I’ve been lonely
I’ve been waiting for you
I’m pretending and that’s all I can do
The love I’m sending
Ain’t making it through to your heart
You’ve been hiding, never letting it show
Always trying to keep it under control
You got it down and you’re well
On the way to the top
But there’s something that you forgot

What about love
Don’t you want someone to care about you
What about love
Don’t let it slip away
What about love
I only want to share it with you
You might need it someday

I can’t tell you what you’re feeling inside
I can’t sell you what you don’t want to buy
Something’s missing and you got to
Look back on your life
You know something here just ain’t right

What about love
Don’t you want someone to care about you
What about love
Don’t let it slip away
What about love
I only want to share it with you
What about love
Don’t you want someone to care about you
What about love
Don’t let it slip away
What about love
I only want to share it with you

In listening to lead singer Ann Wilson belt out these lyrics from the rock band Heart’s famous song, “What About Love,” I was mindful of how music can capture the emotions we all feel when we are in love. Ann’s rendition of these lyrics poignantly expresses the challenges of establishing and maintaining intimacy. What makes it difficult to establish and maintain long-lasting feelings of love? What are the trials we go through that challenge our ability to sustain love over the course of a lifetime?

Our capacity for intimacy begins in childhood, as we establish the initial emotional bonds with our mother and father. Typically these are our first experiences with another human being, and they have a profound influence on our emotional development, and later capacities to form intimate relationships. For some, these child-parent bonds may be rock solid, trustworthy and secure; in which case our capacity for intimacy will be well developed and stable. For others, during the course of our childhood years our parents may be unavailable, inconsistent and self-absorbed, emotionally volatile, and/or physically or sexually abusive; and in these instances our capacity for later-life intimacy will be damaged. These emotional wounds may be expressed in a number of ways, as our yearnings for a stable love relationship encounter our fears of commitment, feelings of mistrust, and narcissistic injuries that form the residue of the damaging parental relations of childhood. “What About Love” captures the lingering effects of this trauma beautifully, as Ann sings:

I can’t tell you what you’re feeling inside
I can’t sell you what you don’t want to buy
Something’s missing and you got to
Look back on your life
You know something here just ain’t right

As we move into adulthood, love relationships that don’t work out may further wound the human heart. A series of disappointing love affairs, the breakup of a long-term committed relationship, or marital separation and divorce may leave lasting emotional traumas that play out to damage or destroy the possibility of later intimate relations. At times the breakups are the result of making poor choices, for example repeatedly engaging in relationships with people suffering from Narcissistic Personality Disorder. At other times we might select someone capable of providing us adult love, empathy and compassion, yet our own conflicts over intimacy may contribute to or cause a breakup.

As a result of these negative childhood, adolescent or adult experiences a “repetition compulsion” may develop, where one unconsciously repeats earlier traumas through patterns of self-sabotaging behavior carried out in existing or new relationships, time and time again. These unconscious behaviors may interfere with or destroy intimate bonds. Feelings of love and tenderness may develop toward one another, but difficulties in trusting and expressing these emotions directly, out of fear of further hurt, loss, or a lack of reciprocal feelings from one’s loved one, complicate the relationship. The number one hit song by Heart, entitled “Alone” poignantly captures aspects of these conflicts:

I hear the ticking of the clock
I’m lying here the room’s pitch dark
I wonder where you are tonight
No answer on the telephone
And the night goes by so very slow
Oh I hope that it won’t end though
Alone

Till now I always got by on my own

I never really cared until I met you
And now it chills me to the bone
How do I get you alone
How do I get you alone

You don’t know how long I have wanted
to touch your lips and hold you tight
You don’t know how long I have waited
and I was going to tell you tonight
But the secret is still my own
and my love for you is still unknown
Alone

Till now I always got by on my own
I never really cared until I met you
And now it chills me to the bone

How do I get you alone
How do I get you alone
How do I get you alone
How do I get you alone
Alone, alone

In these lyrics the singer describes someone who is deeply in love, who has previously tried to get by on their own without depending on another, and now she or he finds themself alone and feeling somewhat desperate. Perhaps it is because they have not expressed their tender feelings to the one they love, or their loved one is afraid to spend intimate time alone with just the two of them because it feels too close and threatening. Fears of further hurt, rejection, a lack of reciprocal feelings of love, dependency and vulnerability can all play a part in interfering with intimacy.

Examples of self-sabotaging repetition compulsions include the young adult woman who acts out sexually with a series of young (or older) men, in a futile attempt to find emotional intimacy, love and affection. Or the young man who engages in a series of meaningless hookups to prove his prowess, and gain narcissistic gratification, because of underlying self-esteem problems that began as a child, perhaps resulting from repeated disappointments in his relationship with his mother or father where he felt powerless. Some of these young adult relationship themes are captured in the song by Pat Benatar entitled, “Love is a Battlefield”

We are young, heartache to heartache we stand
No promises, no demands
Love Is A Battlefield
We are strong, no one can tell us we’re wrong
Searchin’ our hearts for so long, both of us knowing
Love Is A Battlefield

You’re beggin’ me to go, you’re makin’ me stay
Why do you hurt me so bad?
It would help me to know
Do I stand in your way, or am I the best thing you’ve had?
Believe me, believe me, I can’t tell you why
But I’m trapped by your love, and I’m chained to your side

We are young, heartache to heartache we stand
No promises, no demands
Love Is A Battlefield

We are strong, no one can tell us we’re wrong
Searchin’ our hearts for so long, both of us knowing
Love Is A Battlefield

We’re losing control
Will you turn me away or touch me deep inside?
And before this gets old, will it still feel the same?
There’s no way this will die
But if we get much closer, I could lose control
And if your heart surrenders, you’ll need me to hold

We are young, heartache to heartache we stand
No promises, no demands
Love Is A Battlefield

We are strong, no one can tell us we’re wrong
Searchin’ our hearts for so long, both of us knowing
Love Is A Battlefield

We are young, heartache to heartache we stand
No promises, no demands
Love Is A Battlefield

We are strong, no one can tell us we’re wrong
Searchin’ our hearts for so long, both of us knowing
Love Is A Battlefield

Another example is when one repeatedly and unconsciously picks a fight following intense closeness and feelings of happiness (for example, following highly passionate sex), as a way of creating emotional distance because of feeling vulnerable, a loss of control, and the fear of dependency that is engendered by intimacy. And not uncommon is the adult who has lived through a painful divorce, who dreads what he or she believes may become another conflict-ridden relationship. Consciously or unconsciously they avoid falling in love again, or sabotage the development of intimacy in a new love relationship, because of the unresolved emotional trauma resulting from the prior marital separation and divorce.

