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Friday 28 October 2011

Medications: What is Serotonin?

(This is part of a series of posts on the basics of psychopharmacology that I’m posting so that I can refer people back to it.  The first defined neurons, and the second described neuronal transmission.)

Serotonin is one of many chemicals in the human body that function as neurotransmitters – chemicals that allow individual neurons to communicate with one another.

In the early 20th century chemical transmission was hypothesized to be the method whereby neurons communicated with one another. This was demonstrated experimentally by Otto Loewi in 1921. The first neurotransmitter to be identified was acetylcholine.

Serotonin was discovered in 1935 by Vittorio Erspamer. He was looking at the contraction of cells in the intestinal system, and called the substance that seemed to produce the effect enteramine (for enteral, related to the intestines). In 1948 Maurice Rapport isolated the substance. He demonstrated that serotonin acted to increase the tension (or tone) in the tiny muscles governing the diameter of blood vessels. Blood is serum, thus the name became sero-tonin, the “blood vessel toner.”

Serotonin has subsequently been found to have many other effects as well, so its name is a result of the accident of discovery. It is also known by its chemical name, 5-hydroxytryptamine, or 5-HT.

For many years it was believed that serotonin was found exclusively in the peripheral nervous system (as opposed to the central nervous system, or CNS: the brain and spinal cord). This, like much else believed about it, was wrong.

About 95% of the body’s serotonin is found outside the central nervous system, mainly in the gastrointestinal tract.  About 5% is in the CNS.  This makes it a bit odd that almost every reference to serotonin in the popular press talks about its central (brain) effects.

The blood brain barrier

While we’re on the subject, let’s consider a common question: If people are thought to have problems due to serotonin deficits in the brain (more on this idea later), why don’t we just feed them extra serotonin?

The body is designed to protect the brain from infection, and to keep a relatively stable chemical soup for it to sit in. Consequently, the membranes separating the blood supply from the brain are somewhat more elaborate than those in the rest of the body.

This “blood-brain barrier” means that some chemicals, including drugs, that can reach the rest of the body are blocked from entering the central nervous system. Serotonin, oddly enough, is one of these. So if we fed a person large quantities of serotonin (a dangerous thing to do), the result would be no increase in brain levels.

Serotonin is manufactured within the body (and within the central nervous system) from other substances, some of which are in the diet. These chemicals, being earlier in the set of steps that eventually lead to serotonin, are termed precursors. Precursors for serotonin include substances such as tryptophan and s-adenosylmethionine (or SAM-e). Some precursors, like those just mentioned, can cross the blood-brain barrier, and so can be absorbed from the diet.

So why bother with the various drugs designed to help brain-based serotonin systems? Why not just dose up on precursors, which would result in more serotonin?

This seems like a sensible idea, but there are some problems with it.

For example, the precursor we choose may not be the limiting factor in the production of serotonin. Imagine that in order to create a serotonin molecule we need equal parts of Substance A and Substance B. We decide to provide supplements of Substance A. But, unbeknownst to us, the person already has an ample supply of Substance A. They lack Substance B. We can give them as much Substance A as they can stand, and it won’t make any difference to the amount of serotonin they produce.

This seems obvious, but in practice the process of neurotransmitter manufacture is sufficiently complicated that precursor supplementation is extremely tricky.

Tricky or not, another option is to do it anyway and just see what happens. (Of course, many substances are toxic at high doses, so we have to be somewhat cautious about this.) The result is that attempts to raise brain serotonin levels – and resolve problems thought to be related to serotonin deficiency – with supplementation just haven’t tended to work out well.

Next:  What is the monoamine hypothesis?

Wednesday 26 October 2011

Medications: The CDC on Antidepressant Use in the US

How many people use antidepressants?

A recent report by the Centers for Disease Control and Prevention on the use of these medications by persons 12 and over from 2005 to 2008 provides some answers.  Canadian use patterns tend to be broadly similar to the US, so we can assume that the figures are not too different for people above the 49th parallel.

The full report can be found here.

