BrainTwits of Michael Lara, MD

The Tao of Twitter: 5 Lessons from Lao-Tzu on Twitter Etiquette

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If you want to govern the people,
you must place yourself below them.
If you want to lead the people,
you must learn how to follow them...

~Tao Te Ching, 66

It's unlikely that Lao-tzu, the author of Tao, had Twitter on his mind when he penned these words more than 2,000 years ago, but his writings remain remarkably prescient.  In my re-reading of the Tao, I came across several passages that are no less relevant in today's world of Twitter. Here are the top 5 lessons I've gleaned from the Tao and their relevance to Twitter: 

1. Imagine the Possibilities

The Tao is like a well:
used but never used up.
It is like the eternal void:
filled with infinite possibilities
~Tao Te Ching, 4

Anyone who's spent time on Twitter can attest to this.  We've all felt exhilirated, overwhelmed, even manic, at the boundless possibilities of Twitter once we "get it". What possibilities for your business or enterprise do you dare to imagine?

2. Know When Enough is Enough

Fill your bowl to the brim
and it will spill.
Keep sharpening your knife
and it will blunt.
Chase after money and security
and your heart will never unclench.
Care about people's approval
and you will be their prisoner.
~Tao Te Ching, 9

Quite simply, we need to know when enough is enough. When we've self-promoted enough. When we've tweeted enough. When we've attracted enough followers. Do you know when you've had or done enough?

3. Build Your Following One Tweet At A Time

He who stands on tiptoe
doesn't stand firm.
He who rushes ahead
doesn't go far.
He who tries to shine
dims his own light....
If you want to accord with the Tao,
just do your job, then let go.
~Tao Te Ching, 24

We all know stars in the universe of Twitter, but we've also seen meteoric falls out of twitterverse. Avoid schemes that promise you immediate surges in followers. Build a following tweet by tweet, day by day, and establish a solid following.  Do your work, then stand back.

4. Do Unto Others....

Without opening your door,
you can open your heart to the world.
Without looking out your window,
You can see the essence of the Tao.
~Tao Te Ching, 47

 As I write these words in the pre-dawn darkness of my office nestled among the California redwoods, I am receiving Direct Messages from all over the world--New York City, Finland, England. No, I'm not psychic. I'm on Twitter. Return the courtesy by responding promptly to Direct Messages and the world will show up at your doorstep. 

5. Start Small, but Think Big

Act without doing;
work without effort.
Think of the small as large
and the few as many.
Confront the difficult
while it is still easy;
accomplish the great task
by a series of small acts.
~Tao Te Ching, 63

Are you beginning to see what I mean about Lao-Tzu's prescience? From a series of small messages less than 140 characters in length,  I have build a slow but steady following, nurtured ideas for blog posts, and have attracted new patients to my medical practice. Not through expensive advertising campaigns or glossy marketing campaigns or media blasts. I've built my tribe 140 characters at a time. Imagine what you can accomplish with a series of small acts--140 characters at a time....

Michael Lara, MD is a physician in private practice near San Francisco, California.  He writes frequently about the intersection of medicine and technology. 

How Twitter Seduces Us

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Twitter and The Art of Seduction

Se-duce: transitive verb: Late Latin seducere, from Latin, to lead away, from se- apart + ducere to lead

The only way to get rid of temptation is to yield to it
~Oscar Wilde

Have you ever stayed awake at night wondering why you spend so much time twittering?

Have you ever vowed to tweet less, only to jump out of bed  the next morning and check your replies, direct messages and…admit it…your follow count?

When you realize how much time you’ve procrastinated, you promise to tweet less.  You withhold your tweets for a few hours…a day…maybe even a week.

But then it happens: the next morning, you yield to temptation and you’re back on Twitter again. 

What’s going on here?

The answer? Seduction. 

Twitter enacts the phases of seduction as outlined in Robert Greene’s book, The Art of Seduction. As Greene points out, we're seduced in four phases.

Here’s my take on how Twitter seduces us:

• Phase One: Separation: Stirring Interest and Desire

The tweets run through your mind like a ticker tape of the collective internet consciousness, “How to Make Internet Millions”, “How to Attract More Followers,” “Seven Secrets You Must Know About Twitter”  Or maybe it's just an interesting headline “What The Monkey Saw: AIG and The Bailout”, Or it might even be a profile picture from someone who responded your tweets.  Whatever. Someone…somewhere…somehow has attracted your interest.

