Anxiety and OCD articles

Book Review - Why Zebras Don't Get Ulcers

noreply@blogger.com (Paul Greene, Ph.D.) — Sat, 07 Nov 2009 19:17:00 +0000

We each have different ways of managing the stress in our lives. Make no mistake, we all have some stress to deal with. Most of us have been through times when the stress in our lives felt overwhelming. For many of us, these times are few and far between. But for some people, stress can feel overwhelming on a chronic basis.

Why Zebras Don't Get Ulcers, by Robert Sapolsky, Ph.D., explains in significant detail the similarities and differences between the human stress response and animal stress responses. One strength of this book, in comparison to other mass market books about science and health, is the emphasis on experimental science that has shaped our understanding of stress over the years. The author gives the reader credit for being able to understand the complex physiology of stress, and does not "dumb down" the material. If you are looking for "Chicken Soup for the Stressed," this book is not for you. There are no recommendations here for which type of scented candles will be the most relaxing during your bath; but there are descriptions of many of the important and groundbreaking experiments that form the basis for current knowledge about stress.

Some of these experiments fall under the topic of stress and illness. The links between stress, pain, the immune response, and various illnesses are covered, as are the effects of aging on our ability to handle stress. The relationship between stress and depression is also addressed, in particular the role of "learned helplessness." Learned helplessness is a concept established in animal experiments. The basic idea is that when we learn that we cannot control our environments to prevent negative experiences, we experience surprisingly negative consequences. We have trouble coping with situations that may have otherwise seemed quite manageable. We may assume that we cannot control other, unrelated, negative events that in reality are quite preventable. One of the reasons this concept has received the attention it has is because it is a testable theory. Unlike, for example, a theory that depression is often caused by an unresolved Oedipal complex, learned helplessness has been demonstrated in well-crafted experiments, some of which are described in the book.

If someone has "learned" that small stressors are unmanageable, it doesn't take a rocket scientist to see how that person may experience greater day-to-day stress. Cognitive therapy can help us "unlearn" some of these lessons. As adults, this learning takes the form of beliefs. These beliefs can be about ourselves, life, the world, or other people. Typically we do not stop to ask ourselves how accurate these beliefs really are. While we might be quite likely to stop and assess the validity of our other beliefs about religion (e.g., "God created mankind") or politics (e.g., "changing term limits for our mayors is a bad idea"), we seldom do the same for beliefs about our ability to positively influence our lives (e.g., "others don't find me likable"). Certain beliefs we have about our lives can have important effects on our stress levels, as Sapolsky explains.

Sapolsky explains about the importance of predictability and a sense of control as factors that impact how much stress we experience. An example can be seen in the contrast between two workers: one who averages 60-hour work weeks because she feels a sense of responsibility to get her sizable amount of work done; and another who averages 60-hour work weeks because her boss randomly demands that she stay late and work weekends. It is likely that the former woman will feel less stress because she feels a greater sense of control over the demands put on her, and sees her work schedule as more predictable. Sapolsky presents us with the scientific basis for these principles, explaining the animal experiments that demonstrate these ideas, and providing the human side as well.

The writer explained in an interview how his writing style was partially influenced by an experience during his graduate training, when he lectured on science to textile design students with little science background. During these lectures he describes feeling "an enormous pressure to be clear, and to have a good sense as to when people are about to go berserk with too many terms," and "when you have to stop and give an anecdote or metaphor." This sensitivity to the background and interests of the lay reader comes through in "Why Zebras Don't Get Ulcers," which is written in an engaging style that is typically easy to follow. While there are points in the book where some readers may feel overwhelmed with details about the secretion of glucocorticoids, by and large this book makes a very complex topic remarkably digestible for the average reader.

Am I Gay? Part II: Coping with Sexual Obsessions

noreply@blogger.com (Paul Greene, Ph.D.) — Sun, 22 Mar 2009 03:22:00 +0000

As previously described, obsessive thoughts about one’s sexual orientation are not uncommon for sufferers of OCD. How can one cope with these troubling thoughts? There are two strategies often used – one good, one bad. We’ll start our discussion with the bad.

