About Bipolar Disorder

In any given year, approximately 5.7 million American adults (about 2.6 percent of the population) have bipolar disorder (International Bipolar Foundation). It is estimated that people with bipolar disorder have an increased risk of suicide compared to the general population, with some research suggesting that up to 20% of individuals with bipolar disorder (especially if left untreated) end their life by suicide (Dome, Rihmer, & Gonda, 2019). 
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Correct diagnosis of bipolar disorder is essential for developing an appropriate treatment plan. Proper diagnosis involves doing a thorough clinical interview which is likely to include various assessments and coordination of care with other providers.

Bipolar I disorder is diagnosed when an individual meets criteria for at least one manic episode. When an individual meets criteria for at least one hypomanic episode and one depressive episode, bipolar II is diagnosed. More information on diagnosing bipolar disorder can be found in my Monday Facebook blog post.

Evidence-based treatment for bipolar disorder involves a combination of medication and Cognitive-Behavioral Therapy. Other effective treatment interventions may include ACT and DBT strategies.

Medication

Some of the medications that have been found to be effective in treating bipolar disorder include: lithium, anticonvulsants, antipsychotics, antidepressants, and calcium channel blockers (Fast & Preston, 2006). It will be important to work with your doctor to determine what medication regimen will work best for you. Your therapist can work with you to help identify important questions to ask regarding your medication. Important facts about your medication include: what drugs you are taking, specific symptoms they are treating, recommended dosage, any potential interactions, and their side effects (Fast & Preston, 2006). Additionally, it is important to consult with your doctor prior to taking any supplements. There are certain over-the-counter supplements which can cause serious problems for individuals with bipolar disorder. For example, anything that reduces depression such as SAM-e and St.-John’s-wort, can potentially provoke a manic episode (Fast & Preston, 2006).

Therapy Interventions

When managing mental or physical health problems, lifestyle changes are often necessary. If an individual is diagnosed with diabetes or heart problems, it is important to develop a healthier lifestyle. The same is true when managing mental health issues such as depression, anxiety, or bipolar disorder.

Cognitive-behavioral therapy (CBT) includes the following strategies: psychoeducation, identification of triggers, thoughts, feelings, and behaviors associated with symptoms, and implementation of proactive measures and coping strategies. Cognitive-restructuring is a CBT strategy that involves identifying distorted thinking that exacerbates problems. Your therapist will spend time helping you to develop more balanced, realistic thoughts. Significant time is also spent identifying and altering behavior that exacerbates symptoms.

Development of a wellness plan is a preventive strategy that increases awareness of symptoms and how to manage them effectively. Items that are typically included are: symptoms, triggers, warning signs, medications, support system, and lifestyle changes. Once this plan is developed, your therapist may help you identify trusted individuals with whom you can share this plan. Many clients need the assistance of support people to help them recognize warning signs and problematic behaviors.

Regular risk assessment is part of treatment for bipolar disorder. This includes assessing for suicidal thoughts, plans, or intentions, as well as self-harm urges or other risk-taking behaviors. Safety plans entail steps that can be taken when a client feels unsafe. These are often developed in treatment as part of the wellness plan.

Various Acceptance and Commitment Therapy (ACT) strategies can also be useful in therapy. Clients can experience feelings of guilt and shame about what happens during various mood episodes. Learning and practicing self-compassion can be an important part of their treatment. Additionally, assisting clients in identifying their values and behaviors that honor those values can help clients adhere to their wellness plan.

Clients often benefit from distress tolerance strategies. Urge-delay is a strategy that can be used to help clients refrain from engaging in self-destructive behaviors. The clinician may guide the client in creating a coping card containing healthy alternative behaviors. When a client experiences a self-destructive urge, they are instructed to set a timer, usually for at least 20 minutes, and then choose from the healthy behaviors listed on their card.  

Grief and Bipolar Disorder

Many clients experience grief associated with their diagnosis of bipolar disorder. Part of treatment should allow clients to grieve losses associated with their diagnosis. These losses can be personal and professional. Individuals may mourn the loss of their former identity prior to the diagnosis.

It can be daunting to receive a diagnosis of bipolar disorder. The good news is that it is very treatable. With the help of a proper medication regimen and treatment plan, individuals can lead productive and fulfilling lives.

Resources

Listed below are some resources that may help supplement treatment for bipolar disorder.

Depression and Bipolar Support Alliance (DBSA): https://www.dbsalliance.org/

International Bipolar Foundation: https://ibpf.org/about-bipolar-disorder/

If you or someone you care about is thinking of harming themselves, it is imperative to seek immediate assistance. Options include:

• Call 911 or visit your nearest emergency room.
• Call an ambulance to take you or your loved one to the hospital.
• Contact 988 Suicide and Crisis Lifeline- provides 24/7 free and confidential support.

References

American Psychiatric Association. (2022). Bipolar and Related Disorders. In Diagnostic and statistical manual of mental disorders (5th ed., text rev.).

Fast, J.A. and Preston, J. (2006). Take charge of bipolar disorder: A 4-step plan for you and your loved ones to manage illness and create lasting stability. Grand Central Life & Style Hachette Book Group.

