Depression and physical activity

A while back, I bookmarked an interesting article (pdf link) that I've been meaning to write about. As I haven't had a chance to really digest the material and compose a longer entry, I thought I just get it up on the site for wider consumption. The gist of the research highlighted therein is that Tai Chi Chih seems to have a positive impact on geriatric depression. Given the relative reluctance some geriatric patients have to psychotherapy and the complicating factors of drug interactions, anything we can do to help that doesn't involve traditional medication management and/or psychotherapy is welcomed. The question remains what is the mechanism of change for this particular intervention. I suspect that it's a result of the increased ability to focus on an activity and the consequent ability to focus away from unwanted ruminations that helps, but that's just my slightly biased-towards-mindfulness explanation.

Depression isn't forever, but like an unwelcome houseguest, it finds its way back. Be ready.

As I was digging through the articles I've collected to read and post about, I came across this one with some research conducted by some local mental health professionals, amongst others. The study described in the article was a large multi-site data analysis in which adolescents with a Major Depressive Episode were followed-up over the course of several years after treatment. The researchers found that:

• recovery rates were good, with 96.4% of participants recovering during the follow-up period, with over two-thirds recovering during the first year of treatment.
• treatment modality was unrelated to recovery.[1]
• nearly half of those who recovered had a recurrence of symptoms within 5 years.

We've long known that a past major depressive episode predicts a future one. As a result, this finding is not surprising. What is interesting about the research here is that there is a predictive factor of both gender and co-occuring anxiety disorder.

As far as clinical implications go, this finding highlights the importance of skills acquistion for self-recovery after the completion of therapy by a trained professional. In addition, the should focus not just on the management of the depression symptoms but also of the anxiety features present. I'd like to see more follow-up on specific types of therapy and the longevity of their effects, but longitudinal study is hard and expensive, so we may never get to see that clinical application of these findings.

Depression isn't forever, but like an unwelcome houseguest, it finds its way back. Be ready.

---

Footnotes: [1] This was not a study looking at the efficacy of various types of treatment, just a look at the efficacy of all treatments. The treatment options for participants in this study received either Cognitive Behavioral Therapy, fluoxetine (prozac), a combination or a placebo.

Guilt and pain

"When reminded of an immoral deed, people are motivated to experience physical pain."

This is the opening line of the discussion section in a recent article published in Psychological Science. The hook is alluring, isn’t it? Thinking about times that you were “bad” makes you want to punish yourself. I was attracted to this article for review because of my interest in working with self-injurious patients. There are two predominant reasons people engage in self-injurious behavior (SIB):

1. He/She wants to regulate his/her emotions through distraction or
2. He/She wants to punish him/herself for some perceived wrong or defect.

As a starting point in understanding SIB, these two perspectives are helpful. They give us a framework to begin to explain possible motivations and the function of that particular SIB. In other words, how do we get those needs met without having to engage in SIB?

The Article

Getting back to the article, the authors engaged in a simple experimental manipulation in which participants were assigned to either the recall of “immoral”[1] interpersonal behavior or more generic interpersonal behavior. Participants rated their affect using the PANAS[2] and then engaged in the pain part of the study. Following the painful/non-painful experience, their level of “guilt” was measured by completing the PANAS again.[3]

The researchers found that participants in the guilt inducing/pain condition expressed lower levels of guilty feelings after the manipulation, leading them to conclude that the painful experience caused a drop in guilt ratings.[4]

The participants in the guilt/pain condition also perceived more physical pain during the manipulation than those in the non-guilt/pain condition.[5]

Reading the Tea Leaves

The authors go on to claim that the motivation for causing pain is to reduce guilt. I believe they’ve got their conclusions backwards. Guilt is reduced because of the pain, not the other way around. Getting into divining motivation is a specious area at best. Unfortunately, I don’t see how the results of their study supports that explanation. This reading of the data is basically saying that the second of my two reasons for SIB listed above is the reason for engaging in the behavior. However, I believe that emotion regulation aspect of painful experience is not to be understated.

Pain as Emotion Regulation

The explanation of this article is a long way around to talk about my favorite therapeutic technique — mindfulness. Specifically, using mindfulness as a way to stop thinking about particular experiences can help reduce the intensity of those thoughts and the subsequent emotion. Rumination on particular misdeeds fires off a host of strong emotions and breaking into that ruminative cycle prevents continued emotional experience. In this particular case, the ice was an unavoidable mental focus and we can see support for this supposition in the subjective experience of the pain.

To further draw out the supposition, without too much of a stretch, we can say that people actively avoid thinking about times they did something “wrong”. When the participants were presented with a mental “out”, they took it. Ice is painful and it’s relatively easy to focus on pain. Focus on the physical pain increases the subjective experience of the pain. Two conclusions can be drawn from this:

*For those who were suffering from emotional pain as a result of the manipulation — those in the “guilt” condition — this physical pain was deemed to be less intense, so they focused on the ice.

