Running From Depression

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A recent study by Cruz et al, “Anxiety and Depression in Cystic Fibrosis,” (Semin Respir Crit Care Med 2009; 30: 569-578) came across my desk the other day.  Oddly, I was in the middle of creating a talk about exercise and was on the exact slide where I talk about my favorite book on the subject of exercise, Spark, by Dr. John Ratey.

Ratey is a psychiatrist at Harvard and one of his areas of expertise is the neurochemistry of exercise.  I read this book when it first came out and have practically forced most of my clients and several family members to do the same.

The Cruz study points out in grave detail the increased prevalence of both anxiety and depression in people with cystic fibrosis, noting that these have important consequences, including poorer disease outcomes and lower scores on measures of quality of life.  Depression especially wreaks havoc on adherence.   It makes sense, really.  When you are depressed, it is very easy to blow off treatments.  When you don’t care, why bother? When you are consumed with anxiety, a trip to the gym is not the first thing you think about doing.

After these grave facts are discussed, the authors conclude that better screening for depression and anxiety should be done on patients with CF, and treatment given to those with symptoms, including medication or therapy (or both).  I would add one more tool to the bag, one that in fact would also likely work as a preventative measure.  And…it’s free (a big plus these days).

If Ratey is to be believed (and he gives sound reasoning and research to back up his material), the BEST time to head to the gym or lace up your walking shoes is when you are blue and don’t feel like doing anything.   The reason is that exercise acts as an antidepressant.  In fact, exercise is nature’s perfect antidepressant…with no side effects.  The reasons are complex, but I am going to try to simplify:

First and foremost, to call “depression” a disease is like calling a “cough” a disease.  A cough is a symptom that something is wrong.  Perhaps you have asthma.  Maybe you are choking on a marble.  It could be that the air is extremely polluted and all sentient beings are suffocating.  The bottom line is the cough tells you that something is wrong.  The underlying cause is yet to be named.

In the same way, depression is a symptom.  Many things can cause depression: pain, stress, medications, trauma, addiction, AND altered neurochemistry, to name a few.  Just looking at the last one, the brain’s chemistry can be messed up in completely different pathways and yet the final result can look similar.  This is why a medication that blocks the re-uptake of serotonin may work on me, but not you.  Someone else may only respond to a medication that increases Dopamine…or Norepinephrine.  The names are not important.  What is important is to understand that the whole thing is very complex.

And yet, one thing that we all can do at some level, exercise, seems to be able to jolt the brain back into balance.  It seems to regulate the neurotransmitters that antidepressants target….all of them…and at just the right dose.

Almost immediately when starting to exercise vigorously, norepinephrine is elevated.  This is the wake up and get going chemical that also works mysteriously on boosting self-esteem.  Also, dopamine, the brain’s attention system and regulator of feelings of well being, is elevated.  Finally, the well-known chemical serotonin, important for mood, self-esteem and impulse control, bumps up.  And to add frosting to this cake, endorphins are made within the brain upon exercise, and we all know what endorphins do…

So that’s the chemical story.   But there is an architectural one as well.  Exercise causes release of something called BDNF (brain-derived neurotropic factor), which Ratey calls “Miracle-Gro for the brain.”  This, and other neurotropins cause the brain to a) make new cells, and 2) create and foster new connections between brain cells.  As he explains, depression is caused not just by a lack of neurotransmitters, but also by a lack of connections within the brain itself.  BDNF fixes this.  Exercise releases BDNF.

Yes we are at high risk for depression.  And yes, depression is very bad for compliance with a complicated medical regimen.  Sure, we could take another pill or two or three (and some of us may need to) to combat depression.  But one easy thing to try right now is to move.  Every day.

Posture For the Sick and Happy

A few days ago, I uploaded the above video to YouTube.  I think posture is an incredibly important thing to think about when living with a pulmonary disease, so I thought it deserved a blog post.

