Telling someone to “just try to be more social” isn’t helpful

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I recently came across the webpage of a talented designer who has a few comics on social anxiety. Here is an example:

Social anxiety comic

(Click on the comic to see the original post.)

This comic is very insightful, and beautifully illustrates two points:

  • People without social anxiety often fall victim to the cognitive fallacy “something that is easy and natural for me should also be easy and natural for everyone else – all they need to do is try”. These are usually well-meaning individuals, but they couldn’t be more wrong.
  • Overcoming social anxiety is difficult. Like learning a language, it requires learning and practicing a new set of skills. This takes time and dedicated effort. In fact, overcoming social anxiety is much more difficult than acquiring most new skills, such as an instrument or a language. This is because it involves critically evaluating and challenging core thinking and behavior patterns, which operate at both emotional and cognitive levels.

Please let me know if you’ve seen any other social anxiety-inspired art.

In other news, I’m off to Lima, Peru in a few days for the The World Congress of Behavioral and Cognitive Therapies. I will be presenting data from several projects, including the latest AI-Therapy results. Stay tuned!

Fjola

Fjola  Helgadottir, PhD, MClinPsych, is a clinical psychologist, a senior research clinician at the University of Oxford, and is a co-creator of AI-Therapy.com, an online CBT treatment program for overcoming social anxiety

Is a diagnosis necessary for online treatment?

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Earlier this year I presented the Overcome Social Anxiety treatment program to my colleagues in the Department of Psychiatry at the University of Oxford. One of the questions from the audience was: How do you diagnose social anxiety in order to treat individuals? My answer: I don’t.

 

In the last blog I discussed the controversy around the new DSM-5. The goal of the DSM is to define the criteria for a formal diagnosis. In other words, it helps a practitioner determine whether or not person X has condition Y. I pointed out the shortcomings of this approach. In particular, the severity of a mental disorder is best measured using a continuous scale, rather than a binary classification.

 

A DSM diagnosis is important in a situation where a patient may be prescribed medication (recall that the DSM is published by the American Psychiatric Association). Most drugs have negative side effects, and they carry the risk of addiction. Therefore, taking medication for mild or moderate cases may not be a good idea. In this case, the DSM plays a vital role in determining who receives treatment. The DSM also plays a crucial role for clinical psychologists, as it guides the diagnosis and treatment of patients.

 

The situation for online self-help is different. For example, consider our Overcome Social Anxiety program. At the start of the program each user completes a series of standardized questionnaires (e.g. the “Fear of Negative Evaluation Scale” and the “Depression, Stress and Anxiety Scale”). The goal of this assessment is not a diagnosis. Rather, the goal is to determine where the user falls on the social anxiety spectrum prior to treatment. After the user completes the treatment program, they fill out the same questionnaires. The results are compared to the user’s pre-treatment results to see if their symptoms have improved.

 

We don’t require a diagnosis to use the program since people from along the whole social anxiety spectrum, from mild to severe, can benefit from treatment. The program uses online cognitive behavior therapy (CBT), which is known to be helpful in a wide range of cases. CBT involves revisiting thinking styles and behaviors. Unlike drugs, there are no negative side effects of CBT. Therefore, it can help everyone make better choices in their day to day life. This typically leads to an overall improvement in happiness and confidence, regardless of a DSM diagnosis.

 

Fjola

Fjola  Helgadottir, PhD, MClinPsych, is a clinical psychologist, a senior research clinician at the University of Oxford, and is a co-creator of AI-Therapy.com, an online CBT treatment program for overcoming social anxiety

The controversy over DSM 5

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If you regularly read mental health or science blogs, you’ve probably seen some recent posts about the controversy over DSM 5. There is quite a bit of controversy about it, so in this blog I’m going to give an overview, and share some of my thoughts.

 

What is the DSM?

The “Diagnostic and Statistical Manual of Mental Disorders” (DSM) is a manual published by the American Psychiatric Association (APA) that defines mental disorders, and specifies the criteria for a clinical diagnosis. In other words, it is the commonly accepted authority for answering the question: does person X have the mental disorder Y?

