Dysregulation of the Anxiety System & Bipolar

As per usual, I'm trying to focus on work now, but get completely derailed with a thought I feel the need (compulsively) to blog about.

I saw that someone somewhere on a remote part of the globe was reading a post I wrote a while ago postulating that fear was the first emotion to appear on the evolutionary scene. I decided to revisit it. Here's the link: http://taradeliberto.blogspot.com/2011/03/first-emotion-fear.html

While rereading the post, I had the thought that bipolar disorder may result from a dysregulation of the anxiety system. Long story short, in depression, we see that prolonged anxiety can lead to chronic sadness (via chronic exposure to cortisol and what I conceptualize as over-use of the hypothalamus-pituitary-adrenal axis). We can also see that exhilaration and anxiety are quite similar emotions. Combining these two thoughts, perhaps bipolar disorder could arise out of the dysregulation of a primary anxiety system - sometimes leading to chronic sadness and other times leading to chronic exhilaration.

Interestingly, bipolar is pretty hereditary, but like most psychiatric disorders, it is thought to be prompted by none other than stress, perhaps indicating that it stems directly from some a dysregulation of the anxiety system.

I realize that this is being done already, but the fact that stress / anxiety can trigger the onset of disorders might be a signal to look at how anxiety relates to the course of the illness (with the consideration that anxiety could be the ultimate primary emotion). In this case, while stress may trigger bipolar disorder, lack of ability to regulate anxiety may maintain the behavior. While research in which I am involved examines reward sensitivity in bipolar, I'm wondering if a layer beneath reward sensitivity is anxiety sensitivity, being that we're conceptualizing anxiety as the ultimate primary emotion in this post.

I also realize that to say anxiety dysregulation may prompt bipolar disorder because stress prompts the onset utilizes circular reasoning. But circular reasoning notwithstanding (lol), I still think this is interesting to consider anxiety sensitivity as it relates to two separate constructs of bipolar - both onset and course of the illness.

Ok, back to work.

Triggers - Avoid or Expose?

I was just thinking about the practice of identifying and avoiding triggers in therapy. Sure, inherently harmful triggers are best avoided... but what about triggers that are what we call "conditioned stimuli?"

[For the non-psychologists out there: some of us are triggered by certain things that are actually harmless, but during the course of our lives, we somehow came to associate them with feeling like crap. For instance, walking by a restaurant you used to frequent with an ex could trigger negative emotions. The restaurant itself is harmless, but you've been conditioned to feel sad when walking by it. As such, the restaurant is now a trigger.]

Some therapists may urge their patients to simply avoid all triggers. Sure, this sounds like a good idea, but is it truly helpful? If the patient is in acute / reactive pain, then throwing some more negative experiences their way probably isn't a good idea. But typically, I think that systematically exposing people to triggers, just like you would to anxiety provoking stimuli, would lead to habituation.

While this may be common practice for treating some disorders, it doesn't seem to be the case for all of them (i.e. eating disorders). For instance, when a particular food may trigger a binge, the general advice simply seems to be to avoid that food. Well, I'm just not so sure.

Yet Another Reason CBT & ACT are Compatible

Every now & again on this blog, I'm going to really dork-out and get technical. While most of the posts are certainly for the general public, this one is coming from my inner Ph.D.-student.

While folding laundry, I was ironically in my head thinking about the concept of coming into contact with the present moment. This is the thought that indirectly caused me to put my shirts in the sock drawer: CBT instructs people not to ruminate about the past or worry about the future, while ACT provides a substitute behavior (i.e. mindfully coming into contact with the present moment). In other words, roughly speaking, CBT works from the negative and ACT works from the positive in terms of action.

This is yet another reason why I think CT might be useful for some people before an ACT intervention. Allow me to explain. If you were writing a research proposal, for example, first you'd go through all of the problems with the past research and explain why it isn't sufficient. After this, you'd go onto explain exactly what you intend to do instead. Therefore, in order to make some changes on a research level, first you need to understand the problem, then you do something new. Similarly, I think cognitive techniques are useful in explaining what does not work, while ACT is really good at providing what does work.

