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The Aviator - Progression of Howard Hughes' OCD

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Medical Imaging Center of Southern California

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Documentary about OCD (Obsessive Compulsive Disorder) made for a college project. Actor - John Finegan Camera Operators - Jim Kealy, Tess Masero Brioso Gaffer - Simon Doran Sound Recordist - Adam Heapes Producer - Jasmine Reuben-Breslin Director - Tess Masero Brioso

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Obsessions are reoccurring and persistent thoughts.

Obsessive thoughts are not based on reality, for example, a sufferer may believe that germs and bacteria exist everywhere, which cause feelings of anxiety.

Compulsions are repetitive behaviours.

The compulsions are physical urges to perform actions, for example repetitive hand-washing, in order to reduce the feelings of anxiety, caused by the obsessive thoughts.

70% of OCD sufferers experience both obsessions and compulsions combined. However, 20% experience just obsessions alone and 10% experience just compulsions alone.

Behavioural characteristics

The behavioural component of OCD centres on the compulsive behaviour and for sufferers of OCD, compulsions have two properties.

Firstly, compulsions are repetitive in nature and sufferers will often feel compelled to repeat a behaviour, for example, repetitive hand washing.

Secondly, compulsions are used to manage or reduce anxiety, for example, the excessive hand washing is caused by an excessive fear of germs and bacteria and is therefore a direct response to the obsession.

Emotional characteristics

The emotional characteristics of OCD are mainly characterised by anxiety which is caused by the obsessions, however some sufferers of OCD also experience depression.

Obsessions are persistent and/or forbidden thoughts and ideas, which cause high levels of anxiety in OCD sufferers.

Furthermore, OCD can often lead to depression, as the anxiety experienced can often result in a low mood and loss of pleasure in everyday activities (see above), because everyday activities are interrupted by obsessive thoughts and repetitive compulsions.

Cognitive characteristics

Obsessive thoughts are the main cognitive feature of OCD. Examples of reoccurring thoughts include:

Fear of contamination, by dirt or germs; Fear of safety, by leaving doors or windows; religious fears, from being immoral; perfectionism, a fear of not being the best.

For sufferers of OCD, these thoughts occur over and over again.

Some sufferers of OCD adopt cognitive strategies to deal with their obsessions. For example, suffers with religious obsessions may pray over and over, to reduce their feelings of being immoral. Furthermore, sufferers of OCD know that their obsessions and compulsions are irrational and experience selective attention directed towards the anxiety-generating stimuli (similar to the selective attention found in phobias).

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Obsessive Compulsive Disorder | tutor2u Psychology

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Obsessions are reoccurring and persistent thoughts. Obsessive thoughts are not based on reality, for example, a sufferer may believe that germs and bacteria exist everywhere, which cause feelings of anxiety. Compulsions are repetitive behaviours. The compulsions are physical urges to perform actions, for example repetitive hand-washing, in order to reduce the feelings of anxiety, caused by the obsessive thoughts.

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Melanie says, "It wasn't a surprise to me that David has OCD because his mum is always tidying things, putting them in order and checking switches". Emma says, "Really, I didn't know that. I always thought that people with OCD have something in their brains that makes them behave in that way". Outline and evaluate neural and genetic explanations of obsessive-compulsive disorder. Refer to the conversation above in your answer. [12 marks]
The following answer was written by Patrick as Buttershaw Business and Enterprise College in May 2016. It received 12/12: The genetic explanation for obsessive-compulsive disorder (OCD) includes two genes the COMT and the SERT genes. The COMT gene is involved in the regulation of dopamine in the brain. Dopamine is an excitatory neurotransmitter and has been linked to OCD when in higher levels. The COMT gene, when mutated, does not regulate the dopamine as well as it should, this means levels rise, and high levels of dopamine can cause OCD. The SERT gene is involved in the transportation of serotonin, an inhibitory neurotransmitter. When levels of serotonin are low, a person is more likely to get OCD. The SERT gene if mutated reduces serotonin levels to lower than they should be, which causes a person to be more likely to get OCD. Melanie is saying that David inherited one or both of these genes from his mother, causing him to have OCD.

The neural explanation for OCD includes the 'worry circuit', in the brain. The two main areas of the brain associated with OCD are the Orbit Frontal Cortex and the caudate nucleus. The OFC is responsible for sending the worry signals, which are picked up by the thalamus and directed around the body. The caudate nucleus is responsible for suppressing some of these worry signals. If the caudate nucleus is not working properly, the worry signals do not get surprised, and a person worries too much this cab cause OCD. Emma is also right in saying that it is something in someone's brain that causes OCD both can be used to explain OCD.

A strength of the genetic explanation for OCD is that research was done by Choy et al. shows that serotonin can cause OCD at low levels. Choy tested SSRI's, a type of drug that blocks the reuptake of serotonin, and found that they were successful in most patients, this shows that low levels of serotonin are linked with OCD. Therefore a strength of the genetic explanation to explain OCD is that there is supporting research which highlights the implication of serotonin in the development of OCD.

A further strength of the explanations is that there is research that says that OCD can be inherited through genes. Soomro studied people with OCD and their family members and found that if a first generation relative had OCD, an individual is five times more likely to get it at some point in their lives, than if a relative did not have it. This supports the genetic explanation and suggests that OCD runs in the family.

However, a limitation of the genetic explanation is that not everyone with these genes has OCD. This means that there must be other factors that can cause or contribute to an individual getting OCD (e.g. environmental influences such as a negative experience with hygiene and becoming sick). Therefore, a limitation of the genic explanation for OCD is that it does not take other factors (environmental) into account and other psychologists (e.g. behaviourists) would argue that OCD is a learnt condition.
Some students failed to considered neural and genetic explanations and referred to cognitive explanations (related to Emma's 'thinking'). While there are cognitive explanations of OCD this is odd given the nature of the question and the specification requirements. Some answers failed to acknowledge the STEM which costs students important application marks. However, the most common error/confusion was over the role of the COMT and SERT gene and whether serotonin increases/decreases. Finally, some students evaluated the biological approach generally and failed to apply their evaluation to the question and psychopathology.

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Model Answer for Question 10 Paper 2: AS Psychology, June 2016 (AQA) | tutor2u Psychology

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Melanie says, "It wasn't a surprise to me that David has OCD because his mum is always tidying things, putting them in order and checking switches". Emma says, "Really, I didn't know that. I always thought that people with OCD have something in their brains that makes them behave in that way".

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The House Partnership - CBT & Counselling

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A phobia is an anxiety disorder involving excessive and persistent fear of a situation or object. Exposure to the source of the fear triggers an immediate anxiety response.

Phobias are one of the most common mental illnesses in the United States. According to the National Institute of Mental Health (NIH), approximately 12.5% of adults in the U.S. will deal with a specific phobia in their lifetime. Women are more likely to experience phobias than men. Typical symptoms of phobias can include nausea, trembling, rapid heartbeat, feelings of unreality, and being preoccupied with the fear object.

Types of Phobias

The American Psychiatric Association (APA) identifies three different categories of phobias:

1. Social phobias: Now known as social anxiety disorder, this phobia is marked by a fear of social situations in which a person might be judged or embarrassed.

2. Agoraphobia: This phobia involves an irrational and extreme fear of being in places where escape is difficult. It may involve a fear of crowded places or even of leaving one's home.

3. Specific phobias: When people talk about having a phobia of a specific object such as snakes, spiders, or needles, they are referring to a specific phobia.

While not comprehensive, this list of phobias offers a glimpse of the many phobias that can have a serious impact on a person's life. As you may notice while you browse through this list, most specific phobias fall into one of four major categories:

Fears of the natural environment

Fears related to animals

Fear related to medical treatments or issues

Fears related to specific situations

These names themselves are often formed by taking a Greek prefix that represents the fear object and adding the -phobia suffix. Because of this, any attempt at a completely exhaustive list of phobias would be a futile exercise. Any list of phobias could grow with the addition of newly coined terms for previously unnamed specific phobias.

A-Z List of Some of the More Common Phobias

This article lists more than 100 of the most common phobias. It also covers some of the treatment options that are available.

Ablutophobia: Fear of bathing

Achluophobia: Fear of darkness

Acrophobia: Fear of heights

Aerophobia: Fear of flying

Algophobia: Fear of pain

Agoraphobia: Fear of open spaces or crowds

Aichmophobia: Fear of needles or pointed objects

Amaxophobia: Fear of riding in a car

Androphobia: Fear of men

Anemophobia: Fear of air

Anginophobia: Fear of angina or choking

Angrophobia: Fear of anger

Anthrophobia: Fear of flowers

Anthropophobia: Fear of people or society

Aphenphosmphobia: Fear of being touched

Arachibutyrophobia:Fear of peanut butter

Arachnophobia: Fear of spiders

Arithmophobia: Fear of numbers

Astraphobia: Fear of thunder and lightning

Astrophobia: Fear of outer space

Ataxophobia: Fear of disorder or untidiness

Atelophobia: Fear of imperfection

Atychiphobia: Fear of failure

Automatonophobia: Fear of human-like figures

Autophobia: Fear of being alone

Bacteriophobia: Fear of bacteria

Barophobia: Fear of gravity

Bathmophobia: Fear of stairs or steep slopes

Batrachophobia: Fear of amphibians

Belonephobia: Fear of pins and needles

Bibliophobia: Fear of books

Botanophobia: Fear of plants

Cacophobia: Fear of ugliness

Catagelophobia:Fear of being ridiculed

Catoptrophobia: Fear of mirrors

Chionophobia: Fear of snow

Chrometophobia: Fear of spending money

Chromophobia: Fear of colors

Chronomentrophobia: Fear of clocks

Chronophobia: Fear of time

Cibophobia: Fear of food

Claustrophobia: Fear of confined spaces

Climacophobia: Fear of climbing

Coulrophobia: Fear of clowns

Cyberphobia: Fear of computers

Cynophobia: Fear of dogs

Iatrophobia:Fear of doctors

Insectophobia:Fear of insects

Leukophobia: Fear of the color white

Lilapsophobia: Fear of tornadoes and hurricanes

Lockiophobia:Fear of childbirth

Mageirocophobia:Fear of cooking

Megalophobia: Fear of large things

Melanophobia: Fear of the color black

Microphobia: Fear of small things

Mysophobia: Fear of dirt and germs

Necrophobia:Fear of death or dead things

Noctiphobia: Fear of the night

Nomophobia: Fear of being without your mobile phone

Nosocomephobia: Fear of hospitals

Nyctophobia: Fear of the dark

Papyrophobia: Fear of paper

Pathophobia: Fear of disease

Pedophobia:Fear of children

Philematophobia: Fear of kissing

Philophobia: Fear of love

Phobophobia: Fear of phobias

Podophobia: Fear of feet

Porphyrophobia: Fear of the color purple

Pteridophobia: Fear of ferns

Pteromerhanophobia: Fear of flying

Pyrophobia: Fear of fire

Samhainophobia: Fear of Halloween

Scolionophobia: Fear of school

Scoptophobia: Fear of being stared at

Selenophobia: Fear of the moon

Sociophobia: Fear of social evaluation

Somniphobia:Fear of sleep

Venustraphobia: Fear of beautiful women

Verminophobia: Fear of germs

Wiccaphobia: Fear of witches and witchcraft

Xenophobia: Fear of strangers or foreigners

Zoophobia: Fear of animals

Zuigerphobia: Fear of vacuum cleaners

Recap

Symptoms of Phobias

Phobias lead to physical, emotional, and behavioral symptoms. Common symptoms include:

Chest tightness or pain

Chills or hot flashes

Choking sensations

Confusion

Difficulty breathing

Dizziness

Dry mouth

Increased blood pressure

Nausea

Racing heartbeat

Shaking or trembling

Sweating

In addition to these physical symptoms, people may experience dread, a sense of impending doom, fear of losing control, or even the feeling that death is imminent. To avoid such feelings, people with phobias may avoid any situation where they might potentially encounter the source of their fear.

Causes of Phobias

The exact causes of phobias are not known, but it is likely that a combination of factors plays a part. Some factors that increase the risk of developing a phobia include:

Genetics: People with a close family member with a phobia or another anxiety disorder also have a greater risk of a phobia. It is important to note, however, that people who don't have family members with the condition still develop phobias.

Traumatic experiences: A difficult, stressful, or traumatic experience can also trigger the onset of a phobia. For example, being bitten by a dog as a child might trigger a fear of dogs in adulthood.

Common vs. Rare Phobias

Some phobias are more common, while others are often quite rare. Five of the most common phobias include arachnophobia (the fear of spiders), ophidiophobia (the fear of snakes), glossophobia (the fear of public speaking), acrophobia (the fear of heights), and social phobia (the fear of social interactions).

Rare phobias may be novel terms coined to identify a single, unique case or fear that occur quite infrequently. Some different rare specific phobias include spectrophobia (the fear of mirrors), chiclephobia (the fear of chewing gum), and hippopotomonstrosesquipedaliophobia (the fear of long words).

Treatment for Phobias

While phobias can be distressing and create disruptions in your life, they are treatable. Some of the different treatment options include therapy and medication.

Exposure Therapy

Exposure-based treatments are the first-line approach in the treatment of phobias. In this type of treatment, you are gradually and progressively exposed to what you fear. You might start by just thinking about your phobia trigger and then move slowly toward looking at images of the object and finally being near the object in real life.

Types of exposure-based treatments that may be used include:

In vivo exposure: This involves being exposed to the source of your fear in real life.

Virtual exposure: This involves the use of virtual reality to practice gradual exposure.

Systematic desensitization: This involves being gradually exposed until you become desensitized to the source of your fear.

During this process, you'll also practice relaxation techniques to help calm your body when your fear response kicks in.

Cognitive Behavioral Therapy

Often referred to as CBT, cognitive behaviorial therapy involves learning to identify the underlying negative thoughts that contribute to feelings of fear. Once you become better at noticing these thoughts, you can then work on replacing them with more positive, helpful thoughts.

Eye Movement Desensitization and Reprocessing

Eye movement desensitization and reprocessing (EMDR) therapy utilizes rhythmic eye movements to help people process and recover from traumatic experiences. It is frequently used in the treatment of post-traumatic stress disorder (PTSD), but can also be effective in the treatment of a variety of other mental health conditions including phobias.

Medications

Medications may be prescribed in some cases to help manage some of the symptoms you might be experiencing as a result of your phobia. Medications your doctor might prescribe include selective serotonin reuptake inhibitors (SSRIs), beta-blockers, and anti-anxiety drugs.

A Word From Verywell

Phobias can have a serious impact on well-being, but it is important to remember that you are not alone. Phobias are common and treatable. If you believe that you have the symptoms of some type of phobia, consult a doctor for further evaluation and treatment advice.

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Phobias are intense fears of an object, place, situation, or animal. Learn about the many different kinds that exist in this list of some of the most common phobias.

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The behavioural characteristics of phobias can be divided into two characteristics: avoidance and panic.

The key behavioural characteristic of a phobia is avoidance. If a person with a phobia is presented with the object or situation they fear, their immediate response is to avoid it. For example, a person with arachnophobia will avoid being near spiders and people with a social phobia will avoid being in large crowds.

However, people are not always able to avoid their fears and sometimes they come face-to-face with an object or situation they fear, which results in panic, causing high levels of stress and anxiety. Sometimes, the fear response is so intense, it results in a person 'freezing', which is part of the 'fight or flight' fear response. The freezing response is an adaptive response to make a predator think that their prey is dead.
Emotional characteristics
They key emotional characteristics of a phobia, are excessive and unreasonable fear, anxiety and panic. An emotional response is triggered by the presence, or the anticipation of, a specific object or situation, which is excessive in relation to the danger actually posed.
Cognitive characteristics
The cognitive characteristics of phobias are also divided into two characteristics: selective attention and irrational beliefs.

If a person with a phobia is presented with an object or situation they fear, they will find it difficult to direct their attention elsewhere. Therefore, a person's selective attention will cause them to become fixated on the object they fear, because of their irrational beliefs about the danger posed.

Furthermore, a person's phobia is defined by their irrational thinking towards the object or situation. For example, a person with arachnophobia may believe that all spiders are dangerous and deadly, despite the fact that no spiders in the UK are actually deadly.

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Characteristics of Phobias | tutor2u Psychology

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The behavioural characteristics of phobias can be divided into two characteristics: avoidance and panic. The key behavioural characteristic of a phobia is avoidance. If a person with a phobia is presented with the object or situation they fear, their immediate response is to avoid it.

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https://www.wired.com/2012/04/jonah-lehrer-meets-stephen-fry-the-paradoxes-of-bipolar-and-creativity/

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Last night, reading the wonderful third chapter of Jonah Lehrer's Imagine, I came across some material, new to me, on the links between melancholy and creativity. I'm fairly familiar with this literature, but not the the last couple years' worth, and in that time the stack has grown. Experimental work by researchers like Joe Forgas and Modupe Akinola, which shows that melancholy can sharpen cognition, now fattens the pile of studies pioneered by researchers such as Nancy Andreasen.

Andreasen, for instance, found that prominent British novelists and poets were eight times as likely as the general population to suffer from major depression. In another paper she

found that nearly 40 percent of the successful creative people she investigated had the disorder, a rate that's approximately twenty times higher than it is in the general population. (More recently, the psychiatrist Hagop Akiskal found that nearly two-thirds of a sample of influential European artists were bipolar. )

But why? In the past, Andreasen has offered that the energy and confidence that mania produces can help someone start and finish an ambitious work of art - damned handy, since every ambitious work at times (usually many times) seems impossible. Now she adds that the ideas one comes up with during such phases tend to be quite original, as the manic person, in a set of long-distance synaptic leaps that Lehrer explains earlier, draws associations that lie beyond the reach of more ordinary modes of thought. (NB: Not everyone with bipolar gets these manic "highs.")* The ideas they come up with, in short, can be a bit crazy. If they spit them out then and published them, they'd likely be of little worth. But, as Lehrer explains,

then the mania ebbs. The extravagant high descends into a profound low. While this volatility is horribly painful, it can also enable creativity, since the exuberant ideas of the manic period are refined during the depression.

In other words, the emotional extremes of the illness reflect the extremes of the creative process: there is the ecstatic generation phase, full of divergent thoughts, and the attentive editing phase, in which all those ideas are made to converge. This doesn't take away, of course, from the agony of the mental illness, and it doesn't mean that people can create only when they're horribly sad or manic. But it does begin to explain the significant correlations that have been repeatedly observed between depressive syndromes and artistic achievement.

A new idea is borne during mania, refined when it subsides. If you read only that, you can mistakenly think bipolar disorder is a good thing to have, to let run amok. Lehrer is quick to note that but fairly quickly to move on - he's writing a book about creativity, not depression.

But today, as I was pondering these dynamics, the Internet's own synaptic genius brought me another exploration of just these paradoxes, one that lingers longer on the downside, in the form of a wonderful documentary that Stephen Fry and the BBC made a few years ago. Fry made the two-part film after he had a near-fatal manic-depressive collapse. At one level this beautifully produced program is yet another wonderful BBC exploration of a complex subject - a look from many angles unified by the sensibility and presence of a smart, amiable, literate guide. But here thge power of Fry's own story and insight, and the extremely high stakes at hand - the highest possible - raises it another notch. Fine work by one of Britain's finest. I'm not sure we have his match here in the U.S. - a comic entertainer who is also a public intellectual and a searingly honest man.

Hat-tip to the glorious Open Culture for bringing this film to my attention.

*Added 4/10/12, 6:13 a.m. EDT. Thanks to a friend for a prod on this. Fry addresses it in the film, but I forgot to include that definitional wrinkle in my post the first time through.
Please also see my follow-up: Madness Ain't All It's Cracked Up to Be: A Corrective

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Jonah Lehrer Meets Stephen Fry - The Paradoxes of Bipolar and Creativity

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Last night, reading the wonderful third chapter of Jonah Lehrer's Imagine, I came across some material, new to me, on the links between melancholy and creativity. I'm fairly familiar with this literature, but not the the last couple years' worth, and in that time the stack has grown.

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Andy, a 32-year-old IT consultant, is used to people laughing at him when he tries to explain his crippling fear of buttons, specifically those on shirts and jackets.

"I've worked in corporate environments, full of people in suits, and there are buttons everywhere you look. This situation is to me what other people may feel being locked in a burning building, or drowning and not be able to swim to the surface," he says, his voice audibly shaking at the mere thought of rooms full of shirt buttons.

Andy's condition is called koumpounophobia. It is not as common as some phobias - but still affects around one in every 75,000 people. Sufferers report losing contact with family and friends because they are unable to attend weddings and funerals, or abandoning their careers and doing jobs that allow for remote working or casual clothing.

Phobias are irrational fears which are classified as either simple - of a particular object, such as in Andy's case - or complex, when they pertain to a circumstance or situation. Because of the ridicule sufferers are often met with, people tend to suffer in silence and phobias go untreated. "I thought I'd be laughed out of a GP's office," says Andy. "I knew this was a real thing, but didn't know how to explain it without feeling like an idiot."

Another reason many people don't seek help is because of what the treatment entails. The NHS offers cognitive behavioural therapy (CBT) to people with phobias, which includes "exposure" to the object of the fear. A person develops a phobia when their brain has learned to respond to certain non-dangerous situations (such as seeing a small spider) with a "fight-or-flight" response, which causes symptoms that include panic attacks, palpitations, hysterical crying, and the urge to run. Exposure can work because if patients slowly learn to respond to seeing, say, a spider in a calm way - eventually even holding one in their hands - they can essentially "rewire" their brains. But the thought of facing a phobia in such a way can, understandably, be terrifying.