Healthline. (2022, July 26). Suicide and bipolar disorder: Symptoms, Treatment, and Prevention. https://www.healthline.com/health/suicide-and-bipolar

​International Bipolar Foundation (n.d.) What is bipolar disorder. https://ibpf.org/about-bipolar-disorder/

Welcome to Neurodiversity Week! This week will be filled with information and tips regarding attention-deficit/hyperactivity disorder (ADHD).  Webster’s Dictionary defines neurodiversity as the range of differences in individual brain function and behavioral traits, regarded as part of normal variation in the human population (used especially in the context of autistic spectrum disorders). Harvard Medical School further expands that definition to include other neurological or developmental conditions such as ADHD or learning disabilities.

ADHD stands for attention-deficit/hyperactivity disorder. As an aside, the use of the term ADD has been discontinued. It is now considered part of the broader ADHD term, and you do not have to experience hyperactivity to have ADHD. There are 3 different types of ADHD: hyperactive/impulsive, inattentive, and combined type.  When people visualize someone with ADHD, they often picture a child (usually a boy) who cannot sit still in a classroom setting.  While this can be one way that ADHD presents, it is not the only way it shows up in children. It can also show up as a child who needs to be reminded four times that they need to get their materials out of their backpack to start their day…every day. The diagnosis has nothing to do with a lack of attention. It is not a character flaw.  It is a condition that individuals are born with that results in executive functioning issues (otherwise known as executive dysfunction). According to leading expert Dr. Russell Barkley, executive function can be described as:

• Self-Awareness
• Inhibition: Self-Restraint
• Non-Verbal Working Memory: the ability to picture things mentally
• Verbal Working Memory: internal speech or inner voice
• Emotional Self-Regulation: using the prior 4 executive functions (self-awareness, inhibition, words, and images) to process your own emotional state and cope with those emotions
• Self-Motivation
• Planning and Problem-Solving

Not every person with ADHD struggles as significantly in each area, but will have difficulty with most. If you are questioning the possibility of yourself or a loved one (including a child) qualifying for a diagnosis of ADHD then I hope to help you on this journey.

Step 1: I highly recommend that you take a reputable online questionnaire to see if you or a loved one would qualify.  I recommend taking this one: https://www.additudemag.com/symptom-checker/ 

Step 2: Save a copy of your questionnaire results somewhere you can access it again or print it out to take with you. Consider how long these symptoms have been a part of your life. Is this something you have always had trouble with? Or other similar areas?

Step 3: Pursue getting formally diagnosed. This is helpful for seeking treatment (therapy and/or medication). Getting a diagnosis seems like it should be straightforward; however, it needs to be given by a medical doctor (like your primary care provider); a psychiatrist, or a psychologist. Psychologists/Neuropsychologists can perform comprehensive diagnostic testing to make or confirm a diagnosis (if you wish to use insurance for testing, ensure this is covered by your insurance provider). Getting a diagnosis is often one of the most difficult steps to get accomplished. Unfortunately, the medical community has varying levels of comfort with ADHD diagnoses. It may require seeing a psychiatrist. Being able to bring a copy of the ADHD questionnaire results with you may be helpful, but they may have you complete an assessment regardless.

For Children:
If you are seeking a diagnosis for a child, it will most likely require an assessment by a child psychiatrist.  You can get a referral from your pediatrician (if they are not comfortable making the diagnosis themselves). This is a multi-step process, as they will try to get information from others in your child’s life (such as teachers, daycare providers, etc.).  This can be very hard to diagnose in children that are not yet in school, but can be accomplished with persistence. Note that this can take some time to get the questionnaires completed by a teacher and back to the psychiatrist. This step will be followed by another appointment with your provider to discuss next steps.

For Adults: 
It is likely that you will need to see a psychiatrist for an assessment. You may be able to just see your primary doctor, but don’t be surprised if they refer you out. Sometimes, this can take some advocacy as well. You will want to keep in mind what will fit best with your lifestyle. I know an individual who was diagnosed with ADHD, but was told by their doctor that they should quit their high stress job and find a personal assistant to help them get the tasks done that they were struggling with in their life because that doctor did not like to prescribe ADHD medication. To say that was not a feasible option was an understatement!  Luckily, this person did not give up and was able to finally get the help they needed through a different provider.  

Unfortunately, there are still people, including professionals, that believe that ADHD is “not real”, “over-diagnosed”, “is something that everyone has”, or “something that you grow out of”.  For some, it can seem like an uphill battle to get properly assessed, even though a correctly identified diagnosis can make such a positive difference in someone’s life.  If you chose not to get formally diagnosed and just prefer to see a therapist, they can still help with behavioral interventions, but to get an official diagnosis may require one of the options mentioned above. 

After diagnosis, you have the option of getting medication and/or therapy. Medication alone can be helpful, but does not address the emotional aspects of ADHD, which is where therapy can prove beneficial.