And then there are the life stage crises that test the bonds of love and marital fidelity. Our life cycle brings different challenges to the human heart at each phase. These trials may include: a fear of commitment during courtship and early marriage; the demands of child rearing that make intimate moments difficult to establish, with longings to return to a simpler time with fewer responsibilities and more romance and freedom; conflicts over how to raise children; a mid-life crisis where one may have intense doubts about choices they have made, or feel highly dissatisfied with their level of professional or financial accomplishment; periods of financial distress; the death of one’s parents; and the realization of one’s own mortality, and the issues surrounding growing old and dying (such as a loss of power, chronic health problems, and major life regrets).

Sometimes a couple may grow apart as they evolve in different directions, or one member may outgrow the other emotionally or intellectually. This can place significant strains on the relationship, as compellingly characterized in the movie, “The Blue Valentine.”

The human heart is complicated, isn’t it?

Psychotherapy can be very helpful in uncovering the unconscious causes of repetitive failed relationships, and the difficulties in establishing or maintaining intimacy. The therapist engages the patient in a caring and trusting relationship, encourages the patient to free associate about their thoughts, feelings, fantasies and memories related to the current and earlier love relationships, and over time the unconscious conflicts emerge. Both the therapist and the patient need to commit to a longer-term therapy to work through the emerging issues that interfere with intimacy. This takes courage. At times it involves emotionally painful sessions, as the patient intensely relives earlier traumatic relations in what is called “abreaction.”  The therapeutic process uncovers prior experiences of conflicted relationships that damaged feelings of closeness and intimacy, and the development of trust. The patient grieves the loss of what had been yearned for yet remained unfulfilled, and reaches an understanding that puts into perspective the reasons for the earlier disappointments and heartbreaks. This process enables one to let go of the traumatic experiences, bringing with it a freedom to experience healthier adult love. It is very gratifying for the therapist to see the patient emerge from this process happily engaged in a more mature love, with their heart finally released from the emotional bonds created by the past traumas. What is learned in therapy will hopefully be applied time and again over the course of one’s lifetime; because intimacy, once achieved, is fragile.

“Knowing yourself is the beginning of all wisdom.” This quote from Aristotle is the cornerstone of all insight-oriented psychotherapies. I genuinely admire those who engage in psychotherapy and commit to seeing it through – thereby bringing about personal emotional growth and a more satisfying life. Patients enter therapy for a variety of reasons. Perhaps they want to end a pattern of self-sabotaging behavior; where they may deny themselves the experience of true intimacy with another, behave in ways that preclude the possibility of joyful living, repeatedly choose narcissistic personalities with whom they fall in love, or find other ways to unconsciously live out what is known as “the repetition compulsion.” There may also be recurring symptoms of anxiety or depression for which they seek understanding and symptom relief. A life crisis around the end of a love relationship, the illness or death of a loved one, or severe job stress may lead one to seek therapy on an urgent basis, seeking immediate relief.

What is necessary in making this commitment to therapy, in sitting with a psychotherapist and examining one’s life? At its core, the psychotherapeutic relationship requires shared courage on the part of the patient and the therapist. At the beginning of psychotherapy, and from time-to-time throughout its course, the experience can feel quite scary for the patient. Coming to terms with certain realities heretofore avoided is emotionally challenging, and may feel daunting and overwhelming. At times extremely painful feelings, embarrassing or shameful fantasies, and troubling memories will arise during the course of therapy, all demanding the courage to confront, explore, understand, and resolve them.

Then there is the phenomenon known as “resistance” that develops during the course of psychotherapy. Resistance is based in defense mechanisms that protect the conscious mind from experiencing emotionally threatening unconscious memories, fantasies and feelings. Sometimes resistance is experienced as an urge to run – to avoid facing these issues – as it is human nature to seek pleasure and avoid pain. Internal conflicts also arise over feelings of dependency toward the therapist, in opposition to feelings of wanting to remain independent and self-sufficient. This is often manifested by the belief that seeking treatment is “a sign of weakness” and that “I should be able to manage my problems without the help of a therapist.” To the contrary, when one commits to the therapeutic process and sees it through to conclusion, it is a sign of admirable strength of character.

Two novel perspectives on therapy were recently shared with me. A young patient of mine – a tough, charismatic, and highly talented college football player – put it like this, “You have to man up, and face yourself in therapy.” Another patient, a middle-aged professional woman from the financial services industry, described therapy as a place where “You are not a side effect of your life, you are an active participant in your own well-being.”

Patients will commonly develop unconscious and conscious feelings and fantasies toward the therapist, called “transference,” that must be openly discussed in the session, no matter how embarrassing it might feel. The patient “transfers” onto the therapist feelings and fantasies they had toward important figures from their earlier life, such as their parents. These may include longings to be loved, fearfulness, erotic fantasies, yearnings to be taken care of, and so on. If the transference feelings are not candidly revealed, the therapy will grind to a halt. An open and honest discussion will pave the way toward uncovering important unresolved issues with one’s mother or father that, once resolved, enable one to move on with his or her life and love relationships in a healthier fashion.

The therapist in turn will develop a “countertransference” toward the patient. Countertransference occurs when the patient elicits conscious or unconscious feelings, fantasies and memories in the therapist based upon how the therapist was raised by his or her parents, and from other important relationships. It is important that the therapist have engaged in his or her own personal psychotherapy or psychoanalysis, to be able to identify and analyze their countertransference reactions (particularly the unconscious ones), so as to not act them out on the patient, or contaminate the therapy through imposing their own personal neurotic agenda. Among the most challenging and beneficial experiences in my own life were the years I spent on the psychoanalysts’ couches – first as a psychoanalytic institute trainee – and later following the death of my father – both of which helped to forge my identity as a psychiatrist. A personal psychoanalysis enables the psychiatrist or psychotherapist to more effectively empathize with, support, and emotionally “hold” their patient while being mindful of the potential interference from one’s own childhood relationships.