Around 10 million people in the UK suffer from phobias, yet research into causes and treatments is incredibly limited compared with other mental health conditions. Nicky Lidbetter, chief executive of Anxiety UK, has herself suffered from phobias and is a keen supporter of CBT treatment, but argues it needs to be improved and that further research is crucial.

"I remember when anxiety used to be bundled in with depression, despite being a very different condition. We worked hard to raise the profile of anxiety as a separate disorder that could be just as crippling. This is what we need to do with phobias," she says. "Because they often seem comical and irrational, the media doesn't take them seriously and I think this mentality has seeped into the medical world, which is why there's so little funding and research."

Amy is a 25-year-old marketing manager based in Leeds. She says: "I knew that if I told a doctor I was scared of heights they'd make me go on a rollercoaster or something. Just seeing a long flight of stairs was making my heart race. I'd start to shake, and couldn't stop myself from running away." Amy eventually sought help when she and her boyfriend were looking to move in together and it became too limiting to find a ground-floor or basement flat.

Her treatment involved various exercises, such going up in a lift every day and getting off one floor higher each week. She is now able to manage her phobia, although it hasn't disappeared.

CBT and exposure therapy has been proven effective in a lot of cases, but some experts disagree with the way it is applied across-the-board to all patients. Guy Baglow is the director of Mindspa Phobia Clinic in Harley Street, London. "CBT is about correcting thinking patterns, and it works really well for a lot of conditions, but I don't think it's effective in treating phobias," he says. "We deal with a lot of clients who have had exposure therapy, and it has actually reinforced the patterns we want to break. CBT tackles the conscious mind, trying to teach us to reason against our phobias, but most people know their phobias are irrational to begin with, so this doesn't feel helpful."

Despite being overwhelmed at the prospect of exposure, Andy did eventually see his GP, who referred him to a counsellor. "She was really friendly but I had to wait a month for a half-hour phone consultation, and then all I was going to have was one 45-minute session every two weeks. By this point I was too terrified to leave the house."

Even at home, Andy was in a constant state of alert. TV and movies were impossible, in case a close-up of a button appeared onscreen. He needed urgent help. "I moved back in with my parents and spent hundreds of pounds on intensive private therapy, but after a couple of sessions they tried to make me look at some pictures of shirts, and I started panicking. I couldn't get the image out of my head for weeks and it made me constantly terrified. I couldn't go back."

More recently, though, life has become a little easier, and he recently bought his first ever pair of button-fly jeans. "I'm so lucky to have had the support system I do, because without my family I really think I might have considered taking my own life," he says. "Looking back, it's so tragic to realise that while my friends were joking about my weird little quirk and playing pranks on me, on the inside I was battling my own brain every minute of every day. It was so exhausting and stressful, I can't imagine anyone would find it funny if they knew what it was really like."
Names have been changed. Topics

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The misery of weird phobias: 'In the office, there are buttons everywhere'

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Andy, a 32-year-old IT consultant, is used to people laughing at him when he tries to explain his crippling fear of buttons, specifically those on shirts and jackets. "I've worked in corporate environments, full of people in suits, and there are buttons everywhere you look.

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https://www.youtube.com/watch?v=DkaeVrs7-ZA

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Part 3 Primal Fears - BBC Explorations | Storyteller Media

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Jackie is petrified of feathers, Ryan cant fly, and Trevors scared of heights. Irrational phobias are damaging their lives. Will the latest treatments help like dropping them in at the deep end? When fear goes wrong it can turn into a phobia an irrational fear so strong it sometimes ruins lives.

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Sharing is caring.

You have definitely heard about CBT.

You may not know it, or you may not immediately assign meaning to those three letters placed side by side, but there's almost no doubt that you have at least a passing familiarity with CBT.

If you've ever interacted with a therapist, a counselor, or a clinician in a professional setting, you have likely participated in CBT. If you've ever heard friends or loved ones talk about how a mental health professional helped them recognize their fears or sources of distress and aided them in altering their behavior to more effectively work towards their goals, you've heard about the impacts of CBT.

CBT, or cognitive behavioral therapy, is one of the most used tools in the psychologist's toolbox. It's based on a fairly simple idea which, when put into practice, can have wildly positive outcomes.
Become a Science-Based Practitioner!
What is CBT?

This simple idea is that our unique patterns of thinking, feeling, and behaving are significant factors in our experiences, both good and bad. Since these patterns have such a significant impact on our experiences, it follows that altering these patterns can change our experiences (Martin, 2016).

CBT aims to change our thought patterns, the beliefs we may or may not know we hold, our attitudes, and ultimately our behavior in order to help us face our difficulties and more effectively strive towards our goals.

The founder of CBT is a psychiatrist named Aaron Beck, a man who practiced psychoanalysis until he noticed the prevalence of internal dialogues in his clients, and realized how strong the link between thoughts and feelings can be. He altered the therapy he practiced in order to help his clients identify, understand, and deal with the automatic, emotion-filled thoughts that arise throughout the day.

Beck found that a combination of cognitive therapy and behavioral techniques produced the best results for his clients. In describing and honing this new therapy, Beck laid the foundations of the most popular and influential form of therapy of the last 50 years.

This form of therapy is not designed for lifelong participation, but focuses more on helping clients meet their goals in the near future. Most CBT treatment regimens last from five to ten months, with one 50 to 60 minute session per week.

CBT is a hands-on approach that requires both the therapist and the client to be invested in the process and willing to actively participate. The therapist and client work together as a team to identify the problems the client is facing, come up with new strategies for addressing them, and thinking up positive solutions (Martin, 2016).

Cognitive Distortions

Many of the most popular and effective CBT techniques are applied to what psychologists call "cognitive distortions" (Grohol, 2016).

Cognitive distortions: inaccurate thoughts that reinforce negative thought patterns or emotions.

Cognitive distortions are faulty ways of thinking that convince us of a reality that is simply not true.

There are 15 main cognitive distortions that can plague even the most balanced thinkers at times:

Filtering

Filtering refers to the way many of us can somehow ignore all of the positive and good things in our day to focus solely on the negative. It can be far too easy to dwell on a single negative aspect, even when surrounded by an abundance of good things.

Polarized Thinking / "Black and White" Thinking

This cognitive distortion is all about seeing black and white only, with no shades of grey. This is all-or-nothing thinking, with no room for complexity or nuance. If you don't perform perfectly in some area, then you may see yourself as a total failure instead of simply unskilled in one area.

Overgeneralization

Overgeneralization is taking a single incident or point in time and using it as the sole piece of evidence for a broad general conclusion. For example, a person may be on the lookout for a job but have a bad interview experience, but instead of brushing it off as one bad interview and trying again, they conclude that they are terrible at interviewing and will never get a job offer.

Jumping to Conclusions

Similar to overgeneralization, this distortion involves faulty reasoning in how we make conclusions. Instead of overgeneralizing one incident, however, jumping to conclusions refers to the tendency to be sure of something without any evidence at all. We may be convinced that someone dislikes us with only the flimsiest of proof, or we may be convinced that our fears will come true before we have a chance to find out.

Catastrophizing / Magnifying or Minimizing

This distortion involves expectations that the worst will happen or has happened, based on a slight incident that is nowhere near the tragedy that it is made out to be. For example, you may make a small mistake at work and be convinced that it will ruin the project you are working on, your boss will be furious, and you will lose your job. Alternatively, we may minimize the importance of positive things, such as an accomplishment at work or a desirable personal characteristic.

Personalization

This is a distortion where an individual believes that everything they do has an impact on external events or other people, no matter how irrational the link between. The person suffering from this distortion will feel that they have an unreasonably important role in the bad things that happen around them. For instance, a person may believe that the meeting they were a few minutes late in getting to was derailed because of them, and that everything would have been fine if they were on time.

Control Fallacies

Another distortion involves feeling that everything that happens to you is a result of external forces or due to your own actions. Sometimes what happens to us is due to forces we can't control, and sometimes what happens is due to our actions, but the false thinking is in assuming that it is always one or the other. We may assume that the quality of our work is due to working with difficult people, or alternatively that every mistake someone else makes is due to something we did.

Fallacy of Fairness

We are often concerned about fairness, but this concern can be taken to extremes. As we know, life is not always fair. The person who goes through life looking for fairness in all their experiences will end up resentful and unhappy. Sometimes things will go our way, and sometimes they will not, regardless of how fair it may seem.

Blaming

When things don't go our way, there are many ways we can explain or assign responsibility for the outcome. One method of assigning responsibility is blaming others for what goes wrong. Sometimes we may blame others for making us feel or act a certain way, but this is a cognitive distortion because we are the only ones responsible for the way we feel or act.

Shoulds

"Shoulds" refer to the implicit or explicit rules we have about how we and others should behave. When others break our rules, we are upset. When we break our own rules, we feel guilty. For example, we may have an unofficial rule that customer service representatives should always be accommodating to the customer. When we interact with a customer service representative that is not immediately accommodating, we might get angry. If we have an implicit rule that we are irresponsible if we spend money on unnecessary things, we may feel exceedingly guilty when we spend even a small amount of money on something we don't need.

Emotional Reasoning

This distortion involves thinking that if we feel a certain way, it must be true. For example, if we feel unattractive or uninteresting in the current moment, we must be unattractive or uninteresting. This cognitive distortion boils down to:

"I feel it, therefore it must be true."

Clearly our emotions are not always indicative of the objective truth, but it can be difficult to look past how we feel.

Fallacy of Change

The fallacy of change lies in expecting other people to change as it suits us. This ties into the feeling that our happiness depends on other people, and their unwillingness or inability to change, even if we push and press and demand it, keeps us from being happy. This is clearly a damaging way to think, since no one is responsible for our happiness except for us.

Global Labeling / Mislabeling

This cognitive distortion is an extreme form of generalizing, in which we generalize one or two instances or qualities into a global judgment. For example, if we fail at a specific task, we may conclude that we are a total failure in not only this area, but all areas. Alternatively, when a stranger says something a bit rude, we may conclude that he or she is an unfriendly person in general. Mislabeling is specific to using exaggerated and emotionally loaded language, such as saying a woman has abandoned her children when she leaves her children with a babysitter to enjoy a night out.

Always Being Right

While we all enjoy being right, this distortion makes us think we must be right, that being wrong is unacceptable. We may believe that being right is more important than the feelings of others, being able to admit when we've made a mistake, or being fair and objective.

Heaven's Reward Fallacy

This distortion involves expecting that any sacrifice or self-denial on our part will pay off. We may consider this karma, and expect that karma will always immediately reward us for our good deeds. Of course, this results in feelings of bitterness when we do not receive our reward (Grohol, 2016).

Many tools and techniques found in CBT are intended to address or reverse these cognitive distortions.

You can download the printable version of the infographic here.

9 Essential CBT Techniques and Tools

There are many tools and techniques used in CBT, many of which have spread from the therapy context to everyday life. The nine techniques and tools listed below are some of the most common and effective CBT practices.

Journaling

This technique is a way of "gathering data" about our moods and our thoughts. This journal can include the time of the mood or thought, the source of it, the extent or intensity, and how we responded to it, among other factors. This technique can help us to identify our thought patterns and emotional tendencies, describe them, and find out how to change, adapt, or cope with them.

Unraveling Cognitive Distortions

This is a main goal of CBT, and can be practiced with or without the help of a therapist. In order to unravel the cognitive distortions you hold, you must first become aware of which distortions you are most vulnerable to. Part of this involves identifying and challenging our harmful automatic thoughts, which frequently fall into one of the categories listed earlier.

Cognitive Restructuring

Once you identify the distortions or inaccurate views on the world you hold, you can begin to learn about how this distortion took root and why you came to believe it. When you discover a belief that is destructive or harmful, you can begin to challenge it. For example, if you believe that you must have a high paying job to be a respectable person, but you lose your high paying job, you will begin to feel bad about yourself.

Instead of accepting this faulty belief that leads you to think unreasonably negative thoughts about yourself, you could take this opportunity to think about what makes a person "respectable," a belief you may not have explicitly considered before.

Exposure and Response Prevention

This technique is specifically effective for those who suffer from obsessive compulsive disorder (OCD). You can practice this technique by exposing yourself to whatever it is that normally elicits a compulsive behavior, but doing your best to refrain from the behavior and writing about it. You can combine journaling with this technique, or use journaling to understand how this technique makes you feel.

Interoceptive Exposure

This technique is intended to treat panic and anxiety. It involves exposure to feared bodily sensations in order to elicit the response, activate any unhelpful beliefs associated with the sensations, maintain the sensations without distraction or avoidance, and allow new learning about the sensations to take place. It is intended to help the sufferer see that symptoms of panic are not dangerous, although they may be uncomfortable.

Nightmare Exposure and Rescripting

Nightmare exposure and rescripting is intended specifically for those suffering from nightmares. This technique is similar to interoceptive exposure, in that the nightmare is elicited, which brings up the relevant emotion. Once the emotion has arisen, the client and therapist work together to identify the desired emotion and develop a new image to accompany the desired emotion.

Play the Script Until the End

This technique is especially useful for those suffering from fear and anxiety. In this technique, the individual who is vulnerable to crippling fear or anxiety conducts a sort of thought experiment, where they imagine the outcome of the worst case scenario. Letting this scenario play out can help the individual to recognize that even if everything they fear comes to pass, it will likely turn out okay.

Progressive Muscle Relaxation (PMR)

This is a familiar technique to those who practice mindfulness. Similar to the body scan, this technique instructs you to relax one muscle group at a time until your whole body is in a state of relaxation. You can use audio guidance, a YouTube video, or simply your own mind to practice this technique, and it can be especially helpful for calming nerves and soothing a busy and unfocused mind.

Relaxed Breathing

This is another technique that is not specific to CBT, but will be familiar to practitioners of mindfulness. There are many ways to relax and bring regularity to your breath, including guided and unguided imagery, audio recordings, YouTube videos, and scripts. Bringing regularity and calm to your breath will allow you to approach your problems from a place of balance, facilitating more effective and rational decision making (Megan, 2016).

These techniques can help those suffering from a range of mental illnesses and afflictions, including anxiety, depression, OCD, and panic disorder, and they can be practiced with or without the guidance of a therapist. To try some of these techniques without the help of a therapist, see the next section for worksheets and handouts to assist with your practice.

You can download the printable version of the infographic here.

Cognitive Behavioral Therapy Worksheets (PDF) To Print and Use

If you're a therapist looking for ways to guide your client through treatment or a hands-on person who loves to learn by doing, there are many CBT worksheets that can help.

Alternative Action Formulation

This worksheet instructs the user to first list any problems or difficulties you are having. Next, you list your vulnerabilities (i.e., why you are more likely to experience these problems than someone else) and triggers (i.e., the stimulus or source of these problems).

Once you have defined the problems and understand why you are struggling with them, you go on to list coping strategies. These are not solutions to problems, but ways in which you can deal with the effects of these problems that can have a temporary impact. Next, you list the effects of these coping strategies, such as how they make you feel in the short-term and long-term, and the advantages and disadvantages of each strategy.

Finally, you move on to listing alternative actions. If your coping strategies are not totally effective against the problems and difficulties that are happening, you are instructed to list other strategies that may work better.

This worksheet gets you (or your client) thinking about what you are doing now and whether it is the best way forward. You can find it here.

Functional Analysis

One popular technique in CBT is functional analysis. This technique helps you (or the client) learn about yourself, specifically what leads to specific behaviors and what consequences result from those behaviors.

In the middle of the worksheet is a box labeled "Behaviors." In this box, you write down any potentially problematic behaviors or other behaviors you wish to analyze.

On the left side of the worksheet is a box labeled "Antecedents," in which you or the client write down the factors that preceded a particular behavior. These are factors that led up to the behavior under consideration, either directly or indirectly.

On the right side is the final box, labeled "Consequences." This is where you write down the consequences of the behavior, or what happened as a result of the behavior under consideration. "Consequences" may sound inherently negative, but they are not necessarily negative; some positive consequences can arise from many types of behaviors, even if more negative consequences result as well.

This worksheet can help you or your client to find out whether particular behaviors are adaptive and helpful in striving towards your goals, or destructive and self-defeating. Follow this link to print out this worksheet and give it a try.

Longitudinal Formulation

This worksheet helps you address what some CBT therapists call the "5 P Factors" - presenting, predisposing, precipitating, perpetuating, and positives. This formulation process can help you connect the dots between your core beliefs and thought patterns and your present behavior.

This worksheet presents five boxes at the top of the page, which should be completed before moving on to the rest of the worksheet.

1. The first box is labeled "Precipitating Events / Triggers," and corresponds with the Precipitating factor. In this box, you are instructed to write down the events or stimuli that provoke a certain behavior.

2. The next box is labeled "Early Experiences" and corresponds to the Predisposing factor. This is where you list the experiences that you had early on, all the way back to childhood, that may have contributed to the behavior.

3. The third box is "Core Beliefs," which is also related to the Predisposing factor. This is where you write down some of the relevant core beliefs you have regarding this behavior. These are beliefs that may not be explicit, but that you believe deep down, such as "I'm bad" or "I'm not good enough."

4. The fourth box is "Old Rules for Living," which is where you list the rules that you adhere to, whether consciously or subconsciously. These implicit or explicit rules can perpetuate the behavior, even if it is not helpful or adaptive. Rules are if-then statements that provide a judgment based on a set of circumstances. For instance, you may have the rule "If I do not do something perfectly, I'm a complete failure."

5. The final box is labeled "Presenting Problems / Effects of Old Rules." This is where you write down how well these rules are working for you. Are they helping you to be the best you can be? Are they helping you to effectively strive towards your goals?

Below this box there are two flow charts that you can fill out based on how these behaviors and feelings are perpetuated. You are instructed to think of a situation that produces a negative automatic thought, and record the emotion and the behavior that this thought provokes, as well as the bodily sensations that can result. Filling out these flow charts can help you see what drives your behavior or thought and what results from it.

Below these two charts is the box "Protective Factors." This is where you list the factors that can help you deal with the problematic behavior or thought, and perhaps help you break the perpetuating cycle. This can be things that help you cope once the thought or behavior arises or things that can disrupt the pattern once it is in motion.

Finally, the last box is "New Rules for Living." This box relates to the Positive factor, in that it provides you with an opportunity to create new rules for yourself that will disrupt the destructive cycle and allow you to become more effective in meeting your therapeutic goals. Click here if you'd like to try this worksheet.

Dysfunctional Thought Record

This worksheet is especially helpful for people who are struggling with negative thoughts and need to figure out when and why they are most likely to pop up. By learning more about what provokes certain automatic thoughts, they become easier to address and reverse.

The worksheet is divided into seven columns:

1. On the far left, there is space to write down the date and time a dysfunctional thought arose.

2. The second column is where the situation is listed. The user is instructed to describe the event that led up to the dysfunctional thought in detail.

3. The third column is for the automatic thought. This is where the dysfunctional automatic thought is recorded, along with a rating of belief in the thought on a scale from 0% to 100%.

4. The next column is where the emotion or emotions elicited by this thought are listed, also with a rating of intensity on a scale from 0% to 100%.

5. The fifth column is labeled "Distortion." This column is where the user will identify which cognitive distortion(s) they are suffering from with regards to this specific dysfunctional thought, such as all-or-nothing thinking, filtering, jumping to conclusions, etc.

6. The second to last column is for the user to write down alternative thoughts, more positive and functional thoughts that can replace the negative one.

7. Finally, the last column is for the user to write down the outcome of this exercise. Were you able to confront the dysfunctional thought? Did you write down a convincing alternative thought? Did your belief in the thought and/or the intensity of your emotion(s) decrease? To give this worksheet a try, click here.

Fact or Opinion

One of my favorite CBT worksheets is the "Fact or Opinion" worksheet, because it can be extremely helpful in recognizing that your thoughts are not necessarily true.

At the top of this worksheet is an important lesson:

Of course, it can be hard to accept this, especially when we are in the throes of a dysfunctional thought or intense emotion. Filling out this worksheet can help you come to this realization.

The worksheet includes 16 statements that the user must decide are either fact or opinion. These statements include:

I'm a bad person.

I failed the test.

I'm selfish.

I didn't lend my friend money when they asked.

This is not a trick - there is a right answer for each of these statements. (In case you're wondering, the right answers for the statements above are as follows: opinion, fact, opinion, fact.)

This simple exercise can help the user to see that while we have lots of emotionally charged thoughts, they are not all objective truths. Recognizing the difference between fact and opinion can assist us in challenging the dysfunctional or harmful opinions we have about ourselves and others.

If you'd like to print out this worksheet to give it a try, click here.

Cognitive Restructuring

This worksheet employs the use of Socratic questioning, a technique that can help the user to challenge irrational or illogical thoughts.

The top of the worksheet describes how thoughts are a running dialogue in our minds, and they can come and go so fast that we hardly have time to address them. This worksheet aims to help us capture one or two of these thoughts and analyze them.

1. The first box to be filled out is "Thoughts to be questioned." This is where you write down a specific thought, usually one you suspect is destructive or irrational.

