Figure 12-1: The cycle of depression.
Obtaining a new outlook
A depressed outlook is typically bleak. The future seems impossible to contemplate because everything seems tinged with grey. Even as you make steps toward recovery, your outlook may remain stubbornly negative for some time. Constructing a new optimistic outlook and practising it daily - even several times each day - can be useful. You may not feel as though you believe it at first but, with time, this bright outlook will probably begin to ring true. Try adopting these new outlooks:
‘I look forward to feeling better soon.'
‘I may not see the light at the end of the tunnel but I know it's there.'
This will pass.'
I'll deal with the future when it comes; I don't need to worry about it now.'
Hanging on is worth it because things will get better.'
The road to recovery from depression is rarely a steady uphill climb. Setbacks and difficult days are part and parcel of a normal recovery. Don't be too disappointed if, after a series of good days, you have a hard one. This difficult day isn't a return to square one or a sign that you're not improving. Just saddle up and get back on the horse.
Managing Suicidal Thoughts
The most dangerous element of depression is that the feelings of hopelessness you can experience may become so strong that you try to take your own life. Don't panic about having suicidal thoughts if you're depressed. Such thoughts are very common and having them doesn't necessarily mean that you'll act on them.
If you've been feeling very hopeless about the future and have started to make plans about how to kill yourself, you must immediately seek medical assistance. Go to see your regular doctor as a first point of call, or attend Accident and Emergency (Casualty) if you feel at risk of suicide outside of surgery hours.
Here are some tips on managing suicidal thoughts:
Recognise your feelings of hopelessness about the future as a symptom of depression, not a fact.
Remember that depression is a temporary state and there's lots of ways to treat it. Decide to tackle your depression for, say, six weeks, as an experiment to see whether things can improve.
Tell a friend or family member how you're feeling.
See a doctor and/or therapist, or join a support group for further help and support if you're finding it difficult to overcome your depression alone.
Try instigating the problem-solving process we outline in the previous section in this chapter, for any problem you currently see as hopeless.
Famous and depressed
One of the most crucial aspects of recovering from depression is shedding any feelings of shame you may have about the problem. Realising that no one has a guarantee that they won't get depressed can help here. Depression has affected all kinds of people, from all walks of life, and of all creeds, colours and levels of intelligence.
Dozens of famous people have publicly reported or discussed their battles with depression during their lives. Celebrities are now ‘coming out' about their suffering from depression or bipolar affective disorder (formerly known as manic depression). We hope that their actions can help to remove the stigma of mental health problems and enable more people to identify and seek help for depression.
Here are just a few famous types who've suffered from depression or bipolar affective disorder:
Buzz Aldrin (astronaut)
Ludwig van Beethoven (composer)
William Blake (poet)
Winston Churchill (British Prime Minister)
John Cleese (comedian, actor and writer)
Charles Dickens (writer)
Germaine Greer (writer and journalist)
Spike Milligan (comedian, actor and writer)
Isaac Newton (physicist)
Mary Shelly (writer)
Vincent Van Gogh (artist)
Lewis Wolpert (embryologist and broadcaster)
In our clinical practice we often treat doctors, psychiatrists and other mental health professionals for depression. So it just goes to show that anyone can suffer from psychological illness - even those who earn a living treating it.
Chapter 13: Overcoming Obsessions
In This Chapter
Identifying obsessional problems
Managing upsetting intrusive thoughts
Facing fears and reducing rituals
Decreasing preoccupations with health and appearance
This chapter aims to introduce you to common obsessional problems and how to tackle them using CBT. Specifically, in this chapter we focus on obsessive-compulsive disorder (OCD), health anxiety, and body dysmorphic disorder (BDD). These problems can cause significant levels of distress and interference in daily living. However, if you have one or more of these disorders, you can use the CBT principles we outline in this chapter to reduce your obsessions and preoccupations. If you have a more severe form of these problems you should consider adding some professional help, but the core principles can still be very useful.
