Tag: Mind

To Boost Memory: Study, Wait, Then Exercise

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Credit Illustration by Renaud Vigourt

Learning requires more than the acquisition of unfamiliar knowledge; that new information or know-how, if it’s to be more than ephemeral, must be consolidated and securely stored in long-term memory.

Mental repetition is one way to do that, of course. But mounting scientific evidence suggests that what we do physically also plays an important role in this process. Sleep, for instance, reinforces memory. And recent experiments show that when mice and rats jog on running wheels after acquiring a new skill, they learn much better than sedentary rodents do. Exercise seems to increase the production of biochemicals in the body and brain related to mental function.

Researchers at the Donders Institute for Brain, Cognition and Behavior at Radboud University in the Netherlands and the University of Edinburgh have begun to explore this connection. For a study published this month in Current Biology, 72 healthy adult men and women spent about 40 minutes undergoing a standard test of visual and spatial learning. They observed pictures on a computer screen and then were asked to remember their locations.

Afterward, the subjects all watched nature documentaries. Two-thirds of them also exercised: Half were first put through interval training on exercise bicycles for 35 minutes immediately after completing the test; the others did the same workout four hours after the test.

Two days later, everyone returned to the lab and repeated the original computerized test while an M.R.I. machine scanned their brain activity.

Those who exercised four hours after the test recognized and recreated the picture locations most accurately. Their brain activity was subtly different, too, showing a more consistent pattern of neural activity. The study’s authors suggest that their brains might have been functioning more efficiently because they had learned the patterns so fully. But why delaying exercise for four hours was more effective than an immediate workout remains mysterious. By contrast, rodents do better in many experiments if they work out right after learning.

Eelco van Dongen, the study’s lead author and a former researcher at Radboud University (he is now a policy officer at the Netherlands Organization for Scientific Research), hopes that future studies will help determine both the optimal time to exercise and the ideal activity to reinforce learning. Workouts that are too strenuous “could be less positive or even detrimental” to acquiring knowledge, Dr. van Dongen says, while gentle exertions — “a short, slow walk,” he adds — might not prompt enough of an increase in the biochemicals needed to influence how the brain learns.

For now, he says, if you are trying to memorize a PowerPoint narrative or teach yourself macroeconomics, it could be beneficial to exercise a few hours after a study session. “Long-term memory is not only influenced by what happens when you learn new things,” he says, “but also by the processes that take place in the hours and days afterward, when new information is stabilized and integrated in your brain.”

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The Narcissist Next Door

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Credit Paul Rogers

Does this sound like anyone you know?

*Highly competitive in virtually all aspects of his life, believing he (or she) possesses special qualities and abilities that others lack; portrays himself as a winner and all others as losers.

*Displays a grandiose sense of self, violating social norms, throwing tantrums, even breaking laws with minimal consequences; generally behaves as if entitled to do whatever he wants regardless of how it affects others.

*Shames or humiliates those who disagree with him, and goes on the attack when hurt or frustrated, often exploding with rage.

*Arrogant, vain and haughty and exaggerates his accomplishments; bullies others to get his own way.

*Lies or distorts the truth for personal gain, blames others or makes excuses for his mistakes, ignores or rewrites facts that challenge his self-image, and won’t listen to arguments based on truth.

These are common characteristics of extreme narcissists as described by Joseph Burgo, a clinical psychologist, in his book “The Narcissist You Know.” While we now live in a culture that some would call narcissistic, with millions of people constantly taking selfies, spewing out tweets and posting everything they do on YouTube and Facebook, the extreme narcissists Dr. Burgo describes are a breed unto themselves. They may be highly successful in their chosen fields but extremely difficult to live with and work with.

Of course, nearly all of us possess one or more narcissistic trait without crossing the line of a diagnosable disorder. And it is certainly not narcissistic to have a strong sense of self-confidence based on one’s abilities.

“Narcissism exists in many shades and degrees of severity along a continuum,” Dr. Burgo said, and for well-known people he cites as extreme narcissists, he resists making an ad hoc diagnosis of narcissistic personality disorder, as defined by the American Psychiatric Association.

The association’s diagnostic manual lists a number of characteristics that describe narcissistic personality disorder, among them an impaired ability to recognize or identify with the feelings and needs of others, grandiosity and feelings of entitlement, and excessive attempts to attract attention.

Dr. Giancarlo Dimaggio of the Center for Metacognitive Interpersonal Therapy in Rome, wrote in Psychiatric Times that “persons with narcissistic personality disorder are aggressive and boastful, overrate their performance, and blame others for their setbacks.”

According to the Mayo Clinic, people with a narcissistic personality disorder think so highly of themselves that they put themselves on a pedestal and value themselves more than they value others. They may come across as conceited or pretentious. They tend to monopolize conversations, belittle those they consider inferior, insist on having the best of everything and become angry or impatient if they don’t get special treatment.

