Psychiatric disorders don’t just change how you feel – they can also break down the brain’s ability to remember, prioritize, and perform simple tasks. It’s easy to brush your teeth, pay your bills, and stay on schedule when those cognitive abilities are intact, but when they fumble even the simplest task is overwhelming, or as one patient colorfully put it “Shopping at the grocery store is like trying to take an SAT test with a box of crayons.”
Kellie Newsome: Generalized anxiety. Major depression. Explosive anger. Mood disorder. Reading the names of these common mental health problems makes it sound like psychiatrists treat emotional disorders. But emotions are just the tip of the iceberg. What psychiatrists are really concerned with is helping people function in their lives, and that involves symptoms that are difficult to see or feel – things like judgment, prioritizing, memory, and attention. We call these cognitive symptoms, and today we’re going to tell you about a new app that helps you measure and track them at home.
Dr. Aiken: You know a lot of what Sigmund Freud said has not held up over time, but he got this right. Someone once asked him what the goal of psychotherapy was, and he replied “To love and work – [these are] are the cornerstones of our humanness.” I get a little teared up every time I read that, because those are the things that psychiatric disorders so often rob people of. Psychiatric disorders rank right alongside pain and cancer as a leading cause of disability. And that disability is not just about work. Functioning is also about the ability to maintain good relationships with friends and family, to enjoy recreation and hobbies, and to take care of yourself from showering to going to the doctor.
Kellie Newsome: And when those things are in place – relationships, work, leisure, and self care – people generally feel well. Well, not all the time. I mean work is stressful, relationships can be hard, and even a well-planned vacation can be a disappointment. Those emotional set-backs are the normal ups and downs of life; heartbreak is not the same thing as depression. But when you can’t hold a job, keep up a hobby, and maintain relationships – well who wouldn’t feel depressed if those things fell apart time and again? And that is the vicious cycle of mental illness. When cognitive functioning goes down – when the brain is not working as well – life falls apart. When life falls apart, people feel depressed. And when they are clinically depressed their brain really doesn’t work well – it can be hard to put one thought in front of another – and finding a meaningful role in life is even more challenging. At the heart of this vicious cycle is functioning. That’s why cognition is so important to recovery. You need to be able to solve problems, stick with a plan, and change gears when necessary to get through life, and all of those are cognitive abilities.
Linda Logan’s Story
Dr. Aiken: Let’s hear from a patient on this. Linda Logan suffered from bipolar disorder, and in 2013 she wrote an article in the New York Times Magazine that struck a nerve in a lot of people. You can read it online and we have the link in the show notes. She wrote that psychiatry is so caught up with symptoms that they don’t take the time to address what is really important to patients: The self. If you’ve never lost your sense of self, you may not know what she means, because the self is that thing that – if we’re lucky – we take for granted. But Linda gives us some good clues as to what she means. Let’s look at how life was for her when she lost her sense of self.
- She lost her career as a writer and teacher.
“If someone asked what I did for a living, I would say, “Nothing” — a remarkably effective conversation stopper.”
- She felt disconnected from her role as a mother.
“I took three-hour naps every afternoon, trying to remember to set the alarm clock, so I would be awake when the kids came home from school. Many times they met a closed bedroom door.”
- She didn’t feel comfortable around other people.
“I couldn’t bear the thought of socializing… I tried to imitate the other mothers, their relaxed camaraderie, their confidence, the way they threw their heads back when they laughed.”
- And eventually, she lost her marriage.
“As he rubbed my feet, he told me he was leaving. It was, at once, a scene of tenderness and savagery.”
But what caused Linda to lose all those things? Here’s how Linda described what was going on in her mind – the source of the problem:
“I lost my sense of competence. Word retrieval was difficult and slow. It was as if the door to whatever part of the brain that housed creativity had locked. Clarity of thought, memory and concentration had all left me. I was slowly fading away.”
A patient said something similar to me this week, and a little more colorful: “I cannot think. Literally. A trip to the grocery store is like taking the SAT with a crayon.”
Kellie Newsome: We take for granted things like shopping for groceries or even brushing our teeth when our mind is working well. One man told me that he was unable to brush his teeth when depressed – and it wasn’t that he lacked the motivation. He would stare at his toothbrush and couldn’t think of what to do next – of course it seems obvious when you’re not depressed – pick up the tooth brush, then pick up the tooth paste with your other hand. No wait you should take the cap off the tooth paste first when your other hand is free. Then pick up the brush. Now squeeze the tooth paste on the bristles, but not too much. Then put it in your mouth – but wait first put the tooth paste down then put the brush in your mouth. As I think about it, brushing your teeth is a lot more complicated than it seems!
Dr. Aiken: And when our mind is working well it intuitively goes through all those steps for us. We don’t have to think about it in that excruciating detail. It’s like the difference between an automatic transmission and a stick shift. There’s a lot more to think about when you have to change the gears yourself.
Breaking Down an Overwhelming Task
Kellie Newsome: And that’s actually a technique we use in therapy for cognitive problems. We have people think of a simple task they’ve been avoiding, like holiday shopping. Then they break it down into smaller steps. First, set a budget. Then make a list of everyone you want to buy gifts for. Write down their age, gender, and interests, and use those specs to search online for gift ideas for each person – like google “Good gifts under $20 for an 8 year old girl who likes basketball.” Then buy the gifts, wrap them, and feel satisfied that you’ve done a good enough job.
