Ice Water and Googles Therapeutic Approaches for Depression Treatment

Two new theories of depression are refining traditional interest in the once fashionable topic of how the left and right sides of the human brain interact.

Dr. Jack Pettigrew, a neuroscientist at the University of Queensland in Brisbane, Australia, proposed that people with manic depression have a ''sticky switch'' somewhere deep in their brains.



In normal people, the switch allows either the left or right hemisphere to be dominant during different mental tasks, with the two sides constantly taking turns. In people with manic depression, one hemisphere becomes locked into a dominant position in periods of depression while the other hemisphere is locked at times of mania. In a truly bizarre finding, Dr. Pettigrew reported that the placement of ice water into one ear seems to unstick the switch.



The second theory is being put forth by Dr. Frederic Schiffer, a psychiatrist at Harvard Medical School. He maintains that one hemisphere can be more immature than the other and that this imbalance leads to different mental disorders. Dr. Schiffer has designed special goggles to help people ''talk'' to each half of the brain separately, to learn which is less mature, and to bring the two hemispheres into harmony.



Both ideas have been well received by brain lateralization authorities eager to see a revival of their specialty.



''It's nice to see the left and right hemispheres are back,'' said Dr. Brenda Milner, a cognitive neuroscientist at the Montreal Neurological Institute in Quebec. The notion that the human brain has two halves and that the left side is associated with logical, analytical thinking while the right side is more intuitive, emotional and creative was popularized about 20 years ago, she said, and soon became received wisdom about how the brain works. ''This idea fell from fashion not because people didn't like it but because they got interested in other things,'' she said.

Dr. Marcel Kinsbourne, a cognitive scientist at the New School for Social Research in New York City and early pioneer in brain lateralization studies, believes that left and right brain ideas also fell from fashion because they were oversold. People looked for universal dichotomies -- the left brain is a whiz at legal briefs but the right brain is deft at poetry -- that carried things too far. But the new theories are ''intriguing,'' Dr. Kinsbourne said, although they have a long way to go before they can be accepted as valid. ''We are in half-baked land here,'' he said.



The new theories are also appealing to many experts because they take on a question that has divided researchers for decades. Do people have one overarching mind that spans the two hemispheres? Or are they born with two separate minds -- one on the left and one on the right -- which operate so seamlessly that the person simply does not notice that there are two?



The subjective sense of having just one mind is overwhelming and unmistakable, said Dr. Joseph Bogen, a neurosurgeon at the University of Southern California in Los Angeles. But if the thick band of fibers connecting the two hemispheres is severed, he explained, humans seem to end up with two separate minds that show different abilities. In one dramatic disparity, the left hemisphere does all the talking while the mute right hemisphere has better access to emotions. For example, when the right brain is shown a photograph, the talkative left brain will say that it does not see anything and cannot comment. But the left hand, which is connected to the right brain, can raise a thumb up or down in response to the question, ''Do you like the picture?'' These kinds of experiments led to a dichotomy of opinion among neuroscientists, Dr. Bogen said. One camp held that in splitting the brain, a single mind is cut into two but that it is abnormal to have two brains. The other camp said every person is born with two brains but because the two sides get along so well, people simply have the illusion of one mind.



After thousands of experiments carried out on normal subjects and split-brain patients, scientists still passionately disagree. But one feature has clearly emerged, said Dr. Terry Sejnowski, a neuroscientist at the Salk Institute in San Diego: Human brains show enormous variation in lateralization. The claim that certain talents or abilities lie in one hemisphere or the other is usually based on averaging the brains of many people, he said. Because each individual brain is a complex system that evolves in response to a unique environment, many brain functions do not end up in the same place. This is further complicated by the fact that the left and right hemisphereprobably communicate through deeper pathways that are not affected in split-brain patients.

The new ideas about lateralization will not resolve the question of one versus two brains, but they do add insights and suggest new ways to treat mental patients, said Dr. Schiffer, whose research was set off by his observation that many of his patients seemed to have a kind of double personality. ''On the one hand, they are very mature and stable, but on the other hand, they can be irrational, overly emotional and compulsive,'' he said. ''Often these two sides appear to struggle against or sabotage each other. The troubled part seems

stuck in a traumatic past, whereas the other part seems more mature and in control.''



