Staying Awake: The Surprisingly Effective Way to Treat Depression

Heathline Article

The first sign that something is happening is Angelina’s hands. As she chats to the nurse in Italian, she begins to gesticulate, jabbing, moulding and circling the air with her fingers. As the minutes pass and Angelina becomes increasingly animated, I notice a musicality to her voice that I’m sure wasn’t there earlier. The lines in her forehead seem to be softening, and the pursing and stretching of her lips and the crinkling of her eyes tell me as much about her mental state as any interpreter could.Angelina is coming to life, precisely as my body is beginning to shut down. It’s 2am, and we’re sat in the brightly lit kitchen of a Milanese psychiatric ward, eating spaghetti. There’s a dull ache behind my eyes, and I keep on zoning out, but Angelina won’t be going to bed for at least another 17 hours, so I’m steeling myself for a long night. In case I doubted her resolve, Angelina removes her glasses, looks directly at me, and uses her thumbs and forefingers to pull open the wrinkled, grey-tinged skin around her eyes. “Occhi aperti,” she says. Eyes open.This is the second night in three that Angelina has been deliberately deprived of sleep. For a person with bipolar disorder who has spent the past two years in a deep and crippling depression, it may sound like the last thing she needs, but Angelina – and the doctors treating her – hope it will be her salvation. For two decades, Francesco Benedetti, who heads the psychiatry and clinical psychobiology unit at San Raffaele Hospital in Milan, has been investigating so-called wake therapy, in combination with bright light exposure and lithium, as a means of treating depression where drugs have often failed. As a result, psychiatrists in the USA, the UK and other European countries are starting to take notice, launching variations of it in their own clinics. These ‘chronotherapies’ seem to work by kick-starting a sluggish biological clock; in doing so, they’re also shedding new light on the underlying pathology of depression, and on the function of sleep more generally.“Sleep deprivation really has opposite effects in healthy people and those with depression,” says Benedetti. If you’re healthy and you don’t sleep, you’ll feel in a bad mood. But if you’re depressed, it can prompt an immediate improvement in mood, and in cognitive abilities. But, Benedetti adds, there’s a catch: once you go to sleep and catch up on those missed hours of sleep, you’ll have a 95 per cent chance of relapse.The antidepressant effect of sleep deprivation was first published in a report in Germany in 1959. This captured the imagination of a young researcher from Tübingen in Germany, Burkhard Pflug, who investigated the effect in his doctoral thesis and in subsequent studies during the 1970s. By systematically depriving depressed people of sleep, he confirmed that spending a single night awake could jolt them out of depression.

Benedetti became interested in this idea as a young psychiatrist in the early 1990s. Prozac had been launched just a few years earlier, hailing a revolution in the treatment of depression. But such drugs were rarely tested on people with bipolar disorder. Bitter experience has since taught Benedetti that antidepressants are largely ineffective for people with bipolar depression anyway.

His patients were in desperate need of an alternative, and his supervisor, Enrico Smeraldi, had an idea up his sleeve. Having read some of the early papers on wake therapy, he tested their theories on his own patients, with positive results. “We knew it worked,” says Benedetti. “Patients with these terrible histories were getting well immediately. My task was finding a way of making them stay well.”

So he and his colleagues turned to the scientific literature for ideas. A handful of American studies had suggested that lithium might prolong the effect of sleep deprivation, so they investigated that. They found that 65 per cent of patients taking lithium showed a sustained response to sleep deprivation when assessed after three months, compared to just 10 per cent of those not taking the drug.

Since even a short nap could undermine the efficacy of the treatment, they also started searching for new ways of keeping patients awake at night, and drew inspiration from aviation medicine, where bright light was being used to keep pilots alert. This too extended the effects of sleep deprivation, to a similar extent as lithium.

“We decided to give them the whole package, and the effect was brilliant,” says Benedetti. By the late 1990s, they were routinely treating patients with triple chronotherapy: sleep deprivation, lithium and light. The sleep deprivations would occur every other night for a week, and bright light exposure for 30 minutes each morning would be continued for a further two weeks – a protocol they continue to use to this day. “We can think of it not as sleep-depriving people, but as modifying or enlarging the period of the sleep–wake cycle from 24 to 48 hours,” says Benedetti. “People go to bed every two nights, but when they go to bed, they can sleep for as long as they want.”

San Raffaele Hospital first introduced triple chronotherapy in 1996. Since then, it has treated close to a thousand patients with bipolar depression – many of whom had failed to respond to antidepressant drugs. The results speak for themselves: according to the most recent data, 70 per cent of people with drug-resistant bipolar depression responded to triple chronotherapy within the first week, and 55 per cent had a sustained improvement in their depression one month later.

And whereas antidepressants – if they work – can take over a month to have an effect, and can increase the risk of suicide in the meantime, chronotherapy usually produces an immediate and persistent decrease in suicidal thoughts, even after just one night of sleep deprivation.

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Angelina was first diagnosed with bipolar disorder 30 years ago, when she was in her late 30s. The diagnosis followed a period of intense stress: her husband was facing a tribunal at work, and they were worried about having enough money to support themselves and the kids. Angelina fell into a depression that lasted nearly three years. Since then, her mood has oscillated, but she’s down more often than not. She takes an arsenal of drugs – antidepressants, mood stabilisers, anti-anxiety drugs and sleeping tablets – which she dislikes because they make her feel like a patient, even though she acknowledges this is what she is.

If I’d met her three days ago, she says, it’s unlikely I would have recognised her. She didn’t want to do anything, she’d stopped washing her hair or wearing make-up, and she stank. She also felt very pessimistic about the future. After her first night of sleep deprivation, she’d felt more energetic, but this largely subsided after her recovery sleep. Even so, today she felt motivated enough to visit a hairdresser in anticipation of my visit. I compliment her appearance, and she pats her dyed, golden waves, thanking me for noticing.

At 3am, we move to the light room, and entering is like being transported forward to midday. Bright sunlight streams in through the skylights overhead, falling on five armchairs, which are lined up against the wall. This is an illusion, of course – the blue sky and brilliant sun are nothing more than coloured plastic and a very bright light – but the effect is exhilarating nonetheless. I could be sitting on a sun lounger at midday; the only thing missing is the heat.

