Seasonal Affective Disorder (SAD) was officially recognized as a distinct disorder more than 20 years ago. More common in higher latitudes and thought to be more influenced by day length than temperature, it consists of a pattern including some or all of the following: depressed mood, decreased energy, increased need for sleep, loss of interest, enjoyment and motivation, increased appetite and/or cravings for sweets or carbohydrates, with associated weight gain. Onset is typically late fall to early winter, with symptoms remitting in Spring. A recent NIMH-funded study* concluded that most SAD symptoms can be traced to a disruption of body rhythms resulting from winter’s late dawn and early dusk.

Treatment of SAD using full-spectrum lights was proposed many years ago, and research has established light therapy as safe and effective. In many studies light therapy provided benefits equal to those found with antidepressant medication, often with faster results. While light therapy is the treatment of choice for SAD, other therapies also have been shown to be effective, either alone or in combination with light therapy. Lewy and colleagues* found that administration of small amounts of melatonin, usually in mid-afternoon, was a useful adjunct to morning light therapy in restoring normal daily rhythms and alleviating symptoms of SAD. Light therapy can be effective for a range of depressive disorders beyond its traditional use to treat seasonal affective disorders. It offers a safe alternative to antidepressant medication during pregnancy, and shows some promise in the treatment of premenstrual dysphoric disorder. It also has been used successfully for treating jet lag and sleep disorders among shift workers.

The standard dose is exposure to 10,000 lux of diffused white fluorescent light upon awakening in the morning. The timing and duration of light exposure can be tailored to individual needs, with some people benefiting from a longer exposure and others doing well with less. There has been much research and debate about the type and intensity of light that is safest and most effective. It is inadvisable to construct home-made light boxes due to the possibility of eye injury. The light apparatus should filter out wavelengths less than 450 nm to avoid damage to the eyes. Certain photosensitizing medications, including many standard antidepressants and
antipsychotics, can interact with ultraviolet and short-wavelength blue light with the risk of retinal damage. People who are taking medication should check with their physicians before beginning light therapy to avoid the possibility of eye damage. More information about commercially available lights and features to look for is available at the website of the Center for Environmental Therapeutics, www.cet.org.

An intriguing adjunct to light exposure is “wake therapy” consisting of either a full night’s sleep deprivation or sleep deprivation for the second half of the night only. This therapy is surprisingly effective for many types of depression, but the benefits wear off quickly when normal sleep is resumed. Some researchers have combined wake therapy with instructions to the patient to go to bed at 5:00 pm the following evening, with bedtimes advancing by two hours each night until a normal sleep-wake cycle is established. Light therapy and sleep phase advance have both prevented relapse after wake therapy. “Dawn simulation”--- exposure to light that gradually increases in intensity to mimic a natural dawn--- is also effective.

Cognitive behavioral therapy with a specific focus on seasonal issues and behavioral changes including engaging in enjoyable outdoor winter activities have also been demonstrated to be effective treatments for SAD, and the latter combines the known antidepressant benefits of exercise with those of light exposure.

References

*Lewy, Alfred J, Lefler, Bryan J, Emens, Jonathan S and Bauer, Vance K. (2006).
The circadian basis of winter depression. Proceedings of the National Academy of Science, Vol. 103, No. 19, 7414-7419.

DeAngelis, Tori (2006).
Promising new treatments for SAD. Monitor on Psychology, Vol 37, no. 2

Susan S. Arquette, Ph.D., L.P. is a psychologist at BHSI in Woodbury. She is BHSI’s Director of Regulatory Compliance and Director of BHSI's Woodbury and Fridley Clinics.
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For more than two decades, Screening for Mental Health, Inc. (SMH) has partnered with organizations to provide mental health education and screening programs, including National Depression Screening Day, National Alcohol Screening Day®, and the National Eating Disorders Screening Program®. These programs are designed to educate, reduce stigma and screen people for mood and anxiety disorders as well as alcohol problems.

Posttraumatic Stress Disorder (PTSD) is a mental health condition that affects millions of individuals worldwide. While it is often closely associated with combat veterans and other members of the military, the fact is PTSD can affect anyone who experiences a traumatic event.  During the past year, many communities across the U.S. have experienced devastating tragedies. Hurricane Sandy, the shootings in Newtown, the Boston Marathon bombings, and most recently, cases of severe weather in the Plains states have left many individuals, families and communities reeling. While most people are amazingly resilient following trauma, for some, the emotional toll these events cause can last much longer.

About 60 percent of men and 50 percent of women will experience at least one traumatic event in their lifetime, according to the National Center for PTSD, U.S. Department of Veteran Affairs. Overall, about 8 percent of men and 20 percent of women will develop PTSD. While traumatic events such as natural disasters, fires or acts of violence can affect an entire community, other instances like a terrifying car accident can affect a single individual.