Think about it:  When you have cystic fibrosis, or any other pulmonary disease, every single alveolus is precious (“alveolus” is medical speak for the tiny little air sac that, together with it’s millions of comrades, comprise the lung and allow for oxygen exchange–I like to think like a doctor sometimes).

As we get older, (happily, we all are now, aren’t we) there are two forces working against our lungs–gravity, and CF.  We tend to think that we have little control over either, but we do!  I write all the time about how we can positively influence our health by controlling what we can about CF.  We can do our treatments.  We can eat nutritiously.  We can exercise religiously.  We can get enough sleep.  We can make sure we go to all of our clinic appointments….etc.

Today, my focus is on how to control gravity!  Really.

Now mind you, I like gravity.  It does many very positive things!  It would be quite a chore to sit here and type without the assistance of gravity.  But, gravity can wreak havoc on your body if you don’t learn to use it properly.

Huh?

Our bodies were designed by a genius(es…who knows?).  The bottom line is that our bones, muscles, tendons and ligaments all start out aligned to oppose gravity perfectly…until we screw it up.  As I sit and type right now, my shoulders are rounded, my upper back is hunched over my computer, and my chin is jutted out over my chest.  I know that’s sort of a scary image, but stick with me here.

Look around.  Isn’t just about everyone assuming that position?  It doesn’t just happen when typing or sitting at a computer all day.  We gravitate unconsciously to this position  when we play video games (watch your kids do this for a good shock), when we drive, when we play poker, when we slouch on the couch, you name it.  It happens as we rush from one thing to the next.  Isn’t your chin usually the first thing to enter the room?  There are opportunities for this posture all day long!  Over time–and not that much time– our default position consists of forward rounded shoulders, hunched over upper backs, and forward jutting chins.  Compensating for all of this often comes a sway-back position of the lumbar spine.  Suddenly, gravity is our arch enemy.

When you throw your body into this position, the muscles, ligaments and tendons  of your back and neck HAVE to work overtime to simply keep you upright.  These poor muscles become chronically overworked…and they let you know it.  Slowly, the muscles of your upper back become stretched to a position that is not optimal, and they are thus weakened.  At the same time, the muscles of the front of your shoulders and chest, low back and hip flexors (remember that sway back thing?) becomes tight and shorter than their optimal length, thus weakened.  So, front and back muscles are weak, and working over time to keep you from falling on your face.

Ok, now throw in a chronic cough.  Does your back and chest wall  go into spasm just thinking about this?  Now you understand REASON ONE for establishing good posture when you have CF.

Now for REASON TWO:  Conjure up that image again, the one of the rounded shoulders, and slumped upper back.  Do you think it is possible to take a full breath using all available lung tissue when in this position?  Not a chance.  You  can use most of your upper lungs when you are collapsed that way.

It is estimated that poor posture can rob you of __% of lung tissue.  Now, I don’t know about you, but I need every bit of my lung tissue with every breath I take.  I can’t afford the improper effects of gravity1

So watch the video, and try to incorporate at least one or two of these exercises every day.  They aren’t hard, and they don’t take much time.  They will slowly work to strengthen and shorten those overstretched back muscles, and stretch and strengthen those tight chest and shoulder muscles.  The result will be that you will be able to pull your shoulder blades back and down, thus opening your chest and allowing for full expansion of your lungs.

The next trick will be actually remembering to do this!  I have some tricks for this, too.  Watch for my “mindful breathing intervals” in a blog post coming to you soon!

THE TRYING, I MEAN ADOLESCENT, YEARS

My oldest son is about to turn 12, and I am getting a first taste of what is to come.  This will require fortitude….and the ability to dance.  No, I don’t mean really “dance,” I mean mentally and emotionally dance with him, as he comes into his own.  Now, if he had CF and I were trying to get him to exercise as a method of airway clearance and self-esteem enhancement, I would:

1. Not exactly phrase it that way.
2. Make sure it included other peers (unless this causes additional discomfort, embarrassment, etc…).
3. Introduce weight training as soon as he/she is capable of following direction and mature enough to be safe.
4. Strictly enforce the bike/walk/scooter/skate to school, the store, a friend’s house, etc… rule.
5. Hope that he/she liked to play soccer, basketball, baseball, or whatever team sport was available, so that a “coach” ordered the training, and not me.
6. Continue to use enticement, aka bribery, to encourage daily exercise.

