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Friday, December 31, 2010

The Problem with Shoulds--New Years Resolutions Revisited

I have written before about New Years Resolutions and why I don't particularly have any confidence in them.  And I have also written about the problems with "should" thoughts.  Today, I would like to talk about both of these together and how they relate to each other.

People often tell themselves what they should do or should have done (e.g., "I should have known that was going to happen," "I should study harder," "I should exercise," and so on.)  These types of shoulds often cause feelings of shame, guilt, and inadequacy.  They are probably best used only when there is a moral issue at stake, e.g., "I shouldn't be lying," or "I shouldn't be stealing from this person," etc.

But there is another problem with shoulds.  We use them as if we believe that they will motivate us.  We say, "It's a new year, and I should be exercising."  Or something like that.  We use "should" thoughts to try to motivate ourselves and get us going.  But my experience is that this tactic rarely works.  Much has been written about what can bring about true behavior change, but to my knowledge focusing on the fact that I "should" diet in the coming year has not been found to lead to reliable weight loss.

The reasons why "shoulds" do not work are unclear, but I can think of several possibilities. 

1.  They involve rather shallow neural processing.  They are not focused on the reasons why change needs to occur, the benefits of changing, the problems if we don't change, the methods that can be used to bring about change, analyzing the obstacles which will get in the way of change.  They simply assert that "I should change and will change."  Thus, there is relatively simplistic cognitive activity involved in the brain.  My guess is that it taps into more primitive brain regions which are not well equipped to accomplish complex behaviors.

2.  They often evoke feelings of shame.  The thought that I "should" exercise is not far away from a shame based feeling that I am bad for not exercising.  Shame generally makes us feel bad about ourselves and seems to evoke negative behaviors rather than positive behaviors.

3.  They are often based on what others think we need to be doing rather than what we want.  We may not really want to exercise but only believe that it is the right thing to do because others tell us it is.

As an alternative to prodding ourselves with shoulds, I would recommend that we focus on the "I want" aspect of change.  "I want to exercise because I will feel better" or "I want to diet because I will look better."  A variety of different brain circuits will be used if we imagine how much better we will feel after behavior change, and if we connect the behavior with wanting rather than shame or guilt.  Other brain circuits will be involved if we analyze the obstacles which have kept us from the behavior, discuss our plan to change with a friend, and so on. 

There are a variety of strategies which can be used to assist in behavior change, but "should" thoughts are at the bottom of the list in my opinion.

There are a variety of good web sites on changing behavior.  Here's one from the University of Arizona that I found:

Thursday, December 30, 2010

Are Near Death Experiences Scientific?

I have a strong interest in near death experiences.  One issue which I often grapple with is whether they are scientific.

In a sense, this is the wrong question.  Every phenomenon is worthy of study.  What is scientific or unscientific is the way that it is studied.

Can NDE's be studied scientifically?  One element of science is reproduceability, and that is probably the Achilles heel of NDE research.  It is very difficult to reproduce them.  In fact, we don't really want to reproduce them.  We don't want to cause people to be near death. 

On the other hand, they are reproduceable in the sense that they are occurring over and over. 

There have been other situations in science where a phenomenon could not be reproduced at will.  We had to wait to study it.  The fall of meteorites was one example.  The use of solar eclipses to study the bending of space and light wave paths due to solar gravitation would be another example.  So reproduceability does not mean that something has to be reproduceable upon demand.  It simply has to occur again repeatedly in the future so that new observations can be made and replicated.

Another aspect of scientific method is the ability to objectively measure something.  In NDE's, objective measurements are difficult.  However, science does not totally require objective measurement.  For example, if I am studying depression, it might be quite useful for me to be able to measure monoamine activity in the brain.  But I can also do research which asks the person what their mood is, what their appetite is like, how much support they feel they are receiving from their spouse, what their view of the future is, and so on.  This is subjective, and it is still legitimate scientific research.

The problem is that NDE's appear to be outside of the current scientific frame of reference.  Thus, the methodology used in their study requires even greater scrutiny than other areas of research.

There are a few lines of evidence suggesting the objective reality of NDEs.

1.  They are generally similar to each other--not always, but usually.  If I interview two patients with major depression, I will find that they are generally similar.  But they will not be similar in every way.  One may have appetite problems and no sleep problems.  Another patient may have that reversed.  But they may both experience fatigue, loss of interest, pessimism, and social withdrawal.  The overall cluster of signs and symptoms is generally constant from depressed patient to depressed patient, but usually not two depressed persons are exactly alike.

2.  NDEs have occurred in history prior to the publication of popular books on the subect.  This is not a phenomenon that began in the 20th century.

3.  NDEs occur at times in young children who have never heard of NDEs.  There are numerous child expeiences of this sort; and yet many of these children have never heard of the concept of a NDE.