An important element in longer-term psychoanalytic or psychodynamic therapy is analyzing the unconscious causes of self-sabotaging behaviors that often originate in childhood relationships. In the course of therapy, as the patient grows increasingly familiar with the technique of “free association”, he or she will speak whatever comes into their mind, without holding back or censoring their thoughts, fantasies or feelings. As free association proceeds, the patient may re-experience prior events in his or her life with great emotional force, at times so powerful that they literally believe that they are actually living through the experience at that moment. This is called abreaction. As a result of the abreactive experiences, and the caring and empathy provided by the therapist, the traumatic event may be recast in a new cognitive framework, and be viewed without distortion through adult eyes, enabling the patient to finally let go of the trauma and leave it behind.

The foundational elements of a successful therapy include tenacity, the development of trust, feeling understood and cared about, feeling emotionally “held” through difficult and painful moments, mutual respect, a high level of technical skill on the part of the therapist, and a shared optimism regarding the outcome. The therapist must also embody a deeply held belief in the human spirit’s capacity for growth and change. Ultimately it takes heart, and a strong belief in the patient’s (and one’s own) courage, to forge ahead into the unknown.

The brain is the organ of the mind. Our ability to think, feel, and experience life is dependent upon neurobiological processes governed by the interaction between our genes and various types of psychological, environmental, and physiologic influences and stressors. New research in the field of “epigenetics” offers compelling support for the combination of psychotherapy, nutrition, and medication management in the treatment of patients suffering from anxiety, depression, or bipolar disorder. Epigenetics means “over or above genetics,” and refers to how both the external environment and internal physiologic environment can interact with the DNA within the nucleus of each cell in the body, to alter how these cells function. In psychiatry, this field brings us knowledge regarding the epigenetic influences on brain cell function in patients suffering from mood disorders and anxiety. This knowledge carries profound implications for how we live our lives.

In mood and anxiety disorders, there is no “depression gene” or “anxiety gene.” One inherits a susceptibility to these conditions through multiple different genes, but the genes alone do not cause the illnesses. The genetic material within the nucleus of brain cells must first be influenced by epigenetic factors that come from outside the brain, such as external environmental or internal physiologic factors. Certain types of interpersonal stress with loved ones, or colleagues at work; inflammation, such as that caused by fat cells; and alcohol or drugs of abuse; can interact with these susceptibility genes to cause major depression or bipolar disorder; or cause anxiety disorders such as generalized anxiety, obsessive compulsive disorder (OCD), or panic disorder.

Two types of interpersonal stress can contribute to triggering psychiatric disorders. The first is called “learned helplessness,” defined as “a behavioral state of a person who believes that he or she is ineffectual, his or her responses are futile, and control over the environment has been lost.” The second is termed “social defeat stress,” and is defined as “relationships characterized by aggression, bullying, chronic subordination and humiliation.” Research has demonstrated that both learned helplessness and social defeat stress are epigenetic factors associated with psychiatric disorders.

Drugs of abuse such as cocaine trigger epigenetic changes in certain brain regions, affecting hundreds of genes at a time. Some of these changes remain long after cocaine has been cleared from the body. Research suggests that some of the long-term effects of drug abuse and addiction (including high rates of relapse) may be written into the epigenetic code (again, the interaction between the environment and the genes). Cocaine not only alters the epigenetic status of genes but also induces specific epigenetic modifications depending on how often the drug is used. Certain genes are switched on by infrequent administration, while others are switched on only after chronic administration (such as in addiction). Some are switched on by both This may relate to cocaine’s ability to “kindle” mood disorders Alcohol abuse has also been associated with epigenetic changes to the chromatin of the DNA in brain cells, predisposing to anxiety symptoms. And at a recent Society for Neuroscience meeting, marijuana use in teens was associated with cognitive deficits, reduced executive functioning (attention, focus and decision making), and changes in brain function in the frontal cortex. Whether marijuana asserts its effects through epigenetic mechanisms is the subject of ongoing research.

Obesity and nutritional aspects of a person’s lifestyle can also have profound effects on mood regulation and the onset of depression. We now know that fat cells release cytokine and C-reactive proteins. These proteins are known to cause inflammation throughout the body, and are associated with psychiatric disorders in the brain. They lead to alterations in neurotransmitter levels, neuroendocrine systems, and how brain synapses function. This leads us to conclude that obesity is also a type of stressor that contributes directly to altered brain function associated with mood disorders – more specifically depression.

How do these multiple internal and external influences interact with the genetic material within our brain cells to initiate the onset of an emotional disorder? In the brain, an important function of the DNA that makes up our genes and chromosomes is to code messenger RNA, which in turn codes so-called neuroprotective proteins. These protective proteins, for example BDNF (Brain Derived Neurotrophic Factor), support and protect normal brain cell structure and function, and enhance memory, learning, higher order thinking, and neurogenesis – the growth of new brain cells which occurs throughout the lifespan.

Below is a picture of how depression and anxiety are triggered by the interaction between various types of stressors and the DNA found in every brain cell. As depicted from left to right, multiple different genes predispose the patient to developing depression or anxiety, as they are exposed to one or more of the stressors cited above. The genes are necessary but not sufficient to cause the illness by themselves. In response to the stressors, the genes are suppressed in their ability to manufacture the neuroprotective proteins such as BDNF; and Bcl-2, which prevents brain cell death. As the levels of these protective proteins drop, the brain cells begin to function abnormally; and the energy centers of the cells, the mitochondria, begin to malfunction as well. This in turn affects the function and structure of the brain cells that form information processing circuits, which then results in the changes in mood, behavior and thinking we see in those who suffer from depression, bipolar disorder, and anxiety.

