Sources of bias

Why Pudsey Bear is awful: An annually pointless grudge.

A bear that isn’t Pudsey. I wasn’t sure on the copyright and didn’t want to give him another reason to come after me.

Every year in connection with Children in Need I tell the story of why I don’t like Pudsey Bear. I’m told by my friends (who despite what I’m told by others, do exist) that it wouldn’t be a real Children in Need without this story. They’re humouring me of course, but humouring me is 92% of the work of being my friend, so that’s fine.  I apologise if you started reading this thinking it was a complex critique of the inadequate wealth redistribution of Children in Need or a political discourse on how if society were better we wouldn’t even require Children in Need.  I don’t know if the former is true and while the latter certainly is, there are people far better qualified than I am to discuss it. I’m afraid my story is a short, bitter, pointless grudge against a monocular bear associated with a worthy cause. If you like, at the end, you can tut and say “One night isn’t Children in Need, children are always in need.” Yes.

Are we sitting comfortably? Then I’ll begin.

As a much younger man, a child even, I was ill and had been to the see a doctor. I can’t remember what the illness was. I imagine it was probably just a virus that had gone on a bit too long or possibly the ongoing inflammation of my pedantry gland.  Of course I would be remiss if I didn’t point out that the pedantry gland doesn’t exist. After leaving the clinic, in fact just outside the clinic, I did a manly collapse (fainted). On my trajectory towards the ground, I decided that my head should take a slight detour towards the wall. I broke my glasses. Like most people who wear them, (*narrows eyes at hipsters*) I need my glasses for seeing. As a result, this was almost literally adding insult to injury. Actually, I guess it was just adding inconvenience to injury. As I lay there, bewildered and pathetic, head hurting, glasses broken, I notice a blurry figure approach out of the blurry distance into the slightly less blurry foreground. It was Children in Need at the time and this figure was Pudsey Bear! He was obviously out collecting money for Children in Need. That being the thing that he’s in to. Who better than the mascot of Children In Need to help a child in need outside a healthcare professional’s building? Pudsey stepped over me and carried on walking.

I’m not a fan of Pudsey Bear.

“Perhaps Pudsey didn’t see you, his vision can’t be that good.”

“Why did he step over me and carry on down the street instead of tripping over me and carrying on towards the pavement?”

I’m not a fan of Pudsey Bear.

Another acceptable bear.

It is known from studies into altruism, that the decision to stop and help someone is influenced by a number of factors. If people feel they are short of time, see someone is bleeding, think there are lots of people around so one of them will help (diffusion of responsibility) or simply don’t identify with the person who needs assistance, then they are much less likely to engage in altruistic behaviour (the bystander effect).

Perhaps Pudsey was late for an important bear appointment, was put off when he saw I was losing haemoglobin, thought one of the other people would help me and noticed I wasn’t a bear like him, so didn’t help. Perhaps Pudsey’s just awful.

I’m not a fan of Pudsey Bear.

I am a fan of the work done by Children in Need. They do good work that shouldn’t be necessary. So please give generously. Because Pudsey won’t.

Or there are lots of good charities, so you can pick one. You might as well, otherwise reading this stupid story about my ridiculous grudge against a visually-impaired ursine has been a complete waste of time.

Does stigma against mental illness increase as people get older?

Want to feel old?
Then continue living.

Some say that children are our future. This seems like nonsense given that in the future, all the children will be old people. Are old people the future? This is clearly a facetious point, albeit one with tangential relevance given the trend in Western society for people to live longer. In the United Kingdom, there are currently about 10 million people who are over 65 years old and it is predicted that this number will increase to 19 million by 2050. The phrases “grumpy old man” and “grumpy old woman” may just have to become “grumpy man” and “grumpy woman” simply due to commonality. Or ultimately, “man” and “woman” as grumpiness becomes the ground state. This is rubbish and I hate it.

