Mar 12

Bipolar and Creativity

Creativity and BipolarBipolar and creativity have a well known relationship. Kay Redfield Jamison eloquently described aspects of this relationship in her book, “Touched with Fire.”

More recently, a movie by the same name, tells one story about two young people learning and experiencing aspects of artistic expression and bipolar.

There are several aspects of bipolar that may account for this relationship.

Many people with bipolar have higher scores on ratings of divergent thinking. Impulsivity, or reduced inhibition, may also be connected with creativity, as may more intense emotions.


Simon Kyaga, and fellow researchers, conducted two studies looking at the relationship between bipolar disorder and two types of professional success: leadership achievement and creativity. They used registry data from Sweden that covers health information and other demographic information on the entire population of that country.

In keeping with other researchers, they found that individuals with bipolar disorder and healthy siblings of people with bipolar disorder were overrepresented in the creative professions. As you can see in the chart below, this was a strong correlation. Bipolar individuals were 1.35 x as likely as others to have creative professions, and siblings without bipolar were almost 1.5 x as likely to work in a creative career.

Bipolar and Creative Occupations.jpg


McCraw found a specific link between hypomania and creativity in their study.

82% of BP patients affirmed being creative when hypo/manic, with comparable results for the BP I and BP II subtypes (84% and 81% respectively).

Of course, this means that there may be periods when creativity ebbs.

Bipolar Hope has an interesting article about what to do when creativity goes away…


Gartner, J. The Hypomanic Edge: The Link Between (A Little) Craziness and (A Lot of) Success in America. Simon & Schuster. 2005

Higier RG, Jimenez AM, Hultman CM, Borg J, Roman C, Kizling I, Larsson H, Cannon TD. Enhanced neurocognitive functioning and positive temperament in twins discordant for bipolar disorder. Am J Psychiatry. 2014 Nov 1;171(11):1191-8. doi: 10.1176/appi.ajp.2014.13121683. PubMed PMID: 25124743.

Kyaga S, Lichtenstein P, Boman M, Hultman C, Långström N, Landén M. Creativity and mental disorder: family study of 300,000 people with severe mental disorder. Br J Psychiatry. 2011 Nov;199(5):373-9. doi: 10.1192/bjp.bp.110.085316. PubMed PMID: 21653945.

McCraw S, Parker G, Fletcher K, Friend P. Self-reported creativity in bipolar disorder: prevalence, types and associated outcomes in mania versus hypomania. J Affect Disord. 2013 Dec;151(3):831-6. doi: 10.1016/j.jad.2013.07.016. PubMed PMID: 24084622.

Smith DJ, Anderson J, Zammit S, Meyer TD, Pell JP, Mackay D. Childhood IQ and risk of bipolar disorder in adulthood: prospective birth cohort study. BJPsych Open. 2015 Aug 20;1(1):74-80. PubMed PMID: 27703726; PubMed Central PMCID: PMC4995557.

For More Information

Touched with Fire


Kay Jamison

Mar 12

Acceptance and Commitment Therapy Part 3: Present Moment Awareness

I hope you have a few minutes to engage in a few exercises with me….

First, I’d like you to take 1 or 2 minutes to imagine that you are sitting on a white sand beach looking at the ocean, watching the waves roll onto the shore. Set your phone timer if that would be helpful. And….go.

What did you notice? If your mind is anything like mine, it ran off on you to thoughts about plans for later in the day, work or chores that have to get done, maybe an urge to get up and make a cup of coffee, or clean off the clutter on my desk, or… Our minds are constantly pulling us in many different directions. The bummer is that it would do this, even if you actually were on a sandy beach! Our minds are like puppies, constantly running and jumping around and often up to trouble!

Here’s another exercise:

Where are your feet?

I hope you’ll take a moment or two to really consider that question. Where are your feet?

What did you notice?

One of my mentors in graduate school used to ask me this when he noticed my mind running away from me…either into the past or into the future. You might have noticed that this question brought your attention to the room you are in, the sensations of your feet on the floor…the moment you are actually experiencing in this moment.

Present-moment awareness, or mindfulness, is a central component of acceptance and commitment therapy, and is the topic of part three of this blog series that describes–experientially–the 6 core processes in ACT. Present-moment awareness means bringing awareness to the moment that you are actually living, without judgement of your experience (e.g., good, bad). It means participating in your life—not only in the fun moments but the challenging moments as well, as best you can with curiosity and openness.

When we practice mindfulness regularly, our minds can be trained (just like a puppy!) to focus and join us in our lives. Practice can take any number of forms including:

  • Set an alarm on your phone to remind you to notice where you are, maybe ask yourself, “Where are my feet?” twice per day.
  • Take one or two or five minutes and use your sensations to help bring you into the moment. For example, notice the colors or the sounds around you.
  • Eat a snack or meal mindfully–or even a bite or two; really noticing what your food tastes like, what if feels like in your mouth.
  • Use guided mindfulness practices. You can search for guided exercises online, or use an app such as Headspace or CALM.

“I suck at mindfulness” is what I hear often from folks just beginning to practice mindfulness. These practices are simple but not easy! Our puppy minds want to go here, there, and everywhere. Becoming distracted is totally normal and expected. When you notice your mind has wandered–great! You are mindful again! And then bring it back to the sensation your are attending to in that moment. Again and again and again. If your mind is feeling particularly busy, guided mindfulness exercises can be helpful because there are often cues to remind us to bring our attention back when our minds have wandered. As best you can, have fun with this…I’m sure you can come up with additional ways and moments that might be interesting to use for practice as well!

Click here for Part 1 on Willingness and Part 2 on Defusion. (Being mindful is an important component of both!)

By: Kelsey E. Schraufnagel, PsyD

Mar 08

Mixed Depression and Anxiety or Bipolar ?

Mixed Anxiety and DepressionA young man who recently graduated from chiropractic school came in for a second opinion. He has had a many year history of depressive episodes with prominent anxiety symptoms.

Is this mixed depression and anxiety?

This past summer, he went to see a new psychiatrist to get help with another episode of depression. The psychiatrist started him on Lexapro (a serotonin anti-depressant). Right after starting the medicine he experienced one day of an optimistic, energized state. Then he had a series of very unpleasant days with prominent irritability, anxiety, and bouts of depressed mood.

His psychiatrist diagnosed this as bipolar disorder type two. They young man wondered what I thought about the diagnosis. It didn’t make sense to him, since almost all of the problems he had had with his mood related to depression.

This kind of question is one of the most tricky that I confront in my clinical practice. Anxiety can lead to a kind of agitation and may also be associated with irritability, so why is this story not compatible with a mixture of anxiety and depression?

To try to sort this out I asked a couple of questions:

1. Was the state of mind that he initially described clearly a positive, optimistic, energized state? And if so, had there ever been periods like it?

Pure optimistic hypomania is relatively distinct. He said that it was a distinct optimistic period and, on further questioning, he reported at least a couple of other periods, all brief, and all mild enough that they were associated with no adverse effects, during which he had similar experiences in the last few years.

2. How had he responded to medications?

I think it’s easy to make the error of assuming that someone who responds to a mood stabilizer must be bipolar, but certainly medication response is useful. In his case, there was a clear pattern of improved mood stability when he was put on a therapeutic dose of lithium, and when he was tapered off of the medication because of adverse cognitive effects, his mood became unstable again.

3. Was the anxiety and irritability a relatively persistent experience?

Generalized anxiety, which is the type of anxiety that this would be most similar to, is a fairly stable state. Across different times and places, a person feels a high level of anxiety and irritability, and the irritability tends to vary along with anxiety. In other words, when the person is very irritable, their anxiety is high.