4.  NDEs often have a strong impact on the beliefs, behavior, and feelings of people.  This is a kind of evidence for its reality, although by itself, it is not enough.  But when we see how people often change their lifestyles because of the near death experience, that is a fact not to be overlooked.

5.  Sometimes people experiencing NDEs, as in surgery, may be able to  report objective events which occurred while they were anesthetized, and when their heart had stopped beating.  This is truly objective data.  It is sometimes reported as true; it is hard to fully document that it actually happened.

Much more could be said about NDEs, but this one article certainly can't address all of the issues.

Why is this important psychologically?  One reason is that NDEs can have a destabilizing effect on people.  It can make them much happier, more productive people.  On the other hand, they can temporarily have a depressing effect, too.  While people usually experience feelings of elation, freedom, meaning, joy, and knowledge during them, they often don't want to come back.  They often say that they were compelled to return.  This can be depressing and confusing to them. 

Secondly, sometimes health professionals dismiss their experience as the effect of anesthesia, or offer some other explanation which readily falls in their scientific frame of reference.  This does not help people to integrate their experience into their lives.  It causes them to feel discounted, and this can cause them to be depressed or confused.

As mental health professionals, we need to be open to our patients' experiences without discounting them or explaining them away.

Is It ADHD--Or Is It Anxiety--Or Is Depression?

In psychology and psychiatry, we are almost always presented with the issue referred to as differential diagnosis.  There is often more than one diagnosis which can explain a set of symptoms.

For example, with ADHD, there are deficits in attention and other aspects of executive functioning.  However, these deficits can be caused by many reasons.  Some of the most typical causes (besides ADHD) are depression and anxiety.

In depression, if it is severe enough, the brain is not working at maximum efficiency.  In fact, it is like a car trying to go up a hill when three out of six spark plugs are not working.  There just isn't the power to do what it needs to do.  Concentration and memory consolidation are affected.

For an example of a pet scan in depression, go to
(Pet scans are like an xray of the brain.  However, instead of revealing structure, they reveal activity levels.  They show the level of glucose utilization.  Red and orange areas show high levels of glucose utilization, hence indicating higher levels of brain activity.  Purples and blues indicate lower levels of brain activity.)  In the petscan at the Mayo Clinic link, you can see how the brain which has recovered from depression is more active than the brain in a state of depression.)

In anxiety, the person has a hard time concentrating.  They may feel fuzzy headed, or they may be distracted by their worries.  This interferes with attention, and when there is impaired attention, it is hard to learn.

Of course, it is quite possible that a person will have both depression and ADHD, or anxiety and ADHD.  Depression, at least in a mild form, is often a result of ADHD in children and teenagers because they are not doing well in school and perhaps not being accepted by their peers.  On the other hand, the more severe that the depression is, the less likely it is to be explained by depression, and the more we have to start looking at other causes.

Wednesday, December 29, 2010

Two Opposite Trends in Psychology

I find it interesting that there are currently two very opposite trends in psychology--both of which are critically important.  I have already commented on the different levels which human psychology can be viewed.  The two extreme polar opposites are neuropsychology and human potential awareness.  The latter term is not a current term; it is from the '60s.  But I use it to make my point.  The current term is actually "positive psychology" or "the psychology of happiness."  The main difference between the two is that there is much more of an empirical (experimental) base to positive psychology.  (Human potential psychology was often referred to disparagingly as "armchair psychological theorizing").

But both of these trends are absolutely useful and important.  They describe the human experience at different levels, using different metaphors.  And they are both true, if by "true", we mean that there is experimental evidence collected to verify their theories. 

The studies on happiness have immediate relevance to all of us.  But the the neuroscience studies have relevance too, in a different way.  The happiness studies let us know that certain behaviors, such as altruism, can bring positive effects in our lives.  They are not just something taught by religious texts.  The neuroscience studies lead to new medications, but they also suggest new psychotherapy techniques.  And perhaps most importantly for the layman, they give us that humility that I have spoken of in other postings--the humility of understanding the complexity of motivation and that there are often fundamental physiological reasons that we and those we know act in certain ways.

Unfortunately, at times in the past each of these perspectives tried to invade and take over the doman rightfully occupied by the other.  For example, it used to be taught that autism was caused by cold, rejecting mothers.  And it was also taught by some that altruism did not really exist; it was just a conditioned behavior, or the result purely of our evolutionary past and survival mechanisms.  The micro and deterministic trues to subsume the macro and holistic and vice versa.  But they are both important, separate ways of viewing the world which are both important.

It's a wonderful age that we live in that it is scientifically acceptable to converse and conceptualize human behavior in so many different ways and at so many different levels.  It is intellectually freeing, and it frees each of us to explore our own psychology in ways that our ancestors never could.

