Monday, January 26, 2009

Waking Up and Getting Out of Bed Update

It’s been two weeks since the initiation of my waking up, getting up, and feeling better routine and I thought I should share my progress since setting a goal, and not quite acquiring it, can be very dissuading, particularly if you think you are alone in the matter.

At the risk of over self-disclosure here, and yet as a proponent of un-stigmatising mental illnesses, I would like to share with you that I am (among other things) depressed. I am sharing this information because I know how easy it is for anyone suffering from depression to assume that advice and public success stories are for ‘healthy’ people and that similar ambitions just won’t work for them. Furthermore, I would also like to state that the severity of my depression can be very extreme, because I also know how easy it is to attribute another person’s success to them having a milder form of depression.

Making any kind of change in your life can be difficult. If you additionally suffer from any psychiatric conditions, that level of difficulty can greatly increase. Yet, and at the risk of sounding trite, it also makes life more triumphant. Change takes time. There will be days where everything goes smoothly and according to plan, perhaps exceeding your expectations, and there will also be days when nothing seems to work right.

It is important to remember that life doesn’t always follow a schedule or plan and that any deviations in the structure of the path to your goal are not failures. Sometimes you need to try things a different way. And sometimes you just need to take a day or two off. This is ok. Just as long as you don’t let your depression completely overwhelm you, by which I mean that even when you are debilitated by depression, be conscious of your own ability to act within it. Maybe one day you can’t quite motivate yourself to take out the garbage, but the next day you notice you have slightly more energy and are able to get a chore or two done. Whenever the depression lets up, even if it is just a little bit, make use of that opportunity to get yourself back on track.

So, with all this in mind, here is my update…

I never was able to get my day started at 7:30. The original plan was to start waking up at 8:45 and gradually set the alarm a bit earlier each day, but I found I had quite a few enjoyable evening activities that prevented me from getting to bed earlier. So for the first week, I was waking up at about 8:30 using bird sounds, music, and a therapeutic light box. By the end of the week, I was turning away from the light or hiding under the covers and sleeping through the birds (though having The Pixies set to automatically play after 15 minutes tended to wake me up). The second week there were social obligations and an increasing depressive state that interrupted this plan, but I did learn that it is easier for me to wake up without the audio soundtrack.

Having water beside the bed didn’t help perk me up much, but when I made the switch to Gatorade (juice or soda would also work) I noticed an increase in alertness. Also, on the one night my boyfriend stayed over and actually got up before me, having him bring me a cup of coffee in bed was a delightful way to wake up. If you have someone that you live with, I recommend asking for this as a favour, if you’re a coffee drinker. Maybe work out a trade with a roommate where you offer to bring them their tea in the evening or take on an extra chore. If you don’t live with anyone, having an automated coffee pot helps.

Exercise hasn’t made its way into my morning routine yet, but I have high hopes for this one.

Now for the modified routine to be carried out for the next two weeks….

8:00-8:30 – Have alarm set. Turn on light. Take meds. Mentally review goals for the day. Also, allow time for lazy mornings to read in bed or whatever.

8:45 – Go for a walk outside.

9:00 – Have coffee and breakfast while doing stuff on the internet (or some other pleasurable activity). If this stuff includes reading on-line articles or writing blog entries, allow self more time. If stuff is limited to checking email, try not to waste too much time (1/2hr). Take vitamins (I recently invented adding instant breakfast powder to my coffee to increase the amount of vitamins I get each day. And it’s tasty.).

10:00 – Shower and groom.

(For more details and suggestions on this routine see the first post)

I am happy to say, and hope others will find some hope and motivation in this, that after four days of not doing much of anything and not wanting to get out of bed at all, that I am looking forward to tomorrow morning.

Thursday, January 22, 2009

Catch-It (Competent Adulthood Transition with Cognitive-behavioral and Interpersonal Training)

The November issue of The Journal of the Canadian Academy of Child and Adolescent Psychiatry featured a research article describing an internet based intervention for adolescent depression. While the published results showed some improvement in subjects, I have a few criticisms of the self-help site.

