Happiness

 

Happiness

Dr Jonathan Haverkampf, M.D.

 

Happiness as an Emotion

Happiness is an emotion we often feel when we are engaged in something that is meaningful and valuable to us. When we are engaged in something that is meaningful, that contains the promise of something novel that can change us, we feel happiness. Whether solving a science problem, observing another person, having sex or talking to someone else, we are engaged in processes that produce new meaning, new information, and often a sense of happiness. Communication with oneself and others, the exchange of meaningful information, is ultimately what leads to more meaning and greater happiness.

 

Research into Happiness

Happiness in its broad sense is the label for a family of pleasant emotional states, such as joy, amusement, satisfaction, gratification, euphoria, and triumph. [1] For example, happiness comes from “encountering unexpected positive events”, [2] “seeing a significant other”, [3] and “basking in the acceptance and praise of others”. [4] More narrowly, it refers to experiential and evaluative well-being. Experiential well-being, or “objective happiness”, is happiness measured in the moment via questions such as “How good or bad is your experience now?”. In contrast, evaluative well-being asks questions such as “How good was your vacation?” and measures one’s subjective thoughts and feelings about happiness in the past. Experiential well-being is less prone to errors in reconstructive memory, but the majority of literature on happiness refers to evaluative well-being. The two measures of happiness can be related by heuristics such as the peak-end rule. [5]

 

Happiness is not solely derived from external, momentary pleasures. [6] Studies suggest that happiness is rather stable over time. [7][8] Happiness is partly genetically based. [9][10] Based on twin studies, 50 percent of a given human’s happiness level is genetically determined, 10 percent is affected by life circumstances and situation, and a remaining 40 percent of happiness is subject to self-control. [11]

The capacity for loving attachments and relationships, especially with parents, is the strongest predictor of well-being later in life. [13] Meditation has been found to lead to high activity in the brain’s left prefrontal cortex, which in turn has been found to correlate with happiness. [14] Money can increase happiness up to an annual income of roughly $60,000, beyond which it does not increase happiness significantly. “Beyond the point at which people have enough to comfortably feed, clothe, and house themselves, having more money – even a lot more money – makes them only a little bit happier.” [15] “Spending money on others actually makes us happier than spending it on ourselves”. [16]

There have been some studies of how religion relates to happiness. Causal relationships remain unclear, but more religion is seen in happier people. Religion may provide a sense of meaning and connection to something bigger, beyond the self. Religion may also provide community membership and hence relationships. Another component may have to do with ritual.

Maslow’s hierarchy of needs is a pyramid depicting the levels of human needs, psychological, and physical. When a human being ascends the steps of the pyramid, he reaches self-actualization. Beyond the routine of needs fulfilment, Maslow envisioned moments of extraordinary experience, known as peak experiences, profound moments of love, understanding, happiness, or rapture, during which a person feels more whole, alive, self-sufficient, and yet a part of the world. This is similar to the flow concept of Mihály Csíkszentmihályi. Self-determination theory relates intrinsic motivation to three needs: competence, autonomy, and relatedness.

 

Values, Wants and Needs

One’s values and basic interests determine what is valuable to oneself. Happiness requires that one engages in an activity that is meaningful and of value to oneself. Engaging in these activities and situations brings more positive emotions, happiness, and a greater sense of fulfilment in life. Wants and Needs that create greater happiness have to be in sync with one’s values.

 

The Call of Happiness

Almost everyone strives for happiness in life, and the pursuit of happiness is enshrined in the US constitution and many other important documents, but many people feel it is beyond their reach. Some may suffer from a mental health condition like depression, which reduces the amplitude of one’s felt emotions overall, including happiness, and may require treatment. A larger problem is possibly missing direction in life and decision-making, which often is a result of being disconnected from oneself. If one feels what is valuable and meaningful to oneself, this leads to actions and thoughts that generate greater happiness.

 

The Search for Things that Make Happy

Happiness begins with finding out what makes one happy. This does not have to be anything external. It can be things to think about or something interesting to read. It can also be meditation in silence. Many people feel the pressure from what they think the world expects of them. Simply internalizing external expectations will not bring happiness. My thoughts and actions have to make sense in relation to how I see myself and what I value. This self-image can be affected by mental health conditions like depression, but one’s basic values seldom are.

 

The Stability of the Self and One’s Values

Our values are mostly stable over time, but meaning depends on the information we exchange with our environment, which again depends on how we communicate with ourselves and others. One can be happy in solitude, but this happiness depends on how I communicate with myself and the non-human world around me and on my interactions with the world when I am with others. Most people do need companionship once in a while.

 

Connecting the Inside and the Outside

Happiness is when we are connected to the inside and outside world, when we can communicate freely with both. Fears prohibit us from getting in touch with ourselves and others to the extent that can bring about happiness. Happiness is when an organization strives to be optimally adapted to itself and the environment, when it is changed by it and can change it in beneficial ways. This does not require great activity for humans. Even sitting in one’s chair at home can bring about happiness, when we feel ourselves and the world around us. Everything contains information, a tree and even a stone. Humans on the other hand are great information processing systems and we send and receive information all the time. Happiness as an emotion is also a consequence of how we process information, of how we think, which is one reason why we need to take stock of how we process information on the inside (think) and how we process information on the outside (interact with others). Happiness thus depends to a great extent on how we arrange our surroundings and ourselves in these surroundings.

 

Values and Meaning lead to Greater Happiness

Focusing on one’s values and finding meaning in things leads to greater happiness. This does not have to be time consuming. It just requires doing what feels important, which can be a radically new way of doing things.

 

 

 

References

 

[1] Algoe, Sara B.; Haidt, Jonathan (2009). “Witnessing excellence in action: the ‘other-praising’ emotions of elevation, gratitude, and admiration”. The Journal of Positive Psychology. 4 (2): 105–27. doi:10.1080/17439760802650519. PMC 2689844. PMID 19495425.

[2] Cosmides, Leda; Tooby, John (2000). “Evolutionary Psychology and the Emotions”. In Lewis, Michael; Haviland-Jones, Jeannette M. Handbook of emotions (2 ed.). New York [u.a.]: Guilford Press. ISBN 978-1572305298.

[3] Lewis, Michael. “Self-Conscious emotions”. In Barrett, Lisa Feldman; Lewis, Michael; Haviland-Jones, Jeannette M. Handbook of Emotions (Fourth ed.). Guilford Publications. p. 793. ISBN 9781462525362. Retrieved 1 April 2017.

[4] Marano, Hara Estroff (1 November 1995). “At Last—a Rejection Detector!”. Psychology Today. Retrieved 1 April 2017.

[5] Kahneman, Daniel; Riis, Jason (2005). “Living, and thinking about it: two perspectives on life” (PDF). In Huppert, Felicia A; Baylis, Nick; Keverne, Barry. The science of well-being. Oxford; New York: Oxford University Press. doi:10.1093/acprof:oso/9780198567523.003.0011. ISBN 9780198567523.

[6] Seligman, Martin E. P. (2004). “Can happiness be taught?”. Daedalus. 133 (2): 80–87. doi:10.1162/001152604323049424. JSTOR 20027916.

[7] Baumeister, Roy F.; Vohs, Kathleen D.; Aaker, Jennifer L.; Garbinsky, Emily N. (November 2013). “Some key differences between a happy life and a meaningful life”. The Journal of Positive Psychology. 8 (6): 505–516. doi:10.1080/17439760.2013.830764.

[8] Costa, Paul T.; McCrae, Robert R.; Zonderman, Alan B. (August 1987). “Environmental and dispositional influences on well-being: Longitudinal follow-up of an American national sample”. British Journal of Psychology. 78 (3): 299–306. doi:10.1111/j.2044-8295.1987.tb02248.x.

[9] Okbay, Aysu; et al. (18 April 2016). “Genetic variants associated with subjective well-being, depressive symptoms, and neuroticism identified through genome-wide analyses”. Nature Genetics. 48 (6): 624–633. doi:10.1038/ng.3552.

[10] Bartels, Meike (1 January 2015). “Genetics of Wellbeing and Its Components Satisfaction with Life, Happiness, and Quality of Life: A Review and Meta-analysis of Heritability Studies”. Behavior Genetics. 45 (2): 137–156. doi:10.1007/s10519-015-9713-y. ISSN 0001-8244.

[11] Lyubomirsky, Sonja (2008). The How of Happiness: a new approach to getting the life you want. New York: Penguin Books. p. 56. ISBN 978-0143114956.

[12] Seligman, Martin E. P. Flourish: A Visionary New Understanding of Happiness and Well-being. Simon and Schuster. p. 16. ISBN 9781439190760.

[13] Vaillant, George E. Triumphs of Experience. Harvard University Press. p. 191. ISBN 9780674067424.

[14] Claire Bates (2012-10-31). “Is this the world’s happiest man? Brain scans reveal French monk found to have ‘abnormally large capacity’ for joy, and it could be down to meditation”. Mail Online.

[15] Bennett, Drake (23 August 2009). “Happiness: A buyer’s guide”. The Boston Globe. Retrieved 1 April 2017.

[16] Dunn, E. W.; Aknin, L. B.; Norton, M. I. (2008). “Spending Money on Others Promotes Happiness”. Science. 319 (5870): 1687–88. Bibcode:2008Sci…319.1687D. doi:10.1126/science.1150952. PMID 18356530.

 

 

 

Dr Jonathan Haverkampf, M.D. trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. The author can be reached by email at jonathanhaverkampf@gmail.com or on the websites www.jonathanhaverkampf.com and www.jonathanhaverkampf.ie.

This article is solely a basis for academic discussion and no medical advice can be given in this article, nor should anything herein be construed as advice. Always consult a professional if you believe you might suffer from a physical or mental health condition. Trademarks belong to their respective owners. No checks have been made.

 

Adjustmennt Disorder

 

Adjustment Disorder

Dr Jonathan Haverkampf, M.D.

  

New circumstances

When a relationship breaks apart, a loved one dies or a job is lost, but also in happy circumstances, such as winning the lottery, people need to adjust to the new circumstances, which may temporarily, and sometimes even in the long run, lead to psychiatric symptoms. The important characteristic of the new circumstances is that they appear relevant to the individual and that the world has become more uncertain. Usually, this means also that one is faced with finding out more about oneself and one’s values, in order to get a sense of direction again in a changed world.

 

Symptoms

Common symptoms of an adjustment disorder are light to moderate depression, various degrees of anxiety or traumatic stress, or a combination of these. There are several different flavours of adjustment disorders, but they all have in common that the person feels out of sync with oneself and experiences a heightened state of anxiety or depression because the sense of safety and certainty in the world has declined.

