Tag Archives: depression

Anxiety – It’s not a ‘real’ disease until it is

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“I feel awful, doc”, one man said to me today. “I’m never going to call a cold ‘the flu’ again”, he said as he shivered away under three jumpers, aching and mildly delirious.

It’s the middle of winter here in Australia, and Influenza A is cutting a swathe through the community. Everyone who walks in with a stuffy nose thinks they have ‘the flu’, that is, until they actually get Influenza and they realise just how atrocious having the real flu is.

It’s the same with mental health and illness. So many people think think that anxiety or depression aren’t real diseases. They think that everyone gets a bit sad at times, or gets a bit stressed, so depression and anxiety aren’t real diseases, they’re just normal emotions, or what weak people experience because they don’t have the inner strength to cope.

Such stigma isn’t helped when people who like to think they’re experts in mental health write blogs which declare that “anxiety is a signal that we need to listen to, not an illness we need to manage. It is a reaction to life’s challenges, not a biological disease to be treated.”

Yes, that’s right people, pretend experts are quick to tell you that the debilitating condition you’re experiencing isn’t a real disease.

Saying “Anxiety isn’t a real disease, it’s just a warning sign, a normal part of life” is a bit like saying, “You don’t really have Influenza, you just have a cold. Harden up princess … you don’t need to be ventilated in ICU, it’s just a virus. I took some Vitamin C and I was better in just a couple of days. What’s wrong with you?”

Part of the problem is because of how we use the word “anxiety”, which can mean different things to different people. To a lot of people, being anxious is the same as being a little frightened. To others, it’s being really scared, but with good reason (like if you were confronted by a very venomous snake).

Medically speaking, anxiety isn’t just being frightened or stressed. After all, it’s normal to be frightened or stressed. A little bit of fear is protective. There are dangers all around us, and our brain is our “don’t get killed” organ. If we had no fear at all, we’d end up becoming road kill. A little bit of fear, in the right amount, for the right reason and in the right place and time, is actually very protective.

But to label all anxiety as normal, or to claim that anxiety is not a mental illness is obnoxious and ignorant.

That’s because anxiety at the wrong time and in the wrong amount can disrupt our day-to-day tasks and make it hard to live a rich and fulfilling life. At the extreme, anxiety disorders are as debilitating as any major illness.

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. Clinical psychologists Dan Grupe and Jack Nitschke from the University of Wisconsin wrote in Nature Reviews Neuroscience that “Anxiety is a future-orientated emotion, and anticipating or ‘pre-viewing’ the future induces anxiety largely because the future is intrinsically uncertain.” [1]

The fear of uncertainty that defines anxiety comes from genetic changes that affect the structure and function of the brain, primarily in the regions of the amygdala and the pre-frontal cortex. As a result of these changes, the brain processes information incorrectly.

For example:
> 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 avoidance, and
> the brain assumes that unavoidable uncertainty is more likely to be bad than good.

It’s important to understand at this point that anxiety disorders aren’t the result of poor personal choices. They’re 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 people who don’t suffer from anxiety disorders have a fully functional capacity for resilience [3,4].

