Blue Snow

CBT: tame the elephant...

noreply@blogger.com (Stef) — Sun, 27 Jun 2010 08:54:00 +0000

One eye opener of the last few years for me has been Jonathan Haidt’s metaphor of the “elephant and the rider” for the human mind. Here is a summary of the first two chapters from his book “the Happiness Hypothesis”, pulled from the website http://www.happinesshypothesis.com:

Ch.1: The divided self - The mind is divided in many ways, but the division that really matters is between conscious/reasoned processes and automatic/implicit processes. These two parts are like a rider on the back of an elephant. The rider’s inability to control the elephant by force explains many puzzles about our mental life, particularly why we have such trouble with weakness of will. Learning how to train the elephant is the secret of self-improvement.

Ch.2: Changing your mind - Why are some people optimists and others pessimists? Why do people tend to choose mates, and even professions, whose names resemble their own? The automatic emotional reactions of the elephant guide us throughout our lives. Learn how to change those automatic reactions, using meditation, cognitive therapy, and Prozac.

I think that despite its simplicity, the Buddhist rider-and-the-elephant model of the mind is very effective at explaining many of our struggles, and in particular those pertaining to stress, anxiety, or depression. The wild elephant – our emotional brain – does most of the work, is powerful, largely unconscious, and impulsive. The rider or trainer – the rational brain – holds the reigns, is self-aware, self-controlled and smart, but small!

Stress, anxiety, and depression (paper tigers if you like) affect the elephant in the first place, and our conscious mind – the rider – watches in disbelief and horror how the large animal it sits on becomes “uncontrollable”. Many of us experience this split, this “divided self” where the emotional brain gets carried away by fear or despair, and the conscious part, while starkly aware of what happens and of the inappropriateness of the emotions, is powerless to stop the runaway elephant.

Cognitive Behavioral Therapy (CBT) is all about helping the rider to regain control of the wild elephant. CBT aims to leverage that last bastion of sanity (the rational brain) to cure the rest. Mind over matter. Like mindfulness, CBT is both a theory and a toolkit. The theory helps us understand the mechanics of a dysfunctional mind, and from there develops practical exercises to train the neurotic elephant in us. Let me cover both from a self-help perspective below; as you can well imagine, taming the elephant is not easy: it takes know how, repetition, and a lot of patience!

CBT in theory
Under construction…

CBT in practice
Under construction…

Further reading
The Happiness Hypothesis: Finding Modern Truth in Ancient Wisdom by Jonathan Haidt, 2006
Self-help stuff that works by Adam Khan, 1999

4. Distraction: give your mind a break...

noreply@blogger.com (Stef) — Sat, 21 Nov 2009 03:45:00 +0000

Anxiety and depression are characterized by obsessive thinking (rumination), which hijacks all our energy and attention. Rumination makes us progressively lose touch with the outside world, people and loved ones, as well as once-enjoyable activities, in order to focus all our attention and energy on our inner turmoil.

What to do?
Rumination is a kind of misdirected attention focused on negative feelings, worries, and yourself. When severely depressed or anxious, rumination can be so overpowering and uncontrollable that it forestalls the mindful approach (previous posts). More serious distraction is called for in order to minimize its hold.

What are good distractions? The best ones are those that

Reclaim your 5 senses and your undivided attention
Leave little room or time to think (about worries or depression)
Are easily implemented
You (used to) enjoy

Take the time to write up your own list of (potentially) enjoyable activities. Anything goes: play a ballgame, play with children or pets, meet a friend, gardening, cook dinner for family or friends, going out (restaurant, concert...), sing to your favorite music, make love, get a massage, write a blog, etc...
Keep the list in your pocket, and start planning some of the ideas for the coming week.
Check your list now and then as a reminder.
Keep the list up to date. For that purpose it helps to keep a companion "positive log" in your pocket, i.e. a little diary of positive events that you can log each day. Note things or events that made you smile, that were enjoyable, that gave you energy, however trivial. The log has its own virtue, as re-reading entries reminds you of the positive things in life and counters the negative bias of depressive moods and excessive worry.

What to expect and when?
Distraction is not a silver bullet. Its effectiveness depends on the balance between how engaging the distraction is on one hand, and how self-conscious, anxious, or depressed you are on the other. If however you can forget yourself for an hour, you have won a battle. Even if the feeling doesn't last, every positive experience reminds you that there is hope, that moods too are impermanent and can sometimes be held in check.
There is this model of depression in Cognitive Behavioral Therapy: draw a circular arrow on a piece of paper and along the arrow write the words: activity > pleasure > mood. It goes like this: when we're active and engaged in leasurable activities we may experience pleasure, pleasure in turn elevates mood, and a positive mood motivates us to be more active, and so on. Conversely, a down or anxious mood tends to make us more passive or avoidant, so that we become less active, and inactivity in turn minimizes our experience of pleasant activities, which lowers our mood, and so on.
Positive distractions are designed to break this vicious circle and curb the downward spiral. As often as possible.

What’s so hard about this?
The hardest thing is when we've lost so much of our capacity for pleasure that a distraction turns out not to be as pleasant as we hoped for. This can be unsettling and frightening, to the point that we may decide to stop trying, and avoid "having fun" and "seeing people" altogether, which remind us of our lost capacity for pleasure.
Don't give in to that self-defeating feeling. How? Acknolewdge and simply accept the fact that you're not enjoying something as much as you had hoped for. It can happen. So what if you don't enjoy yourself? So what if you do? At least you've tried. Be patient and kind with yourself. With a bit of luck and patience the feeling may pass. If not, that's ok too, next time better.

Another disclaimer is that it's quite a stretch to plan major distractions day in day out. Worse still, such a goal may be so unrealistic that it makes you feel worse for "failing" before you even tried. Don't overdo it. Consider both big and small distractions in your strategy (e.g. doing a crosswork puzzle or a sudoku, talking to a colleague, or picking up that book you didn't finish), anything to keep your mind busy from time to time - rumination loves an idle mind!