For those in the non-guilt — those without emotional pain — the physical pain was more uncomfortable to they focused *away from it, leading to subjectively less pain.

Mindfulness as Emotion Regulation

The revealing thing about this article is that a mindful experience can be emotionally regulating. In DBT, we talk about using ice as a distress tolerance skill. This research, coming from a non-DBT perspective, corroborates that belief. I don’t believe that you necessarily need to subject yourself to physical pain to get the same sense of relief — you don’t need to punish yourself to feel better, at least all the time — you just need to be able to mindfully turn away from your rumination.

The process isn’t as easy as it sounds since being able to turn away from your ruminative thoughts is work. Our minds have a tendency to stick to things that we least like them to stick to. Cultivating mental control through regular practice and developing a sense of forgiveness and genuine caring for yourself can help. You should not let yourself violate your values if you can avoid it, but if you have, make up for it and then move on.

Footnotes

[1] The authors defined “immoral” behavior as ostracizing someone. I’d buy that as a particularly embarrassing experience.

[2] The PANAS is a well-validated measure of affect. I’m not sure how well it measures guilt, but since this is a peer-reviewed article, I’m going to give the authors the benefit of the doubt.

[3]This type of within subject/repeated measure design is common in psychological research. It’s designed to measure change across time or via experimental manipulation and has much theoretical support. It’s an especially powerful design because each subject is his/her own control.

[4]Given that this was an experimental design, causal conclusions are warranted.

[5]This finding, I believe, is particularly salient.

DBT again shown to be effective

The American Psychological Association highlights some key findings regarding the treatment of personality disorders. Help for personality disorders:

In a study comparing dialectical behavior therapy and traditional psychotherapy, women who underwent dialectical behavior therapy were more successful at reducing suicide attempts, self-mutilating and such self-damaging behaviors as gambling and substance abuse.

As we've known for a long time, DBT helps immensely when used to treat personality disorders. I'm always happy to see more research supporting its use. We, at Durham DBT, take pride in our training and our use of a comprehensive DBT model to help those with personality disorders, Borderline Personality Disorder, specifically, and people who are struggling with emotion generally. Treatment works.

Text messaging can help save your life, too.

There has been no end of bad press for the scourge of text messaging. You can hardly listen to the news or read a newspaper without stumbling upon some other negative consequence of texting. There are clearly some issues with text messaging, from the danger while driving to the inordinate amount of time some people spend doing it. So, finally, texting has found a little bit of positive news in a pair of studies out recently. Text messaging helps smokers break the habit:

"Text messaging may be an ideal delivery mechanism for tailored interventions because it is low-cost, most people already possess the existing hardware and the messages can be delivered near-instantaneously into real world situations," said the study, which is scheduled to appear this week in Health Psychology, the journal of the American Psychological Association.

There is so much value in getting therapy out of the office and this study highlights why it is key. Behavior change needs to occur in your context, not in the context of a therapy room. We like immediate gratification and if there's some way to help with that immediacy, treatment is going to be much more likely to be successful.

Paying penance or distracting?

When reminded of an immoral deed, people are motivated to experience physical pain.

---

This is the opening line of the discussion section in a recent article published in Psychological Science. The hook is alluring, isn’t it? Thinking about times that you were “bad” makes you want to punish yourself. I was attracted to this article for review because of my interest in working with self-injurious patients. There are two predominant reasons people engage in self-injurious behavior (SIB):

1) He/She wants to regulate his/her emotions through distraction or 2) He/She wants to punish him/herself for some perceived wrong or defect.

As a starting point in understanding SIB, these two perspectives are helpful. They give us a framework to begin to explain possible motivations and the function of that particular SIB. In other words, how do we get those needs met without having to engage in SIB?

The Article

Getting back to the article, the authors engaged in a simple experimental manipulation in which participants were assigned to either the recall of “immoral”[1] interpersonal behavior or more generic interpersonal behavior. Participants rated their affect using the PANAS[2] and then engaged in the pain part of the study. Following the painful/non-painful experience, their level of “guilt” was measured by completing the PANAS again.[3]

The researchers found that participants in the guilt inducing/pain condition expressed lower levels of guilty feelings after the manipulation, leading them to conclude that the painful experience caused a drop in guilt ratings.[4]

The participants in the guilt/pain condition also perceived more physical pain during the manipulation than those in the non-guilt/pain condition.[5]

Reading the Tea Leaves

The authors go on to claim that the motivation for causing pain is to reduce guilt. I believe they’ve got their conclusions backwards. Guilt is reduced because of the pain, not the other way around. Getting into divining motivation is a specious area at best. Unfortunately, I don’t see how the results of their study supports that explanation. This reading of the data is basically saying that the second of my two reasons for SIB listed above is the reason for engaging in the behavior. However, I believe that emotion regulation aspect of painful experience is not to be understated.

