I have often been told by patients that the analogies I use to explain things are helpful: I will therefore list some of them here. The symptoms of the illness which doctors frequently dwell on, like anxiety, can be misleading in terms of making a diagnosis and assessing the severity of people’s current illness. As part 1 explains, this is because many of those symptoms are variable according to the degree of discrepancy between functional capacity and the demands tasks make on people. That gap has got as much to do with people’s situation as it has to do with the severity of the illness, so the severity of resultant symptoms can therefore be misleading in relation to the underlying severity of the illness. It is therefore helpful to focus on the central and basic changes that drive the illness — these are anergia and anhedonia.
The concept of mental anaemia has useful parallels with anaemia of the blood. Consider somebody with mild anaemia who lives, like we do, by the beach, a long way from any significant hills. When I exercise my dogs, I am always walking on the flat. If I lived in the mountains, I would not be able to walk far without having to go up a slope. It does not take much reflection to appreciate that if I was mildly anaemic, I would not be likely to notice significant breathlessness walking on the flat; whereas if I live in the mountains I would probably notice my breathlessness even when my anaemia was mild. Likewise, anxiety and stress (equivalent to breathlessness) will be more readily noticeable in someone who lives a high pressure and demanding lifestyle, whereas we would expect it to be much less noticeable in someone who lives an easy-going low-pressure lifestyle. For those more mechanically minded, the analogy of an old battery that will not hold its charge and is going flat is also a good one. This makes it especially important to assess energy and motivation in relation to what would normally be expected for that individual when well.
The Waves on the beach: Variability of symptoms
The day-to-day variability of symptoms, largely dependent on the variation of day-to-day challenges and difficulties, can cause considerable confusion when trying to assess the severity of illness, and especially when trying to assess the degree of improvement subsequent upon treatment. The analogy here is that making this judgement is like watching the waves on the beach. The waves represent the day-to-day variation of the illness and the tide coming in represents the illness getting better over many days. If you visited, and came down to the beach with me and I asked you to take on a bet as to whether the tide was coming in or going out, what would you do? You would probably want to watch the waves for several minutes before committing yourself to a bet. You know that the variation in the height of the waves is great, compared to the slow and inexorable march of the tide. Thus it can take a little while to be sure what is happening. So, it is with judging the improvement of illness when relying on symptoms. It is important to look at how symptoms are generally, on average, over a period of week, not just a day or two. That needs to be compared with another period of similar duration to estimate the overall change. Compare the average week to week, not day by day (and pay special attention to the actual achievement of work, social, and leisure activities, not just symptoms).
The Overloaded Boat
The ups and downs of life can be likened to the waves on the sea, sometimes things are calm and sometimes stormy. However, most boats stay afloat most of the time; but, the more a boat is weighed down in the water, the more it becomes susceptible to being over-whelmed by smaller and smaller waves. The illness weighs one down in the water by lowering both coping ability and confidence, so one is like the overloaded boat, and as soon as things get a bit rough, you just do not have the buoyancy to cope.
The Glowing Embers
To some extent it is useful to regard anxiety symptoms as established patterns of behavior, one gets into the habit of expecting to fail. They are particularly likely to arise in the context of low motivation and poor confidence, which changes lie at the heart of the illness. With severe and chronic illness such anxiety symptoms can become quite deeply embedded and persistent. It is useful to be aware of this as improvement in drive, energy, and motivation occur, during recovery. Not only do we have the paradox of transiently increased anxiety in the early phase of recovery (see below) but also anxiety symptoms may recur more easily than would be usual for quite a long time after recovery has started, indeed sometimes for many months (old habits die hard, as they say).
The analogy I found useful was that such anxiety symptoms are like the embers of a dying fire. The following day the campfire might look like a lifeless heap of grey ashes, but if a good wind comes up a few flames will soon be rekindled. It is similar with anxiety symptoms. Even after a period of improvement they can be rekindled by relatively smaller stresses or stimuli. An awareness of this tendency can be helpful in maintaining confidence in the fact that long-term improvement is steadily building, despite occasional flare-ups.
What may be even better, in terms of estimating change and severity of illness, is to try to concentrate on functional capacity. If your energy is improving it is almost inevitable that you will find yourself doing more. It may be that the increase in activity is not obvious if you do not know what to look for. If you make a list of your activities of daily living covering everything from getting up, personal hygiene, reading, socialising, hobbies, and all the other simple day-to-day activities that engage you normally, then you will begin to see how much you are doing. If an improvement is occurring, it is almost inevitable that you will find yourself spontaneously engaging more in such activities. We sometimes used to get people to make a record of simple things like how many phone calls they had made or received, how far they had driven the car — in other words, objectively measurable outcomes, in order to make it clear to both them, and us, how much increased activity was occurring, often despite the fact that subjectively people would say they did not feel any better.
