Responding to the Anxious and Depressed Patient

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Responding to the Anxious and Depressed

• Dr Douglas Kong
• Retired Psychiatrist
• Executive/Business and Life Coach

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STRESS
SEPARATION/AMBIVALENCE
LOSS
DEPRESSION
ANXIETY
UNDERLYING BIOLOGICAL VULNERABILITIES
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The Autonomic System
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STRESS Response curve
OPTIMAL ZONE
EUSTRESS
DISTRESS
EFFICIENCY OF PERFORMANCE
STRESS TOO LOW
STRESS TOO HIGH
LEVEL OF STRESS
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Why Zebras dont have ulcers?
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The hormonal effects of stress

• Acute Transient Stress

• Chronic stress

• Hormone involved epinephrine
• Activates the Autonomic Nervous System
• Psychological and Somatic symptoms

• Hormone involved Cortisol
• Increase glucose levels in blood
• Narrows the arteries
• Weight gain through fat storage
• Depress immune system function
• Link to chronic diseases

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Stress and Cell Death
STRESS
Glucocorticoids
Dendritic branching
BDNF
Atrophy/death of neurons
Normal survival and growth
BDNFbrain-derived neurotrophic factor.Sapolsky
RM. Arch Gen Psychiatry. 200057925-935. Duman
RS, et al. Biol Psychiatry. 200048732-739.
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Can Treatment Prevent or Reverse the Damage?
ECTelectroconvulsive therapy. Sapolsky RM. Arch
Gen Psychiatry. 200057925-935. Duman RS, et al.
Biol Psychiatry. 200048732-739.
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STRESS Response curve
OPTIMAL ZONE
EUSTRESS
DISTRESS
EFFICIENCY OF PERFORMANCE
STRESS TOO LOW
STRESS TOO HIGH
LEVEL OF STRESS
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Optimal performance more than ANS
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SURVIVING MODE
Amy Arnsten, 2009
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Safety- explore the environment
THRIVING MODE
Amy Arnsten, 2009
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Stress vs Ideal Human Functioning

• Stress
• Mid brain in charge
• Protected Mode
• Survival
• Paranoia
• Dissociating
• Escape
• Relief
• Epinephrine then cortisol

• Mental focus and involvement
• Forebrain in control
• Learning Mode
• Creative innovation
• Trust and emotional security
• Connecting
• Attend to those in need
• Reward
• Epinephrine then glutamate

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The anxious and depressed patient

• The person is suffering from their
  anxiety/depression
• Understand that their pain, including physical,
  is real
• They may feel helpless, isolated and a failure
• Feelings range from guilt, hopelessness to
  frustration
• They want relief from suffering
• They have been struggling to help themselves
  without success

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Responding to the anxious/depressed

• Respect the person, their suffering and their
  feelings about it
• They will have doubts and mistrust about
  relationships
• People they are close to may have prejudge them,
  criticise them
• Do not criticise them, their choices or their
  doubts about others
• Do not offer advice or solutions to their
  conflicts, problems
• Do not say, itll get better, this will blow over

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What to do with the Anx/Dep

• Do stay with them, they will feel comforted
• Get them to talk about their troubles
• When asked questions, emphasize that their
  feelings are valid
• Ask them for their own answers to these questions
• Very often, they show the confusion, perplexity
  they have
• When asked for solutions, emphasize each person
  has to seek own solution

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Know where you stand when you respond to them

• Recognize that each person is unique
• They are in a seeking phase and looking for
  support
• So to provide answers is to judge them
• Giving answers and solutions too quickly masked
  their struggles, confusion and perplexity
• Make them feel more useless, guilty, frustrated
  etc
• All their feelings valid they point the way to
  what needs to be done
• Tolerate the fact that you have NO answers
• NOT your responsibility to provide answers

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How to be helpful to people

• Learn to listen to others
• If necessary, a comforting hand on their arms
  and/or shoulders
• Learn to be comfortable with their sorrow,
  anxiety and suffering
• Listen to them what they are saying
• Ask open-ended questions so that they are able to
  open up
• Closed ended questions, with yes/no answers
  should be used sparingly
• Closed ended questions ended up proving you are
  right, the client remain in misery

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Clarifying their crises, difficulties

• Ask questions to help them explain what happen
• Find out how many people are involved
• Learn what incidents come first before another
• Gently ask them for how they think about the
  people, incidents
• Gently get them to share how they feel about
  people, incidents
• Clarifying questions, who, what, when, how and
  rarely why (blame)
• Purpose of clarifying ---- understand the person

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Handling silence

• If they are unable to talk, listen to their
  silence
• Attention to their body language and their
  emotional expression
• What is their meaning of their silence?
• Embarrassment
• Contemplative
• Reverie- contentment
• Stay with their silence

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Handling criminal desires including desires to
harm

• Hold on to your judgement or distaste of what
  they do
• Get them to talk about it
• Ask them if they have a plan
• Ask them for the consequences
• Would they like to seek for help
• Inform them of your legal responsibility

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Handling suicidal urges, sexual impulses

• Get them to talk about it
• Ask how much they have thought about it
• Ask for details as to how they had thought to do
  it
• Ask them for their views as to the effects of
  their act
• When you exhaust your questioning, ask them would
  they still do it
• Remind them they have a choice
• Offer support when they decide NOT to do it

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The goal of responding

• Your goal in talking to them is to listen to them
  and understand them
• Often talking about it make them feel better
• Many times, perhaps 90 of time, they know the
  solution
• They are seeking for support
• What they feel, or desire, or plan to do make
  them feel lonely and isolated
• Commonly there is a sense of being abandoned
• By talking with them you accept them as they
  are
• Healing is reconciliation, to self and to others

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Prescription for Wellness living in the
Optimal Zone

• 1. Exercise at least 30 minutes 3 to 4 times a
  week
• 2. Nutrition avoidance of food that will burden
  the bodys detox load
• 3. Omega 3 fatty acids
• 4. Practice of mindfulness and reinforce a
  positive frame of mind
• 5. have good, positive and supportive
  relationships
• 6. Adequate sleep and exposure to sunlight

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How to effectively help people in distress

• Take care of yourself
• Be willing to learn
• Dont do it all by yourself, get supervision,
  join a community
• Do not get yourself emotionally involved
• Never go beyond your competency, also refer
  onwards
• Be careful of being manipulated by those you help

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Experiential exercise

• We will again form groups of 3, a client, an
  interviewer, and an observer. You should try to
  change your role from last weeks session eg if
  you are an interviewer, switch to being a
  client or an observer and likewise for the
  other two roles
• For the client, select a problem or crisis you
  have faced, or someone whom you know has faced to
  share and talk about it. If the problem is not
  yours, own the problem, get into the client
  shoes and feel the problem like it is your very
  own.
• For the interview, your role is to listen and to
  understand the client, ask good questions, if
  possible powerful questions. You have succeeded
  if the client feel that they were being heard
  or being understood.
• The observer will listen carefully to the
  proceedings and evaluate it according to the
  evaluation sheet given to you. Highlight lessons
  learnt in the evaluation sheet.

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www.theoptimalistway.com

• If you are actively engaged in helping such
  mentally distressed individuals and should you
  need professional support and supervision, you
  may inquire of me at douglas_at_theoptimalistway.com
  
• Information about what I offer is available at
  www.theoptimalistway.com
• To contact me for the slides and for any other
  information or service contact me at
  douglas_at_theoptimalistway.com or
  support_at_theoptimalistway.com