When I’d interviewed her seven hours earlier, with the help of an interpreter, Angelina’s face had remained expressionless as she’d replied. Now, at 3.20am, she is smiling, and even beginning to initiate a conversation with me in English, which she’d claimed not to speak. By dawn, Angelina’s telling me about the family history she’s started writing, which she’d like to pick up again, and inviting me to stay with her in Sicily.

How could something as simple as staying awake overnight bring about such a transformation? Unpicking the mechanism isn’t straightforward: we still don’t fully understand the nature of depression or the function of sleep, both of which involve multiple areas of the brain. But recent studies have started to yield some insights.

The brain activity of people with depression looks different during sleep and wakefulness than that of healthy people. During the day, wake-promoting signals coming from the circadian system – our internal 24-hour biological clock – are thought to help us resist sleep, with these signals being replaced by sleep-promoting ones at night. Our brain cells work in cycles too, becoming increasingly excitable in response to stimuli during wakefulness, with this excitability dissipating when we sleep. But in people with depression and bipolar disorder, these fluctuations appear dampened or absent.

Depression is also associated with altered daily rhythms of hormone secretion and body temperature, and the more severe the illness, the greater the degree of disruption. Like the sleep signals, these rhythms are also driven by the body’s circadian system, which itself is driven by a set of interacting proteins, encoded by ‘clock genes’ that are expressed in a rhythmic pattern throughout the day. They drive hundreds of different cellular processes, enabling them to keep time with one another and turn on and off. A circadian clock ticks in every cell of your body, including your brain cells, and they are coordinated by an area of the brain called the suprachiasmatic nucleus, which responds to light.

“When people are seriously depressed, their circadian rhythms tend to be very flat; they don’t get the usual response of melatonin rising in the evening, and the cortisol levels are consistently high rather than falling in the evening and the night,” says Steinn Steingrimsson, a psychiatrist at Sahlgrenska University Hospital in Gothenburg, Sweden, who is currently running a trial of wake therapy.

Recovery from depression is associated with a normalisation of these cycles. “I think depression may be one of the consequences of this basic flattening of circadian rhythms and homeostasis in the brain,” says Benedetti. “When we sleep-deprive depressed people, we restore this cyclical process.”

But how does this restoration come about? One possibility is that depressed people simply need added sleep pressure to jump-start a sluggish system. Sleep pressure – our urge to sleep – is thought to arise because of the gradual release of adenosine in the brain. It builds up throughout the day and attaches to adenosine receptors on neurons, making us feel drowsy. Drugs that trigger these receptors have the same effect, whereas drugs that block them – such as caffeine – make us feel more awake.

To investigate whether this process might underpin the antidepressant effects of prolonged wakefulness, researchers at Tufts University in Massachusetts took mice with depression-like symptoms and administered high doses of a compound that triggers adenosine receptors, mimicking what happens during sleep deprivation. After 12 hours, the mice had improved, measured by how long they spent trying to escape when forced to swim or when suspended by their tails.

We also know sleep deprivation does other things to the depressed brain. It prompts changes in the balance of neurotransmitters in areas that help to regulate mood, and it restores normal activity in emotion-processing areas of the brain, strengthening connections between them.

And as Benedetti and his team discovered, if wake therapy kick-starts a sluggish circadian rhythm, lithium and light therapy seem to help maintain it. Lithium has been used as a mood stabiliser for years without anyone really understanding how it works, but we know it boosts the expression of a protein, called Per2, that drives the molecular clock in cells.

Bright light, meanwhile, is known to alter the rhythms of the suprachiasmatic nucleus, as well as boosting activity in emotion-processing areas of the brain more directly. Indeed, the American Psychiatric Association states that light therapy is as effective as most antidepressants in treating non-seasonal depression.

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© Eva Bee for Mosaic

In spite of its promising results against bipolar disorder, wake therapy has been slow to catch on in other countries. “You could be cynical and say it’s because you can’t patent it,” says David Veale, a consultant psychiatrist at the South London and Maudsley NHS Foundation Trust.

Certainly, Benedetti has never been offered pharmaceutical funding to carry out his trials of chronotherapy. Instead, he has – until recently – been reliant on government funding, which is often in short supply. His current research is being funded by the EU. Had he followed the conventional route of accepting industry money to run drug trials with his patients, he quips, he probably wouldn’t be living in a two-bedroom apartment and driving a 1998 Honda Civic.

The bias towards pharmaceutical solutions has kept chronotherapy below the radar for many psychiatrists. “A lot of people just don’t know about it,” says Veale.

It’s also difficult to find a suitable placebo for sleep deprivation or bright light exposure, which means that large, randomised placebo-controlled trials of chronotherapy haven’t been done. Because of this, there’s some scepticism about how well it really works. “While there is increasing interest, I don’t think many treatments based on this approach are yet routinely used – the evidence needs to be better and there are some practical difficulties in implementing things like sleep deprivation,” says John Geddes, a professor of epidemiological psychiatry at the University of Oxford.

Even so, interest in the processes underpinning chronotherapy is beginning to spread. “Insights into the biology of sleep and circadian systems are now providing promising targets for treatment development,” says Geddes. “It goes beyond pharmaceuticals – targeting sleep with psychological treatments might also help or even prevent mental disorders.”

In the UK, the USA, Denmark and Sweden, psychiatrists are investigating chronotherapy as a treatment for general depression. “A lot of the studies that have been done so far have been very small,” says Veale, who is currently planning a feasibility study at Maudsley Hospital in London. “We need to demonstrate that it is feasible and that people can adhere to it.”

So far, what studies there have been have produced mixed results. Klaus Martiny, who researches non-drug methods for treating depression at the University of Copenhagen in Denmark, has published two trials looking at the effects of sleep deprivation, together with daily morning bright light and regular bedtimes, on general depression. In the first study, 75 patients were given the antidepressant duloxetine, in combination with either chronotherapy or daily exercise. After the first week, 41 per cent of the chronotherapy group had experienced a halving of their symptoms, compared to 13 per cent of the exercise group. And at 29 weeks, 62 per cent of the wake therapy patients were symptom-free, compared to 38 per cent of those in the exercise group.