My biggest complaint is that there is a lot of reading and uninterrupted text. The font is small, uniform, and there is a lack of eye-catching contrasting colours to captivate attention of reader. In particular, the paragraph highlighting time commitment and brief instruction/motivation could be set in bold or colour. The chapter menu for the fourteen modules was on the small side. It actually took me a few minutes to look at the associated text to discover, after a few misdirections, that that was the menu.

I did not go through all of the modules, but I did look at quite a few. The TRAP chapter was primarily focused on negative behaviours and repercussions with only a very small amount of space (three lines out of about seven pages) devoted to goal exercises. It wasn’t until the following chapter that alternative coping strategies as well as character example stories demonstrating how to combat negative habits was introduced. Even still, I thought, the chapter used too much negative language and still focused heavily on unhealthy aspects.

On the positive side, it had a lot of information regarding depression, different treatments, and coping strategies. The character examples were nicely varied to help those working through the exercises relate to common feelings and learn some language to help describe what they are going through. There was contact information for anyone who might need to get in touch with a doctor as well as links to other help networks (also posted below). The fun, frivolous internet links at the end of each module helped break up the monotony of the previous pages and were a nice reprieve, even though I didn’t use any of them, before heading on to the next chapter.

Overall, I think any resource is a positive thing to develop. This particular site is helpful for identifying, more than correcting, negative emotions and behaviours. However, it is a quite thorough information resource. For those who use it, especially in conjunction with other therapies for more difficult disorders, it may help, but I wouldn’t recommend it on its own. Hopefully, in the near future, the original design team will make improvements to the outstanding structure.

Youth Crisis Hotline


National Domestic Violence Hotline

Tuesday, January 20, 2009

A, Sort of, Basic Explanation of fMRI

The question of why white matter is displayed in brain images when it is only neurons, gray matter, that are active came up in a discussion today with one of my colleagues. Here is the answer:

The Very Basic Answer:

Measurements are made of protons in the water molecules in the body (or brain or region of interest). One frequency, or specific magnetic field, is induced within the scanner to align the direction of all the protons (with the direction of the magnetic field inside the scanner). A second, different, frequency is then transmitted which alters this orientation and the time it takes to return to the original position is measured.

The More Complicated Answer:

Protons, as well as some other nuclei, have a spin of ½ and this spin has two different orientations – up and down (so the two different spin values can be thought of as +1/2 and -1/2). The organisation of spins in a molecule is such that the resulting energy of the molecule will be the lowest possible. At lower energy levels (you can think of the energy levels as in the Bohr model of an atom. Though it is technically wrong, it is good for illustrative purposes.), this is achieved by orienting each additional spin ½ nuclei in the opposite direction of the previous nuclei so that the total spin, say in H2 which has two protons, is S= ½ + (-1/2) = 0. Because Hydrogen is only one proton, it always has a spin value of ½. It is this non-zero spin value (magnetic moment) that allows the magnetic field to change the orientation of the proton (hydrogen).

Once the protons are aligned with the magnetic field within the MRI machine, the second frequency is transmitted causing the protons to alter their orientation. But once this frequency is turned off, the protons will re-align with the magnetic field. The time it takes for this re-alignment to occur is called the relaxation time and varies in different tissues. (Other magnetic fields are also transmitted once the second frequency is turned off to determine the location of the protons). The energy released during the realignment is what is measured by the MRI scanner and the differences in energy/relaxation time create the contrasts of white matter, gray matter, and cerebrospinal fluid in the black and white image produced.

The process of neuroimaging for research purposes is called functional MRI (fMRI) and measures differences in neuron activity. This is what produces the bright red and blue spots (active areas) you see in pictures. When a neural network is activated, the brain demands a higher oxygen: blood ratio in that area and this ratio can be measured over time (each scan in fMRI is about 2-3 seconds), so the BOLD (Blood Oxygen Level Dependent) signal can be measured over, typically, 20-30 seconds displaying the level of neural activity in different areas of the brain. Exactly how this relationship between blood-oxygen and neural activity works is still being investigated.

So, the reason you see white matter activation in fMRI images even though it is only the gray matter neurons that are firing, is because it is the blood-oxygen level in the vascular system supplying these areas that is being measured, not the neurons themselves.

And new research indicates that white matter, typically ignored in relation to gray matter, may actually be important in cognition and memory.

