feeling good the new mood therapy 
by david burns 


DAVIDD.BURNStM.D. REVISED AND UPDATED MORE THAN THREE
MILLION COPIES IN PRINT NOW WITH THE ALL-NEW CONSUMER'S
GUIDE TO ANTIDEPRESSANT DRUGS AND A NEW INTRODUCTION
FROM THE AUTHOR fOJflG 00D Ttif Hew ITIOOD Ttif RflPY The
Clinically Proven Drug-free Treatment for Depression
HEALTH Fff uriG Good fff ls W OflDfRfUL The good news is that anxiety,
guilt, pessimism, procrastination, low self-esteem, and other "black holes" of
depression can be cured without drugs. In FEELING GOOD, eminent
psychiatrist David D. Burns, M.D., outlines the remarkable, scientifically proven
techniques that will immediately lift your spirits and help you develop a positive
outlook on life: • Recognize what causes your mood swings • Nip negative
feelings in the bud • Deal with guilt • Handle hostility and criticism • Overcome
addiction to love and approval • Beat "do-nothingism" • Avoid the painful
downward spiral of depression • Build self-esteem • Feel good every day BEGIN
NOW, TO EXPERIENCE THE JOY OF Fff uriG Good "f\ BOOK TO READ
AND RE-READ!"—Los Angeles Times ISBN 0-380-73176-2 Quill An Imprint
of blaiperCoUinsPublishers www.harpercollins.com 51 8038031763" A USA
$15.00 Canada $23.00 |
Feeling Good: The New Mood Therapy has sold more than 3 million copies
worldwide to date. In a recent national survey, Feeling Good was rated as the
most helpful book on depression— from a list of over 1,000 self-help books—
and was the most frequently recommended book for de- depressed individuals
by American mental health professionals. Dr. Burns' Feeling Good Handbook
was rated #1 in the same survey. Although self- help books are quite
controversial, five controlled outcome studies published in scientific journals
over the past decade indicated that 70 percent of depressed individuals who read
Feeling Good improved within four weeks even though they re- received no
other treatment. In addition, these pa- patients have maintained their
improvement during follow-up periods of up to three years. SurprisSurprisingly, the antidepressant effects of Feeling Good appear to be as strong as
antidepressant medica- medications or individual psychotherapy for patients
suffering from episodes of major depression! Although Dr. Burns does not
recommend any self- help book as a substitute for professional therapy, Feeling
Good should prove immensely illu- illuminating to anyone suffering from
depression or anxiety. Feeling Good Feels Wonderful! You Owe It to Yourself
to Feel Good! "I would personally evaluate David Burns' Feeling Good as one of
the most significant books to come out of the last third of the Twentieth
the most significant books to come out of the last third of the Twentieth
Century." Dr. David F. Maas, Professor of English, Ambassador University
Also by David D. Burns, M.D. The Feeling Good Handbook Intimate
Connections Ten Days to Self Esteem The Leader's Manual
fffuno GOOD vj jut new DAVIDD.BURNS.M.D. Preface by Aaron T hd, H D
Quill An Imprint ofHarperCoWmsPubhshers
The ideas, procedures, and suggestions contained in this book are not intended as
a substitute for consulting with your physician. All matters regarding your health
require medical supervision. A hardcover edition of this book was published in
1980 by William Morrow and Company, Inc. FEELING GOOD. Copyright ©
1980 by David Burns. All rights reserved. Printed in the United States of
America. No part of this book may be used or reproduced in any manner
whatsoever without written permission except in the case of brief quotations
embodied in critical articles and reviews. For information address HarperCollins
Publishers Inc., 10 East 53rd Street, New York, NY 10022. HarperCollins books
may be purchased for educational, business, or sales promotional use. For
information please write: Special Markets Department, HarperCollins Publishers
Inc., 10 East 53rd Street, New York, NY 10022. First WholeCare edition
published 1999. Reprinted in Quill 2000. Library of Congress Cataloging-inPublication Data is available. ISBN 0-380-73176-2 09 08 07 06 RRD 30 29 28
27
This book is dedicated to Aaron T Beck, M.D., in admiration of his knowledge
and courage and in ap- appreciation of his patience, dedication and empathy.
Acknowledgments I am grateful to my wife, Melanie, for her editorial assisassistance and patience and encouragement on the many long evenings and
weekends that were spent in the preparation of this book. I would also like to
thank Mary Lovell for her enthusiasm and .for her technical assistance in typing
the manuscript. The development of cognitive therapy has been a team effort
involving many talented individuals. In the 1930s, Dr. Abraham Lowe, a
physician, began a free-of-charge self-help movement for individuals with
emotional diffi- difficulties, called "Recovery Incorporated," which is still in
existence today. Dr. Lowe was one of the first health pro- professionals to
emphasize the important role of our thoughts and attitudes on our feelings and
behavior. Although many people are not aware of his work, Dr. Lowe deserves a
great deal of credit for pioneering many of the ideas that are still in vogue today.
In the 1950s, the noted New York psychologist, Dr. Al- Albert Ellis, refined
In the 1950s, the noted New York psychologist, Dr. Al- Albert Ellis, refined
these concepts and created a new form of psychotherapy called Rational
Emotive Therapy. Dr. El- Ellis published over fifty books that emphasize die
role of negative self-talk (such as "shoulds" and "oughts") and irrational beliefs
(such as "I must be perfect") in a wide • • VII
viii Acknowledgments variety of emotional problems. Like Dr. Lowe, his
brilliant contributions are sometimes not sufficiently acknowledged by academic
researchers and scholars. In fact, when I wrote the first edition of Feeling Good,
I was not especially fa- familiar with the work of Dr. Ellis and did not really
appre- appreciate the importance and magnitude of his contributions. I want to
set the record straight here! Finally, in the 1960s, my colleague at the University
of Pennsylvania School of Medicine, Dr. Aaron Beck, adapted these ideas and
treatment techniques to the problem of clin- clinical depression. He described the
depressed patient's neg- negative view of the self, the world, and the future, and
proposed a new form of "thinking therapy" for depression, which he called
"cognitive therapy." The focus of cogni- cognitive therapy was helping the
depressed patient change these negative thinking patterns. Dr. Beck's
contributions, like those of Drs. Lowe and Ellis, have been substantial. His Beck
Depression Inventory, published in 1964, allowed cli- clinicians and researchers
to measure depression for the first time. The idea that we could measure how
severe a pa- patient's depression was, and track changes in response to treatment,
was revolutionary. Dr. Beck also emphasized the importance of systematic,
quantitative research so we could get objective information on how well the
different kinds of psychotherapy actually worked, and how effective they are in
comparison to antidepressant drug therapy. Since the time of those three early
pioneers, many hun- hundreds of gifted researchers and clinicians throughout the
world have contributed to this new approach. In fact, there has probably been
more published research on cognitive therapy than on any other form of
psychotherapy ever de- developed, with the possible exception of behavior
therapy. Clearly, I cannot mention all the individuals who have made important
contributions to the development of cog- cognitive therapy. In the early days of
cognitive therapy, during the 1970s, I worked with several colleagues at the
Univer- University of Pennsylvania School of Medicine who helped to create
many of the treatment techniques still in use today.
Acknowledgments ix They included Drs. John Rush, Maria Kovacs, Brian Shaw,
Gary Emery, Steve Hollon, Rich Bedrosian, Ruth Green- berg, Ira Herman, Jeff
Young, Art Freeman, Ron Coleman, Jackie Persons, and Robert Leahy. Several
individuals have given me permission to refer to their work in detail in this book,
individuals have given me permission to refer to their work in detail in this book,
including Drs. Raymond Novaco, Arlene Weissman, and Mark K. Goldstein. I
would like to make special mention of Maria Guarnas- chelli, the editor of this
book, for her endless spark and vitality which have been a special inspiration to
me. During the time I was engaged in the training and re- research which led to
this book, I was a Fellow of the Foun- Foundations' Fund for Research in
Psychiatry. I would like to thank them for their support which made this
experience possible. And my thanks to Frederick K. Goodwin, M.D., a former
chief at the National Institute of Mental Health, for his val- valuable consultation
with regard to the role of biological fac- factors and antidepressant drugs in
treating mood disorders. Two Stanford colleagues, Drs. Greg Tarasoff and Joe
Bel- lenoff, provided helpful feedback about the new drug chap- chapters. I
would like to thank Arthur P. Schwartz for his encour- encouragement and
persistence. I would also like to thank Ann McKay Thoroman at Avon Books for
editorial help on the new psychopharmacology chapters. Finally, I would like to
thank my daughter, Signe Burns, for extraordinarily helpful suggestions and
meticulous ed- editing of the new material in this 1999 edition.
Preface I am pleased that David Burns is making available to the general public
an approach to mood modification which has stimulated much interest and
excitement among mental health professionals. Dr. Burns has condensed years of
re- research conducted at the University of Pennsylvania on the causes and
treatments of depression, and lucidly presents the essential self-help component
of the specialized treat- treatment that has derived from that research. The book
is an important contribution to those who wish to give them- themselves a ' 'top
flight'' education in understanding and mas- mastering their moods. A few words
about the evolution of cognitive therapy may interest readers of Feeling Good:
The New Mood Therapy. Soon after I began my professional career as an
enthusiastic student and practitioner of traditional psychoanalytic psychipsychiatry, I began to investigate the empirical support for the Freud- Freudian
theory and therapy of depression. While such support proved elusive, the data I
obtained in my quest suggested a new, testable theory about the causes of
emotional distur- disturbances. The research seemed to reveal that the depressed
in- individual sees himself as a "loser," as an inadequate person doomed to
frustration, deprivation, humiliation, and failure. Further experiments showed a
marked difference between the xi
xii Preface depressed person's self-evaluation, expectations, the aspiraaspirations on the one hand and his actual achievements—often very striking—
on the other. My conclusion was that depres- depression must involve a
disturbance in thinking: the depressed person thinks in idiosyncratic and
disturbance in thinking: the depressed person thinks in idiosyncratic and
negative ways about him- himself, his environment, and his future. The
pessimistic mental set affects his mood, his motivation, and his relationships
with others, and leads to the full spectrum of psychological and physical
symptoms typical of depression. We now have a large body of research data and
clinical experience which suggests that people can learn to con- control painful
mood swings and self-defeating behavior through the application of a few
relatively simple prin- principles and techniques. The promising results of this
in- investigation have triggered interest in cognitive theory among psychiatrists,
psychologists, and other mental health professionals. Many writers have viewed
our find- findings as a major development in the scientific study of
psychotherapy and personal change. The developing the- theory of the emotional
disorders that underlies this research has become the subject of intensive
investigations at ac- academic centers around the world. Dr. Burns clearly
describes this advance in our under- understanding of depression. He presents, in
simple language, innovative and effective methods for altering painful dedepressed moods and reducing debilitating anxiety. I expect that readers of this
book will be able to apply to their own problems the principles and techniques
evolved in our work with patients. While those individuals with more severe
emotional disturbances will need the help of a mental health professional,
individuals with more manageable problems can benefit by using the newly
developed "common sense" coping skills which Dr. Burns delineates. Thus
Feeling Good should prove to be an immensely useful step-by-step guide for
people who wish to help themselves. Finally, this book reflects the unique
personal flair of its
Preface xiii author, whose enthusiasm and creative energy have been his
particular gifts to his patients and to his colleagues. Aaron T. Beck, M.D.
Professor of Psychiatry, University of Pennsylvania School of Medicine
Contents Introduction xvii Part I. THEORY AND RESEARCH 7 1. A
Breakthrough in the Treatment of Mood Disorders 9 2. How to Diagnose Your
Moods: The First Step in the Cure 19 3. Understanding Your Moods: You Feel
the Way You Think 28 Part II. PRACTICAL APPLICATIONS 51 4. Start by
Building Self-Esteem 53 5. Do-Nothingism: How to Beat It 81 6. Verbal Judo:
Learn to Talk Back When You're Under the Fire of Criticism 131 7. Feeling
Angry? What's Your IQ? 149 8. Ways of Defeating Guilt 198 Part III.
"REALISTIC DEPRESSIONS 229 9. Sadness Is Not Depression 231 xv
xvi Contents Part IV. PREVENTION AND 259 PERSONAL GROWTH 10.
xvi Contents Part IV. PREVENTION AND 259 PERSONAL GROWTH 10.
The Cause of It All 261 11. The Approval Addiction 290 12. The Love
Addiction 311 13. Your Work Is Not Your Worth 327 14. Dare to Be Average!
Ways to Overcome Perfectionism 352 Part V. DEFEATING HOPELESSNESS
381 AND SUICIDE 15. The Ultimate Victory: 3 83 Choosing to Live Part VI.
COPING WITH THE 407 STRESSES AND STRAINS OF DAILY LIVING 16.
How I Practice What! Preach 409 Part VII. THE CHEMISTRY OF MOOD 425
17. The Search for "Black Bile" 427 18. The Mind-Body Problem 455 19. What
You Need to Know about Commonly Prescribed Anti- 474 depressants 20. The
Complete Consumer's Guide to Antidepressant Drug Therapy 513 Notes and
References (Chapters 17 to 20) 682 Suggested Resources 688 Index 693
Introduction (Revised Edition, 1999) I h^ve been amazed by the interest in
cognitive behavioral therapy that has developed since Feeling Good was first
published in 1980. At that time, very few people had heard of cognitive therapy.
Since that time, cognitive therapy has caught on in a big way among mental
health professionals and the general public as well. In fact, cognitive therapy has
become one of the most widely practiced and most intensely researched forms of
psychotherapy in the world. Why such interest in this particular brand of
psychother- psychotherapy? There are at least three reasons. First, the basic
ideas are very down-to-earth and intuitively appealing. Second, many research
studies have confirmed that cognitive ther- therapy can be very helpful for
individuals suffering depression and anxiety and a number of other common
problems as well. In fact, cognitive therapy appears to be at least as helpful as
the best antidepressant medications (such as Pro- Prozac). And third, many
successful self-help books, including my own Feeling Good, have created a
strong popular de- demand for cognitive therapy in the United States and
throughout the world as well. Before I explain some of the exciting new
developments, let me briefly explain what cognitive therapy is. A cogni- xvii
xviii Introduction tion is a thought or perception. In other words, your cogcognitions are the way you are thinking about things at any moment, including
this very moment. These thoughts scroll across your mind automatically and
often have a huge im- impact on how you feel. For example, right now you are
probably having some thoughts and feelings about this book. If you picked this
book up because you have been feeling depressed and dis- discouraged, you may
be thinking about things in a negative, self-critical way: "I'm such a loser. What's
wrong with me? I'll never get better. A stupid self-help book like this couldn't
possibly help me. I don't have any problem with my thoughts. My problems are
real." If you are feeling angry or annoyed you may be thinking: "This guy Burns
is just a con artist and he's just trying to get rich. He prob- probably doesn't even
is just a con artist and he's just trying to get rich. He prob- probably doesn't even
know what he's talking about." And if you are feeling optimistic and interested
you may be think- thinking: "Hey, this is interesting. I may learn something
really exciting and helpful." In each case, your thoughts create your feelings.
This example illustrates the powerful principle at the heart of cognitive therapy
—your feelings result from the messages you give yourself. In fact, your
thoughts often have much more to do with how you feel than what is actually
happening in your life. This isn't a new idea. Nearly two thousand years ago the
Greek philosopher, Epictetus, stated that people are dis- disturbed "not by things,
but by the views we take of them." In the Book of Proverbs B3: 7) in the Old
Testament you can find this passage: "For as he thinks within himself, so he is."
And even Shakespeare expressed a similar idea when he said: "for there is
nothing either good or bad, but thinking makes it so" (Hamlet, Act 2, Scene 2).
Although the idea has been around for ages, most de- depressed people do not
ieally comprehend it. If you feel depressed, you may think it is because of bad
things that have happened to you. You may think you are inferior and destined to
be unhappy because you failed in your work or
Introduction xix were rejected by someone you loved. You may think your
feelings of inadequacy result from some personal defect— you may feel
convinced you are not smart enough, suc- successful enough, attractive enough,
or talented enough to feel happy and fulfilled. You may think your negative
feelings are the result of an unloving or traumatic childhood, or bad genes you
inherited, or a chemical or hormonal imbalance of some type. Or you may blame
others when you get up- upset: "It's these lousy stupid drivers that tick me off
when I drive to work! If it weren't for these jerks, I'd be having a perfect day!"
And nearly all depressed people are con- convinced that they are facing some
special, awful truth about themselves and the world and that their terrible
feelings are absolutely realistic and inevitable. Certainly all these ideas contain
an important germ of truth—bad things do happen, and life beats up on most of
us at times. Many people do experience catastrophic losses and confront
devastating personal problems. Our genes, hormones, and childhood experiences
probably do have an impact on how we think and feel. And other people can be
annoying, cruel, or thoughtless. But all these theories about the causes of our bad
moods have the tendency to make us victims—because we think the causes
result from some- something beyond our control. After all, there is little we can
do to change the way people drive at rush hour, or the way we were treated when
we were young, or our genes or body chemistry (save taking a pill). In contrast,
you can learn to change the way you think about things, and you can also change
your basic values and beliefs. And when you do, you will often experience
your basic values and beliefs. And when you do, you will often experience
profound and lasting changes in your mood, outlook, and productivity. That, in a
nutshell, is what cognitive therapy is all about. The theory is straightforward and
may even seem overly simple—but don't write it off as pop psychology. I think
you will discover that cognitive therapy can be surprisingly helpful—even if you
feel pretty skeptical (as I did) when you first learn about it. I have personally
conducted more than thirty thousand cognitive therapy sessions with hunxx Introduction dreds of depressed and anxious individuals, and I am al- always
surprised about how helpful and powerful this method can be. The effectiveness
of cognitive therapy has been con- confirmed by many outcome studies by
researchers throughout the world during the past two decades. In a recent
landmark article entitled "Psychotherapy vs. Medication for Depres- Depression:
Challenging the Conventional Wisdom with Data," Drs. David O. Antonuccio
and William G. Danton from the University of Nevada and Dr. Gurland Y.
DeNelsky from the Cleveland Clinic reviewed many of the most carefully
conducted studies on depression that have been published in scientific journals
throughout the world.1 The studies re- reviewed compared the antidepressant
medications with psy- psychotherapy in the treatment of depression and anxiety.
Short-term studies as well as long-term follow-up studies were included in this
review. The authors came to a number of startling conclusions that are at odds
with the conven- conventional wisdom: • Although depression is conventionally
viewed as a medical illness, research studies indicate that genetic influences
appear to account for only about 16 percent of depression. For many individuals,
life influences ap- appear to be the most important causes. • Drugs are the most
common treatment for depression in the United States, and there is a widespread
belief, popularized by the media, that drugs are the most ef- effective treatment.
However, this opinion is not consis- consistent with the results of many carefully
conducted outcome studies during the past twenty years. These studies show that
the newer forms of psychotherapy, especially cognitive therapy, can be at least
as effective as drugs, and for many patients appear to be more ef- effective. This
is good news for individuals who prefer to be treated without medications—due
to personal preferences or health concerns. It is also good news for
, Introduction xxi the millions of individuals who have not responded adadequately to antidepressants after years and years of treatment and who still
struggle with depression and anxiety. • Following recovery from depression,
patients treated with psychotherapy are more likely to remain unde- undepressed
and are significantly less likely to relapse than patients treated with
antidepressants alone. This is es- especially important because of the growing
antidepressants alone. This is es- especially important because of the growing
awareness that many people relapse following recovery from de- depression,
especially if they are treated with antidepres- sant medications alone without any
talking therapy. Based on these findings, Dr. Antonuccio and his coau- coauthors
concluded that psychotherapy should not be consid- considered a second-rate
treatment but should usually be the initial treatment for depression. In addition,
they empha- emphasized that cognitive therapy appears to be one of the most
effective psychotherapies for depression, if not the most effective. Of course,
medications can be helpful for some individ- individuals—even life-saving.
Medications can be combined with psychotherapy for maximum effect as well,
especially when the depression is severe. It is extremely important to know that
we have powerful new weapons to fight depression, and that drug-free
treatments such as cognitive therapy can be highly effective. Recent studies
indicate that psychotherapy can be helpful not only for mild depressions, but
also for severe depres- depressions as well. These findings are at odds with the
popular belief that "talking therapy" can only help people with mild problems,
and that if you have a serious depression you need to be treated with drugs.
Although we are taught that depression may result from an imbalance in brain
chemistry, recent studies indicate that cognitive behavioral therapy may actually
change brain chemistry. In these studies, Drs. Lewis R. Baxter, Jr., Jefxxii Introduction 4 frey M. Schwartz, Kenneth S. Bergman, and their colcolleagues at UCLA School of Medicine, used positron emission tomography
(PET scanning) to evaluate changes in brain metabolism in two groups of
patients before and after treatment.2 One group received cognitive behavioral
therapy and no drugs, and the other group received an an- tidepressant
medication and no psychotherapy. As one might expect, there were changes in
brain chemis- chemistry in the patients in the drug therapy group who improved.
These changes indicated that their brain metabolism had slowed down—in other
words, the nerves in a certain region of the brain appeared to become more
"relaxed." What came as quite a surprise was there were similar changes in the
brains of the patients successfully treated with cognitive behavioral therapy.
However, these patients received no medications. Further, there were no
significant differences in the brain changes in the drug therapy and
psychotherapy groups, or in the effectiveness of the two treatments. Because of
these and other similar studies, investigators are starting for the first time to
entertain the possibility that cognitive behavior therapy—the methods described
in this book— may actually help people by changing the chemistry and
architecture of the human brain! Although no one treatment will ever be a
panacea, re- research studies indicate that cognitive therapy can be helpful for a
panacea, re- research studies indicate that cognitive therapy can be helpful for a
variety of disorders in addition to depression. For example, in several studies
patients with panic attacks have responded so well to cognitive therapy without
any medi- medications that many experts now consider cognitive therapy alone
to be the best treatment for this disorder. Cognitive therapy can also be helpful in
many other forms of anxiety (such as chronic worrying, phobias, obsessivecompulsive disorder, and post-traumatic stress disorder), and is also be- being
used with some success in the personality disorders, such as borderline
personality disorder. Cognitive therapy is gaining popularity in the treatment of
many other disorders as well. At the 1998 Stanford Psy- chopharmacology
Conference, I was intrigued by the pres- presentation by a colleague from
Stanford, Dr. Stuart Agras. Dr.
Introduction xxiii Agras is a renowned expert in eating disorders such as binge
eating, anorexia nervosa, and bulimia. He presented the results of numerous
recent studies on the treatment of eating disorders with antidepressant
medications versus psychother- psychotherapy. These studies indicated that
cognitive behavior therapy is the most effective treatment for eating disorders—
better than any known drug or any other form of psychotherapy .* We are also
beginning to learn more about how cognitive therapy works. One important
discovery is that self-help seems to be a key to recovery whether or not you
receive treatment. In a series of five remarkable studies published in the
prestigious Journal of Consulting and Clinical Psy- Psychology and in The
Gerontologist, Dr. Forest Scogin and his colleagues at the University of
Alabama studied the ef- effects of simply reading a good self-help book like
Feeling Good—without any other therapy. The name of this new type of
treatment is "bibliotherapy" (reading therapy). They discovered that Feeling
Good bibliotherapy may be as effective as a full course of psychotherapy or
treatment with the best antidepressant drugs.3 Given the tremendous pressures to
cut health care costs, this is of considerable interest, since a paperback copy of
the Feeling Good book costs less than two Prozac pills—and is presumably free
of any troublesome side effects! In a recent study, Dr. Scogin and his colleague,
Dr. Christine Jamison, randomly assigned eighty individuals seeking treatment
for a major depressive episode to one of two groups. The researchers gave the
patients in the first group a copy of my Feeling Good and encouraged them to
read it within four weeks. This group was called the Im- Immediate
Bibliotherapy Group. These patients also received a booklet containing blank
copies of the self-help forms in the book in case they decided to do some of the
suggested exercises in the book. *No current treatment is a panacea, including
cognitive therapy. Another new short- term therapy, called interpersonal therapy,
has also shown some promise for patients with eating disorders. In the future,
has also shown some promise for patients with eating disorders. In the future,
studies like those conducted by Dr. Agras and his colleagues will undoubtedly
lead to more powerful and specific treatments for eating disorders.
xxiv Introduction Patients in the second group were told they would be placed
on a four-week waiting list before beginning treat- treatment. This group was
called the Delayed Bibliotherapy Group because these patients were not given a
copy of Feeling Good until the second four weeks of the study. The patients in
the Delayed Bibliotherapy Group served as a control group to make sure that any
improvement in the Immediate Bibliotherapy was not just due to the passage of
time. At the initial evaluation, the researchers administered two depression tests
to all the patients. One was the Beck De- Depression Inventory (BDI), a timehonored self-assessment test that patients fill out on their own, and the second
was the Hamilton Rating Scale for Depression (HRSD), which is administered
by trained depression researchers. As you can see in Figure 1, there was no
difference in the depres- depression levels in the two groups at the initial
evaluation. You can also see that the average scores for the patients in the
Immediate Bibliotherapy Group and the Delayed Biblioth- Bibliotherapy group
at the initial evaluation were both around 20 or above on the BDI and on the
HRSD. These scores in- indicate that the depression levels in both groups were
similar to the depression levels in most published studies of anti- depressants or
psychotherapy. In fact, the BDI score was nearly identical to the average BDI
scores of approximately five hundred patients seeking treatment at my clinic in
Phil- Philadelphia during the late 1980s. Every week a research assistant called
the patients in both groups and administered the BDI by telephone. The assistant
also answered any questions patients had about the study and encouraged the
patients in the Immediate Bib- Bibliotherapy Group to try to complete the book
within four weeks. These calls were limited to ten minutes and no counseling
was offered. At the end of the four weeks, the two groups were com- compared.
You can see in Figure 1 that the patients in the Im- Immediate Bibliotherapy
Group improved considerably. In fact, the average scores on both the BDI and
HRSD were around 10 or below, scores in the range considered normal.
Introduction xxv Immediate Bibliotherapy Group Severe Moderate 20 Happy
Intake 4 Weeks 3 Months Severe 25 Moderate 20 Mild Normal Happy Delayed
Bibliotherapy Group Intake 4 Weeks 3 Months □ BDI ■ HRSD Figure 1. The
patients in the Immediate Bibliotherapy Group (top chart) received Feeling Good
at the intake evaluation. The patients in the Delayed Bibliotherapy Group
(bottom chart) received Feeling Good at the four-week evaluation. BDI=Beck
Depression Inventory. HRSD=Hamilton Rating Scale for Depression. These
Depression Inventory. HRSD=Hamilton Rating Scale for Depression. These
changes in depression were very significant. You can also see that the patients
maintained their gains at the three- month evaluation and did not relapse. In fact,
there was a tendency for continued improvement following the com- completion
of the bibliotherapy treatment; the scores on both depression tests were actually
lower at the three-month evaluation.
xxvi Introduction In contrast, you can see in Figure 1 that the patients in the
Delayed Bibliotherapy Group barely changed and were still around 20 at the
four-week evaluation. This showed that the improvement from Feeling Good
was not just due to the passage of time. Then Drs. Jamison and Scogin gave the
patients in the Delayed Bibliotherapy Group a copy of Feeling Good and asked
them to read it during the second four weeks of the study. Their improvement in
the next four weeks was similar to the improvement in the Imme- Immediate
Bibliotherapy Group during the first four weeks of the study. You can also see in
Figure 1 that the patients in both groups did not relapse but maintained their
gains at the three-month evaluation. The results of this study indicated that
Feeling Good ap- appeared to have substantial antidepressant effects. At the end
of the first four-week Bibliotherapy period, 70 percent of the patients in the
Immediate Bibliotherapy Group no longer met the criteria for a major depressive
episode, ac- according to the diagnostic criteria for a major depressive episode
that are outlined in the American Psychiatric As- Association's official
Diagnostic and Statistical Manual (DSM). In fact, the improvement was so great
most of these patients did not need any further treatment at the medical center.
To the best of my knowledge, these are the first published scientific studies
showing that a self-help book can actually have significant antidepressant effects
in pa- patients suffering from episodes of major depression. In contrast, only 3
percent of the patients in the Delayed Bibliotherapy Group recovered during the
first four weeks. In other words, the patients who did not read Feeling Good
failed to improve. However, at the three-month evaluation, when both groups
had read Feeling Goody 75 percent of the patients in the Immediate
Bibliotherapy Group and 73 percent of the patients in the Delayed Bibliotherapy
Group no longer qualified for a diagnosis of major depressive ep- episode
according to DSM criteria. The researchers compared the magnitude of the
improve- improvement in these groups with the amount of improvement in
Introduction xxvii published outcome studies using antidepressant medications
or psychotherapy or both. In the large National Institute of Mental Health
Collaborative Depression study, there was an average reduction of 11.6 points
on the HRSD in pa- patients who received cognitive therapy from highly trained
on the HRSD in pa- patients who received cognitive therapy from highly trained
therapists for twelve weeks. This was very similar to the 10.6-point change in
the HRSD observed in the patients who read Feeling Good after just four weeks.
However, the bibliotherapy treatment seemed to work significantly faster. My
own clinical experience confirms this. In my private practice, very few patients
have recovered during the first four weeks of treatment. The percentage of
patients who dropped out of the bib- bibliotherapy therapy was also very small,
around 10 percent. This is less than most published outcome studies using drugs
or psychotherapy, which typically have dropout rates from 15 percent to over 50
percent. Finally, the patients developed significantly more positive attitudes and
thinking patterns after reading Feeling Good. This was consistent with the
premise of the book; namely, that you can defeat depression by changing the
negative thinking patterns that cause it. The researchers concluded that the
bibliotherapy was ef- effective for patients suffering from depression and might
also have a significant role in public education and in de- depression prevention
programs. They speculated that Feeling Good bibliotherapy might help prevent
serious episodes of depression among individuals with a tendency toward negnegative thinking. Finally, the researchers addressed another important conconcern: would the antidepressant effects of Feeling Good last? Skillful
motivational speakers can get a crowd of people excited and optimistic for brief
periods of time—but these brief mood-elevating effects often don't last. The
same problem holds for the treatment of depression. Following successful
treatment with drugs or psychotherapy, many pa- patients feel tremendously
improved—only to relapse back into depression after a period of time. These
relapses can be devastating because patients feel so demoralized.
xxviii Introduction In 1997, the investigators reported the results of a three- year
follow-up of the patients in the study I've just de- described.7 The authors were
Drs. Nancy Smith, Mark Floyd, and Forest Scogin from the University of
Alabama and Dr. Christine Jamison from the Tuskegee Veterans Affairs Medical
Center. The researchers contacted the patients three years after reading Feeling
Good and administered the depression tests once again. They also asked the
patients several questions about how they had been doing since the completion
of the study. The researchers learned that the patients did not relapse but
maintained their gains during this three-year period. In fact, the scores on the
two de- depression tests at the three-year evaluation were actually slightly better
than the scores at the completion of the bib- liotherapy treatment. More than half
of the patients said that their moods continued to improve following the
completion of the initial study. The diagnostic findings at the three-year
evaluation con- confirmed this—72 percent of the patients still did not meet the
criteria for a major depressive episode, and 70 percent did not seek or receive
criteria for a major depressive episode, and 70 percent did not seek or receive
any further treatment with medi- medications or psychotherapy during the
follow-up period. Al- Although they experienced the normal ups and downs we
all feel from time to time, approximately half indicated that when they were
upset, they opened up Feeling Good and reread the most helpful sections. The
researchers speculated that these self-administered "booster sessions" may have
been important in maintaining a positive outlook following recovery. Forty
percent of the patients said that the best part of the book was that it helped them
change their neg- negative thinking patterns, such as learning to be less perfectionistic and to give up all-or-nothing thinking. Of course, this study had
limitations, like all studies. For one thing, not every patient was "cured" by
reading Feel- Feeling Good. No treatment is a panacea. While it is encourencouraging that many patients seem to respond to reading Feeling Good, it is
also clear that some patients with more severe or chronic depressions will need
the help of a therIntroduction xxix apist and possibly an antidepressant medication as well. This is
nothing to be ashamed of. Different individuals re- respond better to different
approaches. It is good that we now have three types of effective treatment for
depression: an- antidepressant medications, individual and group psychotherpsychotherapy, and bibliotherapy. Remember that you can use the cognitive
bibliotherapy between therapy sessions to speed your recovery even if you are in
treatment. In fact, when I first wrote Feeling Goody this is how I imagined the
book would be used. I intended it to be a tool my patients could use between
ther- therapy sessions to speed up the treatment and never dreamed that it might
someday be used alone as a treatment for de- depression. It appears that more
and more therapists are beginning to assign bibliotherapy to their patients as
psychotherapy "homework" between therapy sessions. In 1994, the re- results of
a nationwide survey about the use of bibliotherapy by mental health
professionals were published in the Au- Authoritative Guide to Self-Help Books
(published by Guilford Press, New York). Drs. John W. Santrock and Ann M.
Min- net from the University of Texas in Dallas and Barbara D. Campbell, a
research associate at the university, conducted this study. These three researchers
surveyed five hundred American mental health professionals from all fifty states
and asked whether they * 'prescribed'' books for patients to read between
sessions to speed recovery. Seventy percent of the therapists polled indicated
that they had recom- recommended at least three self-help books to their patients
dur- during the previous year, and 86 percent reported that these books provided
a positive benefit to their patients. The ther- therapists were also asked which
self-help books, from a list of one thousand, they most frequently recommended
self-help books, from a list of one thousand, they most frequently recommended
for their patients. Feeling Good was the number-one-rated book for depressed
patients, and my Feeling Good Hand- Handbook (published as a Plume
paperback in 1989) was rated number two. I was not aware this survey was
being conducted, and was thrilled to learn about the results of it. One of my
goals
xxx Introduction when I wrote Feeling Good was to provide reading for my own
patients to speed their learning and recovery between therapy sessions, but I
never dreamed this idea would catch on in such a big way! Should you expect to
improve or recover after reading Feeling Good? That would be unreasonable.
The research clearly indicates that while many people who read Feeling Good
improved, others needed the additional help of a mental health professional. I
have received many letters (probably more than ten thousand) from people who
read Feeling Good. Many of them kindly described in glowing terms how
Feeling Good had helped them, often after years and years of unsuccessful
treatment with medications and even electroconvulsive therapy. Others indicated
that they found the ideas in Feeling Good appealing but needed a referral to a
good local therapist to make these ideas work for them. This is understandable—
we are all different, and it would be unrealistic to think that any one book or
form of therapy would be the answer for everyone. Depression is one of the
worst forms of suffering, be- because of the immense feelings of shame,
worthlessness, hopelessness, and demoralization. Depression can seem worse
than terminal cancer, because most cancer patients feel loved and they have hope
and self-esteem. Many de- depressed patients have told me, in fact, that they
yearned for death and prayed every night that they would get cancer, so they
could die in dignity without having to commit su- suicide. But no matter how
terrible your depression and anxiety may feel, the prognosis for recovery is
excellent. You may be convinced that your own case is so bad, so overoverwhelming and hopeless, that you are the one person who will never get well,
no matter what. But sooner or later, the clouds have a way of blowing away and
the sky suddenly clears and the sun begins to shine again. When this haphappens, the feelings of relief and joy can be overwhelming. And if you are now
struggling with depression and low self-esteem, I believe this transformation can
happen for
Introduction xxxi you as well, no matter how discouraged or depressed you may
feel. Well, it's time to get on to Chapter 1 so we can start to work together. I
want to wish you the very best as you read it, and hope you find these ideas and
methods helpful! David D. Burns, M.D. Clinical Associate Professor of
methods helpful! David D. Burns, M.D. Clinical Associate Professor of
Psychiatry and Behavioral Sciences, Stanford University School of Medicine
References 1. Antonuccio, D. O., Danton, W. G., & DeNelsky, G. Y. A995).
Psychotherapy versus medication for depression: Challenging the conventional
wisdom with data. Profes- Professional Psychology: Research and Practice,
26F), 574- 585. 2. Baxter, L. R., Schwartz, J. M., & Bergman, K. S., et al.
A992). Caudate glucose metabolic rate changes with both drug and behavioral
therapy for obsessive- compulsive disorders. Archives of General Psychiatry, 49,
681-689. 3. Scogin, F., Jamison, C, & Gochneaut, K. A989). The comparative
efficacy of cognitive and behavioral bib- liotherapy for mildly and moderately
depressed older adults. Journal of Consulting and Clinical Psychology, 57, 403-
407. 4. Scogin, F., Hamblin, D., & Beutler, L. A987). Biblio- therapy for
depressed older adults: A self-help alterna- alternative. The Gerontologist, 27,
383-387. 5. Scogin, F., Jamison, C, & Davis, N. A990). A two-year follow-up of
the effects of bibliotherapy for depressed
xxxii Introduction older adults. Journal of Consulting and Clinical PsyPsychology, 58, 665-667. 6. Jamison, C, & Scogin, F. A995). Outcome of
cognitive bibliotherapy with depressed adults. Journal of Con- Consulting and
Clinical Psychology, 63, 644-650. 7. Smith, N. M., Floyd, M. R., Jamison, C, &
Scogin, F. A997). Three-year follow-up of bibliotherapy for de- depression.
Journal of Consulting and Clinical Psychol- Psychology, 65B), 324-327.
Part I Theory and Research
Chapter 1 A Breakthrough in the Treatment of Mood Disorders Depression has
been called the world's number one public health problem. In fact, depression is
so widespread it is considered the common cold of psychiatric disturbances. But
there is a grim difference between depression and a cold. Depression can kill
you. The suicide rate, studies indicate, has been on a shocking increase in recent
years, even among children and adolescents. This escalating death rate has
occurred in spite of the billions of antidepressant drugs and tranquilizers that
have been dispensed during the past several decades. This might sound fairly
gloomy. Before you get even more depressed, let me tell you the good news.
Depression is an illness and not a necessary part of healthy living. What's more
important—you can overcome it by learning some simple methods for mood
elevation. A group of psy- psychiatrists and psychologists at the University of
Pennsyl- Pennsylvania School of Medicine has reported a significant
breakthrough in the treatment and prevention of mood dis- disorders.
Dissatisfied with traditional methods for treating depression because they found
them to be slow and inef- ineffective, these doctors developed and systematically
them to be slow and inef- ineffective, these doctors developed and systematically
tested
10 David D. Burns, M.D. an entirely new and remarkably successful approach to
de- depression and other emotional disorders. A series of recent studies confirms
that these techniques reduce the symptoms of depression much more rapidly
than conventional psy- psychotherapy or drug therapy. The name of this
revolutionary treatment is "cognitive therapy." I have been centrally involved in
the development of cognitive therapy, and this book is the first to describe these
methods to the general public. The systematic application and scientific
evaluation of this approach in treating clinical depression traces its origins to the
innovative work of Drs. Albert Ellis and Aaron T. Beck, who began to refine
their unique approach to mood transformation in the mid-1950* s and early
1960's.* Their pioneering efforts began to emerge into prominence in the past
decade because of the research that many mental-health professionals have
undertaken to refine and evaluate cognitive therapy methods at academic
institutions in the United States and abroad. Cognitive therapy is a fast-acting
technology of mood modification that you can learn to apply on your own. It can
help you eliminate the symptoms and experience per- personal growth so you
can minimize future upsets and cope with depression more effectively in the
future. The simple, effective mood-control techniques of cog- cognitive therapy
provide: 1. Rapid Symptomatic Improvement: In milder depres- depressions,
relief from your symptoms can often be ob- observed in as short a time as twelve
weeks. "The idea that your thinking patterns can profoundly influence your
moods has been described by a number of philosophers in the past 2500 years.
More recently, the cognitive view of emotional disturbances has been explored
in the writings of many psychiatrists and psychologists including Alfred Adler,
Albert Ellis, Karen Homey, and Arnold Lazarus, to name just a few. A history of
this movement has been described in Ellis, A., Reason and Emotion in
Psychotherapy. New York: Lyle Stuart, 1962.
FEELING GOOD 11 2. Understanding: A clear explanation of why you get
moody and what you can do to change your moods. You will learn what causes
your powerful feelings; how to distinguish "normal" from "abnormal" emoemotions; and how to diagnose and assess the severity of your upsets. 3. Selfcontrol: You will learn how to apply safe and effective coping strategies that will
make you feel bet- better whenever you are upset. I will guide you as you
develop a practical, realistic, step-by-step self-help plan. As you apply it, your
moods can come under greater voluntary control. 4. Prevention and Personal
Growth: Genuine and long- lasting prophylaxis (prevention) of future mood
Growth: Genuine and long- lasting prophylaxis (prevention) of future mood
swings can effectively be based on a reassessment of some basic values and
attitudes which lie at the core of your tendency toward painful depressions. I will
show you how to challenge and reevaluate certain as- assumptions about the
basis for human worth. The problem-solving and coping techniques you learn
will encompass every crisis in modern life, from minor ir- irritations to major
emotional collapse. These will include realistic problems, such as divorce, death,
or failure, as well as those vague, chronic problems that seem to have no obobvious external cause, such as low self-confidence, frustra- frustration, guilt, or
apathy. The question may now occur to you,' 'Is this just another self-help pop
psychology?" Actually, cognitive therapy is one of the first forms of
psychotherapy which has been shown to be effective through rigorous scientific
research under the critical scrutiny of the academic community. This therapy is
unique in having professional evaluation and val- validation at the highest
academic levels. It is nor just another self-help fad but a major development that
has become an important part of the mainstream of modern psychiatric reresearch and practice. Cognitive therapy's academic foun12 David D. Burns, M.D. dation has enhanced its impact and should give it
staying power for years to come. But don't be turned off by the professional
status that cognitive therapy has acquired. Un- Unlike much traditional
psychotherapy, it is not occult and anti-intuitive. It is practical and based on
common sense, and you can make it work for you. The first principle of
cognitive therapy is that all your moods are created by your "cognitions," or
thoughts. A cognition refers to the way you look at things—your perperceptions, mental attitudes, and beliefs. It includes the way you interpret things
—what you say about something or someone to yourself. You feel the way you
do right now because of the thoughts you are thinking at this moment. Let me
illustrate this. How have you been feeling as you read this? You might have been
thinking, "Cognitive ther- therapy sounds too good to be true. It would never
work for me." If your thoughts run along these lines, you are feeling skeptical or
even discouraged. What causes you-to feel that way? Your thoughts. You create
those feelings by the dia- dialogue you are having with yourself about this book!
Conversely, you may have felt a sudden uplift in mood because you thought,
"Hey, this sounds like something which might finally help me." Your emotional
reaction is generated not by the sentences you are reading but by the way you are
thinking. The moment you have a certain thought and believe it, you will
experience an immediate emotional response. Your thought actually creates the
emo- emotion. The second principle is that when you are feeling de- depressed,
your thoughts are dominated by a pervasive negativ- negativity. You perceive
not only yourself but the entire world in dark, gloomy terms. What is even worse
not only yourself but the entire world in dark, gloomy terms. What is even worse
—you'll come to be- believe things really are as bad as you imagine them to be.
If you are substantially depressed, you will even begin to believe that things
always have been and always will be negative. As you look into your past, you
remember all the bad things that have happened to you. As you try to imagine
the future, you see only emptiness or unending problems
FEELING GOOD 13 and anguish. This bleak vision creates a sense of hopelesshopelessness. This feeling is absolutely illogical, but it seems so real that you
have convinced yourself that your inadequacy will go on forever. The third
principle is of substantial philosophical and therapeutic importance. Our research
has documented that the negative thoughts which cause your emotional turmoil
nearly always contain gross distortions. Although these thoughts appear valid,
you will learn that they are irrational or just plain wrong, and that twisted
thinking is a major cause of your suffering. The implications are important. Your
depression is prob- probably not based on accurate perceptions of reality but is
often the product of mental slippage. Suppose you believe that what I've said has
validity. What good will it do you? Now we come to the most important result of
our clinical research. You can learn to deal with your moods more effectively if
you master methods that will help you pinpoint and eliminate the mental
distortions which cause you to feel upset. As you begin to think more
objectively, you will begin to feel better. Htiw effective is cognitive therapy
compared with other established and accepted methods for treating depression?
Can the new therapy enable severely depressed individuals to get better without
drugs? How rapidly does cognitive therapy work? Do the results last? Several
years ago a group of investigators at the Center for Cognitive Therapy at the
University of Pennsylvania School of Medicine including Drs. John Rush, Aaron
Beck, Maria Kovacs and Steve Hollon began a pilot study com- comparing
cognitive therapy with one of the most widely used and effective antidepressant
drugs on the market, Tofranil (imipramine hydrochloride). Over forty severely
depressed patients were randomly assigned to two groups. One group was to
receive individual cognitive therapy sessions and no drugs, while the other group
would be treated with Tofranil and no therapy. This either-or research design
was chosen because it provided the maximum opportunity to see how
14 David D. Burns, M.D. the treatments compared. Up to that time, no form of
psy- psychotherapy had been shown to be as effective for depres- depression as
treatment with an antidepressant drug. This is why antidepressants have
experienced such a wave of interest from the media, and have come to be
regarded by the pro- professional community in the past two decades as the best
regarded by the pro- professional community in the past two decades as the best
treatment for most serious forms of depression. Both groups of patients were
treated for a twelve-week period. All patients were systematically evaluated with
ex- extensive psychological testing prior to therapy, as well as at several
monthly intervals for one year after completion of treatment. The doctors who
performed the psychological tests were not the therapists who administered the
treat- treatment. This ensured an objective assessment of the merits of each form
of treatment. The patients were suffering from moderate to severe de- depressive
episodes. The majority had failed to improve in spite of previous treatment with
two or more therapists at other clinics. Three quarters were suicidal at the time
of their referral. The average patient had been troubled by chronic or intermittent
depression for eight years. Many were absolutely convinced their problems were
insoluble, and felt their lives were hopeless. Your own mood prob- problems
may not seem as overwhelming as theirs. A tough patient population was chosen
so that the treatment could be tested under the most difficult, challenging
conditions. The outcome of the study was quite unexpected and en- encouraging.
The cognitive therapy was at least as effective as, if not more effective than, the
antidepressant drug ther- therapy. As you can see (Table 1-1, page 15), fifteen of
the nineteen patients treated with cognitive therapy had shown a substantial
reduction of symptoms after twelve weeks of active treatment.* An additional
two individuals had im- ♦Table 1-1 was adapted from Rush, A. J., Beck, A. T.,
Kovacs, M., and Hollon, S. "Comparative Efficacy of Cognitive Therapy and
Pharmacoth- erapy in the Treatment of Depressed Outpatients." Cognitive
Therapy and Research, Vol. 1, No. I, March 1977, pp. 17-38.
FEELING GOOD !5 Table 1-1. Status of 44 Severely Depressed Patients, 12
Weeks After Beginning Treatment Number Who Entered Treatment Number
who had recovered completely* Number who were considerably improved but
still experienced borderline to mild depression Number who were not
substantially improved Number who dropped out of treatment Patients Treated
with Cognitive Therapy Only 19 IS 2 1 1 Patients Treated with Antidepressant
Drug Therapy Only 25 5 7 5 8 ♦The superior improvement of the patients treated
with oogmtive therapy was miitticiiiy significant proved, but were still
experiencing borderline to mild de- depression. Only one patient had dropped
out of treatment, and one had not yet begun to improve at the end of this period.
In contrast, only five of the twenty-five patients as- assigned to antidepressant
drug therapy had shown complete recovery by the end of the twelve-week
period. Eight of these patients dropped out of therapy as a result of the adverse
side effects of the medication, and twelve others showed no improvement or
only partial improvement. Of particular importance was the discovery that many
only partial improvement. Of particular importance was the discovery that many
patients treated with cognitive therapy improved more rap- rapidly than those
successfully treated with drugs. Within the first week or two, there was a
pronounced reduction in suicidal thoughts among the cognitive therapy group.
The effectiveness of cognitive therapy should be encouraging
16 David D. Burns, M.D. for individuals who prefer not to rely on drugs to raise
their spirits, but prefer to develop an understanding of what is troubling them
and do something to cope with it. How about those patients who had not
recovered by the end of twelve weeks? Like any form of treatment, this one is
not a panacea. Clinical experience has shown that all individuals do not respond
as rapidly, but most can never- nevertheless improve if they persist for a longer
period of time. Sometimes this is hard work! One particularly encouraging
development for individuals with refractory severe depres- depressions is a
recent study by Drs. Ivy Blackburn and her as- associates at the Medical
Research Council at the University of Edinburgh in Scotland.* These
investigators have shown that the combination of antidepressant drugs with
cognitive therapy can be more effective than either modality above. In my
experience the most crucial predictor of recovery is a persistent willingness to
exert some effort to help yourself. Given this attitude, you will succeed. Just how
much improvement can you hope for? The av- average cognitively treated
patient experienced a substantial elimination of symptoms by the end of
treatment. Many reported they felt the happiest they had ever felt in their lives.
They emphasized that the mood-training brought about a sense of self-esteem
and confidence. No matter how miserable, depressed, and pessimistic you now
feel, I am convinced that you can experience beneficial effects if you are willing
to apply the methods described in this book with persistence and consistency.
How long do the effects last? The findings from follow- up studies during the
year after completion of treatment are quite interesting. While many individuals
from both groups had occasional mood swings at various times during the
*Blackburn, I. M., Bishop, S., Glen, A. I. M., Whalley, L. J. and Christie, J. E.
"The Efficacy of Cognitive Therapy in Depression. A Treatment Trial Using
Cognitive Therapy and Pharmacotherapy, Each Alone and in Combination."
British Journal of Psychiatry, Vol. 139, January 1981, pp. 181-189.
FEELING GOOD 17 year, both groups continued on the whole to maintain the
gains they had demonstrated by the end of twelve weeks of active treatment.
Which group actually fared better during the follow-up period? The
psychological tests, as well as the patients' own reports, confirmed that the
cognitive therapy group continued to feel substantially better, and these
differences were statistically significant. The relapse rate over the course of the
differences were statistically significant. The relapse rate over the course of the
year in the cognitive therapy group was less than half that observed in the drug
patients. TTiese were sizable differences that favored the patients treated with
the new approach. Does this mean that I can guarantee you will never again have
the blues after using cognitive methods to eliminate your current depression?
Obviously not. That would be like saying that once you have achieved good
physical condition through daily jogging, you will never again be short of breath.
Part of being human means getting upset from time to time, so I can guarantee
you will not achieve a state of never-ending bliss! This means you will have to
reapply the techniques that help you if you want to continue to master your
moods. There's a difference between feeling better—which can occur
spontaneously—and getting bet- better—which results from systematically
applying and reapplying the methods that will lift your mood whenever the need
arises. How has this work been received by the academic com- community? The
impact of these findings on psychiatrists, psy- psychologists, and other mentalhealth professionals has been substantial. It has now been twenty years since this
chapter was first written. During that time, numerous well- controlled studies of
the effectiveness of cognitive therapy have been published in scientific journals.
These studies have compared the effectiveness of cognitive therapy with the
effectiveness of antidepressant medications as well as other forms of
psychotherapy in the treatment of depres- depression, anxiety, and other
disorders. The results of these stud- studies have been quite encouraging.
Researchers have
18 David D. Burns, M.D. confirmed our early impressions that cognitive therapy
was at least as effective as medications, and often more effec- effective, both in
the short term and in the long term. What does this all add up to? We are
experiencing a crucial development in modern psychiatry and psychology— a
promising new approach to understanding human emo- emotions based on a
cogent testable therapy. Large numbers of mental-health professionals are now
Showing a great inter- interest in this approach, and the ground swell seems to
be just beginning. Since the first edition of Feeling Good in 1980, many
thousands of depressed individuals have been successfully treated with cognitive
therapy. Some had considered them- themselves hopelessly untreatable and
came to us as a last-ditch effort before commmitting suicide. Many others were
simply troubled by the nagging tensions of daily living and wanted a greater
share of personal happiness. This book is a carefully thought-out practical
application of our work, and it is designed for you. Good luck!
Chapter 2 How to Diagnose Your Moods The First Step in the Cure Perhaps you
Chapter 2 How to Diagnose Your Moods The First Step in the Cure Perhaps you
are wondering if you have in fact been suffering from depression. Let's go ahead
and see where you stand. The Burns Depression Checklist (BDC) (see Table 2—
1, page 20) is a reliable mood-measuring device that detects the pres- presence
of depression and accurately rates its severity.* This sim- simple questionnaire
will take only a few minutes to complete. After you have completed the BDC, I
will show you how to make a simple interpretation of the results, based on your
total score. Then you will know immediately whether or not you are suffering
from a true depression and, if so, how severe it is. I will also lay out some
important guidelines to help you determine whether you can safely and
effectively treat your own blue mood using this book as your guide, or whether
you have a more serious emotional disorder and might benefit from professional
intervention in addition to your own efforts to help yourself. As you fill out the
questionnaire, read each item carefully and put a check (/) in the box that
indicates how you have been feeling during the past few days. Make sure you
check one answer for each of the twenty-five items. If in doubt, make your best
guess. Do not leave any questions unanswered. Regardless of the outcome, this
can be your first step toward emotional improvement. :Some readers may recall
that I included the Beck Depression Inventory 19
20 David D. Burns. M.D. Table 2-1. Burns Depression Checklist* Instructions:
Put a check (•) to indicate how much you have experienced each symptom
during the past week, including today. Please answer all 25 items. 0—Not At All
1—Somewhat 2—Moderately 3—A Lot j 4—Extremely | Thoughts and Feelings
1. Feeling sad or down in the dumps 2. Feeling unhappy or blue 3. Crying spells
or tearfulness 4. Feeling discouraged 5. Feeling hopeless 6. Low self-esteem 7.
Feeling worthless or inadequate 8. Guilt or shame 9. Criticizing yourself or
blaming yourself 10. Difficulty making decisions Activities and Personal
Relationships 11. Loss of interest in family, friends or colleagues 12. Loneliness
13. Spending less time with family or friends 14. Loss of motivation 15. Loss of
interest in work or other activities 16. Avoiding work or other activities 17. Loss
of pleasure or satisfaction in life Physical Symptoms 18. Feeling tired 19.
Difficulty sleeping or sleeping too much 20. Decreased or increased appetite 21.
Loss of interest in sex 22. Worrying about your health
FEELING GOOD 21 Burns Depression Checklist continued 0—Not At All 1—
Somewhat 2—Moderately i 4—Extremely Suicidal Urges** 23. Do you have
any suicidal thoughts? 24. Would you like to end your life? 25. Do you have a
plan for harming yourself? Please Total Your Score on Items 1 to 25 Here -^ *
Copyright © 1984 by David D. Burns, M.D. (Revised, 1996.) **Anyone with
Copyright © 1984 by David D. Burns, M.D. (Revised, 1996.) **Anyone with
suicidal urges should seek help from a mental health professional. Interpreting
the Burns Depression Checklist. Now that you have completed the test, add up
the score for each of the twenty-five items and obtain the total. Since the highest
score you can get on each of the twenty-five symptoms is 4, the highest score for
the whole test would be 100. (This would indicate the most severe depression
possible.) Since the lowest score for each item is 0, the lowest score for the test
would be zero. (This would indicate no symptoms of depression at all.) You can
now evaluate your depression according to Ta- Table 2-2. As you can see, the
higher the total score, the more severe your depression. In contrast, the lower the
score, the better you are feeling. Although the BDC is not difficult or timeconsuming to fill out and score, don't be deceived by its simplicity. You have
just learned to use a highly sophisticated tool for de- (BDI) in the 1980 edition of
Feeling Good. The BDI is a time-honored instrument that has been used in
hundreds of research studies on depres- depression. Dr. Aaron Beck, the creator
of this test, deserves a great deal of credit for creating the BDI during the early
1960s. It was one of the first instruments for measuring depression in clinical
and research settings, and I was grateful for his permission to reproduce it in the
earlier edition of Feeling Good.
22 David D. Burns, M.D. Table 2-2. Interpreting the Burns Depression Checklist
Total Score 0-5 6-10 11-25 26-50 51-75 76-100 Level of Depression* no
depression normal but unhappy mild depression moderate depression severe
depression extreme depression * Anyone with a persistent score above 10 may
benefit from professional treatment. Anyone with suicidal feelings should seek
an immediate consul- consultation with a mental health professional. tecting
depression and measuring its severity. Research studies have demonstrated that
the BDC is highly accurate and reliable. Studies in a variety of settings, such as
psy- psychiatric emergency rooms, have indicated that instruments of this type
actually pick up the presence of depressive symptoms far more frequently than
formal interviews by experienced clinicians. *Mental health professionals may
be interested to learn that the psycho- psychometric properties of the BDC are
excellent. The reliability of the twenty - five-item BDC has been assessed in a
group of ninety depressed outpatients seeking treatment at the Center for
Cognitive Therapy in Oak- Oakland, California, and in a group of 145
outpatients seeking treatment at a Kaiser facility in Atlanta, Georgia. The
reliability was extremely high and identical in both groups (Cronbach's
coefficient alpha = 95%). The high correlation between the BDC and the BDI
rF8) = .88, p < .01 in the Oakland group indicates that these two scales assess a
similar if not iden- identical construct. When both instruments were purged of
errors of measure- measurement using structural equation modeling techniques,
errors of measure- measurement using structural equation modeling techniques,
the correlation between the scales was not significantly different from 1.0. The
BDC was also normed against the widely used depression subscale of the
Hopkins Symptom Checklist-90 in the Atlanta, Georgia, sample. The extremely
high correlation between the two measures r(\3l) = .90, p < .01 further confirmed
the validity of the BDC. Extensive clinical experience with the BDC in a variety
of treatment settings indicates it is well accepted by patients. Many have
commented that the test is easy to complete and score and helpful for tracking
changes in symptoms over time. A brief, five-item BDC with outstanding
psycho- psychometric properties has also been developed. The brief BDC is
ideal for testing patients on a session-by-session basis because patients can comFEELING GOOD 23 You can use the BDC with confidence to monitor your
progress as well. In my clinical work, I have insisted that every patient must fill
out the test on his or her own between all sessions and report the score to me at
the beginning of the next session. Changes in the score show me whether the papatient is getting better, worse, or staying the same. As you apply the various
self-help techniques described in this book, take the BDC test at regular intervals
to assess your progress objectively. I suggest a minimum of once a week.
Compare it to weighing yourself regularly when you're on a diet. You will notice
that various chapters in this book focus on different symptoms of depression. As
you learn to overcome these symptoms, you will find that your total score will
begin to fall. This will show that you are improving. When your score is under
ten, you will be in the range considered normal. When it is under five, you will
be feeling especially good. Ideally, I'd like to see your score under five the
majority of the time. This is one aim of your treatment. Is it safe for depressed
individuals to try to help them- themselves using the principles and methods
outlined in this book? The answer is—definitely yes\ This is because the crucial
decision to try to help yourself is the key that will allow you to feel better as
soon as possible, regardless of how severe your mood disturbance might seem to
be. Under what conditions should you seek professional help? If your score is
between 0 and 5, you are probably feeling good already. This is in the range of
normal, and most people with scores this low feel pretty happily contented. If
your score was between 6 and 10, it is still in the range of normal, but you are
probably feeling a bit on the "lumpy" side. There's room for improvement, a
little mental "tune- up," if you will. The cognitive therapy techniques in this
book can often be remarkably helpful in these instances. Problems plete it in less
than one minute. It has performed well with adults and adolescents in a variety
of psychiatric and medical settings, including re- recently arrested juveniles in
the California judicial system. Mental health professionals who are interesting in
the California judicial system. Mental health professionals who are interesting in
learning more about these and many other assessment instruments that can be
used in clinical or research set- settings (including an electronic patient testing
module) are cordially invited to visit my Web site at www.FeelingGood.com
24 David D. Burns, M.D. in daily living bug all of us, and a change of
perspective can often make a big difference in how you feel. If your score was
between 11 and 25, your depression, at least at this time, is mild and should not
be a cause for alarm. You will definitely want to correct this problem, and you
may be able to make substantial progress on your own. Systematic self-help
efforts along the lines proposed in this book, combined with frank
communication on a number of occasions with a trusted friend, may help a great
deal. But if your score remains in this range for more than a few weeks, you
should consider professional treatment. The help of a therapist or an
antidepressant medication may considerably speed your recovery. Some of the
thorniest depressions I have treated were actually individuals whose scores were
in the mild range. Often these individuals had been mildly depressed for years,
sometimes for most of their entire life. A mild chronic depression that goes on
and on is now called "dys- thymic disorder." Although that is a big, fancysounding term, it has a simple meaning. All it means is, "this person is awfully
gloomy and negative most of the time." You probably know someone who is
like that, and you may have fallen into spells of pessimism yourself. Fortunately,
the same methods in this book that have proven so helpful for severe depressions
can also be very helpful for these mild, chronic depressions. If you scored
between 26 and 50 on the BDC, it means you are moderately depressed. But
don't be fooled by the term, "moderate." A score in this range can indicate pretty
intense suffering. Most of us can feel quite upset for brief periods, but we
usually snap out of it. If your score remains in this range for more than two
weeks, you should definitely seek professional treatment. If your score was
above 50, it indicates your depression is severe or even extreme. This degree of
suffering can be almost unbearable, especially when the score is increased above
75. Your moods are apt to be intensely uncomfort- uncomfortable and possibly
dangerous because the feelings of despair and hopelessness may even trigger
suicidal impulses. Fortunately, the prognosis for successful treatment is exexcellent. In fact, sometimes the most severe depressions reFEELING GOOD 25 spond the most rapidly. But it is not wise to try to treat a
severe depression on your own. A professional consultation is a must. Seek out a
trusted and competent counselor. Even if you receive psychotherapy or
antidepressant medications, I am convinced you can still benefit greatly by
antidepressant medications, I am convinced you can still benefit greatly by
applying what I teach you. My research studies have indicated that the spirit of
self-help greatly speeds up re- recovery, even when patients receive professional
treatment. In addition to evaluating your total score on the BDC, be sure you pay
special attention to items 23, 24, and 25. These items ask about suicidal feelings,
urges, and plans. If you had elevated scores on any of these items, I would
strongly rec- recommend that you obtain professional help right away. Many
depressed individuals have elevated scores on item 23, but zeros on items 24 and
25. This usually means they have suicidal thoughts, such as "I'd probably be
better off dead," but no actual suicidal intentions or urges and no plans to
commit suicide. This pattern is quite common. If your scores on item 24 or 25
are elevated, however, this is a cause for alarm. Seek treatment immediately) I
have provided some effective methods for assessing and reversing suicidal
impulses in a later chapter, but you must consult a professional when suicide
begins to appear to be a desirable or necessary option. Your conviction that you
are hopeless is the reason to seek treatment, not suicide. The majority of
seriously depressed individuals believe they are hopeless beyond any shadow of
a doubt. This de- destructive delusion is merely a symptom of the illness, not a
fact. Your feeling that you are hopeless is powerful evi- evidence that you are
actually not! It is also important for you to look at item 22, which asks if you
have been more worried about your health re- recently. Have you experienced
any unexplained aches, pains, fever, weight loss, or other possible symptoms of
medical illness? If so, it would be worthwhile to have a medical consultation,
which would include a history, a complete physical examination, and laboratory
tests. Your doctor will probably give you a clean bill of health. This will suggest
that your uncomfortable physical symptoms are related to your emotional state.
Depression can mimic a great number of medical disorders because your mood
swings often ere26 David D. Burns, M.D. ate a wide variety of puzzling physical symptoms.
These include, to name just a few, constipation, diarrhea, pain, insomnia or the
tendency to sleep too much, fatigue, loss of sexual interest, light-headedness,
trembling, and numb- numbness. As your depression improves, these symptoms
will in all likelihood vanish. However, keep in mind that many treatable illnesses
may initially masquerade as depression, and a medical examination could reveal
an early (and life- saving) diagnosis of a reversible organic disorder. There are a
number of symptoms that indicate—but do not prove—the existence of a serious
mental disturbance, and these require a consultation with and possible treatment
by a mental-health professional, in addition to the self- administered personalgrowth program in this book. Some of the major symptoms include: the belief
that people are plotting and conspiring against you in order to hurt you or take
that people are plotting and conspiring against you in order to hurt you or take
your life; a bizarre experience which the ordinary per- person cannot understand;
the conviction that external forces are controlling your mind or body; the feeling
that other people can hear your thoughts or read your mind; hearing voices from
outside your head; seeing things that aren't there; and receiving personal
messages broadcast from ra- radio or television programs. These symptoms are
not a part of depressive illness, but represent major mental disorders. Psychiatric
treatment is a must. Quite often, people with these symptoms are con- convinced
that nothing is wrong with them, and may meet the suggestion to seek
psychiatric therapy with suspicious re- resentment and resistance. In contrast, if
you are harboring the deep fear that you are going insane and are experiencing
episodes of panic in which you sense you are losing control or going over the
deep end, it is a near certainty that you are not. These are typical symptoms of
ordinary anxiety, a much less serious disorder. Mania is a special type of mood
disorder with which you should be familiar. Mania is the opposite of depression
and requires prompt intervention by a psychiatrist who can pre- prescribe
lithium. Lithium stabilizes extreme mood swings and allows the patient to lead a
normal life. However, until ther- therapy is initiated, the disease can be
emotionally destructive. The symptoms include an abnormally elated or irritable
FEELING GOOD 27 mood that persists for at least two days and is not caused
by drugs or alcohol. The manic patient's behavior is char- characterized by
impulsive actions which reflect poor judgment (such as irresponsible, excessive
spending) along with a grandiose sense of self-confidence. Mania is
accompanied by increased sexual or aggressive activity; hyperactive, concontinuous body movements; racing thoughts; nonstop, excited talking; and a
decreased need to sleep. Manic individuals have the delusion that they are
extraordinarily powerful and brilliant, and often insist they are on the verge of
some philosophical or scientific breakthrough or lucrative money- making
scheme. Many famous creative individuals suffer from this illness and manage to
control it with lithium. Be- Because the disease feels so good, individuals who
are having their first attack often cannot be convinced to seek treat- treatment.
The first symptoms are so intoxicating that the victim resists accepting the idea
that his or her sudden acquisition of self-confidence and inner ecstasy is actually
just a man- manifestation of a destructive illness. After a while, the euphoric
state may escalate into un- uncontrollable delirium requiring involuntary
hospitalization, or it may just as suddenly switch into an incapacitating
depression with pronounced immobility and apathy. I want you to be familiar
with the symptoms of mania because a significant percentage of individuals who
experience a true major depressive episode will at some later time develop these
experience a true major depressive episode will at some later time develop these
symptoms. When this occurs, the personality of the afflicted individual
undergoes a profound transformation over a period of days or weeks. While
psychotherapy and a self-help program can be extremely helpful, concomitant
treatment with lithium under medical supervision is a must for an optimal
response. With such treatment the prognosis for manic illness is excellent. Let's
assume that you do not have a strong suicidal urge, hallucinations, or symptoms
of mania. Instead of moping and feeling miserable, you can now proceed to get
better, using the methods outlined in this book. You can start en- enjoying life
and work, and use the energy spent in being depressed for vital and creative
living.
Chapter 3 Understanding Your Moods: You Feel the Way You Think As you
read the previous chapter, you became aware of how extensive the effects of
depression are—your mood slumps, your self-image crumbles, your body
doesn't func- function properly, your willpower becomes paralyzed, and your
actions defeat you. That's why you feel so totally down in the dumps. What's the
key to it all? Because depression has been viewed as an emotional disorder
throughout the history of psychiatry, therapists from most schools of thought
place a strong emphasis on "getting in touch" with your feelings. Our research
reveals the unexpected: Depression is not an emotional disorder at all! The
sudden change in the way you feel is of no more causal relevance than a runny
nose is when you have a cold. Every bad feeling you have is the result of your
distorted negative thinking. Illogical pessimistic attitudes play the central role in
the development and continuation of all your symptoms. Intense negative
thinking always accompanies a depres- depressive episode, or any painful
emotion for that matter. Your moody thoughts are likely to be entirely different
from those you have when you are not upset. A young woman, about to receive
her Ph.D., expressed it this way:
FEELING GOOD 29 Every time I become depressed, I feel as if I have been hit
with a sudden cosmic jolt, and I begin to see things differently. Jhe change can
come within less than an hour. My thoughts become negative and pessimistic.
As I look into the past, I become convinced that every- everything that I've ever
done is worthless. Any happy pe- period seems like an illusion. My
accomplishments appear as genuine as the false facade for the set of a Western
movie. I become convinced that the real me is worthless and inadequate. I can't
move forward with my work because I become frozen with doubt. But I can't
stand still because the misery is unbearable. You will learn, as she did, that the
negative thoughts that flood your mind are the actual cause of your self-
negative thoughts that flood your mind are the actual cause of your selfdefeating emotions. These thoughts are what keep you lethargic and make you
feel inadequate. Your negative thoughts, or cog- cognitions, are the most
frequently overlooked symptoms of your depression. These cognitions contain
the key to relief and are therefore your most important symptoms. Every time
you feel depressed about something, try to identify a corresponding negative
thought you had just prior to and during the depression. Because these thoughts
have actually created your bad mood, by learning to restructure them, you can
change your mood. You are probably skeptical of all this because your negnegative thinking has become such a part of your life that it has become
automatic. For this reason I call negative thoughts "automatic thoughts." They
run through your mind automatically without the slightest effort on your part to
put them there. They are as obvious and natural to you as the way you hold a
fork. The relationship between the way you think and the way you feel is
diagramed in Figure 3-1. This illustrates the first major key to understanding
your moods: Your emotions result entirely from the way you look at things. It is
an obvious neurological fact that before you can experience any event, you must
process it with your mind and give it
30 David D. Burns, M.D. Figure 3-1. The relationship between the world and the
way you feel. It is not the actual events but your perceptions that result in
changes in mood. When you are sad, your thoughts will represent a realistic
interpretation of negative events. When you are de- depressed or anxious, your
thoughts will always be illogical, dis- distorted, unrealistic, or just plain wrong.
THOUGHTS: You interpret the events with a series of thoughts that contincontinually flow through your mind. This is called your "internal dialogue."
WORLD: A series of positive, neutral, and negative events. MOOD: ^our feelfeelings are created by your thoughts and not the actual events. All experiexperiences must be processed through your brain and given a conscious
meaning before you experience any emotional re- response. meaning. You must
understand what is happening to you before you can feel it. If your
understanding of what is happening is accurate, your emotions will be normal. If
your perception is twisted and distorted in some way, your emotional response
will be abnormal. Depression falls into this category. It is always the result of
mental "static"—distortions. Your blue moods
FEELING GOOD 31 can be compared to the scratchy music coming from a
radio that is not properly tuned to the station. The problem is not that the tubes
or transistors are blown out or defective, or that the signal from the radio station
is distorted as a result of bad weather. You just simply have to adjust the dials.
When you learn to bring about this mental tuning, the music will come through
When you learn to bring about this mental tuning, the music will come through
clearly again and your depres- depression will lift. Some readers—maybe you—
will experience a pang of despair when they read that paragraph. Yet there is
nothing upsetting about it. If anything, the paragraph should bring hope. Then
what caused your mood to plunge as you were reading? It was your thought,
"For other people a little tuning may suffice. But I'm the radio that is broken
beyond repair. My tubes are blown out. I don't care if ten thousand other
depressed patients all get well—I'm convinced beyond any shadow of doubt that
my problems are hopeless." I hear this statement fifty times a week! Nearly
every de- depressed person seems convinced beyond all rhyme or reason that he
or she is the special one who really is beyond hope. This delusion reflects the
kind of mental processing that is at the very core of your illness! I have always
been fascinated by the ability certain people have to create illusions. As a child, I
used to spend hours at the local library, reading books on magic. Saturdays I
would hang out in magic stores for hours, watching the man behind the counter
produce remarkable effects with cards and silks and chromium spheres that
floated through the air, defying all the laws of common sense. One of my
happiest childhood memories is when I was eight years old and saw "Blackstone
—World's Greatest Magician" perform in Denver, Colorado. I was invited with
several other children from the audience to come up on stage. Blackstone ininstructed us to place our hands on a two-feet by two-feet birdcage filled with
live white doves until the top, bottom, and all four sides were enclosed entirely
by our hands. He stood nearby and said, "Stare at the cage!" I did. My eyes were
bulging and I refused to blink. He exclaimed, "Now
32 David D. Burnsr M.D. I'll clap my hands." He did. In that instant the cage of
birds vanished. My hands were suspended in empty air. It was impossible! Yet it
happened! I was stunned. Now I know that his ability as an illusionist was no
greater than that of the average depressed patient. This includes you. When you
are depressed, you possess the remarkable ability to believe, and to get the
people around you to be- believe, things which have no basis in reality. As a
therapist, it is my job to penetrate your illusion, to teach you how to look behind
the mirrors so you can see how you have been fooling yourself. You might even
say that I'm planning to dis-illusion you! But I don't think you're going to mind
at all. Read over the following list of ten cognitive distortions that form the basis
of all your depressions. Get a feel for them. I have prepared this list with great
care; it represents the distilled essence of many years of research and clinical
experience. Refer to it over and over when you read the how-to-do-it section of
the book. When you' are feeling upset, the list will be invaluable in making you
aware of how you are fooling yourself. Definitions of Cognitive Distortions /.
aware of how you are fooling yourself. Definitions of Cognitive Distortions /.
AII-or-Nothing Thinking. This refers to your ten- tendency to evaluate your
personal qualities in extreme, black- or-white categories. For example, a
prominent politician told me, "Because I lost the race for governor, I'm a zero."
A straight-A student who received a B on an exam con- concluded, "Now I'm a
total failure." All-or-nothing thinking forms the basis for perfectionism. It causes
you to fear any mistake or imperfection because you will then see yourself as a
complete loser, and you will feel inadequate and worth- worthless. This way of
evaluating things is unrealistic because life is rarely completely either one way
or the other. For ex- example, no one is absolutely brilliant or totally stupid.
SimFEELING GOOD 33 ilarly, no one is either completely attractive or totally ugly.
Look at the floor of the room you are sitting in now. Is it perfectly clean? Is
every inch piled high with dust and dirt? Or is it partially clean? Absolutes do
not exist in this uni- universe. If you try to force your experiences into absolute
categories, you will be constantly depressed because your perceptions will not
conform to reality. You will set yourself up for discrediting yourself endlessly
because whatever you do will never measure up to your exaggerated
expectations. The technical name for this type of perceptual error is "dichotomous thinking." You see everything as black or white—shades of gray do
not exist. 2. Overgeneralization. When I was eleven years old, I bought a deck of
trick cards at the Arizona State Fair called the Svengali Deck. You may have
seen this simple but impressive illusion yourself: I show the deck to you—every
card is different. You choose a card at random. Let's assume you pick the Jack of
Spades. Without telling me what card it is, you replace it in the deck. Now I
exclaim, * 'Svengali!'' As I turn the deck over, every card has turned into the
Jack of Spades. When you overgeneralize, this is performing the mental
equivalent of Svengali. You arbitrarily conclude that one thing that happened to
you once will occur over and over again, will multiply like the Jack of Spades.
Since what happened is invariably unpleasant, you feel upset. A depressed
salesman noticed bird dung on his car win- window and thought, "That's just my
luck. The birds are always crapping on my window!" This is a perfect example
of overgeneralization. When I asked him about this experience, he admitted that
in twenty years of traveling, he could not remember another time when he found
bird dung on his car window. The pain of rejection is generated almost entirely
from overgeneralization. In its absence, a personal affront is tem- temporarily
disappointing but~ cannot be seriously disturbing. A shy young man mustered
up his courage to ask a girl for
34 David D. Burns, M.D. a date. When she politely declined because of a
previous engagement, he said to himself, "I'm never going to get a date. No girl
would ever want a date with me. I'll be lonely and miserable all my life." In his
distorted cognitions, he concluded that because she turned him down once, she
would always do so, and that since all women have 100 percent identical tastes,
he would be endlessly and repeat- repeatedly rejected by any eligible woman on
the face of the earth. Svengali! 3. Mental Filter. You pick out a negative detail in
any situation and dwell on it exclusively, thus perceiving that the whole situation
is negative. For example, a depressed college student heard some other students
making fun of her best friend. She became furious because she was thinkthinking, "That's what the human race is basically like—cruel and insensitive!"
She was overlooking the fact that in the previous months few people, if any, had
beenrcruel or in- insensitive to her! On another occasion when she completed her
first midterm exam, she felt certain she had missed approximately seventeen
questions out of a hundred. She thought exclusively about those seventeen
questions and concluded she would flunk out of college. When she got the paper
back there was a note attached that read, "You got 83 out of 100 correct. This
was by far the highest grade of any student this year. A 4-" When you are
depressed, you wear a pair of eyeglasses with special lenses that filter out
anything positive. All that you allow to enter your conscious mind is negative.
Because you are not aware of this "filtering process," you conclude that
everything is negative. The technical name for this process is "selective
abstraction." It is a bad habit that can cause you to suffer much needless anguish.
4. Disqualifying the Positive. An even more spectacular mental illusion is the
persistent tendency of some depressed individuals to transform neutral or even
positive experiences into negative ones. You don't just ignore positive expertFEELING GOOD 35 ences, you cleverly and swiftly turn them into their nightnightmarish opposite. I call this "reverse alchemy." The medieval alchemists
dreamed of finding some method for transmuting the baser metals into gold. If
you have been depressed, you may have developed the talent for doing the exact
opposite—you can instantly transform golden joy into emotional lead. Not
intentionally, however—you're prob- probably not even aware of what you're
doing to yourself. An everyday example of this would be the way most of us
have been conditioned to respond to compliments. When someone praises your
appearance or your work, you might automatically tell yourself, "They're just
being nice." With one swift blow you mentally disqualify their compliment. You
do the same thing to them when you tell them, "Oh, it was nothing, really." If
you constantly throw cold water on the good things that happen, no wonder life
seems damp and chilly to you! Disqualifying the positive is one of the most
seems damp and chilly to you! Disqualifying the positive is one of the most
destructive forms of cognitive distortion. You're like a scientist intent on finding
evidence to support some pet hypothesis. The hypothesis that dominates your
depressive thinking is usu- usually some version of "I'm second-rate." Whenever
you have a negative experience, you dwell on it and conclude, ' 'That proves
what I've known all along.'' In contrast, when you have a positive experience,
you tell yourself, "That was a fluke. It doesn't count." The price you pay for this
tendency is intense misery and an inability to appreciate the good things that
happen. While this type of cognitive distortion is commonplace, it can also form
the basis for some of the most extreme and intractable forms of depression. For
example, a young woman hospitalized during a severe depressive episode told
me, "No one could possibly care about me because I'm such an awful person. I'm
a complete loner. Not one person on earth gives a damn about me." When she
was discharged from the Hospital, many patients and staff members exexpressed great fondness for her. Can you guess how she negated all this? "They
don't count because they don't see
36 David D. Burns, M.D. me in the real world. A real person outside a hospital
could never care about me." I then asked her how she reconciled this with the
fact that she had numerous friends and family outside the hospital who did care
about her. She replied, "They don't count because they don't know the real me.
You see Dr. Burns, inside I'm absolutely rotten. I'm the worst person in the
world. It would be impossible for anyone to really like me for even one
moment!" By disqualifying positive experiences in this manner, she can
maintain a negative belief which is clearly unrealistic and inconsistent with her
everyday experiences. While your negative thinking is probably not as extreme
as hers, there may be many times every day when you do inadvertently ignore
genuinely positive things that have hap- happened to you. This removes much of
life's richness and makes things appear needlessly bleak. 5. Jumping to
Conclusions. You arbitrarily jump to a negative conclusion that is not justified
by the facts of the situation. Two examples of this are "mind reading" and "the
fortune teller error." mind reading: You make the assumption that other peopeople are looking down on you, and you're so convinced about this that you
don't even bother to check it out. Suppose you are giving an excellent lecture,
and you notice that a man in the front row is nodding off. He was up most of the
night on a wild fling, but you of course don't know this. You might have the
thought, "This audience thinks I'm a bore." Suppose a friend passes you on the
street and fails to say hello because he is so absorbed in his thoughts he doesn't
notice you. You might erroneously conclude, "He is ig- ignoring me so he must
not like me anymore." Perhaps your spouse is unresponsive one evening because
not like me anymore." Perhaps your spouse is unresponsive one evening because
he or she was criticized at work and is too upset to want to talk about it. Your
heart sinks because of the way you interpret the si- silence: "He (or she) is mad
at me. What did I do wrong?" You may then respond to these imagined negative
reac- reactions by withdrawal or counterattack. This self-defeating
FEELING GOOD 37 behavior pattern may act as a self-fulfilling prophecy and
set up a negative interaction in a relationship when none exists in the first place.
the fortune teller error: It's as if you had a crystal ball that foretold only misery
for you. You imagine that something bad is about to happen, and you take this
pre- prediction as ei fact even though it is unrealistic. A high-school librarian
repeatedly told herself during anxiety attacks, *Tm going to pass out or go
crazy." These predictions were unrealistic because she had never once passed out
(or gone crazy!) in her entire life. Nor did she have any serious symptoms to
suggest impending insanity. During a therapy session an acutely depressed
physician explained to me why he was giving up his practice: "I realize I'll be
depressed forever. My misery will go on and on, and I'm absolutely convinced
that this or any treatment will be doomed to failure." This negative prediction
about his prognosis caused him to feel hopeless. His symptomatic improvement
soon after initiating therapy indicated just how off-base his fortune telling had
been. Do you ever find yourself jumping to conclusions like these? Suppose you
telephone a friend who fails to return your call after a reasonable time. You then
feel depressed when you tell yourself that your friend probably got the message
but wasn't interested enough to call you back. Your distorton?—mind reading.
You then feel bitter, and decide not to call back and check this out because you
say to yourself, "He'll think Fm being obnoxious if I call him back again. I'll
only make a fool of myself." Because of these negative predictions (the fortune
teller error), you avoid your friend and feel put down. Three weeks later you
learn that your friend never got your message. All that stewing, it turns out, was
just a lot of self-imposed hokum. Another painful product of your mental magic!
6. Magnification and Minimization. Another thinking trap you might fall into is
called "magnification'' and ' 'min- 'minimization," but I like to think of it as the
"binocular trick"
38 David D. Burns, M.D. because you are either blowing things up out of
proportion or shrinking them. Magnification commonly occurs when you look at
your own errors, fears, or imperfections and exaggerate their importance: "My
God—I made a mistake. How terrible! How awful! The word will spread like
wild- wildfire! My reputation is ruined!" You're looking at your faults through
the end of the binoculars that makes them appear gigantic and grotesque. This
the end of the binoculars that makes them appear gigantic and grotesque. This
has also been called "catas- trophizing" because you turn commonplace negative
events into nightmarish monsters. When you think about your strengths, you
may do the opposite—look through the wrong end of the binoculars so that
things look small and unimportant. If you magnify your imperfections and
minimize your good points, you're guar- guaranteed to feel inferior. But the
problem isn't you—it's the crazy lenses you're wearing! Z Emotional Reasoning.
You take your emotions as evidence for the truth. Your logic: "I feel like a dud,
there- therefore I am a dud." This kind of reasoning is misleading because your
feelings reflect your thoughts and beliefs. If they are distorted—as is quite often
the case—your emotions will have no validity. Examples of emotional reasoning
include "I feel guilty. Therefore, I must have done some- something bad"; "I feel
overwhelmed and hopeless. Therefore, my problems must be impossible to
solve"; "I feel inad- inadequate. Therefore, I must be a worthless person"; "I'm
not in the mood to do anything. Therefore, I might as well just lie in bed"; or
"I'm mad at you. This proves that you've been acting rotten and trying to take
advantage of me." Emotional reasoning plays a role in nearly all ydur depresdepressions. Because things feel so negative to you, you assume they truly are. It
doesn't occur to you to challenge the validity of the perceptions that create your
feelings. One usual side effect of emotional reasoning is procras- procrastination.
You avoid cleaning up your desk because you tell yourself, "I feel so lousy when
I think about that messy desk, cleaning it will be impossible." Six months later
you
FEELING GOOD 39 finally give yourself a little push and do it. It turns out to
be quite gratifying and not so tough at all. You were fooling yourself all along
because you are in the habit of letting your negative feelings guide the way you
act. 8. Should Statements. You try to motivate yourself by saying, "I should do
this" or "I must do that." These statements cause you to feel pressured and
resentful. Par- Paradoxically, you end up feeling apathetic and unmotivated.
Albert Ellis calls this "mwstarbation." I call it the "shouldy" approach to life.
When you direct should statements toward others, you will usually feel
frustrated. When an emergency caused me to be five minutes late for the first
therapy session* the new patient thought, "He shouldn't be so self-centered and
thoughtless. He ought to be prompt." This thought caused her to feel sour and
resentful. Should statements generate a lot of unnecessary emotional turmoil in
your daily life. When the reality of your own behavior falls short of your
standards, your shoulds and shouldn'ts create self-loathing, shame, and guilt.
When the all-too-human performance of other people falls short of your
expectations, as will inevitably happen from time to time, you'll feel bitter and
self-righteous. You'll either have to change your expectations to approximate
self-righteous. You'll either have to change your expectations to approximate
reality or always feel let down by human behavior. If you recognize this bad
should habit in yourself, I have outlined many effective "should and shouldn't"
removal methods in later chapters on guilt and anger. 9. Labeling and
Mislabeling. Personal labeling means creating a completely negative self-image
based on your errors. It is an extreme form of overgeneralization. The
philosophy behind it is "The measure of a man is the mis- mistakes he makes."
There is a good chance you are involved in a personal labeling whenever you
describe your mistakes with sentences beginning with 'Tm a.. ." For example,
when you miss your putt on the eighteenth hole, you might
40 David D. Burns, M.D. say, "/'m a born loser" instead of "I goofed up on my
putt." Similarly, when the stock you invested in goes down instead of up, you
might think, "/'m a failure" instead of "I made a mistake." Labeling yourself is
not only self-defeating, it is irra- irrational. Your self cannot be equated with any
one thing you do. Your life is a complex and ever-changing flow of thoughts,
emotions, and actions. To put it another way, you are more like a river than a
statue. Stop trying to define yourself with negative labels—they are overly
simplistic and wrong. Would you think of yourself exclusively as an "eater" just
because you eat, or a "breather" just because you breathe? This is nonsense, but
such nonsense becomes painful when you label yourself out of a sense of your
own inadequacies When you label other people, you will invariably gengenerate hostility. A common example is the boss who sees his occasionally
irritable secretary as "an uncooperative bitch." Because of this label, he resents
her and jumps at every chance to criticize her. She, in turn, labels him an
"insensitive chauvinist" and complains about him at every opportunity. So,
around and around they go at each other's throats, focusing on every weakness or
imperfection as proof of the other's worthlessness. Mislabeling involves
describing an event with words that are inaccurate and emotionally heavily
loaded. For example, a woman on a diet ate a dish of ice cream and thought,
"How disgusting and repulsive of me. I'm & pig." These thoughts made her so
upset she ate the whole quart of ice cream! 10. Personalization. This distortion is
the mother of guilt! You assume responsibility for a negative even when there is
no basis for doing so. You arbitrarily conclude that what happened was your
fault or reflects your inadequacy, even when you were not responsible for it. For
example, when a patient didn't do a self-help assignment I had sugFEELING GOOD 41 gested, I felt guilty because of my thought, "I must be a
lousy therapist. It's my fault that she isn't working harder to help herself. It's my
responsibility to make sure she gets well." When a mother saw her child's report
responsibility to make sure she gets well." When a mother saw her child's report
card, there was a note from the teacher indicating the child was not working
well. She immediately decided, "I must be a bad mother. This shows how I've
failed." Personalization causes you to feel crippling guilt. You suffer from a
paralyzing and burdensome sense of respon- responsibility that forces you to
carry the whole world on your shoulders. You have confused influence with
control over others. In your role as a teacher, counselor, parent, phy- physician,
salesman, executive, you will certainly influence the people you interact with,
but no one could reasonably expect you to control them. What the other person
does is ultimately his or her responsibility, not yours. Methods to help you
overcome your tendency to personalize and trim your sense of responsibility
down to manageable, realistic proportions will be discussed later on in this book.
The ten forms of cognitive distortions cause many, if not all, of your depressed
states. They are summarized in Table 3-1 on page 42. Study this table and master
these concepts; try to become as familiar with them as with your phone number.
Refer to Table 3-1 over and over again as you le&rn about the various methods
for mood modification. When you become familiar with these ten forms of
distor- distortion, you will benefit from this knowledge all your life. I have
prepared a simple self-assessment quiz to help you test and strengthen your
understanding of the ten distortions. As you read each of the following brief
vignettes, imagine you are the person who is being described. Circle one or more
answers which indicate the distortions contained in the negative thoughts. I will
explain the answer to the first question. The answer key to subsequent questions
is given at the end of this chapter. But don't look ahead! I'm certain you will be
able to identify at least one distortion in the first question—and that will be a
start!
Table 3-1. Definitions of Cognitive Distortions 1. ALL-OR-NOTHING
THINKING: You see things in black-and-white categories. If your performance
falls short of perfect, you see yourself as a total failure. 2.
OVERGENERALIZATION: You see a single negative event as a never-ending
pattern of defeat. 3. MENTAL FILTER: You pick out a single negative detail
and dwell on it exclusively so that your vision of all reality becomes darkened,
like the drop of ink that colors the entire beaker of water. 4. DISQUALIFYING
THE POSITIVE: You reject positive experiences by insisting they "don't count"
for some rea- reason or other. In this way you can maintain a negative belief that
is contradicted by your everyday experiences. 5. JUMPING TO
CONCLUSIONS: You make a negative interpretation even though there are no
definite facts that convincingly support your conclusion. a. Mind reading. You
arbitrarily conclude that someone is reacting negatively to you, and you don't
arbitrarily conclude that someone is reacting negatively to you, and you don't
bother to check this out. b. The Fortune Teller Error. You anticipate that things
will turn out badly, and you feel convinced that your prediction is an alreadyestablished fact. 6. MAGNIFICATION (CATASTROPHIZING) OR MINIMINIMIZATION: You exaggerate the importance of things (such as your goofup or someone else's achievement), or you inappropriately shrink things until
they appear tiny (your own desirable qualities or the other fellow's imperimperfections). This is also called the "binocular trick." 7. EMOTIONAL
REASONING: You assume that your neg- negative emotions necessarily reflect
the way things really are: "I feel it, therefore it must be true." 8. SHOULD
STATEMENTS: You try to motivate yourself with shoulds and shouldn'ts, as if
you had to be whipped and punished before you could be expected to do
anything. "Musts" and "oughts" are also offenders. The emotional consequence
is guilt. When you direct should statements toward others, you feel anger,
frustration, and resentment.
FEELING GOOD 43 Table 3-1. cont. 9. LABELING AND MISLABELING:
This is an extreme form of overgeneralization. Instead of describing your error,
you attach a negative label to yourself: "I'm a loser." When someone else's
behavior rubs you the wrong way, you attach a negative label to him: "He's a
goddam louse." Mislabeling involves describing an event with language that is
highly colored and emotionally loaded. 10. PERSONALIZATION: You see
yourself as the cause of some negative external event which in fact you were not
primarily responsible for. 1. You are a housewife, and your heart sinks when
your husband has just complained disgruntledly that the roast beef was
overdone. The following thought crosses your mind: "I'm a total failure. I can't
stand it! I never do anything right. I work like a slave and this is all the thanks I
get! The jerk!" These thoughts cause you to feel sad and angry. Your distortions
include one or more of the following: a. all-or-nothing thinking; b.
overgeneralization; c. magnification; d. labeling; e. all the above. Now I will
discuss the correct answers to this question so you can get some immediate
feedback. Any answer(s) you might have circled was (were) correct. So if you
circled anything, you were right! Here's why. When you tell your- yourself, 'Tm
a total failure," you engage in all-or-nothing thinking. Cut it out! The meat was a
little dry, but that doesn't make your entire life a total failure. When you think, "I
never do anything right," you are over generalizing. Never? Come on now! Not
anything! When you tell your- yourself, "I can't stand it," you are magnifying the
pain you are feeling. You're blowing it way out of proportion because you are
standing it, and if you are, you can. Your husband's grumbling is not exactly
what you like to hear, but it's not
44 David D. Burns, M.D. a reflection of your worth. Finally, when you proclaim,
"I work like a slave and this is all the thanks I get! The jerk!" you are labeling
both of you. He's not a jerk, he's just being irritable and insensitive. Jerky
behavior exists, but jerks do not. Similarly, it's silly to label yourself a slave.
You're just letting his moodiness sour your evening. Okay, now let's continue
with the quiz. 2. You have just read the sentence in which I informed you that
you would have to take this self-assessment quiz. Your heart suddenly sinks and
you think, "Oh no, not other test! I always do lousy on tests. I'll have to skip this
section of the book. It makes me nervous, so it wouldn't help anyway." Your
distortions include: a. jumping to conclusions (fortune teller error); b.
overgeneralization; c. all-or-nothing thinking; d. personalization; e. emotional
reasoning. 3. You are a psychiatrist at the University of Pennsyl- Pennsylvania.
You are attempting to revise your manuscript on depression after meeting with
your editor in New York. Although your editor seemed extremely enthusiastic,
you notice you are feeling nervous and inadequate due to your thoughts, "They
made a terrible mistake when they chose my book! I won't be able to do a good
job. I'll never be able to make the book fresh, lively, and punchy. My writing is
too drab, and my ideas aren't good enough." Your cog- cognitive distortions
include: a. all-or-nothing thinking; b. jumping to conclusions (negative
prediction); c. mental filter; d. disqualifying the positive; e. magnification.
FEELING GOOD 45 4. You are lonely and you decide to attend a social affair
for singles. Soon after you get there, you have the urge to leave because you feel
anxious and defensive. The following thoughts run through your mind: "They
probably aren't very interesting people. Why torture myself? They're just a
bunch of losers. I can tell because I feel so bored. This party will be a drag."
Your errors involve: a. labeling; b. magnification; c. jumping to conclusions
(fortune teller error and mind reading); d. emotional reasoning; e.
personalization. 5. You receive a layoff notice from your employer. You feel
mad and frustrated. You think, "This proves the world is no damn good. I never
get a break." Your distortions include: a. all-or-nothing thinking; b. disqualifying
the positive; c. mental filter; d. personalization; e. should statement. 6. You are
about to give a lecture and you notice that your heart is pounding. You feel tense
and nervous because you think, "My God, I'll probably forget what I'm supposed
to say. My speech isn't any good anyway. My mind will blank out. I'll make a
fool of myself.'' Your thinking errors involve: a. all-or-nothing thinking; b.
disqualifying the positive; c. jumping to conclusions (fortune teller error); d.
minimization; e. labeling.
46 David* D. Burns, M.D. 7. Your date calls you at the last minute to cancel out
46 David* D. Burns, M.D. 7. Your date calls you at the last minute to cancel out
because of illness. You feel angry and disappointed because you think, 'Tm
getting jilted. What did I do to foul things up?" Your thinking errors include: a.
all-or-nothing thinking; b. should statements; c. jumping to conclusions (mind
reading); d. personalization; e. overgeneralization. 8. You have put off writing a
report for work. Every night when you try to get down to it, the whole project
seems so difficult that you watch TV instead. You begin to feel overwhelmed
and guilty. You are thinking the follow- following: 4Tm so lazy I'll never get
this done. I just can't do the darn thing. It would take forever. It won't turn out
right anyway." Your thinking errors include: a. jumping to conclusions (fortune
teller error); b. overgeneralization; c. labeling; d. magnification; e. emotional
reasoning. 9. You've read this entire book and after applying the methods for
several weeks, you begin to feel better. Your BDC score went down from
twenty-six (moderately de- depressed) to eleven (borderline depression). Then
you sud- suddenly begin to feel worse, and in three days your score has gone
back up to twenty-eight. You feel disillusioned, hope- hopeless, bitter, and
desperate due to thinking, "I'm not getting anywhere. These methods won't help
me after all. I should be well by now. That 'improvement' was a fluke. I was
fooling myself when I thought I was feeling better. I'll never get well." Your
cognitive distortions include: a. disqualifying the positive; b. should statement;
c. emotional reasoning;
FEELING GOOD 47 d. all-or-nothing thinking; e. jumping to conclusions
(negative prediction). 10. You've been trying to diet. This weekend you've been
nervous, and, since you didn't have anything to do, you've been nibbling,
nibbling. After your fourth piece of candy, you tell yourself, "I just can't control
myself. My dieting and jogging all week have gone down the drain. I must look
like a balloon. I shouldn't have eaten that. I can't stand this. I'm going to pig out
all weekend!" You begin to feel so guilty you push another handful of candy into
your mouth in an abortive effort to feel better. Your dis- distortions include: a.
all-or-nothing thinking; b. mislabeling; c. negative prediction; d. should
statement; e. disqualifying the positive. 1. 2. 3. 4. 5. A A A A A B B B B C C C
D C D E E D ANSWER KEY E 6. 7. 8. 9. 10. A C A A A C D B B B D C C C E
D D D E E E Aren't Facts At this point you may be asking yourself, "Okay. I ununderstand that my depression results from my negative thoughts because my
outlook on life changes enormously when my moods go up or down. But if my
negative thoughts are so distorted, how do I continually get fooled? I can think
48 David D. Burns, M.D. as clearly and realistically as the next person, so if
what I am telling myself is irrational, why does it seem so right?" Even though
what I am telling myself is irrational, why does it seem so right?" Even though
your depressing thoughts may be distorted, they nevertheless create a powerful
illusion of truth. Let me expose the basis for the deception in blunt terms—your
feelings are not facts! In fact, your feelings, per se, don't even count—except as
a mirror of the way you are thinking. If your perceptions make no sense, the
feelings they create will be as absurd as the images reflected in the trick mirrors
at an amusement park. But these abnormal emotions feel just as valid and
realistic as the genuine feelings created by undistorted thoughts, so you
automatically attribute truth to them. This is why depression is such a powerful
form of mental black magic. Once you invite depression through an "automatic"
se- series of cognitive distortions, your feelings and actions will reinforce each
other in a self-perpetuating vicious cycle. Because you believe whatever your
depressed brain tells you, you find yourself feeling negative about almost everyeverything. This reaction occurs in milliseconds, too quickly for you even to be
aware of it. The negative emotion feels realistic and in turn lends an aura of
credibility to the dis- distorted thought which created it. The cycle goes on and
on, and you are eventually trapped. The mental prison is an illusion, a hoax you
have inadvertently created, but it seems real because it feels real. What is the key
to releasing yourself from your emotional prison? Simply this: Your thoughts
create your emotions; therefore, your emotions cannot prove that your thoughts
are accurate. Unpleasant feelings merely indicate that you are thinking
something negative and believing it. Your emo- emotions follow your thoughts
just as surely as baby ducks follow their mother. But the fact that the baby ducks
follow faithfully along doesn't prove that the mother knows where she is going!
Let's examine your equation, "I feel, therefore I am." This attitude that emotions
reflect a kind of self-evident, ultimate truth is not unique to depressed people.
Most psyFEELING GOOD 49 chotherapists today share the conviction that becoming
more aware of your feelings and expressing them more openly represent
emotional maturity. The implication is that your feelings represent a higher
reality, a personal integrity, a truth beyond question. My position is quite
different. Your feelings, per se, are not necessarily special at all. In fact, to the
extent that your negative emotions are based on mental distortions—as is all too
often the case—they can hardly be viewed as desirable. Do I mean you should
get rid of all emotions? Do I want you to turn into a robot? No. I want to teach
you to avoid painful feelings based on mental distortions, because they are
neither valid nor desirable. I believe that once you have learned how to perceive
life more realistically you will ex- experience an enhanced emotional life with a
greater appre- appreciation for genuine sadness—which lacks distortion—as
well as joy. As you go on to the next sections of this book, you can learn to
well as joy. As you go on to the next sections of this book, you can learn to
correct the distortions that fool you when you are upset. At the same time, you
will have the opportunity to reevaluate some of the basic values and assumptions
that create your vulnerability to destructive mood swings. I have outlined the
necessary steps in detail. The modifications in illogical thinking patterns will
have a profound effect on your moods and increase your capacity for productive
living. Now, let's go ahead and see how we can turn your problems around.
Part II Practical Applications
Chapter 4 Start by Building Self-Esteem When you are depressed, you
invariably believe that you are worthless. The worse the depression, the more
you feel this way. You are not alone. A survey by Dr. Aaron Beck revealed that
over 80 percent of depressed patients ex- expressed self-dislike.* Furthermore,
Dr. Beck found that de- depressed patients see themselves as deficient in the
very qualities they value most highly: intelligence, achievement, popularity,
attractiveness, health, and strength. He said a depressed self-image can be
characterized by the four D's: You feel Defeated, Defective, Deserted, and
Deprived. Almost all negative emotional reactions inflict their dam- damage
only as a result of low self-esteem. A poor self-image is the magnifying glass
that can transform a trivial mistake or an imperfection into an overwhelming
symbol of personal defeat. For example, Eric, a first-year law student, feels a
sense of panic in class. "When the professor calls on me, I'll probably goof up."
Although Eric's fear of "goofing up" was foremost on his mind, my dialogue
with him re- *Beck, Aaron T. Depression: Clinical, Experimental, & Theoretical
As- Aspects. New York: Hoeber, 1967. (Republished as Depression: Causes and
Treatment. Philadelphia: University of Pennsylvania Press, 1972, pp. 17- 23.) 53
54 David D. Burns, M.D. vealed that a sense of personal inadequacy was the real
cause of the problem: David: Suppose you did goof up in class. Why would that
be particularly upsetting to you? Why is that so tragic? Eric: Then I would make
a fool of myself. David: Suppose you did make a fool of yourself. Why would
that be upsetting? Eric: Because then everyone would look down on me. David:
Suppose people did look down on you? What then? Eric: Then I would feel
miserable. David: Why? Why is it that you would have to feel miserable if
people were looking down on you? Eric: Well, that would mean I wouldn't be a
worth- worthwhile person. Furthermore, it might ruin my ca- career. I'd^et bad
grades, and maybe I could never be an attorney. David: Suppose you didn't
become an attorney. Let's assume for the purposes of discussion that you did
flunk out. Why would that be particularly upsetting to you? Eric: That would
flunk out. Why would that be particularly upsetting to you? Eric: That would
mean that I had failed at something I've wanted all my life. David: And what
would that mean to you? Eric: Life would be empty. It would mean I was a
failure. It would mean I was worthless. In this brief dialogue, Eric showed that
he believed it would be terrible to be disapproved of or to make a mistake or to
fail. He seemed convinced that if one person looked down on him then everyone
would. It was as if the word REJECT would suddenly be stamped on his
forehead for
FEELING GOOD 55 everyone to see. He seemed to have no sense of selfesteem that was not contingent upon approval and/or success. He measured
himself by the way others looked at him and by what he had achieved. If his
cravings for approval and ac- accomplishment were not satisfied, Eric sensed he
would be nothing because there would be no true support from within. If you
feel that Eric's perfectionistic drive for achieve- achievement and approval is
self-defeating and unrealistic, you are right. But to Eric, this drive was realistic
and reasonable. If you are now depressed or have ever been depressed, you may
find it much harder to recognize the illogical thinking patterns which cause you
to look down on yourself. In fact, you are probably convinced that you really are
inferior or worthless. And any suggestion to the contrary is likely to sound
foolish and dishonest. Unfortunately, when you are depressed you may not be
alone in your conviction about your personal inadequacy. In many cases you will
be so persuasive and persistent in your maladaptive belief that you are defective
and no good, you may lead your friends, family, and even your therapist into
accepting this idea of yourself. For many years psy- psychiatrists have tended to
"buy into" the negative self- evaluation system of depressed individuals without
probing the validity of what the patients are saying about them- themselves. This
is illustrated in the writings of such a keen observer as Sigmund Freud in his
treatise ' 'Mourning and Melancholia," which forms the basis for the orthodox
psy- psychoanalytic approach to treating depression. In this classic study Freud
said that when the patient says he is worthless, unable to achieve, and morally
despicable, he must be right. Consequently, it was fruitless for the therapist to
disagree with the patient. Freud believed the therapist should agree that the
patient is, in fact, uninteresting, unlovable, petty, self-centered, and dishonest.
These qualities describe a hu- human being's true self, according to Freud, and
the disease process simply makes the truth more obvious:
56 David D. Burns, M.D. The patient represents his ego to us as worthless, inincapable of any achievement and morally despicable; be reproaches himself,
vilifies himself and expects to be cast out and punished. ... It would be equally
vilifies himself and expects to be cast out and punished. ... It would be equally
fruit- fruitless from a scientific and therapeutic point of view to contradict a
patient who brings these accusations against his ego. He must surely be right in
some way [emphasis mine] and be describing something that is as it seems to
him to be. Indeed we must at once confirm some of his statements without
reservation. He really is as lacking in interest and incapable of love and
achievement as he says [emphasis mine].... He also seems to us justified in
certain other self-accusations; it is merely that he has a keener eye for the truth
than other people who are not melancholic [emphasis mine]. When in his
heightened self-criticism he describes him- himself as petty, egoistic, dishonest,
lacking in inde- independence, one whose sole aim has been to hide the
weaknesses of his own nature, it may be so far as we know, that he has come
pretty near to understand- understanding himself [emphasis mine]; we only
wonder why a man has to be ill before he can be accessible to truth of this kind.
—Sigmund Freud, "Mourning and Melancholia"* The way a therapist handles
your feelings of inadequacy is crucial to the cure, as your sense of worthlessness
is a key to depression. The question also has considerable phil- philosophical
relevance—is human nature inherently defective? Are depressed patients
actually facing the ultimate truth about themselves? And what, in the final
analysis, is the source of genuine self-esteem? This, in my opinion, is the most
important question you will ever confront. First, you cannot earn worth through
what you do. *Freud, S. Collected Papers, 1917. (Translated by Joan Riviere,
Vol. IV, Chapter 8,"Mourning and Melancholia," pp. 155-156. London: Hogarth
Press Ltd., 1952.)
FEELING GOOD 57 Achievements can bring you satisfaction but not
happiness. Self-worth based on accomplishments is a "pseudo- esteem," not the
genuine thing! My many successful but depressed patients would all agree. Nor
can you base a valid sense of self-worth on your looks, talent, fame, or fortune.
Marilyn Monroe, Mark Rothko, Freddie Prinz, and a mul- multitude of famous
suicide victims attest to this grim truth. Nor can love, approval, friendship, or a
capacity for close, caring human relationships add one iota to your inherent
worth. The great majority of depressed individuals are in fact very much loved,
but it doesn't help one bit because self-lovz and self-esteem are missing. At the
bottom line, only your own sense of self-worth determines how you feel. "So,"
you may now be asking with some exasperation, "how do I get a sense of selfworth? The fact is, I feel damn inadequate, and I'm convinced I'm really not as
good as other people. I don't believe there's anything I can do to change those
rotten feelings because that's the way I basically am." One of the cardinal
features of cognitive therapy is that it stubbornly refuses to buy into your sense
of worthlessness. In my practice I lead my patients through a systematic re-
of worthlessness. In my practice I lead my patients through a systematic reevaluation of their negative self-image. I raise the same ques- question over and
over again: "Are you really right when you in- insist that somewhere inside you
are essentially a loser?" The first step is to take a close look at what you say
about yourself when you insist you are no good. The evidence you present in
defense of your worthlessness will usually, if not always, make no sense. This
opinion is based on a recent study by Drs. Aaron Beck and David Braff which
indicated that there is actually a formal thinking disturbance in depressed
patients. De- Depressed individuals were compared with schizophrenic papatients and with undepressed persons in their ability to interpret the meaning of
a number of proverbs, such as "A stitch in time saves nine." Both the
schizophrenic and de- depressed patients made many logical errors and had
difficulty in extracting the meaning of the proverbs. They were overly
58 David D. Burns, M.D. concrete and couldn't make accurate generalizations.
Al- Although the severity of the defect was obviously less profound and bizarre
in the depressed patients than in the schizo- schizophrenic group, the depressed
individuals were clearly ab- abnormal as compared with the normal subjects. In
practical terms the study indicated that during periods of depression you lose
some of your capacity for clear think- thinking; you have trouble putting things
into proper perspective. Negative events grow in importance until they dominate
your entire reality—and you can't really tell that what is happening is distorted.
It all seems very real to you. The illusion of hell you create is very convincing.
The more depressed and miserable you feel, the more twisted your thinking
becomes. And, conversely, in the absence of mental distortion, you cannot
experience low self-worth or depression! What types of mental errors do you
make most generally when you look down on yourself? A good place to begin is
with the list of distortions you began to master in Chapter 3. The most usual
mental distortion to look out for when you are feeling worthless is all-or-nothing
thinking. If you see life only in such extreme categories, you will believe your
performance will be either great or terrible—nothing else will exist. As a
salesman told me, "Achieving 95 percent or better of my goal for monthly sales
is acceptable. Ninety-four percent or below is the equivalent of total failfailure." Not only is this all-or-nothing system of self-evaluation highly
unrealistic and self-defeating, it creates overwhelm- overwhelming anxiety and
frequent disappointment. A depressed psy- psychiatrist who was referred to me
noticed a lack of sexual drive and a difficulty in maintaining erections during a
two- week period when he was feeling blue. His perfectionistic tendencies had
dominated not only his illustrious profes- professional career but also his sexual
life. Consequently, he had intercourse regularly with his wife every other day
life. Consequently, he had intercourse regularly with his wife every other day
precisely on schedule for the twenty years of their married life. In spite of his
decreased sex drive—which is a common sympFEELING GOOD 59 torn of depression—he told himself, "I must continue to
perform intercourse on schedule." This thought created such anxiety that he
became increasingly unable to achieve a satisfactory erection. Because his
perfect intercourse track record was broken, he now began clubbing himself with
the "nothing" side of his all-or-nothing system and concluded, "I'm not a full
marriage partner anymore. Fm a failure as a husband. I'm not even a man. I'm a
worthless nothing." Although he was a competent (and some might even say
brilliant) psychiatrist, he confided to me tearfully, "Dr. Burns, you and I both
know it is an undeniable fact that I will never be able to have intercourse again."
In spite of his years of medical training, he could actually convince himself of
such a thought. Overcoming the Sense of Worthfessness By now you might be
saying, "Okay, I can see that there is a certain illogic which lurks behind the
sense of worth- lessness. At least for some people. But they are basically
winners; they're not like me. You seem to be treating famous physicians and
successful businessmen. Anyone could have told you that their lack of selfesteem was illogical. But I really am a mediocre nothing. Others are, in fact,
better looking and more popular and successful than I am. So what can I do
about it? Nothing, that's what! My feeling of worthlessness is very valid. It's
based on reality, so there is little consolation in being told to think logically. I
don't think there's any way to make these awful feelings go away unless I try to
fool myself, and you and I both know that won't work." Let me first show you a
couple of popular approaches, used by many therapists, which I feel do not
represent satisfactory solutions to your problem of worth- worthlessness. Then
I'll show you some approaches that will make sense and help you. In keeping
with the belief that there is some deep truth in your conviction you are basically
worthless, some psy60 David D. Burns, M.D. chotherapists may allow you to ventilate these feelings
of inadequacy during a therapy session. There is undoubtedly some benefit to
getting such feelings off your chest. The cathartic release may sometimes, but
not always, result in a temporary mood elevation. However, if the therapist does
not provide objective feedback about the validity of your self-evaluation, you
may conclude that he agrees with you. And you may be right! You may, in fact,
have fooled him as well as yourself! As a result you probably will feel even
more inadequate. Prolonged silences during therapy sessions may cause you to
become more upset and preoccupied with your critical internal voice—much like
become more upset and preoccupied with your critical internal voice—much like
a sensory-deprivation experi- experiment. This kind of nondirective therapy, in
which the ther- therapist adopts a passive role, frequently produces greater
anxiety and depression for the patient. And even when you do feel better as a
result of achieving emotional release with an empathetic and caring therapist, the
sense of improve- improvement is likely to be short-lived if you haven't
significantly transformed the way you evaluate yourself and your life. Unless
you substantially reverse your self-defeating thinking and behavior patterns, you
are likely to slip back again into depression. Just as emotional ventilation for its
own sake is usually not enough to overcome the sense of worthlessness, insight
and psychological interpretation generally don't help either. For example,
Jennifer was a writer who came for treatment for panic she experienced before
publication of her novel. In the first session she told me, "I have been to several
therapists. They have told me that my problem is perfec- perfectionism and
impossible expectations and demands on my- myself. I also have learned that I
probably picked up this trait from my mother, who is compulsive and
perfectionistic. She can find nineteen things wrong with an incredibly clean
room. I always tried to please her, but rarely felt I succeeded no matter how well
I did. Therapists have told me, 'Stop seeing everyone as your mother! Stop being
so perfectionFEELING GOOD 61 istic.' But how do I do this? I'd like to, I want to, but no
one ever was able to tell me how to go about it." Jennifer's complaint is one I
hear nearly every day in my practice. Pinpointing the nature or origin of your
problem may give you insight, but usually fails to change the way you act. That
is not surprising. You have been practicing for years and years the bad mental
habits that helped create your low self-esteem. It will take systematic and
ongoing effort to turn the problem around. Does a stutterer stop stuttering
because of his insight into the fact that he doesn't vocalize properly? Does a
tennis player's game improve just because the coach tells him he hits the ball into
the net too often? Since ventilation of emotions and insight—the two staples of
the standard psychotherapeutic diet—won't help, what will? As a cognitive
therapist, I have three aims in dealing with your sense of worthlessness: a rapid
and decisive trans- transformation in the way you think, feel, and behave. These
results will be brought about in a systematic training pro- program that employs
simple concrete methods you can apply on a daily basis. If you are willing to
commit some regular time and effort to this program, you can expect success
proportionate to the effort you put in. Are you willing? If so, we've come to the
beginning. You're about to take the first crucial step toward an im- improved
mood and self-image. I have developed many specific and easily applied techtechniques that can help you develop your sense of worth. As you read the
techniques that can help you develop your sense of worth. As you read the
following sections, keep in mind that simply reading them is not guaranteed to
bolster your self-esteem— at least not for long. You will have to work at it and
practice the various exercises. In fact, I recommend that you set some time aside
each day to work at improving your self- image because only in this way can
you experience the fastest and most enduring personal growth.
62 David D. Burns, M.D. Specific Methods for Boosting Self-Esteem /. Talk
Back to That Internal Critic! A sense of worth- lessness is created by your
internal self-critical dialogue. It is self-degrading statements, such as "I'm no
damn good," "I'm a shit," "I'm inferior to other people," and so on, that create
and feed your feelings of despair and poor self- esteem. In order to overcome
this bad mental habit, three steps are necessary: a. Train yourself to recognize
and write down the self- critical thoughts as they go through your mind; b. Learn
why these thoughts are distorted; and c. Practice talking back to them so as to
develop a more realistic self-evaluation system. One effective method for
accomplishing this is the "tri- "triple-column technique." Simply draw two lines
down the center of a piece of paper to divide it into thirds (see Figure 4-1, page
63). Label the left-hand column "Automatic Thoughts (Self-Criticism)," the
middle column "Cognitive Distortion," and the right-hand column "Rational
Response (Self-Defense)." In the left-hand column write down all those hurtful
self-criticisms you make when you are feeling worthless and down on yourself.
Suppose, for example, you suddenly realize you're late for an important meeting.
Your heart sinks and you're gripped with panic. Now ask yourself, "What
thoughts are going through my mind right now? What am I saying to myself?
Why is this upsetting me?" Then write these thoughts down in the left-hand
column. You might have been thinking, "I never do anything right," and "I'm
always late." Write these thoughts down in the left-hand column and number
them (see Figure 4-1). You might also have thought, "Everyone will look down
at me. This shows what a jerk I am." Just as fast as these thoughts cross your
mind, jot them down. Why? Because they are the very cause of your emotional
upset. They rip away at you like knives tearing into your flesh. I'm sure you
know what I mean because you've felt it.
Figure 4-1. The "triple-column technique" can be used to restructure the way you
think about yourself when you have goofed up in some way. The aim is to
substitute more objective rational thoughts for the illogical, harsh self- criticisms
that automatically flood your mind when a negative event occurs. Automatic
Thought (SELF-CRITICISM) 1. I never do anything right. 2. I'm always late. 3.
Everyone will look down on me. 4. This shows what a jerk I am. 5. I'll make a
Everyone will look down on me. 4. This shows what a jerk I am. 5. I'll make a
fool of myself. Cognitive Distortion 1. Overgeneralization 2. Overgeneralization
3. Mind reading Overgeneralization All-or-nothing thinking Fortune teller error
4. Labeling 5. Labeling Fortune teller error 1. 2. 3. 4. 5. Rational Response
(SELF-DEFENSE) Nonsense! I do a lot of things right. I'm not always late.
That's ridiculous. Think of all the times I've been on time. If I'm late more often
than I'd like, I'll work on this problem and develop a method for being more
punctual. Someone may be disappointed that I'm late but it's not the end of the
world. Maybe the meeting won't even start on time. Come on, now, I'm not "a
jerk/' Ditto. I'm not "a fool" either. I may appear foolish if I come in late, but this
doesn't make me a fool. Everyone is late sometimes.
64 David D. Burns, M.D. What's the second step? You already began to prepare
for this when you read Chapter 3. Using the list of ten cognitive distortions (page
42), see if you can identify the thinking errors in each of your negative automatic
thoughts. For instance, "I never do anything right" is an example of
overgeneralization. Write this down in the middle column. Continue to pinpoint
the distortions in your other automatic thoughts, as shown in Figure 4—1. You
are now ready for the crucial step in mood trans- transformation—substituting a
more rational, less upsetting thought in the right-hand column. You do not try to
cheer yourself up by rationalizing or saying things you do not believe are
objectively valid. Instead, try to recognize the truth. If what you write down in
the Rational Response column is not convincing and realistic, it won't help you
one bit. Make sure you believe in your rebuttal to self- criticism. This rational
response can take into account what was illogical and erroneous about your selfcritical auto- automatic thought. For example, in answer to "I never do anything
right," you could write, "Forget that! I do some things right and some wrong, just
like everyone else. I fouled up on my appointment, but let's not blow this up out
of proportion." Suppose you cannot think of a rational response to a particular
negative thought. Then just forget about it for a few days and come back to it
later. You will usually be able to see the other side of the coin. As you work at
the triple-column technique for fifteen minutes every day over a period of a
month or two, you will find it gets easier and easier. Don't be afraid to ask other
people how they would answer an upsetting thought if you can't figure out the
ap- appropriate rational response on your own. One note of caution: Do not use
words describing your emotional reactions in the Automatic Thought column.
Just write the thoughts that created the emotion. For example, suppose you
notice your car has a flat tire. Don't write "I feel crappy" because you can't
disprove that with a rational
FEELING GOOD 65 response. The fact is, you do feel crappy. Instead, write
down the thoughts that automatically flashed through your mind the moment you
saw the tire; for example, "I'm so stupid—I should have gotten a new tire this
last month," or "Oh, hell! This is just my rotten luck!" Then you can substitute
rational responses such as "It might have been better to get a new tire, but I'm
not stupid and no one can predict the future with certainty." This process won't
put air in the tire, but at least you won't have to change it with a deflated ego.
While it's best not to describe your emotions in the Au- Automatic Thought
column, it can be quite helpful to do some "emotional accounting" before and
after you use the triple- column technique to determine how much your feelings
actually improve. You can do this very easily if you record how upset you are
between 0 and 100 percent before you pinpoint and answer your automatic
thoughts. In the pre- previous example, you might note that you were 80 percent
frustrated and angry at the moment you saw the flat tire. Then, once you
complete the written exercise, you can record how much relief you experienced,
say, to 40 percent or so. If there's a decrease, you'll know that the method has
worked for you. A slightly more elaborate form developed by Dr. Aaron Beck
called the Daily Record of Dysfunctional Thoughts allows you to record not only
your upsetting thoughts but also your feelings and the negative event that
triggered them (see Figure 4-2, page 66). For example, suppose you are selling
insurance and a potential customer insults you without provocation and hangs up
on you. Describe the actual event in the Situation column, but not in the
Automatic Thoughts) column. Then write down your feelings and the negative
distorted thoughts that created them in the appropriate column. Finally, talk back
to these thoughts and do your emotional accounting. Some individuals prefer to
use the Daily Record of Dys- Dysfunctional Thoughts because it allows them to
analyze negFigure 4-2. Daily Record of Dysfunctional Thoughts' Situation Briefly describe
the actual event leading to the unpleasant emotion. Potential cus- customer hangs
up on me when I call to describe our new insur- insurance program He said, "Get
out of my god- goddam hair!" Emotion(s) I. Specify sad/ anxious/ angry, etc. 2.
Rate degree of emotion, 1-100%. Angry, 99% Sad, 50% Automatic Thought(s)
Write the auto- automatic thought(s) that accompany the emotion(s). 1. I111
never sell a policy. 2. I'd like to strangle the bastard. 3. I must have said the
wrong thing. Cognitive Distortions) Identify the dis- tortion(s) present in each
automatic thought. 1. Overgenerali- zation 2. Magnification; labeling 3. Jumping
to conclusions; personaliza- personalization Rational Response(s) Write rational
re- sponse(s) to the auto- automatic thought(s). 1. I've sold a lot of policies. 2. He
acted like a pain in the butt. We alt do at times. Why let this get to me? 3. 1
acted like a pain in the butt. We alt do at times. Why let this get to me? 3. 1
actually didn't do anything different from the way I usu- usually approach a new
customer. So why sweat it? Outcome Specify and rate subse- subsequent emoemotions, 0- 100%. Angry, 50% Sad, 10% Explanation: When you experience
an unpleasant emotion, note the situation that seemed to stimulate it. Then, note
the automatic thought associated with the emotion. In rating degree of emotion,
1 = a trace; 100 = the most intense possible. ♦Copyright 1979, Aaron T. Beck.
