Posts tagged Mental health
Today I will approach the problem of depression, but from a particular vantage point – that steeped in cognitive theory and informed by the work of Martin Seligman.
There have been other views about depression- a psychoanalytical one whereby depression was deemed as rage turning upon inwards and directed towards the self; and a biomedical one whereby depression is considered a disease of the brain/body- imbalances in neurotransmitters etc. . Seligman rejects both models and considers depression (even clinically defined) as just the other extreme of response to loss etc. This is important to note as unipolar depression, clinically defined, is usually considered a type rather than a degree phenomena, i.e. people in depressive phase are qualitatively different from those who are not clinically depressed as per the prevalent model.However, note that even Seligman considers the mild form of depression as distinct from sadness.
The theory of depression that Seligman and colleagues came up with is based on his famous experiments with dogs whereby experimental dogs were subjected to uncontrollable mild shocks while the control dogs either received no shocks or shocks that they could stop and control. When the dogs who were subjected to uncontrollable shocks were placed in anew chamber whereby they could escape shocks by climbing over a low barrier, they sat passively. They had learned or internalized that nothing they do with respect to shocks makes the shocks go away and had even generalized it to new situations when things were actually under their control. Also the feelings of helplessness reflected in many diverse behaviors like less aggressiveness or exploration etc and was sort of generalized across situations too. So not only the experimental dogs made permanent attributions about their lack of control, but also pervasive attributions and thus became depressed.
Seligman and colleagues designed and executed similar experiments with rats and also humans. Using these experiments they were able to create a model of depression. That model of depression requires different things to come together, but typically as its called learned helplessness model of depression, the focus has been on the learned helplessness following a loss of control.
The different components of the model, when explicated, have different implications for treatment/ prevention. To start with before the process can start one has to have loss of control – if our environments provided more opportunity for control over our experiences and in general if people learned to feel more in control of their life, despite losses and all, then the chain stops at its beginning itself. While some losses are inevitable, say loss of loved one, other losses like pink slips can be minimized and then no matter what the loss is , one can choose one’s own attitude towards the loss – the last of human freedom’s as per Frankl.
Once loss/ dejection/rejection/ loss of control has happened, almost all of us will temporarily become helpless. However, becoming helpless is not same as becoming mildly depressed too. For some of us who have a habitual pessimistic explanatory style, in terms of seeing the negative events in our lives as being permanent and pervasive, the learned helplessness turns into momentary , mild depression. We have sad affect, disturbed sleeping, eating etc. However, for those who have optimistic explanatory styles, we re-bounce from the learned helpless and do not become depressed. So changing the habitual explanatory style is another intervention opportunity.
Finally, the mild and momentary depression become full-fledged clinical unipolar depression, when the symptoms continue for 2 weeks or more and as per Seligman this happens when one adds a ruminating thinking style to the mix. Thus a person who has a pessimistic style and also keeps thinking about his own thoughts is more likely to get clinically depressed. Again , if we can prevent or reduce rumination we can prevent the clinical variant.
Cognitive behavioral therapy , which has been found to be quite effective for depression, has been shown to work on some of these aspects increasing optimistic explanatory style and challenging negative automatic thoughts but probably can be augmented by focusing on preventing rumination and story-editing techniques to re-frame issues of loss and control.
In the end, in my view depression has complex roots – some steeped in biology and temperament, while others due to environmental stressors and our reactions to them. A clearer understanding of the learned helplessness model of depression is likely to aid in therapy.
I have Obstructive Sleep Apnea (OSA). I am also bipolar.
Now which of the above statements shocked/ surprised you more? If I am guessing correctly the latter statement about my being bipolar came across as more of a shock/ surprise/ concern. Now what does that say about your own reactions to mental illness and your own involvement in perpetuating the stigma against mental illness?
Both of the above are chronic diseases to an extent. My OSA (snoring in popular parlance) cannot be treated by surgery, so the only viable option I have is to use a CPAP machine while sleeping to get a good night’s sleep. Bipolar disorder as we all know can only be contained, and I take my medicines regularly to ensure that there are no relapse into either a manic or a depressive episode.
