But I’m normally a rational person …

She shifted uncomfortably in her seat, her uneasy hands fidgeting together, her eyes flitting around as she tried to focus on the wall across from her, unable to find a target for her empty gaze.

“But … I’m normally a rational person,” she said, finally putting words to the thought that had been evading her for half a minute.

She was a woman in her mid thirties, with a comfortable job, a family and a mortgage in the suburbs.  We were halfway through a standard GP consult, and we had already discussed and resolved something trivial before she finally plucked up the courage to change tack and reveal the hidden agenda she’d hoped to discuss all along.

“I’m anxious all the time.  I try so hard, but I can’t seem to stop thinking about all the things that could go wrong.”

I empathised.  I’ve been there too – I’ve lived through times when my anxiety disorder was so debilitating that I wouldn’t call someone on the phone for fear of dialling the wrong number.  Or when I was so depressed that I couldn’t see anything positive for the future, when nearly every thought I had was saturated with moribund darkness.

I was anxious as a teenager, but I was depressed as an adult.  I’d been through medical school and I had attained by GP fellowship when my depression took hold.  During the four years or so that I spent with the black dog, I was constantly haunted by the same narrative that now haunted my patient … “I’m a rational person, why am I thinking like this?”

The fact I had fellowship level medical training intensified my mental self-flagellation, “I know all about depression.  I understand CBT.  I know I’m ruminating on catastrophic thoughts.  So why can’t I stop them?  If only I could think more positively, I’d be so much better.”

I found myself in a self-defeating spiral, often called the struggle switch, where I thought I knew how to climb out of my psychological mire, but all I achieved in trying to climb out was to sink further in, making me feel more defeated, even more of a failure.  It was a very difficult time which I thought would never end.

Eventually it lifted, like a heavy fog thinning in the morning sunlight, but it certainly wasn’t the result of anything clever I did.  So why did my rational brain keep filling my mind with irrational thoughts?

The answer lay in a paradigm shift away from the long held beliefs that we were taught at medical school and in our general practice training.  We’ve been lead to believe for so many years that our thoughts were the key driver of our behaviour, but it turns out that it’s actually the other way around, our behaviour is but one of a number of key driver of our thoughts.

The foundation of CBT is the notion that challenging maladaptive thoughts helps to empower behavioural change.  Except that research suggests that cognitive therapy specifically targeting problem thoughts offers no extra improvement over behavioural therapy alone.

Herbert and Forman confirm this when they point out that, “proponents of behavioral activation point to the results of component control studies of CT, in which behavioral activation or exposure alone is compared to behavioral activation (or exposure) plus cognitive restructuring. The majority of these studies have failed to demonstrate incremental effects of cognitive restructuring strategies.” [1]

This fact has been further confirmed by a number of meta-analyses [2] and by a large randomised controlled trial comparing behavioural therapy and cognitive therapy side by side with medication for depression [3].

So therapies aimed at fixing thinking works equally as well as therapies aimed only at promoting therapeutic action.  However, when thinking therapies are added to behaviour therapies, they add no extra benefit over and above the behaviour therapies alone [2].  This suggests that action is the driver of the therapeutic effects of psychological therapy.  If thinking were the driving force of psychological change, the addition of cognitive therapy to behaviour therapy should have an incremental effect.

That cognitive therapy works equally well as behavioural therapy may be related to their fundamental similarities. Dobson et al explains, “Behavioural Activation is implemented in a manner that is intended to both teach coping skills and to reduce future risk. The same is true for Cognitive Therapy, which adds an emphasis on cognitive change, but otherwise takes a similar skills-training approach.” [3]  In other words, cognitive behavioural therapy is just behavioural therapy with bling.

Herbert and Forman summarise it nicely, “The ideas that thoughts and beliefs lead directly to feelings and behavior, and that to change one’s maladaptive behavior and subjective sense of well-being one must first change one’s cognitions, are central themes of Western folk psychology.  We encourage friends to ‘look on the bright side’ of difficult situations in order to improve their distress. We seek to cultivate ‘positive attitudes’ in our children in the belief that this will lead to better academic or athletic performance. Traditional cognitively-oriented models of CBT (e.g., CT, stress inoculation training, and rational emotive behavior therapy) build on these culturally sanctioned ideas by describing causal effects of cognitions on affect and behavior, and by interventions targeting distorted, dysfunctional, or otherwise maladaptive cognitions.” [1]

I understand this is going to ruffle some feathers, and not everyone is going to be keen to dispense with CBT just yet, but I hope this gets us thinking about thinking at the very least.

For me, coming to an understanding that my thoughts were just the dashboard and not the engine helped me to pay less attention to them and to focus my healing energies on what was really important, taking values based action rather than just fighting with my stream of thoughts.

And it’s helped me to empathise differently with my patients and reassure them that you can still be a rational person even if your thoughts don’t always seem to follow suit.

References
[1]       Herbert JD, Forman EM. The Evolution of Cognitive Behavior Therapy: The Rise of Psychological Acceptance and Mindfulness. Acceptance and Mindfulness in Cognitive Behavior Therapy: John Wiley & Sons, Inc., 2011;1-25.
[2]       Longmore RJ, Worrell M. Do we need to challenge thoughts in cognitive behavior therapy? Clinical psychology review 2007 Mar;27(2):173-87.
[3]       Dobson KS, Hollon SD, Dimidjian S, et al. Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the prevention of relapse and recurrence in major depression. Journal of consulting and clinical psychology 2008 Jun;76(3):468-77.


KINTSUKUROI CHRISTIANS – Available at Koorong, Amazon, iBooks and other good book retailers

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Kintsukuroi Christians

When I was a kid growing up, there wasn’t much that my father couldn’t repair.

Dad was extremely gifted with his hands, a talent that I certainly didn’t inherit. He was able to take a problem, come up with a practical solution in his mind’s eye, then build it out of whatever scraps of wood, metal or plastic he could lay his hands on. It was the ultimate expression of frugality and recycling that comes from a limited income and four growing children.

