Articles - Anxiety, Depression & Other Disorders

Spending Out of Control?

Social Anxiety

Bipolar Disorder

Winter Blues

Attention Deficit Disorder in Adults

Anxiety and Panic Attacks

How to Recognize Depressive Illness

What can you do if you think you have a problem with compulsive shopping or spending? Start by putting away the credit cards, and only pay for purchases with cash, check or debit card. Before you go to a store, make a list of what you need, and buy only what’s on the list. Try going for 30 days without buying anything (other than food, gas, or essential items). Can you do it? Most people will need professional counseling and/or a self-help support group to deal with this problem. A counselor can help you identify the feelings behind your urges to shop or spend, and then work with you to develop healthier habits. Counseling can also help with related problems, like depression, bipolar disorder, low self-esteem, or other addictive behaviors you may have. There are Debtors Anonymous groups in most communities where you can find support from others who share this problem and have made a commitment to change their behavior.

SOCIAL ANXIETY  (September 2007)

September still seems to me like the start of the year, even though I’ve been out of school for decades. I remember always having mixed feelings of anticipation and anxiety, both looking forward to seeing old friends, while dreading the awkwardness of having to meet new people. Though I didn’t know it then, I was suffering from a very common condition: social anxiety.

Social anxiety is when you get nervous or uncomfortable in situations that involve being observed, scrutinized or judged by others, e.g. meeting new people, or speaking in front of a group. Usually the underlying feeling is worry about being embarrassed or humiliated. It’s often confused with shyness, however shy people tend to be more introverted and are uncomfortable in most situations involving interpersonal contact, whether in a group or one-on-one; whereas even people who are normally outgoing may experience social anxiety at times.

The most common scenario for experiencing social anxiety is public speaking (in fact there's an old joke about the fear of speaking in public being even greater than the fear of death - but worst of all is the fear of dying while speaking in public!) Eating, demonstrating an activity or performing a task in front of others are also typical situations that can cause social anxiety.

While almost everyone gets anxious in social situations from time to time, for some people the intensity of the anxious feelings, and/or the frequency of situations where social anxiety occurs, are so great as to interfere with functioning. Severe social anxiety is known as social phobia.

Typical physical symptoms of social anxiety are heart beating rapidly, shortness of breath, sweating, shaking, blushing, dizziness or nausea. Common thoughts or beliefs that accompany these feelings may include "if I make a mistake, people will think I'm incompetent", "if others see that I'm nervous, that would be awful", or "if I get too anxious, I'll faint."

Avoidance is the most common behavior related to social anxiety: people may avoid feared situations completely, or seek to escape from them as quickly as possible. While avoidance is effective in the short term, it's a temporary fix, because most people can't avoid anxiety-producing situations permanently. Also, avoidance keeps the anxiety alive by reinforcing beliefs like "I can't do this", and preventing any opportunity to learn how to survive such situations.

Another common behavior is using alcohol or drugs to calm jittery nerves. In fact, small amounts of alcohol, or prescription sedatives like Valium or Xanax, can help to relieve social anxiety. The risks of this approach are a) using too much, which may create altogether another sort of public embarrassment, and/or b) developing an alcohol or drug dependence.

A more effective and proven approach to dealing with social anxiety is to use a combination of strategies: breathing and relaxation techniques to calm the body; cognitive-behavioral therapy to change negative or self-limiting thoughts and beliefs; and medication if necessary as a back-up.

For more information on overcoming social anxiety, an excellent book is "Ten Simple Solutions to Shyness" by Martin Antony, PhD (available at www.newharbinger.com); or contact me.

BIPOLAR DISORDER (March 2006)

Lately I’ve seen a definite increase in clients in my private practice who have been diagnosed with Bipolar Disorder, or know someone who has; and “bipolar” seems to have joined “schizo” and “psycho” as a common slang term for strange or crazy behavior (as in “that’s so bipolar”). What is Bipolar Disorder? What causes it, and how common is it? Is it a new disorder?

