Tag Archives: Depression

The Script (Part 1) Depression & Anxiety


I believe every adult has a preconceived idea about what “should happen” as they progress though this thing called life.  At some point, and that point is likely different for everyone, we come to acquire expectations for the future.  The net difference between our expectations for the present and the reality of the present is how I measure depression and anxiety.  If the situation in question resides in the future, or if you feel your self-talk “spinning” on something forthcoming, then anxiety is the penchant of your present feeling.  If you linger on the past, your history, what could have been… then depression is probably your poison of choice.  What is the secret to not being depressed or anxious you ask?  Live in the moment.  If, even for one moment, you find yourself able to let go of the past and not worry about the future ~ you will almost certainly find peace.  If you can do it once, you can do it again.  If you pursue the combination of thought, feeling, and action that produces a persistent state of present mindedness ~ you will almost certainly reach whatever goals you set.

I love that Carmax commercial that purveys a place to start.  If you were going to start looking for a car, they think the best place to start is their car-lot because you can test drive every make and model before you make a decision.  Now, if you were going to start on your own mental health, where would you choose to start?

What Effect Does Violence have on Kids? – Practical Application of Stanley Greenspan’s Theory of Emotional Development to Violent Behavior


I have chosen to apply the Theory of Emotional Development as seen by Stanley Greenspan to violent behavior.  I can see where this theory can explain how violent behavior gets embedded into a person, especially when the behavior is experienced from birth or from a young age, either by witnessing or by being victimized by violence.

Greenspan’s Theory assumes that children learn behavior by experiencing it.  The behavior would then continue into adulthood unless something drastic affects them.  It would have to be to the point that they feel they need to change the behavior.  In the case of violence, this drastic happening could be, going to jail or prison, going too far with the violence, or even being injured bad enough to be hospitalized for a while.  This of course depends on the person.

There are several assumptions from the theory that I will compare to the affects of violence on children.  I will also compare the milestones within the stages of emotional development to the stages the children go through when submerged in a violent environment.

There are also several reasons why violence would be someone’s first reaction to any situation.  There are many signs that a child could have violent tendencies, we could see these as they grow older.  Some children show behavioral problems at very young ages, their mental health status could grow worse and there are often problems academically and behaviorally throughout adolescence.

It seems that how often someone is exposed to violent behavior and the age at which they are first exposed determines the severity of the violent actions the child may eventually commit.

If a child is exposed to violence through a victim standpoint, it is most likely that as parents, the violence will be committed against their immediate family, but it is also likely that violence will be committed against outsiders as well.

If a child is exposed to violence through a witness standpoint, negative results could include becoming aggressive and having developmental challenges. Also, some criminal behavior could be seen.

There are many long-term effects that can take hold of a person when they are exposed to violence, especially if it was for a very long period of time.   These effects include depression, antisocial behavior, and substance abuse.  The child also learns to associate a positive attitude to violent behavior, if they are continually exposed.  They end up feeling as if the perpetrator is rewarded for the behavior.

In the Theory of Emotional Development one assumption is, “the capacity to organize experiences is present early in life”.  When violence is present in a person’s life, it is generally something that has been experienced from a very early time in their life.  Generally it is in the form of domestic violence toward a parent or themselves.

The violence that is experienced through the child’s life is organized when the child either accepts this behavior as normal or decides that the behavior is wrong and then fights against it.

This theory, “Assumes that initially organization is emotion based rather than cognition based”.  The research associated with violent behavior shows the learning of violence is cognition based.  It is a learned behavior in that, the more a child is exposed to various types of violence, the more likely they are to become offenders and the worse the offences become.

It also says, “Infants organize their emotions differently at different stages of ego development”.  Infants who emerge into life where violence is prevalent will organize their emotions accordingly.  These babies will startle easily, as loud noise and yelling does anyway, but then will grow into toddlers who may sense something is wrong, but will also be desensitized to the violent behavior around them.  Also, because of the actions that are prevalent in the home, they will see the violence as normal because they have no ability to compare it to others’ behavior.

This theory says, “With the maturation of the brain, interpreting progresses to higher levels of organization”.  As the child progresses into elementary school age, and they are exposed to other children’s life styles, they will begin to understand, maybe truly for the first time, that the behavior they are experiencing is wrong.

At this point, and as they grow, they will start to compare their own home life to their friends’ and then start to really organize how they feel as to whether the behavior is normal in other peoples lives.  Because they are starting to comprehend what’s happening in their household, they will generally devise a way to hide what’s happening to them in order to appear normal to everyone else.

This theory also states, “Emotional organization is acquired through relationships with those who care for the child”.  The child’s primary caretaker is generally their abuser.  Because of this, the emotions acquired in this relationship are generally those of confusion.  This is because the parent usually tells them that they are loved, but then the actions of that parent don’t agree with the words.  The child unknowingly learns to develop hate; sometimes toward the abuser and sometimes toward themselves because they feel they can never do what it takes to feel the love promised them so often.  These emotions carry through to adulthood and usually affect their own relationships, even as early as Jr. High or High School relationships.

