Sunday, September 13, 2009

Timing Literature Review Source

Improved brain timing is at the heart of most of the big breakthroughs for clients in my practice. I've tried to keep up with the literature, but it is vast and complex. Now Kevin McGrew and Amy Vega have put together a review of theory, diagnosis and treatment research. It is available here in PDF format. There are additional appendices for those who wish to delve deep into the literature. The appendices can be accessed via Kevin McGrew's August 14th blog. In that blog, he gives an interesting introduction to the paper. Check it out.

Wednesday, January 28, 2009

Emotions as an Input Sense - Part II

I'm wandering into the psychologist's territory armed with my occupational therapy (OT) sensory integration framework. I'm married to a psychotherapist, and so I suppose that I'm not only armed but dangerous. But come with me on a short look at emotions as a source of sensory input from an OT's perspective. I will use the sensory integration framework to talk about emotions as an input sense, much like other senses.

OTs treat clients with PTSD, TBI, autism, dementia, stroke and many other diagnoses in which the emotional system may be fragile. As an OT working with a child or adult in a therapy setting, I need to have tools available to help keep my client emotionally organized and well-modulated so that the interventions are better accepted.

From the sensory integration viewpoint, we can (to keep it simple) speak of three aspects of emotional skill: registration, seeking/aversion behaviors, and modulation.
  • Registration of emotions refers to whether or not we sense them, and to what degree we sense them.
  • If we excessively seek or excessively avoid emotional experiences then we have seeking or aversive behaviors.
  • The degree to which we are affected by emotions and react to them are aspects of modulation.
Registering Emotion
We speak of "palpable emotions" - you walk into a room and you can feel the excitement, fear, sadness or joy of a person or a group. I think of this as "sensing emotion", in the same way that we "sense" taste or vision. I believe that we all are able to sense emotion to some degree. There are three categories of emotional sensitivity: typically sensitive, hypo-sensitive, and hypersensitive. A person with hypo-sensitive emotions will have difficulty registering emotional content and may not understand why others are affected in certain emotional situations. A person with hypersensitive emotions senses emotional content more intensely than others. He or she may even be bombarded by it.

Seeking/Avoiding Emotions
Some of us seek positive or negative emotional experiences, or both. We may seek emotions because we are hypo-sensitive and our brains are trying to get the sensation. We may seek emotional experiences because we are hyper-sensitive and enjoy the sensation and want more. We may avoid emotional experiences for a variety or reasons. We may be hyper-sensitive and easily overwhelmed by emotional experiences. We may be hypo-sensitive and find the experience boring or confusing.

Handling Emotions (Modulation)
We can split emotional modulation into two aspects: receptive and expressive. We need to be able to modulate both our reception of emotions and our reactions to emotional experience. A well-modulated person moves in and out of sensory experience with ease. An emotionally well-modulated individual moves in and out of emotional experiences with ease.

The topic of emotions is incredibly complex. Briefly, from the eyes of an OT, here are some simple examples of poor receptive emotional modulation: inability to understand cultural differences, inability to see someone else's plight, inability to process complex emotional situations. At the other extreme are people who "feel too deeply" and who perhaps read too much into a situation they are witnessing.

Some examples of poor modulation of expressive emotions include tantrums and rages, social phobia, and heavy emoting. At the other extreme is the lack of expression of emotion.

The OT Viewpoint
As a sensory-based OT, I am concerned with the physiological aspect of sensing and reacting to emotions. My interventions incorporate recorded music, social situations, excitement level in the environment, sensory input and special tools such as sound therapy to shape the mood and induce the appropriate reaction. I work in the same village as the behaviorist or cognitive therapist, but do not offer the same practices nor do I necessarily look for the same results.

Sunday, January 25, 2009

Winter Depression and Low Dose Melatonin

Over the Counter Treatment for Seasonal Affective Disorder

The short story: Low daily doses of liquid melatonin taken every day for 4 weeks once SAD has set in, can lift the mood. A low dose of melatonin - .3 mg - can be obtained by using small amounts of liquid melatonin. The time of day it is taken is important. For most people it is in the afternoon. For some (30%) it should be taken in the morning. (Per research (2) cited below.)

Melatonin is available over the counter, but one should consult a doctor regarding usage.

Long Story:

A running theory of the cause of seasonal affective disorder (SAD) or winter depression, is that a person's circadian rhythms are out of sync. NIHM defines this: "A person's rhythms are synchronized when the interval between the time the pineal gland begins secreting melatonin and the middle of sleep is about 6 hours. (1)" There are a number of therapies aimed at correcting the problem including lights, exercise, anti-depressants and melatonin. (See the Wikipedia entry.)