Wednesday, January 14, 2009


Ok, I’ve known for some time that the DSM-V was in progress, but what I didn’t know about was that the process was supposedly a closed-doors, hush-hush thing. And that made me ask, ‘WTF?’

Pardon the language, but seriously, what is it the people working on the new DSM feel the need to hide? I don’t have anything against the DSM per se, it’s generally useful as a general guide for at least knowing which medications to prescribe, but it’s certainly not a psychiatric rule book that begs absolute obedience. And the categories and labels have changed so significantly since the manual’s conception (homosexuality used to be a psychiatric condition and the number of disorders has greatly increased) that the manual is more of a dictionary educating physicians on which words to use to communicate with each other for the next few years. And clarity is a good thing. And revisions as we learn more about psychiatric illness are a good thing. Certainly labels are helpful in certain official situations, like court where the difference between sociopathy and psychopathy might be relevant, but who really cares if they are in separate categories in the DSM or are chaptered under the umbrella of antisocial personality disorders?

I think it would be funny if the DSM task force put a bunch of symptoms into one hat and a bunch of diagnoses into another and picked the categories at random. Which is probably the most dramatic (or maybe not) change that would be made to the current edition. My point: it’s just the DSM. For those working in psychiatry, it’s not like a new diagnosis is going to suddenly appear and completely change the world. There is no conspiracy…probably.


- Wall Street Journal blog post

- I think the link title is descriptive enough

Tuesday, January 13, 2009

The Anti-DSM…

I might get in trouble from some people for this post as if highlighting the positive traits of borderlines, or any psychiatric disorder, is somehow a justification for the negative aspects, but screw them because it’s not. Every person has redeemable qualities and so much of psychiatric literature is focused on the negative that I feel the need to balance things out a bit. This list pertains to traits associated with BPD (borderline personality disorder) since that was what my last post was about, but I will do this for other disorders as well.

A list of positive traits in BPD:

  1. Energetic
  2. Entertaining
  3. Adaptable
  4. Passionate
  5. Empathetic (There was a recent study, Flury, suggesting this might not be true, however the study looked at how BPD persons perceived non-BPD persons and vice-versa. It did not compare how BPD and non-BPD persons view the same subject. Another study, Frank and Hoffman, showed evidence for greater non-verbal sensitivity among BPD persons.)
  6. Imaginative, creative
  7. Purposeful
  8. Good listeners
  9. Attention to detail
  10. Experienced
  11. Confident
  12. Able to tolerate pain
  13. Varied interests
  14. Productive
  15. Brave
  16. Intelligent
  17. Survivors
  18. Kind, thoughtful
  19. Compromising


Judith M. Flury, William Ickes, and William Schweinle. The borderline empathy effect: Do high BPD individuals have greater empathic ability? Or are they just more difficult to “read”? Journal of Research in Personality Volume 42, Issue 2, April 2008, Pages 312-332.

Hallie Frank and Norman Hoffman. Borderline empathy: An empirical investigation. Comprehensive Psychiatry. Volume 27, Issue 4, July-August 1986, Pages 387-395.

Monday, January 12, 2009

Borderline Personality Disorder Uncovered

In my years of study, each time I have come across any article or book about borderline Personality Disorder, I have been left with a feeling incompleteness and an almost disgust at the medical community. When looking at the diagnostic criteria, borderlines come across as something like pathological whiners. As a strong advocate for those suffering from mental illness, I was upset by this limited view of what is one of the most complicated disorders in psychiatry. Yet, knowing there must be more to the borderline, it wasn’t until just recently that I finally encountered a piece of literature that describes in great detail what exactly a borderline person is. Marsha Linehan is well known in the psychiatric community for her development of dialectical behavioural therapy and her book, Cognitive Behavioral Treatment of Borderline Personality Disorder, finally filled in the many empty spaces in other descriptions of BPD.

I do not want to be a promoter of selling anything, but this is a book that should be read by everyone practising therapy. Since that is unlikely to happen, I also strongly encourage people suffering from BPD to read the book themselves. Borderlines are among the most difficult people to treat requiring a lot of skill and energy on the side of the practitioner, as well as with the patient whom is constantly struggling to make sense of themselves and their environment. There is a lot of great language used to describe the struggle of borderlines and for the patient this may help you communicate more clearly to your therapist.