Suspecting he was seeing two minds working at cross purposes, Dr. Schiffer designed a pair of goggles that forced his patients to view the world from either the left or right hemisphere separately.



Many experiments show that it is possible to stimulate one hemisphere and inhibit the other so that a person looks at the world using half a brain at a time, Dr. Schiffer explained. When people gaze to the far right and engage their left brains, they do better on verbal memory tasks, he said, and when they look far to the left, to engage the right brain, they feel more inertia and fatigue.



To test how this affects psychiatric patients, Dr. Schiffer made two types of goggles. One permits vision only in the right visual field, thus activating the left brain. The other allows a person to see objects in the left visual field, which activates the right brain. Each brain hemisphere controls the opposite side of the body. When patients looked through goggles, they reported very definite feelings, depending on which side of the brain was being engaged, Dr. Schiffer said. Some felt negative symptoms like anxiety and sadness when the right brain was activated. Others felt bad when the left brain was engaged. In general, he said, depressed patients felt worse when the right side was stimulated and people with post-traumatic stress syndrome fared poorly when the left side was more active.



Dr. Schiffer speculates that in certain mental disorders, one hemisphere is less mature than the other. The immature side is the repository of past traumas and can come to dominate the healthy side. Thus each hemisphere has mental properties with some autonomy from the other side. Each can hold separate opinions, have a different sense of human and carry a different perspective on the world.



Many people feel no mood difference when wearing the goggles, Dr. Schiffer said. This may be because both their hemispheres have similar outlooks, being equally calm or equally troubled.



Dr. Schiffer uses the goggles in therapy sessions to help patients recognize their two minds and to help the mature side take control over the immature side. Patients wearing goggles can actually converse with the opposite hemisphere, he said, and through talk therapy work toward recovery. The goggles do not support the idea that the right brain is poetic and the left is logical, Dr. Schiffer said. People are very different. Each hemisphere is individualistic; either one can be messed up or both sides can be in balance.



Dr. Pettigrew, who invented the sticky-switch idea of depression, also falls into the two-minds camp. He theorizes that patients cycle between bouts of mania and depression for days, weeks or months at a time. ''Because the hemispheres have different cognitive styles, I thought it doesn't make sense to have them both working at the same time,'' Dr. Pettigrew said in an interview at the neuroscience meeting. ''So I thought there should be a switch. This would allow each side to take turns dominating.''



Dr. Pettigrew said there was plenty of evidence that different parts of each hemisphere cycle back and forth, left and right, during everyday tasks. Parts of the visual cortex switch dominance every few seconds, he said, whereas parts of the frontal lobes cycle every couple hours.

To measure how fast the two sides switch dominance in a visual task, Dr. Pettigrew used a standard apparatus that measures so-called binocular rivalry. When a target of horizontal lines is shown to the right eye and vertical lines are shown to the left eye, and the targets are flashed, the brain does not fuse the lines into a hatched pattern. One side of the brain sees vertical, the other side sees horizontal and the two take turns seeing a pure target. Most people switch sides every two to three seconds, Dr. Pettigrew said. But patients with manic depression require 20 to 30 seconds to switch between the two targets. ''I think they have a sticky switch between the hemispheres,'' he said. If the switch is stuck, it may be possible to unstick it, Dr. Pettigrew said, by turning to a strange observation made several years ago by Italian scientists.



''If you tilt a person's head 30 degrees to the side and put ice water into one ear, the opposite brain hemisphere will become activated,'' he said. Thus cold water in the left ear, activating the right hemisphere, might temporarily reduce the symptoms of mania. Depression might be temporarily reduced by placing cold water in the right ear.



Ice water in the ear is a traditional neurological test that has been performed, among other things, on astronauts in space to help understand space sickness. How ice water stimulates one hemisphere is not precisely known, but it seems to activate orientation pathways in one ear (which tell people where they are in space), and these pathways are connected to mid- and higher-brain regions in the opposite side of the head, Dr. Pettigrew said. Trying the ice water in his own left ear, Dr. Pettigrew, who suffers from manic depression, said, ''I sat on my couch at home for 40 hours, ruminating about my life.'' His left brain was stuck in the depression phase. It was, he said, an unpleasant experience.



While both theories provide interesting insight a give way to new practical therapeutic approaches, they probably cannot be considered as stand-alone therapies. "But I don't do goggle therapy," Schiffler says firmly. "The glasses are just a tool I use as an adjunct to traditional psychotherapy. They sometimes assist in freeing a patient who gets stuck at a certain point in therapy, and they can be useful in providing insights to a patient about his or her problems."



