BEATING THE BLAHS Confidently Tackling Dysthymia in the Family Practice Office

1. BEATING THE BLAHSConfidently Tackling Dysthymia in the Family Practice Office Dr. Wendy Tink, CCFP, FCFP Clinical Assistant Professor University of Calgary Family Medicine Forum 2010 Family Medicine Forum Vancouver 2010

2. Conflict of Interest • None Family Medicine Forum Vancouver 2010

3. Goals • Increase skill and ease caring for low mood patients • Take away nimble tools for use in a busy office • Brief practice using tools today Family Medicine Forum Vancouver 2010

4. Is it Dysthymia? Family Medicine Forum Vancouver 2010 Dysthymia • Low mood • Most days • ≥ 2 years • Symptom free • ≤ 2 mo Depression • ↑↓appetite • ↓↑ sleep • ↓↑energy • ↑ fatigue • ↓ concentration / memory

5. Dysthymia Experience Thoughts Physical Symptoms Mood Behaviours Family Medicine Forum Vancouver 2010

6. Reasons for Low Mood Family Medicine Forum Vancouver 2010

7. Thoughts: Negative Thinking Generally low mood people focus on themselves or others in an unhealthy way Family Medicine Forum Vancouver 2010

8. Thoughts: Negative Thinking • I have worth because of what I do (performance) • I have worth because of what I have (attribute) • I have worth because you think I do (other based self esteem) Family Medicine Forum Vancouver 2010

9. Thoughts: Happiness Thinking The ability to hold oneself in warm positive regard in spite of imperfections • I am enough and I matter • I have worth, no better or worse than others • Worth is a given; it need not be earned • Worth comes from within Family Medicine Forum Vancouver 2010

10. Problematic Beliefs Often Formed In Early Years Family Medicine Forum Vancouver 2010

11. Recognizing Problem Beliefs Watch for shame or grandiosity • Shame • Feeling inherently less than • Feeling unlovable • Disempowerment in childhood • Women more often Family Medicine Forum Vancouver 2010

12. Recognizing Problem Beliefs Watch for shame or grandiosity • Grandiosity • Feeling better than others • Putting self in one up position • Putting others down, anger • Men more often Family Medicine Forum Vancouver 2010

13. Recognizing Problem Beliefs Watch for anger- usually fear wearing the mask of aggression (Baker 2003) • Anger reactions • Usually learned from past failures • Usually the result of feeling victimized in some way Family Medicine Forum Vancouver 2010

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15. Recognizing Problem Beliefs Watch for VERBs(Baker, 2003) • I’m a Victim • I’m Entitled to more • I’ll be Rescued • Someone else is to Blame • Enemies of happiness • Destroy personal power Family Medicine Forum Vancouver 2010

16. Beliefs: Everyone’s Bill of RightsPATIENT HANDOUT • to act in ways that promote your dignity and self-respect • to be treated with respect • to say “no” and not feel guilty • to feel and express your feelings • to take time to slow down and think • to change your mind • to ask for what you want • to do less than you are humanly capable of doing • to ask for information • to make mistakes, and learn lessons • to feel good about yourself • to be listened to and taken seriously Family Medicine Forum Vancouver 2010

17. to set your own priorities • to get what you pay for • to choose not to respond • not to know everything • to share responsibilities • to take a risk and to change our pattern of behaving even if it causes “ripples” • to enjoy your own bodies • to our own sexuality

18. Beliefs: Happiness Thinking The ability to hold oneself in warm positive regard in spite of imperfections • I am enough and I matter • I have worth, no better or worse than others • Worth is a given; it need not be earned • Worth comes from within Family Medicine Forum Vancouver 2010

19. Feelings: Are they problematic? Watch for guilt* most powerful and distressing emotion Good guilt- wrongdoing behavior change to feel better about YOURSELF Bad Guilt- identify emotional distress change YOUR behavior to make OTHERS feel better root cause of anxiety, depression, relationship issues Family Medicine Forum Vancouver 2010

20. Happiness ToolPATIENT HANDOUT • CHOICE • step vs stuck • APPRECIATION • express appreciation vs search for appreciation • good feelingjournal • LEAD WITH STRENGTHS • rather than the opposite • MULTIDIMENSIONAL LIVING • relationships, health, and purpose-why are we here? • PERSONAL POWER • we control thoughts, actions, interpretations vs others Family Medicine Forum Vancouver 2010

21. Thought Tools PATIENT/PHYSICIAN Challenge Worry Tool Write/identify all your worries. ASK: What is the most problematic? Ask: What is the likelihood that will happen? Ask: What would you do if that happened? Ask: What would other people do if that happened? Ask: Where is the evidence? Is it always true? Is this reasonable? Ask: Would you teach others to think this way? Family Medicine Forum Vancouver 2010

22. Thought Tools Thought Record Tool • Identify a situation that upset you. • Ask: What was your automatic interpretation? • Ask: How did it make you feel? • Ask: Could that event be interpreted differently? • Ask: How could the new interpretation make you feel?