Underlying their overt behavior, however, may be “secret feelings of insecurity, shame, vulnerability and humiliation,” Mayo experts wrote. To ward off these feelings when criticized, they “may react with rage or contempt and try to belittle the other person.”

Dr. Burgo, who sees clients by Skype from his home in Grand Lake, Colo., noted that many “grandiose narcissists are drawn to politics, professional sports, and the entertainment industry because success in these fields allows them ample opportunity to demonstrate their winner status and to elicit admiration from others, confirming their defensive self-image as a superior being.”

The causes of extreme narcissism are not precisely known. Theories include parenting styles that overemphasize a child’s special abilities and criticize his fears and failures, prompting a need to appear perfect and command constant attention.

Although narcissism has not been traced to one kind of family background, Dr. Burgo wrote that “a surprising number of extreme narcissists have experienced some kind of early trauma or loss,” like parental abandonment. The family lives of several famous narcissists he describes, Lance Armstrong among them, are earmarked by “multiple failed marriages, extreme poverty and an atmosphere of physical and emotional violence.”

As a diagnosable personality disorder, narcissism occurs more often in males than females, often developing in the teenage years or early adulthood and becoming more extreme with age. It occurs in an estimated 0.5 percent of the general population, and 6 percent of people who have encounters with the law who have mental or emotional disorders. One study from Italy found that narcissistic personality traits were present in as many as 17 percent of first-year medical students.

As bosses and romantic partners, narcissists can be insufferable, demanding perfection, highly critical and quick to rip apart the strongest of egos. Employee turnover in companies run by narcissists and divorce rates in people married to them are high.

“The best defense for employees who choose to stay is to protect the bosses’ egos and avoid challenging them,” Dr. Burgo said in an interview. His general advice to those running up against extreme narcissists is to “remain sane and reasonable” rather than engaging them in “battles they’ll always win.”

Despite their braggadocio, extreme narcissists are prone to depression, substance abuse and suicide when unable to fulfill their expectations and proclamations of being the best or the brightest.

The disorder can be treated, though therapy is neither quick nor easy. It can take an insurmountable life crisis for those with the disorder to seek treatment. “They have to hit rock bottom, having ruined all their important relationships with their destructive behavior,” Dr. Burgo said. “However, this doesn’t happen very often.”

No drug can reverse a personality disorder. Rather, talk therapy can, over a period of years, help people better understand what underlies their feelings and behavior, accept their true competence and potential, learn to relate more effectively with other people and, as a result, experience more rewarding relationships.

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An Early Bedtime for Kids May Fight Weight Gain

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Preschool children who are in bed by 8 p.m. are far less likely to be obese during adolescence than children who stay up late, a study has found. Their risk of teenage obesity is half the risk faced by preschoolers who stay up past 9 p.m.

The research analyzed data gathered on nearly 1,000 children born in 1991 whose bedtimes were recorded when they were 4½ years old, and whose height and weight were recorded at age 15. The children were part of the Study of Early Child Care and Youth Development, done under the auspices of the National Institute of Health’s Eunice Kennedy Shriver National Institute of Child Health and Human Development.

Among the children who were in bed by 8 p.m., 10 percent were obese as teens, compared to 16 percent of those who went to bed between 8 and 9 and 23 percent of those who went to bed after 9, according to the study, published in The Journal of Pediatrics.

The researchers adjusted for such factors as socioeconomic status, maternal obesity and parenting style and still found that the children who went to bed by 8 p.m. were at less than half the risk of teenage obesity as those who were up past 9, said Sarah E. Anderson, the paper’s lead author and an associate professor of epidemiology at the Ohio State University College of Public Health in Columbus.

Although the study does not prove that early bedtimes protect against obesity, Dr. Anderson said, “there is a great deal of evidence linking poor sleep, and particularly short sleep duration, to obesity, and it’s possible the timing of sleep may be important, above and beyond the duration of sleep.”

“This provides more evidence that having an early regular bedtime and bedtime routine for young children is helpful,” she said.

With Coercive Control, the Abuse Is Psychological

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Credit Maggie Chiang

Lisa Fontes’s ex-boyfriend never punched her, or pulled her hair. But he hacked into her computer, and installed a spy cam in her bedroom, and subtly distanced her from her friends and family.

Still, she didn’t think she was a victim of domestic abuse. “I had no way to understand this relationship except it was a bad relationship,” said Dr. Fontes, 54, who teaches adult education at the University of Massachusetts, Amherst.

It was only after doing research on emotional abuse that she discovered a name for what she experienced: Coercive control, a pattern of behavior that some people — usually but not always men — employ to dominate their partners. Coercive control describes an ongoing and multipronged strategy, with tactics that include manipulation, humiliation, isolation, financial abuse, stalking, gaslighting and sometimes physical or sexual abuse.

