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.

More on rain

• How do you predict the rain?
• How do you predict emotion?
• Why do we still get caught in the rain?

Answer these questions and I think you’ll have a nice understanding of how one might look at emotions in a different light.

We know how to predict when it’ll rain. We understand the science behind it, but we can’t make it rain or make it stop once it’s started. Sometimes all we can do is prepare ourselves.

Similarly, we understand what creates an emotion. We can pretty well predict what might make someone emotional but we have little control over emotions.

We do have control over how we respond to them.

Ψ If it's raining outside...

If it’s raining outside, and you happen to be out there, you’re probably going to get wet. That is, unless you’ve prepared by bringing a raincoat, umbrella, poncho or trash bag. This truism is often the way I frame my discussion of emotion. It’s generally accepted by most people that when it’s raining outside, you’ve got a couple options to avoid getting wet - prepare by bringing the aforementioned gear or don’t go outside. To expect not to get wet without doing either of those things is kind of absurd¹. Natural reactions - getting wet - to everyday occurrences - rain - are, umm, natural, and, double ummm, normal.

We don’t expect people not to get wet just by willing themselves to be dry or by believing that if they only thought about things differently, they’d stay dry.

Or that if “normal” people were in the same situation, they’d be dry.

It’s. Just. Not. True.

If someone is able to stay dry in a rain storm, chances are they’ve got a nice big golf umbrella, a good pair of hiking boots and a fancy Gore-tex jacket. You may not have any of those things right now, but you can learn to get them. And, in the meantime, you can work on using what you’ve got, maybe a trash bag or an old newspaper, to keep yourself as dry as possible.

With that tidy metaphor out of the way, let’s get down to the business of learning about emotion. Understanding it so that we know what we’re dealing with. Emotion comes from prompting events. These events can be internal (e.g., thoughts) or external (e.g., a car accident). They can be actual or they can be just perceived. It doesn’t really matter because in dealing with emotions, perception is reality.

A prompting event can lead to an interpretation of that event. These interpretations are deeply personal and are often what people think of when they try to deal with emotions. I don’t know how many times I’ve heard, “If I could just think differently, I wouldn’t feel so bad.” That’s sort of true. And sort of not true at the same time. In other words, just thinking about things differently (or changing your interpretations), is not always going to work to change how you feel². If it always were so easy, self-help books would be all anyone ever needed for therapy and I’d be out of a job!

A prompting event can also lead to any number of physiological reactions. When you get frightened and get goosebumps? That’s the sort of thing I’m referring to. Flushing face, tension in your shoulders. Additionally, interpretations can also lead to physiological reactions. “Someone’s broken into my house and my life’s in danger” will lead to a racing heart and quickened breathing, for example. These physiological reactions are hard-wired and not something that we can just stop doing³ right away.

We then have what are called, in DBT parlance, “action urges.” These are the things that you are driven to do as a result of the situation/interpretation/physiological reaction. When you’re scared, you run. When you’re angry, you lash out. When you’re ashamed, you hide. Again, these are all considered hard-wired reactions. Think of it from an evolutionary perspective. Back in the day, things that caused fear were often life threatening. It made sense to run when your life was threatened. Right?

So, we have at least 3 sources for the formation of an emotion. There are other potential sources, such as history and vulnerability factors, and we’ll get to those in another post. But, to get back to our metaphor, there are 3 storm fronts that are moving your way and there’s not much you can do to keep them from getting to you. At least right now, all you can do is cope with them⁴.

Footnotes:

1. Not absurd in the “crazy” way, but just absurd in the strict definitional sense.↩
2. Read about behaviorism and learning theory to understand why.↩
3. We can do things like progressive muscle relaxation to deal with these reactions.↩
4. As we progress through these skills, you’ll be able to control the weather. How cool will that be?↩

Ψ What is DBT?

What is DBT?

We are often asked this question by friends and family and, while there are a number of websites devoted to DBT, it’s hard to get a clear answer on this very important question. Keep in mind that there is no one, specific answer you’ll get to this question. Ask 10 DBT therapists “what is DBT?”, though, and you’ll likely get some combination of these points:

• Dialectical Behavior Therapy
• An empirically supported treatment for the treatment of Borderline Personality Disorder. It is expanding its research support to include other conditions such as anxiety disorders, depression, substance use and eating disorders.
• A skills-based treatment to help one develop a “life worth living”.
• An acceptance-based treatment designed to help one cope with life.

All of these descriptions are accurate but they don’t really help explain what DBT means and how it might help you more than other types of treatment like Cognitive Behavioral Therapy (which, itself is an EST for a variety of conditions).

When we’re asked what DBT is, depending on the audience, we will go into talking about how DBT is a “third-wave psychological treatment which is based on CBT but adds some essential components like Mindfulness and Acceptance.” Again, this is a completely accurate description, but doesn’t give you a sense of what that actually means.