• Phase Two: Lead Astray—Creating Pleasure and Confusion

You yield to temptation. You follow the clicks.  Yes, momentary pleasure as you skim the blog post, click through to that funny video clip or picture.  But then confusion may arise… How does this work? Why is this website asking for my twitter password? What does this twitterer really want from me?

• Phase Three: The Precipice—Deepening the Effect Through Extreme Measures

As Green writes, “The goal in this phase is to make everything deeper—the effect you have on their mind, feelings of love and attachment, tension within your victims. With your hooks deep into them, you can push them back and forth, between hope and despair, until they weaken and snap”

In this phase, you’ve already gone through your nocturnal deliberations….and yet you continue to return. This time you do more than just click through:  you subscribe to the newsletters, you give out your email address, and maybe…your Twitter password.  But the curiosity consumes you…”What if I don’t do this?”

• Phase Four: Moving In For The Kill

Greene: “First you worked on their mind—the mental seduction. Then you confused and stirred them up—the emotional seduction. Now the time has come for hand-to-hand combat—the physical seduction. At this point, your victims are weak and ripe with desire: by showing a little coldness or uninterest, you will spark panic—they will come after you with impatience and erotic energy.”

This phase of seduction occurs while you are away from Twitter. It refers to the actions you take away from the computer. Maybe you buy a book on internet marketing or copywritng. Maybe you sign up for a local class on blogging.  Or maybe you yield to the coup de grace of Twitter seduction: You attend the Tweetup.

And as you stand there, drink in hand, mingling with new faces at your next Tweetup , it dawns on you: You’re been seduced by Twitter.

 Let the games begin. 

Valley Fever

The following is an excerpt from Michael Lara's forthcoming book, Our Chemical Romance: 7 Stories on The Misuse Of Medication in America

Valley Fever

I.

“So, basically, before I tell you my story,  I need to know if you are Indian.”

The patient, Rajeev as I shall call him, is a 29-year old Indian engineer who comes to my psychopharmacology clinic at the insistence of his wife for, as she had informed me over the phone a week earlier, “unmanageable instability.” Rajeev, dressed Silicon Valley Casual--a custom-fitted dress shirt with silver cufflinks, a dark blue sports jacket and slacks, black Salvatorre Ferragamo loafers-- sits at the edge of the couch in my office, gazing intently at me as he awaits an answer. 

“Well,” he gestures impatiently, “I suppose it does not matter.”

Rajeev sits up, cranes his neck to one side, and stretches his arms forward to adjust his shirt sleeves--gestures a conductor might make in the hushed moments before the music begins. 

“Basically, I came here to California from India after graduating at the top of my class from the best university in New Delhi--I was, you should know, the top student out of 347 students. From there I went to Stanford for a PhD in triple E,  Electrical Engineering and Economics, and from my dissertation, which I completed in 3 years, I published 45 papers and started three different companies and you should know that I have five patents to my name and  have been featured in Fortune and have had stories written about me in the Wall Street Journal and New York Times and ... you are not Indian, right?...No, well then you maybe you would not understand  my problem... after all, you are not Indian... Basically, I have been having panic attacks and these intense mood swings because I'm afraid that I will not fulfill my destiny as the Vedic astrologers in Bangalore have predicted; it is my destiny, you should know...quite simply....to change the world.”

 And with that, Rajeev sits back into the couch, crosses his arms, thrusts out his legs and contemplates the tips of his Ferragamos as he wags them impatiently. A few moments later he glances expectantly at his wife, Sanjita, who sits beside him on the couch.

 An attractive green-eyed Indian woman in beige slacks and a white designer blouse, Sanjita, remains silent and continues to gaze deferentially at the carpet in my office.  Her silence is broken by the bright tinkling of her bracelets as she raises her hand to her mouth to clear her throat. We collude, sharing in the knowledge that, were it not for her phone call a week earlier to request an urgent consultation, Rajeev would not be here in my office today.  While her husband’s frenetic narrative and body language are, I believe, an easy read to my psychiatric/detective eye, Sanjita remains elusive--her minimalist facial expressions and body language neither confirm nor deny the truth of her husband’s account.  Nevertheless, I suspect that Rajeev’s impetuous temperament, fast-paced talking, restlessness, and grandiose delusions are suggestive of one and only one condition, and in the silence that ensues I furtively scribble my working diagnosis: Bipolar disorder 