Tuesday, December 28, 2010

Why Did I Do That?

Few things are as certain as human motivation.  When people do things we don't like, we often want to know why they did them.  But that is a very slippery path.

Let me explain.

Take for example, the sixth grader who is bugging the person ahead of him in class.  The teacher gets on to him.  He stops--for a few moments.  And then twenty  minutes later, he is doing it again.  The teacher asks him why--why are you doing this after I got onto you for it only 20 minutes ago?  He sits there sheepishly.  She asks him again.  He shakes his head.  He doesn't know.  But she doesn't settle for that answer.  She wants to know why.  She might even say something like, "If you don't  know why you are doing it then who does?"

But the actual answer is complex, difficult, and even profound.  Because even if he were to tell the teacher something that sounded contrite and convincing, it might well be wrong.  Let's start with what he might say.  He might say, "I'm sorry; I'm not trying hard enough.  I will do better."  Here the explanation is something like he isn't trying hard enough.  The teacher might accept that, but she might have her own explanation--he is a bad kid.  Or she might have a more sophisticated explanation--he comes from a troubled home.  Or she might even think that he has ADHD.

A neuropsychologist might trace his impulsive and restlessness to the prefrontal region of the brain and to the child's father and grandfather who had similar problems.  One thing is for certain, the child is not likely to say:

"The reason I did it is that I am impulsive.  That is a symptom of my Attention Deficit Hyperactivity Disorder, Predominantly Hyperactive/Impulsive Type.  I inherited that from my father and grandfather.  As a result, my prefrontal region of my brain does not inhibit impulses well and does not screen out irrelevant stimuli well."

In some classes, such an explanation might get the child a smack for being "sassy."  But not to worry, it won't happen, because a child cannot articulate such a sophisticated explanation.

A family therapist might even look at other explanations.  They might point to the turmoil in the family at home and how the child's symptom of acting out at school is a predictable result of that turmoil.

A behavioral psychologist might point toward the system of rewards and consequences.  He/she might point out that the substitute teacher last week imposed no consequences on this behavior.  Or perhaps they would point out that the child being tormented inadvertently gave positive reinforcement for the behavior by what they said.

And we could go on looking at a variety of other explanations.  Why is the child doing what they are doing?  The "Why?" question is always very slippery.   Sometimes a behavior is determined by multiple causes, and the one we choose as the REAL reason may not be the real reason, or it may be only one of several reasons which accumulate to produce the final behavior.

Similarly, in marriage and in the family setting, we are tempted to ask the why question.  And when marriages are young and new, we are kind and assume the best of the other person.  But when relationships deteriorate, we often choose the most unkind explanation for what the other person did, which accentuates our anger.  Even adults do not always know why they are doing certain things.  They may not know why they are in a bad mood, or snappy. 

When we are tempted to ask the why question, we need to be aware that we are in dangerous territory.  We all want to know why things happen.  We want to know why our husband chose to be late getting home, why our wife chose not to do what she said she was going to do.  And the answers to those questions may be very important and very relevant to our lives.  But we also need to keep a level of humiility about our ability to discern the real causes and reasons behind behavior.  Even if the other person tells us the answer, we may still not know.  Keeping a level of humility about our explanations for Johnny acting up in class, or our husband taking the long way home, and so on, may keep us from overreacting to situations with excessive anger, disgust, or punishing responses.

One Way of Understanding How Psychotherapy Works--Achieving Higher Levels of Integration in Our Neural Processing

One of the basic concepts in the book that I have already referred to--the Neuroscience of Psychotherapy--is that therapy helps people to achieve a higher level of neural integration.  What does that mean exactly?  Well imagine a house with several computers in it, and each computer is linked by a single line to one central router.  Actually, that is not too different from what most of us have.  Now, imagine in the future that each computer is linked directly to every other computer, and every router is linked directly to every other router.  A new level of  functionality could be be achieved by that integration.

The theory is that many people lack neural integration because of a variety of factors, mostly environmental.  These could include neglect of the individual by their parents when they were growing up.  They could include defense mechanisms such as repression, denial, reaction formation, and so on.  When we have a feeling (such as anger or lust) and our response is "that's not me!" then we are preventing integration.  (A different response might be "Wow, some part of me feels that!?")  Integration can be vertical (neocortex down to limbic system) and lateral (right to left brain, etc.)  The technicalities are not important here.  What is important is that in psychotherapy, people have the opportunity to grow new dendritic branches to make more connections.  This in turn increases their level of self awareness of the problem and increases their flexibility in problem solving.

