For combat veterans, posttraumatic stress disorder (PTSD) is an all too common psychiatric condition. The symptoms of PTSD include high anxiety, a heightened state of arousal, aggression, and sleep disturbances. Many with PTSD report feelings similar to combat situations, as if they never really left the battlefield. When it is accompanied by moderate or major depression, those with PTSD are notoriously unresponsive to traditional therapies and medications. Self-injurious and self-destructive behaviors, even psychotic behaviors, are not uncommon events for the most severely affected veterans. Finding new and better treatment protocols is therefore essential.

Recent research indicates that Abilify (aripiprazole), a relatively new antipsychotic medication, may represent a moderately more successful approach for treating PTSD and major depressive disorder in veterans. Study authors performed a retrospective review of veterans’ charts to determine what effect, if any, the introduction of Abilify had on these patients’ PTSD and depression scores. A total of 27 charts were analyzed. Many of these patients were also receiving traditional antidepressants, anti-anxiety medications, or psychotherapy. All consented to participate in research on the use of Abilify to manage their symptoms. Most had shown very little or no response to their prior courses of treatment.

The study consisted of a 12-week trial of Abilify, with regular monitoring for side effects or improvements in mood. The overall positive response rate, both in terms of PTSD and depression, were rather low. At the end of 12 weeks, about 20% of these veterans showed significant improvement in their depression. Likewise, 37% showed improvement in their PTSD symptoms. These are not excellent results, but historically this population has been very resistant to most clinical approaches. Any improvement over failed techniques is worthwhile, and even small improvements to quality of life are deemed worth pursuing. Furthermore, Abilify has no potential for abuse and relatively few side effects. It is much better tolerated than many of the traditional antidepressants and anti-anxiety medications.

PTSD makes readjustment to civilian life an uphill battle for many veterans. Too many find themselves in a cycle of fear, self-loathing, anger, depression, and substance abuse. Abilify, originally developed as a first-line treatment for schizophrenic patients, has shown the potential to ease the symptoms of PTSD in at least some of these veterans. More research is needed, but the outlook is promising.

References
Richardson, J.D., Fikretoglu, D., Liu, A., McIntosh, D. (2011). Aripiprazole augmentation in the treatment of military-related PTSD with major depression: a retrospective chart review. BMC Psychiatry, 11, 86.

Did you know that your imagination is a powerful tool for positive change? Or that, without your intentional guidance, it can be your greatest enemy? Many people neglect their imagination, allowing outside influences to guide and direct this powerful engine and then wonder why their lives are less than satisfying. Your imagination is yours to develop as you will, but ignored and neglected it can become a liability—the very source of depression, anxiety, interpersonal problems, and unconscious self-sabotage. Unless you take the initiative to choose your goals and begin to exercise discretion in what messages you allow your brain to receive and process, all the forces of marketing that bombard us on a daily basis—television, email, pop–ups, and Facebook—will shape your choices (and therefore your destiny) without your input, and often without your awareness.

When we don’t exercise careful choice over what we feed our imagination, we can end up developing habits of thought that impede success. Habits of thought are things like catastrophizing—thinking about worst-case scenarios—a habit of thought guaranteed to generate anxiety and/or depression; or habits of thought like filling in the blanks when you really don’t know—a habit of thought that can lead to all kinds of interpersonal problems if you make the mistake of believing that your imagination knows what is unknowable.

The first step to taking charge of your life is to take charge of your imagination. You can begin with a few simple exercises. Imagine a very unpleasant scene from a horror movie. If you allow this scene to fill up your whole imagination your feelings will follow—heart racing, palms sweating, a ball in your stomach, the whole nine yards. You see, your imagination cannot tell the difference between what is real and what is not. Now imagine that you are seeing the same unpleasant scene on a small flat-screen TV. Notice that you still have some of the same reactions you did before, but not as intensely. Now shrink the screen down to a very small size. Remember, this is your imagination, so you can do whatever you want with the image. Now turn the TV off.

Ok, that was interesting. But it was an unpleasant image. Now try it with a pleasant one. Bring up one of your all-time favorite memories. Perhaps recall a time when you really felt loved, or maybe a time when you had just accomplished something very hard and fairly important. Allow that image to fill your imagination and keep it on the screen in your mind. If it fades or slips, bring it back, and focus in on some random detail. The more you focus on some detail of this experience, the more vivid it will likely become and the more practiced you will get at using your imagination for your own good. While you’re focusing on this image in your mind, notice the warm feelings that result. Notice where in your body you feel these warm feelings of love, happiness, joy, and delight—usually right in the middle of your chest.

