College Students and Prozac

What does it mean that there has been an explosion in the number of college students taking psychiatric medication? Does it mean that more students with mental illness are attending college? That people are more willing than in the past to seek treatment for anxiety and depression? That mental illness has been redefined? Or is it something else?

Katherine Sharpe -- a writer who discloses that she took antidepressants while attending college in the late 1990s -- makes a thoughtful attempt to answer these questions in the latest issue of the Chronicle of Higher Education. Facing increased stress, competition and pressure on campus, students feel the need to present themselves to others as being without flaws or weaknesses, writes Sharpe. Citing the research of Joseph Davis, a sociology professor at the University of Virginia, Sharpe says that students use medication to protect themselves from experiencing the emotions that they deem unacceptable -- emotions such as “discouragement and loneliness, nervousness and insecurity, jealousy and emotional vulnerability, shame and humiliation, shame and self-blame.” The desire to avoid such emotions diminishes, for these students, the appeal of traditional therapy, any form of which will require some exploration of the unpleasantness they feel. Medication, by contrast, can seem quicker and less painful.

What is going on, Sharpe writes, is a kind of “medicalization” of negative emotions -- a perception that if you experience these emotions, they must be connected to some kind of disorder. What can be lost is the opportunity to explore and reflect on normal negative emotions that may in fact have some significance and meaning. Overall, the emergence of effective psychiatric medications has enabled many students and non-students to thrive and few would argue with that. However, it is unfortunate if these medications also contribute to college students’ sense that they must achieve emotional perfection, and their mistaken belief that those around them have already achieved it. Much research shows that medication and psychotherapy can be more effective when used in tandem than either approach is when used by itself; it would be a shame if college students were to lose the added benefit of therapy because they want to avoid feelings of vulnerability.

Technology and Eating Disorders

Technology has changed our lives in ways that we don’t often think about. Remember when the only way to look something up was in a book? Or the only way to access the Internet was on a desktop computer? Now we have uninterrupted access to information that’s always easy to seek out -- even when it may not be good for us.

Information access, for example, is not always such a good thing when it comes to eating disorders. In a recent article at Thefix.com, a website covering addiction and recovery, a colleague, Diana Freed, discusses how technology can be detrimental to people with eating disorders. She describes working with a 24 year-old woman who constantly checks her iPhone -- a phone loaded with apps that count calories, record her weight, and track her body mass index and body fat. Though the patient severely restricts her own food intake, she has also downloaded onto her iPhone recipe apps that she can look at and think about. In other words, at the same time she is seeking treatment to help her alter her preoccupation with weight and food, technology makes it easier for her to constantly retrieve images and information fueling the very impulses she is seeking to change.

Freed’s article raises an array of technology-related issues that I need to consider in my work. It’s important to know how much time a patient is spending on the Internet or engaging in social media, and what he or she believes to be getting from those experiences. Does using a certain app make you feel worse about yourself? Or are there apps you can use in the service of recovery? These are just two of the questions about technology that I and other psychologists must now explore.

How to Change a Habit

Habits die hard. In The Power of Habit:Why We Do What We Do and How We Can Change It, Charles Duhigg tries to make it easier, by exploring how habits develop, how entrenched they can become, and how they can be changed.

From my perspective as a psychologist, the most interesting part of the book focuses on what Duhigg calls the habit loop. A habit loop consists of a cue, a routine, and a reward. Follow the loop a few times, and the habit becomes automatic and, well, a habit. Start smoking when you have your morning coffee, and pretty soon the coffee will cue you to crave the cigarette. The cigarette becomes the routine, and the nicotine, relaxation and distraction of the cigarette and coffee become the reward.

The key to changing the habit, says Duhigg, is identifying the cue, substituting another routine, and providing the same reward. One example he uses is how Alcoholics Anonymous can help people break the cycle of alcohol abuse. AA members are encouraged to explore the triggers, or cues, to which they have responded in the past by drinking. The hope is that, when faced with these cues again, they will instead develop the routine of going to a meeting or talking with a sponsor and enjoy the reward of companionship and support, rather than the reward they felt in the past from taking a drink.

Of course, real life is not as straightforward as the habit loops Duhigg describes. Motivations and rewards can be complicated. For example, the first part of the loop, identifying the cue, is not always immediately clear. When you walk into your apartment and immediately go to the refrigerator, what is the cue? Is it boredom, hunger, or a desire to escape from responsibilities? Next, you have to change the behavior -- perhaps going into another room first or finding a different escape. The last part to identify is the reward. Is it relaxation? Numbness? Without having a real understanding of what the payoff is for you, it will be difficult to find another behavior that can provide as reliable a reward.

Nevertheless, the model of the habit loop does provide an interesting way to look at behavior and can be helpful in devising ways to cue yourself in a positive direction. If you want to exercise, for example, you can put your gym clothes out the night before. At the very least you can use the concept of the habit loop to recognize habits you may not even be aware you have.

Yoga and Mood

There are many paths to managing moods, and one is through the body. Exercise has been shown in many studies to help with depression and anxiety. In his new book The Science of Yoga, William J. Broad takes a close look at one form of exercise, and finds it can have a dramatic effect on people’s mood.