While distraction is a proven coping strategy for depression and also brings temporary relief from anxiety symptoms (while distracted), it can cause anxiety to rebound as soon as distraction stops. Distraction techniques are thefore not recommended in anxiety alone, except for short term use in managing an anxiety-inducing situation.

Alternatives and combos
Distraction and mindfulness are two sides of the same anti-rumination coin. Both are tools to redirect the attention onto an activity (distraction) or a body/mind focus, like the breath (meditation).
Many people find formal meditation too difficult to do when the hold of depression and anxiety is strong. Mindfulness may even be counterindicated. Simple distractions are arguably less sophisticated, but relatively effective and just as important. Let your wellness and your personal preferences guide you in the choice of a strategy that works for you.

Aerobic activities (see the run entry), especially with a social component (team sports, group exercises, walking the dog, etc.) are excellent "distractions". Activities done outdoors combine the benefits of distraction and daylight (see the light entry).

Personal experience
I have mixed experiences with distractions. I can still remember the ones that took me by surprise and cleared my depressive mood for a day or more (concerts of Damien Rice and Cold Play). Then there were major distractions (movie going for instance) that worked against me, because I was so fixated on the outcome (must have fun!) and self-conscious (am I having fun yet? No? Why?) that my mood slipped into a downward spiral. Failing is not important, trying is: the moments where you'll finally "forget" your self will surprise you and be priceless, by reminding you that you still have capacity for pleasure, however diminished, and give you hope: "this too, shall pass".

Why does it work?

Research by Nolen-Hoeksema shows that it is possible to decrease rumination in depressed people with a tendency for it (perfectionists, neurotics, and those with a history of trauma) through distraction. This may be as trivial as training oneself to redirect awareness (see "informal midfulness" in an earlier post), taking small actions to begin solving problems (see upcoming procrastination post), etc. Minimizing rumination is key in breaking the depression vicious circle, as he sudy shows that ruminators have a 4 times higher chance to develop major depression.
"Ruminative coping" and "distractive coping" are two opposed coping styles of depressed moods. A study by Huffziger et al (Journal of Abnormal Psychology, 2009), found that in depressed patients, distractive coping predicted lower level of depressions. The authors conclude that “our study revealed clear protective effects of habitual distraction for the long-term course of depressive symptoms in formerly depressed inpatients,” and advocate behavioral activation interventions that teach patients to direct attention away from ruminative thoughts and toward immediate experience.
Unsurprisingly, two important articulations in countering the downward spiral of depression in Cognitive Behavioral Therapy (CBT), are "activation" and "pleasure", i.e. engaging in activities that have the potential of being pleasurable - distractions.
A research team in Zurich is developing an educational program to minimize the risks of burn-out (and ultimately depression). The second rule in the program (after energy management - healthy eating patterns, regular exercise - and before social support) is to counterbalance stress with pleasurable activities. Any activity or hobby will do, as long as it is engaging and potentially pleasurable.

Further reading
Burned out by Ulrich Kraft, Scientific American Mind, June/July 2006, pp. 29-33

Self help stuff: what others say

noreply@blogger.com (Stef) — Tue, 03 Feb 2009 21:46:00 +0000

To complement my limited view of self-help strategies against depression, I want to share with you a very comprehensive research done by Amy Morgan and Anthony Jorm from the Department of Psychiatry at the University of Melbourne, Australia.

Morgan and Jorm published the results of two studies in 2008 (see references below). In the first study, of 2214 self-help strategies (!) the researchers selected 282 and presented those to a panel of "depression consumers" and another of health professionals. The panels were asked to rate each strategy in terms of helpfulness and feasibility. The top 15 of most helpful and feasible self-help strategies included:

Exercise
Good sleep hygiene
Regular sleep schedule
Doing enjoyable things
Involvement in purposeful activities
Rewards for meeting goals
Relaxation methods
Talking
Informing family and friends
Healthy diet

In a second study, the researchers reviewed evidence for 38 self-help strategies. Of the strategies falling into the categories psychological methods, lifestyle changes, and physical/sensory methods, here are the best in class according to available evidence:

Autogenic training (resembles mindfulness): promising
Bibliotherapy (reading self-help books): helpful
Computerised intervention (Cognitive Behavioral Therapy via computer): promising
Distraction (to counter rumination): helpful
Relaxation training (to relieve anxiety): may be helpful but not as much as psychological treatment
Exercise: good evidence
Pleasant activities: reasonably good evidence
Sleep deprivation (staying awake one night and following day): helpful but temporary
Yoga: may be beneficial
Light therapy: good evidence for seasonal Affective Disorder (SAD) and also helpful for non-seasonal depression (smaller effect though)
Massage: immediate and long term effects

There were more categories in that study, including herbal remedies, dietary supplements, substances, and dietary methods, which I exclude here.
Note in passing that meditation was included in the study but no evidence for it was found (or against it for that matter).
The sleep deprivation is a curious one that I experienced by accident one night, and then tried again on purpose - I'll come back to that in a follow-up post, which will be about sleep.
I'll refrain from further comments and let you judge for yourself. Comparing the above to my own list one thing is clear: must get a massage...

References
Self-help strategies that are helpful for sub-threshold depression: a Delphi consensus study by A.J. Morgan and A.F. Jorm, Journal of Affective Disorders 2008
Self-help interventions for depressive disorders and depressive symptoms: a systematic review by A.J. Morgan and A.F. Jorm, Annals of General Psychiatry 2008, 7:13

3. Be mindful...

noreply@blogger.com (Stef) — Sat, 24 Jan 2009 05:35:00 +0000

Before 2007, I was allergic to all things "spiritual" and convinced of the superiority of reason uber alles. I've changed my mind. A shift of attitude is needed - a different way of dealing with stress, including that stemming from anxiety and depression.

The very purpose of mindfulness, in the Buddhist tradition, is to combat the roots of suffering. Other approaches like exercise, light, etc., are important and provide short-term symptom relief - but mindfulness lays a foundation for the long term by teaching us new behaviors to respond to stress. Having said that, I'm the first to admit that mindfulness is also the most difficult lifestyle change to embrace, because for most of us it means unlearning months and often years of bad habits...