Pain as Emotion Regulation

The explanation of this article is a long way around to talk about my favorite therapeutic technique — mindfulness. Specifically, using mindfulness as a way to stop thinking about particular experiences can help reduce the intensity of those thoughts and the subsequent emotion. Rumination on particular misdeeds fires off a host of strong emotions and breaking into that ruminative cycle prevents continued emotional experience. In this particular case, the ice was an unavoidable mental focus and we can see support for this supposition in the subjective experience of the pain.

To further draw out the supposition, without too much of a stretch, we can say that people actively avoid thinking about times they did something “wrong”. When the participants were presented with a mental “out”, they took it. Ice is painful and it’s relatively easy to focus on pain. Focus on the physical pain increases the subjective experience of the pain. Two conclusions can be drawn from this:

• For those who were suffering from emotional pain as a result of the manipulation — those in the “guilt” condition — this physical pain was deemed to be less intense, so they focused on the ice.
• For those in the non-guilt — those without emotional pain — the physical pain was more uncomfortable to they focused away from it, leading to subjectively less pain.

Mindfulness as Emotion Regulation

The revealing thing about this article is that a mindful experience can be emotionally regulating. In DBT, we talk about using ice as a distress tolerance skill. This research, coming from a non-DBT perspective, corroborates that belief. I don’t believe that you necessarily need to subject yourself to physical pain to get the same sense of relief — you don’t need to punish yourself to feel better, at least all the time — you just need to be able to mindfully turn away from your rumination.

The process isn’t as easy as it sounds since being able to turn away from your ruminative thoughts is work. Our minds have a tendency to stick to things that we least like them to stick to. Cultivating mental control through regular practice and developing a sense of forgiveness and genuine caring for yourself can help. You should not let yourself violate your values if you can avoid it, but if you have, make up for it and then move on.

Footnotes

[1] The authors defined “immoral” behavior as ostracizing someone. I’d buy that as a particularly embarrassing experience.

[2] The PANAS is a well-validated measure of affect. I’m not sure how well it measures guilt, but since this is a peer-reviewed article, I’m going to give the authors the benefit of the doubt.

[3]This type of within subject/repeated measure design is common in psychological research. It’s designed to measure change across time or via experimental manipulation and has much theoretical support. It’s an especially powerful design because each subject is his/her own control.

[4]Given that this was an experimental design, causal conclusions are warranted.

[5]This finding, I believe, is particularly salient.

More disheartening treatment utilization news

The NIMH reports on a recent study released in Archives of General Psychiatry:

About 3 percent of U.S. adolescents are affected by an eating disorder, but most do not receive treatment for their specific eating condition, according to an NIMH-funded study published online ahead of print March 7, 2011, in the Archives of General Psychiatry.

While the data on the success of treatment for an eating disorder in adolescence is unclear, the fact that most of anyone suffering from a major mental disorder isn't getting treatment is quite disturbing. Given the extremely powerful reinforcement contingencies in place for an eating disorder, earlier intervention is needed.

Exercise and memory

I stumbled upon this article while surfing the web (which, despite my assertions, is not really exercise). It's a little on the technical side but here's a choice quote:

Our data show that 14 days of exercise increased the rate of acquisition in the Y maze, improved retention of previously ac- quired information, and facilitated reversal learning. The fact that exercise had a positive effect on Y-maze acquisition ... We show for the first time that physical exercise not only promotes the acquisition of a spatial learning task but also is beneficial for the retrieval of spatial reference memory.

It's fascinating how the brain can work like this. We know that exercise helps you sleep and eat better and help your mood in the process, but that it can also help your memory? Now we just need something to help us remember to exercise and we'll be golden.

Pros and cons of medications

As always when taking medications, even ones that don't seem like they might affect brain functioning, it's important to pay attention to potential side effects. Statins are medications like Crestor and Lipitor the help control cholesterol levels. These medications can affect myelin sheaths that help our brains conduct electrical signals, resulting in potential impact on learning and memory. Scientific American weighs in:

Two small trials published in 2000 and 2004 by Matthew Muldoon, a clinical pharmacologist at the University of Pittsburgh, seem to suggest a link between statins and cognitive problems. The first, which enrolled 209 high-cholesterol subjects, reported that participants taking placebo pills improved more on repeated tests of attention and reaction time taken over the course of six months—presumably getting better because of practice, as people typically do. Subjects who were on statins, however, did not show the normal improvement...

That said, it's important to recognize the typical nature of research:

But other studies have found no significant link between statins and memory problems. Larry Sparks, director of the Laboratory for Neurodegenerative Research at the Sun Health Research Institute in Sun City, Ariz., goes so far as to say that “you’ve got a better chance of buying a winning lottery ticket, walking outside and getting hit by lightning and dying” than you do of suffering a cognitive side effect from statins.

Just remember to pay attention to what's happening with you and if you notice a change in your cognitive functioning, bring it up. Better to be aware than to ignore something so simple yet important. This also reinforces the notion that there are pros and cons to taking medications and in some instances it may be better to control your cholesterol behaviorally rather than medically.