 

Values and Interests

The perceived enormity of the change depends on one’s values. Winning the lottery changes the world for someone who values material possessions highly more than that of a Trappist monk. One common observation is that those for whom a particular change is more difficult to process are those with poorly defined value systems, who only have tenuous contact with what they feel is important in their lives. If a change happens, it adds further instability to an already unstable system. The result is anxiety, a state of fear of the unknown and the uncertain. Working patients on their interests, values and aspirations is especially important in cases of adjustment disorder.

 

Loss of Direction

The sense of loss of direction is visible in the typical patient with adjustment disorder: He or she is rather young, has more identified psychosocial and environmental problems and has undergone shorter or no treatment, especially not psychodynamic treatment. However, it can affect people of all ages and from all walks of life. The basic requirement seems to be that the change is outside the reach of their usual coping mechanisms. If someone already has very narrow, rigid or fragile coping mechanisms with little flexibility, they are likely to break down earlier and expose the person to the anxiety of uncertainty and insecurity.

 

Culture

We live in a world where changes in one’s individual situation are the norm rather than the exception. Many cultures and societies have adapted to this by internalizing change (‘change is good’). The more this springs from their basic values and beliefs, the better it works. In this sense, a social group is not very different from an individual. The more one is in contact with one’s fundamental values, the less change will affect the person. This is also an important principle in dealing with anxiety and making oneself more resilient to adjustment difficulties.

Meaning defines the information that can bring about change, while value provides a direction for decision-making. Fundamental values are very stable and there is probably a rudimentary biological program for us to have them. Many derivative values are probably formed in childhood.

 

Security versus Certainty

If one’s world has changed in a fundamental aspect, the sense of certainty and predictability is affected. However, there is a difference between security and certainty. I can face uncertain times but still feel secure. As long as I know I have a system in place to make decisions that are good for me, I can feel quite secure even if I do not know which decisions I will have to take. The more flexible we are in our perspectives and our outlook on the world the less likely we are to have problems with adjustment in a changing world. But this requires knowing there is a good and solid decision-making system, which is where one’s values, interests and aspirations come into play.

What helps in times of change is to focus on the things that remain constant, our values and interests, our sense of self and who we are. Having a stable sense of self helps in the face of sudden change, whether positive or negative change. Winning the lottery has ripped many from their comfortable paths and actually left them worse off psychologically and financially in the long- and even medium-term.

 

Finding Stability

So, what are these stable components and how can one learn about them? You know what you are interested in because doing it feels god over the long run. Your values are what you get emotional about when they are touched in some way.

 

State of Confusion

Our internal and external communication points us to our values by exposing us to messages that resonate or do not. Something may be meaningful to us but does not resonate with our values and interests, which makes the message less relevant. Adjustment disorder often represents a state of confusion. The reason is that if one is not sure about one’s values everything can potentially be of value. The result is an urge to respond to everything and take on stressful tasks in the hope that one will be the ‘right’ one, which results in procrastination or burnout and not doing things which are congruous with one’s values.

If you find it difficult to feel anything about something, it may not be relevant to you.  You learn about what may be irrelevant to you and your happiness by communicating openly with yourself and reflecting. Many people have gotten out of touch with themselves because they think they have to adapt their values and interests to what they believe is expected in society. But values do not change much over time, if at all, because they are too closely linked with who we are and our sense of self. When we do things that are congruous with them we feel ourselves more and are happier.

 

Self-Confidence

Self-confidence is about doing things one enjoys. Feeling good is a prerequisite for building self-confidence because it attaches good feelings to what you do and think, and thereby also to yourself. Lasting and stable self-confidence requires activities that are congruous with oneself, but it is very effective as a defence against various kinds of adjustment disorders. Self-confidence is built by better communicating with oneself and others, learning about one’s own values and having a profound interest in people. It does not mean having to be an extrovert but adopting a habit of observation and reflection.

 

Coping Strategies

Coping mechanisms are the strategies we use to deal with the emotional consequences of stressors. This means the more experience one has with dealing with changing situations in life the better one may cope with them. Children are thus more likely to suffer from an adjustment disorder in the same situation as an adult, if the changes are not outside usual human experience, such as rape or serious violence. We learn these tools in our interactions with other people. Thus, social skills and the ability to communicate helps one deal with adjustment problems. Another advantage is that communication helps one to respond more flexibly to react to changing life situations.

 

Trauma

Trauma in the past, especially if they have occurred repeatedly, can increase the risk of adjustment problems. One reason might be that traumata leave more vulnerable coping and defense systems, another that traumata lead to greater rigidity from the experience of a not only hurtful but also unpredictable world. If one’s value system, which gives a sense of stability to the self, is seriously compromised or damaged, this can lead to a variety of self-defeating behaviors. The goal is to reconnect the patient with his or her true values in a therapeutic interaction that affects the internal communication in the patient.

 

Sustained Change

Individuals need to have a sense that their changed circumstances can be reconciled with their values and interests. This requires finding out more about oneself and then adopting strategies to find a suitable connection between the outside and the inside world.

 

 

Dr Jonathan Haverkampf, M.D. trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. The author can be reached by email at jonathanhaverkampf@gmail.com or on the websites www.jonathanhaverkampf.com and www.jonathanhaverkampf.ie.

This article is solely a basis for academic discussion and no medical advice can be given in this article, nor should anything herein be construed as advice. Always consult a professional if you believe you might suffer from a physical or mental health condition. Trademarks belong to their respective owners. No checks have been made.

 

No More Stress

No More Stress (2) Ch Jonathan Haverkampf 

 

No More Stress

Dr Jonathan Haverkampf

 

A Feeling

Stress is a feeling. It is a signal that forces are applied to the organism which are greater than what the organism is usually accustomed to. Over the long-run the forces exerting stress can lead to the breakdown of healthy physical and mental mechanisms. But they can also lead to a strengthening of the organism. Much depends on whether the organism needs to change in a direction that is suitable for the organism, or whether it does not. In human parlance, ‘suitable to the organism’ means that one sees meaning in one’s actions, one’s job, one’s relationship and one’s goals, that they are in sync with one’s values and fundamental interests. If I spend a lot of resources on something I do not value, I will feel stress.

 

Good versus Bad Stress

There are many different kinds of stress and a general distinction is between ‘good’ (positive) and ‘bad’ (negative) stress. Which kind of stress we are faced with is contained within the feeling. Unfortunately, one actually has to be attentive to the information the feeling of stress contains. Many people say they are ‘stressed’ without looking at more closely what is encapsulated within this feeling. If they did that, they would see what is out of sync, and begin thinking about ways to become better connected with oneself and do the things one really values.

 

The feeling is individual and subjective

When we say that we are under a lot of stress, what we really mean is that we are in a situation where we experience this feeling of stress. People can perceive vastly different situations as stressful. Since it is a feeling it depends on how one as an individual perceives the world and processes this information, which in turn depends on one’s biological endowment, social environment and mental processes. Imagination, self-confidence and self-confidence play a role, as well as one’s values, interests and aspirations. But most importantly it depends on how we communicate with ourselves and others.

 

A Result of Various Emotions

Stress is a result of various other emotions, such as anger, hurt, loneliness or loss, that drive us to do engage in certain behaviours and communicate in a certain way with ourselves and our environment.

 

A Loss of Flexibility

Stress often causes a narrowing of one’s perspective as flexibility and openness are decreased. The focus is increasingly on accomplishing narrowly defined objectives in life. If these objectives are not congruent with one’s basic values, interests and aspirations, one’s actions lack meaning, which often results in negative stress. Change is no longer constructive, but leads one away from the desirable goals in life.

 

‘Must’ versus ‘Want’

If tasks on the job or relationship activities are just performed because they ‘must’, they can over time lead to the negative kind of stress. So, the first step of doing something about stress requires finding out what various activities mean to you. This involves shedding some light on one’s values and interests, which in practice shows to be a very effective approach against stress. This is often not easy, often out of a fear of the necessity for a sudden change to one’s direction in life. Instead the process often needs to be more gradual, making changes in little steps with a view to change in the medium- to long-un. Knowing about one’s values, interests and aspirations at the least helps improve decision-making in the long-run. Once our compass works, we are less likely to get caught up in irrelevant things.

 

Indecisiveness

Indecisiveness in itself can be very stressful. As long as one is uncommitted there are still a number of options that need to be kept ‘open’, which requires additional effort and information. Taking decisions and assuming responsibility for these decisions is usually effective in reducing stress. If a decision needs to be modified later, often there is the option to modify the course of events later. Usually, we do not have all the information we would like to have before we make a decision, especially if the outcome depends on other people’s reactions and unknown future events. All one can do is to collect a reasonable amount of information and decide in a practical way. Accepting this means that one cannot blame oneself for a ‘wrong’ decision. One tried one’s best at the moment the decision was made, based on the information that was available at the time. People usually try to act in their best interest, which also includes the welfare of others. If others do not feel good, we do not feel good.

 

Discovering one’s values and fundamental interests

Making better decisions in the face of stress also requires the information, that is unlikely to change much over time, one’s fundamental values and interests. If I make a decision with these in mind I am unlikely to consider my decision ‘bad’ in the future, even if it turns out some facts were different. Doing things with one’s fundamental values, interests and aspirations in mind reduces stress. On the other hand, if a path does not sync with one’s core values, it will not be a happy journey.

 

Improving Communication

Stress can also be a result of problems communicating with the world around. Oftentimes people have difficulties telling others about how they see things or what they want, whether out of fear that they lose a job or relationship or hurt someone. However, the result often is that vital information does not get shared and the stress on oneself, the job or relationship gets even worse. Sometimes there might be a valid reason not to share and to withhold information, but such instances are very rare. Communication generates feedback, and this information can be helpful in getting a situation resolved.

 

Living by one’s values and fundamental interests to reduce stress

I have lined out in my other work on how to best explore one’s values. The deep values are the most important ones, on top of which derivative values can be build. For example, financial fortune is usually not an end in itself, but a means to satisfy needs. Pursuing financial gain without knowing why and what for leads to stress, because there is potentially no end to it, and one accumulates the means to satisfy a need, but ultimately never satisfies it.

 

Happiness

Money buys goods and services. Some want security, others a house for their family, and again others the ability to create something in the world. In the second case, for example, it is not the money but having a family which is the deeper value. Knowing this makes it easier to stay on course, take pride in one’s achievements and be happier. The deeper values tend to be more stable than the more derivative ones, which are more likely to depend on the situation one is in. Feeling safe, also financially, or being seeing as someone who is caring may be deeper values, getting a plaque for being the employee of the month is a more derivative one. To eliminate stress, it is important to identify the deeper values and to find the most efficient and rewarding ways to pursue them. This increases happiness, because if we pursue what we value we are happier.

 

Dr Jonathan Haverkampf, M.D. trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. The author can be reached by email at jonathanhaverkampf@gmail.com or on the websites www.jonathanhaverkampf.com and www.jonathanhaverkampf.ie.

