Negative and positive affect have been studied at length with respect to depression and anxiety. Although negative affect presents similarly in people with both mood states, positive affect does not. Specifically, people with anxiety experience both positive and negative affect, and increases in positive affect do not cause decreases in negative affect. However, people with depression do see symptom improvements when they have increases in positive affect. In fact, research has suggested that high trait positive affect or increases in positive affect can act as buffers against relapse in depression. Major life events have also been considered as influential on depressive and anxious symptoms. But they have not been examined as positive or negative life events, or in relation to affect. Therefore, John H. Riskind of the Department Psychology at George Mason University in Virginia recently conducted a study to illuminate this aspect of depression.

Using two separate experiments, Riskind looked at whether or not positive affect provided a protective effect against negative affect in college students with depression, and also how negative and positive life events affected mood. He found that unlike symptoms of anxiety, symptoms of depression were directly impacted by positive affect. The participants with depression and low baseline positive affect had higher levels of symptomology than those with high positive affect, regardless of their level of negative affect. This supports the theory that positive affect does directly influence symptoms of depression.

When Riskind looked at life events however, he found quite a different outcome. “Individuals who had few negative events and the most positive events seemed to be at far greater (rather than lower) risk for increased depression.” This result was quite unexpected, but Riskind believes can be explained in several ways. First, individuals who experience a spike in mood due to a positive event often quickly return to their previous mood state. For the participants here, the sudden spike and then decline could exacerbate stress and increase symptoms of depression. Second, the experience of a positive event, such as getting married or taking on a new job, can also cause anxiety, tension, and psychological stress. These emotions, even though borne out of a positive event, can increase negative symptoms. Finally, positive events often mean change, which can be very unsettling to some people, further increasing the risk of depressive symptoms. The results presented in this study provide a unique look into the relationship between positive events and depression, but are limited to some degree. Future work should expand upon these findings by using a broader demographic base of participants and by assessing the influence of other psychological conditions.

Reference:
Riskind, John H., Evan M. Kleiman, and Karen E. Schafer. (2013). “Undoing” effects of positive affect: Does it buffer the effects of negative affect in predicting changes in depression? Journal of Social and Clinical Psychology 32.4 (2013): 363-80.ProQuest. Web.

Family burden is a term that encompasses all of the challenges that may exist for an individual who lives with someone who has experienced a significant illness, particularly a long-term illness. Even if the illness does not require that the family member provide care for their loved one, the emotional toll that the illness can have on the family is part of the overall burden. Additionally, any caregiving responsibilities and financial, relational, and personal effects are considered part of family burden. Because family caregiving is becoming increasingly popular and more individuals are living for longer periods with physical and mental illnesses, it is imperative to understand how family burden affects the caregivers and even significant others who do not have to provide care. Therefore, Edel Ennis of the School of Psychology at the University of Ulster in the UK recently conducted a study that explored the relationship between family health, family burden, and participant psychological well-being.

Ennis considered the type of illness, noting that some illnesses such as bipolar, dementia, and Alzheimer’s are particularly emotionally taxing on family members, the relationship between the participant and ill family member, marital status, income, and gender. After examining over 3,000 participants, Ennis found a direct and distinct relationship between family burden and individual mental health. Specifically, the higher the perceived family burden was; the worse the psychological well-being of the participant. For women, high family burden was related to increased risk for depression. For men and women, low income, and singlehood were risk factors for increased stress and poor mood. Ennis believes that limited finances and lack of other people in the home to provide support could explain this finding.

One result that was unexpected was that the participant’s relationship to the ill family member did not affect overall psychological well-being. Previous research has suggested that caring for a spouse is often more emotionally depleting than caring for a parent or child. However, in this study, that was not the case. But, Ennis did find that younger caregivers were more vulnerable to negative psychological outcomes. For all the participants, higher family burden was reported for family member mental health problems versus physical health problems. In conclusion, this study shows that individuals living with an ill family member, even those who do not directly provide care, are at risk for psychological problems and should be targeted for interventions. Ennis added, “This is essential given the increasing numbers of individuals requiring additional support, and the increasing reliance on the family to provide this support.”

Reference:
Ennis E., Bunting, B.P. (2013). Family burden, family health and personal mental health. BMC Public Health 13: 255. Published online 2013 March 21. doi: 10.1186/1471-2458-13-255

Children are a product of their environments. Just as children who are brought up in loving, supportive, and caring environments are more likely to behavior that way as adults, children who are brought up in fear, anger, and hostility have a higher chance of experiencing similar environments in adulthood. But does this same theory apply to acoustic and physical chaos? Syeda Shamama-tus-Sabah of the National Institute of Psychology at Quaid-i-Aaam University in Pakistan wanted to explore this question. In a recent study, Shamama-tus-Sabah reviewed parent and teacher reports on 150 elementary school children. The children ranged in age from 8 to 11 years old and were all living with educated mothers. The children were assessed for depression and aggression to measure adjustment.

Shamama-tus-Sabah found a direct link between chaos and adjustment. “The results indicate that children from high chaotic families exhibit more aggression and depressive symptoms as compared to children from low chaotic families as reported by their parents and teachers,” said Shamama-tus-Sabah. This finding suggests that children who are not living in structure and routine may be more likely to struggle with behavior problems. This can lead to risk taking, including alcohol and drug use, tobacco initiation, and even sexually risky behavior. When Shamama-tus-Sabah looked at gender as a contributing factor, she found no difference in the chaos-adjustment relationship for girls and boys.