These changes in energy and functional capacity are particularly easy to see when observing patients in hospital on a daily basis. The reduction of mental energy manifests itself most clearly in people’s speed of thinking, especially as reflected in their speed and intonation of speech, combined with facial expression. In the illness people’s speech becomes quieter, slower, more hesitant and with less tonal variation, they become less animated. It is just like someone is reducing the voltage of the battery. This can be regarded as a physical sign, rather than a subjective symptom, because it is objectively measurable by someone else, rather than being simply something someone feels themselves but cannot show other people.
In this context the measurement of functional capacity is the quantity and intonation of speech, combined with other more subtle features such as the hesitancy in forming utterances and replying to interchanges and the degree of emotion contained in the response.
Paradoxical increase in anxiety
As people start to get better there is sometimes an apparently paradoxical increase in anxiety symptoms. I hope the explanations above makes it easier to understand why this might occur, especially in long-standing and more severe illnesses. As energy increases the natural tendency is to use that energy to do more. However, that usually means challenging yourself with more difficult tasks when your confidence has been chronically low. Because ‘practice makes perfect’ you need to do more things successfully to increase your confidence: but the very act of doing things may make people more anxious — that does vary a bit depending on personality and capability. That is the paradox.
For many people with less severe illnesses, that is not often a big problem and does not require any specific assistance. However, in other circumstances it is useful to have a structured approach to overcoming such difficulties.
That is where the principles of cognitive behavior therapy (CBT) can be helpful, provided they are applied within the framework of understanding the basic changes underlying the illness.
That is not my specific area of expertise, but a few comments in relation to this, linking it to the above principles, will be helpful.
The aphorisms that I used to send people home with were:
‘Slow and steady wins the race’
‘Do not bite off more than you can chew’
‘Do not try to run before you can walk’.
If you imagine grading the tasks ahead of you according to the anticipated degree of difficulty, then it is clear one should tackle the less difficult tasks first. If the degree of difficulty is high the gap between demand and capability is high, then anxiety will be high. Therefore, you tackle the less difficult aspects first and chop bigger tasks up into small pieces: i.e. salami tactics. If you continue at an easier level until you have had a bit of practice then confidence will build up and you can then tackle more difficult things.
It is frequently possible to break things up into smaller tasks simply by thinking about things differently. For instance, you do not set yourself the task of cleaning the car, or the house, as one single task. You split it up into lots of separate bits and set yourself a goal of, for instance, cleaning the windows, or just polishing the door handles, or whatever. Simply thinking about it differently can help to maximize the positive feedback that you get when you do only a little bit. Sometimes, making this whole procedure more concrete, by writing out a timetable for your activities, a bit like a school timetable, and filling in the time periods, with preplanned tasks of predictable levels of difficulty, will aid this process.
Because the illness involves a reduced ability to feel positive about good things that happen a deliberate attempt to magnify your perception of your successes is helpful. This can be achieved in a variety of ways, most simply by giving yourself a mark out of 10 on your timetable for how you feel you have succeeded with each small task. If possible, it can be even better to get someone else to do that for you, and to keep reminding you of your successes in order to reinforce the positive feedback.
Another little aside: if you go through the process of drawing up a timetable and filling in the activities that you are going to do on it, that fulfils another need: that is the need to protect yourself against unpredictable demands. This is something that is often a problem, especially for people who find it difficult to say ‘no’ to other people when they are being asked to things. It is a bit like having an appointment diary, and saying ‘wait a minute let me look at my diary …’, ‘I will have to get back to you later, after I’ve checked my diary’ … ‘no I can’t, I’m busy’. Also notice, that sentence does not contain the word sorry. Monitoring how often you use the word sorry may help to focus your attention on how you got into the habit of blaming yourself and apologizing excessively to other people. It is a good habit to get out of because it reduces your self-esteem.