Overall, the figures are quite interesting:

Percentage of US citizens 12 and over taking antidepressant medication: 10.8
Men:  6.0
Women: 15.4 (about 2.5 times the rate of males)

Age group with highest prescription rate: 40-59, 15.9%
Men: 60 years and over, 9.4%
Women: 40-59, 22.8%

Teens age 12-17 taking antidepressants: 3.7%
Males: 2.8%
Females: 4.6%

Rank of antidepressants of all drug classes in terms of frequency of use:  3
For persons 18-44:  1

Change in rate of antidepressant use between a 1988-94 sample and the 2005-08 sample: +400%

Relationship between income and likelihood of taking antidepressants: Small but positive (more income, more medication use).
This may mean that higher-income people receive more medical care or are more likely to be able to afford antidepressants. The relationship of income level to frequency of depressive symptoms is not reported.

Percentage of persons 12 and over with no depressive symptoms taking antidepressant medication: 7.6%
Of those with severe symptoms:  33.9%
Some of those taking medication without symptoms may be prescribed the medication for another disorder (such as an anxiety problem); and some may be symptom-free because the medication is working well.

Of those taking a single antidepressant, number who have seen a mental health professional in the past year:  29.3%
Of those taking more than one antidepressant:  48.2%
In Canada, the majority of people treated for depression see their GP only; this seems to parallel the US.

Tuesday 25 October 2011

Exercise in Everyday Life

New Yorkers: An exception?
When I teach outside Canada people sometimes ask me to compare cultures and lifestyles.  What are the main similarities and differences between people?

Recently I spent some time in California at a conference and noticed something that made me think there is a perfect research study just waiting for someone to conduct.

The meeting was held at an enormous conference centre on two levels that were connected by escalators and stairs.  The first morning I wanted to attend a talk on the upper level and stepped onto the escalator.  I automatically began climbing the risers but soon stopped behind a pair of fellow conventioneers who were chatting amiably on the way up.

Looking past them I saw that everyone was similarly stopped, waiting for the escalator to deliver them to the top.  Some singles stood on the right, others on the left.

In much of Canada this would result in a number of people saying “excuse me” and squeezing past, plus at some times of day some unpleasant looks.  The usual habit is to stand on the right, leaving the left for people to climb the steps.  Couples usually stand one in front of the other on the right, or stand side-by-side, but step up or down and to the side when climbers pass.

For the rest of the conference I paid attention every time I changed floors.  Feeling vaguely self-righteous, I made a point of using the stairs.  This was helpful for a) waking me up between sessions, b) partially compensating for the lack of exercise at the convention (I tend not to seek out the local gym), and c) making me feel childishly superior.

As I watched I noticed that very few people seemed to walk either up or down the escalators.  Those that did seemed flustered and sweaty, obviously rushing to a late meeting.  Virtually no one used the stairs.

Is this a general phenomenon?  I have no idea.  The convention centre had high ceilings, so the escalators were a little longer than usual.  And I was only in one city.  It would be interesting to compare different cities, states, and – most interestingly of all – countries.

So:  The study?  Send experimenters with clipboards to shopping malls around the world and surreptitiously watch escalator behaviour.  Note how many people walk and how many ride.  Where escalators are beside stairs, calculate the proportion of people who use one or the other.

I’m always encouraging exercise for the people I see at the clinic.  For depression, anxiety, anger problems, and just about anything else exercise can be remarkably helpful.  And I encourage people to get their exercise not just in the gym, or on dedicated runs or swims, but in everyday life.

I suggest that they forget that elevators are capable of taking them three floors or less, and (hypocritically) encourage them to think of escalators as very dangerous devices to be avoided whenever possible.  When they take transit I encourage carelessness, so that they get off a stop earlier or later and have to walk a little further to their destination.

Somehow we've created a culture in which getting exercise means getting in the car, driving someplace, getting changed, exercising while accomplishing absolutely nothing else (not harvesting crops, not hunting buffalo, not traveling to the next village - nothing at all), getting changed again, and driving home.  Exercise is a complete add-on to our lives. No wonder we neglect it.

Instead of this (or in addition - our culture is organized so that no matter what we do we can't get enough exercise without making that the focus) we should become less efficient and waste a great deal of the one energy source that we need to expend more:  our own.

Friday 21 October 2011

Medications: How does neuronal signal transmission work?