The umbrella problem of borderlines is that they live in a world composed of opposites with little in between. Attempts at reconciliation of these two poles leads to confusion, depression, withdrawal, anxiety, and anger (often directed towards the self). It is easy for a therapist to misinterpret any of a borderline’s behaviours in these attempts at reconciliation, which has the negative impact of invalidating their emotions and further perpetuating the negative perception of the self of the borderline in relation to others.

The borderline person feels everything with an exaggerated affect. Simple tasks can quickly escalate into crises with the precipitating event lost in the confusion. Furthermore, the borderline person is always feeling; they have no ‘off’ switch, so to speak of, and this constant state of crises is what eventually leads to more dramatic behaviours, including suicidal acts, as a means of communicating and reconciling their own feelings with the perceived expectations of the environment with the additional belief that they deserve to be punished . As such, treatment needs to be more focused on behavioural skills rather than crisis intervention. However, notice must be taken when the situation has progressed into the suicidal realm, but without over-emphasising the behaviour or precipitating event.

“borderline individuals are the psychological equivalent of third-degree burn patient. They simply have…no emotional skin. Even the slightest touch or movement can create immense suffering. Yet, on the other hand, life is movement. Therapy, at its best, requires both movement and touch. Thus, both the therapist and … therapy…cannot fail to cause intensely painful emotional experiences…Both the therapist and the patient must have the courage to encounter the pain that arises.”

“…borderline individuals tend at times to appear to others, including their therapists, deceptively less emotionally vulnerable than they are. One consequence of this state of affairs is that the sensitivity of borderline patient’s is far more difficult to comprehend and keep in mind… We can imagine not having physical skin; it is much harder for most of us to imagine what life would be like if we were always emotionally vulnerable or did not have psychological skin ourselves. That is the life of borderline patients.”

“Rarely have I seen such vengeance as that of borderline individuals’ hatred towards themselves.”

The therapist needs to understand that the demeanour of the borderline may not at all be indicative of what they are actually experiencing in the moment or of what they experience outside of session. It is easy for the therapist to discredit the patient’s descriptions of extreme emotional distress when such descriptions are made calmly on the part of the patient. However, it is essential to understand that the patient is trying to communicate as best they can and that what they are describing is in fact true, not an act of manipulation. It is also important for the therapist to remember that the patient “believes that she has communicated clearly [and] that a simple description of how she feels…is sufficient. She may not be aware that the nonverbal message is discordant…Yet when others fail to pick up the message, the individual is usually quite distressed. This failure is understandable, however, since most individuals faced with discrepant verbal and nonverbal affect cues will trust the nonverbal over the verbal cues.” This discrepancy between what is said and what is seen can lead to the many other negative assumptions of a borderline’s motivations including manipulation and laziness.


While this article details the difficulties in treating BPD, I do not mean to discourage. On the contrary, BPD can be overcome. However this requires commitment and patience of both the caregiver and the borderline. Both therapist and patient need to validate each other. If you are a borderline and in treatment, make sure to tell your therapist every once in a while that you understand the difficulties in overcoming the disorder and you appreciate their efforts. Outside of therapy, also ensure to tell others in your long-term support network that you appreciate them as well. If you are a therapist or a support person, make sure you do the same for the person you are caring for, and do so frequently. Knowing that their efforts are being noticed and validated is essential for treatment.

I could go on with this, and I will come back to the topic, but for now I will refer the reader to Linehan’s book CBT of BPD. If money is an issue, copies are available at many libraries. Or, buy the book from a store and read it without damaging it, then return it.


- an article that says mental health professionals believe care for BPD’d patients is inadequate

- one psychiatrist’s notes about BPD

- Darth Vader and BPD

- another person irritated with the ignorance surrounding BPD and a funny comic

There are so many resources and blogs about BPD. Search around for what motivates and interests you the most. If you have BPD, you may find other’s personal journals to be of help in knowing you are not crazy and you are not alone.

* all quotes are from Linehan's CBT of BPD

Saturday, January 10, 2009

Waking Up Children (with ADHD)

I thought I would put up a quick post with some suggestions of how to adapt a morning routine to wake up children, particularly those with ADHD.

