Your Pandemic Blues Have a Name: Adjustment Disorder
The coronavirus crisis has turned life as we know it upside down. Since March, millions of people have been sheltering at home without clear answers for when normal life will resume. Consequently, we’re experiencing an unprecedented level of widespread anxiety. At Brightside, the telemedicine service that I co-founded to provide expert care for depression and anxiety, we’ve seen a 50% surge in new members seeking mental health support. Countless people are wondering if the discomfort they’re experiencing is “normal” or if others are in the same boat.
Not only is the feeling normal given the circumstances. It has a name: adjustment disorder. Clinically speaking, adjustment disorder is a stress response syndrome people experience in light of an identifiable life stressor (loss of a loved one, job, or home due to a natural disaster, etc.). In the absence of a catastrophe, generally around 1% of the population experience it. The COVID-19 crisis has challenged our notions of what to expect from our lives, our routines, and the core institutions in our society. Many of the things we cherish and value now seem more fragile than we imagined.
The number of people experiencing adjustment disorder has likely skyrocketed, with people suffering from heightened anxiety, a depressed mood (often called situational depression), and trouble focusing on work or school. In the worst cases, it can also increase the risk of suicidal ideation and substance abuse.
If this sounds like something you’re experiencing, you might be asking yourself a few questions. How long will it last and what can you do to feel better? Is professional treatment necessary? How can it be safely accessed from home? Or, if you run a company, how can you help your team weather this storm? Let’s dive in.
SYMPTOMS AND TIMELINES
Symptoms of adjustment disorder typically start within three months of the stressful incident. They can feel a lot like depression and anxiety, and in some cases evolve into more full-fledged cases of mental health disorders (more on that later). In addition to the symptoms outlined above, you may notice that you no longer enjoy things that used to bring pleasure, or experience trouble with sleeping or appetite, or find yourself avoiding important tasks more often than usual.
Typically, symptoms last no longer than six months after the stressful event. However, chronic adjustment disorder can persist, especially if what’s causing it is ongoing, such as unemployment, illness, or in our case, many of these factors combined within a global pandemic. Acknowledging symptoms early, and creating a plan to tackle them head-on, can help avoid prolonging the symptoms or have them evolve into clinical depression or anxiety.
WHAT YOU CAN DO TO FEEL BETTER
For the majority of people experiencing adjustment disorder, symptoms will be temporary. Unlike clinical depression, which does not require a reason or stressful life event to be associated with it, what triggers adjustment disorder will, in most cases, eventually come to an end. Timelines related to COVID-19 remain uncertain, which exacerbates the anxiety associated with it. But reminding yourself that we will get to the other side of this can greatly help your mental state.
Addressing your feelings is also helpful. When I am working with patients, I ask people to name the emotion they’re feeling. This seems simple, but categorizing the feeling can be very helpful. If there’s something specific you are worried about, hit the play button and imagine how that worry plays out. If there is something you can specifically do to alleviate it or avert it, then act on it. If it is out of your control, it is probably best to distract or sublimate with a soothing activity—exercise, a walk in fresh air, stretching, a warm bath, cooking, art projects, etc.
If money is a concern, creating a budget, researching local food banks, or applying for unemployment may all be useful tactics. Random fears about whether schools will reopen in the fall or worrying about when we will have a vaccine is unlikely to be something you can act on if you are not a school administrator or a virologist. So, distraction or sublimation is best put into play as a coping mechanism.
HOW YOU CAN HELP OTHERS (AND YOUR TEAM)
The social stigmas associated with mental health issues have prevented people from discussing their struggles—and seeking help for them—long before COVID-19. The isolation that many people now find themselves in can exacerbate this phenomenon. For many, opportunities to talk about their feelings have all but vanished. The good news is that with COVID-19, we are alone, together. Even though we may be physically isolated, we are in this together in that it is affecting all of our fellow humans, so it’s more important than ever to connect with others, even if you personally feel okay.