Most people will have stress-related reactions following a traumatic event, yet only some will develop PTSD. If these reactions do not begin to go away over time or get worse, or impact day to day life, it may be PTSD. 
PTSD symptoms often include:
* Reliving the event through nightmares and flashbacks
* Avoiding situations that remind you of the event, such as large crowds or driving a car
* Negative changes in beliefs and feelings. This can include feelings of guilt, fear or shame.
* Feeling keyed up or jittery

“PTSD is a condition that many people believe only affects members of the military and veterans, but that simply is not the case,” says Dr. Douglas G. Jacobs, founder and medical director of Screening for Mental Health, Inc. “While combat veterans do have a high rate of PTSD, we also see PTSD in members of the public, especially among first responders, victims of violence or those affected by natural disasters.”

It is recommended that anyone who was been exposed to a traumatic event over a month ago and is experiencing symptoms of PTSD take an anonymous PTSD assessment at www.bhsiclinics.com .   By answering a series of basic questions, people can determine if they are showing symptoms of PTSD, and if so, where to find the help they need. While these screenings are not diagnostic, the results will indicate whether further assessment by a clinician is advisable. The screening website, provided by the nonprofit Screening for Mental Health, is accessible year-round to the public.
 

We want it to be "the most wonderful time of the year," but the holiday season is also a time of increased incidence of depression and anxiety problems.  Our lives can quickly become filled with social engagements, shopping, countless errands, and historical “baggage” --  even the most spirited individual can feel emotionally drained.  Those who have lost loved ones are particularly at risk for developing emotional problems during the holidays.
 
Taking good care of yourself is the best thing you can do to prevent or minimize emotional problems during the holidays.  Here are some useful tips:
 
 1. Plan ahead, shop and make travel plans early to decrease last-minute anxiety.
 
2. Don't do everything on your own. Get others in the family to help with holiday tasks.
 
3. Set realistic goals and scale down your expectations.

 4. Pace yourself and leave extra time for last minute changes.

 5. Take time to relax every day. Deep breathing exercises, relaxation tapes, meditation and yoga are some techniques that can help.

 6. Exercise. If you already have a regular exercise routine, be sure to maintain it through the holidays.

 7. Monitor your feelings and share them with those close to you. Even a quick phone call or email exchange can help you feel better.

8. Above all, keep proper perspective.  Go big picture.  Don’t get ensnared by the small stuff.

9. Get help if you need it. 

If you are feeling overwhelmed or haven’t been feeling like yourself lately, you can take an anonymous mental health screening at www.bhsiclinics.com.
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Most of us have an annual physical but one of our most critical organs tends to go “under the radar.” Our brains are the control centers for our bodies -- but how often do we make lifestyle choices that take our brain health into consideration? The amount of alcohol we drink is an example, or the amount of sleep we get each night. Neglecting to take steps to alleviate the stress in our lives can also impact brain functioning. All of these things can take a toll and contribute to mental health problems like depression.

March 12-18 is Brain Awareness Week. Why not take a free, anonymous online screening to give yourself a check up from the neck up. You can take a screening for depression, PTSD, anxiety, or bipolar disorder – it’s totally anonymous and will only take up a few minutes of your time. The program is sponsored by Behavioral Health Services (BHSI) and is offered 24/7. Click here to take your free and anonymous self-assessment.

Recent research stirred controversy and made the popular press by concluding that commonly prescribed antidepressants produced results that were not meaningfully different from placebos. This was the finding of researchers who analyzed the U.S. Food and Drug Administration (FDA) database of trials used in the initial approval of popular antidepressant medications. The analysis included the efficacy data from 38 randomized, blinded, placebo-controlled studies involving 6,944 patients treated for an average of 6 weeks with one of the six most widely prescribed antidepressants approved between 1987 and 1999 : fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), venalfaxine(Effexor), nefazodone (Serzone), and citalopram (Celexa). Specifically, the authors found that approximately 80% of the antidepressant effect was duplicated by placebo. While the results showed a statistical difference favoring active antidepressants over placebo, the authors concluded that the difference was clinically insignificant. The researchers also found that improvement at the highest doses of antidepressant medication was not different from improvement at the lowest doses.

Implications for Providers.

• The conclusion that 80% of the drug effect is accounted for by a placebo effect is misleading and inaccurate. Researchers suggest that antidepressant drug and placebo effects are not additive. Thus, the true drug effect is greater than the drug/placebo difference reflected in the FDA data. All conditions that have an effect on depression, whether they are drug treatments, psychotherapy, or placebo, must have some action on the brain. However, these actions may not be duplicated, additive, or consistent across conditions. Recent research indicates that placebo responders and anti-depressant responders have different brain changes suggesting that these two effects are indeed different and not additive.

• A true antidepressant drug response is masked in drug/placebo comparisons by a progressive increase in the placebo effect. The placebo response has dramatically increased over the last two decades from about 30% to 50%. Factors resulting in a high placebo-response rate may include an unusual amount of attention and overly encouraging behaviors of those conducting the trial that evoke high expectations for improvement, financial rewards for rapid patient enrollment in trials, and trial designs that do not include a placebo wash-out phase.

