Cognitive Dysfunction in Depression

I have Major Depressive Disorder (MDD). It's a battle I have to fight everyday. I'm proud to say I haven't lost yet. It's hard to make family and friends understand that this is a serious struggle. The symptoms commonly associated with MDD are changes in sleep, appetite and energy, combined with a lack of interest, low self-esteem and hopelessness. This gives MDD the image of an emotional attitude, something you can change or just snap out of. That's not it at all.

I like to compare MDD to the weather. It's always there, it changes, you can't control it, but with skill, you can predict it and take precautions. It's like a fog that rolls in and clouds your outlook on life. It's dark and difficult to see through. It could last anywhere from hours to months. Then, a beam of light or a gust of wind dissipates it and the world looks brighter again. So asking why can't they snap out of it is like asking why is the sky blue.

I'm hoping recent research on the symptoms of MDD will help lift the stigma. The old myth that depression is purely a mood disorder is slowly being overturned. Research has shown that patients with MDD can also suffer from cognitive dysfunction. What's that you say? It's that foggy feeling you get in your brain. You can't concentrate, you forget what you've just read and processing information, let alone doing anything is hard. It's not an excuse give up and be lazy. It's a frustrating difficulty that we have to learn to work with.

What is cognition?

Cognition is not academic skills. Academic skills include knowledge about specific subjects like math or philosophy. Cognitive skills refer to thinking and how you interact with your environment, things everyone does everyday. Cognition allows you to perceive, acquire, understand and respond to information through abilities such as attention, memory, information processing, problem-solving and organization. These abilities are essential to function in our society. Cognitive dysfunction is when these abilities are impaired.

Recent Findings

Cognitive dysfunction can have a huge impact on the quality of life. Until recently, changes in cognitive function weren’t linked to the diagnosis of MDD. Using well-developed, objective cognitive function tests, Cogstate showed that the prevalence of cognitive dysfunction is almost 50% across a group of MDD participants. Those with cognitive dysfunction have lower productivity levels compared to normals and those who were depressed but cognitively normal. These cognitive symptoms are stubborn too. They don't come and go with the fog of a depressive episode. They persist through the better times too. Researchers believe that cognitive symptoms may be more debilitating than the physical symptoms of MDD, possibly the underlying cause of disability.

Parts of the Brain Involved

Areas in the brain involved in cognition overlap and communicate with regions responsible for mood and emotion, namely the frontal-limbic circuitry and the hippocampus. The frontal part of the brain is responsible for cognition while the limbic system handles emotion and the hippocampus manages memory storage and processing. These areas communicate via neurotransmitters that I'm sure you are familiar with; serotonin, norepinephrine and dopamine. After all, these are what our medications aim to increase. A decreased level of serotonin explains the lack of motivation and will power that characterizes depression. Lower levels of norepinephrine decrease abilities to concentrate, while decreases in dopamine take away enjoyment. MDD is not just low levels of neurotransmitters, otherwise our anti-depressants would have put us all in complete remission.

Eureka!

Recent research has determined that our brains are structurally different from people who do not have MDD. Structural abnormalities are seen in the frontal-limbic and hippocampal areas of the brain. They are there at the beginning of MDD and may even precede it! This is shown by imaging studies on those experiencing their first major depressive episode, before starting treatment. After multiple episodes of depression, the volume of the hippocampus decreases. This decrease correlates with observed memory problems.

So far, research has determined the regions of the brain that are affected by MDD, but we don't know why and there are few, if any effective treatments. Tune in tomorrow to learn about what is available to help combat the cognitive symptoms of MDD. Ultimately, more research needs to be done in this area to give sufferers relief from the frustrating cognitive symptoms.
 
MDD is not just a mood disorder or an attitude that you can change. Have you ever wished you had something to show for your pain...a broken leg, a tumor or something to explain why you are the way you are? There are physical abnormalities to explain my foggy thoughts and crumby short-term memory. Unfortunately we can't all go get brain imaging done to prove it, but knowing that my issues are scientifically validated give me comfort. Even though I've known it for a while, a lot of the world doesn't. I'm not lazy, I have MDD. It's real. Take that stigma!

