C is for Cognitive Behaviour Therapy (CBT)

Cognition is so important in terms of mental health. It is the whole basis of cognitive behaviour therapy (CBT). The belief in CBT is that your life experiences consist of five components; environment (past and present), thoughts, moods, behaviours and physical reactions. These components are all interconnected and a change in one can influence the others. Although adjustments in all five areas are probably needed to improve mental health, CBT puts the emphasis on your thoughts. Thinking patterns are thought to be most important when trying to make lasting positive changes in your life. A change in thought patterns from the usual negative to more positive and constructive can cause similar changes in the other components.

must stay positive

Of course, it isn’t as easy as it sounds. Your negative thoughts are automatic. You have to actively identify them and then use a strategy to combat them. I like to use logic. What are the facts? What information do I have to support my thoughts? What is the proof? I use previous experiences too. What has happened in similar situation? How did I cope? What have I learned that will help me this time? You have to work at it before it becomes natural. CBT has really helped me manage anxiety and perfectionism.

Then, there is depression. My issue is self-loathing. I hate the way I look, I’m not successful, I am inadequate. These are my thoughts. I know they are negative and I know I need to combat them. There is nothing wrong with the way I look. I get compliments, no one calls me ugly. I am successful. I am a Ph.D. candidate, that can’t be a failure. I am adequate. I am a good person, I work hard, I try to lead a balanced life. That is adequate. I have re-framed my negative thoughts into more positive ones. I realize my self-loathing is irrational and there are no flaws in my logic, so why do I feel worse?

The whole thing creates a conflict in my head. I know my thoughts are irrational, but logic is not enough to change the way I feel. It seems like I am lying to myself. Not only that, but I am a failure because I can’t get CBT to work for me. I gave up on therapy for a while because of this. Only after doing my own research and talking to the mental health community online did I figure out there were other forms of therapy I hadn’t tried. I guess CBT is either the front line in terms of talk therapy or it was for my specific case. All the clinicians I worked with wanted to go in that direction.

Here is a list of some of the other options.

  • Psychoanalysis – This was developed by everyone’s favourite psychologist, Freud (note the sarcasm here) and is where the whole lying on the couch thing came from. It is intense, several sessions a week are required. It focuses on bring unconscious thoughts and behaviours to the surface.
  • Interpersonal Therapy (IPT) – This one examines the relationships in your life. There is a focus on communication and may involve role playing with the therapist.
  • Dialectical Behaviour Therapy (DBT) – This is centered around the discussion of opposing views and work on how to balance the two extremes. There are usually individual and group sessions. This form of therapy is often recommended for Borderline Personality Disorder.
  • Mindfulness-based Therapy – It is focused on talking and mediation. Its purpose is to reduce stress and prevent a relapse in depression
  • Eye Movement Desensitization and Reprocessing (EMDR) – This method stimulates the brain through eye movements intending to make distressing memories less intense.
  • Life Coaching – The focus is on hopes and ambitions. It uses empowering and motivational methods to reach goals and make changes in life.
  • Arts-based Therapies – Involves expression through various art forms, visual arts being the most common. The aim is to help you release emotions and understand yourself better.
  • Bibliotherapy – The use of self-help books.
  • Acceptance and Commitment Therapy (ACT) – Uses acceptance and mindfulness strategies to increase psychological flexibility.
  • Hypnotherapy – Uses hypnosis to modify behaviour, emotional content and attitude.
  • Somatic Psychology – Focuses on the link between mind and body. It teaches you to become more aware of the physical body and how the mind interacts with it.
  • Humanistic Therapy – The focus is on the person as a whole. It explores your relationship with different parts of yourself (emotions, behaviours, mind, body, etc.).
  • Existential Therapy – It is a holistic therapy that considers depression the result of how you make sense of yourself and the world around you.
  • Compassion Focused Therapy (CFT) – This is usually recommended for those that have high levels of shame and self-criticism. It has Buddhist and evolutionary elements.

My psychiatrist recommended I try DBT next. I was supposed to start in January. In the mean time I have been art journaling and I have a couple self-help books on ACT and mindfulness.

Did you know there were so many different types of talk therapy? Do you have experience with any of these therapies? What do you think is the best approach? Is medication the more important element?

help quote

Depressed or Dehydrated?

I’m continuing with the A to Z Blogging Challenge. Today is “D”. D is for depressed or dehydrated….or both!