(This is part of a series of posts on the basics of psychopharmacology that I’m posting so that I can refer people back to it.)
Two neurons, not quite touching...

Remember from our last post that cells are made up of dendrites, one or more axons and, at the ends of the axons, terminal buttons that sit on the dendrites of adjacent neurons.

Electrical (or chemical, if you prefer) signals flow along one neuron, then jump the gap to the next neuron in line. If the signal has sufficient strength, an impulse is created that travels along the next neuron to its own terminal buttons, where it jumps to the next neurons in line. Neurons are usually thought of as binary switches: signals either reach the strength to produce an impulse, or they don’t - something like computers, which operate entirely using sequences of 0’s and 1’s.

Most of the attention paid to neuronal transmission focuses on what happens at the point of contact between one neuron and the next.
Neurotransmitter being released and received

The signal travels down the axon to the terminal buttons. Within the cell there are small sacs of chemicals called neurotransmitters. When a signal arrives, some of the neurotransmitter is exuded into the tiny gap between the button and the next cell’s dendrites. The molecules of neurotransmitter float across the gap, and some of them attach to chemical receptor sites on the receiving neuron. If neurotransmitter molecules dock with enough of the receptor sites, the next neuron will fire.

Once the sending cell has released its transmitter, it opens ports that gather some of the transmitter back again to be used the next time. This is the process called reuptake – which is important in discussions of the action of antidepressants and other medications.

Serotonin on the move?
When I taught this material at university many years ago I found it helpful to use analogies. Sometimes this can come across as juvenile, but sometimes it helped get an idea across without doing too much violence to the concept. So my apologies for what comes next.

I live in British Columbia, which apparently has the largest fleet of car ferries in the world, operating between closely-spaced islands and the mainland. Inevitably, when I think of neural transmission I think of ferries.

One station, let’s call it Victoria, builds ferries. When it receives a signal, it sends out a collection of boats in the direction of the other port, which we’ll call Vancouver. Vancouver’s station has to have docks that can accept the specific ferries that Victoria creates. If enough Victoria ferries arrive at Vancouver docks, the resulting vehicles can form a convoy and move through Vancouver to Horseshoe Bay, where more ferries are being built to travel to Gibsons Landing.

Once the ferries have been sent, Victoria can open its own docks again to gather back up any ferries that don’t make it across to Vancouver. Then it can recycle the ferries next time there is a signal.

This sounds simple, but lots of things can go wrong.

Sometimes Victoria doesn’t have the right parts to build ferries. The result is too few ferries in the fleet. Translation: Nerve cells need the building blocks from which the transmitter chemicals are made. If these are unavailable, there is a shortage of transmitter.

Vancouver may not have enough docks built. This makes it difficult to get enough vehicles across to create a convoy. Translation: Sometimes receiving cells lose their receptor sites or do not create enough to make transmission work easily.

Other ships may occupy Vancouver’s docks, preventing the real ferries from arriving. Translation:  Receptor sites are not completely exclusive to the neurotransmitter. Some chemicals can bind to the receptor sites without contributing to a signal. These effectively block transmission.

Victoria may open too many of its own docks for returning boats, and may do it too early. As a result, the recently launched ferries return to Victoria and there are not enough of them to make it across to Vancouver. Translation: Reuptake may be too enthusiastic, or if there is a shortage of transmitter the reuptake pumps may operate normally but still take back too much transmitter so that the next neuron doesn’t fire.

More can go wrong.  But that’s enough to get us started.

Next:  What is serotonin?

Tuesday 18 October 2011

Trauma Explained: Is Treatment Necessary? PsychologySalon at UBC Robson Square, October 25 2011

The Tuesday October 25 PsychologySalon presentation at UBC Robson Square (7-9 pm) will feature Dr Nancy Prober.
Dr Nancy Prober

Dr Prober is a registered psychologist at Changeways Clinic providing treatment for anxiety (including trauma-related anxieties) and depression. She has seven years of experience providing trauma-focused assessment and treatment for veterans, soldiers, and RCMP personnel. I spoke with her about the topic and the upcoming talk.

What is a trauma?