This is the power of your imagination to influence your emotions. All your thoughts and all your emotions are neurochemical events in your brain and in your body. So when you choose to develop your imagination and your ability to focus and direct your imagination, you gain the ability to guide and shift and direct your emotions as well. And when you have the ability to direct your imagination and modulate your emotions, then you also have the ability to influence the neurochemicals in your brain and in your body, too. Like all things mental, this ability is learned, and, like all things learned, this ability is made proficient through repetition. You do not learn to read overnight. You learn to read through repetition. Repetition makes proficiency.

Once you become proficient at managing your own imagination, you can do all kinds of other things—like set goals and define all the small steps that make up progress toward that goal. You can anticipate problems and anticipate solutions. You can try out various solutions and develop the confidence you need to translate goals into actions. You can step back from emotional triggers. You can pull yourself out of funks and you can stave off anxiety. You can even improve your sex life. But we’ll talk more about that later.

Related articles:
Changing Brain Chemistry, Changing Paradigms
Help! My Brain is Betraying Me!: Intrusive Thoughts in Motherhood

According to a new study led by A.C. Burnett of the Department of Psychology at the University of Melbourne in Australia, children born prematurely and with low birth weights (LBW) are three-and-a-half times more likely to develop mental health problems such as depression and anxiety than normal birth weight (NBW) children. Children born prematurely are already at increased risk for physical health problems, learning disabilities, and other cognitive challenges. Some research has provided evidence that children who are born prematurely are at a higher risk for behavioral problems and even attention-deficit hyperactivity disorder (ADHD). But until now, there has been little evidence suggesting that these children are also more vulnerable to mood disorders and mental health problems later in life.

In order to examine the relationship between LBW and mental health problems, Burnett analyzed previous studies and looked specifically at prematurity/LBW and how it influenced the development of anxiety and depression in adolescence and young adulthood. Burnett assessed data that was published between 1995 and 2010 and included individuals born prematurely with LBW, ranging in age from 10 to 25 years old. After review, Burnett discovered that children who were born prematurely and had LBW had a significantly higher risk than NBW peers, for the development of psychiatric problems later in life. In particular, the study revealed that the LBW participants were three times more likely to develop an anxiety or depressive disorder in adolescence or young adulthood than those who were born full-term.

The results of this study, the first of its kind, have significant clinical implications. Burnett believes that professionals treating the physical and cognitive impairments in LBW children should be aware of the negative psychological predisposition that these children possess, paying particular attention to mental health needs during adolescence and young adulthood. Burnett added, “The studies reviewed here indicate that, in addition to monitoring and management of medical and cognitive sequelae, the psychological well-being of formerly preterm individuals should be a key part of ongoing care in collaboration between clinicians, individuals and their families.”

Reference:
Burnett, A. C., Anderson, P. J., Cheong J., Doyle, L. W., Davey, C. G., Wood, S. J. Prevalence of Psychiatric Diagnoses in Preterm and Full-term Children, Adolescents and Young Adults: A Meta-analysis. Psychological Medicine 41.12 (2011): 2463-474. Print.

Many people, but primarily young, educated, Western women, struggle to sustain a positive body image—for a multitude of reasons that have been discussed in previous posts. Often a negative body image leads to a poor relationship with the body and other aspects of self. It is associated with impoverished self-care and unhealthy eating and lifestyle habits.

Having a negative body image is related to general low self-esteem and depression or anxiety. Women with poor body image often struggle with boundaries in relationship to self and others. In this post, I will attempt to shed some light on the issue of boundaries related to poor body image, a concept often discussed and infrequently understood.

Women with poor body image tend to have a compartmentalized approach to well-being. For example, they may be overly focused on certain parts of the body or particular goals, such as weight loss, while devaluing other important aspects of overall health and fitness. People who have poor body image demonstrate an all-or-nothing approach to wellness, swinging from one extreme to the other, sometimes within the same day. They tend to have an exceptional level of acquired knowledge about what is healthy and set idealistic goals based on this knowledge and also are frequently disappointed and blame themselves when they are unable to attain these goals.

The lack of a holistic perspective is evidenced in an inability to balance fitness with relaxation, healthy food choices with enjoyment of food, and so on. Not surprisingly, it is common to hear that they have dissatisfying relationships with others. The all-or-nothing tendency is implicated in their sense of being overwhelmed in relationships. They sometimes become preoccupied with the other person, swinging from feeling too close to feeling uncomfortably vulnerable even feeling lost in a relationship and wanting to cut it off.