“The number of abusive behaviors don’t matter so much as the degree,” said Dr. Fontes, the author of “Invisible Chains: Overcoming Coercive Control in Your Intimate Relationship.” “One woman told me her husband didn’t want her to sleep on her back. She had to pack the shopping cart a certain way, wear her clothes a certain way, wash herself in the shower in a certain order.”

While the term “coercive control” isn’t widely known in the United States, the concept of nonphysical forms of mistreatment as a kind of domestic abuse is gaining recognition. In May, the hashtag #MaybeHeDoesntHitYou took off on Twitter, with users sharing their own stories.

Last December, England and Wales expanded the definition of domestic abuse to include “coercive and controlling behavior in an intimate or family relationship,” making it a criminal offense carrying a maximum sentence of five years. To date, at least four men have been sentenced under the new law.

“In this approach, many acts that had been treated as low-level misdemeanors or not treated as offenses at all are considered as part of a single course of serious criminal conduct,” said Evan Stark, a forensic social worker and professor emeritus at Rutgers University, whose work helped shaped the new law in England and Wales.

Dr. Stark, the author of “Coercive Control,” noted that the English law pertains to a course of conduct over time. American law still does not address coercive control; it deals only with episodes of assault, and mainly protects women who have been subjected to physical attacks. But in about 20 percent of domestic violence cases there is no bodily harm, he said.

Coercive control often escalates to spousal physical violence, as a 2010 study in The Journal of Interpersonal Violence found. “Control is really the issue,” said Connie Beck, a co-author of the study and an associate professor of psychology at the University of Arizona. “If you can control a person’s basic liberties verbally — where they go, who they see, what they do — you do not necessarily have to hit them regularly, but if a person is not complying, then often physical abuse escalates.”

To a victim of coercive control, a threat might be misinterpreted as love, especially in the early stages of a relationship, or when one is feeling especially vulnerable.

Dr. Fontes, for example, was in her 40s and newly divorced when she met her ex-boyfriend. He was charming and adoring, and though he was a little obsessive, she overlooked it. Never mind that she has a Ph.D. in counseling psychology, and specializes in child abuse and violence against women.

“For a person looking for love and romance, it can feel wonderful that someone wants to monopolize your time,” she admitted.

For Rachel G., 46, a mother of three who lives outside Boston (she didn’t want her full name used to protect her privacy), the manipulation was all-consuming. Her ex-husband made them share a toothbrush, and wouldn’t let her shut the bathroom door — ever. He set up cameras around the house, and fastened a GPS in her car to track her movements. Sometimes he would show up at her work unannounced, “always framed as him needing to know where I was in case the kids needed me, or because he missed me and wanted to see me, but it was just his way of regulating my behavior.”

She was miserable, but stuck it out for 18 years. It never occurred to her to leave: She had three children, and “he had convinced me that I would be unhappy anywhere,” said Ms. G., who does fund-raising for a nonprofit. “I wasn’t only a bad wife — in every respect — but I was a negligent mother, or an overbearing mother, I was unsupportive of him, I was a bad cook, I prioritized work over family, my family liked him better than me, our friends liked him better than me. The worse I felt about myself and doubted myself and internalized his view of me and the way the world should work, the more submissive and accommodating I became.”

In the end, it was he, not she, who filed for divorce, after catching her in an extramarital affair. She is not proud of her actions, but she is grateful it got her out of the relationship. “I would never have left if he hadn’t filed,” she said. “I was afraid.” Since then, she has been trying to re-establish connections with family members and friends.

Dr. Fontes ultimately left her partner after four years. The decision came after she spent two weeks away from him, and realized how diminished she had become. “There were repeated telephone calls and emails every day, but it was such a relief to wake up and go to sleep without having to check in with this other person,” she said. “I recovered a sense of who I was as a separated person, my own opinions, my own perspective.”

The Connections Between Spanking and Aggression

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Credit iStock

In the 1990s, in my first month in practice as a pediatrician, I asked the mother of a 4-year-old about discipline and she told me that her son was often out of line and wild, and spanking was the only thing that worked, though she was sure I was going to tell her not to, just as her previous pediatrician had done. Around the same time, my colleague in the same clinic walked into an exam room to find a cranky toddler who was acting out, and a frustrated father who was taking off his belt and threatening punishment. In each case, and in many others, we had to decide how to talk to the parents, and whether to bring up the issue of child abuse — which is definitely an issue when a child is being struck, or threatened, with a belt.

Corporal punishment, also known as “physical discipline,” has become illegal in recent decades in many countries, starting with Sweden in 1979. The United States is not one of those countries, and pediatricians regularly find ourselves talking with parents about why hitting children is a bad idea. The American Academy of Pediatrics officially recommends against physical discipline, saying that evidence shows it is ineffective and puts children at risk for abuse; pediatricians are mandated reporters, responsible for notifying the authorities if we think there is a possibility of abuse, though the boundaries are not clearly defined by law.

