Orthorexia – a new type of eating disorder?

You might have heard some of the negativity in the press recently about so called ‘clean eating’ and it’s advocates, who promote a lifestyle which involves cutting out any processed food and often entire food groups (gluten/dairy etc). This is not because of any medical reason, but simply just to be as ‘healthy’ as possible. I’m not going to go anymore into the debate around clean eating today (there’s too much to say, and several people have done it already) but I’ve mentioned it here as it has been linked to a rise in a condition known as orthorexia.

Orthorexia nervosa (so called by Steven Bratman, 1996) is characterised by a fixation with healthy food consumption. More than just dieting, sufferers will become obsessed with healthy food, and food will become preoccupying and a source of anxiety. Other problems often caused by this disorder include social isolation due to having to have complete control over their food intake, and some nutrient deficiencies caused by an extremely limited diet.

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image from http://www.thefullhelping.com/neda-week-2014-considering-orthorexia

People with orthorexia (like some who ‘eat clean’) will often cut whole food groups or types of food out of their diet, thinking this will benefit their health. Common foods to be avoided are those which include artificial colours, flavours or preservatives, or foods perceived as containing too much sugar, or salt (Catalina et al., 2005). Orthorexics will also develop strict rules about food, which may also extend to rituals around food preparation (Chaki et al, 2013).

However, despite it’s increasing recognition, orthorexia isn’t listed as an official disorder by the DSM-V diagnostic manual for mental illness. As it is a relatively new disorder, research on orthorexia is lacking compared to other eating disorders such as anorexia or bulimia. There is some debate about whether orthorexia is a subtype of one of these existing eating disorders (Zamora et al, 2005), an eating disorder in it’s own right (Bratman & Knight, 2000), or a type of obsessive-compulsive disorder (e.g. Mathieu, 2005). Alternatively, some researchers view it as a combination of the above e.g. Brytek-Matera (2012) who describes orthorexia as “a disturbed eating habit which is connected with obsessive-compulsive symptoms.”

As researchers are still unclear how to categorise orthorexia, it is unsurprising it hasn’t yet made it in the DSM-V. However, despite it’s absence, Bratman & Knight (2000) have developed some guidelines for diagnosing orthorexia. These include:

  • preparing healthy food overtaking other activities in life, with sufferers spending over 3 hours a day thinking about or preparing food
  • following a very strict and restrictive diet plan
  • a healthy diet becoming linked to self-esteem, and feelings over superiority over others who do not follow such a strict regime
  • the nutritional value of a meal becoming more important than it’s taste or the joy from eating it

Orthorexia can be treated successfully, with a combination of cognitive behaviour therapy and medication such as SSRIs (a type of antidepressant) being shown to be effective in some cases (Mathieu, 2005). This study also suggested that orthorexics responded better to treatment than suffers of other eating disorders, perhaps due to their concerns and increased awareness about their health.

There is no question that more research needs to be done to establish more data on people living with this condition, which will enable preventative measures and effective treatments to be developed.

 

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The Power of Conversation

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It’s a well known fact that a problem shared is a problem halved, right? But when you’re feeling down or worried sometimes talking about your feelings can seem too hard. For some people it could be easier to bury these feelings and try and carry on regardless, or for others admitting how they truly felt would seem a sign of weakness.

As you may know it’s Mental Health Awareness week in the UK, so this year I’ve decided to write about the power of conversation, and why you don’t have to deal with everything on your own.

Talking to others about their feelings is something men can be particularly bad at, especially when it comes to any concerns about their physical or mental health. To quote the columnist and campaigner Bryony Gordon in her recent article “Women are encouraged to talk about their problems. Men just have football.” Prince Harry was recently praised for his honesty in talking about his mental health – something which will hopefully change the stereotypical view that British men should have a ‘stiff upper lip’ and not show any sign of emotion.

This gender divide has led to inequality in mental health. In 2016, 3 times more men committed suicide than women. Suicide takes more lives of men under the age of 45 than accidents or disease.