FEELING GOOD 67 ative events, thoughts, and feelings in a systematic way.
Be sure to use the technique that feels most comfortable to you. Writing down
your negative thoughts and rational re- responses may strike you as simplistic,
ineffective, or even gimmicky. You might even share the feelings of some papatients who initially refused to do this, saying, "What's the point? It won't work
—it couldn't work because I really am hopeless and worthless." This attitude can
only serve as a self-fulfilling prophecy. If you are unwilling to pick up the tool
and use it, you won't be able to do the job. Start by writing down your automatic
thoughts and rational responses for fifteen minutes every day for two weeks and
see the effect this has on your mood, as measured by the Burns Depression
Checklist. You may be surprised to note the beginning of a period of personal
growth and a healthy change in your self-image. This was the experience of
Gail, a young secretary whose sense of self-esteem was so low that she felt in
constant danger of being criticized by friends. She was so sensitive to her
roommate's request to help clean up their apartment after a party that she felt
rejected and worthless. She was initially so pessimistic about her chances for
feeling better that I could barely persuade her to give the triple-column technique
a try. When she reluctantly decided to try it, she was surprised to see how her
self-esteem and mood began to undergo a rapid transformation. She reported that
writing down the many negative thoughts that flowed through her mind during
the day helped her gain objectivity. She stopped taking these thoughts so
seriously. As a result of Gail's daily written exercises, she began to feel better,
and her interpersonal relationships improved by a quantum leap. An excerpt
from her written homework is included in Figure 4-3. Gail's experience is not
unusual. The simple exercise of answering your negative thoughts with rational
responses on a daily basis is at the heart of the cognitive method. It is one of the
most important approaches to changing your
Figure 4-3. Excerpts from Gail's daily written homework using the "triplecolumn technique." In the left column she recorded the negative thoughts that
automatically flowed through her mind when her roommate asked her to clean
up the apartment. In the middle column she identified her distortions, and in the
up the apartment. In the middle column she identified her distortions, and in the
right- hand column she wrote down more realistic interpretations. This daily
written exercise greatly accelerated her personal growth and re- resulted in
substantial emotional relief. Automatic Thoughts (self-criticism) Cognitive
Distortion Rational Response (self-defense) 1. Everyone knows how disdisorganized and selfish I am. Jumping to conclusions (mind reading);
overgeneraliza- tion 2. I'm completely All-or-nothing self-centered thinking and
thoughtless. I'm just no good. 3. My roommate probably hates me. I have no real
friends. Jumping to conclusions (mind reading); all-or-nothing thinking 1. I'm
disorganized at times and I'm or- organized at times. Everybody doesn't think the
same way about me. 2. I'm thoughtless at times, and at times I can be quite
thoughtful. I prob- probably do act overly self-centered at times. I can work on
this. I may be imperfect but I'm not "no good!" 3. My friendships are just as real
as any- anyone's. At times I take criticism as re- rejection of me, Gail, the
person. But oth- others are usually not rejecting me. They're just ex- expressing
dislike for what I did (or said)—and they still accept me af- afterwardFEELING GOOD 69 thinking. It is crucial to write down your automatic
thoughts and rational responses; do not try to do the exercise in your head.
Writing them down forces you to develop much more objectivity than you could
ever achieve by letting responses swirl through your mind. It also helps you
locate the mental errors that depress you. The triple-column technique is not
limited to problems of personal inadequacy, but can be applied to a great range
of emotional difficulties in which distorted thinking plays a central role. You can
take the major sting out of problems you would ordinarily assume are entirely
"realistic," such as bankruptcy, divorce, or severe mental illness. Finally, in the
section on prophylaxis and personal growth, you will learn how to apply a slight
variation of the automatic-thought \ method to penetrate to the part of your
psyche where the causes of mood swings lurk. You will be able to expose and
transform those "pres- "pressure points" in your mind that cause you to be
vulnerable to depression in the first place. 2. Mental Biofeedback. A second
method which can be very useful involves monitoring your negative thoughts
with a wrist counter. You can buy one at a sporting-goods store or a golf shop; it
looks like a wristwatch, is inexpensive, and every time you push the button, the
number changes on the dial. Click the button each time a negative thought about
yourself crosses your mind; be on the constant alert for such thoughts. At the end
of the day, note your daily total score and write it down in a log book. At first
you will notice that the number increases; this will continue for several days as
you get better and better at identifying your critical thoughts. Soon you will
begin to notice that the daily total reaches a plateau for a week to ten days, and
begin to notice that the daily total reaches a plateau for a week to ten days, and
then it will begin to go down. This indicates that your harmful thoughts are
diminishing and that you are getting better. This approach usually requires three
weeks. It is not known with certainty why such a simple technique works so
well, but systematic self-monitoring frequently helps develop increased selfcontrol. As you learn to stop
70 David D. Burns, M.D. haranguing yourself, you will begin to feel much
better. In case you decide to use a wrist counter, I want to emphasize it is not
intended to be a substitute for setting aside ten to fifteen minutes each day to
write down your distorted negative thoughts and answering them as outlined in
the previous pages. The written method cannot be by- bypassed because it
exposes to the light of day the illogical nature of the thoughts that trouble you.
Once you are doing this regularly, you can then use your wrist counter to nip
your painful cognitions in the bud at other times. ., Cope, Don't Mopef—The
Woman Who Thought She Was a "Bad Mother." As you read the previous secsections, the following objection may have occurred to you: "All this deals with
is my thoughts. But what if my problems are realistic? What good will it do me
to think differently? I have some real inadequacies that need to be dealt with."
Nancy is a thirty-four-year-old mother of two who felt this way. Six years ago
she divorced her first husband and has just recently remarried. She is completing
her college degree on a part-time basis. Nancy is usually animated and
enthusiastic and quite committed to her family. However, she has experienced
episodic depressions for many years. During those low periods she becomes
extremely critical of herself and others, and expresses self-doubt and insecurity.
She was referred to me during such a period of depression. I was struck by the
vehemence of her self-reproach. She had received a note from her son's teacher
stating that he was having some difficulty in school. Her immediate re- reaction
was to mope and blame herself. The following is an excerpt from our therapy
session: Nancy: I should have worked with Bobby on his home- homework
because now he is disorganized and not ready for school. I spoke to Bobby's
teacher, who said Bobby lacks self-confidence and doesn't follow directions
adequately. Conse- Consequently, his school work has been deteriorating.
FEELING GOOD 71 I had a number of self-critical thoughts after the call and I
felt suddenly dejected. I began to tell myself that a good mother spends time
with her kids on sortie activity every night. I'm respon- responsible for his poor
behavior—lying, not doing well in school. I just can't figure out how to handle
him. I'm really a bad mother. I began to think he was stupid and about to flunk
and how it was all my fault. My first strategy was to teach her how to attack the
state- statement "I am a bad mother," because I felt this self-criticism was hurtful
state- statement "I am a bad mother," because I felt this self-criticism was hurtful
and unrealistic, creating a paralyzing internal anguish which would not help her
in her efforts to guide Bobby through his crisis. David: Okay. What's wrong with
this statement, "I am a bad mother'' ? Nancy: Well... David: Is there any such
thing as a "bad mother"? Nancy: Of course. David: What is your definition of a
"bad mother"? Nancy: A bad mother is one who does a bad job of raising her
kids. She isn't as effective as other mothers, so her kids turn out bad. It seems
ob- obvious. David: So you would say a "bad mother" is one who is low on
mothering skills? That's your defini- definition? Nancy: Some mothers lack
mothering skills. David: But all mothers lack mothering skills to sdme extent.
Nancy: They do? David: There's no mother in this world who is perfect in all
mothering skills. So they all lack moth72 David D. Burns, M.D. ering skills in some part. According to your definition,
it would seem that all mothers are bad mothers. Nancy: I feel that /'ma bad
mother, but not everybody is. David: Well, define it again. What is a "bad
mother'*? Nancy: A bad mother is someone who does not under- understand her
children or is constantly making dam- damaging errors. Errors that are
detrimental. David: According to this new definition, you're not a * 'bad mother,
* * and there are no' 'bad mothers'' because no one constantly makes damaging
er- errors. Nancy: No one... ? David: You said that a bad mother constantly
makes damaging errors. There is no such person who constantly makes
damaging errors twenty-four hours a day. Every mother is capable of doing
some things right. Nancy: Well, there can be abusive parents who are al- always
punishing, hitting—you read about them in the papers. Their children end up
battered. That could certainly be a bad mother. David: There are parents who
resort to abusive behav- behavior, that's true. And these individuals could imimprove their behavior, which might make them feel better about themselves and
their children. But it's not realistic to say that such parents are constantly doing
abusing or damaging things, and it's not going to help matters by attaching the
label "bad" to them. Such individuals do have a problem with aggression and
need train- training in self-control, but it would only make mat- matters worse if
you tried to convince them that
FEELING GOOD 73 their problem was badness. They usually already believe
they are rotten human beings, and that is part of their problem. Labeling them as
"bad mothers" would be inaccurate, and it would also be irresponsible, like
trying to put out a fire by throwing gasoline on it. At this point I was trying to
show Nancy that she was just defeating herself by labeling herself as a "bad
mother.'' I hoped to show her that no matter how she defined "bad mother," the
mother.'' I hoped to show her that no matter how she defined "bad mother," the
definition would be unrealistic. Once she gave up the destructive tendency to
mope and label herself as worthless, we could then go on to coping strategies for
helping her son with his problems at school. Nancy: But I still have the feeling I
am a * 'bad mother.'' David: Well, once again, what is your definition? Nancy:
Someone who doesn't give her child enough attention, positive attention. I'm so
busy in school. And when I do pay attention, I'm afraid it may be all negative
attention. Who knows? That's what I'm saying. David: A "bad mother" is one
who doesn't give her child enough attention, you say? Enough for what? Nancy:
For her child to do well in life. David: Do well in everything, or in some things?
Nancy: In some things. No one can do well at every- everything. David: Does
Bobby do well at some things? Does he have any redeeming virtues? Nancy: Oh
yes. There are many things he enjoys and does well at. David: Then you can't be
a "bad mother" according to your definition because your son does well at many
things.
74 David D. Burns, M.D. Nancy: Then why do I feel like a bad mother? David:
It seems that you're labeling yourself as a "bad mother" because you'd like to
spend more time with your son, and because you sometimes feel inadequate, and
because there is a clear-cut need to improve your communication with Bobby.
But it won't help you solve these problems if you conclude automatically you are
a "bad mother.'' Does that make sense to you? Nancy: If I paid more attention to
him and gave him more help, he could do better at school and he could be a
whole lot happier. I feel it's my fault when he doesn't do well. David: So you are
willing to take the blame for his mistakes? Nancy: Yes, it's my fault. So I'm a
bad mother. David: And you also take the credit for his achieve- achievements?
And for his happiness? Nancy: No—he should get the credit for that, not me.
David: Does that make sense? That you're responsible for his faults but not his
strengths? Nancy: No. David: Do you understand the point I'm trying to make?
Nancy: Yep. David: ' 'Bad mother'' is an abstraction; there is no such thing as a
"bad mother" in this universe. Nancy: Right. But mothers can do bad things.
David: They're just people, and people do a whole va- variety of things—good,
bad, and neutral. "Bad mother" is just a fantasy; there's no such thing. The chair
is a thing. A "bad mother" is an abstraction. You understand that? Nancy: I got
it, but some mothers are more experienced and more effective than others.
FEELING GOOD 75 David: Yes, there are all degrees of effectiveness at
parenting skills. And most everyone has plenty of room for improvement. The
meaningful ques- question is not "Am I a good or bad mother?" but rather "What
are my relative skills and weak- weaknesses, and what can I do to improve?"
Nancy: I understand. That approach makes more sense and it feels much better.
Nancy: I understand. That approach makes more sense and it feels much better.
When I label myself "bad mother," I just feel inadequate and de- depressed, and
I don't do anything productive. Now I see what you've been driving at. Once I
give up criticizing myself, I'll feel better, and maybe I can be more helpful to
Bobby. David: Right! So when you look at it that way, you're talking about
coping strategies. For example, what are your parenting skills? How can you
begin to improve on those skills? Now that's the type of thing I would suggest
with regard to Bobby. Seeing yourself as a "bad mother" eats up emotional
energy and distracts you from the task of improving your mothering skills. It's
irresponsible. Nancy: Right. If I can stop punishing myself with that statement,
I'll be much better off and I can start working toward helping Bobby. The
moment I stop calling myself a bad mother, I'll start feel- feeling better. David:
Yes, now what can you say to yourself when you have the urge to say "I'm a bad
mother"? Nancy: I can say I don't have to hate my whole self if there is a
particular thing I find I dislike about Bobby, or if he has a problem at school. I
can try to define that problem, and attack that prob- problem, and work toward
solving it.
76 David D. Burns, M.D. David: Right. Now, that's a positive approach. I like it.
You refute the negative statement and then add a positive statement. I like that.
We then worked on answering several " automatic thoughts" she had written
down after the call from Bobby's teacher (see Figure 4—4, below). As Nancy
learned to refute her self-critical thoughts, she experienced much-needed
emotional relief. She was then able to develop some specific coping strategies
designed to help Bobby with his difficul- difficulties. Figure 4-4. Nancy's written
homework concerning Bobby's diffi- difficulties at school. This is similar to the
"triple-column technique," except that she did not find it necessary to write down
the cognitive distortions contained in her automatic thoughts. Automatic
Thought Rational Response (SELF-CRITICISM) (SELF-DEFENSE) 1. I didn't
pay attention to 1. I really spend too much Bobby. time with him; I'm overprotective. 2. I should have worked with 2. Homework is his respon- him on his
homework, and sibility, not mine. I can ex- now he is disorganized and plain to
him how to get not ready for school. organized. What are my reresponsibilities? a. Check homework; b. Insist it be done at a cer- certain time; c.
Ask if he's having any difficulties; d. Set up a reward system. 3. A good mother
spends time 3. Not true. I spend time when with her kids on some ac- I can and
want to, but it tivity every night. isn't feasible always. Be- Besides, his schedule
is his. 4. I'm responsible for his poor 4. I can only guide Bobby. It's behavior and
not doing well up to him to do the rest, in school.
FEELING GOOD 77 Figure 4-4. cont. Automatic Thought Rational Response
(self-criticism) (self-defense) 5. He wouldn't have gotten 5. That is not so.
Problems into trouble at school if I will occur even if I'm had helped him. If I
had su- around to oversee things, pervised his homework ear- earlier, this
problem wouldn't have occurred. 6. I'm a bad mother. I'm the 6. I'm not a bad
mother; I try. cause of his problems. I can't control what goes on in all areas of
his life. Maybe I can talk to him and his teacher and find out how to help him.
Why punish myself whenever someone I love has a problem? 7. All other
mothers work 7. Overgeneralization! Not with their kids, but I don't true. Stop
moping and start know how to get along with coping. Bobby. The first step of
her coping plan was to talk to Bobby about the difficulties he had been having so
as to find out what the real problem was. Was he having difficulties as his
teacher had suggested? What was his understanding of the problem? Was it true
that he was feeling tense and low in confidence? Had his homework been
particularly hard for him recently? Once Nancy had obtained this information
and defined the real problem, she realized she would then be in a position to
work toward an appropriate solution. For example, if Bobby said he found some
of his courses par- particularly difficult, she could develop a reward system at
home to encourage him to do extra homework. She also
78 David D. Burns, M.D. decided to read several books on parenting skills. Her
re- relationship with Bobby improved, and his grades and be- behavior at school
underwent a rapid turnabout. Nancy's mistake had been to view herself in a
global way, making the moralistic judgment that she was a bad mother. This
type of criticism incapacitated her because it created the impression that she had
a personal problem so big and bad that no one could do anything about it. The
emotional upset this labeling caused prevented her from defining the real
problem, breaking it down into its specific parts, and applying appropriate
solutions. If she had con- continued to mope, there was the distinct possibility
that Bobby would have continued to do poorly, and she would have become
increasingly ineffectual. How can you apply what Nancy learned to your own
situation? When you are down on yourself, you might find it helpful to ask what
you actually mean when you try to define your true identity with a negative label
such as "a fool," "a sham," "a stupid dope," etc. Once you begin to pick these
destructive labels apart, you will find they are arbitrary and meaningless. They
actually cloud the issue, creating confusion and despair. Once rid of them, you
can define and cope with any real problems that exist. Summary. When you are
experiencing a blue mood, the chances are that you are telling yourself you are
inherently inadequate or just plain "no good." You will become con- convinced
that you have a bad core or are essentially worthless. To the extent that you
that you have a bad core or are essentially worthless. To the extent that you
believe such thoughts, you will ex- experience a severe emotional reaction of
despair and self- hatred. You may even feel that you'd be better off dead because
you are so unbearably uncomfortable and self- denigrating. You may become
inactive and paralyzed, afraid and unwilling to participate in the normal flow of
life. Because of the negative emotional and behavioral con- consequences of
your harsh thinking, the first step is to stop telling yourself you are worthless.
However, you probably won't be able to do this until you become absolutely
conFEELING GOOD 79 vinced that these statements are incorrect and unrealistic.
How can this be accomplished? You must first consider that a human life is an
ongoing process that involves a constantly changing physical body as well as an
enormous number of rapidly changing thoughts, feelings, and behav- behaviors.
Your life therefore is an evolving experience, a con- continual flow. You are not
a thing; that's why any label is constricting, highly inaccurate, and global.
Abstract labels such as "worthless" or "inferior" communicate nothing and mean
nothing. But you may still be convinced you are second-rate. What is your
evidence? You may reason, "I feel inadequate. Therefore, I must be inadequate.
Otherwise, why would I be filled with such unbearable emotions?" Your error is
in emotional reasoning. Your feelings do not determine your worth, simply your
relative state of comfort or discomfort. Rotten, miserable internal states do not
prove that you are a rotten, worthless person, merely that you think you are;
because you are in a temporarily depressed mood, you are thinking illogically
and unreasonably about yourself. Would you say that states of mood elevation
and hap- happiness prove you are great or especially worthy? Or do they simply
mean that you are feeling good? Just as your feelings do not determine your
worth, neither do your thoughts or behaviors. Some may be positive, crecreative, and enhancing; the great majority are neutral. Others may be irrational,
self-defeating, and maladaptive. These can be modified if you are willing to
exert the effort, but they certainly do not and cannot mean that you are no good.
There is no such thing in this universe as a worthless human being. "Then how
can I develop a sense of self-esteem?" you may ask. The answer is—you don't
have to! You don't have to do anything especially worthy to create or deserve
self- esteem; all you have to do is turn off that critical, ha- haranguing, inner
voice. Why? Because that critical inner voice is wrong! Your internal self-abuse
springs from il80 David D. Burns, M.D. logical, distorted thinking. Your sense of
worthlessness is not based on truth, it is just the abscess which lies at the core of
worthlessness is not based on truth, it is just the abscess which lies at the core of
depressive illness. So remember three crucial steps when you are upset: 1. Zero
in on those automatic negative thoughts and write them down. Don't let them
buzz around in your head; snare them on paper! 2. Read over the list of ten
cognitive distortions. Learn precisely how you are twisting things and blowing
them out of proportion. 3. Substitute a more objective thought that puts the lie to
the one which made you look down on yourself. As you do this, you'll begin to
feel better. You'll be boosting your self-esteem, and yoi^r sense of worthworthlessness (and, of course, your depression) will dis- disappear.
Chapter 5 Do-Not h ing ism: How to Beat It In the last chapter you learned that
you can change your mood by changing how you think. There is a second major
approach to mood elevation that is enormously effective. People are not only
thinkers, they are doers, so it is not surprising that you can substantially change
the way you feel by changing the way you act. There's only one hitch— when
you're depressed, you don't feel like doing much. One of the most destructive
aspects of depression is the way it paralyzes your willpower. In its mildest form
you may simply procrastinate about doing a few odious chores. As your lack of
motivation intensifies, virtually any activity appears so difficult that you become
overwhelmed by the urge to do nothing. Because you accomplish very little, you
feel worse and worse. Not only do you cut yourself off from your normal
sources of stimulation and pleasure, but your lack of productivity aggravates
your self-hatred, resulting in further isolation and incapacitation. If you don't
recognize the emotional prison in which you are trapped, this situation can go on
for weeks, months, or even years. Your inactivity will be all the more frustrating
if you once took pride in the energy you had for life. Your do-nothingism can
also affect your family and friends, who, like yourself, cannot understand your
behavior. They may 81
82 David D. Burns, M.D. say that you must want to be depressed or else you'd
"get off your behind.'' Such a comment only worsens your an- anguish and
paralysis. Do-nothingism represents one of the great paradoxes of human nature.
Some people naturally throw themselves into life with great zest, while others
always hang back, defeating themselves at every turn as if they were involved in
a plot against themselves. Do you ever wonder why? If a person were
condemned to spend months in isolation, cut off from all normal activities and
interpersonal rela- relationships, a substantial depression would result. Even
young monkeys slip into a retarded, withdrawn state if they are separated from
their peers and confined to a small cage. Why do you voluntarily impose a
similar punishment on yourself? Do you want to suffer? Using cognitive techtechniques, you can discover the precise reasons for your dif- difficulties in
techniques, you can discover the precise reasons for your dif- difficulties in
motivating yourself. In my practice I find that the great majority of the dedepressed patients referred to me improve substantially if they try to help
themselves. Sometimes it hardly seems to matter what you do as long as you do
something with the attitude of self-help. I know of two presumably "hopeless"
cases who were helped enormously simply by putting a mark on a piece of
paper. One patient was an artist who had been convinced for years that he
couldn't even draw a straight line. Consequently he didn't even try to draw.
When his therapist suggested he test his conviction by actually at- attempting to
draw a line, it came out so straight he began drawing again and soon was
symptom-free! And yet many depressed individuals will go through a phase in
which they stubbornly refuse to do anything to help themselves. The moment
this crucial motivational problem has been solved, the depression typically
begins to diminish. You can there- therefore understand why much of our
research has been directed to locating the causes of this paralysis of the will.
Using this knowledge, we have developed some specific methods to help you
deal with procrastination. Let me describe two perplexing patients I treated
recently.
FEELING GOOD 83 You might think their do-nothingism is extreme and
wrongly conclude they must be "crazies" with whom you would have little in
common. In fact, I believe their prob- problems are caused by attitudes similar to
yours, so don't write them off. Patient A, a twenty-eight-year-old woman, has
done an experiment to see how her mood would respond to a variety of
activities. It turns out that she feels substantially better when she does nearly
anything. The list of things that will reliably give her a mood lift includes
cleaning the house, playing tennis, going to work, practicing her guitar, shopshopping for dinner, etc. Only one thing makes her feel reliably worse; this
single activity nearly always makes her in- intensely miserable. Can you guess
what it is? DO- NOTHINGISM: lying around in bed all day long, staring at the
ceiling and courting negative thoughts. And guess what she does weekends.
Right! She crawls right into bed on Saturday morning and begins her descent
into inner hell. Do you think she really wants to suffer? Patient B, a physician,
gives me a clear, definite message early in her therapy. She says she understands
that the speed of improvement is dependent on her willingness to work between
sessions, and insists she wants to get well more than anything else in the world,
having been wracked by depression for over sixteen years. She emphasizes she'll
be happy to come to therapy sessions, but I must not ask her to lift one finger to
help herself. She says that if I push her to spend five minutes on self-help
assignments, she'll kill herself. As she describes in detail the lethal, gruesome
assignments, she'll kill herself. As she describes in detail the lethal, gruesome
method of self-destruction she had carefully planned in her hospital's operating
room, it becomes obvious that she is deadly serious. Why is she so determined
not to help her- herself? I know your procrastination is probably less severe and
only deals with minor things, like paying bills, a trip to the dentist, etc. Or
maybe you've had trouble finishing a rela- relatively straightforward report that
is crucial to your career. But the perplexing question is the same—why do we
fre- frequently behave in ways that are not in our self-interest?
84 David D. Burns, M.D. Procrastinating and self-defeating behavior can seem
funny, frustrating, puzzling, infuriating, or pathetic, de- depending on your
perspective. I find it a very human trait, so widespread that we all bump into it
nearly every day. Writers, philosophers, and students of human nature
throughout history have tried to formulate some explanation for self-defeating
behavior, including such popular theories as: 1. You're basically lazy; it's just
your "nature." 2. You want to hurt yourself and suffer. You either like feeling
depressed, or you have a self-destructive drive, a "death wish." 3. You're
passive-aggressive, and you want to frustrate the people around you by doing
nothing. 4. You must be getting some "payoff" from your pro- procrastination
and do-nothingism. For example, you en- enjoy getting all that attention when
you are depressed. Each of these famous explanations represents a different
psychological theory, and each is inaccurate! The first is a "trait" model; your
inactivity is seen as a fixed personality trait and stems from your "lazy streak."
The problem with this theory is that it just labels the problem without explainexplaining it. Labeling yourself as "lazy" is useless and self- defeating because it
creates the false impression that your lack of motivation is an irreversible, innate
part of your makeup. This kind of thinking does not represent a valid scientific
theory, but is an example of a cognitive distortion (labeling). The second model
implies you want to hurt yourself and suffer because there is something
enjoyable or desirable about procrastination. This theory is so ludicrous I
hesitate to include it, except that it is widespread and vigorously supported by a
substantial percentage of psychotherapists. If you have the hunch that you or
someone else likes being depressed and doing nothing, then remind yourself that
FEELING GOOD 85 depression is the most agonizing form of human suffering.
Tell me—what is so great about it? I haven't yet met a patient who really enjoys
the misery. If you aren't convinced but think you really do enjoy pain and
suffering, then give yourself the paper-clip test. Straighten out one end of a
paper clip and push it under your fingernail. As you push harder and harder, you
may notice how the pain becomes more and more excruciating. Now ask
may notice how the pain becomes more and more excruciating. Now ask
yourself—is this really enjoyable? Do I really like to suffer? The third
hypothesis—you're "passive-aggressive"— represents the thinking of many
therapists, who believe that depressive behavior can be explained on the basis of
"in- "internalized anger." Your procrastination could be seen as an expression of
that pent-up hostility because your inaction often annoys the people around you.
One problem with this theory is that most depressed or procrastinating
individuals simply do not feel particularly angry. Resentment can somesometimes contribute to your lack of motivation, but is usually not central to the
problem. Although your family may feel frustrated about your depression, you
probably do not intend them to react this way. In fact, it is more often the case
that you fear displeasing them. The implication that you are intentionally doing
nothing in order to frustrate them is insulting and untrue; such a suggestion will
only make you feel worse. The last theory—you must be getting some "payoff"
from procrastination—reflects more recent, behaviorally oriented psychology.
Your moods and actions are seen as the result of rewards and punishments from
your environ- environment. If you are feeling depressed and doing nothing about
it, it follows that your behavior is being rewarded in some way. There is a grain
of truth in this; depressed people do sometimes receive substantial support and
reassurance from others who try to help them. However, the depressed person
rarely enjoys all the attention he receives because of his profound tendency to
disqualify it. If you are depressed and
86 David D. Burns, M.D. someone tells you they like you, you will probably
think, "He doesn't know how rotten I am. I don't deserve this praise." Depression
and lethargy have no real rewards. Theory number four bites the (Just with the
others. How can you find the real cause of motivational paralysis? The study of
mood disorders gives us the unique opportunity to observe extraordinary
transformations in levels of per- personal motivation within short periods of
time. The same individual who ordinarily bursts with creative energy and
Optimism may be reduced during an episode of depression to pathetic, bedridden
immobility. By tracing dramatic mood swings, we can gather valuable clues that
unlock many of the mysteries of human motivation. Simply ask yourself, "When
I think about that undone task, what thoughts im- immediately come to mind?"
Then write those thoughts down on a piece of paper. What you write will reflect
a number of maladaptive attitudes, misconceptions, and faulty as- assumptions.
You will learn that the feelings that impede your motivation, such as apathy,
anxiety, or the sense of being overwhelmed, are the result of distortions in your
thinking. Figure 5-1 shows a typical Lethargy Cycle. The thoughts on this
patient's mind are negative; he says to himself, "There's no point in doing
patient's mind are negative; he says to himself, "There's no point in doing
anything because I am a born loser and so I'm bound to fail." Such a thought
sounds very convincing when you are depressed, immobilizing you and making
you feel inadequate, overwhelmed, self-hating, and helpless. You then take these
negative emotions as proof that your pessimistic attitudes are valid, and you
begin to change your approach to life. Because you are convinced you will botch
up anything, you don't even try; you stay in bed instead. You lie back passively
and stare at the ceiling, hoping to drift into sleep, painfully aware you are letting
your career go down the drain while your business dwindles into bankruptcy.
You may refuse to answer the phone for fear of hearing bad news; life becomes
a treadmill of boredom, apprehension, and misery. This vicious cycle can go on
indefinitely unless you know how to beat it.
i self-defeating THOUGHTS: "There's no point in doing any- anything. I don't
have the energy. I'm not in the mood. I'll probably fail if I try. Things are too
difficult. There wouldn't be any satisfac- satisfaction if I did anything*anyway. I
don't feel like doing anything, so I don't have to. I'll just lie here in bed for a
while. I can sleep and forget about things. It's much easier. Rest is best." SELFDEFEATING EMOTIONS: You feel tired, bored, apathetic, self-hating,
discouraged, guilty, helpless, worth- worthless, and overwhelmed. SELFDEFEATING ACTIONS: You stick to bed. You avoid people, work, and all
potentially satisfying activities. CONSEQUENCES OF THE LETHARGY
CYCLE: You be- become isolated from friends. This convinces you that you
really are a loser. Your decreased produc- productivity convinces you that you
ac- actually are inadequate. You sink deeper and deeper into an un- motivated
state of paralysis. Figure 5-1. The Lethargy Cycle. Your self-defeating negative
thoughts make you feel miserable. Your painful emotions in turn convince you
that your distorted, pessimistic thoughts are actually valid. Similarly, selfdefeating thoughts and actions reinforce each other in a circular manner. The
unpleasant consequences of do- nothingism make your problems even worse.
88 David D. Burns, M.D. As indicated in Figure 5-1, the relationship between
your thoughts, feelings, and behaviors is reciprocal—all your emotions and
actions are the results of your thoughts and attitudes. Similarly, your feelings and
behavior patterns in- influence your perceptions in a wide variety of ways. It
follows from this model that all emotional change is ultimately brought about by
cognitions; changing your behavior will help you feel better about yourself if it
exerts, a positive influence on the way you are thinking. Thus, you can modify
your self-defeating mental set if you change your behavior in such a way that
you are simultaneously putting the lie to the self-defeating attitudes that
represent the core of your motivational problem. Similarly, as you change the
represent the core of your motivational problem. Similarly, as you change the
way you think, you will feel more in the mood to do things, and this will have an
even stronger positive effect on your think- thinking patterns. Thus, you can
transform your lethargy cycle into a productivity cycle. The following are the
types of mind-sets most commonly associated with procrastination and donothingism. You may see yourself in one or more of them. /. Hopelessness.
When you are depressed, you get so frozen in the pain of the present moment
that you forget entirely that you ever felt better in the past and find it
inconceivable that you might feel more positive in the future. Therefore, any
activity will seem pointless because you are absolutely certain your lack of
motivation and sense of oppression are unending and irreversible. From this perperspective the suggestion that you do something to "help yourself" might sound
as ludicrous and insensitive as telling a dying man to cheer up. 2. Helplessness.
You can't possibly do anything that will make yourself feel better because you
are convinced that your moods are caused by factors beyond your control, such
as fate, hormone cycles, dietary factors, luck, and other people's evaluations of
you.
FEELING GOOD 89 3. Overwhelming Yourself. There are several ways you
may overwhelm yourself into doing nothing. You may mag- magnify a task to
the degree that it seems impossible to tackle. You may assume you must do
everything at once instead of breaking each job down into small, discrete,
manageable units which you can complete one step at a time. You might also
inadvertently distract yourself from the task at hand by obsessing about endless
other things you haven't gotten around to doing yet. To illustrate how irrational
this is, imagine that every time you sat down to eat, you thought about all the
food you would have to eat during your life- lifetime. Just imagine for a moment
that all piled up in front of you are tons of meat, vegetables, ice cream, and thouthousands of gallons of fluids! And you have to eat every bit of this food before
you die! Now, suppose that before every meal you said to yourself, "This meal is
just a drop in the bucket. How can I ever get all that food eaten? There's just no
point in eating one pitiful hamburger tonight." You'd feel so nauseated and
overwhelmed your appetite would vanish and your stomach would turn into a
knot. When you think about all the things you are putting off, you do this very
same thing without being aware of it. 4. Jumping to Conclusions. You sense that
it's not within your power to take effective action that will result in satisfaction
because you are in the habit of saying, "I can't," or "I would but..." Thus when 1
suggested that a depressed woman bake an apple pie, she responded, "I can't
cook anymore." What she really meant to say was, "I have the feeling I wouldn't
enjoy cooking and it seems like it would be awfully difficult." When she tested
enjoy cooking and it seems like it would be awfully difficult." When she tested
these assumptions by attempting to bake a pie, she found it sur- surprisingly
satisfying and not at all difficult. 5. Self-labeling. The more you procrastinate,
the more you condemn yourself as inferior. This saps your self- confidence
further. The problem is compounded when you
90 David D. Burns, M.D. label yourself "a procrastinator" or "a lazy person."
This causes you to see your lack of effective action as the ' 'real you'' so that you
automatically expect little or nothing from yourself. 6. Undervaluing the
Rewards. When you are de- depressed you may fail to initiate any meaningful
activity not only because you conceive of any task as terribly difficult, but also
because you feel the reward simply wouldn't be worth the effort. "Anhedonia" is
the technical name for a diminished ability to experience satisfaction and
pleasure. A common thinking error—your tendency to "disqualify the posipositive"—may be at the root of this problem. Do you recall what this thinking
error consists of? A businessman complained to me that nothing he did all day
was satisfying. He explained that in the morning he had attempted to return a
call from a client, but found the line was busy. As he hung up, he told himself,
"That was a waste of time." Later in the morning he successfully completed an
important business negotiation. This time he told himself, "Anyone in our firm
could have handled it just as well or better. It was an easy problem, and so my
role wasn't really important." His lack of satisfaction re- results from the fact that
he always finds a way to discredit his efforts. His bad habit of saying "It doesn't
count" suc- successfully torpedoes any sense of fulfillment. 7. Perfectionism.
You defeat yourself with inappropri- inappropriate goals and standards. You will
settle for nothing short of a magnificent performance in anything you do, so you
frequently end up having to settle for just that—nothing. 8. Fear of Failure.
Another mind-set which paralyzes you is the fear of failure. Because you
imagine that putting in the effort and not succeeding would be an overwhelming
personal defeat, you refuse to try at all. Several thinking errors are involved in
the fear of failure. One of the most
FEELING GOOD 91 common is overgeneralization. You reason, "If I fail at
this, it means I will fail at anything." This, of course, is impossible. Nobody can
fail at everything. We all have our share of victories and defeats. While it is true
that victory tastes sweet and defeat is often bitter, failing at any task need not be
a fatal poison, and the bad taste will not linger forever. A second mind-set that
contributes to the fear of defeat is when you evaluate your performance
exclusively on the outcome regardless of your individual effort. This is illogical
and reflects a "product orientation" rather than a "process orientation." Let me
explain this with a personal example. As a psychotherapist I can control only
explain this with a personal example. As a psychotherapist I can control only
what I say and how I interact with each patient. I cannot control how any parparticular patient will respond to my efforts during a given therapy session.
What I say and how I interact is the process; how each individual reacts is the
product. In any given day, several patients will report that they have benefited
greatly from that day's session, while a couple of others will tell me that their
session was not particularly helpful. If I eval- evaluated my work exclusively on
the outcome or product, I would experience a sense of exhilaration whenever a
patient did well, and feel defeated and defective whenever a patient reacted
negatively. This would make my emotional life a roller coaster, and my selfesteem would go up and down in an exhausting and unpredictable manner all
day long. But if I admit to myself that all I can control is the input I provide in
the therapeutic process, I can pride myself on good consistent work regardless of
the outcome of any par- particular session. It was a great personal victory when I
learned to evaluate my work based on the process rather than on the product. If a
patient gives me a negative report, I try to learn from it. If I did make an error, I
attempt to correct it, but I don't need to jump out the window. 9. Fear of Success.
Because of your lack of confidence, success may seem even more risky than
failure because you are certain it is based on chance. Therefore, you are con92 David D. Burns, M.D. vinced you couldn't keep it up, and you feel your
accom- accomplishments will falsely raise the expectations of others. Then when
the awful truth that you are basically "a loser" ul- ultimately comes out, the
disappointment, rejection, and pain will be all the more bitter. Since you feel
sure you will eventually fall off the cliff, it seems safer not to go mountain
climbing at all. You may also fear success because you anticipate that people
will make even greater demands on you. Because you are convinced you must
and cant meet their expecta- expectations, success would put you into a
dangerous and impos- impossible situation. Therefore, you try to maintain
control by avoiding any commitment or involvement. 10. Fear of Disapproval or
Criticism. You imagine that if you try something new, any mistake or flub will
be met with strong disapproval and criticism because the people you care about
won't accept you if you are human and imperfect. The risk of rejection seems so
dangerous that to protect yourself you adopt as low a profile as possible. If you
don't make any effort, you can't goof up! / /. Coercion and Resentment. A deadly
enemy of mo- motivation is a sense of coercion. You feel under intense prespressure to perform—generated from within and without. This happens when
you try to motivate yourself with moralistic "shoulds" and 4toughts." You tell
yourself, t4I should do this" and t4I have to do that." Then you feel obliged,
burdened, tense, resentful, and guilty. You feel like a de- delinquent child under
burdened, tense, resentful, and guilty. You feel like a de- delinquent child under
the discipline of a tyrannical probation officer. Every task becomes colored with
such unpleasant- unpleasantness that you can't stand to face it. Then as you
procras- procrastinate, you condemn yourself as a lazy, no-good bum. This
further drains your energies. 12. Low Frustration Tolerance. You assume that
you should be able to solve your problems and reach your goals
FEELING GOOD 93 rapidly and easily, so you go into a frenzied state of panic
and rage when life presents you with obstacles. Rather than persist patiently over
a period of time, you may retaliate against the "unfairness" of it all when things
get tough, so you give up completely. I also call this the "entitlement syndrome"
because you feel and act as if you were entitled to success, love, approval,
perfect health, happiness, etc. Your frustration results from your habit of
comparing reality with an ideal in your head. When the two don't match, you
condemn reality. It doesn't occur to you that it might be infinitely easier simply
to change your expectations than to bend and twist reality. This frustration is
frequently generated by should state- statements. While jogging, you might
complain, "For all the miles I've gone, I should be in better shape by now."
Indeed? Why should you? You may have the illusion that such punishing,
demanding statements will help you by driving you on to try harder and to put
out more effort. It rarely works this way. The frustration just adds to your sense
of futility and increases your urge to give up and do nothing. 13. Guilt and Selfblame. If you are frozen in the con- conviction you are bad or have let others
down, you will nat- naturally feel unmotivated to pursue your daily life. I
recently treated a lonely elderly woman who spent her days in bed in spite of the
fact that she felt better when she shopped, cooked, and socialized with her
friends. Why? This sweet woman was holding herself responsible for her
daughter's divorce five years earlier. She explained, "When I visited them, I
should have sat down and talked things over with my son-in-law. I should have
asked him how things were going. Maybe I could have helped. I wanted to and
yet I didn't take the opportunity. Now I feel I failed them." After we reviewed
the illogic in her thinking, she felt better im- immediately and became active
again. Because she was human and not God, she could not have been expected to
predict the future or to know precisely how to intervene.
94 David D. Burnsr M.D. By now you may be thinking, "So what? I know that
my do-nothingism is in a way illogical and self-defeating. I can see myself in
several of the mental sets you've de- described. But I feel like I'm trying to wade
through a pool of molasses. I just can't get myself going. You may say all this
oppression just results from my attitudes, but it feels like a ton of bricks. So what
oppression just results from my attitudes, but it feels like a ton of bricks. So what
can I do about it?" Do you know why virtually any meaningful activity has a
decent chance of brightening your mood? If you do noth- nothing, you will
become preoccupied with the flood of negative, destructive thoughts. If you do
something, you will be tem- temporarily distracted from that internal dialogue of
self- denigration. What is even more important, the sense of mastery you will
experience will disprove many of the dis- distorted thoughts that slowed you
down in the first place. As you review the following self-activation techniques,
choose a couple that appeal most to you and work at them for a week or two.
Remember you don't have to master them all! One man's salvation can be
another's curse. Use the methods that seem the most tailored to your particular
brand of procrastination. The Daily Activity Schedule. The Daily Activity
Sched- Schedule (see Figure 5-2, page 95) is simple but effective, and can help
you get organized in your fight against lethargy and apathy. The schedule
consists of two parts. In the Pro- Prospective column, write out an hour-by-hour
plan for what you would like to accomplish each day. Even though you may
actually carry out only a portion of your plan, the simple act of creating a
method of action every day can be im- immensely helpful. Your plans need not
be elaborate. Just put one or two words in each time slot to indicate what you'd
like to do, such as "dress," "eat lunch," "prepare re- resume," etc. It should not
require more than five minutes to do this. At the end of the day, fill out the
Retrospective column. Record in each time slot what you actually did during the
day. This may be the same as or different from what you
Figure 5-2. Daily Activity Schedule. 1 1 ( TIME 8-9 9-10 10-11 11-12 12-1 1-2
2-3 3-4 4-5 5-6 6-7 7-8 8-9 9-12 PROSPECTIVE: *lan your activities on an
lour-by-hour basis at the start )f the day. RETROSPECTIVE: At the end of the
day, record what you actually did and rate each activity with an M for mastery or
a P for plea- pleasure.* ♦Mastery and pleasure activities must be rated from 0 to
5. the higher the number, the greater the sense of satisfaction.
96 David D. Burns, M.D. actually planned; nevertheless, even if it was just
staring at the wall, write it down. In addition, label each activity with the letter
M for mastery or the letter P for pleasure. Mastery activities are those which
represent some accomplishment, such as brushing your teeth, cooking dinner,
driving to work, etc. Pleasure might include reading a book, eating, going to a
movie, etc. After you have written M or P for each activity, estimate the actual
amount of pleasure, or the degree of difficulty in the task by using a zero to five
rating. For example, you could give yourself a score of M-l for particularly easy
tasks like getting dressed, while M-4 or M-5 would indicate you did something
more difficult and challenging, such as not eating too much or applying for a job.
more difficult and challenging, such as not eating too much or applying for a job.
You can rate the pleasure activities in a similar manner. If any activity was
pleasurable in the past when you were not depressed, but today it was nearly or
totally devoid of pleasure, put a P-V2 or a P-0. Some activities, such as cooking
dinner, can be labeled M and P. Why is this simple activity schedule likely to be
helpful? First, it will undercut your tendency to obsess endlessly about the value
of various activities and to debate counter- productively about whether or not to
do something. Ac- Accomplishing even a part of your scheduled activities will
in all probability give you some satisfaction and will combat your depression. As
you plan your day, develop a balanced program that provides for enjoyable
leisure activities as well as work. If you are feeling blue, you may want to put a
special emphasis on fun, even if you doubt you can enjoy things as much as
usual. You may be depleted from having asked too much of yourself, causing an
imbalance in your "give-and-get" system. If so, take a few days of "vacation"
and schedule only those things you want to do. If you adhere to the schedule,
you will find your moti- motivation increasing. As you start doing things, you
will begin to disprove your belief that you are incapable of functioning
effectively. As one procrastinator reported, "By scheduling my day and
comparing the results, I have become aware of
FEELING GOOD 97 how I spend my time. This has helped me take charge of
my life once again. I realize that I can be in control if I want to." Keep this Daily
Activity Schedule for at least a week. As you review the activities in which you
participated during the previous week, you will see that some have given you a
greater sense of mastery and pleasure, as indicated by higher scores. As you
continue planning each upcoming day, use this information to schedule more of
those activ- activities, and avoid others which are associated with lower satsatisfaction levels. The Daily Activity Schedule can be especially helpful for a
common syndrome I call the "weekend/holiday blues." This is a pattern of
depression most often reflected in people who are single and have their greatest
emotional difficulties when alone. If you fit this description, you probably
assume these periods are bound to be unbearable, so you do very little to care for
yourself creatively. You stare at the walls and mope, or lie in bed all day
Saturday and Sunday; or, for good times, you watch a boring TV show and eat a
meager dinner of a peanut-butter sandwich and a cup of instant coffee. No
wonder your weekends are tough! Not only are you depressed and alone but you
treat yourself in a way that can only inflict pain. Would you treat someone else
in such a sadistic manner? These weekend blues can be overcome by using the
Daily Activity Schedule. On Friday night, schedule some plans for Saturday on
an hourly basis. You may resist this, saying, 4'What's the point? I'm all alone."
an hourly basis. You may resist this, saying, 4'What's the point? I'm all alone."
The fact that you are all alone is the very reason for using the schedule. Why
assume you're bound to be miserable? This prediction can function only as a
self-fulfilling prophecy! Put it to the test by adopting a productive approach.
Your plans need not be elaborate in order to be helpful. You can schedule going
to the hairdresser, shopping, visiting an art museum, reading a book, or walking
through the park. You will discover that laying out and adhering to a simple plan
for the day can go a long way toward lifting your mood. And who knows—if
98 David D. Burns, M.D. you are willing to care for yourself, you may suddenly
notice that others will act more interested in you as well! At the end of the day
before you go to bed, write down what you actually did each hour and rate each
activity for Mastery and Pleasure. Then make out a new schedule for the
following day. This simple procedure may be the first step toward a sense of
self-respect and genuine self-reliance. The Antiprocrastination Sheet In Figure 5-
3 is a form I have found effective in breaking the habit of procrastiprocrastination. You may be avoiding a particular activity because you predict it
will be too difficult and unrewarding. Using the Antiprocrastination Sheet, you
can train yourself to test these negative predictions. Each day write down in the
ap- appropriate column one or more tasks you have been putting off. If the task
requires substantial time and effort, it is best to break it down into a series of
small steps so that each one can be completed in fifteen minutes or less. Now
write down in the next column how difficult you predict each step of the task
will be, using a 0-to-100 percent scale. If you imagine the task will be easy, you
can write down a low estimate such as 10 to 20 percent; for harder tasks, use 80
to 90 percent. In the next column, write down your pre- prediction of how
satisfying and rewarding it will be to com- complete each phase of the task,
again using the percentage system. Once you've recorded these predictions, go
ahead and complete the first step of the task. After you've com- completed each
step, take note of how difficult it actually turned out to be, as well as the amount
of pleasure you gained from doing it. Record this information in the last two colcolumns, again using the percentage system. Figure 5-3 shows how a college
professor used this form to overcome several months of putting off writing a
letter applying for a teaching position opening up at another uni- university. As
you can see, he anticipated that writing the letter would be difficult and
unrewarding. After he recorded his pessimistic predictions, he became curious to
outline the letter and prepare a rough draft to see if it would be as
Figure 5-3. A professor procrastinated for several months in writing a letter
because he imagined it would be difficult and unrewarding. He decided to break
because he imagined it would be difficult and unrewarding. He decided to break
the task down into small steps and to predict on a O-to-100 percent scale how
difficult and rewarding each step would be (see the appropriate columns). After
completing each step, he wrote down how difficult and rewarding it actually
was. He was amazed to see how off-base his negative expectations really were.
The Antiprocrastination Sheet (Write down the predicted difficulty and
satisfaction before you attempt the task. Write down the actual difficulty and
satisfaction after you have completed each step.) Date 6/10/99 Activity (Break
each task down into small steps) 1. Outline letter. 2. Write rough draft. 3. Type
up final draft. 4. Address the envelope and mail the letter. Predicted Difficulty
@-100%) 90 90 75 50 Predicted Satisfaction @-100%) 10 10 10 5 Actual
Difficulty @-100%) 10 10 5 0 Actual Satisfaction @-100%) 60 75 80 95
100 David D. Burns, M.D. tedious and unrewarding as he thought. He found to
his great surprise that it turned out to be easy and satisfying, and he felt
sufficiently motivated that he went on to complete the letter. He recorded this
data in the last two columns. The information gained from this experiment so
greatly astonished him that he used the Antiprocrastination Sheet in many other
areas in his life. Consequently, his produc- productivity and self-confidence
underwent a dramatic increase, and his depression disappeared. Daily Record of
Dysfunctional Thoughts. This record, introduced in Chapter 4, can be used to
great advantage when you are overwhelmed by the urge to do nothing. Simply
write down the thoughts that run through your mind when you think about a
particular task. This will immedi- immediately show you what your problem is.
Then write down appropriate rational responses that show these thoughts are
unrealistic. This will help you mobilize enough energy to take that first difficult
step. Once you've done that, you will gain momentum and be on your way. An
example of this approach is indicated in Figure 5-4. Annette is an attractive,
young single woman who owns and operates a successful boutique (she is
Patient A, de- described on page 83). She does well during the week because of
all the bustle at her store. On weekends she tends to hide away in bed unless she
has social activities lined up. The moment she gets into bed, she becomes
despondent, yet claims it is beyond her control to get out of bed. As Annette
recorded her automatic thoughts one Sunday evening (Fig- (Figure 5-4), it
became obvious what her problems were: She was waiting around until she felt
the desire, interest, and energy to do something; she was assuming that there was
no point in doing anything since she was alone; and she was persecuting and
insulting herself because of her inac- inactivity. When she talked back to her
thoughts, she reported that the clouds lifted just a bit so that she was able to get
up, take a shower, and get dressed. She then felt even better
up, take a shower, and get dressed. She then felt even better
Figure 5-4. Daily Record of Dysfunctional Thoughts. Date Situation Emotions
Automatic Thoughts Rational Responses Outcome 7/15/99 stayed in bed all day
Depressed Sunday—slept off Exhausted and on—no desire or Guilty energy to
get up or do Self-hatred anything productive. Lonely I have no desire to do
anything. That's because I'm Felt some relief doing nothing. Re- and decided to
member motivation get up and take a follows action! shower at least. I don't
have the energy I can get out of bed; to get out of bed. I'm not crippled. I'm a
failure as a per- person. I have no real interests. I do succeed at things when I
want to. Doing nothing makes me de- depressed and bored, but it doesn't mean
I'm "a failure as a person'' be- because there is no such thing! I do have interests,
but not when I'm doing nothing. If I get started at something, I'll prob- probably
get more interFigure 5-t4- cont. Date Situation Emotions Automatic Thoughts Rational
Responses Outcome I'm self-centered be- because I don't care about anything
that's going on around me. Most people are out en- enjoying themselves. I don't
enjoy anything. I do care about other things when I'm feel- feeling really good.
It's natural to be less inter- interested when you're de- depressed. So what does
that have to do with me? I'm free to do anything I want to. I enjoy things when I
feel good. If I do some- something I'll probably en- enjoy it once I get started,
even though it doesn't seem that way when I'm lying in bed.
I'll never have a nor- normal energy level. I don't want to talk to anyone or see
anyone. I have no proof of that; I'm working on it now and seeing some reresults. When I feel good, I'm full of en- energy. When I get in- involved in
things, I get more energetic. So don't! No one's forcing me to talk. So, decide to
do something on my own. At least I can get out of bed and start doing things.
104 David D. Burns, M.D. and arranged to meet a friend for dinner and a movie.
As she predicted in the Rational Responses column, the more she did, the better
she felt. If you decide to use this method, be sure you actually write down
upsetting thoughts. If you try to figure them out in your head, you will in all
probability get nowhere because the thoughts that stymie you are slippery and
complex. When you try to talk back to them, they'll come at you even harder
from all angles with such speed that you won't even know what hit you. But
when you write them down, they become exposed to the light of reason. This
way you can reflect on them, pinpoint the distortions, and come up with some
helpful answers. The Pleasure-Predicting Sheet One of Annette's self- defeating
attitudes is her assumption that there is no point in doing anything productive if
attitudes is her assumption that there is no point in doing anything productive if
she is alone. Because of this belief, she does nothing and feels miserable, which
just confirms her attitude that it's terrible to be alone. Solution: Test your belief
that there is no point in doing anything by using the Pleasure-Predicting Sheet
shown in Figure 5-5, page 105. Over a period of weeks, schedule a number of
activities that contain a potential for personal growth or satisfaction. Do some of
them by yourself and some with others. Record who you did each activity with
in the appropriate column, and predict how satisfying each will be—between 0
and 100 percent. Then go and do them. In the Actual Satisfaction column, write
down how enjoy- enjoyable each activity really turned out to be. You may be
surprised to learn that things you do on your own are more gratifying than you
thought. Make sure that the things you do by yourself are of equal quality as
those you do with others so that your comparisons will be valid. If you choose to
eat a TV dinner alone, for example, don't compare it with the fancy French
restaurant dinner you share with a friend! Figure 5-5 shows the activities of a
young man who learned that his girl friend (who lived 200 miles away) had
Figure 5-5. The Pleasure-Predicting Sheet. Date Activity for Satisfaction. Who
Did You Do This (Sense of Achievement With? (If Alone, or Pleasure) Specify
Self) Predicted Satisfaction Actual Satisfaction @-100%). (Write This
@-100%). (Record This Before the Activity) After the Activity) 8/2/99 Reading
A hour) 8/3/99 Dinner + bar w/Ben 8/4/99 Susan's party 8/5/99 N.Y.C. and Aunt
Helen 8/5/99 Nancy's house 8/6/99 Dinner at Nancy's 8/6/99 Luci's party 8/7/99
Jogging 8/8/99 Theater 8/9/99 Harry's 8/10/99 Jogging 8/10/99 Phillies game
8/11/99 Dinner 8/12/99 Art museum 8/12/99 Peabody's 8/13/99 Jogging self Ben
self parents and grandma Nancy and Joelle 12 people Luci + 5 people self Luci
Harry, Jack, Ben and Jim self Dad Susan and Ben self Fred self 50% 80% 80%
40% 75% 60% 70% 60% 80% 60% 70% 50% 70% 60% 80% 70% 60% 90%
85% 30% 65% 80% 70% 90% 70% 85% 80% 70% 70% 70% 85% 80%
106 David D. Burns, M.D. a new boyfriend and didn't want to see him. Instead
of moping in self-pity, he became involved with life. You will notice in the last
column that the satisfaction levels he ex- experienced by himself ranged from 60
to 90 percent, while those with other people ranged from 30 to 90 percent. This
knowledge strengthened his self-reliance because he realized that he wasn't
condemned to misery because he lost his girl, and that he didn't need to depend
on others to enjoy himself. You can use the Pleasure-Predicting Sheet to test a
num- number of assumptions you might make that lead to procrastiprocrastination. These include: 1. I can't enjoy anything when I'm alone. 2.
There's no point in doing anything because I failed at something important to me
(e.g., I didn't get the job or promotion I had my heart set on). 3. Since I'm not
(e.g., I didn't get the job or promotion I had my heart set on). 3. Since I'm not
rich, successful, or famous, I can't really enjoy things to the hilt. 4. I can't enjoy
things unless I'm the center of attention. 5. Things won't be particularly
satisfying unless I can do them perfectly (or successfully). 6. I wouldn't feel very
fulfilled if I did just a part of my work. I've got to get it all done today. All of
these attitudes will produce a round of self-fulfilling prophecies if you don't put
them to the test. If, however, you check them out using the Pleasure-Predicting
Sheet, you may be amazed to learn that life can offer you enormous fulfillment.
Help yourself! A question that commonly comes up about the PleasurePredicting Sheet is: "Suppose I do schedule a number of activities, and I find out
they are just as unpleasant as I had anticipated?" This might happen. If so, try
noting your negative thoughts and write them down, answering them with the
Daily Record of Dysfunctional Thoughts. For ex- example, suppose you go to a
restaurant on your own and feel
FEELING GOOD 107 tense. You might be thinking, "These people probably
think I'm a loser because I'm here all alone." How would you answer this? You
might remind yourself that other people's thoughts do not affect your mood one
iota. I have demonstrated this to patients by telling them I will think two
thoughts about them for fifteen seconds each. One thought will be extremely
positive, and the other will be intensely negative and insulting. They are to tell
me how each of my thoughts affects them. I close my eyes and think, "Jack here
is a fine person and I like him." Then I think, "Jack is the worst person in
Pennsylvania." Since Jack doesn't know which thought is which, they have no
effect on him! Does that brief experiment strike you as trivial? It's not— because
only your thoughts can ever affect you. For ex- example, if you are in a
restaurant feeling miserable because you are alone, you really have no idea what
people are thinking. It's your thoughts and only yours that are making you feel
terrible; you!re the only person in the world who can effectively persecute
yourself. Why do you label your- yourself a "loser" because you're in a
restaurant alone? Would you be so cruel to someone else? Stop insulting
yourself like that! Talk back to that automatic thought with a rational response:
"Going to a restaurant alone doesn't make me a loser. I have just as much right to
be here as anyone else. If someone doesn't like it, so what? As long as I respect
myself, I don't need to be concerned with others' opinions.'' How to Get off Your
"But"—the But Rebuttal. Your "but" may represent the greatest obstacle to
effective ac- action. The moment you think of doing something productive, you
give yourself excuses in the form of buts. For example, "I could go out and jog
today, BUT ..." 1. I'm really too tired to; 2. I'm just too lazy; 3. I'm not
particularly in the mood, etc.
particularly in the mood, etc.
108 David D. Burns, M.D. Figure 5-6. The But-Rebuttal Method. The zigzag
arrows trace your thinking pattern as you debate the issue in your mind. But
Column But Rebuttal I really should mow the lawn, but I'm just not in the mood.
But now it's so long it would take forever. But I'm too tired. I'd rather rest now or
watch TV. But I'm just too lazy to do it today. > I'll feel more like it once I get
started. When I'm done I'll feel terrific. It won't take that much extra time with
the power mower. I can always do a part of it now. -> So just do some of it and "
rest. ■> I can, but I won't feel very / good about it knowing this chore is hanging
over my head. ->That can't be true—I've done it on numerous occa- occasions in
the past. Here's another example. * 'I could cut down on my smoking, BUT..." 1.
I don't have that kind of self-discipline; 2. I don't really feel like going cold
turkey, and cutting down gradually would be slow torture; 3. I've been too
nervous lately. If you really want to motivate yourself, you'll have to learn how
to get off your but. One way to do this is with the * 'But-Rebuttal Method"
shown in Figure 5-6. Suppose it's Saturday and you've scheduled mowing the
lawn. You've procrastinated for three weeks, and it looks like a jungle. You tell
yourself, "I really should, BUT I'm just
FEELING GOOD 109 not in the mood." Record this in the But column. Now
fight back by writing a But Rubuttal: 'Til feel more like it once I get started.
When I'm done, I'll feel terrific." Your next impulse will probably be to dream
up a new objection: "BUT it's so long it will take forever." Now fight back with
a new rebuttal, as shown in Figure 5-6, and continue this process until you've run
out of excuses. Learn to Endorse Yourself. Do you frequently convince yourself
that what you do doesn't count? If you have this bad habit, you will naturally feel
that you never do anything worthwhile. It won't make any difference if you are a
Nobel laureate or a gardener—life will seem empty because your sour attitude
will take the joy out of all your endeavors and defeat you before you even begin.
No wonder you feel unmotivated! To reverse this destructive tendency, a good
first step would be to pinpoint the self-downing thoughts that cause you to feel
this way in the first place. Talk back to these thoughts and replace them with
ones that are more objective and self-endorsing. Some examples of this are
shown in Figure 5-7. Once you get the knack of it, practice con- consciously
endorsing yourself all day long for the things you do even if they seem trivial.
You may not feel a pleasant emotional lift in the beginning, but keep practicing
even if it seems mechanical. After a few days you will begin to experience some
mood lift, and you will feel more pride about what you're doing. You may
object, "Why should I have to pat myself on the back for everything I do? My
object, "Why should I have to pat myself on the back for everything I do? My
family, friends, and busi- business associates should be more appreciative of
me." There are several problems here. In the first place, even if people are
overlooking your efforts, you are guilty of the same crime if you also neglect
yourself, and pouting won't im- improve the situation. Even when someone does
stroke you, you can't absorb the praise unless you decide to believe and therefore
validate what is being said. How many genuine compliments fall on
110 David D. Burns, M.D. Figure 5-7. Self-Downing Statement Self-Endorsing
Statement Anybody could wash these If it's a routine, boring job, I dishes.
deserve extra credit for doing it. There was no point in washing That's just the
point. They'll these dishes. They'll just get be clean when we need them, dirty
again. I could have done a better job Nothing in the universe is per- straightening
up. feet, but I did make the room look a hell of a lot better. It was just luck the
way my It wasn't a matter of luck. I speech turned out. prepared well and
delivered my talk effectively. I did a darn good job. I waxed the car, but it still
The car looks a heck of a lot doesn't look as good as my better than it did. I'll
enjoy neighbor's new car. driving it around. your deaf ears because you mentally
discredit them? When you do this, other people feel frustrated because you don't
respond positively to what they are saying. Naturally, they give up trying to
combat your self-downing habit. Ulti- Ultimately, only what you think about
what you do will affect your mood. It can be helpful simply to make a written or
mental list of the things you do each day. Then give yourself a mental credit for
each of them, however small. This will help you focus on what you have done
instead of what you haven't gotten around to doing. It may sound simplistic, but
it works! TIC*TOC Technique. If you are procrastinating about getting down to
a specific task, take note of the way you are thinking about it. These TICs, or
Task-Interfering CogFEELING GOOD 111 nitions, will lose much of their power over you if you
simply write them down and substitute more adaptive TOCs, or Task-Oriented
Cognitions, using the double-column tech- technique. A number of examples are
shown in Figure 5-8. When you record your TIC-TOCs, be sure to pinpoint the
distortion in the TIC that defeats you. You may find, for example, that your
worst enemy is all-or-nothing thinking or disqualifying the positive, or you may
be in the bad habit of making arbitrary negative predictions. Once you become
aware of the type of distortion that most commonly thwarts you, you will be able
to correct it. Your procrastination and time-wasting will give way to action and
creativity. You can also apply this principle to mental images and daydreams as
well as to thoughts. When you avoid a task, you probably automatically fantasize
about it in a negative, defeatist fashion. This creates unnecessary tension and ap-
about it in a negative, defeatist fashion. This creates unnecessary tension and apapprehension, which impairs your performance and increases the likelihood that
your dreaded fear will actually come true. For example, if you have to give a
speech to a group of associates, you may fret and worry for weeks ahead of time
because in your mind's eye you see yourself forgetting what you have to say or
reacting defensively to a pushy question from the audience. By the time you give
the speech, you have effectively programmed yourself to behave just this way,
and you're such a nervous wreck it turns out just as badly as you had imagined!
If you dare to give it a try, here's a solution: For ten minutes every night before
you go to sleep, practice fan- fantasizing that you deliver the speech in a positive
way. Imag- Imagine that you appear confident, that you present your material in
an energetic manner, and that you handle all questions from the audience
warmly and capably. You may be sur- surprised that this simple exercise can go
a long way to im- improving how you feel about what you do. Obviously there is
no guarantee things will always come out exactly as you imagine, but there's no
doubt that your expectations and mood will profoundly influence what actually
does happen.
Figure 5-8. The TIC-TOC Technique. In the left-hand column, re- record the
thoughts that inhibit your motivation for a specific task. In the right-hand
column, pinpoint the distortions and substitute more objective, productive
attitudes. TICs TOCs (Task-interfering Cognitions) (Task-oriented Cognitions)
Housewife: Overgeneralization; all-or- I'll never be able to get the ga- nothing
thinking, rage cleaned out. The junk's Just do a little bit and get been piling up
for years. started. There's no reason I have to do it all today. Bank Clerk:
Disqualifying the positive. My work isn't very important It may seem routine to
me, but or exciting. it's quite important to the peo- people who use the bank.
When I'm not depressed, it can be very enjoyable. Many people do routine work
but this doesn't make them unimpor- unimportant human beings. Maybe I could
do something more ex- exciting in my free time. Student: All-or-nothing
thinking. Writing this term paper is Just do a routine job. It doesn't pointless. The
subject is bor- have to be a masterpiece. I ing. might learn something, and it will
make me feel better to get it done. Secretary: Fortune teller error. I'll probably
flub typing this I don't have to type perfectly, and make a bunch of typos. I can
correct the errors. If he's Then my boss will yell at me. overly critical, I can
disarm him, or tell him I'd do better if he were more supportive and less
demanding. "*■" Politician: Fortune teller error; labeling. If I lose this race for
governor, It's not shameful to lose a po- 1*11 be a laughing stock. litical contest.
A lot of people respect me for trying and tak- taking an honest stand on some
Figure 5-8. cont. TICs TOCs (Task-interfering Cognitions) (Task-oriented
Cognitions) important issues. Unfortu- Unfortunately, the best man often doesn't
win, but I can believe in myself whether or not I come out on top. Mind reading.
I have no way of knowing. Give it a try. At least he asked me to call back. Some
people will be interested and I have to sift the chaff from the wheat. I can feel
productive even when someone turns me down. I'll sell one policy on the avaverage for every five people who turn me down, so it's to my advantage to get
as many turndowns as possible! The more turndowns, the more sales! Insurance
Salesman: What's the point in calling this guy back? He didn't sound ininterested. Shy Single Man: If I call up an attractive girl, she'll just dump on me,
so what's the point? I'll just wait around until some girl makes it real obvious that
she likes me. Then I won't have to take a risk. Author: This chapter has to be
great. But I don't feel very creative. Athlete: I can't discipline myself. I have no
self-control. I'll never get in shape. Fortune teller error; over- generalization.
They can't all turn me down, and it's not shameful to try. I can learn from any
rejection. I've got to start practicing to improve my style, so take the big plunge!
It took courage to jump off the high dive the first time, but I did it and survived.
I can do this too! All-or-nothing thinking. Just prepare an adequate draft. I can
improve it later. Disqualifying the positive; all- or-nothing thinking. I must have
self-control be- because I've done well. Just work out for a while and call it quits
if I get exhausted.
114 David D. Burns, M.D. Little Steps for Little Feet. A simple and obvious
self- activation method involves learning to break any proposed task down into
its tiny component parts. This will combat your tendency to overwhelm yourself
by dwelling on all the things you have to do. Suppose your job involves
attending lots of meetings, but you find it difficult to concentrate due to anxiety,
depression, or daydreaming. You can't concentrate effectively because you think,
"I don't understand this as I should. Gosh, this is boring. I'd really prefer to be
making love or fishing right now." Here's how you can beat the boredom, defeat
the dis- distraction, and increase your ability to concentrate: Break the task down
into its smallest component parts! For ex- example, decide to listen for only
three minutes, and then take a one-minute break to daydream intensively. At the
end of this mental vacation, listen for another three min- minutes, and do not
entertain any distracting thoughts for this brief period. Then give yourself
another one-minute break to daydream. This technique will enable you to
maintain a more ef- effective level of overall concentration. Giving yourself perpermission to dwell on distracting thoughts for short periods will diminish their
power over you. After a while, they will seem ludicrous. An extremely useful
way to divide a task into manageable units is through time limitation. Decide
way to divide a task into manageable units is through time limitation. Decide
how much time you will devote to a particular task, and then stop at the end of
the allotted time and go on to something more enjoyable, whether or not you're
finished. As simple as this sounds, it can work wonders. For example, the wife
of a political VIP spent years harboring resentment toward her husband for his
successful, glamorous life. She felt her life consisted of an oppressive load of
child-rearing and housecleaning. Because she was compulsive she never felt she
had enough time to complete her dreary chores. Life was a treadmill. She was
straddled by depression, and had been unsuccessFEELING GOOD 115 fully treated by a long string of famous therapists for over
a decade as she looked in vain for the elusive key to personal happiness. After
consulting twice with one of my colleagues (Dr. Aaron T. Beck), she
experienced a rapid mood swing out of her depression (his therapeutic wizardry
never ceases to astonish me). How did he perform this seeming miracle? Easy.
He suggested to her that her depression was due in part to the fact that she wasn't
pursuing goals that were meaningful to her because she didn't believe in herself.
Instead of acknowledging and confronting her fear of taking risks, she blamed
her lack of direction on her husband and complained about all the undone
housework. The first step was to decide how much time she felt she wanted to
spend on the housework each day; she was to spend no more than this amount
even if the house wasn't perfect, and she was to budget the rest of the day to
pursue activities that interested her. She decided that one hour of housework
would be fair, and enrolled in a graduate program so she could develop her own
career. This gave her a feeling of liberation. Like magic, the depression vanished
along with the anger she harbored toward her husband. I don't want to give you
the idea that depression is usually so easy to eliminate. Even in the above case,
this patient will probably have to fight off a number of depressive rerecurrences. She may at times fall back temporarily into the same trap of trying
to do too much, blaming others, and feeling overwhelmed. Then she will have to
apply the same solution again. The important thing is—she has found a method
that works for her. The same approach might work for you. Do you tend to bite
off bigger pieces than you can comfortably chew? Dare to put modest time limits
on what you do! Have the courage to walk away from an unfinished task! You
may be amazed that you will experience a substantial increase in your proproductivity and mood, and your procrastination may become a thing of the past.
116 David D. Burnsr M.D. Motivation Without Coercion. A possible source of
your procrastination is an inappropriate system for self- motivation. You may
inadvertently undermine what you attempt by flagellating yourself with so many
inadvertently undermine what you attempt by flagellating yourself with so many
"oughts," "shoulds," and "musts" that you end up drained of any desire to get
moving. You are defeating yourself by the way you kill yourself to get moving!
Dr. Albert Ellis describes this mental trap as "mwsferbation." Reformulate the
way you tell yourself to do things by eliminating those coercive words from your
vocabulary. An alternative to pushing yourself to get up in the morning would be
to say, "It will make me feel better to get out of bed, even though it will be hard
at first. Although I'm not obliged to, I might end up being glad I did. If, on the
other hand, I'm really benefiting from the rest and relaxation, I may as well go
ahead and enjoy it!" If you translate shoulds into wants, you will be treating
yourself with a sense of respect. This will produce a feeling of freedom of choice
and personal dignity. You will find that a reward system works better and lasts
longer than a whip. Ask yourself, "What do I want to do? What course of action
would be to my best advantage?" I think you will find that this way of looking at
things will enhance your motivation. If you still have the desire to lie in bed,
mope, and feel doubtful that getting up is really what you want to do, make a list
of the advantages and disadvantages of staying in bed for another day. For
example, an accountant who was far behind in his work around tax time found it
hard to get up each day. His customers began to complain about the undone
work, and in order to avoid these embarrassing confronta- confrontations, he lay
in bed for weeks trying to escape, not even answering the phone. Many
customers fired him, and his business began to fail. His mistake was in telling
himself, "I know I should go to work but I don't want to. And I don't have to
either! So I won't!" Essentially, the word "should" created the il- illusion that the
only reason for him to get out of bed was to please a bunch of angry, demanding
customers. This was
FEELING GOOD 117 Figure 5-9. Advantages of Lying in Bed Disadvantages of
Lying in Bed 1. It's easy. 2. I won't have to 2. do anything or face my probproblems. 3. I can sleep escape. and While it seems easy, it gets awfully boring
and painful after a while. It's actually not so easy to do nothing and to lie here
moping and criticizing my- myself hour after hour. I won't be obliged to do
anything if I get out of bed either, but it might feel better. If I avoid my problems
they won't go away, they'll just get worse, and I won't have the satisfacsatisfaction of trying to solve them. The short-term discomfort of facing up to
things is probably less depressing than the endless anguish of staying in bed. 3. I
can't sleep forever, and I really don't need any more sleep since I have been
sleeping nearly sixteen hours a day. I will probably feel less fatigued if I get up
and get my arms and legs moving rather than lie around in bed like a cripple
waiting for my arms and legs to rot! so unpleasant that he resisted. The absurdity
waiting for my arms and legs to rot! so unpleasant that he resisted. The absurdity
of what he was doing to himself became apparent when he made a list of the
advantages and disadvantages of staying in bed (Figure 5-9, above). After
preparing this list, he realized it was to his advantage to get out of bed. As he
subsequently became more involved with his work, his mood rapidly improved
in spite of the fact that he had lost many accounts during the period of inactivity.
Disarming Technique. Your sense of paralysis will be intensified if your family
and friends are in the habit of
118 David D. Burns, M.D. pushing and cajoling you. Their nagging should
statements reinforce the insulting thoughts already echoing through your head.
Why is their pushy approach doomed to failure? It's a basic law of physics that
for every action there's an equal and opposite reaction. Any time you feel
shoved, whether by someone's hand actually on your chest or by someone trying
to boss you around, you will naturally tighten up and resist so as to maintain
your equilibrium and balance. You will attempt to exert your self-control and
preserve your dignity by refusing to do the thing that you are being pushed to do.
The paradox is that you often end up hurting yourself. It can be very confusing
when someone obnoxiously in- insists you do something that actually would be
to your ad- advantage. This puts you in a "can't win" situation because if you
refuse to do what the person tells you, you end up defeating yourself just in order
to spite him or her. In con- contrast, if you do what the person tells you to do,
you feel had. Because you gave in to those pushy demands, you get the feeling
the individual controlled you, and this robs you of self-respect. No one likes to
be coerced. For example, Mary is a woman in her late teens who was referred to
us by her parents after many years of depression. Mary was a real "hibernator,"
and had the capacity to sit alone in her room watching TV soap operas for
months at a time. This was due in part to her irrational belief that she looked
"peculiar," and that people would stare at her if she went out in public, and also
by her feeling of being coerced by her domineering mother. Mary admitted that
doing things might help her feel better, but this would mean giving in to her
mother, who kept telling her to get off her duff and do something. The harder
Mom pushed, the more stubbornly Mary resisted. It is an unfortunate fact of
human nature that it can be extremely difficult to do something when you sense
you are being forced into it. Fortunately, it's very easy to learn how to handle
people who nag and harangue you and try to run
FEELING GOOD 119 your life. Suppose you are Mary, and after thinking
things over, you decide you would be better off if you got involved in doing a
number of things. You've just made this decision when your mother comes into
your bedroom and announces, "Don't you lie around any longer! Your life is
your bedroom and announces, "Don't you lie around any longer! Your life is
going down the drain. Get moving! Get involved in things the way the other girls
your age do!" At that moment, in spite of the fact that you already have decided
to do just that, you develop a tremendous aversion to it! The disarming technique
is an assertive method that will solve this problem for you (other applications of
this verbal maneuver will be described in the next chapter). The essence of the
disarming technique is to agree with your mother, but to do so in a way that you
remind her you are agreeing with her based on your own decision, and not
because she was telling you what to do. So, you might answer this way: "Yes,
Mom, I just thought the situation over myself and decided it would be to my
advantage to get moving on things. Because of my own decision, I'm going to do
it." Now you can start doing things and not feel had. Or if you wish to put more
of a barb in your comments, you can always say, "Yes, Mom, I have in fact
decided to get out of bed in spite of the fact that you've been telling me to!"
Visualize Success. A powerful self-motivation method involves making a list of
the advantages of a productive action you've been avoiding because it requires
more self- discipline than you have been able to muster. Such a list will train you
to look at the positive consequences of doing it. It's only human to go after what
you want. Furthermore, clubbing yourself into effective action doesn't usually
work nearly as well as a fat, fresh carrot. Suppose, for example, you want to quit
smoking. You may be reminding yourself about cancer and all the other dangers
of smoking. These fear tactics make you so nervous that you immediately reach
for another cigarette; they don't work. Here's a three-step method that does work.
120 David D. Burns, M.D. The first step is to make a list of all the positive
conse- consequences that will result when you become a nonsmoker. List as
many as you can think of, including: 1. Improved health. 2. I'll respect myself. 3.
I'll have greater self-discipline. With my new self- confidence, I may be able to
do a whole lot of other things I've been putting off. 4. I will be able to run and
dance actively, and still feel good about my body. I'll have lots of stamina and
extra energy. 5. My lungs and heart will become strong. My blood pressure will
go down. 6. My breath will be fresh. 7. I'll have extra spending money. 8. I'll live
longer. 9. The air around me will be clean. 10. I'll be able to tell people that I've
become a non- smoker. Once you have prepared the list, you're ready for the
second step. Every night before you go to sleep, fantasize you are in your
favorite spot—walking through the woods in the mountains, on a crisp autumn
day, or maybe lying on a quiet beach near a crystal-blue ocean, with the sun
warming your skin. Whatever fantasy you choose, visualize every enjoyable
detail as vividly as possible, and let your body relax and let go. Allow every
muscle to unwind. Let the tension flow out of your arms and legs and leave your
muscle to unwind. Let the tension flow out of your arms and legs and leave your
body. Notice how your muscles begin to feel limp and loose. NoticeJhow
peaceful you feel. Now you are ready for the third step. Fantasize that you are
still in that scene, and you have
FEELING GOOD 121 become a nonsmoker. Go through your list of benefits
and repeat each one to yourself in the following way: "Now I have improved
health and I like it. I can run along the beach, and I want this. The air around me
is clean and fresh, and I feel good about myself. I respect myself. Now I have
greater self-discipline, and I can take on other challenges if I want to. I have
extra spending money," etc. This method of habit management through the
power of positive suggestion works amazingly well. It enabled me and many of
my patients to quit smoking after a single treatment session. You can do it easily,
and you'll find it's well worth your efforts. It can be used for self-improvement in
losing weight, lawn mowing, getting up on time in the morning, adhering to a
jogging routine, or for any other habit you'd like to modify. Count What Counts.
A three-year-old boy named Stevie stood by the edge of the children's pool,
afraid to jump in. His mother sat in the water in front of him, urging him to take
the leap. He held back; she cajoled. The power struggle went on for thirty
minutes. Finally, he jumped. The water felt fine. It wasn't so difficult, and there
was actually nothing to fear. But his mother's efforts backfired. The unfortunate
message imprinted on Stevie's mind was "I have to be pushed before I can do
anything risky. I don't have the gumption to jump in on my own like the other
kids." His mother and father got the same idea; they began to think, 4'Left to his
own devices, Stevie would never dare go into the water at all. If he isn't
constantly pushed, he'll do nothing by himself. Raising him is going to be a long,
hard struggle." Sure enough, as Stevie grew up, the drama was repeated over and
over. He had to be persuaded and pushed to go to school, to join the baseball
team, to go to parties, and so on. He rarely initiated any action on his own. By
the time he was referred to me at age twenty-one, he was chron- chronically
depressed, living with his parents, and not doing much
122 David D. Burns, M.D. with his life. He was still waiting around for people
to tell him what to do and how to do it. But by now his parents were fed up
trying to motivate him. After each therapy session, he would leave the office
charged with my enthusiasm to follow through on whatever self-help assignment
we had discussed. For example, one week he decided to smile or say hello to
three people he didn't know as a small first step in breaking his isolation. But the
next week he would come into my office with a drooping head and a sheepish
look that let me know he had "forgotten" to say hello to anyone. Another week,
look that let me know he had "forgotten" to say hello to anyone. Another week,
his assignment was to read a three-page article I had written for a singles
magazine on how an unmarried man learned to overcome his loneliness. Steve
came back the next week and said he had lost the manuscript before having a
chance to read it. Each week as he left, he would feel a great surge of eagerness
to help himself, but by the time he was in the elevator, he would "know" in his
heart of hearts that the week's assignment, however simple, would just be too
hard to do! What was Stevie's problem? The explanation goes back to that day at
the swimming pool. He still carries in his mind the powerfully imprinted idea
that "I really can't do anything on my own. I'm the kind of guy who's got to be
pushed." Because it never occurred to him to challenge this belief, it continued
to function as a self-fulfilling prophecy, and he had over fifteen years of
procrastination to back up his belief that he "really was" like that. What was the
solution? First Stevie had to become aware of the two mental errors that were the
key to his problem: mental filter and labeling. His mind was dominated by
thoughts about the various things he put off doing, and he ignored the hundreds
of things he did each week that did not involve his being pushed by someone
else. "All--of that is well and good," Stevie said after we discussed this. "You
seem to have explained my problem, and I think that's correct. But how can I
change the situ- situation?"
FEELING GOOD 123 The solution turned out to be simpler than he anticipated.
I suggested he obtain a wrist counter (as discussed in the last chapter), so that
each day he could count the things he did on his own without prodding or
encouragement from anyone. At the end of the day he was to write down the
total number of clicks he scored and keep a daily log. Over a several-week
period, he began to notice that his daily score increased. Every time he clicked
the counter, he reminded himself that he was in control of his life, and in this
way he trained himself to notice what he did do. Stevie began to feel increased
self-confidence, and to view himself as a more capable human being. Does it
sound simple? It is! Will it work for you? You probably don't think so. But why
not put it to the test? If you have a negative reaction and are convinced the wrist
counter won't work for you, why not evaluate your pessi- pessimistic prediction
with an experiment? Learn to count what counts; you may be surprised at the
results! Test Your "Cants." An important key to successful self- activation
involves learning to adopt a scientific attitude toward the self-defeating
predictions you make about your performance and abilities. If you put these
pessimistic thoughts to the test, you can discover what the truth is. One common
self-defeating thought pattern when you are depressed or procrastinating is to
"can't" yourself every time you think of something productive to do. Perhaps this
stems from your fear of being blamed for your do- nothingism. You try to save
stems from your fear of being blamed for your do- nothingism. You try to save
face by creating the illusion that you are just too inadequate and incompetent to
do a single thing. The problem with defending your lethargy in this manner is
that you may really start believing what you are telling yourself! If you say, "I
can't," over and over often enough it becomes like a hypnotic suggestion, and
after a while you become genuinely convinced you really are a paralytic invalid
who can't do anything. Typical "can't" thoughts include: 'i can't cook," "I can't
func- function," *i can't work," "I can't concentrate," "I can't
124 David D. Burns, M.D. read/' "I can't get out of bed," and 4'I can't clean my
apartment." Not only do such thoughts defeat you, they will sour your
relationships with those you love because they will see all your "I can't"
statements as annoying whining. They won't perceive that it really looks and
seems impossible for you to do anything. They will nag you, and set up
frustrating power struggles with you. An extremely successful cognitive
technique involves testing your negative predictions with actual experiments.
Suppose, for example, you've been telling yourself: "I'm so upset I can't
concentrate well enough to read anything at all." As a way of testing this
hypothesis, sit down with today's newspaper and read one sentence, and then see
if you can summarize the sentence out loud. You might then predict—"But I
could never read and understand a whole paragraph." Again—put this to the test.
Read a paragraph and summarize. Many severe, chronic depressions have been
cracked open with this powerful method. The "Can't Lose" System. You may
feel hesitant to put your "can'ts" to the test because you don't want to run the risk
of failure. If you don't run any risks, at least you can maintain the secret belief
that you're basically a terrific person who's decided for the time being not to get
involved. Behind your aloofness and lack of commitment lurks a pow- powerful
sense of inadequacy and the fear of failure. The "Can't Lose" System will help
you combat this fear. Make a list of the negative consequences you might have
to deal with if you took a risk and actually did fail. Then expose the distortions
in your fears, and show how you could cope productively even if you did
experience a dis- disappointment. The venture that you have been avoiding may
involve a financial, personal, or scholastic risk. Remember that even if you do
fail, some good can come from it. After all, this is how you learned how to walk.
You didn't just jump up
FEELING GOOD 125 from your crib one day and waltz gracefully across the
room. You stumbled and fell on your face and got up and tried again. At what
age are you suddenly expected to know everything and never make any more
mistakes? If you can love and respect yourself in failure, worlds of adventure
mistakes? If you can love and respect yourself in failure, worlds of adventure
and new experiences will open up before you, and your fears will vanish. An
example of a written *'Can't Lose" System is shown in Figure 5-10. Don't Put
the Cart Before the Horsef I'll bet you still may not know for sure where
motivation comes from. What, in your opinion, comes first—motiva- first—
motivation or action? If you said motivation, you made an excellent, logical
choice. Unfortunately, you're wrong. Motivation does not come first, action
does! You have to prime the pump. Then you will begin to get motivated, and
the fluids will flow spontaneously. Individuals who procrastinate frequently
confuse moti- motivation and action. You foolishly wait until you feel in the
mood to do something. Since you don't feel like doing it, you automatically put it
off. Your error is your belief that motivation comes first, and then leads to
activation and success. But it is usually the other way around; action must come
first, and the motivation comes later on. Take this chapter, for example. The first
draft of this chapter was overwritten, clumsy, and stale. It was so long and
boring that a true procrastinator would never even have the fortitude to read it.
The task of revising it seemed to me like trying to go swimming with concrete
shoes. When the day I had scheduled for revising it came—I had to push myself
to sit down and get started. My motivation was about 1 percent, and my urge to
avoid the task was 99 percent. What a hideous chore!
Figure 5-10. The "Can't Lose" System. A housewife used this technique to
overcome her fear of applying for a part-time job. Negative Consequences of
Being Turned Down for a Job Positive Thoughts and Coping Strategies 1. This
means I'll never get a job. 2. My husband will look down on me. 3. But what if
he's not sym- sympathetic? He might say this shows I belong in the kitchen and
don't have what it takes. 4. But we're nearly broke. We need the money. 5. If I
don't get a job, I won't be able to afford some de- decent new school clothes for
the kids. They'll look scraggly. 6. A lot of my friends have jobs. They'll see I
can't cut the mustard in the business world. 1. Overgeneralization. This is
unlikely. I can test this by applying for a series of other jobs and putting my best
foot forward to see what happens. 2. Fortune teller error. Ask him. Maybe he
will be sympathetic. 3. Point out to him I'm doing my best and that his rejectrejecting attitude doesn't help. Tell him that I am disap- disappointed, but that I
credit myself for trying. 4. We've survived so far and haven't missed a single
meal. 5. I can get some clothes later on. We'll have to learn to get along with
what we have for a while. Happiness doesn't come from clothes but from our
self-respect. 6. They're not all employed, and even my friends who do have jobs
can probably remember a time when they were out of work. They haven't done
anything so far to indicate they look down on me.
anything so far to indicate they look down on me.
FEELING GOOD 127 After I got involved in the task, I became highly motimotivated, and the job seems easy now. Writing became fun after all! It works
like this: First: Action i Second: Motivation «■ Third: More Action- If you are a
procrastinator, you probably aren't aware of this. So you lie around in bed
waiting for inspiration to strike. When someone suggests you do something, you
whine, "I don't feel like it." Well, who said you were supposed to feel like it? If
you wait until you're "in the mood," you may wait forever! The following table
will help you review the various activation techniques and select what's most
helpful to you.
Table 5-1. Synopsis of Self-Activation Methods Target Symptoms SelfActivation Techniques Purpose of the Method I. You feel disorganized. You
have I. Daily Activity Schedule nothing to do. You get lonely and bored on
weekends. 2. You procrastinate because tasks seem too difficult and
unrewarding. 3. You feel overwhelmed by the urge to do nothing. 2. The
Antiprocrastination Sheet 3. Daily Record of Dysfunc- Dysfunctional Thoughts
4. You feel there's no point in doing 4. Pleasure-Predicting Sheet anything when
you're alone. 1. Plan things one hour at a time and record the amount of mastery
and pleasure. Virtually any activity will make you feel better than lying in bed
and will undercut your sense of inadequacy. 2. You put your negative
predictions to the test. 3. You expose the illogical thoughts that paralyze you.
You learn that motivation follows action, not vice versa. 4. Schedule activities
with the poten- potential for personal growth or satis- satisfaction, and predict
how rewarding they will be. Compare the actual satisfaction you expeexperience when you are alone and when you are with others.
5. You /give yourself excuses for 5. But-Rebuttal avoiding things. 6. You have
the idea that whatever 6. Self-Endorsement you do isn't worth much, 7. You
think about a task in a self- 7. TIC-TOC Technique defeating manner. 8. You
feel overwhelmed by the mag- magnitude of everything you have to do. 9. You
feel guilty, oppressed, obliged, and duty-bound. 8. Little Steps for Little Feet 9.
Motivation Without Coercion 5. You get off your "but" by com- combatting
your "buts" with realistic rebuttals. 6. Write down the self-downing thoughts and
talk back to them. Look for distorted thought pat- patterns, such as "all-ornothing thinking" Make a list of things you do accomplish each day. 7. You
substitute task-oriented cog- cognitions (TOCS) for task-interfer- taskinterfering cognitions (TICS). 8. Break the task down into its tiny component
parts, and do these one step at a time. 9. a. You eliminate "shoulds," "musts,"
and "oughts" when you give yourself instructions, b. You list the advantages and
and "oughts" when you give yourself instructions, b. You list the advantages and
dis- disadvantages of any activity so you can begin to think in terms of what you
want to do rather than what you must do.
Table 5-1. cont. Target Symptoms Self-Activation Techniques Purpose of the
Method 10. Someone else nags and harangues you. You feel pressured and reresentful, so you refuse to do any- anything at all. 11. You have difficulty
modifying a habit such as smoking. 10. Disarming Technique 11. Visualize
Success 12. You feel unable to do anything on your own initiative because you
see yourself as' 4a procrastinator.'' 12. Count What Counts 13. You feel
inadequate and incom- 13. Test Your Can'ts petent because you say, t4I can't."
14. You are afraid to fail, so you risk 14. "Can't Lose" System nothing. 10. You
assertively agree with them and remind them that you are ca- capable of doing
your own thinking. 11. You make a list of the positive benefits of having
changed the habit. You visualize these after in- inducing a state of deep
relaxation. 12. You count the things you do each day on your own initiative,
using a wrist counter. This helps you overcome your bad habit of con- constantly
dwelling on your inade- inadequacies. 13. You set up an experiment in which
you challenge and dis- disprove your negative predictions. 14. Write down any
negative con- consequences of failure and develop a coping strategy ahead of
time.
Chapter 6 Verbal Judo: Learn to Talk Back When You're Under the Fire of
Criticism You are learning that the cause of your sense of worthless- ness is your
ongoing self-criticism. This takes the form of an upsetting internal conversation
in which you constantly harangue and persecute yourself in a harsh, unrealistic
man- manner. Frequently your inner criticism will be triggered by someone
else's sharp remark. You may dread criticism sim- simply because you have
never learned effective techniques for handling it. Because it is relatively easy to
do, I want to emphasize the importance of mastering the art of handling verbal
abuse and disapproval nondefensively and without a loss of self-esteem. Many
depressive episodes are set in motion by external criticism. Even psychiatrists,
who are supposedly profes- professional abuse-takers, can react adversely to
criticism. A psy- psychiatric resident called Art received negative feedback
intended to be helpful from his supervisor. A patient had complained that several
comments Art made during a ther- therapy session were abrasive. The resident
reacted with a wave of panic and depression when he heard this, due to his
thought, "Oh God! The truth is out about me. Even my 131
132 David D. Burns, M.D. patients can see what a worthless, insensitive person I
132 David D. Burns, M.D. patients can see what a worthless, insensitive person I
am. They'll probably kick me out of the residency program and drum me out of
the state." Why is criticism so hurtful to some people, while others can remain
unperturbed in the face of the most abusive attack? In this chapter you will learn
the secrets of people who face disapproval fearlessly, and you will be shown
specific, concrete steps to overcome and eliminate your own exquisite
vulnerability to criticism. As you read the follow- following sections, keep this
in mind: Overcoming your fear of criticism will require a moderate amount of
practice. But it is not difficult to develop and master this skill, and the positive
impact on your self-esteem will be tremendous. Before I show you the way out
of the trap of crumbling inwardly when criticized, let me show you why
criticism is more upsetting to some people than to others. In the first place, you
must realize that it is not other people, or the critical comments they make, that
upset you. To repeat, there has never been a single time in your life when the
critical comments of some other person upset you—even to a small extent. No
matter how vicious, heartless, or cruel these comments may be, they have no
power to disturb you or to create even a little bit of discomfort. After reading
that paragraph you may get the impression that I am cracking up, mistaken,
highly unrealistic, or some combination thereof. But I assure you I am not when
I say: Only one person in this world has the power to put you down—and you
are that person, no one else! Here's how it works. When another person criticizes
you, certain negative thoughts are automatically triggered in your head. Your
emotional reaction will be created by these thoughts and not by what the other
person says. The thoughts which upset you will invariably contain the same
types of mental errors described in Chapter 3: overgeneralization, all-or-nothing
thinking, the mental filter, labeling, etc. For example, let's take a look at Art's
thoughts. His panic was the result of his catastrophic interpretation: "This critcriticism shows how worthless I am." What mental errors is
FEELING GOOD 133 he making? In the first place, Art is jumping to
conclusions when he arbitrarily concludes the patient's criticism is valid and
reasonable. This may or may not be the case. Further- Furthermore, he is
exaggerating the importance of whatever he actually said to the patient that may
have been undiplomatic (magnification), and he is assuming he could do nothing
to correct any errors in his behavior (the fortune teller error). He unrealistically
predicted he would be rejected and ruined professionally because he would
repeat endlessly whatever error he made with this one patient
(overgeneralization). He focused exclusively on his error (the mental filter) and
over- overlooked his numerous other therapeutic successes (disqual-
(disqualifying or overlooking the positive). He identified with his erroneous
behavior and concluded he was a "worthless and insensitive human being"
behavior and concluded he was a "worthless and insensitive human being"
(labeling). The first step in overcoming your fear of criticism con- concerns your
own mental processes: Learn to identify the neg- negative thoughts you have
when you are being criticized. It will be most helpful to write them down using
the double- column technique described in the two previous chapters. This will
enable you to analyze your thoughts and recognize where your thinking is
illogical or wrong. Finally, write down rational responses that are more
reasonable and less upsetting. An excerpt from Art's written homework using the
dou- double-column technique is included (Figure 6-1). As he learned to think
about the situation in a more realistic man- manner, he stopped wasting mental
and emotional effort in ca- tastrophizing, and was able to channel his energy into
creative, goal-oriented problem solving. After evaluating precisely what he had
said that was offensive or hurtful, he was able to take steps to modify his clinical
style with patients so as to minimize future similar mistakes. As a result, he
learned from the situation, and his clinical skills and maturity increased. This
gave his self-confidence a boost and helped him overcome his fear of being
imperfect. To put it succinctly, if people criticize you the comments they make
will be right or wrong. If the comments are
134 David D. Burns, M.D. Figure 6-1. Excerpt from Arts written homework,
using the dou- double-column technique. He initially experienced a wave of
panic when he received critical feedback from his supervisor about the way he
handled a difficult patient. After writing down his negative thoughts, he realized
they were quite unrealistic. Consequently, he felt substantial relief. Automatic
Thoughts (self-criticism) Rational Responses (self-defense) 1. Oh, God! The
truth is out about me. Even the patients can see what a worthless, insensitive
individual I am. 2. They'll probably kick me out of the residency pro- program.
1. Just because one patient complains it doesn't mean that I am a 4'worthless, ininsensitive individual." The majority of my patients do, in fact, like me. Making
a mistake doesn't reveal my 44true essence." Everyone is entitled to make mismistakes. 2. This is silly and rests on several erroneous assump- assumptions: (a)
all I do is bad things; (b) I have no capac- capacity to grow. Since (a) and (b) are
absurd, it is ex- extremely unlikely my posi- position here is threatened. I have
on many occasions re- received praise from my su- supervisor. wrong, there is
really nothing for you to be upset about. Think about that for a minute! Many
patients have come to me in tears, angry and upset because a loved one made a
critical comment to them that was thoughtless and inaccur- inaccurate. Such a
reaction is unnecessary. Why should you be disturbed if someone else makes the
mistake of criticizing you in an unjust manner? That's the other guy's error, not
yours. Why upset yourself? Did you expect that other people would be perfect?
yours. Why upset yourself? Did you expect that other people would be perfect?
On the other hand, if the criticism is
FEELING GOOD ! 35 accurate, there is still no reason for you to feel overoverwhelmed. You're not expected to be perfect. Just acknowl- acknowledge
your error and take whatever steps you can to correct it. It sounds simple (and it
is!), but it may take some effort to transform this insight into an emotional
reality. Of course, you may fear criticism because you feel you need the love and
approval of other people in order to be worthwhile and happy. The problem with
this point of view is that you'll have to devote all your energies to trying to
please people, and you won't have much left for creative, productive living.
Paradoxically, many people may find you less interesting and desirable than
your more self-assured friends. Thus far, what I have told you is a review of the
cognitive techniques introduced in the previous chapter. The crux of the matter
is that only your thoughts can upset you and if you learn to think more
realistically, you will feel less upset. Right now, write down the negative
thoughts that ordinarily go through your head when someone criticizes you.
Then identify the distortions and substitute more objective rational responses.
This will help you feel less angry and threatened. Now I would like to teach you
some simple verbal tech- techniques which may have considerable practical
relevance. What can you say when someone is attacking you? How can you
handle these difficult situations in a way that will enhance your sense of mastery
and self-confidence? Step One—Empathy. When someone is criticizing or
attacking you, his (or her) motives may be to help you or to hurt you. What the
critic says may be right or wrong, or somewhere in between. But it is not wise to
focus on these issues initially. Instead, ask the person a series of specific
questions designed to find out exactly what he or she means. Try to avoid being
judgmental or defensive as you ask the questions. Constantly ask for more and
more specific in- information. Attempt to see the world through the critic's eyes.
If the person attacks you with vague, insulting labels, ask him or her to be more
specific and to point out exactly
136 David D. Burns, M.D. what it is about you the person dislikes. This initial
ma- maneuver can itself go a long way to getting the critic off your back, and
will help transform an attack-defense interaction into one of collaboration and
mutual respect. I often illustrate how to do this in a therapy session by roleplaying an imaginary situation with the patient so that I can model this particular
skill. I'll show you how to role- play; it's a useful skill to develop. In the dialogue
that follows, I want you to imagine you are an angry critic. Say the most brutal
and upsetting thing to me you can think of. What you say can be true, false, or
and upsetting thing to me you can think of. What you say can be true, false, or
partly both. I will respond to each of your assaults with the empathy technique.
You (playing the role of angry critic): Dr. Burns, you're a no-good shit. David:
What about me is shitty? You: Everything you say and do. You're insensitive,
self-centered, and incompetent. David: Let's take each of these. I want you to try
to be specific. Apparently I've done or said a number of things that upset you.
Just what did I say that sounded insensitive? What gave you the impresimpression I was self-centered? What did I do that seemed incompetent? You:
When I called to change my appointment the other day, you sounded rushed and
irritable, as if you were in a big hurry and didn't give a damn about me. David:
Okay, I came across in a rushed, uncaring way on the phone. What else have I
done that irritated you? You: You always seem to hurry me out at the end of the
session—just like this was a big production line to make money. David: Okay,
you feel I've been too rushed during ses- sessions as well. I may have given you
the impresFEELING GOOD 137 sion I'm more interested in your money than in you. What
else have I done? Can you think of other ways I might have goofed up or
offended you? What I am doing is simple. By asking you specific quesquestions I minimize the possibility that you will reject me com- completely.
You—and I—become aware of some specific concrete problems that we can
deal with. Furthermore, I am giving you your day in court by listening to you so
as to understand the situation as you see it. This tends to defuse any anger and
hostility and introduces a problem-solving orientation in the place of blame
casting or debate. Re- Remember the first rule—even if you feel the criticism is
totally unjust, respond with empathy by asking specific questions. Find out
precisely what your critic means. If the person is very hot under the collar, he or
she may be hurling labels at you, perhaps even obscenities. Nevertheless, ask for
more information. What do those words mean? Why does the person call you a
"no-good shit"? How did you offend this individual? What did you do? When
did you do it? How often have you done it? What else does the person dislike
about you? Find out what your action means to him or her. Try to see the world
through your critic's eyes. This ap- approach will frequently calm the roaring
lion and lay the groundwork for a more sensible discussion. Step Two—
Disarming the Critic If someone is shooting at you, you have three choices: You
can stand and shoot back—this usually leads to warfare and mutual destruction;
you can run away or try to dodge the bullets—this often results in humiliation
and a loss of self-esteem; or you can stay put and skillfully disarm your
opponent. I have found that this third solution is by far the most satisfying.
When you take the wind out of the other person's sails, you end up the winner,
and your opponent more often than not will also feel like a winner. How is this
and your opponent more often than not will also feel like a winner. How is this
accomplished? It's simple: Whether your
138 David D. Burns, M.D. critic is right or wrong, initially find some way to
agree with him or her. Let me illustrate the easiest situation first. Let's assume
the critic is primarily correct. In the previous ex- example when you angrily
accused me of sounding rushed and indifferent on several occasions, I might go
on to say: "You're absolutely right. I was rushed when you called, and I probably
did sound impersonal. Other people have also pointed this out to me at times. I
want to emphasize that I didn't intend to hurt your feelings. You're also right that
we have been rushed during several of our sessions. You might recall that
sessions can be any length you like, as long as we decide this ahead of time so
that the scheduling can be appropriately adjusted. Perhaps you'd like to schedschedule sessions that are fifteen or thirty minutes longer, and see if that's more
comfortable." Now, suppose the person who's attacking you is making criticisms
you feel are unfair and not valid. What if it would be unrealistic for you to
change? How can you agree with someone when you feel certain that what is
being said is utter nonsense? It's easy—you can agree in principle with the
criticism, or you can find some grain of truth in the statement and agree with
that, or you can acknowledge that the person's upset is understandable because it
is based on how he or she views the situation. I can best illustrate this by
continuing the role-playing; you attack me, but this time say things that are
primarily false. According to the rules of the game, I must A) find some way to
agree with whatever you say; B) avoid sarcasm or defensiveness; C) always
speak the truth. Your statements can be as bizarre and as ruthless as you like,
and I guarantee I will stick by these rules! Let's go! You (continuing to play the
role of angry critic): Dr. Burns, you're a shit. David: I feel that way at times. I
often goof up at things. You: This cognitive therapy is no damn good!
FEELING GOOD 139 David: There's certainly plenty of room for improveimprovement. You: And you're stupid. David: There are lots of people who are
brighter than I am. I'm sure not the smartest person in the world. You: You have
no real feelings for your patients. Your approach to therapy is superficial and
gimmicky. David: I'm not always as warm and open as I'd like to be. Some of
my methods might seem gimmicky at first. You: You're not a real psychiatrist.
This book is pure trash. You're not trustworthy or competent to manage my case.
David: Pm terribly sorry I seem incompetent to you. It must be quite disturbing
to you. You seem to find it difficult to trust me, and you are genuinely skeptical
about whether we can work together effectively. You're absolutely right—we
can't work together successfully unless we have a sense of mutual respect and
can't work together successfully unless we have a sense of mutual respect and
teamwork. By this time (or sooner) the angry critic will usually lose steam.
Because I do not fight back but instead find a way to agree with my opponent,
the person quickly seems to run out of ammunition, having been successfully
disarmed. You might think of this as winning by avoiding battle. As the critic
begins to calm down, he or she will be in a better mood to communicate. Once I
have demonstrated these first two steps to a patient in my office, I usually
propose we reverse roles to give the patient the chance to master the method.
Let's do this. I will criticize and attack you, and you will practice the emempathy and make up your own answers. Then see how closely they are accurate
or nonsensical. To make the following dialogue a more useful exercise, cover up
the responses called "You" and make up your own answers. Then see
140 David D. Burns, M.D. how closely they correspond with what I have
written. Re- Remember to ask questions using the empathy method and find
valid ways to agree with me using the disarming tech- technique. David (playing
the role of angry critic): You're not here to get better. You're just looking for
sympathy. You (playing the role of the one under attack): What gives you the
impression I'm just looking for sympathy? David: You don't do anything to help
yourself between sessions. All you want to do is come here and complain. You:
It's true that I haven't been doing some of the written homework you suggested.
Do you feel I shouldn't complain during sessions? David: You can do whatever
you want. Just admit you don't give a damn. You: You mean you think I don't
want to get better, or what? David: You're no good! You're just a piece of
garbage! You: I've been feeling that way for years! Do you have some ideas
about what I can do to feel differ- differently? David: I give up. You win. You:
You're right. I did win! I strongly suggest you practice this with a friend. The
role-playing format will help you master the necessary skills needed when a real
situation arises. If there is no one you feel comfortable with who could role-play
with you effec- effectively, a good alternative would be to write out imaginary
dialogues between you and a hostile critic, similar to the ones you've been
reading. After each harangue write down how you might answer using the
empathy and disarming
FEELING GOOD 141 technique. It may seem difficult at first, but I think you'll
catch on quite readily. It's really quite easy once you get the gist of it. You will
notice you have a profound, almost irresistible tendency to defend yourself when
you are unjustly accused. This is a MAJOR mistake! If you give in to this
tendency, you will find that the intensity of your opponent's attack increases*
You will paradoxically be adding bullets to that person's arsenal every time you
You will paradoxically be adding bullets to that person's arsenal every time you
defend yourself. For ex- example, you be the critic again, and this time I'll
defend myself against your absurd accusations. You'll see how quickly our
interaction will escalate to full-scale warfare. You (in the role of critic again):
Dr. Burns, you don't care about your patients. David (responding in a defensive
manner): That's un- untrue and unfair. You don't know what you're talking
about! My patients respect all the hard work I put in. You: Well, here's one who
doesn't! Good-bye! (You exit, having decided to fire me. My defensive- ness
leads to a total loss.) In contrast, if I respond with empathy and disarm your
hostility, more often than not you will feel I am listening to you and respecting
you. As a result you lose your ardor to do battle and quiet down. This paves the
way for step three—feedback and negotiation. You may find initially that in
spite of your determination to apply these techniques, when a real situation
arises in which you are criticized, you will be caught up by your emotions and
your old behavior patterns. You may find yourself sulking, arguing, defending
yourself vehemently, etc. This is understandable. You're not expected to learn it
all overnight, and you don't have to win every battle. It is important, however, to
analyze your mistakes afterward so that you can review how you might have
handled the sit142 David D. Burns, M.D. uation differently along the lines suggested. It can be
im- immensely helpful to find a friend to role-play the difficult situation with
you afterward so that you can practice a va- variety of responses until you have
mastered an approach you are comfortable with. Step Three—Feedback and
Negotiation Once you have listened to your critic, using the empathy method,
and disarmed him by finding some way to agree with him, you will then be in a
position to explain your position and emo- emotions tactfully but assertively, and
to negotiate any real dif- differences. Let's assume that the critic is just plain
wrong. How can you express this in a nondestructive manner? This is simple:
You can express your point of view objectively with an acknowledgment you
might be wrong. Make the conflict one based on fact rather than personality or
pride. Avoid directing destructive labels at your critic. Remember, his error does
not make him stupid, worthless, or inferior. For example, a patient recently
claimed that I sent a bill for a session for which she had already paid. She
assaulted me with "Why don't you get your bookkeeping straight!" Knowing she
was in error, I responded, "My records may indeed be wrong. I seem to recall
that you forgot your checkbook that day, but I might be confused on this point. I
hope you'll allow for the possibility that you or I will make errors at times. Then
we can be more relaxed with each other. Why not see if you have a canceled
check? That way we can find out the truth and make appropriate adadjustments." In this case my nonpolarizing response allowed her to save face
adjustments." In this case my nonpolarizing response allowed her to save face
and avoided a confrontation in which her self- respect was at risk. Although it
turned out she was wrong, she later expressed relief that I acknowledged I do
make mistakes. This helped her feel better about me, as she was afraid I would
be as perfectionistic and demanding with her as she was with herself. Sometimes
you and the critic will differ not on a matter
FEELING GOOD 143 of fact but of taste. Once again, you will be a winner if
you present your point of view with diplomacy. For example, I have found that
no matter how I dress, some patients respond favorably and some negatively. I
feel most comfortable in a suit and tie, or in a sports coat and tie. Suppose a
patient criticizes me because my clothes are too formal and this is iritating
because it makes me appear to be part of the "Es- "Establishment." After
eliciting further specific information about other things this person might dislike
about me, I could then respond, "I can certainly agree with you that suits are a bit
formal. You would be more comfortable with me if I dressed more casually. I'm
sure you'll understand that after dressing in a variety of ways, I have found that a
nice suit or sports coat is most acceptable to the majority of the people I work
with, and that's why I've decided to stick with this style of dressing. I'm hopeful
you won't let this interfere with our continued work together." You have a
number of options when you negotiate with the critic. If he or she continues to
harangue you, making the same point again and again, you can simply repeat
your assertive response politely but firmly over and over until the person tires
out. For example, if my critic continued to insist I stop wearing suits, I might
continue to say each time, "I understand your point entirely, and there is some
truth to it. Nevertheless, I've decided to stick with more formal attire at this
time." Sometimes the solution will be in between. In this case negotiation and
compromise are indicated. You may have to settle for part of what you want. But
if you have con- conscientiously applied the empathy and disarming techniques
first, you will probably get more of what you want. In many cases you will be
just plain wrong, and the critic will be right. In such a situation your critic's
respect for you will probably increase by an orbital jump if you asser- assertively
agree with the criticism, thank the person for pro- providing you with the
information, and apologize for any hurt you might have caused. It sounds like
old-fashioned com- common sense (and it is), but it can be amazingly effective.
144 David D. Burns, M.D. By now you may be saying, "But don't I have a right
to defend myself when someone criticizes me? Why should I always have to
empathize with the other person? After all, he may be the ninny, not I. Isn't it
human just to get angry and blow your stack? Why should I always have to
human just to get angry and blow your stack? Why should I always have to
smooth things out?" Well, there is considerable truth in what you say. You do
have the right to defend yourself vigorously from criti- criticism and to get angry
at anyone you choose whenever you like. And you are right on target when you
point out that it is often your critic, and not you, whose thinking is fouled up.
And there is more than a grain of truth behind the slogan "Better mad than sad."
After all, if you're going to con- conclude that someone is "no damn good," why
not let it be the other fellow? And furthermore, sometimes it does feel so much
better to be mad at the other person. Many psychotherapists would agree with
you on this point. Freud felt that depression was "anger turned in- inward." In
other words he believed depressed individuals direct their rage against
themselves. In keeping with this view, many therapists urge their patients to get
in touch with their anger and to express it more frequently to others. They might
even say that some of the methods described in this section amount to a
repressive cop-out. This is a false issue. The crucial point is not whether or not
you express your feelings, but the manner in which you do it. If your message is
"I'm angry because you're criti- criticizing me and you're no damn good," you
will poison your relationship with that person. If you defend yourself from
negative feedback in a defensive and vengeful way, you will reduce the prospect
for productive interaction in the future. Thus, while your angry outburst
momentarily/ee/s good, you may defeat yourself in the long run by burning your
bridges. You have polarized the situation prematurely and unnecessarily, and
eliminated your chance to learn what the critic was trying to convey. And what
is worse, you may experience a depressive backlash and punish yourself
inordinately for your burst of temper.
FEELING GOOD 145 Antiheckler Technique. A specialized application of the
techniques discussed in this chapter might be particularly helpful for those of
you who are involved in lecturing or teaching. I developed the "antiheckler
technique" when I began lecturing to university and professional groups on
current depression research. Although my lectures are usu- usually well
received, I occasionally find there is a single heck- heckler in the audience. The
heckler's comments usually have several characteristics: A) They are intensely
critical, but seem inaccurate or irrelevant to the material presented; B) they often
come from a person who is not well accepted or regarded among his or her local
peers; and C) they are expressed in a haranguing, abusive style. I therefore had
to develop an antiheckler technique which I could use to silence such a person in
an inoffensive man- manner so that the rest of the audience could have an equal
opportunity to ask questions. I find that the following method is highly effective:
AI immediately thank the per- person for his or her comments; B) acknowledge
AI immediately thank the per- person for his or her comments; B) acknowledge
that the points brought up are indeed important; and C) I empha- emphasize that
there is a need for more knowledge about the points raised, and I encourage my
critic to pursue mean- meaningful research and investigation of the topic.
Finally, I in- invite the heckler to share his or her views with me further after the
close of the session. Although no verbal technique is guaranteed to bring a
particular result, I have rarely failed to achieve a favorable effect when using this
upbeat approach. In fact, these heck- heckling individuals have frequently
approached me after the lecture to compliment and thank me for my kind
comments. It is sometimes the heckler who turns out to be most dedemonstrative and appreciative of my lecture! Summary. The various cognitive
and verbal principles for coping with criticism are summarized in the accompaaccompanying diagram (see Figure 6-2, page 146). As a general rule, when
someone insults you, you will immediately go down one of three pathways—the
sad route, the mad route, or the glad route. Whichever option you choose will be
a
Figure 6-2. The three ways that you might react to criticism. Depending on how
you think about the situation, you will feel sad, mad, or glad. Your behavior and
the outcome will also be greatly influenced by your mental set. COPING WITH
CRITICISM: Your boss says, "You've been doing sloppy work and goofing off
lately " / m No Gooil' Response Thought: "I'm always goofing up I'm worthless."
Feeling: Sad, anxious Behavior: Isolation, moping, giving up OUTCOME: You
lie in bed, avoid work, and put yourself down. You sink deeper into the
quicksand of depres- depression. You are put on probation at work. You're No
Good" Response SelJ-E.steem Response Thought: "That stupid SOB ts on my
back again'" Thought: "Here's a chance to learn something." Feeling: Angry,
frustrated Behavior: Obscenities and accusations are hurled. Feel- Feeling:
Secure Behavior: You inquire, "What ways have I been goofing off9"
OUTCOME: You are fired on the spot. You fume for days, constantly telling
yourself the world is no damn good. You learned nothing and poisoned your
relationship with your boss. OUTCOME: The problem is defined and a solution
is proposed. You experience self-esteem and mood elevation. Your boss is
satisfied with how you handled his complaint.
FEELING GOOD 147 total experience, and will involve your thinking, your
feel- feelings, your behavior, and even the way your body functions. Most
people with a tendency to depression choose the sad route. You automatically
conclude the critic is right. Without any systematic investigation, you jump to
the con- conclusion that you were in the wrong and made a mistake. You then
magnify the importance of the criticism with a series of thinking errors. You
magnify the importance of the criticism with a series of thinking errors. You
might overgeneralize and wrongly conclude that your whole life consists of
nothing but a string of errors. Or you might label yourself a "total goof-up." And
because of your perfectionistic expectation that you are supposed to be flawless,
you will probably feel convinced that your (presumed) error indicates you are
worthless. As a result of these mental errors, you will ex- experience depression
and a loss of self-esteem. Your verbal responses will be ineffectual and passive,
characterized by avoidance and withdrawal. In contrast, you may choose the
mad route. You will defend yourself from the horrors of being imperfect by
trying to convince the critic that he or she is a monster. You will stubbornly
refuse to admit any error because according to your perfectionistic standards,
this would be tantamount to admitting you are a worthless worm. So you hurl
accusations back on the assumption that the best defense is a good offense. Your
heart beats rapidly, and hormones pour into your bloodstream as you prepare for
battle. Every muscle tightens and your jaws are clenched. You may feel a temtemporary exhilaration as you tell your critic off in self-righteous indignation.
You'll show him what a no-good piece of crap he is! Unfortunately, he doesn't
agree, and in the long run your outburst is self-defeating because you've
poisoned the relationship. The third option requires that you either have selfesteem or at least act as if you did. It is based on the premise that you are a
worthwhile human being and have no need to be perfect. When you are
criticized, your initial response is investigative. Does the criticism contain a
grain of truth?
148 David D. Burns, M.D. Just what did you do that was objectionable? Did you
in fact goof up? Having defined the problem by asking a series of nonjudgmental questions, you are in a position to propose a solution. If a
compromise is indicated, you can negotiate. If you were clearly in the wrong,
you can admit it. If the critic was mistaken, you can point this out in a tactful
manner. But whether your behavior was right or wrong, you will know that you
are right as a human being, because you have finally perceived that your selfesteem was never at issue in the first place.
Chapter 7 Feeling Angry? What's Your IQ? What's your IQ? I'm not interested in
knowing how smart you are because your intelligence has little, if anything, to
do with your capacity for happiness. What I want to know is what your/rritability
Quotient is. This refers to the amount of anger and annoyance you tend to absorb
and harbor in your daily life. If you have a particularly high IQ, it puts you at a
great disadvantage because you overreact to frus- frustrations and
disappointments by creating feelings of re- resentment that blacken your
disappointments by creating feelings of re- resentment that blacken your
disposition and make your life a joyless hassle. Here's how to measure your IQ.
Read the list of twenty- five potentially upsetting situations described below. In
the space provided after each incident, estimate the degree it would ordinarily
anger or provoke you, using this simple rating scale: 0—You would feel very
little or no annoyance. 1—You would feel a little irritated. 2—You would feel
moderately upset. 3—You would feel quite angry. -You would feel very angry.
Mark your answer after each question as in this example: 149
150 David D. Burns, M.D. You are driving to pick up a friend at the airport, and
you are forced to wait for a long freight train. 2 The individual who answered
this question estimated his reaction as a two because he would feel moderately
irritated, but this would quickly pass as soon as the train was gone. As you
describe how you would ordinarily react to each of the following provocations,
make your best general estimate even though many potentially important details
are omitted (such as what kind of day you were having, who was in- involved in
the situation, etc.). Novaco Anger Scale* 1. You unpack an appliance you have
just bought, plug it in, and discover that it doesn't work. 2. Being overcharged by
a repairman who has you over a barrel. 3. Being singled out for correction, when
the actions of others go unnoticed. 4. Getting your car stuck in the mud or snow.
5. You are talking to someone and they don't answer you. 6. Someone pretends
to be something they are not. 7. While you are struggling to carry four cups of
coffee to your table at a cafeteria, someone bumps into you, spilling the coffee.
8. You have hung up your clothes, but someone knocks them to the floor and
fails to pick them up. *This scale was developed by Dr Raymond W. Novaco of
the Program in Social Ecology at the University of California, Irvine, and part of
it is reproduced here with his permission. The full scale contains eighty items.
FEELING GOOD 151 9. You are hounded by a salesperson from the moment
that you walk into a store. 10. You have made arrangements to go somewhere
with a person who backs off at the last minute and leaves you hanging. 11. Being
joked about or teased. 12. Your car is stalled at a traffic light, and the guy behind
you keeps blowing his horn. 13. You accidentally make the wrong kind of turn
in a parking lot. As you get out of your car someone yells at you, "Where did
you learn to drive?" 14. Someone makes a mistake and blames it on you. 15.
You are trying to concentrate, but a person near you is tapping their foot. 16.
You lend someone an important book or tool, and they fail to return it. 17. You
have had a busy day, and the person you live with starts to complain about how
you forgot to do something that you agreed to do. 18. You are trying to discuss
something important with your mate or partner who isn't giving you a chance to
something important with your mate or partner who isn't giving you a chance to
express your feelings. 19. You are in a discussion with someone who persists in
arguing about a topic they know very little about. 20. Someone sticks his or her
nose into an argument between you and someone else. 21. You need to get
somewhere quickly, but the car in front of you is going 25 mph in a 40 mph
zone, and you can't pass. 22. Stepping on a gob of chewing gum. 23. Being
mocked by a small group of people as you pass them.
152 David D. Burns, M.D. 24. In a hurry to get somewhere, you tear a good pair
of slacks on a sharp object. ___ 25. You use your last dime to make a phone call,
but you are disconnected before you finish dialing and the dime is lost. Now that
you have completed the Anger Inventory, you are in a position to calculate your
IQ, your Irritability Quo- Quotient. Make sure that you have not skipped any
items. Add up your score for each of the twenty-five incidents. The lowest
possible total score on the test would be zero. This would mean you put down a
zero on each item. This in- indicates you are either a liar or a guru! The highest
score would be a hundred. This would mean you recorded a four on each of the
twenty-five items, and you're constantly at or beyond the boiling point. You can
now interpret your total score according to the following scale: 0-45: The
amount of anger and annoyance you gen- generally experience is remarkably
low. Only a few percent of the population will score this low on the test. You are
one of the select few! 46-55: You are substantially more peaceful than the
average person. 56-75: You respond to life's annoyances with an av- average
amount of anger. 76-85: You frequently react in an angry way to life's many
annoyances. You are substantially more irritable than the average person. 86-
100: You are a true anger champion, and you are plagued by frequent intense
furious reactions that do not quickly disappear. You probably harbor negative
feelings long after the initial insult has passed. You may have the repureputation of a firecracker or a hothead among
FEELING GOOD 153 people you know. You may experience fre- frequent
tension headaches and elevated blood pressure. Your anger may often get out of
control and lead to impulsive hostile outbursts which at times get you into
trouble. Only a few percent of the adult population react as intensely as you do.
Now that you know how much anger you have, let's see what you can do about
it. Traditionally psychotherapists (and the general public) have conceptualized
two primary ways to deal with anger: (a) anger turned "inward"; or (b) anger
turned "outward." The former solution is felt to be the "sick" one—you
internalize your aggression and absorb resentment like a sponge. Ultimately it
corrodes you and leads to guilt and depression. Early psychoanalysts such as
Freud felt that internalized anger was the cause of depres- depression.