In Martiny’s second study, severely depressed hospital inpatients who had failed to respond to antidepressant drugs were offered the same chronotherapy package as an add-on to the drugs and psychotherapy they were undergoing. After one week, those in the chronotherapy group improved significantly more than the group receiving standard treatment, although in subsequent weeks the control group caught up.

No one has yet compared wake therapy head-to-head with antidepressants; neither has it been tested against bright light therapy and lithium alone. But even if it’s only effective for a minority, many people with depression – and indeed psychiatrists – may find the idea of a drug-free treatment attractive.

“I’m a pill pusher for a living, and it still appeals to me to do something that doesn’t involve pills,” says Jonathan Stewart, a professor of clinical psychiatry at Columbia University in New York, who is currently running a wake therapy trial at New York State Psychiatric Institute.

Unlike Benedetti, Stewart only keeps patients awake for one night: “I couldn’t see a lot of people agreeing to stay in hospital for three nights, and it also requires a lot of nursing and resources,” he says. Instead, he uses something called sleep phase advance, where on the days after a night of sleep deprivation, the time the patient goes to sleep and wakes up is systematically brought forward. So far, Stewart has treated around 20 patients with this protocol, and 12 have shown a response – most of them during the first week.

It may also work as a prophylactic: recent studies suggest that teenagers whose parents set – and manage to enforce – earlier bedtimes are less at risk of depression and suicidal thinking. Like light therapy and sleep deprivation, the precise mechanism is unclear, but researchers suspect a closer fit between sleep time and the natural light–dark cycle is important.

But sleep phase advance has so far failed to hit the mainstream. And, Stewart accepts, it’s not for everybody. “For those for whom it works, it’s a miracle cure. But just as Prozac doesn’t get everyone better who takes it, neither does this,” he says. “My problem is that I have no idea ahead of time who it’s going to help.”

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Depression can strike anyone, but there’s mounting evidence that genetic variations can disrupt the circadian system to make certain people more vulnerable. Several clock gene variations have been associated with an elevated risk of developing mood disorders.

Stress can then compound the problem. Our response to it is largely mediated through the hormone cortisol, which is under strong circadian control, but cortisol itself also directly influences the timing of our circadian clocks. So if you have a weak clock, the added burden of stress could be enough to tip your system over the edge.

Indeed, you can trigger depressive symptoms in mice by repeatedly exposing them to a noxious stimulus, such as an electric shock, from which they can’t escape – a phenomenon called learned helplessness. In the face of this ongoing stress, the animals eventually just give up and exhibit depression-like behaviours. When David Welsh, a psychiatrist at the University of California, San Diego, analysed the brains of mice that had depressive symptoms, he found disrupted circadian rhythms in two critical areas of the brain’s reward circuit – a system that’s strongly implicated in depression.

Staying awake: the surprisingly effective way to treat depression
© Eva Bee for Mosaic

But Welsh has also shown that a disturbed circadian system itself can cause depression-like symptoms. When he took healthy mice and knocked out a key clock gene in the brain’s master clock, they looked just like the depressed mice he’d been studying earlier. “They don’t need to learn to be helpless, they are already helpless,” Welsh says.

So if disrupted circadian rhythms are a likely cause of depression, what can be done to prevent rather than treat them? Is it possible to strengthen your circadian clock to increase psychological resilience, rather than remedy depressive symptoms by forgoing sleep?

Martiny thinks so. He is currently testing whether keeping a more regular daily schedule could prevent his depressed inpatients from relapsing once they’ve recovered and are released from the psychiatric ward. “That’s when the trouble usually comes,” he says. “Once they’re discharged their depression gets worse again.”

Peter is a 45-year-old care assistant from Copenhagen who has battled with depression since his early teens. Like Angelina and many others with depression, his first episode followed a period of intense stress and upheaval. His sister, who more or less brought him up, left home when he was 13, leaving him with an uninterested mother and a father who also suffered from severe depression. Soon after that, his father died of cancer – another shock, as he’d kept his prognosis hidden until the week before his death.

Peter’s depression has seen him hospitalised six times, including for a month last April. “In some ways being in hospital is a relief,” he says. However, he feels guilty about the effect it has on his sons, aged seven and nine. “My youngest boy said he cried every night I was in hospital, because I wasn’t there to hug him.”

So when Martiny told Peter about the study he had just started recruiting for, he readily agreed to participate. Dubbed ‘circadian-reinforcement therapy’, the idea is to strengthen people’s circadian rhythms by encouraging regularity in their sleep, wake, meal and exercise times, and pushing them to spend more time outdoors, exposed to daylight.

For four weeks after leaving the psychiatric ward in May, Peter wore a device that tracked his activity and sleep, and he completed regular mood questionnaires. If there was any deviation in his routine, he would receive a phone call to find out what had happened.

When I meet Peter, we joke about the tan lines around his eyes; obviously, he’s been taking the advice seriously. He laughs: “Yes, I’m getting outdoors to the park, and if it’s nice weather, I take my children to the beach, for walks, or to the playground, because then I will get some light, and that improves my mood.”

Those aren’t the only changes he’s made. He now gets up at 6 every morning to help his wife with the children. Even if he’s not hungry he eats breakfast: typically, yoghurt with muesli. He doesn’t take naps and tries to be in bed by 10pm. If Peter does wake up at night, he practises mindfulness – a technique he picked up in hospital.

Martiny pulls up Peter’s data on his computer. It confirms the shift towards earlier sleep and wake times, and shows an improvement in the quality of his sleep, which is mirrored by his mood scores. Immediately after his release from hospital, these averaged around 6 out of 10. But after two weeks they’d risen to consistent 8s or 9s, and one day, he even managed a 10. At the beginning of June, he returned to his job at the care home, where he works 35 hours a week. “Having a routine has really helped me,” he says.

Staying awake: the surprisingly effective way to treat depression
© Eva Bee for Mosaic

So far, Martiny has recruited 20 patients to his trial, but his target is 120; it’s therefore too soon to know how many will respond the same way as Peter, or indeed, if his psychological health will be maintained. Even so, there’s mounting evidence that good sleep routine can help our mental wellbeing. According to a study published in Lancet Psychiatry in September 2017 – the largest randomised trial of a psychological intervention to date – insomniacs who underwent a ten-week course of cognitive behavioural therapy to address their sleep problems showed sustained reductions in paranoia and hallucinatory experiences as a result. They also experienced improvements in symptoms of depression and anxiety, fewer nightmares, better psychological wellbeing and day-to-day functioning, and they were less likely to experience a depressive episode or anxiety disorder during the course of the trial.