What to do?

Make time for formal meditation practice 3 to 5 days a week - see mindfulness post for details.

If you are a beginner, avoid setting high expectations. Meditation sounds simple but can be surprisingly challenging. Start small, say 5 minutes at a time, and progressively build up to 10 mn, 15 mn, and 30 mn when you're ready for it. In the MBCT program, it takes 8 weeks to learn the basics techniques and develop a 45 mn a day routine. Do not beat yourself up about losing your focus or dozing off, it's all part of the practice. You cannot "succeed" or "fail" at meditation, you either do it or you don't!
Try to stick to a fixed routine. Mindfulness is a lifestyle change that requires discipline.
Complement formal practice with informal mindfulness (see mindfulness post for ideas).
Meditation practice is well suited for depression prevention and relapse prevention. If however you are in the middle of a major depressive episode or are severely depressed, avoid formal meditation practices and stick to the informal methods until you get better. Seriously consider the cognitive behavioral approach, i.e. CBT.

What to expect and when?

The mood lifting or calming effect of mindfulness is for the long run. Whereas exercise can provide symptom relief, mindfulness aims to change your attitude to life's challenges, to your own states of mind, incl. depression and anxiety. That takes time. In fact, studies have shown that meditation practice, MBCT, etc., work to prevent depression and depression relapse.
Often, though not always, recalling the lessons of mindfulness (e.g. "this is just a feeling, it's ok, sit it out...") and some of the informal meditation techniques (e.g. breathing and positive rumination) can bail you out of rumination or relativize a perceived threat.
Even if you do not immediately feel the benefits of mindfulness, keep at it long enough (typically 8 weeks or more) to reap its potential benefits.

What’s so hard about this?
Formal meditation practice is harder to do than running therapy. Both require about the same time investment and discipline, but exercise uses the body to heal the mind (the ASICS motto), whereas mindfulness relies on the mind to heal itself. Tricky.
What helps a lot is to join a meditation course or even better Mindfulness-Based-Cognitive-Therapy (MBCT). MBCT is Buddhist meditation without the Buddhism bit, and specifically geared towards depression prevention. The program typically lasts 8 weeks. The advantage of such a course over self-help is that there is a teacher to motivate you, with the added benefit of getting out of the house and meeting new people, both of which are very therapeutic.
The next best thing to a formal class is to buy one or two guided-meditation CDs and let them talk you through mindfulness territory.

A word of caution. Formal meditation practice is not recommended if you are in the middle of a major depressive episode or are severely depressed. It can make you feel worse, and I have experienced that effect during the MBCT course. It did pass but I found it unsettling. Better to wait until you are well enough to learn new skills. On the other hand, everyday informal meditation is safe even in your darkest hours. I invite you to read and re-read that part of my earlier mindfulness post, and try to put it into practice on a daily basis.

Alternatives and combos
There is no alternative to mindfulness, in one form or other. Short of being able to eliminate all stressors in your life, you need to change something in yourself in order to cope with your depression or anxiety disorder, or to prevent relapse. Don't expect peace of mind to simply dawn on you.

Some of us (the right-brained ones) will have difficulties buying the spiritual or "left-brained" bits of mindfulness or meditation. Read the evidence in the "why does it work" section below, and have a look at some references. Not convinced? Here is the best alternative for no-nonsense types: Cognitive Behavioral Therapy or CBT. Also, in contrast to meditation or MBCT, CBT can be applied even in the middle of a depressive episode. As it turns out, CBT and mindfulness are not as different as you might think. More on that in a later post...

I found out by accident that 15 mn of formal meditation of the breath (sitting) just before going to bed, significantly increased my chance of having a good night’s sleep! Although meditation is not aimed at better sleep (or happiness for that matter), it’s a useful spin off.

Personal experience
My first mindfulness revelation was that I am by nature pretty “mindless”. My second revelation is that I am a very undisciplined meditation student. Formal meditation practice is usually the first thing I drop when feeling tired or down (running is easy in comparison, believe me). On the other hand, I nowadays find dependable comfort and support from informal practice (see the mindfulness entry): that’s more my cup of tea.
In fact, I’m convinced that mindfulness played an important role in preventing full-blown relapses since 2008. Although I still suffer from anxiety and depressive moods, and outside circumstances have been as bad as those presiding to my nervous breakdown in spring 2007 at times, I haven't had a total relapse since then, nor missed a day of work (that says a lot in my case). I am functioning, sometimes poorly, sometimes feeling bad and diminished, but nevertheless functioning.

Acceptance is the key. That’s the difference somehow. Accepting events and moods as they come, pleasant or painful, including depressive moods and anxieties. Paradoxically, acceptance alone (the little voice that says “so what?”) has the potential to blunt pain and distress, and helps you sit through it until it passes. That, and the notion that everything is impermanent: wait long enough, and every monsoon gives way to blue sky. Why struggle? It only makes the wait seem longer.

Why does it work?

It took me a while to understand the logic of meditation practice. There is nothing magical about it. The first reason is the challenge - which you'll experience from day 1 - to hold the posture and keep your cool despite physical discomfort or even pain; this is a stepping stone towards accepting and working with emotional pain. The second reason is that mindfulness teaches us to be aware of when we're ruminating, to disengage from it, and "get back to the practice" i.e. redirecting attention to what we were doing before being hijacked by negative thoughts.
Two studies by Teasdale and others indicate that after MBCT, the risk of depression relapse is halved. Note that this holds for people who have had at least 3 depressive episodes.
A recent study at the University of Exeter shows that MBCT is at least as good as anti-depressant drugs in preventing depression relapse amongst people with recurrent depression.
Since the nineties, neuroscientist Richard Davidson has investigated the effect of meditation using brain imaging techniques. His findings show that long time practitioners (Tibetan monks!) exhibit unprecedented brain activation levels, especially in the left prefrontal cortex region associated with happiness and positive thoughts. Meditation practice, like other activities, can seemingly train and modify brain circuitry, a concept known as neuro-plasticity.
Researchers at the James Cook University of North Queensland looked at the effect of meditation versus running on brain chemistry. They found that both equally increased levels of the CRH hormone related to positive mood changes. However, only running increased the level of beta-endorphin, the brain’s opium.