Seeking reassurance about one’s sexuality is perhaps the most commonly used strategy for people with OCD who have sexual obsessions. Seeking reassurance can be either mental, or it can be behavioral. For a straight male, mental efforts to reassure oneself could be remembering all the women or girls that he had previously been attracted to or been involved with. Similarly, the man might imagine an attractive female and mentally “check” whether the finds the girl/woman attractive. It may be more common, however, for the OCD sufferer to engage in behavioral reassurance seeking. This is the strategy that Rob, in the companion article to this one, used in the airport. Examples of behavioral reassurance seeking can be seeking out members of the opposite sex, either to interact with or to look at, in the hopes of feeling an attraction. Some people with these types of obsessions will begin or continue romantic relationships partially for the purpose of achieving this kind of reassurance. Sharon (not her real name) was a heterosexual 22-year-old woman when she began to have obsessive thoughts that she was gay. She had been in three romantic relationships, all with men, and had never entertained the idea that she might be gay. Her best friend at the time was a gay woman. One evening, Sharon though that her friend was acting flirtatiously with her. She thought nothing of it, and was not particularly bothered by it. However, days later, the thought occurred to her that if she didn’t mind her friend’s flirting, she must actually be gay too. Why else would she have reacted the way she did? The thought sent Sharon into a panic. She felt that a rug had been pulled out from under her, as she had never had reason to question her sexuality before. She thought back to her experience in high school and college, thinking about whether she had missed any hints of attraction to gay women she had known in the past. She mentally reviewed some romantic and sexual experiences she’d had with men to “decide” whether she had really enjoyed them, or whether part of her just suffered through them. The more she tried to reassure herself that she was straight, the more unsettled and panicky she became. Eventually, she decided that she needed to become involved with a new boyfriend to feel sure about her sexual identity. However, Sharon was unable to free herself of these troubling thoughts despite her new relationship and all her best efforts.

This brings us to a more helpful strategy – anxiety tolerance can lead to long term reductions in anxiety and obsessive thoughts. When Sharon first came in for cognitive-behavioral therapy, she was unable to seriously entertain the notion that it can be helpful to experience the intense anxiety she experiences when obsessive thoughts about being gay came up. She had become so accustomed to seeking reassurance that she was straight that it was difficult to imagine doing anything else. When she began Exposure and Ritual Prevention therapy, she tried hard to learn to bear the anxiety that followed thoughts about being gay. With the help of her therapist, she trained herself to respond to that anxiety by talking back to it. She would say, “maybe enjoying flirty interactions with my friend means I am gay, or maybe not. It’s hard to tell,” and would then try her best to resist the temptation to “figure out” whether she was gay or not. This was difficult for her, but after working hard at her exposure exercises, she was able to change her response to these thoughts. Sharon noticed a decrease in the anxiety that such thoughts caused her. Eventually, the thoughts became less frequent, as well as less distressing. Her therapist explained that through her hard work, she had taught herself to tolerate the anxiety associated with her obsessions instead of giving into her compulsive urge to reassure herself. Sharon left cognitive-behavioral therapy feeling much better prepared to deal with obsessive thoughts about her sexual identity. Her symptoms had all but disappeared.

Sharon was lucky to have found a therapist that correctly understood her symptoms as a type of obsessive-compulsive pattern. Many people who have come to see me describe talking to many friends, therapists, and other well-meaning people who have told them that “it’s okay to be gay,” “we still accept you for who you are, gay or not,” or even, “I went through a similar tough time when I realized that I was gay.” As well intentioned as these sentiments may be, they are unhelpful to the person with sexual obsessions, who often comes away from these conversations feeling more misunderstood than before. Therapy in particular can be dangerous for people with sexual obsessions if the therapist does not have expertise with OCD and sexual obsessions. Unfortunately, these patients are sometimes told that their confusion is due to denial or to repression of their true identity, and that the sooner they face up to that, the better. Mike (not his real name), a heterosexual man, was 21 when he came to see me about his OCD. He had seen two prior therapists who apparently misunderstood his sexual obsessions as a part of the coming out process. Mike suspected he had OCD, and was aware of research suggesting that cognitive-behavioral therapy can be helpful. In college, Mike was told by some friends that he was likely “fighting a losing battle” against realizing that he was gay. After having struggled with obsessive thoughts about being gay all through high school and college, he decided to have a sexual encounter with another man, in order to perhaps gain some certainty about his sexuality. While he came away from the experience feeling assured that he was straight, he described lingering regret that “(he) was so confused” at the time. Using the techniques of Exposure and Ritual Prevention therapy, Mike eventually learned to manage these thoughts by coming to accept the possibility that he might be gay, while at the same time accepting the possibility that he might be straight. Becoming more comfortable with the uncertainty in the combination of those two ideas is a key skill. While Mike never saw the obsessive thoughts disappear completely, he learned to manage his response to them such that they were no longer distressing.