If you think an employee, teammate, or friend is struggling, the easiest thing you can do is check in on them. Make it clear they have a safe space to talk candidly about how they are doing and what they are experiencing. Don’t confuse this with a suggestion to interrogate them about their mental health. An open-ended “How are you doing with all of this?” can disarm whatever is holding them back and make them feel more comfortable opening up.
If you’re an employer, the best thing you can do is address the mental health implications of what we’re all going through in the open for the entire team to see. You might even share this post so they know what adjustment disorder is. If you aren’t already regularly holding all-hands meetings to keep the team engaged, it’s a good time to start. Mentioning the topic of mental health during those meetings can be helpful. If it’s feasible for your business, providing mental health services, or at least resources, to your staff is a good idea. Revisit your employee assistance programs to make sure you’re offering all that you can when it comes to mental health.
HOW TO KNOW IF YOU SHOULD SEEK PROFESSIONAL HELP
In the same way that we don’t know how many asymptomatic coronavirus carriers there are relative to those with frank illness, we also don’t know if adjustment disorder is the larger iceberg lurking under the water’s surface. Among those struggling with adjustment disorder, some percentage will progress into real illness, which will manifest as clinical anxiety or depression.
When symptoms start to interfere with your ability to work or practice self-care, or important relationships in your life, it’s time to consider speaking with a professional. If you’re unsure how severe your symptoms are, taking a clinically validated screening tool is a useful way to score them. You can find these for free online—we have one available on Brightside.com and will provide recommendations based on your symptoms and scores.
THE SILVER LINING OF COVID-19
It’s hard to think of a time when this many people were feeling as introspective as they are now and looking for ways to talk about it and feel better. Paying attention to mental health is extremely important, and it seems we’re finally hitting a tipping point of acceptance.
There’s a lot of uncertainty related to COVID-19, but the truth is life has always been uncertain. This period has not only given us an intense boot camp in resilience; it has also provided an opportunity to ask ourselves what really matters. All of us have thought about what we’ve missed most during shelter-in-place, but it has also reframed exactly what we actually need to be happy. When thinking through what your new normal might look like, you might want to evaluate which parts of your old normal you might like to leave behind. You may never have such a clear opportunity to do so again.
Rituals: A Key Ingredient of Success
Having raced long distance triathlon for over a decade, I often joke that the endurance sports community is rife with obsessive-compulsive disorder (OCD). OCD is defined as an anxiety disorder characterized by recurrent intrusive thoughts and repetitive behaviors and rituals aimed at reducing anxiety.
Having raced long distance triathlon for over a decade, I often joke that the endurance sports community is rife with obsessive-compulsive disorder (OCD). OCD is defined as an anxiety disorder characterized by recurrent intrusive thoughts and repetitive behaviors and rituals aimed at reducing anxiety.
Nowhere is this more manifest than in athletes' pre-race rituals and superstitions. As an important race looms, triathletes find themselves needing to eat specific foods, wear lucky clothes, groom in particular ways (shave, paint nails, braid hair), listen to certain music, and do ritualized pre-race workouts and warm-ups. Some athletes need to carry a lucky charm on race day.
In professional sports, superstitious behaviors are pervasive, and recognized as a routine part of play. There is the famous Sports Illustrated jinx -- the notion that appearing on the cover of Sports Illustrated represents the kiss of death. Teammates won’t speak to the pitcher during a no-hitter game. Michael Jordan was known to wear his blue North Carolina shorts under his Bulls uniform.
Rituals also abound. Baseball players spit in their hands. Tennis players and basketball players bounce the ball a certain number of times before serving or taking a foul shot. Getting to the top of a sport clearly takes an obsessive focus, and a willingness to practice and repeat routines in a somewhat compulsive way.
Distinguishing Superstitions and Rituals
Superstitions are typically developed in hindsight. The athlete notices that he or she did something that coincided with a good result, and attributes the success in performance to the circumstances. Those circumstances then become a necessary precursor to competition. Triathlete Chris McCormack admits that his mother used to make him lasagna before soccer games, and now he must eat it before every race.
Sports with high accident and injury rates seem to elicit superstitious behaviors. The behavior alleviates the athlete’s performance anxiety or fear of injury. Several professional cyclists have refused to race with the number 13.