Dad was also able to resurrect nearly everything that broke in our house. Plates, cups, teapots, toys, tools … it seemed there wasn’t anything that couldn’t be fixed by the careful application of Araldite.

Araldite, for those unfamiliar with it, is some sort of epoxy resin that, in the right hands, possesses mystical properties of adhesion. It would stick anything to anything.

Dad’s gift for repairing things with Araldite meant that a lot of our things were patched up. Some of our most loved possessions were the most cracked. Despite being glued together several times, each item was still functional. Maybe not as pretty as it may have once been, but still useful, and more importantly, still treasured. Each time the Araldite came out, it taught me that whilst all things have the capacity to be broken, they also have the capacity for redemption.

There’s an ancient Japanese tradition that shares the same principles. For more than 400 years, the Japanese people have practiced kintsukuroi. Kintsukuroi (pronounced ‘kint soo koo ree’) is the art of repairing broken pottery with gold or silver lacquer, and the deep understanding that the piece is more beautiful for having been broken.

The edges of the broken fragments are coated with the glue made from Japanese lacquer resin and are bonded back into place. The joints are rubbed with an adhesive until the surface is perfectly smooth again. After drying, more lacquer is applied. This process is repeated many times, and gold dust is also applied. In kintsukuroi, the gold lacquer accentuates the fracture lines, and the breakage is honoured as part of that piece’s history.
Mental illness is a mystery to most people, shrouded by mythology, stigma, gossip or Hollywood hype. It’s all around us, affecting a quarter of the population every year, but so often those with mental illness hide in plain sight. Mental illness doesn’t give you a limp, a lump, or a lag. It affects feelings and thoughts, our most latent personal inner world, the iceberg underneath the waters.

On the front line of medicine, I see people with mental health problems every day, but mental health problems don’t limit themselves to the doctor’s office. They’re spread throughout our everyday lives. If one in four people have a mental health problem of one form or another, then one in four Christians have a mental health problem of one form or another. If your church experience is anything like mine, you would shake hands with at least ten people from the front door to your seat. Statistically speaking, two or three of them will have a mental illness. Could you tell?

It’s a fair bet that most people wouldn’t know if someone in their church had a mental illness. Christians battling with mental illness learn to present a happy façade, or face the judgment if they don’t), so they either hide their inner pain, or just avoid church altogether.
Experiencing a mental illness also makes people feel permanently broken. They feel like they’re never going to be whole again, or good enough, or useful, or loved. They’re often treated that way by well-meaning but ill-informed church members whose idea’s and opinions on mental illness is out-of-date.

The truth is that Christians who have experienced mental ill-health are like a kintsukuroi pot.

Mental illness may break them, sure. But they don’t stay broken. The dark and difficult times, and their recovery from their illness is simply God putting lacquer on their broken pieces, putting them back together, and rubbing gold dust into their cracks.
We are all kintsukuroi Christians – we’re more beautiful and more honoured than we were before, because of our brokenness, and our recovery.

I’m pleased to announce that my book, Kintsukuroi Christians, is now available. I’ve written this book to try and bring together the best of the medical and spiritual.
Unfortunately, good scientific information often bypasses the church. The church is typically misled by Christian ‘experts’ that preach a view of mental health based on a skewed or outdated understanding of mental illness and cognitive neuroscience. I want to present a guide to mental illness and recovery that’s easy for Christians to digest, adopting the best spiritual AND scientific perspective.

In the book, I look at some scientific basics. Our mental world is based on the physical world. Our mind is a function of the brain, just like breathing is a function of our lungs. Just as we can’t properly understand our breathing without understanding our lungs, so it is that if we’re going to understand our thinking and our minds, we are going to have to understand the way our brain works. So the first part of this book will be an unpacking of the neurobiology of thought.

We’ll also look at what promotes good mental health. Then we’ll look at what causes mental illness, specifically looking at the most common mental health disorders. I will only look at some of the most common disorders to demonstrate some general principles of psychiatric illnesses and treatments. This book won’t be an encyclopaedia, and it doesn’t need to be. I hope to provide a framework so that common and uncommon mental health disorders can be better understood. I also discuss suicide, which is sadly more common than most people realise, and is rarely discussed.

I know mental illness is difficult, and we often look at ourselves or others as though the brokenness is abhorrent, ugly and deforming.
My hope is that through Kintsukuroi Christians, you’ll see the broken pieces are mended with gold, and realise that having or recovering from a mental illness doesn’t render someone useless or broken, but that God turns our mental brokenness into beauty.

Kintsukuroi Christians is available to purchase from good Christian bookstores around the world including:

Kooyong = https://www.koorong.com/search/product/kintsukuroi-christians-christopher-pitt/9780994596895.jhtml

Amazon US = https://www.amazon.com/Kintsukuroi-Christians-TURNING-MENTAL-BROKENNESS/dp/0994596898/

Amazon UK = https://www.amazon.co.uk/Kintsukuroi-Christians-TURNING-MENTAL-BROKENNESS/dp/0994596898/

Smashwords = https://www.smashwords.com/books/view/720425

~~

Mental illness can be challenging. Sometimes learning about mental illness can bring up difficult feelings or emotions, either things that you’ve been through yourself, or because you develop a better understanding of what a loved one is going through or has been through. Sometimes old issues that have been suppressed or not properly dealt with can bubble up to the surface. If at any point you feel distressed, I strongly encourage you to talk to your local doctor, psychologist, or pastor. If the feelings are so overwhelming that you need to talk to someone quickly, then please don’t delay, but reach out to a crisis service in your country

In Australia
Lifeline 13 11 14, or
BeyondBlue
Call 1300 22 4636
Daily web chat (between 3pm–12am) and email (with a response provided within 24 hours)  https://www.beyondblue.org.au/about-us/contact-us.

USA = National Suicide Prevention Lifeline 1-800-273-TALK (8255)

New Zealand = Lifeline Aotearoa 24/7 Helpline 0800 543 354

UK = Samaritans (24 hour help line) 116 123

For other countries, Your Life Counts maintains a list of crisis services across a number of countries: http://www.yourlifecounts.org/need-help/crisis-lines.