2. Next, you write down the evidence for and against this thought. What evidence is there that this thought is accurate? What evidence exists that calls it into question?

3. Once you have identified the evidence, you can make a judgment on this thought, specifically whether it is based on facts or your feelings.

4. Next, you answer a question on whether this thought is truly a black and white situation, or whether reality leaves room for shades of grey. This is where you think about whether you are using all-or-nothing thinking, or making things unreasonably simple when they are truly complex.

5. In the last box on this page, you consider whether you could be misinterpreting the evidence or making any unverified assumptions.

On the next page, you are instructed to think about whether other people might have different interpretations of the same situation, and what those interpretations might be.

Next, ask yourself whether you are looking at all the relevant evidence, or just the evidence that backs up the belief you already hold. Try to be as objective as possible.

The next box asks you whether your thought may an exaggeration of a truth. Some negative thoughts are based in truth, but extended past their logical boundaries.

Next, you are instructed to consider whether you are entertaining this negative thought out of habit or because the facts truly support it.

Once you have decided whether the facts support this thought, you are encouraged to think about how this thought came to you. Was it passed on from someone else? If so, are they a reliable source for truth?

Finally, you complete the worksheet by identifying how likely the scenario your thought brings up actually is, and whether it is the worst case scenario.

These " Socratic questions" encourage a deep dive into the thoughts that may plague you, and offer an opportunity to analyze and evaluate them for truth. If you are having thoughts that do not come from a place of truth, this worksheet can be an excellent tool for identifying and defusing them.

For more CBT worksheets and handouts, visit this website.

Some More CBT Interventions and Exercises

Haven't had enough CBT tools and techniques yet? Continue on for more useful and effective exercises!

Behavioral Experiments

These are related to thought experiments, in that you engage in a "what if" consideration. Behavioral experiments differ from thought experiments in that you actually test out these "what ifs" outside of your thoughts (Boyes, 2012).

In order to test a thought, you can experiment with the outcomes that different thoughts produce. For example, you can test the thought:

"If I criticize myself, I will be motivated to work harder" vs. "If I am kind to myself, I will be motivated to work harder."

First, you would try criticizing yourself when you need motivation to work harder and record the results. Then you would try being kind to yourself and recording the results. Next, you would compare the results to see which thought was closer to the truth.

These behavioral experiments can help you learn how to best strive towards your therapeutic goals and how to be your best self.

Thought Records

Thought records are useful in testing the validity of your thoughts (Boyes, 2012). They involve gathering and evaluating the evidence for and against a particular thought, allowing for an evidence-based conclusion on whether the thought is valid or not.

For example, you may have the belief "My friend thinks I'm a bad friend." You would think of all the evidence for this belief, such as "She didn't answer the phone the last time I called" or "She cancelled our plans at the last minute", and evidence against this belief, like "She called me back after not answering the phone" and "She invited me to her barbecue next week. If she thought I was a bad friend, she probably wouldn't have invited me."

Once you have evidence for and against, the goal is to come up with more balanced thoughts, such as

"My friend is busy and has other friends, so she can't always answer the phone when I call. If I am understanding of this, I will truly be a good friend."

Thought records apply the use of logic to ward off unreasonable negative thoughts and replace them with more balanced, rational thoughts (Boyes, 2012).

Pleasant Activity Scheduling

This technique can be especially helpful for dealing with depression (Boyes, 2012). It involves scheduling activities in the near future that you can look forward to.

For example, you may write down one activity per day that you will engage in over the next week. This can be as simple as watching a movie you are excited to see or calling a friend to chat. It can be anything that is pleasant to you, as long as it is not unhealthy (i.e., eating a whole cake in one sitting or smoking).

You can also try scheduling an activity for each day that provides you with a sense of mastery or accomplishment (Boyes, 2012). It's great to do something pleasant, but doing something small that can make you feel accomplished may have longer lasting and farther reaching effects.

This simple technique can introduce more positivity into your day and help you make your thinking less negative.

Imagery Based Exposure

This exercise involves thinking about a recent memory that produced strong negative emotions and analyzing the situation.

For example, if you recently had a fight with your significant other and they said something hurtful, you can bring that situation to mind and try to remember it in detail. Next, you would try to label the emotions and thoughts you experienced during the situation and identify the urges you felt (e.g., to run away, to yell at your significant other, to cry).

Visualizing this negative situation, especially for a prolonged period of time, can help you to take away its ability to trigger you and reduce avoidance coping (Boyes, 2012). When you expose yourself to all of the feelings and urges you felt in the situation and survive experiencing the memory, it takes some of its power away.

Situation Exposure Hierarchies

This technique may sound complicated, but it's relatively simple.

Situation Exposure Hierarchies involves making a list of things that you would normally avoid (Boyes, 2012). For example, someone with severe social anxiety may typically avoid making a phone call instead of emailing or asking someone on a date.

Next, you rate each item on how distressed you think you would be, on a scale from 0 to 10, if you engaged in it. For the person suffering from severe social anxiety, asking someone on a date may be rated a 10 on the scale, while making a phone call instead of emailing might be rated closer to a 3 or 4.

Once you have rated each item, you rank them according to their distress rating. This will help you recognize the biggest difficulties you face, which can help you decide which items to address and in what order. It may be best to start with the less distressing items and work your way up to the most distressing items.

A CBT Manual and Workbook for Your Own Practice + for Your Client

If you're interested in giving CBT a try with your clients, there are many books and manuals that can help get you started. Some of these books are for the therapist only, and some are to be navigated as a team or with guidance from the therapist.

There are many manuals out there for helping therapists apply CBT in their work, but these are some of the most popular:

For clients or for therapist and client to work through together, these are some of the most popular manuals and workbooks:

There are many other manuals and workbooks out there that can help get you started with CBT, but these are a good start.

5 Last Cognitive Behavioral Activities

Before we go, there are a few more CBT activities and exercises that may be helpful for you or your clients that we'd like to cover.

Mindfulness Meditation

As readers of this blog will likely know by now, mindfulness can have a wide range of positive impacts, including helping with depression, anxiety, addiction, and many other mental illnesses or difficulties.

Mindfulness can help those suffering from harmful automatic thoughts to disengage from rumination and obsession over these thoughts by helping them stay firmly grounded in the present.

Successive Approximation

This is a somewhat fancy name for a simple idea that you have likely already hear of: breaking up large tasks into small steps to make it easier to accomplish.

It can be overwhelming to be faced with a huge goal we would like to accomplish, like opening a business or remodeling a house. This is true in mental health treatment as well, since the goal to overcome depression or anxiety and achieve mental wellness can seem like a monumental task to those who are suffering from severe symptoms.

By breaking the large goal into small, easy to accomplish steps, we can map out the path to success and make the journey seem a little less overwhelming.

Writing Self-Statements to Counteract Negative Thoughts

This technique can be difficult for someone just beginning their CBT treatment or suffering from severe symptoms, but it can also be extremely effective (Anderson, 2014).

When you (or your client) are being plagued by negative thoughts, it can be hard to confront them, especially if your belief in these thoughts is strong. To counteract these negative thoughts, it can be helpful to write down a positive, opposite thought.

For example, if the thought that you are worthless keeps popping into your head, try writing down a statement like "I am a person with worth" or "I am person with potential." In the beginning, it can be difficult to accept these replacement thoughts, but the more you bring out these positive thoughts to counteract the negative ones, the stronger the association will be.

Visualize the Best Parts of Your Day

When you are feeling depressed or negative, it is difficult to recognize that there is good in your life as well. This simple technique of bringing to mind the good parts of your day can be a small step in the direction of recognizing the positive (Anderson, 2014).

All you need to do is write down the things in your life that you are most thankful for or the things that are most positive in your day. The simple act of writing down these good things can forge new associations in your mind which make it easier to see the positive, even when there is plenty of negative as well.

Reframe Your Negative Thoughts

It can be all too easy to succumb to negative thoughts as a default setting. If you find yourself immediately thinking a negative thought when you see something new, such as entering an unfamiliar room and thinking "I hate the color of that wall," give reframing a try (Anderson, 2014).

Reframing involves countering the negative thought(s) by noticing things you feel positive about as quickly as possible. For instance, in the example where you immediately think of how much you hate the color of that wall, you would push yourself to notice five things in the room that you feel positively about (e.g., the carpet looks comfortable, the lampshade is pretty, the windows let in a lot of sunshine).

You can set your phone to remind you throughout the day to stop what you are doing and think of the positive things around you. This can help you to push your thoughts back into the realm of the positive instead of the negative.

You can download the printable version of the infographic here.

A Take Home Message

As always, I hope this post has been helpful. There are a lot of great tips and techniques in here that can be extremely effective in the battle against depression, anxiety, OCD, and a host of other problems or difficulties.

However, as is the case with many treatments, they depend on you (or your client) putting in a lot of effort. I would encourage you to give these techniques a real try, and allow yourself the luxury of thinking they may actually work. When we approach a potential solution with the assumption that it will not work, then it will probably not work. When we approach a potential solution with an open mind and the thought that it just might work, it has a much better chance of succeeding.

So if you are struggling with negative automatic thoughts, please consider these tips and techniques and give them a real shot. Likewise, if your client is struggling, encourage them to make the effort, because the payoff can be better than they can imagine.

If you are struggling with severe symptoms of depression or suicidal thoughts, please call the following number in your respective country:

USA: National Suicide Prevention Hotline at 1-800-273-8255

UK: Samaritans hotline at 116 123

The Netherlands: Netherlands Suicide Hotline at 09000767

France: Suicide écoute at 01 45 39 40 00

Germany: Telefonseelsorge at 0800 111 0 111 for Protestants, 0800 111 0 222 for Catholics, and 0800 111 0 333 for children and youth

For a list of other suicide prevention websites, phone numbers, and resources, see this website.
Become a Science-Based Practitioner!
Please know that there are people out there who care and that there are treatments that can help.

Thank you for reading, and please let us know about your experiences with CBT in the comments section. Have you tried it? How did it work for you? Are there any other helpful exercises or techniques that we did not touch on in this piece?

References

Anderson, J. (2014, June 12). 5 get-positive techniques from Cognitive Behavioral Therapy. Everyday Health. Retrieved from http://www.everydayhealth.com/hs/major-depression-living-well/cognitive-behavioral-therapy-techniques/

Boyes, A. (2012, December 6). Cognitive behavioral therapy techniques that work: Mix and match Cognitive Behavioral Therapy techniques to fit your preferences. Psychology Today. Retrieved from https://www.psychologytoday.com/blog/in-practice/201212/cognitive-behavioral-therapy-techniques-work

Grohol, J. (2016). 15 common cognitive distortions. Psych Central. Retrieved from https://psychcentral.com/lib/15-common-cognitive-distortions/

http://www.infocounselling.com/list-of-cbt-techniques/

Martin, B. (2016). In-Depth: Cognitive Behavioral Therapy. Psych Central. Retrieved from https://psychcentral.com/lib/in-depth-cognitive-behavioral-therapy/

Megan, R. (2016, August 8). List of CBT techniques - cognitive behavioral therapy. Info Counselling. Retrieved from http://www.infocounselling.com/list-of-cbt-techniques/

http://psychologytools.com

http://www.therapistaid.com

www.webmd.com - http://www.webmd.com/depression/guide/cognitive-behavioral-therapy-for-depression#1

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25 CBT Techniques and Worksheets for Cognitive Behavioral Therapy

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Sharing is caring. You have definitely heard about CBT. You may not know it, or you may not immediately assign meaning to those three letters placed side by side, but there's almost no doubt that you have at least a passing familiarity with CBT .

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Recent article on depression and biological causes/treatments

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Recent article on depression and biological causes/treatments

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Scientists have raised hopes for more effective treatments for depression, a condition that affects over 300 million people globally, after mapping out the genetic foundations of the mental disorder in unprecedented detail.

In the world's largest investigation into the impact of DNA on the mental disorder, more than 200 researchers identified 44 gene variants that raise the risk of depression. Of those, 30 have never been connected to the condition before.

By tripling the number of gene regions linked to depression, scientists now hope to understand more about why the disorder strikes some but not others, even when they have similar life experiences. The work could also help in the search for drugs to treat the condition which affects as many as one in four people over a lifetime.

"If you have a lower genetic burden of depression, perhaps you are more resistant to the stresses we all experience in life," said Cathryn Lewis, professor of statistical genetics and a senior author on the study at King's College London.

Previous work with twins suggests that genetics explains about 40% of depression, with the rest being driven by other biological factors and life experiences. If people are ranked according to the number of genetic risk factors for depression they carry, those in the top 10% are two-and-a-half times more likely to experience depression than those in the bottom 10%, Lewis said.

While the scientists found 44 gene variants linked to depression, these are only a small fraction of the total, because many more will have had too small an effect to be discovered in the latest study. "We know that thousands of genes are involved in depression with each having a very modest effect on a person's risk," said Lewis. "There is certainly no single gene for depression."

Clinical depression is a debilitating condition the causes of which are still largely unknown. According to the World Health Organization, it is the leading cause of disability globally, costing the global economy as much as $1tn annually with no country on the planet immune.

Sufferers can experience a range of "losses" - of appetite, mood, sleep, concentration, love, joy, enthusiasm, energy and serenity. As many as 3% of people with major depressive disorder attempt suicide.

But there are few new treatments in the pipeline, as big pharmaceuticals companies have largely withdrawn from expensive research into the next generation of anti-depressants.

In the study, the researchers pooled seven separate datasets from the UK, the US, Iceland and Denmark, to glean genetic information on 135,000 people who reported having depression, and 345,000 mentally healthy individuals. The scientists then compared DNA across the groups to find gene variants that were more common in those with depression.

The work, published in Nature Genetics, revealed a substantial overlap in the genetics that underpins depression and other mental disorders such as anxiety, schizophrenia and bipolar disorder, but also body mass index, where DNA that predisposes people to obesity also raises the risk of depression.

As expected, many of the genes reported in the study have a role in how neurons grow, operate and send signals around the brain, where two regions known as the prefrontal cortex and the anterior cingulate cortex are the most important for depression.

Gerome Breen, a co-author on the paper, said that some of the gene variants they found are linked to neurotransmitters such as serotonin, which existing antidepressants work on. But other gene variants point to new biological mechanisms that the next generation of drugs might target.

"What we've had in recent decades is a shortage of new mechanisms that underlie depression and psychiatric disorders," he said. "The hope is that in new data we identify new processes that can be targeted by newly developed types of drugs, which have different mechanisms of action to existing medications."

It will take more research to confirm that the gene variants found in the study are really linked to depression. Many of the participants involved in the research self-reported depression, which is far less reliable than a clinical diagnosis. This means that some of the gene variants the scientists link to depression could turn out not to be involved in the disorder.

Jonathan Flint, who studies the genetics of depression at the University of California in Los Angeles said: "Our current treatments for depression are relatively ineffective - roughly speaking, only about half of patients improve - so we really need better therapies. To discover new treatments and to deliver the ones we have more effectively, we need a better understanding of what causes depression. Finding genetic risk variants is a way to do just that - the risk variants point to genes that are involved in the disease, and thus provide clues to how depression arises."
Topics

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'Gene map for depression' sparks hopes of new generation of treatments

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Scientists have raised hopes for more effective treatments for depression, a condition that affects over 300 million people globally, after mapping out the genetic foundations of the mental disorder in unprecedented detail. In the world's largest investigation into the impact of DNA on the mental disorder, more than 200 researchers identified 44 gene variants that raise the risk of depression.

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This is a definition of abnormality. The idea is that there are various theoretical descriptions of 'normality' and if someone does not fit within this theoretical idea of normality their behaviour is abnormal.

An example of a theoretical description of abnormality is the one suggested by Marie Jahoda in 1958.

She suggested that there were 6 criteria that needed to be fulfilled for ideal mental health ('normality'). The six criteria were a positive attitude towards the self, self-actualisation, autonomy, resistance to stress, environmental mastery and an accurate perception of reality. These are outlined below:
Positive attitude towards the self
This is linked to the individual's level of self-esteem. For ideal mental health the positive attitude should be at a good level, so that the individual feels happy with themselves.
Self-actualisation
Self-actualisation is being in a state of contentment, feeling that you have become the best you can be.
Autonomy
This is having the independence and self-reliance. The ability to function as an individual and not depending on others.
Resistance to stress
This criteria is that an individual should not feel under stress and they should be able to handle stressful situations competently.
Environmental mastery
Having environmental mastery means that the person can adapt to new situations and be at ease at all situations in their life.
Accurate perception of reality
This criteria is focused on how the individual sees the world around them and to achieve ideal mental health they should have a perspective that is similar to how others see the world. This is focused very much on the distortions of thinking that some people, e.g. people with schizophrenia, may experience.

Jahoda stated that for ideal mental health to be achieved the individual should experience all of these criteria for optimum ideal mental health and that if some are not fulfilled the person will experience difficulties.
Strengths of the definition
Focused: A strength is that this definition allows for an individual who is struggling to have targeted intervention if their behaviour is not 'normal'. For example, their distorted thinking could be addressed to help their behaviour become normal, as if their thinking is biased then their behaviour will be too.

Positive: This definition focuses on what is helpful and desirable for the individual, rather than the other way round

Achievement of goals: This idea allows for clear goals to be set and focused upon to achieve ideal mental health, and, in Jahoda's opinion, to achieve normality.
Weaknesses of the definition
Feasibility: The criteria outlined by Jahoda makes ideal mental health (normality) practically impossible to achieve. This means that the majority of the population, using this definition, would be abnormal.

Ethnocentrism: The criteria of autonomy makes the collectivist cultures, where the greater good and helping / relying on others is encouraged, seem abnormal. As most western cultures are individualist the criteria outlined by Jahoda seem a reasonable fit, but non-western cultures cannot relate to the criteria she outlines. This means that the definition is not global.

Subjectivity: The criteria that Jahoda stipulates are vague and are therefore very difficult to measure. This makes the decision as to whether someone fulfils the criteria difficult to make.

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Deviation from Ideal Mental Health | tutor2u

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This is a definition of abnormality. The idea is that there are various theoretical descriptions of 'normality' and if someone does not fit within this theoretical idea of normality their behaviour is abnormal. An example of a theoretical description of abnormality is the one suggested by Marie Jahoda in 1958.

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We've just flicked the switch on moving all our digital resources to instant digital download - via our new subject stores.

For every subject you can now access each digital resource as soon as it is ordered. This will always be the latest edition of each resource too (and we'll update you automatically if there is an upgraded version to use).

Simply add the required resources to your cart, checkout using the usual options and your resources will be available to access immediately via your mytutor2u account.

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Psychopathology - Definitions of Abnormality | tutor2u Psychology

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We've just flicked the switch on moving all our digital resources to instant digital download - via our new subject stores. For every subject you can now access each digital resource as soon as it is ordered. This will always be the latest edition of each resource too (and we'll update you automatically if there is an upgraded version to use).

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Biological Explanation as an Alternative

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Biological Explanation as an Alternative

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Biological explanations of dysfunctional behaviour centres around physiology, and refers to aspects of biology such as genetics and brain functioning. The biological explanation of depression specifically refers to two factors: In terms of genes, family research - especiallyOne study which conducted family correlational research into depression was
neurotransmitter dysfunction and inherited genes. In terms of neurotransmitter dysfunction, the biological approach would explain that depression is significantly associated with low levels of serotonin, which has been also been associated with many forms of dysfunctional behaviour including excess anger, anxiety, poor social functioning and other mood disorders. Serotonin is believed to have a variety of roles, and affects brain functioning; though it is not known whether depression is caused by serotonin levels, or whether depression causes low serotonin, or if there is another factor causing them both.
twin and adoption studies - has shown there to be a genetic link to depression, and that this suggests some people may carry genes that predispose them to depression and other mood disorders. Thus, depression could be explained in terms of genetic predispositions. Wender et al. It was an adoption study which looked at whether environment or genetics appeared to be more associated with depression in adopted adults. The study used a sample of 71 adults who had been adopted and who had a mood disorder, and 71 controls with the same mean age who'd also been adopted but did not have a mood disorder. All had been removed from their mothers at a young age. Psychiatric evaluations were conducted of both the biological and adoptive parents to see whether there was a stronger correlation between depression in adopted adults and depression in adopted parents or biological parents. The results showed that there was an eight fold increase in unipolar depression among the biological parents of the adults. In other words, adoptive parents were eight times less likely to have depression, and the biological parents having depression correlated more significantly with depression in the adopted children than the adopted parents having depression.

Thus mood disorders appear to have a genetic link, and biological psychologists would thus attribute depression to genetics.

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Biological explanations of dysfunctional behaviour centres around physiology, and refers to aspects of biology such as genetics and brain functioning. The biological explanation of depression specifically refers to two factors: In terms of genes, family research - especiallyOne study which conducted family correlational research into depression was neurotransmitter dysfunction and inherited genes.

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Great abstract on importance of therapist in CBT - AO3

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Great abstract on importance of therapist in CBT - AO3

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Therapist competence, comorbidity and cognitive-behavioral therapy for depression. - PubMed - NCBI

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Rational emotive behavior therapy, also known as REBT, is a type of cognitive-behavioral therapy developed by psychologist Albert Ellis. REBT is focused on helping clients change irrational beliefs.

Let's take a closer look at how rational emotive behavior was developed and how it works.

History of Rational Emotive Behavior Therapy

As a young man, Ellis found himself longing for companionship yet experienced a severe fear of talking to women.