To answer the last question first: no, it’s not a new illness at all, but rather a relatively new name for manic-depressive illness. Its key characteristic is extreme mood swings, from manic highs to severe depressions. Only about 1 – 2% of the population has the true mood disorder, however it is often mis-diagnosed in people who may be moody for other reasons. And like most forms of mental illness, there isn’t a clear cause, though it does tend to run in families.

In the manic phase, people experience different combinations of the following: elated or euphoric mood, irritable mood, decreased need for sleep, an inflated sense of themselves and their abilities, racing thoughts, increased talkative-ness and activity, and reckless behavior. During the depressed phase, symptoms include: feeling sad or blue, loss of interest in things ordinarily enjoyed, noticeable appetite and weight loss (or gain), fatigue, lack of energy, difficulty sleeping or increased need for sleep, trouble concentrating, and thoughts of death and dying.

These phases may last anywhere from days to months, with relatively symptom-free periods in between. In some cases they may occur simultaneously (mixed episode) or in rapid succession (rapid cycling). Also, there is a milder form, called Bipolar II, where the manic phase is more muted (hypomania). Not everyone with this disorder experiences clearly defined phases, which makes it a difficult disorder to diagnose: in fact, the average length of time between first symptoms and diagnosis is eight years!

Bipolar disorder is generally treated with a combination of medication and psychotherapy. Typical medications include Lithium to stabilize moods, plus an anti-depressant like Prozac and/or anti-anxiety medication like Ativan. An anti-psychotic like Zyprexa may be prescribed when grandiose or delusional thinking is part of the manic phase. Brief hospitalization may be necessary to stabilize someone on medication, especially if there is self-injurious behavior.

Because the impact of this disorder on both moods and behavior can be extreme, even life-threatening (think Barret Robbins), it’s important to get an accurate diagnosis and the right medication regimen. But some people have strong feelings about taking medication and don’t take it even when it would clearly help. I have clients who struggle with this dilemma.

Certain individuals who have a strong social support network, including a psychotherapist, may be able to get along for periods without medication, by careful adherance to daily routines, and maintaining a healthy lifestyle. For example, it’s critical to stick to a regular sleep schedule, not skipping meals and avoiding alcohol and non-prescribed drugs. Keeping a chart of mood cycles can help to identify early warning signs of mania or depression.

To learn more, I recommend reading “The Bipolar Disorder Survival Guide” by David J. Miklowitz, or go to the Depression and Bipolar Support Alliance’s website (www.dbsalliance.org) for information and a list of local meetings.

WINTER BLUES (January 2006)

When the days get shorter does your energy sag? Does the stormy weather bring on dark moods? Do you crave sweets and starchy food more, or just want to stay in bed during the winter months? If you tend to feel tired and blue at this time of year, you may have Seasonal Affective Disorder, or SAD.

It’s normal to feel a little low once the frenzy of holiday activities is over (and the credit card bills begin to arrive); but SAD is more than just a post-holiday letdown. People with this disorder experience true symptoms of depression, such as: a change in appetite, a drop in energy level, fatigue, a desire to sleep more than usual, irritability, and/or avoidance of social situations.

SAD is caused by the body’s reaction to seasonal changes in the amount of available sunlight, therefore these symptoms tend to intensify during the winter months and disappear in spring, and they reoccur at about the same time every year, unlike other forms of depression.

While the primary cause of SAD seems to be lack of sunlight, there may be other factors, such as the effect of spending more time indoors in dry, overheated environments, lack of exercise, or the increase in mold and mildew that occurs in damp, rainy weather. SAD is more common in northern areas than in California, where we usually are blessed with plenty of sunshine.

The best treatment for SAD is exposure to natural sunlight, preferably first thing in the morning, for 15 minutes to an hour a day. If it’s dark outside when you go to work, and dark again by the time you get home, then you might try to take a “sunshine” break during the middle of the day. Go for a short walk, or sit in the sun to eat your lunch. It’s most beneficial for sunlight to indirectly enter your eyes, so you can stay bundled up if it’s cold, but remove the dark glasses, though of course you never want to look directly into the sun.