Another assumption from this theory is, “Socialplay is the vehicle for promoting emotional organization”.  Children who live with violence in the home are more likely to try to stay away from the home as much as possible.  As soon as they realize they have an escape at a friend’s house they will make any excuse to try to go there in order to get away from either viewing the violence or becoming a victim of it.

Socialplay then becomes more and more about what their friends have access to that the child doesn’t feel they have.  These things do not necessarily have a monetary value, but emotional value.  Affection, courteousness, and other familial values are not found at home, so they take comfort in finding them in other people’s homes.

Greenspan also says, “Experiences must be age appropriate; have range, depth, and stability; and be personally unique.”  Unfortunately for children who experience violence on a daily basis there are not many age appropriate experiences.  These children quickly learn the keys to survival and how to fend for themselves.  These methods become intertwined into daily life and as the child grows, it becomes a way of life.  This is usually the start of the person committing violent acts when they are older.  It is not generally something they see as being a chosen action, but more something that just happens.

Greenspan has defined six milestones within the stages of emotional development. These milestones are self regulation, intimacy, two-way communication, complex communication, emotional ideas, and, emotional thinking.  Each of these milestones represents a phase or stage of a child’s life, and what they should accomplish during that phase where emotional development is concerned.

The first stage of emotional development is engagement.  This stage usually lasts from about three weeks of age until about eight months of age.

During this stage the “infants learn to share attention, relate to others with warmth, positive emotion, and expectation of pleasant interactions, and trust they are secure”.  This is the stage in which self regulation and intimacy are learned.  During these crucial early weeks and months of a child’s life, if they are involved in a violent environment, they would learn the opposite of what is involved in engagement.  They would eventually learn there are not many, if any, pleasant interactions and would not feel secure in their own actions.  In fact their first reaction to attention would come to be the flight reaction and then when older the fight reaction.

Two-way communication is the second stage of emotional development.  This stage usually lasts from about six months of age until about 18 months of age.  During this stage “infants learn to signal needs and intentions, comprehend others’ intentions, communicate information (motorically and verbally), make assumptions about safety, and have reciprocal interactions”.  This is the stage in which two-way communication is learned.  The children in this age group are still too young to recognize that the violence in their environment is not normal; yet, they are learning skills to survive there.  The two-way communication they are learning is how to signal their needs in the least threatening way.  Whether they are experiencing violence by witnessing it or are being abused, they learn the other person’s intentions could be painful and their safety could be compromised if not handled with care.  They carry this skill into later life when dealing with others.

The third stage of emotional development is shared meanings.  This stage usually lasts from about 18 months of age until about 36 months of age.  During this stage “children learn to relate their behaviors, sensations, and gestures to the world of ideas, engage in pretend play, intentionally use language to communicate, and begin to understand cognitive concepts”.  There are two milestones associated with this stage, complex communication and emotional ideas.  A lot of children who are exposed to violence from an early age end up learning things like complex communication at a later time than other children.  Because of this, these children sometimes develop learning disabilities which eventually become a sore spot for these children.  When other children don’t understand what is happening in that child’s life and choose to use that child’s slower development as something hurtful, the violent feelings tend to erupt as this is what that child has been taught at home.

The fourth and final stage in Greenspan’s theory is emotional thinking.  This stage usually lasts from about three years of age to about six years of age.  During this stage, “children can organize experiences and ideas, make connections among ideas, begin reality testing, gain a sense of themselves and their emotions, see themselves in space and time, and develop categories of experience”.  Emotional thinking is developed in this stage.  This is the age when children start to recognize that things in their home environment are not quite right.  They start to put together the fact that other children’s home lives do not involve violence on a regular basis.  At this point the child is still unsure of what, if anything, they can do about the violence in their own home.  This can be the turning point in a child’s life.

It can be when they subconsciously decide if they will incorporate the violence their caregiver has unknowingly taught them into their own lives and become violent with other people, or if they will become more docile and turn inward.

I feel that this theory, if taken further into research about violent behavior, would be a good one to look at in order to help predict violent tendencies in children.  If we do this we can try to incorporate treatment earlier and possibly cut out a lot of the violence we are seeing today.  The assumptions and the stages of the theory for emotional development are very helpful when looking at violence from an outside perspective.

References

Cullen, P.  (2009, May 21). Physical, emotional and sexual abuse was widespread in State institutions. The Irish Times p. 9.

Fagan, J.  (1996). The Criminalization of Domestic Violence: Promises and Limits
National Institute of Justice. Retrieved from LexisNexis database.

Nader, C. (2008, December 3). Death often tragic end to history of domestic violence.  The Age p. 11.