In order to tackle his fear, Ellis decided to perform an experiment. For a month, his visited a nearby park and forced himself to talk to 100 different women. Over time, Ellis found that his fear of speaking to women had diminished considerably. Ellis later explained that this experience served as a basis for developing his approach to therapy, combining behavioral strategies with assessing underlying thoughts and emotions.

Ellis had trained as a clinical psychologist. As he treated patients, he became increasingly dissatisfied with the results offered by the traditional psychoanalytic approach to therapy that he was using at the time. He noted that while his patients were able to become aware of their underlying problems, their behavior did not necessarily change as a result. Simply becoming conscious of the problem was not enough to lead to actual changes in behavior, he concluded.

By the 1950s, Ellis had started experimenting with other types of psychotherapy and was heavily influenced by philosophers and psychologists including Karen Horney and Alfred Adler as well as the work of behavioral therapists.

Ellis's goal was to develop what he viewed as an action-oriented approach to psychotherapy designed to produce results by helping clients manage their emotions, cognitions, and behaviors.

According to Ellis, "people are not disturbed by things but rather by their view of things." The fundamental assertion of rational emotive behavior therapy (REBT) is that the way people feel is largely influenced by how they think.

When people hold irrational beliefs about themselves or the world, problems can result. Because of this, the goal of REBT is to help people alter illogical beliefs and negative thinking patterns in order to overcome psychological problems and mental distress.

Rational emotive behavior therapy was one of the very first types of cognitive therapies. Ellis first began developing REBT during the early 1950s and initially called his approach rational therapy. In 1959, the technique was redubbed rational emotive therapy and later rechristened rational emotive behavior therapy in 1992. Ellis continued to work on REBT until his death in 2007.

The ABC Model

Ellis suggested that people mistakenly blame external events for unhappiness. He argued, however, that it is our interpretation of these events that truly lies at the heart of our psychological distress. To explain this process, Ellis developed what he referred to as the ABC Model:

A - Activating Event: Something happens in the environment around you.

B - Beliefs: You hold a belief about the event or situation.

C - Consequence: You have an emotional response to your belief.

The events and situations that people encounter throughout life are only one piece of the puzzle.

In order to understand the impact of such events, it is also essential to look at the beliefs people hold about these experiences as well as the emotions that arise as a result of those beliefs.

The Basic Steps in Rational Emotive Behavior Therapy

In order to better understand how REBT looks, it is important to take a closer look at how the therapeutic process itself.

1. Identify the Underlying Irrational Thought Patterns and Beliefs

The very first step in the process is to identify the irrational thoughts, feelings, and beliefs that lead to psychological distress. In many cases, these irrational beliefs are reflected as absolutes, as in "I must," "I should," or "I cannot." According to Ellis, some of the most common irrational beliefs include:

Feeling excessively upset over other people's mistakes or misconduct.

Believing that you must be 100 percent competent and successful in everything to be valued and worthwhile.

Believing that you will be happier if you avoid life's difficulties or challenges.

Feeling that you have no control over your own happiness; that your contentment and joy are dependent upon external forces.

By holding such unyielding beliefs, it becomes almost impossible to respond to situations in a psychologically healthy way. Possessing such rigid expectations of ourselves and others only leads to disappointment, recrimination, regret, and anxiety.

2. Challenge the Irrational Beliefs

Once these underlying feelings have been identified, the next step is to challenge these mistaken beliefs. In order to do this, the therapist must dispute these beliefs using very direct and even confrontational methods. Ellis suggested that rather than simply being warm and supportive, the therapist needs to be blunt, honest, and logical in order to push people toward changing their thoughts and behaviors.

3. Gain Insight and Recognize Irrational Thought Patterns

As you might imagine, REBT can be a daunting process for the client. Facing irrational thought patterns can be difficult, especially because accepting these beliefs as unhealthy is far from easy. Once the client has identified the problematic beliefs, the process of actually changing these thoughts can be even more challenging.

While it is perfectly normal to feel upset when you make a mistake, the goal of rational emotive behavior therapy is to help people respond rationally to such situations. When faced with this type of situation in the future, the emotionally healthy response would be to realize that while it would be wonderful to be perfect and never make mistakes, it is not realistic to expect success in every endeavor. You made a mistake, but that's okay because everyone makes mistakes sometimes. All you can do is learn from the situation and move on.

It is also important to recognize that while rational emotive behavior therapy utilizes cognitive strategies to help clients, it also focuses on emotions and behaviors as well. In addition to identifying and disputing irrational beliefs, therapists and clients also work together to target the emotional responses that accompany problematic thoughts. Clients are also encouraged to change unwanted behaviors using such things as meditation, journaling, and guided imagery.

A Word From Verywell

REBT can be effective in the treatment of a range of psychological disorders including anxiety and phobias as well as specific behaviors such as severe shyness and excessive approval-seeking.

Sources:
Ellis, A. Reason and emotion in psychotherapy. New York: Carol; 1991. Ellis, A. Reflections on Rational-Emotive Therapy. Journal of Consulting and Clinical Psychology, 61, 199-201; 1993. Ellis, A & Dryden, W. The Practice of Rational Emotive Behavior Therapy. New York: Springer Publishing Company, Inc.; 1997.

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How Does Rational Emotive Behavior Therapy Work?

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Rational emotive behavior therapy, also known as REBT, is a type of cognitive-behavioral therapy developed by psychologist Albert Ellis. REBT is focused on helping clients change irrational beliefs. Let's take a closer look at how rational emotive behavior was developed and how it works.

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I have depression. [CBT is] very, very good for helping [me] not listen to [my] self critical voice, which is so damaging.

What's the theory behind CBT?

CBT is based on the idea that the way we think about situations can affect the way we feel and behave. For example, if you interpret a situation negatively then you might experience negative emotions as a result, and those bad feelings might then lead you to behave in a certain way.

How does negative thinking start?

Negative thinking patterns can start from childhood onwards. For example, if you didn't receive much attention or praise from your parents or teachers at school, you might've thought "I'm useless, I'm not good enough".

Over time you might come to believe these assumptions, until as an adult these negative thoughts become automatic. This way of thinking might then affect how you feel at work, university or in your general life.

If your negative interpretation of situations goes unchallenged, then these patterns in your thoughts, feelings and behaviour can become part of a continuous cycle:

How does CBT work?

In CBT you work with a therapist to identify and challenge any negative thinking patterns and behaviour which may be causing you difficulties. In turn this can change the way you feel about situations, and enable you to change your behaviour in future.

You and your therapist might focus on what is going on in your life right now, but you might also look at your past, and think about how your past experiences impact the way you see the world.

CBT is learning to stop the cycle of negative thinking. I still have relapses now and it is the one tool that I use to get me out of the truly dark spots.

Watch Holly talk about how CBT has helped her manage her mental health problems:

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I have depression. [CBT is] very, very good for helping [me] not listen to [my] self critical voice, which is so damaging. CBT is based on the idea that the way we think about situations can affect the way we feel and behave.

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Cognitive behavioural therapy (CBT) is a talking therapy that can help you manage your problems by changing the way you think and behave.
It's most commonly used to treat anxiety and depression, but can be useful for other mental and physical health problems.

How CBT works

CBT is based on the concept that your thoughts, feelings, physical sensations and actions are interconnected, and that negative thoughts and feelings can trap you in a vicious cycle.

CBT aims to help you deal with overwhelming problems in a more positive way by breaking them down into smaller parts.

You're shown how to change these negative patterns to improve the way you feel.

Unlike some other talking treatments, CBT deals with your current problems, rather than focusing on issues from your past.

It looks for practical ways to improve your state of mind on a daily basis.

Uses for CBT

CBT has been shown to be an effective way of treating a number of different mental health conditions.

In addition to depression or anxiety disorders, CBT can also help people with:

CBT is also sometimes used to treat people with long-term health conditions, such as:

Although CBT cannot cure the physical symptoms of these conditions, it can help people cope better with their symptoms.

What happens during CBT sessions

If CBT is recommended, you'll usually have a session with a therapist once a week or once every 2 weeks.

The course of treatment usually lasts for between 5 and 20 sessions, with each session lasting 30 to 60 minutes.

During the sessions, you'll work with your therapist to break down your problems into their separate parts, such as your thoughts, physical feelings and actions.

You and your therapist will analyse these areas to work out if they're unrealistic or unhelpful, and to determine the effect they have on each other and on you.

Your therapist will then be able to help you work out how to change unhelpful thoughts and behaviours.

After working out what you can change, your therapist will ask you to practise these changes in your daily life and you'll discuss how you got on during the next session.

The eventual aim of therapy is to teach you to apply the skills you have learnt during treatment to your daily life.

This should help you manage your problems and stop them having a negative impact on your life, even after your course of treatment finishes.

Pros and cons of CBT

Cognitive behavioural therapy (CBT) can be as effective as medicine in treating some mental health problems, but it may not be successful or suitable for everyone.

Some of the advantages of CBT include:

it may be helpful in cases where medicine alone has not worked

it can be completed in a relatively short period of time compared with other talking therapies

the highly structured nature of CBT means it can be provided in different formats, including in groups, self-help books and online

it teaches you useful and practical strategies that can be used in everyday life, even after the treatment has finished

Some of the disadvantages of CBT to consider include:

you need to commit yourself to the process to get the most from it - a therapist can help and advise you, but they need your co-operation

attending regular CBT sessions and carrying out any extra work between sessions can take up a lot of your time

it may not be suitable for people with more complex mental health needs or learning difficulties, as it requires structured sessions

it involves confronting your emotions and anxieties - you may experience initial periods where you're anxious or emotionally uncomfortable

it focuses on the person's capacity to change themselves (their thoughts, feelings and behaviours) - this does not address any wider problems in systems or families that often have a significant impact on someone's health and wellbeing

Some critics also argue that because CBT only addresses current problems and focuses on specific issues, it does not address the possible underlying causes of mental health conditions, such as an unhappy childhood.

How to find a CBT therapist

You can get psychological therapies, including CBT, on the NHS.

You can refer yourself directly to an NHS psychological therapies service (IAPT) without a referral from a GP.

Or your GP can refer you if you prefer.

If you can afford it, you can choose to pay for your therapy privately. The cost of private therapy sessions varies, but it's usually £40 to £100 per session.

The British Association for Behavioural & Cognitive Psychotherapies (BABCP) keeps a register of all accredited therapists in the UK and The British Psychological Society (BPS) has a directory of chartered psychologists, some of whom specialise in CBT.

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Overview - Cognitive behavioural therapy (CBT)

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Cognitive behavioural therapy (CBT) is a talking therapy that can help you manage your problems by changing the way you think and behave. It's most commonly used to treat anxiety and depression, but can be useful for other mental and physical health problems. CBT is based on the concept that your thoughts, feelings, physical sensations and actions are interconnected, and that negative thoughts and feelings can trap you in a vicious cycle.

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Diet therapy as a treatment for depression

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Diet therapy as a treatment for depression

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Abstract

Background

The possible therapeutic impact of dietary changes on existing mental illness is largely unknown. Using a randomised controlled trial design, we aimed to investigate the efficacy of a dietary improvement program for the treatment of major depressive episodes.

Methods

'SMILES' was a 12-week, parallel-group, single blind, randomised controlled trial of an adjunctive dietary intervention in the treatment of moderate to severe depression. The intervention consisted of seven individual nutritional consulting sessions delivered by a clinical dietician. The control condition comprised a social support protocol to the same visit schedule and length. Depression symptomatology was the primary endpoint, assessed using the Montgomery-Åsberg Depression Rating Scale (MADRS) at 12 weeks. Secondary outcomes included remission and change of symptoms, mood and anxiety. Analyses utilised a likelihood-based mixed-effects model repeated measures (MMRM) approach. The robustness of estimates was investigated through sensitivity analyses.

Results

We assessed 166 individuals for eligibility, of whom 67 were enrolled (diet intervention, n = 33; control, n = 34). Of these, 55 were utilising some form of therapy: 21 were using psychotherapy and pharmacotherapy combined; 9 were using exclusively psychotherapy; and 25 were using only pharmacotherapy. There were 31 in the diet support group and 25 in the social support control group who had complete data at 12 weeks. The dietary support group demonstrated significantly greater improvement between baseline and 12 weeks on the MADRS than the social support control group, t(60.7) = 4.38, p < 0.001, Cohen's d = -1.16. Remission, defined as a MADRS score <10, was achieved for 32.3% ( n = 10) and 8.0% ( n = 2) of the intervention and control groups, respectively ( χ (1) = 4.84, p  = 0.028); number needed to treat (NNT) based on remission scores was 4.1 (95% CI of NNT 2.3-27.8). A sensitivity analysis, testing departures from the missing at random (MAR) assumption for dropouts, indicated that the impact of the intervention was robust to violations of MAR assumptions.

Conclusions

These results indicate that dietary improvement may provide an efficacious and accessible treatment strategy for the management of this highly prevalent mental disorder, the benefits of which could extend to the management of common co-morbidities.

Trial registration

Australia and New Zealand Clinical Trials Register (ANZCTR): . Registered on 29 February 2012.

Background

There is now extensive observational evidence across countries and age groups supporting the contention that diet quality is a possible risk or protective factor for depression [-]. Although there are many versions of a 'healthful diet' in different countries and cultures, the available evidence from observational studies suggests that diets higher in plant foods, such as vegetables, fruits, legumes and whole grains, and lean proteins, including fish, are associated with a reduced risk for depression, whilst dietary patterns that include more processed food and sugary products are associated with an increased risk of depression [, , ]. Whilst cognisant of the limitations of observational data, these associations are usually observed to be independent of socioeconomic status, education and other potentially confounding variables and not necessarily explained by reverse causality (see, e.g. [-]).

Recently, a meta-analysis confirmed that adherence to a 'healthful' dietary pattern, comprising higher intakes of fruit and vegetables, fish and whole grains, was associated with a reduced likelihood of depression in adults []. Similarly, another meta-analysis reported that higher adherence to a Mediterranean diet was associated with a 30% reduced risk for depression, with no evidence for publication bias []. The Mediterranean diet is recognised as a healthful dietary pattern and has been extensively associated with chronic disease risk reduction []. More recently, a systematic review confirmed relationships between unhealthful dietary patterns, characterised by higher intakes of foods with saturated fat and refined carbohydrates, and processed food products, and poorer mental health in children and adolescents []. Several cohort studies also reported associations between the quality of women's diets during pregnancy and the risk for emotional dysregulation in children [-], with new insights into potential mechanisms of action that include brain plasticity [], the gut microbiota [] and inflammatory [] and oxidative stress [] pathways.

Although there are data suggesting that some nutritional supplements may be of utility as adjunctive therapies in psychiatric disorders [], the field of research focusing on the relationships between overall dietary quality and mental disorders is new and has thus far been largely limited to animal studies and observational studies in humans. Thus, whilst the existing observational data support a causal relationship between diet quality and depression on the basis of the Bradford Hill criteria [] and are supported by extensive experimental data in animals (see, e.g. []), randomised controlled trials are required to test causal relationships and identify whether or not dietary change can improve mental health in people with such conditions. We conducted a systematic review and identified a number of interventions with a dietary change component that had examined mental health-related outcomes []. Whilst approximately half of these studies reported improvements in measures of depression or anxiety following the intervention, at the time of the review no studies fulfilling quality criteria had been conducted in mental health populations or had been designed to test the hypothesis that dietary improvement might result in improvements in mental health. Since then, one study has been published evaluating the possible impact of a lifestyle program, comprising both diet and exercise, on mental health symptoms in patients with depression and/or anxiety; this study failed to show any differences in symptom levels between those in the intervention and those in the attention control group []. On the other hand, post hoc analysis of a large-scale intervention trial provides preliminary support for dietary improvement as a strategy for the primary prevention of depression. Individuals at increased risk for cardiovascular events were randomised to a Mediterranean diet supplemented with either extra-virgin olive oil or mixed nuts, or a low-fat control diet []. Whilst not statistically powered to assess the effectiveness of the intervention for preventing depression, there was evidence (albeit non-significant) of a reduced risk for incident depression for those randomised to a Mediterranean diet with nuts. This protective effect was statistically significant in those with type 2 diabetes, who comprised approximately half the sample [].

Using a randomised controlled trial (RCT) design, we thus aimed to investigate the efficacy of a dietary program for the treatment of major depressive episodes. In this trial, Supporting the Modification of lifestyle In Lowered Emotional States (SMILES), we hypothesised that structured dietary support, focusing on improving diet quality using a modified Mediterranean diet model, would be superior to a social support control condition (befriending) in reducing the severity of depressive symptomatology.

Methods

Study design

This was a 12-week, parallel-group, single blind RCT of a dietary intervention in the treatment of moderate to severe depression (for the protocol see []). This trial was registered in the Australia and New Zealand Clinical Trials Register (ANZCTR): (ACTRN12612000251820) prior to commencing recruitment. Participants were recruited from two sites: Barwon Health in Geelong and St. Vincent's Health in Melbourne (Victoria, Australia) over a 3-year period. Participants were randomised to receive either dietary support or social support ('befriending' []). Participants in both groups completed assessments prior to program commencement (baseline), with the primary and secondary outcomes measured at program completion (12 weeks, primary endpoint). Approval to conduct the study was received from Human Research Ethics Committees of St. Vincent's and Barwon Health. Written informed consent was obtained from all participants after they had received a complete description of the study. The study's protocol was developed in accordance with the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) guidelines. Reporting of findings pertaining to primary and secondary outcomes was done in accordance with the Consolidated Standards of Reporting Trials (CONSORT) 2010 guidelines and their extension to non-pharmacologic treatments.

Participants

Inclusion criteria

Eligibility criteria included participants who were at screening: aged 18 or over and could provide informed consent; successfully fulfilled the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV-TR) diagnostic criteria for a major depressive episode (MDE); scored 18 or over on the Montgomery-Åsberg Depression Rating Scale (MADRS) []; and scored 75 or less, out of a possible score of 104, on a Dietary Screening Tool (DST) [] modified for Australian food products. The DST was completed to confirm 'poor' dietary quality, before enrolment. This screening tool was used to reflect usual daily or weekly intake of specified foods. Broadly defined, participants had to report a poor (low) intake of dietary fibre, lean proteins and fruit and vegetables, and a high intake of sweets, processed meats and salty snacks. If participants were on antidepressant therapy or undergoing psychotherapy, they were required to be on the same treatment for at least 2 weeks prior to randomization. Participants had to be readily available for a 12-week period and have the ability to eat foods as prescribed, without religious, medical, socio-cultural or political factors precluding participation or adherence to the diet.

Exclusion criteria

Participants were ineligible if they had: (1) a concurrent diagnosis of bipolar I or II disorder; (2) two or more failed trials of antidepressant therapy for the current MDE; (3) known or suspected clinically unstable systemic medical disorder; (4) pregnancy; (5) commencement of new psychotherapy or pharmacotherapy within the preceding 2 weeks; (6) severe food allergies, intolerances or aversions; (7) current participation in an intervention targeting diet or exercise; (8) a primary clinical diagnosis of a personality disorder and/or a current substance use disorder.

Sample recruitment

Community-based recruitment strategies were used to identify study participants, including flyers in medical waiting rooms, pharmacies and university campuses; newsletters; and contact with potential referral sources (e.g. general practitioners, private psychiatrists and local psychiatric inpatient units). Media interviews and advertisements in social media (e.g. Twitter, Facebook), Google, local newspapers and radio stations were also employed as recruitment strategies. Ethics committee requirements meant that we needed to be explicit regarding our planned intervention, with the advertisements stating: 'We are trialling the effect of an educational and counselling program focusing on diet that may help improve the symptoms of depression'.

Interventions

Dietary support

The dietary intervention comprised personalised dietary advice and nutritional counselling support, including motivational interviewing, goal setting and mindful eating, from a clinical dietician in order to support optimal adherence to the recommended diet. This comprised the 'Mod iMedDiet', developed by RO and CI, which was based on the Australian Dietary guidelines [] and the Dietary Guidelines for Adults in Greece [] and is concordant with our previous dietary recommendations for the prevention of depression []. The primary focus was on increasing diet quality by supporting the consumption of the following 12 key food groups (recommended servings in brackets): whole grains (5-8 servings per day); vegetables (6 per day); fruit (3 per day), legumes (3-4 per week); low-fat and unsweetened dairy foods (2-3 per day); raw and unsalted nuts (1 per day); fish (at least 2 per week); lean red meats (3-4 per week) [], chicken (2-3 per week); eggs (up to 6 per week); and olive oil (3 tablespoons per day), whilst reducing intake of 'extras' foods, such as sweets, refined cereals, fried food, fast-food, processed meats and sugary drinks (no more than 3 per week). Red or white wine consumption beyond 2 standard drinks per day and all other alcohol (e.g. spirits, beer) were included within the 'extras' food group. Individuals were advised to select red wine preferably and only drink with meals. The dietary composition of the Mod iMedDiet was as follows: protein 18% of total energy (E); fat 40% of E; carbohydrates 37% of E; alcohol 2% of E; fibre/other 3% of E. The diet was designed to be easy to follow, sustainable, palatable, and satiating. Individuals were advised to consume the diet ad libitum, as the intervention did not have a weight loss focus. The method for scoring the Mod iMedDiet is similar to those used in PREDIMED [] and the Framingham Offspring Cohort []. It is a criterion-based diet score that uses pre-defined absolute or normative goals of consumption for specific food items, independent of the individual's characteristics. It was developed based on the recommended intakes of the 11 food group components that comprise the Mod i MedDiet (as above), and of the score has a theoretical maximum value of 120.

