Winter Blue or a Deeper SAD?

The angles and tones of light are different.  There are ribbons of crispness in the air.  The landscape is dry and colors are draining.  I see it. I feel it. It is autumn.

Many traditions and cultures mark this season as a time of reaping, quiet, reflection, contemplation, and rest. Like other species, our bodies change as well, going through a seasonal shift in our sleep patterns, appetite and energy.  There is evidence that we experience a decrease in optimism and risk-taking, a shift that has been tracked in stock market data.

While a general quieting is common, for some this change can become distressing especially if one has a tendency toward negativity and obsessive thought patterns.  The result can be the unhappy mood and lethargy known as the “winter blues”.  For others, the blues may actually meet criteria for a variant of clinical depression known as seasonal affective disorder or SAD.

SAD symptoms must occur at least two years in a row. Typically, SAD starts in the fall and continues through the winter lifting in the spring and summer.  Symptoms include:

  • Sadness most days,
  • Hopelessness,
  • Anxiety,
  • Depressed energy and interest,
  • Feeling heavy and “leadened,”
  • Social withdrawal,
  • Difficulty concentrating,
  • Oversleeping,
  • Appetite changes especially craving carbohydrates, and
  • Weight gain.

SAD varies by latitude with rates varying from 0.4%- 2.6% in the general population and climbing towards 10% at higher latitudes. Milder “winter blues” have been estimated as high as 25% of the population in extreme latitudes. Research also indicates that there can be a seasonal worsening of symptoms for adults and children with other diagnoses including depression, bipolar diagnoses, substance abuse problems and dementia.

The causes of SAD are not completely understood.  Since rates are quite low in Iceland, despite the high latitude, there is the possibility of a genetic component.  Another theory is based on the winter drop in serotonin levels. Serotonin is a neurotransmitter that affects mood and appetite regulation. Deficient serotonin is implicated in depression.  Others claim that the changes in natural light disrupt the balance of melatonin, a hormone that affects sleep and mood. It might be that the reduction in light disrupts the internal clock, your circadian rhythms, affecting sleep and wake cycles.  Chronic disrupted sleep is known to adversely affect mood.

SAD treatment depends on severity.  If symptoms are not significant consider exercising regularly, getting outside in the natural light, exposing yourself to bright lights indoors, socializing, and practicing stress management. However, if symptoms are causing significant distress and dysfunction in your life, or if you are turning to alcohol or drugs to regularly manage your moods, it is time to see a doctor.   First you want to eliminate any other causes for mood and energy changes.  Then your medical professional will help determined if you meet the criteria for SAD.  Treatments at this time are quite standardized.

Light Therapy – This is considered the first line of treatment.  It provides mood relief for 50% to 80% of sufferers.  The great benefit of this therapy is that it starts working in 2-4 days and has few side effects.  The disadvantage is the inconvenience.  Light therapy requires a specialized light and daily sessions of 30 minutes or more. This must be continued throughout the winter as rapid relapse occurs if you stop treatment.

Medications – Given the link with deficient serotonin, the next most common treatment is the class of antidepressants known as selective serotonin reuptake inhibitors (SSRIs). These medications lead to the same remission rates as light therapy. The advantage is the convenience of taking a medication once a day.  The disadvantage is that it may take 4-6 weeks to realize benefits and there may side effects.  Nevertheless, this is a very common and generally safe treatment.  By beginning them before the seasonal onset of symptoms, these medications can be used as a preventative.

Alternative Medications and Therapies – There are herbal remedies and supplements that are commonly used for depression.  A naturopathic doctor can help with these types of treatments.  While not a conclusive list, these could include St. John’s Wort, SAMe, melatonin (appropriately timed) and other supplements.  Acupuncture may also be helpful in the treatment of SAD.

Counseling Therapy – While many counseling therapies may work, the scientific research is focused on cognitive behavioral therapy (CBT) for the treatment of SAD.  CBT helps people understand how their minds create thoughts that can undermine them and create negative mood patterns.  Individuals learn to monitor thoughts, reframe them, and take responsibility for choosing their behaviors. Across many SAD studies, CBT has the same remission rates as light therapy and antidepressants.  In addition, one study that reevaluated participants a year later found that relapse rates were 7% of those who received only CBT, 37% of those who received only light therapy, and 5.5% of those who received both CBT and light therapy.  That is, CBT appears to have lasting effects.  The disadvantage is that it does require an initial investment in therapy and a commitment to using the techniques to change thought patterns.

BIBLIOGRAPHY

Lam, R.W. et al, “The Can-SAD Study: A Randomized Controlled Trial of the Effectiveness of Light Therapy and Fluoxetine in Patients with Winter Seasonal Affective Disorder,” The American Journal of Psychiatry, May 1, 2006; 163: 805-812.

Mayo Clinic Staff, “Seasonal Affective Disorder (SAD),  September 2011. Retrieved September 12, 2012: www.mayoclinic.com/health/seasonal-affective-disorder/DS00195.