Black is the new black – Mental illness touches more of us than we realise (or want to admit)

I rarely get sick.

I say this while superstitiously touching my wooden desk to try and avoid putting the mockers on myself.  Thankfully, I have a fairly robust immune system and, after years or working in hospital paediatrics and general practice, and having been sneezed at or coughed on multiple times a day, I have been exposed to just about every variation of the cold virus and influenza possible.

Even for those of us with an immune system as solid as a prize bull, we still get sick every now and then.  We all get upper respiratory viruses so commonly that we just consider it a normal part of life.  Most people will take some paracetamol or ibuprofen and keep going.  Some people will go to their GP, and while a most will (… should …) come away some simple reassurance, occasionally some will need a prescription medication for a nastier bacterial infection.  An even smaller percentage will need admission to hospital because of a much more severe infection.

I read an interesting blog this week on Psychology Today by Dr David Rettew.  Its provocative title was, “Is Mental Illness the Rule Rather Than the Exception?”

The blog discussed the study being carried on in Dunedin which has been following a cohort of a thousand people for the last thirty-five years.  This particular study looked for common factors that were shared by those people who had never been affected by a certifiable psychiatric disorder.  What was interesting was that only seventeen percent of the people in that cohort had NOT been affected by a mental illness at some point in that thirty-five-year time frame.

Now for the average Australian, there are some obvious kiwi jokes going begging here (like, I’d be depressed too if I had to live in New Zealand, or how can someone tell if a sheep is really depressed or not, etc. etc.).  All jokes aside, seventeen percent of people not affected … that’s a remarkable figure.  In researching my latest book (soon to be released …) I had come across the figure of fifty percent of people had a lifetime prevalence of any mental illness.  That’s one in every two, and chances are that if you weren’t the person affected, you would know someone who was affected, but the Dunedin figures are even higher.  If you can accurately extrapolate them, four out of every five people will be affected by mental illness at some point in their lives.

The inevitable response from modern psychiatry’s critics is entirely predictable – there will be claims that the DSM5 is simply making diseases out of normal human life experiences, that our humanity is being pathologised and over-medicated for the benefit of big Pharma.

But as Rettew points out in a separate blog post, something may be such a common occurrence as to be considered part of the normal human experience but it can still be a pathology.  The common cold is so common that it’s a normal part of life, but it’s still a disease.

Whether four out of every five people will be affected by mental illness or one out of two, whatever the number, the idea that most of our population will be afflicted with a mental illness at some point in their lives isn’t necessarily a negative thing.  As Rettew also discusses, we don’t arbitrarily change the definitions of physical illnesses to match how many people we think should suffer from them, and neither should we arbitrarily change the diagnostic boundaries of mental illness so less people appear mentally unwell.

We need to accept that, at times, people will be functionally impaired to varying degrees because of mental illness just like people will be functionally impaired by physical illness.  We need to treat mental illness with the same respect as we would physical illness.

In the same way that not all physical illnesses require medication, neither do all mental illnesses.  By and large, most mental illnesses that people suffer from will be short lived and self-limiting, the psychiatric equivalent of having a cold.  Some people will need treatment for their mental illness, but usually this takes the form of structured behavioural therapy like ACT or CBT.  Occasionally, people will need to take a medication and very occasionally, some people will need to be hospitalised because of their mental illness.

For too long, mental illness has been viewed from an extreme perspective – mental illness is uncommon and severe. The nuances of mental illness have been lost or ignored in the white noise of ignorance and sanctimony.  The lack of subtlety and understanding has failed us as a community.  When treated early, mental illness has a much better prognosis, but the stigma, fear and misunderstanding perpetuated by the all-or-nothing approach has left a lot of people without treatment and therefore with worse outcomes overall.

If people were to realise that most of us will be touched by mental illness at some point, then perhaps there would be more understanding and less judgement, something that would lead to less suffering because of mental illness.