Some research has suggested that boys are more sensitive to chaotic environments, and therefore have higher levels of maladjustment than girls from similar environments. This research provided no support for that theory, but future research might explore that more in order to see if other types of maladjustment, aside from depression and aggression, manifest in boys more than girls. In western cultures, chaotic homes are not uncommon. However, in Pakistan, the increase in chaotic home lives, with more parents working and cities becoming overcrowded, could increase the risk for maladjustment in the youth population. In order to get a broader picture of the effects of chaos, future work should examine the gender aspect more thoroughly and should include parents of varying degrees of education and socioeconomic status.

Reference:
Shamama-tus-Sabah, Syeda, et al. (2013). Chaotic home conditions and children’s adjustment: Study of gender differences. Pakistan Journal of Psychological Research 27.2 (2012): 297-313. ProQuest. Web.

Most people get a massage in order to relax, perhaps a pleasurable way to unwind after a long work week. Others go to address some physical discomfort or injury. Maybe your lower back aches from sitting too much in front of a computer. Massage can be a sumptuous delight that treats your body’s aches and pains.

But it can also be an effective choice of treatment for a number of psychological issues: depression, attention-deficit hyperactivity, and posttraumatic stress, to name a few. After a massage, we may find our spirits have been lifted, or that we’ve broadened our everyday perspectives. The opportunity is one for self-awareness.

The benefit of massage on mental health is not a surprise if we think about the connection between the mind and body. The body is a miraculous manifestation that gives us direct access to unknown parts of ourselves. The body revealed by posture, muscle contraction, and flexibility demonstrates the sort of armor we use to protect ourselves in a sometimes difficult world. For instance, an individual with depression might tense up or constrict the stomach or back in order to be less vulnerable to particular emotions.

[fat_widget_right]The massage therapist is as much a student of the mind as they are of the body. The massage therapist bears witness to our mounting stresses and vulnerabilities, and helps unblock the passageways that allow us to fully breathe in life. They soothe feelings of angst that cause depression, and prevent us from connecting to our bodies and experiencing joy.

An observant massage therapist need only consult a client’s muscles to gain an understanding of their psychology. For instance, some individuals’ muscles may come across as more or less penetrable. A hardened collection of back muscles can serve as a force field, making it difficult to reach deeper layers of musculature. Such a force field is simultaneously physical and psychological. Psychologically, it may represent a general distrust or impermeability to others. Granted, such armor can be invaluable in adapting to threatening situations.

If the client is unaware of this “body armor,” the therapist has an opportunity to bring it to the their attention. With such awareness, the individual may choose to slowly “disarm” if they are carrying “unnecessary armor.” While massaging, the therapist may ask the client to “breathe into it,” which encourages the development of a deeper trust. Every point of contact on the body is an opportunity for self-awareness. Psychological healing occurs when we sink into the reality of our bodies.

Technological advances in communication can paradoxically leave many feeling more isolated and alone. When that happens, our life forces may dwindle. We communicate with greater numbers of people, especially online, but it may be less direct contact and interaction. The mind and body become estranged from physical and emotional stimulation. You may then experience feelings of dissociation, depression, or detachment. What is needed is a return to a nurturing touch, both physically and emotionally.

Depression can be seen as an estrangement from a caring world. The sense of being “held” in a massage awakens a feeling of being cared about, as the therapist’s focus is a kind of concentrated care for the client. Massage offers an opportunity for learning a different way of being. Your body may begin to realize that you don’t have to tense up so much when work gets stressful. If depression is the expectation that you will not receive the connection and nurture that you need, a massage can rattle the rigid sense of isolation. Rigidity then dissolves. It liquefies into the stream of life.

Hypnosis has long been fodder for television shows and stand-up acts, and most people are familiar with hypnotists who claim to be able to make anyone do anything while under hypnosis. But hypnosis is no longer just a sideshow performance, and an increasing number of people are turning to hypnosis to quit smoking, get over depression and anxiety, lose weight, and forget about phobias.

Hypnosis is still controversial within mental health, partially because it’s often part of a comedy act and not real treatment and partially because some hypnotherapists have induced false memories under regression-based hypnotherapy.

What Is It?
Hypnosis isn’t a magic trick. It’s an altered state of consciousness that hypnotists induce via the power of suggestion. Hypnotists may use relaxation techniques, key words, guided imagery, or some combination of these to help clients slowly relax. Then, while under hypnosis, hypnotists make suggestions about changes in behavior.

The idea behind hypnosis is that, even when the conscious mind wants to do something, the unconscious mind might not fully accept this change. Hypnotists claim that, under the right conditions, they can subtly alter the effects the unconscious mind has on the conscious mind and help bring about behavioral changes. Some hypnotists use hypnosis to help gradually alter a client’s perceptions. A person struggling with pain, for example, might undergo hypnosis to help him or her see the pain as pressure. An increasing number of women are even using hypnosis to help cope with the pain of childbirth.

