Paradox of Exposure and Acceptance

Psychologist Reid Wilson states that Obsessive Compulsive Disorder (OCD) and other anxiety "Wins," i.e. maintains and gets stronger, by making the rules of the "game." By making the rules, it always wins. He sees the rules as:

1. Be careful or you might cause a horrible problem OR you have already harmed
someone.
2. If a fearful thought ("content") occurs, take it seiously.
3. You MUST feel ABSOLUTELY certain.
4. Use your anxiety as a gauge. If you feel uncomfortable, then there IS danger.
5. ALWAYS act defensively. Avoid, worry, escape, and do rituals.

In order to stop the anxiety from continuing to win, he suggests the following NEW RULES:

1. Don't pay attention to the "Content," i.e., the specific obsessions and
fears.
2. Accept the obsession when it pops up - "It's fine that I just had that
thought."
3. Tell yourself "I WANT to be anxious and STAY anxious. It's NOT about the
content." It's purposefully choosing to feel the generic sense of
uncertainty and anxiety.
4. If necessary, make rules and follow them, i.e., "Here is how I am going to
wash my hands, check doors, etc." This means what procedures and limits will
be used, as opposed to doing those things until they "feel right."

On first take, this is counter-intuitive - and sounds impossible to anyone struggling with significant anxiety. The natural response to this type of anxiety is to avoid and try to escape. Avoidance and escape is how anxiety maintains itself and gets stronger.

By this logic, if you have your fingers in a Chinese finger trap, you pull your fingers apart. The result is the finger trap becoming tighter on your fingers, making escape impossible. The only escape is pushing your fingers together, just as Dr. Wilson suggests accepting and inviting the anxiety.

What happens when you accept and stay with the anxiety is that over time, it diminishes. This is called habituation. I have often seen anxiety decrease (not totally go away) in a matter of mainutes. It is important to note that this may take longer. It is routinely suggested to spend an hour for exposure practice. Habituation generally occurs most quickly when you perform exposure frequently, you accept a higher level of anxiety, and you stay with it for longer periods of time.

Here are some ways he suggests responding to various "content:"

When obsessive doubts occur, responding to them with statements like "I'm glad that I'm having these doubts." "I'm not answering that question."
"If I imagine something inappropriate, then it means I'm a bad person - AND I CAN handle that."
"If I imagine something inappropriate, then it means Ill feel uncertain and anxious - AND I CAN handle that."
"If I don't check the stove, it will be my fault that the house will burn down - AND I CAN handle that."
"If I have a "bad thought," it means that I really feel that way - AND I CAN handle that."
"If X does/not happen, something bad will happen and it will be my fault - AND I CAN handle that."

The more you "play" by the new rules, the weaker the anxiety will become. Maintaining the anxiety rules, maintains the anxiety and makes it stronger. Several videos are available for viewing on Dr. Wilson's website (www.anxieties.com) or YouTube.

Comments on Haiti

If nothing else, the recent earthquake in Haiti should give us perspective with all that we have in our lives. We can focus on the stock markets correction or other negative things. But, we are alive. Our economy didn't collapse. We have clean water and food. We didn't lose our homes.

Most of us were born in the United States. Perhaps by accident? Why weren't WE born in Haiti? Or in Darfur? Or other places with vast disease and lacking adequate food, shelter, medicine, jobs, etc? What did we do to be born in the world's greatest country? Many of us come from modest means. But took advantage of opportunities available to many of us.

Some look away from this tragedy out of indifference. Others don't follow very closely, as they would otherwise be so overwhelmed by the sheer horror that many are continuing to experience.

I think that we minimally should acknowledge that we could have just as easily to have been born in Haiti or other undeveloped countries. For those of faith, we need to offer prayers for Haiti and other places of great need. We need to continue to give thanks for our many blessings. When you open your heart, how can you not do something? I for one, believe that we ARE our brothers' keepers.