Imagine the following.  You are in a bad part of town.  It is dark.  You want to get to the freeway, but you keep hitting "dead end" and "detour" signs.  Now imagine a totally different scenario--no matter which way you go, the streets lead to more streets, and all of them give you routes to the freeway.  This can be seen as the role of therapy, opening up new routes to flexible action through the growth of dendritic branching and the increased integration of the brain.  This helps to overcome old defense mechanisms and can lead to totally new ways of behaving.

The idea that our brains can continue to change and grow is an exciting one.  It means that we don't have to be stuck with the attitudes of our childhood.  We don't have to continue in old, well-trodden, but self-defeating ways.  It is the goal, and the job, of a good therapist to help make that happen.  Sometimes we succeed, and sometimes we don't, but that it is the goal.  And when it happens--it's exciting!

Wednesday, December 22, 2010

Aspergers--The Most Underdiagnosed Disorder?

What is the most underdiagnosed psychological disorder?  Twenty years ago, I would have said that it was Attention Deficit Hyperactivity Disorder.  However, public awareness of that problem has grown.  And I wouldn't say it is depression.  Both ADHD and depression can respond somewhat to medication, which has been an incentive for drug companies to spend considerable resources on public education through the TV and other means.

Right now, I would say that the most underdiagnosed disorder is Asperger's Disorder.  Considered by many to be a high functioning type of autism, it can cause major problems in a person's life.  But most of the time, the problems are simply attributed to being an odd personality.  Or the person gets a diagnosis, but it only captures part of the person's problem, such as the ADHD component, the anger, the depression, etc.

Asperger's Disorder is mostly a problem with social communication.  It inhibits the persons ability to communicate with others of their age group.  They usually lack the social skills to easily interact.  If they are told to "just be themselves," they don't know what that means.  Social skills have to be learned step by step with someone to instruct them. 

Persons with AD often have some unusual sensory integration problems, what I refer to as "sensory hypersensitivities."  They may have difficulty with certain foods, certain sounds, loud noises, strong light, and so on.  Aspergers children often avoid certain foods, not because they taste bad, but because the texture of them looks "yucky" or "nasty", or because the texture of the food feels bad in their mouth.

Often AD children have a particular area of interest which is unusual in either its focus or the amount of time they spend on it.  They may focus on a typical area of childhood interest, such as cars, but be more knowledgeable than most adults about the area.  Or they may focus on an area which is not typical for children, such as learning a certain foreign language.

Persons with AD are often withdrawn, preferring their own company to being in a group. They can do quite well at tasks which involve taking things apart and putting things together, but they do not do well with interpersonal tasks.  Children with AD generally prefer the company of adults, where more objective, less emotional communication is the norm, or the company of younger children.  They generally do not make friends easily with children of the same age.

Sometimes, but not always, they have an aversion to being touched.  This can cause great distress to their parents, who may wonder if they did something wrong to cause this.

There is much more that could be said about Asperger's than I can put in this one single column.  And there are many good resources on the web.  The best place to start, if you suspect that you have if or a family member has it, would be looking at the DSM-IV criteria for it.  DSM-5 criteria will take effect in a couple of years.  Asperger's Disorder will probably be renamed Autism Spectrum Disorder at that time, and it will be somewhat more difficult to be diagnosed, based on those criteria.

Sunday, December 19, 2010

Finding Your Passion

Who are the luckiest people in the world?  I'm sure there are many answers to this, some psychological, some spiritual, and some material.

Let me make one suggestion.  They are the people who have found a passion in life.  They have found a source of energy that comes from deep within.  Their work is not just a job.  It is a calling.

Or it may not be their work.  It may be their hobby that is their passion. 

What is a passion?  It is something which energizes us as we think about it and pursue it.  It feels like more than passing time.  It provides pleasure, but it is more than pleasure.

It can perhaps be thought of as something which produces a feeling of flow.  (See Wikipedia article

We need to help our children find their passion in life.  One way we can do this is to find our own passion.  We can show them by our actions that there is something to be enthused about in life.

Of course, there are many things which can get in the way of this, such as stress, depression, severe life disappointments, and so on.  And I don't want to disparage anyone who doesn't have this feeling.   There may be very good reasons that they don't have it. 

But I encourage all of my patients to look for what is most important and most exciting to them and follow that vision.  I believe that we are all here for a reason.  We need to discover what that is, and if we do, then we are likely to find that it is not just a job but a passion.

Varnish It and Frame It--Loving Life's Little Moments

When painting, there may be times when for one reason or another, artists don't paint large, grand canvases.  Sometimes, they paint very small pictures, or vignettes.  These may only be 4x6 inches, or something like that.

The large, grand canvases are wonderful, but it is not always possible to paint them.  They may  require more time, money, skill, or resources than the artist has at that moment.