Why is it that men are more at risk of suicide than women, when more women are diagnosed with a common mental illness? One explanation is that men aren’t as good at accessing healthcare as women – for example in the first 3 quarters of 2015, only 36% of those who accessed Improving Access to Psychological Therapy (IAPT) services were male*. Men are also less willing to let others know if they have a problem, with one survey finding that only a quarter of men said they had disclosed a mental health problem to a friend within a month, compared to a third of women. Almost 30% of men said they never tried to access help for their last mental health problem, compared to just under 20% of women **.

Accessing the correct care early is vital in the successful treatment of mental illness. For most common mental illnesses, talking therapies are used as a form of treatment (possibly in conjunction with medication). These include Cognitive Behavioural Therapy (CBT), Psychotherapy, Dialectic Behaviour Therapy, or Counselling – just to name a few. Having the opportunity to talk about thoughts and behaviours with a trained professional can give you the space to work out the cause of your worry or identify any patterns in your thinking which contribute to negative feelings. Therapies such as CBT also try to change behaviours using set goals agreed between the patient and professional which can lead to an improvement in mental wellbeing.

This evidence shows that the culture has to change. Why should it be taboo for men to speak about their feelings in the pub with their mates, as I do with my girlfriends over dinner? Anyone should feel like they have someone to talk to about their problems, even if that person is a healthcare professional – they’re there to help.

On a final note – one project I’m proud to be involved in which is aiming to reduce the stigma of mental illness is a zine called ‘do what you want’. This includes articles from a range of writers and has been featured in the Guardian, BBC and Grazia. All proceeds go to mental health charities, and the ebook (and print version whilst it’s still in stock!) can be ordered here: http://dowhatyouwantzine.co.uk

* https://www.menshealthforum.org.uk/key-data-mental-health

**https://www.mentalhealth.org.uk/news/survey-people-lived-experience-mental-health-problems-reveals-men-less-likely-seek-medical

Exercise and Mental Health

This blog post was inspired by the recent London Marathon, who’s official charity was Head’s Together (a charity set up by the Duke and Duchess of Cambridge and Prince Harry, which aims to reduce the stigma of mental illness) making it the first mental health marathon.

As well as raising millions of pounds for charities which work to improve our mental health, the physical act of training for and running the marathon can also provide a boost to our mental health.

That high you get after going for a run, dancing with your friends or a hard gym session? It’s caused by an increase in endorphins, a neurotransmitter released by the pituitary gland which have been shown to act as a painkiller, and improve your mood.

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Exercise has been found to have benefits for people suffering from different types of mental illness, from depression (Balchin et al, 2016), bipolar disorder (Ng et al, 2007) and schizophrenia (Gorczynski & Faulkner, 2010). Other studies have suggested that exercise could also help protect people from neurodegenerative conditions which can affect us as we get older, such as Alzheimer’s or Parkinson’s disease, as well as improving symptoms and quality of life for people with these conditions (Deslandes et al, 2009). This could be because exercise stimulates blood flow in the brain as well as improving overall fitness. Increased levels of exercise in older adults has been linked to have several positive outcomes, including improved mental health and social integration (Chodzko-Zajko et al, 2009).

Exercise can also help to improve mood in sedentary (but otherwise healthy) participants. One study in Turkey (Taspinar et al, 2014) compared participants who took part in either a Hatha yoga or a Resistance workout program where they trained for an average of 50 minutes, 3 times a week for 7 weeks, to participants who did no extra exercise. The researchers found that participants in the exercise groups showed improved quality of life, body image, self-esteem and lower symptoms of depression after taking part. Participants in the control group showed no change. Yoga was better for improving symptoms of tiredness and depression, and self-esteem, whilst resistance training led to higher improvements in body image perception. This study also shows that it doesn’t matter what type of exercise you do to get the benefits – although it probably helps to find one you enjoy as it means you’re more likely to continue. In case you’re still not convinced, this graphic summarises the 5 main ways exercise can improve your mood:

Exercise

However it is important to note that if you are suffering from a mental illness, exercise on its own may not be enough. For some people, it may be hard enough to get out of bed in the morning, to them going for a run would be completely unrealistic. This is why exercise can be so effective in conjunction with other therapies, be it medication or talking therapies like CBT. Once symptoms have started to improve, then incorporating exercise could be a good way to manage your mood.

