Monday, May 20, 2019

Growth Mindset: A Proven Antidote for Depression When Facing Adversities


Psychologist Carol Dweck describes people having two types of mindsets – the fixed mindset and the growth mindset (Dweck, 2008). Individuals with a fixed mindset believe that their qualities, temperament, abilities, talents, aptitudes, and interests are fixed and cannot be changed. Thus, when faced with a failure, individuals with a fixed mindset attribute this to their lack of talent or ability in the domain they failed (e.g., “I am never good in relationships” or “I am such a loser”). These people mistakenly assume that one doesn’t need to put in effort or take risks to succeed if one is talented to begin with. Therefore, they don’t challenge themselves and don’t reach their full potential. In contrast, individuals with a growth mindset view their personal attributes such as talents and abilities as being malleable and are open to improving themselves by learning from failures, stretching beyond their comfort zone, and making concerted efforts. They don’t blame their personality for failures and their usual response following failures is, “I need to try harder next time.”

Fixed mindset fosters depression by perpetuating a feeling of hopelessness and despair that adversities are a fixed and stable part of one’s future. While individuals with a fixed mindset have been shown to have higher levels of depressive symptoms, growth mindset in people with depression leads to more action toward solving one’s problems (Dweck, 2008). Individuals with a growth mindset tend to achieve more than those with a fixed mindset because they worry less about looking smart and put more energy into learning. Growing evidence suggests that brief interventions targeting the growth mindset can decrease the subsequent risk of depressive symptoms (Miu & Yeager, 2015; Schleider & Weisz, 2016). Remarkably, a single intervention that promotes a growth mindset and lasts only for 30 minutes has been shown to decrease depression and anxiety in kids who “worry or feel sad more than other kids” even after nine months of the intervention (Schleider & Weisz, 2018).

A couple of exercises that will help you explore the growth mindset are described below (Dweck, 2008).

1. Think of a person who you believe outdid you and you assumed that they were smarter or more talented. Now get yourself in a growth mindset and consider if this person did one or more of the following:
  • Used better strategies
  • Learned more about what they were doing
  • Worked harder
  • Worked through obstacles
If they can do it, you can do it too!

2. The next time you use a negative label on yourself such as being stupid, idiot, loser, or “this is just how I am,” ask yourself the following question:
              “Is this something I can learn more about, work harder on, or stretch my abilities?”

People usually hold on to a fixed mindset because at some point in their lives it may have served to stoke their self-esteem (e.g., "I am good at this and don't need to improve"). However, when things don't happen according to plan, these people with fixed mindsets ruminate and end up tormenting themselves with the notion that the setback is a reflection of their being incompetent, a harbinger of depression. The good news is that you are in charge of your mind and you can help it grow by using it in the right way. Just being cognizant of the fact that you have elements of both fixed and growth mindsets provides you the impetus to switch from a fixed to a growth mindset, especially when faced with adversities. 

To learn more about evidence-based self-management techniques that are proven to work for depression, check out Dr. Duggal's Author Page.

HARPREET S. DUGGAL, MD, FAPA

REFERENCES


Dweck, C. S. (2008). Mindset: The new psychology of success. New York, NY: Ballantine Books.

Miu, A. S., & Yeager, D. S. (2015). Preventing symptoms of depression by teaching adolescents that people can change: effects of a brief incremental theory of personality intervention at 9-month follow-up. Clinical Psychological Science, 3(5), 726-743.

Schleider, J. L., & Weisz, J. R. (2016). Reducing risk for anxiety and depression in adolescents: effects of a single-session intervention teaching that personality can change. Behavior Research and Therapy, 87, 170-181.

Schleider, J., & Weisz, J. (2018). A single session growth mindset intervention for adolescent anxiety and depression: 9-month outcomes of a randomized trial. Journal of Clinical Psychology and Psychiatry, 59(2), 160-170.


Friday, April 19, 2019

Value-Based Goals: The Cure for “Success Depression”


A disconnect between your present accomplishments and your core values may make you suffer from success depression wherein despite “having it all” (e.g., successful career, stable relationships, healthy children, etc.), you still struggle with depression and view your accomplishments as hollow (Zettle, 2007). The cure for this malaise is to clarify your core values and have goals and actions that are driven by these values.

Psychologist Russ Harris describes values as our heart’s deepest desires for the way we want to interact with the world, other people, and ourselves. They are what we want to stand for in life, how we want to behave, what sort of person we want to be, and what sort of strengths and qualities we want to develop (Harris, 2009). Values are subjective; what one may consider as a value (e.g., being famous) may be considered as being cocky by another person. Moreover, values do change with time. For instance, you may value social popularity and raising a family in your early years and maintaining a good health and giving back to the community later in your life. Success depression results when your accomplishments are out of sync with your core values mostly because you have held on to your values too doggedly despite a change in your circumstances.

Compared to thoughts and behaviors, values provide a far more stable compass to motivate you to achieve your goals, even when faced with personal adversity (Hayes et al., 2012). The next exercise called “What Do You Want Your Life to Stand For?” will help you be in touch with your values (Hayes et al., 2012):

"Take a few deep breaths, relax, and close your ideas. Imagine that through some twist of fate you have died, but you are able to attend your funeral in spirit. You are watching and listening to the eulogies offered by your spouse, children, and friends. Try to be present in the situation emotionally. Now visualize what you would like these people who were part of your life to remember you for. What would you like your spouse to say about you as a partner? Have him/her say that and let her say exactly what you would most want them to say if you had totally free choice of about what that would be. Now repeat the same thing with your children and friends. Make a mental note of the things these people say."

This exercise gives you an insight into your values – what really matters in your life. Also, this exercise helps you reconsider the importance of minor goals in your daily life that you may be taking for granted. Another variant of the above exercise is to imagine that you can write anything on your tombstone that says what you stood for in your life. What would you like your tombstone to say, if it could be absolutely anything?

Value-focused exercises also make you aware of the discrepancies between what you are pursuing in your life at present and what you really want your life to stand for. This discrepancy generates the drive and motivation to pursue goals that are more in line with your values. Research suggests that goals that are self-concordant, i.e., representing one’s values, lead to the largest degree of enhanced well-being (Sheldon & Elliot, 1999).

Besides these value-focused exercises, below are some additional questions that you may ask yourself to evaluate your values (Miller & Rollnick, 2013):
  • “What do I care most about in life?”
  • “What matters most to me?
  • “How do I hope my life will be different a few years from now?”
  • “What are the rules I live by?”
  • “If I were to write a mission statement for my life, describing my goals or purpose in life, what would I write?”
  • “If I were to ask my closest friends to tell me what would I live for, what matters most to me, what do I think they would say?”
Below is a list of commonly reported values (Grant & Greene, 2001):
  • Accomplishment
  • Accuracy
  • Adventure
  • Authenticity
  • Collaboration
  • Community
  • Comradeship
  • Courage
  • Creativity
  • Empowerment
  • Excellence
  • Focus
  • Freedom to choose
  • Generosity
  • Giving
  • Growth
  • Harmony
  • Honesty
  • Humor
  • Independence
  • Integrity
  • Interdependence
  • Joy
  • Lightness
  • Love
  • Nurturing
  • Order
  • Participation
  • Peace
  • Personal Power
  • Recognition
  • Reward
  • Respect
  • Self-actualization
  • Success
  • Zest
This list of values is not exhaustive and you can add to it. Focusing on values helps you move from flaws, deficits, and problems to what your strengths are and hone in on them to direct your life.

It is crucial that you identify values that are at your core rather than values designed to please or appease others or are influenced by social desirability or political correctness. In terms of psychological growth and well-being, the three essential needs that nurture and promote growth of the human psyche are the needs for autonomy, competence, and relatedness (Sheldon & Elliot, 1999). Value-based goals that satisfy these three intrinsic psychological needs are more predictive of well-being and are associated with lower levels of depression (Ryan et al., 1996).

The next time you feel empty inside despite all the successes, you may want to do some soul-searching and ask yourself if you are living a value-driven life. You may have climbed the ladder of success but that ladder may have been propped against the wrong wall.

To learn more about evidence-based self-management techniques that are proven to work for depression, check out Dr. Duggal's Author Page

HARPREET S. DUGGAL, MD, FAPA

REFERENCES

Grant, A. M., & Greene, J. (2001). Coach yourself: Make real change in your life. Cambridge, MA: Perseus Publishing.

Harris, R. (2009). ACT made simple. Oakland, CA: New Harbinger Publications, Inc.

Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2012). Acceptance and commitment therapy: The process and practice of mindful change. (2nd ed.). New York, NY: The Guildford Press.

Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Helping people change (3rd ed.). New York, NY: The Guilford Press.

Ryan, R. M., Sheldon, K. M., Kasser, T., & Deci, E. L. (1996). All goals are not created equal: an organismic perspective on the nature of goals and their regulation. In P. M. Gollwitzer & J. A. Bargh (Eds.), The psychology of action: Linking cognition and motivation to behavior (pp. 7-25). New York, NY: Guilford Press.

Sheldon, K. M., & Elliot, A. (1999). Goal striving, need satisfaction, and longitudinal well-being: the self-concordance model. Journal of Personality and Social Psychology, 76(3), 482-497.

Zettle, R. D. (2007). ACT for depression. Oakland, CA: New Harbinger Publications, Inc.







Friday, March 29, 2019

Increase Your Happiness Using the “CASIO” Model



Quality of Life Therapy (QOLT) has been used as a positive psychology intervention to promote happiness and wellbeing and has also been shown to be an effective treatment for depression (Frisch, 2006; Grant et al., 1995). One of the core techniques of QOLT that you can use to boost your life satisfaction and thereby increase your happiness is the CASIO model. The five strategies in this model target satisfaction in important areas in one’s life, with satisfaction defined as one’s subjective evaluation of the degree to which one’s most important needs, goals, and wishes have been fulfilled. The acronym CASIO stands for:

  • Objective Circumstances of an area in life
  • Attitude or perception of an area
  • Standards of fulfillment for an area
  • Importance placed on an area for one’s overall happiness
  • Satisfaction one experiences in Other areas not of immediate concern

To apply this technique, first identify areas of your life you are unhappy with and want to change and then use the five strategies below to enhance happiness in those areas of your life. 

1. Change your circumstances: This involves changing the objective circumstances of a particular area in your life. Circumstances include the specific characteristics of an area. For example, if work is an area that you want to focus on, then circumstances in that area include pay, job security, surroundings, relationships with coworkers, availability of resources, supervision, etc. If you are unsatisfied with one or more areas of life, then the first strategy would be to brainstorm solutions to change your circumstances in those areas, which are amenable to change. For example, if relationship is an area of concern, then seeking couples counseling would be something to consider.

2. Change your attitude: Sometimes the circumstances may not lend themselves to change or the change is prolonged. In such situations, use the second strategy of changing your attitude about the situation in order to correct any underlying irrational pessimistic thinking. Two questions are helpful in this context:
  • “What is really happening here?” This question will help you assess if a situation is really as bad as you are making it to be, i.e., are you misperceiving a situation.
  • “What does it mean to me?” This questions will help you assess if you are misinterpreting the implications of a situation for your well-being.

Whereas the first strategy of changing one’s circumstances focuses on changing the objective reality, this strategy focuses on changing the subjective reality. One’s perception about a situation may not be based on facts and, therefore, be inaccurate. For example, if your coworker doesn’t respond to you greeting them “Good Morning,” then does this mean that they are ignoring you on purpose. Sometimes your situation may be supported by facts, but your perception of the consequences may be irrational. For example, if you had a recent break-up, then does it mean that you will be a failure in all your relationships and are unlovable.

3. Change your goals and standards: You may have to reset your standards up or down based on a situation. For example, if individuals face irreversible serious medical problems, then it would help lowering expectations for fulfillment in key areas of their life to maintain their satisfaction with life. Regarding goals, the key idea is to set realistic, but challenging goals for each area of life that you care about. Focusing on process goals or standards that are within your control rather than outcome goals or standards will help you soften your tough goals and standards. It would also make the journey toward your goals more fulfilling. Resetting one’s goals and standards is particularly helpful in reducing depression as people prone for depression are often plagued with impossibly high standards, no matter what the circumstances are in their life.

4. Change your priorities or what is important: This strategy involves reevaluating your priorities and emphasizing those areas of your life that you have control over and de-emphasizing those areas of your life that you cannot do much about. For example, if you have chronic medical conditions, then it may be helpful to emphasize other areas such as relationships or work. This, however, doesn’t mean that you ignore your health; rather the focus is on shifting priorities.

5. Boost satisfaction in other areas: If you put all your emotional eggs in one basket and try to derive happiness from one particular area of your life and something goes wrong with this area, then you are likely to feel depressed. To maximize your happiness, spread your need for fulfillment across all the areas of your life, even ones that are not of immediate concern or that you did not consider before.

To learn more about evidence-based self-management techniques that are proven to work for depression, check out Dr. Duggal's Author Page.

HARPREET S. DUGGAL, MD, FAPA


REFERENCES


Frisch, M. B. (2006). Quality of life therapy. Hoboken, NJ: John Wiley & Sons, Inc.

Grant, G. M., Salcedo, V., Hynan, L. S., Frisch, M. B., & Puster, K. (1995). Effectiveness of quality of life therapy for depression. Psychological Reports, 76, 1203-1208.







Thursday, February 28, 2019

The Do's and Don'ts of Communicating with Your Partner


Improving communication is a proven intervention for improving relationships and entails not only learning how to address negative issues in a relationship but also how to consistently express positive feelings to each other. When you communicate, you are doing one of three things:

1. Speaking: Sending a message or sharing your thoughts or feelings.
2. Listening: Hearing and paying attention to what the other person is telling you.
3. Responding: Replying or answering back to your partner after listening to them.

Failure to communicate can be due to a problem at any or all of these processes of communication. Below are some guidelines to improve your communication skills (Duggal, 2018):

Improving Speaking Skills 

  • Establish eye contact and maintain eye contact with your partner to ensure that they have your attention.
  • Speak in clear and direct fashion. Don’t beat around the bush and play games.
  • Make sure that what you are communicating is in line with your non-verbal communication – tone and volume of your voice and your body language.
  • Ask for feedback to ensure the message was accurately received by your partner.
  • Avoid the temptation of interpreting your partner’s behavior and telling them what you think their problem is. Concentrate on expressing your own feelings as they arise in the dialogue – fear, resentment, appreciation, anxiety, etc.
  • Use “I” statements (“I feel X when you do Y in situation Z”) to share your feelings and thoughts. “You” messages come across as parental or judgmental and usually elicit a defensive response from your partner. When there is no need to defend, there is more openness and more information flows through.
  • Beware of the “pseudo-I” statements. These statements are accusations or blame under the guise of “I” statements. For example, “I feel you are being selfish,” or “I feel you are a jerk.”
  • Don’t confuse “I feel…” statements with “I feel that…” statements. When you add the word “that,” then what follows is not a feeling, but a judging statement usually directed at the other person.
  • Stay in here and now. Don’t bring up issues from the past in your present conversation and be specific about events, feelings, and people involved now.
  • Avoid generalizing words such as “always” or “never” as they add to confusion about what is being communicated. For example, when you say, “you are always watching television when you come home from work,” are you implying that your partner should watch television less often, or are you implying that your partner spend more time doing something else other than watching television, or are you implying that your partner should spend more time with you.
  • Try to communicate the “feeling behind the feeling.” For instance, a partner may say, “You never take time to check with me on how I have been doing at work. You are only concerned about yourself. Well, I am sick of it.” The feelings that are being communicated in these statements are of frustration, resentment, and blame. However, the underlying feelings may be those of feeling lonely and unappreciated. Restated, this communication would be on the lines, “I feel lonely and unappreciated when you don’t take the time to check on how I have been doing at work.”
  • Ask and state what you want and do not expect your partner to know intuitively what you feel or need.
  • Change your statement of resentment into a demand. For instance, “I resent being left with all the clean up after the guests leave” translates into, “I want you to help me clean up.”
  • When talking about your partner, state your feelings about your partner, not just about an event or a situation.
  • Speak in turns – limit your message to one main idea with elaboration and then let your partner respond.
  • If you are asking for help, don’t hedge your request with statements like, “I know this is asking a lot…” or “I am sorry to have to ask you, but...” or “I know this is the last thing you want to do, but I need…” Hedging makes the other person react more defensively in their mind, “Gosh, what’s he going to ask for that’s so much, anyway?” Be specific about what help you are requesting to avoid misunderstanding and a premature negative reaction from your partner.

