Monday, June 29, 2009

Fear of Flying


Aerophobia, aviatophobia, aviophobia or pteromechanophobia (my personal favourite) is an anxiety disorder encompassing many different psychiatric disorders including claustrophobia, anxiety, fear of heights, concerns as to security, PTSD, and others.

Everyone has heard it, and the statistics on the safety of flying may not be comforting if your fear is not based on flying safety, but it is a good point to remind yourself of such unlikely probabilities when confronting your fear. From an article written by a flight attendant:

"Air travel is the second-safest mode of mass transportation in the world. This is second only to the escalator and elevator. Your chances of being involved in an aircraft accident are approximately 1 in 11 million. Your chances of being killed in an automobile accident are 1 in 5000. The most dangerous part of your flight is the drive to the airport.

You have more of a chance of dying from the food onboard than being involved in an accident."

In treating many other phobias, it is advised that when feelings of anxiety and discomfort reach intolerable levels, to retreat to a safe environment. Of course, when you’re on a plane, you can’t get off any time you want, which makes gradual exposure therapy difficult.

A review of the literature in a newly developed area of treatment examines the efficacy of virtual reality exposure (VRE) and found VR treatments to be effective, with or without cognitive-behavioural therapy.

One study found VRE to be superior to traditional exposure therapy with respect to overall decreased anxiety in potential flyers.

Another study did a long-term follow up and at six months, found there was no difference between VRE and placebo groups.

Pharmacologically, anxiolytics and sedatives may be helpful during pre-flight therapies and for the actual flying event.

For some self-administered exposure steps check out this site or refer to any phobia workbook.

Tips for the flight:

• Travel with someone who can support you. If this is not feasible, at least have someone take you to and wait with you at the airport.

• Know your seat preference (if you’ve never flown before, you might not know this); some people find looking out the window at the blue sky and white clouds comforting, others prefer to be near the aisle for more of a sense of being able to escape, and others might like the security of sitting between two other passengers. If you can not get your desired seat at check in, talk to one of the airline attendants upon boarding who will gladly help you find a comfortable place. As well, if you feel the need to change seats during the flight, don’t hesitate to ask.

• Bring a comforting object with you – a blanket, stuffed toy, stress ball, photograph.

• Bring distractions with you – a book to read, some notepaper to write on, favourite (calm) music, puzzle books, portable DVD player.

• Use other distractions. Keep an elastic band around your wrist that

• Remember, turbulence is normal. Think of these little bumps as nothing more than potholes on a road. Also, turbulence is supposedly less apparent if you sit closer to the front of the plane.

• Ask to talk to the pilot. Again, staff will likely be more than willing to make sure you are feeling comfortable. Leering about the pilot and how planes are flown may reduce your anxiety.

• Choose your flight plan accordingly; if your greatest fear is take-off, you may want to book a longer non-stop flight. But if you tend to feel claustrophobic, more shorter flights might be in order.

• Avoid caffeine and other stimulants. I don’t personally recommend alcohol, but if a glass helps you, then by all means, just don’t overdo it.

• Breathe.

[For those who are afraid of being afraid of flying, check out the many “Fear of Flying Phobia” sites.]


Additional References: 1, 2, 3

Wednesday, June 17, 2009

Broken Heart Syndrome


Broken heart syndrome (BHS) is a weakening of the myocardium (heart muscle). It goes by other, less romantic, names including stress-induced cardiomyopathy and takotsubo cardiomyopathy. The last of these titles is derived from the, romantic, tale of a Japanese fisherman who fell in love with his octopus and upon rejection, died of a broken heart (takotsubo can be translated as ‘octopus trap.’ Also, upon reflection, I think that something along the lines of acute myocardial infarction might be more romantic than unrequited-octopus-love-induced suicide.).