One concern in an ageing society is mental health care. There are an increasing number of older adults in need of psychological care and it has been identified that cultural and organisational aspects of mental health care in later life present some of the main barriers to quality services. Stigma can be described as a sign of disgrace setting a person apart from others and Erving Goffman, defined stigma as “the process by which the actions of others spoils normal identity.” Stigma against people with mental illness can result in a lack of funding for services, and difficulty gaining employment, a mortgage or holiday insurance. Feelings of shame from perceived stigma can also cause people to delay seeking help or even deny the existence of their symptoms. Stigma surrounding mental illness has therefore been identified as one of the primary barriers to providing sufficient mental health care.

It seems obvious that attitudes and perspectives change throughout life with identifiable trends. The perspectives of a 20-year-old are unlikely to be exactly the same as those of a 90-year-old, whether this is due to differences in lived experience or due to age itself. So perhaps attitudes towards people with mental health change as we age. If attitudes towards people with mental illness improve as we age, then great. Let’s see why and see if we can use what we learn in anti-stigma interventions for younger people. Older people really are the future. Someone should write a song. If attitudes towards people with mental illness worsen and become more stigmatising as we get older then not great. Nobody should write that song. Not even if it contains the line “Oh. Think twice. Just another day for you and me with prejudice.” However, at least if it is known that stigmatising attitudes against people with mental illness worsen with increasing age then interventions against stigma can be targeted towards older people. Why? Because of the reasons we’ve discussed e.g. stigma is bad and causes bad things to happen to vulnerable people.

To investigating these issues, a study was carried out with the aim of determining whether stigmatising attitudes towards people with mental illness increased with age. This study will be described here.

Method

Three surveys were given to German citizens aged over 18 years in 1990, 2001 and 2011. Individuals taking the surveys were selected randomly and once they had provided consent, were interviewed face-to-face.

Data were collected through face-to-face interviews. This picture probably isn’t representative of that process.

During the interviews, participants were presented with short stories describing either a person with schizophrenia or major depression. The stories did not specifically state the diagnosis of the person, although the symptoms described fulfilled the criteria set out by the World Health Organization’s (WHO) Diagnostic and Statistical Manual of Mental Disorders (DSM) III. During the 1990 and 2011 interviews, the sex of the individual within the story was varied at random. However, during the 2001 interviews, only responses to stories describing a male with mental illness were recorded. As a result, only responses recorded in reaction to stories containing males were included in the analysis. Once again, there doesn’t seem to be much that men won’t try to take control of.

Stigmatising attitudes against people with mental illness were measured using a social distance scale. That is to say, the participants’ willingness to engage in various everyday activities with a person with a mental illness was measured. Such activities included working together, being a neighbour, recommending for a job and letting them take care of a small child. Willingness was rated on a scale of 0−5 and combined across all activities into an overall social distance score out of 28. A higher score indicates a higher desire for greater social distance, and potentially greater stigmatising attitudes.

The effects of age, birth-cohort (group that was born at a similar time) and time period on social distance (the measure of stigmatising attitude against people with mental illness) were then analysed. Maths was involved. What are the chances?

Results

Participants

• 7,835 participants aged 18 to 93 years
• 3,925 participants heard the story describing the person with symptoms of schizophrenia and 3,910 heard the story describing the person with symptoms of major depression.
• Age groups included were 18 to 30 years, 30 to 39 years, 40 to 49 years, 50 to 59 years, 60 to 69 years and equal or over than 70 years.
• The number of participants within each age group were reasonably evenly matched, with slightly fewer within the equal or over than 70 years population.

Effects

Age

For both illnesses described, there was a significant effect of age, with a higher social distance score with increasing age.

Attitudes towards people with mental illness become more negative (higher social distance scores) with growing age.

Cohort

Cohort only appeared to have an effect in relation to the story describing someone with symptoms of major depression and not regarding the story describing someone with symptoms of schizophrenia. People born in later years showed lower social distance scores towards the person with symptoms of major depression, regardless of the effects of age or time period.