Further reading
Meditation: take a stress-reduction break wherever you are at www.mayoclinic.com
The mindful way through depression: freeing yourself from chronic unhappiness by J. Mark G. Williams, John D. Teasdale, Zindel V. Segal, and Jon Kabat-Zinn, 2007

Mindfulness in a nutshell

noreply@blogger.com (Stef) — Sun, 18 Jan 2009 09:49:00 +0000

Google "mindfulness" and you'll find millions of web pages with endless variations on that theme. Trust me, there is a common denominator to all of this. In fact, the teachings and practice of mindfulness are deceptively simple, once you strip them of religiosity and new age hokiness. Here is my little cheat sheet on the topic.

Mindfulness teachings

Mindfulness = to see and accept things and feelings as they are, and direct attention to the present moment. When your mind is lost in thoughts, dwells on the past or worries about the future, make a note of what it does (e.g. "worrying, worrying"), then gently but firmly refocus your mind on what you were doing before wandering off - meditation practitioners call this, "go back to the practice". Repeat as needed, a thousand times a day if you must. You're not failing, you're practicing!
Can you see that mindfulness is the opposite of rumination? Everybody can be "mindful", the difference is who practices (even unknowingly), and who doesn't.

Thoughts and feelings are creations of the mind, nothing more, nothing less. They are neither reality nor you. They are mental events that come and go like clouds: don't try to stop them or escape them, the trick is to watch them pass by with as much detachment as you can summon ("don't believe everything you think"). I like to use the analogy of physical pain: it is well known that the fear of pain is worse than pain itself, and that struggle against pain tends to make it worse. Conversely, making a conscious attempt to sidestep fear and the pain avoidance reflex, e.g. by staying calm and breathing slowly, can diminish the experience of pain. So too with emotional pain, including anxiety, panic, and depressive feelings. Easier said than done of course, but the principle is the same.

Stop wanting things to be different, just because you feel bad. Accept the present moment and everything that comes with it as is, and work from there. Certainly do not fight against your own emotions; do not flee them either, as it only fuels more stress. It's ok to be down or anxious; that too, shall pass. Sit it out.

As you can see, mindfulness has a lot to do with acceptance and equanimity. That's enough theory for now, let's have a look at the practice, which is the only thing that really counts...

Formal meditation practice (meditation of the breath)

Sit comfortably but don't slouch. Minimize distractions.

Close your eyes but try not to fall asleep! Take a few deep breaths.

Now focus on the breath, the physical sensations of it: "watch your breath". If you find it difficult to watch the breath, count (1... 2... 1...) or name (in... out... in...) each breath.

You mind will invariably wander off and get caught in a stream of thoughts or feelings. Every time, briefly note what it is doing, and gently but firmly escort the mind back to the practice. "Mindless" people get carried away by the thought stream and identify with it. From now on, try to disengage the autopilot everytime: anxious or depressed, yes, but mindful. Note that meditation is not about "succeeding" in directing your attention to the breath or a mantra; each distraction as a reminder, an opportunity to practice refocusing.

If you feel physical discomfort or pain, don't shift your position or try to get rid of the sensation. Stay calm, briefly note the sensation and associated feelings, and go back to the practice. From now on the discomfort or pain is part of the practice, and may remain in the background. It's ok ("be comfortable feeling comfprtable"). Dealing with physical discomfort, itches, or even pain, will train you do deal with emotional suffering in the same way.

Try it 5 to 15 mn each day for a start.

What is it about the breath you may ask? There are countless meditation practices, but they only differ in the object of attention. You can meditate about the breath, parts of the body, an image or sounds, a thought or a phrase (mantra), feelings, etc. The thing about the breath is that it's with you everywhere you go and it is less emotionally charged to "watch" than anything else. Also, its mantra-like repetitive nature is very helpful.

Just like there is making time for "formal" physical exercise (e.g. 45 mn running a few times a week) and "informal" exercise (e.g. deciding to take the stairs instead of the lift), there is formal and informal meditation practice. Some find informal meditation easier to stick to and also more rewarding in the short term. Both could be important. Try both.

Informal meditation practice

Switch off the autopilot: as soon as you notice it, disengage from rumination and refocus on what you were doing (mindlessly), using your 5 senses this time round. Walking, dishwashing, showering, cooking, gardening, all can be done mindfully. Every time the mind wanders, make a mental note of it and go back to the "practice". With this exercise, every moment of the day becomes meditation ground. This minimizes rumination and prevents mood spinning out of control.
Take regular breaks to touch base with yourself: stop what you're doing, close your eyes, and take five slow breaths; watch the breath.
Find a private place (e.g. the washroom at work), and do a 3 mn meditation, e.g. of the breath or a "body scan" (direct your attention to a part of your body, the physical sensation of it, and scan your entire body that way).
Count-your-blessings variant: I call it positive rumination. Example: think, "(breathe in) I was kind to X... (Breathe out) I'm proud of this..." and repeat this "mantra" for the duration of the meditative break, a minimum of 10-20 times.
Visualization: recall a nice memory or image (you may use a photograph), or better think about a pleasurable activity that you have planned for yourself later. Repeat as in the positive-rumination exercise. When depressed, beware that happy memories could make you feel worse by contrast: instead, focus on a neutral image or future events like week-end or holiday plans.
Listen to your favorite uplifting music. I really mean "listen", i.e. mindfully as in paying attention to the lyrics, or singing along, etc.
Pick a good book on spirituality and read it for inspiration and support (avoid internet). Some suggestions are provided below.