Dialectical Behavior Therapy is a treatment that works on a number of levels, including some of the same ones found in Cognitive Behavior Therapy. In CBT, there has been, historically, a great emphasis placed upon changing and challenging your thoughts to change how you feel. This is all well and good for many situations and emotions, but there is an essential piece of the puzzle missing. Emotions aren’t just the product of thoughts. As emotion researcher Paul Ekman talks about in his book, Emotional Awareness: Overcoming Obstacles to Psychological Balance, emotions are not just thought about, they are felt, physiologically. As a result, you may be able to successfully challenge your thoughts but still feel the way that you do.

This line of thinking about emotions also leads one to the somewhat judgmental conclusion that if you would just “think differently,” you would feel differently. That is, it’s your fault you feel as you do. While it may be your responsibility to address how you feel, change the situations you find yourself in, and accept your lot in life, it most certainly not your fault. Just like it’s not your fault if you get wet when you’re standing in the rain.

How does DBT address this problem?

DBT focuses on a model of emotion that takes into account not only the thoughts that precede an emotion, but also the physiological changes one experiences prior to its onset. It teaches ways to address those changes so that you can approach emotions in a multi-faceted way. In DBT, You will learn the skills required to effectively challenge your thoughts.You will learn how to change your physiology. But, most importantly, you will learn how to understand and accept your emotions to help keep them from taking over your life. This, I believe, is the key difference between DBT and CBT and the reason DBT is applicable to many conditions aside from the currently researched ones. It is surely not the only treatment that could work, but I find that it is the most useful approach to take.

DBT is a principle-driven, as opposed to protocol-driven, approach to therapy. You will not have an “agenda” per se set at the beginning of a session, for example. What are the principles that can help us understand your current situation and what technique would be helpful to address it?

A comprehensive DBT program is important to help you learn these skills and generalize them to your environment.

DBT will also help you address interpersonal problems that have arisen in your life and get through those times that are so overwhelming all you can hope to do is tread water. On top of all of this is the notion that Mindfulness is a key to your psychological well-being.

The Big Picture

When one talks about DBT as a treatment modality, it’s important to recognize that it’s not just about skills training group. These groups are an essential part of any DBT program, but it’s not the only part. A comprehensive DBT program will incorporate all of the following components:

• Weekly individual therapy where goals are discussed, motivation is maintained and problem-solving is taught.
• Weekly group therapy where skills are taught and practiced.
• Telephone coaching where skills are generalized to your environment.
• And therapist consultation team meetings where your therapist makes sure he or she is delivering the treatment effectively and not missing important details.

Further, behavior tracking using “diary cards” is important to help you monitor what is going on in your life and how you are dealing with them with your skills. These diary cards also give your therapist a chance to get a quick glance of your week and see where things need to be addressed.

If this sounds like an approach you think might be helpful, contact us.

TED talks: Music is medicine

The TED series of lectures and conferences is fascinating. There are some really interesting presentations covering all sorts of topics and subject materials, presented by some very talented people. All the talks I’ve seen have been thought provoking and just visually appealing. 

Ψ Mind your emotion

One of the complaints I often hear with respect to blogs is that they feel a lot like opinion and very little like research and data[1]. A primary objective of this particular blog is to present to you data that supports my assertions. Since I’m not a researcher (and there are many more talented people doing good work) I’m going to review articles for you. It may be that you don’t have access to these articles or you don’t understand them because of all the research-ese that goes into them. No matter the reason, I hope to help.

First up in our ”mindfulness articles” series is “Minding One's Emotions: Mindfulness Training Alters the Neural Expression of Sadness ” (warning: pdf link). This technical article examines the differences in fMRI data from a control group and a practiced mindfulness trained group in response to induced sadness. [2] As with much rigorous research, the groups were randomly assigned to control or treatment status and data were compared with the same stimuli.

The researchers utilized 3 minute clips of video, alternating in valence between sad and neutral video types and gathered data on participants’ subjective degree of sadness. The data were analyzed using a multivariate procedure designed to test for significant differences between groups and across time points and valence of the video (technically called a 2x2x4 mixed model ANOVA). This type of analysis allows us to draw conclusions about what the actual differences are between these various conditions.

Interestingly, the researchers found no difference between the control and mindfulness-trained groups on level of subjective sadness. That’s right - there was no difference between the participants who were trained in mindfulness and others on how affected they perceived themselves to be by the video clips. They were, however, less physiologically reactive to the stimuli.

Examining the effects of MT, we found that despite similar levels of self-reported dysphoria, the MT group demonstrated less neural reactivity to sadness provocation than the control group.

In other words, their brains reacted differently to the information presented by their “emotional system”. We find some information about what could be occurring in the fMRI data also collected during the study. There appeared to be less activation in the areas of the brain associated with self-referential processing [3] and autobiographical memory. Similarly, the mindfulness trained group exhibit less inhibition in brain areas associated with interoceptive awareness. This difference suggests that they are somehow regulating their emotional response (which, you’ll recall, is similar across both groups) differently/more effectively than untrained participants because they are aware that something is happening to them. In other words, they are mindful of their current emotion.