Bipolar disorder, or manic-depression as it was once termed, affects more than two million Americans every year.  In its classic manifestation, symptoms can include any of the following: increased activity and restlessness; extreme irritability; racing thoughts; distractability (often mistaken for attention deficit); a decreased need for sleep; poor judgment; spending sprees; substance abuse (especially of alcohol and cocaine); and, tragically, denial that anything is wrong.  “How could anything be wrong”, patients often protest, “I’m more productive than ever!” Experts in the field concur that the two million figure is a gross underestimate of the actual prevalence of bipolar disorder, as this figure does not include sub-syndromal manifestations at the softer end of the bipolar spectrum.  Researchers in the field have identified as many as six different subtypes of bipolarity and place the actual prevalence closer to seven million, more than seven times the population of San Francisco. It also turns out that, contrary to what most Americans believe,“mood swings” are not the most characteristic feature of bipolar disorder.  Instead, the disorder reveals itself in an insidious crescendo of  sleepless nights and eighteen-hour work days, in an obsessive quest for perfectionism at any price, of high stakes risk-taking and fast-talking--characteristics, some might say, of any successful entrepreneur.  Many times, anxiety and panic attacks, not mood swings,  are the harbingers of an impending manic episode. It is not until this behavior spirals out of control and threatens to sabotage million-dollar deals or undo marriages that they come to me, as Rajeev has, seeking reprieve to a life interrupted.

II.

For the last ten years I have practiced psychiatry in the Silicon Valley and have witnessed the emotional aftermath of the internet bust in 2001.  Prior to the bust, I have had the privilege of working with the nouveau riche as they struggled to embrace their new found glory; the privilege of listening to their stories of how they struggled, persevered, and finally reached their promised land of venture capital funding; the privilege of sharing a sliver of their American Dream. As I psychiatrist, I was trained to remain indifferent to the personal fortunes of my patients, but after dozens had recounted their victories, I could not help but feel a tinge of envy.  Although I was born and raised in quite a different valley, I too longed for my own slice of the American Dream. 

In the 1960s and ‘70s my family lived in the outskirts of Chino Valley, located about 40 miles east of Los Angeles.  While long known by locals for its quaint dairy farms and fragrant walnut groves, Chino was at that time beginning a process of gentrification that would eventually supplant the dairies and walnut groves with housing developments for the Hispanic laborers who worked the fields. My family lived in one of the first housing developments, the 13th Street Housing Project, comprised of clusters of cinder-block housing units stuccoed over in pale pink.   It was here, among the undulating, redolent hills of the valley and under the watchful eye of Cousin Bruno, that I began my journey into psychiatry and the mysteries of bipolar disorder.

“No, no, Cuz. You have to jump back as high as you can, and when you feel yourself coming down to earth, then you shoot. Don’t wait ‘til you’re already down. And shoot the ball above your head, not from your chest, ‘cause then you look like a chavala, a sissie.”

We are on the basketball court at Gird Elementary and Bruno is sharing with me the secrets of his fade away jump shot. Bruno is twelve-years old, three years my senior, and is recognized among the 6th and 7th graders as the best outside shooter in town.  Slender, with a slight muscular build, the apple of his biceps flexes as he executes a perfect shot.  As he stands there in the schoolyard with his t-shirt sleeves rolled above his shoulders, black pompadour hair slicked back and one hip jutting forward, he resembles a younger, slightly darker-skinned version of James Dean.

“See, you have to keep on top of your game... keep it tight.”

And Bruno had kept on top of his other games. Two years prior, just after his 10th birthday, his picture appeared on the front page of our local paper, The Chino Champion, with the title, “Local Talent Sweeps Chess Tournament”.   Bruno sits poised before the the chess board,  nibbling contemplatively on the fingernail of his pinky.  Surrounded by a sea of privileged well-to-do spectators who lived on the other side of the railroad tracks, his is the only brown face in the photo. Later he would confide in me his secret to taking the tournament, “King’s Indian Defense--pendejo.”