Of course, this is not to say that out-of-the-office and on-the-spot cognitive disputation isn't ineffective. In fact, I really think it is - especially when one is either first grappling with identifying maladpative cognitions or is having a particularly difficult time. The point is that after one has identified a maladaptive cognition and worked out why it isn't effective, it is helpful to then learn what to do next (i.e. to shift into the present moment). In this way, I think ACT techniques are perfect for where CBT leaves off.

Ok, back to laundry!

Acceptance and Commitment Therapy is Officially Listed as Effective!

Great news! The United States Substance Abuse and Mental Health Services Administration (SAMHSA) has now listed Acceptance and Commitment Therapy (ACT), a therapy I practice that is based on Eastern Mindfulness techniques, as an official treatment that has been shown by research to work!!

This is part of SAMHSA'sNational Registry of Evidence-based Programs and Practices (NREPP). What a wonderful initiative. Bravo.
http://174.140.153.167/ViewIntervention.aspx?id=191&

Combining Cognitive Therapy and Mindfulness

by Tara Deliberto


I was lucky enough to have the opportunity yesterday to get together with a neuroscientist friend and colleague with whom I used to work in Cambridge, MA. Eventually we got on the topic of merging ACT & CBT and he asked some thought provoking questions I thought I would share.

The first question - and the topic of this blog post - that got me really thinking was something like: "how long does it take before an alternative rational response replaces the (long-ingrained and continually environmentally reinforced) negative & irrational automatic thoughts?" In the moment I threw out some arbitrary response based on my extensive 2.5 years of clinical experience (lol), and immediately realized I had no clue what the answer was. Being as sharp as he is, he also immediately realized (but politely pointed out) that my response was b.s. Of course it will vary for every person, but we came to the conclusion that duration of irrational thought replacement it is probably a lot longer than the literature on how quickly people respond to CBT would suggest.

While CBT can reduce symptoms in a handful of sessions - maybe around 10-15 - and CBT w/ d-cycloserine for fear reconditioning can reduce symptoms in even fewer sessions, the time it takes before negative automatic thoughts are completely replaced could widely vary. In fact, they may never disappear. Members of the ACT community actually set expectations that negative automatic thoughts never decrease in frequency (for decent reasons I won't expound upon here). Furthermore, the difference between completely disappearing and having thoughts that one relates to effectively enough to show up as a statistically v.s. clinically significant decreases in symptoms are all very different things. While clinical improvement may be apparent from research, it is likely that people continue to have intrusive thoughts (that are experienced as at least unpleasant) well after their 10-15 sessions of CBT have ended.

There are also likely varying stages of having negative automatic thoughts disappear, ranging from:
- the thought pops up, it is suppressed, and reoccurs w/ a vengeance
- the thought pops up and one struggles to restructure it w/ a rational response
- the thought pops up and one is able to quickly ward it off w/ a rational response
- the thought pops up and one immediately labels it as irrational & mindfully releases it
- the thoughts generally tend to decrease in intensity/frequency over time
- the thought is completely irradiated

Now, the question my friend asked is important because it lead us to this idea: if there is some truth to these stages, mindfully dismissing something in the moment might interfere with the practicing of retraining the mind to have different and rational responses to the thoughts.

Perhaps if one truly retrains the mind away from irrational thoughts, they will decrease in frequency, which is arguably more favorable than continually having negative intrusive thoughts pop up that one learns to relate to differently with the use of mindfulness. It should be noted, however, that mindful awareness and release of thoughts may also, as a practice, decrease the frequency of thoughts over time. At this point, everything is speculative and is simply (what I would consider to be) interesting food for thought.

While the constant use of mindfulness early in treatment may hypothetically interfere in some way w/ long-term retraining, it is certainly a very useful practice in many situations like when refocus in the moment is paramount. Being mindfully aware of thoughts also has the major benefit of preventing people from slipping back into responding to certain irrational thoughts as if they were real and/or of utility.

I know a lot of people may have an issue with framing mindfully releasing a thought in this way; however, I am not suggesting it is a form of suppression. With mindfulness of thoughts, there is an active acknowledgement and awareness of the thoughts, which separates it from suppression. However, when it is feasible, encouraging the patient to extensively retrain themselves with engaging in active grappling with irrational thoughts might be favorable before moving into a mindfulness-based approach.