A trauma, as psychologists use the term, is an event that is experienced as life-threatening. Day-to-day use of the word in our culture is quite loose, but as a technical term it is quite specific. We’d say that something is a significant trauma when there is a sense that we might actually die, and we go through a set of typical reactions.

Reactions like what?

Usually there is a strong fight or flight response, which involves an adrenaline rush, and causes increased heart rate, an increase in muscle tone in the body and limbs - or there is a freezing response. Often the attention gets very narrowed, which allows the person to focus very intently on the threat. At the time, this is often adaptive. Over the long run that can be very problematic.

Additionally, trauma often challenges the basic assumptions that people make about their safety in the world, the trustworthiness of other people, and the extent of their own competence.

Is trauma a distinct entity, or is it a matter of degree?

The diagnostic criteria make it a very specific thing – where there is a life threat either to oneself or to someone close to you. Usually there is a sense of horror, fear, and helplessness at the time – at least according to the diagnostic manual. Sometimes - for example with military personnel - those immediate reactions aren’t present to the same degree – or they become aware of it only later on. People often say “It happened, and I just got on with my job.” But later a reaction can develop.

Why is trauma a problem after it is over?

Immediately after the trauma, most people are going to experience typical trauma-related reactions – anxiety, tension, nightmares, intrusive memories, and so on. If they are able to re-establish a sense of safety fairly quickly and have a lot of support so that they can face what has happened to them, then the symptoms tend to go away over the next weeks or months.

What we know about PTSD is that when people are not able to do these things, when they avoid reminders of the trauma or thoughts and feelings about the trauma, then they tend to experience symptoms for a longer period of time. We believe that avoidance tends to fuel the disorder.

How is trauma treated?

Treatment follows from the cause. So very gradually and in a structured way we get people to talk about what happened, and we have them do things that remind them of the trauma. For example, a person who has been in a terrible car accident might visit the intersection where it happened, or they might practice sitting or riding in a car again.

Over time the anxiety tends to decrease while they are in the presence of these reminder cues. It also helps the person to differentiate between what happened in the past and what’s going on right now. As they start to have success with the treatment, people start to rediscover a sense of personal competence again.

What will your talk at PsychologySalon be about?

It’s important to realize that the talk itself isn’t therapy. I’ll talk about the nature of trauma, typical reactions that people experience, and things that people can do to make it likely that they’ll get through the situation more quickly. Then I’ll talk about what PTSD is, what the treatment looks like, and signs that you or a loved one may benefit from treatment.

Thank you!

Friday 14 October 2011

Medications: What is a Neuron?

I've had some requests from clients and readers to discuss the basics of psychopharmacology and the recent storm of controversy surrounding the antidepressants. So for the next while, Friday posts will be devoted to a primer on the brain, and on some of the medications and their use.

I won't be exhaustive on the subject, but hopefully at least some of what I say may be helpful. I want to be fairly even-handed on the issue, though I have no doubt that some readers (including fellow professionals) may have a different take on what I have to say. Feedback is welcome, as always.

Here are the titles of the next few Friday posts, to give you an idea where we are headed:

  • What is a neuron? (today)
  • How does neuronal signal transmission work?
  • What is serotonin?
  • What is the monoamine hypothesis?
  • How are SSRI antidepressants supposed to work?

Then we'll go from there.

So let's start with the basics, before we even look at medications.  For some this will be just a bit TOO basic, for which my apologies.

What is a neuron?

The brain is made up of neurons, or neural cells, and glial, or support cells (which greatly outnumber the neurons).  Most scientific attention has been given to the neurons because they seem to be the important ones.  Essentially, all they do is communicate with one another using electrochemical impulses.

Until recently it has been assumed that glial cells simply act as insulators or feeder cells for the neurons, and so they have seemed to be of less interest.  Lately, however, suspicions have been growing that the glial cells have more roles than we once thought.  Like most treatments of the subject, however, I’ll pretty much ignore them.

Neurons are typically described as being in three sections.

  • The cell body contains the DNA and most of the cell organs – mitochondria and the like – that are common to most cells.
  • The axon (or axons) is a channel down which an electrical signal can pass.  At the end of the axon are terminal buttons, which look a bit like little feet sitting on adjacent neurons.  Calling these “buttons” was a bad idea, because these days we think of a button as something that gets pressed, thereby receiving a signal.  In fact, the buttons send the signal.
  • Dendrites are the receivers – the stretches of cell upon which other cells’ terminal buttons sit.