Sexual Obsessions: "Am I Gay?"

noreply@blogger.com (Paul Greene, Ph.D.) — Sun, 30 Nov 2008 20:34:00 +0000

Obsessive thoughts can come in several varieties. Among the most popular themes for these thoughts are blasphemy, violence, and sex. One thing all obsessions have in common is that they consist of a thought (e.g., “I want to pick up that knife and stab myself”) followed by intense anxiety at having had that thought. Another thing obsessions have in common is that it is difficult to completely disprove the fear they describe. For example, if someone has an obsessive thought about harming themselves, how can they definitively prove that it’s not true? If someone has an obsessive thought like “I hate God,” how can they then convince themselves that they don’t? If someone has an obsessive thought about wanting to sexually molest their dog, how can they prove to themselves that they will never do it? For people with OCD, the uncertainty that accompanies these situations can be very distressing.

This is the paradox of obsessive thinking: we become anxious about the possibility of something that we cannot prove or disprove, and the search for such proof only leads to more anxiety. One example of this process can be seen in obsessive thoughts about being gay. This is not an uncommon type of obsessive thought to have, typically for heterosexual people suffering from OCD. (Someone who identifies as homosexual, on the other hand, might be vulnerable to obsessive thoughts about being straight.) For the person with this type of obsession, finding immediate proof that one is not gay can be difficult. After all, how do people “know” whether they are straight or gay?

Take, for example, the case of Robert (not his real name), a straight man in his later 30s. Robert had struggled with OCD since his late teens, and had dealt with symptoms as diverse as excessive handwashing, having to get up and sit down “just right,” and obsessions about harming others. For Robert, the obsessions about being gay started suddenly. When in an airport terminal with some time to kill, he wandered into a bookstore, and was looking at the various magazines. One of the magazines, Mens’ Vogue, featured a picture of an attractive male actor on the cover. Rob noticed that he had a hard time taking his eyes off the picture, and thought, “I like the way he looks.” This was followed by the thought, “Does this mean I’m gay?” and Rob immediately became very anxious. He had never even wondered before whether he was gay or straight. He had been in several heterosexual relationships, and never been involved with another man. In Rob’s very alarmed state of mind, he wracked his brain to reassure himself that he was straight. He looked at the magazines with attractive women on the cover to gauge his reaction. He looked for an attractive woman in the terminal, and finding one, looked at her to see if she “did it” for him. After a while, he was able to reassure himself that he was not, in fact, gay. However, Rob was not able to prevent this thought from coming back, and was troubled by this fear that he might be gay for years following the incident in the airport.

How can we effectively deal with these types of troubling thoughts? Check back for Part 2 of this article to find out.

How to Pick a Therapist

noreply@blogger.com (Paul Greene, Ph.D.) — Wed, 26 Nov 2008 18:17:00 +0000

It can be difficult to decide if and when psychotherapy would be helpful. There are many different ways people make this decision. A general guideline that I offer is what might be called the “interference rule.” That is, if a problem is significantly interfering in your ability to live your life the way you’d like, then psychotherapy may be helpful.

Another question follows. Once you’ve decided to seek help, how should you go about finding a therapist?

There are a few factors to consider in making this decision. One factor to consider is finding a therapist with competence or expertise in the issues you want to work on. While it is impossible to have an exhaustive list of issues that prompt people to seek therapy, here I will discuss a few common issues and how to find a qualified therapist for each.

For issues to do with a romantic relationship, it is helpful to see a therapist qualified to do couples therapy. Even if you’re not interested in couples therapy at the beginning, it’s useful to have this option available.
For issues relating to a very difficult experience such related to a car accident, an assault, a rape, the attacks of 9/11/01, or other life-threatening experiences, it is helpful to find a therapist qualified to use cognitive-behavioral therapy (CBT). CBT that includes something called “exposure” has been shown in clinical research trials to be effective for these types of difficulties.
For depression, there are several types of psychotherapy that have been shown to be helpful. Three of the best known are interpersonal therapy (IPT), CBT, and behavioral activation. Click here to for a nationwide listing of qualified therapists competent in one of these areas.
For issues relating to overuse of alcohol or drugs, I recommend finding a therapist with a specialty in substance abuse issues, particularly one who has significant experience treating addiction. It is not necessary to find a therapist with a personal history of addiction, although some people find this helpful.
For issues relating to eating – including anorexia, binge eating, etc. – I would recommend contacting an eating disorder treatment center, even if it’s not local to you. The reason for this is that larger centers such as the Renfrew Centers can refer you to a local provider with the relevant expertise.
For panic attacks, anxiety attacks, chronic anxiety, or phobias, it is important to find a CBT therapist. One effective way to do this is to visit the provider listing at http://www.abct.org/, which permits searches by locality.
For difficulties stemming from perfectionism, obsessions, compulsively repeated behaviors, “germophobia” or contamination fears, it is important to seek out a therapist with training in Exposure and Response Prevention, a type of CBT. http://www.ocfoundation.org/ is a good resource for this, and has a nationwide therapist directory.