It should be noted. however, that thought disputation may not be a particularly useful type of practice for people with Borderline Personality Disorder. In fact, for this population, it might be favorable to start with mindfulness of thoughts and thought defusion exercises. In fact, research I presented in 2006 at a conference in Chicago suggests that appraising thoughts might actually be a mechanism of change in Dialectical Behavior Therapy - a treatment for BPD that does not (really) use cognitive disputation. So that mindfulness of thoughts may foster their reappraisal naturally.

Can Two Useful But Contradictory Treatments be Combined?

by Tara Deliberto


In no way do I think that Acceptance and Commitment Therapy (ACT) and Cognitive Therapy (CT) are incompatible. In fact, combining techniques from both treatment modalities in a preplanned sequence has great potential.

For argument's sake, let's assume that the two treatments can be merged in a meaningful way. If they can be merged, how would we go about integrating the different techniques (we'll save integrating the philosophies for a different day)? Well, some may argue that placing an emphasis on honing the ability to catch thoughts with the use of mindfulness techniques must precede the teaching of disputing irrational thoughts. At first glance this seems logical perhaps because it is assumed that one must be mindfully aware of a thought before being able to dispute it. I'm not so sure.

Through cognitive restructuring, if patients are first made aware of the fact that their thoughts are irrational, they may have a better framework in which to do ACT work. After cognitive restructuring, they have not only identified which thoughts are dysfunctional or irrational, but have been lead through a reasoning process of why these thoughts are inaccurate. Now with a deeper understanding of why their thoughts are irrational and a clinically significant lesser degree of belief in the verity of the content of these thoughts, they could be in a better position to recognize from which cognitions are best to defuse. Speaking practically from an ACT perspective, using the chessboard metaphor as an example, patients may better be able to identify the "black" pieces from which to defuse, while still being able to maintain self-as-context (i.e. understanding that they are the chessboard that houses the battling white and black pieces). After cognitive restructuring and focusing on self-as-context, it seems to me that people have a greater fighting chance of being able to accomplish the very cerebrally taxing feat of letting thoughts float by. In short, by first providing cognitive restructuring and framing the self as a container of both rational and irrational thoughts, increased understanding, use, and efficacy of mindfulness techniques may follow.

Of course I recognize that "irrational" thoughts are not the only type of cognitions associated with negative or dysregulated affect. There are a range of painful memories, facts, images, and maybe even manic tendencies with which disputation may not be particularly effective, and whereby defusion and mindfulness may be more appropriate; however, systematically disputing the cognitions associated with negative affect that are irrational before getting into ACT work may still generally be helpful.

Thoughts?

The Common Bond Between Self-Control & Addiction: Glucose?

by Tara Deliberto

Believe it or not, glucose levels can have direct effects on your ability to control yourself. Studies done by Gailliot et al. show that slightly depleted glucose levels lead to more errors on tasks and less persistence, indicating decreased self-control. Because our natural instincts are so strong, the act of self-control over these impulses are thought to be the most mentally expensive cognitive ability.

Although we are less able to process glucose at night, some people have trouble controlling their glucose regardless of the time of day. Considering depleted glucose leads to a lack of self-control, perhaps it isn't surprising to learn that evidence suggests people who engage in criminal behavior have problems processing glucose. Along with criminal behavior, it makes sense to me that people with addictions may have similar physiological deficits.

Interestingly, there is evidence to suggest that people can actually be physiologically addicted to sugar. While one can develop a psychological addiction to almost anything, physiological addiction is indicated by the presence of a withdrawal process after the substance ceases to be used. Because the drug naloxone will induce withdrawal only if a person has a physiological addition, administering this drug tells us whether or not an addiction is present. Fascinatingly, it has been shown that giving this drug to rats consuming large quantities of glucose in fact causes withdrawal, indicating that physiological addition to sugar is possible(Colantioini et al., 2002).

Are you thinking what I'm thinking?

While it may be a stretch... perhaps over time people are negatively reinforced (this is when an aversive stimulus is taken away, not when a punishment is introduced)after eating sugar and not engaging in a problematic behaviors. They could even be positively reinforced by being able to complete a task successfully (etc) after consuming glucose. If addiction could be mediated by the inefficient processing of glucose, could increasing sugar intake work as a self-medicating impulse control process?

