The under-reported story of Terri Schiavo’s eating disorder

The case of Terri Schiavo seems to have attracted a considerable amount of media attention in recent weeks, both in the U.S. and abroad.

As most are probably aware, Terri Schiavo is the 41 year-old American woman whose heart stopped beating in 1990, resulting in extensive brain damage. Her husband, Michael Schiavo, originally sought to keep her alive, hoping for a miraculous recovery. Instead of improving, however, her condition continued to deteriorate. She is currently in a “persistent vegetative state”; cerebrospinal fluid occupies the space where her higher brain centers used to be.

Eight years after the incident, Mr. Schiavo asked a Florida State judge for permission to remove his wife’s feeding tube and allow her to die. Her parents battled in the courts to keep the feeding tube in, insisting that therapy might bring about improvement. Ten courts have found the parents’ case without merit, and the feeding tube was removed. Most recently, President Bush and the U.S. Congress attempted to intervene by forcing the case into federal court, but to no avail. At the time of this writing, Ms. Schiavo remains without sustenance. Her death appears imminent.

It is not my intention to add to the volumes that have been written and said about the legal, ethical, and political issues raised by this tragic case. There is one aspect of the event which has been underreported, however, and it concerns the psychological disturbance responsible for producing Ms. Schiavo’s heart attack, an eating disorder known as Bulimia Nervosa.

Individuals suffering from “bulimia” episodically eat excessive amounts of food, usually in secrecy. Later, they attempt to compensate for the food intake to prevent weight gain. They do this most often by artificially inducing vomiting; however, other methods may be used, including fasting, excessive exercise, and the misuse of laxatives, diuretics, or enemas.

Prior to the heart attack that damaged her brain, health care providers failed to recognize that Ms. Schiavo suffered from an eating disorder, and thus failed to refer her to a specialist for appropriate treatment for her condition. The courts awarded Ms. Schiavo a medical malpractice award in the amount of two million U.S. dollars, or about 77,385,000 Thai baht.

Had Ms. Schiavo been treated for bulimia, the tragic events that followed could have been avoided. Frequently inducing vomiting disrupts the balance of electrolytes necessary for normal cardiac activity. In essence, Ms. Schiavo’s heart attack was self-inflicted, albeit indirectly and unintentionally.

One of the most interesting facts concerning bulimia is its tendency to appear at a relatively high rate of incidence in certain societies, while remaining conspicuously absent in others. It also appears with ten times greater frequency among those of a particular gender and age group.

Bulimia develops primarily among young females living in societies that stress the importance of a slender figure. Only about one in ten bulimia sufferers is male. It usually develops during late adolescence to early adulthood, a very tender and impressionable time in the course of human emotional development. Experts believe social pressures on young females to conform to an idealized body type plays an important role in the development of the disorder. Biological, personality, and family factors have also been suggested as contributing to the illness.

Messages that encourage young people to conform to socially-dictated standards of beauty and attractiveness seem rampant in our modern visually oriented media. Many contemporary young people appear lacking in the values and skills necessary to resist these powerful pressures toward conformity. Further, our societies often seem lacking in the sophistication and resources to recognize and treat eating disorders and other emotional problems.

It seems a cruel irony that the tragedy of the Schiavo case could be averted if a tiny fraction of the effort that has been mounted to litigate the issue of her right to die had been focused upon providing the treatment she needed to overcome her eating disorder.

One more reason to go for that diploma

What benefits result from a higher education? While some seem obvious, there may be a few you never thought of.

Students often seem attracted by the prospects of a higher income, more rewarding work, and higher employment associated with earning a university degree. Educators might emphasize the value of critical thinking skills gained by graduates, their introduction to the world of ideas and the merits of preparation for a life of learning. Societal benefits might include such things as a decreased dependence upon public assistance, greater civic involvement, increased volunteerism and better health associated with higher levels of education.

