The decision that matters in depression

The decision that matters in depression. 

One of the things that characterizes many mental health problems, particularly depression is the vicious cycle that a person finds himself caught up in. The lack of ability to pull oneself out of problematic behavior patterns, contributes to more problems with self esteem and hopelessness which in turn sap a person’s strength more. The result is a state of inaction and stagnation. A person starts doubting their ability to do much of anything, if this cycle continues. 

I will illustrate this point with a single example. Most people with depression are too tired (both physically and emotionally) to go out of the house and do things. They will not wake up in the morning on weekends. They will not go out of the house for a walk at sunset. They will not go look at the flowers. They will not pick up the phone and invite someone for lunch. And most of the time these things are discounted as superfluous. “How much effect can one action have on the persistent sadness that pervades me”, they think. “Even if I can just manage to meet my responsibilities that would be more than enough”. I need to rest, so I have energy to do the important things. I do not have time to do anything else”. 

This kind of thinking is usually because of a cognitive distortion. That means that the depressed person will rely on a finite number of thought patterns that have been found to propagate depression. These are thoughts that are part of the vicious downward spiral and they deserve to be noticed. A lot cognitive behavioral therapists work with these thoughts. A stage in cognitive behavior therapy is called behavioral activation. This is the stage in which a person acts and take initiatives that they were previously not taking. 

Just like there is a negative spiral that can spin out of control, similarly, there is a positive spiral that can help us. Part of our job is to identify and then make use of the wafting currents of the positive spiral. 

For example, the person who decides instead of sleeping at 8pm, goes out for dinner with a friend will find that her one decision does not help her only in terms of that night. One positive decision multiplies. At dinner, she might find herself enjoying the food and decide to find a way to replicate it at home. Or that person might see the lights and people laughing and decide that she should get out more often. Or the friend that she meets might make her laugh. Or the friend might invite her to another lunch where there would be more people to connect with. Or that friend might talk about catching a movie together. Or she might want to go to see an interesting movie by herself. Or she might learn something about the new interest her friend has and she might start thinking about picking it up. Or her friend might share something sad about his life. It is possible that she might find herself as someone who is giving comfort rather than someone who is seeking it. Or she might find herself humming a song at the end of the night. Or she might think of a funny moment at dinner, while trying to go to sleep. Or next day she might have a thought about the dinner and reach out and say thank you to her friend. Or follow up on something else. 

I will invite you to compare this with her having gone to bed at 8pm and waking up in the morning. The one decision to pick up the phone and plan a dinner with her friend does not give dividends for just that evening. One decision followed through has the potential for giving structure to multiple other times. And this gift of life multiplies with every decision that we make. Not every dinner goes perfect. But not every dinner is a disaster. Chances are there will be some fun stuff, some boring stuff, some cheerful thoughts, some depressing thoughts. But regardless there is the promise of future happiness. And sometimes promises are the things that keeps us going on in life. So when it is time make the decision that is positive for your goals, make it. Faith is about making the decision without knowing what is out there but hoping for the best. It does come down to one decision at a time.

Healing spontaneity

 Healing spontaneity

 Spontaneity is a voluntary or undetermined action. It is frequently observed that in difficult times, spontaneity disappears. A state akin to freezing up happens. Security is desired. Predictability is desired.  Spontaneous decisions tend to be a trade off for more predictable decisions. Both have their role in helping us adapt to everyday life. If our response to stressful situations in life are causing us difficulties then, there is high probability that that we have our predictability/spontaneity balance wrong.

If difficulties are faced with withdrawing into a shell, "playing it safe", isolation results. Anxiety about things cause us to start planning things in a way that they are predictable, hence under our control. Infact almost all freezing up or danger of freezing up is because of lack of spontaneity.
I will give the example of this common scenario by introducing to you Sarah.

Sarah went through a bitter divorce. As a result she stopped trusting people for a while. She felt that people were out to take advantage of her. She started withdrawing from her friends. She did not want to go to work, because it was exhausting to put on a face in front of everyone. She did not want to talk to her relatives because those five minutes in which she was talking to her relatives seemed an eternity. She would sit and watch TV all day. She would spend her time thinking how she could arrange things so that they would not overwhelm her. Social encounters, projects, sleep, appetite all needed to be planned. In her fragile state, something unpredictable carried a huge risk of ruining her entire day. 