Peiser, B., “Seasonal affective Disorder and exercise treatment: a review,” Biological Rhythem Research, February 2009, Vol. 40:1: 85-9

Rohan KJ. Coping with the seasons: A cognitive-behavioral approach to seasonal affective disorder, therapist guid, New York: Oxford University Press; 2009.

University of Rochester Medical Center (2007, January 25) “Getting SAD is More than Having the Blues,” ScienceDaily. Retrieved September 12, 2012: www.sciencedaily.com/releases/2007/01/070124143805.htm.

University of Toronto, Rotman School of Management (2011, October 11). “Fall market jitters a SAD thing: Less daylight in fall may lead to depressed markets,” ScienceDaily. Retrieved September 12, 2012: www.sciencedaily.com/releases/2011/10/111011132058.htm.

Westrin, A. and Lam, R. “Long-Term and Preventative Treatment for Seasonal Affective Disorder,” CNS Drugs, 2007, vol. 21:11: 901-909

The Elusive Definition of Trauma

Trauma is an event that involves a threat to life, limb or personhood.  We often think of trauma as violent and physical, bringing to mind images of war, gangs, assault, vehicle accidents, sexual violence, child abuse and acts of nature that are very destructive like earthquakes and fires.  These are most certainly traumatic, but trauma does not always have to be intense physical violence.  From a more inclusive perspective, a traumatic event is any event that causes a sudden, intense, significant, and negative change in our sense of who we are, what we are capable of, our sense of the world, how it works, our place in it, and our belief about our future. So the concept of trauma can also include events such as job loss, business failure, relationship failure, family conflict, non-violent death of a loved one, being diagnosed with a serious medical condition, abandonment by a significant person, being bullied, and many other experiences.  For example, my friends, who were evacuated twice from the path of a large forest fire but did not lose their home, feel a new and profound sense of helplessness in the face of natural disasters. They are now acutely aware about how uncertain their world can be and how in a very short amount of time, what they believed their lives to be and their futures, could go up in flames with very little warning.  They feel insecure, lost, and overwhelmed.  Losing a home to such a fire just intensifies the trauma.

I also want to make a special note here about children.  I do not define trauma for a child.  What is traumatic for a child is defined by the child and affected by psychological and biological development stages, family and social support structures, and a vast array of other factors.  As I said, traumatic events cause sudden, intense, significant, and negative changes in our sense of who we are, what we are capable of, our sense of the world, how it works, our place in it, and our belief about our future.  For children with limited capabilities in abstract thinking, they can internalize even the most benign events as traumatic and then organize around the suffering of the experience.  For example, many children internalize parental conflict and divorce as life threatening.  While they cannot articulate it as such, their physical and emotional experience is that their lives are at risk as the two most important caregivers in their life might disappear on them.  Imagine the anxiety that is produced.  On top of that, very young children (3-6 years old) often believe that they are the cause of the conflict, adding to the anxiety a negative belief that they are somehow bad or evil.  Another example is the child’s experience when confronted by a clown.  While some do fine with this experience, others literally feel a tremendous threat and react as though fearful for their lives.  This experience can be internalized as a belief that the world is a dangerous place and can lead to increased anxiety. And while they are intended to be silly and funny, many people grow up to have a phobia or at least a discomfort around clowns.  I would argue that this is a legacy of that first threatening meeting.  It is interesting that many adults cognitively understand a clown to be funny; many also feel in their guts that clowns are creepy and threatening.  They are after all the subject of horror movies and at times real life horror as we witnessed in the recent Denver (Aurora) shootings.

Why do we suffer our past traumas?

Welcome to my blog!

In my work, I am constantly honored to meet amazing people who are good, intelligent, creative, wonderful people and who continue to suffer a past trauma in such a way that they are inhibited from the whole potential of their lives.  They suffer, sometimes quietly sometimes explosively.  I firmly believe that there are several options for these folks to work though, empower, and come out the other side with added richness, brilliance and confidence to live their whole lives.

The following posts are intended to educate and create hope.  I will distinguish among trauma, normal trauma stress reactions and the development of more long term problems such as anxiety and depression as well as the more insidious and pathogenic post-trauma disorders that can occur including what is known as posttraumatic stress disorder (PTSD) and complex PTSD (C-PTSD).  I will also talk about treatment options. My goal here is that you learn that the brain is an amazing organ and that it has truly phenomenal capabilities of repair, resilience and adaptation in the face of trial, tribulation, and trauma.  And like any amazing organ, machine, ecosystem (pick your metaphor), at times, the brain can become overwhelmed and processing and integration of a trauma event can falter in significant ways. When this occurs, suffering is the symptom.  The great risk is that the person begins to organize their lives around the past trauma and the suffering in such a way that it is never “done” or “over” and never secured into the past.

Let me offer you hope that there is a way through; there is a way to live your full life potential.