I am not a psychologist or CBT therapist, but some of these observations derive inexorably and inevitably from a simple biological understanding of how the illness affects people. So, I will add one more comment from my experience. Because resisting the inappropriate demands that others make on you is so important in building up your sense of confidence and independence and autonomy, it is useful to have a fallback position prepared to deal with imposers and demanding situations. It does not usually take much thought to imagine what these situations might be: examples might include impositions from relatives, people turning up unexpectedly at your door, telephone calls, and if you are still working, a multitude of work situations. It is worthwhile preparing a written script to use to respond to these situations so that when they happen you do not have to think too hard about what to say. My advice to patients was usually that such scripts are better if they do not contain either explanations, or excuses or apologies, and that they may sometimes, depending on your personal feelings about this, contain straightforward statements about not being able to do something because you are unwell.
A cruel trick: diurnal variation
This section on diurnal variation of mood was added in 2017, after talking to someone with depression over Skype and explaining about diurnal variation. That reminded me of an analogy I used.
Persistent diurnal variation of mood is one of the more reliable markers of a biological depression. However, something I have observed over the years, which does not seem to crop up in the literature, is this: the improvement of mood that occurs in the afternoons and evenings, and the return of severe symptoms on waking next morning, is something that gradually gets less noticeable if the illnesses becomes more severe and has been present for some time. In other words, as the illness is developing diurnal variation is most noticeable, if-and-when the illness reaches a severe degree, then diurnal variation becomes less noticeable. People just feel like ‘death-warmed-up’ the whole time.
The converse is also true. As more severe illnesses start to improve and respond to treatment, the early improvement is usually most noticeable in the afternoons and evenings, but then, when people wake up next morning, they feel as bad as ever. If you ask someone with severe illness ‘what is your first thought about the day ahead when you awake’, the answer is frequently ‘OMGAD’ (Many suffers guess that immediately, I spell out that acronym below***). Hence the heading of this piece, ‘A cruel trick’. I am sure that this phenomenon has been responsible for many people giving up on treatment, or despairing of improvement, because they feel better in the afternoon and think the illness is improving, only to wake up as-bad-as-ever the next morning. If no one has provided the above explanation that phenomenon is a profoundly discouraging experience.
Remember the ‘waves on the beach’ analogy above, remember to compare like with like, i.e. afternoons with afternoons, or mornings with mornings, and remember to compare averages of several days, with a gap of a few days in between, in order to more reliably judge change.
Also, as I often commented to patients ‘I do not care how you feel’. That made people stop and listen! Instead I want to know what you have done, compared to before.
This point was illustrated only a few days ago, in another Skype ‘consultation’: ‘How are you going’? ‘I am more anxious …’. This person felt they were not improving. But a couple of brief questions made things clear. They had in fact managed to go shopping, alone, twice in that week, in order to get the ingredients to cook a meal (for the first time in a while) and also been to a drinks party and ‘coped quite well and enjoyed it, a bit’. And there was more! No wonder anxiety had increased. In relation to this remember ‘Salami tactics’ above, and the aphorisms, ‘Slow and steady wins the race’, ‘Do not try to run before you can walk’, and ‘Do not bite off more than you can chew’.
If people are doing more activity that is strong evidence that they have more drive and energy: if that core symptom is improving one can be quite sure they are getting better. As president Nixon is quoted as saying,
‘When you’ve got them by the balls, their hearts and minds are sure to follow’.
Enough said. *** The acronym: ‘Oh my god, another day’.
Cognitive Behavior Therapy
In many ways CBT is just a special application of critical analytical thinking. That is a skill that, unfortunately, is not much taught in general school education. Many people finish their schooling having gained little by way of the skills of critical analytical thinking. If formal cognitive behavior therapy is available to you it can be extremely helpful.
However not all CBT therapists have a clear perception of the medical aspects of the illness, which leads to the danger of encouraging people to do more than their illness allows. That does have negative consequences. If somebody keeps telling you that such techniques should be making you better and they are not, that is ‘rubbing salt into the wound’. Obviously attempting to repeat tasks that have caused undue distress, or at which you have already had an absence of success, is not a sensible strategy. Such feelings may be because the underlying illness is not improving and the discrepancy between the difficulty of what you are attempting, and your coping capacity, is too great.
Again, the analogy here is with ‘mental anaemia’ if your anaemia is being treated, but it is not improving, it will be no good doing physical exercise running up and down hills and wondering why you’re still breathless. So, it is essential to balance the degree of improvement in the illness against the degree of difficulty of tasks that you attempt.
