Recovering patients describe their battles with an "anorexia voice"

People with anorexia find comfort in their illness at first, but then it becomes over-powering and they end up battling for control of their own minds. That's according to Sarah Williams and Marie Reid, who conducted an online focus group and email interviews with 14 people recovering from anorexia nervosa, aged 21 to 50 and including two men.

A consistent theme to emerge was that anorexia at first provided a sense of control and identity. The participants recalled enjoying striving for perfection. They saw thinness as an ideal that was within their means to reach. "Anorexia became a friend," said Natalie*. "When I was alone ... I knew that at least I had A." Jon said: "It was a way to control what was happening to me on a day to day basis, and also my weight."

Eventually though, rather than being a solution, anorexia became a problem all of its own. Said Lisa: "I call my anorexia 'the demon' who controls my thoughts, feelings, emotions and actions." Jon: "It's like there are two people in my head: the part that knows what needs to be done and the part of me that is trying to lead me astray. Ana is the part that is leading me astray and dominates me."

"Having developed the anorexic voice, participants came to feel that it was to an extent split from their authentic selves," said Williams and Reid. The research pair explained how their findings, placed in the context of similar results from past studies, provided useful ideas for therapeutic intervention. In particular, they suggested the need for recovering anorexia clients to acknowledge other positions beyond the anorexia voice and their own authentic self. "Wellness cannot simply be the absence of anorexia nervosa symptoms because this can intensify the inner battle with the anorexic voice," they said.

Williams and Reid advised using therapy to help build clients' sense of self. "This study suggests that this means developing the self beyond an ambivalent conflict between the authentic self and the anorexic voice," they said. "This would allow a new more positive dominant position to develop."

One approach that may be particularly suitable, according to Williams and Reid, is emotion-focused therapy (EFT). A technique used in EFT is for clients to address an empty chair, which represents their critical "anorexia voice". With the aid of the therapist, this can lead to a softening of the anorexic critic and the fostering of a new dominant position in the self. However, the researchers cautioned that there are "as yet ... no studies investigating the efficacy of externalisation techniques such as those used in EFT and this warrants further attention."
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Williams, S., and Reid, M. (2011). ‘It's like there are two people in my head’: A phenomenological exploration of anorexia nervosa and its relationship to the self. Psychology and; Health, 1-18 DOI: 10.1080/08870446.2011.595488

*The names used here are the pseudonyms that appear in the paper.

Post written by Christian Jarrett for the BPS Research Digest.

Positive psychology exercises can be harmful for some

Positive psychology exercises work by developing people's strengths and emotional resources, thereby building their resilience to depression. For a new study, Susan Sergeant and Myriam Mongrain wanted to test the idea that these exercises will be more effective if they're tailored to people's particular personality type. They focused on two traits associated with vulnerability to depression: being excessively self-critical and being excessively needy.

Sergeant and Mongrain predicted that a gratitude exercise would be especially effective for self-critics by replacing a negative self-focus with an appreciation for the external world. And they thought a positive-music listening exercise would be particularly suited to needy people, offering them a practical tool that they could use independently. A control condition involved recalling early childhood memories.

The take-home finding is that whilst there was some evidence that self-critical people benefited more from the gratitude exercise than the music or control exercises (in terms of a greater happiness boost), the high neediness participants actually experienced reductions in their self-esteem following the gratitude and music exercises compared with the control exercise, and no benefits. "The present findings provide the first hint of deleterious effects that can be incurred by the use of positive psychology exercises," the researchers said.

The findings came from an Internet study of 772 volunteers. After completing baseline measures of self-esteem, happiness, depression, physical health, and the key traits of self-criticism and neediness, the participants were randomly allocated to a one-week intervention: either gratitude, music or the control task. The daily gratitude exercise involved recalling five things to be grateful for that day; the music task involved listening to three or four uplifting songs of their choosing each day; the memory task involved writing about a different childhood memory each day. Follow-up measures of depression and the rest were completed after the week's intervention and again at one, three and six-months. Two hundred and eighty-three participants stayed the course until the study end.

Why did high scorers in neediness actually show reductions in self-esteem after the positive exercises? Sergeant and Mongrain can't be sure, but they speculated that they'd chosen the wrong kind of exercise for these people. "... [B]oth tasks were focused on independent activity and required little involvement with other people," they said. "Needy people rely on having secure intimate bonds with others in order to experience well-being." It's also possible that the exercises were merely ineffectual for the needy participants, rather than harmful, but that they chose to take out their frustration about this on the outcome measures. Other study weaknesses include the impersonal nature of an Internet study and the brevity of the intervention.

These results add to an existing literature on the potential hazards of self-help. A 2010 study found that CBT-based self-help books were harmful for high ruminators (people who spend a lot of time thinking about their own thoughts and emotions); and a 2009 study found that uttering positive self-help mantras (e.g. "I'm a lovable person") backfired for people with low self-esteem.
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Sergeant, S., and Mongrain, M. (2011). Are positive psychology exercises helpful for people with depressive personality styles? The Journal of Positive Psychology, 6 (4), 260-272 DOI: 10.1080/17439760.2011.577089

Post written by Christian Jarrett for the BPS Research Digest.

"Most people with a mental disorder are happy"

It's easy for us to slip into all-or-nothing mindsets. An example would be: a person has some psychological problems so their life must be miserable. But that's a mistaken assumption. So argue a team of Dutch positive psychologists, who've studied over seven thousand people over a three year period. Yes, those participants with a psychological disorder were less happy than those without, but the majority (68.4 per cent) of the mentally troubled said they "often felt happy" during the preceding four weeks (this compares with 89.1 per cent of those without a psychological problem). "The possibility of coexisting happiness and mental disorders is of clinical relevance," write Ad Bergsma and his team. "A narrow focus on what goes wrong in the lives of the client and forgetting what goes well, may limit therapeutic results."

The researchers recruited their sample, representative of the general population, from across the country. Trained interviewers questioned volunteers in person or over the telephone to establish signs of psychological disorder in the past month, with 16.5 per cent of the sample being judged to have a disorder based on psychiatric diagnostic criteria. Happiness was measured with a single question about frequency of happy moods over the preceding four weeks, on a scale from "never" to "always". Relying on people's reports of their own happiness, using this one question, is an obvious weakness of the study.

Not surprisingly, among those with a psychological problem, happiness was lowest in those with anxiety and depression (although still a significant minority of these people reported frequent happy moods). By contrast, happiness was highest in those with an alcohol abuse disorder, being nearly as frequent as in the healthy participants. There weren't enough cases of eating disorders and psychosis to examine these conditions separately.