Further reading
Guardians of Being, by Eckhart Tolle and Patrick McDonnell, 2009
The mindful way through depression: freeing yourself from chronic unhappiness by J. Mark G. Williams, John D. Teasdale, Zindel V. Segal, and Jon Kabat-Zinn, 2007 (includes a guided meditation CD)
Meditation for life by Martine Batchelor, 2001
The Little Book of Calm by Paul Wilson, 1999
Self-help stuff that works by Adam Khan, 1999
Full catastrophe living by Jon Kabat-Zinn, 1990
The relaxation response by Herbert Benson, 1975

Paper tigers, windmills and vicious loops

noreply@blogger.com (Stef) — Sat, 17 Jan 2009 14:02:00 +0000

I was going to start my next entry about mindfulness, when I realized that I needed first to share one or two things about depression itself, my field notes if you like. That's because any psychological, cognitive or "mindful" approach to dealing with anxiety or depression requires that we understand some of their underlying mechanisms.

The precursor to depression and anxiety is always stress, in one form or another. Initially, stress is defined as the body's state of alarm in reaction to a perceived threat or "stressor". Stress in itself is not a bad thing, we couldn't survive without the flight-or-fight response that it triggers. But stress is quite demanding on body and mind and is designed by mother nature to be a short-lived state. Problems really start with chronic stress caused by unresolved and long-term stressors. Chronic stress eventually leads to burnout, illness, anxiety and/or depression.

Stressors like an abusive boss or illness are facts of life, often we cannot avoid them nor fend them off. If we can't deal with the stressor itself, then our only hope and challenge is to change the way our mind and body respond to stress. Take two persons A and B facing some misfortune: A withdraws and indulges in feelings of helplessness or anger, while B takes up the challenge and adapts to the new situation. Same stressor, different responses. But the story doesn't end there - under chronic stress A's maladaptive "stress response" can spiral out of control into anxiety and depression...

I have read zillions of things about depression trying to understand what was happening to me. But of all these, a single one stands out. To be honest, it took a second reading before the "aha" moment. I quote Williams et al (see ref. below):

At the very earliest stages in which mood starts to spiral downward, it is not the mood that does the damage, but how we react to it.

What does it mean? It means that while worry and distress are perfectly normal reactions, when you start to worry about your worry, you're crossing some invisible line. Why is that? While B is focused on the stressor out there, in problem-solving mode, she has no time to ruminate about her mood. In contrast, A worries about her anxiety and may become paralized by her own depressed mood. It's a vicious circle. A's very mood has become her #1 stressor; A ends up beating herself up in a struggle she can't win or run from, because it takes place entirely inside her mind, like Don Quixote's "wind mills of the heade". This also reminded me of Roosevelt's inaugural words in the wake of the Great Depression:

So, first of all, let me assert my firm belief that the only thing we have to fear is fear itself - nameless, unreasoning, unjustified terror which paralyzes needed efforts to convert retreat into advance.

The irony is that there may not even be a real threat anymore. Like A, our mind has become locked into a vicious feedback loop in which anxiety and depression fuel themselves through rumination and self-critique, and have promoted themselves to chronic stressors! We're stuck.

How to become unstuck? First, we need to recognize that the stressors that keep our mind spinning are not real, not out there, but are our own thoughts and feelings, fear itself - paper tigers. Nothing more, nothing less. This awareness, this acceptance, is the first step on the mindful path from A to B...

Further reading
The mindful way through depression: freeing yourself from chronic unhappiness by J. Mark G. Williams, John D. Teasdale, Zindel V. Segal, and Jon Kabat-Zinn, 2007

2. Let there be light

noreply@blogger.com (Stef) — Tue, 13 Jan 2009 22:27:00 +0000

Together with exercise and sleep, light is one of three physical self-help tools I propose to mitigate depression. I rank "light therapy" high on my list because it is relatively effective (although more modestly so than exercise) and so simple to implement.

What to do?

Maximize your exposure to daylight, especially when the sun is out. Two key moments in the day are the morning (on getting up) and midday. Make time to be outdoors, minimum 30 mn either in the morning or midday, or both.
Overall, try to be outdoors as much as possible and as long as possible (for reference, the light level in an office is about 500 "lux", an overcast day yields 15000 "lux", and a sunny day 80000). If you have the choice, go walking instead of driving or taking public transport. When relaxing (or trying to) and if the weather allows, choose to sit outside rather than indoors.
When indoors, let in as much light in as possible by keeping curtains and blinds open. Whenever possible, choose a spot in the light to sit down. If your office has no windows or insufficient lighting, consider talking a walk outside during lunchtime to catch some sun.
Your life circumstances may not allow you to get enough sunlight during daytime. If that is the case, consider then investing in a "light box" (10000 lux white light, or blue light equivalent), and follow the instructions for light therapy in the morning and/or midday (some light boxes are portable and can be carried to work, for instance).
If hypomania is an issue or if you are bipolar, you are advised to avoid morning exposure - midday exposure however is safe.
Conversely, in the evenings, say after 9-10 PM, dim the lights, switch off TV and computers (look who's talking, it's now 1 AM!), and read instead...

What to expect and when?

For respondents to light therapy, symptom reduction will be felt within one week of "treatment."
Sometimes you may notice a brightening of mood when the sun breaks through the clouds or at sunrise for instance. Get exposure...

What’s so hard about this?
Not much really. The main issue is that we cannot always control the light levels, which is why you may want to buy a light box, to be used during winter mornings, for instance.

I only caution the bipolars amongst us, for whom morning light therapy can trigger hypomania or mixed states. If that happens, switch to midday exposure.

Alternatives and combos
Daylight and sunlight are the best, but as already mentioned we cannot always get them when we need them. That is why there are light boxes.

My personal best combo is to exercise outdoors instead of at the gym or on the treadmill. Two or three times a week, I will skip work lunch, put my ASICS on and go run outside the office: that way I get running therapy and daylight therapy in one go. I'm jumping ahead but there is a triple combo: run, outdoors, and running meditation; to be honest with you I have never succeeded in meditating while running. But you could more "zen" than I am...
It has indeed been shown that exercise and light exposure together have a strong regulating effect on our biological clock, which is often disrupted by depression or the bipolar condition. Think for instance of jogging at dawn, shortly after wake-up (and a good coffee). I prefer to run around noon.