• FDA initial antidepressant clinical trials are constructed to identify effective treatments and doses but not to determine dose relatedness in a scientific manner consistent with the principles of pharmacology. The trials are intended to identify a drug response or clinically significant reduction in symptom severity. In most cases, FDA drug trials are not designed to look at remission, relapse, or recurrence. Thus, the finding from the FDA data that highest and lowest doses yielded no improvement differences is interesting, but far from conclusive.

•Antidepressants are consistently superior to placebo at preventing relapse. Relapse rates for drug continuation patients over one year are commonly around 10%, but those assigned to placebo have close to a 50% relapse rate.

•In drug/placebo comparisons, antidepressants are far superior to placebo with severe and/or chronically depressed patients. Placebo response is directly related to severity of depression: the milder the depression, the more significant the placebo response. While 50% to 70% of mildly depressed patients improve with placebo, more severe hospitalized depressed patients have placebo response rates around 20%. The FDA sample tends to fall on the mild end of the depressive spectrum. Similarly, chronic depressed patients show less placebo response than acute patients. Placebo response rates are 50% versus 13% for patients who have been depressed for 3 months and 2 years, respectively.

What Consumers Should Know.

•FDA clinical trials show that between 55% and 75% of all patients improve with antidepressant treatment. The trials also show considerable variability in response to antidepressant drugs.

•Studies show that many treatments are about equally effective in the treatment of mild depression, but that for severe or chronic depression, antidepressant medication has a clear advantage over both the psychotherapies and placebo.?
•People who take antidepressant medications are much less likely to experience a relapse in depressive symptoms.?

•Placebos are used in research to identify side effects and for comparison purposes, but they may not be a good indicator of a drug’s true effect.?

•A combination of antidepressants and psychotherapy is consistently the most effective treatment for depression.

Paul Hill, PhD, LP is a psychologist at BHSI at Shakopee and North St Paul offices, and BHSI's Director of operations.

www.bhsiclinics.com

Provided by the American Psychological Association (APA)

A 2008 holiday stress poll by the APA showed that more than eight out of 10 Americans anticipate stress during the holiday season. In particular, the holidays can be a stressful time for parents, especially if you're wondering where to get the money to buy holiday gifts. Households with children were more likely to report anticipating stress during the holidays than those without, and one-third expected stress due to pressure to buy gifts or because of too many things to do. Additionally, APA’s 2010 Stress in America survey found that 76 percent of Americans report money as a significant source of stress.

Heightened stress during the holidays can lead to unhealthy stress management behaviors, such as overeating and drinking to excess. People tend to reduce their stress in ways they have learned over the course of time because they turn to what they know. You may take comfort in unhealthy stress management techniques because they’re familiar, even though they’re not good for your health. But, there are other behaviors you can learn to further relieve stress and its effects that may be both healthier for you and longer lasting.

Here are some tips to help parents deal with holiday stress and build resilience:

Set expectations. Talk to your kids about expectations for gifts and holiday activities. Be open with them if money is an issue. Depending on a child's age, parents can use this as an opportunity to teach their kids about the value of money and responsible spending. And be realistic. Take small concrete steps to deal with holiday tasks instead of overwhelming yourself with goals that are too far reaching for a busy time.

Keep things in perspective. Try to consider stressful situations in a broader context and keep a long-term perspective. Avoid blowing events out of proportion. And teach your kids how to keep things in perspective, including what type of and the number of gifts they receive.

Make connections. Good relationships with family and friends are important. So, view the holidays as a time to reconnect with people. Additionally, accepting help and support from those who care about you can help alleviate stress. Even volunteering at a local charity with your kids is a good way to connect with others, assist someone in need and teach your kids about the value of helping others.

Take care of yourself. Pay attention to your own needs and feelings during the holiday season. Engage in activities that you and your family enjoy and find relaxing. Taking care of yourself helps keep your mind and body healthy and primed to deal with stressful situations. Consider cutting back television viewing for kids and instead, get the family out together. It promotes activity and takes kids away from sedentary time and possible influence from advertisements.

This publication is provided by the American Psychological Association, and may be reprinted in its entirety without modification.

By the American Psychological Association

Everyone feels anxious from time to time. Stressful situations such as meeting tight deadlines or important social obligations often make us nervous or fearful. Experiencing mild anxiety may help a person become more alert and focused on facing challenging or threatening circumstances.

But individuals who experience extreme fear and worry that does not subside may be suffering from an anxiety disorder. The frequency and intensity of anxiety can be overwhelming and interfere with daily functioning. Fortunately, the majority of people with an anxiety disorder improve considerably by getting effective psychological treatment.

What are the major kinds of anxiety disorders?

There are several major types of anxiety disorders, each with its own characteristics.

* People with generalized anxiety disorder have recurring fears or worries, such as about health or finances, and they often have a persistent sense that something bad is just about to happen. The reason for the intense feelings of anxiety may be difficult to identify. But the fears and worries are very real and often keep individuals from concentrating on daily tasks.