The main point of this post is simply this – pretend experts are everywhere, and they are usually various combinations of ignorant, stupid or lazy. They might try and tell you that your debilitating anxiety isn’t really a mental illness, but they’re usually the ones who have never experienced just how atrocious a true anxiety disorder is. Don’t listen to them, no matter how many equally ignorant followers they have on social media. Just like Influenza can make you really sick but there is treatment, so it is with an anxiety disorder – the anxiety disorder may be much harder to get through, but with the right treatment and support, you can get through it.

~~~

If you are struggling with anxiety or depression, help … real help … is available. See your general practitioner or psychologist, or if you’re in crisis and you need to talk to someone urgently:

In Australia
> you can call either Lifeline on 13 11 14, or
> BeyondBlue provides a number of different support options
> the BeyondBlue Support Service provides advice and support via
>> telephone 24/7 (call 1300 22 4636)
>> daily web chat (between 3pm–12am) and
>> email (with a response provided within 24 hours) via their website https://www.beyondblue.org.au/about-us/contact-us.
In the US
> call the National Suicide Prevention Lifeline by calling 1-800-273-TALK (8255).
In New Zealand
> call Lifeline Aotearoa 24/7 Helpline on 0800 543 354
In the UK
> Samaritans offer a 24 hour help line, on 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

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.

Thinking about suicide

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Do you think about dying? I do, quite often.

In an article published last week in the Sydney Morning Herald, Daniel Mezrani wrote about his father’s suicide. Daniel’s tone was honest and heartfelt. His message was sobering. Daniel’s father was an emergency physician, highly respected, with “three teenage children, dozens of enamoured colleagues and an innumerable network of people he had touched with his generosity, humour and passion for social justice”, yet he ended his life.

Throughout the article, Daniel approaches suicide through a social framework. “I don’t think that suicide should be viewed as a purely psychiatric issue” he writes. “The idea that suicide is always the consequence of a definable mental illness continues to dominate the public consciousness despite a growing consensus among the academic community that there is much more at play.”

“We know that isolation significantly increases suicide risk, as do other social stressors such as unemployment and relationship failure. A new paradigm in suicide prevention emerges – if we begin to see people in context, we become privy to external factors that may be causing them distress and can thus look out for more subtle cues that they may be at risk.”

He’s not incorrect. Social factors are important to a person’s risk of suicide, though mental health is very important too.

“There is no simplicity in this conclusion, but there is promise. It means that anything we do to address stigma, discrimination and hardship at a systemic level has the potential to bring down our national suicide rate. If we really want to stop people dying in this most horrific way, we need to make it easier for them to live.”

True again. More suicides are prevented through decisions at a systems and government level than through direct personal intervention.

He concludes by saying, “They are tangible reminders that things can get better, and that we are never, ever alone.”

It’s a lovely way of rounding out an article on a very difficult topic, I give him credit for that. And for the average person, it seems like a very reasonable thing to say … things do get better, no one is ever truly alone.

Except that’s not how someone who’s suicidal will see it.

Daniel succinctly encapsulated the essence of suicide earlier on in his article: “The final common pathway is not neurochemical disturbance or a discrete socioeconomic stressor, it is an anguish that feels otherwise inescapable; hopelessness manifest.”

I’ve battled with depression for a long time now, the chronic latent adversity of pathological hopelessness. Most of the time it sits on me like an emotional weight vest, making the simplest tasks feel like so much more of an effort, subtly stealing my energy, tempering my sense of joy. But there are times when I feel like I’m being crushed by a tonne of wet sand and I can’t move or breath or see. There are other times where I feel like someone has ripped out my heart and is pouring battery acid into my chest, and all I can feel is pain.

I think about suicide. Depending on where my mood is, there are times when I think about it a lot. The recurrent theme connecting all those times is hopelessness.

Shame brings isolation, inequality brings inertia, but it is hopelessness that finally destroys.

Most people have never felt the depths of despair that true hopelessness brings, and I hope they never do. Unless you’ve been there, it’s impossible to truly understand how overwhelming it is. The only way I think I could describe it would be to imagine that you’re out to sea and your boat sinks, leaving you stranded in the middle of the ocean at night in the middle of a storm – it’s dark, it’s disorientating, numbingly cold, fighting to try and keep your head above the water when the swells and the currents are constantly dragging you down.