Sources and Additional Information:

http://www.appliedmeditation.org/The_Heart/hemisphere_balance.pdf

http://www.healthyplace.com/depression/shocked-ect/can-taped-goggles-heal-emotional-disorders/menu-id-1362/

http://www.ect.org/selfhelp/goggles.html

http://www.news.harvard.edu/gazette/2002/04.04/01-goggles.html

Interpersonal Therapy: Proven Anti-Depression Treatment

What Is Interpersonal Therapy?

Interpersonal therapy (IPT) is a type of treatment for patients with depression which focuses on past and present social roles and interpersonal interactions. During treatment, the therapist generally chooses one or two problem areas in the patient's current life to focus on. Examples of areas covered are disputes with friends, family or co-workers, grief and loss and role transitions, such as retirement or divorce.

IPT does not attempt to delve into inner conflicts resulting from past experiences. Rather it attempts to help the patient find better ways to deal with current problems.

Historical Background

• IPT has no specific theoretical origin although its theoretical basis can be seen as coming from the work of Sullivan, Meyer and Bowlby. Whilst Sullivan wrote of a type of "interpersonal therapy" in the 1930s, this was more in the form of a long term analytic but relational based therapy and would not be seen to resemble the current form of IPT. Attachment theorists view the experience of loss and to a lesser degree disordered attachment as underlying much of human psychopathology. IPT can be seen as indirectly addressing these issues within the therapeutic frame.


• The current form of the treatment was developed by the late Gerald Klerman and Myrna Weissman in the 1980s as a means of operationalizing the interpersonal approach to psychotherapy for a series of treatment studies in depression conducted in the United States. Since that time it has been modified for a variety of other indications including Dysthymia, Bulimia Nervosa, Substance Misuse, Somatization and depression in a variety of clinical settings. Preliminary studies in Anorexia Nervosa, Bipolar Disorder, PTSD and some anxiety disorders are underway. In each adaptation the fundamentals of the treatment manual are adhered to, however different components are emphasized.

Interpersonal Therapy

Subtypes of Interpersonal Therapy

There are two subtypes of IPT. The first type is used for the short-term treatment of a depressive episode. The patient and therapist typically meet weekly for two to four months and treatment ends once the symptoms subside. The second type is maintenance treatment (IPT-M), which is long-term treatment with the goal of preventing or reducing the number of future episodes of depression. IPT-M may consist of monthly sessions over a period of two to three years.

Structure and Duration of Sessions

• IPT usually runs from 12 to 16 one hour sessions that usually occur weekly. The initial sessions are devoted to information gathering and clarifying the nature of the patient's illness and interpersonal experience. The patient's illness is then formulated and explained in interpersonal terms and the nature and structure of the IPT sessions are explained. This phase of treatment concludes with the composition of the "interpersonal inventory" which is essentially a register of all the key relationships in the individual's life. Within the interpersonal inventory relationships are categorized according to the four areas mentioned above.

• Sessions 3 - 14 are devoted to addressing the problematic relationship areas and there is little focus upon the specific illness process apart from enquiries as to symptom severity and response to treatment modalities.

• The final sessions 15 - 16 focus upon termination, which is usually formulated as a loss experience from which the patient can learn a great deal about their own responses to loss and how well the modifications attempted in the therapeutic process have evolved.

Four Basic Problem Areas Identified by Interpersonal Therapy

IPT identifies four basic problem areas which contribute to depression. The therapist helps the patient determine which area is the most responsible for his depression and therapy is then directed at helping the patient deal with this problem area.

The four basic problem areas recognized by Interpersonal Therapy are:

• Interpersonal Disputes

These tend to occur in marital, family, social or work settings. They can be conceptualized as a situation in which the patient and other parties have diverging expectations of a situation and that this conflict is excessive enough to lead to significant distress. One example may be a marital dispute in which a wife's attempts to use initiative leads to conflict with her spouse. In these circumstances IPT would aim to define how intractable the dispute was, identify sources of misunderstanding via faulty communication and invalid or unreasonable expectations and the aim to intervene by communication training, problem solving or other techniques that aim to facilitate change in the situation.

