Labs worldwide report converging evidence that undermines the low-sugar theory of depleted willpower

One of the main findings in willpower research is that it's a limited resource. Use self-control up in one situation and you have less left over afterwards - an effect known as "ego-depletion". This discovery led to a search for the underlying physiological mechanism. In 2007, Roy Baumeister, a pioneer in the field, and his colleagues reported that the physiological correlate of ego-depletion is low glucose. Self-control leads the brain to metabolise more glucose, so the theory goes, and when glucose gets too low, we're left with less willpower.

The breakthrough 2007 study showed that ego-depleted participants had low blood glucose levels, but those who subsequently consumed a glucose drink were able to sustain their self-control on a second task. In the intervening years the finding has been replicated and the glucose-willpower link has come to be stated as fact.

"No glucose, no willpower," wrote Baumeister and his journalist co-author John Tierney in their best-selling popular psychology book Willpower: Rediscovering Our Greatest Strength (Allen Lane, 2012). The claim was also endorsed in a guide to willpower published by the American Psychological Association earlier this year. "Maintaining steady blood-glucose levels, such as by eating regular healthy meals and snacks, may help prevent the effects of willpower depletion," the report claims.

But now two studies have come along at once (following another published earlier in the year) that together cast doubt on the idea that depleted willpower is caused by a lack of glucose availability in the brain. In the first, Matthew Sanders and his colleagues in the US report what they call the "Gargle effect". They had dozens of students look through a stats book and cross out just the Es, a tiresome task designed to tax their self-control levels. Next, they completed the famous Stroop task - naming the ink colour of words while ignoring their meaning. Crucially, half the participants completed the Stroop challenge while gargling sugary lemonade, the others while gargling lemonade sweetened artificially with Splenda. The participants who gargled, but did not swallow, the sugary (i.e. glucose-containing) lemonade performed much better on the Stroop task.

The participants in the glucose condition didn't consume the glucose and even if they had, there was no time for it to be metabolised. So this effect can't be about restoring low glucose levels. Rather, Sanders' team think glucose binds to receptors in the mouth, which has the effect of activating brain regions involved in reward and self-control - the anterior cingulate cortex and striatum.

The other study that's just come out was conducted by Martin Hagger and Nikos Chatzisarantis based in Australia and the UK. Their approach was similar to Sanders' except that participants gargled and spat out a glucose or artificially sweetened solution prior to performing a second taxing task, rather than during. Also, this research involved a series of 5 experiments involving many different ways of testing people's self-control, including: resisting delicious cookies; reading boring text in an expressive style; unsolvable puzzles; and squeezing hand-grips. But the take-home finding was the same - participants who gargled, but did not swallow, a glucose drink performed better on a subsequent test of their willpower; participants who gargled an artificially sweetened drink did not. So again, willpower was restored without topping up glucose levels. Moreover, the benefit of gargling glucose was displayed only by participants who'd had their self-control taxed in an initial task. It made no difference to participants who were already in an untaxed state.

Hagger and Chatzisarantis agree with the interpretation of the Sanders' group, except they make a distinction. The effect of glucose binding to receptors in the mouth could either stimulate activity in brain regions like the anterior cingulate that tend to show fatigue after a taxing task. Or they say that glucose in the mouth could trigger reward-related activity that prompts participants to interpret a task as more rewarding, thus boosting their motivation. The explanations are complementary and need not be mutually exclusive.

The key point is the new results suggest depleted willpower is about motivation and the allocation of glucose resources, not about a lack of glucose. These findings don't prove that consuming glucose has no benefit for restoring willpower, but they suggest strongly that it's not the principle mechanism. It's notable that the new findings complement previous research in the sports science literature showing that gargling (without ingesting) glucose can boost cycling performance.

"While our findings are consistent with the predictions of the resource-depletion account, they also contribute to an increasing literature that glucose may not be a candidate physiological analog for self-control resources," write Hagger and Chatzisarantis. "Instead ego-depletion may be due to problems of self-control resource allocation rather than availability." An important next step is to conduct brain-imaging and related studies to observe the physiological effects of gargling glucose on the brain, and on motivational beliefs. There are also tantalising applications from the new research - for example, could the gargle effect (perhaps in the form of glucose-infused chewing gum) be used as a willpower aid for dieters and people trying to give up smoking?

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Hagger, M., and Chatzisarantis, N. (2012). The Sweet Taste of Success: The Presence of Glucose in the Oral Cavity Moderates the Depletion of Self-Control Resources. Personality and Social Psychology Bulletin DOI: 10.1177/0146167212459912

Sanders, M., Shirk, S., Burgin, C., and Martin, L. (2012). The Gargle Effect: Rinsing the Mouth With Glucose Enhances Self-Control. Psychological Science DOI: 10.1177/0956797612450034

--Further reading--
From The Psychologist: Roy F. Baumeister outlines intriguing and important research into willpower and ego depletion.

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Cope with pain by changing how you picture it

Most people who suffer from serious pain have one or more mental images that they associate with the discomfort and what it represents to them. A new study by Clare Philips and Debbie Samsom has shown that these pain-sufferers can be taught to re-imagine this pain imagery in a more positive light, bringing them instant relief and emotional comfort.

Of 73 volunteers at an occupational rehab centre in Vancouver, 57 had pain and said they experienced imagery associated with that pain, and so they were recruited into the study (there were 24 men, the average age was 45).

After being interviewed about their baseline pain and their psychological state - including feelings of mental defeat, anxiety and depression - the participants were asked to select their most powerful and distressing pain-related mental image. "I see myself on all fours - like a dog but unable to move," said one. All participants spent time forming this "index image" in their mind before answering more questions about how they were feeling. Focusing on the unpleasant image increased pain and emotional distress. Remember, this is an image that the participants experienced spontaneously in their everyday lives (for nearly half of them, it came to mind several times a day).

Next, after a six-minute gap talking about where they grew up (as a distraction), 26 of the participants were taught to re-picture their pain. They were asked to think "how would you rather see the image?" and to describe in detail what this would entail. They then focused on this new image - for example, the participant above who'd previously described the dog-image now imagined: "I am at the start of a race….the gun goes off and the crowd cheers as I take off." The remaining participants acted as controls and spent the same time focused on their original, unpleasant index image.