By following their sample up over time, the researchers established that more happiness at the study start was associated with better outcomes later on, in terms of recovery from mental disorder. Further analysis suggested this was because higher happiness was a proxy for having fewer mental disorders, being younger, and having better "emotional role functioning" (as indicated by managing to spend time on work and other activities). The fact that happiness was associated with later outcomes provides some support for the validity of the way that happiness was measured.

"Our knowledge of mental disorders is incomplete if we only look at the negative side of the spectrum," the researchers said. "This study aims to broaden the view on positive functioning and human strengths in the context of mental disorders."
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Bergsma, A., Have, M., Veenhoven, R., and Graaf, R. (2011). Most people with mental disorders are happy: A 3-year follow-up in the Dutch general population. The Journal of Positive Psychology, 6 (4), 253-259 DOI: 10.1080/17439760.2011.577086

Post written by Christian Jarrett for the BPS Research Digest.

When humans play dead

When a rabbit or other animal is trapped by a predator, it will freeze and assess the situation. It might then flee or attack, what we usually call the "fight or flight response". If that fails, a last-ditch defence mechanism is to go completely immobile, to play dead.

Researchers in Brazil now say that in times of grave danger, this same automatic last resort is also exhibited by humans and is experienced as a terrifying feeling of being "locked-in". The team led by Eliane Volchan performed what they describe as the first lab-study of "tonic immobility" in humans, and they argue that greater awareness of the response could help our understanding of people's reactions in real-life situations. For example, rape victims often experience shame after not resisting physically, and in some jurisdictions their passive response is interpreted as a sign of consent. Similarly, police officers and related professionals may be condemned for not reacting proactively in danger situations.

Volchan and her colleagues recruited 33 trauma survivors (15 women), including 18 with a dignosis of Post-Traumatic Stress Disorder (PTSD). They were asked to describe their ordeals in minute detail and these accounts were transformed into a 60-second audio narrative presented by a male voice in the second-person, present tense (e.g. "You are walking home and a man appears ..."). Each participant's account was played back to them over head-phones while they stood on a platform that records body sway. Their heart rate was also monitored and afterwards they were asked questions about how they felt as they listened to the recording.

The results provided physiological evidence of "tonic immobility" in humans. Participants who reported a strong sense of being paralysed, frozen, unable to move or scream, tended to show less body sway, higher heart rate and less heart rate variability. This was true across both PTSD and non-PTSD patients, but it was the PTSD patients who were more likely to report feelings of paralysis whilst listening to the recording of their ordeal.

"We succeeded in experimentally inducing tonic immobility in humans and recording its biological correlates, indicating that tonic immobility is preserved in humans as an involuntary defensive strategy to life-threatening events," the researchers said.

"Tonic immobility still remains largely unrecognized in humans," they added. "Thus, essential steps to alleviate entrapment symptoms, guilt and prejudice in the aftermath of tonic immobility are the recognition of tonic immobility and dissemination of this knowledge to the public."
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Volchan, E., Souza, G., Franklin, C., Norte, C., Rocha-Rego, V., Oliveira, J., David, I., Mendlowicz, M., Coutinho, E., Fiszman, A., Berger, W., Marques-Portella, C., and Figueira, I. (2011). Is there tonic immobility in humans? Biological evidence from victims of traumatic stress. Biological Psychology, 88 (1), 13-19 DOI: 10.1016/j.biopsycho.2011.06.002

Post written by Christian Jarrett for the BPS Research Digest.

Psychosis isn't always pathological

Unusual, psychotic-like symptoms, such as hearing voices, are not as rare among the general population as you might think. For example, it's estimated that ten per cent of us hear voices that aren't there, with only a small minority of hearers likely to ever receive a clinical diagnosis. According to a new study, this means that the factors that cause psychotic-like symptoms are likely different from those that lead to a diagnosis of pathological psychosis. Charles Heriot-Maitland and his colleagues argue that this distinction has been missed by the majority of past studies that hunted the causes of psychosis by focusing only on patients, neglecting those who live happily with their psychotic-like experiences.

To make a start rectifying this situation, Heriot-Maitland's team interviewed six patients with psychosis (recruited via psychosis teams in SE England) and six "healthy" non-patients, who reported similar unusual experiences (recruited via UK networks involved with spiritual or psychic phenomena). Across both groups, these experiences included: receiving visions from God, hearing voices, and feeling that their body had been taken over. Based on their symptoms alone, you couldn't tell which group a participant belonged to - clinical or non-clinical. The researchers asked all the participants open-ended questions about the circumstances that led to the onset of their unusual experiences, how they felt about them, and how their friends, relatives and other people had responded.

Using a qualitative method called Interpretative Phenomenological Analysis, the researchers looked for emerging themes in the participants' answers. Both similarities and differences emerged. In both groups, their unusual psychotic experiences had started after a period of negative emotion, most often accompanied by feelings of isolation and deep contemplation about the meaning of life. However, the groups differed in how they responded to and perceived their odd experiences. Members of the non-clinical group had been more aware of non-medical interpretations of their symptoms; they viewed them as transient and desirable; and people close to them shared this non-pathologising perspective. By contrast, the patients encountered invalidating, medical interpretations of their experiences and were themselves less able to accept their experiences and to incorporate them into their personal and social worlds.

From a theoretical point of view, Heriot-Maitland and his colleagues said there was a need for a more precise approach to the study of psychosis, which distinguishes risk factors for psychotic experiences from risk factors for actual clinical vulnerability. "It would seem that the more out-of-the-ordinary experiences are associated with clinical psychosis, the less chance people have of recognising their desirability, transiency, and psychological benefits, and the more chance they have of detrimental clinical consequences."

The researchers added that this has important clinical implications: "psychotic experiences should be normalised," they said, "and people with psychosis should be helped to re-connect the meaning of their out-of-the-ordinary experiences with the genuine emotional and existential concerns that preceded them." They also acknowledged that more studies, including quantitative investigations, are needed to build on this initial work.
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Heriot-Maitland, C., Knight, M., and Peters, E. (2011). A qualitative comparison of psychotic-like phenomena in clinical and non-clinical populations. British Journal of Clinical Psychology DOI: 10.1111/j.2044-8260.2011.02011.x

Further reading: The British Psychological Society's response to the planned changes to the DSM - psychiatry's diagnostic code. In its response the BPS airs its concerns about the over-medicalisation of people's experiences.

