Skill Building for Psychosis

skill buildingOne of the very hard things about many psychiatric disorders, including bipolar disorder and schizophrenia, is that they often begin at a time that is critical to the development of many skills and abilities needed for successful adult life.

Many years ago we visited a wonderful program in Atlanta developed for young people with schizophrenia called STARS. The program was intended to be a comprehensive treatment approach that helped people with schizophrenia live fulfilling adult lives. It had remarkable rates of success.

One of the many creative things about the approach that the STARS program took, was that it tried to address practical social skills as well as skills related more directly to managing the symptoms of schizophrenia.

Perhaps the most popular educational component involved having young college volunteers come in and coach the patients on dating skills. After all, many of them missed out entirely on this experience because they were so symptomatic. And if you miss out on dating skills in high school and college, you end up at a serious disadvantage for the rest of your life.

We ran across this article, which summarizes a comprehensive review of the literature on the importance of skill building for all treatment programs and we were reminded of our visit to STARS, and of the importance of providing comprehensive help to people with serious psychiatric disorders…

Skill building—which involves strategies for helping adults with serious mental illness manage their illness, develop daily-living skills, and succeed in recovery—should be a foundation for rehabilitation services covered by comprehensive insurance benefit plans. That’s the finding from the study, “Skill Building: Assessing the Evidence,” published in Psychiatric Services in Advance.

Researchers from multiple institutions searched meta-analyses, research reviews, and individual studies from 1995 through March 2013. In this review, they examined four key components of skill building: social skills training (including life skills training), social cognitive training, cognitive remediation, and cognitive-behavioral therapies that target skills for coping with psychotic processes. The researchers chose from three levels of evidence (high, moderate, and low) on the basis of benchmarks for the number of studies and quality of their methodology.

More than 100 randomized controlled trials and quasi-experimental studies support rating the level of evidence as high. Study outcomes indicated strong effectiveness for social skills training, social cognitive training, and cognitive remediation, especially if these interventions are delivered through integrated care approaches. Results are somewhat mixed for life skills training (when studied alone) and cognitive-behavioral approaches.

“The current body of research has established the value of skill-building approaches,” the researchers said. “Although further research will help clarify their effects on some outcomes, research is not needed to support the decision to include skill-building approaches as covered services, particularly for individuals with schizophrenia and other psychotic disorders.”

Summer Vacation: Taking a Break from Therapy

therapyMaybe because it’s summer, and everybody’s thinking about vacations, or maybe it’s just a coincidence, but we’ve been spending a lot of time talking with people these past two weeks about taking a break from treatment or drastically cutting back on treatment, etc.

All of it has us wondering about how to think sensibly about these types of decisions.

After some consideration, we decided that there are three important questions:

1. How serious was the problem that led you into treatment in the first place?

2. How urgent is your feeling that you need to reduce or stop therapy?

3. How long have you been seeing this person?

The warning signs are when somebody who had a potentially life threatening condition suddenly feels an urgent need to cut back on treatment, especially if this treatment has been going on for awhile.

To give an extreme analogy, we probably all recognize that there is something a little strange about the thinking of someone who has just come through an intensive treatment for cancer who, learning that the cancer is in remission, decides to take a break from seeing his or her oncologist or getting any further studies, on the grounds that they are feeling good and thinking about cancer is depressing.  It’s not too difficult to see how the case of someone who has only recently come through intensive treatment for suicidal depression, and is feeling good, and now decides to take a break from treatment is potentially similar to the person who has just gone into remission from cancer.

It’s not that we think that everyone should be in treatment forever.  There aren’t enough good therapist and psychiatrists to treat all the people who need help.  It’s just that the process of ending or winding down treatment, needs more attention than many people give it.  We’d like to see a couple of things.

1.  Some thought about what is an appropriate level of monitoring or self monitoring for a return of symptoms.  The fact of the matter is that, the feeling that you want to take a break from treatment can easily end up being reflected in a wish to pay no attention to early symptoms.  This can be potentially disastrous. We are always more optimistic about a reduction in treatment frequency if there is a strong commitment to continuing mood charting, for example. 

2. A plan about what signs or symptoms might suggest resuming treatment or increasing the frequency. This is better done now when you are feeling good than waiting until you are feeling a little “off” – but at the same time trying not to acknowledge that because it makes you feel even worse to see what is happening.

Talk about it with your therapist or psychiatrist first. Develop that plan. And then try making the change. And try not to set it up so that it is a “failure” if you need to modify the plan for reduction.