The biggest and most obvious issue I see in working with women with poor body image is that most of the information used to make decisions about relationships and well-being comes from external sources. A total and complete lack of trust in the body and the self’s ability to regulate is obvious in their decision making. There is usually a clear history in the development of this lack of trust with regard to personal, familial, and cultural messages that have been internalized. (A full discussion of these factors is beyond the scope of this article). A lack of trust in the body and in the self leads to poor listening and misinterpretation of the cues that emerge from within. After a prolonged period of not paying attention to these signals, one’s ability to understand and act in accordance to one’s own needs becomes weakened. The needs of others become the focus of too much energy and attention, often referred to as a boundary issue.

Boundaries can be physical, mental, or emotional. Clear boundary violations are easy to identify and are well known as something that is usually morally or legally wrong and/or clearly harmful to another person’s safety, integrity, or well-being. However, there is a huge gray area between what is ideal and what is harmful, and sometimes subtle violations can lead to hurt, shame, self-doubt, and low self-esteem. Violations usually happen by the person who is in a perceived position of power, as in the obvious case of an adult taking advantage of or imposing his or her personal needs on a child, or a doctor over a patient. But there are other relationships in which people can feel vulnerable and open to influence, harmful or positive. In these more subtle cases of power and vulnerability, the delivery of emotional (or more direct) messages about the self can also lead to unhealthy attitudes, self-doubt, and low self-worth. For example, people in positions of perceived or felt power who regularly directly or indirectly impose their opinions and choices can influence others to have doubts about their own choices.

A healthy boundary between people is a perceived buffering zone, whereby a felt sense of acceptable difference exists. Respectful support of differences by people in positions of perceived power and influence can help a person grow a strong sense of self and hence the ability to re-enact these perceived boundaries in other relationships. Good boundaries lead to healthy awareness of needs of the self and also positive choices that enhance the sense of self and relationships. Supporting an individual’s development involves a strong sense of self and honoring differences in others, an open attitude of acceptance and humility. A supportive stance involves allowing another person to feel, think, struggle, learn, and identify what is right for him or her without unwelcome advice or control tactics or too much distance or silence.

Recognizing and accepting differences, a supportive stance, involves sharing personal views and opinions with a sense of humility and recognizing that they are indeed personal and individual and should not be imposed on others. Offering help when it is asked for and refraining from taking over, micromanaging, or rescuing another person is important. Healthy boundaries lead to healthy relationships, and healthy relationships lead to healthy development of individuals.

Where the development of healthy boundaries has been challenged, an individual will often be overly dependent on external information and feedback to feel safe in their decision making and hence may have a poorly developed or negative sense of their own worth. In the case of the person with poor body image, this person becomes adept at information gathering, using perceived feedback to set expectations for the self that are often unrealistic. Perception itself is flawed and is often skewed towards negative, self-fulfilling ideas of self-worth. By engaging in a selection bias, people with low self-esteem will seek out and attend to cues that confirm what they think they know about themselves that is usually negative. In addition, they may believe it is possible to please others all of the time, which is clearly faulty.

Emphasis on interpretation and internalization of other people’s expectations is a recipe for impoverished self-worth. Living according to perceived notions of other people’s expectations often leads to repressed resentment, disempowerment, and disappointment. In some cases, the only way to assert the self is in a passive-aggressive manner, which is usually not received well by others. While indeed it is healthy to have a sense of social expectation and be kind and thoughtful towards others, these behaviors need to be enacted based on a clear and healthy sense of self, which requires an awareness of personal thoughts, beliefs, feelings, and needs and the differences between self and other. Healthy self and healthy relationships interrelate and influence the development of both. The development of clear boundaries has a positive impact on individuals and on others with whom they have relationships.

However, the responsibility for nurturing clear boundaries falls on individuals in a position of power of any kind. Most people in some domain of their lives are in a position to help or hinder the development of another person. It is important that we always be aware of the difference between our own needs and feelings and those of others and to refrain from overstepping and imposing or, conversely, mistakenly taking on responsibility for other people in a way that invalidates or challenges their own development.

Where boundaries were violated, or not properly developed, psychotherapy can help to personalize new ways of being that include more emotional self-awareness and self-regulation, as well as assertiveness and effective communication skills. Healthy boundaries and self-esteem are achievable goals.

Related articles:
Our Bodies/Ourselves
The Vanity Myth: Eating Disorders and Beauty
Self-Esteem and Standards

According to a new study, individuals from Western cultures are more willing to express positive emotions than those from Eastern cultures. “All around the world, people should generally want to feel positive emotions and avoid feeling negative emotions,” said Yuri Miyamoto of the Department of Psychology at the University of Wisconsin-Madison. “Depending on individuals and situations, people sometimes try to down-regulate positive emotions. For example, when experiencing positive emotions, people low in self-esteem tend to become anxious and dampen their positive emotions compared with people high in self-esteem.” Miyamoto believes that cultural differences influence how people regulate their response to positive emotions. “In Western culture, the dominant cultural script is to maximize positive emotions and minimize negative emotions,” said Miyamoto. “Although positive emotions are generally considered to be more desirable and appropriate than negative emotions are across cultures, positive emotions are considered to be more desirable in Western cultures than in Eastern cultures, whereas negative emotions are considered to be more undesirable in Western cultures than in Eastern cultures.”