Post written by Christian Jarrett for the BPS Research Digest.

The woman misdiagnosed with Alzheimer's, and how we can all be affected by the suggestion that we have psychological problems

Psychologists in the Netherlands have documented the case of a 58-year-old woman who was misdiagnosed with Alzheimer's Disease. The would-be patient consulted a neurologist at a stressful time in her life, in the knowledge that her mother had had the illness. A brain scan indicated reduced activity at the front of her brain ("hypofrontality"), and the neurologist also estimated her performance on a test of cognitive impairment as poor (though no formal test was conducted). On this basis he diagnosed Alzheimer's*.

The woman was devastated and thereafter her condition deteriorated significantly, to the point that she was permanently confused and, at one point, suicidal. Some months later, after receiving advice from an Alzheimer's helpline, the woman consulted a different neurologist for a second opinion. She completed comprehensive memory tests and undertook a further brain scan. All results were normal. This neurologist surmised that her earlier hypofrontality was associated with depression. He also went to great lengths to explain the good news about her results and the misinterpretation of her earlier scan, but it proved extremely difficult to assuage her concerns.

Years later, Harald Merckelbach and his team have interviewed the woman and they report that she continues to experience intrusive thoughts about the misdiagnosis and to catastrophise her memory lapses. Merckelbach's group believe the effect of a misdiagnosis has parallels with the implantation of false memories. Just as false memories are difficult to reverse, so too are mistaken diagnoses. "Conferring a diagnostic label is far from a neutral act," they said. "Many diagnostic labels have strong stereotypical connotations and sometimes, these will automatically shape the experiences and behaviour of patients, a phenomenon called 'diagnoses threat'."

To test these ideas further, Merckelbach, with colleagues Marko Jelicic and Maarten Pieters, gave 78 undergrads a psychological symptoms questionnaire to complete. Afterwards the students performed Suduko puzzles as a distraction. Next, the researchers went through some of the students' answers with them. During this review, the researchers inflated two of the answers they'd given to anxiety items. For example, imagine a student had originally indicated that she never had trouble concentrating. The researcher would inflate that answer by two points on the scale, as if she'd said that she sometimes had trouble concentrating, and they then asked the student to explain why she'd given that answer. Remarkably, 63 per cent of the participants failed to notice that their answers had been altered, and they proceeded to describe their experience of the symptoms (readers may notice parallels here with a phenomenon known as "choice blindness", in which people seem to have little insight into a recent choice they made).

Ten minutes later, and again after one week, all the students re-took the psychological symptoms questionnaire. At both time points, students who'd earlier failed to notice that two of their answers had been altered, now gave higher ratings to those two items, as if they considered themselves to have those symptoms. Such an effect was not observed among the minority of students who'd earlier noticed that their answers had been altered. An analysis of all the students' original baseline answers uncovered higher average baseline symptoms among those who would fail to notice the inflation of their answers. "Apparently a non-zero symptom intensity level introduces ambiguity; thereby raising the probability that misinformation is accepted," the researchers said. However, it's not the case that the influenced participants were simply more keen to give answers that the researchers wanted - they scored just the same on a test of social desirability.

The results from this study are consistent with past research showing how misinformation about physical symptoms can shape how people feel: for example, false feedback about asthmatic wheezing can trigger breathlessness in children with asthma.

Harald Merckelbach and his colleagues said their findings had particular significance for the way medical professionals interact with patients with unexplained symptoms, including those labelled with chronic fatigue, fibromyalgia, irritable bowel syndrome, and chronic pain. "... Expressing concern about the possibility of an underlying illness and, related to this, excessive investigation and attending patient support groups may all contribute to symptom escalation. What these interventions have in common is that they convey the message to the patient that his or her symptoms might be more intense and severe than he/she thinks they are. Our study suggests that blindness to unintended misinformation about the severity of the symptoms may underlie escalation of symptoms."

The researchers recommend that medics avoid mentioning the whole spectrum of possible symptoms when interviewing patients with medically unexplained symptoms. They also pointed to interesting avenues for future research. For example, notwithstanding the ethical issues involved, could patients benefit from receiving misinformation that lowered their symptom ratings? Also, is the inflated self-reporting of symptoms observed here based purely on exaggerated report, or is it grounded in an altered experience of symptoms?
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Merckelbach, H., Jelicic, M., and Jonker, C. (2011). Planting a misdiagnosis of Alzheimer's disease in a person's mind. Acta Neuropsychiatrica DOI: 10.1111/j.1601-5215.2011.00586.x

Harald Merckelbach, Marko Jelicic and Maarten Pieters (In Press). Misinformation increases symptom reporting – a test – retest experiment. J R Soc Med Sh Rep.

*Many years later, the neurologist was found guilty of having misdiagnosed several patients with Alzheimer's and 26 malpractice suits were filed against him (the woman featured in this case study was not part of that litigation).

This post was written by Christian Jarrett for the BPS Research Digest.

Are people with social anxiety preoccupied by social rank?

People with a diagnosis of social anxiety disorder find social situations nerve wracking, from mixing with friends to speaking in public. A number of explanations have been proposed for why they feel this way, including that they are pre-occupied with creating the right impression. A new study makes a related but distinct claim, which is that people with social anxiety are overly concerned with social hierarchy, and struggle with what's called the affiliative side of relationships. In simple terms this means they tend to perceive social situations as competitive, judging themselves as having low rank compared with other people, and they also have difficulty forming close relationships.

Ora Weisman and her colleagues made their claims after surveying 42 social anxiety disorder clients at a public clinic in Israel and 47 community controls. Potential recruits to the client group were excluded if they had depression, schizophrenia or an addiction problem. Comparing the two groups, the researchers found that the clients with social anxiety tended to report more submissive behaviour (e.g. agreeing to being wrong, even when knowing they were right), saw themselves as having low social rank, were more sensitive to rejection, had less closeness to their friends, and avoided getting too attached to romantic partners.

A second study was similar to the first, except this time the researchers compared clients with a joint diagnosis of social anxiety and depression against clients with an anxiety diagnosis other than social anxiety (e.g. panic disorder, generalised anxiety disorder) plus depression. Once again, it was the social anxiety group who scored higher on submissive behaviour, avoidance of attachment, lower perceived social rank and greater rejection sensitivity. Together both studies suggest that social anxiety is associated with these characteristics above and beyond the influence of depression.

Limitations of the study include its reliance on self-report and the fact that clients weren't followed up over time. This means it's difficult to tell if the measured characteristics (such as perceiving oneself as having low social rank) are a cause or a consequence of social anxiety.

