Holiday Tips During Your Fertility Journey

For a couple that has been struggling with infertility, the holidays can be a particularly painful time. Family gatherings that may be filled with babies and children can serve as bittersweet reminders of what didn’t happen for you this year. You may have had one or more failed cycles or even miscarriages over the past several months. While you and your partner tried to avoid getting your hopes up, it is likely that with each embryo transfer you found yourself daydreaming of holding your precious little one at holiday family gatherings. Whether you’ve been private about your fertility journey or an open book, you can depend on the fact that you are bound to be subject to some uncomfortable conversations about your ability to bear children. 

One woman described a horrific episode early in her fertility journey. Her first retrieval had gone very well and the couple had gotten pregnant on the first embryo transfer. The elated couple shared the good news with both sets of parents and several friends only to learn that they had miscarried at eight weeks. To the woman’s mortification, her husband’s parents had shared the news of their pregnancy with friends who were eager to offer their congratulations at the family’s annual holiday party. She was faced with the task of glumly informing virtual strangers about the miscarriage throughout the endless evening. 

Here are some things to keep in mind as you face gatherings and celebrations with friends and family this holiday season.

  1. Discuss who you will share information with and be specific. Prior to discussing your fertility journey with anyone, it is important that you and your spouse clearly designate who is allowed to be in the know well as any particular details either of you would prefer to keep private. Key to avoiding situations such as the one described above is to tell the people that you confide in that you’d prefer to remain private about you efforts to conceive.

  2. How to handle booze. You might find yourself mid-cycle during the holidays and abstaining from alcohol. This can lead to eyebrow raises and even pointed questions about possible pregnancies. It can be helpful to plan how you are going to handle these situations. Some couples prefer to abstain from alcohol together, while some women feel more comfortable nursing a Sprite to blend in. Whatever your approach, it helps to think about what you’ll say and do when asked about your drink preferences so you aren’t caught off guard.

  3. Plan for invasive questions. It seems that almost every family has that person that asks the awkward and intrusive questions. It can be very difficult to graciously field Aunt Sally’s third degree about your sex life with your partner. Thus, it is essential to anticipate some common situations and plan some responses. Remember, you do not OWE anyone information about your private life and, conversely, the people who are prying are likely well-meaning. By thinking of pithy ways to handle questions and comments, you can avoid being caught off guard.

  4. Come up with a cue. Plan as you will to field awkward and intrusive family and friends, it is likely that one or both of you will find that you need to check in and get strength from one another throughout holiday festivities. It’s helpful to come up with a secret cue that can serve as a signal for your partner to come and give you support. A hand on the shoulder or a stolen moment in a hallway could be just what both of you need to get through a difficult moment at a party or function.

  5. Spend some time processing losses alone. Though the holidays are typically crazy, hustle and bustle times, it is important to make space to process the losses and trials you have been through over the past year. Set aside some time, perhaps a quiet evening, to burn a candle and take turns sharing your thoughts and feelings about your fertility journey. Don’t shy away from shedding tears or expressing your hopes and fears to one another.

  6. Give yourself permission to take breaks or go home early. Finally, it is perfectly acceptable to be choosy about where you go and how long your stay. There is no edict that says you must go to every single gathering for the entire time. Feel free to make brief appearances or choose to spend time with friends and family that are the most safe of supportive of you during this time.

Taking time to plan ahead and care for yourself and your partner can make the holidays more enjoyable. This preparation and thoughtfulness can also help you and your partner to feel closer and better supported by one another and by those you have chosen to include in your fertility journey.

Dr. Angela Williams is a licensed clinical psychologist, specializing in cognitive-behavioral and humanistic/existential approaches to therapy. She has extensive training in Brief Crisis Intervention as well as mindfulness based therapeutic approaches. Her therapeutic style blends strength-based acceptance with practical skill development. Incorporating mindfulness-based interventions, she helps her clients move through difficult experiences and be more present in their lives.

Hypnosis: How Does It Really Work?

For many, hypnosis conjures images of a man with a vest, swinging a pocket watch, speaking slowly and encouraging sleepiness. Alternatively, hypnosis has been incorporated into many stage shows, with depictions of previous shy audience members, bursting forth into maniacal dance moves while hypnotized. However, the use of clinical hypnosis has been gaining momentum over the past several years. It is now accepted as a valid subject of scientific research and is a useful clinical tool for a variety of medical conditions, including: 

  • Acute and Chronic Pain

  • Phobias

  • Anxiety

  • Depression

  • Eating Disorders

  • Smoking

  • Obesity

There are many theories on hypnosis and how it works. It is often referred to as a procedure involving cognitive processes in which an individual is guided to respond to suggestions for changes in sensations, perceptions, thoughts, feelings, and behaviors. Alternately, hypnosis can also be defined of its effect (Barnier & Nash, 2008). This refers to the fact that not all individuals will respond the same way to a hypnotic suggestion during treatment or even become hypnotized. Therefore, the response to hypnosis can differ from widely from one individual to the next. In short, hypnosis can either be defined by “what it looks like” (hypnosis-as-procedure) or “what it does” (hypnosis-as-response; [Jensen, 2011]).”  

Hypnosis begins with an induction and is followed by one or more suggestions for making positive changes. At times, these suggestions are designed to result in a positive response during the treatment, as well as after the session, becoming “permanent and automatic.”  In the first phase, hypnotic induction, the individual is guided through suggestion to relax, concentrate, and/or to focus his or her attention on one thing. The second phase, hypnotic suggestion, is when the individual is guided to undergo changes in experience. There are different types of suggestions including: 

  • Ideomotor Suggestions – experience a movement

  • Challenge Suggestions –told he or she will not be able to do some particular thing and then is asked to perform the prohibited behavior

  • Cognitive Suggestions – experience changes in sensations, perceptions, thoughts or feelings

Hypnosis is generally used as a clinical tool for making direct suggestions to reduce symptoms or as an addition to other forms of psychological treatment. For example, hypnotic analgesia helps a patient undergoing a painful medical procedure (e.g., surgery, a lumbar puncture, spinal tap) by suggesting that the affected body part (i.e., the back) is numb and insensitive to pain through hypnosis. Hypnosis can alter and eliminate the psychological experience of pain and the brain’s neurophysiological processing of pain. Remember that not everybody responds the same way to a hypnotic suggestion during treatment or even becomes hypnotized. 