A number of recent studies have demonstrated that a higher level of education may provide benefits we never anticipated, namely, protection from a decline in memory and other cognitive abilities that comes as we grow older. This month researchers at the University of Toronto published findings that shed light on how higher education helps protect older people from certain declines in mental abilities.

Melanie Springer and a team of psychologists examined patterns of brain activity in subjects performing memory tasks. The procedure involved scanning the brains of participants using functional magnetic resonance imaging (MRI). The scans produced pictures that reveal specific brain areas which become active in response to subjects performing memory tasks. They then examined the relationship between those brain regions used, the age of subjects, and their levels of education.

Previous studies had shown that older adults exhibit greater activity in the frontal regions of the brain as compared to younger adults. The main finding of this study was that the frontal lobes, the area of the brain directly behind the forehead, and the medial temporal lobes, the areas on each side of the brain, exhibited differing patterns of activity, depending on the age and education of the subjects.

Young adults, ages 18 to 30 with higher education, seemed inclined to rely more on the temporal lobes and less on the frontal lobes while performing memory tasks. Older adults, aged 65 and up, used more frontal lobes and less of their temporal lobes while performing the same tasks. This increase in frontal lobe activity among older adults was most pronounced among those that were more highly educated.

The authors suggested that the frontal lobes represent an available resource that can be called upon to compensate for reduced functioning of the temporal regions associated with aging. The more education a person has, the greater this effect.

Neuropsychologists have contributed dramatically to our understanding of the brain in recent years. They have demonstrated that the brain is a dynamic system of neurons capable of growing new connections in response to more complex and stimulating environments. It is speculated that education, particularly while the brain is maturing before age 30, may stimulate the formation of more connections between various brain regions. These additional connections might provide a kind of redundancy which acts to buffer the decline that comes when connections are inevitably lost due to aging.

If you are among those thinking about going back for that university diploma, there’s one more reason to take the plunge. Better do it soon though, before you forget!

Harm reduction for sex workers

Pattaya is known around the world as a popular tourist destination. The area boasts of many mainstream tourist attractions, such as miles of sandy beaches, luxurious resorts, luscious golf courses, and plentiful water sports. It is no secret, however, that a major attraction of this former sleepy fishing village is the ready availability of relatively inexpensive commercial sex.

Although illegal in Thailand, the commercial sex industry is permitted to flourish openly here in Pattaya, as well as in other parts of the country. The economic benefits provided by sex tourism appears a powerful incentive for authorities to look the other way, as opposed to biting the hand that feeds an arguably feeble local economy.

Economic considerations aside, attitudes of societies toward human sexual behavior generally, and commercial sex in particular, might be characterized as contentious. On one extreme is the attitude that sex work is a legitimate and acceptable form of employment which is freely chosen by consenting adults. Proponents of this view include many feminists, sex workers, and prostitutes’ rights advocates. From their perspective, the criminalization of prostitution helps perpetuate the stigma associated with sex work, and represents an infringement of liberty and personal freedom by the state.

Opponents of the practice argue that prostitution is degrading to the women and men thus employed, and that the practice causes severe psychological damage. The feminist writer Sheila Jeffreys, for example, views men’s commercial use of women for sex as intrinsically violent, abusive, and a violation of human rights. Others opposing prostitution base their arguments upon moral codes rooted in Judeao-Christian taboos concerning fornication and sexual promiscuity.

A psychological approach to the issue of sex work would not necessarily approach it as a moral issue. Psychological research often examines issues such as factors contributing to a person’s decision to become a sex worker, whether engaging in sex work is necessarily psychologically damaging, and the health risks that are attendant to that profession.

A recent study by Melissa Farley, for example, found that 55 percent of a sample of Thai sex workers reported having experienced physical assault during the course of their work, 57 percent had been raped. Sadly, 72 percent met the criteria for a diagnosis of partial post-traumatic stress disorder (PTSD). Farley’s study also found that 56 percent reported current or past homelessness, 71 percent reported a current physical health problem, 56 percent acknowledged having an alcohol problem, and 39 percent reported a current drug problem.

