PsychNotes June 2013
by Monica A. Frank, Ph.D.
Clinical and Sport Psychologist

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June 30, 2013 This relaxation for children (and the young at heart) describes finding a magic book that creates pleasant images from your mind. It guides you through discovering a special place and teaches mindful imagery and relaxation. About 19 minutes.

June 29, 2013 This audio discusses the concept of excessive responsibility to help those with Obsessive-Compulsive Disorder (OCD) challenge the underlying thinking of certain types of compulsions.

Many people with OCD have problems with excessive responsibility because they want to control or prevent bad events. When you first listen to this audio it may be uncomfortable because it challenges irrational beliefs. However, if it seems relevant to the obsessions you have, it is best to listen to it repeatedly to help change the thinking.

June 27, 2013

Too often my clients experience negative feedback from others regarding their anxiety. Because anxiety is a normal experience of life, many people have the attitude about anxiety disorders of “Just do it!” They believe that the anxiety a person with an anxiety disorder experiences is the same as the anxiety they might experience when faced with a difficult situation. “I had to speak in front of a group at work and I was anxious but I did it anyway. So you shouldn't have to a avoid a simple thing like talking to someone” is the message they might give to someone with social anxiety. Or, “After I had an accident I was fearful of driving, too, but I just made myself do it and I got over it” they might say to someone with panic disorder.

However, normal anxiety and an anxiety disorder are two very different things even though they may have commonalities. One aspect that is different is the length of time the anxiety may be experienced. Normal anxiety tends to be more fleeting or just focused on a certain event whereas anxiety from an anxiety disorder tends to last much longer. Try to imagine normal anxiety that does not subside and that you feel continuously.

I once had a client who had cancer who was complaining of the nausea. I couldn't fully understand what she was experiencing until I was on an ocean fishing excursion on a rough day and experienced severe sea-sickness. I kept myself focused on the fact that in a couple hours I would be back on land so I knew I could get through it. However, I thought about my client “What if I felt this way all the time and couldn't do anything about it?” That gave me a much better perspective of what she was experiencing as I couldn't even imagine how I could cope with that!

Another aspect of an anxiety disorder that is different is the intensity of the anxiety. Although most of us will experience a panic attack sometime in our lives due to physical or emotional stress, we don't often experience that level of intense anxiety. There really is not a comparison between normal anxiety that is meant to bring our attention to a problem and the intense anxiety of an anxiety disorder.

Therefore, an anxiety disorder is NOT the inability to cope with normal anxiety or normal stressors. It is a deregulation in the body's system that causes an intense and long-lasting reaction that is beyond the normal level. The solution to it is much more involved than “Just do it!” Forcing a person with an anxiety disorder to face an uncomfortable situation by pressuring them does not help. In fact, it is likely to sensitize the person further.

Unfortunately, the people who probably need to understand this information are not the people likely to be reading it. However, if you have an anxiety disorder, don't allow yourself to be pressured into believing that you are weak and unable to cope with the normal anxiety of life. It is difficult enough managing an anxiety disorder without feeling bad about yourself as well.

June 23, 2013 This article discusses generalizing which is the irrational belief that because an outcome occurred one time it is more likely to occur again. This irrational type of thinking justifies not trying to succeed due to the assumption that failure will occur again.

June 21, 2013 This is a follow-up to my previous PsychNote (May 18, 2013) about stomach bacteria as a potential cause of depression. Researchers have shown that probiotics (consumed in yogurt) has the effect of regulating emotional response in healthy women. In other words, a randomized study that provided healthy women probiotics for four weeks found that they were less likely to respond emotionally to tasks that elicited an emotional response in women who did not consume the probiotics.

Although this has not been studied in those with clinical depression yet, the accumulating evidence is indicating a possible connection between stomach bacteria and emotion. In the meantime, until this connection is fully understood, eating yogurt with probiotics may be worth a try.

Tillisch, K., Labus, J., Kilpatrick, L., Jiang, Z., Stains, J., Ebrat, B., Guyonnet, D., Legrain-Respaud, S., Trotin, B., Naliboff, B., Mayer, E.A. (June, 2013). Consumption of fermented milk product with probiotic modulates brain activity. Gastroenterology, 144, 1394-1401.

June 19, 2013 Examines the Internal Control Fallacy of needing to be in control and responsible for everything and the External Control Fallacy which is believing everything that happens is due to luck or uncontrollable circumstances.

June 18, 2013 Describes the pitfalls of emotional reasoning which is listening to emotions without evaluating the validity of the emotion.

June 14, 2013 Most of us understand that a polygraph test measures a person's physiological response to determine whether the person is lying or telling the truth. For instance, when someone is lying, the heart rate increases. However, what you may not know is that our physiological responses guide our behavior. What this means is that when most people perceive a fast heart beat they are more likely to act morally.