There are simple tasks, known as test suggestions, that can help determine how a person may respond to hypnosis. The number of test suggestions that a person responds to (or passes) indicates their level of suggestibility. Each individual will differ in terms of how high or low they fall on suggestibility, which is a marker for how much or how little a person will respond to hypnosis. Below is a simple task called the Chevreul Pendulum Demonstration that can be used to test whether a person is suggestable or not.

Instructions:  

  1. Obtain scissors, string, and ½ inch washers at a hardware store.

  2. Cut a 5-7-inch length of string and tie it to the washer.

  3. You will have an opportunity to experience an imaginative suggestion.

  4. Place your right elbow on your right thigh and hold the string between your right thumb and index finger so the washer is suspended beneath.

  5. Hold your hand as still as possible.

  6. Now imagine that the washer is beginning to move from left to right. The washer is beginning to move from left to right. Continue imagining that the washer is moving from left to right. Continue to imagine this for another minute or so.

  7. Now I want your hand return back to normal.

*NOTE. There will be a range of responses.  Some of you will show no response at all.  Others will find that their washer moves quite a bit. The degree of movement is suggestive of your degree of suggestibility. Remember suggestibility accounts for a portion of how much or how little you respond to hypnosis. However, research strongly indicates that the vast majority of people can benefit from hypnosis interventions.

Common Myths about Clinical Hypnosis (NONE OF THE BULLET POINTS BELOW ARE TRUE)

  • Individuals undergoing hypnosis lose control and can be made to say or do whatever the hypnotist wants.

  • Individuals may not be able to come out of hypnosis.

  • Hypnosis only affects naïve and gullible people.

  • Hypnosis reliably enhances the accuracy of memory.

  • Hypnosis enables people to re-experience a past life.

  • Hypnosis depends primarily on the skill of the hypnotherapist.

Dr. Narineh Hartoonian is a Clinical Health and Rehabilitation psychologist at the Rowan Center for Behavioral Medicine. She has several years of interdisciplinary clinical and research experience in health and rehabilitation psychology and has served the needs of many individuals with chronic medical conditions and disability. Dr. Hartoonian received her Bachelor and Master of Science in Physiology from the University of California, Los Angeles (UCLA) and her Doctorate in Clinical Psychology from Loma Linda University (LLU). She has taught various graduate and undergraduate courses in the physiological sciences, health and psychobiology.

REFERENCES

Barabasz, A. F., & Barabasz, M. (2008). Hypnosis and the brain. In M. R. Nash & A. Barnier (Eds.), The Oxford handbook of hypnosis: Theory, research and practice, 337-363. Oxford, UK: Oxford University Press

Jensen, M. P. (2011). Hypnosis for chronic pain management: Therapist guide. Oxford University Press, USA.

More than Medications: Integrated Treatment for Chronic Pain

There are many people who suffer from what doctor’s describe as chronic pain. The management of this type of ongoing pain can be complex, which is why an integrative approach to treatment is essential to helping patient’s get relief and find a better quality of life.

Pain is considered to be chronic when it lasts longer than 3 months, above and beyond what would be considered a normal healing period. Ongoing pain can cause structural and functional changes to the nervous system. As a result of these changes, the pain can continue to exist even after the injury has healed. 

Chronic pain can manifest as a result of various diseases and illnesses. Certain risk factors may increase the likelihood of experiencing chronic pain such as traumatic injuries, stressful life events, worsening medical or surgical conditions, and family history. Chronic pain is a significant problem for many individuals with other medical conditions as well, including, multiple sclerosis, stroke, brain injury, spinal cord injury and amputations (O’Connor et al. 2008; Sackly et al. 2008). If the pain is left untreated it can lead to many physical and mental health difficulties, lowering an individual’s quality of life and causing great distress and suffering. Often individuals who suffer from chronic pain seek treatment from many healthcare providers. Individuals are typically put on many different medications with unpleasant side-effects to control pain and some have even tried multiple surgeries. Individuals with chronic pain are often left without hope when told that nothing else can be done. 

Chronic pain is often coupled with psychosocial difficulties. Relationships can be affected as those individuals suffering from chronic pain become isolated from their friends and family,  and can exhibit symptoms of depression, insomnia, and frustration with the healthcare system. Because chronic pain is a complicated problem that affects the individual’s mental and physical health, chronic pain management often requires a combined treatment effort. It is recommended that rehabilitation psychology, musculoskeletal medicine and a pain management specialist treat the patient in an integrative manner. Most importantly, individuals with chronic pain can significantly reduce the severity of their pain by being actively involved in their pain control plan.  A rehabilitation or health psychologist can assist individuals to move towards reaching this goal. They can help increase active involvement in pain control plan by working to develop a physical activity routine and mental health exercises. Though the outcomes of psychological treatment have shown to be significantly effective for managing chronic pain, studies show that very few (10-15%) individuals with co-morbid disability and chronic pain report having tried a psychological intervention (Ehde et al., 2006; Hanley et al., 2006; Widerstrom-Noga & Turk, 2003). 

An example of a psychologically-focused treatment strategy is chronic pain acceptance, which is based on the principals of Acceptance and Commitment Therapy (ACT). This approach focuses on both thinking (willingness to experience pain) and doing (engagement in life), and it is related to positive adjustment, lower pain interference and decreased depression. More specifically, patients are taught to allow some pain some of the time,  how to be willing to experience pain and still engage with life. They are also taught non-judgmental awareness of pain and how to act with intention. Using Acceptance and Commitment Therapy (ACT) in treating chronic pain emphasizes the importance of flexibility in responding to pain. This is different from commonly-studied coping strategies that focus on using distraction techniques to redirect attention away from the pain, reframing thoughts and eliminating pain. 

Other evidence-based treatment also includes Cognitive Behavioral Therapy (CBT) for Pain and Hypnosis. Hypnosis treatment for acute and chronic pain has been shown to be very effective. Though studies on hypnosis for pain have focused primarily on acute pain, more recent studies are examining its effect for chronic pain management when coupled with CBT. Those who are interested in this combined treatment should discuss this with a health or rehabilitation psychologist.