In an effort to provide support for this theory, Miyamoto interviewed East Asian and European American undergraduates after they recalled specific positive memories. He found that all of the participants wanted to experience and savor their positive emotions, but the East Asian participants were more prone to minimize the impact of the positive memory. Additionally, Miyamoto found that the East Asian students continued to experience less positive emotions than the European Americans even a full day after the event. “Overall, these results suggest that a dialectical cultural script not only underlies cultural differences in hedonic emotion regulation but also has consequences on subsequent emotional experiences.”  Miyamoto said, “This might have practical implications, for instance, for therapists.” He added, “Therapists may want to be aware that a lack of hedonic emotion regulation might not be necessarily indicative of a mental health problem for Asians. Instead, helping Asians strive to achieve a more ‘middle way’ in their emotion regulation strategies might lead to optimal mental health.”

Reference:
Miyamoto, Yuri, and Xiaoming Ma. “Dampening or Savoring Positive Emotions: A Dialectical Cultural Script Guides Emotion Regulation.” Emotion 11.6 (2011): 1346-347. Print.

Depression and anxiety are among the most common mood problems, regardless of age or demographics. Children and adolescents experience anxiety and depression at a significant rate, although treatment for this population brings some complicating factors. The most frequently prescribed antidepressant medications incur a small but real risk of suicide or suicidal thoughts in young people. Known as selective serotonin reuptake inhibitors (SSRIs), this class of antidepressants is otherwise well regarded for both safety and effectiveness. When parents and physicians are cautious and attentive, SSRIs can be prescribed to children with a fair degree of safety. However, other side effects appear in younger patients that do not seem to affect adults. Hyperactivity, for example, is one such side effect of SSRIs that is confined to children and adolescent patients.

A review of previous studies revealed that so-called “activation events” might be extremely common in children taking certain antidepressants. Activation events are defined by abnormal energy, hyperactivity, and disinhibition. None of these effects reaches the level of mania, however, and sometimes it’s difficult to distinguish between “normal” activity levels and hyperactivity in young children. In a clinical trial of Luvox (fluvoxamine) prescribed to children, nearly 50% of participants experienced an activation event. Age appeared to be a significant factor—younger children were more likely to experience these side effects. Blood tests also showed that children who experienced activation events had higher concentrations of Luvox in their blood, despite lowering the dosage to mitigate side effects. This suggests that the medication is metabolized differently depending on the individual.

In the case of Luvox, hyperactivity as a side effect is not typically serious enough to require a change of medication. If the side effect is accompanied by self-injurious behavior, however, then a medication change is likely the best solution. Insomnia and aggressiveness are also signs of mania beyond simple hyperactivity. In a review of published work, researchers determined that demographic or family characteristics were not predictive of activation side effects. In addition, these side effects typically diminished and did not recur once the dosage was lowered.

In summary, because of differences in metabolism and physiology, children and adolescents react differently to medications. With Luvox and other antidepressants, there is a strong possibility of hyperactive or disinhibited behavior but not to the point of mania. Physicians and parents should always monitor children taking antidepressants for signs of worsening symptoms or suicidal tendencies. The side effect of hyperactivity by itself is generally not considered to be a cause for concern.

References

1. PubMed Health [Internet]. (n.d.). Bethesda (MD): National Library of Medicine. Fluvoxamine. National Center for Biotechnology Information. Retrieved April 4, 2012, from http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0000955/
2. Reinblatt, S.P., dos Reis, S., Walkup, J.T., Riddle, M.A. (2009). Activation adverse events induced by the selective serotonin reuptake inhibitor fluvoxamine in children and adolescents. Journal of Child and Adolescent Psychopharmacology, 19(2), 119-126.