That would only be a good thing.

~~~~~

If you think you might be affected by mental illness or if you would like to know more, see your local GP, family physician or psychologist.  On line information can be found at many reputable sites including Beyond Blue – https://www.beyondblue.org.au

60 seconds – Dr Leaf and Anxiety

Screen Shot 2016-08-22 at 9.32.03 PM

Dr Caroline Leaf, communication pathologist and self-titled cognitive neuroscientist, says that “A chaotic mind filled with rogue thoughts of anxiety and worry sends out the wrong signals and affects you right down to the level of your DNA!” She also says that “Toxic thinking destroys the brain!”

In other words:

Anxiety → Toxic thought → DNA changes +  Brain damage

But that’s not what science says. According to modern research, anxiety disorders are the result of a genetic predisposition to increased vulnerability to early life stress, and to chronic stress [1]. The other way of looking at it is that people who don’t suffer from anxiety disorders have a fully functional capacity for resilience [2,3].

In other words:

DNA changes + External stress → Anxiety

Dr Leaf’s teaching is backwards. Perhaps it’s time she turned it around.

References

[1] Duman EA, Canli T. Influence of life stress, 5-HTTLPR genotype, and SLC6A4 methylation on gene expression and stress response in healthy Caucasian males. Biol Mood Anxiety Disord 2015;5:2
[2] Wu G, Feder A, Cohen H, et al. Understanding resilience. Frontiers in behavioral neuroscience 2013;7:10
[3] Russo SJ, Murrough JW, Han M-H, Charney DS, Nestler EJ. Neurobiology of resilience. Nature neuroscience 2012 November;15(11):1475-84

Dr Leaf and Anxiety

Dr Caroline Leaf and the struggle spiral

Screen Shot 2016-05-04 at 12.01.10 AM

In Proverbs 12:25, the incredibly wise King Solomon wrote that, “Worry weighs us down; a cheerful word picks us up.”

Today, Dr Leaf posted to her social media stream that “An undisciplined mind is filled with worries, fears and distorted perceptions – These lead to degeneration of the mind and body.”

Well, that’s about as uplifting as a lead balloon.

Dr Caroline Leaf is a communication pathologist and a self-titled cognitive neuroscientist.  I’m sure her heart was in the right place when she posted her latest jewel of wisdom, but it may not be as encouraging or as helpful as she may have intended.

The biggest problem is her opening premise, “An undisciplined mind is filled with worries, fears and distorted perceptions”.  So … that’s not really accurate. The normal human mind is filled with worries, fears and distorted perceptions. It really doesn’t matter whether you discipline your mind or not, you won’t shift these ‘negative’ thoughts.

That’s because we’re meant to experience appropriate levels of fear and worry.  They’re a survival mechanism.  Without a certain amount of fear, we’d end up as a Darwin Award.  And as human beings, we’re naturally inclined to so many different cognitive biases that there’s a very long list (although ironically, those with the strongest confirmation bias will probably be the least likely to accept this).

By erroneously linking normal cognitive function to the concept of mental ill-discipline, Dr Leaf is simply setting people up for an unrealistic struggle with their normal psyche as they unnecessarily try to discipline it.

And for the people who really do struggle with excessive or inappropriate worry, fear or incorrect perceptions – i.e. people who suffer from formal anxiety disorders – this sort of statement is misleading because again, their issue isn’t mental ill-discipline. Anxiety is the result of a genetic predisposition and increased vulnerability to stress.

The second part of Dr Leafs meme is as unhelpful as the first.  For a start, it’s not true that worries, fears and distorted perceptions cause degeneration of the mind and body.  There may be a correlation between stress and some long term health problems, but correlation does not equal causation.  As Cohen and colleagues noted, “Although stressors are often associated with illness, the majority of individuals confronted with traumatic events and chronic serious problems remain disease-free.” [1]  Dr Leaf’s claim seems little more than a scare tactic, which can only lead to increased anxiety not increased motivation.

The important things to remember here are:
1. Experiencing worries, fears and distorted perceptions is normal, and not something that can be changed by disciplining your mind.  Don’t fall into the trap of trying to treat something that isn’t a disease.
2. If you do suffer from an anxiety disorder, don’t blame yourself.  That sets up a spiral of struggle.  Thoughts are just words. They have no power over you unless you engage with them.  Instead of trying to repress every worry and every fear, allow your thoughts to bubble away in the background, and instead, focus your energy on taking values based committed action which will ultimately help you live a life of meaning, not just struggling.

References

[1]     Cohen S, Janicki-Deverts D, Miller GE. Psychological stress and disease. JAMA: the journal of the American Medical Association 2007;298(14):1685-87.

The Prospering Soul – Christians and Anxiety

When you say the word “anxiety”, it can mean different things to different people. To a lot of people, anxiety is the same as being a little frightened. To others, it’s being really scared, but with good reason (like if you have to give a speech and you’re afraid of public speaking).

Medically speaking, anxiety isn’t just being frightened or stressed. After all, it’s normal to be frightened or stressed. God made us so that we could experience fear, because a little bit of fear is actually protective. There are dangers all around us, and if we had no fear at all, we’d end up becoming lunch for a wild animal, or road-kill. So there’s nothing wrong with a little bit of anxiety – in the right amount, for the right reason.

But anxiety in the wrong amount or for the wrong reason, can disrupt our day-to-day tasks and make it hard to live a rich and fulfilling life. That’s the anxiety that we’ll be talking about today.

The official description of anxiety reflects this idea of the wrong amount of anxiety about the wrong things: “… marked symptoms of anxiety accompanied by either general apprehension (i.e. ‘free-floating anxiety’) or worry focused on multiple everyday events, most often concerning family, health, finances, and school or work, together with additional symptoms such as muscular tension or motor restlessness, sympathetic autonomic over-activity, subjective experience of nervousness, difficulty maintaining concentration, irritability, or sleep disturbance. The symptoms are present more days than not for at least several months and result in significant distress or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning.” (This is taken from the beta-version of the latest WHO diagnostic guidelines, the ICD-11, but has yet to be formally ratified).

There are six main disorders that come under the “anxiety disorders” umbrella, reflecting either an abnormal focus of anxiety or an abnormal intensity:
1. Panic Disorder (abnormally intense anxiety episodes)
2. Social Anxiety Disorder (abnormal anxiety of social interactions)
3. Post-traumatic Stress Disorder (abnormally intense episodes of anxiety following trauma)
4. Obsessive-Compulsive Disorder (abnormally intense and abnormally focussed anxiety resulting in compulsive behaviours)
5. Specific phobias (abnormally focussed anxiety on one particular trigger), and
