Dr. Grossi's Blog
Our current failure or poor success in treating drug use disorder is partially due to our poor understanding of the complex natural history and its development and change over time. If we consider three potential transitions from non-use to asymptomatic use and to problem use and abandon the older designations of abuse and addiction, then we may more meaningfully arrive at fruitful conclusions.
Crompton et al. published recently in the American Journal of Psychiatry the findings of a study they carried out in which they made two assessments of individuals done at three year intervals. Less than 5% started using during the three year interval but of those over 50% had trouble at the three year follow-up. Of those asymptomatic users at the first assessment, 66% had stopped at follow-up while 20% progressed to problem usage. Of the problem users at baseline, 49% had stopped at the three year follow-up, 40% returned to problem usage, and 11% became asymptomatic users.
A variety of factors appear to influence transitions. Drug initiation appears to be linked to younger age, alcohol and nicotine usage and major depressive disorder. Drug initiation progression to problem usage seems related to lack of health insurance, poor physical and psychological health, and a family history of substance abuse. Higher persistent drug abuse is associated with child abuse and schizotypal and narcissistic personality disorders.
The study demonstrates that the course of drug use and problem use is influenced by factors at many levels including sociodemographic, family history of substance use, history of child abuse, current physical/psychological health and psychopathology.
Violence against women is a world-wide phenomena and is a significant issue for public health and social policy. The most common form of this violence is intimate partner violence and can express itself in physical, sexual, or psychological forms. The health impact on women can be seen in increased levels of depression and suicidal behavior, increased homicidal deaths of women, and increased acquisition of HIV. These in turn result in increased economic costs.
There is a growing consensus among most countries to promote gender equality and empower women. These is also a consensus in the research community about studying this problem which has resulted in an expansion in the number of studies examining this violence toward women. A digest of these results shows that globally in 2010 30% of women aged 15 and over have experienced physical and/or sexual intimate partner violence. Regional variation in prevalence is noteworthy. Central Sub-Saharan Africa shows an average percentage of violence toward woman is 65.4%, islands of the tropical pacific region 35.2%, South Asia 41.7 %, Western Europe 19.3%, Middle East 35.4%, and high income North America 21.3%.
The relatively high prevalence in all regions suggests that efforts at prevention are clearly warranted. Experiences of violence in childhood and later perpetuation of violence in adulthood are definitely associated suggests that preventing child maltreatment is an important intervention. This would involve changing parenting styles and social norms. Advanced education of women is associated with lower prevalence of violence although this varies with culture and geography. From the societal level it would be important to convert attitudes that such violence is private into a public concern. Interventions to put a spotlight on problematic drinking patterns in men which are commonly associated with physical abuse of women. Laws should be changed to symbolize the unacceptable nature of this behavior and to provide legal recourse.
Violence toward women is a complex problem and there are no easy or quick solutions. The interventions should be multiple, varied and cut across social, cultural, legal, economic and educational areas.
The other day I was thinking about the mistakes in judgment that people make. There is a dazzling array of mistakes. They include choosing the wrong job, wrong spouse, incorrect medical decisions, mistakes regarding money, mistakes regarding children, etc. As I began to think about this, several associations came to mind. First I recalled my childhood fascination with optical illusions in which the eye which looks out onto the world makes a mistake in its perception. What is really interesting is that it is the same mistake, a consistent mistake, and not some random mistake. Then I thought about seeing into the future which is something uniquely human. How do we do this? We use something called imagination. This is our wormhole, our creation of a virtual reality in which we project future events and more importantly our feelings about those events. This is a truly remarkable feat, to see the world not as it was but as it might be. The brain is filling in what is not known with information from what is known which is exactly analogous to the way sight is produced.
The imagination of future events leads to an overestimation of the likelihood of their occurrence. Most people tend to imagine positive events more frequently than bad events. This is likely the result of more positive historical experiences. In turn an unrealistic, over-optimistic stance eventuates. On the other hand, it's not all champagne and chocolates. Imagining distasteful or unpleasant events do have value at times as motivational tools and can have the effect of reducing their impact on us. Why do we do this? Our brains want to know the future so that they can better control it. People enjoy making things happen and feeling less helpless, a distinctively unpleasant feeling. The paradox of this desire to control our direction is simply that the way we see the future is fundamentally inaccurate because we are seeing it through the lens of the present. This is analogous to illusions of eyesight and illusions of hindsight.
The use of imagination has several substantial problems affecting its reliability. When our eyes look out at the scene in front of us, many different neurons are stimulated by different components of the scene and these are combined in the visual cortex of our brain. The brain pieces these fragments together to form the picture we see. Imagining the features and consequences of future events cannot possibly consider each and every feature and consequence because they are unknown.Therein lies the problem. Another shortcoming of imagination is the tendency to project the present feelings and experience onto the future. In other words how we feel now influences how we think we will feel in the future. The final problem is that future events will look different once they occur. It is these factors that conspire to produce errors in human judgment that are frequent and persistent and often predictable.