Another factor has to do with the training of the therapist. (For more information on this, see http://drpaulgreene.com/2006/08/frequently-asked-questions.html.) Many therapist listings will turn up results that include all kinds of professionals, including Psy.D.s, L.M.H.C.s, Ph.D.s, LCSWs, M.D.s, and several others. There are no hard and fast rules I can offer about which of these types of professionals make the most effective therapists. However, there are important differences in the training of each.

Social workers (LMSWs, LCSWs) have completed at two years of graduate training to attain their degree. LCSWs, specifically, have also completed at least 3 years of clinical training after getting their MSW degree; this is not a requirement however for LMSWs.
M.D.’s (psychiatrists, typically) are the only group of professionals trained to prescribe medication. Sometimes medication is necessary, sometimes it isn’t. Psychiatrists have typically completed four years of medical school and, typically, a 3-4 year residency in psychiatry. Some psychiatrists only provide medication management with periodic meetings that can vary in frequency from monthly to biannually or less frequent; some psychiatrists also provide weekly therapy (although this may be less common).
LMHCs (licensed mental health counselors), LCATs (licensed creative art therapists), and MFTs (marriage and family therapists) have typically completed a 1.5 to 2 year masters degree in counseling.
Psy.D.s and Ph.D.s (psychologists) typically complete doctoral training of 5-7 years, and in NY state must complete one additional year of training before becoming licensed. Psychologists, in this author’s opinion, are the most likely to have extensive training in specialized therapy for a given problem or disorder.

Another factor to consider in picking a therapist is the "match" between you and the therapist. Research on psychotherapy has consistently shown that the more that the better your relationship with your therapist, the more you feel you two are on the same page, the more effective the therapy will be. It is important that you feel your therapist understand what you want to get from therapy, and that the two of you agree on how to accomplish that.

If you leave your first therapy session with serious concerns about your compatibility, consider trying out another therapist. While this represents an additional commitment of time and money, it may be well worth your while.

Buddhism and Cognitive-Behavioral Therapy (CBT)

noreply@blogger.com (Paul Greene, Ph.D.) — Wed, 21 May 2008 02:24:00 +0000

"In the words of the Buddha, … ’We are what we think. All that we are arises with our thoughts. With our thoughts we make the world.’ It's an idea that's in line with current thinking in psychology. In fact, this simple philosophy – that changing the way we think can change the way we feel – underpins the very practice of Cognitive Behavior Therapy (CBT), an approach widely used in clinical psychology and counseling, as well as stress management programs.” So writes Kathy Graham, in a thoughtful article on Buddhism and happiness, which can be found here.

The radical and powerful notion that our thoughts make up our realities may seem silly at first, especially when we think of how important circumstances can be in our lives. Even the word “reality” itself is often used in such a way as to connote external circumstances; for example, the phrases “back to reality,” “harsh reality,” or “the real world” usually refer to external circumstances, not our own thoughts. A typical example of how someone might describe their “reality” would include the facts that they are a single mother, 42 years old, working as a project manager at a big company, and making mortgage payments on a condominium. But are these facts enough to explain our experience? This question deserves some thought; on one hand, this is how we usually define our “reality,” but on the other, it’s easy to imagine how two people in these same circumstances could have quite different experiences. One person might be more optimistic and cheerful, enjoying each day, whereas someone else might be more pessimistic and anxious, and enjoy life less.

But what is it that makes one person anxious and other person optimistic? We each have our tendencies toward different thought patterns. We can call these tendencies by various names: personality traits, temperaments, reactions to formative experiences, genetic predispositions, or what have you. However we understand these tendencies, their moment-by-moment impact on us happens via our thoughts.

One of the most important aspects of cognitive therapy is the idea that we can change the content of our thoughts, and thus impact how we feel. Many of us have tried to change the way we think about something, with varying degrees of success. A common example would be the ex-boyfriend or ex-girlfriend, trying to resist temptation to reunite with their ex, that resolves to think only of their negative qualities or to convince themselves their ex is a horrible person. This is not the focus of cognitive therapy, where the therapist focuses on helping you understand how certain thought patterns are

1) contributing to making you more depressed or anxious, and
2) not necessarily based on sound reasoning.

For example, someone who is depressed may tend to have more thoughts like “I can’t do anything right,” or “No wonder he doesn’t like me, I’m a loser” than someone who is not depressed. Someone who tends to be anxious, on the other hand, may tend to have thoughts like “This is going to be a disaster,” or “Why hasn’t she called? She must have been in accident.” For whatever reason, we have a tendency to believe these thoughts a bit more than they deserve. Looking at the examples above, it’s not hard to see how a close examination might show that the statements the thoughts may be exaggerations or false predictions based on insufficient evidence. Even though on some level we know this, we often have difficulty extricating ourselves from the sadness and anxiety such thoughts can bring on. This is where cognitive therapy can help.