Let’s take them one at a time, shall we?

The Wording and the Timing of the Wording
First, the word “exercise” has unfortunately taken on a negative connotation among many of our youth these days.  I don’t quite get it, frankly.  When I was a kid, the trick was in getting me and my friends to come in at night.  Now it is the exact opposite.  I suppose it has something to do with the myriad forms of indoor entertainment these days.  The problem has become that in trying to entice some form of movement away from electronic screens, we (and by we, I mean I) use the words “You need to get some exercise!”  Instant negative reinforcement.  “Exercise” is equated with  the taking away of something good…screentime.

If you are a psychology buff, you know that this negative reinforcement is not going to promote the behavior (exercise) that you want.  A more useful way to reinforce that behavior is to associate something positive with it.  Like Pavlov and the dog! Remember, bell…food.   So yes, get them away from the screen.  By all means.  But don’t repeat my mistake, and use getting exercise as the reason why.  Bad idea.

More on positive reinforcement later.

Make it Social

Though not a universal characteristic of teenagers, most would rather hang out with friends than do pretty much anything else.  If I ask my son to please take the dog for a walk, I get a, “Why….?  I don’t want to….I had gym class today….I’m tired…etc…”  If I instead say, “Will you take the dog over to your friend’s house and see if he’ll walk his dog with you?”, he’s off like a flash.  It’s just (teenage) human nature.  So why fight it?  This is one of those Aikido moments…use the opponents force to get them to do what you want.

When I was a teenager, it was only by starting to hang out with active friends that I discovered my inner athlete.  My parents didn’t really encourage it….it just happened.  I still wonder what would have happened had I stayed in my shell.

Weight Training

It is an old wives’ tale that teenagers shouldn’t lift weights until they are fully grown for fear of damage to the epiphyseal plates.  The truth is that as soon as a kid is mature enough to follow instructions and be safe in a gym with a trainer, it is perfectly fine to start weight training.

And the teenage years are the best for starting this habit early on.  Why?  For one thing, body image issues become overwhelming at this age, as we all can remember.  Now imagine going through that again, but this time with CF.  As a teen with CF, you deal with growth delay, puberty delay, an “unpredictable” body when it comes to lung function and GI function.  Your friends see you take a handful of pills and wonder what is wrong with you.  You spend inordinate amounts of time in bathrooms, your fingernails look weird…you get the picture.

Wouldn’t it be nice to be able to do something that had a visible, positive effect on your body that CF didn’t really effect?

The answer is unquestionably, yes!  It had a profound effect on me, and I have spoken with many other adults who say the same thing.  This is an issue where a child can actually have an “internal locus of control.”  They can get stronger!  They can put on muscle!  They can start winning arm wrestiing matches!  And CF can’t touch this.

Make Use of Multitasking

We are all pretty good at multitasking, so this one should be a no-brainer.  We all have to go places…even our children.  School, friends’ houses, the store, downtown, ball games, church….whatever.  We travel.  It is easy (I know) to get locked into a pattern of driving to all of these places.  Certainly, when the weather is bad, we need to do this.  But how many times could we just say, “I’m not driving you today.  I’ll walk or ride bikes with you…but we are going to get there the low tech way today….just for fun.”

Just as it is with small kids, it is not necessary to get all of ones aerobic exercise for the day done in one session.  It works just as well to break it into two or three smaller chunks.  So that 15 minute bike ride (each way) to school, if done intensely, could be just what the doctor (or coach) ordered for the daily goal.