But many parents continue to spank, even when they don’t think it does much good. In a recent report by the nonprofit organization Zero to Three of a national sample of 2,200 parents of children birth to age 5, parents were asked which discipline strategies they used a few times a week or more. Twenty-six percent said they “pop or swat” their child, 21 percent spank, and 17 percent reported hitting with an object like a belt or a wooden spoon. (Parents could respond that they used more than one strategy.) Zero to Three reported that even those who used these strategies frequently did not rate them as effective, and 30 percent agreed with the statement, “I spank even though I don’t feel O.K. about it.”

One reason the A.A.P. opposes spanking is because of evidence that it is associated with aggressive behavior in children. But does that mean that hitting children produces aggressive behavior, or that aggressive behavior in children elicits more and sterner parental measures?

Michael MacKenzie, an associate professor of social work and pediatrics at Rutgers, called the association “bidirectional and transactional.” How you discipline your child shapes your child, but also shapes you as a parent. But if you control for the child’s behavior, comparing more aggressive young children with other children who behave in the same ways, those who are frequently hit or spanked are more likely to show aggressive behavior and rule-breaking later on.

In a study published last year, he and his colleagues looked at these bidirectional effects. Children who were spanked were more likely to show disruptive, aggressive behaviors later on. Those behaviors, in turn, made it more likely that those children would be spanked more in the future.

“It mattered for everybody, but it mattered more for these kids in riskier contexts, the families facing more stress,” Dr. MacKenzie said. Other research showed that spanking was associated with poorer cognitive outcomes for children, even when the researchers controlled for factors such as maternal intelligence, maternal depression and cognitive stimulation in the home.

Dr. MacKenzie suggested that some families get caught in a “feedback loop,” in which children who are spanked respond more aggressively, and become even more challenging, reinforcing parents’ sense that only harsh discipline will work, so parents find themselves escalating the discipline, which in turn evokes more intense behavior.

“We want to think about these cycles and how they amplify,” he said, and to think as well about how to support families early on so that they set up different patterns. “We’ve sort of suggested the removal of a tool that many parents use, most parents use, without discussion of what the alternatives might be.”

Michael Lorber, a research scientist in the Family Translational Research Group at New York University, has found that parents who interpret their children’s behavior more negatively than an objective observer tend to use more harsh discipline. These patterns begin younger than we think, he told me, with parents in their studies clearly identifying children as young as 8 months old as difficult and aggressive.

“We think the infancy period is probably the time when parents begin to develop their disciplinary practices,” Dr. Lorber said. “Call it difficult temperament or incipient externalizing behaviors or contentiousness, it’s definitely the case that infants’ behaviors influence their parents, including physical discipline.”

One complicated question that researchers raise about physically aggressive children and their physically aggressive parents is whether there may be a genetic component to this behavior, which would be shared across the generations.

Leslie Leve, a professor of counseling psychology and human services at the University of Oregon College of Education, said that it was possible there were genetic predispositions toward aggressive behavior, which might affect both parents and children. “There is a common misperception that when people think of a behavior as ‘genetic’ that it’s not changeable, and that is not true,” Dr. Leve said. “With A.D.H.D. or aggression we know there is a genetic component, but there is a lot we can do in a family or educational environment. Genetics does not mean immutable.”

Dr. Leve has participated in studies of adopted infants, which can help tease out these effects, but which also show how complex the interactions are, with harsh parental responses affected by the child’s characteristics but also by factors in their own temperaments and their marriage.

Zero to Three reported that 69 percent of the parents said that “if they knew more positive parenting strategies they would use them.” Pediatricians try to help parents develop such strategies, discussing what behavior is developmentally realistic for young children; helping them interpret behavior without regarding it as defiant; counseling them about setting limits; and helping them find positive behaviors to praise and enjoy.

Disciplinary choices reflect parental stress, family circumstances and the whole complex cocktail of emotion and personal history and daily life at home. What parents do affects their children — their brains and their behavior — and the ways that children behave affects their parents. And the cycle of spanking and aggressive behavior seems to leave everyone worse off.

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The Challenges of Male Friendships

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Credit Paul Rogers

Christopher Beemer, a 75-year-old Brooklynite, is impressed with how well his wife, Carol, maintains friendships with other women and wonders why this valuable benefit to health and longevity “doesn’t come so easily to men.”

Among various studies linking friendships to well-being in one’s later years, the 2005 Australian Longitudinal Study of Aging found that family relationships had little if any impact on longevity, but friendships boosted life expectancy by as much as 22 percent.

Mr. Beemer urged me to explore ways to promote male friendships, especially for retired men who often lose regular contact with colleagues who may have similar interests and experiences.