Repressive coping is a strategy of self-protection that involves dismissing or ignoring strong emotions. People who use repression as a means of coping often do so out of self-defense and tend to experience the same negative emotional symptoms as those who struggle with anxiety. In a new study, Marcus Mund, of the Friedrich Schiller University in Germany, sought to determine if repressive coping also led to the development of physical symptoms associated with anxiety, such as hypertension, asthma, cardiovascular disease and cancer. “If repressive copers repressed unwanted feelings permanently, and if repression of feelings was associated with the mentioned physiological features, it is close at hand to infer that a high proportion of repressors should be affected by pathologically high blood pressure or associated diseases like coronary heart disease (CHD). Indeed, there are numerous studies linking both and showing serologically an increased risk for severe cardiovascular diseases (CVD),” said Mund. “Additionally, repressive coping is assumed to be associated with the development of cancer.” He added, “The same is true for asthma and diabetes, which both can be linked to several immune features.”

Mund and his colleagues analyzed data from over 6,700 clients. They found that those who repressed their feelings were 31% more likely to be diagnosed with diabetes, CVD, hypertension, asthma or cancer. With respect to cancer, those who used repression coping were 51% more likely to be diagnosed with the illness than those who did not. However, Mund said, “For cancer, the present results imply that repressive coping does not precede the diagnosis, but is rather a consequence of it.” He added, “Concerning CVD, the meta-analysis showed that repressors’ risk of suffering from at least elevated blood pressure is increased by 80% compared to non-repressors.” Mund believes the heightened state of arousal that repressors experience causes an increase in cortisol, which directly affects blood pressure and indirectly affects other somatic symptoms. “The current meta-analysis revealed significant associations between repressive coping, cancer, and cardiovascular diseases, especially hypertension,” said Mund. “These results add to the notion of repressive coping as a consequence of cancer as well as to its important role for the issue of hypertension.”

Reference:
Mund, M., & Mitte, K. (2011, November 14). The Costs of Repression: A Meta-Analysis on the Relation Between Repressive Coping and Somatic Diseases. Health Psychology. Advance online publication. doi: 10.1037/a0026257

Sharing emotional experiences, or engaging in emotional disclosure, can be a cathartic process, resulting in reductions in stress, anxiety and tension. “In an opposite manner, the active concealment of distressing information is associated with psychological distress and physical symptoms such as headaches and backaches,” said Angela M. Garrison of the Department of Counselor Education and Counselor Psychology at Western Michigan University. Similarly, people with depression or anxiety often suppress their emotions to avoid facing negative feelings. Research has shown that individuals who have attachment issues struggle with emotional disclosure as well. Because emotional disclosure is so closely linked to depression and attachment, it is difficult to determine how each condition affects emotional regulation. “Specifically, depression symptoms and attachment are both associated with emotional disclosure, but depression symptoms and attachment are also related to each other,” said Garrison, lead author of a recent study on emotional disclosure. “For theory clarification, it is therefore important to disentangle the effect of depression symptoms on emotional disclosure from the potential effects of attachment on emotional disclosure.”

In order to isolate the effects, Garrison and her colleagues assessed 121 college students for depression and attachment problems, as well as emotional disclosure using a daily diary for seven days. “Results indicated that depression symptoms were negatively related to generalized disclosure tendencies and to intra-individual daily intensity-disclosure slopes,” said Garrison. “Attachment avoidance was negatively related to both generalized disclosure tendencies and to daily disclosure, and attachment anxiety moderated the relation between daily event intensity and disclosure.” She believes clinicians should be aware that a depressed client may need encouragement to disclose particularly difficult emotions. “Knowing this may enable clinicians to encourage these clients to talk about their emotions even when their initial reaction is to not share their feelings.” She added, “It may also be important for clinicians to encourage disclosure differently in clients who are avoidantly or anxiously attached given that recent research has supported the notion that attachment orientation does impact clients’ levels and patterns of disclosure in psychotherapy.”

Reference:
Garrison, A. M., Kahn, J. H., Sauer, E. M., & Florczak, M. A. (2011, November 7). Disentangling the Effects of Depression Symptoms and Adult Attachment on Emotional Disclosure. Journal of Counseling Psychology. Advance online publication. doi: 10.1037/a0026132

Shyness is a behavior that can cause problems for children and adults. But adolescents, who experience elevated emotional turmoil, are more vulnerable to the symptoms of extreme shyness. “Although they might be easy to overlook, they probably experience much private unhappiness, as adolescent shy behavior is linked to loneliness, having fewer friends, and other internalizing problems such as anxiety, low self-worth, depression, social phobia, and eating disorders among women,” said Neira van Zalk of the Center for Developmental Research at Orebro University in Sweden. Shyness has also been shown to cause stress in social situations, leading to social anxiety that can result in negative thoughts, impaired job performance and general dysfunction. These symptoms can be caused by a number of factors, but recently, researchers have begun to examine how parenting styles influence the development of shyness in children. “As a number of reviews show, different forms of socially fearful behaviors, such as shyness, behavioral inhibition, social anxiety, social withdrawal, and reticence, are associated in young children with two forms of parental psychological control: intrusive control and criticism or rejection,” said van Zalk. Parents who are over-controlling, although their intentions are good, may shield their children from stressful life situations, thus prohibiting their ability to develop coping skills and self-regulation. Another factor linked to childhood shyness is the amount of warmth exhibited by parents. Studies suggest that children who receive praise and warmth experience less anxiety, stress and loneliness than children who receive little parental warmth.