Best wishes,

Mike
http://drmikemiller.com

Commentary About Study Questioning Anti-Depressants Effectiveness for Mild to Moderate Depression

An article just published in The American Journal of American Medicine (JAMA) questions the efficacy of the use of anti-depressant medications (ADM) with mild to moderate depressions. The article is not an easy read! Here is an abstract from JAMA.

It looked at six studies with randomized control groups. Three of the studies evaluated imipramine (an older anti-depressant) and three evaluated Paxil. The conclusion is that ADM may be no better than placebo for mild to moderate depression. Further, that there was greater change with ADM as the depression was more severe. The authors reported that it has been known for more than 50 years that more severe medical and psychiatric conditions respond to a greater degree than less severe conditions.

It was also reported that FDA studies of ADM study only those with severe depressions, which they correctly report are not the impressions that Pharma's advertising gives us.

One statement in the Abstract is questionable: “Antidepressant medications represent the best established treatment for major depressive disorder.” Studies comparing ADM with several brief psychotherapies show that the latter are equally effective to ADM. Other studies show regular exercise to also be very effective. Further, therapy and exercise have dramatically lower relapse rates.

So what does this mean if you are on ADM? My suggestion is that if it is working, continue it. Don't suddenly stop altogether. Direct your questions and concerns to your prescribing physician. However, be aware that much of what many physicians know about medications, especially newer ones, is given to them by drug representatives.

email reponse to feature on depression by WCPN

This morning, there was a segment on depression treatments on our local public radio station (WCPN). It was 99% about medical (brief reference to exercise at end) treatments, i.e., anti-depressants, deep brain stimulation, etc. This unbalanced and shallow report bothered me enough to email WCPN. Below is the email I sent to them. I am interested in how YOU feel about this.

Your brief report on depression was woefully lacking. One was left with the impression that the only treatments for depression depression are medical. It is clear that Ms. Cuda had little prior knowledge about depression and that her sources were MDs, medical websites, and/or drug companies.

There have been debates in the past that depression was biological OR psychological. For 25 years, most acknowledge it is BOTH. It would be more accurate to describe it as a bio-psycho-social process.

Trauma can alter one's biology. Negative thoughts can also alter one's biology. Turning the negative thoughts around can IMPROVE one's biology. Schwartz showed this about 20 yrs ago with PET scans of those treated for OCD.

I missed ANY reference to brief psychotherapies that have proven at least equally effective as the anti-depressants. There is about 35 yrs of research that prove this. The research with exercise is another 5 to 10 yrs longer.

A good place to get a more balanced understanding of depression is http://www.nimh.nih.gov/health/topics/depression/index.shtml

While a study reported this week questions the efficacy of anti-depressants for mild to moderated depression http://blogs.consumerreports.org/health/2010/01/antidepressants-most-effective-for-severe-depression-best-buy-drugs-for-treating-depression.html do NOT make the mistake that this message is an attack on medications. Rather, it is a criticism for a lack of depth and balance. I expect MUCH better from WCPN.

Mike Miller, PhD
Psychologist

http://drmikemiller.com/depression.html

Seasonal Affective Disorder for Dummies book review

While some may be put off by the “For Dummies” series title, I have found most to be excellent starting points. Seasonal Affective Disorder for Dummies by Laura Smith and Charles Elliot is where I would suggest you begin if you have questions or interest in Seasonal Affective Disorder (SAD). It references up to date research in a practical, readable manner. It is very well organized and written.

While there is a very good chapter on Light Therapy, what I appreciate most is that most of the book addresses other interventions. What is known to date, is that effective treatments for depression are effective treatments for SAD. Another thing I like is how the authors give examples of negative thoughts in various chapters, followed by healthier thinking. Many will see their own negative thoughts and then see how they can begin to change it to healthier thinking.

If SAD is an issue for you, I highly recommend Seasonal Affective Disorder for Dummies.

Happy Holidays,

Mike

http://drmikemiller.com/sad.html