suggests critical steps we can take as individuals and a society to achieve that elusive, all-important 
shut-eye. 
The Broken Cycle 
For over a decade, insufficient sleep has been well established as a​ health​-risk factor: A seminal 2002 study revealed 
a strong relationship between an individual's reported sleep and mortality. "People who slept less than seven hours a 
night—or more than nine—were at increased risk for all-cause mortality," says University of Pittsburgh psychiatrist 
Martica Hall. Other studies revealed a similar curvilinear relationship between sleep duration and conditions such as 
cardiovascular disease and obesity, although it remains relatively unclear just how disturbed sleep affects our health. 
New research suggests that the answer is connected to the functioning of our circadian clock, which evolved to follow 
the roughly 24-hour light-and-dark cycle of the Earth's daily rotation. The existence of the body's "master clock," the 
suprachiasmatic nucleus (SCN) located in the hypothalamus, has been known for decades. But only recently have 
molecular biology and​ genetics​ yielded the startling finding that "circadian regulation exists in every cell of the 
body—the liver, the kidneys, even skin fibroblasts," Dinges says. "It's coordinated and entrained internally, and then 
entrains to the outside world." 
Some researchers compare the system to an orchestra, in which the SCN is the conductor and the other body clocks 
are the players. The clocks operate all the way down to the genetic level." A decade ago scientists estimated that 
about 10 percent of genes in the body were under clock control," notes John Hogenesch of the University of 
Pennsylvania. "Now we're finding that over a third of your genome—including more than half of all drug response 
pathways—are." If these genetic clocks fall out of sync with the master clock in the SCN, vital processes can be 
affected—and one way for that to happen is the disruption of overall​ circadian rhythm​ by not getting enough sleep. 
Research from the University of Surrey published earlier this year helps explain how insufficient sleep alters gene 
expression—offering important clues to the ways in which sleep and health are linked at the molecular level. The 
study authors found that after a single week of insufficient sleep (fewer than six hours nightly) blood samples from 
participants revealed altered activity in over 700 genes—including those related to heart disease, diabetes, 
metabolism, and inflammatory, immune, and stress responses. While the activity of some genes ceased to cycle in a 
circadian pattern, other genes' activity, which doesn't typically follow a daily rhythm, began doing so. 
 
A Drowsy Mind 
Night by sleepless night, we undermine our cognitive functioning, yet the true extent of our cognitive shortcoming 
goes largely undetected—except by the scientists who study sleep loss. 
In 2003, a team including Dinges, lead by his then colleague at Penn, Hans Van Dongen, conducted a major 
experiment in which participants were divided into three separate groups: one that slept four hours a night, one for 
six hours, and a control group for eight hours. The study went on for two weeks and each day participants were 
repeatedly given a​ memory​ test and a psychomotor vigilance task, a simple computer-based assessment of 
attentiveness and response. 
 
Developed by Dinges, the PVT is simplicity itself: Subjects sit for 10 minutes in front of a screen, hitting a button 
whenever a bright spot appears; meanwhile, reaction times and other sleepiness indicators (such as droopy eyelids) 
are monitored. The test measures precisely the sort of cognitive and physiological abilities that insufficient sleep 
dulls or eliminates. A mere half-second delay in response indicates a lapse of wakefulness—or as researchers term it, 
"microsleep." 
  

  13 

 
As might be expected, eight-hour sleepers showed no impairment of functioning on the tests. But those getting less 
sleep did—and performance declined steadily over time, even though participants were getting consistent, if limited, 
sleep each night. By the study's end, even the performance of the six-hour sleepers had deteriorated as much as if 
they had been up for 24 hours straight. (A similar study at the Walter Reed Army Institute of Research found that the 
performance of seven-hour sleepers declined markedly over time as well.) 
 