Does sex work lead to emotional or behavioral disturbance? Early psychological theories, particularly those derived from Freudian or psychoanalytic theory, tended to view emotional disturbance as developing as a result of unresolved conflicts, usually rooted in early childhood development. By contrast, modern psychological theorists generally hold the view that people develop emotional and behavioral disturbance not purely as a result of their experiences, childhood or otherwise, although experiences are undeniably a factor. Cognitive theorists like Albert Ellis, Aaron Beck, Martin Seligman, and Donald Meichenbaum point out that people play a significant role in creating and perpetuating emotional disturbance by the way they think about the adversities which they experience in life.

On the question of whether sex work is intrinsically damaging to the sex worker, there is little evidence to support this conclusion. At most, it could be inferred that sex work places sex workers at increased risk for experiencing a number of adversities, including violence, physical assault, rape, and exposure to sexually transmitted diseases (STDs). Those experiences are, in turn, associated with an increased risk for developing psychological and medical problems, including PTSD, alcohol and drug problems, and homelessness.

Given the fact that the oldest profession is unlikely to be legislated out of existence, authorities would do well to institute appropriate harm-reduction strategies to provide sex workers with the knowledge and skills they need to reduce the risk of assault, rape and other occupational hazards. In addition, steps should be taken to increase the availability of medical, mental health and rehabilitation services to individuals employed in the sex industry.

When the driving habits of others seem to drive us crazy

A common complaint heard in Thailand, particularly when in the company of “farangs,” concerns the unconventional (in the experience of some) driving habits of many of the local inhabitants.

Negotiating one’s way through dense herds of unruly motorcycles roaming the urban roadways of this country represents a distinct challenge to some drivers. The number of passengers carried by those motorcycles is frequently in violation of legal regulations, not to mention the laws of physics. The tender age of many passengers, some of whom are mere babes in mothers’ arms, further contributes to the dangerous mix. Additionally, those motorcyclists often seem inclined to tempt fate by traveling against the conventional flow of traffic. Those acculturated to local driving norms appear quite unconcerned. For those of us accustomed to a different set of norms, however, the experience can be quite unnerving.

Driving hazards are not confined to those of the motorcycle variety. Certain routine practices by those driving cars, trucks, vans, farm vehicles, and motorized contraptions which defy description can become a cause of concern for those unfamiliar, and even some long familiar, with such dangerous behavior.

Most critics of local drivers, it seems, appear to treat this problem with acceptance, resignation and occasionally a bit of humor: The Thai phrase, “Mai ben rai” seems the operative attitude of many. Although they find driving experiences frightening and, of course dangerous, these individuals respond to the problem merely with annoyance, and perhaps take special precautions to drive more cautiously or defensively as a result.

Other drivers respond quite differently. They can easily become quite upset by others’ driving habits, shouting, cursing, and using the rich and expressive language of gestures to convey their contempt for their errant fellow motorists. At the extreme, some drivers have been known to retaliate against thoughtless or discourteous drivers by threatening them, chasing them down, running them off the road, and even physically assaulting them as the opportunity arises.

What distinguishes those whose emotions become volatile in response to driving norms from the “Mai ben rai” crowd? While the reckless behavior of motorists is an important factor, it alone cannot explain the response of those who become emotionally upset and respond with homicidal rage. We are, all of us, dealing with virtually the same driving behavior, yet we are not all responding the same emotionally and behaviorally.

A key difference between emotionally hot and emotionally cool drivers is the way they think about their driving experiences. One’s thoughts, attitudes, and beliefs about other motorists’ dangerous driving habits is instrumental in producing our emotional response. For example, if I entertain the notion that people MUST drive the way I very much prefer that they drive, I am likely to upset myself when they don’t. If I instead decide that I merely prefer that they drive according to my standards, I will likely be annoyed when they don’t. I will, however, spare myself the pain and emotional distress that I experience when my absolute demands are not met.