In the same way, we often want the larger picture of our lives to be grand and wonderful.  But circumstances may not allow that.  Sometimes, the larger picture is painful to look at.

In my painting class, my teacher made a small vignette example  picture for me, to give me some instruction on how to paint.  I like the little picture.  When I varnish it (it takes 3-6 months before a painting can be varnished), it will bring out the color and luster even more.  And if I put a little frame of some sort around it, it will highlight it even better.

Life has little moments like that.  They need to be varnished and framed.  If we can't enjoy the larger picture of our lives, we need to be aware of the small moments that are beautiful and focus on them.  At least we can zero in on the delightful and the positive, even if the larger picture is not going well

So--if something good happens in your life, even if it is small--varnish it and frame it!

To Accept Limitations or Not?

One of Freud's basic ideas was that the pleasure principle had to be replaced by the reality principle.  The baby's belief that it could have whatever it wanted (fantasy) had to be replaced by the reality that it has to do things to get what it wants, and that some goals and objects are simply not obtainable.

Manic persons can be delusional and lose sight of the reality of their limitations when they are manic, particularly in a psychotic mania.

But here is the problem.  When we accept our limitations, we automatically close off certain possibilities because we know that they will never occur.  It automatically becomes a self-fulfilling prophecy.  We know we cannot accomplish something so we don't try. 

Thus, as a psychotherapist, I have to struggle to walk the line between not giving patients false hope (e.g., becoming a nationally known singer) and not giving them the encouragement to reach their true potential. 

Last night I had the opportunity to listen to and talk to a jazz pianist who has only been playing five years.  He was going to be an military policeman when an accident injured him and caused a dramatic change in his life.  He has only been playing five years but is polished, professional, and a delight to listen to.  He takes lessons from a teacher in New York City and has performed in a jazz festival outside of Rome, Italy.  He has to struggle right now to feed his family (he still works as an Oklahoma City policeman) and practice and perform.  But he is almost there--almost to the point of being a full time jazz pianist.  He has a gift, and he will undoubtedly reach his goal.

Another person I know has built a multi-million dollar company in the space of a year's time.  At this point, it is not clear if there will really be a limit to what he can accomplish financially. 

So the question is, how are we to view the reality principle?  Are we to believe that we have limitations, or not?

One clue to answering this question is to look at the fact that one of the above persons is in his young 30's and the other in his late 20's.  So perhaps one way of answering the question would be to look at the age of a person.  I am in my sixties.  I have less energy than I used to.  And I have less time on Earth left.  So it would be best if I was realistic about what I could and could not accomplish.  Another clue to answering the queston is that both of the above men made some tangible progress towards their goals within a few years.  Other people may fantasize more than actually doing something. Both of the above men are full of energy and work hard at accomplishing their goals.

But I am left wondering, is it better to accept limitations or not?  Right now, I guess I just don't have the answer.

Thursday, December 16, 2010

In Love and Out Again--The Dilemma of Many of My Patients

Why do people fall out of love?  I have asked myself this many times as I have worked with clients.  What went wrong that these two people have come to this point of distance, or indifference, or anger, or even hate?  It is often hard for me to imagine what has caused such a wrenching change in a couple's relationship.

Most of us understand that love cannot continue in its white hot state forever.  But still, why does it go away entirely?

There are both active reasons and passive reasons.

The passive reason is that we ignore it.  It is a plant starved at the roots because it is not fed.  It is taken for granted.  And many times, the energy given to the children is one reason that it is not nourished.  That energy is needed elsewhere.  Or we funnel the energy to our jobs.

On the other hand, there is an active reason as well.  We kill it.  We kill it when we allow discussions to become arguments, and arguments to become fights.  Arguments are inevitable, but they can be limited in their scope and time duration to do less harm.  We kill it when we threaten divorce over and over.  Long, ongoing arguments, or arguments where divorce is mentioned, are destructive.  And then sometimes arguments beomce fights.  In fights, people try to hurt each other.

So my recommendation to couples is to nourish the relationship.  Give it time and energy.  And limit arguing.  Limit its scope and its length.  And never, ever, fight.  That is, never, ever try to hurt the other person.

Try to remember what made you fall in love with the other person to begin with.  Try to bring back those feelings by remembering how wonderful it was and all the things which initially attracted you to them.

Saturday, December 11, 2010

The Myth of Christmas Depression?

Through my career, I have often been asked to speak on the topic of holiday depression. The problem is that research indicates that it may not exist--at least for our country as a whole.

There is no evidence that there is more depression around Christmas than at other times of the year. In fact, the suicide rate is highest in the spring, not at Christmas.  There is no apparent in suicide around Christmastime.

Most clinicians do find a rise in depression in late fall, for persons who are normally prone to depression. While this could be due to the approaching holidays, there is more evidence to support the idea that it is due to Seasonal Affective Disorder and the lessening sunlight of fall.