Neurodiversity reflects the reality that our brains all work in very different ways. Understanding the way that your brain works (or the brain of a loved one) can help you in your life in so many ways.  One of the best comparisons that I have come across for ADHD is this: If you tell someone who is nearsighted to “just look harder”, they cannot. That person is not physically capable. That’s the same thing that happens when you tell someone with ADHD to “just try harder” or “it’s not that difficult”.  They may not be capable of making that happen in the same way. Getting properly assessed and treated can be an important step in getting help. 

Many of my patients who have been diagnosed with PTSD describe their traumatic memory as if the event just happened yesterday. They tell me it feels dangerous to examine the memory and to allow it into their minds. They tell me that any reminder of the memory also feels dangerous. This makes sense for a variety of reasons.

First, thinking about the worst day or days of your life will understandably feel awful. Second, one component of PTSD is experiencing intrusive thoughts about the traumatic experience and other symptoms related to feelings of re-living the trauma, otherwise known as re-experiencing symptoms (American Psychiatric Association, 2013). Intrusive symptoms reflect the nature of PTSD as a recovery disorder (Resick et al., 2017). Although most people experience PTSD symptoms after a traumatic event, most people recover in a month or less. What does recovery mean? In part, it means that these individuals are able to think of the traumatic experience without feeling significant anxiety or distress. However, if the memory continues intruding into your conscious awareness and causing significant distress, it generally is a sign that the brain did not properly process the memory and place it into long term memory storage (Foa & Kozak, 1985). The brain thereafter keeps prompting intrusive thoughts about the traumatic memory in order to remind the individual to process and properly store the memory. Unfortunately, this means that the memory continues feeling very fresh, in a way that some patients describe as ‘hot.’

​These intrusive memories provoke anxiety symptoms because the brain continues believing this event to be a recent occurrence that we must be vigilant of and prevent from happening again. In addition, without proper processing and storage, the brain will continue forcing the memory into awareness but instead of allowing the memory to be present, individuals with PTSD push the memory away. The longer we try to avoid something, the harder it becomes to face and the more anxiety one will experience when the intrusion comes to mind. Therefore, from a psychological perspective, avoidance is one of the main reasons memories continue feeling dangerous. When we tell our brains, “hey, don’t think about that, it’s scary,” we develop a stronger fear response if we do not look. 

From a biological perspective, memories feel dangerous because they are activating the part of our brain that detects danger, the amygdala (Resick et al., 2017). Specifically, experts have explained this activation as part of the neurocircuitry model of PTSD (Rauch et al., 2006; Hughes & Shin, 2011) which suggests that three areas of the brain contribute to an extreme fear response to traumatic memories when an individual has PTSD. While the amygdala is over-reactive to the memory, creating a fear response to the memory, various regions in the part of our brain involved in rational processing, known as the prefrontal cortex, is under-reactive (Hughes & Shin, 2011). Therefore, the prefrontal cortex fails to remind individuals with PTSD that they are not rationally in any danger when they experience the memory (Rauch et al., 2006; Hughes & Shin, 2011). In addition, the part of our brain responsible for long-term memory storage, the hippocampus, functions abnormally in individuals with PTSD (the exact nature of these abnormalities are still being examined by researchers; Hughes & Shin, 2011). The abnormal functioning in these three regions interfere with fear extinction (Hughes & Shin, 2011). For these reasons, when I ask my patients with PTSD if it feels like the event is still happening, they often say yes, even if the event or events took place a decade or decades ago. 

Many of my patients feel like these memories will always feel dangerous. This is a fair assumption because, since the event or events occurred, the memories have likely triggered. The good news is, the memories are not actually dangerous and they do not need to be avoided. In fact, one major aspect of PTSD treatment is reducing and eventually eliminating avoidance of traumatic memories so that your brain can properly process and store these memories. We will eventually even help you process what are known as, hotspots, or the aspect of the traumatic memory that triggers the highest levels of anxiety or distress when re-experienced (Nijdam et al., 2013); oftentimes, hot spots represent the most terrifying aspects of a memory. Your provider will help you do so by using treatments and techniques that challenge avoidance of memories. One technique is called an imaginal exposure, in which processing takes place by imagining the event. By doing so, the brain will learn that the memory is actually not dangerous and is not still happening. The memory is in the past and we are here to help your brain recover from the past.

Please call 630-570-0050 or email us at Contact.OH@OakHeartCenter.com to get started with your healing process. 


References 

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

Foa, E. B., Hembree, E. A., & Rothbaum, B. O. (2007) Prolonged Exposure for PTSD: Emotional Processing of Traumatic Experiences: Therapist Guide. Oxford University Press.

Foa, E. B., & Kozak, M. J. (1985). Treatment of anxiety disorders: Implications for
psychopathology. In A. H. Tuma & J. D. Maser (Eds.), Anxiety and the anxiety
disorders (pp. 421–452). Erlbaum.