Does It Work?
You can’t be hypnotized to do something that is outside of your moral compass or that you don’t really want to do. People who try to quit gambling or spending through hypnosis will likely not see results if they’re quitting only because of family pressure. Hypnosis can’t change the way you think; it simply makes it easier to follow through with behavioral changes. Hypnosis can also bring about a state of relaxation, and some hypnotherapists teach their clients how to self-hypnotize under stressful conditions. For people with anxiety issues, severe stress, or depression, this can help ease the symptoms.

But hypnosis is not a panacea, and is most effective when it’s used in conjunction with therapy and lifestyle changes. Particularly for long-term, chronic problems, it may take several hypnosis sessions to see results. Some people don’t see any results at all; because hypnosis thrives on suggestibility, if you’re not particularly suggestible it probably won’t work.

Choosing a Hypnotist
If you’re thinking about trying hypnotherapy, get a recommendation from your therapist. The American Society of Clinical Hypnosis also maintains a directory of qualified hypnotists with a clinical background. Make sure you know how long your hypnotist has been practicing and what methods he or she uses. The messages you hear under hypnosis should not come as a surprise, and your hypnotist should discuss the specific tools he or she is going to use before hypnotizing you.

Regression-based hypnosis, which is used to recover repressed memories, can be dangerous. Because people are more suggestible under hypnosis, the hypnotist can inadvertently fabricate memories that didn’t actually occur. Particularly if these memories are traumatic, this can lead to additional mental health issues. People with a history of psychosis should not undergo hypnosis without first taking to their doctors, because hypnosis increases their risk of a psychotic episode.

References:

1. About the society. (n.d.). American Society of Clinical Hypnosis. Retrieved from http://www.asch.net/
2. Beattie-Moss, M. (n.d.). Does hypnosis work? Research Penn State. Retrieved from http://www.rps.psu.edu/probing/hypnosis.html
3. Mental health and hypnosis. (n.d.). WebMD. Retrieved from http://www.webmd.com/anxiety-panic/guide/mental-health-hypnotherapy
4. Portenoy, R. (2008, August 18). How does hypnosis work, can anyone be hypnotized, and when is it used? ABC News. Retrieved from http://abcnews.go.com/Health/TreatingPain/story?id=4047906

It is not unusual for someone who experiences a loss to romanticize the person, identity, or object they are grieving. This can occur even when what is lost was not just imperfect, but harmful. This tendency occurs more often and can be more harmful with folks who experienced depression, anxiety, or other mental health issues prior to the loss.

Myths can be helpful in meeting the obligation of respect and mourning we may feel toward the person. They can push us to broaden our memory of the person who died or the relationship we had beyond just the negative event to more positive or helpful content. They can influence the “story” of what was lost in a way that makes thoughts and emotions associated with the loss more tolerable to access and communicate individually and within our support systems.

It is natural to go back in time and reevaluate our perceptions of events and the decisions made during that time. Those who struggle with depression or anxiety already have a distorted view of reality that usually presents a world that’s unsafe or themselves as incapable. Both of these factors can set the stage for harmful myths.

Beliefs that drive guilt, regret, and failure are usually present and, when applied to the loss of a relationship, can set the stage for a rewrite on reality. These factors can result in a person deriving a meaning or value from what was lost that is heightened and, in his or her mind, exposes an inability and unworthiness in obtaining and holding onto the things people deserve to pursue. Even if the person holds some, or the majority of, responsibility in the loss, what was lost was probably imperfect and the behaviors that led to the loss are changeable. We’re human, and life is usually a trial-and-error thing.

Myths can also amplify the lack of purpose one feels after losing a job, becoming hospitalized, or losing a relationship. This is particularly true if the loss involved something the person felt defined them: “This is who I was, and now that it’s gone, where does that leave me?” Myths can hold us to the belief that purpose is unchangeable and who we were before the loss was the best we could have been.

In reality, there may have been significant problems and costs to the identity that we were not attentive to; these costs may have been a factor in causing the loss. Myths hold us back from an honest analysis of what led us to “the problem,” which in turn, prevents us from changing our behaviors or priorities in a way that works for us now. Myths can make us risk-averse, because if it can’t be the same, what’s the point? The answer is that “it” being different may be what we need, and the loss could be used as a wake-up call. In holding onto myths, we may reenact patterns and behaviors that are maladaptive.

When the loss involves a person who was both a family member and a perpetrator, myths can act as an obstacle to accessing traumatic content. Survivors of childhood abuse utilize several strategies to survive their environments and maintain a positive view of those they love because of the meaning that relationship may have in their minds (“she is my mother; I’m supposed to love her”). From their perspective, pushing for change may have a greater cost than living with it. This capacity or inclination can prevent survivors from feeling as if they have permission to think about the person they lost in a negative light. These are common issues for any trauma survivor, but holding on to the myth after a loss may make the work in acknowledging and processing the trauma that much harder.

Within a familial context, myths can create a perceived demand for adherence to a “story” that may feel objectionable to some within the family. Trauma survivors can feel uncomfortable in processing the loss authentically with those they may feel closest to for fear of making waves or hurting them.

Grounding ourselves in fact can go a long way in helping us cope with a loss. Being factual means focusing on what we know, not what we believe, so that we can derive a reasonable meaning from the loss experience. It allows us to acknowledge and mourn the good while identifying what was harmful so that the work of adaptive grieving and behavior change can move forward.