Things can get better, and we are never alone, but when overwhelmed by deep existential despair, you can’t see it.

It might sound like I’m against addressing stigma, discrimination and hardship, but I’m not. The purpose of this article isn’t to advocate for one solution or another. I certainly don’t pretend to know all, or maybe any of, the answers. The purpose of speaking out like this is simple … I want to add to the conversation.

At the opening plenary of the conference I attended this weekend, Dr Geoff Toogood, a doctors mental health advocate, spoke about his own personal journey with mental illness as a way of starting the conversation. It’s a hard conversation, but it’s one we have to have, and it needs to be authentic if it’s going to have any real resonance. It would be much easier to simply hide away, masking the pain, pretending it’s not there, but lets face it, we’ve tried that strategy already and it’s killing us.

I can’t offer answers, but I do promise authenticity.

I also wanted to broach the key issue of hope. How do we give people hope? Hope doesn’t come from a pill or a program, but where does it come from? Can we mobilise hope? Can we give hope to the hopeless, and if so, how do we communicate hope to those who struggle the most to hear it?

I know there will be people reading this who have thought about, or might even be thinking about suicide. I know what you’re feeling. I know how hard it is.

Again, I don’t pretend to know all the answers. All I can say is that you’re not the only one, and you’re not alone. I know it’s not easy, but find even the faintest glimmer of hope – in your family, in your job, in people around you, in a faith. Hold on to it. The storm will pass and day will break.

Sometimes even the simplest connection to another person can help. If you need to talk to someone, there are always people that can help. In Australia, call Lifeline ~ 13 11 14, BeyondBlue ~ 1300 22 4636 or https://www.beyondblue.org.au/about-us/contact-us or the Suicide Callback Service ~ 1300 659 467 or https://www.suicidecallbackservice.org.au. In the USA, call the National Suicide Prevention Lifeline ~ 1-800-273-TALK (8255). In New Zealand, call Lifeline Aotearoa 24/7 Helpline ~ 0800 543 354. In the UK, call Samaritans ~ 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.

Kudos to Daniel Mezrani. It’s shattering to lose someone you love so much, and it takes a special kind of person to turn that tragedy into something that will help other people. I wish him and his family all the best as they continue on their difficult journey.

Stigma, discrimination and hardship do need to be addressed at a systemic level if we are going to help lower our nation’s suicide rate.

We also need to better understand hope, how to foster it in those whose hope is dormant, and how to help those who have lost all hope to find it again.

We need to keep talking too. The conversation is extremely challenging, but without an open and authentic dialogue, many will continue to suffer, silent and alone, instead of getting the help they deserve.

Fake science is no joke

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Happy Easter everyone.

I went to church this morning, and came home to get a lamb ragu going in the slow cooker, and thought I would just hop onto Facebook to see what was going on in the world. I was greeted with this:

“Your body literally treats negative thoughts like an infection.” Dr Peter Amuaquarshie

Oh dear … oh dear, oh dear, oh dear …

Easter is meant to be about redemption, about hope, about God’s great love for us. Clearly #TheDrLeafShow isn’t any of that.

Unfortunately, this is more pseudoscience from Dr Leaf and her cabal.  And while it might also be April Fools Day, fake science is no joke.

Dr Peter Amua-Quarshie has been in cahoots with Dr Leaf since the beginning of her teaching. He has supplied most of the illustrations for Dr Leaf’s ministry over the years, so I’m sure he’s profiting handsomely from Dr Leaf’s enormous sales and influence.

It’s so sad to see academics trade their integrity and sell their soul for the sake of the ill-gotten gains of popular pseudoscience.

Your body doesn’t “literally” treat negative thoughts like an infection. Our thoughts have literally no bearing on our immune function. In research work that has intentionally studied thought separately to stress, thought has not been associated with any significant changes in stress or health behaviour [1]. It’s also been confirmed that thought alone does not lead to detrimental biological changes, such as significant changes in immune function [2].

If anything, it’s the other way around – our immune system and our thoughts respond to physical changes in our bodies internal milieu. For example, an adrenaline surge causes us to feel fear and engage in fight or flight behaviours, and to respond quickly to injury, the balance of our immune system’s cells and cytokines changes to prepare for possible injury.