Van Zalk and a team of researchers analyzed data collected from several waves of a larger study conducted on Swedish adolescents. The teens were interviewed for symptoms of anxiety and shyness, and reported how they perceived the parenting they received. “In this study,” said van Zalk, “We found that the more shy adolescents were, the more intrusively controlling, rejecting, and less emotionally warm they perceived their parents to be over time. There was also some evidence that the more youths perceived parents as intrusively controlling, the more their shyness increased over time.” Van Zalk added that the teens with the most severe shyness received the least parental warmth. “Why would shyness elicit these behaviors from parents? One possible explanation is that parents mistakenly see the adolescent’s social isolation as intentional and that they tend to do this more as youths age,” said van Zalk. “Their lack of warmth and rejection might reflect frustration or concern that is not expressed properly. Another possibility is that some correlate of shyness helps to explain parents’ critical, rejecting reactions.” Van Zalk added, “Maybe parents whose children show shy behavior can help by being aware of their children’s oversensitivity and their own responses to their children.”

Reference:
Van Zalk, Nejra, and Margaret Kerr. “Shy Adolescents’ Perceptions of Parents’ Psychological Control and Emotional Warmth: Examining Bidirectional Links.” Merill-Palmer Quarterly 57.4 (2011): 375-401. Print.

Mandy nuzzled her 3 month old baby happily as she warmed his bottle. It felt so good to breathe in his sweet baby smell and touch his soft delicate skin, his little body curled in a warm embrace into the curve of her neck. Mandy was starting to feel like she had her “sea-legs’ as a new mom and was particularly enamored of the fact that her new baby was sleeping through the night. The rough night-time awakenings were beginning to subside as baby Noah matured and slept for longer periods. She was looking forward to meeting a new mom friend in the park with their babies after she gave Noah a bottle.

Suddenly, in the wink of an eye, the tender moment vanished. Mandy watched the water warm Noah’s bottle on the stove. She  was blind-sided by a  horrific thought, flashing through her mind of the  water morphing into hot lava and scalding her baby boy. Mandy flinched, gasping and clenching tightly onto Noah, quickly backing away from the oven. The thought terrified her, and she could not believe such an image threatened to envelop her mind. Mandy’s entire body tensed as she began to pant, shallow breaths. She didn’t know it at the time, but, she was well on her way to her first panic attack after experiencing an intrusive thought…a hallmark symptom of perinatal depression and/or perinatal OCD.

Experiences like Mandy’s are common in some 20% of all child-bearing women who develop perinatal mood/anxiety disorders (the clinical term for depression/anxiety during pregnancy and up through the first year after having a baby). Some women develop symptoms of anxiety with intrusive thoughts while others may not experience these often debilitating and traumatic images. Others may have more depression symptoms with a smattering of anxiety, panic attacks, and sometimes intrusive thoughts.

PMADs (perinatal mood/anxiety disorders) are the clinical term for a myriad of symptoms under the umbrella of depression and anxiety from conception through the first year following childbirth.  In layman’s terms, perinatal challenges/neurobiochemical imbalances while pregnant and after having a baby often leave women completely stunned, horrified, and traumatized…because  women don’t know what hit them. And no one talks about it.

The reality is that PMADs are very common, and most likely under-reported due to the stigma connected to them. Mothers can be wracked with so much guilt about any of the symptoms, particularly if she has intrusive thoughts, that they are loathe to talk to a specialist to get help or to a family member. Many women report they feel like they are “going crazy” or afraid to be “like that woman on TV who killed her kids.”

I want to underscore the importance of supporting a woman who is experiencing intrusive thoughts to not delay in seeking help, to get help immediately with a trained specialist in perinatal challenges. The differential amongst these particular perinatal struggles is quite delicate. Furthermore, to receive the best care, she must have help from a skilled perinatal psychotherapist who can provide a comprehensive bio-psycho-social assessment and steer her in the appropriate direction for what is ideally a multidisciplinary approach to treatment.