So next time you’re feeling worried about an exam, stressed about a deadline or feeling lacking in motivation why not try going for a walk or a dance class? You might get hooked on a new hobby which can do much more than just improve your fitness.

Imposter Syndrome – Not feeling good enough and how to beat it

I’m sure you’ve all been there – earning a promotion, getting into uni or finding your dream job. All your hard work and sacrifices have paid off, and you should feel on top of the world. And for most of the time, you do. You feel happy and accept people’s congratulations of “I knew you could do it!” But despite all this, what about that niggling feeling of ‘why me?’, the feeling that you don’t quite fit in with your peers and that they are all so much smarter and more deserving to be there than you? Why can you not share the confidence in yourself held by your friends and family? This is known as Imposter Syndrome and tends to affect high achieving individuals, and is especially common in women (although men can of course suffer from this too).

Imposter syndrome can negatively affect your self-esteem, mood, and locus of control (this means you feel as though you have little control over things that happen to you). It has been found to be worse in people who feel as though they are outsiders, which could perhaps lead to feelings of not being as good as those around you.

 

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The term Imposter Syndrome was first coined by Clance & Imes in 1978, where it was identified to affect high achieving women. They studied women who were towards the top of the career ladder, or who were studying at either undergraduate or postgraduate level.

The women in the study who had the condition reported that they felt like a fraud, and thought they had only achieved their PhD or got onto their current role because of other factors, for example a mistake in the admissions process or because of others overestimating their abilities. Despite their excellent achievements they didn’t feel qualified to be working or studying at the level they were at and were fearful of being found out. Clance & Imes explain that the women ‘do not experience an internal feeling of success’ which leads them to overlook their achievements.

This inability to have an internal feeling of success is an important symptom to note. One of the causes of imposter syndrome has been identified as having problems with attributions of success. For someone who suffers with these symptoms, they tend to explain a positive event such as a promotion as being down to an external unstable cause, such as luck or someone else’s mistake. The ‘external’ is important here, as it reinforces the fact that successes are not attributed to their own skills and actions. This has been shown to occur more in women than men, who are more likely to attribute success to an internal cause, such as skill or hard work (Deaux, 1976). This author hypothesised that if a women refers to a success as due to an unstable external factor, it does not give her confidence that she will be successful in the future, which causes a cycle of feelings of being an imposter.

So what next? If you’re suffering from Imposter Syndrome, what can you do to overcome it?

I spent a while searching academic journals for evidence on interventions that have been successful in reducing these symptoms. Unfortunately, any combination of the words *imposter* *syndrome* *treatment* or *overcoming* found no relevant results at all.

So instead, here are some recommendations that I did manage to find – mostly from various news articles or academic blogs (see below) mixed with my own advice. Also please remember that I’m not a healthcare professional, but I hope you find them helpful.

  • Be mindful of your self expectations. Don’t expect to be the best at everything and accept you don’t know it all and that’s okay. Don’t be afraid to ask if you don’t know something, that’s much more productive than sitting there feeling inadequate because of it.
  • Make sure you acknowledge the work you’ve done and remember that you’ve worked hard to be where you are now. Once my colleague corrected me when I described myself as ‘lucky’ for getting my current role – “no you weren’t, you applied to loads and worked really hard”. It turned out to be a very helpful comment – good things don’t just happen, you have to make them.
  • Aim to be ‘good enough’ – it isn’t realistic to strive for perfection. If you’re trying to make something perfect, it is likely you will never finish it. Instead accept that ‘good enough’ can sometimes be the way to go.
  • Finally, talk to someone about how you’re feeling – they will probably say they’ve felt like that before too, and you’ll realise you’re not alone.