6. Generalised Anxiety Disorder (abnormal anxiety of everything)

The common underlying theme of anxiety is uncertainty. Grupe and Nitschke wrote, “Anxiety is a future-orientated emotion, and anticipating or ‘pre-viewing’ the future induces anxiety largely because the future is intrinsically uncertain.” [1]

The dysfunctional approach to uncertainty that underlies anxiety is in turn related to genetic changes which affect the structure and function of the brain, primarily in the regions of the amygdala and the pre-frontal cortex, which then alters the processing of our brain in five different areas:
> Inflated estimates of threat cost and probability
> Hypervigilance
> Deficient safety learning
> Behavioural and cognitive avoidance
> Heightened reactivity to threat uncertainty

In simpler language:
> the brain thinks that threats are more likely and will be worse than they are
> the brain spends more time looking for possible threats
> the brain fails to learn what conditions are safe, which is aggravated by
> the brain over-using avoidance as a coping mechanism, and
> the brain assumes that unavoidable uncertainty is more likely to be bad.

It’s important to understand at this point that anxiety disorders aren’t the result of poor personal choices. They are the result of a genetic predisposition to increased vulnerability to early life stress, and to chronic stress [2].

The other way of looking at it is that some people are blessed with amazing tools for resilience [3, 4].

It’s not to say that our choices have no impact at all, but we need to be realistic about this. Everyone will experience stressful situations at some point in their lives, and everyone will also make dumb choices in their lives. Some people are naturally better equipped to handle this, whereas some people have genes that make them more vulnerable. It’s wrong to blame yourself, or allow other people to blame you, for experiencing anxiety, just as it’s wrong for other people to assume that if one person can cope with the same level of stress, then everyone else should too.

It’s not to say that you shouldn’t fight back though. Just because your facing a mountain doesn’t mean to say you can’t climb it. It will be hard work, and you’ll need good training and support, but you can still climb that mountain.

Managing anxiety is very similar to managing depression like we discussed in a previous post. Following the tap model, there’s overflow when there is too much going into the system, the system is too small to handle it, and the processing of the input is too slow. So managing anxiety involves reducing the amount of stress going into the system, increasing the systems capacity through learning resilience and coping skills, and sometimes by improving the systems processing power with medications.

Reducing the input – stress management

Sometimes the best way of coping with anxiety is to reduce the stress that’s fanning the flames. It mightn’t seem to come naturally, but as we discussed in the last chapter, there are a few basic skills that are common to all stress management techniques that can form the platform of ongoing better skills in this area.

Engaging the “vagal brake” as proposed by the “Polyvagal Theory” [5] is as important in anxiety as it is in depression. By performing these techniques, the activity of the vagus nerve on the heart via the parasympathetic “rest-and-digest” nervous system is increased, which not only slows down the heart, but enhances the activity of other automatic parts of our metabolism. Some of the techniques allow a relaxed body to have a relaxed brain which can cope better with whatever is confronting it. The full list will be a blog for another time, but the simplest technique is to breathe!

It’s really simple. Sit in a comfortable position. Take slow, deep breaths, right to the bottom of your lungs and expanding your chest forward through the central “heart” area. Count to five as you breathe in (five seconds, not one to five as quickly as possible) and then count to five as you breathe out. Keep doing this, slowly, deeply and rhythmically, in and out. Pretty simple! This will help to improve the efficiency of your heart and lungs, and reduce your stress levels.

Remember, B.R.E.A.T.H.E. = Breathe Rhythmically Evenly And Through the Heart Everyday.

Increasing capacity – coping and resilience

Like with depression, anxiety responds well to psychological therapies which help to increase coping skills and enhance our innate capacity for resilience. And like depression, anxiety improves with CBT and ACT [6, 7], which enhance the activity of the pre-frontal regions of the brain [8]. For anxiety, CBT teaches new skills to handle uncertain situations, and to re-evaluate the chances of bad things happening and what would happen if they do. ACT puts the train of anxious thoughts and feelings in their place, and teaches engagement with the present moment, and a future focusing on values, and accepting the discomfort of uncertainty by removing the distress associated with it.

Practicing each of these skill sets is like practicing any other skill. Eventually, with enough practice, they start to become more like a reflex, and we start to cope with stress and anxiety better automatically.

Increased processing – Medications

Sometimes, to achieve long-term successful management of anxiety, a little extras help is needed in the form of medication. Like depression, the main group of medications used are the Selective Serotonin Reuptake Inhibitors (or SSRI’s for short). Medications appear to reduce the over-activity of a number of brain regions collectively called the limbic system [8], which are involved with many innate and automatic functions, but in its simplest form, the limbic system controls many of our emotions and motivations, including fear, anger and certain aspects of pleasure-seeking [9]. So essentially, SSRI’s help the anxious brain to make better sense of the incoming signals.

There are other medications commonly used for anxiety treatment, collectively called benzodiazepines. Most people wouldn’t have heard that term before, but would have heard of the most famous member of the benzo family, Valium. Benzos are like having a bit too much alcohol – they slow down the activity of the brain, and induce a feeling of relaxation. When used appropriately (i.e.: in low doses and in the short term), they can be helpful in taking the edge off quite distressing feelings of anxiety or panic. But benzos are not a cure, and after a while, the body builds a tolerance to them, where a higher dose is required to achieve the same effect. Continued long term use eventually creates dependence where a person finds it difficult to cope without them.

The final way to help manage anxiety is prayer. Like for depression, there is limited scientific information on the effects of prayer on, although a small randomised controlled trial did show that prayer with a prayer counsellor over a period of a number of weeks was more effective than no treatment [10].

Though given that anxiety is a future orientated emotion, excessively anticipating possible unwelcome scenarios and consequences, it’s easy to see why prayer should work well for anxiety. Trusting that God has the future in hand and knowing “that in all things God works for the good of those who love him, who have been called according to his purpose” (Romans 8:28) means that the future is less uncertain. The Bible also encourages us, “Do not be anxious about anything, but in every situation, by prayer and petition, with thanksgiving, present your requests to God. And the peace of God, which transcends all understanding, will guard your hearts and your minds in Christ Jesus.” (Philippians 4:6-7) When we give the future to God, he will give us peace in return.