This article is solely a basis for academic discussion and no medical advice can be given in this article, nor should anything herein be construed as advice. Always consult a professional if you believe you might suffer from a physical or mental health condition. Trademarks belong to their respective owners. No checks have been made.

 

Shyness

 

Shyness

Dr Jonathan Haverkampf, M.D.

 

The world as one sees it

Shyness itself is not a medical condition. It is a subjective perception, which is triggered by a complex set of emotions. One actually has to see oneself as being shy. If an individual does not perceive oneself as shy, then there is no shyness. This may sound counterintuitive, but even if one is very introverted and prefers to spend all day reading a book, one does not have to experience shyness. It depends on where one sees oneself in a social context. Only if one’s expectations are different from present reality, one may experience negative emotions, which may lead to a sense of shyness.

 

Shyness is not social anxiety

Social anxiety, unlike shyness, is a psychiatric diagnosis and it is present if certain criteria are met.

 

Manifestations of shyness

Shyness means feeling apprehension and discomfort around other people. Quite frequently, there is concern about what other people think about oneself. Minor details of one’s outward appearance, voice or behavior are focused on repeatedly. This constant analyzing of other people’s opinions and thoughts about oneself is often associated with low self-esteem, depressed thoughts, anxiety and setting high standards for oneself. One becomes very self-conscious in the presence of other people rather than being really self-aware. One’s own unrealistic expectations about the outcome of a situation may make it even more difficult. It is quite often the fact that shy people often expect too much rather than two little in social settings. Romantic Hollywood movies with love on first sight or rousing boardroom speeches that completely turn the destiny of a company are not what usually happens in the real world. Most social interactions are much more mundane, which does not make them less important. To see this can be quite liberating to a shy person.

 

Unfamiliar situations

Shyness is most likely to occur during unfamiliar situations, although not always. Unfortunately, situations remain unfamiliar if shy people avoid them. Shyness may fade with time, but avoiding unfamiliar situations. Usually shy individuals want contact to other people and relationships, which makes them struggle against shyness. However, this often makes the problem worse. By focusing on shyness as a problem within oneself self-esteem and self-confidence can further be lowered.

 

Social Skills

Developing social skills may help, but it may not take care of the underlying problems. Especially if there is low self-esteem, there is a risk the newly learned social skills merely cover up a problem further down below. This can have a negative effect on one’s self-esteem and self-confidence in the long-run because deeper down the individual does not believe the image he/she is projecting into the world.

Learning communication skills can be helpful in giving shy individuals more confidence. Behavioral traits in social situations such as smiling, easily producing suitable conversational topics, assuming a relaxed posture and making good eye contact, may not be second nature for a shy person. It may also be worthwhile to explore other communication channels. The internet, for example, has helped shy people become more active in a dating environment. Exchanging a number of messages and photos first, makes the other person less unknown, which helps the shy person be less intimidated and self-conscious.

Communication training can improve the situation as the individual learns to more easily interact with others and receive valuable feedback in return. Focusing on an exploration of one’s values, interests and aspirations can facilitate communication by raising one’s confidence in talking about certain issues. If one sees meaning and value in a topic, it is far easier to converse about it.

 

Predisposition for Shyness

There is some evidence for a genetic predisposition for shyness. Some research has indicated that shyness and aggression are related—through long and short forms of the gene DRD4, but this is merely a working hypothesis. Further, it has been suggested that shyness is related to obsessive-compulsive disorder. However, because of the numbers of factors involved and the difficulties in linking a basic cell mechanism to a group of thoughts and behaviors, this remains speculative.

A long form of the serotonin transporter promoter region polymorphism (5-HTTLPR) seems to be somewhat correlated with shyness in grade school children. [1] Interestingly, a connection between this form of the gene and both obsessive-compulsive disorder and autism has been shown in previous studies. [2] The dopamine D4 receptor gene (DRD4) exon III polymorphism, had been the subject of studies in shyness and aggression and “novelty seeking” traits.

 

Medication

Substances from the class of antidepressants known as selective serotonin reuptake inhibitors (SSRIs) can be used to treat shyness in individuals who feel inhibited in their daily life because of low self-esteem and psychological symptoms, such as depression or loneliness. They can often be a valued support in combination with psychotherapy. As the individual can better communicate with his or her environment they may no longer be needed after a while. They are generally viewed as non-addictive and can be discontinued relative easily, but to solidify and maintain any positive changes they should be taken for at least a year, and especially in cases of social anxiety longer, if they are well tolerated.

 

Psychotherapy

Psychotherapy can help uncover some of the conflicts and emotions underlying the anxiety and fears in the presence of unknown others. Often there are issues from one’s personal history that add difficulties and fears. If they are dealt with, the shyness can become much less or even disappear. Imagining situations and developing a good communication skill set can go a long way. Ultimately, the explorations of one’s values, interests and aspirations can relieve stress, psychological pressure and help one avoid situations that are more harmful than beneficial, such as unwanted relationship constellations or work situations that lack meaning. (Re)establishing a sense of the inner compass can work miracles in cases of shyness.

According to research, early intervention methods that expose shy children to social interactions involving teamwork, especially team sports, decrease their anxiety in social interactions and increase their self-confidence later on. One possible reason is that a greater set of skills in communicating information, such as emotions and needs, to other people, allows for more variation and better adaptation to different communication situations and environments.

 

Being Oneself

Shyness can seem to be a part of one’s personality. The difference between this and anxiety is fluid. The important question is whether we are really dealing with shyness or heightened sensitivity and insight, which can also be central to creativity. The key is to find out what the person values and finds important and how the individual can lead a more fulfilling and happier life, which frequently resolves the subjective problems with shyness in the process.

 

References

 

[1] Arbelle, Shoshana; Benjamin, Jonathan; Golin, Moshe; Kremer, Ilana; Belmaker, Robert H.; Ebstein, Richard P. (April 2003). “Relation of shyness in grade school children to the genotype for the long form of the serotonin transporter promoter region polymorphism”. American Journal of Psychiatry. 160 (4): 671–676. doi:10.1176/appi.ajp.160.4.671.PMID 12668354.

[2] Brune, CW; Kim, SJ; Salt, J; Leventhal, BL; Lord, C; Cook Jr, EH (2006). “5-HTTLPR Genotype-Specific Phenotype in Children and Adolescents with Autism”. The American Journal of Psychiatry. 163 (12): 2148–56. doi:10.1176/appi.ajp.163.12.2148. PMID 17151167.

 

 

Dr Jonathan Haverkampf, M.D. trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. The author can be reached by email at jonathanhaverkampf@gmail.com or on the websites www.jonathanhaverkampf.com and www.jonathanhaverkampf.ie.

This article is solely a basis for academic discussion and no medical advice can be given in this article, nor should anything herein be construed as advice. Always consult a professional if you believe you might suffer from a physical or mental health condition. Trademarks belong to their respective owners. No checks have been made.

 

Facing Your Fears

Face Your Fears (2)

 

Facing Your Fearsbv

Dr Jonathan Haverkampf, M.D.

 

Facing one’s fears means acting, even if one feels anxious or fearful, to ultimately reduce fears that are a hindrance. These are fears that do not benefit or protect us, but interfere with our lived in a detrimental way.

Reasonable vs Unreasonable Fears

Our mind may tell us that a fear of tall buildings is unnecessary, but our emotions tell us otherwise. Some of these fears may be linked with experiences from one’s own past, others with innate programs in our brain. Emotions have an evolutionary function to guarantee our survival by providing simple signals to induce action or stop an action. However, the brain circuits leading to fear, for example, are partly hardwired for specific information. A fear of heights on top of a tall building makes sense, because tall buildings have only been around for a fraction of human history. In earlier times, standing close to a precipice on a tall cliff or mountain was indeed a dangerous affair.

Change

The brain processes information, and fortunately we can consciously select information and teach our brain new ways of dealing with information. But this requires taking a close look at our basic values and fundamental interests, which ultimately drive any change. If you feel that something is important to you, you are more likely to spend energy on figuring out a way to effect a change. Knowing why doing something is valuable and important to oneself is an important force in doing something even if one is fearful (as long as there is no real threat of harm from the activity).

In many cases, however, feeling pressure to go through with a feared activity can be counterproductive. As the need to take the elevator, for example, increases, the fear increases as well. The problem is that the activity is seen as a ‘need’ dictated by the outside world. Overcoming a fear should come from an internal need, the fulfilment of a basic value or fundamental interest.

Thoughts and Emotions

The thoughts and emotions we perceive arise in one interconnected system of nerve cells (neurons) and they are messages representing a set of information flowing from one location in the brain to another. If we do something, it should make sense but also feel good. Emotions are not as accessible to rationality because we are not conscious of the large amount of information that goes into them, a process that happens largely in our subconscious.

It is only worth facing one’s fears where an action makes sense in the context of one’s values and aspirations. This means using one’s thoughts and feelings to find those things which make one happy and are enjoyable, as well as being in sync with one’s values. This is a first important step in breaking down fears and developing the motivation and initiative to overcome them.

Communication and Fear

How we communicate with others has an influence of the fears we are experiencing. Meaningful helpful communication can reduce fears, if delivered with empathy and understanding, while negative communication or a lack of communication can increase fears. When we face those fears, communicating with someone else or others can be helpful in overcoming the fears.

Building the Motivation to Overcome One’s Fears

Reconnecting with ourselves should allow us to identify our value and aspirations which can be very effective in building the motivation to overcome fears and even to reduce them. Doing something we feel strongly about might not reduce the nervousness we feel, but it can lower the amount of fear or even transform it into excitement. It is easier to overcome one’s fears if one knows why this is beneficial to oneself and others.

Information Overload

In the complex world we live in our brains can get overloaded with information, a situation that in itself can cause fears. So, an important first step is to untangle the web of complexity by picking out the information that is important to us. Being selective requires knowing what one wants and what one is looking for. This is why getting in touch with one’s values can be so important. They tell us what is important to us and what we should be looking for. Openness is important to find new interests, make better decisions, formulate new plans and aspire to even greater things, but if we do things that are not in sync with our core sense of ourselves as person and our basic values[1], there will be little happiness in these activities.

Humans often spend too much resources on information that is not relevant to them or where they cannot change anything. If you cannot change an issue, there is not much sense in wasting mental or physical resources on it. In such a situation, it is more important to deal with your emotions, be they fears, sadness or anger. One way is to find a way to communicate them in a meaningful way. Communicating an emotion helps to resolve it. This could be in the form of talking about it, writing about it, or even making a movie about it.