Participants received seven individual dietary support sessions of approximately 60 minutes each, delivered by an Accredited Practising Dietician; the first four sessions occurred weekly and the remaining three sessions occurred every 2 weeks. At the first session, the dietician conducted a diet history to assess usual dietary intake. Participants were provided with supporting written information specifically designed for the intervention to assist with achieving dietary adherence. In order to provide examples of serving sizes and exposure to the recommended foods, participants were also provided with a food hamper, incorporating the main components of the diet, along with recipes and meal plans. Subsequent sessions used motivational interviewing techniques, and participants were encouraged to set personalised goals.

Social support

The social support control condition comprised a manualised 'befriending' protocol [], using the same visit schedule and length as the dietary support intervention. Befriending consists of trained personnel discussing neutral topics of interest to the participant, such as sport, news or music, or in cases where participants found the conversation difficult, engaging in alternate activities such as cards or board games, with the intention of keeping the participant engaged and positive. This is done without engaging in techniques specifically used in the major models of psychotherapy. Research assistants (RAs) in this trial completed manual-guided training and also participated in role-playing training exercises to ensure consistent delivery of the protocol. Befriending aims to control for four factors: time; client expectancy; therapeutic alliance; and therapist factors when compared to the intervention group in an RCT and is often used as a control condition for clinical trials of psychotherapy []. Participants in the social support control group were provided with movie tickets as compensation for their time and participation in the study and were offered participation in a group dietary counselling session at the conclusion of the trial.

Assessments and outcomes

Once deemed to be eligible, participants completed a 7-day food diary and the Cancer Council of Victoria food frequency questionnaire [], in the week leading up to baseline assessment. Participants attended a local pathology clinic to provide fasting blood samples before undertaking baseline assessment and randomization.

Baseline and follow-up assessments

Details of baseline and follow-up assessments have been reported elsewhere []. Briefly, primary and secondary endpoints were as described in the following sections.

Primary outcome

The MADRS was used to assess the change in depressive symptomatology at baseline and at the primary endpoint of 12 weeks. The MADRS is an interviewer-rated instrument, comprising 10 items, each measured on a 6-point scale (scores range from 0-60 with higher scores depicting greater symptom severity). It has been found to be a robust and psychometrically sound measure of depressive symptomatology [].

Secondary outcomes

The Hospital Anxiety and Depression Scale (HADS) [] was administered as a self-report questionnaire. The Profile of Mood States (POMS) was used to assess mood [], and the Clinical Global Impression - Improvement (CGI-I) Scale [] was used to assess change in symptoms from baseline to endpoint. The World Health Organization wellbeing scale (WHO-5) [] and the Generalized Self-Efficacy Scale [] were used to assess wellbeing and self-efficacy, respectively. Clinical data including height, weight and waist circumference were also collected and the body mass index (BMI) was calculated. Participants were also asked the following: whether they were a current smoker (yes/no); if they had an existing medical condition (physical or mental); and the names and doses of any medications they were taking. Current levels of physical activity were assessed using International Physical Activity Questionnaire (IPAQ) scores, which capture Metabolic Equivalent of Task (MET) minutes per week. A total MET score was calculated for each participant as a summary of Walking, Moderate and Vigorous MET scores []. Dietary quality was assessed using the Mod iMedDiet score, which was based on consumption of the key food groups (i.e. wholegrains, vegetables, fruits, legumes, nuts, fish, lean red meats, chicken, low fat dairy, eggs, olive oil, extras) and will be presented in more detail, along with the dietary strategy, in a forthcoming publication. Dietary assessments, using 7-day food diaries, were administered at baseline and endpoint to both groups to identify dietary changes and adherence to the recommended diet; this was done by assessing change in the Mod i MedDiet score, which is based on the consumption of the key food groups. Biomarkers, including plasma fatty acids, fasting glucose, total and HDL and LDL cholesterol and triglycerides were also assessed.

Sample size

Our original sample size calculation required 88 people per group, assuming an attrition of 15%, with 8 predictors. For a one-tailed analysis with type I error or alpha set at the .05 level, the study would have been powered at 80% to detect a true difference in rating scale score between the diet and befriending groups if the effect size was 0.15 or greater on the MADRS.

Randomization

The randomization sequence was computer generated by an independent person (OD) using a 2 × 2 block design. The sequence was saved to a password-protected spreadsheet, and groups were coded A and B. The randomization allocation was managed by the trial dieticians or 'befrienders', in order to ensure that the research assistants responsible for mental health assessments were blind to participants' group allocations, and the randomization schedule and coding of group allocations were not, at any time, accessible to the research assistants conducting the assessments, or to the biostatistician (SC). At the conclusion of the baseline appointment, the dietician/befriender would meet privately with the participant and inform them of their group allocation in order to maintain blinding of the research assistants.

Blinding

Although full blinding of participants to condition in this study was not possible, several strategies were employed to reduce the risk of bias. First, participants were provided with only partial information on the study hypothesis; the social support control condition was termed 'befriending' and research assistants emphasised the link between social support and mental health as an outcome of interest; and participants in both the intervention and the social support control group were provided with standardised care, with all participants attending appointments in the same location and with the same format, as well as similar duration and frequency. All communication between participants and research staff during the period of intervention (i.e. scheduling concerns, questions regarding intervention) was done directly between participants and their respective 'clinician'. Participants were clearly instructed only to contact the dietician/befriender personally and to avoid contact with the research assistant, and voice messages were checked daily by the dietician/befriender to avoid unintended contact or information on participants' allocation. Research assistants did not have direct contact with participants for the duration of the intervention. Final assessments were organised by the dietician or befriender, and research assistants remained blind to condition for the final assessment of outcomes. Prior to assessment, participants were reminded not to reveal the group to which they had been assigned. Statistical analyses were conducted by an external statistician (SC), who was blind to group allocation prior to analysis.

Data analyses

The analyses were conducted in accordance with the International Conference on Harmonization E9 statistical principles. Independent samples t tests and chi-square ( χ ) analyses were used to compare participants who completed and did not complete the 12 weeks of the trial.

Intention-to-treat (ITT) analyses were adopted. The primary efficacy analysis was based on between-group differences in average change from baseline to 12 weeks for the primary outcome measure (MADRS); these analyses were conducted using planned comparisons within a restricted maximum likelihood (REML)-based mixed-effects model, repeated measures (MMRM) approach. Within the MMRM, treatment and assessment occasion and the interaction between treatment group and assessment occasion were included as fixed factors. The MMRM approach is the preferred method of dealing with clinical trial data in psychiatry []. The benefits of these MMRM methods are that all available participant data are included in the model []. By planning to use MMRM, we made the a priori assumption that missing data were missing at random (MAR); however, we tested these assumptions in sensitivity analyses (as below). The Toeplitiz covariance structure was used to model the relations between observations on different occasions. Planned comparisons using MMRM were also conducted to examine group differences in mean change on the secondary outcome measures from baseline to 12 weeks. Cohen's d as a measure of effect size was calculated based on observed data. Supplementary sensitivity analyses with the MMRM models were conducted, controlling for relevant confounding variables such as gender, education, physical activity, baseline BMI and baseline Mod iMedDiet score. All tests of treatment effects were conducted using an alpha level of 0.05 and reporting 95% confidence intervals. Pearson's product-moment correlations were calculated to determine whether changes in MADRS scores correlated to changes in biomarkers. Analysis of covariance (ANCOVA) was implemented to evaluate interactions between group allocation and change adherence to Mod i MedDiet on MADRS scores at 12 weeks, adjusting for MADRS at baseline. Whilst acknowledging the increased potential for type 1 errors, given that reported comparisons for all primary and secondary outcomes were pre-planned comparisons that were determined a priori and documented in the trial protocol, we did not make adjustments for multiple comparisons.

Sensitivity analyses

We compared demographic, health measures, current treatment, diet quality and psychological measures at baseline between participants with complete follow-up and those with missing data at follow-up, using the chi-squared test for categorical data and t tests for continuous measures. To test departures from missing at random (MAR), a weighted sensitivity analysis using the Selection Model Approach was applied to the main outcome findings [, ]. Briefly, once data had been imputed under MAR ( n  = 5), parameter estimates from each imputed dataset were reweighted to allow for the data to be missing not at random (MNAR). The chosen constant values used to add to the imputed missing data to account for MNAR were multiplications of standard error (i.e. 1.6) for main outcome comparison under MAR assumptions. To evaluate the robustness of our findings, different degrees of departure from the MAR assuming plausible values ranging from 10*SE to -8*SE were considered.

Results

We assessed 166 individuals for eligibility. Of these, 99 were excluded. We thus randomised 67 individuals with MDD to the trial (intervention, n = 33; social support control, n = 34). Figure presents a CONSORT flow chart. Baseline characteristics of all enrolled participants are presented in Table . The dietary group had significantly lower scores on the dietary screening tool and the Mod iMedDiet score than the social support control group at baseline, primarily due to lower intakes of fruit and higher intakes of extras. Otherwise, groups were well matched on characteristics.

Completer analysis

Fifty-six individuals (83.6%) completed the assessment at the 12-week endpoint. There were significantly more completers in the dietary support group (93.9%, n = 31) than the social support control group (73.5%, n = 25), χ (1) = 5.08, p = 0.024. Those who did not complete the intervention were significantly more likely to have post-secondary education (81.8%, n = 9) than those who completed (45.5%, n = 25), χ (1) = 4.85, p = 0.028; this relationship was observed for the social support control group, χ (1) = 6.92, p = 0.009 and not in the dietary support group, χ (1) = 0.01, p  = 0.965.

Primary outcome: depressive symptomatology

The dietary support group demonstrated significantly greater improvement in MADRS scores between baseline and 12 weeks than the social support control group, t(60.7) = 4.38, p < .001 (Fig. ). The effect size for this difference was a Cohen's d of -1.16 (95% CI -1.73, -0.59) and represented an estimated average between group difference, in terms of change from baseline to 12 weeks, of 7.1 points on the MADRS ( SE = 1.6). The MMRM was rerun, adjusting for variables such as sex, education, physical activity, baseline BMI and baseline Mod iMedDiet score; the significant between-group difference in change from baseline to 12 weeks remained, t(58.7) = 4.40, p <  0.001.

Results from sensitivity analyses accounting for missing data under the NMAR assumption are presented in Fig. . Two NMAR scenarios were investigated in the sensitivity analyses: (1) dropouts in the intervention group had worse MADRS outcome at 12 weeks, and (2) dropouts in the control group had better MADRS outcomes. As Fig. shows, findings were insensitive to assumption 1, even when assuming outcomes as large as 10*SE (an increase of 16 in MADRS score compared to imputation under the MAR assumption). Findings were also robust under assumption 2, and only a large departure from the MAR assumption (i.e. 8*SE = 12.8 reduction on MADRS) made the observed intervention effect non-significant.

Secondary outcomes

At 12 weeks, 32.3% ( n = 10) of the dietary support group and 8.0% ( n = 2) of the social support control group achieved remission criteria of a score less than 10 on the MADRS; this between-group difference was significant, χ (1) = 4.84, p  = 0.028. Based on these remission data, the number needed to treat (NNT) is 4.1 (95% CI of NNT 2.3-27.8).

Concordant with the findings for the MADRS, the dietary support group demonstrated significantly greater improvement from baseline to 12 weeks than the social support control group on the Hospital Anxiety and Depression Scale (HADS)-depression subscale, t(55.1) = 2.20, p = 0.032 (Table ). Similar findings were obtained with the HADS-anxiety subscale, t(59.0) = 2.19, p = 0.033. These significant differences remained after controlling for sex, education, physical activity, baseline BMI and baseline Mod iMedDiet scores. Cohen's d for HADS-depression was -0.632 (95% CI -1.186, -0.078), and for HADS-anxiety it was -0.594 (95% CI -1.147, -0.042).

On the CGI-I at 12 weeks, the dietary support group had significantly lower average scores ( M = 2.1, SD = 1.3) than the social support control group ( M = 3.0, SD = 1.3), t(50) = -2.58, p  = 0.013. Based on these figures, the dietary support group on average had 'much improved' scores, whereas the social support control group had 'minimally improved' scores on the CGI-I.

On the POMS total mood disturbance score, as well as the subscale scores (subscales not reported) there were no significant differences between the groups. Similarly, there were no significant differences between groups with respect to self-efficacy or wellbeing.

At intervention cessation, the dietary support group had significant improvements in the consumption of the following food groups: whole grain cereals (mean increase 1.21 (SD 1.77) servings/day); fruit (0.46 (0.71) servings/day); dairy (0.52 (0.72) servings/day); olive oil (0.42 (0.49) servings/day); pulses (1.40 (2.39) servings/week); and fish (1.12 (2.65) servings/week). With respect to the consumption of unhealthful food items, intake of extras substantially declined (mean decrease 21.76 (SD 16.01) servings/week) in the dietary support group. Conversely, there were no significant changes observed in the social support control group for any of the key food groups. These findings were confirmed by analysis of the Mod iMedDiet scores: the dietary support group showed significantly greater improvement from baseline to 12 weeks on Mod iMedDiet scores than controls, t(55.6) = -4.78, p < 0.001; the differences remained after controlling for sex, education, physical activity, baseline BMI and baseline Mod iMedDiet score. Cohen's d for the Mod i MedDiet was 1.36 (95% CI 0.74-1.98). There were no significant differences between groups with respect to BMI or physical activity.

Data on change in psychopharmacological medications over the 12 weeks were available for 53 individuals. One person in each of the dietary support and social support groups started taking psychopharmacological medications over the 12 weeks. There were two patients in the social support group who ceased their medications. There were too few participants to undertake inferential statistics. Changes in biomarkers are also detailed in Table . The only significant difference between the two groups was with respect to change in total polyunsaturated fatty acids; the social support group showed a significant drop in polyunsaturates over the 12 weeks, t(54.9) = -2.41, p = 0.019. Changes in MADRS did not correlate with any of the changes in biomarkers; all correlations were less than 0.2 and were not significant at the p < .050 level. Finally, change in dietary quality, measured using 12 week Mod iMedDiet score differences from baseline scores, was associated with change in depression scores in the intervention group: the interaction between group allocation and change in Mod iMedDiet scores after adjusting for baseline MADRS scores was statistically significant, F(2) = 9.6, p < 0.001. The correlation was only significant in the intervention group ( p  < 0.001); the unstandardised beta coefficient was -0.22 (95% CI -0.32, -0.12), indicating a 2.2 score improvement in MADRS with every 10% increase in dietary adherence.

Discussion

These results provide preliminary RCT evidence for dietary improvement as an efficacious treatment strategy for treating major depressive episodes. We report significant reductions in depression symptoms as a result of this intervention, with an overall effect size of -1.16. These effects appear to be independent of any changes in BMI, self-efficacy, smoking rates and/or physical activity. Concordant with our primary outcome, significant improvements were also observed on self-reported depressive and anxiety symptoms and on the Clinical Global Impressions Improvement scale. Whilst other mood (POMS) and wellbeing (WHO-5) scores did not differ between groups, changes were in the expected direction and were likely affected by lack of statistical power. Critically, substantial improvements on the Mod i MedDiet score were evident in the dietary support group but not in the social support control group, and these changes correlated with changes in MADRS scores.

The results of this trial suggest that improving one's diet according to current recommendations targeting depression [] may be a useful and accessible strategy for addressing depression in both the general population and in clinical settings. Whilst there are many data to suggest that eating a more healthful diet is more expensive than a less healthful diet [], our detailed modelling of the costs of 20 of the SMILES participants' baseline diets compared to the costs of the diet we advocated showed that our strategy can be affordable []. Indeed, we estimated that participants spent an average of AU$138 per week on food and beverages for personal consumption at baseline, whilst the costs per person per week for the diet we recommended was AU$112 per week, with both estimations based on mid-range product costs [].

A pertinent observation was that improvements in depressive symptoms were independent of weight change. These findings were expected, as the diet intervention was ad libitum and did not have a weight loss focus, but provide further support for the beneficial role of dietary improvement per se. The extensive observational evidence linking diet quality to mental health has repeatedly shown that the observed relationships exist independently of various measures of body composition.

Although dietary changes were not reflected in the traditional cardiovascular disease biomarkers, the protective effects of healthful dietary patterns are often independent of these risk factors []. There are many other biological pathways by which dietary improvement may influence depressive illness; previous discussions have centered on inflammatory [] and oxidative stress [] pathways, as well as brain plasticity [] and the new evidence base focused on the gut microbiota []. Each of these pathways is suggested to play a role in depression and is also influenced by diet quality. Moreover, behavioural changes associated with food (cooking/shopping/meal patterns) are an expected outcome of a nutrition intervention, and these changes in activity may also have had a therapeutic benefit.

Strengths and limitations

There are methodological features of our study that must be considered. Firstly, there is the issue of expectation bias due to the fact that we needed to be explicit in our advertising regarding the nature of the intervention and to the inability to blind the participants to their intervention group; this may have biased the results and also resulted in differential dropout rates. Moreover, in regard to our randomisation process, a block size of four, whilst recommended for small sample sizes to avoid imbalances in allocation, may have been insufficient to support allocation concealment. As discussed above, to mitigate these issues significant effort was made to mask our hypothesis from the participants, and emphasis was placed on the potential benefit of social support to mental health. Clearly, our results must also be considered in light of the small sample size. Failure to reach our planned sample size increases the possibility that our sample was not representative and limited our ability to conduct subgroup analyses. It may also have inflated the effect size we observed. However, our original power calculations were based on a very small effect size; arguably, this would not have been clinically significant. There were differential completion rates in each group: 94% versus 73.5% in the dietary and social support groups, respectively. This suggests that the mechanisms underpinning missingness may be different between the two groups; however, results from comprehensive sensitivity analyses testing alternatives to the MAR assumption revealed that, whilst under the NMAR assumptions observed intervention effects moved towards the null, our findings remained robust against departures from the MAR assumption. A larger sample size and assessments at more than two time points would have afforded more sophisticated statistical modelling; this should be a key focus of future replication studies.

Importantly, the high completion rates in the intervention group point to the acceptability of the dietary intervention to the participants. The fact that the dietary intervention group was able to make significant improvements to their diet quality suggests that dietary improvement is achievable for those with clinical depression despite the fatigue and lack of motivation that are prominent symptoms of this disorder. On the other hand, the challenges we had with recruiting this clinical population, likely due to the aforementioned symptoms and the requirement to attend the study centre on several occasions, points to the need to utilise different methods for delivering the intervention that do not require attendance with the dietician in person, such as telephone or Skype. Finally, given that we recruited participants on the basis of existing 'poor' quality diet, this may limit the generalisability of our findings to the wider population of individuals with depression. However, evidence suggests that our study sample was not necessarily a special subgroup; the recent 2014-2015 Australian Health Survey tells us that only 5.6% of Australian adults had an adequate intake of vegetables and fruits. In this study, only 15 out of 166 people screened were excluded on the basis of a pre-existing 'good' diet, suggesting that - concordant with the wider population - poor diet is the norm in those with depressive illness.

Implications

Recent updates to clinical guidelines for the treatment of mood disorders in Australia have, in recognition of the emerging and established data regarding the importance of health behaviours (diet, exercise, sleep and smoking) to mood disorders, made explicit recommendations regarding the need to address these behaviours as a first step in the treatment of patients []. The results of this RCT offer further support for the need to focus on addressing poor diet in clinical practice and provide some guidance regarding the strategies that may be used to support this imperative. They suggest the new possibility of adding clinical dieticians to multidisciplinary mental health teams and making dietician support available to those experiencing depressive symptoms in primary and other care settings. Clearly, successfully improving diet quality in patients will also benefit the physical illnesses that are so commonly comorbid with depression and which are both a cause and consequence of depression. Upskilling dieticians to best deliver this program to this patient population may also be required.

Conclusions

In summary, this is the first RCT to explicitly seek to answer the question: If I improve my diet, will my mental health improve? Whilst emphasising the preliminary nature of this study and the imperative for replication in studies with larger sample sizes, the results of our study suggest that dietary improvement guided by a clinical dietician may provide an efficacious treatment strategy for the management of this highly prevalent mental disorder. Future work in this new field of nutritional psychiatry research should focus on replication, ensuring larger samples and more sophisticated study designs, in order to confirm effects and afford sensitivity analyses to identify predictors of treatment response. The scaling up of interventions and identification of the pathways that mediate the impact of dietary improvement on depressive illness are also key imperatives. Clinicians should also consider promoting the benefits of dietary improvement and facilitating access to dietetics support for their patients with depression.

Declarations

Acknowledgements

We would like to acknowledge the contributions of Josephine Pizzinga, Melanie Ashton, Siobahn Housden, Laura Nicholls, Thea Valkidis, Thaise Mondin, Meghan Hockey, Olivia Young and Clare Daley - all of whom contributed their time and efforts to the running of this RCT. Finally, we offer our profound thanks to the participants, who contributed their time to this study.