Murrell, A.R., Christoff, K.A., Henning, K.R. (2007, July 17).  Characteristics of Domestic Violence Offenders: Associations with Childhood Exposure to Violence.                                  J Fam Viol, 22:523-532

Appleyard, K., Egeland, B., van Dulmen, M.H.M., Sroufe, L.A. (2004. February 2). When more is not better: the role of cumulative risk in child behavior outcomes. Journal of Child Psychology and Psychiatry, 46:3, 235-245

Bergen, D. (2008). Human Development Traditional and Contemporary Theories. Pearson Prentice Hall.

Comparing PTSD and Somatization Disorder


Comparing PTSD and Somatization Disorder shows that there are some similarities in the symptoms but for the most part they are different.  Somatization Disorder has a lot more physical symptoms while PTSD has more symptoms leaning toward emotional.  The symptoms the two disorders have in common are headaches and stomachaches.  In both cases symptoms can be so severe and last so long that it completely disrupts the person’s life.

Do you have medically unexplained physical, or somatic, symptoms?

Somatization disorder can cause a person towards an emotional reaction such as depression or even suicide because they feel so much pain and can never get a diagnosis for it.  The symptoms often lead to substance abuse.  Thereby leaving them to feel hopeless, as if they will never get the help they need.  Somatization disorder has a wide range of physical symptoms.  A person with this disorder will report many different symptoms over a period of time with no real medical explanation.  These symptoms are often pain throughout the body, but not usually all at the same time.  Pain in the form of headaches, stomach ache, joint or muscle pain.  It could also be internal, such as vomiting, or it could come about as a sexual or menstrual problem.  Neurological symptoms are also common, often occurring as problems with balance or vision and even paralysis.

Generally for a patient to be diagnosed they will have experienced a minimum of eight symptoms.  There will be a minimum number of symptoms from a given category.  An example of this is that a patient will experience four or more symptoms from the pain category, two or more symptoms from the gastrointestinal category, one or more symptoms from the sexual symptoms category, and one or more symptoms from the pseudoneurological symptoms.  When a person is showing signs of these symptoms they will be unexplainable and a medical diagnosis is not usually possible.  Generally the person will explain the pain they are having in a fashion that makes it seem as if they are in more pain than you think they should be in, as if they are over exaggerating the symptoms.

Somatization Disorder lasts for a very long time which is one thing this disorder has in common with PTSD.  PTSD symptoms can last anywhere from months to years.   Most PTSD symptoms are different from Somatization Disorder because they come from more of a psychological background than a physical background.  PTSD symptoms are generally geared more towards an emotional aspect, some examples are worry over dying, acting younger than the chronological age, having an impaired memory or obsessiveness.  It seems that PTSD actually transforms a person’s behavior instead of changing them physically.  This is because when traumatic experiences occur, the feelings they experience, such as shock, nervousness or fear continue on for a length of time and gradually get stronger.  The stronger they get the less of a normal life the person is able to lead.

These increased symptoms can include nightmares or night terrors, hypervigilance, panic attacks, hypersensitivity, low self-esteem and shattered self-confidence or a physical or mental paralysis.  There are three categories often used by clinicians in order to type or group people who are diagnosed with PTSD.  The categories used are re-living, avoiding, and increased arousal.  The people in the re-living group are people who suffer from living through the trauma they have been through over and over again.  This can happen through a flashback or a hallucination or just by being reminded even in small ways.  The people in the avoiding group tend to try to stay away from people, places or things that can remind them of the event.  Unfortunately the person can start to isolate themselves and eventually can turn completely inward from detachment.  The people in the increased arousal group lean towards either having difficulty showing their emotions or on the other end of the spectrum showing overly exaggerated emotions.  This group is also the group who has some physical symptoms such as higher blood pressure, muscle tension and nausea.

In conclusion, it has become very apparent to me that while there are some similarities between PTSD and Somatization Disorder, there are a lot more differences.  It has also become very apparent to me that the people who suffer from these disorders are dealing with a lot of pain, and whether it is physical or emotional, this pain can cause the person suffering from it to shut down and disable them from enjoying the life they were meant to lead.

References

Netherton, S.D., Holmes, D., Walker, C.E. (1999). Child and Adolescent Psychological Disorders.   New York, NY: Oxford University Press.

Blaney, P.H., Millon, T. (2009). Oxford Textbook of Psychopathology.

New York, NY: Oxford University Press.

(2009, February 9). Anxiety & Panic Disorders Guide. WebMD.com. Retrieved October 5, 2009, from http://www.webmd.com/anxiety-panic/guide/post-traumatic-stress-disorder

(Retrieved 2009, October 5). Somatization Disorder. Intelihealth.com.  http://www.intelihealth.com/IH/ihtPrint/W/8271/25759/187986.html?d=dmtHealthAZ&hide=t&k=base

(Retrieved 2009, October 5). Posttraumatic Stress Disorder. American Academy of Child & Adolescent Psychiatry. AACAP.org

http://www.aacap.org/cs/root/facts_for_families/posttraumatic_stress_disorder_ptsd

(Retrieved 2009, October 5). Somatization Disorder. PsychNet-UK.

http://www.psychnet-uk.com/dsm_iv/somatization_disorder.htm

Kinchin, D. (2005). Post Traumatic Stress Disorder The Invisible Injury.

