The Habits of Stress-Resilient People

Presented by

John D. Preston, Psy.D., ABPP

Alliant International University, Sacramento

Disclosure Dr. Preston is the co-author of two books on Psychopharmacology that are sold through IBP. In this program, Dr. Preston will include off label uses.

Sponsored by

Institute for Brain Potential

PO Box 2238 Los Banos, CA 93635

COURSE OBJECTIVES Health professionals in medical, dental, and behavioral settings completing this new and practical 6-hour program should be able to identify one or more habits that: 1. Protect the brain and body from toxic effects of stress and cortisol, 2. Manage stress-related cravings, 3. Overcome fears or generalized anxiety, 4. Produce positive moods, and 5. Experience calm, mindfulness, meaning and happiness. Policies and Procedures 1. Questions are encouraged. However, please try to ask questions related to the topic being discussed. You may ask your question by clicking on “chat.” Your questions will be communicated to the presenter during the breaks. Dr. Preston will be providing registrants with information as to how to reach him by email for questions after the day of the live broadcast.

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In the unlikely event that you lose your certificate, please send your request in writing and a check for $20 payable to IBP at PO Box 2238, Los Banos, CA 93635, email [email protected], or call 866 -652-7414. IBP is a nonprofit scientific and educational organization dedicated to promoting advances in behavioral medicine. IBP is entirely supported by the tuition it charges for its seminars and the sale of educational materials. Neither IBP, its planning committee, nor any of its instructors has a material or financial interest with any entity, product, or service mentioned in the seminar unless such relationship is disclosed at the beginning of the program. The information presented is of a general nature. For specific advice, please consult a specialist in your area. Habits of Rippling Stress‐Resilient People Institute for Brain Potential

John Preston, Psy.D, ABPP Alliant International University Sacramento, CA USA

Resilience Adaptive • Psychological sturdiness Neuro‐ • Successful coping plasticity • Recover, adjust, and GROW following misfortune and change

Resiliency Not Covered Today • Chiropractic • Energy therapies “Those who have not avoided • Massage • Recreational Therapy • Acupuncture • Equine therapy stress, but rather have found • Prayer • Pet therapy ways to face it, learn to regulate • Yoga ▪ Grounding • Dietary supplements • Tai Chi ▪ Qigong • Hypnosis emotions and choose to take on • Music; dance • Nutrition (a bit) challenges: this is the way to • Art * Homeopathy • Meditation (a bit) • Occupational Therapy • Spirituality Build Resiliency.” • Psychopharmacology And a lot more

1 Sources of Resiliency Some sources of Let’s take a closer look resiliency are biologically based… Nature, Nurture . and Luck

However, Many Brain Regulation Neurologically‐based Problems and Disorders are NOT Hardwired Brain changes are possible

Life Style Choices Environmental Have a Huge Impact Effects on On Brain Regulation Brain Development and Regulation

2 Bright Light Biological Exposure and Adaptations Brain regulation 365 days a year All organisms

Circadian Stabilization & Serotonin Regulation

Sleep: Probably Slept more Than we do ?

3 Americans Today sleep 1.5 hours less per night than 100 years ago

Need for sleep:7‐8 hours

Environmental Factors Influencing “Natural” Brain Regulation Prolonged Holding and Rocking Likely the norm for millions of years • Bright Light Exposure • Exercise • Sleep • Communal Living

Building a Better Brain The Brain is not Hard‐wired Two Key Concepts Neuro‐plasticity

4 Use it or lose it… Neuro‐protective Proteins BDNF: brain‐derived neurotrophic factor GDNF: glial derived neurotrophic factor Myokines The following from Muscles Use it a lot… during exercise * • VEGF: increases capillaries (brain and body) • IGF‐1: increases serotonin and glutamate it grows • FGF‐2: enhances neurogenesis release

* “Spark” John Ratey, MD (2008)

•BDNF: brain‐derived neurotrophic factor > neuro‐protection > neurogenesis (hippocampus) > neuronal growth > strengthen synapses

Depression, Powerlessness, and Immobility ↓ BDNF Mastery Dendrite Growth: via BDNF ↑ BDNF * Strengthening Can be measured in Blood Neuronal Connections

5 Psychiatric Drugs that BDNF Increase BDNF • All anti‐depressants •Certain psychiatric • , Tegretol () medications • Lamictal () , Seroquel (), Abilify (), Latuda (), Saphris (asenapine); possibly other newer antipsychotics

What About Micro doses Primary Tactile Area: Parietal of Lithium?

