View Full Version : Positive versus negative expectations and the "nocebo effect"


Kunga Dorji
08-16-14, 11:21 PM
<style type="text/css">P { margin-bottom: 0.21cm; }</style> The effect of negative expectations in recovery from ADHD.
“The Barkley Effect”


A discussion of Russell Barkley's You Tube Presentation
“ADHD: Emotional Regulation”.


http://www.youtube.com/watch?v=7cw8jHUkHiA


Awareness of one's suffering is regarded as the first step on the path of spiritual development.
There is no doubt that ADHD is a common, and potentially impairing condition that can lead to profoundly negative life outcomes. Awareness of this is a good thing- it motivates us to change- if we believe that change is possible.


In Buddhism faith(confidence that there is a path out of suffering,) is regarded as the second step on the path to liberation. If you have no confidence that there is a path-- why even try?


Professor Russell Barkely has been a leading advocate for ADHD recognistion and treatment, but many of those of us who have ADHD have deep reservations about his approach.


While Russell Barkley has done very good work to raise awareness of adult ADHD and the potential severity of the impairments associated with it, he remains very focussed on the "disability model" and part of this model is the superiority of the practitioner over the patient. While other authors acknowledge many predictable and common character strengths very common in ADHD individuals Barkley remains dismissive of these “ADHD gifts” and contemptuously dismissive of those authors (usually successful ADHD individuals) who highlight them.


Other problems with his approach is that the sort of behavioural modifications resemble the sort of strict approach to discipline that has worsened the function of many ADHD sufferers. In this regard he is clearly a prisoner of his culture.


I personally am in the relatively unusual position of being a family physician who has ADHD. I am widely read in the area, and treat many ADHD patients.

To me- Barkely presents an unnecessarily bleak and rigid view of ADHD- one which does reduce our self esteem and our confidence in our self efficacy.

Barkely's video on "ADHD Emotional Regulation" is an apt one- as it highlights an abnormality which can make the condition look more concrete and permanent than it really is. He makes good points though- and I often refer my patients to study it to get an understanding of what is happening for them when their ADHD is in a destabilised state.

His presentation misses the important fact that the deficits of self regulation in ADHD are intermittent and (to some extent) situation dependent.

Even worse he fails to mention that there is now hard scientific evidence that appropriate mindfulness training actually increases the activation and thickness of the grey matter in the anterior cingulate gyrus.

You could look at that video and just come away feeling defeated, and deflated, and bereft of hope.

For a practicing psychologist, he seems blind to the fact that motivation is dependent upon positive expectation. Maybe I am missing something- but I have never seen him acknowledge this or discuss ways to work this approach into therapy.


The ADHD individual who listens to too much of his work is likely to become dispirited, more than ever convinced of his failings and the permanency of his condition and less and less enthusiastic about the many practical steps such as mindfulness that he can take to improve his functioning. Technically speaking this is a NOCEBO effect.


I believe I may be the first one to have coined the term "The Barkley Effect" for nocebo effect induced by listening to his views on ADHD too much.

daveddd
08-16-14, 11:28 PM
i personally think emotional dysregulation is the worst or complete underlaying part of adhd

i do not think barkley has a good grasp on it, he misses the whole over controlled population , and like you say makes emotional regulation seem impossible to adhders when we know that isn't the case

mildadhd
08-17-14, 03:26 AM
There are 7 separate positive and negative interconnected primary instinctual feeling systems, originating in the midbrain areas.

SEEKING/Expectancy(+) FEAR(-) RAGE(-) LUST(+) CARE(+) GRIEF/PANIC(-) PLAY(+)

And they are interconnected and communicate with each other.


Chronic negative or positive stimulation, leads to combination of emotional imbalances and commorbbidities, depending on individual emotional temperament and emotional experiences, etc.

At homeostasis, the primarily dopamine (DA+) driven, "General Pos. Motivate SEEKING/expectancy system (http://www.addforums.com/forums/showthread.php?p=1636861#post1636861)" is a positively (+) charged primary emotion.


SEEKING, FEAR , RAGE, are from the reptilian realm (first 3 around the longest)

SEEKING, FEAR, RAGE, LUST, CARE, GRIEF/PANIC, PLAY, (last 4) are from the mammalian realm


The pos. motivation SEEKING/Expectations(+) emotional system, is the General, of all the emotional systems.