Defer to the Coach

This trick works if you son or daughter is on a sport team, and practices with the team.  Then your job is easy…the coach makes your kid work, and you are off the hook.  If this describes your situation, count your lucky stars.

Not all kids are “team” types, of course.  So then what do you do?  Well, here is my pitch for wellness coaching.  If your child is mature and appreciates the need to  establish an exercise habit, working with a wellness coach is a great idea.  There are a couple of caveats, though.  First, if your child is not into the idea and only you are…it doesn’t work.  Behavior change is tricky business, and one thing is for sure, the changee has to want to do the hard work of changing.  The coach doesn’t do it….the parent doesn’t do it.  Second, I’ve learned through doing this that until a child is in their teens, it is best to scheule “family coaching” sessions.  Taking on a new habit is a big job, and a child needs support from not just a coach, but also from their family members.  Everyone in the familly needs to understand the plan, and be ready with support and encouragement.

Bribery

Now, we could call this something else I suppose.  But the truth is that is isn’t such a bad thing for a kid to understand the concept of quid pro quo.  Just as I said this works for younger aged children (remember pedometer steps for video time, stickers for exercise), when kids become teens, the concept still works; the stakes just get to be a bit higher.  Now we may be talking going to the movies, getting the car keys, going out with friends…you name it.

When you start feeling guilty about this, remember that the ultimate goal is for your chilld to learn for themselves during this time that they actually feel better when they exercise, and will hopefully find some activities that they love to do, and will keep loving to do into adulthood.  This is a critical time..and it calls for some …unorthodox methods.

If you have great ideas that have worked for you in encouraging your teenager with CF to exercise, please share them here.

HOW TO GET FIT IN THREE EASY STEPS

Got your attention, didn’t I?
I wish it were that simple, but alas, it does take some planning and some discipline.

The first easy step is to find out why you want to be fit!  How simple.  You don’t even need running shoes for this one.  Take out a sheet of paper and list as many ways  you can come up with to answer the following:
“I want to be fit because…..”
Aim for at least 20 reasons.  If you can’t think of 20, go back to number one, and ask yourself, “Why is that important to me?”  Then do the same for number 2, 3, 4…,
This is an important step, so although you may think it sounds stupid, don’t skip it.  Now scan down your list, and underline the things that matter most to you, not to your doctor, or your parents, or spouse, or friends…just to you.  This is the real list…the one you want to post on your bathroom mirror, or some similar spot where you are sure to see it every day.

The second easy step is to discover what you love to do for exercise.  This may occur as you remember what you loved as a kid playing outside for hours, or it may mean getting brave and trying a few new things.  It doesn’t have to be marathon running or swimming the English Channel.  It just has to be something where you move…and something where, when you want to, you can increase the intensity enough to get your heart rate up and breathe deeply.

The third easy step is to DO IT.  Every day.  Start small…maybe just 5-10 minutes.  But commit to doing something every day (unless you are sick, of course).
I heard a great mantra about this somewhere:

Stand up.  Take a step.  Repeat.

Some days, you may not feel motivated!  Surprise, surprise.  But that happens to everyone.  Don’t let it stop you!  Look at your list from #1, then tell yourself to go out and do a little bit.  Sometimes when I do that, I end up having the best workout ever.

There is no good reason not to do this.  There are so many reasons to do this, that I will make it a separate post.

Discover Your Strengths and USE Them Every Day

I am a personal fan of the field of positive psychology.  I love to read about what it is and what it is teaching us about the science of happiness.  I like to take courses and attend conferences about the subject.  In fact, the whole purpose of this blog (and hopefully of a future book) is what the scientific study of positive emotion can teach people with serious health concerns about optimizing their happiness and wellness within the context of illness (hence the title of the blog).

The “D” in my acronym stands for “Discover Your Strengths and Use Them Every Day.”  First, I want to describe why this is important when it comes to happiness.  Then I will show you how to discover your strengths the high tech way (an online resource).  Of course, you could just ask you mother.  Then I’m going to describe a project I am designing for this blog that allows me to use my strengths as an example of putting this “rule” into action.