And, if excellence in games of physical and mental strategy weren’t enough, Bruno was universally praised by his math teachers for the high marks he attained in algebra.  To this day I can still picture the cryptic pages of equations he would post on Grandmother’s refrigerator, especially the thick scrawl of red ink-- “Great Job, Bruno!” Several years later, in his 9th and final year of public education, Bruno dated the Junior Prom Queen of Chino High, the daughter of a wealthy Dutch family of dairy owners.  She would go on later that year, rumor had it,  to make a guest appearance on the Brady Bunch as Greg Brady’s girlfriend. Only decades later would I understand the pattern behind Bruno’s victories, only later would I recognize the pattern behind his thrill-seeking, fast-paced, no regrets way of life, the pattern behind his sleepless nights spent prowling the streets in search of something, anything, that would lull the incessant rumblings of his unquiet mind.

 III.

“Basically what you have prescribed has worked. I am 70% better I would say ... maybe 75%”

Rajeev is back in my office, alone this time,  for his one week follow-up visit.  He appears calmer, more relaxed, as he takes his seat.  A triumphant smile flickers across his face.  “Sanjita agrees.  We are not arguing as much.”

After the initial consultation, I had diagnosed Rajeev with Bipolar Disorder, Type I, and had prescribed a combination of an antipsychotic, risperidone, and a sedative-hypnotic, clonazepam.  The pharmacologic armamentarium for the treatment of bipolar disorder, though far from perfect, has progressed in the last decade; gone are the days where our options were limited to older antipsychotic medications, lithium, or valproate--all medications whose side effects (involuntary muscle movements, tremors, kidney and liver toxicity) were in some instances worse than the symptoms they were intended to treat. Today, no less than ten medications are indicated by the Food and Drug Administration for the treatment of Bipolar Disorder.  They include all of the next generation antipsychotics (now relabelled as “mood stabilizers”), a new class of anticonvulsant drugs that include lamotrigine (a mood stabilizer with antidepressant properties), time release versions of valproate and carbamazepine (less toxic and easier to dose than their parent drugs), and in a reincarnation of an old concept, combination capsules that mix an antidepressant with an antipsychotic (Symbyax=fluoxetine + olanzapine). Yet despite these advances, there remains one vexing fact in the management of bipolar disorder: more than sixty-percent of patients do not adhere to their medications.  Patients, the experts believe, eventually yearn for the creative highs of their hypomanias, a time when symptoms are just below the threshold of chaos, a time of effortless flow and peak performance.

“I need to know one thing, Dr. Lara.  Do these pills that I am taking, will they take away my ambition and drive to succeed?  I think I mentioned last time that my biggest fear is that I will not fulfill my destiny to change the world. And one other thing: As soon as I am back to 100%, I plan to stop these medications.”

Rajeev’s predicament is not uncommon.  Like many of my other bipolar patients, Rajeev really wants to know when he can discontinue his medications so that he can resume his demanding work schedule.  My immediate concern is that, despite taking antipsychotic medication, Rajeev persists in his grandiose delusions. Or so I thought.  It turns out that everything that Rajeev has said about appearing in Fortune magazine and The Wall Street Journal, about starting and selling companies--every word of it--is absolutely true. In the years I have treated bipolar disorder, or “Valley Fever” as I sometimes refer to it , I have come to appreciate the utility of the internet search engines in verifying the incredulous narratives of my patients. In Rajeev’s case, I did not learn of the veracity of his account until after I had given him my diagnosis and started him on medication for bipolar disorder; only later did I google him and discover the extent of his Silicon Valley stardom.

Rajeev’s case raises some interesting questions for psychiatrists who treat bipolar disorder: do we really want to medicate away hypomania, however prevalent? It is worth remembering that some of the most brilliant minds in history have suffered from the illness: Vincent Van Gogh, Lord Byron, Emily Dickinson, Edvard Munch, Robert Schumann, Jackson Pollock--the list goes on.  And in my own generation it turns out that entrepreneurs like Rajeev have disproportionately high rates of bipolar disorder compared to the general population.  The experts are divided on this issue: some argue that it is better to let patients “run warm” for a while (they will, after all, stop their medications, and besides, they make a hell of a lot of money when they are hot) while others argue that it is best to medicate  at the earliest symptoms--decreased sleep and increased irritability--invoking the kindling hypothesis, which maintains that with each excursion into mania, it becomes increasingly easier to cycle up into subsequent episodes.

IV.

I last met with Bruno during Thanksgiving of 2004.  Now in his mid 40s, he is but a shadow of the athlete that he once was. Gaunt and balding, he walks with a cane (the consequence of gunshot wound to the knee) and takes a seat across from me at my aunt’s kitchen table.  He is wasting at the temples and the sagging skin of his neck and arms are covered with faded tattoos in bleeding Gothic script.  For the last 24 years he has been locked up at Pelican Bay, California’s highest security prison, for various drug and gang-related offenses. 