To return to the quote excerpted in the Kathy Graham article, “We are what we think. All that we are arises with our thoughts. With our thoughts we make the world,” it seems that the third idea, ‘with our thoughts we make the world’ seems most consistent with cognitive therapy. At least, the notion that with our thoughts we influence our mood and anxiety is quite consistent with cognitive therapy. But let’s look at what the quote is really getting at. The quote is a statement about something deeper than just mood or anxiety, it’s talking about reality. The idea that “we are what we think” may sound like a cute maxim suitable for getting a laugh at cocktail parties, but it refers to the Buddhist notion of anatman, the idea that at the core of our beings, there is no individual self. Rather, what we mistakenly identify with as a “self” is a combination of a physical body, sensations, emotions, and bundles of thoughts. The Buddha would suggest that if any of us were to closely inspect this “self” through meditation, we would realize that it has no inherent nature or existence; that it is an illusion of sorts.

Cognitive therapy focuses not only on thoughts that contribute to depression and anxiety, but also on beliefs that serve the same function. The difference between thoughts and beliefs is that thoughts are events in time lasting only for a moment, whereas beliefs are more stable and long-lasting. Beliefs can range from the specific, e.g., “I’m no good at bowling, I’ve never been any good at bowling” to the global, e.g., “I’m unlikeable,” or “I am really good at everything.” We all have lots of beliefs like these, covering the full range from the specific to the global. These beliefs span wide ranges of accuracy, helpfulness, and healthiness. Cognitive therapy considers these beliefs to be relevant, sometimes, to why we experience depression, anxiety, or other problems. From the perspective of Buddhist psychology, these beliefs begin to comprise what we think of as the self. Consider the example of a 68-year-old male, recently retired from a successful career as a bussinessman in New York. Several months after retirement, he began to become depressed and tried to re-enter the business world. His involvement was not as welcomed as he had hoped, and his mood became more depressed as he realized he would not be able to resume his career. Eventually he sought treatment for depression. This man identified with his career to such an extent that once it was over, he was unsure how to think of himself. A cognitive therapist might contend that he could no longer rest on his beliefs about himself as an effective businessman, and depression followed. Buddhist philosophy might suggest that the man had relied on an illusory conception of himself; the illusion was that of stability and permanence. This leads us to the phrase quoted from the Buddha, that “all that we are arises with our thoughts.”

We have a tendency to want to believe that something about ourselves is permanent. We would like to think that many things about us are not subject to change. One of the fundamental concepts of Buddhism is anicca (flux, or impermanence). This is the idea that everything that comes into existence will eventually cease to exist. This applies to everything from the Roman Empire to a blade of grass. It applies to people too; for the retired businessman mentioned above, he relied on an identity as a successful businessman in such a way that he didn’t really think it would end. When it did, the effect was similar to a rug being pulled out from under him. When considering the Buddha’s quote, “all that we are arises with our thoughts,” we need to remember the importance of anicca. According to Buddhism, there is nothing permanent in what we regard as the self. Just as all things are subject to continual change, each of us is constantly changing. So if we pin our identity on one aspect of our lives, like the retired businessman did, eventually we will be left in a bit of a crisis. In saying that we are nothing more than our thoughts, the Buddha is saying that not only is there nothing solid in our existence, but that what we think of as ourselves is generated by our own minds.

While this philosophy is clearly a further-reaching model than that described by cognitive therapy, we can see that the two are more consistent with one another than one might think.

What are ERP and ExRP?

noreply@blogger.com (esq.) — Thu, 08 Feb 2007 04:17:00 +0000

ERP and ExRP are kinds of psychotherapy used to treat obsessive-compulsive disorder (OCD). ERP stands for Exposure and Response Prevention. Innovations in this psychotherapy over the past ten years resulted in its being given a new name: Exposure and Ritual Prevention (ExRP). The two therapies are similar, and both build on core behavioral therapy concepts. The purpose of this article is to provide information about what these therapies involve, and how they might be helpful to people suffering from OCD.

OCD is a psychological disorder that has been documented for thousands of years. OCD is characterized by the presence of either obsessions, compulsions, or both. Obsessions can be thought of as intrusive thoughts that cause anxiety. They are difficult to get rid of, despite one’s best efforts. Compulsions are activities, often performed repetitively. We often experience anxiety when we are not able to perform the compulsion.