Remember, it is very important to receive treatment in an integrative manner. Therefore, if you seek treatment from a psychologist make sure they take every step to ensure that care is coordinated with your other providers, including your primary care doctor, pain specialist and/or musculoskeletal medicine physician. Providers should also strive to offer an interdisciplinary holistic/integrated approach to any treatment that they provide for individuals with chronic pain. 

When should an individual with chronic pain consider seeking treatment from a psychologist?

  • Symptoms of depression are present: Individuals who are depressed are less likely to engage in self-management

  • Increased levels of anxiety or worry related to daily activities or fear of pain

  • Increased levels of pain interference with activities, including sleep, relationships, and physical activity

  • If catastrophizing or very negative thinking about pain management exists

  • Low self-efficacy for pain management

Here is a list of evidence-based psychological treatments offered for individuals with pain: 

  • Cognitive Behavioral Therapy (CBT) for chronic pain

  • Hypnosis for acute and chronic pain

  • Acceptance and Commitment Therapy (ACT) for Chronic Pain

  • Mindfulness-Based Intervention for pain

Resources :

Dr. Narineh Hartoonian is a Clinical Health and Rehabilitation psychologist at the Rowan Center for Behavioral Medicine. She has several years of interdisciplinary clinical and research experience in health and rehabilitation psychology and has served the needs of many individuals with chronic medical conditions and disability. Dr. Hartoonian received her Bachelor and Master of Science in Physiology from the University of California, Los Angeles (UCLA) and her Doctorate in Clinical Psychology from Loma Linda University (LLU). She has taught various graduate and undergraduate courses in the physiological sciences, health and psychobiology.

REFERENCES

O’Connor, A. B., Schwid, S. R., Herrmann, D. N., Markman, J. D., & Dworkin, R. H. (2008). Pain associated with multiple sclerosis: systematic review and proposed classification. PAIN®, 137(1), 96-111..

Sackley, C., Brittle, N., Patel, S., Ellins, J., Scott, M., Wright, C., & Dewey, M. E. (2008). The prevalence of joint contractures, pressure sores, painful shoulder, other pain, falls, and depression in the year after a severely disabling stroke. Stroke, 39(12), 3329-3334.

Ehde, D. M., Osborne, T. L., Hanley, M. A., Jensen, M. P., & Kraft, G. H. (2006). The scope and nature of pain in persons with multiple sclerosis. Multiple Sclerosis, 12(5), 629-638.

Hanley, M. A., Jensen, M. P., Ehde, D. M., Robinson, L. R., Cardenas, D. D., Turner, J. A., & Smith, D. G. (2006). Clinically significant change in pain intensity ratings in persons with spinal cord injury or amputation. The Clinical journal of pain, 22(1), 25-31.

Widerström-Noga, E. G., & Turk, D. C. (2003). Types and effectiveness of treatments used by people with chronic pain associated with spinal cord injuries: influence of pain and psychosocial characteristics. Spinal Cord, 41(11), 600-609.

Thyroid Function, Mood Disturbance & Cognitive Impairments

It has been evidenced that changes in thyroid hormone is associated with mood, neuropsychiatric and cognitive changes (1). Thyroid hormone receptors are widely distributed in the brain including in the emotional center of the brain (limbic system structure), and studies indicate that thyroid hormone interacts with the neurotransmitter system (Norepinphrine, 5-HT and dopamine; 2-6) that are believed to play a major role in the regulation of mood and behavior.  Thyroid hormone has show to be involved in the reduction of the sensitivity of 5-HT1A receptor (this is where the neurotransmitter 5-HT binds in the brain) in the raphe nuclei and increase in 5-HT2 receptor sensitivity (5). Thyroid hormone also interacts with dopamine post-receptor and signal transducing processes, as well as gene regulatory mechanisms. Several studies have evidenced that blunted thyroid stimulating hormone (TSH) response to thyroid releasing hormone (TRH) has been found to be associated with depression (7-10). Additionally, lower concentration of cerebral spinal fluid (CSF) transthyretin have been found in depressed patients than in healthy controls despite normal peripheral blood thyroid hormone measure.

The most frequently occurring thyroid diseases for adults are autoimmune disorders (Hashimoto’s and Graves Disease). For example, Hashimoto’s encephalopathy may be an independent risk factor for depression or cognitive impairments (11-14) and can mimic neurological disorders. Graves Disease, has also been shown to cause secondary complications including, 1) cardiovascular complication; 2) decreased attention/concentration; 3) sleep disturbance and irritability. Both hypothyroidism and hyperthyroidism are associated with changes in mood and intellectual performance and severe hypothyroidism can mimic melancholic depression and dementia (15-17). Neurocognitive impairments are usually reversed rapidly by treatment and severe cases of hypothyroidism may result in irreversible dementia if untreated (18-19).

Cognitive symptoms are often reported in with patients with hypothyroidism. These symptoms can range from minimal to severe changes in general intelligence to reports of defects in psychomotor speed, visual-spatial skills, and memory (15, 20-24). Studies have shown that the memory disturbances may be attributed to specific retrieval deficits and not attention-related deficits (24-27). Other cognitive symptoms that have shows less of an impact include, motor skills, language, inhibitory efficiency, and sustained attention (21-24).

The bottom line is that if you or your loved ones have a diagnosis of thyroid disease or have genetic loading for these diseases and are experiencing psychological difficulties, including changes in mood and/or cognitive function please get your thyroid function evaluated by your primary care physician or an endocrinologist. The chances are that the mood and cognitive symptoms can be reversed when the thyroid disease is properly treated. Of course, if the emotional difficulties are interfering with your social, occupational and personal functioning, please seek assistance from a mental health professional. 

Etiology and Types of Thyroid Disease

Hypothyroidism:

  • Thyroiditis- is an inflammation of the thyroid gland.

–            postpartum thyroiditis- occurs in 5-9% of women after giving birth
–            drug-induced thyroiditis
–            radiation-induced thyroiditis
–            acute infection thyroiditis

  • Hashimoto’s thyroiditis- is a painless disease of the immune system that is typically hereditary.

  • Iodine deficiency-Because Iodine is used by the thyroid to produce hormones a lack of this element can impact thyroid hormone production. Although prevalent before the 50s in the US, iodine deficiency has been nearly wiped out by the use of iodized salt.