Hughes, K.C., & Shin, L. M. (2011). Functional neuroimaging studies of post-traumatic stress disorder. Expert Rev Neurother, 11(2), 275-285. https://doi.org/10.1586/ern.10.198

Nijdam, M. J., Baas, M. A. M., Olff, M., & Gersons, B. P. R. (2013). Hotspots in Trauma Memories and Their Relationship to Successful Trauma-Focused Psychotherapy: A Pilot Study. Journal of Traumatic Stress, 26(1), 38-44. https://doi.org/10.1002/jts.21771

Rauch, S. L., Shin, L. M., & Phelps, E. A. (2006). Neurocircuitry models of posttraumatic stress disorder and extinction: human neuroimaging research – past, present, and future. Biol Psychiatry, 60(4), 376-382. https://doi.org/10.1016/j.biopsych.2006.06.004

Resick, P. A., Monson, C. M., & Chard, K. M. (2017). Cognitive Processing Therapy for PTSD. The Guilford Press.

​As 2023 continues and a new month unfolds, I wanted to share some tools about staying motivated, identifying and resolving barriers, and engaging in healthy reflection in order to make & maintain progress toward goals using CBT.

Our thoughts are powerful. I think this becomes super evident during times of stress - all of a sudden, it's easy to downward spiral into thinking "nothing ever works out," "I always mess it up," and "nobody cares." The key is to slow down and recognize when words such as "always," "ever," "never," "nobody," and "everybody" play through your mind. Part two is to become curious. Some examples of becoming curious about these thoughts are: "Things have NEVER worked out before?", "Is there an example of a time when something did work out well?", "Do I ALWAYS mess things up?" "Is there a time where I did something and found success?"

Slow down, pause, and be mindful and curious about thoughts that include words such as "always," "never," "ever," "nobody," and "everybody."

Emotions are helpful in providing information. Here's some examples of how: anger is helpful and might inform a person that healthy boundaries need to be put in place in some area of life. Sadness is helpful and might inform other people that the person feeling sad may need some extra support and connection. Nervousness is helpful and might show a person what they care about. Fear is helpful and might alert a person to actual danger in order to stay safe. Emotions aren't "bad." 

It is common for clients to experience aversion to emotions, especially anger and sadness. The unfortunate reality is that emotions can't be cherry-picked, meaning I can't choose to avoid feeling angry and still hope to experience joy at full capacity. If I numb anger, overtime, I will also numb joy. Emotional identification, expression, and regulation are key techniques in experiencing healing & progress. 

To help clients identify emotions I sometimes ask clients to imagine what that emotion could look like. What color would anger be? How much room would it take up? Does it show up physically somehow - tensed muscles, an increase in body temperature? Using a feelings wheel can also prove to be beneficial in this stage of emotion identification.
To help clients express difficult emotions, I will reflect the emotion I see based on how the client identified it would look like. I pause for a minute. Silence is helpful in providing intentional space for emotions that may have been invalidated in the past. 
To help clients emotionally regulate, I'll invite clients to practice a grounding exercise and one of their favorite breathing techniques.

Emotions aren't "bad." However, sometimes the behaviors that follow as a result of the emotion can be unhealthy and unhelpful. This is part of the process where clients begin unlearning ways of being that are no longer helpful. Let's use this example: "I'm not good enough and always fail at things" --> leads to feelings of X (maybe anxiety, sadness, anger, etc.) --> leads to X behavior (avoidance of activity, numbing/excessive use of substance or social media, etc) and the cycle continues. Due to the behavior including avoidance of the activity in an attempt to minimize difficult emotions, the unhelpful thought of "I'm not good enough and always fail at things" is reinforced. 

The goal is to educate clients about the connection between thoughts, emotions, and behaviors and then to increase awareness of the internal thought process and how it impacts emotions and behaviors. 

I'd ask what type of behaviors would become easier if happiness was experienced and anxiety lessened? What barriers, if any, need to be identified and resolved? And then together, that's how an action plan is created. Action plans can be written down or they can be verbalized. Clients would also be encouraged to "give themselves credit" once they accomplish parts of their action plan that week - that could look like practicing verbal affirmation or writing a positive affirmation on a post-it note.

Prior to the end of a session, clients are asked to summarize what the action plan steps are for the week. This helps clients feel confident in being capable of producing change in their own lives. 

Mental Health Hygiene is much like physical hygiene, consistently practiced activities that help ensure both short-term and long-term health and contribute to our quality of life. The following are 4 categories I believe are important components of good mental health hygiene and ones I teach to my clients regularly:

The Physical 3: Mental health hygiene includes physical health hygiene (and vice versa). Mental health benefits greatly from some physical health basics. These include getting restful sleep, getting physical exercise, and eating nutritious food. I often refer to these as foundational to mental health hygiene. Similar to Maslow’s Hierarchy of Needs, it will be more challenging to achieve comprehensive mental health hygiene without these foundational physical health basics. 

The Behavioral Activation 3: Therapists often include behavioral activation as a highly effective tool in combating depression and anxiety. Behavioral activation involves encouraging “activation, “interaction with one’s environment in a way that offers opportunities for positive feedback from the environment and increases in self-worth and trusting oneself. Typical components of behavioral activation include engaging in daily activities that give an individual a sense of meaning, pleasure, and mastery. Read more about Behavioral Activation here: https://www.oakheartcenter.com/oakheart-blog/behavioral-activation-for-depression-what-why-and-how

The Social 3: Investing in relationships and spending time with people whom we care about (and who care about us), sharing kindness with others, and “working out” with a “personal mental health trainer” (aka a therapist/counselor). Most of us desire relationships with other people, and getting regular face-time with others can do wonders for our mood. Of note, interactions with others who are capable of making us feel worthy and loved and seen is important. Helping others and showing kindness can also be incredibly rewarding and help fulfill values and/or our sense of meaning. And working with a therapist/counselor can be a powerful source of support and guidance. This might be particularly true for those struggling with significant mental health concerns such as trauma, mood disorders, eating disorders, anxiety disorders, etc. 