One important aspect of remaining factual is communicating the emotional and cognitive content we hold to another person we trust. This allows us to expose any distorted beliefs or thinking to another person’s logic and perception. This is important because it creates an external brace against unreasonable thinking. By not allowing exposure, the only thing left to challenge the distorted narrative is the source of it.

Family, friends, and other natural supports (priests, rabbis, the lady who does your nails) are usually the best options if safety is not an issue because they represent long-term, sustainable resources you can access anytime. If safety is an issue or you are experiencing symptoms that go beyond a normal grief reaction, seeking professional help (therapists, psychiatrists, medical doctor) can provide more intensive support and a greater assurance of confidentiality.

Imagine losing someone very close to you; perhaps your partner dies. How might you feel and behave in the weeks following this death? You might feel a sense of sadness and emptiness so intense that it is difficult to hold back tears. Perhaps you would have little interest in activities that you usually enjoy. Maybe you would find it difficult to sleep after sharing a bed with your partner for so many years. You might begin eating more or less and either gain or lose a significant amount of weight. It might be difficult to concentrate on your work. You might be preoccupied with a sense of guilt, wondering whether you could have done something to prevent your partner’s death. You might even wish for the day that you and your partner are reunited in death.

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These kinds of feelings and behaviors, while certainly difficult, probably seem like pretty normal and appropriate responses to a significant loss. They certainly don’t seem indicative of a diagnosable mental illness, right? Well, until the fifth version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) is released in May, your hunch is correct. Currently, these feelings and behaviors aren’t considered evidence of mental illness.

In order to meet the diagnostic criteria for major depressive disorder (MDD), five out of nine specific symptoms must be exhibited, more often than not, for two weeks or longer, and they must impair your ability to function. The example above actually includes seven of the nine symptoms of MDD. These symptoms would probably be present much of the day for several weeks and would certainly impair normal functioning.

Currently, however, there is an exemption for bereavement in the diagnostic criteria that allows for such symptoms to persist for up to two months after the death of a loved one. Only after two months of persistent and pervasive depressive symptoms can a diagnosis of MDD be made in the context of bereavement. This exemption acknowledges that while grieving can look and feel virtually identical to depression, it is, quite simply, not depression. Unfortunately, the new version of the DSM will remove the bereavement exemption from the diagnostic criteria, and come May, the very appropriate reaction to the death of a loved one described above will be pathologized and diagnosed as MDD.

The world looks to the field of psychology to understand normal versus abnormal behavior, and the field of psychology uses the DSM as its guide for drawing the often fine line between what is normal and abnormal. This is a responsibility that should not be taken lightly. Labeling someone as mentally ill has significant implications. In the best case, a person who receives a diagnosis is given a lens through which to better understand himself or herself. It can be deeply empowering for someone to understand that the thoughts, feelings, and behaviors that have plagued him or her have a name, and that there are not only treatment options, but hope­ as well—hope for healing, hope for growth, and hope to become the person he or she has always wanted to be.

However, in cases where a perfectly healthy person is labeled as mentally ill, the implications can be devastating—just ask the gay man who was considered mentally ill in the early 1970s before homosexuality was removed from the DSM. To be labeled as sick, to be pathologized, for being who you are, or for being appropriately devastated by the loss of a loved one, serves no purpose and may be quite harmful.

Imagine being told that the anguish you are feeling over the loss of your partner means that you are mentally ill. Is there any way that this could be helpful, or would it just serve to make you feel much more lost and hopeless? What would it be like if a doctor suggested you take medication? Imagine being told to take a pill to get over the death of a loved one. Should you find yourself in a therapist’s office grieving the loss of a loved one and your therapist suggests a diagnosis of MDD, don’t be so quick to accept the label—it is entirely possible that you are simply, and appropriately, grieving.

While not everyone’s experience is the same, when people have a major depressive episode, generally the world looks, feels, and is understood completely differently than before and after the episode. During a major depressive episode, the world can literally seem like a dark place. What was beautiful may look ugly, flat, or even sinister. The depressed person may believe loved ones, even their own children, are better off without them. Nothing seems comforting, pleasurable, or worth living for. There’s no apparent hope for things ever feeling better, and history is rewritten and experienced as confirmation that everything has always been miserable, and always will be.

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When this reality shift happens, it’s difficult to remember or believe what seemed normal before the episode. What the person believes during the episode seems absolutely real, and anything that conflicts with it is as unbelievable as a memory or message telling him or her that the sky is purple. For example, if the person is unable to feel love for a spouse, and someone reminds the person that he or she used to feel that love, the person may firmly believe he or she had been pretending to himself/herself and others—though at the time he or she really felt it. The person can’t remember feeling the love, and can’t feel it during the episode, and thus concludes he or she never felt it. The same process happens with happiness and pleasure. Attempts to tell the person that he or she used to be happy, and will feel happy again, can cause the person to feel more misunderstood and isolated because he or she is convinced it’s not true.

Even if nothing was wrong before the episode, everything seems wrong when it descends. Suddenly, no one seems loving or lovable. Everything is irritating. Work is boring and unbearable. Any activity takes many times more effort, as if every movement requires displacing quicksand to make it. What was challenging feels overwhelming; what was sad feels unbearable; what felt joyful feels pleasureless—or, at best, a fleeting drop of pleasure in an ocean of pain.