Broken heart syndrome presents most commonly in post-menopausal women. Symptoms are similar to those of a heart attack – chest pain, shortness of breath, and sense of impending doom. However, unlike a heart attack, in BHS neither of the arteries is fully blocked, cardiac enzymes are not significantly elevated, muscle damage is reversible, and recovery time is quicker. (1)

Triggers of the syndrome include various forms of sudden, stressful, psychic trauma such as bereavement, abuse, or surprises (BHS may also be triggered by physical trauma or without precedent). Further increasing risk of heart illnesses are self-injurious behaviours and medical non-compliance, also associated with stress. “A sense of hopelessness, in particular, appears to be strongly correlated with adverse cardiovascular outcomes.” (2)

Major depressive disorder is, not surprisingly, associated with coronary heart disease. (3)

Just as obvious, suicidal ideation was found to be greater among widowers (females greater than males, though men more often complete suicide attempts) than married persons. But when these results were controlled for with emotional loneliness, the marital factor became insignificant. (4)

Another study looking at suicidal ideation among the bereaved also found a positive association between the two. I am in no way doubting the effect of grief on a person’s psyche and actions, but it is interesting to note that the grief-subjects were those who were survivors of a suicide victim and this may have increased the likelihood of suicidal ideation. (5)

A small but interesting study sought to examine the physiological differences between clinical depression and bereavement-induced depressive feelings citing differences in heart rate and heart rate variability. It’s difficult to say how significant these results are, but it is certainly admirable to work on distinguishing different psychiatric disorders. (6)

The remedies for depression-induced-stress-related cardiac problems are the usual treatments prescribed for psychiatric illnesses, all of which I recommend, particularly in times of stress even though it is during these times that hopelessness may lead to apathy. “These include psychosocial support, regular exercise, stress reduction training, sense of humor, optimism, altruism, faith, and pet ownership.” (2)

So it appears that although incredibly painful, potentially life-threatening, and possibly demanding of emergency attention, broken hearts are unlikely to kill you and will actually heal very quickly (two weeks at most, they say). (7)

References: 1, 2, 3, 4, 5, 6, 7

Monday, June 15, 2009

Brain-Derived Neurotrophic Factor


The brain-derived neurotrophic factor (BDNF) is a neurotrophin (growth factor for neurons) which acts on the hippocampus, basal forebrain, and frontal cortex. These areas of the brain are involved in important functions of memory and cognition which are closely linked with psychiatric illnesses.

A new study has proposed using BDNF levels as a means of distinguishing between BP depression and MDD citing findings of greater BDNF levels in persons with MDD than with BP depression. (1)

Another study also examining serum levels of BDNF among different psychiatric disorders found that there was no significant difference between groups of unipolar depression, BD-I, or BD-II. However, measurements were done during euthymic states whereas the previous study measured serum levels during acute depressive episodes.(2) Since it is typically during a depressive episode that a patient will present for medical attention, evaluating BDNF levels during this phase seems more prudent.

Results of research done into the effects of ECT on BDNF levels have shown no correlation. (3) (Yet another article I don’t have full access to so I can not critique the study design, but it would be interesting to know when BDNF serum levels were measured as there is likely to be a time delay effect)…

…Especially when there is other research out there with long follow up periods indicating an association between ECT responders and BDNF levels.(4,5)

There have also been many studies linking the positive effects of different antidepressants to increased BDNF serum levels.(6, 7)

References: 1, 2, 3, 4, 5, 6, 7

Saturday, June 13, 2009

SSRIs


Low serotonin, 5-HT, levels have reportedly been associated with depression. Because Mind Hacks has already written a concise and interesting article on the low-serotonin myth, I will direct you there for more information on the hypothesis.

Selective serotonin reuptake inhibitors work by preventing nerve cells in the brain from reuptaking serotonin, which is released into the synapse between communicating nerves, thereby leaving more serotonin available for brain function and neurotransmission.

SSRIs include: Fluoxetine (Prozac), Paroxetine (Paxil, Seroxat), Escitalopram (Lexapro, Cipralex), Citalopram (Celexa), Sertraline (Zoloft), Fluvoxamine (Luvox).

These medications may also be used to treat other disorders such as anxiety, insomnia, sexual dysfunction, OCD, phobias, panic disorder, and eating disorders.

There is hesitation about the use of SSRIs in treating children and pregnant women. Concerns over the degree to which increased risk of suicidal behaviours occurs in adolescents are being researched. In regards to pregnancy, “both continuous SSRI exposure and continuous untreated depression were associated with preterm birth rates exceeding 20%.” (2) Additional research has found negative effects on growth and the possibility of increased hypertension and preeclampsia (3).

While SSRIs are reportedly better tolerated than other types of antidepressants, side effects include:
• Nausea, loss of appetite, diarrhoea.
• Anxiety or irritability.
• Problems sleeping or drowsiness.
• Loss of sexual desire or ability, sexual dysfunction.
• Headaches or dizziness.
• Weight gain.