Weisman and her team said their findings have treatment implications. Therapists should include techniques that focus on negative self-perception, they advised, including the use of video-feedback, and ways to overcome submissive behaviours. This work could extend to reducing the frequency of emotions such as shame and humiliation, they said, which may contribute to clients downplaying their social status. Also the affiliation side should be addressed too, Weisman's group said: "...issues such as sharing and self-disclosure can help achieve intimacy and closeness with others and reduce social anxiety."
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O Weisman, I Aderka, S Marom, H Hermesh, and E Gilboa-Schechtman (2011). Social rank and affiliation in social anxiety disorder. Behaviour Research and Therapy DOI: 10.1016/j.brat.2011.03.010

This post was written by Christian Jarrett for the BPS Research Digest.

Beware the "super well" - why the controls in psychology research are often too healthy

Many studies in clinical psychology and psychiatry are making the mistake of using healthy controls who are too healthy. That's according to a thought-provoking opinion piece by Sharon Schwartz and Ezra Susser - experts in the epidemiology of mental health.

Schwartz and Susser invite readers to consider a hypothetical study that samples participants from a wider group made up of people exposed to a virus prenatally and people not exposed to that virus. Imagine that a psychiatric registry is used to identify all the participants from this wider group who are diagnosed with schizophrenia, and they are compared with a slice of healthy participants recruited from the same source. The aim is to see what proportion of the participants with schizophrenia were exposed to the virus and what proportion of the healthy controls were exposed to the virus. If the history of exposure is higher among the schizophrenia participants, then this would suggest there may be an association between the virus and the later development of schizophrenia. In Schwartz and Susser's hypothetical scenario, there is no difference between patients and controls in rates of virus exposure and so the virus seems unassociated with schizophrenia. So far, so good - this is a classic case-controlled study.

The problem identified by Schwartz and Susser is that many such studies apply an exclusion criterion or criteria to the healthy controls that they don't also apply to the patient group. For example, they might rule out healthy controls with an alcohol problem, or depression, or even a physical disorder. The motivation for this is often the fear that these other disorders will obscure the potential link between the cause of interest and the condition of interest (virus exposure and schizophrenia in our ongoing example).

But to apply such exclusion criteria in a one-sided fashion (to the controls but not the patients), creates a serious confound. In our example, imagine that depressed "healthy" controls are excluded and imagine too that there is an underlying association between the virus exposure and depression. Excluding healthy controls with depression in this scenario would distort the results such that the virus appeared wrongly to be associated with schizophrenia (check out the full paper for the data behind this).

"With all the potential sources of bias in a biologic case-control study, why do we focus on the use of well controls?" the researchers asked. "We do so because the use of well controls is a common, and often recommended, method to select controls. Yet it is time-consuming and expensive, can cause considerable bias and does not improve study results."

If researchers include patient participants with other co-morbid diagnoses in their case-controlled studies, Schwartz and Susser went on to explain, then they must also include "healthy" controls who happen to have these other conditions. On the other hand, if researchers want to exclude other conditions, so as to clean up their investigation, then they must exclude both patient participants and controls with these other diagnoses.
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Schwartz, S., and Susser, E. (2011). The use of well controls: an unhealthy practice in psychiatric research. Psychological Medicine, 41 (06), 1127-1131 DOI: 10.1017/S0033291710001595

This post was written by Christian Jarrett for the BPS Research Digest.

Does retail therapy work?

It might not be possible to buy happiness, but you can buy relief from low mood. That's according to an investigation of retail therapy by Selin Atalay and Margaret Meloy. Through three separate studies the pair concluded that retail therapy generally works, that people deploy the practice strategically, rather than impulsively, and that there are few if any negative emotional side-effects.

But before you head off for a quick spending spree, note the caveats: the study relied on US participants, mostly university students; measures of mood were self-report; and there was deviation into a study of chocolate consumption, as opposed to actual buying behaviour.

The investigation kicked off at a US shopping mall, with nearly two hundred shoppers surveyed on their way in and way out. This confirmed that people use retail therapy as a mood enhancer. Those participants who reported being in a bad mood on their way into the mall were more likely to admit on their way out to having made an unplanned self-indulgent purchase.

For a second study, dozens of students thought they were taking part in a taste test to do with developing new ice-cream flavours, for which they had the opportunity to sample a number of chocolate snack bars. Half these participants had been primed earlier with a short passage of text that said impulsive people are far less creative than more restrained folk. These same participants also completed an earlier word search task that included restraint-related words like "careful". All this was intended to set them a goal of wanting to be restrained.

The subsequent finding was that participants in low mood at the study outset tended to eat more of the sample snack bars, unless, that is, they'd been exposed to the restraint-based text and word-search. Eating more chocolate led to a lift for those in low mood at the study outset, but so too did succeeding at restraint for those primed with that goal. Atalay and Meloy said this result shows that consumers are strategic rather than impulsive. "If there are mood reparatory benefits associated with showing restraint, individuals are capable of not acting on their impulses," they said.

Lastly the researchers had 69 undergrads complete two retrospective consumption diaries, two weeks apart, documenting their purchasing behaviour, mood and regrets. All the participants admitted in the first diary to having bought themselves a treat (mostly clothes, but also food, electronics, entertainment products and so on). Sixty-two per cent of these purchases had been motivated by low mood, 28 per cent as a form of celebration. Surprisingly perhaps, treats bought as a form of mood repair were generally about half the value of treats bought for celebration, reinforcing the notion that retail therapy is constrained, not out of control. Moreover, according to the diaries, the retail therapy purchases were overwhelmingly beneficial, leading to mood boosts and no regrets or guilt, even when they were unplanned. Only one participant who'd made a retail therapy purchase said that she would return it, given the opportunity.

"It is not suggested here that every retailer suddenly make a small treat item available at checkout to tempt consumers, or that mall planners strategically locate candy stores near every mall exit," the researchers said. "What is suggested is that perhaps practitioners have it 'right' when they appeal to consumers with slogans that encourage them to buy themselves small splurges. There seem to be positive consequences to buying oneself a small treat; one does feel better."
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Atalay, A., and Meloy, M. (2011). Retail therapy: A strategic effort to improve mood. Psychology and Marketing, 28 (6), 638-659 DOI: 10.1002/mar.20404

A related study was published recently: The Plastic Trap: Self-Threat Drives Credit Usage and Status Consumption.

This post was written by Christian Jarrett for the BPS Research Digest.