* Panic disorder involves sudden, intense and unprovoked feelings of terror and dread. People who suffer from this disorder generally develop strong fears about when and where their next panic attack will occur, and they often restrict their activities as a result.

* A related disorder involves phobias, or intense fears, about certain objects or situations. Specific phobias may involve things such as encountering certain animals or flying in airplanes, while social phobias involve fear of social settings or public places.

* Obsessive-compulsive disorder is characterized by persistent, uncontrollable and unwanted feelings or thoughts (obsessions) and routines or rituals (compulsions) in which individuals engage to try to prevent or rid themselves of these thoughts. Examples of common compulsions include washing hands or cleaning house excessively for fear of germs, or checking work repeatedly for errors.

* Someone who suffers severe physical or emotional trauma such as from a natural disaster or serious accident or crime may experience post-traumatic stress disorder. Thoughts, feelings and behavior patterns become seriously affected by reminders of the event, sometimes months or even years after the traumatic experience.

Symptoms such as extreme fear, shortness of breath, racing heartbeat, insomnia, nausea, trembling and dizziness are common in these anxiety disorders. Although they may begin at any time, anxiety disorders often surface in adolescence or early adulthood. There is some evidence that anxiety disorders run in families; genes as well as early learning experiences within families seem to make some people more likely than others to experience these disorders.

Why is it important to seek treatment for these disorders?

If left untreated, anxiety disorders can have severe consequences. For example, some people who suffer from recurring panic attacks avoid any situation that they fear may trigger an attack. Such avoidance behavior may create problems by conflicting with job requirements, family obligations or other basic activities of daily living.

People who suffer from an untreated anxiety disorder often also suffer from other psychological disorders, such as depression, and they have a greater tendency to abuse alcohol and other drugs. Their relationships with family members, friends and coworkers may become very strained. And their job performance may decline.

Are there effective treatments available for anxiety disorders?

Absolutely. Most cases of anxiety disorder can be treated successfully by appropriately trained mental health professionals such as licensed psychologists. Research has demonstrated that a form of psychotherapy known as "cognitive-behavioral therapy" (CBT) can be highly effective in treating anxiety disorders. Psychologists use CBT to help people identify and learn to manage the factors that contribute to their anxiety.

Behavioral therapy involves using techniques to reduce or stop the undesired behaviors associated with these disorders. For example, one approach involves training patients in relaxation and deep breathing techniques to counteract the agitation and rapid, shallow breathing that accompany certain anxiety disorders.

Through cognitive therapy, patients learn to understand how their thoughts contribute to the symptoms of anxiety disorders, and how to change those thought patterns to reduce the likelihood of occurrence and the intensity of reaction. The patient's increased cognitive awareness is often combined with behavioral techniques to help the individual gradually confront and tolerate fearful situations in a controlled, safe environment.

Along with psychotherapy, appropriate medications may have a role in treatment. In cases where medications are used, the patient's care may be managed collaboratively by more than one provider of treatment. It is important for patients to realize that there are side effects to any drugs, which must be monitored closely by the provider who prescribed the medication.

How can licensed psychologists help someone suffering from an anxiety disorder?

Licensed psychologists are highly trained and qualified to diagnose and treat people with anxiety disorders using techniques based on best available research. Psychologists' extensive training includes understanding and using a variety of psychotherapies, including CBT.

Psychologists sometimes use other approaches to effective treatment in addition to individual psychotherapy. Group psychotherapy, typically involving unrelated individuals who all have anxiety disorders, can be an effective approach to delivering treatment and providing support. Further, family psychotherapy can help family members better understand their loved one's anxiety and learn new ways of interacting that do not reinforce the anxiety and associated dysfunctional behaviors.

Individuals suffering from anxiety disorders may also want to consider mental health clinics or other specialized treatment programs dealing with specific anxiety disorders such as panic or phobias that may be available in their local area.

How long does psychological treatment take?

The large majority of people who suffer from an anxiety disorder are able to reduce or eliminate their anxiety symptoms and return to normal functioning after several months of appropriate psychotherapy. Indeed, many people notice improvement in symptoms and functioning within a few treatment sessions. The patient should be comfortable from the outset with the psychotherapist. Together the patient and psychotherapist should develop an appropriate treatment plan. The patient's cooperation is crucial, and there must be a strong sense that the patient and therapist are collaborating well as a team to treat the anxiety disorder.

No one plan works well for all patients. Treatment needs to be tailored to the needs of the patient and to the type of disorder, or disorders, from which the individual suffers. The psychotherapist and patient should work together to assess whether a treatment plan seems to be on track. Patients respond differently to treatment, and adjustments to the plan sometimes are necessary. Anxiety disorders can severely impair a person's functioning in work, family and social environments. But the prospects for long-term recovery are good for most individuals who seek appropriate professional treatment. People who suffer from anxiety disorders can work with a qualified and experienced mental health professional such as a licensed psychologist to help them regain control of their feelings and thoughts - and their lives.

Updated June 2010

This article is produced by the American Psychological Association and may be reproduced in its entirety with credit given to the APA.