 

Whether or not you are a student or work in academia, I can recommend this posts on Imposter Syndrome: http://jameshaytonphd.com/phd-impostor-syndrome/

 

 

Body Image Therapy for Anorexia – what is it and how does it work?

Today’s post is for eating disorder awareness week, which this year has a focus on early detection and intervention. Often, sufferers are unable to access treatment until they have been ill for some time, which makes recovery so much harder than if treatment happened once symptoms first began. As well as having obvious benefits for patients, there is also a financial advantage of early intervention (sadly, cost has to be taken into consideration when deciding if a new treatment is worth it). With the current state of the NHS it is important from a financial point of view, as preventive rather than curative medicine is much cheaper overall. So with the benefits of early intervention being brought to our attention, today I thought I’d write about a type of treatment for anorexia – Body Image Therapy.

For those of you who aren’t already aware of the symptoms, Anorexia Nervosa is characterised by:

  • severely restricting food intake, leading to extremely low body weight
  • a fear of gaining weight
  • distorted body image perceptions, with sufferers believing they are fatter than they are.

 

Contrary to what you might think, it isn’t just girls and young women who can have anorexia, men make up about 10% of total suffers (although some studies estimate higher). It is also becoming more common, with inpatient hospital admissions increasing by about 7% a year since 2005. As well as this increase, raising awareness and improving treatment is so important as anorexia has the highest mortality rate of any mental illness.

One of the reasons anorexia can be so hard to overcome is that sufferers have a distorted body image and believe they are much bigger than they truly are. This reinforces the cycle of restricting food or overexercising, and makes anorexia hard to beat. Studies have also shown (e.g. Fairburn et al, 1985) that the symptom of body image disturbances is also a predictor for relapse once therapy has been completed.

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Diagram adapted from Fairburn et al (2008)

Therefore, it makes sense to include body image therapy when treating a patient with anorexia. It is a type of cognitive therapy, which aims to reduce the harmful thoughts about body and weight. One type of body image therapy is Mirror Therapy, in which patients view their body in front of a mirror during a therapy session. Exposure can be increased over time and leads to an immediate emotional response which can be discussed during therapy. The therapist encourages the patient to look at their body as a whole rather than focus on perceived flaws, and to describe their body accurately as opposed to using negative language. This helps patients to learn that there are other ways of viewing their body and the consequences of negative thoughts about it (Delinsky & Wilson, 2006). Over time, cognitive therapy with mirror therapy has been shown to be more effective in terms of reducing body dissatisfaction and avoidance compared to cognitive therapy alone (Key et al, 2001).

Body image training in anorexia is therefore important as it could help to overcome the cognitive processes which make it hard to break the cycle of disordered eating and improve recovery rates for people suffering from an eating disorder.

Thanks for reading, and don’t forget to help spread awareness using the hashtag #eatingdisorderawarenessweek

If you would like to read more about the possible causes of eating disorders then see a previous post here or read about body dysmorphia in anorexia here

If you or someone you know is suffering from an eating disorder then there is help available. Contact your doctor or charities such as Beat, who can provide you with the correct support.

 

 

Patient H.M.