After Marla Paul, a Chicago-area writer, wrote a book, “The Friendship Crisis: Finding, Making, and Keeping Friends When You’re Not a Kid Anymore,” about establishing meaningful friendships with other women, she was inundated with requests from men to give equal treatment to male friendships.

“A lot of men were upset because I didn’t include them,” Ms. Paul told me. “They felt that making and keeping friends was a lot harder for men, that close friendships were not part of their culture. They pointed out that women have all kinds of clubs, that there’s more cultural support for friendships among women than there is for men.”

In a study in the 1980s about the effect on marriage of child care arrangements, two Boston-area psychiatrists, Dr. Jacqueline Olds and Dr. Richard Stanton Schwartz, found that, “almost to a man, the men were so caught up in working, building their careers and being more involved with their children than their own fathers had been, something had to give,” Dr. Schwartz said. “And what gave was connection with male friends. Their lives just didn’t allow time for friendships.”

In their book, “The Lonely American: Drifting Apart in the Twenty-First Century,” the doctors, who are a husband-and-wife team, noted a current tendency for men to foster stronger, more intimate marriages at the expense of nearly all other social connections.

When these men are older and work no longer defines their social contacts, “there’s a lot of rebuilding that has to be done” if they are to have meaningful friendships with other men, Dr. Schwartz said in an interview.

From childhood on, Dr. Olds said, “men’s friendships are more often based on mutual activities like sports and work rather than what’s happening to them psychologically. Women are taught to draw one another out; men are not.”

Consciously or otherwise, many men believe that talking about personal matters with other men is not manly. The result is often less intimate, more casual friendships between men, making the connections more tenuous and harder to sustain.

Dr. Olds said, “I have a number of men in my practice who feel bad about having lost touch with old friends. Yet it turns out men are delighted when an old friend reaches out to revive the relationship. Men might need a stronger signal than women do to reconnect. It may not be enough to send an email to an old friend. It may be better to invite him to visit.”

Some married men consider their wives to be their best friend, and many depend on their wives to establish and maintain the couple’s social connections, which can all but disappear when a couple divorces or the wife dies.

Differences between male and female friendships start at an early age. Observing how his four young granddaughters interact socially, Mr. Beemer said, “They have way more of that kind of activity than boys have. It may explain why as adults they continue to do a much better job of it.”

In defense of his gender, he observed, “Men have a harder time reaching their emotions and are less likely than women to reveal their emotional side. But when you have a real friendship, it’s because you’ve done just that.”

He has found that “it’s important to expose yourself and be honest about what’s going on. If you reveal yourself in the right way to the right person, it will be just fine. There are risks, you can’t force it. Sometimes it doesn’t work — you get a don’t-burden-me-with-that kind of response and you know to back off. But more often men will respond in kind.”

Mr. Beemer has worked hard to establish and maintain valuable relationships with other men of a similar vintage. He joined a men’s book group that meets monthly, and after about two years, he said, “it became a group where the members really mean something to one another.”

He’s also in a men’s walking group that meets three times a week and gathers after each walk to share more conversation and a snack at a local cafe. When one member of the group had a heart attack, they visited him, cheering him up with the latest gossip and a favorite cafe snack.

“What sustains relationships over time is a regular rhythm of seeing each other,” Dr. Schwartz said. “It’s best to build a regular pattern of activities rather than having to make a special effort to see one another.”

He recalls “curing” a 70-year-old patient of his loneliness by encouraging him to join a bunch of guys who regularly dined and joked around at a neighborhood Panera Bread. “There are a lot of cafes in the Boston area where small groups of older men get together for breakfast everyday,” Dr. Schwartz said.

Dr. Olds said of her husband, “Richard has a regular group phone call with friends who live in different parts of the country. We program it into our schedule or it would disappear.”

Among other ways men can make new friends in their later years are participating in classes, activities, trips and meals at senior centers; taking continuing education courses at a local college; joining a gym or Y and taking classes with people you then see every week; volunteering at a local museum, hospital, school or animal shelter; attending worship services at a religious center; forming a group that plays cards or board games together; perhaps even getting a dog to walk in the neighborhood.

After my dentist’s wife died, he made several new friends and enjoyed lovely dinners with other men when he joined a group called Romeo, an acronym for retired old men eating out.

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Reading Novels at Medical School

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Credit Getty Images

Sitting in a classroom at Georgetown Medical School usually reserved for committee meetings, we begin by reading an Emily Dickinson poem about the isolating power of sadness:

I measure every Grief I meet
With narrow, probing, eyes –
I wonder if It weighs like Mine –
Or has an Easier size.

It’s a strange sight: me, a surgical resident, reading poetry to 30 medical students late on a Tuesday night. Some of us are in scrubs, others in jeans; there are no white coats. Over the past four years, as the leader of the group, this has become my routine.