Freud felt that internalized anger was the cause of depres- depression.
Unfortunately, there is no convincing evidence in sup- support of this notion.
The second solution is said to be the "healthy" one— you express your anger,
and as you ventilate your feelings, you presumably feel better. The problem with
this simplistic approach is that it doesn't work very well. If you go around
ventilating all your anger, people will soon regard you as loony. And at the same
time you aren't learning how to deal with people in society without getting
angry. The cognitive solution transcends both of these. You have a third option:
Stop creating your anger. You don't have to choose between holding it in or
letting it out because it won't exist. In this chapter I provide guidelines to help
you assess the pros and cons of experiencing anger in a variety of situations so
you can decide when anger is and isn't in your best self- interest. If you choose,
you can develop control over your feelings; you will gradually cease to be
plagued by excessive irritability and frustration that sour your life for no good
reason.
154 David D. Burnsr M.D. Just Who Is Making You Angry? "People! Shit! I'm
fed up with them! I need a vacation from people." The woman who recorded this
thought at 2:00 a.m. couldn't sleep. How could the dogs and noisy neighbors in
her apartment building be so thoughtless? Like her, I'll bet you're convinced it's
other people's stupid, self-centered actions that make you angry. It's natural to
believe that external events upset you. When you're mad at someone, you
automatically make them the cause of all your bad feelings. You say, "You're anannoying me! You're getting on my nerves." When you think like this, you're
actually fooling yourself because other peo- people really cannot make you
angry. Yes—you heard me right. A pushy teenager might crowd in front of you
in line at the movie theater. A con artist might sell you a fake ancient coin at an
antique shop. A "friend" might screw you out of your share of a profitable
business deal. Your boyfriend might always show up late for dates in spite of his
knowing how important promptness is to you. No matter how out- outrageous or
unfair others might appear to you, they do not, never did, and never will upset
you. The bitter truth is that you're the one who's creating every last ounce of the
outrage you experience. Does that sound like heresy or stupidity to you? If you
think I'm contradicting the obvious, you may feel like burn- burning this book or
throwing it down in disgust. If so, I dare you to read on, because— Anger, like
all emotions, is created by your cognitions. The relationship between your
thoughts and your anger is shown in Figure 7-1. As you will note, before you
can feel irritated by any event you must first become aware of what is occurring
and come to your own interpretation of it. Your feelings result from the meaning
you give to the event, not from the event itself.
you give to the event, not from the event itself.
FEELING GOOD ! 55 Figure 7-1. It is not negative events but your perceptions
and thoughts about these events that create your emotional response.
EXTERNAL EVENTS: (not within your control) The actions of other people.
INTERNAL EVENTS: (within your control) ' " Thoughts t's unfair!" That damn
jerk!" I won't stand for it!" Behaviors You tell the other guy off or withdraw
icily. You scheme to retal- retaliate so as to even the score. Emotions Anger,
frustration, fear, guilt. For example, suppose that after a hectic day you put your
two-year-old child to sleep in his crib for the night. You close his bedroom door
and sit down to relax and watch television. Twenty minutes later he suddenly
opens the door to his room and walks out giggling. You might react to this in a
variety of ways, depending on the meaning you attach to it. If you feel irritated,
you're probably thinking, "Damn it! He's always a bother. Why can't he stay in
bed and behave like he should? He never gives me a minute's rest!" On the other
hand, you could be delighted to see him pop out of his room because you're
thinking, "Great! He just crawled out of his crib on his own for the first time.
He's
156 David D. Bums, M.D. growing up and getting more independent." The event
is the same in both cases. Your emotional reaction is deter- determined entirely
by the way you are thinking about the sit- situation. 1*11 bet I know what you're
thinking now: 'That example with the baby is not applicable. When / get angry
there's a justifiable provocation. There's plenty of genuine unfair- unfairness and
cruelty in this world. There's no valid way I can think about all the crap I have to
put up with each day without getting uptight. Do you want to perform a
lobotomy and turn me into an unfeeling zombie? NO THANKS!" You are
certainly right that plenty of genuinely negative events do go on every day, but
your feelings about them are still created by the interpretations you place on
them. Take a careful look at these interpretations because anger can be a twoedged sword. The consequences of an im- impulsive outburst will frequently
defeat you in the long run. Even if you are being genuinely wronged, it may not
be to your advantage to feel angry about it. The pain and suffering you inflict on
yourself by feeling outraged may far exceed the impact of the original insult. As
a woman who runs a restaurant put it, "Sure—I have the right to fly off the
handle. The other day I realized the chefs forgot to order ham again even though
I had specifically reminded them, so I exploded and threw a cauldron of hot soup
across the kitchen floor in disgust. Two minutes later I knew I'd acted like the
biggest asshole in the world, but I didn't want to admit it, so I had to spend all
my energy for the next forty- eight hours trying to convince myself I had the
right to make a jackass of myself in front of twenty employees! It wasn't worth
right to make a jackass of myself in front of twenty employees! It wasn't worth
it!" In many cases your anger is created by subtle cognitive distortions. As with
depression, many of your perceptions are twisted, one-sided, or just plain wrong.
As you learn to replace these distorted thoughts with others that are more
realistic and functional, you will feel less irritable and gain greater self-control.
What kinds of distortion occur most often when you are
FEELING GOOD 157 angry? One of the greatest offenders is labeling. When
you describe the person you're mad at as "a jerk" or "a bum" or "a piece of shit,"
you see him in a totally negative way. You could call this extreme form of
overgeneralization '"globalizing" or "monsterizing." Someone may in fact have
betrayed your trust, and it is absolutely right to resent what that person did. In
contrast, when you label someone, you create the impression that he or she has a
bad essence. You are directing your anger toward what that person ' 'is.'' When
you write people off this way, you catalog in your mind's eye every single thing
about them you don't like (the mental filter) and ignore or discount their good
points (disqualifying the positive). This is how you set up a false target for your
anger. In reality, every human being is a complex mix of positive, negative, and
neutral attributes. Labeling is a distorted thinking process that causes you to feel
inappropriately indignant and morally superior. It's destructive to build your selfimage this way: Your labeling will inevitably give way to your need to blame the
other person. Your thirst for retaliation intensifies the conflict and brings out
similar attitudes and feelings in the person you're mad at. Labeling inevitably
functions as a self-fulfilling prophecy. You polarize the other person and bring
about a state of interpersonal warfare. What's the battle really all about? Often
you're involved in a defense of your self-esteem. The other person may have
threatened you by insulting or criticizing you, or by not loving or liking you, or
by not agreeing with your ideas. Consequently, you may perceive yourself in a
duel of honor to the death. The problem with this is that the other person is not a
totally worthless shit, no matter how much you insist! And, furthermore, you
cannot enhance your own esteem by denigrating someone else even if it does
feel good temporarily. Ultimately only your own negative, distorted thoughts can
take away your self-respect, as pointed out in Chapter 4. There is one and only
one person in this world who has the power to threaten your self-esteem—and
that is you. Your sense of worth can go down only if you put
158 David D. Burns, M.D. yourself down. The real solution is to put an end to
your absurd inner harangue. Another distortion characteristic of angergenerating thoughts is mind reading—you invent motives that explains to your
satisfaction why the other person did what he or she did. These hypotheses are
satisfaction why the other person did what he or she did. These hypotheses are
frequently erroneous because they will not describe the actual thoughts and
perceptions that motivated the other person. Due to your indignation, it may not
occur to you to check out what you are saying to yourself. Common explanations
you might offer for the other per- person's objectionable behavior would be "He
has a mean streak"; "She's unfair"; "He's just like that"; "She's stu- stupid";
"They're bad kids"; and so forth. The problem with these so-called explanations
is that they are just additional labels that don't really provide any valid
information. In fact, they are downright misleading. Here's an example: Joan got
hot under the collar when her husband told her he'd prefer to watch the Sunday
football game on TV rather than go with her to a concert. She felt miffed
because she told herself, "He doesn't love me! He always has to get his own
way! It's unfair!" The problem with Joan's interpretation is that it is not valid. He
does love her, he doesn't always get his way, and he isn't intentionally being
"unfair." On this particular Sunday the Dallas Cowboys are locking spurs with
the Pitts- Pittsburgh Steelers, and he really wants to see that game! There's no
way he's going to want to get dressed and go to a concert. When Joan thinks
about her husband's motivations in such an illogical fashion, she creates two
problems for the price of one. She has to put up with the self-created illusion that
she's unloved in addition to missing out on his company at the concert. The third
form of distortion that leads to anger is mag- magnification. If you exaggerate
the importance of the negative event, the intensity and duration of your
emotional reaction may get blown up out of all proportion. For example, if you
are waiting for a late bus and you have an important
FEELING GOOD 159 appointment, you might tell yourself, "I can't take this!"
Isn't that a slight exaggeration? Since you are taking it, you can take it, so why
tell yourself you carift The inconven- inconvenience of waiting for the bus is bad
enough without creating additional discomfort and self-pity in this way. Do you
really want to fume like that? Inappropriate should and shouldn't statements
represent the fourth type of distortion that feeds your anger. When you find that
some people's actions are not to your liking, you tell yourself they "shouldn't"
have done what they did, or they "should have" done something they failed to
do. For example, suppose you register at a hotel and discover they lost the record
of your reservation, and now there are no rooms available. You furiously insist,
"This shouldn't have happened! Those stupid goddam clerks!" Does the actual
deprivation cause your anger? No. The deprivation can only create a sense of
loss, disappointment, or inconvenience. Before you can feel anger, you must
necessarily make the interpretation you are entitled to get what you want in this
situation. Consequently, you see the goof-up on your reservation as an injustice.
situation. Consequently, you see the goof-up on your reservation as an injustice.
This perception leads to your feeling angry. So what's wrong with that? When
you say the clerks shouldn't have made a mistake, you are creating unnecesunnecessary frustration for yourself. It's unfortunate your reserva- reservation
was lost, but it's highly unlikely anyone intended to treat you unjustly, or that the
clerks are especially stupid. But they did make an error. When you insist on
perfection from others, you will simply make yourself miserable and become
immobilized. Here's the rub: Your anger probably won't cause a room to appear
magically, and the incon- inconvenience of going to another hotel will be far less
than the misery you inflict on yourself by brooding for hours or days about the
lost reservation. Irrational should statements rest on your assumption that you
are entitled to instant gratification at all times. So on those occasions when you
don't get what you want, you go into panic or rage because of your attitude that
unless you
160 David D. Burns, M.D. get X, you will either die or be tragically deprived of
joy forever (X can represent love, affection, status, respect, promptness,
perfection, niceness, etc.). This insistence that your wants be gratified at all
times is the basis for much self-defeating anger. People who are anger-prone
often for- formulate their desires in moralistic terms such as this: If I'm nice to
someone, they should be appreciative. Other people have free will, and often
think and act in ways that aren't to your liking. All of your insistence that they
must fall in line with your desires and wishes will not produce this result. The
opposite is more often true. Your attempts to coerce and manipulate people with
angry de- demands most often will alienate and polarize them and make them
much less likely to want to please you. This is because other people don't like
being controlled or dominated any more than you do. Your anger will simply
limit the creative possibilities for problem solving. The perception of unfairness
or injustice is the ultimate cause of most, if not all, anger. In fact, we could
define anger as the emotion which corresponds in a one-to-one manner to your
belief that you are being treated unfairly. Now we come to a truth you may see
either as a bitter pill or an enlightening revelation. There is no such thing as a
universally accepted concept of fairness and justice. There is an undeniable
relativity of fairness, just as Einstein showed the relativity of time and space.
Einstein postu- postulated—and it has since been experimentally validated—
there is no "absolute time" that is standard throughout the uni- universe. Time
can appear to "speed up" and "slow down," and is relative to the frame of
reference of the observer. Similarly, "absolute fairness" does not exist.
"Fairness" is relative to the observer, and what is fair to one person can appear
quite unfair to another. Even social rules and moral strictures which are accepted
quite unfair to another. Even social rules and moral strictures which are accepted
within one culture can vary substantially in another. You can protest that this is
not the case and insist that your own personal moral system is universal, but it
just ain't so! Here's proof: When a lion devours a sheep, is this unfair?
FEELING GOOD 161 From the point of view of the sheep, it is unfair, he's
being viciously and intentionally murdered with no provocation. From the point
of view of the lion, it is fair. He's hungry, and this is the daily bread he feels
entitled to. Who is ''right"? There is no ultimate or universal answer to this
question because there's no "absolute fairness" floating around to resolve the
issue. In fact, fairness is simply a perceptual interpretation, an abstraction, a selfcreated con- concept. How about when you eat a hamburger? Is this "un-
"unfair"? To you, it's not. From the point of view of the cow, it certainly is (or
was)! Who's "right"? There is no ultimate "true" answer. In spite of the fact that
"absolute fairness" does not exist, personal and social moral codes are important
and useful. I am not recommending anarchy. I am saying that moral statements
and judgments about fairness are stipulations, not objective facts. Social moral
systems, such as the Ten Commandments, are essentially sets of rules that
groups decide to abide by. One basis for such systems is the en- enlightened selfinterest of each member of the group. If you fail to act in a manner that takes
into account the feelings and interests of others you are likely to end up less
happy because sooner or later they will retaliate when they notice you are taking
advantage of them. A system which defines "fairness" varies in its generality
depending on how many people accept it. When a rule of behavior is unique to
one person, other people may see it as eccentric. An example of this would be
my patient who washes her hands ritualistically over fifty times a day to "set
things right" and to avoid extreme feelings of guilt and anxiety. When a rule is
nearly universally accepted it becomes part of a general moral code and may
become a part of the body of law. The prohibition against murder is an example.
Nevertheless, no amount of general acceptance can make such systems
"absolute" or "ultimately valid" for everyone under all circumstances. Much
everyday anger results when we confuse our own personal wants with general
moral codes. When you get
162 David D. Burns, M.D. mad at someone and you claim that they are acting
"un- "unfairly," more often than not what is really going on is that they are
acting "fairly" relative to a set of standards and a frame of reference that differs
from yours. Your assump- assumption that they are "being unfair" implies that
your way of looking at things is universally accepted. For this to be the case,
everyone would have to be the same. But we aren't. We all think differently.
When you overlook this and blame the other person for being "unfair" you are
When you overlook this and blame the other person for being "unfair" you are
unnecessarily polarizing the interaction because the other person will feel
insulted and defensive. Then the two of you will argue fruitlessly about who is
"right." The whole dispute is based on the illusion of "absolute fairness."
Because of your relativity of fairness, there is a logical fallacy that is inherent in
your anger. Although you feel convinced the other guy is acting unfairly, you
must realize he is only acting unfairly relative to your value system. But he is
operating from his value system, not yours. More often than not, his
objectionable action will seem quite fair and reasonable to him. Therefore, from
his point of view— which is his only possible basis for action—what he does is
"fair.'' Do you want people to act fairly? Then you should want him to act as he
does even though you dislike what he does, since he is acting fairly within his
system! You can work to try to convince him to change his attitudes and
ultimately modify his standards and his actions, and in the meantime you can
take steps to make certain you won't suffer as a result of what he does. But when
you tell yourself, "He's acting unfairly," you are fooling yourself and you are
chasing a mirage! Does this mean that all anger is inappropriate and that the
concepts of "fairness" and "morality" are useless be- because they are relative?
Some popular writers do give this impression. Dr. Wayne Dyer writes: We are
conditioned to look for justice in life and when it doesn't appear, we tend to feel
anger, anxiety or
FEELING GOOD 163 frustration. Actually, it would be equally productive to
search for the fountain of youth, or some such myth. Justice does not exist. It
never has, and it never will. The world is simply not put together that way.
Robins eat worms. That's not fair to the worms. . . . You have only to look at
nature to realize there is no justice in the world. Tornadoes, floods, tidal waves,
droughts are all unfair.* This position represents the opposite extreme, and is an
example of all-or-nothing thinking. It's like saying—throw your watches and
clocks away because Einstein showed that absolute time does not exist. The
concepts of time and fairness are socially useful even though they do not exist in
an absolute sense. In addition to this contention that the concept of fairness is an
illusion, Dr. Dyer seems to suggest that anger is use- useless: You may accept
anger as a part of your life, but do you realize it serves no utilitarian purpose? . .
. You do not have to possess it, and it serves no purpose that has anything to do
with being a happy, fulfilled person. . . . The irony of anger is that it never works
in changing others. . . . ** Again, his arguments seem to be based on cognitive
dis- distortion. To say anger serves no purpose is just more all-or- nothing
thinking, and to say it never works is an over- generalization. Actually, anger
can be adaptive and productive in certain situations. So the real question is not
can be adaptive and productive in certain situations. So the real question is not
4'Should I or should I not feel anger?" but rather "Where will I draw the line?"
*Dr. Wayne W. Dyer, Your Erroneous Zones (New York: Avon Books, 1977),
p. !73 **Ibid , pp 218-220
164 David D. Burns, M.D. The following two guidelines will help you to
determine when your anger is productive and when it is not. These two criteria
can help you synthesize what you are learning and to evolve a meaningful
personal philosophy about anger: 1. Is my anger directed toward someone who
has know- knowingly, intentionally, and unnecessarily acted in a hurt- hurtful
manner? 2. Is my anger useful? Does it help me achieve a desired goal or does it
simply defeat me? Example: You are playing basketball, and a fellow on the
other team elbows you in the stomach intentionally so as to upset you and get
you off your game. You may be able to channel your anger productively so you
will play harder and win. So far your anger is adaptive.* Once the game is over,
you may no longer want that anger. Now it's maladaptive. Suppose your threeyear-old son runs mindlessly into the street and risks his life. In this case he is
not intentionally inflicting harm. Nevertheless, the angry mode in which you
express yourself may be adaptive. The emotional arousal in your voice conveys
a message of alarm and importance that might not come across if you were to
deal with him in a calm, totally objective manner. In both these examples, you
chose to be angry, and the magnitude and expression of the emotion were under
your control. The adaptive and positive effects of your anger differentiate it from
hostility, which is impulsive and uncontrolled and leads to aggression. Suppose
you are enraged about some senseless violence you read about in the paper. Here
the act seems clearly hurtful and immoral. Nevertheless, your anger may not be
adaptive if—as is usually the case—there is nothing you plan to do about it. If,
in contrast, you choose to help the '"Adaptive means useful and self-enhancing;
maladaptive means useless and self-destructive.
FEELING GOOD 165 victims or begin a campaign to fight crime in some way,
your anger might again be adaptive. Keeping these two criteria in mind, let me
give you a series of methods you can use to reduce your anger in those situations
where it is not in your best interest. Develop the Desire. Anger can be the most
difficult emotion to modify, because when you get mad you will be like a furious
bulldog, and persuading you to stop sinking your teeth into the other person's leg
can be extremely tough. You wont really want to rid yourself of those feelfeelings because you will be consumed by the desire for re- revenge. After all,
because anger is caused by what you perceive to be unfair, it is a moral emotion,
and you will be extremely hesitant to let go of the righteous feeling. You will
and you will be extremely hesitant to let go of the righteous feeling. You will
have the nearly irresistible urge to defend and justify your anger with religious
zeal. Overcoming this will require an act of great willpower. So why bother?
The first step: Use the double-column technique to make a list of the advantages
and disadvantages of feeling angry and acting in a retaliatory manner. Consider
both the short- and long-term consequences of your anger. Then review the list
and ask yourself which are greater, the costs or the benefits? This will help you
determine if your resentment is really in your best self-interest. Since most of us
ulti- ultimately want what's best for us, this can pave the way for a more peaceful
and productive attitude. Here's how it works. Sue is a thirty-one-year-old woman
with two daughters from a previous marriage. Her husband, John, is a hardworking lawyer with one teenage daughter from his prior marriage. Because
John's time is very limited, Sue often feels deprived and resentful. She told me
she felt he wasn't giving her a fair shake in the marriage because he was not
giving her enough of his time and attention. She listed the advantages and
disadvantages of her irritability in Figure 7-2. She also made a list of the positive
consequences that
166 David D. Burns, M.D. Figure 7-2. The Anger Cost-Benefit Analysis.
Advantages of My Anger 1. It feels good 2. John will understand that 1 strongly
disapprove of him. 3. I have the right to blow my stack if 1 want to. 4. He'll
know I'm not a doormat. 5. I'll show him I won't stand for being taken advantage
of 6. Even though 1 don't get what 1 want, 1 can at least have the satsatisfaction of getting revenge 1 can make him squirm and feel hurt like I do.
Then he'll have to shape up. 1 2. 3 4 5 6 7. 8 9 Disadvantages of My Anger 1
will be souring my relationship with John even more He will want to reject me. 1
will often feel guilty and down on my- myself after 1 blow my stack He will
probably retaliate against me and get angry right back, since he doesn't like
being taken advantage of either My anger inhibits both of us from corcorrecting the problem that caused the anger in the first place. It prevents
resolution and sidetracks us from dealing with the issues. One minute I'm up,
one minute I'm down My irritability makes John and the people around me never
know what to expect. I get labeled as moody and cranky and spoiled and
immature. They see me as a childish brat 1 might make neurotics out of my kids
As they grow up, they may resent my explosions and see me as someone to stay
away from rather than to go to for help. John may leave me if he gets enough of
my nagging and bitching. The unpleasant feelings 1 create make me teel
miserable. Life becomes a sour and bitter experience, and 1 miss out on the joy
and creativity I used to prize so highly. might result from eliminating her anger:
A) People will like me better. They will want to be near me; B) I will be more
predictable; C) I will be in better control of my emotions; D) I will be more
predictable; C) I will be in better control of my emotions; D) I will be more
relaxed; E) I will be more comfortable with myself; F) I will be viewed as a
positive, nonjudg- mental, practical person; G) I will behave more often as an
adult than as a child who has to get what it wants; (8) I will
FEELING GOOD 167 influence people more effectively, and I'll get more of
what I want through assertive, calm, rational negotiation than through tantrums
and demands; and (9) my kids, husband, and parents will respect me more. As a
result of this as- assessment, Sue told me she was convinced that the price of her
anger substantially exceeded the benefits. It is crucial that you perform this same
type of analysis as a first step in coping with your anger. After you list the
advantages and disadvantages of your anger, give yourself the same test. Ask
yourself, if the upsetting situation that provokes me doesn't change immediately,
would I be will- willing to cope with it instead of getting angry? If you can
answer yes, then you are clearly motivated to change. You will probably succeed
in gaining greater inner peace and self-esteem, and you will increase your
effectiveness in life. This choice is up to you. Cool Those Hot Thoughts. Once
you've decided to cool down, an invaluable method that can help you is to write
down the various "hot thoughts" that are going through your mind when you are
upset. Then substitute less upset- upsetting, more objective "cool thoughts,"
using the double- column method (Figure 7-3). Listen for those "hot thoughts"
with your "third ear" so as to tune in to the antagonistic statements that go
through your head. Record this private dialogue without any censorship. I'm sure
you'll notice all kinds of highly colorful language and vengeful fantasies—write
them all down. Then substitute "cool thoughts" that are more objective and less
inflammatory. This will help you feel less aroused and overwhelmed. Sue used
this technique to deal with the frustration she felt when John's daughter, Sandy,
acted manipulative and wrapped John around her finger. Sue kept telling him to
be more assertive with Sandy and less of a soft touch, but he often reacted
negatively to her suggestions. He felt Sue was nagging and making demands to
get her way. This made him want to spend even less time with her, which
contrib- contributed to a vicious cycle.
Figure 7-3. Sue wrote down her "Hot Thoughts" when her hus- husband acted
like a soft touch in response to his teenage daughter's selfish manipulations.
When she substituted less upsetting "Cool Thoughts," her jealousy and
resentment diminished. Hot Thoughts Cool Thoughts 1. How dare he not listen 1
to me! 2. Sandy lies. She says 2. she's working, but she's not. Then she expects
John's help. 3. John doesn't have much 3. free time and if he spends it helping
her, I will have to be alone and take care of my kids by myself. 4. Sandy's taking
her, I will have to be alone and take care of my kids by myself. 4. Sandy's taking
time 4. away from me. 5. John's a schmuck. 5. Sandy uses people. 6. I can't stand
it! 6 7. I'm a baby brat. I de- 7 serve to feel guilty. Easily. He's not obliged to do
everything my way. Besides he is listening, but he's being defensive because I'm
acting so pushy. It's her nature to lie and to be lazy and to use people when it
comes to work in school. She hates work. That's her prob- problem. So what. I
like being alone. I'm capable of taking care of my kids by myself. I'm not
helpless. I can do it. Maybe he'll want to be with me more if I learn not to get
angry all the time. That's true. But I'm a big girl. I can tolerate some time alone. I
wouldn't be so upset if he were working with my kids. He's a big boy. If he
wants to help her he can. Stay out of it. It's not my business. I can. It's only
temporary. I've stood worse. I'm entitled to be immature at times. I'm not perfect
and I don't need to be. It's not nec- necessary to feel guilty. This won't help.
FEELING GOOD 169 Sue wrote down the "hot thoughts" that made her feel
jealous and guilty (see Figure 7-3). As she substituted "cool thoughts," she felt
better, and this served as an antidote to her urge to try to control John. Although
she still felt he was wrong in letting Sandy manipulate him, she decided he had
the "right" to be "wrong." Consequently, Sue pushed John less, and he began to
feel less pressured. Their rela- relationship improved and ripened in a climate of
mutual free- freedom and respect. Simply talking back to her "hot thoughts" was,
of course, not the only ingredient that led to a suc- successful second marriage
for Sue and John, but it was a necessary and gigantic first step without which
both of them could have easily ended up stalemated again! You can also use the
more elaborate chart, the "Daily Record of Dysfunctional Thoughts/' to deal with
your anger (see Figure 7-4, page 170). You can describe the provoc- provocative
situation and assess how angry you feel before and after you do the exercise.
Figure 7-4 shows how a young woman coped with her frustration when she was
dealt with tersely by a prospective employer over the telephone. She reported
that pinpointing her "hot thoughts" and putting the lie to them helped her nip an
emotional explosion in the bud. This prevented the fretting and fuming that
normally would have soured her entire day. She told me, "Before I did the
exercise I thought my enemy was the man on the other end of the phone. But I
learned that / was treating myself ten times worse than he was. Once I
recognized this, it was relatively easy to substitute cooler thoughts, and I
surprised myself by feeling a whole lot better right away!" Imagining
Techniques. Those negative "hot thoughts" that go through your mind when you
are angry represent the script of a private movie (usually X-rated) that you
project onto your mind. Have you ever noticed the picture on the screen? The
images, daydreams, and fantasies of revenge and violence can be quite colorful
images, daydreams, and fantasies of revenge and violence can be quite colorful
indeed! You may not be aware of these mental pictures unless
Figure 7-4. Daily Record of Dysfunctional Thoughts. Provocative Situation
Emotions Hot Thoughts Cool Thoughts Outcome Called ad in paper for pantime med- medical transcriptionist. Ad said—needs "some experience." First, the
man wouldn't even tell me what kind of company it was Then he turned me
down for job 'cause he didn't think 1 had enough experience! Anger hatred
frustration 98% I. That jerk \ Who the hell does he think 1. Why am I getting so
excited? I he is\ I have more than enough ex- didn't like the tone of his voice
penence anyway. So he didn't allow me to really explain my experience. I know
I'm good So it's not my fault I didn't get the job—it's his. Besides, would I want
to work for someone like that? 2 That was the best ad in the paper, 2. I'm
blowing things out of pro- and I lost it. 3. My parents will kill me. 4. I'm going to
cry. portion. There are many other jobs I can get. 3. Of course they won't. At
least I'm trying. 4. Now isn't that ridiculous? Why should someone make me
cry? This isn't worth crying over. I know my worth—that's what counts. Anger
hatred frustration 15%
FEELING GOOD 171 you look for them. Let me illustrate. Suppose I ask you to
visualize a red apple in a brown basket right now. You can do this with your
eyes open or closed. There! Do you see it now? That's what I'm referring to.
Most of us have these visual images all day long. They are a part of normal conconsciousness, the pictorial illustrations of our thoughts. For example, memories
sometimes occur to us as mental pic- pictures. Conjure up an image now of some
vivid past event— your high-school graduation, your first kiss (do you still
remember it?), a long hike, etc. Do you'see it now? These images can affect you
strongly, and their influence can be positively or negatively arousing, just like
erotic dreams or nightmares. The exhilarating effect of a positive image can be
intense. For instance, on your way to an amusement park you might have an
image of that first daz- dazzling descent down the roller coaster, and you may
expe- experience the excited rush in your belly. The daydream actually creates
the pleasurable anticipation. Similarly, negative im- images play a powerful role
in your level of emotional arousal. Visualize right now someone whom you've
gotten good and mad at sometime in your life. What images come to mind? Do
you imagine punching them in the nose or tossing them into a vat of boiling oil?
These daydreams actually keep your anger alive long after the initial insult has
occurred. Your sense of rage may eat away at you for hours, days, months, or
even years after the irritating event has long since passed. Your fantasies help
keep the pain alive. Every time you fantasize about the occurrence you shoot
new doses of arousal into your system. You become like a cow chewing on
new doses of arousal into your system. You become like a cow chewing on
poison cud. And who is creating this anger? You are because you chose to put
those images in your mind! For all you know, the person you are mad at lives in
Timbuktu, or maybe isn't even alive anymore, so he or she could hardly be the
culprit! You are the director and producer of the film now, and, what's worse,
you're the only one in the audience. Who has to watch and experience all the
arousal? YOU EX)! You're the one who's subjected to a continual clenching, a
172 David D. Burns, M.D. tightening of back muscles, and an outpouring of
adrenal hormones into the bloodstream. You're the one whose blood pressure is
going up. IN A NUTSHELL: You're making yourself hurt. Do you want to keep
this up? If not, you will want to do something to reduce the anger- generating
images that you are projecting onto your mind. One helpful technique is to
transform them in a creative way so they become less upsetting. Humor
represents one powerful tool you can use. For example, instead of imagimagining wringing the neck of the person you are furious with, fantasize that he
is walking around in diapers in a crowded department store. Visualize all the
details: the potbelly, the diaper pins, the hairy legs. Now what's happening to
your anger? Is that a broad smile spreading across your face? A second method
involves thought stoppage. As you no- notice the images crossing your mind
each day, remind your- yourself that you have the right to turn the projector off.
Think about something else. Find someone and engage him or her in
conversation. Read a good book. Bake bread. Go jogging. When you don't
reward the anger images with your arousal, they will recur less and less often.
Instead of dwelling on them, think about an upcoming event that excites you, or
switch to an erotic fantasy. If the upsetting memory is per- persistent, engage in
vigorous physical exercise such as push- pushups, rapid jogging, or swimming.
These have the additional benefit of rechanneling your potentially hurtful arousal
in a highly beneficial way. Rewrite the Rules. You may frustrate and upset
yourself needlessly because you have an unrealistic rule about per- personal
relationships that causes you to be let down all the time. The key to Sue's anger
was her belief she was entitled to John's love because of her rule "If I'm a good
and faithful wife, I deserve to be loved." As a result of this innocent-sounding
assumption, Sue experienced a constant sense of danger in her marriage bebecause anytime John wasn't giving her an appropriate helping of love and
attention, she would experience it as a confirFEELING GOOD 173 mation of her inadequacy. She would then manipulate
and demand attention and respect in a constant battle to defend herself against a
loss of self-esteem. Intimacy with him became like slipping slowly toward the
loss of self-esteem. Intimacy with him became like slipping slowly toward the
edge of an icy cliff. No wonder she was desperately grabbing onto John, and no
wonder she would explode when she sensed his indiffer- indifference—didn't he
realize her life was at stake? In addition to the intense unpleasantness that her
"love" rule created, it didn't work well in the long run. For a while Sue's
manipulations did, in fact, get her some of the atten- attention she craved. After
all, she could intimidate John with her emotional explosions, she could punish
him with her icy withdrawal, and she could manipulate him by arousing his
guilt. But the price Sue pays is that the love she receives isn't— and can't—be
given freely and spontaneously. He will feel exhausted, trapped, and controlled.
The resentment he's been storing up will press for release. When he stops buying
into her belief that he has to give in to her demands, his desire for freedom will
overpower him, and he will explode. The destructive effects of what passes for
love never cease to amaze me! If your relationships are characterized by this
cyclic ten- tension and tyranny, you may be better off rewriting the rules. If you
adopt a more realistic attitude, you can end your frustration. It's much easier than
trying to change the world. Sue decided to revise her "love" rule in the following
way: "If I behave in a positive manner toward John, he will respond in a loving
way a good bit of the time. I can still respect myself and function effectively
when he doesn't." This formulation of her expectations was more realistic and
didn't put her moods and self-esteem at the mercy of her husband. The rules that
get you into interpersonal difficulty often won't appear to be malignant. On the
contrary, they often seem highly moral and humanistic. I recently treated a
woman named Margaret who had the notion that "marriages should be fifty-fifty.
Each partner should do for the other
174 David D. Burns, M.D. equally." She applied this rule to all human
relationships. 4 If I do nice things for people, they should reciprocate." So what's
wrong with that? It certainly sounds "reason- "reasonable" and "fair." It's kind of
a spin-off from the Golden Rule. Here's what's wrong with it: It's an undeniable
fact that human relationships, including marriages, are rarely spontaneously
"reciprocal" because people are different. Reciprocity is a transient and
inherently unstable ideal that can only be approximated through continued effort.
This involves mutual consensus, communication, compromise, and growth. It
requires negotiation and hard work. Margaret's problem was that she didn't
recognize this. She lived in a fairytale world where reciprocity existed as an
assumed reality. She went around always doing good things for her husband and
others and then waited for their reciprocity. Unfortunately, these unilateral
contracts fell apart because other people usually weren't aware that she expected
to be repaid. For example, a local charity organization advertised for a salaried
to be repaid. For example, a local charity organization advertised for a salaried
assistant director to start in several months. Mar- Margaret was quite interested
in this position and submitted her application. She then gave large amounts of
her time doing volunteer work for the organization and assumed that the other
employees would "reciprocate" by liking and re- respecting her, and that the
director would "reciprocate" by giving her the job. In reality, the other
employees did not respond to her warmly. Perhaps they sensed and resented her
attempt to control them with her "niceness" and virtue. When the director chose
another candidate for the position, she hit the roof and felt bitter and
disillusioned because her "reciprocity" rule had been violated! Since her rule
caused her so much trouble and disap- disappointment she opted to rewrite it,
and to view reciprocity not as a given but as a goal she could work toward by
pursuing her own self-interest. At the same time she relin- relinquished her
demand that others read her mind and respond as she wanted. Paradoxically, as
she learned to expect less, she got more!
FEELING GOOD 175 Figure 7-5. Revising "Should Rules.' Self-Defeating
Should Rule Revised Version 1. If I'm nice to someone, 1 they should be
apprecia- appreciative. 2. Strangers should treat 2. me courteously. 3. If I work
hard for some- 3 thing, I should get it. 4. If someone treats me 4 unfairly, I
should get mad because I have the right to get mad and be- because it makes me
more human. 5. People shouldn't treat 5 me in ways I wouldn't treat them. It
would be nice if people were always appreciative, but this isn't realistic. They
will often be appreciative, but sometimes they won't be. Most strangers will treat
me courteously if I don't act like I have a chip on my shoulder. Occasionally
some sourpuss will act obnoxious. Why let this bother me? Life is too short to
waste time concen- concentrating on negative details. This is ridiculous. I have
no guarantee I'll always be suc- successful in everything. I'm not perfect and I
don't have to be. All human beings have the right to get mad whether or not
they're treated unfairly. The real issue is—is it to my ad- advantage to get mad?
Do I want to feel angry? What are the costs and benefits? Hogwash. Everyone
doesn't live by my rules, so why ex- expect they will? People will often treat me
as well as I treat them, but not always. If you have a "should" or "shouldn't" rule
that has been causing you disappointment and frustration, rewrite it in more
realistic terms. A number of examples to help you do this are shown in Figure 7-
5. You will notice that the sub176 David D. Burns, M.D. stitution of one word—"it would be nice */" in place
of "should"—can be a useful first step. Learn to Expect Craziness. As the anger
in Sue's rela- relationship with John cooled down, they became closer and more
loving. However, John's daughter, Sandy, responded to his increased intimacy by
loving. However, John's daughter, Sandy, responded to his increased intimacy by
even greater manipulations. She began to lie, borrowed money without returning
it; she sneaked into Sue's bedroom, went through drawers, and stole Sue's
personal items; she left the kitchen messy, etc. All these actions effectively got
Sue's goat because she told herself, "Sandy shouldn't act so sneaky. She's crazy!
It's unfair!" Sue's sense of frustration was the product of two necessary
ingredients: 1. Sandy's obnoxious behavior; 2. Sue's expectation that she should
act in a more mature way. Since the evidence suggested that Sandy wasn't about
to change, Sue had only one alternative: She could discard her unrealistic
expectation that Sandy behave in an adult, ladylike fashion! She decided to write
the following memo to herself entitled: Why Sandy Should Act Obnoxiously It
is Sandy's nature to be manipulative because she be- believes that she's entitled
to love and attention. She believes that getting love and attention is a matter of
life and death. She thinks she needs to be the center of attention in order to
survive. Therefore, she will see any lack of love as unfair and a great danger to
her sense of self-esteem. Because she feels she has to manipulate in order to get
attention, she should act in a manipulative way. Therefore, I can expect and
predict that she will continue to act this way until she changes. Since it is
unlikely that she will
FEELING GOOD 177 change in the near future, I can expect her to continue to
behave this way for a period of time. Therefore, I will have no reason to feel
frustrated or surprised because she will be acting the way she should act.
Furthermore, I want all humans including Sandy to act in a manner that they
believe to be fair. Sandy feels she's entitled to more attention. Since her
obnoxious behavior is based on her sense of entitlement, I can remind myself
that what she does is fair from her point of view. Finally, I want my moods to be
under my control, not hers. Do I want to make myself feel upset and angry at her
"fair, obnoxious" behavior? No! Therefore, I can begin to change the way I react
to her: 1. I can thank her for stealing since this is what she "should" do! 2. I can
laugh to myself about her manipulations since they are childish. 3. I can choose
not to be angry unless it is my decision to use the anger to accomplish a specific
goal. 4. If I feel a loss of self-esteem due to Sandy's manip- manipulations, I can
ask myself, Do I want to give a child such power over me? What is the desired
effect of such a memorandum? Sandy's provocative actions are probably
knowingly mali- malicious. Sandy consciously targets Sue because of the reresentment and helpless frustration she feels. When Sue gets upset, she
paradoxically gives Sandy exactly what she wants! She can greatly reduce her
frustration as she changes her expectations. Enlightened Manipulation. You may
fear that you will be a pushover if you change your expectations and give up
fear that you will be a pushover if you change your expectations and give up
your anger. You might sense that other people would take advantage of you.
This apprehension reflects your sense of inadequacy as well as the fact that you
probably have not
178 David D. Burns, M.D. been trained in more enlightened methods of going
after what you want. You probably believe that if you didn't make demands on
people you'd end up empty-handed. So what's the alternative? Well, as a starting
point let's review the work of Dr. Mark K. Goldstein, a psychologist who has
done some brilliant and creative clinical research on the behavioral conditioning
of husbands by wives. In his work with neglected and angry wives, he became
aware of the self-defeating methods they used to get what they wanted from their
husbands. He asked himself: What have we learned in the laboratory about the
most effective scientific methods for influencing all living organisms, including
bac- bacteria, plants, and rats? Can we apply these principles to wayward and
sometimes brutal husbands? The answer to these questions was straightforward
—re- straightforward—reward the desired behavior instead of punishing the
undesired behavior. Punishment causes aversion and resentment and brings
about alienation and avoidance. Most of the deprived and abandoned wives he
treated were misguidedly trying to punish their husbands into doing what they
wanted. By switching them to a reward model in which the desired behavior got
copious attention, he observed some dramatic turnabouts. The wives Dr.
Goldstein treated were not unique. They were ensnarled in the ordinary marital
conflicts that most of us confront. These women had a long history of giving
their spouses attention either indiscriminately or, in some cases, primarily in
response to undesirable behavior. A ma- major shift had to occur in order for
them to elicit the kind of response they desired from their husbands but were not
getting. By keeping meticulous scientific records of their interactions with their
husbands, the women were able to achieve control over how they responded.
Here's how it worked for one of Dr. Goldstein's patients. After years of fighting,
wife X reported she lost her husband. He abandoned her and moved in with his
girl friend. His primary interactions with wife X had centered around abuse and
indifference. It appeared on the surface as if he didn't
FEELING GOOD 179 care much about her. Nevertheless, he did call her occaoccasionally, indicating he might have some interest in her. She had the choice
of cultivating this attention or crushing it further by continued inappropriate
responses. Wife X defined her goals. She would experiment to see if she could in
fact get her husband back. The first milestone would be to determine if she could
effectively increase his rate of contact with her. She measured meticulously the
effectively increase his rate of contact with her. She measured meticulously the
frequency and duration of his every telephone call and visit home, recording this
information on a piece of graph paper taped to the refrigerator door. She
carefully assessed the crucial relationship between her behavior (the stimulus)
and the frequency of his contacts (the response). She initiated no contacts with
him at all on her own, but instead responded positively and affectionately to his
calls. Her strategy was straightforward. Rather than noticing and reacting to all
the things about him that she didn't like, she began to reinforce systematically
those that she did like. The rewards she used were all the things that turned him
on—praise, food, sex, affection, etc. She began by responding to his rare calls in
an upbeat, positive, complimentary manner. She flattered and encourencouraged him. She avoided any criticism, argument, demands, or hostility, and
found a way to agree with everything he said, using the disarming technique
described in Chapter 7. Initially she terminated all these calls after five to ten
min- minutes to ensure the likelihood the conversations would not deteriorate
into an argument or become boring to him. This guaranteed that her feedback
would be pleasant to him, and that his response to it would not be suppressed or
eliminated. After she did this a few times, she noticed her husband began to call
more and more frequently because the calls were positive, rewarding
experiences for him. She noted this increased rate of telephoning on her graph
paper just as a scientist observes and documents the actions of an experimental
rat. As his phone calls increased, she began to feel encouraged, and some of her
irritation and resentment melted away.
180 David D. Bums, M.D. One day he appeared at the house and according to
her plan, she announced, "I'm so happy you dropped by be- because I just
happen to have a fresh, fancy imported Cuban cigar in the freezer for you. It's
the expensive type you really like." She actually had a whole box of them
waiting so she was able to repeat this each time he visited—re- visited—
regardless of why or when he came. She noticed the frequency of his visits
substantially increased. In a similar manner, she continued to "shape" his bebehavior using rewards rather than coercion. She realized how successful she
had been when her husband decided to leave his girl friend and asked if he could
move back in with her. Am I saying that is the only way to relate and to
influence people? No—that would be absurd. It's just a pleasant spice, not the
whole banquet or even the main course. But it's a frequently overlooked delicacy
that few appetites can resist. There's no guarantee it will work—some situations
may be irreversible, and you can't always get what you want. At any rate, try the
upbeat reward system. You may be pleasantly surprised at the remarkable
effectiveness of your secret strategy. In addition to motivating the people you
care about to want to be around you, it will improve your mood because you
care about to want to be around you, it will improve your mood because you
learn to notice and focus on the positive things that others do rather than dwell
on their negatives. "Should" Reduction. Because many of the thoughts which
generate your anger involve moralistic "should" statements, it will help you to
master some "should" re- removal methods. One way is to make a list, using the
double- column method, of all the reasons why you believe the other person
"shouldn't" have acted as he did. Then challenge these reasons until you can see
why they are unrealistic and don't actually make good sense. Example: Suppose
the carpenter on your new house did a sloppy job on the kitchen cabinets. The
doors are poorly aligned and don't close properly. You feel irate because you see
this as "unfair." After all, you paid full union wages, so you feel entitled to
excellent workmanship from
FEELING GOOD 181 Figure 7-6. Reasons He Should Have Taken More Pride
in His Work Rebuttals I. Because I paid top dollar. 1 2. Because it's only decent
to 2. do a good job. 3. Because he should make 3. sure he gets it done right. 4.
Because / would if 1 were 4. a carpenter. 5. Because he should care 5, more
about his product. 6. So why must / get the one 6. who does sloppy work? He
gets paid the same wage whether or not he takes ex- extra pride in his work. He
probably felt he did an adequate job. And the paneling he did actually looks
quite decent. Why should he? But he's not me—he's not trying to meet my stanstandards. There's no reason for him to care more. Some carpen- carpenters care
a lot about their work, and for others it's just a job. All the people who worked
on your house didn't do sloppy work. You can't ex- expect to get 100 percent
top- notch people. That would just be unrealistic. a top craftsman. You fume as
you tell yourself, "The lazy bastard should take some pride in his work. What's
the world coming to?" You list the reasons and rebuttals de- detailed in Figure 7-
6. The rationale for eliminating your "should" statement is simple: It's not true
that you are entitled to get what you want just because you want it. You'll have
to negotiate. Call the carpenter, complain, and insist the job be corrected.
182 David D. Burns, M.D. But don't double your trouble by making yourself
exces- excessively hot and bothered. The carpenter probably wasn't trying to hurt
you, and your anger might simply polarize him and put him on the defensive.
After all, half of all the carpenters (and psychiatrists, secretaries, writers, and
den- dentists, etc.) throughout human history have been below av- average. Do
you believe that? It's true by definition because * 'average" is defined as the
halfway point! It's ludicrous to fume and complain that this particular carpenter's
average talent is "unfair," or that he "should" be other than he is. Negotiating
Strategies. At this point you may be bris- bristling because you are thinking,
Strategies. At this point you may be bris- bristling because you are thinking,
"Well! That's a fine kettle offish! Dr. Burns seems to be telling me I can find
happiness by believing that lazy, incompetent carpenters should do mediocre
work. After all, it's their nature, the good doctor claims! What weak-spined hog
wash! I'm not going to be stripped of my human dignity and let people walk all
over me and get away with second-rate crappy work I'm paying a fortune for."
Cool down! Nobody's asking you to let the carpenter pull the wool over your
eyes. If you want to exert your influence in an effective way instead of moping
angrily and creating inner turmoil, a calm, firm, assertive approach will usually
be the most successful. Moralistic "shoulding," in contrast, will simply aggravate
you and polarize him, and cause him to feel defensive and to counterattack.
Remember—fighting is a form of intimacy. Do you really want to be so intimate
with this carpenter? Wouldn't you prefer to get what you want instead? As you
stop consuming your energy in anger, you can focus your efforts on getting what
you want. The following negotiating principles can work effectively in such a
situ- situation: 1. Instead of telling him off, compliment him on what he did
right. It's an undeniable fact of human nature that few people can resist flattery
even if it's blatantly
FEELING GOOD 183 insincere. However, since you can find something good
about him or his work, you can make your com- compliment honest. Then
mention the problem with the cupboard doors tactfully, and calmly explain why
you want him to come back and correct the alignment. 2. Disarm him if he
argues by finding a way to agree with him regardless of how absurd his
statements are. This will shut him up and take the wind out of his sails. Then
immediately— 3. Clarify your point of view again calmly and firmly. Repeat the
above three techniques over and over in vary- varying combinations until the
carpenter finally gives in or an acceptable compromise is reached. Use
ultimatums and in- intimidating threats only as a last resort, and make sure you
are ready and willing to follow through when you do. As a general principle, use
diplomacy in expressing your dis- dissatisfaction with his work. Avoid labeling
him in an in- insulting way or implying he is bad, evil, malignant, etc. If you
decide to tell him about your negative feelings, do so objectively without
magnification or an excess of inflam- inflammatory language. For example, "I
resent shoddy work when I feel you have the ability to do a good professional
job" is far preferable to "You mother ! Your work is an outrage." In the
following dialogue I will identify each of these techniques. You: I was pleased
with how some of the work came out, and I'm hopeful I'll be able to tell other
people I was happy with the whole job. The paneling was especially well done.
I'm a little concerned about the kitchen cab- cabinets, however. (Compliment)
I'm a little concerned about the kitchen cab- cabinets, however. (Compliment)
Carpenter: What seems to be the trouble? You: The doors aren't lined up, and
many of the handles are on crooked.
184 David D. Burns, M.D. Carpenter: Well, that's about the best I can do on
those kinds of cabinets. They're mass-produced, and they just aren't made the
best. You: Well, that's true. They aren't as well made as a more expensive type
might be. (Dis- (Disarming technique) Nevertheless, they aren't acceptable this
way, and I'd appreciate it if you'd do something to make them more presentable.
(Clarification; tact) Carpenter: You'll have to talk to the manufacturer or the
builder. There's nothing I can do about it. You: I can understand your frustration
(Disarm- (Disarming technique), but it's your responsibility to complete these
cabinets to our satisfac- satisfaction. They're simply not acceptable. They look
shoddy, and they don't close properly. I know it's an inconvenience, but my poposition is that the job can't be considered complete and the bill won't be paid
until you've corrected it. (Ultimatum) I can see from your other work that you
have the skill to make them look right in spite of the extra time it will take. That
way we'll be com- completely satisfied with your work, and we can give you a
good recommendation. (Com- (Compliment) Try these negotiating techniques
when you are at log- loggerheads with someone. I think you'll find they work
more effectively than blowing your stack, and you'll feel better because you'll
usually end up getting more of what you want. Accurate Empathy. Empathy is
the ultimate anger an- antidote. It's the highest form of magic described in this
book,
FEELING GOOD 185 and its spectacular effects are firmly entrenched in
reality. No trick mirrors are needed. Let's define the word. By empathy, I do not
mean the capacity to feel the same way someone else feels. This is sympathy.
Sympathy is highly touted but is, in my opinion, somewhat overrated. By
empathy, I do not mean acting in a tender, understanding manner. This is
support. Support is also highly valued and overrated. So what is empathy?
Empathy is the ability to comprehend with accuracy the precise thoughts and
motivations of other people in such a way that they would say, "Yes, that is
exactly where I'm coming from!" When you have this ex- extraordinary
knowledge, you will understand and accept without anger why others act as they
do even though their actions might not be to your liking. Remember, it is
actually your thoughts that create your anger and not the other person's behavior.
The amazing thing is that the moment you grasp why the other person is acting
that way, this knowledge tends to put the lie to your anger-producing thoughts.
You might ask, If it's so easy to eliminate anger through empathy, why do people
get so damn mad at each other every day? The answer is that empathy is difficult
get so damn mad at each other every day? The answer is that empathy is difficult
to acquire. As humans we are trapped in our own perceptions, and we react
automatically to the meanings we attach to what people do. Getting inside the
other person's skull requires hard work, and most people don't even know how to
do this. Do you? You will learn how in the next few pages. Let's start with an
example. A businessman recently sought help because of his frequent episodes
of angry out- outbursts and abusive behavior. When his family or employees
didn't do what he wanted, he'd bite their heads off. He usually succeeded in
intimidating people, and he enjoyed dominating and humiliating them. But he
sensed that his impulsive explosions ultimately caused problems for him because
of his reputation as a sadistic hothead. He described a dinner party he attended
where the waiter
186 David D. Burns, M.D. forgot to fill his wineglass. He felt a surge of rage
due to his thought, "The waiter thinks I'm unimportant. Who the hell does he
think he is anyway? I'd like to wring the mother 's neck." I used the empathy
method to demonstrate to him how illogical and unrealistic his angry thoughts
were. I suggested that we do some role-playing. He was to play the waiter, and I
would act the part of a friend. He was to try to answer my questions as truthfully
as possible. The following dia- dialogue evolved: David (playing the role of the
waiter's friend): I no- noticed that you didn't fill the wineglass of that
businessman there. Patient (playing the role of waiter): Oh, I see that I didn't fill
his glass. David: Why didn't you fill his glass? Do you think he is an
unimportant person? Patient (after a pause): Well, no, it wasn't that. I ac- actually
don't know much about him. David: But didn't you decide that he was an unimunimportant person and refuse to give him any wine because of that? Patient
(laughing): No, that isn't why I didn't give him any wine. David: Then why didn't
you give him wine? Patient (after thinking): Well, I was daydreaming about my
date for tonight. Furthermore, I was looking at that pretty girl across the table. I
was distracted by her low-cut dress, and I just overlooked his wineglass. This
role-playing episode created great relief for the pa- patient because by placing
himself in the waiter's shoes he was able to see how unrealistic his interpretation
had been. His cognitive distortion was jumping to conclusions (mind
FEELING GOOD 187 reading). He automatically concluded the waiter was
being unfair, which made him feel he had to retaliate to maintain his self-pride.
Once he acquired some empathy, he was able to see that his righteous
indignation was caused entirely and exclusively by his own distorted thoughts
and not the wait- waiter's actions. It is often extremely difficult for angry-prone
individuals to accept this at first because they have a nearly irresistible urge to
individuals to accept this at first because they have a nearly irresistible urge to
blame others and to retaliate. How about you? Does the idea that many of your
angry thoughts are invalid seem abhorrent and unacceptable? The empathy
technique can also be quite useful when the other person's actions appear more
obviously and inten- intentionally hurtful. A twenty-eight-year-old woman
named Melissa sought counseling around the time she was sepa- separating from
her husband, Howard. Five years earlier Melissa discovered that Howard was
having an affair with Ann, an attractive secretary who worked ip his building.
This rev- revelation was a heavy blow to Melissa, but to make matters even
worse, Howard was hesitant to make a clean break with Ann, and so the affair
dragged on for eight additional months. The humiliation and rage Melissa felt
during this period was a major factor that led to her ultimate decision to leave
him. Her thoughts ran along these lines: A) He had no right to act like that. B)
He was self-centered. C) It was unfair. D) He was a bad, rotten person. E) I must
have failed. In the course of a therapy session, I asked Melissa to play Howard's
role, and then I cross-examined her to see if she could explain precisely why he
had had the affair with Ann and acted as he did. She reported that as the roleplaying evolved, she suddenly saw where Howard had been coming from, and at
that moment her anger toward him completely vanished. After the session she
wrote a description of the dramatic disappearance of the anger she had harbored
for years: After Howard's affair with Ann presumably ended, he insisted on
continuing to see her and was still very
188 David D. Burns, M.D. much bound up with her. This was painful to me. It
made me feel that Howard really didn't respect me and considered himself more
important than I was. I felt that if he really did love me he wouldn't put me
through this. How could he continue to see Ann when he knew how miserable it
made me feel? I felt really angry at Howard and down on myself. When I tried
the empathy approach and played the role of Howard, I saw the "whole." I
suddenly saw things differently. When I imagined I was Howard, I could see
where he was coming from. Putting myself in his place, I saw the problem of
loving Melissa my wife, as well as Ann my lover. It dawned on me that Howard
was really trapped in a "can't-win" system created by his thoughts and feelings.
He loved me but was desperately attracted to Ann. As much as he wanted to he
couldn't stop seeing her. He felt very guilty and couldn't stop himself. He felt he
would lose if he left Ann, and he would lose if he left me. He was unwilling and
unable to come to terms with either form of loss, and it was his indecisiveness
rather than any inadequacy on my part which caused him to be slow in making
up his mind. The experience was a revelation for me. I really saw what had
happened for the first time. I knew Howard had not done anything deliberately to
happened for the first time. I knew Howard had not done anything deliberately to
hurt me, but had been incapable of doing anything other than what he did. I felt
good being able to see and understand this. I told Howard when I spoke to him
next. We both felt a lot better about this. I also got a really good feeling from the
experience with the empathy technique. It was very exciting. More real than
what I had seen before. The key to Melissa's anger was her fear of losing selfesteem. Although Howard had indeed acted in a genuinely
FEELING GOOD 189 negative manner, it was the meaning she attached to the
experience that caused her sense of grief and rage. She assumed that as a ''good
wife" she was entitled to a "good marriage." This is the logic that got her into
emotional trouble: Premise: If I am a good and adequate wife, my husband is
bound to love me and be faithful to me. Observation: My husband is not acting
in a loving, faithful way. Conclusion: Therefore, either I am not a good and adeadequate wife, or else Howard is a bad, immoral person because he is breaking
my "rule." Thus, Melissa's anger represented a feeble attempt to save the day
because within her system of assumptions, this was actually the only alternative
to suffering a loss of self- esteem. The only problems with her solution were (a)
she wasn't really convinced he was "no good"; (b) she didn't really want to write
him off since she loved him; and (c) her chronic sour anger didn't/^/ good, it
didn't look good, and it drove him farther away. Her premise that he would love
her as long as she was good was a fairy tale she had never thought to question.
The empathy method transformed her thinking in a highly beneficial way by
allowing her to relinquish the grandiosity inherent in her premise. His
misbehavior was caused by his distorted cognitions, not her inadequacy. Thus,
he was re- responsible for the jam he was in, not she! This sudden insight struck
her like a lightning bolt. The moment she saw the world through his eyes, her
anger vanished. She became a much smaller person in the sense that she no
longer saw herself as responsible for the actions of her husband and the people
around her. But at the same time she experienced a sudden increase in selfesteem. In the next session I decided to put her new insight to the acid test. I
confronted her with the negative thoughts that had originally upset her to see if
she could answer them effectively:
190 David D. Bumsr M.D. David: Melissa David: Melissa David: Melissa:
David: Melissa: David: Melissa: David: Howard could have stopped seeing her
sooner. He made a fool out of you. No—he couldn't stop because he was
trapped. He felt a tremendous obsession, and he was attracted to Ann. But then
he should* ve gone off with her and broken up with you so he could stop
torturing you. That would've been the only decent thing to do! He felt he couldn't
break off with me either because he loved me and was committed to me and to
break off with me either because he loved me and was committed to me and to
our children. But that was unfair, to keep you dangling so long. He didn't mean
to be unfair. It just happened. It just happened! What Pollyanna nonsense! The
fact is, he shouldn't have gotten into such a situation in the first place. But that's
where he was at. Ann represented excitement, and he felt bored and
overwhelmed by life at the time. Eventually one day he just couldn't resist her
flirting any more. He took one small step over the line in a moment of weakness,
and then the affair was off and run- running. Well, you are less of a person
because he wasn't faithful to you. This makes you inferior. It has nothing to do
with being less of a person. I don't have to get what I want all the time to be
worthwhile. But he never would have sought excitement elsewhere if you were
an adequate wife. You're undesirable and unlovable. You're second-rate, and
that's why your husband had an affair.
FEELING GOOD 191 Melissa: The fact is, he ultimately chose me over Ann,
but that doesn't make me any better than Ann, does it? Similarly, the fact that he
chose to deal with his problems by escaping doesn't mean that I'm unlovable or
less desirable. I could see that Melissa was clearly unruffled by my vigorous
attempts to get her goat, and this proved she had transcended this painful period
of her life. She traded in her anger for joy and self-esteem. Empathy was the key
that freed her from being trapped in hostility, self-doubt, and despair. Putting ft
All Together: Cognitive Rehearsal. When you get angry, you may feel you react
too rapidly to be able to sit down and assess the situation objectively and apply
the various techniques described in this chapter. This is one of the characteristics
of anger. Unlike depression, which tends to be steady and chronic, anger is much
more eruptive and episodic. By the time you are aware you are upset you may
already feel out of control. "Cognitive rehearsal" is an effective method for
solving this problem and for synthesizing and using the tools you have learned
thus far. This technique will help you learn to overcome your anger ahead of
time without actually ex- experiencing the situation. Then when the real thing
happens, you'll be prepared to handle it. Begin by listing an "anger hierarchy" of
the situations that most commonly trigger you off and rank these from -I-1 (the
least upsetting) to + 10 (the most infuriating), as shown in Figure 7-7. The
provocations should be ones that you'd like to handle more effectively because
your anger is maladaptive and undesirable. Start with the first item on the
hierarchy list that is the least upsetting to you, and fantasize as vividly as you
can that you are in that situation. Then verbalize your "hot thoughts" and write
them down. In the example given in Figure 7-7, you're feeling annoyed because
you're telling
192 David D. Burns, M.D. Figure 7-7. The Anger Hierarchy. + I-I sit in a
restaurant for fifteen minutes, and the waiter doesn't come. + 2-1 call a friend
who doesn't return the call. + 3-A client cancels an appointment at the last
minute without explanation. + 4-A client fails to show up for an appointment
without informing me. + 5-Someone criticizes me nastily. + 6-An obnoxious
group of juveniles crowd in front of me in line at a theater. -f- 7—1 read in the
paper about senseless violence, such as rape. + 8-A customer refuses to pay a bill
for goods I've deliv- delivered and skips town so that I can't collect. + 9-Local
delinquents repeatedly knock down my mailbox in the middle of the night over a
several-month period. There's nothing I can do to catch them or stop them. 4-10-
1 see a television report that someone—presumably a group of teenagers—have
broken into the zoo at night, and stoned a number of small birds and animals to
death and mutilated others. yourself, 'The goddamn mother ing waiters don't
know what the they're doing! Why don't the lazy bas- bastards get off their butts
and move? Who the hell do they think they are? Am I supposed to starve to
death before they'll give me a menu and a glass of water?" Next fantasize flying
off the handle, telling off the maitre d\ and storming out and slamming the
restaurant door. Now record how upset you feel between 0 and 100 per- percent.
Then go through the same mental scenario, but substitute more appropriate "cool
thoughts" and fantasize that you feel relaxed and unperturbed; imagine that you
handle the situa- situation tactfully, assertively, and effectively. For example,
FEELING GOOD 193 you might tell yourself, "The waiters don't seem to be
noticing me. Perhaps they're busy and overlooked the fact that I haven't gotten a
menu yet. No point in getting hot under the collar about this." Then instruct
yourself to approach the headwaiter and explain the situation assertively,
following these principles: Point out tactfully that you've been waiting; if he
explains they are busy, disarm him by agreeing with him; compli- compliment
him on the good business they are doing; and repeat your request for better
service in a firm but friendly way. Finally, imagine that he responds by sending a
waiter who apologizes and gives you top-notch VIP service. You feel good and
enjoy the meal. Now practice going through this version of the scenario each
night until you have mastered it and can fantasize handling the situation
effectively and calmly in this manner. This cognitive rehearsal will enable you to
program yourself to respond in a more assertive and relaxed way when the actual
situation confronts you again. You might have one objection to this procedure:
You may feel it is unrealistic to fantasize a positive outcome in the restaurant
since there is no guarantee the staff will in reality respond in a friendly way and
give you what you want. The answer to this objection is simple. There's no
guarantee they'll respond abrasively either, but if you expect a negative response,
guarantee they'll respond abrasively either, but if you expect a negative response,
you'll enhance the probability of getting one be- because your anger will have an
enormous capacity to act as a self-fulfilling prophecy. In contrast, if you expect
and fantasize a positive outcome and apply an upbeat approach, it will be much
more likely to occur. You can, of course, also prepare for a negative outcome in
a similar way, using the cognitive rehearsal method. Imagine you do approach
the waiter, and he acts snotty and superior and gives you poor service. Now
record your hot thoughts, then substitute cool thoughts and develop a new
coping strategy as you did before. You can continue to work your way up your
hierarchy
194 David D. Burns, M.D. list in this way until you have learned to think, feel,
and act more peacefully and effectively in the majority of the pro- provocative
situations you encounter. Your approach to these situations will have to be
flexible, and different coping tech- techniques may be required for the different
types of provoca- provocations listed. Empathy might be the answer in one
situation, verbal assertiveness could be the key to another, and chang- changing
your expectations might be the most useful approach to a third. It will be crucial
not to evaluate your progress in your an- anger-reduction program in an all-ornothing way because emotional growth takes some time, especially when it
comes to anger. If you ordinarily react to a particular provocation with 99
percent anger and then find you become 70 percent upset next time, you could
view this as a successful first try. Now keep working at it, using your cognitive
rehearsal method, and see if you can reduce it to 50 percent and then to 30
percent. Eventually you will make it vanish altogether, or at least you will have
brought it down to an acceptable, irre- irreducible minimum. Remember that the
wisdom of friends and associates can be a potential gold mine you can utilize
when you're stuck. They may see clearly in any area where you have a blind
spot. Ask them how they think and behave in a particular situation that makes
you feel frustrated, helpless, and enraged. What would they tell themselves?
What would they actually do? You can learn a surprising amount rapidly if you
are willing to ask. Ten Things You Should Know About Your Anger 1. The
events of this world don't make you angry. Your 4'hot thoughts" create your
anger. Even when a gen- genuinely negative event occurs, it is the meaning you
attach to it that determines your emotional response. The idea that you are
responsible for your anger is
FEELING GOOD 195 ultimately to your advantage because it gives you the
opportunity to achieve control and make a free choice about how you want to
feel. If it weren't for this, you would be helpless to control your emotions; they
feel. If it weren't for this, you would be helpless to control your emotions; they
would be irreversibly bound up with every external event of this world, most of
which are ultimately out of your control. 2. Most of the time your anger will not
help you. It will immobilize you, and you will become frozen in your hostility to
no productive purpose. You will feel better if you place your emphasis on the
active search for creative solutions. What can you do to correct the difficulty or
at least reduce the chance that you'll get burned in the same way in the future?
This attitude will eliminate to a certain extent the helplessness and frustration
that eat you up when you feel you can't deal with a situation effectively. If no
solution is possible because the provocation is totally beyond your control, you
will only make yourself miserable with your resentment, so why not get rid of it?
It's difficult if not impossible to feel anger and joy simultaneously. If you think
your angry feelings are especially precious and important, then think about one
of the happiest moments of your life. Now ask yourself, How many minutes of
that period of peace or jubilation would I be willing to trade in for feeling
frustration and irritation instead? 3. The thoughts that generate anger more often
than not will contain distortions. Correcting these distortions will reduce your
anger. 4. Ultimately your anger is caused by your belief that someone is acting
unfairly or some event is unjust. The intensity of the anger will increase in
proportion to the severity of the maliciousness perceived and if the act is seen as
intentional. 5. If you learn to see the world through other people's eyes, you will
often be surprised to realize their actions
196 David D. Burns, M.D. are not unfair from their point of view. The
unfairness in these cases turns out to be an illusion that exists only in your mind\
If you are willing to let go of the unrealistic notion that your concepts of truth,
justice, and fairness are shared by everyone, much of your resentment and
frustration will vanish. 6. Other people usually do not feel they deserve your
punishment. Therefore, your retaliation is unlikely to help you achieve any
positive goals in your interac- interactions with them. Your rage will often just
cause further deterioration and polarization, and will function as a self-fulfilling
prophecy. Even if you temporarily get what you want, any short-term gains from
such hostile manipulation will often be more than counterbalanced by a longterm resentment and retaliation from the people you are coercing. No one likes
to be controlled or forced. This is why a positive reward system works better. 7.
A great deal of your anger involves your defense against loss of self-esteem
when people criticize you, disagree with you, or fail to behave as you want them
to. Such anger is always inappropriate because only your own negative distorted
thoughts can cause you to lose self-esteem. When you blame the other guy for
your feelings of worthlessness, you are always fooling yourself. 8. Frustration
your feelings of worthlessness, you are always fooling yourself. 8. Frustration
results from unmet expectations. Since the event that disappointed you was a
part of "reality," it was *'realistic." Thus, your frustration always re- results from
your unrealistic expectation. You have the right to try to influence reality to
bring it more in line with your expectations, but this is not always practical,
especially when these expectations represent ideals that don't correspond to
everyone else's concept of human nature. The simplest solution would be to
FEELING GOOD 197 change your expectations. For example, some ununrealistic expectations that lead to frustration include: a. If I want something
(love, happiness, a promo- promotion, etc.), I deserve it. b. If I work hard at
something, I should be success- successful. c. Other people should try to
measure up to my standards and believe in my concept of "fair- "fairness." d. I
should be able to solve any problems quickly and easily. e. If I'm a good wife,
my husband is bound to love me. f. People should think and act the way I do. g.
If I'm nice to someone, they should reciprocate. 9. It is just childish pouting to
insist you have the right to be angry. Of course you do! Anger is legally
permitted in the United States. The crucial issue is— is it to your advantage to
feel angry? Will you or the world really benefit from your rage? 10. You rarely
need your anger in order to be human. It is not true that you will be an unfeeling
robot without it. In fact, when you rid yourself of that sour irrit- irritability, you
will feel greater zest, joy, peace, and productivity. You will experience liberation
and en- enlightenment.
Chapter 8 Ways of Defeating Guilt No book on depression would be complete
without a chapter on guilt. What is the function of guilt? Writers, spiritual
leaders, psychologists, and philosophers have grappled for- forever with this
question. What is the basis of guilt? Does it evolve from the concept of "original
sin"? Or from Oedipal incestuous fantasies and the other taboos that Freud pospostulated? Is it a realistic and helpful component of human experience? Or is it
a ' 'useless emotion" that mankind would be better off without, as suggested by
some recent pop psychology writers? When the mathematics of calculus was
developed, sci- scientists found they could readily solve complex problems of
motion and acceleration that were extremely difficult to handle using older
methods. The cognitive theory has sim- similarly provided us with a kind of
"emotional calculus" that makes certain thorny philosophical and psychological
ques- questions much easier to resolve. Let's see what we can learn from a
cognitive approach. Guilt is the emotion you will experience when you have the
following thoughts: 1. I have done something I shouldn't have (or 1 have failed
to do something that I should have) because my 198
FEELING GOOD 199 actions fall short of my moral standards and violate my
concept of fairness. 2. This "bad behavior" shows that I am a bad person (or that
I have an evil streak, or a tainted character, or a rotten core, etc.). This concept
of the "badness" of self is central to guilt. In its absence, your hurtful action
might lead to a healthy feeling of remorse but not guilt. Remorse stems from the
^distorted awareness that you have willfully and unneces- unnecessarily acted in
a hurtful manner toward yourself or another person that violates your personal
ethical standards. Re- Remorse differs from guilt because there is no implication
your transgression indicates you are inherently bad, evil, or im- immoral. To put
it in a nutshell, remorse or regret are aimed at behavior, whereas guilt is targeted
toward the "self." If in addition to your guilt you feel depression, shame, or
anxiety, you are probably making one of the following assumptions: 1. Because
of my "bad behavior," 1 am inferior or worthless (this interpretation leads to
depression). 2. If others found out what I did, they would look down on me (this
cognition leads to shame). 3. I'm in danger of retaliation or punishment (this
thought provokes anxiety). The simplest way to assess whether the feelings
created by such thoughts are useful or destructive is to determine if they contain
any of the ten cognitive distortions described in Chapter 3. To the extent that
these thinking errors are present, your guilt, anxiety, depression, or shame
certainly cannot be valid or realistic. I suspect you will find that a great many of
your negative feelings are in fact based on such thinking errors. The first
potential distortion when you are feeling guilty
200 David D. Burns, M.D. is your assumption you have done something wrong.
This may or may not actually be the case. Is the behavior you condemn in
yourself in reality so terrible, immoral, or wrong? Or are you magnifying things
out of proportion? A charming medical technologist recently brought me a
sealed envelope containing a piece of paper on which she had written something
about herself which was so terrible she couldn't bear to say it out loud. As she
trembling handed the envelope to me, she made me promise not to read it out
loud or laugh at her. The message inside was—"I pick my nose and eat it!" The
apprehension and horror on her face in contrast to the triviality of what she had
written struck me as so funny I lost all professional composure and burst into
laughter. Fortunately, she too broke into a belly laugh and expressed a sense of
relief. Am I claiming that you never behave badly? No. That position would be
extreme and unrealistic. I am simply insisting that to the extent your perception
of goofing up is unrealistically magnified, your anguish and self-persecution are
inappropriate and unnecessary. A second key distortion that leads to guilt is
when you label yourself a "bad person" because of what you did. This is actually
the kind of superstitious destructive thinking that led to the medieval witch
the kind of superstitious destructive thinking that led to the medieval witch
hunts! You may have engaged in a bad, angry, hurtful action, but it is
counterproductive to label yourself a "bad" or "rotten" person because your
energy gets channeled into rumination and self-persecution instead of creative
problem-solving strategies. Another common guilt-provoking distortion is
person- personalization. You inappropriately assume responsibility for an event
you did not cause. Suppose you offer a constructive criticism to your boyfriend,
who reacts in a defensive and hurt manner. You may blame yourself for his
emotional upset and arbitrarily conclude that your comment was ininappropriate. In fact, his negative thoughts upset him, not your comment.
Furthermore, these thoughts are probably distorted. He might be thinking that
your criticism means he's no good and conclude that you don't respect him.
FEELING GOOD 20! Now—did you put that illogical thought into his head?
Ob- Obviously not. He did it, so you can't assume responsibility for his reaction.
Because cognitive therapy asserts that only your thoughts create your feelings,
you might come to the nihilistic belief that you cannot hurt anybody no matter
what you do, and hence you have license to do anything. After all, why not run
out on your family, cheat on your wife, and screw your partner financially? If
they're upset, it's their problem be- because it's their thoughts, right? Wrong!
Here we come again to the importance of the concept of cognitive distortion. To
the extent that a person's emotional upset is caused by his distorted thoughts,
then you can say he is responsible for his suffering. If you blame yourself for
that individual's pain, it is a personalization error. In contrast, if a person's
suffering is caused by valid, undistorted thoughts, then the suffering is real and
may in fact have an external cause. For example, you might kick me in the
stomach, and 1 could have the thoughts, "I've been kicked! It hurts! !" In this
case the respon- responsibility for my pain rests with you, and your perception
that you have hurt me is not distorted in any way. Your remorse and my
discomfort are real and valid. Inappropriate "should'* statements represent the
"final common pathway" to your guilt. Irrational should state- statements imply
you are expected to be perfect, all-knowing, or all-powerful. Perfectionistic
shoulds include rules for living that defeat you by creating impossible
expectations and rigidity. One example of this would be, "I should be happy at
all times." The consequence of this rule is that you will feel like a failure every
time you are upset. Since it is obviously unrealistic for any human being to
achieve the goal of perpetual happiness, the rule is self-defeating and
irresponsible. A should statement that is based on the premise you are allknowing assumes you have all the knowledge in the universe and that you can
predict the future with absolute certainty. For example, you might think, "I
predict the future with absolute certainty. For example, you might think, "I
shouldn't have
202 David D. Burns, M.D. gone to the beach this weekend because I was coming
down with the flu. What a jerk I am! Now I'm so sick I'll be in bed for a week."
Berating yourself this way is unrealistic because you didn't know for certain that
going to the beach would make you so ill. If you had known this, you would
have acted differently. Being human, you made a decision, and your hunch
turned out to be wrong. Should statements based on the premise you are allpowerful assume that, like God, you are omnipotent and have the ability to
control yourself and other people so as to achieve each and every goal. You miss
your tennis serve and wince, exclaiming, "I shouldn't have missed that serve!"
Why shouldn't you? Is your tennis so superb that you can't possibly miss a
serve? It is clear that these three categories of should statements create an
inappropriate sense of guilt because they do not represent sensible moral
standards. In addition to distortion, several other criteria can be helpful in
distinguishing abnormal guilt from a healthy sense of remorse or regret. These
include the intensity, duration, and consequences of your negative emotion. Let's
use these criteria to evaluate the incapacitating guilt of a married fifty- two-yearold grammar-school teacher named Janice. Janice had been severely depressed
for many years. Her problem was that she continually obsessed about two
episodes of shoplifting that had occurred when she was fifteen. Although she
had led a scrupulously honest life since that time, she could not shake the
memory of those two incidents. Guilt- provoking thoughts constantly plagued
her: 'Tm a thief. I'm a liar. I'm no good. I'm a fake." The agony of her guilt was
so enormous that every night she prayed that God would let her die in her sleep.
Every morning when she woke up still alive, she was bitterly disappointed and
told herself, 4Tm such a bad person even God doesn't want me." In frustration
she finally loaded her husband's pistol, aimed it at her heart, and pulled the
trigger. The gun misfired and did not go off. She had not cocked it properly. She
felt
FEELING GOOD 203 the ultimate defeat: She couldn't even kill herself! She put
the gun down and wept in despair. Janice's guilt is inappropriate not only
because of the obvious distortions, but also because of the intensity, duduration, and consequences of what she was feeling and telling herself. What she
feels cannot be described as a healthy remorse or regret about the actual
shoplifting, but an irre- irresponsible degradation of her self-esteem that blinds
her to living in the here and now, and is far out of proportion to any actual
transgression. The consequences of her guilt cre- created the ultimate irony—her
transgression. The consequences of her guilt cre- created the ultimate irony—her
belief that she was a bad person caused her to attempt to murder herself, a most
destructive and pointless act. The Guilt Cycle Even if your guilt is unhealthy and
based on distortion, once you begin to feel guilty, you may become trapped in an
illusion that makes the guilt appear valid. Such illusions can be powerful and
convincing. You reason: 1. I feel guilty and worthy of condemnation. This
means I've been bad. 2. Since I'm bad, I deserve to suffer. Thus, your guilt
convinces you of your badness and leads to further guilt. This cognitiveemotional connection locks your thoughts and feelings into each other. You end
up trapped in a circular system which I call the "guilt cycle." Emotional
reasoning fuels this cycle. You automatically assume that because you're feeling
guilty, you must have fallen short in some way and that you deserve to suffer.
You reason, "Ifeel bad, therefore I must be bad." This is irrational because your
self-loathing does not necessarily prove that you did anything wrong. Your guilt
just reflects the fact that you believe you behaved badly. This might be
204 David D. Burns, M.D. the case, but it often is not. For example, children are
frequently punished inappropriately when parents are feeling tired and irritable
and misinterpret their behavior. Under these conditions, the poor child's guilt
obviously does not prove he or she did anything wrong. Your self-punishing
behavior patterns intensify the guilt cycle. Your guilt-provoking thoughts lead to
unproductive actions that reinforce your belief in your badness. For ex- example,
a guilt-prone neurologist was trying to prepare for her medical-board
certification examination. She had dif- difficulty studying for the test, and felt
guilty about the fact that she wasn't studying. So she wasted time each night
watching television while the following thoughts raced through her mind: "I
shouldn't be watching TV. I should be preparing for my boards. I'm lazy. I don't
deserve to be a doctor. I'm too self-centered. I ought to be punished." These
thoughts made her feel intensely guilty. She then reasoned, 'This guilt proves
what a lazy no-good person I am." Thus, her self-punishing thoughts and her
guilty feel- feelings reinforced each other. Like many guilt-prone people, she
had the idea that if she punished herself enough she would eventually get movmoving. Unfortunately, quite the opposite was true. Her guilt simply drained her
energy and reinforced her belief that she was lazy and inadequate. The only
actions that resulted from her self-loathing were the nightly compulsive trips to
the refrigerator to "pig out" on ice cream or peanut butter. The vicious cycle that
she trapped herself in is shown in Figure 8-1. Her negative thoughts, feelings,
and behaviors all interacted in the creation of the self-defeating, cruel illusion
that she was "bad" and uncontrollable. The Irresponsibility of Guilt If you have
actually done something inappropriate or hurtful, does it follow that you deserve
to suffer? If you feel the answer to this question is yes, then ask yourself, "How
to suffer? If you feel the answer to this question is yes, then ask yourself, "How
long must I suffer? One day? A year? For the rest of my life?" What sentence
will you
FEELING GOOD 205 Figure 8-1. A neurologist's self-critical thoughts caused
her to feel so guilty that she had difficulty preparing for her certification
examination. Her procrastination strengthened her conviction that she was bad
and deserved punishment. This further undermined her motivation to solve the
problem. Thoughts I shouldn't be watching TV. I'm lazy and no good. I'm a selfindulgent pig. Emotions Quilt Anxiety Self-loathing Behaviors Procrastination
Binge-eating choose to impose on yourself? Are you willing to stop suffering
and making yourself miserable when your sentence has expired? This would at
least be a responsible way to punish yourself because it would be time-limited.
But what is the point of abusing yourself with guilt in the first place? If you did
make a mistake and act in a hurtful way, your guilt won't reverse your blunder in
some magical manner. It won't speed your learning processes so as to reduce the
chance you'll make the same mistake in the future. Other people won't love and
respect you more because you are feeling guilty and putting yourself down in
this manner. Nor will your guilt lead to productive living. So what's the point?
Many people ask, "But how could I behave morally and control my impulses if I
don't feel guilt?" This is the
206 David D. Bums, M.D. probation-officer approach to living. Apparently you
view yourself as so willful and uncontrollable that you must con- constantly
castigate yourself in order to keep from going wild. Certainly, if your behavior
has a needlessly hurtful impact on others, a small amount of painful remorse will
add to your awareness more effectively than a sterile recognition of your goof-up
with no emotional arousal. But it certainly never helped anyone to view himself
as a bad person. More often than not, the belief that you are bad contributes to
the "bad" behavior. Change and learning occur most readily when you (a)
recognize that an error has occurred and (b) develop a strategy for correcting the
problem. An attitude of self-love and relaxation facilitates this, whereas guilt
often interferes. For example, occasionally patients criticize me for mak- making
a sharp comment that rubs them the wrong way. This criticism usually only hurts
my feelings and arouses my guilt if it contains a grain of truth. To the extent that
I feel guilty and label myself as "bad," I tend to react defensively. I have the urge
to either deny or justify my error, or to counterattack because that feeling of
being a "bad person" is so odious. This makes it much more difficult for me to
admit and correct the error. If, in contrast, I do not harangue myself or
experience any loss of self-respect, it is easy to admit my mistake. Then I can
experience any loss of self-respect, it is easy to admit my mistake. Then I can
readily correct the problem and learn from it. The less guilt I have, the more
effectively I can do this. Thus, what is called for when you do goof up is a
process of recognition, learning, and change. Does guilt help you with any of
these? I don't believe it does. Rather than facilitating your recognition of your
error, guilt engages you in a coverup operation. You want to close your ears to
any criticism. You can't bear to be in the wrong because it feels so terrible. This
is why guilt is counterproductive. You may protest, "How can I know I've done
something wrong if I don't feel guilty? Wouldn't I just indulge in a blind
rampage of uncontrolled, destructive selfishness if it weren't for my guilt?"
FEELING GOOD 207 Anything is possible, but I honestly doubt this would
happen. You can replace your guilt with a more enlightened basis for moral
behavior—empathy. Empathy is the ability to visualize the consequences, good
and bad, of your be- behavior. Empathy is the capacity to conceptualize the
impact of what you do on yourself and on the other person, and to feel
appropriate and genuine sorrow and regret without la- labeling yourself as
inherently bad. Empathy gives you the necessary mental and emotional climate
to guide your be- behavior in a moral and self-enhancing manner in the absence
of the whip of guilt. Using these criteria, you can now readily determine whether
your feelings represent a normal and healthy sense of remorse or a selfdefeating, distorted sense of guilt. Ask yourself: 1. Did I consciously and
willfully do something "bad," 44unfair," or needlessly hurtful that I shouldn't
have? Or am I irrationally expecting myself to be perfect, all-knowing, or allpowerful? 2. Am I labeling myself a bad or tainted person because of this
action? Do my thoughts contain other cognitive distortions, such as
magnification, overgeneralization, etc.? 3. Am I feeling a realistic regret or
remorse, which results from an empathic awareness of the negative impact of my
action? Are the intensity and duration of my painful emotional response
appropriate to what I ac- actually did? 4. Am I learning from my error and
developing a strategy for change, or am I moping and ruminating nonproductively or even punishing myself in a destructive manner? Now, let's review
some methods that will allow you to rid yourself of inappropriate guilty feelings
and maximize your self-respect.
208 David D. Burns, M.D. /. Daily Record of Dysfunctional Thoughts. In earlier
chapters you were introduced to a Daily Record of Dys- Dysfunctional Thoughts
for overcoming low self-esteem and inadequacy. This method works
handsomely for a variety of unwanted emotions, including guilt. Record the
activat- activating event that leads to your guilt in the column labeled
activat- activating event that leads to your guilt in the column labeled
"Situation." You may write, "I spoke sharply to an as- associate," or "Instead of
contributing ten dollars, I threw my alumni fund-raising appeal in the
wastebasket." Then "tune in" to that tyrannical loudspeaker in your head and
identify the accusations that create your guilt. Finally, iden- identify the
distortions and write down more objective thoughts. This leads to relief. An
example of this is demonstrated in Figure 8-2. Shirley was a high-strung young
woman who decided to move to New York to pursue her acting career. After she
and her mother had spent a long and tiring day looking for apart- apartments,
they took a train back to Philadelphia. After board- boarding, they discovered
they had mistakenly taken a train without food service or a lounge car. Shirley's
mother began to complain about the lack of cocktail service, and Shirley felt
flooded with guilt and self-criticism. As she recorded and talked back to her
guilt-provoking thoughts, she felt substantial relief. She told me that by
overcoming her guilt, she avoided the temper tantrum she would normally have
thrown in such a frustrating situation (see Figure 8-2, page 209). 2. Should
Removal Techniques. Here are some methods for reducing all those irrational
"should" statements you've been hitting yourself with. The first is to ask
yourself, "Who says I should? Where is it written that I should?" The point of
this is to make you aware that you are being critical of yourself unnecessarily.
Since you are ultimately making your own rules, once you decide that a rule is
not useful you can revise it or get rid of it. Suppose you are telling yourself that
you should be able to make your spouse happy all the time. If your experience
teaches you that this is
Figure 8-2. Situation Emotions Guilt-provoking Thoughts Cognitive Distortions
Rational Responses Outcome My mother is very tired and due to her lack of
understanding of the train schedule, we take a tram without comforts. Extreme
guilt; frustration, anger; self-pity 1. Gee, Mom walked all over New York with
me today, and now she can't even get a dnnk because I realty didn't explain the
schedule properly. 1 should have explained that "no food" did not mean snacks.
2. Now I feel terrible—I'm so selfish. 3 Why do I always foul up everything?
Personalization; mental filter; should statement. 2. Emotional reasoning 3
Overgeneralization, personalization. 1. I feel bad for Mom— Substantial but the
train nde is only relief \Vi hours. I thought I explained everything. I guess we all
make mis- mistakes sometimes. 2 I am more upset than Mom. What's done is
done—don't cry over spilt milk. 3. 1 don't foul up every- everything it's not my
fault she misunderstood. 4. She's so good to me, and I'm a louse. 4. Labeling; allor-nothing thinking. 4. One incident does not make a louse.
210 David D. Burns, M.D. neither realistic nor helpful, you can rewrite the rule
210 David D. Burns, M.D. neither realistic nor helpful, you can rewrite the rule
to make it more valid. You might say, t4I can make my spouse happy some of
the time, but I certainly can't at all times. Ulti- Ultimately, happiness is up to him
or her. And I'm not perfect any more than he or she is. Therefore, I will not
anticipate that what I do will always be appreciated." In deciding about the
usefulness of a particular rule, it can be helpful to ask yourself, "What are the
advantages and disadvantages of having that rule for myself?" "How will it help
me believe I should always be able to make my spouse happy, and what will the
price be for believing this?" You can assess the costs and benefits, using the
double- column method shown in Figure 8-3. Another simple but effective way
to rid yourself of should statements involves substituting other words for
"should," using the double-column technique. The terms "It would be nice if" or
"I wish I could" work well, and often sound more realistic and less upsetting. For
example, instead of Figure 8-3. The advantages and disadvantages of believing
"I should be able to make my wife happy all the time." Advantages
Disadvantages 1. When she is happy, I will I. When she's unhappy, I'll feel feel
I'm doing what I'm guilty and I'll blame myself, supposed to. 2. I'll work very
hard to be a 2. She'll be able to manipulate me good husband. with my guilt.
Anytime she wants her way she can act unhappy, and then I'll feel so bad I'll
have to back down. 3. Since she is unhappy a good bit of the time, I'll often feel
like a fail- failure. Since her unhappiness often has nothing to do with me, this
will be a waste of energy. 4. I'll end up feeling resentful that I'm paradoxically
giving her so much power over my moods!
FEELING GOOD 21 1 saying, "I should be able to make my wife happy," you
could substitute ' 'It would be nice if I could make my wife happy now because
she seems upset. I can ask what she's upset about and see if there might be a way
I could help." Or instead of "I shouldn't have eaten the ice cream," you can say,
"It would have been better if I hadn't eaten the ice cream, but it's not the end of
the world that I did." Another anti-should method involves showing yourself that
a should statement doesn't fit reality. For example, when you say, "I shouldn't
have done X," you assume A) it is a fact that you shouldn't have, and B) it is
going to help you to say this. The "reality method" reveals—to your surprise—
that the truth is usually just the opposite: (a) In point of fact, you should have
done what you did; and (b) it is going to hurt you to say you shouldn't have.
Incredulous? Let me demonstrate. Assume you've been trying to diet and you ate
some ice cream. So you have the thought, "I shouldn't have eaten this ice
cream." In our dialogue I want you to argue that it's really true that you shouldn't
have eaten the ice cream, and I will try to put the lie to your arguments. The
following is modeled after an actual conversation, which I hope you find as
following is modeled after an actual conversation, which I hope you find as
delightful and helpful as I did: David: I understand you're on a diet, and you ate
some ice cream. I believe you should have eaten the ice cream. You: Oh, no.
That's impossible. I shouldn't have eaten it because I'm on a diet. You see, I'm
trying to lose weight. David: Well, I believe you should have eaten the ice
cream. You: Burns, are you dense? I shouldn't have because I'm trying to lose
weight. That's what I'm try- trying to tell you. How can I lose weight if I'm
eating ice cream? David: But in point of fact you did eat it.
212 David D. Burns, M.D. You: Yeah. That's the problem. I shouldn't have done
that. Now do you see the light? David: And apparently you're claiming that
"things should have been different" than they were. But things were the way they
were. And things usu- usually are the way they are for a good reason. Why do
you think you did what you did? What's the reason you ate the ice cream? You:
Well, I was upset and I was nervous and I'm basically a pig. David: Okay, you
were upset and you were nervous. Have you had a pattern in your life of eating
when you've been upset and nervous? You: Yeah. Right. I've never had any selfcontrol. David: So, wouldn't it be natural to expect then that last week when you
were nervous you would do what you have habitually done? You: Yeah. David:
So, wouldn't it be sensible therefore to conclude that you should have done that
because you had a very long-standing habit of doing it? You: I feel like you're
telling me that I should just keep eating ice cream and end up like a fat pig or
something. David: Most of my clients aren't as difficult as you! At any rate, I'm
not telling you to act like a pig, and I'm not recommending you continue this bad
habit of eating when you're upset. What I'm saying is that you're giving yourself
two prob- problems for the price of one. One is that you did in fact break your
diet. If you're going to lose weight, this will slow you down. And the second
problem is that you're being hard on yourself about having done that. The second
headache you don't need.
FEELING GOOD 213 You: So you're saying that because I have a habit of
eating when I'm nervous it's predictable that un- until I learn some methods for
changing the habit, I'll continue to do it. David: I wish I'd said it that well
myself! You: Therefore, I should have eaten the ice cream because I haven't
changed the habit yet. As long as the habit continues, I will and should keep
overeating when I'm nervous. I see what you mean. I feel a whole lot better,
Doctor, except for one thing. How can I learn to stop doing this? How can I
develop some strategies for modifying my behavior in a more productive way?
David: You can motivate yourself with a whip or a car- carrot. When you tell
yourself, "I should do this" or "I shouldn't do that" all day long, you get bogged
down with a shouldy approach to life. And you already know what you end up
down with a shouldy approach to life. And you already know what you end up
with— emotional constipation. If you'd rather get things moving instead, 1
suggest you try to motivate yourself through rewards rather than punishment.
You might find that these work more effectively. In my case I used the "Dots
and doughnuts" diet. Mason Dots (a gum candy) and glazed doughnuts are two
of my favorite sweets. I found that the most difficult time to control my eating
was in the evening when 1 was studying or watch- watching TV. I'd have an
urge to eat ice cream. So, I told myself that if I controlled this urge, I could
reward myself with a big, fresh, glazed doughnut in the morning and a box of
Mason Dots in the evening. Then Vd concentrate on how good they'd taste, and
this helped me forget the ice cream. Incidentally, 1 also had the rule that if I did
goof up and eat the ice cream, I could still have the Dots and the doughdoughnut as a reward for trying or as a commiseration for slipping back. Either
way it helped me, and I lost over fifty pounds this way.
214 David D. Burns, M.D. I also made up the following syllogism: (A) Human
beings on diets goof up from time to time. (B) I'm a human being. * (C)
Therefore, I should goof up from time to time. This helped me greatly too, and it
enabled me to binge on weekends and feel good about it. I usually lost more durduring the week than I gained on weekends; so, overall I lost weight and enjoyed
myself. Every time 1 goofed up in my diet I didn't allow myself to criticize the
lapse or feel guilty. I began to think about it as the "Binge-on-whatever-you want
- whenever - you - want - to - without - guilt - and - enjoy - it diet/' and it was so
much fun it was a mild disappointment when I finally achieved my aimed-for
weight. I actually lost over ten more pounds at that point because the diet was so
enjoyable. 1 believe that the proper attitude and feelings are the key. With them
you can move mountains—-even moun- mountains of flesh. The major thing that
holds you back when you're trying to change a bad habit like eating, smoking, or
drinking too much is your belief you are out of control. The cause of this lack of
control is those should statements. They defeat you. Suppose, for example, you
are trying to avoid eating ice cream. There you are watching TV, saying, "Oh, I
really should study and I shouldn't eat any ice cream." Now ask yourself, "How
do I feel when 1 say these things to myself?" I think you know the answer: You
feel guilty and nervous. Then what do you do? You go and eat! That is the point.
The reason you're eating is that you're telling yourself you shouldn't! Then you
try to bury your guilt and anxiety under more piles of food. Another simple
should removal technique involves your wrist counter. Once you become
convinced that the shoulds are not to your advantage, you can count them. Every
time you make a should statement, click the counter. If you do this, be sure to set
up a reward system based on the daily
up a reward system based on the daily
FEELING GOOD 215 total. The more shoulds you spot this way, the greater the
reward you deserve. Over a period of several weeks, your daily total of should
statements will begin to go down, and you'll notice you're feeling less guilty.
Another should removal technique zeroes in on the fact that you don't really trust
yourself. You may believe that without all these should statements you would
just turn wild and go on a rampage of destruction or murder, or even iceicecream eating. A way to evaluate this is to ask yourself if there was any period
in your life when you were particularly happy and felt reasonably fulfilled,
productive, and under control. Think it over for a moment before you read on,
and make sure you have a mental picture of this time. Now ask yourself,' 'During
that period in my life, was 1 whipping myself with a lot of should statements?" I
believe your answer will be no. Now tell me—were you doing all these wild,
terrible things then? I think you'll realize you were 44should-free" and under
control. This is proof that you can lead a productive, happy life without all those
shoulds. You can test this hypothesis with an experiment in the next couple of
weeks. Try reducing your should statements using these various techniques, and
then see what happens to your mood and self-control. 1 think you'll be pleased.
Another method that you can fall back on is the obses- obsessional-filibuster
technique described in Chapter 4. Schedule two minutes three times a day to
recite all your should statements and self-persecutions out loud: "I should have
gone to the market before it closed/' and shouldn't have picked my nose at the
country club," and 4Tm such a rotten bum," etc. Just rattle off all the most
abusive self- criticisms you can think of. It might be especially helpful to write
them down or dictate them into a tape recorder. Then read them later out loud, or
listen to the tape. I think this will help you see how ludicrous these statements
are. Try to limit your shoulds to these scheduled periods so you won't be
bothered by them at other times. Another technique to combat should statements
involves getting in touch with the limits of your knowledge. When
216 David D. Burns, M.D. I was growing up, I often heard people say,4'Learn to
accept your limits and you'll become a happier person," but no one ever bothered
to explain what this meant or how to go about doing it. Furthermore, it always
sounded like a bit of a put-down, as if they were saying, 4t Learn what a secondrate dud you actually are." In reality, it's not as bad as all that. Suppose you frefrequently look into the past and mope about your mistakes. For example, as you
review the financial section of the paper, you tell yourself, "I shouldn't have
bought that stock. It's gone down two points." As a way out of this trap, ask
yourself, 44Now, at the time I bought the stock, did I know it was going to go
yourself, 44Now, at the time I bought the stock, did I know it was going to go
down in value?" I suspect you'll say no. Now ask, "If I'd known it was going
down, would I have bought it?" Again you'll answer no. So what you're really
saying is that if you'd known this at the time, you'd have acted differently. To do
this you would have to be able to predict the future with absolute certainty. Can
you predict the future with absolute certainty? Again your answer must be no.
You have two options: You can either decide to accept yourself as an imperfect
human being with limited knowledge and realize that you will at times make
mistakes, or you can hate yourself for it. Another effective way to combat
shoulds is to ask, 44Why should I?" Then you can challenge the evidence you
come up with so as to expose the faulty logic. In this way you can reduce your
should statement to the level of absurdity. Suppose, for example, you hire
someone to do some work for you. It could be lawn work, or a painting job, or
any- anything. When he submits his bill, it seems higher than you understood it
would be, but he gives you some fast talk, so you give in and end up paying his
price. You feel taken advantage of. You begin to berate yourself for not acting
more firmly. Let's do some role-playing, and you can pre- pretend that you're the
poor sucker who paid too much. You: Yesterday I should have told that guy that
his bill was too high.
FEELING GOOD 217 David: You should have told him that he gave you a
lower estimate? You: Yeah. I should have been more assertive. David: Why
should you have? I agree that it would have been to your advantage to speak up
for yourself. You can work on developing your assertive skills so that in the
future you'll do better in situations like that. But the point is: Why should you
have been more effective yesterday? « You: Well, because I'm always letting
people take advantage of me. David: Okay, let's think about your line of
reasoning. "Because I'm always letting people take advan- advantage of me, 1
should have been more assertive yesterday." Now—what is the rational response
to this? Is there anything about your statement that seems a little bit illogical? Is
there anything fishy about your reasoning? You: Mmmm ... let me think. Well,
in the first place, it's not exactly true that I'm always letting people take
advantage of me. That would be an over- generalization. I sometimes do get my
way. In fact, I can be quite demanding at times. Fur- Furthermore, if it were true
that I was always getting taken advantage of in certain situations, then it would
follow that I should have behaved exactly as I did since this is my habit. Until
I've mastered some new ways to deal with people, I'll probably continue to have
this problem. David: Great. I couldn't have put it better. I see you've been
absorbing what I've been telling you about should statements! I hope all my
readers are as smart and attentive as you are! Are there any other reasons you
readers are as smart and attentive as you are! Are there any other reasons you
think you should have behaved differently?
218 David D. Burns, M.D. You: Uh, well, let me see. How about: I should have
been more assertive because I wouldn't have had to pay more than I owed?
David: Okay. Now what's the rational response to that? What is illogical about
that argument? You: Well, since I'm human I won't always do the right thing.
David: Exactly. In fact, the following syllogism may help you. First premise: All
human beings make mistakes, like sometimes paying too much. Do you agree
with me so far? You: Yes. David: And what are you? You: A human being.
David: And what follows? You: I should make mistakes. David: Right. That
should be enough should removal techniques for you. Oops! I just did it myself!
Let me say—it would be nice if you found those methods helpful. I think you'll
find that by reducing this mental tyranny, you'll feel better be- because you won't
be berating yourself. Instead of feeling guilty, you can use your energy to make
necessary changes and enhance your self-control and productivity. 3. Learn to
Stick to Your Guns. One of the big disad- disadvantages of being guilt-prone is
that others can and will use this guilt to manipulate you. If you feel obligated to
please everyone, your family and friends will be able to coerce you effectively
into doing many things that may not be in your best self-interest. To cite a trivial
example, how many social invitations have you halfheartedly accepted so as not
to hurt someone's feelings? In this case the price you pay for saying yes when
you really would have preferred to say no is not great. You only end up wasting
one evening. And
FEELING GOOD 219 there is a payoff. You will avoid feeling guilty, and you
can fantasize that you are an especially nice person. Fur- Furthermore, if you try
to decline the invitation, the disap- disappointed host may say, "But we are
expecting you. Do you mean you are going to let the old gang down? Aw, come
on." And then what would you say? How would you feel? Your obsession with
pleasing others becomes more tragic when your decisions become so dominated
by guilt that you end up trapped and miserable. The irony is that, more often
than not, the consequences of letting someone manipulate you with guilt end up
being destructive not only to you but to the other person. Although your guiltmotivated actions are often based on your idealism, the inevitable effects of
giving in turn out to be quite the opposite. For example, Margaret was a happily
married twenty- seven-year-ol^J woman whose obese brother, a gambler, tended
to take advantage of her in a variety of ways. He borrowed money when he ran
short and often forgot to repay it. When he was in town (often for several months
at a time) he assumed it was his right to eat dinner with her family every night,
to drink up the liquor, and to use her new car whenever he wanted. She
to drink up the liquor, and to use her new car whenever he wanted. She
rationalized giving in to his de- demands by saying: "If I asked him for a favor or
needed his help, he'd do the same for me. After all, a loving brother and sister
should help each other out. And besides, if I tried to say no to him he'd explode
and 1 might lose him. Then I'd feel like / did something wrong." At the same
time, she was able to see the negative con- consequences of continually giving
in: A) She was supporting his dependent, self-defeating life-style and gambling
addic- addiction; B) She felt trapped and taken advantage of; C) The basis of the
relationship was not love but blackmail—she was constantly having to say yes to
his demands to avoid the tyranny of his temper and her own sense of guilt.
Margaret and I did some role-playing so she could learn to say no and stick to
her guns in a tactful but firm manner. I played Margaret's role, and she pretended
to be her brother:
220 David D. Burns, M.D. Brother Margaret Brother: Margaret: Brother:
Margaret: Brother: Margaret: Brother: Margaret: Brother: Margaret: Brother:
Margaret: (played by Margaret): Are you using the car tonight? (played by me):
I'm not planning to now. Do you mind if I borrow it later? Fd prefer that you
don't. Why not? You're not going to use it. It'll just be sitting there. Do you feel
I'm obliged to loan it to you? Well, I'd do the same for you if 1 had a car and you
needed it. I'm glad you feel that way. Although I'm not planning to use the car,
I'd like to have it available in case 1 decide to go somewhere later on. But you're
not planning to use it! Haven't we been brought up to help each other? Yes we
have. Do you think that means I always have to say yes to you? We both do a
great deal for each other. You have made a lot of use of my car and from now on
I'd feel more comfortable if you'd begin to ar- arrange your own transportation.
I'm just planning to use it for an hour, so I'll get it back in case you need it. It's
very important and it's only a half mile away, so I won't wear your car out, don't
worry. It sounds like it is something important to you. Perhaps you can arrange
some other transportation. Could you walk that dis- distance? Oh, that's fine! If
that's how you feel, don't come to me for any favors! It sounds like you're pretty
mad because I'm not doing what you want. Do you feel I'm always obliged to
say yes?
FEELING GOOD 221 Brother: You and your philosophy! Shove it! I refuse to
listen to any more of this hog wash! (Be- (Begins to storm off). Margaret: Let's
not talk about it any further then. Maybe in a couple of days you'll feel more like
talking about it. I think we do need to talk things over. After this dialogue we
reversed roles so that Margaret could practice being more assertive. When I
played her brother's role, I gave her as tough a time as I could, and she learned
played her brother's role, I gave her as tough a time as I could, and she learned
how to handle me. This practice boosted her courage. She felt it was helpful to
keep certain principles in mind when standing up to her brother's manipulations.
These were: A) She could remind him it was her right not to say yes to all his
demands. B) She could find a grain of truth in his arguments (the disarming
technique) so as to take the wind out of his sails, but she could then come back
to her position that love did not mean always giving in. C) She was to adopt a
strong, decisive and uncompromising position as tactfully as possible. D) She
was not to buy into his role as a weak, inadequate little boy who couldn't stand
on his own feet. E) She was not to respond to his anger by getting angry herself,
because this would reinforce his belief he was a victim who was being unjustly
deprived by a cruel, selfish witch. F) She had to risk the possibility he would
temporarily withdraw and thwart her by refusing to talk to her or to consider her
point of view. When he did this, she was to let him storm off but she could let
him know there were some things she wanted to talk over with him later on
when he was more in the mood to communicate. When Margaret did confront
him she found he was not nearly as tough a customer as she imagined. He
actually seemed relieved and began to act more adult when she put some limits
on the relationship. If you choose to apply this technique, you will have to be
determined to stick to your guns because the other guy (or gal) may try to bluff
you into believing that you're
222 David D. Burns, M.D. mortally wounding them by not giving in to their
requests. Remember that the hurt you inflict in the long run by not following
your best self-interest is usually far greater. Practicing ahead of time is the key to
success. A friend will usually be happy to role-play with you and provide some
useful feedback. If such a person is not available to you, or you feel too shy to
ask, write out an imaginary dialogue of the type illustrated. This will go a long
way to firing up the appropriate circuits in your brain so you'll have the
necessary courage and skill to say no diplomatically but forcefully and make it
stick when the time actually comes! 4. Antiwhiner Technique. This is one of the
most sur- surprising, delightfully effective methods in this book. It works like a
charm in situations where someone—usually a loved one—makes you feel
frustrated, guilty, and helpless through whining, complaining, and nagging. The
typical pattern works like this: The whiner complains to you about somesomething or someone. You feel the sincere desire to be helpful, so you make a
suggestion. The person immediately squashes your suggestion and complains
again. You feel tense and inadequate, so you try harder and make another
suggestion. You get the same response. Anytime you try to break loose from the
conversation, the other person implies he or she is being abandoned, and you are
conversation, the other person implies he or she is being abandoned, and you are
flooded with guilt. Shiba lived with her mother while she completed graduate
school. Shiba loved her mother, but found her constant harangues about her
divorce, the lack of money, etc., so intolerable she sought treatment. I taught her
the antiwhiner method the first session, as follows: Regardless of what her
mother said, Shiba was to find some way to agree (the disarming technique), and
then instead of offering advice, she was to say something genuinely
complimentary. Shiba initially found this approach astonishing and rather bizarre
because it differed radically from her usual approach. In the following dialogue,
I asked Shiba to play the role of Mother while I played her role so I could
demonstrate this technique:
FEELING GOOD 223 Shiba (as her mother): Do you know that during the
divorce proceedings it came out that your dad sold his share in the business, and
I was the last person to know about it? David (as Shiba): That's absolutely
correct. You didn't hear about it until the divorce proceedings. You really
deserve better. Shiba: I don't know what we're going to do for money. How am I
going to put your brothers through college? David: That is a problem. We are
short on money. Shiba: It was just like your father to pull something like this.
His head isn't screwed on straight. David: He never was too good at budgeting.
You've always been much better at that. Shiba: He's a louse! Here we are on the
verge of pov- poverty. What if I get sick? We'll end up in the poorhouse! David:
You're right! It's no fun at all to live in the poorhouse. I agree with you
completely. Shiba reported that in her role as Mother she found it was "no fun"
to complain because I kept agreeing with her. We did a role-reversal so she
could master the tech- technique. In fact, it is your urge to help complainers that
maintains the monotonous interaction. Paradoxically, when you agree with their
pessimistic whining, they quickly run out of steam. Perhaps an explanation will
make this seem less puzzling. When people whine and complain, they are usuusually feeling irritated, overwhelmed, and insecure. When you try to help them,
this sounds to them like criticism because it implies they aren't handling things
properly. In contrast, when you agree with them and add a compliment, they feel
endorsed, and they then usually relax and quiet down. 5. Moorey Moaner
Method. A useful modification of this technique was proposed by Stirling
Moorey, a brilliant
224 David D. Burns, M.D. British medical student who studied with our group
in Phil- Philadelphia and sat in with me during therapy sessions during the
summer of 1979. He worked with a chronically severely depressed fifty-twoyear-old sculptor named Harriet with a heart of gold. Harriet's problem was her
friends would often bend her ear with gossip and personal problems. She found
friends would often bend her ear with gossip and personal problems. She found
these problems upsetting because of her excessive capacity for empathy.
Because she wouldn't know how to help her friends, she felt trapped and
resentful until she learned the "Moorey Moaner Method." Stirling simply
instructed her to find a way to agree with what the person was saying, and then
to distract the moaner by finding something positive in the complaint and
commenting on it. Here are several examples: 1. Moaner: Oh, what in the world
can I ever do about my daughter? I'm afraid she's been smok- smoking pot again.
Response: There sure is a lot of pot going around these days. Is your daughter
still doing that outstanding art work? I heard she re- recently got an important
award. 2. Moaner: My boss didn't give me my raise, and my last raise was nearly
a year ago. I've been here for twenty years, and I think I deserve better.
Response: You certainly do have seniority here and you've made tremendous
contributions. Tell me, what was it like when you first started working twenty
years ago? I'll bet things were a lot different then. 3. Moaner: My husband never
seems to have enough time at home. Every night he's out with that darned
bowling league. Response: Weren't you also doing some bowling re- recently? I
heard you got some pretty high scores yourself!
FEELING GOOD 225 Harriet mastered the Moorey Moaner Method quickly
and reported a dramatic change in her mood and outlook because it gave her a
simple, effective way to handle a problem that had been very real and
overwhelming. When she returned for the next session, her depression—which
had crippled her for over a decade—had lifted and was entirely gone. She was
bubbling and joyous, and heaped well-deserved praise on Stirling's head. If you
have a similar problem with your mother, mother-in-law, or friends, try Stirling's
method. Like Harriet, you'll soon be smiling! 6. Developing Perspective. One of
the commonest dis- distortions that leads to a sense of guilt is personalization—
the misguided notion that you are ultimately responsible for other people's
feelings and actions or for naturally occurring events. An obvious example
would be your sense of guilt when it rained unexpectedly on the day of a large
picnic you had organized to honor the retiring president of your club. In this case
you could probably shake your absurd reaction off without a great deal of effort
because you clearly cannot control the weather. Guilt becomes much more
difficult to overcome when someone suffers substantial pain and discomfort and
insists it results from their personal interaction with you. In such cases it can be
helpful to clarify the extent to which you can realistically assume responsibility.
Where does your responsibility end and the other person's begin? The techtechnical name for this is "disattribution," but you might call it putting things
into perspective. Here's how it works. Jed was a mildly depressed college student
into perspective. Here's how it works. Jed was a mildly depressed college student
whose twin brother, Ted, was so seriously depressed he dropped out of school
and began to live like a recluse with his parents. Jed felt guilty about his
brother's depres- depression. Why? Jed told me he had always been more
outgoing and hardworking than his brother. Consequently, from early childhood
he always made better grades and had more friends than Ted. Jed reasoned that
the social and academic success he enjoyed caused his brother to feel inferior
and
226 David D. Burns, M.D. left out. Consequently, Jed concluded that he was the
cause of Ted's depression. He then carried this line of reasoning to its illogical
ex- extreme and hypothesized that by feeling depressed himself, he might help
Ted stop feeling depressed and inferior through some type of reverse (or
perverse) psychology. When he went home for the holidays, Jed avoided the
usual social activities, minimized his academic success, and em- emphasized
how blue he was feeling. Jed made sure he gave his brother the loud and clear
message that he too was down and out. Jed took his plan so seriously that he was
quite hesitant to apply the mood-control techniques I was trying to teach him. In
fact, he was downright resistant at first because he felt guilty about getting better
and feared his recovery might have a devastating impact on Ted. Like most
personalization errors, Jed's painful illusion that he was at fault for his brother's
depression contained enough half-truths to sound persuasive. After all, his
brother probably had felt inferior and inadequate since early child- childhood
and undoubtedly did harbor some jealous resentment of Jed's success and
happiness. But the crucial questions were: Did it follow that Jed caused his
brother's depression, and could Jed effectively reverse the situation by making
himself miserable? In order to help him assess his role in a more objective way, I
suggested Jed use the triple-column technique (Figure 8-4). As a result of the
exercise, he was able to see that his guilty thoughts were self-defeating and
illogical. He reasoned that Ted's depression and sense of inferiority were
ultimately caused by Ted's distorted thinking and not by his own happiness or
success. For Jed to try to correct this by making himself miserable was as
illogical as trying to put out a fire with gasoline. As Jed grasped this, his guilt
and depression rapidly lifted, and he was soon back to normal functioning.
Figure 8-4. Automatic Thoughts Cognitive Distortion Rational Responses 1. I
am part of the cause for Ted's depres- depression due to our relationship since
early childhood. I have always worked harder and been more successful. 2. I feel
it would upset Ted if I told him I was having a good time at school while he is
home alone doing nothing. 3. If Ted is sitting around doing nothing, it is my
responsibility to correct the sit- situation. 1. Jumping to conclusions (mind
responsibility to correct the sit- situation. 1. Jumping to conclusions (mind
reading); personalization 2. Jumping to conclusions (fortune teller error) 3.
Personalization 1. I myself am not the cause of Ted's depression. It is Ted's
illogical thoughts and attitudes that are causing his depression. The only
responsibility that I can take is that of being part of the environment that Ted is
interpret- interpreting in a negative, distorted manner. 2. It might cheer Ted up
and give him some hope if he knows I'm feeling better and having a good time.
It prob- probably only depresses Ted more if I act as miserable as he does
because this takes away his hope. 3. I can encourage him to do things, but I
cannot force him. Ultimately this is his responsibility.
Figure 8-4. cont. Automatic Thoughts Cognitive Distortion Rational Responses
4. I will be doing something for him by not doing anything for myself. In fact, it
will help him if I am depressed. 4. Jumping to conclusions (mind reading) 4. My
actions are totally independent of his actions. There is no reason to think that my
depression will be helpful to him. He has even told me he doesn't want me to be
dragged down. If he sees that I am improving, this might actually encourage
him. I can possibly be a good role model for him by show- showing him that I
can be happy. I can't eliminate his sense of inadequacy by botching up my life.
Part III "Realistic" Depressions
Chapter 9 Sadness \s Not Depression "Dr. Burns, you seem to be claiming that
distorted thinking is the only cause of depression. But what if my problems are
real?" This is one of the most frequent questions I encounter during lectures and
workshops on cognitive ther- therapy. Many patients raise it at the start of
treatment, and list a number of "realistic" problems which they are convinced
cause "realistic depressions." The most common are: bankruptcy or poverty; old
age (some people also view infancy, childhood, adolescence, young adulthood
and mid-life as periods of inevitable crisis); permanent physical disability;
terminal illness; the tragic loss of a loved one. I'm sure you could add to the list.
However, none of the above can lead to a "realistic depression." There is, in fact,
no such thing! The real question here is how to draw the line between desirable
and undesirable negative feelings. What is the difference between "healthy
sadness" and depression? The distinction is simple. Sadness is a normal emotion
created by realistic perceptions that describe a negative event involving loss or
disappointment in an undistorted way. 231
232 David D. Burns, M.D. Depression is an illness that always results from
thoughts that are distorted in some way. For example, when a loved one dies,
thoughts that are distorted in some way. For example, when a loved one dies,
you validly think, "I lost him (or her), and I will miss the companionship and
love we shared." The feelings such a thought creates are tender, realistic, and
desirable. Your emotions will enhance your humanity and add depth to the
meaning of life. In this way you gain from your loss. In contrast, you might tell
yourself, 'Til never again be happy because he (or she) died. It's unfair!" These
thoughts will trigger in you feelings of self-pity and hopelessness. Because these
emotions are based entirely on distortion, they will defeat you. Either depression
or sadness can develop after a loss or a failure in your efforts to reach a goal of
great personal importance. Sadness comes, however, without distortion. It
involves a flow of feeling and therefore has a time limit. It never involves a
lessening of your self-esteem. Depression is frozen—it tends to persist or recur
indefinitely, and always involves loss of self-esteem. When a depression clearly
appears after an obvious stress, such as ill health, the death of a loved one, or a
business reversal, it is sometimes called a "reactive depression." At times it can
be more difficult to identify the stressful event that triggered the episode. Those
depressions are often called "endogenous" because the symptoms seem to be
generated entirely out of thin air. In both cases, however, the cause of the
depression is identical—your distorted, negative thoughts. It has no adaptive or
positive function whatsoever, and represents one of the worst forms of suffering.
Its only redeeming value is the growth you experience when you recover from it.
My point is this: When a genuinely negative event occurs, your emotions will be
created exclusively by your thoughts and perceptions. Your feelings will result
from the meaning you attach to what happens. A substantial portion of your
suffering will be due to the distortions in your thoughts. When you eliminate
these distortions, you will find that coping with the "real problem" will become
less painful.
FEELING GOOD 233 Let's see how this works. One clearly realistic problem
involves serious illness, such as a malignancy. It is unfor- unfortunate that the
family and friends of the afflicted person are often so convinced that it is normal
for the patient to feel depressed, they fail to inquire about the cause of the
depres- depression, which more often than not turns out to be completely
reversible. In fact, some of the easiest depressions to resolve are those found in
people facing probable death. Do you know why? These courageous individuals
are often "su- percopers" who haven't made misery their life-style. They are
usually willing to help themselves in any way they can. This attitude rarely fails
to transform apparently irreversible and "real" difficulties into opportunities for
personal growth. This is why I find the concept of "realistic depres- depressions"
so personally abhorrent. The attitude that depression is necessary strikes me as
so personally abhorrent. The attitude that depression is necessary strikes me as
destructive, inhuman, and vic- victimizing. Let's get down to some specifics, and
you can judge for yourself. Loss of Life. Naomi was in her mid-forties when she
received a report from her doctor that a "spot'' had appeared on her chest X ray.
She was a firm believer that going to doctors was a way of asking for trouble, so
she procrastin- procrastinated many months in checking this report out. When
she did, her worst suspicions were validated. A painful needle biopsy confirmed
the presence of malignant cells, and sub- subsequent lung removal indicated that
a spread of the cancer had already occurred. This news hit Naomi and her family
like a hand grenade. As the months wore on, she became increasingly desponddespondent over her weakened state. Why? It was not so much the physical
discomfort from the disease process or the chemotherapy, although these were
genuinely uncomfort- uncomfortable, but the fact that she was sufficiently weak
that she had to give up the daily activities that had meant a great deal to her
sense of identity and pride. She could no longer work around the house (now her
husband had to do most of the chores), and she had to give up her two part-time
234 David D. Burns, M.D. jobs, one of which was volunteer reading for the
blind. You might insist, ''Naomi's problems are real. Her misery is not caused by
distortion. It's caused by the situation." But was her depression so inevitable? I
asked Naomi why her lack of activity was so upsetting. I explained the concept
of "automatic thoughts," and she wrote down the following negative cognitions:
A) I'm not contributing to society; B) I'm not accomplishing in my own personal
realm; C) I'm not able to participate in active fun; and D) I am a drain and drag
on my husband. The emotions as- associated with these thoughts were: anger,
sadness, frustra- frustration, and guilt. When I saw what she had written down,
my heart leaped for joy! These thoughts were no different from the thoughts of
physically healthy depressed patients I see every day in my practice. Naomi's
depression was not caused by her malignancy, but the malignant attitude that
caused her to measure her sense of worth by the amount she produced! Because
she had always equated her personal worth with her achievements, the cancer
meant—"You're over the hill! You're ready for the refuse heap!" This gave me a
way to intervene! I suggested that she make a graph of her personal ' 'worth''
from the moment of birth to the moment of death (see Figure 9-1, page 235). She
saw her worth as a constant, estimating it at 85 percent on an imaginary scale
from 0 to 100 percent. I also asked her to estimate her productivity over the same
period on a similar scale. She drew a curve with low productivity in infancy,
increasing to a maximum plateau in adulthood, and finally decreasing again later
in life (see Figure 9-1). So far, so good. Then two things suddenly dawned on
her. First, while her illness had reduced her productivity, she still contributed to
herself and her family in numerous small but nevertheless important and
herself and her family in numerous small but nevertheless important and
precious ways. Only all-or-nothing thinking could make her think her
contributions were a zero. Second, and much more important, she realized her
personal worth was constant and steady; it was a given that was unrelated to her
achieveLLJ < o CO X 100 75-- 50+ 25 + 0 SELF-ESTEEM—WORTH AS A HUMAN
BEING T 45 now 10 20 30 40 50 60 70 AGE (in years) TOTAL
CONTRIBUTION TO SOCIETY, FAMILY AND SELF lu 100-p 10 20 30 40
50 60 70 AGE (in years) Figure 9-1. Naomi's worth and work graphs. In the
upper figure Naomi plotted her human "worth" from the time of her birth to the
time of her death. She estimated this at 85 percent. In the lower figure she
plotted her estimated productivity and achieve- achievement over the course of
her life. Her productivity began low in childhood, reached a plateau in
adulthood, and would ultimately fall to zero at the time of death. This graph
helped her comprehend that her "worth" and "achievement" were unrelated and
had no correlation with each other.
236 David D. Burns, M.D. ments. This meant that her human worth did not have
to be earned, and she was every bit as precious in her weak- weakened state. A
smile spread across her face, and her depres- depression melted in that moment.
It was a real pleasure for me to witness and participate in this small miracle. It
did not eliminate the tumor, but it did restore her missing self- esteem, and that
made all the difference in the way she felt. Naomi was not a patient, but
someone I spoke with while vacationing in my home state of California during
the win- winter of 1976. I received a letter from her soon after which I share
with you here: David— An incredibly belated, but really important "P.S." to my
last letter to you. To wit: the simple little "graphs" you did of productivity as
opposed to self-worth or self- esteem or whatever we shall call it: It has been
especially sustaining to me, a plus which I dose out liberally! It really turned me
into a psychologist without having to go for my Ph.D. I find that it works with
lots of things that badger and bother people. I've tried these ideas out on some of
my friends. Stephanie is treated like a piece of furniture by a chit of a secretary
one-third her age; Sue is put down constantly by her 14 year old twins; Becky's
husband has just walked out; Ilga is being made to feel like an interloper by her
boy friend's 17 year old son, etc. To them all I say "Yes, but your personal worth
is a CONSTANT, and all the garbage the world heaps on you doesn't touch it!"