Improving Listening Skills

  • Face your partner and maintain eye contact.
  • Use your tone of voice, facial expression, and posture to tell your partner that you are paying attention to what they are saying.
  • Acknowledge that you are hearing your partner using simple gestures as “uh huh.”
  • Notice for signs if the person has more on their mind than words are expressing. Is their voice wavering? Are they struggling to find the right words? Do you see any signs of body tension? Do they seem distracted?
  • Wait for your partner to complete a thought without interrupting to express your own ideas.
  • Rather than thinking about a solution or coming up with an opinion, put yourself in your partner’s shoes and try to look at the situation from their perspective – how they think and feel about the issue. You have to relate to the feelings before you can understand the facts.
  • People express themselves differently based on their cultural background, how they were raised, where they were born, gender, and also the kind of work they do. For example, women tend to ask more personal questions to show interest and form relationships, whereas men are more likely to interrupt, offer opinions and suggestions, and state facts in conversations. People of certain cultures may not see you in the eye as a sign of respect. By acknowledging and accepting these differences, you can reduce misunderstandings, frustrations, and resentment that you experience in your communication with your partner.

Improving Responding Skills

  • If you are not sure you understood the message, ask questions and seek clarification. These are “what” and “how” questions and not “why” questions as the latter lead to analyzing and rationalizing without addressing the problem on hand.
  • Don’t ask any questions other than those for clarification, especially opinions that are masked as questions. For example, “Don’t you think we will enjoy going to the movies more than the dinner?”
  • After your partner has finished speaking, summarize and restate what their feelings, desires, conflicts, and thoughts are about the issue. Use statements starting with “You are saying” or “You are feeling” or “You are thinking.” This is done without editorializing, judging, or interpreting and helps clear any ambiguities in the message received.
  • Don’t express your own viewpoint or opinion.
  • Don’t offer solutions to attempt to solve a problem, if one exists.
  • Don’t attach new meanings or make judgments on what your partner has said.
  • If you notice that the body language and words of your partner don’t match, gently point this out to your partner. For example, you might say, “Dear, I hear you saying that you would like to go for the movie tonight, but you look tired and you are yawning as you speak. Would you prefer if we go some other day?”
  • If you feel that a discussion is getting off the topic and the emotions are running high, then ask for time to think about the issue and respond later. For example, you may say, “I think I understand your concerns, but I need more time to think about it before I can respond.” Or, “I hear what you are saying, but I am too frustrated to respond now. I need to find out more information about this before I can answer you.”
A word of caution about improving communication is that interventions that improve communication are successful in moving only about 50% of couples from distressed to non-distressed state and may not work for the following couples (Gordon et al., 1999):
  • Couples who do not desire to share a great deal with each other
  • Couples who do not feel the need to resolve all the conflicts
  • Couples who have decided that one person will make all or most of the decisions
  • Couples who do not believe that having a great deal of intimate and equitable communication is important for marital adjustment
Adapted from the book The Happiness Guide to Self-Management of Depression

HARPREET S. DUGGAL, MD, FAPA

REFERENCES

Duggal, H.S. (2018). The happiness guide to self-management of depression. Bloomington, IN: Archway Publishing.

Gordon, K. C., Baucom, D. H., Epstein, N., Burnett, C. K., & Rankin, L. A. (1999). The interaction between marital standards and communication patterns: how does it contribute to marital adjustment? Journal of Marital and Family Therapy, 25(2), 211-223.


Saturday, January 26, 2019

Beyond Medication: Bright Light Therapy for Depression


What Is Bright Light Therapy?

Bright light therapy involves exposure of the eyes to bright light for a specific duration of time on a daily basis. The person sits next to a light box or a lamp that emits a full-spectrum light. It is a safe, rapid, and effective way of treating depression, both the seasonal variety which commonly happens during winter and the non-seasonal ones (American Psychiatric Association, 2010; Morgan & Jorm, 2008). Bright light therapy is also beneficial for sleep disorders in people with sleep-wake cycle disturbance, especially in older adults (Sloane et al., 2008).

Seasonal Depression and Bright Light Therapy

If you are getting symptoms of depression every fall or winter and they usually go away around springtime, then it is likely that you have a seasonal pattern of depression. Of course, having a stressor such as being without a job every winter will preclude such a diagnosis. Having two episodes of depression during a particular time of the year in the last two years with no non-seasonal episodes and having this pattern of depression over your life time further emboldens a diagnosis of seasonal depression (American Psychiatric Association, 2013). Younger people seem to be more prone for winter depression.

People with seasonal depression usually have “atypical” depressive symptoms such as increased sleep, increased appetite, carbohydrate craving, and weight gain (Praschak-Rieder & Willeit, 2003). In fact, having the above symptoms increases your chances of responding to bright light therapy (Terman et al., 1996). Bright light therapy has been considered as the first-line treatment for seasonal depression for decades now. With bright light therapy, you may notice improvement in your symptoms as soon as 1 week of starting treatment compared to 3 to 4 weeks for antidepressants (Praschak-Rieder & Willeit, 2003). Remission, defined as greater than 50% reduction in depressive symptoms as measured by a depression rating scale, is highest for morning exposure to bright light compared to evening exposure (Terman et al., 1989).

How Does Bright Light Therapy Work?

We don’t know exactly how bright light improves mood. Our brain has specialized centers that keep our biological rhythms (circadian rhythm) of waking, sleeping, melatonin and cortisol secretion, and body temperature in sync with the external 24-hour day/night cycle. In people with seasonal depression, these rhythms may get adrift and it is hypothesized that exposure to bright light restores them. As bright light therapy improves mood in people with non-seasonal depression, it is postulated that bright light may also be regulating other neurotransmitters such as serotonin or stress hormones such as cortisol leading to improvement in depression.

Who Can Benefit from Bright Light Therapy?

The American Psychiatric Association’s guidelines for treatment of major depressive disorder (American Psychiatric Association, 2010) and other studies (Epperson et al., 2004; Sloane et al., 2008) document that bright light therapy is effective in:
  • People with major depressive disorder or bipolar disorder and having a seasonal pattern of depression. 
  • Non-seasonal major depressive disorder. A study showed that bright light therapy is more effective than placebo either as a stand-alone treatment or in combination with the antidepressant fluoxetine for non-seasonal depression (Lam et al., 2015). Interestingly, in this study, compared to bright light therapy, fluoxetine alone was not effective. However, the small size of the study may have precluded meaningful comparisons between the various active treatments. 
  • As an addition to antidepressants and other strategies used to treat depression such as sleep deprivation. Bright light therapy has been shown to speed up the antidepressant response. 
  • People with milder depression who don’t meet criteria for major depressive disorder. 
  • Pregnant women with depression who don’t want to take medications. 
  • People with certain sleep disorders. 


The Practical Aspects of Bright Light Therapy

Quantity of light: The clinical standard for bright light therapy is 10,000 lux. To put things in perspective, 2,500 lux is equivalent to being out on a cloudy day and 10,000 lux is roughly equivalent to being outdoors on a sunny, but not excessively bright day.

Spectrum: White light is recommended for bright light therapy. Any device used for bright light therapy should have a filter for screening out the harmful ultraviolet (UV) light.

Duration and timing of exposure: Thirty minutes of exposure to bright light at an intensity of 10,000 lux in the morning is what is usually recommended. If using a device with lower intensity of 2,500 lux, the exposure is for 2 hours in the morning. As mentioned before, morning exposure has greater effect of deceasing depression compared to evening exposure. It has been suggested that if you don’t see any response after two weeks of treatment, then the exposure should be increased to 30 minutes in the morning and 30 minutes in the evening (Praschak-Rieder & Willeit, 2003). If you don’t perceive any benefit after another two weeks, it may be time to switch over to a different modality of treatment after consulting with your primary care or mental health provider. In one study, the effect of bright light therapy became apparent at four weeks (Lam et al., 2015).

Length of treatment: Bright light therapy is effective if it is used on a daily basis until springtime or at least for five months (the usual duration of seasonal depression). As bright light therapy can be very effective pretty quickly, people may be tempted to stop it, which may increase the chance of relapse of depressive symptoms.

Precautions and Side Effects

If you are leery of taking antidepressant medications or have not tolerated the side effects of antidepressants, then bright light therapy may be a good option for you. Although there are no absolute contraindications of bright light therapy, it is recommended that if you have certain eye conditions such as macular degeneration and skin conditions such as porphyria or solar urticaria, then you need to consult an ophthalmologist or dermatologist before you start bright light therapy. In addition, if you are taking drugs that can cause a photosensitive reaction (examples include certain antipsychotic medications like chlorpromazine, antiarrhythmic drugs like amiodarone, some antimalarial drugs, St. John’s Wort, tetracycline, psoralen drugs, hydrochlorthiazide, sulfonamides, and tricyclic antidepressants), then consulting with your prescribing physician is advisable.

