Age 10-11

This blog is in progress, it is a multi-week project.  Please stay tuned.

How many psychiatrists does it take to change a light bulb? One, but only if it really wants to change.

Ten year old children hearing that joke would think in a rather concrete manner. Their thoughts would be, “how could a light bulb want to change?” They might imagine a psychiatrist standing up on a ladder changing a light bulb in the ceiling.

Before age 12, children have a concrete thinking pattern. They believe that things are the way they superficially perceive them. There isn’t much depth to their thinking. Pre-teenager thinking is rule based. If you see a ten-year-old who is throwing stones against the window and you say, “Don’t throw stones against the window,” he would ask, “why?” If you say, “We have a rule here, to not throw stones against the window.” and he say, “Okay” and not throw stones against the window. Children tend to follow rules because their thinking is organized around rules.

Pre-teenage children are also oriented toward their families. A child feels at home and protected in a bubble that includes their mother and father and siblings. They are aware that there is a world outside that bubble, including their school, their town and maybe their country, but children’s emotional concerns are mostly with their mother and father and siblings.

During the adolescent years, youth get two “brain upgrades.” I use the word “upgrade” because it is almost like what happens with a computer when the Pentium Processor is upgraded with a faster one. The difference with teenagers, is that the upgrades do not happen suddenly. They occur gradually in fits and starts over a period of time. One major brain upgrade occurs at age twelve and another major brain upgrade occurs at age sixteen.

Copyright 2010, Henry Doenlen, M.D. All rights reserved.

Age 12-13

This blog is in progress, it is a multi-week project.  Please stay tuned.

During age eleven to thirteen years, children start to understand how other people behave. They observe, learn, and they make assumptions about what other people think and feel. They are particularly attuned to what their peers think about them. Permanent psychological damage can result from children being mean to each other, particularly in middle school. When children are made to be outside the peer groups, and when other children repeatedly made fun of them, permanent damage may result because these children will not trust other people when they grow up. As adults, they will consider that other people may be nice in their outward behavior but are thinking negative things about them.

Students can be really mean at some middle schools, and sometimes the meanness goes well above and beyond the call of duty. Years ago, two eighth grade girls in the same middle school attempted suicide. When they got back to school, word got around. Some of the students came up to them and said, "Why don't you just try to kill yourself right here in front of the class?" They would do this over and over again. One girl went on to repeat her suicide attempt. The other girl made the taunters feel guilty, but went on to abuse drugs and drop out of high school.

Pre-teenagers and teenagers look for the respect of their peers. Being considered "popular" is one way of getting respect from peers. Some children try to gain popularity by interfering with their peers respect of others, and they make fun of other children. The thought is that if a peer is less respected, then logically, the one who is doing the damage can be more respected. Fortunately, that thought does not last forever, or otherwise, we would have a terrible world as adults.

Copyright 2010, Henry Doenlen, M.D. All rights reserved.

Age 14-15

This blog is in progress, it is a multi-week project.  Please stay tuned.

At age fourteen to fifteen, teenagers are very peer oriented. They gradually loose their family identity as their sense of themselves becomes oriented toward their peers. In this age, teenagers tend to make relationships in collective groups of peers. Sometimes, these groups are called cliques. It is almost as if a second family is created, except this time, there is nobody in charge. The members of a group have high regard for each other.

The thoughts of fourteen and fifteen-year-old teenagers are intense and single-minded. When they get an idea, they focus on that idea with passion. They do not allow anything to interfere with that idea. They believe that just by their force of will, they should be able to get things accomplished.

Teenagers tend to be self-centered, particularly around age thirteen, fourteen and fifteen. Their self-centeredness is not necessarily selfish, in that they don't always want everything for themselves. They are self-centered in that they assume that other people think the way they do. For example, if a fourteen-year-olds are asked "Can you imagine what that starving child in Africa feels like?" They will answer that they do understand, but the answer they give would be how they would feel if they were in that starving person's shoes. They do not consider that a person might think even differently than them. That can cause a very confusing situation in boy-girl relationships, because the thirteen, fourteen and fifteen-year-olds will assume that members of the opposite sex think the way they do. The truth is that boys and girls think very differently in this age range.

Copyright 2010, Henry Doenlen, M.D. All rights reserved.

Age 16-17

This blog is in progress, it is a multi-week project.  Please stay tuned.