The idea that we humans are very talented in creating and maintaining emotional disturbance by entertaining irrational and disturbing thoughts is a key feature of an elegant modern theory of human emotional disturbance developed by psychologist Albert Ellis called Rational Emotive Behavior Therapy (REBT).

In Ellis’s view, it is possible for someone who habitually finds himself yelling, cursing, and experiencing homicidal thoughts to defuse his hostility and respond more appropriately to various adversities. We can, with effort, gain control over our emotional responses by learning to recognize the irrational thoughts which give rise to our emotional upsets. We can then learn techniques for disputing them, and replace them with thoughts which are more compatible with appropriate, non-disturbed emotions, and more rational and effective behavior.

Learned helplessness, learned optimism

A cartoon by Leigh Rubin depicts a psychotherapist saying to his patient, “You seem to have trouble accepting responsibility.” The patient on the couch replies, “It’s my parents’ fault.”

When things go wrong in your life, do you accept the lion’s share of responsibility, or do you tend to pin the blame on other people or events? Do you view the world as being run by rich and powerful people behind the scenes, or can the “little people” like you and me make a real difference? Does getting ahead in life depend upon what you do or don’t do, or is it simply a matter of luck, of being in the right place at the right time? To what degree do you feel capable of bringing about important changes in your life? To what degree is your life controlled by chance or by outside factors?

Our answers to questions like these reflect something about our sense of personal control. According to research by social psychologists like Martin Seligman, our sense of personal control, in turn is related to other important aspects of how we relate to the people and situations in our lives.

Seligman views events “as successes or failures of personal control.” He uses the term, “learned helplessness” to describe the mentality of a person who gives up, quitting some project or task out of a conviction that his efforts will likely be ineffective. A related idea is that of “explanatory style.” This refers to the strategy one habitually uses to understand the causes of various events. An optimistic explanatory style tends to view events as under one’s own control, and appears to protect one from feelings of helplessness. A pessimistic explanatory style promotes helplessness. Explanatory style, in Seligman’s view, is “a habit of thought learned in childhood and adolescence.”

The concept of learned helplessness is nicely illustrated by Seligman’s classical experiment using dogs as subjects. One dog was exposed to mild but uncomfortable shocks, but provided a means of escape. A second dog was given identical shocks, but not allowed to escape. A third dog was not shocked. The following day the dogs were placed in a shuttle box which consisted of two compartments, divided by a low barrier over which the animal could easily jump.

It didn’t take long for the dog that had previously learned to control shocks to discover that he could escape the shock by jumping over the barrier. The dog that had not been shocked likewise, quickly learned the escape procedure. The dog that had been exposed to uncontrollable shocks, however, never even tried to escape, despite being able to see over the barrier to the shock-free zone. In Seligman’s view, the dog that had the prior experience of being unable to control the shock had learned the lesson that its actions are futile. This lesson later affected its ability to initiate effective action when it became possible to escape the shocks.

Similar results have been produced in experiments designed for human subjects. Learning theorists have suggested that learned helplessness is the cognitive or “thought” component of the emotional disorder we know as clinical depression. Learned helplessness has been used to explain why some people seem to give up when faced with difficult, yet surmountable challenges. For example, it may shed light on the behavior of victims of domestic abuse who typically appear unwilling or unable to take available actions to remove themselves from daily contact with their abusers. The issue of domestic abuse is obviously a complex one, and learned helplessness is but one factor among several that may work against an individual in breaking free of this dangerous cycle of violence.

The good news is that helplessness, as a learned habit of thought, can also be unlearned, and optimism can be learned. This is done by developing an explanatory style more consistent with feelings of personal control and self-efficacy. So the next time you are tempted to hold your parents, family members, spouse, coworkers, boss, political leaders, fate, or God himself responsible for life’s adversities, think again. You may find that you are better able to cope with and resolve difficulties by first determining that a source of control resides within yourself.