Rituals, such as pre-race visualization or movements are encouraged by sports psychologists, as they help athletes get in the right mindset, and activate the neuromuscular system to prime the brain for competition. Used properly, they will make the athlete feel engaged, with an optimal level of arousal.
A ritualized pre-race routine lays the groundwork for a focused performance state. This is why so many elite athletes have developed a highly choreographed set of rituals.
How Rituals Work
If an athlete believes that a ritual will improve his or her performance, and that belief is reinforced over time by a series of successful experiences, the ritual then delivers a powerful boost in confidence.
Rituals function as a useful coping mechanism to deal with pre-race anxiety and the pressure to succeed. As well as preparing the athlete mentally, rituals help the athlete relax, shake feelings of self-doubt and feel confident. Confidence promotes performance.
There is even evidence to suggest that the brain shows reduced activation in response to failure after performing rituals. Given that failure is part and parcel of every activity we undertake, having measures in place that protect from the experience of failure help us respond in a more balanced and measured way.
So, in short, our personal rituals help us turn down levels of anxiety and increase performance and confidence.
So, are there any lessons that we can borrow from athletes to help us in our day to day lives?
Creating Your Own Ritual
Rituals are not just for athletes. Our daily lives abound with performance challenges, whether it’s meetings, presentations, managing others, or making deadlines. If you are trying to maximize your mental performance or handle work stresses more effectively, creating your own rituals can help.
Try introducing rituals in your life. Here are some examples of how to do this:
Start the day with a ritual. This might be a morning meditation session, a stretching routine or a short workout to clear your head and prepare you for the day.
Have some ritual around meals. Looking forward to the food, and sitting down to eat can help us properly relish the meal, and pay more attention to our appetite.
Workspace rituals: Having a designated workspace and routine can help focus and concentration. Block of calendar time for working meetings with yourself to accomplish key tasks, and turn off notifications to avoid distractions.
A bedtime ritual: The end of the day is a good time for reflection. Reinforcing positive thoughts, goals or expressions of gratitude are helpful, as well as lining up one’s things or workout clothes for the next day.
The most important thing is find a ritual that is yours. Embrace it, no matter how quirky and make it part of your identity.
Thomas Jefferson was quoted as saying, “I’m a great believer in luck, and I find the harder I work, the more I have of it.”
Or, as tennis champion Jack Kramer was known to say, “Luck is when preparation meets opportunity.”
Prepare for your challenges, find a focused routine... and if wearing those lucky socks makes you feel on top of your game then by all means do it.
The Power of Will
Studies have also repeatedly established that will power is a limited resource or energy, and that the conscious mind lacks the awareness to control all our unconscious decision making processes. Self control is less about having an iron will, and more about setting ourselves up for success with appropriate triggers, and techniques to distract.
For our college reunion, my alma mater sent out a survey to members of the class, asking about various aspects of their lives, work, health and habits. One question was the following:
I need more (pick one only):
love
money
recognition
sleep
responsibility
sex
time
will power
A good friend who is living the dream (or his dream, anyway) pointed out that all he really wanted more of was will power. Ah, the ever elusive sense of will power and self control... if only there were a way to summon up more mental discipline.
Research has shown that self-control is twice as important as IQ in predicting high-school performance and grades. Kids who can rein in and control their impulses tend to do well both in school and in life.
Studies have also repeatedly established that will power is a limited resource or energy, and that the conscious mind lacks the awareness to control all our unconscious decision making processes. Self control is less about having an iron will, and more about setting ourselves up for success with appropriate triggers, and techniques to distract. People with superior will power develop habits that point them towards success. And, as much as putting good daily habits into place, success is also about avoiding bad ones. Will power is really about tricking the unconscious mind into making the right decisions.
When we think about self-control, we think of people who have it, and people who don’t. The reality is that all of us experience fluctuations in our self-control. Our rational brains don’t tun out to be that important in exercising self-control in the moment. Giving people all the reasons not to eat French fries doesn’t help when the person finds themselves hungry and in front of their favorite burger joint. Information is relatively ineffective at changing behavior.