The APA periodically publishes updated versions of the manual to reflect the latest research findings. The first version was published in 1952, and the 5th version (DSM 5) was published earlier this month. Since there is quite a bit of time between publications, it usually generates a lot of interest.

 

What is the controversy about?

Each version of the DSM introduces new disorders, and updates the criteria for existing ones. This leads to the following situations:

  1. Some previously “normal” conditions are now a diagnosed mental illness. There is some concern that this will lead to drugs being prescribed to people who don’t really need them. Furthermore, some feel that the latest version of the manual goes too far, over-diagnosing the general population. Some professionals estimate that up to 50% of people now fit the criteria for at least one mental disorder. At what point does a “disorder” become normal human behavior?
  2. Some people will lose their diagnosis. In some cases, this could lead to individuals losing access to healthcare benefits they have come to rely on.

In both cases, the people and their symptoms haven’t changed. The only change is that a manual has been published.

 

The tyranny of the discontinuous mind

I believe many of the problems are related to what Richard Dawkins calls the “tyranny of the discontinuous mind”. We seem to have a natural inclination towards putting things in discrete categories, even when no such categories exist in nature.

The goal of a diagnosis is two divide people into two groups: those who have a disorder, and those who don’t. However, most mental disorders exist on a spectrum, and there is no precise boundary that cleanly partitions people into these categories. Any attempts to define such a boundary will inevitably lead to disagreements, since some people will argue the criteria should be relaxed, and others will argue they should be stricter. This is an unavoidable consequence of information loss when applying a threshold to a spectrum.

This is not an easy problem to solve. There are practical reasons why it is useful to have formal criteria for a diagnosis. For example, how else would a healthcare insurance provider decide who is eligible to be covered for a treatment? Therefore, the DSM plays a vital role in mental health treatment.

The main lesson is that a clinical diagnosis is only part of the story. People with mild symptoms can benefit from therapy, even if they don’t fit the criteria as specified in the DSM. This has some implications for online treatment, which I’ll talk about in a future post.

Fjola

Fjola  Helgadottir, PhD, MClinPsych, is a clinical psychologist, a senior research clinician at the University of Oxford, and is a co-creator of AI-Therapy.com, an online CBT treatment program for overcoming social anxiety

Social anxiety and depression

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How are social anxiety and depression related?

Social anxiety and depression often occur together, and research has shown that targeting social anxiety can lead to an overall increase in mood and happiness. In this blog we look at an example of how the two can be connected.

Waking up with anxiety

A thought pattern that can be a contributing factor to depression is rumination. Let’s consider the following scenario: you’ve been to an evening party, and the first thought that pops into your head the next morning is “Oh no, did I really say that? I wish I hadn’t – I may have offended someone.” You continue to dwell on the thought, and over time your feelings of anxiety amplify. Eventually, you convince yourself that it was a terrible scene, and you become angry and upset.

Rumination following social situations is a common symptom of social anxiety. The social anxiety is leading you to (a) set unrealistic expectations for yourself, and (b) over-analyze the event after the fact. By targeting social anxiety, you will be less likely to ruminate, and therefore spend less time being self-critical.

As a side note, this is consistent with the results that we are observing with our social anxiety program. In particular, there is a (statistically significant) decrease in symptoms of low mood for those who complete the program. Dealing with social anxiety can have follow-on effects that lead to a happier, more fulfilling life.

Fjola

Fjola  Helgadottir, PhD, MClinPsych, is a clinical psychologist, a senior research clinician at the University of Oxford, and is a co-creator of AI-Therapy.com, an online CBT treatment program for overcoming social anxiety

 

AI-Therapy’s new release: Statistics for Psychologists

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You may have noticed we have been a little slow on the blog updates lately. The reason is that we have been very busy working on our new product, and are pleased to announce:

 

Statistics for Psychologists

This is a little different than our core area (online self-help), so let me explain why we’ve created it. There are lots of statistics programs out there. However, some of them are hard for non-statisticians to use, some are expensive, and most require you to install software on your computer. We wanted something accessible, easy to use, and not loaded with options we don’t need. Given our extensive background in statistics and software, we decided to create our own solution.