Major depression feels like intense pain that can’t be identified in any particular part of the body. The most (normally) pleasant and comforting touch can feel painful to the point of tears. People seem far away—on the other side of a glass bubble. No one seems to understand or care, and people seem insincere. Depression is utterly isolating.

There is terrible shame about the actions depression dictates, such as not accomplishing anything or snapping at people. Everything seems meaningless, including previous accomplishments and what had given life meaning. Anything that had given the person a sense of value or self-esteem vanishes. These assets or accomplishments no longer matter, no longer seem genuine, or are overshadowed by negative self-images. Anything that ever caused the person to feel shame, guilt, or regret grows to take up most of his or her psychic space. That and being in this state causes the person to feel irredeemably unlovable, and sure everyone has abandoned or will abandon him or her.

It’s difficult to describe all of this in a way that someone who’s never experienced it can make sense of it. I can’t emphasize enough that when this happens, what I am describing is absolutely the depressed person’s reality. When people try to get the person to look on the bright side, be grateful, change his or her thoughts, or meditate, or they minimize or try to disprove the person’s reality, they are very unlikely to succeed. Instead, they and the depressed person are likely to feel frustrated and alienated from one another. I do believe cognitive therapy has an important place, but generally not in the throes of a major depressive episode.

Support for People with Depression

So what does a person whose reality has shifted in this way need? Please keep in mind that I am talking about a major depressive episode—severe depression that has lasted more than two weeks. I would take a different approach for someone with milder depression, or one that is a response to a terrible loss.

For some people in a major depression, psychotropic medication works and is the only thing that works. The same could be said for electroshock treatment, though it’s not for everyone. Many people will emerge from major depression in time, though episodes seem to make more episodes more likely, so if medication works to end the episode, it’s usually prudent to take it. Nutrition, acupuncture, and other body-based treatments as well as therapy can help without the side effects of medication.

What Loved Ones Can Do

Loved ones can gently hold and show love and commitment to the depressed person, try not to take on the person’s reality, but also not argue with him or her about it. They can also gently remind the person that depression causes his or her perspective on everything to change, and he or she is unable to think outside of depression mode at the moment. It is a time for the person to avoid making decisions, or avoid doing anything significant that requires a nondepressed perspective. If this is a repeated experience for this person, it can be helpful to discuss all of this between episodes so he or she is more prepared when caught in the quicksand.

As someone who loves a person with depression, it can be emotionally difficult or stressful at times to support that person. It can be beneficial to focus on your own needs and self-care, and to reach out for help if you need it such as seeking the support of a counselor or therapist.

Kaethe Weingarten of the Department of Psychiatry at Harvard Medical School recently published a paper describing her experience with four clients who experienced chronic sorrow. The clients, who were all successful, vibrant women, had different pasts and different conditions that caused them to lose their sense of self. Despite these differences, the result was the same for each. They struggled with a sense of deep sadness or chronic sorrow. In one’s case, illness had caused her to lose her independence and ability to live the life she once knew. Another woman became addicted to medication that was prescribed to treat a health problem. The addiction led to psychosis that lasted two years. The third woman was born with a heart defect and has lived a life of longing to be the woman she knows she cannot be. The fourth woman was diagnosed with Chronic Fatigue Syndrome. After over a decade of being doubted by family members, medical professionals, and even therapists, this client eventually committed suicide.

Weingarten, having dealt with her own disability, is all too familiar with the shift from a life of autonomy and ability to one of utter dependence and incapacity. She believes her own experience and those of her clients gives her an insight into chronic sorrow and how to best approach this issue with patients. First, Weingarten believes that chronic sorrow is rooted in a loss of self. The self-narrative of those living with chronic sorrow becomes shattered, dissociative, and disrupted. This can happen as a result of one catastrophic event, such as a debilitating medical diagnosis, or a series or progression of events and symptoms, as was the case for the client with Chronic Fatigue Syndrome. Regardless of how it occurs, this broken narrative is not one that can be fixed. Instead, Weingarten believes that companionship and compassionate witnessing are the keys to living with, and not necessarily overcoming, chronic sorrow.

She believes that witnessing requires developing an empathic understanding of a client’s situation and taking actions to alleviate the psychological pain that ensues. Rather than trying to fully understand, a compassionate witness should accept that they will never fully be able to feel the feelings or loss of their client. Instead of pathologizing and labeling these clients’ reactions to loss of self as bipolar, schizophrenic, or psychotic, a truly compassionate witness will empathize without ever really understanding. “People who live with chronic sorrow need accompaniment,” said Weingarten. By this, she means that clients with chronic sorrow need someone to be with them as they discover how they will interact with the limitations of their minds and bodies. It means showing them the way to peace, teaching them how to tolerate the inconsistency of their lives with support, education, and even humor. It also means requires self-care so that the therapist can be aware of the client’s own boundaries while they take this journey with their client. Weingarten does not believe chronic sorrow can be fixed or healed. But she believes it can be lived with and she suggests compassionate witnessing and companionship as ways to do that.

Reference:
Weingarten, Kaethe. Sorrow: A therapist’s reflection on the inevitable and the unknowable. Family Process 51.4 (2012): 440-55. Print.