Over-arousal of SEEKING/expectancy(+) system = mania?

Under-arousal of SEEKING/expectancy(+) = manic?


Consider the questions below and compare your answers with the biology of the 7 basic emotional systems, key brain areas and key neuromodulators involved in each system. (link above)


Questions.

Over-arousal of the FEAR(-) system = ?

Under-arousal of the FEAR(-) system = ?


Over arousal of the RAGE(-) system = ?

Under arousal of the RAGE(-) system = ?


Over arousal of the LUST(+) system = ?

Under arousal of the LUST(+) system = ?


Over arousal of the CARE(+) system = ?

Under arousal of the CARE(+) system = ?


Over arousal of the GRIEF/PANIC(-) system = ?

Under arousal of the GRIEF/PANIC(-) system = ?


Over arousal of the PLAY(+) system = ?

Under arousal of the PLAY(+) system = ?


Opinions/corrections appreciated

(these are my layman interpretation, of Affective Neuroscience please leave room for learning)

P

meadd823
08-17-14, 09:02 AM
Although this is an interesting discussion going on here is there any way we can have it without violating the guidelines and insulting Americans who by the way still make up the majority of the membership.

The following behaviors are still are not allowed.


Discriminatory remarks - this includes remarks stereotyping an entire group of people because they live in a certain region, country or are of a specific ethnic background. This is insulting to them as well as yourself so why do it?

Discussion of war, which can't help but be politically charged thus belong in private debates.

Links to commercial sites even if the information on them is interesting, a live link is not appropriate. I would never go to one restaurant and publicly promote another.

Kunga Dorji
08-17-14, 11:07 AM
Although this is an interesting discussion going on here is there any way we can have it without violating the guidelines and insulting Americans who by the way still make up the majority of the membership.

The following behaviors are still are not allowed.


Discriminatory remarks - this includes remarks stereotyping an entire group of people because they live in a certain region, country or are of a specific ethnic background. This is insulting to them as well as yourself so why do it?

Discussion of war, which can't help but be politically charged thus belong in private debates.

Links to commercial sites even if the information on them is interesting, a live link is not appropriate. I would never go to one restaurant and publicly promote another.


My apologies meadd- I had made those comments as part of a private email and hastily re-posted the whole thing - as I was dashing to catch a plane.
I had intended to edit them out.

The same subject will come up from a very different angle soon though- my plane was back from Bali to home in Australia- and I am fascinated at both the cultural differences (it is a VERY different culture to the one prevalent in the UK/US/ Australia axis) and what looks to be a noticeably lower rate of ADHD like behaviours.

I am very much at one with SB here in that I believe high expressed interpersonal aggression is a factor which will exacerbate ADHD symptoms.
The absence of such aggression was a very notable factor in Bali-- the capacity of people to cope with heavy traffic and let people take turns without any road rage was quite intriguing.

Fraser_0762
08-17-14, 12:32 PM
Life is simply one's own personal experience. That experience is defined by how that person thinks.

If you think the worst of everything, then your life experience will be that of a negative one.

If you tune the brain to seek out positive opportunities, even in the worst of situations, then your life experience will be that of a positive one.

The one single importance in life is how you think. Its your experience, nobody elses.

Mantaray14
08-17-14, 12:56 PM
I am very much at one with SB here in that I believe high expressed interpersonal aggression is a factor which will exacerbate ADHD symptoms.
The absence of such aggression was a very notable factor in Bali-- the capacity of people to cope with heavy traffic and let people take turns without any road rage was quite intriguing.

I own informed intuition agrees strongly with this. I grew up undiagnosed and unmedicated, and although I had a terribly difficult childhood, I would not trade places with anyone for anything in the world (they have more grey hair than me or less hair in general, among other things).

Raising a son with the same issue's brings this whole philosophical issue to the front and center for me. I want "better" for him (so that requires treatment), but how do I define better? I do not believe Barkley's Method is better qualitatively IMHO. Hallowell offers more of an "unwrapping the gift" approach as demonstrated by the many innovative individuals throughout history who were thought to have ADD. But unfortunately most of the clinician's we meet subscribe to the Barkley method. Not surprising since It is the most scientific Approach.