Both, if un-diagnosed and untreated can cause havoc. OSA which was un-diagnosed/ untreated for about a couple of years or so in my case led to excessive daytime drowsiness, less alertness and lowered productively etc; if untreated OSA can cause increased risk of injury to self and others while driving as you may actually get into micro sleeps while driving. Even if not that dramatic, on a daily basis the quality of your sleep and waking life can become very diminished. The downsides of having a manic or depressive episodes are well known- at least to readers of this blog. However, what may be less well known is that even in the throes of psychotic extremes, the risk to others from violence by bipolar people is very little and if anything they may be subjected to violence than otherwise.
When treated, that is when I use my CPAP machine regularly I have no problems at all due to my OSA either in my work life or in my personal life – I am as refreshed in morning as ever. Rather I believe I might be getting better sleep than the average person. When treated, that is when I regularly use medicine, and take other precautions like having regular sleep cycles etc for my bipolar, I am totally episode free- rather I believe I have an advantage when it comes to managing my energy and mood.
However, given all the above, which disclosure do you think has drastically lowered my chances of employment (if I was seeking employment, which I am thankfully not:-)); which disclosure would have led to discrimination in the workplace or at least got me some amused and funny looks? About which of these are my friends and acquaintances likely to gossip more? Why as a society we are still not that accepting of mental illness and stigmatize those who have it?
Some immediate consequences I can think of:
- readers of The Mouse Trap will no longer take my interest in psychology as non-partisan. They will think of me as being interested in psychology only due to my being bipolar (to set the record straight I became interested in psychology in 1996 during my IIT delhi days, while my first episode happened while I worked with Hughes in 2001). Also when I take a position like association of biploar with creativity, I will be considered biased; however nobody will say that a ‘normal’ person advocating otherwise is biased due to his being ‘normal’.
- Some will start to see signs of craziness in my old/ new posts and wonder whether when I was writing them I was in a normal frame of mind or episodic. Its usually my style to try and combine seemingly disparate research ideas and that is especially prone to this analysis.
- I will start getting sympathy, but like anyone living with say OSA or diabetes etc I think one should just ignore the fact about my being bipolar and not let it redefine my relationship with you. I am much more than a person with bipolar or OSA, and I prefer it that way.
- there will be some embarrassment for my near and dear ones.
Why did I not disclose for so many years?
- because I feared discrimination (and funny looks) at the workplace. It might have been imaginary but I was not strong enough to experiment. Now that I am self employed the stakes are much lower and I don’t care.
- I myself was grappling with my being bipolar. For initial some years it was hard to accept; later I struggled with accepting medication as necessary ; but now for quite some years I am at peace and thankfully episode free.
- As I believe it never affected adversely my performance at work , I did not deemed it necessary to inform my employers etc as I thought ,and still think, its none of their business.
Why did I decide to disclose publicly about this?
- I have no delusions (pun intended) that I am Deepika Padukone that my talking about a mental health issue is going to raise awareness drastically; still I want to do my bit to fight stigma and the journey starts with oneself. I had a decent career in software despite my being biploar and being biploar hasn’t stopped me from taking risks and experimenting with a second career; hopefully that can inspire or provide mental support to a person or two.
- Some immediate triggers- a mouse trap reader on facebook privately messaged me asking if I only have theoretical knowledge about psychosis etc or if I had some personal experiences too. I think it was a legitimate question that deserves a legitimate answer.
- Another immediate trigger- I came across a tweet by https://twitter.com/akhileshlinky about his year end ‘confession’ about being bipolar and I though heck why not ‘come out’ yourself.
- but really, it doesn’t matter to me one way or other – the only upside of sharing more publicly is that it can help combat stigma.
What I expect from you?
- don’t define me exclusively as being biploar.
- reflect on your own attitudes about mental illness and try to overcome that implicit bias
- resist discrimination and stigma
Lastly, thanks are due to my family and friends who have been prone to this ‘secret’ over the years and who have provided the necessary support and encouragement.
Most of us have heard about the BioPsychoSocial model of mental illnesses and have also heard about the stress-diathesis model. Today as I was contemplating the two, taking cue from my ABCD model of psychology, I tried combining the two and find quite some merit in that approach.
To recap, BioPsychoSocial model says that any disease is a result of multiple interacting factors- some of them biological in nature while others psychological and social. The mind affects the body and the body affects the mind and together they may lead to health or illness. This model is as opposed to the BioMedical model which considers the disease to be predominantly due to biological factors.