Sleep, routine and daylight. It’s a simple formula, and easy to take for granted. But imagine if it really could reduce the incidence of depression and help people to recover from it more quickly. Not only would it improve the quality of countless lives, it would save health systems money.

In the case of wake therapy, Benedetti cautions that it isn’t something people should try to administer to themselves at home. Particularly for anyone who has bipolar disorder, there’s a risk of it triggering a switch into mania – although in his experience, the risk is smaller than that posed by taking antidepressants. Keeping yourself awake overnight is also difficult, and some patients temporarily slip back into depression or enter a mixed mood state, which can be dangerous. “I want to be there to speak about it to them when it happens,” Benedetti says. Mixed states often precede suicide attempts.

A week after spending the night awake with Angelina, I call Benedetti to check her progress. He tells me that after the third sleep deprivation, she experienced a full remission in her symptoms and returned to Sicily with her husband. That week, they were due to be marking their 50th wedding anniversary. When I’d asked her if she thought her husband would notice any change in her symptoms, she’d said she hoped he’d notice the change in her physical appearance.

Hope. After she has spent more than half her life without it, I suspect its return is the most precious golden anniversary gift of all.

This article first appeared on Mosaic and is republished here under a Creative Commons licence.

You are familiar with gas lighting where we twist reality over and over again in order to create doubt. You begin to question yourself, doubt your recollection and feel like you are losing your sanity. 593 more words

via The Terrible Gaslighting Twenty — Knowing the Narcissist

It is a well known fact that those that suffer from PTSD are at a much higher risk for falling into substance abuse. Many people with PTSD often find themselves going for the bottle or something else harmful to help quickly find relief from their pain. But could early substance abuse actually lead to PTSD? […]

via Could Substance Abuse be Causing PTSD? — Beva’s PTSD Blog

The Wolf In Sheep’s Clothing: How To Spot A Covert Narcissist And The One Thing That Always Gives Them Away

See ThoughtCatalog Article Here
By Shahida Arabi

The term “wolf in sheep’s clothing” has biblical origins and is used to describe someone who pretends to be outwardly innocent and harmless. However, within, they are predatory “wolves,” ready to devour their prey. Who they present themselves to be is far different from who they truly are. Many wolves in sheep’s clothing disguise themselves as upstanding citizens and pillars of their community, all while they commit heinous crimes behind closed doors.

I’ve come across many convincing predators in my lifetime, but perhaps none are more skilled and dangerous than the proverbial wolf in sheep’s clothing. This term’s origins goes as far back as the bible: “Beware of false prophets, which come to you in sheep’s clothing, but inwardly they are ravening wolves” (Matthew 7:15). It is used to describe those who appear to be harmless but are actually sneaky, conniving saboteurs looking to fulfill their own selfish agenda at the expense of everyone else’s rights.

This term is quite fitting for the toxic manipulators, covert narcissists or sociopaths who dress themselves as innocent, charitable people while committing unspeakable acts of violence behind closed doors. These predators can come across as agreeable, kind, successful, giving, even shy, insecure and introverted; they can also have a deeply seductive charisma that draws people into their toxicity. Yet their glowing public image is no match for their nefarious private deeds. These wolves lurk anywhere and everywhere, waiting to ensnare their victims into their twisted web.

Another word for the wolf in sheep’s clothing is “the covert aggressor.” Dr. George Simon, the author of In Sheep’s Clothing: Understanding And Dealing With Manipulative People, notes:

“If you’re dealing with a person who rarely gives you a straight answer to a straight question, is always making excuses for doing hurtful things, tries to make you feel guilty, or uses any of the other tactics to throw you on the defensive and get their way, you can assume you’re dealing with a person who — no matter what else he may be — is covertly aggressive.”

There is no limit to where these covert manipulators and aggressors can be found. They may be drawn to careers that distinguish them as givers rather than takers, but ultimately, their own self-interest takes precedent over the welfare of any of the people they purport to help.

They could be the head therapist of a counseling center; they may be the pastors at your church, the leaders of altruistic companies, passionate advocates of the local charity. They could be the seemingly benevolent social worker, the compassionate teacher, the seemingly selfless counselor.

According to Dr. Martha Stout, author of The Sociopath Next Door, covert manipulators rely on our empathic nature to get us to fall for them. They prey on our sympathy and our compassion, our willingness to give toxic people the benefit of the doubt. That is why wolves in sheep’s clothing get away with their behavior, time and time again.

Yet there is one thing that can distinguish them early on.

Aside from their use of pity to make you feel sorry for them and their inability to correct their toxic behavior or own up to it, there is one thing I’ve noticed that consistently exposes wolves in sheep’s clothing and differentiates them from those who are genuine. This can help distinguish them even in the early onset of any sort of relationship or interaction with them.

Contempt. 

Initially when a wolf in sheep’s clothing tries to “groom” you into making you their victim, they may act humble, generous, soft-spoken. They are heavy-handed with their compliments, their praise and their laser-focused attention (also known as love-bombing). They are seemingly empathic. Yet their true self is always eventually revealed once you get closer to them and actually realize they lack the emotional equipment to follow through with their promises or perceived character.

If you observe a manipulator closely, they always display micro-signals of contempt when they are speaking. No matter how hard they try to disguise these beneath their façade, their disgust for the human race and the silly “morals” of lesser mortals seeps through every pore of their skin, every shift in their tone, every twitch in their gestures. It seeps through their proposed principles and exposes their real feelings. It finds its way into their rhetoric and the ways in which they talk about the world, the way they speak about others, and eventually, the ways in which they’ll come to speak about you.

Whenever you’re in the presence of a ravenous wolf, you will at some point notice a look of disdain, or a haughty tone of voice when they talk about people they consider “beneath” them. It’s the air of perceived superiority that distinguishes them – and they can’t keep the mask on for long, either.