Yet amazingly, steadily deteriorating alertness was barely reflected in the participants' subjective feelings of 
sleepiness." By the end of the 14 days of sleep restriction, when performance was at its worst, subjects in the [four- 
and six-hour] sleep period conditions reported feeling only slightly sleepy," the authors wrote. Dinges suggests that 
those who are chronically sleep deprived may no longer be capable of reliably appraising their own sleepiness—or 
they simply don't experience levels of sleepiness in any way commensurate with their actual deprivation. The finding 
"may explain why sleep restriction is widely practiced: People have the subjective impression they have adapted to it 
because they don't feel particularly sleepy," the study authors theorize. 
 
"People are impaired at much lower levels of sleep deprivation than they realize," the NTSB's Rosekind agrees. 
Summarizing Van Dongen's research and other related findings, he notes: "Getting two hours less sleep than you 
need is enough to impair you and get you into a car crash. You may think you're okay, but if we were to actually 
measure your performance or alertness, it could be horrible." 
 
The lack of self-awareness about sleep loss is particularly alarming given that deprivation affects high-level cognitive 
functioning. Over a decade ago, U.K. researchers Yvonne Harrison and James Horne reviewed multiple studies on the 
impact of sleep deprivation on​ decision making​ and problem solving. They concluded that it can lead to impaired 
communication, a lack of flexibility and willingness to try alternatives, a reduced ability to innovate, and an inability 
to deal with rapidly changing situations. 
 
We've all made choices while exhausted that we came to regret once we had the chance to rest and reconsider; 
fortunately, it's usually not too big a deal. But for those among us 
operating nuclear power plants, managing others' investments, 
or performing​ brain​ surgery, subjective blindness to the reality of 
fatigue can have serious consequences, costing money, time, and 
lives. 
 
Sleeping On Company Time 
For modern Americans, the type of work we do—and the 
increasing hours we've spent doing it since the recession 
began—is a major reason we're not getting the sleep we need. 
While some occupations are associated with more sleep loss than 
others, none is exempt. A recent CDC report noted that about 27 
percent of people in the financial and insurance businesses are 
sleep-deprived, with the figure rising to 42 percent among mine 
workers. "The challenges of schedules cut across many 
occupations and industries," confirms Roger Rosa, a researcher at 
the National Institute for Occupational Safety and Health. Still, he observes, "certain ones seem to be more prone to 
demanding work schedules." 
 
  

  14 

He singles out manufacturing, which uses a lot of shift work schedules, and anything involving continuous processes, 
like oil refineries. He also notes that sleep loss is a frequent problem for people in seasonal industries, such as 
construction. "It's not only night versus day work, it could be long hours that people experience, trying to meet 
deadlines or take advantage of weather or things like that," he says. "Emergency response is another example where 
often what needs to get done will take a lot of staff working many hours." 
 
Another​ career​ notorious for chronic sleep deprivation is medicine, particularly during residency, when fledgling 
doctors routinely work up to 28-hour shifts. Last year, a study in the ​Archives of Surgery f​ ound that residents were 
critically impaired by fatigue during more than a quarter of waking hours—and that, when sleep deprived, they were 
22 percent more likely to commit medical errors. Meanwhile, a 2009 JAMA study revealed an increased rate of 
complications when surgical procedures were performed by physicians who had less than a six-hour window for sleep 
between their last procedure the day before and the first procedure the next day. 
 
Finally, Rosa notes, transportation also ranks among the most sleep-challenged industries. 
According to a 2011 Federal Aviation Administration report, overwhelming fatigue from long, irregular hours and a 
lack of breaks was the chief concern among flight attendants, far outranking other complaints. Furthermore, the long 
hours, with the sleep that they cost and the exhaustion they engender, have been recognized as a major factor in all 
sorts of airline accidents for decades. 
 
In the early 1990s, the FAA was thwarted in an attempt to update flight and duty-time regulations. Yet support for 
change swelled after a 2009 plane crash outside Buffalo, New York, in which 50 people died. A contributing factor in 
the crash? According to the NTSB: fatigue. 
 
Rest For The Weary 
Even if we can't fully overcome the effects of not getting enough shut-eye, it's possible to balance our biology with 
the demands of our society. The first step is to admit that sleep loss is a problem that must be faced individually and 
culturally. 
 