The simplest-looking neurons are long cells used in sensation or movement.  As a result, most of us learned about neurons from diagrams of these.

Imagine a monstrous creature that walks erect like a human.  Its head has one central eye (the cell nucleous), crowned with a nest of spiky hair (the dendrites).  It has a long, impossibly skinny body (the single axon) ending in multiple tiny feet (the terminal buttons).  Pull back and we see that it’s standing in the hair of another neuron, which is standing in the hair of another, and so on.

In reality, most neurons don’t look like this.  They’re more like a bush of axons, dendrites, and terminal buttons, sitting in a tangled mass of other bushes.  Neurons in the brain communicate with dozens or hundreds of others.

Now:  How do neurons communicate with one another?  That's for next week.

Wednesday 12 October 2011

WORKSHOP: Private Practice Made Simple

My book Private Practice Made Simple (New Harbinger Publications 2011) is now out and in bookstores.

In 2012 Changeways Clinic and PsychologySalon will be offering the one-day workshop on which the book is based in cities across Canada - most likely Halifax, Toronto, Ottawa, Winnipeg, Edmonton, Calgary, and Vancouver.

We're in the planning stages of these workshops and hope to have dates and locations finalized within several weeks.

If your organization would like to cosponsor the program, email us at and let us know.  Sponsors generally help out with promotions and organization, and can share in revenues or provide spaces free (or at discounted rates) to their membership.

For a list of past hosts, click here.

Tuesday 11 October 2011

The Goals Escalator

People who are depressed, burned out, or who feel stuck in their lives often describe a sense of listless inertia. It’s hard to get out of bed, open the mail, work on ongoing projects, and even complete small chores. Most of us have been there to at least some degree at some point in our lives.

In this state, people can be shocked at how little they seem to accomplish in a day.

“I used to get out of bed, get myself organized and out of the house, work a full day, come home, make dinner, and accomplish a few things in the evening.  Now I can’t seem to get myself started. The simplest things, like cleaning out the hall closet, make me feel completely overwhelmed. But sitting and watching daytime television makes me feel worse.”

Naturally, people wonder if they will ever get back to something resembling the level of accomplishment they used to achieve. Even if this is possible, they don’t know how to get there. What they would like is a metaphorical escalator to lead them out of the pit.

Fortunately, there is one. As is so often the case, the key is something we might call the “middle path.” It isn't the total solution to depression, or to burnout, or to dissatisfaction with our lives. But it is a very useful tool.

During depression, burnout, or just a period of stuckness in our lives, it becomes quite easy to feel overwhelmed. Trying to write an essay, finish a tax form, clean out the garage, or open a stack of mail can bring about a feeling of hopeless anxiety.  And yet it can feel important to do all these things.  "I need to, but I can't."

The temptation is to flip from feeling overwhelmed to the opposite pole: avoid almost everything and instead watch television, play video games, stay in bed, isolate, or retreat in some other way. The hidden reasoning is often that doing so will allow us to recharge our batteries. We will eventually feel an upswing in energy and get back to living our lives.

Unfortunately, this avoidant activity tends not to recharge us. The anxiety continues and we feel more and more incapable of handling the challenges around us. A feeling of crawling desperation begins to take hold. Life can feel both gratingly unpleasant and ploddingly boring.

All of these feelings – hopelessness, anxiety, overwhelm-ment, and boredom – are recognizable precisely because we have felt them before. And we survived. So although they feel unpleasant, they are not, in themselves, dangerous. We can welcome them as guides to action.

But what kind of action? Imagine a three-layered cake, or Neapolitan ice cream (strawberry, chocolate, vanilla), or the layered B52s served in 1980s bars (Kahlua, Bailey’s, Grand Marnier).

The bottom layer is mired, inactive, avoidant boredom. Sitting in this layer makes the inertia more intense.

The top layer is frantic, anxious activity – or a skittering litany of all the things we should be doing if only we weren’t so stuck. This makes the feeling of being overwhelmed worse.

