PTSD Treatment for Teen Survivors of Sexual Abuse

Dr. Katherine Dahlsgaard, Lead Psychologist at The Anxiety Behaviors Clinic and the Children’s Hospital of Philadelphia, recently wrote an article that nicely summarized recent findings from a research study on PTSD treatment for teenage girls who experienced sexual abuse.

The study was conducted in Philadelphia at the Center for the Treatment and Study of Anxiety, where I worked from 2008-2012. An incredible amount of work and coordination went into this well-executed study, and the results have important implications for teens in need of effective PTSD treatment. They show that cognitive-behavioral therapy (in this case, prolonged exposure), which is known to be very effective for treating adult survivors of trauma, can also be life changing for teenagers with PTSD.

Dr. Dahlsgaard’s write-up is available here.

Stressed and Sleepy in America

The American Psychological Association recently released the results of its “Stress in America” survey, based on responses from nearly 2000 adults and over 1000 teens. I want to highlight some of the findings related to stress and sleep.

We all know that feeling stressed can get in the way of sleep. Who can sleep well when the mind is agitated and the body is restless? Importantly, the reverse is also true: Lack of sleep leads to stress. So when we’re stressed and sleepless, we can fall into a vicious circle where stress and lack of sleep feed each other.

The effects of lack of sleep are striking. When we don’t sleep enough we’re more likely to neglect responsibilities, lose patience, skip exercise, and yell at the people we love. These behaviors can further compound our sense of being overwhelmed.

So what can we do when we’re feeling stressed out and are having a hard time sleeping? First we have to recognize when our stress has risen to an unhealthy level. If it has, there are effective ways to manage the stress. For example, there are mindfulness-based stress reduction programs that most people find to be extremely helpful for managing their responses to stress. (For example, Penn has a very well regarded program; check it out here.) Working with a therapist can also be very helpful in learning how to make changes to reduce our stress, or to deal better with the stress of life that’s unavoidable.

Thankfully as we learn to manage stress, sleep also tends to improve, and better sleep leads to a better sense of being able to cope.

The press release is available here: http://www.apa.org/news/press/releases/stress/2013/sleep.aspx#

Your Dreaming Brain

Some people seem to remember their dreams every night, whereas others rarely remember any dreams. What accounts for these differences?

A recent study by a group of French neuroscientists provides a potential explanation. The researchers recruited subjects who remembered their dreams either often or rarely, and compared the brain activity of these two groups during sleep and during wakefulness.

Two brain areas were more active in high dream recallers during rapid eye movement (REM) sleep, when our most vivid and memorable dreams occur: the temporoparietal junction (where the temporal and parietal lobes meet, as the name suggests) and the medial prefrontal cortex in the frontal lobes.

So what does it mean that there was greater activity in these areas? The study authors offered some possible interpretations. One possibility is that these brain differences reflect something meaningful about the dreams themselves. In particular, they might indicate that people who often remember their dreams tend to have more exciting dreams.

Another explanation the authors propose is that individuals who remember their dreams more often are more likely to awaken during the night, allowing them to encode their dreams into memory (since memory generally is “turned off” during sleep).

Of course, these two explanations aren’t mutually exclusive. It could be that more interesting dreams are more likely to awaken a person, making their dreams doubly likely to be recalled the next day.

Incidentally, these two explanations are consistent with why REM dreams are more likely to be remembered than are dreams during non-REM deep sleep. Although we can dream in any sleep stage, our REM dreams tend to be the most gripping, and we’re also more likely to awaken briefly after a REM stage than after a stage of deep sleep, making it more likely that we’ll remember the dream.

So for people who wish they had more exciting dreams, perhaps better sleep is a nice consolation prize!

Reference: J.-B. Eichenlaub et al. (in press). Resting brain activity varies with dream recall frequency between subjects. Neuropsychopharmacology.

It Turns Out Smoking Is Bad for You

A surgeon general’s report released today underscores what’s been known for decades–that being a cigarette smoker is the single best way to get sick and die young. In the past 50 years, over 20 million premature deaths in the US can be linked to smoking.