Many people have some degree of obsessional behaviour, such as checking or ordering, that doesn't particularly interfere with their lives. This level of problem is usually regarded as subclinical. However, problems like OCD are very disruptive and distressing when they reach more severe levels. A report from the World Health Organisation (WHO) states that people with OCD can experience an impact on their lives similar to that of people with HIV infection.
Fortunately, obsessional problems are being diagnosed more accurately than ever before. Problems such as OCD are now among some of the most common psychiatric disorders. This increase is probably due to increased awareness and more accurate assessment measures. CBT is well-recognised as the psychological treatment of choice for obsessional problems, and has far superior relapse rates compared to medication alone.
Identifying and Understanding Obsessional Problems
Obsessional problems are among the most disabling of common emotional-behavioural problems. People with obsessional problems can spend many hours a day plagued by upsetting thoughts and feel driven to repeatedly carry out rituals or avoid certain situations. This section outlines three key obsessional problems: OCD, health anxiety and BDD.
Some degree of obsessionality is entirely normal - for example, around half of all people have a particular thing that they check more than they think is necessary, such as whether the gas cooker has been switched off or the door's been bolted. Obsessional problems have their roots in normal experiences, but the rituals and avoidance behaviours serve to make the frequency, severity and duration of obsessions worse. The more you try to rid yourself of doubts, the more they tend to play on your mind.
We define the terms related to obsessions in the list below:
An obsession is a persistent, unwanted thought, image, doubt or urge that intrudes into your mind and triggers distress. Obsessions are said to have reached a ‘psychiatric problem' level when they cause significant levels of distress, interfere with your life and are present for more than an hour a day.
Preoccupation means being absorbed with something troubling that's on your mind. In this chapter we focus on preoccupations with appearance and health. Preoccupations are usually the result of you frequently focusing your attention on an idea (such as ‘I'm seriously ill' or ‘I'm repulsive to look at') or doubt (‘Did I lock all the windows?') that's distressing to you. Preoccupations are similar to obsessions in that they're regarded as problematic when they cause significant distress, interfere with your life, and last for more than an hour per day.
Compulsions, also called rituals, are the actions you may take in response to your obsessions or preoccupation, but do not particularly help you in your life. Compulsions can be observable behaviours (such as checking or washing your hands) or can be carried out in your mind (such as repeating a phrase in your head or counting). Compulsions are usually attempts to either get rid of a thought, image, urge or doubt; an attempt to reduce danger; or an attempt to reduce discomfort.
Avoidance b
ehaviours are things you do to avoid triggering your obsession or preoccupation. Your avoidance behaviour may be avoiding driving; avoiding visiting a hospital; or avoiding being seen in bright light.
Rituals and avoidance behaviours are the lifeblood of obsessional problems. Add to these catastrophic thinking (see Chapters 2 and 9), negative emotions (see Chapter 6) and attention bias (see Chapter 5), and you have the anatomy of obsessional problems
Understanding obsessive-compulsive disorder (OCD)
According to the American Psychiatric Association, OCD is:
A problem in which the sufferer is plagued by either obsessions or compulsions, or usually both. [They experience] unwanted recurrent intrusive thoughts, impulses, or images that cause marked distress and are not simply excessive worries about real life problems. The sufferer makes attempts to ignore, suppress [or] neutralize the obsessions and recognizes them as the products of their own mind.
Common obsessions in OCD include the following:
Fear of contamination
Fear of accidentally causing harm to yourself or others
Preoccupation with order or symmetry
Religious obsessions, for example fear of offending God
Sexual obsessions, for example fear of being a paedophile
Fear of losing something important (such as a possession, paperwork or ideas)
Fear of becoming violent or aggressive
Compulsions frequently associated with OCD include the following:
Checking (for example, if a light is switched off or the front door is locked)
Cleaning or washing (such as yourself, others or home)
Counting
Repeating actions or special words, images or numbers in one's mind
Ordering and making things ‘just so'
Hoarding (excessive keeping of possessions such as newspapers that have no real value, interest or function)
Making lists
Replaying or repeating scenes, images or actions in your mind
The prevalence of OCD is estimated to be around 1 per cent of the population, with some studies suggesting more. The severity and impact of OCD varies greatly, and in its most extreme form individuals can become totally housebound, even bedridden. Whilst the severity of symptoms can wax and wane, most people with OCD do function, have relationships, hold down jobs and complete education, but will be under considerable extra strain. Clearly, very many people may recognise some degree of the excessive worries and rituals outlined above. The question is how much choice you feel you have to stop a ritual without distress, and how much interference OCD is causing in your life.