Advanced yoga practitioners, says Broad, have a superior ability to control their autonomic nervous system, which controls bodily functions such as respiration rate, heart rate, digestion, and sexual arousal. Yoga has a particularly strong effect on the parasympathetic system, which enables us to slow down our body’s fight-or-flight response. In other words, certain poses, such as inversions, induce the heart into beating more slowly, which contributes to relaxation. Other research has shown that yoga can increase levels of the neurotransmitter GABA, which aids in relaxation and reducing anxiety.

Broad writes:

The portrait of yoga that emerges from decades of mood and metabolic studies is of a discipline that succeeds brilliantly at smoothing the ups and downs of emotional life. It uses relaxation, breathing, and postures to bring about an environment of inner bending and stretching. The actions echo, in a way, how yoga pushes the limbs into challenging new configurations. They promote inner flexibility.

Psychotherapy is one way to address anxiety or depression. But it is limited to time spent in the therapist’s office. Yoga is one of many helpful activities that people can pursue on their own and that increase one’s ability to manage emotions and control stress.

Mindful Eating

On the same day that The New York Times published a front-page story about the latest trends in multi-tasking (think multiple computer screens), the newspaper also ran an article about the benefits of something that is almost exactly the opposite of multi-tasking: mindful eating.

Based in Buddhism, mindful eating is the practice of attending closely to how the senses are engaged when one has a meal. When one mindfully eats, one is focusing on nothing but the food. There’s no reading the newspaper, no watching TV -- not even any conversation at the table.

Mindfulness offers a take on food different from the more common view of “good” and “bad” foods. Instead of avoiding a certain food because it’s “bad” to eat too much of it, you slow down the experience of eating the food. You savor it, think about it -- try to really taste it. Mindful eating is a surprisingly challenging thing to do, since we have so many distractions at mealtimes and we’re so used to using food itself to distract ourselves from what we’re feeling, both emotionally and physically. Mindful eating is widely used in treating people with eating disorders because so much of that disordered behavior is about consuming food, not tasting it.

Mindful eating is a difficult practice to master; even the experts quoted can’t do it all the time. But even thinking about the concept and trying it can help us. Compare the difference between really looking, smelling and tasting a piece of chocolate and then just popping it into your mouth without paying attention. It can be a completely different and more pleasurable experience when you taste the chocolatey taste and feel the melting texture of the chocolate. You may find that you feel satisfied with less, and enjoy what you have eaten more.

Athletes and Disordered Eating

Knowing when we have taken a healthy behavior too far can be hard to judge. In the March issue of Runner’s World, Caleb Daniloff writes about how his attention to nutrition, while training for his first marathon, drifted into bad eating habits. Believing that losing weight would help him train better and run faster, he ended up restricting his eating, drastically cutting calories, becoming preoccupied with his weight and body, and avoiding foods that he formerly ate with abandon. He caught himself before developing a full-fledged eating disorder, but the article describes several elite athletes who didn’t.

Disordered eating — that is, eating behavior that doesn’t meet the medical definition of an eating disorder, but can be injurious nonetheless — is widespread. Three-fourths of American women between 25 and 45 display some disordered eating, according to a study cited in Daniloff’s article.

How do you know whether your eating is disordered? The most common sign, according to Leslie Bonci, a nutritionist quoted in the story, is this: “Food choices become about what not to eat.”

The article includes some common food rules people adopt that can signal disordered eating. The magazine’s list of danger signs is directed at athletes, but it’s useful for everyone. Here’s a paraphrase:

1. Eating energy bars as meals rather than eating real foods.
2. Avoiding fat, or carbs, or a particular basic food group.
3. Rigidly scheduling mealtimes rather than eating according to feeling hungry.
4. Logging calories precisely.
5. Avoiding eating with others if it doesn’t fit with your food rules.
6. Skipping fuel on long runs.

When you’ve taken all the pleasure out of food for yourself — when food rules take precedence over friends and family, when it’s all about what you’re taking away from yourself, rather than what you’re giving to yourself — you’ve crossed over from moderation to disordered behavior. Athletes and non-athletes alike would benefit from shifting their focus from food as an obstacle to weight loss to food as a means of fueling and replenishing one’s body.

The Fat Trap

Just in time for New Year’s and New Year’s resolutions, Tara Parker-Pope has written a sobering article about weight and weight loss. In "The Fat Trap," published in the January 1 issue of The New York Times Magazine, she describes research on the difficulty of maintaining weight loss. Some key points: the body can go into “defense” mode to defend a higher weight, which is why lost weight can be so hard to maintain. In addition, weight loss is much more than simply a matter of willpower -- people lose and gain weight differently, based on body type, genetics and biology.

From the viewpoint of an individual wanting to lose weight, the article is discouraging, because it details how much work it takes to maintain significant weight loss (including daily exercise and careful monitoring of diet). The article, however, also strongly makes the case that being overweight or failing to lose weight is not a personal failing, but a result of a complex interplay of factors, some of which are beyond a person’s control. As Parker-Pope writes:

It is true that people who are overweight, including myself, get that way because they eat too many calories relative to what their bodies need. But a number of biological and genetic factors can play a role in determining exactly how much food is too much for any given individual. Clearly, weight loss is an intense struggle, one in which we are not fighting simply hunger or cravings for sweets, but our own bodies.

In my practice, I have found that many of my clients with weight-related issues.have harshly judged themselves for their inability to lose weight, or have been harshly judged by others. We are far too comfortable criticizing others’ weight or making value judgments about it. I hope this article contributes to more acceptance of different weights and sizes.