What does tend to work is using a moment of high self-control to create some rules and structure. This means putting tasks and behavior first, and limiting thinking and analysis. An example of this would be to cut up fresh vegetables in advance and put them at eye level in the fridge, so that when you find yourself hungry and staring into the fridge for inspiration...Volià!
Aristotle said: “We acquire virtues by first having put them into action... we become just by the practice of just actions, self-controlling by exercising self-control, and courageous by performing acts of courage.” It turns out if we want to be good, one of the best approaches is to act good.
So how do we put good virtues/habits into action:
Remember that it’s easier to change your environment than yourself. Marketers know this and trick us into buying items we don’t want (changing our minds) with strategic product placement (changing our environment). We respond to triggers in our environment. Create an environment that leads you down a path of success. The less you have to think and the more you have to just show up, the more easily success will come. If setting out the running clothes the night before (or sleeping in them) makes you more likely to get the morning run done, than do it.
Keep in mind that plans often go awry, so don’t just set goals; make contingency plans.
Success arises from lots of little good influences. The devil (or God) is in the detail. Whatever you do, try to do it thoroughly, and with attention. It’s easy to start thinking about what’s next, or what's already been. Try to stay absorbed with the present and proper execution.
Find support: it’s hard to build self-control alone. Find a community and surround yourself with people who practice the way you aspire to practice. Find role models, as well as peers. Study the people you admire, and notice what they do.
Perception is more powerful than reason. Use the power of small repetitive actions to rewire your brain and change the perception of your situation, and from there you will have the power to make different choices.
5 Common Misconceptions About Antidepressants
While antidepressants are in common use, myths abound about their benefits and risks. Here we hope to address some of the common misconceptions surrounding antidepressants so we can determine if they are right for you.
While antidepressants are in common use, myths abound about their benefits and risks. Here we hope to address some of the common misconceptions surrounding antidepressants so we can determine if they are right for you.
Antidepressants 101
Medication can be a useful part of a treatment plan to help you feel better and manage your symptoms of depression. There is absolutely no shame in taking medication. Like using insulin for diabetes or antihypertensive medication for high blood pressure, antidepressant medication plays an important––though not a singular––role in the treatment of depression.
Many antidepressants work by boosting the levels of neurotransmitters available to your brain cells, particularly those associated with mood, anxiety, and cognitive function. Neurotransmitters are the chemical messengers used by the brain cells to communicate with each other. Several neurotransmitters play a role in depression, including serotonin, dopamine, and norepinephrine.
Depression is associated with some brain changes, including loss of volume in a region called the hippocampus that is involved in memory. The hippocampus is a brain region that continues to grow new brain cells (neurons) throughout life, and there is some evidence that the stress hormones produced in depression may reduce the brain’s ability to generate these new cells. Antidepressants may counter this effect by contributing to the formation of new neurons. These cells may be critical for mood regulation. Treatment with antidepressants may restore normal brain structure and function so that individuals can eventually wean from medication and lead healthy and happy lives.
Antidepressants: Myth or Fact?
There are many misconceptions around antidepressants. Arming yourself with the facts is crucial to making an informed decision on if antidepressants are right for you. Let’s debunk some of the common myths surrounding antidepressants––or investigate if there is any truth behind them.
Myth #1: Antidepressants are addictive.
Fact: Antidepressants are not physiologically or psychologically addictive, but they can cause a discontinuation syndrome if stopped abruptly.
The discontinuation syndrome is a consequence of abruptly stopping certain types of antidepressants––particularly selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs).
Discontinuation syndrome can include a range of symptoms that may occur in patients who suddenly stop their SSRIs or SNRIs. These are the most common symptoms of discontinuation syndrome1:
Feelings of vertigo
Trouble sleeping
Odd sensory symptoms, such as tingling feelings in the skin, or what some people describe as a “zapping” sensation in the brain
Feeling anxious
Everyone should consult their physician before stopping an antidepressant. Discontinuation syndrome can be avoided by carefully weaning off the medication under a doctor's supervision1.