Does Psychiatric Treatment Work?

psychiatric treatmentHow well do psychiatric treatments work? Aren’t psychiatric medications just placebos? Does psychotherapy really do anything?

These are the kind of questions that mental health clinicians run into all the time.

Dr. Maximilian Huhn and colleagues from the Munich Technical Institute (Huhn – reference 1) have conducted a major review of the data. They evaluated results from 852 clinical trials involving 137,126 patients with 21 psychiatric disorders.

They looked at the “effect size” of treatments. Effect size is a way of summarizing the magnitude of the benefit. Comparing the group that got treatment with the group that didn’t get treatment what is the nature of the difference in outcomes? Jacob Cohen proposed that effect sizes could be considered small, medium or large. A “moderate” effect size means that the effectiveness of the treatment should be “easily visible.”

They found that, in general, psychiatric treatments had  medium effect sizes (0.50). Interestingly, psychotherapy had a somewhat higher effect size than pharmacotherapy for acute treatment (ESs, 0.58 for therapy and  0.40 for medications).  [The authors suggested that this could be due to the fact that the psychotherapy studies tended to be done with smaller numbers of people in the study and thus there might be more bias in the results.]

How does this effect size compare with the effectiveness of non-psychiatric medications?2014-06-15_7-00-49

The same group at the Munich Technical Institute (Lucht – reference 3) earlier published the results of their systematic review of data on effect sizes for non-psychiatric medications.

The white dots show the results of clinical trials of medications used for treating common medical problems like hypertension, heart disease, high cholesterol, etcetera. The blue dots show the results of the clinical trials of psychiatric medications. The further up the chart the larger the effect size.

As you can, there were not big differences in effectiveness. In fact, psychiatric medications, in general, were somewhat more effective than non-psychiatric medications.

Other findings from Huhn’s study were that combination treatment (medications and therapy) generally worked better than one type of treatment alone (especially for more severe conditions).  Of 12 meta-analyses of combinations of pharmacotherapy and psychotherapy (range of study participants, 23–2131), 7 found that combination treatment was more effective than either therapy type alone.

They also found that acute treatment was somewhat less effective than maintenance treatment. In other words, psychiatric treatments were not as good at taking care of an acute depression as they were at preventing a recurrence of depression once you were better. 

Citation(s):

  1. Huhn M et al. Efficacy of pharmacotherapy and psychotherapy for adult psychiatric disorders: A systematic overview of meta-analyses. JAMA Psychiatry 2014 Apr 30; [e-pub ahead of print]. (http://dx.doi.org/10.1001/jamapsychiatry.2014.112)
  2. Correll CU and Carbon M.Efficacy of pharmacologic and psychotherapeutic interventions in psychiatry: To talk or to prescribe: Is that the question? JAMA Psychiatry 2014 Apr 30; [e-pub ahead of print]. (http://dx.doi.org/10.1001/jamapsychiatry.2014.301)
  3. Lucht S et al. Putting the efficacy of psychiatric and general medicine medication into perspective: review of meta-analyses.
    The British Journal of Psychiatry (2012)200: 97-106 doi:10.1192/bjp.bp.111.096594

Internet Therapies Generate Interest

2014-03-31_10-55-45There is increasing interest in “apps” that can support mental health (one of our most enthusiastic readers recently posted a query on this topic on the forum). Apps are rarely intended to deliver “therapy” – they are usually not written by mental health professionals (although mental health professionals may be consulted along the way). Their goal is to be appealing so that they sell.

There is a parallel movement to put mental health treatments online. This has been sparked, in part, by the lack of access to trained therapists who can deliver effective, evidence based treatments in many parts of the country, and the world.

An example of this is to be found on our website in the Topics section on the Sleep and Insomnia page. It is called SHUTi and it is a highly effective program designed to address insomnia. Studies find it to be as effective as sleeping medications, but, unlike sleeping medications, the effects last long after the program is done, and there are no side effects.

Now we are pleased to see that the International Society for Research on Internet therapy has begun to publish a journal, in order to enhance the quality of the science that supports these interventions.

