May 27

Better Sleep with SHUTi – Gina

Better SleepUsing Shuti to Get Better Sleep

Better sleep is a priority for many of the people I see.

Recently I’ve started supporting clients in using an online CBTi (Cognitive Behavioral Therapy for Insomnia) program. I decided to check out the program for myself to get a better feel for what clients are working with. Ultimately I recommend SHUTi to clients struggling with initial (difficulty falling asleep), middle (difficulty staying asleep) and late (difficulty related to waking up too early) insomnia.

Research shows that sleep can greatly impact depressive symptoms and that CBTi treatment can improve depressive symptoms and sleep simultaneously. Helping clients work with an evidenced based program that supports them in improving their sleep hygiene and quality of sleep can be implemental in their treatment. According to the NYTimes article, “Curing Insomnia to Treat Depression,” two studies have shown that,

“A small amount of cognitive behavioral therapy to treat insomnia, when added to a standard antidepressant pill to treat depression, can make a huge difference in curing both insomnia and depression in many patients”

Once I got started working with clients around using SHUTi, I became very curious around the specifics of the program. While I knew about the theory, techniques and evidence behind the program, I had not experienced using the program myself. One month ago that changed. I began by reviewing the core trainings (psychoeducation modules about sleep hygiene, how behaviors and thoughts can impact sleep, and tools to use to improve sleep). I started keeping sleep diaries and practicing what I learned. Here is what I noticed…

First off, it was very hard to change sleep habits that I had been engaging in for longer than I can remember. It was not easy! An important tool for improving sleep is to only use your bed for sleep. No reading, watching TV, eating, or chatting on the phone – all things I can be guilty of. During my first night committing to SHUTi it was a struggle to not get on my laptop and start to research an upcoming trip I was planning. When I couldn’t fall asleep within the first fives minutes I started to think about what type of airbnb’s I could find in the area. I ultimately gave in and found my top five accommodation preferences but ended up not falling asleep for another hour and felt exhausted the next day.

It was also hard to commit to going to bed by a certain time. SHUTi helps you create a regular sleep schedule and stick to it. While I had planned to go to sleep by 11pm that first week, a dinner with friends ran late and left me with a delayed start. While I struggled at first to stick to my goals at the start of my SHUTi experience, the more I have been able to stick to a schedule and commit to the sleep hygiene recommendations, the easier it has been to overcome these barriers.

I’ve started to notice improvements in my sleep. I fall asleep more quickly and wake up less frequently throughout the night. And, when I do wake up in the middle of the night, I fall back asleep more easily. Ultimately I have already found myself feeling more rested in the mornings and less anxious about getting enough sleep throughout the week. While it definitely was a difficulty to make the changes SHUTi advised me to make in the beginning I have ultimately found them worth the challenge.


For More Information

Sleep and Insomnia

Best Treatment for Chronic Insomnia


The Editorial Board (2013 Nov. 23). Curing Insomnia to Treat Depression.

May 24

Radical Acceptance and Coping with Bipolar Disorder – Gina

What is radical acceptance?

Radical acceptance is an approach named by Marsha Linehan, PhD who created Dialectical Behavior Therapy that is about completely and totally accepting something, stopping the fight against reality, and ultimately, suffering less. Things will regularly happen in our lives that are outside of our control, such as having a diagnosis of bipolar disorder or experiencing a loss of a loved one. Perhaps it’s an experience of a trauma in the past. There are also things that we will do in our lives that we regret but at the same time have no power to go back in time to change them. Radical acceptance is about accepting the reality of the situation which allows us to shift from fighting our situation toto having more space to figure what you want to do to move forward. Dr. Linehan explains the three components of radical acceptance:

“The first part is accepting that reality is what it is. The second part is accepting that the event or situation causing you pain has a cause. The third part is accepting life can be worth living even with painful events in it.”

What is the difference between pain and suffering?

It can be helpful to distinguish between pain and suffering when exploring radical acceptance. Pain is inevitable in life and something everyone faces as a human being. However, suffering and misery are not and are often a result of how we respond to pain. If we fight against our pain, we are more likely to experience shame, hopelessness, anger, etc and get stuck in not seeing action steps we can take in moving forward. Suffering is the interpretation of the story you tell yourself about pain. Through acceptance, one can change that story and reduce suffering. Dr. Linehan states, “pain without acceptance = suffering.”

How can radical acceptance serve someone with bipolar disorder?

There are many things related to bipolar disorder that cause pain, frustration and sadness. Working with patients with bipolar disorder has allowed me to see ways in which radical acceptance has allowed them to acknowledge this pain, reduce their suffering and continue to work towards living their lives fully. I have seen this take shape in the form of radical acceptance of the diagnosis, medication regimens, regrets of actions that occurred during hypomanic and manic episodes, and acceptance of strong emotions that can often come with shifts in moods and result in feeling overwhelmed. It’s a tool that can help someone hold the reality of what is, and also ask the questions of – what do I want to do next now that I have this information.

Willing Hands

One way to support yourself in practicing radical acceptance is to position your body into a pose that promotes acceptance. The willing hands exercise is one way to do this as it cues your mind through your body to emotionally respond to a situation with willingness and acceptance. Dr. Linehan describes it as a “way of accepting reality with your body.” To practice willing hands, try the following:

1. Standing: Drop your arms down from your shoulders, keep them straight or bent slightly at the elbows. With hands unclenched, turn your hands outward, with thumbs out to your sides, palms up, and fingers relaxed.

2. Sitting: Place your hands on your lap or your thighs. With hands unclenched, turn your hands outward, with palms up and fingers relaxed.

3. Lying down: Arms by your side, hands unclenched, turn your palms up with fingers relaxed.

To learn more about radical acceptance and DBT skills talk to your therapist or, if you are in the Bay Area and looking for someone to work with contact me at

– Gina Gregory, LCSW 

For More Information

Distress Tolerance

Distress Tolerance

May 21

12 Steps

12 stepsThere are a few people in my experience who are as impressive in maturity and integrity as those people we have worked with who have been the most involved in 12 Step Programs.

I didn’t come to this observation from any pre-conceived bias in favor of 12 Step Program. If anything, my involvement with 12 Step early on was pretty negative. It was almost universally true, 15 or 20 years ago, that 12 Step Programs tended to view all psychiatric medications as “psychoactive substances” that were to be avoided. I sometimes run into this bias still, but nowadays most 12 Step meetings are far from this anti-mental health bias.

But back to the original comment. I was talking with a wonderful attorney that I’ve had an opportunity to work with and get to know for a few years. That conversation reminded me of other conversations with longtime AA members. Most of them were, as this attorney said, ne’er do well’s in their youth who caused a lot of trouble and a lot of pain, but eventually found the will to stop using substances through a slow process of increasing involvement in 12 Step Programs as participants and then sponsors.

This gentleman noted something that we’ve also seen, which is how often people will start out in AA (Alcoholics Anonymous) and gradually move into Alanon. He described AA this way: “It’s about getting people who are being extremely selfish to think about others and become more selfless.”

On the other hand, Alanon, he said, is about teaching people how to take care of yourself well and it involves learning how to say no sometimes. In AA, you almost never say no.

We don’t know if it is common wisdom or just something that he has noticed (as have we) but it points to the interesting relationships between 12 Step Programs and psychological self-awareness. Some of the programs are more psychologically minded.