Although sugar consumption may act directly on the problematic system, other behaviors are most likely a result of the lack of regulation without the direct self-medicating component. For example, while drinking excessively could be used to self-medicate emotional problems, the immediate effect of drinking 15 beers is depleted glucose, not increased glucose. Although the impulsive act of drinking to excess in the first place could be partially due to a lack of glucose (with alcohol exacerbating lack of control), alcohol consumption doesn't act to solve the potential underlying problem of glucose being processed ineffciently in the way the sugar consumption may.

Any thoughts?

P.S. This is an edit from 2/15/12 - I just read a review paper by David Benton in Clinical Nutrition, 29, that suggests sucrose is not physiologically addicting in the same way substances are. Interesting.

One Argument for Measuring Decreases in Anxiety: Depression

by Tara Deliberto

This post is an augmentation of a previous post entitled "Two Thoughts on Depression: Dexamethasone Suppression Tests and Cortisol."

As stated in previous entries, Acceptance and Commitment Therapy (ACT) does not advocate conscious attempts at anxiety reduction in favor of having the client experience and work through anxiety. Although I really do think this is a useful skill for many reasons (honest! see previous posts), I would argue it is very important not to lose sight of how important long term anxiety reduction can be for the health of the patient.

We know several facts:
1. Prolonged anxiety leads to prolonged cortisol exposure
2. Prolonged cortisol exposure leads to dysfunctions of the Hypothalamic-Pituitary-Adrenal axis (HPA-axis; which is involved w/ regulating emotions)
3. HPA dysfunction can lead to depression

Along with many other reasons previously stated, because constantly experiencing anxiety rather than decreasing anxiety may lead to depression (and I'd bet other physiological problems), I would argue that treatment should include as ONE metric, measurable decreases in the experience of anxiety over time.

If that is too subjective for you, I would advocate going straight to the source and measuring early morning levels of cortisol over time. Afterall, studies such as the one published in 2005 by Portella et al. suggest that elevated morning levels of cortisol can be a *risk factor* for depression, not just an indicator of current depression. I realize this is usually only done in research and not clinical practice; however, psychology should move in the direction of making clinical decisions from hard physiological data. I don't think it is beyond reason to suggest that in the future, people should be able to go to the doctor, expectorate (aka drool) into a tube, and have their cortisol levels tested a few times a year to see if they're at risk for developing depression, one of the most costly diseases in the country that puts people at risk for death by suicide.

D-Cycloserine and Evaluative Conditioning

by Tara Deliberto

I'd like to preface this blog post by saying that I've chosen this particular medium through which to share my thoughts with you because I am able to take leaps & bounds beyond the current state of research without having it irreversibly published for eternity and marring my name. In this post, I take two budding areas of research, combine them, and proceed to *attempt* (cut me some slack!) following the combination of facts to their logical conclusion.

So here are the two budding areas of psychological research:

1) The drug D-Cycloserine (DCS) is known to help enhance behavioral unlearning during psychological treatment. For example, while a person may have learned to fear spiders and subsequently developed a spider phobia, DCS will accelerate the speed at which the person unlearns the fear of spiders during behavior therapy. In this case, behavior therapy would involve repeated exposure to spiders until the fear subsides. In addition, DCS prolongs the effects of this type of behavioral therapy. This process is theorized to work by changing cognitive associations, not necessarily conscious thoughts, over time.

2) Along w/ DCS being a very exciting new avenue of research, psychologists have developed a new type of technique called Evaluative Conditioning that implements a computer task that helps retrain the mind's associations. For example, while a person with depression associates sadness w/ themselves, repeatedly asking the person to pair a smiley face with the word "me" during a computer task will help retrain the previous association so that the person now associates happiness w/ themselves.

With these facts in mind, I would argue it is worth studying the combined effects of DCS and Evaluative Conditioning. It seems to me that DCS will probably enhance the effects of Evaluative Conditioning. Right? The idea here being: since Evaluative Conditioning is used to retrain cognitive associations and DCS has been used to facilitate exposure therapy (i.e. unlearning behavior), which is hypothesized to work via changing associations, the use of DSC w/ Evaluative Conditioning could enhance the retraining of maladaptive associations. Of note, it would most likely only work if the evaluative conditioning stimuli were potent enough to instill fear in participants as DCS only facilitates fear learning. Perhaps the fear doesn't even have to be specific to what the person's pathology is - maybe watching a scary movie beforehand would suffice.