Didcot, Oxfordshire OX11 9YS, UK.  Retrieved October 5, 2009, from http://www.successunlimited.co.uk/books/ptsympt.htm

 

The Effects of Exercise on Self-Esteem


How often do we hear, “Get a workout, it will make you feel better.”?

Exercise For Life – For Your Good Health

Exercise is a very broad spectrum of activities; it can be walking, hiking, bicycling, running or any one of a number of sports.  It can also be moving along to a video that has choreographed moves geared toward a traditional exercise routine, or dancing, or Yoga and Pilates.  It could also be going to a gym and lifting weights or using the cardio equipment.

People often say you always feel better after a workout, or, if you can get some exercise in, you would feel so much better.  Is this truly the case?  How can causing your muscles to work and be sore actually help you emotionally?  Some studies that support a connection between exercise and positive self-esteem are: Physical Fitness and Enhanced Psychological Health; Associations Between Physical Activity and Reduced Rates of Hopelessness, Depression and Suicidal Behavior Among College Students; and The Relationships Among Self-Esteem, Exercise and Self-Rated Health in Older Women.

Each study shows slightly different statistics, but come to a similar conclusion.  This would be that physical activity does help a person have an increase in self-esteem, be it through the lessening of depression symptoms, or having the ability to perceive one’s self as healthy and high functioning in older age or simply by an elevation in a person’s mood, which gives that person the chance to understand that things are better than they seemed an hour ago.  All of these things apply to a person’s self-esteem in one way or another and these studies show that exercise helps to put a positive spin on each of them.

I feel that more studies will confirm that exercise or physical activity will help increase traits in a person’s self-esteem.

References

Plante, T., & Rodin, J. (1990).  Physical fitness and enhanced psychological health.  Current Psychology,9(1), 3. Retrieved from Academic Search Premier database. (Document ID: 9701290177)

Misra, R., Alexy, B., & Panigrahi, B.. (1996). The relationships among self-esteem, exercise, and self-rated health in older women. Journal of Women & Aging, 8(1), 81.  Retrieved December 30, 2009, from ProQuest Psychology Journals. (Document ID: 9825352).

Taliaferro, L., Rienzo, B., Pigg, R., Miller, M., & Dodd, V.. (2009). Associations Between Physical Activity and Reduced Rates of Hopelessness, Depression, and Suicidal Behavior Among College Students. Journal of American College Health, 57(4), 427-36.  Retrieved February 7, 2010, from ProQuest Psychology Journals. (Document ID: 1623326411).

Dysthymic Disorder


My choice of Dysthymic Disorder for purposes of this essay was both personal and professional.  First and foremost, I was attracted to this disorder because it resides in the gray area somewhere between an Axis I disorder and a personality disorder.  Because of this unique diagnostic positioning I feel as though I could reasonably justify techniques that are traditionally associated with all of the major schools of psychotherapy I have studied to date: Behavior Therapy, Cognitive Behavior Therapy, Schema Therapy, Existential Psychotherapy, and/or (perhaps most importantly) my own personal brand of psychotherapy that shall remain unnamed.  With some amalgamation of techniques derived from the above, as dictated by individual client needs, I have confidence I would have a reasonable chance of having “success” (however we mutually choose to define that) with the majority of clients that present with Dysthymic Disorder.  Secondly, it seems to me a young clinician’s time is best spent on the disorders he is mostly likely to encounter.  Prevalence rates of Dysthymic Disorder could be as high as 6% in a nationally representative sample, and as high as 22% in outpatient mental health settings.  (Dougherty, Klein, & Davila, 2004)  It’s extremely unlikely that I will not encounter Dysthymic Disorder during the course of my professional life.  Third and finally, this disorder is close to me because someone I love endured it for the better part of 10 years.  Thankfully – I can report at this time that it is in full remission.  The journey to full remission was one that tested all of our capacities for change and growth.  This essay represents a personal and professional journey that is has led to significant gains in my own understanding of mood disorders.  Successfully navigating through the dark forest that is Dysthymic Disorder is no easy task.  It is my hope that my clients don’t have to endure the dark thoughts any longer than is absolutely necessary.

The essential feature of Dysthymic Disorder is a chronically depressed mood that occurs for most of the day, more days than not, for at least two years.  (American Psychiatric Association, Diagnostic and statistical manual of mental disorders, 2000, p. 376)  During periods of depressed mood, at least two of the following additional symptoms are present: poor appetite or overeating, insomnia (sleep too little?) or hypersomnia (sleep too much?), low energy or fatigue, low self-esteem, poor concentration or difficulty making decisions, and feelings of hopelessness.  (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000, p. 377)  In my example case the individual was laden with hypersomnia, fatigue, and poor concentration.  It is noteworthy that are over 700 different combinations of symptoms that any single individual could potentially present with and still have the same diagnosis of Dysthymic Disorder.  As a result, it bears mentioning that the following analysis is in no way suggesting that this is the only right way to treat the disturbance.  Manualized treatment is probably doomed to failure when it comes to treating Dysthymic Disorder.  Any reasonable attempt to work toward complete remission of Dysthymic Disorder should be guided by a professional.