The editor (Gerhard Andersson, PhD, Professor of Clinical Psychology, Linköping University and 
Guest Professor, Karolinska Institute) had this to say in the first volume –

The Internet is increasingly used for delivering interventions aimed at improving mental and physical health. Internet interventions — often self-guided or partly self-guided — have proven effective in treating a number of psychiatric conditions, including depression, panic syndrome, social anxiety disorder, posttraumatic stress disorder, eating disorders, and insomnia, as well as more general medical conditions, including headache, back pain, tinnitus, diabetes management, problem drinking and smoking cessation. The increase in interest in Internet interventions can be traced to the many unique advantages: Internet interventions are geographically independent and cost-efficient. In addition to the advantages of lowering the help-seeking threshold and providing evidence-based healthcare to larger numbers, technological advances allow for novel intervention components, such as user-friendly visual screening instruments, video-based exposure therapy, interactive role-playing, automated reasoning models and more. Having received the approval of government and medical insurers, Internet interventions have already been integrated into the regular healthcare systems in the US and UK, and in Sweden, the Netherlands and Australia, to name a few examples.

Family Therapy Effective for Bipolar Teenagers

family therapyFamily Therapy–

Family-focused treatments have been shown to be effective adjunctive therapy to mood stabilizing medicine in adults with bipolar disorder (especially young, female adults), but whether this approach holds true in adolescents, has been unclear. Researchers from the University of California at Los Angeles (UCLA) assessed 145 adolescents with bipolar disorder to see if adding 9 months of family focused therapy (FFT) to  pharmacotherapy improved outcomes.

The study, “Pharmacotherapy and Family-Focused Treatment for Adolescents with Bipolar I and II Disorders: A 2-Year Randomized Trial,” is published in AJP in Advance.

Teens receiving the combination of medications and FFT were more likely to have less-severe manic symptoms after two years than those receiving pharmacotherapy with brief psychoeducation.

“The emphasis in FFT on early recognition of prodromal signs of recurrence and communication and problem-solving skills may not translate into benefits for patients until families have implemented these strategies during new cycles of illness,” David Miklowitz, Ph.D, director of the Children and Adolescent Mood Disorders Program at UCLA, told Psychiatric News. Miklowitz concluded that intensive family interventions may be most useful when high family stress and the long-term course of hypomanic or manic symptoms are primary treatment targets.

When the Grown-ups Disappear: On Self-Destructive Behavior

self-destructive behaviorA brilliant young man I know has been stuck in a pattern of self-destructive behavior and constant and terrifying self-criticism. Nothing seems to be helping him get out of this cycle. We have thoughtful conversations about the problem and come up with various solutions but then, the next time we get together, the behavior remains unchanged.

I often feel as though in my conversations with him we are talking about a third person – this mysterious other Paul, who is such a tough nut to crack….

Thinking about this pattern I decided I would try to diagram what was going on as though we were talking about the interactions of several people. And used the model that I often find helpful of an internal Child, Adult and Parent.

This is what I came up with:

Paul’s internal Parent has struck a deal with his internal Child – you get to do all the acting out you want to, staying up late at night, not doing your work, using drugs and drinking too much, if I can mercilessly chastise you in the morning.

Thinking about this some more I realized that this “deal” was actually just a recreation of the pattern from his childhood.

His mother suffered from debilitating depression and was often not around to prevent Paul from getting into trouble, but then would come across the unavoidable evidence of his misbehavior and would tear into him with a ferocity no doubt driven by anxiety and guilt. 2014-03-06_7-59-52

Missing in action in this equation is, and was, the competent adult.

And my own discussions with Paul often involved this Adult who seemed baffled about what to do…

As is often the case, the value of this conceptualization will revolve around its ability to call attention to a process that has been happening largely outside full awareness. Will Paul be able to notice the cycle of acting out and then self criticism in real time and change that pattern? Time will tell.

 

Games People Play: The Basic Handbook of Transactional Analysis.I’m OK–You’re OKScripts People Live: Transactional Analysis of Life Scripts

Distress Tolerance

distress toleranceI have been doing some blog – surfing and happened upon a wonderful series, on the “disorderly chickadee” site that I have referred to in the past, about the skill of “Distress Tolerance.”

In working with patients with depression, we often find ourselves encouraging them to learn about Dialectical Behavior Therapy (DBT). And of the many parts of DBT that may be useful to people with depression or bipolar, mindfulness and distress tolerance are the ones that top the list.

Now DeeDee (the author of the disorderly chickadee site) has begun a series of articles on DBT and has published one of the best discussions I know on the subject of distress tolerance and its relevance to someone with bipolar moods.

Check it out! And if you like it leave a comment.