We learn spontaneity in childhood. One of the first thing we practice is play. Play is impossible if one does not take risks or experiments. The delight of play is usually accompanied by delight in oneself, a confidence in one's abilities and the ability to act authentically in accordance to one's genuine beliefs. Every play is unique to that individual and serves as an affirmation of their personality. It is only with spontaneity that one can make a statement to the universe, "I am who I am and I love who I am".

Sarah worked hard in therapy. She recognized the fact, that she lived in her mind, more than she lived in the world. She started engaging in little acts that seemed dangerous to her. She went to a completely new grocery store, at the other end of town and spent time discovering things that made it different from the one that she used to get grocery at. She started smiling at babies or children that she came across. In the office, she started wishing a good morning to five people everyday. She had a script of three opening sentences and three topics, with which she would carry a conversation, and she found out that she did not have to use a second topic in the conversations that she started. Gradually she stopped preparing for conversations. She reconnected with positive people in her life. She picked up biking again. That had healing effects which originated from her childhood. 

During re(dis)covery, one of the most important things is to rediscover the play in oneself. Rediscovering this quality in the uncontaminated nature of childhood can be a life saver (literally). A buildup of confidence is paramount in preparation for this rediscovery but the best part is that it is a positive cycle that reinforces itself to multiply. People who are successful in their risk to be spontaneous, usually get an amazing sense of relief and rekindling of hope. This makes them try being more spontaneous. And so the one act multiplies.

Discovering potential areas in which to practice spontaneity is something that happens in therapy. Discovering protective boundaries in which spontaneity can be nurtured without being overwhelmed is something that happens in therapy. Discovery of habits, things or people who aid our spontaneity are all things that happen in therapy. "A loosening up", "go with the flow", "it's ok to smile", "it's ok to take risks on people and circumstances", "i can deal with it regardless of what might come my way", are all positive affirmations that happen in therapy. Usually when all this happens, one can see the multiplication of spontaneity in a person's life and then re(dis)covery.

Treatment Resistant Depression- case example and implications

The connotations of TRD are truly mind boggling when one takes a minute and thinks about it. Yes there is the TRD which is seen in some patients with maladaptive personality dynamics and then there is TRD which is people with good adaptive skills. On one side of the swing if there is no way to determine what another person is going through and there is no way of quantifying misery and depression then we are in the danger of not giving enough credence to a condition that we cannot imagine. Take the phenomenon of fibromyalgia. However there is the other side also to which the swing tends to go. Calling a mood state TRD medicalizes the whole interaction in to a disease like diabetes. Medicalizing the field of psychiatry which has its basis in biopsychosocial etiology risks neglecting the psychosocial aspects. Yes, a psychiatrist who is doing 15 minute medication check will definitely tend to benefit from it, as is illustrated in the following example but whatever semblance of a connection that is built in these visits will be on a faulty premise of being in cahoots with the patient's selective inattention (like Harry Stack Sullivan points out). The only playing field and the opportunity of intervention then left is in the same vein as the reason why such a restriction in physician patient interaction exists. It exists because there is a need for efficiency. It exists because of the devaluation of the physician patient interaction to the business model. A business model that take the same thing and repeats itself over and over again without having the ability in it for any play to cater for the uniqueness of the patient. Winnicott's rising to the challenge of the case is not killed only but defiled when using the term treatment resistant depression.
Here is a case example. Ofcourse a lot of the case is fictional but reflects actual clinical material garnered from actual patient interactions.

