Emily Hanau, Psy.D.
Learning More About Mental Health
Here you can find an explanation of some of the issues I work with and a description of how I treat these conditions.
Depression
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WHAT IS DEPRESSION?
Depression is an experience that is distinct from sadness or a bad mood. It involves extended periods of low mood or lack of interest in activities (‘anhedonia’) along with several other cognitive and physical experiences such as guilty thoughts, difficulty sleeping, and appetite changes. According to updated information from the CDC, the current prevalence rate of depression in the United States is 18.5%.
“Depression” is a catch-all term that incorporates several different conditions including major depressive disorder, dysthymia (otherwise known as persistent depressive disorder), and other related disorders. The difference between the specific diagnosis given has to do with the length of time the symptoms last and the number of symptoms you may experience.
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HOW CAN DEPRESSION BE TREATED?
Thankfully, research has shown robust support for several treatments of depression. The American Psychiatric Association suggests that, for mild to moderate depression, both psychotherapy and psychiatric medications are effective treatments. Medication can be prescribed by a primary care doctor or a psychiatrist. It is important to note that going for a psychiatry consultation does not obligate you to take a medication or agree to treatment. When my patients are on psychiatric medications, I work with their prescribers to make sure that we are working together towards the same goals and have a unified approach.
Psychotherapy for depression may differ depending on the clinician’s approach. Cognitive Behavioral Therapy (CBT) for depression involves identifying the link between triggering situations, thoughts about those situations, and the resulting feelings, mood, and behaviors that follow. This treatment helps modify thoughts and interpretations in order to help change the negative feelings. You will learn about how thoughts, feelings, and actions affect one another, and about how changing any one of those can interrupt the cycle of depression. Some treatments that fall under the CBT umbrella are behavioral activation, mindfulness-based approaches, and acceptance and commitment therapy (ACT).
Psychodynamic psychotherapies take a different type of approach. In this therapy, you will delve into your history to try to understand the why behind your thoughts, feelings, and behaviors. You will work to identify any significant events or interpersonal patterns that have lingered in your mind and continue to affect your thoughts and feelings today. You will identify the defenses that you built up in response to early stressors and think about how those defenses may or may not serve you today. You will consider patterns of interaction with loved ones, whether there is a common thread, and why you relate in that way. Once you have recognized how these ‘old wounds’ keep showing up today, you will be able to choose how to respond to your life today any way you like.
Obsessive Compulsive Disorder
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WHAT IS OCD?
Let’s start with what OCD is not. It’s not being careful to line up your pens by color code. It’s not being very clean. It’s not being on time. Obsessive compulsive disorder is a condition that involves compulsive behaviors and/or obsessive thoughts. These behaviors are referred to as compulsive because the person feels compelled to complete them, even if he/she does not actually want to complete them. These behaviors are time consuming and upsetting to the person engaging in them.
Compulsions are typically in response to obsessive thoughts, that is, repetitive and distressing thoughts. The repetitive, distressing intrusions typically fall into a few categories: contamination, symmetry, forbidden ideas/thoughts (aggressive thoughts, sexual thoughts, etc.), and harm to self/others. Sometimes people can worry about their sexuality – this is sometimes referred to as “H-OCD.” Other times, people may have excessive doubts about their relationships – this is sometimes referred to as “R-OCD.”
Compulsions are an attempt to neutralize the negative thoughts. For example: If I wash my hands enough times, I will ensure that there are no germs left. Alternatively, if I just check one more time that I did not just run someone over, I won’t have to worry about that for the rest of the day. This becomes a cycle that can feel as if it is taking over someone’s life. It can take hours to ‘complete’ the compulsions and neutralize the obsessions, and this can sometimes leave little time for other pursuits or activities. There is a wide range of severity of OCD, with some people engaging with OCD for 1-2 hours per day, and others for almost the entire day. Sometimes, OCD presents only in a person’s mind. In this form of OCD, referred to as “Pure O” OCD, there are many obsessive and intrusive thoughts with no obvious compulsive behaviors associated with neutralizing the thought. However, updated research (see here, for example) has demonstrated that what may appear to be OCD with only obsessional thoughts is actually typically associated with mental compulsions and reassurance seeking. So while someone may not engage in a compulsion that would be visible to others, she may be spending significant amounts of time reassuring herself or reviewing scenarios in her head in order to achieve some level of relief from the obsessional thoughts.
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HOW CAN OCD BE TREATED?
The good news is that Exposure and Response Prevention is known to be an effective treatment for OCD. Sometimes referred to as ERP or EXRP, this treatment can help reduce or eliminate engagement in compulsions. Often, the obsessional thoughts are reduced as well.
Someone with OCD can become reliant on compulsions because, to some extent, they provide some relief from the anxiety and obsessional thoughts. One problem with this is that this relief is short-lived. In fact, as time goes on, the relief provided by the compulsions often becomes shorter and shorter. One may need to do more frequent, more intense, and longer compulsions in order to counteract the anxiety associated with the intrusive thoughts. The other problem with relying on compulsions to alleviate anxiety is that it sends an unhelpful message to the brain: that something must be done about this anxiety to make it go away—it will never dissipate on its own. The more one engages in compulsions, the stronger the association becomes between obsession and compulsion.