Today’s blog post is about one of the most studied individuals in psychology and neuroscience. By studying him, scientists were able to massively expand their knowledge of how to human brain is structured, and how different abilities (or “functions”) are located in different cortical areas.
H.M. was born in 1928, and was 10 when he first started having epileptic seizures. These were extremely debilitating, and although several medications were tested, none had any affect. When H.M. was 27, a pioneering neuroscientist called William Scoville worked out where the seizures in H.M.’s brain were coming from, and decided that the best way to stop them was to operate, and cut out the parts of the brain that was responsible.
In terms of removing his seizures, this surgery was largely successful. However it came at a cost: H.M. could no longer form new long term memories, nor remember anything from X years before his operation. The image below is a scan taken of H.M.’s brain, and shows the lesions made during surgery, and how this differs from a normal brain scan.
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As you can see from this image, H.M. was left with extensive damage to the central parts of his brain – this area is known as the medial temporal lobe. By analysing the brain damage, neuroscientists were able to make inferences about where certain brain functions are located. As H.M.’s memory was impaired, but other cognitive functions such as language were not, the medial temporal lobe was identified as being important in the formation of long term memories.
Perhaps unsurprisingly, things aren’t as simple as this. H.M.’s long term memory was affected, so severely that he was unable to remember things that happened a few minutes ago. However his short term memory was intact, with a normal digit span (a string of numbers that you can keep in your mind at once) of 7 +/- 2. Therefore, the structures damaged can’t be involved in short term memory.
There are also distinctions that can be made within long term memory. This can be divided into 3 different types of memory: semantic, which is general knowledge about the world; episodic, which are memories about ourselves and our lives; and procedural, which are learned physical movements e.g. riding a bike. Only H.M.’s episodic and semantic memory were damaged, which shows that our procedural memory must be located elsewhere. Other brain areas such as the cerebellum have been identified as involved in this. Not only was his procedural memory intact, he could also improve it by practicing new movements over time. The image below shows a mirror drawing task, where participants have to trace an image by only looking at its reflection in a mirror.
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H.M.’s performance improved each time he did this task, even though he had no recollection of ever doing the task before! This illustrates nicely the different between the automatic, learned ‘procedural’ memories, and the episodic memories about previous experiences.
One last question remains – why did H.M. lose his episodic memories from the years before the operation, but not ones from when he was much younger? There are several theories for this, with one being that older memories are ‘consolidated’ into the rest of the cortex – only newer memories remain in medial temporal structures such as the hippocampus. Therefore, when this area of brain was destroyed, so were the newer long term memories.
When H.M. died in 2008 aged 82, scientists were able to reveal his real name – Henry Molaison. He made a massive contribution to the field of neuroscience, and is thought to have been one of the most tested patients in medical history.
For those interested in reading more about H.M., I would recommend this article, written while he was still alive: Corkin, S. (2002). What’s new with the amnesic patient HM?. Nature Reviews Neuroscience3(2), 153-160.
And finally, I’ll leave you with a quote from H.M. himself, when he was asked “Are you happy?”
“Yes. Well the way I figure it is, what they find out about me helps them to help other people. And that’s more important.”

Prevention is better than cure – Youth Mental Health in the UK

In Theresa May’s recent speech to parliament she stated that she wanted to end the stigma of mental illness and improve the state of mental healthcare in the UK. As a researcher into mental health services for children and adolescents, I hear often about the struggle parents have to get an appointment for their child to be seen by a psychologist, or the problems they face when care ends at 16-18, without the smooth transition to adult services enabling continuity of care.
Whilst it is vital that more money is spent on the NHS as a whole (recent talks of ‘crisis’ in A&E departments shows the obvious need for more resources), money which is promised to mental health services cannot be diverted to other areas which are struggling. These areas are definitely important, but they should not be funded to the detriment of youth mental health services.
Research by Young Minds (2014) found that 77% of NHS Trusts who responded had cut or frozen their Child and Adolescent Mental Health Service (CAMHS) funding between 2013 and 2015. Significantly, demand for these services increased over this time. This increase reflects a general trend over the last 20 or so years, for example the number of 15-16 year olds with depression nearly doubled between the 1980s and 2000s, and the number of young people being admitted to hospital for self harm has gone up by a massive 68% in the last 10 years (http://www.youngminds.org.uk/training_services/policy/mental_health_statistics).
Current services do not meet the need for care, with up to one in every four or five teenagers thought to have a mental illness. In a typical school, this would be around 3 in each classroom in the UK. With 75% of mental illness having an onset before the age of 24 (Kessler et al, 2005), it is vital that young people can access the services they need during this critical time in their development.
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As mentioned above, care at CAMHS often ends when a young person is between the ages of 16 and 18. There are separate services for children and adults (CAMHS, versus AMHS) and this can represent a significant disruption of care. Young people have to move to a new adult service, in a new location and form a relationship with new healthcare professionals.  Previous research has found that only 4% of patients experienced an optimal transition (Singh et al 2010). Problems identified included a shortfall in time spent planning for transition, inadequate information transfer, and poor continuity of care. There may not even be an appropriate adult service in the local area which the young person can move to, for example in the case of autism or attention deficit disorder.
I am a researcher on the Milestone Project, an EU funded study currently investigating transition in nine different countries in Europe. My role involves interviewing young people and parents about their experiences of mental health services in the UK, and following them up over a period of time to see what happens to them when they leave CAMHS. The results of this study won’t be ready for some time, however it is clear to me that more needs to be invested into improving access for young people to mental health services.

