Tag Archives: depression

Meeting the Challenges – Adjusting Thinking pg2

This entry is part of a series, Cambell meeting the challenges»

The last article discussed a number of ways to manage depression and worry. This article describes another technique for managing emotions: changing your thoughts.

The Connections Among Thoughts, Feelings and Actions

To understand the powerful effect that thoughts can have, imagine the reactions of two patients to an increase in symptoms following a short walk. One says: “Another setback! I’ll never get any better.” This person has a pessimistic way of interpreting experience. She sees specific events as examples of permanent, far-reaching negative forces. The thought “I’ll never get any better” tends to lead to frustration, depression and despair. The mood of despair is associated with learned helplessness, the sense of not having control and a belief that effort will not be effective.

Pessimistic thoughts can increase your suffering. Negative thoughts make you feel anxious, sad and hopeless, which in turn makes it difficult to act constructively. Worry and preoccupation with suffering may even intensify symptoms and trigger another round of negative thinking. The cycle can be very demoralizing and make it difficult to motivate yourself.

Being in a situation in which you seem to lack control can create a sense of helplessness. Modern psychology has coined the term learned helplessness to describe the lasting effects of an uncontrollable bad situation.

But just as feelings of pessimism and despair can be learned in response to experience, so can optimism. Imagine that the second patient responds to her increase in symptoms by saying: “I walked too far today.” She has a more optimistic way of seeing her experience. She sees an event as something specific, limited and temporary. Her thought is more hopeful. It suggests the person can learn from experience, that tomorrow need not be the same. The more optimistic mood is associated with the willingness and even eagerness to try again.

Negative thoughts can be quite common in chronic illness. Focusing on symptoms, for example, can lead to thoughts like “I’m always in pain.” Such thoughts lead to frustration and discouragement. An inner dialogue featuring the word “should” can also produce frustration and anger towards oneself. An examples is saying “I should be able to do more.” Self-esteem can be undermined by thoughts like “I’m useless.”

The Effect of Expectations on Emotions and Symptoms

A student in one of our early groups provided a good example of how thoughts can affect emotions and symptoms. At a birthday party one year, she took on the role of the good hostess, moving about and worrying whether everyone was having a good time. She found herself tired and cranky after an hour. For a similar party a year later, she decided to create a different expectation for herself. She imagined she was a queen who was observing the situation from a throne. Freed from her self-imposed expectation that she should make sure everyone enjoyed themselves, she found herself with good energy for more than two hours. By making a mental adjustment (changing her thoughts), she reduced her worry, extended her energy and reduced her symptoms.

In this article, we will explore how you can recognize and break the cycle in which negative thoughts and symptoms reinforce one another, so that you can use your thoughts to help you, rather than having them increase your suffering.

Recognizing Automatic Thoughts

The process of changing explanatory style from a pessimistic, helpless one to a more optimistic and hopeful one occurs in three steps. The first is learning to recognize one’s self-defeating thoughts. This is not easy to do because the thoughts are automatic and habitual, so deeply ingrained that they seem self-evident.

A technique for recognizing automatic thoughts is the Thought Record, which is described in the book Mind Over Mood by Dennis Greenberger and Christine Padesky. Using this form offers a way to become aware of your automatic thoughts and their effects on your mood and behavior. (You can find similar techniques in other books, such Learned Optimism by Martin Seligman, Feeling Good by David Burns or books by Albert Ellis.)

To see how this technique works, we’ll use an example of a patient who took a walk one day and felt very tired when she got home. Feeling discouraged, she asked herself what thoughts were going through her mind. The answer: “I’ll never get better. Every time I try something, it fails.” She wrote a description of the event in column 1 of the Thought Record. (See below.) In the second column, she recorded her emotions at the time, noting that she felt depressed and hopeless. And in the third, she wrote the thoughts going through her mind when the emotions were strongest: “I’ll never get better. Every time I try something, it fails.”

The purpose of this exercise is to help you gain some distance from your thoughts, to remove their taken-for-granted or self-evident character. Often we are more harsh and judgmental toward ourselves in our inner dialogue than we would be with others. Self-defeating thoughts often go through our minds when something upsetting occurs. Because these thoughts are automatic, they can be hard to recognize and it can take some time to develop this skill.

Evaluating Negative Thoughts

Once you have identified negative thoughts, the next step is to examine them for “reasonableness.” In evaluating your thoughts, ask yourself to what extent the thoughts are valid. Negative thoughts tend to ignore facts or to select only the worst aspects of a situation. One way to determine reasonableness is by asking “What is the evidence for and against my thoughts?” The idea is to suspend temporarily your belief that the thoughts are true, and instead look for both evidence that supports and evidence that refutes the thoughts. Writing down the evidence you find helps you gain distance from your thoughts and makes them less self-evident.

You use column 4 in the Thought Record for evidence for, and column 5 for evidence against. The patient in our example wrote in column 4 that she has frequent setbacks and that she had often felt worse after exercising. She wrote in column 5 that she had improved over the last year and knew that many CFIDS patients improve.