My other issue is live in very competitive area with high levels of interpersonal aggression. I noticed my son issues always flair up when dealing these issues. ADD has way of throwing a monkey wrench in some else's established hierarchy, but then shunning is the next logical step from the group"leaders". All these situations start up when children start to pattern this behavior, learned from their parents around 2nd grade, I noticed.

All this being said, how to reconcile these concepts with effective treatments is what Im preoccupied on a full time basis. Finding doctors and couselors (or even school admistrators and teachers)I have full faith in has been challenging. Moving to a less competitive city is another thing I've been discussing. There ARE still cities where people wait their turn at the intersection, something I witnessed on a recent family trip. I wasn't suprised when I noticed this as the only North American city in a top ten best cities to live based on quality of life (ie happiness). So there's a lot to think about. I've thumbed through many of Hallowells books and they are vague in concrete steps to take. Where there's a will there's a way has always worked for me....

mildadhd
08-17-14, 01:50 PM
But unfortunately most of the clinician's we meet subscribe to the Barkley method. Not surprising since It is the most scientific Approach.



In my honest opinion, Dr.Barkley's approach/method are not scientific enough.

But its not just Dr.Barkley method that is not scientific enough.

We might have trouble explaining what we know, but we all know, that ADHD is not primarily a cognitive problem.

Dr.Barkley covers the components involved in ADHD, based on top down theory, cognitive theory.

But Norepinephrine and Dopamine producing cells originate in the brain stem midbrain areas.

Dr.Barkley acknowledges these ground up facts, but then explains them from a prefrontal top down regulation view (which is not wrong, but is only half the scientific story being told.)




Affective Neuroscience has mapped, the 7 primary emotional systems originating in the lower subcortical midbrain areas.

At birth these raw emotional affective(feelings) systems mature before the higher learning and regulation processes.

Cognitive, learning and regulation processes are built upon emotional affects.

The 7 primary emotional affective systems, that learning and self regulation are built upon, (early ground up development) ,are missing from most current ADHD theories, including Dr.Barkley's.



P

daveddd
08-17-14, 01:55 PM
In my honest opinion, Dr.Barkley's approach/method are not scientific enough.

But its not just Dr.Barkley method that is not scientific enough.

We might have trouble explaining what we know, but we all know, that ADHD is not primarily a cognitive problem.

Dr.Barkley covers the components involved in ADHD, based on top down theory, cognitive theory.

But Norepinephrine and Dopamine producing cells originate in the brain stem midbrain areas.

Dr.Barkley acknowledges these ground up facts, but then explains them from a prefrontal top down regulation view (which is not wrong, but is only half the scientific story being told.)




Affective Neuroscience has mapped, the 7 primary emotional systems originating in the lower subcortical midbrain.

At birth these raw emotional systems mature before the higher learning and regulation processes.

Cognitive, learning and regulation processes are built upon emotional affects.

The 7 primary emotional affective systems, that learning and self regulation are built upon, (early ground up development) ,are missing from most current ADHD theories, including Dr.Barkley's.



P

Great post.

meadd823
08-17-14, 01:56 PM
My apologies meadd- I had made those comments as part of a private email and hastily re-posted the whole thing - as I was dashing to catch a plane.
I had intended to edit them out.

The same subject will come up from a very different angle soon though- my plane was back from Bali to home in Australia- and I am fascinated at both the cultural differences (it is a VERY different culture to the one prevalent in the UK/US/ Australia axis) and what looks to be a noticeably lower rate of ADHD like behaviours.

I am very much at one with SB here in that I believe high expressed interpersonal aggression is a factor which will exacerbate ADHD symptoms.
The absence of such aggression was a very notable factor in Bali-- the capacity of people to cope with heavy traffic and let people take turns without any road rage was quite intriguing.

Thanks -

ADD is indeed environmentally determined {IMNHO} what is dysfunctional in one cultural may be functional in another - Bali culture is structured and very community orientated - which are traits I wish my western culture employed more of - The strict structure may indeed compensate for the ADD traits of individual members.

Really to name every child the same name based upon the order of birth would be rather confusing. The caste system is just another monetary system. In Bali every one is required to marry - OKay to too much communal structure would stifle individuality = balance is key here.