Discontinuation of SSRIs should be done slowly and under the supervision of a physician. Withdrawal symptoms can be quite intense and include: shock-like electrical activity in brain, dizziness, sweating, nausea, vertigo, insomnia, and tremors.

An article in the Journal of Psychiatry and Neuroscience (1) reviews and discusses important non-pharmacological approaches to manipulating serotonin levels including induced mood changes, meditation, light-therapy, exercise, and diet.

References: 1, 2, 3, 4

Wednesday, June 3, 2009

Exercise


Many studies have shown positive results for the treatment and prevention of depression and anxiety (BP depression still needs to be evaluated though I believe exercise is one of those generic activities which can help anybody feel better) with an effectiveness comparable to pharmacotherapy and CBT. Not that exercise should replace other therapies, but rather should be used in conjunction with your current treatment plan.

The exercise can be either aerobic or strength training allowing for a lot of flexibility in an exercise routine. According to one study examining dose response of exercise, the benefits for alleviating and preventing depressive and anxious symptoms are obtained when one engages in physical activity according to the public health dose which is roughly 1200 calories burned per week (roughly 1/2hr of moderate activity per day) and exercise is performed at least 3 days per week.

With a psychiatric illness, finding the motivation to start any project can be extra difficult. It is recommended to not jump into the routine at full speed. Start small. Begin adding exercise into your daily routine with short durations of activity a couple of days a week and build on that as you adjust to having a new activity in your life. Think of exercise as a medication; you start at a small dose and increase that dose in appropriate increments until you reach therapeutic levels. Eventually, according to myself, exercise, like medications, should be something you give yourself everyday.

Once you have started, some tips for maintaining your routine include having a support system with your therapist, individualise your routine (type of exercise, time of day, listening to music, indoor vs. outdoor activities…), vary the types of exercises you do, and be creative in your selections. You may also find it helpful to keep an exercise diary where you note your activity, day and time, duration, and mood. I also think it can be very beneficial to practice mindfulness techniques during this time, even if only for a few minutes, you will begin to notice how your body responds to different stimuli which is especially important for feelings of anxiousness and other somatic symptoms.

For more motivation techniques, see my post on motivation techniques.

Some of the benefits of a regular exercise routine are increased self-esteem, community building (try incorporating at least one group physical activity), movement, and practice with goal setting.

Some ideas for different exercises (for a more extensive list including caloric output see this site):

• Morning walks – This might not be as vigorous as the others, but early morning is a great time for mindful walking. If you can get up at around sunrise, it’s a cheap light therapy which can improve your mood and help establish more regular sleep cycles. You don’t even have to change out of your pyjamas, just put on a jacket and some shoes.

• Rebounder – It’s like jumping on the bed for adults. Weights can be included in the routine. A note of caution, this may not be the most appropriate activity if you live in a basement with low ceilings, even if you’re short.

• Sledding – Some people like the snow. Run, instead of walk, back up the hill for extra exercise.

• Hair-dryer squats – I learned this from a colleague. Do squats while you’re drying your hair. It doesn’t cost any extra time from your day.

• Walk backwards and sideways on the treadmill - Because walking forwards is so passé. Also, it will work different muscle groups and improve balance.

• DDR (Dance Dance Revolution) – Put it on competition mode and press as many buttons as fast as you can.

• Sex.

• Tightrope walking – There is actually a product you can buy for your home. You can also go to an outdoor sports store and ask them what you need for zip-lining and set up the line between some trees or whatever.

• Balance beam – Turn a 2x4 on its side.

• Kitten fishing – Run around the house with a piece of string.

• Kitten chasing – Like kitten fishing, but there’s no string and the cat is running away from, instead of towards, you.

• Substitute cycling for driving or bussing once in awhile.

• Climb a tree.

• Chin-ups – There are bars you can install in your home. Or, you can see how many areas in your house you can do pull-ups off of without ripping of the moulding.

• Grocery weights – Carry your groceries with your arms fully extended. It looks funny, but is a great strengthening exercise.

• Free weights – You can pick these up cheap anywhere, but I find the Physician’s Desk Reference is a particularly effective object. Cats work well too, but you may want to feed them extra food as you get stronger.

• Hacky-sac – Old school yo.

• Ballet – Because Summer Glau does it.



References: 1, 2, 3, 4