Lithium in tap water

Supplements: Lithium Orotate 5 mg Experimental

Increasing Size of Brain Maps Increasing Size of Brain Maps •Learning braille: • By 6 months, noticeable > 2 hours of class, 5 days a week change in size of tactile area for 6 months • Most brain areas: increased size

Pascual‐Leone, R., et al. (1999) via dendrite proliferation

6 Anterior Cingulate…Amygdala The Concept of Major Control Center for Anxiety Top‐Down Control

X

Neuro‐Biology of 2 Brains Stress and Survival: (amygdala and cortex/hippocampus) Designed to Respond to Here and Now Danger Each: Learns, Perceives danger and Activates an independent response

Threat Appraisal Cortical‐level Appraisal Two Levels • In awareness • Complex, detailed appraisal • Can reality testing . • Inhibition verses Reflective, impulsive thinking

7 Amygdala‐Level Appraisal Information Processing and Responding: Amygdala • Rapid, crude, adaptive • Pattern recognition • Appraisal beneath the radar • Cannot reality test of consciousness • 3 • Branded in memory circuits Why this matters….vignette • Prone to false alarms

8 Pushing Our Buttons Resilient People Sensitivity to • Figure out their triggers •Judgment….criticism • Make sense of the origin •Rejection…abandonment • Exercise self‐compassion •Shaming…humiliation • Make wise choices •Fear of anger ………… (e.g. relationships; occupations)

Living “Your” Life • Career or volunteer work 9/10 Regretting • Expressing your feelings, beliefs, etc. • Saying “NO” what I didn’t do • Relationships • Pursue talents/hobbies/dreams • Letting go of shoulds and scripts

Appraisal The First Responder: (also internally generated) Sympathetic Nervous System Mobilizing the Body

Three waves of activation

9 Sympathetic NS Responses GSR: Galvanic Skin Response • Rapid heart rate • Increased blood pressure • Sweating • Trembling

Second Responder Third Sympathetic Nervous System Responder Activates Adrenal Medulla

•Releases Adrenalin Cortisol and Norepinephrine into circulation

Beneficial Effects of Cortisol •  Glucose (energy) •  Cardiac Output • Improves memory • Emotion regulation (HPA Axis) →

10 Toxic Stress and The Culprits the Brain • Adrenalin and norepinephrine • Excessive cortisol

• Decreased BDNF (and other proteins) • Chronic Inflammation

Normal Sleep Architecture Sleep Impairment: Hormones • Adrenalin and norepinephrine: initial insomnia (falling asleep)

Sleep Impairment: Hormones Normal Sleep Stages •Cortisol: decrease in deep sleep

11 Impact of Sustained Cortisol

Causes of: Hypercortisolemia Hypercortisolemia Sustained, Toxic •Major Depression ↑ cortisol levels of Cortisol (some ↑ in all depressions…toxic levels in 60%) •Stress: extremely severe, prolonged, inescapable (perceived lack of control)

“War Zones” • Child abuse • Elder abuse • Domestic violence • Caring for loved ones with chronic, severe medical conditions • Abuse of disabled people • Homelessness ▪ Severe Bullying • Severe Chronic pain; terminal illnesses • Severe mental illness • Racism…other prejudices • Combat, POWs and refuges

12 Impact of Chronic Exposure: Impact on the Body Hypercortisolemia •Damage to arteries •Specific Brain Damage ↑ rates: heart attacks > Hippocampus and strokes > Anterior cingulate → •Osteoporosis

Over time: with Repeated Episodes Progressive Brain Damage

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Chronic Inflammation As Cortisol Levels • Chronic Over release of increase: pro‐inflammatory cytokines co‐occurring • “sickness behavior”: lethargy, ↓ BDNF low motivation/enthusiasm • May cause: depression

13 Chronic Inflammation Chronic Inflammation •Chronic or frequent Urinary tract infection •Inflammation in the •Chronic Gum disease absence of infection

Brain Repair: Brain Repair ↑ BDNF, etc. •New nerve cells: • Dendrite growth: “neurogenesis” hippocampus & hippocampus anterior cingulate

Reducing Inflammation •Antidepressants are anti‐inflammatory (reduce pro‐inflammatory cytokines)