Although AA can seem rigid and inhospitable to psychological concepts, the people that we are thinking of have found ways of accommodating ideas like “a higher power” and some of the other concepts that may be difficult in 12 Step Programs. They found a way of giving personal meaning to these concepts and making use of them in their lives, rather than rebelling against them.

Those who made use of 12 step effectively decided that, if there were concepts that they could not make sense of, they left those ideas behind and focused on the many things that were useful. This is an that our colleague and friend Matt Tierney often recommends to those he works with: “take what works and leave the rest behind.”

For More Information

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

Alcoholics Anonymous


May 16

Sadness Benefits

Sadness BenefitsAre there sadness benefits?

It often seems as though the work I am supposed to do is to eliminate all negative emotion on behalf of the people who come to me for psychiatric help. But is that possible, and if it were possible would it be a good thing to do? Are there sadness benefits that would be lost if we tried to create the life of perfect happiness imagined in Voltaire’s book Candide?

Scientia Professor of Psychology, at the University of New South Wales, has published an eloquent defense of the benefits of the full range of human emotion, including sadness.

He begins by noting that he is not talking about serious depression, the kind of all-consuming mood of despair that eliminates all hope.

Then he talks about the importance of human emotion in general in our lives.

“Psychologists who study how our feelings and behaviours have evolved over time maintain all our affective states (such as moods and emotions) have a useful role: they alert us to states of the world we need to respond to.

In fact, the range of human emotions includes many more negative than positive feelings. Negative emotions such as fear, anger, shame or disgust are helpful because they help us recognise, avoid and overcome threatening or dangerous situations.”

He suggests a few sadness benefits.

  1. It can increase intimacy and human connection. When we feel sad and show sadness it often serves as a signal to those who care about us to draw closer and to be comforting. Equally, the experience of mild sadness enhances our capacity to be attuned to the emotions of others.
  2. The emotion of sadness has inspired many creative works. 
    “Sadness can also enhance empathy, compassion, connectedness and moral and aesthetic sensibility. And sadness has long been a trigger for artistic creativity… In fact, many of the greatest achievements of the human spirit deal with evoking, rehearsing and even cultivating negative feelings. Greek tragedies exposed and trained audiences to accept and deal with inevitable misfortune as a normal part of human life. Shakespeare’s tragedies are classics because they echo this theme. And the works of many great artists such as Beethoven and Chopin in music, or Chekhov and Ibsen in literature explore the landscape of sadness, a theme long recognised as instructive and valuable.”
  3. It improves our ability to see the world as it is, and to remember events. Psychologists have long known that people in a “normal” mood are less accurate in interpreting situations than people experiencing mild sadness. Positive emotions make us biased towards slightly unrealistic positive interpretations of events. Dr. Forgas summarizes some of this literature, ” For instance, slightly sad judges formed more accurate and reliable impressions about others because they processed details more effectively. We found that bad moods also reduced gullibility and increased scepticism when evaluating urban myths and rumours, and even improved people’s ability to more accurately detect deception. People in a mild bad mood are also less likely to rely on simplistic stereotypes.”
  4. It can serve as a powerful motivation for positive change. Sadness draws our attention to things that need to change in our lives. Emma Gut eloquently wrote about this role for both sadness and mild depression in her book and in an article on productive and unproductive depression. Productive depression is a state that motivates change, that calls attention to a situation that needed to be righted or improved.

Other benefits that he describes include the fact that sadness results in:

  • “with better communication The more attentive and detailed thinking style promoted by a bad mood can also improve communication. We found people in a sad mood used more effective persuasive arguments to convince others, were better at understanding ambiguous sentences and better communicated when talking.
  • increased fairness Other experiments found that a mild bad mood caused people to pay greater attention to social expectations and norms, and they treated others less selfishly and more fairly.”

For More Information

Awareness and Acceptance

Fallow Fields

Winter Leads to Spring


Gut, E. (1985), Productive and Unproductive Depression: Interference in the Adaptive function of the Basic  Depressed Response. British Journal of Psychotherapy, 2: 95–113. doi:10.1111/j.1752-0118.1985.tb00929.x



May 14

PTSD Prediction

For people who have been exposed to violence or trauma, and who naturally experience some symptoms of anxiety, what approaches are most useful for PTSD prediction? The majority of people exposed to violence or trauma do not go on to develop posttraumatic stress disorder or PTSD, but, depending on the nature of the trauma (sexual trauma has the highest risk) a significant minority will go on to develop PTSD and these individuals may benefit from more intensive early intervention.

European researchers looked at the question of PTSD prediction two different ways. Their study looked at data from 171 assault survivors, who completed a self-report assessment of acute symptoms at 2 weeks after the traumatic event and a structured clinical interview to assess PTSD diagnosis at 6 months after the traumatic event.

First they looked at all of the symptoms in the DSM-IV PTSD diagnostic criteria and rated them individually in terms of the “Odds Ratio”  of developing chronic PTSD if the individual symptom was present at two weeks. Using this criteria the greatest risk of developing PTSD was in those who experienced recurrent and intrusive dreams or nightmares (those who had this symptom at two weeks had a more than three times higher risk of developing chronic PTSD, compared with those who did not) and those who experienced recurrent or distressing intrusive memories (again with a more than three times increased risk).

PTSD Prediction Table of Symptoms

Others have looked at PTSD prediction in this way, finding various combinations of symptoms that provide the best PTSD prediction.

These researchers also looked at how individual symptoms affected each other. They conducted a path analysis designed to show which symptoms seemed most central to the development of chronic PTSD and which symptoms seemed to exert their effect indirectly through their relationship to other symptoms. Using this technique they showed that three symptoms appear to be most closely connected to the development of PTSD: intrusive dreams and nightmares, easy startle, and a sense of a foreshortened future.

Of these three, a sense of a foreshortened future might be the symptom that is the hardest to explain or describe. One of my patients so I’ve been seeing for a few weeks and who was in a terrible and sudden automobile accident, describes it this way: “I feel as if I am certain to die in the next year. I constantly feel as if I will be in another accident or something else will happen that will end my life.”

Feelings of detachment and emotional numbing related to a sense of a foreshortened future. Avoiding situations that reminded the person of the trauma as well as sleep disruption and intrusive memories all related to the experience of intrusive dreams and nightmares, but it was intrusive nightmares that seemed to best predict chronic PTSD. Hypervigilance and easy startle were very strongly correlated with each other and easy startle somewhat predicted the development of chronic PTSD.

The implication of this study is that it might be possible to focus on a reduced symptom list of the key mediators of developing chronic PTSD: intrusive nightmares, a sense of a foreshortened future, and to a lesser extent, easy startle. Of these three, intrusive nightmares and easy startle have been shown to respond to medications such as prazosin and clonidine that reduce sympathetic nervous system activity. And a sense of a foreshortened future should be very responsive to targeted psychotherapy interventions.

The next step for this group of researchers is to see if developing a specific treatment approach that focuses on these core symptoms results in preventing the development of chronic PTSD for those exposed to acute trauma.


Haag C, Robinaugh DJ, Ehlers A, Kleim B. Understanding the Emergence of Chronic Posttraumatic Stress Disorder Through Acute Stress Symptom Networks. JAMA Psychiatry. Published online May 10, 2017. doi:10.1001/jamapsychiatry.2017.0788

Bryant RA, Creamer M, O’Donnell M, et al. Acute and chronic posttraumatic stress symptoms in the emergence of posttraumatic stress disorder. JAMA Psychiatry. 2017;74(2):135-142.

Kleim B, Ehlers A, Glucksman E. Early predictors of chronic post-traumatic stress disorder in assault survivors. Psychol Med. 2007;37(10):1457-1467.