Differential diagnosis can be a challenge with Dysthymic Disorder.  “This is the way it’s always been” is not an unexpected response from patients whom suffer from Dysthymic Disorder.  There is no rest for the wicked: During the two year period of the disturbance, the individual may not have been without the qualifying symptoms in for more than 2 consecutive months.  Furthermore, no major depressive episode should be present during the first two years of the disturbance and the disturbance cannot be better accounted for by the diagnoses of chronic Major Depressive Disorder, or Major Depressive Disorder, In Partial Remission.  (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000, p. 380)  Double depression, or the comorbid combination of Major Depressive Disorder and Dysthymia, is also a very real consideration since major depressive episodes are often superimposed on mild chronic depression.  (Dougherty et al., 2004, p. 1012; Morrison, 2007, p. 139)  There should never have been a manic, hypomanic, or mixed episode that would be contraindicative of Dysthymic Disorder and indicative of either Cyclothymic Disorder or Bipolar Disorder (I or II).  The disturbance should not occur exclusively during the course of a chronic psychotic disorder (like schizophrenia, for example) or be the direct physiological effects of a substance (like methamphetamine, for example) and/or general medical condition (like a traumatic brain injury, for example).  As is the case with most DSM diagnoses, the disturbance should cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.  (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000, p. 381)  This differential diagnosis quandary is further exacerbated by the fact that depression “shares borderlands with bereavement and other losses, problems of living, and adjustment disorders.”  (Morrison, 2007, p. 127)  A thorough investigation of antecedents and mitigating factors is absolutely critical to accurately “anchor your boat” so you can “wade into the river” with a correct diagnosis.

Family history is an important consideration when determining the hypothetical etiology of a disturbance, especially in the case of mood disorders.  “Family history is more useful in starting the train of diagnostic thought than in determining its final destination.”  (Morrison, 2007, p. 133)  Research suggests that the strongest predictors for Dysthymic Disorder include a history of sexual abuse, quality of the patient’s relationship with both parents, and higher familial loadings for drug abuse and ‘Cluster A’ personality disorders.  Unfortunately, we could use that same laundry list of antecedent events for just about every personality disorder in the DSM-IV-TR… so that doesn’t tell us much.  Childhood adversity and familial psychopathology and have greater predictive utility for Dysthymic Disorder when compared with demographic and clinical variables.  (Durbin, Klein, & Schwartz, 2000)  Translation: nurture appears to trump nature.  Nature continues to play a significant role in the development and maintenance of the disturbance, however.  A patient with a parent (or parents) with unipolar depression exhibited significantly higher rates of Affective/Mood Disorders including Major Depressive Disorder and Dysthymic Disorder – yet another marker that can guide the patient-clinician dyad in the right direction.  (Klein, Clark, Dansky, & Margolis, 1988)

A full exploration of the potential therapeutic interventions is beyond the scope of this paper, but there are a few empirically supported treatments that are noteworthy.  Supportive therapies, coupled with cognitive behavioral interventions, have been effective in extinguishing negative verbalizations and normalizing daily functioning.  (Elligan, 1997)  This is consistent with my “necessary but not sufficient” position when it comes to person centered therapies practiced by the late great Carl Rogers (1902-1987).  Although I concede that the research I found doesn’t specifically point to Schema Therapy as a potential treatment modality for Dysthymic Disorder, I would consider it based in part on event-related brain potential research.  (Yee, Deldin, & Miller, 1992)  Processing deficits including selective attention may be modified and corrected vis-à-vis Schema therapy.  Since research suggests that resource allocation is the issue, not resource capacity, the goal of Schema Therapy would be to allow for attention resources to be more effectively and efficiently focused on task performance.  (Yee & Miller, 1994)  Pharmacological interventions have been less effective on Dysthymic Disorder when compared with other mood disorders, so I would not consider this to be a first line of defense except in cases of Double Depression or in cases where talk therapy would be otherwise unproductive without the value added by antidepressant medications.  Other noteworthy psychological treatments that have garnered empirical support for the treatment of clinical depression include Behavior Therapy (Behavioral Activation), Cognitive Therapy, Cognitive Behavioral Analysis System of Psychotherapy, Interpersonal Therapy, Problem-Solving Therapy, Self-Management/Self-Control Therapy, Acceptance and Commitment Therapy, Behavioral Couples Therapy, Emotion-Focused Therapy (Process-Experiential), Reminiscence/Life Review Therapy, Self-System Therapy, and Short-Term Psychodynamic Therapy.  (Hayes & Strunk, n.d.)  In the end, the choice is one that will be made based on the training and expertise of the respective therapist and the needs of the individual patient.  Not all therapists are created equal.  In the end, every clinician should know a little about most of the treatment options above so they can make a referral if your particular variant of Dysthymia will not be well served by the treatment modalities that your clinician is versed in.