Neurogenesis is also critically important in the recovery from mood disorders, and can be positively affected by exercise, antidepressant medication, and through psychotherapy. Psychotherapy enables the patient to overcome the causes of learned helplessness and socially induced defeat-stress, characterized by repeated experiences of being overpowered and feeling helpless and trapped, whether in relationships at home or at work. Therapy empowers patients and enables them to leave behind destructive relationships from the past which have been internalized (for example damaging childhood experiences with a parent); and to modify or end current relationships that are characterized by repeated emotional battering. These emotionally damaging relationships may originate in one’s immediate or extended family, or in the workplace. In learning how to better manage or separate oneself from these types of stressful internal and external relationships, it can lead to increased resilience, new and richer social experiences, and result in neurogenesis.

Healthy nutrition can also play a key role in the recovery from a major mood or anxiety disorder. Reducing one’s body fat percentage to reasonable levels, for example 21% to 24% for women, and 13% to 17% for men, will reduce the release of the inflammatory proteins from fat cells. This not only has a salutary effect on brain cell function, but also reduces the likelihood of developing Type 2 Diabetes, coronary artery disease, hypertension, and stroke. Diets rich in lean protein, such as chicken, fish, egg whites, turkey, and whey protein shakes blended with fresh or frozen fruit; and filled with low glycemic index carbohydrates, such as fresh fruits and vegetables; with the use of olive oil (and not other vegetable oils or butter); combined with aerobic exercise three to four times per week; can assist in achieving these important goals of reducing body fat percentages. A sustainable program with proven success in accomplishing these objectives is The Joe Dillon Difference. Joe Dillon has coached many business executives, professionals and their families, in addition to 22 Olympic medalists who have won 60 medals, in a lifestyle for busy people with demanding schedules, that provides for increased energy, improved mood, and less anxiety and stress. I met with Joe along with other professional and executive colleagues of mine. Many of us have adopted his lifestyle recommendations, achieved positive results, and hold him in high regard.

Through the use of therapeutic interventions such as psychotherapy, healthy nutrition and aerobic exercise that reduce body fat percentage, and antidepressant medication, the destructive epigenetic processes may be reversed. As demonstrated in the picture below, these healing influences can activate so-called DNA “promoters” that enable the brain cell to code the RNA responsible for the production of neuroprotective proteins, resulting in increasing levels of these proteins. This restores normal cellular and mitochondrial energy functions, which in turn improve the information processing capabilities in multiple interacting circuits of the brain. This results in the normalization of emotional, cognitive and behavioral functioning.

These events are illustrated in the picture below. On the left hand side, the DNA is “promoted” to produce increased levels of BDNF. On the right hand side from top to bottom, in response to increased BDNF, the dendrites of the brain cells then regrow their branches, and the axons of the brain cells become re-enriched with dense packets of neurotransmitters. This restores and enhances healthy emotional functioning.

In viewing this process of regeneration, one can imagine that the implementation of psychotherapy, proper nutrition, and antidepressant medication is akin to the arrival of Spring, when tree limbs (and the human spirit) blossom, and experience a rebirth!

It seems like almost every other week that we are introduced to a new antidepressant medication through an ad on TV. For patients suffering from depression and their worried family members, they may wonder, “Why are there so many antidepressants on the market? What are the differences in how they treat depression? How do they work? How do I know if my antidepressant treatment should be modified, or changed altogether?”

It is important to note that depression is a major health problem worldwide. The World Health Organization (WHO) predicts that by 2020 depression will be the second largest cause of the global health burden – and major depression is already the central nervous system (CNS) disorder with the highest prevalence. There are about 40 million diagnosed cases in the United States, France, Germany, Italy, Spain, United Kingdom, and Japan. The lifetime prevalence of major depression across the population ranges from 3% in Japan, to 17% in the United States, to 30% of men and 40% of women in the Netherlands and Australia.

In 2008, global sales of antidepressants totaled $20 Billion. In the United States, the use of antidepressants doubled over one decade, from 1996 to 2005. Antidepressant drugs were prescribed to 13 million people in 1996 and increased in number to 27 million by 2005. In 2008, more than 164 million prescriptions for antidepressants were written in the U.S. alone. It is fair to say that there is an epidemic of depression in the civilized world, and fortunately our understanding of how to treat depression has become increasingly sophisticated, through advances in molecular biology and neurophysiology that tell us how brain cells function in their normal state and in a depressed state, leading to more effective and targeted therapies.

Given the prevalence of depression throughout the world, and the deep and pervasive emotional pain it causes to patients and their loved ones, it is not surprising that the pharmaceutical industry would endow physicians with an extensive armamentarium of medications to treat major depressive disorder. As a result there are multiple drugs within each of several different classes of antidepressants, that boost levels of certain neurotransmitters such as serotonin, dopamine, or nor-epinephrine in the mood-regulating regions of the brain. Mood regulating brain cells are organized into circuits, within which the cells interact with one another using electrochemical mechanisms. The mechanism by which they interact, and how antidepressant medications work to enhance these interactions is simple, yet elegant, as illustrated in the picture below:

When the first brain cell (the presynaptic neuron) “fires,” it releases neurotransmitters into the synaptic cleft. Some of these transmitters then travel across the synapse and bind onto receptors of the next brain cell (the postsynaptic neuron), which can then cause that cell to fire (as illustrated in pathway #1 in the picture above). Other transmitters do not make the journey safely across the synapse, because they are reabsorbed back into the first cell (called “reuptake”) or are degraded by enzymes such as COMT and MAO (as illustrated in pathway #3 above). If the neurotransmitter levels are low in depression, it makes sense to block the reuptake, or block the enzymes that degrade them, to increase their numbers in the synapse, thereby increasing the likelihood that they will bind to the next brain cell

The most popularly prescribed antidepressants are the “SSRI” or “SRI” group, standing for serotonin-specific reuptake inhibitors. Examples are Prozac (Fluoxetine), Zoloft (Sertraline), Paxil (Paroxetine), Celexa (Citalopram), and Lexapro (Escitalopram). A different antidepressant, Wellbutrin (Bupropion), inhibits the reuptake of dopamine. Another class of antidepressants works to boost both serotonin and nor-epinephrine. These “SNRI,” serotonin/nor-epinephrine reuptake inhibitors include medications such as Cymbalta (Duloxetine), Effexor (Venlafaxine), and Remeron (Mirtazepine). Still another class is called the “MAOI” or monamine oxidase inhibitor antidepressants such as Parnate (Tranylcypromine) or Nardil (Phenelzine). These work by blocking the enzyme MAO (monoamine oxidase) that breaks down the neurotransmitters, but these are not widely used because they interact with many foods and drugs.