With careful questioning, we were able to identify three mood states: a mixed anxious and irritable state which was fairly unpleasant, an upbeat and optimistic energized state, and a lethargic depressed state. This pattern is similar to what I have described elsewhere as “tripolar disorder” – a pattern often seen in people with bipolar, and rarely in others.

A careful history is usually the key to a difficult diagnosis, such as this one.

For More Information

Tripolar Disorder

Anxiety and Bipolar

Mood Charting for Complicated Problems

Mar 05

Sustained Attention and Denial

Sustained Attention and DenialHow can sustained attention deal with denial?

Let’s say an older parent is refusing to get necessary medical care, afraid that going to the doctor will uncover a feared illness, cancer or dementia, what to do?

The seriousness of the problem suggests the need for a heroic intervention. Thoughts come up about performing an “intervention” in the way that is done sometimes for someone in denial about a substance abuse problem… Bringing in family and friends for a one time, intense, meeting designed to overcome resistance.

This past week I saw many examples of an alternative strategy that seems to low key to have a chance of working and yet which can be remarkably powerful.

It involves increased engagement with the person in denial. Visiting them more often, being more present in their lives. Trying to see the world from their perspective.

And then, after becoming more engaged, mentioning in a low key way the issue of concern. Without trying to come to any agreement about what should be done, but just so that you can share your concern and your perspective.

And doing this over and over again, so that it becomes clear that the topic is one that you are really committed to attending to.

A woman whose mother has clearly been gradually developing dementia, but who has angrily responded to several planned conversations on the topic… suddenly scheduled an appointment with her doctor after the daughter started showing up several times a week to spend some time with the mother, mentioning, in passing, each time, her concern.

The father of one of my close friends, who had been refusing potentially life saving heart surgery, despite many well thought out and articulate discussions about the urgency of the matter, finally agreed to get a work up after the family took turns spending “time with Dad” and “noticing” how hard it was for him to get around due to his fatigue… “wondering” if he had thought any more about the operation…

The problem with the “intervention” approach is that a one time meeting may be, in some ways, easier to resist, than the ongoing and consistent expression of concern from someone who seems to genuinely care and who has taken the time to really understand a person’s fears and concerns.


Writer Julie Fast wrote an article on this topic for BP Hope in 2011 which is one of the most commonly read and commented upon articles on that website.

She had some points to consider:

Find the sweet spot. Are there periods when your loved one is more open to discussion? Often people are more receptive during a mild depression…

Hold on to hope. I’ve known many people who accepted treatment after years of denial, often when loved ones learn simple strategies and get them help at the right time. It isn’t easy to hang on until then. Nothing with bipolar disorder is easy! But bipolar is treatable, even for those who currently refuse to admit they are ill.

I think her point about timing is an important one, as is the embedded idea that, in most situations, dealing with denial is something that is likely to take weeks or even months and having realistic expectations (and also taking care of yourself in the process) is an important part of achieving success. Too many people alternate between a sense of urgency about getting the problem taken care of and interspersed periods of not talking about it at all. Find your moment to talk about it but also don’t pretend that the problem doesn’t exist even when it might not be timely to bring it up.

It is helpful to conceptualize the process of dealing with denial as one that involves a marathon rather than a sprint.

The idea of setting expectations touches upon another important point. For most people what they most care about is people’s behavior. This is something that is objective and less likely to be a topic of disagreement than the more abstract notion of “being bipolar.” Focus on the behavior is often helpful and more realistic than focusing on “insight” about what is going on. To put it in a different way, it’s okay if the person takes medication or agrees to see a mental health professional just “to please you.” That is often the first step.

Dr. Xavier Amador is another writer who has written books on the subject (I Am Not Sick I Don’t Need Help) that I often recommend to loved ones as a starting point.

For More Information

Julie Fast’s article

Xavier Amador’s website

The Problem of Denial: How to Help Loved Ones with Substance Use and Other Destructive Habits

Denial: I’m not Bipolar, Doctor

Mar 04

Happy Acts by Gina

Happy ActsThe Happy Acts Challenge

Did you know that giving can activate the reward centers of the brain? We think regularly about techniques to support us in managing our mood including exercise, eating healthy, regular sleep routine, etc. Is giving back or volunteering also on your list? If not, you should consider it.

Researchers are finding that areas of the brain that are activated during pleasurable activities such as eating chocolate are also activated when engaging in charitable giving. As many of us are familiar with in our lives, often times helping others feels as rewarding, if not more rewarding than being helped by others. Giving back to those around us or those in need can ultimately be a way of giving back to ourselves and supporting our mood. An article in US News and World Report (see link at the end of this post) talks about some of these effects…

The feel-good effects of giving begin in the brain. It’s called “giver’s glow,” says Stephen G. Post, director of the Center for Medical Humanities, Compassionate Care and Bioethics at New York’s Stony Brook University. The response, he says, is triggered by brain chemistry in the mesolimbic pathway, which recognizes rewarding stimuli.

Philanthropy “doles out several different happiness chemicals,” Post says, “including dopamine, endorphins that give people a sense of euphoria and oxytocin, which is associated with tranquility, serenity or inner peace.”

In fact two large studies suggest that generosity can have pretty profound health effects as well.

One study published in 2013 in the American Journal of Public Health found that giving time and assistance to others reduced the mortality risk tied to stress, a known risk factor for many chronic diseases. According to the study, which looked at 846 adults in the Detroit area, stress did not predict mortality for participants who had helped others within the previous year. But the link between stress and mortality was apparent in people who didn’t lend a helping hand, even after adjusting for age, health and other variables. 

A colleague recently told be about Live Happy, a group devoted to living happy and making the world work a happier place. This month they created a campaign of daily happy acts to engage in, such as cooking a meal for a friend or telling someone your favorite joke. They are encouraging people to reflect on how doing a daily act of giving impacts their happiness over the course of the month. Do you think you are up for the challenge?

Check out the calendar:

– Gina

For More Information


Mar 02

Recovery from Bipolar

Planning for Recovery from Bipolar

Recovery from BipolarI recently came across a great account from a man living with Bipolar Disorder, Steven Propst. In an insightful and direct way, he describes what recovery has looked like for him and helpful steps in finding it for yourself. By examining the importance of accepting his diagnosis, gathering information to cope with his ups and downs, finding the right medication, developing a WRAP plan, and taking action to stop putting his life on hold, Steven Propst summarizes his path of recovery ( ).

In my work as a therapist, I have seen many patients benefit from the work he describes. I think approaching one’s diagnosis from a place of acceptance and finding ways to move forward in one’s life can be very challenging. Especially, after a recent diagnosis I see many struggle with grief and trauma related to their past manic episode. Finding support and a safe place to process related emotions, whether it is with a therapist, support group, or close support system, has been invaluable to some that I have worked with.

Additionally, finding tools that work specifically for you to cope with ups and downs is essential. The WRAP plan is a great way to individualize and solidify steps to support oneself. WRAP stands for Wellness Recovery Action Plan and is a tool to plan for both wellness and preventing a crisis. It thoroughly helps outline steps you can take in your everyday life to support your well being in addition to identifying warning signs leading up to crises and ways to respond to prevent hospitalization.

Another tool I find especially helpful when working with clients to re-engage in their lives (as Mr. Propst put’s it “getting to it”) are SMART goals. SMART goals stand for specific, measurable, realist and time-limited goals. Often setting goals for oneself can feel overwhelming. This can cause anxiety that acts as a barrier to getting started. By setting small achievable goals within a specific time frame, I have found clients are better able to take actionable steps. For example, if my goal is to start exercising again that could feel very daunting and could mean many different things. Does that mean going to the gym for hours every day? Or running a 5k every Saturday? Instead if I were to start small and specific and made the goal of going to 2 yoga classes in the next week on Monday and Friday, the task would feel more achievable to me.