Bay Area Bipolar Educational Group

educational groupDr. Descartes Li (see interview in our “Conversations” section) is starting another Psycho-Educational Group for Bipolar Disorder this spring. We are happy to encourage all readers in the Bay Area to find out more information about these excellent groups. The group is an especially good option if you still suffer from mood swings, or have questions about managing your meds (and their side effects), or wonder how best to talk with your family, friends, psychiatrist about bipolar disorder.LOCATION:
UCSF Parnassus Campus
401 Parnassus Avenue
San Francisco, CADATES:  Begins January 27, 2014. 8-Session Weekly Group

MEETING TIMES: Mondays, 10:30AM – 11:45AM

Some topics covered in Bipolar Disorder Group Sessions:
– Self Awareness and Mood Charting
– Medications: How to Get the Most (and Least) out of Your Meds
– Sleep Management
– Communication Skills and Stigma
– Coping with Depression and Problem-Solving

The group focuses on common challenges faced by individuals with bipolar disorder with an emphasis on learning specific information about bipolar disorder.  The style is supportive, while maintaining an atmosphere of mutual respect.

Fees: There is a fee for these sessions, although your mental health insurance may cover most or all of the expense involved.

FOR MORE INFORMATION, CALL: Descartes Li, MD   (415) 476-7448

Please also see the UCSF Bipolar Disorder Program webpage: http://psych.ucsf.edu/lpphc.aspx?id=354
 
A flyer with information about the group is available below, as well as a schedule of meetings.

Sleep Therapy and Depression

sleep therapyWhat would you do if you could double the effectiveness of your antidepressants? Let’s say that this new treatment also had no known side effects, and was completely safe.

That is what four studies have suggested could happen if people who were started on antidepressants received cognitive behavioral therapy for insomnia (CBTi). However, this treatment is not widely available. We are aware of perhaps five psychologists who do this in the Bay Area.

The American Board of Sleep Medicine has certified just 400 practitioners in the United States to administer it, and there are few of them even in big cities.

As the New York Times notes,

There aren’t many of us doing this therapy,” said Shelby Harris, the director of the behavioral sleep medicine program at Montefiore Medical Center in the Bronx, who also has a private practice in Tarrytown, N.Y. “I feel like we all know each other.

CBTi is a combination of techniques that each have been shown to be somewhat effective, and in combination the results are quite effective, at least as powerful as sleep medications, and more durable (generally once you learn the techniques you can keep using them indefinitely without a refresher, unlike sleep medications)

MoodSurfing is very pleased to be able to provide access to this treatment for our readers via a very well designed online program that incorporates all of the techniques of CBTi into a two to three month program of treatment that is, in our experience, very effective and more convenient than having to go see a therapist once a week (the usual way CBTi is delivered in practice). It also costs less than one session of CBTi. The program is called SHUTi.

SHUTi (Sleep Healthy Using The Internet) is an interactive, web-based training program designed to help people who have problems with sleep, including:

  • Falling asleep
  • Staying asleep
  • Waking too early in the morning

The help offered by SHUTi is based on interventions for insomnia that have been developed over the past 20 years and tested in numerous scientific studies. Typically, this type of training is only available from psychologists and physicians who have been specially trained in behavioral sleep medicine, and only offered in weekly face-to-face sessions. SHUTi was created to make this kind of help available to more people through a convenient home-based program which can be accessed at any time via the Internet.

To find out more – and to receive a special discount on the program – follow this link:

SHUTi Program for Insomnia

 

PTSD Psychotherapy Affects Gene Activity

 

PTSD
René Descartes’s illustration of dualism. Inputs are passed on by the sensory organs to the epiphysis in the brain and from there to the immaterial spirit.

Mind-body dualism seems alive and well in the land of mental health. I am still surprised how often someone will say, “well that’s not a biological depression.” Meaning that it is the kind of depression that can be understood as a result of events in that person’s life, or that it can be treated effectively with therapy, or that it can’t be treated biologically.

If only life were that simple. But it isn’t.

Another reminder that you can’t draw a neat line and separate “psychology” and “biology” comes from a just published article that finds that cognitive-behavioral therapy (CBT) appears affects gene expression and changes the size of the hippocampus (a key part of the brain involved in memory) in patients with posttraumatic stress disorder (PTSD).

PTSD has profound effects on the brain’s cortisol system (a part of the overall stress response system), and it has been shown to reduce activity of a specific gene that regulates the cortisol receptor –  FKBP5.

In the study, the patients with PTSD had much lower levels of activity of this gene (what you would expect) as well as decreased volumes of the hippocampus and medial orbitofrontal cortex. 

However, after receiving  CBT, the researchers found that this abnormality was somewhat corrected.  FKBP5 expression in the patients with PTSD went up. And after the CBT treatment, hippocampal volumes in patents and control subjects were equal – meaning that therapy had completely reversed the abnormally low volumes of people with PTSD.