Why positive fantasies make your dreams less likely to come true

It's a trusted tool in the self-help armoury - visualising yourself having achieved your goals, be that weighing less, enjoying the view atop Everest, or walking down the aisle with the girl or boy of your dreams. Trouble is, reams of research shows that indulging in positive fantasies actually makes people's fantasised ambitions less likely to become reality. Why? A new study claims it's because positive fantasies are de-energising.

They "make energy seem unnecessary" say Heather Kappes and Gabriele Oettingen.  "By allowing people to consummate a desired future", the researchers explain, positive fantasies trigger the relaxation that would normally accompany actual achievement, rather than marshaling the energy needed to obtain it.

The researchers demonstrated this process across four studies. The first was the least convincing and read like a throwback to the 1960s. Women who were asked to fantasise positively about looking and feeling good in high-heeled shoes subsequently demonstrated lower energy, as revealed by their having lowing blood pressure, than did women asked to fantasise more critically about the pros and cons of wearing trendy, high-heeled shoes.

The research improved. In the second study, participants asked to fantasise positively about winning an essay contest subsequently reported feeling less energised than did participants asked to fantasise more negatively about their prospects.

Next, a positive fantasy about the coming week led participants to feel less energised, and when surveyed a week later, they'd achieved fewer of their week's goals, than had control participants who'd originally been asked to day-dream freely about the coming week.

Finally, Kappes and Oettingen highlighted the role of context, showing that positive fantasies about a pressing need are particularly de-energising. This elaborate study involved asking student participants to refrain from food and water for several hours, and then having some of them eat crackers (ostensibly as part of a taste test). For these super-thirsty participants it was a positive fantasy about a tall glass of icy water, not a fantasy about exam success, that led them to be de-energised (as indicated by a drop in blood pressure). For participants allowed to have a glass of water, by contrast, it was positive fantasies about exam success, not water, that led to them being de-energised.

Across all the studies, the researchers took pains to factor out other explanations - for example, they ruled out the effect of irritation, in case negative fantasies are energising by virtue of being irritating. They ruled out the possibility that some fantasies are easier to conjure than others. And they had a neutral fantasy condition, allowing them to confirm that positive fantasies really are de-energising, rather than it simply being that negative fantasies are energising.

So, is there any benefit to positive fantasies? From a survival perspective, if a goal, such as food or water, is unobtainable, there could be some advantage to enjoying a fantasy that switches you into a low-energy mode. Similarly, if a task fills you with dread and your short-term goal is relaxation, then indulging in positive fantasies about desired outcomes could be a way to reduce anxiety.

But ultimately, Happes and Oettingen believe that positive fantasies are likely to scupper your chances of obtaining your goals. "Instead of promoting achievement, positive fantasies will sap job-seekers of the energy to pound the pavement, and drain the lovelorn of the energy to approach the one they like," they write. "Fantasies that are less positive - that question whether an ideal future can be achieved, and that depict obstacles, problems and setbacks - should be more beneficial for mustering the energy needed to obtain success."

This study isn't the first to explode the myth of a traditional self-help tool. A 2009 paper found that repeating positive mantras about themselves led people low in self-esteem to feel worse.
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Kappes, H., and Oettingen, G. (2011). Positive fantasies about idealized futures sap energy. Journal of Experimental Social Psychology, 47 (4), 719-729 DOI: 10.1016/j.jesp.2011.02.003

This post was written by Christian Jarrett for the BPS Research Digest.

Sweaty work in the hunt for the brain basis of social anxiety

Anxiety has overtaken depression to become the most commonly diagnosed psychological disorder in the United States, with social anxiety its most frequent manifestation. Part of the cause of extreme social anxiety is thought to be related to bad experiences - being laughed at in class, blushing in front of friends, choking on a first date - so that a person learns to fear social situations. But that's unlikely to be the whole story. Social anxiety runs in families suggesting some people have an innate predisposition for the disorder. The authors of a new study believe they've identified, for the first time, a neural correlate of this vulnerability.

Wen Zhou and colleagues scanned the brains of nineteen women while they were exposed to the smell of two types of men's sweat, a floral scent, and the human steroid (and putative pheromone) androstadienone. One of the male sweat types was sexual, the other was neutral, and they were collected from men's armpits as they watched either a sexual film or an educational documentary. The women weren't told what the different smells were or where they came from.

Human sweat is known to convey social signals. For example, it's been shown that people can tell a person's emotional state purely from the smell of their sweat. The key findings in this new study are that the two types of sweat, compared to the other odours, led to increased activation in the orbitofrontal cortex (OFC) of the women's brains, and that the level of this activation was related to the women's amount of self-reported trait social anxiety. The women didn't have any psychiatric diagnoses but the higher they scored on a measure of trait social anxiety (e.g. they said they felt uncomfortable in large groups), the less activation they exhibited in their OFC when exposed to the men's sweat.

It's important to emphasise that most of the women (nearly 90 per cent) didn't realise the smells were from humans, and the smells had no effect on their in-the-moment mood or anxiety levels. Consistent with this, the different smells didn't differentially affect the amygdala, a bilateral subcortical structure associated with fear processing. What the study appears to be showing is that subconscious social signals trigger increased OFC activity compared with nonsocial smells, and that the level of this activity is moderated by trait social anxiety.

Why the OFC? The OFC is heavily interconnected with the amygdala and is known to be involved in the learning of rewards and punishments and in decision-making. Another brain imaging study found that public speaking was associated with increased activation in the amygdala and reduced activation in the OFC. So it makes sense that people with a predisposition for social anxiety may have an OFC cortex that functions differently from those without such a disposition.

'Whether such inherent variations can be directly mapped onto genetic differences or personality traits in both normal and clinical populations, is an important open question and this deserves serious studies in the future,' the researchers said.
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Zhou, W., Hou, P., Zhou, Y., and Chen, D. (2010). Reduced recruitment of orbitofrontal cortex to human social chemosensory cues in social anxiety. NeuroImage DOI: 10.1016/j.neuroimage.2010.12.064

When a client confesses to murder

Dr. Jennifer Melfi: What line of work are you in?
Tony Soprano: Waste management consultant.

Client confidentiality in psychotherapy only goes so far. If a client threatens the therapist, another person, or themselves, and the threat is perceived as serious, then most jurisdictions (including the BPS ethics code) recognise this as a valid reason to breach the client's privacy and go to the authorities. But what about the situation in which the client confesses to a past violent act for which they were never prosecuted? What if they tell their therapist that they've previously murdered someone?