The laid back life style of the Bali culture does not make westernized culture "bad" it makes the two cultures different.

I agree that we could learn a lot from other cultures this in no way means any one should be ashamed of their own.


Although I had to moderate first and be a member later on a personal level I found your initial post to contain a rather interesting contradiction which may have been missed - I agree that too much focusing on the bad traits in ADD especially when accompanied by a strong focus on the all the negative things to be a determinant to any healthy approach to ADD. You know how I feel about Barkley, my disdain of his approach to ADD is not done in secret.

The real irony here is the same need for a balance perspective holds true for culture - While westernized culture does have it's negative aspects it also has it's strengths and those too should be acknowledge.



. . . .

daveddd
08-17-14, 01:56 PM
Life is simply one's own personal experience. That experience is defined by how that person thinks.

If you think the worst of everything, then your life experience will be that of a negative one.

If you tune the brain to seek out positive opportunities, even in the worst of situations, then your life experience will be that of a positive one.

The one single importance in life is how you think. Its your experience, nobody elses.

Absolutely. Everything is perception.

Unfortunately some negative perceptions can become deeply ingrained though

Fraser_0762
08-17-14, 02:08 PM
Absolutely. Everything is perception.

Unfortunately some negative perceptions can become deeply ingrained though

Indeed. The brain is like a fusion reaction. Each process feeds off of one another to keep everything fuctioning.

Because of this, a negative (or positive) thought can bounce from process to process in a long lasting cycle.

That's why a persons perception is so vital to their overall well-being. It's important to be able to see the positive in situations, regardless of how dire the situation seems at first glance.

mildadhd
08-17-14, 05:49 PM
Cognition is not the brain's primary state of consciousness.

We feel (affective consciousness) before we think (cognitive consciousness).

Healthy development of affective consciousness is required for healthy development of cognitive consciousness.

Infants born without a higher neocortex to think(regulate), still have primary emotional(affective) consciousness, but they don't have the awareness to regulate these instinctual feeling systems. (requiring extended family to help guide and regulate experiences with them)


Phineas Gage was able to regain consciousness after traumatic brain injury to the higher prefrontal cortex, with some learning and regulation impairments.

But if Phineas Gage's traumatic brain injuries where to the lower subcortex/midbrain areas, Phineas Gage would have never regained consciousness, at all.



P

mildadhd
08-17-14, 07:11 PM
..when people are severely depressed they often suffer from hippocampal damage because an excess of cortisol can cause hippocampal cells to shrivel and at times even die off.

Perhaps surprisingly to some, tickling rats and provoking the rats to "laugh" can promote the sprouting of new neurons in the hippocampus (see Chapter 10).

The hippocampus is a brain structure that is essential for the creation of declarative and episodic memories--conscious memories of knowledge and experiences (see Chapter 6).

Without this brain region, one would live in a perpetual present, with no memory of events that have passed.

Thus, excessive cortisol release can participate in a number of serious mental disorders, including memory deficits.





Similarly, in small doses, opiates will elevate mood and promote social solidarity.

In large doses, they promote intoxication.

In fact, appropriate amounts of endogenous opioids can have medically beneficial effects.

For example, the placebo effect, whereby patients respond favorably to fake medications, can be explained in terms of this emotional chemistry.

If a patient feels that his needs are being considered and tend to, then the positive feelings of being cared for are accompanied by the release, in the brain of calming endogenous opioids, which diminish the feelings associated with the GRIEF/PANIC system.



In addition to producing good emotional feelings, opioids also reduce stressful arousal, reduce feelings of physical as well as psychological pain, and produce various immune benefits.

So these patients will feel comforted and be much better off medically than they would be if they thought that no one seemed to care.

We now know the placebo effect is real medicine that operates mainly through the activation of brain opioid systems.

These healing tendencies can thus be reduced, and even eliminated, by drugs like naloxone and naltrexone, which block the effects of opioids.



In the past, when an apparently healthy patient appeared emotionally agitated and complained of physical symptoms, doctors tended to believe that the symptoms were psychosomatic, "all in the mind," and therefore not physical or "real".

This is no longer an accepted view of psychosomatic illness.

