Dr. Grossi's Blog
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.
I continue to be challenged by patients when the diagnosis of bipolar disorder is made. For this reason I have decided to write another blog regarding this subject. This is a bit like standing alongside a carousel and trying to draw a picture of a horse on the rotating carousel. Each time the horse passes you draw a line. After fifteen or twenty passes, you have a picture of a horse. After fifteen or twenty blogs, we will have a complete picture of bi-polar disorder.
The bipolarity index takes into account a number of dimensions that are not included in the DSM. It contributes to the idea of bipolarity not as a "do I have it or don't I have it", a yes or no phenomena; but, rather as a how much of this do I have. I always emphasize that my diagnosis at the first interview should be viewed as a statistical probability and that the proposed treatment should be viewed as an empirical test, i.e., does it produce the result desired. This is a bit like dating. You don't ask someone to get married on the first date and start a family. That can occur over a long period of time and shared experience. Treatment is the same.
The Bipolarity Index, developed about seven years ago by Gary Sachs and his colleagues at the Harvard Department of Psychiatry, includes ratings in five dimensions and each dimension is given point scores from twenty to two points. The five dimensions are 1) episode characteristics, 2) age of onset, 3) illness course and other features, 4) response to medications, and 5) family history.
With regard to episode characteristics, most points are awarded for manic symptoms especially euphoria, grandiosity, and expansiveness. The next most points for symptoms of mania with dysphoria and/or irritability. Following those is hypomania or mania following use of an antidepressant. With regard to age of onset, the most points are awarded for onset between 15 to 19 years of age; the next most for age of onset between 20 to 30 or below 15 years of age. Less points are awarded for onset between 30 to forty and even less for onset over 45 years of age. With regard to the illness course, most points are awarded for manic episodes separated by full recovery, less points are awarded for incomplete recovery between manic episodes or hypomania with full recovery between episodes. Less points are given for incomplete recovery between manic episodes or substance abuse, or psychosis during mood episodes or legal problems associated with mania. The dimension of response to medications awards the most points for full recovery within 4 weeks of treatment with mood stabilizers. The next most points are given for full recovery within 12 weeks of treatment or relapse within 12 weeks of stopping mood stabilizers or switch to mania within 12 weeks of starting an antidepressant. The dimension of family history awards the most points for having a first degree relative (brother, sister, parent, child -50% identical DNA) with clear bipolar disorder, the next most points for second degree relative with bipolar disorder or first degree relative with unipolar disorder.
Please note that the above includes the most important aspects of the bipolarity index. For those interested in examining it in complete detail, please search for it on the web where it is easily found. Using the bipolarity index to score patients with a number is an error as the points meaning has not been worked out, although, most bipolar I patients score above 60.
Several years ago Malcolm Gladwell wrote a book entitled Blink. In this book he discussed research on the quick inferences from snippets of behavior, biases in judgment and the differences between automatic and controlled processes in perceptions and attitudes. He described how people filter complex information and come up with snap judgments. This can be a huge impediment to good judgment. The Gladwell book left a lot to be desired in terms of explanations and ramifications. Daniel Kahneman's book, Thinking, Fast and Slow is a much more comprehensive text.
Kahneman, who won the 2002 Nobel Prize in economics, challenges the idea that individuals are rational and shows that fear and love explain many of the departures from rationality. He also shows that luck plays a major role in our successes or failures. Early in the book Kahneman introduces the two major players whom he calls System 1 (S1) and System 2 (S2). S1 is fasts acting, can't be turned off, has little if any understanding of logic, operates automatically, effortlessly and without conscious control. S2 is rational, diligent, compares and contrasts, weight pros and cons, plans and tries to control our thoughts and behaviors emanating from S1. S1 is gullible, S2 is forever doubting. It is the interplay between these two forces that determines our success or failure in out perceptions and judgments.
Kahneman discussed Bayesian theory, regression to the mean, loss aversion (losses are more important than gains), and the operation of heuristic principles such as anchoring, representativeness, and availability. He also discusses prospect theory ( how losses and gains are represented).
We would all like to be better decision makers. After reading this book I was left a bit frustrated because experts repeat their mistakes just as novices do and the effort to overcome biases is extraordinarily labor-intensive with lots of self-monitoring and self-control. One will need to know when to activate S2 to correct biases generated by S1 and furthermore to know when to activate S2 to correct the perceptions and judgments of others. I learned a lot by reading the book and I became even more aware of the pitfalls at hand and in the future.