Mental health screening data collected in 2005 as compared to 2010 shows an increase in the number of Americans reporting symptoms of depression and other mood and anxiety disorders. The data, collected and analyzed by Screening for Mental Health, Inc.*, a nonprofit organization that provides mental health education, screening and treatment resources, also showed a 14% decrease in the number of Americans who are currently being treated for depression or who have received treatment in past.

Other key findings include:

•A 34% increase in the very likelihood of depression among men
•A 23% increase in the very likelihood for depression among Black or African American people
•A 49% increase in the very likelihood for depression among people who are divorced or separated
•A 15% increase in the very likelihood for depression among Hispanic and Latino people
•A 17% increase in the very likelihood for depression among people ages 18-25
•An 18% increase in women who scored positive for symptoms of posttraumatic stress disorder
•A 76% increase in people in the workplace being treated for generalized anxiety disorder

"The data is staggering and emphasizes the need to focus on screenings as a means to help people who may be suffering," said Dr. Douglas G. Jacobs, M.D., associate clinical professor of psychiatry at Harvard Medical School and the founder of Screening for Mental Health. "Research supports the use of online mental health screenings with getting people into treatment. In an independent study we commissioned, 55% of study participants who completed an online depression screening sought treatment within three months of completing the screening."
Depression symptoms are present on an almost constant basis for two or more weeks and are often marked by a deep feeling of sadness or loss of interest or pleasure in otherwise enjoyable activities. Warning signs of depression include:

•Changes in appetite that result in weight losses or gains unrelated to dieting
•Insomnia or oversleeping
•Loss of energy or increased fatigue
•Restlessness or irritability
•Feelings of worthlessness or inappropriate guilt
•Difficulty thinking, concentrating or making decisions
•Thoughts of death or suicide or attempts at suicide

A video of Dr. Jacobs discussing the warning signs of depression is available at
http://www.youtube.com/watch?v=8-b61X0xawg.

About Screening for Mental Health

For two decades, Screening for Mental Health has worked with organizations to provide mental health education and screening programs, including National Depression Screening Day®, National Alcohol Screening Day®, and the National Eating Disorders Screening Program®. These programs are designed to educate, reduce stigma, and screen people for mood and anxiety disorders, alcohol problems and eating disorders.

National Depression Screening Day is October 7th, and through this program individuals have the opportunity to take a take a free, anonymous mental health screening. Individuals can locate a screening site by visiting www.HelpYourselfHelpOthers.org , or take the screening any day of the year at www.bhsiclinics.com .

For more information about Screening for Mental Health, visit www.MentalHealthScreening.org or find them on Facebook at http://www.facebook.com/HelpYourselfHelpOthers and Twitter http://twitter.com/HYSHO.

*Data compares individuals who self-selected to take an online mental health assessment in 2005 to those who took it in 2010.

Resilience is the process of adapting well in the face of adversity, trauma, tragedy, threats or significant sources of stress – such as family and relationship problems, serious health problems, or workplace and financial stressors. Resilience is not a trait that people either have or do not have. It involves behaviors, thoughts and actions that anyone can learn and develop.

Developing your resilience is a personal journey. An approach to building resilience that works well for one person might not work for another. People use varying strategies. Some variation may reflect cultural differences. For example, an individual’s culture might have an impact on whether and how he or she connects with others and communicates feelings.

The following pointers may be helpful to consider in developing your own strategy for building resilience.

Make connections
Good relationships with close family members, friends, or others are important. Accepting help and support from those who care about you and will listen to you strengthens resilience. Some people find that being active in civic groups, faith-based organizations or other local groups provides social support and can help with reclaiming hope. Assisting others in their time of need can also benefit the helper.

Avoid seeing crises as insurmountable problems
You can't change the fact that highly stressful events happen, but you can change how you interpret and respond to these events. Try looking beyond the present to how future circumstances may be a little better. Note any subtle ways in which you might already feel somewhat better as you deal with difficult situations.

Accept that change is a part of living
Certain goals may no longer be attainable as a result of adverse situations. Accepting circumstances that cannot be changed can help you focus on circumstances that you can alter.

Move toward your goals
Think about possible solutions to the problems you are facing and decide what realistic goals you want to achieve. Do something regularly – even if it seems like a small accomplishment – that enables you to move forward. Focus away from tasks that seem unachievable. Instead, ask yourself, "What's one thing I know I can accomplish today that helps me move in the direction I want to go?"

Many people find it helpful to track their progress by making a record of any accomplishment that moves them toward their goals. It is important to spend a moment reflecting on the fact that you are taking action and achieving what you believe you need to do.

Take decisive actions
Act on adverse situations as much as you can. Take decisive actions, rather than detaching from problems and stresses and wishing they would just go away. Being active instead of passive helps people more effectively manage adversity.

Find positive ways to reduce stress and negative feelings
Following a stressful event, many people feel they need to turn away from the negative thoughts and feelings they are experiencing. Positive distractions such as exercising, going to a movie or reading a book can help renew you so you can re-focus on meeting challenges in your life. Avoid numbing your unpleasant feelings with alcohol or drugs.