Personal experience
My mood is quite sensitive to weather conditions (which is to say that my depression type is "reactive", as with 90% of depression sufferers). Gloomy or rainy weather tends to lower my mood, while a change of weather for the better or a sunny dawn can subtly elevate my mood. This mood brightening is not systematic however and I obviously cannot control weather. Nevertheless, I do try to be outside as often as possible - do the same.

Why does it work?

A broad study conducted on two different days (one sunny the other rainy), asked people on the street to self-rate their state of "happiness" on a scale from 1 to 10. Controlling for all other variables, it appeared that the bad weather alone accounted for an average drop in happiness from 7 to 4. Turn that around: bright daylight alone has the potential of upping our mood by 3 points.
Conventional wisdom and studies indicate that hours of sunlight and rising temperatures correlate with mood brightening and anxiety relief. To be fair, a few studies (most recently Denissen et al., 2008) show only minor correlation, but these studies often do not control the amount of sunlight exposure, which seems to be the critical factor.
The connection between anxiety and temperature is noteworthy because studies of the impact of exercise on mood have also suggested that elevated body temperature explains the anxiety decrease response of exercise.
There is a coupling between mood and the so-called "circadian rhythm" (our 24-hour biological clock). This is a bit of a chicken and the egg story, but in any case when one is disrupted then the other will be too (think of sleep disorders, stress coping, and Seasonal Affective Disorder - the winter blues). The mechanisms behind the circadian rythm are complex and not yet fully understood. However, the primary external cue to reset the biological clock is daylight, therefore daylight exposure has been proven to be efficacious in treating mood disorders such as SAD. In addition, recent meta-studies concluded that even for (non-seasonal) depression, "light therapy offers modest though promising antidepressant efficacy."
Sleep and wakefulness are governed - amongst other things - by the interplay of two important brain molecules, serotonin (produced during wakefulness) and melatonin (produced during sleep). The two are coupled since melatonin is synthesized from serotonin. Interestingly, low serotonin plays a role in depression and anxiety disorders, while low melatonin plays a role in sleep disorders, and as we all know, the two go hand in hand. Light levels govern the serotonin-to-melatonin switch. The advice is clear: in the evening, dim the lights to promote sleep (melatonin), and at dawn, let light strike your eyes to reset your biological clock and trigger wakefulness (serotonin). More on this topic in the sleep post. Leave your shades at homes.
Also note that even an overcast day exposes you to much more light than artifical light can, so don't wait for the sun to be outside.
Last but not least, a deficiency in vitamine D has been shown to precipitate depressive moods, amongst other things. The way the body makes vitamine D is by sunlight exposure on the skin. Sunblock counters this, so don't overprotect yourself.

Further reading
Light therapy at www.mayoclinic.com

1. Run!

noreply@blogger.com (Stef) — Sat, 10 Jan 2009 23:25:00 +0000

This week, having picked up my ASICS and running after a 12-day break, I was doubly reminded of the phrase "a sound mind in a sound body" (Anima Sana In Corpore Sano). If I were only allowed to do one thing to curb my depressive moods or anxieties, then without hesitation I would pick exercise.

What to do?

Make time for exercise, 3 to 5 days a week, and exercise at least 30 mn to 40 mn each time. The key words here are regularity and intensity.
In terms of intensity, the exercise should "draw sweat". Ideally "aerobic", i.e. a moderate to vigorous cardio training that can be sustained over a relatively long period of time. The most effective activity is endurance running.
If you are a beginner, avoid pushing too fast too soon, you'll burn up your resources and your motivation! Always allow for 10 mn warm-up, go slow and build up a level of effort you should be able to maintain for at least 20 mn, and finish up with a cooling down period (another 10 mn). Over time you will know your limits and optimize your routine.
Try to stick to a fixed program, if only for motivational reasons. Set yourself goals, however modest. It is a lifestyle change. Depending on the activity, seek advice on a suitable training program for you.
To reduce stress or improve self-confidence, throw in a training session a few hours before an important appointment or after a stressful day.
Choose an activity you have a chance to enjoy. It's hard enough as it is.

What to expect and when?

I experience a noticeable calming, sometimes mood-lifting effect about 4 times out of 5 after a single sustained workout session. The effect is subtler when seriously depressed, but it's there. For a robust response try to stick to the regular 3-5 times a week routine.
I liken the anxiolytic/antidepressant effect of one workout to that of 10 mg oxazepam or equivalent, but without the rebound anxiety and the addiction issue.
The effect is most noticeable when working close to the upper limit of aerobic effort for the length of the workout (80% max. heart rate). Sometimes, you may experience the runner's "flow" or "high", but don't look for it, it's pretty elusive.
Running is arguably the most efficient forms of exercise, but any aerobic activity involving large muscle groups will do the trick: fast cycling, lap swimming, brisk walking, gardening, serious cleaning up, etc. You may need to lengthen somewhat exercise duration for activities other than running, but the essential message is simply: "break a sweat"
Even if you do not think you feel the short-term benefits of exercise (for instance when severely depressed), try to keep at it long enough to test the longer term response, e.g. 10 weeks. Remember: you don't have to like it, just do it.

What’s so hard about this?
What's hard about the running therapy is not so much the running, but depression itself, which robs us of the very thing we need to get going and get better: motivation. Lack of motivation and the feeling of hopelesness are our biggest challenges when starting up an exercise program or sticking to it, for example when missing a training session ("that's it, I can't do this, it's hopeless..."). I have only one simple advice: sidestep your inner critic. It's perfectly ok to lack motivation.

What may help you further is for you to involve partner or friends in this ASICS therapy, either by going along with it or by motivating you to put on your training gear and kick you out of the house when you don't feel like it.

The most common excuse for not exercising is the elusive "lack of time" we all seem to suffer from. I do struggle with that one too, but must admit that what I really lack is usually motivation not time. Make time or reprioritize, as this is more important than work or ruminating on the couch. Here are a few tips to help you though: establish a fixed training schedule and stick to it; you can exercise instead of lunch 2-3 times during the work week; when you wake up at 4 AM get up right away and run, it's better than tossing and turning and brooding in bed.