Initially I was thinking that lessening the role of the therapist could lead to the benefit (eventually & if it worked) to decreased cost of treatment; however, paying to use the computer program along w/ the cost of the medication could be prove to be steep. In any event, if the combined effects of DCS and Evaluative Conditioning statistically outperform other methods of treatment, that fact would be useful in and of itself.

On the other hand, if the combined effects prove to be on par with similar psychological treatments, the use of either combined DCS+EC or DCS+regular therapy should be evaluated for specific use in different populations. For example, people w/ autism may respond better to DCS+EC than DCS+regular therapy because of the removed social component. I do realize, though, that one could argue that removing the social component of treatment for people w/ autism could be detrimental because social interaction could facilitate increased social skill. However, to get rid of a troublesome fears quickly, a combined DCS+EC treatment could theoretically be useful. Furthermore, in addition to DCS+EC, a separate targeted social intervention treatment would probably be called for.

More Cognitive Defusion vs Cognitive Reappraisal Thoughts

by Tara Deliberto

Note: It may be best to read the post immediately prior to this one first, "Quibbles with Acceptance and Commitment Therapy."

Topic: Currently, Acceptance and Commitment Therapy completely rejects the use of thought manipulation techniques used in Cognitive Therapy in favor of meditative mindfulness techniques.

Thoughts: It seems like the next line of research in psychological treatment should focus on the implementation of specific techniques for specific problems (a`la Barlow's unified treatment protocol). Being that cognitive reappraisal (CR) and cognitive defusion (CD) are, in fact, two different techniques, I've simply been wondering (and I'm sure I'm not alone) whether or not one technique can be more useful than the other in certain situations.

[definitions: CR = a technique used in Cognitive Therapy that involves monitoring and evaluating negative thoughts and replacing them with positive thoughts/images; CD = a technique used in Acceptance and Commitment Therapy that involves deliteralizing the meaning of thoughts by actively "observing thoughts as thoughts" and recognizing that all thoughts may not be true ]

For the sake of providing an example, while CR may be more effective during moments of anhedonia (inability to experience pleasure) in that it could get the client actively engaged in positive thinking [which may or may not enable the person to engage in active behavior but I would argue, decreases suffering in the present moment], CD may be more suitable for moments of anxiety in that it has the quiet quality of observing and focus on being present while anxiety arouses people and can cause a lack of presence. I use the term "moments" here in order to highlight that comorbidity of anxiety and depression is common and implementing the different tools at different times for the same person may be beneficial. Simply, I think that abandoning cognitive therapy (CT) techniques such as CR completely without conclusive research indicating one method is superior in all cases to the other is premature.

Referring back to the comment about decreasing suffering by using CR as a technique for people w/ anhedonia: On a slightly more theoretical note, I have been struggling with the idea of whether or not the primary/ultimate goal of therapy should be on helping the person to live life in accordance with ones values as in Acceptance and Commitment Therapy (ACT) or to decrease the net amount of life suffering. Perhaps decreasing the total amount of life suffering should be done through helping the person live life in accordance with ones values. As per my previous post, I think that perhaps behaviorally activating by living life in accordance with one's values should decrease long-term suffering and shouldn't be an end in itself. Perhaps, somewhat ironically, if the client concentrates on symptom reduction as the end goal of behavioral activation (BA), less symptom reduction could possibly occur. With the mindset that engaging in BA will lead to symptom reduction, if the effects are not immediate, the person may abandon the strategy. Because ACT encourages people to engage in BA regardless of outcome, the person may be more likely to continue engaging in BA as a result of a lack of discouragement about immediate results; however, I would argue that it is important not to lose sight of the fact that decreasing suffering should be the ultimate goal, even if it is not presented to the client in this light. I fear the mindset that decreasing suffering or increasing positive emotion isn't important may lead to the rejection useful techniques such as CR that may help the person lead life in accordance with their values.