Knowing nothing about my potential client, I would begin the treatment from a cognitive behavioral perspective because I believe that it is the “best bang for the buck” in a brief therapy environment.  The most likely scenario for a first session could be summed up in the word “triage.”  Something brought the client into therapy and we need to “stop the bleeding.”  Behavioral activation in the form of cognitive behavioral homework is absolutely critical to get the ball rolling.  Although we can only speculate without a specific case study to reference, we would likely begin with some simple behavioral activation like “going on a walk with a friend for one hour, once a week.”  Ideally the target behavior would be specific, measurable, and relatively easy to complete (at least at the beginning).  Reversing that “downward spiral” as soon as is possible is an important first step in the treatment of Dysthymic Disorder.  (Beck, 2011, p. 80)  After identifying avoidance behaviors and potential reinforcing activities, I would endeavor to implement some form of self-reinforcement whereby transfer, generalization, and long-term maintenance of the desired behavior can be established and maintained.  (Spiegler & Guevremont, 2010, p. 135)  It should be a foregone conclusion but it bears mentioning that the homework should be customized for the specific patient and, if deemed necessary, “contracted” to increase the likelihood of compliance.

Furthermore, I would work to identify chronic stressors that appear to be contributing to the maintenance and onset-recurrence of the disturbance.  (Dougherty et al., 2004, p. 1012)  I typically engage in a series of assessments including interviews, behavioral checklists, assessments (ex: Beck Depression Inventory), and direct ecological observation to obtain both direct and indirect data regarding the antecedent variables and functional relations that serve to perpetuate the disturbance.  (Cooper, Heron, & Heward, 2007, p. 50)  I would pay particular attention to social, medical, family circumstances in the past, present, and anticipated future.  I would also make certain to note any vested friends and family without whom behavior change cannot be successful.  (Cooper et al., 2007, p. 51)  Parallel to that search for natural supports, I would engage in a systematic search for pool of appropriate people whom the individual could potentially model.  (Cooper et al., 2007, p. 413)  Finally, it bears mentioning that the continued inclusion of data from multiple sources (people) and situations (cultural contexts and mediating factors) makes the process of culturally competent cognitive behavioral therapy a possible since “identification of important, controllable, causal functional relationships” is an intimately subjective process laden with unique cultural issues and challenges.  (Hays & Iwamasa, 2006, p. 255-256)

The next logical step after the aforementioned behavioral interventions is a series of cognitive interventions that help the patient establish a bridge between automatic thoughts and behavior.  The cognitive elements of belief modification may need to be undertaken in parallel with behavioral interventions if the patient isn’t “buying the rationale” or is repeatedly unable to traverse unforeseen cognitive obstacles.  (Beck, 2011, p. 295)  The process of teaching a patient to identify and monitor automatic thoughts is of paramount importance for long term success and maintenance.  If the patient-clinician dyad comes to consensus about a longer treatment course, Schema Therapy would be my personal tool of choice since we can reasonably anticipate it will take at least 12-24 months to modify an individual’s core belief system.

There are a number of anticipated complications that we can reliably predict before treatment commences.  The first and most obvious complication is that negative self talk and poor self image are so much a part of the typical patient with Dysthymic Disorder that compliance is likely to be a huge issue.  Resistance is likely to be moderate to high, especially once core issues are identified.  Metaphorically, we are talking about convincing someone that gravity doesn’t exist… it’s sure to be an uphill battle.  By virtue of the fact that I have endured the disorder myself, countertransference is a real and pertinent issue.  I would personally address this by attending my own individual sessions to ensure that I don’t get in the way of the best interest of my patient.  Finally, it must be noted that an individual with Dysthymic Disorder should be considered extremely vulnerable and handled with the utmost care.  For example, individuals with Dysthymic Disorder often exhibit symptoms such as fatigue and low self-esteem.  These symptoms may lead to tension in interpersonal relationships, thereby increasing the probability of terminating therapy.  Although these life events may appear to be the “cause” a major depressive episode, the episode is often predated by deficits in informational processing that lead to pre-morbid deterioration of the relationship.  (Harkness & Luther, 2001)

Because Dysthymic Disorder is largely defined and distinguished by its protracted course, longitudinal studies are uniquely positioned to investigate the prognosis of the disorder.  Due to the staggering costs associated with longitudinal studies, few have been conducted on the naturalistic course of Dysthymic Disorder.  (Klein, Norden, Ferro, Leader, & Kasch, 1998)  The overall consensus is that success treating Dysthymic Disorder is better addressed on a case by case basis – making a generalization about expected treatment outcomes and prognosis is probably ill advised.  However, we can reasonably expect that there will be some measure of improvement in cognitive functioning, motivation, mood, and affect.  I would be cautious about setting expectations for full recovery or total remission until the underlying core beliefs are identified.  Assuming I could obtain permission from the patient, I would endeavor to track relevant data over the course of treatment as we consider the transition to schema therapy together, if applicable.  Individuals whom suffer from Dysthymic Disorder often find that the minor daily hassles that happen to everyone may spiral into more serious life events that trigger depression.  (Harkness & Luther, 2001, p. 570)  Tracking those hassles seems to a reasonably simple way to measure the effectiveness of the therapy being provided and adjusting it if necessary.