These are our target audiences:

  1. Academia: The online calculators provide academic researchers with tools to help them distinguish between effective and non-effective therapies. Naturally our focus is psychology, but the tools themselves will be equally useful to researchers in any field.
  2. Clinicians:  Too often clinicians never give stats a second thought after they finish their degree. However, chances are that you are surrounded by interesting data in your clinic. We encourage you to run some therapy data through the program, as you may be surprised by what you find!
  3. Students: Learning stats isn’t easy. What we’ve created is something between an online tutorial and an interactive calculator. One way to learn the concepts is by interacting with the tools and visualizations. Try to get a feel for how changes to the input impact the results.
  4. Everyone else: Statistics is much more important in our day to day lives than most people give it credit for. In particular, it helps us make sense of the world around us. Take the plunge, and see what it’s all about!

Please get in touch and let us know if you have any feedback or feature requests. Also, help us spread the word if you know of anyone who might find this useful.

 

Sample graph from AI-Therapy's Statistics for Psychologists

Are you in control?

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One of the things I love about living in Oxford is all of the great museums around. The closest museum to my house is called the Pitt Rivers Museum, and it has the most unbelievable collection of, for lack of a better word, stuff I’ve ever seen. One section that always interests me is called Amulets and Charms, and it contains thousands of artifacts that someone at some point in history believed had magical powers. The exhibit always reminds me of how deeply we desire to feel a sense of control over our lives and environment.

The desire to feel in control is part of the human psyche, and has wide ranging impacts.  For example, many people who suffer from depression feel that they do not have enough control over their lives. In contrast, many people suffering from anxiety problems try too hard to control every aspect of their life. In this blog I’m going to take a quick look at some research I have been involved in.

 

Control and anxiety

Does knocking wood help?

Superstition is an example of one way we can increase our feeling of control. For example, if you knock on wood after saying something you hope doesn’t happen, the superstitious belief is that the act of knocking of wood will magically influence the outcome of a future event in the real world.  Regardless of whether or not you actually believe in magic, if you conduct this ritual enough times it can lead to a pattern of learned behavior. If the undesired event does not occur, you may feel like you have contributed to the outcome, even if it was completely outside of your control. Therefore, you get a small reward for knocking on the wood, which reinforces the behavior. In the long run, this can create the illusion that you are responsible for things you have no control over. In some cases this can help maintain a form of anxiety known as obsessive compulsive disorder.

Superstition and obsessive compulsive symptoms

As mentioned above, over time superstitious behavior can lead to people believing that they can impact the outcomes of events which they actually have no control over. As a result, some people develop a strong sense of responsibility. For example, someone may have the obsessive and intrusive thought “if  I don’t knock on wood, something bad will happen and it will all be my fault”. This thought is an example of magical thinking, since magic is needed to explain a causal relationship between knocking on wood and an unrelated future event.

Several studies have observed a correlation between magical thinking and obsessive compulsive thoughts. Given this relationship, my PhD supervisor Ross Menzies and his colleague Dr Danielle Einstein had a new idea. Would it be possible to treat obsessive compulsive disorder by targeting magical thinking? The idea is as follows: if someone truly understands that there is no way that knocking on wood will impact a future event, they may be less likely to engage in the compulsive behavior. We took a look at this idea, and our early results indicate that there is some promise to this approach.