Sleep apnea is an issue that causes pauses in breathing throughout the sleep cycle. This issue can cause people to awaken frequently, snore loudly, and experience disturbances in their dreams. The condition is potentially life-threatening because it can interfere with the brain’s oxygen supply.

But people experiencing sleep apnea aren’t just stuck dealing with its physical effects. They may also experience mental health challenges.

Depression
A study by the Centers for Disease Control and Prevention found that people with sleep apnea were more likely to experience depression than people in the general population. Disturbances in sleep can affect mental health, and the stress of having a serious medical condition is sufficient to send some people into depression. But sleep apnea is particularly likely to interfere with mental health because of the reduced oxygen supply to the brain at night, which can alter brain functioning and thus increase a person’s likelihood of developing depression.

Anxiety
The fact sleep apnea affects people while they’re sleeping—a time when people are supposed to be at peace—can be particularly jarring. Some people have to wear special masks connected to continuous positive airway pressure (CPAP) machines to ensure that they breathe normally throughout the night, and the threat of breathing problems can cause severe anxiety. This anxiety, in turn, may make sleep problems worse, and sleep deprivation can contribute to both depression and anxiety, a vicious cycle for people with sleep apnea.

Relationship Problems
For many people, the first sign that they have sleep apnea is a spouse’s complaints about snoring. Even extremely supportive spouses might not want to listen to a person with sleep apnea snore all night, and some people with the condition end up sleeping in separate bedrooms. This can decrease opportunities for intimacy and increase relationship dissatisfaction, contributing to stress for both parties.

Changes in Dreams
Many mental health professionals believe dreams are an opportunity to process the events of the day and to encode memories. Dreams also provide a testing ground for anxiety-inducing scenarios, long-term goals, and everyday interactions. Because people with sleep apnea awaken frequently, they may be unable to enter the rapid eye movement (REM) sleep that is necessary for dreaming. Among people who do not enter or remain in REM sleep, there may be a number of mental health problems, ranging from anxiety to difficulty with memory.

Cognitive Impairment
If you can’t sleep, can’t dream, and are worried about a chronic medical condition, it’s not surprising that you might have difficulty concentrating. People with sleep apnea may be exhausted during the day and have trouble focusing on important tasks, including job-related activities. Sleep problems can alter mood, making people with sleep apnea jumpy or quick-tempered, and making it more difficult for them to navigate the challenges of everyday life.

Many of the problems associated with sleep apnea are interconnected, and stress during the day can make sleep apnea worse at night. There are effective treatments, though you might have to try several approaches before something works. If you have sleep problems, consult your doctor.

References:

1. Lyon, L. (2009, August 24). 7 things that make sleep apnea worse. US News. Retrieved from http://health.usnews.com/health-news/family-health/articles/2009/08/24/7-things-that-make-sleep-apnea-worse
2. Sleep and mental health. (n.d.). Harvard Health Publications. Retrieved from http://www.health.harvard.edu/newsletters/Harvard_Mental_Health_Letter/2009/July/Sleep-and-mental-health
3. Sleep apnea can cause depression. (n.d.). New Technology Publishing, Inc. Retrieved from http://www.healthyresources.com/sleep/apnea/articles/depress.html

The uninvited house guest often stays on well beyond the point of “wearing out his or her welcome.” Likewise, for many people, chronic illness/disability is not a short-term inconvenience but rather a long-term, often permanent way of life. In the early stages of adaptation, the changes that happen in our lives and families may seem tolerable—at least while we still think there is a chance that the diagnosis is wrong or the cure is in the magic pipeline offered by big pharma.

Eventually, denial and bargaining give way to anger and depression. The uninvited guest is still ever-present, and no amount of cajoling or suggestions result in change. Bouts of anger may become a way of life for a while.

Anger
Many people flow in and out of anger and depression, rather than progressing neatly through one stage and into the next. It is often said that depression is anger turned inward, which makes expression of anger in a safe and effective way very important. Getting adequate support from formal and informal support networks is critical.

It is not unusual for tempers to flare and fuses to shorten during this period of adjustment. People who are typically long-suffering seem to be constantly on edge; those with fewer coping skills may be in a chronic state of agitation and irritability, if not outright rage. It often seems as if they are pushing away those who are closest to them at the time when they need them most.

Loved ones may unconsciously spend less time with the person who seems to find fault in their best efforts. Children are often left confused and afraid. Doctors and other providers frequently find themselves being blamed for their inability to help. This is all part of the process of adaptation.

While most people understand cognitively that their loved one is struggling and coping as well as can be expected, their own feelings of inadequacy and powerlessness may lead them to retreat on some level—if not physically, then emotionally. This often feels like abandonment to the person who is already overwhelmed by disability or illness. It is very important for caregivers and loved ones to be aware of their own feelings and find support.

Coping skills: Separate the person from the behavior. Try to remain aware of the real target for your anger—the illness or disability, not the person in your midst. Remember that we often treat those we love the most with the least respect; make amends as soon as possible if you do so. Give each other a break and extend the benefit of the doubt when possible. If your loved one treats you badly, remember that everyone is under extreme stress and doing the best they can at that moment. It is also good to remember that your caregivers and medical providers are probably not inadequate, but the resources they have to work with may be.