Steven Walfish and his colleagues have investigated this issue in a survey of 162 US psychological psychotherapists recruited randomly via the National Register of Health Service Providers. Astoundingly, 21 of the psychologists said that on at least one occasion they'd had a client disclose in therapy that they'd murdered someone, but never been found out (one unlucky psychologist said they'd encountered this scenario six times!).

One hundred and three of the psychologists said they'd had a client disclose having committed an act of previously unreported sexual assault, and 111 of them had had a client disclose a previously unreported act of physical assault. The majority of psychologists said disclosure of past physical assault had happened on three or more occasions; one of them said it had happened more than 200 times!

From an ethical point of view these disclosures of past violent acts are trickier to resolve than threats of future violence, especially if there's no other reason to believe that the client remains a threat. Among the psychologists surveyed in the current research, the majority (63.2 per cent) said such disclosures had had a neutral effect on therapy, 18.8 percent said it was harmful to therapy and a similar proportion (17.9 per cent) viewed it as beneficial.

From a therapeutic perspective, the researchers pointed out that those therapists who viewed the disclosure negatively were at obvious risk of 'negative counter-transference'. This is a fancy way of saying that the disclosure could negatively affect the way the therapist relates to their client, especially if the therapist has themselves previously been a victim of violence. Psychotherapists could be trained to guard against this, but Walfish and his colleagues point out that it's not unusual for therapists to be attacked or threatened by clients and so: 'fears of potential client violence may not always represent an unresolved conflict on the part of the therapist. The psychotherapist knowing this piece of clinical information [the disclosure about past violence], and knowing that the best predictor of future behaviour is past behaviour, may be concerned that they themselves may become a victim of violence.'

Somewhat worryingly, nearly one fifth of the current sample did not feel fully informed about what to do when a client makes a disclosure about past acts of violence, and nearly two thirds felt inadequately prepared for the situation by their graduate training.

Walfish and his colleagues concluded that therapists need to be prepared to hear any material in their consulting rooms, 'regardless of how unusual or unpleasant.' They also need to be aware of their own emotional reactions to disclosures of past violence, how to maintain their own safety, as well as their legal and ethical obligations. 'Graduate training programmes, internship and postdoctoral training settings, and continuing education courses should be encouraged to explore this often difficult topic area in greater depth,' the researchers said.
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Walfish, S., Barnett, J., Marlyere, K., and Zielke, R. (2010). “Doc, There's Something I Have To Tell You”: Patient Disclosure to Their Psychotherapist of Unprosecuted Murder and Other Violence. Ethics and Behavior, 20 (5), 311-323 DOI: 10.1080/10508422.2010.491743 [ht: Ian Leslie]

A further note on the BPS Ethics Code: The code emphasises the importance of peer support and supervision. If you are a psychologist and unsure how to proceed following a client disclosure, you should seek guidance from your peers and supervisor, fully evaluate the situation, consider alternative courses of action and fully document the process of decision making [thanks to Dr Lisa Morrison Coulthard for this advice]

Provoking paranoid interpretations in a 'healthy' sample

Traditionally, psychiatrists saw the paranoia exhibited by patients with schizophrenia as qualitatively different from the feelings of mistrust and suspicion expressed by 'healthy' people. Today that view is changing. New research, much of it by psychologists, is demonstrating that clinical paranoia is on a continuum with the experiences of the general public (see earlier). Much of this has involved use of questionnaires or interviews to gauge rates of paranoid feeling in non-clinical samples. Better than this, though, would be observing people's actual paranoid interpretations unfolding in response to real events. Catherine Green and her team think they've found a way.

The researchers had 58 healthy participants sit in a room with a male experimenter and write about their journey to the lab that day (ostensibly as part of research into people's 'understanding of the causes of events'). Next, a male colleague knocked on the door and asked the experimenter if he could come outside for a moment. After the experimenter exited, the sound of male laughter was played for 35 seconds on speakers in the corridor.

What would you think if an experimenter left the room to talk to a colleague and then you heard laughter outside? Asked to explain these events, two of the participants thought the experimenter's departure had something to do with them; five of them thought the laughter was about them; and two participants thought both events were somehow connected to themselves. 'They laughed at something they read in my questionnaires,' one participant said. In all, 15.5 per cent of the healthy sample showed evidence of mild paranoia - what's known as 'an idea of reference' in which they misattributed self-relevance to the events. None of the participants showed more severe persecutory paranoia, and in fact 28 participants failed to notice the laughter.

'The current study illustrates that paranoid explanations for events can be elicited and assessed in a real life situation,' Green and her colleagues said. Questionnaires completed before and after the main part of the study showed that those participants who came up with more paranoid explanations also tended to score higher on 'trait' paranoia. However, they scored no higher on a measure of social avoidance and distress, which suggests their paranoid explanations were not merely a consequence of social anxiety. They did however score higher on interpersonal sensitivity and negative self-regard.

'The current data suggest that some of the processes considered central to clinical paranoia ... may also be operating at the milder end of the spectrum,' the researchers concluded, 'but the data raise questions as to what processes might be responsible for transition across the spectrum from ideas of reference to persecutory ideation.'
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Green CE, Freeman D, Kuipers E, Bebbington P, Fowler D, Dunn G, and Garety PA (2011). Paranoid explanations of experience: a novel experimental study. Behavioural and cognitive psychotherapy, 39 (1), 21-34 PMID: 20846468

Further reading: Is paranoia increasing? Free Psychologist magazine article.

What is mental illness?

Illness is like the street you've driven down your whole life. So familiar you've never bothered to look around. We've all experienced illness, either first-hand or via someone we know, but rarely do we stop to wonder what it really is.

You might say it's when something mental or physical isn't working as it should be. But then who is to say how things should be working? This is easier to answer in relation to physical health, but still tricky. Pain, a loss of ability, a shortening of life expectancy, perhaps? These criteria seem far from satisfactory. Pain is highly subjective and can be triggered by mundane ailments like toothaches or stubbed toes - are they really illnesses? Loss of ability seems more objective, but is surely only a necessary rather than sufficient criterion. After all, temporary fatigue and age both cause a loss of ability. Similarly, driving cars fast and other dangerous hobbies will likely shorten your life. These philosophical conundrums are magnified when it comes to mental illness. When does a hobbyist collector become a compulsive hoarder? How tightly do the shackles of shyness have to constrain a person before he or she is considered ill? What if the solitude of the social phobic allows them to pen great poetry or novels - is that adaptive or maladaptive?