Another example, a physical infection from a microbe of some kind (bacterial or virus) causes a flood of chemical mediators called cytokines to float around the blood stream. This inflammatory response leads to an immune system that is better able to fight off infection, but it also changes our feelings and our thoughts – this flood of cytokines is the reason why we feel tired, achey and miserable when we’re sick.

Having “negative thoughts” is not the same as having an infection. Infections are disease states, whereas “negative thoughts” are normal and more often than not, beneficial. It’s normal to feel sad. It’s normal to feel angry. It’s normal to feel disgusted or embarrassed. These feelings are adaptive. Without them, we wouldn’t grow or change. Without them, we couldn’t have a rich, full life.

Dr Leaf claims that her goal is to “equip and empower you to use your mind to overcome labels and mental ill health (depression, anxiety, etc) to live a more fulfilled and successful life.” It’s a bit hard to do that by promoting fake science.

For his part, Amua-Quarshie should know better. He’s a teaching academic by trade and has a medical degree from the University of Ghana, after all. Unfortunately, it appears that Dr Amua-Quarshie has been exiled from mainstream academia, leaving a full-time position as an Adjunct Professor (lecturer) at the University of Wisconsin-Stout in Menomonie, Wisconsin and is now working as a lecturer in a school for chiropractors (Parker University, Dallas, Texas).

Though that’s more of an aside. The bottom line here is that Dr Leaf might claim that she wants people to overcome ‘labels and mental ill health’ but she isn’t going to do that by promoting such obvious mistruths that mislead people into fearing normal, adaptive human emotions. She isn’t promoting a more fulfilled and successful life, she’s promoting imbalance. She’s promoting false hope.

I know it’s April Fools, but believe me, this is no joke.  Fake science is misleading and harmful.  If Dr Leaf really wants people to live a more fulfilled and successful life, she should refrain from using it.

References
1. Doom, J.R. and Haeffel, G.J., Teasing apart the effects of cognition, stress, and depression on health. Am J Health Behav, 2013. 37(5): 610-9 doi: 10.5993/AJHB.37.5.4
2. Segerstrom, S.C. and Miller, G.E., Psychological stress and the human immune system: a meta-analytic study of 30 years of inquiry. Psychol Bull, 2004. 130(4): 601-30 doi: 10.1037/0033-2909.130.4.601

The lost art of joy – Something to look forward to

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Bacon.

With only about eight hours left in 2017, I should be contemplating bigger things … the lessons learnt from the year gone by, what did I achieve, where did I fall down, what can I learn from those experiences.

Instead, I feel like bacon, so I’m cooking bacon.

Bacon is delectable. It’s one of those foods that proves God’s love. On it’s own, it’s special, but you can also add bacon to almost any other food and it will add to the gustatory experience of pleasure. The auditory and olfactory stimulation of bacon frying is distinctly pavlovian – I’m drooling just thinking about the culinary delights that await me.

As I was standing over the frypan, listening to the crackling and popping, smelling the juicy aroma and mopping up my hypersalivation, it also stimulated the rusty gears of my cognition.

Why do I drool when bacon is cooking? For all I know, the bacon could be rancid, or I could have cooked it wrong, or it could be too salty, or it could be pigeon meat in disguise.

But I have hope.

I can’t say, rationally and with certainty, that “the bacon will be good” because there are lots of reasons why it might be bad, but I have hope that the bacon will be delicious.

Hope. It is “the quintessential human delusion, simultaneously the source of your greatest strength, and your greatest weakness.”
Hope is “being able to see that there is light, despite all of the darkness”. (Desmond Tutu)
Hope “smiles from the threshold of the year to come, whispering, ‘It will be happier.’” (Alfred Lord Tennyson)

Like we discussed yesterday, happiness is someone to love and something to do. Happiness is also something to look forward to.

Hope is like joy’s air. In order for joy to breathe, it has to be surrounded by hope. Without hope, joy can not survive.

Research bears this out. Numerous studies over the years have shown that those with higher levels of hope had higher academic and sports achievements. Lower levels of hope correlate to general maladjustment and thoughts of suicide. Hope is a crucial factor in dealing with major life stressors and traumas, such as cancer and old age. The impact of hope on depression and adjustment was studied in people with traumatic spinal cord injuries, and it was found that those with higher levels of hope had less depression and greater overall mental and social adjustment irrespective of how long it had been after the injury. In another study, lower levels of hope was related to higher levels of depressive symptoms in general.