Again, like in the case of depression, it’s sometimes hard for Christians to understand how strong Christians can suffer from anxiety in the first place. After all, we’ve just read how God gives us peace. And the Bible says that the fruit of the Spirit is peace (Galatians 5:22).

So when you’re filled with the opposite, when all you feel is overwhelming fear, it makes you feel like a faithless failure. Christians without anxiety assume that Christians with anxiety aren’t living in the Spirit. And it’s the logical conclusion to draw after all – if the fruit of the Spirit is peace, and you’re not filled with peace, then you mustn’t be full of the Spirit.

But like depression, when you look through the greatest heroes in the Bible, you see a pattern where at one point or another in their lives, they went through physical and emotional destitution, including mind-numbing fear … Moses argued with God about how weak and timid he was (Exodus 3 and 4), Elijah ran for his life in panic and asked God to kill him, twice, over the period of a couple of months after Queen Jezebel threatened him (1 Kings 18 and 19). Peter had spent three years with Jesus, the Messiah himself, hearing him speak and watching him perform miracle after miracle after miracle. But Peter denied his Messiah three times when he was confronted with possible arrest (John 18).

For the same pattern is also seen in King David, Gideon, and a number of other great leaders through the Bible. The take home message is this: it’s human nature to suffer from disease and dysfunction. Sometimes it’s physical dysfunction. Sometimes it’s emotional dysfunction. It’s not a personal or spiritual failure to have a physical illness. Why should mental illness be treated any different?

As the stories of Moses, Elijah and Peter testify, being a strong Christian doesn’t make you impervious to fear and anxiety. Hey, we’re all broken in some way, otherwise why would we need God’s strength and salvation? Having anxiety simply changes your capacity to experience God’s peace. As I said in the last chapter, closing your eyes doesn’t stop the light, it just stops you experiencing the light. Being anxious doesn’t stop God’s peace, it just makes it harder to experience God’s peace.

In summary some anxiety, at the right time and at the right intensity, is normal. It’s not unhealthy or sinful to experience some anxiety. Anxiety at the wrong time or at the wrong intensity, can disrupt our day-to-day tasks and make it hard to live a rich and fulfilling life. Anxiety related to a dysfunctional approach to uncertainty, and is a future-orientated emotion because anticipating or ‘pre-viewing’ the future induces anxiety largely because the future is intrinsically uncertain. Anxiety disorders can be debilitating.

Like depression, anxiety disorders can be managed in four main ways, by reducing the amount of stress coming in with stress management techniques, by increasing capacity to cope with psychological therapies like CBT and ACT, and sometimes by using medications, which help the brain to process the uncertainty of each situation more effectively. Prayer is can also useful to helping to manage anxiety.

Christians are not immune from anxiety disorders, and it’s important for the church to understand that Christians who suffer from anxiety are not weak, backsliding or faith-deficient. Having anxiety is not because of making poor choices. Though if you have anxiety, trust in the promises of the Bible, that God has the future under control.

References

[1]        Grupe DW, Nitschke JB. Uncertainty and anticipation in anxiety: an integrated neurobiological and psychological perspective. Nature reviews Neuroscience 2013 Jul;14(7):488-501.
[2]        Duman EA, Canli T. Influence of life stress, 5-HTTLPR genotype, and SLC6A4 methylation on gene expression and stress response in healthy Caucasian males. Biol Mood Anxiety Disord 2015;5:2.
[3]        Wu G, Feder A, Cohen H, et al. Understanding resilience. Frontiers in behavioral neuroscience 2013;7:10.
[4]        Russo SJ, Murrough JW, Han M-H, Charney DS, Nestler EJ. Neurobiology of resilience. Nature neuroscience 2012 November;15(11):1475-84.
[5]        Porges SW. The polyvagal perspective. Biological psychology 2007 Feb;74(2):116-43.
[6]        James AC, James G, Cowdrey FA, Soler A, Choke A. Cognitive behavioural therapy for anxiety disorders in children and adolescents. The Cochrane database of systematic reviews 2013;6:CD004690.
[7]        Swain J, Hancock K, Hainsworth C, Bowman J. Acceptance and commitment therapy in the treatment of anxiety: a systematic review. Clinical psychology review 2013 Dec;33(8):965-78.
[8]        Quide Y, Witteveen AB, El-Hage W, Veltman DJ, Olff M. Differences between effects of psychological versus pharmacological treatments on functional and morphological brain alterations in anxiety disorders and major depressive disorder: a systematic review. Neuroscience and biobehavioral reviews 2012 Jan;36(1):626-44.
[9]        Sokolowski K, Corbin JG. Wired for behaviors: from development to function of innate limbic system circuitry. Frontiers in molecular neuroscience 2012;5:55.
[10]      Boelens PA, Reeves RR, Replogle WH, Koenig HG. A randomized trial of the effect of prayer on depression and anxiety. Int J Psychiatry Med 2009;39(4):377-92.

If you’re suffering from anxiety or any other mental health difficulties and if you want help, see your GP or a psychologist, or if you’re in Australia, 24 hour telephone counselling is available through:

 Lifeline = 13 11 14 – or – Beyond Blue = 1300 22 4636

Dr Caroline Leaf and her can of worms

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Dr Caroline Leaf is a communication pathologist and a self-titled cognitive neuroscientist. She also likes to think that she’s an expert on mental health. So this morning, she felt like she was quite justified in publishing a meme about the evils of psychiatric medications.

She quoted Professor Peter Gøtzsche, stating that “Psychiatric Drugs are the third leading cause of death, after heart disease and cancer.” Then followed it with “Take all thoughts into captivity, not drug all thoughts into captivity. You have the mind of Christ! (1 Cor 2:16) **DRUG WITHDRAWAL should ALWAYS be done under the supervision of a qualified professional. These drugs alter your brain chemistry, and withdrawal can be a difficult process.”

The subsequent comments were primarily made up of the usual sycophantic responses that Dr Leaf has cultivated by blocking anyone that disagrees with her. But there were more than the usual responses confused by her meme, and quite a few that we’re asking for help in weaning off the medications that they were on.

Then there were those who weren’t happy at all. One respondent, a certified Nurse Practitioner, wrote, “I am appalled that you are posting this inaccurate information and causing vulnerable people to possibly stop taking medication that may be allowing them to function and live.” The same person followed up with another comment soon after, quoting the CDC figures for the top ten causes of death in the US, in which the third on the list wasn’t psychiatric drugs at all, but chronic lower respiratory diseases.

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The overall response must have taken her aback, because Dr Leaf posted a follow-up comment to explain herself, an unusual step for her.