Of course in many cases I realize it's an over-simplification and cannot be an
anodyne for all things, but boy is it helpful and useful! Again, thank you, sir! As
ever, Naomi She died in pain but with dignity six months later.
ever, Naomi She died in pain but with dignity six months later.
FEELING GOOD 237 Loss of Limb. Physical handicaps represent a second catcategory of problems felt to be "realistic." The afflicted in- individual—or the
family members—automatically assume that the limitations imposed by old age
or by a physical disability, such as an amputation or blindness, necessarily imply
a decreased capacity for happiness. Friends tend to offer understanding and
sympathy, thinking this represents a humane and "realistic" response. The case
can be quite the opposite, however. The emotional suffering may be caused by
twisted thinking rather than by a twisted body. In such a situation, a sympathetic
response can have the undesirable effect of reinforcing self-pity as well as
feeding into the attitude that the handicapped individual is doomed to less joy
and satisfaction than others. In contrast, when the afflicted individual or family
members learn to correct the distortions in their thinking, a full and gratifying
emo- emotional life can frequently result. For example, Fran is a thirty-fiveyear-old married mother of two, who began to experience symptoms of
depression around the time her husband's right leg became irreversibly paralyzed
because of a spinal injury. For six years she sought relief from her intensifying
sense of despair, and received a variety of treatments in and out of hospitals,
including antidepressant drugs as well as electroshock therapy. Nothing helped.
She was in a severe depression when she came to me, and she felt her problems
were insoluble. In tears she described the frustration she experienced in trying to
cope with her husband's decreased mobility: Every time I see other couples
doing things we can't do tears come to my eyes. I look at couples taking walks,
jumping in the swimming pool or the ocean, riding bikes together, and it just
hurts. Things like that would be pretty tough for me and John to do. They take it
for granted just like we used to. Now it would be so good and wonderful if we
could do it. But you know, and I know, and John knows—we can't.
238 David D. Burns, M.D. At first, I too had the feeling Fran's problem was
realistic. After all, they couldn't do many things that most of us can do. And the
same could be said of old people, as well as those who are blind or deaf or who
have had a limb am- amputated. In fact, when you think of it, we all have
limitations. So perhaps we should all be miserable. . . ? As I puzzled over this,
Fran's distortion suddenly came to my mind. Do you know what it is? Look at
the list on page 42 right now and see if you can pick it out. . . that's right, the
distortion that led to Fran's needless misery was the mental filter. Fran was
picking out and dwelling on each and every activity that was unavailable to her.
At the same time the many things she and John could or might do together did
not enter her conscious mind. No wonder she felt life was empty and dreary. The
not enter her conscious mind. No wonder she felt life was empty and dreary. The
solution turned out to be surprisingly simple. 1 pro- proposed the following to
Fran: 4'Suppose at home between sessions you were to make a list of all the
things that you and John can do together. Rather than focus on things that you
and John can't do, learn to focus on the ones you can do. I, for example, would
love to go to the moon, but I don't happen to be an astronaut, so it's not likely I'll
ever get the opportunity. Now, if I focused on the fact that in my profession and
at my age it is extremely unlikely I could ever get to the moon, I could make
myself very upset. On the other hand, there are many things 1 can do, and if 1
focus on these, then 1 won't feel disappointed. Now, what would be some things
you and John can do as a couple?" Fran: Well, we enjoy each other's company
still. We go out to dinner, and we're buddies. David: Okay. What else? Fran: We
go for rides together, we play cards. Movies, Bingo. He's teaching me how to
drive. . . David: You see, in less than thirty seconds you've al- already listed six
things you can do together. SupFEELING GOOD 239 pose I gave you between now and next session to
continue the list. How many items do you think you could come up with? Fran:
Quite a lot of them. I could come up with things we've never thought of, maybe
something un- unusual like skydiving. David: Right. You might even come up
with some more adventurous ideas. Keep in mind that you and John might in
fact be able to do many things you are assuming you can't do. For example, you
told me you can't go to the beach. You mentioned how much you'd like to go
swimming. Could you go to a beach that's a little more secluded so you wouldn't
have to feel quite so self- conscious? If I were on a beach and you and John were
there, his physical disability wouldn't make one darn bit of difference to me. In
fact, I re- recently visited a fine beach on the North Shore of Lake Tahoe in
California with my wife and her family. As we were swimming, we suddenly
happened upon a cove that had a nude beach, and here were all these young
people with no clothes on. Of course, I didn't actually look at any of them, I want
you to understand! But in spite of this I did happen to notice that one young man
had his right leg missing from the knee down, and he was there having fun with
the rest of them. So I'm not absolutely convinced that just because someone is
crippled or missing a limb they can't go to the beach and have fun. What do you
think? Some people might scoff at the idea that such a 4 'difficult and real"
problem could be so easily resolved, or that an intractable depression like Fran's
could turn around in re- response to such a simple intervention. She did in fact
report a complete disappearance of her uncomfortable feelings and
240 David D. Burns, M.D. said she felt the best she had in years at the end of the
session. In order to maintain such improvement, she will obviously need to make
session. In order to maintain such improvement, she will obviously need to make
a consistent effort to change her thinking patterns over a period of time so she
can overcome her bad habit of spinning an intricate mental web and getting
trapped in it. Loss of Job. Most people find the threat of a career re- reversal or
the loss of livelihood a potentially incapacitating emotional blow because of the
widespread assumption in Western culture that individual worth and one's
capacity for happiness are directly linked with professional success. Given this
value system, it seems obvious and realistic to anticipate that emotional
depression would be inevitably linked with financial loss, career failure, or
bankruptcy. If this is how you feel, I think you would be interested in knowing
Hal. Hal is a personable forty-five-year-old fa- father of three, who worked for
seventeen years with his wife's father in a successful merchandising firm. Three
years be- before he was referred to me for treatment, Hal and his father- in-law
had a series of disputes about the management of the firm. Hal resigned in a
moment of anger, thus giving up his interests in the company. For the next three
years, he bounced around from job to job, but had difficulty finding satisfactory
employment. He didn't seem to be able to suc- succeed at anything and began to
view himself as a failure. His wife started working full time to make ends meet,
and this added to Hal's sense of humiliation because he had always prided
himself on being the breadwinner. As the months and years rolled on, his
financial situation worsened, and he experienced increasing depression as his
self-esteem bottomed out. When I first met Hal, he had been attempting to work
for three months as a trainee in commercial real-estate sales. He had rented
several buildings, but had not yet finalized a sale. Because he was working on a
strict commission basis, his income during this break-in period was quite low.
He was plagued by depression and procrastination. He would
FEELING GOOD 241 at times stay at home in bed all day, thinking to himself,
4'What's the use? I'm just a loser. There's no point in going to work. It's less
painful to stay in bed." Hal volunteered to permit the psychiatric residents in our
training program at the University of Pennsylvania to ob- observe one of our
psychotherapy sessions through a one-way mirror. During this session, Hal
described a conversation in the locker room of his club. A well-to-do friend had
informed Hal of his interest in the purchase of a particular building. You might
think he would have jumped for joy on learning this, since the commission from
such a sale would have given his career, confidence, and bank account a much
needed boost. Instead of pursuing the contact, Hal procrastinated several weeks.
Why? Because of his thought, 'it's too complicated to sell a commercial property.
I've never done this before. Anyway, he'll probably back out at the last minute.
That would mean I couldn't make it in this business. It would mean I was a
That would mean I couldn't make it in this business. It would mean I was a
failure." Afterward, I reviewed the session with the residents. I wanted to know
what they thought about Hal's pessimistic, self-defeating attitudes. They felt that
Hal did in fact have a good aptitude for sales work, and that he was being unrealistically hard on himself. I used this as ammunition during the next session.
Hal admitted that he was more critical of himself than he would ever be toward
anyone else. For example, if one of his associates lost a big sale, he'd simply say,
'it's not the end of the world; keep plug- plugging." But if it happened to him
he'd say, "I'm a loser." Essentially, Hal admitted he was operating on a "double
standard"—tolerant and supportive toward other people but harsh, critical, and
punitive toward himself. You may have the same tendency. Hal initially
defended his double stan- standard by arguing it would be helpful to him: Hal:
Well, first of all, the responsibility and interest that I have in the other person is
not the same as the responsibility that I have for myself. David: Okay. Tell me
more.
242 David D. Burns, M.D. Hal: If they don't succeed, it's not going to be bread
off my table, or create any negative feelings within my family unit. So the only
reason I'm interested in them is because it's nice to have everybody succeed, but
there. . . David: Wait—wait—wait! You're interested in them be- because it's
nice to have them succeed? Hal: Yeah. I said . . . David: The standard you apply
to them is one that you think would help them succeed? Hal: Right. David: And
is the standard you apply to yourself the one that will help you succeed? How do
you feel when you say, "One missed sale means I'm a failure"? Hal:
Discouraged. David: Is this helpful? Hal: Well, it hasn't produced positive
results, so ap- apparently it's not helpful. David: And is it realistic to say "One
missed sale and I'm a failure"? Hal: Not really. David: So why are you using this
all-or-nothing standard on yourself? Why would you apply helpful and realistic
standards to these other people who you don't care so much about and selfdefeating, hurtful standards to yourself who you do care something about? Hal
was beginning to grasp that it wasn't helping him to live by a double standard.
He judged himself by harsh rules that he would never apply to anyone else. He
initially de- defended this tendency—as many demanding perfectionists will—
by claiming it would help him in some way to be so
FEELING GOOD 243 much harder on himself than on others. However, he then
quickly owned up to the fact that his personal standards were actually unrealistic
and self-defeating because if he did try to sell the building and didn't succeed, he
would view it as a catastrophe. His bad habit of all-or-nothing thinking was the
key to the fear that paralyzed him and kept him from trying. Consequently, he
spent most of his time in bed, moping. Hal asked for some specific guidelines
spent most of his time in bed, moping. Hal asked for some specific guidelines
concerning things he might do to rid himself of his perfectionistic double
standards so that he could judge all individuals, including himself, by one
objective set of standards. I proposed that as a first step, Hal might use the
automatic-thought, rational- response technique. For example, if he were sitting
at home procrastinating about work, he might be thinking, "If I don't go to work
early and stay all day and get caught up on all my work, there's no point in even
trying. I might as well lie in bed." After writing this down, he would substitute a
rational response, "This is just all-or-nothing thinking, and it's baloney. Even
going to work for a half day could be an important step and might make me feel
better." Hal agreed to write down a number of upsetting thoughts before the next
therapy session at those times he felt worth- worthless and down on himself.
(See Figure 9-2, page 244.) Two days later he received a layoff notice from his
employer, and he came to the next session highly convinced his self- critical
thoughts were absolutely valid and realistic. He'd been unable to come up with a
single rational response. The notice implied that his failure to show up at work
neces- necessitated his release from his job. During the session, we discussed
how he could learn to talk back to his critical voice. David: Okay, now let's see if
we can write down some answers to your negative thoughts in the Rational
Response column. Can you think of any answer based on what we talked about
last session? Con244 David D. Burns, M.D. Figure 9-2. Hal's homework for recording and
challenging his self- critical thoughts. He wrote down the Rational Responses
during the therapy session (see text). Negative Thoughts (self-criticism) 1. I am
lazy. 2. I enjoy being ill. 3. I am inadequate. I am a failure. 4. This lying around
doing nothing repre- represents the real me. 5. I could have done more. Rational
Responses (self-defense) I. I have worked hard much of my life. 2. It's not fun. 3.
I've had some degree of suc- success. We've had a good home. We've reared
three outstand- outstanding children. People admire and respect me. I have ininvolved myself in community activity. 4. I am experiencing symptoms of an
illness. It's not the "real me." 5. At least I did more than most people. It's
meaningless and pointless to say, li could have done more" because anyone
could say this. sider your statement ltI am inadequate." Would this in any way
result from your all-or-nothing thinking and perfectionistic standards? The
answer might be clearer to you if we do a role-reversal. It's sometimes easier to
speak objectively about someone else. Suppose I came to you with your story
and told you that I was employed by my wife's father. Three years ago we had a
fight. I felt I was being taken advantage of. I walked out. I've kinda been feeling
blue ever since that time, and I've been tossing around from job to job. Now I've
blue ever since that time, and I've been tossing around from job to job. Now I've
been fired from a job
FEELING GOOD 245 that was purely on a commission basis, and that's really a
double defeat for me. In the first place, they didn't pay me anything, and then in
the second place, they didn't even figure I was worth that much, so they fired me.
I've concluded that I'm inadequate—an inadequate human being. What would
you say to me? Hal: Well, I... assuming that you'd gotten up to that point, say the
first forty years or more of your life, you obviously were doing something.
David: Okay, write that down in the Rational Response column. Make a list of
all the good, adequate things you did for the first forty years of your life. You've
earned money, you've raised chil- children who were successful, etc., etc. Hal:
Okay. I can write down that I've had some suc- success. We've had a good home.
We've reared three outstanding children. People admire and respect me, and I
have involved myself in com- community activities. David: Okay, now those are
all the things you've done. How do you reconcile this with your belief that you
are inadequate? Hal: Well, I could have done more. David: Great! I was certain
you'd figure out a clever way to disqualify your good points. Now write that
down as another negative thought: "I could have done more." Beautiful! Hal:
Okay, I've written it down as number five. David: Okay, now what's the answer
to that one? (long silence) David: What is it? What's the distortion in that
thought? Hal: You're a tricky bugger! David: What is the answer?
246 David D. Burns, M.D. Hal: At least I did more than most people. David:
Right, and what percent do you believe that? Hal: That I believe one hundred
percent. David: Great! Put it down in the Rational Response col- column. Now,
let's go back to this "I could have done more." Suppose you were Howard
Hughes sitting up in his tower, with all those millions and billions. What could
you say to yourself to make yourself unhappy? Hal: Well, I'm trying to think.
David: Just read what you wrote down on the paper. Hal: Oh. "I could have done
more." David: You can always say that, can't you? Hal: Yeah. David: And that's
why a lot of people who have won fame and fortune are unhappy. It's just an exexample of perfectionistic standards. You can go on and on and on, and no
matter how much achievement you experience, you can always say, "I could
have done more." This is an ar- arbitrary way of punishing yourself. Do you
agree or not? Hal: Well, yeah. I can see that. It takes more than one element
really to be happy. Because if it was money, then every millionaire and
billionaire would be euphoric. But there are more circum- circumstances that
involve being happy or satisfied with yourself than making money. That's not the
drive that paralyzes me. I've never had a drive to go after money. David: What
drive that paralyzes me. I've never had a drive to go after money. David: What
were your drives? Did you have a drive to raise a family? Hal: That was very
important to me. Very important. And I participated in the rearing of the
children.
FEELING GOOD 247 David: And what would you do in raising your children?
Hal: Well, I would work with them, teach them, play with them. David: And
how did they come out? Hal: I think they're great! David: Now, you were writing
down, "I'm inadequate. I'm a failure." How can you reconcile this with the fact
that your aim was to raise three children and you did it? Hal: Again, I guess I
wasn't taking that into account. David: So how can you call yourself a failure?
Hal: I have not functioned as a wage earner ... as an effective money-maker for
several years. David: Is it realistic to call yourself a "failure" based on that?
Here's a man who has had a depression for three years, and he finds it difficult to
go to work, and now it's realistic to call him a failure? People with depressions
are failures? Hal: Well, if I knew more of what caused depression, I would be
better able to make a value judgment. David: Well, we're not going to know the
ultimate cause of depression for some time yet. But our under- understanding is
that the immediate cause of depres- depression is punitive, hurtful statements
that you hit yourself with. Why this happens more to some people than others we
don't know. The bio- biochemical and genetic influences have not yet been
worked out. Your upbringing undoubtedly contributed, and we can deal with that
in another session if you like. Hal: Since there is no final proof yet of the
ultimate cause of depression, can't we think of that in terms of a failure in itself?
I mean, we don't know where it's coming from ... It must be
248 David D. Burns, M.D. something wrong with me that caused it... some way
that I have failed myself that causes the depression. David: What evidence do
you have for that? Hal: I don't. It's just a possibility. David: Okay. But to make
an assumption as punishing as that. . . anything is a possibility. But there is no
evidence for that. When patients get over depressions, then they become just as
productive as they ever were. Seems to me that if their problem was that they
were failures, when they got over the depression they would still be fail- failures.
I've had college professors and corporate presidents who have come to me. They
were just sitting and staring at the wall, but it was because of their depression.
When they got over the depression, they started giving conferences and
managing their businesses like before. So how can you possibly say that
depression is due to the fact that they are failures? Seems to me that it's more the
other way around—that the failure is due to the depression. Hal: I can't answer
that. David: It's arbitrary to say that you're a failure. You have had a depression,
and people with depres- depression don't do as much as when they are unde-
and people with depres- depression don't do as much as when they are undeundepressed. Hal: Then I'm a successful depressive. David: Right! Right! And
part of being a successful de- depressive means to get better. So I hope that's
what we're doing now. Imagine that you had pneumonia for the past six months.
You wouldn't have earned any dough. You could also say, 'This makes me a
failure." Would that be re- realistic?
FEELING GOOD 249 Hal: I don't see how I could claim that. Because I
certainly wouldn't have willfully created the pneumonia. David: Okay, can you
apply the same logic to your depression? Hal: Yeah, I can see it. I don't honestly
feel that my depression was willfully induced either. David: Of course it wasn't.
Did you want to bring this on? Hal: Oh boy, no! David: Did you consciously do
anything to bring it on? Hal: Not that I know of. David: And if we knew what
was causing depression, then we could put the finger someplace. Since we don't
know, isn't it silly to blame Hal for his own depression? What we do know is
that de- depressed people get this negative view of them- themselves. And they
feel and behave in accord with this negative vision of everything. You didn't
bring that on purposely or choose to be incapa- incapacitated. And when you get
over that vision and when you have switched back to a nondepressed way of
looking at things, you are going to be just as productive or more so than you've
ever been, if you're typical of other patients that I've worked with. You see what
I mean? Hal: Yeah, I can see. It was a relief for Hal to realize that although he
had been financially unsuccessful for several years, it was nonsensical to label
himself as "a failure." This negative self-image and his sense of paralysis
resulted from his all-or-nothing thinking. His sense of worthlessness was based
on his ten- tendency to focus only on the negatives in his life (the mental filter)
and to overlook the many areas where he had expe250 David D. Burns, M.D. rienced success (discounting the positive). He was
able to see that he was aggravating himself unnecessarily by saying, "I could
have done more," and he realized that financial value is not the same as human
worth. Finally, Hal was able to admit that the symptoms he was experiencing—
lethargy and procrastination—were simply manifestations of a temporary disease
process and not indications of his "true self." It was absurd for him to think his
depression was just punishment for some personal inadequacy, any more than
pneumonia would be. At the end of the session, the Beck Depression Inventory
test indicated that Hal had experienced a 50 percent im- improvement. In the
weeks that followed, he continued to help himself, using the double-column
technique. As he trained himself to talk back to his upsetting thoughts, he was
able to reduce the distortions in his harsh way of evaluating himself, and his
able to reduce the distortions in his harsh way of evaluating himself, and his
mood continued to improve. Hal left the real-estate business and opened a
paperback bookstore. He was able to break even; but in spite of conconsiderable personal effort, he was unable to show enough profit to justify
continuing beyond the first year's trial pe- period. Thus, the marks of external
success had not changed appreciably during this time. In spite of this, Hal
managed to avoid significant depression and maintained his self- esteem. The
day he decided to "throw in the towel" on the bookstore, he was still below the
zero point financially, but his self-respect did not suffer. He wrote the following
brief essay which he decided to read each morning while he was looking for a
new job: Why Am I Not Worthless? As long as I have something to contribute to
the well- being of myself and others, I am not worthless. As long as what I do
can have a positive effect, I am not worthless.
FEELING GOOD 251 As long as my being alive makes a difference to even one
person, I am not worthless (and this one person can be me if necessary). If
giving love, understanding, companionship, en- encouragement, sociability,
counsel, solace means anything, I am not worthless. If I can respect my opinions,
my intelligence, I am not worthless. If others also respect me, that is a bonus. If I
have self-respect and dignity, I am not worthless. If helping to contribute to the
livelihood of my em- employees' families is a plus, I am not worthless. If I do
my best to help my customers and vendors through my productivity and
creativity, I am not worthless. If my presence in this milieu does makes a
difference to others, I am not worthless. I am not worthless. I am eminently
worthwhile! Loss of a Loved One. One of the most severely depressed patients I
treated early in my career was Kay, a thirty-one- year-old pediatrician whose
younger brother had committed suicide in a grisly way outside her apartment six
weeks earlier. What was particularly painful for Kay was that she held herself
responsible for his suicide, and the arguments she proposed in support of this
point of view were quite convincing. Kay felt she was confronted by an
excruciating problem that was entirely realistic and insoluble. She felt that she
too deserved to die and was actively suicidal at the time of referral. A frequent
problem that plagues the family and friends of an individual who successfully
commits suicide is the sense of guilt. There is a tendency to torture yourself with
such thoughts as, "Why didn't I prevent this? Why was I so stupid?" Even
psychotherapists and counselors are not immune to such reactions and may
castigate themselves: "It's really my fault. If only I had talked to him differently
in that last session. Why didn't I pin him down on whether
252 David D. Burns, M.D. or not he was suicidal? I should have intervened more
252 David D. Burns, M.D. or not he was suicidal? I should have intervened more
forcefully. I murdered him!" What adds to the tragedy and irony is that in the
vast majority of instances, the suicide occurs because of the victim's distorted
belief that he has some insoluble problem which, viewed from a more objecobjective perspective, would seem much less overwhelming and certainly not
worth suicide. Kay's self-criticism was all the more intense because she felt that
she had gotten a better break in life than her brother, and so she had gone out of
her way to try to com- compensate for this by providing emotional and financial
sup- support for him during his long bout with depression. She arranged for his
psychotherapy, helped pay for it, and even got him an apartment near hers so
that he could call her whenever he was very down. Her brother was a physiology
student in Philadephia. On the day of his suicide, he called Kay to ask about the
effects of carbon monoxide on the blood for a talk he was to give in class.
Because Kay is a blood specialist, she thought the question was innocent and
gave him the information with- without thinking. She didn't talk to him very long
because she was preparing a major lecture to deliver the following morning at
the hospital where she worked. He used her information to make his fourth and
final attempt outside her apartment window while she was preparing her lecture.
Kay held herself responsible for his death. She was understandably miserable,
given the tragic sit- situation she confronted. During the first few therapy
sessions she outlined why she blamed herself and why she was con- convinced
that she would be better off dead: "I had assumed the responsibility for my
brother's life. I failed, so I feel I am responsible for his death. It proves that I did
not ade- adequately support him as I should have. I should have known that he
was in an acute situation, and I failed to intervene. In retrospect, it's obvious that
he was getting suicidal again. He'd had three prior serious suicide attempts. If I
had just asked him when he called me, I could have saved his life.
FEELING GOOD 253 I was angry with him on many occasions during the
month before he died, and in all honesty he could be a burden and a frustration at
times. At one time I remember feeling an- annoyed and saying to myself that
perhaps he would be better off dead. I feel terrible guilt for this. Maybe I wanted
him to die! I know that I let him down, and so I feel that I deserve to die." Kay
was convinced that her guilt and agony were appro- appropriate and valid. Being
a highly moral person with a strict Catholic upbringing, she felt that punishment
and suffering were expected of her. I knew there was something fishy about her
line of reasoning, but I couldn't quite penetrate her illogic for several sessions
because she was bright and persuasive and made a convincing case against
herself. I almost began to buy her belief that her emotional pain was "realistic."
Then, the key that I hoped might free her from her mental prison suddenly
dawned on me. The error she was making was number ten discussed in Chapter
dawned on me. The error she was making was number ten discussed in Chapter
3—per- 3—personalization. At the fifth therapy session, I used this insight to
challenge the misconceptions in Kay's point of view. First of all, I emphasized
that if she were responsible for her brother's death, she would have had to be the
cause of it. Since the cause of suicide is not known, even by experts, there was
no reason to conclude that she was the cause. I told her that if we had to guess
the cause of his suicide, it would be his erroneous conviction that he was
hopeless and worthless and that his life was not worth living. Since she did not
control his thinking, she could not be responsible for the illogical assumptions
that caused him to end his life. They were his errors, not hers. Thus, in assuming
respon- responsibility for his mood and actions, she was doing so for something
that was not within her domain of control. The most that anyone could or would
expect of her was to try to be a helping agent, as she had been within the limits
of her ability. I emphasized that it was unfortunate she did not have the
254 David D. Burns, M.D. knowledge necessary to prevent his death. If it had
dawned on her that he was about to make a suicide attempt, she would have
intervened in whatever manner possible. How- However, since she did not have
this knowledge, it was not possible for her to intervene. Therefore, in blaming
herself for his death she was illogically assuming that she could predict the
future with absolute certainty, and that she had all the knowledge in the universe
at her disposal. Since both these expectations were highly unrealistic, there was
no reason for her to despise herself. I pointed out that even professional
therapists are not infallible in their knowledge of human nature, and are
frequently fooled by suicidal pa- patients in spite of their presumed expertise.
For all these reasons, it was a major error to hold herself responsible for his
behavior because she was not ultimately in control of him. I emphasized that she
was responsible for her own life and well-being. At this point it dawned on her
that she was acting irresponsibly, not because she "let him down" but because
she was allowing herself to become depressed and was contemplating her own
suicide. The re- responsible thing to do was to refuse to feel any guilt and to end
the depression, and then to pursue a life of happiness and satisfaction. This
would be acting in a responsible man- manner. This discussion was followed by
a rapid improvement in her mood. Kay attributed this to a profound change in
her attitude. She realized we had exposed the misconceptions that made her want
to kill herself. She then elected to remain in therapy for a period of time in order
to work on enhancing the quality of her own life, and to dispel the chronic sense
of oppression that had plagued her for many years prior to her brother's suicide.
Sadness Without Suffering. The question then arises, What is the nature of
"healthy sadness" when it is not at all contaminated by distortion? Or to put it
"healthy sadness" when it is not at all contaminated by distortion? Or to put it
another way— does sadness really need to involve suffering?
FEELING GOOD 255 While I cannot claim to know the definitive answer to
this question, I would like to share an experience which occurred when I was an
insecure medical student, and I was on my clinical rounds on the urology service
in the hospital at Stanford University Medical Center in California. I was
assigned to an elderly man who recently had had a tumor successfully removed
from his kidney. The staff anticipated his rapid discharge from the hospital, but
his liver function suddenly began to deterioriate, and it was discovered that the
tumor had metastasized to his liver. This sad compli- complication was
untreatable, and his health began to fail rapidly over several days. As his liver
function worsened, he slowly began to get groggier, slipping toward an
unconscious state. His wife, aware of the seriousness of the situation, came and
sat by his side night and day for over forty-eight hours. When she was tired, her
head would fall on his bed, but she never left his side. At times she would stroke
his head and tell him, "You're my man and I love you." Because he was placed
on the critical list, the members of his large family, including children,
grandchildren, and great- greatgrandchildren, began to arrive at the hospital from
various parts of California. In the evening the resident in charge asked me to stay
with the patient and attend the case. As I entered the room, I realized that he was
slipping into a coma. There were eight or ten relatives there, some of them very
old and others very young. Although they were vaguely aware of the seseriousness of his condition, they had not been informed of just how grave the
imminent situation was. One of his sons, sensing the old gentleman was nearing
the end, asked me if 1 would be willing to remove the catheter which was
draining his bladder. 1 realized the removal of the catheter would indicate to the
family that he was dying, so I went to ask the nursing staff if this would be
appropriate to do. The nursing staff told me that it would because he was indeed
dying. After they showed me how to remove a cath- catheter, I went back to the
patient and did this while the family
256 David D. Burns, M.D. waited. Once 1 was done, they realized that a certain
support had been removed, and the son said, 'Thank you. I know it was
uncomfortable for him, and he would have appre- appreciated this." Then the son
turned to me as if to confirm the meaning of the sign and asked, 4'Doctor, what
is his con- condition? What can we expect?" I felt a sudden surge of grief. I had
felt close to this gentle, courteous man because he reminded me of my own
grandfather, and I realized that tears were running down my cheeks. I had to
make a decision either to stand there and let the family see my tears as I spoke
make a decision either to stand there and let the family see my tears as I spoke
with them or to leave and try to hide my feelings. I chose to stay and said with
considerable emotion, "He is a beautiful man. He can still hear you, although he
is nearly in a coma, and it is time to be close to him and say good-bye to him
tonight." I then left the room and wept. The family members also cried and sat
on the bed, while they talked to him and said good-bye. Within the next hour his
coma deepened until he lost con- consciousness and died. Although his death
was profoundly sad for tH^e family and for me, there was a tenderness and a
beauty to the experience that I will never forget. The sense of loss and the
weeping reminded me—"You can love. You can care." This made the grief an
elevating experience that was entirely devoid of pain or suffering for me. Since
then, I have had a number of experiences that brought me to tears in this same
way. For me the grief represents an elevation, an experience of the highest
magnitude. Because I was a medical student, I was concerned that my behavior
might be seen as inappropriate by the staff. The chairman of the department later
took me aside and informed me that the patient's family had asked him to extend
their appreciation to me for being available to them and for helping make the
occasion of his passing intimate and beautiful. He told me that he too had always
felt strongly toward this particular individual, and showed me a painting of a
horse the elderly man had done which was hanging on his wall.
FEELING GOOD 257 The episode involved a letting go, a feeling of closure,
and a sense of good-bye. This was in no way frightening or terrible; but in fact, it
was peaceful and warm, and added a sense of richness to my experience of life.
Part IV Prevention and Personal Growth
Chapter 10 The Cause of It All When your depression has vanished, it's a
temptation to enjoy yourself and relax. Certainly you're entitled. Toward the end
of therapy, many patients tell me they feel the best they've ever felt in their lives.
It sometimes seems that the more hopeless and severe and intractable the
depression seemed, the more extraordinary and delicious the taste of happiness
and self-esteem once it is over. As you begin to feel better, your pessimistic
thinking pattern will recede as dramatically and predictably as the melting of
winter's snow when spring arrives. You may even wonder how in the world you
came to believe such unrealistic thoughts in the first place. This profound
transformation of the human spirit never ceases to amaze me. Over and over I
have the op- opportunity to observe this magical metamorphosis in my daily
practice. Because your change in outlook can be so dramatic, you may feel
convinced that your blues have vanished forever. But there is an invisible
residue of the mood disorder that remains. If this is not corrected and eliminated,
residue of the mood disorder that remains. If this is not corrected and eliminated,
you will be vulnerable to attacks of depression in the future. There are several
differences between feeling better and getting better. Feeling better simply
indicates that the painful symptoms have temporarily disappeared. Getting better
im- implies: 261
262 David D. Burns, M.D. 1. Understanding why you got depressed. 2. Knowing
why and how you got better. This involves a mastery of the particular self-help
techniques that worked specifically for you so that you can reapply them and
make them work again whenever you choose. 3. Acquiring self-confidence and
self-esteem. Self- confidence is based on the knowledge that you have a good
chance of being reasonably successful in per- personal relationships and in your
career. Self-esteem is the capacity to experience maximal self-love and joy
whether or not you are successful at any point in your life. 4. Locating the
deeper causes of your depression. Parts I, II, and III of this book were designed
to help you achieve the first two goals. The next several chapters will help you
with the third and fourth goals. Although your distorted negative thoughts will
be sub- substantially reduced or entirely eliminated after you have re- recovered
from a bout of depression, there are certain "silent assumptions" that probably
still lurk in your mind. These silent assumptions explain in large part why you
became depressed in the first place and can help you predict when you might
again be vulnerable. And they contain therefore the key to relapse prevention.
Just what is a silent assumption? A silent assumption is an equation with which
you define your personal worth. It represents your value system, your personal
philosophy, the stuff on which you base your self-esteem. Examples: A) "If
someone criticizes me, I feel miserable because this automatically means there is
something wrong with me." B) "To be a truly fulfilled human being, I must be
loved. If I am alone, I am bound to be lonely and miserable." C) "My worth as a
human being is proportional to what I've achieved." D) "If I don't perform (or
feel or act) perfectly, I have failed." As you will learn, these illogical
FEELING GOOD 263 assumptions can be utterly self-defeating. They create a
vulnerability that predisposes you to uncomfortable mood swings. They
represent your psychological Achilles' heel. In the next several chapters you will
learn to identify and evaluate your own silent assumptions. You might find that
an addiction to approval, love, achievement, or perfection forms the basis of
your mood swings. As you learn to expose and challenge your own selfdefeating belief system, you will lay the foundation for a personal philosophy
that is valid and self-enhancing. You will be on the road to joy and emotional
enlightenment. In order to unearth the origins of your mood swings, most
enlightenment. In order to unearth the origins of your mood swings, most
psychiatrists, as well as the general public, assume that a long and painfully slow
(several years) therapeutic process is necessary, after which most patients would
find it difficult to explain the cause of their depression. One of the greatest
contributions of cognitive therapy has been to circumvent this. In this chapter
you will learn two different ways to iden- identify silent assumptions. The first is
a startlingly effective method called the "vertical-arrow technique," which
allows you to probe your inner psyche. The vertical-arrow technique is actually a
spin-off of the double-column method introduced in Chapter 4, in which you
learned how to write down your upsetting automatic thoughts in the left-hand
column and substitute more ob- objective rational responses. This method helps
you feel better because you deprogram the distortions in your thinking patpatterns. A brief example is shown in Figure 10-1. It was written by Art, the
psychiatric resident described in Chapter 7, who became upset after his
supervisor tried to offer a constructive criticism. Putting the lie to his upsetting
thoughts reduced Art's feelings of guilt and anxiety, but he wanted to know how
and why he made such an illogical interpretation in the first place. Perhaps
you've also begun to ask yourself—is there a pattern inherent in my negative
thoughts? Is there some psychic kink that exists on a deeper level of my mind?
264 David D. Burns, M.D. Figure 10-1. Automatic Thoughts 1. Dr. B said the
patient found my comment ab- —♦ rasive. He probably thinks I'm a lousy thertherapist. Rational Responses 1. Mind reading; mental filter; labeling. Just
because Dr. B pointed out my error it doesn't follow he thinks I'm a 'Mousy
therapist/' I'd have to ask him to see what he really thinks, but on many
occasions he has praised me and said I had outstanding talent. Art used the
vertical-arrow technique to answer these questions. First, he drew a short
downward arrow directly beneath his automatic thought (see Figure 10-2, page
265). This downward arrow is a form of shorthand which tells Art to ask
himself, " If this automatic thought were actually true, what would it mean to
me? Why would it be upsetting to me?" Then Art wrote down the next automatic
thought that immediately came to mind. As you can see, he wrote, "If Dr. B.
thinks I'm a lousy therapist, it would mean I was a lousy therapist because Dr. B.
is an expert." Next Art drew a second downward arrow beneath this thought and
repeated the same process so as to generate yet another automatic thought, as
shown in Figure 10-2. Every time he came up with a new automatic thought, he
immediately drew a vertical arrow beneath it and asked himself, "If that were
true, why would it upset me?" As he did this over and over, he was able to
generate a chain of automatic thoughts, which led to the silent assumptions that
gave rise to his problems. The downward-arrow method is analogous to peeling
gave rise to his problems. The downward-arrow method is analogous to peeling
successive layers of skin off an onion to expose
Figure 10-2. Exposing the silent assumption(s) that give rise to your automatic
thoughts with the use of the vertical-arrow meth- method. The downward arrow
is a form of shorthand for the following questions: "If that thought were true,
why would it upset me? What would it mean to me?" The question represented
by each downward arrow in the example appears in quotation marks next to the
arrow. This is what you might ask yourself if you had written down the
automatic thought. This process leads to a chain of au- automatic thoughts that
will reveal the root cause of the problem. Automatic Thoughts Rational
Responses 1. Dr. B. probably thinks —* I'm a lousy therapist. i 'if he did think
this, why would it be upsetting to me?" 2. That would mean I was —> a lousy
therapist because he's an expert. | "Suppose I was a lousy therapist, what would
this mean to me?" 3. That would mean I was —> a total failure. It would mean I
was no good. i "Suppose I was no good. Why would this be a problem? What
would it mean to me?" 4. Then the word would spread and everyone would find
out what a bad person I was. Then no one would respect me. Td get drummed
out of the medical society,
266 David D. Burns, M.D. Figure 10-2. cont. Automatic Thoughts Rational
Responses and Pd have to move to another state. 1 "And what would that
mean?" 5. It would mean I was worthless. I'd feel so miserable I'd want to die.
the ones beneath. It is actually quite simple and straight- straightforward, as you
will see in Figure 10-2. You will notice that the vertical-arrow technique is the
opposite of the usual strategy you use when recording your automatic thoughts.
Ordinarily you substitute a rational re- response that shows why your automatic
thought is distorted and invalid (Figure 10-1). This helps you change your thinkthinking patterns in the here and now so that you can think about life more
objectively and feel better. In the vertical-arrow method you imagine instead that
your distorted automatic thought is absolutely valid, and you look for the grain
of truth in it. This enables you to penetrate the core of your problems. Now
review Art's chain of automatic thoughts in Figure 10-2 and ask yourself—what
are the silent assumptions that predispose him to anxiety, guilt, and depression?
There are several: 1. If someone criticizes me, they're bound to be correct. 2. My
worth is determined by my achievement. 3. One mistake and the whole is ruined.
If I'm not suc- successful at all times, I'm a total zero. 4. Others won't tolerate my
imperfection. I have to be
FEELING GOOD 267 perfect to get people to respect and like me. When I goof
up, I'll encounter fierce disapproval and be punished. 5. This disapproval will
up, I'll encounter fierce disapproval and be punished. 5. This disapproval will
mean I am a bad, worthless person. Once you have generated your own chain of
automatic thoughts and clarified your silent assumptions, it is crucial to pinpoint
the distortions and substitute rational responses as you usually do (see Figure 10
—3, page 268). The beauty of the downward-arrow method is that it is inductive
and Socratic: Through a process of thoughtful questioning, you discover on your
own the beliefs that defeat you. You unearth the origin of your problems by
repeating the following questions over and over: "If that negative thought were
true, what would it mean to me? Why would it upset me?" Without introducing
some therapist's subjec- subjective bias or personal beliefs or theoretical
leanings, you can objectively and systematically go right to the root of your
problems. This circumvents a difficulty that has plagued the history of
psychiatry. Therapists from all schools of thought have been notorious for
interpreting patients' experiences in terms of preconceived notions that may have
little or no experimental validation. If you don't "buy" your therapist's
explanation of the origin of your problems, this is likely to be interpreted as
"resistance" to the "truth." In this subtle way, your troubles get forced into your
therapist's mold regardless of what you say. Imagine the bewildering array of
explanations for suffering that you would hear if you went to a religious
counselor (spiritual factors), a psychi- psychiatrist in a Communist country (the
social-political-economic environment), a Freudian analyst (internalized anger),
a be- behavior therapist (a low rate of positive reinforcement), a drug-oriented
psychiatrist (genetic factors and brain- chemistry imbalance), a family therapist
(disturbed inter- interpersonal relationships), etc.! A word of caution when you
apply the vertical-arrow method. You will short-circuit the process if you write
down
Figure 10-3. After eliciting hischain of automaticthoughts, us- using the
downward-arrow method, Art Identified the cognitive dis- distortions and
substituted more objective responses. Automatic Thoughts Rational Responses I.
Dr. B. probably thinks I'm a lousy therapist. i "If he did think this, why would it
be upsetting to me?" 2. That would mean I was a lousy therapist because he's an
expert. i "Suppose I was a lousy therapist, what would this mean to me?" 3. That
would mean I was a total failure. It would mean I was no good. i "Suppose I was
no good. Why would this be a problem? What would it mean to me?" 4. Then
the word would spread and everyone 1. Just because Dr. B. pointed out my error
it doesn't follow he thinks I'ma "lousy therapist." I'd have to ask him to see what
he really thinks, but on many occasions he has praised me and said I had
outstanding talent. 2. An expert can only point out my specific strengths and
weaknesses as a therapist. Any time any- anyone labels me as "lousy" they are
weaknesses as a therapist. Any time any- anyone labels me as "lousy" they are
simply making a global, de- destructive, useless state- statement. I have had a lot
of success with most of my patients, so it can't be true I'm "lousy" no matter who
says it. 3. Overgeneralization. Even if I was relatively unskilled and ineffective
as a therapist, it wouldn't mean I was "a total failure" or "no good." I have many
other interests, strengths, and desirable qualities that aren't re- related to my
career. 4. This is absurd. If I made a mistake, I can correct
FEELING GOOD 269 Figure 10-3. cont. Automatic Thoughts would find out
what a bad person I was. Then no one would respect me. I'd get drummed out
—» of the medical society, and I'd have to move to another state. | "And what
would that mean?" 5. It would mean I was worthless. I'd feel so —> miserable
I'd want to die. Rational Responses it. "The word" isn't going to spread around
the state like wildfire just because I made an error! What are they going to do,
publish a headline in the newspaper: "noted PSYCHIATRIST MAKES
MISTAKE"? 5. Even if everyone in the world disapproves of me or criticizes
me, it can't make me worthless be- because I'm not worthless. If I'm not
worthless, I must be quite worth- worthwhile. So, what is there to feel miserable
about? thoughts that contain descriptions of your emotional reac- reactions.
Instead, write down the negative thoughts that cause your emotional reactions.
Here's an example of the wrong way to do it: First Automatic Thought: My
boyfriend didn't call me this weekend as he promised he would. >i "Why is that
upsetting to me? What does it mean to me?" Second Automatic Thought: Oh, it's
awful and terrible be- because I can't stand it. This is useless. We already know
you feel awful and terrible. The question is—what thoughts automatically
crossed your mind that caused you to feel so upset? What would it mean to you
if he had neglected you? Here's the correct way to do it:
270 David D. Burns, M.D. 1. My boyfriend didn't call me this weekend as he
promised he would. 4 "Why would that be upsetting to me? What does it mean
to me?" 2. That means he's neglecting me. That means he really doesn't love me.
4 "And suppose that were true. What would that mean to me?" 3. That would
mean there's something wrong with me. Otherwise he'd be more attentive. | "And
suppose that were true. What would that mean to me?" 4. That would mean I
was going to be rejected. 4 "And if I were in fact rejected, what then? What
would that mean to me?" 5. That would mean I was unlovable and I would
always be rejected. | "And if that happened, why would it upset me?" 6. That
would mean I'd end up alone and miserable. Thus, by pursuing the meaning
rather than your feelings, your silent assumptions became obvious: A) If I'm not
loved I'm not worthwhile; and B) I'm bound to be miserable if I'm alone. This is
not to say your feelings aren't important. The whole point is to deliver the real
not to say your feelings aren't important. The whole point is to deliver the real
McCoy—valid emotional transformation. The Dysfunctional Attitude Scale
(DAS). Because of the crucial importance of eliciting the silent assumptions that
give rise to your mood swings, a second, simpler method for eliciting them
called the "Dysfunctional Attitude Scale"
FEELING GOOD 271 (DAS) has been developed by a member of our group,
Dr. Arlene Weissman. She has compiled a list of one hundred self-defeating
attitudes that commonly occur in individuals predisposed to emotional disorders.
Her research has indi- indicated that while negative automatic thoughts are
reduced dramatically between episodes of depression, a self- defeating belief
system remains more or less constant during episodes of depression and
remission. Dr. Weissman's stud- studies confirm the concept that your silent
assumptions rep- represent a predisposition to emotional turbulence that you
carry with you at all times. Although a complete presentation of the lengthy DysDysfunctional Attitude Scale would be beyond the scope of this book, I have
selected a number of the more common atti- attitudes and have added several
others which will be useful. As you fill out the questionnaire, indicate how much
you agree or disagree with each attitude. When you are finished, an answer key
will let you score your answers and generate a profile of your personal value
systems. This will show your areas of psychological strength and vulnerability.
Answering the test is quite simple. After each of the thirty-five attitudes, put a
check in the column that represents your estimate of how you think most of the
time. Be sure to choose only one answer for each attitude. Because we are all
different, there is no "right" or "wrong" answer to any statement. To decide
whether a given attitude is typical of your own philosophy, recall how you look
at things most of the time.
272 David D. Burns, M.D. EXAMPLE: 35. People who have the marks of
success (good looks, social sta- status, wealth, or fame) are bound to be happier
than those who do not. Agree Strongly Agree Slightly J Neutral Disagree
Slightly Disagree Very Much In this example the checkmark in the Agree
Slightly column indicates that the statement is somewhat typical of the attitudes
of the person completing the inventory. Now go ahead. The Dysfunctional
Attitude Scale* I. Criticism will ob- obviously up- upset the person who receives
the criticism. Agree Strongly Agree Slightly Neutral Disagree Slightly Disagree
Very Much ♦Copyright 1978, Arlene Weissman.
FEELING GOOD 273 2. It is best to give up my own inter- interests in order to
please other peo- people. 3. I need other people's ap- approval in order to be
please other peo- people. 3. I need other people's ap- approval in order to be
happy. 4. If someone important to me expects me to do something, then I really
should do it. 5. My value as a person de- depends greatly on what others think of
me. 6. I cannot find happi- happiness without being loved by another person.
Agree Strongly Agree Slightly Neutral Disagree Slightly Disagree Very Much
274 David D. Burns, M.D. 7. If others dislike you, you are bound to be less
happy. 8. If people whom I care about reject me, it means there is something
wrong with me. 9. If a person I love does not love me, it means I am unlovable.
10. Being iso- isolated from others is bound to lead to un- happiness. 11. If I am
to be a worth- worthwhile per- person, I must be truly out- outstanding in at least
one major re- respect. Agree Strongly Agree Slightly Neutral Disagree Slightly
Disagree Very Much
FEELING GOOD 275 12. I must be a useful, pro- productive, creative perperson or life has no pur- purpose. 13. People who have good ideas are more
wor- worthy than those who do not. 14. If I do not do as well as other people, it
means I am inferior. 15. If I fail at my work, then I am a failure as a person. 16.
If you can- cannot do something well, there is little point in doing it at all. Agree
Strongly Agree Slightly Neutral Disagree Slightly Disagree Very Much
276 David D. Burns, M.D. 17. It is shame- shameful for a person to display his
weaknesses. 18. A person should try to be the best at everything he underundertakes. 19. I should be upset if 1 make a mis- mistake. 20. If 1 don't set the
high- highest stan- standards for myself, I am likely to end up a second-rate
person. 21. If I strongly believe I deserve something, I have reason to expect that
I should get it. Agree Strongly Agree Slightly Neutral Disagree Slightly
Disagree Very Much
FEELING GOOD 277 22. It is neces- necessary to be- become frustrated if you
find ob- obstacles to getting what you want. 23. If 1 put other peo- people's
needs before my own, they should help me when I need some- something from
them. 24. If I am a good hus- husband (or wife), then my spouse is bound to love
me. 25. If I do nice things for someone, I can antici- anticipate that they will rerespect me and treat me just as well as I treat them. Agree Strongly Agree
Slightly Neutral Disagree Slightly Disagree Very Much
278 David D. Bums. M.D. 26. I should as- assume re- responsibility for how
people feel and behave if they are close to me. 27. If I criticize the way someone
does some- something and they become angry or de- depressed, this means I
have upset them. 28. To be a good, worthwhile, moral per- person, I must try to
have upset them. 28. To be a good, worthwhile, moral per- person, I must try to
help everyone who needs it. Agree Strongly Agree Slightly Neutral Disagree
Slightly Disagree Very Much
FEELING GOOD 279 29. If a child is having emo- emotional or be- behavioral
difficulties, this shows that the child's par- parents have failed in some imimportant re- respect. 30. I should be able to please everybody. 31. I cannot exexpect to con- control how I feel when something bad hap- happens. 32. There is
no point in trying to change up- upsetting emo- emotions because they are a
valid and inevitable part of daily living. Agree Strongly Agree Slightly Neutral
Disagree Slightly Disagree Very Much
280 David D. Burns, M.D. 33. My moods are primar- primarily created by
factors that are largely be- beyond my control, such as the past, or body chemchemistry, or hormone cycles, or biorhythms, or chance, or fate. 34. My happihappiness is largely de- dependent on what hap- happens to me. 35. People who
have the marks of success (good looks, social sta- status, wealth, or fame) are
bound to be happier than those who do not. Agree Strongly Agree Slightly
Neutral Disagree Slightly Disagree Very Much
FEELING GOOD 281 Now that you have completed the DAS, you can score it
in the following way. Score your answer to each of the thirty-five attitudes
according to this key: Agree Strongly -2 Agree Slightly -1 Neutral 0 Disagree
Slightly + 1 Disagree Very Much + 2 Now add up your score on the first five
attitudes. These measure your tendency to measure your worth in terms of the
opinions of others and the amount of approval or crit- criticism you receive.
Suppose your scores on these five items were -1-2; + 1; — 1; +2;0. Then your
total score for these five questions would be + 4. Proceed in this way to add up
your score for items 1 through 5, 6 through 10, 11 through 15, 16 through 20, 21
through 25, 26 through 30, and 31 through 35, and record these as illustrated in
the following example: SCORING EXAMPLE: Value System I. Approval II.
Love III. Achievement IV. Perfectionism Attitudes 1 through 5 6 through 10 11
through 15 16 through 20 Individual Scores + 2, +1, -1, +2,0 -2, -1, -2, -2,0 + 1,
+1,0, 0, -2 + 2, +2, + L + L + 1 Total Scores + 4 _ -j 0 + 7
282 David D. Burns, M.D. SCORING EXAMPLE continued: Value System V.
Entitlement VI. Omnipotence VII. Autonomy Attitudes 21 through 25 26
through 30 31 through 35 Individual Scores + 1, +», -1. +1,0 -2. -1,0, -1, +1 ~2,
~2, -1,-2,-2 Total Scores + 2 -3 — G RECORD YOUR ACTUAL SCORES
HERE: Value System I. Approval II. Love HI. Achievement IV. Perfectionism
V. Entitlement VI. Omnipotence VII. Autonomy Attitudes 1 through 5 6 through
V. Entitlement VI. Omnipotence VII. Autonomy Attitudes 1 through 5 6 through
10 II through IS 16 through 20 21 through 25 26 through 30 31 through 35
Individual Scores Total Scores
FEELING GOOD 283 Each cluster of five items from the scale measures one of
seven value systems. Your total score for each cluster of five items can range
from + 10 to — 10. Now plot your total scores on each of the seven variables so
as to develop your "personal-philosophy profile" as follows: SCORING
EXAMPLE: 03 O CO If co i= CL(f) co <D • MM* Ej UJ lit IV. V. VI. VII
284 David D. Burns, M.D. As you can see, a positive score represents an area
where you are psychologically strong. A negative score represents an area where
you're emotionally vulnerable. This individual has strengths in the areas of
approval, perfectionism, and entitlement. His vulnerabilities lie in the areas of
love, omnipotence, and autonomy. The meanings of these concepts will be
described. First, plot your own personal-philosophy profile here. '5b g «/3 w CU
CO o 2 o £ uu > 4- If) t + 2l 0 _ 2 L - 4 II - 6 I - 8 -io 4- 1 II. Ill IV. V. VI. VII
FEELING GOOD 285 Interpreting Your DAS Scores /. Approval. The first five
attitudes on the DAS test probe your tendency to measure your self-esteem based
on how people react to you and what they think of you. A positive score between
zero and ten indicates you are in- independent, with a healthy sense of your own
worth even when confronted with criticism and disapproval. A negative score
between zero and minus ten indicates you are exces- excessively dependent
because you evaluate yourself through other people's eyes. If someone insults
you or puts you down, you automatically tend to look down on yourself. Since
your emotional well-being is exquisitely sensitive to what you imagine people
think of you, you can be easily manipulated, and you are vulnerable to anxiety
and depres- depression when others criticize you or are angry with you. //. Love.
The second five attitudes on the test assess your tendency to base your worth on
whether or not you are loved. A positive score indicates you see love as
desirable, but you have a wide range of other interests you also find gratifying
and fulfulling. Hence, love is not a requirement for your happiness or selfesteem. People are likely to find you attractive because you radiate a healthy
sense of self- love and are interested in many aspects of living. A negative score
indicates you are a 'Move junkie." You see love as a "need" without which you
cannot survive, much less be happy. The closer your score is to minus ten, the
more dependent on love you are. You tend to adopt inferior, put-down roles in
relationships with people you care about for fear of alienating them. The result
of this, more often than not, is that they lose respect for you and consider you a
of this, more often than not, is that they lose respect for you and consider you a
burden because of your attitude that without their love you would collapse. As
you sense that people drift away from you, you become gripped by a painful,
terrifying withdrawal syndrome. You realize you may not be able to "shoot up"
with your daily dose of affection and attention. You then become consumed by
the driving com286 David D. Burns, M.D. pulsion to "get love." Like most junkies, you may
even resort to coercive, manipulative behavior to get your "stuff." Ironically,
your needy, greedy love addiction drives many people away, thus intensifying
your loneliness. ///. Achievement Your score on attitudes 11 through 15 will help
you measure a different type of addiction. A neg- negative score indicates you
are a workaholic. You have a constricted sense of your own humanity, and you
see your- yourself as a commodity in the marketplace. The more negative your
score, the more your sense of self-worth and your capacity for joy are dependent
on your productivity. If you go on vacation, if your business slumps, if you retire
or become ill and inactive, you will be in danger of an emo- emotional crash.
Economic and emotional depressions will seem identical to you. A positive
score, in contrast, indicates that you enjoy creativity and productivity, but do not
see them as an exclusive or necessary road to self-esteem and satis- satisfaction.
IV. Perfectionism. Items 16 through 20 measure your tendency to perfectionism.
A negative score indicates you are hooked on searching for the Holy Grail. You
demand perfection in yourself—mistakes are taboo, failure is worse than death,
and even negative emotions are a disaster. You're supposed to look, feel, think,
and behave superbly at all times. You sense that being less than spectacular
means burning in the flames of hell. Although you drive yourself at an intense
pace, your satisfactions are meager. Once you do achieve a goal, another more
distant goal instantly re- replaces it, so you never experience the reward of
getting to the top of the mountain. Eventually you begin to wonder why the
promised payoff from all your effort never seems to materialize. Your life
becomes a joyless, tedious tread- treadmill. You are living with unrealistic,
impossible personal standards, and you need to reevaluate them. Your problem
does not lie in your performance, but in the yardstick you use to measure it. If
you bring your expectations in line
FEELING GOOD 287 with reality, you will be regularly pleased and rewarded
instead of frustrated. A positive score suggests you have the capacity to set
meaningful, flexible, appropriate standards. You get great satisfaction from
processes and experiences, and you are not exclusively fixated on outcomes.
You don't have to be outstanding at everything, and you don't always have to
You don't have to be outstanding at everything, and you don't always have to
"try your best." You don't fear mistakes, but you see them as golden
opportunities to learn and to endorse your hu- humanity. Paradoxically, you are
likely to be much more pro- productive than your perfectionistic associates
because you do not become compulsively preoccupied with detail and corcorrectness. Your life is like a flowing river or a geyser com- compared with
your rigid perfectionistic friends who appear more like icy glaciers. V.
Entitlement Attitudes 21 through 25 measure your sense of "entitlement." A
negative score indicates that you feel "entitled" to things—success, love,
happiness, etc. You expect and demand that your wants be met by other people
and by the universe at large because of your inherent goodness or hard work.
When this does not happen—as is often the case—you are locked into one of
two reactions. Either you feel depressed and inadequate or you become irate.
Thus, you consume enormous amounts of energy being frustrated, sad, and mad.
Much of the time you see life as a sour, rotten experience. You complain loudly
and often, but you do little to solve problems. After all, you're entitled to have
them solved, so why should you have to put out any effort? As a result of your
bitter, demanding attitudes, you invariably get far less of what you want from
life. A positive score suggests you don't feel automatically entitled to things, so
you negotiate for what you want and often get it. Because of your awareness that
other people are unique and different, you realize there is no inherent reason why
things should always go your way. You ex- experience a negative outcome as a
disappointment but not a
288 David D. Burns, M.D. tragedy because you are a percentage player, and you
don't expect perfect reciprocity or "justice" at all times. You are patient and
persistent, and you have a high frustration tol- tolerance. As a result, you often
end up ahead of the pack. VI. Omnipotence. Attitudes 26 through 30 measure
your tendency to see yourself as the center of your personal universe and to hold
yourself responsible for much of what goes on around you. A negative score
indicates you often make the personalization error discussed in Chapters 3 and 6.
You blame yourself inappropriately for the negative ac- actions and attitudes of
others who are not really under your control. Consequently, you are plagued by
guilt and self- condemnation. Paradoxically, the attitude that you should be
omnipotent and all-powerful cripples you and leaves you anxious and
ineffectual. A positive score, in contrast, indicates you know the joy that comes
from accepting that you are not the center of the universe. Since you are not in
control of other adults, you are not ultimately responsible for them but only for
yourself. This attitude does not isolate you from others. Quite the opposite is
true. You relate to people effectively as a friendly collaborator, and you are not
threatened when they disagree with your ideas or fail to follow your advice.
threatened when they disagree with your ideas or fail to follow your advice.
Because your attitude gives people a sense of freedom and dignity, you
paradoxically become a human magnet. Others often want to be close to you
because you have relinquished any attempt to control them. People frequently
listen to and respect your ideas because you do not polarize them with an angry
in- insistence they must agree with you. As you give up your drive for power,
people repay you by making you a person of influence. Your relationships with
your children and friends and associates are characterized by mutuality instead
of dependency. Because you don't try to dominate people, they admire, love, and
respect you. VII. Autonomy. Items 31 through 35 measure your au- autonomy.
This refers to your ability to find happiness within
FEELING GOOD 289 yourself. A positive score indicates that all your moods
are ultimately the children of your thoughts and attitudes. You assume
responsibility for your feelings because you rec- recognize they are ultimately
created by you. This sounds as if you might be lonely and isolated because you
realize that all meaning and feelings are created only in your head.
Paradoxically, however, this vision of autonomy frees you from the petty
confines of your mind and delivers the world to you with a full measure of all
the satisfaction, mystery, and excitement that it can offer. A negative score
suggests you are still trapped in the belief that your potential for joy and selfesteem comes from the outside. This puts you at a great disadvantage because
everything outside is ultimately beyond your control. Your moods end up the
victim of external factors. Do you want this? If not, you can eventually free
yourself from this at- attitude as surely as a snake sheds its skin, but you will
have to work at it with the various methods outlined in this book. When it's
finally your turn to experience the transformation to autonomy and personal
responsibility, you will be amazed—or awestruck—or pleased—or delightfully
over- overwhelmed. It's well worth a major personal commitment. In the
following chapters a number of these attitudes and value systems will be
examined in detail. As you study each one, ask yourself: A) Is it to my
advantage to maintain this particular belief? B) Is this belief really true and
valid? C) What specific steps can I take that will allow me to rid myself of
attitudes that are self-defeating and unrealistic, and substitute others that are
more objective and more self- enhancing?
Chapter 11 The Approval Addiction Let's consider your belief that it would be
terrible if some- someone disapproved of you. Why does disapproval pose such
a threat? Perhaps your reasoning goes like this: "If one person disapproves of
me, it means that everyone would disapprove of me. It would mean there was
me, it means that everyone would disapprove of me. It would mean there was
something wrong with me." If these thoughts apply to you, your moods will
shoot up every time you are being stroked. You reason, 'i got some positive
feedback so I can feel good about myself." Why is this illogical? Because you
are overlooking the fact that it is only your thoughts and beliefs which have the
power to elevate your spirits. Another person's approval has no ability to affect
your mood unless you believe what he or she says is valid. But if you believe the
compliment is earned, it is your belief which makes you feel good. You must
validate external approval before you experience mood elevation. This validation
represents your personal self- approval. Suppose you were visiting the
psychiatric ward of a hos- hospital. A confused, hallucinating patient approaches
you and says, "You are wonderful. I had a vision from God. He told me the
thirteenth person to walk through the door would be the Special Messenger. You
are the thirteenth, so I know 290
FEELING GOOD 291 you are God's Chosen One, the Prince of Peace, the Holy
of Holies. Let me kiss your shoe." Would this extreme approval elevate your
mood? You'd probably feel nervous and uncomfortable. That's because you don't
believe what the patient is saying is valid. You discredit the comments. It is only
your beliefs about yourself that can affect the way you feel. Others can say or
think whatever they want about you, good or bad, but only your thoughts will
influ- influence your emotions. The price you pay for your addiction to praise
will be an extreme vulnerability to the opinions of others. Like any addict, you
will find you must continue to feed your habit with approval in order to avoid
withdrawal pangs. The mo- moment someone who is important to you expresses
disap- disapproval, you will crash painfully, just like the junkie who can no
longer get his "stuff." Others will be able to use this vulnerability to manipulate
you. You will have to give in to their demands more often than you want to
because you fear they might reject or look down on you. You set yourself up for
emotional blackmail. You may come to see that your addiction to approval is not
to your advantage, but still believe that other people really do have the right to
judge not only the merit of what you do and say but also your worth as a human
being. Imagine that you made a second visit to the psychiatric hospital ward.
This time a different hallucinating patient approaches you and says, "You're
wearing a red shirt. This shows you are the Devil! You are evil!" Would you feel
bad because of this criticism and disapproval? Of course not. Why would these
disapproving words not upset you? It's simple—because you don't believe the
statements are true. You must "buy into" the other person's criticism— and
believe that you are in fact no good—in order to feel bad about yourself. Did it
ever occur to you that if someone disapproves of you, it might be his or her
ever occur to you that if someone disapproves of you, it might be his or her
problem? Disapproval often reflects other people's irrational beliefs. To take an
extreme
292 David D. Burns, M.D. example, Hitler's hateful doctrine that Jews were
inferior did not reflect anything about the inner worth of the people he intended
to destroy. There will, of course, be many occasions when disap- disapproval
will result from an actual error on your part. Does it follow that you are a
worthless, no-good person? Ob- Obviously not. The other person's negative
reaction can only be directed toward a specific thing you did, not at your worth.
A human being cannot do wrong things all the time! Let's look at the other side
of the coin. Many well-known criminals have had bands of fervent admirers
regardless of how repulsive and abhorrent their crimes. Consider Charles
Manson. He promoted sadism and murder, yet was regarded as a messiah by his
numerous followers, who seemed to do whatever he suggested. I want to make it
abundantly clear that I am not advocating atrocious behavior, nor am I an
admirer of Charles Manson. But ask yourself these ques- questions: If Charles
Manson did not end up totally rejected for what he did or said, what have you
ever done that was so terrible that you will be rejected by everyone? And do you
still believe in the equation: approval = worth? After all, Charles Manson
enjoyed the intense adulation of his "fam- "family." Did the approval he received
make him an especially worthy person? This is obvious nonsense. It's a fact that
approval feels good. There's nothing wrong with that; it's natural and healthy. It
is also a fact that disapproval and rejection usually taste bitter and unpleasant.
This is human and understandable. But you are swimming in deep, turbulent
waters if you continue to believe that approval and disapproval are the proper
and ultimate yard- yardsticks with which to measure your worth. Did you ever
criticize someone? Did you ever disagree with a friend's opinion? Did you ever
scold a child because of his or her behavior? Did you ever snap at a loved one
when you were feeling irritable? Did you ever choose not to associate with
someone whose behavior was distasteful to you? Then ask yourself—when you
disagreed, or criti- criticized, or disapproved—were you making the ultimate
moral
FEELING GOOD 293 judgment that the other person was a totally worthless,
no- good human being? Do you have the power to make such sweeping
judgments about other people? Or were you sim- simply expressing the fact that
you held a different point of view and were upset with what the other person did
or said? For example, in the heat of anger you may have blurted out to your
spouse, "You're no damn good!" But when the flame cools down a day or two
later, didn't you admit to yourself that you were exaggerating the extent of his or
later, didn't you admit to yourself that you were exaggerating the extent of his or
her "badness"? Sure, your loved one may have many faults, but isn't it absurd to
think your outburst of disapproval or criticism makes him or her totally and
forever worthless? If you admit your disapproval does not contain enough moral
atomic power to devastate the meaning and value of another person's life, why
give their disapproval the power to wipe out your sense of self-worth? What
makes them so special? When you tremble in terror because someone dislikes
you, you magnify the wisdom and knowledge that person pos- possesses, and
you have simultaneously sold yourself short as being unable to make sound
judgments about yourself. Of course, someone might point out a flaw in your
behavior or an error in your thinking. I hope they will because you can learn this
way. After all, we're all imperfect, and others have the right to tell us about it
from time to time. But are you obliged to make yourself miserable and hate
yourself every time someone flies off the handle or puts you down? The Origin
of the Problem. Where did you get this ap- approval addiction in the first place?
We can only speculate that the answer may lie in your interactions with people
who were important to you when you were a child. You may have had a parent
who was unduly critical when you misbehaved, or who was irritable even at
times when you weren't doing anything particularly wrong. Your mother may
have snapped, "You're bad for doing that!" or your father may have blurted out,
"You're always goof- goofing up. You'll never learn." As a small child you
probably saw your parents as gods.
294 David D. Burns, M.D. They taught you how to speak and tie your shoes, and
most of what they told you was valid. If Daddy said, "You will be killed if you
walk out into traffic," this was literally true. Like most children, you might have
assumed that nearly everything your parents said was true. So when you heard
"You're no good" and "You'll never learn," you literally believed it and this hurt
badly. You were too young to be able to reason, "Daddy is exaggerating and
overgen- eralizing" And you didn't have the emotional maturity to see that
Daddy was irritable and tired that day, or per- perhaps had been drinking and
wanted to be left alone. You couldn't determine whether his outburst was his
problem or yours. And if you were old enough to suggest he was being
unreasonable, your attempts to put things into a sane per- perspective may have
been rapidly deprogrammed and dis- discouraged with a swift smack on the
behind. No wonder you developed the bad habit of automatically looking down
on yourself every time someone disapproved of you. It wasn't your fault that you
picked up this tendency as a child, and you can't be blamed for growing up with
this blind spot. But it is your responsibility as an adult to think the issue through
realistically, and to take specific steps to outgrow this particular vulnerability.
realistically, and to take specific steps to outgrow this particular vulnerability.
Just how does this fear of disapproval predispose you to anxiety and depression?
John is an unmarried, soft-spoken fifty-two-year-old architect who lives in fear
of criticism. He was referred for treatment because of a severe recurring
depression, which had not diminished in spite of several years of therapy. One
day when he was feeling particularly good about himself, he approached his boss
enthusiastically with some new ideas about an important project. The boss
snapped, "Later, John. Cant you see I'm busy!" John's self-esteem collapsed
instantly. He dragged himself back to his office, drowning in despair and selfhatred, telling him- himself he was no good. "How could I have been so thoughtthoughtless?" he asked himself. As John shared this episode with me, 1 asked
him the simple and obvious questions, "Who was the one who was
FEELING GOOD 295 acting goofy—you or your boss? Were you actually
behav- behaving in an inappropriate manner, or was your boss acting irritable
and unpleasant?" After a moment's reflection, he was able to identify the true
culprit. The possibility that the boss was acting obnoxiously had not occurred to
him be- because of his automatic habit of blaming himself. He felt relief when
he suddenly realized he had absolutely nothing to be ashamed of in how he had
acted. His boss, who was aloof, was probably under pressure himself and off the
mark that day. John then raised the question, "Why am I always strug- struggling
so hard for approval? Why do I fall apart like this?" He then remembered an
event that occurred when he was twelve. His only sibling, a younger brother, had
tragically died after a long bout with leukemia. After the funeral he overheard
his mother and grandmother talking in the bed- bedroom. His mother was
weeping bitterly and said, "Now I've got nothing to live for." His grandmother
responded, "Shush. Johnny is just down the hall! He might hear you!" As John
shared this with me, he began to weep. He had heard these comments, and they
meant to him, "This proves I'hi not worth much. My brother was the important
one. My mother doesn't really love me." He never let on that he had been
listening, and through the years he tried to push the memory out of his mind by
telling himself, "It really isn't important whether or not she loves me anyway."
But he struggled intensely to please his mother with his achieve- achievements
and his career in a desperate bid to win her approval. In his heart he didn't
believe he had any true worth, and perceived himself as inferior and unlovable.
He tried to compensate for his missing self-esteem by earning other people's
admiration and approval. His life was like a con- constant effort to inflate a
balloon with a hole in it. After recalling this incident, John was able to see the
irrationality of his reaction to the comments he had over- overheard in the hall.
His mother's bitterness, and the emptiness she felt, were a natural part of the
His mother's bitterness, and the emptiness she felt, were a natural part of the
grieving process that any parent goes through when a child dies. Her comments
had
296 David D. Burns, M.D. nothing to do with John, but only with her temporary
depres- depression and despair. Putting this memory into a new perspective
helped John see how illogical and self-defeating it was to link his worth to the
opinions of others. Perhaps you too are beginning to see that your belief in the
importance of external approval is highly unrealistic. Ultimately you, and only
you, can make yourself consistently happy. No one else can. Now, let's review
some simple steps that you can take to put these principles into practice so you
can transform your desire for self-esteem and self-respect into an emotional
reality. The Path to Independence and Self-Respect Cost-Benefit Analysis. The
first step in overcoming your belief in any of the self-defeating assumptions
from the DAS test is to perform a cost-benefit analysis. Ask yourself, what are
the advantages and disadvantages of telling myself that disapproval makes me
less worthwhile? After listing all the ways this attitude hurts you and helps you,
you will be in a position to make an enlightened decision to develop a healthier
value system. For example, a thirty-three-year-old married woman named Susan
found she was overly involved with church and community activities because
she was a responsible and capable worker and was frequently selected for
various com- committees. She felt enormously pleased every time she was
chosen for a new job and she feared saying no to any request because that would
mean risking someone's disapproval. Because she was terrified about letting
people down, she became more and more addicted to the cycle of giving up her
own interests and desires in order to please others. The DAS test and the
"Vertical Arrow Technique" de- described in the previous chapter revealed one
of her silent assumptions to be: "I must always do what people expect me to do."
She seemed reluctant to give up this belief, so she performed a cost-benefit
analysis (Figure 11-1). BeFigure 11-1. The Cost-Benefit Method for Evaluating "Silent Assumptions."
ASSUMPTION: "I must always do what people expect me to do." Advantages
Disadvantages of of Believing This Believing This 1. If I'm able to meet peo- I. I
sometimes compromise and end up pie's expectations, I can doing things that are
not in my best feel I'm in control. This interest that I don't really want to do. feels
good. 2. When I please people ( 2. This assumption keeps me from test- will feel
secure and safe. ing relationships—I never know if I could be accepted just for
me. Thus, I always have to earn love and the right to be close to people by doing
what people want me to do. I become like a slave. 3. I can avoid a lot of guilt 3.
It gives people too much power over and confusion. I don't me—they can coerce
It gives people too much power over and confusion. I don't me—they can coerce
me with the have to think things out, threat of disapproval. since all I have to do
is what others want me to. 4. 1 don't have to worry 4. It makes it hard for me to
know what about people being upset I really want. I'm not used to setting with
me or looking down priorities for myself and making in- on me. dependent
decisions. 5. I can avoid conflict and I 5. When people do disapprove of me,
don't have to be assertive as is inevitable at times, then I con- and speak up for
myself. elude I've done something to dis- displease them, and I experience
severe guilt and depression. This puts my moods under the control of other peopeople instead of myself. 6. What other people want me to do may not always be
what's best for me, since they often have their own interests at heart. Their
expectations for me may not always be realistic and valid. 7. I end up seeing
other people as so weak and fragile that they are de- dependent on me and would
be hurt and miserable if I let them down.
298 David D. Burns, M.D. Figure 11-1. cont. Advantages Disadvantages of of
Believing This Believing This 8. Because I fear taking risks and hav- having
someone upset with me, my life becomes static. I don't feel moti- motivated to
change, to grow or to do things differently so as to enhance my range of
experiences. cause the disadvantages of her approval addiction greatly
outweighed the advantages, she became much more open to changing her
personal philosophy. Try this simple tech- technique with regard to one of your
self-defeating assumptions about disapproval. It can be an important first step to
per- personal growth. Rewrite the Assumption. If, based on your cost-benefit
analysis, you see that your fear of disapproval hurts you more than it helps, the
second step is to rewrite your silent assumption so that it becomes more realistic
and more self- enhancing (you can do this with any of the 35 attitudes on the
DAS test that represent areas of psychological vulner- vulnerability for you). In
the above example, Susan decided to revise her belief as follows: 'it can be
enjoyable to have someone approve of me, but I don't need approval in order to
be a worthwhile person or to respect myself. Disapproval can be uncomfortable,
but it doesn't mean I'm less of a person." The Self-Respect Blueprint. As a third
step it might help you to write a brief essay entitled "Why It Is Irrational and
Unnecessary to Live in Fear of Disapproval or Criticism." This can be your
personal blueprint for achieving greater self-reliance and autonomy. Prepare a
list of all the reasons why disapproval is unpleasant but not fatal. A few have
already been mentioned in this chapter, and you might re- review them before
you begin to write. In your essay include
FEELING GOOD 299 only what seems convincing and helpful to you. Make
FEELING GOOD 299 only what seems convincing and helpful to you. Make
sure you believe each argument you write down so your new sense of
independence will be realistic. Dorit rationalize! For example, the statement, "If
someone disapproves of me, I don't need to get upset because they're really not
the kind of person I'd care to have as a friend," won't work because it's a
distortion. You are trying to preserve your self-esteem by writing the other
person off as no good. Stick with what you know to be the truth. As new ideas
come to you, add them to your list. Read it over every morning for several
weeks. This might be a first step in helping you trim other people's negative
opin- opinions and comments about you down to life-size. Here are a few ideas
that have worked well for a lot of people. You might use some of them in your
own essay. 1. Remember that when someone reacts negatively to you, it may be
his or her irrational thinking that is at the heart of the disapproval. 2. If the
criticism is valid, this need not destroy you. You can pinpoint your error and
take steps to correct it. You can learn from your mistakes, and you don't have to
be ashamed of them. If you are human, then you should and must make mistakes
at times. 3. If you have goofed up, it does not follow that you are a BORN
LOSER. It is impossible to be wrong all the time or even most of the time. Think
about the thou- thousands of things you have done right in your life! FurFurthermore, you can change and grow. 4. Other people cannot judge your worth
as a human being, only the validity or merit of specific things you do or say. 5.
Everyone will judge you differently no matter how well you do or how badly
you might behave. Dis- Disapproval cannot spread like wildfire, and one
rejection cannot lead to a never-ending series of rejections. So even if worse
comes to worst and you do get rejected by someone, you can't end up totally
alone.
300 David D. Burns, M.D. 6. Disapproval and criticism are usually
uncomfortable, but the discomfort will pass. Stop moping. Get in- involved in an
activity you've enjoyed in the past even though you feel certain it's absolutely
pointless to start. 7. Criticism and disapproval can upset you only to the extent
that you "buy into" the accusations being brought against you. 8. Disapproval is
rarely permanent. It doesn't follow that your relationship with the person who
disapproves of you will necessarily end just because you are being criticized.
Arguments are a part of living, and in the majority of cases you can come to a
common under- understanding later on. 9. If you are criticizing someone else, it
doesn't make that person totally bad. Why give another individual the power and
right to judge you? We're all just human beings, not Supreme Court justices.
Don't magnify other people until they are larger than life. Can you come up with
some additional ideas? Think about this topic over the next few days. Jot your
some additional ideas? Think about this topic over the next few days. Jot your
ideas down on a piece of paper. Develop your own philosophy about disdisapproval. You'll be surprised to find how much this can help you change your
perspective and enhance your sense of independence. Verbal Techniques. In
addition to learning to think dif- differently about disapproval, it can be a lot of
help to learn to behave differently toward individuals who express disdisapproval. As a first step, review the assertive methods such as the disarming
technique presented in Chapter 6. Now we will discuss some additional
approaches to help you build your skills in coping with disapproval. First of all,
if you fear someone's disapproval, have you ever thought of asking the person if
he or she, in fact, does look down on you? You might be pleasantly surprised to
FEELING GOOD 301 learn that the disapproval existed only in your head. AlAlthough it requires some courage, the payoff can be tremen- tremendous.
Remember Art, the psychiatrist described in Chapter 6, who was receiving
training at the University of Pennsyl- Pennsylvania? Art had no suspicion that a
particular patient of his might be suicidal. The patient had no history or
symptoms of depression, but felt hopelessly trapped in an intolerable marriage.
Art received a call one morning that his patient had been found dead with a
bullet hole through his head. Although the suspicion of homicide was raised, the
probable cause of death was suicide. Art had never lost a patient in this way. His
reaction included sadness, because of his fondness for this particular patient, and
anxiety, for fear that his supervisor and peers would disapprove of him and look
down on him for his "mistake" and lack of foresight. After discussing the death
with his supervisor, he asked frankly, "Do you feel I have let you down?" His
super- supervisor's response conveyed a sense of warmth and empathy, not
rejection. Art was relieved when his supervisor told him that he too had
experienced a similar disappointment in the past. He emphasized that this was an
opportunity for Art to learn to cope with one of the professional hazards of being
a psychiatrist. By discussing the case and refusing to give in to his fear of
disapproval, Art learned that he had made an "error"—he had overlooked the
fact that a feeling of "hopelessness" can lead to suicide in individuals who are
not clinically depressed. But he also learned that others did not demand
perfection of him, and that he wasn't expected to guarantee a successful outcome
for any patient. Suppose it had not turned out so well and his supervisor or peers
had condemned him for being thoughtless or in- incompetent. What then? The
worst possible outcome would have been rejection. Let's talk about some
strategies for coping with the worst conceivable eventuality. Rejection Is Never
Your Fault! Aside from bodily injury or a destruction of your assets, the greatest
pain a person
302 David D. Burns, M.D. can try to inflict on you is through rejection. This
threat is the source of your fear when you are being "put down." There are
several types of rejection. The most common and obvious is called "adolescent
rejection," although it is not limited to the adolescent age-group. Suppose you
have a romantic interest in someone you are dating or have met, and it turns out
you're not his or her cup of tea. Perhaps it's your looks, race, religion, or
personality style that are the problem. Or maybe you are too tall, short, fat, thin,
old, young, smart, dull, aggressive, passive, etc. Since you don't fit that person's
mental image of an ideal mate closely enough, he or she rebuffs your advances
and gives you the cold shoulder. Is this your fault? Obviously not! The
individual is simply turning you down because of subjective preferences and
tastes. One person may like apple pie better than cherry pie. Does this mean that
cherry pie is inherently undesirable? Romantic interests are almost infinitely
variable. If you are one of those toothpaste-commercial types who is blessed
with what our culture defines as "good looks" and an ap- appealing personality,
it will be much easier for you to attract potential dates and mates. But you will
learn this mutual attraction is a far cry from developing a loving permanent
relationship, and even the beautiful and handsome types will have to cope with
rejection sometimes. No one can turn on each and every person they meet. If you
are only average or below average in appearance and personality, you will have
to work harder initially to attract people, and you may have to cope with more
frequent turndowns. You will have to develop your social skills and master some
powerful secrets of making people feel at- attracted to you. These are: A) Don't
sell yourself short by looking down on yourself. Refuse to persecute yourself.
Boost your self-esteem to the hilt with the methods outlined in Chapter 4. If you
love yourself, people will respond to this sense of joy you radiate and want to be
close to you. B) Express genuine compliments to people. Instead of waitwaiting around nervously to find out if they will like you or
FEELING GOOD 303 reject you, like them first and let them know about it. C)
Show an interest in other people by learning about what turns them on. Get them
to talk about what excites them most, and respond to their comments in an
upbeat manner. If you persevere along these lines, you will eventually discover
there are people who find you attractive, and you in turn will discover you have
a great capacity for happiness. Adolescent rejection is an uncomfortable
nuisance, but it's not the end of the world and it's not your fault. "Ah ha!" you
retort. "But how about the situation where a lot of people reject you because you
turn them off with your abrasive mannerisms? Suppose you're conceited and
self-centered. Certainly that's your fault, isn't it?" This is a second type of
rejection, which I call "angry rejection." Again, I think you will see that it's not
rejection, which I call "angry rejection." Again, I think you will see that it's not
your fault if you are angrily rejected because of a personal fault. In the first
place, other people aren't obliged to reject you just because they find things
about you they don't like— they have other options. They can be assertive and
point out what they don't like about your behavior, or they can learn not to let it
bother them so much. Of course, they have the right to avoid and reject you if
they want, and they are free to choose any friends they prefer. But this doesn't
mean that you are an inherently "bad" human being, and it is definitely not the
case that everyone will react to you in the same negative way. You will
experience a sponta- spontaneous chemistry with some people, whereas you will
tend to clash with others. This is no one's fault, it's just a fact of life. If you have
a personality quirk that alienates more people than you would like—such as
being excessively critical or losing your temper frequently—it would definitely
be to your advantage to modify your style. But it's ridiculous to blame yourself if
someone rejects you based on this im- imperfection. We're all imperfect, and
your tendency to fault yourself—or to "buy into" the hostility that someone else
directs at you—is self-defeating and pointless. The third type of rejection is
"manipulative rejection."
304 David D. Burns, M.D. In this case the other person uses the threat of
withdrawal or rejection to manipulate you in some way. Unhappy spouses, and
even frustrated psychotherapists, sometimes resort to this ploy to coerce you into
changing. The formula goes like this: "Either you do such and such or we're all
through!" This is a highly irrational and usually self- defeating way of trying to
influence people. Such manip- manipulative rejection is simply a culturally
taught coping pattern, and it is usually ineffective. It rarely leads to an enhanced
relationship because it generates tension and resentment. What it really indicates
is a low frustration tolerance and poor interpersonal skills on the part of the
individual making the threat. It certainly isn't your fault that they do this, and it
usually isn't to your advantage to let yourself be manip- manipulated this way.
So much for the theoretical aspects. Now, what can you say and do when you are
actually getting rejected? One effective way to learn is to use role-playing. To
make the dialogue more entertaining and challenging, I will play the role of the
rejector and confront you with the worst things about you I can think of. Since
I'm acting caustic and insulting, begin by asking if I am in fact rejecting you
because of the way I've been treating you lately: You: Dr. Burns, I notice you've
been acting somewhat cool and distant. You seem to be avoiding me. When I try
to talk to you, you either ignore me or snap at me. I wonder if you're upset with
me or if you've had thoughts of rejecting me. Comment: You don't accuse me
initially of rejecting you. That would put me on the defensive. Furthermore, I
initially of rejecting you. That would put me on the defensive. Furthermore, I
might not be rejecting you—I might be upset about the fact that nobody's buying
my book, so I'm just generally irritable. Just for practice, let's assume the worst
—that I am trying to dump you.
FEELING GOOD 305 David: I'm glad we got it out in the open. I have in fact
decided to reject you. You: Why? Apparently I've been turning you off a lot.
David: You're a no-good piece of rot. You: I can see you're upset with me. Just
what have I been doing wrong? Comment: You avoid defending yourself. Since
you know you are not a "piece of rot," there's no point in insisting to me that
you're not. It will just fire me up more, and our dialogue will quickly deteriorate
into a shouting match. (This "empathy method" was presented in detail in ChapChapter 6.) David: Everything about you stinks. You: Can you be specific? Did I
forget to use deo- deodorant? Are you upset by the way I talk, some- something
I've said lately, my clothes, or what? Comment: Again, you resist getting sucked
into an ar- argument. By urging me to pinpoint what I dislike about you, you are
forcing me to fire my best shot and say something meaningful or end up looking
like an ass. David: Well, you hurt my feelings when you put me down the other
day. You don't give a damn about me. I'm just a "thing" to you, not a human
being. Comment: This is a common criticism. It tips you off that the rejector
basically cares for you, but feels deprived and fears losing you. The rejector
decides to lash out at you to protect his shaky self-esteem. The rejector might
also say you're too stupid, too fat, too selfish, etc. Whatever the nature of the
criticism, your strategy is now twofold: (a) Find some grain of truth in the
criticism and let the rejector know you agree in part (see the * 'disarming tech306 David D. Burns, M.D. nique," Chapter 6); (b) apologize or offer to try to
correct any actual error you actually did make (see "feedback and
negotiation,"Chapter 6). You: I'm really sorry I said something that rubbed you
the wrong way. What was it? David: You told me I was a no-good jerk. So I've
had it with you—this is the end. You: I can see that was a thoughtless, hurtful
comment I made. What other things have I said that hurt your feelings? Was that
all? Or have I done this many times? Go ahead and say all the bad things you
think about me. David: You're unpredictable. You can be sweet as sugar, and
then all of a sudden you're cutting me to shreds with your sharp tongue. When
you get mad, you turn into a foul-mouthed pig. I can't stand you, and I can't see
how anyone else puts up with you. You're arrogant and cocky, and don't give a
damn about anyone but yourself. You're a selfish snot, and it's time you woke up
and learned the hard way. I'm sorry I've got to be the one to put you down, but
it's the only way you're going to learn. You have no real feelings for anyone but
it's the only way you're going to learn. You have no real feelings for anyone but
yourself, and we're through for good! You: Well, I can see there are numerous
problems in our relationship we've never looked at, and it sounds like I've really
been missing the boat. I can see that I have been acting irritable and thoughtless.
I can see how unpleasant I've been and how uncomfortable it's been for you. Tell
me more about this side of me. Comment: You then continue to extract negative
com- comments from the rejector. Avoid being defensive and continue to find
some grain of truth in what the rejector says. After
FEELING GOOD 307 you have elicited all the criticisms and agreed with
whatever was true about them, you are ready to fire the sharpest arrow straight
into the rejector's balloon. Point out that you have acknowledged your
imperfections and that you are willing to try to correct your errors. Then ask the
rejector why he is rejecting you. This maneuver will help you see why rejection
is never your fault! You are responsible for your errors, and you will assume
responsibility for trying to cor- correct them. But if someone rejects you for your
imperfec- imperfections, that's their goofiness, not yours! Here's how this works.
You: I can see I've done and said a number of things you don't like. I'm certainly
willing to try to correct these problems to the greatest extent pos- possible. I
can't promise miracles, but if we work at it together, I see no reason why things
can't improve. Just by talking this way, our commu- communications are already
better. So why are you going to reject me? David: Because you infuriate me.
You: Well, sometimes differences come up between people, but I don't see that
this has to destroy our relationship. Are you rejecting me because you feel
infuriated or what? David: You're a no-good bum, and I refuse to talk to you
again. You: I'm sorry you feel that way. I'd much prefer to continue our
friendship in spite of these hurt feel- feelings. Do we need to break off entirely?
Maybe this discussion was just what we needed to un- understand each other
better. I don't really know why you've decided to reject me. Can you tell me
why? David: Oh, no! I'm not being tricked by you. You goofed up once too
often, and that's it! No second chances! Good-bye!
308 David D. Burns, M.D. Comment: Now whose goofy behavior is this? Yours
or the one who is rejecting you? Whose fault is it that the rejection occurs? After
all, you offer to try to correct your errors and to improve the relationship through
frank com- communication and compromise. So how can you be blamed for the
rejection? Obviously you can't. Using the above approach may not prevent all
actual rejections, but you will enhance the probability of a positive outcome
sooner or later. Recovering from Disapproval or Rejection. You ac- actually
have been disapproved of or rejected in spite of your efforts to improve the
relationship with the other person. How can you most quickly overcome the
relationship with the other person. How can you most quickly overcome the
emotional upset you understandably feel? First, you must realize that life goes
on, so this particular disappointment need not impair the quality of your
happiness forever. Following the rejec- rejection or disapproval it will be your
thoughts which are doing the emotional damage, and if you fight these thoughts
and stubbornly refuse to give in to distorted self-abuse, the upset will pass. One
method which might be quite helpful is one that has aided people who
experience prolonged grief reactions fol- following the loss of a loved one. If
bereaved individuals schedule periods each day to allow themselves to be
flooded by the painful memories and thoughts of the deceased loved one, this
can accelerate and complete the grieving process. If you do this when you are
alone, it will be most helpful. Sympathy from another person often backfires;
some studies have reported that it prolongs the painful period of mournmourning. You can use this "grieving" method to cope with rejec- rejection or
disapproval. Schedule one or more periods of time each day—five to ten minutes
are probably enough—to think all the sad, angry, and despairing thoughts you
want. If you feel sad, cry. If you feel mad, pound a pillow. Keep flooding
yourself with painful memories and thoughts for the full time period you have
set aside. Bitch, moan and complain
FEELING GOOD 309 nonstop! When your scheduled sad period is over, STOP
IT and carry on with life until your next scheduled cry session. In the meantime,
if you have negative thoughts, write them down, pinpoint the distortions, and
substitute rational responses as outlined in previous chapters. You may find this
will help you gain partial control over your dis- disappointment and hasten your
return to full self-esteem more quickly than you anticipated. Turning on the
"Inner Light" The key to emotional enlightenment is the knowledge that only
your thoughts can affect your moods. If you are an approval addict, you are in
the bad habit of flicking your inner switch only when someone else shines their
light on you first. And you mistakenly confuse their approval with your own
self-approval because the two occur almost si- simultaneously. You mistakenly
conclude that the other per- person has made you feel good! The fact that you do
at times enjoy praise and compliments proves that you know how to approve of
yourself \ But if you are an approval addict, you have developed the selfdefeating habit of endorsing your- yourself only when someone you respect
approves of you first. Here's a simple way to break that habit. Obtain the wrist
counter described in earlier chapters and wear it for at least two or three weeks.
Every day try to notice positive things about yourself—things you do well
whether or not you get an external reward. Each time you do something you apapprove of, click the counter. For example, if you smile warmly at an associate
approve of, click the counter. For example, if you smile warmly at an associate
one morning, click whether he scowls or smiles back. If you make that phone
call you were putting off—click the counter! You can "endorse" yourself for big
or trivial things. You can even click it if you remember positive things you did in
the past. For example, you might recall the day you got your driver's license or
your first job. Click the counter whether or not you have a positive emoemotional arousal. Initially you may have to force yourself to
310 David D. Burns, M.D. notice good things about yourself, and it may seem
me- mechanical. Persist anyway because after several days 1 think you will
notice that the inner light is beginning to glow— dimly at first and then more
brightly. Every night look at the digits on the counter and record the total
number of personal endorsements on your daily log. After two or three weeks, I
suspect you will begin to learn the art of self- respect, and you will feel much
better about yourself. This simple procedure can be a big first step toward
achieving independence and self-approval. It sounds easy—and it is. It's
surprisingly powerful, and the rewards will be well worth the small amount of
time and effort involved.
Chapter 12 The Love Addiction The "silent assumption" which often goes hand
in hand with the fear of disapproval is "I cannot be a truly happy and fulfilled
human being unless 1 am loved by a member of the opposite sex. True love is
necessary for ultimate happiness." The demand or need for love before you can
feel happy is called "dependency." Dependency means that you are unable to
assume responsibility for your emotional life. The Disadvantages of Being a
Love Junkie. Is being loved an absolute necessity or a desirable option? Roberta
is a thirty-three-year-old single woman who moped around her apartment
evenings and weekends be- because she told herself, "It's a couple's world.
Without a man 1 am nothing." She came to my office attractively groomed, but
her comments were bitter. She was brimming with resentment because she was
sure that being loved was as crucial as the oxygen she breathed. However, she
was so needy and greedy that this tended to drive people away. I suggested that
she start by preparing a list of the ad- advantages and disadvantages of believing
that "without a man (or woman) I am nothing." The disadvantages on RoRoberta's list were clear-cut: "A) This belief makes me de- 311
312 David D. Burns, M.D. spondent since I have no lover. B) Furthermore, it
takes away any incentive I might have to do things and go places. C) It makes
me feel lazy. D) It brings on a sense of self- pity. E) It robs me of self-pride and
confidence, and makes me envious of others and bitter. F) Finally, it brings on
self-destructive feelings and a terrible fear of being alone." Then she listed what
self-destructive feelings and a terrible fear of being alone." Then she listed what
she thought were the advantages of believing that being loved was an absolute
necessity for happiness: "A) This belief will bring me a companion, love, and
security. B) It will give purpose to my life and a reason to live. C) It will give me
events to look forward to." These advantages reflected Roberta's belief that
telling herself she couldn't live without a man would somehow bring a comcompanion into her life. Were these advantages real or imaginary? Although RoRoberta had believed for many years that she couldn't exist without a man, this
attitude still hadn't brought a desirable mate. She admitted that making men so
totally important in her life was not the magic charm that would bring one to her
doorstep. She acknowledged that clinging and de- dependent individuals often
demand so much attention from other people and appear so needy that they have
great dif- difficulty not only initially attracting people of the opposite sex but
also maintaining an ongoing relationship. Roberta was able to grasp the idea that
people who have found happiness within themselves are usually the most
desirable to members of the opposite sex and become like magnets because they
are at peace and generate a sense of joy. Ironically, it is usually the dependent
woman, the "man- aholic," who ends up alone. This really isn't so surprising. If
you take the position you ''need" someone else for a sense of worth, you broadbroadcast the following: "Take me! I have no inherent worth! I can't stand
myself!" No wonder there are so few buyers! Of course, your unstated demand
does not endear people to you either: "Since you're obliged to love me, you're
rotten shit if you don't." You may cling to your dependency because of the erFEELING GOOD 313 roneous notion that if you do achieve independence,
others will see you as a rejecting person and you will end up alone. If this is your
fear, you are equating dependency with warmth. Nothing could be farther from
the truth. If you are lonely and dependent, your anger and resentment stem from
the fact that you feel deprived of the love you believe you are entitled to receive
from others. This attitude drives you farther into isolation. If you are more
independent, you are not obliged to be alone—you simply have the capacity to
feel happy when you are alone. The more independent you are, the more secure
you will be in your feelings. Further- Furthermore, your moods will not go up
and down at someone else's mercy. After all, the amount of love that someone
can feel for you is often quite unpredictable. They may not appreciate everything
about you, and they may not act in an affectionate way all the time. If you are
willing to learn to love yourself, you will have a far more dependable and
continuous source of self-esteem. The first step is to find out if you want
independence. All of us have a much greater chance of achieving our goals if we
understand what they are. It helped Roberta to realize that her dependency was
understand what they are. It helped Roberta to realize that her dependency was
condemning her to an empty ex- existence. If you are still clinging to the notion
that it is desirable to be "dependent," list the advantages, using the doublecolumn technique. Spell out how you benefit if you let love determine your
personal worth. Then in order to assess the situation objectively, write down the
counter- counterarguments, or rational responses, in the right-hand column. You
may learn that the advantages of your love addiction are partially or totally
illusory. Figure 12-1 shows how a woman with a problem similar to Roberta's
assessed these issues. This written exercise motivated her to look within herself
for what she had been seeking in others, and enabled her to see that her
dependency was the real enemy because it incapacitated her. Perceiving the
Difference Between Loneliness and Being Alone. As you read the previous
section you may
Figure 12-1. An Analysis of the Presumed 'Advantages" of Being a "Love
Junkie." Advantages of Being Dependent on Love to Be Happy Rational
Responses I. Someone will take care of me when I'm hurt. 2. But if I am
dependent, I won't have to make decisions. 3. But as an independent person, I
might make the wrong decision. Then I'd have to pay the consequences. 4. But if
I am a depen- dependent person, I won't have to think. I can just react to things.
1. This is also true of independent people. If I am in an auto acci- accident, they
will take me to an emergency room. The doctors will care for me whether I am a
dependent or independent per- person. It is nonsense that only de- dependent
people get help when they are hurt. 2. But as a dependent person, I will have
much less control over my life. It is unreliable to depend on other people to
make decisions for me. For example, do I want someone else to tell me what to
wear today or what to eat for dinner? They might not choose the thing that is my
first choice. 3. So pay the consequences—you can learn from your mistakes if
you are independent. No one can be perfect, and there are no guar- guarantees of
absolute certainty in life. The uncertainty can be part of the spice of life. It's how
I cope—not whether I am right all the time—that forms the basis of self-respect.
And besides, I will be able to take the credit when things work out well. 4.
Independent people can also choose not to think if they want to. There is no rule
that says that only dependent people have the right to stop thinking.
Figure 12-1. cont. Advantages of Being Dependent on Love to Be Happy
Rational Responses 5. But if I am dependent, 5. I will be gratified. It will be like
eating candy. It feels good to have someone to care for me and to lean on. 6. But
if I am a depen- 6. dent person, I will be loved. Without love I couldn't live. 7.
But some men are 7. looking for dependent women. Candy gets nauseating after
But some men are 7. looking for dependent women. Candy gets nauseating after
a while. The person I choose to depend on may not be willing to love and stroke
me, and take care of me forever. He may get tired of it after a while. And if he
withdraws from me either through anger or resentment, I will then feel miserable
because I'll have nothing else to rely on. They will be able to manipulate me if I
am dependent, just like a slave or robot. As an independent person, I can learn to
love myself and this may make me even more desirable to others, and if I can
learn to love myself, I can always be loved. My dependency in the past has
driven others away from me more frequently than it has at- attracted people to
me. Babies can't survive without love and support, but I won't die without love.
There's some truth to this, but relationships which are based on dependency
frequently fall apart and culminate in divorce be- because you are asking the
other person to give you something which they are not in the position to give:
namely, self-esteem and self-respect. Only I can make myself happy, and if I
rely on someone else to do this for me, I am likely to be bitterly disapdisappointed in the end.
316 David D. Burns, M.D. have concluded that it would be to your advantage if
you could learn to regulate your moods and find happiness within yourself. This
would give you the capacity to feel as alive when you are alone as when you are
with someone you love. But you may be thinking, "That all sounds well and
good, Dr. Burns, but it is not realistic. The truth is that it is undeniably
emotionally inferior to be alone. AH my life I have known that love and
happiness are identical, and all my friends agree. You can philosophize until
you're blue in the face. But when it comes down to the bottom line, love is where
it's at and being alone is a curse!" In fact, many people are convinced that love
makes the world go around. You see this message in ads, you hear it in popular
songs, you read it in poems. You can however convincingly disprove your
assumption that love is necessary before you can experience happiness. Let's
take a hard look at the equation, alone = lonely. Consider, first, that we get many
of life's basic satisfac- satisfactions by ourselves. For example, when you climb a
moun- mountain, pick a flower, read a book, or eat a hot fudge sundae, you do
not require someone else's company for these ex- experiences to be enjoyable. A
physician can enjoy the sat- satisfaction of treating a patient whether or not he
and the patient are involved in a meaningful personal relationship. When writing
a book, an author is generally by himself or herself. As most students know, you
do most of your learn- learning when you are alone. The list of pleasures and
satisfac- satisfactions that you can enjoy when alone is endless. This indicates
that many sources of gratification are ac- accessible to you whether or not you
are with someone else. Can you add to that list? What are some pleasures that
you can have alone? Do you ever listen to good music on your stereo? Do you
you can have alone? Do you ever listen to good music on your stereo? Do you
enjoy gardening? Jogging? Carpentry? Hik- Hiking? A lonely bank teller named
Janet, who was recently separated from her husband, enrolled in a creative
dancing class and found (to her surprise) that she could derive enor- enormous
pleasure from practicing by herself at home. As she became caught up in the
rhythm of the movements, she felt
FEELING GOOD 317 at peace with herself in spite of the fact that she had no
one to love. Perhaps you are thinking now, "Oh, Dr. Burns, is that your point?
Well, it's trivial*. Of course, I can experience temporary moments of mediocre
distraction by doing things when I'm alone. This might take the edge off the
blues, but those things are just some crumbs from the table that might keep me
from starving totally. I want the banquet, the real thing! Love! True and
complete happiness!" That was exactly what Janet told me before she enrolled in
the dancing class. Because she assumed it was miserable to be alone, it hadn't
occurred to her to do enjoyable things and care for herself during the separation
from her husband. She had been living according to a double standard whereby
if she was with her husband, she would go to great lengths to plan pleasurable
activities, but when she was alone, she would simply mope and do very little.
This pattern obviously functioned as a self-fulfilling prophecy, and she did in
fact find it unpleasant to be alone. Why? Simply because she failed to treat
herself in a caring way. It had never occurred to her to challenge her lifelong
assumption that all her ac- activities would be unsatisfactory unless she had
someone to share them with. On another occasion, instead of heating a TV
dinner after work, Janet decided to plan a special meal, just as if she were going
to entertain a man she cared a lot about. She carefully prepared her dinner and
set the table with candles. She began with a glass of fine wine. After dinner she
read a good book and listened to her favorite music. To her amazement, she
found the evening a total pleasure. The next day, which was Saturday, Janet
decided to go to the art museum alone. She was surprised to discover that she got
more enjoyment out of this excursion alone than she had in the past when
dragging her reluctant and disinterested husband along. As a result of adopting
an active, compassionate attitude toward herself, Janet discovered for the first
time in her life that she could not only make it on her own but could really enjoy
herself.
318 David D. Burns, M.D. As is so often the case, she began to generate an
infectious joy of living that caused many individuals to feel attracted to her, and
she began to date. In the meantime her husband began to get disillusioned with
his girl friend and wanted his wife back. He noticed Janet was happy as a lark
his girl friend and wanted his wife back. He noticed Janet was happy as a lark
without him, and at this point the tables began to turn. After Janet told him she
no longer wanted him back, he suffered a severe depression. She ultimately
established a very satis- satisfying relationship with another man and remarried.
The key to her success was simple—as a first step, she proved that she could
develop a relationship with herself. After this, the rest was easy. The PleasurePredicting Method I don't expect you to rely on my word on this topic, or even
on the reports of others like Janet who have learned how to experience the joys
of self-reliance. Instead, I pro- propose you perform a series of experiments, just
as Janet did, to test out your belief that ''being alone is a curse." If you are
willing to do this, you can arrive at the truth in an objective, scientific manner.
To help you, I have developed the ''Pleasure-Predicting Sheet" shown in Figure
12-2. This form is divided into a series of columns in which you predict and
record the actual amount of satisfaction you derive from various work and
recreational activities you engage in when alone, as well as from those you share
with other people. In the first column, record the date of each experiment. In the
second column, write down several activities that you plan to do as a part of that
day's experiments. I suggest that you carry out a series of forty or fifty
experiments over a two- to three- week period. Choose activities that would
ordinarily give you a sense of accomplishment or pleasure, or which have the
potential for learning or personal growth. In the third column, record who you do
the activity with. If you do it alone, write "self" in this column. (This word will
remind
Figure 12-2. The Pleasure-Predicting Sheet. Date 8/18/99 8/19/99 8/26/99
8/30/99 9/2/99 9/6/99 9/9/99 9/10/99 9/10/99 9/14/99 9/15/99 9/16/99 9/16/99
Activity for Satisfaction. (Sense of Achievement or Pleasure) Visit arts and
crafts center Go to rock concert Movie Party Read novel Jogging Go shopping
for blouse at boutique Go to market Walk to the park Date Study for exam Go
for driving test Ride bicycle to ice cream store Who Did You Do This With? (If
Alone, Specify Self) self self Sharon Many invited guests self self self mother
Sharon Bill self mother self Predicted Satisfaction @-100%). (Write This Before
the Activity) 20% 15% 85% 60% 75% 60% 50% 40% 60% 95% 70% 40% 80%
Actual Satisfaction @-100%). (Record This After the Activity) 65% 75% 80%
75% 85% 80% 85% 30% (argument) 70% 80% 65% 95% (passed test!) 95%
320 David D. Burns, M.D. you that you are never really alone, since you are
always with yourself!) In the fourth column, predict the satisfaction you think
you will derive from this activity, estimating it on a scale of between 0 and 100
percent. The higher the number, the greater the anticipated satisfaction. Fill in
percent. The higher the number, the greater the anticipated satisfaction. Fill in
the fourth column before you do each planned activity, not after! Once you have
filled in the columns, proceed with the activities. Once they are completed,
record the actual sat- satisfaction in the last column, using the same 0- to 100-
percent rating system. After you have performed a series of such experiments,
you will be able to interpret the data you have collected. You can learn many
things. First, by comparing the pre- predicted satisfaction (column four) with the
actual satisfaction (column five), you will be able to find out how accurate your
predictions are. You may find that you typically un- underestimate the amount of
satisfaction you anticipate ex- experiencing, especially when doing things alone.
You might also be surprised to learn that activities with others are not always as
satisfying as anticipated. In fact, you may even find that there are many times
when it was more enjoyable to be alone, and you might discover that the highest
ratings you received when you were alone were equal to or higher than those for
activities involving others. It can be helpful to compare the amount of
satisfaction you derived from work activities versus pleasurable activities. This
infor- information can help you achieve an optimal balance between work and
fun as you continue to plan your activities. Questions are probably now crossing
your mind, "Sup- "Suppose I do something and it isn't as satisfying as I
predicted? Or suppose I make a low prediction and it really comes out that
way?" In this case try to pinpoint the automatic negative thoughts that dampen
the experience for you. Then talk back to these thoughts. For example, a lonely
sixty-five-year-old woman whose children were all grown and married decided
to enroll in an evening course. All the other students were of college freshman
age. She felt tense the first week of classes because of her thought, 'They
probably think I'm
FEELING GOOD 321 an old bag with no right to be here." When she reminded
herself she had no idea what the other students thought of her, she felt some
relief. After talking to another student, she found out that some of them admired
her gumption. She then felt much better, and her satisfaction levels began to
climb. Now let's see how the Pleasure-Predicting Sheet can be used to overcome
dependency. Joanie was a fifteen-year- old high-school student who had suffered
from a chronic depression for several years after her parents moved to a new
town. She had difficulty making friends in the new high school, and believed, as
many teenage girls do, that she had to have a boyfriend and be a member of the
"in crowd" before she could be happy. She spent nearly all her free time at home
alone, studying and feeling sorry for herself. She resisted and resented the
suggestion she start going out and doing things because she claimed there would
simply be no point in doing them alone. Until a circle of friends magically
dropped into her lap, she seemed deter- determined to sit and brood. I persuaded
dropped into her lap, she seemed deter- determined to sit and brood. I persuaded
Joanie to use the Pleasure-Predicting Sheet. Figure 12-2 shows that Joanie
scheduled a variety of ac- activities, such as visiting an arts and crafts center on a
Sat- Saturday, going to a rock concert, etc. Because she did them alone, she
anticipated they would be unrewarding, as in- indicated by her low predictions in
column four. She was surprised to find she actually did have a reasonably good
time. As this pattern tended to repeat itself, she began to realize that she was
predicting things in an unrealistic neg- negative way. As she did more and more
on her own, her mood began to improve. She still wanted friends, but no longer
felt condemned to misery when she was alone. Because she proved she could
make it on her own, her self-confidence went up. She then became more
assertive with her peers, and invited several people to a party. This helped her
de- develop a network of friends, and she found that boys as well as girls in her
high-school class were interested in her. Joanie continued to use the PleasurePredict ing Sheet to evaluate
322 David D. Burns, M.D. the levels of satisfaction she experienced in dates and
ac- activities with her new friends. She was surprised to find that they were
comparable to the enjoyment levels she experi- experienced in doing things
alone. There is a difference between wanting and needing some- something.
Oxygen is a need, but love is a want. I repeat: LOVE IS NOT AN ADULT
HUMAN NEED! It's okay to want a loving relationship with another human
being. There is noth- nothing wrong with that. It is a delicious pleasure to be
involved in a good relationship with someone you love. But you do not need that
external approval, love, or attention in order to survive or to experience maximal
levels of happiness. Attitude Modification. Just as love, companionship, and
marriage are not necessary for happiness and self-esteem, they are not sufficient
either. The proof of this is the millions of men and women who are married and
miserable. If love were the antidote to depression, then I would soon be out of
business because the vast majority of the suicidal indi- individuals I treat are in
fact loved very dearly by their spouses, children, parents, and friends. Love is
not an effective an- tidepressant. Like tranquilizers, alcohol, and sleeping pills, it
often makes the symptoms worse. In addition to restructuring your activities
more crea- creatively, challenge the upsetting negative thoughts that flow
through your mind when you are alone. This was helpful to Maria, a lovely
thirty-year-old single woman, who found that when she did activities on her
own, she sometimes soured the experience unnecessarily by tell- telling herself,
"Being alone is a curse." In order to combat the feelings of self-pity and
resentment this thought created, she wrote a list of counterarguments (see Figure
12-3, page 323). She reported this was very helpful in breaking the cycle of
12-3, page 323). She reported this was very helpful in breaking the cycle of
loneliness and depression. Over a year after terminating my work with her I sent
her an early draft of this chapter, and she wrote back: "Last night I read very
thoroughly the chapter... It proves that
FEELING GOOD 323 Figure 12-3. "Being alone is a curse." Counterarguments:
The advantages of being alone. 1. Being alone gives a person the opportunity to
explore what she or he really thinks, feels, and knows. 2. Being alone gives the
person a chance to try all sorts of new things that might be harder to try if one
had ties to a housemate, spouse, etc. 3. Being alone forces you to develop your
personal strengths. 4. Being alone enables you to put aside excuses for taking
responsibility for yourself. 5. Being a woman alone is better than being a woman
with an unsuitable male mate. The same applies to a man. 6. Being a woman
alone can be an opportunity to develop into a full human being and not be an
appendage to a man. 7. Being a woman alone can be helpful in making you more
understanding of the problems women in different situations face. This can help
you learn to be more supportive of other women and can enable you to develop
more meaningful relationships with them. The same could also apply to men and
their understanding of various male problems. 8. Being a woman alone can show
a woman that even if she later lived with a man, she need not be constantly
afraid of his leaving her or dying. She knows that she can live alone and has the
potential for happiness within herself; thus, the relationship can be one of mutual
enhancement rather than one of mutual dependency and demandingness. it is not
being alone that is so bad or so good, but rather how one thinks regarding that or
any other condition of being. Thoughts are so powerful! They can make or break
you, right? ... It is almost funny, but now I am almost afraid to 'have a man.' I do
rather well, maybe better, without one . . . Dave, did you ever think you would
hear this from me?" The double-column technique can be especially useful in
helping you overcome the negative thinking pattern that
324 David D. Burns, M.D. makes you fear standing on your own two feet. For
example, a divorced woman with one child contemplated suicide be- because her
lover—a married man—had broken off with her. She had an intensely negative
self-image, and didn't believe that she would ever be capable of sustaining an
ongoing relationship. She was sure she would always end up a reject and a loner.
She wrote in her journal the following thoughts as she contemplated a suicide
attempt: The empty place in the bed next to me silently mocks me. I am alone—
alone—my greatest fear, my most dreaded fate, a reality. I am a woman alone
and in my mind that means I am nothing. The logic I am operating on goes
something like this: 1. If I were desirable and attractive there would be a man
something like this: 1. If I were desirable and attractive there would be a man
beside me now. 2. There is no man beside me. 3. Therefore I am undesirable and
unattractive. 4. Therefore there is no point in living. She went on to ask herself
in her journal, "Why do I need a man? A man would solve all my problems. He
would take care of me. He would give my life direction and most importantly he
would provide me with a reason to get out of bed each morning when all I now
want to do is put my head under the covers and sink into oblivion." She then
utilized the double-column technique as a way of challenging the upsetting
thoughts in her mind. She la- labeled the left-hand column "Accusations of My
Dependent Self," and labeled the right-hand column "Counterargu-
"Counterarguments of My Independent Self." She then carried out a dialogue
with herself to determine what the truth of the matter really was (see Figure 12-
4, page 325). After doing the written exercise, she decided to read it over each
morning in order to develop the motivation to get out of bed. She wrote the
following outcome in her personal diary:
FEELING GOOD 325 Figure 12-4. I. 2. 3. 4. 5. 6. 7. 8. Accusations of My
Dependent Self I need a man. Because I can't cope on my own. Okay. But I'm
lonely. Yes, but they don't count. But people will think no man wants me. I think
I am nothing without a man. Actually nothing. Everything important I've done
on my own. I guess I don't need a man. I just want one. Counterarguments of My
Independent Self I. Why do you need a man? 2. Have you been coping so far in
life? 3. Yes, but you have a child and you do have friends, and you have enjoyed
being with them very much. 4. They don't count because you dismiss them. 5.
People will think what they want to think. What is impor- important is what you
think. Only your thoughts and beliefs can affect your moods. 6. What did you
accomplish hav- having a man that you couldn't ac- accomplish on your own? 7.
Then why do you need a man? 8. It's fine to want things. They just can't become
so important that life loses its meaning with- without them. I learned to see that
there is a big difference between wanting and needing. I want a man but I no
longer feel that I must have a man to survive. By maintaining a more realistic
inner dialogue with myself and by looking at my own strengths, by listing and
reading and reading again the things that I have obtained on my own, I slowly
am beginning to develop a sense of
326 David D. Burns, M.D. confidence in my ability to handle what might come.
I find that I am taking better care of myself. I am treating myself as I would have
treated a beloved friend in the past with kindness and compassion, with a toltolerance for flaws and an appreciation of assets. Now I can view a difficult
situation not as a pestilence es- especially contrived to plague me but as an
opportunity to practice the skills I am learning, to challenge my negative
opportunity to practice the skills I am learning, to challenge my negative
thoughts, to reaffirm my strengths and to en- enhance my confidence in my
ability to deal with life.
Chapter 13 Your Work Is Not Your Worth A third silent assumption that leads to
anxiety and depression is "My worth as a human being is proportional to what I
have achieved in my life." This attitude is at the core of Western culture and the
Protestant work ethic. It sounds innocent enough. In fact, it is self-defeating,
grossly in- inaccurate, and malignant. Ned, the physician described in earlier
chapters, called me at home one recent Sunday evening. He had been feeling
panicky all weekend. His upset was triggered by plans to attend the twentieth
reunion of his college class (he grad- graduated from an Ivy League college). He
had been invited to give the keynote address to the alumni. Why was Ned in
such a state of apprehension? He was concerned that he might meet up with
some classmate at his reunion who had achieved more than he had. He explained
why this was so threatening: "It would mean I was a failure." Ned's exaggerated
preoccupation with his achievements is particularly common among men. While
women are not immune to career concerns, they are more likely to be dedepressed after the loss of love or approval. Men, in contrast, are especially
vulnerable to concerns about career failure because they've been programmed
from childhood to base their worth on their accomplishments. The first step in
changing any personal value is to deter- 327
328 David D. Burns, M.D. mine if it works more to your advantage or
disadvantage. Deciding that it will not really help you to measure your worth by
what you produce is the crucial first step in chang- changing your philosophy.
Let's begin with a pragmatic approach, a cost-benefit analysis. Clearly, there can
be some advantage to equating your self-esteem with your accomplishments. In
the first place, you can say "I'm okay" and feel good about yourself when you
have achieved something. For example, if you win a golf game, you can pat
yourself on the back and feel a little smug and superior to your partner because
he missed his putt on the last hole. When you go jogging with a friend and he
runs out of breath before you do, you can puff up with pride and tell yourself,
"He's a good guy for sure, but I'm just a little better!" When you make a big sale
at work, you can say, "I'm producing today. I'm doing a good job. My boss will
be pleased and / can respect myself.'' Essen- Essentially, your work ethic allows
you to feel you've earned personal worth and the right to feel happy. This belief
system may make you especially motivated to produce. You might put extra
effort into your career because you're convinced this will give you extra
worthiness units, and you will therefore see yourself as a more desirable person.
worthiness units, and you will therefore see yourself as a more desirable person.
You can avoid the horrors of being "just average." In a nutshell, you may work
harder to win, and when you win you may like yourself better. Let's look at the
other side of the coin. What are the disadvantages of your philosophy of' 'worth
equals achieve- achievement"? First, if your business or career is going well, you
may become so preoccupied with it that you may inadver- inadvertently cut
yourself off from other potential sources of sat- satisfaction and enjoyment as
you slave away from early morning to late night. As you become more and more
of a workaholic, you will feel excessively driven to produce because if you fail
to keep up the pace, you will experience a severe withdrawal characterized by
inner emptiness and despair. In the absence of achievement, you'll feel worthless
FEELING GOOD 329 and bored because you'll have no other basis for selfrespect and fulfillment. Suppose as a result of illness, business reversal, retireretirement, or some other factor beyond your control, you find you are unable to
produce at the same high level for a period of time. Now you may pay the price
of a severe depression, triggered by the conviction that because you are less proproductive it means you are no good. You'll feel like a tin can that's been used
and is now ready for the trash. Your lack of self-esteem might even culminate in
a suicide attempt, the ultimate payment for measuring your worth exclusively by
the standards of the marketplace. Do you want this? Do you need this? There
may be other prices to pay. If your family suffers from your neglect, a certain
resentment may build up. For a long time they may hold it in, but sooner or later
you'll get the bill. Your wife has been having an affair and is talking about
divorce. Your fourteen-year-old son has been arrested for burglary. When you
try to talk with him, he snubs you: "Where've you been all these years, Dad?"
Even if these unfortunate developments do not happen to you, you will still have
one great disadvantage—the lack of true self-esteem. I have recently begun
treating a very successful busi- businessman. He claims to be one of the top
money earners in the world in his profession. Yet he is victimized by episodic
states of fear and anxiety. What if he should fall off the pinnacle? What if he had
to give up his Rolls-Royce Silver Cloud and drive a Chevrolet instead? That
would be un- unbearable! Could he survive? Could he still love himself? He
doesn't know if he could find happiness without the glamour or glory. His nerves
are constantly on edge because he can't answer these questions. What would
your answer be? Would you still respect and love yourself if you experienced a
substantial failure? As with any addiction, you find that greater and greater doses
of your "upper" will be needed in order to become
330 David D. Burns, M.D. "high." This tolerance phenomenon occurs with
330 David D. Burns, M.D. "high." This tolerance phenomenon occurs with
heroin, "speed" (amphetamines), alcohol, and sleeping pills. It also happens with
riches, fame, and success. Why? Perhaps because you automatically set your
expectations higher and higher once you have achieved a particular level. The
ex- excitement quickly wears off. Why doesn't the aura last? Why do you keep
needing more and more? The answer is obvious: Success does not guarantee
happiness. The two are not identical and are not causally related. So you end up
chasing a mirage. Since your thoughts are the true key to your moods and not
success, the thrill of victory fades quickly. The old achievements soon become
old hat—you begin to feel sadly bored and empty as you stare at your trophy
case. If you do not get the message that happiness does not reliably and
necessarily follow from success, you may work even harder to try to recapture
the feeling you once had from being on top. This is the basis for your addiction
to work. Many individuals seek guidance or therapy because of the
disillusionment that begins to dawn on them in their middle or later years.
Eventually these questions may con- confront you as well: What's my life all
about? What's the meaning of it all? You may believe your success makes you
worthwhile, but the promised payoff seems elusive, just beyond your grasp. As
you read the above paragraphs, you may suspect that the disadvantages of being
a success junkie outweigh the advantages. But you may still believe it is
basically true that people who are superachievers are more worthwhile— the big
shots seem "special" in some way. You may be convinced that true happiness, as
well as the respect of others, comes primarily from achievement. But is this
really the case? In the first place, consider the fact that most human beings are
not great achievers, yet most people are happy and well respected. In fact, one
could say that the majority of the people in the United States are loved and
happy, yet by definition most of them are pretty much average. Thus, it
FEELING GOOD 331 cannot be the case that happiness and love come only
through great achievement. Depression, like the plague, is no respecter of status
and strikes those who live in fancy neighborhoods as often—if not more
frequently—as it does those of average or below-average means. Clearly, happihappiness and great achievement have no necessary connection. Does Work =
Worth? Okay, let's assume you've decided that it's not to your advantage to link
your work and your worth, and you also admit that achievement will not reliably
bring you love, respect, or happiness. You may still feel convinced that on some
level, people who achieve a lot are somehow better than others. Let's take a hard
look at this notion. First, would you say that everybody who achieves is
particularly worthwhile just because of their achievement? Adolf Hitler was
clearly a great achiever at the height of his career. Would you say that made him
particularly worth- worthwhile? Obviously not. Of course, Hitler would have
particularly worth- worthwhile? Obviously not. Of course, Hitler would have
insisted he was a great human being because he was a successful leader and
because he equated his worth and achievements. In fact, he was probably
convinced that he and his fellow Nazis were supermen because they were
achieving so much. Would you agree with them? Perhaps you can think of a
neighbor or someone you don't like very much who does achieve a lot and yet
seems overly grasping and aggressive. Now, is that person espe- especially
worthwhile in your opinion just because he or she is an achiever? In contrast,
perhaps you know someone you care for or respect who is not a particularly
great achiever. Would you say that person is still worthwhile? If you answer yes,
then ask yourself—if they can be worthwhile without great achievement, then
why can't I be? Here's a second method. If you insist your worth is dedetermined by your achievement, you are creating a self- esteem equation: worth
= achievement. What is the basis
332 David D. Burns, M.D. for making this equation? What objective proof do
you have that it is valid? Could you experimentally measure people's worth as
well as their achievement so as to find out if they were in fact equal? What units
would you use to measure it? The whole idea is nonsense. You can't prove the
equation because it is just a stipu- stipulation, a value system. You're defining
worth as achieve- achievement and achievement as worth. Why define them as
each other? Why not say worth is worth and achievement is achievement? Wprth
and achievement are different words with different meanings. In spite of the
above arguments, you may still be con- convinced that people who achieve more
are better in some way. If so, I'm going to hit you now with a most powerful
method which, like dynamite, can shatter this attitude even when it appears to be
etched in granite. First, I would like you to play the role of Sonia (or Bob), an
old friend from high-school days. You have a family and teach school. I have
pursued a more ambitious career. In the dialogue you will assume that human
worth is deter- determined by achievement, and I will push the implications of
this to their obvious, logical, and obnoxious conclusion. Are you ready? I hope
so because you're about to be as- assaulted in a most unpleasant way by a belief
you apparently still cherish. David: Sonia (or Bob), how are you doing? You
(playing the role of my old friend): Just fine, David. How are you? David: Oh,
great. I haven't seen you since high school. What's been happening? You: Oh,
well, I got married, and I'm teaching at Parks High School and I have a little
family at home. Things are great. David: Well, gee. I'm sorry to hear that. I
turned out a lot better than you. You: How's that? Come again?