“So, Cuz, what you up to?” I notice a rattling sound emanating from deep within his chest as he struggles to enunciate.

“You know, I told the vatos at Pelican Bay that I had a cousin who went to Harvard and Stanford, a cousin who was gonna be a doctor.  None of them believed me. Shit, half of them never even heard of Harvard or Stanford. Pinche pendejos. So what you up to?”

“I am a psychiatrist... a psychopharmacologist.”

Bruno cocks his head back in disbelief. “A psychiatrist? I thought you wanted to be a doctor?” The rattling in his chest becomes louder.

“Well, what I do is treat illness--mental illness-- with medications and talk therapy.”

“Oh, so you give drugs to people?”

“Yeah, that’s essentially what a psychiatrist does.”

“You give drugs to people to make them feel better?”

“Yeah, I guess so.  I suppose you could say I give drugs to people to make them feel better.”

“And you get paid to do this?”

“Yeah...”

“So let me get this straight: you get paid to give drugs to people to make them feel better?”

“Yes.”

“So tell me one thing: how is that any different from what I used to do on the corner of 13th back in the day? Shit, go figure...you go to Harvard and get paid and I go to Pelican Bay and get 24 years.  Well, I guess I taught you right, Cuz, you kept it tight and kept on top of your game after all”

 And in a way Bruno is right. The sad truth is that Bruno had everything Rajeev had, and more--intelligence, good looks, ambition, notoriety, beautiful girlfriends.  But, unlike Rajeev, Bruno had the misfortune of growing up in a time and a place that did not recognize manic depression, in a time and place where there were no psychiatrists, in a time and place where treatment choices were limited: to self-medicate or to self-destruct. The irony is that Bruno showed as much promise in his earlier years as my most accomplished executive patients; the irony is that Bruno, not my medical school professors, was my best psychopharmacology teacher; the irony is that Bruno, a jaded convict, was and still is capable of moments of unmatched tenderness as he shared with me secrets of the King’s Indian Defense and the fade away jump shot.

Rajeev and Bruno, at different times and in different places, were victorious despite their illness.  The essential difference is that Rajeev had access to the best chemicals medicine could offer to combat his illness. Bruno had neither the access nor the means and so, like any good entrepreneur, he invented his own. 

How Physicians (Should) Use Twitter

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Will Twitter change the way physicians practice medicine?

Probably not.

Does Twitter have any practical uses in the late-adopting tribe that is modern medicine?

Maybe.

As an early-adopter with all things technical, I've found Twitter to be a useful adjunct to my private medical practice. Along the way, I've stumbled upon a few practical, time-saving techniques for integrating Twitter into an office-based medical practice.

Generally speaking, Twitter use falls under three categories:

As a Tool For Information Collection:

• Medical News Updates
• Job Openings
• CME opportunities

As A Tool for Information Sharing:

• Physician to Physician communication for general medical questions, curbside consults
• Live blogging from medical conferences

As a Tool for Communications Regarding Direct Patient Care:

• Physician-to-team member about non-urgent matters
• Office staff-to-patient about appointment reminders

I've also found that there are several scenarios where Twitter should NOT be used:

• To communicate directly with patients and their families

• To communicate with anyone regarding matters that require urgent or timely action

• To answer inquiries from anyone regarding details about patient care, even if from a recognized Twitter account.

Furthermore, under no circumstances should patients be referred to by name or other identifiable means, even via Direct Messages.

For Twitter to work as a viable tool in an office-based medical practice, everyone should have a basic understanding of how Twitter works.  Every team member, for example, should understand the difference between a Direct Message and the Public Timeline.  Our rule is to tweet only via Direct Messages, but assume that the tweet will be on the Public Timeline.

Another Twitter tenet is understanding how and when key team members integrate Twitter into their work day.  For example, key members of my teams and office staff know that I tweet from 5:00 am to 5:30 am and again from 7:00 pm-7:30 pm.  Team members also understand that some of my tweets are distributed throughout the day (I use TweetLater), so even though my tweets might be appearing during the workday, I'm not necessarily tweeting live.

There are, no doubt, other potential ways of integrating twitter into an office-based medical practice. 

Any other ideas? Please share them below.

