Abilify (aripiprazole), manufactured by Bristol-Myers Squibb, was approved for use by the U.S. Food and Drug Administration in 2002. An antipsychotic medication, Abilify has shown noteworthy success in treating the symptoms of schizophrenia. Since its introduction, this medication has also been used for easing manic depression in adults. In people who have not responded well to traditional antidepressants, Abilify is sometimes prescribed as a secondary, additional treatment. As a result of increasingly diverse uses, this medication has entered the top 15 in terms of total drug sales. Like all psychotropic drugs, Abilify works by altering the levels of certain chemicals in the brain called neurotransmitters.

Determining the toxic dose of any new medication is essential in developing appropriate safety guidelines. According to the authors of a study published in Clinical Toxicology, “Limited data exist describing the characteristics of [Abilify] poisonings” (Young et al., 2009). Part of the reason for such limited data is undoubtedly the newness of the medication itself. In an effort to fill in these gaps in knowledge, researchers performed an analysis of Abilify overdose events recorded in the California Poison Control Center database. They excluded cases where the record was not sufficiently complete or other substances were ingested along with Abilify. After eliminating such results, researchers were left with 286 usable cases.

Slightly more than half of these cases were female, and the overall median age was about 19 years. The youngest recorded overdose patient was 6 months old. Researchers divided the cases into three distinct age groups (0-6, 7-17, 18+ years) to determine whether there might be an age-related response to Abilify overdose. A standard dosage for this medication depends a great deal on the individual case; however, dosage typically starts at 2 mg for pediatric patients and can increase to 15 mg for adults. It should be noted that Abilify is not prescribed for children less than 13 years old (PubMed Health, 2011). Researchers also placed each case into a group based on dosage level. Group 1 consisted of doses less than 20 mg. In group 2, dosage ranged from 21 to 90 mg. All doses of 91 mg or higher fell into group 3.

Results of the analysis showed that out of 286 cases, 128, or nearly half, showed no symptoms whatsoever. For those who did report symptoms, drowsiness was the most common complaint, followed by nausea/vomiting, muscle twitch, and tremors. In no case was the overdose considered life threatening, and none of the patients appeared to have experienced permanent effects. For adults, only those in dosage group 3 (91 mg+) were statistically likely to experience symptoms. In pediatric cases, symptoms presented themselves even at the group 2 level. In 176 cases of overdose, no treatment was required other than observation. When treatment was administered, activated charcoal given orally was the most common course of action.

While this was only one study of one database, the data seem to indicate that Abilify is not an especially toxic medication. However, the effects of overdose vary from person to person, and underlying conditions may play a role in an individual’s response. As always, keeping medications in a secure location and following dosage instructions to the letter are essential safety measures.

References

1. PubMed Health [Internet]. (n.d.). Bethesda (MD): National Library of Medicine. Retrieved February 19, 2012. Available from: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0000221/
2. Mayo Clinic. (n.d.). Dystonia. Retrieved February 19, 2012. Available from: http://www.mayoclinic.com/health/dystonia/DS00684
3. Young, M. C, Shah, N., Cantrell, F. L., Clark, R. F. (2009). Risk assessment of isolated aripiprazole exposures and toxicities: a retrospective study. Clinical Toxicology, 47, 580-583.

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

Psychotherapy is the first form of treatment for depression or anxiety and involves a variety of treatment techniques. During psychotherapy, the person experiencing depression or anxiety speaks with a licensed psychologist or therapist who helps him or her to identify and work on the causative factors. These factors trigger depression or anxiety by working in combination with chemical imbalances in the brain or heredity factors.