Hope is applied optimism. Optimism is the general expectancy that good rather than bad will happen. Hope is “the belief that the future will be better than the present, along with the belief that you have the power to make it so.”  Hope is the ultimate fusion of acceptance, values and committed action – knowing which direction you want to go in, having a path leading in that direction and then going, not knowing what will happen but accepting that not everything will be perfect but believing that it will be better.

So what about 2018? I can’t say, rationally and with certainty, that “2018 will be a great year” because there are lots of reasons why it might be bad.

Still, I have hope that 2018 will be a great year.

Do you have hope? Do you believe 2018 will be a better year? Do you believe that you have the power to make it so? Over the last month, we’ve explored the lost art of joy; the ingredients of joy and how these can shape our lives; the things that can suffocate joy and the things that can help joy flourish. Do you believe that you can apply these principles to experience a life of greater joy, a richer life of deeper meaning and fulfilment? In all sincerity, I hope you can.

Thank you for coming on my journey with me. On the 1st of December when I had the bright idea of writing a blog post a day for a whole month, I thought it would be easy. When I got to the 5th of December, I thought I was going to run out of ideas and I should have thought twice before committing to such a huge project. Now, on the 31st of December, I’m glad I made that ill-considered commitment. It has challenged me for sure. It’s helped me to clarify concepts, to grow in knowledge and make me that little bit more proficient as a writer.

My hope is that my 31-day challenge will not just help me, but help others who are struggling to see the light and to experience the warmth of joy in their souls. “These things have I spoken unto you, that my joy might remain in you, and that your joy might be full.”

Happy New Year! May you all have a safe, prosperous, and joyous 2018.

Oh, and by the way, the bacon was delicious.

The lost art of joy – Rest

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So Christmas 2017 has come and gone for those of us just to the right of the International Date Line. How did you fare? Was your Christmas a day of joy?

Now we’re in the post-Christmas hangover, the come down from the sugar and ethanol excesses of the day before. In Australia, New Zealand and the UK, we call December 26th “Boxing Day”, although it doesn’t have anything to do with pugilism. The name most likely derives from the giving of Christmas “boxes”, a tradition which may date back to the Middle Ages when church members would collect money for the poor in alms boxes which were opened on the day after Christmas in honour of St Stephen, the first Christian martyr, whose feast day falls on 26 December. The tradition may even be older than that, possibly dating back to the Christianised late Roman empire. Either way, at some point St Stephen’s Day became associated with public acts of charity.

In modern Australia, the boxes that are usually associated with Boxing Day are the boxes you put all the loot you’ve acquired in the post-Christmas sales into. So it’s a bit of an irony that what was once a day of giving to those less fortunate have become about acquiring more things for yourself.

But I digress.

The post-Christmas sales are traditionally a day of high-stress chaos as throngs of enthusiastic shoppers crowd the malls again, to fight for car parking spaces, tables at cafes, space to walk around, and toilet cubicles. Hours of this at a time can suck the positivity out of even the hardiest of shoppers.

It doesn’t have to be this way though. The cure for post-Christmas languor doesn’t have to be more stress, but if anything, Boxing Day could easily be a day of rest.

Making time to rest is an important part of maintaining good health. Forms of deep relaxation, such as meditation, not only relieve stress and anxiety, but also improve mood. Deep relaxation can also decrease blood pressure, relieve pain, and improve your immune and cardiovascular systems. Relaxation doesn’t always mean sleeping (although good sleep also helps to maintain a good mood and good health overall) or just things like meditation. Rest and relaxation can involve having a laugh, which decreases pain, promotes muscle relaxation and can reduce anxiety. Rest and relaxation can involve taking the time to simply connect with friends without having to work hard to try and impress them. Even something as simple as a hug from a good friend, or patting your dog or cat, can be relaxing and mood lifting. Remember, R+R involves anything that makes you feel better at the end than it did at the beginning.

So, there’s still joy to be found, even in the post-Christmas hangover. This can be done as they did traditionally, by giving to those less fortunate, or in taking the time to relax and unwind from the celebration of Christmas, or even in the simple connection of a hug from a friend.

The lost art of joy – Music

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With only five days to go before Christmas, most people are rushing into the shops to purchase those last minute items.

The average shopping centre in the pre-Christmas week is an auditory and visual cacophony. Not only are there people EVERYWHERE, there are fairy lights, baubles, and tinsel everywhere! Then there are those Christmas carols, the auditory froth of tinny Christmas melody bubbling incessantly in the background. It’s all enough to make you want to shop on-line.