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In it, she said, “I do not speak out against psychiatric medication because I want to condemn people, or make them feel guilty. I want to help people. If, for example, I knew that eating some food could kill you or seriously injure you, and kept this to myself, you would justifiably be angry at me. These drugs have serious, proven long term side affects that are hidden from the public, and the logic behind them is not God’s desire for you to be healthy in your spirit, soul and body. Psychiatric drugs are based off of a theoretical view of evolution as a mindless, unguided process that created you as mechanistic individual with a biological brain that has chemicals that need to be “balanced”. You are more than your biology; you are the temple of the Lord, created in his image. This is not a game: these drugs can decrease your lifespan by 15-25 years. I want you to have those 15-25 years, and I want them to be characterized by God’s perfect, good plan for your life. I ask you to not to just take my word for this, but to do your own research. You can find a multitude of references on my site http://www.drleaf.com under Scientific FAQs. It is my earnest desire that people do not perish for lack of knowledge (Hosea 4:6). **DRUG WITHDRAWAL should ALWAYS be done under the supervision of a qualified professional. These drugs alter your brain chemistry, and withdrawal can be a difficult process.”

But it was too late. Dr Leaf had opened a can of worms, and once out, those wriggly little critters are impossible to put back in.

Both her initial offering and her reply shows just how poor Dr Leaf’s understanding of mental health truly is. She is fixated on the notion that the mind controls the brain, and she is unwilling to consider any other notion, instead preferring to accept any opinion that conforms to her world view, no matter how poorly conceived it might be. This includes the work of Gøtzsche, accepting it as gospel even though he has critics of his own.

It’s important to examine Dr Leaf’s reply in more detail as her statement has the potential to cause a great deal of harm to those who are the most vulnerable. Lets break down Dr Leaf’s statement and review each piece, and then I will outline some other important and contradictory considerations of Dr Leaf’s stance.

  1. The safety of psychiatric medications

Dr Leaf claims that “These drugs have serious, proven long term side affects {sic} that are hidden from the public” and “This is not a game: these drugs can decrease your lifespan by 15-25 years.”

Dr Leaf is right in saying that psychiatric medications have serious proven long term side effects. And we should be careful. I mean, if you knew that thrombocytopenia, anaphylaxis, cutaneous hypersensitivity reactions including skin rashes, angioedema and Stevens Johnson syndrome, bronchospasm and hepatic dysfunction were the potential side effects for a medication, would you take it?

Most people wouldn’t.   Reading the list makes that drug sound really dangerous.  We should be up in arms about such a dangerous drug … except that this list of side effects isn’t for a psychiatric drug at all, but is actually the side effect profile of paracetamol (Panadol if you’re in Australia, Tylenol if you’re in the US). People take paracetamol all the time without even thinking about it. Saying that we shouldn’t take medications because of potential side effects is a scarecrow argument, a scary sounding straw man fallacy. All drugs have serious proven long term side effects, and most of the time, those serious long term side effects don’t occur.  Licensing and prescribing a medication depends on the overall balance of the good and the risk of harm that a medication does.

Oh, and no one has ever hidden these side effects from the public as if there’s some giant conspiracy from the doctors and the pharmaceutical companies. The side effects are listed right there in the product information (here is the product information for fluoxetine. See for yourself).

As for Dr Leaf’s assertion that psychiatric medications decrease your lifespan by 10-25 years, I think that’s a red herring. I read through Dr Leaf’s ‘Scientific FAQ’ and I couldn’t find any references that back up these statements, so who knows where she got this figure of ’15-25 years’ from.

On the contrary, what is known is that severe mental illness is associated with a 2 to 3-fold increase in mortality, which translates to an approximately 10-25 year shortening of the lifespan of those afflicted with severe depression, schizophrenia or bipolar disorder [1]. So Dr Leaf has it backwards. It isn’t the medications that cause people who take them to die 25 years earlier than they would have without the illness, but it’s the illness itself.

  1. The benefits of long term psychiatric medications

So psychiatric medications have their side effects, true, but they also have protective benefits which Dr Leaf consistently fails to acknowledge.

Correll and colleagues note in the conclusion to their article that “Although antipsychotics have the greatest potential to adversely affect physical health, it is important to note that several large, nationwide studies providing generalizable data have suggested that all-cause mortality is higher in patients with schizophrenia not receiving antipsychotics.” [1]

More specifically, in one recent study, the use of any anti-psychotic medication for a patient with schizophrenia decreased their mortality by nearly 20% [2]. In another study, the mortality of those with schizophrenia who did not take anti-psychotics was nearly ten times that of the healthy population, but taking anti-psychotic medication cut that back to only four times the risk [3].

These findings are mirrored by other studies on other psychiatric medications. For example, as noted by Correll and colleagues, “clozapine, antidepressants, and lithium, as well as antiepileptics, are associated with reduced mortality from suicide. Thus, the potential risks of antipsychotics, antidepressants and mood stabilizers need to be weighed against the risk of the psychiatric disorders for which they are used and the lasting potential benefits that these medications can produce.” [1]

So psychiatric medications are not useless. Let me be clear, I’m not saying that taking psychiatric medications always makes life a cake-walk – there are still side effects from the medications, and the disease isn’t always fully controlled. But on average, well treated patients with psychiatric conditions clearly do better than patients who are not treated.

Therefore Dr Leaf’s assertion that psychiatric medications are harmful are inaccurate. And given that there are genuine benefits to these medications, particularly in the prevention of suicide, Dr Leaf’s discouragement of these medications has the real potential to result in real harm to those of her followers who take her at her word.

  1. The ‘logic’ behind psychiatric medications

Dr Leaf says in her statement, “the logic behind them (psychiatric medications) is not God’s desire for you to be healthy in your spirit, soul and body. Psychiatric drugs are based off of a theoretical view of evolution as a mindless, unguided process that created you as mechanistic individual with a biological brain that has chemicals that need to be ‘balanced’. You are more than your biology; you are the temple of the Lord, created in his image.”

Dr Leaf’s argument here is that based on a false premise and some straw man fallacies which inevitably leads to a false conclusion.