Psychotherapy helps people with depression or anxiety in the following ways:

• Understanding the behaviors, ideas, and emotions that contribute to depression or anxiety
• Identifying the problems or events that contribute to depression or anxiety and understanding which aspects of the problem they can solve
• Helping to regain a sense of control and pleasure in their lives
• Teaching them problem solving skills and coping techniques

Although psychotherapy can be performed in different ways, such as individual, family, and group therapy, there are also different approaches that psychotherapists can use to provide therapy. After having a brief talk with the client, the therapist will decide on the approach to use based on the underlying factors that contribute to the person’s depression. Many therapists specialize in one or more specific techniques or approaches. These different approaches to psychotherapy include psychodynamic therapy, interpersonal therapy, cognitive behavioral therapy, and solution focused therapy.

Psychodynamic Therapy
This therapy assumes that the person is depressed due to unresolved, unconscious conflicts that often stem from childhood. The goal of this therapy is for the person to understand and cope better with these feelings by talking about such experiences. Psychodynamic therapy usually takes place over several months and can produce excellent results.

Interpersonal Therapy
Interpersonal therapy mainly focuses on the person’s behaviors and interactions with family and friends. The goal of this therapy is to enhance self-esteem and improve communication skills during a short period of time. This therapy usually lasts for 3 to 4 months and works well for depression caused by social isolation, mourning, major life events, and relationship conflicts.

Psychodynamic therapy and interpersonal therapy help people resolve depression or anxiety caused by loss or grief, role transitions (like becoming a parent or caregiver), and relationship conflicts.

Cognitive Behavioral Therapy
Cognitive behavioral therapy helps people experiencing depression or anxiety to identify and change inaccurate perceptions they have about themselves and the world around them. The psychotherapist helps the client to think differently by directing attention to both the accurate and inaccurate assumptions they have about themselves and others.

This therapy is recommended for the following types of persons:

• People who think and behave in ways that trigger and perpetuate depression
• People who experience disability or interpersonal problems due to depression

Solution Focused Therapy
Solution focused therapy is a symptom-specific approach, which means it targets one or two stressors that are causing problems. The result might be helping the person find a better way to handle the boss at work or children at home. A person may simply learn techniques to handle anxiety. One therapist commented that solution focused therapy is like getting new tools in your toolbox to use immediately in your life, therefore helping you feel better quicker.

For an individual living with depression or anxiety, psychotherapy can promote better understanding of the condition and associated symptoms. For a person with depression, being able to talk with a psychologist or therapist who is there to listen, inquire, and help can be comforting as well as rewarding. After just a few sessions of psychotherapy, clients may feel a difference. Research suggests that three to five sessions often cause significant change. Talking through the issues can help identify behaviors and detrimental reactions or circumstances. Coping techniques can also be investigated during therapy sessions, and progress reports can be used to keep track of how these techniques work. For individuals experiencing anxiety or depression, being surrounded by loved ones or being encouraged to attend therapy sessions can provide immense support.

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.

Depression among older adults is an often-overlooked health crisis. Studies show that more than half of all people older than 60 diagnosed with depression fail to respond to initial treatment programs. In general, a psychotropic medication such as Lexapro (escitalopram) is one option of many as a first treatment. A variety of factors, however, complicate the successful treatment of elderly depression. Comorbid conditions, such as anxiety or poor physical health, may exacerbate the symptoms of depression. For reasons not fully understood, elderly patients respond more slowly to psychotropic medications in general. The patient’s level of independence likewise contributes to the success or failure of standard treatments. Despite the well-documented difficulty of treating depression in the elderly, relatively little work has been done to find more age-appropriate solutions to the problem.

In the case of elderly adults with depression, behavioral therapy may be at least as important as medication. One form of therapy known as depression care management (DCM) focuses on educating the patient about depression, their treatment, and practical measures for improving mood and daily functioning. Another therapy, known as interpersonal psychotherapy (IPT), is more intense and individually targeted. IPT resembles traditional cognitive-behavioral therapy, whereas DCM is more akin to routine counseling.