For More Information

PTSD Psychotherapy Affects Gene Activity

PTSD information – from our sister site – Gateway Psychiatric


May 12

Depression Is Often Untreated

Depression Is Often UntreatedDepression is often untreated, according to the results from the federal government’s National Health and Nutrition Examination study.

The vast majority of Americans with depression didn’t seek help from a mental health professional

Only 35% of people with severe depression and 20% of those with moderate depression said they had sought help from a mental health professional, according to the report from the U.S. Centers for Disease Control and Prevention.

That’s worrying since therapy combined with medication is the most effective treatment for depression, especially for severe depression. Antidepressants might be prescribed by a primary care doctor, but only a mental health clinician could give psychotherapy.

Overall, 2.9% of the participants had suffered “severe depressive symptoms” in the two weeks before they were interviewed, and another 4.7% had “moderate depressive symptoms.”

Americans in their 40s and 50s had the highest rate of depression, nearly 10% reported moderate or severe depression in the two weeks before the interviews. Americans between the ages of 18 and 39 had the second highest rate (7.4%).

Depression had a big impact on people’s lives

About 43% of those with severe depression said they had “serious difficulty” managing their work, home and social activities, and another 45% had “some difficulty.”


Pratt LA, Brody DJ. Depression in the U.S. household population, 2009–2012. NCHS data brief, no 172. Hyattsville, MD: National Center for Health Statistics. 2014.

May 10

Shame and Guilt After Mania – Gina

ShameAddressing Shame and Guilt After a Manic Episode

I have witnessed the immense pain caused by the shame and guilt experienced by people with bipolar disorder following a manic episode.After a manic episode, most have engaged in behaviors that they regret. The resulting shame and guilt can contribute greatly to symptoms of depression that follow an episode. Understanding techniques and approaches to help work through shame and reduce guilt can be very helpful in the recovery process.

It is important to first understand the difference between shame and guilt. One of my favorite shame researchers, Dr. Brene Brown, explains this well:

“Shame is a focus on self, guilt is a focus on behavior. Shame is, “I am bad.” Guilt is, “I did something bad.” How many of you, if you did something that was hurtful to me, would be willing to say, “I’m sorry. I made a mistake?” How many of you would be willing to say that? Guilt: I’m sorry. I made a mistake. Shame: I’m sorry. I am a mistake.”

With guilt, one can apologize for things that he or she did, and for many, seeking amends after a manic episode can be apart of someone’s recovery. This takes great courage and is not easy; and at the same time, can be essential in moving forward.

Using therapy as a means to process guilt and shame can also be especially valuable. Having a safe space to build awareness around thoughts and beliefs surrounding shame and guilt, and promoting compassion and acceptance can assist someone in working through their recent experiences.

Brene Brown explains that there are three tricks to battling shame: talk to yourself like someone you love, reach out to someone you trust, and tell your story. Dr. Brown recommends that “if we can share our story with someone who responds with empathy and understanding, shame can’t survive.” Empathy is key to battling shame, both showing empathy and compassion towards oneself and receiving it from others. If you are having a difficult time imagining what you can say to yourself to be empathetic or compassion, go back to the suggestion of exploring what you would say to someone you love. What would you say to a friend in a similar situation? Try now saying that to yourself. Is there someone in your life that you trust to share your story with? If so, what would it look like to reach out to them?

In Robin Flanigan’s recent blog post, “Bipolar and Letting Go of Guilt”, she examines what others have done following a manic episode to reduce guilt and move forward with their lives. Check out some firstline experiences here: Also, to learn more about what Dr. Brene Brown has to say about shame, watch her tedtalk:

May 09

Bipolar 101 Online

2017-05-07_12-42-30-0000We are putting our Bipolar 101 course online. The first portion of that 9 part course is going to be available free on our sister site, Gateway Psychiatric Services, but here is a preview of one section entitled “What is Bipolar?”

Future sections will address self care, medications, other therapies, and a host of other issues and concerns.

May 06

Circadian Rhythms and Food

Circadian Rhythms and FoodScientists are uncovering a fascinating relationship between circadian rhythms and food consumption. It looks as though when you eat can have a big impact on how your body metabolizes the food and on whether or not you gain weight.

It has long been clear that light exposure plays an important role in setting a number of circadian rhythms in the brain and body. A part of the brain called the suprachiasmatic nucleus (SCN), perched right beside the nerve pathways that transmit signals from the eye to the part of the brain that processes visual information, plays a central role in this process. The SCN synchronizes many of the hundreds, perhaps thousands of “clocks” throughout the body that regulate aspects of physiology that need to be coordinated with the cycle of night and day taking place outside the body.

It now seems that the parts of the body involved in metabolizing food, and, in particular, sugar, may be partly controlled by when we eat. In other words, these clocks are set by the timing of food intake. And when our pattern of eating does not match the pattern of light and dark exposure our eating and our metabolism can get dysregulated. One of the consequences of this is weight gain.

A common example of this mismatch between the two biorhythms is someone who eats almost all of his or her food after dark in the evening. This fairly common pattern seems to be associated with a greater tendency to weight gain and to elevated cholesterol and elevated blood sugar.

People who switch to eating during daylight hours can expect to see improvements in metabolism.

In a recent study by Gill and colleagues, participants were asked to restrict the timing of their caloric consumption between the hours of 06:00 and 18:00 h for up to 1 year and document the timing of meals on a mobile phone application Similar to the studies on other animals, they found a significant decrease in weight after 16 weeks of intervention. Furthermore, participants reported concurrent increases in overall energy levels and morning energy levels and decreases in hunger at bedtime.

For More Information

Why Do I Have To Have a Regular Schedule?


Broussard JL, Van Cauter E. Disturbances of sleep and circadian rhythms: novel risk factors for obesity. Curr Opin Endocrinol Diabetes Obes. 2016 Oct;23(5):353-9. doi: 10.1097/MED.0000000000000276. PubMed PMID: 27584008; PubMed Central PMCID: PMC5070789.

McHill AW, Wright KP Jr. Role of sleep and circadian disruption on energy expenditure and in metabolic predisposition to human obesity and metabolic disease. Obes Rev. 2017 Feb;18 Suppl 1:15-24. doi: 10.1111/obr.12503. Review. PubMed PMID: 28164449.

Gill S, Panda SA. Smartphone app reveals erratic diurnal eating patterns in humans that can be modulated for health benefits. Cell Metab2015; 22: 789798.

May 01

Boost Creativity by Walking


Walking Increases Creativity“How can I get my creativity back?”

One of my patients, who has been wrestling with depression for quite a while, asked me if I could think of anything that might help give her creativity a boost.

My quick, off the cuff, reply was “go running again” (she was an avid runner before she got depressed), in part because of the clear evidence that aerobic exercise enhances cognitive function generally.

Later I thought I would do some searching in the UCSF library to see if I could find evidence based recommendations.

Imagine my surprise when the first article I ran across was all about how walking outdoors could have this effect.

“Four experiments demonstrate that walking boosts creative ideation in real time and shortly after.

  • In Experiment 1, while seated and then when walking on a treadmill, adults completed Guilford’s alternate uses (GAU) test of creative divergent thinking … Walking increased 81% of participants’ creativity on the GAU…
  • In Experiment 2, participants completed the GAU when seated and then walking, when walking and then seated, or when seated twice. Again, walking led to higher GAU scores. Moreover, when seated after walking, participants exhibited a residual creative boost.
  • Experiment 3 generalized the prior effects to outdoor walking.
  • Experiment 4 tested the effect of walking on creative analogy generation. Participants sat inside, walked on a treadmill inside, walked outside, or were rolled outside in a wheelchair. Walking outside produced the most novel and highest quality analogies. The effects of outdoor stimulation and walking were separable.