[definition: BA = getting the client to engage in meaningful behavior; this technique is now thought to be the most potent component across various forms of psychological treatments]

From a funcitonal perspective (and in keeping with the thoughts expressed in me previous blog post about the endogenous reward system) it seems that both thinking positively through CR and BA can activate the reward system in the brain. My guess is that BA would be more potent than changing a negative thought to a positive one, but both could produce similar effects- reward via positive reinforcement in the form of opioids. While BA and CR may work through positive reinforcement, CD may work through negative reinforcement- taking an aversive stimulus away (NOT to be confused with introducing a punishment). By distancing oneself from a negative thought, the aversiveness is decreased. If viewed in the light that both CR/BA and CD work on reinforcement schedules by decreasing suffering, the notion that it isn't important to decrease suffering in therapy no longer makes much sense to me.

It is worth noting that while BA releases opioids, it may not necessarily equate a feeling of happiness, and therefore a direct reward in the form of positive reinforcement. From a more biological perspective, during BA, the release of opioids may not result in an overall emotion of happiness, but perhaps their release has effects on a subconscious level (for lack of a better term). I'm trying to get at the essence of what maintains a behavior biologically. I implicate opioids, but it may be any known or unknown substance in the brain that is released during BA that helps form associations between action and reward (see the part Endogenous Reward System post pertaining to feedback loops).

From a psychological perspective, I would argue that although BA may not lead directly to a feeling of happiness (i.e. when a person with depression first gets off the couch, it is dreadful), it may still be maintained via positive reinforcement because by behaviorally activating, one is living life in accordance w/ ones values, which may lead to a more abstract reward than feeling intense bodily pleasure in the moment. I'm sure physiologists and hard scientists may have a problem with this view; however, my stance is one of actually erring on the side of pure biology. I think that all thoughts are biological - even the more abstract ones that science has yet to understand. I would argue that a biological reward must exist even for the experience and consequent emotions of abstract thought. After all, when biological brain tissue dies, so does abstract thought.

A Few Quibbles with Acceptance and Commitment Therapy

by Tara Deliberto

In a recent lab meeting, I was engaged in a discussion of the paradigm shift between the focus of therapy being symptom reduction, as seen in other therapies (i.e. cognitive-behavioral therapy), towards helping the client to live a life in accordance with their values, as in ACT. The irresolution of an argument centering on this point prompted me to write this entry.

In ACT there is not only an emphasis on living life in accordance with one’s values, but it seems a fairly outright denunciation of attempting to control or manipulate thoughts as a form of emotion regulation. Although I am aware of the research indicating thought/expressive suppression is an unsuccessful method of controlling thoughts/emotions, often resulting in increases in the targeted thoughts/emotions, there is evidence to suggest that cognitive reappraisal, the revaluation of negative thoughts, is effective (in fact, I presented research at the Associations for Behavioral and Cognitive Therapies conference in 2006 on cognitive reappraisal being a potential mechanism of change in intensive DBT). I understand that because attempts at suppressing thoughts are futile, as a therapist one should not encourage this; however, I do not understand what appears to possibly be an overgeneralization to advise against ever attempting forms of thought manipulation, especially when reappraising cognitions appears to be beneficial [If this blog entry were actual dialogue, this would be the point where I may get into a semantics discussion with ACT practitioners about the word “beneficial.” Although this word was previously used in reference to symptom reduction, I would argue that it is safe to say that using cognitive reappraisal as a tool can also help one to lead a life in accordance with one’s values.].

That is not to say, of course, that cognitive reappraisal should be a focus of the treatment or that mindfulness should be abandoned. Quite the opposite. I am merely suggesting that perhaps all attempts at thought/emotion manipulation should not be abandoned. Perhaps mindfulness can be used as a tool the majority of the time for some problems whereas cognitive reappraisal can be used as a tool occasionally for other types.

Of note, I have come to conceptualize two types of mindfulness, which may be incorrect, but here they are:
1) allowing oneself to fully experience a thought/emotion without attempt at suppression
2) allowing oneself to view thoughts/emotions objectively as thoughts/emotion

I realize the following thought is not original; however, it may be worth noting here that the first conceptualization of mindfulness may be effective through means similar to that of exposure. Basically, if one stops avoiding or attempting to avoid the emotion, it is learned that the emotion can be experienced and survived.