Conclusions

There appears to be two take-home points from the afore-reviewed article. Our mindfulness-trained participants did not generate self-referential thoughts in response to the video clips. This cognitive distance appeared to allow some separation between the participants and the subject matter. And, secondly, there a marked awareness of the physiological processes occurring during the emotional experience and that process was observed as such - a physiological change.

A plausible mechanism of action for mindfulness effects may include the development of metacognitive skills for detached viewing of emotions, rather than the elaboration of emotional content through cognitive reappraisal.

This suggests a different way forward for dealing with significant negative emotion. Typically, our best efforts at dealing with emotional information is to re-attribute, re-evaluate, re-interpret the events. We work on generating alternative explanations for behavior or shifting “locus of control” to an external object, as well as using perspective taking (e.g., “How would you tell your friend to react to this situation?”). One of the problems with this type of strategy is that we have a tendency to end up in circular arguments with one “side” being more persuasive than the other depending on, guess what? Your mood. And when you’re already depressed, you’ve got a harder time doing this reappraisal work. [4]

By shifting the plane of focus to something other than the cognitive back and forth we typically see, mindfulness can allow a different way to process information. By exiting this necessarily circular argument, we can start to make progress on dealing with emotion as it is: a natural reaction to events. When we start viewing emotions as natural phenomena and not events that need to be challenged or beaten back, we may finally be able to end the fight against reality in which we have been engaged.

---

Footnotes:

[1] I personally don’t subscribe to this view of blogs. There are a great many that are better, in my opinion, than “real” news

[2] They used movie clips that were chosen for their ability to elicit sadness.

[3] Self-referential processing is defined as one’s tendency to relate information to him or herself

[4] Keightley, M., Seminowicz, D., Bagby, R., Costa, P., Fossati, P., & Mayberg, H. (2003). Personality influences limbic-cortical interactions during sad mood induction. NeuroImage, 20, 2031–2039.

Jon Kabat-Zinn: Coming to our senses

As you might be able to tell, I’m a big fan of Jon Kabat-Zinn. Here he’s talking about his book Coming to Our Senses: Healing Ourselves and the World Through Mindfulness. The video is quite long, so grab a warm cup of tea and enjoy it.

Reflections on addiction

I found this article written about video games and addiction to be quite fascinating. From a therapeutic perspective, I’m not sure there’s much to be gained, but from a purely “understanding the disorder” perspective, I found it to be insightful.

Many children who want to believe their tastes are adult will bravely try coffee, find it to be undeniably awful, but recognise something that could one day, conceivably, be enjoyed. Once our tastes as adults are fully developed, it is easy to forget the effort that went into them. Adult taste can be demanding work – so hard, in fact, that some of us, when we become adults, selectively take up a few childish things, as though in defeated acknowledgment that adult taste, with its many bewilderments, is frequently more trouble than it is worth.

Many parents, I’m sure, wonder about whether playing video games can make kids violent or glorify deviant behavior. This is such a tough question to answer and I don’t believe that there’s any real consensus on the subject. I’ve been gathering a number of articles recently written on both sides of the argument and I hope to writing a more lengthy piece later about it. For now, I think, as with all good parenting, you’ve got to be involved in what your kids are playing. End of story. 

Progressive Muscle Relaxation

The topic of PMR came up today in one of my groups and I encouraged them to do a google search on progressive muscle relaxation. I figured I’d do the same and post my results here.

I found a site at Arizona State University that has audio of someone reading a PMR script. I haven't heard the audio but the transcript looks good. Have a listen.

Mindfulness and affective experience

A recent study (.pdf link) published by researchers at the University of Pennsylvania points to the benefit of mindfulness practice on working memory and emotion.

In the MT [mindfulness training] group, WMC [working memory capacity] decreased over time in those with low MT practice time, but increased in those with high practice time. Higher MT practice time also corresponded to lower levels of negative affect and higher levels of positive affect (indexed by the Positive and Negative Affect Schedule). The relationship between practice time and negative, but not positive, affect was mediated by WMC, indicating that MT-related improvements in WMC may support some but not all of MT’s salutary effects.

It seems like this blog is turning into one about mindfulness. This is really an unintentional side-effect of the fact that I have found mindfulness practice can be an integral part of many empirically supported psychological treatments.

Take for example CBT for panic disorder. Some core components are:

• Identifying automatic thoughts
• Challenging negative automatic thoughts
• Identifying emotion associated with those thoughts
• Interoceptive awareness and interoceptive exposure
• Relaxation techniques

All of these key techniques are enhanced when one is practiced at being mindful. The same can be said for the treatment of depression and other types of anxiety. Further, I believe that the affective “stability” (for lack of a better word) afforded one practiced in mindfulness, can enhance life in a number of ways.

Does that mean that people who are “good” at being mindful don’t get depressed? No, but I believe that they don’t suffer nearly as much. And reducing suffering is what I try to do.