Dr. Aiken: There’s a lot you can do to improve cognition. Therapists who specialize in cognition use two types of strategies to help people recover: Remediation and compensation. Remediation means sharpening the brain – directly improving skills like memory, attention, and problem-solving. Compensation means finding ways to creatively adapt to cognitive problems that haven’t improved, such as breaking down tasks into smaller, more manageable chunks as Kellie just described. Other compensatory strategies include using a calendar, setting alarms on your phone, organizing your home so things are easy to find, and keeping to-do lists. But my favorite compensatory strategy is just giving yourself enough time, or more than enough. Recognize that it’s going to take a little longer to do the laundry or shop for groceries, and be kind – give yourself the time you need.
Kellie Newsome: A therapist can help you find practical ways to adapt to cognitive problems. When it comes to remediation, people often wonder if brain-training apps really work. Well, they do, sort of. Few of them make a big difference, and it’s not always clear that that difference translates into anything beyond scoring higher on the app. But here’s an interesting fact – so called dexterity games are actually pretty good at sharpening cognition. This includes things like ping pong, darts, bowling, and video game versions – at least the more active “exergames” like the Nintendo wii. Two of the wii programs – Wii Bowling and wii fit – have some of the best evidence to improve cognitive decline. These games require you to constantly adjust to reality – if the ball swerves too far to the left you’ll need to straighten your arm a little more next time. And that is what functioning in life is all about – trying things out in the world and seeing what happens, then readjusting so we do a little better next time. That’s what helps us get things done at work and maintain friendships. So it’s no surprise that exergames improved mood, cognition, quality of life, and relationships – according to a review of 22 clinical trials that used the Nintendo Wii to help cognition in older adults.
Dr. Aiken: Dexterity games can help cognition, but I wouldn’t play them all day long. In these studies, people used them for 30-90 minutes every other day. There’s even a new videogame out that was approved by the Food and Drug Administration to treat attention deficit disorder called EndeavorRX. You have to navigate down a river that’s filled with obstacles and creatures – some of which you need to avoid and others you need to run into. Sounds like dozens of popular video games, like Mario Kart or Tetris, so what makes EndeavorRX so special? Well, for one thing, the game automatically shuts off after 20 minutes of play per day. All things in moderation.
Kellie Newsome: But what about those brain training apps that promise to improve cognition with memory games? Those can help, but you don’t want to overdo them – 20-30 minutes a day is enough. Some of the apps that have decent evidence backing them up are BrainHQ, Nintendo’s Big Brain Academy, Cognifit, and the Dual N-Back game. That last one is a simple game that’s a bit like the card game Memory or Concentration we played as kids – and there are free versions of it online – just google “Dual N-Back”.
The Top 3: Diet, Exercise, and Sleep
Dr. Aiken: But dexterity games and brain training apps are actually not our top choices to improve cognition. The three things that have the biggest effect on memory and cognition are:
- A healthy diet with lots of fruits and vegetables, healthy oils like olive oil, whole grains, nuts and beans, fish and lean meats. If you want to follow a specific diet that is known to improve cognition, try the Mediterranean diet, the Dash diet, or a Japanese or Scandanvian-style diet. The Mediterranean diet improves depression and it cuts the risk of dementia in half, and last month the DASH diet – which is a diet for high blood pressure that’s very similar to the Mediterranean diet – actually treated ADHD. We’ve combined these brain diets into an easy to follow plan called the Antidepressant Diet – you can find it at www.moodtreatmentcenter.com/lifestyle.
- Aerobic exercise. That means anything that gets your heart beating faster and your breath rate up. Dance, swimming, and biking all count, but the simplest way is just brisk walking – faster than a walk but slower than a job. About 30 minutes a day of walking will improve mood and cognition, and it also strengthens the brain cells in the memory center – the hippocampus. There are measurable increases in brain derived neurotrophic factor or BDNF – a chemical involved in brain repair – even after a single round of exercise.
- Sleep. And we’re talking about quality sleep, not just quantity. When people don’t sleep well, they have trouble learning things the next day – from studying for school to learning physical skills like sports and music. They also have trouble thinking outside the box – or finding creative solutions to life’s many problems. Last month, we covered behavioral strategies that improve sleep, and the guidance there is a good place to start if you want to improve cognition.
Kellie Newsome: Those are also some of the top things you can do for physical health, which reminds me – what’s good for the body is good for the brain. The brain needs good blood flow, stable glucose-sugar levels, and healthy vitamins and nutrients to function just like the rest of the body does. You don’t want it clogged up with gunks of cholesterol or inflamed from all the artificial ingredients in fast food and processed foods. Psychiatric disorders may be felt mentally, but they aren’t just in your head – they are tightly linked to the health of the brain and body.
Dr. Aiken: Now that you’ve got a start on improving your cognition, the next step is to measure your progress. Join us next month where we’ll talk about how to do that.
About the Carlat Report
The Carlat Report is an independent publisher of all things psychiatric. Its books, journals, and podcasts have operated free of advertising and pharmaceutical industry support since 2003.