After picturing a "re-scripted" pain image, the participants in that group experienced a dramatic drop in their pain levels. In fact, 49 per cent of them said they felt no pain at that time, compared with 11 per cent of them feeling no pain after imagining their index image. "The pain decrements were fast, easily produced and dramatically large," the researchers said. The re-script group also exhibited improvements in anxiety, sadness, mental defeat and beliefs about their own fragility. The control participants, by contrast, experienced none of these improvements.

There was another six-minute gap and the re-script group again pictured their positively re-imagined pain image. The controls were now also taught how to re-imagine their pain image - the local research ethics committee had insisted on this. The original re-script group continued to enjoy reduced pain and psychological benefits, which counts against the idea that the novel image had merely served as a temporary distraction. The controls now also enjoyed the benefits of re-picturing their pain.

Philips and Samsom said that the participants found it easy and pleasurable to re-script their pain images. Of course there is a need now for research to see whether these benefits of re-picturing pain can last into the long term. It would also help to have a different kind of control group - for example, one that merely visualised random positive images, to see if the effects of specifically re-picturing pain are more powerful. Where this study focused on the sensory detail of pain images, future work could also look into the re-writing the images' cognitive meaning.

The findings add to a broader literature showing that our experience of pain is affected by many psychological factors, such as our beliefs about our ability to cope. This doesn't mean the pain isn't real, but it does mean that psychological techniques can be incredibly effective at bringing relief and improvements to people's quality of life.

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Philips C, and Samson D (2012). The rescripting of pain images. Behavioural and cognitive psychotherapy, 40 (5), 558-76 PMID: 22950868

-Further reading-
Psychologist magazine special issue on the psychology of pain
Acceptance, not distraction, is the way to deal with pain (Digest item)
Verbal reassurance can dull the effect of pain, but only if it's from someone we identify with (Digest item)

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Self-licensing: when you indulge through reason, not lack of willpower

We usually think of over-indulgence in terms of a lack of willpower. I scoff the doughnut because I can't marshal the necessary self-control to resist it. A great deal of psychology research has pursued this particular line, demonstrating, for example, that willpower seems to be a finite resource. Expend it in one situation and you'll have less left over for another.

A new study by Jessie de Witt Huberts and her colleagues at Utrecht University takes a different perspective. They point out that we often over-indulge, not because we can't help it, but because we reason that it's okay to do so. After that half-hour run, we tell ourselves, we deserve the doughnut! de Witt Huberts' team call this self-licensing and they say it's surprisingly under-researched.

Previous studies have shown how self-licensing affects our choices. For example, after working harder, people are more likely to choose a cake over a fruit-salad. But before now, no-one's looked to see how self-licensing might affect actual indulgent consumption.

Before they got started, de Witt Huberts and her team had to confront a complication with researching this topic - the need to separate out the effects of low energy from self-licensing. If someone's been working hard, not only might this encourage them to think they deserve a naughty snack, their lack of energy might also deplete their willpower (indeed, studies have suggested that low sugar levels reduce willpower).

To get around this problem, de Witt Huberts and her colleagues needed a way to trick people into thinking they'd worked hard (inviting self licensing) without actually diminishing their willpower levels. They did this by having participants test-out what they were told was a new screening tool for dyslexia. It involved looking at 200 words on a computer screen, one at a time, and pressing the key on the keyboard that corresponded to the first letter of each word. Crucially, one group of participants did this for five minutes, and were then told they had to do it all over again for another five minutes to check the reliability of the screening tool. The other participants simply had a one-minute break between two 5-minute sessions.

In a pilot study with 106 women, the group who thought they'd had to test the screening tool twice, felt like they'd worked harder than the other group, who thought they'd done it just once (even though both groups had worked for the same length of time). Next, both groups completed the Stroop test, a classic measure of self control that requires people to read colour words (e.g. blue), whilst ignoring the ink colour they're written in. This test confirmed that both groups had the same levels of self control even though one group felt like they'd worked harder than the other.

When it came to the study proper, 39 women were split into two groups - one did the dyslexia screening tool in two phases, to make them feel like they'd worked harder, and the other group did it in one bash. Next, ostensibly as part of a separate consumer research study, all the women taste-tested some crisps, M&Ms, Wine gums and Chocolate chip cookies.

The take-home finding? Both groups said their willpower levels felt the same, but the women who thought they'd worked harder tended to eat more of the naughty food. In the ten minutes available, they consumed an average of 26 grammes of more snack-food, which equated to 130 more calories. As well as feeling like they'd worked harder, they also said they felt more hungry, but this wasn't correlated with the amount they ate. The researchers speculated that the feelings of hunger could have been a further form of self-licensing - "I've worked hard and I'm hungry".

This study is one of the first steps towards uncovering the part that self-licensing plays in giving in to temptation. It's limited in that the sample only included women and the self-licensing was implicit. The women who thought they'd worked harder were more indulgent, but we don't know anything about the way they reasoned with themselves, or if the effect was conscious at all. "Nevertheless," the researchers concluded, "although many questions about self-licensing require further investigation, the current studies demonstrate that sometimes people strategically choose to indulge and that gratification of our desires is not inevitably governed by our impulses."
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ESSIE C. DE WITT HUBERTS, CATHARINE EVERS, and DENISE T. D. DE RIDDER (2012). License to sin: Self-licensing as a mechanism underlying hedonic consumption. European Journal of Social Psychology DOI: 10.1002/ejsp.861

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Smile your way to a vegetable-loving child

Maybe you've tried giving them names - Sally Sprout or Brian the Broccoli. Or perhaps you've made noises of gastronomic delight, "hmm, yummy!" Yet still your young child refuses to eat their greens. Maybe it's because of that slight, but all too visible, sneer on your face. After all, you're not wild about veggies either. Well, it's time for you to become a better actor. A new study suggests that young children are particularly sensitive to the emotional expressions of other eaters, and that these emotions are likely to affect their eating habits.