There is no doubt that Christmas is depressing for some people. We are bombarded by happy images on the TV, and if our family isn't/wasn't like that, then we may indeed feel down. However, for other people, Christmas is a time that lifts their spirits, and so there is an offsetting effect for people in general.

I don't want to make light of the problems that some people have with Christmas and Thanksgiving. For some, it may be really difficult. But the idea that there is more depression at Christmas is essentially an urban myth. There can be depression at any time of the year, and like any depression, if it goes on long enough, it might be wise to seek treatment.

Friday, December 10, 2010

Getting "Over the Hump"

Many times my depressed patients find themselves stuck. They are at home, fatigued, sad, and filled with negative thoughts. What is often needed at times like that is to get out of the house and get some new experiences. Staying at home and watching TV is not sufficient stimulation to distract them from their internal negative thoughts. However, getting out can be difficult. It requires energy, and that is something they often don't have.

But once they are out, they usually feel better than if they had stayed at home. It would seem like a paradox. Why don't we do what is good for us?

I think that one answer is to use the example of a lawnmower. It takes initial energy to get the process started. Then once it is started, it runs on its own. A scientist patient of mine compared it to the energy of activation of a chemical reaction. It takes an external input of energy to get the reaction started; after that it is self-sustaining.

So the depressed individual needs something to get them "over the hump," to get them going. Then once they are out of the house, they often feel better than they would have felt if they just stayed at home watching TV or sleeping.

What is the solution? In therapy, I find that it works best if there is a plan. Once the patient has a plan, they are more likely to follow through. One plan is to make a commitment to get together with other people. Another type of plan is to buy tickets. People often will follow through with a concert or event because they have already put money down on the tickets. Another type of plan is to have someone come by to pick up the person and go out. It is hard to turn someone down who has made the trip over. There are probably many other types of solutions to this, but these are a few.

I think that another important type of plan is to look objectively at the consequences of staying home. Does it make the person feel better? If not, then the next time they have a chance to get out, they need to remember that staying home may be the easiest thing to do for a few minutes or an hour, but it may lead to more depression over the next several hours than getting out would.

Thursday, December 09, 2010

Stress, Cortisol, and Depression

What’s the evidence to think there’s a link between stress and depression?

There are 23,000 references in PubMed if you type in stress and depression.

The first type of evidence is epidemiological: People who have just had major stressful events are statistically more likely to fall into a depression.

Stressors are 2.5 times more likely in depressed patients compared to controls.

In community samples, 80% of depressed cases were preceded by major life events

Most episodes of major depression are preceded by stressful life events (although
most people do not become depressed even if they experience a negative life event).

It all seems so obvious that stress could lead people to be depressed. But actually it’s not.

For example, why doesn’t excessive stress cause something else? Why doesn’t it cause us to run amok, doing all sorts of wild and crazy things? Why depression?

Why doesn’t stress cause us to work harder? That would be logical–for our bodies to pump out more adrenalin and make us work harder to fix the problems we face.

The answer is we don’t know.

But to have any chance of understanding the human stress response and depression, we have to start with the basic nature of the human stress response.

We have a generalized response to a variety of stresses. Psychological stress and physical stress on the body generally lead to the same set of hormonal responses within the body, which is in itself unusual, or at least, counterintuitive.

We have one main stress response syndrome in our body:
Perception of threat
Hypothalamus activation
Pituitary activation
Adrenal gland activation

During stress, a chain reaction of physical and chemical processes prepares the body for a fight or flight situation. After the logical, thinking part of the brain recognizes that danger is present, another part of the brain, the hypothalamus releases Corticotropin Hormone Releasing Factor (CRF). This in turn stimulates the pituitary (the “master gland”) to release Adrenocorticotrophic Hormone (ACTH). The release of ACTH triggers the secretion of cortisol from the adrenal cortex (the adrenals are located on the kidneys) to provide energy and to help suppress inflammation. Through a neural pathway (that is, via a nerve rather than chemical release in the blood stream), the adrenals are also stimulated to produce more chemicals called adrenaline and noradrenaline. These in turn serve to accelerate the pulse rate, elevate blood pressure, and stimulate the central nervous system.

The fight or flight response is a good thing. It has saved many of our forbears from saber tooth tigers and other dangers. But what is good for us in the short run is not necessarily good for us in the long run.

And cortisol is one of those things. I believe that our best bet at the current time to understand why stress would lead to depression is cortisol.

We do have some evidence that that may be true.

Cortisol like drugs, i.e., steroids, can cause depression as one of their side effects.
People who are given high levels of synthetic glucocorticoids for autoimmune disorders or inflammatory issues have greatly increased risk of going into a depression.