Walking opens up the free flow of ideas, and it is a simple and robust solution to the goals of increasing creativity and increasing physical activity.”


Oppezzo M, Schwartz DL. Give your ideas some legs: the positive effect of walking on creative thinking. J Exp Psychol Learn Mem Cogn. 2014 Jul;40(4):1142-52. doi: 10.1037/a0036577. Epub 2014 Apr 21. PubMed PMID: 24749966.

For More Information

Bipolar and Creativity

Creativity and Mood

Apr 28

Impulsivity – Gina

ImpulsivityImpulsivity is something everyone has experienced. We have all had moments when we have said something impulsively that we regret or have gotten carried away with an idea. Sometimes the consequences of an impulsive action are minimal.  But that is not always the case.

Impulsive decision-making is more common in people with bipolar. And this increase is not just something seen during a mood episode, people with bipolar seem to have a generally increased tendency to quick or impulsive decisions.

Nevertheless, in a hypomanic or manic state, an increase in impulsive decision-making is often a key feature of the change in mood. It can result in compulsive gambling, risky sex, excessive spending, and other risky behavior.

When depressed, especially in a “mixed” state, impulsive decisions in bipolar increase the risk of suicide. I

n addition, to impulsivity being linked to mood states, Robin Flanigan in her blog post “Bipolar and Controlling Impulsivity,” notes that research suggests a link to brain differences in people with bipolar disorder regardless of mood states which makes them more prone to risk and impulsivity.

“Studies suggest that the part of the brain that plans and analyzes tends to have a weaker grip on emotional circuitry in people with bipolar—akin to worn brake pads that can’t stop a speeding car in time.

In addition, the reward system seems to be more sensitive, so that the lure of a prize wields more power.

On the one hand, the greater lure of reward can fuel goal-directed achievement. This led John Gartner to write a book arguing that hypomania is responsible for some of the success of American entrepreneurs, The Hypomanic Edge: The Link Between (A Little) Craziness and (A Lot of) Success in America.

“Why is America so rich and powerful?” asks Gartner. The answer lies in our genes, he says. “My new hypothesis became that American entrepreneurs are largely hypomanic,” writes Gartner. “Hypomanics are brimming with infectious energy, irrational confidence and really big ideas. They think, talk, move and make decisions quickly. Anyone who slows them down with questions ‘just doesn’t get it.’ Hypomanics are not crazy, but ‘normal’ is not the first word that comes to mind when describing them. Hypomanics live on the edge, between normal and abnormal.”

On the other hand, impulsivity increases susceptibility to addiction and intensifies cravings for excitement that can be profoundly self-destructive.

The Brain

What is happening in the brain to someone with bipolar disorder that may differ from someone without the diagnosis that may account for an increase in impulsivity? Robin Flanigan discusses some of the relevant research in her blog post “Impulsivity: What’s Happening in the Brain.”

“When  British researchers had a group of people with bipolar perform a roulette-style task, they showed stronger activation in the nucleus accumbens than a comparison group of people without bipolar.”

That 2014 study also found different patterns of activity within an area called the ventromedial prefrontal cortex (roughly, a “forward and middle” segment) that is active when we are weighing risk versus reward.

Those with bipolar had greater neural activity for risky bets, while those in the comparison group showed more response to “safe” bets.

The ventromedial prefrontal cortex has been implicated in other behaviors that involve deciding between future consequences and immediate pleasure, such as overeating, overspending, and substance overuse.

Meanwhile, a neighboring area called the ventrolateral prefrontal cortex (“forward and left”) may be “increasingly relevant to our understanding of impulsivity, particularly in people with bipolar disorder,” says Mary L. Phillips, MD, director of the Mood and Brain Laboratory at the University of Pittsburgh School of Medicine.

In certain situations where a big reward is possible, such as gambling, ventrolateral activity is heightened significantly more in people with bipolar disorder than in those without bipolar.

Furthermore, Phillips and her colleagues have found that the excitement associated with the possibility of a future reward increases disproportionately during mania, feeding even more juice to emotional urges and compromising the ability to regulate them—much as floodwaters may overwhelm a normally sturdy dam.

“These series of vulnerabilities often lead to risky decisions,” Phillips notes.”


Working with people with bipolar, I have learned several helpful strategies that they use to support themselves around managing risks related to impulsivity and risky decision making.

Pause and Reflect

Taking a moment to pause and observe can be incredibly helpful. A regular mindfulness practice can help people be able to take a moment to reflect before an abrupt act. The more often we practice mindfulness, the more readily able we are to use the skill during more challenging times.

Recruit a Helper

Sometimes having someone you can trust to reality test with around a possible decision you want to make can make a huge difference. This can be a therapist, friend, significant other, parent — someone you can check in with to explore if the decision could have negative consequences you are not prepared to face. They can help you weigh the pros and cons – to act, or not to act!

The 48 Hour Rule

If you are considering making an impulsive decision, try waiting 48 hours before acting. Check in with yourself after that timeline to see if anything has changed? Do you have any new information that may inform whether or not you want to act.

Know Your Triggers and Your Warning Signs

Being able to identify when you mood may be shifting can be essential to increasing your awareness around your risk to act impulsively. This may be you noticing a change in your thoughts, sleep patterns, etc. Also, know which triggers make you most vulnerable regardless of your mood state. Are there certain people or situations you are more likely to act impulsively around? Can you come up a with a plan ahead of time around how you may take time to pause before acting?

– Gina


Flanigan, R. (2017, April, 7). “Impulsivity: What’s Happening in the Brain.”

Flanigan, R. (2017, April, 7). “Bipolar and Controlling Impulsivity.”

For More Information

Bipolar and Creativity

Early Warning Signs

Janelle Caponigro and Erica Lee

Apr 25

Mood Trends


Mood TrendsMood trends are useful to track in order to prevent a full blown episode of depression, hypomania or mania.

I think of them as equivalent to the idea of a falling or rising barometer.

Before satellites and modern weather forecasting, whether the barometer was rising or falling was the best predictor of the weather. If the barometer was rising it meant sunnier weather, and if it was falling it could be sign of a future storm.

Similarly, keeping track of certain markers of mood can help predict where your mood is headed and therefore what to watch for and how what kind of self care to focus on.

Let’s say you notice that you are waking up a bit earlier in the morning, and that you are feeling like tackling more projects, or are talking to friends more, or chatting more online, this could be a sign that your mood barometer is trending up. It doesn’t mean that you are hypomanic, but it does mean that you are more likely to head in that direction than to suddenly dip into depression.

Or maybe you find yourself having a harder time getting out of bed, feeling like putting decisions off to the future, feeling like you want more quiet time and more rest, it doesn’t mean you are depressed, just that you might be heading in that direction.

Trending Up or Trending Down

Take Advantage of the Trend

Certain things are easier to do when you are trending up or trending down.

When you are trending down –

  • It may be easier to have deeper conversations with good friends than to do a lot of socializing with many people.
  • Quiet and contemplative activities may make more sense. Reading may be easier or listening to more complex music.

When you’re trending up –

  • It may be a good time for generating new ideas and new approaches to problems.
  • Tackle decisions that don’t require too much contemplation or analysis.
  • Clean the house or organize things.