What Big Pharma Can Learn from Basquiat

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The frenetic energy in the paintings of Jean-Michel Basquiat were often punctuated with the tag line he made famous: "SAMO" (Basquiat's acronym for Same Ol' S***).

Later this month Sanofi-Aventis will be launching their new drug Aplenzin, an extended release form of an older antidepressant Wellbutrin.  What's unique about Aplenzin?  Not counting the curious choice of dosage strengths (174mg, 348mg, 522 mg)....not much.

SAMO.

But the release of Aplenzin does highlight a recurring theme in the pharmaceutical industry: increasingly desperate attempts to extend patent lives of drugs.

In the last several years, "new" medications are brought to market that turn out to be variations on one of three basic themes:

1) Extended Release, Sustained Release, Controlled Release of ...
2) Isomer of....
3) Metabolite of...

(For an interesting take on these shenanigans, check out Malcolm Gladwell's article, "High Prices: How To Think About Prescription Drugs")

What is lacking in drug development is inquiry into new targets for drug development, not variations on the same theme. But there's promise on the horizon: witness the advent of nanotechnology for drug delivery for treating drug addiction, the very disorder that Basquiat succumbed to at the age of 27.

In the mean time, we can reflect on how remarkably prescient Basquiat was, speaking not about the pharmaceutical industry, but about his anti-establishment stance against "art school "artists:

"SAMO for the indirectly involved, the easily convinced, and the baffled..."

May your spirit live on, Baquiat.

Stressed? Anxious? How Is Your Strategy Working For You?

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As a psychiatrist in private practice, I've found that there’s a predictable sequence of events that finally lands people in my office for a consult.  These events occur in 5 stages:

• Stage 1: "Who, me?" This stage is characterized by denial and minimization of the problem: anxiety, depression, insomnia, whatever.   Behaviorists refer to this as precontemplation. Listen to these rationalizations: "Oh, everyone going through what I'm going through would feel the same way," or "I'm not crazy, just stressed"

• Stage 2: "Well, maybe I have a problem" This is the stage of ambivalence, of contemplation. You might agree that there's a bit of a problem, but you put it off for another day because you're too busy dealing with the very things that make you stressed and anxious. Most people who eventually seek help can spend years in this stage.

• Stage 3: "I have a problem, but I can fix it." You begin to concede and make tiny changes in your routine, you experiment with supplements, you consider diet and exercise.  But, after months or years, still not better.

• Stage 4: "Ok, I'm gonna need some help here." At this stage you concede. How? By asking family and friends, "Do YOU think I have a problem?" You might even take a specific action and seek professional help, typically through "unstigmatized" channels: chiropractic, accupuncture, your primary care physician.  The vast majority of people NEVER get beyond this stage.

• Stage 5: "We're gonna need a bigger boat." You make the ultimate concession on the advice of a family member or loved one, you finally seek help from a mental health professional.  But by this time, the problem--anxiety, depression, stress--has grown.  Sometimes to the point of being "treatment resistant," unresponsive to first-line therapies such as medication or talk therapy.

Earlier this week, Lily announced that their drug Symbyax had received FDA approval for "treatment-resistant depression." An interesting marketing ploy and play on words here. 

You see, It’s not the disease that's treatment resistant; it’s the patient.
 
So I ask:  How’s your strategy working for you?

The Happiness Formula Revealed: H = S + C + V

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What is the key to happiness? Money? Relationships? Good genes?

As happiness researchers have found out, the answer may be that none of these alone really matters.

Researchers in the field of positive psychology have identified the factors that do seem to matter, and the answers will surprise you.

Psychologists studying happiness have identified what they call "the happiness formula" :

H = S + C + V

In other words, the level of happiness that you experience (H) is equal to your biological set point (S) plus the conditions of your life (C) plus the voluntary activities that you do (V). 

Let's break these factors down:

• (S) Set point: Largely determined by your genes, there's not much you can do to change this. The key idea is that everyone has a happiness set point that is, surprisingly, affected very little by external conditions, such as how much money you have in the bank or how big your house is.

• (C) Conditions: External conditions refers to factors that we can manipulate to enhance our well-being. Happiness researches have identified several conditions that seem to matter:

1) Noise, especially noise that is intrusive and intermittent, increases amounts of stress hormones. Do everything you can to limit extraneous noise from your environment. Use earplugs. Turn off the TV. Move away from traffic. 