Laetitia Barthomeuf and her team presented 43 5-year-olds, 38 8-year-olds and 42 adults with photographs of two women eating various foods. As they ate, the women either looked happy, disgusted or just had a neutral expression. There were six different foods - three that the participants had earlier said they liked (chocolate, bread and cream cake) and three that they said they disliked (kidney, black pudding, cooked sausage with vegetables). Twenty-seven additional participants had been excluded earlier because their preferences didn't fit this pattern.

As they looked at each photo, the child and adult participants were asked to say how much, on a scale of 1 to 10, they desired to eat the food that the woman in the photo was eating. The take home finding - the children, especially the five-year-olds, were influenced much more by the facial expressions of the women, than were the adults.

If the woman in the photo had a look of disgust, this reduced the children's, and to a lesser extent, the adults', desire to eat foods that they liked. In contrast, if the woman had a look of pleasure on her face, this  increased the children's, and to a lesser extent, the adults', desire to eat foods they didn't like (for five-year-olds only, it also increased their desire to eat foods they liked). Even a neutral facial expression in the eating women made a difference - increasing and decreasing the participants' desire for liked and disliked foods, respectively, especially in the children.

The researchers speculated that the influence of the women's facial expressions occurred because seeing their expressions led to simulations of those same emotions in the minds of the participants. They further suggested that this process is accentuated in younger children because of the immaturity of their prefrontal cortex.

The study has some obvious weaknesses, acknowledged by the researchers - they didn't measure actual eating behaviour, and the stimuli were photos, as opposed to a real-life dining situation. Nonetheless, they predicted the effects of other people's emotional expressions might be even larger in a more realistic situation and that the results therefore have important implications for the encouragement of children's healthy eating habits. "Adults may unconsciously influence children's food preferences via their facial expressions of pleasure or disgust," they said.

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Barthomeuf, L., Droit-Volet, S., and Rousset, S. (2012). How emotions expressed by adults’ faces affect the desire to eat liked and disliked foods in children compared to adults. British Journal of Developmental Psychology, 30 (2), 253-266 DOI: 10.1111/j.2044-835X.2011.02033.x

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Strong reassurances about vaccines can backfire

Unwarranted public anxiety about vaccinations can have deadly consequences. Unfortunately, the challenge of communicating health risks is full of psychological complexity. A new German study brings this home, showing how messages that deny vaccination health risks in unequivocal terms can backfire, actually increasing concern among parents.

Cornelia Betsch and Katharina Sachse recruited 115 participants online (mean age 34; 34 per cent were male; 43 per cent had one or more children). The participants were asked to imagine they were a parent of an 8-month-old and to read an account of a fictitious illness Phyxolitis pulmonis. They were further told that their paediatrician had advised vaccinating their child against this condition. Next, the participants were presented with anti-vaccine statements that they'd ostensibly found on the internet (e.g. "Multiple vaccines overwhelm the infant's immune system"). Finally, they read statements of reassurance about the vaccine, which claimed any risks were low - half the participants read weak versions (e.g. "There is only sporadic evidence that repeated vaccinations overwhelm the immune system") and half read strong versions of these statements (e.g. "there is no evidence that repeated vaccinations overwhelm the immune system").

The key finding here was that participants who read the strong statements of reassurance actually reported greater perceptions of risk afterwards, and lower intentions to vaccinate their child. This effect was heightened among participants who had a preference for complementary medicine. Results didn't vary according to whether participants were a parent in real life or not.

A second study with a further 119 participants was similar but this time the source of the reassuring statements was varied, either being from a pharmaceutical company (untrusted) or from a government health department (a trusted source). Again, strong statements of reassurance backfired, increasing risk perception and reducing vaccination intentions, but only if those statements came from an untrusted source. Again, this paradoxical effect was stronger among participants who favoured complementary medicine.

This study can't reveal why the paradoxical effect occurs. However, one possibility proposed by Betsch and Sachse is that an extreme statement of no risk is more attention-grabbing, which only serves to highlight the possibility that risk is an issue. Another potential explanation is that people look for ways to combat claims they disagree with, and if those claims are stated more strongly then that encourages people to marshal even stronger counter-claims of their own.

The results have obvious implications for real-life risk communication. "Especially when organisations lack complete knowledge about how much trust the public puts in them, optimal risk negation is likely to profit from moderate rather than extreme formulations," the researchers said.
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Betsch, C., and Sachse, K. (2012). Debunking Vaccination Myths: Strong Risk Negations Can Increase Perceived Vaccination Risks. Health Psychology DOI: 10.1037/a0027387


Previously on the Research Digest:
How to promote the MMR vaccine.
The psychological barriers facing MMR promotion campaigns.


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Mental health problems worsen after cosmetic surgery

Are people who opt for medically unnecessary, cosmetic surgery psychologically vulnerable? Does having such surgery bring them psychological relief?

These are tricky questions. There's actually evidence of increased mental health problems among people who've undergone cosmetic surgery. But whether that's a harmful side-effect of the surgery, or a hangover from pre-operative problems, it's difficult to say.

Randomly controlled trials would help, but of course that's not possible in this situation for ethical reasons. What's needed is a large-scale prospective study that follows thousands of people up over many years. Hopefully a sub-set will opt for cosmetic surgery during that time and then it should be possible to look for any psychological vulnerabilities preceding the surgery and any changes post-surgery.

That's exactly what a team of Norwegian researchers have done. Tilmann von Soest and his colleagues began in 1992 with a sample of over 12,000 school students aged 12 to 19 years, and then surveyed them periodically for several years. Attrition of the sample left 2,890 participants at the final survey in 2005 (many participants were lost early in the study, in 1994, because they changed schools). By 2005, 106 of the participants had had at least one cosmetic surgery procedure. This included 78 women - that's 4.9 per cent of women in the sample; and 28 men - 2.2 per cent of the men in the sample.

Because of the lack of men, the researchers focused only on the women. The majority of their operations were for breast augmentation (26.8 per cent) or reduction (19.5 per cent), with other procedures including liposuctions, ear and nose modifications.

There was strong evidence that women with psychological problems were more likely to opt for surgery. The female participants who went on to have cosmetic surgery were more likely to have a history of poorer mental health, including more depression and anxiety, more illicit drug use, self-harm and suicide attempts. Unsurprisingly, the women who had breast surgery more often had a history of less satisfaction with that part of their body (although general appearance satisfaction wasn't related to undertaking surgery). By contrast, sociodemographic factors were not related to who had surgery and who didn't.