23. Patient scenario: challenge thoughts and beliefs • I have to go to the in-laws for Christmas. • No one ever has a good time. • Ned’s mother would be devastated if she didn’t see the grandkids. • We never get to see my family at Christmas”. Beliefs? Thoughts? Actions? Family Medicine Forum Vancouver 2010

24. I am so nice to everyone around me. • I try to make them happy. • No one appreciates me at all. • I hate going to work. • Why can’t they be as nice to me as I am to them? Beliefs? Thoughts? Actions?

25. Take Action to reduce Dysthymia People feeling low tend not to be active decision makers Family Medicine Forum Vancouver 2010

26. Take Action to reduce Dysthymia • Exercise, meditation, relaxation, sleep, healthy eating, etoh, social contact • Master the art of attainable goal setting* • Ultimate Goal • Target Date Family Medicine Forum Vancouver 2010

27. Set and Attain Goals to reduce Dysthymia • To reach the goal I will do these three (or more) things • I will know I have reached my goal because • Two things that will help me stick to reaching my goal Family Medicine Forum Vancouver 2010

28. Take Action to reduce dysthymia • Master the skill of turning problems into plans* • List and prioritize problems • Break problems and goals into bits Family Medicine Forum Vancouver 2010

29. Take responsibility for yourself Assertiveness Standing up for your own rights without violating the rights of others Family Medicine Forum Vancouver 2010

30. Taking ResponsibilityPatient Handout: Assertiveness Family Medicine Forum Vancouver 2010

31. Taking ResponsibilityPatient Handout: Saying No • Acknowledge, repeat request, consider if reasonable • Take time to think it over • Explain reason to decline • Say NO • ? Possible alternate solution Family Medicine Forum Vancouver 2010

32. TAKING RESPONSIBILITYAssertiveness Disarming Anger • I see you are angry (acknowledge) • I do want to help solve the problem • I may have made a mistake Family Medicine Forum Vancouver 2010

33. Patientscenario: take action, DESC script, disarm anger • I just hate it when Suzy comes in from school. She is in such a bad mood. • We just disappear while she raids the fridge and stomps around. • To make matters worse she leaves the kitchen in a mess. • I am afraid to say anything to her. Action? Ask for what you want? Assertiveness? Disarm?

34. Positive Trusting Relationships • Critical for good mental health • Avoids social isolation that invites dysthymia • Tools required* Family Medicine Forum Vancouver 2010

35. Positive Trusting Relationships • Let go of negativity, grudges • Learn to forgive, lower expectations • Learn to express feelings • Accept personality differences Family Medicine Forum Vancouver 2010

36. Positive Trusting Relationships • Be clear and assertive what you need from others what is and is not acceptable • Increase communication skills* Family Medicine Forum Vancouver 2010

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38. Relationship sabotage (Burns, 1999) Believing only you hold the truth Blame/scapegoating/putdown Martyrdom - one innocent victim Hopelessless Entitlement – feel entitled to better treatment/refuse to directly ask for what is desired Denial – deny feelings of anger, hurt or sadness when present Passive Aggression - pout, withdraw or say nothing. Sarcasm - words/tone convey hostility which you don't acknowledge Helping - try to solve the problem rather than just listening Counterattack - respond to criticism by criticizing back Diversion - list grievances about past injustices rather than dealing with the here and now.

39. Tools for Effective Communication Self Expression Skills • I “feel” statements • Stroking– find something genuinely positive to say to the other person Family Medicine Forum Vancouver 2010

40. Tools for Effective Communication Listening Skills • Disarming technique – • find some truth in what the other person is saying • Empathy – • put yourself in the other person’s shoes (thoughts and feelings) • Inquiry – • ask gentle, probing questions to learn more Family Medicine Forum Vancouver 2010

41. Beating the Blahs: Summary • Everyone has equal worth and rights • Beware false beliefs • Perfection, please others, control • Beware learned helplessness (VERBs) • Learn assertiveness skills • DESC script, Saying NO, Disarm anger • Take Action • Practice what happy people know • Appreciation • Strengthen relationships • Communication, state your needs, watch for guilt, find meaning and purpose Family Medicine Forum Vancouver 2010

42. BEATING THE BLAHSConfidently Tackling Dysthymia in the Family Practice Office Dr. Wendy Tink, CCFP, FCFP Clinical Assistant Professor University of Calgary tink@ucalgary.ca Family Medicine Forum Vancouver 2010