In a study of elderly adults, researchers tested whether DCM alone or coupled with IPT is more beneficial for those with a history of poor response to antidepressant medication. Study participants were administered standard prescriptions for Lexapro, which was increased as needed after an initial 6 weeks. People who experienced remission with medication alone were dropped from the study. Poor responders were divided into a DCM group and a DCM plus IPT group. Eighty percent of these individuals saw some improvement, while half experienced full remission of symptoms. Interestingly, there were no significant differences between the groups. Researchers theorized that “quantity” of therapeutic attention was less important than the existence of the attention at all. Therefore, the addition of DCM alone produced benefits; adding IPT did not produce more benefits.

The study was somewhat limited because researchers did not control for external variables, other than medical conditions that might argue against the use of Lexapro. In addition, some patients might have improved simply because of increased dosages and not behavioral interventions. More investigation is necessary to answer such questions.

References
Reynolds III, C. F., Dew, M. A., Martire, L. M., Miller, M. D., Cyranowski, J. M., Lenze, E., et al. (2010). Treating depression to remission in older adults: a controlled evaluation of combined escitalopram with interpersonal psychotherapy versus escitalopram with depression care management. International Journal of Geriatric Psychiatry, 25(11), 1134-1141.

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

According to Randy P. Auerbach of Harvard Medical School, McLean Hospital, positive feelings and feelings of happiness are the result of intrinsic pursuits. “Intrinsically-motivated goals are thought to be inherently interesting, pleasurable, and/or meaningful,” said Auerbach. “In contrast, extrinsically-motivated goals are typically sought in order to attain a reward (i.e., material goods or money) or to avoid punishment.” Research has shown that pursuing both intrinsic and extrinsic goals can be beneficial, but not when one is at the expense of the other. Auerbach said, “Guided by self-determination theory, the research posits that the neglect of intrinsic goals ultimately thwarts the satisfaction of core, inherent psychological needs for relatedness, competence and autonomy, which in turn contributes to negative psychological outcomes including depressive symptoms.” Additionally, people who value extrinsic goals over intrinsic goals may neglect their interpersonal relationships and exert all of their time and energy in the pursuit of material objects and money. Another concern is that children whose parents value extrinsic goals above intrinsic ones may not foster sufficient interpersonal skills in their children, creating maladaptive relationship models for them as adults.

To test how the prioritization of values affected the psychological well-being of adolescents from various cultures, Auerbach and his colleagues studied over 600 teens from Canada and China. They found that the teens with the highest motivation toward extrinsic goals had elevated levels of interpersonal stress. “Further, consistent with past research examining the relationship between stress generation and prospective depressive symptoms, dependent interpersonal stress predicted higher levels of depressive symptoms over time.” The team added, “In conclusion, the present study highlights the relationship between aspirations, stress, and depressive symptoms in culturally distinct samples of adolescents. Traditional prevention and treatment programs primarily target cognitive and interpersonal vulnerability factors. However, the findings in the present study suggest that clinicians must also understand a patient’s core values as they may play an important role in shaping stress generation and subsequent symptoms.”

Reference:
Auerbach, Randy P., Christian A. Webb, Meghan Schreck, Chad M. McWhinnie, Moon-Ho Ringo Ho, Xiongzhao Zhu, and Shuqiao Yao. “ExaMining the PathWay through Which Intrinsic and Extrinsic Aspirations Generate Stress and Subsequent Depressive SyMptoMs.” Journal of Social and Clinical Psychology 30.8 (2011): 856-86. Print.

“Gay and bisexual men experience numerous negative health conditions, including high rates of mental health problems,” said Beth N. Fischgrund of the Department of Psychiatry & Behavioral Sciences at Northwestern University, and lead author of a new study examining masculinity and mental health in gay and bisexual men. “Empirical studies show that a strong adherence to masculine norms is correlated with poor health outcomes, such as mental health problems and risky sexual behaviors.” National studies have shown that gay men are nearly twice as likely to suffer from depression and anxiety as heterosexual men, and that suicide rates for these men are nearly double those of other men.