Your thoughts at moments of strong emotion may seem irrefutable, so it may help to have in mind some questions you can ask yourself in order to find evidence that does not support your thoughts.

Among them:

Do I know of situations in which the thought is not completely true all the time?

If someone else had this thought, what would I tell them?

When I felt this way in the past, what did I think that helped me feel better?

Five years from now, am I likely to view this situation differently?

Am I blaming myself for something not under my control?

Seeing Alternatives

In the first step, you identify your self-defeating thoughts by recording the thoughts associated with strong emotions. In the second step, you challenge the accuracy of the thoughts by testing them to find distortions and irrationalities. In the last step of the process, you propose a new understanding of your experience.

You use column 6 of the Thought Record for this purpose. What you write in column 6 should be either an alternative interpretation of your experience (if you refuted the thought) or a balanced thought that summarizes the valid points for and against (if the evidence was mixed). In either case, what you write should be consistent with the evidence you recorded in columns 4 and 5. Reviewing the evidence she had written in columns 4 and 5, our patient decided that the evidence was mixed. She wrote a balanced thought that combined the evidence for and the evidence against. “I have frequent relapses and don’t know if I will have lasting improvement. But I’ve made progress and that gives me hope.”

The Goal: More Realistic Thinking

The process described here involves changing deeply ingrained habits of thought. The long-term results can be dramatic, but improvement is gradual. The reason to use thought records is not to replace negative thoughts with positive but inaccurate ones. I am not suggesting you adopt something like the motto “every day, in every way, I am getting better and better.” Rather, the goal is to learn to see your situation in an accurate, yet hopeful way: retraining your habits of thought in a more realistic direction. The kind of thinking advocated here integrates all evidence both positive and negative. It should reduce your stress by helping you feel better, less anxious and sad. And, at the same time, it should help you to deal more effectively with your illness.

Bruce Campbell:Meeting the Challenges of LongTerm Illness

This entry is part of a series, Cambell meeting the challenges»

Depression & Worry
By Bruce Campbell

So far in this series, we have focused on symptom management, suggesting that you will help yourself control symptoms if you honor your limits and address the stresses in your life. But because long-term illness affects so many parts of life, managing it requires more than symptom management. The rest of the series discusses three challenges beyond controlling symptoms: managing emotions, getting support, and moving beyond loss to build a new life.

Emotions in Chronic Illness

Strong emotions like fear, anger, grief and depression are common reactions to having chronic illness. Such emotions are a normal and understandable response to being in a situation that isolates, creates tremendous uncertainty, brings loss and imposes limits.

Unfortunately, CFIDS and fibromyalgia seem to make emotional reactions even stronger than before and harder to control. This reaction seems part of the physical basis of the illness. The strength of emotions can create a vicious cycle. Emotions can intensify symptoms, which in turn may increase worry and depression. As one student in our program said: “My emotions are much more sensitive than ever before. I cry more easily, and I have less emotional reserve to listen to my teenagers and husband and talk with them about their concerns.”

Self-help can play a role in managing the emotional aspects of chronic disease. The stress reduction techniques described in an earlier article: Relaxation for stress reduction] in this series may be helpful. Relaxation, for example, can short-circuit the feedback effect in which symptoms and emotions reinforce one another. Also, changing your thinking, as outlined in the next article, may be useful. The techniques described there have been proven to be especially helpful in counteracting the effects of anxiety and depression. Another general approach is to identify those situations (and sometimes people) that trigger strong emotions and plan a strategy of response ahead of time. Often, avoiding or minimizing stressful situations can reduce emotions, as described in the last article.

With those general comments about feelings as background, let’s look at several emotions and how to manage them.

Depression

Depression is very common in chronic illness. This should not be surprising. After all, illness turns lives upside down, bringing great losses and tremendous uncertainty. Also, serious illness is isolating. We spend less time with people and more time alone. In addition, sometimes depression may be part of our illness, with real physical causes. Prolonged stress may alter the biochemistry of the body, causing depression.

Depression is often divided into two types: situational and biochemical. Both may apply to people with CFIDS and fibromyalgia. Situational depression, which means depression that occurs as a response to a particular set of circumstances, lends itself to self-management strategies such as those described below. But not all depression is best handled this way. If you are deeply depressed about your illness or you have biochemical depression, which has its roots in the chemistry of the brain, medication and professional help are indicated. Self-management strategies may also be helpful.

There are many things you can do to improve your situation. If you are depressed, you may not want to try, but remember that depression feeds on itself. Your attitude becomes a self-fulfilling prophecy. If you believe you can get better, you will take actions such as those listed below that have a good chance of helping.

Rest: Some depression seems to be associated with physical symptoms such as fatigue and pain. Resting to reduce these symptoms can also improve mood.

Reach Out to Others: Simple human contact is often very soothing. Calling a friend or getting together to talk, share a meal or see a movie counteracts the sense of isolation, preoccupation with problems and the low mood often associated with chronic illness. Just explaining yourself can often give you perspective. Fellow patients can be very helpful.

Get Out of the House: Just like contact with others, getting out of the house counteracts isolation and boredom, provides stimulation and can reduce depression.