I tend to ruminate even when running (no "flow" for me). At one point, rumination got so out of hand that there was this voice in my head shouting: "you could stop now. Come on, take a break. STOP NOW!" All within a few seconds. And for a while, my mind would give up before I had time to realize what was going on and "take over". This was a clear case of "mind gives up before the body does". After a few weeks, I could catch myself doing this, and say to myself: it's just a trick of the mind, I don't have to listen, just keep on running.

One common pitfall of beginners who start to get the hang of it and to feel the benefits, is to want to go too far too soon. On occasions I systematically warped my training schedule, skipping warm ups, days of rest, even entire training weeks ("more endorphins!"), only to end up in injury. The injuries in themselves were not that bad - what was bad was that each time I was deprived of the uplifting effect of exercise for an entire month. Go slow, stick to the program, and know your limits: exercise doesn't have to be intense to reap the benefits. Another pitfall is to seek out runner's high; the high itself feels great of course and can sometime last for a day, but there is also the risk of a mild "crash" when the endorphins are exhausted. Don't go for the high, go for the flow.

Just like there is a runner's high, there also is a runner's blues. It usually is a fallout of the so-called OTS or Over-Training Syndrome. It is no coincidence that the concept of "burnout" originated in sports, describing a total exhaustion of physical and mental resources. Many top athletes at peak performance flirt with OTS and burnout. The symptoms of burnout largely overlap those of depression, and increasingly experts believe the two to be the same. In my experience, burnout is foreplay to clinical depression, the actual nervous breakdown. So watch out: don't over-train.

Alternatives and combos
I don't believe there is an alternative to exercise as such, but there are many ways to break a sweat even when your physical condition (age, weight, heart) doesn't allow for aerobic exercise. If you can't run, have a (brisk) walk. If you can't walk, clean the house or spend an afternoon gardening, etc.

I have found by accident that a very effective way to boost the benefits of aerobic exercise is to play a ballgame. That's because focusing on a ball combines the advantages of mindfulness and distraction with exercise, while minimizing rumination time. Additionally, a ballgame is social and the occasional speed bursts make you flirt with the aerobic limit (where the runner's high lives).

Personal experience
At the time of writing, I run about 4 hours a week following a training schedule (in a book), and I set myself a target (half-marathon in one month from now). My love story with running however has had many ups and downs, including false starts, injuries, loss of motivation, and skipped training sessions. I always come back to running though, because it works and I know it. As a matter of fact, I started running before becoming acutely depressed - during what I call my "burnout" period early 2007. At that time running clearly did not prevent the looming nervous breakdown - I was simply overwhelmed by my inner turmoil and foolishly ignored all the alarm bells.

Nowadays I follow the training schedule as best as I can, and additionally I throw in a training session just before or after a stressful event such as an important meeting at work - which works great so far to reduce anxiety and boost confidence.

Why does it work?

A substantial body of evidence has been gathered since the 70's linking exercise to mental health benefits, esp. in terms of antidepressant and stress-reduction effects.
To date the jury is still out on the mechanism(s) behind exercise's mood-lifting effect. Multiple pathways are likely to be involved, such as a decrease in cortisol (the "stress hormone") and an increase in certain neurotransmitters (incl. pain-relief and well-being endorphins and the "bliss" neurotransmitter anandamide).
Various comparative studies have shown that regular exercise was at least as effective as psychotherapy or medication (SSRI), and obviously without side-effects.
While most studies have looked into regular exercise, a new U. of Texas (Austin) study - and common knowledge of course - shows that a single workout can boost mood.
Beyond the biochemical explanation, exercise also has obvious psychological benefits such as: improved physical condition, weight loss, becoming proactive, increased self-esteem, distraction, and for certain activities getting out and/or meeting people.
Exercise is also good in preventing depression or relapse. A recently concluded study (J. of Psychiatric Research, Oct. 8 2008) spanning nearly 40 years and 14000 people found a "dose-response" relationship between fitness and depression prevention (the fitter the merrier, if you like), fit males for instance having 20% less chance of depressive symptoms.

Further reading
Burned out by Ulrich Kraft, Scientific American Mind, June/July 2006, pp. 29-33
Depression and anxiety: exercise eases symptoms at www.mayoclinic.com
Find your training program at http://www.runnersworld.com
The Joy of running by Tad Kostrubala, 1976
Lifting depression: a neuroscientist's hands-on approach to activating your brain's healing power by Kelly Lambert, 2006

Method

noreply@blogger.com (Stef) — Sat, 03 Jan 2009 19:43:00 +0000

The advice I provide lives in self-help land, talks about things you can do to help yourself. The challenge of self-help is that you have to do the hard work; on the other hand the good news is that self-help puts you in control, something we all feel to have completely lost at some stage. Here is the rationale behind my shortlist.

What I've done over the last few years is 1) try stuff on and off, 2) keep stuff that appears to work more than 50% of the time, and dump the rest, 3) cross-validate keepers against common wisdom and research. I define "working" tools as the ones that in my experience have a noticeable short-term mood lifting or anxiety-relieving effect (say within one hour to hours). I have not included "second-order" remedies, the effects of which were too subtle for me to notice or not robust enough.
In my experience, the probability of success of the self-help tools is higher than 50%. By that I mean that more often that not, some mood lifting effect will be felt. This is important, as a higher than 50% chance gives you confidence that you will be able to rely on the tool in the future, and hope in itself can be an important "mood lifter".
In later posts, I elaborate on each self-help tool, explaining what to do and what to expect and when. I also include an often overlooked aspect of self-help: what’s so hard about it. I try to offer alternatives in cases where there may be contraindications. I will also share with you some of my personal experience about the success – and failures – of each. Last but not least, for those of us who need the reassurance, I also include a why it works section.
This blog is not a comprehensive textbook. I must say that most self-help books - or the vast Internet for that matter - do not help me when I need help, because in my darkest mood, a profusion of advice simply feels overwhelming. I can then barely handle one thing at a time...
Caution and humility are in order. Firstly I’m not a medical doctor – I only speak from experience. Secondly, I have only one guinea pig (myself), hence my observations are hardly statistically significant. My circumstances could be quite unique, and the things that help me may not necessarily help you. I do compensate the small sample size by a lot of personal research, and only consider self-help that have been tried and documented by many others.