Facial Expression, Communication's Second Channel

It is said that we use only 10 percent of our brain at any one time. That is fortunate, because even with only 10 percent active, the brain is using 20 percent of our oxygen, 20 percent of our nutrients, and 20 percent of our blood. The brain is the only organ with four separate arteries bringing blood to it. If we used 100 percent of our brain, out bodies would be like large balloons to breath enough oxygen, and we would eat constantly to get enough nutrients to support a fully active brain. (Image shown here is modified from The Human Brain Atlas at the Michigan State University Brain Biodiversity Banks, Sudheimer DK, Winn BM, Kerndt GM, Shoaps JM, Davis KK, Fobbs AJ, Johnson JI. Radiology Department, Communications Technology Laboratory, and College of Human Medicine, Michigan State University; National Museum of Health and Medicine, Armed Forces Institute of Pathology)


The parts of brain being used turned on, are given more blood, then turned off as information moves and is processed by different parts of the brain, which then are turned on, are given more blood, then turned off. The functional MRI is able to tell the difference between oxygenated hemoglobin and hemoglobin which is not carrying oxygen. Thus, the functional MRI is able to detect which parts of the brain are active at any given instant by detecting which parts of the brain are recieving more blood.  Using the functional MRI, researchers have been able watch the areas of activity skip across sections of the brain after a face is viewed. (Face perception is mediated by a distributed cortical network. Ishai A, Schmidt CF, Boesiger P. Brain Res Bull. 2005 Sep 30;67(1-2):87-93.)

The image of the face is constructed in the visual cortex (VC) from data recieved from the eyes. The facial image is then moved to the superior lateral sulcus (SLS) and the fusiform gyrus (FG). The superior lateral sulcus very quickly extracts the emotional information from the image of the face, and mostly from the area around the eyes. The emotional information is sent to the amygdala (Amyg) where a an initial personal emotional response is generated. The emotions from the face along with the personal emotional response is sent to the prefrontal cortex (PFC) for thinking and decisions about behavior. You can feel this pathway working particularly when you have a sudden emotion reaction to some else rolling their eye. (Affective neural circuitry during facial emotion processing in pediatric bipolar disorder. Pavuluri MN, O'Connor MM, Harral E, Sweeney JA. Biol Psychiatry. 2007 Jul 15;62(2):158-67. Epub 2006 Nov 9.)

Simultaneously, the fusiform gyrus (FG) performs a more detailed topographic analysis, looking separately at the eyes and surrounding area, the mouth, and the remaining face. The topographical information also sent to the frontal lobe, to be considered with the emotional information and the words which were heard. This pathway is used when you study the face, trying to figure out what makes that face look interesting. The fusiform gyrus pathway is also used when you ask, "where do I know him from," trying to recall the name that goes with the face. (Effective connectivity within the distributed cortical network for face perception. Fairhall SL, Ishai A. Cereb Cortex. 2007 Oct;17(10):2400-6. Epub 2006 Dec 26.)

Face-to-face conversation provides a second channel of communication in addition to the spoken words. Observing facial expression gives important information about emphasis and importance in what is being said, as well as how well we are being understood. When face-to-face, we can combine the speaker's words with their emotion, adding our own emotional reaction, and determine our own reaction with words, expressions, and behaviors. Texting or messaging with Facebook or another messenger allows for more frequent communication, but does not give the emotional richness of personal contact.

Personal interaction is important in the transfer of emotions. Interacting with a person who expresses happiness can induce a happy feeling in ourselves. The superior lateral sulcus to amygdala connection allows us to feed off other people's emotions. That is why attitude is so important, why happy people are more attractive, why happy people make a class or workplace more pleasant.

Copyright 2010, Henry Doenlen, M.D. All rights reserved.

4 symptoms & 5 rules for Bipolar Disorder

Several research studies have shown that the left amygdala plays a key role in bipolar disorder. By the time teenagers are developing bipolar disorder, there appears to some loss of volume in the left amygdala, which is shown in MRI images of the brain. (Dickstein DP, Milham MP, Nugent AC, Drevets WC, Charney DS, Pine DS, Leibenluft E. Frontotemporal alterations in pediatric bipolar disorder: results of a voxel-based morphometry study. Arch Gen Psychiatry. 2005 Jul;62(7):734-41). There also appears to be greater activation in the left amygdala of teenagers with bipolar disorder when they process facial expression, which has been shown in functional MRI images. (Rich BA, Vinton DT, Roberson-Nay R, Hommer RE, Berghorst LH, McClure EB, Fromm SJ, Pine DS, Leibenluft E. Limbic hyperactivation during processing of neutral facial expressions in children with bipolar disorder. Proc Natl Acad Sci U S A. 2006 Jun 6;103(23):8900-5.) Functional MRI's show the specific areas of the brain that are active from the increased blood flow to an active area.