Selecting Information

The way we select, process and manage information is important in alleviating fears. You may be anxious of something or of a situation, but maybe one reason is that you do not have enough information about it. We live in a world where information is very readily available, so informing oneself is often not that difficult. And if you do not find answers to a question you have, consider if you are asking the right question, one that is helpful to you.

Often, we ask questions that do not really provide us direction or useful answers, so we get lost in ruminations and endless spirals of meaningless thought cascades. Try to split up a question, and see if you might not get at least partial answers to the component that is relevant, while leaving the irrelevant part unanswered.

Any information is helpful if it helps one live according to one’s values and basic interests. Life is going along a path. You cannot know the entire path until you have lived your life, but your values provide a good compass and they help dispel fear whenever it pops up along the way.

Generalisation

Quite often fears generalize in what is called a ‘generalised anxiety’. This can lead to a general fear of life itself. Here it is important to determine which emotions and specific fears are underlying the generalised anxiety.

You may identify something that triggered the anxiety, but the reasons for it can go back a long time. Dealing with some of the underlying issues may require identifying your values and interests. You want to cut down on thoughts and fears that are irrelevant to you, and focus constructively on the issue that are relevant to you by finding helpful information.

Generalised anxiety occurs often when people feel they have to fix something or find answers or make decisions, when they do not know where to look for them, or even where to start. Take a step back, see the situations for what it is with its relevant and irrelevant components, and measure your options against what you truly need and want. Much in life is noise and irrelevant to one’s path.

Communication to Counter Fear

It helps to be in contact with someone else to make the fears manageable. Facing fears with another may make it easier to deal with your fears and anxieties because you know you do not have to face them alone. When you talk to your neighbour on an airplane, for example, you might not even notice the take-off, and the brief interaction with the stranger reduces the emotional pressure on the inside.

Dr Jonathan Haverkampf, M.D. MLA (Harvard) LL.M. trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. The author can be reached by email at jonathanhaverkampf@gmail.com or on the websites www.jonathanhaverkampf.com and www.jonathanhaverkampf.ie.

This article is solely a basis for academic discussion and no medical advice can be given in this article, nor should anything herein be construed as advice. Always consult a professional if you believe you might suffer from a physical or mental health condition. Trademarks belong to their respective owners. No checks have been made.

© 2012-2017 Christian Jonathan Haverkampf. All Rights Reserved.

[1] One’s sense of self, one’s personality and one’s values usually change little over one’s life span, except for exposure to extreme, and especially traumatic, experiences.

Sleep Disorders and Medication

 

 Sleep Disorders and Medication (2)

 

Sleep Disorders and Medication

Dr Jonathan Haverkampf, M.D.

 

Sleep problems affect many people. Especially in our complex and fast paced world remaining thoughts or emotions from the day can occupy us at night. Dealing with stress effectively, such as prioritizing the activities in one’s life in line with one’s values and interests, can improve sleep considerably. The mental health diagnostic manual DSM-IV defines insomnia as difficulty initiating sleep or maintaining sleep.

Several mental health conditions can also cause sleeplessness. Major depression, PTSD, trauma, anxiety, bipolar disorders, psychosis and many more can cause insomnia. Many organic diseases can also cause insomnia, as can sleep apnea and chronic pain syndromes. In some cases, where no other reason can be found, an idiopathic insomnia may itself be a mental health problem.

The first step is to identify whether there is a sleep problem that requires treatment. People who sleep seven to eight hours usually do not have a problem with lack of sleep. In the case of paradoxical insomnia, although one believes to have a sleep problem, electrophysiological measurements show no sign of a sleep disturbance.

The second step is to identify if there is inadequate sleep hygiene. If there are behaviors that are not conducive to good sleep, they should be addressed first. Some behaviors increase arousal, such as consuming caffeine or nicotine in the evening or at night. Various drugs, legal and illegal, can affect one’s sleep greatly. Intense thoughts or emotions can also disturb one’s sleep, as do day-time naps or significant irregularities in the daily sleep-wake schedule.

Treatment of insomnia should also always include psychotherapy. It can help reduce the worries about and consequences of sleeplessness, and thereby break the vicious cycle of insomnia. Feeling less anxious about the ability to get a goodnight’s sleep often improves one’s sleep. Cognitive therapy, CBT, but also psychodynamic approaches can be helpful.

There are several over-the-counter sleep aids available, often with questionable effectiveness. Nonprescription drugs, such as sedating antihistamines, protein precursors, and a host of other substances can work in individual cases, but they are often not strong enough even in cases of moderate insomnia. L-Tryptophan has been withdrawn from the market after it was linked to outbreaks of eosinophilia. Melatonin may help some individuals, although the placebo should not be underestimated.

Most hypnotics are approved by the U.S. Food and Drug Administration (FDA) only for short-term use. The z-drugs zolpidem (Stilnoct®, Ambien®, Ambien CR®, Intermezzo®, Stilnox® and eszopiclone (Lunesta®), as well as the melatonin-receptor agonist ramelteon (Rozerem®) are exceptions.  The z-drugs are by their function related to the benzodiazepines and are also considered potentially addictive if taken regularly. This means that if they are stopped one’s sleep might be worse for a while. There could also be an additional increase in anxiety and, at least theoretically, panic attacks. Benzodiazepines and z-drugs should not be used while driving a car or operating heavy machinery, and the longer lasting ones can lead to a hangover in the morning and drowsiness during the day.

If the insomnia has lasted for a while and is expected to reoccur for at least a couple of weeks, sleep inducing antidepressants should be considered first choice. Mirtazapine (Remeron®) is often a good option, which in clinical experience is more sleep inducing at lower doses (15mg) than at higher doses (45mg). Second-generation antipsychotics, such as Olanzapine (Zyprexa®) are also used, but it seems there should be some other symptom or reason that justifies their use because of the potentially more serious die-effects. If the insomnia is combined with some types of obsessive thoughts or even Tourette’s syndrome, for example, sleep inducing second-generation antipsychotics may be a logical choice.

Psychotherapeutic treatment of insomnia is discussed in my other articles, but medication as a supportive measure seems warranted in some cases, especially if a modern antidepressant can help the patient maintain a job or a relationship, while using therapy to explore the reasons of the sleep disturbance.

Listed below are some substances that are used to treat insomnia.

We will start with the group of benzodiazepines and then move on to the pharmacologically closely related z-drugs, which should usually be preferred to the former, if they are used at all.

 

Benzodiazepines

The most commonly used class of hypnotics for insomnia are the benzodiazepines. Benzodiazepines are not significantly better for insomnia than antidepressants. [1] While they have an important role in anxiety and panic attacks, especially in the time interval until an antidepressant works, their role in the treatment of insomnia should only occur in niche cases, and only over a short internal. The z-drugs, which also work on the benzodiazepine receptor should be preferred, if at all necessary. In clinical practice, the risk for dependency seems higher if the benzodiazepines are used as sleeping pills than if they are used in acute anxiety attacks.

Benzodiazepines all bind unselectively to the GABA-A receptor. There is some indication that certain benzodiazepines (hypnotic benzodiazepines) have significantly higher activity at the α1 subunit of the GABA-A receptor compared to other benzodiazepines (for example, triazolam and temazepam have significantly higher activity at the α1 subunit compared to alprazolam and diazepam, making them superior sedative-hypnotics – alprazolam and diazepam, in turn, have higher activity at the α2 subunit compared to triazolam and temazepam, making them superior anxiolytic agents). Modulation of the α1 subunit is associated with sedation, motor impairment, respiratory depression, amnesia, ataxia, and reinforcing behavior (drug-seeking behavior). Modulation of the α2 subunit is associated with anxiolytic activity and disinhibition. For this reason, certain benzodiazepines may be better suited to treat insomnia than others.

  • Triazolam (Halcion®)
  • Temazepam (Restoril®)
  • [Alprazolam (Xanax®)]

and others may be useful as an insomnia medication that stays in the system longer. For instance, they have been effectively used to treat sleep problems such as sleepwalking and night terrors. However, these drugs may cause sleepiness during the day and can also cause tolerance.

Chronic use

With chronic use, the sleep inducing effect of the benzodiazepines often goes away, while the risk of tolerance increases quite quickly if they are used as hypnotics. Chronic users of hypnotic medications have more regular nighttime awakenings than patients suffering from insomnia who are not taking hypnotic medications. [2] Hypnotics should be prescribed for only a few days at the lowest effective dose and avoided altogether wherever possible, especially in the elderly. [3] Between 1993 and 2010, the prescribing of benzodiazepines to individuals with sleep disorders has decreased from 24% to 11% in the US, coinciding with the first release of nonbenzodiazepines. [4]

Common Side Effects

The benzodiazepine and nonbenzodiazepine hypnotic medications have a number of side-effects such as day time fatigue, changes in reaction time potentially leading to motor vehicle crashes and other accidents, cognitive impairments and falls and fractures. Elderly people are more sensitive to these side-effects. [5]

Some benzodiazepines have demonstrated effectiveness in sleep maintenance in the short term but in the longer-term benzodiazepines can lead to tolerance, physical dependence, benzodiazepine withdrawal syndrome upon discontinuation, and long-term worsening of sleep, especially after consistent usage over long periods of time. Benzodiazepines, while inducing unconsciousness, actually worsen sleep as—like alcohol—they promote light sleep while decreasing time spent in deep sleep. [6] A further problem is, with regular use of short-acting sleep aids for insomnia, daytime rebound anxiety can emerge. [7]

Although there is little evidence for benefit of benzodiazepines in insomnia compared to other treatments and evidence of major harm, prescriptions have continued to increase. [8] This is likely due to their addictive nature, both due to misuse and because—through their rapid action, tolerance and withdrawal—they can “trick” insomniacs into thinking they are helping with sleep. There is a general awareness that long-term use of benzodiazepines for insomnia in most people is inappropriate and that a gradual withdrawal is usually beneficial due to the adverse effects associated with the long-term use of benzodiazepines and is recommended whenever possible. [9]

 

Z-Drugs

  • Zolpidem (Ambien®, Intermezzo®)

They often work quite well, but some patients wake up in the middle of the night. Zolpidem is now available in an extended release version, Ambien CR®. This helps prolong the effect of the medication. The FDA has approved a prescription oral spray called Zolpimist®, which contains zolpidem, for the short-term treatment of insomnia brought on by difficulty falling asleep.

  • Eszopiclone (Lunesta®)

Studies show people sleep an average of seven to eight hours. Because of the risk of impairment, the next day, the FDA recommends the starting dose of Lunesta® be no more than 1 mg.

  • Zaleplon (Sonata®)

Zaleplon stays active in the body for the shortest amount of time. That means patients can try to fall asleep on their own. Then, if they are still not asleep at 2 a.m., they can take it without feeling drowsy in the morning. However, if one tends to wake during the night, this might not be the best choice.