Secondly, we know that long term exposure to cortisol results in some really nasty effects on the brain, particularly the hippocampus. The hippocampus is the memory center of the brain. It also does something else. It modulates the release of cortisol. Long term exposure of the hippocampus to stress leads to loss of neural branches called dendrites. And it leads to problems with memory loss.

If cortisol has a damaging effect on the hippocampus, then it also might have a damaging effect on other parts of the brain. There is only one article I found on this , but it could be true. The negative effects of prolonged cortisol exposure occur throughout the body, so it is not a far stretch to believe that we have only begun to understand the negative effects of it on the brain.

Thirdly, about 50% of people with depression hypersecrete cortisol. Of course, by itself this proves nothing. But it would be consistent with the hypothesis that too much cortisol leads to – too much cortisol. In other words, stress leads to too much cortisol, which can lead to damage of the hippocampus, which unleashes more cortisol.

By the way, elevated cortisol levels occur in mania as well as depression.

Now, let’s transition from looking at depression as a biological disorder to looking at the psychological aspects of depression.

It is certainly possible that once we become depressed, the depression itself stresses us. It enhances our negative thoughts, which increase our perception of threat and stress, which increases our cortisol output, which in turn would further cause disorder of brain functioning.

There is some evidence that the anterior cingulate, a curved bundle of nerves around the corpus callosum between the limbic system and the prefrontal cortex is affected by or is causing depression. And there is a small amount of evidence that high cortisol levels can cause atrophy or smaller volume in the anterior cingulate.

And there, the physiological trail runs cold. We just don’t know the rest. But sometimes a bad theory is better than no theory at all.

So here is the theory in my head when I am working with patients.

Stress begins for most people as a psychological process, although there are also physical components. If my wife is in the hospital, I may sleep different hours, eat different meals, and so on. But also there is mainly psychological stress.

Then the HPA axis causes the release of cortisol. If this is on a sustained basis, the long term effects of cortisol affect the hippocampus and perhaps the anterior cingulate.

Since the hippocampus is supposed to help regulate the HPA axis, if it is impaired, then the HPA axis may get further out of control leading to more cortisol.

Ultimately, the anterior cingulate and the serotonin pathways are affected, leading the person to become depressed if this goes on for too long, and the person has certain genetics.

But even if the trail runs cold, we may know enough to inform our decision making. Stress, particularly prolonged and severe stress is not our friend. Combatting stress takes time and energy, and in some ways it is simply easier to let ourselves be stressed out, even if that is more painful. But it is not good for our brains and it is not good for us. And depending on our genetics, it is often a luxury that we just can’t afford.

Thinking about stress psychologically.

Stress is not just the result of a situation. It is the combination of the situation and our way of perceiving the situation.

We used to think of, or I used to think of, stress as something which could go away. And once it went away, then everything would return back to normal. This way of thinking clearly has gone out the window. Memory will sometimes return back to normal after exposure to chronic stress is over, but not always.

And multiple depressions leave us even more vulnerable to further depressions. Thus, we cannot conclude that we simply return back to normal.

I sometimes say to my patients that stress is a luxury that we can’t afford. What do I mean by that? Because oftentimes, there is little that we can do about stress. Either we are stressed or we aren’t.

But that’s not quite true. There are things we can do about stress.

Cognitive therapy, for example, is aimed at helping people to be less stressed by situations than they otherwise would be.

So there is some sense in saying that stress is a luxury that we can’t afford. To the degree that we do have any control at all over our stress, we cannot afford to let ourselves sink to the bottom of the pit, with the idea that we will eventually bounce out. For some of us, this undoubtedly triggers a genetic response of biological depression. For others of us, it may impair our hippocampus if this goes on for months or years. And for others of us, it may do both.

So if stress is a luxury that we cannot afford, what can we do about it?

This is where the panoply of typical depressive therapies comes in.

Cognitive therapy works to reduce irrational negative thoughts. Why is this important? Because without excessive negative thinking, our body just might turn off the stress response. Which could turn off the cortisol. Which would give our brains a chance to heal.

Behavior therapy sometimes works on assertiveness training. Why is this important? Because assertiveness often fixes situations that we perceive as threatening, which means we don’t have to be stressed, which means that our bodies can turn off the cortisol, which lets our brains heal.

Interpersonal therapy works on improving interpersonal relationships. Which again often fixes situations that we perceive as threatening, which means we don’t have to be stressed, which means that our bodies can turn off the cortisol, which lets our brains heal.

Therapy sometimes helps the person to gain control, or at least enhance their feeling of control, which etc etc.

Get the picture? We cannot afford the luxury of stress. If there is anything that we can do which can turn off the stress response, then we need to do it. If we can divert our attention for a few hours, so much the better. If we can fix the situation, so much the better. If we can find more adaptive ways of thinking about the problem so much the better.