The researchers concluded –

Clinical improvement in individuals with PTSD was associated with increased expression of FKBP5 and increased hippocampal volume, which were positively correlated.

In other words, the biology of the brain is changed by effective therapy.

Take that René Descartes!

Therapy for Anxiety in Bipolar

therapyAnxiety is very common in people with bipolar moods. In fact, anxiety is typically the first sign of mental health problems (often it is present in childhood) for people who later develop bipolar.

As a psychiatrist, I am aware that we have fewer useful long term treatments for anxiety in bipolar than we do for the mood swings of the disorder.

Some of the things that people use to help anxiety can actually make bipolar worse (marijuana, gabapentin, and sometimes antidepressants). The most common treatment for anxiety (benzodiazepine medications like Valium, Xanax or Ativan) is much better for treating short-term anxiety. But the anxiety associated with bipolar is usually long term.

A recent study from the Systematic Treatment Enhancement Program for Bipolar Disorder suggests that psychotherapy is often the best answer.

The study ( Do Comorbid Anxiety Disorders Moderate the Effects of Psychotherapy for Bipolar Disorder? Results From STEP-BD) looked at 269 patients who either had an anxiety disorder (as well as bipolar) or did not. The patients were then randomly assigned to medications plus “collaborative care” (medication management and general counselling) or medications plus psychotherapy.

The study found that the addition of therapy to medication management made a significant difference for those patients with an additional anxiety disorder, but did not make a significant difference for those people with bipolar who did not have anxiety.

The picture at right shows that there was no significant difference in the percentage of people with bipolar who had full recovery (had resolution of almost all of their symptoms) who did or did not receive psychotherapy, 10-8-2013 7-07-35 AMexcept for the group with an additional anxiety disorder. In that group, the percentage who had full recovery was much lower (compared with those without anxiety) if they only received medication management.

However the addition of cognitive behavioral therapy (CBT) for their anxiety reversed that difference. In fact, with therapy, patients with anxiety actually did slightly better than those without anxiety.

There were benefits from therapy for all people with anxiety disorders, but the findings were particularly marked for people with generalized anxiety or posttraumatic stress disorder. These are the results cited in the article (collaborative care meant medication management):

 

Sixty percent (N=18) of participants with current generalized anxiety disorder recovered with psychotherapy, whereas 19% (N=4) recovered in collaborative care… Sixty-four percent (N=9) of participants with current PTSD recovered with psychotherapy, whereas 40% (N=4) recovered in collaborative care.”

 

Treatment as Punishment

punishmentI have spent the last two days mulling over an interaction with a patient and with his therapist.

The patient is a brilliant, young man who has somehow entered into a conflictual relationship with me.

The nature of that relationship was encapsulated for me in a comment by his therapist. She called to let me know that he was escalating into mania. When I suggested that I call him to see how I could help, she said that he didn’t want to talk to me about how best to treat this change in mood. He felt I might become “punitive” and suggest that he needed to see me sooner than his next scheduled appointment in a month. And she wondered, would I really do that.

Of course, my immediate reaction was to want to reassure the therapist that I would never punish someone for calling about a change in mood. But then I started to think about the implications of the whole conversation.

The notion that encouraging someone to come in and see their doctor when they were doing poorly was “punishment” was a hard one to incorporate into my world, a world where I try very hard to not “stigmatize” those with mental disorders. In other words to treat people with those conditions similarly to the way that a person with any other chronic condition (hypertension, heart disease, diabetes) would be treated.

Is it possible that someone with diabetes calling their doctor because their blood sugar was out of control would feel that the doctor was “punishing” them by suggesting an office visit? Probably. But would the doctor go along with that view and back away from the recommendation?

I am sensitive to the fact that coming in to see me costs money. But my experience is that offering not to charge for extra visits almost never solves the problem.

That offer is seen as a “manipulation” or coercion to get the person to come in.

The basic issue seems to be that needing to see a psychiatrist is stigmatizing to the person, and the suggestion to come in early is seen as further stigmatization.

But, just backing away and saying come in and see me when you want to can sometimes lead to catastrophe.

So, what to do?

I am not sure what the right answer is, but I think that ultimately I have to refuse to accept the view that treatment is punishment.

Acceptance versus Avoidance

9-20-2013 6-36-41 PMAcceptance and Commitment Therapy (ACT) is based on the belief that five fundamental errors are responsible for much of human distress.