The Mindful 3: Practicing staying present and externally focused, practicing non-judgmentalness (especially towards the self which includes self-compassion), and practicing gratitude. Many mental health disorders and symptoms result in either living in the past (rumination, shame spirals, checking back in time, etc.), living in the future (worrying about catastrophic possibilities, what if’s, over-planning/preparing, etc.) or living focused inward (focusing on physical symptoms, being consumed by thoughts or trying to figure something out, engaging in mental compulsions, etc.). Learning to stay present-focused and externally-focused are powerful tools. Children have a knack for this skill, and as we age, we lose this powerful natural gift…to live every moment for exactly what it is. We also have a natural proclivity towards judgment, of ourselves and others. Learning to be aware of the assumptions we are making and to approach the world and ourselves with a noticing versus judging mentality can be an important mental health hygiene tool. As is practicing gratitude. 

With the holiday season in full swing, it can be easy to get caught up in the celebrations and overindulgence that can happen during this time of year. Below are a few tips to aid in keeping your sobriety from getting lost in the hustle of the season.
  

1. Be Mindful: This means being able to identify early warning signs your sobriety may be at risk. Early warning signs may be mood changes, changes in daily routine, or changes in sleeping patterns. Being able to recognize early warning signs and applying healthy coping skills may help avoid a relapse in the future.
2. Social Supports: Building strong social support is a key component to having a successful sober holiday season. Social support can be someone to attend parties with, can be a person you share emotions with, or be someone to help bring attention to high-risk situations that haven't been previously addressed. 
3. Written Plan: Taking the time to complete a written relapse prevention plan is a valuable resource to have in being able to support sobriety. It can be used to reflect on goals and steps to support those goals. It can also include triggers, healthy coping skills to utilize against triggers, contact information for social support, information for sober support meetings (AA, Smart Recovery), and ways to relax during the holiday season. 

Taking the time to prepare in advance for the upcoming holiday season can aid in making the season a success for recovery. If reading the information provided above resonated with you and you may be a good fit for one of my specializations, reach out. I’d like to connect and find out more about how I can support you on your journey.

When it comes to eating disorder recovery, the holiday season can be a significant stressor. I work with several of my clients in recovery on developing an action plan for their holiday experience, specifically their holiday gatherings that may be triggering for them. When my clients and I discuss planning, we usually write a plan that can be reviewed when emotions are more intense or uncomfortable. Unfortunately, people struggle with accessing these plans from their memory when emotions are high, so I always encourage my clients to write them down or put them in the note section of their phones for easy access.

When clients have plans on how to deal with difficult experiences, they tend to feel more confident in their ability to navigate those stressors. I aim to empower my clients to take control of their lives so they can learn to enjoy the holiday season again. 
I will share five tips I use with clients for navigating the holiday season when recovering from a restrictive eating disorder.

Tip 1: Make a plan regarding confronting fear foods

Fear foods may still be tough to consume depending on where a person is in their recovery process. I encourage my clients to consider the types of foods that will likely be served at their holiday gatherings. Together we work on preparing to come in contact with those foods and discuss how to manage each of those contacts as they present. Suppose a client is far enough in recovery and is working on their exposures to fear foods. In that case, we may even work on consuming those foods together in sessions to gather evidence to violate their eating disorder beliefs and to increase their acceptance of uncomfortable emotions. 

Tip 2: Know your boundaries and hold them

My clients in recovery are often encouraged to develop their own healthy boundaries that they can hold to while at gatherings. Boundaries are different for everyone and personal, so I usually spend some time exploring the types of boundaries my clients want to set with others surrounding body talk, diet talk, and comments about appearance. Additionally, I encouraged my clients to identify their food action plan so they can be clear in the feedback they may give others if people start to push food that the client is not yet ready to approach. Furthermore, I work with my clients on assertive communication to confidently communicate those boundaries effectively and respectfully.  

Tip 3: Identify your support people

I encourage all my clients in recovery to identify 1-3 support people they can turn to if they become too overwhelmed during the holiday festivities. Of course, I prepare my clients to feel some distress during their holiday festivities, but in the event they become overly activated, it is essential that they have supports available who can assist with emotional regulation. Therefore, I plan with my clients to reach out to their support system before engaging in any eating disorder behaviors. Having a support system to help distract them and direct them toward coping strategies can make a big difference for people in recovery. Likewise, having someone who can acknowledge how well you navigated the holiday can be reinforcing. 