But Make Sure to Balance That with Opposite Action

To avoid going from a trend to a full-blown mood episode consciously balance your activities to include some that counter the trend.

When you’re trending down –

  • Focus on not sleeping in. You may want to restrict yourself to a little bit shorter sleep time and make sure to get plenty of bright light in the morning.
  • Make sure you’re getting enough exercise. 30 minutes a day of brisk walking is plenty.
  • Do reach out to those close friends who can help you keep a sense of perspective when your mind tends to focus on the negative too much.
  • Consciously avoid negative news sources.

When you are trending up –

  • Make sure you’re getting enough sleep. Set alarms on your devices so that you stop using them in time to get ready for sleep.
  • Be cautious about beginning lots of projects or committing to big new ideas.
  • Even a small dose of mindfulness meditation (5 minutes twice a day of can help moderate the trend to hypomania.

The Science Behind This

The STEP-BD research project, the largest longitudinal study of people with bipolar ever found that so-called sub-syndromal or residual mood symptoms were a major predictor of new episodes.

In particular, residual mood symptoms early in recovery appear to be a powerful predictor of recurrence, particularly for depression. Risk of depressive recurrence increases by 14% for every DSM-IV depressive symptom present at recovery… This is consistent with the work of Keller et al. that found that subsyndromal symptoms were associated with risk of recurrence…

Perlis RH, Ostacher MJ, Patel JK, Marangell LB, Zhang H, Wisniewski SR, Ketter TA, Miklowitz DJ, Otto MW, Gyulai L, Reilly-Harrington NA, Nierenberg AA, Sachs GS, Thase ME. Predictors of recurrence in bipolar disorder: primary outcomes from the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD). Am J Psychiatry. 2006 Feb;163(2):217-24. PubMed PMID: 16449474.

Apr 23

Bipolar Type 4

bipolarWe’ve recently been re-reading some of the works of Hagop Akiskal, one of the most important writers about Bipolar of the last 50 years.  He is particularly focused on identifying sub-types of bipolar as well as exploring the relationship between bipolar and creativity.  We were particularly struck with his description of type 4 bipolar.  This is someone (he says usually a man) who has what he calls a hyperthymic temperament.  By this he means someone who has always been very successful at work and in business relationships.  Someone who is high energy and often quite creative.  The example that my colleague came up with was Bill Clinton, not sure if that’s accurate or not.  But it gives you some idea of who Hagop is describing.

Such a person does not generally come in for treatment until he or she develops a depression, usually later in life.

As Hagop points out, someone who has always been filled with energy, enthusiasm, and creativity often is hard pressed to tolerate even a small amount of depression.  He or she comes in for treatment with a great sense of urgency about getting well.  Hagop proposes that this type of bipolar, when depressed, maybe at particularly high risk of suicide because of that difficulty adapting to or tolerating the change.

The good news is that treatment is often very effective, although as with all treatment of bipolar depression, it may take many weeks to see the good results that can eventually be achieved.

We’ll be describing some of the other types over the course of the next week or so as we review some of the material that we presented recently to the residents in psychiatry at the University of California, San Francisco as part of their course on Bipolar Disorder.

Apr 23

Childhood Insomnia

In an eYoung girl frustrated by wakeup of alarm clockra of ever-present video and constant texting and snapchatting, many parents are trying to figure out how to deal with childhood insomnia.

Here is a quick guide for busy parents of things to think about and things to do if your child is having trouble getting to sleep or getting enough sleep.

Consider possible causes –

  • Stress. Kids, just like adults can suffer from stress. Show interest in your child’s life and build trust so they feel comfortable sharing their worries with you. How are things going at school. Online bullying (cyberbullying) is an increasingly common problem for pre-teens and teenagers.  Is everything under your own roof running smoothly (ie, is there arguing, fighting between siblings, marital or financial problems; has there been a death in the family, a recent job change; has the family recently moved)? Children worry more than you might think and excess worry and stress can lead to insomnia.
  • Use of caffeine or other stimulants. Even some clear sodas (Mountain Dew) and most energy drinks have caffeine.
  • Medical, psychiatric and other sleep disorders. Uncontrolled nighttime asthma, a stuffy nose from allergies or itchy skin from eczema can get in the way of good sleep. Also, depression and anxiety, which may show up without clear signs and symptoms, can be a cause of disturbed sleep.

What else to do?

  • Sleep hygiene habits. Restrict time spent in bed to just sleeping (no reading, doing homework or watching TV in bed); maintaining a regular sleep schedule (going to bed and waking up at the same time each day including weekends and holidays); avoiding caffeinated products 4-6 hours before bedtime (caffeinated products include coffee, tea, colas, some non-cola pops, energy drinks, and chocolates); and establishing a bedtime routine that does not include stimulating activities within an hour of bedtime (such as TV watching, electronic gaming, heavy homework, or computer gaming).
  • Comfortable sleep environment. Make sure your child’s bedroom is quiet, calm, comfortable (< 75 degrees F), and dark (a nightlight is acceptable for children afraid of a dark bedroom).
  • Teach children how to relax. We love and there are several guides for mindfulness and relaxation specifically for children on the Calm apps.
  • Set bedtime so that enough sleep is possible. Set bedtime so that your child gets his or her usual amount of sleep (Children between the ages of 6 and 12 need about 10 to 11 hours of sleep each night; teens need about 9 hours of sleep each night.)
  • Get up out of bed if your child can’t get to sleep. If your child can’t get to sleep in a half an hour, it is better to get up and do something calming in relatively low light for 15-20 minutes (for example reading or listening to calming music), rather than lying in bed and tossing and turning. After staying out of bed for 20-30 minutes or so, they may return and attempt to sleep. If after a 15-20 minute attempt there is no success, they should get up again and try the relaxing activity again. Repeat the cycle as necessary.
  • Consider cognitive behavioral therapy. Specialists in behavioral and cognitive therapy can work with the child and family to establish regular sleep rhythms. CBT for insomnia is very helpful and can have long term benefits.
  • For kids who have trouble getting to sleep and tend to wake up late. Circadian rhythm disorders can occur in children as in adults. If you have a childhood “owl” trying to function in a world of early rising “larks” a recent article suggests that a combination of nighttime melatonin and early morning bright light may help to reset circadian rhythms. Light therapy consisting of daily bright blue light exposure during 30 minutes between 6:00 and 8:00 am and 3 mg of immediate release melatonin at 7:00 pm. The melatonin treatment was more effective than the light therapy alone and only those receiving melatonin treatment had more total sleep time.


Astill RG, Van der Heijden KB, Van Ijzendoorn MH, Van Someren EJ. Sleep, cognition, and behavioral problems in school-age children: a century of research meta-analyzed. Psychol Bull. 2012 Nov;138(6):1109-38. doi: 10.1037/a0028204. Epub 2012 Apr 30. PubMed PMID: 22545685.

Dewald JF, Meijer AM, Oort FJ, Kerkhof GA, Bögels SM. The influence of sleep
quality, sleep duration and sleepiness on school performance in children and
adolescents: A meta-analytic review. Sleep Med Rev. 2010 Jun;14(3):179-89. doi:
10.1016/j.smrv.2009.10.004. Epub 2010 Jan 21. PubMed PMID: 20093054.

van Maanen A, Meijer AM, Smits MG, van der Heijden KB, Oort FJ. Effects of Melatonin and Bright Light Treatment in Childhood Chronic Sleep Onset Insomnia With Late Melatonin Onset: A Randomized Controlled Study. Sleep. 2017 Feb 1;40(2). doi: 10.1093/sleep/zsw038. PubMed PMID: 28364493.