Did the surgeon's scalpel benefit the psychological health of these women? With one specific exception, it seems the answer is a categorical "no". Breast surgery was associated with increased satisfaction with that part of the body, but having cosmetic surgery of any kind was associated with increases in anxiety and depression, eating disorders, more alcohol use and more suicide attempts. Surgery didn't boost general appearance satisfaction.

The study isn't without its shortcomings, as the authors acknowledge. For instance, the apparent adverse effects of cosmetic surgery may not be specific to cosmetic procedures but could apply to having surgery of any kind. The study also relied on participants reporting their own mental health.

This study provides "no evidence that cosmetic surgery should be used to alleviate mental health problems in women dissatisfied with their appearance," the researchers concluded. "Nor do the results support the notion that cosmetic operations in exceptional cases should be covered by the public health-care system due to a potential psychotherapeutic effect for the patient."
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  von Soest, T., Kvalem, I., and Wichstrøm, L. (2012). Predictors of cosmetic surgery and its effects on psychological factors and mental health: a population-based follow-up study among Norwegian females. Psychological Medicine, 42 (03), 617-626 DOI: 10.1017/S0033291711001267

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Want to eat less? Try using your non-dominant hand

Much of our eating behaviour is habitual. Many of us eat biscuits with tea, nibbles before dinner, popcorn at the cinema and so on. A new study by David Neal and his colleagues has put these habits under the microscope and shown just how entrenched they can become and how they can be broken.

One hundred and fifty-eight participants were recruited to either watch movie trailers at a cinema or music videos in a university department meeting room. In both settings they were given popcorn to eat, which was either stale or fresh. Now, some of the participants were habitual popcorn eaters at the movies, others weren't. The notable finding was that in the cinema setting the habitual popcorn eaters ate just as much of the popcorn when it was stale as when it was fresh. This they did even though they said they liked it less (just as the non-habitual popcorn eaters did), and regardless of whether they were hungry or not. Neal's team said this highlights how habits are driven by context (the cinema) and are immune to attitudes (i.e. liking) and motivation (i.e. hunger). By contrast, when in the department meeting room (not the usual setting for eating popcorn), the habitual popcorn eaters ate less of the stale popcorn and their consumption was influenced by hunger. This shows that if you escape the context that usually drives a habit then its power weakens and motives and intentions can take over.

A second study was similar to the first except this time half the participants were told to eat the popcorn with their non-dominant hand (i.e. right-handers had to eat with their left). This manipulation, which obstructs the automatic execution of a habit, had a similar effect to changing the environmental context. Habitual popcorn eaters allowed to use their dominant hand again ate just as much stale popcorn as fresh, in spite of liking it less, and regardless of their hunger levels. But those instructed to use their non-dominant hand were freed of their usual habit - they ate less of the stale popcorn and their consumption was driven more by hunger and liking.

"Habit change may ... require impeding habit activation [by contexts] or interrupting fluid habit execution," the researchers said. "Although our findings suggest that both avenues are effective, it is not always possible for dieters to avoid or alter the environments in which they typically overeat. More feasible, perhaps, is for dieters to actively disrupt the execution of the activated eating sequence by simple manipulations such as eating with the non-dominant hand and, in so doing, bring their eating under their personal control."
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Neal, D., Wood, W., Wu, M., and Kurlander, D. (2011). The Pull of the Past: When Do Habits Persist Despite Conflict With Motives? Personality and Social Psychology Bulletin DOI: 10.1177/0146167211419863

Further reading: How to form a habit.
Seven ways to be good.

Post written by Christian Jarrett for the BPS Research Digest.

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The woman misdiagnosed with Alzheimer's, and how we can all be affected by the suggestion that we have psychological problems

Psychologists in the Netherlands have documented the case of a 58-year-old woman who was misdiagnosed with Alzheimer's Disease. The would-be patient consulted a neurologist at a stressful time in her life, in the knowledge that her mother had had the illness. A brain scan indicated reduced activity at the front of her brain ("hypofrontality"), and the neurologist also estimated her performance on a test of cognitive impairment as poor (though no formal test was conducted). On this basis he diagnosed Alzheimer's*.

The woman was devastated and thereafter her condition deteriorated significantly, to the point that she was permanently confused and, at one point, suicidal. Some months later, after receiving advice from an Alzheimer's helpline, the woman consulted a different neurologist for a second opinion. She completed comprehensive memory tests and undertook a further brain scan. All results were normal. This neurologist surmised that her earlier hypofrontality was associated with depression. He also went to great lengths to explain the good news about her results and the misinterpretation of her earlier scan, but it proved extremely difficult to assuage her concerns.

Years later, Harald Merckelbach and his team have interviewed the woman and they report that she continues to experience intrusive thoughts about the misdiagnosis and to catastrophise her memory lapses. Merckelbach's group believe the effect of a misdiagnosis has parallels with the implantation of false memories. Just as false memories are difficult to reverse, so too are mistaken diagnoses. "Conferring a diagnostic label is far from a neutral act," they said. "Many diagnostic labels have strong stereotypical connotations and sometimes, these will automatically shape the experiences and behaviour of patients, a phenomenon called 'diagnoses threat'."

To test these ideas further, Merckelbach, with colleagues Marko Jelicic and Maarten Pieters, gave 78 undergrads a psychological symptoms questionnaire to complete. Afterwards the students performed Suduko puzzles as a distraction. Next, the researchers went through some of the students' answers with them. During this review, the researchers inflated two of the answers they'd given to anxiety items. For example, imagine a student had originally indicated that she never had trouble concentrating. The researcher would inflate that answer by two points on the scale, as if she'd said that she sometimes had trouble concentrating, and they then asked the student to explain why she'd given that answer. Remarkably, 63 per cent of the participants failed to notice that their answers had been altered, and they proceeded to describe their experience of the symptoms (readers may notice parallels here with a phenomenon known as "choice blindness", in which people seem to have little insight into a recent choice they made).