 

Melatonin-receptor agonist

  • Ramelteon (Rozerem®)

This is a sleep medication that works differently than the others. It works by targeting the sleep-wake cycle, not by depressing the central nervous system. It is prescribed for people who have difficulty falling asleep. Rozerem® can be prescribed for long-term use, and the drug has so far shown no evidence of abuse or dependence.

 

Antidepressants

  • Mirtazapine (Remeron®)
  • Doxepine (Silenor®)

This tricyclic antidepressant is approved for use in people who have trouble staying asleep. Silenor® may help with sleep maintenance by blocking histamine receptors. Dosage is based on health, age, and response to therapy. Caution is required with all the tricyclic antidepressants as they can prolong the QT interval and have a number of other potentially severe side-effects.

  • Trazodone (Desyrel®)

 

Antipsychotics

Certain antipsychotic drugs like Olanzapin (Zyprexa®) also have a sedative effect and they are sometimes used in slow doses as sleep medication. However, because of the rare but potentially severe side-effects of neuroleptics, even in the second generation, they should not be used as sleep medication without any other rational for using them.

 

Over-the-Counter Sleep Aids

Most of these sleeping pills are antihistamines. They generally work well but can cause some drowsiness the next day. They are generally considered safe enough to be sold without a prescription. However, if combined with other drugs that also contain antihistamines, like cold or allergy medications, one could inadvertently take too much.

 

Sleep medication can have a number of side-effects. In 2007, the FDA issued warnings for prescription sleep drugs, alerting patients that they can cause rare allergic reactions and complex sleep-related behaviors, including “sleep driving.” Medication should in the case of a sleeping disorder always be the last option. Better sleep hygiene and psychotherapy/counselling should come long before it and be the first choice. No sleeping pill can take away worries about the job or one’s relationship or correct for drinking coffee in the evening or sleeping next to one’s laptop.

 

References

[1]   Buscemi, N.; Vandermeer, B.; Friesen, C.; Bialy, L.; Tubman, M.; Ospina, M.; Klassen, T. P.; Witmans, M. (2007). “The Efficacy and Safety of Drug Treatments for Chronic Insomnia in Adults: A Meta-analysis of RCTs”. Journal of General Internal Medicine. 22 (9): 1335–1350. doi:10.1007/s11606-007-0251-z. PMC 2219774Freely accessible. PMID 17619935.

[2]   Ohayon, M. M.; Caulet, M. (1995). “Insomnia and psychotropic drug consumption”. Progress in neuro-psychopharmacology & biological psychiatry. 19 (3): 421–431. doi:10.1016/0278-5846(94)00023-B. PMID 7624493.

[3]   “What’s wrong with prescribing hypnotics?”. Drug and therapeutics bulletin. 42 (12): 89–93. 2004. doi:10.1136/dtb.2004.421289. PMID 15587763.

[4]   Kaufmann, Christopher N.; Spira, Adam P.; Alexander, G. Caleb; Rutkow, Lainie; Mojtabai, Ramin (2015). “Trends in prescribing of sedative-hypnotic medications in the USA: 1993–2010”. Pharmacoepidemiology and Drug Safety. 25: 637–45. doi:10.1002/pds.3951. ISSN 1099-1557. PMID 26711081.

[5]   Glass, J.; Lanctôt, K. L.; Herrmann, N.; Sproule, B. A.; Busto, U. E. (2005). “Sedative hypnotics in older people with insomnia: Meta-analysis of risks and benefits”. BMJ. 331 (7526): 1169. doi:10.1136/bmj.38623.768588.47. PMC 1285093Freely accessible. PMID 16284208.

[6]   Tsoi, W. F. (1991). “Insomnia: Drug treatment”. Annals of the Academy of Medicine, Singapore. 20 (2): 269–272. PMID 1679317.

[7]   Montplaisir, J. (2000). “Treatment of primary insomnia”. Canadian Medical Association Journal. 163 (4): 389–391. PMC 80369Freely accessible. PMID 10976252.

[8]   Carlstedt, Roland A. (13 December 2009). Handbook of Integrative Clinical Psychology, Psychiatry, and Behavioral Medicine: Perspectives, Practices, and Research. Springer. pp. 128–130. ISBN 0-8261-1094-0.

[9]   Authier, N.; Boucher, A.; Lamaison, D.; Llorca, P. M.; Descotes, J.; Eschalier, A. (2009). “Second Meeting of the French CEIP (Centres d’Évaluation et d’Information sur la Pharmacodépendance). Part II: Benzodiazepine Withdrawal”. Thérapie. 64 (6): 365–370. doi:10.2515/therapie/2009051. PMID 20025839.

 

Dr Jonathan Haverkampf, M.D. MLA (Harvard) LL.M. trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. The author can be reached by email at jonathanhaverkampf@gmail.com or on the websites www.jonathanhaverkampf.com and www.jonathanhaverkampf.ie.

This article is solely a basis for academic discussion and no medical advice can be given in this article, nor should anything herein be construed as advice. Always consult a professional if you believe you might suffer from a physical or mental health condition. Trademarks belong to their respective owners. No checks have been made.

© 2012-2017 Christian Jonathan Haverkampf. All Rights Reserved.

 

 

 

 

 

Psychotherapeutic Technique: A Brief Overview

Psychotherapeutic Technique A Brief Overview (3) Ch Jonathan Haverkampf

 

Psychotherapeutic Technique: A Brief Overview

Dr Jonathan Haverkampf, M.D.

 

Introduction

When patients come to see a therapist, they often have a long list of things that do not work for them in their lives. It is easy to overlook that one of the hardest steps towards health has been taken, stepping into the office of a therapist. Psychotherapeutic Technique is then largely about helping the patient find his or her path and to have the courage to follow it. Empathy, common sense, and a good dose of optimism are helpful in this line of work, as is thinking about what is happening and has happened in the life of the patient, how they relate to themselves and the world, and that in the end everything should make sense to the head and to the heart.

The reasoning mind plays a greater role in psychotherapy than it is given credit for. Many mental health conditions arise because of what we think we have to achieve, because we think there are no alternative options or because we think we have failed. If one’s thoughts can make one feel worse, it also makes sense to look to one’s thoughts to make oneself feel better. However, the goal is not to engage in endless loops of thinking about unanswerable questions but to engage with one’s thoughts by asking whether they make sense or not.

 

Making Sense

In the best-case scenario, a patient engages in a process of ‘making sense’ with the help of the therapist. This does not just mean using logic, but seeing one’s thoughts within the context of one’s values and aspirations on one side, and one’s experiences and interactions with other people on the other side. In the end, the objectives and goals of one’s thoughts have to make sense within the context of one’s values. This ultimately leads to stable and persistent happiness and mental well-being.

Let us look at an example, which applies to many people. If one of my values is to provide a safe environment for my family, thinking about how to make more money can lead to greater happiness (and less stress), if I am aware that I am thinking about earning money to be able to buy a house that can offer my family a greater sense of security. If I see money as an end in itself, on the other hand, it can lead to an obsession, which may become endless, because I lose sight of when I have reached my goal.

In other words, life becomes easier once we see our actions and interactions with other people as something that ultimately makes sense for us. One does not need to have a specific outcome in mind. A feeling of significance to oneself is already a good starting point. Many people lack even this general feeling in most of their daily lives, which can lead to emotional disengagement, burnout, depression anxiety, panic attacks, heightened OCD, and so forth. Therapy has to bring ‘sense’ and meaning into the equation again.

 

Guided Self-Help

Much of what can happen in therapy depends on the expectations of the patient. It determines how much he or she will participate in therapy and contribute to the process in general. This makes it worthwhile to point out early to the basic working in principle in therapy, that the therapist can help patients help themselves, but should under normal circumstances not tell them what to do.

 

The Search for Meaning

Therapy is about meaning, helping a patient find relevance in things, which also asks patients to look at their fundamental values and basic interests. Following one’s values and basic interests leads to happiness and not knowing them to such conditions as anxiety and burnout. Many people in today’s busy and increasingly complex world lose their ability to see relevance in the world and in what they do. Helping people to reconnect the world as they perceive it with what they value is an important aspect of therapy. It requires the ability to communicate with oneself and between the inside and outside worlds.

 

The Therapeutic Relationship

Therapy is an exchange of information, which ultimately should help the patient to lead a happier and more fulfilling life, as well as be free from any symptoms that interfere with these goals. The motivation for it should come for a need for the feedback and information that is provided in therapy. The therapeutic relationship is the bundle of channels along which the therapeutic communication takes place.

Observation

The therapist should be able to see how patients deal with information and interact with themselves and the world around them. Better communication with oneself and others can lead to the patient feeling safer, developing greater abilities of introspection and reflection and facilitating a healthier communication with oneself and the environment. All this requires that the therapist has an understanding of the dynamics of interactions in general and of the interactions of the patient in specific, the mutual flow of information and the values, aspirations and interests everyone holds.

Empathy and Interest

Therapeutic work requires empathy and an honest and true interest in the patient and his or her inner worlds. The therapist should also have an interest for the own inner worlds and how they are are influenced by the communication of the patient. In psychoanalysis, the concepts of transference and counter-transference are used here.

Reason

Mostly therapy is about leading the patient with questions and comments to find new perspectives, open up to new information and process information in new ways. The epiphanies should take place in the patient, while the therapist can create the setting in which they take place. The motivation, ownership and integration into the own person that takes place in them is important for the success of therapy.

 

Values, Interests and Aspirations

The psychodynamic process helps to shift through derivative values and non-derivative values to get to the fundamental values which everyone holds. Here are the things which are really important to the individual, whose pursuit makes happy and life worth living for. To compromise these values causes great suffering and a loss of direction.

 

Self-Connectedness

The information to be gained from inside one’s body can be tremendous if one is willing to listen to it. We produce a lot of information in our body, which, though it requires the environment to interact with, is in many ways a very complicated self-contained system. The parallel information processing power of the nervous system and the networks of cells of the rest of the body, connected by chemical and electric pathways, is very large. Even information coming in from the outside world has to pass through cellular networks to reach higher brain centers.

Self-connectedness means being aware that the information reaching the brain is made up of information that is largely influenced by the information processed in our bodies. It requires becoming aware of the shear infinity of information sources our brain is processing, and not just the sentence one may see on a computer screen at work. This awareness is important to deal with anxiety, OCD, burnout, depression, psychosis and a host of other conditions. It does not mean one has to process all this information consciously, just that the processes are stable, while the sources and the information may change. Our values as a result of these processes change little, while our experiences on the summer vacation may be vastly different from year to year.

 

Time

To many patients, time has become convoluted. They do not know what to do with their past, are afraid to think about their feature, and are caught between past and present which deprives them of the present. Making sense of the relationship between the present, the past and the future establishes the bridges that can anchor them in the present moment. Awareness, feelings, feedback and communication are important factors in this process.