(P.S. I'm not a doctor or an expert, I'm just sharing what I've read that makes me say Wow!)

Sources:
cogstate.com 
Office of Mental Health 
Trivedi and Greer, 2014

Overcoming the Perfectionist Attitude

Hi. I'm the Somber Scribbler and I'm a perfectionist.

Perfectionism is not only annoying, it's often the cause of low self-esteem and anxiety. Perfectionists have unrealistically high expectations of themselves, others, or life in general. They are often highly focused on details, particularly the negatives and they tend to discount the positives. Are you a perfectionist? Here are some of the signs....

• You are motivated by fear of failure or sense of duty. I should, I must, I have to...
• You are critical of every effort. Your accomplishments never satisfy you, you have to be number one.
• You have to earn your self-esteem. You must be accomplished or you wont be loved or accepted by others.
• You are terrified by failure. If you don't reach your goal, you think you are a failure as a human being.
• You must always be in strong control of your emotions, otherwise you might be seen as weak.
• You tend to think in two categories (black and white, success and failure) rather than on a continuum.
• You make conclusions that go beyond a situation. If it happened once, it will always happen.

Sound like you? It sure sounds like me. There are tips all over the place about how to get over it. For example, make more realistic goals, stop focusing on the little negatives, don't discount the positive stuff and find more pleasure in life. It's good advice, but how do you do that? It's hard to just turn off that black and white thinking when you've been doing it your whole life.

I want to share some painfully obvious things that I have realized lately. Reminding myself of these things has helped me to be more successful in following the anti-perfectionist tips.

Existence = Worth
Society measures our worth by outer achievements, so that's how I measure my own worth. How much education do I have? How many friends do I have? How much money do I have? How thin am I? Sounds about right, right? Wrong! Your worth is a given just because you exist. People give pets and plants worth just for being there. Why shouldn't we give ourselves the same treatment?

Mistakes Are ok as Long as You Are Still in Control
You are human, you make mistakes. You probably make several a day (I do!) and that's ok. They are not worth dwelling on. It just gives you more anxiety. There is no learning without mistakes. I know you've heard that before and it's not that comforting, but what about this? Think about how many mistakes you can make before you lose control of the situation. There's a lot of room for error there. Feel better? I do.

Would you Demand the Same From Your Best Friend?
I applied to optometry school out of high school. I didn't get in. I hated myself. Would I hate my friend if she didn't get in? No. Would I feel bad for her? Yes. It's ok to be disappointed because of set backs, but don't let it turn into something as extreme as self-loathing.

The Right Perspective
Perfectionists tend to focus on mistakes that have minute consequences let alone any real long term effects. This mistake you made feels crappy right now, but will it matter next month? Next year? I know you want to kick me for saying that. It doesn't make you feel better right now, but it does put things in perspective. I failed my driver's test several times. I was devastated. Does it matter now? No. Does it affect my life in the long run? No. It wasn't worth all the anxiety I had over it.

Stop and Smell the Roses
Perfectionists are often rigid and self-denying. You can't keep giving 100% without recharging your batteries. Make time to do something you enjoy. I got to the point where I didn't enjoy anything anymore. Everything stressed me out. I realized it was because I was focusing on the finish line and not on the process. My favourite pass-time was drawing and I stopped doing it because I wasn't any good at it. I was so focused on what my artwork looked like in the end that I forgot it was the drawing part that I enjoyed. Focus on the process.

When I remind myself of these things I find it easier to follow the tips on how not to be a perfectionist. I'm still a perfectionist, but I'm working on it. Thinking in black and white and focusing on the negative is still automatic, but remembering these points helps me talk myself out of it and it has reduced my anxiety by leaps and bounds. I hope it can be of some use to you too.

The Ball of Shame

Happy St. Patty's!!

Happy St. Patrick's Day!