Look for opportunities for self-discovery
People often learn something about themselves and may find that they have grown in some respect as a result of their struggle with loss. Many people who have experienced tragedies and hardship have reported better relationships, greater sense of strength even while feeling vulnerable, increased sense of self-worth, a more developed spirituality and heightened appreciation for life.

Nurture a positive view of yourself
Developing confidence in your ability to solve problems and trusting your instincts helps build resilience.

Keep things in perspective
Even when facing very painful events, try to consider the stressful situation in a broader context and keep a long-term perspective. Avoid blowing the event out of proportion. Strong emotional reactions to adversity are normal and typically lessen over time.

Maintain a hopeful outlook
An optimistic outlook enables you to expect that good things will happen in your life. Try visualizing what you want, rather than worrying about what you fear. Take care of yourself. Pay attention to your own needs and feelings. Engage in activities that you enjoy and find relaxing and that contribute to good health, including regular exercise and healthy eating. Taking care of yourself helps keep your mind and body primed to deal with situations that require resilience.

Additional ways of strengthening resilience may be helpful
For example, some people write about their deepest thoughts and feelings related to trauma or other stressful events in their life. Meditation and spiritual practices help some people build connections and restore hope. The key to developing an effective personal strategy is to identify ways of building your resilience that are likely to work well for you.

Where to look for help
Getting help when you need it is crucial to building your resilience. Many people turn to family members, friends and others who care about them for the support and encouragement they need.

Self-help and community support groups can aid people struggling with hardships, such as the death of a loved one. By sharing information, ideas and emotions, group participants can assist one another and find comfort in knowing that they are not alone in experiencing difficulty.

For many people, using their own resources and getting help from others may be sufficient for building resilience. At times, however, an individual might get stuck or have difficulty making progress on the road to resilience.

A licensed mental health professional such as a psychologist can assist people in developing an appropriate strategy for moving forward. It is important to get professional help if you feel like you are unable to function or perform basic activities of daily living as a result of a traumatic or otherwise stressful life experience.

Different people tend to be comfortable with different styles of interaction. A person should feel at ease and have a good rapport when working with a mental health professional or participating in a support group.

This fact sheet is adapted largely from “The Road to Resilience,”available on the Psychology Help Center, located online. The American Psychological Association Practice Directorate gratefully acknowledges the assistance of Rick Allen, PhD; Lillian Comas-Diaz, PhD; Suniya S. Luthar, PhD; Salvatore R. Maddi, PhD; H. Katherine (Kit) O’Neill, PhD; Karen W. Saakvitne, PhD; and Richard Glenn Tedeschi, PhD, in developing this material.

This publication is provided by the American Psychological Association, and may be reprinted in its entirety without modification.

Few behaviors are more alarming than self-injurious behavior (SIB). SIB is commonly defined as deliberate infliction of physical injury to one’s body without intent to die. While there may be no intent to die, it is precisely the potential lethality of this behavior that creates alarm.

One of the most prevalent types of SIB is “Impulsive SIB”, which includes spontaneous and often symbolic acts such as skin cutting, skin burning, or self-hitting. These acts often start out as isolated incidents but can become habitual. This type of SIB is frequently associated with borderline personality disorder, eating disorders, posttraumatic stress disorder, or some form of trauma or abuse.

Why Do People Deliberately Injure Themselves?

Several factors help make sense of this seemingly baffling behavior. (a) Affect Regulation: Many people who engage in SIB react abnormally to negative feelings. Their level of arousal goes up much more quickly, peaks at a higher level, and takes more time to settle. In theory, these people have learned to reduce their negative emotions through SIB. One-half to three-fourths of SIB patients report anesthesia or relief during the SIB. On a biological level, the anesthesia might be explained by an addiction hypothesis. This hypothesis suggests that the endogenous opioid system has been chronically over-stimulated for the purpose of alleviating negative feelings. The individual develops a tolerance to the influx of endogenous opioids, cyclically suffers a withdrawal reaction, and is driven to release more endogenous opioids through SIB. (b) Dissociation: For some people, stress leads them to disconnect from reality or dissociate. The pain associated with SIB may help them to break through their detachment, reconnect with reality, and feel again. Many people who engage in SIB report that the behavior helps them feel or that the pain.

On a biological level, the pain hypothesis suggests that stress or emotional pain triggers overproduction of opioids or a failed negative feedback loop does not “shut off” release of opioids. The increased levels of endogenous opioids leads to numbness and dissociation, a state that only SIB can break through. (c) Limited Problem-solving skills: While maladaptive, impulsive SIB tends to serve as a coping response for people with limited problem-solving skills. Like more adaptive coping responses, SIB influences others in ways that alleviate difficult circumstances or demands. SIB can also elicit assistance and support. The SIB is reinforced by a responsive environment. (d) Shame: More than other emotions, shame appears to be associated with SIB. Many people who engage in SIB learn to devalue and blame themselves through experiences of childhood trauma, including sexual and physical abuse, or an unempathic or invalidating environment. For some, SIB is described as concrete atonement for being bad, and an aggressive, impulsive response to self-directed hate. The relief they experience is akin to relief that follows completion of penance. On a biological level, a strong correlation exists between decreased serotonin function and increased impulsivity, aggression, and suicidality.