They may suddenly speak rudely about a friend who they once praised (who you later find out they are envious of); they may abruptly devolve into a scathing manifesto about the waiter who ‘failed’ to give them the right order; they may suddenly start to attack an ex-girlfriend or ex-boyfriend who left them with a shocking hostility that seems altogether out of place with their sweet nature.

You may witness them giving the cold shoulder or cruel, undeserving reprimands to the people who have been nothing but kind and loyal to them. And undoubtedly, you will be placed next in their queue of unsuspecting victims.

When the person who once soothed you with sweet nothings, grand gestures and loving support morphs into a person who is speaking with excessive hatred or disdain for people they don’t know, or people who they do know all too well, watch out. You’re probably in the presence of someone who will one day look down upon you, too.

Contempt is also prominent throughout the abuse cycle with a covert wolf. In the devaluation phase of any relationship with a narcissist, this type of perpetrator who once made you feel like you were the only one in the room – suddenly swoops you off the pedestal and makes you beg for their approval.

They do this by dishing out intense contempt and dislike targeted towards you periodically throughout the relationship.

Where once they couldn’t get enough of your personality, your talents, your attention, now they act as if everything you do makes you beneath them. They once celebrated your achievements; now they act as if you are a burden.

They pin the blame on you for things that were their fault. When you speak out or protest their unfair behavior, they make you out to be the “troublemaker” when you are actually just the truth-teller. They blindside you by making you the scapegoat, the black sheep they must persecute and devalue so no one realizes it is they who are the wolves in sheep’s clothing.

Wolves are out for blood, for live prey, and malignant narcissists are no different. They will treat you appallingly once they’ve gotten you hooked on their praise and presence.

They will treat you are like you are nothing to them, even though they initially pretended you were everything.

To wean yourself off from any sense of self-blame you may be feeling, remember that the way a predatory individual idealized you and any other victim is temporary – it is used as bait.

Once wolves have trapped their prey, they have no mercy in devouring you. This is just their nature and it has nothing to do with what you might have done or who you are. It becomes clear that you were not the woman or man of their dreams as they claimed you were: you were just used as sustenance.

To detach from a wolf? You must develop a sense of “contempt” or disgust for their wrongdoings and the holes in their dubious character. Replace your once idealized fantasy of who they were with the truth, and you will find yourself less likely to fall prey to their schemes.

Once a wolf, always a wolf – but you don’t have to remain their sheep.

Which Mental Illness Is Most Disabling?

Psychology Today Link Here

While there is no consensus on the exact definition of disability (especially psychological disability), there is greater recognition these days that, like physical disease, psychological conditions can cause functional impairment and dysfunction—some more so than others. In a paper, published in the November issue of Social Psychiatry and Psychiatric Epidemiology, Edlund et al. conclude that among the 15 mental health conditions examined, mood disorders (e.g., depression) are associated with the greatest functional impairment and disability.1

The Mental Health Surveillance Study
Data for the present research came from the Mental Health Surveillance Study (MHSS). The MHSS is a sub-sample of 2008-2012 National Survey on Drug Use and Health (NSDUH), an annual survey of non-institutionalized US civilians 12 years or older. MHSS, however, includes only individuals aged 18 and over.

For the Mental Health Surveillance Study, researchers conducted phone interviews with participants, utilizing the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders-IV-TR. Of the original NSDUH 2008-2012 sample of 220,000 adults, 5,653 completed the MHSS interview (48% men; 67% White, 14% Latino/Hispanic, and 12% Black).

Using these interviews, researchers attempted to determine if participants met the criteria for any of the following 15 psychiatric conditions:

Mood disorders (major depressive disorder, mania, and dysthymic disorder), anxiety disorders (post-traumatic stress disorder, panic disorder, agoraphobia, social phobia, specific phobia, obsessive-compulsive disorder, and generalized anxiety disorder), alcohol use disorder, illicit drug use disorder, intermittent explosive disorder, adjustment disorder, and psychotic symptoms.

Other conditions (e.g., eating disorders) were not examined because of their low prevalence in the sample.

Three measures of disability
Functional impairment was assessed using three measures (modified for this investigation):

Global Assessment of Functioning (GAF)
Days-out-of-role (DOR)
World Health Organization Disability Assessment Schedule 2.0 (WHODAS)
Scores for GAF range from 0 to 100 (higher means better functioning). GAF scores are based on both functional impairment and symptom severity (whichever happens to be worse).

StockSnap/Pixabay
Source: StockSnap/Pixabay
Unlike GAF, which is determined by clinical judgment and thus has a subjective element, WHODAS and DOR are based strictly on objective criteria and the patient’s responses.

DOR measures the number of days in the past year when an individual could not function at all because of mental health issues.

WHODAS assesses cognitive abilities (e.g., memory, concentration), social relations, social participation, self-care, and ability to do one’s duties (whether related to work, home, or school). In this study, a 0-24 score range was used, with the higher score meaning worse functioning.

Mental illness and disability: Results
Descriptive statistics revealed the sample’s average…

GAF = 74.1 (median 75)
WHODAS = 3.5 (median 1)
DOR = 6.7 (median 0)
Researchers performed a series of regression analyses, and concluded that among 15 mental health conditions, mood disorders were associated with the greatest functional impairment; anxiety disorders, with intermediate functional impairment; and substance use disorders, with less functional impairment.

For instance, in the fully adjusted model, the greatest decrease in GAF scores was seen in psychotic symptoms (22), followed by depression (16), and mania (13). In WHODAS modeling, mania (9), depression (6), and social phobia (5) had the largest coefficients. And, in the final analysis, only depression, adjustment disorder, and panic disorder, had a significant association with DOR.

These results are comparable with those of a 2007 study, which also included a nationally representative sample, used DOR, and employed similar statistical methods. In that investigation, mood disorders resulted in higher days-out-of-role than most other disorders examined.2

Commentary on use of disability measures
Aside from suggesting that mood disorders are associated with the greatest disability among conditions examined, the present investigation highlights the importance of using multiple measures in determining disability.1

Employing a single measure paints a misleading picture. For instance, as mentioned above, the median value for days-out-of-role was zero. Indeed, 70% of participants with one mental disorder, and over half of those with two disorders, had zero days-out-of-role. Only 3/15 disorders were statistically linked with DOR scores (8/15 with WHODAS; all 15 with GAF).