Ultimately, finding tools that work for you and hearing from others about the tools they have found most valuable can be helpful in the recovery process. To connect further with other people blogging about their experience with Bipolar Disorder, check out the list of Heathline’s list of top 13 Bipolar Disorder Blogs:



Additional Resources

Bipolar for Beginners

Blessings of a Bipolar Crisis

Feb 26

Factors Linked to Bipolar Cycle Acceleration – Arnrow


cycle accelerationFactors Linked to Bipolar Cycle Acceleration–

Researchers at the Norwegian University of Science and Technology, Trondheim conducted a study consisting of 210 participants (53.3% women) with bipolar I (68.1%) and bipolar II (31.9%)  to identify factors linked to bipolar cycle acceleration (rapid cycling).

They found the following factors (listed in order of importance):

  1. Severity of episodes – there was a higher chance of rapid cycling when individual episodes were more severe.
  2. Depression dominant bipolar – There was a suggestion that rapid cycling was more likely with depression-dominant bipolar disorder.
  3. Bipolar II disorder, especially where depression was the first mood episode, had a higher rate of rapid cycling.
  4. Severe mania reduced the frequency – There was a negative correlation with the number of hospitalizations for mania.
  5. Positive correlation with hypomanic or manic episodes triggered by alcohol use or antidepressants.
  6. As with previous studies, women had a higher risk of rapid cycling.

What do you think about these conclusions? I would love to hear from people who identify and don’t identify with these factors to see if they experience cycle acceleration differently!

Check out this News Medical article and this PubMed page for more information.




Feb 24

Bipolar Downshifting – Suzy B

bipolar angry parisian womanShe wakes up from a fitful sleep and within an instant knows the day will be hard. Lying on the bed for a moment she stares at the bathroom door. It’s the first port of call, but for what? Because that’s what you do. You go to the bathroom and prepare for the day before moving on. It’s what you do.

She turns over and stares at the opposite wall. It’s neutral without a picture, plants or anything. There is nothing there to provoke the senses. But its blandness is perfect for the bipolar projectionist letting her see and create ideas and images out of nothing. The blank wall gives her moment for reflection.  Surely there is a choice? I can paste upon it positive things: exciting past events, good people I’ve known, and wonderful places visited… all evoking a sense of pleasant nostalgia.

But despite this rational thought, the choice simply isn’t available. Her bipolar downswing gives her no choice. Something in her refuses to allow the choice. She’s locked down below and there is nothing to lift the mood. Yet all she wants is for the myriad of miserable thoughts and images to go away.

Maybe it would be just good to lie here and with luck fall back sleep, she thinks. It could be nice to trace a dream or two – to lose oneself in sub-conscious imagination. But nature calls. That plus the alarm make the next move inevitable. She must get up.

She swings her legs off the bed. Its warm embrace has offered relief from the maddening mood. It feels like she’s carrying a sack of coal over her back as she walks slowly towards the bathroom.

She climbs into the shower. ‘Shall I face this way or that’, she thinks. ‘Perhaps I should sing or imagine playing croquet….’Silly, a head full of random thoughts that for the most part make no sense and offer little value.  They float by like diatoms moving slowing or fast. There isn’t a narrative, just random thought.

‘Now I must do the tiresome business of washing head to toe’, she thinks. She has choices. She can start with the arms or feet. ‘Perhaps I could do the left foot followed by the right knee’. She’s used different types of soap to make the morning routine a more uplifting experience that may life the tenor of the day:  rose-scented soap or the aroma of patchouli – even ‘no nonsense’ tar soap from England. Today, she uses the first shower wash she finds.

Her thoughts continue to swirl drift and race. No direction, just a succession of ideas:  beautiful or horridly graphic ideas or fleeting images of ghostly apparitions, fleeting thoughts whirl by in a glance. It’s like watching a movie, she thinks. ‘I am a plankton at the mercy of the ocean current’. ‘But I will make choices, I will fly somewhere and dine with friends sitting cross-legged on plush pillows in some exotic foreign restaurant somewhere.’

She feel quite desperate for a change of scenery, but remembers advice given one time. ‘If you don’t deal with it you take the problem with you’.

‘Ah, Sherlock I note that beside the toilet there is a wildlife magazine left no doubt by my ex Beau. It looks interesting enough ‘There is a world of wonderment to discover beyond me’,

There is a lot to read, but there are pictures, too, and in this frame of mind a picture fires the imagination and generates a loose story line or a raft of partly related ideas. Photographs of frozen northern forests are evocative and generate a kaleidoscope of actions, stories and frozen images that she hangs onto until they are smashed by another thought.

‘Hell, this could take me to lunchtime, but I could be 10 kg lighter and little better educated’, she concludes. If only for a while the magazine proves a distraction. ‘The world is full of interesting things like plankton, wolves, big spiders, and oh did you know Wolves don’t like Wagner’’? She pauses ‘where did that come from? Silly, silly thoughts: silly, silly thinking. A Timber Wolf would not know his Ray Charles from his Handel. The magazine is tossed aside. She is back in the bathroom; she is back in her head. Private education in the bathroom? It might have changed her mood, but it hasn’t. It hasn’t generated exciting ideas which could generate energy, the sort of energy that bounces you up from your sprung mattress high into a new day.

She looks at herself in the mirror. ‘Why do I feel so very, very down? My evening was lovely. I was buzzy and I went to bed feeling good. Now I feel just like s**t’. Why the downshift again? Why can I not sustain that good-time feeling?

I’m cycling again she thinks: ‘Bouncy, bouncy bipolar ball, but I won’t play this game at all!’

It ‘s dodge ball, except that the only players are me and me together with me and me and – I slam that rubbery ball repeatedly against myself. Yet I still lose.  Surely there should be a winner and that winner me?

Today, again, I carry the burden of bipolar: the ’ Beast of Burden’. STOP THIS!! No Money in idiotic thinking. Stay straight if possible there are things to do.

She leaves the flat. Out into a chaotic world. She knows it’s going to be one of those days and she must block out the world – keeping the palms of her hands firmly pressed to her temples to screen out the city noise and the endless movement as she navigates between people on a busy street. She’s already wincing as if in the strongest of sunlight. Fear turns to anger. It can be just like that.  Anxiety gives way to aggression. She walks faster. Somehow this attitude does not warrant examination it’s mindless. It just keeps her sane. She collides with someone, but offers no apology. Why?

She’s on the subway and watches some business guy absently mindedly picking his nose. She wants to go up to him and start picking his other nostril and, once done, simply say, “you’re welcome” and leave the train. Silly and slightly aggressive idea: silliness brought on by this barrage of sensory overload. But still she stares at him. He notices and doesn’t mistake the look as a ‘come on’. It feels very uncomfortable. Eyes can snarl. Fortunately, the next stop is his and he leaves promptly.

But this cacophony of noise! She can’t think sanely! It invokes within her that cycling turn of anxiety and then anger. This aggression makes her question her sanity.  Apparently, they use audio recordings of babies wailing as a method of torture. Sometimes the inability to discern relevant from irrelevant sensations feels like a perpetual onslaught, or a confederation of wailing, screaming babies.

Disjointed sounds everywhere; this is a busy city: the sirens, cars, loud voices, jackhammers, trains, loud conversations in cafes and restaurants. She is from a noisy, busy city, but this experience is way more than just a noisy city.

No tolerance, no wish to interact, just grinding her teeth as she listens to stupid people speaking in clichés – one shallow thought elicits an equally inane reply and on, and on, and on…

‘These people would be better employed down a mine’, she thinks. ‘Oh silly intolerance! I’m being childish again, just let it all wash over you’. But despite herself she listens and quickly grows more irritated, enraged by their laughter and ease.  She disdains with passion the useless observations of everyday life.