14 Reducing Inflammation Anti‐Inflammatory Nutrients • St. John’s Wort: • Fish, fruit, vegetables, walnuts anti‐inflammatory flax and whole grains • Omega 3 fatty acids • Omega‐3 EPA 1000 mg/day • Anti‐inflammatory • Spices: sage, ginger, chili peppers, foods/diets → black pepper, curcumin

Mediterranean Diet Plus Exercise • Fruit, nuts, legumes, fish Parasympathetic • Moderate alcohol use Responses: • N: 10,094….Spain (relaxation response) • 4.5 year follow‐up study Anti‐inflammatory

Exercise: Maximize Adaptive Anti‐inflammatory Brain functioning: Three Keys > Sleep > Light Exposure > Exercise

15 Turn off a “Busy Brain” . > Getting to sleep “To Do” List > Treat sleep disorders . > Avoid certain Substances James Pennebaker’s > Exercise Technique > Calm Evenings > Sleep Cool

Web Sites and APPS •Sleep.org sleep hygiene, etc. Nat’L Sleep Foundation •Pzizz.com music affecting brain wave action (free trial) iTunes

Normal Sleep Architecture Slow wave (deep) sleep • Restorative sleep • Deprivation: > Fatigue Deep, slow > Troubles concentrating Wave sleep > Impaired emotion regulation > Impaired immune function

16 Very Common Conditions: That Disrupt Deep Sleep Top of the List • Anxiety (adrenalin; norepinephrine) • Common, often over‐looked • Depression (cortisol) * Circadian disruption and treatable • Primary Sleep Disorders: • Chronic, mild hypothyroid > Restless legs; > Apnea: (frequent episodes of arrested breathing) causing depression • Pain * Pregnancy • Primary Sleep disorders • Frequent urination * Menopause • Substance use/abuse • Substance use * Gastric reflux • Loud bed partner or baby

Hypo‐Thyroid: 10% of all Thyroid depressions TSH Thyroid stimulating hormone Sub‐clinical hypothyroid

Optimal TSH Level: Mood Disodrer Top of the List

High Normal Range 3.0 • Primary sleep disorders | 2.4 | Restless legs 10% Median | 1.0 Obstructive Sleep Apnea | Men: 24% Women: 9% Low Normal Range 0.3

miliIU/Liter

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17 Obstructive Increasing slow wave sleep Sleep Apnea •Avoid substances that Made interfere with Worse with Alcohol deep sleep and Tranquilizers

Drugs and Sleep Disturbances Does not Include •Caffeine • Low dose • Alcohol Trazodone (25‐75 mg) • Tranquilizers • Not recommended in those • Most Rx Sleeping pills → over the age of 60 Orthostatic hypotension

Does Not Include Impact of Caffeine • Remeron (mirtazapine) 7.5‐15 mg • Elavil (amitriptyline) or nortriptyline (chronic pain) • Silenor (doxepin) 3‐6 mg X • Benadryl (diphenhydramine) 25‐100 mg

18 More deep sleep the body must cool down by 2‐3 degrees

sleep cool

Increasing Deep, Restorative sleep Web Sites and APPS • Sleep cool… and reduce blue light one hour before bedtime •f.lux eliminates blue (especially: TV & Computers) • Melatonin light: computers, cell do not use in excess of 0.5 mg • Problems with higher doses phones… circadian rhythm…can increase depression and destabilize www.justgetflux.com bipolar disorder

19 Increasing Deep, Restorative sleep

• Melatonin Supplements do not use in excess of 0.5 mg • Problems with higher doses circadian rhythm…can increase depression and destabilize bipolar disorder

Lack of Quality Control Products Endorsed By: • BMC Medicine (2013) • 44 Products…dozens of companies USP (US Pharmacopia) • 50% contained plant species not listed on the bottle www.consumerlab.com • 30% had none of the plant listed on the bottle • One St. John’s Wort product: no SJW…

instead: an herbal laxative 118

Bright Light Exposure •All forms of depression •Anxiety

20 High‐intensity light Exposure • 10‐20 minutes a day High Intensity Light Boxes • 10,000 LUX • Must be 10,000 lux • Light entering the eye • Many options: Amazon.com not the skin: don’t get melanoma • Light box or going outside (without sun • Northern Light Technologies glasses) • Verilux :Happy Light Liberty • Contraindicated for people with eye diseases These are examples; not • Caution with bipolar disorder: Endorsements. Speaker has no financial can provoke mania relationship with these companies