Thinking about values and interests helps to rebuild a future, but this might confront the patient with ‘bad decisions’ in the past. The best way to deal with this is through acceptance and integration. This means the past has to be accepted and to a certain extent embraced, which is an important process in therapy.

 

Questions

The most important communication tool one has in psychotherapy is to ask questions. In Socratic questioning the question can lead to insights for both, the patient and the therapist. However, to ask questions that bring greater insight requires having a sense of the type of answers that will be useful to allowing the patient greater awareness, insight and connectedness. The type of answers may often not be apparent early in therapy. However, they should be related to greater happiness, and thus a knowledge of the patient’s values, interests and aspirations.

 

Meaningful Communication

One needs to have faith that the interaction between therapist and patient will reveal the information that provides the course in treatment. And this will always happen if there is meaningful communication, which means that something new is communicated every time information travels between the two partners in the interaction. Information can be little gestures or a twitch on the forehand which signal emotions or thought processes, words that can be understood by the other person and in general every signal that can be sent and received by therapist and patient. This requirement is easy to satisfy, if there is a minimal openness to engage in a therapeutic process.

 

Types of Intervention

An intervention should create greater awareness, insight and connectedness in the patient. A few examples follow.

Questioning

“I want to be in control in social situations.”

“What does it mean to be in control in social situations?”

“I would feel free, I would not think anymore so much, I would not analyze so much what other people think.”

 

Assembling

The next step is to put together the information from the client that reaches the therapist.

“So, you are telling me that you …”

 

The Logic Test

The logical test is a result from assembling the information. Here contradictions can become clear, or spots that have not been thought about at all. These do not make up the world we imagine, but are the things that have to be overcome to get closer to one’s wished states.

 

Imagining

Imagining is that step in which people project their wishes, needs and aspirations into their inner world using building blocks they know from the real world. It is here where we build the world we compare the real world with. This comparison motivates us to change our world, but it can also raise emotions, such as fear or happiness. As emotions have influence over the worlds we imagine, so the worlds we imagine have influence over our emotions.

Our vision of the future plays an especially important role, because it can provide motivation and a sense of direction, as long as it is congruent with the person’s underlying values, aspirations and interests.

“Can you imagine what it would be like not to feel socially anxious anymore?”

 

Bridging real and imagined world

This requires looking at the changes that may have to be made in the present world to get closer to the imagined world. These thoughts should then lead to behavior changes that get the patient closer to where he/she wants to be.

 

Creating new communication pattern

Change also means we have to communicate with the world in new ways. This grows out of the rediscovered values and interests, the feedback and dynamics in the work with the therapist and the life of the patient outside the therapy. Over time, the new communication patterns should solidify as the patient is reinforced by better interactions with the environment.

 

Conclusion

Psychotherapy is both, creative and supportive work. It requires a keen eye for the process and the dynamics unfolding within a session. Working with the patient on communication patterns, interaction dynamics, uncovering values and basic interests often goes a long way towards a successful therapy.

 

 

Dr Jonathan Haverkampf, M.D. MLA (Harvard) LL.M. trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. The author can be reached by email at jonathanhaverkampf@gmail.com or on the websites www.jonathanhaverkampf.com and www.jonathanhaverkampf.ie.

This article is solely a basis for academic discussion and no medical advice can be given in this article, nor should anything herein be construed as advice. Always consult a professional if you believe you might suffer from a physical or mental health condition. Trademarks belong to their respective owners. No checks have been made.

© 2012-2017 Christian Jonathan Haverkampf. All Rights Reserved.

 

Anxiety and Panic Attacks

 

 

Anxiety and Panic Attacks (2)

Dr Jonathan Haverkampf, M.D.

 

 

Anxieties can cause incredible suffering, especially in combination with panic attacks, which are usually a short-lived but more intense form of anxiety.

 

Anxiety Disorders

Anxiety disorders are a group of mental disorders characterized by feelings of anxiety and fear. [1] Anxiety is a worry about future events and fear is a reaction to current events. These feelings may cause physical symptoms, such as a fast heart rate and shakiness. There are a number of anxiety disorders: including generalized anxiety disorder, specific phobia, social anxiety disorder, separation anxiety disorder, agoraphobia, panic disorder, and selective mutism. Often the same individual has more than one anxiety disorders, but in many cases, there might only be one type.

 

Panic Attack

The first panic attack can occur as from nowhere and the sudden sense of imminent death or literally going crazy usually comes as an enormous and sudden shock. In many cases, it has five stages:

  1. An ominous feeling of an imminent panic attack. A heightened sense of self-consciousness with beginning hyperventilation and other symptoms.
  2. The sense that there is no way to avert the full-blown panic attack.
  3. The panic attack with hyperventilation, heart palpitations, the sense of imminent doom and/or death.
  4. Alternations in the intensity of the panic attack, leading to a decline after about ten minutes.
  5. A post-panic phase in which there is a sense of exhaustion and sometimes elation that it is over.

Since the first panic attack often occurs in adolescence or young adulthood, the individual might not know what a panic attack is. In older people, panic attacks often lead to visits to the hospital emergency admission.

 

Invisibility

A feature of many anxieties and panic attacks is that they go largely unnoticed by the environment. Anxieties and panic attacks can lead to the inability to leave the house and interfere with almost every sphere of life, professional, social, and one’s relationships. When anxiety reaches into all areas of life and no longer seems specific to certain situations and locations, we call it ‘generalized’. It is then the pure form of a disturbing feeling that no longer is attached to specific object, but ‘floats freely’.

 

Loss of Control

Anxiety and Panic Attacks do not seem to be so much a fear that something happens to the world, but that one loses control somehow. Often patients mention the sense of loss of control. But it is important to turn this around. The question is why is there such a need for control in the first place? It is because there is probably a loss of something stabilizing on the inside. After all, patients usually describe the sense of losing control over themselves. This is also what maintains the vicious cycle of fear of fear, felling anxious that the anxiety might mean a total loss of control. It is important to mention that I have never seen a single case, in which someone was seriously harmed who suffered from this fear of losing control. But the feeling is there and it needs to be looked at more closely.

 

A Signal of Change

But anxieties are actually something quite interesting because they signal a necessary change if someone is willing to go a new route. The necessity for a more global change lies already in the definition of anxiety. It is not a fear of something specific, but of uncertainty itself. Communication which binds humans together is no longer felt as something really stable.

 

Fear of Imminent Death: Somatic (Body) Reaction

Panic attacks often trigger thoughts of an imminent death, such as not being able to breathe anymore or a heart attack. They frequently go along with bodily ‘fear’ reactions, such as heart palpitations and dizziness. In general, there is a general sense of a loss of control over one’s body and even one’s mind, which further worsens the panic attack. Often panic attacks start in adolescence and young adulthood and frequently they are triggered by relationship events and social situations. But if they remain untreated, they can spread out and become ‘generalized’. They can reach a point where they even occur when someone is at home lying in back or after waking up at night. In the extreme, this can lead to a situation in which a patient is not only house but also bed bound.

 

Certainty and Security

Under the surface of the symptoms of anxiety and panic attacks there often is a fear of losing a fundamental feeling of losing of certainty and security in one’s life. As babies and small children learn to rely on their interactions with others, especially primary caretakers, to meet their needs, they build up a sense of safety in regard to the world around them and a secure sense of self. As we figure out the ‘rules of daily life’ as children we learn to be reasonably in the world. Things might still be unpredictable at times, but in a caring and supportive environment surprises are seen as a fact of life that one might not be able to control, but one can learn from them and the world moves on anyway, for oneself and for everyone else.

However, if this process does not work properly for a number of reasons, a greater sense of uncertainty and a greater susceptibility to anxiety develops, especially if anxieties, OCD, panic attacks and other conditions of elevated anxiousness vis-à-vis the world and other people run in the family.

Society has developed a number of ways to deal with anxiety and reduce uncertainty. Many human endeavours aim to provide a greater sense of safety. Laws and scientific progress deal with both, uncertainty in people and uncertainty in the natural world. However, in generalized anxiety and panic attacks, it is less a certainty in the outside world than in the inside world which is really what individuals with anxiety strive for, and it is here that therapy needs to begin.

 

Meaningful Relationships

Meaningful social interactions and meaningful relationships are effective against anxiety, where it is the quality rather than the quantity which counts. The reason is that meaningful communication reconnects the individual with others, but it also aids in self-regulation and gives the individual a greater sense of being effective in taking care of oneself through the interactions with others.

 

Values and Interests

The other important element is finding not only the strength in oneself but also the direction to proceed in the life. Often there are many paths that can be taken, which confuses people and causes anxiety. Without a sense of one’s trues values, interests and aspirations it is more difficult to make the relevant decisions in life that lead to greater happiness. If one’s sense for one’s own values and fundamental interests and aspirations is compromised because of a loss of connection with one’s thinking and emotional self, stress, anxiety and burnout can ensue. It is like running in place without getting anywhere, while having a strong desire to get somewhere.

True values, part biology, part social learning from other human beings, means a fundamental belief that acting according to these values and interests and attaining one’s aspiration will really mean happiness in the long run. In anxiety, these values and fundamental interests are out of sync with our lives.

 

Inner Conflicts

Anxiety is caused by inner conflicts, which in the cognitive behavioural therapy tradition are assumed to be conscious or ‘near-conscious’, while the psychodynamic or psychoanalytic psychotherapy traditions see most of it in the domain of the unconscious. This largely explains the differences in treatment times between the two approaches, but on a theoretical level both can actually complement each other quite well. Fundamentally the causes are difficulties in communicating one’s underlying needs and wishes in a way that subjectively strengthens rather than weakens a relationship out of a fear of further loss. This also makes the internal conflicts persist. Our communication with the people in our lives has an impact on how we talk to ourselves, because they provide crucial feedback to us. When our social interactions become meaningless, our sense of shaping our world in a way that makes us feel secure and happy suffers.

 

Self-Talk

When I refer to ‘talking to oneself’ I do not mean literally talking to oneself in the street but bouncing back and forth thoughts in one’s head, observing one’s thought process and reflecting on it. This requires the exchange of highly complex information in even more complex webs of networks of nerve cells in the brain. Since our brain is a highly complex network of ever smaller networks of nerve cells it allows the brain to process information in parallel. This is the reason why we can ‘listen’ to our own thoughts. Brain cells are in contact with other brain cells and they can alter the properties of their own connections depending on the information they transmit. Medication can alter certain types of transmissions in this system, but if we want to be more specific, we have to expose ourselves to meaningful information which the brain can use to refigure itself. This is essentially what psychotherapy does. As many empirical studies have shown, psychotherapy can bring about changes in connectivity and activation of the brain, which in turn can have a lasting effect on certain conditions, such as anxieties and panic attacks.

