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Depression & Mood Disorders

Treatment for mental health disorders are based on the assessment and diagnosis of the patient's presenting problems. The assessment takes into consideration the developmental history of the problem to determine if it is situational (due to an identified specific situation) acute or chronic. It also considers whether or not the presenting problem is triggered by a mind based--over stressed psyche, and to what extent personality and character issues, or flaws, play a role in the onset of the condition.

Treatment for situation specific depression and anxiety is usually shorter in duration than psyche based conditions, and the stress tends to be reduced as the situation subsides, or the patient gets a grip and feels in control of the situation outcome. In the early stages on the problem, the patient could feel overwhelmed and powerless over the situation leading to feeling depressed and anxious; or, the he or she could feel a serious threat to their position in life in anticipation of an impending loss of something quite valuable to them such as their job, love one, or their possessions.

As a rule, when under high levels of stress, the mind and body are in a survival mode, which allows minimal access to rational thought, decision-making ability, and perceivable options. Additionally alarm reactions produce mechanisms of defense when there are threats to the ego and self-image. Getting third party professional guidance is always beneficial in order to get objective and viable suggestions for solutions and options. This alone provides relief.

Most of the time, situational depression and anxiety only require guidance, coaching, understanding, insight, options, and support. Because it is less specific and more difficult to identify in terms of the source and roots to the problem, chronic depression and anxiety tend to be more clinical in nature and is likely to require more intense psychotherapy. This is true even though the condition could be triggered by a specific and identifiable situation. It usually has an internal and intra-personal base that results from long-term repressed and unsettled feelings of anger and resentment, or disappointments that the patient is unable to identify.

More often than not, these repressed feeling are strongly rooted in unresolved early childhood issues related the same sex parent or the absence of one. Additionally some of the depression could be genetically based which could complicate and extend the treatment process. If the patient is in an exhaustive or burnout phase of the depression, anti-depressants or anti-anxiety medications may be required in conjunction with psychotherapy.

Generally, the primary agents of severe and chronic levels of depression and anxiety are feelings of detachment, inadequate or devoid sense of emotional or spiritual connection, lack of trusting support systems, feelings of isolation, identity confusion, and an undefined sense of meaning or direction and purpose in life. Like a self perpetuating cycle, each of these are dispositions that tend to produce dysfunctional character adjustments, such as emotional aloofness, trust issues, excessive self-reliance, and exaggerated fears of vulnerability; each of which fortify, mystify, and prolong the depression, or induce troublesome anxiety conditions.

The climax of chronic or long-term depression often comes during midlife. This is sometimes identified as a "midlife crisis." At midlife, somewhere between the ages of 40 and 60, there is a sudden existential awareness to the depressed person that they have been existing more so than living. This acute awareness draws a sense of desperation and fear that life will be over before they get a chance to live or find meaning. This could agitate the depression with strong feelings of regret and despair or aggravate a strong need for action and life changes that are sometime irresponsible and immature--definitely a time to seek some professional assistance.

Anxiety Disorders

Anxiety and fear, like anger, are indispensable survival mechanisms and emotions that triggers a response when under threat. We would not live very long without them. For animals these mechanisms are raw instincts that are beyond their control unless they are socialized, conditioned, or trained by humans. Humans, unlike animals, have a system that allows them to restrain their emotions prior to action, giving time to consider socially acceptable responses. However as our minds gathers information about a situation in our environment perceived as a threat, as the information is on its way to our central nervous system for rational processing and action consideration, traces of that information falls upon a small section on the brain call the amygdala.

The amygdala is also known as our emotional brain. It is in this section of the brain where emotional associations are made that trigger reflex fight-flight responses. When traces of current information that is similar in perceived danger as past painful emotional memories, it can trigger strong emotions such as anger and fear that can be disabling or out of control. It sets off an alarm reaction that short circuits the information before it gets to the brain for rational consideration of rational or socially acceptable actions.

These segments of past traumatic events that rest on the emotional brain could be early childhood conditioned responses to certain aversive stimuli, or more recent experiences related to exposure to the trauma of others, such as in war, or having lived in a grossly abusive and unbearable situation. The idea in treating anxiety disorders is not to get rid of anxiety but to learn to control it. One has to find new ways to respond to triggers by developing the ability to distinguish between rational and irrational fears and responses. The prognosis depends on the severity of the imprinting of the past experience on the emotional brain. I generally have my patients take note or record each time they have a irrational impulsive response or avoidance. This should be followed by practicing or role-playing what would be or should have been a more  appropriate response.  In this way the individual will be better prepared, when a similar situation presents itself, to give a more rational and appropriate response.

Anxiety problems or disorders is characterized by irrational avoidance behaviors and reactions, and from a clinical perspective, they lead to dysfunctions that hamper the quality of ones life. If rendered completely dysfunctional, medications may be required during the process of treatment to aid in building courage to challenge the learned irrational fears. There are many types of anxiety disorders and treatment should be sought for appropriate diagnosis and treatment depending of the severity of disablement to everyday functioning.