This is where EXRP comes in. The basic goal of EXRP is to separate the obsessional thought from the compulsion so that you can learn that you don’t need the compulsions in order to withstand the obsessional thoughts. EXRP falls under the umbrella of CBT, Cognitive Behavioral Therapy. It uses exposure therapy to help you face your feared situations. Over time, you will realize that either the terrible outcome that you fear will not actually happen, or that the outcome can/will happen, but that you can handle it and will be okay, without needing to engage in compulsions. You will work collaboratively in therapy to come up with what types of exposures would be helpful to you, and in what order. You will do them together with your therapist during session, and then practice at home. The therapy can help you realize that we all have strange, intrusive, troubling thoughts, and that these thoughts can sometimes create a sense of anxiety. But you will realize that you don’t necessarily need to do anything to make the thought or the feeling go away – that will happen on its own, in time.
Posttraumatic Stress Disorder
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WHAT IS PTSD?
PTSD, or posttraumatic stress disorder, has to do with a particular type of reaction to a traumatic event. Over time, the definition of what is considered “trauma” has changed. Currently, a trauma is thought to be something that you do not expect to occur in the natural course of life. This includes witnessing death or experiencing/witnessing threatened death, witnessing or experiencing serious injury, or experiencing violation of body integrity, including sexual violence.
Most people who experience a trauma do not go on to develop PTSD. In fact, less than half of people who are exposed to a trauma will go on to develop PTSD. Symptoms, if they are going to happen, usually begin within the first 3 months after the trauma.
If one does develop PTSD, it can have many varied symptoms. There may be intrusive symptoms, such as unwanted memories, dreams, dissociation, feeling very upset when exposed to triggers, or bodily reaction when exposed to triggers. PTSD also typically involves avoidance of thoughts/feelings/memories of the trauma and avoidance of reminders of the trauma. PTSD is associated with changes in thinking, so that the person may not remember parts of the trauma, may have negative beliefs about self/others/world and the future, and may develop unhelpful ways of understanding why the trauma happened and what its consequences are. There may be emotional changes such as being in a state of horror/anger/guilt/shame, having less interest in activities, feeling detached from others, and finding it hard to feel positive emotions. Finally, there can be changes in level of arousal, so that there is increased irritability, angry outbursts, dangerous behavior, hypervigilance, startle response, difficulty concentrating, and/or difficulty sleeping.
Some clinicians also delineate a special category of PTSD called Complex PTSD or C-PTSD. This refers to trauma that occurs repeatedly and cumulatively. Typical examples are child abuse or intimate partner abuse/violence. There are several symptoms that are specific to C-PTSD: difficulty regulating emotion, amnesia or dissociation, feelings of guilt and worthlessness, taking on beliefs of the perpetrator, unstable relationships, psychosomatic medical issues, and belief that it will be impossible to find someone who understands.
HOW CAN PTSD BE TREATED?
There are several treatments that have been developed for PTSD. In my practice, I used CPT, or Cognitive Processing Therapy. This is a form of Cognitive Behavioral Therapy (CBT), that pays special attention to the cognitive, or thought-related, component of the trauma response. Cognitive Processing Therapy is an evidence-based treatment.
Many of the cognitive (thought-related) symptoms of PTSD involve a disturbance in processing the trauma. Someone who experiences a trauma may wonder: why did the trauma happen to me? And now that it’s happened, what does that mean about people in general? What does it mean about the world, and its level of safety? In PTSD, the answers the person has to these questions often stand in the way of being able to move on or “file away” the trauma. Typically, those with PTSD believe that they are to blame, that there was something they could have done to prevent the trauma from happening. They may believe that the traumatic event demonstrates that the world is a dangerous place, that nobody can be trusted, that healthy relationships are impossible. It is understandable that these beliefs can form in response to the trauma. However, these beliefs can stand in the way of living a fulfilling life in the years after a trauma. Therefore, CPT aims to help modify these beliefs so that moving on can become possible. CPT specifically addresses beliefs about whether the world is a safe place, whether a person has control over his/her own life, whether close relationships are possible, whether people can be trusted, and self-esteem/self-worth.
Other evidence-based treatments for PTSD are Prolonged Exposure (another offshoot of CBT, this one more focused on behavioral exposure work) and EMDR – Eye Movement Desensitization Therapy.
The research on treatment for Complex PTSD is mixed. Some have concluded that it is important to begin with focusing on safety, regulating emotions, and basic self-care before delving into trauma treatment. Others begin with trauma therapy at a typical pace. The best approach is likely person-centered, so that the patient and therapist determine together the patient’s readiness for engagement in trauma processing and collaboratively discuss whether there are life circumstances that are preventing possible engagement with treatment.