The middle layer is the upward escalator. We need to get ourselves out of the utter inactivity (or avoidant activity) to begin doing very small tasks – washing a few dishes, opening a single piece of mail, spending 5 minutes on the garage cleanout, walking a single city block.

But we also need to relinquish the ambition to be the person we once were – the level of accomplishment we have achieved for most of our lives. We must consciously let go of the intention to finish cleaning out the garage, to get fully caught up in our paperwork, to run all the way in a marathon.

Instead, we need to focus on what will almost always seem like a trivial task – something our “old self” could have dispensed with in a few minutes. The mission is to tolerate this sense of dissatisfaction at the level of challenge, and the inevitable thought that “I’ll never get anywhere at this rate.”

Finding this narrow middle zone of activity can serve as a kind of escalator. It leads upward, and we become capable of a bit more and a bit more.

All along in this process, it is important to monitor emotions. Feeling overwhelmed means we are sliding up into the over-anxious layer; feeling flat, dull, or bored means we are sliding down into the inertia layer.

Feeling very slightly challenged, confident that we can do what we have set out to do, and sensing ourselves being somewhat held back, as though we are straining on a leash a bit, tells us we are on the escalator again.

Will we get back to the capable person we once were? Yes, probably. Not as fast as we might have liked, and not without effort. But we will not get there by pretending we are as energetic as we have been at our best, nor by siting on the couch recharging.

We will get there by finding the middle route and following it upward.

Friday 7 October 2011

Thanksgiving: Is It Cognitive Therapy?

(FYI to international readers: Monday October 10 is Canada's Thanksgiving - we celebrate ours earlier than the USA so that we have an extra six weeks to work up the appetite for more turkey at Christmas.)

In a time when fewer and fewer people identify with traditional religious ideas, Thanksgiving can seem like an anachronism from an earlier, theistic, agrarian age.

After all, if you are giving thanks, the obvious question lurks at the edge of consciousness:  Just whom are you thanking, exactly? If you don’t believe in a specific deity, it’s difficult to know whom to address. Even if you count yourself a believer, you can catch yourself asking just why the deity asks for or requires incessant praise from His/Her creations.

But this mental debate targets the receiver of the thanks, rather than the giver. It subtly frames gratitude as a process by which a good, one’s thanks, is subtracted from the mental bank account of the giver and added to the account of the receiver. If there is no receiver, or if the receiver has no great need of the good, then the resource has simply been wasted.

There’s another perspective, obviously.

The central principle of cognitive therapy is that our emotions and actions are based, largely, on what we pay attention to, and what we think it means. If we invite three friends to Thanksgiving dinner and two of them accept the invitation, our reaction will depend entirely on where we focus our attention, and on how we interpret what we see.

If we dwell on the absent party and imagine that they declined due to a wise and accurate awareness of our worthlessness, we will feel one way. If we focus on the two who arrived and the prospect of a pleasant conversation over dinner, we may feel blessed.

Our minds spontaneously tend to look at what is lacking rather than what we have – likely because in an evolutionary environment it was what we lacked that demanded the most attention. The result is an inborn vulnerability to a sense of poverty. No matter how good our lives are, the human mind will drift off to what is missing. That cushion on the sofa isn’t quite the right shade of fuchsia. The asparagus isn’t nearly as firm as we would like. The yacht has an unsightly scratch where it brushes against the dock.

Thanksgiving invites us to gently prod our minds over to what we have, not what is missing. By attending to our harvest (of apples, of friends, of central heating, of life in a peaceful society, of health) we can shift our minds from poverty to wealth.

So whom should we thank? Perhaps it does not really matter. God, karma, fate, luck, the universe, that crystal on the bookshelf? We don’t have to decide.

We can simply attend to all of the things that we would miss if they were taken from us, and offer our thanks outward. The thankee is irrelevant. It is the thanks that count.

Tuesday 4 October 2011

The Capacity Wave: Depression, Burnout, and Feeling Overwhelmed

How much can you do in a day?
Our capacity varies day by day

It’s hard to quantify.  Some days you have energy, some days you haven’t had enough sleep.  Some days the task is a pile of paperwork, some days it’s gardening.  Some days you get an invigorating variety; other days you have to focus and push through one chore.  The amount you can do varies accordingly.