This most important thing is to have a routine, review it daily, and stick with it. Probably the best way to remind the child of the routine is to make a chart of what needs to be done in the morning giving each task a box that can be checked off or confirmed with a sticker. For children with whom reading is problematic, the tasks can be labelled with pictures instead of words.

You may want to add personalised items to the daily routine chart. Maybe give the child their own plant to water in the morning. But this will depend on each individual child’s independence. Start simple. Break activities down into smaller pieces if necessary. For example instead of having a box on the chart for ‘brush teeth’ have a few boxes for ‘wet toothbrush under tap,’ ‘put toothpaste on toothbrush,’ ‘brush teeth,’ ‘rinse mouth,’ ‘rinse toothbrush,’ and so on. However, once the child has learned the task without having to refer to each step, remove the extra steps from the chart to avoid future confusion and becoming overwhelmed. A possibility is to have a small chart in different specific locations. So the brushing teeth chart would be in the bathroom, the getting-dressed chart would be on the closet doors, while the master chart with the generalised activities is kept somewhere else. That way the child isn’t overwhelmed with a myriad of activities on one big chart.

Try to wake up your child yourself if you can. Open the curtains, use gentle touch, and speak to them softly. You may need to leave the room for a few minutes while they are waking; this would be a good time to put on some music. If an alarm is necessary, choose sounds that will not startle the child. As soon as the child is awake enough, have them take their morning medications (stimulants are often used in the treatment of ADHD).

Prepare as much the night before as you can - lay out clothes, make lunch. Remember children with ADHD don’t sleep as well, so be patient during the morning. Check in on their progress in getting ready and gently urge them back on track when they get distracted. Some children will be more independent and once they are up can dress and brush their teeth on their own. Others will need to be encouraged every few minutes.

Ensure they eat a healthy breakfast. You may also want to have an emergency snack prepared for the days when things don’t move as smoothly so if your child needs to leave the house before they’ve eaten, they will have something healthy to eat in the car or on the bus.

Remove distractions such as tv, computer, and video games. Review any homework that was completed the day before. Use this time to socialise and enjoy the company of your child.

Ensure exercise is a part of the morning routine. Put aside fifteen minutes for the child to jump or run around. This is time you can use to get ready yourself.

Be in a good mood yourself. Children adapt to their environment. If they see you enjoying your mornings, they will be more likely to themselves. If you find you are becoming stressed, take a few moments for yourself to catch your breath and relax. Even if you can’t get away to be by yourself, try to concentrate on your breathe while supporting your child. And always keep in mind your child isn’t being difficult on purpose; they need your support. Enjoy this extra time you get to spend with them and know that you are making a positive difference in their day, even when it doesn’t seem like it.

Sunday, January 4, 2009

Waking Up and Getting Out of Bed

Read Update and Mornings for Children with ADHD

It’s winter, it’s dark, it’s cold, and it is so very easy to stay in bed. But it is also January and while I am not one for making resolutions, I am regularly trying to make changes. The most dramatic goal on my list currently is structuring a healthy morning schedule. The following ideal is a combination of suggestions I have found on other sites, advice from doctors, and my own experiences. Having a structured morning routine can help those suffering from anxiety, depression, bipolar disorder, ADHD, and plain old lethargy. There are also adjustments that can be made by parents in order to encourage their children to wake more easily and gently.

Although I have some knowledge of different psychiatric medications, I am not a doctor. Please check with your doctor before making any changes in your medications.

7.30 :

Have an alarm set. This should be something non-alarming like nature sounds, classical music (though I would stay away from Gould first thing in the morning), or quiet talk. The cheapest and easiest strategy would be an old clock radio set to an all-talk station. I personally don’t like to listen to the news upon awakening, nor do I recommend it. An alternative idea is to set the radio to a French station. For recorded music, you can use a clock with a cd player or have a cd player set up next to your bed (so you don’t have to get out of bed to turn it on). Another idea I came across is to go into the BIOS menu of your computer and set it to start at the time you want to wake up as well as setting your media player to start automatically.

Turn on a light. A therapeutic light box can be beneficial to those with SAD as well as helping your body set its circadian clock. I turn on my light box to the low setting for the first 15 minutes of waking. Full-spectrum lights are also nice and can be found at growing stores. But any light will do. The advantage of having your computer set to start, if it is beside your bed, is that it provides light as well as sound.