  • Congenital thyroid disease- affects 1 in 4,000 newborns. If the problem is not corrected, it can result in permanent mental retardation and growth failure.

Hyperthyroidism

  • Grave’s Disease- also an autoimmune disease and is the most common cause of hyperthyroidism. It is believed that Graves’ disease is caused by an antibody that mimics thyroid stimulating hormone and continues to stimulates the thyroid too much. This overstimulation causes the excess production of thyroid hormone. Common in young to middle-aged women. Also tends to run in families.

  • Toxic nodular goiter (also knows as multinodular goiter)- Condition in which 1 or more nodules of the thyroid becomes overactive. Cause unknown

  • Thyroiditis- Thyroiditis also causes temporary hyperthyroidism, usually followed with hypothyroidism.

Dr. Narineh Hartoonian is a Clinical Health and Rehabilitation psychologist at the Rowan Center for Behavioral Medicine. She has several years of interdisciplinary clinical and research experience in health and rehabilitation psychology and has served the needs of many individuals with chronic medical conditions and disability. Dr. Hartoonian received her Bachelor and Master of Science in Physiology from the University of California, Los Angeles (UCLA) and her Doctorate in Clinical Psychology from Loma Linda University (LLU). She has taught various graduate and undergraduate courses in the physiological sciences, health and psychobiology.

REFERENCES

1.  Bauer, M., Goetz, T., Glenn, T., Whybrow, P.C., The Thyroid-Brain Interaction in Thyroid Disorder and Mood Disorder. Journal of Neuroendocrinology 2008; 20, 1101-1114

2.   Whybrow PC, Prange AJ Jr. A hypothesis of thyroid-catecholamine- receptor interaction. Arch Gen Psychiatr 1981; 38: 106–113.

3.  Marwaha J, Prasad KN. Hypothyroidism elicits electrophysiological nor- adrenergic subsensitivity in rat cerebellum. Science 1981; 214: 675– 677

4.   Gordon JT, Kaminski DM, Rozanov CB, Dratman MB. Evidence that 3,3¢,5-triiodothyronine is concentrated in and delivered
from the locus coeruleus to its noradrenergic targets via anterograde axonal transport. Neuroscience 1999; 93: 943–954.

5. Bauer M, Heinz A, Whybrow PC. Thyroid hormones, serotonin and mood: of synergy and significance in the adult brain. Mol Psychiatr 2002; 7: 140–156.

6.  Mason GA, Bondy SC, Nemeroff CB, Walker CH, Prange AJ Jr. The effects of thyroid state on beta-adrenergic and serotonergic receptors in rat brain. Psychoneuroendocrinology 1987; 12: 261–270.

7.  Bauer MS, Whybrow PC. Rapid cycling bipolar affective disorders. II. Treatment of refractory rapid cycling with high-dose levothyroxine: a preliminary study. Arch Gen Psychiatr 1990; 47: 435–440.

8. Baumgartner A, Bauer M, Hellweg R. Treatment of intractable non-rapid cycling bipolar affective disorder with high-dose thyroxine: an open clinical trial. Neuropsychopharmacol 1994; 10: 183–189.

9. Jackson IM. The thyroid axis and depression. Thyroid 1998; 8: 951–956. 

10.  Gyulai L, Bauer M, Bauer MS, Garcia-Espana F, Cnaan A, Whybrow PC. Thyroid hypofunction in patients with rapid-cycling bipolar disorder after lithium challenge. Biol Psychiatry 2003; 53: 899–905.

11. Pop VJ, Maartens LH, Leusink G, van Son MJ, Knottnerus AA, Ward AM, Metcalfe R, Weetman AP. Are autoimmune thyroid dysfunction and depression related? J Clin Endocrinol Metab 1998; 83: 3194–3197. 

12.   Kuijpens JL, Vader HL, Drexhage HA, Wiersinga WM, van Son MJ, Pop VJ. Thyroid peroxidase antibodies during gestation are a marker for subsequent depression postpartum. Eur J Endocrinol 2001; 145: 579–584.

13.      Harris B, Oretti R, Lazarus J, Parkes A, John R, Richards C, Newcombe R, Hall R. Randomised trial of thyroxine to prevent postnatal depression in thyroidantibody-positive women. Br J Psychiatry 2002; 180: 327– 330.

14.  Chong JY, Rowland LP, Utiger RD. Hashimoto encephalopathy: syn- drome or myth? Arch Neurol 2003; 60: 164–171.

15.  Whybrow PC, Prange AJ Jr, Treadway CR. Mental changes accompanying thyroid gland dysfunction. Arch Gen Psychiatry 1969; 20: 48–63.

16.  Whybrow PC, Bauer M. Behavioral and psychiatric aspects of hypothy- roidism. In: Braverman LE, Utiger RD, eds. Werner & Ingbar’s The Thy- roid. A Fundamental and Clinical Text, 9th edn. Philadelphia: Lippincott Williams & Wilkins, 2005: 842–849.

17.  Whybrow PC, Bauer M. Behavioral and psychiatric aspects of thyrotoxi- cosis. In: Braverman LE, Utiger RD, eds. Werner & Ingbar’s The Thyroid. A Fundamental and Clinical Text, 9th edn. Philadelphia: Lippincott Wil- liams & Wilkins, 2005: 644–650.                

18.  Haupt M, Kurz A. Reversibility of dementia in hypothyroidism. J Neurol 1993; 240: 333–335.

19. Davis JD, Stern RA, Flashman LA. Neuropsychiatric aspects of hypothy- roidism and treatment reversibility. Minerva Endocrinol 2007; 32: 49–65.

20.  Denicoff KD, Joffe RT, Lakshmanan MC, Robbins J, Rubinow DR. Neuro- psychiatric manifestations of altered thyroid state. Am J Psychiatry 1990; 147: 94–99.

21. Haggerty JJ Jr, Evans DL, Prange AJ Jr. Organic brain syndrome associ- ated with marginal hypothyroidism. Am J Psychiatry 1986; 143: 785– 786.

22. Osterweil D, Syndulko K, Cohen SN, Pettler-Jennings PD, Hershman JM, Cummings JL, Tourtellotte WW, Solomon DH. Cognitive function in nondemented older adults with hypothyroidism. J Am Geriatr Soc 1992; 40: 325–335.

