Postcards from the Id

Self-Esteem - Book Quote - An Arsenal of Shoulds

From Self-Esteem, page 17:

"The critic has many weapons.  Among the most effective are the values and rules of living you grew up with.  the critic has a way of turning your"shoulds" against you.  He compares the way you are with the way you ought to be and judges you inadequate or wrong.  he calls you stupid if the A you should have had slips to a B.  He says, "A real man supports his family," and calls you a loser when you're laid off from work.  He says, "The kids come first," and calls you selfish when you crave some nights off."

In addressing many neurotic mental health issues, you'll come across the concept of rigid thinking, and how it contributes to depression, anxiety, etc.  The paragraph above demonstrates how this type of thinking leads to misinterpretations of environmental activities, which then leads to negative/maladaptive feelings, which in turn lead to less optimal behavioral responses.  Albert Ellis is generally credited with the modern therapeutic framework for addressing rigid thinking patterns and their unhealthy impact on our well-being (Rational-Emotive-Behavior Therapy, or REBT). 

When tackling low self-esteem, adressing rigid thinking patterns (as voiced by this "inner critic") is of paramount importance.  The book goes into some detail as to why, as well as how to confront these cognitive errors.  For now, let us just say that, in general, excessively rigid thinking is, first and foremost, wrong.  Period.  To consistently judge oneself against erroneous standards, then, puts us at a disadvantage.  This is why confronting the inner critic, and correcting the rigid beliefs inherent in the inner critics' statements, is so important.  Next up, I'll provide further quotes from the book, and provide a few examples.

Exercise Improves One's Body Image Regardless of Fitness Level

Interesting article here regarding the impact of exercise on one's own body image.  It seems that if an individual engages in exercise, they experience an improved sense of their body image, regardless of their overall fitness level.  From the article:

People who don't achieve workout milestones such as losing fat, gaining strength or boosting cardiovascular fitness feel just as good about their bodies as their more athletic counterparts, said Heather Hausenblas, a UF exercise psychologist. Her study is published in the September issue of the Journal of Health Psychology.

"You would think that if you become more fit that you would experience greater improvements in terms of body image, but that's not what we found," she said. "It may be that the requirements to receive the psychological benefits of exercise, including those relating to body image, differ substantially from the physical benefits."

The article also addresses the relevance of the research, in that dissatisfaction with one's body image has increased dramatically in this country over the last 20 years.  As a result, people spend tons of money on all sorts of products, diets, etc. in an effort to address their poor self-image.  According to this research, people will experience an improved sense of self regardless of whether they reach specific fitness markers, in terms of type/duration of exercise, or physiologic measurements.  Only frequency of participation appeared significant in the findings, which suggests that simply getting people to participate in some fitness-related activity regularly, regardless of length, will have a psychological benefit - one doesn't have to achieve certain thresholds before the benefits are experienced.

What is nice about this in the context of therapy is that, when exercise is a behavioral intervention (such as when treating depression), the only really important number one needs to worry about in terms of goal-setting is frequency of an activity.  The client can slide on some of the other goals (like the length of the workout, walk, jog, etc.); it is simply the act of engaging in the activity for some length of time on multiple occasions during the week that will trigger an improvement in this area.  Helping the client by adding the social/interpersonal dimension, such as "I will walk with my wife five days per week," will further increase the likelihood of initial compliance to the goal.  As improvement occurs, the other issues (such as the length of the walk) can be examined more specifically. 

In addition, this research may be important to provide as education to clients who have extremely poor body image, and/or are reluctant to initiate a workout routine due to concerns regarding "how they'll look in front of everyone."  I get that, and there can be ways to work around this issue (go for walks instead of going to the gym, for example).  However, there are certain exercise regimens that might be better for certain individuals, or certain exercises the client would otherwise prefer except for this one concern.  This research might help a client overcome their self-conciousness and facilitate their participation in an exercise routine they are otherwise more likely to participate in and enjoy. 

Self-Esteem - Book Quote - The Pathological Critic

“The pathological critic is a term coined by psychologist Eugene Sagan to describe the negative inner voice that attacks you.  Everyone has a critical inner voice.  But people with low self-esteem tend to have a more vicious and vocal pathological voice.