Consider Medications: Tranquilizers and narcotic painkillers intensify depression. If you are depressed, it may be in part a medication side effect. Check with your doctor. On the other hand, if your depression is bio-chemical in origin, you may be helped by an anti-depressant.

Exercise: Exercise is a natural anti-depressant. It relieves tension, lessens stress and improves mood. Most exercise also involves being out of the house, thus bringing the adding benefits of a change of scene.

Practice Problem-Solving: Taking action to solve a problem lifts the spirit as well as having practical benefits. Doing something counteracts the sense of helplessness and replaces it with a sense of control and power. In the words of one student, “I handle emotions better if I do something rather than passively suffer.”

Do Something Pleasant: Doing something in which you can become absorbed distracts from bad moods and puts you in touch with positive forces. Such activities might include reading, playing or listening to music, sitting in the sun, solving jigsaw puzzles, doing needlework, spending time with friends, being out in nature and laughing.

Get Help: If you are seriously depressed, suicidal or have been depressed for some time, get help now. Phone a suicide prevention center, talk to your doctor, see a psychologist or call a friend. If your problems are less severe, consider seeing a psychotherapist. Look for one who has experience working with people who have chronic illness. A therapist can provide an outside view of your situation, help you to accept your illness and support you in your efforts to improve. If you have family tension because of illness, you might also consider couples or family counseling.

Establish Good Daily Habits: Keeping to a daily routine regardless of how you feel can help counteract depression. Your daily round of activities will depend on the severity of your illness, and might include things like getting dressed every day, making the bed, cooking meals, taking a walk and watching a favorite TV program. Forcing yourself to do these things even if you don’t want to counteracts the inertia of depression.

Help Others: Get involved with something larger than yourself to counteract the isolation and preoccupation with symptoms that often accompany illness and to rebuild self-esteem. We usually feel better if we do something for another person. Helping others might involve a regular commitment like helping to lead a support group or something as simple as a phone call to an older relative or checking in with an old friend.

Manage Your Stress: Controlling stress can help you manage your emotions, because stress tends to make emotions more intense. Living within your energy envelope and managing the stresses in your life will make emotions more manageable.

Fear and Anxiety

Fear and anxiety often accompany chronic illness. These reactions are common in situations in which we feel an increased vulnerability in combination with a decreased sense of power. Because of having a serious illness, we experience a loss of control over our bodies and over our ability to plan and predict. Our illness brings uncertainty about the future. We may be unclear about our prognosis and wonder whether we will improve and, if so, how much. We may worry about how far down we might slide and about becoming dependent or financially destitute.

Strategies like those below are often helpful with fear and worry reactions. For more suggestions, see “Fifty Tips on the Management of Worry without Using Medication” in the book Worry by Edward Hallowell.

Use Problem-Solving: Taking action to solve a problem has a double payoff. You reduce or eliminate a practical concern that is bothering you. Also, the process of taking action often reduces worry.

Practice Stress Reduction: Learning relaxation and other stress reduction techniques can help reduce the intensity of your emotional reactions and, by doing so, reduce the echo effect in which emotions and symptoms amplify one another. A regular stress reduction practice can also lower “background worry,” the ongoing anxiety that results from long-term stresses like chronic illness.

Change Your Thinking: If you have a tendency to think of the worst that might happen, you can take steps to short-circuit the process in which your thoughts increase your anxiety. One antidote is to retrain yourself to speak soothingly when worried, saying things like “I’ve been here before and survived” or “this is probably not as bad as it seems.” For more on this, see the next article in this series.

Connect with Other People: Feeling that you are part of something larger than yourself counteracts worry. Also, contact distracts you from preoccupation with your problems, and provides reassurance.

Exercise: One of the best treatments for worry, exercise is both relaxing and distracting.

Pleasurable Activity. Reading, music, good conversation and other activities in which you can become immersed help change mood.

Don’t Worry Alone: The act of sharing a worry almost always reduces its size and emotional weight. Discussion may help you find solutions, but almost always makes the worry feel less threatening. Putting a worry into words translates it from the realm of imagination into something concrete and manageable.

Medications: Just as drugs can help with depression, some people find that medications help them deal with anxiety. A drug will not be a complete solution to problems of anxiety, but it can be an important part of a comprehensive response.

Panic

About 10 percent of people with CFIDS experience an especially severe and frightening form of fear called panic attacks. These are brief episodes of terror in which a person may feel he or she is about to die. Symptoms may include chest pain, heart palpitations and dizziness. In spite of overwhelming fear, people survive but may live a life of dread, apprehensive about when the next attack may occur. This kind of fear is treatable. For discussions on how to conquer panic, see Edward Hallowell’s book Worry or Martin Seligman’s What You Can Change and What You Can’t.

Summary

In sum, you aren’t crazy to experience strong emotions in reaction to having your life turned upside down. It would be surprising if you didn’t respond that way. Emotions like depression and anxiety are common responses to situations of loss and uncertainty. But there are many things you can do to reduce the strength of these emotions. Like other aspects of chronic illness, emotions can be managed.