23. Dugbartey AT. Neurocognitive aspects of hypothyroidism. Arch Intern Med 1998; 158: 1413–1418.

24. Burmeister LA, Ganguli M, Dodge HH, Toczek T, DeKosky ST, Nebes RD. Hypothyroidism and cognition: preliminary evidence for a specific defect in memory. Thyroid 2001; 11: 1177–1185.

25.  Jaeschke R, Guyatt G, Gerstein H, Patterson C, Molloy W, Cook D, Har- per S, Griffith L, Carbotte R. Does treatment with L-thyroxine influence health status in middle-aged and older adults with subclinical hypothy- roidism? J Gen Intern Med 1996; 11: 744–749.

26.  Miller KJ, Parsons TD, Whybrow PC, van Herle K, Rasgon N, van Herle A, Martinez D, Silverman DH, Bauer M. Memory improvement with treatment of hypothyroidism. Int J Neurosci 2006; 116: 895–906.

27. Miller KJ, Parsons TD, Whybrow PC, Van Herle K, Rasgon N, Van Herle A, Martinez D, Silverman DH, Bauer M. Verbal memory retrieval deficits associated with untreated hypothyroidism. J Neuropsychiatry Clin Neu- rosci 2007; 19: 132–136.

Techniques to Improve Memory for People with Multiple Sclerosis

Generation Effect:

Information that is self-generated, or generated from your own mind, is remembered better than information supplied to you.  

This effect has been studied and observed in the general population for decades,1, 2 but was recently studied in multiple sclerosis. Individuals were divided into two groups. The first group was asked to learn new information using the Generation Effect. The second group was simply provided the same information. Both groups were tested immediately after learning, 30 minutes later, and then again one week later. The individuals that used self-generation remembered significantly more than those that were simply provided with the information.3, 4

Let’s try a few examples:

1.  What is the opposite of hot?                                                    c________________

2.  Name this picture:                                                                        h________________

3.  Complete this sentence:   

After the winter storm, I went outside to walk in the cold white ______.        s________________

4.  Name a body part that rhymes with sand:                                                             h_______________d

This technique can be very helpful when you generate the correct information. However, if you generate the wrong information the same rules apply. You will remember the wrong information better, even if you are corrected (i.e., provided the correct answer). 

Think about trying to learn someone’s name.  Was there ever a time when you generated the wrong name and that same wrong name kept popping into your head despite knowing it was incorrect?  Or a time when you opened a particular website, entered the wrong password, then continued to enter that same wrong password during future sessions? These kinds of “memory lapses” happen to everyone. They are not necessarily examples of impaired thinking.  

We just need to learn to use the Gen______n Eff__t (what’s the name of this technique again? Fill in the blanks!) to aid our memory, not work against us. 

Using this Technique in the Real World.

  • Employ the help of a friend or family member. If you are trying to learn someone’s name, have your friend or family member give you hints until you can generate the name yourself. It should be easier to remember next time.

  • Can you generate any additional ways this technique can be used in daily life?

WITHOUT LOOKING, what were the 4 words you generated above?

_________________     _________________     _________________     _________________

Spacing Effect:

Retention of information is improved when individuals use spaced learning (learning that is spaced out over time), rather than massed learning (“cramming”).

Throughout school, I was told to space my studying out over time.  However, like many of my peers, I ignored this recommendation. Little did I know, this recommendation is based on cognitive research. 

The Spacing Effect was also studied in persons with MS.5Individuals were divided into two groups. The first group was given a paragraph to read three times, with a 5 minute break in between each reading (spaced).  The second group was asked to read the paragraph three times in a row, with no break (massed). The spaced group remembered significantly more information in the paragraph than the group who read it three times in the row.  

As adults, many of us are no longer studying to take tests. However, we can still apply this strategy to real life. For example, you may have to give a presentation at work. This requires remembering what you want to say and when.  Review your notes or slides several times, but take breaks in-between each review.  Can you think of any other ways the Spacing Effect can be used in daily life?  

Testing Effect:

Information is remembered better when you are tested on it. 

Remember pop quizzes?  Whether our teachers knew it or not, getting tested on material enhances retention. In fact, testing was found to be more effective than restudying for long-term memory.  In multiple sclerosis, the testing effect was even stronger than the spaced effect for retention of new information.6    

What does this mean for daily life? Test yourself; have a friend or family member test you. 

  • After being introduced to a new person, test yourself on their name.

  • Trying to remember where you parked your car? As you are walking away from the car (or into the store) test yourself on the location of your parking spot.

  • When you are trying to remember some facts for your presentation at work, turn your notes over and test yourself on the content.

What are some other ways you could test yourself throughout the day?

Imagery:

Memory is enhanced through the use of imagery (images in your mind). Several studies in MS have shown that the use of imagery enhances learning and memory.7, 8

A traditional use of imagery is a mnemonic technique called the method of loci.  Let’s pretend you need to remember a list of grocery items, but don’t have a writing utensil or paper to write them down.  You picture a well-known place or building. For example, you might picture your bedroom. Then, in your mind’s eye, “place” needed items around the familiar room.  You might picture a bag of apples on top of a pillow, milk spilled on the top of your dresser, or melted butter on the carpet. Once you get to the store, you can pull up the image of your bedroom, and use the imagery to recall the needed items.  

Imagery can be used in other ways. 

  • If you frequently forget where you placed your keys, try to actively create an image of where they are located when you put them down.

  • You need to pick up your kids from karate today. When the task pops into your mind, imagine getting in your car, as well as the route to the karate studio. This should help trigger the needed task when you get behind the wheel at the end of the day.

  • Can you think of other ways imagery could be useful?

Verbal Rehearsal:

Bringing your attention to the present task by verbally stating the steps out loud. 

Throughout the day we are pulled in many directions. It is very common for our minds to wander to the next task or worry while in the midst of a current task, and this impacts memory.  Here are a few examples:

  • In the midst of cooking, you are worrying about your next doctor’s appointment and suddenly can’t remember how many cups of flour you added

  • You are thinking about the errands you need to run today, then realize you can’t remember if you placed those bills in the mailbox or left them on the kitchen table

  • You walk into a room and can’t remember what you were doing or looking for

  • You park the car and walk into the store while thinking about the items on your grocery list, when you come out of the store you can’t remember where the car is parked

To encode or learn information, your mind first needs to pay attention.  Too often we are thinking about something else in the midst of a current task, which disrupts your brain’s ability to learn and store new information.  Verbal rehearsal brings your mind to the present task, aids attention, and enhances encoding. 