Take away: 7 things to do in limbo

noreply@blogger.com (Stef) — Fri, 26 Dec 2008 10:15:00 +0000

If you're suffering from a nervous breakdown or acute depression, please go back to the "read me first" post and get some help. For the rest of us (mild to moderate depression and relapse prevention), here is my credit-card-format shortlist of depression self-help. I'll elaborate on each item in future posts; here I've selected my most effective self-help tools, i.e. with a mood-brightening and/or anxiety-relieving effect that is noticeable and with a relatively rapid onset of action:

Run* therapy 45mn, 3-5 times/week
Light** therapy morning/midday 30mn min.
Mindfulness*** practice day in day out
Give your self a break: hobby, concert, etc.
Zero procrastination: act before you think
Talk to a friend/psy; write a diary/blog
Fixed nighttime routine, no snooze or nap!

*Alternately: play a ballgame, bike, swim, walk, ...
**Get outdoors or get a 10000-lux lamp
***MBCT or CBT, meditation, massage, yoga, relaxation, ...

A word of caution: if you recently touched bottom, try one thing at a time, keep at it long enough to build a routine and enough self discipline if you can, then work down the list. With a bit a imagination, you can combine things (e.g. run + outdoors) and adapt to your own circumstances or limitations (e.g. walk instead of run).

Post Scriptum: even in the "maintenance" phase of managing depression (as opposed to the "acute" phase), it still is a good idea to stick to the 3 lifesavers of the earlier "read me first" post.

Read me first: 3 things to do at the bottom

noreply@blogger.com (Stef) — Wed, 24 Dec 2008 23:59:00 +0000

First things first.

The first and best advice I ever had from a psychiatrist, and the most important by far, consists of the following 3 lifesaving rules to uphold coute-que-coute during the acute phase of depression (aka burnout, nervous breakdown, reaching the bottom, etc.):

Give the day a head start. Get out of bed right away, and have a good coffee.
Do not go to bed during the day. Under no circumstance, however difficult it seems or however tired you feel! Avoid the couch too.
Take a few minutes under the shower to plan something, one thing, you can to today that has a chance of making you feel better(and which doesn't involved a bed or a couch)... Implement the plan.

It doesn't seem like much, but this particular psychiater claimed he had polished the wording over many years of dealing with depressed "clients". As it turns out, the lifesavers are strangely difficult to honor when you've reached the bottom (I speak from experience). Here's hope though: the acute phase doesn't last. You don't know how long you'll have to suffer, but eventually it passes, just like a storm subsides. The 3 rules help shorten the duration of the acute phase, that's the whole point of them. As I often tell myself: "you don't have to like it, just do it."

Why does it work?
No-snooze-no-nap leaves as little room as possible to rumination or brooding, our worst enemy. In addition, it helps to structure the day and to maximize the chance of night time sleep.
Acute depression burns out almost all of our energy and motivation, so planning "one thing" each day is all we can wish for, and still infinitely more constructive than doing nothing, which means giving in to depression. Also, planning one potentially-pleasant or constructive activity tends to counter negatively-biased thinking.
All in all, the 3 rules are about discipline and reclaiming some of the control we lose to depression.

Of course, if you feel this advice applies to you and you haven't already done so, I ask you: seek professional help, talk at least to your GP and/or loved ones, help them help you.

Introduction

noreply@blogger.com (Stef) — Wed, 24 Dec 2008 22:28:00 +0000

In the past 2 years I have gone through the different stages of burnout, generalized anxiety (and panic attacks), acute depression and depressive moods, rapid cycling, cold turkey, remission, and relapses. I have taken several anti-depressants with mixed results, augmented by anxiolytics and/or hypnotics, and I tried various therapies as well as lifestyle changes. I'm a "neurotic", and in retrospect probably was anxiety- and depression-prone since my early teens.

The "Blue Snow" blog is intended as a self-help guide for coping with anxiety/depression, burnout, and nervous breakdowns. The blog is in part a reaction to my frustration of not finding answers on internet, or rather finding too many answers. Because too much good advice is bad advice, in the blog I've tried to trim down my experiences to their essence. Can my blog cure you? Probably not. The blog does provide some support and tools to better manage mood swings, and if you suffer a bit less for it, then I've done my job.
I tend to take a "scientific" approach to my condition, what I try to do about it, and the interpretation of the outcome. I am not impressed by an apparent betterment of mood even when it coincides with some new experiment of mine, like trying multi-vitamins for instance: a mere correlation could be nothing more than a coincidence, whishful thinking, or placebo. Remember that most depressions and anxiety disorders naturally waxe and wane with time. It is a fact that two-thirds of depressed people recover within 6 months, regardless of treatment.

I am not a success story and I have no silver bullet, nobody has. If there was such a thing, depression as an illness would not exist today. Some of us will remit, but often the best we can hope for is to learn the skills to live with anxieties and depressive moods, and to minimize the probability of relapse.

To date I still waver between wellness and illness – and strive to find the right balance between relevant and doable advice, esp. when depressed. Even then, I’m the first one to admit how damn hard it can be at times to muster the motivation and energy to do any of the things I recommend – but it’s definitely worth a try, believe me.

Disclaimer
The Blue Snow blog hopes to provide readers with helpful and accurate information. However, this blog is not intended to be a substitute for professional health care. Readers of this blog should always seek the advice of qualified health professionals with questions concerning their condition or disorder.

I avoid topics of pharmacopea and medical or psychiatric advice. This omission should not be confused with a "negative advice" on my behalf, on the contrary. The information on the Blues Snow blog is not a substitute for professional medical treatment. At best, the information or advice provided on the Blue Snow blog should be considered to be complementary to adequate professional advice and treatment.

Don't do it alone: get professional advice and the support of your loved ones first.

Kind Regards,

S.G.