Fortunately,there are signs that attitudes about sleep's importance are changing. Last fall, after 22 years, the NTSB 
removed the problem of fatigue from their Most Wanted list, the result of three federal agencies issuing new hours of 
service regulations for aviation, rail, and commercial trucking. (One example: Commercial airline rules now require a 
10-hour minimum rest period for pilots prior to flight duty—and mandate pilots be given the opportunity to sleep 
uninterrupted for eight of those hours.) "That's a great example of the cultural change that's starting," Rosekind says. 
"But at the same time, you can look at those rules and say, 'They didn't totally get it.' For example, these new rules 
don't apply to cargo pilots. They're not quite there yet." 
Similarly, 2011 ushered in revised regulations for medical residents, limiting first-year residents to 16-hour shifts 
prior to an eight-hour break. Second- and third-year residents may still work up to 28-hour shifts (although they are 
prohibited from accepting new patients within the last four hours). 
The shifting cultural tide may also aid an important group of workers who need to stay alert for long, unpredictable 
hours under significant amounts of stress: soldiers in combat. Modern warfare and technology have heightened the 
effects of​ sleeplessness​ in the military. 
 
Researchers Thomas Balkin, Sharon McBride, and Nancy Wesensten of Walter Reed are currently developing an 
alertness/performance​ management​ system, which includes a wrist actigraph device that monitors the wearer's 
movements with an accelerometer and displays information on recent sleep history and its implications. 
  

  15 

Such a "sleep watch" can provide an individualized picture that allows troops to know when they're fully on the ball 
and in sync with their natural rhythms, and when it's time to knock off and catch some Zs before a mission. The wrist 
actigraph is anticipated to become standard gear for soldiers and could probably also eventually be used by truckers, 
pilots, cops, and doctors—anyone whose work puts them at risk for sleep deprivation. 
Meanwhile, the​ adoption​ of officially sanctioned nap time at companies such as Zappos, Google, and​ The Huffington 
Post​ may be another early signal of a cultural sea change. Though the idea of allowing workers to snooze on the clock 
might sound outlandish, there's hard data to back the benefits of the practice. Recalling a pivotal NASA study 
conducted in​ collaboration​ with Dinges, Rosekind describes how "we gave pilots a planned rest period in the cockpit 
and showed that a 26-minute nap boosts performance 34 percent and alertness 54 percent." 
Of course, the recognition that organizations like Google give to the importance of sleep remains a rare perk for 
employees. Even as research progresses, sleep deprivation will continue to undermine our well-being until policies 
limiting work hours, allowing for naps (and providing spaces for them), and encouraging flexible work hours become 
commonplace across industries. 
Thomas Edison, the famous​ workaholic​ insomniac who did so much to change our relationship with sleep through 
his creation of the light bulb, once dismissed sleep as "a waste of time." He was wrong: It's essential not only for our 
personal health and well-being, but for the safety and​ productivity​ of everyone else. 
Ultimately, we can't change our biology or adjust our need for sleep. We can't abolish the fundamental rhythms of 
life that have evolved over millions of years. But as we learn more about how they work, we can adapt by modifying 
our attitudes and enacting regulations and business practices that better mesh with our normal human patterns. 
That certainly won't eliminate every tragedy like the Staten Island Ferry and Buffalo crashes, but it may ensure that 
when disasters occur, they won't be due to something as avoidable as missing a few hours of shut-eye. 
A Shift In Time 

Although the problem of sleep deprivation cuts 

across all occupations, it's a particular concern for 
those who work the night shift. "Humans evolved in a 
world where there wasn't electricity to make shift 
work possible. We're forcing people to live under 
conditions that we're not suited for," says Charmane 
Eastman, director of the biological rhythms research 
laboratory at Rush University Medical Center. "Even 
when workers use melatonin or sleeping pills to sleep 
during the day, they're still going to become sleepy at 
night because their circadian clock says, 'Okay, it's 
night.'" 