Time Period

Time period effects were examined for 1990, 2001 and 2011. Time period appeared to have a significant effect on social distance, with people from more recent time periods displaying higher social distance scores against people with symptoms of mental illnesses.

Conclusions

The authors concluded that over the life-span, social distance scores and therefore attitudes towards people with mental illness become more negative (higher social distance scores) with growing age. The effect of cohort seems to differ across disorders, although only two sets of diagnostic criteria were examined within this study. People from more recent time periods tended to display higher social distance scores (and therefore potentially more negative attitudes) against people with symptoms of mental illnesses.

The authors state that the findings of increasing negative attitudes towards people with mental illness with increasing age is due to a tendency for conservative attitudes to grow with age and to the preference of older participants to prefer familiar social partners who are less likely to trigger negative feelings. It may also have been the case that as the person featuring in both stories was of working age, social distance score may have increased with age simply due to a perceived age difference between the participant and the person being described.

It’s ultimately concluded that stigma against people with mental illness in old age is amplifying burden in a population that is already vulnerable to social isolation and that this is likely to contribute to more negative health outcomes.

Limitations

No “control” story describing a person without symptoms of mental illness was included as part of the interviews.

Only one story was presented to each participant. Attitudes recorded may therefore represent those held towards the individual within the one story with that particular set of symptoms rather than stigma towards people with mental illness as a whole. Having said that, people with mental illness represent a highly varied population, you know, because they’re people, and asking a study to narrow down one particular set of attitudes towards this entire population may be too much to ask. However, it may have been useful to include responses to more than one story, describing symptoms of more than one recognised mental illness diagnosis to attempt to capture attitudes to a broader range of people.

No “control” story describing a person without symptoms of mental illness was included as part of the interviews. As such, there is no baseline score for social distance score and how it changes with increasing age. For example, it may be that social distance score increases with age due to the greater risk of social isolation that has been reported with age. There is no way to determine from these results whether attitudes relate specifically to people with mental illness.

As the study was conducted solely in Germany, the attitudes concerning people with mental illness that were revealed at most may only hold in similar cultures e.g. Western industrialised countries, or at least just within Germany. Further study across varying cultural groups would be required to determine whether the attitude trends identified exist cross-culturally.

The study doesn’t mention the composition of the participant population in terms of sex. This seems an oversight given that only stories featuring males were included and attitudes regarding gender and/or sex from different genders and/or sexes can be highly complex. In addition, we can’t necessarily assume that the participant population was approximately 50% female and 50% male, as the study includes people across a wide range of ages. In Western cultures, with increasing age, the proportion of males tends to decrease. However, as it stands, there is no way to determine whether the attitudes towards the person with mental illness within the story were influenced by the sex of the person described or the sex of the participant.

There seems to be no attempt to describe whether participants in the study had any history of mental illness or any experience with people with mental illness. This would undoubtedly affect attitudes towards mental illness. The authors state that the effect of contact could not be included as information regarding this variable was not consistently elicited. Given how common mental illness is, it could be argued that with increasing age, probability of encountering someone with experience of mental illness and/or experiencing it personally increases, and examining how this interacts with attitudes and increasing age is vital for future studies.

Summary

Take two of these twice a day and stop being prejudiced.
Seek doctors’ advice if you’re a member of UKIP.

The findings describe how attitudes towards people with mental illness become more negative with growing age. However, the limitations of this study mean that this cannot be stated from these results with any degree of certainty.

Ultimately we do know that stigma against people with mental illness is a real problem with real negative impact in terms of mental distress and various life and health outcomes. While more research is needed to examine whether stigma towards people with mental illness increases with age and if so, why, the growing proportion of older people within Western societies means that tackling stigma in more elderly people may be a priority regardless.