The synchronization can be off in two ways: - a longer-than or a shorter-than 6 hour interval. A study by Lewy, et al (2), showed that subjects who took low dosages of melatonin every day for 4 weeks found an improvement in mood. The dosage was as follows: for those who's interval is less than 6 hours, .3 mg in the afternoon. For those with a longer than 6 hour interval, .3 mg in the morning. If you have to guess which you are, the odds from the study favor the short interval (71% to 29%). The study gave 2 small doses adding up to .3 mg in 2 hours.

Melatonin is available over the counter, but generally in high dose formulations. The study used capsule formulation. There are liquid forms of melatonin available in some health food stores. (Again, I found Natrol 1 mg, and adjusted the amount.)

Both articles cited are available on line.

1. April 2006 article from the National Institute of Mental Health, "Properly Timed Light, Melatonin Lift Winter Depression by Syncing Rhythms".

2. Lewy AJ, Lefler BJ, Emens JS, Bauer VK. The circadian basis of winter depression. Proc Natl Acad Sci U S A. 2006 Apr 28.

Friday, January 16, 2009

Jam-packed therapy

Here is a story about using Interactive Metronome (IM) and Therapeutic Listening (TL) simultaneously. AND, mom and dad put on the headphones, too.

"Gary" is a very sweet 12 year old who suffered severe deprivation in early life. His parents are now able to provide him with a safe, loving environment, but he still has tons of stuff to work through (sensory seeking, emotional neediness, act-out behaviors, plus some motor planning problems), and it is hard on the entire family.

He was referred to me for Interactive Metronome (IM), and that made sense as an initial approach. Four to six weeks of IM can provide breakthroughs in a range of body-brain areas and make therapy go faster. However, it turns out that Gary is bullying other kids at school and has act-out behaviors at home, too. He needed some self-regulation. IM provides that, but it takes a few weeks to kick in. In the meantime, it can ramp-up personal intensity. In the end, that is a positive effect, but I was worried that it might increase the outbursts at school and home in the short term.

And so I thought of Therapeutic Listening or Samonas. Sound therapy programs focus first on self-regulation. But they too, have a drawback. They work more slowly and a person can go through weeks of emotional passivity while the brain reorganizes. The other side of a bully is an insecure human being. I didn't want Gary to flip-flop. I also wanted to make faster progress. With sound therapy, Gary might invest several months before getting to the heart of many issues.

In the end, Gary's family opted to do both therapies simultaneously. And so began some jam-packed therapy sessions in which Gary would independently do his IM program while mom, dad and I discussed strategies for home and in the community. During Gary's breaks, he would play on the sensory equipment, try out sound therapy disks or join us for some discussions about behavior. Within a couple of weeks, mom and dad asked if they might benefit from listening to the sound therapy CDs, too. Why, yes. Of course. It had been a long road for them, as well as for Gary, and the music would help to remove some of the built up trauma that they had undergone.

Last week, Gary finished his IM program. He will continue to listen to Therapeutic Listening and Samonas CDs for another 6-10 weeks, depending. His dad gave me an update. "The changes are subtle, but they are deep." He was very pleased. He was seeing cooperation and motivation to change where there was none before. Parents sometimes miss these changes in their children. But they are profound and grow with time.

Gary told me that everything in his life felt a little easier. I measured Gary's performance on motor-skills tasks, and he gained 18-24 months in fine motor skills and upper body movement and coordination. The results for cognitive and sensory gains are not in yet.

Gary's parents seem to have relaxed several magnitudes since I first met them. In early sessions, they spoke through clenched teeth. Now there are smiles.

Wednesday, January 14, 2009

Core:Tx and Interactive Metronome

Mark is a 12 year old boy with high functioning autism who returned to occupational therapy after a break of several years. Although Mark was doing well in school, he was unable to fully dress himself or bathe himself. In terms of neuromuscular control, Mark had poor overall tone, poor postural control, and significant motor planning issues. He walked with a very wide gait (total deviation of 80 degrees), had poor handwriting, and lacked the ability to plan and execute movements with his arms and hands that would allow him to reach the top of his head and flex his fingers to wash his hair. In addition, he chewed his food in the front of his mouth and for this reason preferred a soft foods diet. Mark’s social skills were quite limited. He rarely looked at others while speaking and limited his conversations to single words.

Given the range of problems Mark faced, it was decided that a course of Interactive Metronome (IM) would reduce the time in therapy. Mark did IM twice per week for 30 minute sessions. He started each session with a few minutes in the ball pit to help him relax and self-organize. He then did 10 minutes of IM, took a short break on a swing or trampoline and then a final 10 minutes of IM. As his skills improved (and he moved to phase 4 of the IM program), he did 20 minutes of IM and then practiced dressing skills or handwriting.