Drink eight 8-ounce glasses of water a day. That’s about 2L. I’m sure you’ve heard this before, but do you actually do it? I know I don’t. This 2L is just for a regular day. If it’s hot out, or you are exercising, then you need even more! Chronic dehydration leads to all sorts of problems; fatigue, constipation, high blood pressure, digestive disorders….. I could go on forever. Your body is a bio-electric machine whose major component is water. In fact, the body is 70% water. Of course something is going to go wrong if you don’t get enough of it.

When the body doesn’t get enough water, it has to ration what it does have, which means cutting back on function. This means it takes water from your muscles, bones and brain. Yes, the brain! The brain is 85% water, 2% of the body’s water weight and it receives 15-20% of the body’s blood supply, most of which is water. Thirst is the survival mechanism that we’ve adapted to tell us our body needs more water. Thirst is the warning that occurs before function is too compromised and survival is at risk. The problem is, by the time thirst kicks in, we are already suffering the effects of mild dehydration. Mild dehydration occurs when 1.5% of normal body water volume is lost. That is not a big amount. Thirst is triggered somewhere between a 1-2% loss. By the time you feel like drinking, it has already had an effect on your mind.

Dehydration affects mood, energy and ability to think clearly. A study investigating mild dehydration in men reported that they complained of tension, anxiety and fatigue. On a cognitive test battery, they had trouble with working memory and concentration. It was even worse for women. They reported headaches in addition to fatigue. On the cognitive tests, like the men, women had difficulty concentrating, but they also reported the tasks to be more difficult compared to when they did them fully hydrated.

Why does this happen? There are a couple reasons. One is tryptophan, an amino acid and the precursor to serotonin, a neurotransmitter that contributes to our feelings of well-being and happiness. Tryptophan is an essential amino acid. This means it is essential for life and it cannot be synthesized by the body, so we must get it from our diet. Tryptophan is absorbed from the gut into the blood stream where it is transported to the brain. Here, it must cross the blood-brain-barrier before it can be converted into serotonin. Dehydration impedes the transport of tryptophan across this barrier leading to a drop in brain serotonin levels.

Another reason is histamine, another neurotransmitter. Histamine is responsible for triggering the thirst mechanism and rationing a limited water supply. When you are dehydrated, histamine levels increase. What does this have to do with anything? Histamine stimulates the release of….wait for it….serotonin, norepinephrine AND dopamine. All of which play a role in mood. Low levels of histamine cause high levels of dopamine which have been associated with hallucinations. Too much histamine distorts the release of serotonin, norepinephrine and dopamine causing the “racing mind” feeling.

So there you have it. Depression via dehydration. Are you depressed or just dehydrated? Only you know that answer, but I bet you’d feel better if you drank enough water. I mean pure water, no juice or tea and definitely no coffee or alcohol, those are dehydrating! There is some water in those drinks, but there are also a lot of other things in them that your body needs water to digest. In the end your body will need more water to digest that glass of juice than the juice actually provides. How do you know if you are drinking enough? You can tell by the colour of you urine. A pale yellow means the body has enough water while a deep yellow indicates concentrated urine, a sign of dehydration.

drink water

Sources:
PsychCentral
Armstrong et al., 2012

C is for Cognitive

Cognition is a huge part of mental health. That’s why I have dedicated the letter “C” from the A to Z blogging challenge to cognitive aspects of depression. I have already talked about the cognitive dysfunction experienced by some depression sufferers and how to combat those symptoms. Today I want to talk about a popular topic in cognitive behaviour therapy (CBT), cognitive distortions.

What is CBT? CBT assumes a relationship between thoughts, mood and behaviour and by changing maladaptive thinking, you can change your mood and your behaviour. The idea is to challenge your negative way of thinking. These automatic negative thoughts are called cognitive distortions. There are methods to counteract these cognitive distortions but first, you must learn to catch yourself in a negative thought. To do this I kept a Thought Record. I recorded the situation, what I was thinking and the cognitive distortion. Here is a list of the most common cognitive distortions.