Contrary to popular belief, melatonin isn't required for sleep, though it definitely has a​ sedative​ effect. Eastman 
explains: "It's the way the internal circadian clock tells the body what time it is. Melatonin is the 'dark signal.'" 
Through careful adjustment of light exposure (the main signal that the SCN uses to "set" the body's internal clock by 
controlling the flow of melatonin from the pineal gland) and sometimes administering extra melatonin with pills, 
Eastman has demonstrated that it's possible to phase-shift night workers' circadian clock to a new rhythm—which 
can help them get the sleep they so critically need. 

Strategies include exposing shift workers to controlled amounts of bright light with the use of light boxes at work, 
then limiting their light exposure after their shift by having them wear sunglasses on their commute home (to reduce 
  

  16 

the amount of light reaching the SCN through the eyes), as well as going to sleep immediately after getting home in 
as dark a room as possible. 

Still, maintaining such lifestyle changes can be difficult. "Sometimes society is working against you, wanting you to 
do things in the morning," Eastman says. "For night shift workers to do it right, they have to have cooperation from 
their employer in the form of bright light at work. They need cooperation from their family to let them sleep late on 
days off and after the night shift. The world has to be sympathetic to the fact that it's really hard to do shift work." 
Summoning Sleep 

Often, the most difficult step toward improving your sleep is realizing that not sleeping enough 
is indeed a real problem. With some relatively simple shifts in habit, we can all help ourselves to 
get better rest. 

For example, while you may have stopped keeping a regular bedtime decades ago when your 
mother stopped tucking you in, sticking to a sleep schedule—one in tune with your natural 
proclivity towards being a night owl or an early bird—in which you hit the sack at the same time 
each night, is important. 

If you find that your schedule is at odds with your natural sleep preferences (say you must leave 
for work by 6 a.m. but don't become sleepy until midnight) you can help prime your body to 
drift off on the earlier side by manipulating the sleep homeostat. Our bodies naturally 
experience a sharp drop in temperature at the onset of sleep, and you can recreate this process 
by taking a hot bath or shower just before you get into bed. As your body cools off afterward, it 
will help usher in a feeling of sleepiness. 

Simply unplugging is also​ wise​. The thought of leaving your laptop at the office or not checking 
your iPhone before bed might make you anxious, but limiting technology use after 
dark—particularly in the bedroom—is critical. "Just getting light from computer and other 
screens before bed can throw off your circadian cycles," notes fatigue researcher Mark. R. 
Rosekind. "Data show, for example, that kids with technology in their bedroom—video games, 
tablets, phones—get up to two hours less sleep than those without it." 

You might even consider installing dimmers on your light switches and then lowering the lights 
in the hours leading up to bedtime. "Light exposure in the evening makes us more alert, pushes 
our rhythms later, and suppresses the normal secretion of melatonin," Harvard biologist Jeanne 
Duffy explains. "Even if you're just in regular room light in the evening, nothing bright, it will 
have a biological effect—probably resulting in your going to bed later, which can shorten sleep 
overall," she says. 
  

  17 

Taken together, such small changes can engender a significant—and lasting—improvement in 
the quality of your nights. "It's not as if you have to have surgery or take a pill,"observes the 
University of Pittsburgh's Martica Hall. "Sleep is a modifiable challenge." 

 
Addiction 
Overdosed America 
Denis G. Patterson D.O. 

I remember sitting thinking to myself, “how did I get here?" 

At that moment in time, a patient was voicing displeasure to me because I would not prescribe 
opioid​ pain medications for a​ chronic pain​complaint that did not warrant such medications. It 
wasn’t the first time, and it certainly wouldn’t be the last. I had provided several other medical 
recommendations—but all the patient heard was “I will not be refilling your oxycodone today.” 

I could already see the Yelp review that was headed my way later that day. 

How did we get here? How did the United States become the only country currently facing a 
prescription epidemic of this magnitude? As a country, we are opioid overdosed. 

Prior to 1986,​ opioids​ were really used only to treat acute pain, cancer pain, or terminally ill 
patients. The use of opioids to treat non-cancer pain was controversial. Two physicians 
(Portenoy and Foley) wanted to find out if chronic nonmalignant pain patients could benefit 
from using opioids. They ended up treating 38 patients with non-cancer pain for greater than 
six months with a median daily dose of less than 20 morphine milligram equivalents per day. 
They published their results in 1986. The lack of clinically significant adverse events led them 
to believe that physicians could safely and effectively prescribe opioid medications to patients 
without a history of​ substance abuse​with “relatively little risk of producing maladaptive 
behaviors.” The results of this paper began the push of physicians towards greater acceptance 
of the use of opioid analgesics to treat non-cancer pain. 