Progress with IM
The program of IM had profound effects on Mark. He developed a self-awareness and motivation that led to greater independence. First, he figured out how to regulate the shower temperature. Next, he tried to wash his hair on his own, although he still lacked the correct motor-planning for that task. He took an interest in outside activities and began to talk about what he did. He displayed a good sense of humor. He saw gains in motor planning and postural control. He learned to dress himself entirely with the exception of buttoning pants at the waist and tying shoes. He learned to chew with his whole mouth. His wide stance improved, so that his feet were better aligned by 5-10 degrees.

After 19,000 repetitions, therapy took a new direction. It was time for Mark to learn a variety of new skills through exercise and repetition. Mark was aware and motivated, but with his new sense of humor, he was also very playful. It was difficult to keep him on task to perform the more difficult work of exercising his body to make additional gains. For example, when asked to lay over a therapy ball to work on posture, he would fall off the ball and roll on the floor and giggle. When asked to pretend to wash his hair by moving his hands together on top of his head, he would pat the sides of his head with extended fingers, as if to say, “there, all done.”

Core:Tx proved to be the solution for getting him to perform exercises correctly. Its game-like nature engaged him, and he paid attention to the instructions rather than acting-out with silly behaviors. On the first day he performed scaption (shoulder/rotator cuff) exercises. As he attempted to keep Core:Tx’s red ball within the square, he made smooth movements with his arms to the top of his head, using full range of motion, for the first time. He was proud of himself and after two sessions, he developed the motor planning to successfully wash his hair independently. He currently uses Core:Tx in both physical therapy and occupational therapy to address postural control, lower extremity motor planning and gait issues.

Monday, January 12, 2009

Personal Genome Project: Nature & Nurture

Yesterday's New York Times Magazine (1/11/09) had an interesting cover story by cognitive scientist, Steven Pinker, who is a participant in the Personal Genome Project. The genome project will create technology and practices allowing individuals to access and interpret their personal genetic information.

The identification of a person's traits (personal genomics) using DNA is in its infancy. We can identify risks for some diseases, and map some physical attributes such as hair color and skin tone, but not always accurately. We can identify ancestral lineages (- which is very cool!).

What I found most interesting in Dr. Pinker's article is that personality and behavioral traits such as extroversion, intelligence, religiosity, neuroticism, mental illnes can be mapped to our genes to some degree. And giving nurture (as opposed to nature) its due, our differences from each other can be also attributed to culture, shared environments (homes, work and schools), and unshared environments. However, gentic studies are finding that the older we get, the more our behaviors appear to revert to our genetic traits. That is, we move away (perhaps literally) from the cultural and environmental factors as we grow and mature and back to the original DNA expression of ourselves.

Hmm... this will surely impact psychotherapy, spiritual development and a slew of other areas. The nature vs. nurture debate should explode in the near future.

Friday, January 9, 2009

Your Brain on Music

Just finished reading the 2006 book, This is Your Brain on Music, The Science of a Human Obsession by Daniel J. Levitin. No surprise that it was a finalist for the LA Times' Book Prize.

This wonderful book looks at music and the brain from a-to-z. In doing so, it demonstrates how music and modulated music travel about the brain in a way that influences our ability to trust, self-regulate, identify sounds in space, motor plan, communicate, organize, discriminate sounds, multi-task and relax. In other words, the book provides insight into how sound therapy works -- but without ever mentioning the term sound therapy.

Music operates independent from language. Some aspects of music, like pitch, are hard-wired into brain areas. They have their own neural centers on the right side of the brain. For example, a neuro-surgeon can pinpoint the note, C#, in the open brain. Other aspects of music: musical syntax, timbre, rhythm, etc., are processed simultaneously in their own specialized regions across the brain. Music can be an intellectual, regulatory, emotional and/or social experience. We admire the construction of a song, work to the beat of a driving rhythm, allow ourselves to move with musically expressed emotions, and make music a part of our social events and rituals.

The brain has two main pathways for music. The first moves from the inner ear into the auditory processing areas where it then moves to other high-functioning cortical regions including executive functioning and memory. The second pathway moves directly from the inner ear to the primitive cerebellum where motor planning and our fight-or-flight is centered. The cerebellum is also the seat of the brain's timing and rhythm, and has important emotional function. Both pathways are bi-connected to each other and to a variety of emotional centers in the brain including those responsible for pleasure and reward.

Why did music evolve into animals? Darwin linked music to sexual selection by virtue of music's seductive powers. Others have noted that it was (and continues to be) an important aspect of social bonding and cohesion. This would make it important to the evolution of social beings like ourselves.

The book is full of deep information as well as interesting tidbits.