how i feel

Negative Thoughts – Emotional Reasoning

  • All-or-Nothing Thinking. This is when you look at things in absolute categories; black or white. You forget about the continuum, the shades of grey. If you make a mistake, you see yourself as a total failure.
  • Over-generalization. This is when you look at a negative event as a never-ending pattern of defeat. If it happened once, it will always happen.
  • Discounting the Positives. This was one of my first posts. You ignore your accomplishments and good qualities. It’s like they don’t count for anything.
  • Mind-Reading. You assume you know what other people are thinking, failing to consider more likely possibilities. For example, when someone laughs, you think they are laughing at you, but really they are probably having a conversation or remembering something cute their kid did that morning.
  • Labeling. You identify yourself with your short-comings instead of considering a more complex reality. Instead of shrugging off a mistake, you conclude you are a loser because of it.
  • Magnification/minimization. You blow a negative situation out of proportion or shrink a good situation inappropriately.
  • “Shoulds”. You motivate and criticize yourself with “shoulds”, “ought to’s”, “have to’s” and “musts”.
  • Emotional Reasoning. You feel it therefore you are. I feel fat therefore, I must BE fat.
  • Personalization. You blame yourself for something that wasn’t entirely under your control. I blame myself for not getting a lot of research data. In reality, there are a lot of factors that contribute to this. For example, people don’t want to participate!
  • Filtering. You dwell on the negative and ignore the rest of the situation.
  • Catastrophizing. You automatically assume the situation will turn out badly without considering other outcomes. You fear one negative event will be part of a chain of negative events without end.
  • Selective abstraction. You jump to conclusions without having all the facts.

Once you are able to identify these cognitive distortions it is time to come up with a strategy to challenge them. Being a scientist, I find it easiest to look at the facts of the situation. What are the facts? What information do I have to support my thoughts? What is the proof? You can use previous experiences too. What has happened in similar situation? How did I cope? What have I learned that will help me this time? This line of thinking does not come naturally. You have to literally stop what you are doing and think about it, ask yourself these questions. The good news? It does get easier and more natural over time. It has helped me to manage my anxiety. I hope it helps you too.

Combating Cognitive Symptoms in Depression

Yesterday I told you about some of the reading I’ve been doing on the cognitive symptoms of major depressive disorder (MDD). It might have been too research-oriented for some of you, sorry about that. This stuff is what makes my heart go pitter-patter, sometimes I get carried away. Today I’ll be more practical and talk about what I’ve read about treating these cognitive symptoms.

Medication Helps

Contrary to popular belief, antidepressant therapy is not the cause of you feeling like you’ve got a head full of cotton. Some medications can induce similar symptoms, but it is not a common side effect. Most people improve with antidepressant therapy. Only about 20% still have trouble with concentration and decision making after remission. Serotonin and norepinephrine re-uptake inhibitors (SNRIs) are pretty good at relieving cognitive symptoms. In a study comparing the cognitive status between depressives on selective serotonin re-uptake inhibitors (SSRIs) and those on SNRIs it was found that there was more improvement in the SNRI group. Those on the SSRIs were still having difficulty with episodic memory. They still had deficits in both verbal and visual memory. Episodic memory refers to memory linked to emotion and past experience as opposed to semantic memory which is memory of knowledge. So it looks like antidepressants that target more than one neurotransmitter are more helpful in the cognitive department. Remember, serotonin is involved in motivation and norepinephrine in concentration.

Bupropion, an atypical antidepressant has also been shown to improve cognitive symptoms. The primary focus of this one is increasing dopamine circulation in the brain. It also has an effect, although weaker, on norepinephrine and acetylcholine receptors. Again, remember, dopamine is for enjoyment and norepinephrine is for concentration. What about acetylcholine you say? That’s a big one. It acts on neurons throughout the whole body. I’m not going to get into it, that’s a whole biology lecture, but know that this is why bupropion is sometimes prescribed to help quit smoking.

Psychotherapy Strategies

Remediation techniques aim to improve someone’s situation by targeting a specific cognitive skill. This technique is highly individualized. Programs are based on you personal interests and strengths. It involves various pen and paper tasks and some psychophysical computer tasks. The problem with remediation is that it is time-intensive. Your therapist needs to get to know your strengths and problem areas, then design the training program. Since it it’s based on training, you have to do it often, sometimes several times a week.

Another strategy is compensation which relies on trade-offs. You find alternate ways of performing a task you have difficulty with. For this to work, your therapist has to be familiar with your learning style. You are basically taught to alter the course of your behaviour to suit your cognitive dysfunction. It has been found that doing this does not come naturally to people with MDD. From what I’ve read, it sort of sounds like cognitive behaviour therapy.

Finally there’s the adaptive approach. Here you change the environment rather than the individual. This may mean changing jobs and/or depending on other people. This is used as a last resort when remediation and compensation are not working.

The Answer

There is no real answer, not yet. The cognitive side of MDD is only beginning to be studied. There is a long way to go. I have tried venlafaxin (SNRI) and it did give me better clarity. I couldn’t handle the side effects and the withdrawal when I missed a dose, so I eventually came off it. Also, not a pretty experience. I am currently on bupropion in combination with some others. I did notice a difference when I added bupropion. Most days are alright, but the fog still comes and goes.