It’s such a shame the way Christmas carols have been subjugated and exploited for commercial gain. So many of the old Christmas carols are euphonious in their own right, with a lyrical profundity that encapsulates the deeper meaning of Christmas in just a few words.

In fact, music in general is fundamental to us as a language of emotion. The linguist Steven Pinker once said that music was “auditory cheesecake,” a purposeless byproduct of language development. But music is deeper than language. Neuroscience suggests that we’re hardwired to interpret and react emotionally to music from before we’re able to crawl, and well and truly before we develop language. Music activates most of our brain, from our frontal lobe and temporal lobe to process the sounds across both sides of the brain. Music also activates our visual cortex, our motor cortex, our memory centres and, not surprisingly, our deep emotional brain centres. It’s only if the song has lyrics that our language processing areas are activated.

Music has been shown to affect our physical bodies and our minds. Music helped to reduce blood pressure, heart rate and anxiety in heart disease patients, while upbeat music can have a very positive effect on our emotional wellbeing, so long as the music was happy and upbeat. Music that we expect to be happy also results in an increase of dopamine, the neurotransmitter of pleasure.

So the emotional connection that music carries is very important for our overall joy.

Listening to music can increase our joy. While the research supports the improvement in mood that comes from listening to happy, upbeat music, there’s a place for ‘sad’ or ‘angry’ songs too, which can connect directly to our souls and provide a type of catharsis that goes beyond trying to express our emotions through the clunky limitation of speech.

Music can help to scaffold memories, especially emotional memories. Remember the music playing when you had your first kiss? Or the song that they played at a friends funeral? Playing those songs related to happy times in your life can help you to recall and re-experience those uplifting emotions if you’re feeling down.

Music creates opportunities for healing. Hospitalised children were happier during music therapy (in which all the children were involved and could play with simple musical instruments like maracas and bells while a leader played the guitar) than they were in standard play therapy when their options puzzles and toys.

But more than anything, music increases joy through the power of human connection. Music is emotionally deeper than language and the social bond that music can create between people is much stronger than any intellectual or verbal connection. There have been numerous studies that demonstrate this – people who go to concerts and who go dancing report higher levels of subjective wellbeing than those people who listen to music on their own. People who create music together have higher levels of happiness and find other activities more pleasurable overall, an effect which has been demonstrated in groups of both adults and school children.

So if you want to increase your joy, engage with music, and use music to engage with other people … even if it is singing Christmas carols.

The lost art of joy – Laughter

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(and part 2 – https://youtu.be/cZ4R4e_f3-c)
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

I was lectured by Patch Adams once. He took his pants off.

When I was in medical school in the early 1990’s at the University of Queensland, Patch Adams gave a guest lecture. He was originally booked on a speaking tour and sadly, his other engagements cancelled, but he was extremely generous with his time, and visited our humble university anyway, to share his life story and his less-than-conventional views on practicing medicine. This was before the movie based his life was released (it came out in 1998), where he was portrayed by none other than the great Robin Williams.

It took a little while for the audience of young, idealistic, somewhat naive medical students to warm up, and in order to engage us, Patch took off his pants.

Everybody laughed!

It had the desired effect. He had everyone’s attention and it broke down the pretence and barriers. He later put on a pair of clown pants and continued to use humour to communicate his message of laughter, advocacy and social justice.

For the record, I have never taken my pants off to enable better communication with my patients, just so you (and anyone from the medical board who’s reading this) knows. It was the first and only time in my whole seven years of medical school that anyone ever delivered a lecture in their boxer shorts, and it’s not a customary way of engaging with one’s audience. Still, he made us laugh, and it was once of the most memorable lectures I have ever been to.

Laughter connects us. It certainly helped Patch Adams engage with people from all walks of life. Laughter equalises, because it is one of the most ubiquitous and natural of all human emotions.