The stress-diathesis model posits that people have underlying biological or psychological vulnerabilities and when exposed to an environmental stressor may develop a mental disease with varying probabilities. The same stressor may be harmless to a person who does not have those many vulnerabilities, but prove detrimental for someone with the right kind of vulnerabilities.
Combining the two models together, one can have biological, psychological or social diathesis or vulnerabilities and when exposed to the right environmental toxin/stressor may lead to the emergence of a mental health issue in the individual.
To elucidate by way of an example. Consider a person whose serotonin neurotransmitter system is such that he typically has lower levels of baseline serotonin. This would be a biological vulnerability to depression. He also has tendency towards negative automatic thoughts or pessimism. This would be a psychological vulnerability. Moreover he has limited social support and is unmarried and from a low SES background. This would be the social vulnerability. Strike three. On top of this, lets say he suddenly loses hos job and is laid off. That environmental life event may be enough to drive this person to clinical depression.
The BioPsychSocioEnvironmental model has application not only in psychopathology, but I believe its a powerful framework for normal development too. For e.g., if we replace diathesis-stress model with differential susceptibility thesis then the diathesis or sensitivity to context can interact with both positive and negative environmental events to lead to positive or negative life outcomes.
To me combining the two models is immensely fruitful; hope you too find it useful.
Today, i.e. 15th may 2013 is being celebrated as a mental health blog day by APA and in the spirit of the day I am posting a review of ‘A Lethal Inheritance’ by Victoria Costello. It is a book chronicling how ‘ a mother uncovers the science behind three generations of mental illness‘ and is an apt topic for the day highlighting the importance of public education and discourse about the topic of mental health. this blog pots and book review is a homage to all the people who silently suffer from mental illness, most of the time undiagnosed, or even after diagnosis kept under warps due to associated stigma, and their family members who face the burden of not just care-giving but the counterproductive and unnecessary guilt that many of them either by themselves feel or are made to feel by indirect societal gestures.
Let me also take this opportunity to apologize to Prometheus Books and Victoria : the book had come out a year ago and I was sent a review copy promptly, but could not review it earlier. Better late than never!
The book, as the subtitle reveals, revolves around three generations of Victoria’s family (this book is autobiographical) : her two sons Alex and Sammy, which have their own mental health challenges and the unraveling of one of them: a first time encounter with a psychotic experience which could be quite disconcerting for everyone involved: leads her on on her journey to trace the roots of this malady affecting her family and also on a scientific pilgrimage where she continues to search for reasons, symptoms and preventive measures for the various mental health conditions afflicting her family’s three generations.
If the third generation is her sons, the second generation comprises of her and her sister Rita. While she struggles with undiagnosed/ untreated depression for most of her life, her sister is found struggling with serious substance dependence and addiction- which in the end cost her her life.
The first generation consist of an Irish immigrant grandpa in USA, whose claim to family fame, is that nobody wants to talk about his death: a purported accident where he feel asleep /drunk on the railroads and died. Now Victoria is a journalist and a good investigative journalist at that. Not satisfied with the account her mother has narrated to her, she undertakes an investigation of her own that leads to surprising discoveries like the fact that her grandpa had dies seven months before hew mother was born , rather than afterwards as believed. Also that his official death transcript reads as died from accidental drowning in a lake, thus casting doubts over the real conditions surrounding his death and also raising a question, could we ever really know if someone had committed suicide or died accidentally even if the incident was of yesterday and not many years before. The fact that his grandpa was an alcoholic, an immigrant laborer most probably facing economic stress and suffering from some mental illness, and likely committed suicide, based on the guilt/ disgust and many other emotions it aroused in his relatives (wife , daughter etc) points to the various ways genes (Irish inheritance) and environmental factors come together to wreak havoc.
The book is large part sensitive narration of one’s own story, some part thrilling investigative journalism and remaining parts informed scientific documentation of symptoms, risk factors, early signs, preventive measures and genes-environment interplay in the making and unmaking of mental health. While the scientific facts are up-to-date, they wont be path breaking as this is not mostly a scientific book- its value lies more in a first hand account of how a family deals with mental health issues and how there are common genetic risk factors that manifest in various forms- from a teen having conduct problems and eventually psychosis, to an adult in the grips of substance use and addiction, to a mother fighting and feigning at the same time that she does not suffer from depression, to a long dead grandpa who was alcoholic and probably committed suicide, to traces of violence in other relatives.