There is good reason to assert that cognitive behavior therapy can be a powerful technique for helping many people and I would urge readers to familiarize themselves with its principles: but only when they are in a less severe phase of illness. Some indication of what CBT principles are is embodied in this commentary. Also, a recent book by Robertson , which can be viewed online, reminds one of the connections between Stoic philosophy and modern CBT, and Ellis’s rational emotive therapy, in an illuminating way. My analogy of the young men jumping from a plane, above, is less powerful than Robertson’s reminder to us of the experiences of James Stockdale. More may be learned about Stockdale by looking in Wikipedia.
I am nurturing a theory that the early Greek Stoic philosophers got some of their ideas simply from observing dogs. Think about it! The aphorisms at the end of part three also contain much of this wisdom. Here is one clue: Stoics might argue that your expectations of how people will, or should, behave are what lead to you being disappointed when they do not behave as expected — when my dog drops the ball at my feet and I fail to kick it for him, he does not exhibit any disappointment, or resentment; he tries a few times more, then he lies down, and waits for a few minutes. Then tries again with equal enthusiasm! That is Stoic philosophy in action. I could go on.
Cognitive restructuring and irregular verbs
A light-hearted approach that injects a little bit of humour into learning can frequently ease people into an understanding of a topic. For those who have the misfortune not to be familiar with the old British comedy series “Yes Prime Minister” (I urge you to read a little of it, e.g. see Wikipedia), let me explain that one of the Prime Ministers pedantic civil servants, Bernard, would sometimes comment on his pronouncements. If he said something tactless or ill-advised this might be reinterpreted by means of what were called ‘irregular verbs. For instance, if the Prime Minister said one of his political opponents was bigoted, Bernard might have replied thus: ‘That is an irregular verb Prime Minister:
I have clear opinions,
You are inflexible,
He is bigoted.
Or, one of my favourites:
I have an original mind,
You are eccentric,
He is mad.
It is not difficult to see how this potential party game can be adapted to help people get into the habit of cognitive restructuring. For somebody who has a negative self-image related to weight problems the irregular verb might be:
I enjoy good food,
You eat too much,
He is fat.
People may make the formation of negative appraisals a habit, that creates a tendency to negative over-reaction which fosters worry, guilt, self-denigration, shame, etc. that is out of proportion.
Examples of cognitive biases are:
Selective attention bias,
Minimization bias (its antithesis)
Disqualifying the positive bias,
All-or-nothing thinking etc.
This is not a commentary on CBT, but it is important to explore its potential usefulness, especially during the recovery phase when your concentration and energy is a little better. That is the time to work on disadvantageous mental habits, which like anxiety symptoms, can endure for some time, especially if not given specific remedial attention.
There are now quite a large number of both freely accessible and fee-for-service CBT services available via the Internet. A sample of one or two links may be found below. It may be worthwhile contacting your local university teaching hospital and the state or nation-wide bodies related to professional psychologists and psychiatrists for further information.
Critical Thinking and CBT
Reflecting about this problem, of thinking and CBT, made me think of something useful, that I would like to share. I am a lifelong sceptic, and I use that word in its proper and traditional sense, not in the distorted hijacked sense that the muddled climate change debate has produced, in which context a sceptic is equated with someone denies climate change. That is a misuse of the word and a distortion of its meaning. I was recently listening to a debate about climate change and what struck me most forcibly was that those doubting the reality of it were exhibiting a wide range of classic errors of critical and logical thinking. When I started to look for sources to direct people to (about critical analytical thinking) I was struck by how similar much of that material is to the material used in cognitive behavior therapy. On reflection, one can see why this is so. Both conducting a logical focused argument about climate change and understanding how one’s own faulty thinking can give rise to psychological problems and distress, are really two sides of the same coin.
What it illustrates is that learning how to think well and critically is the equivalent of being physically fit. One simply cannot function optimally if one is physically unfit, or if one is incapable of thinking properly (i.e. logically and critically). It is that simple.
The positive aspect of reformulating thinking is that improving is a fun and a useful exercise in which everyone can participate, whether they have problems or not. The techniques that it is beneficial to learn are mostly common to both everyday critical thinking and CBT, as it is applied to specific problems.
Just look again at the forms of appraisal bias above; selective attention bias would have to be a common thinking error frequently exhibited by climate deniers (and most of our politicians) and a common source of error for bad and careless scientists. Good science is about using techniques to minimise and negate such influences.
There is more information relating to this at http://www.criticalthinking.org
especially relevant is:
See part 3 References 1. Robertson, D., The Philosophy of Cognitive Behavioural Therapy (CBT): Stoic Philosophy as Rational and Cognitive Psychotherapy. 2010: Karnac Books Ltd 118 Finchley Road, London NW3 5HT.
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