The movement gained momentum in the 1990s, when state medical boards curtailed 
restrictions on laws governing the prescribing of opioids for the treatment of chronic 
non-cancer pain. This led to new pain​ management​ standards for in-patient and outpatient 
medical care implemented by the Joint Commission on the Accreditation of​ Health​Care 
Organizations (JCAHO) in 2000. These new standards led to an increased awareness of the right 
  

  18 

to pain relief, which provided further justification for physicians to use opioids to treat 
non-cancer pain. 

Other factors that fueled the increase were aggressive​ marketing​ by the pharmaceutical 
industry and the promotion of increased use of opioids in the treatment of non-cancer pain by 
myriad medical organizations. 

I entered medical school in 1998 in the midst of this movement. I vividly remember one of my 
first lectures detailing how I could be disciplined by the medical board or even sued by a patient 
if I did not aggressively treat their pain. Today, we have many physicians contributing to the 
epidemic with a lack of​ understanding​ about the long term effects of opioid prescribing and also 
over prescribing. 

We can’t just blame the doctors. Patients often feel entitled to the medications they feel they 
want. They can be demanding, insulting, and uncooperative with regard to treatments offered 
as alternatives, often because they are facing an addiction. Other patients demand immediate 
satisfaction instead of putting the work into building a healthy body. Reputable physicians have 
to resort to checking a patient’s state prescription records and random drug testing. 

What has been the net result of this opioid movement? The quantity of prescription painkillers 
(i.e. opioid medications) sold to pharmacies, hospitals, and doctors’ offices was four times 
larger in 2014 than in 1999. According to the CDC, drug overdose death rates in the United 
States have more than tripled since 1990. In 2015, there were over 22,000 deaths involving 
prescription opioids, equivalent to about 62 deaths per day. Almost all of these opioids involved 
in overdoses have been prescribed legally.The misuse and​ abuse​ of prescription painkillers was 
responsible for more than 475,000 emergency department visits in 2009, a number that nearly 
doubled from the previous five years. 

Alongside this epidemic, the awareness and attention to chronic pain improved our options for 
treating patients. There are many alternatives to treating pain that should be considered before 
opioids are prescribed. Although prescription opioids can help manage some types of pain, 
there is not enough evidence that they improve chronic pain, function, or quality of life. 

Often times, the best of intentions backfire. Dr. Portenoy has since been quoted as saying “well 
we didn’t know then what we know now.” 

 
  

  19 

Addiction and the Brain 

Fran Simone Ph.D. 

Addiction​ and the​ brain 

“I don’t understand why he just can’t stop abusing alcohol.” Turns out that addiction is a whole 
lot more complicated than just saying “no.” Although the stigma of addiction as a​ moral​ failing 
persists, we now know that addiction is a brain disease. The September issue of National 
Geographic deals with the science of addiction and how “addiction disrupts pathways and 
processes that underlie desire,​ habit formation​, pleasure, learning, emotional regulation, and 
cognition​.” It causes hundreds of changes in brain chemistry and remolds it to value drugs and 
alcohol. Antonello Bonci, a neurologist at the National Institute of Drug​ Abuse​ says, “In a 
sense, addiction is a pathological form of learning.” 

Addiction is a disease 

Knowledge is power. Learning about the science of addiction can help us better understand and 
cope with our loved one’s self-defeating behaviors.​ Resources​ are available, including the 
article mentioned above, which considers the chicken-and-egg question: “Does addiction cause 
these (brain) impairments, or do brain vulnerabilities due to​ genetics​,​ trauma​,​ stress​ and other 
factors increase the risk of becoming addicted?” Perhaps some day science will provide a 
definitive answer to that question. In the meantime we know that addiction is a chronic disease 
that requires long term​ management​ for successful recovery.​ Understanding​ what’s happening 
that makes a loved one behave the way she does under the influence of drugs or​ alcohol​ can 
lead to less judgment and more compassion. This knowledge has helped me to become less 
reactive. I try to remember that behind my adult son’s disease is a person. I try to avoid “You’re 
wrong” and “I’m right” scenarios. I try to think before I speak. I try to judge less and empathize 
more. And I try to​ forgive​ myself when I react with​ anger​, frustration, impatience, and self-pity. 