This article is not intended to be a primer on the difference between perinatal intrusive thoughts and hallucinations since such is the subject of a workshop or conference. And, each set of circumstances requires a different course of treatment (both medically and in psychotherapy). Generally speaking, however, when a woman experiences intrusive thoughts, she is grounded in reality and horrified of the images that are occurring, feeling that her body is betraying her. She will often respond with disgust at the images and in turn demonstrate behaviors that lessen her anxiety and protect her baby (for example, Mandy avoided ovens for a time because such objects were a trigger for her). Intrusive thoughts can be part of perinatal depression and will remit with psychotherapy and in many cases, medication management (typically an SSRI), along with a good self-care plan and social supports in place.  Hallucinations, on the other hand, are considered a medical emergency and potentially part of a more rare PMAD, perinatal bipolar disorder or psychosis. In such a case, the woman is not grounded in reality, and hallucinations can cause her to do or say things that she would not normally do and have the potential to be life-threatening to her or the baby. If you suspect that you or a loved one are experiencing hallucinations, call 911 or go to your nearest emergency room immediately. Do not attempt to diagnose.

Fortunately for Mandy, she realized something was amiss in her brain biochemistry and immediately sought help with a trained perinatal psychotherapist. Upon consulting with a psychiatrist specializing in reproductive mental health, she agreed to try an antidepressant (Zoloft) to help her biochemistry restore itself. Mandy’s recovery was swift because she sought help immediately, she received support, non-judgment, validation, psycho-education, as well as cognitive behavioral strategies in psychotherapy to help her diminish the anxiety and intrusive thoughts. She worked with her therapist on a solid self-care plan and put in place the help of a doula (hired caregiver specifically for new parents). Mandy feels empowered now as a new mom, free of intrusive thoughts and filled with pride at the arrival of Noah in her life. She is now on to a full recovery, enjoying her 7 month old son. (Please note: swiftness of recovery times vary with each individual’s unique circumstances).

If you or someone you love appears to have intrusive thoughts after having a baby (or even while pregnant), do not attempt to diagnose her. Do find a trained perinatal specialist to help the woman you care about to get treatment. The good news is that PMADs are treatable and temporary, and with help, women recover fully.

Other useful resources:

• Postpartum Support International—www.postpartum.net – largest non-profit dedicated to PMAD awareness; vast clearinghouse of information on PMADs, down-loadable fact sheets, online support groups for moms and dads, chat with an expert, stellar bibliography of recommended books, latest research findings and trainings in the perinatal world; current legislation in support of PMAD awareness, destigmatization, and treatment; coordinator/volunteers link callers/e-mailers with trained professionals; warmline in English/Spanish
• Postpartum Progress—www.postpartumprogress.com – most widely read blog on perinatal challenges, by Katherine Stone; the reader can subscribe to a daily news feed and a daily affirmation of hope.
• Real Mom Experts - www.realmomexperts.com – website dedicated to supporting women with PMADs, written by perinatal psychotherapists; self-care techniques for moms

Great book on intrusive thoughts:
Dropping the Baby and Other Scary Thoughts: Breaking the Cycle of Unwanted Thoughts in Motherhood by Karen Kleiman and Amy Wenzel (2010). –excellent book for new moms dealing with PMADs, also for perinatal professionals

According to a new study, certain cultures actually make people feel worse about feeling bad. Researchers at the University of Queensland, the University of Leuven, the University of Melbourne, and Kyoto University, collaborated to determine if society can exacerbate negative feelings. “We argue that when people believe that others expect them not to feel certain kinds of emotion, this perceived social pressure leads them to experience those unwanted emotions more frequently and more intensely,” said the team. “Specifically, we focus on the belief that others expect us not to feel negative emotions such as sadness or anxiety.”

The authors noted that popular culture and television in particular, stress the importance of happiness. “Meanwhile, commonplace emotional experiences such as sadness, depression, or anxiety are pathologized and medicalized, viewed as deviant from the desired norm,” they said. In four separate studies, involving participants from Australia and Eastern Asia, the researchers discovered that people from Western cultures experience an increase in negative feelings when they feel bad. “However, the importance placed on happiness and the devaluation of sadness is not as apparent in Asian cultures,” said the researchers. “In Japan, acceptance, emotional balance, and even hardship are highly valued, and the pursuit of happiness often has ‘immoral’ connotations.” The study looked at personal and social expectancies, focusing on both positive and negative emotions. They said, “Across four studies, we found evidence that perceived social expectations not to feel negative emotions are associated with more negative emotion and lower well-being.”

The researchers believe their findings are important for overall mental health and sense of life satisfaction. They said, “This finding highlights the potentially harmful effects of perceived social expectations for emotional experience. When social norms place pressure on people not to experience negative emotion, people react to these perceived norms with increased negative emotional responding.” They concluded by saying, “Our work shows that the more people hold beliefs that others expect them not to experience negative emotions, the more frequently and intensely they are likely to experience those negative emotions. Such ironic effects also relate to indicators of well-being, such as satisfaction with life and depression.”