The book is also important as it highlights that mental illness and genetic risk does not respect diagnostic boundaries- from depression to conduct disorders to substance use to psychosis – all manifest in the same family tree and were perhaps myriad manifestations of a same common inheritance.
My recommendations; read it, read it as a piece of fiction , as an autobiographical account; as an educative opportunity to know more about mental illness and risk factors or just to get a first hand experiential account of what it meas to live under the weight of a lethal inheritance- read it whichever way you like, but you are bound to come out with an enhanced and more nuanced perspective that would be richer for having read this .
I have a post over at Psychology Today about Labeling and its deleterious effects. That did lead to some heated discussions on Facebook, so be sure to add your voice to the discussion by commenting on the post.
The way I have framed the above issues, I’m sure you know by now, which way my sympathies lie. To make it explicit, I do not like labelling children / adult who have slightly differently wired brains, or who are temporarily thrown off-track due to acute stressors and circumstances beyond their control, with mental disease/illness labels – I believe the stigmatisation that accompanies such a labelling does more harm than good. This does not mean labelling per se is bad- we do need to label differences amongst us, both to harness properly the special abilities that such a diverse population presents, and to help them overcome whatever shortcomings they have by providing adequate and tailored societal support to accommodate such differences. Labelling becomes bad and counterproductive when the label is seen as permanent and innate (even a ‘gifted’ label is counterproductive if such giftedness is seen as innate and non-malleable), and has a negative, stigmatising and disability connotation.
Read the rest at the source; the last point needs elaboration. Just as labeling someone as Gifted may have negative effects, labeling someone as stupid or incapable also has long lasting negative effects. My TOI blog post touches on how Sir John Gurdon faced such a situation and came out victorious.
What are the chances that you would overcome such negative feedback, not be irrevocably scarred by such negativity, but instead show a high degree of resilience and positive attitude and take that as a challenge rather than a setback; and finally become not only a successful scientist, but also receive the highest honour in your field- a Nobel Prize? If that seems too good to be true, take heart. Sir John Gurdon, who received the Nobel Prize in physiology or medicine for 2012 has actually lived that life. However, while most of us may wither into nothingness after getting so much negative early feedback; he took that as a challenge – he got that report framed and put above his desk in the Gurdon Institute in Cambridge (the only piece of accomplishment he ever got framed!) – And decided to prove his teacher wrong.
This brings me to announcing my brand new blog at Times Of India, which would be targeted more towards the layman, and also have a contemporary and Indian touch. My first post, on the occasion of world Mental Health day, questioned the exclusive focus on disease and illness to the detriment of a focus on health and positive aspects.
Consider again the widely available public knowledge that some children, having a particular genetic vulnerability (one form of Serotonin transporter gene), if abused as children, have a greater likelihood of getting depressed when they grow up. How many of us, also know of the recent Orchid and Dandelion hypothesis, whereby the genetic vulnerability is more of a heightened sensitivity to environment, whereby the same vulnerable children, if abused, can become depressed; but if provided a nurturing and supportive environment, can paradoxically be more resilient and resistant to stressors than those not having that gene variant. However, as the discourse on protective and resilient factors is lacking, the spotlight continues to shine on seeing such children as ‘at-risk’, rather than seeing them as resilient, if provided the right early start. These orchid children, requiring exquisite early care, to bloom fully, continue to be seen as liabilities rather than assets to be proud of.
And that finally brings me to my Split Blog Disorder. I think I owe a post listing all my various blogs. If you are reading this you are already aware of The Mouse Trap.
My other psychology themed blog is at Psychology Today, called The Fundamental Four.
I use my The Creativity Post blog The Muses and The Furies to focus exclusively on creativity and intelligence and also their relationship to insanity.
I have started blogging for Times Of India, and Mind Cafe focuses on topics of general interest with a psychological angle.
Apart from this I have a Tumblr blog Flotsam and Jetsam, where i typically post quotes that I find interesting.