Successfully treating the symptoms of depression with an antidepressant is both an art and a science, and the choice of antidepressant can depend upon a variety of factors. Family history of response to a particular medication among genetically-related family members can be a helpful predictor, as can the presence of certain symptoms to target, which are known to respond to increases in one or more of the neurotransmitters noted above. For example, panic attacks may respond to SRIs or SNRIs and be worsened by Wellbutrin. Social anxiety and obsessive–compulsive disorder symptoms may respond to SRIs and also be worsened by Wellbutrin. ADHD symptoms may respond to the dopamine increase provided by Wellbutrin, but not to SRIs. In patients with depression, social anxiety, and ADHD, an SNRI may be helpful by boosting both serotonin and norepinephrine to address their broad spectrum of symptoms.

Not uncommonly, the patient’s depressive symptoms will only partially respond to the first medication selected, or they may not respond at all. In the event of a partial response, and where there are no troubling side effects, the medication is not switched but is “augmented” to make it more effective. Adding one or more “augmenters” to the antidepressant is analogous to adding a turbocharger to a car engine – they both provide a boost – they add power. Antidepressant augmenters include Folic Acid (a B vitamin), Omega 3 fish oil, thyroid hormone, testosterone, lithium, a second antidepressant from a different class (e.g. adding Wellbutrin to an SRI), an atypical antipsychotic medication (e.g. Abilify), and N-Acetylcysteine. The use of each of these augmenters may have a different rationale – for example Abilify may be used in the depressed patient struggling with many negative thoughts or mood instability – while Wellbutrin could be used to boost the energy level of a patient who has partially responded to an SRI, but continues to suffer from a lack of motivation and drive. In the more treatment-resistant patient, multiple augmenters may be used.

If there is no response whatsoever to the initial antidepressant, and it was given an “adequate trial” (defined as six weeks duration of treatment, at the maximum dose of the medication compatible with not causing side effects), then a different class of medication should be considered. Sometimes medications will be combined to boost all three neurotransmitters – for example using both Cymbalta and Wellbutrin – in certain patients with a treatment resistant depression that is not responding to the methods described above.

Our knowledge of antidepressant treatment continues to advance. Having been trained in “The Golden Age of Psychiatry”, I have been inspired by the evolution of pharmacologic treatment of depression over the past several decades – from the unsophisticated early days which offered limited choices of medications that caused dry mouth, constipation, lightheadedness, and other unpleasant side effects – to our present-day level of advanced knowledge with the ability to choose among many “clean” drugs that are tolerated so well that most patients forget that they are taking them. While researchers in some circles doubt the effectiveness of antidepressant medications, my experience over the years is that the efficacy of antidepressants is unequivocal. Responses to these medications range from enhanced self esteem and improved quality of life for those patients who are mildly to moderately depressed, to restoring basic daily functionality and providing lifesaving benefits for those who are moderately to severely depressed.

Used alone, or in combination with psychotherapy, antidepressants are life-altering; and offer the hope to millions of patients and their loved ones that they can climb out of that deep dark hole into daylight, and even into radiant sunshine.

A stable, positive feeling about oneself is to be cherished. For many people it is hard to come by, at least for extended periods of time. Some patients report that they may feel good about themselves from time-to-time, yet they can be plunged into the depths of despair and emotional vulnerability seemingly without cause and with no warning. These episodes may be mild and short-lived, lasting a few hours to a day or two; or they may be more severe and incapacitating, and last for several weeks to a number of months. Others report that as far back as they can remember they have lacked positive self-esteem, and have been unable to experience joy. Still others report that their feelings about themselves are quite unstable, ranging from times where they feel inadequate, helpless, hopeless and have difficulty getting out of bed and functioning; to other times where they are filled with great energy, sleep very little, are immensely productive, and may come across as abrasive or aggressive to loved ones and colleagues.

Self esteem regulation is a central problem for all patients with mood disorders, and difficulties with self-esteem can have neurobiological, psychological, social, and existential origins. Let’s explore each of these potential causes under the BioPsychoSocial Model of emotional illness.

Beginning with the biology of mood disorders, normally the DNA in a brain cell codes messenger RNA that then codes what are called “neuroprotective proteins,” that protect the normal structure and function of the brain cells from the negative effects of stress. While there is no “mood disorder gene,” we now know that certain types of repetitive stress such as learned helplessness, defeat stress, substance abuse, and oxidative stress; when experienced by individuals who have a genetic susceptibility to a mood disorder; may cause serious problems in maintaining a stable feeling of self worth. Learned helplessness (“No matter what I do it doesn’t make a difference – I have little or no power in the relationship – I feel helpless and powerless”) and defeat stress (“In the relationship I frequently feel emotionally abused or neglected”) interact with the DNA in the nucleus of the brain cells to cause fundamental changes in the type of messenger RNA and proteins that are coded, such that the neuroprotective protein levels decline, the structure and the function of the brain cells are adversely affected, and self-esteem regulation may be severely impacted. Here is a picture that summarizes how this works:

At the top right of the next picture, the unprotected brain cells are shown to have shrinkage of their branching portions, called dendrites, and a decline in the number of chemical transmitters available to make the multiple interacting circuits work. With effective treatments such as medication and psychotherapy, these changes are reversed and normal function is restored as demonstrated at the bottom right of the picture. The treatments restore positive feelings of self-esteem and self worth, or in some instances enable the patient to experience healthy self-regard for the first time in their entire life.

With respect to the psychology of mood disorders, what life events predispose a person to developing low self-esteem as a child, which is then carried over into adulthood? There are many unconscious psychological influences on self esteem that have their origins in childhood, ranging from sibling rivalry, to being raised by a critical or unempathic parent, to suffering from ADHD or other disability, to parental divorce or death, to physical or sexual abuse.