• Role Transitions

Role transitions are situations in which the patient has to adapt to a change in life circumstances. These may be developmental crises, adjustments in work or social settings or adaptations following life events or relationship dissolutions. In those who develop depression, these transitions are experienced as losses and hence contribute to the development of psychopathology. IPT aims to help the patient with role transitions to reappraise the old and new roles, to identify sources of difficulty in the new role and fashion solutions for these. In many cases clarification of inconsistencies or clear errors in the patient's cognitions as well as problem solving and encouragement of affect within the therapeutic frame are suitable interventions.

• Grief

Grief is simply defined in IPT as "loss through death". Whilst many clinicians would formulate sequelae of severe medical e.g. loss of function illness as grief, in IPT the term is reserved specifically for bereavement. In IPT, if grief is formulated as an issue of relevance in the interpersonal inventory, the assumption of the patient and therapist is that the grieving process has been complicated by delay or in many cases excess. The IPT therapist will help to reconstruct the patient's relationship with the deceased and by encouraging affect as well as clarification and empathic listening help facilitate the mourning process with the aim of helping the patient to establish new relationships.

• Interpersonal Deficits

These would be diagnosed when a patient reports impoverished interpersonal relationships in terms of both number and quality of the relationships described. In many cases the interpersonal inventory will be sparse and the patient and therapist will need to focus upon both old relationships as well as the relationship with the therapist. In the former common themes should be identified and linked to current circumstances. In using the therapeutic relationship the therapist aims to identify problematic processes occurring such as excess dependency or hostility and aim to modify these within the therapeutic frame. In this way the therapeutic relationship can serve as a template for further relationships which the therapist will aim to help the patient create. This group of problems is common in the more chronic affective disorders such a dysthymia in which significant degrees of social impoverishment have occurred either before or after the illness.

Interpersonal Therapy

Techniques used in IPT

• IPT utilizes several techniques within the therapeutic process. Many of these are modified interventions borrowed from other therapies such as cognitive-behavior therapy and brief crisis intervention.

• The use of various questioning styles such as "Clarification" which seeks to obviate the patient's biases in describing interpersonal issues as well as "Supportive Listening" are often therapeutic within themselves. "Role playing" and "Communication Analysis" are highly behavioral interventions and are invaluable tools in intervening in interpersonal disputes. The "Encouragement of Affect" allows the patient to experience unpleasant or unwanted affects (that have perhaps resulted in the deployment of pathogenic defense mechanisms) safely within the therapeutic frame. This process allows the patient to acknowledge the affective component of an interpersonal issue e.g. grief and helps the patient to accept it as a part of their experience. The "Use of the Therapeutic Relationship" has been described earlier.

• There is some degree of debate as to whether therapists should be more or less active in the conduct of the sessions other than keep the focus on interpersonal issues. There are clearly no distinct guidelines in this area although the goal of IPT is to facilitate the process of the patient generating their own interventions and thus progressively phasing the therapist out of the process. It is likely that the process of patient initiated changes is the likely mechanism to account for the observation that symptomatic improvement arising from IPT often peaks 3 - 6 months subsequent to the termination of treatment.

Conclusion

IPT is most useful for people who are in the midst of recent conflicts with significant others and/or have experienced difficulty adjusting to stressful life transitions. As with CBT, patients who are unable or unwilling to practice skills taught in therapy are not likely to gain significant symptom relief. Most therapists recommend that clients remain in ongoing, maintenance therapy if that is possible. Maintenance IPT (IPT-M) is often used following termination of the short-term phase of therapy. Recent research suggests that IPT-M may prevent future episodes of depression, particularly in women.

In clinical trials, both CBT and IPT have been found to be effective treatments for depression. There is no certain way to know up front (without actually trying them) whether one form of therapy will be a better fit for patients than the other. The available studies are too small and specific to recommend a specific type of person who would benefit best from one or another type of therapy. Just as patients may need to try different types of antidepressant medication, the may also need to try different types of therapy, or even different therapists within a particular therapeutic approach to gain maximum relief.

Sources and Additional Information:

http://depression.about.com/od/psychotherapy/a/interpersonal.htm

http://interpersonalpsychotherapy.org/

http://www.apa.org/divisions/div12/rev_est/ipt_depr.html

http://www.mentalhelp.net/poc/view_doc.php?type=doc&id=13026&cn=5