The report specifies even more diseases that seem to be caused by smoking, on top of the obvious ones like lung cancer and emphysema. The list now includes such wide ranging conditions as macular degeneration (a common cause of blindness), diabetes, erectile dysfunction, and rheumatoid arthritis, among others. Being exposed to secondhand smoke increases the risk for stroke.

And yet, an estimated 45 million Americans still smoke. Part of the reason may be that smokers–especially ones who are young and haven’t started hacking and coughing–may feel like “it won’t happen to me.”

But what about smokers who have terrible smoking-related health problems, like cancer of the lung, head, or neck? If ever there were a group that would be motivated to quit, this would be it! Nevertheless, a recent review found that even these individuals were unlikely to stop smoking. For example, one of the larger studies in the review found that 70% of cancer patients continued to smoke–even after getting smoking cessation treatment.

As I discussed in a previous post, quitting smoking is really hard, and simply being motivated often is not enough to get a person there. While existing treatments help, there’s obviously plenty of room for improvement. Researchers and clinicians continue to work to develop more effective medications and psychotherapies. With effective treatment, more ex-smokers get to enjoy added years of better quality life.

Mindfully Quitting Smoking

Anyone who’s been addicted to cigarettes knows that stopping smoking can be painfully difficult. People who try to quit often aren’t successful, and those who do manage to quit often relapse. For these reasons, cigarette smokers can benefit from tools that make it easier to quit.

In the past few years more and more studies have suggested that training in mindfulness can be a powerful aid for people who want to stop smoking. (In a nutshell, mindfulness means accepting our present experience as it is.) For example, one study (ref. 1) found that more than half of individuals who received training in mindfulness were smoke-free after 6 weeks of treatment.

Another study (ref. 2) compared a mindfulness-based treatment to standard nicotine replacement therapy (the patch) and tracked smoking outcomes for up to a year, which is very important given the high relapse rates even after effective treatment. Results showed that the therapy worked as well as the patch at the end of 7 weeks of treatment, with about one-third of participants quitting smoking in each group. The long-term outcomes were striking: 35% of individuals who had received the mindfulness-based treatment were smoke-free after 1 year, compared to only 15% of those who had used the patch. Other studies have found similar results (for example, ref. 3).

So how is it that paying attention to the present moment in a nonjudgmental way can help a person to stop smoking? Researchers have been trying to answer this question. One answer (ref. 4) seems to be that mindfulness increases “distress tolerance,” or the ability to withstand being uncomfortable. Craving nicotine and having withdrawal symptoms like headaches and irritability is nothing if not uncomfortable! It’s well established that mindful attention can get us through all kinds of painful experiences, both physical and psychological. The results about distress tolerance are consistent with the finding that although mindfulness training doesn’t get rid of urges to smoke, it does help smokers to “ride out” these urges (ref. 5).

Taken together, these results are good news for smokers trying to quit and stay quit.

References

  1. Davis et al. (2007). A pilot study on mindfulness based stress reduction for smokers. BMC Complementary and Alternative Medicine, 7:2.
  2. Gifford et al. (2004). Acceptance-based treatment for smoking cessation. Behavior Therapy, 35, 689-705.
  3. Brewer et al. (2011). Mindfulness training for smoking cessation: Results from a randomized controlled trial. Drug and Alcohol Dependence, 119, 72-80
  4. Luberto et al. (in press). The role of mindfulness skills in terms of distress tolerance: A pilot test among adult daily smokers. American Journal of Addictions. doi:10.1111/j.1521-0391.2013.12096.
  5. Bowen & Marlatt (2009). Surfing the urge: Brief mindfulness-based intervention for college student smokers. Psychology of Addictive Behaviors, 23, 666-671.

Anxiety or Anxiety Disorder?

On December 14th the New Jersey division of the National Alliance on Mental Illness held their annual conference in Jamesburg. Despite the snow there was a good turnout for their well-organized meeting. Attendees included students, clinicians, and mental health researchers as well as individuals who experience mental illness and their family members.