It used to be that to “improve ourselves,” we were to work on our weaknesses. However, new research shows that living and working from our unique strengths rather than paying attention to deficits creates lasting personal happiness and allows for peak performance. When we identify and further develop our unique talents and character strengths, we contribute more effectively and enjoy the process more.

It makes sense, really.  Imagine that you are doing something that you are really good at, working towards a goal that you strongly believe is important.  In fact, go ahead and close your eyes and remember such a time.  Remember the feeling of mastery and  flow you might have felt during the activity, and the sense of accomplishment when you were finished.

Now remember the last time you struggled to do something that was beyond your skill level.  It was likely something that you were not innately good at, and likely caused great frustration and a feeling of inadequacy.

Clearly, the first situation leads to positive emotion; the latter, not so much.

What are your strengths?  You probably have a good idea without a scientifically designed questionnaire.  But, if you take it, you might be surprised.  I know I was.

In his book, Authentic Happiness, Martin Seligman describes how he and his colleagues came up with the Values In Action (VIA) classification of character strengths. There are 24 character strengths each describing a specific aspect of positive human character. The strengths are grouped into six categories termed virtues. These virtues have been determined cherished among most religious and philosophical traditions.  Collectively, they are said to capture the notion of good character.  The characteristics of character strengths are:

•    They are moral traits and can be developed and strengthened by choice.
•    They are valued for themselves rather than as a means to an end.
•    Using them elevates rather than diminishes others.
•    They are ubiquitous.

We all have the ability to exhibit any of the 24 character strengths but tend to rely on some more than others. The website www.authentichappiness.com offers a free, online survey called the VIA (Values in Action) Signature Strengths Questionnaire, which ranks your strengths in order of importance to you. Your top five strengths are your Signature Strengths.

When I took this questionnaire, I was intrigued by what turned out to be my top five strengths.  I won’t go into them all now, but one that struck me as quite useful for me to have was number two:

Hope, optimism, and future-mindedness
You expect the best in the future, and you work to achieve it. You believe that the future is something that you can control.

Maybe that has something to do with why I have done so well (so far) even though I have cystic fibrosis.

I love to do projects…especially projects related to either learning something, or achieving an athletic goal.  I love to set a goal, and then plan my strategy to achieve it.  I am now, and always have been, very goal oriented.  Goals excite me…they challenge me, and bring out the same self-discipline that carried me through medical school.

Not surprisingly, I was a sucker for the P90X home exercise program this spring, and have written about that experience and the unexpected results in a previous post, “How I Grew a New Lung in 90 Days.”  Now that I have a PICC in for IV antibiotics again, I am already starting to plan for the next round of “get Julie back in shape”.  And, now that I have this blog, I am going to post what I do and how it felt each day.  Why?  So that if any of you are interested in joining me, you can do so, and we can motivate each other!  The best thing about a blog is that it allows comments…both to and from the blogger.

So, if you want to join me, the start date is Monday, September 29.  This will be a three-month program (unless my lungs say differently).  I am creating a program that merges the P90X program with a weight-training regimen I have done in the past to successfully gain muscle mass.  There will be six exercise sessions per week with one rest day.  Each session will take about an hour…except on ab days (ouch).  You will go at your own pace, but I will recommend a given “perceived exertion level.”

The equipment needed is: you, water, supportive athletic shoes, some light free weights, and a chin up bar.  If you can, buy the P90X program.  I will use their aerobic and ab routines because they are great!  Also, if you don’t want to go to a gym, you can do the weight training sessions with just the above equipment.  The program I am doing is a modified P90X because I love going to the gym and lifting heavier weights.  The P90X weight workouts are good, and if you do them, you will definitely get stronger.  I just need to atmosphere of my gym, and want to use heavier weights because I have some significant strength to regain.

Are you game?