Ten minutes later, and again after one week, all the students re-took the psychological symptoms questionnaire. At both time points, students who'd earlier failed to notice that two of their answers had been altered, now gave higher ratings to those two items, as if they considered themselves to have those symptoms. Such an effect was not observed among the minority of students who'd earlier noticed that their answers had been altered. An analysis of all the students' original baseline answers uncovered higher average baseline symptoms among those who would fail to notice the inflation of their answers. "Apparently a non-zero symptom intensity level introduces ambiguity; thereby raising the probability that misinformation is accepted," the researchers said. However, it's not the case that the influenced participants were simply more keen to give answers that the researchers wanted - they scored just the same on a test of social desirability.

The results from this study are consistent with past research showing how misinformation about physical symptoms can shape how people feel: for example, false feedback about asthmatic wheezing can trigger breathlessness in children with asthma.

Harald Merckelbach and his colleagues said their findings had particular significance for the way medical professionals interact with patients with unexplained symptoms, including those labelled with chronic fatigue, fibromyalgia, irritable bowel syndrome, and chronic pain. "... Expressing concern about the possibility of an underlying illness and, related to this, excessive investigation and attending patient support groups may all contribute to symptom escalation. What these interventions have in common is that they convey the message to the patient that his or her symptoms might be more intense and severe than he/she thinks they are. Our study suggests that blindness to unintended misinformation about the severity of the symptoms may underlie escalation of symptoms."

The researchers recommend that medics avoid mentioning the whole spectrum of possible symptoms when interviewing patients with medically unexplained symptoms. They also pointed to interesting avenues for future research. For example, notwithstanding the ethical issues involved, could patients benefit from receiving misinformation that lowered their symptom ratings? Also, is the inflated self-reporting of symptoms observed here based purely on exaggerated report, or is it grounded in an altered experience of symptoms?
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Merckelbach, H., Jelicic, M., and Jonker, C. (2011). Planting a misdiagnosis of Alzheimer's disease in a person's mind. Acta Neuropsychiatrica DOI: 10.1111/j.1601-5215.2011.00586.x

Harald Merckelbach, Marko Jelicic and Maarten Pieters (In Press). Misinformation increases symptom reporting – a test – retest experiment. J R Soc Med Sh Rep.

*Many years later, the neurologist was found guilty of having misdiagnosed several patients with Alzheimer's and 26 malpractice suits were filed against him (the woman featured in this case study was not part of that litigation).

This post was written by Christian Jarrett for the BPS Research Digest.

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Take vitamin pill, eat cake. How supplements can encourage unhealthy behaviour

Have you ever had that feeling, after an energetic gym session, or perhaps a long walk, that you've earned the right to a mountainous slice of cake, or to lounge lazily in front of the telly? Psychologists call these licensing effects and a new study has documented a similar phenomenon following the simple act of taking a vitamin pill. The researchers say the finding could help explain why the explosive rise in the consumption of dietary supplements (approximately half the US population take them, according to recent data) has not led to a commensurate improvement in public health.

Wen-Bin Chiou and his colleagues gave an inert pill to 82 participants recruited via posters in the Taiwanese city of Kaohsiung. Half the participants were told it was a placebo; the other half were told it was a vitamin pill. They were instructed to suspend their usual intake of supplements, if any, for the duration of the study.

Afterwards, compared with placebo participants, the participants who thought they'd taken a vitamin pill rated indulgent but harmful activities like casual sex and excessive drinking as more desirable; healthy activities like yoga as less desirable; and they were more likely to choose a free coupon for a buffet meal, as opposed to a free coupon for a healthy organic meal (these associations held even after controlling for participants' usual intake of vitamin pills. Participants also said at the end that they hadn't guessed the purpose of the study).

The vitamin-takers also felt more invulnerable than the placebo participants, as revealed by their agreement with statements like "Nothing can harm me". Further analysis suggested that it was these feelings of invulnerability that mediated the association between taking a postulated vitamin pill and the unhealthy attitudes and decisions.

A second study with student recruits was similar to the first, but this time, participants who'd taken what they thought was a vitamin pill opted to walk a shorter distance to return a pedometer to a researcher located elsewhere on campus (even though they'd just been reminded of the health benefits of walking). Again, this association, between the vitamin pill and behaviour, was mediated by feelings of invulnerability.

"People who rely on dietary supplements for health protection may pay a hidden price: the curse of licensed self-indulgence," the researchers said. "Policy interventions that remind individuals to monitor the licensing effect may help translate the increased use of dietary supplements into improved public health."
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Chiou, W., Yang, C., and Wan, C. (2011). Ironic Effects of Dietary Supplementation: Illusory Invulnerability Created by Taking Dietary Supplements Licenses Health-Risk Behaviors. Psychological Science DOI: 10.1177/0956797611416253

This post was written by Christian Jarrett for the BPS Research Digest.

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The dark side of swearing - it may deter emotional support from others

Each culture has its agreed-upon list of taboo words and it doesn't matter how many times these words are repeated, they still seem to retain their power to shock. Scan a human brain, swear at it, and you'll see its emotional centres jangle away.

Recent research has shown that this emotional impact can have an analgesic effect, and there's other evidence that strategically deployed swear words can make a speech more memorable. But it's not all positive. A new study suggests that swear words have a dark side. Megan Robbins and her team recorded snippets of speech from middle-aged women with rheumatoid arthritis, and others with breast cancer, and found those who swore more in the company of other people also experienced increased depression and a perceived loss of social support.

The sample sizes were small (13 women with rheumatoid arthritis and 21 women with breast cancer), but the technology was neat. The women wore "an electronically activated recorder" that periodically sampled ambient sounds, including speech. A lapel microphone recorded 50s every 18 minutes over two weekends for the arthritis sample and 50s every 9 minutes over one weekend for the breast cancer patients. Two months or four months after baseline the women repeated measures of their depression and perceived social support - the latter measured by agreement with statements like "I get sympathy and understanding from someone". The key finding is that higher rates of swearing in someone else's company, but not solitary swearing, were associated with an increase in depression symptoms and a drop in perceived social support. Moreover, statistical analysis suggested the effect of swearing on depression was mediated by the lost social support.

"This is one of the first studies to provide evidence of how swearing is implicated in the coping process," the researchers concluded. "It highlights a potential cost of swearing - that it can undermine psychological adjustment, possibly via repelling emotional support."