 

Three Steps

The first step is to become aware of situations that trigger anxieties and panic attacks, such as relationship problems or work-related stress. But these problems might not always be obvious, and they might not even explain the anxiety. Problems in a relationship or shyness in social situations are normally not the ultimate explanation for anxiety or panic attacks. We need to analyse in the specific case why losing a relationship causes such threatening fears as anxieties or panic attacks suggest. Sometimes it is worthwhile taking a look into one’s past and reconstruct how an individual dealt with his or her environment as a child or adolescent and how the environment dealt with the individual. At other times it may be important to ‘dissect’ the thought patterns in the here and now and to try to find out what they could mean. “If I leave the house I might have to figure out what I really want to do in life. “If this relationship breaks up I might have to figure out what I need and what I want, who I am, who I want to be with …” and so on. This step is about better understanding one’s needs, values and aspirations, and thus oneself.

The second step is to determine if the current approach, such as avoidance or negation, is the best strategy. It always never is. But this does not mean that one has to radically alter one’s current lifestyle or social life, though in special cases it might. The actual life we have starts in our head, so it is first and foremost about determining the questions that matter and how to approach them. This is actually easier than most people think, because it is not so much about having certain answers but about learning how to think and communicate in novel ways. Change usually means widening one’s mental repertoire, not narrowing it. The more effective tools are in our toolbox and the more meaningful information we have access to, the better will be our answers and decisions.

The third step is to act according to this novel information. This might sound like a tall order in the face of fears, anxieties and panic attacks, but once someone reaches this stage, the hurdles are often diminished or gone altogether. The fears usually disappear during the first and the second step. The reason is that we are usually more afraid of an uncertain ill-defined event than a certain defined event. When you are facing a threatening event, the uncertainty about an unlikely ill-defined outcome can be more painful than the certainty about a certain well-defined event. The certainty of death does not disturb people nearly as much as not knowing how they will die.

 

Happiness

The goal is not absolute certainty in life but the attainment of happiness. Anxiety does not necessarily mean a shift in the balance between happiness and writing a meaningful story for one’s life, rather, it often is a wake-up call for us to re-evaluate who we are and what we really want in life to make us happier.

 

Most people want to lead lives which feel true to themselves for the simple reason that they believe it will make them happy. The only certainty that really helps against anxiety is the certainty that one follows one’s own path. To help a patient reach this path and follow it with confidence is an important objective of psychotherapy and counselling.

 

 

 

 

References

[1] Diagnostic and Statistical Manual of Mental Disorders. American Psychiatric Association (5th ed.). Arlington: American Psychiatric Publishing. 2013. pp. 189–195. ISBN 978-0890425558.

 

 

 

Dr Jonathan Haverkampf, M.D. MLA (Harvard) LL.M. trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. The author can be reached by email at jonathanhaverkampf@gmail.com or on the websites www.jonathanhaverkampf.com and www.jonathanhaverkampf.ie.

This article is solely a basis for academic discussion and no medical advice can be given in this article, nor should anything herein be construed as advice. Always consult a professional if you believe you might suffer from a physical or mental health condition. Trademarks belong to their respective owners. No checks have been made.

© 2012-2017 Christian Jonathan Haverkampf. All Rights Reserved.

 

Psychotherapeutic Technique: An Overview

Psychotherapeutic Technique A Brief Overview (2) Ch Jonathan Haverkampf

 

Psychotherapeutic Technique: A Brief Overview

Dr Jonathan Haverkampf, M.D

 

Introduction

When patients come to see a therapist, they often have a long list of things that do not work for them in their lives. It is easy to overlook that one of the hardest steps towards health has been taken, stepping into the office of a therapist. Psychotherapeutic Technique is then largely about helping the patient find his or her path and to have the courage to follow it. Empathy, common sense, and a good dose of optimism are helpful in this line of work, as is thinking about what is happening and has happened in the life of the patient, how they relate to themselves and the world, and that in the end everything should make sense to the head and to the heart.

 

Guided Self-Help

Much of what can happen in therapy depends on the expectations of the patient. It determines how much he or she will participate in therapy and contribute to the process in general. This makes it worthwhile to point out early to the basic working in principle in therapy, that the therapist can help patients help themselves, but should under normal circumstances not tell them what to do.

 

The Search for Meaning

Therapy is about meaning, helping a patient find relevance in things, which also asks patients to look at their fundamental values and basic interests. Following one’s values and basic interests leads to happiness and not knowing them to such conditions as anxiety and burnout. Many people in today’s busy and increasingly complex world lose their ability to see relevance in the world and in what they do. Helping people to reconnect the world as they perceive it with what they value is an important aspect of therapy. It requires the ability to communicate with oneself and between the inside and outside worlds.

 

The Therapeutic Relationship

Therapy is an exchange of information, which ultimately should help the patient to lead a happier and more fulfilling life, as well as be free from any symptoms that interfere with these goals. The motivation for it should come for a need for the feedback and information that is provided in therapy. The therapeutic relationship is the bundle of channels along which the therapeutic communication takes place.

Observation

The therapist should be able to see how patients deal with information and interact with themselves and the world around them. Better communication with oneself and others can lead to the patient feeling safer, developing greater abilities of introspection and reflection and facilitating a healthier communication with oneself and the environment. All this requires that the therapist has an understanding of the dynamics of interactions in general and of the interactions of the patient in specific, the mutual flow of information and the values, aspirations and interests everyone holds.

Empathy and Interest

Therapeutic work requires empathy and an honest and true interest in the patient and his or her inner worlds. The therapist should also have an interest for the own inner worlds and how they are are influenced by the communication of the patient. In psychoanalysis, the concepts of transference and counter-transference are used here.

Reason

Mostly therapy is about leading the patient with questions and comments to find new perspectives, open up to new information and process information in new ways. The epiphanies should take place in the patient, while the therapist can create the setting in which they take place. The motivation, ownership and integration into the own person that takes place in them is important for the success of therapy.

 

Values, Interests and Aspirations

The psychodynamic process helps to shift through derivative values and non-derivative values to get to the fundamental values which everyone holds. Here are the things which are really important to the individual, whose pursuit makes happy and life worth living for. To compromise these values causes great suffering and a loss of direction.

 

Self-Connectedness

The information to be gained from inside one’s body can be tremendous if one is willing to listen to it. We produce a lot of information in our body, which, though it requires the environment to interact with, is in many ways a very complicated self-contained system. The parallel information processing power of the nervous system and the networks of cells of the rest of the body, connected by chemical and electric pathways, is very large. Even information coming in from the outside world has to pass through cellular networks to reach higher brain centers.

Self-connectedness means being aware that the information reaching the brain is made up of information that is largely influenced by the information processed in our bodies. It requires becoming aware of the shear infinity of information sources our brain is processing, and not just the sentence one may see on a computer screen at work. This awareness is important to deal with anxiety, OCD, burnout, depression, psychosis and a host of other conditions. It does not mean one has to process all this information consciously, just that the processes are stable, while the sources and the information may change. Our values as a result of these processes change little, while our experiences on the summer vacation may be vastly different from year to year.

 

Time

To many patients, time has become convoluted. They do not know what to do with their past, are afraid to think about their feature, and are caught between past and present which deprives them of the present. Making sense of the relationship between the present, the past and the future establishes the bridges that can anchor them in the present moment. Awareness, feelings, feedback and communication are important factors in this process.

Thinking about values and interests helps to rebuild a future, but this might confront the patient with ‘bad decisions’ in the past. The best way to deal with this is through acceptance and integration. This means the past has to be accepted and to a certain extent embraced, which is an important process in therapy.

 

Questions

The most important communication tool one has in psychotherapy is to ask questions. In Socratic questioning the question can lead to insights for both, the patient and the therapist. However, to ask questions that bring greater insight requires having a sense of the type of answers that will be useful to allowing the patient greater awareness, insight and connectedness. The type of answers may often not be apparent early in therapy. However, they should be related to greater happiness, and thus a knowledge of the patient’s values, interests and aspirations.

 

Meaningful Communication

One needs to have faith that the interaction between therapist and patient will reveal the information that provides the course in treatment. And this will always happen if there is meaningful communication, which means that something new is communicated every time information travels between the two partners in the interaction. Information can be little gestures or a twitch on the forehand which signal emotions or thought processes, words that can be understood by the other person and in general every signal that can be sent and received by therapist and patient. This requirement is easy to satisfy, if there is a minimal openness to engage in a therapeutic process.

 

Types of Intervention

An intervention should create greater awareness, insight and connectedness in the patient. A few examples follow.

Questioning

“I want to be in control in social situations.”

“What does it mean to be in control in social situations?”

“I would feel free, I would not think anymore so much, I would not analyze so much what other people think.”

 

Assembling

The next step is to put together the information from the client that reaches the therapist.

“So, you are telling me that you …”

 

The Logic Test

The logical test is a result from assembling the information. Here contradictions can become clear, or spots that have not been thought about at all. These do not make up the world we imagine, but are the things that have to be overcome to get closer to one’s wished states.

 

Imagining

Imagining is that step in which people project their wishes, needs and aspirations into their inner world using building blocks they know from the real world. It is here where we build the world we compare the real world with. This comparison motivates us to change our world, but it can also raise emotions, such as fear or happiness. As emotions have influence over the worlds we imagine, so the worlds we imagine have influence over our emotions.

Our vision of the future plays an especially important role, because it can provide motivation and a sense of direction, as long as it is congruent with the person’s underlying values, aspirations and interests.

“Can you imagine what it would be like not to feel socially anxious anymore?”

 

Bridging real and imagined world

This requires looking at the changes that may have to be made in the present world to get closer to the imagined world. These thoughts should then lead to behavior changes that get the patient closer to where he/she wants to be.

 

Creating new communication pattern

Change also means we have to communicate with the world in new ways. This grows out of the rediscovered values and interests, the feedback and dynamics in the work with the therapist and the life of the patient outside the therapy. Over time, the new communication patterns should solidify as the patient is reinforced by better interactions with the environment.

 

Conclusion

Psychotherapy is both, creative and supportive work. It requires a keen eye for the process and the dynamics unfolding within a session. Working with the patient on communication patterns, interaction dynamics, uncovering values and basic interests often goes a long way towards a successful therapy.

 

 

Dr Jonathan Haverkampf, M.D. MLA (Harvard) LL.M. trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. The author can be reached by email at jonathanhaverkampf@gmail.com or on the websites www.jonathanhaverkampf.com and www.jonathanhaverkampf.ie.

This article is solely a basis for academic discussion and no medical advice can be given in this article, nor should anything herein be construed as advice. Always consult a professional if you believe you might suffer from a physical or mental health condition. Trademarks belong to their respective owners. No checks have been made.