Therefore, DOR was the least sensitive of the three measures used. If we were to rely only on days-out-of-role numbers, we would miss significant dysfunction and disability.

darkerstar/Pixabay
Source: darkerstar/Pixabay
While GAF is likely the most sensitive of the three measures, it does not always assess functional status. As mentioned, GAF scores depend on functional impairment and symptom severity; when there is disagreement between the two values, GAF score is determined by the worse of the two. For instance, if symptoms are severe but functioning is okay, GAF scores will still be low.

Thus, it is important to use complementary measures of disability; doing so allows clinicians to achieve greater accuracy in determining a patient’s needs and in monitoring a patient’s progress. Use of complementary measures can also inform public policy and resource allocation. Physicians, politicians, and the public cannot make informed decisions about how to improve functional impairment if they fail to recognize disability in the first place.

PTSD And Complex PTSD: What Happens When You’ve Lived In A Psychological War Zone

ThoughtCatalog’s Link!

Normally when we think about “PTSD,” our minds jump to those who’ve been in combat. While it is certainly an issue for those who’ve been in real-life war zones, Post-Traumatic Stress Disorder (PTSD) and Complex PTSD isn’t just exclusive to war veterans. In fact, many survivors of childhood emotional neglect, physical or emotional abuse, domestic violence, sexual assault and rape can suffer from the symptoms of PTSD or Complex PTSD if they endured long-standing, ongoing and inescapable trauma.

These individuals face combat and battle in invisible war zones that are nonetheless traumatic and potentially damaging. According to the National Center for PTSD, about 8 million people can develop PTSD every year and women are twice as likely than men to experience these symptoms.

What Are The Symptoms of PTSD and Complex PTSD?
There are four types of symptoms that are part of PTSD and some additional symptoms for Complex PTSD as listed below. Complex PTSD, which develops due to chronic, ongoing trauma, is more likely to occur due to long-term domestic violence or childhood sexual and/or physical or emotional abuse. Around 92% of people who meet the criteria for Complex PTSD also meet the criteria for PTSD (Roth, et. al 1997).

It is recommended that you seek professional support if you’re struggling with any of these symptoms, especially if your symptoms last longer than one month, cause great impairment or distress and/or disrupt your ability to function in everyday life. Only a licensed mental health professional can diagnose you and provide an appropriate treatment plan.

1. Reliving and Re-experiencing the Trauma
PTSD: Memories, reoccurring nightmares, persistent unwanted and upsetting thoughts, physical reactivity, vivid flashbacks of the original event can all be a part of PTSD. You may also encounter triggers in everyday life – whether it be something you see, smell, hear, that brings you back to the original event. This can look different for every survivor. A sexual assault survivor might hear the voice of someone who resembles her assailant and find herself reliving the terror of being violated. A domestic violence victim might find herself being triggered by someone raising their voice. Triggers can be seemingly minor or overwhelmingly major, depending on the severity and longevity of the trauma endured.

Complex PTSD: According to trauma therapist Pete Walker (2013), you may also suffer from emotional flashbacks where you ‘regress’ back into the emotional state of the original event and you behave maladaptively to the situation as a result. Walker states that for people with Complex PTSD, individuals develop four “F” responses when they are triggered by emotional flashbacks: they may fight, flee, fawn (seek to please) or freeze. These responses are protective, but they may end up further harming the survivor because the survivor might fail to enforce their boundaries or may use excessive force in protecting themselves.

2. Avoidance of Situations That Remind You Of The Event
PTSD: You go to great lengths to avoid anything that might potentially trigger memories or feelings associated with the traumatic events. If you were in an abusive relationship, for example, you might isolate yourself from others or stop dating in an attempt to avoid being harmed by others.

If you were raped, you might avoid situations where any form of physical contact might arise, whether it be getting a massage or being affectionate with a romantic partner. If you suffered bullying, you might avoid places where group activities are likely to happen, such as large parties or even certain careers that might require high levels of social interaction. This avoidance can include trying to avoid trauma-related thoughts, too; you might keep yourself persistently busy so you don’t have to face any thoughts regarding what you went through.

Complex PTSD: Throughout your life, you may go to excessive lengths to avoid abandonment and resort to people-pleasing or “fawning” behavior. This might result in you having trouble setting boundaries with others, standing up for yourself when your rights are violated and becoming enmeshed in codependent relationships. You might be hypersensitive to signs of disapproval or micro-signals of abandonment.

As therapist Pete Walker (2013) writes, “The Abandonment Depression is the complex painful childhood experience that is reconstituted in an emotional flashback. It is a return to the sense of overwhelm, hopelessness and helplessness that afflicts the abused and/or emotionally abandoned child. At the core of the abandonment depression is the abandonment melange – the terrible emotional mix of fear and shame that coalesces around the deathlike feelings of depression that afflict an abandoned child.”

3. Skewed Belief Systems and Negative Perceptions, Including Self-Blame and Toxic Shame
PTSD: There is a shift in your belief systems and self-perception after the traumatic events. You might suffer from low self-esteem, depression, excessive ruminations, negative self-talk, memory loss related to the trauma, decreased interest in activities you used to enjoy and a heightened sense of self-blame.

Complex PTSD: Individuals with Complex PTSD may struggle with guilt, a sense of toxic shame and feeling different from others or even defective in some way. They may have a heighted “inner critic” that develops as a result of any verbal, emotional, physical or sexual abuse they went through in their lifetime. This inner critic might judge everything you do or say, prevent you from taking risks or pursuing your goals, can lead to a sense of learned helplessness and can often mimic the voices of any abusers you encountered, especially if you had toxic parents.

4. Hyperarousal and Hypervigilance
PTSD: You develop an excessive sense of alarm concerning your surroundings. You may experience a heightened startle reaction, increased irritability or aggression, engage in risky behavior, and have difficulty concentrating or sleeping.

Complex PTSD: Survivors with Complex PTSD can struggle with emotional regulation, suicidal thoughts and self-isolation. They may engage in self-harm, develop substance abuse addictions, and have a hard time trusting themselves and their intuition. They may end up in unhealthy, abusive relationships in what trauma expert Judith Herman calls “a repeated search for a rescuer” (Herman, 1997). They may have a deep mistrust of others but also a heightened attunement to changes in their environment as well as a hyperfocus on changes in microexpressions, shifts in tone of voice or gestures in others.