The students are here after long days in class and on the wards because they have discovered that medical education is changing them in ways that are unsettling. I remember that uneasiness well. My own medical education began with anatomy lab. The first day with the cadaver was unnerving, but after the first week the radio was blaring as we methodically dissected the anonymous body before us.

Two years later, on my first clinical rotation, I discovered that it does not take long to acclimate to the cries of patients as I hurried past their rooms, eager not to fall behind in a setting where work must be done quickly and efficiently. This practiced detachment feels necessary, a form of emotional and physical self-preservation. But with little time to slow down, ignoring our own thoughts and feelings quickly hardens into a habit.

During my first year in medical school, I found myself gravitating toward my old comfort zone — literature. As an English major, I had grown accustomed to the company of books and was feeling their absence now that “Don Quixote” had been displaced by Netter’s “Atlas of Human Anatomy.” I could look to Netter for concrete answers, but I needed Cervantes to help me formulate questions I had trouble pinning down, like why it was so easy to ignore the dead (and later, living) bodies around me? Illustrated cross-sections of the brain did little to illuminate the workings of my own mind. I needed time and space for introspection. The solution came in the form of a book club that later became an official course.

At Georgetown, the goal of our new literature and medicine track is to foster habits of reflection over four years of medical school. On the surface, the assigned books have nothing to do with medicine. We read no patient narratives, doctors’ memoirs or stories about disease.

Today’s topic is Haruki Murakami’s novel “Colorless Tsukuru Tazaki and His Years of Pilgrimage,” which tells the story of a depressed middle-aged Tokyoite’s attempt to retrace his past in order to understand how his life became so empty. We talk about the main character’s colorless perception of the world, and why his mind feels so inaccessible to us.

I receive an email from a student later that evening. He, an aspiring psychiatrist, tells me the story of a much-admired college mentor. “I heard last week that he committed suicide. I am still crushed,” he writes. “He was diagnosed with depression but seemed to be doing great.” If he so misjudged his teacher’s state of mind, he worries, how will he make it as a psychiatrist?

Earlier this year, we placed the ethics of animal testing under the magnifying glass of Karen Joy Fowler’s “We Are All Completely Beside Ourselves.” The novel is narrated by a woman whose “sibling,” we later discover, is a chimpanzee who was raised with her as part of a human-chimp experiment. We used the book to think through real-life examples like the Silver Spring Monkeys — a series of gruesome primate experiments that both galvanized American animal-rights groups and led to breakthrough scientific discoveries.

A third-year student talked about the three years he spent working with rhesus macaques. Research from his lab led to breakthrough discoveries about memory and behavior and contributed to therapies such as deep brain stimulation. “Doesn’t that answer the ethical questions?” he asked.

Another student talked about studies that she worked on for several years before starting medical school. “Have you heard of professional testers?” she asked the room. “People whose only source of income is volunteering for different studies, mostly college kids and immigrants? Shouldn’t we be talking about human research also?” For me, the discussion proved transformative. I walked into that class firmly supporting animal research and walked away still supporting research but no longer eating meat.

Our busy jobs on the hospital wards require precision and efficiency, but in literature class we can slow down and explore human lives and thoughts in a different, more complex way. The class is an anatomy lab of the mind. We examine cultural conventions and conflicting perspectives, and reflect on our own preconceived notions about life and work. Reading attentively and well, we hope, will become a sustaining part of our daily lives and practice.

As I’m walking out of the classroom at the end of the evening, a third-year student approaches me to tell me he’s been thinking more deeply about his experience of being an unrelated organ donor to his step-uncle, a man he barely knew. “It’s been on my mind since we read Ishiguro’s ‘Never Let Me Go’ last month,” he says. “I want to write about it. I don’t even know how I feel about it, and I need to figure it out.”

Daniel Marchalik, M.D., is a urologist in Washington and heads the literature and medicine track at the Georgetown University School of Medicine.

Alzheimer’s Disease as an Adventure in Wonderland

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A page from “Aliceheimer’s: Alzheimer’s Through the Looking Glass,” by Dana Walrath.

A page from “Aliceheimer’s: Alzheimer’s Through the Looking Glass,” by Dana Walrath.Credit

In her memoir “Aliceheimer’s: Alzheimer’s Through the Looking Glass,” Dana Walrath uses drawings and stories to chronicle three years of caregiving for her mother, Alice, who was in the middle stages of Alzheimer’s disease. The experience turned out to be a magical trip down the rabbit hole of memory loss, an outcome that inspired Dr. Walrath, a medical anthropologist who taught at the University of Vermont College of Medicine and who also studied art and writing, to share their tale.