FEELING GOOD 333 David: / went to graduate school and / got my Ph.D. and /
FEELING GOOD 333 David: / went to graduate school and / got my Ph.D. and /
have become quite successful in business. I'm earning a lot of money. In fact, I'm
one of the wealthier people in town now. I've achieved a great deal. More than
you by a long shot. I don't mean to insult you or anything, but I guess that means
I'm a lot better person than you, huh? You: Well, gee, Dave, I'm not sure what to
say. I thought I was a rather happy person before I started to talk to you. David: I
can understand that. You're at a loss for words, but you might as well face facts.
I've got what it takes, and you don't. I'm glad you're happy, though. Mediocre,
average people are entitled to a little happiness too. After all, I certainly don't
begrudge you a few crumbs from the banquet table. But it's just too bad you
couldn't have done more with your life. You: Dave, you seem to have changed.
You were such a nice person in high school. I get the feeling you don't like me
anymore. David: Oh, no! We can still be friends as long as you admit you're an
inferior, second-rate person. I just want to remind you to look up to me from
now on, and I want you to realize that I'll look down on you because I'm more
worthwhile. This follows from the assumption that we have— worth equals
achievement. Remember that atti- attitude you cherish? I've achieved more, so
I'm worth more. You: Well, I sure hope I don't run into you soon again, Dave.
It's not been such a pleasure talking to you. That dialogue cools most people off
very quickly because it illustrates how the inferior-superior system follows loglogically from equating your worth with your achievement.
334 David D. Burns, M.D. Actually, many people do feel inferior. The roleplaying can help you see how ludicrous the assumption is. In the above dialogue,
who was acting jerky? The happy house- housewife/schoolteacher or the
arrogant businessman trying to make a case that he was better than other people?
I hope this imaginary conversation will help you see clearly how screwball the
whole system is. If you like, we can do a role-reversal to put the icing on the
cake. This time you play the role of the very successful person, and 1 want you
to try to put me down as sadistically as you can. You can pretend to be the editor
of Cosmopolitan magazine, Helen Gurley Brown.* I went to high school with
you; I'm just an average high-school teacher now, and it's your job to argue that
you're better than I am. You (playing the role of Helen Gurley Brown): Dave,
how have you been? It's been a long time. David: (playing the role of a highschool teacher): Well, fine. I have a little family, and I'm teaching high school
here. I'm a physical education teacher and really enjoying life. I understand
you've made it big. You: Yeah. Well, I really have been kind of lucky. I'm editor
of Cosmopolitan now. Perhaps you heard. David: Of course I have. I've seen you
on TV on the talk shows plenty of times. I hear you make a huge income, and
you even have your own agent. You: Life's been good. Yeah. It's really been
you even have your own agent. You: Life's been good. Yeah. It's really been
terrific. David: Now there's just one thing I heard about you that I really didn't
understand. You were talking to a friend of ours, and you were saying how
you're so much better than I am now that you've made "This is a purely
imaginary dialogue having no bearing on the real Helen Gurley Brown.
FEELING GOOD 335 it big, whereas my career is just average. What did you
mean by that? You: Well, Dave, I mean, just think about all the things I've
accomplished in my life. Here I am influencing millions, and whoever heard of
Dave Burns in Philadelphia? I'm hobnobbing with the stars, and you're bouncing
a basketball around in the court with a bunch of kids. Don't get me wrong.
You're certainly a fine, sincere, average person. It's just that you never made it,
so you might as well face facts! David: You've made a great impact, and you're a
woman of influence and fame. I respect that a lot, and it sounds quite rewarding
and exciting. But please forgive me if I'm dense. I just don't understand how that
makes you a better person. How does that make me inferior to you or make you
more worthwhile? With my little local mind, I must be missing something
obvious. You: Face it, you just sit around and interact with no particular purpose
or destiny. I have charisma. I'm a mover and shaker. That gives me a bit of an
edge, wouldn't you say? David: Well, I don't interact to no purpose, but my
purposes may seem modest in comparison with yours. I teach phys ed, and I
coach the local football games and that kind of thing. Your orbit is certainly big
and fancy in comparison with mine. But I don't understand how that makes you a
better person than I am, or how it follows that I'm inferior to you. You: I'm just
more highly developed and more elab- elaborate. I think about more important
things. I go on the lecture circuit, and people flock to hear me by the thousands.
Famous authors work for me. Who do you lecture to? The local PTA?
336 David D. Burns, M.D. David: Certainly in achievement, money, and
influence you're way ahead of me. You've done very well. You were very bright
to begin with, and you've worked very hard. You're a big success now. But how
does that make you more worthwhile than I am? You must forgive me, but I still
don't grasp your logic. You: I'm more interesting. It's like an amoeba versus a
highly developed biological structure. Amoe- bas are kind of boring after a
while. I mean your life must be like an amoeba's. You're just bum- bumbling
around aimlessly. I'm a more interesting, dynamic, desirable person; you're
second-rate. You're the burnt toast; I'm the caviar. Your life is a bore. I don't see
how I can say it more clearly. David: My life isn't as boring as you might think.
Take a close look at it. I'd be surprised to hear what you have to say here because
I can't find anything boring about my life. What I do is exciting and vital to me.
The people I teach are every bit as important to me as the glamorous movie stars
The people I teach are every bit as important to me as the glamorous movie stars
you interact with. But even if it were true that my life was more tedious and
routine and less interesting than yours, how would that make you a better person
or more worthwhile? You: Well, I suppose it just really boils down to the fact
that if you have an amoeba existence, then you can only judge it on the basis of
your amoeba mentality. I can judge your situation, but you can't judge mine.
David: What is the basis for your judgment? You can call me an amoeba, but I
don't know what that means. You seem to be reduced to name-calling. All it
means is that apparently my life is not especially interesting to you. Certainly I'm
not
FEELING GOOD 337 nearly as successful or glamorous, but how does that
make you a better or more worthwhile per- person? You: I'm almost starting to
give up. David: Don't give up here. Press on. Perhaps you are a better person!
You: Well, certainly society values me more. That's what makes me better.
David: It makes you more highly valued by society. That's undoubtedly the case.
I mean Johnny Car- Carson hasn't contacted me for any appearances re- recently.
You: I've noticed that. David: But how does being more highly valued by sosociety make you a more worthwhile person? You: I'm earning a huge salary.
I'm worth millions. Just how much are you worth, Mr. School- Schoolteacher?
David: You clearly have more financial worth. But how does that make you a
more worthwhile human being? How does commercial success make you a
better person? You: Dave, if you're not going to worship me, I'm not going to
talk to you. David: Well, I don't see how that would make me less worthwhile
either. Unless you have the idea that you're going to go around deciding who's
worth- worthwhile based on who worships you! You: Of course I do! David:
Does that go along with being editor of Cos- Cosmopolitan! If so, please tell me
how you make these decisions. If I'm not worthwhile, I'd def- definitely like to
know why so that I can give up feeling good and considering myself equal to
other people.
338 David D. Burns, M.D. You: Well, it must be that your orbit is rather small
and dreary. While I'm on my Lear jet to Paris, you're in a crowded school bus
going to She- boy gan . David: My orbit may be small, but it's very gratifying. I
enjoy the teaching. I enjoy the kids. I like to see them develop. I like to see them
learn. At times they make mistakes, and I have to let them know. There's a lot of
real love and humanity that goes on there. A lot of drama. What about that seems
dreary to you? You: Well, there's not as much to learn. No real chal- challenge.
It seems to me that in a world as small as yours you learn just about everything
there is to learn, and then you just repeat things over and over. David: Your
there is to learn, and then you just repeat things over and over. David: Your
work presents quite a challenge as it turns out. How could I know everything
there is to know about even one student? They all seem complex and exciting to
me. I don't think I have anybody figured out completely. Do you? WorkWorking with even one student is a complex challenge to all my abilities.
Having so many young people to work with is a challenge beyond what I could
ask for. I don't understand what you mean when you say my world is small and
boring and every- everything is figured out. You: Well, it just seems to me that
you are unlikely to run into many people in your world who are going to develop
as highly as I have. David: I don't know. Some of my students have high IQ's
and may develop the same way you did, and some of them are mentally
subnormal and will only develop to a modest level. Most are average and each
one is fascinating to me. What did you mean when you said they were boring?
FEELING GOOD 339 Why is it that only the great achievers are interinteresting to you? You: I give in1 Uncle! I hope you did in fact "give in" when
you played the role of the successful snob. The method I used to thwart your
claim you were better than I was quite simple. When- Whenever you claimed
you were a better or more worthy person because of some specific quality such
as intelligence, influ- influence, status, or whatever, I immediately agreed with
you that you are better in that particular quality (or set of qual- qualities) and
then I asked you—"But how does that make you a better (or more worthwhile)
person?" This question can- cannot be answered. It will take the wind out of the
sails of any system of values that sets some people up as being superior to
others. The technical name for this method is ' 'operationaliza- tion." In it you
must spell out just what quality makes anyone more or less worthwhile than
anyone else. You can't do it! Of course, other people would rarely think or say
such insulting things to you as were said in the dialogues. The real put-down
goes on in your head. You are the one who's telling yourself your lack of status,
or achievement, or pop- popularity, or love, etc., makes you less worthwhile and
de- desirable; so you're the one who's going to have to put an end to the
persecution. You can do this in the following way: Carry on a similar dialogue
with yourself. Your im- imaginary opponent, who we'll name the Persecutor,
will try to argue that you are inherently inferior or less worthwhile because of
some imperfection or lack. You simply asser- assertively agree with the grain of
truth in his criticism, but raise the question of how it follows that you are less
worthwhile. Here are several examples: 1. Persecutor: You're not a very good
lover. Sometimes you don't even get a firm erection. This means you're less of a
man and an inferior person.
340 David D. Burns, M.D. You: It certainly shows that I'm nervous about sex
and not a particularly skilled or confident lover. But how does this make me less
of a man or less of a person? Since only a man can feel nervous about an
erection, this would seem to be an especially "manly" experience; doing it well
makes you more of a man! Furthermore, there's a great deal more to being a man
than just having sex. 2. Persecutor: You're not as hardworking or as successsuccessful as most of your friends. You're lazy and no good. You: This means
I'm less ambitious and hardworking. I may even be less talented, but how does it
follow that I'm "lazy and no good"? 3. Persecutor: You're not worth much
because you're not outstanding in anything. You: I agree that I don't hold a single
world cham- championship. I'm not even second best at anything. In fact, at most
things I'm pretty much average. How does it follow that I'm not worth much? 4.
Persecutor: You're not popular, you don't even have many close friends, and no
one cares about you much. You have no family and not even any casual lovers.
So you're a loser. You're an inadequate person. There's obviously something
wrong with you. You're worthless. You: It's true I have no lover at this time, and
there are just a few friends I feel close to. How many do I need to be an
"adequate person"? Four? Eleven? If I'm not popular, it may be that I'm
relatively un- unskilled socially, and I may have to work harder at this. But how
does it follow that I'm a "loser"? Why am I worthless? I suggest you try out the
method illustrated above. Write down the worst persecutory insults you can level
at yourself and then answer them. It may be hard at first, but eventually the truth
will dawn on you—you can be imperfect or unFEELING GOOD 341 successful or unloved by others, but not one iota less
worth- worthwhile. Four Paths to Self-Esteem You might ask, "How can I attain
self-esteem if my worth doesn't come from my success or from love or approval?
If you peel all these criteria away one by one and expose them as invalid bases
for personal worth, it seems there will be nothing left. Just what is it that I have
to do?" Here are four valid paths to self-esteem. Choose the one that seems most
useful to you. The first path is both pragmatic and philosophical. Es- Essentially,
you must acknowledge that human "worth" is just an abstraction; it doesn't exist.
Hence, there is actually no such thing as human worth. Therefore, you cannot
have it or fail to have it, and it cannot be measured. Worth is not a "thing," it is
just a global concept. It is so generalized it has no concrete practical meaning.
Nor is it a useful and enhancing concept. It is simply self-defeating. It doesn't do
you any good. It only causes suffering and misery. So rid yourself immediately
of any claim to being "worthy," and you'll never have to measure up again or
fear being "worth- "worthless." Realize that "worthy" and "worthless" are just
empty concepts when applied to a human being. Like the concept of your "true
empty concepts when applied to a human being. Like the concept of your "true
self," your "personal worth" is just mean- meaningless hot air. Dump your
"worth" in the garbage can! (You can put your "true self" in there too, if you
like.) You'll find you've got nothing to lose! Then you can focus on living in the
here and now instead. What problems do you face in life? How will you deal
with them? That's where the action is, not in the elusive mirage of "worth." You
may be afraid to give up your "self" or your "worth." What are you afraid of?
What terrible thing will happen? Nothing! The following imaginary dialogue
may make this clearer. Let's assume that I am worthless. I want you to rub it in
and try to make me feel upset.
342 David D. Burns, M.D. You: Burns, you're worthless! David: Of course I'm
worthless. I fully agree. I realize that there is nothing about me that makes me
4'worthy." Love, approval, and achievement can't give me any "worth," so I'll
accept the fact that / have none\ Should this be a problem for me? Is something
bad going to happen now? You: Well, you must be miserable. You're just "no
good." David: Assuming I am "no good," so what? What spe- specifically do I
have to be miserable about? Does being "worthless" put me at a disadvantage in
some way? You: Well, how can you respect yourself? How could anyone?
You're just a scum! David: You may think I'm a scum, but I do respect myself,
and so do lots of other people. I see no valid reason not to respect myself. You
may not respect me, but I don't see that as a problem. You: But worthless people
can't be happy or have any fun.You're supposed to be depressed and dedespicable. My panel of experts met and deter- determined that you're a total
zero. David: So, call the papers and let them know. I can see the headline:
''Philadelphia Physician Found to Be Worthless." If I'm really that bad off, it's
reassuring because now I have nothing to lose. I can live my life fearlessly.
Furthermore, I am happy and I am having fun, so being a "total zero" can't be
bad. My motto is —"Worthless is Wonderful!" In fact, I'm thinking of having a
T-shirt made up like that. Perhaps I'm missing out on something, though.
Apparently you're worthwhile, whereas I'm not. What good does this "worth" do
you? Does it make you better than people like me, or what?
FEELING GOOD 343 The question may occur to you—"If I gave up my belief
that success adds to my personal worth, then what would be the point in doing
anything?" If you stay in bed all day, the probability that you will bump into
something or some- someone that will make your day a little brighter is very
small. Furthermore, there can be enormous satisfactions from daily living that
are totally independent of any concept of personal worth. For example, as I am
writing this I feel very turned on, but it isn't due to my belief that I am
writing this I feel very turned on, but it isn't due to my belief that I am
particularly "worth- "worthwhile" because I'm writing it. The exhilaration comes
from the creative process, pulling ideas together, editing, watch- watching
clumsy sentences sharpen up, and wondering how you will react when you read
this. This process is an exciting adventure. Involvement, commitment, and
taking a risk can be quite stimulating. This is an adequate payoff, to my way of
thinking. You might also wonder—"What is the purpose and meaning of life
without a concept of worth?" It's simple. Rather than grasp for "worth," aim for
satisfaction, plea- pleasure, learning, mastery, personal growth and communicacommunication with others every day of your life. Set realistic goals for yourself
and work toward them. I think you will find this so abundantly gratifying you'll
forget all about "worth," which in the last analysis has no more buying power
than fool's gold. "But I'm a humanistic or spiritual person," you might argue.
"I've always been taught that all human beings have worth, and I just don't want
to give up this concept." Very well, if you want to look at it that way, I'll agree
with you, and this brings us to the second path to self-esteem. Ac- Acknowledge
that everyone has one "unit of worth" from the time they are born until the time
they die. As an infant you may achieve very little, and yet you are still precious
and worthwhile. And when you are old or ill, relaxed or asleep, or just doing
"nothing," you still have "worth." Your "unit of worth" can't be measured and
can never change, and it is the same for everyone. During your lifetime, you can
enhance your happiness and satisfaction through pro344 David D. Burns, M.D. ductive living, or you can act in a destructive manner
and make yourself miserable. But your "unit of worth" is al- always there, along
with your potential for self-esteem and joy. Since you can't measure it or change
it, there is no point in dealing with it or being concerned about it. Leave that up
to God. Paradoxically, this solution comes down to the same bot- bottom line as
the previous solution. It becomes pointless and irresponsible to deal with your
"worth," so you might as well focus on living life productively instead! What
prob- problems do you confront today? How will you go about solving them?
Questions such as these are meaningful and useful, whereas rumination about
your personal "worth" just causes you to spin your wheels. Here is the third path
to self-esteem: Recognize that there is only one way you can lose a sense of selfworth—by persecuting yourself with unreasonable, illogical negative thoughts.
Self-esteem can be defined as the state that exists when you are not arbitrarily
haranguing and abusing yourself but choose to fight back against those
automatic thoughts with meaningful rational responses. When you do this efeffectively, you will experience a natural sense of jubilation and selfendorsement. Essentially, you don't have to get the river flowing, you just have
endorsement. Essentially, you don't have to get the river flowing, you just have
to avoid damming it. Since only distortion can rob you of self-esteem, this
means that nothing in "reality" can take away your sense of worth. As evidence
for this, many individuals under conditions of extreme and realistic deprivation
do not ex- experience a loss of self-esteem. Indeed, some individuals who were
imprisoned by the Nazis during World War II refused to belittle themselves or
buy into the persecutions of their captors. They reported an actual enhancement
of self-esteem in spite of the miseries they were subjected to, and in some cases
described experiences of spiritual awakening. Here is the fourth solution: Selfesteem can be viewed as your decision to treat yourself like a beloved friend.
Imagine that some VIP you respect came unexpectedly to visit you one day.
How might you treat that person? You would wear
FEELING GOOD 345 your best clothes and offer your finest wine and food, and
you would do everything you could to make him feel com- comfortable and
pleased with his visit. You would be sure to let him know how highly you valued
him, and how honored you were that he chose to spend some time with you.
Now— why not treat yourself like that? Do it all the time if you can! After all, in
the final analysis, no matter how impressed you are with your favorite VIP, you
are more important to you than he is. So why not treat yourself at least as well?
Would you insult and harangue such a guest with vicious, distorted put-downs?
Would you peck away at his weak- weaknesses and imperfections? Then why do
this to yourself? Your self-torment becomes pretty silly when you look at it this
way. Do you have to earn the right to treat yourself in this loving, caring way?
No, this attitude of self-esteem will be an assertion that you make, based on a
full awareness and acceptance of your strengths and imperfections. You will
fully acknowledge your positive attributes without false hu- humility or a sense
of superiority, and will freely admit to all your errors and inadequacies without
any sense of inferiority or self-depreciation whatever. This attitude embodies the
essence of self-love and self-respect. It does not have to be earned, and it cannot
be earned in any way. Escape from the Achievement Trap You might be
thinking, "All that philosophizing about achievement and self-worth is well and
good. After all, Dr. Burns has a good career and a book on the market, so it's
easy for him to tell me to forget about achievement. It sounds about as genuine
as a rich man trying to explain to a beggar that money isn't important. The raw
fact is, I still feel bad about myself when I do poorly, and I believe that life
would be a whole lot more exciting and meaningful if I had more success. The
truly happy people are the big shots, the ex- executives. I'm only average. I've
never done anything really
346 David D. Burns, M.D. outstanding, so I'm bound to be less happy and
346 David D. Burns, M.D. outstanding, so I'm bound to be less happy and
satisfied. If this isn't right, then prove it to me! Show me what I can do to change
the way I feel, and only then will I be a true believer." Let's review several steps
you might take to liberate your- yourself from the trap of feeling you must
perform in an out- outstanding manner in order to earn your right to feel
worthwhile and happy. Remember to Talk Back. The first useful method is to
keep practicing the habit of talking back to those negative, distorted thoughts
which cause you to feel inadequate. This will help you realize that the problem is
not your actual performance, but the critical way in which you put yourself
down. As you learn to evaluate what you do realistical- realistically, you will
experience increased satisfaction and self- acceptance. Here's how it worked for
Len, a young man pursuing a career playing the guitar in rock bands. He sought
treatment because he felt like a "second-rate" musician. From the time he was
young, he was convinced he had to be a 4'ge- 4'genius" in order to be
appreciated. He was easily hurt by criticism, and often made himself miserable
by comparing himself with better-known musicians. He would feel de- deflated
when he told himself, "I'm a nobody in comparison with X." He was certain that
his friends and fans also viewed him as a mediocre person, and he concluded
that he could never receive his fair share of the good things in life: praise,
admiration, love, etc. Len utilized the double-column technique to expose the
nonsense and illogic in what he was saying to himself (Fig- (Figure 13-1). This
helped him to see that it was not a lack of musical talent that was the cause of his
problems, but his unrealistic thinking patterns. As he began to correct this
distorted thinking, his self-confidence improved. He de- described the effect of
this: ' 'Writing down my thoughts and answering them helped me to see how
hard I was being on
FEELING GOOD 347 Figure 13-1. Len's homework form for recording and
answering his upsetting thoughts about being "the greatest." Automatic Thoughts
Rational Responses 1. If I'm not "the greatest," I (All-or-nothing thinking).
Whether it means I won't get any or not I'm "the greatest," people attention from
people. will listen to me, they will see me perform, and many will respond
positively to my music. 2. But everybody doesn't like 2. This is true of all
musicians, even the kind of music I play. Beethoven or Bob Dylan. No mumusician can please everybody. Quite a few people do respond to my mumusic. If I enjoy my music, then that should be enough. 3. But how can / enjoy
my 3. By playing music that turns me on, music if I know I'm not just as I
always have! Besides, "the greatest"? there's no such thing as "the world's
greatest musician " So stop trying to be it! 4. But if I were more famous 4. How
many fans and how many girl and talented, then I'd have friends do I need before
many fans and how many girl and talented, then I'd have friends do I need before
I'll be more fans. How can I be happy? happy on the sidelines when the bigname per- performers with charisma are in the spotlight? 5. But I feel that no girl
could 5. Other people are loved who are just really love me until I be- "average"
in their work. Do I really come a big-name talent. have to be a big shot before
someone will love me? Many of the guys 1 know get plenty of dates and they're
not so unusual. myself, and it gave me a sense there was something I could do to
change. Instead of sitting there getting bombed by what I was telling myself, I
suddenly had some antiaircraft artillery to fight back with."
348 David D. Burns, M.D. Tune In to What Turns You On. One assumption
which might be driving you to constant preoccupation with achievement is the
idea that true happiness comes only through success in your career. This is
unrealistic because the majority of life's satisfactions do not require great
achievement at all. It takes no special talent to enjoy an average walk through
the woods on an autumn day. You don't have to be "outstanding" to relish the
affectionate hug of your young son. You can enjoy a good game of volley ball
tremendously even though you're just an average player. What are some of life's
pleasures that have turned you on? Music? Hiking? Swimming? Food? Travel?
Con- Conversation? Reading? Learning? Sports? Sex? You don't have to be
famous or a top performer to enjoy these to the hilt. Here's how you can turn up
the volume so that this kind of music comes in loud and clear. Josh is a fiftyeight-year-old man with a history of de- destructive, manic mood swings as well
as incapacitating depressions. When he was a child, Josh's parents emphaemphasized over and over that his career was destined to be ex- extraordinary, so
he always felt he had to be number one. He eventually did make an exceptional
contribution in his cho- chosen field, electrical engineering. He won numerous
awards, was appointed to presidential commissions, and was cred- credited with
many patents. However, as his cyclic mood dis- disorder became increasingly
severe, Josh began to have 4'high" episodes. During these periods, his judgment
be- became grossly impaired and his behavior was so bizarre and disruptive that
he had to be hospitalized on several occa- occasions. Sadly, he came down off
one high to learn he had lost his family as well as his prestigious career. His wife
had filed for divorce, and he had been forced into an early retirement by the
company he worked for. Twenty years of achievement went down the drain. In
the years that followed, Josh was treated with lithium and developed a modest
consulting business. Eventually he was referred to me for treatment because he
still experienced
FEELING GOOD 349 uncomfortable mood swings, especially depression, in
FEELING GOOD 349 uncomfortable mood swings, especially depression, in
spite of the lithium. The crux of his depression was clear-cut. He was disdiscouraged about his life because his career no longer mea- measured up in
terms of the money and prestige he had experienced in the past. While he had
enjoyed the role of charismatic *'charger" as a young man, he was now apapproaching sixty and felt alone and ''over the hill." Because he still believed the
only way to true happiness and personal worth was through superlative, creative
achievements, he felt certain that his constricted career and modest life-style
made him second-rate. Since he was still a good scientist at heart, Josh decided
to test his hypothesis that his life was destined to be mediocre by using the
Pleasure-Predicting Sheet (described in pre- previous chapters). Each day he
agreed to schedule various activities that might give him a sense of pleasure,
satisfac- satisfaction, or personal growth. These activities could be related to his
consulting business as well as hobbies and recreational pursuits. Before each
activity he was to write down his prediction of how enjoyable it would be and
mark it between 0 percent (no satisfaction at all) and 99 percent (the maxmaximum enjoyment a human being can experience). After filling out these
forms for several days, Josh was surprised to find that life had just as much
potential for joy and satisfaction as it ever had (see Figure 13-2). His disdiscovery that work was at times quite rewarding and that numerous other
activities could be just as enjoyable, if not more so, was a revelation to him. He
was amazed one Saturday night when he went roller-skating with his girl friend.
As they moved to the music, Josh found he began to tune into the beat and the
melody, and as he became absorbed in the rhythm, he experienced a great sense
of exhilaration. The data he collected on the Pleasure- Predicting Sheet indicated
he didn't need a trip to Stockholm to receive the Nobel Prize to experience the
ultimate in satisfaction—he didn't have to go any farther than the skatFigure 13-2. The Pleasure-Predicting Sheet. Date 4/18/99 4/19/99 4/19/99
4/19/99 4/20/99 Activity for Pleasure or Satisfaction Work on consulting project
Take long walk before breakfast Prepare written report Make a "missionary call"
on a potential customer Roller-skating Who Did You Do This With? (If Alone,
Specify Self) self self self self girl friend Predicted Satisfaction @-100%).
(Record This Before the Activity) 70% 40% 50% 60% 50% Actual Satisfaction
@-100%). (Record This After the Activity) 75% 85% 50% 40% (no new
business) 99%!
FEELING GOOD 351 ing rink! His experiment proved that life was still filled
with abundant opportunities for pleasure and fulfillment if he would enlarge his
mental focus from a microscopic fixation on work and open himself up to the
broad range of rich experiences that living can offer. I am not arguing that
broad range of rich experiences that living can offer. I am not arguing that
success and achievement are un- undesirable. That would be unrealistic. Being
productive and doing well can be enormously satisfying and enjoyable.
However, it is neither necessary nor sufficient to be a great achiever in order to
be maximally happy. You don't have to earn love or respect on the treadmill, and
you don't have to be number one before you can feel fulfilled and know the
meaning of inner peace and self-esteem. Now doesn't that make good sense?
Chapter 14 Dare to Be Average I— Ways to Overcome Perfectionism I dare you
to try to be ''average." Does the prospect seem blah and boring? Very well—I
dare you to try it for just one day. Will you accept the challenge? If you agree, I
predict two things will happen. First, you won't be partic- particularly successful
at being "average." Second, in spite of this you will receive substantial
satisfaction from what you do. More than usual. And if you try to keep this
"aver- ageness" up, I suspect your satisfaction will magnify and turn to joy.
That's what this chapter is all about—learning to defeat perfectionism and enjoy
the spoils of pure joy. Think of it this way—there are two doors to enlightenenlightenment. One is marked "Perfection," and the other is marked "Average."
The "Perfection" door is ornate, fancy, and seductive. It tempts you. You want
very much to go through. The "Average" door seems drab and plain. Ugh! Who
wants it? So you try to go through the "Perfection" door and always discover a
brick wall on the other side. As you insist on trying to break through, you only
end up with a sore nose and a headache. On the other side of the "Average" door,
in contrast, there's a magic garden. But it may never have occurred to you to
open this door to take a look! 352
FEELING GOOD 353 You don't believe me? I didn't think so, and you don't
have to. I want you to maintain your skepticism! It's healthy—but at the same
time I dare you to check me out. Prove me wrong! Put my claim to the test.
Walk through that "Average" door just one day in your life. You may end up
amazed! Let me explain why. "Perfection" is man's ultimate il- illusion. It simply
doesn't exist in the universe. There is no perfection. It's really the world's
greatest con game; it prom- promises riches and delivers misery. The harder you
strive for perfection, the worse your disappointment will become be- because it's
only an abstraction, a concept that doesn't fit reality. Everything can be improved
if you look at it closely and critically enough—every person, every idea, every
work of art, every experience, everything. So if you are a per- perfectionist, you
are guaranteed to be a loser in whatever you do. "Averageness" is another kind
of illusion, but it's a benign deception, a useful construct. It's like a slot machine
that pays a dollar fifty for every dollar you pyt in. It makes you rich—on all
that pays a dollar fifty for every dollar you pyt in. It makes you rich—on all
levels. If you're willing to explore this bizarre-sounding hy- hypothesis, let's
begin. But beware—don't let yourself be- become too average because you may
not be used to so much euphoria. After all, a lion can eat only so much meat
after the kill! Do you remember Jennifer, the perfectionistic writer- student
mentioned in Chapter 4? She complained that friends and psychotherapists kept
telling her to stop being such a perfectionist, but no one ever bothered to tell her
how to go about doing this. This chapter is dedicated to Jennifer. She's not the
only one who feels in a quandry about this. At my lectures and workshops,
psychotherapists have often asked me to prepare a how-to-do-it manual that
illustrates the fifteen techniques I have developed for overcoming perperfectionism. Well—here's the manual. These methods work. You have nothing
to fear or lose because the effects are not irreversible.
354 David D. Bums, M.D. /. The best place to begin your fight against
perfection- perfectionism is with your motivation for maintaining this approach.
Make a list of the advantages and disadvantages of being perfectionistic. You
may be surprised to learn that it is not actually to your advantage. Once you
understand that it does not in fact help you in any way, you'll be much more
likely to give it up. Jennifer's list is shown in Figure 14-1. She concluded that her
perfectionism was clearly not to her advantage. Now make your list. After you
have completed it, read on. 2. Using your list of the advantages and
disadvantages of perfectionism, you might want to do some experiments to test
some of your assumptions about the advantages. Like many people, you may
believe "Without my perfectionism I'd be nothing. I couldn't perform
effectively." I'll bet you never put this hypothesis to the test because your belief
in your inadequacy is such an automatic habit it has never even occurred to you
to question it. Did you ever think that maybe you've been as successful as you
are in spite of your per- perfectionism and not because of it! Here's an
experiment that will allow you to come to the truth of the matter. Try altering
your standards in various activities so you can see how your performance
responds to high standards, middle standards, and low standards. The results
may surprise you. I've done this with my writing, my psychotherapy with
patients, and my jogging. And in all cases I have been pleasantly shocked to
discover that by lowering my standards not only do I feel better about what I do
but I tend to do it more effectively. For example, I began jogging in January
1979 for the first time in my life. I live in a very hilly region, and initially I
couldn't run more than two or three hundred yards without having to stop and
walk because there are hills in all di- directions from my driveway. Each day I
made it my aim to run a little less far than the day before. The effect of this was
that I could always accomplish my goal easily. Then I would feel so good it
that I could always accomplish my goal easily. Then I would feel so good it
would spur me on farther—and every step was gravy, more than I had aimed for.
Over a period of months I built up to the point at which I could run seven
Figure 14-1. Jennifers list of advantages and disadvantages of perfectionism. She
concluded, 'Clearly the disadvantages out- outweigh the one possible
advantage." Advantages of Perfectionism Disadvantages 1. It can produce fine 1.
It makes me so "tight" and ner- work. Til try hard to come up with an exexceptional result. 7. vous I can't produce fine work. I become afraid and
unwilling to risk the mistakes necessary to come up with a fine product. It makes
me very critical of my- myself. I can't enjoy life because I can't admit my
successes or allow myself to revel in them. I can't ever relax because I'll alalways be able to find something somewhere that isn't perfect, and then I'll get
self-critical. Since I can never be perfect, I'll always be depressed. It makes me
intolerant of others. I end up without many friends be- because people don't
appreciate being criticized. I find so many faults in people I lose my capacity to
feel warm and to like them. Another disadvantage is that my perfectionism keeps
me from trying new things and making dis- discoveries. I'm so afraid of making
mistakes that I don't do much at all besides the same familiar things I'm good at.
The result is that it narrows my world and makes me bored and restless bebecause I have no new challenges.
356 David D. Burns, M.D. miles over a steep terrain at a fairly rapid pace. I have
never abandoned my basic principles—to try to accomplish less than the day
before. Because of this rule I never feel frus- frustrated or disappointed in my
running. There have been many days when due to sickness or fatigue, I actually
didrit run far or fast. Today, for example, I could only run a quarter mile because
I had a cold and my lungs said NO FARTHER! So I told myself, 'This is as far
as I was supposed to go." I felt good because I achieved my goal. Try this.
Choose any activity, and instead of aiming for 100 percent, try for 80 percent, 60
percent, or 40 percent. Then see how much you enjoy the activity and how proproductive you become. Dare to aim at being average! It takes courage, but you
may amaze yourself! 3. If you are a compulsive perfectionist you may believe
that without aiming for perfection you couldn't enjoy life to the maximum or
find true happiness. You can put this notion to the test by using the
Antiperfectionism Sheet (Fig- (Figure 14-2). Record the actual amount of
satisfaction you get from a wide range of activities, such as brushing your teeth,
eating an apple, walking in the woods, mowing the lawn, sunbathing, writing a
report for work, etc. Now estimate how perfectly you did each activity between
0 and 100 percent, as well as marking how satisfying each was between 0 and
0 and 100 percent, as well as marking how satisfying each was between 0 and
100 percent. This will help you break the illusory connection between perfection
and satisfaction. Here's how it works. In Chapter 4 I referred to a physician who
was convinced he had to be perfect at all times. No matter how much he
accomplished he would always raise his standards slightly higher, and then he'd
feel miserable. 1 told him he was the Philadelphia all-or-nothing thinking
champion! He agreed but protested he didn't know how to change. I persuaded
him to do some research on his moods and accomplishments, using the
Antiperfectionism Sheet. One weekend he did some plumbing at home because a
pipe broke and flooded the kitchen. He was a novice plumber, but did manage to
fix the leak and clean up the mess. On the sheet he recorded this as 99 percent
satisfaction (see
FEELING GOOD 357 Figure 14-2. The Antiperfectionism Sheei Activity Fix
broken pipe in kitchen Give lecture to medical school class Play tennis after
work Edit draft of my latest paper for on( hour Talk to student about his career
options Record How Effectively You Did This Between 0% and 100% L Record
How Satisfying This Was Between 0% and 100% 20% (I took a long 99% (I
actually did time and made a lot of mistakes.) 98% (I got a standing ovation.)
60% A lost the match but played okay.) 75% A stuck with i it and corrected
many errors, and smoothed out the sentences.) 50% (I didn't do anything special.
I just listened to him and offered a few obvious sugges- suggestions.) it!) 50% (I
usually get a standing ovation. I wasn't particu- particularly thrilled with my
performance.) 95% (Really felt good. Enjoyed the game and the exer- exercise.)
15% (I kept telling myself it wasn't the definitive paper and felt quite frusfrustrated.) 90% (He really seemed to appreci- appreciate our talk, so I felt
turned on.) Figure 14-2). Since it was the first time he'd ever tried to fix a pipe,
he recorded his expertise as only 20 percent. He got the job done, but it was
time-consuming and required considerable guidance from a neighbor. In
contrast, he re- received low degrees of satisfaction from some activities he did
an outstanding job on. This experience with the Antiperfectionism Sheet perpersuaded him that he did not have to be perfect at something to enjoy it, and,
furthermore, that striving for perfection
358 David D. Burns, M.D. and performing exceptionally did not guarantee
happiness, but indeed tended to be associated more frequently with less
satisfaction. He concluded he could either give up his com- compulsive drive for
perfection and settle for joyous living and high productivity, or make his
happiness of secondary im- importance and constantly push for greatness, and
settle for emotional anguish and modest productivity. Which would you choose?
settle for emotional anguish and modest productivity. Which would you choose?
Try out the Antiperfectionism Sheet and put yourself to the test. 4. Let's assume
that you've decided to give up your perfectionism at least on a trial basis just to
see what hap- happens. However, you have the lingering notion that you really
could be perfect in at least some areas if you tried hard enough, and that when
you achieve this, something magical will happen. Let's take a hard look at
whether this goal is realistic. Does a model of perfection ever really fit reality? Is
there anything you have personally encountered that is so perfect it could not be
improved? To test this, look around you right now and see how things could be
improved. For example, take someone's clothing, a flower arrangement, the color
and clarity of a television picture, the quality of a singer's voice, the efeffectiveness of this chapter, anything at all. I believe you can always find some
way in which something could be improved. When I first did this exercise, I was
riding on a train. Most things, such as the dirty, rusty old tracks, were so
obviously imperfect I could easily find many ways to improve them. Then I
came to a problem area. A young black man had his hair in one of those fuzzy
naturals. It looked perfectly smooth and sculptured, and I couldn't think of any
way it could possibly be improved. I began to panic and saw my whole
antiperfectionist philosophy going down the drain! Then I suddenly noticed
some spots of gray on his head. I felt instant relief! His hair was imperfect after
all! As I looked more closely, I noticed a few hairs that were too long and out of
place. The closer I examined the young man, the more uneven hairs I could see
—hundreds
FEELING GOOD 359 in fact! This helped convince me that any standard of perperfection just doesn't fit reality. So why not give it up? You are guaranteed to
be a sure loser if you maintain a standard for evaluating your performance that
you can't ever meet. Why persecute yourself any longer? 5. Another method for
overcoming perfectionism in- involves a confrontation with fear. You may not
be aware that fear always lurks behind perfectionism. Fear is the fuel that drives
your compulsion to polish things to the ultimate. If you choose to give up your
perfectionism, you may in- initially have to confront this fear. Are you willing?
There is, after all, a payoff in perfectionism—it protects you. It may protect you
from risking criticism, failure, or disap- disapproval. If you decide to start doing
things less perfectly, at first you may feel as shaky as if a big California
earthquake were about to hit. If you don't appreciate the powerful role that fear
plays in maintaining perfectionistic habits, the exacting behavior patterns of
perfectionistic people can seem incomprehen- incomprehensible or infuriating.
There is, for example, a bizarre illness known as "compulsive slowness," in
which the victim be- becomes so totally bound up with getting things "just right"
that simple everyday tasks can become totally consuming. An attorney with this
that simple everyday tasks can become totally consuming. An attorney with this
brutal disorder became preoccupied with how his hair looked. For hours each
day he would stand before a mirror with a comb and scissors trying to make
adjustments. He became so involved in this, he had to cut back on his legal
practice so he could have more and more time to work on his hair. Each day his
hair got shorter and shorter because of all his furious clipping. Eventually it was
only an eighth of an inch long all over his head. Then he became preoccupied
with balancing the hairline along his forehead, and started shaving it to get it
"just right." Each day the hairline receded farther and farther until eveneventually he had shaved his head totally bald! Then he felt a sense of relief and
let it all grow back again, hoping it would come in "even." After the hair grew
back, he would start
360 David D. Burns, M.D. clipping it again, and the whole cycle would be
repeated. This ludicrous routine went on for years and left him a substantially
disabled person. His case may seem extreme but cannot be considered severe.
Far worse forms of the disorder exist. Although the victims' strange habits may
seem absurd, the effects are tragic. Like alcoholics, these individuals may
sacrifice ca- career and family to their miserable compulsions. You too may be
paying heavily for your perfectionism. What motivates these exacting,
overcontrolled individ- individuals? Are they insane? Usually not. What traps
them in the senseless drive for perfection is fear. The moment they try to stop
what they are doing, they are gripped by a powerful uneasiness that rapidly
escalates to raw terror. This drives them back to their compulsive ritual in a
pathetic attempt to find relief. Getting them to give up their perfectionistic
malignancy is like trying to persuade a man hanging by his fingers from the edge
of a cliff to let go. You may have noticed compulsive tendencies in yourself to a
much less severe degree. Have you ever pushed re- relentlessly to look for an
important item like a pencil or a key you misplaced when you knew it was best
to forget about it and wait for it to show up? You do this because it's tough to
stop. The moment you try, you become uneasy and nervous. You feel somehow
"not right" without the lost item, as if the whole meaning of your life were in the
balance! One method of confronting and conquering this fear is called "response
prevention." The basic principle is simple and obvious. You refuse to give in to
the perfectionistic habit, and you allow yourself to become flooded with fear and
discomfort. Stubbornly stick it out and do not give in no matter how upset you
become. Hang in there and allow your upset to reach its maximum. After a
period of time the compulsion will begin to diminish until it disappears
completely. At this point—which might require as much as several hours or as
little as ten to fifteen minutes—you have won! You've defeated your compulsive
little as ten to fifteen minutes—you have won! You've defeated your compulsive
habit.
FEELING GOOD 361 Figure 14-3. The Response-Prevention Form. Record the
de- degree of anxiety and any automatic thoughts every one or two minutes until
you feel completely relaxed. The following experi- experiment was performed
by someone who wanted to end a bad habit of compulsively checking door
locks. Time 4:00 4:02 4:04 4:06 4:08 4:10 4:12 4:14 4:16 Percent of Anxiety or
Uneasiness 80% 95% 95% 80% 70% 50% 20% 5% 0% Automatic Thoughts
What if someone steals the car? This is ridiculous. Why not just go and make
sure the car is okay? Someone may be in it right now. I can't stand this! This is
boring. The car will probably be okay. Hey—I did it! Let's take a simple
example. Suppose you are in the habit of double-checking the house or car locks
several times. Certainly it's okay to check things once, but more often than that is
redundant and pointless. Drive your car to a parking lot, lock the doors, and walk
away. Now—refuse to check them! You will feel uneasy. You'll try to persuade
yourself to go back and "just make sure." DON'T. In- Instead, record your
degree of anxiety every minute on the ''Response-Prevention Form" (see Figure
14-3) until the anxiety has vanished. At this point, you win. Often, one such
exposure is sufficient to break a habit permanently, or you may need numerous
exposures as well as a booster shot from time to time. Many bad habits lend
themselves to this format, including various "checking rituals" (checking to
362 David D. Burns, M.D. see if the stove is turned off or if the mail has fallen
into the mailbox, etc.), cleaning rituals (compulsive hand- washing or excessive
housecleaning), and others. If you are ready and willing to break free of these
tendencies, I think you'll find the response-prevention technique quite helpful. 6.
You may be asking yourself about the origin of the crazy fear that drives you to
compulsive perfectionizing. You can use the vertical-arrow method described in
Chapter 10 to expose the silent assumption that causes your rigid, tense approach
to living. Fred is a college student who was so preoccupied with getting a term
paper ' 'just right'' that he dropped out of college to work on it for an entire year
to avoid the horrors of turning in a product he wasn't entirely satisfied with. Fred
finally enrolled in college again when he felt ready to turn the paper in, but
sought treatment for his perfectionism because he realized it might take too long
to complete college this way! He had his confrontation with fear when he was
required to turn in another term paper at the end of his first semester back in
school. This time the professor gave him the ulti- ultimatum of either turning it
in by six p.m. on the due date, or getting docked one full grade for every day it
was late. Since Fred had an adequate draft of the paper, he realized it wouldn't be
was late. Since Fred had an adequate draft of the paper, he realized it wouldn't be
wise for him to try to polish it and revise it, so he reluctantly turned it in at 4:55,
knowing that there were a number of uncorrected typographical errors as well as
some sections he wasn't entirely satisfied with. The mo- moment he turned it in,
his anxiety began to mount. Minute by minute it increased, and soon Fred was
gripped by such a severe panic attack that he called me at home late in the
evening. He was convinced that something terrible was about to happen to him
because he had turned in an imperfect paper. I suggested he use the verticalarrow method to pinpoint just what he was so afraid of. His first automatic
thought was, "I didn't do an excellent job on the paper." He wrote this down (see
Figure 14-4, page 363), and then asked himself, "If that were true, why would it
be a problem for
Figure 14-4. Fred used the vertical-arrow method to uncover the origin of his
fears about turning in an "imperfect" paper for a class. This helped relieve some
of the terror he was experiencing. The question next to each vertical arrow
represents what Fred asked himself in order to uncover the next automatic
thought at a deeper level. By unpeeling the onion in this way, he was able to
expose the silent assumptions which represented the origin and root of his
perfectionism (see text). Automatic Thoughts Rational Responses 1. I didn't do
an excellent job on the paper. 4 'if that were true, why would it be a problem for
me?" 2. The professor will notice all the typos and the weak sections. i "And
why would that be a problem?" 3. He'll feel that I didn't care about it. "Suppose
he does. What then?" 4. I'll be letting him down. i 'if that were true and he did
feel that way, why would it be upsetting to me?" 5. I'll get a D or an F on the
paper. 4 "Suppose I did—what then?" 1. All-or-nothing thinking. The paper is
pretty good even though it's not per- perfect. 2. Mental filter. He proba- probably
will notice typos, but he'll read the whole pa- paper. There are some fairly good
sections. 3. Mind reading. I don't know that he will think this. If he did, it
wouldn't be the end of the world. A lot of students don't care about their papers.
Besides I do care about it, so if he thought this he'd be wrong. 4. All-or-nothing
thinking; fortune teller error. I can't please everyone all the time. He's liked most
of my work. If he does feel disappointed in this paper he can survive. 5.
Emotional reasoning; fortune teller error. I feel this way because I'm up- upset.
But I can't predict the future. I might get a B or a C, but a D or an F isn't very
likely.
Figure 14-4. cont. Automatic Thoughts 6. That would ruin my ac- academic
record. i "And then what would happen?" 7. That would mean I wasn't the kind
of student I was supposed to be. i "Why would that be upsetting to me?" 8.
People will be angry with me. I'll be a failure. | "And suppose they were angry
People will be angry with me. I'll be a failure. | "And suppose they were angry
and I was a fail- failure? Why would that be so terri- terrible?" I 9. Then I would
be ostra- ostracized and alone. i "And then what?' 10. If I'm alone, I'm bound to
be miserable. Rational Responses 6. All-or-nothing thinking; fortune teller error.
Other people goof up at times, and it doesn't seem to ruin their lives. Why can't I
goof up at times? 7. Should statement. Who ever laid down the rule I was
"supposed" to be a certain way at all times? Who said I was predes- predestined
and morally obliged to live up to some partic- particular standard? 8. The fortune
teller error. If someone is angry with me, it's their problem. I can't be pleasing
people all the time—it's too ex- exhausting. It makes my life a tense, constricted,
rigid mess. Maybe I'd do better to set my own stan- standards and risk someone's
anger. If I fail at the pa- paper, it certainly doesn't make me "A FAILFAILURE." 9. The fortune teller error. Everyone won't ostracize me! 10-
Disqualifying positive data. Some of my hap- happiest times have been when I'm
alone. My "misery" has nothing to do with being alone, but comes from the fear
of disapproval and from persecuting myself for not living up to perfec- tionistic
standards.
FEELING GOOD 365 me?" This question generated the upsetting thought
lurking behind it, as demonstrated in Figure 14-4. Fred wrote down the next
thought that came to mind, and continued to use the downward-arrow technique
to reveal his fears at a deeper and deeper level. He continued peeling the layers
off the onion in this way until the deepest origin of his panic and perfectionism
was uncovered. This required only a few min- minutes. His silent assumption
then became obvious: A) One mistake and my career will be ruined. B) Others
demand perfection and success from me, and will ostracize me if I fall short.
Once he wrote down his upsetting automatic thoughts, he was in a position to
pinpoint his thinking errors. Three distortions appeared most often—all-ornothing thinking, mind reading, and the fortune teller error. These distordistortions had trapped him in a rigid, coercive, perfectionistic, approval-seeking
approach to life. Substituting rational re- responses helped him recognize how
unrealistic his fears were and took the edge off his panic. Fred was skeptical,
however, because he wasn't entirely convinced a catastrophe was not about to
strike. He needed some actual evidence to be convinced. Since he'd been keeping
the elephants away by blowing the trumpet all his life, he couldn't be absolutely
sure a stampede wouldn't occur once he decided to set the trumpet down. Two
days later Fred got the needed evidence: He picked up his paper, and there was
an A — at the top. The typo- typographical errors had been corrected by the
professor, who wrote a thoughtful note at the end that contained substantial
praise along with some helpful suggestions. If you are going to let go of your
praise along with some helpful suggestions. If you are going to let go of your
perfectionism, then you may also have to expose yourself to a certain amount of
initial unpleasantness just as Fred did. This can be your golden opportunity to
learn about the origin of your fears, using the vertical-arrow technique. Rather
than run from your fear, sit still and confront the bogeyman! Ask yourself,
"What am I afraid of?" "What's the worst that could hap- happen?" Then write
down your automatic thoughts as Fred
366 David D. Burns, M.D. did, and call their bluff. It will be frightening, but if
you tough it out and endure the discomfort, you will conquer your fears because
they are ultimately based on illusions. The exhilaration you experience when you
make this trans- transformation from worrier to warrior can be the start of a more
confident assertive approach to living. The thought may have occurred to you—
but suppose Fred did end up with a B, C, D, or an F? What then? In reality, this
usually doesn't happen because in your perfectionism, you are in the habit of
leaving yourself such an excessively wide margin of safety that you can usually
relax your efforts considerably without a measurable reduction in the quality of
the actual performance. However, failures can and do occur in life, and none of
us is totally immune. It can be useful to prepare ahead of time for this possibility
so that you can benefit from the experience. You can do this if you set things up
in a ''can't lose" fashion. How can you benefit from an actual failure? It's simple!
You remind yourself that your life won't be destroyed. Getting a B, in fact, is one
of the best things that can happen to you if you are a straight A student because
it will force you to confront and accept your humanness. This will lead to
personal growth. The real tragedy occurs when a student is so bright and
compulsive that he or she successfully wards off any chance of failure through
overwhelming personal effort, and ends up graduating with a perfect straight A
average. The paradox in this situation is that success has a dangerous effect of
turning these students into cripples or slaves whose lives become obsessively
rigid attempts to ward off the fear of being less than perfect. Their careers are
rich in achievement but frequently impoverished in joy. 7. Another method for
overcoming perfectionism in- involves developing a process orientation. This
means you focus on processes rather than outcomes as a basis for evalevaluating things. When I first opened my practice, I had the feeling I had to do
outstanding work with each patient every session. I thought my patients and
peers expected this of me, and so I worked my tail off all day long. When a
patient
FEELING GOOD 367 indicated he benefited from a session, I'd tell myself I
was successful and I'd feel on top of the world. In contrast, when a patient gave
was successful and I'd feel on top of the world. In contrast, when a patient gave
me the runaround or responded neg- negatively to that day's session, I'd feel
miserable and tell my- myself I had failed. I got tired of the roller-coaster effect
and reviewed the problem with my colleague, Dr. Beck. His comments were
extremely helpful, so I'll pass them on to you. He suggested I imagine I had a job
driving a car to City Hall each day. Some days I'd hit mostly green lights and I'd
make fast time. Other days I'd hit a lot of red lights and traffic jams, and the trip
would take much longer. My driving skill would be the same each day, so why
not feel equally sat- satisfied with the job I did? He proposed I could facilitate
this new way of looking at things by refusing to try to do an excellent job with
any patient. Instead, I could aim for a good, consistent effort at each session
regardless of how the patient responded, and in this way I could guarantee 100
percent success forever. How could you set up process goals as a student? You
could make it your aim to A) attend lectures; B) pay at- attention and take notes;
C) ask appropriate questions; D) study each course between classes a certain
amount each day; E) review class study notes every two or three weeks. All
these processes are within your control, so you can guarantee success. In
contrast, your final grade is not under your control. It depends on how the
professor feels that day, how well the other students did, where he sets the curve,
etc. How could you set up process goals if you were applying for a job? You
could A) dress in a confident, appealing manner; B) have your resume edited by
a knowledgeable friend and typed professionally; C) give the prospective
employer one or more compliments during the interview; D) express an interest
in the company and encourage the interviewer to talk about himself; E) when the
prospective employer tells you about his work, say something positive, using an
upbeat approach; F) if the interviewer makes a
368 David D. Burns, M.D. critical or negative comment about you, immediately
agree, using the disarming technique introduced in Chapter 6. For example, in
my negotiations with a prospective pub- publisher about this book, I noticed the
editor expressed a num- number of negative reactions in addition to a few
positive ones. I found the use of the disarming technique worked extremely well
in keeping the waters flowing nonturbulently during potentially difficult
discussions. For example, Editor X: One of my concerns, Dr. Burns, involves the
emphasis on symptomatic improvement in the here and now. Aren't you
overlooking the causes and origins of depressions? (In the first draft of this book,
I had written several chap- chapters on the silent assumptions that give rise to
depression, but apparently the editor was not adequately impressed with this
material or had not read it. I had the option of coun- counterattacking in a
defensive manner—which would have only polarized the editor and made her
feel defensive. Instead, I chose to disarm her in the following way.) David:
feel defensive. Instead, I chose to disarm her in the following way.) David:
That's an excellent suggestion, and you're ab- absolutely right. I can see you've
been doing your homework on the manuscript, and I appreciate hearing about
your ideas. The readers obviously would want to learn more about why they get
depressed. This might help them avoid future depressions. What would you
think about ex- expanding the section on silent assumptions and introducing it
with a new chapter we could call "Getting Down to Root Causes"? Editor: That
sounds great! David: What other negative reactions do you have to the book? I'd
like to learn as much as I can from you.
FEELING GOOD 369 I then continued to find a way to agree with each
criticism and to praise Editor X for each and every suggestion. This was not
insincere because I was a greenhorn in popular writing, and Editor X was a very
talented, well-established individual who was in a position to give me some
much- needed guidance. My negotiating style made it clear to her that I
respected her, and let her know that we would be able to have a productive
working relationship. Suppose instead that I had been fixed on the outcome
rather than on the negotiating process when the editor in- interviewed me. I
would have been tense and preoccupied with only one thing—would she or
would she not make an offer for the book? Then I would have seen her every
crit- criticism as a danger, and the whole interpersonal process would have fallen
into unpleasant focus. Thus, when you are applying for work, do not make it
your aim to get the job! Especially if you want the job! The outcome depends on
numerous factors that are ultimately out of your control, including the number of
applicants, their qualifications, who knows the boss's daughter, etc. In fact, you
would do better to try to get as many rejections as possible for the following
reason: Suppose on the average it takes about ten to fifteen interviews for each
acceptable job offer you receive in your profession (a typical batting average for
people I know who have been recently looking for work). This means you've got
to go out and get those nine to fourteen rejections over with in order to get the
job you want! So each morning say, *11 try to get as many rejections as possible
today." And each time you do get rejected you can say, "I was successfully
rejected. This brings me one important step closer to my goal." 8. Another way
to overcome perfectionism involves as- assuming responsibility for your life by
setting strict time limits on all your activities for one week. This will help you
change your perspective so you can focus on the flow of life and enjoy it. If you
are a perfectionist, you are probably a real pro370 David D. Burns, M.D. crastinator because you insist on doing things so
thoroughly. The secret to happiness is to set modest goals to accomplish them. If
thoroughly. The secret to happiness is to set modest goals to accomplish them. If
you want misery, then by all means cling to your perfectionism and
procrastination. If you would like to change, then as you schedule your day in
the morning, decide on the amount of time you will budget on each activity. Quit
at the end of the time you have set aside whether or not you have completed it,
and go onto the next project. If you play the piano and tend to play for many
hours or not at all, decide instead to play only an hour a day. I think you'll
enhance your satisfaction and output substantially this way. 9. I'll bet you're
afraid of making mistakes! What's so terrible about making mistakes? Will the
world come to an end if you're wrong? Show me a man who can't stand to be
wrong, and I'll show you a man who is afraid to take risks and has given up the
capacity for growth. A particularly powerful method for defeating perfectionism
involves learn- learning to make mistakes. Here's how you can do this. Write an
essay in which you spell out why it is both irrational and self-defeating to try to
be perfect or to fear making mistakes. The following was written by Jennifer, the
student mentioned earlier: Why It's Great to Be Able to Make Mistakes 1. I fear
making mistakes because I see everything in absolutist, perfectionistic terms—
one mistake and the whole is ruined. This is erroneous. A small mistake
certainly doesn't ruin an otherwise fine whole. 2. It's good to make mistakes
because then we learn— in fact, we won't learn unless we make mistakes. No
one can avoid making mistakes—and since it's going to happen in any case, we
may as well accept it and learn from it.
FEELING GOOD 37? 3. Recognizing our mistakes helps us to adjust our bebehavior so that we can get results we're more pleased with—so we might say
that mistakes ultimately op- operate to make us happier and make things better.
A. If we fear making mistakes t we become paralyzed— we're afraid to do or try
anything, since we might (in fact, probably will) make some mistakes. If we
restrict our activities so that we won't make mistakes, then we are really
defeating ourselves. The more we try and the more mistakes we make, the faster
we'll learn and the happier we'll be ultimately. 5. Most people aren't going to be
mad at us or dislike us because we make mistakes—they all make mis- mistakes,
and most people feel uncomfortable around 4'perfect" people. 6. We don't die if
we make mistakes. Although such an essay does not guarantee that you will
change, it can help get you started in the right direction. Jennifer reported an
enormous improvement the week after she wrote the essay. She found it useful
in her studies to focus on learning rather than obsessing constantly about
whether or not she was great. As a result, her anxiety de- decreased and her
ability to get things done increased. This relaxed, confident mood persisted
through the final exam- examination period at the end of the first semester—a
through the final exam- examination period at the end of the first semester—a
time of extreme anxiety for the majority of her classmates. As she explained, "I
realized I didn't have to be perfect. I'm going to make my share of mistakes. So
what? I can learn from my mistakes, so there's nothing to worry about." And she
was right! Write a memo to yourself along these lines. Remind your- yourself
that the world won't come to an end if you make a mistake, and point out the
potential benefits. Then read the memo every morning for two weeks. I think
this will go a long way toward helping you join the human race!
372 David D. Burns, M.D. 10. In your perfectionism you are undoubtedly great
at focusing on all the ways you fall short. You have the bad habit of picking out
the things you haven't done and ignoring those you have. You spend youMife
cataloging every mis- mistake and shortcoming. No wonder you feel inadequate!
Is somebody forcing you to do this? Do you like feeling that way? Here's a
simple method of reversing this absurd and pain- painful tendency. Use your
wrist counter to click off the things you do right each day. See how many points
you can ac- accumulate. This may sound so unsophisticated that you are
convinced it couldn't help you. If so, experiment with it for two weeks. I predict
you'll discover that you will begin to focus more on the positives in your life and
will con- consequently feel better about yourself. It sounds simplistic because it
is! But who cares, if it works? //. Another helpful method involves exposing the
ab- absurdity in the all-or-nothing thinking that gives rise to your perfectionism.
Look around you and ask yourself how many things in the world can be broken
down into all-or-nothing categories. Are the walls around you totally clean? Or
do they have at least some dirt? Am I totally effective with all of my writing? Or
partially effective? Certainly every single paragraph of this book isn't polished to
perfection and breathtakingly helpful. Do you know anyone who is totally calm
and confident all the time? Is your favorite movie star perfectly beautiful? Once
you recognize that all-or-nothing thinking doesn't fit reality very often, then look
out for your all-or-nothing thoughts throughout the day, and when you notice
one, talk back to it and shoot it down. You'll feel better. Some ex- examples of
how a number of different individuals combat all- or-nothing thoughts appear in
Figure 14-5. 12. The next method to combat perfectionism involves personal
disclosure. If you feel nervous or inadequate in a situation, then share it with
people. Point out the things you feel you've done inadequately instead of
covering them up.
Figure 14-5. How to replace all-or-nothing thoughts with others that are more in
tune with reality. These examples were contrib- contributed by a variety of
individuals. All'Or-Nothing Thinking Realistic Thoughts 1. What a lousy day! 1
2. This meal I cooked really turned out terrible. 3. I'm too old. 4. Nobody loves
2. This meal I cooked really turned out terrible. 3. I'm too old. 4. Nobody loves
me. 4. 5. I'm a failure. 6. My career is over the 6. 'hill. 7. My lecture was a 7
flop! 8. My boyfriend 8 doesn't like me! A couple of bad things have haphappened, but everything hasn't been a disaster. It's not the best meal I ever
cooked, but it's okay. Too old for what? Too old to have fun? No. Too old for
occasional sex? No. Too old to enjoy friends? No. Too old to love or be loved?
No. Too old to enjoy music? No. Too old to do some productive work? No. So
what am I "too old" for? It really has no meaning! Nonsense. I have many
friends and family. I may not get as much love as I want when I want it, but I
can work on this. I've succeeded at some things and failed at others, just like
every- everybody. I can't do as much as when I was younger, but I can still work
and produce and create, so why not enjoy it? It wasn't the best lecture I ever
gave. In fact, it was below my average. But I did get some points across, and I
can work to improve my next lectures. Remember— half my lectures will be
below my average, and half will be above! He doesn't like me enough for what?
He may not want to marry me, but he takes me out on dates, so he must like me
partially.
374 David D. Burns, M.D. Ask people for suggestions on how to improve, and if
they're going to reject you for being imperfect, let them do it and get it over with.
If in doubt as to where you stand, ask if they think less of you when you make a
mistake. If you do this, you must of course be prepared to handle the possibility
that people will look down on you because of your imperfections. This actually
happened to me during a teaching session I was conducting for a group of
therapists. I pointed out an error I felt I had made in reacting angrily to a
difficult, manipulative patient. I then asked if any of the therapists present
thought less of me after hearing about my foible. I was taken aback when one
replied in the af- affirmative, and the following conversation took place:
Therapist (in the audience): I have two thoughts. One thought is a positive one. I
appreciate your taking that risk to point out your error in front of the group
because I would have b^en scared to do it. I think it takes great courage on your
part to do this. But I have to admit I'm ambivalent about you now. Now I know
that you do make mistakes, which is real- realistic, but... I feel disappointed in
you. In all honesty, I do. David: Well, I knew how to handle the patient, but I
was so overcome with my anger that I just got caught up in the moment and
retaliated. I was overly abrupt in the way I reacted to her. I admit I handled it
quite poorly. Therapist: I guess in the context that you see so many patients each
week for so many years, if you make one blunder like that it's definitely not
earthshattering. It's not going to kill her or anything. But I do feel let down, I
have to admit. David: But it isn't just one rare error. I believe that all therapists
have to admit. David: But it isn't just one rare error. I believe that all therapists
make many blunders every sinFEELING GOOD 375 gle day. Either obvious ones or subtle ones. At least I do.
How will you come to terms with that? It seems you're quite disappointed in me
because I didn't handle that patient effectively. Therapist: Well, I am. I thought
you had a sufficiently wide behavioral repertoire that you could easily handle
nearly anything a patient said to you. David: Well, that's untrue. I sometimes
come up with very helpful things to say in difficult situations, but sometimes I'm
not as effec- effective as I'd like to be. I still have a lot to learn. Now with that
knowledge, do you think less of me? Therapist: Yeah. I really do. I have to say
that. Because now I see that there's a reasonably easy kind of conflict that can
upset you. You were unable to handle it without showing your vulnerabilities.
David: That's true. At least that time I didn't handle it well. It's an area where I
need to focus my efforts and grow as a therapist. Therapist: Well, it shows that at
least in that case, and I assume in others, that you don't handle things as well as I
thought you did. David: I think that's correct. But the question is, why do you
think less of me because I am imperfect? Why are you looking down on me?
Does it make me less a person to you? Therapist: You're exaggerating the whole
thing now, and I don't feel that you are necessarily of less value as a human or
anything like that. But on the other hand, I think you're not as good as a therapist
as I thought you were.
376 David D. Burns, M.D. David: That's true. Do you think less of me because
of that? Therapist: As a therapist? David: As a therapist or as a person. Do you
think less of me? Therapist: Yes, I suppose I do. David: Why? Therapist: Well, I
don't know how to say this. I think 4'therapist" is the primary role that I know
you in. I'm disappointed to find you're so imperfect. I had a higher expectation of
you. But perhaps you're better in other areas of your life. David: I hate to
disappoint you, but you'll discover that in many other aspects of my life I'm even
more imperfect. So if you're looking down on me as a therapist, I presume you'll
look down on me more as a person. Therapist: Well, I do think less of you as a
person. I think that's an accurate description of how I'm feeling about you.
David: Why do you think less of me because I don't measure up to your standard
of perfection? I'm a human and not a robot. Therapist: I'm not sure I understand
that question. I judge people in terms of their performance. You goofed up, so
you have to face the fact I'll judge you negatively. It's tough, but it's reality. I
thought you should perform better because you're our preceptor and our teacher.
I expected more of you. Now it sounds like I could have handled that patient
better than you did! David: Well, I think you could have done better than I did
better than you did! David: Well, I think you could have done better than I did
with that patient that day, and this is
FEELING GOOD 377 an area where I think I can learn from you. But why do
you look down on me for this? If you get disappointed and lose respect each
time you notice I've made a mistake, pretty soon you'll be totally miserable, and
you'll have no respect for me at all because I've been making errors every day
since I was born. Do you want all that discomfort? If you want to continue and
enjoy our friend- friendship, and I hope you will, you'll just have to accept the
fact that I'm not perfect. Maybe you'd be willing to look for mistakes I make and
point them out to me so I can learn from you while I'm teaching you. When I
stop making mistakes, I'll lose much of my ca- capacity to grow. Recognizing
and correcting my errors and learning from them is one of my greatest assets.
And if you can accept my humanity and imperfection, maybe you can also
accept your own. Maybe you'll want to feel that it's okay for you to make
mistakes too. This kind of dialogue transcends the possibility you will feel put
down. Asserting your right to make mistakes will paradoxically make you a
greater human being. If the other person feels disappointed, the fault is really his
for having set up the unrealistic expectation you are more than human. If you
don't buy into that foolish expectation, you won't have to become angry or
defensive when you do goof up— nor will you have to feel any sense of shame
or embar- embarrassment. The choice is clear-cut: You can either try to be
perfect and end up miserable, or you can aim to be human and imperfect and feel
enhanced. Which do you choose? 13. The next method is to focus mentally on a
time in your life when you were really happy. What image comes to mind? For
me the image is of climbing down into Ha- vasupai Canyon one summer
vacation when I was a college
378 David D. Burns, M.D. student. This canyon is an isolated part of the Grand
Can- Canyon, and you have to hike into it or arrange for horses. I went with a
friend. Havasupai, an Indian word meaning ''blue-green water people," is the
name of a turquoise river that bubbles out of the desert floor and turns the
narrow canyon into a lush paradise many miles long. Ultimately, the Havasupai
River empties into the Colorado River. There are a number of waterfalls several
hundred feet high, and at the bottom of each, a green chemical in the water preprecipitates out and makes the river's bottom and edges smooth and polished,
just like a turquoise swimming pool. Cotton- wood trees and Jimsonweed with
purple flowers like trum- trumpets line the river in abundance. The Indians who
live there are easygoing and friendly. It is a blissful memory. Perhaps you have a
similar happy memory. Now ask yourself—what was perfect about that
experience? In my case, nothing* There were no toilet facilities, and we slept in
experience? In my case, nothing* There were no toilet facilities, and we slept in
sleeping bags outdoors. I didn't hike perfectly or swim perfectly, and nothing
was perfect. There was no electricity available in most of the village because of
its remoteness, and the only available food in the store was canned beans and
fruit cock- cocktail—no meat or vegetables. But the food tasted darn good after a
day of hiking and swimming. So who needs perfec- perfection? How can you
use such a happy memory? When you are having a presumably pleasurable
experience—eating out, taking a trip, going to a movie, etc.—you may
unnecessarily sour the experience by making an inventory of all the ways it falls
short and telling yourself you can't possibly enjoy it. But this is hogwash—it's
your expectation that upsets you. Suppose the motel bed is too lumpy and you
paid fifty- six dollars for the room. You called the front desk, and they have no
other beds or rooms available. Tough! Now you can double your trouble by
demanding perfection, or you can conjure up your "happy, imperfect" memory.
Remem- Remember the time you camped out and slept on the ground and loved
it? So you can certainly enjoy yourself in this motel room if you choose! Again,
it's up to you.
FEELING GOOD 379 14. Another method for overcoming perfectionism is the
4'greed technique." This is based on the simple fact that most of us try to be
perfect so we can get ahead in life. It may not have occurred to you that you
might end up much more successful if your standards were lower. For example,
when I started my academic career, I spent over two years writing the first
research paper I published. It was an ex- excellent product, and I'm still quite
proud of it. But I noticed that in the same time period, many of my peers who
were of equal intelligence wrote and published numerous papers. So I asked
myself—am I better off with one publication that contains ninety-eight "units of
excellence," or ten papers that are each worth only eighty "units of excellence"?
In the latter case, I would actually end up with 800 "excellence units," and I
would be way ahead of the game. This re- realization was a strong personal
persuader, and I decided to lower my standards a bit. My productivity then
became dramatically enhanced, as well as my levels of satisfaction. How can this
work for you? Suppose you have a task and you notice you're moving slowly.
You may find that you've already reached the point of diminishing returns, and
you'd do better by moving on to the next task. I'm not advocating that you slough
off, but you may find that you as well as others will be equally if not more
pleased with many good, solid performances than with one stress-producing
master- masterpiece. 75. Here's the last approach. It involves simple logic.
Premise one: All human beings make mistakes. Do you agree? Okay, now tell
me: What are you? A human being, you say? Okay. Now, what follows? Of
me: What are you? A human being, you say? Okay. Now, what follows? Of
course—you will and should make mistakes! Now tell yourself this every time
you persecute yourself because you made an error. Just say, "I was supposed to
make that mistake because I'm human!'' or "How human of me to have made that
mistake." In addition, ask yourself, "What can I learn from my mistake? Is there
some good that could come from this?" As an experiment, think about some
error you've made and write down everything you learned from it. Some of the
380 David D. Burns, M.D. best things can be learned only through making
mistakes and learning from them. After all, this is how you learned to talk and
walk and do just about everything. Would you be willing to give up that kind of
growth? You may even go so far as to say your imperfections and goof-ups are
some of your greatest assets. Cherish them! Never give up your capacity for
being wrong because then you lose the ability to move forward. In fact, just
think what it would be like if you were perfect. There'd be nothing to learn, no
way to improve, and life would be completely void of challenge and the
satisfaction that comes from mastering something that takes effort. It would be
like going to kindergarten for the rest of your life. You'd know all the answers
and win every game. Every project would be a guaranteed success because you
would do everything correctly. People's con- conversations would offer you
nothing because you'd already know it all. And most important, nobody could
love or relate to you. It would be impossible to feel any love for someone who
was flawless and knew it all. Doesn't that sound lonely, boring, and miserable?
Are you so sure you still want per- perfection?
PartV Defeating Hopelessness and Suicide
Chapter 15 The Ultimate Victory: Choosing to Live Dr. Aaron T. Beck reported
in a study that suicidal wishes were present in approximately one-third of
individuals with a mild case of depression, and in nearly three-quarters of people
who were severely depressed.* It has been estimated that as many as 5 percent
of depressed patients do actually die as a result of suicide. This is approximately
twenty-five times the suicide rate within the general population. In fact, when a
person with a depressive illness dies, the chances are one in six that suicide was
the cause of death. No age group or social or professional class is exempt from
suicide; think of the famous people you know of who have killed themselves.
Particularly shocking and gro- grotesque—but by no means rare—is suicide
among the very young. In a study of seventh- and eighth-grade students in a
suburban Philadelphia parochial school, nearly one third of the youngsters were
significantly depressed and had su- suicidal thoughts. Even infants who undergo
significantly depressed and had su- suicidal thoughts. Even infants who undergo
maternal sepa- separation can develop a depressive syndrome in which failure
*Beck, Aaron T. Depression: Causes and Treatment. Philadelphia: UniUniversity of Pennsylvania Press, 1972, pp. 30-31. 383
384 David D. Burns, M.D. to thrive and even self-imposed death from starvation
can result. Before you get overwhelmed, let me emphasize the pos- positive side
of the coin. First, suicide is unnecessary, and the impulse can be rapidly
overcome and eliminated with cog- cognitive techniques. In our study, suicidal
urges were reduced substantially in patients treated with cognitive therapy or
with antidepressant drugs. The improved outlook on life occurred within the first
week or two of treatment in many cognitively treated patients. The current
intensive emphasis on the prevention of depressive episodes in individuals prone
to mood swings should also result in a long-term reduction in suicidal impulses.
Why do depressed individuals so frequently think of su- suicide, and what can be
done to prevent these impulses? You will understand this if you examine the
thinking of people who are actively suicidal. A pervasive, pessimistic vision
dominates their thoughts. Life seems to be nothing but a hellish nightmare. As
they look into the past, all they can remember are moments of depression and
suffering. When you feel down in the dumps, you may also feel so low at times
that you get the feeling you were never really happy and never will be. If a
friend or relative points out to you that, except for such periods of depression,
you were quite happy, you may conclude they're mistaken or only trying to cheer
you up. This is because while you are de- depressed you actually distort your
memories of the past. You just can't conjure up any memories of periods of
satisfaction or joy, so you erroneously conclude they did not exist. Thus, you
mistakenly conclude that you always have been and always will be miserable. If
someone insists that you have been happy, you may respond as a young patient
recently did in my office, "Well, that period of time doesn't count. Happiness is
an illusion of some kind. The real me is de- depressed and inadequate. I was just
fooling myself if I thought I was happy." No matter how bad you feel, it would
be bearable if you
FEELING GOOD 385 had the conviction that things would eventually improve.
The critical decision to commit suicide results from your illogical conviction that
your mood can't improve. You feel certain that the future holds only more pain
and turmoil! Like some depressed patients, you may be able to support your
pessimistic prediction with a wealth of data which seems to you to be
overwhelmingly convincing. A depressed forty-nine-year-old stockbroker
recently told me,"Doctor, I have already been treated by six psychiatrists over a
ten-year-period. I have had shock treatments and all types of antidepressants,
ten-year-period. I have had shock treatments and all types of antidepressants,
tranquilizers, and other drugs. But in spite of it all, this depression won't let up
for one minute. I have spent over eighty thousand dollars trying to get well. Now
I am emotionally and financially depleted. Every doc- doctor has said to me.
'You'll beat this thing. Keep your chin up.' But now I realize it wasn't true. They
were all lying to me. I'm a fighter, so I fought hard. You'd better realize when
you are defeated. I've got to admit I'd be better off dead." Research studies have
shown that your unrealistic sense of hopelessness is one of the most crucial
factors in the development of a serious suicidal wish. Because of your twisted
thinking, you see yourself in a trap from which there seems to be no escape. You
jump to the conclusion that your problems are insoluble. Because your suffering
feels unbearable and appears unending, you may erroneously con- conclude that
suicide is your only way of escape. If you have had such thoughts in the past, or
if you are seriously thinking this way at present, let me state the mes- message of
this chapter loud and clear: You Are Wrong in Your Belief That Suicide Is the
Only Solution or the Best Solution to Your Problem. Let me repeat that. You
Are Wrong! When you think that you are trapped and hopeless, your thinking is
illogical, distorted, and skewed. No matter how thoroughly you have
386 David D. Burns, M.D. convinced yourself, and even if you get other people
to agree with you, you are just plain mistaken in your belief that it is ever
advisable to commit suicide because of de- depressive illness. This is not the
most rational solution to your misery. I will explain this position and help point
the way out of the suicide trap. Assessing Your Suicidal Impulses Although
suicidal thoughts are common even in individ- individuals who are not
depressed, the occurrence of a suicidal impulse if you are depressed is always to
be regarded as a dangerous symptom. It is important for you to know how to
pinpoint those suicidal impulses which are the most threatening. In the Burns
Depression Checklist in Chapter 2, questions 23, 24, and 25 refer to your
suicidal thoughts and impulses. If you have checked a one, two, three, or four on
these questions, suicidal fantasies are present, and it is important to evaluate
their seriousness and to intervene if necessary (see page 21). The most serious
error you could make with regard to your suicidal impulses is to be overly
inhibited in talking them over with a counselor. Many people are afraid to talk
about suicidal fantasies and urges for fear of disapproval or because they believe
that even talking about them will bring on a suicide attempt. This point of view
is unwarranted. You are more likely to feel a great sense of relief in disdiscussing suicidal thoughts with a professional therapist, and consequently you
have a much better chance of defusing them. If you do have suicidal thoughts,
ask yourself if you are taking such thoughts seriously. Are there times when you
ask yourself if you are taking such thoughts seriously. Are there times when you
wish you were dead? If the answer is yes, is your death wish active or passive?
A passive death wish exists if you would prefer to be dead, but you are unwilling
to take active steps to bring this about. One young man confessed to me, 44
Doctor, every night when I go to bed I pray to God to let
FEELING GOOD 387 me wake up with cancer. Then I could die in peace, and
my family would understand." An active death wish is more dangerous. If you
are se- seriously planning an actual suicide attempt, then it's impor- important to
know the following: Have you thought about a method? What is your method?
Have you made plans? What specific preparations have you made? As a general
rule, the more concrete and well-formulated your plans are, the more likely you
may actually make a suicide attempt. The time to seek professional help is now!
Have you ever made a suicide attempt in the past? If so, you should view any
suicidal impulse as a danger signal to seek help immediately. For many people
these previous attempts seem to be "warm-ups," in which they flirt with suicide
but have not mastered the particular method they have selected. The fact that an
individual has made this attempt unsuccessfully on several occasions in the past
in- indicates an increased risk of success in the future. It is a dangerous myth that
unsuccessful suicide attempts are sim- simply gestures or attention-getting
devices and are therefore not to be taken seriously. Current thinking suggests
that all suicidal thoughts or actions are to be taken seriously. It can be highly
misleading to view suicidal thoughts and actions as a "plea for help." Many
suicidal patients want help least of all because they are 100 percent convinced
they are hope- hopeless and beyond help. Because of this illogical belief, what
they really want is death. Your degree of hopelessness is of the greatest
importance in assessing whether or not you are at risk for making an active
suicide attempt at any time. This one factor seems more closely linked with
actual suicide attempts than any other. You must ask yourself, "Do I believe that
I have absolutely no chance of getting better? Do I feel that I have exhausted all
treatment possibilities and that nothing could possibly help? Do I feel convinced
beyond all doubt that my suffering is unbearable and could never come to an
end?" If you answer yes to these questions, then your degree of hopelessness is
high, and professional treatment is in388 David D. Burns, M.D. dicated now\ I would like to emphasize that
hopelessness is as much a symptom of depression as a cough is a symptom of
pneumonia. The feeling of hopelessness does not in fact prove that you are
hopeless, any more than a cough proves you are doomed to succumb to
pneumonia. It just proves that you are suffering from an illness, in this case,
pneumonia. It just proves that you are suffering from an illness, in this case,
depres- depression. This sense of hopelessness is not a reason to make a suicide
attempt, but gives you a clear signal to seek com- competent treatment. So, if
you feel hopeless, seek help! Do not consider suicide for one more minute! The
last important factor concerns deterrents. Ask your- yourself, "Is there anything
that is preventing me from com- committing suicide? Would I hold back because
of my family, friends, or religious beliefs?" If you have no deterrents, the
possibility is greater that you would consider an actual su- suicide attempt.
SUMMARY: If you are suicidal, it is of great importance for you to evaluate
these impulses in a matter-of-fact man- manner, using your common sense. The
following factors put you in a high-risk group: 1. If you are severely depressed
and feel hopeless; 2. If you have a past history of suicide attempts; 3. If you have
made concrete plans and preparations for suicide; and 4. If no deterrents are
holding you back. If one or more of these factors apply to you, then it is vital to
get professional intervention and treatment immediately. While I firmly believe
that the attitude of self-help is im- important for all people with depression, you
clearly must seek professional guidance right away.
FEELING GOOD 389 The Illoglc of Suicide Do you think depressed people
have the "right" to com- commit suicide? Some misguided individuals and
novice ther- therapists are unduly concerned with this issue. If you are
counseling or trying to help a chronically depressed indi- individual who is
hopeless and threatening self-destruction, you may ask yourself, "Should I
intervene aggressively, or should I let him go ahead? What arc his rights as a
human being in this regard? Am I responsible for preventing this attempt, or
should I tell him to go ahead and exercise his freedom of choice?" I regard this
as an absurd and cruel issue that misses the point entirely. The real question is
not whether a depressed individual has the right to commit suicide, but whether
he is realistic in his thoughts when he is considering it. When I talk to a suicidal
person, I try to find out why he is feeling that way. I might ask, "What is your
motive for wanting to kill yourself? What problem in your life is so terrible that
there is no solution?" Then I would help that person expose the illogical thinking
that lurks behind the suicidal impulse as quickly as possible. When you begin to
think more real- realistically, your sense of hopelessness and the desire to end
your life will fade away and you will have the urge to live. Thus, I recommend
joy rather than death to suicidal indi- individuals, and I try to show them how to
achieve it as fast as possible! Let's see how this can be done. Holly was a
nineteen-year-old woman who was referred to me for treatment by a child
psychoanalyst in New York City. He had treated her unsuccessfully with
analytic therapy for many years since the onset of a severe unremitting
depression in her early teens. Other doctors had also been unable to help her. Her
depression in her early teens. Other doctors had also been unable to help her. Her
depression originated during a period of family turbulence that led to her parents'
separation and divorce. Holly's chronic blue mood was punctuated by numerous
wrist-slashing episodes. She said that when periods of frus390 David D. Burns, M.D. tration and hopelessness would build up, she would
be over- overcome by the urge to rip into her flesh and would experience relief
only when she saw the blood flowing across her skin. When I first met Holly, I
noticed a mass of white scar tissue across her wrists that attested to this
behavior. In addition to these episodes of self-mutilation, which were not suicide
attempts, she had tried to kill herself on a number of oc- occasions. In spite of all
the treatment she had received, her depres- depression would not let up. At times
it became so severe that she had to be hospitalized. Holly had been confined to a
closed ward of a New York hospital for several months at the time she was
referred to me. The referring doctor recommended a minimum of three years of
additional continuous hospi- hospital izat ion, and appeared to agree with Holly
that her prog- prognosis for substantial improvement, at least in the near future,
was poor. Ironically, she was bright, articulate, and personable. She had done
well in high school, in spite of being unable to go to classes during the times she
was confined to hospitals. She had to take some courses with the help of tutors.
Like a number of adolescent patients, Holly's dream was to be- become a
mental-health professional, but she had been told by her previous therapist that
this was unrealistic because of the nature of her own explosive, intractable
emotional problems. This opinion was just one more crushing blow for Holly.
After graduation from high school, she spent the majority of her time in inpatient
mental-hospital facilities because she was considered too ill and uncontrollable
for outpatient therapy. In a desperate attempt to find help, her father concontacted the University of Pennsylvania because he had read about our work in
depression. He requested a consultation to determine whether any promising
treatment alternatives existed for his daughter. After speaking to me by phone,
Holly's father obtained custody of her and drove to Philadelphia so that I could
talk to her and review the possibilities for treatment. When I
FEELING GOOD 391 met them, their personalities contrasted with my expectaexpectations. He proved to be a relaxed, mild-mannered individual; she was
strikingly attractive, pleasant, and cooperative. I administered several
psychological tests to Holly. The Beck Depression Inventory indicated severe
depression, and other tests confirmed a high degree of hopelessness and serious
suicidal intent. Holly put it to me bluntly, "I want to kill myself." The family
history indicated that several relatives had attempted suicide—two of them
history indicated that several relatives had attempted suicide—two of them
successfully. When I asked Holly why she wanted to kill herself, she told me
that she was a lazy human being. She explained that because she was lazy, she
was worthless and so de- deserved to die. I wanted to find out if she would react
favorably to cog- cognitive therapy, so I used a technique that I hoped would
capture her attention. I proposed we do some role-playing, and she was to
imagine that two attorneys were arguing her case in court. Her father, by the
way, happened to be an attorney who specialized in medical malpractice suits!
Be- Because I was a novice therapist at the time, this intensified my own
anxious, insecure feelings about tackling such a tough case. I told Holly to play
the role of the prosecutor, and she was to try to convince the jury that she
deserved a death sentence. I told her I would play the role of the defense
attorney, and that I would challenge the validity of every accusation she made. I
told her that this way we could review her reasons for living and her reasons for
dying, and see where the truth lay: Holly: For this individual, suicide would be
an escape from life. David: That argument could apply to anyone in the world.
By itself, it is not a convincing reason to die. Holly: The prosecutor replies that
the patient's life is so miserable, she cannot stand it one minute longer.
392 David D. Burns, M.D. David: She has been able to stand it up until now, so
maybe she can stand it a while longer. She was not always miserable in the past,
and there is no proof that she will always be miserable in the future. Holly: The
prosecutor points out that her life is a burden to her family. David: The defense
emphasizes that suicide will not solve this problem, since her death by suicide
may prove to be an even more crushing blow to her family. Holly: But she is
self-centered and lazy and worthless, and deserves to die! David: What
percentage of the population is lazy? Holly: Probably twenty percent... no, I'd
say only ten percent. David: That means twenty million Americans are lazy. The
defense points out that they don't have to die for this, so there is no reason the
patient should be singled out for death. Do you think laziness and apathy are
symptoms of depression? Holly: Probably. David: The defense points out that
individuals in our culture are not sentenced to death for the symp- symptoms of
illness, whether it be pneumonia, de- depression, or any other disease.
Furthermore, the laziness may disappear when the depression goes away. Holly
appeared to be involved in this repartee and amused by it. After a series of such
accusations and defenses, she conceded that there was no convincing reason she
should have to die, and that any reasonable jury would have to rule in favor of
the defense. What was more important was that Holly was learning to challenge
and answer her negative thoughts about herself. This process brought her partial
but
but
FEELING GOOD 393 immediate emotional relief, the first she had experienced
in many years. At the end of the consultation session, she said to me, 'This is the
best that I have felt in as long as I can remember. But now the negative thought
crosses my mind, This new therapy may not prove to be as good as it seems.'" In
response to this she felt a sudden surge of depression again. I assured her,
"Holly, the defense attor- attorney points out that this is no real problem. If the
therapy isn't as good as it seems to be, you'll find out in a few weeks, and you'll
still have the alternative of a long-term hospitalization. You'll have lost nothing.
Furthermore, the therapy may be partially as good as it seems, or conceivably
even better. Perhaps you would be willing to give it a try." In response to this
proposal, she decided to come to Phil- Philadelphia for treatment. Holly's urge to
commit suicide was simply the result of cognitive distortions. She confused the
symptoms of her illness, such as lethargy and loss of interest in life, with her true
identity and labeled herself as a *'lazy person." Because Holly equated her worth
as a human being with her achieve- achievement, she concluded she was
worthless and deserved to die. She jumped to the conclusion that she could never
recover, and that her family would be better off without her. She magnified her
discomfort by saying, "I can't stand it." Her sense of hopelessness was the result
of the fortune-telling error—she illogically jumped to the conclusion that she
could not improve. When Holly saw that she was simply trapping herself with
unrealistic thoughts, she felt a sudden relief. In order to maintain such
improvement, Holly had to learn to correct her negative thinking on an ongoing
basis and that took hard work! She wasn't going to give in that easily! Following
our initial consultation, Holly was transferred to a hospital in Philadelphia,
where I visited her twice a week to initiate cognitive therapy. She had a stormy
course in the hospital with dramatic mood swings, but was able to be discharged
after a five-week period, and I persuaded her to enroll as a part-time summerschool student. For a while
394 David D. Burns, M.D. her moods continued to oscillate like a yo-yo, but she
showed an overall improvement. At times Holly would re- report feeling very
good for several days. This constituted a real breakthrough, since these were the
first happy periods she had experienced since the age of thirteen. Then she
would suddenly relapse into a severe depressive state. At these times she would
again become actively suicidal, and would try her best to convince me that life
was not worth living. Like many adolescents, she seemed to carry a grudge
against all mankind, and insisted there was no point in living any longer. In
addition to feeling negative about her own sense of worth, Holly had developed
an intensely negative and dis- disillusioned view of the entire world. Not only
an intensely negative and dis- disillusioned view of the entire world. Not only
did she see herself as trapped by an endless, untreatable depression, but like
many of today's adolescents, she had adopted a personal theory of nihilism. This
is the most extreme form of pes- pessimism. Nihilism is the belief that there is
no truth or mean- meaning to anything, and that all of life involves suffering and
agony. To a nihilist like Holly, the world offers nothing but misery. She had
become convinced that the very essence of every person and object in the
universe was evil and horrible. Her depression was thus the experience of hell on
earth. Holly envisioned death as the only possible surcease, and she longed for
death. She constantly complained and harangued cynically about the cruelties
and miseries of liv- living. She insisted that life was totally unbearable at all
times, and that all human beings were totally lacking in redeeming qualities. The
task of getting such an intelligent and persistent young woman to see and admit
how distorted her thinking was provided a real challenge to this therapist! The
following lengthy dialogue illustrates her intensely negative attitudes as well as
my struggles to help her penetrate the illogic in her thinking: Holly: Life is not
worth living because there is more bad than good in the world.
FEELING GOOD 395 David: Suppose I was the depressed patient and you were
my therapist and I told you that, what would you say? (I used this maneuver with
Holly because I knew her goal in life was to be a therapist. I figured she'd say
something reasonable and upbeat, but she outfoxed me in her next statement.)
Holly: I'd say that I can't argue with you! David: So, if I were your depressed
patient and told you that life is not worth living, you'd advise me to jump out the
window? Holly (laughing): Yes. When I think about it, that's the best thing to do.
If you think about all the bad things that are going on in the world, the right
thing to do is to get really upset about them and be depressed. David: And what
are the advantages to that? Does that help you correct the bad things in the world
or what? Holly: No. But you can't correct them. David: You can't correct all the
bad things in the world, or you can't correct some of them? Holly: You can't
correct anything of importance. I guess you can correct small things. You can't
really make a dent in the badness of this uni- universe. David: Now, at the end of
each day if I said that to myself when I went home, I could really become upset.
In other words, I could either think about the people that I did help during the
day and feel good, or I could think of all the thousands of people that I will never
get a chance to see and work with, and I could feel hopeless and help- helpless.
That would incapacitate me, and I don't
396 David D. Burns, M.D. Holly: David: Holly: David: Holly: David: Holly:
David: think that it is to my advantage to be incapaci- incapacitated. Is it to your
David: think that it is to my advantage to be incapaci- incapacitated. Is it to your
advantage to be incapacitated? Not really. Well, I don't know. You like being
incapacitated? No. Not unless I were completely incapacitated. What would that
be like? I would be dead, and I think I would be better off being that way. Do
you think being dead is enjoyable? Well, I don't even know what it's like. I
suppose it might be horrible to be dead and to experience nothing. Who knows?
So it might be horrible, or it might be nothing. Now the closest thing to nothing
is when you are being anesthetized. Is that enjoyable? It's not enjoyable, but it's
not unenjoyable either. I'm glad you admit that it's not enjoyable. And you're
right, there's really nothing enjoyable about nothing. But there are some things
enjoy- enjoyable about life. (At this point I thought I had really made a mark.
But again, in her adolescent insistence that things were no good, she continued
to outmaneuver me and contradict everything I said. Her contrariness made my
work with her challenging and more than a bit frustrating at times.) Holly: But
you see, there are so few things that are enjoyable about life, and there is so
much other stuff that you have to go through to get those few enjoyable things
that it seems to me it just doesn't weigh out. David: How do you feel when
you're feeling good? Do you feel that it doesn't weigh out then, or do you just
feel this way when you're feeling bad? Holly: David:
FEELING GOOD 397 Holly: It all depends on what I want to focus on, right?
The only way I get myself not to be depressed is if I don't think about all the
lousy things in this universe that make me depressed. Right? So when I am
feeling good, that means I'm focusing on the good things. But all the bad things
are still there. Since there is so much more bad than good, it is dishonest and
phony to look only at the good and feel good or feel happy, and that's why
suicide is the best thing to do. David: Well, there are two kinds of bad things in
this universe. One is the pseudo-bad. This is the unreal bad that we create as a
figment of our imagination by the way we think about things. Holly
(interrupting): Well, when I read the newspa- newspapers, I see rapes and
murders. That seems to me to be the real bad. David: Right. That's what I call the
real bad. But let's look at the pseudo-bad first. Holly: Like what? What do you
mean by pseudo-bad? David: Well, take your statement that life is no good. That
statement is an inaccurate exaggeration. As you pointed out, life has its good
elements, its bad elements, and its neutral elements. So the statement that life is
no good or that everything is hopeless is just exaggerated and unrealistic. This is
what I mean by the pseudo-bad. On the other hand, there are the real problems in
life. It's true that people do get murdered and that people do get cancer, but in
my experience these unpleasant things can be coped with. In fact, in your life
you will probably make the decision to commit yourself to some aspect of the
you will probably make the decision to commit yourself to some aspect of the
world's problems where you think you can make a con- contribution to a
solution. But even there, the mean- meaningful approach involves interaction
with the
398 David D. Burns, M.D. problem in a positive way rather than getting
overwhelmed by it and sitting back and moping. Holly: Well, see, that's what I
do. I just get immediately overwhelmed with the bad things I encounter, and
then I feel like I ought to kill myself. David: Right. Well, it might be nice if there
were a universe where there were no problems and no suffering, but then there
would be no opportunity for people to grow or solve these problems either. One
of these days you'll probably take one of the problems in the world, and contribcontributing to its solution will become a source of satisfaction to you. Holly:
Well, that's not fair to use problems in that way. David: Why don't you test it
out? I wouldn't want you to believe anything that I say unless you test it out for
yourself and find out if it's true. The way to test it out is to begin getting
involved in things, to go to classes, do your work, and establish relationships
with people. Holly: That's what I am beginning to do. David: Well, you can see
how it works out over a period of time, and you may find that going to summer
school and making a contribution to this world, and meeting with friends and
getting involved with activities, and doing your work and getting adequate
grades, and experiencing a sense of achievement and pleasure in doing what you
can—all of this might not be satisfying to you, and you might conclude, "Hey,
depression was better than this." And "I don't like being happy." You might say,
"Hey, I don't like being involved in life." If that's true, you can always go back to
being depressed and hopeless. I'm not going to take anything away from you.
But don't knock happiness until you've tried it.
FEELING GOOD 399 Check it out. See what life is like when you get involved
and make an effort. Then we'll see where the chips fall at that time. Holly again
experienced a substantial emotional relief as she realized, at least in part, that her
intense conviction that the world was no good and life was not worth living was
simply the result of her illogical way of looking at things. She was making the
mistake of focusing only on negatives (the mental filter) and arbitrarily insisting
that the positive things in the world didn't count (disqualifying the positive).
Consequently, she got the impression that everything was negative and that life
was not worth living. As she learned to correct this error in her thinking, she
began to experience some improvement. Although she continued to have a numnumber of ups and downs, the frequency and severity of her mood swings
diminished with time. She was so successful in her summer-school work that she
was accepted in the fall as a full-time student at a top Ivy League college.
was accepted in the fall as a full-time student at a top Ivy League college.
Although she made many pessimistic predictions that she would flunk out
because she didn't have the brains to make it in aca- academics, to her great
surprise she did outstandingly well in her classes. As she learned to transform
her intense nega- negativity into productive activity, she became a top-notch stustudent. Holly and I had a parting of the ways after less than a year of weekly
sessions. In the middle of an argument, she fled from the office, slammed the
door, and vowed never to return. Maybe she didn't know any other way to say
goodbye. I believe she felt she was ready to try and make it on her own. Perhaps
she finally got tired of trying to batter me down; after all, I was just as stubborn
as she was! She called me recently to let me know how things turned out.
Although she still struggles with her moods at times, she is now a senior and at
the top of her class. Her dream of going to graduate school to pursue a
professional career appears to be a certainty. God bless you, Holly! Holly's
thinking represents many of the mental traps that
400 David D. Burns, M.D. can lead to a suicidal impulse. Nearly all suicidal
patients have in common an illogical sense of hopelessness and the conviction
they are facing an insoluble dilemma. Once you expose the distortions in your
thinking, you will experience considerable emotional relief. This can give you a
basis for hope and can help you avert a dangerous suicide attempt. In addition,
the emotional relief can give you some breathing room so you can continue to
make more substantive changes in your life. You may find it difficult to identify
with a turbulent ad- adolescent like Holly, so let's take a brief look at another
more common cause for suicidal thoughts and attempts—the sense of
disillusionment and despair that sometimes hits us in middle age or in our senior
years. As you review the past, you may conclude that your life hasn't really
amounted to much in comparison with the starry-eyed expectations of your
youth. This has been called the mid-life crisis—that stage in which you review
what you have actually done with your life compared with your hopes and plans.
If you cannot resolve this crisis successfully, you may experience such intense
bitterness and such profound disappointment that you may attempt suicide. Once
again, the problem turns out to have little, if anything, to do with reality. Instead,
your turmoil is based on twisted thinking. Louise was a married woman in her
fifties who had em- emigrated from Europe to the United States during World
War II. Her family brought her to my office one day after she had been
discharged from an intensive care unit, where she had been treated for an almost
successful and totally un- unexpected suicide attempt. The family was unaware
she had been experiencing serious depression, so her sudden suicide attempt was
a complete surprise. As I spoke with Louise, she told me bitterly that her life had
a complete surprise. As I spoke with Louise, she told me bitterly that her life had
not measured up. She had never experienced the joy and fulfillment that she
dreamed of as a girl: she complained of a sense of inade- inadequacy and was
convinced she was a failure as a human
FEELING GOOD 401 being. She told me that she had accomplished nothing
worthwhile and concluded her life was not worth living. Because I felt a rapid
intervention was necessary in order to prevent a second suicide attempt, I used
cognitive tech- techniques to demonstrate to her as fast as possible the illogic of
what she was saying to herself. I first asked her to give me a list of things she
had accomplished in life as a way of testing her belief that she hadn't succeeded
at anything worthwhile. Louise: Well, I helped my family escape from the Nazi
terrorism and relocate in this country during World War II. In addition, I learned
to speak many languages fluently—five of them—when I was growing up.
When we came to the United States, I worked at an unpleasant job so that
enough money would be available for my fam- family. My husband and I raised
a fine young son, who went on to college and is now a highly successful
businessman. I'ma good cook; and in addition to perhaps being a good mother,
my grandchildren seem to think I'm a good grand- grandmother. These would be
the things which I feel I have accomplished during my life. David: In light of all
these accomplishments, how can you tell me you have accomplished nothing?
Louise: You see, everyone in my family spoke five lan- languages. Getting out
of Europe was just a matter of survival. My job was ordinary and required no
special talent. It is a mother's duty to raise her family, and any good housewife
should learn to cook. Because these are all the things I was supposed to do, or
that anyone could have done, they are not real accomplishments. They are just
ordinary, and this is why I have decided to com- commit suicide. My life is not
worthwhile.
402 David D. Burns, M.D. I realized that Louise was upsetting herself
unnecessarily by saying, t4It doesn't count'' with regard to anything good about
herself. This common cognitive distortion, called "disqualifying the positive,"
was her main enemy. Louise focused only on her inadequacies or errors, and
insisted that her successes weren't worth anything. If you discount your
achievements in this way, you will create the mental illusion that you are a
worthless zero. In order to demonstrate her mental error in a dramatic fashion, I
proposed that Louise and I do some role-playing. I told her that I would play the
role of a depressed psychi- psychiatrist, and she was to be my therapist, who
would try to find out why I have been feeling so depressed. Louise (as therapist):
Why is it you feel depressed, Dr. Burns? David (as depressed psychiatrist): Well,
Why is it you feel depressed, Dr. Burns? David (as depressed psychiatrist): Well,
I realize that I've accomplished nothing with my life. Louise: So you feel you've
accomplished nothing? But that doesn't make sense. You must have accomaccomplished something. For example, you care for many sick depressed
patients, and I understand you publish articles about your research and give
lectures. It sounds like you have accomplished a great deal at such a young age.
David: No. None of those things count. You see, it is every doctor's obligation to
care for his patients. So that doesn't count. I'm just doing what I'm supposed to
do. Furthermore, it is my duty at the university to do research and publish the
results. So these are not real accomplishments. All the faculty members do this,
and my research is not very important, at any rate. My ideas are just ordinary.
My life is basically a failure. Louise (laughing at herself—no longer being the
ther- therapist): I can see that I have been criticizing my- myself like that for the
past ten years.
FEELING GOOD 403 David (as therapist again): Now, how does it feel when
you continually say to yourself, 'it doesn't count" whenever you think about the
things you have accomplished? Louise: I feel depressed when 1 say this to
myself. David: And how much sense does it make to think of the things that you
haven't done that you might have liked to do, and to overlook the things that you
have done which turned out well and were the result of substantial effort and
determina- determination? Louise: It doesn't make any sense at all. As a result of
this intervention, Louise was able to see she had been arbitrarily upsetting
herself by saying over and over, "What I have done isn't good enough." When
she recognized how arbitrary it was to do this to herself, she experienced
immediate emotional relief, and her urge to commit suicide disappeared. Louise
realized that no matter how much she had accomplished in her life, if she wanted
to upset herself she would always be able to look back and say, 'it wasn't
enough." This indicated to her that her problem was not realistic but simply a
mental trap she had fallen into. The role-reversal seemed to evoke a sense of
amusement and laughter in her. This stimulation of her sense of humor appeared
to help her recognize the absurdity of her self-criticism, and she achieved a much
needed sense of compassion for herself. Let's review why your conviction that
you are "hope- "hopeless" is both irrational and self-defeating. First, remember
that depressive illness is usually, if not always, self-limiting, and in most cases
eventually disappears even without treat- treatment. The purpose of treatment is
to speed the recovery process. Many effective methods of drug therapy and psypsychotherapy now exist, and others are being rapidly devel- developed. Medical
science is in a constant state of evolution. We are currently experiencing a
renaissance in our ap-
404 David D. Burns, M.D. proaches to depressive illness. Because we cannot
predict yet with complete certainty which psychological interven- intervention or
medication will be most helpful for a particular patient, a number of techniques
must sometimes be applied until the right key to the locked-up potential for
happiness is found. Although this does require patience and hard work, it is
crucial to keep in mind that nonresponse to one or even to several techniques
does not indicate that all methods will fail. In fact, the opposite is more often
true. For example, recent drug research has shown that patients who do not
respond to one antidepressant medication often have a better than average
chance of responding to another. This means if you fail to respond to one of the
agents, your chances for improvement when you are given another may actually
be enhanced. When you consider that there are large numbers of effective
antidepressants, psychotherapeutic interven- interventions, and self-help
techniques, the probability for eventual recovery becomes tremendously high.
When you are depressed, you may have a tendency to confuse feeling with facts.
Your feelings of hopelessness and total despair are just symptoms of depressive
illness, not facts. If you think you are hopeless, you will naturally feel this way.
Your feelings only trace the illogical pattern of your thinking. Only an expert,
who has treated hundreds of depressed individuals, would be in a position to
give a meaningful prognosis for recovery. Your suicidal urge merely indicates
the need for treatment. Thus, your con- conviction that you are "hopeless" nearly
always proves you are not. Therapy, not suicide, is indicated. Although gengeneralizations can be misleading, I let the following rule of thumb guide me:
Patients who feel hopeless never actually are hopeless. The conviction of
hopelessness is one of the most curious aspects of depressive illness. In fact, the
degree of hope- hopelessness experienced by seriously depressed patients who
have an excellent prognosis is usually greater than in ter- terminal malignancy
patients with a poor prognosis. It is of great importance to expose the illogic that
lurks behind your
FEELING GOOD 405 hopelessness as soon as possible in order to prevent an
actual suicide attempt. You may feel convinced that you have an insoluble
problem in your life. You may feel that you are caught in a trap from which
there is no exit. This may lead to extreme frustration and even to the urge to kill
yourself as the only escape. However, when I confront a depressed patient with
respect to precisely what kind of trap he or she is in, and I zero in on the person's
"insoluble problem," I invariably find that the patient is deluded. In this
situation, you are like an evil magician, and you create a hellish illusion with
mental magic. Your suicidal thoughts are il- illogical, distorted, and erroneous.
Your twisted thoughts and faulty assumptions, not reality, create your suffering.
Your twisted thoughts and faulty assumptions, not reality, create your suffering.
When you learn to look behind the mirrors, you will see that you are fooling
yourself, and your suicidal urge will disappear. It would be naive to say that
depressed and suicidal in- individuals never have "real" problems. We all have
real problems, including finances, interpersonal relationships, healfh, etc. But
such difficulties can nearly always be coped with in a reasonable manner without
suicide. In fact, meet- meeting such challenges can be a source of mood
elevation and personal growth. Furthermore, as pointed out in Chapter 9, real
problems can never depress you even to a small extent. Only distorted thoughts
can rob you of valid hopes or self- esteem. I have never seen a "real" problem in
a depressed patient which was so "totally insoluble" that suicide was indicated.
Part V! Coping with the Stresses and Strains of Daily Living
Chapter 16 How I Practice What I Preach "Physician, heal thyself/'—Luke 4:23
A recent study of stress has indicated that one of the world's most demanding
jobs—in terms of the emotional tension and the incidence of heart attacks—is
that of an air-traffic controller in an airport tower. The work involves precision,
and the traffic controller must be constantly alert—a blunder could result in
tragedy. I wonder however if that job is more taxing than mine. After all, the
pilots are cooperative and intend to take off or land safely. But the ships I guide
are sometimes on an intentional crash course. Here's what happened during one
thirty-minute period last Thursday morning. At 10:25 I received the mail, and
skimmed a long, rambling, angry letter from a patient named Felix just prior to
the beginning of my 10:30 session. Felix announced his plans to carry out a
"blood bath," in which he would murder three doctors, including two
psychiatrists who had treated him in the past! In his letter Felix stated, "I'm just
waiting until I get enough energy to drive to the store and purchase the pistol and
the bullets." I was unable to reach Felix by phone, so I began my 10:30 session
with Harry. Harry was emaciated and looked like a concentration camp victim.
He was unwilling to eat because of a delusion 409
410 David D. Burns, M.D. that his bowels had "closed off," and he had lost
seventy pounds. As I was discussing the unwelcome option of hos- hospitalizing
Harry for forced tube feeding to prevent his death from starvation, 1 received an
emergency telephone call from a patient named Jerome, which interrupted the
session. Jerome informed me he had placed a noose around his neck and was
seriously considering hanging himself before his wife came home from work. He
announced his unwilling- unwillingness to continue outpatient treatment and
insisted that hos- pitalization would be pointless. I straightened out these three
insisted that hos- pitalization would be pointless. I straightened out these three
emergencies by the end of the day, and went home to unwind. At just about
bedtime 1 received a call from a new referral—a well-known woman VIP
referred by another patient of mine. She indicated she'd been depressed for
several months, and that earlier in the evening she'd been standing in front of a
mirror practicing slitting her throat with a razor blade. She explained she was
calling me only to pacify the friend who referred her to me, but was unwilling to
schedule an appointment because she was convinced her case was "hopeless."
Every day is not as nerve-racking as that one! But at times it does seem like I'm
living in a pressure cooker. This gives me a wealth of opportunities to learn to
cope with intense uncertainty, worry, frustration, irritation, disappointment, and
guilt. It affords me the chance to put my cognitive techniques to work on myself
and see firsthand if they're actually effective. There are many sublime and
joyous mo- moments too. If you have ever gone to a psychotherapist or
counselor, the chances are that the therapist did nearly all the listening and
expected you to do most of the talking. This is because many therapists are
trained to be relatively passive and non- directive—a kind of "human mirror"
who simply reflects what you are saying.* This one-way style of communication
*Some of the newer forms of psychiatric treatment, such as cognitive therapy,
allow for a natural tifty-fHty dialogue between the client and therapist, who
work together as equal members of a team.
FEELING GOOD 41 1 may have seemed unproductive and frustrating to you.
You may have wondered—"What is my psychiatrist really like? What kinds of
feelings does he have? How does he deal with them? What pressures does he
feel in dealing with me or with other patients?" Many patients have asked me
directly, "Dr. Burns, do you actually practice what you preach?" The fact is, I
often do pull out a sheet of paper on the train ride home in the evening, and draw
a line down the center from top to bottom so I can utilize the double-column
technique to cope with any nagging emotional hangovers from the day. If you
are curious to take a look behind the scenes, I'll be glad to share some of my selfhelp homework with you. This is your chance to sit back and listen while the
psychiatrist does the talking! At the same time, you can get an idea of how the
cognitive techniques you have mastered to overcome clinical depression can be
applied to all sorts of daily frus- frustrations and tensions that are an inevitable
part of living for all of us. Coping With Hostility: The A/Ian Who Fired Twenty
Doctors One high-pressure situation I often face involves dealing with angry,
demanding, unreasonable individuals. I suspect I have treated a few of the East
Coast's top anger champions. These people often take their resentment out on the
people who care the most about them, and sometimes this includes me. Hank
was an angry young man. He had fired twenty doctors before he was referred to
was an angry young man. He had fired twenty doctors before he was referred to
me. Hank complained of episodic back pain, and was convinced he suffered
from some severe medical disorder. Because no evidence for any physical
abnormality had ever surfaced, in spite of lengthy, elaborate medical
evaluations, numerous physicians told him that his aches and pains were in all
likelihood the result of emotional tension, much like a headache. Hank had dif412 David D. Burns, M.D. ficulty accepting this, and he felt his doctors were
writing him off and just didn't give a damn about him. Over and over he'd
explode in a fury, fire his doctor, and seek out someone new. Finally, he
consented to see a psychiatrist. He resented this referral, and after making no
progress for about a year, he fired his psychiatrist and sought treatment at our
Mood Clinic. Hank was quite depressed, and I began to train him in cognitive
techniques. At night when his back pain flared up, Hank would work himself up
into a frustrated rage and impulsively call me at home (he had persuaded me to
give him my home number so he wouldn't have to go through the answering
service). He would begin by swearing and accusing me of misdiagnosing his
illness. He'd insist he had a medical, not a psychiatric, problem. Then he'd
deliver some unreasonable demand in the form of an ultimatum: "Dr. Burns,
either you arrange for me to get shock treat- treatments tomorrow or I'll go out
and commit suicide tonight." It was usually difficult, if not impossible, for me to
comply with most of his demands. For example, I don't give shock treatments,
and furthermore I didn't feel this type of treat- treatment was indicated for Hank.
When I would try to explain this diplomatically, he would explode and threaten
some impulsive destructive action. During our psychotherapy sessions Hank had
the habit of pointing out each of my imperfections (which are real enough). He'd
often storm around the office, pound on the furniture, heaping insults and abuse
on me. What used to get me in particular was Hank's accusation that I didn't care
about him. He said that all I cared about was money and maintaining a high
therapy success rate. This put me in a dilemma, because there was a grain of
truth in his criti- criticisms—he was often several months behind in making paypayments for his therapy, and I was concerned that he might drop out of
treatment prematurely and end up even more disillusioned. Furthermore, I was
eager to add him to my list of successfully treated individuals. Because there was
FEELING GOOD 413 some truth in Hank's haranguing attacks, I felt guilty and
defensive when he would zero in on me. He, of course, would sense this, and
consequently the volume of his crit- criticism would increase. I sought some
guidance from my associates at the Mood Clinic as to how I might handle Hank's
outbursts and my own feelings of frustration more effectively. The advice I
outbursts and my own feelings of frustration more effectively. The advice I
received from Dr. Beck was especially useful. First, he emphasized that I was
4'unusually fortunate" because Hank was giving me a golden opportunity to
learn to cope with criticism and anger effectively. This came as a complete
surprise to me; I hadn't realized what good fortune I had. In addition to urging
me to use cognitive techniques to reduce and eliminate my own sense of
irritation, Dr. Beck proposed I try out an unusual strategy for interacting with
Hank when he was in an angry mood. The essence of this method was: A) Don't
turn Hank off by defending yourself. Instead, do the opposite—urge him to say
all the worst things he can say about you. B) Try to find a grain of truth in all his
criticisms and then agree with him. C) After this, point out any areas of
disagreement in a straightforward, tactful, nonargumentative manner. D)
Emphasize the im- importance of sticking together, in spite of these occasional
disagreements. I could remind Hank that frustration and fighting might slow
down our therapy at times, but this need not destroy the relationship or prevent
our work from ul- ultimately becoming fruitful. 1 applied this strategy the next
time Hank started storming around the office screaming at me. Just as I had
planned, 1 urged Hank to keep it up and say all the worst things he could think
of about me. The result was immediate and dramatic. Within a few moments, all
the wind went out of his sails—all his vengeance seemed to melt away. He
began communicating sensibly and calmly, and sat down. In fact, when I agreed
with some of his criticisms, he suddenly began to defend me and say some nice
things about me! I was so impressed with this result that I began using the
414 David D. Burns, M.D. same approach with other angry, explosive
individuals, and I actually did begin to enjoy his hostile outbursts because I had
an effective way to handle them. I also used the double-column technique for
recording and talking back to my automatic thoughts after one of Hank's
midnight calls (see Figure 16-1, page 415). As my associates suggested, I tried to
see the world through Hank's eyes in order to gain a certain degree of empathy.
This was a specific antidote that in part dissolved my own frustration and anger,
and I felt much less defensive and upset. It helped me to see his outbursts more
as a defense of his own self- esteem than as an attack on me, and I was able to
compre- comprehend his feelings of futility and desperation. I reminded myself
that much of the time he was damn hardworking and cooperative, and how
foolish it was for me to demand he be totally cooperative at all times. As I began
to feel more calm and confident in my work with Hank, our relationship
continually improved. Eventually, Hank's depression and pain subsided, and he
terminated his work with me. I hadn't seen him for many months when I
received a message from my answering service that Hank wanted me to call him.
received a message from my answering service that Hank wanted me to call him.
I suddenly felt apprehensive; memories of his turbulent tirades flooded my mind,
and my stomach muscles tensed up. With some hes- hesitation and mixed
feelings, I dialed his number. It was a sunny Saturday afternoon, and I'd been
looking forward to a much needed rest after an especially taxing week. Hank
answered the phone: "Dr. Burns, this is Hank. Do you remember me? There's
something I've been meaning to tell you for some time ..." He paused, and I
braced for the impending explosion. 'Tve been essentially free of pain and
depression since we finished up a year ago. I went off disability and I've gotten a
job. I'm also the leader of a self-help group in my own hometown." This wasn't
the Hank I remembered! I felt a wave of relief and delight as he went on to
explain, "But that's not why I'm calling. What I want to say to you is . . ." There
was another moment of silence—"I'm grateful for your
Figure 16-1. Coping with Hostility. Automatic Thoughts Rational Responses 1.
I've put more energy 1. Stop complaining. You sound into working with Hank
like Hank! He's frightened and than nearly anyone, and frustrated, and he's
trapped in this is what I get— his resentment. Just because abuse! you work hard
for someone, it doesn't necessarily follow that they'll feel appreciative. Maybe he
will some day. 2. Why doesn't he trust 2. Because he's in a panic, he's me about
his diagnosis extremely uncomfortable and and treatment? in pain, and he hasn't
yet got- gotten any substantial results. He'll believe you once he starts getting
well. 3. But in the meantime, he 3. Do you expect him to show re- should at least
treat me spect all the time or part of the with respect! time? In general, he exerts
tre- tremendous effort in his self-help program and does treat you with respect.
He's determined to get well—if you don't ex- expect perfection, you won't have
to feel frustrated. 4. But is it fair for him to 4. Talk it over with him when call me
so often at you're both feeling more re- home at night? And laxed. Suggest that
he supple- does he have to be so ment his individual therapy by abusive? joining
a self-help group in which the various patients call each other for moral support.
This will make it easier for him to cut down on calls to you. But for now,
remember that he doesn't plan these emergen- emergencies, and they are very
terri- terrifying and real to him.
416 David D. Burns, M.D. efforts, and I now know you were right all along.
There was nothing dreadfully wrong with me, I was just upsetting myself with
my irrational thinking. I just couldn't admit it until I knew for sure. Now, I feel
like a whole man, and I had to call you up and let you know where I stood ... It
was hard for me to do this, and I'm sorry it took so long for me to get around to
telling you." Thank you, Hank! I want you to know that some tears of joy and
pride in you come to my eyes as I write this. It was worth the anguish we both
pride in you come to my eyes as I write this. It was worth the anguish we both
went through a hundred times over! Coping With Ingratitude: The Woman Who
Couldn't Say Thank You Did you ever go out of your way to do a favor for
someone only to have the person respond to your efforts with indif- indifference
or nastiness? People shouldritbt so unappreciative, right? If you tell yourself this,
you will probably stew for days as you mull the incident over and over. The
more inflammatory your thoughts and fantasies become, the more disturbed and
angry you will feel. Let me tell you about Susan. After high-school graduagraduation, Susan sought treatment for a recurrent depression. She was very
skeptical that I could help her and continually reminded me that she was
hopeless. She had been in a hysterical state for several weeks because she
couldn't de- decide which of two colleges to attend. She acted as though the
world would come to an end if she didn't make the "right" decision, and yet the
choice was simply not clear- cut. Her insistence on eliminating all uncertainty
was bound to cause her endless frustration because it simply couldn't be done.
She cried and sobbed excessively. She was insulting and abusive to her
boyfriend and her family. One day she called me on the phone, pleading for
help. She just had to make up her mind. She rejected every suggestion I made,
and
FEELING GOOD 417 angrily demanded I come up with some better approach.
She kept insisting, "Since I can't make this decision, it proves your cognitive
therapy won't work for me. Your methods are no damn good. I'll never be able to
decide, and I can't get better." Because she was so upset, I arranged my
afternoon schedule so that I could have an emergency consultation with a
colleague. He offered several outstand- outstanding suggestions; I called her
right back and gave her some tips on how to resolve her indeciveness. She was
then able to come to a satisfactory decision within fifteen minutes, and felt an
instantaneous wave of relief. When she came in for her next regularly scheduled
ses- session, she reported she had been feeling relaxed since our talk, and had
finalized the arrangements to attend the college that she chose. I anticipated
waves of gratitude because of my strenuous efforts on her behalf, and I asked her
if she was still convinced that cognitive techniques would be in- ineffective for
her. She reported, "Yes, indeed! This just proves my point. My back was up
against the wall, and I had to make a decision. The fact that I'm feeling good
now doesn't count because it can't last. This stupid therapy can't help me. I'll be
depressed for the rest of my life." My thought: "My God! How illogical can you
get? I could turn mud into gold, and she wouldn't even notice!" My blood was
boiling, so I decided to use the double-column technique later that day to try and
calm my troubled and insulted spirits (see Figure 16-2, page 418). After writing
calm my troubled and insulted spirits (see Figure 16-2, page 418). After writing
down my automatic thoughts, I was able to pinpoint the irrational assumption
that caused me to get upset over her ingratitude. It was, "If 1 do something to
help someone, they are duty-bound to feel grateful and reward me for it." It
would be nice if things worked like this, but it's simply not the case. No one has
a moral or legal ob- obligation to credit me for my cleverness or praise my good
efforts on their behalf. So why expect it or demand it? I decided to tune in to
reality and adopt a more realistic attitude: "If I do something to help someone,
the chances are the person will be appreciative, and that will feel good.
Figure 16-2. Coping with Ingratitude. Automatic Thoughts Rational Responses I.
How can such a briiliant I girl be so illogical? 2. But I can't. She's de- 2.
termined to beat me down. She won't give me an ounce of satisfac- satisfaction.
3. But she should admit I 3 helped her! She should be grateful! Easily! Her
illogical thinking is the cause of her depression. If she didn't continually focus on
negatives and disqualify positives, she wouldn't be de- depressed so often. It's
your job to train her in how to get over this. She doesn't have to give you any
satisfaction. Only you can do this. Don't you recall that only your thoughts affect
your moods? Why not credit your- yourself for what you did? Don't wait around
for her. You just learned some exciting things about how to guide people in
making decisions. Doesn't that count? Why "should" she? That's a fairy tale. If
she could she probably would, but she can't yet. In time she'll come around, but
she'll have to re- reverse an ingrained pattern of illogical thinking that's been
dominating her mind for over a decade. She may be afraid to admit she's getting
help so she won't end up disillusioned again. Or she might be afraid you'll say, "I
told you so." Be like Sherlock Holmes and see if you can figure out this puzzle.