Reference:
Bastian, B., Kuppens, P., Hornsey, M. J., Park, J., Koval, P., & Uchida, Y. (2011, July 25). Feeling Bad About Being Sad: The Role of Social Expectancies in Amplifying Negative Mood. Emotion. Advance online publication. doi: 10.1037/a0024755

If hope is the thing with feathers, as Emily Dickenson said, then trust floats on gossamer wings.

Most people lose that child-like trust with the end of a first love, but not all. I have known a handful of souls who maintained it until death, or appeared to, but it’s certainly not the norm. Life intrudes on the fantasy that someone will be an all-loving, supportive parent. Paradoxically, if you had toxic parents, it’s even harder to relinquish this desire as yearning for a kinder, gentler life becomes a mission to get what you missed as a child.

Whether trust is broken by an affair, an addiction, or the gradual departure of someone’s heartfelt interest, it requires a radical shift in your world view. Emotionally adjusting to that cognitive terra incognita takes time and energy, but is worth it as it builds maturity and a commitment to being responsible for yourself.

At the end of the day, if you truly trusted someone and found out he or she was unworthy of that level of faith, you may swing to the opposite side of the pendulum and feel wary of everyone. That’s OK. It’s temporary. When you have been badly burned it’s natural to fear fire. Eventually, you will allow people into your heart again. You may never trust anyone else 100%. That’s fine,  because the real task is learning to trust yourself. Before we explore ways to build self trust, let’s look at what trust entails.

Trust may mean your parent, child, mate, friend, business partner will:

• Take care of you when you’re sick or old.
• Tell you the truth.
• Treat you kindly.
• Be faithful.
• Keep your secrets.
• Honestly, and with compassion, share most of their thoughts, feelings, and personal information.
• Listen to your thoughts, opinions, and concerns.
• Have your best interests at heart.

Everyone has their own notion of what trust feels like. On some level, trust is having faith in someone else’s ability to truly know and support you. This may mean nurturing, protecting, listening, contributing financially, knowing what you are thinking without you having to say it, anticipating your desires, etc. As you can see, it’s a tall order. The most realistic approach is to hope someone who loves you will do their best, most of the time, to act for your highest good. It doesn’t hurt to remember that everyone is after their own happiness, and they will usually put that before yours. So, if the relationship is reciprocal and they feel they are getting most of what they want, they will make a bigger effort to please you. If not, they will have less incentive.

There are two important things to remember about trust:

1. Your decision to trust someone is a gift to you, not to them. You do it for peace of mind.
2. If they betray you, it is a reflection of who they are, and says nothing about you.

If you have been betrayed and your trust was breached, it may be a good idea to use the above concepts as mantras until they become automatic. When something bad happens, it is all too easy to let feelings of insecurity, vulnerability, and grief distort your perception. Thinking more clearly will change your feelings from anger, despair, worthlessness, hopelessness, depression, and anxiety to acceptance, optimism, sadness, and concern, all of which will help you adjust to a new reality.

Trusting yourself is much harder than handing yourself over to someone else. After all, you came into the world as a helpless infant who needed adult care and attention, so on some very deep level, it’s tempting to want to feel fully nurtured by someone. Since everyone has some abandonment issues, this desire is heightened by the fear that those we love the most will eventually leave. The good news is until you drop the body, as they say in India, you can always count on yourself. It may take a lot of practice to prove to yourself you are truly capable of healthy self-care, but you are. Keep at it and the emotional rewards will accrue, until, one day, you will automatically guide yourself towards self-loving thoughts and behaviors.

How can you build inner security and self-trust?

• Patiently accept your own pace as you move forward in your journey.
• Take responsibility for yourself emotionally, financially, physically, socially, intellectually, vocationally, and spiritually.

Practice supportive self-talk by saying loving things to yourself. Even if you are lucky enough to have friends, family, or a therapist who repeatedly tells you calming, helpful things, there is something deeply soothing about being able to hear those words in your head, and comfort yourself with them anytime—knowing you really mean them. Either way, the more you hear them, the more quickly they will become second nature, eventually eclipsing the cacophony of internal self-downing you may have been immersed in for as long as you can remember.

Everything, no matter how awful it might feel in the moment, is for your highest good and personal evolution. When you are struggling, miserable, grief-stricken, and saturated with anxiety, it seems almost impossible to remember this deep truth. Even if you don’t believe it, just keep repeating it. Eventually, you will see the way life constantly shifts and changes. It’s just like a seesaw, only now, you know you are the fulcrum.