Side effects of bright light therapy are usually minor and transient (Sloane et al., 2008). Common side effects involving the eye include eye strain, blurred vision, seeing spots, glare, and eye burning. Other side effects include skin photosensitivity, headache, nausea, jitteriness, anxiety, and possible induction of hypomanic symptoms. The latter may be true for people with an underlying bipolar disorder and must be closely monitored for in people with this diagnosis. Since most of the commercially available bright light therapy devices that have been used in clinical trials are designed to filter out the ultraviolet light, concerns of permanent damage to eyes or increasing the risk of skin cancer are only speculative.

What to Look for in a Bright Light Device?

The Center for Environmental Therapeutics recommends the following criteria for selecting a light box or high intensity desk lamp for bright light therapy:
  • The device should have been clinically tested in independent trials. 
  • The device should provide 10,000 lux of light intensity. 
  • The device should specify the distance at which it should be placed. The device should be powerful enough to deliver an intensity of 10,000 lux at a distance of 60 to 90 cm. 
  • The nature of the light should be white rather than colored. 
  • The device should allow the light to be projected at an angle of 30 to 60 degrees with respect to your eyes to avoid eye glare and discomfort (Praschak-Rieder & Willeit, 2003). 
  • The device should filter out all ultraviolet rays. 
  • The device should be big enough to allow adequate range of motion for your head so that it doesn’t take the eyes out of the therapeutic range of the light. 
  • Compare prices and warranty before you make a purchase. 
The take-home message here is that one doesn't have to have seasonal depression to benefit from bright light therapy. Also, for individuals with clinical or sub-clinical depression who prefer not to take medication, bright light therapy is an evidence-based treatment to consider.

To learn more about evidence-based self-management techniques that are proven to work for depression, check out Dr. Duggal's Author Page.



HARPREET S. DUGGAL, MD, FAPA

REFERENCES
American Psychiatric Association (2010). Practice guidelines for the treatment of patients with major depressive disorder (3rd ed.). Arlington, VA: American Psychiatric Association.

American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

Epperson, C. N., Terman, M., Terman, J. S., Hanusa, B. H., Oren, D.A., Peindl, K. S., & Wisner, K. L. (2004). Randomized clinical trial of bright light therapy for antepartum depression: preliminary findings. Journal of Clinical Psychiatry, 65(3), 421-425.

Lam, R. W., Levitt, A. J., Levitan, R. D., Michalak, E. E., Cheung, A. H., Morehouse, R., Ramasubbu, R., Yatham, L. N., & Tam, E. M. (2015). Efficacy of bright light treatment, fluoxetine, and the combination in patients with nonseasonal major depressive disorder: a randomized clinical trial. JAMA Psychiatry, 73(1), 56-63.

Morgan, A. J., & Jorm, A. F. (2008). Self-help interventions for depressive disorders and depressive symptoms: a systematic review. Annals of General Psychiatry, 7, 13. doi: 10.1186/1744-859X-7-13.

Praschak-Rieder, N., & Willeit, M. (2003). Treatment of seasonal affective disorders. Dialogues in Clinical Neuroscience, 5(4), 389-397.

Sloane, P. D., Figueiro, M., & Cohen, L. (2008). Light as therapy for sleep disorders and depression in older adults. Clinical Geriatrics, 16(3), 25-31.

Terman, M., Terman, J. S., Quitkin, F. M., McGrath, P. J., Stewart, J. W., & Rafferty, B. (1989). Light therapy for seasonal affectice disorder. A review of efficacy. Neuropsychopharmacology, 2(1), 1-22.

Terman, M., Amira, L., Terman, J. S., & Ross, D. C. (1996). Predictors of response and nonresponse to light treatment for winter depression. American Journal of Psychiatry, 153(11), 1423-1429.



Tuesday, December 18, 2018

How You Respond to Good News Matters in Relationships


When good fortune knocks, our first response is often to contact significant others to share the news. Sharing of good news with others promotes well-being by enhancing positive emotions and life satisfaction (Gable et al., 2004). However, this also depends on how you actually respond to the good news. Gable and colleagues elaborate that people respond to their partner’s sharing of good news in four different ways. Below is an exercise to gauge what your partner’s response to your sharing of good news is (or what your response is being perceived by your partner) (Gable et al., 2004):

"Please take a moment to consider how your partner responds when you tell him or her about something good that has happened to you. For example, imagine that you come home and tell your partner about receiving a promotion at work, having a great conversation with a family member, getting a raise, winning a prize, or doing well on an exam at school or a project at work. Please consider to what extent your partner does the following things (bulleted items below) in response to your good fortune".

1. Active-Constructive Response:
  • My partner usually reacts to my good fortune enthusiastically 
  • I sometimes get the sense that my partner is even more happy and excited than I am 
  • My partner often asks a lot of questions and shows genuine concern about the good event 
2. Passive-Constructive Response:
  • My partner tries not to make a big deal out of it but is happy for me 
  • My partner is usually silently supportive of the good things that occur to me
  • My partner says little, but I know he/she is happy for me 
3. Active-destructive Response: 
  • My partner often finds a problem with it 
  • My partner reminds me that most good things have their bad aspects as well 
  • He/she points out the potential down sides of the good event 
4. Passive-Destructive:
  • Sometimes I get the impression that he/she doesn’t care much 
  • My partner doesn’t pay much attention to me 
  • My partner often seems disinterested 
This exercise will help you recognize your partner’s (or your) predominant responding style to good news. For a couple of weeks, you can also track your own responses to good news shared by someone close to you. Research shows that only active-constructive responses are associated with commitment, satisfaction, intimacy, and trust in a relationship (Gable et al., 2004). Even passive-constructive responses are not helpful in relationships. You can extend active-constructive responses to other people who share their good fortune with you – relatives, friends, and coworkers. Of course, use common sense when the news that is good to the person delivering is not exactly music to your ears. You obviously don’t want to respond with enthusiasm when your partner tells you that they have found someone else to marry!

To learn more about evidence-based self-management techniques that are proven to work for depression, check out Dr. Duggal's Author Page.


HARPREET S. DUGGAL, MD, FAPA 

REFERENCES:

Gable, S. L., Reis, H. T., Impett, E. A., & Asher, E. R. (2004). What do you do when things go right? The intrapersonal and interpersonal benefits of sharing positive events. Journal of Personality and Social Psychology, 87(2), 228-245.

Saturday, November 17, 2018

3 Ways to Express Gratitude



Gratitude is one of the most commonly used and proven positive psychology interventions that not only enhances well-being but also is an effective way of self-managing depression. Grateful people experience higher levels of positive emotions such as joy, enthusiasm, love, happiness, and optimism. Gratitude buffers you from hurtful feelings of envy, resentment, greed, and bitterness. In addition, grateful people can cope more effectively with everyday stress and show increased resilience in the face of trauma-induced stress (Emmons, 2013).

Whether or not you have a grateful disposition, the good news is that it is possible to cultivate gratitude intentionally. You can choose one of the following three methods to express gratitude, but most beginners start with a gratitude list at it is a simple yet effective strategy.

Gratitude lists

This the “classic” and the most studied method of expressing gratitude. It involves making written lists of several things for which you are grateful on a regular basis. The most common method of this intervention is through a gratitude diary or journal. Writing down your blessings helps you organize your thoughts, facilitates integration, and helps you accept your own experiences and put them in context. A simple instruction for counting blessings is, “What three things went well today and why they went well?” Below are some tips to enhance your experience of gratitude journaling (Duggal, 2018):
  • Gratitude is not a short-term habit, but a positive virtue that you consciously cultivate. 
  • You can express gratitude for the simple blessings of life that you may normally take for granted. For example, before meals, you may take a moment to offer your heartfelt thanks for the food to the farmers, the earth, food handlers, chef, etc. An easy way to remember who to thank for simple things in life is the concept of gratitude chain. You express gratitude to all the individuals who sequentially made that thing possible for you. 
  • In order to overcome boredom with routine counting of daily blessings (also known as gratitude fatigue), research suggests doing the gratitude exercise once a week (Lyubomirsky, 2007). In addition, vary the domains of life in which you express gratitude (e.g., work, relationships, health, etc.) to keep the act of expressing gratitude “fresh” and meaningful. Try to include some surprise or unanticipated blessings to keep the dopamine neurons, which modulate reward, pleasure, and motivation, firing in your brain. You may choose to pick up a different domain of life each week to express gratitude. 
  • When writing about a blessing or a benefit you received from another person, be specific, break it down to individual elements, and then write in detail about each element. 
  • It is OK to repeat blessings, but make sure you elaborate on them and give specific details on how they have impacted your life or the life of your loved one and, if possible, how your life would be different if that particular thing hadn’t happened. 
  • Use gratitude prompts as a reminder to keep flexing your gratitude muscle to make it strong. For example, you can pick a rock with a smooth texture or another small object and carry it in your pocket or keep it on your desk. Whenever you see or touch the rock or the small object, it is a reminder for you to pause and think about at least one thing you are grateful for. 
  • Instead of using a journal or a diary, you can write three things you are grateful about once or twice a week on strips of paper and put them in a gratitude jar. Take a few notes out of the jar on your low days for a quick boost to your mood. 
  • You may also count as blessings negative events or situations that you avoided, prevented, escaped, or turned into something positive. 
  • You may use one of the several smartphone apps on gratitude to transform this into a habit. 