Quick Fix Exercise: Stress Reducer Habit Control and “Energy Booster”

• 10 minute brisk walk:  energy 60‐120 minutes • Rapid reduction: anxiety (Gauvin, et al.., 2000)

Overcoming Fears via Exposure

21 “Fear Thou Not” Neurobiology of Courage Nili, et al., Neuron, 2010

• Ss: > afraid of snakes > not afraid of snakes • Functional MRI →

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“Fear Thou Not” Neurobiology of Courage Nili, et al., Neuron, 2010

• Ss: > afraid of snakes: advance > afraid of snakes: retreat > not afraid of snakes

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“Fear Thou Not” “Fear Thou Not”

• In scanner: asked to move • Advancers: on‐going activity a snake closer and closer to in anterior cingulate their heads • Reduced activity in amygdala • Measured metabolic activity, * Reduced GSR …. despite fear GSR, and subjective • Retreat: drop in activity in AC sense of fear 131 132

22 Dys‐control Control

Zone of emotional tolerance

Vignette: Fred Vignette: Fred

• His wife died 4 months ago • Always first look for multiple • He’s collapsed into major causes depression…thinks he is • Case formulation: normal falling apart grief and mourning blocked by over‐defendedness

Dys‐control Control

Blocking Avoidance Reinforcement

23 A related Issue: Professional “Burn‐out” Burnout !

• Very high rates: (30‐65%) www.helpguide.org/articles/ > Medicine stress/preventing‐burnout.htm > Social work > Teachers > Counselors > Nursing

Reduce Upward Arousal Affect Regulation Techniques: •Relaxation Techniques (reduce muscle tension)

Sensory input Collateral axons

24 CRYING CRYING BEHAVIOR (William Frey) (William Frey) •A “Good Cry” • Average Duration of Crying Spells: 1‐6 minutes •Parasympathetic • Felt better after a “Good Cry”: response Women: 85% Men: 73% •Emotional Tears →

THE BIOLOGY OF CRYING Kegel Exercise

Kegel response: impact on vagus nerve: ACTH pelvic floor… (20‐30”)… rapid activation of PNS And …Parasympathetic activation

Kegel Exercise

25 Voluntary Regulated Breathing Practices (VRBP)

• A number of positive RCTs • Inhale…pause…exhale…pause 4………..2……….4……….2

Voluntary Regulated Diaphragmatic Breathing Breathing Practices (VRBP) with Stretching • Activates a parasympathetic Response via stretch receptors

(lungs, diaphragm & thoracic muscles → stimulates vagus nerve normalizes heart rate variability)

Hyperventilation Deep breathing not . recommended if there is ↓↓ CO2 shortness of breath and hyperventilation respiratory alkalosis

causes vasoconstriction in the brain hemoglobin binds O2 tightly

26 Hyperventilation 1 ½ minutes Vaso‐constriction: too little CO2

Dehydration and Mood Regulation • Mild dehydration: 1.3% or greater • Noticeable impact on cognition and mood • Measuring hydration

www. ncbi.nih.gov/pubmed/22190027

Painful Emotional States Resilient People have are Amplified by learned how to Negativity Bias Maintain Loss of Perspective ! Perspective

27 Key Stress Management Strategies 60 Second Reality Check “Clear Thinking” • Predictions • Pause … • Re‐evaluate “urgency” • In the grand scheme • Some measure of control how important is this ? say “no”…”Let Go” • How am I likely to feel • Outlets for pent‐up tension in 48 hours ?

What went well today? Buddhist Tradition Technique from Positive Psychology •Struggling against pain •Each day ask: ↑ suffering > “what three things went well today?”

Muddy water… Let stand… Radical Becomes clear Acceptance ‐Lao Tzu

28 Radical Acceptance Grief and Loss • Do not struggle with facing the truth • Acceptance: this did happen • Give permission to experience normal human emotions • In this moment…I am doing the best I can

Common Sources Of Loss Common Sources Of Loss • Death of a loved one • Divorce or Separation • Brain Injuries/Disease, • Estrangement; betrayal loss of Vision, Hearing • Geographic Relocation or cognitive functioning • Miscarriages, Still births, • Loss of a Dream Abortions and Infertility • Losses associated with • Kids leaving home retirement, etc. • Loss of a home…unemployment • Loss of security