I have not previously heard interpretations of why I think the second type of mindfulness may be effective. I realize that while mindfulness and defusion are separate concepts, perhaps mindfulness facilitates defusion, the process of observing thoughts as thoughts. Through mindfulness practices such as watching our thoughts float by, maybe we are essentially creating distance with our thoughts. This distance may help facilitate a non-judgmental stance of one’s thoughts. I was attempting to make the point that maybe the non-judgmental quality of viewing thoughts in essence may be a “reappraisal” of the thoughts in that they no longer hold a negative valence (not that they are being judged as positive, per se). At the end of the process of cognitive reappraisal, thoughts also no longer hold negative valences. Perhaps the reasons why mindfulness & cognitive defusion along with cognitive reappraisal seem to be effective could be similar, not that they are necessarily the same process. In short, these processes may achieve similar ends through different means. I do, however, suspect that mindfulness probably achieves these means in a more effective manner. Because people with emotional disorders are in the habit of attempting to suppress thoughts while healthy controls are more able to accept their negative emotions and function in society, an approach geared away from thought manipulation in general may be appropriate.

In addition, I am aware that in light of the recent literature suggesting that behavioral activation- simply put, carrying out daily activities despite symptoms- is a main mechanism of change in many psychological treatments, all the talk of cognitions seems futile; however, I think it is necessary. It is interesting that behavioral activation is so closely in line with the goal of ACT: living life towards ones values in the context of one’s symptoms. With this as a treatment goal, one is essentially turning the client’s attention away from thought/emotional suppression and gearing them to behaviorally activate. The “gearing” or framework in which the behavioral activation is nestled may be the determining factor in whether or not one actually begins to behaviorally activate or start living life in accordance with one’s values. Therefore packaging behavioral activation in ACT with mindfulness may be more useful than packaging it with the cognitive (and other) pieces of cognitive behavioral therapy. It is also of note that while in cognitive-behavioral/behavioral therapy, behavioral activation is the means through which symptoms are reduced, in ACT, the goal is to behaviorally activate without necessary symptom reduction. It is possible that gearing the therapy without the expectation of symptom reduction, as in ACT, may actually result in greater symptom reduction than CBT for some people. Again, this could possibly be because people with emotional disorders are constantly struggling with control and suppression of thoughts/emotions so that when they are in a context encouraging them to largely give up control, behavioral activation could be facilitated more so than in a treatment focused on symptom reduction.

Two Thoughts on Depression: Dexamethasone Suppression Tests and Cortisol

by Tara Deliberto

Cortisol and Depression:

1) The research on depression shows us that when dexamethasone is administered to people w/ depression and controls, people with depression do not show a decrease in their cortisol levels unlike their non-depressed counter-parts. In addition, we know that increased glucocorticoids such as cortisol increases the susceptibility of the brain (Gubba et al 2000; Sapolsky, 1985). Judging from these facts, it seems to me that people with a predisposition to non-suppression of cortisol who are on long term steroid treatment (i.e. people w/rheumatoid arthritis taking prednisone), could end up with depression because of prolonged exposure to cortisol as a side effect from the drug.

2) We also know that people with depression have higher levels of early morning cortisol. Although people w/ depression may have trouble suppressing cortisol in general, perhaps the early morning elevations of cortisol could, in part, simply have to do with having bad dreams. Chronically high level of cortisol produced during sleep could possibly lead to a dysfunctional HPA axis (hypothalamic-pituitary-adrenal axis - part of the neuroendocrine system that helps regulate stress). If this could be the case, perhaps treating people with prodromal depression/ depression with both drugs that have been shown to decrease production of nocturnal cortisol (probably through the decreased occurrence of nightmares) and perhaps even training in lucid dreaming or relaxation may be useful. Because high levels of anxiety can lead to prolonged problems, unlike many of my Acceptance and Commitment Therapy counterparts, I would argue that stress reduction training can be a very useful long term benefit.

In other words, since we know that prolonged anxiety leads to prolonged cortisol exposure, which could lead to dysfunction of the HPA axis, which leads to depression... maybe we shouldn't discount trying to decrease anxiety!