My Dad's side of the family is Irish. We've been in Canada for generations, but one of my great uncles still had an Irish accent. It was awesome. I live in Montreal and we have a rather large, close-knit Irish community. There are St. Patrick's Day Galas, a pageant to select the Queen of the Parade, special Irish breakfasts, everything and everyone downtown turns green and the Irish pubs go nuts! People are all dressed up in crazy outfits and drinking green beer on the streets. It's actually a lot of fun.

My cousin runs the pageant. She was queen once herself. It's not a typical pageant. It's more like a public speaking contest. Contestants have to introduce themselves and their Irish background. They prepare a speech on Irish history or literature and they have to answer a current events question on the spot. Whoever is elected queen gets a trip to Ireland, leads the parade and spends the year volunteering in the Irish community. It's a pretty good program.

It has become a tradition for my family to watch the parade together and then retire to my aunt and uncle's place for Irish coffee and food. Every year we gather on the same street corner to watch. Kids, adults, dogs, the lot of us, plus our friends. There is usually about 25 of us.

Yesterday was parade day.....and I didn't go. It's not that I didn't want to. I enjoy the parade, especially the music. I even bought a green sweater to wear for the occasion! It's also been a while since I've seen my extended family. I'm dying to see them. So what's the problem? I don't want them to see me. Do you ever feel that way? It's kind of a weird state to be in. It's not like I have anxiety about it or don't have the energy for it, which is usually the case. Maybe ashamed is the right word? I'm ashamed of myself.

My family is going to want updates on what has been going on. I don't know what to tell them. I've stagnated at work (or school, whatever you consider Ph.D. work to be). My own research is stuck in ethics, I'm having trouble getting volunteers for the other studies I am involved in and I have no publications to report. Then, there is the bad news about my husband's job (see yesterday's post). On top of that, I'm fat and ugly and my clothes don't fit nicely anymore. I have been gaining weight (thus why my clothes look bad), my skin is a mess and I haven't washed my hair. This is not how I want the people I care about to know me.

So you think maybe I should have put on my best clothes, gone and kept the conversation focused on them. Impossible. My cousins are the type of people who look you in the eye, ask how are you? and actually wait to hear the response. I can't avoid talking about myself a bit. So I stayed home. I missed out on my family, the fun I could have had and the memories I could have made. This makes me sad.

I should just put real clothes on and go. That's what I usually end up doing, forcing myself out the door everyday. For some reason, this time, I can't and I can't quite explain why. Just get over it I tell myself, they are your family, they will love you anyway. I know this is true, but it doesn't seem to help. I want to be successful, confident, pretty, fit and charismatic. Don't we all right? Sometimes I pretend that I am. I fool my friends and co-workers pretty well. Acting gets to be exhausting though. Family and very close friends are different. I feel guilty putting on a show for them. It's not really me after all. I'm so afraid of being less than what they expect. I don't want to disappoint them. Now you say, you are disappointing them by not going. I know that too, but it doesn't compare to the disappointment they would have in interacting with me.

The Ball of Shame that holds me hostage

So now we have fear, sadness, guilt and shame cycling through my head. Are these feelings what is keeping me housebound? Is that it, or is there more to it? I don't want that to be it. Seriously?! Feelings are stopping me from doing things? That makes me angry at myself. I think I'd feel better if there were some sort of physical barrier stopping me or someone holding me hostage.

Usually my posts are a little more upbeat. I try to talk about more positive experiences or at least experiences where I have learned something, but I'm afraid I just haven't figured this one out yet. Have any insight? I'll be sure to let you know when I do.

Stess in Life, Stress in Sleep - Most Common Anxiety Dreams

I use sleep to escape my really low points. This works for the most part, unless I have anxiety dreams. In this case, sleep is stressful, life is stressful and I wake up exhausted. Things usually spiral out of control pretty quick.

Dream research from the University of California has found continuities between dream elements and waking life. Typically, the elements represented the concerns and interests of the dreamer, suggesting that dreams do have meaning. They have also found similarities among cultures, genders and age groups. Dream interpretation is complex and individual. Two people can have similar dreams, but their life situations differ, ultimately giving different symbolism to the elements in their dream. Having an anxiety dream about a growing mass of insects could mean you have an insect phobia, or it could mean that you have a growing problem in your life. It's open to interpretation.