When researchers provided false heart rate information to participants indicating a fast heart rate, they found that when heart rate was perceived as faster people were more likely to volunteer for a good cause and were less likely to lie for personal gain. However, people were not as influenced by their heart rate when they more mindfully focused on their decision. This indicates that the physiological response may be an important factor with increasing moral behavior (Zhong and Page-Gould, 2013).

Although trusting this process with moral decision-making may be useful, trusting it completely can lead to problems. For instance, I see the same process occur in my clients with anxiety disorders. They make avoidance decisions based on their physiological response rather than thinking through the situation. In cognitive therapy, we refer to this irrational thinking style as "emotional reasoning". For example, the person thinks "My heart is pounding, I feel scared, this must be a dangerous situation so I must avoid it." Now, for many people those thoughts aren't as obvious as what I just described so it seems like a much more automatic response.

Much of cognitive therapy when people engage in emotional reasoning is to help them think through the situation:

Client: "I'm afraid of flying."

Therapist: "What are you concerned about when flying?"

Client: "I'm afraid the plane will crash and I will die."

Therapist: "What is the evidence for that?"

Client: "I know that flying is the safest form of travel but I still FEEL scared."

Therapist: "Is that feeling reality or is it just a learned response?"

Client: "I guess it is a learned response."

Therapist: "So what can you do about it?"

Client: "I can tell myself that flying is safe and that my heart pounding doesn't mean anything."

Obviously, actual sessions aren't this simple but it gives you an idea of the process of learning to think through a situation so as to use the brain to determine whether the physiological response is accurate or not. Notice that I said "determine whether the physiological response is accurate or not." What I mean by this is that we need to listen to our emotions because sometimes they are accurate indicating something actually is dangerous. However, we need to evaluate the emotions before making decisions. For more info, read : Use Your Head! And Your Heart!

Zhong, C. and Page-Gould, E. (2013). Listen to Your Heart: When False Somatic Feedback Shapes Moral Behavior. Journal of Experimental Psychology: General, 142, 307-312.

June 12, 2013 Question: I've had to work at different locations due to personal conflict with my boss. At the beginning of this saga, I stated to my sister who works for the same company "I'll never work for that boss again." Well, after a year of drama, it looks like I will be going back to that location. I feel like my sister is trying to rub my nose in it. She left a long-winded message on the phone about me returning and told my mother about it. I feel irritated by it. What should I do?

Response: Obviously, we aren't privy to the tone of the sister's comments, but according to the writer's description we can assume the tone is either sarcastic or somewhat gleeful such as "I guess you're going back after all." In that case, this would be an example of back-stabbing passive-aggressive behavior (PA) because when the writer needs her support, the sister uses sensitive information against her. Read More

June 11, 2013 Many parents are experiencing difficulties with adult children living at home. Although I imagine most adult children are respectful and appreciative of their parents' assistance, some parents report frustration regarding their children not helping around the house. Yet, because they are adults, there are few consequences available short of kicking them out of the house.

In one such case, the parent stated "I just want her to pick up her dishes and put them in the sink." This parent had made the request repeatedly, but to no avail. So we decided on the following strategy.

Again, as in the previous post, the Mother quit saying anything about the dishes. Instead, she calmly gathered them up and put them outside her daughter's bedroom door. Now obviously, this requires more effort on the Mother's part than just doing the dishes herself. However, after a few days, the daughter started taking care of her dishes.

This example is actually what we call a logical consequence rather than a natural consequence as it requires a more creative solution instead of just allowing whatever happens. For example, a natural consequence is allowing the adult child to oversleep and be late for work rather than taking on the responsibility of trying to wake him or her. The natural consequence is whatever occurs for being late to work. The parent is removed from the process.

(My apologies to any adult children living at home who suddenly find dishes in front of their door.)

June 7, 2013

Discusses the difficulty many people with depression experience when trying to engage in cognitive-behavioral therapy (CBT). The effort required seems overwhelming. This article provides some simple suggestions to help get started with CBT.

June 5, 2013

A review of studies conducted in clinics throughout the world showed that children treated for anxiety with cognitive-behavioral therapy (CBT) not only benefited from therapy, but 50% of those who completed therapy were symptom-free. In additon, for those who were not symptom-free at the conclusion of therapy, studies with follow-up data showed that symptoms continued to improve after the completion of treatment. Finally, for the 20% who did not complete therapy, it is not clear whether they quit due to improvement or due to dissatisfaction with treatment (Lee et.al, 2013).