The study has its limitations, as the researchers acknowledged. For example, the methodology doesn't allow an alternative causal direction to be ruled out. Perhaps diminishing support or increasing depression provoked some of the women into swearing more. In that sense it was a shame the researchers weren't able to look for changes in rates of swearing. Another important limitation is the sample - perhaps swearing by middle-aged women has an adverse effect on their social support because of society norms, which dictate that women, especially of a certain age, shouldn't swear. The same study performed with young men may have produced a different result. "Swearing may even serve a bonding function among men, or younger people, and in different contexts," the researchers said.
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Robbins, M., Focella, E., Kasle, S., López, A., Weihs, K., and Mehl, M. (2011). Naturalistically observed swearing, emotional support, and depressive symptoms in women coping with illness. Health Psychology DOI: 10.1037/a0023431

This post was written by Christian Jarrett for the BPS Research Digest.

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Good news and bad for a popular willpower-enhancing strategy

In rich countries, temptation is never far and many of us struggle to achieve our long-term aims of moderation, dedication and fidelity. An increasingly popular strategy for regaining control is to form so-called implementation intentions. Rather than having the vague goal to eat less or exercise more, you spell out when, where and how you will perform a given activity, and rehearse that thought regularly. For example, "when in the cafeteria at lunch I will buy orange juice rather than cola". A more specific variant is to form an 'if-then' plan, as in "if it is a Tuesday morning, then I will go for a run," and again, this is rehearsed mentally on a regular basis.

Past research has found these plans to be successful, helping people to live more healthily. There's even evidence that they are particularly beneficial to those who have had their willpower compromised by brain damage or by taxing laboratory tasks. Two new studies add to this literature, one of them cautionary, the other more hopeful.

Sue Churchill and Donna Jessop studied 323 students tasked with eating more fruit and vegetables. They found that implementation intentions helped students achieve this task over a 7-day period, but only if they scored low on a measure of "urgency", as revealed by their agreement or not with statements like "When I am upset, I often act without thinking." The researchers said this suggests implementation intentions may not be a panacea: "Ironically, people who possess poor self-regulatory skills insofar as they tend to act on impulse when distressed, who are arguably most in need of assistance in achieving their goals, may benefit least from behaviour change interventions based on implementation intention formation."

Why the contradiction with earlier research showing implementation intentions are most helpful to those with compromised willpower? Churchill and Jessop can't be sure, but they said one possibility could be because their task of eating more fruit and veg is more complex than some of the lab tasks studied previously.

That's the cautionary news. The good news comes from a study by Barbel Knauper and her colleagues who found that using mental imagery boosted the benefit of implementation intentions for students attempting to increase their fruit consumption over seven days. Rather than merely forming an if-then plan, such as "If I see orange juice at lunch, then I will buy it", they also imagined themselves performing this act, with as much sensory detail as possible. A promising result, and the researchers expressed their surprised that no-one had thought to investigate the combination of these two strategies before.

Here's a curious observation across both studies. Knauper's team failed to find the usual benefit of forming simple implementation intentions (without the addition of mental imagery) and her team said one possible explanation for this was the simplicity of their task of eating more fruit. Recall that Churchill and Jessop thought the same task (admittedly, also including vegetables) was relatively complicated compared with tasks used in earlier research. It just shows how much room there is for interpretation.

Both studies suffered from a reliance on retrospective self-report - the students told the researchers whether they'd managed to eat more fruit and veg or not over the preceding week. They also had short study durations - we need our newfound healthy habits to last longer than a week. But together the studies point to some interesting avenues for future research. Perhaps implementation intentions plus imagery will prove to be effective for people who have particularly weak willpower?
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S Churchill, and D Jessop (2011). Too impulsive for implementation intentions? Evidence that impulsivity moderates the effectiveness of an implementation intention intervention. Psychology and Health DOI: 10.1080/08870441003611536

B Knauper, A McCollam, A Rosen-Brown, J Lacaille, E Kelso, and M Roseman (2011). Fruitful plans: Adding targeted mental imagery to implementation intentions increases fruit consumption. Psychology and Health DOI: 10.1080/08870441003

This post was written by Christian Jarrett for the BPS Research Digest.

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More serious brain injuries associated with more life satisfaction

Psychologists investigating the well-being of patients with an acquired brain injury (ABI) have documented a curious phenomenon, whereby the more serious a person's brain injury, the higher their self-reported life-satisfaction.

With the help of the charity Headway UK, Janelle Jones and her colleagues recruited 630 people (aged 9 to 81) with an acquired brain injury. Most had sustained their injuries from road accidents, with other causes including stroke and falls. Based on the time they'd spent in a coma, the majority of the participants' injuries were judged to be moderate to severe.

The participants answered a brief, 20-item questionnaire about their sense of identity (e.g. 'I think of myself as someone who has survived a brain injury'), their social support, relationship changes since their injury, and their life-satisfaction.

Having a strong sense of identity, seeing oneself as a survivor, having plenty of social support and improved relationships were all independently related to higher life satisfaction. These different factors also influenced each other. '...[I]t is likely that personal identity and social network support factors operate in a cyclical way,' the researchers said, 'whereby becoming personally stronger from effectively relying on social support also makes individuals more likely to continue to seek out social support and, in that way, to develop social capital.'

Perhaps the most curious finding was that participants who'd sustained more serious injuries tended to report being more satisfied with their lives. This association was mediated by the social and identity factors - that is, participants who'd sustained a more serious injury also tended to identify more strongly as a survivor, and to have more social support and improved relationships.

An obvious suggestion is that the more seriously injured participants might not have complete insight into their lives. Jones and her colleagues doubt this is the case, in part because of the logic of the results, with identity and social support mediating the higher life satisfaction among these participants.