Tip 4: Self-care, self-compassion, and mindfulness

When my clients in recovery from an eating disorder are preparing for the holiday season, I always remind them of the importance of self-care and self-compassion. The truth is all eating disorders encourage negative self-talk and comparisons. So I work with my clients on mindfulness to help reduce comparisons and assist clients with reducing negative evaluations of themselves, others, and even food. I encourage clients to practice listening to their body needs, such as rest and fueling their body when it communicates hunger. I also teach clients to practice compassion and kindness when they get off track. I ask clients to consider a dialog they would use with the people they love most and to echo those communications with themselves.  

Tip 5: Practice gratitude and keep vulnerabilities to the emotional mind low

It can be hard to focus on gratitude. However, the holiday season is a good time for people to remember everything they have to be grateful for. The truth is our brain is hardwired to focus on danger and stressors. Biologically, it makes sense to focus on these because our species' survival depends on our abilities to identify and avoid risk. I teach my clients to make room for intentional gratitude. I encourage them to protect time to reflect on what they feel grateful for and also to turn their appreciation toward their body. When clients learn to show their body gratitude, they are significantly more likely to listen to their bodies' messages and comply.   
Finally, I work with my clients on keeping their vulnerabilities to their emotional minds low. This means I encourage them to get a healthy amount of sleep, to take any prescribed medications or medically recommended supplements as prescribed or recommended, and to resist the use of alcohol or drugs. Most people don't realize how impactful and helpful a good night's rest can be for their ability to tolerate stressful situations. 

Navigating the holiday season while in recovery from a restrictive eating disorder can be challenging, but the truth is nothing worth doing is ever easy. I usually remind my clients that the determination that kept them in the disorder is the exact ingredient needed to get out of it. If you are struggling with navigating the holiday or life in general due to an unhealthy relationship with food or your body, I invite you to look into evidence-based treatment providers in your geographical location to get started on your recovery process.   

Before diving into tips and tricks to improve personal hygiene, let's quickly review what depression is. Depression is a common mental health disorder and set of symptoms that may negatively affect how you feel, the way you think, and how you act. Depression affects an estimated 1 in 15 adults (6.7%) in any given year. 1 in 6 people (16.6%) will experience depression at some time in their life.  Depression is a condition that can be treatable with either medication management via a prescribing physician and/or therapy/counseling treatment.

Depression can include, but is not limited to, feelings of sadness and/or a loss of interest in activities you once enjoyed, fatigue, feelings of hopelessness, poor sleep patterns, as well as suicidal ideations. People who live with depression may find themselves engaging in behavioral patterns and avoiding certain tasks, both healthy and unhealthy. Many individuals with depression find that there are more days than not when they do not have the energy or motivation to shower, brush their teeth, change their underwear, tidy up the house, or wash a pile of dirty dishes. What are normal daily habits for others, can seem unobtainable for those with depression.  
 
Here are some helpful tips and tricks that can help improve depression and poor hygiene.

1. Move more often: Getting outside with fresh air is idea; however, with winter upon us going outside to take a walk, realistically may not happen. So while you’re home and there's a commercial break on the TV, get up and walk around, or even walk up and down the stairs a few times. 
2. Maintain connections with friends and family, even for 5 to 10 minutes daily: This could look like communicating via text, phone, or FaceTime. This is something that can help reduce the isolative behaviors that are often associated with depression.
   
3. Set small goals for yourself: I am a firm believer in taking a big task and breaking it down into smaller more obtainable goals. For instance, if you need to clean the kitchen, don't set the goal to clean the ENTIRE kitchen. This will immediately result in feeling overwhelmed and the potential inability to follow through. Instead, have a small goal to accomplish such as (a) emptying and/or loading the dishwasher; (b) sweeping or mopping the floor. 
   
4. Using Mouthwash When You Can’t Brush Your Teeth: Obviously brushing and flossing our teeth is the best, but mouthwash is something that takes little to no effort and is better than not engaging in any oral hygiene at all. 
   
5. Set personal hygiene alarms on your phone: Something I found to be helpful is not allowing oneself to turn off the alarm until you get up to complete said task. 
   
6. Dry shampoo and baby wipes can come in handy: When we are having those really bad moments where we have gone days without showering or washing our hair; it's okay to get creative and use dry shampoo to help re-freshen your hair, or baby wipes to help clean and stay fresh.
   
7. Take a seat: Remember depression exhausts the body, and it can make the easiest of tasks (i.e., standing) extremely difficult; so investing in a shower seat can be helpful and can make showering easier. 
   
8. Finally, and most importantly, build a routine: We want to slowly build a routine, this will help alleviate feelings of stress and being overwhelmed. Having a routine will tell us what days we will focus on what. I have worked with adolescents AND adults to build what looks similar to a chore chart to help clients remember their routine responsibilities. For example, Mon & Wed & Sat can be shower days, and Mondays can be washing your body and shaving underarm & legs, Wednesday is when you wash your body and shampoo and condition your hair and Sat can be a quick body wash. Building routine also looks like making sure we routinely are changing out of our dirty undergarments and stinky socks and at minimum cleaning teeth 1x/day. 

For so many people who are grieving, getting from November to January every year seems practically impossible.  People would oftentimes just rather skip the whole thing and hibernate the season away.  The impulse is certainly understandable, since this is a time of year where family and happiness are emphasized everywhere around us.  While it is certainly very difficult and heartbreaking, you can make it through the holidays.