For several decades after the early psychoanalysts wrote about obsessions (starting in the late nineteenth century), treatment for OCD would typically involve psychoanalysis that strove to root out the unconscious cause for an obsession. More recent thinking in the field conceptualizes obsessions and compulsions a bit differently. Recent research has shown that obsessions and compulsions respond to treatments that do not focus at all on unconscious causes; successful psychotherapeutic treatment will typically focus on developing new ways of responding to the obsessions and compulsions in the here and now, regardless of their cause. While there has been much theorizing and speculating about the origin of obsessions, there has not been a research-supported consensus in the field about what causes OCD. However, therapies like ERP and ExRP have been shown to treat OCD successfully without focusing on the cause, whatever it might be.

When an obsessive thought occurs, feelings of anxiety will usually occur as well. The anxiety is very uncomfortable, and as a result, people with OCD typically engage in an activity that they have found will relieve the anxiety. This can take many forms. For some, a behavior like washing one’s hands will relieve the anxiety. For others, seeking reassurance from a loved one or other source will relieve the anxiety. In the past several years, the internet has become an increasingly popular resource for people with OCD who seek to reassure themselves, and thus lower their level of anxiety. Still others with OCD would love to find something that would relieve their anxiety, but have not been able to. Whatever the strategy used to deal with the increased anxiety, the unpleasant feelings are seen as scary and as something to get rid of, if possible.

Cognitive-behavioral therapies like ExRP try to change one’s reaction to these unpleasant feelings. By doing so, one can experience obsessive thoughts and the need to perform compulsions a bit differently. This kind of change is a difficult one to enact, and takes some hard work. Much of this hard work will come in the form of “exposure” exercises that will be discussed by you and your therapist. Through these exercises, one can gradually learn to tolerate feelings of anxiety better. The OCD sufferer is “exposed” to feelings of anxiety during the exercise, which helps break some unhelpful patterns that have been established. These patterns have often taken shape over several years of OCD.

It is often said that we are creatures of habit. This is certainly true in a brief examination of how OCD can become entrenched in our thoughts and behavior. People suffering from OCD have often developed habitual ways of dealing with feelings of anxiety when they arise. If these habits result in a quick lessening of anxiety, then each time we do it, the habit becomes a bit stronger. This is a basic principle of behavioral psychology called negative reinforcement. Negative reinforcement is when the removal of a negative stimulus follows performance of a certain action, thus making us more likely to perform that action again next time.

For example:

Sara (not her real name) experienced anxiety whenever the thought of AIDS came into her mind. She found that she could reduce this anxiety by checking on the internet to confirm that nothing she was doing in her life right now put her at risk for contracting HIV. Sara was rewarded for her internet research with reduced anxiety. While she had found a short-term fix for her anxiety, she found that over time, she had to spend more and more time on the internet. This began to impact her personal life and her work life.

Exposure
One centrally important aspect of therapy for OCD is exposure. This will take different forms depending on the nature of the obsessions or compulsions. For Sara, the woman described above who had obsessive thoughts around HIV and AIDS, the exposure exercises would address her reaction to those thoughts. If Sara found herself thinking, “what if I got HIV when I was at work yesterday,” then when she was ready, her therapist would probably recommend an exposure exercise addressing her reaction to that thought. Sara might try to “expose” herself to the idea that it is possible that she did, in fact contract HIV at work yesterday. Often, such an exercise will have very little appeal to the person with obsessions about HIV contamination. If one has already invested so much effort in steering clear of the risk of infection, why go out of one’s way to contemplate the possibility of infecting oneself?

The answer to that is that beating OCD involves changing your habits. Sara, from the above example, had gotten herself in the habit of checking on the internet whenever she became anxious that she had become contaminated. If a website could convince her that she was not infected, she would feel at ease once again. With the assistance of her therapist, Sara began doing exposure exercises that involved purposefully refraining from going on the internet when she was anxious about contamination. She exposed herself to the anxiety that accompanied thoughts of HIV infection without responding in her habitual way. When done correctly, this type of exposure exercise has the effect of helping achieve a long-term reduction in obsessions, and in the anxiety they cause. Sometimes these exposure exercises will last only a few minutes, sometimes significantly longer. These exercises are not designed to make you feel better in the short term; they are designed to help you in the long term by helping you build a different relationship with your obsessive thoughts.

Rituals
Some people with OCD find that they have to do certain things in order to make their anxiety go away. These are called compulsions, or compulsive behaviors. Sometimes these actions are relatively simple, as Sara’s habit of going on the internet to get information about HIV infection. Other examples of compulsions can be even quicker, such as washing one’s hands, or checking to make sure the stove is off before leaving home. However, some compulsive behaviors take a long time. Some compulsive patterns actually involve a series of behaviors. For example, many people with OCD describe taking long showers. They describe having to wash themselves in a particular way, sometimes washing the same area a set number of times. This is an example of something called a ritual, which is a series of compulsive behaviors. It is possible for these rituals to have a significant impact on the life of the person suffering from OCD.