For More Information

Cleveland Clinic’s Insomnia for Children was the source of much of the information in this article. 

Apr 23

Avoid Intimidation

Avoid IntimidationRick Hanson has written an elegant and timely newsletter article about how to avoid intimidation and fear from paper tigers and media demagogues.

I love his weekly email newsletters and it is again time to encourage readers of this blog to sign up.

Here is the link.

One of Rick’s themes, elegantly outlined in this most recent article, is how we evolved to be much more responsive to threats than to positive news. It was a survival technique that worked well for hundreds of thousands of years. But may no longer be serving us well in an era when threats are not immediate and clear (like a hungry tiger) but distant and complex (like Kim Jong-un’s isolated regime in North Korea).

To keep our ancestors alive, Mother Nature evolved a brain that routinely tricked them into making three mistakes: overestimating threats, underestimating opportunities, and underestimating resources (for dealing with threats and fulfilling opportunities). This is a great way to pass on gene copies, but a lousy way to promote quality of life.

So for starters, be mindful of the degree to which your brain is wired to make you afraid, wired so that you walk around with an ongoing trickle of anxiety (a flood for some) to keep you on alert. And wired to zero in on any apparent bad news in a larger stream of information (e.g., fixing on a casual aside from a family member or co-worker), to tune out or de-emphasize reassuring good news, and to keep thinking about the one thing that was negative in a day in which a hundred small things happened, ninety-nine of which were neutral or positive. (And, to be sure, also be mindful of any tendency you might have toward rose-colored glasses or putting that ostrich head in the sand.)

Additionally, be mindful of the forces around you that beat the drum of alarm – whether it’s a family member who threatens emotional punishment or political figures talking about inner or outer enemies. Consider for yourself whether their fears are valid – or whether they are exaggerated or empty, while downplaying or missing the larger context of opportunities and resources. Ask yourself what these forces could be getting out of beating that scary drum.

This bias towards threat is even more strongly present in people who have been exposed to trauma. Posttraumatic stress disorder is a brain mechanism that was designed to “turn up the gain” on our already hyperactive threat detection system. A crude but effective system for making us even more watchful after we have been exposed to serious threat.

For More Information

Stand Up to Intimidation

Foundations of Wellbeing

Rick Hanson – Trust in Love

Apr 22

Move It

You have the potential to change your life. There is an almost magical system for activating hundreds of genes associated with better health and better brain function that you have access to. And it won’t cost you.

I have written a lot about this amazing system, but this video does a better job than any of my posts.

For those who want the science explained in more detail this video of John Ratey, author of Go Wild, Spark, and Driven to Distraction—discusses the research showing the big benefits of physical activity and connecting with nature—mainly for your mind, not just your body.

I hope you are inspired by these two videos. They came to me courtesy of my subscription to the Foundations of Wellbeing which remains one of my favorite websites on the internet.

The Foundations of Well-Being Program

For More Information

Exercise for Health

Exercise Dose – Update

Apr 21

Exercise for Health

Exercise is essential to healthy life. It offers multiple rewards. It improves mood, lowers blood pressure, and improves blood cholesterol levels. It reduces the risk of cardiovascular disease, diabetes, and some cancers. Regular physical activity helps develop and maintain healthy bones, muscles, and joints. It relieves arthritis pain and keeps you younger than your years. If that weren’t enough, it helps control your weight. And many people learn to love exercise, once they have done it for a while.

In order to stay healthy, people who don’t need to lose weight should get a minimum of 30 minutes of moderately intense physical activity every day, or nearly every day. It should preferably be aerobic activity (good for the cardiovascular system), such as brisk walking, running, cycling, or swimming. Vigorous work like raking and bagging leaves or washing the floor can also serve the purpose.

If you need to lose weight, extend your routine to at least an hour a day, six or seven days a week. Do something that raises your heart rate and makes you breathe faster and sweat.

A study (JAMA v. 290: 1323-1330. 2003) found a direct correlation between weight loss at twelve months and duration of exercise in women who were given instruction in how to diet.

Women in this study who exercised less than 150 minutes a week (and who received instructions to follow a low fat, low calorie diet) lost about 5% of their total body weight, women who exercised 150 – 200 minutes a week lost 7% of their total body weight, and women who exercised more than 200 minutes a week lost almost 10% of their total body weight.

In addition, those women who had the highest levels of exercise were still losing weight at the end of the study, whereas those women who exercised the least were quickly regaining lost weight.

Almost all studies of weight loss find that there is a net regain in weight after the first six months, so that the usual goal is to minimize that weight regain in order to maintain the weight loss benefits of the intervention. This study finds that exercise for more than 200 minutes a week may be one of the few interventions that keeps on delivering weight loss for a full year.

You don’t need to pack all your exercise into one session. Short bouts of exercise during the course of the day have an additive benefit, 3 10-minute or 20-minute sessions will do you as much good as one longer session.

Walking is the most practical, accessible exercise as well as the safest. But casual strolling is not enough. Aim for a brisk pace, about 3.5 to 4 miles per hour (so you walk a mile in 15 to 17 minutes). If you are just starting a walking program, check your pace by walking on a treadmill or timing yourself as you walk a measured mile — typically four times around a school track, for example. If you haven’t been exercising it may take you a few weeks to get used to walking briskly.

Make exercise a habit. Walk whenever possible, in preference to driving or taking a bus. Skip the escalator or elevator and take the stairs.

If you are very overweight, have always been sedentary, or are over 70, you may find it hard to get going. A walking pace of 3.5 to 4 miles an hour may seem impossible to achieve. But keep trying. Do what you can do. It is never too late to start exercising and reaping the rewards.

As you get accustomed to a routine, add some strength training with free weights or weight machines. This is especially important for bone health as you grow older. If you have never done any weight training a few lessons can be an excellent investment to get you started.

Elsewhere on this website we have more information on the psychological benefits of exercise.

Apr 19

Sleep Apps and Wearable Devices

Sleep Apps and WearablesMany of the people I see complain of poor quality sleep, and a number of them have tired using various sleep apps and wearable devices to try to get figure out why they are sleeping poorly and what they can do about it.

One of my techie colleagues says she thinks that this is a good thing and praises one app, which is the most popular sleep app in the iPhone App Store, in particular…

“About a third of my clients are using Sleep Cycle. I like it because it marks the 4 sleep stages and doesn’t smooth the splines on the waves, so you can see roughness if sleep is fragmented. The “sleep quality” measure is bogus because it includes time in bed in its nebulous calculation, but the rest of the app I like a lot. A friend turned me onto it a couple years ago. I’d had a sleep problem for several years and when I saw it on the little monitor and guessed at the etiology I was able to correct the issue in 2 days. I’ve tweaked regimens, ordered sleep studies, and caught a lot of late night drinking with this thing.”

This sounded very positive. However many of my patients report different experiences with sleep apps. Sometimes when I look at the graphs on their smart phones it’s hard to know what the data shows and how reliable it is.

In this brief review I will try to summarize the existing data about smart phone sleep apps as well as wearable devices for monitoring sleep and activity.

Sleep Apps

The boom in smart phone apps designed to improve and monitor sleep is phenomenal and it’s impossible to keep track of all of them.