References

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.

Beck, J. S. (2011). Cognitive behavior therapy: Basic and beyond (2nd ed.). New York, NY: Guilford Press.

Cooper, J. O., Heron, T. E., & Heward, W. L. (2007). Applied Behavior Analysis (2nd ed.). Upper Saddle River, NJ: Pearson Education.

Dougherty, L. R., Klein, D. N., & Davila, J. (2004, Dec). A growth curve analysis of the course of dysthymic disorder: The effects of chronic stress and moderation by adverse parent-child relationships and family history. Journal of Consulting and Clinical Psychology, 72(6), 1012-1021. doi: 10.1037/0022-006X.72.6.1012

Durbin, E. C., Klein, D. N., & Schwartz, J. E. (2000, Feb). Predicting the 21/2-year outcome of dysthymic disorder: The roles of childhood adversity and family history of psychopathology. Journal of Consulting and Clinical Psychology, 68(1), 57-63. doi: 10.1037/0022-006X.68.1.57

Elligan, D. (1997). Culturally sensitive integration of supportive and cognitive behavioral therapy in the treatment of a bicultural dysthymic patient. Cultural Diversity and Mental Health, 3(3), 207-213. doi: 10.1037/1099-9809.3.3.207

Harkness, K. L., & Luther, J. (2001, Nov). Clinical risk factors for the generation of life events in major depression. The Journal of Abnormal Psychology, 110(4), 564-572. doi: 10.1037/0021-843X.110.4.564

Hayes, A., & Strunk, D. (n.d.). Depression. Retrieved May 28, 2012, from http://www.div12.org/PsychologicalTreatments/disorders/depression_main.php

Hays, P. A., & Iwamasa, G. Y. (Eds.). (2006). Culturally responsive cognitive-behavioral therapy. Washington DC: American Psychological Association.

Klein, D. N., Clark, D. C., Dansky, L., & Margolis, E. T. (1988, Aug). Dysthymia in the offspring of parents with primary unipolar affective disorder. The Journal of Abnormal Psychology, 97(3), 265-274. doi: 10.1037/0021-843X.97.3.265

Klein, D. N., Norden, K. A., Ferro, T., Leader, J. B., & Kasch, K. L. (1998). Thirty-month naturalistic follow-up study of early-onset dysthymic disorder: Course, diagnostic stability, and prediction of outcome.. The Journal of Abnormal Psychology, 107(2), 338-348. doi: 10.1037/0021-843X.107.2.338

Morrison, J. (2007). Diagnosis made easier: Principles and techniques for mental health clinicians. New York: Guilford Press.

Spiegler, M. D., & Guevremont, D. C. (2010). Contemporary Behavior Therapy (5th ed.). Belmont, CA: Wadsworth: Cengage Learning.

Yee, C. M., & Miller, G. A. (1994, Nov). A dual-task analysis of resource allocation in dysthymia and anhedonia. The Journal of Abnormal Psychology, 103(4), 625-636. doi: 10.1037/0021-843X.103.4.625

Yee, C. M., Deldin, P. J., & Miller, G. A. (1992, May). Early stimulus processing in dysthymia and anhedonia. The Journal of Abnormal Psychology, 101(2), 230-233. doi: 10.1037/0021-843X.101.2.230

What Kind of Therapy is Out There?


In reviewing treatments for depression, it seems the three most common, two of which are very broad, treatments are anti depressant medications, electro-convulsive therapy or ECT, and psychotherapy. Each of these treatments has their own purpose and regimen and can be combined in various ways even though they are different. In fact it is most likely because they are so different that they work well together.

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Antidepressant medication gives a therapist and a patient many options. These options have both positive and negative effects. There are different side effects with each type of medication, some tolerable, some need to be managed with other medications. It is different for everyone; this is why it is important to continue trying different combinations until an agreeable treatment plan is found. One example of medication is SSRIS, which are Selective Serotonin Reuptake Inhibitors. This medication is usually the first choice for treatment. The reasoning behind this is that SSRI’s are the most tolerated with very little side effects and most people find they work very well for them. Some side effects are headache or insomnia, but often any side effects subside in the first month. This medication allows a high amount of serotonin to be blocked in the synapse. By doing this, the cells that are neglected are resaturated allowing relief from depression symptoms.

Tricyclic anti-depressants or TCAs are a second choice in medications, if for some reason the SSRI is unable to help the patient. This medication was developed sometime during the 1950’s and 60’s. TCAs seem to be used for more moderate or severe depression because the side effects are more likely to be serious. TCAs work in the brain synapses and increase norepinephrine. Some of the side effects include dry mouth or visual focus, but the more serious side effects include things such as urinary obstruction or delirium. People who have had a lot of strokes or have been diagnosed as having seizure disorders should not be given any TCAs as medication.