I spoke in one of the afternoon sessions on how cognitive behavioral therapy helps anxiety, depression, and related conditions. I appreciated the attendees’ insightful comments and questions. One attendee noted that the anxiety conditions I was describing, especially specific phobias like fear of snakes or spiders, sounded like “things we all experience.” Her observation opened up an interesting discussion about how we define a “mental illness” and what distinguishes “normal” anxiety from the more distressing and disabling experiences that define anxiety disorders.

Being diagnosed with a specific phobia requires more than just being afraid of certain things or situations. For example, the person has to experience “intense distress” in response to the phobic object, and the fear response has to be unrealistic compared to the actual danger. So although many people don’t enjoy being around snakes or spiders, getting a shot, going to the dentist, flying in an airplane, and other common phobic situations, not all of these individuals will meet criteria for a specific phobia.

It’s also worth pointing out that there’s often a judgment call involved in determining whether diagnostic criteria are met. For example, what’s “significant distress or impairment”? What’s “marked fear or anxiety”? Nevertheless, there tends to be pretty good agreement across raters for making these kinds of diagnoses.

I wanted to thank the conference organizers for the opportunity to be a part of NAMI NJ’s conference, and in particular Ms. Neha Mehta for her hard work and assistance. She and the many others who are part of NAMI are working to raise awareness and reduce stigma around mental illness, and to increase access to treatment.

Treat Insomnia, Help Depression

In an earlier post I discussed the link between sleep problems and depression. In many cases, sleep problems like insomnia come first, and then lead to depression.

Traditional clinical wisdom suggested that when depression and insomnia were both present, the depression should be treated first, with the hope that improvements in depression would also improve sleep.

A recent study has generated a lot of buzz because it showed that resolving insomnia in depressed individuals nearly doubles the effectiveness of the depression treatment (in this study, an antidepressant medication). Among individuals whose insomnia lifted, nearly 90% saw their depression improve.

The insomnia treatment was cognitive-behavioral therapy for insomnia (CBT-I), which includes several components that are highly effective in improving the sleep of people with insomnia. For example, activities in the bedroom are limited to sleep (sex is the one exception), so that the link between bed and sleep is strengthened. CBT-I therapists also work with patients to identify the optimal amount of time to spend in bed to make sleep more efficient.

The results of this study have clear implications for the treatment of co-occurring depression and insomnia. Therapists should consider directly treating the insomnia in conjunction with depression treatment, using a well-validated treatment program like CBT-I. This approach is likely to maximize patient gains and promote long-term wellness.

Results from the study have not yet been published; a report can be found here.

Seeking, and Sometimes Finding, OCD Treatment That Works

Obsessive-compulsive disorder (OCD) is associated with tremendous impairment and distress. Successful treatment of OCD requires at least two major steps: Seeking treatment, and finding one of the effective treatments that are available.

 A study published last month in the Journal of Obsessive-Compulsive and Related Disorders addressed questions related to both of those steps. The researchers reviewed 20 existing studies to see what percentage of people with OCD seek treatment, and of those who seek help, how many receive a treatment that has been shown to work.

The results were striking and rather dismaying. In answer to the first question, at least 60-70% of individuals with OCD never receive treatment specifically for their OCD.

So what happens for the 30-40% who do seek treatment? The authors’ review concluded that between one-third and one-half of these individuals do not receive one of the first line psychological treatments for OCD like exposure and response prevention (ERP). This finding is in line with the stories of many readers of the ocdtalk blog, who described misdiagnoses and unhelpful treatments.

Thankfully OCD activists, researchers, and clinicians are working hard to bring good treatment to OCD sufferers who need it. And clearly a lot of work remains to be done.

Reference:
Schwartz, C., Schlegl, S., Kuelz, A. K., & Voderholzer, U. (2013). Treatment-seeking in OCD community cases and psychological treatment actually provided to treatment-seeking patients: A systematic review. Journal of Obsessive-Compulsive and Related Disorders, 2, 448-456.