Grief • Not pathological • Self esteem is preserved • No anhedonia (waves) • Functional • Engagement in life

29 “How long does it take Significant Distress following Loss to get over the loss • 4‐7 years after death of spouse of a loved one ?” majority still had very painful feelings about the loss • Much longer: death of a child • Grief comes in waves

Research: Koyanisqatsi Habits that are associated with •A Hopi word meaning: greater sustained levels Life out of balance of well being

30 Mindfulness Focused Awareness (mind‐fullness) • Resilient people take things in: moment‐to‐moment Being Awake (spend time…take it in) The opposite of • Concrete reminders to savor the automatic pilot moment

Fun, Humor and Re‐circulating Self Nurturing Joyful States • The habit of recapturing positive Survival Mode memories –Photos, scrapbooking, digital It’s All about photo frames… Maintaining Balance reminiscing with old friends

Expressing Emotions In Brief… –Empathy ‐ Compassion • Setting Limits…limit “rescues” –Gratitude • If you are riding a dead horse… dismount ! “the mother (toxic people and obligations) of all virtues” Cicero 43 BC

31 Actions that Have Highest Actions that Have Highest Yield in Promoting Well‐Being Yield in Promoting Well‐being • The most potent way to improve • Keeping clear about what mood: matters Once a day: an act of kindness • Daily contact with nature and toward a stranger other living creatures

Actions that have High Yield in Promoting Well‐being “A ship is safe in harbor, but that’s not what • Establish a daily routine ships are for” • Giving money away ‐ Grace Hopper

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Depression: Five common Mistakes in treatment and 5 Five “Must dos”

Mistakes: 1. The diagnosis is incorrect: two common mistakes: the person is suffering from grief, not clinical depression and the person is suffering from depression but it is a type of depression associated with bipolar disorder. With bipolar disorder: caution: antidepressants can make bipolar significantly worse. A careful diagnosis is crucial. Red Flags for bipolar: #1. between depressions: periods of upbeat mood accompanied by decreased need for sleep, “good energy” which may only last a few days. #2. Depression accompanied by excessive sleeping (10+ hours a day) along with significant fatigue. 2. Not detecting that the depression may be caused by an underlying medical condition (most common: low grade, subclinical hypothyroid [details about this follow], restless legs, obstructive sleep apnea, chronic pain, fluctuations in female hormones). In every case of depression, these factors must be evaluated. They account for at least 10% of depressions. 3. Failure to address sleep disturbances caused by drugs: caffeine, alcohol, tranquilizers (all can cause restless sleep and inadequate deep sleep) 4. Unaddressed psychological problems: in the United States most people treated for depression only receive antidepressants. Emotional/psychological problems must be evaluated and treated with psychotherapy for effective outcomes (often antidepressant and psychotherapy are used together 5. Some drugs cause depression and yet go unrecognized or unaddressed: Most common: Alcohol, steroids, tranquilizers, some high blood pressure medications (e.g. alpha‐2 agonists such as Clonidine and beta blockers such as propranolol). Must Do: when people are depressed they almost always have difficulty following through with the recommendations listed below. The most helpful thing to do is to have a “coach”…spouse, partner, best friend who will provide kind but firm encouragement. 1. Stay engaged in live: push yourself to continue normal life activities 2. Exercise: at least two, ten minute brisk walks a day. 3. If antidepressants are being taken, keep in mind that they take 3‐5 weeks to begin working. Many people stop too early. Always discuss any and all concerns with your therapist or prescriber. 4. During depressions people are very prone to becoming harsh with themselves…it is very important to adopt a kind and compassionate attitude towards yourself. Negative criticism and put‐downs always intensify depression. 5. Psychotherapy: this is very important. Find a therapist who has specific training and experience in treating depression…find a therapist who is a compassionate and decent person and a therapist who won’t give up on you.

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Understanding and Managing Habits

Habits are an essential part of life. Thousands of times each day we rely on habits to make life easier (e.g. you do not have to really think about it when fastening your seat belt…it’s an automatic habit). But, admittedly, some habits are maladaptive and sometimes, ultimately dangerous (for example, the over use of alcohol or dangerous drugs, or excessive binge eating).