Gratitude visit

In gratitude visit, you write a letter to a benefactor thanking them for the gift you received and read the letter to them in person. The purpose of the exercise is to express your gratitude in a thoughtful and purposeful manner beyond the cursory “thank you” note. Instructions for the gratitude visit are as below (Seligman, 2002):

"Think about a person who is still alive who years ago did something or said something that made a major difference in your life and to whom you have never fully expressed your thanks. Your task is to write a letter of about 300 words, which should be specific about what the person did for you and how it affected your life. Also, mention in the letter what you are doing now and how you often remember what they did for you. Once you have written the letter, call the person and tell them that you would like to visit them, but be vague about the purpose of the visit; this exercise is much more fun when it is a surprise. When you meet the person, read your letter slowly, with expression, and with eye contact. Let the person react to your letter unhurriedly. Take whatever time it takes – a few days to a few weeks – to complete your letter".

Not everyone would be comfortable delivering a letter of gratitude to someone they haven’t met in years. There is good news though. A study showed that all three formats of the gratitude visit – in person, or over the phone, or by mailing the letter either by standard or electronic mail are equally effective (Schueller, 2012).

Grateful contemplation

The practice of grateful contemplation is less specific than gratitude lists in that you think and write about list of activities you were grateful for in a global fashion (past memories of grateful events or things). For example, list of activities over the summer that you are grateful for. People usually choose from one or more of the following categories to write about grateful activities:
  • Education 
  • Health
  • Safety/security 
  • Possessions 
  • Break/vacation/weekends/holidays 
  • Act of kindness/support from others 
  • Achievement/performance 
Another variant of grateful contemplation is contrasting your current state to a state of deprivation. When you think about a negative life event, you feel better when you compare it with an even worse outcome (e.g., “I only got a warning from my supervisor, but at least I didn’t get fired”). Along the same lines, when you think about something you feel grateful about, you can enhance the feeling of gratitude if you can imagine how that thing might never have happened. Also, if the expression of gratitude is accompanied by an element of surprise, then it bolsters the experience of gratefulness. To put these suggestions into practice, after identifying and writing your memories about grateful activities, elaborate more using the following two instructions:
1. Describe ways that this thing or event might never have happened or might never have been a part of your life.
2. Describe ways in which it is surprising that this thing or event is a part of your life.

To learn more about evidence-based self-management techniques that are proven to work for depression, check out Dr. Duggal's Author Page.

HARPREET S. DUGGAL, MD, FAPA

Reference

Duggal, H. S. (2018). The happiness guide to self-management of depression. Bloomington, IN: Archway Publishing.

Emmons, R. A. (2013). Gratitude works! San Francisco, CA: Jossey-Bass.

Lyubomirsky, S. The how of happiness. New York, NY: Penguin Books.

Schueller, S. M. (2012). Personality fit and positive interventions: Extraverted and introverted individuals benefit from different happiness and increasing strategies. Psychology, 3(12A), 1166-1173.

Seligman, M. E. P. (2002). Authentic happiness. New York, NY: Atria Paperback.



Saturday, October 6, 2018

3 Ways Money Can Buy You Happiness



For the longest time, armchair philosophers have told us that money can’t buy happiness. It has been postulated that after a person has enough income to meet basic needs of food, clothing, shelter, and security, additional income seems to have little impact on happiness. However, recent research disproves this notion. Money can buy you happiness – the only catch is that if you spend it in of the one of the following three ways:

1. Spending on others: Social scientists have found that spending money to buy gifts for others or donating to charities promotes happiness (Dunn et al., 2008). You don’t have to shell out enormous amounts of money on others to reap this benefit; amounts as low as $5 spent on others are sufficient to produce significant gains in happiness. However, people are still hesitant to spend money on others, mainly because they feel that spending money on themselves will make them happier than spending money on others. Research shows otherwise.

2. Buying an experience: Studies support spending money on an experience (e.g., events, trips, vacations, spas, massages, concerts, sporting events, dining, etc.) lead to greater happiness compared to spending money for acquiring material possessions (e.g., televisions, clothing, jewelry, electronic equipment, cars, etc.) (Van Boven, 2005). This is because experiences, in contrast to material possessions, provide you with a more memorable story, don’t diminish in their subjective pleasurable value on comparison with others, and bring family and friends together. In other words, you are more likely to reminisce about a vacation with a family than a big screen television, and your memories of the vacation are not going to get tarnished if your neighbor were to buy a television that was bigger than yours. This doesn’t mean that material possessions or things cannot be used to provide you with an experience. For example, you buy a book because it is a collector’s item and never read it (a thing) or you buy a book and plunge into with gusto, savoring every plot twist, making it an experience. The latter will lead to more enduring happiness. It comes as no surprise that happy people tend to extract experiences out of material possessions.

But before you book your next holiday, a couple of caveats are in order here. First, people who buy experiences mainly for bragging rights so that they get more “likes” on social media may not get pleasure from such experiences (Seidman, 2016). Second, recent research shows that individuals with abundant resources are happier from purchasing experiences than material goods compared to individuals with limited resources in whom both material purchases and experiences provide happiness (Lee et al., 2018). Put in real life terms, if one is resource-strapped, then they would experience equal happiness buying a new pair of shoes or going on a weekend getaway.

3. Buying time: Despite rising incomes, people are feeling pressed for time, which undermines wellbeing. Research shows that spending money on time-saving services promotes happiness (Whillans et al., 2017). What this means is that if you outsource chores that you dislike such as cleaning your home, mowing the lawn, etc., then you have more time to relax, catch up with friends, or pursue your hobbies.

The take-home message here is that money, even small amounts of it, can buy you happiness; you only need to know how to spend it.

To learn more about evidence-based self-management techniques that promote happiness and also work for depression, check out Dr. Duggal's Author Page.

HARPREET S. DUGGAL, MD, FAPA 

REFERENCES

Dunn, E. W., Aknin, L. B., & Norton, M. I. (2008). Spending money on others promotes happiness. Science, 319, 1687-1688.

Lee, J. C., Hall, D. L., & Wood, W. (2018). Experiential or material purchases? Social class determines purchase happiness. Psychological Science, 29(7), 1031-1039.

Seidman, E. (2016). Fourteen ways to jump for joy. In S. O’Connor (Ed.), The Science of happiness (pp.34-41). New York, NY: Time Books.

Van Boven, L. (2005). Experientialism, materialism, and the pursuit of happiness. Review of General Psychology, 9(2), 132-142.

Whillans, A. V., Dunn, E. W., Smeets, P., Bekkers, R., & Norton, M. I. (2017). Buying time promotes happiness. Proceedings of the National Academy of Sciences, 114(32), 8523-8527.



Saturday, September 8, 2018

Perfectionism and Depression


Perfectionism and Depression

If your thoughts are, “I have to do it right,” “I have to do it all,” “I cannot fail,” “I have to keep up with others,” “Is this good enough?” or “I need to be in control,” then you are letting perfectionism dictate your life. In being a perfectionist, you hold yourself to high ideals or expectations that originate from your irrational thoughts. These irrational thought patterns include all-or-none thinking and “should” and “must” statements. If you don’t meet your perfectionist standards, you start to feel worthless, which then fuels more depressive thinking. Perfectionists often seek pleasure by focusing on the results of their activities rather than enjoying the process. This then prevents them from savoring simple pleasures of everyday life. In fact, perfectionism increases one’s vulnerability for depression, possibly because of lack of self-compassion (Ferrari et al., 2018). In other words, perfectionist individuals are more likely to judge themselves harshly and criticize themselves for mistakes because of their concerns about being negatively evaluated by others. This then engenders feelings of shame, which in turn makes these individuals more vulnerable for depression. With depression setting in, one experiences loss of pleasure (anhedonia), which then creates a double whammy for a perfectionist as they are already not experiencing much joy to begin with.

According to Paul Gilbert, author of Overcoming Depression, perfectionism sometimes stems from irrational attitude of competitiveness that one has to keep up with others or get ahead of others (Gilbert, 2001). The mindset in competitive perfectionism is, “If they can do this, so should I” or “If they can do this, then I can do this better.” As evident, these perfectionists let others around them set their standards and are prone to feeling worthless when they don’t meet these standards. Other causes of perfectionistic tendencies include fear of failure or of being rejected. Pressure to succeed and unrealistic expectations of seeking approval from others can also drive perfectionism.