Refusing to accept the dominant narrative of Alzheimer’s disease as a horror story, Dr. Walrath used the techniques of graphic medicine to create “Aliceheimer’s,” an 80-page, 35-picture tribute to her mother’s animated mind. Graphic medicine uses text and graphics to, as she writes in the book’s introduction, “let us better understand those who are hurting, feel their stories, and redraw and renegotiate those social boundaries.”

We spoke with Dr. Walrath to learn more about graphic medicine, how the book came into being, and what it can teach others about caring for someone with Alzheimer’s disease. Here’s an edited excerpt of our conversation.

Q.

You say that “Aliceheimer’s” found you, not the other way around. What’s the backstory of your story?

A.

After a lifetime of mutually abrasive interaction, my mother moved into my home when a lock-down memory-care unit was her only other option. The years of living together not only brought us closure, but it also integrated my disparate career threads. Medical anthropology, creative writing, visual art — who knew they were connected? I sure didn’t. But Alice must have. During dementia, she said to me, “You should quit your job and make art full time.”

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A page from “Aliceheimer’s: Alzheimer’s Through the Looking Glass,” by Dana Walrath.

A page from “Aliceheimer’s: Alzheimer’s Through the Looking Glass,” by Dana Walrath.Credit

Q.

What is “graphic medicine” and how did you discover the genre?

A.

I started making “Aliceheimer’s” comics before I knew that graphic medicine existed. Watching Alice — a lifelong reader who was finding straight prose too hard to track — eat up books like “Maus,” “Persepolis,” “American Born Chinese” and “Fun Home” when she lived with me, made me certain that to tell our story I wanted to use a form that a person with dementia could access. When a fellow medical anthropologist introduced me to graphic medicine, I knew I had found my tribe. The “Graphic Medicine Manifesto” defines graphic medicine as “the intersection of the medium of comics and the discourse of health care.”

Q.

Which came first: your drawings or your stories? When and how did they merge?

A.

The drawings came first. If you page through “Aliceheimer’s” looking only at the left-hand pages, you can read the original comic, a love story in pictures. I started writing short vignettes, each one in response to one of the original drawings. I began posting them on a blog until the content felt right for the intimate interior of a book.

Q.

How did the “Alice in Wonderland” theme come into play?

A.

My father had read it out loud to us as kids, and during dementia Alice and I often recited parts of it together. But the day I cut up a cheap paperback copy of “Alice in Wonderland” to depict Alice’s bathrobe, her favorite garment, I knew I had found the voice for the story. Life with dementia is filled with alternate realities and magic, both scary and uplifting. Accepting wonderland as our baseline made day to day life an adventure.

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<strong> </strong>A page from “Aliceheimer’s: Alzheimer’s Through the Looking Glass,” by Dana Walrath.

A page from “Aliceheimer’s: Alzheimer’s Through the Looking Glass,” by Dana Walrath.Credit

Q.

How might “Aliceheimer’s” influence the medical, artistic and caregiving communities?

A.

I would love to see “Aliceheimer’s” contribute to reframing dementia as a diversity issue. Of course there is loss involved, but the more we can see people living in this state as useful true humans who might teach us all something about living in the present, about knowing sides of our loved ones that social processes kept inaccessible, the better it will be.

I would love for the medical community to start to touch on the opportunities for closure and forgiveness that this condition might bring instead of the ongoing fight for the cure. For artistic and caregiving communities, I hope the book empowers people to tell their stories, particularly in comics form.

Q.

In “Aliceheimer’s,” you suggest new ways of thinking about Alzheimer’s. How did your mother’s memory-stealing disease open your mind?

A.

The dominant zombie story of bodies without minds strips people with dementia of their humanity and interferes with creating new kinds of familial connections. How many of us have the privilege of knowing our parents as children? Through connection we heal. Comics lead us to light because, subconsciously, we associate comics with laughter, and we need permission to laugh at sickness and not just describe it in medical terms. Laughter is respite. It opens new possibilities for how to cope.

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A page from “Aliceheimer’s: Alzheimer’s Through the Looking Glass,” by Dana Walrath.

A page from “Aliceheimer’s: Alzheimer’s Through the Looking Glass,” by Dana Walrath.Credit

Q.

What suggestions do you have for people caring for a loved one with Alzheimer’s?

A.

Learn to read the signs and messages embedded in your loved one’s actions. Often what looks delusional is an attempt to express a deeply felt need or desire. Dementia has them communicating through a code that we can track. Use the “Yes, and” principle from improv — in which you accept what the other person has said (“yes”) and then expand on that line of thinking (“and”) — to build on what your loved one is experiencing instead of contradicting them, and it will be easier to decipher his or her intentions.

Dementia lets all of us connect back to our deepest memories, to a time when we could communicate — give and receive stories — through the looks in each other’s eyes, through touch, facial expressions, actions and gestures. In this way, even in the midst of loss, dementia lets us heal.