‘Oh, for god sake!  Why cannot I let this go ‘? Why pass judgement? Why think all these silly thoughts that simply elicit more frustration and exacerbate an already restless emotionally cycling mind? Bipolar hell?

Oh yes!



Feb 22

Biological Basis of Depression

A recent review article in the American Journal of Psychiatry examines data from many functional neuroimaging studies in order to define more clearly the biological basis of depression.

Abnormalities in two sets of neural circuits seem to be the most consistent findings in people with depression:Serotonin Implicit Emotion Circuits

  1. Serotonin anxiety and distress circuits that connect the amygdala and several locations in the medial prefrontal cortex.
  2. Dopamine reward circuits that connect the ventral striatum and medial prefrontal cortex.

dopamine reward circuit

The serotonin circuit is illustrated in the picture to the right.

The amygdala can be thought of as the threat or fear of respondents said of portion of the limbic or emotional brain. Serotonin signalling from the prefrontal cortex to the amygdala seems to reduce emotional response to negative information and a tendency to see threats in the world. Increases in serotonin signaling in the prefrontal cortex areas that connect to the amygdala reduces threat response.

I have described the experience of low serotonin in the circuits as akin to the constant playing of “scary music” from a horror film. It’s like those moments in a horror film when everything seems normal but all of a sudden you hear the scary music and you know that there must be something about to happen. Imagine that feeling continually occurring and I think you have some sense of what abnormalities in this circuit feel like.

People with abnormalities in the serotonin circuit seem to respond better to serotonin antidepressants. The most striking finding from a number of studies designed to evaluate predictors of antidepressant response is an association between hypermetabolism, as measured with PET, or greater activity, measured with fMRI, in the pregenual anterior cingulate cortex (part of the serotonin circuit) and better response to a single serotonin antidepressant (SRI). No such association was found for response to the dopaminergic medication bupropion (Little et al).

The dopamine circuit is illustrated in the picture to the left.

Abnormalities in the dopamine circuit seem to be associated with reduced pleasure and difficulty being motivated to do things because of the loss of anticipatory pleasure. There is less data on treatment outcomes being correlated with abnormalities in this circuit but, as I’ve noted in another post, there is some evidence to suggest that anhedonia or the lack of pleasure correlates with a better response to dopamine antidepressants. Anhedonia may be a predictor of a better response to ketamine and ketamine profoundly affects these dopamine circuits.


Phillips ML, Chase HW, Sheline YI, et al. “Identifying Predictors, Moderators, and Mediators of Antidepressant Response in Major Depressive Disorder: Neuroimaging Approaches.” American Journal of Psychiatry. Volume 172 Issue 2, February 01, 2015, pp. 124-138.

Little JT, Ketter TA, Kimbrell TA, et al: Bupropion and venlafaxine responders differ in pretreatment regional cerebral metabolism in unipolar depression. Biol Psychiatry 2005; 57:220–228

Feb 18

Bipolar 101 – The Basics and Beyond

Bipolar 101, an online course hosted by Gateway Psychiatric begins March 17, 2017: Bipolar 101 – The Basics and Beyond.

The class is based on the acclaimed Barcelona Bipolar Disorders Program.

Bipolar 101 – An online course will cover topics such as:

  • “What is Bipolar?” – What do we know about the causes and what are the implications of this information.
  • How and Why to Keep Track of Mood” – Options for mood charting and why this can make such a difference in how you manage moods.
  • “Medications” – The good, the bad, and the ugly. What you need to know about medication options.
  • “Substance Use” – The latest on how substances from CBD to LSD affect bipolar. Are some of these potential treatments? We’ll look at the data.
  • “Early Detection and Prevention of Severe Mood Swings” – Strategies for preventing routine small ups and downs from turning into mood episodes.
  • “Healthy Routines” – How a certain morning routine can help you achieve more stability.
  • “Other Treatments” – Non-medication approaches to treatment.

It will be taught by Dr. Peter Forster and Gina Gregory, and will have an interactive format with plenty of opportunity to answer your questions.

The class will be offered at a nominal charge (to cover the cost of the online course hosting) of 20$, one time only.

After this, the course will be offered at a cost of 150$ for the 16 90 minute sessions.

If you are interested contact us now.

Feb 11

Loving Someone Bipolar

Pills as a heartLoving someone bipolar can seem like an overwhelming challenge at times.

A quick survey of the internet combined with years of conversations with loved ones struggling to navigate the sometimes stormy waters, yields a great diversity of perspectives.

Julie Fast, a well known bipolar writer, describes her experience living with her partner during a manic episode…

Years ago, my much-loved partner, Ivan, went into a massive manic and psychotic episode that lasted for almost five months. As his sole caretaker, I was very confused and scared. During his manic and psychotic episode Ivan slept with someone else, told me he didn’t love me and wanted a divorce, had the idea that someone was stalking me, and eventually came very close to suicide. Believe me, I’ve been through it all. And we survived. Your relationship can survive as well.

Bipolar disorder is a medical condition that manifests in behaviors that look like personal choices. It’s hard for partners to understand this as the symptoms feel so personal. When a person with bipolar spends a child’s college fund, makes horrible accusations, cuts down all of the trees in the back yard, refuses to listen to reason, and comes close to destroying a relationship, it’s hard to step back and think, This is an illness, but it needs to happen.

Terri Cheney, writing on the Psychology Today website, takes a somewhat less medical model view of bipolar relationships…

I’m frequently asked, “What’s the best way to love someone with bipolar disorder?”  Usually the person asking me has the traces of a frown on his face.  I empathize.  We’re not the easiest bunch in the world, the 5.7 million of us with bipolar disorder.  But then, simplicity is not what you fell in love with in the first place, is it? 

No.  Most likely you were attracted to the volatility, the edginess, the uncertainty.  Loving someone who’s bipolar means loving a panoply of characters:  the girl who’s overcast one morning and the one who’s radiant by mid-afternoon.  There’s an excitement about not ever being able to predict the emotional weather; but it calls on all your relationship skills.

These two perspectives highlight the duality of bipolar: sometimes it is clearly a disorder that is best approached from a medical perspective and sometimes it is a set of traits that include an emotional breadth and an inspirational creativity that is easy to be drawn towards.

I know, as a psychiatrist I found myself drawn to bipolar patients early in my residency training, but I also know that at times I feel completely depleted from trying to help someone who seems to reject any offer of help and deny even needing help, while at the same time heading off in a perilous and self-destructive direction.

Acute or chronic problem?

Julie makes an important point in her article: it matters whether the problems you are dealing with are acute or chronic. Someone with one hypomanic or manic episode needs to be treated with understanding as a victim of disordered brain chemistry. On the other hand, a person who flirts with danger by refusing medical care, or doing things that increase the risk of a manic episode (such as using drugs or ignoring warning signs), is clearly creating a relationship issue that has to be addressed.

It is reasonable within a relationship to insist that one’s partner make a serious effort to take care of themself.

Hold on to Hope

As a psychiatrist, and therapist, for people with mood disorders of all kinds, I know that one of the most important, and sometimes one of the hardest, roles I play is as the keeper of hope.

Terri talks about this function in her post –

Don’t ever give up on hope.  It’s scary when symptoms manifest, and it’s frustrating for everyone when they don’t go away.  But the weird blessing of bipolar disorder is that it’s a disease of constant change.  Eventually, a mood will shift.  Or one of the many medications now available will start to take effect.  I know this intellectually; but I forget it instantly when I’m suffering.