For parents who are concerned about medicating their children, such studies are encouraging. Most children can reduce anxiety symptoms significantly and safely by learning the CBT methods. Parents need to be aware of this information because although cBT has been recommended as the first-line of treatment, most children with anxiety disorders are not referred for CBT. In fact, although CBT is the treatment of choice, most children suffering from anxiety do not receive CBT even when meeting with a therapist claiming to provide CBT (Seligman and Ollendick, 2011)!

How can a parent know if CBT is being provided? CBT teaches skills. It is NOT just talking to a therapist. The therapist should be training the child how to manage different situations by thinking about them differently or by using anxiety reduction methods. Discuss with the therapist the specifics of how the child will be taught to manage anxiety.

Lee, C.M., Horvath, C. and Husley, J. (2013). Does It Work in the Real World? The Effectiveness of Treatments for Psychological Problems in Children and Adolescents. Professional Psychology: Research and Practice, 44, 81–88.

Seligman, L.D. and Ollendick, T.H. (2011). Cognitive Behavioral Therapy for Anxiety Disorders in Youth. Child and Adolescent Psychiatric Clinics of North America, 20, 217–238.

June 3, 2013 One of the reasons more people don't benefit from cognitive-behavioral therapy (CBT) is that it involves determination and work—two things that can be overwhelming for depressed individuals. A examination of over 30 studies of CBT and depression shows that CBT is effective but in real-world outpatient settings there is a 25% drop-out rate (Gutenberg & Hiller, 2013).

If the drop-out rate is that high with personal encouragement from a therapist, it is likely much higher when someone is attempting to use self-help materials such as the apps by Excel At Life. Such work can be difficult for someone who is seriously depressed and doesn't feel like doing anything including basic self-care activities.

Certainly, it can be overwhelming for even a non-depressed person to make major changes in his/her life. That is why the Android app Depression CBT Self-Help Guide encourages the users to take small steps. The app contains many different strategies but not for the purpose of doing all of them. By providing many suggestions, the hope is that the depressed individual may find one that can be a starting point.

So, if you are depressed and using the app, don't focus on making too many changes. Instead, focus on something that seems doable. For instance, listen to an audio even if you can't give it full attention. Or, read the positive affirmations even if you don't create one yourself. Eventually you are likely to find that you will be able to do more and obtain more benefit.

Gutenberg, J. and Hiller, W. (2013). Effectiveness of and Dropout From Outpatient Cognitive Behavioral Therapy for Adult Unipolar Depression: A Meta-Analysis of Nonrandomized Effectiveness Studies Journal of Consulting and Clinical Psychology, 81, 75–88.

June 2, 2013 This audio discusses the concept of probability to help those with Obsessive-Compulsive Disorder (OCD) challenge certain types of obsessions.

Many people with OCD have problems with probability because they want 100% certainty which is an impossible goal to attain. When you first listen to this audio it may be uncomfortable because it challenges irrational beliefs. However, if it seems relevant to the obsessions you have, it is best to listen to it repeatedly to help change the thinking.

June 1, 2013 A controversial change to psychiatry's new diagnostic manual (DSM-V) now makes grief that lasts beyond 2 weeks a mental illness which allows physicians to label millions more people as mentally ill and prescribe medications to treat grief. Interestingly, almost 70% of the panel developing the diagnostic criteria have ties to the pharmaceutical companies (Cosgrove and Krimsky, 2012) which indicates possible bias.

Why is this a problem? My observations in my clinical practice has been that when the symptoms of grief are medicated, the individual is not able to properly engage in the normal healing process. As a result, the grief is repressed only to return when the medication is discontinued.

Not only that, but the serious side effects of most anti-depressants can reduce quality of life especially when used for a normal condition. Although the pharmaceutical companies may report lower levels of side-effects when using self-report measures which are notoriously inaccurate, when valid and reliable measurements are used the side-effect statistics are often much higher. For instance, the sexual side-effects of the SSRIs are closer to 55% rather than the 2-7% reported in the drug inserts. In addition, the average weight gain is 15-24 pounds and increased sleep disturbance is common (Ferguson, 2001).

Who does it benefit to label grief as a mental illness? In my opinion, it does not benefit the general public who may be prescribed these powerful drugs that can have serious unwanted side-effects. This is especially true when there are other more effective methods to help people experiencing grief. In addition, with the current move to electronic health records many more people will forever be labeled, and unfortunately, there is still a stigma attached to mental illness.

Cosgrove, L. and Krimsky, S. (2012). A Comparison of DSM-IV and DSM-5 Panel Members' Financial Associations with Industry: A Pernicious Problem Persists. PLoS Med 9(3): e1001190. doi:10.1371/journal.pmed.1001190

Ferguson, J.M. (2001). SSRI Antidepressant Medications: Adverse Effects and Tolerability.The Primary Care Companion to the Journal of Clinical Psychiatry, 3, 22-27.