Reward centers in the brain are complex and involve two main elements: anticipation (ranging from benign anticipations such as getting excited about eating a good meal...to out of control cravings) and the actual feeling of pleasure. Anticipating activates the neurotransmitter dopamine. A number of things we, as human beings like and look forward to are not at all maladaptive, and are in fact the spice of life (listening to beautiful music, appreciating art, , intimate sexual experiences with a loved one, watching moving or thrilling movies or sporting events, playing with our children or grandchildren, spending time in nature, gardening or walking with our dog, comfort from a hug, planning vacations, hearing funny jokes, enjoying pleasant thoughts or memories, feeling proud, touched deeply by hymns or patriotic music, and so forth). The anticipation of such events causes a very slight increase in dopamine release in the brain and it is experienced as excitement or up‐beat anticipation. This is the build‐up phase to part two: actually having the experience that feels good (dopamine plays a minor role in this…but a host of other brain chemicals are involved, e.g. endorphins, GABA, oxytocin, endogenous cannabinoids, etc.). Nothing pathological about this!

However, some substances or experiences can eventually lead to very maladaptive outcomes or even frank addictions. These include: highly addictive drugs such as nicotine, cocaine, prescription narcotics or drugs such as heroin; for some individuals the list contains pathological gambling, internet pornography, “addictions” to video gaming, excessive eating or binging, risky behavior such as road rage or shoplifting, and malignant needs to over‐power, win or control others). These habits which can lead to the break‐up of relationships, being fired from a job, legal problems, health problems and sometimes great harm to others, are often very hard to control. Understanding the neurobiology of such habits has led to strategies that are often successful.

When highly maladaptive or addictive habits are developed this leads to an abnormal change in the reward center dopamine system. Anything that ignites thoughts about acting on the habit (e.g. starting to think about drinking alcohol in a person who has been trying to overcome alcohol abuse, activates an intense surge of dopamine…well beyond what is ever experienced with more benign expectations, such as waiting for your meal to be served at a restaurant). Eventually, the magnitude of dopamine activation is not at all pleasant…in fact it results in very unpleasant feelings of uneasiness, sometimes agitation, irritability and dysphoria (intense negative feelings). This pathological overload of dopamine is only quelled by “using” (e.g. taking the drug, gambling or binge eating). But this is not the end of increasing pathological changes in the brain. At some point giving in to the urge and “using” may offer a bit of relief, but begins to yield no actual pleasure. Finally, it can lead to the release of a chemical dynorphin, which actually results in intense feelings of depression. The intense suffering associated with the severe dopamine activation, is often not appreciated by others who may sit in judgment, concluding that the person is simply out of control and this is a “choice” or character flaw, without realizing that the inner experience is one of significant suffering (often also accompanied by the addicted person’s feelings of self‐hatred, powerlessness or shame).

Keys to Managing Highly Maladaptive Habits:

1. Avoid “triggers”…such reminders powerfully ignite this pathological and very distressing dopamine surge and activate desperate attempts to find relief. Triggers for those who binge eat may be opening the freezer door and simply seeing the container of chocolate ice cream; for those with alcohol problems opening the cupboard and seeing the bottle of wine or one’s old shot glass; for internet pornography, just wanking by the room in one’s house where the computer is. One of the most important keys to habit control is to do some careful refection and discover specific “triggers”, and then get rid of or avoid them altogether. This often also extends to interactions with friends with whom one has spent time drinking or using drugs; avoiding the snack section of the grocery store, not driving down the street with a past, favorite liquor store, etc. 2. Beyond triggers: What ultimately may result in a slower activation of dopamine and movement towards intense craving are more subtle feelings that can begin earlier in the day, and like an avalanche, begin to intensify later in the day. Most common are: physical sensations of stress (anxiety and or depression), boredom, and fatigue. The key to managing this again starts with identifying such feelings early…feelings that at first may be subtle. Then, nip them in the bud. For example for fatigue: drink a large glass of water can quickly relieve some fatigue; and also take a 10 minute brisk walk or jog. For boredom, anticipate that this can happen and develop a list of specific activities that can be either distracting or mentally energizing and enjoyable. Then, take action and just do it. For stress related symptoms….again look for your own unique early warning signs, e.g. muscle tension, gritting your teeth, a sense of uneasiness or restlessness…and then employ stress management techniques discussed in this class or make contact with a close friend. Early identification and action can interfere with a cycle that might ultimately lead to maladaptive habits/solutions later in the day. 3. Over‐eating: Never have unhealthy snacks available in the house (or only occasionally and in very small amounts). With meals, eat only what you need not what you want. This is best achieved by only cooking enough for one serving, thus no opportunity for “seconds”…and even serving moderate amounts of food on smaller size plates. No kidding…often this really works.