The critic blames you for things that go wrong.  The critic compares you to others - to their achievements and abilities - and finds you wanting.  The critic sets impossible standards of perfection and then beats you up for the smallest mistake.  The critic keeps an album of your failures, but never once reminds you of your strengths or accomplishments.  The critic has a script describing how you ought to live and screams that you are wrong and bad if your needs drive you to violate its rules.  The critic tells you to best the best - and if you’re not the best, you’re nothing.  He calls you names - stupid, incompetent, ugly, selfish, weal - and makes you believe that all of them are true.  The critic reads your friends’ minds and convinces you that they are bored, turned off, disappointed, or disgusted by you.  The critic exaggerates your weaknesses by insisting that you “always say stupid things,” or “always screw up a relationship,” or “never finish anything on time.”

- From Self-Esteem, page 15

In short, the more you grapple with an internal voice like this, the more likely it is you sense of self-worth is being compromised by this cognitive style.  The good news is, the inner critic is much like the loud, obnoxious drunk at a party; everyone listens to what he says because he is loud and obnoxious, but with a bit of confrontation and some logic, everything he says can be disproved.

Depression In College Students Increases Likelihood Of Dropping Out

I came across this article, which discusses the impact of depression, and to a lesser extent anxiety, on both the completion rate and academic performance of college students.  While it makes intuitive sense that students with depression might struggle with college more than those without depression, what I like about this research is its exploration of the types of depression involved.  In terms of academic performance, it is the loss of motivation, rather than the experience of depressed affect, which impairs the student’s academic performance.  From the article:

There are two core symptoms of depression---loss of interest and pleasure in activities, or depressed mood---but only loss of interest is associated with lower grade point averages.

"The correlation between depression and academic performance is mainly driven by loss of interest in activities," Eisenberg said. "This is significant because it means individuals can be very depressed and very functional, depending on which type of depression they have. I think that this can be true for many high achieving people, who may feel down and hopeless but not lose interest in activities.

"Lots of students who have significant depression on some dimension are performing just fine, but may be at risk and go unnoticed because there is no noticeable drop in functioning."

The article also discusses how comorbid anxiety (very common, as anxiety and depression tend to go together) increases the degree of academic impairment:

"If you take a student at the 50th percentile of the GPA distribution and compare them to a student with depression alone, the depressed student would be around the 37th percentile---a 13 percent drop," Eisenberg said. "However, a student with depression and anxiety plummets to about the 23rd percentile, a 50 percent drop."

There are some important insights to be gained from research like this.  First, depending on the type of depression one experiences, a change in behavior may not necessarily be evident.  Just because someone continues to maintain a certain degree of functioning does not mean they are not experiencing depression.  However, depression ought to be screened should a change in functioning occur, especially absent some other apparent cause.  It seems like colleges are dramatically improving in their ability to assess, recognize, and intervene with students who are experiencing mental health difficulties, which often emerge, or increase, during young adulthood.  This is especially important because the individuals who would normally be most familiar with a change in presentation - family members - are often no longer seeing their child on a regular basis.  The ability of school employees and fellow students to be informed and make educated observations can help pick up the slack.

Maternal Depression and Infant Sleep Disturbance

This article discusses the recent finding that infants born to mothers with depression exhibit sleep difficulties as soon as two weeks after birth.  This finding, though preliminary (this initial research only had 18 subjects) is important, in that early sleep difficulties are associated with the later development of early-onset depression.  From the article:

Results indicate that infants born to mothers with depression had significant sleep disturbances compared to low-risk infants; the high-risk group had an hour longer nocturnal sleep latency, shorter sleep episodes and lower sleep efficiency than infants who were born to mothers without depression. Although average sleep time in a 24 hours did not differ by risk group at eight two or four weeks, nocturnal total sleep time was 97 minutes longer in the low-risk group at both recording periods. High-risk infants also had significantly more daytime sleep episodes of a shorter average duration.

The article also discusses the potential reversibility of these sleep difficulties as a way of potentially reducing or eliminating the later development of depression.  I've posted several articles regarding the importance of sleep, and the assocation of sleep problems with other issues, and it is no surprise that sleep problems at infancy is associated with later mood difficulties.  Hopefully further research will allow for early detection and intervention.

Childhood Predictors of Adolescent Depression

Here’s an interesting article summing up recent research into the precursors of adolescent depression. For boys, it’s primarily anxiety, but with girls, it’s anxiety as well as antisocial behavior. Surprisingly, early depression did not predict later depression as much as these other warning signs. From the article:

"Anti-social behavior has typically been viewed as a big problem among boys, so it tends to be ignored among girls. Boys with early anti-social behavior typically go on to show more anti-social behavior while girls may turn inward with symptoms, morphing into other mental health problems such as depression eating disorders, anxiety and suicidal behavior during adolescence ," said James Mazza, a UW professor of educational psychology and lead author of the new study. He is currently serving as the past president of the American Association of Suicidology.