Caregivers and loved ones should speak up if they are being treated badly. Being sick is not an excuse to mistreat people, particularly if there is a pattern of abusive behavior developing. These behaviors need to be identified and discussed in a calm, loving way (not in the heat of the moment). This may require professional help, or perhaps the assistance of a minister or family friend who is not emotionally involved.

Most of the time, the person who lashes out or treats people badly feels guilty and needs the opportunity to make amends. For those who are unaware of how their behavior comes across, specific examples of the unacceptable behavior or hurtful/abusive language helps them develop a better awareness of their inappropriate behavior. In some cases, this is a manifestation of the illness or disability. In others, it may be the result of coping skills that are maxed out. Either way, left unattended, it usually gets worse. This is not the time to let conflicts and hurt feelings stack up. If you need help addressing these issues, ask your medical provider for a referral. Providers often have therapists or chaplains they work with who may be able to help.

Depression
Depression often occurs during the adaptation process, and may happen at other times or continue. Clinical depression can be very difficult to manage. It is more than sadness or disappointment; depression is a collection of symptoms that exist most days for two weeks or longer and create some level of impairment in daily functioning. The symptoms may include many of the following:

• sadness/tearfulness
• low energy or agitation/irritability
• loss of interest in things previously enjoyed
• problems with concentration/foggy thinking or trouble making decisions
• changes in sleep or eating patterns
• feelings of guilt or worthlessness
• thoughts of death or suicide/not wanting to live
• rumination/negative thinking
• others (physical pain, changes in motor skills, etc.)

If you or someone you know have four or more of these symptoms that are present for more days than not over a two-week period, talk to your medical provider about getting help.

There is also a type of depression called situational depression that is a normal reaction to a loss or change. Almost all people with chronic illness or disabilities and their loved ones experience this. The same symptoms are involved, but the symptoms may not be present most of the time, or may not be severe enough to impair your ability to function (relationships, work, taking care of your kids, etc.).

Situational depression can linger or become more serious after a while, becoming clinical depression. If the symptoms begin to impair functioning or last longer than a few weeks, it is wise to speak with a medical provider or therapist. People with situational depression are often able to experience periods of happiness when receiving good news, or other momentary reprieves from the darkness of depression. Those with clinical depression may be unable to experience even brief moments of relief when the situation calls for it.

The best treatment for depression is believed to be a combination of talk therapy, exercise (I know—it is very hard to exercise when you are depressed), a good diet, and medication, if deemed medically necessary. The right intervention for depression depends on which type of depression you are experiencing. For those with a few symptoms that are not present all the time, self-help may be sufficient. People with four or more symptoms that are present most of the time probably need to see a therapist and possibly a psychiatrist.

Anyone who is suicidal should seek professional help immediately. This national hotline is for people struggling with depression. The crisis line is staffed 24 hours a day by trained volunteers: 1-800-273-TALK.

Coping skills: I recommend that people talk with a therapist when dealing with situational depression and try to get as much activity in as possible. This may mean simply walking outside to get the mail, sitting on the porch for 20 minutes to have a cup of coffee or juice, watering the plants, or walking the dog. Sunshine is another natural remedy that increases vitamin D, which is often deficient in people who are depressed and those who do not go outside often. Eating properly is also critical, and there are natural supplements available at your local health store that may help with situational depression. Talk to your medical provider or therapist about these options.

Support groups and self-help groups can be very helpful. Groups provide a great resource for people living with chronic illness and disabilities and their loved ones. You can find online and local resources, and most are free. Many are affiliated with local hospitals or nonprofit agencies that serve people with chronic illness or disabilities.

If depression is serious enough to impair functioning, or you/your loved one has thoughts of suicide or not wanting to live, it is important to get professional help immediately. Start with your medical provider or therapist unless the person with depression has a plan to cause self-injury or death.

In situations where someone’s safety is at risk, call 911 or the local emergency number for your area, or take the suicidal person to the closest emergency room. Your role in the situation is not to intervene, but to get professionals involved as soon as possible. If the suicidal person is unwilling to go to the ER (or medical provider’s office during business hours) or you believe it may be unsafe to transport them, simply call for the emergency medical providers to come to you.

Don’t worry about the person who is suicidal being upset by your actions—when people are in crisis, they are usually not thinking clearly, so it becomes crucial for you to make good decisions on their behalf. The medical professionals who are trained to help in these situations will make the decisions once they arrive. This will likely mean that the person who is suicidal will be transported to the hospital for an evaluation, and may need to stay there for a few days until stabilized.

Again, it is not up to you to make that decision, only to make sure the person is safe until medical professionals can take over. It is a lot of responsibility and instills fear in most of us, but in the end, when your loved one is thinking rationally again, he or she will likely be grateful. If not, you will know that you have done what you needed to during the crisis.

Ongoing thoughts of suicide or not wanting to live need to be addressed with mental health and/or medical professionals regularly. Some states (Washington, Oregon, and Montana) permit medical professionals to participate in a well-thought-out, documented plan to end life (known as rational suicide), but most do not. Discussion of a patient’s end-of-life wishes should also be considered carefully and documented in a legal document for your specific state. Legal resources such as a living will specifically identify a person’s end-of-life wishes.