Some apps detect movement on a bed. These apps use the movements registered by the phone, tucked under a pillow, to estimate whether the user is in a state of wakefulness or of light or deep sleep. They offer varying degrees of analysis of sleep patterns, and some propose to wake the user at a moment that is most opportune according to the app’s algorithms. Other apps claim to track sleep parameters by measuring the extent to which the user is snoring (Stippig et al., 2014), or the levels of sleep talking, or (as with my friends app, Sleep Cycle) claim to use a “patented, proprietary technology” which can distinguish the sounds of movement during sleep from other sounds, and can even tell whether it is you moving in the bed or your partner… Fascinating and exciting stuff…

It is a lot easier to keep track of the studies that have been published in the research literature comparing sleep apps with the “gold standard” for measuring sleep duration and quality: polysomnography, than the various apps being brought to market, because there is hardly any published data on these apps.

“In the only study comparing a smartphone app to PSG in adults, Bhat et al. evaluated the Sleep Time™ app that provides users with a graph detailing wakefulness and light and deep sleep and, in addition, claims to help users wake up only during light sleep.Sleeptime

In this study, the authors compared the PSG sleep data from 20 healthy adult subjects with no previously diagnosed sleep disorders with data obtained from the app. There was poor correlation between the app and PSG in terms of sleep efficiency, light sleep, and deep sleep. In addition, there was no correlation between app and PSG sleep latency. The app was poor in terms of detecting wakefulness. Finally, there was no evidence that the app consistently awakened subjects only during light sleep (p = 0.159).”

That’s it. Only one published study on the accuracy of the data in smart phone apps and that study found that the data was very inaccurate.

Wearable DevicesWearable Devices

The Technology

Wearable devices rely on actigraphy (movement monitoring) to try to determine a person’s pattern of wakefulness, activity and sleep. The fundamental idea is a sound one which is actually used in clinical settings.

“Actigraphy, a portable wrist-worn sleep monitoring device, is used in clinical sleep medicine for assessing certain sleep disorders, such as circadian rhythm sleep–wake disorders, and for characterizing day-to-day patterns or sleep disturbances in insomnia [Ando K, Kripke DF, Ancoli-Israel S. Delayed and advanced sleep phase symptoms. Isr J Psychiatry Relat Sci. 2002;39(1):1118.Kripke DF, Youngstedt SD, Elliott JA, et al. Circadian phase in adults of contrasting ages. Chronobiol Int. 2005;22(4):695709.]. It is also used to assess response to treatment in insomniacs and as an adjunct source of information in patients who are unable to provide a clear history Wilson SJ, Rich AS, Rich NC, et al. Evaluation of actigraphy and automated telephoned questionnaires to assess hypnotic effects in insomnia. Int Clin Psychopharmacol. 2004;19(2):7784.Morgenthaler T, Alessi C, Friedman L, et al. Practice parameters for the use of actigraphy in the assessment of sleep and sleep disorders: an update for 2007. Sleep. 2007;30(4):519529].

Wrist actigraphy is based on the principle that physical movements are increased during wakefulness and reduced during sleep [Tilmanne J, Urbain J, Kothare MV, et al. Algorithms for sleep-wake identification using actigraphy: a comparative study and new results. J Sleep Res. 2009;18(1):8598.Sadeh A. The role and validity of actigraphy in sleep medicine: an update. Sleep Med Rev. 2011;15(4):259267]. It has been found to have a reasonable degree of agreement with PSG, with reported agreement rates of 78.8–99.7% for sleep and 48.5–79.8% for wake [Tryon WW. Nocturnal activity and sleep assessment. Clin Psychol Rev. 1996;16(3):197213.]. Actigraphy has been shown to be sensitive to changes in sleep patterns in response to pharmacologic and nonpharmacologic interventions [Sadeh A. The role and validity of actigraphy in sleep medicine: an update. Sleep Med Rev. 2011;15(4):259267]. However, its validity in special populations such as the elderly, in subjects with poor sleep quality, or in those with major health problems is not well established [Sadeh A. The role and validity of actigraphy in sleep medicine: an update. Sleep Med Rev. 2011;15(4):259267].”

The Studies

There are more studies looking at the accuracy of wearable devices and the findings from the studies are more reassuring.

The table below lists details of these summaries. First, though, a word of caution, these studies used somewhat different methodologies and so it may not be possible to directly compare the outcomes.

Studies looking at sleep apps

The studies looked at a few devices – two Fitbit devices and the Jawbone UP.

One study of the current  Fitbit model, when compared with the gold standard of polysomnography (PSG), found that the device had a sensitivity of 0.87 and specificity of 0.52 in the ‘normal’ mode and 0.70 and 0.79, respectively, in the ‘sensitive’ mode.

This means that in the normal mode, 90% of the time when someone was asleep it categorized that time period as sleep, but only about half of the time that the device said someone was asleep were they actually asleep. The device overestimated sleep time significantly in the normal mode. In the sensitive mode the device overestimated sleep time less.

The Fitbit Ultra device was also compared to a stand alone actigraphy device in that study and was found to similarly overestimate sleep time when compared with a professional actigraphy device.

In summary, Fitbit was fairly good at detecting sleep but poor at detecting wakefulness. Furthermore, results varied according to age group and sleep apnea status. The older the patient and the more difficulty they had with insomnia, the poorer the correlation with either PSG or actigraphy.

Jawbone UPJawbone™ UP is an activity tracker that also claims to track sleep utilizing bioimpedance sensors.

Three studies looked at the accuracy of the Jawbone.

  • De Zambotti et al. compared the accuracy of Jawbone in measuring nighttime sleep to PSG in a sample of 65 healthy adolescents and young adults (ages 12–22 years) with no prior sleep problems.
  • De Zambotti et al. also studied the same device, Jawbone, in a sample of 28 adult women (mean age 50.1 ± 3.9 years).
  • Toon et al. compared the Jawbone UP device and MotionX 24/7, a smartphone-based app against PSG and actigraphy in a pediatric sample with suspected sleep-disordered breathing (N = 78; mean age 8.4 ± 4.0 years, range 3–18 years).

Across all of these studies, the Jawbone was relatively poor at determining wakefulness, but did a better job at identifying sleep (sensitivity for sleep was high but specificity was not great). Light and deep sleep measured by Jawbone did not correspond with light (stages N1 and N2) and deep sleep (stages N3 and REM) measured by PSG.

However, overall the studies suggested that the Jawbone may be slightly more accurate than Fitbit and Fitbit Ultra in determining sleep parameters and both devices were much more accurate than smartphone apps.

Apps for Sleep Apnea Detection

A final role for smartphone apps is as an inexpensive way of identifying possible sleep apnea. There seems to be better data suggesting that sleep apnea detecting smartphone apps are reasonably accurate than the data looking at general sleep apps.

Nandakumar et al. evaluated a smartphone-based application, ApneaApp™, designed to detect sleep-related respiratory events.

The app uses the smartphone’s microphone to emit an inaudible wave, which functions similar to a sonar system to detect amplitude changes during breathing. It uses a sophisticated algorithm to detect and calculate hypopneas (partial sleep apnea episodes) and obstructive and central apneas. The app measures sleep time by identifying non-breathing body movements and subtracting them from the total recording time. In this study, where the smartphones were used alongside PSG in a sleep laboratory setting, the events as measured by the app showed good correlation with the total number of events recorded on PSG. The ApneaApp correctly classified 32 of 37 subjects with regard to their sleep apnea severity status, and correctly identified those requiring treatment.

The ApneaApp is designed for Android phones with at least two microphones. This includes Samsung Galaxy and HTC One.