Epilepsy

Epilepsy is a neurological condition characterised by repeated seizures. Seizures are caused by electrical activity in the brain, although may appear differently from person to person (not all seizures involve convulsions, despite what you might think).

As with many conditions there is not a single cause that can be identified as a precursor to epilepsy. Genetics (a mutation in the KCNC1 gene has recently been identified as a cause of a progressive inherited form of epilepsy – Muona et al 2015), brain tumours, or head injuries, and the cause of many patients’ epilepsy remains unknown. Several studies have shown that you are more likely to develop epilepsy after a head injury e.g. Christensen et al (2009) found that people were 2% more likely to develop epilepsy after a mild head injury. This rose to 7% more likely following a severe head injury, with risk also increasing slightly with age.

The image below is taken from the EFEPA and shows what to do if someone is having a seizure:

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As mentioned earlier there are different types of epileptic seizures which depends on which part of the brain they originate in. Seizures can be classified by how much of the brain is affected: partial/focal seizures (when only a small part of the brain is affected) or generalised (if most of the brain, or all of it, it affected).

Focal seizures can also originate in different parts of the brain, with the temporal lobe being the most comment (epilepsy.com). The temporal lobe is the part of the brain above your ear, and is responsible for processing hearing, and our memories (this is simplified – it does a bit more than this!). Therefore, one of the common features of temporal lobe epilepsy is memory disturbances (Ko et al, 2013). The famous patient H.M.’s amnesia was caused by an operation to remove the source of his severe temporal epilepsy – this was carried out in the 50s before brain functions were accurately known and too much of the medial temporal lobe was taken away. This destroyed part of the hippocampus, the structure in the brain responsible for memory processing. Due to the nature of his amnesia, he was probably one of the most studied individuals ever in psychology. See this post for more on H.M. and memory research. Operations are carried out to remove part of the temporal lobe in patients now with much better outcomes!

The second most common is frontal lobe epilepsy, where seizures originate in the front part of the brain. They often occur during sleep, and can affect the motor areas of the brain, leading to problems with motor skills (e.g. Beleza & Pinho, 2011). If patients are not eligible for surgery to remove the specific part of the brain responsible for the seizures, anti-convulsive medication and electrical brain stimulation can be helpful in reducing symptoms (Kellinghaus & Luders, 2004).

 

 

 

Déjà vu

I’m sure you’ve all experienced that feeling where you find yourself thinking that things you are currently experiencing have happened before. Déjà vu (meaning ‘already seen’) can feel kind of creepy, but why does it happen?

Déjà vu has been reported to occur in about 60-80% of the healthy population (e.g. Adachi et al, 2003), but is also thought to be linked to temporal lobe epilepsy (Stevens, 1990). There have been several different theories about why this occurs, including the two sides of the brain not functioning together, a sense of familiarity to one part of an experience being mistakenly applied to it all, a problem with how we perceive the timescale of an event, so that something which is happening at the moment is viewed as happening long ago, or a problem with processing sensory information, so that it is processed and reviewed at the same time (see review by Wild, 2005 for a full list).