Myth #2: Antidepressants don’t work.
Fact: Antidepressants are an effective means to treat depression and are best used with other therapy tools.
Studies have shown that antidepressants are effective at relieving symptoms of depression about 40–60% of the time2. While medication can be an effective part of a treatment plan, there are some common reasons people feel like antidepressants did not work for them in the past. These reasons include:
Stopping antidepressants after only a couple of weeks because no improvement in mood was felt. In reality, it can take up to four to six weeks for the medication to take effect.
Not allowing appropriate time to determine if a dose increase is necessary or if a switch in medications is needed. This trial-and-error process can be discouraging for some patients.
Being prescribed the wrong medication in the first place.
Stopping medication as soon as a mood improvement was felt. Doing this increases the likelihood of the depression returning.2
While we may have considered depression to be a “chemical imbalance” at the end of the 20th century, the truth is that depression is a highly complex condition. Depression may involve not only brain chemicals but also brain circuitry, genetics, neurotransmitters, hormones, and inflammation. This complexity underscores the need to move away from one-size-fits-all depression treatment and adopt a more tailored mental health care strategy for depression patients. To get the most effective depression care, consider these three strategies:
Data can help. New approaches suggest that using data may help target the right treatments to the right patients based on symptom clusters and personal characteristics, delivering better outcomes.
A comprehensive approach is needed. Comprehensive approaches to care, which combine multiple treatment approaches like self care, therapy, and medication, often have the best outcomes. A comprehensive approach can help address multiple underlying causes and symptoms of depression.
Talk to an expert. To get the best results with medication, it’s important to choose the right medication for you, and consistently measure progress during treatment. This allows you and your doctor to make informed decisions for any necessary adjustment in your treatment. To minimize side effects and maximize benefits, adjusting medication or dosage is common when starting antidepressants.
Antidepressants are not a miracle cure3 nor a one-size-fits-all treatment and the first antidepressant you try may not work for you. It is important to select the one matched to your specific needs and subtype of depression.
Myth #3: Antidepressants have long-lasting side effects.
Fact: While antidepressants can have side effects, it's usually possible to find a medication where both the benefits outweigh the side effects, and side effects are minimal.
People are often reluctant to take antidepressants because they're afraid of side effects. Like all medications, antidepressants can have side effects. Side effects usually occur during the first few weeks of treatment and are less common later on2. Patients who are taking SSRIs sometimes have a change in their sexual response, such that it can take longer to climax, or require more stimulation.
Side effects also depend somewhat on the drug, the dose used, and the individual. Sometimes, side effects can be used to our advantage. For example: if you are having trouble sleeping at night and a medication has the side effect of making you sleepy, then taking the medication at night will be useful.
These side effects are sometimes short-term, happening during the initial stages of treatment and tapering off as the patient’s body gets used to the medication. If the side effects persist, you may want to talk with your doctor about switching to another medication or figuring out the best way to treat them.
Myth #4: I’ll have to take antidepressants for the rest of my life.
Fact: If this is your first episode of depression, you will likely need to take antidepressants for nine to twelve months.
The goal in the first few weeks and months of treatment is to relieve the symptoms and, if possible, make the depression go away. Once that has been achieved, the treatment is then continued for six to nine months. This continuation therapy is necessary to stop the symptoms from coming back. Longer-term antidepressant usage is considered only for a smaller percentage of people who have had two or more relapses of major depression in their lifetime.
Myth #5: Taking an antidepressant is a sign of weakness.
Fact: Just like any other organ in the body, the brain is also susceptible to illness. Taking medication does not make you a weak person.
Would someone who takes medication for diabetes or a heart condition be considered “weak”? Taking antidepressants to treat depression is an attempt to care about your wellbeing. Antidepressants are not a chemical crutch, and you do not need to feel shame or embarrassment for taking them to manage your depression.
Takeaways
There are many different forms of depression, and each person’s brain chemistry is unique. Therefore, getting the best result requires matching each individual to the right medication and then fine-tuning a treatment based on their response.
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