It's pointless to de- demand that she be different from the way she is.
FEELING GOOD 419 But every now and then, someone will not respond the
way I want. If the response is unreasonable, this is a reflection on that person,
not me, so why get upset over it?" This attitude has made life much sweeter for
me, and overall I have been blessed with as much gratitude from patients as I
could desire. Incidentally, Susan gave me a call just the other day. She'd done
well at college and was about to graduate. Her father had been depressed, and
she wanted a referral to a good cognitive therapist! Maybe that was her way of
saying thank you! Coping With Uncertainty and Helplessness: The Woman Who
Decided to Commit Suicide On my way to the office on Monday, I always
wonder what the week will hold in store. One Monday morning I was in for an
abrupt shock. As I unlocked the office, I found some papers had been slipped
under the door over the week- weekend—a twenty-page letter from a patient
under the door over the week- weekend—a twenty-page letter from a patient
named Annie. An- Annie had been referred to me several months earlier on her
twentieth birthday, after having received eight years of com- completely
successful treatment from several therapists for a horrible, grotesque mood
disorder. From age twelve on, Annie's life had deteriorated into a nightmarish
pattern of depression and self-mutilation. She loved to slash her arms to shreds
with sharp objects, one time requiring 200 stitches. She also made a number of
nearly successful suicide at- attempts. I tensed as I picked up her note. Annie had
recently expressed a deep sense of despair. In addition to depression, she
suffered from a severe eating disorder, and the previous week had engaged in a
bizarre three-day spree of compul- compulsive, uncontrollable binge-eating.
Going from restaurant to restaurant, she would stuff herself for hours nonstop.
Then she'd vomit it all up and eat some more. In her note she described herself
as a "human garbage disposal," and ex- explained that she was beyond hope. She
indicated that she
420 David D. Burns, M.D. had decided to give up trying because she realized
she was basically "a nothing." Without reading further, I called her apartment.
Her roommates told me that she had packed up and "left town" for three days
without giving any indication of where or why. Alarms sounded in my head!
This is exactly what she had done on her last several suicide attempts prior to
treat- treatment—she'd drive to a motel, sign in under an assumed name, and
overdose. I continued to read her letter. In it she stated, lTm drained, I'm like a
burnt-out light bulb. You can pipe electricity into it, but it just won't light up. I'm
sorry but I guess it's just too late. I'm not going to feel false hope any longer. . .
During the last few moments I do not feel particularly sad. Once every so often I
try to grasp onto life, hoping to clench my hands around something, anything—
but I keep grasping nothing, empty." It sounded like a bona fide suicide note,
although no explicit intention was announced. I suddenly became subsubmerged by a massive uncertainty and helplessness—she had disappeared and
left no traces. I felt angry and anxious. Because I could do nothing for her, I
decided to write down the automatic thoughts that flowed through my mind. I
hoped some rational responses would help me cope with the intense uncertainty I
was facing (see Figure 16-3, page 421). After recording my thoughts, I decided
to call my as- associate, Dr. Beck, for a consultation. He agreed that I should
assume she was alive unless it was proved otherwise. He suggested that if she
were found dead, I could then learn to cope with one of the professional hazards
of working with depression. If she was alive, as we assumed, he em- emphasized
the importance of persisting with treatment until her depression finally broke.
The effect of this conversation and the written exercise was magnificent. I
realized I was under no obligation to assume "the worst," and that it was my
realized I was under no obligation to assume "the worst," and that it was my
right to choose not to make myself miserable over her possible suicide attempt.
Figure 16-3. Coping with Uncertainty. Automatic Thoughts Rational Responses
1. She's probably made a 1 suicide attempt—and succeeded. 2. if she's dead, it
means 2. I killed her. 3. If I'd done something 3, different last week, I could have
prevented this. It's my fault. 4. This shouldn't have 4. happened—I tried so hard.
5. This means my ap- 5 proach is second-rate. 6. Her parents v/ill be an- 6. gry
with me. 7. Dr. Beck and my asso- associates will be angry with me—they'll
know I'm incompetent, and they'll look down on 7, me. There's no proof she's
dead. Why not assume she's alive until proven otherwise? Then you won't have
to worry and obsess in the meantime. No, you're not a killer. You're trying to
help. You're not a fortune teller— you can't predict the future. You do the best
you can based on what you know—draw the line there and respect yourself on
this basis. Whatever happened did hap- happen. Just because you make maximal
efforts, there's no guarantee about the results. You can't control her, only your
efforts. Your approach is one of the finest ever developed, and you apply
yourself with great effort and commitment, and get out- outstanding results. You
are not second-rate. They may and they may not. They know how you've
knocked yourself out for her Extremely unlikely. We'll all be disappointed to
lose a pa- patient we've gone to such ex- extreme lengths to help, but your peers
won't feel you've let them down. If you're at all concerned, call them! Practice
what you preach, Burns.
422 David D. Burns, M.D. Figure 16-3. cont. Automatic Thoughts Rational
Responses 8. I'll feel miserable and 8. You'll only feel miserable if guilty until I
find out you make a negative assump- what happened. I'm ex- tion. Odds are (a)
she's alive pected to feel that way. and (b) she'll get better. As- Assume this and
you'll feel good! You have no obligation to feel bad—you have the right to rerefuse to get upset. I decided I couldn't take on responsibility for her actions,
only for mine, and that I had done well with her and would stubbornly continue
to do so until she and I had finally defeated her depression and tasted victory.
My anxiety and anger disappeared completely, and I felt relaxed and peaceful
until I received the news by telephone on Wednesday morning. She had been
found unconscious in a motel room fifty miles from Philadelphia. This was her
eighth suicide attempt, but she was alive and complaining as usual in the
Intensive Care Unit of an outlying hospital. She would survive, but would
require plastic surgery to replace the skin over her elbows and ankles because of
sores which had developed during the long period of uncon- unconsciousness. I
arranged for her transfer to the University of Pennsylvania, where she would be
arranged for her transfer to the University of Pennsylvania, where she would be
back in my relentless, cognitive clutches again! When I spoke with her, she was
enormously bitter and hopeless. The next couple of months of therapy were esespecially turbulent. But the depression finally began to lift in her eleventh
month, and exactly one year to the day of her referral, her twenty-first birthday,
the symptoms of depression disappeared. The Payoff. My joy was enormous.
Women must have this feeling when they first see their child after delivery—all
FEELING GOOD 423 the discomfort of pregnancy and the pain of delivery are
forgotten. It's the celebration of life—quite a heady expe- experience. I find that
the more chronic and severe the depres- depression, the more intense the
therapeutic struggle becomes. But when the patient and I at last discover the
combination that unlocks the door to their inner peace, the riches inside far
exceed any effort or frustration that occurred along the way.
Part VII The Chemistry of Mood NOTE: Numbered Notes and References for
Chapters 17-20 can be found on pages 682-687. Because some References are
cited more than once, the superscript numbers assigned to those References will
appear in these chapters more than once.
Chapter 17 The Search for "Black Bile (Notes and References appear on pages
682-687.) Some day, scientists may provide us with frightening tech- technology
that will allow us to change our moods at will. This technology may be in the
form of a safe, fast-acting med- medication that relieves depression in a matter
of hours with few or no side effects. This breakthrough will represent one of the
most extraordinary and philosophically confusing de- developments in human
history. In a sense, it will almost be like discovering the Garden of Eden again—
and we may face new ethical dilemmas. People will probably ask quesquestions like these: When should we use this pill? Are we entitled to be happy
all the time? Is sadness sometimes a normal and healthy emotion, or should it
always be con- considered an abnormality that needs treatment? Where do we
draw the line? Some people think such technology has already arrived in the
form of a pill called Prozac. When you read the next few chapters, you will see
that this is not really the case. Although we have large numbers of antidepressant
medi- medications that work for some people, many people do not respond to
antidepressant medications in a satisfactory way, and when they do improve, the
improvement is often in- incomplete. Clearly, we are still a long way from our
goal. In addition, we still do not really know how the brain 427
428 David D. Burns, M.D. creates emotions. We do not know why some people
are more prone to negative thinking and gloomy moods throughout their lives,
are more prone to negative thinking and gloomy moods throughout their lives,
whereas others seem to be eternal optimists who always have a positive outlook
and a cheer- cheerful disposition. Is depression partially genetic? Is it due to
some type of chemical or hormonal imbalance? Is it some- something we're born
with, or something we learn? The answers to these questions still elude us. Many
people wrongly be- believe we already have the answers. The answers to
questions about treatment are equally un- unclear. Which patients should be
treated with medications? Which patients need psychotherapy? Is the
combination better than either type of treatment alone? You will see that the
answers to questions as basic as these are more contro- controversial than you
might expect. In this chapter, I address these issues. I discuss whether depression
is caused more by biology (nature) or the en- environment (nurture). I explain
how the brain works, and review evidence that depression might be caused by a
chemical imbalance in the brain. I also describe how anti- depressant drugs
attempt to correct this imbalance. In Chapter 18, I discuss the "mind-body
problem" and address the current controversies about treatments that af- affect
the "mind" (for instance, cognitive therapy) versus treatments that affect the
"body" (for instance, antidepres- sants.) In Chapters 19 and 20, I will give you
practical information about all the antidepressant drugs that are cur- currently
prescribed for mood problems. Do Genetic or Environmental Influences Play a
Greater Role in Depression? Although much research is being conducted to try
to tease out the relative strengths of the genetic and environ- environmental
influences on depression, scientists do not yet know which influences are the
most important. With regard to bipolar (manic-depressive) illness, the evidence
is quite
FEELING GOOD 429 strong: genetic factors seem to play a strong role. For exexample, if one identical twin develops bipolar manic- depressive illness, the
odds are high that the other twin will also develop this disorder E0 percent to 75
percent). In contrast, when one of two nonidentical twins develops bipolar
(manic-depressive) illness, the odds that the other twin will develop the same
illness are lower A5 percent to 25 percent). The odds of developing bipolar
illness if a parent or nontwin sibling has this disorder are around 10 percent. All
these odds are considerably higher than the odds that someone in the general
population will de- develop bipolar illness—the lifetime risk is estimated at less
than 1 percent. Keep in mind that identical twins have identical genes, whereas
nonidentical twins share only half their genes. This is probably why the
likelihood of bipolar (manic- depressive) illness is so much higher if you have an
iden- identical twin than if you have a nonidentical twin with this disorder, and
why these rates are so much higher than the rates for bipolar illness in the
why these rates are so much higher than the rates for bipolar illness in the
general population. The in- increased risk for bipolar illness among identical
twins is even true if the identical twins are separated at birth and raised by
different families. Although the adoption of iden- identical twins by separate
families is rare, it does happen on occasion. In some cases, scientists have been
able to locate the twins later in life to determine how similar or different they
are. These " natural" experiments can tell us a great deal about the relative
importance of genes versus environ- environment because the separately raised
identical twins have identical genes but their environments are different. Such
studies highlight the importance of strong genetic influ- influences in bipolar
disorder. With regard to the far more common garden-variety de- depression
without episodes of uncontrollable mania, the ev- evidence for genetic factors is
still quite fuzzy. Part of the problem facing genetic researchers is that the
diagnosis of depression is much less clear-cut than the diagnosis of bi430 David D. Burns, M.D. polar (manic-depressive) illness. Bipolar manicdepressive illness is such an unusual disorder, at least in its more severe forms,
that the diagnosis is often obvious. The pa- patient has a sudden and alarming
change in personality that comes on without drugs or alcohol, along with
symptoms such as: • intense euphoria, often with irritability; • incredible energy
with constant exercising or restless, agitated body movements; • very little need
for sleep; • nonstop, pressured talking; • racing thoughts that skip from subject to
subject; • grandiose delusions (for example, the sudden belief that one has a plan
for world peace); • impulsive, reckless, and inappropriate behaviors (such as
spending money foolishly); • inappropriate, excessive flirtatiousness and sexual
ac- activity; • hallucinations (in severe cases). These symptoms are usually
unmistakable and often so un- uncontrollable that the patient may require
hospitalization with medication treatment. Following recovery, the individindividual usually returns to absolutely normal functioning again. These distinct
features of bipolar illness make genetic re- research relatively straightforward,
since it is usually not dif- difficult to determine when individuals have the
disorder and when they do not. In addition, this disorder usually begins fairly
early in life, with the first episode often occurring by the age of twenty to
twenty-five. In contrast, the diagnosis of depression is much less ob- obvious.
Where does normal sadness end and clinical depression begin? The answer is
somewhat arbitrary, but the decision will have a big impact on the results of reREELING GOOD 431 search. Another difficult question genetic researchers
face is this: How long should we wait before we decide whether or not a person
has developed a clinical depression during his or her life? Suppose, for example,
has developed a clinical depression during his or her life? Suppose, for example,
that an individual with a strong family history of depression dies in an auto
accident at the age of twenty-one without ever having had an episode of clinical
depression. We might conclude that she or he did not inherit the tendency for
depression. But if that individual had not died, she or he might have dedeveloped an episode of depression later on in life, since a first episode of
depression can often occur when you are older than twenty-one. Problems like
this are not insurmountable, but they do make genetic research on depression
difficult. In fact, many previously published studies on the genetics of
depression are quite flawed and do not permit us to make any unamunambiguous conclusions about the importance of heredity ver- versus
environment in this disorder. Fortunately, more sophisticated studies are now
under way, and we may have better answers to these questions during the next
five to ten years. Is Depression Caused by a "Chemical Imbalance" in the Brain?
Throughout the ages, humans have searched for the causes of depression. Even
in ancient times there was some suspicion that blue moods were due to an
imbalance in body chemistry. Hippocrates D60-377 B.C.) thought that "black
bile" was the culprit. In recent years scientists have spearheaded an intensive
search for the elusive black bile. They have tried to pinpoint the imbalances in
brain chem- chemistry that might cause depression. There are hints about the
answer, but in spite of increasingly sophisticated research tools, scientists have
not yet discovered the causes of de- depression. At least two major arguments
have been advanced to
432 David D. Burns, M.D. support the notion that some type of chemical
imbalance or brain abnormality may play a role in clinical depression. First, the
physical (somatic) symptoms of severe depression support the notion that
organic changes might be involved. These physical symptoms include agitation
(increased ner- nervous activity such as pacing or hand-wringing) or enormous
fatigue (motionless apathy—you feel like a ton of bricks and do nothing). You
also may experience a "diurnal" var- variation in your mood. This refers to a
worsening of the symptoms of depression in the morning and an improveimprovement toward the end of the day. Other physical symptoms of depression
include disturbed sleep patterns (insomnia is the most common), constipation,
changes in appetite (usu- (usually decreased, sometimes increased), trouble
concentrating, and a loss of interest in sex. Because these symptoms of
depression "feel" quite physical, there is a tendency to think that the causes of
depression are physical. A second argument for a physiologic cause for depresdepression is that at least some mood disorders seem to run in families,
suggesting a role for genetic factors. If there is an inherited abnormality that
suggesting a role for genetic factors. If there is an inherited abnormality that
predisposes some individuals to depression, it could be in the form of a
disturbance in body chemistry, as with so many genetic diseases. The genetic
argument is interesting but the data are in- inconclusive. The evidence for
genetic influences in bipolar manic-depressive illness is much stronger than the
evidence for genetic influences in the more common forms of de- depression that
afflict most people. In addition, lots of things that do not have genetic causes run
in families. For ex- example, families in the United States nearly always speak
English, and families in Mexico nearly always speak Span- Spanish. We can say
that the tendency to speak a certain lan- language also runs in families, but the
language you speak is learned and not inherited. I don't mean to discount the
importance of genetic fac- factors. Recent studies of identical twins who were
separated at birth and raised in different families show that many traits we think
of as being learned are actually inherited.
FEELING GOOD 433 Even such personality traits as a tendency toward shyness
or sociability appear to be partly inherited. Personal pref- preferences, such as
liking a particular flavor of ice cream, may also be strongly influenced by our
genes. It seems plausible that we may also inherit a tendency to look at things
either in a positive, optimistic way or in a negative, gloomy way. Much more
research will be needed to sort out this possi- possibility. How Does the Brain
Work? The brain is essentially an electrical system that is similar in some ways
to a computer. Different portions of the brain are specialized for different kinds
of functions. For exam- example, the surface of the brain toward the back of
your head is called the "occipital cortex." This is where vision takes place. If you
had a stroke that affected this region of the brain, you would have trouble with
your vision. A small region on the surface of the left half of your brain is called
"Broca's area." This is the part of your brain that allows you to talk to other
people. If this part of your brain were injured by a stroke, you would have
difficulty talking. You might be able to think of what you wanted to say, but find
that you had "forgotten" how to speak the words. A prim- primitive part of your
brain called the "limbic system" is thought to be involved in the control of
emotions such as joy, sadness, fear, or anger. However, our knowledge of where
and how the brain creates positive and negative emo- emotions is still very
limited. We do know that nerves are the "wires" that make up the electrical
circuits in the brain. The long thin part of a nerve is called the "axon." When a
nerve is stimulated, it sends an electrical signal along the axon to the end of the
nerve. A nerve is much more complex than a simple wire, however. For
example, a nerve may receive input from tens of thousands of other nerves. Once
it is stimulated, its axon may send out signals to tens of thousands of other
nerves.
nerves.
434 David D. Burns, M.D. Serotonin Recepto Hi! My name Is Sara Tonin! I'm a
neurotransmitter! MAO Enzyme Nerve Fires Postsynaptic Nerve Presynaptic
Nerve Synapse Figure 17-1. When the presynaptic nerve fires, packets of serotoserotonin molecules (neurotransmitters) are released into the synapse. They
swim over to the receptors on the surface of the postsynaptic nerve. This is
because the axon can divide and send out many branches. Each of these branches
also divides into even more branches, in much the same way that the trunk of a
tree divides into more and more branches. Because of this branching tendency, a
single nerve in the brain may send out signals to as many as 25,000 other nerves
that are lo- located throughout the entire brain. How do the nerves in your brain
communicate their elec- electrical signals to other nerves? To understand this,
take a look at Figure 17-1 above. You can see a simplified dia- diagram of two
nerves. The region where they meet is called the "synapse." You may not be
familiar with that term, but don't feel intimidated by it. It just means the space
between two nerves. The left-hand nerve is called the "pre- "presynaptic nerve"
and the right-hand nerve is called the "postsynaptic nerve." Again, these terms
do not have any other fancy or special meanings. They merely refer to the nerve
that ends (presynaptic nerve) or begins (postsynaptic nerve) on the left or right
edge of the synapse in the figure. The communication of the electrical signal
across this
FEELING GOOD 435 synapse is important to our understanding of how the
brain works. The synaptic region between the presynaptic nerve on the left and
the postsynaptic nerve on the right is filled with fluid. This discovery was a
major breakthrough in the history of neuroscience. When you think of it, this
discov- discovery is not so surprising since our bodies are made up pri- primarily
of water. However, scientists were puzzled because they knew that the electrical
impulses of nerves were too weak to travel across the synaptic fluid. So how
does the presynaptic nerve on the left in Figure 17-1 send its elec- electrical
signal across the fluid-filled synapse to the postsy- postsynaptic nerve? As an
analogy, imagine that you are hiking and you come to a river. You really need to
get to the other side, but the water is too deep. Furthermore, there's no bridge and
it's too far to jump. How do you get to the other side? You might need a canoe,
or you might have to swim for it. Nerves face a similar problem. Because their
electrical impulses are too weak to jump across synapses, the nerves send little
swimmers across with their messages. These little swimmers are chemicals
called "neurotransmitters." The nerve in Figure 17-1 uses a neurotransmitter
called sero- serotonin. You can see in Figure 17-1 that when the presynaptic
called sero- serotonin. You can see in Figure 17-1 that when the presynaptic
nerve fires, it releases many tiny packets of serotonin into the synapse. Once
released, these chemical messengers migrate or "swim" through a process called
diffusion across the fluid-filled synapse. At the other side of the syn- synapse,
the serotonin molecules become attached to receptors on the surface of the
postsynaptic nerve. This signal tells the postsynaptic nerve to fire, as illustrated
in Figure 17-2 on page 436. Different kinds of nerves use different kinds of
neuro- transmitters. There are a great many of these neurotrans- mitters in the
brain. Chemically, many of them are categorized as "biogenic amines" because
they are man- manufactured from amino acids in the foods we eat. These amine
transmitters are the brain's biochemical messengers.
436 David D. Burns, M.D. We're swimming to the receptors! Serotonin
Receptors MAO Enzyme Nerve Fires Presynaptic Nerve i Postsynaptic Nerve
This is STIMULATING!, Figure 17-2. The serotonin molecules become
attached to the re- receptors on the postsynaptic nerve. This stimulates the nerve
to fire. Three of the amine transmitters in the limbic (emotional) regions of the
brain are called serotonin, norepinephrine, and dopamine. These three
transmitters have been theorized to play a role in many psychiatric disorders and
have been intensively studied by psychiatric researchers. Because these chemical
messengers are called biogenic amines, the theories linking them to depression
or mania are sometimes referred to as the biogenic amine theories. But we are
get- getting ahead of ourselves. How does a chemical messenger cause the
postsynaptic nerve to fire once it becomes attached to the nerve? Let's imagine
for a moment that the chemical transmitter in the presynaptic nerve is serotonin.
(I could have chosen any of them, since they all work in a similar manner.) On
the surface of the postsynaptic nerve there are tiny areas called "serotonin
receptors." You can think of these receptors as locks because they cannot be
opened up without the right key. These receptors are on the membranes that
form the outer surface of nerves. These nerve membranes are some- something
like the skin that covers your body. Now, think of the serotonin as the key to the
lock on the
FEELING GOOD 437 Reuptake Pump We're swimming home now! Our work
is done! MAO Enzyme Serotonin Recepto Presynaptic Nerve Postsynaptic
Nerve Figure 17-3. The serotonin molecules swim back to the presynaptic nerve
where they are pumped back inside. Once inside, MAO de- destroys them.
postsynaptic nerve. Just like a real key, the serotonin works only because it has a
specific shape. There are many other chemicals floating around in the synaptic
region, but they will not open the serotonin lock because they do not have the
right molecular shape. Once the key fits into the lock, the lock opens up. This
right molecular shape. Once the key fits into the lock, the lock opens up. This
triggers additional chemical reac- reactions that cause the postsynaptic nerve to
fire electrically. When the nerve fires, the serotonin (the key) is released from
the receptor (the lock) on the postsynaptic nerve and ends in the synaptic fluid
again. Finally, it "swims" back to the presynaptic nerve (again, through a process
called diffusion), as illustrated in Figure 17-3 above. The serotonin has done its
job, and the presynaptic nerve needs to get rid of it; otherwise it will hang
around in the synapse and it might swim back to the postsynaptic nerve again.
This could create confusion, because the postsynap- postsynaptic nerve may
think there is a new signal and it may get stimulated to fire again. To solve this
problem, the presynaptic nerve has a pump on its surface. Once the serotonin
swims back, it attaches to a receptor (another "lock") on the surface of the prepresynaptic nerve and it is pumped back into the nerve by
438 David D. Burns, M.D. something called the "membrane pump*' or the
"reuptake pump,*' as you can see in Figure 17-3. After the serotonin is pumped
back inside, the presynap- tic nerve can recycle it or it can destroy the excess
serotonin if it already has enough saved up for the next electrical signal. It
destroys the excess serotonin through a process called "metabolism," which
means changing one chemical into another chemical. In this case, the serotonin
is changed into a chemical that can be absorbed into the bloodstream. The
enzyme in the nerve that performs this service is called monoamine oxidase, or
MAO for short. The MAO enzyme transforms the serotonin into a new chemical
called - hydroxyindoleacetic acid," or 5-HIAA. That is another big name, but
you can simply think of 5-HIAA as the waste product of the serotonin. The 5-
HIAA leaves your brain, enters your bloodstream, and is carried to your kidneys.
Your kidneys remove the 5-HIAA from your blood and send it to your bladder.
Finally, you get rid of the 5-HIAA when you urinate. That's the end of the
serotonin cycle. Of course, the pre- synaptic nerve must continually manufacture
a new supply of serotonin to use in nerve-firing so that the total amount of
serotonin does not get depleted. What Goes Wrong in Depression? First of all,
let me reemphasize that scientists do not yet know the cause of depression or any
other psychiatric dis- disorder. There are lots of interesting theories, but none of
them has yet been proven. One day, we may have the an- answer and look back
on the thinking of this era as a quaint historical curiosity. However, science has
to start some- somewhere, and research on the brain is moving forward at an
explosive rate. New and very different theories will un- undoubtedly emerge in
the next decade. The explanations in this section will be very simplified. The
brain is enormously complex and our knowledge about
FEEUNGGOOD 439 how it works is still extremely primitive. There is a vast
amount we do not know about the brain's hardware and software. How does the
firing of a nerve or a series of nerves get translated into a thought or a feeling?
This is one of the deepest mysteries of science, as amazing to me as questions
about the origin of the universe. We won't even attempt to answer those
questions here; for the moment, our goals are much more humble. If you
Understood Figures 17-1 to 17-3, it should be pretty easy for you to understand
current theories about what goes wrong in depression. You have already learned
that nerves in the brain send messages to each other with chemical messengers
called neurotransmitters. You also know that some of the nerves in the limbic
system of the brain use serotonin, norepi- nephrine, and dopamine as their
chemical messengers. Some scientists have hypothesized that depression may reresult from a deficiency of one or more of these biogenic amine transmitter
substances in the brain, while mania (states of extreme euphoria or elation) may
result from an excess of one or more of them. Some researchers believe that
serotonin plays the most important role in depression and mania; others believe
that abnormalities in norepineph- rine or dopamine also play a role. A corollary
of these biogenic amine theories is that an- tidepressant drugs may work by
boosting the levels or ac- activity of serotonin, norepinephrine, or dopamine in
depressed patients. We will talk some more about how these drugs work in a
little while. What would happen if a chemical messenger such as serotonin
became depleted from the presynaptic nerve in Figure 17-1? Then this nerve
could not send its nerve sig- signals properly across the synapses to the
postsynaptic nerve. The wiring in the brain would develop faulty connections,
and the result would be mental and emotional static, much like the music that
comes out of a radio with a loose wire in the tuner. One type of emotional static
(serotonin defi440 David D. Burns, M.D. ciency) would cause depression, and another type of
static (serotonin excess) would cause mania. Recently, these amine theories have
been modified quite a bit. Some scientists no longer believe that a deficiency or
excess of serotonin causes depression or mania. Instead, they postulate that
abnormalities in one or more of the re- receptors on the nerve membranes may
lead to mood abnor- abnormalities. Examine Figure 17-2 again, and imagine that
there is something wrong with the serotonin receptors on the postsynaptic nerve.
For example, there might not be enough of them. What would happen to the
communication between the nerves? Although there might be plenty of seserotonin molecules in the synapse, the postsynaptic nerves might not fire
consistently when the presynaptic nerves fired. And if there were too many
serotonin receptors, this could have the opposite effect of causing overactivity in
serotonin receptors, this could have the opposite effect of causing overactivity in
the serotonin system. To date, at least fifteen different kinds of serotonin rereceptors have been identified throughout the brain and more are being identified
all the time. All these receptors prob- probably have different effects on
hormones, feelings, and be- behavior. Scientists do not have a very clear picture
of what any of these different receptors do, nor do they know if abnormalities in
any of them play a causal role in depres- depression or mania. Research in this
area is evolving at an ex- extremely rapid pace, and we will have better
information about the physiologic and psychological effects of these many
serotonin receptors in the near future. Although our knowledge about the role of
serotonin re- receptors in brain function is still quite limited, there is evievidence that the number of receptors on the postsynaptic nerves may change in
response to antidepressant drug ther- therapy. For example, if you give a drug
that boosts the levels of serotonin in the synapses between the nerves, the
number of serotonin receptors on the postsynaptic nerve membranes will
decrease after a few weeks. This might be a way that the nerves attempt to
compensate for the excess stimula- stimulation—the nerves are trying to turn
down the volume of the
FEELING GOOD 441 signal, so to speak. This kind of reaction is called "downregulation." In contrast, if you deplete the serotonin from the presynaptic nerve
in Figure 17-1, much less serotonin will be released into the synapse. After
several weeks, the postsynaptic nerves may compensate by increasing the
number of serotonin receptors. The nerves are trying to turn up the volume of the
signal. This kind of reaction is called "up-regulation." Again, these are big words
with simple meanings. "Up- regulation" means "more receptors," and "downregulation" means "fewer receptors." We could also say that up-regulation
means turning the system up, and down- regulation means turning the system
down—just like a ra- radio. It is known that antidepressant drugs usually require
sev- several weeks or more to become effective. Researchers have been trying to
figure out why. Some researchers have spec- speculated that down-regulation
may account for the antide- antidepressant effects of these drugs. In other words,
antidepressants may work not because they boost the se- serotonin system, as
originally proposed, but because they turn the serotonin system down after
several weeks. This would imply that decreased serotonin levels might not be the
cause of depression after all. Depression might instead be due to increased
serotonin activity in the brain. Anti- depressant drugs may correct this after
several weeks be- because they turn the serotonin system down. How well
established and proven are these theories? Not at all. As I have suggested, it is
awfully easy to make up a theory, but much harder to prove it. To date, it has not
awfully easy to make up a theory, but much harder to prove it. To date, it has not
been possible to validate or disprove any of these theories in a convincing way.
In addition, there are no clinical or laboratory tests we could give to groups of
patients or to individual patients that will reliably detect any chemical imbalance
that causes depression. The main value of the current theories is to stimulate
research so that our knowledge of brain function will be- become more
sophisticated over time. Eventually, I believe
442 David D. Burns, M.D. we will develop much more refined theories and far
better tools for testing them. Now you may be thinking, "Is that all there is to it?"
Do scientists just sit around and say, "Depression could be due to an excess or a
deficiency of this or that transmitter or receptor in the brain?" On some level,
that really is all there is to it. Part of the problem is that our models of the brain
are still very primitive, and so our theories of de- depression are not yet very
sophisticated either. It may turn out that depression is not due to problems with
any transmitter chemical or receptor. We may one day discover that depression
is actually more of a "software" problem, and not a "hardware" problem. In other
words, if you have a computer, you know that computers crash all the time.
Sometimes this results from a problem with the hardware. For example, your
hard drive may become de- defective. But more often, there's a problem with the
soft- software—a bug that makes the program work poorly in certain situations.
So with regard to brain research on depression, we may be looking for a problem
in the "hardware" (for example, a chemical imbalance we are born with) whereas
the real problem is in the "software" (for example, a neg- negative thinking
pattern based on learning). Both kinds of problems would be "organic," since
brain tissue is in- involved, but the solutions to them would be radically difdifferent. Another major problem facing depression researchers is the chickenversus-the-egg dilemma. Are changes we mea- measure in the brain the cause of
the depression or the result? To illustrate this problem, let's conduct a thought
experi- experiment involving a deer in a forest. The deer is happy and contented.
Imagine that we have a special machine that al- allows us to visualize the
chemical and electrical activity in the deer's brain. We might have, for example,
a futuristic portable brain imaging machine that can work from a dis- distance,
like the laser guns the police use to see how fast you're driving. However, the
deer does not know we are monitoring its brain activity. Suddenly, the deer spots
a pack of hungry wolves approaching. Panic strikes! Our
FEELING GOOD 443 brain imaging machine detects instantaneous massive
changes in the electrical and chemical activity in the deer's brain. Are these
chemical and electrical changes the cause of the fear or the result of the fear?
chemical and electrical changes the cause of the fear or the result of the fear?
Would we say the deer is afraid because it has developed a sudden "chemical imimbalance" in its brain? Similarly, there are all kinds of chemical and electrical
changes in the brains of depressed patients. Our brains change quite dramatically
when we feel happy, angry, or frightened. Which brain changes result from the
strong emotions we feel, and which brain changes are the causes? Separating
cause from effect is one of the thorniest chal- challenges facing depression
researchers. This problem is not impossible to solve, but it is not easy, and those
eager to endorse the current theories about depression do not always
acknowledge it. Clearly, the research necessary to test any of these the- theories
can be daunting. One significant problem is that it is still very difficult to get
accurate information about the chemical and electrical process in the human
brain. We can't just open up the brain of a depressed individual and look inside!
And even if we could, we really wouldn't know where or how to look. But new
tools, such as PET (positron emission tomography) scanning and MRI (mag-
(magnetic resonance imaging), do make such research possible. For the first
time, scientists can begin to "see" the activity of nerves and chemical processes
inside the brains of hu- human beings. This research is still in its infancy, and we
can look forward to a great deal of progress in the next decade. How Do
Antidepressant Drugs Work? The modern era of research on the chemistry of
depres- depression got a big boost accidentally in the early 1950s when
researchers were testing a new drug for tuberculosis called iproniazid.1 As it
turned out, iproniazid was not an effective treatment for tuberculosis. However,
the investigators no444 David D. Burns, M.D. ticed pronounced mood elevations in a number of
patients who received this drug, and hypothesized that iproniazid might have
antidepressant properties. This led to an explo- explosion of research by drug
companies who wanted to be the first to develop and market antidepressant
drugs. Researchers knew that iproniazid was an inhibitor of the MAO enzyme
discussed previously. The drug was therefore categorized as an MAO inhibitor,
or MAOI for short. Sev- Several new MAOI drugs that were similar in chemical
struc- structure to iproniazid were developed. Two of them, phenylzine (Nardil)
and tranylcypromine (Parnate), are still in use to- today. A third MAOI called
selegiline (trade name Eldepryl) has been approved for the treatment of
Parkinson's disease. This drug is also occasionally used in the treatment of mood
disorders. Other new MAOIs in use abroad may eventually be marketed in the
United States. The MAOIs are no longer prescribed nearly as frequently as they
used to be. This is because they can cause danger- dangerous elevations of blood
pressure if the patient combines them with certain foods such as cheese. The
MAOIs can also cause toxic reactions when combined with certain drugs.
MAOIs can also cause toxic reactions when combined with certain drugs.
Because of these hazards, newer and safer antide- pressants have been
developed. These new drugs work quite differently from the MAOIs.
Nevertheless, the MAOIs can be extremely helpful for some depressed papatients who do not respond to other medications, and they can be used safely if
the patient and doctor follow a number of guidelines that I will spell out in
Chapter 20. The iproniazid discovery helped to usher in a new era of biological
research on depression. Scientists were eager to find out how the MAOIs
worked. It was known that the MAOIs prevented the breakdown of serotonin,
norepineph- rine, and dopamine, the three chemical messengers that are
concentrated in the limbic regions of the brain. Scientists hypothesized that a
deficiency in one or more of these sub- substances might cause depression and
that antidepressant drugs might work by increasing the levels of these subFEELING GOOD 445 stances. This is how the biogenic amine theories actually
originated. Now let's see how much you've learned about how the brain works.
Look at Figures 17-1 to 17-3 again. When the presynaptic nerve fires, serotonin
is released into the synapse. After it attaches to a receptor on the postsynaptic
nerve, it swims back to the presynaptic nerve, where it is pumped back inside
this nerve and destroyed by the MAO enzyme. Now ask yourself this question:
What would hap- happen if we prevented the MAO enzyme from destroying the
serotonin? As you have probably guessed, the serotonin would ac- accumulate in
the presynaptic nerve, because this nerve is always manufacturing new
serotonin. If this nerve could not get rid of its serotonin, the concentration of
serotonin in the nerve would continue to increase. Whenever the pre- presynaptic
nerve fired, it would release much more serotonin than usual into the fluid-filled
synaptic region. The excess serotonin in the synapse would cause a greater-thanexpected stimulation of the postsynaptic nerve. This would be the chemical
equivalent of turning up the volume on the radio. These effects of the MAOI
antidepressants are illus- illustrated in Figure 17-4 on page 446. Could this be
the reason the MAOI drugs cause a mood elevation? This is possible, and
scientists have hypothesized that this is exactly how these MAOI drugs work.
Research studies have confirmed that when these MAOI drugs are given to
humans or animals, brain levels of serotonin, nor- epinephrine, and dopamine do
increase. However, it is not known for certain if the antidepressant effects result
from an increase in one of these biogenic amines, or from some other effect of
these drugs on the brain. Can you think of another theory about why or how
these MAOI drugs might work? Does the increase in mood have to result from
the extra stimulation of the postsynaptic nerve, or could there be another
possible explanation? Think about what you read about down-regulation in the
possible explanation? Think about what you read about down-regulation in the
446 David D. Burns, M.D. We fee! safe! MAO cant get us now! wow! iff really
getting crowded In here! MAO Is blocked Serotonin Receptors Nerve Fires
Nerve Fires Postsynaptic Nerve Presynaptic Nerve {11 Figure 17-4. MAOIs
block the MAO enzyme inside the presynaptic nerve, so serotonin levels
increase. The excess serotonin is re- released into the synaptic region whenever
the nerve fires. This pro- provides a stronger stimulation of the postsynaptic
nerve. previous section and see if you can come up with an answer before you
read any further. You probably recall that the effects on the postsynaptic nerves
after several weeks can be the opposite of the effects on these nerves when you
first take a drug. All the extra serotonin in the synapse may cause a downregulation of the postsynaptic serotonin receptors after several weeks, and this
down-regulation may correspond to the antide- pressant effects. (Remember that
although some scientists think depression results from a serotonin deficiency,
others believe depression results from increased brain serotonin activity.) If you
thought of this, it shows you are really learning your neurochemistry. You get an
A-plus on this pop quiz! If you said that the antidepressant effects of the MAOI
drug could result from effects on some other system in the brain, you also get an
A-plus. These theories about how the antidepressant drugs relieve depression are
not proven facts. The effects of the MAOIs on the brain are vastly more complex
than the simple model depicted in Figure 17-4. The effects of any antidepressant
are probably not
FEELING GOOD 447 limited to one specific region or one specific type of
nerve in the brain. Remember that each nerve in the brain con- connects with
many thousands of other nerves, and all of them in turn connect with thousands
of others. When you take an antidepressant, there are massive changes in
numerous chemical and electrical systems throughout your brain. Any of these
changes could be responsible for the improvement in your mood. Trying to
figure out exactly how these drugs work is still a little like looking for a needle
in a haystack. But the important thing for the moment is that these drugs do seem
to help sonfie depressed patients, regardless of how or why they work. As I have
mentioned, many new and different kinds of antidepressant drugs have been
developed and marketed since the 1950s. Unlike the MAOIs, the newer
antidepres- sants do not cause a buildup of transmitters like serotonin in the
presynaptic nerve depicted in Figure 17-4. Instead, they mimic the effects of the
brain's natural transmitter sub- substances by attaching to receptors on the
surfaces of the pre- presynaptic or postsynaptic nerves. To understand how these
newer antidepressants can do this, remember our analogy of the lock and the
newer antidepressants can do this, remember our analogy of the lock and the
key. A natural transmitter substance is like a key, and the receptor on the surface
of the nerve is like a lock. The key is able to unlock the lock only because it has
a certain shape. But if you were a magician, like the famous Harry Houdini, you
could easily pick the lock and open it without the key. An antidepressant
medication is like a counterfeit key that a drug company has manufactured.
Because the chem- chemists know the three-dimensional shape of a natural
trans- transmitter like serotonin, norepinephrine, or dopamine, they can create
new drugs that have a very similar shape. These drugs will fit into the receptors
on the surfaces of nerves and mimic the effects of the natural transmitters. The
brain does not know that an antidepressant is in the lock—the brain has been
tricked into thinking that the natural trans- transmitter chemical is attached to the
receptor on the surface of the nerve.
448 David D. Burns, M.D. In theory, the artificial key (the antidepressant) can
do one of two things when it becomes attached to the receptor. It can either open
the lock, or it can jam the lock without actually opening it. Drugs that open the
locks are called "agonists." Agonists are simply drugs that mimic the ef- effects
of the natural transmitters. Drugs that jam up these locks are called
"antagonists." Antagonists block the ef- effects of the natural transmitters and
prevent them from be- being effective. We can imagine several different ways
that antidepres- antidepressant drugs could influence the receptors on the
presynaptic and postsynaptic nerves. For the purpose of this discussion, imagine
that the transmitter used by the presynaptic nerve is serotonin, but the same
considerations apply to any trans- transmitter. What would happen if we blocked
the receptors on the reuptake pump? The presynaptic nerve could no longer
pump the serotonin from the synapse back inside. Each time the nerve fired,
more and more serotonin would be released into the synaptic region. As a result,
the synapse would get flooded with serotonin. This is precisely how most of the
currently prescribed antidepressants work. As you can see in Figure 17-5 on
page 449, they block the receptors for the reuptake pumps on presynaptic nerves,
and so the transmitters build up in the synaptic region. The end result of this
process is similar to the effects of giving the MAOI drugs discussed above. In
both instances, the levels of serotonin build up in the synaptic region. When the
presynaptic nerve fires, more serotonin than normal will "swim" to the
postsynaptic nerve and stimulate it to fire. Once again, we have "turned up" the
serotonin system, so to speak. Is this good? Is this why these antidepressant
drugs can improve our moods? That's the current theory, but no one really knows
the answers to this question yet. Different antidepressants block different amine
pumps and some of them have more specific effects than others. The older
"tricyclic" antidepressants, such as amitriptyline (Elavil) or imipramine
"tricyclic" antidepressants, such as amitriptyline (Elavil) or imipramine
(Tofranil) and others, block the
FEEUNG GOOD 449 Reuptake pump is blocked Nerve Fires I can't get back
Inside! Serotonin Receptors Nerve Fires Presynaptic Nerve QS Postsynaptic
Nerve Figure 17-5. Most antidepressants block the reuptake pumps, so serotonin
remains in the synapse after the nerve fires. Because se- serotonin builds up in
the synaptic region, the stimulation of the post- postsynaptic nerve is stronger.
reuptake pumps for serotonin and norepinephrine. (Tri- cyclic means "three
wheels," like a tricycle, because the chemical structure of these drugs resembles
three linked rings.) Therefore, these transmitters build up in the brain if you take
one of these drugs. Some tncyclic antidepressants have relatively stronger effects
on the serotonin pump, and some of them have relatively stronger effects on the
nor- norepinephrine pump. Drugs with stronger effects on the se- serotonin
pump are called "serotonergic" and drugs with relatively stronger effects on the
norepinephrine pump are called "noradrenergic." What do you think we would
call a drug with a strong effect on the dopamine pump? If you guessed
"dopaminergic," you would be correct! Some of the newer antidepressants, such
as fluoxetine (Prozac), differ from the older tricyclic compounds in that they
have highly selective and specific effects on the se- serotonin pump. If we want
to use one of our new words, we can say that Prozac is highly "serotonergic"
because levels of serotonin will build up in the brain when you take it. However,
because Prozac blocks only the serotonin pump, the levels of other transmitters,
such as norepinephrine and
450 David D. Burns, M.D. dopamine, will not build up. Prozac is classified as a
selec- selective serotonin reuptake inhibitor (SSRI for short) because of its
selective and specific effects on the serotonin pump. Again, SSRI is an
intimidating name with a humble mean- meaning. SSRI means, "this drug blocks
only, the serotonin pump and it doesn't block any other pumps." Five SSRls are
currently prescribed in the United States and I will dis- discuss them in detail in
Chapter 20. Some new antidepressants are not so selective—they block more
than one type of reuptake pump. For example, venlafaxine (Effexor) blocks the
serotonin and norepineph- rine pumps, so it has been called a dual reuptake
inhibitor. The drug company that manufactures venlafaxine promotes the idea
that this drug may be more effective because the levels of two transmitters
(serotonin and norepinephrine) increase, rather than just one. Actually, this is not
such a novel feature. As you just learned, most of the older (and much cheaper)
antidepressants do exactly the same thing. In addition, there is no evidence that
venlafaxine works any better or any faster than the older drugs. However, venla-
venlafaxine works any better or any faster than the older drugs. However, venlavenlafaxine has fewer side effects than some of the older tricyclic
antidepressants. This might justify the increased cost of venlafaxine in some
instances. So far you have learned about the MAOIs and the pump inhibitors,
such as the tricyclics and the SSRls. Are there any other ways that antidepressant
drugs might work? If you were a chemist working for a drug company and you
wanted to create a completely novel antidepressant, what kinds of effects would
your new drug have? One possibility would be to create a drug that directly
stimulated the se- serotonin receptors on the postsynaptic nerves. A drug like
this would mimic the effect of the natural serotonin. It would be a kind of
counterfeit serotonin. Buspirone (BuSpar) works like this. This drug directly
stimulates se- serotonin receptors on postsynaptic nerves. Buspirone was
marketed a number of years ago as the first nonaddictive drug for anxiety, but it
also has some mild antidepressant effects. However, its antidepressant and
antianxiety propFEELING GOOD 451 Nerve fires ► Presynaptic Nerve Heyf someone is
blocking my receptor. This is unfair! Serotonin receptors are blocked Nerve does
not fire Postsynaptic Nerve Figure 17-6. Serotonin antagonists block the
serotonin receptors on the postsynaptic nerve, so the serotonin cannot stimulate
the postsynaptic nerve after the presynaptic nerve fires. erties are not especially
strong. As a result, buspirone has not emerged as a particularly popular drug for
anxiety or depression. Why is it that buspirone is not more effective for dedepression? Scientists don't actually know the answer. Re- Remember, though,
that there are at least fifteen different kinds of serotonin receptors throughout the
brain. All of these receptors have different functions that are not yet fully
understood. Perhaps drugs that stimulated different kinds of serotonin receptors
would have stronger antide- pressant effects. As you might have gathered, things
get complicated fairly quickly as we learn more and more about how the brain
works. If you were a drug company chemist, you could also create drugs that
blocked the serotonin receptors on the postsynaptic nerves, as illustrated in
Figure 17-6 above. Because such drugs would prevent the natural serotonin from
having its effects, they would theoretically make de- depression worse. In fact,
drugs that block serotonin receptors have been created. Two of them are called
nefazodone (Ser- zone) and trazodone (Desyrel). Although they are catego452 David D. Burns, M.D. rized as "serotonin antagonists," these drugs are also
used as antidepressants. Some drugs have complex effects on several kinds of
pre- and postsynaptic nerve receptors. Mirtazapine (Reme- ron) is another new
antidepressant that has been available in the United States since 1996.
antidepressant that has been available in the United States since 1996.
Mirtazapine appears to block serotonin receptors on the postsynaptic nerves, but
it also stimulates receptors on presynaptic nerves that use nor- epinephrine as a
transmitter. This causes an increase in the release of norepinephrine by these
nerves. So when you take mirtazapine, the serotonin system gets turned down
and the norepinephrine system gets turned up. The antidepressant effects of
nefazodone, trazodone, and mirtazapine are exactly the opposite of what you
might pre- predict from the serotonin theory. Although they turn the seserotonin system off, they are antidepressants. How can this be possible? If you
are starting to get confused, join the club! Remember that there are many types
of serotonin re- receptors in the brain and they all have different kinds of effects.
Remember, too, that there are many high-speed and complex interactions among
the different circuits in the brain. When we perturb one system of nerves in one
region of the brain, we almost instantly create changes in thousands or millions
of other nerves in other regions of the brain. In the final analysis, even the
world's top neu- roscientists do not have a very clear understanding of why or
how these drugs relieve depression. In summary, most of the currently
prescribed antidepres- antidepressants have effects on the serotonin,
norepinephrine, or do- pamine systems. Some of them are highly selective for
one transmitter system, and others have effects on many trans- transmitter
systems. However, the effects of the currently pre- prescribed antidepressants on
these three systems do not really account for their beneficial effects in a very
consistent or convincing way. For example, you have learned that some
antidepressants stimulate serotonin levels, some of them block serotonin
receptors, and some of them seem to have no effects at all on serotonin. And yet
they all work about
FEELING GOOD 453 equally well. Clearly, the models I have drawn in Figures
17-4 to 17-6 are overly simplified, and current theories about how antidepressant
medications work appear to be incomplete at best. I do not mean to sound overly
negative. Keep in mind that I am not challenging the effectiveness of the
currently prescribed antidepressant drugs; I am simply saying that our theories
about how these drugs work do not account for all the facts. Fortunately, most
neuroscience researchers now ac- acknowledge this. The focus of research has
expanded greatly. Instead of focusing narrowly on levels of one or another
biogenic amine, researchers are pursuing a wide variety of strategies which focus
on regulatory mechanisms throughout the brain, and new theories have been
proposed. These theories deal with other transmitters in the brain, or with a
variety of pre- or postsynaptic receptors, or with "second messenger" systems
within the nerves, or with ion flux across nerve membranes, as well as with
neuroendo- crine systems, immune systems, and biological rhythm ab-
neuroendo- crine systems, immune systems, and biological rhythm ababnormalities. I believe the wider net that has now been cast will eventually lead
to much better understanding of how the brain regulates moods. Sophistication
in brain research has accelerated tremen- tremendously and will accelerate even
more rapidly in the next decade. This research will hopefully lead to
improvements such as these: • clinical tests for the chemical imbalance that
causes depression (if, indeed, such an imbalance actually ex- exists); • tests to
detect the genetic abnormalities that make cer- certain individuals more
vulnerable to depression as well as manic-depressive illness; • safer medications
with fewer side effects—as you will learn in Chapter 20, significant advances
have already been made in this area;
454 David D. Burns, M.D. • drugs and psychotherapeutic treatments that are
more effective and faster-acting; • drugs and psychotherapeutic treatments that
minimize or entirely prevent relapses of depression following re- recovery.
Although our current level of understanding is still prim- primitive, an important
scientific effort has been launched. One day this effort may even lead us to the
identification of the mysterious "black bile."
Chapter 18 The Mind-Body Problem (Notes and References appear on pages
682-687,) Ever since the time of the French philosopher, Rene Des- Descartes,
scholars have been puzzled by the "mind-body problem." This is the idea that as
human beings we have at least two separate levels of existence—our minds and
our bodies. Our minds consist of our thoughts and our feel- feelings, which are
invisible or ethereal. We know they are there because we can experience them,
but we do not know why or how they exist. In contrast, our bodies consist of
tissue—blood, bones, muscle, fat, and so forth. The tissue ultimately consists of
molecules, and the molecules are ultimately made up of atoms. These building
blocks are inert—presumably, atoms have no consciousness. So how can the
inert tissue in our brains give rise to our conscious minds, which can see, feel,
hear, love, and hate? According to Descartes, our minds and bodies must be
connected in some manner. Descartes called the portion of the brain that links
these two separate entities the "seat of the soul." For centuries, philosophers
have tried to locate the "seat of the soul." In the modern era, neuroscientists
continue this search as they attempt to figure out how our brains create emotions
and conscious thoughts. The belief that our minds and bodies are separate is re455
456 David D. Burns, M.D. fleeted in our treatments for problems such as
depression. We have biological treatments, which work on the "body," and
depression. We have biological treatments, which work on the "body," and
psychological treatments, which work on the "mind." Biological treatments
usually involve medications, and psy- psychological treatments usually involve
some type of talking therapy. There is often intense competition between the
"drug therapy" camp and the "talking therapy" camp. On the average,
psychiatrists are more likely to be in the drug ther- therapy camp. This is
because psychiatrists are first trained as physicians (M.D.s). They can prescribe
medications, and they are more likely to be influenced by the medical model of
diagnosis and treatment. If you are depressed and you go to a psychiatrist, there's
a good chance that she or he will tell you that your depression is caused by a
chemical imbalance in your brain, and will recommend treatment with an
antidepressant medication. If your family physician treats your depression, drug
treatment is also very likely. This is because many family physicians have little
training in psychotherapy and very little time to talk to patients about the
problems in their lives. In contrast, psychologists, clinical social workers, and
other types of counselors are more likely to be in the talking therapy camp. They
do not have medical training and can- cannot prescribe medications.2 Their
education usually focuses more on the psychological and social factors that may
cause depression. If you are depressed and you go to a therapist in the talking
therapy camp, she or he is more likely to focus on your upbringing, your
attitudes, or stressful events such as the loss of love or the loss of your job. Your
ther- therapist will probably also recommend psychotherapeutic treatment, such
as cognitive behavioral therapy. However, there are many exceptions to this
generalization. Many non- medical therapists believe that biological factors do
play a role in depression, and many psychiatrists are gifted psypsychotherapists. Psychiatrists and nonmedical therapists sometimes work
together in teams so that their patients can benefit from both types of treatment.
FEELING GOOD 457 Nevertheless, the split between the mind (psychological)
and body (biological) schools is sharp, and the dialogue between them is often
intense, combative, and bitter. Po- Political and financial considerations
sometimes seem to in- influence the tone of these discussions more than
scientific findings. Some recent studies suggest that these arguments may
amount to much ado about nothing and that the di- dichotomy between the mind
and the brain may be illusory. These studies indicate that antidepressant drugs
and psy- psychotherapy may have similar effects on our minds and on our brains
—in other words, they might work in the same way. For example, in a classic
study published in the Archives of General Psychiatry in 1992, Drs. Lewis R.
Baxter, Jr., Jeffrey M. Schwartz, Kenneth S. Bergman, and their col- colleagues
at UCLA School of Medicine studied changes in the brain chemistry of eighteen
at UCLA School of Medicine studied changes in the brain chemistry of eighteen
patients with obsessive- compulsive disorder (OCD). Half of these patients were
treated with cognitive behavioral therapy (and no drugs) and half were treated
with antidepressant drugs (and no psychotherapy).3 The patients in the no-drug
group received individual and group psychotherapy that had two main
components. The first component was exposure and re- response prevention.
This is a behavior therapy technique which involves encouraging patients not to
give in to their compulsive urges to check locks, to wash their hands rerepeatedly, and so forth. The second component was cogni- cognitive therapy
along the lines described in this book. Remember that patients in this group did
not receive any medications at all. These investigators used positron emission
tomography (PET scanning) to study the metabolic rate for sugar (glu- (glucose)
in various brain regions before and after ten weeks of treatment with either drugs
or psychotherapy. This method of brain scanning assesses the activity of the
nerves in different areas of the brain. One brain region they were particularly
interested in was the caudate nucleus on the right half of the brain.
458 David D. Burns, M.D. Both treatments were effective: the majority of
patients in both groups improved, and there were no significant dif- differences
in the two treatments. This was not surprising; previous researchers have also
reported that drugs and cog- cognitive behavioral psychotherapy have similar
effects in the treatment of OCD. However, the results of the PET study were
quite surprising. The investigators reported compara- comparable reductions in
the activity in the right caudate nucleus in the successfully treated patients
regardless of whether they were treated with drugs and no psychotherapy, or
psy- psychotherapy and no drugs. In addition, the symptoms and thinking
patterns of the two groups improved to a similar degree—neither treatment was
superior. Finally, the amount of improvement in symptoms was significantly
cor- correlated with the degree of change in the right caudate nu- nucleus. In
other words, patients who improved the most had, on average, the greatest
reductions in brain activity in the right caudate nucleus. The reduced activity
meant that the nerves in this region of the brain had calmed down, re- regardless
of whether they were treated with drugs or psy- psychotherapy. One implication
of this study is that excessive activity in the right caudate nucleus might play a
role in the devel- development or maintenance of the symptoms of obsessivecompulsive disorder. A second important implication is that antidepressant
medications and cognitive behavioral ther- therapy might be equally effective in
restoring the structure and function of the brain back to normal. Like most
published studies, this one had some fairly significant flaws. One problem is that
any brain changes you observe in a particular psychiatric disorder might simsimply represent "downstream" effects rather than true causal effects. In other
simply represent "downstream" effects rather than true causal effects. In other
words, the increased neural activity in the right caudate nuclei of patients with
obsessive-compulsive disorder might simply reflect a more general pattern of
dis- distress throughout the brain and may not be the cause of the symptoms, as
we have discussed above. Another problem was that the number of patients
studied
FEELING GOOD 459 was extremely small, and the number of brain regions the
investigators studied was fairly large, so it is possible— even likely—that these
findings were the result of chance. This possibility is consistent with the fact that
other inves- investigators have reported different patterns of brain activity in
patients treated with antidepressant medications. This is why replications with
more patients conducted by indepen- independent investigators are needed
before the results of any study c^n be accepted. In spite of these limitations, the
report by Dr. Baxter and his colleagues was the first of its kind and may open the
door to an important new type of integrated research on the ways that drugs and
psychotherapy can in- influence brain function and emotions. Other studies have
shown that antidepressants may ac- actually work by helping depressed patients
change their neg- negative thinking patterns. Indeed, in an investigation
conducted at Washington University School of Medicine in St. Louis, Drs. Anne
D. Simons, Sol L. Garfield, and George E. Murphy randomly assigned depressed
patients to treatment with either antidepressants alone or cognitive therapy alone.
They studied changes in the negative think- thinking patterns of both groups of
patients. They discovered that the negative thinking of patients who responded to
the antidepressants improved as much as the negative thinking of depressed
patients who responded to the cognitive ther- therapy.4 Remember that the drug
patients received no psycho- psychotherapy and the cognitive therapy patients
received no medications. Thus this study indicated that antidepressant drugs
change negative thinking patterns in much the same way that cognitive therapy
does. The effect of antidepres- antidepressant drugs on attitudes and thoughts
may explain their an- antidepressant effects just as well or even better than more
biological explanations of their effects on different trans- transmitter systems in
the brain. These remarkable studies suggest that we might do better to let go of
this ' 'mind-body'' split and begin to think about how these different treatments
may be working in tandem on the mind and on the brain. This combined
approach
460 David D. Burns, M.D. could foster a greater sense of teamwork among
therapists and researchers approaching the problem from different an- angles and
may lead to more rapid advances in our under- understanding of emotional
may lead to more rapid advances in our under- understanding of emotional
disorders. Even if there is some type of genetic or biological disorder in at least
some depres- depressions, psychotherapy can often help to correct these probproblems, even without medications. Many research studies, as well as my own
clinical experience, have confirmed that severely depressed patients who appear
very "biologi- "biologically" depressed with lots of physical symptoms often rerespond rapidly to cognitive therapy alone without any drugs.5 It can work the
other way as well. I have worked with many depressed patients who were still
stuck after I had tried numerous psychotherapeutic interventions. When I
prescribed an antidepressant medication, many of these pa- patients started to
turn the corner, and the psychotherapy be- began to work better. It seemed as if
the medication really did help them change their negative thinking patterns as
they recovered from the depression. If Depression Is Inherited, Doesn't It Mean
We Should Treat It with Drugs? In Chapter 17 we talked about the fact that we
don't yet know how strong the genetic influences are in the more common forms
of depression that do not involve mania. But suppose scientists eventually
discover that nearly all forms of depression are inherited, at least in part. Would
it mean we should treat depression with drugs? The answer is: not necessarily.
For example, a blood phobia is thought to be at least partially genetic, but it can
nearly always be treated quickly and easily with behavior therapy. The treatment
of choice for most phobias is to expose the person to the frightening situation
and to urge them to face it and endure the anxiety until the fear dimindiminishes and disappears. Most patients are so frightened that
FEELING GOOD 461 they resist the treatment at first, but if they can be
persuaded to hang in there, the success rate is extraordinarily high* I can attest
to this personally. While growing up, I was terrified of blood. When, in medical
school, it was time to draw blood from each other's arms, I felt so unenthusiastic
that I dropped out of medical school. For the next year, I decided to work in the
clinical laboratory of the Stanford University Hospital so I could try to get over
my fear. They gave me a job doing nothing but drawing blood out of people's
arms and I had to do this all day long. The first few times I had to draw blood, it
made me very anxious, but after those initial anxious moments, I got used to it.
Pretty soon, I loved my new job. This shows that at least some genetic
tendencies can respond to a behavioral treat- treatment without drugs. To state
an even more commonplace example, we all inherit a tendency to have a
particular type of body. Some of us are genetically taller or shorter than .others.
Some of us have larger frames, others have smaller frames. But our diets and
habits hugely influence the types of bodies we have as adults. Many professional
bodybuilders were skinny and embarrassed about their looks when growing up.
bodybuilders were skinny and embarrassed about their looks when growing up.
TTiis motivated them to go to the gym and work out. TTiis intense effort
transformed many of them into cham- champions. Their genes may have greatly
influenced what they were born with, but their behaviors and determination
dom- dominated where they ended up. The opposite is also true. If it turned out
that depression was entirely caused by the environment and that there were no
genetic influences, this would not minimize the potential value of antidepressant
drugs. For example, if you are ex- exposed to someone with a strep throat, you
may get a strep throat because streptococcal bacteria are so infectious. We can
say that the causes of your strep throat are almost en- entirely environmental and
not genetic. Nevertheless, we would still treat your strep throat with an
antibiotic, and not with behavior therapy! With regard to bipolar manicdepressive illness, the an462 David D. Burns, M.D. swer is clear. This disorder appears to have an
extremely strong biological cause, and although we don't yet know exactly what
this cause may be, treatment with a mood stabilizer such as lithium or valproic
acid (Depakene) is usually a must. Other medications will also be used during
episodes of depression or severe mania. However, good psychotherapy can also
make a big contribution in the treat- treatment of bipolar illness. In my
experience, the combination of a drug like lithium or valproic acid along with
cognitive therapy has been far more effective than treatment with medications
alone. From a practical point of view, the question I face as a clinician is this:
How can I best treat each particular patient who is suffering from depression,
regardless of the cause? Whether or not genes play a role, drugs can sometimes
help and psychotherapy can sometimes help. Sometimes, a com- combination of
psychotherapy and antidepressant medications seems to be the best approach. Is
It Better to Be Treated with Drugs or Psychotherapy?' A number of studies have
compared the effectiveness of antidepressant drug treatment with cognitive
therapy.5""8 On the whole, these studies have indicated that during the acute
phase of treatment, when patients first seek treatment for their depressions, both
treatments seem to work reasonably well. Following recovery, the picture is a
little different. Several long-term studies indicate that patients who receive
cognitive therapy, alone or in combination with antidepres- antidepressant
medications, appear to stay undepressed longer than patients who receive only
antidepressant medication ther- therapy and no psychotherapy.5 This is probably
because cog- nitively treated patients have learned many coping tools to help
them to deal with any mood problems they might ex- experience in the future. If
you would like to learn more about recent research on
FEELING GOOD 463 the effectiveness of drugs versus psychotherapy, you can
FEELING GOOD 463 the effectiveness of drugs versus psychotherapy, you can
read an excellent article on this topic by Drs. David O. Antonuccio and William
G. Danton from the University of Nevada and Dr. Gurland Y. DeNelsky from
the Cleveland Clinic.5 These authors reviewed the world research literaliterature on the effectiveness of psychotherapy versus medica- medications for
depression and came up with some rather startling conclusions that are quite
different from the popular per- perceptions about these treatments. They argue
that cognitive therapy appears to be at least as effective, if not more ef- effective,
than medications in the treatment of depression. They conclude that this is even
true for severe depressions that appear to be "biological" because they have
many physical side effects such as fatigue or a loss of interest in sex. The authors
also question the methods used by drug companies to test new antidepressants.
This scholarly and provocative article is clearly written, so look it up if you are
curious. My own clinical experience has convinced me that pure "test-tube
treatment" with drugs alone is not the answer for most patients. There appears to
be a definite role for effective psychological interventions, even if you have had
the good fortune to respond to an antidepressant medica- medication. If you
learn cognitive therapy self-help techniques like those described in this book, I
believe you will be better prepared to cope with any mood problems that develop
again in the future. My clinical practice has always been predicated on an
integrated approach. At my clinic in Philadelphia, approx- approximately 60
percent of our patients received cognitive ther- therapy with no drugs, and
approximately 40 percent of our patients received a combination of cognitive
therapy along with antidepressants. Patients in both groups did well, and we
found both types of treatment tools to be valuable. We did not treat patients with
drugs alone and no psychother- psychotherapy because in my experience this
approach has not been satisfactory. It may be that for certain types of depression,
the addi464 David D. Burns, M.D. tion of the proper antidepressant to help your
treatment pro- program might make you more amenable to a rational self-help
program and greatly speed up the therapy. As I have men- mentioned earlier
above, I can think of many depressed indi- individuals who seemed to "see the
light" with regard to their illogical, twisted, negative thoughts more rapidly once
they began taking an antidepressant. My own philosophy is this: I'm in favor of
any reasonably safe tool that will help you! I believe that your feelings about the
type of treatment that you receive may be important to the outcome. If you are
more biologically oriented, you may do better with drug treatment. In contrast, if
you are more psychologically ori- oriented, you may do better with
psychotherapy. If you and your therapist do not see eye to eye, you may lose
psychotherapy. If you and your therapist do not see eye to eye, you may lose
confi- confidence and resist the treatment, and this can reduce the chances for a
successful result. In contrast, if the treatment makes sense to you, you will feel
more hope, trust and confidence in your doctor. Consequently your chances for a
positive outcome will be increased. I have also seen that certain negative
attitudes and irra- irrational thoughts can interfere with proper drug treatment or
with psychotherapeutic treatment. I would like to expose twelve hurtful myths at
this time. The first eight myths con- concern medication treatment and the last
four myths concern psychotherapy. With regard to medications, I believe that
enlightened caution in taking any drug is well advised, but an excessively
conservative attitude based on half-truths can be equally destructive. I also
believe that one should be appropriately skeptical and cautious about
psychother- psychotherapy, but that too much pessimism can also interfere with
effective treatment. Myth Number 7. "If I take this drug, I won't be my true self.
I'll act strange and feel unusual." Nothing could be further from the truth.
Although these drugs can some- sometimes eliminate depression, they do not
usually create ab- abnormal mood elevations and, except in rare cases, they will
not make you feel abnormal, strange, or' 'high.'' In fact, many
FEELING GOOD 465 patients report that they feel much more like themselves
after they take an antidepressant medication. Myth Number 2. * 'These drugs are
extremely danger- dangerous." Wrong. If you are receiving medical supervision
and cooperate with your doctor, you will have no reason to fear most
antidepressant drugs. Adverse reactions are rare and can usually be safely and
effectively managed when you and your doctor work together as a team. The
antidepres- sants are far safer than the depression itself. After all, de- depression,
if left untreated, can kill—through suicide! This does not mean you should be
complacent about an- antidepressant drugs—or any drug you take, for that
matter, including aspirin. In the following chapters, you will learn about the side
effects and toxic effects of all the different antidepressants and mood-stabilizing
agents. If you are tak- taking one or more of these drugs, educate yourself and
read about them in Chapter 20. This should not be difficult, and the information
will enhance your chances of having a safe and effective experience with the
antidepressant your doc- doctor has prescribed. Myth Number 3. "But the side
effects will be intoler- intolerable." No, the side effects are mild and can usually
be made barely noticeable by adjusting the dose properly. If in spite of this you
find the medication uncomfortable, you can usually switch to another medication
that will be equally effective with fewer side effects. Remember, too, that
untreated depression also has many "side effects." These include feelings of
tiredness, in- increases or decreases in appetite, difficulties sleeping, a loss of
tiredness, in- increases or decreases in appetite, difficulties sleeping, a loss of
motivation and energy, a loss of interest in sex, and so forth. And if you respond
favorably to an antidepressant, these "side effects" will usually disappear. Myth
Number 4. "But I'm bound to get out of control and use these drugs to commit
suicide." Some of the an- antidepressant drugs do have a lethal potential if you
take
466 David D. Burns, M.D. them in overdose or combine them with certain other
drugs, but this need not be a problem if you discuss your concerns with your
physician. If you feel actively suicidal, it might be helpful to obtain only a few
days' or one week's supply at a time. Then you will not be likely to have a lethal
supply on hand. Your doctor may also decide to treat you with one of the newer
antidepressant drugs that are much safer than the older antidepressants if taken in
accidental or in- intentional overdose. Remember that as the drug begins to
work, you will feel less suicidal. You should also see your therapist frequently
and receive intensive therapy, either as an outpatient or as an inpatient, until any
suicidal urges have passed. Myth Number 5. "I'll become hooked and addicted,
like the junkies on the street. If I ever try to go off the drug, I'll fall apart again.
I'll be stuck with this crutch for- forever." Wrong again. Unlike sleeping pills,
opiates, barbi- barbiturates, and minor tranquilizers (benzodiazepines), the
addictive potential of antidepressants is extremely low. Once the drug is
working, you will not need to take larger doses to maintain the antidepressant
effect. As noted above, if you are learning cognitive therapy techniques and
focus- focusing on relapse prevention, in most instances your depres- depression
will not return when you discontinue the drug. When it is time to go off the
medicine, it would be ad- advisable to do this gradually, tapering off over a week
or two. This will minimize any discomfort that might occur from abruptly
stopping the medicine, and will help you nip any relapse in the bud before it
becomes full blown. Many doctors now advocate long-term maintenance thertherapy for patients with severe depressions that return on many occasions. A
prophylactic effect can sometimes be achieved if you take the antidepressant
over a period of a year or two after you have recovered. That can minimize the
prob- probability of your depression returning. If you have had a sig- significant
problem with recurrences of depression over a period of years, this might be a
wise step for you. But you
FEELING GOOD 467 should be reassured that antidepressant drugs are
definitely not addictive. In my practice through the years, I have had very few
patients who had to remain on antidepressant drugs for more than a year, and
almost no patients who stayed on antidepressants indefinitely. Myth-Number 6.
"I won't take any psychiatric drug because that would mean I was crazy." This is
"I won't take any psychiatric drug because that would mean I was crazy." This is
quite mis- misleading. Antidepressants are given for depression, not for
"craziness." If your doctor recommends an antidepressant, this would indicate he
or she is convinced you have a mood problem. It does not mean that she or he
thinks you are crazy. However, it is crazy to refuse an antidepressant on this
basis because you may bring about greater misery and suffering for yourself.
Paradoxically, you may feel normal more quickly with the help of the medicine.
Myth Number 7. "But other people are bound to look down on me if I take an
antidepressant. They'll think I'm inferior." This fear is unrealistic. Other people
will not know you're taking an antidepressant unless you tell them— there's no
other way they could know. If you do tell some- someone, they're more likely to
feel relieved. If they care about you, they'll probably think more of you because
you're doing something to help eliminate your painful mood dis- disorder. Of
course, it is possible that someone might question you about the advisability of
taking a drug, or even criticize your decision. This will give you the golden
opportunity to learn to cope with disapproval and criticism along the lines
discussed in Chapter 6. Sooner or later, you're going to have to decide to believe
in yourself and stop giving in to the disabling terror that someone might or might
not agree with something you do. Myth Number 8. "It is shameful to have to
take a pill. I should be able to eliminate the depression on my own."
468 David D. Burns, M.D. Research on mood disorders conducted throughout
the world has clearly shown that many individuals can recover without pills if
they engage in an active, structured, self- help program of the type outlined in
this book.5' 9~13 However, it is also clear that psychotherapy does not work for
everyone, and that some depressed patients re- recover faster with the help of an
antidepressant. In addition, in many cases an antidepressant can facilitate your
efforts to help yourself, as described above. Does it really make sense to mope
and suffer endlessly, stubbornly insisting you must "do it on your own" without
a medication? Obviously, you must do it yourself—with or without a
pharmacological boost. An antidepressant may give you that little edge you need
to begin to cope in a more productive manner. This can accelerate the natural
healing process. Myth Number 9. "I feel so severely depressed and overwhelmed
that only a drug could help me." Drugs and psychotherapy both have a lot to
offer in the treatment of severe depression. I believe that the passive attitude of
let- letting a drug do it for you is unwise. My own research has indicated that the
willingness to do something to help your- yourself can have powerful
antidepressant effects, whether or not you are also taking a medication. The selfhelp work patients complete between sessions also seems to speed rerecovery.14' l5 So if you combine a medication with a good form of
recovery.14' l5 So if you combine a medication with a good form of
psychotherapy, you will have more weapons in your arsenal. As I have already
stated, many patients I have treated with drugs alone did not recover completely.
When I added the cognitive therapy, many of them improved. I believe that the
combination of drugs and psychotherapy can work better and quicker than drugs
alone and frequently leads to better long-term results. This seems to be true for
mildly depressed patients and for severely depressed patients as well. For
example, we treat many severely depressed in- patients at the Stanford
University Hospital with group cogFEELING GOOD 469 nitive therapy techniques. These techniques are similar to
the ones you have learned about in this book. We have found that the group
format can be especially helpful. I have seen many of these patients improve
significantly dur- during these therapy groups. The improvement often occurs
wkhin the actual therapy group. At the moment the patient sees how to talk back
to his or her negative thoughts in a convincing manner, there is often a strong,
immediate uplift in mood and outlook. Keep in mind that these inpatients also
receive antidepressant drugs that their attending psy- psychiatrists prescribe for
them. So nearly all of them receive a combination of drugs and psychotherapy—
we are not purists devoted only to one approach or the other. I can recall one
woman who was so severely depressed that she would burst into tears almost
every time she tried to speak. If you even looked at her, it seemed it was enough
to trigger an outburst of uncontrollable sobbing. I asked what she was thinking
about when she was sobbing. She said she was thinking about something that her
psychiatrist told her. He said her depression was "biological" and the causes
were genetic. She concluded that if the depression was genetic, it meant she
must have passed it down to her children and her grandchildren. One of her sons
was, in fact, having a hard time. She attributed this to his "de- "depression gene"
and blamed herself for ruining his life. She castigated herself for even having
gotten married and given birth to children in the first place and felt certain they
would all endure horrible suffering forever. As she explained this, she began
sobbing again. Now from your perspective, her self-blame may seem incredibly
unrealistic. Her insistence that all her children and grandchildren would lead
lives of endless and irrevers- irreversible suffering may seem equally unrealistic.
But from her perspective, all her self-criticisms seemed entirely justified and
negative predictions seemed completely valid. Her self- loathing and suffering
were incredibly intense. After she stopped crying, I asked what she would say to
another depressed woman with children. Would she be so
470 David D. Burns, M.D. hard on her? This intervention did not work. She did
470 David D. Burns, M.D. hard on her? This intervention did not work. She did
not even seem to comprehend what I said. Instead of answering my question, she
sobbed so uncontrollably that her entire body shook as the tears streamed down
her cheeks. After a while she stopped crying again. I asked if two other patients
would volunteer to do a role-play to help her out. I call this exercise
"externalization of voices" because you verbalize the negative thoughts in your
mind and learn to talk back to them. I wanted the other patients to illustrate how
she might talk back to her own negative thoughts so that all she would have to
do was watch. I told her to imagine that these other women were very similar to
her. They were depressed and had children and grandchildren. The first
volunteer played the role of the negative part of her mind and said out loud the
sort of things the de- depressed woman had been thinking: "If my depression is
partly genetic, then it means I am to blame for my son's depression." The second
volunteer played the role of the more positive, realistic, self-loving part of her
mind. This volunteer talked back to the negative thought along these lines: "I
certainly wouldn't blame another depressed woman for her son's depression, so it
makes no sense to blame myself, either. If there is a conflict with my son, or if
he is having problems, I can try to be helpful to him. That's what any loving
mother would try to do." Then they continued with this dialogue and modeled
ways she could talk back to her other self-critical thoughts. The two volvolunteers took turns in the roles of the negative thoughts and the positive
thoughts. After the role-play was over, I asked the tearful patient which voice
was winning and which voice was losing. Was it the negative voice or the
positive voice? Which voice was more realistic, more believable? She said that
the neg- negative voice was unrealistic, and that the positive voice was winning.
I pointed out that the volunteers were actually verbalizing her own selfcriticisms. Although her depression did not improve dramatically by the end of
that group, it seemed that the clouds lifted just
FEELING GOOD 471 a little bit. The next time I saw her in a. group, her mood
had brightened up considerably. She was quite personable and could talk without
crying for the first time since ad- admission. She said she wanted to practice the
role-playing in the group so she could learn how to do it. She said she was also
intent on getting a referral to a cognitive therapist near her home after discharge
so she could continue the work that was proving to be so helpful to her. The
method that helped this% patient is also called the 4'double-standard technique."
It is based on the idea that many of us operate on a double standard. We may
judge ourselves in a harsh, critical, demanding way, and yet we judge others in a
more compassionate and reasonable man- manner. The idea is to give up this
double standard and agree to judge all human beings, including ourselves, by
one set of standards that is based on truth and compassion instead of using a
one set of standards that is based on truth and compassion instead of using a
separate standard that is distorted and mean when we judge ourselves. Myth
Number 10. "It is shameful to receive psycho- psychotherapy because it means I
am weak or neurotic. It is more acceptable to be treated with a drug because it
means I have a medical illness, like diabetes." Actually, the sense of shame is
common in depressed patients who are treated with drugs or psychotherapy.
Often, the double-standard technique just described above can be helpful.
Imagine, for example, that you've just discovered that a dear friend of yours
received psychotherapy for depression and found that the treatment was helpful.
Ask yourself what you would say to your friend. Would you say: "Oh, the
psychotherapy just shows what a weak and defective neurotic you are. You
should have taken a drug instead. What you did was shame- shameful." If you
would not say this to a friend, then why give yourself these messages? That's the
essence of the double- standard technique. Myth Number 11.' 'My problems are
real, so psycho- psychotherapy couldn't possibly help me." Actually, cognitive
472 David D. Burns, M.D. therapy seems to work the best with depressed
individuals with real problems in their lives, including catastrophic medical
problems such as terminal cancer or an amputation, bankruptcy, or severe
personal relationship problems. In many cases, I have seen individuals with
problems like this who improved in a handful of cognitive therapy sessions. In
contrast, chronically depressed individuals without any obvious problems that
triggered their depressions are often more difficult to treat. Although the
prognosis is excellent, they may require more intensive and prolonged treatment.
Myth Number 12. "My problems are hopeless, so no psychotherapy or drug
could possibly help me." This is your depression talking, and not reality.
Hopelessness is a common but horrible symptom of depression that is based on
twisted thinking, just as the other symptoms are. One of the distortions is called
"emotional reasoning." The de- depressed individual may reason: I feel hopeless,
therefore I must be hopeless. Another cognitive distortion that leads to feelings
of hopeless is fortune-telling—you are making a negative prediction that you
will never improve, and as- assuming this prediction is really a fact. Other
distortions can lead to feelings of hopelessness as well. These include the
following: • all-or-nothing thinking—you think of yourself as com- completely
happy or completely depressed; shades of gray do not count, so if you are not
completely happy or completely recovered, you assume you are completely
depressed and hopeless; • overgeneralization—you see your current feelings of
depression as a never-ending pattern of defeat and suf- suffering; • mental filter
—you selectively think of all the times you have been depressed, and end up
thinking your whole life will be bad forever;
thinking your whole life will be bad forever;
FEELING GOOD 473 • discounting the positive—you insist that the times you
were not depressed don't count; • "should" statements—you use up all your
energy tell- telling yourself you "shouldn't" be depressed (or you "shouldn't"
have gotten depressed again) instead of systematically working to overcome the
feelings; • labeling—you tell yourself you are hopelessly and ir- irreversibly
defective and conclude that you could never really feel whole, or happy, or
worthwhile. Other cognitive distortions, such as magnification or perpersonalization, can also lead to feelings of hopelessness. Al- Although these
feelings are not realistic, they can act like self-fulfilling prophecies. If you give
up, nothing will change and you will conclude that you really were hopehopeless. Patients who feel hopeless usually cannot see that they are deceiving
themselves. They are nearly always con- convinced these feelings are entirely
valid. If I can persuade them to challenge these hopeless feelings and try to get
better—even though they feel in their hearts that this is impossible—they usually
do begin to improve, slowly at first and then more rapidly, until they feel a
whole lot bet- better. One of the most important tasks of any therapist is to help
depressed patients find the courage and determination to resist and fight these
hopeless feelings. This battle is often fierce and rarely easy, but nearly always
rewarding in the long run.
Chapter 19 What You Need to Know about Commonly Prescribed
Antidepressants (Notes and References appear on pages 682-687.) This chapter
contains practical general information about the use of antidepressants. You will
learn who is the most— and least—likely to benefit from an antidepressant, how
you can tell whether an antidepressant drug is really work- working, how much
mood elevation you can anticipate, how long you should stay on it, and what you
can do if it doesn't work. You will also learn how to monitor and minimize side
effects and prevent potentially dangerous interactions between antidepressants
and other drugs you may take, in- including prescription drugs as well as
nonprescription (over- the-counter) drugs you can obtain at the drug store or
grocery store. In the next chapter, I will provide specific information about each
antidepressant and mood-stabilizing drug currently in use. When you read this
chapter, keep in mind that the use of antidepressants is still a blend of art and
science. Each practitioner has a slightly different philosophy, and your doctor's
approach may differ from mine. I will state my own biases up front. First, I am
quite demanding in terms of what I expect 474
FEELING GOOD 475 from an antidepressant. I believe that any antidepressant
FEELING GOOD 475 from an antidepressant. I believe that any antidepressant
medication should have a pretty profound and dramatic ef- effect in order to
justify its continued use. In addition, I firmly believe that every patient taking
antidepressants should take a mood test like the one in Chapter 2 at least once a
week. Your score on this test (or any other good depression test) is a highly
reliable measure of how well your antidepressant is working. I do not encourage
patients to continue taking drugs that have only modest or questionable
beneficial ef- effects on mood. When the score on the test goes down only a little
bit (for example, a 30 percent or 40 percent im- improvement), I would be
inclined to call this a placebo effect and not a real drug effect. This amount of
improvement could be due to the passage of time, the psychotherapy, or the
belief that the drug will work. If the improvement in mood is minimal, and
assuming the patient has had a suf- sufficient dose of the medication for a
sufficient period of time, I would probably take the patient off the drug and try
an- another medication, a combination of medication and psychopsychotherapy, or psychotherapy alone. Now some readers may think, "but a 40-
percent im- improvement in my mood sounds pretty good. This sounds like real
improvement. I'm almost half better." Certainly, any improvement is desirable,
but research studies indicate that inactive placebos can also have large
antidepressant effects. A 40-percent improvement has been shown to be a typical
placebo response. The only justification for taking any antidepressant drug is
this: Is the drug doing its job? To my way of thinking, the goal of treatment is to
recover from depression. Most patients want complete recovery, not just a slight
or moderate improvement in their mood. If an antidepressant is not
accomplishing this goal after a rea- reasonable trial, then I would recommend
switching to another drug or treatment approach. Second, I never treat patients
with medications alone. If I prescribe an antidepressant for a patient, I always
combine the medication treatment with psychotherapy as well. Al- Although I
tried the medication-only approach with large
476 David D. Burns, M.D. numbers of patients early in my career, I almost
never found this approach to be satisfactory. For example, when I was a
postdoctoral fellow following my residency training at the University of
Pennsylvania, I ran the lithium clinic at the Philadelphia VA Hospital. I treated
many depressed veterans suffering from bipolar manic-depressive illness with a
combination of lithium and other antidepressant drugs. Although the medications
ap- appeared to be helpful, the results were not very encouraging. Most of these
poor veterans were going in and out of the hospital almost constantly, and few
were leading produc- productive, joyous, stable lives. Later in my career, when I
learned cognitive therapy, I treated all my manic-depressive pa- patients with a
combination of medications plus psychother- psychotherapy. The results were
combination of medications plus psychother- psychotherapy. The results were
much better. From that point on, I can recall only one manic-depressive patient I
treated who required hospitalization for an episode of mania. The results with
depressed patients were similar. Early in my career, I treated depressed patients
with the drugs alone or drugs combined with traditional supportive psypsychotherapy. I administered a depression test like the one in Chapter 2 to
every patient every session. I could see very clearly that while some patients
were helped a lot by anti- depressants, many were not. A lot of patients
improved only slightly, and some did not improve at all. Later in my career, I
began to combine antidepressant drugs with the new cognitive therapy
techniques I was learning, and saw much better results. Eventually, I gave up
treating patients with drugs alone. Third, I usually use one medication at a time,
rather than a combination of many different kinds of drugs, although there are
certainly many exceptions to this or any rule. The idea behind polypharmacy is
that if one drug is good, two, three, or more will be even better. Some doctors
also use additional drugs to try to combat the side effects of other drugs the
patient is taking. The potential drawbacks to polyFEELING GOOD 477 pharmacy are many, including more side effects and
more possible adverse drug interactions. I discuss polypharmacy in detail at the
end of Chapter 20 and describe a number of specific situations in which the use
of more than one drug may be justified. Finally, I have usually not kept patients
on antidepressant drugs indefinitely following recovery. Instead, I slowly tataper patients off their antidepressants after they have been feeling really good
for several months. I have found that in most cases, patients who have recovered
can continue to remain undepressed without medications. Keep in mind that all
my patients have received cognitive therapy, whether or not they also received
an antidepressant. The cognitive ther- therapy is probably responsible for the
good long-term results, because patients learn tools they can use for the rest of
their lives whenever they are feeling upset. Many doctors practice very
differently. They tell their patients that they must continue taking their
antidepressants indefinitely to correct a "chemical imbalance in the brain" and to
prevent relapses into depression. While relapse is an important issue, I have
found that training patients to use their cognitive therapy tools whenever they
need them seems to maintain improvement following recovery. In fact, a number
of well-controlled long-term follow-up studies have confirmed that this works
better than drugs to prevent relapses. While this is my philosophy in a nutshell,
remember that there is no single "correct" approach, and your doctor's
philosophy might differ from mine. In addition, there are many exceptions to any
rule, and your own diagnosis or personal history may mandate a different
rule, and your own diagnosis or personal history may mandate a different
approach from the one I have just outlined. If you have questions about your
treatment, discuss your concerns with your physician. In my experience, the
sense of teamwork and mutual respect is still the most important ingredient in
any successful treat- treatment.
478 David D. Burns, M.D. If I Am Depressed, Does It Mean that I Have a
"Chemical Imbalance" in My Brain? There is an almost superstitious belief in
our culture that depression results from a chemical or hormonal imbalance of
some type in the brain. But this is an unproven theory and not a fact. As
discussed in Chapter 17, we still do not know the cause of depression and we do
not know how or why antidepressant drugs work. The theory that depression
results from a chemical imbalance has been around for at least two thousand
years, but there is still no proof of this, so we really do not know for sure.
Furthermore, there is no test or clinical symptom that could demonstrate that a
par- particular patient or group of patients has a * 'chemical imbal- imbalance"
that is causing the depression. If I Am Depressed, Does It Mean that I Should
Take an Antidepressant? Many people also believe that if you are depressed you
should be on an antidepressant. However, I do not insist that every depressed
patient must take an antidepressant. Large numbers of well-controlled studies
published in re- respected scientific journals indicate that the newer forms of
psychotherapy can be just as effective as, and sometimes more effective than,
antidepressants. Certainly many depressed people have been treated sucsuccessfully with antidepressants and swear by them. They are valuable tools
and I am glad to have them available in my treatment arsenal. Sometimes
antidepressants are helpful, but they are rarely total answers, and often they are
not necessary.
FEELING GOOD 479 How Can I Decide Whether or Not to Take an
Antidepressant? I always ask my patients during their initial evaluations whether
or not they would prefer to take an antidepressant. If a patient strongly feels that
she or he would prefer to be treated without an antidepressant, I treat with
cognitive therapy alone, and this is usually successful. However, if the patient
has been working hard in therapy for six to ten weeks without any improvement,
I sometimes suggest we try to add an antidepressant to put some ' 'high octane''
in the tank, so to speak. In some cases, this makes the psy- psychotherapy more
effective. If a patient feels strongly that she or he would like to receive an
antidepressant at the initial evaluation, I treat with a combination of an
antidepressant medication and psychotherapy right away. However, I almost
never treat patients with antidepressant medications alone, as noted previously.
never treat patients with antidepressant medications alone, as noted previously.
In my experience, the drugs-only approach has not been satisfactory. The
combination of medications with psychotherapy seems to produce better results
in the short term and in the long term than treating patients with drugs alone. It
may sound unscientific to base the medication decision on the patient's
preferences, and certainly there are excep- exceptional cases where I feel I have
to make a recommendation that differs from my patient's wishes. But the
majority of time, I have found that patients do well when treated with the
approach they are most comfortable with. So if you are depressed and you have
strong positive feelings that an antidepressant drug will help you, this inincreases the likelihood that you will be helped by one of these medications. And
if you feel strongly that you would prefer to be treated with a drug-free form of
therapy, the likelihood of a successful outcome is also good. But I would urge
flexibility in your thinking. If you are receiving a medication, I strongly believe
that cognitive or interper- interpersonal psychotherapy can enhance your
recovery. If you are
480 David D. Burns, M.D. receiving psychotherapy and your progress is slow,
an an- tidepressant might accelerate your recovery. Can Anyone Take an
Antidepressant? Most people can, but competent medical supervision is a must.
For example, special precautions are indicated if you have a history of epilepsy,
heart, liver, or kidney dis- disease, high blood pressure, or certain other
disorders. For the very young and elderly, some medications should be avoided,
and smaller dosages may be indicated. And, as noted above, if you are taking
medicines in addition to an antidepressant, special precautions are sometimes
required. Properly administered, an antidepressant is safe and may be lifesaving.
But don't try to regulate it or administer it on your own. Medical supervision is a
must. Should a pregnant woman use an antidepressant? This sensitive question
often requires consultation between the psychiatrist and the obstetrician. Since
fetal abnormalities might occur, the potential benefit, the severity of the dedepression, and the stage of pregnancy must all be taken into account. Other
treatment approaches should usually be em- employed first, and an active selfhelp program of the type described in this book might eliminate the need for a
med- medication. This would give optimal protection to the devel- developing
child, of course. On the other hand, if the depression is very severe, there may be
cases where it makes sense to use an antidepressant. Who Is Most—and Least—
Likely to Benefit from an Antidepressant Drug? Your chance of responding to
an appropriate drug may be enhanced:
FEELING GOOD 481 1. If you are unable to carry on with your day-to-day
activities because of your depression. 2. If your depression is characterized by
activities because of your depression. 2. If your depression is characterized by
many organic symptoms, such as insomnia, agitation, retardation, a worsening of
symptoms in the morning, or an in- inability to feel cheered up by positive
events. 3. If your depression is severe. 4. If your depression had a reasonably
clear-cut begin- beginning. 5. If your symptoms are substantially different from
the way you normally feel. 6. If you have a family history of depression. 7. If
you have had a beneficial response to antidepres- sant drugs in the past. 8. If you
strongly feel that you would like to take an antidepressant drug. 9. If you are
strongly motivated to recover. 10. If you are married. Your chance of responding
to an appropriate drug may be diminished: 1. If you are very angry. 2. If you
have a tendency to complain and to blame others. 3. If you have a history of an
exaggerated sensitivity to drug side effects. 4. If you have a history of multiple
physical complaints that your doctor has been unable to diagnose, such as
tiredness, stomach ache, headache, or pains in your chest, stomach, arms, or
legs. 5. If you have a long history of another psychiatric dis- disorder or
hallucinations preceding your depression.
482 David D. Burns, M.D. 6. If you feel strongly that you do not want to take an
antidepressant drug. 7. If you are abusing drugs or alcohol and you are ununwilling to go into a recovery program. 8. If you are receiving financial
compensation for your depression, or if you hope to receive financial comcompensation. For example, if you receive disability payments for depression, or
if you are involved in a lawsuit and hope to receive financial compensation
because of your depression, then any form of treat- treatment is going to be
difficult. This is because if you recover, you will lose money. This is a conflict
of interest. 9. If you have failed to respond to other antidepressants you have
been given. 10. If for any reason you have mixed feelings about get- getting
better. These guidelines are of a general nature and are not in- intended to be
comprehensive or precise. Our ability to pre- predict who will respond best to a
medication or to psychotherapy is still extremely limited. Many people with all
the positive indicators may fail to respond to antide- antidepressants, and many
people with all the negative indicators may respond beautifully to the first drug
they receive. In the future, the use of antidepressant drugs will hopefully become
more precise and scientific, just as the use of an- antibiotics has become. If you
have many of the negative indicators, is this bad? I don't think so. Most patients
with all the negative indi- indicators can be treated quite successfully, but it may
some- sometimes take a little longer. In addition, as I have emphasized
repeatedly, a combination of medication with good psycho- psychotherapy along
the lines described in this book is sometimes more effective than treatment with
antidepressant drugs alone.
antidepressant drugs alone.
FEELING GOOD 483 How Fast and How Well Do Antidepressant Drugs
Work? Most studies indicate that approximately 60 percent to 70 percent of
depressed patients will respond to an anti- antidepressant medication. Since
approximately 30 percent to 50 percent of depressed patients will also respond to
a sugar pill (a placebo), these studies indicate that an antidepressant will increase
your chances for recovery. However, remember that the word "respond" is
different from the word "recover," and the improvement from an antidepressant
is often only partial. In other words, your score on a mood test like the one in
Chapter 2 may improve without going into the range considered truly happy
(less than 5). This is why I nearly always combine antidepressant medication
treatment with cognitive and behavioral tech- techniques like those described in
this book. Most people are not interested in just partial improvement. They want
the real McCoy. They want to get up in the morning and say, "Hey, it's great to
be alive!" As I have emphasized, most of the depressed and anxious people I
have treated have problems in their lives such as a marital conflict or a career
difficulty, and nearly all of them beat up on themselves with negative thinking
patterns. In my experience, medication therapy is usually more ef- effective—
and more satisfying—when it is combined with psychotherapy. Many doctors do
prescribe medications alone without psychotherapy, but I have not found this apapproach to be satisfactory. Which Antidepressants Are the Most Effective? All
of the currently prescribed antidepressant drugs tend to work about equally well,
and equally rapidly, for most patients. So far, no new type of antidepressant
medication has been shown to be more effective or faster-acting than
484 David D. Burns, M.D. the older drugs that have been available for several
decades. However, there are dramatic differences in the costs of the different
types of antidepressants and in the side effects they have. Essentially, the newer
medications are much more expensive because they are still on patent. However,
they are far more popular because they usually have fewer side effects than the
older, cheaper drugs. If you have cer- certain kinds of medical conditions, some
antidepressants will be relatively safer for you than others. I will discuss these
issues in greater detail in Chapter 20. Sometimes a patient will respond
particularly well to one antidepressant or kind of antidepressant. Unfortunately,
we cannot usually predict this ahead of time for the individual, and so most
physicians use a trial-and-error approach. There are, however, a few
generalizations about the kinds of antidepressants that work best for certain
kinds of prob- problems. For example, drugs that have stronger effects on the
serotonin systems in the brain are generally considered to be effective for
serotonin systems in the brain are generally considered to be effective for
patients who suffer from obsessive- compulsive disorder (called OCD for short).
These patients have recurrent illogical thoughts (like a fear that the stove will
catch fire and burn the house down) and perform com- compulsive rituals over
and over (such as checking repeatedly to make sure that the stove is turned off).
Drugs often pre- prescribed for OCD include several of the tricyclic antideantidepressants, including clomipramine (Anafranil), one of the SSRIs, such as
fluoxetine (Prozac) or fluvoxamine (Luvox), or one of the MAOIs, such as
tranylcypromine (Parnate). If a depressed patient also has symptoms of anxiety,
such as panic attacks or social anxiety, the physician might also choose one of
the SSRI or MAOI antidepressants, since these often seem to be quite effective.
Or the physician might choose one of the more sedative antidepressants, such as
trazodone (Desyrel) or doxepin (Sinequan), think- thinking that the relaxation
might help reduce the anxiety. In my practice, I have treated many patients with
a par- particularly difficult type of chronic and severe depression known as
borderline personality disorder (called BPD for
FEELING GOOD 485 short). Patients with this disorder have intense and conconstantly fluctuating negative moods such as depression, anx- anxiety, and
anger. Patients with BPD also experience lots of turbulence in their personal
relationships. In my experience, quite a few BPD patients have responded
dramatically to the MAOI antidepressants, and so I might be more inclined to
choose an MAOI for patients with these features. Of course, some patients with
BPD have poor impulse control, and they may do better with one of the newer
and safer antidepressants. This is because the MAOIs can be quite dangerous if
patients mix these drugs with certain forbidden foods and medications that I will
describe in detail in Chap- Chapter 20. There are a number of other guidelines as
well, but they should not be taken too literally because there are so many
exceptions to them. The bottom line is this: any depressed patient has a
reasonably good chance of having a positive response to almost any
antidepressant medication if it is prescribed at the correct dose for a reasonable
period of time. You can ask your physician if she or he has a reason for
recommending a particular antidepressant. However, most physicians will
prescribe antidepressants they are fa- familiar with. This is good practice. Few
doctors can master the myriad details about all the currently prescribed antiantidepressants, and so most doctors try to become familiar with the one or two
agents they use most frequently. In this way, they will have the greatest expertise
about the medi- medication they are recommending for you. How Can I Tell if
My Antidepressant Is Really Working? My own philosophy is to use a
depression test like the one in Chapter 2 as a guide. Take the test once or twice a
week during treatment. This is really important. The test will show whether and
week during treatment. This is really important. The test will show whether and
to what extent you have improved. If you are not getting better, or if you are
getting worse,
486 David D. Burns, M.D. your scores will not improve. If your scores are
steadily improving, this indicates the drug is probably helping. Unfortunately,
most doctors do not require their patients to complete a mood test like the one in
Chapter 2 between therapy sessions. Instead, they rely on their own clinical
judgment to evaluate the effectiveness of the treatment. This is quite unfortunate,
because studies have indicated that doctors are often poor judges of how patients
feel in- inside. How Much Mood Elevation Can I Anticipate? Your aim should
be to reduce the score on the depression test in Chapter 2 until it is in the range
considered normal and happy. This is true whether you are being treated with an
antidepressant, with psychotherapy, or with a combina- combination of the two.
Treatment cannot be considered completely successful if your score remains in
the depressed range. If One Antidepressant Works Somewhat, Will It Be Even
Better to Take Two or More Antidepressants at the Same Time? As a general
rule, it is usually not necessary (or even beneficial) to take two or more different
antidepressant drugs simultaneously. The two drugs may interact in ways that
are unpredictable, and the side effects may increase substantially. There are
exceptions to this, of course. For example, if you are restless and having trouble
sleeping, your doctor may sometimes add a small dose of a second, more
sedating antidepressant at night to help you get a good night's sleep. Or your
doctor may add a small dose of a second antidepressant to try to increase the
effectiveness of the first antidepressant. This is called an "augmentation"
strategy, and I will discuss this approach in greater detail
FEELING GOOD 487 in Chapter 20. But on the average, one drug at a time usuusually works best. How Long Will It Take Before I Can Expect to Feel Better?
It typically requires a minimum of two or three weeks before an antidepressant
medicine begins to improve your mood. Some drugs may take even longer. For
example, Prozac may not become effective for five to eight weeks. It is not
known why antidepressants have this delayed re- reaction (and whoever
discovers the reason will probably be a good candidate for a Nobel prize). Many
patients have the impulse to discontinue their antidepressants before three weeks
have passed because they feel hopeless and believe the medicine is not working.
This is illogical, since it is unusual for these agents to become effective right
away. What Can I Do if My Antidepressant Doesn't Work? I have seen many
patients who failed to respond ade- adequately to one or many antidepressants.
In fact, at my clinic in Philadelphia, most of the patients were referred to me
In fact, at my clinic in Philadelphia, most of the patients were referred to me
after unsuccessful treatments with a variety of antidepres- antidepressant drugs
and therapy as well. Most of the time we were eventually able to get an excellent
antidepressant effect, often through a combination of cognitive therapy and ananother medication that the patient had not yet tried. The im- important thing is
to keep persisting in your efforts until you recover. Sometimes this requires
enormous dedication and faith. Patients often feel like giving up, but persistence
nearly always pays off. I have stated earlier that the feelings of hopelessness are
probably the worst aspect of depression. These feelings sometimes lead to
suicide attempts because patients feel so
488 David D. Burns, M.D. convinced that things will never get any better. They
think that things have always been this way and that their feelings of
worthlessness and despair will go on forever. In addition, there is a kind of
genius about depression. Patients can be so incredibly persuasive about their
hopelessness that even their doctors and families may start believing them after a
while. Early in my career I grappled with this and often felt tempted to give up
on particularly difficult patients. But a trusted colleague urged me never to give
in to the belief that any patient was hopeless. Throughout my career, this policy
has paid off. No matter what type of treatment you receive, faith and persistence
can be the keys to success. I cannot emphasize this enough. How Long Should I
Take an Antidepressant if It Doesn't Seem to Be Working? Of course, you
should always check with your physician before making any changes in your
medication, but on av- average, a trial of four or five weeks should be adequate.
If you do not have a clear-cut and fairly dramatic improve- improvement in your
mood, then a switch to another drug is prob- probably indicated. It is important,
however, that the dose be adjusted correctly during this time, since doses that are
too high or too low may not be effective. Sometimes your doc- doctor may order
a blood test to make sure the dose you are taking is adequate for you. One of the
commonest errors your doctor may make is to keep you on a particular
antidepressant for many months (or even years) when there is no clear-cut
evidence that you have improved. This makes absolutely no sense to me!
However, I have seen many severely depressed individuals who reported that
they had been treated continuously with the same antidepressant for many years
but were not aware of any beneficial effects from the medication. Their scores
on the mood test in Chapter 2 usually indicated they were
FEELING GOOD 489 still severely depressed. When I asked them why they
were taking the drug for such a long time, they usually said that theirs doctors
told them that they needed it, or that it was necessary because of their "chemical
told them that they needed it, or that it was necessary because of their "chemical
imbalance." If your mood has not improved, it seems clear that the drug has not
worked, so why keep taking it? If a drug does not have fairly substantial
beneficial effects, as indicated by a clear and continuing improvement in your
score on a depression test like the one in Chapter 2, then it is usually appropriate
to switch to another antidepressant medication. How Long Should I Continue to
Take the Antidepressant if It Does Help Me? You and your doctor will have to
make this decision together. If this is your first episode of depression, you can
probably go off the medicine after six to twelve months and continue to feel
undepressed. In some cases, I have discontinued antidepressants after only three
months with good results, and rarely found that treatment for more than six
months was necessary. But different doctors have dif- different opinions about
this. One of the strongest predictors of relapse in research studies is the degree of
improvement at the end of treat- treatment. In other words, if you are happy and
completely free of depression, and this is documented by a score below 5 on the
depression test in Chapter 2, the likelihood of a prolonged depression-free period
is high. On the other hand, if you are partially improved but your depression
score is still somewhat elevated, the likelihood is much greater that the
depression will worsen or return in the fu- future, whether or not you continue to
take an antidepressant medication. This is another reason why I like to combine
antidepres- antidepressant medications with cognitive behavioral therapy. The
pa- patients usually have a much better response, and very few
490 David D. Burns, M.D. patients in my private practice appeared to relapse
and re- return for additional treatment following recovery. What if My Doctor
Tells Me I Have to Stay on the Antidepressant Indefinitely? Patients with certain
kinds of depressions will almost def- definitely need to take medications on a
long-term basis. For example, if a patient has bipolar (manic-depressive) illness
with uncontrollable highs as well as lows, long-term treat- treatment with a
mood-stabilizing medication such as lithium, valproic acid, or carbamazepine
may be necessary. If you have had many years of unremitting depression or if
you have been prone to many recurrent attacks of de- depression, you might
want to consider maintenance therapy for a longer period of time. Since doctors
are becoming more aware of the relapsing nature of mood disorders, the use of
antidepressants on a long-term or prophylactic basis is gaining greater favor.
Some doctors routinely recommend therapy with anti- depressants indefinitely,
in much the same way they might insist that patients with diabetes must take
daily insulin to regulate their blood sugar. Several research studies suggest that
such maintenance therapy can reduce the incidence of depressive relapses.
However, research studies also indicate that treatment with the cognitive therapy
techniques de- described in this book can also reduce depressive relapses. In
techniques de- described in this book can also reduce depressive relapses. In
addition, these studies suggest that the preventive effect of cognitive therapy
may be greater than the preventive effect of antidepressant medications. One
important advantage of cognitive behavioral therapy is that you learn new skills
to minimize or prevent future depressions. For example, the simple exercise of
writing down and challenging your own negative thoughts when you are under
stress can be invaluable. In my private practice, the vast majority of the
depressed patients I have treated have not had to stay on antidepresFEELING GOOD 491 sant drugs indefinitely following recovery. Most of them
did extremely well with no medications simply by using the cognitive therapy
skills they learned whenever they be- became upset again in the future. This is
very encouraging, and it shows there is quite a bit you can do not only to treat
your own depression, but also to minimize the prob- probability of severe and
prolonged depressions in the future. It also suggests that if you are taking an
antidepressant, it might be very helpful for you to study and practice the methods
in this book. Once you discover how to change your own negative thinking
patterns using the techniques I describe, you may find that you will be able to
remain undepressed without any medications. But certainly, you will want to
discuss this with your physician. It is never smart to go off a med- medicine or to
change the dose of a medication unless you talk this over with your doctor first.
What if I Start Getting More Depressed When I Taper Off the Medication? This
is actually pretty common, and I will tell you how 1 have handled it in my own
practice. First, I make sure the patient continues to take the depression test in
Chapter 2 at least once or twice a week while she or he is tapering off the
medication. Then we develop a plan for slowly re- reducing the dose of the
antidepressant. I tell patients that if they start to feel depressed again while
tapering off the drug, and this is reflected by an increased score on the
depression test, then they should temporarily raise the dose slightly for a week or
two. This usually leads to an im- improvement in mood again. Then they can
slowly continue to taper off the drug again. This approach is reassuring because
it puts the patient in control. After a couple tries like this, most patients have
been able to taper off their antidepressants without becoming depressed again.
492 David D. Burns, M.D. What Should I Do if the Depression Comes Back in
the Future? If your depression returns, the chances are excellent that you will
again respond to the same drug that helped you the first time. It may be the
proper biological "key" for you. So you can probably use that drug again for any
future episode of depression. If any blood relative of yours de- develops a
depression, this drug might also be a good choice for them because a person's
depression, this drug might also be a good choice for them because a person's
response to antidepressants, like the depression itself, appears to be influenced
by ge- genetic factors. The same reasoning applies to the psychotherapy techtechniques. I have found that for most people, the same kinds of events (for
example, being criticized by an authority fig- figure) tend to trigger depression,
and the same kinds of cog- cognitive therapy technique usually reverse the
depression for a particular patient. In most cases patients have been able to
reverse a new episode of depression fairly rapidly with- without having to take
the medication again. I encourage my patients to come in for a little "tune-up" if
they become depressed again in the future. Often these "tune-ups" con- consisted
of only one or two therapy sessions, since we were usually able to reapply the
same technique that had helped them so much the first time I treated them. What
Are the Most Common Side Effects of the Antidepressants? As discussed in
Chapter 17, all the medications pre- prescribed for depression, anxiety, and other
psychiatric prob- problems can cause different kinds of side effects. For
example, many of the older antidepressants (such as amitriptyline, trade name
Elavil) cause fairly noticeable side effects such as dry mouth, sleepiness,
dizziness, and weight gain, among others. Many of the newer antidepressants
(such as fluox- etine, trade name Prozac) can cause nervousness, sweating,
FEELING GOOD 493 upset stomach, or a loss of interest in sex as well as diffidifficulties having an orgasm. I will describe the specific side effects of every
antide- pressant in Chapter 20. You will see that some medications produce lots
of side effects whereas others produce very few. The Side Effects Checklist on
pages 494-496 can pro- provide you and your physician with extremely accurate
in- information about any side effects that you experience while you are taking a
medication. If you take this test a couple times per week, this will show how the
side effects change over time. Remember, however, that many of these so-called
side effects can occur even if you are not taking any medication, since many side
effects are also symptoms of depression. Feeling tired, having trouble sleeping at
night, or a loss of interest in sex would be good examples. So it can be very
useful to complete the Side Effects Checklist at least once or twice before you
start any medication. That way, you can see if a side effect began before or after
you started the drug. Obviously, if you had the same side effect before you
started taking a drug, then the drug is probably not to blame for it. It is also good
to remember that patients who only take placebo medications (sugar pills) during
research studies tend to report lots of side effects. This is because they think they
ate taking a real drug. So there is no proof that a particular side effect is
necessarily caused by the drug you are taking. When in doubt, talk this over with
your physi- physician. Let me give you a particularly vivid example of how the
your physi- physician. Let me give you a particularly vivid example of how the
mind can occasionally play tricks on us. I once treated a high school teacher for
depression. She was not responding well to the psychotherapy and I had the
hunch that she would respond to a particular antidepressant drug called
tranylcypromine (Parnate) that is described in Chapter 20. However, she was
somewhat stubborn and had a strong fear of taking any medication. She
complained that she would
494 David D. Burns, M.D. Side Effects Checklist* Instructions: Put a check (i/)
after each item to indicate if you have had this type of side effect during the past
several days. Please answer all the items. I CO £L <D O CO £ CO <D O CM o <
<D X ULJ 4 Mouth and Stomach 1. dry mouth 2. frequently thirsty 3. loss of
appetite 4. nausea or vomiting 5. stomach cramps or upset stomach 6. increase in
appetite or eating too much 7. weight gain or loss 8. constipation 9. diarrhea
Eyes and Ears 10. blurred vision 11. overly sensitive to light 12. changes in
vision, such as halos around objects 13. ringing in your ears Skin 14. sweating
too much 15. rash 16. excessive sunburn when exposed to sun 17. change in skin
color 18. bleeding or bruising easily Sex 19. loss of interest in sex 20. difficulties
getting sexually excited 21. difficulties getting an erection (men)
FEELING GOOD < Side Effects Checklist continued 22. difficulties having an
orgasm 23. difficulties with your period (women) 0—Not At All 1—Somewhat
2—Moderately 3—A Lot 495 4—Extremely Stimulation and Nervousness 24.
stimulated 25. agitated 26. anxious, worried or nervous 27. feeling strange or
"spaced out" 28. excess energy Sleep Problems 29. feeling tired or exhausted 30.
loss of energy 31. sleeping too much 32. trouble falling asleep 33. sleep that is
restless or disturbed 34. waking up too early in the morning 35. nightmares or
strange dreams Muscles and Coordination 36. muscle jerks or twitches 37.
slurred speech 38. tremor 39. difficulty walking or loss of balance 40. feeling
slowed down 41. stiffness of the arms, legs, or tongue 42. feeling restless, like
you have to keep moving your arms or legs 43. hand-wringing 44. constant,
regular, rhythmic leg jiggling 45. abnormal movements of your face, lips, tongue
496 David D. Burns, M.D. Side Effects Checklist continued Instructions: Put a
check (•/) after each item to indicate if you have had this type of side effect
during the past several days. Please answer all the items. 46. abnormal
movements of other parts of your body, such as your fingers or shoulders 47.
muscle spasms of your tongue, jaw, or neck 0—Not At All 1—Somewhat >» <D
CO <D T3 O t 3—A Lot 4—Extremely Other 48. difficulty remembering things
49. feeling dizzy, light-headed, or faint 50. feeling your heart race or pound 5 J.
swelling in your arms or legs 52. trouble starting urination 53. headache 54.
swelling in your arms or legs 52. trouble starting urination 53. headache 54.
breast swelling or enlargement 55. milk secretion from the nipples Please
describe any other side effects: '^Copyright © 1998 by David D. Burns, M.D.
not be able to tolerate the side effects. I explained that I planned to prescribe a
low dose and that in my experience most patients did not have many side effects
with this med- medication, especially when the dose was low. But my efforts
were to no avail—she insisted the side effects of the drug would be unbearable,
and refused to accept a prescription.
FEELING GOOD 497 I asked if she would be willing to do a little experiment to
check this out. I told her I would give her two weeks' worth of pills in fourteen
separate envelopes. Each enve- envelope was labeled with the date and day of
the week she was to take the pills inside it. I explained that some enveenvelopes would contain placebo pills that could not have any side effects
whatsoever. Half the pills would be yellow and half would be red, but she would
not know whether she was taking the real medication or a placebo on any given
day. The envelope for the first day contained one yellow pill and the envelope
for the second day contained one red pill. The envelopes for the third and fourth
days contained two yellow pills each, and the envelopes for the fifth and sixth
days contained two red pills each. Finally, each en- envelope for the second
week contained three yellow pills or three red pills. I asked her to complete the
Side Effects Checklist every day and to record the date. I explained how this
experiment would help us determine whether any side effects she exexperienced on a given day were due to the real drug or the placebo effect. She
reluctantly agreed, but insisted that her body was very sensitive to drugs and
predicted the exper- experiment would prove just how wrong I was. Shortly after
she started taking the pills she started calling me almost daily with alarming
reports about severe side ef- effects, especially on the days she was taking the
yellow pills. She said these effects also spilled over to the'days she took the red
pills as well. I explained the side effects usually di- diminished over time and
encouraged her to try to continue. On Sunday evening she had the answering
service page me at home for an emergency. She stated that the side ef- effects
did not diminish but were getting worse. In fact, they were so severe that she
simply could no longer function. She was dizzy and confused and fatigued. Her
mouth was as dry as cotton. She staggered when she tried to walk and could
barely get out of bed. She had severe headaches. She said she would not take any
more pills and wanted to know why I had put her through such grief. I
apologized, told her to stop the medications immedi498 David D. Burns, M.D. ately and made an appointment to see her the first
498 David D. Burns, M.D. ately and made an appointment to see her the first
thing Monday morning for an emergency session. I reassured her that none of
her symptoms sounded life-threatening, al- although she was obviously in great
distress. I told her to bring her daily Side Effects Checklists to the session and
promised that we would break the code together the next morning so we could
find out which days she had taken the placebos and which days she had taken the
real pills. The next morning I explained that all the pills she had taken were
placebos I had obtained from the hospital phar- pharmacist. They were simply
red placebos and yellow place- placebos—there were no Parnate pills in any of
the envelopes. This information surprised her, and tears began rolling down her
cheeks. She acknowledged that she never would have believed that her mind
could have such powerful ef- effects on her body. She had been totally
convinced the side effects were real. She then went ahead to take the Parnate in
small doses and her mood improved substantially over the next month or two.
She also started working very hard on her psychotherapy homework between
sessions. She continued to fill out the Depression Test and the Side Ef- Effects
Checklist once a week, but she did not report many side effects. I do not mean to
imply that all side effects are in your mind. On rare occasions this can occur, but
most of the time the side effects are quite real, and the vast majority of my
patients have reported them accurately. If you use the Side Effects Checklist on a
daily basis, it will help you and your doctor assess the specific type and severity
of any symptoms you might experience. Then the appropriate medication
adjustments can be made if the side effects are excessive or dangerous. Why Do
Antidepressant Drugs Have Side Effects? You learned in Chapter 17 that
antidepressant drugs can stimulate or block the receptors for the neurotransmitter
FEELING GOOD 499 chemicals that nerves use to send messages to each other.
In that chapter, we focused on serotonin, since this trans- transmitter is felt to be
involved in the regulation of mood. One of the most important and helpful
discoveries of the past two decades is that antidepressants can also interact with
the receptors for several additional chemical transmitters in the brain. These
interactions appear to be responsible for many of the side effects of the
antidepressants. The three brain receptors that have been studied the most
intensively are called histamine receptors, alpha-adrenergic receptors, and
muscarinic receptors. These are located on nerves that use histamine,
norepinephrine, and acetylcho- line, respectively, as their chemical transmitters.
Drugs that block histamine receptors are called "antihistamines," a term you are
probably familiar with. Drugs that block alpha-adrenergic receptors are called
"alpha-blockers," and drugs that block muscarinic receptors are called "anticholinergics." Each type of receptor is responsible for certain kinds of side
ticholinergics." Each type of receptor is responsible for certain kinds of side
effects. You can predict the side effects of any drug if you understand how
strongly the drug affects each of these three brain systems. Antidepressant
medications produce many of their side effects because they block histaminic
receptors, alpha-adrenergic receptors, and cholinergic re- receptors (which are
also called "muscarinic" receptors) that are located on the surfaces of nerves
inside of your brain and throughout your body as well. In case you do not recall
what a "receptor" is, it is simply an area on the surface of a nerve that can turn
the nerve on or off. The histamine receptors are located on nerves that use
histamine as a chemical transmitter; the alpha-adrenergic receptors are lolocated on nerves that use norepinephrine as a chemical trans- transmitter; and
the cholinergic receptors are located on nerves that use acetylcholine as a
chemical transmitter. If you block any of these three types of receptors, you will
turn the nerves off. The effects of different antidepressant med- medications on
these three receptors help explain many of the side effects of these drugs. For
example, amitriptyline (Elavil) is an older antide500 David D. Burns, M.D. pressant that can cause many side effects, including
sleep- sleepiness, weight gain, dizziness, dry mouth, blurred vision, and
forgetfulness, to name just a few of the more common ones. Most of these side
effects are not dangerous, but they can be uncomfortable. Let's see if we can
understand these side effects a little better by examining the effects of amitriptyline on the three kinds of nerve receptors. Scientists have learned that
amitriptyline blocks the cho- cholinergic, histamine, and alpha-adrenergic
receptors in the brain. Let's examine its anti-cholinergic effects first. What do
these cholinergic nerves ordinarily do? Among other things, they control the
amount of lubrication in your mouth. If you stimulate cholinergic nerves, more
fluids will flow into your mouth from glands that are located in your cheeks.
What would happen if you turned off these nerves that normally lubricate your
mouth? Your mouth would feel dry. You may have experienced a dry mouth
when you were very nervous (cottonmouth) or when you were exer- exercising
for a long time in the sunshine without drinking any water. Cholinergic nerves
also slow the heart, and so anti- cholinergic drugs like amitriptyline will cause
the heart to speed up. Anticholinergic drugs can also cause forgetful- ness,
confusion, blurred vision, constipation, and difficul- difficulties getting your
urine started. Amitriptyline also blocks alpha-adrenergic receptors on nerves that
use norepinephrine as a transmitter substance. If you stimulate these alphaadrenergic receptors, your blood pressure will usually increase. Conversely,
when you block them, your blood pressure will usually fall. This is why
amitriptyline can cause a drop in blood pressure in certain individuals. This
problem is especially noticeable when you suddenly stand up, because the drop
problem is especially noticeable when you suddenly stand up, because the drop
in blood pressure makes you dizzy. Dizziness when standing is a common side
effect of amitriptyline and many other anti- depressants. As noted above,
amitriptyline also blocks histamine re- receptors in the brain. Drugs that block
these receptors are called "antihistamines." You've probably taken an antihistamine if you've had an allergy or a stuffy nose. Drugs
FEELING GOOD 501 that block histamine receptors can make you sleepy and
hungry. This is why amitriptyline, as well as many other antidepressant drugs
that block histamine receptors, causes tiredness and weight gain. Many of the
older antidepressant medications are cate- categorized as "tricyclic"
antidepressants. The tricyclics have relatively strong effects on these three kinds
of brain re- receptors, and so they tend to cause quite a few side effects. In fact,
on pages 530-532 in Chapter 20 you will find a table that lists each tricyclic and
shows how strong its ef- effects are on each of these three types of brain
receptors. This information indicates how strong the different kinds of side
effects will be for each medication. In contrast, many of the newer
antidepressants (such as Prozac and the other SSRIs) generally have only weak
ef- effects on the histaminic, alpha-adrenergic, and cholinergic receptors in the
brain. Consequently, they usually produce fewer side effects than the older drugs
like amitriptyline. For example, the SSRIs are less likely to cause sleepiness,
excessive appetite, dizziness, dry mouth, constipation, and so forth. The SSRIs
also have little effect on the rate or rhythm of the heart. However, we are now
discovering that the SSRIs such as Prozac have new and different side effects of
their own. For example, as many as 30 percent to 40 percent of the patients
taking these drugs experience sexual difficulties such as a loss of interest in sex
or difficulties having an orgasm. They can also cause upset stomach, loss of
appe- appetite, weight gain, nervousness, difficulties sleeping, fatigue, tremor,
and excessive sweating, and a number of other side effects. What Can I Do to
Prevent or Minimize these Side Effects? The likelihood and severity of any side
effect usually depends on the dose of the medication you are taking. As a general
rule, if you start out with a small dose and in502 David D. Burns, M.D. crease the dose gradually, the side effects can be
mini- minimized. In addition, many side effects tend to diminish over time.
Sometimes a reduction in dose will minimize side effects without reducing the
effectiveness of an antidepres- sant; sometimes a change to another type of
antidepressant medication will be needed. If you and your doctor work together,
you can usually find a medication that will have a beneficial effect on your mood
without excessive side effects. Your doctor might also add a second medication
without excessive side effects. Your doctor might also add a second medication
to help combat the side effects of an antidepressant medication or a mood
stabilizer. Sometimes this is necessary and justified and sometimes it is not
necessary. I will discuss this issue in greater detail in Chapter 20 but I will give
you a couple of specific examples here. Let's assume that you are taking lithium
for manic- depressive illness. A common side effect of lithium is a tremor of the
hands. You may find it difficult to write your name clearly or your hand may
shake while you are at- attempting to hold a cup of coffee. One of my patients
trem- trembled so much that the coffee would actually spill out of the cup.
Obviously such a severe side effect is not acceptable. Your doctor may add one
of the drugs called beta- blockers to help combat the tremor. The drug
propranolol (Inderal) is often used for this purpose. However, beta- blockers
have potent effects on the heart and they can also have a number of side effects
of their own. Furthermore, both lithium and beta-blockers have the potential for
ad- adverse interactions with other drugs your psychiatrist or fam- family
physician may prescribe, and so the situation rapidly becomes quite complex. In
my mind, the question becomes: Is this tremor so severe and disabling that it
justifies adding a potent cardiac drug? Is there another way to deal with this side
effect without adding more drugs? Would a re- reduction in dose be indicated?