Here are some of the most common anxiety dreams and some interpretations of the elements in them.

My teeth fall out. I absolutely hate this one. I have it the most often. It happens slightly differently each time. So I always think OMG it's actually happening for real this time!! I'm never quite sure that it's just a dream until I've checked in the mirror and tried to wiggle a few teeth.
What it means. Apparently this one is really common. Have you had it? Teeth are often interpreted as a symbol of power. So losing them would signify a loss of control. In other cases teeth could represent losing face. Maybe you have a situation where you are worried about what others might think of you?

Unprepared for an exam. I have to write the final exam and I haven't even been to class yet. This one really makes me sweat since I am, technically, still in school. Usually it's a math exam and I haven't gone to classes because I've been too depressed. In real life, I am teaching myself statistics, so you see how confusing this can get.
What it means. This one is rather obvious. You are likely feeling unprepared for a real life situation. Often people having this dream have a lot of work-related stress.

The Car is not working. I'm in the car and I can't control it. I've had this dream since before I could actually drive. I'm in the car and it's moving forward, slowly. Sometimes there are people with me, sometimes not. Nothing in the car is working. Not the steering, not the breaks. I just keep moving forward slowly towards something...usually something that puts me into panic mode. Like on-coming traffic. With this one, I can usually figure out I'm dreaming and take back control.
What it means. This one is interpreted in different ways. Sometimes it means some part of your life is dysfunctional, like a relationship for instance. Another variation, If you are the passenger, perhaps you are uneasy relinquishing control to the driver. If you are the one in the driver's seat (this is what I dream), it could symbolize responsibility. You are not quite comfortable in the driver's seat of your own life.

I'm being chased. I've only had this one once that I can recall. You are running from someone/thing and can't get away. I imagine this scenario is often accompanied by screaming or fighting. It drives me nuts when I try to scream and it comes out at a conversational level or when you try to punch the bad guy and it all happens in slow motion. So frustrating! I usually know I'm dreaming then though and it's not so bad anymore.
What it means. The key to this one is figuring out what the pursuer represents. It is usually someone/thing you are threatened by.

I'm naked in public. I didn't start having this one until very recently. I'm usually in a bathing suit environment and have forgotten my top or something. I'm completely embarrassed, but no one seems to notice my predicament.
What it means. This usually represents a life scenario where you are feeling vulnerable, not confident or unskilled. Since no one is noticing, it may mean your feelings are unfounded. A better meaning than other dreams, but a stressful dream none the less.

I'm drowning. This one is scary. I'm underwater, running out of air and I can see the surface. I swim towards it, but I can never seem to break through. I usually wake up at this point because I've been holding my breath.
What it means. This is most often associated with being overwhelmed or denying yourself an emotion that you need to be feeling.

I'm falling. I've never had this one, but it is considered common.
What it means. It usually means you feel unsupported or out of control in a real life situation.

I see dead people. I don't mean zombies here. This is the absolute worst one I have by far! I always wake up in tears and gasping for air. I dream that my Gran has been alive all these years and no one has told me. They left me thinking she was dead. In reality, she died ten years ago this month.
What it means. I've read that seeing a dead relative means you miss them and it's a coping mechanism or a last opportunity to say goodbye. That part makes sense but, I don't really know why I would be thinking she was dead and only find out later she was still alive. I'm lost as to what that detail means. Any ideas? It really bothers me.

How do you make them stop?
There are so many methods to try. Most of them involve some form of relaxation exercise and altering you're thought patterns either before bed of during the dream. This doesn't work for me. I don't know how to relax and I can only alter my thought patterns in some dream scenarios (like the car or when I'm fighting someone). In more extreme cases, there are medications, but they stop the good dreams too and if you are like me and have your own personal pharmacy in the medicine cabinet, then you don't really want to add to it. Diet and exercise can influence your dreams too. Seems like those two factors influence everything. All you can really do is try these methods and see what works for you. Everyone is different.