It is this type of ritual referred to in “Exposure and Ritual Prevention.” The example of Sara refraining from checking on the internet discussed above describes one type of “ritual prevention.” Another example can be seen in the example of Robert:

Robert (not his real name) came to see me because he had been arriving later and later to work. This had caused him to be reprimanded by his supervisor on three different occasions, and he was concerned about his job security. Robert had OCD, and was engaging in rituals at home in the morning which made him late for work. In the beginning, he was able to just stop them when he had to leave the house, but eventually he was unable to do even that. His ritual began with trying on every pair of shoes in his closet to see which one felt the best. This was not so time consuming. Eventually, his ritual became more complex and he described needing to try on every shirt, pair of pants, and jacket he owned before he left the house. This left Robert feeling exasperated; he knew that it was unnecessary to try on so many different articles of clothing, and was especially frustrated at his felt need to try on jackets even in the summertime, when he wouldn’t wear one anyway.

This example illustrates two important characteristics of rituals. For one, this ritual started out seeming harmless, but eventually became complicated and time-consuming. Secondly, Robert described knowing that his behavior was excessive and unnecessary, but eventually found himself feeling powerless to stop the ritual. This is often the case, and a very frustrating part of OCD. Fortunately there is hope for people suffering with this type of ritual to get some help.

Robert was able to effect lasting change through his work in Exposure and Ritual Prevention. Once he understood how OCD had put him in this situation, and how he could make some changes, he began to use exposure exercises to gradually change his ritualizing. First, he was able to experience the anxiety that came up when he decided to limit his trying on of jackets to three. Through the exercise he began to retrain his autonomic nervous system – he taught himself how to tolerate the unpleasant feelings that accompanied leaving something incomplete. After a while, he was able to skip the jackets altogether, and eventually was able to get dressed in only five minutes’ time. Robert described this process as a challenging one, but one he was ultimately very pleased about.

Can ExRP bring about lasting change?
One advantage of ExRP and other cognitive-behavioral therapies over medication is that you can use the skills you learn in therapy to change how you deal with anxiety and OCD. This is often a long lasting change. While medication is often helpful to reduce symptoms of OCD, many patients report that they are again vulnerable to obsessions and compulsions once they come off their medication. Many of the patients I have seen tell me that they feel better equipped to handle OCD because of therapy, although they often say it remains a challenge after therapy is over. Some describe having few to no symptoms of OCD after ending therapy. Others describe having persistent obsessions and compulsions, although these have a lessened impact on their lives. It is very difficult to predict what kind of an outcome someone will have in therapy. However if someone is willing to learn “new tricks,” and willing to put in the effort required of the exposure exercises, there is every reason to be optimistic about their ability to benefit from therapy.

Dissertation excerpt: STRESS REACTIVITY, HEALTH, AND MEDITATION: A Path Analytic Approach

noreply@blogger.com (esq.) — Thu, 08 Feb 2007 02:50:00 +0000

Following is the conclusion section of my dissertation. The dissertation itself is currently in preparation for publication.

The present study found some meaningful relationships between meditation variables, stress reactivity, and health variables. Stress reactivity was strongly negatively correlated with several physical and mental health variables. Stress reactivity was also shown to be more strongly associated with recent meditation and health variables than were total stress or number of stressors. Overall, the present study found that stress reactivity is a meaningful variable in ongoing efforts to understand the meditation’s mechanisms of action.

Recent meditation appeared to be more important to stress reactivity than was lifetime meditation experience. Additionally, recent meditation was significantly associated with vitality and mental health, whereas lifetime meditation experience was not; implications of this for MBSR research include the importance of continued mindfulness meditation practice to maintaining positive health outcomes. The notion of trying to effect change in perceived stress by altering meditation habits was bolstered by the path analysis results. It is recommended that future research explore ways to effect patients’ continued regular meditation practice after completion of MBSR.

This study has been a first step in investigating questions involving stress reactivity and meditation. A clear next step involves testing some of the relationships found in the present study in a clinical study of a meditation-based clinical intervention. Such research could eliminate remaining questions from the present study due to the sample’s limited range of the education level and baseline health status variables. Further research could also investigate the possible mediating role of stress reactivity in the relationship between completion of a meditation-based treatment and healthful outcome. Additionally, future research on stress reactivity could investigate the role of neuroticism or other relevant personality variables.