Evolution is a mindless unguided process
Evolution says that you are just a machine
Psychiatric illness is because of a chemical imbalance in that machine (a false premise)

therefore taking psychiatric medication is accepting evolution (a straw man fallacy)

and

You are more than your biology,
you are the temple of the Lord, created in his image,

therefore evolution is wrong (another straw man fallacy)

therefore psychiatric medications are not God’s desire (false conclusion)

The problem with this logic is that it could be applied to all medications, since modern medicine has predominantly been devised by agnostic scientists within an evolutionary framework, and nearly all disease is defined by an imbalance of one thing or another.

For example, simply rewording Dr Leaf’s statement shows up the distorted logic that it entails:

“Insulin can have serious, proven long term side affects that are hidden from the public, and the logic behind it is not God’s desire for you to be healthy in your spirit, soul and body. Diabetes is based off of a theoretical view of evolution as a mindless, unguided process that created you as mechanistic individual with a biological pancreas that has chemicals that need to be ‘balanced’.”

You can’t have this both ways. If psychiatric medications are against God’s plan, then all medications are against God’s plan. But if we accept medications for physical ailments, then we also have to accept medications for psychological ailments.

  1. The Mind-Brain link

Dr Leaf tried to protect herself with a glib disclaimer at the end of both posts in question today, “**DRUG WITHDRAWAL should ALWAYS be done under the supervision of a qualified professional. These drugs alter your brain chemistry, and withdrawal can be a difficult process.”

Which is interesting, because in her Scientific FAQ, Dr Leaf has this to say about the mind,

“The Brain is part of the Physical Body and therefore is controlled by the Mind. The Mind does not emerge from an accumulation of Brain activity. Brain activity, rather, reflects Mind activity. Even though the Mind controls the Brain, the Brain feeds back to, and influences, the Mind. The Brain seats the Mind, and therefore the Mind influences the Physical world through the Brain.”

So if that’s true, then why is withdrawal from psychiatric medication so difficult? If the mind is outside the physical realm and controls the brain as Dr Leaf proposes, then the medications effect on brain chemistry should make little or no difference to the mind, and withdrawal should be simple.

The fact that withdrawal from these medications is not simple is testament to the fact that the mind is a function of the brain, and does not control the brain as Dr Leaf proposes here and through her books and other written materials.

Issuing the warning is responsible, but shows again just how far Dr Leaf’s teaching is from scientific reality.

  1. Dr Leaf’s motivations

Finally, I want to talk about Dr Leaf’s motivation. In her statement, Dr Leaf said, “I do not speak out against psychiatric medication because I want to condemn people, or make them feel guilty. I want to help people.” And, “I want you to have those 15-25 years, and I want them to be characterized by God’s perfect, good plan for your life … It is my earnest desire that people do not perish for lack of knowledge (Hosea 4:6).”

I want to state, for the record, that I believe Dr Leaf when she says this. I don’t doubt her motives are to try and help people. But good intentions are not enough. What she says has real life consequences.

Dr Leaf is idolised by her followers and portrayed as a mental health expert by the churches she preaches at. People don’t question experts recommended to them by their pastors or their friends. So when she says that psychiatric medications kill people, people on psychiatric medications will want to come off them, because of fear, because of stigma, because of their desire to live true to God and his good and perfect plan. Without wanting to sound melodramatic, there is a very real chance that some of those people who were stable on their medications but who unnecessarily cease them because Dr Leaf told them to, may harm themselves or take their own life, since that’s what the studies tell us [1, 4]. At the very least, they are likely to have a shorter life expectancy because of it [2, 3]. So telling people that psychiatric medications are dangerous is morally and ethically dubious.

There are also potential legal implications too. God forbid, but if a person committed suicide because they went off their medication because of what Dr Leaf wrote, law suits could easily follow. No one wants that situation. Dr Leaf also runs the risk of being accused of practicing medicine without a licence, since some of her followers have asked personal medical questions in the comments, and the reply from Dr Leaf’s Facebook team is to direct them to their programs like the 21-day detox, which depending on the legal interpretation and the mood of a judge, could be seen as giving medical advice, which Dr Leaf is not legally qualified to give.

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To summarise, I certainly hope that neither of these hypothetical scenarios becomes reality, but Dr Leaf and her social media team are skating on thin ice, and a glib disclaimer at the end of a post won’t necessarily cut it.

I would hope that Dr Leaf and her social media team would reconsider their approach. In fact, I would suggest that Dr Leaf unequivocally apologises for what she’s written, retracts her statement, and encourages people to see their doctors if they have concerns about their medication, or their mental health.

Indeed, I would implore Dr Leaf to step back and re-evaluate the entire breadth of her teaching, and the advice that she is giving. Dr Leaf is obviously a very smart woman and a very engaging speaker. With great power comes great responsibility. If she were to reconsider her teaching and start from a basis of scientific fact, then she could be a major force for the good of the church and its physical and mental health. At the moment, I fear that she is doing the opposite.

This is not a game: people’s lives are at stake. I hope that Dr Leaf sees this before it’s too late.

References

[1]        Correll CU, Detraux J, De Lepeleire J, De Hert M. Effects of antipsychotics, antidepressants and mood stabilizers on risk for physical diseases in people with schizophrenia, depression and bipolar disorder. World psychiatry : official journal of the World Psychiatric Association 2015 Jun;14(2):119-36.
[2]        Tiihonen J, Lonnqvist J, Wahlbeck K, et al. 11-year follow-up of mortality in patients with schizophrenia: a population-based cohort study (FIN11 study). Lancet 2009 Aug 22;374(9690):620-7.
[3]        Torniainen M, Mittendorfer-Rutz E, Tanskanen A, et al. Antipsychotic treatment and mortality in schizophrenia. Schizophrenia bulletin 2015 May;41(3):656-63.
[4]        Tiihonen J, Suokas JT, Suvisaari JM, Haukka J, Korhonen P. Polypharmacy with antipsychotics, antidepressants, or benzodiazepines and mortality in schizophrenia. Archives of general psychiatry 2012 May;69(5):476-83.

Here’s my glib disclaimer: This article is a rebuttal of Dr Leaf’s opinion regarding psychiatric medication.  This blog doesn’t constitute individual medical advice.  If you do not like your medication or think you should come off it, please talk to your own GP or psychiatrist.  Do not stop it abruptly or without adequate medical advice.