The image above shows the amygdala in red. (Image is from Anatomography maintained by Life Science Databases (LSDB), Japan.)  Although the amygdala is not much bigger than an almond, it has many functions. It appears to have a major role in the processing of emotions, particularly fear and anger. It plays an essential role in learning from stress. A popular term, "amygdala hijack," refers to a strong emotional reaction that briefly takes over reasonable thinking.

The research shows that the left amygdala has slightly less volume and a significantly greater signal output in people with bipolar disorder. If the amygdala functions as a "volume control" on the emotions, then it is possible that the changes in bipolar disorder cause the volume control to be set at a higher intensity than is needed. People with bipolar disorder tell me that the experience this effect, when they are happy, they are too happy. When sad, they are too sad. When angry, they are too angry. When worried, they are too worried. The emotions that they experience are more intense than the situation calls for.

Although excessive emotions is part of bipolar disorder, it is not enough to diagnose bipolar disorder, or even be considered a definite early sign of this condition., It is important to try to identify children or teenagers who are on the way to developing bipolar disorder early, because with treatment, it is possible to avoid many of the problems, and sometimes even prevent the development of the full disorder.  The best way to determine the beginnings of bipolar disorder is to watch for definite manic episodes of high mood with rapid speech and decreased sleep alternating with depressed episodes of depressed mood with lower energy. The manic and depressed episodes lasts for days, and there can be times of relatively normal moods, energy, and sleep.

Many times, it is difficult to observe definite manic and depressed episodes that lasts for days. In my work with teenagers who were developing bipolar disorder, and adults who had bipolar disorder, I have found that there are four early symptoms, and having three of them appear to predict the development of bipolar disorder. The four symptoms are, (1) bouts of rapid thinking, (2) violent videos, (3) arguing in the mind, and (4) annoying sexual thinking.  The bouts of rapid thinking last 20 minutes to much longer, with the thoughts so rapid that reasoning or school work is not possible. Violent videos are highly graphic with blood and injury, generally occur during times of anger, but do not mean that the person will act out the violence. Arguing in the mind seems as though two people are intensely arguing in the thoughts, but it is not a hallucination.

I ask those who have or are developing bipolar disorder to follow five rules:

1. Manage rages
2. Avoid drama.
3. Don't trust your feelings.
4. Take medication.
5. Don't use drugs or alcohol.

Managing rages involves learning where the "switch" is, and to be able to avoid "flipping the switch" into an angry rage that dominates reason. Reducing anger can be done with an activity that uses the parietal lobe of the brain, which are visual activities or music. Avoiding drama means avoiding people and situations that brings unnecessary stress. Don't trust your feelings for making decisions, because the feelings are too intense or even out of control. Make decisions based on reasoning, logic, and good advise. The last two rules are easy to understand, take medication that is prescribed, and avoid alcohol as well illegal and unprescribed drugs, which can destabilize the mood.

Copyright 2010, Henry A. Doenlen, M.D. All rights reserved.

The Brain's Happy Signal

For me, one of the most exciting findings was published early in 2009. It showed a happy signal activated in the brain.

This image is drawn based on the article, Altered striatal activation predicting real-world positive affect in adolescent major depressive disorder, by Forbes EE, Hariri AR, Martin SL, Silk JS, Moyles DL, Fisher PM, Brown SM, Ryan ND, Birmaher B, Axelson DA, Dahl RE, in the American Journal of Psychiatry. 2009 Jan;166(1):64-73. The scientists developed a game in which teenagers could win money while their heads were in the functional MRI scanner. The functional MRI scan detects which parts of the brain are energized and active based on the increased flow of oxygenated blood to the area of activity.

Teenagers who were depressed and matched teenagers who did not have depression were scanned at the moment they were told that they won. The teenagers who did not have depression showed activation in the caudate nucleus, shown in yellow and orange in the image. The teenagers who had depression had cortical activity reflecting thought, but no activation in the caudate. Thus, the yellow and orange in the image depicts a happy signal.

A similar finding was in a previous article, Reward, motivation, and emotion systems associated with early-stage intense romantic love, by Aron A, Fisher H, Mashek DJ, Strong G, Li H, Brown LL, in the Journal of Neurophysiology. 2005 Jul;94(1):327-37. When young adults who were in love were shown photos of their loved once, their scans showed activation in the ventral tegmental area, shown in red, and in the caudate. Brain cells in the ventral tegmental area send connections to the caudate.

This changed what I thought about depression. I used to think that depression involved excessive stress and negativity in life. But this showed that depression involves not having sufficient happy signals to balance out stress and negativity. This implies that to avoid depression and maintain a reasonably happy life, it is important to always make sure that there are enough positive activities to generate enough happy signals to balance out the signals of stress and dealing with negative events.