A sibling who is perceived as favored, or more talented and capable, can cause one to feel demoralized and stir up feelings of competitive envy and jealousy, which can undermine the development of self-confidence. The child may feel that no matter how hard they try they simply can’t compete, which creates for them the experience of learned helplessness.

A parent who is excessively critical and demanding, and who lacks compassion and empathy can also predispose the child to feel “not good enough,” even unlovable. This can of course create an emotional environment of defeat stress for the child.

A disability such as ADHD may undermine the feeling of positive self worth. Chronic feelings of frustration and humiliation develop as a result of the struggle to absorb, retain, and effectively work with information presented in class or through reading and homework assignments. Increased conflicts at home may occur due to what is perceived as “not listening” to parents; along with messiness and procrastination. Because fellow students seem to “get it” faster and better, and the child with ADHD frequently misses important social cues, feelings of low self regard can intensify all the more. The pervasive effects of ADHD in a child’s life can create both learned helplessness and defeat stress.

Parental divorce or death, and various forms of abuse, can destroy the “protective envelope” of childhood. These events constitute losses of one form or another, which breach a child’s sense of stability and security, disrupt and disturb feelings of trust, may lead to feelings of guilt and self-blame, and serve to undermine or erode the development of positive self regard. Since the child is helpless to prevent these losses or abuses, learned helplessness stress can bring about the alterations of brain cell activity depicted above.

A number of childhood psychological stressors can predispose the child, adolescent or adult to developing a major mood disorder. What determines whether this becomes a Major Depressive Disorder or Bipolar Disorder? Here is where the genetic contributions play a key role. Most people with major depression do not have close relatives with bipolar disorder, but the relatives of people with bipolar disorder are at increased risk of both major depression and bipolar disorder. With this in mind, what childhood experiences conclusively interact with a genetic predisposition to increase the likelihood of developing a major mood disorder? The answer to this question has the potential to help us prevent the development of a major depressive or bipolar disorder in childhood or later in life.

The interaction of psychological factors with specific family genetics certainly play a role in the development of Major Depressive Disorder. The heritability of major depression is probably 40-50%, and may be higher for severe depression. This means that around 50% of the cause is genetic, and around 50% is unrelated to genes (with contributions by psychological or physical factors).What we don’t know is whether this means that in some cases of depression the tendency to become depressed is almost completely genetic, and in other cases it is not really genetic at all. We do know that severe childhood physical or sexual abuse, childhood emotional and physical neglect, and severe life stress are probably all risk factors. Losing a parent early in life probably also increases risk to some extent.

Psychological factors interacting with family genetics also plays a role in the development of Bipolar Disorder. Studies show a 10 times greater risk of developing bipolar disorder if a first degree relative, such as a parent or sibling, has the disorder, for an overall 8.7% chance. How do we know whether this is from a genetic susceptibility or results from how the child is raised? The answer lies in the fact that there is a much greater chance (around 65%) that identical twins will share the disorder, vs. around a 5% to 20% chance for fraternal twins. Since the figure for identical twins is 65% and not 100% science has determined that certain environmental factors also predispose to the development of Bipolar Disorder; such as sexual abuse, highly critical parents, and low levels of maternal warmth. Substance abuse can also “kindle” abnormal activity in the temporal lobes of the brain, the so-called “seat of emotions,” resulting in a higher likelihood of developing Bipolar Disorder.

Social factors in the immediate or extended family also play a role. Divorce, death of a child or spouse, severe setbacks in ones career, economic reversals, or a child with a physical or mental illness can all contribute to feelings of despair and hopelessness, and engender both defeat and learned helplessness forms of stress. A major mood disorder including severely disrupted self esteem can then ensue. Once again the common theme is the experience of specific types of stress that involve loss, and real or perceived powerlessness to effect a different outcome, that interact with a genetic susceptibility to Major Depression or Bipolar Disorder.

Finally, existential factors can contribute to a diminution of self-esteem. At significant transition points in an individual’s life, one may experience an “existential crisis.” A useful framework for understanding the developmental challenges at each life stage, and the corresponding opportunities for emotional growth, is provided by psychologist Erik Erickson’s Stages of Psychosocial Development. In Erickson’s description of eight life stages, an “identity” or “existential” crisis may develop in stages five through eight, if the developmental challenges of one or more of these stages is not successfully confronted, negotiated and mastered. This may be manifested as an identity crisis in the adolescent or young adult, failure at achieving intimacy and commitment in early adulthood, a career that lacks a sense of accomplishment and social value in middle adulthood, or despair in late life when reminiscence brings regret and a sense of failure.

In “The Psychiatrist as Psychotherapist” I wrote about the psychiatrist’s capacity to integrate a knowledge base comprising neurobiology, general medicine, the unconscious, behavioral science, family systems, workplace/environmental stressors, and nutrition, to design and implement holistic treatment plans. To create positive feelings of self worth for the very first time in a patient’s life, or to restore confidence following the onset of a major depression, or to stabilize wide swings in self esteem in someone suffering from bipolar disorder, necessitates drawing from all of these knowledge bases, and is both a science and an art. Influence is brought to bear at the level of gene expression, brain cell circuit function, the unconscious, family interaction, and existential meaning and purpose.

A psychiatrist is privileged when he or she is able to work with a determined and earnest patient, as they embark upon a journey toward that cherished place – the achievement of stable, positive feelings of self-regard. This cherished place includes an abundance of newly discovered riches: such as the ability to enter into a committed relationship and feel safe; looking at yourself in the mirror and liking what you see; hopeful feelings about the future; an end to comparing yourself to others, and coming up short; no longer being your own harshest critic; and leaving behind those self-sabotaging behaviors that preclude a more joyful experience of self and others. As their work together creates both social value and a great sense of accomplishment, the journey provides one additional benefit – it is exceptionally good for the middle-aged psychiatrist’s own self esteem!