Authors' contributions

FNJ conceived the study and developed the protocol, led the RCT and has been primarily responsible for drafting the manuscript. AON acted as trial coordinator in the first year of the RCT, developed and applied for ethical approvals, played a primary role in overseeing the RCT and has made a substantial contribution to the drafting of the manuscript. RO and CI were responsible for the development of the Mod i MedDiet and the associated score, and RO played a primary role in delivering the dietary intervention. CI (and AON) developed the bloods protocol for the RCT. Both RO and CI have made a substantial contribution to the data interpretation and the drafting of the manuscript. As the team statistician, SC played the primary role in data analysis, as well as data interpretation and the drafting of the manuscript. MM undertook sensitivity and adherence analyses at the review stage and contributed to the final manuscript. SD has made a substantial contribution to the running of the study, the data collation, cleaning and analysis and the drafting of the manuscript. CM, MLC, LB, OMD and AMH have all made an important contribution to the original design of the study protocol, data interpretation and the drafting of the manuscript. DC and MB were the consultant psychiatrists on the study and made an important contribution to the design of the study protocol, the running of the study, the interpretation of the data and the drafting of the manuscript. All authors read and approved the final manuscript.

Competing interests

This study was supported by a grant from the National Health and Medical Research Council of Australia (NHMRC) (#1021347). Woolworths Limited provided sponsorship in the form of food vouchers for participants. Village cinemas donated cinema vouchers and Carman's Fine Foods donated muesli bars for participants. A grant from Meat and Livestock Australia (2013) funded biochemistry data collected and analysed as part of the SMILES trial.

These sponsors had no role in the design, analysis or preparation of the manuscript for publication.

Felice N Jacka has received Grant/Research support from the Brain and Behaviour Research Institute, the National Health and Medical Research Council (NHMRC), Australian Rotary Health, the Geelong Medical Research Foundation, the Ian Potter Foundation, Eli Lilly, Meat and Livestock Australia, Woolworths Limited and The University of Melbourne and has received speakers honoraria from Sanofi-Synthelabo, Janssen Cilag, Servier, Pfizer, Health Ed, Network Nutrition, Angelini Farmaceutica, Metagenics and Eli Lilly. She is supported by an NHMRC Career Development Fellowship (2) (#1108125).

Adrienne O'Neil has received funding from Meat and Livestock Australia and is supported by an NHMRC ECR Fellowship (#1052865).

Catherine Itsiopoulos has received funding from the NHMRC, the University of Melbourne, Deakin University, La Trobe University, Meat and Livestock Board, Australian Society for Enteral and Parenteral Nutrition, Harokopio University in Athens, Commonwealth Department of Education, Employment and Workplace relations, Diabetes Australia and SWISSE Wellness P/L. She has received speaker honoraria from Astra Zeneca, Boehringer Ingelheim and Dairy Australia.

Cathrine Mihalopoulos is supported by an NHMRC Early Career Development Fellowship (#1035887). She has received funding support from the NHMRC, Cancer Council, Mental Illness Research Fund, Medibank Private Health Research Fund, Macquarie University and Beyond Blue.

David Castle has received grant monies for research from Eli Lilly, Janssen Cilag, Roche, Allergen, Bristol-Myers Squibb, Pfizer, Lundbeck, Astra Zeneca and Hospira and travel support and honoraria for talks and consultancy from Eli Lilly, Bristol-Myers Squibb, Astra Zeneca, Lundbeck, Janssen Cilag, Pfizer, Organon, Sanofi-Aventis, Wyeth, Hospira and Servier. He is a current Advisory Board Member for Lu AA21004; Lundbeck; Varenicline: Pfizer; Asenapine: Lundbeck; Aripiprazole LAI: Lundbeck; Lisdexamfetamine: Shire; Lurasidone: Servier. He has no stocks or shares in any pharmaceutical company.

Olivia Dean has received grant support from the Brain and Behaviour Foundation, Marion and EH Flack Trust, Simons Autism Foundation, Australian Rotary Health, Stanley Medical Research Institute, Deakin University, Eli Lilly, NHMRC, Australasian Society for Bipolar and Depressive Disorders and Servier. She has also received in-kind support from BioMedica Nutracuticals, NutritionCare and Bioceuticals.

Michael Berk has received Grant/Research Support from the NIH, Cooperative Research Centre, Simons Autism Foundation, Cancer Council of Victoria, Stanley Medical Research Foundation, MBF, NHMRC, Beyond Blue, Rotary Health, Geelong Medical Research Foundation, Bristol Myers Squibb, Eli Lilly, Glaxo SmithKline, Meat and Livestock Board, Organon, Novartis, Mayne Pharma, Servier and Woolworths. He has been a speaker for Astra Zeneca, Bristol Myers Squibb, Eli Lilly, Glaxo SmithKline, Janssen Cilag, Lundbeck, Merck, Pfizer, Sanofi Synthelabo, Servier, Solvay and Wyeth, and served as a consultant to Allergan, Astra Zeneca, Bioadvantex, Bionomics, Collaborative Medicinal Development, Eli Lilly, Glaxo SmithKline, Janssen Cilag, Lundbeck Merck, Pfizer and Servier. He is supported by an NHMRC Senior Principal Research Fellowship (#1059660).

The other authors have no relevant financial disclosures to declare.

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/ ), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated.

Authors' Affiliations

IMPACT Strategic Research Centre, Deakin University, Geelong, Australia

School of Population Health, The University of Melbourne, Melbourne, Australia

Orygen, The National Centre of Excellence in Youth Mental Health, Parkville, Australia

Department of Psychiatry, University of Melbourne, Melbourne, Australia

School of Allied Health, La Trobe University, Melbourne, Australia

Department of Medicine, The University of Melbourne, Melbourne, Australia

Centre for Population Health Research, Deakin University, Geelong, Australia

Cancer Epidemiology and Intelligence Division, Cancer Council Victoria, Carlton, Australia

Centre for Adolescent Health, Murdoch Childrens Research Institute, Melbourne, Australia

The Florey Institute of Neuroscience and Mental Health, Parkville, Australia

Food & Mood Centre, Deakin University, IMPACT SRC, School of Medicine, Geelong, Australia

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8. Opie R, Segal L, Jacka FN, Nicholls L, Dash S, Pizzinga J, et al. Assessing healthy diet affordability in a cohort with major depressive disorder. J Publ Health Epidemiol. 2015;7(5):159-69.

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A randomised controlled trial of dietary improvement for adults with major depression (the 'SMILES' trial)

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The possible therapeutic impact of dietary changes on existing mental illness is largely unknown. Using a randomised controlled trial design, we aimed to investigate the efficacy of a dietary improvement program for the treatment of major depressive episodes. 'SMILES' was a 12-week, parallel-group, single blind, randomised controlled trial of an adjunctive dietary intervention in the treatment of moderate to severe depression.

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What is CBT? | Making Sense of Cognitive Behavioural Therapy

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Case study clinical example CBT: First session with a client with symptoms of depression (CBT model)

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OCD and Anxiety Disorders: Crash Course Psychology #29

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Lynne Malcolm: Hi, it's All in the Mind on RN, I'm Lynne Malcolm. Today, the psychology of hoarding.

Journalist: Well, it's Sydney's most notorious house of hoarders, and it's on the market. The Bondi home of Mary Bobolas is being sold, even though it's full of rubbish and her family is refusing to leave.

Journalist: One of Sydney's longest running property disputes will continue, at least until today, after a family of notorious hoarders were granted a last minute stay against the forcible sale of their property. The sheriff's office is currently trying to sell the Bobolas family's Bondi home to recover about $160,000 in outstanding clean-up costs and legal fees.

Lynne Malcolm: News reports from a recent high profile case of hoarding in Sydney.

Catherine: It's not a happy thing, being a hoarder, because you can't share it with anybody. It's very sad. And sort of unnecessary. Why have I wasted my life? I could have been in relationships, I could have done things instead of this hoarding

Mercy Splitt: The act itself around hoarding is extremely secretive, unlike a lot of other things where we can actually see it, we can see people going for a drink at the clubs or gambling or whichever like that, but it's not uncommon for somebody to have two lives. You've got your 9-to-5, going to work, coming home, and then you've got that home life, that behind closed doors that no one sees.

Lynne Malcolm: Mercy Splitt, hoarding and squalor resource manager with Catholic Community Services in Sydney.

Some studies suggest that hoarding disorder affects somewhere between 2% and 5% of the population, which is double or triple the frequency of obsessive compulsive disorder for example.

Professor Randy Frost is a psychologist, at Smith College Massachusetts. He's researched and written about hoarding for over two decades.

Randy Frost: Well, hoarding is the acquisition of and failure to let go of a large number of possessions, even though those possessions may not have a great deal of instrumental value for the person. What makes hoarding a disorder is when those possessions begin to clutter the living areas of the home and prevent us from using them in the way in which they were designed, and when they create distress and impairment in the ability to function.

Of course the most extreme is the unfortunate case when people end up dying in a hoarded house because of a house fire, and this is unfortunately one of the real dangers of this problem. A study done in Australia, the Melbourne Fire Brigade covered a 10-year period of time and what they found was that hoarding occurred in less than one-quarter of 1% of all residential house fires. But those fires where hoarding was involved, they counted for nearly one-quarter of all the fire related deaths in residential house fires. So those are certainly the most extreme cases. In terms of clutter we've seen cases where rooms are so cluttered that they can't be entered, so the door is completely covered so that there's only a few inches between the top of the stuff and the ceiling. So these cases can be pretty severe.

Catherine: Hello?

Lynne Malcolm: Oh hello, it's Lynne Malcolm here from the ABC.

Catherine: Is the gate open?

Lynne Malcolm: I'll just try, hold on...

I'm visiting Catherine whose hoarding problem has developed over years, though recently she feels she's improved after getting help from a treatment program at Lifeline.

Good to meet you.

Catherine: Thank you.

Lynne Malcolm: Okay, so this is your home.

Catherine: Yes, this is me. Did you want to have a look through quickly?

Lynne Malcolm: Yes, so if we just walk through, this is the balcony...

Catherine: Yes, it had a lot of storage under it for a long time.

Lynne Malcolm: So we are surrounded by lots and lots of plants, and I can see plastic containers and bins and a fire brazier, and I can see a number of different plastic watering cans and pots. Do you often sit out here?

Catherine: Not a lot, no. I used to, but the clutter is a bit of a problem. In fact all these frames were under furniture on the balcony.

Lynne Malcolm: Okay, we are going into your bedroom now? So there's not a lot of room, is there, around your bed.

Catherine: No, there's not, but it was better than when there was a double bed and a tiny little track around, so it does look cluttered to you, but to me it's quite an improvement.

Lynne Malcolm: There are bookshelves up to the ceiling with all sorts of things stacked on them, there are lots and lots of books and drawers, and there's a couple of irons and some scarves...and what else can I see?

Catherine: More books around here.

Lynne Malcolm: More books behind me. And there's a clothing rack here. So do you use all these things?

Catherine: Well, that's the thing about hoarding, you don't get to use a lot of the items you think you need, you think will satisfy you. I've got scarves that I've never worn. I buy them at op shops though. You think you're getting a bargain, but no, I don't wear a lot of the things.

Lynne Malcolm: And what about the books? How many of the books will you have read?

Catherine: Well, very similar, I buy them because...particularly self-help books have been a really big feature of my acquisition, and I don't complete them.

Lynne Malcolm: And I can see here you've got some cassettes which are a thing of the past now, lots of cassettes.

Catherine: Yes, they are thing of the past, yes. It's the same with CDs, I don't tend to listen to them all that often, but I have quite a few, in case.

Lynne Malcolm: So we are going through the bathroom here, also again the walls are lined with cassettes and drawers and books and boxes of paper, lots of clothes hanging up on coat hangers on the door.

Catherine: Yes, summer clothing that should go downstairs to a storage cage but I haven't quite got there yet.

Lynne Malcolm: And what room would you call this?

Catherine: This would be the second bedroom.

Lynne Malcolm: There's no bed in it because there's not enough room for a bed.

Catherine: Well, it's only up against the wall.

Lynne Malcolm: Oh, it's standing up against the wall, with pillows stacked on top, and there's a clothing rack here with every manner of coat hanger you can imagine. You do have a little desk here with a computer, but it's pretty hard to get in to the desk.

Catherine: It is a little bit, and it's all about moving things, which is a pain in the neck.

Lynne Malcolm: This is another little toilet and laundry, and there is really no room here at all for anything, you could hardly get in here. In fact how do you get to the washing machine?

Catherine: Well, this is it, I have to move numerous items to get to the actual washing machine and then put them back.

Lynne Malcolm: And then you put them back?

Catherine: Yes.

Lynne Malcolm: Catherine.

Joanna also has a long-term hoarding problem. She lives in a three-bedroom house, with a large lounge room, two verandas and a car port. She says she can't use most of that space because of the extreme clutter.

So there is no space for you to move around? Where do you mainly spend your time?

Joanna: Well, I'm sitting in a corner opposite the TV, which takes up most of my day, and it's a bit dark and it's cold now. I wouldn't dare put a fire on. And if I do anything at all, it has to be outside.

Lynne Malcolm: And what sort of stuff do you accumulate?

Joanna: Well, there was a time when anything I'd use, a bottle top or a nail or little things that I saw. But basically it's down to a lot of clothes that I'll never wear, paper of every kind, and the newspaper collection and magazines, they are 35 years' worth. While it was liveable before for two people, I seem to have changed in some way and created a real untidy place, but I'm not a squalor person.

Lynne Malcolm: How do you feel about living in that space?

Joanna: Well, it's a bit scary. The Fire Brigade said if there was a fire I would never get out because of all the paper and plastic boxes, and I couldn't reach a window, so that's a bit scary. And I don't want to fall and have trouble with the ambulance not being able to get in, which was the case with my husband with the stretcher, but he didn't die until much later, from a cardiac arrest in the hospital.

Lynne Malcolm: Have you always lived like this?

Joanna: No. I lived in a room when I came here at 21, because I am a perfectionist, like most hoarders, and then I moved into a two-bedroom place in Bondi and never used the second room. But then due to the stress at work and various losses in my life or problems like cancer, miscarriages and so forth, which didn't worry me, but in my subconscious obviously something went wrong and I started to pick up newspapers. And things got out of hand, and I didn't realise I had all this stuff until my husband died and there it was staring me in the face.

Lynne Malcolm: So you talk about your husband, he died several years ago, I think you were overseas, for a period of time.

Joanna: Yes, I don't know what happened. He lay on the floor for a week I estimated, and three rooms were blocked by fallen stuff. However, nothing appeared to have struck him and I'll never know if he was startled or if somebody was in the house and sent things flying, because he couldn't talk and tell me, so I have to live with that mystery.

Lynne Malcolm: Do you feel that it's some way related to the state of the house?

Joanna: Well, I see that there was an avalanche, it must have had something to do with it, but I'm not sure what.

Lynne Malcolm: Psychologist Randy Frost has researched hoarding for many years and is the author of two books on the subject.

Randy Frost: People with hoarding problems, interestingly enough, tend to be more perfectionistic than other people. They are very concerned about making mistakes, and often that fear of making mistakes leads them to avoid things like discarding or passing up a possible purchase that they perhaps don't need.

Another feature that is characteristic of many people with hoarding problems is depression. I lot of comorbidity with depression, some comorbidity with other anxiety disorders like social phobia or generalised anxiety disorder.

A couple of other features that are common is an inability to make decisions easily, and here we get into some issues related to information processing and the way it's different. There's a great deal more complex thinking on the part of people with hoarding problems. These information processing deficits that we see in hoarding appear to be related to the amount of information that is being processed.

Let me give you an example. One of the cases in our book Stuff is a woman we called Irene, and Irene, when I got to her house one day her eyes lit up and she said, 'I've got to show you something,' and she went into the next room and she came back with a large clear plastic bag filled with bottle caps, and she said, 'Look at these bottle caps, aren't they beautiful, look at the shape and the colour and the texture.' When I see a bottle cap without a bottle, the information that goes through my head is very simple, it's that it is trash and how do I get rid of it. But for Irene the information flowing through her head was all about these unique details, these special features of the bottle cap and their meaning and what she could do to take advantage of those features.

So one of the things we think is going on is that information is being processed in a very different way in the brain, and that way makes it much more complex for people with hoarding problems to try to make a decision. There are some scanning studies that suggest a particular circuit is involved here, and the circuit is not unlike that circuit we find in obsessive compulsive disorder, and it's the anterior cingulate that's involved in this process.

Lynne Malcolm: Professor Randy Frost.

Joanna reflects on whether her hoarding has an emotional basis.

Joanna: Well, it's hard to say because I'm an only child, I never mix with people, I used to collect little things, and certainly since my husband died I would say so because, as I mentioned, things that were tidy but too much are now all over the place and I just don't care anymore. But now I can't use my kitchen. It was never like that before.

Lynne Malcolm: You've said that you remembered sometimes if you'd throw something out, you know, you wanted to throw out a bottle or something, and your mother would say, 'That bottle will cry if you throw it out.'

Joanna: I did break that habit because if I saw something on the ground, like something that had been dropped in a park, and then I saw another, if I left two of them on the ground, they'd have each other. Now, that sounds crazy but that's how I broke that addiction to the ground. If it was one thing I felt sorry for it, but if there were two I would turn my head and walk away and know that they had each other. It sounds crazy and I'm not crazy, but that's what happened with those sort of things.

Lynne Malcolm: How do you feel when you have to part with things?

Joanna: Well, I'd probably fight you if you tried to take one of my papers out of the house. I would never part with anything good. But I did put something in my mother's coffin. She died last year, 101, and I bitterly regretted it afterwards. I stopped eating, and it's taken a long time, and it wasn't even something that I cared about. And so I think if people made me take a lot of reasonable stuff away it would be terrible. I don't mind charity shops, I just don't know which ones to choose, I can't make decisions.

Lynne Malcolm: You're with All in the Mind on RN, I'm Lynne Malcolm, today with an insight into hoarding disorder.

Psychologist Randy Frost is a respected specialist in hoarding research.

Randy Frost: The attachments that form to possessions seemed to fall into two different categories. The first category is an emotional sort of attachment, where the object is sometimes given humanlike qualities, so there's a lot of anthropomorphism in hoarding. Also it's as though these possessions somehow come to be felt as a part of the person. By that I mean almost a part of their physical being. So people with hoarding problems, when other people have thrown away their things, it feels to them like they've been physically violated, it is like the feeling like someone cut off my arm somehow, the attachment is that strong.

A second way in which this attachment forms has to do with the beliefs about responsibility. That is, responsibility for making sure that possessions don't get wasted. So that's why we find lots of people with hoarding problems who fill their house with stuff that looks like trash to other people. But if you think about each individual item, each of those items might still have some utility for someone somewhere in the world. And it's almost as though ownership carries with it the responsibility for making sure that object doesn't get wasted. This is such a prominent feature, we've started calling it material scrupulosity because it looks something like scrupulosity concerns that we see in obsessive compulsive disorder.

Lynne Malcolm: So I wonder if you could further explain what the psychological mechanism that operates in hoarding between emotions and perhaps past trauma and the things that people collect.

Randy Frost: Well, we see trauma in about half of the hoarding cases, that is some kind of past trauma. The extent to which that trauma is associated with the development of hoarding is not so clear. And for many of the objects that people who have faced trauma save, these objects seem to give them a sense of comfort and safety. And it's almost as though the collecting of all these things and the gathering and the clutter that surrounds them seems to form some kind of buffer for them where they feel somehow protected and where there is at least some suggestion...we don't have data on this yet, but one of our hypotheses is that this collection of things that people surround themselves with buffer them against the development of post-traumatic stress disorder symptoms, especially for people who have had some kind of trauma.

Lynne Malcolm: One of the things that's very common for people to collect is newspapers, piles and piles of newspapers. Why is that?

Randy Frost: Well, information is one of the major things we see as valued in people with hoarding disorder, so newspapers, books, magazines. Even people who don't have hoarding problems often will collect and save lots of newspapers. Part of it is tied to this notion of perfectionism and needing to do things perfectly, because many people with hoarding problems will say that before they can get rid of a newspaper they need to read everything in a newspaper and remember it all. And that's a task that most of us don't even attempt. In part it's related to a phenomena that is kind of funny in hoarding and that is a special view of opportunities, that all information provides us with an opportunity for something. And it's almost as though people with hoarding problems can't let go of opportunities. All of us as we grow and mature learn that if we take advantage of one opportunity, we are letting go of other opportunities and we learn to tolerate that, but what if you couldn't let go of any opportunity? What if you wanted to experience everything in life and not let anything go? That is kind of what it's like for some people with hoarding problems, and especially with respect to information.

Lynne Malcolm: Randy Frost.

Catherine also has trouble dealing with paper.

And then we are going down a very cluttered corridor. This is the living area. And there's a desk over there that's got a whole lot of stuff on it that's covered up. Oh, that's the paperwork.

Catherine: That's the paperwork. I have trouble discarding paperwork at this point, but I'm working on it, I am working on it.

Lynne Malcolm: But you wouldn't be able to find anything that you wanted there, would you?

Catherine: Well, it can be difficult, it can be very time consuming.

Lynne Malcolm: So why do you think you've accumulated so much paperwork, for example?

Catherine: When I started nesting, so to speak, settled, I just accumulated a lot of paperwork. And because I didn't have a tin opener I got a lot of items from garage sales, but I went overboard, sort of making up for not being able to do it in earlier years...possibly, I'm not sure.