From my own experience, I know that holding on to hope means that sometimes I have to pay special attention to ensuring that my own health needs are addressed. And sometimes it means that I have to get help from a mental health colleague. Both of these are even more important for someone living with a bipolar partner.

Develop a Plan

We love the Wellness Recovery Action Plan as a model for planning for future episodes. Working on this together can be a great way of strengthening the relationship. And a thoughtful discussion, when your partner is not in a mood episode, can help to build emotional intimacy and optimism.

Part of that plan might call for sharing the burden of support with others.

Discussing when and how to reach out to the partner’s therapist or psychiatrist.

And thinking about times when a little bit of distance might be useful, for example when your partner is in a safe environment and is mildly manic, it can sometimes be good to create some distance so that you are not constantly annoying each other.

Two More Perspectives

After I posted this I ran across a wonderful video hosted by the International Bipolar Foundation.

For More Information

Loving Someone with Bipolar by Julie Fast

How Do I Love Thee When You Are Bipolar by Terri Cheney

What is love and how does it work? by Zoey Miller

Avoiding Heartbreak in a Relationship

It Takes Two to Fight

Feb 11

Stand Up to Intimidation

Boy being bullied in schoolHow and when to stand up to intimidation is a topic much on the minds of many people in the United States and around the world. I’m on the board of a regional society of psychiatrists and at our most recent meeting this topic generated the most vigorous and enthusiastic discussion that I have seen at that meeting in years. The psychiatrists wanted to share ideas about how they might personally respond as well as how best to support their patients who are dealing with their own anxiety and fear.

This blog post will be at least a temporary location for information and good ideas that I find from various sources about ways of responding to the current situation.

Longtime readers will recall that I am a big fan of Rick Hanson who distributes regular emails called “Just One Thing.” This week he wrote a thoughtful piece entitled “Stand Up to Bullies” from which I will abstract a few ideas. I encourage you to read it and to sign up for the emails that he sends out on a number of helpful topics. They are free.

Rick offers these thoughts…

See It
If it walks like a duck, quacks like a duck, swims like a
duck … it’s probably a duck. Bullies have most if not all of these identifying characteristics:
  • Dominating – Have to be the “alpha”; fear of looking “one-down”; thus must find targets who seem seem weaker; no compassion
  • Defensive – Never wrong; fault and scorn others; avoid personal responsibility
  • Deceptive – Manipulate grievances to gain support; blame scapegoats; cheat; hide truth since power is based on lies
Recognize Enablers
Some people and organizations make use of bullies, sort of like profiting from a crime someone else commits. Or they pretend all is normal, or that a relatively small issue to the side is a more important focus than what the bully is doing. Or they try to justify bullying, such as: “both sides do it,” “but she’s your mother,” “kids are like that,” or “they need a tough CEO.” From playgrounds to parliaments, people with an authoritarian personality style often have an affinity for bullying leaders, and commonly form the core of their supporters…
Stand with Others
Bullies target lone individuals or minority groups to prove their dominance and create fear. So gather allies who will stand with you if you’re being bullied. For example, a teacher was harassing our daughter (and we found out, girls in general), so we reached out to other parents and enlisted the aid of the principal; things changed. 
And together, stand with and for those who are bullied. It may make no material difference. But it always makes a moral and psychological difference to those who stand – and to those they stand for.
The New York Times just posted an interesting article with tools and strategies for political activism that includes some tools for standing with others… detects your location and shows you contact information for your congressman and senator and also gives you tools and tips for communicating with them about your concerns. can help you find the “others” who will stand with you. You can find groups of like minded individuals of almost all kinds.

For More Information

Feb 09


I am not a psychopharmacologistI am not a psychopharmacologist.

A patient who I have been seeing for almost a year and who has been depressed throughout that period came in to see me today and we talked about her mood over the last couple of months.

She has been markedly less depressed, and I was congratulating myself on the most recent medication change we had made. Then, almost by accident, just as she was leaving our appointment, she happened to mention that she was feeling a little bit sad today because of relationship with a young man that had just ended.  So I asked her when it had started, because I know that relationships matter a huge deal in terms of her mood, and she told me that it had started at almost exactly the time that her mood started to improve.

As it happened, she and I have had some challenges working together. She had previously seen a psychiatrist who practiced in the more or less traditional New York psychopharmacologist manner, meaning fifteen or twenty-minute appointments every two or three months. I don’t have “medication visit” appointments,  and she continually wondered why I felt the need for longer appointments. She also often told me that “you don’t need to know that” when I would ask a personal question about, for example, her relationship status.

Back to my session, I pointed out that there was a perfect correlation between her improved mood and starting this new relationship, and noted that we had discussed the reasons for the improvement and had concluded that it was due to a medication change, when, in fact, it correlated better with her starting the relationship. I wondered why she hadn’t told me about the relationship.  She said she didn’t think that it was relevant and then I said, “but we know relationships matter a huge amount and that when you ended your last relationship is when you started becoming more depressed.” She had to admit that this was the case and, after an extended discussion, she decided that the issue was really that she felt uncomfortable talking about relationships with me. It is not something that psychopharmacologists need to know. In other words, it was an issue about her sense of being uncomfortable with me, which is, ironically, a good part of the reason why I felt we needed to meet more often, to try to develop a relationship in which she would feel comfortable talking about personal matters that affect mood. It is really hard to develop much of a close relationship with a psychiatrist who you see for only ten or fifteen minutes every three or four months.

Another example of the challenge with the traditional “psychopharmacologist” role is that the quality of the relationship in the sense that I am working as a real partner to someone struggling with depression is very important. Without time to get to know the other person it’s easy to miss changes in how the person’s feeling about our working relationship. For example, another one of my patients came in today and reported that her depression had increased even though there had been no change in medication. It emerged, as we talked some more, that for the first time she’d actually been forgetting some of her doses of medication (which could of course explain her dip in mood, except that her dip in mood preceded those forgetful episodes).

I found myself wondering about the conversation that we had in our last session and it occurred to me that in that session we had, jointly I thought, decided that we would taper one of her medications before starting a new antidepressant. At first she said that she had felt that that was a joint decision and so it couldn’t explain the dip in mood and that change in her ability to remember her medications. But on further reflection she decided that she had come into the session hopeful about starting and antidepressant, and even though she had agreed with my logic about discontinuing the other medication before starting the antidepressant, she had come away from the meeting feeling more discouraged.

Again, that knowledge which also allowed us to reestablish our strong working relationship and agree on a new plan, would not have been possible had I just been seeing her for brief medication check visits, as her former psychiatrist had done.

All of this is part of why I do not consider myself a psychopharmacologist.  In my practice I find that it’s only possible to figure out whether mood changes are due to medication changes if I know about other aspects of a person’s life, and that’s only possible with a certain degree of comfort and connection.

And it’s also true that a strong collaborative relationship and a realistic sense of hope about the future is almost always part of recovery from a chronic depression, or other mood condition.

Feb 04

Contemplative Practice Options

Contemplative Practice OptionsContemplative Practice Options Explored in New Research

Mindfulness has been much in the news. Skeptical readers have commented that it seems to be “good for what ails you,” no matter what the challenge. Others have noticed that mindfulness seems to now encompass some practices (focused meditation) that were historically seen to be an alternative to mindfulness practice.

“Contemplative practice” is a broader category that encompasses mindfulness as well as various forms of meditation and spiritual practice.

In a ground-breaking article in JAMA Psychiatry in February 2017, three different types of contemplative practice were studied to see if they could affect “perceived loneliness,” which has been shown to be a significant longitudinal risk factor for pain and fatigue, clinical depression, and dementia, myocardial infarction and high blood pressure, and early mortality.