45 year old lady who was seen for the first visit for depression. She had already tried multiple medications before including ECTs and came in for an evaluation of TRD. Some other physician had been kind enough to give her the handle and an image of how to present herself to other physicians. She signaled challenge and she signalled hopelessness. She has been doing an excellent job at trying to do all the normal things that "normal people" do. She dresses well, she has the average life that an average doctor would have. She was the epitomy of average-ness. She has a job. She has everything that will NOT raise the flags to maladaptive personality dynamics. She is a seasoned patient who has learnt how to interact with the medical system and whether she knows it or not she is going to be very genuine in this role. I asked ofcourse for all the records in her case. In the next visit, I was dutifully given access to a huge file of all the treatments she had tried. I spent two hours on a weekend making a list of all the medication combinations she had been on and the time lines of various treatments by this excellent physician who had retired and had bequeathed this lady in my care. She started on antidepressants, ofcourse the SSRIs. She went through all of them without response to depressive symptoms and then she  went through the SNRIs and after that she turned to tricyclics and then various combinations including the california cocktail and then with all of them add in ECT and then along with ECT mood stabilizers and then atypicals and then two different times of taper of the medications and MAOIs. Then of course were the multiple dietary aids including fish oil, deplin, vitamin D. And to top it off there were analeptics and Modafinil and some talk about Cannibinoids which I do not think ever happened.
This was clearly a textbook of how psychiatry is practiced in 15 minute med checks. The things keep on increasing and increasing. This woman had seen the psychiatrist for 20 years. Either it was the connection to the psychiatrist or her protective factors that she was alive. She of course has always had a therapist and when I made contact with her, she talked about how much progress she had made in therapy over the years. The only progress I could see was that she had learnt the system and gotten used to her suffering identity.
I contemplated on what I was going to tell her in the next visit. Should I continue this game of changing medications. Would she come back if I told her that hope for a cure is impossible.
Anyways after one year of seeing her she has had one crises and I feel it was to test me, but she remains depressed and is still waiting for the magic cure. I continue covering the same grounds with her as before. She knows it but she also knows that this is the limitations of the system that is close ended. Lately I have been trying to steer her away from VNS and DBS but who knows maybe that is where things will go.
Here is when I ask myself if things could have been different when she was 25. Maybe, maybe not. I do not know and she does not know. I spend 15 minutes with her and she spends 15 minutes with me every 4 weeks and she is not content and I am not content. Would 45 minutes with her leave her more content and would it leave me more content or would it be the reverse.

As Pink Floyd says "running over the same old ground. What have we found? The same old fears." 

Alice in Wonderland; the second example of the importance of defending what is valuable

I just finished watching Tim Burton's Alice in Wonderland. It brings to mind the genius of Lewis Carroll. One of the many writers who have been saying the same thing all along. It would almost seem pretty straight forward that the message that we get is repeated so oft, yet we fail to get it. We realize it though. That is what makes "moving" works of art so moving. They are not stationary in one dimension but move across the dimension of static repetition to the dimension of continuous renewal. The movie opens up with the tedious world of the constant operator. Status for the sake of status (blind hoarding with the only purpose is to grow larger and larger). Alice is apparently a girl that fails to adjust to this world. Is the world abnormal or is Alice abnormal. A psychiatrist in that world would most likely have treated Alice with antipsychotics. Because she tends to be overrun by the many forces in this world that are not in her control. Alice finds herself in to the world underground. This world is threatened to be over run with the red queen which is the same thing as what was happening in the world above her. The mad hatter, the march hare, the white queen hardly seem "fit" companions for any proper child in this world. That is the disdain of transitional things that are taught to us by all the gang systems. Imagine if Alice's wannabe fiance, would have visited this world. He would have tried to get the same comfortable constancy in to this transitional world. He would have most probably sided with the red queen.


The true genius of Lewis Carroll however is not exposing the corruption of the constant operator but the dangers of the transitional operator.

Many other authors have exposed the constant operator time and time again without much difficulty. You build a plot long enough till it truly begins to grow and it will start becoming monotonous and we will feel it and call it so. We will use the words boring and repetitious, exactly what the constant operator is about. Sartre in Nausea does an excellent job of converting this triteness in to an art. What the dangers of the transitional operator are shown by the two rivaling factions of the underworld. The red queen is the reflection of the world Alice has left behind. And in her "dream" she comes to realize the vulnerability of the all that is refreshing. The transitional operator (typified by the white queen) is basically helpless against the attack of the red queen. Conquering and wars are not the function of the transitional operator. Every moment is new for the transitional operator. For the compatriots of the white queen, everybody is living in the moment. The ideal senselessness is present in the tea party. Nobody knows the time, nobody cares about guests, it is a free for all, party time for everyone. That is the danger of the transitional operator. It will not get things done. It can give an excellent good feeling but when you need things to be fair and orderly, only Alice can make things right by using her "muchness" (which is a very constant operator terminology). Only by the muchness can she save the transitional denizens of her dream world and save herself in the onslaught of all things constant in her real world. Her ability to demonstrate her ability to go downstream to the battle and upstream to enjoy her friends is the fundamental operator.