MAOIs or monoamine oxidase inhibitors are another common medication prescribed to depression patients. These are generally a last choice because the side effects are often serious. MAOIs are usually effective in treating depression and were actually the first anti-depressant. It works by blocking monoamine oxidase in the brain synapses and increasing norepinephrine. MAOIs inhibit the body’s ability to break down tyramine which is found in very common foods such as wine, nuts, and chocolate. When this food is consumed while the person is taking an MAOI, it is possible for the tyramine to cause blood pressure to rise to dangerous levels.

While anti-depressants can be mixed or left as a single treatment, they do provide a lot of options to help deal with side effects or other issues that may come up.  They are always the best option; another treatment option for depression is electroconvulsive therapy or ECT.

When electroconvulsive therapy is chosen as treatment the patient receives an electrical current which is passed through the brain causing a seizure. The seizure usually continues for twenty to ninety seconds. This treatment is said to offer a patient a quick relief of their depression symptoms. A common side effect of this treatment is confusion that can last up to several hours and short term memory loss, both of which are short term.

Psychotherapy is the last type of treatment discussed and is often referred to as talk therapy. There are various types of psychotherapy such as cognitive behavioral therapy, interpersonal therapy, and psychodynamic therapy. The most common type of talk therapy is the cognitive behavioral therapy. During sessions a patient not only talks about their depression, they have the opportunity to learn more about it. The patient is then able to focus on knowing what their negative patterns are and changing those into positive behaviors. Interpersonal therapists’ help their patients look at the destructive relationships a person is in that may be helping to grow the depression instead of helping to keep it at bay. Psychodynamic therapy helps a patient work through and resolves whatever internal conflicts the patient may be living with.

All of these types of psychotherapy focus on one thing, helping the patient talk through and learn how to deal with events in their lives so they don’t feel like they are drowning in depression.

Out of all of these treatments I would actually think electroconvulsive therapy to be the quickest and most effective. I can’t imagine going under sedation in order to endure treatment and then waking up not only with memory loss but also being confused about your whereabouts, among other things, even if only temporarily.

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References:

Child and Adolescent Psychological Disorders.

Oxford Textbook of Psychopathology.

Depression. medicinenet.com. http://www.medicinenet.com/script/main/art.asp?articlekey=342&pf=3&page=6

Depression (Major Depression).  Mayoclinic.com. http://www.mayoclinic.com/health/depression/DS00175/METHOD=print&DSECTION=all

Is There More Than One Kind Of Depression?


Dysthymic Disorder and Major Depressive Disorder are actually two different versions of depression.  Dysthymic Disorder is noted for chronic depression.

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The definition for Dysthymic Disorder is that it is a “mood disorder with chronic depressive symptoms that are present most of the day, more days than not, for a period of at least two years.”  (Minddisorders.com).  The symptoms are usually present for years and can include low self esteem, decreased motivation, change in sleeping patterns and change in appetite patterns.  Causes of this type of depression are things like a person’s upbringing.  If a person is brought up in a home where abuse is prevalent an adult can suffer from depression for their entire life.  Treatment for this type of depression is generally psychotherapy but sometimes is combined with antidepressants.

Similarly Major Depressive Disorder is the next level of depression and is defined as, “a condition characterized by a long lasting depressed mood or marked loss of interest or pleasure in all or nearly all activities” (Minddisorder.com).   This form of depression has an intense impact on a person’s life.  It usually comes about when a person suffers a traumatic event, but this does not always happen.  Symptoms can include a disturbed mood throughout most of the day, a change in the sleep pattern, a change in the appetite pattern, a loss of interest in things that are considered pleasurable, but then go further to include problems when trying to concentrate or think in depth, psychomotor retardation or agitation and thoughts of suicide.  If this form of depression is left untreated it can last longer than four months and recurrence is eminent.  Treatments for Major Depressive Disorder include psychotherapy or talk therapy, electroconvulsive therapy or ECT and antidepressant medications or a combination of these treatments.

Nearly everything about these two disorders are similar, the main difference is that major depressive disorder is an extension of Dysthymic Disorder in that symptoms and moods are more severe therefore treatments need to be more involved and more inclusive.

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References:

Netherton, S.D., Holmes, D., Walker, C.E., Child and Adolescent Psychological Disorders

Blaney, P.H., Millon, T., Oxford Textbook of Psychopathology.

Depression (Major Depressive Disorder) http://psychcentral.com/disorders/sx22.htm

Dysthymic Disorder. minddisorder.com.  http://www.minddisorders.com/Del-Fi/Dysthymic-disorder.html

Dissociative Identity Disorder. Psychnet-uk.com. http://www.psychnet-uk.com/dsm_iv/dissociative_identity_disorder.htm

Major Depressive Disorder. minddisorder.com. http://www.minddisorders.com/Kau-Nu/Major-depressive-disorder.html