The technique of verbal rehearsal asks you to say out loud what you are currently doing, or what you want to remember. 

  • “One cup of flour, two cups of flour, three cups of flour, I’m done with the flour.”

  • “I’m placing the bills in the mailbox.”

  • “I’m walking to the living room to find my glasses.”

  • “I parked the car near the tall tree with red leaves.”

  • “I’m placing my car keys on the kitchen table.”

It may feel silly at first, but it works! Eventually, when you have the technique down, you can start to say the verbal cues in your head. But first start by saying them out loud. 

In Sum, these are just a few strategies that can be used to enhance your memory.  It can be difficult to incorporate new strategies into your life.  Therefore, start small!  Pick one strategy and try it for a week. When it becomes habit, or you find it does not work for you, try a second one.   

Meghan Beier, PhD is a Rehabilitation Psychologist and Clinical Researcher specializing in multiple sclerosis (MS) at the Johns Hopkins University School of Medicine (Dr. Beier’s profile). Dr. Beier obtained her Ph.D. from Yeshiva University. She also completed a 2-year National Multiple Sclerosis Society (NMSS) funded MS rehabilitation research fellowship in the Department of Rehabilitation Medicine at the University of Washington. Her research and clinical focus is the cognitive and emotional symptoms common to multiple sclerosis.

REFERENCES

1.    Greenwald AG, Johnson MM. The generation effect extended: memory enhancement for generation cues. Mem Cognit 1989;17(6):673-81.

2.    Rosner ZA, Elman JA, Shimamura AP. The generation effect: activating broad neural circuits during memory encoding. Cortex 2013;49(7):1901-9.

3.    O’Brien A, Chiaravalloti N, Arango-Lasprilla JC, Lengenfelder J, DeLuca J. An investigation of the differential effect of self-generation to improve learning and memory in multiple sclerosis and traumatic brain injury. Neuropsychol Rehabil 2007;17(3):273-92.

4.    Chiaravalloti ND, Deluca J. Self-generation as a means of maximizing learning in multiple sclerosis: an application of the generation effect. Arch Phys Med Rehabil 2002;83(8):1070-9.

5.    Goverover Y, Hillary FG, Chiaravalloti N, Arango-Lasprilla JC, DeLuca J. A functional application of the spacing effect to improve learning and memory in persons with multiple sclerosis. J Clin Exp Neuropsychol 2009;31(5):513-22.

6.    Sumowski JF, Chiaravalloti N, Deluca J. Retrieval practice improves memory in multiple sclerosis: clinical application of the testing effect. Neuropsychology 2010;24(2):267-72.

7.    Chiaravalloti ND, Moore NB, Nikelshpur OM, DeLuca J. An RCT to treat learning impairment in multiple sclerosis: The MEMREHAB trial. Neurology 2013;81(24):2066-72.

8.    Ernst A, Blanc F, Voltzenlogel V, de Seze J, Chauvin B, Manning L. Autobiographical memory in multiple sclerosis patients: assessment and cognitive facilitation. Neuropsychol Rehabil 2013;23(2):161-81.

Please feel free to call the Rowan Center for Behavioral Medicine for further information 818-446-2522 or email info@rowancenterla.com.

Physical Activity in Multiple Sclerosis: Does it Improve Cognition?

Many individuals diagnosed with Multiple Sclerosis (MS) will tell you that they not only have to deal with the physical disabling features of MS but also with changes in cognition. Approximately 22-60% of individuals with MS report cognitive impairments in processing speed, new learning and memory, and executive functioning (organizing, problem solving, planning and execution). These difficulties can impact an individuals quality of life, their jobs, and activities of daily living. Many people with MS continue to wonder what they can do to improve their cognitive functioning.  

In a recent study I co-authored with Dr. Beier from the University of Washington School of Medicine, we looked at the relationship between physical fitness and cognitive performance in people with MS (1). A total of 88 individuals with MS participated in this controlled trial (2). Participants had a choice in what health promotion activity they wanted to engage in. In this study we focused on those participants who chose to implement an exercise practice. We wanted to see if improving overall fitness through exercise could help improve the cognitive difficulties that MS patients face during the course of their medical condition. In order to do this the participants in this study were assessed on strength, aerobic fitness and cognition before and after exercising. 

After controlling for the effects of demographic and disease characteristics (age, sex, ethnicity, education, disease activity and MS type), participants who showed improvement in either muscle strength and/or aerobic endurance also showed improvement in executive functioning (remember, this includes higher level cognitive skills such as problem solving, planning and execution, organizing etc.) after 12 weeks of exercise. 

The results of this recent study supports findings from previous research which highlight the positive relationship between physical fitness and cognitive health in people with MS (3-5). Other studies have also shown that physical activity can help improve cardiovascular fitness, range of motion, reduce fatigue, improve flexibility, decrease muscle deterioration, and improve quality of life (6-9)

Physical Activity Recommendations

In the study I presented above, participants engaged in any physical activity of their choice. Some decided to walk daily, others engaged in swimming, some increased there activity by increasing the time they spend on household chores, others engaged in more structured exercises like lifting weights at the gym.  So it is all up to you what type of physical activity you want to engage in. Whatever you decide to do just make sure it has both a strengthening and aerobic training (e.g., walking) component so you can get maximum benefits. 

There really is no prescribed formula of physical activity that would yield the best outcomes. However, there are some evidence-based guidelines that do discuss the frequency, intensity, duration and type of exercise that would increase aerobic capacity and muscle strength. Current evidence-based guidelines are recommending moderate intensity aerobic activity 2 times/week and strength training 2x/week to increases aerobic capacity and muscular strength (10). So basically suggesting that one should try to exercise for a total of 4 days a week, two of the days would be focused on walking, cycling or whatever activity that will increase your aerobic capacity, and the other 2 days would focus on activities that improve muscle strengths (e.g., lifting). Remember always consult with your physician and physical therapist before engaging in any activity.