Anger Management

Anger and depression rest on opposite ends of the same emotional pole. Anger is the antithesis of depression. One cannot be angry and depressed at the same time. Anger is often triggered as a defense against depression. When angry, one feels powerful and in control--whereas when feeling depressed, one feels powerless or incapacitated. Depression means just what the word implies, depressed. When depressed or feeling depressed, one’s feeling have been depressed. Usually these feelings are unbarable and places stress and agitation upon the mind that often demand relief.

Frequently, due to the perceived fear of consequences to the expression of ones feelings, the feelings are suppressed and bottled up, and often to unbearable degrees. And when expressed impulsively or beyond our control, they are sometimes expressed in outburst that could be fearsome to others. When this side of the character is exposed, many times the individual is identified as having an "anger problem."

Some people are more limited in perceived options or tolerance for ambiguity than others and tend to handle their limitations in self-defeating ways with little flexibility or ability to find middle ground. This results in withdrawal and depression or anger outburst. Emotional management and assertion training can be a helpful mode of treatment, in addition to role playing and situation modeling. Unless there are serious character issues present, patients generally respond well to short  term problem centered treatment without the need for intensive psychotherapy.  (
More PSM anger management information)

Addiction & Substance Abuse

My orientation towards the treatment of addiction and substance abuse follows the same lines of treatment irrespective of the drug of choice, be it alcohol, drugs, food, gambling, sex and porn, shopping, or work obsession. Addiction is the compulsion to indulge with an inability to self-regulate. When one is obsessed and compelled to indulge beyond self-regulation, that person is a victim to his or her own compulsion. Generally the addicts cannot quit or refrain from the drug abuse unless they come under the threat of loosing something they value more than the drug and must choose between the two. Ultimatums and empty threats seldom serve as a deterrent. Many addicts are quite generous and responsible to those that depend on their support, however this often gives a false sense of entitlement to their drug abuse.

The most significant fears and threats of loss tend to be possibilities of loss of job, spouse, and family, and money; or, having the details or extent of their addiction disclosed to others, such as their close friends, family members or co-workers. The onset of a life threatening health condition related to the drug can also be a major threat, as well as getting in trouble with the law and loss of certain social freedoms ( e.g., incarceration, revoked drivers license, etc.). The theory the addict cannot stop until he or she hits bottom holds many truths. The principal trait and defense mechanism of addicts is "denial." Denial supports their rationalization that they will always get another chance. This is especially so when forgiven for repeated violations and subsequent infractions, which weaken the threats, or invalidates their feared consequences. Reaching the bottom means the loss of some, or all of the foregoing. Different people have to reach different levels of the bottom in order to be moved to quit or get treatment.

Today we do not think of an addict in terms of the amount and frequency of use of the drug so much we consider whether or not the use causes a problem in society, relationships, family, or work. The person is an addict when there is a known problem, and no matter how dysfunctional it is, they refuse and resist discontinuation of use.  
For most addicts that go or come for treatment of addiction, they are under the assumption that kicking the habit is the end goal and if successful they are cured and will not return to the drug. This is a myth. Abstinence or cleaning the system of the drug is only the tip of the iceberg in drug addiction treatment. Unless the underlying causes that produced the addiction are addressed, more than likely, they will return to the same drug, or tend to unconsciously become victim to another one that will take its place.

Most addicts carry a duel diagnosis. The drug addiction tends to be a self-medication that camouflage or smother the underlying clinical diagnosis for depression, anxiety problems, low self-esteem, or profound insecurity. However the underlying problems cannot be addressed until the addiction has been brought under control. Most of the fears that the addict has about sobriety is that the underling diagnosis perceived as unbearable, will surface and render him exposed and vulnerable.  Addicts have a grave fear of vulnerability. The drug, whatever the choice has been, provides insulation form their vulnerability and isolation fears, and fulfills the void left by their emotional detachment. Although they fear isolation, at the same time, they are repelled by spiritual and emotional closeness. For these reasons they make an attempt to have their cake and eat it too.  They want to retain normal relationships while keeping the relationship with the drug, and claiming that their addiction has no impact on those around them. Most often the addiction will be practiced to a great extent in secret. The secrecy however, tends to heighten,  add reinforcement, or strength to the compulsion.

The addict can seldom function without an enabler (one who shelters the addict) who generally feels dependent of the addict in some form or another. For these reasons it is always advisable that the addict’s codependent, or enabler, become involved in the treatment. For as long as that addict has an enabler that has a tolerance for the behavior or drug consumption, the motivation and discipline to accept and complete the treatment will subside.

Most addiction programs have anonymous support groups, such as AA for alcoholics anonymous, SA for sex addicts anonymous, GA for gamblers anonymous. or DAA for drug addicts anonymous.  Most of these anonymous groups offer Al-Anon or Ala-teen support groups for the families of the addicts who suffer inadvertently from the disease of the addict.   Completion of a 12-step program is an essential component to the treatment process for long term success, as it tends to address the various aspects of the character flaws and isolation that produces a void that renders the subject susceptable to the addiction. Anonymous groups also gives support to addict's challenge to his or her fears of sobriety.

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