“Once upon a time there was a man named Narcissus who came across a deep pool in a forest from which he took a drink. As he did, he saw his reflection for the first time in his life, and fell in love with the beautiful boy who was staring back at him. Realizing that he could not kiss or hold his own image, (only the water), he pines, withers away, and dies.” (From Greek Mythology)

Much has been written about the Narcissistic Personality in the last 30 years in the psychoanalytic literature and in popular psychology. There are important lessons that can be gleaned from this research in how to identify the Narcissist in love and at work…such that you can avoid unnecessary pain in relationships with Narcissists… as they inevitably result in breached commitments, dishonored contracts, and broken hearts.

What are some of the hallmarks of the Narcissistic personality? First and foremost is excessive self absorption. The Narcissist is rarely, if ever, truly interested in others. He or she may go on at length about themselves, but rarely demonstrate a meaningful interest in you.

Second, Narcissists are incapable of true empathy. They may be able to feign empathy because they are intelligent enough to have learned the concept of empathy, and may use it as a technique to manipulate others and win people over. But true empathy requires compassion and understanding – capacities that the Narcissist sorely lacks. When he or she attempts empathy, it has a shallow quality that will not resonate within you emotionally, and will lack a feeling of emotional connection. Genuine empathy is felt as a deep emotional resonance within your heart that comes along with a caring emotional connection with another human being.

Third, the Narcissist is only interested in his or her own happiness, and you exist only to make them happy. A Narcissist attends to your happiness only when it can bring them something they desire or covet – whether it is showing you off to others, getting you into bed, or manipulating some favor. It is all about boosting their self esteem and sense of self by fulfilling their needs. In contrast, someone capable of mature love is concerned about his or her own happiness, but is also genuinely committed to helping you find happiness in your own life.

The Narcissist may be extremely attractive, charming, interesting, fun and exciting for quite some time in the early phase of a relationship. They may sweet talk you – saying how important you are to them and how much they need you in their life. However, the Narcissist can “talk-the-talk” but cannot “walk-the -walk.” Count on the Narcissist to bolt when reality, ambivalence, or conflict that isn’t resolved in their favor start to enter the relationship. “Bolting” may take place at an emotional level where they withdraw from you into self-absorbtion, or it may involve their ending the relationship to move onto the next object of their Narcissistic pleasure. When the inevitable conflicts arise in a real relationship, count on the Narcissist to focus on your flaws and the various ways you don’t satisfy them, as opposed to working toward an understanding your point of view, as well as expressing their own, to enable a win-win resolution of conflicts.

The Narcissist can outwardly radiate a great aura of confidence and competence that may be beguiling. At times this personality trait may be expressed as arrogance. This posturing often masks deep feelings of insecurity, inadequacy, and unmet dependency needs that are threatening and frightening to them at an unconscious level. The Narcissist may jealously and possessively attempt to control you, or alternatively remain at an emotional distance, as a result of his or her unresolved dependency needs, which threaten the development of true intimacy. Thus a relationship with a Narcissist can feel like a very lonely place, even while being physically together and participating in an active social life.

Not all narcissism is bad. “Healthy Narcissism” is a positive trait that brings along with it positive self-regard and self-esteem; an appreciation of one’s strengths and capabilities; the confidence to explore the world, adult relationships, and one’s own inner life; the ability to ensure that one’s own needs are met in a relationship, along with a keen interest in meeting the needs of one’s partner, and a willingness to compromise to achieve mutual happiness; and a rock-solid set of principles and virtues that are not shaken or influenced by external pressures. If one has healthy narcissism and finds themselves becoming involved with a Narcissist, they typically have the inner strength to break away and move on, even if it means bearing the feelings of loneliness, and living alone.

Many adults repeatedly become engaged with Narcissistic Personalities. Due to unconscious forces, lack of self esteem, a repetition of earlier formative relationships, and a compulsion to repeat self-sabotaging behaviors, they seek out love relationships (and enter business relationships) that from the beginning are destined to bring heartache and failure.

“Knowing Yourself is the Beginning of All Wisdom.” Many clients first come in for psychotherapy in the midst of a crisis, or when they have recognized a pattern in their lives where they have been involved in a series of relationships that don’t work out, and where they feel chronically unhappy. We come to learn in the course of therapy that they repeatedly choose Narcissists as lovers and companions. We also uncover the sources of their low self-esteem that serve to perpetuate this pattern. Through psychotherapy, the unconscious determinants and propagators of this pattern can be identified and resolved, and healthy narcissism can be nurtured and strengthened. Through the process of therapy one makes healthier choices – seeking out and finding true partners who provide mature love, an emotional connection, empathy, support, and a durable love. Successful therapy helps to ensure that future relationships do not wither away and die, but remain alive and vibrant.

In television, movies, and books, consumers are frequently presented with an image of love that is passionate, blissful, and all-encompassing. Characters such as Wesley and Buttercup in the movie The Princess Bride, and Edward and Bella in the movie Twilight, exhibit undying devotion and affection which sustains them through every hardship they encounter. These movies, and others in this genre in which we have been immersed since childhood, present an idealized view of a love relationship, which may cause us to develop unrealistic expectations for the love relationships in our own lives. To have a successful romantic relationship, one must first understand the components of a REAL love life, as opposed to a fantasy.

A romantic relationship may evolve through three phases – the first phase is what we might call the “romanticized phase,” or “phase of idealization.” This is where you feel enraptured and incredibly excited about the other person. You think about them almost all of the time, there are frequent calls and/or text messages, and you feel that they are the greatest thing that has ever happened to you. Feeling as if you are on Cloud 9 can last as little as a night or two, or as much as several months. However, it is important to note that this romanticized phase will always end. (This does not necessarily mean the end of romance in the relationship, which is different).

The second phase is what we might call the beginning of the “reality phase.” This phase begins when you are still having fun together and are attracted to each other, yet you begin to notice the flaws in the other person, or they comment upon flaws in you. You begin to feel disappointed in a variety of ways. They may let you down or make you angry…or you may feel neglected or poorly treated. Some of this may be normal disillusionment and expectable in a real relationship. At other times it may be that the person is too self-absorbed and narcissistic to be able to truly satisfy your basic needs. (Look for a subsequent blog on “The Narcissist”).The beginning of the reality phase of a romantic relationship can be a difficult phase to negotiate, and for this reason many romantic relationships end here.