One of these errors is the tendency to want to avoid painful feelings at all costs.

Our addiction to our cell phones can serve as a distraction from the distress of loneliness. Or drinking. Or smoking.

A colleague suggested that this interview with comedian Louise C.K outlines the difference between acceptance and avoidance in a way that is unusually clear. He also talks about why avoiding unpleasant feelings is ultimately self-destructive.

 

Dual Treatment: Medications and Therapy Work Together to Treat Depression

treatmentA review in the prestigious journal JAMA Psychiatry suggests that there may be a clear biological explanation of how medications and psychotherapy work together to treat depression.

The authors note that recent, unexpected, research findings suggest that antidepressant medications reactivate the brain’s ability to relearn old lessons. The medications allow the brain to modify old neuron connections in a way that is usually only possible in the brains of young people.

They review data that suggests that recovery from depression, rather than being caused by increases or decreases in specific brain neurotransmitters (serotonin or norepinephrine) is actually the result of changes in the physical connections in parts of the brain that control mood related behavior. In other words, medications enhance the brain’s ability to unlearn old connections (between stress and depression, for example) and to relearn ones that are more adaptive.

This data suggests that “pre-treatment” with antidepressants may enhance the ability of psychotherapies to teach people with depression new associations, and new patterns of response to stressful situations.

In humans there is also evidence that part of what may make depression so hard to treat is that the depressed state further inhibits neuronal plasticity (the ability to change maladaptive connections). In other words, people with depression are less able to change brain connections than other adults.

Antidepressants may counteract this tendency and allow brains that are locked into depression to process new information via psychotherapy.

Neuronal Plasticity and Recovery from Depression. Eero Castren. JAMA Psychiatry. 2013:70(9):983-989. doi:10:1001/jamapsychiatry.2013.1

Therapy or Medications for Depression?

9-6-2013 7-37-04 PMA new study published in the most prestigious psychiatric journal (JAMA Psychiatry – see reference below) strongly suggests that a brain scan might be able to help people decide whether therapy or medications are more likely to treat their depression.

As background, although some people feel that for more severe depression medications are more effective, the fact is that most studies find that both types of treatment are about equally effective.

And although the notion that it is possible to identify a “biological depression” based on the presence or absence of psychological reasons for the depression is widely held, there is no evidence to suggest that that distinction is really helpful in deciding between the two approaches to treatment.

This study, which comes from researchers at Emory University in Atlanta, reports that a particular type of brain scan (positron emission tomography or PET scan) was able to tell which people would respond to psychotherapy (and probably would not respond well to medications) and vice versa.

Don’t rush to get your PET scan, though. The study needs to be replicated before we can be sure the technique is reliable.

What is at least as exciting is that the particular abnormality (either increased or decrease activity in a region of the brain called the anterior cingulate) may help us unlock some of the secrets about how depression happens, and how to make useful distinctions between types of depression.

What do we know about the anterior cingulate?Anterior_cingulate_gyrus_animation

Well, it is about midway between the frontal cortex (conscious thought) part of the brain – where psychotherapy seems to work to treat depression and the limbic (emotional) part of the brain – where medications seem to work.

We also recently learned that meditation activates the anterior cingulate gyrus (increases activity). So we know that things that are more conscious and cognitive and move the brain away from depression increase activation of the anterior cingulate.

This study showed that low activity in the anterior cingulate predicted a good response to cognitive therapy.

This makes sense if therapy, like meditation, increases activity in the anterior cingulate.

By contrast, if your anterior cingulate is already hyperactive, therapy is unlikely to work and medications are more likely to work.

Stay tuned for more on this story, but it could be a very significant finding in terms of our understanding of depression and perhaps other psychiatric problems.

 

McGrath, Callie L., et al. “Toward a Neuroimaging Treatment Selection Biomarker for Major Depressive Disorder.” JAMA psychiatry (Chicago, Ill.)(2013): 1-9.

Recovery from Disability

disabilitySometimes we are privileged to help someone who is disabled due to bipolar or depression to recover and resume a full and happy life.

In the beginning we face many questions about the process.

Family members may have become very skeptical about the value of treatment. Or they may wonder if the disabled person is exaggerating his or her symptoms or impairment.

Many people who find themselves in this dead end become very discouraged themselves. They go from having a sense of confidence and optimism about the future – working towards a career and a happy life – to a sense of deep doubt and despair.

Life is lived day by day. The goal is to avoid the next catastrophe, which is always lurking right around the corner.