What Can Medical Providers and Educators Do?

1. Provide supportive communication. Maintain an accepting, open attitude about the person who self-mutilates. Don’t make judgmental statements, browbeat, or avoid the subject due to your own discomfort. Blame and attack only induce shame and continue the cycle of self-hatred and frustration that leads to SIB. Pay more attention to healthier things the individual does than to SIB. Inquire about any efforts to delay or avoid the act of SIB and praise and encourage any successes.
2. No medications have received U.S. Food and Drug Administration approval for treatment of impulsive SIB, nor have any double-blind placebo-controlled medication trials been performed. Selective Serotonin Reuptake Inhibitors (SSRIs) have been shown to decrease impulsive-aggressive behaviors and have received mixed support for reducing SIB. Because these medications are well-tolerated and pose a low risk for deliberate overdose, they are usually a good first choice in pharmacologic treatment. Sedative/hypnotic class drugs often are not helpful (i.e.,disinhibit in a negative way) and carry a high risk of abuse. Beyond this, medication strategies tend to focus on targeting symptoms that may be specifically associated with SIB (e.g., ß-blockers for dissociation).
3. Help your patient or student learn strategies to exert more control over their SIB. Have them develop a list of things they can do to distract or delay SIB (e.g., call a friend, write in a journal, go somewhere especially around people, watch a movie or listen to music, exercise). Help them set limits to the amount of time they spend focused on SIB. Help your patient or student learn strategies to cope with intense emotions. Sometimes the first step can be to replace lethal forms of SIB with behaviors that do not produce lasting results. The strategies that are most commonly suggested include squeezing an ice cube or snapping oneself with a rubber band.
4. The most effective treatment of impulsive SIB involves a combination of psychotherapy and psychopharmacology. A therapeutic alliance is a critical element of treatment given the problems commonly reported by patients who engage in SIB (e.g., problems with trust, mood regulation, self-soothing, and suicidal behavior).

Paul Hill, PhD, LP is a psychologist at Behavioral Health Services (BHSI) in Shakopee, Director of BHSI in North St Paul, and is BHSI’s Director of Operations.

Behavioral Health Services (BHSI), Woodbury, MN
http://www.bhsiclinics.com/

Seasonal Affective Disorder (SAD) was officially recognized as a distinct disorder about 20 years ago. More common in higher latitudes and thought to be more influenced by day length than temperature, it consists of a pattern including some or all of the following: depressed mood, decreased energy, increased need for sleep, loss of interest, enjoyment and motivation, increased appetite and/or cravings for sweets or carbohydrates, with associated weight gain. Onset is typically late fall to early winter, with symptoms remitting in Spring. A recent NIMH-funded study* concluded that most SAD symptoms can be traced to a disruption of body rhythms resulting from winter’s late dawn and early dusk.

Treatment of SAD using full-spectrum lights was proposed many years ago, and research has established light therapy as safe and effective. In many studies light therapy provided benefits equal to those found with antidepressant medication, often with faster results. While light therapy is the treatment of choice for SAD, other therapies also have been shown to be effective, either alone or in combination with light therapy. Lewy and colleagues* found that administration of small amounts of melatonin, usually in mid-afternoon, was a useful adjunct to morning light therapy in restoring normal daily rhythms and alleviating symptoms of SAD. Light therapy can be effective for a range of depressive disorders beyond its traditional use to treat seasonal affective disorders. It offers a safe alternative to antidepressant medication during pregnancy, and shows some promise in the treatment of premenstrual dysphoric disorder. It also has been used successfully for treating jet lag and sleep disorders among shift workers.

The standard dose is exposure to 10,000 lux of diffused white fluorescent light upon awakening in the morning. The timing and duration of light exposure can be tailored to individual needs, with some people benefiting from a longer exposure and others doing well with less. There has been much research and debate about the type and intensity of light that is safest and most effective. It is inadvisable to construct home-made light boxes due to the possibility of eye injury. The light apparatus should filter out wavelengths less than 450 nm to avoid damage to the eyes. Certain photosensitizing medications, including many standard antidepressants and
antipsychotics, can interact with ultraviolet and short-wavelength blue light with the risk of retinal damage. People who are taking medication should check with their physicians before beginning light therapy to avoid the possibility of eye damage. More information about commercially available lights and features to look for is available at the website of the Center for Environmental Therapeutics, www.cet.org.