One of the problems with the research on loneliness is that we have not advanced much beyond the “go find a friend” approach to solving the problem of loneliness. As a clinician, it is hard to get very interested in studies that don’t lead to anything helpful. The authors of the study write…

Interventions to increase perceived social connectedness are few in number and only weakly effective, with a mean effect size of 0.2 in a meta-analysis of randomized controlled trials.

What is Contemplative Practice?

In an accompanying editorial, Richard Davidson writes about the broad set of practices known as “contemplative practice.”

Contemplative practices have figured prominently in religious, philosophical, and humanistic traditions since antiquity. The boundary that defines what falls within the category of contemplative practices is somewhat hazy, but from a general perspective, we can say that this form of training emphasizes self-awareness, self-regulation, and/or self-inquiry to enact a process of psychological transformation. These practices thus involve some form of mental training, even when they also involve physical movement or dialogue-based exercises… As we can see from the work of Kok and Singer, contemplative practices are not limited to solitary meditation practices. Indeed, frameworks of contemplative training are rich and varied. Modes of contemplative training include introspective meditations, interpersonal dialogue and intersubjective inquiry, and also practices that involve bodily movements such as yoga and tai chi. These modes of training, moreover, can be used to target different psychological processes. Some practices train meta-awareness and other attentional processes, some aim to cultivate qualities such as equanimity and compassion, and others use self-inquiry to develop self-understanding and insight…

An important contribution of the work of Kok and Singer is that their ReSource Project investigates different families of contemplative practice, including those that target self-awareness (presence), emotion (affect), and cognition (perspective), and also different modes of training, including both solitary meditation and interpersonal dialogue. These represent 2 important dimensions of contemplative practice that have received little attention from the research community. The breadth of the ReSource Project thus provides an important window into the differential and synergistic effects of different families of contemplative practice and modes of training.

The study looked at three different contemplative training “modules” –

Of these three types of training, the “perspective module” most closely resembles traditional mindfulness practice.

The new “twist” in two of these modules was the introduction of a social aspect to the practice. This is a description of how that worked…

2 partners are assigned to disclose their thoughts and feelings to one another in structured meditation-based interactions. Contemplative dyads are a “loud meditation”: the speaker voices whatever comes to mind regarding a topic as the listener’s presence promotes focus for the other’s contemplation.

Another interesting aspect of the interventions was that the “social” part of the trainings took place using smartphone connections. This has obvious implications in terms of replicating these studies in the real world.

The authors concluded that…

Perceiving oneself as socially connected is deeply embedded in human functioning, and the absence of feeling connected prospectively predicts both mental and physical illness and premature mortality.8- 13,49 Because many mental illnesses are characterized, in part, by social dysfunctions that threaten social connectedness, interventions that bolster connectedness have a particular relevance to clinicians.1- 7 Here we provide evidence that regular dyadic contemplative practice at home can be used to foster perceived social connectedness. Individuals currently experiencing chronic loneliness, which is often accompanied by abnormalities in social cognition, may benefit from dyadic contemplative practices as a way to undo maladaptive sociocognitive tendencies…

Two types of daily 10-minute contemplative dyadic exercises teaching adaptive socioaffective and sociocognitive skills increased perceived social connectedness, measured as social closeness and self-disclosure, over 6 months of training. The dyads were comparable to classical meditations in compliance, motivation to practice, and liking. 

Contemplative Practice Research


Davidson RJ, Dahl CJ. Varieties of Contemplative Practice. JAMA Psychiatry. 2017;74(2):121-123. doi:10.1001/jamapsychiatry.2016.3469

Kok BE, Singer T. Effects of Contemplative Dyads on Engagement and Perceived Social Connectedness Over 9 Months of Mental Training – A Randomized Clinical Trial. JAMA Psychiatry. 2017;74(2):126-134. doi:10.1001/jamapsychiatry.2016.3360

For More Information

Rick Hanson – Trust in Love

Seeing the Other – Kelsey




Feb 02

Harm Reduction

A hand locked to glass of alcoholReducing the Harm of Substances in Your Life: A Harm Reduction Approach

Have you noticed that your substance use is impacting your mood, relationships, or work? Are you looking to reduce the negative impact substances are playing in your life? Harm Reduction methods can be useful in exploring ways to prevent harm and reduce risks in your life caused by substances.

One Harm Reduction approach to explore is “drug, set, setting”. The substance and amount used (the drug), the mindset and emotional state one is in while using (set), and the setting one uses in (setting), are all areas where helpful interventions can be applied to assist you in reducing the harm substances have in your life.

For example, if you are using alcohol and find that you use a large amount quickly, is there a way you can slow down or drink more water? Do you find that you drink when you are stressed (mind set)? Can you try to exercise or call a friend before having your first drink to explore other ways to cope with the stress? Do you tend to overuse when you are alone or socializing (setting)? Changing the setting you use in can change the pattern of overuse. Abstinence is also a form of harm reduction and falls on the harm reduction spectrum. Is abstinence an approach you are open to and if so, what support resources are available and are you interested in exploring?

Applying these interventions can be very helpful. Talk with your provider more about harm reduction approaches and support available in your community to explore resources and treatment approaches that best fit your needs at this time.

– Gina

For More Information

4 Ways You Can Help a Loved One Cope with Addiction and Mental Illness

Patrick Kennedy Talks about Bipolar and Addiction

The Problem of Denial: How to Help Loved Ones with Substance Use and Other Destructive Habits

Alcoholics Anonymous

Feb 01

Bipolar and Success

Bipolar and SuccessWhat is the relationship between bipolar and success?

This excerpt from the American Psychiatric Association’s book Understanding Mental Disorders, suggests one kind of relationship…

“The symptoms of bipolar disorder can damage relationships, cause problems with work or school, and even lead to suicide. People with the disorder may feel out of control or ruled by their extreme moods and behaviors. Although there may be periods of normal mood as well, people with a bipolar disorder will often continue to have these mood episodes if the condition is left untreated… Although these disorders are lifelong once they begin, treatment can relieve symptoms and bring hope… With the right treatment, people with bipolar disorders can lead full and productive lives.”

All of this is true and yet, the story is much more complicated.

A set of population-based studies suggests that, just as there are many people with bipolar who face huge challenges reaching the goal of “full and productive lives,” there are also many people who achieve greatness despite, or perhaps because of, the traits that predispose them to bipolar mood swings.

One of the most renowned proponents of the view that a little bipolar can lead to great success is author, and psychiatrist, John Gartner, whose book, The Hypomanic Edge: The Link Between (A Little) Craziness and (A Lot of) Success in America, argues that hypomania may be what has made America great.

The book is great fun, and an entertaining read, but it doesn’t have a strong evidence base.

These new studies, however, support some of his ideas.

Daniel Smith, and colleagues, used data from the Avon Longitudinal Study of Parents and Children (ALSPAC), a large UK birth cohort, to look for an association between measures of childhood IQ at age 8 years and lifetime manic features assessed at age 22–23 years using the Hypomania Checklist-32. They found that early measures of high IQ were associated with a higher risk of bipolar symptoms in adulthood. The association existed for all of the components of IQ but was strongest for verbal intelligence.

Simon Kyaga, and fellow researchers, conducted two studies looking at the relationship between bipolar disorder and two types of professional success: leadership achievement and creativity. They used registry data from Sweden that covers health information and other demographic information on the entire population of that country.

In keeping with other researchers, they found that individuals with bipolar disorder and healthy siblings of people with bipolar disorder were overrepresented in the creative professions. As you can see in the chart below, this was a strong correlation. Bipolar individuals were 1.35 x as likely as others to have creative professions, and siblings without bipolar were almost 1.5 x as likely to work in a creative career.