Maladaptive habits don’t disappear on their own. Getting full support for doing these things from a friend or loved one is also enormously helpful. Often help from a support group or a mental health professional can be a life saver. And finally, it is crucial to approach habit control strategies while being kind toward yourself. We are all human and these are difficult challenges. Self‐compassion is always at the heart of successful behavioral changes.

Specific habit control books and home study courses that cover this topic in more detail are available from the Institute for Brain Potential.

Subclinical hypothyroid (a subtle form of thyroid dysfunction) can complicate the treatment of both major unipolar depression and bipolar disorder. This condition can be identified by TSH (thyroid stimulating hormone) levels that are in the upper half of the normal range (i.e. 1.5-3.0). T3 and T4 are in the normal range. TSH values in this range are considered to be completely normal for most individuals, but this often is not the case for those experiencing severe depression. In people vulnerable to depression such TSH levels can, and often do, cause depression, complicate depression and can interfere with treatment with antidepressants. This condition may be the cause of up to 10% of those with depression. Failure to recognize and treat this condition can result in inadequate responses to both psychotherapy and antidepressants. Treatment involves the use of very low doses of thyroid replacement hormone (e.g. 25-50 mcg Cytomel). This treatment generally takes 4-6 weeks to gradually reduce TSH levels to an optimal level: 1.0 Please note: this applies only to those suffering from significant depression. Failure to evaluate thyroid functioning in people with mood disorders is a very common reason for inadequate treatment response and unnecessary suffering. Please see references below. Also see: PsychEducation.org Thyroid dysfunction: may be seen in up to 2/3rds of those suffering from bipolar disorder and must be monitored. In addition, those taking lithium may, over a period of time, develop hypothyroid as a side effect of lithium treatment. This is not dangerous, and can be corrected with thyroid hormone replacement therapy (see Goodwin and Jamison, below). Thyroid augmentation references 1. Cooper‐Kazaz, R. et al. (2008) Efficacy and safety of T3 supplementation in patients with major depressive disorder treated with SSRIs. International Journal of Neuropsychopharmacology. 11: 685‐699. 2. Bauer, M., et al. (2008) The thyroid‐brain interaction in thyroid disorders and mood disorders. Journal of Neuroendocrinology. 20: 1101‐1114 3. Joffe, R.T. et al. (2013) Subclinical hypothyroidism, mood and cognition in older adults: A review. Internal Journal Geriatric Psychiatry. 28: 111‐118. 4. DeBattista, C. (2006) Augmentation and combination strategies for depression. Journal of Psychopharmacology. 20 (3): 11‐18. 5. Phelps, J. (2006) Why am I Still Depressed: Treating and recognizing soft bipolar disorder. McGraw‐Hill: New York 6. Stahl, S.M. (2013) Stahl’s Essential Psychopharmacology Fourth Edition. Cambridge University Press: New York. 7. Goodwin, F.K. and Jamison, K.R. (2007) Manic‐Depressive Illness: Bipolar Disorders and Recurrent Depression. Oxford University Press: New York 8. Zweifel, I.E., et al. (1997) A meta‐analysis of the effect of hormone replacement therapy upon depressed mood. Psychoneuroendocrinology . 22: 189‐212. 9. Phelps, J.(2016) A Spectrum Approach to Mood Disorders. WW Norton: New York

Restless Legs and Amber lenses for screening out blue light: The following are neither endorsements nor advertisements, but are in response to many questions from attendees:

1. Amber/yellow-orange lenses that block blue light, indicated for use in treating mood disorders (as described in the class) are found on the internet…however, in order for such lenses to be effective, they must block 90% of blue light wave emissions. Most products on the internet only block 10%. Two products are available that block 90%: SKYPER SCT: orange lens, model # 3S1933X and Ultraspec # 2000 (the latter go over regular eyeglasses). 2. FDA approved drugs for treating restless legs are: Mirapex and Requip. Always first monitor and reduce or eliminate Caffeine intake: a common cause of restless legs; Magnesium L-threonate , citrate, aspartate, or lactate .