"When all the risk factors were analyzed, anti-social behavior and anxiety were the most predictive of later depression. It just may be that they are more prevalent in the early elementary school years than depression." He noted that depression and anxiety share a number of symptoms.

A couple of quick observations. First, it is a general trend that women display high incidences of “inward” mental health difficulties (e.g. depression, anxiety) while men tend to have higher incidences of “outward” mental health diagnoses (i.e. antisocial personality disorder). Interesting how the antisocial stuff continues to develop in boys, but with the girls, the focus shifts once adolescence is reached.

Also, this research again confirms the link between early anxiety and later depression, which I wrote about here. Again, if you are a parent or professional, please do not discount anxiety in kids: anxious kids grow up to be depressed adults, which is not a good thing. Nip these types of problems early, when the symptoms are more manageable, and a whole lot of discomfort and misery can be avoided.

What is also interesting about this study is that it demonstrates that children have some insight into their moods - the authors indicated the kids were able to successfully communicate their difficulties with the help of questionnaires. This is a good thing, insofar as we don’t have to rely solely on the observations of parents, teachers, and others. What this also means is that we need to take kids seriously - obviously, an over-reaction to the occasional stressor is one thing, but if a child is communicating regular discomfort with worry, it is worth it to examine it further.

Infants Placed In Incubators At Less Risk for Later Depression

According to new research, infants who require placement in incubators following birth are at less risk for later onset of depression than infants who aren’t placed in incubators. Girls in particular experience a significant decrease in later depression. Not much to add, aside from my interest in this article was in part personal (my son was born two months premature, which necessitated a significant amount of time in an incubator - that's him in the pics, then and now!). The article covers the thinking behind the results, which seems to make sense to me. Check it out.

Watching Television and Level of Happiness

This article has been out for about a week now, but I figure I ought to comment on it, since I’ve pushed this meme on this blog on more than a few occasions. According to the research cited in this article, an analysis of 30 years worth of data from the General Social Survey is consistent with Robert Putnam’s conclusions in Bowling Alone: That is, happier people are more socially active, more religiously involved, more politically involved, and read the newspaper more frequently. In contrast, unhappier people spend a significantly higher amount of time watching television. It is noted in this article that there is a contrast between these findings, and recent research that showed people rating television-watching as a pleasurable activity in time diaries. From the article:

In contrast, unhappy people watched significantly more television in their spare time. These results also raise questions about recent and previous time-diary data, in which television rated quite highly when people were asked to rate how they felt when they engaged in various activities in "real time" in these daily diaries.

"These conflicting data suggest that TV may provide viewers with short-run pleasure, but at the expense of long-term malaise," said Professor Robinson. He also noted that earlier general satisfaction surveys also showed people rating TV below average as a significantly less satisfying free-time activity on the whole. "What viewers seem to be saying is that while TV in general is a waste of time and not particularly enjoyable, the shows I saw tonight were pretty good."

The ease and convenience of watching television is noted as a possible explanation for the generally high marks people will give to watching television in the moment. However, it is also pointed out that the short-term pleasure associated with watching T.V. is contrasted with a longer-term malaise.

Robert Putnam goes into even more detail in his book. He points out that more socially active/happier people not only differ in the amount of television they watch, when compared to less socially involved people, but also in the content of the programming that is watched, as well as how the television is watched. For example, from what I recall, individuals who are less socially involved will tend to leave the television on throughout the day, even when not actively watching it.

My general take on television, when I’ve applied it to treatment, is that it’s like most everything else: moderation is fine, but too much is no good. I’ve found that many of my depressed clients have watched way too much television, which lends extremely informal support to the arguments made by this article, and by Putnam. In addition, I’ve seen television creeping into areas of peoples’ lives where it is unhealthy, and interferes with social activity, even on a spousal or familial level. The main example of this, of course, is the family that has the television on during dinner.

This article would seem to be one more piece of evidence suggesting that reducing one’s television watching, and increasing one’s social activity, makes for a healthier, happier you. Then again, if you’ve been reading this blog, you already knew that’s where I stand.