'Sustaining a head injury does not always lead to a deterioration in one's quality of life,' the researchers concluded. '...[D]ata from this study serves to tell a coherent story about the way in which the quality of life of those who experience ABIs can be enhanced by the personal and social "identity work" that these injuries require them to perform. ... Nietzsche, then, was correct to observe that that which does not kill us can make us stronger.'
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Jones, J., Haslam, S., Jetten, J., Williams, W., Morris, R., and Saroyan, S. (2011). That which doesn't kill us can make us stronger (and more satisfied with life): The contribution of personal and social changes to well-being after acquired brain injury. Psychology and Health, 26 (3), 353-369 DOI: 10.1080/08870440903440699

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Bribing kids to eat their greens really does work

Try bribing him with a sticker

Some experts have warned that bribing children to eat healthy foods can be counter-productive, undermining their intrinsic motivation and actually increasing disliking. Lucy Cooke and colleagues have found no evidence for this in their new large-scale investigation of the issue. They conclude that rewards could be an effective way for parents to improve their children's diet. '...rewarding children for tasting an initially disliked food produced sustained increases in acceptance, with no negative effects on liking,' they said.

Over four hundred four- to six-year-olds tasted six vegetables, rated them for taste and then ranked them in order of liking. Whichever was their fourth-ranked choice became their target vegetable. Twelve times over the next two weeks, most of these children were presented with a small sample of their target vegetable and encouraged to eat it. Some of them were encouraged with the reward of a sticker, others with the reward of verbal praise, while the remainder received no reward (a mere exposure condition). A minority of the children formed a control group and didn't go through an intervention of any kind.

After the two-week period, all the intervention children showed equal increases in their liking of their target vegetable compared with the control children. However, when given the chance to eat as much of it as they wanted (knowing there was no chance of reward), the kids who had previously earned stickers chose to eat more than the kids who'd just been repeatedly exposed to the vegetable without reward.

At one- and three-month follow-up, the intervention children's increased liking of their target vegetable was sustained regardless of the specific condition they'd been in. However, in terms of increased consumption (when given the opportunity to eat their target vegetable, knowing no reward would be forthcoming), only the sticker and verbal praise children showed sustained increases.

So, how come previous studies have claimed that bribery can undermine children's intrinsic motivation, actually leading to increases in disliking of foods? Cooke and her colleagues think this may be because past lab studies have often targeted foods that children already rather liked. Consistent with this explanation, it's notable that past community studies that reported the successful use of rewards targeted unpopular vegetables just as this study did.

An important detail of the current study is that verbal praise was almost as effective as tangible reward. 'Social reward might be particularly valuable in the home,' the researchers said, 'because it may help parents avoid being accused of unfairness in offering incentives to a fussy child but not to the child's siblings.'
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Cooke, L., Chambers, L., Anez, E., Croker, H., Boniface, D., Yeomans, M., and Wardle, J. (2011). Eating for Pleasure or Profit: The Effect of Incentives on Children's Enjoyment of Vegetables. Psychological Science DOI: 10.1177/0956797610394662

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Can psychology help combat pseudoscience?

From homeopathy to dodgy nutritional supplements, support for pseudoscience and quackery thrives on people believing falsely that one thing causes another, when in fact it doesn't. Meanwhile, psychologists study belief formation, and specifically illusions of control (see earlier), whereby people wrongly believe that they're controlling something when they're not. In a new paper, three psychologists at Deusto University in Bilbao argue that the psychological literature can be mined for ways to help combat pseudoscience, and they've performed a small study to test the principle.

One of the psychological findings that Helena Matute and her colleagues focus on is that people are particularly likely to form an illusion of control when: (1) a desired outcome occurs frequently and (2) they, or someone else, perform some ineffectual action lots of times. In the context of health, this would be akin to having a condition from which recovery occurs frequently without intervention (e.g. back pain), whilst at the same time receiving a frequent, but ineffectual, treatment. This leads to the inevitable pairing of the desired outcome with the ineffectual intervention, thus giving rise to the false belief that the intervention is causing the positive outcome.

Matute's team tested this in a fictional scenario. One hundred and eight participants (recruited online) read about a fictional medicine 'Batarim' that could potentially cure the pain caused by a fictitious disease 'Lindsay Syndrome'. They were told about 100 patients, one at a time, in each case learning whether the patient had been given Batarim and whether their pain had subsided.

Crucially, half the participants heard about 80 patients who'd taken the drug and 20 who hadn't, whilst the other participants heard about 20 patients who'd taken the drug and 80 who hadn't. For both groups, the rates of recovery, at 80 per cent, were the same regardless of whether patients had taken Batarim or not - in other words, on this evidence, the drug doesn't make any difference to recovery rates.

Next, the participants were asked to rate the drug's effectiveness. All of them believed the drug had had some effect, thus showing how easily confused people are about issues of cause and effect. The key finding, however, is that those participants in the group who'd heard about just 20 patients who'd taken Batarim were far more accurate in their appraisals. Presumably this is because they'd had the opportunity to see that recovery often occurred without the drug, whereas participants in the other group were blinded by the more frequent pairing of drug with recovery (even though they too witnessed recovery occurring at just the same rate without the drug).

Matute and her colleagues said this suggests a simple way for pseudoscience claims to be challenged on TV and in news reports: '...simply showing participants the actual proportion of patients that felt better without following the target treatment helps them detect the absence of contingency for themselves. This should counteract the effect of all those miracle-products advertisements that focus their strategies on presenting confirmatory cases.'

Another finding from the psychological literature that Matute's team focused on relates to the wording used in questions about cause and effect. They predicted that people are more likely to endorse pseudoscientific beliefs when asked how effective a given treatment is, compared with when asked whether it caused the desired outcome. The latter should focus people's minds on the probabilities involved. That's exactly what was found in the current study - participants gave the fictional drug more realistic ratings when asked whether it had been 'the cause of the healings' compared with when asked how 'effective' it had been.

The main point of this study was to demonstrate, in principle, that findings in psychology can be exploited to help combat the ubiquity of pseudoscientific belief, and Matute's team feel they've done that. 'Our research proves that developing evidence-based educational programmes should be effective in helping people detect and reduce their own illusions,' they said.
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Matute, H., Yarritu, I., and Vadillo, M. (2010). Illusions of causality at the heart of pseudoscience. British Journal of Psychology DOI: 10.1348/000712610X532210

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If-then plans help protect us from the 'to hell with it' effect

You're probably familiar with what could be called the 'to hell with it' effect. It's when (as demonstrated by lots of research) a bad mood causes us to take risky decisions or engage in risky behaviour. Like when you're feeling down and you drive home dangerously fast or go out and get drunk. Now a team led by Thomas Webb at the University of Sheffield says that we can protect ourselves from this effect by forming 'if-then' implementation decisions in advance. These are self-made plans which state that if a certain situation occurs, then I will respond in a pre-specified way.