Here are some more specific tips to get you started*

1.    Set daily goals- The likelihood of completing an activity is higher if the goal is actually written down on paper. So set daily goals and do your best to complete it!
2.    Prepare– Pick a cool, well-ventilated area, wear loose clothing and always have water with you.
3.   Get proper shoes– Since stability could potentially be an issue for some people with MS, you will want to invest in some tennis shoes that will help maximize balance. 
4.    Track activity– If you have a pedometer or even an iPhone use it to track your level of activity. Studies show that those who use activity tracking end up walking or exercising more. Unless you are in a wheelchair this is an effective way to built up your exercise program and can even be helpful in keeping you moving when you are at home. 
5.   Pace your activity-Don’t dive into a challenging workout. The likelihood of drop-out is higher when you take on something difficult and get discouraged because you were unable to complete it. Also, recommendations state that you should start with 10 minutes/day and build up to 40 minutes gradually. 
6.   Do your activity in intervals– As many of you know fatigue and weakness will come on quickly. Take frequent breaks if needed. 
7.   Talk to your Physician– Be sure to consult with your provider before starting any exercise program. You insurance will likely cover the initial cost of seeing a physical therapist (PT) so take advantage of consulting with a PT who can help you tailor your exercises and improve your technique. 

*Always consult with your physician and physical therapist before starting any exercise program.

This study was presented to the European Committee for Treatment and Research in Multiple Sclerosis (ECTRMS), October 4, 2013, Copenhagen, Denmark and Published in Archives of Physical Medicine and Rehabilitation March, 4, 2014. 

About the Authors:

Dr. Narineh Hartoonian is a Clinical Health and Rehabilitation psychologist at the Rowan Center for Behavioral Medicine. She has several years of interdisciplinary clinical and research experience in health and rehabilitation psychology and has served the needs of many individuals with chronic medical conditions and disability. Dr. Hartoonian received her Bachelor and Master of Science in Physiology from the University of California, Los Angeles (UCLA) and her Doctorate in Clinical Psychology from Loma Linda University (LLU). She has taught various graduate and undergraduate courses in the physiological sciences, health and psychobiology.


Dr. Meghan Beier  is a Rehabilitation Psychologist and Clinical Researcher at the University of Washington Medicine Multiple Sclerosis Center. Dr. Beier obtained her Ph.D. from Yeshiva University, and completed a 2-year Multiple Sclerosis rehabilitation research fellowship in the Department of Rehabilitation Medicine at the University of Washington School of Medicine, which was funded by the National Multiple Sclerosis Society. Her research and clinical focus is the cognitive and emotional symptoms common to multiple sclerosis. 

Dr. Beier is also the author of the Multiple Sclerosis and Anxiety blog published on April 22, 2015. Click on the link if you are interested in finding out more about how to screen for anxiety and resources that are available to you. 

REFERENCES 

1.   Beier, M., Bombardier, C. H., Hartoonian, NMotl, R., Kraft, G. (2014) Is improved physical fitness associated with improved cognition in multiple sclerosis? Archives of Physical Rehabilitation and Medicine. DOI: 10.1016/j.apmr.2014.02.017 

2.   Bombardier CH, Cunniffe M, Wadhwani R, Gibbons LE, Blake KD, Kraft GH. The efficacy of telephone counseling for health promotion in people with multiple sclerosis: a randomized controlled trial. Arch Phys Med Rehabil 2008;89:1849-56.

3.   Motl RW, Sandroff BM, Benedict RH. Cognitive dysfunction and multiple sclerosis: developing a rationale for considering the efficacy of exercise training. Mult Scler 2011;17:1034-40. 

4.   Prakash RS, Snook EM, Erickson KI, et al. Cardiorespiratory fitness: a predictor of cortical plasticity in multiple sclerosis. Neuroimage 2007;34:1238-44. 

5.   Sandroff BM, Motl RW. Comparison of ActiGraph activity monitors in persons with multiple sclerosis and controls. Disabil Rehabil 2013; 35:725-31. 

6.   Prakash RS, Snook EM, Motl RW, Kramer AF. Aerobic fitness is associated with gray matter volume and white matter integrity in multiple sclerosis. Brain Res 2010;1341:41-51. 

7.   Motl RW. Physical activity and irreversible disability in multiple sclerosis. Exerc Sport Sci Rev 2010;38:186-91.

8.   Motl RW, Arnett PA, Smith MM, Barwick FH, Ahlstrom B, Stover EJ. Worsening of symptoms is associated with lower physical activity levels in individuals with multiple sclerosis. Mult Scler 2008;14:140- 2.

9.   Motl RW, Weikert M, Suh Y, Dlugonski D. Symptom cluster and physical activity in relapsing-remitting multiple sclerosis. Res Nurs Health 2010;33:398-412.

10.  Latimer-Cheung, A. E., Martin Ginis, K. A., Hicks, A. L., Motl, R. W., Pilutti, L. A., Duggan, M., . . . Smith, K. M. (2013). Development of evidence-informed physical activity guidelines for adults with multiple sclerosis. Arch Phys Med Rehabil, 94(9), 1829-1836 e1827. doi: 10.1016/j.apmr.2013.05.015

Multiple Sclerosis and Anxiety

Multiple sclerosis (MS) is a common neurologic disease that affects approximately 2.3 million individuals around the world. Emotional disorders, such as anxiety, are more common in people diagnosed with MS than in the general population. In fact, approximately 40% of people with MS will experience impactful anxiety in their lifetime. 

What Ways Do People With MS Experience Anxiety?
Anxiety is an umbrella term. There are many different ways people can feel or experience anxiety. Some examples include: generalized anxiety, social anxiety, panic attacks, phobia, obsessive-compulsive disorder (OCD), and post-traumatic stress disorder (PTSD). Panic attacks, specific phobia (an intense fear of a particular thing, such as injections or spiders), and obsessive-compulsive disorder (OCD) are more common in MS than in the general population. However, the most common form of anxiety in MS is generalized anxiety, which is characterized by chronic daily worry. If chronic daily worry reaches a certain threshold of intensity or frequency, and it interferes with your ability to function day-by-day it can be diagnosed as an anxiety disorder. This is called generalized anxiety disorder (GAD). 