Treatment for PTSD and Complex PTSD
Treatment for PTSD and Complex PTSD requires highly skilled therapy with a trauma-informed and validating counselor who can help guide you safely through your triggers. Based on research, effective treatments can include some form of trauma-focused psychotherapy such as prolonged exposure therapy (PE) which involves facing the negative feelings you’ve been avoiding, cognitive processing therapy (CPT) which teaches the client to reframe their thoughts about the trauma, or Eye-Movement Desensitization and Reprocessing (EMDR) therapy which involves processing the trauma by following a back-and-forth movement of light or sound. You can learn more about treatments for PTSD here.

Keep in mind that not every treatment is suitable for every survivor and should always be discussed with a counselor. Supplemental remedies may include trauma-focused yoga and meditation to heal parts of the brain affected by trauma and release trapped emotions in the body (van der Kolk, 2015).

Although PTSD is manageable with the right support and resources, recovery from Complex PTSD is admittedly a more lifelong process as it deals with trauma that usually originated from childhood, further exacerbated by traumas in adulthood. Grieving the losses associated with the trauma or traumas experienced is an essential part of the journey.

It is important to remember that healing has no deadline and that recovery is a cyclical, rather than linear, process. Every survivor recovers in their own way and is worthy of the support it takes to get to the other side of healing. TC mark

The Pain Will End, But You Will Not

*just keep swimming*
^Reblogged from

When people talk about mental illness, they always say people who are struggling need to reach out, but when you are struggling, reaching out can feel impossible. Reaching out can be the last thing you want to do.

There is an expectation that when someone is struggling with self-harm, suicidal thoughts, etc., it is their responsibility to reach out and tell someone.

But what happens when you’ve reached out time and time again, only to be met with criticism? What happens when you’ve reached out time and time again, only to be met with fear? Only to be met with anger or misunderstanding? What happens when reaching out isn’t helpful?

Telling someone about your struggles is difficult. You never know what reaction someone is going to have, and when you’ve had a negative reaction before, reaching out again seems even more difficult than before. It feels like a risk.

When you reach out to someone and don’t receive the help you need, remember these things:

You are important.

You are worth it.

No one is perfect.

Sometimes, people do not understand what you are going through. You will not always be met with perfect responses. People may make you feel broken or like a burden, but you are not. People might make you feel guilty for feeling what you feel, but you are only a human being.

Someone else’s inability to be there for you in a healthy way does not mean you are not worth it or cared for.

Needing to be reminded of your worth is okay. Needing to have someone hold your hand on the hard nights is okay. Needing people is okay.

Having needs is okay.

You are in a fight that feels like it’s never going to end, but it will.

Rain stops.

Snow melts.

Mountains crumble.

Walls can be broken down.

The pain will end, but you will not.

Read This If You Find Yourself Confronting Narcissistic Abuse

*Warning: If you’re experiencing physical abuse, expect it to continue or escalate. Get help immediately.

Narcissist Assh*oles
^Reblogged from here

We’re all capable of abuse when we’re frustrated or hurt. We may be guilty of criticizing, judging, withholding, and controlling, but some abusers, including narcissists, take abuse to a different level. Narcissistic Abuse can be physical, mental, emotional, sexual, financial, and/or spiritual. Some types of emotional abuse are not easy to spot, including manipulation. It can include emotional blackmail, using threats and intimidation to exercise control. Narcissists are masters of verbal abuse and manipulation. They can go so far as to make you doubt your own perceptions.

The Motivation for Narcissistic Abuse

Remember that narcissistic personality disorder (NPD) and abuse exist on a continuum, ranging from silence to violence. Rarely will a narcissist take responsibility for his or her behavior. Generally, they deny their actions and augment the abuse by blaming the victim. Particularly, malignant narcissists aren’t bothered by guilt. They can be sadistic and take pleasure in inflicting pain. They can be so competitive and unprincipled that they engage in anti-social behavior.

The objective of abuse is power. Narcissists may intentionally diminish or hurt other people. It’s important to remember that narcissistic abuse stems from insecurity and is designed to dominate you. Abusers’ goals are to increase their control and authority while creating doubt, shame, and dependency on their victims. They want to feel superior to avoid hidden feelings of inferiority. Understanding this can empower you. Like all bullies, despite their defenses of rage, arrogance, and self-inflation, they suffer from shame. Appearing weak and humiliated is their biggest fear. Knowing this, it’s essential not to take personally the words and actions of an abuser. This enables you to confront narcissistic abuse.

Mistakes in Dealing with Abuse

When you forget an abuser’s motives, you may naturally react in some of these ineffective ways:

Appeasement. If you placate to avoid conflict and anger, it empowers the abuser, who sees it as weakness and an opportunity to exert more control.

Pleading. This also shows weakness, which narcissists despise in themselves and others. They may react dismissively with contempt or disgust.

Withdrawal. This is a good temporary tactic to collect your thoughts and emotions but is not an effective strategy to deal with abuse.

Arguing and Fighting. Arguing over the facts wastes your energy. Most abusers aren’t interested in the facts, but only in justifying their position and being right. Verbal arguments can quickly escalate to fights that drain and damage you. Nothing is gained. You lose and can end up feeling more victimized, hurt, and hopeless.

Explaining and Defending. Anything beyond a simple denial of a false accusation leaves you open to more abuse. When you address the content of what is being said and explain and defend your position, you endorse an abuser’s right to judge, approve, or abuse you. Your reaction sends this message: “You have power over my self-esteem. You have the right to approve or disapprove of me. You’re entitled to be my judge.”

Seeking Understanding. This can drive your behavior if you desperately want to be understood. It’s based on the false hope that a narcissist is interested in understanding you, while a narcissist is only interested in winning a conflict and having the superior position. Depending upon the degree of narcissism, sharing your feelings may also expose you to more hurt or manipulation. It’s better to share your feelings with someone safe who cares about them.

Criticizing and Complaining. Although they may act tough, because abusers are basically insecure, inside they’re fragile. They can dish it, but can’t take it. Complaining or criticizing an abuser can provoke rage and vindictiveness.