2) Commuting: People never fully adapt to longer commutes, especially in heavy traffic. If you can, live closer to work.

3) Lack of control: When workers, students, or patients have a sense of control over their environment, outcomes are almost always better than those who don't.  Learn to focus on what you can control, and let go of what you can't.

4) Shame: Believe it or not, individuals who have had plastic surgery to enhance their appearance, report higher levels of satisfaction with the process and they report decreases in psychiatric symptoms years after the process. Positive psychologists theorize that these appearance-altering procedures do a lot to reduce years of shame associated with a perceived defects. So yes, there might be a valid reason to get that breast augmentation or those porcelain veneers after all.

5) Relationships: If you had to pick the most important (C), this would be it. Research almost invariably shows that those who are in good relationships are happier than those who aren't.

• And, finally, (V) voluntary activities. These include engaging more often in activities that are matched to your abilities, what the Hungarian-born cofounder of positive psychology, Mihalyi Csikszentmihalyi, calls "flow." Another pioneer in positive psychology, Martin Seligman, makes a distinction between pleasures, temporary but fleeting delights, and gratifications, activitie that engage your strengths and lead to flow.  Choose to engage in pleasures intermittently (a glass of wine, chocolate), but focus on identifying and engaging in your gratifications, your signature strengths, every day.  To find your strengths, visit www.authentichappiness.org.

Happiness, then, really is within our reach, as long as we know which conditions to aim for and which  activities to engage in more often. 

Still chasing after that perfect job or that bigger house?

Maybe it's time to focus instead on your Cs and Vs. 

Interval Running to Keep Your Body and Your Brain Fit

The verdict is in:  Exercise boosts brain power.

Decades of research has shown clearly that aerobic exercise boosts the production of chemical messengers in the brain that facilitate the growth of and connections between neurons. This, in turn, translates to sharper thinking and improved mood. 

In recommending exercise to my patients, one of the most common questions I'm asked is what type of exercise to do and how to do it.  My answer: rhythmic interval running.  

Recommended equipment: a heart rate monitor and a metronome.  Or, instead of a metronome, you can listen to one of the many paced music tracks at Podrunner.com.

Step 1: Start Low and Go Slow

Begin by warming up with a steady jog at a comfortable pace.  With a heart rate monitor your warm up pace can be estimated by the formula 180 - (Age + 30).  So, a 40-year-old in otherwise good health would warm up at a heart rate of approximately 110 beats per minute. Continue at this pace for a minimum of 15 minutes.

Step 2: Step to the Beat

Next, gradually pick up the pace of your run so that you are running at approximately 160-180 steps/minute.  If you're using a metronome, set it to 80-90 and time every other foot strike to the beat. Or if your using Podrunner, select a track in the range of 160-180 beat per minute and adjust your footstrikes to the beat.  Try to keep your heart rate at 30 beats/min higher than your warm up rate. (For our 40-year old in the previous step, the baseline rate would now be 130 bpm) We'll refer to this as your baseline heart rate (BHR). Continue for 5-10 minutes.

Step 3: Pyramid Intervals

Here's where things get really interesting.  Continuing at the same baseline beat of 160-180 step/min, run  faster by leaning slightly forward and lengthening your stride.  Run until your heart rate is 15 beats higher than your BHR. Then slow to a comfortable walk.  Continue walking until your heart rate falls to BHR, then pick up the pace again and run until your monitor reads 20 beats higher than your BHR. Talk another walk break until your reach your BHR.  Repeat once more until your heart rate is 25 beats higher than your BHR. Now descend in the opposite way: BHR to 20, walk, BHR to 15, walk. 

Step 4: Walk It Down

Congratulations! You've completed your pyramid interval run. For the next 10 minutes, gradually slow your run from your BHR down to a comfortable walk.  The goal of this step is to gradually reduce your heart rate, sometimes referred to as the "bleed", from BHR to a comfortable warm-down rate.

This workout requires you to keep pace with the prescribed tempo of 160-180 steps/min while at the same time sequentially increasing your heart rate.  The combination of the tempo run with a controlled, step-wise increase in interval intensity produces a hypnotic yet energizing effect that will boost your brain power and leave you looking forward to the next pyramid run.  See for yourself...

5 Secrets to Finding a Superb Psychiatrist

Let's face it.

These are difficult times. And in difficult times like these, we're more likely than ever to do the unthinkable: consider seeing a psychiatrist.