Sometimes the beta-blocker may be justified; sometimes it may not be
necessary. The same kind of reasoning applies to antidepressants. Sometimes a
second drug is necessary to combat a side effect, but often it is not the best
choice. Let's assume that
FEELING GOOD 503 you are being treated with fluoxetine (Prozac) for depresdepression. Three common side effects of Prozac include insom- insomnia,
anxiety, and sexual problems. Let's examine how your doctor might handle each
of these. • If you are overly stimulated from Prozac and you are having trouble
sleeping, your doctor may add a small dose of a second, more sedative
antidepressant at night. For example, 50 to 100 mg of trazodone (Desyrel) is
often used. This is a pretty good approach, because the trazodone differs from
most sleeping pills in that it is not addictive. However, you may also be able to
com- combat the excessive stimulation by taking a smaller dose of Prozac and
by taking it earlier in the day. Then you might not need to add a second drug.
Keep in mind, too, that the excessive stimulation from Prozac tends to occur
when you first start taking it and may also disappear after a week or two. •
Prozac can cause anxiety or agitation, especially when you first start taking it.
Your doctor may want to add a benzodiazepine (minor tranquilizer) such as
clona- zepan (Klonopin) or alprazolam (Xanax) to combat the nervousness. But
the benzodiazepines can be addictive when taken daily for more than three
the benzodiazepines can be addictive when taken daily for more than three
weeks, and anx- anxiety can usually be managed without adding one of these
agents. A reduction in the dose of the Prozac will often help. The effectiveness
of the SSRI antidepres- sants such as Prozac does not seem to depend on the
dose, so there is little justification for taking a dose that creates excessive
discomfort. The passage of time will often help as well, since the anxiety from
Prozac seems to diminish or disappear after the first few weeks. Some patients
develop a second wave of nervous- nervousness and restlessness after they have
been on Prozac for a number of weeks or months. Sometimes this pat- pattern of
agitation is called "akathisia"—a syndrome in which your arms and legs become
so extremely restless that you simply cannot sit still. This intensely uncom504 David D. Burns, M.D. fortable side effect is quite common with the
neurolep- tic drugs used to treat schizophrenia but occurs much less often with
most antidepressants. Prozac leaves your blood very slowly, however, so the
levels increase more and more during the first five weeks that you are taking it.
Even though a particular dose of Prozac, such as 20 mg or 40 mg per day, may
have been fine at first, after a month or so that same dose may become much too
high for you. A dramatic reduction in dose might greatly reduce the side effects
without reducing the antidepressant effects at all. However, many pa- patients
with akathisia have to be taken off the Prozac and switched to another
medication because the akath- akathisia has become so severe and
uncomfortable. Your doctor may add another drug temporarily to combat
akathisia, but it seems prudent to reduce the dose of Prozac or to go off the drug
entirely if akathisia de- develops. • As noted above, as many as 40 percent of
men and women on Prozac (as well as the other SSRI antide- antidepressants)
develop sexual problems, including a loss of interest in sex as well as difficulties
having an orgasm. Your doctor might want to add one of several drugs
(bupropion, buspirone, yohimbine, or amantadine) cur- currently being used to
try to combat these sexual side effects. Once again, the potential benefit should
be weighed against the hazards of these agents, and alter- alternative strategies
can be considered. I have rarely, if ever, kept a patient on an SSRI indefinitely,
so most patients have elected just to put up with this side effect, knowing it
would not be a long-term problem. If the SSRI is causing a dramatic
improvement in mood and there are no other side effects, the loss of interest in
sex for several months may be an acceptable trade-off. But of course these are
subjective issues, and you will have to make your own decision about this after
dis- discussing your options with your physician.
FEELING GOOD 505 In the next chapter, you will see that I recommend against
combination drug therapies for most patients taking antidepressants. If you take
combination drug therapies for most patients taking antidepressants. If you take
more than one drug at a time, you increase the chances for dangerous drug
interactions. In addition, the second medication may create new and difdifferent side effects. In most cases, if you and your doctor work together and
use a little common sense, it will not be necessary to treat antidepressant drug
side effects by adding additional drugs. How Can I Prevent Potentially
Dangerous Interactions between Antidepressants and Other Drugs, Including
Nonprescription Drugs? In recent years doctors have become increasingly aware
that certain types of drugs may interact with each other in ways that can be
dangerous. Two drugs may be quite safe and have few or no side effects if you
take either one sep- separately; but if you take the two drugs at the same time,
there could be serious consequences because of how the two drugs interact with
each other. This problem of drug interactions has become increas- increasingly
important in recent years for two reasons. First, there is an increasing trend
among psychiatrists to prescribe more than one psychiatric drug at a time to
many of their patients. This is not an approach with which I am entirely comfortcomfortable, but it is nevertheless very common. Each new drug raises the
possibility of drug interactions, since different psychiatric drugs can interact
with each other in potentially dangerous ways. And, as noted in the last chapter,
more and more patients are being put on antidepressant drugs (as well as other
types of psychiatric drugs) for prolonged per- periods of time, sometimes
indefinitely. This is also not an approach with which I am comfortable, and I
have found that long-term drug treatment for depression is not neces- necessary
for most patients. But many psychiatrists do pre506 David D. Burns, M.D. scribe drugs for prolonged times—the practice is in
vogue. And if you do take a psychiatric drug for a long time, even- eventually
you will probably receive one or more prescriptions from other doctors for other
medical problems. For exam- example, your doctor might prescribe a medication
for an al- allergy, high blood pressure, pain, or an infection. In addition, you
might take an over-the-counter medication for a cold, a cough, a headache, or an
upset stomach. Now the possibility of drug interactions has to be considered, bebecause these drugs may interact with the psychiatric drug you have been taking.
Of course, it goes without saying that psychiatric drugs can also interact with
tobacco and alcohol as well as street drugs such as cocaine or amphetamines. In
some cases these interactions can also be quite dangerous and even fa- fatal.
Some antidepressants interact in extremely dangerous ways with commonly used
drugs, including over-the- counter medications. I am not trying to be overly
alarmist here. With a little education and good teamwork with your physician,
you can take an antidepressant safely. In this section I will explain why and how
you can take an antidepressant safely. In this section I will explain why and how
drug inter- interactions happen. In addition, in Chapter 20, I will describe a
number of important drug interactions for each drug or category of drug you
might be taking. Remember that knowledge about these drug interactions is
rapidly evolv- evolving. New information comes out almost on a daily basis.
Make certain each doctor you see has a complete and ac- accurate list of every
drug you are taking, including any over- the-counter (nonprescription) drugs you
take. Ask your doctor if there are any drug interactions that could be imimportant. Ask your pharmacist the same thing. If they are not sure, ask them to
check it out for you. It is virtually impossible to keep all potential drug
interactions in your mind, because so much new information is constantly
emerging. References and computer programs that list dan- dangerous drug
interactions are readily available to help with this task. If you are appropriately
assertive and have a little education about the topic, you will be in a better
position
FEELING GOOD 507 to have an intelligent discussion with your doctor about
interactions among the drugs you are taking. You will see in Chapter 20 that I
have prepared detailed charts listing drug interactions for specific
antidepressants or mood stabilizers you may be taking. So, for example, if you
are taking Prozac, you can review the table that lists its drug interactions. This
should take only a minute or two. You may think that you shouldn't have to
study these charts, because your doctor should know all about any dandangerous drug interactions and ensure that nothing bad hap- happens to you.
There are several problems with this line of reasoning. First, though your doctor
may be extremely knowledgeable, she or he is also human and cannot keep up
with all the new information that is emerging, no matter how smart she or he
may be. Second, even if your doctor told you about every conceivable drug
interaction, there is no way you could remember all of them! And third, in this
era of managed care, doctors are having to manage more and more patients, and
you may get only a few minutes with your prescribing physician at infrequent
intervals to review your symptoms and the dose of the medication. There may
simply not be enough time to discuss all the possible drug interactions you need
to know about. How and Why Do These Drug Interactions Occur? There are
four basic ways that two drugs can interact. First, one drug can cause the level of
a second drug in your blood to increase—sometimes to an alarming degree, even
though you are taking only a "normal" dose of both drugs. What are the
consequences of a sudden increase in the level of a drug in your blood? First,
you may experience more side effects, since they are usually related to the dose.
Sec- Second, many psychiatric drugs lose their effectiveness when the dose is
Sec- Second, many psychiatric drugs lose their effectiveness when the dose is
too high or too low. And third, there can be
508 David D. Burns, M.D. toxic and even fatal reactions when the blood level of
any drug becomes too high. A second type of drug interaction is just the
opposite. One drug can cause the level of another drug in your blood to decrease.
This can cause the second drug to become in- ineffective, even though you are
taking a normal dose. You and your doctor may wrongly conclude that the drug
does not work for you when the real problem is that your blood level is too low.
A third type of interaction is when two drugs each have similar effects or side
effects that intensify each other. Sup- Suppose, for example, that you are being
treated for high blood pressure and then you begin to take a psychiatric drug that
also lowers blood pressure as a side effect. The result could be that you might
experience a sudden drop in blood pres- pressure and possibly even faint when
you suddenly stand up. A fourth and more ominous type of drug interaction is
not related to changes in blood levels but simply to toxic effects of certain drug
combinations. In other words, two drugs that are safe when taken separately may
lead to ex- extremely dangerous interactions when you take them to- together.
Now let's examine the first two types of drug interactions in more detail. Why
does one drug sometimes cause the level of a second drug to increase or fall
dramatically? Well, a simple way to think about it would be to imagine that you
are trying to fill a bathtub with water. If the plug is out, the water will have a
tendency to go out as fast as it comes in. As a result, the water level in the tub
will not go up high enough to take a bath, no matter how long you leave the
faucet on. In contrast, if the plug is in the tub and you don't turn the water off,
the tub will overflow. Now compare your body to the bathtub. (I do not mean to
imply that you have a bad figure!) The medicine you take each day is like the
water coming into the tub. Certain enzyme systems in your liver can be
compared to the hole in the bottom of the tub. These enzymes in your liver
chem- chemically change drugs into other substances (called "metabFEELING GOOD 509 olites") that your kidneys can get rid of more easily. This
process is called "metabolism." Metabolites of the drugs you take usually end up
in your urine. When you add a second drug, your liver may metabolize the first
drug more slowly. This would be comparable to plugging up the hole at the
bottom of the tub. And so, as you keep taking the first medicine, your blood
level gets too high, in just the same way that the water in the tub gets too high
and eventually spills over the side. Or the second drug you take could have the
opposite effect of making the hole in the bottom of the tub much bigger. In this
case, your liver's metabolism speeds up and rids your body of the first drug
much faster. In this case, you may keep talcing the same dose of the first drug
much faster. In this case, you may keep talcing the same dose of the first drug
each day but your blood level remains too low to have the desired antidepressant
effect. In this case, the water goes out of the tub just as fast as it comes in. That's
pretty much the basic principle. The drugs that are likely to interact with each
other are those that are meta- metabolized by the * *cytochrome P450'' enzyme
systems in the liver. There are many of these enzyme systems, and differdifferent kinds of drugs are metabolized by different enzyme systems. Only
certain drugs or combinations of drugs will stimulate or inhibit any of these
enzyme systems. Psychi- Psychiatric drugs can interact with other psychiatric
and nonpsy- chiatric drugs, such as antibiotics, antihistamines, or painkillers. In
other words, psychiatric drugs can affect other drugs your doctor may prescribe
(such as a pill for high blood pressure), in exactly the same way that those other
drugs can have an impact on any psychiatric drugs you may be taking. The
bottom line is that the level of any drug you are taking might become too high or
too low if you are also taking another drug at the same time. Let me now give
you some specific examples of these drug interactions. Suppose you are taking
one of the new selective serotonin reuptake inhibitors called paroxetine (trade
name Paxil). This drug is very similar to Prozac. Now suppose that the
paroxetine is not working very well,
510 David D. Burns, M.D. which sometimes happens, and you are still feeling
de- depressed. Your doctor might decide to add a second anti- depressant. If
your doctor chooses desipramine (trade name Norpramin), the paroxetine you
are taking will have the effect of "plugging up the tub." Now your body will not
be able to metabolize the new drug (desipramine) very well. As a result, your
blood level of desipramine may increase to three to four times higher than
expected. Most psychia- psychiatrists are aware of this drug interaction and will
be careful to prescribe desipramine in a tiny dose if a patient is taking an SSRI
like paroxetine. But if your psychiatrist was not aware of this particular drug
interaction and decided to give you a "normal" dose of desipramine, you could
develop a toxic level of desipramine in your blood. Is this serious? Well, there
are three potential problems. First, desipramine is not effective at excessively
high blood levels. Second, there will be many more side effects at high levels.
And third, in rare instances, excessive blood levels of desipramine can trigger
abnormal heart rhythms and oc- occasionally even cause death. Is this type of
drug interaction rare? No. The levels of antidepressants can sometimes increase
or decrease quite dramatically when combined with common prescription or
over-the-counter drugs you might take without thinking twice. The tables in
Chapter 20 will delineate the interac- interactions most important to any
antidepressant you might be taking. Finally, some toxic and dangerous drug
antidepressant you might be taking. Finally, some toxic and dangerous drug
interactions do not necessarily depend on doses or blood levels. For ex- example,
many of the newer antidepressants such as Prozac have powerful effects on the
serotonin systems in the brain. The monoamine oxidase inhibitors (MAOIs) also
affect the serotonin systems in the brain, but through a different mechanism. The
antidepressant tranylcypromine (trade name Parnate) is an example of one of
these MAOI drugs. If you take Prozac and Parnate at the same time, the comcombination could trigger an extremely dangerous reaction known as the
"serotonin syndrome." The symptoms can
FEELING GOOD 511 include fever, muscle rigidity, and rapid changes in blood
pressure, along with agitation, delirium, seizures, coma, and death. Obviously,
this combination of drugs should not be given! You will see in Chapter 20 that
many medications can be dangerous if you are taking an MAOI. The list of forforbidden drugs includes many antidepressants, some decon- gestants (especially
if they contain dextromethorphan, a common ingredient of cold preparations),
antihistamines, local anesthetics, some anticonvulsants, some painkillers such as
meperidine (Demerol), antispasmodics including cyclobenzaprine (Flexeril) and
weight-loss preparations. Some of these drugs will cause the serotonin syndrome
de- described above, and some of them will cause another dan- dangerous
reaction known as a "hypertensive crisis." In extreme cases, the symptoms of a
hypertensive crisis in- include brain hemorrhage, paralysis, coma, and death.
Certain common foods such as cheese are also on the "forbidden" list if you are
taking one of the MAOIs, because they can cause a hypertensive crisis as well.
Many doctors do not prescribe the MAOIs because of concerns about these toxic
interactions. You may also think: "Well, I will just take a safer drug so I won't
have to worry." This makes good sense, since many safer med- medications are
available. However, many commonly pre- prescribed antidepressants can cause
dangerous interactions. For example, two common antidepressants, nefazodone
(trade name Serzone) and fluvoxamine (trade name Luvox) should not be
combined with several commonly prescribed drugs because these particular
combinations can trigger an abnormal heart rhythm that may result in sudden
death. The drugs include terfenadine (trade name Seldane and used for allergies),
astemizole (trade name Hismanal and used for allergies), or cisapride (trade
name Propulsid, a stimulant for the gastrointestinal tract). I do not mean to give
the impression that it is dangerous to take antidepressant drugs. To the contrary,
they are usu- usually quite safe and effective, and the catastrophic drug in512 David D. Burns, M.D. teractions I have described are fortunately rare. In
addition, most psychiatrists go to great lengths to educate themselves about
addition, most psychiatrists go to great lengths to educate themselves about
recent developments and try to keep up with new information about side effects
and drug interactions. But in the real world we live in, no doctor is perfect and
no doctor can have comprehensive knowledge about all possible drug
interactions. For example, your primary care physician may not be familiar with
some new antidepressant your psychi- psychiatrist has prescribed. And so a little
research on your part will be helpful. As an enlightened consumer, you can read
about any antidepressant medicine you are taking in Chap- Chapter 20 and in
other readily available references such as the Physician's Desk Reference (PDR),
You can find these books at any library, bookstore, or pharmacy. You can also
find the PDR at your doctor's office. You can also review the drug insert that
comes with the medication. It doesn't take more than five or ten minutes to
review this infor- information. Then you can ask informed questions and bring
out the best in your physician. The teamwork can give you a safer and better
experience with your antidepressant. This is definitely one case where an ounce
of prevention can be worth more than a pound of cure.
Chapter 20 The Complete Consumer's Guide to Antidepressant Drug Therapy*
(Notes and References appear on pages 682-687.) In this chapter I will give you
practical information about the costs, doses, side effects, and drug interactions
for all the currently available antidepressant and mood-stabilizing drugs. I would
recommend you use this chapter as a ref- reference source rather than trying to
read it all at once—there is just too much detailed information to digest at one
sitting. If you want to learn about a particular drug that you or a family member
may be taking, the Table of Antidepressants on pages 514-515 will help you
locate the information you need in this chapter. Let's assume, for example, that
you are taking fluoxetine (Prozac). You can read the section on the SSRI
antidepressants starting on page 547. In addition, *I would like to thank Joe
Bellenoff, M.D., a psychopharmacology fellow at Stanford University Medical
School, and Greg Tarasoff, M.D., a senior psychiatric resident at Stanford, for
helpful suggestions during the revision of this chapter. In addition, much useful
information was obtained form the excellent Manual of Clinical PsyPsychopharmacology, Third Edition, by Alan F. Schatzberg, M.D., Jonathan
Cole, M.D., and Charles DeBattista, D.M.H., M.D. (Washington: American
Psychiatric Press, 1997). This scholarly but highly readable book is an
invaluable reference. I highly recommend it foi individuals who would like more
information on the medications currently used in the treatment of emotional
problems. 513
514 David D. Burns, M.D. Table of Antidepressants Antidepressant Drug Class
Chemical Name (and Trade Name)a Page # Tricyclic Antidepressants 524
Chemical Name (and Trade Name)a Page # Tricyclic Antidepressants 524
amitriptyline (Elavil, Endep) clomipramine (Anafranil) desipramine (Norpramin,
Pertofrane) doxepin (Adapin, Sinequan) imipramine (Tofranil) nortriptyline
(Aventyl) protriptyline (Vivactil) trimipramine (Surmontil) Tetracyclic
Antidepressants amoxapine (Asendin) maprotiline (Ludiomil) 524 SSRI
Antidepressants citalopram (Celexa) fluoxetine (Prozac) fluvoxamine (Luvox)
paroxetine (Paxil) sertraline (Zoloft) 547 MAO Inhibitors isocarboxazid
(Marplan) phenelzine (Nardil) selegiline (Eldepryl) tranylcypromine (Parnate)
564 Serotonin Antagonists nefazodone (Serzone) trazodone (Desyrel) 599 Other
Antidepressants bupropion (Wellbutrin) venlafaxine (Effexor) mirtazapine
(Remeron) 605 605 611 615
FEELING GOOD 515 Antidepressant Drug Class Mood Stabilizers Chemical
Name (and Trade Name)" carbamazepine (Tegretol) gabapentin (Neurontin)
lamotrigine (Lamictal) lithium (Eskalith) valproic acid (Depakene) and
divalproex sodium (Depakote) Page # 617 640 651 652 617 634 "Many of the
antidepressants are now available as generic brands (see Table 20-1). Only the
trade names of the original brands are listed in this table. the section on drug
costs starting on this page, as well as the information starting on page 659,
should be of general interest to all readers. Costs of Antidepressant Medications
We often think that more expensive means better, but this is not always the case
with antidepressants. As it turns out, there are some very dramatic differences in
the costs of the different antidepressants that do not reflect differences in efeffectiveness. In other words, sometimes a drug that is much cheaper will be just
as effective, or even more effective, than another drug that costs more than forty
times more. Therefore, if the cost of the medication is a concern for you, then a
little education may save you a great deal of money. The costs and doses of the
most commonly prescribed antidepressants and mood stabilizing agents are
listed in Table 20-1 on pages 518-523. Note that I am quoting the cheapest
wholesale price for each antidepressant drug in Table 20-1. The retail price you
pay for the same medi- medication at the drug store will probably be higher. If
you choose a different brand of the same medication, it may be higher yet.
Please keep this in mind in all of the following discussions of drug costs. If you
compare the costs of the different types of drugs
516 David D. Burns, M.D. and the different doses, it will provide you with some
in- interesting information. You will see, for example, that many of the older
tricyclic and tetracyclic drugs are now available generically. When a drug is first
manufactured, the drug company gets a seventeen-year patent so it can market
the drug exclusively. The relatively high cost of the newer drugs that are still
the drug exclusively. The relatively high cost of the newer drugs that are still
protected by patents helps to cover the costs of the research, development, and
testing. After the patent expires, other companies can compete and manufacmanufacture the drug, and so the price goes down drastically. You will see in
Table 20-1 that these so-called "ge- "generic" medications are much less costly
than the newer drugs that are still under patent. Let's assume that your doctor
prescribes a dose of 150 mg per day of imipramine for your depression. The cost
of the three 50-mg pills you will take will be less than 10 cents per day, or
roughly $3 per month. This is because imipramine is now available generically.
In contrast, if your doctor prescribes two 20- mg Prozac pills per day, your cost
will be nearly $4.50 per day or $135 per month—over forty times more than the
imipramine. And if she or he prescribes four Prozac pills— the maximum dose
—your cost will be $270 per month. This is a steep price for many people. Don't
forget these are wholesale prices—you may pay even more. Is Prozac forty to a
hundred times more effective than imipramine? Definitely not. As you will learn
below, most of the antidepressants tend to be comparably effective. ReResearch studies have not confirmed that Prozac is any more effective than
imipramine—in fact it may be slightly less effective for severe depressions.
However, the big advan- advantage of Prozac is that it has fewer side effects
(such as dry mouth or sleepiness) than imipramine. This may be quite important
to some people and may make the price differ- difference worthwhile. On the
other hand, you will learn that Prozac has some side effects of its own, such as
problems with sexual functioning (difficulty achieving orgasm) in as many as 30
percent to 40 percent of patients, and possibly more. People who don't like this
particular side effect might actually prefer the cheaper medication.
FEELING GOOD 51 7 You will also see in Table 20-1 that pills which contain a
larger quantity of a particular drug are not necessarily more expensive than pills
which contain a smaller quantity. This is especially true if you are taking one of
the newer drugs that is still under patent, so you may be able to save money by
buying pills containing a larger dose. For ex- example, you will see in Table 20-
1 that the cost of a hundred nefazodone (Serzone) tablets is $83.14 for the 100-
mg size. The price for a hundred tablets of the larger sizes A50 mg to 250 mg) is
exactly the same. So if you are taking a large dose, say 500 mg per day, you
could either take five of the 100-mg pills (cost of $4.16 per day) or two of the
250-mg pills (cost of $1.66 per day). In addition, you can often save money by
buying a larger size of a medication and breaking a pill in half. So to concontinue with the same example, if you are taking 250-mg pills, it will cost you
approximately half as much if you purchase 500-mg pills and break them in half.
For the generic drugs, things are different. On the aver- average, the costs are
For the generic drugs, things are different. On the aver- average, the costs are
low overall and depend on the dose, and the savings at higher doses are not so
drastic. In addition, because so many different companies manufacture these
drugs, the prices for the different doses are not always en- entirely consistent—
sometimes a smaller dose will actually cost more than a larger dose. For
example, look at the pric- pricing structure for the tricyclic antidepressant,
desipramine (trade name Norpramin) on page 518. You will see that a hundred
of the 10-mg pills cost $15.75, while a hundred of the 25-mg pills costs only
$7.14. So the larger pill is ac- actually cheaper. This is because different
companies manu- manufacture the two sizes. To make things even more
confusing, there are other cases where a larger dose costs substantially more and
you can save money by taking a smaller size. For example, take another look at
the costs of desipramine on page 518. You will see that a hundred 75-mg
desipramine pills cost $12.42, and that a hundred 150-mg desipramine pills cost
$109.95 (again, because of different manufacturers). So you
Table 20-1. Names, Doses, and Costs of Antidepressant Medications Chemical
Name" Trade (Brand) Nameb Available Sizes (mg) & Cheapest Wholesale Cost
per 100 Pills' Daily Dose Ranged Are Generics Availablee Trieyelie
Antidepressants amitriptyline clomipramine desipramine doxepin Elavil
Anafranil Norpramin Sinequan 10 mg 25 mg 50 mg 75 mg 100 mg 150 mg 25
mg 50 mg 75 mg 10 mg 25 mg 50 mg 75 mg 100 mg 150 mg 10 mg 25 mg 50
mg 75 mg 100 mg $1.73 $1.85 $2.78 $3.53 $4.28 $2.09 $78.29 $105.57 $138.97
$15.75 $7.14 $10.91 $12.42 $40.89 $109.95 $3.98 $4.43 $6.60 $8.93 $11.25 75-
300 mg 150-250 mg 150-300 mg 150-300 mg Yes No Yes Yes
imipramine hydrochloride imipramine pamoate nortriptyline protriptyline
trimipramine Tofranil Tofranil-PM (sustained release) Aventyl Vivactil
Surmontil 10 mg 25 mg 50 mg 75 mg 100 mg 125 mg 150 mg 10 mg 25 mg 50
mg 75 mg 5 mg 10 mg 25 mg 50 mg 100 mg $1.88 $2.33 $3.08 $103.67 $136.29
$169.95 $193.73 $11.55 $15.90 $19.43 $24.83 $46.46 $67.36 $64.08 $108.14
$157.20 150-300 mg 150-300 mg 50-150 mg 15-60 mg 150-300 mg Yes No Yes
No No amoxapine maprotiline Asendin Ludiomil Tetracyclic Antidepressants 25
mg 50 mg 100 mg 150 mg 25 mg 50 mg 75 mg $32.87 $53.44 $89.16 $43.87
$19.43 $29.10 $40.88 150-450 mg 150-225 mgf Yes Yes
Table 20-1. Cont. Chemical Name" Trade (Brand) Nameb Available Sizes (mg)
& Cheapest Wholesale Cost per 100 Pills? Daily Dose Ranged Are Generic s
Available* citalopram fluoxetine fluvoxamine paroxetine sertraline Celexa
Prozac Luvox Paxil Zoloft SSRI Antidepressants 20 mg 40 mg 10 mg 20 mg 50
mg 100 mg 10 mg 20 mg 30 mg 50 mg 100 mg $161.00 $168.00 $218.67
mg 100 mg 10 mg 20 mg 30 mg 50 mg 100 mg $161.00 $168.00 $218.67
$224.54 $198.67 $204.37 $189.33 $189.20 $214.80 $176.23 $181.33 20-60 mg
10-80 mg 50-300 mg 10-50 mg 25-200 mg No No No No No MAO Inhibitors
phenelzine selegiline tranylcypromine isocaboxazid Nardil Eldepryl Parnate
Marplan 15 mg $40.24 5 mg $215.90 10 mg $45.80 10 mg unavailable 15-90 mg
20-50 mg 10-50 mg 10-50 mg No No No unavailable
nefazodone trazodone bupropion venlafaxine mirtazapine Serzone Desyrel
Wellbutrin Effexor Serotonin Antagonists 100 mg 150 mg 200 mg 250 mg 50
mg 100 mg 150 mg Other Antidepressants Effexor XR (Extended Re- Release
Capsules) Remeron 75 mg 100 mg 25 mg 37.5 mg 50 mg 75 mg 100 mg 37.5
mg 75 mg 150 mg 15 mg $83.14 $83.14 $83.14 $83.14 $5.03 $11.70 $58.43
$62.17 $82.96 $105.53 $108.68 $111.93 $118.66 $125.78 $193.88 $217.14
$236.53 $198.00 300-500 mg 150-300 mg 200-450 mg 75-375 mg 75-375 mg
15-45 mg No Yes No No No No
Table 20-1. Cont. Chemical Name0 Trade (Brand) Nameb Available Sizes (mg)
& Cheapest Wholesale Cost per 100 Pills' Daily Dose Range11 Are Generics
Availablee Mood Stabilizers* lithium carbamazepine valproic acid divalproex
sodium lamotrigine gabapentin Eskalith Lithobid, Eskalith CR (sus- (sustained
release) Tegretol Depakene Depakote1 Lamictal Neurontin 150 mg 300 mg 600
mg 300 mg 450 mg 100 mg 200 mg 250 mg 125 mg 250 mg 500 mg 25 mgj 100
mg 150 mg 200 mg 100 mg 300 mg 400 mg $7.63 $5.25 $13.23 $15.53 $35.80
$14.67 $10.08 $12.98 $30.95 $60.76 $112.08 .— $175.54 $184.43 $193.33
$37.80 $94.50 $113.40 900-1500 mg'' 800-1200 mg 750-3000 mg 750-3000 mg
50-150 mgk 900-2000 mg Yes Yes Yes No No No
dIf your doctor prescribes the chemical or "generic" name on the prescription,
your pharmacist can often substitute an inexpensive brand that can be much less
costly than the trade-name dings. bOnly the brand name of the original drug is
listed. Generic versions of these drugs have their own brand names. cCost
source: Mosby's GenRx, 1998 (8th Edition): The Complete Reference Guide for
Generic and Brand Drugs. St. Louis: Mosby. The average wholesale price for
100 pills of the least expensive brand currently available is listed. This is the
price your local retail phai'macist would have to pay for the product without any
special discounts. Your cost will be more and will depend on the markup by
your pharmacist. dThe doses would be used for the treatment of an episode of
depression. Some patients may benefit from doses higher or lower than the
normal range. If prolonged treatment is necessary following recovery, a smaller
dose may be sufficient. Always consult with your doctor before changing the
dose may be sufficient. Always consult with your doctor before changing the
dose. These are drugs with generic brands available in 1998. More of the current
antidepressant drugs will become available as generic brands when their original
drug patents expire. fMaprotiline should not exceed 175 mg per day if a patient
is kept on the drug for an extended period. The manufacturer suggests that the
dose should not exceed a maximum of 225 mg for periods of up to six weeks.
sThe doses of several mood stabilizers must be monitored by blood tests and will
therefore be highly individualized for each patient, depending on your age,
gender, weight, diagnosis, and individual metabolism, as well as other
medications you may be taking. hHigher doses may be required during acute
mania because the body appeals to metabolize lithium more rapidly during
manic episodes. 'This is also available as Depakote Sprinkle A25 mg), which can
be sprinkled onto food. JThe price of the 25 mg Lamictal was not listed in
Mosby's GenRx A998 edition). This is the recommended dose range for epilepsy
when given in conjunction with valproic acid. When given alone, the
recommended dose range for epilepsy is 300 mg to 500 mg per day.
524 David D. Burns, M.D. can save lots of money by taking two 75-mg pills
instead of one 150-mg pill. Again, this is because different com- companies
manufacture the 75-mg and 150-mg sizes. This may strike you as odd, but the
pricing structure in some in- instances is completely out of whack. If you or a
family member is taking an antidepressant, make sure you study Table 20-1 and
discuss these cost issues with your druggist. A little quick and easy research on
your part may result in large savings. Another important point, not illustrated in
the table, is that the cost of the same generic drug and dose can vary greatly
because the generics often have so many different manufacturers. In Table 20-
1,1 have always listed the least costly generic brand of each pill; other more
costly versions of the same pill are not listed. For example a hundred 50- mg
imipramine pills manufactured by the drug company HCFA FFP will cost only
$3.08. Because this was the lowest-priced generic brand, I listed it in Table 20-1.
In contrast, a hundred of the same size imipramine manufac- manufactured by
Novartis, another drug company, will cost $74.12—more than twenty times
more. Keep in mind that if your doctor prescribes the antidepressant by its
chemical name (as listed in Table 20-1), your druggist will have the freedom to
provide you with the least costly generic brand if one is available. My goal is not
to promote any one drug or class of drug. All antidepressants have merit, and
they all have some draw- drawbacks. The key point is this: more expensive does
not always mean better. If you review the costs of these drugs, you can work
with your doctor and pharmacist to choose the med- medication and brand that
will make the most sense for you. Specific Kinds of Antidepressants Tricyclic
and Tetracyclic Antidepressants The first drugs listed in the Table of
and Tetracyclic Antidepressants The first drugs listed in the Table of
Antidepressants on page 514 are called "tricyclic" and "tetracyclic" antideFEELING GOOD 525 pressants. The tricyclic and tetracyclic antidepressants
dif- differ slightly in their chemical structures. "Tri" means three and "tetra"
means four. "Cyclic" refers to a circle or ring. The tricyclic compounds consist
of three linked molecular rings, while the tetracyclics consist of four. You will
see that eight tricyclic and two tetracyclic an- antidepressants are listed in the
Table of Antidepressants. The eight tricyclic drugs include amitriptyline (Elavil),
clomi- pramine (Anafranil), desipramine (Norpramin), doxepin (Sinequan),
imipramine (Tofranil), nortriptyline (Aventyl), protriptyline (Vivactil), and
trimipramine (Surmontil). These eight tricyclic drugs used to be the most widely
pre- prescribed antidepressants. They are still among the most ef- effective of all
the antidepressants. Many of them are also the least expensive because generic
brands have become available. However, tricyclics tend to have more side efeffects than the newer drugs, and so they are less popular than they used to be.
By the same token, they have been prescribed for several decades and have a
long track record of reasonably good effectiveness and safety. The two
tetracyclic antidepressant medications listed on the table are called amoxapine
(Asendin) and maprotiline (Lu- diomil). These two tetracyclics were synthesized
and released after the tricyclics had been in use for some time. It was hoped that
they would represent significant improvements in treat- treatment, either because
of increased effectiveness for certain types of depression, or because of fewer
side effects. Unfortunately, these expected improvements did not re- really
materialize. For the most part, the effectiveness, mech- mechanism of action,
and side effects of the eight tricyclic and the two tetracyclic antidepressants are
quite similar. Doses for the Tricyclic and Tetracyclic Antidepres- sants. Table
20-1 on pages 518-523 lists the costs and dose ranges of the eight tricyclic and
the two tetracyclic antidepressant medications. As noted above, many of them
are inexpensive because they are no longer on patent, and so generic brands are
readily available. Don't be fooled into
526 David D. Burns, M.D. thinking the cheaper antidepressants are less
effective, how- however. A number of studies suggest they may be slightly more
effective than many of the newer antidepressants such as Prozac. The most
common error your doctor is likely to make is to prescribe a dose of a tricyclic
antidepressant that is too low. This statement may run against your grain if you
feel you should take the lowest dose possible. In the case of tricyclics, if the
prescribed dose is too low, the medication will not be effective. If you insist on
taking a dose that is too low, you may be wasting your time. It simply will not
taking a dose that is too low, you may be wasting your time. It simply will not
help you. On the other hand, dosages above those recom- recommended in Table
20-1 can be dangerous and may lead to a worsening of your depression. Having
said that, let me also say that there are cases in which people do respond to doses
that are smaller than those listed (especially the elderly), and there are also times
when people may need larger doses. One reason for this is that there can be
considerable differences in how rapidly people metabolize antidepressant drugs.
These differences are par- partially genetic, and are due to levels of certain
enzymes in your liver, as described previously. If you are a "fast meta- bolizer"
you will need a larger dose to maintain an effective blood level, and if you are a
"slow metabolizer" you will need a smaller dose. In addition, you will learn
below about other drugs that can make tricyclic blood levels fall and lose their
effectiveness or increase and become more toxic. If you suspect you may be
taking an inappropriately large or small dose, review the dose ranges in Table
20-1 and discuss your concerns with your physician. Blood-level testing for most
of the tricyclic antidepressants is readily available, so your doctor may order a
blood test to make sure that the dose you are taking is neither too high nor too
low for you. The best way to begin taking a tricyclic medicine is to start out with
a small dose and to increase the amount each day until a dose within the normal
therapeutic range is achieved. This buildup can usually be completed within one
FEELING GOOD 527 or two weeks. For example, a typical daily dose schedule
for imipramine, one of the most commonly prescribed tri- tricyclic
antidepressant drugs listed in Table 20-1, might be the following: Day one—50
mg at bedtime; Day two—75 mg at bedtime; Day three—100 mg at bedtime;
Day four—125 mg at bedtime; Day five—150 mg at bedtime. You and your
doctor may prefer to build up the dose a bit more gradually. Doses of up to 150
mg per day can be conveniently taken once a day at night. The antidepressant
effect will last all day long, and the most bothersome side effects will occur at
night, when they will be least noticed. If doses larger than 150 mg per day are
required, the ad- additional medicine should be given in divided doses during the
daytime. For the more sedating tricyclic antidepressants, up to half the maximum
indicated dose may be taken on a once-per- day basis before bedtime. This
dosage promotes sleep. Sev- Several of the tricyclic antidepressants, including
desipramine, nortriptyline, and protriptyline, can be stimulating. They can be
taken in divided doses in the morning and at noon. If taken too late in the day,
they may interfere with sleep. If you reduce the dose of a tricyclic antidepressant
or if you decide to stop taking the medicine, it is best to reduce the dose
gradually and never abruptly. Sudden discontinu- discontinuation of any
antidepressant may result in side effects. These include upset stomach, sweating,
antidepressant may result in side effects. These include upset stomach, sweating,
headache, anxiety, or in- insomnia. Usually, you can go off a tricyclic
antidepressant safely and comfortably by tapering the dose gradually over a oneor two-week period. Side Effects of the Tricyclic Antidepressants. The most
frequent side effects of the tricyclic antidepressants are listed in Table 20-2 on
pages 530-532. You will see in this table that all the tricyclic antidepressants
have quite a number of side effects, and this is their greatest drawback.
528 David D. Burns, M.D. The most common side effects include sleepiness,
dry mouth, a mild hand tremor, temporary light-headedness when you suddenly
stand up, weight gain, and constipation. They can also cause excessive sweating,
difficulties with sex, twitches or jerking when you fall asleep at night, and a
number of other effects listed in Table 20-2. Most of these side effects are not
dangerous, but they can be annoying. You learned earlier that the side effects of
antidepressant drugs can be predicted if you know how strongly they block
histamine receptors, alpha-adrenergic receptors, and mus- carinic receptors (also
called cholinergic receptors) in the brain. You can see from Table 20-2 that each
antidepres- antidepressant has a different profile of side effects depending on its
action on these three receptor systems in the brain. Blockade of the brain's
histamine receptors makes you hungry and sleepy. Table 20-2 indicates that four
of the tricyclic antidepressants (amitriptyline, clomipramine, dox- epin, and
trimipramine) have rather strong effects on the histamine receptors.
Consequently, these four antidepres- antidepressants are more likely to make
you feel sleepy and hungry. If you are having trouble sleeping, this side effect
could be a benefit, but if you are already feeling sluggish and un- motivated,
these drugs may make things worse for you. If you have been losing weight due
to depression, the appetite boost could be beneficial. However, if you are
overweight, you might have to pay more attention to your diet and ex- exercise
more in order to avoid weight gain, which can be demoralizing. Since there are
now many available antide- antidepressants that do not cause weight gain, it
might be better to switch to one of them. You can see in Table 20-2 that three of
the tricyclics (desipramine, nortriptyline, and pro- triptyline) have only weak
effects on the histamine recep- receptors. These antidepressants will be less
likely to cause sleepiness and weight gain. There are many antidepressants in
other categories as well that do not cause sleepiness and weight gain. You may
also recall that blockade of the brain's alpha- adrenergic receptors causes a drop
in blood pressure. This can result in temporary light-headedness or dizziness
when
FEELING GOOD 529 you suddenly stand up because your leg veins become
more relaxed, and blood temporarily pools in your legs. As a result, your heart
more relaxed, and blood temporarily pools in your legs. As a result, your heart
temporarily does not have enough blood to pump up to your brain, and so your
vision may get black and you may feel dizzy or woozy for a few seconds. Antidepressants with relatively strong effects on the brain's alpha-adrenergic
receptors will be more likely to cause dizziness when you suddenly stand up.
You will see in Table 20-2 that many tricyclics have strong effects on alphaadrenergic receptors, but that two of them (desipra- mine and nortriptyline) have
only weak effects on them. Consequently, these two drugs are less likely to
cause diz- dizziness or a drop in blood pressure. Finally, blockade of the brain's
muscarinic receptors causes side effects such as dry mouth, constipation, blurred
vision, difficulties getting your urine flow started, and a speeding up of the heart,
even when you are resting. Be- Because of these effects on the heart, the
tricyclic medications in Table 20-2 with the strongest effects on these muscarinic
receptors may not be advisable for patients with cardiac problems. Drugs with
strong anticholinergic effects can also create problems with memory. Many
patients have told me that they cannot remember a word they want to use, or
they forget someone's name when they take these drugs. The memory effects are
dose-related and should disappear when you stop taking the drug. You can see
that two of the tricyclic drugs in Table 20-2 (desipramine and nortriptyline) have
relatively weak anti- anticholinergic effects. These two drugs will be the least
likely to cause side effects like dry mouth and forgetfulness. These two also tend
to have weaker effects on the hista- minic and alpha-adrenergic receptors.
Because they have fewer side effects, they are among the most popular tritricyclic antidepressants. The effects of antidepressant drugs on these three brain
re- receptor systems do not completely explain all their side effects. In the righthand column, I have listed many of the more com- common or significant side
effects for each drug. For example, you will see that some of them can cause
skin rashes.
Table 20-2. Side Effects of Tricyciic Antidepressants' Note: This list is not
comprehensive. In general, side effects that occur in 5% or 10% or more of
patients are listed, as well as rare but dangerous side effects. Side Effect Brain
Receptor amitriptyline (Elavil, Endep) clomipramine (Anafranil) Sedation and^
Weight Gainc histamine (Hj) receptors + + + + + to + + + Light- Headedness
and Dizziness alpha-adrenergic @Cj) receptors + + + + + + Blurred Vision,
Constipation, Dry Mouth, Speeded Heart, Urinary Retention muscarinic (Mj)
receptors + + + + + to + + + Common or Significant Side Effects dizziness;
speeded heart; abnormal ECG; dry mouth; constipation; weight gain; trouble
urinating; blurred vision; ringing in ears; sweating; weakness; headache; tremor;
tiredness; insomnia; confusion dizziness; speeded heart; abnormal ECG; dry
tiredness; insomnia; confusion dizziness; speeded heart; abnormal ECG; dry
mouth; upset stomach; loss of appetite; constipation; weight gain; trouble
urinating; menstrual changes; disturbed sexual
desipramine (Norpramin, Pertofrane) doxepin (Adapin, Sinequan) • • imipramine
(Tofranil) nortriptyline (Aventyl) to to + to to to functioning; blurred vision;
sweating; weakness; muscle cramps; tremor; tiredness; insomnia; anxiety;
headache; rash; seizures dry mouth; rashes; agitation; anxiety; headache;
insomnia; stimulation dizziness; speeded heart; dry mouth; constipation; weight
gain, blurred vision; sweating; sleepiness dizziness; speeded heart; abnormal
ECG; dry mouth; constipation; weight gain; trouble urinating; blurred vision;
sweating; weakness; headache; tiredness; insomnia; anxiety; stimulation; rash;
seizures; sensitivity to light; stimulation dry mouth; constipation; tremor;
weakness; confusion; anxiety or stimulation
Side Effect Brain Receptor protriptyline (Vivactil) trimipramine (Surmontil)
Sedation and Weight Gainc histamine (H2) receptors Oto + Light-Headedness
and Dizziness alpha-adrenergic (Olj) receptors + to + + + 4- tO + + + Blurred
Vision, Constipation, Dry Mouth, Speeded Heart, Urinary Retention muscarinic
(Mj) receptors + + to + + + Common or Significant Side Effects dizziness;
decreased or increased blood pressure; abnormal ECG; nausea; constipation;
blurred vision; sweating; weakness; insomnia; stimulation; headache dizziness;
decreased or increased blood pressure; abnormal ECG; dry mouth; constipation;
weight gain; blurred vision; sweating; weakness; headache; tremor; sleepiness;
confusion; intolerance to heat or cold aThe + to + + + ratings in this table refer to
the likelihood that a particular side effect will develop. The actual intensity of
the side effect will vary among individuals and will also depend on how large
the dose is. Reducing the dose can often reduce side effects without reducing
effectiveness. bMany side effects, if troublesome, can be minimized by a
reduction in dosage. Side effects are usually greatest in the first few days and
tend to disappear later. The drugs that are the most sedative may also have
greater antianxiety effects. In other words, they may calm you and make you less
nervous. When given at night, the sedative agents help reduce insomnia.
FEELING GOOD 533 Some tricyclics, most notably clomipramine (Anafranil),
can cause seizures, and so this drug would not be a good choice for individuals
with epilepsy. If you and your doctor are choosing one of the antide- pressants
listed in Table 20-2, you might want to consider the side-effect profile when
making your choice. This is because all these medications are comparably
effective, so their side effects may be the most important criteria for you in
effective, so their side effects may be the most important criteria for you in
deciding among them. So if you are having trouble sleep- sleeping at night, one
of the more sedative antidepressants may be useful. These sedative agents are
also somewhat calming and so they might be helpful if you are experiencing
anx- anxiety. Many of the side effects of the tricyclic antidepressants listed in
Table 20-2 occur in the first few days. With the exception of dry mouth and
weight gain, these side effects frequently diminish as you become accustomed to
the drug. If you can simply put up with the side effects, many of them will
disappear after a few days. If the effects are strong enough to make you
uncomfortable, your doctor may decide to reduce the dose, which usually helps.
Some side effects suggest you are taking an excessive dose. These include
difficulty in urination, blurred vision, confusion, severe tremor, substantial
dizziness, or increased sweating. A dose reduction for such symptoms is
definitely indicated. A stool softener or laxative can help if consti- constipation
develops. As noted above, light-headedness is most likely to occur when you
stand up suddenly, because the blood flow to your brain is temporarily
diminished. The dizzy feeling usually persists for only a few seconds. If you get
up more carefully and slowly, or if you exercise your legs before standing (by
tightening and then relaxing your leg muscles, as when you run in place), this
should not be a problem. The movement of your legs causes your leg muscles to
"pump" the blood back up to your brain. Sup- Support stockings can also help.
Some patients describe feeling "strange," "spaced out," or "unreal" for several
days when they first start taking a
534 David D. Burns, M.D. tricyclic antidepressant. In my experience, one of the
tri- cyclics called doxepin (Sinequan) seems more likely to cause this "spaced
out" effect. When patients report feeling strange on the first day or two of taking
an antidepressant, I usually advise them to stick with it. In nearly all cases the
sensation disappears completely within a few days. If you give patients sugar
pills (placebos) they think are antidepressants, they will also report side effects
that are similar to the side effects reported by patients taking anti- depressants.
For example, in one study, 25 percent of the patients taking clomipramine
reported difficulties sleeping, so you might conclude that this drug causes
insomnia in a quarter of those who take it. However, 15 percent of the patients in
the same study who received only placebo also reported insomnia. So the
likelihood of insomnia actually caused by clomipramine would be 25 percent
minus 15 percent, or 10 percent. Clearly, this side effect is "real," but it is
somewhat less common than you might at first expect. Such studies indicate that
many "side effects" may not actually be caused by the medication you are
taking. Some side effects may result from fears about the medication, or from
the depression itself, or from other stressful events in your life such as a conflict
the depression itself, or from other stressful events in your life such as a conflict
with your spouse, rather than from the drug itself. Side Effects of the Tetracydic
Antidepressants. You can see in Table 20-3 on pages 536-537 that the side efeffects of the tetracyclic antidepressants are similar to those of the tricyclic
antidepressants. However, they have some special side effects of their own that
should be considered if you are taking one of these drugs. Maprotiline
(Ludiomil) appears to be more likely than the eight tricyclic antideantidepressant drugs to cause seizures, a particularly troublesome side effect.
Although the likelihood of seizures is low, pa- patients with a history of seizures
or head trauma should prob- probably avoid this drug. Recent studies suggest
that the likelihood of seizures with maprotiline is significantly
FEELING GOOD 535 greater when the dose is increased too rapidly, or when
patients are kept on higher-than-recommended doses B25 to 400 mg per day) for
more than six weeks.16 Therefore the manufacturer has suggested that
maprotiline should be started and increased very slowly, and that the dose should
be maintained at no more than 175 mg per day if patients take this drug for more
than six weeks. Amoxapine (Asendin) has a distinct and troublesome type of
side effect not shared with most other antidepres- sants. This is because one of
its metabolites blocks dopa- mine receptors in the brain, much like antipsychotic
drugs such as chlorpromazine (Thorazine) and many others which are used in the
treatment of schizophrenia. Thus, patients who take amoxapine can in rare
instances develop some of the same types of side effects that occur in patients
who take antipsychotic drugs. For example, women may expe- experience
galactorrhea (the production of milk by the breast.) Any of several so-called
"extrapyramidal" reactions can also develop. One of them, called akathisia, is a
motor rest- restlessness syndrome. This is an unusual kind of muscular
"itchiness"—your arms or legs feel intensely restless and so you cannot sit still.
You feel the compulsion to keep moving or pacing about. Akathisia is
uncomfortable but not dangerous. In rare instances amoxapine can also cause
symptoms that mimic Parkinson's disease. Symptoms include passive inactivity,
a "pill-rolling" tremor of the thumb and fingers while at rest, decreased swinging
of the arms when walk- walking, stiffness, stooped posture, and others. If these
symp- symptoms develop, notify your doctor right away. She or he will probably
want you to stop the drug and try an alternative medication. Although alarming,
these symptoms are not dangerous and should disappear when you stop taking
the amoxapine. However, a more serious side effect of amoxapine (as well as
many other antipsychotic drugs) is called "tardive dyskinesia." Patients with
tardive dyskinesia develop in- involuntary, repetitious movements of the face,
especially the
especially the
Table 20-3. Side Effects of Tetracyclic Antidepressants2 Note: This list is not
comprehensive. In general, side effects that occur in 5% or 10% or more of
patients are listed, as well as rare but dangerous side effects. Side Effect Brain
Receptor amoxapine (Asendin) maprotiline (Ludiomil) Sedation and Weight
Gain histamine (H}) receptors Light- Headedness and Dizziness alpha-adrene
rgic (otj) receptors * Blurred Vision, Constipation, Dry Mouth, Speeded Heart,
Urinary Retention muscarinic (M}) receptors + to + + Common or Significant
Side Effects dizziness; speeded heart; dry mouth; stomach upset; constipation;
trouble urinating; blurred vision; rashes; tremor; tiredness; insomnia; EPSb;
lactation; restlessness; excessive stimulation; tardive dyskinesia; galactorrhea;
NMSC dry mouth; constipation; weight gain; blurred vision; rashes; sleepiness;
seizures; stimulation; sensitivity to light; edema (swelling of ankles)
aThe + to + + + ratings in this table refer to the likelihood that a particular side
effect will develop. The actual intensity of the side effect will vary among
individuals and will also depend on how large the dose is. Reducing the dose can
often reduce side effects without reducing effectiveness. bEPS = extrapyramidal
symptoms (described in text) including akathisia and dystonic reactions and
tardive dyskinesia. CNMS = neuroleptic malignant syndrome. This is a
potentially fatal reaction that also occurs in reaction to antipsychotic drugs (also
known as neuroleptics). The symptoms include increased fever, rigid muscles,
altered mental status, irregular pulse or blood pressure, rapid heart, profuse
sweating, and abnormal heart rhythms.
538 David D. Burns, M.D. lips and tongue. The abnormal movements can also
involve the arms and legs. Once it begins, tardive dyskinesia some- sometimes
becomes irreversible or difficult to treat. The risk ap- appears to be the highest
among elderly women, but it can occur with any patient. The risk of tardive
dyskinesia also increases the longer you have been on the drug, but it can
develop after only a brief period of treatment at a low dose. Finally, as if that
weren't enough to frighten you, amox- apine can, in rare cases, cause a dreaded
complication known as neuroleptic malignant syndrome, or NMS. NMS consists
of high fever, delirium, and muscle rigidity, along with changes in blood
pressure, heart rate and rhythm, and sometimes death. All these risks should
obviously be care- carefully balanced against any potential benefits of
amoxapine; it may sometimes be difficult to justify using this medicamedication when so many equally effective and safer drugs are readily available.
Tricyclic and Tetracyclic Antidepressant (TCA) Drug Interactions. I described
the problem of drug interactions in Chapter 19. Briefly, when you are taking
the problem of drug interactions in Chapter 19. Briefly, when you are taking
more than one drug, there is a possibility that the drugs may interact in ways that
will be detrimental to you. One drug may cause the level of the second drug to
increase or decrease in your blood. As a result, the second drug may cause
excessive side effects (if its blood level gets too high) or it may be- become
ineffective (if its blood level falls). In addition, some- sometimes the interaction
of two drugs can lead to toxic reactions that are quite dangerous. A number of
drug interactions for the tricyclic and tetra- tetracyclic antidepressants are listed
in Table 20-4 on pages 540-547. This list is not comprehensive, but it does
include many of the more common or important interactions. If you are taking
any other medications along with a TCA, it would be wise to review this table.
Note that both prescrip- prescription and nonprescription drugs are listed,
including many psychiatric and nonpsychiatric drugs as well. In addition,
FEELING GOOD 539 you should ask your physician and pharmacist if there are
any drug interactions among the drugs you are taking. You can see in Table 20-4
that smoking cigarettes and drinking alcohol can both cause the blood level of a
TCA to fall, thus reducing the likelihood that the drug will be effective. Your
doctor may need to do a blood test to find out if your blood level is adequate. In
addition, alcohol can enhance the sedative effects of the tricyclic antidepressants,
a combination that can be quite hazardous if you are driving or operating
dangerous machinery. Certain antidepressants can be particularly hazardous for
individuals with specific medical conditions. In particular, the tricyclics can be
dangerous to individuals with cardio- cardiovascular disease, including those
with a previous heart at- attack, abnormalities in heart rhythm, or high blood
pressure. Special precautions should also be taken for individuals with thyroid
disease. Make sure you mention any medical problems you have to the doctor
who is prescribing your antidepressant so that she or he can take the proper
precau- precautions. As noted above, several of the tricyclic and tetracyclic
antidepressants can cause seizures in rare instances. An in- incidence of seizures
as high as 1 percent to 3 percent has been reported with clomipramine,
imipramine, and mapro- tiline.17 These estimates may be overly high. At any
fate, the risk can be reduced by making sure the dose is not excessive and by
raising the dose gradually. Nevertheless, these drugs should be used with
caution, if at all, in indi- individuals with a history of seizure disorders, head
trauma, or other neurologic disorders associated with seizures. In ad- addition,
caution should be used if these drugs are combined with other drugs that can
lower the seizure threshold, such as the major tranquilizers (neuroleptics) and
others. Rapid withdrawal from sedative agents, such as alcohol, minor
tranquilizers, and barbiturates can also trigger seizures, and so clomipramine,
tranquilizers, and barbiturates can also trigger seizures, and so clomipramine,
imipramine, and maprotiline should be used with great caution in combination
with these agents.
540 David D. Burns, M.D. Table 20-4. Drug Interaction Guide for Tricyclic and
Tetracyclic Antidepressants (TCAs)a Note: The drugs in the left-hand column
can interact with TCAs. The comments describe the types of interactions. This
list is not exhaustive; new information about drug interactions comes out
frequently. If you are taking a TCA and any other medication, ask your doctor
and pharmacist if there are any drug interactions you should know about.
Antidepresssants Drug tricyclic and tetracyclic antidepressants (TCAs can
interact with other TCAs) SSRIs MAOIs serotonin antagonists, including
trazodone (Desyrel) and nefazodone (Serzone) bupropion (Wellbutrin)
venlafaxine (Effexor) mirtazapine (Remeron) Comment desipramine causes an f
in other TCAs—abnormal heart rhythms can result TCA levels can f (as much as
2- to 10-fold); abnormal heart rhythms can result; SSRI levels can also f
serotonin syndrome b [especially clomipramine (Anafranil)]; low blood
pressure; hypertensive reactions nefazodone may cause low blood pressure t in
risk of seizures; extreme caution required probably okay; in theory TCA could
cause f in venlafaxine blood levels information not yet available Drug
chloramphenicol (Chloromycetin) doxycycline (Vibramycin) isoniazid (INH,
Nydrazid) Antibiotics Comment TCA levels and toxicity may f TCA levels and
effectiveness may I TCA levels and toxicity may f
FEELING GOOD 541 Antifungal Agents Drug imidazoles such as fluconazole
(Diflucan), itraconazole (Sporanox), ketoconazole (Nizoral) and miconazole
(Monistat vaginal suppositories or cream) griseofulvin (Fulvicin) Comment TCA
levels may f , especially nortriptyline TCA levels may I Diabetes Medications
Drug insulin oral hypoglycemic drugs Comment greater-than-expected drop in
blood sugar greater-than-expected drop in blood sugar Medical Conditions
Condition glaucoma heart disease liver disease seizure disorder thyroid disease
Comment highly anticholinergic TCA can trigger attacks of narrow-angle
glaucoma; symptoms include eye pain, blurred vision, and halos around lights
use TCA with extreme caution; may trigger abnormal heart rhythms use TCA
with caution; the metabolism by the liver may be impaired, with excessively
high blood levels and increased side effects and toxic effects use TCA with
caution; TCA may cause f in seizures (TCA lowers the seizure ' 'threshold") use
TCA with caution in patients with thyroid disease or those taking thyroid
medication; may trigger abnormal heart rhythms
542 David D. Burns, M.D. Medications for Abnormal Heart Rhythms Drug
disopyramide (Norpace) epinephrine quinidine Comment abnormal heart
rhythms TCA may enhance the effects, leading to rapid heart, abnormal heart
rhythms, and t in BP blood levels of quinidine and TCA may f ; abnormal heart
rhythms and weakened heart muscle can lead to congestive heart failure
Medications for High Blood Pressure Drug beta-blockers such as propranolol
(Inderal) clonidine (Catapres) calcium channel blockers guanethidine (Ismelin)
methyldopa (Aldomet) prazosin (Minipress) Comment beta-blockers may cause
increased depression; TCA may cause greater- than-expected drop in BP TCA
[e.g., desipramine (Norpramin)] may reduce effectiveness of clonidine because
blood levels I BP drop may be greater than expected may lose antihypertensive
effect when combined with TCA [e.g., desipramine (Norpramin)] BP drop may
be greater than expected, especially with amitriptyline (Elavil); some TCAs
[e.g., desipramine (Norpramin)] may reduce the antihypertensive effect BP may
f because levels of prazosin may |
FEELING GOOD 543 Drug reserpine (Serpasil) thiazide diuretics such as
hydrochlorothiazide (Dyazide) Comment may cause greater-than-expected drop
in BP; may also cause excessive stimulation blood-pressure drop may be greater
than expected; effects of TCA may increase Medications for Low Blood
Pressure (for patients in shock) Drug epinephrine Comment TCA may enhance
the effects, leading to rapid heart, abnormal heart rhythms, and t inBP Mood
Stabilizers and Anticonvulsants Drug carbarn azepine (Tegretol) lithium
(Eskalith) phenytoin (Dilantin) valproic acid (Depakene) Comment blood levels
of TCA and carbamazepine may j; TCA can make seizures more likely may
enhance antidepressant effects blood levels of TCA may f or I; TCA can make
seizures more likely t in blood levels of amitriptyline (Elavil) and valproic acid
Pain Medications and Anesthetics Drug acetaminophen (Tylenol) aspirin
halothane (Fluothane) Comment TCA levels may f ; acetaminophen levels may j
TCA levels may f TCA levels may j ; TCA with strong anticholinergic effects
may cause abnormal heart rhythms
544 David D. Burns, M.D. Pain Medications and Anesthetics cont. Drug
cyclobenzaprine (Flexeril) (a muscle relaxant used to treat muscle spasm)
methadone (Dolophine) meperidine (Demerol) morphine (MS Contin)
pancuronium (Pavulon) Comment may cause abnormal heart rhythms may have
greater-than-expected narcotic effect; for example, desipramine (Norpramin)
may double the blood level of methadone greater-than-expected narcotic effect;
lower doses of meperidine or another painkiller may be needed greater-thanexpected narcotic effect and sedation; TCA levels may | abnormal heart rhythms,
expected narcotic effect and sedation; TCA levels may | abnormal heart rhythms,
especially TCA with strong anticholinergic effects Sedatives and Tranquilizers
Drug alcohol barbiturates (such as phenobarbital) buspirone (BuSpar) chloral
hydrate (Noctec) ethchlorvynol (Placidyl) Comment May have enhanced
sedative effects. This could be hazardous when driving or operating dangerous
machinery. May cause TCA levels to | enhanced sedative effects; may cause
TCA levels to 1 enhanced sedative effects as described above TCA levels may I
Temporary mental confusion has been reported when combined with
amitriptyline (Elavil), but could conceivably occur with other TCAs as well
FEELING GOOD 545 Drug major tranquilizers (neuroleptics) minor
tranquilizers (neuroleptics) Comment levels of TCA and phenothiazine
neuroleptics [such as chlorpromazine (Thorazine)] may f , leading to more side
effects and greater potency; abnormal heart rhythms have been observed with
thioridazine (Mellaril), clozapine (Clozaril), and pimozide (Orap) enhanced
sedative effects Stimulants (Pep Pills) and Street Drugs Drug amphetamines
("speed" or "crank*') cocaine benzedrine benzphetamine (Didrex)
dextroamphetamine (Dexedrine) methamphetamine (Desoxyn) methylphenidate
(Ritalin) Comment These drugs may boost the blood levels and effects of some
TCA [(e.g., imipramine (Tofranil), clomipramine (Anafranil), desipramine
(Norpramin)] and vice versa; abnormal heart rhythms and increased blood
pressure have been observed with cocaine, but seem possible when any
stimulants are combined with TCA Weight-Loss and Appetite-Suppression
Medications Drug fenfluramine (Pondimin) Comment Possible serotonin
syndrome when combined with clomipramine; increased TCA levels
546 David D. Burns, M.D. Other Medications Drug antihistamines
acetazolamide (Diamox) birth control pills and other medications containing
estrogen caffeine (in coffee, tea, soda, chocolate) charcoal tablets cholestyramine
(Questran) cimetidine (Tagamet) disulfiram (Antabuse) ephedrine (can be found
in Bronkaid, Marax, Primatene, Quadrinal, Vicks Vatronol nose drops, and
several other asthma and cold medications) high fiber diet liothyronine (T3,
Cytomel) Comment increased drowsiness; it is safer to use antihistamines that
are not sedative TCA blood levels may |; blood pressure may fall TCA blood
levels may f , with greater side effects; higher doses of estrogen may reduce the
effects of TCA TCA blood levels may f TCA blood levels may I due to poor
absorption from the stomach and intestinal tract TCA blood levels may j TCA
blood levels may f (greater side effects) TCA blood levels may f (greater side
effects); in two reported cases, disulfiram plus amitriptyline (Elavil) caused a
severe brain reaction (organic brain syndrome) with mental confusion and
severe brain reaction (organic brain syndrome) with mental confusion and
disorientation TCA may block the f in BP ordinarily caused by ephedrine;
ephedrine levels and effects may j TCA blood levels may 1 due to poor
absorption from the stomach and intestinal tract can enhance the effects of TCA;
abnormal heart rhythms can result; TCA blood levels may T
FEELING GOOD 547 Drug prochlorperazine (Compazine) psyllium
(Metamucil) scopolamine (Transderm) L-dopa (Sinemet) theophylline
(Bronkaid) tobacco (smoking) Comment TCA blood levels may f with increased
side effects and toxic effects TCA blood levels may 1 due to poor absorption
from the stomach and intestinal tract may cause f in TCA blood levels
absorption of TCA from the stomach and intestinal tract into the blood may I;
effects of both TCA and L-dopa may | TCA blood levels may | TCA blood levels
may I "Information in this table was obtained from several sources including the
Manual of Clinical Psychopharmacology1 and Psychotropic Drugs Fast Facts.11
These excellent references are highly recommended. bThis is a dangerous and
potentially fatal syndrome which includes rapid changes in vital signs (fever,
oscillations in blood pressure), sweating, nausea, vomiting, rigid muscles,
myoclonus, agitation, delirium, seizures, and coma. Selective Serotonin
Reuptake Inhibitors (SSRIs) Currently, the most popular antidepressant drugs
are the selective serotonin reuptake inhibitors, or SSRIs. At this time, five SSRIs
are prescribed in the United States. These include citalopram (Celexa), the
newest SSRI which was released in the U.S. in 1998, fluoxetine (Prozac), the
first SSRI which was released in 1988, and fluvoxamine (Lu- vox), paroxetine
(Paxil), and sertraline (Zoloft). The effects of these SSRIs on the brain are much
more specific and selective than the older tricyclic and tetracyclic drugs disdiscussed above. Instead of interacting with many different systems in the brain,
these drugs have selective effects on nerves that use serotonin as a transmitter
substance. When it first appeared on the market, there was a great deal of
excitement about Prozac because it was chemically
548 David D. Burns, M.D. quite different from the older antidepressants. Unlike
the tricyclic and tetracyclic drugs, it has specific effects on the serotonergic
nerves in the brain. Since a serotonin defi- deficiency was hypothesized to be the
cause of depression, it was hoped that Prozac would be dramatically more effeceffective than the tricyclic and tetracyclic drugs which seemed to affect so many
different systems in the brain in a less specific manner. It was also expected that
Prozac (and the other SSRIs) would have fewer side effects than the tri- tricyclic
and tetracyclic drugs. This is because Prozac does not have such strong effects
on the histaminic, alpha- adrenergic, and muscarinic receptors. Only one of these
two hopes was fulfilled. Prozac and the other four SSRIs do cause significantly
two hopes was fulfilled. Prozac and the other four SSRIs do cause significantly
fewer side ef- fects than the tricyclic and tetracyclic antidepressants and are
more pleasant to take. For example, they are less likely to cause sleepiness,
weight gain, dry mouth, dizziness, and so on. They are also much safer since
they are less likely to have adverse effects on the heart, and they are much less
likely to result in death if a patient intentionally or unin- unintentionally takes an
overdose. The biochemists who created these new drugs deserve credit in this
regard. Unfortunately, the SSRIs are not more effective than the older drugs. As
many as 60 percent to 70 percent of de- depressed patients will improve when
treated with SSRIs, and these percentages are no better than the older drugs.
Among chronically depressed patients, the probability of respond- responding
appears to be lower. The SSRIs also appear to be slightly less effective than the
older tricyclic antidepressants for more severely depressed patients. In addition,
the amount of improvement is often only partial—the patient may become less
depressed, but may not return to full self- esteem and joyous daily living. This is
a problem for all the antidepressants, and not just the SSRIs. Although they are
no more effective, the SSRIs are dramatically more ex- expensive than the older
drugs. In addition, the SSRIs have some new and different side effects described
below that were not publicized when they were first released.
FEELING GOOD 549 Because of their favorable safety record and diminished
side effects, though, the SSRIs have truly captured the an- tidepressant market.
More money was spent on Prozac in 1995 ($2.5 billion) than was spent on all
other antidepres- sants in 1991 ($2.0 billion). One reason for the upsurge in
popularity is that primary care physicians now feel com- comfortable prescribing
antidepressants because the SSRIs are so safe. As a result, many depressed
patients who would not think of going to a psychiatrist or psychologist receive
SSRIs from their family physicians. Because the SSRIs are used so widely and
because they have received so much media attention, many people be- believe
they are incredibly powerful and almost magically ef- effective. But this is
simply not the case, as noted above. For some depressed people, the SSRIs can
be very effective. For many others, they are only somewhat effective. And often
they do not seem to have any antidepressant effects at all. It is the same story
with all of our currently available antidepressants—they are valuable tools to
fight depression but they are often not the entire answer and they are cercertainly not a panacea for what ails you. The fact that the SSRIs are not more
effective than the older drugs has caused scientists to reconsider the validity of
the "serotonin" theory of depression which I described in Chapter 17. You will
recall that according to this theory, a deficiency of serotonin in the brain causes
depression, and an increase in serotonin should reverse it. If this theory were
depression, and an increase in serotonin should reverse it. If this theory were
valid, the SSRIs should cause depressed patients to become undepressed almost
immediately—but Prozac can take as many as five to eight weeks to become
effective. Regardless of what causes depression or why antidepresantidepressants work, the SSRIs have been helpful to many depressed
individuals. Doses of SSRIs. The doses of the five SSRIs are listed in Table 20-1
on page 520. Unlike the older antidepres- antidepressants, which are often
prescribed in doses that are too low, the SSRIs are often prescribed in doses that
are unneces- unnecessarily high. Because they have so few side effects, doctors
550 David D. Burns, M.D. feel comfortable prescribing high doses and may
prescribe more than is really needed. For example, although 20 mg to 80 mg per
day was the dose range initially recommended for Prozac, a single dose of 10 mg
per day will be sufficient for many patients. Once they are feeling better, many
pa- patients need only 5 mg per day, or even less. These smaller doses are much
less expensive and will produce fewer side effects. These low doses are effective
because Prozac stays in the body for a much longer period of time than most
other drugs—as long as several weeks. When you take Prozac, your blood level
continues to increase each day because the Prozac leaves your body so slowly.
After a while your blood level becomes quite high. This is why you may need
only a tiny dose if you have been taking Prozac for several weeks or more. To
understand this better, let's go back to the bathtub analogy I introduced in
Chapter 19 to explain drug inter- interactions. Let's imagine that the Prozac you
are taking is like the water going into the bathtub, but the hole in the bottom of
the tub is tiny. Over time, the water level increases, because more water goes
into the tub than goes out. The water level can be compared to the level of the
Prozac in your blood. After four to five weeks, the water level finally gets up to
the correct therapeutic range. Now you can turn the faucet down quite a bit so
that the level in the tub does not continue to increase and overflow. This would
be anal- analogous to reducing the dose of Prozac after you have been on it for
several weeks. Paradoxically, you are now taking much smaller doses than when
you first started taking the Prozac, but your blood level is far higher.
Technically, we say that "steady state" has been reached. Steady state means that
the blood level remains more or less constant, because the amount you take each
day is similar to the amount that your body eliminates each day. The other four
SSRIs do not have this property, be- because they leave the body much faster
than Prozac. You generally cannot reduce the doses after several weeks. The
effectiveness of very low doses of Prozac is now
FEELING GOOD 551 well known among the psychiatric profession, but I first
FEELING GOOD 551 well known among the psychiatric profession, but I first
learned this from my patients soon after Prozac was re- released onto the market.
Many patients reported that after they had been on Prozac for a month or two,
they seemed to need only tiny doses, often as little as one tenth of a pill per day,
and sometimes even less. At first I thought these patients had overly lively
imaginations, but soon many pa- patients were reporting the same thing. I
advised them to take one Prozac pill, grind it up, and dissolve it in water or apple
juice to store in the refrigerator. Then they adjusted their dose of Prozac by
drinking a certain amount of the fluid each day. So, for example, if you have
dissolved one 20 mg pill in some apple juice and you drink one tenth of the juice
each day, this would correspond to a dose of 2 mg per day. But if you try this,
make sure you label the juice clearly so that no one drinks your Prozac for
breakfast! Also, make sure you talk it over with your doctor and that she or he
approves of what you are doing. It is also important for you to know that after
you stop taking Prozac, it will stay in your body for a long time because it leaves
your body so slowly. This would be like a bathtub that takes an extraordinarily
long time to empty out after you pull the plug because the drain is plugged up.
After you are no longer taking the Prozac, significant levels will remain in your
blood for as many as five weeks or more before the drug is entirely cleared out
of your system. Many medications can be dangerous to mix with Prozac. You
must not take these specific medications until you have been off the Prozac
entirely for at least five weeks. For example, tranylcypromine (Parnate) is an
antidepressant known as an MAO inhibitor that will be discussed below.
Tranylcypromine (as well as other MAO inhibitors) can cause dangerous and
potentially fatal reactions if mixed with Prozac. After you stop taking Prozac, a
delay of at least five to eight weeks will be necessary before you can safely start
taking tranylcypromine. The other SSRIs, such as citalopram (Celexa), fluvoxamine (Luvox), sertraline (Zoloft) and paroxetine (Paxil), leave the body more
rapidly than Prozac but they are still
552 David D. Burns, M.D. metabolized rather slowly. For example, if you stop
taking one of these drugs, it will take your body approximately one day to get rid
of one half of the amount in your body. It will take approximately four to seven
days for most or all of the drug to leave your body. This is much faster than
Prozac. Therefore, these other SSRIs drugs do not build up to such high levels in
your blood after you have been taking them for more than a few weeks. Because
they go in and out of your blood more rapidly, they are usually taken sevseveral times per day, whereas Prozac can be taken once a day. Age can also
influence your dose requirements if you are taking an SSRI. For example, levels
of citalopram (Celexa), fluoxetine (Prozac), and paroxetine (Paxil) are approxiapproximately twice as high in older individuals (over 65 years of age) than in
approximately twice as high in older individuals (over 65 years of age) than in
younger individuals. If you are taking one of these drugs and you are over 65,
you will need a lower dose. Blood levels of sertraline (Zoloft) are also higher in
older individuals, although the differences are not as pro- pronounced. In
contrast, fluvoxamine (Luvox) blood levels do not seem to be affected by age.
Sometimes gender can play a role as well. For example, the blood levels of
fluoxetine (Prozac) are 40 percent to 50 percent lower in males than in females.
Similarly, young men develop blood levels of sertraline (Zoloft) that are 30
percent to 40 percent lower, on the average, than young women. Men may need
relatively higher doses of these drugs, whereas women may need relatively
lower doses. Health problems can also influence your dose requirerequirements. Individuals with liver, kidney, or heart disease may not get rid of
SSRIs as rapidly, and so smaller doses may be needed. Make sure you ask your
doctor about this if you are being treated for a liver, kidney or heart ailment.
Side Effects of SSRIs. The most frequent side effects of the five SSRIs are listed
in Table 20-5 on pages 553-554. As noted above, the side effects of the SSRIs
are milder than the older drugs, and this is the reason for their enorFEELING GOOD 553 Table 20-5. Side Effects of SSRI Antidepressants Note:
This table was adapted with permission from Preskorn23 and from the
prescribing information for citalopram. Only the more common side effects of
each drug are listed. The numbers in the table represent the percent of patients
receiving the drug who reported each side effect minus the percent of patients on
placebo who reported the same side effect. For example, if 20% of patients on
Prozac reported nervousness as a side effect, while 10% of patients on placebo
reported this same side effect, the number 10% would appear in this chart. This
would be an estimate of the "true" nervousness actually caused by Prozac. For
each side effect, the drug or drugs with the highest percentages are indicated in
boldface. # of patients on drug # of patients on placebo fluoxe- tine (Prozac)
1730 799 fluvoxam- ine (Luvox) 222 192 paroxe- tine (Paxil) 421 421 sertraline (Zoloft) 861 853 citalo- citalopram (Celexa) 1063 466 General Symptoms
headache dizziness nervousness tiredness difficulty sleeping weak or fatigued
tremor 5% 4% 10% 6% 7% u /v 6% 3% 1% 8% 17% 4% f\°/n \j /O 6% 0% 8%
5% 14% 7% 1ft% JLU IV 6% 1% 5% 4% 8% 8% T.OL D /O 8% a 1% 8% 1%
2% Mouth, Stomach, and Intestinal Tract dry mouth loss of appetite nausea or
upset stomach diarrhea constipation 4% 7% 11% 5% 1% 2% 9% 26% 0% 11%
6% 5% 16% 4% 5% 7% 1% 14% 8% 2% 6% 2% 7% 3% —
554 David D. Burns, fluoxe- tine (Prozac) M.D. fluvoxa- mine (Luvox) paroxeparoxetine (Paxil) sertra- sertraline (Zoloft) citalo- pram (Celexa) Other
paroxetine (Paxil) sertra- sertraline (Zoloft) citalo- pram (Celexa) Other
excessive sweating 5% 0% 9% 6% 2% Sexual loss of interest in sex delayed or
no orgasm Specific comparative data on the sexual side effects of the SSRIs
were not available. However, it ap- appears that 30% to 40% of patients
receiving SSRIs do experience some sexual side effects.b dA dash means that
the incidence of this side effect was not greater than placebo. bDuring the initial
drug testing studies patients were not explicitly asked about sexual side effects.
Consequently, the estimates of sexual side effects in the PDR are too low. mous
popularity. They are less likely than the tricyclic anti- depressants to cause dry
mouth, constipation, or dizziness. They do not stimulate the appetite when you
first start tak- taking them; if anything, some patients taking SSRIs lose weight
in the beginning. Unfortunately, when the SSRIs are taken for a prolonged
period of time, their side effects sometimes increase. For example; some patients
taking these agents report increases in appetite and weight gain after a while,
even though they lost weight at first. Some of the most common and
troublesome side effects of the SSRIs include nausea, diarrhea, cramping,
heartburn, and other signs of stomach upset. Approximately 20 percent to 30
percent of patients reported these symptoms in the earliest studies with the
SSRIs.18 You will see in Table 20-5 that flu- voxamine (Luvox) is the most
likely to cause constipation, whereas sertraline (Zoloft) is more likely to cause
diarrhea. Patients taking paroxetine (Paxil) and sertraline (Zoloft) are more likely
to complain of a dry mouth because of the anti- cholinergic effects of these
drugs. In some studies, as many as 20 percent of the patients taking paroxetine
(Paxil) reported dry mouth. (However, the percentages in the table are much
lower because the placebo effects have been subtracted out.)
FEELING GOOD 555 Most of these effects on the stomach and intestinal tract
tend to occur in the first week or two and then disappear as the body adjusts to
the medicine. In addition, if you start the SSRI at a low dose and then increase
the dose gradually, these side effects are less likely to occur. It can also help if
you take the medication with meals. (The tricyclic and tetracyclic drugs
discussed in the previous section can also be taken with meals to minimize any
adverse effects on the stomach and gastrointestinal tract.) The SSRI drugs can
occasionally cause headaches when you first start to take them. In Table 20-5 the
rates for headache seem to be the highest for fluoxetine (Prozac) and
fluvoxamine (Luvox); in contrast, the rates for citalopram (Celexa), paroxetine
(Paxil), and sertraline (Zoloft) appear to be no greater than the rates of headaches
reported by patients who take placebos. Excessive sweating has also been
reported, especially with paroxetine (Paxil), but this is not usually severe.
Patients taking high doses of the SSRIs may also complain of tremor, and this
Patients taking high doses of the SSRIs may also complain of tremor, and this
side effect seems to be equally common among all of the SSRI drugs. Although
initially reported as a "rare" side effect, it is now clear that delayed time to
orgasm is quite common for men and women taking SSRIs. Some patients also
complain of a loss of interest in sex or an inability to achieve an erection. These
side effects were reported in fewer than 5 percent of patients during the
premarketing research trials. However, now that the drugs are widely used, it has
be- become clear that these side effects are far more common than reported in
clinical trials and can occur in 30 percent or more of patients. The sexual side
effects may be a reason- reasonable trade-off if the drug helps you overcome
your depres- depression. Keep in mind that a loss of interest in sex can also be a
symptom of depression itself. In addition, you will probably not need to stay on
the drug indefinitely. Once you are feeling better and you stop taking the SSRI,
your sexual functioning should return to normal. You might wonder why these
side effects were not noted in the premarketing research studies. At the 1998
Stanford
556 David D. Burns, M.D. Psychopharmacology Conference, one of the
speakers jok- jokingly mentioned that the drug companies seem to have a "don't
ask, don't tell" policy about certain kinds of ad- adverse effects, including sexual
side effects. I guess the idea is that what you don't know won't hurt you. I think
this policy is unfortunate, because the FDA (and potential con- consumers) may
be given an overly rosy picture about the ef- effectiveness, side effect profile,
and safety of a new drug. After the drug has been in widespread use for several
years, a different picture often emerges. The effects on sex are so predictable
that one of these drugs, paroxetine (Paxil) is now recognized as an effective
treatment for men who experience premature ejaculation (having orgasms too
rapidly during sex). Some people do not experience a delayed orgasm on SSRIs.
Others expe- experience it but are not bothered, and some actually view it as a
benefit. What is important is that if this feels like a prob- problem for you, you
should discuss it with your doctor before discontinuing the medication on your
own. It might be pos- possible to reduce the dose without a loss of the
antidepressant effects. Several drugs can be combined with an SSRI in an atattempt to combat the sexual difficulties. Four which show promise include
bupropion (Wellbutrin, in doses of up to 225 mg to 300 mg per day), buspirone
(BuSpar; 15 to 30 mg per day), yohimbine E mg three times daily), or amantadine A00 mg three times daily). Citalopram (Celexa), one of the newest SSRIs
on the American market, may have fewer sexual side effects than the other
SSRIs. You can see in Table 20-5 that it does appear to have fewer side effects
in general than the other four SSRIs. In addition, there is the hope that it will be
more effective for severe depressions than the SSRIs. It will be interesting to see
more effective for severe depressions than the SSRIs. It will be interesting to see
if citalopram (Celexa) is more effective and does actually have fewer side effects
after the drug has been in widespread use for a period of time. Sometimes
marketing claims when drugs are first released turn out not
FEELING GOOD 557 to be supported by clinical experience or by subsequent
research by independent investigators. Among the SSRIs, fluoxetine (Prozac)
appears to be the most activating (stimulating), although fluvoxamine (Lu- vox)
seems almost as likely to cause this side effect. Be- Because fluoxetine (Prozac)
is stimulating, it is sometimes given in the morning and at noon, rather than at
bedtime. The stimulation can often be a benefit to depressed patients who feel
tired, sluggish, and unmotivated. On the other hand, fluoxetine (Prozac) and
fluvoxamine (Luvox) can also cause anxiety or jitteriness in as many as 10
percent to 20 percent of patients. These side effects can sometimes create
additional difficulties for depressed patients who already have these kinds of
symptoms. The stimulating effects of fluoxetine (Prozac) are not necessarily bad,
even for anxious patients. Anxiety and de- depression nearly always go hand in
hand to a certain extent, and many patients need treatment for both kinds of
prob- problems. Patients with significant anxiety, such as chronic wor- worrying,
panic attacks, or agoraphobia, are often the ones who complain that fluoxetine
(Prozac) makes them feel more nervous initially. I often tell these patients that
the nerv- nervousness they feel is a good thing, because it shows the drug is
working in the brain. I encourage them to stick with it, because in a few weeks
or less they may notice a significant improvement in their depression as well as
their anxiety. Most anxious patients have been able to stick with the fluoxetine
(Prozac), and the predicted improvement often does occur. This illustrates how a
positive attitude can sometimes help patients overcome drug side effects.
Although any of the SSRIs can cause trouble with sleep- sleeping, not all of
them are as stimulating as fluoxetine (Pro- (Prozac). In fact, paroxetine (Paxil)
and fluvoxamine (Luvox) can be quite sedating for some patients. In other
words, these drugs will tend to relax or tire you, instead of stim- stimulating you
the way fluoxetine (Prozac) does. In fact, pa558 David D. Burns, M.D. roxetine (Paxil) is sometimes given two hours before
bedtime so that the maximum sleepiness will occur at the time that you
ordinarily go to sleep. Paroxetine (Paxil) or fluvoxamine (Luvox) might be good
choices if insomnia is a major aspect of your depression. Note, however, that papatients taking paroxetine (Paxil) are also somewhat more likely to complain of
weak or fatigued muscles. Citalopram (Celexa) and sertraline (Zoloft) appear to
be halfway in- between—they do not typically cause excessive stimulation or
be halfway in- between—they do not typically cause excessive stimulation or
sedation, but are more neutral in this respect. In the section below on serotonin
antagonists, I will de- describe an antidepressant called trazodone (trade name
De- syrel) which has calming, sedative properties. Trazodone can be given in
small doses E0 to 100 mg at bedtime) to patients who are taking SSRIs. This has
three potential ben- benefits: A) the calming effects of trazodone will reduce the
nervousness caused by the SSRIs; B) the trazodone can be given at bedtime to
improve sleep; C) trazodone may sometimes boost the antidepressant effects of
the SSRI and increase the likelihood of recovery. In spite of these advantages, I
usually try to treat patients with one drug at a time. This avoids any extra side
effects and minimizes the possibility of adverse drug interactions. In my
experience, treatment with one drug at a time is usually successful. If you reduce
the dose of any SSRI, you can often minimize the side effects without having to
add additional drugs. I will address the problem of using more than one drug at
the same time toward the end of this chap- chapter. For example, if you are
starting fluoxetine (Prozac) and you are bothered by nervousness, insomnia, or
upset stom- stomach, you can take a lower dose and increase the dose more
gradually. In addition, if you have been on fluoxetine (Pro- (Prozac) for several
weeks or more, there is an excellent chance you can reduce the dose, often quite
dramatically. This will often minimize the side effects without interfering with
the antidepressant effects of this drug. As noted above, this is because levels of
fluoxetine (Prozac) build up after a period
FEELING GOOD 559 of time, so the same dose may produce far more side
effects because your blood level has become so much higher. There is really no
need for large doses or excessively high blood levels of any of the SSRIs,
because low doses have been shown to be just as effective as high doses. SSRI
Drug Interactions. A number of common drug in- interactions for the SSRIs are
listed in Table 20-6 on pages 560-563. You will see in Table 20-6 that many
other psy- psychiatric drugs can interact with the SSRIs, including antidepressants, major and minor tranquilizers, and mood stabilizers. Important
interactions with nonpsychiatric drugs are also listed. If you are taking an SSRI
and one or more additional drugs at the same time, it would be wise to re- review
this table. Make sure you also ask your physician and pharmacist if there are any
drug interactions you should be aware of. This includes prescription drugs as
well as non- prescription drugs that are sold over the counter. As you can see,
SSRIs have a tendency to cause the blood levels of other antidepressants to
increase. This is be- because the SSRIs slow down the metabolism of these other
drugs in the liver, as discussed in Chapter 19. In some cases, this could be
dangerous. For example, the combination of an SSRI with a tricyclic
dangerous. For example, the combination of an SSRI with a tricyclic
antidepressant can potentially cause ab- abnormal heart rhythms. Although this
complication is rare, the effects on the heart can be serious. The combination of
an SSRI with bupropion (Wellbutrin) can increase the risk of seizures—an
uncommon but serious side effect of bupro- bupropion. However, as noted
above, bupropion is often added to an SSRI in low doses to try to minimize the
sexual side ef- effects of the SSRIs. This can usually be done safely. Make sure
you inform your physician if you have any history of head trauma or seizures,
because this particular drug combi- combination may not be advisable for you.
As mentioned in Chapter 19, the interaction of an SSRI with an MAOI
antidepressant is extremely dangerous re- regardless of the dose of either drug.
This combination should be avoided because it can result in the potentially lethal
"serotonin syndrome" described in Chapter 19. In addi560 David D. Burns, M.D. Table 20-6. Drug Interaction Guide for SSR1
Antidepressants.3 Antidepressants Drug tricydic and tetracyclic antidepressants
SSRI antidepressants monoamine oxidase inhibitors (MAOIs) serotonin
antagonists [trazodone (Desyrel) and nefazodone (Serzone)] bupropion
(Wellbutrin) venlafaxine (Effexor) mirtazapine (Remeron) Comment SSRIs can
cause TCA levels to f ; abnormal heart rhythms can result not usually combined;
f in SSRI blood levels can result serotonin syndrome5 blood levels of
nefazodone or trazodone and their metabolite (mCPP) may | and cause anxiety t
risk of seizures; caution required may cause \ in levels of venlafaxine no
information available as yet Antihistamines Drug terfenadine (Seldane) and
astemizole (Hismanal) cyproheptadine (Periactin) Comment fluvoxamine
(Luvox) may f levels of terfenadine and astemizole; fatal heart rhythms can
occur may reverse the effects of SSRIs Diabetes Medications Drug tolbutamide
(Orinase) insulin Comment fluvoxamine (Luvox) may levels of tolbutamide; low
blood sugar may result fluvoxamine (Luvox) may cause | in blood sugar; insulin
levels may need to be adjusted
FEELING GOOD 561 Heart and Blood Pressure Medications Drug digoxin
(Lanoxin) and digitoxin (Crystodigin) medications for high blood pressure
medications for abnormal heart rhythms Comment t in blood levels of digitoxin
and potential toxic effects including mental confusion levels of beta-blockers
including metoprolol (Lopressor) and propranolol (Inderal) also used for angina
may f , leading to excessive heart slowing and ECG abnormalities; calcium
channel blockers including nifedipine (Procardia) and verapamil (Calan) may
also f, leading to more potent effects on blood pressure SSRI may f risk of
abnormal heart rhythms when combined with drugs to control heart rhythms,
such as flecainide (Tambocor), encainide, mexiletine (Mexitil), and propafenone
such as flecainide (Tambocor), encainide, mexiletine (Mexitil), and propafenone
(Rythmol) Other Psychiatric Drugs Drug benzodiazepines (minor tranquilizers)
including alprazolam (Xanax), diazepam (Valium) and others Comment levels of
benzodiazepines may f; excessive drowsiness or confusion; lower doses of
benzodiazepines may be needed, fluvoxamine (Luvox) has strongest effect, but
problems have also been reported with fluoxetine (Prozac); clonazepam
(Klonopin) and temazepam (Restoril) may be safer than alprazolam (Xanax) and
diazepam (Valium)
562 David D. Burns, M.D. Other Psychiatric Drugs cont. Drug buspirone
(BuSpar) lithium L-tryptophan major tranquilizers (neuroleptics) such as
haloperidol (Haldol), perphenazine (Trilafon) and thioridazine (Mellaril)
methadone (Dolophine) mood stabilizers and anticonvulsants Comment may
enhance the effects of SSRIs; however, fluoxetine (Prozac) may reduce the
effectiveness of BuSpar, some patients with obsessive compulsive disorder who
received this combination experienced a worsening of symptoms f or i levels
may result; may lead to lithium toxicity at normal lithium levels can cause
agitation, restlessness, and upset stomach as well as the serotonin syndrome
blood levels of major tranquilizer may f leading to increased side effects;
fluvoxamine (Luvox) may be the safest SSRI to combine with neuroleptics;
risperidone (Risperdal) and clozapine (Clozaril) may block the antidepressant
effects of the SSRIs fluvoxamine (Luvox) leads to f in blood levels SSRIs,
especially fluvoxamine (Luvox) and fluoxetine (Prozac), can cause f in levels of
carbamazepine (Tegretol) and phenytoin (Dilantin). The combination of either
SSRI with phenytoin can cause phenytoin toxicity Other Medications Drug
alcohol Comment increased drowsiness
FEELING GOOD 563 Drug caffeine (in coffee, tea, soda, chocolate) cisapride
(Propulsid) cyclosporine (Sandimmune; Neoral) (an immunosuppressive drug
used in organ transplants) dextromethorphan (a cough suppressant in many overthe- counter medications) tacrine (Cognex) tobacco (smoking) theophylline
(Bronkaid) warfarin (Coumadin) (a blood- thinner) Comment fluvoxamine
(Luvox) causes levels to t; excess nervousness may result fluvoxamine (Luvox)
may f levels of cisapride; fatal heart rhythms can occur levels of cyclosporine
may f hallucinations reported with fiuoxetine (Prozac), possible with any SSRI
fluvoxamine (Luvox) leads to f in blood levels levels of fluvoxamine (Luvox)
may I fluvoxamine (Luvox) leads to ] in blood levels and can produce toxic
effects, including excess nervousness fluvoxamine (Luvox) may f levels of
warfarin (Coumadin); increased bleeding may result. The increased bleeding can
also result without any changes in the prothrombin test (this bleeding test is used
also result without any changes in the prothrombin test (this bleeding test is used
to monitor the dose of warfarin). This is because the SSRIs can also impair
clotting through their effects on blood platelets, whereas warfarin affects the
clotting proteins -'Information in this table was obtained from several sources
including the Manual of Clinical Psychopharmacology1 and Psychotropic Drugs
Fast Facts.11 These excellent references are highly recommended. bThis is a
dangerous and potentially fatal syndrome which includes rapid changes in vital
signs (fever, oscillations in blood pressure), sweating, nausea, vomiting, rigid
muscles, myoclonus, agitation, delirium, seizures, and coma.
564 David D. Burns, M.D. tion, remember that both the SSRIs and the MAOIs
can re- require a considerable period of time to clear out of your body after you
have stopped taking them. If you stopped taking Prozac and then started an
MAOI several weeks later, it could trigger the serotonin syndrome because
Prozac would still be present in your bloodstream. Similarly, if you were to start
Prozac within two weeks of stopping an MAOI, this might also trigger the
serotonin syndrome. The effects of the MAOIs last only one to two weeks, so
you will not have to wait as long when you switch from an MAOI to an SSRI as
when you switch in the opposite direction. A number of other important
interactions which are listed in the table involve common drugs that many
people might take for a cold or flu, diabetes, high blood pressure, aller- allergies,
and so on. For example, dextromethorphan is a cough suppressant in many overthe-counter cold preparations. When combined with an SSRI, dextromethorphan
can cause visual hallucinations. This has been reported with fluoxetine (Prozac)
but could theoretically occur with any SSRI. You will also see that two common
antihistamines, terfenadine (Seldane) and astemizole (Hismanal), can proproduce abnormal and potentially fatal heart rhythm abnor- abnormalities when
combined with certain SSRIs, and a third antihistamine called cyproheptadine
(Periactin) can block the antidepressant effects of an SSRI. Make sure you
review this table if you are taking an SSRI. If you have any questions, discuss
them with your doctor and pharmacist. The SSRIs are safe for the overoverwhelming majority of individuals who take them. With a little good
teamwork between you and your doctor, your experience with an SSRI can be
positive. MAO Inhibitors The Table of Antidepressants on pages 514-515 lists
four drugs known as monoamine oxidase inhibitors (MAOIs). They include
isocarboxazid (Marplan), phenelzine (Nardil),
FEELING GOOD 565 selegiline (Eldepryl), and tranylcypromine (Parnate). You
may recall from Chapter 17 that the MAOIs fell into rela- relative disuse when
the newer and safer compounds were de- developed. They are probably vastly
the newer and safer compounds were de- developed. They are probably vastly
underutilized because they can be quite dangerous if mixed with a number of
common foods (such as cheese) and medicines (including many common overthe-counter cold, cough, and hay fever drugs) and because they require fairly
sophisticated medical skills on the part of the prescribing doctor. In recent years
the MAOIs have experienced a much- deserved resurgence of popularity because
they are often remarkably effective for patients who do not respond to other
kinds of antidepressants. Many of these patients have experienced so many years
of chronic depression that their illness has become an unwelcome lifestyle. The
beneficial effects of the MAOIs can sometimes be quite impressive. The MAOIs
can also be particularly effective in an "atypical depression" that is characterized
by the following types of symptoms: • overeating (as opposed to a loss of
appetite in classic depression); • fatigue and sleeping too much (rather than
trouble with sleeping); • irritability or hostility (in addition to the depression); •
extreme sensitivity to rejection. Patients with this form of depression sometimes
also em- emphasize chronic feelings of fatigue as well as a "leaden paralysis." It
is not clear whether this really represents a subtype of depression or simply a
particular group of symp- symptoms that any depressed individual might
experience. Nevertheless, studies conducted at Columbia University suggest that
the MAOIs may actually be better than the cyclic antidepressants for patients
with these kinds of symp- symptoms. The MAOIs can also be remarkably
effective when high levels of anxiety accompany the depression, including
phobias (such as social phobia), panic attacks, or hypo566 David D. Burns, M.D. chondriacal complaints. Patients with recurrent
obsessive thoughts and compulsive, ritualistic, nonsensical habits (such as
recurrent hand-washing or repetitive checking of door locks) may also
experience relief when treated with MAOIs. The MAOIs can also be helpful
when chronic anger or impulsive self-destructive behavior accompanies the dedepression. Patients with these features are sometimes diag- diagnosed as having
"borderline personality disorder." Although these individuals can sometimes be
quite difficult to treat, I have seen many who were dramatically helped by the
MAOIs. Of course, all patients who take MAOIs must agree to follow the
dietary restrictions and medication guidelines religiously. If a patient is
unreliable or will not agree to this, other types of medications should be used
instead. The mechanism of action of the MAOIs is different from that of the
other antidepressant drugs. You learned in Chap- Chapter 17 that most
antidepressants act by blocking the pumps for neurotransmitters at the nerve
endings. As a result, the levels of the chemical transmitters such as serotonin,
nor- epinephrine, or dopamine build up in the synaptic regions. In contrast, the
MAOIs seem to work by preventing the breakdown of chemical messengers
MAOIs seem to work by preventing the breakdown of chemical messengers
within the nerves. As a result, levels of serotonin, norepinephrine, and dopamine
build up inside the nerve terminals and these messengers are released into the
synapses in much higher concentra- concentrations when the nerves fire. This
results in a greater stimu- stimulation of the nerves at the other side of the
synaptic junctions. The MAOIs require careful medical management and close
teamwork with your doctor. They are well worth the effort because they can
sometimes lead to profound mood transformations, even when other drugs have
been ineffec- ineffective. Because they may cause increases in blood pressure,
they are not usually recommended for individuals over sixty years of age or
individuals with heart problems. In
FEELING GOOD 567 addition, they are not usually prescribed for individuals
with significant cerebrovascular disorders, such as strokes or aneurysms, or
individuals with brain tumors. Paradoxi- Paradoxically, though, they can
sometimes be used with individuals with high blood pressure because they
usually cause the blood pressure to fall.19 Consultation with a cardiologist
would be necessary to make sure there are no dangerous interactions with your
other blood pressure medications. Like other antidepressants, the MAOIs usually
require at least two or three weeks to become effective. Your doctor will
probably want to obtain a medical evaluation before starting you on this type of
drug. This evaluation may in- include a physical examination, a chest X ray, an
electrocar- electrocardiogram, a blood count, blood chemistry tests, and a
urinalysis. Doses of MAOIs. The doses of the MAOIs are listed in Table 20-1 on
page 520. The two most commonly pre- prescribed drugs for depression and
anxiety are tranylcyprom- ine (Parnate) and phenelzine (Nardil). One of the
MAOIs, isocarboxazid (Marplan), is no longer available in the United States but
is available in some other countries in- including Canada. In addition, selegiline
(Eldepryl) is rarely used for depression but is often used in small doses E mg to
10 mg per day) in the treatment of Parkinson's disease. It is just starting to be
used for depression and some other psychiatric disorders, although in higher
doses than for Par- Parkinson's disease, as indicated in Table 20-1. Although the
Food and Drug Administration (FDA) has not yet approved selegiline for use in
psychiatric disorders, recent studies indicate that it can also be effective for
patients with atyp- atypical depression as well as those with chronic, severe dedepression. A common prescribing error with the MAOIs is to give too big a
dose too soon. For example, you will see in Table 20-1 on page 520 that the
usual dose range for tranylcy- promine (Parnate) is 10 mg to 50 mg per day.
Some doctors prescribe larger doses, but I have seen many patients re-
568 David D. Burns, M.D. spond to just one or two pills per day. Because the
MAOIs can have some toxic side effects, I think it is prudent to start them at low
doses, to increase very slowly, and not to push the dose too high. I usually start
the patient on just one pill per day of an MAOI for the first week, and then
increase to two pills per day. If the patient does not respond to a reasonable dose,
say three or four pills per day of tranylcypromine or phenelzine, I usually do not
increase the dose further but instead try an alternative medication along with a
different psychotherapeutic strategy. How long should you stay on an MAOI if it
does not seem to be working? It seems obvious to me that if you have not had a
fairly dramatic response after three or four weeks, as confirmed by your weekly
scores on the mood test in Chapter 2, then you have probably given the drug a
fair trial. You might respond better to another type of drug or to the cognitive
therapy techniques described in this book. How long should you stay on an
MAOI if you do re- respond favorably? As with any antidepressant, you will
have to discuss this with your physician, and many different ap- approaches are
currently in vogue. Some physicians believe that patients need antidepressants
indefinitely to correct a "chemical imbalance," but I have not usually found it
nec- necessary to keep patients on MAOIs or other antidepressants indefinitely. I
have found that patients nearly always do well when they discontinue their
MAOIs after a reasonable period of feeling good. Sometimes this may be as
short as three months, sometimes as long as six to twelve months. As with most
antidepressants, you should taper off an MAOI gradually so there will be no
withdrawal effects. Tapering too rapidly has caused some patients to experience
sudden manic reactions. Suddenly going off selegiline can cause nausea,
dizziness, and hallucinations, so one has to be especially careful to taper slowly.
What if you go off the MAOI and then get depressed again in the future? If you
have responded to an MAOI in the past, you may respond more rapidly if you
take the
FEELING GOOD 569 same MAOI again in the future. In my practice I have
had many patients who experienced a positive response to an MAOI (usually
Parnate) and continued to feel undepressed for many years after they stopped
taking the drug. Even- Eventually, a few of them became depressed again and
called for a "tune-up" appointment. I always gave them the first available
appointments. If they sounded quite depressed, I told them to start the
medication again. I also told them to start doing their psychotherapy homework
again, especially the exercise of writing down and challenging their negative
thoughts. When I saw them a few days later, many of them were already feeling
better. Some of them told me that they began to improve in as little as one day or
less when they took the MAOI for the second time. I believe that the med-
less when they took the MAOI for the second time. I believe that the medmedication as well as the cognitive therapy contributed to the rapid
improvement. I have not seen this rapid response with other types of
antidepressants and do not know why it sometimes happens with MAOIs.
Several patients explained that their bodies seemed to "recognize" the effects of
the MAOI right away, especially the pleasurable stimulation that
tranylcypromine (Parnate) causes. This helped them "remember" what it was like
not to feel depressed. In a few cases, the improve- improvement in mood came
within an hour or two of the first pills they took. In the majority of cases, one or
two cognitive therapy sessions seemed to reverse the relapse of depresdepression. Side Effects of MAOIs. The most frequent side effects are listed in
Table 20-7 on pages 572-573. As noted above, tranylcypromine (Parnate) tends
to be stimulating. The stimulating effects of tranylcypromine (Parnate) can be
es- especially helpful to depressed individuals who feel tired, le- lethargic, and
unmotivated. Tranylcypromine (Parnate) may provide them with some muchneeded "go power." Be- Because tranylcypromine (Parnate) tends to be
stimulating, it can also cause insomnia. In order to minimize the insomnia, the
entire dose can be taken once a day in the morning or
570 David D. Burns, M.D. in divided doses in the morning and at noon. The
latest rec- recommended time to take tranylcypromine (Parnate) is 6:00 p.m.
Phenelzine (Nardil) is less stimulating than tranylcy- tranylcypromine (Parnate)
and may be an attractive option for pa- patients who feel too stimulated by
tranylcypromine (Parnate). The other side effects of the MAOIs are similar to
those of the tricyclic and tetracyclic drugs described previously, but they are
usually mild, especially when the MAOIs are taken in low doses. As you can see
in Table 20-7, the MAOIs do not have strong effects on the muscarinic rereceptors (you will recall that these are also called cholinergic receptors).
Consequently, they are not likely to cause dry mouth, blurred vision,
constipation, or a delay in starting the urine flow. Weight gain also does not
seem to be so much of a problem with these drugs, although some pa- patients
experience an increased appetite. Weight gain appears to be less of a problem
with tranylcypromine (Parnate) than phenelzine (Nardil). Because
tranylcypromine is stimulat- stimulating, it may actually reduce your appetite, as
do some of the SSRIs including fluoxetine (Prozac). Some patients experience
light-headedness when stand- standing suddenly because these drugs have
relatively strong ef- effects on the alpha-adrenergic receptors. If dizziness does
develop, the interventions described previously can help. These include: A) ask
your doctor if you can lower the dose—often you can still maintain the
antidepressant effect; B) get up more slowly and exercise your legs by walking
antidepressant effect; B) get up more slowly and exercise your legs by walking
in place immediately when you stand; C) wear support stockings; D) drink
adequate fluids and make sure you eat enough foods with salt to maintain your
body's electrolytes. Like most antidepressants, the MAOIs can sometimes cause
a rash, although I do not recall ever seeing this. A loosening of the stool or
constipation might also occur. Some patients report an upset stomach. Taking
the medi- medication with meals can alleviate this. Some patients report muscle
twitches, but this is usually not dangerous. If you experience muscle pains,
cramps, or tingling fingers—side effects I have never observed—a daily dose of
50 to 100
FEELING GOOD 571 mg of vitamin B6 (pyridoxine) may help. This is because
MAOI drugs may interfere with pyridoxine metabolism, so taking extra
pyridoxine may compensate for this effect. Some doctors recommend taking
vitamin B6 routinely if you are on an MAOI. The MAOIs can sometimes
interfere with sexual func- functioning, especially in higher doses. Some patients
experi- experience a decreased interest in sex and difficulties maintaining an
erection or achieving orgasm. In this regard, the MAOIs are a lot like the SSRIs
described previously. The sexual side effects may result from their effects on the
serotonin receptors in the brain, but this is not known for sure. Al- Although the
sexual side effects can be disconcerting, these difficulties may be a worthwhile
trade-off if the medication is having a beneficial effect on your mood. You
should be reassured that the sexual side effects are dose-related and usually
disappear entirely when you are no longer taking the MAOI. One young man I
treated actually found the sexual side effects to be helpful. He reported that he
had always had a problem with premature ejaculation. Once he started taking
tranylcypromine (Parnate), the problem disappeared. In fact, he reported he
could make love for prolonged periods without any danger at all of having a
premature orgasm. He said his girlfriend thought this was a great miracle, and he
advised me to buy stock in the company that manufac- manufactured the drug!
One pleasurable side effect of an MAOI is an excessively positive reaction to the
drug. In other words, quite a number of patients not only overcome their
depressions but begin to feel euphoric or high. This is not necessarily bad, but in
some cases may become so extreme that the patient expe- experiences the
symptoms of mild mania. In the rare patient with a history of bipolar manicdepressive illness (patients with previous extreme highs and lows that were not
caused by drugs or alcohol), there is the possibility that an MAOI might trigger a
full-blown manic episode. This is actually true of most antidepressants, and not
just the MAOIs.
Table 20-7. Side Effects of Monoamine Oxidase Inhibitors3 Note: This list is not
comprehensive. In general, side effects that occur in 5% or 10% or more of
patients are listed, as well as rare but dangerous side effects. Side Effect Brain
Receptor isocarboxazid (Marplan) phenelzine (Nardil) Sedation and Weight
Gain histamine (Hj) receptors * Light-Headedness and Dizziness alphaadrenergic @Cj) receptors Blurred Vision, Constipation, Dry Mouth, Speeded
Heart, Urinary Retention muscarinic (M}) receptors Oto + 0 to + Common or
Significant Side Effects" headache; changes in heart rhythm and rate;
overactivity or mania; tremor; jittery; confusion; memory problems; insomnia;
edema; weakness; sweating; upset stomach; delayed orgasm dizziness;
headache; fatigue; trouble sleeping; weakness; tremor; twitching; dry mouth;
upset stomach; constipation; weight gain; delayed orgasm; jittery; euphoria;
trouble starting urine; swelling;
selegiline (Eldepryl) tranylcypromine (Parnate) 0 Oto + Oto 4- (limited
information available);6 nausea; weight loss; delayed orgasm; confusion; dry
mouth; dizziness; possibly other side effects overstimulation; euphoric or manic
feelings; restlessness; anxiety; trouble sleeping; tiredness or weakness;
twitching; tremor; muscle spasms; upset stomach; loss of appetite; constipation;
diarrhea; headache; delayed orgasm; numbness or tingling; swelling; racing
heart; blurred vision "The + to + + + ratings in this table refer to the likelihood
that a particular side effect will develop. The actual intensity of the side effect
will vary among individuals and will also depend on how large the dose is.
Reducing the dose can often reduce side effects without reducing effectiveness.
"Many of the side effects of the MAOIs can often be reduced or eliminated by
reducing the dose. They usually have very few side effects, and can often be
quite effective, at small doses. This is because this drug is usually prescribed for
patients with Parkinsonism who take many other drugs, and also have many
symptoms due to their illness. Therefore, it is difficult to determine how
frequently selegiline would cause side effects in depressed individuals. At higher
doses, the side effects of selegiline are probably very similar to the other
MAOIs.
574 David D. Burns, M.D. If you do start to feel unusually happy, it would be
wise to keep in touch with your prescribing doctor to make sure these feelings do
not get out of hand. In my experience, this is not usually a serious problem—the
euphoric feelings provide a welcome relief from the depression and tend to
diminish in a week or so. The euphoric feelings also re- respond to a reduction in
dose. Dr. Alan Schatzberg and his colleagues1 have pointed out that some
patients may seem drunk or intoxicated when taking MAOIs. Patients may also
patients may seem drunk or intoxicated when taking MAOIs. Patients may also
feel confused and have trouble with coordination. These adverse reactions are
more likely when the doses are pushed to very high levels. Ob- Obviously, the
dose should be reduced immediately if these toxic effects develop. I have
personally never seen these effects because I have never pushed the doses of
MAOIs to unusually high levels. Two of the MAOI drugs, phenelzine (Nardil)
and iso- carboxazid (Marplan), can have negative effects on the liver. Therefore,
your doctor may want to do a blood test to monitor levels of certain enzymes
that reflect liver func- function before you start these drugs, and then again every
few months while you are taking them. Patients with liver dis- disease or
abnormal liver function tests are usually advised not to take any of the MAOIs,
including tranylcypromine (Parnate). Dr. Alan F. Schatzberg and his colleagues1
have pointed out that selegiline (Eldepryl) may have fewer side effects than the
other MAOI drugs, at least at low doses. At low doses, selegiline seems less
likely to cause dizziness when standing, sexual problems, or difficulties
sleeping. How- However, selegiline is much more expensive than the other
MAOIs, and in most cases the other MAOIs will do the job just as effectively. In
addition, the side effects of all the MAOI antidepressants tend to be minimal at
lower doses. In my experience, many patients have responded favorably to low
doses of the MAOIs, so selegiline may not really have any significant
advantages over the two older and cheaper drugs.
FEELING GOOD 575 As you will learn next, all the MAOIs can cause dandangerous blood pressure elevations when patients ingest the forbidden foods.
Selegiline is less likely to have this effect, but only if the selegiline is taken in
small doses A0 mg per day or less). Larger doses of selegiline are often needed
for psychiatric problems. At these higher doses it is nec- necessary to observe
the same dietary precautions that you would observe with any of the MAOIs.
This is unfortunate because it was initially hoped that depressed patients would
be able to take selegiline and not have to restrict their diets so religiously.
Hypertensive and Hyperpyretic Crises. In rare cases, the MAOIs can produce
two types of serious toxic reactions if they are not used properly. This is why so
many doctors avoid using them. With good education and preventive
medications, the MAOIs can be administered safely, but you will need to study
this section quite carefully if you are taking an MAOI. One of the dangerous
reactions is called a "hypertensive crisis." "Hyper" means high and "tensive"
refers to blood pressure, so a hypertensive crisis is a sudden increase in your
blood pressure. Increases in blood pressure are not usually dangerous and can
occur in many normal situations even if you are not taking medications. For
example, when you are lifting weights, your blood pressure can easily go into
example, when you are lifting weights, your blood pressure can easily go into
the range of 180/100 or higher at the moment you are straining and exerting
maximum effort to raise the barbell. Our bodies are used to these temporary
elevations in blood pressure. However, if you were on an MAOI and you ate one
of the forbidden foods, your blood pressure might in- increase to dangerous
levels and remain elevated for an hour or more. If you continued to eat the
forbidden foods that interact with the MAOIs, sooner or later a vessel in your
brain could rupture because of the mechanical stress. This would cause a stroke,
certainly an excessive price to pay for taking an antidepressant. The initial
symptoms of a ruptured or leaking vessel in
576 David D. Burns, M.D. your brain can include an excruciating headache, a
stiff neck, nausea, vomiting, and sweating. As the bleeding con- continues,
paralysis, coma, and death can occur. Because of the danger of hypertensive
reactions, your doctor will check your blood pressure at each session. The risk of
a stroke is higher in individuals over sixty because our arteries become less
resilient with age and are more likely to tear or rupture when subjected to the
stress of a sudden increase in blood pressure. Regardless of your age, you will
need to monitor your blood pressure and watch your diet carefully when taking
an MAOL These hypertensive crises are sometimes also called "no- radrenergic
crises" because they are thought to be due to an excessive release of
norepinephrine. Norepinephrine is a transmitter substance used by nerves in your
brain and in your body. Hypertensive crises usually occur if you eat cer- certain
forbidden foods containing a substance called tyramine or if you take one of the
forbidden drugs that I will describe in detail below. If you are careful, the risk of
a serious hypertensive crisis is very small. The other dangerous reaction to an
MAOI is called a "hyperpyretic crisis." "Pyretic" refers to fire, or fever. The
patient with a hyperpyretic crisis may develop a high fever along with a number
of alarming symptoms that can include sensitivity to light, rapid changes in
blood pressure, rapid breathing, sweating, nausea, vomiting, rigid muscles,
jerking and twitching, confusion, agitation, delirium, sei- seizures, shock, coma,
and death. A hyperpyretic crisis is sometimes also called a "serotonin syndrome"
because it is due to an abnormal and dangerous increase in levels of serotonin in
the brain. A hyperpyretic crisis occurs when the patient takes certain forbidden
medications that must not be combined with the MAOIs. These drugs cause an
increase in levels of serotonin in the brain. Obviously, a hyperpyretic crisis
requires immediate discontinuation of the MAOI along with emergency medical
treatment. The treatment may include intravenous fluids and treatment with
FEELING GOOD 577 the serotonin antagonist, cyproheptadine (Periactin), at a
dose of 4 mg to 12 mg. Several decades ago when MAOIs were first available,
dose of 4 mg to 12 mg. Several decades ago when MAOIs were first available,
doctors were not as aware of the blood pressure elevations that resulted from
eating foods containing tyramine or from taking the kinds of drugs described
below, and so these hypertensive reactions were more common and severe. Now
doctors and patients are much more aware of the prob- problem and the risk is
much smaller. In fact, extreme hyper- hypertensive and hyperpyretic reactions
are quite rare. I am personally aware of only one patient, treated by a colleague
in Boston, who developed a stroke due to a hypertensive crisis (noradrenergic
syndrome) while taking an MAOL I have had about half a dozen patients over
the years who paged me because they suddenly developed elevated blood
pressure. I told each of them to go to a local hospital emer- emergency room for
observation. In every case, the blood pres- pressure quickly subsided without
any treatment aside from observation. None of these patients experienced any
ad- adverse effects. I have never seen a patient who developed a hyperpyretic
crisis (serotonin syndrome) while on an MAOI. This is because we know a great
deal about what causes these two kinds of reactions and how they can be
avoided. If you are taking an MAOI, you will need to educate your- yourself by
studying the following sections carefully. You will have to avoid taking certain
types of drugs and exercise a little self-discipline in your diet in order to be safe.
You will find it is well worth the extra effort required to protect yourself. How to
Avoid a Hypertensive or Hyperpyretic Crisis. There are two important keys to
preventing a hypertensive or hyperpyretic crisis if you are taking an MAOI.
First, you must obtain a blood-pressure cuff and monitor your own blood
pressure carefully. Second, you must carefully avoid certain foods or
medications (including some street drugs) that will predictably trigger these
reactions. I will describe
578 David D. Burns, M.D. these forbidden foods and medicines in detail below.
You will see that the substances that can trigger a hypertensive crisis are
somewhat different from the substances that can trigger a hyperpyretic crisis.
You can obtain a blood-pressure cuff at your local phar- pharmacy so you can
monitor your own blood pressure when- whenever you want. Practice using the
cuff. Although it may seem a little awkward or confusing at first, you will find
that it gets pretty easy to take your blood pressure after you have practiced a few
times. In my practice I have required every patient taking an MAOI to do this. In
the rare situ- situation where a patient did not want to go to the trouble of
obtaining a cuff and learning how to use it, I have refused to prescribe an MAOI.
Initially you can monitor your blood pressure once a day or even twice a day if
you are so inclined. After you have been taking the MAOI for a couple weeks,
you will not need to monitor your blood pressure so frequently. Once a week
you will not need to monitor your blood pressure so frequently. Once a week
will usually be sufficient. You can check your blood pressure if you forget and
eat one of the forbidden foods. You can also check it if you feel woozy or
nauseous or if you get an excruciating or severe headache. We all get headaches
from time to time, and they rarely ever indicate a stroke. However, if you have a
blood-pressure cuff, you can check your blood pressure and make sure it is not
dan- dangerously elevated. If your blood pressure goes up to a dangerous level,
you should call your doctor or go to an emergency room. How much elevation is
dangerous? The blood pressure consists of two numbers. The higher number is
called the "systolic" blood pressure and the lower number is called the "diastolic" blood pressure. A value of 120/80, for example, would be considered
normal for most people. Most emer- emergency room doctors would not be
particularly concerned until these numbers reach the range of 190 to 200 over
105 to 110. At that level, they might observe you carefully and monitor your
blood pressure every few minutes. Most of
FEELING GOOD 579 the time, the elevated blood pressure will subside without
treatment. If your blood pressure continues to rise, the ER doctor could give you
an antidote (such as phentolamine or prazosin) to lower your blood pressure
back into a safe range. The best time to take your blood pressure is about one to
one and a half hours after you have taken the medication. About 25 percent of
my patients have noted modest blood pressure elevations at this time even if they
have not eaten any of the forbidden foods in Table 20-8 on pages 580- 581 or
taken the medicines in Table 20-9 on pages 584- 590. These increases were not
usually extreme or danger- dangerous—a 20- or 30-point elevation in the
systolic blood pres- pressure was typical. Nevertheless, in those cases, I have
recommended stopping the medication because these pa- patients seemed overly
sensitive to the effects of the MAOI on their blood pressure. It just did not seem
worth the worry and risk, especially since a different antidepressant might be
just as effective. Foods to Avoid. Hypertensive crises may occur if you eat foods
(see Table 20-8) that contain a substance known as tyramine. If you are taking
an MAOI, too much tyramine can interfere with your brain's ability to regulate
your blood pressure. Tyramine causes nerves to release more norepi- nephrine
into the synaptic regions that separate them from the postsynaptic nerves. These
postsynaptic nerves may be- become overly stimulated when too much
norepinephrine is released. Because these nerves help to regulate blood prespressure, all the extra norepinephrine that is released can cause a dangerous and
sudden increase in blood pressure. You will recall from Chapter 17 that an
enzyme called monoamine oxidase (MAO) is located inside the presynap- tic
nerves. This enzyme usually destroys any excess nor- norepinephrine that builds
nerves. This enzyme usually destroys any excess nor- norepinephrine that builds
up inside these nerves and prevents these nerves from releasing too much
norepinephrine when they fire. But the MAOI drugs block this enzyme, and so
the norepinephrine levels inside these nerves increase sub580 David D. Burns, M.D. Table 20-8. Foods and Beverages to Avoid If You
Are Taking a Monoamine Oxidase Inhibitor (MAOI)a Foods to Avoid
Completely Cheese, particularly strong or aged cheese (cottage cheese and
cream cheese are allowed) Beer and ale: particularly tap beers, beers from
microbreweries and strong ales Red wine: especially Chianti wine Brewer's yeast
tablets or yeast extracts (breads and cooked forms of yeast are safe. The yeast
extracts from health food stores are dangerous. Yeast extracts may be found in
certain soups. Some powdered protein diet supplements contain yeast extracts.)
Pods of fava beans, also called Italian green beans (regular green beans are safe)
Meat or fish that is smoked, dried, fermented, unrefrigerated, or spoiled,
including: • fermented or air-dried sausages, such as salami and mortadella
(some experts state that bologna, pepperoni, summer sausage, corned beef, and
liverwurst are safeI7 • pickled or salted herring • liver (beef or chicken),
especially old chicken liver (fresh chicken liver is safe) Overripe bananas or
avocados (most fruits are completely safe) Sauerkraut Some soups, including
those made from beef bouillon or Asian soup stocks (e.g., miso soup). (Tinned
and packet soups are felt to be safe, unless made from bouillon or meat extracts)
Foods or Beverages that May Cause Problems in Large Amounts White wine or
clear alcohol, such as vodka or gin Sour cream Yogurt: must be pasteurized and
less than 5 days old to be safe Soy sauce NutraSweet (the artificial sweetener)
Chocolate Caffeine in beverages (coffee, tea, and soda) and chocolate
FEELING GOOD 581 Foods or Beverages Once Thought to Cause Problems
which Are Probably Safe in Small Amounts Figs (avoid overripe figs) Meat
tenderizers Caviar, snails, tinned fish, pate Raisins "Modified from B. McCabe
and M. T. Tsuang, "Dietary Considerations in MAO Inhibitor Regimens,"
Journal of Clinical Psychiatry 43 A982): 178-181. stantially. When you eat
foods containing tyramine, all that extra norepinephrine suddenly spills into the
synaptic re- region, causing a massive stimulation of the nerves that reg- regulate
your blood pressure. If you watch your diet carefully, the likelihood is good that
you will experience no adverse blood-pressure eleva- elevation. The most
common trigger is cheese, especially strong cheese. You will have to give up
pizza and grilled cheese sandwiches for a while if you are taking an MAOI.