 

References

Danielle A. Einstein, Ross G. Menzies, Tamsen St Clare, Juliette Drobny and Fjola Dogg Helgadottir (2011). The treatment of magical ideation in two individuals with obsessive compulsive disorder.  The Cognitive Behaviour Therapist, 4, 16-29 

Fjóla Dögg Helgadóttir, Ross G. Menzies and Danielle A. Einstein. (2012). Magical thinking and obsessive–compulsive symptoms in Australia and Iceland: A cross-cultural comparison. Journal of Obsessive-Compulsive and Related Disorders, 1. 216-219

Coming up: Paper at the World Congress of Behavioral and Cognitive Therapies WCBCT 2013, July, Peru, Lima. Title: Superstitious behaviour in Iceland during and after the global financial crisis simulates the aetiology of obsessive-compulsive disorder. More…

 

fdh

 

Fjola  Helgadottir, PhD, MClinPsych, is a clinical psychologist, a senior research clinician at the University of Oxford, and is a co-creator of AI-Therapy.com, an online CBT treatment program for overcoming social anxiety

 

CBT changes your brain

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There is a well known 2011 study that looks at the brains of London taxi drivers. The map of London is complex, and taxi drivers are required to memorize the complete layout and pass a difficult exam before being given their taxi license. The study found that the hippocampus region of the brain, which plays an important role in memory, actually grows (in a physical sense) while the prospective drivers are studying for the exam. This is an interesting result since it clearly shows that our actions can make real, measurable changes to our brains.

 

Can you change your brain with therapy?

In short, yes.

Some people view psychological treatments as “softer” than using medication, since drugs can directly target neurochemical aspects of the brain. However, this view is unjustified, since there is mounting evidence that therapy can make very real structural changes to the brain. A great example is CBT.

Cognitive behavior therapy (CBT) is an evidence-based approach to tackling mental health problems, such as anxiety or depression. CBT has been subject to countless clinical trials, and has even been shown to be more effective than medication in some long-term studies. CBT works by targeting the thoughts and behaviours that are maintaining the problem (more information about CBT, and how it can be administered online, can be found here). For example, consider someone who has social anxiety and would like to ask their boss for a raise or promotion. This would be extremely stressful situation for them, and they would likely put it off indefinitely. CBT treatment would examine the thoughts that are leading to this avoidance, and would challenge them through a series of exercises. In much the same way that physical exercise changes the body, these mental exercises can make changes to the structure of your brain!

 

How does CBT change the brain?

The fact that CBT changes the brain is not a particularly new result. However, neuroscience journals tend to announce findings with headlines like “The neurobiological role of the dorsolateral prefrontal cortex in…”. The details are complex, but the general idea is understandable in surprisingly basic terms.

The brain is divided into different regions or modules, each of which is specialized to perform a certain type of task. For example, the visual cortex is the region of the brain that processes the sensory input from the eyes. There are some brain structures that deal with emotions such as stress and fear, and collectively these are sometimes known as the “emotional brain”. These are very “old” areas of the brain, in the sense that we share them with our distant ancestors. When a socially anxious person is nervous when thinking about asking for a raise, it is the emotional brain that is becoming active.

There are higher order brain structures that deal with planning, logic and reasoning. These are sometimes known as the “logical brain”. These brain areas, such as the prefrontal cortex, are “newer” in the sense that they are much larger in primates than in other species. There are two key points:

  • The logical brain is able to override the emotional brain. For example, our socially anxious person can take a rational look at the situation, and realize that he or she is exaggerating the potential risks. He or she might come to the conclusion “the worst case scenario is that the boss says no – that’s not the end of the world!” This thought will help them calm down, and build the confidence to actually ask for the raise.
    –
  • Every time the logical brain overrides the emotional brain, the logical brain “muscle” becomes stronger and stronger. In other words, through CBT training the brain actually reinforces the neural pathways, so it becomes easier and easier to deal with future stressful situations.

This is good news: by changing our thinking and behaviour using CBT, we are making positive, long term, hard coded changes to our brains!

 

 

softonline

 

fdh

 

Fjola  Helgadottir, PhD, MClinPsych, is a clinical psychologist, a senior research clinician at the University of Oxford, and is a co-creator of AI-Therapy.com, an online CBT treatment program for overcoming social anxiety