7.45 :

Turn light box to high setting. If you are using regular lights, you might want to turn on some more. If you sleep with your curtains closed, this would be a good time to open them, even if it’s gray outside.

Change music to something more stimulating. Having stand-up comedy in the background was recommended by one person, although anything you are consciously listening to should work.

Do some small stretches, while still lying in bed, just to get your body moving.

Take morning medications (for people who are on stimulants, this might be a good time to take them) and drink some water (keep a glass or bottle of water beside the bed).

7.50 :

In order to give your body more time to adjust to waking, stay in bed a little longer (15 – 30 min), but be engaged in some activity. A few ideas include reading, journaling, CBT work, and meditating. If you have a laptop bookmark some sites with funny comics or sites that you find motivational. Email is ok as long as it isn’t a stressor; write a letter to a friend.

On the Zen Habits site is a recommendation to set yourself three goals that are most important (called the MIT – Most Important Tasks). I recommend setting these goals the previous night and using this morning time to review them. Mornings can be difficult enough when you’re suffering from any psychiatric ailment, so don’t add stress to the morning by trying to organise the entire day while still in bed. Also, if you are going through a particularly tough period, don’t feel your tasks need to be huge. If the one thing that needs to get done that day is make the bed, that’s alright. If you’re feeling well, maybe challenge yourself on something new you’ve wanted to do for a while. Your daily goals need not be obligations; indulge yourself as well.

You can also use this time to review favourite affirmations or to congratulate yourself on what you accomplished the previous day. If you have pets, children, or a partner spend some time in physical contact with them. It’s much easier to wake when you are engaged with others whom already are active.

8.15 :

Go for a walk (or some other form of exercise). There is some advice out there that says to get out of bed first thing in the morning, but this doesn’t work for me. Instead, getting out of bed tends to make me more tired and unmotivated and I wind up going back to sleep. If you do want to get out of bed right away, try to get outside. You don’t have to walk far, taking out the garbage will suffice, but you will find that as you adjust to the routine the walks will become more enjoyable and longer.

Make your walk more than a chore. Meditate, find new streets to walk down, discover sources of inspiration. If you are getting up a bit later, maybe stop by a coffee shop and get something to go. Whatever you do, try to get outside.

8.30 :

Shower and groom.

9.00 :

Eat and take vitamins. Review goals for the day again and choose one to tackle first. I also like to read while I’m eating.

A few tips to make things even easier:
Give yourself time to settle into a new routine. If you usually wake at noon, don’t try waking up a six right away (or if you do, make sure you adjust your bedtime to avoid fatigue and physical and psychological stress). Don’t adjust your schedule by more than 30 minutes each day and do even less than that if you can.

Have everything set up the night before; make your goal list, set some water out for the morning, have your medications ready, have a variety of music at the bedside as well a book to read and some notepaper and a pen for writing or drawing.

Put everything, or at least have the first light, on a timer. You can get these at a hardware store and set the timer on the plug to go off at whatever time. That way, you don’t have the opportunity of talking yourself out of the rest of the routine before it’s started, which can be a very easy thing to do some days.

Make a cd or playlist such that the music/talk changes without you having to physically change the disc or push any buttons. The goal is to make mornings as comfortable as possible. Waking up happens slowly so don’t push yourself to wake faster than you are comfortable with.

Sleep with your curtains open or switch to fabrics that allow some light to filter through. Natural sunrise is the best light there is for your body.

Make your bedroom an aesthetically pleasing place to be. Live things, pets, humans, flowers (which aren’t technically alive but are very pretty), will make it easier to get up. In addition to all of your morning supplies, keep a goldfish on your bedside table and feed him when you get up. Have a plant next to your bed and water it when you have your first glass of water. Put up art that you find inspirational. Paint your walls a soft colour. Put up mirrors to capture more light. Have some scented candles or other pleasant scents around.

Also, for those of us who procrastinate of New Year’s resolutions, check out the following sites:
- Make your own list of commandments for how you want to live your life
- There are many inspirations activities and helpful suggestions here and it is not overly preachy, religious, spiritual, or trite. This is where you can find more details about MIT. Also try the goal tracker.