I recommend fighting through it. Don’t throw in the towel on those foggy days. The brain is a wondrous thing. If those who lose their vision from traumatic brain injury can regain some of it, who knows what kind of adaptations we could build by just exercising our brains.

Sources:
cogstate.com 
Office of Mental Health 
Trivedi and Greer, 2014

Cognitive Dysfunction in Depression

I have Major Depressive Disorder (MDD). It’s a battle I have to fight everyday. I’m proud to say I haven’t lost yet. It’s hard to make family and friends understand that this is a serious struggle. The symptoms commonly associated with MDD are changes in sleep, appetite and energy, combined with a lack of interest, low self-esteem and hopelessness. This gives MDD the image of an emotional attitude, something you can change or just snap out of. That’s not it at all.

I like to compare MDD to the weather. It’s always there, it changes, you can’t control it, but with skill, you can predict it and take precautions. It’s like a fog that rolls in and clouds your outlook on life. It’s dark and difficult to see through. It could last anywhere from hours to months. Then, a beam of light or a gust of wind dissipates it and the world looks brighter again. So asking why can’t they snap out of it is like asking why is the sky blue.

I’m hoping recent research on the symptoms of MDD will help lift the stigma. The old myth that depression is purely a mood disorder is slowly being overturned. Research has shown that patients with MDD can also suffer from cognitive dysfunction. What’s that you say? It’s that foggy feeling you get in your brain. You can’t concentrate, you forget what you’ve just read and processing information, let alone doing anything is hard. It’s not an excuse give up and be lazy. It’s a frustrating difficulty that we have to learn to work with.

What is cognition?

Cognition is not academic skills. Academic skills include knowledge about specific subjects like math or philosophy. Cognitive skills refer to thinking and how you interact with your environment, things everyone does everyday. Cognition allows you to perceive, acquire, understand and respond to information through abilities such as attention, memory, information processing, problem-solving and organization. These abilities are essential to function in our society. Cognitive dysfunction is when these abilities are impaired.

Recent Findings

Cognitive dysfunction can have a huge impact on the quality of life. Until recently, changes in cognitive function weren’t linked to the diagnosis of MDD. Using well-developed, objective cognitive function tests, Cogstate showed that the prevalence of cognitive dysfunction is almost 50% across a group of MDD participants. Those with cognitive dysfunction have lower productivity levels compared to normals and those who were depressed but cognitively normal. These cognitive symptoms are stubborn too. They don’t come and go with the fog of a depressive episode. They persist through the better times too. Researchers believe that cognitive symptoms may be more debilitating than the physical symptoms of MDD, possibly the underlying cause of disability.

Parts of the Brain Involved

Areas in the brain involved in cognition overlap and communicate with regions responsible for mood and emotion, namely the frontal-limbic circuitry and the hippocampus. The frontal part of the brain is responsible for cognition while the limbic system handles emotion and the hippocampus manages memory storage and processing. These areas communicate via neurotransmitters that I’m sure you are familiar with; serotonin, norepinephrine and dopamine. After all, these are what our medications aim to increase. A decreased level of serotonin explains the lack of motivation and will power that characterizes depression. Lower levels of norepinephrine decrease abilities to concentrate, while decreases in dopamine take away enjoyment. MDD is not just low levels of neurotransmitters, otherwise our anti-depressants would have put us all in complete remission.

Eureka!

Recent research has determined that our brains are structurally different from people who do not have MDD. Structural abnormalities are seen in the frontal-limbic and hippocampal areas of the brain. They are there at the beginning of MDD and may even precede it! This is shown by imaging studies on those experiencing their first major depressive episode, before starting treatment. After multiple episodes of depression, the volume of the hippocampus decreases. This decrease correlates with observed memory problems.

So far, research has determined the regions of the brain that are affected by MDD, but we don’t know why and there are few, if any effective treatments. Tune in tomorrow to learn about what is available to help combat the cognitive symptoms of MDD. Ultimately, more research needs to be done in this area to give sufferers relief from the frustrating cognitive symptoms.

MDD is not just a mood disorder or an attitude that you can change. Have you ever wished you had something to show for your pain…a broken leg, a tumor or something to explain why you are the way you are? There are physical abnormalities to explain my foggy thoughts and crumby short-term memory. Unfortunately we can’t all go get brain imaging done to prove it, but knowing that my issues are scientifically validated give me comfort. Even though I’ve known it for a while, a lot of the world doesn’t. I’m not lazy, I have MDD. It’s real. Take that stigma!

(P.S. I’m not a doctor or an expert, I’m just sharing what I’ve read that makes me say Wow!)

Sources:
cogstate.com 
Office of Mental Health 
Trivedi and Greer, 2014

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