It is a good idea to talk about signing a consent form that allows you to discuss your loved one’s mental health (and physical) treatment with medical providers and therapists. This will enable you to enlist their help if depression becomes unmanageable or a crisis occurs. The consent can be relinquished at any time if the patient is considered to be of sound mind, and could be a great resource. Fortunately, resources are available to assist you in being prepared for a suicidal crisis should you need them.

There are many issues to be discussed regarding suicide, including family members’ thoughts and feelings about it. It is important to remember that euthanasia is against the law in all U.S. states, and assisted suicide with the help of a physician who prescribes a lethal cocktail after careful planning and documentation is legal only in Oregon, Washington and Montana. Legal professionals should be consulted if “rational suicide” is something you or a loved one is considering.

Adaptation
Using the analogy of the uninvited house guest, this is the period when people have settled into their routines and learned to live together with whatever adjustments are necessary. The initial period of adjustment after a disability or illness almost always requires going through each of the stages in the process outlined here. It can take a long time for some to arrive at adaptation, and not everyone in a family gets there at the same time. With some luck, a lot of support, good communication, and teamwork, the process will likely resolve in time for most people.

Unfortunately, surviving the initial period of adjustment does not ensure there will not be others. As mentioned earlier, people tend to get emotionally triggered when there are relapses or new symptoms/stages of the illness or disability occur. Triggering means that some reminder of the initial trauma (usually diagnosis or the actual accident or illness) sets off the same cascade of emotions experienced at the time of the original event.

Living in fear of a relapse or a change in physical status creates a certain amount of anxiety for everyone. The unpredictability of living with a chronic illness or disability will be the focus of our next article.

In the meantime, please share below how you have effectively coped with anger and depression.

The American Psychiatric Association has approved changes to the Diagnostic and Statistical Manual of Mental Disorders, commonly referred to as the DSM. The fifth edition of the flagship guide to psychiatric diagnosis, due for release in May 2013 and known as the DSM-5, features several controversial revisions.

The DSM establishes criteria for the diagnosis of mental health conditions. Because changes to the manual can affect insurance coverage for certain issues and help define “normal” behavior, advocacy groups are often concerned about the effect additions and alterations will have. The latest revision is no exception.

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Children and Mental Health
Diagnosing children with mental health conditions is often dicey because of concerns about stigma and the use, or overuse, of psychiatric drugs. At a time when some groups argue that fewer children should be diagnosed with mental health issues, the DSM-5 adds new diagnostic criteria for children. Those over the age of 6 who display irritability or frequent angry outbursts now qualify for a diagnosis of disruptive mood dysregulation disorder. While some mental health professionals emphasize that this new diagnosis could make it easier to plan early intervention for children who have extreme difficulties controlling their emotions, some advocacy groups have expressed concern that such a diagnosis could stigmatize normal childhood behavior or lead to the prescribing of unnecessary drugs to young children.

Autism Spectrum Disorder
The DSM-5 eliminates Asperger’s syndrome, folding it into a broader category called autism spectrum disorder. Diagnoses of Asperger’s and autism have been steadily increasing over the past several years, and many children with less severe symptoms of autism have been diagnosed with Asperger’s. The DSM-5, however, incorporates several autism-like issues, including Asperger’s, into the diagnosis of autism spectrum disorder. Not everyone is happy with this change. Many people with Asperger’s view the issue as part of their identity and do not want it to be lumped in with other issues. The APA, however, argues that this change will make diagnosis of autism more consistent and access to treatment easier.

Grief and Depression
Previous versions of the DSM incorporated a bereavement exception into depression diagnoses. This exclusion prevented mental health professionals from diagnosing a person who was grieving the death of a loved one with depression. The DSM-5, however, permits depression diagnoses in the bereaved. Members of the APA argued that the old bereavement exception excluded grieving people who had been diagnosed with chronic depression from being diagnosed with, and receiving treatment for, depression. But some people worry that the new changes pathologize grief and turn normal grieving—which often looks a lot like depression—into a mental health diagnosis.

Other Changes
The DSM-5 adds hoarding and excoriation disorder—a diagnosis for people who compulsively pick their skin. The APA also rejected several proposed disorders, including parental alienation syndrome, hypersexual disorder, and anxious depression. While the APA emphasized that the revisions—like all changes to the DSM—are intended to clarify diagnostic criteria and improve consistency in diagnosing, mental health advocacy groups argue that many diagnostic criteria have been loosened and that the DSM-5 will increase the number of people diagnosed with mental health conditions.

Which changes to the DSM did you find most controversial? Please share your comments below.

References:

1. Asperger’s syndrome dropped from American Psychiatric Association manual. (n.d.). MedPage Today. Retrieved from http://www.medpagetoday.com/Psychiatry/DSM-5/36206
2. Gever, J. (n.d.). DSM-5 wins APA board approval. MedPage Today. Retrieved from http://www.medpagetoday.com/Psychiatry/DSM-5/36206
3. Gupta, P. (n.d.). Controversial changes to stay in DSM-5. Salon. Retrieved from http://www.salon.com/2012/12/02/controversial_changes_to_stay_in_dsm_5/
4. Spiegel, A. (2012, November 30). Weekend vote will bring controversial changes to psychiatrists’ bible. NPR. Retrieved from http://www.npr.org/blogs/health/2012/11/30/166252201/weekend-vote-will-bring-controversial-changes-to-psychiatrists-bible