The two articles showed activation of the “reward circuit” (which I call “happy signals”) from winning a game and from seeing a beloved one. There are many other ways to activate happy signals in the brain, including, joking with friends, giving and receiving positive feedback, solving a problem, eating an amazing meal. Nerdy people get happy signals by learning something interesting or engaging in their own nerdy activities. There is even a quiet calming joy in doing an Obsessive-Compulsive activities such as organizing.

Although the research so far implies that happiness involves activity in the caudate, it seems to me that different kinds of happiness can have distinctly different feelings. Eating vanilla ice cream and chocolate ice cream are different experiences, but the both are ice cream. Happiness has different flavors as well.  The elation of love feels a little different from the excitement of a nerdy discovery, which is different yet from the thrill of watching home team win, yet all are happy feelings.

Other feelings don't appear to have different flavors. Anxiety and anger can be of different degrees and intensities, but anxiety or anger from one stress does not feel different from another stress.  Sadness, too, can be of different intensities, but there appears to be two versions, an agitated sadness with crying, and a low energy depression where it is difficult to accomplish tasks.

Copyright 2010, Henry A. Doenlen, M.D. All rights reserved.

The Worse Surgical Resident

During 1978, Dr. Bill (not his real name) had a reputation as being the worse surgical resident at the Thomas Jefferson University Hospital. Actually, he was a very bright young physician, as well as a careful, skilled surgeon. But the surgical residency in our university hospital was high-powered. All of the surgeons-in-training were very bright, and they lived, breathed, and slept surgery. The chief surgical resident even named his cat, “Stitch.” The surgical professors who taught those residents were exacting, perfectionistic, and totally intolerant of even the smallest mistake. Unfortunately for Dr. Bill, the other surgical residents were just a little more skilled than he. Consequently, Dr. Bill was frequently yelled at in the operating room.

Dr. Paul (also not his real name) was a surgeon from the suburbs who was asked by the patient to come to Jefferson University Hospital to remove the patient’s spleen. Maybe feeling a little put out, the house surgeons had Dr. Bill assist him. I was a third year medical student, and I scrubbed in to observe and assist.

What I observed is that Dr. Bill physically performed the surgery, from the first incision to the placement of the last suture. As the teacher, Dr. Paul told Dr. Bill what to do in small steps, giving him 5 to 10 instructions per minute. Under Dr. Paul’s clear direction and close supervision, Dr. Bill performed this difficult surgery in an careful, efficient, effective manner. I had never seen Dr. Bill do so well. In the end, Dr. Paul was satisfied and Dr. Bill was elated. I thought I saw him skip down the hall away from the surgical suite. And I learned what real medical teaching is all about.

Flash forward, thirty years later, and I’m an Assistant Clinical Professor, teaching third-year medical students at the Florida State University College of Medication. They are all brilliant, knowledgeable, enthusiastic, and compassionate, exactly what we want our future physicians to be. But the expectations are high and stress is intense, as they are given tests and compared to the other medical students across the nation. My observations of Dr. Paul’s surgery has shown me how to guide them through the skills they learn, step-by-step, so that when the skills come together, they can independently help the patients.

Copyright 2010, Henry A. Doenlen, M.D. All rights reserved.

How Men Solve the Unsolvable

Women talk about problems, especially unsolvable problems (such as their kids or husbands). Women feel better when they talk about their problems.

My advise for men is that they should listen to the women that they love, and share their feelings when women talk about unsolvable problems. Definitely don't tell her to not think about it, forget it, or think about something else. That works for man-to-man, but never is helpful for a woman. Men should not try to solve the woman's problem, unless the woman asks specifically for help solving the problem. If a woman wants advise, they'll ask for it. What is really needed is to pay attention, listen, share the feelings, and don't give advise. Woman feel much better when talk about problems, and will appreciate their men listening to them.

Men feel worse when they talk about unsolvable problems. Men will talk about a problem with someone who can help with a solution.

But if there is no solution, men usually will try to avoid talking about it.

So, if men won't talk about unsolvable problems, then how to they deal with them? Men IGNORE unsovable problems. Women should not fret if their men do not want to talk about the unsolvable problem that is bothering them.

When an unsolvable problem is ignored, one of three things happen:

1. The problem resolves on it's own. This is the most common outcome to the unsolvable problem.

2. In the course of not thinking about the problem, a solution will bubble-up in the man's mind.

3. The problem will become worse, but in the worsening, a solution to become apparant. For example, a car's intermittant noise is very hard to diagnose and resolve. If the car stops totally, then it becomes easy to diagnose and resolve.

Copyright 2010, Henry A. Doenlen, M.D. All rights reserved

Hello World!

Greetings! This blog is a companion to the teenpsychiatrist.com web site. It is my hope that you will find information here that is interesting and not available anywhere else.