What works for me? Constant, unchanging noise. The sound of a fan, rain hitting the window, the crackle of the fire, things like that. My favourite anti-anxiety dream noise is music from the Phantom of the Opera. The voices and the music blend together in such a way that nothing sticks out and it's just pleasant sound. I've never had a bad dream going to sleep to The Phantom of the Opera. I wonder if other musicals/operas would work?


Sources:
dreamresearch.net
www.dreams.ca

The Panic Devil and the Optimistic Angel

Those of you who have experienced depression know about that battle that goes on inside of yourself. It's a constant struggle between the devil and the angel on your shoulders. The devil tells you you are worthless while the angel tells you to pick yourself up and get in gear. At the end of the battle, you are left exhausted and disappointed because you can't just do what the angel says and leave the devil in the dust. It's not that simple. 

This scenario was triggered in me yesterday when the husband called after work. Bad news, that high school enrollment for next September is down and he'll likely be out of a job. He's a high school science teacher. This really threw me for a loop. I thought we were safe. He had just gotten tenure, meaning the school board would have a position for him. I guess if there are no kids to teach, they can't very well have a teaching post for him. We are a single income (his) household, so this set me into panic mode. What are we going to do? I'll have to quit my Ph.D. to get a job!

What if I did have to get a job? What would I do? I've got a M.Sc. in biology and I'm halfway through a Ph.D. in vision science. So I'm highly educated, but I have no skills and no experience. Who would hire me?  In addition, I live in Quebec and don't speak French. I knew this would come back to bite me eventually. This rules out the possibility of working in retail or service industries. I have babysitting experience, but if I handed my resume full of conference presentations and cadaver research into a daycare center, I'm pretty sure they'd laugh me out of the building.

After some major panic, throwing up and a rather nice chat with some new friends I've made through blogging (thank you!), I came back to Earth. I tried to look at the situation logically. It's not certain there wont be a job for him, so it's not worth more panic....yet. There is a possibility of me getting a government fellowship. Please provincial government, fund me! I wont know about the fellowship until next month. So I can delay more panic until then.

This is the problem with higher education. You get stuck in a small bubble with all the other competitive, highly motivated students and professors and you forget that there are destinations other than being a tenured professor. You forget that there is a whole world out there that requires skills other than being an encyclopedia for a very specific field. It becomes hard to see a relationship between your specialized training and employment in the outside world. At least this is how I was feeling when I started my second round of panic.

Just as the panic devil was about to get me going again, the angel on my other shoulder chimed in. If this were true, then there would be an awful lot more highly educated, unemployed people. Of all the things I've done in grad school, there must be some transferable skills there. I was a teaching assistant for an anatomy lab. I dissected cadavers and taught students what was what. Unless I wanted to be a serial killer, the dissecting wasn't going to help, but the teaching, that was good. I taught them about all the different nerves in the body and how to tell a vein from an artery. That's attention to detail. Another skill! I was starting to feel better. What about all my conference presentations? There's organization, communication and interpersonal skills. Alright! I was starting to feel like a rock star! Albeit, an unemployed rock star.

It's important not to look at a situation through the devil's eyes. You need to knock some sense into that angel too though. Singing empty optimism isn't going to get you anywhere. What is true about the situation? I mean solid facts, not what you think you know or what you assume others think. Facts. Since I am being forced out of my academic bubble I have to make changes. I'm going to take my set of facts (knowledge and transferable skills) and go in a different direction.

I'm feeling better about this forced change. I know it'll be hard and extremely unpleasant and part of me still wants to curl up in a ball and hide in the corner, but I know buried under all that theory, there are transferable skills. The thought of leaving my Ph.D. still breaks my heart, but I know I'm not doomed.

Gratification for Surviving the Day

I often feel like I need something to look forward to get through things. I used to get really depressed during exam period in undergrad. To get through all the monotonous studying I'd pick a TV show to look forward to. If I did some good solid studying during the day, I'd stop and watch the TV show at night. I was lucky my folks had enough channels that there was always something interesting on.