And laughter is the best medicine, as the saying goes. According to the Mayo Clinic, laughter can lighten your load mentally and induce physical changes in your body. Laughing increases your intake of oxygen-rich air and stimulates your heart, lungs and other muscles. Laughter increases the endorphins that are released by your brain.

A good belly-laugh can also stimulate circulation and aid muscle relaxation which can help reduce physical symptoms of stress. Over the longer term, laughter can improve your immune system. Humour can actually release neuropeptides that help fight stress and potentially more-serious illnesses.

Laughter may even help to relieve pain by stimulating the body’s production of endorphins. Laughter can also make it easier to cope with difficult situations – like the saying goes, you either laugh or you cry. Laughter is also thought to lessen depression and anxiety.

Laughter is even thought to improve your cognitive function. As cognitive neuroscientist, Dr Scott Weems says, “Comedy is like mental exercise, and just as physical exercise strengthens the body, comedy pumps up the mind.”

It sort of goes without saying that laughter increases our joy levels. But it’s worth mentioning, because sometimes in the serious business of adulting, we can start taking things too seriously, and sometimes we just need a good laugh.

As always, it comes down to balance. There are times when we need to be serious, but we can’t be serious all the time. There are times when we just need to (metaphorically) take our pants off.

The lost art of joy – Move!

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What’s your vision of bliss? Massage? Sitting by the beach with a pina colada? Enjoying a sumptuous dinner with friends?

Most relaxation fantasies don’t involve sweat.

So it’s almost a bit counter-intuitive that exercise is one of the most frequently associated habits of happy people. Although maybe it’s not so counter-intuitive, as there is strong anecdotal evidence of the “runner’s high” – the feeling of euphoria that some people feel after a session of vigorous exercise, the “endorphin buzz” that ironically doesn’t have anything to do with endorphins!

Endorphin buzz or no, exercise is certainly one way of enhancing the joy in your life. I previously wrote about the work of George MacKerron from the University of Sussex, who used an app he created to map the correlation of happiness to activity and location. Using the hundreds of thousands of data points from the tens of thousands of users, he found that the times that people recorded the highest levels of happiness and life satisfaction were during sexually intimate moments (on a date, kissing, or having sex). Number two was during exercise.

Physical fitness is good for us. I’ve never seen a study that shows exercise to be a bad thing. Ultimately, it’s not how fat you are that’s important for your longevity, it’s how fit you are, and the way to get fit is to exercise. Physical exercise isn’t just good for the body but good for the brain as well. While the exact pathways are still being determined, there’s good evidence that moderate regular physical activity improves the balance of pro- and anti-inflammatory mediators in the body and in the brain. In the brain, this improves the overall function of our brain cells. Exercise is also thought to increase the production of a growth factor called BDNF which helps the brain cells grow new branches and improves their ability to form new pathways, which in turn, has been shown to improve mood disorders like anxiety and depression.

Exercise is great, but not everyone is ready to suddenly get up and run a half-marathon, me included. These days, I’m like a walrus on tranquillisers. I’m certainly not about to jump up and go for a jog. Some people have physical injuries or conditions that limit their capacity for physical exercise.

So how do you find the balance between maximising the joy-enhancing effects of exercise while not pushing yourself so far and causing yourself some unhappiness?

Simply, move more.

Where are you at with you’re level of exercise right now? If you could turn it into a scale from 1 to 10 (where 1 is completely sedentary, and 10 is your ideal version of regular exercise), what would you rate? The next question is, what’s one thing you could do to go one point closer to 10? So let’s just say that you walk 200m from your house to the bus stop in the morning, and the same on the way home at night. For you, that might be a 3/10. What else could you do to make that 3 turn into a 4?

You don’t have to go for vigorous two-hour walks or run up every set of stairs you come across to be happy. Just move, and move that little bit more. That will help build joy in your life.

The lost art of joy – Joy blindness

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Light at the end of the tunnel …

Joy is a ubiquitous human experience, almost an innate function of the human brain.

Joy is a bit like vision for the soul.

Writing an entire months worth of blog posts on joy, then, is a little writing series of blog posts on art appreciation. The readers of a blog on art appreciation will be able to see the art, the blog helping them to better understand the art. The vast majority of people who will be reading these blogs on joy will be able to experience joy and (hopefully) the posts will help them better understand joy.