Addiction can be treated 

Since addiction is a complex disease, quitting generally takes more than good intentions and a 
desire to stop. Treatment can help people recover. Currently, two approaches prevail: first, the 
cure lies in fixing the brain’s faulty chemistry or rewiring it through​ medication​, such as 
naltrexone and buprenorphine. Psychosocial support is viewed as an add-on to medication. A 
second method stresses psychological work (such as 12-step programs and other 
psychotherapeutic approaches) with medication as an adjunct. And recently​ mindfulness​ which 
includes​ meditation​ and other holistic techniques has been shown to be effective. What’s 
important here is trying to find the best fit for a loved one when he or she is ready to quit. There 
  

  20 

isn’t any one size fits all treatment and relapse rates are high. The good news is that 
ever-advancing treatment approaches can help people recover from addiction and lead 
productive lives. Over 23 million Americans have benefited from treatment and living in 
long-term recovery. They celebrate this achievement in​ story​ and​ film​. 

 
Aggression 
Assertive Not Aggressive 
Hara Estroff Marano 

Power is a constant player in interpersonal relationships. And the path to power is not 
dominance over others but the ability to speak up for oneself. The key distinction is the 
difference between aggression and assertion. 

Bullies don't just pick on anybody. Oh sure, in kindergarten they do. But very early on, by about 
the third grade, bullies learn to target their attacks, singling out specific people to prey on. They 
engage in a kind of shopping process to find people they can control. 

Research has shown that those who are victimized by bullies radiate a certain kind of 
vulnerability. They lack the ability to stand up for themselves. One reason bullies get away with 
their ​abuse​ of power is that they choose those who are unable to assert themselves or defend 
themselves even when picked on. The tragedy is that no one comes to their aid because the 
inability to stand up for oneself makes everybody very uncomfortable. Self-assertion is a basic 
skill in life. 

Assertiveness​ means being able to make overtures to other people, to stand up for oneself in a 
nonaggressive way, to speak up when others make demands, and to make suggestions or 
requests to others in a group. 

For some people, assertiveness requires overcoming psychological traits such as extreme 
passivity, sensitivity to criticism, anxiety, insecurity and low ​self-esteem​. 

The real first step toward assertiveness is self-​confidence​. You develop self-confidence only one 
way—through the experience of effectiveness in the world. You have to rack up some successes 
all your own, in specific domains of experience. These commonly encompass friendships and 
other social relationships, academic or work achievements, appearance or style, the cultivation 
of physical or athletic ability, and ​moral​ and ethical rectitude. Competence in any domain is not 
a given. It takes work at developing skills. 
  

  21 

It is also necessary to develop basic communication skills: 

● Leading—offering positive suggestion to peers or colleagues ("I have a fun idea.")  

● Asking questions in a friendly way ("Can I get to speak first in the next unit meeting?" 
rather than "How come you never ask me what I think of our proposal?")  

● Supporting—making explicitly positive statements to peers about ongoing activities 

("Wow, we've got a really strong action plan for the next meeting, don't we!")  

Above all else, expect that overtures sometimes will be met with failure. It happens to everyone. 
The trick is to not shrink into a corner, but to collect your wits and get right back into the game. 
It is not the fact of rejection that distinguishes popular from unpopular people, it is how they 
deal with rejection. 

Whenever a suggestion of yours or a bid for action is met with failure, pick yourself up, dust 
yourself off and generate alternative responses. What are some other things you can say the 
next time that happens? The more ways of responding you can come up with, the more 
successful you will become. 