But where do you look? And even more importantly, how do tell if they're good? How do you separate the good one from those that are "mad, bad, and dangerous to know"? 

Seriously, psychiatrists are really no different from other groups of individals: some are good, most are mediocre, and a few are mad and bad and...you know the rest.

Several years ago, while traveling as a national speaker, educator, and consultant, I had the opportunity to visit hundreds of psychiatric offices and clinics througout the United States.  I noticed that the good ones--the superb ones--generally followed a set of principles and practices that distinguish them from their less-than-stellar colleagues. 

Secret #1: Superb Psychiatrists are Board-Certified by the American Board of Psychiatry and Neurology

I know this one sounds like a no-brainer, but in an age when many people still don't know the difference between a psychiatrist and a psychologist, it's worth mentioning that psychiatrists really are medical doctors who have completed medical school, residency, and demonstrated competency in their chosen area of specialty through the American Board of Psychiary and Neurology.  You can check to see if your doctor is board-certified at their website. 

Secret #2: Superb Psychiatrists Return Their Calls

I know, another no-brainer, but you'd be suprised how many of my colleagues don't return their calls, not just from their own existing patients, but also from prospective new patients. Why? Partly because they're mired in patient care, but also because they have no systems in place for routing and prioritizing calls.  In the high-tech alley of Silicon Valley where I practice, we have a name for this sophisticated system:  front office help.  A good front office person knows exactly what the doctor is doing at all times, know what the day's schedule is like, and knows how to prioritize calls.  And a front office person is just that: someone who is in the front office, not at some virtual call center miles or continents away. I'm going to leave it to you to figure out how your prospective doctors process their calls....

Secret #3: Superb Psychiatrist See Their Patients at Regular Intervals

Beware of the psychiatrist who sees you for 15 minutes at the first evaluation, hands you a prescription, and says, "See you in 6 months".  No. Far to many things can go wrong in that interval, and what is most likely to happen is that you, the patient, will give up.  Give up because you're not seeing the results as quickly as you'd expect. Give up because you don't like the side effects of the medications. Give up because you have second thoughts about psychiatry. Give up because you found out your mother-in-law is taking the exact same prescription....the list goes on.  Although there are no hard and fast rules, superb psychiatrists see their patients at intervals of 1-2 weeks at the initiation of treatment, and every 2-3 months once stable.  Ask your psychiatrist about the plan for follow-up before you sign on. 

Secret #4: Superb Psychiatrists See Their Patients No Less than 15 minutes Per Visit

Many of us had the experience of the 5-8 minute "clinic encounter" with our primary care physicians.  This may suffice for a follow up visit for the treatment of rash, but in the realm of psychiatry, where emotions and physical symptoms collide, much more time is needed. At my clinic and those of my colleagues, the average visit is between 25 and 50 minutes.  Of course, their are exceptions to these guidelines, and I can already hear the grumblings of my seasoned colleagues on this point. Ask your psychiatrist about the length of the typical follow-up appointment before you sign on.

Secret #5: Superb Psychiatrists See Patients

Believe it or not, some "practicing" psychiatrists do NOT see patients.  How can this be? Over the last two decades opportunities for psychiatrists to engage in non-clinical work has exploded: corporate consulting, pharmaceutical speaker's bureaus, clinical research directors, administrators, supervisors for psychiatric residents...the list goes on. The plethora of options has enable some to focus their efforts more on these other activities than on actual patient care.  I know colleagues, for example, who do speak for pharmaceutical companies full-time.  Sure, they see a patient every now and then, but seeing patients, even for a few hours every week, doesn't cut it. Sorry. Those of us in the trenches day-in and day-out think otherwise.  Now please don't misunderstand my point here: there is nothing unethically or morally wrong with seeing patients as a side job to a speaking career.  I mentioned at the beginning of the post that I did this myself for a while.  My point is this: as a prospective patient you deserve...no, you need to know...if your psychiatrist is engaged in these activities, and you need to know if he or she will be available for crises.  Nothing worse than calling your psychiatrist in the middle of a panic attack and finding out that he's on a speaking gig in Hawaii.  Ask your psychiatrist directly, "how many hours each week do you actually see patients?" before signing on. 

So that's it: the five secrets of superb psychiatrists. Opinionated? Yes. Controversial? Maybe. But in the words of a sports legend, "I may be wrong, but I doubt it".