You can find a previous blog with 10 holiday survival tips for grievers here.  I also wanted to share a beneficial article on ways to honor a loved one during Chanukah, which you can find here (source: Aish.com).

This year, I wanted to share some more information on actual ways to plan for the holidays (including escape plans).  These recommendations are just that, only recommendations and may not be right for you or your situation.  Every family tradition is different and has a different importance to them.

To begin, consider what aspects of the holidays seem to be the most difficult.  It is also important to communicate with others in your life about potentially making changes.  While not every loved one’s opinion carries the same weight, it may be a good idea to communicate with children (adult or otherwise) or others who are grieving the loss as well.  It may be beneficial to talk with others about being open to the possibility of changing traditional holiday plans for yourself or your family, that way they are aware and can possibly help you make some decisions about what to do.

There is no rule stating that making a change for this year’s holidays will result in a permanent change.  You can do something different this year and then return to previous traditions next year, it is up to you/your family.  You may decide that you want to make a large change for the holidays, such as going on a vacation to somewhere new and not having your usual holidays at all.  You may choose to keep some elements the same (or feel like you have to) and change others.  It is completely up to you, as there are no right or wrong changes.  The only caution that I have is to use substances in moderation during a time of year where access can be plentiful.  In addition, it can result in increased depression to completely remove yourself from all activities and from your support network.

It may be beneficial to consider all of the tasks that you traditionally do for the holiday season and then decide if these things matter for each area:

• Why that tradition exists or how it began?
• When it is done?
• Where it is done?
• How it is done?
• Who does it or participates?
• If you want to change it?

For example, if you traditionally have hosted a holiday for your family in your home.

• Why did that start?  You liked to host the holiday in the past.
• When?  It was always on Christmas, but your family would be open to moving it to a different day.
• Where?  It took place at your house, but others have hosted in the past.
• How?  It was previously a dinner and then gift-giving with a large number of family members.
• Who?  Immediate and extended family, some family friends invited.
• Change it?  This year, you don’t have the energy to host but you have another family member that is willing to host instead at their home.  Or maybe it can be a very casual gathering at a restaurant earlier in the month.

Some suggestions that others have used in the past to get through the holiday season:

• Going on vacation as a family and getting away from the area completely.
• Putting up a tree with alternative holiday decorations on it (ex. Valentine’s, Halloween).
• Doing very minimal decorations that do not have sentimental value.
• Take any decorations down immediately after an event or the holiday.
• Decorate for winter and not the holiday itself.
• Not listening to holiday music.
• Using headphones while shopping to avoid holiday music.
• Listening to a different variety of holiday music (ex. rock, reggae, jazz).
• Giving only gift cards for the holidays.
• Shop online and have it delivered.
• Sending holiday cards to only a select few people or those who sent one to you.
• If you typically send holiday cards with information about what happened during your year, consider typing up a synopsis of what happened and print it out to add to your card so you don’t have to write about your loss over and over again.
• Maybe your loved one’s favorite food(s) will not be made this year.
• Making only your loved one’s favorite food(s).
• Store bought is fine this year.
• Order groceries or items for pickup to minimize time in the store.
• Choosing not to go to holiday parties this year.
• Letting your loved ones know that your plans will be highly flexible and you may not make it to various activities/holidays.
• Letting your loved ones know that you may leave early.
• Watching a religious service on tv this year.
• Muting holiday commercials or watching a streaming service that does not have them.
• Making a donation in your loved one’s memory.
• Hanging their stocking.
• Not hanging any stockings.
• Leaving an empty chair for your loved one.  You may even choose to have a plate with their favorite foods on it.
• Asking family/friends to share happy memories of prior holidays with the person who is gone.
• Taking part in a local or online memorial service.
• Having a private memorial (small or large) around the holiday for your loved one.
• Lighting a candle for your loved one.
• Making holiday plans with people in your life who are supportive in your grief.
• Making an escape plan for any activity that you plan on attending.

Making an Escape Plan
This is a topic that has been addressed before, so feel free to skip it or skip to the parts that are helpful for you.  If this is a new concept for you, go ahead and keep reading.  An escape plan can be a good idea if you feel worried about “breaking down” or “not being able to handle” something that comes up at a gathering during the holidays.  Even if you feel comfortable being open in your grief, sometimes we just want some alone time.  Creating an escape plan ahead of time can help reduce some of the anxiety you may be feeling about upcoming events.

Some escape plans ideas:

• Take your own transportation to an event.
• Ride with someone else, but make sure that they are willing to help you leave when you are ready…even if that is shortly after you arrive.
• Come up with a code phrase you can use with a friend, family, or partner to allow you to take some time away.
• Think of a quiet spot that you could go in or out of the home/location.
• Excuse yourself to the bathroom.
• Park somewhere you can leave easily and not be stuck waiting for others to move their vehicles.
• Let your host know that you will need to leave early, if you decide to stay longer that will most likely not be an issue.