Relationships 
Relationships: Love Ain't Enough 
Hara Estroff Marano 

More women are having affairs. Couples increasingly prefer cohabitation to ​marriage​, avoiding 
commitment as if it were some kind of disease. The ​divorce​ rate continues to hover at 50 
percent. Still, undeniably, people like to pair up. The need seems to be built into us. And 
surveys show that most people believe that a good marriage is essential for a happy life. More 
and more, we rely on our private relationships for our mental ​health​. But at the same time, they 
are becoming less satisfying. 

"There are few positive models of marriage," contends psychologist David Olsen, Ph.D. "People 
make the assumption that ​love​ is sufficient." It isn't. And then when their marriage goes 
downhill, "unhappy couples can hardly remember what brought them together in the first 
place." For good models of marriage, we have to look at animals, he told the smart marriages 
conference, the world's largest gathering of relationship experts. And with that he dimmed the 
  

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lights and showed video clips of Winged Migration. Downright inspiring! Among the 
information presented at the conference: 

If love isn't enough, what is? For starters, personal financial ​management​ should be required 
education​ for every couple. Money is the number-one source of conflict in relationships. ​Sex​ is 
second. Tension in the ​parents​' marriage affects kids. It is often the cause of teenage defiance. 
When parents fight, children withdraw from their fathers. 

In the first three years after the birth of a first child, 67 percent of couples experience a drop in 
relationship satisfaction. The drop occurs first in the mother, then in the father. 

Everybody handles conflict poorly when a discussion turns negative. What saves romance is 
attempts at repairing the relationship. "I'm sorry," counts. 

​After affairs or other transgressions, ​forgiveness​ is necessary for healing. But some people 
forgive too cheaply. Forgiveness is not the job of the hurt party alone; genuine forgiveness must 
be earned. Forgiving too cheaply keeps people from using the experience to develop more 
intimacy. They also fail to gain insight into their own contribution to the situation. 

​Refusing to forgive is unhealthy, physically and emotionally. "Not forgiving is literally poison," 
said psychologist Janis Abrahms Spring, PhD. After an affair, the offender must pay attention to 
the partner's pain if they want the partner to move on.  ​  

"Physical ​abuse​ is not a relationship problem, it's a ​self-regulation​ problem," says Steven 
Stosny,, Ph.D. "Abusers are filled with ​shame​, an internal ​punishment​ system controlled by 
someone else. When you violate ​attachment​ bonds you feel self-hate. Abusers lack compassion 
for themselves." 

​"The instant we become an adult is the moment when the instinct to love is greater than the 
desire to be loved," Stosny insists.​  

"We kill love by how we treat our partners, by not handling negative feelings well," says Howard 
Markman, Ph.D.  

Lack of commitment is subversive in a relationship, says Markman. Couples are not making it 
clear that they are choosing each other and giving up all other options. Then when problems 
arise they feel "I didn't clearly decide I wanted to be in this," and they don't push to resolve the 
issues -- which will just crop up again in the next relationship. 
  

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"Love doesn't last forever because we need the opportunity for growth and healing," says Israeli 
psychologist Ayala Malach Pines, Ph.D. ""Being with a partner who pushes your buttons is good. 
The button points to the place that is most important for us to work on." 

 
References: 
- https://www.psychologytoday.com/blog/psych-unseen/201603/schizophrenia-doesnt-exist  
- https://www.psychologytoday.com/articles/200505/the-trouble-day-care 
https://www.psychologytoday.com/blog/the-imprinted-brain/201501/testosterone-v-oxytocin-bridging-the
-gene-behaviour-gap 
- https://www.psychologytoday.com/basics/eating-disorders/eating-disorders-0 
- https://www.psychologytoday.com/articles/200404/biorhythms-get-in-step 
- https://www.psychologytoday.com/articles/201309/chasing-slumber 
https://www.psychologytoday.com/blog/navigating-pain-management/201708/overdosed-america 
- https://www.psychologytoday.com/blog/family-affair/201708/addiction-and-the
-brain  
- https://www.psychologytoday.com/articles/200402/assertive-not-aggressive 
- https://www.psychologytoday.com/articles/200407/relationships-love-aint-enou
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