Bipolar and Creative Occupations.jpg

Recently, Nassir Ghaemi argued that many of the most significant leaders in the Western society of the last two centuries (such as Winston Churchill, Abraham Lincoln, and Napoleon Bonaparte) suffered from mood disorders or had a hyperthymic personality, as evidenced by familiality, course of illness, and treatment.

In their population based study, Simon Kyaga, et al, did not find a straightforward relationship between leadership success and bipolar. What they found was that there was a strong relationship between having a family member with bipolar and success in a leadership career.

Bipolar and Leadership

Since the study looked at all people who were diagnosed and treated for bipolar, it is perhaps not surprising that individuals with bipolar weren’t overrepresented among those in leadership positions. It remains true that a bipolar episode, and its treatment, is often associated with significant professional setbacks: loss of a job, loss of important friendships, etcetera. This study suggests that a little bit of the trait, not enough to lead to diagnosis and treatment, may be associated with success.

How to sum up this story.

It appears that at least some of the genes associated with bipolar are also associated with verbal intelligence, creativity, and leadership.

Thus, bipolar is more than just a disorder, it can, in some people, be a source of success.


Gartner, J. The Hypomanic Edge: The Link Between (A Little) Craziness and (A Lot of) Success in America. Simon & Schuster. 2005

Ghaemi SN. A first-rate madness: uncovering the links between leadership and mental illness. New York, NY: Penguin Press; 2011.

Higier RG, Jimenez AM, Hultman CM, Borg J, Roman C, Kizling I, Larsson H, Cannon TD. Enhanced neurocognitive functioning and positive temperament in twins discordant for bipolar disorder. Am J Psychiatry. 2014 Nov 1;171(11):1191-8. doi: 10.1176/appi.ajp.2014.13121683. PubMed PMID: 25124743.

Kyaga S, Lichtenstein P, Boman M, Hultman C, Långström N, Landén M. Creativity and mental disorder: family study of 300,000 people with severe mental disorder. Br J Psychiatry. 2011 Nov;199(5):373-9. doi: 10.1192/bjp.bp.110.085316. PubMed PMID: 21653945.

Kyaga S, Lichtenstein P, Boman M, Landén M. Bipolar disorder and leadership–a total population study. Acta Psychiatr Scand. 2015 Feb;131(2):111-9. doi: 10.1111/acps.12304. PubMed PMID: 24963750.

Smith DJ, Anderson J, Zammit S, Meyer TD, Pell JP, Mackay D. Childhood IQ and risk of bipolar disorder in adulthood: prospective birth cohort study. BJPsych Open. 2015 Aug 20;1(1):74-80. PubMed PMID: 27703726; PubMed Central PMCID: PMC4995557.

Jan 31

Social Media and Mood

Social Media and Mood.jpgResearch looking at the relationship between the use of social media and mood continues to offer tantalizing hints about this new aspect of human experience. Are the effects positive or negative?

There seems to be no doubt about the impact of television watching on mood. Heavy television watching is associated with depression and impaired cognitive function, even when controlling for other risk factors associated with watching television such as physical activity, obesity, alcohol use, etc..

What is the effect of the more interactive experience of social media? Is it similar to in-person friendship, which is clearly positive in terms of its impact on mood? Or is it more like television and, perhaps video gaming?

A large and well designed study looking at Facebook use and mortality suggested that certain kinds of social media involvement is associated with a broad reduction in mortality from medical and psychiatric causes.

A new study, as reported in Psychiatric News, suggests that social media “surfing” may be a particular risk factor…

These findings come from a national survey of 1,787 young adults that asked about their use of 11 popular social media platforms: Facebook, YouTube, Twitter, Google Plus, Instagram, Snapchat, Reddit, Tumblr, Pinterest, Vine, and LinkedIn.

The analysis showed that people who reported using the most platforms (seven to 11) had more than three times the risk of depression and anxiety (odds ratio of 3.08 and 3.27, respectively) than people who used the least amount (zero to 2 platforms).

These increased odds held true even after adjusting for the total time spent on social media and other factors such as race, gender, relationship status, education, and income.”

Lead author Brian Primack, M.D., Ph.D., director of the University of Pittsburgh Center for Research on Media, Technology, and Health, suggested several reasons why this might be the case…

“One possible mechanism is that people who use many different platforms end up multitasking, such as frequently switching between applications or engaging in social media on multiple devices. Studies have found that multitasking is related to poorer attention, cognition, and mood.

Other potential problems of using multiple platforms include an increased risk of anxiety in trying to keep up with the rules and culture associated with each one and more opportunity to commit a gaffe or faux pas since attention is divided.”

As with the Facebook study, which found that being asked by others to be a Facebook friend was associated with significantly reduced mortality, some of the findings in recent studies may not specific to social media. They may reflect the type of experiences that many people with depression have in their interactions with others.

In a study published last November that surveyed 264 young adults, Samantha Rosenthal, Ph.D., M.P.H., a research associate in the Department of Epidemiology at the Brown University School of Public Health, and her colleagues looked at how negative Facebook experiences influenced depression risk.

“The survey revealed that these negative events are common—more than 80 percent of the participants had at least one negative experience on Facebook, and 60 percent had four or more.

After adjusting for other factors, Rosenthal found that negative Facebook experiences were independent predictors of depression risk. The precipitating event did matter, as bullying or other mean behaviors were associated with about 3.5 times higher risk, while unwanted contact was associated with about 2.5 times higher risk. Frequency of negative events contributed to risk as well, though even one instance of bullying could increase the risk of depression.”

Perhaps the best way of summarizing the research on social media use is that how you approach the experience is more important than whether or not you use it.

Some rules that come from this literature –

  • Don’t surf social media. Scanning through stories and switching from platform to platform (which all of us do sometimes) is more likely to be associated with depression, perhaps because distracted attention is more likely to be drawn to negative stories.
  • Look for positive stories. Social media can offer tales of inspiration or catastrophe. Where you look matters in terms of how you feel about yourself and your world.
  • Don’t engage in dialog with people who are critical, bullying or negative. One nice feature of social media is that it is easy to walk away from that kind of interaction.


L.D. Rosen, K. Whaling, S. Rab, L.M. Carrier, N.A. Cheever, Is Facebook creating “iDisorders”? The link between clinical symptoms of psychiatric disorders and technology use, attitudes and anxiety, Computers in Human Behavior, Volume 29, Issue 3, May 2013, Pages 1243-1254, ISSN 0747-5632,

Primack BA, Swanier B, Georgiopoulos AM, Land SR, Fine MJ. Association between media use in adolescence and depression in young adulthood: a longitudinal study. Arch Gen Psychiatry. 2009 Feb;66(2):181-8. doi: 10.1001/archgenpsychiatry.2008.532. PubMed PMID: 19188540; PubMed Central PMCID: PMC3004674.

Harter, S., Stocker, S., & Robinson, N. S. (1996). The perceived directionality of the link between approval and self-worth: the liabilities of a looking glass self-orientation among young adolescents. Journal of Research on Adolescence, 6, 285–308.

Gross, E. . (2004). Adolescent internet use: what we expect, what teens report. Journal of Applied Developmental Psychology, 25, 633–649.

Best, P., Manktelow, R., & Taylor, B. (2014). Online communication, social media and adolescent wellbeing: a systematic narrative re- view. Children and Youth Services Review, 41, 27–36.

Harter, S., Stocker, S., & Robinson, N. S. (1996). The perceived directionality of the link between approval and self-worth: the liabilities of a looking glass self-orientation among young adolescents. Journal of Research on Adolescence, 6, 285–308.

Borelli, J. L., & Prinstein, M. J. (2006). Reciprocal, longitudinal associ- ations among adolescents’ negative feedback-seeking, depressive symptoms, and peer relations. Journal of Abnormal Child Psychology, 34, 154–164.