Anxiety and Depression in Patients Recovering from Bone Marrow and Stem Cell Transplants

noreply@blogger.com (esq.) — Sun, 21 Jan 2007 02:55:00 +0000

A stem cell transplant (SCT) or bone marrow transplant (BMT) is a procedure used in treatment of various types of lymphoma, leukemia, and some other cancers and disorders of the blood. While this procedure has existed for decades, it came into more common use in the early 1990’s. The effectiveness of transplant varies according to the diagnosis, age, and health of the recipient. The present article aims to give general information about the experience of transplant, and purposely omits statistical information and other specifics. If you are considering bone marrow or stem cell transplant as a treatment option, please consult with your doctor for the most accurate, personally applicable, and up-to-date information. Other information resources can be found at the National Marrow Donor Program and the Leukemia and Lymphoma Society.

Patients who are preparing for a bone marrow or stem cell transplant first receive what is called “conditioning” regimen, which will prepare the body for the transplant. This will typically involve chemotherapy, radiation, or both. This phase of treatment aims to reduce the number of diseased marrow cells, sometimes down to zero. The bone marrow is the center for the body’s immune system. Thus, during and after the “conditioning” phase of treatment, immune functioning is weakened, and precautions are taken to avoid infections. Most cancer centers and some major hospitals will have a unit devoted exclusively to stem cell and bone marrow transplant; these units are specifically equipped to minimize risk of infection to patients with weakened immune systems.

Recipients of bone marrow transplant and stem cell transplant can typically expect a recovery period that takes several months. The first few weeks of the recovery period is spent in the hospital, at a transplant unit. Several weeks after transplant, if the patient is healthy enough, he or she is then discharged from the hospital to continue the recovery process at home or, in some cases, in local residential facilities affiliated with the hospital. During this time, patients are asked to follow a specific diet, and to take other steps to minimize exposure to infection. Patients are often asked to avoid crowded public places, like movie theaters. Some patients find that they are soon able to fully return to their previous lifestyle, while others find that they do not return to prior health or energy levels for extended periods after their transplant.

My own clinical experience with survivors of stem cell or bone marrow transplant has primarily been with people who are 1-2 years after their transplant. After a year of recovery, many people find that they have no, or relatively few, symptoms resulting from their transplant. Others find that some physical symptoms continue to bother them. The most common physical symptoms are fatigue, trouble sleeping, and sexual difficulties.

Research has shown that after a year of recovery, about three quarters of survivors of transplant will experience some symptoms of anxiety or depression. Of these, one third find that the depression or anxiety has a substantial impact on their lives. Some patients describe these difficulties as stemming from the illness itself, as opposed to the transplant. Most patients who receive a bone marrow or stem cell transplant do so because they have a serious illness that has the potential to recur (e.g., leukemia, multiple myeloma, or lymphoma). For some, this possibility is the primary cause of any distress. For others, the shock of their initial diagnosis was a traumatic event that still causes real distress. Other survivors say that the experience of transplant itself has been hard to “put behind them.” Many describe reminders of the transplant and subsequent recovery as causing significant distress. Experiencing such reminders as upsetting is a common phenomenon for survivors of any life-threatening experience, including a diagnosis of cancer and BMT/SCT.

Fortunately, research has also demonstrated that the kinds of distress described above can be effectively addressed with cognitive-behavioral therapy. The aim of this type of therapy is to focus on the thoughts and the behaviors that help maintain symptoms of depression and anxiety, and then to address these symptoms with proven methods. For example, a survivor who is depressed may be experiencing thoughts like, “My leukemia will definitely come back,” or “everything bad always happens to me.” There are many other such possibilities as well. The survivor who entered cognitive-behavioral therapy would learn about the impact of these thoughts, and would be encouraged to explore the factual bases for the thoughts. This type of exploration is always done in collaboration with the therapist.

Other survivors report that reminders of their illness and their transplant cause them significant anxiety and distress. Something as seemingly innocent as a bar of soap might remind the survivor of a soap that was used in the hospital, and thus evoke feelings of anxiety. Sometimes this anxiety has a physiological component to it, and may involve increased breathing rate, heart rate, and muscle tension, e.g. The anxiety may also result in the survivor avoiding the reminder in question. This may not affect the survivor’s daily life. However, if the reminder is commonplace, this avoidance can have a substantial impact. For example, imagine the long-term effects of avoiding soap.

Fortunately, as mentioned above, it is a minority of patients that experience the symptoms of psychological distress just described. For these patients, it is also fortunate that cognitive-behavioral therapy provides a proven option to address the depression and anxiety that can follow SCT/BMT.

Comments or questions? Contact the author at Dr.Paul.Greene@gmail.com