A Very Sophisticated Book

One of the most sophisticated books I have read in a long time is The Neuroscience of Psychotherapy: Healing the Social Brain. Psychotherapy books in the 1970's (a long time ago when I was in graduate school) were often criticized as being "pop psychology." This is anything but. It is not easy reading for the layman. But for the sophisticated reader, it can't be beat as a way of understanding how psychotherapy relates to brain functioning. The book tackles the problem of integrating two very different paradigms, or heuristics--psychotherapy metaphors and neuroscience concepts. Both are important.

There is at least one more paradigm which has to be integrated with these two, which is the spiritual paradigm.

I once had a patient, a computer programmer, tell me that he had been reading about how computers can be described as operating at seven different levels. I'm no computer wizard, but I can imagine what he means: the atomic level, the circuit board level, the basic machine language level, the macro language level such as A++, the final interface level with the human operator, etc. The same is true of humans. Their functioning can be described at many different levels, and it is hard to integrate all of these together. It will be a long time before we can integrate all of them. But in the meantime, Louis Cozolino has made a really great start in this book.

Tuesday, December 07, 2010

Settling on a Parenting Philosophy

Many times parents are overwhelmed by the task of parenting. And too often they have never settled on a parenting philosophy. They are just "flying by the seat of their pants," reacting to each situation in turn.

What is a parenting philosophy? It is a guiding set of principles. It is essentially the answer to the question, "What is the most loving thing we can do for our child?"

Here are some questions to consider. Most or all of these do not have a "right" answer. Parents can discuss these without having to always agree. However, I do think that it is important for parents to know where they disagree, and I do think that it is important for parents to agree more than they disagree.

Questions to consider:

Are rewards or punishments more important in raising a child?

Pro Reward View: Punishments tend to have temporary effects. They may cause resentment, anger, and further rebellion. They do not model the positive behavior parents are generally trying to teach.
Pro Punishment View: Sometimes it is necessary to get the attention of the child. Rewards do not necessarily do that. Moreover, setting limits is important, and it is hard to set limits sometimes without there being a punishment included.

Do children do best when left to grow up "naturally," or do they need to have enriched environments and experiences to grow up best?

Pro "Natural" Viewpoint: Many children do grow up well without fancy education or extra experiences. My parents and parents-in-law did quite well with this viewpoint. Children have a natural tendency to explore their environment and learn.

Pro "Enrichment" Viewpoint: Studies have shown that highly stimulating and enriched environments lead to greater proliferation of nerve cell connections in the brain. Additionally, there is just too much to be learned in the modern world without children receiving assistance. Public schools cannot provide this for a variety of reasons, including financial costs. While children may have a natural tendency to explore their environment, they can also get sidetracked into computer games and the internet. They are not necessarily exploring the world in the way our parents did.

Do children need limits more, or praise and warmth more?

This is probably a false choice. They need both. But parents often choose to focus on one or the other more. You probably have a preference and parents will have less conflict over parenting if they are generally on the same side of this issue.

Is it okay to be inconsistent with a child, or is consistency extremely important?

Pro-Consistency Viewpoint: Without consistency, children can be confused. They can pit parents against each other. Children may learn to manipulate. Moreover, they need to learn to deal with real life, and real life has many instances of consistency. When we do certain things, there are negative consequences--touching a hot stove, overspending our credit card limit, and so on. If parents are inconsistent, then children may be surprised and angered when they grow up and these life consistencies fail to budge to their manipulation and complaining.

Pro-Flexibility: Life is too complicated for total consistency. Often there are extenuating circumstances. Often children have learned their lesson without the full punishment being meted out. Setting a good example might not always mean showing total consistency. Setting a good example might mean showing good parental judgement when there are extenuating circumstances.

Is it better to correct children and point out what they have done wrong, or to empathize with their feelings and try to understand why they did what they did?

Should consequences and punishments be mutually agreed upon by parents? Or is it okay for one parent to act unilaterally?

How long should punishments last for? Is it okay to to rescind a punishment once it is stated, or not?

How involved should parents be in helping a child to do their tasks, such as clean their room, etc.? Is it okay to help them, as a way of modeling behavior and making it fun, or is this coddling or enabling?

How important is it for a parent to set a good example and to lead by positive role modeling? Is it okay for the parent to do one thing but then tell the child to do something else?

When children misbehave, is the behavior to be seen as a result of being bad, making bad choices, or as a result of dysfunction (such as brain dysfunction, immaturity, or family dysfunction)?

Some of these are very hard questions. And you may not come up with answers to all of them. But it is better to consider them now, when your children are growing up, than later when they are adults.