I've noticed that as I've gotten older, my daily tasks have gotten bigger and bigger. Three weeks of solid studying for exams is tough by most standards, but now, getting out of bed is hard, going to work is hard, making a meal is hard. Things that I took for granted before have become daunting tasks that I need to have a reason for doing. Most of the time I rely on logic to get things done. I get out of bed because nothing will get done otherwise. I go to work because I want to finish my Ph.D. I make meals because I'll feel sick if I don't eat. Logic doesn't give me much pleasure though.

My basket of rewards has gotten smaller over the years too. TV shows no longer interest me very much and they don't feel like much of a reward after a daunting task. For a while, I was putting money aside. For everyday that I participated in and didn't hide, I'd put a little bit of money away. Eventually I'd have enough to buy myself something I wanted. That worked until I started my Ph.D. Now there is no money.

Lately I've turned to sweets as a reward. I get one of those giant cupcakes I mentioned in an earlier post once a week. They are only a few bucks or if things are too tight, I can persuade myself to bake. But now, not only am I gaining weight, but once a week isn't quite enough. I need a new reward. I've thought about trying drawing as a reward, but I already use that as an outlet for stress and a way to recharge my batteries. I can't really deny myself my drawing time if I don't participate in life for some reason. Any suggestions?

What do you look forward to? What do you use to treat yourself? Or to bribe yourself to get moving?

Misadventures with Dr. Dreamy the Psychiatrist

I'm seeing my psychiatrist today. I'm not looking forward to it. The first time I met him was years ago. My doctor sent me to him to get another opinion on anti-depressant medication. I had never been to a psychiatrist before. I was anxious, but keeping an open mind. So I went to my first appointment and it was awkward. First of all, Dr. Dreamy is very attractive and he's not much older than me. I guess I was expecting someone older and wiser, someone who wasn't a peer. The fact the he was cute and making me blush just made it that much more uncomfortable.

I had waited months and months for the appointment, so I wasn't going to bail now. I was okay talking to him about my anxiety issues. It was harder to talk to him about depression and my body image issues, but I did because I thought it was important. I had two appointments with him before I went back to my regular doctor.

It took Dr. Dreamy about two months to get back to my regular doctor about his opinion on my meds. He said the best thing for me would be Remeron. Remeron?! Are you kidding me?! Had he been listening to anything I was saying? I had basically told him I was obsessed with my weight and miserable because I was fatter than I wanted to be. I told him I was addicted to cake. Remeron is notorious for increasing appetite, especially for junk food and is one of the worst drugs for weight gain. I'm lucky I did my research ahead of time. Otherwise, I would have assumed doctor knows best and just taken what he recommended. Needless to say, I didn't go back to him.

Fast forward a few years. I passed the 25 years old marker which was disastrous. I had to stop seeing my regular doctor because I was no longer considered a youth. 25 is also the cut off for being on your parents' medical insurance, so no more private therapy. Therapy is a little expensive for a grad student. I tried the counseling services at the university, but that didn't go well. A story for another time.

So now what? I started going to a walk-in clinic to get my refills. They refused to give me more than a month's worth. So once a month I'd spend a few hours waiting at the walk-in. Yuck. I was put on a waiting list to see psychiatry (hope!). Then I found out they refer to the same practice that Dr. Dreamy was from. I made sure I requested a woman this time. Not only to avoid Dr. Dreamy, but I was hoping a women would take my body image issues more seriously. It took over 8 months to get an appointment with psych.

So I go to my appointment, feeling hopeful that I'd be able to get some real help again. I'm waiting in the waiting room and I hear my name called. I look up.....and it's Dr. Dreamy again. Doh! Apparently since I started my file with him, I have to stay with him. Unfortunately, the past few years have been good to Dr. Dreamy and he's still as cute as ever.

Since I didn't really have a choice, I gave Dr. Dreamy another chance. He seemed better this time, although talking to him is still awkward. I feel like he is actually listening now. I've gone back to him many times, with long wait times in between. Instead of telling me what medication would be best for me, he has been asking what I think would be best for me. I'm managing my own meds? Does anyone else's psychiatrist do this? At least this way I wont go on anything that causes weight gain, but I'm not a doctor, I don't really know what I'm talking about.....