A first study used a trick anagram task to put some students in a bad mood. They were told the task was easy and should only take them five minutes when in fact three of the anagrams were insoluble (pilot work had shown that this puts students in a grump). Other students were told the truth, so the task wasn't expected to put them in a bad mood. Next, all the students said how they would behave in three imaginary scenarios - whether to drive an old car with brake problems, whether to disclose a secret to a room-mate, and whether to return deliberately damaged shoes to a shop for a refund.

Would being provoked into a bad mood encourage riskier behaviour? It depended whether the students had formed if-then plans in advance. During the previous week, ostensibly as part of a separate study, the students had been asked to keep a mood diary and to try to stay in as positive a mood as possible. Half the students (the control group) followed the simple instruction 'I will try to stay in a positive mood', which they were asked to repeat to themselves three times during the week. The others followed the if-then plan: 'If I am in a negative mood, then I will ... breathe deeply / think only positive thoughts / think how I've dealt successfully with previous situations' (they could choose which ending to use). Again they had to repeat this three times during the week. The key finding was the being provoked into a bad mood by the impossible anagrams led the control students to make riskier decisions (the 'to hell with it effect' in action) but not the students who'd made the if-then implementation plans during the prior week. They seemed to have been inoculated.

This pattern of results was replicated in second study in the context of arousal and a gambling task. Like being in a bad mood, being more aroused is also associated with taking more risks. In this case, Bach's Brandenberg concerto no. 3 was used to increase greater arousal in half the participants (the others listened to Beethoven's moonlight sonata). The gambling task involved betting points on whether a token was hidden inside blue or red boxes on a computer screen. After the arousal induction but before the task, half the students formed the if-then plan 'If I am asked to make a bet, then I will pay close attention to the number of red versus blue boxes'. The control students were simply told to end the game with as many points as they could. Consonant with the first study, increased arousal led the control students to play more riskily, but not the students who'd formed a protective if-then plan.

'Taken together,' the researchers said, 'the findings of the two experiments suggest that people can strategically avoid the detrimental effect of unpleasant mood and arousal on risk taking by forming implementation intentions directed at controlling either the experience of mood or risky behaviour.'

How do if-then plans exert their protective effects? Webb and his colleagues can't be sure, but they think they help form strong links between specific circumstances (e.g. when in a bad mood) and responses (e.g. breathe deeply) thereby making those responses easier to enact. 'Future studies will need to confirm that these processes ... explain how implementation intentions shield behaviour from the deleterious effects of mood,' they said.
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Webb TL, Sheeran P, Totterdell P, Miles E, Mansell W, and Baker S (2010). Using implementation intentions to overcome the effect of mood on risky behaviour. The British journal of social psychology / the British Psychological Society PMID: 21050527

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How to form a habit

This has nothing to do with nuns' clothing. Habits are those behaviours that have become automatic, triggered by a cue in the environment rather than by conscious will. Health psychologists are interested for obvious reasons - they want to assist people in breaking unhealthy habits, while helping them adopt healthy ones. Remarkably, although there are plenty of habit-formation theories, before now, no-one had actually studied habits systematically as they are formed.

Phillippa Lally and her team recruited 96 undergrads (mean age 27) and asked them to adopt a new health-related behaviour, to be repeated once a day for the next 84 days. The new behaviour had to be linked to a daily cue. Examples chosen by the participants included going for a 15 minute run before dinner; eating a piece of fruit with lunch; and doing 50 sit-ups after morning coffee. The participants also logged onto a website each day, to report whether they'd performed the behaviour on the previous day, and to fill out a self-report measure of the behaviour's automaticity. Example items included 'I do it automatically', 'I do it without thinking' and 'I'd find it hard not to do'.

Of the 82 participants who saw the study through to the end, the most common pattern of habit formation was for early repetitions of the chosen behaviour to produce the largest increases in its automaticity. Over time, further increases in automaticity dwindled until a plateau was reached beyond which extra repetitions made no difference to the automaticity achieved.

The average time to reach maximum automaticity was 66 days, although this varied greatly between participants from 18 days to a predicted 254 days (assuming the still rising rate of change in automaticity at the study end were to be continued beyond the study's 84 days). This is much longer than most previous estimates of the time taken to acquire a new habit - for example a 1988 book claimed a behaviour is habitual once it's been performed at least twice a month, at least ten times. In fact, even after 84 days, about half of the current study participants had failed to achieve a high enough automaticity score for their new behaviour to be considered a habit.

Unsurprisingly perhaps, more complex behaviours were found to take longer to become habits. Participants who'd chosen an exercise behaviour took about one and a half times as long to reach their automaticity plateau compared with the participants who adopted new eating or drinking behaviours.

What about the effect of having a day off from the behaviour? Writing in 1890, William James said that a behaviour must be repeated without omission for it to become a habit. The new results found that a single missed day had little impact on later automaticity gains, either early in the study or later on, suggesting James may have overestimated the effect of a missed repetition. However, there was some evidence that too many missed repeats of the behaviour, even if spread out over time, had a cumulative effect, reducing the maximum automaticity level that was ultimately reached.

It seems the message of this research for those seeking to establish a new habit is to repeat the behaviour every day if you can, but don't worry excessively if you miss a day or two. Also be prepared for the long haul - remember the average time to reach peak automaticity was 66 days.

This research has a serious shortcoming, acknowledged by the researchers, which is that it depended entirely on participants' ability to report the automaticity of their own behaviour. Also, the amount of data made it hard to form clear conclusions about the need for consistency in building a habit. However, the study provides an exciting new approach for exploring habit formation and future research could easily remedy these shortcomings.
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Lally, P., van Jaarsveld, C., Potts, H., and Wardle, J. (2010). How are habits formed: Modelling habit formation in the real world. European Journal of Social Psychology DOI: 10.1002/ejsp.674

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