Stress Resilience References

Arden, John (2015) Brain2Brain. Wiley: New York

Cozolino, L. (2010) The Neuroscience of Psychotherapy W.W Norton: New York

Davidson, RJ, et al. (2004) Well-being and affective styles. Philosophical Transactions of the Royal Society. 359: 1395-1411

Doidge, N. (2007) The Brain that Changes Itself. Penguin Books: New York

Farb, N.A.S. et al. (2007) Attending to the present: Mindfulness reveals distinct neural modes of self reflection. SCAN , 2, 313-322.

Gilbert, Daniel (2007) Stumbling on Happiness. Vintage Press: New York

Hanson, R. and Mendins, R. (2009) Buddha’s Brain. New Harbinger: Oakland

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LeDoux (2015) Anxious. Penguin Books: New York

Lin, D. et al. (1997) Maternal care, hippocampal glucocorticoid receptors and HPA responses to stress. Science. 227,1659-1662.

Luthar, S.S. (2003) Resilience and Vulnerability. Cambridge University Press: New York

McEwen, B (2016) In pursuit of resilience: Stress, epigenetics and brain plasticity. Annals of the New York Academy of Science

McEwen, B. and Gianavos, P (2011) Stress and allostasis-induced brain plasticity. Annual Review of Medicine. 62:5, 1-5.15

Meichenbaum, D. (2012) Road Map to Resilience Institute Press: Clearwater, Florida

Nini, U, et al. (2010) Fear thou not: Neurobiology of Courage. Neuron : 66(6) 949-962

Pennebaker, J. (1997) Opening Up Guilford: New York

Phelps, J. (2016) A Spectrum Approach to Mood Disorders. W.W. Norton: New York

Preston, JD (2007) Complete Idiot’s Gide to Managing Your Moods. Penguin Books: New York

Ratey, J. and Hagerman, E. (2008) Spark: The Revolutionary New Science of Exercise and the Brain. Little Brown and Company: New York

Sapolsky, RM (2017) Behave: The Biology of Humans at Our Best and Our Worst .Penguin Press: Ney York (thyroid and mood disorders)

Seligman, MEP (2012) Flourish. Free Press: New York

Trafton, JA, Gordon, WP and Misra, S. (2011) Training Your Brain to Adopt Healthful Habits: Mastering the Five Main Brain Challenges. Institute for Brain Potential: Palo Alto, CA

Wirz-Justice, et al. (2013) Chronotherapeutics for Affective Disorders Karger:New York (the impact of light on brain functioning and in treatment)

IBP programs are designed to be based on the best available evidence from current scientific research. However, the interpretation of evidence-based research may vary among researchers. The views and opinions expressed in this program are those of the presenter and do not necessarily reflect the views and opinions of IBP.

Self-Test: 1. This term/concept refers to the impact that the environment has on gene expression a. Neuroplasticity b. Genetic transmission c. Epigenetics d. Acquired biological resiliency 2. One of the following is considered to be a nerve growth factor a. BDNF b. Cortisol c. Oxytocin d. Secretin 3. Which of the following statement is not true a. Many neural circuits are only partially developed prior to birth and require specific types of stimulation to further develop effective nerve pathways b. Oxytocin is a hormone that plays a role in attachment behaviors c. Bright light is considered to be an important environmental stimulus that regulates brain functioning d. Most neural circuits are hard wired and their functioning is largely dependent on genetic factors 4. The left PFC (pre-frontal cortex) plays an important role in a. Activating approach behaviors b. Understanding spoken words c. Regulating melatonin release and cooling the body d. Memory 5. Hard-wired memories appear to exist in this brain structure a. Hippocampus b. Amygdala c. Anterior cingulate d. Pre-frontal cortex 6. High, sustained levels of cortisol are associated with the following: a. Osteoporosis b. Heart disease c. Type 2 diabetes d. All of the above

7. Melatonin is primarily associated with which of the following a. Reducing body temperature at night b. Inducing sleep c. Dampening excitatory neurotransmitters such as norepinephrine d. Regulating night time cortisol levels 8. Which of the following is not directly associated with activation of the parasympathetic nervous system? a. Kegel exercise b. Diaphragmatic breathing c. 5-10 minutes of aerobic exercise d. Having a “good cry” 9. All of the following can be a cause of depression, except one: a. Osteoporosis b. Sleep apnea c. Restless legs d. Hypothyroid 10. Koyaanisqatsi is a Hopi word/concept that means a. Weariness of life b. Connectedness with nature c. Life out of balance d. Mindfulness approaches to continuing education