But what happens if you can’t experience joy in the first place? What about those people who have ‘joy blindness’, so to speak?

As I’ve been writing this blog every day, I’ve been mindful of those people who struggle to experience joy. For the most part, growing joy in our life is related to our actions or decisions, such as learning acceptance, aligning our direction in life with our values, forgiving ourselves and others etc. Hence why I have been exploring these concepts in my blogs thus far. But there are some people who will read these blogs and say, “But I’ve tried to do all these things, and nothing has worked. I want to experience joy like everyone else but all I have is sadness, anger, loneliness, mourning … I must be doing something wrong … it’s all my fault that I can’t experience joy … I don’t deserve to be happy.”

Remember yesterday when I talked about the work of Sonja Lyubomirsky and her colleagues who estimated that that intentional actions can contribute as much as 40% to a person’s feeling of happiness, where as circumstances could only contribute 10%? In their estimates, our genetics contributed to the other 50% of our overall happiness. Yesterday I made the comment that, even allowing for the generous estimations that were used to come to those final numbers, our actions were of much greater importance in our overall level of happiness than our circumstances.

But there was a second point to come out of the work of Lyubomirsky et al, that our happiness is related to factors beyond our control more than it is related to factors within our control.

For the vast majority of people, our genes, the biggest contributing factor to our joy, work fine. But there are some people whose genes do not work the same way, which makes them much more vulnerable to the effects of circumstances or personal actions. These are the people with major depression, who do not feel joy like the everyday person. There may be sources of joy all around them, but try as they might, they can not perceive it. They have ‘joy blindness’.

Depression is an abnormally low mood for an abnormally long time. Major depression sucks. Major depression is not just letting yourself feel miserable. So often, those without depression think that those with depression are weak, malingering, or wallowing in child-like self-pity. Despite the enormous strides in mental health education and awareness that have been made in the last couple of decades, there’s still a strong current of stigma that flows through our society, adding an additional barrier to improvement for anyone living with or recovering from depression.

Depression affects a lot of people too. About one in ten people will suffer from an episode of major depression in their lifetime.

There’s a lot of good and easily accessible information already available about depression, from organisations like Black Dog Institute or Beyond Blue. I’ve also written about depression and Christianity (Part 1 and Part 2). I don’t want to try and repeat all of that information here.

Rather, I wanted to say just a couple of things. Firstly, if you’re suffering from ‘joy blindness’ – if you long to experience joy in your life but all you feel is sadness, please don’t blame yourself or beat yourself up. It’s not your fault.

And you’re not alone. The depth of despair is so lonely, so isolating. But there are others out there who have gone what you’re going through and have come out the other side. And there are people around you to help you through – whether they’re friends, family, or professionals who can help, like your GP or a psychologist. Those suffering from depression benefit from specific counselling, or talking therapies, and occasionally those suffering from depression might need medication to assist them in their recovery.

For most people who suffer it, ’joy blindness’ isn’t permanent. It’s more like walking through a long dark tunnel rather than being trapped in a cave. If you can keep moving forward, you will eventually get through the other side. I know it’s hard, because I’ve been there myself. I know that in the middle of the tunnel, it feels like there is no end, that you’ll never experience joy again.

The key is hope. Hope keeps us moving forward. If you can keep moving forward, you will overcome the joy blindness of major depression and you will experience joy again.

Don’t lose hope, and you will experience joy again.

If you are struggling with mental illness and you need urgent assistance, please talk to someone straight away:

In Australia:
Lifeline ~ 13 11 14
BeyondBlue ~ 1300 22 4636 or https://www.beyondblue.org.au/about-us/contact-us
Suicide Callback Service ~ 1300 659 467 or https://www.suicidecallbackservice.org.au

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

New Zealand:
Lifeline Aotearoa 24/7 Helpline ~ 0800 543 354

UK:
Samaritans ~ 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.

But I’m normally a rational person …

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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.


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