However, there is hope for conquering this phase. It is important that you talk with your romantic interest about some of your feelings and concerns, and listen to theirs. Do you try to resolve conflicts together? Are you willing to compromise? It is important to get good at talking, listening, and finding a middle ground, with a willingness to make some changes. Intimacy and commitment can feel scary, and make you or your partner want to run away from the relationship, but those feelings can be talked through as opposed to acted upon. Past deep disappointments in love, significant unresolved losses of a loved one, parental divorce, or growing up in a family where the relationships were characterized by emotional distance, can all result in fears of a close and lasting commitment. If you have persisting fears of intimacy that interfere with your love life, or you repeatedly end promising relationships before they can mature, then these issues can be addressed and resolved in psychotherapy . The therapeutic process can assist you in moving on into a healthier and more satisfying relationship.

At this point you may be thinking, “This sounds too complicated. Is there anything I can do to prevent this phase and continue the romanticized phase?” Unfortunately, there is no way to prevent the reality phase from emerging. However, take comfort in the fact that YOU get to decide whether your partner’s traits are satisfying enough to continue on. It is important to recognize that without self- reflection on the part of your partner, independently or through psychotherapy, their negative traits will persist over time. If they frequently disappoint or make you feel inadequate – such that you never develop a comfortable contentment – you may choose to end the relationship.

In the alternative, if you feel that you can fully accept your partner’s flaws, and that the good attributes outweigh the bad, then you may feel willing to continue. Ultimately, if you can each accept each other for who you are, within the context of working on the relationship to bring greater satisfaction, then the bond can develop into a real and durable one.

Sometimes your romantic interest decides to end the relationship. This may elicit feelings of self-doubt, or fears that you are flawed and not good enough. You may question whether you should have behaved differently. Feelings of confusion may arise if you and your partner had seemingly enjoyed your time together both emotionally and physically. There are no simple answers to these questions. Perhaps you chose someone with significant narcissistic problems, who is incapable of mature love. Alternatively, perhaps your own fears of intimacy, excessive emotional dependency, rushing the relationship, or holding back emotionally or physically may have contributed to the demise of the relationship. Sometimes these patterns of thinking, feeling and behaving are unconscious and result from earlier dysfunctional love relationships in your life, and can be addressed and resolved in psychotherapy.

The third phase of a romantic relationship is what we might call the “durable real” phase. Here, you have a wide range of feelings toward that other person. At times you feel love, affection, and sexual excitement. You really enjoy being with them and can’t wait to see them. At other times you may feel furious, and want out. You may feel relatively neutral at times, and just experience your partner as a companion. At other times you may feel ambivalent, as your partner can meet some of your needs, but not others. These conflicting feelings and impulses are the hallmark of a REAL relationship. If you work hard to keep the relationship alive, and motivate yourself to understand your partner; prioritize their happiness in addition to your own, and genuinely try to please them; then it’s possible to build a life together of passion, trust, and devotion. To develop and maintain an adult love relationship, it is essential to align your thoughts and expectations toward what is possible and real (as opposed to fantasized).

At times even a satisfying, mature love relationship can fall into crisis, manifested by stagnation or intense and persistent conflict. Prior repressed emotional traumas, upsetting life events , and aging and health concerns can all serve to undermine what had been very satisfying. Here again individual and/or couple’s therapy can make a significant difference in bringing about understanding that will “unstick” the relationship, provide a tangible pathway toward improvement, and restore the prior feelings of satisfaction and an intimate bond.

Humiliation has been characterized as the most painful of all human emotions. Humiliation is a “public emotion” in that it involves a belief that others will view us as diminished, and will likely mock us. When we are humiliated, particularly by someone that we love, it can engender deep feelings of disappointment, hurt, anger, and even rageful behavior. If the humiliation occurs at a time when one is also feeling generally despondent about their life, the predisposition to anger and ragefulness is even greater. Severe humiliation may create a higher risk of suicide. For example, we have recently witnessed this phenomenon during the severe recession, when several previously prominent and highly affluent professionals lost their jobs, incomes, and much of their assets, and they committed suicide. This is because reduced self-esteem increases one’s general emotional vulnerability, reduces one’s “emotional reserve,” and then the experience of humiliation worsens one’s self-esteem all the more, leading to a downward spiral of hopelessness and a feeling that “there is no way out.”

Why is this dynamic important to recognize, prevent, and treat? To begin with, many of the anger management and depression challenges that our adult clients present to us have at their root persisting childhood experiences of humiliation by one or more parents, or by friends or teachers. As a humiliated child they felt “even smaller,” and at times the feeling of humiliation was so intense that they would feel like disappearing altogether, just to escape the emotional pain. A berating or overly critical parent; the persisting educational challenges posed by Attention Deficit Disorder; a loss of socioeconomic status; a parent suffering from mental illness, alcohol or drug abuse; poor athletic ability; delayed physical maturation; or an older sibling with far greater talent can all contribute to childhood feelings of humiliation, and a persisting vulnerability into adulthood.

From a prevention standpoint, praising a child when they behave in a way that makes them (and you) feel proud, helping a child gain confidence and mastery in their life by supporting activities about which they feel passionate, and helping them over life’s hurdles (without stepping in to take care of the problem, unless absolutely necessary) can assist a child in building healthy self esteem that provides greater resistance to feeling humiliated. There is no absolute means of prevention, as the experience of humiliation is inevitable; and providing empathic parental support goes a long way toward restoring positive self-esteem.

Treatment involves uncovering and explore the childhood experiences of humiliation, and all of the attendant feelings that once came along with these events, and developing a new perspective on them, in an empathic and supportive therapeutic environment. At times, medication can also be helpful in treating an underlying mood or anxiety disorder that has increased one’s vulnerability to feeling humiliated. Sometimes during the treatment process “the cure can feel worse than the disease.” But through a diligent and persistent approach to therapy the client can learn to understand the origins of their vulnerability, how they repeatedly play it out or even unconsciously bring it about in present day life, and then learn to leave it behind them and move on to a healthier, more positive and resilient way of living.

More about Humiliation.

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