A Little More About Generalized Anxiety
Generalized anxiety disorder can be difficult to diagnose and treat because many of the symptoms overlap with common symptoms of MS.  Let’s look at the diagnostic criteria for GAD in more detail:

A diagnosis of GAD is made when an individual experiences excessive, uncontrollable worry and 3 or more of the following symptoms on most days for at least 6 months:
•      Restlessness, feeling “keyed up” or “on edge”
•      *Fatigue
•      *Difficulty concentrating or feeling like your mind goes blank
•      Irritability
•      *Muscle tension
•      *Sleep disturbance: difficulty falling asleep, staying asleep, restless sleep, or unsatisfying sleep

At least 4 of 6 of the GAD symptoms can ALSO be symptoms of MS (*starred above). Thus it can sometimes be difficult to distinguish between what is MS, what is anxiety, and what is both!

So Why Is Anxiety More Common In MS?
Overlap of Symptoms. As we noticed above, a partial explanation is the overlap of symptoms. Because anxiety shares some similar symptoms with MS it is “easier” for someone to meet a diagnostic threshold, or meet the criteria for an anxiety disorder.  However that is not the whole story!

An Emotional Response. Living with a chronic progressive condition, like MS, can be very stressful; there is inherent uncertainty. One might be led down a rabbit hole of worries. You might worry about the disease itself (e.g., Will my disease progress? How fast will it progress? What symptoms might I have in the future? When will I have my next exacerbation?). These thoughts might lead to worries about how MS could impact daily life, work, and family. Anxiety is most common when there is uncertainty about your health condition, especially when newly diagnosed or during relapses.

A Symptom of the Disease. More research is needed to understand the physiological factors that contribute to anxiety in MS. However, there is some evidence that the Fight or Flight Response is disrupted in people with MS who experience anxiety. The Fight or Flights Response is a function of the hypothalamic-pituitary-adrenal axis – a complex system that controls our reaction to stress. Finally, certain medications commonly used in MS have been linked to increased anxiety.

How Do I Know If I’m Anxious?
A questionnaire called the GAD-7 (https://adaa.org/sites/default/files/GAD-7_Anxiety-updated_0.pdf) can help to screen for anxiety. A score of 10 or more on the scale means that anxiety is interfering with your daily life and should be discussed with your medical provider.

Since there are overlapping symptoms between MS and anxiety, it’s best to consult with your health care provider. Your provider will help determine if what you are experiencing is, in fact, anxiety. They can also help you decide the best treatment.

Why Should Anxiety Be Treated?
It is important to treat anxiety. If left untreated, anxiety can interfere with your ability to successfully function in day-to-day life. Anxiety is also associated with: increased pain, poor sleep, more fatigue, MS exacerbations, and pseudo-exacerbations. Anxiety can almost always be treated with counseling (psychotherapy) and/or medications.

Psychotherapy
Cognitive-Behavioral Therapy (CBT) is very effective in treating anxiety disorders. This type of therapy helps you identify and alter maladaptive thinking patterns (cognitions) that reinforce worry and anxiety (e.g., “If I have another exacerbation, I’ll lose my job!”). This therapy also helps you identify and modify actions (behavior) that trigger or reinforce worry and anxiety (for example: avoiding feared situations or objects like injections, doctor appointments, or MRIs).

Acceptance and Commitment Therapy (ACT) is another effective treatment, especially for GAD. The primary goal of ACT is to find ways to pursue your chosen values, despite difficult and potentially unchanging life circumstances (e.g., a diagnosis of MS). 

Medications
Medication does not cure anxiety, but can keep symptoms under control while you learn coping strategies, or until life stressors decrease.  Medications most commonly used for anxiety include: •       Antidepressants: SSRIs, Tricyclics, or MAOIs
•       Anti-Anxiety Medications: benzodiazepines, buspirone
•       Beta-Blockers (prevent the physical symptoms that accompany certain anxiety disorders such as  increased heart rate)

Other strategies for reducing anxiety
•       Mindfulness based stress reduction (MBSR) – Free guided podcasts can be found on the UCLA Mindful Awareness Research Center website (http://marc.ucla.edu/body.cfm?id=22)
•       Deep breathing
•       Regular exercise

How Do I Find Treatment?

If anxiety seems to be a problem for you, talk to your health care provider. He or she can refer you to a mental health professional.  If you are diagnosed with MS, or are the family member/care provider of a person diagnosed with MS, the National MS Society can help. Check out their website (www.natioanlmssociety.org) or call the MS Navigator Program at 1-800-344-4867. Additional resources are listed below.

Resources

National MS Society: Emotional Changes in MS. http://www.nationalmssociety.org/about-multiple-sclerosis/what-we-know-about-ms/symptoms/emotional-changes/index.aspx

National MS Society: Stress

http://www.nationalmssociety.org/living-with-multiple-sclerosis/healthy-living/stress/index.aspx

National MS Society: Exercise is Medicine

http://www.nationalmssociety.org/chapters/was/programs–services/exercise-is-medicine/index.aspx

NIMH: Treatment of Anxiety Disorders

http://www.nimh.nih.gov/health/publications/anxiety-disorders/treatment-of-anxiety-disorders.shtml

 Shadday, A. (2007). MS and your feelings: handling the ups and downs of multiple sclerosis. Alameda CA: Hunter House.

Meghan Beier, PhD is a Rehabilitation Psychologist and Clinical Researcher at the University of Washington Medicine Multiple Sclerosis Center. Dr. Beier obtained her Ph.D. from Yeshiva University, and completed a 2-year Multiple Sclerosis rehabilitation research fellowship in the Department of Rehabilitation Medicine at the University of Washington School of Medicine, which was funded by the National Multiple Sclerosis Society. Her research and clinical focus is the cognitive and emotional symptoms common to multiple sclerosis. 


REFERENCES

1.         Haussleiter IS, Brune M, Juckel G. Psychopathology in multiple sclerosis: diagnosis, prevalence and treatment. Ther Adv Neurol Disord. 2009;2(1):13-29.

2.         S D, Burke T, Bramham J, O’Brien MC, Whelan R, Reilly R, et al. Symptom overlap in anxiety and multiple sclerosis. Mult Scler. 2013.

3.         Eifert G. Acceptance and Commitment Therapy for Anxiety Disorders: Three Case Studies Exemplifying a Unified Treatment Protocol. 2009;16(4):368–85.

Disclaimer

This information is not meant to replace the advice from a medical professional. You should consult your health care provider regarding specific medical concerns or treatment.

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