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There have also been several attempts to use neuroanatomy to explain déjà vu. Brázdil et al (2012) compared the brains of healthy participants who did or did not experience déjà vu using an imaging technique called source-based morphometry to measure the amount of grey matter (neurons) in different cortical areas. They found a correlation in certain subcortical areas of the brain (the hippocampus, STS, insula cortices, basal ganglia, and thalami) between lower amount of grey matter and an increase in déjà vu experienced. Several of these structures are in the mesial temporal lobe, which could therefore explain the link between increased déjà vu in patients with temporal lobe epilepsy.

Work to establish the anatomical basis of déjà vu in patients with temporal lobe epilepsy has also suggested that these mesial areas of the temporal lobe are involved. Bancaud et al (1994) studied the anatomical basis of déjà vu using electrodes in epileptic patients prior to surgery which were placed in the temporal lobe, the hippocampus, and the amygdala (you may remember from previous posts that the hippocampus is a structure important for memory, whilst the amygdala is thought to be involved in emotional processing).  They found that déjà vu could be induced by stimulating all of these areas, but that it was 10 times more likely to occur if stimulation was in the hippocampus or amygdala, suggesting that these areas are key to experiencing déjà vu.

As well as occurring in epilepsy, déjà vu is a feature of other psychiatric disorders including schizophrenia, anxiety disorders (like PTSD), depression, and dissociative disorders. There have also been reported cases of constant déjà vu, with sufferers constantly feeling as though their current experiences have happened before. For example, one case study of a 23 year old male was reported by Wells et al 2014, who concluded that it was caused by his severe anxiety and tendency of depersonalisation. This patient did not show a memory deficit, although other cases of persistent déjà vu have been reported amongst elderly patients with dementia.

One of the things I find interesting about déjà vu is that it is a feature of several psychiatric disorders as well as something which occurs in most of the healthy population. It doesn’t seem that psychiatrists are entirely sure about why is occurs in some people but not others, and like with several other areas of psychology – more research is needed to be sure of it’s true course. Thanks for reading this week’s post, I’ll try to be back soon with more new material!

Behavioural Activation

This week’s post is about a technique used as part of cognitive behavioural therapy for people with depression. As you probably know already, symptoms of depression include low mood, low self-esteem, feelings of anxiety and helplessness, and having low motivation and interest in activities which they previously enjoyed.

Behavioural activation focuses on the ‘B’ of the CBT model, in this case on the last symptom in particular – the withdrawal from usual activities and friends. For example, they may start to avoid social engagement and ignore invites from friends or make excuses as to why they can’t meet up, whereas before they would have been happy to go. Although in the short term this avoidance causes a temporary relief, such as a lowering of anxiety, it simply reinforces feelings of low mood or low self-esteem. This maintenance of the condition is illustrated by this diagram below:

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Therefore, in order to break this cycle, behavioural activation aims to change the unhelpful behaviours which continue the cycle of low mood. It does this by gradually building up activities that the person can do, which is turn will improve their mood, and lead eventually to them getting back to activities they used to enjoy. This progression is important, as the change in mood is needed before larger behavioural changes can occur.

Key features of Behavioural Activation are as follows (taken from Jacobson et al, 2001):

  • Firstly, the model is presented to patients by their clinician, who explain a bit about it and why it works. This is called a treatment ‘rationale’ and it is important for the patient to feel confident that this will work. A good relationship and trust with the therapist is also important.
  • Developing treatment goals through collaboration between the patient and the therapist – these goals are new behaviours rather than moods or emotions.
  • Analysis of causes and maintenance factors of the depression
  • Graded task assignment – e.g. starting with something small such as walking to the corner shop. This is scheduled in between sessions, and a hierarchy is discussed with the therapist.
  • Establishing a routine, in the hope this results in improved mood.

Ultimately, the aim of Behavioural Activation is to help the patient re-engage and find joy in activities which they have been avoiding. This will raise mood, and therefore help someone recover from depression.