Walther, J. B., Liang, Y. J., DeAndrea, D. C., Tong, S. T., Carr, C. T.,Spottswood, E. L., & Amichai-Hamburger, Y. (2011). The effect of feedback on identity shift in computer-mediated communication. Media Psychology, 14, 1–26.

For More Information

An abstract of “Use of Multiple Social Media Platforms and Symptoms of Depression and Anxiety: A Nationally Representative Study Among U.S. Young Adults” can be accessed here. An abstract of “Frequency and Quality of Social Networking Among Young Adults: Associations With Depressive Symptoms, Rumination, and Corumination” is available here. An abstract of “Negative Experiences on Facebook and Depressive Symptoms Among Young Adults” is located here.


Jan 28

Interpersonal Effectiveness and DEAR MAN

Interpersonal Effectiveness DEAR MANFor many people with depression, it can be hard to find an assertive, but not hostile, way of dealing with conflict.

Marsha Linehan’s Dialectical Behavior Therapy (DBT) addresses many practical problems such as this with straightforward answers.

This comes from the “Interpersonal Effectiveness” module of DBT. The acronym to remember is DEAR MAN:


Describe the situation in as objective a way as possible.

“You have not always been cleaning your dishes at night. In the morning I do them and then I ask you again to please make sure to do them when it is your turn.”


Express your feelings about the situation (note the importance of distinguishing between description and feelings).

“I feel frustrated when I am in a hurry in the morning and I have to clean your dishes and take responsibility for reminding you to do them.”


Tell the other person what you think the solution to this problem should be.

“I think that you should do what you need to so that you remember to do your dishes when it is your turn.”

What will the positive outcome be of this change?

“If you do that I will be a more cheerful roommate and our home will no longer be tense.”

Stay Mindful
Stay focused on the goal and avoid getting dragged into argument.

The “broken record” technique can be helpful here… “I know that you feel that you almost always do your dishes and I am too sensitive to those rare times when you don’t, but I would like it if you would do what you need to so that you always remember to do your dishes.”

Appear Confident

One way of staying confident is avoiding the trap of “taking responsibility for the outcome” – all that you can do is present your case in the most effective way – who knows what kind of day your roommate is having… In other words, stay confident and calm in the knowledge that you can present your case clearly, but you can’t “make” the other person agree…


It is often good to expect a bit of “give and take” about the request…

“I could put up a reminder so that I always remember to do the dishes if you could do a better job of putting out the trash when it is your turn.”

We have written quite a bit about negotiation as a framework for effective communication…

For More Information

Negotiation: How to Deal With Conflict

Effective Communication

Books – There are a number of good DBT based books.

Jan 26

Dangers of Mania

Dangers of ManiaA cheerful young woman comes in for a consultation and soon we come to a topic that can be remarkably frustrating for all: trying to explain the dangers of mania.

She is only mildly manic.

It’s true she often gets into arguments that don’t really make much sense and she has been smoking more marijuana and hooking up with an unusual number of young men, but she isn’t doing anything clearly dangerous.

And she is very charming and funny. And self-confident.

We all feel that we understand ourselves better than others do. How to explain to her that what’s happening is the progressive shutting down of the medial prefrontal cortex, the part of our brains that searches for evidence of risk and warns us away from doing thingsMedial Prefrontal Cortex and Mania that are risky. The brain cells that ordinarily monitor for painful outcomes are going to sleep. And the more energized, or manic, she becomes the less aware she will be of risks.

It is what is called a positive feedback loop. Because she is not aware of risk, she doesn’t really understand why she needs to pay attention to sleep, or take medications so that she can get to sleep. And, as a result, she gets more manic. And as she gets more manic she becomes even less aware of harmful consequences of her decisions.

This is why it is important to moderate mania before it becomes clearly excessive. By the time it is causing a person to make dangerous choices it may be too late to intervene. By then the manic person is no longer able to process evidence of potential risks.

Learning to live with hypomania and mania often means creating a plan for identifying when the “danger zone” is approaching. This is where some kind of memo to oneself (for example contained in the Wellness Recovery Action Plan) can be useful. Describing as clearly as possible what things are like when intervention is necessary.

When you are reaching a risky level of mania do you…

  • Need less sleep – If so how much sleep is necessary. For many people sleeping 5 hours a night for more than one night can be a warning sign.
  • Do you feel more energetic and more active – Do you take on new projects, clean the house from top to bottom, these are good things but several days of unusual energy can also be a warning sign.
  • Are you more self-confident – As the risk monitoring part of your brain shuts down you will feel that you can tackle bold new projects, at first this is a blessed relief from the normal hypervigilance of that part of the brain, but are people you know now warning you to be careful?
  • Do you feel more sociable (are you making more phone calls, going out more) – This increased communication with others is such a good predictor of mania that it is sometimes possible to predict mood shifts based only on call logs, or twitter or facebook posts.
  • Do you want to travel and/or are you travelling more
  • Do you tend to drive faster or take more risks when driving – This is obviously a sign that the risk part of your brain is less active.
  • Spending more money or too much money is often one of the first signs that you are entering the danger zone.
  • Planning more activities or projects and having more ideas, or feeling more creative doesn’t sound risky – But tackling too many projects leads to a bigger crash when it turns out that it isn’t possible to complete those projects.
  • Feeling more flirtatious and/or being more sexually active is also something that in a small amount can be a positive – But too much can lead to risks.
  • Other signs are thinking faster, making more jokes or puns when you are talking
    Being more easily distracted – One of my patients would suddenly notice the “very loud” clock in my office when he started to get energized… Sense data becomes more compelling. Colors seem more vivid. Sounds richer. Again, a little of this can be wonderful.
  • Do your thoughts jump from topic to topic – Are these changes in direction becoming difficult even for you to keep up with. Do you find it annoying to talk to others because they seem so slow?
  • Are you more impatient and/or do you get irritable more easily, in fact, can you seem exhausting or irritating for others – One of the risks of mania is that it can lead to burnout in even those who care for you the most, and it can be hard to recover some of those friendships.
  • Do you smoke more cigarettes, take more drugs, or drink more alcohol – Many of these substances act synergistically to increase mania and impulsive decision-making.

Paying attention to these warning signs, and developing a plan for reaching out to others (your psychiatrist or therapist, or trusted family members) when they start to appear, so that you can benefit from their additional perspective on what is happening, can make all the difference between experiencing a mild period of increased energy without harmful consequences and a manic episode with long term negative effects on your life.

For More Information

Tricked by Mania – Bipolar Hope

Dealing with Denial

Positive Change or Mania?

Crisis Prevention


Jan 25

Frequent Lying and Biology

Frequent Lying BiologyFrequent lying and its biology is the subject of a fascinating article in Nature Neuroscience.

Scientists have shown that the brain’s fear and alarm circuitry (the amygdala) is usually triggered when one lies (even lies of omission or “white” lies). They’ve also shown that reducing this response by giving someone medications that affect the amygdala increases the likelihood that a person will lie.

But people who lie once have a somewhat smaller response to the next lie and this process of adaptation continues, seemingly indefinitely. They were also able to show that the reduction in response in the fear and alarm circuitry from one lie predicts the likelihood that in the next conversation a person will lie again. In other words the changes appear to be causal rather than just correlational.

They also found that this progressive increase in lying behavior occurred only for self-serving lies. The reduction in alarm response circuitry when lying didn’t have any effect on lying to help or protect others.


Garrett N, Lazzaro SC, Ariely D, Sharot T. The brain adapts to dishonesty. Nat
Neurosci. 2016 Dec;19(12):1727-1732. doi: 10.1038/nn.4426. PubMed PMID: 27775721;
PubMed Central PMCID: PMC5238933.

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