An intriguing adjunct to light exposure is “wake therapy” consisting of either a full night’s sleep deprivation or sleep deprivation for the second half of the night only. This therapy is surprisingly effective for many types of depression, but the benefits wear off quickly when normal sleep is resumed. Some researchers have combined wake therapy with instructions to the patient to go to bed at 5:00 pm the following evening, with bedtimes advancing by two hours each night until a normal sleep-wake cycle is established. Light therapy and sleep phase advance have both prevented relapse after wake therapy. “Dawn simulation”--- exposure to light that gradually increases in intensity to mimic a natural dawn--- is also effective.

Cognitive behavioral therapy with a specific focus on seasonal issues and behavioral changes including engaging in enjoyable outdoor winter activities have also been demonstrated to be effective treatments for SAD, and the latter combines the known antidepressant benefits of exercise with those of light exposure.

References

*Lewy, Alfred J, Lefler, Bryan J, Emens, Jonathan S and Bauer, Vance K. (2006).
The circadian basis of winter depression. Proceedings of the National Academy of Science, Vol. 103, No. 19, 7414-7419.

DeAngelis, Tori (2006).
Promising new treatments for SAD. Monitor on Psychology, Vol 37, no. 2

Susan S. Arquette, Ph.D., L.P. is a psychologist at BHSI in Woodbury. She is BHSI’s Director of Regulatory Compliance and Director of BHSI's Woodbury and Fridley Clinics.

Posttraumatic stress disorder (PTSD) has been receiving greater attention in recent years because of the high incidence of the disorder among soldiers returning from deployment in Iraq and Afganistan. Additionally, soldiers are not the only people who can develop PTSD. PTSD affects approximately 8 percent of the United States population, with between a quarter and one-third of people who experience a significant trauma developing PTSD.

Significant trauma is considered any event that is dangerous or upsetting such as an assault or violent attack, combat, natural disaster, or vehicle crash (National Institute of Mental Health, 2008). Symptoms of PTSD, which can occur anytime after the event, include re-experiencing the event, such as having recurring nightmares, avoiding reminders of the event, being less responsive including feeling detached and less interested in life activities, and increased arousal, such as having angry outbursts or difficulty sleeping (Grinage, 2003).

The good news is if you or someone you know has been experiencing symptoms such as those described above, treatment is available. BHSI offers the opportunity to take an anonymous screening for PTSD as well as other common mental health conditions. The screenings are free and only take a few minutes. To take a screening visit:

http://www.mentalhealthscreening.org/screening/BHSI

Bell, S. (2007, January 17). The Invisible Injury: PTSD and Iraq War Veterans. Associated Content.
Retrieved from
http://www.associatedcontent.com/article/118081/the_invisible_injury_ptsd_and_iraq.html?cat=70

National Institute of Mental Health. (2008). Post-Traumatic Stress Disorder (Easy-to-Read). Retrieved from http://www.nimh.nih.gov/health/publications/post-traumatic-stress-disorder-easy-to-read/index.shtml

Grinage, B. D. (2003). Diagnosis and Management of Post-traumatic Stress Disorder [Electronic version].
American Family Physician, 68, 2401-2409

The American Academy of Family Physicians estimates that 60% of the health problems brought to physicians are actually related to stress in one way or another. In some instances an illness is the direct result of the body’s sustained stress response, while in other instances the stress response makes pre-existing illness worse. The list of stress-related maladies includes (but is not limited to) psychological disorders, insomnia, tics, headaches, diabetic instability, sexual dysfunction, impaired immunity, hypertension and other cardiovascular diseases, gastrointestinal problems, elevated cholesterol, and impaired wound healing.

The Importance of Coping Skills

Technically speaking, environmental events aren’t the most potent “stressors;” our thoughts are. On the individual level, there is a tremendous range of reactivity to environmental events, and each person’s unique cognitive processing style has a lot to do with it. Stress-hardy individuals view stressors as challenges, are optimistic problem-solvers, and maintain good perspective on the relative importance of each stressor. Those who meditate regularly and who maintain healthy lifestyles also demonstrate far greater coping abilities. It is no surprise that these individuals demonstrate fewer health complications.

In contrast, stress-impaired individuals tend to view problems as direct threats, ruminate pessimistically, over react, and have difficulty distinguishing between big and small problems. They have significantly higher catecholamine and glucocorticoid levels and, consequently, far greater health complications.

Stress Reduction Tips

1. Learn and practice the habits of stress-hardy individuals. Practice optimistic problem solving, view problems as challenges, and maintain proper perspective on the relative importance of each problem.
2. Develop a healthy lifestyle of exercise, proper diet, time with friends, rest, recreation, sleep, minimizing or eliminating use of alcohol and other substances, and realistic scheduling.
3. Learn a relaxation/meditation technique, and practice it daily. The body of research on meditation and health is impressive, with hundreds of studies demonstrating a array of benefits such as fewer infections, faster surgical wound healing, lowered cholesterol, reduced arterial occlusion, and of course reduced anxious reactivity.
4. Read self-help books such as Joan Borysenko’s Minding the Body, Mending the Mind or Herbert Benson’s The Relaxation Response.
5. If you need more extensive help, seek mental health treatment such as individual psychotherapy or participation in a stress reduction group.