Below are some proven ways to overcome perfectionism:

Cognitive Techniques to Overcome Perfectionism

Some questions and techniques geared toward changing your thought process to squelch perfectionism out of your daily routine are as below (Burns, 1999; Gilbert, 2001):
  • Are my expectations based on my own values or they being driven by competitiveness? 
  • Was I trying to avoid being seen as inferior or did I want to be seen as superior? 
  • Are these my own standards or ones that others expect of me? 
  • Am I missing out on the pleasures of doing things by focusing too much on success? 
  • Am I overlooking and not praising myself enough for the small successes? 
  • If I can’t do it all, is there a small part of it that I can do? 
  • What would I tell my best friend if they had perfectionist tendencies? 
  • Is my false sense of pride driving my perfectionism? 
  • Replace your “I should” or “I must” statements with “I prefer” statements. “I should finish this task by today” becomes “I prefer to finish this task by today.” 
  • Learn to recognize that perfectionism is an illusion. No human being is perfect and nothing done by humans is perfect. 
  • Compare the advantages and disadvantages of being a perfectionist. If your goal is to walk at least two miles a day for it to be counted as meaningful, then the advantage of holding on to this belief is that you may get enough exercise if you were to do this. The disadvantages may include “freezing” and not doing anything as this may be too big a goal for you, being afraid of feeling ashamed if you are not able to walk for two miles, not being able to enjoy the walk itself because you are only focusing on the distance, and comparing yourself with others who are walking greater distances, which makes you feel worthless. By drawing out the advantages and disadvantages of your perfectionistic assumptions, you can arrive at a more rational and balanced approach to setting your standards. 
  • Dare to be average as David Burns, author of Feeling Good, puts it. Do a task with lower set of expectations and you will most likely still be satisfied and experience pleasure with it (Burns, 1999). 

Self-Compassion Journal

Self-compassion is another proven antidote for perfectionism (Neff, 2011). Around evening, write in your self-compassion journal any event that made you judge yourself critically, or you felt ashamed, or blamed yourself, or anything that you felt bad about. Next, for each event, use the three components of the compassionate frame of mind – self-kindness, a sense of common humanity, and mindfulness – to process the event in a self-compassionate way.

Let’s consider the following situation to illustrate this technique. You couldn’t meet a deadline at work despite your best efforts and even though your supervisor extended the deadline, you can’t stop feeling bad about the incident and blame yourself for your unsatisfactory performance because you have always held yourself to high standards. Using self-kindness, you use gentle, supportive, and understanding words to accept your shortcomings rather than harshly blaming yourself. For example, “I know I messed up, but it isn’t the end of the world. I understand that it is frustrating to miss the deadline and how this makes me feel. I know I tried very hard to accomplish my task and blaming myself for not performing satisfactorily is only going to get my spirits down.” Using a sense of common humanity, you recognize that all humans fail and make mistakes and no one is perfect. For example, “I know of other people who have not met deadlines at work, and they don’t feel sorry about themselves,” or “Perfectionism is an illusion. No human being is perfect, and nothing done by humans is perfect.” Using mindfulness, you try to focus on the feelings and emotions related to the event without any judgments and without getting caught up in an exaggerated storyline about the negative aspects of the event.

To learn more about evidence-based self-management techniques that are proven to work for depression, check out Dr. Duggal's Author Page.

HARPREET S. DUGGAL, MD, FAPA


REFERENCES

Burns, D. D. (1999). Feeling good: The new mood therapy. New York, NY: Avon Books.

Gilbert, P. (2001). Overcoming depression: A step-by-step approach to gaining control over depression (2nd ed.). New York, NY: Oxford University Press, Inc.

Ferrari, M., Yap, K., Scott, N., Einstein, D. A., & Ciarrochi, J. (2018). Self-compassion moderates the perfectionism and depression link in both adolescence and adulthood. PLoS One, 13(2):e0192022. doi: 10.1371/journal.pone.0192022

Neff, K. (2011). Self-compassion. New York, NY: William Morrow.









Sunday, August 12, 2018

Are Your Worries About Sleep Turning You into an Insomniac?

Are You Worrying About Not Sleeping?

If you are prone for insomnia, then you are already going to bed preoccupied with getting to sleep quickly and obtaining as much sleep as possible. You also worry about the impact of sleep on your physical health and daytime functioning. These excessive worries and ruminations trigger in you a state of physical arousal and emotional distress through activation of the sympathetic nervous system similar to the fight-or-flight response. This arousal and anxious state then narrows your focus to attend to and monitor for sleep-related cues such as:
  • Body sensations for signs consistent with falling asleep: slowing of heart rate and loss of muscle tone. 
  • Body sensations for signs inconsistent with falling asleep: heart pounding quickly and muscle tension. 
  • Surroundings for signs of not falling asleep: noises outside and inside the house. 
  • The clock to see how long it is taking you to fall asleep: “It is 1:30 a.m….I have been trying to sleep for 2 hours and 30 minutes!” 
  • The clock to calculate how much sleep you will get: “Oh no…It is already 2 a.m....which means that I will only get 4 hours of sleep tonight.” 

Unfortunately, this monitoring for sleep-related threats then generates more worrisome and irrational thoughts such as, “I am never going to get to sleep,” or “If I can’t get to sleep soon, there is no way I will be able to function tomorrow.” These irrational thoughts reinforce the worrisome thoughts you had before you went to bed, thus creating a vicious cycle.

What Keeps Your Insomnia Going?

Once you have developed insomnia, several exacerbating processes contribute to maintain it. These include:
  • Existing irrational beliefs about sleep: For example, “I need to sleep at least 8 hours daily to remain healthy” or “Without an adequate night’s sleep, I can hardly function the next day.” 
  • Poor sleep behaviors such as erratic sleep and wake up times, taking day time naps, poor sleep hygiene, etc. 
  • Safety behaviors that include strategies that are developed in an attempt to avoid a feared outcome. For example, trying to suppress thoughts interfering with sleep (which paradoxically increases these thoughts), cancelling work and taking an afternoon nap to avoid feeling tired at work (which then causes more insomnia), or drinking alcohol to help you fall asleep (which may help one fall asleep, but results in poor sleep continuity). 
Below are some pointers on a healthy sleep hygiene that will help you self-manage insomnia.

Sleep Hygiene

Sleep hygiene is a term used to describe healthy sleeping habits and avoidance of behaviors that are incompatible with sleep. Sleep hygiene is effective when used in conjunction with other cognitive-behavioral approaches to treat insomnia. Some of the salient features of sleep hygiene are as below:
  • Stick to a sleep schedule of the same bedtime and wake-up time, even on the weekends. This keeps your body’s internal clock regulated. 
  • Use natural light (that comes through a window) to remind yourself of when it is time to be asleep and awake. This can help you set a healthy sleep-wake cycle. 
  • Exercise daily but avoid doing vigorous exercise too late in the evening. 
  • If you take naps, keep them short and before 5 p.m. 
  • Don’t eat or drink too much when it is close to bedtime. 
  • Avoid caffeine (coffee, tea, chocolate, and cola) and nicotine for several hours before bedtime. 
  • Wind down before going to bed (e.g., take a warm bath, do light reading, and practice relaxation exercises). 
  • Use your bed only for sleep and sex and not for other activities such as watching television or working. Associating your bed with sleep conditions your brain that it is time to wind down and go to sleep. 
  • Sleep in a dark, quiet room that isn’t too hot or too cold and is well-ventilated. 
  • Reduce external noises that distract you if they can be controlled. If these cannot be eliminated, then try white noise to muffle them. 
  • If you are unable to fall asleep within 20 minutes, get up and do something relaxing and then return when you are ready to sleep. This avoids the bed being associated with wakefulness. 
  • Reduce stimulating activities at nighttime such as reading something really exciting, surfing the internet, watching an action-packed movie, or engaging in an emotionally charged conversation. 
  • Avoid watching the clock when you are having trouble falling asleep as clock watching can be arousing and incompatible with sleep. Instead, when it becomes obvious to you that your state of mind is not conducive to sleeping, then get out of the bed and return to it when you are sleepy. 