Sleep Problems in Anxiety and Depression

Today is World Mental Health Day and I’m joining the 3rd Annual World Mental Health Day Blog Party. I thought I’d address the issue of sleep in mental health, particularly in anxiety and depression.

If you’ve ever been depressed or anxious you probably know firsthand that these conditions often are linked to sleep problems. Research studies have shown that having an anxiety disorder quadruples the odds of having insomnia, while depression increases the odds of having insomnia by a factor of 5. For example, Johnson and colleagues found that 43% of individuals with OCD had insomnia, compared to 11% of individuals in the general population.

So do anxiety and depression cause insomnia or does insomnia cause these mental health conditions? There’s evidence that the causal arrows run in both directions. More than one study has shown different patterns of insomnia onset in depression vs. insomnia, with anxiety more likely to precede insomnia and depression more likely to start after insomnia.

It’s not uncommon for insomnia to stick around even after the anxiety or depression is better, which not only is miserable but raises the risk of relapse. Therefore it’s important to address any lingering sleep problems. Following healthy sleep habits can go a long way toward promoting good sleep (a list is here). There are lots of good sleep resources on the web (including a few here), and professional help may be needed in some cases. Fortunately there are cognitive-behavioral treatments that don’t require the use of medications (that don’t tend to be that effective in the long-term anyway).

It’s tough to be hit with the one-two punch of anxiety or depression plus insomnia. The good news is that effective anxiety and depression treatment often improves sleep, and treating insomnia can reduce the risk for future anxiety and depression. And of course good sleep helps with pretty much everything,

References: 
Jansson-Frojmark, M., & Lindblom, K. (2008). A bidirectional relationship between anxiety and depression, and insomnia? A prospective study in the general population. Journal of Psychosomatic Research, 64, 443-449.

Johnson, E. O., Roth, T., & Breslau, N. (2006). The association of insomnia with anxiety disorders and depression: Exploration of the direction of risk. Journal of Psychiatric Research, 40, 700-708.

Neckelmann, D., Mykletun, A., & Dahl, A. A. (2007). Chronic insomnia as a risk factor for developing anxiety and depression. Sleep, 30, 873-880.

Ohayon, M. M., & Roth, T. (2003). Place of chronic insomnia in the course of depressive and anxiety disorders. Journal of Psychiatric Research, 37, 9-15.

Mindful Listening

Have you ever felt like someone really listened to you? Times we’ve truly felt heard tend to stand out, which tells us that they probably don’t happen all that often. We all fail at times to be fully present when we’re talking with others.

Plenty of things get in the way of our ability to listen well. Most of us live busy lives and our minds are great at “listening with one ear” (enough to say “uh huh … yeah … right …”) while making mental lists, planning the rest of our day, or trying to remember if we took care of something. Technology presents an additional challenge as our blinking and beeping mobile devices compete for our attention. And who isn’t guilty of sometimes checking email, scanning the web, or playing computer solitaire while talking on the phone?

Mindful listening can bring us more fully into our daily interactions. One of the exercises that’s commonly used to illustrate mindfulness is eating a raisin with full awareness. That is, we pay careful attention to the way it looks, its smell, the feel of it in our mouth, its taste…. (Try it–you’ll need a raisin.) For many people it’s something of a revelation to really experience what a raisin is like.

If we can notice so many things about a raisin, imagine what we can see in another person–a spouse, a child, a parent, a friend, a co-worker–if we bring our full awareness to our interactions. We can learn to see the people in our lives as they actually are, as though seeing them for the first time again.

The effectiveness of mindfulness training on social interactions has been tested among physicians, probably some of the busiest and most stressed out professionals. Every day they listen to patient after patient, back-to-back, and often are faced with life-or-death decisions. A recent study showed that patients were more satisfied with their visits to a doctor when the doctor had had training in mindfulness. (A nice summary of these issues can be found here.)

Once again we find evidence that mindful awareness can enrich our lives, our relationships, and the lives of others.