The way gay and bisexual men perceive their masculinity has a significant impact on mental health. “Society’s messages about sexuality are not the only cultural attitudes that sexual minority men are confronted with; cultural attitudes also delineate what it means to be a man,” said Fischgrund. She added that some men may exhibit hyper-masculine behaviors when they feel their masculinity is being threatened. “Gay men who endorse hyper-masculine norms might then experience identity incongruence when they are presented with general society’s norms that differ and contradict their own. In these situations, the more integral the hyper-masculine norms are to a man’s identity, the more psychological distress he may experience.”

For her study, Fischgrund recruited 311 gay and bisexual men, nearly a third of which reported an HIV positive status. “Among these gay and bisexual men, those who adhered to norms that incorporate an interpersonal aspect of masculinity (i.e., conceptions of masculinity as social behavior or as sexual  behavior) endorsed higher levels of mental health distress than did men who adhered to norms that focus on the intrapersonal aspects of masculinity (i.e., conceptions of masculinity as physical appearance),” said Fischgrund. “Additionally, men who did not know their HIV status endorsed higher levels of depression.” She emphasized the importance of her findings. “Specifically, designing programs that center on altering the social and sexual masculine norms within the gay male community are needed to decrease the mental health burden of gay and bisexual men, which has been shown to be associated with HIV risky behaviors.”

Reference:
Fischgrund, B. N., Halkitis, P. N., & Carroll, R. A. (2011, October 24). Conceptions of Hypermasculinity and Mental Health States in Gay and Bisexual Men. Psychology of Men & Masculinity. Advance online publication. doi: 10.1037/a0024836

This article is part of a series that explores the ways specific “clusters” of depression symptoms manifest to create different experiences of depression. The previous article in this series discussed the hopeless experience.

The irritable or angry experience of depression is often not recognized as depression, either by the person who experiences it or by those around then. For the person experiencing this kind of depression, the people around them may seem disappointing, irritating, or intolerable, and the depressed person may feel as emotionally uncomfortable as someone with severe poison oak feels physically. They may feel very frustrated that they can’t get the people who seem to be causing their suffering to change. People around the angry or irritable depressed person may see them as mean, angry, or a bully. It may not even occur to onlookers that this person could be depressed.

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Irritability and Anger in Men and Women

I believe men and women may express this experience differently. Many men feel a great deal of pressure not to cry or express vulnerability, so when they get depressed, anger can be a more acceptable way to experience the emotional pain they’re feeling. Men may also feel more pressure to not feel anything, and so turn to drugs and alcohol when they’re in emotional pain to try to numb themselves. So while we associate crying with depression, men may not cry and yet be just as depressed as those who do. I believe this is the main reason women are diagnosed with depression nearly twice as often as men are: many men who are depressed aren’t getting the help they need.

When men are depressed and express it as anger, violence, or addiction, the consequences may further distract from getting the help they need. These consequences can be extreme, like jail or chasing a high, but they may also take the form of loneliness and isolation after alienating people. Self-hate may grow inside as depression festers, and the consequences of anger create more and more to hate.

Women are certainly not immune to experiencing depression as anger. Often in women it comes out as irritability, particularly with their children. This too may go undetected because sometimes, only their children see it, and children rarely call a therapist for their mother.

How Anger Manifests

There are two types of anger:

1. One is a response to something hurtful or unfair happening to or around the person who feels angry.
2. The other is a protection against feeling something more vulnerable.

When someone has been abused or traumatized, they certainly have reason to be angry and often don’t have a chance to express it when the trauma occurs. So anger may linger as a symptom of posttraumatic stress or may become incorporated into a person’s personality over time. When that happens, people feel angry a great deal of the time, and the anger isn’t just anger anymore—it becomes a way of life. It’s probable the anger develops this way in order to protect the person from further abuse and from the painful feelings of sadness, hurt, and fear that were also a part of the traumatic experience.