A Technique to Help with Bedtime Worry

Bedtime worry about future events is a common cause of difficulty falling asleep. If you lie awake at night because your mind won’t stop racing, then taking five minutes before bedtime to write a to-do list for the next day might get you more shuteye. This technique, though seemingly counterintuitive, is supported by research (Scullin et al., 2018). The possible underlying mechanism behind this technique is that when your write your to-do list, it helps you offload your worries about the future rather than ruminate about them and expressive writing is known to reduce anxiety and depression. The instructions for this exercise are below:

Every day before you go to bed, spend five minutes writing down everything you have to remember to do tomorrow and over the next few days. You can write these in paragraph form or in bullet points. Use all five minutes to think and write about tasks you have to complete tomorrow and in the near future, even if few are coming to you. 

A caveat here is in order. Not all sleep disorders are related to worries and unhealthy sleep hygiene habits. It is prudent to first consult with your primary care or mental health provider to exclude other medical conditions that may be leading to insomnia such as pain or other sleep disorders such as sleep apnea or restless legs syndrome.

To learn more about evidence-based self-management techniques that are proven to work depression, check out Dr. Duggal's Author Page.

HARPREET S. DUGGAL, MD, FAPA

REFERENCES
Scullin, M. K., Krueger, M. L., Ballard, H. K., Pruett, N., & Bliwise, D. L. (2018). The effects of bedtime writing on difficulty falling asleep: a polysomnographic study comparing to-do lists and completed activity lists. Journal of Experimental Psychology: General, 147(1), 139-146.


Tuesday, July 31, 2018

The 8 Types of Guilt in Depression



“Feelings of worthlessness or excessive guilt or inappropriate guilt” is one of the nine core symptoms of major depressive disorder according to the American Psychiatric Association. Guilt can be an adaptive emotion when it is appropriate to context, is not excessive, is based on altruism (acting with an unselfish regard for others), and serves the purpose of maintaining attachments. However, in depression, guilt tends to be exaggerated or is inappropriate (not relevant to context) and is called maladaptive guilt. Maladaptive guilt presents in depression in one or more of the eight types as described below:

1. Survivor guilt: Survivor guilt first gained attention when survivors from the concentration camps of World War II were noted to harbor feelings of guilt for the loved ones who were killed in the camps. These survivors, years later, developed symptoms of depression and anxiety. Besides combat and natural disasters, survivor guilt has also been observed in medical situations. People who got better following a surgery whereas their family members or friends died of similar or other ailments experienced depressive symptoms following the medical intervention. Research reveals that compared to non-depressed people, people with depression have higher scores on survivor guilt and the higher the survivor guilt, the more severe the depression. Depressed individuals with survivor guilt may ask themselves, “Why me?” as a result of their irrational belief that they don’t deserve to be alive or experience happiness while others have died or are suffering.

2. Guilt about faring better than others: This is a subtle variant of the survivor guilt in which a person may either inhibit themselves from success or engage in self-sabotage as a form of punishment due to the guilt toward another person who they believe to be worse off than themselves. People suffering from this type of guilt may conceal their happiness or success from others, feel uncomfortable when they are doing better than others, and also adapt a more negativistic view of themselves when interacting with other people. These people harbor the irrational thought that attainment of good things is unfair to those or at the expense of those who have not attained them. People with depression often have irrational thoughts such as labeling themselves as selfish or believing that they don’t deserve to feel better that trigger feelings of guilt. Another reason for harboring this kind of guilt is that depressed individuals fear others may envy them because they are doing better. Therefore, they use self-pity to win others’ approval, which temporarily boosts their low-self-esteem. 

3. Separation guilt: Separation guilt arises from the irrational belief that one is harming one’s loved ones by separating from them, or by pursuing one’s individual goals, or by being different. The underlying theme in separation guilt is the thought of being disloyal to one’s loved ones. People express separation guilt in statements such as, “I feel that bad things may happen to my family if I don’t stay in close contact with them.” Separation guilt can stem from parents or other important people in one’s life inducing feelings of guilt during one’s childhood years. For example, comments such as, “I stayed in this bad marriage just for you,” or “I sacrificed for you,” or admonitions such as, “You disgrace us,” or “You should be ashamed of yourself” induce guilt-ridden childhood memories. These memories then play out as separation guilt when a person tries to gain approval from their loved ones or others who they see in a parental role. 

4. Omnipotent responsibility guilt: This guilt involves a person feeling omnipotently responsible for the happiness and well-being of others without specifically feeling survivor or separation guilt. Omnipotent responsibility guilt can be considered as an exaggerated and irrational form of adaptive guilt. For example, a person with a history of sexual abuse during childhood may carry irrational beliefs that they may be responsible for that or a spouse may have distorted beliefs of blaming themselves for their partner’s unfaithfulness. In depression, the irrational thinking pattern of personalization leads to self-blaming and makes people take too much responsibility for things that may even be beyond their control. People express omnipotent responsibility guilt in statements such as, “I can’t stand the idea of hurting someone else,” “I often find myself doing what someone else wants me to do rather than doing what I would most enjoy,” or “I feel responsible at social gatherings for people who are not able to enter into conversations with others.” This kind of guilt may also arise due to the irrational belief that one may appear less caring, thus risking approval, if one doesn’t assume responsibility for the well-being of others. 

5. Guilt of being a burden to others: People with depression may mistakenly believe that they are a burden on their family or loved ones. They feel a sense of guilt and shame in seeking help and may refrain from sharing their difficulties with others. If they are unable to perform at their previous level in an important aspect of life such as work or relationships, they feel that they are not contributing enough for the well-being of the family. This feeling of guilt can, in some people with severe depression, engender suicidal thoughts. 

6. Self-hate guilt: In this form of guilt, a person carries an extreme negative view of themselves or a general sense of badness. This type of guilt happens in people who have had harsh, punishing, or neglectful parents or it may serve as a mechanism to avoid survivor guilt. Some expressions for this type of guilt include, “If something bad happens to me, then I must have deserved it,” “I always assume I am at fault when something goes wrong,” or “I don’t deserve other people’s respect or admiration.” 

7. Guilt related to grief: Grief can be real or maladaptive after a loss and the latter may happen if one is depressed. An individual with depression, due to irrational thought patterns of personalization, may self-blame following a loss – “I didn’t do enough.” This kind of guilt may also manifest as blaming others when people cannot handle their own sense of culpability and project their guilt onto others. Another presentation of guilt related to grief is the recovery guilt wherein a person goes through the process of grieving and wants to get on their lives but feels guilty that doing so would dishonor the memory of the deceased. Guilt can also arise if one had unresolved conflicts with the deceased and they feel bad about not being able to resolve those before their loved one died. 

8. Delusions of guilt: This guilt is present in people with severe depression. The guilt is not based in reality and the person’s beliefs cannot be shaken despite evidence to the contrary. An example of a delusion of guilt is a depressed parent whose child died and they are convinced that they are responsible for the child’s death because they gave the child the wrong medicine when in fact nothing of that sort happened.

Feelings of guilt, like other symptoms of depression, are amenable to treatment either with psychotherapy or medications. To learn more about evidence-based self-management techniques that are proven to work for depression, check out Dr. Duggal's Author Page.


HARPREET S. DUGGAL, MD, FAPA



Thursday, June 14, 2018

Is it Time to Move on from Self-Help to Self-Management of Depression?





Self-Help Vs Self-Management

You probably have heard the term “self-help” and may have also read a few self-help books. When it comes to depression, most self-help books focus on acute treatment of depression based on a particular model of therapy, usually the Cognitive-Behavioral Therapy (CBT). While the self-help approach tries to address a particular condition using a focused treatment modality over a short period of time, self-management is learning new ways to manage an illness over a longer period of time. In other words, self-management is using the resources and learning the skills to “positively manage” an illness (Lorig et al., 2006). Self-management, besides treating depression, also prevents relapse of depression and helps an individual maintain good mental health on a day-to-day basis. Lorig and colleagues (2006) further elaborate on self-management: it is a “management style” wherein you are a positive self-manager who not only uses the best treatments provided by healthcare professionals but also approach your illness in a proactive manner on a daily basis, leading to a more healthy life.

Unlike self-help strategies that purport to “help” you overcome depression, self-management strategies, in addition to treating depressive symptoms per se, address life style changes, social relationships, communication, problem-solving, and also include elements of wellness and recovery. In other words, self-management teaches you skills that continue to work above and beyond the short-term relief that one may get from self-help strategies. To illustrate this, let’s take diabetes as an example. Good self-managers of diabetes, besides taking medications, educate themselves about diabetes, learn to recognize symptoms of low or high blood sugar, monitor their blood sugar levels regularly, eat healthy and avoid foods that may destabilize their diabetes, exercise to maintain their weight, and seek professional help if their blood sugar levels are staying above or below the normal range. People with diabetes, heart disease, emphysema, asthma, and other long-standing medical conditions have successfully used self-management to live a healthy life. Unfortunately, treatment of depression has lagged behind in incorporating the concept of self-management, even though one in five people with depression will have chronic depression.