Threats. Making threats can lead to retaliation or backfire if you don’t carry them out. Never make a threat you’re not ready to enforce. Boundaries with direct consequences are more effective.

Denial. Don’t fall into the trap of denial by excusing, minimizing, or rationalizing abuse. And don’t fantasize that it will go away or improve at some future time. The longer it goes on, the more it grows, and the weaker you can become.

Self–Blame. Don’t blame yourself for an abuser’s actions and try harder to be perfect. This is a delusion. You can’t cause anyone to abuse you. You’re only responsible for your own behavior. You will never be perfect enough for an abuser to stop their behavior, which stems from their insecurities, not you.

Confronting Abuse Effectively

Allowing abuse damages your self-esteem. Thus, it’s important to confront it. That doesn’t mean to fight and argue. It means standing your ground and speaking up for yourself clearly and calmly and having boundaries to protect your mind, emotions, and body. Before you set boundaries, you must:

Know Your Rights. You must feel entitled to be treated with respect and that you have specific rights, such as the right to your feelings, the right not to have sex if you decline, a right to privacy, a right not to be yelled at, touched, or disrespected. If you’ve been abused for a long time (or as a child), your self-esteem likely has been diminished. You may no longer trust yourself or have confidence. Seek therapy, get support.

Be Assertive. This takes learning and practice to avoid being passive or aggressive. Try these short-term responses to dealing with verbal putdowns:

“I’ll think about it.”

“I’ll never be the good enough wife (husband) that you hoped for.”

“I don’t like it when you criticize me. Please stop.” (Then walk away)

“That’s your opinion. I disagree, (or) I don’t see it that way.”

“You’re saying . . .” (Repeat what was said. Add, “Oh, I see.”)

“I won’t to talk to you when you (describe abuse, e.g. “belittle me”). Then leave.

Agree to part that’s true. “Yes, I burned the dinner.” Ignore “You’re a rotten cook.”

Humor – “You’re very cute when you get annoyed.”

Be Strategic. Know what you want specifically, what the narcissist wants, what your limits are, and where you have power in the relationship. You’re dealing with someone highly defensive with a personality disorder. There are specific strategies to having an impact.

Set Boundaries. Boundaries are rules that govern the way you want to be treated. People will treat you the way you allow them to. You must know what your boundaries are before you can communicate them. This means getting in touch with your feelings, listening to your body, knowing your rights, and learning assertiveness. They must be explicit. Don’t hint or expect people to read your mind.

Have Consequences. After setting boundaries, if they’re ignored, it’s important to communicate and invoke consequences. These are not threats, but actions you take to protect yourself or meet your needs.

Be Educative. Research shows that narcissists have neurological deficits that affect their interpersonal reactions. You’re best approach is to educate a narcissist like a child. Explain the impact of their behavior and provide incentives and encouragement for different behavior. This may involve communicating consequences. It requires planning what you’re going to say without being emotional.

Get Support

To respond effectively requires support. Without it, you may languish in self-doubt and succumb to abusive disinformation and denigration. It’s challenging to change your reactions, let alone those of anyone else. Expect pushback when you stand up for yourself. This is another reason why support is essential. You will need courage and consistency. Whether or not the narcissist makes changes, you’ll get tools to protect yourself and raise your self-worth that will improve how you feel whether you stay or leave. CoDA meetings and psychotherapy provide guidance and support.

02 Snowboarding & Suicide Series: Identifying Depression (How It Took A Suicide Attempt To Show Me I Was Depressed)

*Just some of the symptoms of depression.
I always recommend doing some research yourself because depression looks different to each person.

Depression is a fickle bitch and her face looks different to everyone she meets. Sometimes you don’t even know her real name until she is eating at your table and sleeping in your bed. Sometimes she is loud and the center of attention… locking you in your room and cutting all ties, chaining you to the bed. Sometimes she is like a mom that pretends she’s cool and hip but really can’t let loose. Always nagging at you if you do anything that might be off the beaten path. Whether she restrains or reminds you, she is there.

It turns out I have high-functioning depression.


I really don’t know how I didn’t know I was so depressed at the point of killing myself. I have a B.S in Psychology, I am in Psi Chi – the International Honor Society in Psychology.. I scored in the top 1% in the nation on my Psychology exit exams and have some internship and doctorate training in Clinical Neuropsychology under my belt. This is kind of my thing. I had no idea how bad my mental state had gotten.

I have always had high-functioning anxiety, and some episodes of depression, but I was always convinced that I didn’t need antidepressants or anything – but my xanax is always by my side.

I was able to hold down a job, and manage to get through each day good enough to make myself believe that I was fiiiiiine. Sure, I had no sex drive, didn’t get out of bed if I didn’t have work, barely slept and didn’t do a goddamn THING unless I took a piece of my (prescribed) Adderall. I was getting by.

Why wouldn’t I be anything but happy?
I was number 1 in sales, case commissions, and wine club sign ups for 5 straight months. I was living in Oregon with my amazing boyfriend and our dog child. I was financially secure & had a great support system. What is there to not be happy about?

The thing I didn’t realize until after I tried to kill myself was that it was not that I wasn’t happy… I was numb. Going through the motions. I felt nothing at all. That’s why swallowing the pills and the actuality of how close I was to dying never really sunk in. It didn’t it even feel like it was me that tried that. TOTAL DETACHMENT. I just got back to my life as though it didn’t happen. My boyfriend knew better than to push it but I knew he was worried. Things had to change soon & I knew that, but where do you go when you can’t even grasp the heaviness of the situation and feel any emotion towards it?

The moral of the story is to check in with yourself. Yeah, some stuff in life is going to suck because that is just how it goes. But this shouldn’t be the norm. If you notice that shit that used to get you all excited sort of has a blunt affect then maybe do a little reflecting on how things are going in general.

Laziness, and regular tiredness are not the same as not showering or leaving your bed for three days with the excuse that they are your days off. Every daily situation shouldn’t feel like a hassle you want to escape from, I didn’t realize that wasn’t normal until the Lexapro finally kicked in and I actually had an enjoyable time GETTING HEALTH INSURANCE yesterday. Enjoyable and Health Insurance usually aren’t in the same sentence. That was eye-opening.

Regularly check in with yourself, your habits, and your feelings.






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