There are many other suggestions out there with ways on getting through the holiday season and feel free to get creative with what you would like to do.  Not all of these suggestions will work for everyone and that is completely fine.  There is no wrong way to get through this, just know that you will get through.  Be gentle with yourself this year and don’t feel like you “should” or “shouldn’t” be doing something.  Take it day by day and be flexible in your plans.  Not everyone will understand, but they don’t have to because this is your journey through grief.  Do what you can to take care of you during this difficult time.

Social Anxiety Disorders is defined as persistent, intense fear or anxiety about specific social situations for fear of being judged negatively, embarrassed or humiliated. Individuals with Social Anxiety Disorder will either avoid anxiety-producing social situations completely or endure them with intense fear or anxiety, often using safety behaviors as a way to cope with their distress.

Individuals with Social Anxiety Disorder are thought to experience anxiety in response to social situations because they assume that they will be evaluated negatively and catastrophize about the implications of negative evaluation. More specifically, individuals with Social Anxiety Disorder assume that they will be evaluated negatively because they think that their abilities will fall short of others’ expectations, that there are high expectations for social performance, have unconditional negative beliefs about the self, and assume that acting in certain ways will result in negative consequences (Clark & Wells, 1995).

There are a number of maintaining factors in Social Anxiety Disorder that are targeted in treatment as a way to stop the cycle of anxiety and to help ensure individuals with social anxiety are able to overcome their fears.

Negative Thoughts/Beliefs

Individuals with social anxiety engage in thinking patterns that tend to reflect “cognitive distortions” or thinking errors that put them at risk for anxiety. For example, an individual with social anxiety may predict that others will think that they are incompetent or stupid, or that others will be able to tell that they are very anxious, and that these negative evaluations from other’s will result in disasterour consequences (e.g., “everyone will laugh at me and I will be shamed and have to leave”). These are typically referred to as catastrophic likelihood and cost estimates, and treatment specifically works to target these thoughts/beliefs and alter them to reflect healthy predictions. This can be done either directly via cognitive restructuring, or indirectly via the use of exposures or behavioral experiments. 

Avoidance/Safety Behaviors

Passive Avoidance (complete avoidance of a situation, people, or places) and safety behaviors (behaviors done to help the person feel more safe) can actually create and perpetuate thinking errors because they can: exaggerate physical symptoms of anxiety (e.gripping a podium tightly will increase shaking), prevent an individual from learning that they overestimate the likelihood and severity of their feared social consequences, maintain self-focus of attention and self-monitoring (see below) and potentially increase the likelihood that others will notice symptoms of anxiety. Therefore, treatment aims at helping individuals with Social Anxiety Disorder approach their fears without the use of safety behaviors.

Common safety behaviors in social anxiety are always needing to bring a “safe” person to social events, avoiding eye contact, not asserting oneself, prefacing interactions with excuses such as “I’m not really myself today so excuse me if I seem off,” being a “wallflower,” exiting conversations as quickly as possible, only engaging in social situations with the use of benzodiazepine medications such as Xanax, perfectionistic preparations (e.g., practicing what one will say over and over again), etc.

Internal Self-Focused Attention and Observable Self

Individuals with social anxiety engage in detailed monitoring of themselves which then enhances the individual’s awareness of anxiety symptoms and hinders their ability to gather disconfirming information from their environment (Clark & Wells, 1995). In addition, the individual is then thought to use this internal information to construct an impression of the self (perceived observable self) which they assume is also the impression that observers will construct (when in fact, a socially anxious individual's perceived observed self often significantly differs from what others perceive). For example, a socially anxious individual may assume that others can tell they are terrified and shaking and sweating when others may not notice, or not notice to the same degree. 

Anticipatory and Post-Event Processing

Anticipatory Anxiety refers to the tendency for a socially anxious individual to hyperfocus on an upcoming feared social event and worry intensely about it. For many individuals with social anxiety, their anticipatory anxiety is described as being either equally as anxiety provoking or even more anxiety provoking as the event itself. Some individuals describe this experience as a sense of dread or doom. 

Post-Event Processing is a kind of repetitive thinking pattern that is negative following a social event. For example, an individual that just finished a social interaction may focus on one or two specific incidents that occurred during the social interaction where they felt they failed or embarrassed themselves or didn’t live up to their expectations or the perceived expectations of the other individual(s). They may think to themselves “why did I say that, I’m so stupid, now they think I’m selfish.” The individual will then ruminate about this perceived failure/embarrassment/confirmation of their fears over and over again. In fact, I work with many socially anxious individuals that can recall in great detail a long list of past social events/interactions that they still feel ashamed of and ruminate and think about many years and decades after it took place. For many socially anxious individuals, thinking about these past events can feel very shameful and painful. 

In treatment, individuals with social anxiety are taught several tools to inhibit the use of Anticipatory Anxiety and Post-Event Processing. Some examples include using present-focused attention, de-catastrophizing, self-compassion exercises, worry/possibility exposures, and fact-based evidence processing. 

References

Clark, D. M., & Wells, A. (1995). A cognitive model of SP. In R. G. Heimberg, M. R. Liebowitz, D. A. Hope, & F. R. Schneier (Eds.), SP: Diagnosis, assessment, and treatment (pp. 69-93). New York, NY: Guilford Press.