What are the Components of Self-Management?
While the list below is not exhaustive, the key components of self-management include the following (Barlow et al., 2002):

1. Information:
· Educating self and family members/friends about depression

2. Medication management:
· Taking medications as recommended by your provider
· Overcoming barriers to adherence to medications

3. Symptom management:
· Using various strategies (e.g., cognitive, behavioral, positive psychology interventions, mindfulness, etc.) to manage symptoms of depression
· Self-monitoring of symptoms
· Managing concurrent symptoms of anxiety and/or substance use
· Using techniques to deal with frustration, fatigue, pain, and isolation
· Managing sleep
· Managing symptoms of medical conditions that may be associated with depression
· Relaxation
· Using strategies for preventing relapse of depressive symptoms

4. Life style:
· Exercise
· Overcoming barriers to exercise adherence
· Vacations
· Leisure activities
· Nutrition and diet

5. Social support:
· Family support
· Relationships with peers and friends

6. Communication:
· Assertiveness
· Communication strategies (e.g., with mental health professionals)

7. Others:
· Accessing support services
· Creating action plans
· Decision making
· Goal-setting
· Problem-solving
· Career planning
· Spirituality

It goes without saying that most of the available self-help books on depression woefully fall short of covering a majority of these essential ingredients of self-management and tend to go with one paradigm of treating depression. Depression, however, cannot be treated by one-size-fits-all strategies as suggested by many of these books.

Empower Yourself with Self-Management

Healthcare is moving toward a model of client-centered care. In this model, clients are partners in decisions related to their healthcare and collaborate with their healthcare providers to prioritize and set goals and choose interventions for their illness. In this context, self-management strategies prepare you to be an active player in your own treatment rather than being a passive recipient. With self-management, you assume the primary responsibility of your treatment, though with support from your provider and your social network. Self-management puts one in the driver’s seat with regards to making choices to treat depression. Being able to self-manage your depression enhances your confidence and gives you a sense of control in dealing with your illness. Depression can make you doubt your capability for dealing with stress or sometimes even mundane day-to-day stuff. Self-management provides you with an antidote to counter these negative thoughts.

Robust evidence supports the use of self-management strategies in depression (Houle et al., 2013). Individuals using self-management have reduced depressive symptoms, lower relapse rates of depression, improved quality of life and psychosocial well-being, better adherence with medications, and a greater sense of self-efficacy, i.e., self-confidence in one’s abilities. Even if you are on medications or in therapy, self-management complements your ongoing treatment.

To learn more about evidence-based self-management techniques that are proven to work for depression, check out Dr. Duggal's Author Page.


HARPREET S. DUGGAL, MD, FAPA

REFERENCES


Barlow, J., Wright, C., Sheasby, J., Turner, A., & Hainsworth, J. (2002). Self-management approaches for people with chronic conditions: a review. Patient Education and Counseling, 48, 177-187.

Houle, J., Gascon-Depatie, M., BĂ©langer-Dumontier, G., & Cardinal, C. (2013). Depression self-management support: a systematic review. Patient Education and Counseling, 91, 271-279.

Lorig, K., Halsted, H., Sobel, D., Laurent, D., Gonzalez, V., & Minor, M. (2006). Living a healthy life with chronic conditions (3rd ed.). Boulder, CO: Bull Publishing Company.


Thursday, May 31, 2018

Is Depression Pushing You into the Approval Trap?


We all like getting approval and recognition from others. Approval-seeking is good as long as it remains a desire or a want. For example, your boss approves of your work and you feel happy about it. When approval-seeking turns into a need or a necessity, then you become a victim of the “approval trap” that will either make you vulnerable for depression or if you are already feeling depressed, will make your depression worse. If you have low self-esteem, which is not uncommon in depression, and seek approval to give yourself a temporary boost, then you are setting yourself for the “approval trap.” The trap works somewhat like this:  Depression causes you to feel worthless → when you get approval from others, you feel better and less worthless → you try to seek more approval → in seeking more approval you do things you don’t want to do to please others and avoid your own needs → others get used to your approval-seeking behavior and stop approving your behavior → you feel treated like a doormat → this increases your worthlessness → you try harder to seek approval and the cycle goes on.


Approval seeking behaviors
If you do any of the approval-seeking behaviors below, you may be prone to fall for the approval trap:
·         Feeling insulted or put down when someone says something contrary to your view points.
·         Needing to belong to a group to avoid being seen as inferior or rejected.
·         Needing repeated reassurance from others about your actions and your own self-image.
·         Changing your stance or viewpoint just to please others.
·         Sugar-coating your opinions to avoid displeasing others.
·         Upon receiving criticism from others, indulging in all-or-none-thinking or overgeneralization or mind reading and making critical self-judgments such as, “I am worthless,” “No one likes me,” “Why can’t I get anything right?” “I am such a loser,” “I am stupid.”
·         Feeling depressed or anxious when someone is disapproving.
·         Disliking doing things for others but are unable to say no.
·         Being overly agreeable despite having contrary viewpoints so that you don’t upset others.
·         Seeking permission to do routine things in your life from a significant other.
·         Seeking attention in unhealthy ways, such as acting out, faking knowledge about things, putting down others who may be competing for attention, being late for all occasions that gets people’s attention, and sharing bad news on purpose as you enjoy the attention you get.
·         Discounting other positive things in your life and dwelling only on criticisms.
·         Over-interpreting non-verbal cues to feel that people are putting you down or are disapproving.
·         Ignoring small signs of approval such as a smile because you are used to compliments and other bigger gestures of approval.
·         Forgetting to give approval to others because you are too engrossed in your own approval-seeking thinking and behaviors.
·         Losing your sense of identity because what matters to you is what others think about you.
·         Repeatedly blaming others on how you feel as then you don’t have to take any risks and change anything about yourself.

Strategies to curb approval-seeking behaviors

Here are some specific strategies to counter your approval-seeking behavior, especially if depression is driving you to seek approval to enhance your sense of self-worth:
·         Recognize that as a human being, you are biologically wired to feel happy when you get approval from others. However, excessive approval-seeking is not normal and is based on the irrational assumption that you are not too sure about your own self and view others’ opinion about yourself more important than your own opinion about yourself.
·         Replace your need for approval with a desire for approval. When approval is not a necessity, you won’t feel hurt or rejected when you don’t get it.
·         If someone disapproves or criticizes you, it may be a result of their own irrational thought process or emotional disturbance and has nothing to do with you. Rational and emotionally balanced individuals do not put others down.
·         Resist the temptation of giving into somebody’s opinion, especially when they are manipulatively withholding approval upon you changing your thinking or behavior, but you believe in yourself. Be assertive and respond back with something to the effect, “I think you are hoping that I would change my outlook on this and who doesn’t like approval, but to be honest, this is how I feel about the situation.”
·         Actively seek someone who is disapproving or critical of others and tell yourself that it is alright for them to be the way they are and that it has nothing to do with you. This enhances your skill of dealing with people who are opinionated and critical.
·         Watch for “isn’t it” after your statements, which puts you in an approval-seeking position. For example, when striking a conversation with someone, you comment, “It is a hot day today, isn’t it?” You can simply express your opinion without expecting others to conform to what you believe. This frees you from self-doubt and approval-seeking.
·         Trust yourself and stop seeking verification of facts or validation of your emotions when you are doing something that is in line with your values.
·         Don’t over-apologize. If most of your statements of disagreements start with, “I am sorry, but…”, then inadvertently you are seeking forgiveness for people disliking you for not conforming to their expectations. Seeking excessive forgiveness is a form of approval-seeking behavior and if you feel that the only way you will feel better is by seeking forgiveness, then you are giving too much control to others over your feelings. Seeking excessive forgiveness is different from apologizing when you have done something wrong as the latter is not driven by your approval-seeking tendencies.
·         If you give disapproval to someone, does that make them a worthless person? No, it doesn’t! You will still treat the person with compassion and kindness, especially if they are someone important in your life. For example, you don’t approve of your son’s career choice, but you will not label him as worthless or lose your affection or compassion toward him. Use the same compassion and kindness toward yourself when you are at the receiving end of disapproval or criticism.

To learn more about evidence-based self-management techniques that are proven to work for depression, check out Dr. Duggal's Author Page.


HARPREET S. DUGGAL, MD, FAPA


Growth Mindset: A Proven Antidote for Depression When Facing Adversities

Psychologist Carol Dweck describes people having two types of mindsets – the fixed mindset and the growth mindset (Dweck, 2008). Individu...