Recognising health anxiety
The American Psychiatric Association defines health anxiety as ‘preoccupation with fears of having, or the idea that one has, a serious disease, based on misinterpretation of bodily sensations.' These preoccupations can:
Persist despite medical evaluation and reassurance
Cause significant distress or impairment in social, occupational or other areas of functioning
Last at least six months
People with health anxiety misinterpret body sensations. Examples of common sensations and misinterpretations include the following:
Heart pounding: ‘I'm going to get heart disease.'
Lumps under the skin: ‘I have cancer.'
Tingling or numbness: ‘I have multiple sclerosis.'
Headache: ‘I must have a brain tumour.'
All of the above: ‘I'm dying.'
Compulsions commonly associated with health anxiety include the following:
Seeking reassurance from medical professionals about the nature of physical sensations
Seeking reassurance from others
Checking body parts by poking, prodding and touching
Checking for symptoms in medical textbooks or on the Internet
Examining oneself for signs of disease
Monitoring physical sensations
Looking for evidence that the physical sensations are worsening
Common avoidance behaviours associated with health anxiety include the following:
Avoiding health-related stories in magazines or on TV
Avoiding talking or thinking about death
Avoiding touching body parts
Avoiding exposing body parts
Avoiding having medical check-ups
Health anxiety is estimated to affect between 1-2 per cent of the population. It can result in people becoming tormented with fears that they have an illness that has not been properly diagnosed, or that they might become ill. Frequent trips to doctors are not uncommon when the person is gripped by anxiety and a fear that it would be irresponsible of them not to get themselves checked out. This can then result in even more worry that should they really be ill, they'll be dismissed as a hypochondriac. People with health anxiety usually either make repeated trips to medical specialists trying to get an explanation for their symptoms, or avoid seeing doctors because they fear being told something is severely wrong. We've seen many people who've ended up badly bruised from repeatedly prodding an area of their body, or have spent hours doing research in desperate attempts to check to see what may be wrong with them.
Understanding body dysmorphic disorder (BDD)
BDD is defined by the American Psychiatric Association as follows:
A preoccupation with an imagined defect in appearance. If a slight physical anomaly exists, the person's concern is markedly excessive. The preoccupation causes clinically significant levels of distress and/or impairment in social, occupational or some other important area of functioning.
Don't confuse BDD with an eating disorder, which is when a person restricts their weight, or binges and purges food. If you're very preoccupied with your overall size and shape and have difficulties with eating regular meals, consult your doctor about whether you have an eating disorder. If this is the case, you may need help to tackle your eating behaviours as well as your preoccupation with how you look.
BDD preoccupations can focus on any part of the body and often affect multiple areas. The face is the most common area of preoccupation, particularly the nose, skin, hair, eyes, teeth, lips and chin. People with BBD believe that one or more of their features is too small or too big, or that their face doesn't ‘fit together', is out of proportion, isn't symmetrical or is just plain ugly.
Typical compulsions associated with BDD include the following:
Gazing and checking in mirrors or other reflective surfaces
Avoiding mirrors or other reflective surfaces
Seeking from other people reassurance of attractiveness or how noticeable a ‘defect' in appearance is
Checking features by frequent touching or measuring
Camouflaging features using clothing, padding, hairstyle or make-up
Attempting to distract others from the supposed defective feature with jewellery or by accentuating other body parts
Frequently looking for and trying out new skincare, beauty and haircare products
Researching or seeking cosmetic surgery
Doing excessive exercise
Abusing steroids
Some common avoidance behaviours in people with BDD include the following:
Avoiding social situations
Avoiding ‘attractive' people
Choosing lighting carefully in social situations or near mirrors
Carefully positioning yourself around (or avoiding) mirrors
Cognitive Behavioural Therapy For Dummies Page 22