The psychiatrist Dan Stein at the University of Cape Town and five others have tackled these issues and more in an editorial for the journal Psychological Medicine. Their approach has been to consider the definition of mental disorder stated in the fourth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM), and to recommend modifications to it to be used in the forthcoming fifth edition, for which they are Work Group members.

Stein's team propose that a mental disorder has five features. First, it is a behavioural or psychological syndrome or pattern that occurs in the individual. This emphasis on the individual rules out dysfunctions that exist at the relationship or group level. Interestingly, they acknowledge that this causes problems for the DSM IV diagnosis of Shared Psychotic Disorder (or Folie à deux) in which delusions are passed from one person to another.

Second, the symptoms of a mental disorder are clinically significant distress (e.g. a painful symptom) or disability (i.e. impairment in one more important areas of functioning). Here they explain that 'clinically significant' is meant to distinguish from 'milder distress or difficulty in functioning that may not warrant clinical attention'. They acknowledge that clinical significance is tricky to 'operationalise', but argue that it 'remains useful in differentiating disorder from normality'. Readers will notice that this point doesn't really help us distinguish between personality traits like shyness and disorders like social phobia - it merely acknowledges that somewhere a line of severity is crossed.

Third, the behaviour or symptoms must not merely be an expectable response to common stressors and losses (e.g. the loss of a loved one) or a culturally sanctioned response to a particular event (e.g. trance states in religious rituals). Similar to the last, this point is also intended to help prevent the medicalisation of psychological reactions that are an expected part of life. However, Stein's team acknowledge this is murky territory - for example, they point to the contentious boundaries between 'normal and pathological bereavement.' Also, so-called 'normal' reactions to distress are often associated with increased risk of more serious problems later on - in other words, from a clinical point of view they shouldn't be ignored.

Fourth, a mental disorder must reflect an underlying psychobiological dysfunction. This is an acknowledgement that all illnesses of the mind have an underlying neural correlate. Meanwhile, the 'dysfunction' described here can be interpreted either in evolutionary terms whereby some faculty is not working as it evolved to, or in terms of statistical deviance from what's normal according to the client's own background and future goals. Neither is without problems. Evolutionary interpretations tend to be speculative, and what counts as dysfunctional is subjective and influenced by context. Stein's team give the example of living in a dangerous urban area 'where it may be adaptive to join a gang, but where this requires participating in behaviours listed in the diagnostic criteria for conduct disorder.'

Fifth, to be a mental disorder, Stein and his colleagues say a person's behaviour or symptoms should not primarily be a result of social deviance or conflicts with society. This is yet another safeguard against over-pathologising behaviour. The criterion is required, Stein's team say, 'because psychiatric diagnoses have been used for political purposes in the past and potential future misuse cannot be ruled out'. Indeed, one need only consider the fact that homosexuality was included in the DSM until as recently as 1973 to see the inappropriate influence of social mores on psychiatry.

Finally, Stein and his co-authors outline several further points for DSM 5 to bear in mind when considering what constitutes a mental disorder, including: that the potential benefits of adding a condition to the new DSM should outweigh the potential harms, and that any new diagnostic category should be clinically useful - that is: 'facilitate the process of patient evaluation and treatment rather than hinder it.'

As you can see from these highlights, there are many grey areas when it comes to defining what constitutes a mental illness, especially in relation to judging what counts as abnormal distress or dysfunction. As the authors conclude, the basic position (acknowledged in DSM IV) that mental disorder cannot be 'precisely operationally defined seems ... to be basically correct.' However, on a more optimistic note, Stein's team further argue that the classification system can improve over time as the scientific knowledge base progresses. 'Disorders are more than mere "labels",' they conclude, 'and progress towards a more scientifically valid and more clinically useful nomenclature is possible.'

What do you think? Do you share their optimism?
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Stein, D., Phillips, K., Bolton, D., Fulford, K., Sadler, J., and Kendler, K. (2010). What is a mental/psychiatric disorder? From DSM-IV to DSM-V. Psychological Medicine, 40 (11), 1759-1765 DOI: 10.1017/S0033291709992261

Further reading on the Digest blog:
Are mental disorders real?
New data suggests one in two of us experience mental illness in our life-times.
Psychotherapy has drug-like effect on the brain.

This post is an invited contribution to a mini blogging carnival on the topic 'What is psychopathology?' hosted by The Thoughtful Animal blog.

Grab it, bag it, bin it - a new approach to psychological problem solving

If something's troubling you, write it down, put it in an envelope and seal it. Doing so will help bring you psychological closure. Xiuping Li at NUS Business School asked 80 students to write about a recent decision they regretted. Half of them were then told to seal their written recollection in an envelope. Afterwards, the envelope students felt less negative about the event than control students who just handed in their recollection without an envelope. The finding was replicated with forty female students who were asked to write about a strong personal desire that hadn't been satisfied.

Two further experiments shed some light on the process. Sealing a disturbing news story in an envelope reduced the negative emotional impact of the story and reduced participants' memory of it. By contrast, sealing an unrelated piece of paper did not have these effects, thus showing that it's the act of containing the emotional material that's important, not the mere act of putting anything in an envelope.

Finally, sealing in an envelope a written recollection of a regretted event led participants to feel less negative about the event than simply paper-clipping the pages together - so it's not just the mere act of doing something to a written recollection, it is specifically enclosing that material that is beneficial. What's more, this final experiment showed that the link between enveloping the material and participants' feelings was entirely mediated by their having a greater sense of psychological closure.

'We have shown that the metaphorical act of enclosing and sealing influences the memory, in the sense that the recollection of the emotional details of an event becomes weaker,' the researchers said. 'An effective way to relieve distress may be for the distressed person to seal an object related to his or her emotions in a package.' The researchers added that future research should test whether the effect still occurs if someone else does the sealing of the material, and if participants are told the purpose of the exercise.
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Li X, Wei L, & Soman D (2010). Sealing the emotions genie: the effects of physical enclosure on psychological closure. Psychological science : a journal of the American Psychological Society / APS, 21 (8), 1047-50 PMID: 20622143

What clients think CBT will be like and how it really is

Some people expect cognitive behavioural therapy (CBT) to be more prescriptive than it is, and therapists to be more controlling than they really are. That's according to a series of interviews with 18 clients who undertook 8 sessions (14 hours) of CBT to help with their diagnosis of generalised anxiety disorder.

Henny Westra and colleagues selected for interview nine clients whose therapy had ended positively and nine whose therapy had ended poorly. Four of the clients were male. There were four CBT therapists - two men and two women. One was PhD qualified, two were senior clinical psychology grad students, one was junior.