Lynne Malcolm: Tell me a little bit more about what you think has led to your hoarding?

Catherine: Well, I think a sense of deprivation as a young person. I grew up in a family of 11 children, one older sibling, and I left school very early, I didn't finish primary school, and I looked after my youngest siblings and did a lot of menial work, but I think that early deprivation of not having a lot of things, it comes back later. When you can, you go overboard with it. It's almost insatiable, you need more and more. But I feel very fortunate that I found the Lifeline hoarding course, that has really saved my life.

Lynne Malcolm: The Lifeline course Catherine is doing is based on Randy Frost's self-help program called Buried in Treasures.

Catherine: And in the course they have encouraged us to tolerate the distress that you can experience parting with things. It feels like you are powerless over it, like you have no self-control, and it's very depressing, and it's very hard to be positive and energetic when you are depressed. That's why the course has been so helpful. They walk you through a lot of these things, particularly those questions of do you need this, will this enhance my life, what is it about it that is so essential that I have it, how would you feel if you didn't have it. And the exercises they set to discard things are very, very challenging, and each week you are invited to take along something that you can discard.

I had great success. Then I got into this real flatness and they said that's fine, that's where you are meant to be. So the expectation that you will change overnight in my experience is really unrealistic. This wonderful psychologist came to my place and she said, well, 'You've got a lot of bowls.' Well, if she had seen the bowls before I had discarded...and she said, 'You've got 23 cane baskets.' Well yes, I have I suppose, but you see, I just put them there and they stay there and it becomes part of your life, and I don't need them, I don't use them.

Lynne Malcolm: And so how would that feel if I said, 'Look, I'm just taking away those baskets now, you don't need them,' how would that feel?

Catherine: Well, at this point if I could keep a few it would be tolerable, so that's a very gradual thing. And you start with the easiest things. I had 15 suitcases and I was able to put nine on the street. A lot of them came from the street, but now I've got six. So the progress can seem slow, but in fact to me it has given me this confidence that I can do this. And also what I particularly appreciate is the after-care under the auspices of Lifeline, we meet once a month with other people who've done the course. And we discard something there. And it's quite structured. So to me it's great progress, it's given me confidence and a level of self-control, despite all the cane baskets.

Lynne Malcolm: Catherine.

Randy Frost explains that his Buried in Treasures treatment program has been quite effective for many, and it includes a self-help book for hoarders.

Randy Frost: The research on the Buried in Treasures workshops looks pretty good, it produces change in behaviour, it produces a decrease in these hoarding behaviours and these excessive attachments to objects. It becomes pretty close to what we can achieve in therapy. One of the things we do in Buried in Treasures is try to get the person to start evaluating the true value these possessions hold in their lives. So each of the possessions that people have tell a story. And when people tell that story it's easier for them to let go, to think more flexibly about these objects. One of the things we know about hoarding is often times when the object is acquired and comes into the home, there is no processing of that possession and its importance, it just exists in the home and the person never really interacts with it until we start doing the exercises in Buried in Treasures and they get to look at and talk about that object and really experience what it's like for them and how important that object is for them once they consider, well, what would life be like without this object.

Lynne Malcolm: Mercy Splitt manages hoarding support programs with Catholic Community Services. This involves visiting people in their homes, and, as you can imagine, negotiations can be quite delicate.

Mercy Splitt: It is talking through the process with the person. So it's really important that all of the decisions are made by that person. So we can provide the supports and we can provide the tools, but at the end of the day if a person decides to hold onto something, they've got to make that decision to let it go, otherwise what happens is that we then replace these items with other things because they haven't dealt with the actual letting go of that item. So we look at why did you hold on to this piece of paper and what attachment did you have to it, what were the reasons, are you planning on using this piece of paper down the track? For what? When something is too difficult we tend to put it aside and focus on something else. So bringing it back on track, what are you going to do with it?

Lynne Malcolm: And how often are you successful with that, to actually bring somebody around? That's a very irrational expectation, isn't it, and it's not always a rational behaviour.

Mercy Splitt: It is, it's a slow process, it takes a lot of patience. You know, I've been in situations where I've sat there for two hours and we have managed to remove, say, three pieces of paper, as directed by the person, but they are three pieces of paper that don't come back and they don't get replaced because it was part of that letting go and saying goodbye to those pieces of paper. What it is as well is you are teaching a new practice and you are teaching a new behaviour. So over time it becomes a regular activity to look at something and go, okay, why am I holding onto this, what am I actually going to do with it?

Lynne Malcolm: Mercy Splitt.

Joanna has sought help for her hoarding problem a number of times. She now knows a lot about the disorder and she shares her knowledge with others, but she still struggles with it herself.

Joanna: If I could put everything in warehouse and sort it and then clean the house, everything perfect, and that would be the only way I can do it, because we want perfection and if we can't have it we have chaos. There is nowhere to sort things, it's dark, I can't open the curtains, so what do I do. It's frustrating, but I don't want to die and people come and throw good stuff away. There are things hidden somewhere that could be jewellery, or there could be valuables, I don't even know what I've got.

Lynne Malcolm: Do you ever have people over?

Joanna: One person came in, our best friend, he thought it was funny, made a video, which always causes a laugh. But when I saw that video again, I wish it could be that tidy. The other day I invited him through the house and he was speechless, he never said a word because of course it is way worse than when he made the video. So I know a lot about it but I'm not applying it to my life because I believe that you have to resolve the losses and the causes and clear your head before you can actually do anything.

Lynne Malcolm: And do you see a hope that you can resolve those things for yourself and therefore do something about your hoarding?

Joanna: I feel that I have no feeling, so it's a matter of action and time. I just want to find some place to lay it all out and do it systematically, like an assembly line and then I'd have no trouble, but how do you do that?

Lynne Malcolm: Joanna.

Does Randy Frost believe that full recovery from a hoarding disorder is possible?

Randy Frost: I don't know if I would talk about cure or recovery since we still don't have a full picture of what causes this. But there are people who can get control over it, and I think that's the way to think about this at this point, is gaining mastery over this urge, this urge to acquire and save things, and that is certainly possible.

Lynne Malcolm: Professor Randy Frost.

So, what do you most enjoy now about your life?

Catherine: I just love the idea that I'm capable and I'm confident that I can do this, and it's a very tangible thing. I took 238 books to Lifeline, and 138 another time, bags and bags and bags of them. To me that's practical evidence that it's working, that it has really been worth it.

Lynne Malcolm: Thanks to Catherine and Joanna for sharing their experiences with us today.

Head to the All in the Mind website for further information, including details of Professor Randy Frost's books on hoarding.

Production by Diane Dean and sound engineer Phil McKellar.

I'm Lynne Malcolm, catch you next time.

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Lynne Malcolm: Hi, it's All in the Mind on RN, I'm Lynne Malcolm. Today, the psychology of hoarding. Journalist: Well, it's Sydney's most notorious house of hoarders, and it's on the market. The Bondi home of Mary Bobolas is being sold, even though it's full of rubbish and her family is refusing to leave.

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Introduction to Psychopathology

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Psychological Disorders: Crash Course Psychology #28

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The Psychology of Abnormal Behavior: Understanding the Criteria & Causes of Abnormal Behavior

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Visit Study.com for thousands more videos like this one. You'll get full access to our interactive quizzes and transcripts and can find out how to use our videos to earn real college credit. YouTube hosts only the first few lessons in each course. The rest are at Study.com.

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Psychopathology

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A-level Psychology Psychopathology Revision for Paper 1 | Simply Psychology

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All the Revision notes you need for the A-level psychology psychopathology section on the paper 1 exam, and the AS psychology psychopathology section on the paper 2 exam. Print them off for your reference.

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Nandos Menu Cognitive Approach to Depression

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Nandos Menu Cognitive Approach to Depression

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When working with patients, health professionals often refer to clinical diagnostic manuals to better understand the patient's illness and potential treatment. There are two main recognised diagnostic manuals commonly used around the world today.

The International Classification of Diseases (ICD), is the international standard diagnostic classification for all recognised diseases and related health problems and is mainly used in the UK and much of Europe. ICD codes are alphanumeric designations given to every diagnosis and description of symptoms on medical records. These classifications are developed and monitored by the World Health Organization (WHO).

The ICD is revised periodically and is currently in its tenth edition, the ICD-10, as it is known, was developed in 1992 and the next version, ICD-11 is planned for publication in 2015.

The DSM-IV-TR, is the other diagnostic manual mainly used around the world, and is the American counterpart of ICD- 10.

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is published by the American Psychiatric Association and provides clinicians with official definitions of, and criteria for, diagnosing mental disorders.

There have been five revisions since it was first published in 1952, the last major revision was the fourth edition 'DSM-IV', published in 1994, although a text revision was produced in the year 2000. The fifth edition 'DSM-5' is currently in consultation, planning and preparation, due for publication in May 2013.

Here in the UK, in addition to the ICD-10 and the DSM-IV, the National Institute for Health and Clinical Excellence (NICE) launched their own set of clinical guidelines for the identification, treatment and management of Obsessive-Compulsive Disorder and Body Dysmorphic Disorder, for both children and adults, on the 23rd November 2005.

NICE is an independent organisation, responsible for providing national guidance in England and Wales in respect of the promotion of good health and the prevention and treatment of ill health. Clinical guidelines are recommendations on the appropriate treatment and care of people with specific diseases and conditions within the NHS in England and Wales. They are based on the best available evidence and the guidelines are produced to try to help healthcare professionals in their work.

At present the European International Classification of Diseases (ICD) currently lists OCD in its own subcategory under the category of Neurotic, Stress-related and Somatoform Disorders (F40-F48), although within the same larger category as other anxiety disorders.

With regard to the essential features of OCD, the ICD-10 and DSM-IV-TR manuals state the following diagnostic criteria for Obsessive-Compulsive Disorder.

The International Classification of Diseases (ICD-10) Classification of Obsessive-Compulsive Disorder (ICD-10 Code F42) The essential feature of this disorder is recurrent obsessional thoughts or compulsive acts. (For brevity, "obsessional" will be used subsequently in place of "obsessive-compulsive" when referring to symptoms.) Obsessional thoughts are ideas, images or impulses that enter the individual's mind again and again in a stereotyped form. They are almost invariably distressing (because they are violent or obscene, or simply because they are perceived as senseless) and the sufferer often tries, unsuccessfully, to resist them. They are, however, recognized as the individual's own thoughts, even though they are involuntary and often repugnant. Compulsive acts or rituals are stereotyped behaviours that are repeated again and again. They are not inherently enjoyable, nor do they result in the completion of inherently useful tasks. The individual often views them as preventing some objectively unlikely event, often involving harm to or caused by himself or herself. Usually, though not invariably, this behaviour is recognized by the individual as pointless or ineffectual and repeated attempts are made to resist it; in very long-standing cases, resistance may be minimal. Autonomic anxiety symptoms are often present, but distressing feelings of internal or psychic tension without obvious autonomic arousal are also common. There is a close relationship between obsessional symptoms, particularly obsessional thoughts, and depression. Individuals with obsessive-compulsive disorder often have depressive symptoms, and patients suffering from recurrent depressive disorder may develop obsessional thoughts during their episodes of depression. In either situation, increases or decreases in the severity of the depressive symptoms are generally accompanied by parallel changes in the severity of the obsessional symptoms.

Obsessive-compulsive disorder is equally common in men and women, and there are often prominent anankastic features in the underlying personality. Onset is usually in childhood or early adult life. The course is variable and more likely to be chronic in the absence of significant depressive symptoms.

Diagnostic Guidelines For a definite diagnosis, obsessional symptoms or compulsive acts, or both, must be present on most days for at least 2 successive weeks and be a source of distress or interference with activities. The obsessional symptoms should have the following characteristics: (a) they must be recognized as the individual's own thoughts or impulses: (b) there must be at least one thought or act that is still resisted unsuccessfully, even though others may be present which the sufferer no longer resists; (c) the thought of carrying out the act must not in itself be pleasurable (simple relief of tension or anxiety is not regarded as pleasure in this sense); (d) the thoughts, images, or impulses must be unpleasantly repetitive.

Includes:

anankastic neurosis

obsessional neurosis

obsessive-compulsive neurosis

obsessive-compulsive personality (disorder) ( F60.5 )

Differential Diagnosis Differentiating between obsessive-compulsive disorder and a depressive disorder may be difficult because these two types of symptoms so frequently occur together. In an acute episode of disorder, precedence should be given to the symptoms that developed first; when both types are present but neither predominates, it is usually best to regard the depression as primary. In chronic disorders the symptoms that most frequently persist in the absence of the other should be given priority.
Occasional panic attacks or mild phobic symptoms are no bar to the diagnosis. However, obsessional symptoms developing in the presence of schizophrenia, Tourette's syndrome, or organic mental disorder should be regarded as part of these conditions.
Although obsessional thoughts and compulsive acts commonly coexist, it is useful to be able to specify one set of symptoms as predominant in some individuals, since they may respond to different treatments.

F42.0 Predominantly Obsessional Thoughts Or Ruminations These may take the form of ideas, mental images, or impulses to act. They are very variable in content but nearly always distressing to the individual. A woman may be tormented, for example, by a fear that she might eventually be unable to resist an impulse to kill the child she loves, or by the obscene or blasphemous and ego-alien quality of a recurrent mental image. Sometimes the ideas are merely futile, involving an endless and quasi-philosophical consideration of imponderable alternatives. This indecisive consideration of alternatives is an important element in many other obsessional ruminations and is often associated with an inability to make trivial but necessary decisions in day-to-day living.
The relationship between obsessional ruminations and depression is particularly close: a diagnosis of obsessive-compulsive disorder should be preferred only if ruminations arise or persist in the absence of a depressive disorder.

F42.1 Predominantly Compulsive Acts (Obsessional Rituals) The majority of compulsive acts are concerned with cleaning (particularly hand-washing), repeated checking to ensure that a potentially dangerous situation has not been allowed to develop, or orderliness and tidiness. Underlying the overt behaviour is a fear, usually of danger either to or caused by the patient, and the ritual act is an ineffectual or symbolic attempt to avert that danger. Compulsive ritual acts may occupy many hours every day and are sometimes associated with marked indecisiveness and slowness. Overall, they are equally common in the two sexes but hand-washing rituals are more common in women and slowness without repetition is more common in men. Compulsive ritual acts are less closely associated with depression than obsessional thoughts and are more readily amenable to behavioural therapies.

The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) Classification of Obsessive-Compulsive Disorder (DSM-IV Code 300.3) A. Either obsessions or compulsions: Obsessions as defined by (1), (2), (3) and (4): (1) recurrent and persistent thoughts, impulses, or images that are experienced, at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress. (2) the thoughts, impulses, or images are not simply excessive worries about real-life problems. (3) the person attempts to ignore or suppress such thoughts, impulses, or images, or to neutralize them with some other thought or action. (4) the person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind (not imposed from without as in thought insertion).

Compulsions as defined by (1) and (2): (1) repetitive behaviours (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly (2) the behaviours or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviours or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive . B. At some point during the course of the disorder, the person has recognized that the obsessions or compulsions are excessive or unreasonable. Note: This does not apply to children. C. The obsessions or compulsions cause marked distress, are time consuming (take more than 1 hour a day), or significantly interfere with the person's normal routine, occupational (or academic) functioning, or usual social activities or relationships. D. If another Axis I disorder is present, the content of the obsessions or compulsions is not restricted to it (e.g., preoccupation with food in the presence of an Eating Disorders; hair pulling in the presence of Trichotillomania; concern with appearance in the presence of Body Dysmorphic Disorder; preoccupation with drugs in the presence of a Substance Use Disorder; preoccupation with having a serious illness in the presence of Hypochondriasis; preoccupation with sexual urges or fantasies in the presence of a Paraphilia; or guilty ruminations in the presence of Major Depressive Disorder). E. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.

Specify if: With Poor Insight: if, for most of the time during the current episode, the person does not recognize that the obsessions and compulsions are excessive or unreasonable.
The APA (American Psychiatric Association) (1994) also provides a diagnostic index of OCD subtypes; the categories included are: 'Cleaners', 'Repeaters', 'Completers', 'Checkers', 'Overly Meticulous', 'Compulsive Avoider's', 'Hoarders', and 'Slowness'.
Additional epidemiological facts about the disorder:

The ratio of men to women suffering with the disorder is 1:1, although, more specifically, the disorder's onset is reported to occur earlier in men than women.

Studies have demonstrated that at least a third of all adult sufferers have reported it's onset as occurring during childhood or adolescence.

Possible change to DSM-V categorisation of OCD.

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medication for obsessive compulsive disorder

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When working with patients, health professionals often refer to clinical diagnostic manuals to better understand the patient's illness and potential treatment. There are two main recognised diagnostic manuals commonly used around the world today. The International Classification of Diseases (ICD), is the international standard diagnostic classification for all recognised diseases and related health problems and is mainly used in the UK and much of Europe.

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Research Studies and AO3 Activity Resource

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Research Studies and AO3 Activity Resource

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Everyone has a fear or routine for something

But, someone with an OCD → becomes so invasive and is accompanied by severe anxiety → cant function effectively in daily life

Is the most severe anxiety disorders and is the most difficult to treat

Obsession - persistent and recurrent, thoughts and images which enter the mind and cannot be removed

Compulsive - the element of OCD which is the irresistible urge to carry out repetitive/ritualistically in order to avoid some form of danger or consequence

A third who report it say it started in childhood, however, in many cases it goes undetected

Can last a few years to decades

Sufferers can go through intermittent periods of depression

Affects around 1-3% of population (Source: National Institute of Mental Health)

Affects both men and women equally - women more likely to suffer from compulsions of cleanliness

Characteristics

Sufferers acknowledge their problem - but are powerless to overcome them

Will suffer from severe anxiety (leading to symptoms)

O & C do not alleviate the anxiety → they make it worse

Suffer from severe depression (i.e. a symptom)

Onset → late teens/early 20's

Either obsession or compulsion have to be experienced

Obsession or compulsion have to be time consuming in the daily routine

Its not how much time it takes, it's about how they react to the stimulus.

Cobb (1978) - 78% of a sample of OCD patients viewed their rituals as "rather silly" or 'absurd'
Types

Obsessional Cleanliness - obsession with dirt/contamination → leads to compulsive behaviours e.g. hand-washing

Compulsive Rituals - specific ways/order of doing things, yet have the urge to stop, but cant

Obsessional Doubts - usually related to health and safety concerns e.g. locking the house door

Compulsive Checking - follows on from obsessional doubts, will have to keep checking, double-checking things e.g. the house door.......and never end up leaving

Obsessional Ruminations - internal debates with self, will present themselves with an issue and debate for and against it, even over simple things

Obsessional Impulses - strong urge to perform an embarrassing, dangerous or violent act.

BIOLOGICAL APPROACH

No specific gene has yet been identified

Studies have shown it runs in families (could be due to shared environment)

Genetics Family Studies

Carey & Gottesman (1981) - reported a prevalence of up to 10% in 1st degree relatives.

Lenane (1990) - 30% of 1st degree relatives in their study also had an OCD

Twin Studies

Hoaker & Schnurr (1980) - Found concordance rate of 50-60%

When OCD's run in families they inherit the general nature of it, but not exactly the same symptoms (again, suggests that it could be partly genetic and environment

Dr. Dennis Murphy (2003) - DNA from 170 people, 30 had OCD and 80 healthy people. They were looking for variations of the human serotonin transporter gene which controls the movement of the chemical between nerve cells in the brainFound that 6 out of 7 people in 2 separate families who had 1 gene mutation had an OCD. Whilst the 4 people with the most severe symptoms also had a 2nd mutation in the same gene

Biochemical

OCD may result from a deficiency of serotonin (neurotransmitter) or a malfunction of its metabolism like blocked serotonin receptors.

Research support from studies using drugs

Zohar et al (1996) - Found that some tricyclic drugs inhibit the re-uptake of serotonin → beneficial for around 60% of the OCD sufferers tested.

However, Lydiard et al (1996) - Found that drugs only provided partial alleviation from the symptoms (therefore, drugs are not a cure

SSRI (Selective Serotonin Reuptake Inhibitor) reduces symptoms of OCD

Brain Structure

Rapoport & Wise (1998) - Suggest OCD results from a dysfunction in the C.N.S (specifically the basal ganglia), this theory is supported by disorders such as Huntington's, Parkinson's and Tourette's

Rapoport (1994) - People who had surgery to disconnect the basal ganglia from frontal cortex brought relief in severe cases of OCD.

Evaluation of biological explanations of OCD's

Difficult to identify whether its genetics or the effect of the shared environment

Inconsistency in findings regarding serotonin.

Psychological therapy is very good, due to its success rates and contradicts the serotonin theory

Inconsistency with results regarding basal ganglia e.g. Aylward (1996) - found no difference between OCD and non-OCD sufferers.

Whether OCD is a consequence of increased activity, a cause of it or merely a correlate is still unclear

Head injuries and brain tumours have been associated with the development of OCD

Research into brain structures are still in their infancy due to the technological advancements

Rappoport (1989) - About 20% of OCD patients display nervous tics, implying that there is a link with the anatomy of the nervous system

What causes abnormal brain functions? Answer may lie in the diathesis-stress model which links the biological basis with the findings that the OCD occurs after a stressful event

Seems contradictory that OCD's have genetic basis yet behavioural therapies are most widely used.