What she learns in her dream is what her fundamental strategy to gain control over her real world is. Usually that is what the reorientation function of dreams.

The caterpillar is the sage which travels both worlds in different shapes that are most conducive to the time. It knows the secrets of dying and being reborn. It also knows the secret of what should be defended and how.

Definitions

Constant operator- The dynamic which repeats itself over and over again. The yields are lesser and lesser as time goes on.

Transitional operator- The dynamic which starts afresh at every turn. The yields grow bigger and bigger as time goes on.

Imagine a funnel or a tornado. In one instance when you go from top to bottom you have the perfect example of the constant operator. When you go the other way from bottom up, you have the transitional operator. All dynamics follow these two operators.

It is the fundamental operator that forms a bridge between these two operators and balances things.

O(c) Disorder

The constant operator is the perfect example of the thing that repeats itself over and over again. It sucks the life out of any natural life giving processes. Does it sound like OCD. It is kind of weird that I discovered this link between how OCD is actually an illness of the constant operator. For a detailed description of the constant operator and the transitional operator and the fundamental operator, either see Dr Gustafson's work or I will allude to it in further posts.

Here is how the equation works out so far:

OCD=Obsessive compulsive disorder= O(c)D= Disorder of the constant operator.

The fractal of basal ganglia

The Basal Ganglia can have two parallel circuits which run in conjunction with each other. Motor activity is dependant on the balance between these circuits. One is the venteromedial group of nuclei which have a large input from the limbic cortex. The other group is the dorsolaterlal group of nuclei which have their major input from the frontal lobe. The names of these two groups of nuclei are quite illustrative based on the framework one would want to differentiate them on. In an evolutionary framework, the venteromedial is earlier in development compared to the dorsolateral. Hence its functions are more “primitive” and “less sophisticated” than the dorsolateral counterpart. The dorsolateral pathways can manage inhibition of behaviors as well as activation of behaviors. The venteromedial pathways only manage disinhibiting behaviors. In terms of position also it resides “inwards” compared to the more “outwards” position of the dorsolateral structures. The venteromedial deals more with the inner feelings, hence the connections from the limbic system while the dorsolateral deals with the outer realm of things.
In Obsessive Compulsive Disorder, the venteromedial system is over-activated and an increase in disinhibition can result. This is typified by the disinhibited patterns on behaviors which are termed as compulsions. They can range from counting, checking, hoarding or cleaning. It is a hypothesis that behavioral therapy strengthens the dorsolateral pathways, especially the part which is able to inhibit behaviors.

The dynamics of a person with OCD revolve around behaviors which are dysfunctional. Dysfunction means that the behaviors do not help an individual adapt to the external reality. All behaviors are being driven by the limbic system, or the internal cues. The example is of an autistic child who tries to answer everything in his or her framework. Evolutionary it serves a function of shutting of the “thinking mind” in dangerous situations and the result is an uncontrolled motor activity which is avoidant. The dysfunction comes when this behavior goes on without any danger present in the external environment. Think of a deer that runs regardless of whether it is facing a predator or green pastures.

The balance problem with these structures represents a fractal and this fractal at different level points to a similar dysfunction seen in psychiatric patients. The psychiatric patient engages in similar dysfunctional behaviors in its interaction with other people. There is a reason why Freud called it symptom compulsion. Dr Gustafson has called it the mismatch between the internal and the external world. Think of the system that has figured out how to make profits. Every thing which is not a loss is a profit and since profit is better, all activity will be utilized to get profit. Anything that is not profit is not an activity to be engaged in. The pack will continue to increase to the point of dysfunction.

In an alternative view the venteromedial system could represent the channeling of id. Not all of those behaviors are functional in nature and it requires the functioning of a counterbalance of superego (dorsolateral) system when to inhibit behaviors, control impulses or engage in increased activity in the service of adaptation.

Mature defenses like suppression, humor, sublimation, altruism and asceticism all involve the ability to suppress the internal urges to an extent. However a couple of them like humor, sublimation and altruism actually involve behavior which is adaptable based on the cues of the environment.

However when thinking about this a certain flexibility is required. Implementation of a prefect solution no matter how elegant will run in to failure (and the be the perfect example of the basal ganglia in OCD) the moment consciousness to the uniqueness of a situation is disregarded.