© 2012-2017 Christian Jonathan Haverkampf. All Rights Reserved.

 

Depression and Medication

Depression and Medication (2) 

 

Depression comes in a multitude of flavors. Traditionally a distinction has been made between the reactive or neurotic depression on one end, which has been seen as largely environmentally induced, and the endogenic depression, which was largely seen as driven by biology. We now know that all three factors of biology, psychology and environment interact together in leading to the symptoms of depression.

 

The Circularity of Depression

Due to the plasticity of the brain, which regulates its morphological and chemical balance all the time, environmental influences can affect the circuitry and the functioning of the brain. Since the biology of the brain determines our thoughts and actions, it influences our environment, which again has a feedback on the brain. Thus, all effect depends on communication inside the brain and between the brain and the environment, and vice versa. This plays an immense role in the etiology and the symptoms of depression. It also explains why a combination of medication and psychotherapy in the majority of cases has the best outcome. Medication should be thought of in many cases of depression, except for the lighter reactive versions, while psychotherapy is always indicated if an individual suffers from depression. A condition that relies largely on communication deficits to be maintained, can also be cured through the ‘talking cure’, psychotherapy.

 

The Combination of Psychotherapy and Medication

Depression should in any case be treated with a combination of psychotherapy and medication if it is serious enough. Psychotherapy in most cases takes a few months to work, and medication, while also requiring a few weeks to work, will in many cases get results quicker than psychotherapy alone. In less severe cases, especially when it is a reaction to obvious external factors, psychotherapy alone may do. Medication can especially provide relief before the effect of psychotherapy, which is more geared towards the long-run, takes hold. While medication cannot make life more meaningful per se, it can improve an individual’s mood, which usually leads to more positive thoughts, a more positive outlook on the world, a decrease in ruminations, less anxiety and improved sleep – and appetite if that is desired.

 

Suicidal Ideation

Suicidality needs to be kept in mind in any form of depression and the mainstream opinion has shifted towards addressing these thoughts rather than avoiding talking about them out of fear that it might trigger them. Since the stability of the therapeutic relationship and communication itself are important tools in relieving depression, one should not be too anxious about naming issues that seem relevant.

A concern was that since the activating effect in several antidepressants can occur before the antidepressant affect, the risk for suicide might increase because a patient who still feels depressed becomes more active. However, the clinical experience is that the opportunity to talk about feelings and thoughts openly in a secure relationship reduces the urge towards self-harm.

 

Interests and Values

As I have outlined in another article on depression, facilitating the idea of a future the patient has some control over is often an important step in treating depression. This often means identifying values, interests and aspirations, which can provide greater motivation and a good feeling about the future, should be allowed enough space. There can be sadness about lost opportunities, but this usually subsides in the face of having a clearer direction in life and a greater promise of happiness, if one pursues the things one truly values and aspires to.

 

Medication

Unfortunately, the perfect medication does not exist. But this is also not to be expected since each antidepressant has a unique profile of effects, positive and negative, which can still be influenced largely by the unique biology of the patient. The following antidepressants are the most common ones. Using a single antidepressant (monotherapy) is usually to be preferred over polypharmacy. However, especially in more severe and treatment-resistant cases of depression, combinations may have to be explored, such as combining venlafaxine and mirtazapine (“California rocket fuel”) to yield an especially potent antidepressant and activating combination, which can even improve sleep (at lower to medium doses of mirtazapine).

Selective serotonin reuptake inhibitors (SSRIs)

The selective serotonin reuptake inhibitors (SSRIs) are the most common used antidepressants because of their relative safety and low side-effect profile. Unfortunately, in the beginning the indiscriminate use of the SSRI Prozac® against ‘everything’ from workplace problems to the stress of unhealthy living lead to a backlash in the media, which unfortunately made many patients avoid all medication out of fear to become emotionally flat or experience a change in one’s personality, which has not been shown so far in any convincing way.

There are several other substances, that work as antidepressants, and all have potential side-effects. Often a substance is used which has a ‘desirable’ side-effect and that deals more effectively with the individual constellation of symptoms:

  • Insomnia: Mirtazapine (Remeron® and many generics) is effective in inducing sleep at lower doses (around 15mg), an effect that seems to wear off once one goes up to 45mg. However, the antidepressant effect of 15mg is usually too small. Especially early on ‘hangovers’ in the morning are not uncommon. Among very common side effects are dry mouth, constipation, increased appetite, as well as somnolence, sedation, sleepiness (which may wear off).
  • Lack of activation: Venlafaxine (Effexor®, Effexor XR®, Lanvexin®, Viepax®, Trevilor®) is a noradrenaline and serotonin reuptake inhibitor (NSRI) and often affectively increases activation. However, one should be careful with patients who might harm themselves (or others) because activation often occurs before the antidepressant effect takes hold. Also, if used in cases of anxiety it may increase the anxiety before reducing it.
  • Co-morbidity with anxiety, panic attacks, OCD: the SSRIs are a good first choice. Venlafaxine seems to be helpful with anxiety, but often it increases anxiety early on, and possibly even medium-term.

Tricyclic antidepressants

Tricyclic antidepressants should not be used to treat symptoms that can be treated with the SSRIs or an NSRI, because of the letter’s better safety profile. It is difficult to imagine there still is an application for MAO inhibitors, except in the rare depression that does not respond to treatment. In the latter cases, my experience is that often medication has not been administered long enough or prescribed in the right dose. Quite frequently there has been no or only inadequate psychotherapy. It is worth remembering that psychotherapy is still and will always be the core treatment for what were a century ago referred to the ‘neurotic’ conditions, such as reactive depression, anxiety, OCD and the like. The reason is that the symptomatology can be traced to problems in interactions, communication and human relationships. Generally, there is better empirical evidence for the usefulness of antidepressants in the treatment of depression that is chronic (dysthymia) or severe.

In any case, it can take weeks for the full effect of medication to be noticed. A 2008 review of randomized controlled trials concluded that symptomatic improvement with SSRIs was greatest by the end of the first week of use, but that some improvement continued for at least 6 weeks.

 

Major depressive disorder

The UK National Institute for Health and Care Excellence (NICE) 2009 guidelines indicate that antidepressants should not be routinely used for the initial treatment of mild depression, because the risk-benefit ratio is poor. The guidelines recommend that antidepressant treatment should be considered for:

  • People with a history of moderate or severe depression,
  • Those with mild depression that has been present for a long period,
  • As a second-line treatment for mild depression that persists after other interventions,
  • As a first-line treatment for moderate or severe depression.

The guidelines further note that antidepressant treatment should be used in combination with psychosocial interventions in most cases, should be continued for at least 6 months to reduce the risk of relapse, and that SSRIs are typically better tolerated than other antidepressants.

 

Non-Responders

Between 30% and 50% of individuals treated with a given antidepressant do not show a response. In clinical studies, approximately one-third of patients achieve a full remission, one-third experience a response and one-third are non-responders. Partial remission is characterized by the presence of poorly defined residual symptoms. These symptoms typically include depressed mood, psychic anxiety, sleep disturbance, fatigue and diminished interest or pleasure. It is currently unclear which factors predict partial remission. However, residual symptoms are powerful predictors of relapse, with relapse rates 3–6 times higher in patients with residual symptoms than in those who experience full remission.

 

“Trial and error” switching

The American Psychiatric Association 2000 Practice Guideline advises that where no response is achieved following six to eight weeks of treatment with an antidepressant, to switch to an antidepressant in the same class, then to a different class of antidepressant. A 2006 meta-analysis review found wide variation in the findings of prior studies; for patients who had failed to respond to an SSRI antidepressant, between 12% and 86% showed a response to a new drug. However, the more antidepressants an individual had already tried, the less likely they were to benefit from a new antidepressant trial. A later meta-analysis found no difference between switching to a new drug and staying on the old medication; although 34% of treatment resistant patients responded when switched to the new drug, 40% responded without being switched.

 

Combination

A combination strategy involves adding another antidepressant, usually from a different class of antidepressants to have effect on other mechanisms. Although this may be used in clinical practice, there is little evidence for the relative efficacy or adverse effects of this strategy.

 

Augmentation

For a partial response, the American Psychiatric Association guidelines suggest augmentation, or adding a drug from an altogether different class of substances. These include lithium and thyroid augmentation, dopamine agonists, sex steroids, NRIs, glucocorticoid-specific agents, or the newer anticonvulsants.

 

Which medication to use?

The medication used needs to be tailored specifically to the individual and the set of effects that are desired and those which need to be voided. However, there seem to be clear favorites overall, which the following list of antidepressant prescriptions in the US in 2010 shows:

Drug name Commercial name Drug class Total prescriptions
Sertraline Zoloft® SSRI 33,409,838
Citalopram Celexa® SSRI 27,993,635
Fluoxetine Prozac® SSRI 24,473,994
Escitalopram Lexapro® SSRI 23,000,456
Trazodone Desyrel® SARI 18,786,495
Venlafaxine (all formulations) Effexor (IR, ER, XR) ® SNRI 16,110,606
Bupropion (all formulations) Wellbutrin (IR, ER, SR, XL) ® NDRI 15,792,653
Duloxetine Cymbalta® SNRI 14,591,949
Paroxetine Paxil® SSRI 12,979,366
Amitriptyline Elavil® TCA 12,611,254
Venlafaxine XR Effexor XR® SNRI 7,603,949
Bupropion XL Wellbutrin XL® NDRI 7,317,814
Mirtazapine Remeron® TeCA 6,308,288
Venlafaxine ER Effexor XR® SNRI 5,526,132
Bupropion SR Wellbutrin SR® NDRI 4,588,996
Desvenlafaxine Pristiq® SNRI 3,412,354
Nortriptyline Sensoval® TCA 3,210,476
Bupropion ER Wellbutrin XL® NDRI 3,132,327
Venlafaxine Effexor SNRI 2,980,525
Bupropion Wellbutrin IR NDRI 753,516

 

The Need for Psychotherapy

In any case, medication should always be combined with psychotherapy. In the less severe forms of depression and those that seem to have an explanation and are “reactive”, medication often shows to be less effective and psychotherapy eventually leads in many cases to a full remission of the symptoms.

 

Dr Jonathan Haverkampf, M.D. MLA (Harvard) LL.M. trained in medicine, psychiatry and psychotherapy (psychoanalytic and CBT)  and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. The author can be reached by email at jonathanhaverkampf@gmail.com or on the websites www.jonathanhaverkampf.com and www.jonathanhaverkampf.ie.

This article is solely a basis for academic discussion and no medical advice can be given in this article, nor should anything herein be construed as advice. Always consult a professional if you believe you might suffer from a physical or mental health condition. Trademarks belong to their respective owners. No checks have been made.

© 2012-2017 Christian Jonathan Haverkampf. All Rights Reserved.