As soon as we recognize that affects emerge from emotional systems that are fueled by brain chemicals that can also exert an eventual effect on the functioning of the brain and the body, then the division between emotional and physical disorders narrows to the point of extinction.

Although it may appear that the mind and the brain are different entities, the mind being incorporeal, and the brain being physical, they are really one and the same thing

The MindBrain (or BrainMind) is a unified entity lacking any boundary with the body--it is integral to the physical system as a whole.


An understanding of brain emotional systems, and the psychological and bodily symptoms that they can generate, is not only important for medicine in general; it also offers a totally new perspective for contemporary psychiatry...



Panksepp/Biven, "The Archaeology of Mind", P xiii.



i!i i!i

Kunga Dorji
08-17-14, 09:42 PM
In my honest opinion, Dr.Barkley's approach/method are not scientific enough.

But its not just Dr.Barkley method that is not scientific enough.

We might have trouble explaining what we know, but we all know, that ADHD is not primarily a cognitive problem.

Dr.Barkley covers the components involved in ADHD, based on top down theory, cognitive theory.

But Norepinephrine and Dopamine producing cells originate in the brain stem midbrain areas.

Dr.Barkley acknowledges these ground up facts, but then explains them from a prefrontal top down regulation view (which is not wrong, but is only half the scientific story being told.)




Affective Neuroscience has mapped, the 7 primary emotional systems originating in the lower subcortical midbrain areas.

At birth these raw emotional affective(feelings) systems mature before the higher learning and regulation processes.

Cognitive, learning and regulation processes are built upon emotional affects.

The 7 primary emotional affective systems, that learning and self regulation are built upon, (early ground up development) ,are missing from most current ADHD theories, including Dr.Barkley's.



P

This is well covered in Daniel Goleman's new book "Focus, The Hidden Driver of Excellence"

What is missed by the Barkley approach is that most of the time our attention is subconsciously regulated by "bottom up" intuition rather than by will.

While there is some value in Barkley's overall behavioral approach- some of the major points of his approach are consistency, emotional evenness and
prompt attention to and management of behaviours that are not desired.

Again what is being missed here is that Barkley is asking the parents to become worthy of being attached to and of being learned from. That is tricky when, as is usually the case, one or both of the parents has ADHD- and we have insufficient attention and emotion regulation to perform these feats of consistency, emotional evenness and prompt attention to and management of behaviours ourselves!

Kunga Dorji
08-17-14, 09:59 PM
Thanks -

ADD is indeed environmentally determined {IMNHO} what is dysfunctional in one cultural may be functional in another - Bali culture is structured and very community orientated - which are traits I wish my western culture employed more of - The strict structure may indeed compensate for the ADD traits of individual members.

The structure is not "enforced" in the way that say structure is enforced aggressively in a school or in many workplaces in the West.


Really to name every child the same name based upon the order of birth would be rather confusing.
It is a funny system- but people do have their own personal names too- and seem to pick and choose when they use their "real name" or their "birth order name" or a conveniently Westernised first name sometimes if they work in hospitality/tourism.


The caste system is just another monetary system. In Bali every one is required to marry - OKay to too much communal structure would stifle individuality = balance is key here.

We did meet a woman who was in her 40s and unmarried. She lives in a small village and there were few opportunities. Being unmarried and not having children to take care of one in one's old age is a problem in a culture that does not have a well developed social welfare system. It is also a problem in cultures where the elderly get "warehoused" in nursing homes.
In my line of work I have seen the inside of way to many of those places to ever want to end up in one- even a more prosperous and well appointed one.


The laid back life style of the Bali culture does not make westernized culture "bad" it makes the two cultures different.

I agree that we could learn a lot from other cultures this in no way means any one should be ashamed of their own.


Western culture is in crisis- and the overall increase in mental illness bears witness to that. Sure there are parts of our culture that I would not want to leave behind- but looking closely at the differences and seeing what works in other cultures is a valuable practice.

One of the things that intrigued me so much was the fact that children actually had a lot of freedom, but knew very clearly where safety was. Also in the village- the attachment village that Gabor Mate and Gordon Neufeld talk about was a palpable reality.

Mate is correct- Western society no longer provides optimal conditions for parenting children.