The trouble is that the pervasive pessimism and mistrust (of the disabled person, of treatment, of the disorder) and the focus on making through the next few days without disaster are antithetical to recovery.

Our experience of this process teaches us a few things –

  1. Someone has to have a sense that there may be hope – other than the therapist or psychiatrist. It may be unrealistic to expect the disabled person to have that hope, since they have suffered the most from depression. Although getting so sick and tired of suffering that the disabled person decides to act as if they hope for recovery may be enough to get things going.
  2. The process of recovery involves several stages and often (or usually) takes between 18 months and 2 years. First is “crisis stabilization” – getting safe housing, stabilizing mood enough that thoughts of suicide no longer dominate the person’s mental life, curbing dangerous substance use, etcetera. This often takes 2 or 3 months. Then there is a process of building longer and longer periods of reasonable security, and beginning to hope for real that recovery might be possible. This might take a year or so, since there is almost inevitably one or two setbacks that make the person doubt that he or she is really getting better. Finally there is a shorter (six months or so) process of putting in place the kind of supports and structure (friends, family, school, work, etcetera) that will ensure a long term mood stability.
  3. Recovery is hard work. There is never one quick answer (or “miracle drug”). The way out involves putting together a treatment program that includes several medication trials (often combining two or three medications that worked partially), cognitive retraining to counteract the negative self-talk and sense of helplessness that can otherwise derail recovery, coaching about appropriate life choices (starting with a volunteer job and then working up to a part-time job, being realistic about one’s abilities, and making appropriate relationship choices), and support for getting physically stronger (getting necessary healthcare, exercising, eating a healthier diet, having a healthy sleep / wake cycle).
  4. Recovery is often expensive. There are (sadly) very, very few publicly funded programs that support this process. Most community mental health treatment is focused on minimizing hospitalizations rather than maximizing recovery.
  5. In medicine there is hardly anything that comes close to the improvement in health and functioning that completing this process can create.

Here are a couple of books that may be worth reading that talk about this process –

 

Please also consider attending a local National Alliance for the Mentally Ill (NAMI) meeting.

Just Be Quiet

ConfusedI just met with a smart, funny, attractive graduate student who had a severely traumatic childhood. She came in looking obviously frazzled and announced that she had been crying continuously since she got a terrible haircut the previous day.

 

I wouldn’t be human if I didn’t feel the urge to reassure her. Especially because, in addition to all her other attributes, she is extremely likable but also always seems a bit vulnerable. Paternal feelings of wanting to protect her are often activated during our conversations.

But, I could also see that there was almost as much risk in reassuring her as there would be in agreeing that her hair was a mess.

On the one hand, I would be dismissing her feelings (you shouldn’t feel that way) and on the other hand, agreeing seemed as though it would be cruel (her haircut didn’t look that bad to me… but what do I know?).

So I said nothing.

She went on to say, “I try so hard to look good, I spend hours on my grooming….” And then she added, “I get a lot of criticism.”.. and then talked about negative comments made by her ex-boyfriend, her mother, her sister… in other words, people who were part of her past, but are not in contact with her now.

By now I had formed a hypothesis that the reason I couldn’t find a way to respond was that she was actually having a kind of internal argument (different parts of herself were replaying a discussion that has gone on ever since her terrible childhood).

Her internal mother was saying, You are a real mess, how could anyone want to spend time with you, look at yourself… while her internal adult was saying, What do you mean? There are many things about me that are attractive, even if I do have a bad haircut…

And as sometimes happens in those ongoing arguments, if I had stepped in the two of them might have turned on me.

So I just noticed that she had said “I get so much criticism” (present tense) and then talked only about past experiences, and expressed curiosity about that.
Which led to a pretty good discussion.
Phew, dodged a bullet.

When Your Mirror Lies

mirrorWhen an individual spends massive amounts of time obsessing about minor defects or even normal elements of their appearance that it begins to impair daily life, then they are said to be plagued by Body Dysmorphic Disorder.

Eve Fisher tells her personal story about BDD recovery. When Eve was 16 she began looking in the mirror for long periods of time fixating on the appearance of her nose. When she was younger, she would spend her time with friends and participate in various activities. As she got older, her preoccupation with her appearance prevented her from doing things that she used to enjoy. Eve was so dissatisfied with her nose that she even got plastic surgery. To her dismay however, the plastic surgery did not change the way she felt about her appearance.
Eve’s mom had started using Prozac after being diagnosed with breast cancer. Her mother was so amazed with the improvement in her attitude that she recommended the same treatment for Eve. At that time, Eve refused because she felt that her self loathing was not without reason. One day when in the store, Eve saw a magazine article named, “Hate your looks? What is means when your mirror lies.” The article was abotu Body Dysmorphic Disorder and talked about the different symptoms and treatments. Eve felt that she fit the description of BDD and felt reassured that her family and friends were not lying to her when she said that she looked fine. She realized that maybe she was the one creating a distorted view of herself.