References

Schomerus G, Van der Auwera S, Matschinger H, Baumeister SE, Angemeyer MC. Do attitudes towards persons with mental illness worsen during the course of life? An age-period-cohort analysis. Acta Psychiatr Scand 2015;1−8 [PubMed]

Sartorius N. Iatrogenic Stigma of Mental Illness. BMJ 2002:324:1470−71 [PubMed]

A Bad Case of the Zombies: Could a virus really cause World War Z?

A zombie playing the sousaphone. I wanted one playing the trombone because of the tenuous trombone/bone/zombie connection. Ho hum.

The other day I went to see the film, World War Z. It was fine and thus ends my review of my enjoyment of it. Anyway, the real World War Z will of course be between those who pronounce it “zed” and those who pronounce it “zee”. World War Z is based on the 2006 novel by Max Brooks (a follow-up to his 2003 book, The Zombie Survival Guide). Both books are excellent and if you’re not too bored of zombie-based fiction then you should read them. I say this because there seems to have been a recent upsurge on things about zombies of some kind. The zombies are everywhere, which I suppose is ironic. The film stars Bradley Pitt as a retired United Nations employee who must travel the world to find a way to stop a zombie-like pandemic.

In the film being a zombie (Zombieism? Esprit de corpse? Zombosis?) appears to be caused by a viral infection, primarily caught by being bitten by a zombie. Those who are bitten appear to die within about 30 seconds and then reanimate with slightly cloudy eyes. They then become very aggressive and begin to chase down victims to bite them and spread the infection. They do not appear to eat their victims; rather keep on going just generally being runny and a bit bitey. I say runny as in they run a lot rather than hinting at any advanced state of decomposition. Although eventually the zombies do appear to go a bit rotten.

I accept that all this doesn’t have to be dead-on realistic (ahem) but there are a few problems with the concept. It’s assumed that the mass zombification is caused by a viral pandemic. Yet time from being bitten to turning into a zombie appears to be too rapid for this to be the case. It would take a bit longer for whatever virus it is to circulate, invade cells, hijack their genetic machinery and start producing copies of the virus and manifest symptoms. Especially given that the virus appears to completely take over the host’s central nervous system and musculature while leaving the rest of them deceased. Like a more infectious version of Britain’s Got Talent.

While viruses certainly can be deadly they generally need the thing they’re in to be alive to make more virus and spread them. This might be by sneezing in their co-worker’s face, not washing their hands, licking fruit bowls etc. The zombie virus doesn’t appear to need this. It kills the host and still somehow has them running around. Where is the host’s energy coming from? Could the humans all just hide and wait for the zombies to fall apart? Granted this would make the film quite dull. Nobody wants to watch a film where people eat sandwiches in a bunker waiting for their enemy to decompose. Although Panic Room is OK.

The idea however that an infection can control its host’s behaviour to help its spread is well established in nature. For example, malaria is an infectious disease spread by mosquitoes, caused by one of five species of the Apicomplexan parasite, Plasmodium. Most deaths from malaria are caused by Plasmodium falciparum. It really is an awful disease with the WHO estimating that in 2010 there were 219 million cases of malaria resulting in 660,000 deaths. As I’ve hinted, Plasmodium can change the behaviour of mosquitoes to spread itself faster and wider.

The common Plasmodium Puppet. Also known as the mosquito.

Once in a mosquito, Plasmodium needs time to move to the mosquito’s gut to mate and reproduce to form ookinetes. These are a sort of mobile egg. The story of Plasmodium really ruins Humpty Dumpty. Ookinetes develop into sporozoites (Literally: “animal seed”. Don’t go planting your hamsters though!) and travel to the mosquito’s salivary gland. Prior to this it doesn’t do the Plasmodium much good for the mosquito to bite someone with the risk the mosquito might get killed during the attempt. So Plasmodium tries to alter the mosquito’s behaviour to prevent this. For a mosquito to get your blood it has to drive its proboscis through your skin and find a blood vessel. The longer this takes the greater its chances of being noticed and squashed. Like if McDonalds killed you if you queued too long rather than years later of heart disease. If a mosquito finds it too difficult to draw blood they’ll quickly give up.  A mosquito with ookinetes in it will abandon biting quicker than an uninfected one.