The vast majority of client comments (84 per cent) relating to expectations were that the CBT was not what they'd anticipated. Clients whose outcome was good tended to say they'd been pleasantly surprised - the therapist was collaborative and non-judgmental, and they'd had the opportunity to direct the therapy and choose what to talk about. Of the therapeutic process, the positive outcome clients felt, to their surprise, that they could trust the process, felt comfortable, and that they learned more than they expected. Both good and poor outcome clients worked harder in therapy than they anticipated.

Unsurprisingly, the poor outcome clients tended to say they'd been disappointed by the therapeutic process. In the majority of cases, they took pains not to blame their therapist, instead attributing their lack of progress to time constraints, poor health, their own unrealistic expectations, or their failure to remember the techniques. Direct criticism of the therapist was rare (even though interviewees were reassured their comments were confidential). One person said it would have been better not to have waited until session seven to discuss a key subject from their past.

Sixteen per cent of expectation-related comments conveyed that therapy was just as had been expected. One good outcome client in this category said they thought the therapist would get to the root of their problems, and he did. Poor outcome clients, by contrast, tended to make superficial remarks: 'it was fairly similar to what I expected, I guess'.

The broader context for this research is that client expectations are one of several factors that are known to be associated with therapeutic success (with positive expectations tending to precede good outcomes). However, very little research until now has looked at expectancy violations - that is, when therapy isn't what was expected, for good or bad.

'The findings ... suggest that expectancy disconfirmation in CBT, particularly negative expectations for the therapist and the therapy process, is a common and potentially powerful phenomenon in the experiences of CBT clients with good outcomes,' the researchers said.

A major shortcoming of this research is that the interviews weren't conducted until after the final therapy session, so it's possible that clients recalled their earlier expectations in light of their positive or negative experiences in therapy.
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Westra, H., Aviram, A., Barnes, M., & Angus, L. (2010). Therapy was not what I expected: A preliminary qualitative analysis of concordance between client expectations and experience of cognitive-behavioural therapy. Psychotherapy Research, 20 (4), 436-446 DOI: 10.1080/10503301003657395

Floral arrangement as a cognitive training tool for schizophrenia

It's the hallucinations and delusions associated with schizophrenia that typically attract discussion and research. However, patients with a diagnosis of schizophrenia also exhibit deficits in memory and perception and, importantly, the severity of these is predictive of quality of life, social functioning and autonomy. How can these cognitive deficits be helped? Researchers have found some success with computer-based training but patient motivation can be problem. Now a team of researchers led by Hiroko Mochizuki-Kawai at the delightfully named National Institute of Floricultural Science in Japan have tested out the benefits of floral arranging. 'The use of natural materials may reduce tension and anxiety' they predicted.

Ten patients (six men) with a diagnosis of schizophrenia or schizoaffective disorder agreed to undertake four one-hour sessions of flower arranging, supported by staff, over two weeks. The arranging involved following simple written instructions, holding them in memory one at a time, and placing flowers and leaves into the correct slots in an absorbent sponge. Two patients failed to attend; average attendance for the remainder was 3.1 sessions.

Before the intervention, the flower arranging patients' performance on the 'block-tapping' measure of non-verbal working memory was the same as that displayed by ten controls. After two weeks' flower arranging, however, the flower patients' performance had improved and was now superior to the controls. The block tapping task involves observing blocks being touched one at a time and then reproducing that same order from memory. On another test, which involved copying a complex figure from memory, the flower arranging patients were again no better than controls at the study outset but were superior to controls after the two weeks of training (although this was because the controls had deteriorated at the task rather than because the flower arrangers had improved).

This was only a pilot study and it has obvious short-comings including the small sample sizes, the lack of any comparison intervention for the control group, and no way of measuring the impact of cognitive gains on quality of life. However, the researchers were upbeat in their conclusion: 'We believe that the findings of the present study may contribute to the improvement of cognitive rehabilitation in schizophrenic patients'.
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Mochizuki-Kawai, H., Yamakawa, Y., Mochizuki, S., Anzai, S., & Arai, M. (2010). Structured floral arrangement programme for improving visuospatial working memory in schizophrenia. Neuropsychological Rehabilitation, 20 (4), 624-636 DOI: 10.1080/09602011003715141

Does Darth Vader meet the diagnostic criteria for Borderline Personality Disorder?

In a brazen act of arm-chair diagnosis, Eric Bui and colleagues at Toulouse University Hospital in France have written a short academic article arguing that the Star Wars character Darth Vader probably meets the diagnostic criteria for borderline personality disorder (BPD). The authors point to Anakin Skywalker's (as he was originally known) life history, including fatherly absence, early maternal separation and infantile illusions of omnipotence. They go on to claim that Skywalker meets six of the formal nine DSM (diagnostic and statistical manual) criteria for BPD:

'He presented impulsivity and difficulty controlling his anger and alternated between idealisation and devaluation (of his Jedi mentors). Permanently afraid of losing his wife, he made frantic efforts to avoid her abandonment and went as far as betraying his former Jedi companions. He also experienced two dissociative episodes secondary to stressful events. One occurred after his mother's death, when he exterminated a whole tribe of Tuskan people, while the other one took place just after he turned to the dark side. He slaughtered all the Jedi younglings before voicing paranoid thoughts concerning his former mentor and his wife. Finally, the films depicted his quest to find himself, and his uncertainties about who he was. Turning to the dark side and changing his name could be interpreted as a sign of identity disturbance.'

Does this matter? Bui and his colleagues argue that Skywalker's condition could help explain the appeal of the Star Wars films to teenagers - an age group they say presents 'more frequent BPD traits than adults'. They also suggest that promoting recognition that such a famous fictional character meets the criteria for a BPD diagnosis could help combat the stigma associated with mental illness. 'Finally,' they write, 'as [the Star Wars films are] part of most students' cultural background, this case study could prove useful in teaching the criteria of BPD to medical students and residents.'

Bui first made these claims at a psychiatric conference in 2007. Digest readers seeking a more scholarly consideration of the borderline personality disorder diagnosis could try the journal Personality and Mental Health's special issue published last year [pdf of editorial].
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Bui, E., Rodgers, R., Chabrol, H., Birmes, P., & Schmitt, L. (2010). Is Anakin Skywalker suffering from borderline personality disorder? Psychiatry Research DOI: 10.1016/j.psychres.2009.03.031

Image is from the Star Wars Wiki.