PSYCHODYNAMIC APPROACH

Freud → fixation in the anal stage

Child accepts will of parents being neat and clean → when their natural preference may be messy.

If preference is too strong and parents are too strict → child becomes anally fixated

Occurs at an unconscious level → sufferer believes there really concerned with keeping clean and tidy.

Psychoanalysts believe OCD is most likely to be found in people who show anal personality characteristics e.g. being excessively neat, orderly and punctual.

Obsessions can be defence mechanisms which occupy the mind so as to displace more disturbing thoughts.

There is conflict between the Id and defence mechanisms

Adler (1930) - Disagrees with Freud.

Believes OCD results from when children are kept from developing a sense of competence (especially if parents are too strict).

If preference is too strong and parents are too strict → child becomes anally fixated

Occurs at an unconscious level → sufferer believes there really concerned with keeping clean and tidy. The child establishes a domain where they can actually exert control

Psychoanalysts believe OCD is most likely to be found in people who show anal personality characteristics e.g. being excessively neat, orderly and punctual.

Evaluation of psychodynamic

Hard to experimentally test the idea of the unconscious motivation

Gross (1996) - Reports that studies that examine the potty training of anal personality types (who are not as severe as OCD) find no difference from the potty training of other personality types.

BEHAVIOURAL APPROACH

Suggest that OCD is an extreme form of 'learned avoidance' behaviour:

At first, an event is associated with an anxiety or fear

As a result → avoidance behaviour initially alleviates the fear

BUT consequently, it becomes a conditioned response

Meyer & Cheeser (1970) - Compulsions are learnt responses which are ways of reducing the anxiety brought on by the obsession.

If the behaviour reduces anxiety it becomes reinforced

Superstition Hypothesis (Skinner, 1948) - Found that people who develop OCD's make by chance associations between behaviours and reinforces. This leads them to repeat the behaviours.

Evaluation of behavioural

Symptoms of OCD e.g. avoidance behaviour themselves create anxiety; is hard to argue that people learn these responses in order to reduce their fear

Behavioural therapies are very effective → Baxter et al (1992) and Schwartz et al (1996) both found that behavioural therapies not only reduces the symptoms but also brings about changes in biochemical activity

E.g. athletes 'psych themselves up' before an event, to suppress self-defeating thoughts.

An OCD patient will use strategies to reduce the negative thought, but the effort they put in to trying to inhibit the thoughts ends up inducing a preoccupation with it.

COGNITIVE APPROACH
OCD's are the result of faulty and irrational ways of thinking at an extreme level

Suggests that specific environmental stimuli are paired at some point with an anxiety-provoking thought = a conditioned response

E.g. if I don't clean, I'll get AIDS, so to avoid the possible threat they undertake the compulsive behaviour

This triggers the obsessional thoughts BUT the compulsive rituals try to counter-balance and neutralise them.

Rachman & Hodges (1987) - Argue that some people are more susceptible to obsessional thoughts due to vulnerability factors e.g. genetically determined hyper-arousability, depressed mood or poor socialisation experience

Research by the National Institute of Mental Health have found that OCD patients perform poorly in tasks involving the recall of events

Evaluation of cognitive

Lack of evidence supporting the view that OCD's are a result of poor socialisation experiences.

Sher et al (1983) - Patients who scored highly on a measure of compulsive behaviour also showed a memory deficit for actions recently performed.

Davison & Neale (1994) - Suggest that OCD patients are unable to distinguish between reality and imagination.

Neither biological (specifically medication) nor psychological therapies provide a long term solution to OCD's. Suggests that it is a very complex disorder to understand and treat.
Treatment

Biological/Medical - usually in the form of tricyclic drugs or SSRI drugs, which inhibit the serotonin

Behavioural - Systematic Desensitisation, a process where the patient is gradually exposed more and more directly to their obsession or compulsion. If that's impractical

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Obsessive Compulsive Disorder: Introduction, Explanations and Treatments

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Everyone has a fear or routine for something But, someone with an OCD → becomes so invasive and is accompanied by severe anxiety → cant function effectively in daily life Is the most severe anxiety disorders and is the most difficult to treat Obsession - persistent and recurrent, thoughts and

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Treatments of OCD - Tutor2u - drug therapy

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Treatments of OCD - Tutor2u - drug therapy

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Biological treatments for OCD aim to restore biological imbalances, such as too little serotonin. Drug treatments are based on the assumption that chemical imbalances are the main cause of the problem. Two types of drug are used for the treatment of OCD: (1) anti-depressants and (2) anti-anxiety drugs.

Anti-depressant drugs

The biological explanation suggests that OCD (and depression) is the result of low levels of the serotonin in the brain. SSRIs (selective serotonin re-uptake inhibitors) are one type of anti-depressant drug, which include drugs like Prozac.

The diagram (below) illustrates how SSRIs work.

When serotonin is released from the pre-synaptic cell into the synapse, it travels to the receptor sites on the post-synaptic neuron. Serotonin which is not absorbed into the post-synaptic neuron is reabsorbed into the sending cell (the pre-synaptic neuron). SSRIs increase the level of serotonin available in the synapse by preventing it from being reabsorbed into the sending cell. This increases level of serotonin in the synapse and results in more serotonin being received by the receiving cell (post-synaptic neuron).

Anti-depressants (like anti-anxiety drugs) improve mood and reduce anxiety which is experienced by patients with OCD.

Anti-anxiety drugs

Benzodiazepines (BZs) are a range of anti-anxiety drugs, which include trade names like Valium and Diazepam.

BZs work by enhancing the action of the neurotransmitter GABA (gamma-aminobutyric acid).

GABA tells neurons in the brain to 'slow down' and 'stop firing' and around 40% of the neurons in the brain respond to GABA. This means that BZs have a general quietening influence on the brain and consequently reduce anxiety, which is experienced as a result of the obsessive thoughts.

Evaluation

One strength of biological treatments for OCD comes from research support which uses randomised drug trials. These trials compare the effectiveness of SSRIs and placebos (a 'drug' with no pharmacological value).

Soomro et al. (2008) conducted a review of the research examining the effectiveness of SSRIs and found that SSRIs were more effective than placebos in the treatment of OCD, in 17 different trials. This supports the use of biological treatments, especially SSRIs, for OCD.

Another strength of biological treatments is their cost. Biological treatments, including anti-depressants and anti-anxiety drugs, are relatively cost effective in comparison to psychological treatments, like cognitive behavioural therapy (CBT). Consequently, many doctors prefer the use of drugs over psychological treatments, as they are a cost effective solution for treating OCD (and depression), which is beneficial for health service providers.

Extension:

In addition, psychological treatments like CBT require a patient to be motivated. Drugs however are non-disruptive and can simply be taken until the symptoms subside. As a result, drugs are likely to be more successful for patients who lack motivation to complete intense psychological treatments.

However, one weakness of drug treatments for OCD is the possible side effects of drugs like SSRIs and BZs. Although evidence suggests that SSRIs are effective in treating OCD, some patients experience mild side effects like indigestion, while other might experience more serious side effects like hallucinations, erection problems and raised blood pressure. BZs are renowned for being highly addictive and can also cause increased aggression and long-term memory impairments. As a result, BZs are usually only prescribed for short-term treatment. Consequently, these side effect diminish the effectiveness of drug treatments, as patients will often stop taking medication if they experience these side effects.

Finally, drug treatments are criticised for treating the symptoms of the disorder and not the cause. Although SSRIs work by increasing the levels of serotonin in the brain, which reduces anxiety and alleviates the symptoms of OCD, it does not treat the underlying cause of OCD. Furthermore, once a patient stops taking the drug, they are prone to relapse, suggesting that psychological treatments may be more effective, as a long-term solution.

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Biological treatments for OCD aim to restore biological imbalances, such as too little serotonin. Drug treatments are based on the assumption that chemical imbalances are the main cause of the problem. Two types of drug are used for the treatment of OCD: (1) anti-depressants and (2) anti-anxiety drugs.

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Australian Institute of Professional Counsellors

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Brief Demonstration of Exposure Treatment of Spider Phobia

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Snake Phobia Behavioral (Exposure) Therapy

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The specific phobias, such as animal phobias, or the fear of lightning, are easier, in general, to treat than agoraphobia. Agoraphobia spreads from place to place because the basic fear is not of that place or set of circumstances, but of the feeling the phobic person has in those situations. If agoraphobics are afraid of getting panicky and losing control of themselves, as they are, they will have that fear in any place from which they cannot quickly, and easily, extricate themselves. On the other hand, the fear of dogs, for example, is not likely to spread to other places and things. Just avoiding dogs will usually be enough to allow people afraid of dogs to live their lives comfortably. But not always.

A woman who had a singularly disruptive fear of snakes came for treatment to our Anxiety and Phobia Center. Usually, avoiding snakes is much easier than avoiding dogs. I live in Westchester County, as she did, and I haven't seen a snake outside of a nature center or pet store in the last forty years. She was so afraid of snakes, however, that she had not left her house alone for over ten years-on the odd chance that she would encounter a snake. That was her only fear. She felt at ease in those places-elevators, theaters, restaurants, and so on-that agoraphobics typically avoid. She entered an eight week treatment program along with other more typical phobics and, of course, the trained Phobia Aides we use, almost all of whom had been phobic, themselves, in the past.

During out first group session, she asked me if she would be able to recover completely.

"Sure," I told her. "But to recover completely, you will have to confront snakes closely. In the end, you will have to hold them in your hands."

She began to cry.

After the meeting, the Aides complained to me that I should not have, in this very first meeting, confronted her with what she obviously thought was impossible. I think they were right. If I had scared her too much, she might have left treatment. I wish I were sensitive and adroit enough to say the right thing reliably; but I cannot. I tend to say what I think. I can no more pretend to be circumspect than I can pretend to be neat, rather than messy. I would not be able to pull it off. On the other hand, there are some advantages to being outspoken. The patients always know exactly what I think. In any case, this particular patient was not dissuaded from continuing in treatment.

Besides the weekly group meetings, where progress and difficulties are reported, treatment involves the patient exposing herself, with the help of the Aides, to snakes-the idea of snakes, the fact of snakes--in a series of experiences of graduated difficulty, starting with:

1. Reading about snakes. I like phobics to become very knowledgeable, if possible an expert, about whatever they fear, in the case of snakes, their habits and habitats, whether they are poisonous or not, what they like to eat, how they have evolved. The more the patient knows, the better.

2. Looking at pictures of snakes. Not easy. Even a drawing of a snake could elicit a gut-wrenching feeling at first. But with more pictures and photographs, this became less and less upsetting.

3. Holding a toy snake. Still difficult. The patient had to get used to a stuffed snake first, then a toy snake that squiggled at the end of a stick.

4. Getting a snake skin, and keeping it in different places around the house.

5. Looking at a snake in a pet store, first from a distance, then closer and closer. It turns out a snake in a glass cage is very boring. It doesn't snap or snarl. It sleeps most of the time.

6. Going to a nature center where non-poisonous snakes slither around the floor.

7. Holding a snake.

By the end of eight weeks, this patient was holding, and demonstrating, snakes in the nature center. One of the unexpected things she discovered, she told me, was that the snake always slithered away from her when she inadvertently dropped it.

Months later she was still fine. Her husband, however, was complaining about all the snake skins he found around the house. (c) Fredric Neuman 2012 Follow Dr. Neuman's blog on fredricneumanmd.com/blog

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The specific phobias, such as animal phobias, or the fear of lightning, are easier, in general, to treat than agoraphobia. Agoraphobia spreads from place to place because the basic fear is not of that place or set of circumstances, but of the feeling the phobic person has in those situations.

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Phobias Textbook

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Antidepressants, among the top prescribed drugs on the planet, may be contributing to Alzheimer's and other brain-destroying dementias, new Canadian research suggests.

According to the study, popular Prozac-like pills known as SSRIs - selective serotonin reuptake inhibitors - and other antidepressants are associated with a twofold increase in the odds of developing some form of dementia, including Alzheimer's.

The association was even stronger for people who took antidepressants before age 65.

The study doesn't prove cause and effect. However, the findings, which are published in the journal Depression and Anxiety, are expected to raise fresh concerns about a class of drugs experts say are being wildly and indiscriminately prescribed for everything from ordinary cases of "sadness" to insomnia, pain and hot flashes.

They're almost becoming the antibiotic of this century

"They're being prescribed 'off label,' meaning for non-depression related situations. They're being prescribed to very young children and to the very old," said Dr. Darrell Mousseau, a professor in the department of psychiatry at the University of Saskatchewan and the study's senior author.

"They're almost becoming the antibiotic of this century: 'If you've got a disease, take an SSRI. It's going to help you in one way, shape or form.'"

Mousseau doesn't want to scare people off antidepressants. "They certainly do benefit some people," he said. "But we do find this association (with dementia) and, if nothing else, I think the discussion needs to begin."

Canadians are among the top users of antidepressants in the world. More than 50 million prescriptions were dispensed in 2015 alone, according to market research firm IMS Brogan.

Meanwhile, as people live longer the ranks of those with Alzheimer's and other diseases of the brain grows. Globally, 47.5 million people have dementia; in Canada, the figure is 750,000 and is projected to double within 15 years.

Given the economic and social costs, scientists are searching for risks factors, and over the years there have been hints depression may be one, Mousseau said. "Still, not everyone who has depression gets Alzheimer's disease, and not everyone who has Alzheimer's has had depression."

He wondered whether it is the depression itself, or the drugs used to treat it.

Mousseau has been particularly interested in a class of molecules called monoamines, which include the neurotransmitters serotonin and noradrenaline - brain messengers believed to be involved in depression.

The cells that make serotonin and noradrenaline are also among the first clusters of cells to die off in the brain changes leading to Alzheimer's, he said.

"All of these anti-depressants act on these monamines," added Mousseau, who holds a research chair in Alzheimer's and related dementia jointly funded by the Alzheimer's Society of Saskatchewan and the Saskatchewan Health Research Foundation. "It was just a logical step to look into what these drugs might be doing."

His team searched the medical literature for relevant studies. In the end, only five from an initial pool of more than 4,000 met their criteria.

A total of nearly 1.5 million people were pooled from the five studies. Overall, the pooled estimates showed that people with dementia were twice as likely to have been exposed to an antidepressant compared with people without dementia.

When the studies involved people under 65, the risk was threefold, perhaps reflecting longer drug use, Mousseau said.

The link was strongest with the SSRIs, and lowest with older antidepressants.

The researchers couldn't tell from the data set whether dose, or duration, meaning how long the person had taken an antidepressant, made a difference. And the analysis, in the end, included just five studies.

"But there is something to this association, even if it is not clear what it means," said Dr. Joel Paris, past chair of psychiatry at Montreal's McGill University.

Another study published last year from researchers in Taiwan also linked SSRIs with an increased risk of dementia.

However, a U.S. team reported two years ago the SSRI citalopram (sold under the brand name Celexa) appeared to reduce production of the deadly brain plaques tied to Alzheimer's.

Paris said "replicability" - where one study should produce the same results of another if repeated exactly - "is a crisis in medical research. My own benchmark is to wait until there is enough for a (larger) meta-analysis."

It's possible any increased risk of dementia could be due to how much of an antidepressant the person was on, or from a bigger brain change that caused the more severe depression in the first place, the researchers acknowledged.

Still, they believe a link between antidepressants and Alzheimer's is "biologically plausible."
* Email: skirkey@postmedia.com | Twitter: sharon_kirkey

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Antidepressants may be doubling risk of Alzheimer's and other dementias, study suggests

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Antidepressants, among the top prescribed drugs on the planet, may be contributing to Alzheimer's and other brain-destroying dementias, new Canadian research suggests. According to the study, popular Prozac-like pills known as SSRIs - selective serotonin reuptake inhibitors - and other antidepressants are associated with a twofold increase in the odds of developing some form of dementia, including Alzheimer's.

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Human Brain Genes Increase Lab Mice Intelligence

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Scientists have bred an unusually anxious, compulsively overgrooming mouse by knocking out a single gene called Slitrk5. These genetically altered mice, which behave much like people with obsessive compulsive disorder (OCD), could help researchers better understand and treat the debilitating disorder.

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Deep Brain Stimulation - alternative treatment

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Deep Brain Stimulation - alternative treatment

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This definition states that abnormal behaviour is when an individual is not able to cope with everyday life. It acknowledges that people may act differently but if they have a basic inability to manage in everyday life their behaviour is abnormal.

Ability to function or cope has been defined by Rosenhan and Seligman into seven sections; unpredictability, maladaptive behaviour, personal distress, irrationality, observer discomfort, violation of moral standards and unconventionality.

The Global Assessment of Functioning Scale ( GAF) is a method of measuring how well individuals function in everyday life and it considers Rosenhan and Seligman's sections plus occupational functioning.
Strengths of the definition
Consideration of how the individual feels: This definition is focused on the individual and how they are managing in everyday life from their perspective, so if someone feels as though they are struggling they will be deemed abnormal and get help.

Measurable: The GAF (see above) is a scale and allows for the extent of the failure to function to be measured. This means that the decision of whether a behaviour is abnormal or not can be made in a relatively objective way.

Behaviour is observable: Failure to function adequately can be seen by others around the individual because they may not get out of bed on a morning, or be able to hold a job down. This means that problems can be picked up by others and if the individual is incapable of making a decision or helping themselves others can intervene.
Weaknesses of the definition
Too much focus on the individual: It is argued that abnormal behaviours may not be a problem for the individual, but may be for others around them. For example, someone may be abnormally aggressive and not be worried by it, but their family and friends may feel it is excessive.

Abnormality does not always stop the person functioning: The focus on how someone is coping of this definition may mean that some abnormal behaviour is missed. People may appear fine to others as they fit into society and have jobs and homes, but they may have distorted thinking which is causing them inner distress that they hide.

Everyday life varies: The ability to cope with everyday life depends on what is seen as normal everyday life. This varies within and across cultures. Some body clocks mean that individuals do not rise until midday but they function well at other times. Culturally it is not unusual to have siestas, or move home regularly which may be seen as abnormal. This means that the definition is not clear.

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Failure to Function Adequately | tutor2u

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This definition states that abnormal behaviour is when an individual is not able to cope with everyday life. It acknowledges that people may act differently but if they have a basic inability to manage in everyday life their behaviour is abnormal.

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Obsessive Compulsive Cleaners S04E01 Country House Rescue

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Extreme OCD Camp Episode 1 BBC documentary 2013  journey to the American wilderness

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Extreme OCD Camp Episode 1 Documentary following six British teens and young adults with obsessive-compulsive disorder as they embark on an incredible journey to the American wilderness for treatment. During the week-long intensive camp, the group undergo exposure therapy, where they are challenged to confront their greatest fears.

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Study Notes

This is a mathematical method for defining abnormality. This definition works on the idea that abnormality should be based on infrequency; if it occurs rarely then it is abnormal.

The mathematical element of the definition is about the idea that human attributes fall into a normal distribution within the population.

This means that there is a central average, or mean, and the rest of the population fall symmetrically above and below that mean. Standard deviation as a measure informs us how far scores fall on either side away from the mean.

In a characteristic or attribute that falls into a normal distribution, like IQ, 68% of the population fall within one standard deviation from the mean. 95% of the population fall within two standard deviations from the mean. As the mean of IQ is 100 and the standard deviation for IQ is 15 that means that 68% of the population will score between 85- 115 on an IQ test and 95% of the population will score between 70 and 130.

This definition states that the 5% of the population that fall more than two standard deviations from the mean are abnormal. So, in the IQ example people who score below 70 and above 130 are abnormal.

This is illustrated in Figure 1 below.

Figure 1 An illustration of the normal distribution and percentages of the population to fall within the sections of that distribution

Strengths of the definition
Intuitive: The idea that abnormality is when something does not occur, as stated by this definition, often is an accepted definition for the word and makes sense.

Objective: The mathematical nature of this definition means that it is clear what is defined as abnormal and what is not. There is no opinion involved which means there is no bias.

A useful overview: This definition looks at the whole picture, taking all the population into account so can give a useful insight into the whole picture of a particular characteristic.
Weaknesses of the definition
Inflexible: There is a degree of inflexibility with this definition. It states that scores in the top and bottom 2.5% of the population are abnormal, but we know that there is some behaviour which is deemed abnormal by the diagnostic manuals for mental illness that would not fit within that definition. For example 3% of the population is thought to suffer from OCD but some of those individuals may not be seen as abnormal because they are within 2 standard deviations of the mean. This means that the definition and the current criteria for defining mental health issues are at odds with each other.

Abnormal behaviours can occur frequently: It is not the case that abnormal, as in unhelpful and painful, behaviours occur rarely. Depression is an example, where it is argued that 25% of the population will experience a mental health issue at some point in their lives.

Culture: There is no consideration of cultural differences at all as it argues that the population of the world are contained within the normal distribution. There are variances between cultures and the mathematical nature of this definition does not allow for this. This ultimately means that abnormality could be widespread in one culture because of its comparison with the rest of the world.

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Statistical Infrequency Definition of Abnormality | tutor2u

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This is a mathematical method for defining abnormality. This definition works on the idea that abnormality should be based on infrequency; if it occurs rarely then it is abnormal. The mathematical element of the definition is about the idea that human attributes fall into a normal distribution within the population.