However once the sporozoites reach the mosquito’s mouth, it benefits Plasmodium for the mosquito to bite as much as possible.  The Plasmodium at this stage appears to make the mosquito “hungrier”, causing it to drink more blood and visit more hosts to get it. In these ways and more Plasmodium is manipulating its hosts behaviour to reproduce itself and spread more easily.

Some species of tapeworm live in the three-spined stickleback but also spend part of their lifecycle in the birds that eat these fish. The tapeworms can alter the behaviour of the fish making it more likely they’re caught and eaten. As you’d expect, sticklebacks try to keep away from heron. They stay away from the surface and if a heron appears they dart away. Sticklebacks infected with tapeworm appear to become more fearless, staying near the surface to feed even if a heron is about. These are more likely to be eaten and the tapeworm gets where it wants to go; into the heron.

Similarly, Toxoplasma gondii, a protozoan of “don’t go near the litter tray if you’re pregnant” fame, needs to move between rats and cats and back again to complete its lifecycle.  A healthy, uninfected rat will normally become anxious when it smells cat urine staying away from where they smelled it.  They will literally piss off. Rats infected with Toxoplasma however do not become anxious when they catch the scent of a cat, do not avoid it and increase their chances of becoming dinner.

Toxoplasma also appears to alter the psychology of humans it infects. Men infected with Toxoplasma become less willing to follow rules and less worried about being punished for breaking these rules. Women infected with Toxoplasma become more outgoing. Toxoplasma: the party protozoa! I probably shouldn’t get into marketing. It is not fully known how this occurs although there is some evidence that Toxoplasma increases production of the neurotransmitter dopamine and in males, increases testosterone levels.  It should be noted that this evidence is largely from rats. A lot of evidence is.

Afraid? Are you a man or a mouse? Or are you infected with Toxoplasma?

All of our examples have been parasites, but the infection is World War Z is cited as a virus, which I guess technically can be seen as a parasite. Can a virus alter its host’s behaviour to aid its spread? You bet your hot butter on toast it can! The baculovirus, infects the caterpillars of the European gypsy moth and causes them to climb to the tree-tops. Once there they die and liquefy, releasing thousands of viral particles to rain down and infect more unfortunate caterpillars. In this way Lymantria dispar forces the caterpillar to turn itself into a piñata and explode itself, raining down sweets i.e. a nasty virus, on other unsuspecting future piñata-pillars.

Rabies is another viral disease that manipulates its hosts’ behaviour. Rabies causes acute encephalitis in warm-blooded animals, including humans. More than 55,000 people, mostly in Africa and Asia, die from rabies every year. There are three stages of rabies progression. The first is characterised by behavioural changes and is known as the prodromal stage. The second is the excitative stage. This stage is also known as “furious rabies” as the infected animal is exceptionally aggressive, hyper-reactive and will bite with little provocation. The virus is present in the nerves and saliva and as such the route of infection is usually, but not always, by a bite. With the encephalitis induced aggression and biting, the virus’ manipulation to aid its spread becomes clear. The third stage is the paralytic stage (due to motor neuron damage) which is followed by death.

The excitative stage of rabies is the example we’ve seen that is most similar to our zombie virus and in fact in the film the zombie pandemic (a good name for a band) is initially mistaken for an outbreak of rabies. So could a virus cause the changes seen in World War Z and cause a zombie pandemic with Brad Pitt staring concerned across various international scenes? Probably not, but parasites and viruses can certainly manipulate their hosts behaviour in a variety of subtle and not-so-subtle ways. Although ultimately it might be preferable to have your emotions and behaviour manipulated by watching a film. Panic Room is OK.