Unfortunately, the app is not currently available. The website says that it has been submitted to the FDA for approval –

We can not currently release the app prior to getting the FDA approvals. Please email us at to be on our waiting list so that we can notify you once we get the approval.

There are a number of apps currently available that claim to measure and track snoring. A proof of concept study showed that a smartphone strapped to the anterior chest wall during PSG can detect snoring with reasonable accuracy.

One study of seven commercially available snoring apps suggested that they were not accurate enough to replace current diagnostic standards and worked only in soundproof environments. In real-life environments with background noise, their ability to detect snoring deteriorated considerably.

Quit SnoringAnother study was more positive. Camacho, et al searched Apple iTunes app store for snoring apps that allow recording and playback. Snoring apps were downloaded, evaluated and rated independently by four authors. Two patients underwent polysomnography, and the data were compared with simultaneous snoring app recordings, and one patient used the snoring app at home.

In this study, the Quit Snoring app received the highest overall rating. When this app’s recordings were compared with in-laboratory polysomnography data, app snoring sensitivities ranged from 64 to 96 per cent, and snoring positive predictive values ranged from 93 to 96 per cent.


Camacho M, Robertson M, Abdullatif J, Certal V, Kram YA, Ruoff CM, Brietzke SE, Capasso R. Smartphone apps for snoring. J Laryngol Otol. 2015 Oct;129(10):974-9. doi: 10.1017/S0022215115001978. Epub 2015 Sep 3. PubMed PMID: 26333720.

De Zambotti M, Baker FC, Colrain IM. Validation of sleep-tracking technology compared with polysomnography in adolescents. Sleep. 2015;38(9):14611468

De Zambotti M, Claudatos S, Inkelis S, et al. Evaluation of a consumer fitness-tracking device to assess sleep in adults. Chronobiol Int. 2015;32(7):10241028

Grigsby-Toussaint DS, Shin JC, Reeves DM, Beattie A, Auguste E, Jean-Louis G. Sleep apps and behavioral constructs: A content analysis. Prev Med Rep. 2017 Feb 21;6:126-129. doi: 10.1016/j.pmedr.2017.02.018. eCollection 2017 Jun. PubMed PMID: 28316907; PubMed Central PMCID: PMC5350571.

S. Bhat, A. Ferraris, D. Gupta, et al. Is there a clinical role for smartphone sleep apps? Comparison of sleep cycle detection by a smartphone application to polysomnography. J. Clin. Sleep Med., 11 (7) (2015), pp. 709–715

Kolla BP, Mansukhani S, Mansukhani MP. Consumer sleep tracking devices: a review of mechanisms, validity and utility. Expert Rev Med Devices. 2016 May;13(5):497-506. doi: 10.1586/17434440.2016.1171708. Epub 2016 Apr 18. Review. PubMed PMID: 27043070.

M.T. Bianchi. Consumer sleep apps: when it comes to the big picture, it’s all about the frame. J. Clin. Sleep Med., 11 (7) (2015), p. 695

Nakano H, Hirayama K, Sadamitsu Y, et al. Monitoring sound to quantify snoring and sleep apnea severity using a smartphone: proof of concept. J Clin Sleep Med. 2014;10(1):7378

Nandakumar R, Gollakota S, Watson N. Contactless sleep apnea detection on smartphones. In: Borriello G, Pau G, Gruteser M, Hong J, editors. Proceedings of the 13th Annual International Conference on Mobile Systems, Applications, and Services. Florence (Italy): ACM; 2015. p. 4557.

P.T. Ko, J.A. Kientz, E.K. Choe, M. Kay, C.A. Landis, N.F. Watson. Consumer sleep technologies: a review of the landscape. J. Clin. Sleep Med., 11 (2015), pp. 1455–1461

Stippig A, Hübers U, Emerich M. Apps in sleep medicine. Sleep Breath. 2015;19(1):411417.

Toon E, Davey MJ, Hollis SL, et al. Comparison of commercial wrist-based and smartphone accelerometers, actigraphy, and PSG in a clinical cohort of children and adolescents. J Clin Sleep Med. 2016;12(3):343–350.

Van den Bulck J. Sleep apps and the quantified self: blessing or curse? J Sleep Res. 2015 Apr;24(2):121-3. doi: 10.1111/jsr.12270. Epub 2015 Jan 5. PubMed PMID: 25558955.

Apr 16

The Science of Slow Breathing

In an April 5, 2017 article in the New York Times, Gretchen Reynolds reviews new research on the science of slow breathing and how this ancient technique may work to promote relaxation, reduce anxiety, and prevent panic attacks.

The technique of controlled breathing or pranayama (प्राणायाम) is referred to in the Bhagavad Gita, and thus dates back at least to the second century BC.

“Take a deep breath” is the opening to many ancient and modern relaxation and meditation techniques.

Breathing lies and an interesting intersection between the conscious mind and the unconscious mind.

Panic disorder, which involves a dysregulation of rapid breathing associated with an overly strong connection between anxiety and anxious thoughts and hyperventilation, illustrates the complexity of this relationship. Obviously, anxious thoughts are conscious, and these are often part of the trigger mechanism for hyperventilation, once triggered however this rapid breathing remains active until the unconscious brain’s natural homeostatic processes kick in and normal breathing resumes. In the extreme case this happens if a person faints or loses consciousness, but most of the time it takes place as the brain and body reassert a normal balance between sympathetic and parasympathetic activity.

Scientists at Stanford University have identified a small set of brain cells in the brainstem (more specifically in the preBötzinger complex (pBc) of the ventro-medial medulla) that appear to control the balance between rapid breath and slow breathing.

These same neurons play a major role in anxiety.

When these neurons were deactivated in mice, the mice appeared much calmer than normal mice. But otherwise there was no effect. That is until the researcher started to take a look at breathing rhythms.

The mice with the deactivated neurons did not show the normal breathing response (increased rapid breathing) in the face of anxiety provoking stimuli.

It turns out that the deactivated neurons not only controlled rapid breathing but they connected with another part of the brain that plays a key role in sympathetic nervous system activation (the locus coeruleus), and thus affects the entire fight or flight system.

Back to the question of why slow breathing has such a calming effect. The researchers Reciprocal relationship in cells in the pBcspeculate that this is because there is a reciprocal relationship between activation of the rapid breathing neurons and activation of the slow breathing neurons, so that if we consciously activate slow breathing, it has the same effect as the scientists genetic deactivation of rapid breathing neurons.

And the deactivation of the rapid breathing cells in turn deactivates the “fight or flight” cells in the locus coeruleus.

It generates calm.


Yackle K, Schwarz LA, Kam K, Sorokin JM, Huguenard JR, Feldman JL, Luo L, Krasnow MA. Breathing control center neurons that promote arousal in mice. Science. 2017 Mar 31;355(6332):1411-1415. doi: 10.1126/science.aai7984. Epub 2017 Mar 30. PubMed PMID: 28360327.

Apr 14

Early Intervention Can Prevent Episodes

Early intervention can prevent episodes of depression or hypomania or mania.

This is not always the case but most of the people that we work with find that it is helpful to go through a process of systematically identifying possible early warning signs of an episode and working with a friend or partner to come up with a plan for dealing with early symptoms.

This process is outlined in a new page that we added to the website on this topic:

Early Warning Signs

For More Information

Mania Warning Signs in the Eyes – Gina

Predicting Depression Recurrence

Support a Loved One with Bipolar – Gina

Recovery from Bipolar

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