After this revelation, Eve decided to start using Prozac and noticed positive changes in her attitude and view of herself. Because she didn’t want to be on medication for life, Eve started looking for other treatments with less negatie side effects. She turned to meditation and was able to stop taking medication entirely.

Eve has accepted the way that she looks and is happy that she no longer spends hours in front of the mirror inspecting her faults. She has learned to not equate physical attractiveness with self worth.

The causes of BDD are not known for certain, but there are theories that the disorder is related to low levels of the neurotransmitter serotonin.

Treatments for BDD include CBT, SSRIs, and exposure therapy. Exposing their believed defect in social situations allows individuals to reduce compulsive behaviors after seeing that there fears are not a reality.

More details about Eve’s story can be found at this website:

http://www.helpforbdd.org/resources/personal-stories/a-bdd-recovery-story/

Know Your Body

bodyGeneen Roth talks about how infatuated she was with her imperfections while growing up. She was constantly thinking of how much better looking she would be if she didn’t have certain features. If only she could cut out all the flaws, so just her best features would remain she could be happy.  Roth tried to reach self improvement through shaming and judging herself.

She was under the impression that if she self critiqued and dieted enough, she would achieve a better body and a better life. Roth now realizes that changing an external appearance does not mean having a different life.  The way to achieve an end of happiness is not through self loathing but through kindness.

We must accept the body that we have and truly love and embrace it. If you are born with a particular body type, you must love and embrace it. Trying to force your body to be a shape that it is not will only result in greater unhappiness and distress. Changing your body is only possibly if you understand what your body needs. Do not shame or deprive yourself to the point where you are scarred emotionally.

Roth tells those struggling with body image to eat when they are hungry and feel what it’s like when they are not.

A lot of people have the misconception that they are sad or depressed because of what they weigh. In reality, the heart of the problem is what you eat in the time that you are not actually hungry. People use food to cope with different emotions like boredom, grief, or rejection. Food is a way to suppress the real problem by acting as a distraction. People fall into the trap where they will claim to start making changes once they are thin.

Defuse Dangerous Thoughts

thoughtsWe want to spend a little bit of time talking about one powerful technique for dealing with dangerous thoughts.

Dangerous thoughts are thoughts that make themselves true in powerful and self-destructive ways.  One example of a dangerous thought is from a very attractive young woman who had a terrible childhood of neglect.  She has a powerful, dangerous thought that pops up in her mind often: she is nobody unless she is in a special, romantic relationship.

Because of this thought, she is constantly clinging to those relationships, which confirms that she’s nobody and not really worth being in the relationship with.  The men she’s with end up almost always rejecting her, which proves that she’s nobody, etc.  So here’s a thought that makes itself true.

What to do about this thought?

There are many possible techniques, but here we want to talk about one that draws on ACT treatment models.

In this view of the problem, it’s not so much the existence of the thought that is dangerous, but rather the identification with it.  In other words, it’s the fact that this woman feels that this thought, when it shows up, is really who she is, that makes it dangerous.  The ACT model focuses on defusing or distancing yourself from the thought.  In other words, not being fused with it, or over-identified with it.  Being able to step back from it and see it as a thought, one of probably many thoughts that occur in your brain.  And rather than trying to push it away or reject it or get angry with it or be afraid of it, to just let it exist, but to not get hooked into it or overly identified with it.

One interesting and fun technique involves writing down the worst, self-critical thought you can think of. Really try to spend a few seconds believing as hard as you can that thought is true, and then inserting a phrase in front of the thought that acknowledges the fact that you are not the thought.

For example, if your thought is, I am crazy, you would really try your hardest to believe that that thought is absolutely true for 10 seconds.  Then you would add the phrase, I noticed I am thinking, in front of, I am crazy.  In other words, the phrase becomes, I noticed I am thinking I am crazy.  And now think that thought for 10 seconds.  Notice how the process of identifying that there is an observer present, that there is a self that is observing the thought ,automatically begins to create some increased distance from the thought.

There are a number of other exercises that are useful in the book ACT Made Simple, by Russ Harris.