Nostalgia As Effective Coping Technique Against Loneliness

This article reviews research into the surprising role nostalgia may play in warding off the impact of loneliness, and it amplifies the perception of social support. From the article:

The results showed that individuals who felt the loneliest reported receiving the least amount of social support. What was interesting, however, was that these participants turned out to be the most nostalgic. In addition, when nostalgia was induced in a number of the study participants, they in turn perceived to have the greatest amount of social support. These findings suggest that nostalgia amplifies perceptions of social support, and in this way, counteracts feelings of loneliness. In addition, the findings revealed that the most resilient individuals are more likely to use nostalgia to overcome feelings of loneliness.

The article goes on to suggest, quite reasonably in my opinion, that nostalgia may have an important role in cognitive therapy when treating individuals dealing with isolation, loneliness, or exclusion. There are, of course, some other interesting things to take away from this study. First off, isolation, loneliness, lack of social support, etc., are significantly associated with depression. Further research into the association of nostalgia and depression would be interesting, and might provide a more accurate indicator of just how significant an impact nostalgia might have on an individual’s mood.

Another reaction I had is that of a “balancing act” with respect to an individual’s temporal focus. I tend to agree with the article that a focus on nostalgia may allow individuals coping with loneliness or isolation to manage their functioning as they work through that particular period in their life. Conversely, a retrospective focus without efforts to address one’s current lack of social support might prove to be, at best, a temporary solution. Perhaps the use of nostalgia, combined with efforts to develop new social connections (even through the use of nostalgic memories as a blueprint for future action) might be more effective. Anecdotally, I think about the guy in his 30s who constantly talks about his “glory days” of high school, and hasn’t attempted or achieved much since. Here, there is significant nostalgia, but without any accompanying forward focus. Even with respect to the elderly, who in my experience often use nostalgia most effectively, a forward focus can pay huge dividends in terms of functioning later in life.

The other thought I had as I read this is the necessity of considering an individual’s past prrior to using it as a coping mechanism. This article, as presented, assumes an individual who is isolated now has had previous experiences in life when they were not so isolated, and can call upon their memories of those moments relatively easily. What of the individual who has struggled most of their life, or is struggling now in large part due to a generally negative history? Even if an individual had significant moments of happiness, social support, and relatively high functioning in the past, a significant traumatic event can make sustained recall of those other, less salient events more difficult. An assessment of an individual’s past, as well as their ability to focus on those elements of their past that would be helpful without traumatic memories intruding on their recall, would seem to be an important consideration in terms of any use of nostalgia for therapeutic purposes.

I would be really interested in anyone’s opinion regarding the concept of nostalgia, particularly as it relates to functioning and possible therapeutic value. Please comment!

New Study Finds Both Therapy and Zoloft Effective in the Treatment of Childhood Anxiety

Good news from the world of mental health research. According to this article, a new study has found both cognitive-behavioral therapy (CBT) and Zoloft to be effective in the treatment of childhood anxiety disorders (when compared to a control group that was simply administered a placebo), and that a combination of the two treatments proved to be even more effective. From the article:

The children had been diagnosed with a range of moderate to severe disorders, including separation anxiety, generalized anxiety and social phobia. Some of the children also had more than one disorder, including other anxiety disorders, attention deficit hyperactivity disorder and behavior problems.

Walkup and colleagues found that:

81 per cent of the children in the combined treatment group improved.

This compared with 60 per cent of the children in the CBT only group and 55 per cent Zoloft only group.

In the placebo group, 24 per cent of the children improved.

Children taking Zoloft showed no more side effects that children taking placebo and few children withdrew because of side effects.

No child attempted suicide, a rare side effect that can sometimes accompany use of antidepressants in children.

The article offers a brief description of both CBT and Zoloft, including their mechanism for facilitating improvement. What I appreciate about this particular article is that it noticed the effectiveness of CBT independent of any medication:

The findings reflect other studies that showed Zoloft and other SSRIs were effective treatments for childhood anxiety disorders. But the authors said this study also adds more evidence that high quality CBT, with or without medication, is an effective treatment for childhood anxiety disorders.

Continuing to identify the effectiveness of properly conducted therapy is paramount in helping the general population overcome any concerns or stigma they may have about the process. In addition, not all individuals respond to psychopharmacological treatment; documenting effective alternative treatments will give clients choices when it comes to dealing with these issues.

As I noted in an earlier post, anxiety is not only an important treatment issue in its own right, it is significantly associated with later development of depression. In short, “anxious kids often become depressed adults.” Learning to counteract the cognitive and behavioral patterns that lead to, and maintain, a state of anxiety would be the best preventative method towards reducing depression in adults. The article indicates that this research is continuing, which is also very good news. If you are interested in seeing the actual research article, follow the initial link, and click through at the bottom of that page.