Classic examples of depression expressed as anger include veterans who come home from combat with the experiences of terror of imminent death, sadness from losing friends who were killed, and systematic emotional training to channel all these feelings into anger, revenge, and warfare. Coming home with all of this, it’s not hard to understand why a veteran would be depressed, or why they would express it through domestic violence, picking fights, or even just caustic cynicism. Police officers can have a similar experience, as can people who grow up with angry or sadistic parents who repeatedly abuse them. Even people whose parents used them for their own needs, without concern for their child’s emotional needs, may carry chronic anger that covers the hurt, sadness, and fear.

The Roots of Anger and Depression

In fact, anger almost always covers or is accompanied by hurt, sadness, or fear. When anger is helpfully expressed and begins to resolve, it almost always dissolves into tears and more vulnerable feelings. Usually, as long as a person sticks with the anger, they are stuck in the depression.

One way to look at this is that “frozen” feelings are often at the root of depression. Someone who feels and/or expresses only anger probably has frozen hurt, fear, shame, guilt, or sadness. Someone who never feels or expresses anger may have frozen anger. In either case, the person may be depressed and suffering and probably will continue to suffer until their frozen feelings are safely unlocked, expressed, and resolved.

While feelings of anger caused by depression can feel overwhelming, the support of a therapist helps many people work through these feelings and address their depression in a healthy way. Start here to find a therapist near you who can help.

I have been in practice long enough to see many couples and families develop over the past thirty years. While there are countless stories over a full range of topics, one that greatly interests me involves divorce.

Many couples and individuals have come to counseling after divorcing 15, 20, or 25 years earlier. Most are quite happy in their current lives and marriages. Many, however, have looked back on their previous marriage with one very powerful observation:  Their original divorce did not need to happen!

What an astounding realization! Not only was I impressed by their honesty, but I was also amazed they could look back on their divorces and understand them in a completely new light.

So, what is this all about? As I spoke with these couples it became clear to me that they were looking at how they previously managed emotional reactivity, and how that dovetailed with divorce. Every couple has to manage conflict, but the business of managing emotional reactivity, which is part of managing conflict, is not easy. Knowledge of how the brain works and how to use the brain to one’s advantage is critical to managing reactivity, especially intense reactivity.

Specifically, there are two brains that come into play when managing reactivity. Those two brains are the prefrontal cortex, and the limbic system. The prefrontal cortex and the limbic system are often referred to as the logical and emotional brains, respectively.

Here is a quick overview: the prefrontal cortex is the brain that allows us to make decisions, reductions, inductions, calculations, etc. The prefrontal cortex is the CEO of the brain. The limbic system, otherwise known as the mammalian brain, is the center of all emotions. The limbic system possesses all the pain centers, the pleasure centers, and is the part of the brain that has a very unique connection to the prefrontal cortex. It is the fight-or-flight-brain, among many other things.

Here is how the two brains work in concert: when the limbic brain is activated, it sends an amount of adrenaline up to the pre-frontal cortex commensurate with the degree it wants to inhibit pre-frontal cortex functioning. In short, adrenaline inhibits the pre-frontal cortex from thinking.

Those two brains, in effect, operate in opposition to one another. It is a survival function that allows us to take action without having to think first. Another way to think about these two brains is that they often function inversely. When limbic activity is up, pre-frontal cortex activity is down, and vice versa.

In practical terms this means that the limbic system will inhibit an individual from thinking clearly when they are feeling intense emotions. That is why, in the middle of a heated argument, people may say and do things they wish they could take back—things which sometimes lead to divorce. The one thing that is very important to understand about the brain and conflict is that the limbic brain always wants relief. And the fact that it wants relief is not enough: it wants relief NOW! The lengths to which an individual will go to get relief can include divorce.