But through all of that, you have a general energy level and a capacity to get things done.

Now: How much is demanded of you in a day?  We all have a list of projects we can’t get done by sundown.  Cleaning out that storage closet will have to wait.  Organizing the family photos can hold off until next spring.

But external pressures demand that you get a certain amount done.  The kids have to be fed.  You have to produce a certain amount at work.  Your night school course demands that four chapters of the book are read.

Sometimes the level of absolute demand – the list of things you really think you have to do – approaches or exceeds the amount you are physically capable of accomplishing.

Maybe that sounds okay.  If you can sustainably do 10.2 hours of productive activity a day, then maybe you should get a demand of 10.19 hours.  That way you’d be making the most of your abilities.

And in fact it IS okay.  Every now and then it’s fine to have a day that demands, say, 14 hours of useful activity from us.  We can stretch and do it.  We can even do two days in a row like this.
With excess demands, our capacity drops

But when the level of external demand routinely approaches or exceeds our capacity, the capacity itself is affected.  After a week of demands beyond our sustainable limits, the capacity begins to decline.  Now we can only manage 10.1 hours a day.  Then 9.3.  Then 7.5.  Sometimes the decline is steep.  Maybe it drops to 2.0 hours.  Or 0.3.

At Changeways Clinic one of our specialties is the treatment of clinical depression.  During depression, people’s energy is usually extremely limited.  They buy four items at the grocery store, then go home and collapse, exhausted.  They concentrate enough to pay a single bill, then lose focus and give up on the paperwork.  The bank account of energy and capacity is so low it sometimes seems to have disappeared.

Part of our job is to help the person eliminate the excess demands that they can’t meet anyhow, then set a limited number of goals that they can achieve with the tiny amount of capacity they still have.  By succeeding at these, the capacity begins to come back up.
Reduce demands to the achievable; capacity recovers

Sooner or later almost everyone has a burst of unhealthy enthusiasm that causes them to take on more demands than they can realistically manage, and then they have another dip.  If we can help them reduce expectations enough that they can get back on top of their schedule, their capacity begins increasing again relatively quickly.

Whether you are prone to depression or not, you can feel the capacity wave operating in your own life.  When the snowdrift of chores and paperwork gets too high, your capacity falls.  If you cut back on your expectations sharply enough (and give yourself credit for what you actually accomplish), your capacity begins to rise again.

What is a nervous breakdown?  Psychologists often roll their eyes at the term, because there is no such formal diagnosis.  But the idea persists, because it seems to describe a common experience.  Life builds up to an unmanageable extent, and then your capacity to cope drops.  In the extreme, we might call this a major depressive episode.  To milder degrees, most of us have experienced the problem.

Burnout is another term for it.  We push ourselves (or get pushed by the boss or organization) to excel a bit more and a bit more.  We learn how to “do more with less” or work more efficiently and we genuinely get a bit better at things.  But sometimes we take on more than we can sustainably handle.  “Hey, I’ve shown I can work til 9 pm, so let’s do that every night.”  Or external forces (a major project, a tax audit, a downsized workforce) make a sharp increase in effort imperative, and we discover too late that it cannot be sustained.

The key is to recognize the difference between our temporary capacity (the amount I can do today if I push it) and our sustainable capacity (the amount I can do on an ongoing basis).  We can readily exceed the sustainable capacity now and then.  But if we – or our job or life – makes it important to exceed this routinely, we are on a collision course for trouble.

Online Course

Want additional ideas and strategies for working with life dissatisfaction, inertia, and low mood? PsychologySalon has developed a cognitive behavioral guide to self-care for depression. Though not a substitute for professional face-to-face care, UnDoing Depression may be a useful adjunct to your efforts.  The preview is below. For 50% off the regular fee of $140 USD, use coupon code “changeways70” when you visit our host site, here.

We also have courses for professionals and for the public entitled What Is Depression, What Causes Depression, Diagnosing Depression, Cognitive Behavioral Group Treatment of Depression, How to Buy Happiness, and Breathing Made Easy. For the full list with previews and substantial discounts, visit us at the Courses page of the Changeways Clinic website.