If you have severe seasonal affective disorder, try light therapy. Light therapy has been in use since the 1980s, and is now considered the standard treatment for SAD. It involves sitting in front of a special “light box” that is constructed of high intensity flourescent bulbs covered with a plastic screen that blocks out harmful ultraviolet (UV) rays. The light box can be set on a table or desk, and you sit in front of it with your eyes open, but not staring directly into it. Most people find they can read, watch TV, or use their computer while using their light box.

Simply sitting in front of a lamp in your living room won’t do the trick. Indoor lights don’t provide the type or intensity of light that’s necessary to treat SAD. There are several kinds of light boxes available on the market, as well as other products that claim to treat seasonal affective disorder, but not all of them are effective, so it’s best to get a recommendation from a physician or mental health professional who is knowledgeable in treating depression.

Light boxes don’t work for everyone; sometimes anti-depressant medication is more effective. Other things that can help include dietary changes (reducing intake of carbohydrates, especially sugars, and increasing protein); physical exercise, even for only 15-20 minutes a day; and supportive psychotherapy. For more information on SAD, contact the National Mental Health Information Center at (800) 789-2647 or go to www.mentalhealth.samhsa.gov , or call me!


ATTENTION DEFICIT DISORDER IN ADULTS (June 2005)

Are you easily distracted? Do you tune out in meetings? Are you disorganized? Do you procrastinate, or have trouble finishing projects? When you read, do you often have to reread a paragraph or entire page because you were daydreaming? Are you drawn to high intensity situations? Do you have a hard time relaxing? Do you tend to say or do the first thing that comes to mind, without considering the consequences?

I see many adults in my practice who answer “yes” to these questions, and are surprised to learn that they may have Attention Deficit Disorder. ADD, or ADHD (the H is for hyperactivity) used to be thought of as a childhood disorder that was outgrown, however we now know that at least two thirds of children who have ADD/ADHD will continue to have it into adulthood. Some of my clients were told they had it as a child, but others made it to adulthood without understanding why they couldn’t concentrate on schoolwork or were always in trouble for blurting out the wrong thing or doing something dangerous.

People with undiagnosed ADD/ADHD are often misunderstood and get labeled as disorganized, daydreamers, procrastinators, underachievers, “hyper”, lazy or stupid – while the reality is that they are often highly intelligent, creative and talented individuals who just can’t get all of their mental ducks in a row (and swimming in the same direction at the same time!) for long enough to get anything done.

Actually, ADD is a misnomer – what these individuals have is not a “deficit” of attention per se, but rather an inability to regulate attention properly: while they are easily distracted much of the time, at other times they demonstrate powers of concentration that are laser-beam intense. ADD’s chief characteristics are distractibility, impulsivity and hyperactivity. Not everyone has the hyperactivity, however – some just have a hyperactive mind, without the restless or impulsive behavior.

ADD/ADHD tends to run in families, which is evidence for a genetic pre-disposition. It also seems to be associated with depression, anxiety, or bipolar disorder. Substance abuse can be a problem, as individuals with this disorder often self-medicate, either with alcohol to help them relax, or with stimulant drugs like cocaine or methamphetamine, which have the paradoxical effect of calming their hyperactivity - in the same way that Ritalin, a prescription stimulant, helps children with ADHD.

While medication can help, the best treatments for adult ADD/ADHD involve some kind of counseling or coaching to learn to manage the distractibility and impulsivity. If you think you may have ADD, or would like to learn more about it, an excellent book on the subject is “Driven to Distraction” by Hallowell and Ratey (two psychiatrists who have ADD). You can also go to www.add.org, the website for the Attention Deficit Disorder Association, which focuses on support and resources for adults with ADD/ADHD.


ANXIETY AND PANIC ATTACKS (October 2004)

October is the month I have come to associate with anxiety. At 5:04 p.m. on October 17, 1989, I was on the Bay Bridge during the Loma Prieta earth-quake, stopped less than a mile from where the bridge broke; and on October 20, 1991, the Oakland Hills firestorm came within a mile of my home. For months after the earthquake, I was nervous every time I had to cross the bridge; and to this day I get anxious when those hot, dry “Diablo winds” come blowing in from the east around this time of year.