An unfortunate artifact of those couples who are in constant conflict is that they become so tired of chronic conflict, and the intense emotional reactivity that comes with it, that they will do anything to reduce their emotional reactivity. When the high emotional reactivity has persisted for many months, or in some cases for many years, couples will often decide to get a divorce. They just can’t stand “it” anymore: they want relief.

After a rear-view look in the mirror several years post-divorce, some couples have realized that had they known how to reduce their reactivity as a way to get relief, they may have been able to avoid a painful divorce.

The Catch-22 that comes with divorce as relief is that the divorce process, rather than decreasing reactivity, actually increases it. That is one of the reasons depression often accompanies the divorce process, especially a protracted one. Ironically, a couple may not experience the emotional relief they went down the divorce road looking for until many years later.

That is why it is very important when seeking couples counseling that the couple and the therapist both understand how the brain works. In addition, the therapist must know how to teach a couple to manage emotional reactivity. Once emotional reactivity is managed consistently, then a couple is able to determine whether or not divorce makes sense.

Divorce as an emotional reactivity reduction strategy is not the best way to achieve emotional equilibrium. In fact, is possibly one of the worst ways to reduce reactivity, while couples who have a smooth divorce process tend to be very effective at managing emotional reactivity.

My purpose in cautioning against “relief divorce” is not to moralize against divorce. Clearly there are many couples for whom divorce is the viable alternative, and it may have little to do with reducing emotional reactivity.

Overall, it is important to understand the distinction between divorce as relief from intense emotional reactivity, and divorce that is not about relief of that sort. Remember: reducing emotional reactivity will allow you to think more clearly about the marriage, and also about divorce, because the pre-frontal cortex will not be inhibited by limbic activity.

Reduce emotional reactivity before you choose divorce. You won’t regret it.

For individuals who attempt to maintain a perfect persona, criticism can be difficult to accept. But a new study suggests that perfectionists who receive negative feedback may actually ruminate more and experience increased symptoms of social anxiety and depression. “Implicit in the perfectionism social disconnection model is the notion that people with high levels of interpersonal perfectionism have a heightened sense of interpersonal sensitivity and a tendency to react intensely to negative social feedback,” said researchers from York University. The team, in collaboration with researchers from the University of British Columbia and Brock University, added, “Moreover, the tendency to ruminate about negative interpersonal events involving interpersonal offenses directed at the self should further exacerbate the distress reactions of individuals with higher levels of perfectionism.” They noted that people who exhibit high levels of perfectionism tend to dwell on comments and offensive behaviors of others that are directed to them and can lead to an overall diminished sense of life satisfaction and negative mood.

In order to determine how negative feedback affected the symptoms of depression and social anxiety, as well as the level of rumination in perfectionists, the team enlisted 155 college students for their study. They evaluated the students using the Perfectionistic Self-Presentation Scale, the Multidimensional Perfectionism Scale, the Social Feedback Questionnaire, the Rumination About an Interpersonal Offense and other tools designed to measure anxiety and depression. They discovered that the participants with the highest levels of perfectionism ruminated most frequently. “All six perfectionism dimensions, including self-oriented perfectionism and other-oriented perfectionism, were associated significantly with rumination about an interpersonal offense, but the association with the need to avoid appearing imperfect was strongest,” said the researchers. “Negative social feedback and interpersonal rumination were also correlated with both depressive symptoms and social anxiety.” They added, “Therefore, it seems as though interpersonal and social– cognitive processes, such as ruminating about an interpersonal offense and perceiving a high frequency of negative feedback from others, play instrumental roles in the distress experienced by certain highly perfectionistic individuals.”

Reference:
Nepon, T., Flett, G. L., Hewitt, P. L., & Molnar, D. S. (2011, September 12). Perfectionism, Negative Social Feedback, and Interpersonal Rumination in Depression and Social Anxiety. Canadian Journal of  Behavioural Science/Revue canadienne des sciences du comportement. Advance online publication. doi: 10.1037/a0025032