For U.S. Parents, a Troubling Happiness Gap

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Credit Getty Images

For years, social scientists have known that nonparents are happier than parents. Study after study has confirmed the troubling finding that having kids makes you less happy than your child-free peers.

Now new research helps explain the parental happiness gap, suggesting it’s less about the children and more about family support in the country where you live.

Based on data from 22 countries and two international surveys of well-being, researchers found that American parents face the largest happiness shortfall compared to people who don’t have children. The happiness gap between parents and nonparents in the United States is significantly larger than the gap found in other industrialized nations, including Great Britain and Australia. And in other Western countries, the happiness gap is nonexistent or even reversed. Parents in Norway, Sweden and Finland — and Russia and Hungary — report even greater levels of happiness than their childless peers.

The researchers, led by the University of Texas sociology professor Jennifer Glass, looked for factors that might explain the international differences in parental happiness, and specifically why parents in the United States suffer a greater happiness penalty than their peers around the world.

They discovered the gap could be explained by differences in family-friendly social policies such as subsidized child care and paid vacation and sick leave. In countries that gave parents what researchers called “the tools to combine work and family,” the negative impact of parenting on happiness disappeared.

“We comprehensively tested every other alternative,” said Dr. Glass, the lead author of the study, which will be published in the American Journal of Sociology in September. “The two things that came out most strongly in explaining the variation were the cost of care for the average 2-year-old as a percent of wages and the total extent of paid sick and vacation days.”

Notably, the researchers found that economic differences, whether a parent was married or partnered and whether the pregnancy was planned or unintended had no impact on the happiness gap. They also considered the impact of other family-friendly social policies, such as extended maternity and paternity leaves, flexible schedules and even policies that gave money to parents in the form of a child allowance or monthly payments.

Paid parenting leave has “nowhere near as big an effect as these other two policies, “said Dr. Glass, while the other policies didn’t have a significant impact on the happiness gap. Policies that made it less stressful and less costly to combine child rearing with paid work “seem to be the ones that really matter.”

Those same two policies, she said, were also correlated with increased happiness among nonparents. That more paid sick leave and vacation time would make nonparents happier was no surprise, but “we were a little puzzled that lower child care costs would show an effect on nonparents,” Dr. Glass said. She and her colleagues speculate that the result is what economists call an indirect benefit: Everyone is better off when countries invest in the future of their labor force, and everyone suffers when they don’t.

But while there are certainly distinctions in family policy to be made between the United States and other developed countries, there are also substantial cultural differences in the ways children are raised here and in other countries. Those distinctions are hard to measure, but might also account for some of the relative difference between parental and nonparental happiness.

“There’s an incredible anxiety around parenting here that I just don’t feel in other countries,” said Christine Gross-Loh, the author of “Parenting Without Borders,” a comprehensive look at modern parent culture across the developed world, who is raising her children between the United States and Japan. She points to Americans’ anxiety around children’s college and future prospects, and also to our emphasis on keeping children physically safe, and the harsh judgment of parents who are perceived to be doing a poor job of it.

“In Japan, my 6-year-old and my 9-year-old can go out and take the 4-year-old neighbor, and that’s just normal,” she said, while in the United States that kind of freedom can draw criticism and even lead to interventions by Child Protective Services.

In countries where there is a strong agreement about the norms around parenting, parents may worry less about their own choices. Without a single overarching parenting tradition, American parents may feel like they have “too many choices” as compared to parents in more homogeneous cultures, says W. Bradford Wilcox, an associate professor of sociology and the director of the National Marriage Project at the University of Virginia. “A clear and well-defined script can be psychologically comforting,” he said, and its lack can leave parents feeling “unmoored.”

Dr. Glass agrees that cultural differences add to the greater relative parent and nonparent happiness gap — but she notes that those cultural differences are also reflected in our family policies. Much of our anxiety around our children in the United States, she said, is very clearly a reflection of our policy choices.

“We have to compete for good child care. We compete to live where there’s a good elementary school,” she said. “We compete for activities because a child’s entire fate seems to depend on where he goes to college, because there’s no guarantee — if we don’t, our child might be left behind.”

Those fears, Dr. Glass said, come in part from our country’s high tolerance for unequal access to the resources families need. In countries that offer policies supporting a parent’s ability to balance work and family, she sees a commitment to egalitarianism. “A crucial part of what’s going on is the idea that every child deserves an equal chance in life,” she said.

The good news is that the findings show that the happiness gap of parenting is not inevitable. Stephanie Coontz, who teaches history and family studies at The Evergreen State College in Olympia, Wash., and is co-chairwoman of the Council on Contemporary Families, said it was a pleasant surprise to see the researchers document the need for better family policies.

“Don’t just swoop in and give a longer maternity leave,” Dr. Coontz said. “It’s a lifetime investment in helping people combine work and family for the long haul.”


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