I don’t worry that I’m going crazy at those times, because I know it’s perfectly normal to have some anxiety about things like earthquakes and fires. But I’ve also experienced severe anxiety that seemed to come “out of the blue”, which made me fear I was either going crazy or dying, until I learned that this is called an anxiety attack, or panic attack, and that it’s actually nothing to worry about!

An estimated 10% of the U.S. population suffer from panic attacks, phobias or other anxiety disorders each year. 35% of us will experience at least one panic attack in our lifetime, typically between the ages of 15 and 24, or in middle age (40 – 55).

A panic attack may start with a tightness in the throat or chest, a racing heart, and dizziness. Other symptoms may include sweating, shaking, hot flashes or chills, nausea, and tunnel vision. Because a panic attack can mimic a heart attack, it’s frightening, but before you call 911, take a deep breath – or several.

If you’re having trouble breathing, you might be hyperventilating, so try breathing into a paper bag, or splash ice water on your face. If you’re driving, pull over; if you’re indoors, try to get outside for some fresh air. Usually the physical symptoms of a panic attack will pass within a few minutes. But if your heart won’t stop racing, or you feel a sharp or intense pain in your chest, shoulder or neck, you should get to the ER just in case.

While it’s not always clear what causes panic attacks, anxiety disorders in general tend to run in families, and may indicate a more sensitive sympathetic nervous system. For some, it may be a result of years of accumulated stress; or it may be related to feeling no control over one’s life circumstances. Some people who develop panic attacks or an anxiety disorder in mid-life may be victims of childhood trauma which they had suppressed conscious memories of, only to have some ordinary event, like witnessing an accident while driving to work, serve as a trigger to a flood of anxious feelings.

The good news is anxiety and panic attacks can be effectively treated. Medications like Ativan or Xanax can provide immediate symptom relief; while the best long-term approach is a combination of learning to calm the body through deep breathing and relaxation exercises, along with calming the mind through cognitive therapies to help reduce the anxious thoughts and regain a feeling of being in control.

The following books are all excellent and available through New Harbinger Publications in Oakland (www.newharbinger.com):

• 10 Simple Solutions to Panic, by Martin Antony and Randi McCabe
• The Anxiety and Phobia Workbook, by Edmund J. Bourne
• Calming Your Anxious Mind, by Jeffrey Brantley

HOW TO RECOGNIZE DEPRESSIVE ILLNESS (January 2004)

1. A persistent sad, “empty”, or anxious mood
2. Decreased energy, fatigue, feeling “slowed down”
3. Sleep disturbance (insomnia, early-morning waking, or oversleeping)
4. Eating disturbance (loss of appetite or compulsive overeating)
5. Difficulty concentrating, remembering things, or making decisions
6. Loss of interest in ordinary activities, including sex
7. Feelings of hopelessness or pessimism
8. Chronic aches and pains that don’t respond to treatment
9. “Lashing out” at others, more irritable than usual
10. Excessive crying, or crying for no apparent reason
11. Feelings of guilt, worthlessness, helplessness
12. Thoughts of death or suicide, or suicide attempts

1. Heightened feelings of elation or irritability
2. Decreased need for sleep
3. Increased energy
4. Increased talking, moving, sexual activity
5. Racing thoughts
6. Disturbed decision-making ability
7. Grandiose notions
8. Being easily distracted

When four or more of these symptoms for depression or mania persist for more than two weeks, an accurate diagnosis and professional treatment should be sought.

The good news is that more than 80% of people with clinical depression can be treated successfully. The key is to recognize the symptoms early, and to receive appropriate treatment. Most depressed individuals respond best to a combination of medication and psychotherapy.

Resources for Dealing with Depression:

Because depression is such an energy-sapping illness, with life-threatening potential, I don't recommend trying to tackle it alone. Self-help books can encourage further isolation. But here are some of my favorite books on recognizing and dealing with depression:

• The Feeling Good Workbook, by Dr. David Burns
• For women:The Depression Workbook, by Mary Ellen Copeland
• For men:I Don't Want to Talk About It, by Terence Real