Most of the forbidden foods contain the breakdown prod- products of protein—
including tyramine. So, for example, freshly cooked chicken is perfectly safe,
including tyramine. So, for example, freshly cooked chicken is perfectly safe,
but cooked left- leftover chicken that has been sitting for a couple days can be
dangerous because tyramine forms when the meat decom- decomposes. One of
my patients on tranylcypromine (Parnate) ate some leftover chicken that had
been in the refrigerator for several days. Soon after eating it, he experienced a
signif- significant elevation in blood pressure. This was because the chicken had
partially decomposed due to effects of bacteria. Fortunately, he was not harmed,
but this experience served as a useful warning to be careful. The fermented or
partially decomposed meats on the list in Table 20-8, such as strong sausage or
smoked fish, as well as strong cheese, may con- contain large amounts of
tyramine and can be especially dan- dangerous. Some experts also advise against
eating Chinese food while taking MAOIs. This may be due to the soy sauce, the
monosodium glutamate, or other ingredients. How much tyramine is necessary
to cause a hypertensive reaction? This varies quite a bit from person to person.
On
582 David D. Burns, M.D. average, foods containing at least 10 mg of tyramine
will be sufficient to cause a hypertensive crisis if you are taking phenelzine
(Nardil). As little as 5 mg of tyramine may be sufficient if you are taking
tranylcypromine (Parnate). What foods contain this amount of tyramine? Well,
most beers contain less than 1.5 mg of tyramine, and many contain less than 1
mg, so you would have to drink several beers to run a significant risk. However,
some ales contain 3 mg of tyramine per serving, and some tap beers can also be
particularly risky. For example, one serving of Kronen- bourg, Rotterdam's
Lager, Rotterdam's Pilsner, or Upper Canadian Lager contains between 9 and 38
mg of tyra- tyramine17. So even one glass of these beers could be dangerdangerous. Cheeses can also vary greatly. Processed American cheese contains
only about 1 mg of tyramine per serving, but Liederkranz, New York State
cheddar, English Stilton, blue cheese, Swiss cheese, aged white cheese and Camembert all contain more than 10 mg per single serving.17 Suppose you eat one of
the forbidden foods by accident, and then you check your blood pressure and
discover that it does not go up. What does this mean? There is a lot of individual
variation in the sensitivity to the effects of the forbidden foods. You may be one
of those individuals who is significantly less likely to react with an elevation in
blood pressure. However, you should not become complacent, be- because these
hypertensive reactions are unpredictable. If you cheat and eat the forbidden
foods from time to time, it is a lot like playing Russian roulette. You may get
away with it for a while and then discover that you have experimented once too
often. For example, you may eat a piece of pizza on nine separate occasions
without any increase in blood pressure, and conclude that it is safe to eat pizza.
But this can be very misleading, because the tenth time you eat a piece of pizza
But this can be very misleading, because the tenth time you eat a piece of pizza
you may experience a sudden and severe increase in blood pressure. It is not
known why this hap- happens, but it does underscore the importance of
consistent self-discipline if you are taking an MAOI.
FEELING GOOD 583 Medications and Drugs to Avoid. A number of preprescription drugs, nonprescription drugs, and street drugs that can cause a
hypertensive or hyperpyretic crisis when com- combined with MAOIs are listed
in Table 20-9 on pages 584- 590. These reactions are especially dangerous and
so you must carefully avoid these drugs. Some of the medications that interact
with MAOIs do not cause such severe reac- reactions. For example, caffeine
may cause you to become more jumpy and jittery than usual. Moderate amounts
of caffeine are reasonably safe, however. (You may think of caffeine as more of
a food than a drug, but it is a mild stimulant.) The list of drugs that interact with
MAOIs includes: • most antidepressants—virtually any of them can be
dangerous; • many antiasthma drugs; • many common cold, cough allergy, sinus,
deconges- tant, and hay fever medications that contain sympatho- mimetic
agents (discussed in detail below) or dextromethorphan, the cough suppressant.
You will have to check labels carefully, because many over-the- counter drugs
contain these substances; • drugs used in the treatment of diabetes—they may
be- become more potent than usual if you are taking an MAOI, and can cause
your blood sugar to fall more than expected; • some drugs used in the treatment
of low or high blood pressure—both types of drugs can in some cases cause
blood pressure elevations when combined with MAOIs; • mood stabilizers and
anticonvulsants; • some painkillers, including some local and general ananesthetics; • sedatives (including alcohol) and tranquilizers—they may have
more pronounced effects than usual when you are (continues on page 591)
584 David D. Burns, M.D. Table 20-9. Prescription Drugs and Over-the-Counter
Medications to Avoid If You Are Taking a Monoamine Oxidase Inhibitor
(MAOl)a Note: This list is not exhaustive; new information about drug
interactions comes out frequently. If you are taking an MAOI and any other
medication, ask your doctor and pharmacist if there are any drug interactions.
Antidepressants Drug tricyclic antidepressants,b especially desipramine
(Norpramin, Pertofrane) and clomipramine (Anafranil) tetracyclic
antidepressants, especially bupropion (Wellbutrin) SSRIs (all are extremely
dangerous) other MAOIs serotonin antagonists, including trazodone (Desyrel)
and nefazodone (Serzone) mirtazapine (Remeron) venlafaxine (Effexor)
Comment Some (e.g., clomipramine) may cause a hyperpyretic crisis or
seizures; others (e.g. desipramine) may cause a hypertensive crisis hypertensive
seizures; others (e.g. desipramine) may cause a hypertensive crisis hypertensive
crisis (noradrenergic syndrome) hyperpyretic crisis (serotonin syndrome)
hyperpyretic crisis (serotonin syndrome); hypertensive crisis (nonadrenergig.
syndrome) hyperpyretic crisis (serotonin syndrome) hypertensive crisis
(noradrenergic syndrome) hypertensive crisis (noradrenergic syndrome) Asthma
Medicines Drug ephedrine, a bronchodilator contained in Marax, Quadrinal, and
other asthma drugs inhalants which contain albuterol (Proventil, Ventolin),
metaproterenol (Alupent, Metaprel), or other beta- adrenergic bronchodilators
theophylline (Theo-Dur), a common ingredient in asthma drugs Comment
hypertensive crisis blood pressure elevations and a rapid heart; beclomethasone
and other nonsystemic steroid inhalers are generally safer rapid heart and anxiety
FEELING GOOD 585 Cold, Cough, Allergy, Sinus, Decongestant, and Hay
Fever Medications (including tablets, drops, or sprays) Drug antihistamines:
terfenadine (Seldane-D) dextromethorphan can be found in many cold and cough
medications, especially any drug with DM or Tuss in its name. These include
Bromarest-DM or -DX, Dimetane-DX cough syrup, Dristan Cold & Flu,
Phenergan with Dextromethorphan, Robitussin-DM, several Tylenol cold,
cough, and flu preparations, and many others ephedrine can be found in
Bronkaid, Primatene, Vicks Vatronol nose drops and several other asthma and
cold medications. oxymetazoline (Afrin) nose drops or sprays used to treat nasal
decongestion phenylephrine can be found in Dimetane, Dristan decongestant,
Neo-Synephrine nasal spray and nose drops, and many other similar
preparations, including some eye drop medications Comment can cause an
increase in MAOI blood levels hyperpyretic crisis (serotonin syndrome); may
also cause brief episodes of psychosis or bizarre behavior hypertensive crisis
(noradrenergic syndrome) hypertensive crisis (noradrenergic syndrome)
hypertensive crisis (noradrenergic syndrome)
586 David D. Burns, M.D. Cold, Cough, Allergy, Sinus, Decongestant, and Hay
Fever Medications (including tablets, drops, or sprays) cont. Drug
phenylpropanolamine is contained in Alka-Seltzer Plus Cold and Night-Time
Cold medicine, Allerest, Contac decongestants, Coricidin D decongestants,
Dexatrim appetite pills, Dimetane-DC Cough syrup, Ornade Spansules,
Robitussin- CF, Sinarest, St. Joseph Cold Tablets, Tylenol Cold medicine, and
many others pseudoephedrine can be found in Actifed, Allerest No Drowsiness
formula, Benadryl combinations, CoAdvil, Dimetane-DX Cough syrup, Dristan
Cold Maximum Strength, Robitussin-DAC syrup, Robitussin-PE, Seldane-D
tablets, Sinarest No Drowsiness, Sinutab, Sudafed, Triaminic Nite Light, and
numerous Tylenol allergy, sinus, flu, and cold preparations, as well as several
Vicks products including NyQuil, to mention just a few Comment hypertensive
Vicks products including NyQuil, to mention just a few Comment hypertensive
crisis (noradrenergic syndrome) hypertensive crisis (noradrenergic syndrome)
Diabetes Medications Drug insulin oral hypoglycemic agents Comment may
cause a greater drop in blood sugar as above
FEELING GOOD 587 Medications for Low Blood Pressure (for patients in
shock) Drug sympathomimetic amines including: • dopamine (Intropin) •
epinephrine (Adrenalin) • isoproterenol (Isuprel) • metaraminol (Aramine) •
methyldopa (Aldomet) • norepinephrine (Levophed) Comment hypertensive
crisis (noradrenergic syndrome) because these drugs cause blood vessels to
constrict Medications for High Blood Pressure Drug guanadrel (Hylorel)
guanethidine (Ismelin) hydralazine (Apresoline) methyldopa (Aldomet)
reserpine (Serpasil) beta-blockers calcium channel blockers diuretics Comment
These blood-pressure medications may cause a paradoxical increase in blood
pressure when combined with MAOIs. may be more potent when combined with
MAOIs, leading to a greater-than- expected drop in blood pressure and dizziness
when standing appear to be reasonably safe when combined with MAOIs. Check
with your doctor and monitor blood pressure closely. Watch for a greater- thanexpected drop in blood pressure watch for a greater-than- expected drop in blood
pressure. May increase blood level of MAOI
588 David D. Burns, M.D. Mood Stabilizers Drug carbamazepine (Tegretol)
lithium (Eskalith) Comment hyperpyretic crisis (serotonin syndrome); MAOI
may cause carbamazepine levels to fall, so epileptics may experience seizures
can cause hyperpyretic crisis (serotonin syndrome) in animal studies Painkillers
and Anesthetics Drug anesthetics: general anesthetics: local • cydobenzaprine
(Flexeril) (a muscle relaxant used to treat muscle spasm) meperidine (Demerol)
Comment Tell your anesthesiologist you are on an MAOI. If possible,
discontinue the MAOI two weeks before elective surgery Muscle relaxants such
as succinylcholine and tubocurarine may have a more pronounced or prolonged
effect. General anesthetics such as halothane may lead to excitement, excessive
depression of the brain, or hyperpyretic reactions Some contain epinephrine or
other sympathomimetics— make sure you tell your dentist you are taking an
MAOI hyperpyretic crisis (serotonin syndrome) or severe seizures A single
injection can cause seizures, coma, and death (serotonin syndrome). Most other
narcotics, including morphine and codeine, have been used safely with MAOIs
FEELING GOOD 589 Sedatives and Tranquilizers Drug alcohol barbiturates
(such as phenobarbital) buspirone (BuSpar) major tranquilizers (neuroleptics)
minor tranquilizers (benzodiazepines) such as alprazolam (Xanax), diazepam
minor tranquilizers (benzodiazepines) such as alprazolam (Xanax), diazepam
(Valium) and others sleeping pills L-tryptophan Comment May have enhanced
sedative effects, especially when combined with phenelzine (Nardil). This could
be hazardous when driving or operating dangerous machinery enhanced sedative
effects as described above enhanced sedative effects as described above
enhanced sedative effects as described above; some neuroleptics may cause a
drop in blood pressure when combined with MAOIs enhanced sedative effects as
described above enhanced sedative effects as described above hyperpyretic crisis
(serotonin syndrome); blood pressure elevations; disorientation, memory
impairment, and other neurologic changes Stimulants (Pep Pills) and Street
Drugs Drug amphetamines (speed or crank) cocaine benzedrine benzphetamine
(Didrex) dextroamphetamine (Dexedrine) methamphetamine (Desoxyn)
methylphenidate (Ritalin) Comment the hypertensive crisis (noradrenergic
syndrome) is possible; methylphenidate is considered somewhat less risky than
the amphetamines
590 David D. Burns, M.D. Weight-Loss and Appetite-Suppression Medications
Drug pemoline (Cylert) fenfluramine (Pondimin) phendimetrazine (Plegine)
phentermine and some over- the-counter meds phenylpropanolamine (Acutrim)
stimulants (listed above) Comment drug interactions have not been studied in
humans; great caution should be used; some experts report that pemoline has
been combined with MAOIs in some cases1 hyperpyretic crisis (serotonin
syndrome) hypertensive crisis (noradrenergic syndrome) hypertensive crisis
(noradrenergic syndrome) hypertensive crisis (noradrenergic syndrome)
hypertensive crisis (noradrenergic syndrome) Other MAOI Drug Interactions
Drug caffeine (in coffee, tea, soda, chocolate) disulfiram (Antabuse) (used to
treat alcoholism) L-dopa (Sinemet) (used to treat Parkinson's disease) Comment
Probably safe in moderate amounts; avoid large amounts; may cause blood
pressure elevations, a racing heart, and anxiety Severe reactions when mixed
with an MAOI hypertensive crisis (noradrenergic syndrome) 'Information in this
table was obtained from several sources including the Manual of Clinical
Psychopharmacology* and Psychotropic Drugs Fast Facts.xl These ex- excellent
references are highly recommended. bMany patients have been successfully
ti'eated with a combination of an MAOI and a tricyclic antidepressant under
close observation, but such drug combinations are dangerous and require a high
level of expert supervision.
FEELING GOOD 591 taking an MAOI. The increased sleepiness could be
hazardous if you are driving; • L-tryptophan—the natural amino acid; •
stimulants (pep pills) and street drugs; • many weight-loss (appetite suppressing)
stimulants (pep pills) and street drugs; • many weight-loss (appetite suppressing)
medications; • caffeine, which is present in coffee, tea, many sodas, hot cocoa,
and chocolate. Caffeine is also present in a number of prescription and
nonprescription medica- medications such as Cafergot suppositories and tablets,
Dar- von Compound-65, NoDoz, Fiorinal, Excedrin, and many other cold or
pain preparations; • Disulfiram (Antabuse), used to treat alcoholism; • Levodopa, used in the treatment of Parkinson's dis- disease. Drugs that are
categorized as sympathomimetics are par- particularly dangerous because they
are contained in many over-the-counter drugs for common ailments such as
colds. They are called sympathomimetics because they tend to mimic the effects
of the sympathetic nervous system, which is involved in the control of blood
pressure. Several sympathomimetic drugs are found in large num- numbers of
prescription and over-the-counter cold preparations, cough medicines,
decongestants, and hay fever medica- medications. These include ephedrine,
phenylephrine, phenylpro- panolamine and pseudoephedrine. For example,
ephedrine can be found in Bronkaid, Primatene, Vicks' Vatronol nose drops, and
several other cold and asthma medications. Phenylephrine can be found in
Dimetane, Dristan decon- decongestants, Neo-Synephrine nasal spray and nose
drops, and many other similar preparations. Phenylpropanolamine is contained
in Alka-Seltzer Plus Cold Medicines, Contac de- decongestants, Coricidin D
decongestants, Dexatrim appetite suppressant pills, Dimetane-DC Cough syrup,
Ornade Spansules, Robitussin-CF, Sinarest, St. Joseph Cold Tab- Tablets, and
many other cold medicines. Pseudoephedrine can
592 David D. Burns, M.D. be found in Actifed, Advil Cold & Sinus, Allerest
No- Drowsiness formula, Benadryl combinations, Dimetane-DX Cough syrup,
Dristan Cold Maximum Strength, Robitussin-DAC syrup, Robitussin-PE,
Seldane-D tablets, Sinarest No Drowsiness, Sinutab, Sudafed, Triaminic Nite
Light, and numerous Tylenol allergy, sinus, flu, and cold preparations, as well as
several Vicks products including NyQuil, to mention just a few. Some cold and
cough preparations contain dextrome- thorphan. This is not a sympathomimetic
drug, but a cough suppressant. Dextromethorphan is on the list of forbidden
medications because it can cause a hyperpyretic crisis. Dex- Dextromethorphan
can be found in any drug with "DM" or "Tuss" in its name, as well as many
preparations without these suffixes. A few examples are Bromarest-DM or -DX,
Dimetane-DX Cough syrup, Dristan Cold & Flu, Phenergan with
Dextromethorphan, Robitussin-DM, several Tylenol cold, cough, and flu
preparations, and many other medi- medications as well. Because so many
common over-the-counter medications contain sympathomimetics or
dextromethorphan, it is nearly impossible to keep up with all of them. You can
best protect yourself by reading the warning labels that come with these
best protect yourself by reading the warning labels that come with these
medications and by checking with your doctor or pharmacist before you
combine any with an MAOI. Diabetics taking MAOIs need to know that the
MAOIs may also cause blood levels of insulin as well as some oral
hypoglycemic agents to increase. As a result, your blood sugar may fall more
than expected. This can cause a hy- hypoglycemic reaction, with dizziness,
faintness, sweating, and so forth, because your brain does not get enough sugar
from your blood. Your doctor may have to adjust the doses of your diabetic
medications if you are on an MAOI. Any of the MAOIs can lower your blood
pressure, and so they can intensify the effects of other blood-pressure
medications your doctor has prescribed, including diuretics and beta-blockers.
The MAOIs can also cause the blood levels of a number of blood-pressure
medications to inFEELING GOOD 593 crease. This also tends to intensify their effects. As noted
above, some blood-pressure medications can have the par- paradoxical effect of
causing an increase in blood pressure if you are taking an MAOI. Make sure you
let your doctor know about the MAOI. Many major tranquilizers (neuro- leptics)
can also cause blood pressure to fall, and MAOIs can increase this effect as well.
Some painkillers must be avoided if you are taking an MAOL For example, a
single injection of the painkiller meperidine (Demerol) has been known to cause
seizures, coma, and death in patients taking MAOIs. Other opiates, including
morphine, are thought to be safer. Most mild non- prescription painkillers, such
as aspirin or Tylenol, are also thought to be safe as long as they contain no
caffeine. How- However, cyclobenzaprine (Flexeril), which is commonly used to
treat local muscle spasm, can cause fever, seizures, and death. This drug should
be avoided entirely. Many local and general anesthetics can also interact with the
MAOIs. Some local anesthetics contain epinephrine or other sympathomimetic
drugs that can create hypertensive reactions. Inform your dentist that you are
taking an MAOI so she or he can choose a local anesthetic that will be safe for
you. If you require elective surgery while on an MAOI, it would be best to
discontinue the MAOI for one or two weeks prior to the surgery. Some general
anesthetics, such as halothane, can cause excitement or excessive sedation as
well as hyperpyretic reactions when combined with an MAOI. The muscle
relaxants used by anesthesiologists, such as succinylcholine or tubocurarine,
may also have more potent effects. Make sure you inform your anestheanesthesiologist if you are taking an MAOI. Sedative drugs, including alcohol,
major tranquilizers (neuroleptics) and minor tranquilizers, barbiturates and
sleeping pills, can interact with MAOIs. This is especially true for phenelzine
(Nardil). Because phenelzine also tends to be sedating, it can enhance the effects
(Nardil). Because phenelzine also tends to be sedating, it can enhance the effects
of any other sed- sedative agent. You should try to avoid combining MAOIs
with sedative drugs because the sleepiness you experience
594 David D. Burns, M.D. could be hazardous, especially if you are driving or
oper- operating dangerous machinery. L-tryptophan is another sedative agent
that should not be combined with MAOIs because it can cause a hyperpyretic
crisis (serotonin syndrome). L-tryptophan is an essential amino acid that is
present in certain foods such as meats and dairy products. It used to be available
in health food stores and has been actively promoted as a natural sedative agent
to help people with insomnia. It has also been used as a treatment for depression,
but the evidence for its an- tidepressant effects is meager at best. Following
ingestion, L-tryptophan rapidly accumulates in the brain, where it is converted
into serotonin. If the dose of L-tryptophan is large enough, you will begin to feel
sleepy. If you are tak- taking an MAOI, the increase in brain serotonin may be
mas- massive. This is because your brain cannot metabolize the excess serotonin
when you are on an MAOI, so the levels of serotonin can escalate to dangerous
levels, triggering the serotonin syndrome. However, some researchers have
purposely treated de- depressed patients with an MAOI plus 2 to 6 grams per day
of L-tryptophan in an attempt to make the MAOI treatment more effective. The
purpose of these augmentation strate- strategies is to convert a drug
nonresponder into a drug re- sponder. Some studies have indicated that this
combination can be more potent than treatment with an MAOI alone. Such a
treatment is somewhat dangerous, and should prob- probably be administered by
experts and reserved for patients with very difficult, resistant depressions.20 Dr.
Jonathan Cole and his colleagues have given doses of 3 to 6 grams of Ltryptophan to patients who had been taking an MAOI for several weeks or
more.1 They observed some early signs of the serotonin syndrome in these
patients, suggesting the potential benefits of this drug combination may not be
worth the risk. In animal studies, the combination of lithium with an MAOI can
also cause the serotonin syndrome. This is be- because lithium causes Ltryptophan to enter the brain more rapidly. L-tryptophan is present in the foods
we eat, and a
FEELING GOOD 595 large meal can contain as much as 1 gram of Ltryptophan. If you combine lithium with an MAOI, you may get a large increase
in serotonin in your brain following meals. How- However, some doctors have
added lithium to an MAOI if the MAOI has not been effective, in just the same
way they might add L-tryptophan to try to augment the antidepres- sant effect of
the MAOI. If you receive lithium plus an MAOI, you must be monitored closely
the MAOI. If you receive lithium plus an MAOI, you must be monitored closely
to make sure you do not develop any symptoms of the serotonin syndrome, such
as fever, tremor, jerking of the muscles, or confusion. MAOIs are often
combined with lithium for another rea- reason. Bipolar patients with abnormal
episodic mood eleva- elevations as well as depression are often maintained
indefinitely on lithium or another mood stabilizer, as described below. During
the depressed phase of the cycle, many bipolar pa- patients will need an
antidepressant as well as lithium to re- reverse the depression. The MAOIs, as
well as many other kinds of antidepressants, have been used safely and sucsuccessfully in this way. However, patients need to be moni- monitored closely
for signs of hyperpyretic crises as well as episodes of mania, which can occur on
rare occasions when bipolar patients receive antidepressants. Stimulants, pep
pills, and weight-loss pills are especially dangerous when combined with
MAOIs. Some of these drugs are categorized as sympathomimetics, and they can
cause hypertensive crises. For example, methylphenidate (Ritalin), which is
widely used for the treatment of attention deficit disorder in children and adults,
is a sympathomi- metic that could have this effect. Several commonly abused
street or prescription drugs are also sympathomimetics. These include the
amphetamines such as Benzedrine, Dex- edrine, and Methedrine (also known as
"speed'' or "crank'') and cocaine. Amphetamines used to be pre- prescribed for
weight loss, but their abuse potential is so high that most doctors no longer
prescribe them for this purpose. However, a number of the newer popular
weight-loss drugs can also be quite dangerous when mixed with MAOIs. For
example, phentermine (Adipex; Fastin) can cause hyperten596 David D. Burns, M.D. sive reactions and fenfluramine (Pondimin), the
controver- controversial weight-loss drug that was recently in vogue, can lead to
hyperpyretic crises. As you know, caffeine is also a mild stimulant. It can cause
racing of the heart, an irregular heartbeat, or in- increased blood pressure if you
are taking an MAOI. Al- Although coffee, tea, soda, and chocolate all contain
caffeine, they are not strictly forbidden, especially in moderate amounts, because
their effects are usually mild. Neverthe- Nevertheless, you should avoid caffeine
in large quantities because it could precipitate a hypertensive crisis. Some
experts rec- recommend a daily maximum of two cups of coffee or tea, or two
sodas. In addition, if you monitor your blood pressure with your own bloodpressure cuff, as described above, you can see whether that cup or two of coffee
you love in the morning is actually causing a rise in blood pressure. If so, then
you should cut down or give up caffeine completely while you are on the MAOI.
You can see in Table 20-9 that L-dopa (levodopa), which is used in the treatment
of Parkinson's disease, can also cause increases in blood pressure when
combined with an MAOI. However, patients with Parkinson's disease are
combined with an MAOI. However, patients with Parkinson's disease are
sometimes treated with the MAOI selegiline, as well as other medicines. If these
patients receive an MAOI along with L-dopa, the L-dopa should be started at a
very small dose and increased slowly while checking the blood pressure. As
noted above, most of the forbidden drugs have warn- warning labels to indicate
they can be dangerous when combined with some antidepressant medications. If
you are taking an MAOI, check the warning labels carefully before you take any
new drug, and always check with your druggist or doc- doctor as well. For a
detailed list of drugs that cause hyperten- hypertensive reactions for patients on
MAOIs, see pages 157-160 of Psychotropic Drugs Fast Facts by Drs. Jerrold S.
Max- men and Nicholas G. Ward.17 The Physician's Desk Ref- Reference
(PDRJ1 also lists dangerous drug interactions for any prescription medication
you may be taking. It is avail- available in any library, drugstore, or medical
clinic.
FEELING GOOD 597 The lists of forbidden foods and medications may seem
somewhat confusing or overwhelming. If your doctor pre- prescribes an MAOI,
she or he can give you a card to carry in your wallet that lists the foods and drugs
to avoid. When in doubt, you can check the card. Some experts advise papatients on MAOIs to carry Med-Alert cards so that any emer- emergency room
doctors will know that they are taking an MAOI in case they are in an accident
or found unconscious and in need of emergency treatment. Then the doctors can
take appropriate precautions when administering anesthesia or prescribing other
drugs for you. Remember that the chemical effects of an MAOI remain in your
body for as much as one to two weeks after you stop taking it. This is why you
must continue to observe the drug and dietary precautions for at least two weeks
after you have taken your last MAOI. I would suggest that you actually wait a bit
longer. Then you can begin to eat the forbidden foods, such as cheese, in small
amounts at first, followed by blood-pressure checks. If your blood pressure is not
affected, you can gradually increase the amount you eat until your diet is back to
normal. Similarly, if you are switching from an MAOI to another antidepressant,
you will have to be completely drug-free for two weeks after you take your last
MAOI before starting the new antide- antidepressant. The same is true if you are
starting an MAOI after you have taken another medication—you will have to
wait for a period of time, depending on which medication you took. You will
recall that you have to wait at least five weeks before starting an MAOI after
going off Prozac because this drug remains in your blood for a prolonged time.
Most of the other SSRIs are cleared out of your body more rapidly than Prozac,
and so a two-week waiting period is usually sufficient. Some antidepressant
drugs, such as nefazodone (Serzone) and trazodone (Desyrel), leave your body
drugs, such as nefazodone (Serzone) and trazodone (Desyrel), leave your body
even faster, and you may have to wait only one week after taking them before
starting an MAOI. Always check with your physician before making any
changes in your medications.
598 David D. Burns, M.D. Well, by now you may be asking whether it is worth
it to take a drug like an MAOI which may seem so compli- complicated and
dangerous. This question is especially relevant these days, when so many newer
and safer drugs are avail- available. Usually, I would try at least two other drugs
first. The SSRI drugs, in particular, often help the same types of pa- patients who
used to benefit from the MAOIs. I would like to emphasize, however, that in my
experience, the MAOIs can usually be administered safely. I have prescribed
them for many patients over the years. When doses are kept at a modest level,
the side effects tend to be minimal. And when the MAOIs do work, their effects
can be quite phenomenal. In fact, some of my most impressive successes with
med- medications have been with these MAOI drugs, especially tranylcypromine (Parnate). In addition, I have used these drugs with difficult
patients who had experienced many unsuc- unsuccessful treatments with drugs
as well as psychotherapy. When these individuals did improve, the degree of imimprovement was sometimes extreme. These positive experi- experiences with
MAOIs have made a strong impression on me. I believe the enthusiasm of the
physicians who use the MAOIs is quite justified. If your physician suggests a
med- medication of this type, it might prove to be well worth the necessary extra
effort (taking your blood pressure daily), sacrifice (no pizza!), and self-discipline
(avoiding certain foods and medicines). One last note is that a newer and safer
MAOI drug, mo- moclobemide, is being marketed in other parts of the world,
including Canada, Europe, and South America. Unlike the MAOIs described
above, the effects of moclobemide do not persist after you stop taking it. In
addition, it does not seem to interact with tyramine in the diet to nearly the same
degree. Dr. Alan Schatzberg and his colleagues1 have pointed out that
moclobemide appears to have very few side effects and that the risk of serious
drug interactions is rel- relatively low. Psychiatrists hope that moclobemide or
another new MAOI called brofaromine will eventually be marketed in the
United States.
FEELING GOOD 599 Serotonin Antagonists Two antidepressant drugs in the
table on pages 514-515 are classified as "serotonin antagonists." They are trazotrazodone (Desyrel) and nefazodone (Serzone). Their mecha- mechanism of
action appears to be somewhat different from most other antidepressants.
Trazodone and nefazodone can boost serotonin by blocking its reuptake at nerve
Trazodone and nefazodone can boost serotonin by blocking its reuptake at nerve
synapses, much like the SSRIs described above. However, these drugs have less
potent effects on the serotonin pump than the SSRIs, or even the older tricyclic
antidepressants, and this is prob- probably not how these drugs work. As
described in Chapter 17, trazodone and nefazodone appear to block some of the
serotonin receptor sites on postsynaptic nerve membranes. At least fifteen
different kinds of serotonin receptors have been discovered in the brain. The two
receptors that are blocked by trazodone and nefazodone are called 5-HT2A and
5-HT2C receptors. 5-HT is simply shorthand for serotonin; the number and letter
after the 5-HT identify the specific type of receptor. Trazodone and nefazodone
indirectly stimulate another type of serotonin receptor called the 5-HT1A
receptor. This receptor is thought to be important in depression, anxiety, and
violence. According to one theory, the stim- stimulation of these 5-HT1A
receptor sites might explain the antidepressant effects of trazodone and
nefazodone. In addition, trazodone and nefazodone are effective anti- anxiety
drugs. If you tend to be nervous and worried, like many depressed individuals,
these medications may be especially helpful for you. Doses of Trazodone and
Nefazodone. The starting dose for trazodone is 50 to 100 mg per day. Most
patients will do well on 150 mg to 300 mg per day. The starting dose for
nefazodone is 50 mg twice per day. The doses of both drugs can be increased
very slowly over several weeks to a maximum of 600 mg per day. Nefazodone
and trazodone have short half-lives. The
600 David D. Burns, M.D. half-life is the time it takes your body to get rid of
half of the drug that is in your system. A drug with a short half- life leaves the
blood fairly rapidly and must be taken two or three times per day. In contrast, a
drug like Prozac, with an extremely long half-life, leaves your body slowly and
needs to be taken only once per day. As with any antidepressant, you should
monitor your mood with a test like the one in Chapter 2 while taking trazodone
and nefazodone. This will show whether the drugs are working, and to what
extent. If you have not improved substantially after three or four weeks, it may
be wise to switch to another drug. Although withdrawal symp- symptoms are
quite rare for these medications, it is wise to taper off nefazodone and trazodone
slowly, rather than stopping them suddenly. This is good advice with any
antidepres- antidepressant. Side Effects of Trazodone and Nefazodone. The most
common side effects of these two drugs are listed in Table 20-10 on page 601.
One common side effect is stomach upset (such as nausea). This side effect is
also common with the SSRIs and other drugs that stimulate the serotonin
systems in the brain. The upset stomach is more likely when nefazodone and
trazodone are taken on an empty stomach, and so it can be helpful to take them
with food, just like the SSRIs. Trazodone and nefazodone can also cause dry
with food, just like the SSRIs. Trazodone and nefazodone can also cause dry
mouth in some patients. Both drugs can also cause a temporary drop in blood
pressure when you stand up, resulting in dizziness or light-headedness.
Trazodone is much more likely to cause these problems than nefazodone.
Elderly people are more prone to dizziness and fainting, and so nefazodone may
be a better choice for them. As discussed above, sev- several things can alleviate
this problem: get up more slowly; walk in place when you get up so as to
"pump" blood back to your heart from your legs; use support stockings; and take
adequate amounts of fluid and salt to prevent any dehydration. Talk to your
doctor if you have problems with
Table 20-10. Side Effects of Serotonin Antagonists3 Note: This list is not
comprehensive. In general, side effects that occur in 5% or 10% or more of
patients are listed, as well as rare but dangerous side effects. Side Effect Brain
Receptor nefazodone (Serzone) trazodone (Desyrel) Sedation and Weight Gain
histamine (H2) receptors + to + + + + + Light- Headedness and Dizziness alphaadrenergic ((Xj) receptors + + + + to + + + Blurred Vision, Constipation, Dry
Mouth, Speeded Heart, Urinary Retention muscarinic (Mj) receptors + 0
Common or Significant Side Effects dry mouth and throat; headache; tiredness;
insomnia; nausea; constipation; weakness; dizziness; blurred vision; abnormal
vision; confusion dizziness; dry mouth and throat; upset stomach; constipation;
blurred vision; headache; fatigue; sleepiness; confusion; anxiety; priapism (rare;
see text) The + to + + + ratings in this table refer to the likelihood that a
particular side effect will develop. The actual intensity of the side effect will
vary among individuals and will also depend on how large the dose is. Reducing
the dose can often reduce side effects without reducing effectiveness.
602 David D. Burns, M.D. dizziness or other side effects; she or he may be able
to lower the dose. Another major side effect of trazodone is that it makes you
sleepy. This is why it is best taken at night. If you are taking another
antidepressant, your doctor may also pre- prescribe a small dose of trazodone at
bedtime in order to promote sleep. This is because some antidepressants, such as
Prozac and the MAOIs, tend to be stimulating and may interfere with sleep.
Trazodone is not addictive and it will not cause dependency or addiction the way
some sleeping pills do. The calming, sedative effects of trazodone also help to
reduce anxiety. If you tend to be worried and high- strung, this may be a good
drug for you. Nefazodone is much less sedating than trazodone, and is not a
useful med- medication for insomnia. In fact, it can occasionally have the
opposite effect of causing restlessness, in much the same way that the SSRIs do.
Another adverse side effect of trazodone is called ' 'pri- apism." Priapism is an
Another adverse side effect of trazodone is called ' 'pri- apism." Priapism is an
involuntary erection of the penis. Fortunately, this side effect is quite rare,
occurring in ap- approximately one male patient out of 6,000. It has been rereported in only a few hundred cases so far. Personally, I have never seen a case
of priapism, but men who take tra- trazodone should be aware that it is remotely
possible. If the priapism is not treated right away, it can lead to damage to the
penis and permanent impotence (the inability to get an erection). Some patients
require surgery to correct the pri- priapism. Injecting a drug like epinephrine
directly into the penis can sometimes counteract the priapism if you catch it
quickly enough. If this unusual side effect does occur, or if you are beginning to
notice an erection that will not go away, contact your doctor or go to an
emergency room right away. Nefazodone, on the other hand, does not cause pripriapism. Priapism sounds frightening, but I do not mean to dis- discourage men
from taking this medication. If you read the
FEELING GOOD 603 Physician's Desk Reference carefully, you will see that
there is a remote chance of a dangerous side effect from nearly any drug you
might take, including aspirin. Priapism is a very unlikely side effect of trazodone
and can be treated at any emergency room if you act rapidly when the sympsymptom first develops. Some patients taking these drugs report visual "trails" or
afterimages when they are looking at objects that are moving. This side effect is
also quite unusual and similar in some respects to the visual images reported by
individ- individuals who take LSD, but not dangerous. These visual trails are
more common with nefazodone than with trazodone and occur in slightly more
than 10 percent of patients taking this drug. They often improve over time. Drug
Interactions for Trazodone and Nefazodone. As noted earlier, some drug
combinations can be dangerous because one drug causes the level of the other
drug in your blood to become excessively high. Nefazodone has the ef- effect of
raising the blood level of a number of drugs. These include commonly
prescribed drugs for anxiety, including many of the minor tranquilizers such as
alprazolam (Xanax), triazolam (Halcion), buspirone (BuSpar) and oth- others.
As a result, you should be very cautious when com- combining these drugs with
nefazodone, because you could become excessively sleepy. Trazodone will also
enhance the sedative effects of other sedative drugs because trazodone itself will
make you sleepy. Consequently, trazodone or nefazodone can en- enhance the
sedative effects of any drug that makes you sleepy, such as alcohol, barbiturates,
sleeping pills, pain- painkillers, some major tranquilizers (neuroleptics), and
some antidepressants. Be very cautious if you combine any sed- sedative agents
with nefazodone or trazodone, especially if you are driving or operating
dangerous machinery. Nefazodone can increase the levels of several tricyclic
dangerous machinery. Nefazodone can increase the levels of several tricyclic
604 David D. Burns, M.D. antidepressants in your blood, especially
amitriptyline (Elavil), clomipramine (Anafranil), and imipramine (Tof- ranil), so
the doses of these drugs may need to be lower than usual. If nefazodone is
combined with one of the SSRIs, there is the possibility that a metabolite of
nefazodone called mCPP (m-chlorophenylpiperazine) could build up in your
blood. This substance may lead to agitation or feelings of panic or unhappiness.
If you are switching from an SSRI to nefazodone, mCPP could also build up
because the ef- effects of the SSRIs can persist in your body for several weeks
after you stop taking them. Neither trazodone nor nefazodone should be
combined with an MAOI antidepres- sant because this combination could trigger
the serotonin syndrome (hyperpyretic crisis) described previously. If you are
taking nefazodone, make sure you inform your psychiatrist about any bloodpressure medication you are taking, and inform your general medical doctor as
well. Your blood pressure may drop more than expected if you combine
trazodone with a blood-pressure medication. If your blood pressure does drop
too much, you may notice dizziness when you suddenly stand up. Many
psychiatric medications can also lower the blood pressure, including many of the
tricyclic antidepressants as well as a number of the major tranquilizers
(neuroleptics). If these drugs are combined with trazodone or nefazodone, the
drop in blood pressure may be pronounced. Trazodone can also cause increased
blood levels of the anticonvulsant, phenytoin (Dilantin) as well as the heart
medication, digoxin (Lanoxin). These combinations can lead to toxic blood
levels of phenytoin or digoxin. Make sure your doctor monitors your blood
levels of phenytoin or digoxin carefully if you take trazodone, as excessively
high levels can be dangerous. The effects of trazodone on the blood thinner,
warfarin (Coumadin) are unpredictable. The levels of warfarin may
FEELING GOOD 605 increase or decrease. If the warfarin levels increase, you
may have a greater tendency to bleed, and if the warfarin decreases, your blood
may have a greater tendency to clot. Your doctor can monitor any changes with
blood tests and adjust the dose of warfarin if necessary. Even more dangerous
are the previously described inter- interactions between nefazodone and two
commonly prescribed antihistamines that are given for allergies (terfenadine,
trade name Seldane) and astemizole (trade name Hismanal). Ne- Nefazodone
causes the levels of these two antihistamines to increase, which can result in
potentially fatal changes in heart rhythms. Nefazodone should not be combined
with cisapride (trade name Propulsid, a stimulant for the gastro- gastrointestinal
tract) for the same reason—sudden fatal heart failure can result. Bupropion
(Wellbutrin) Three other types of antidepressant drugs are listed in the Table of
(Wellbutrin) Three other types of antidepressant drugs are listed in the Table of
Antidepressants on pages 514-515. These include bupropion (Wellbutrin),
venlafaxine (Effexor), and mirta- zapine (Remeron). They are somewhat
different from each other and from the antidepressants already discussed.
Bupropion was supposed to be introduced in the United States in 1986, but its
release was delayed until 1989 be- because a number of patients with bulimia
(binge-eating fol- followed by vomiting) who were treated with this drug had
seizures. Further studies indicated that the danger of sei- seizures was related to
the dose of bupropion and that the risk was much lower in patients who did not
have eating dis- disorders, so the drug was released again. Because of the inincreased seizure risk with bupropion, the manufacturer recommends that this
drug not be prescribed to anyone with a history of epilepsy, a major head injury,
a brain tumor, bulimia, or anorexia nervosa. Bupropion does not affect the
serotonin system in the
606 David D. Burns, M.D. brain. Instead, it seems to work by potentiating the
norep- inephrine system, much like the tricyclic antidepressant called
desipramine (Norpramin). There is also some evi- evidence that it may stimulate
the dopamine system in the brain, but these effects are much weaker, and it js
not clear whether they contribute to the antidepressant effects of bu- bupropion.
Nevertheless, bupropion is sometimes classified as a "combined noradrenergicdopaminergic antidepressant," because of its effects on the norepinephrine and
dopamine systems. Bupropion is used to treat depressed outpatients and inpatients over the entire range of depression severity. Pre- Preliminary studies
suggest that it may also be useful for a number of other problems, including
smoking cessation, so- social phobia, and attention deficit disorder. These
widespread effects of bupropion do not mean this drug is special, how- however.
Nearly all antidepressants have been reported to be at least partially effective for
a wide array of problems in- including depression, all of the anxiety disorders,
eating dis- disorders, anger and violence, chronic pain, and many other problems
as well. One possible interpretation for these find- findings is that these drugs
may not really be specific antide- antidepressants. Instead, they may have
widespread effects throughout the brain. A new use for bupropion is to enhance
the effects of the SSRI antidepressants. Suppose, for example, that you are
taking a drug like Prozac but you have not responded to it adequately. Instead of
switching you to a new drug, your doctor may add a low dose of bupropion in an
attempt to enhance the effect of the Prozac. Bupropion, in doses of up to 225 mg
to 300 mg per day, has been added to SSRI antidepressants in an attempt to
combat the sexual side ef- effects of SSRIs, such as loss of libido and difficulties
having orgasms. In my clinical experience, the effects of these drug com-
having orgasms. In my clinical experience, the effects of these drug comcombinations have often been disappointing. I would usually prefer to try
another medication rather than combining drugs when a medication does not
work. I am personally
FEELING GOOD 607 concerned that in some instances patients may be in
danger of being overmedicated by physicians who are a bit too enthusiastic
about adding more and more drugs in larger and larger doses. Also, because I
rely so heavily on psy- psychotherapeutic interventions in my own clinical work,
I do not feel so much pressure to find a solution from drugs alone. Therefore I do
not feel quite so much concern when one or more medications fails to work. I
simply switch to another medication and continue to try a variety of new
psychotherapeutic strategies, a combination that I find most successful. Doses of
Bupropion. You can see in Table 20-1 on pages 518-523 that the usual dose
range for bupropion is 200 to 450 mg per day. At doses below 450 mg per day,
the risk of seizures appears to be about four patients per 1000. However, the risk
is ten times higher at doses above 450 mg per day—four patients per 100 will
experience sei- seizures. Whenever possible, it is good to keep the dose in the
lower range to minimize the chance of seizures. In addition, no single dose
should ever be greater than 150 mg. Side Effects of Bupropion. The most
common side ef- effects of bupropion are listed in Table 20-11 on pages 608-
609. Unlike the tricyclics, bupropion does not cause dry mouth, constipation,
dizziness, or tiredness. It also does not stimulate the appetite. This is a big bonus
for patients who have been bothered by weight gain. However, some pa- patients
have reported upset stomach (nausea). Bupropion is also somewhat activating
and can cause insomnia. Therefore, it may be relatively more effective for
depressed patients who tend to feel tired, lethargic, and un- motivated—the
stimulating effect may help get you mov- moving. In this regard, it is similar to
some of the tricyclic antidepressants (for example, desipramine), the SSRIs (for
example, Prozac) and the MAOIs (for example, tranylcy- promine).
Table 20-11. Side Effects of Other Antidepressants' Note: This list is not
comprehensive. In general, side effects that occur in 5% or 10% or more of
patients are listed, as well as rare but dangerous side effects. Side Effect Brain
Receptor bupropion (Wellbutrin) venlafaxine (Effexor) Sedation and Weight
Gain histamine (Hj) receptors 0 to + 0 Light-Headedness and Dizziness alphaadrenergic ((Xj) receptors 0 to + 0 Blurred Vision, Constipation, Dry Mouth,
Speeded Heart, Urinary Retention muscarinic (M}) receptors Oto + 0 Common
or Significant Side Effects dry mouth; sore throat; upset stomach; loss of
appetite; stomach pain; sweating; headache; insomnia; restlessness; tremor;
appetite; stomach pain; sweating; headache; insomnia; restlessness; tremor;
anxiety; sweating; dizziness; rash; ringing in ears; seizures dizziness; dry mouth
and throat; upset stomach; loss of appetite; constipation; sweating; headache;
drowsiness; insomnia; anxiety;
mirtazapine (Remeron) 4-4-4- 4-4- 4- to 4-4- weakness; tremor; blurred vision;
problems with orgasm; loss of interest in sex; abnormal dreams; increased blood
pressure dry mouth; increased appetite and weight gain; constipation; sleepiness;
dizziness. Warning: Consult your M.D. if you develop signs of an infection
(such as fever). This could indicate a rare fall in the white cell count, a rare but
dangerous side effect. Can also cause increased blood levels of cholesterol and
triglycerides The + to +++ ratings in this table refer to the likelihood that a
particular side effect will develop. The actual intensity of the side effect will
vary among individuals and will also depend on how large the dose is. Reducing
the dose can often reduce side effects without reducing effectiveness.
610 David D. Burns, M.D. Drug Interactions for Bupropion. Because bupropion
can substantially increase the risk of seizures, it should not be combined with
other drugs that can also make a person more vulnerable to seizures. This
includes many psychiatric drugs such as the tricyclic and tetracyclic
antidepressants, the SSRIs, the two serotonin antagonists (trazodone and
nefazodone), and many of the major tranquilizers (neuro- leptics). In addition,
there is a greatly increased risk of sei- seizures when alcoholics suddenly stop
drinking or when individuals abruptly stop taking minor tranquilizers (benzodiazepines such as Xanax or Valium), barbiturates, or sleeping pills.
Bupropion is therefore especially risky for alcoholics and for individuals taking
sedatives or tranquil- tranquilizers regularly. Many nonpsychiatric drugs (for
instance, corticosteroids) can also increase the risk of seizures. Therefore, great
cau- caution must be exercised if bupropion is combined with any of these drugs,
especially if the dose of bupropion is high. Make sure you check with your
pharmacist or druggist about drug interactions if you are taking any other medimedication along with bupropion. There are several other kinds of drug
interactions you need to consider if you are taking bupropion: • Barbiturates can
cause the level of bupropion in the blood to fall. This could make the bupropion
ineffec- ineffective. • Phenytoin (Dilantin) can also cause bupropion levels to
fall, thus making the bupropion less effective. How- However, phenytoin is most
often prescribed for epilepsy, and so patients taking phenytoin are not likely to
re- receive bupropion. • Cimetidine (Tagamet) may increase bupropion levels in
the blood. This can increase the likelihood of side effects or toxic effects,
including seizures. • Bupropion must not be combined with the MAOIs bebecause of the risk of a hypertensive crisis.
because of the risk of a hypertensive crisis.
FEELING GOOD 61 1 L-dopa increases the side effects of bupropion; caution is
required when these drugs are combined. Venlafaxine (Effexor) This is a
relatively new antidepressant that is in a distinct class from other antidepressant
medications. Released in 1994, it is called a "dual uptake inhibitor" or "mixed
up- uptake inhibitor." This has a very simple meaning. It leads to increases in
two types of chemical messengers (also called neurotransmitters) in the brain—
serotonin and nor- epinephrine—by blocking the pumps that transport them back
into the presynaptic nerves after they are released into the synapses. As you will
recall from Chapter 17, this capacity to in- increase levels of two different types
of chemical messengers is not new. Many of the older and cheaper tricyclic antidepressants, such as Elavil (amitriptyline) also do this. The more important
difference with venlafaxine is that it has fewer side effects because it does not
stimulate the hista- minic, alpha-adrenergic, and muscarinic brain receptors that
cause tiredness, dizziness, dry mouth, and so forth. How- However, as you will
see below, venlafaxine has quite a number of side effects of its own. Some of
these, such as nausea, insomnia, and sexual difficulties, are similar to the SSRI
antidepressants, and some (such as tiredness) are similar to the tricyclic
antidepressants. It has been claimed that the onset of action may be faster with
venlafaxine because of its dual effects on serotonin and norepinephrine
receptors. This does not seem likely, because the older tricyclic antidepressants
also have dual effects on serotonin and norepinephrine receptors in the brain, but
do not have rapid antidepressant effects. Research is now in progress to try to
determine whether venlafaxine really does work any more rapidly. Although a
faster-acting antidepressant would represent an important breakthrough, we
should probably not become
612 David D. Burns, M.D. too optimistic about this. Claims about the superior
prop- properties of new antidepressants have often not been substansubstantiated by careful, systematic, independent research after the drugs have
been available on the market for a period of time. In addition, you will see below
that venlafaxine must be started at low doses and increased very slowly to
prevent side effects from developing. For most patients, this will prevent the
drug from having any rapid antidepressant ef- effects. Studies are in progress to
examine the larger question of whether drugs with dual action have stronger
antidepressant effects than SSRIs for certain types of patients, especially
severely depressed patients who are hospitalized. This is important because the
SSRIs (such as Prozac) which are now so popular have not been particularly
effective for these patients. In one study, venlafaxine was more effective than
effective for these patients. In one study, venlafaxine was more effective than
Prozac in the treatment of inpatients with "melan- "melancholic" depression.
"Melancholic" depression refers to a more severe depression with many organic
features, such as waking up too early and a loss of appetite and sexual drive.
Individuals with melancholic depressions may also have anhedonia along with
feelings of guilt that can become extreme or even delusional. Anhedonia refers
to a severe loss of the capacity to experience pleasure or satisfaction. Like all
antidepressants, venlafaxine is beginning to be used for a number of other
disorders as well. These include chronic pain disorder as well as adult attention
deficit dis- disorder (ADD). Remember that all, or nearly all, antidepresantidepressants have been used for a great variety of disorders, so it is not likely
that the effects of venlafaxine are superior for chronic pain or for ADD. Doses of
Venlafaxine. Some experts recommend start- starting venlafaxine at 18.75 mg
twice per day, which is only half the starting dose recommended by the
manufacturer, in order to minimize the likelihood that nausea will de- develop.1
Then the daily dose can be slowly increased by
FEELING GOOD 613 37.5 mg every third day until a total dose of 150 mg per
day or above is reached. Most patients respond to a total dose of 75 mg to 225
mg per day. Higher doses tend to be more effective, but they are associated with
more side ef- effects. Earlier when discussing SSRIs, we talked about the halflife of drugs—this is the time required by the body to elim- eliminate one half of
the drug in your body. Venlafaxine has a sfrort half-life—meaning that it leaves
your body in a mat- matter of hours. Therefore, you must take the medication
two or three times per day to maintain an adequate level in your bloodstream.
The manufacturer has recently marketed an extended (slow) release version of
venlafaxine (called Effexor XR) that you need to take only once per day, which
is more convenient. As you can see in Table 20-1 on page 521, the extended
release capsules appear to be more costly, but this is really an illusion. For
example, you can see in the table that the average wholesale price of a hundred
of the 75 mg capsule of Effexor is $118.66, whereas the price of a hun- hundred
of the 75 mg extended-release capsules is $217.14, or almost twice as much.
When I first saw these figures, I naturally concluded that the extended-release
capsules were twice as expensive as the regular pills. But let's see what happens
in a real-life situation. Sup- Suppose your dose is 75 mg per day. You could take
either one of the regular 37.5 mg pills in the morning and a sec- second 37.5 mg
pill in the evening, for a total cost of $2.17 per day, or one of the 75 mg
extended-release pills once per day. As noted above, the cost of the 75 mg
extended- release pills will also be $2.17 per day. Either way, Effexor is very
expensive, since the daily dose may be as high as 375 mg per day. The high
expensive, since the daily dose may be as high as 375 mg per day. The high
price is especially striking when you compare the cost of Effexor with the cost of
many of the generic tricyclic antidepressants that are just as effective and
available for less than ten cents per day. As with any antidepressant, it is best to
taper off venla614 David D. Burns, M.D. faxine slowly. At least two weeks are recommended,
and some patients may require as much as four weeks. Side Effects of
Venlafaxine. The side effects of venla- venlafaxine are listed in Table 20-11 on
pages 608-609. As you can see, they are similar to the SSRI compounds
described above. The most common side effects of venlafaxine are nausea,
headache, sleepiness, insomnia, abnormal dreams, sweating, nervousness, and
tremor. Venlafaxine can also cause the same types of sexual difficulties as the
SSRIs, including a loss of interest in sex and difficulties achieving orgasm.
These sexual side effects tend to be quite common, just as with the SSRIs. In
spite of the claim that venlafaxine has fewer side effects than the older tricyclic
antidepres- sants, this drug can nevertheless cause dry mouth and diz- dizziness
in some patients. The dizziness is particularly likely if you go off the drug too
quickly. One distinct type of side effect seen with venlafaxine is an increase in
blood pressure. However, the blood-pressure increases are typically seen only at
higher doses B25 mg per day or above). Nevertheless, if you have problems with
your blood pressure, you and your doctor should monitor your blood pressure
carefully, and this drug may not be a good choice for you. At doses less than 200
mg per day, the likelihood of an increase in blood pressure is only about 5
percent. The probability increases to 10 percent or 15 percent at doses greater
than 300 mg per day. Blood- pressure increases of 20 to 30 mm of mercury have
been observed, for example. Drug Interactions for Venlafaxine. Because
venlafax- venlafaxine is relatively new, information about its interactions with
other drugs is still relatively limited. Venlafaxine appears to be less likely to
interact in adverse ways with other med- medications you are taking. Several
drugs may cause blood lev- levels of venlafaxine to increase, and so lower doses
of venlafaxine may be needed. These include:
FEELING GOOD 615 • some tricyclic antidepressants; • the SSRI
antidepressants; • cimetidine (Tagamet). Venlafaxine may cause the blood levels
of several of the major tranquilizers to increase. These include trifluopera- zine
(Stelazine), haloperidol (Haldol), and risperidone (Ris- perdal), and so lower
doses of these drugs may be needed. In theory, these drugs could also cause
blood levels of Ven- Venlafaxine to increase. Venlafaxine must not be combined
with MAOI antide- antidepressants because of the danger of the serotonin
syndrome (hyperpyretic crisis) described on page 576. Remember that it takes up
syndrome (hyperpyretic crisis) described on page 576. Remember that it takes up
to two weeks for the effects of an MAOI to clear out of your body, so a twoweek drug-free period will be required if you stop taking an MAOI and then start
taking venlafaxine. In contrast, if you go off venlafaxine and then start taking an
MAOI, a one-week drug-free period should be sufficient, because venlafaxine
leaves the body fairly rapidly. Mirtazapine (Remeron) Mirtazapine (Remeron)
was released in the United States in 1996. It also enhances both norepinephrine
and serotonin activity, but through a different mechanism from venlafaxvenlafaxine. Premarketing studies suggest that mirtazapine may be effective for
mildly depressed outpatients and for more se- severely depressed inpatients as
well. It may also be partic- particularly helpful for depressed patients who are
very anxious or nervous. Doses of Mirtazapine. The dose range for mirtazapine
is 15 to 45 mg per day. Most physicians will prescribe a smaller amount at first
G.5 mg per day) and then slowly increase the dose. Because mirtazapine causes
sleepiness in
616 David D. Burns, M.D. more than 50 percent of the people who take it, it can
be given once a day at bedtime, usually in doses of 15 to 45 mg per day. Some
physicians report that mirtazapine is less likely to cause less sleepiness when the
dose is increased. This is the opposite of what you might expect intuitively. It is
because the drug may have some stimulating effects at the higher doses. We will
have to wait until there is more clinical experience with this drug to see if this is
really true. Side Effects of Mirtazapine. The side effects of mirta- mirtazapine
are listed in Table 20-11 on pages 608-609. You can see that it blocks the
histaminic, alpha-adrenergic, and muscarinic receptors in much the same way
that the older tricyclic antidepressants do. Therefore, the side effect pro- profile
of mirtazapine is very similar to the tricyclics, espe- especially amitriptylilie,
clomipramine, doxepin, imipramine and trimipramine (see Table 20-2). The
more common side effects include tiredness E4 percent of patients) noted above,
increased appetite A7 percent), weight gain A2 per- percent), dry mouth B5
percent), constipation A3 percent), and dizziness G percent). Keep in mind that
these figures are somewhat inflated because they do not take into account the
placebo effect. For example, 2 percent of patients on placebo also report weight
gain, and so the true incidence of weight gain that can be attributed to the
mirtazepine would be 12 percent minus 2 percent, or 10 percent. MirMirtazepine is not likely to cause the stomach upset, insomnia, nervousness, and
sexual problems commonly seen with the SSRIs such as Prozac. Mirtazapine has
some unique adverse effects not shared with other antidepressants. It can, in rare
cases, cause your white blood cell count to fall. Because these cells are ininvolved in fighting off infections, this could make you more vulnerable to a
involved in fighting off infections, this could make you more vulnerable to a
variety of infections. If you develop a fever while taking this drug, make sure
you contact your physi- physician immediately so that he or she can obtain a
complete blood count. Mirtazapine can sometimes cause an increase in levels of
blood fats such as cholesterol and triglycerides.
FEELING GOOD 617 This could be a problem if you are overweight or have a
heart condition or if your cholesterol and triglycerides lev- levels are already
elevated. Drug Interactions for Mirtazapine. Because mirtaza- pine is relatively
new, very little information about its drug interactions is available. It must not be
combined with the MAOI antidepressants because of the risk of the serotonin
syndrome (hyperpyretic crisis). Because it can be quite sedating, it will enhance
the effects of other sed- sedative drugs. These include alcohol, major and minor
tran- quilizers, sleeping pills, some antihistamines, barbiturates, many other
antidepressants, and the antianxiety drug bus- pirone (BuSpar). The increased
sleepiness you experience when these substances are combined with mirtazapine
could lead to difficulties with coordination and concentra- concentration. This
might be hazardous when driving or operating dangerous machinery. Mood
Stabilizers Lithium In 1949, an Australian psychiatrist named John Cade obobserved that lithium, a common salt, caused sedation in guinea pigs. He gave
lithium to a patient with manic symp- symptoms and observed dramatic calming
effects. Tests of the effects of lithium in other manic patients yielded similar
results. Since that time, lithium has slowly gained popular- popularity
throughout the world. It has been used successfully in the treatment of a number
of conditions, including: • Acute manic states. Although lithium is used to treat
patients with severe mania, they will usually be treated with more potent, fasteracting drugs at the same time until the severe symptoms of mania have subsided.
These other drugs include the antipsychotics (also
618 David D. Burns, M.D. known as major tranquilizers or neuroleptics) such as
chlorpromazine (Thorazine), as well as benzodiaze- pines (also called "minor
tranquilizers") such as clon- azepam (Klonopin) or lorazepam (Ativan). These
additional drugs are used until the mania has been brought under control. Once
the severe manic symp- symptoms subside, the other drugs are discontinued and
the patient continues taking the lithium to prevent future mood swings. •
Recurrent manic and depressive mood swings in indi- individuals with bipolar
manic-depressive illness. Lithium has significant preventative effects, so that the
likeli- likelihood of future manic episodes is reduced. • Single episodes of
depression. Lithium is sometimes added in smaller doses to an antidepressant
drug that is not working in order to try to improve its effective- effectiveness. I
drug that is not working in order to try to improve its effective- effectiveness. I
will describe this and other augmentation strat- strategies later in the chapter. •
Recurrent episodes of depression in patients without manic mood swings.
Lithium maintenance may help to prevent recurrences of depression following
recovery. Some studies indicate that the preventative effects of long-term lithium
treatment may be similar to the ef- effects of long-term treatment with an
antidepressant such as imipramine. However, this preventative effect on
depression may not work for all patients. Lithium is probably more likely to
prevent depressions in pa- patients with a strong family history of bipolar
(manic- depressive) illness. • Individuals with episodic anger and irritability or
out- outbursts of violent rage. • Individuals with schizophrenia. Lithium can be
com- combined with an antipsychotic medication, and the com- combination
may be more effective than the antipsychotic medication alone. The
improvement seems to occur in schizophrenic patients who also experience
mania or
FEELING GOOD 619 depression and in schizophrenic patients without any
symptoms of mania or depression. You should keep in mind that in all of these
conditions, lithium is sometimes helpful but rarely ever curative. Like most
medications, it is a valuable tool but not a panacea. As noted above, manicdepressive illness is sometimes also called bipolar illness. "Bipolar" simply
means "two poles." Patients with bipolar illness experience uncontroluncontrollable euphoric mood swings that often alternate with severe
depressions. The manic phase is characterized by an ex- extremely ecstatic,
euphoric mood, inappropriate degrees of self-confidence and grandiosity,
constant talking, nonstop hyperactivity, increased sexual activity, a decreased
need for sleep, heightened irritability and aggressiveness, and self-destructive
impulsive behavior such as reckless spend- spending binges. This extraordinary
disease usually develops into a chronic pattern of uncontrollable highs and lows
that can come on unexpectedly throughout your life, so your phy- physician may
recommend that you continue to take lithium (or another mood stabilizing drug)
for the rest of your life. If you have experienced abnormal mood elevations
along with your depression, your physician will almost definitely prescribe
lithium or another comparable mood-stabilizing drug. Some studies suggest that
if you are depressed and have a definite family history of mania, you might
benefit from lithium even if you have never been manic yourself. However, most
physicians would first prescribe a standard antidepressant and observe you
carefully. Although anti- depressants do not usually cause euphoria or mania in
peo- people with depression, they can occasionally have this effect in individuals
with bipolar manic-depressive illness. The mania can begin as quickly as twentyfour to forty-eight hours after starting the antidepressant. In my clinical practice,
four to forty-eight hours after starting the antidepressant. In my clinical practice,
the development of a sudden and dangerous manic episode after starting an
antidepressant has been quite rare, even in patients with bipolar illness.
Nevertheless, if you have a personal or family history of
620 David D. Burns, M.D. mania, it is conceivable that you could experience
this side effect. Be sure to tell your doctor about this so you can receive careful
follow-up after starting an antidepressant. Your family, too, should be alerted to
this possibility. Fam- Family members are often aware of the development of a
manic episode before the patient realizes what is happening, and can alert the
doctor that a problem has developed. This is because the distinction between
normal happiness and the beginning of the mania may be unclear to the patient.
Fur- Furthermore, mania feels so good at first that you may not recognize it as a
dangerous side effect of the medication you are taking. Doses of Lithium. As
you will see in Table 20-1, lith- lithium comes in 300-mg dosages, and normally
three to six pills per day in divided doses are required. Your physician will guide
you. Initially, you may take the lithium three or four times per day. Once you are
stabilized on lithium, you may be able to take half your total daily dose in the
morn- morning and half before you go to bed. This twice-a-day sched- schedule
will be more convenient. Sustained-release capsules containing 450 mg are also
available. Because these drugs are released more slowly in the stomach and
gastrointestinal tract, they may cause fewer side effects and they are more
convenient because you don't have to take them so often. However, their
increased cost, as compared with generic lithium, may not justify tak- taking
them. Furthermore, many patients have reported that the side effects of the
inexpensive, generic brands of lith- lithium are no different from the more
expensive slow-release brands. Like the other drugs used for treating mood
disorders, lithium usually requires between two and three weeks to become
effective. When taken for a prolonged period of time, its clinical effectiveness
seems to increase. Thus, if you take it for a period of years, it may help you more
and more. Unfortunately, there appears to be a group of individuals
FEELING GOOD 621 who do well on lithium, stop taking it, become
symptomatic again, and then find that the lithium is less effective when they start
taking it again. This is one reason why you should not stop taking lithium, or any
other medication, without first consulting with your doctor. Lithium Blood
Testing. Too much lithium in your blood can cause dangerous side effects. In
contrast, if your blood level is too low, the drug will not help you. Because there
is a narrow "window" of effectiveness of lithium, blood- level testing is required
to make sure that your dose is nei- neither too high nor too low. Initially, your
to make sure that your dose is nei- neither too high nor too low. Initially, your
doctor will order more frequent blood tests so that she or he can determine what
the proper dose should be. Later on, when your dose and symptoms have
stabilized, you will not need the blood tests nearly as frequently. If you are an
outpatient and you are not experiencing severe mania, your doctor may order
lithium blood tests once or twice a week for the first couple weeks, then once a
month. Eventually, blood tests every three months may be sufficient. If you are
being treated for a more severe episode of mania, more frequent blood tests will
be required. This is because higher blood levels of lithium are usually needed to
control the severe symptoms. In addition, your body tends to get rid of lithium
more rapidly during an episode of mania, so larger doses may be needed to
maintain the proper blood level. As noted above, during a manic episode your
doctor will almost definitely want to combine lithium with more potent drugs for
the first few weeks until your symptoms have subsided. Your blood must be
drawn eight to twelve hours after your last lithium pill. The best time for a blood
test is first thing in the morning. If you forget and take your lithium pill the
morning of a blood test, don't take the test! Try again another day. Otherwise,
the results will be misleading to your doctor. Body size, kidney function,
weather conditions, and
622 David D. Burns, M.D. other factors can influence your lithium dose
requirement, so blood tests should be performed on a regular basis when you are
on lithium maintenance. Your doctor will probably try to maintain your blood
level at somewhere between 0.6 and 1.2 mg per cc, but this will vary with your
symptom level. During an episode of acute mania, your doctor will probably
want to keep your blood level closer to the top of the therapeutic range. Some
doctors feel that levels as low as 0.4 to 0.6 mg per cc can be effective to help
prevent an episode of depression or mania when you are feeling good. Patients
with chronic irritability and anger may also re- respond to lithium at these lower
blood levels, even if they don't suffer from clear symptoms of manic-depressive
ill- illness. The advantage of these lower levels is that there are fewer side
effects. Other Medical Tests. Prior to treatment, the doctor will evaluate your
medical condition and order a series of blood tests and a urinalysis. These blood
tests will usually include a complete blood count, tests of thyroid and kidney
func- function, electrolytes, and blood sugar. Your thyroid function- functioning
should be tested at six-month or yearly intervals while you are taking lithium
because some patients on lithium develop goiters (a swelling or lump on the
thyroid gland) or underactive thyroid glands. Your kidney function must also be
evaluated from time to time because of kidney ab- abnormalities reported in
some patients taking lithium. Your doctor may order an electrocardiogram
some patients taking lithium. Your doctor may order an electrocardiogram
(ECG) before you start taking the lithium, especially if you are over forty or if
you have a history of heart problems. Your doctor will also need to know about
any other drugs you may be tak- taking, because some of them may cause
elevations in your blood lithium level. These include certain diuretics as well as
some anti-inflammatory drugs such as ibuprofen, na- proxen, and indomethacin.
You will learn below that some drugs can have the opposite effect of causing
your lithium level to fall.
FEELING GOOD 623 Side Effects of Lithium. The side effects of lithium are
listed in Table 20-12 on pages 624-625 and compared with the side effects of
two other mood stabilizers I will discuss below. As you can see, lithium tends to
have many side effects. Most of them are mildly uncomfortable but not seserious. Starting with the effects on the muscles and nervous sys- system first,
you will see that lithium can cause a fine tremor of the hands and fingers in 30
percent to 50 percent of patients. This tremor will be present when your hands
are resting and often worsens when you do something pur- purposeful with your
hands. For example, the tremor can make it more difficult to hold a cup of coffee
or to write clearly. The severity of the tremor is related to the dose and may be
more severe when lithium is prescribed along with one of the tricyclic
antidepressants, which can also cause tremor. This tremor is one of the major
reasons that some pa- patients stop taking their lithium. An antitremor drug
called propranolol (Inderal) can be given if the tremor is espe- especially severe
and troublesome, but it is my policy to avoid prescribing an additional drug if
possible. A reduction in dose can also help. If your doctor does prescribe
propranolol, the usual dose to reduce a lithium tremor is 20 to 160 mg per day,
given in divided doses. It is best to start with small doses and increase gradually.
The smallest effective dose is best. This is because propranolol can have other
effects, including a slowing of the heart, a drop in blood pressure, weakness and
fatigue, mental confusion, and upset stomach. Propran- Propranolol can also
cause breathing difficulties and must not be given to patients with asthma. It is
also contraindicated for patients with Raynaud's disease. Metoprolol B5 to 50
mg) or nadolol B0 to 40 mg), drugs similar to propranolol, have also been used
to treat lithium tremor. Lithium may cause tiredness and fatigue initially, but
these effects will generally disappear with time. Some pa- patients complain of
mental slowing or forgetfulness, particTable 20-12. Side Effects of the Mood Stabilizers3 Category Muscles and
Nervous System Stomach and Gastrointestinal Tract Kidneys lithium tremor
problems with coordination tiredness mental slowing or dulling memory loss
upset stomach weight gain diarrhea nephrogenic diabetes insipidus (excessive
upset stomach weight gain diarrhea nephrogenic diabetes insipidus (excessive
urination and thirst) interstitial nephritis, leading to (usually mild) renal
insufficiency valproic acid tremor problems with coordination tiredness
weakness upset stomach weight gain abnormalities in liver function pancreatitis
carbamazepine dizziness problems with coordination tiredness weakness upset
stomach abnormalities in liver function dry mouth syndrome of inappropriate
secretion of antidiuretic hormone (SIADH) A
Skin Heart Blood Hormonal rash hair loss acne ECG changes increased white
blood cell count hypothyroidism rash hair loss decreased platelets with bleeding
problems menstrual changes rash abnormal heart rhythms decreased platelets
with bleeding problems bone marrow failure (rare) decreased levels of thyroid
hormones (T3 and T4) aInformation in this table was obtained in part from the
Manual of Clinical Psychopharmacology1 and Psychotropic Drugs Fast Facts.17
These excellent references are highly recommended.
626 David D. Burns, M.D. ularly younger individuals. The forgetfulness has
been confirmed by memory testing. Other antidepressants that have
anticholinergic properties, such as Elavil, can also cause forgetfulness.
Complaints about these mental changes are very common and cause many
patients to stop taking their lithium. Memory difficulties seem to be more propronounced at higher lithium blood levels, as might be ex- expected, and often
improve when the dose is reduced. Along the same lines, some patients complain
of sub- substantial weakness and fatigue. These symptoms often indi- indicate an
excessive lithium level, and a dose reduction may be indicated. Extreme
sleepiness with mental confusion, a loss of coordination, or slurred speech
suggests a danger- dangerously elevated lithium level. Discontinue the drug and
seek immediate medical attention if such symptoms appear. Some patients
express the fear that they may lose their creativity when they start taking lithium.
This is especially of concern for artists and writers who have used their highs
and lows as a source of painful inspiration for creative ex- expression. Indeed,
many well-known painters and poets through the centuries suffered from manicdepressive ill- illness, and their moods were clearly reflected in their work.
However, three quarters of patients on lithium report that it does not seem to
reduce their creativity, and in some cases their creativity increases.1 Turning
next to the digestive system, lithium can cause an upset stomach or diarrhea that
is most troublesome dur- during the first few days of treatment. These side
effects will usually disappear with time. It may help to take the lithium with food
or to take it in three or four divided doses throughout the day, so that your
stomach isn't hit with a large dose all at once. It can also help to increase the
stomach isn't hit with a large dose all at once. It can also help to increase the
dose of lithium more slowly. In rare cases lithium can cause vomiting as well as
diarrhea, and your body may become dehydrated because of all the fluid loss.
This can make your blood levels of lithium higher, and so the drug becomes
more toxic. This, in turn, can cause more nausea and di- diarrhea, creating a
vicious cycle. Medical attention may be
FEELING GOOD 627 needed to make sure you are adequately hydrated until
the episode has passed. Unfortunately, many patients on lithium experience
weight gain; this is another common reason patients stop taking the drug. Dr.
Alan Schatzberg1 has suggested that this problem will be greater if you are
already overweight. The weight gain results from the stimulation of your apappetite. This is often very difficult to control. Obviously, if you exercise more
and eat less, the weight gain can be prevented or reversed, but this is often much
easier said than done! If the weight gain is excessive or troublesome, switching
to an alternative mood stabilizer, such as carba- mazepine, may be helpful.
Increased thirst and frequent urination can also occur when taking lithium. In
some cases, patients develop in- intense thirst from urination that is so frequent
and volumi- voluminous that the lithium must be stopped. This condition, known
as nephrogenic diabetes insipidus (NDI), results from the effects of lithium on
the kidneys. It is usually reversible when the lithium is stopped. In some cases,
add- adding certain types of diuretics can also help. However, care- careful
lithium monitoring must be performed, because these diuretics can cause
increases in plasma lithium levels. Milder forms of increased urination probably
occur in one half to three quarters of patients who take lithium. Lithium can
cause a form of kidney damage called "in- "interstitial nephritis/' This term
simply means inflammation or irritation of the tissue. When first reported,
psychiatrists were quite alarmed about this complication. Subsequent exexperience has indicated that although the problem may occur in 5 percent or
more of patients who take lithium for many years, the degree of kidney
impairment is usually mild. Your doctor will nevertheless want to monitor your
kidney function periodically while you are on lithium. She or he will order two
blood tests called the creatinine test and the blood urea nitrogen (BUN) test once
or twice a year. These tests can be performed at the same time you are having
your usual lithium blood test taken. If the tests indicate a
628 David D. Burns, M.D. change in kidney function, your doctor may request a
con- consultation with a urologist and order a twenty-four hour cre- atinine
clearance test. This is a more accurate test of kidney function and will involve
saving all your urine for twenty- four hours in a special bottle that the clinical
saving all your urine for twenty- four hours in a special bottle that the clinical
laboratory will give you. The results will help your doctor evaluate whether it
will be safe for you to continue taking lithium. An occasional patient will
develop a rash, and patients with psoriasis who take lithium will often
experience a flare-up of the condition. This may require consultation with a
dermatologist, switching to another brand of lithium, going off lithium
temporarily, or switching to one of the other mood-stabilizing medications. Acne
may also worsen during lithium treatment This can be treated with antibiantibiotics or retinoic acid, but in some cases the lithium may have to be
stopped. Some patients complain of hair loss, but the hair usually grows back,
whether or not the patient continues taking lithium. It is interesting to note that
lithium-related hair loss occurs primarily in women, and hair can disappear from
anywhere on the body. Hair loss is sometimes a sign of hypothyroidism (see
below) and so your doctor may order a thyroid blood test if the problem persists.
Lithium can cause a variety of changes in the electro- electrocardiogram (ECG),
but these are usually not serious. Older patients, as well as those with heart
disease, should have an ECG taken before they start on lithium, as noted above.
The ECG can be repeated once you are stabilized on lithium to see if there are
any changes in heart rhythm that might be a cause for concern. You can see in
Table 20-12 that lithium can also cause an increase in your levels of white blood
cells. These are the cells that normally fight infection. A normal white blood cell
count is in the range of 6,000 to 10,000. The white blood cell count in patients
on lithium typically in- increases to the range of 12,000 to 15,000 per cc,
elevations that are not considered dangerous. However, if you go to a physician
because you are ill, make sure you remind him
FEELING GOOD 629 or her that you are taking lithium and that the lithium
may cause a false elevation of your white blood cell count. Oth- Otherwise, your
doctor may falsely conclude that you have a serious infection, even if you
actually do not. Finally, lithium can affect thyroid functioning in as many as 20
percent of patients. As noted above, one common effect is an increase in the size
of the thyroid gland (called a "goiter") without any changes in thyroid function.
Other patients develop increases in the levels of thyroid stimulat- stimulating
hormone (TSH) in the blood. This indicates that the body is trying harder to
stimulate the thyroid gland. As many as 5 percent of patients on lithium will
develop hy- pothyroidism, and this may require treatment with thyrox- ine @.05
to 0.2 mg per day), a thyroid hormone replacement. Hypothyroidism is more
common in women than in men. Lithium Drug Interactions. As you can see in
Table 20- 13 on pages 630-631, lithium interacts with many other drugs. Make
sure you review this list with your physician if you are taking other medications
at the same time you are taking lithium. The drugs near the top of the table may
at the same time you are taking lithium. The drugs near the top of the table may
cause lithium levels in the blood to increase. This can lead to more side effects,
including lithium toxicity. The dose of lithium may need to be reduced to
maintain blood levels in the proper range. These drugs that cause increased
lithium levels in- include several drugs commonly used in the treatment of high
blood pressure, such as the so-called ACE inhibitors, the calcium channel
blocking agents, and methyldopa (Al- domet). The calcium channel blocking
agents in particular may lead to greater lithium toxicity, with symptoms such as
tremor, loss of coordination, nausea and vomiting, di- diarrhea, and ringing in
the ears. Caution is required if you combine lithium with any of these drugs.
Many common non-steroidal anti-inflammatory drugs (NSAIDs) such as
ibuprofen (Advil, Motrin, and other trade names) can also cause lithium levels to
increase. Several
Table 20-13. Lithium Drug Interactions' Note: This list is not exhaustive; new
information about drug interactions comes out frequently. If you are taking
lithium and any other medication, ask your doctor and pharmacist if there are
any drug interactions. Drugs Which Cause Blood Lithium Levels or Lithium
Toxic Effects to Increase ACE (angiotensin- converting enzyme) inhibitors •
benazepril (Lotensin) • catopril (Capoten) • enalapril (Vasotec) • fosinopril
(Monopril) • lisinopril (Prinivil, Vestril) • quinapril (Accupril) • ramipril (Altace)
alcohol antibiotics • ampicillin (Omnipen) • spectinomycin (Trobicin) •
tetracycline (Achromycin) anticonvulsants • carbamazepine (Tegretol) •
phenytoin (Dilantin) • valproic acid (Depakene) antifungal agents •
metronidazole (Flagyl) calcium channel blockers • diltiazem (Cardizem) •
nifedipine (Procardia) • verapamil (Isoptin) diuretics (loop type) • ethacrynic
acid (Edecrin) • furosemide (Lasix) diuretics (thiazides) * • chlorothiazide
(Diuril) • hydrochlorothiazide (Alsoril) diuretics (potassium- saving type) •
amiloride (Midamor) • spironolactone (in Aldactazide) ketamine low-salt diet
mazindol (Sanorex) methyldopa (Aldomet) non-steroidal anti- inflammatory
drugs • diclofenac (Voltaren) • ibuprofen (Advil) • indomethacin (Indocin) •
ketoprofen (Orudis) • piroxicam (Feldene) • phenylbutazone (Butazolidin)
Drugs Which Cause Blood Lithium Levels or Lithium Toxic Effects to Decrease
acetazolamide (Diamox) bronchodilators • albuterol (Proventil) • aminophylline
(Mudrane) • theophylline (Bronkaid) caffeine (in coffee, tea, soda, chocolate)
corticosteroids • hydrocortisone (Cortef) • methylprednisolone (Medrol) osmotic
diuretics sodium bicarbonate salty foods urea Other Lithium Drug Interactions
Drug antipsychotic agents • chlorpromazine (Thorazine) • haloperidol (Haldol) •
thioridazine (Mellaril) Effect may cause increased lithium toxicity or increase
thioridazine (Mellaril) Effect may cause increased lithium toxicity or increase
the likelihood of neuroleptic malignant syndrome (NMS) (quite rare) Drug
digitalis (Crystodigin; Lanoxin) hydroxyzine (Atarax, Vistaril) tricyclic
antidepressants Effect abnormal heart rhythms and heart slowing abnormal heart
rhythms increased likelihood of tremor aSome information in this table was
obtained from Psychotropic Drugs Fast Facts, pp. 213-215.17 This book is an
excellent source of information on psychiatric medications.
632 David D. Burns, M.D. antibiotics raise lithium levels, as does the common
anti- fungal agent metronidazole (Flagyl), which is often used to treat vaginal
infections. Several anticonvulsants are also listed in the top portion of Table 20-
13. If you are taking any of these medications, you might need lower doses of
lithium. If you have high blood pressure, you may also be treated with a diuretic
(or water pill). Some diuretics cause lithium levels to increase. The loop
diuretics and potassium-saving diuretics in Table 20-13 do not increase lithium
levels as much as the thiazide diuretics that are listed there. Not all diuretics
cause lithium levels to rise. For example, you can see in Table 20-13 that
osmotic diuretics, which work a little differently from the others, can have the
opposite ef- effect of causing lithium levels to fall. Your doctor may prescribe a
low-salt diet if you have high blood pressure. However, a low-salt diet can cause
lithium levels to rise. This is because your kidneys will excrete less salt in an
attempt to preserve it. Since lithium is also a salt that is chemically very similar
to table salt, your kidney will also excrete less lithium. By the same token, if you
are sweating a great deal during the summer months, this can have the same
effect of depleting your body of salt and causing your lithium levels to increase.
Once again, your kidneys will try to preserve salt and lith- lithium as well. Make
sure you maintain an adequate intake of salt to compensate for the salt you will
lose if you are sweating a great deal. The opposite effect can also occur. You can
also see in Table 20-13 that if you eat too much salt, it can cause lithium levels
to fall. This is because your kidneys will sense that there is too much salt in your
blood and will try to get rid of it. Your kidneys will excrete more lithium along
with the extra salt. In contrast, the drugs listed in the middle of Table 20- 13
have the opposite effect of causing lithium levels in the blood to fall. As a result,
lithium can lose its effectiveness. You can see that several drugs used in the
treatment of
FEELING GOOD 633 asthma reduce serum lithium levels. Caffeine also has the
same effect, so if you are a heavy coffee drinker, you may need to cut down on
coffee or take higher doses of lithium. Corticosteroids, which are used in many
conditions includ- including poison ivy, can also cause lithium levels to fall. The
conditions includ- including poison ivy, can also cause lithium levels to fall. The
dose of lithium may need to be increased to maintain blood levels in the proper
range if you are taking any of these drugs. A number of other drug interactions
are listed in Table 20-13. Psychiatrists used to think that the combination of
lithium with certain antipsychotic medications (especially haloperidol) greatly
increased the risk of a toxic effect called NMS (neuroleptic malignant
syndrome). NMS con- consists of severe muscle rigidity and confusion along
with elevated temperature, profuse sweating, increases in blood pressure, rapid
heartbeat and breathing, trouble swallowing, abnormal kidney and liver function,
and other symptoms. However, although any patient on antipsychotic drugs runs
a small risk of developing NMS, recent clinical experience has indicated that the
likelihood of NMS may be increased only slightly when antipsychotics are
combined with lith- lithium. Lithium is now often used in combination with antiantipsychotic drugs and may enhance their effects in the treatment of
schizophrenia, as described above. As with most psychiatric drugs, pregnant
women should avoid lithium, if possible, because its use has been associassociated with birth defects involving the heart. This is not an all-or-nothing
issue, and the potential benefits must be weighed against the potential hazards.
The risk of a heart defect known as Ebstein's anomaly is twenty times greater
than normal in mothers who take lithium, but the likelihood is still less than 1
percent. Other birth defects can also oc- occur, especially when lithium is used
during the first trimes- trimester of pregnancy. In addition, lithium (as well as
some other psychiatric drugs) is secreted in human milk and should be avoided
by nursing mothers. If lithium is needed, breast- breastfeeding should be
avoided. If you or your doctor have any questions about lithium
634 David D. Burns, M.D. (as well as the other mood stabilizers described
below), the lithium information center at the Madison Institute of MedMedicine, Madison, Wisconsin, can often help.22 Valproic Acid Valproic acid is
usually used in the treatment of epilepsy but was recently granted FDA approval
for the treatment of bipolar disorder, especially acute mania. You can see in
Table 20-1 on page 522 that this drug is prescribed in one of two forms: valproic
acid (Depakene) or the slightly more expensive divalproex sodium form
(Depakote). The two forms are equally effective. Studies comparing valproic
acid with lithium indicate that the two drugs are compara- comparably effective
and both appear to be twice as effective as a placebo. Valproic acid, like lithium,
also appears to be ef- effective in preventing or reducing future manic episodes.
The drug may be especially effective in the treatment of the rapid-cycling form
of bipolar disorder. It can help pa- patients who experience mania and
depression at the same time (so-called "mixed states"), as well as patients who
experience the more common forms of bipolar disorder. It is probably less
experience the more common forms of bipolar disorder. It is probably less
effective in the prevention and treatment of depression than in the prevention
and treatment of mania. Doses for Valproic Acid. It is best to start valproic acid
gradually, in order to minimize the side effects. The dose on the first day might
be 250 mg administered with a meal. During the first week, the dosage can be
gradually raised up to 250 mg given three times a day. As with any medimedication, the dose you receive may be slightly different de- depending on
your size, gender, and clinical symptoms. For example, a man who weighs 160
pounds might be started on 500 mg twice a day. During the second and third
weeks, the dose may be slowly increased further. Most patients end up with a
total daily dose in the range of 1,200 to 1,500 mg, given in
FEELING GOOD 635 divided doses (for example, 400 mg three times per day).
Individual doses can vary widely. Some patients respond to as little as 750 mg
per day and others need as much as 3,000 mg per day. As with any drug, doses
outside the normal range are occasionally needed. Some improvement should be
observed within two weeks of attaining a therapeutic blood level. If you respond
to valproic acid, your doctor may suggest that you remain on it for an extended
period of time, just like lithium. Blood Testing. Your doctor will order blood
tests to ad- adjust your dose of valproic acid. Initially your doctor may order a
blood test once a week until your dose and blood level are stabilized. After that
you will need a blood test only every month or two. The blood should be drawn
approximately twelve hours after your last dose, just like the lithium blood test.
Most patients take valproic acid in divided doses twice a day. If so, the blood
can be drawn in the morning, before you take your first daily dose. Most
physicians think that a blood level of 50 to 100 micrograms per ml is
therapeutic, but others are comfortable with blood levels up to 125 meg per ml,
especially if the patient is acutely manic. Of course, more side effects are
observed at the higher blood levels. Prior to treatment, your doctor will probably
order a blood test to check your liver enzymes, a bleeding test, and a complete
blood count (which includes a platelet count). These additional blood tests are
performed because in rare cases valproic acid can cause hepatitis (an
inflammation of the liver) as well as bleeding problems. From time to time after
you have been on valproic acid, your doctor will re- repeat these tests to make
sure that no changes have occurred. Many physicians feel that it is probably
necessary to check the blood count and liver enzymes only every six to twelve
months, especially if the patient has been educated to report immediately any
signs or symptoms that indicate a liver inflammation, as described below. You
should also tell your
636 David D. Burns, M.D. doctor if you notice any excessive bleeding or easy
bruis- bruising. Temporary increases in liver enzymes have been reported in as
many as 15 percent to 20 percent of patients during the first three months of
treatment. In most cases, these elevations are not considered serious.
Nevertheless, if your liver enzymes do change, your doctor will probably reduce
the dose of valproic acid and continue to monitor the liver enzymes. Your doctor
will also want you to be educated about the symptoms of hepatitis so you can
contact him or her immediately if they develop. Jaundice is the classic symptom.
Jaundice is a condition in which your urine be- becomes dark and your skin and
eyes become yellow in color. In addition, your bowel movements become pale.
When the liver becomes inflamed, the pigment that normally causes your bowel
movements to become brown gets backed up in your blood, staining your eyes,
skin, and urine. Other symptoms of hepatitis include fatigue, nausea, a loss of
ap- appetite, tiredness, and weakness. Fortunately, hepatitis only rarely
complicates treatment with valproic acid and can usually be treated successfully,
especially if you notify your physician right away. Although the liver
inflammation is nearly always mild, it is important to watch carefully for these
symptoms be- because they could, in theory, progress to fatal liver failure. This
complication has been observed in infants and is rarely seen in adults. It usually
occurs in individuals taking other anticonvulsants at the same time. In fact, some
experts as- assert that it has not been seen in adults who take only one
anticonvulsant.17 Side Effects of Valproic Acid. The side effects of val- valproic
acid are listed in Table 20-12 on pages 624-625. On the average, valproic acid is
usually better tolerated by pa- patients than lithium because it has fewer side
effects. Sleep- Sleepiness is a common side effect. Taking more of your daily
dose in the evening before you go to bed can often prevent the sleepiness from
being problematic. Valproic acid can
FEELING GOOD 637 also cause stomach upset which can take the form of naunausea, vomiting, cramping, or diarrhea. These effects on the gastrointestinal
tract are less common and can often be helped by taking a drug like Pepcid twice
a day. Drs. J. S. Maxmen and N. G. Ward indicate that the frequency of stomach
upset is greater with valproic acid A5 percent to 20 percent) than with the
enteric-coated divalproex sodium A0 percent) tablets, and so a switch to
divalproex sodium may help if these symptoms are troublesome.17 You can see
in Table 20-12 that valproic acid can also cause tremor. As with lithium, this
effect can sometimes be helped by reducing the dose or by adding one of the
beta- blocking drugs (see the discussion of lithium tremor above). Other
uncommon side effects include a loss of coordination and weight gain. Valproic
acid can cause a rash in 5 percent of patients, much like the two other mood
acid can cause a rash in 5 percent of patients, much like the two other mood
stabilizers listed in Table 20-12. Some patients have also reported hair loss, and
if this develops you should discontinue the drug (after dis- discussing this with
your doctor, or course) because it can take several months for the hair to grow
back. The hair loss is thought to be due to the fact that valproic acid can interfere
with the metabolism of zinc and selenium. Vitamin supple- supplements
containing these two metals can be taken to try to prevent this. Dr. Alan
Schatzberg and his colleagues rec- recommend the vitamin supplement Centrum
Silver for this purpose.1 As many as 20 percent of women have reported menmenstrual irregularities while on valproic acid. This may be due to the fact that
valproic acid can cause blood levels of the relevant hormones to fall, resulting in
impaired ovulation. Paradoxically, valproic acid can also cause certain oral concontraceptives to fail, so in theory you could become pregnant. Make sure you
discuss this possibility with your doctor if you are taking oral contraceptives.
Valproic acid, like a number of other anticonvulsants, may lead to birth defects
and should usually not be taken during pregnancy. The deformities include a
cleft lip, clot638 David D. Burns, M.D. ting abnormalities, spina bifida, and others. During
the lat- latter phases of pregnancy (the third trimester) valproic acid can cause
liver toxicity for the developing baby, especially when blood levels are greater
than 60 meg per ml. Make sure you inform your doctor if you think there is any
chance you could become pregnant while taking this drug. Special precautions
are indicated for women under twenty who receive long-term treatment with
valproic acid. Some studies have suggested that they may be more likely to
develop polycystic ovaries and increased levels of male sex hormones, but the
actual incidence of this complication is not known.17 Drug Interactions for
Valproic Acid. Valproic acid does not seem to have as many drug interactions as
lithium or carbamazepine. Because valproic acid can cause sleepiness, it can
enhance the effects of other sedative drugs such as alcohol, major and minor
tranquilizers, barbiturates, or sleeping pills. These combinations could be
hazardous, es- especially when driving or operating dangerous machinery. In
addition, valproic acid can cause substantial increases in blood levels of
barbiturates, causing extreme sedation or intoxication. Valproic acid may also
cause levels of diaz- epam (Valium) to rise. The resulting depression of the cencentral nervous system can be serious, and so great caution must be exercised if
these drugs are combined with valproic acid. As noted above, valproic acid can
interfere with bleeding and clotting, and so caution needs to be exercised if it is
combined with other drugs that interfere with bleeding or clotting, such as
warfarin (Coumadin) or aspirin. In addi- addition, valproic acid can lead to
warfarin (Coumadin) or aspirin. In addi- addition, valproic acid can lead to
increased blood levels of warfarin. This can also enhance the tendency to bleed.
Some caution should be exercised when valproic acid is combined with a
tricyclic antidepressant (especially nor- triptyline and amitriptyline) because the
blood levels of the antidepressant may increase. Your doctor may want to orFEELING GOOD 639 der a blood test to check the level of the antidepressant so
the dose can be adjusted if necessary. Several types of drugs can cause levels of
valproic acid to increase. These include: • antacids; • non-steroidal antiinflammatory drugs such as aspirin, ibuprofen (Advil, Motrin), and others; •
cimetidine (Tagamet); • erythromycin (Erythrocin); • felbamate (Felbatol), an
anticonvulsant; • lithium. Valproic acid also causes lithium levels to rise, and so
the toxic effects of both drugs can increase; • some antipsychotic drugs,
especially phenothiazines such as chlorpromazine (Thorazine); • SSRI
antidepressants such as fluoxetine (Prozac) and fluvoxamine (Luvox). If you are
taking any of these drugs with valproic acid, your doctor may need to reduce
your dose of valproic acid. Some anticonvulsants, such as carbamazepine
(Tegretol), ethosuximide (Zarontin), phenytoin (Dilantin) and possibly
phenobarbital (Donnatal) can cause blood levels of valproic acid to fall, and so
doses of valproic acid may need to be increased. At the same time, valproic acid
can cause the levels of carbamazepine, phenytoin, phenobarbital, and primidone
(Mysoline) to increase, and so the doses of these drugs may need to be reduced
when they are combined with valproic acid. Patients with difficult cases of
bipolar illness may be treated with more than one mood stabilizer, and some
careful attention to these complex drug interactions will be needed. Finally, the
antibiotic rifampin (Rifadin) can cause blood levels of valproic acid to fall. This
antibiotic is used in the treatment of tuberculosis, and it is also used as a two-to640 David D. Burns, M.D. four-day preventative treatment for individuals who
have been exposed to patients with certain types of meningitis. Carbamazepine
Carbamazepine (Tegretol) was introduced in the 1960s as a treatment for a
certain type of epilepsy that originates in the temporal lobes of the brain. In the
1970s, Japanese in- investigators discovered that carbamazepine was helpful in
treating manic-depressive patients who did not respond to lithium. Although the
FDA has not yet officially approved carbamazepine for the treatment of mania
and depression, it appears to be helpful for 50 percent of bipolar (manicdepressive) patients who have failed to respond to lithium. Carbamazepine can
be combined with lithium or with one of the major tranquilizers (also known as
neuroleptics) in order to enhance the effects of these drugs in the treatment of
mania. Carbamazepine can also be helpful for some rapidly cy- cycling manic-
mania. Carbamazepine can also be helpful for some rapidly cy- cycling manicdepressives. These individuals have more than four manic episodes per year and
can sometimes be chal- challenging to treat. Some studies have also suggested
that carba- carbamazepine may be helpful for manic-depressive patients who
experience anger and paranoia during their "high" phases. Finally, some
psychiatrists report that carbamazepine may be helpful in the treatment of
patients with borderline per- personality disorder when severe anxiety,
depression and anger coexist with impulsive, self-destructive behavior such as
wrist-slashing. However, in one study the therapists but not the patients reported
that the carbamazepine was helpful. It is difficult to know how to interpret such
findings. Many of the studies of carbamazepine have been con- conducted on
patients who were also taking other drugs at the same time, such as lithium or a
neuroleptic. These drugs can also have effects on mania. Dr. Alan Schatzberg
and his colleagues have pointed out that this makes it difficult to tease out the
true effects of the carbamazepine.1 The
FEELING GOOD 641 limited data and patent issues may explain why the drug
is not yet approved as a primary treatment for mania—be- mania—because the
safety and effectiveness of the drug in the treat- treatment of mania have not yet
been convincingly demonstrated through large, well-controlled studies. Doses
for Carbamazepine. The beginning dose of car- bamazepine is 200 mg twice
daily for two days. It may then be raised to 200 mg three times a day for five
days. After this, the dose is gradually increased by 200 mg per day every five
days up to a total daily maximum of 1,200 mg to 1,600 mg. Carbamazepine
usually takes at least one to two weeks to be effective, as do many psychiatric
medications. If it is helpful, your doctor will probably suggest you stay on the
drug for a longer period of time to prevent a relapse of the mania. Blood Testing.
Carbamazepine blood testing is required, just as it is for the two mood stabilizers
discussed above (lithium and valproic acid). You will need a blood test every
week for the first two months. After that, you will need a blood test every one or
two months. The results will guide your doctor in the amount she or he
prescribes. The usual effective blood level for carbamazepine is in the range of 6
mg to 12 meg per ml, but some experts rec- recommend blood levels in the range
of 6 mg to 8 meg per ml for most patients with depression or mania. Like any
drug, there are fewer side effects at lower doses, but if the blood level gets too
low, the drug will lose its effectiveness. Levels of other drugs in your blood may
fall if you are taking carbamazepine. This is because carbamazepine stimstimulates certain liver enzymes, and so your liver clears these drugs out of your
system faster than usual. One of the drugs that is affected by carbamazepine is
carbamazepine! In other words, after you have been on the drug for several
weeks, you may find that you need a larger dose to maintain the same blood
weeks, you may find that you need a larger dose to maintain the same blood
level. This is because your liver begins to
642 David D. Burns, M.D. metabolize the carbamazepine more rapidly, so it
leaves your body faster. Your doctor will probably want to check the blood
levels of certain liver enzymes before you start the carbamazepine, and from
time to time when you are on it. This is because carbamazepine may cause an
elevation of liver enzymes in your blood, indicating possible liver inflammation
or dam- damage. Earlier you learned that valproic acid can have similar effects
on the liver. Some elevation of liver enzymes occurs in most patients taking
carbamazepine, but this is not usu- usually a cause of concern. However, you
will still want to watch out for any signs of hepatitis described in the preprevious section on valproic acid. Your doctor will also order frequent complete
blood counts while you are taking carbamazepine. This is because
carbamazepine may cause a drop in your red blood cells, white blood cells, or
platelets. These cells are all produced by your bone marrow, and carbamazepine
can sometimes make the bone marrow less active. Each type of blood cell serves
a different function. The white cells help to fight infections. If you did not have
enough white cells, you would be more vulnerable to infections. As noted above,
a normal white blood cell count is in the range of 6,000 to 10,000. If your white
cell count falls below 3,000, your physician will immediately consult with a
hematologist (blood specialist). Roughly 10 percent of patients taking
carbamazepine experience a drop in the white blood cell count, and levels below
3,500 are common. You should be reassured to know that a drop in the white
blood cell count rarely develops into a serious problem. If carbamazepine is
helping you, most doctors will continue prescribing it as long as your white cell
counts are above 1,000. However, white cell counts below this level can be
extremely dan- dangerous, so your physician will monitor your blood count
more frequently if your white cell count starts to drop. Levels of red blood cells
and blood platelets may also fall if you are taking carbamazepine. The red blood
cells carry oxygen, and the platelets cause bleeding to stop. If
FEELING GOOD 643 your red blood cells fell to very low levels, you would
experience anemia. You might appear pale and feel fa- fatigued. If your platelets
fell to low levels, you might ex- experience an increased tendency to bleed. Dr.
Alan Schatzberg and colleagues1 state that these changes in the blood count are
expected. They emphasize that good patient education and routine bloodcounts
are the best ways to monitor them.1 If you are taking carbamazepine, make sure
you let your doctor know immediately if you develop any symptoms suggesting
a change in your white cells, plate- platelets, or red blood cells. These include
a change in your white cells, plate- platelets, or red blood cells. These include
fever, sore throat or sores in your mouth (indicating possible infection), bruising
or bleeding (indicating a possible drop in the platelets in your blood), or fatigue
along with pale lips and finger nails (suggesting anemia). On extremely rare
occasions, carbamazepine can cause a dangerous and potentially fatal failure of
the bone marrow. In these cases, all your blood cells may drop to dangerously
low levels. Recent estimates of severe and dangerous bone marrow failure range
from approximately one patient in 10,000 to one in 125,000, so you can see that
this compli- complication is very rare. When carbamazepine was first
introduced, this possibil- possibility frightened many physicians, who were
understandably reluctant to use the drug. Neurologists have been by far the
largest group of doctors prescribing carbamazepine because it can be so valuable
in the treatment of epilepsy as well as trigeminal neuralgia (facial nerve pain).
Neurologists have now had vast experience with this drug and are quite
comfortable with its use. More psychiatrists are also starting to recognize that
this medication can be used safely. Side Effects of Carbamazepine. A number of
common or significant side effects of carbamazepine are listed in Table 20-12 on
pages 624-625. Tiredness is the most com- common side effect, especially at the
start of treatment. A third of patients experience tiredness, and some E percent)
also complain of weakness. Raising the dose more slowly can
644 David D. Burns, M.D. minimize these effects. Usually the drowsiness will
wear off over time. The drowsiness is usually not due to anemia, but just to the
sedative properties of the drug. Approximately 10 percent of patients report
dizziness, especially when standing. This is due to a temporary drop in blood
pressure because blood tends to pool in your legs when you rise. As a result,
there is not enough blood for your heart to pump to your brain, and you get
dizzy. This can usually be minimized by standing more slowly and exexercising your legs (such as walking in place) immediately when you stand up.
This "squeezes" blood from your legs to your heart so your heart can pump the
blood to your brain. You will see that carbamazepine can sometimes cause
problems with coordination. This has been reported in as many as 25 percent of
patients. Patients may appear a bit intoxicated and tend to stagger when walking.
This some- sometimes indicates that the dose is too high. Other symptoms of an
excess dose include double vision, slurred speech, mental confusion, muscle
twitches, tremor, restlessness, and nausea, along with slowed or irregular
breathing, a rapid heartbeat and changes in blood pressure. Immediate medimedical attention is required if these symptoms occur, because in extreme cases
overdoses can lead to stupor, coma, and death. You may also experience some
nausea and vomiting at first. These effects are usually temporary and can usually
nausea and vomiting at first. These effects are usually temporary and can usually
be managed by raising the dose more slowly and by taking the medication with
food. These effects are probably less common than with valproic acid or lithium.
Most patients who have been on carbamazepine for several weeks do not report
these effects. Like the tricyclic antidepressants, carbamazepine can sometimes
cause dry mouth or blurred vision. This is be- because carbamazepine blocks the
cholinergic receptors (also called muscarinic receptors) in the brain. These
anticholin- ergic effects are of special concern to patients with glau- glaucoma,
who have increased pressure in their eyes, because
FEELING GOOD 645 the carbamazepine may cause the glaucoma to worsen. If
you have glaucoma you should have your intraocular pres- pressures monitored
closely while taking carbamazepine (or any drug with anticholinergic
properties). A side effect that involves the kidneys is called the syn- syndrome of
inappropriate secretion of antidiuretic hormone (SIADH), or water intoxication.
Patients develop a great increase in thirst along with mental confusion and a fall
in the levels of sodium in the blood. This side effect has been reported in as
many as 5 percent of patients taking carba- carbamazepine. If you develop
excessive thirst, your doctor may order an electrolyte test to see if your sodium
has dropped. She or he may want to reduce the dose, change to a dif- different
medication, or treat you with a drug called demeclo- cycline (Declomycin). This
drug can often correct the problem of low sodium levels in your blood. Your
doctor will probably monitor your kidney function from time to time by
checking your levels of blood urea nitrogen (BUN) and creatinine.
Carbamazepine can have some adverse effects on the heart. If you are over fifty
years of age you should have an ECG before starting the drug. The ECG should
be repeated after you have been stabilized on the drug to make sure no changes
of a serious nature have occurred. Carbamazepine often causes a slowing of the
heart. These changes appear to be more common in older women. If you have a
history of heart disease you may do better to take another mood- stabilizing drug
with fewer effects on the heart, such as valproicf acid. As many as 5 percent to
10 percent of patients taking carbamazepine may develop a rash. You will see in
Table 20-12 that any of the mood stabilizers (as well as many antidepressants)
can cause a rash, but this is somewhat more common with carbamazepine. It can
sometimes help to avoid direct sunlight (which may provoke the rash in some
cases), to take an antihistamine, or to change to a different brand of
carbamazepine. This is because you may be allergic to an ingredient in the pill
other than the car646 David D. Burns, M.D. bamazepine itself. On extremely rare occasions, two
severe and potentially fatal skin rashes (called Lyell's syndrome and the Stevens-
severe and potentially fatal skin rashes (called Lyell's syndrome and the StevensJohnson syndrome) have been reported in patients taking carbamazepine. Make
sure you report any severe skin changes to your doctor immediately. Like many
other psychiatric drugs, carbamazepine can cause birth defects, especially spina
bifida. A number of other fetal abnormalities have also been reported recently,
especially when the drug is taken during the first trimester of pregnancy.
Therefore, the potential benefit must clearly outweigh this risk if the drug is
taken during pregnancy. The risk appears to be significantly higher when
carbama- carbamazepine is combined with other anticonvulsants. If a pregpregnant woman definitely needs the drug, some experts recommend folic acid
supplements that may reduce the likelihood of birth defects. Carbamazepine is
secreted in mother's milk. The con- concentration of carbamazepine in the milk
is approximately 60 percent of the concentration in the mother's blood, and so
the issue of nursing must be discussed with the pedia- pediatrician. Drug
Interactions for Carbamazepine. You can see in Table 20-14 on pages 648-650
that many drugs can influ- influence the blood level of carbamazepine, and vice
versa, so you and your physician will have to be very careful in this regard. At
the top of the table, drugs are listed that cause carbamazepine level and toxicity
to increase. If you are taking any of these drugs, your doctor may need to reduce
the dose of carbamazepine. For example, many of the ma- crolide antibiotics
(erythromycin is a common example) can double the blood level and toxicity of
carbamazepine. You can also see in Table 20-14 that some drugs, such as
diuretics (water pills) and other anticonvulsant medica- medications can cause
the level of carbamazepine to fall. Your physician may have to give you a larger
dose of carba- carbamazepine to compensate for this.
FEELING GOOD 647 Just as certain drugs can cause blood levels of carbacarbamazepine to rise or fall, carbamazepine can change the lev- levels of other
drugs you are taking. Blood levels of the drugs that are listed next on the table
may fall when combined with carbamazepine. This is because carbamazepine
stim- stimulates the liver enzymes that metabolize these drugs. As a result, the
liver gets rid of these drugs more rapidly than usual. This would be equivalent to
pulling out the plug while you are trying to fill the bath; the water may not rise
to the proper level. One important example would be birth control pills. The
consequence of the decreased blood level is that the birth control pills may
become ineffective, and you might be- become pregnant even though you are
taking your birth con- control pills consistently. Levels of other drugs listed in
the table that may fall when combined with carbamazepine in- include some
antidepressants, antipsychotic drugs, anticon- vulsants, antibiotics, thyroid
hormones, and others. Sometimes the drug interactions work in both directions.
hormones, and others. Sometimes the drug interactions work in both directions.
A drug may cause the blood level of carbamazepine to fall, and carbamazepine
may in turn cause the blood level of the other drug to fall. For example, if you
are taking an anti- psychotic medication like haloperidol (Haldol), which is ofoften also given for mania, the haloperidol may cause the level of carbamazepine
to fall. At the same time the car- carbamazepine may cause the blood level of
haloperidol to drop substantially. As a result, it may seem that neither drug is
working properly, and the mania may not be controlled adequately. Your
physician may need to do blood tests to determine the levels of both drugs so
that the doses can be adjusted properly. Carbamazepine probably has similar efeffects on other antipsychotic drugs as well. Finally, several other potentially
dangerous drug inter- interactions with carbamazepine are listed at the bottom of
the table. In particular, carbamazepine must not be combined with any of the
MAOIs discussed on page 564 because of
Table 20-14. Carbamazepine Drug Interactions' Note: This list is not exhaustive;
new information about drug interactions comes out frequently. If you are taking
lithium and any other medication, ask your doctor and pharmacist if there are
any drug interactions. Drugs Which Can Cause Carbamazepine Levels or Toxic
Effects to Increase acetazolamide (Diamox) antibiotics (macrolides) •
azithromycin (Zithromax) • clarithromycin (Biaxin) • erythromycin (Pediazole) •
troleandomycin (Tao) • other macrolides antibiotics (other) • doxvcvcline
(Vibramycin) • tetracycline (Achromycin) • ketoconazole (Nizoral) • isoniazid
(INH) anticonvulsants • valproic acid (Depakene, Depakote) antidepressants
(SSRIs) • fluoxetine (Prozac) • fluvoxamine (Luvox) • sertraline (Zoloft) • others
antidepressants (other) • nefazodone (Serzone) cimetidine (Tagamet) calcium
channel blockers • diltiazem (Cardizem) • verapamil (Calan) danazol
(Danocrine) dextroprophoxyphene (Darvon) hpid lowenng drugs • gemfibrozil
(Lobid) • isonicotinic acid • niacinamide • nicotinamide lithium mexiletene
(Mexitil) prednisolone (Delta- Cortef) propoxyphene (Darvon) terfenadine
(Seldane) viloxazine
anticonvulsants • ethosuximide (Zarontin) • phenytoin (Dilantin) • primidone
(Mysoline) barbiturates • phenobarbital • others Drugs Which Can Cause
Carbamazepine Levels to Decrease diuretics fentanyl (Duragesic) major
tranquilizers (neuroleptics) • haloperidol (Haldol) methadone
Blood Levels of the Following Drugs May Fall When Combined with
Carbamazepine acetaminophen (Tylenol) antibiotics • doxycycline (Vibramycin)
• cyclosporine (Sandimmune; Neoral) anticonvulsants • phenobarbital •
primidone (Mysoline) • phenytoin (Dilantin) • valproic acid (Depakene,
primidone (Mysoline) • phenytoin (Dilantin) • valproic acid (Depakene,
Depakote) antidepressants • bupropion (Wellbutrin) • imipramine (Tofranil) •
others antipsychotics (neuroleptics) • haloperidol (Haldol) • others
benzodiazepines (minor tranquilizers) • alprazolam (Xanax) • clonazepam
(Klonopin) • others corticosteroids • dexamethasone (Decadron) •
methylprednisolone (Medrol) • prednisolone (Delta-Cortef) emergency
intubation drugs • pancuronium (Pavulon) • vecuronium (Norcuron) fenantyl
(Duragesic) mebendazole (Vermox) methadone (Dolophine) oral contraceptives
theophylline (Theo-Dur) thyroid hormones warfarin (Coumadin) Other
Carbamazepine Drug Interactions Drug clozapine (Clozaril) digitalis, digoxin
(Lanoxin) MAOI antidepressants Effect increased possibility of bone marrow
suppression levels rise, may cause toxicity including slowing of the heart
serotonin syndrome (fever, seizures, coma) aSome information in this table was
obtained from Psychotropic Drugs Fast Facts, pp. 213-215.17 This book is an
excellent source of information on psychiatric medications.
FEELING GOOD 651 the risk of the potentially fatal serotonin syndrome.
Although Table 20-14 is lengthy, it is not comprehensive because new drugs and
new information about drug inter- interactions are constantly emerging. As noted
previously, only a small percentage of the potential drug interactions have been
studied, and our knowledge about them is rapidly ex- expanding. Other drugs
may have important interactions with carbamazepine, so make sure your
physician knows of all the medications you are taking. Ask specifically if any of
them interact with carbamazepine. Other Mood Stabilizing Agents Until
recently, lithium, valproic acid, and carbamazepine were the main drugs used for
the treatment of bipolar ill- illness. Recently, new drugs have been synthesized
which may soon be available to treat patients with this disorder. Many of these
new drugs are actually anticonvulsants that were designed for the treatment of
epilepsy. At least two of them are already being used in the treatment of bipolar
(manic-depressive) illness, and many others will undoubt- undoubtedly become
available in the next several years. It seems likely that at least some of them will
provide powerful new tools for treating bipolar illness and possibly other psychipsychiatric disorders as well. These new drugs (as well as the three mood
stabilizers discussed previously) are quite different from the antide- pressants
because they do not significantly increase levels of serotonin, dopamine, and
norepinephrine in the brain. Instead, they seem to stimulate a transmitter
substance called GABA (gamma-amino butyric acid) or inhibit a transmitter
substance known as glutamate. GABA and glu- tamate are used by a large
percentage of the nerves in the brain. The anticonvulsants that stimulate GABA
tend to cause sleepiness. Medications in this category include val- valproic acid,
tend to cause sleepiness. Medications in this category include val- valproic acid,
discussed above, as well as gabapentin (Neu- rontin), tiagabine (Gabitril),
vigabatrin (Sabril), and several
652 David D. Burns, M.D. others. The anticonvulsants that inhibit glutamate
tend to cause stimulation and anxiety. Medications in this category include
felbamate (Felbatol), lamotrigine (Lamictal), topi- ramate (Topamax), and
several others. Although it is not known for certain why or how these drugs
prevent epilepsy or stabilize manic-depressive illness, it is known that the
GABA system and the glutamate sys- system in the brain tend to compete with
one another. This may be why drugs that stimulate GABA or inhibit glutaglutamate are helpful for epilepsy and for bipolar illness. Most anticonvulsant
drugs also inhibit sodium transport across nerve membranes in the brain.
Sodium, as you know, is present in table salt. It is known as an ion, because it
carries a tiny positive electrical charge when it is dissolved in a fluid. The
electrical impulses of nerves result when ion channels in the nerve membranes
open up and positively charged ions like sodium and potassium suddenly rush
across the membrane. These ion fluxes create the electrical impulses in the
nerves. Because these drugs inhibit the so- sodium channels, they may stabilize
nerve conduction in the brain by making nerves less excitable. Because nearly
all anticonvulsants have this property, they are sometimes clas- classified as
"sodium blockers." The sodium-blocking effects may also explain why these
new drugs can prevent seizures and stabilize manic-depressive illness. Of course,
all new drugs have unforeseen benefits and hazards, and the new anticonvulsant
drugs are no exception. Quite a bit of testing will be necessary before we can
iden- identify which ones have most promise for patients with epi- epilepsy and
bipolar illness. There is considerable excitement about one of the new drugs,
called gabapentin (Neurontin), because it seems to have very few side effects, an
excellent safety record, and few if any toxic interactions with other drugs. In
addition, it does not require blood testing like the three mood stabilizers
discussed above. So far, the FDA has approved gabapentin only for the treatment
of epilepsy. Although it has not yet been officially approved for psychiatric
disorders, many psychiatrists are
FEELING GOOD 653 beginning to prescribe gabapentin for patients with
difficult bipolar illness who have not responded to other medica- medications. Its
eventual role will have to be determined by clin- clinical experience and by
controlled outcome studies. At least eight studies of the use of gabapentin in
mood disorders were published in 1997, and many more will un- undoubtedly be
published in subsequent years. In these stud- studies, gabapentin was reported to
published in subsequent years. In these stud- studies, gabapentin was reported to
be effective for many patients with bipolar illness. Gabapentin also appeared to
have antidepressant and antianxiety properties, and it may be useful in the
treatment of chronic pain (including mi- migraine headaches), as well as PMS
(premenstrual syn- syndrome), panic disorder, and social phobia. Doses for
Gabapentin. The current dose of gabapentin for epilepsy is 300 mg to 600 mg
three times daily, for a total dose range of approximately 900 to 2000 mg per
day. In studies of bipolar patients, the average dose was about 1700 mg per day,
with some investigators giving doses as high as 3600 mg per day. The absorption
of gabapentin from the stomach and in- intestinal tract is not affected by food.
However, the antacid Maalox can reduce the absorption of gabapentin from the
stomach by about 20 percent. Therefore, you should wait at least two hours after
taking Maalox before you take ga- gabapentin. About half of a dose of
gabapentin disappears from the body within five to seven hours, so it must be
taken several times per day rather than all at once. If you take a high dose of
gabapentin on a single occasion, a smaller propor- proportion of the dose will be
absorbed from your stomach and intestinal tract into your blood. For example,
only 75 per- percent of a single 400-mg dose is absorbed, as compared with 100
percent of a 100-mg dose. From a practical point of view, this should not be a
concern if you are taking gaba654 David D. Burns, M.D. pentin since you will be taking the medication several
times per day in divided doses. There is no evidence that men and women
require dif- different doses because of differences in metabolism, but inindividuals over seventy years of age may need only about half the doses used
for younger people. This is because of changes in kidney function that occur
with aging. Because the kidneys excrete gabapentin, individuals with impaired
kidney function will require smaller doses. Unlike lithium, carbamazepine, and
valproic acid, blood testing does not appear necessary with gabapentin. This is
another advantage of this medication. Side Effects of Gabapentin. The main side
effects are listed in Table 20-15 on pages 656-657. You can see that they include
sleepiness, noted above, along with dizziness, tremor, problems with
coordination, weight gain, and some visual side effects. All of these side effects
will be more pronounced at higher doses and less noticeable at lower doses.
Overall, the side effect profile of gabapentin is very favorable, especially when
compared with the other cur- currently available mood stabilizers. In the studies
cited in Table 20-15, gabapentin was given to patients with epilepsy who were
already receiving one or more other anticonvulsants. Therefore, the side effects
that were actually due to the gabapentin were lower. The best way to get a more
realistic estimate of any side effect is to subtract the percentage seen in the
realistic estimate of any side effect is to subtract the percentage seen in the
placebo group from the percentage seen in the gabapentin group. For example,
11.0 percent of the gabapentin group experienced fatigue, whereas 5.0 percent of
the placebo group experienced this side effect. The difference in these two
numbers is 6.0 per- percent. This is a better estimate of the true incidence of fafatigue that can be attributed to gabapentin. Like nearly all psychiatric drugs,
gabapentin should be used with great caution in pregnant women. Although
there are no well-controlled studies of the effects of gabapentin on the
developing fetus in pregnant women, fetal abnorFEELING GOOD 655 malities have been observed when gabapentin was
admin- administered to pregnant mice and rabbits. Although animal studies do
not always predict human responses, gabapentin should be used in pregnancy
only if the need is great and if the potential benefit outweighs the potential risk
to the developing fetus. Although it is not yet known whether gabapentin is
secreted into human milk, many drugs are secreted into human milk;
consequently, gabapentin should probably not be used by mothers who are
nursing. Cer- Certainly, you should discuss this risk with your physician. Drug
Interactions for Gabapentin. Gabapentin has one unusual and desirable property;
it is not metabolized by the liver, but is excreted unchanged by the kidneys
directly into the urine. For this reason, it does not seem to interact in adverse
ways with other drugs. You will recall from pre- previous discussions that all the
antidepressants and mood sta- stabilizers have fairly complicated interactions
with lots of other drugs. This is because these drugs compete with each other for
certain metabolic enzymes in the liver. With ga- gabapentin, this is not a
problem, so it is much safer to com- combine gabapentin with other medications.
In fact, many experts believe that gabapentin has no metabolic interacinteractions at all with other drugs. One benefit is that gabapentin can be
combined with other mood stabilizers for patients with difficult cases of bipolar
illness or epilepsy who have not responded to other medications. The properties
of gabapentin are certainly very appeal- appealing. Is there a downside?
Sometimes problems with new medications surface after the medication has
been in wide- widespread use for a period of time and the initial excitement has
worn off. Gabapentin may be no exception. One con- concern already voiced by
some neurologists and psychiatrists is that the drug may not be particularly
effective for either epilepsy or bipolar illness. This would be disappointing, since
the drug has so few side effects or interactions with other drugs. A colleague
with considerable experience with gabapentin told me she is using it primarily to
help anxious
Table 20-15, Side Effects of Gabapentin (Neurontin) Note: The information in
Table 20-15, Side Effects of Gabapentin (Neurontin) Note: The information in
this table was adapted from the 1998 Physician's Desk Reference (PDR). In
these studies, gabapentin or placebo was given to individuals with epilepsy who
were already taking at least one other drug for epilepsy. The side effects in
individuals not taking other drugs are likely to be less. Only the more common
side effects are listed. Gabapentin (n = 543) Placebo (n = 378) Digestive System
weight gain dry mouth upset stomach 2.9% 1.7% 2.2% 1.6% 0.5% 0.5% Energy
fatigue sleepiness 11.0% 19.3% 5.0% 8.7%
Nervous System dizziness trouble with coordination tremor slurred speech
memory problems 17.1% 12.5% 6.8% 2.4% 2.2% 6.9% 5.6% 3.2% 0.5% 0.0%
Eyes nystagmus (tremor of the eyes) double vision blurred vision 4.0% 1.9%
1.1%
658 David D. Burns, M.D. patients with insomnia, because it has excellent
sedative and relaxing properties and is not habit-forming. UnfortuUnfortunately, she feels it may not be powerful enough to be a primary mood
stabilizer for bipolar patients, but it may have value when it is used in
combination with other med- medications. Another new anticonvulsant,
lamotrigine (Lamictal) has also been approved by the FDA for the treatment of
epi- epilepsy. Like gabapentin, lamotrigine has been used in the treatment of
treatment-resistant bipolar illness. Dr. Alan F. Schatzberg and colleagues1 point
out that very few formal studies of lamotrigine have been conducted in
psychiatric patients, and so the reports of its effectiveness are still mainly
anecdotal. In addition, lamotrigine has some signif- significant and troubling
side effects. In particular, rashes and skin reactions occur in as many as 5 percent
or more of the adults taking lamotrigine. While most of these rashes are not
dangerous, lamotrigine can cause a severe and life- threatening skin reaction
known as the Stevens-Johnson syndrome in 1 percent to 2 percent of cases.
These skin reactions are more common in pediatric patients than in adults, and
so lamotrigine should not be given to individ- individuals under sixteen years of
age. Taking lamotrigine at higher doses or in combination with other drugs, such
as valproic acid, may make these feared skin reactions more likely. In
premarketing trials, five patients taking lamotri- lamotrigine died from liver
failure or multiorgan failure. Lamotrigine causes many other side effects such as
head- headache and neck pain, nausea and vomiting, dizziness, loss of
coordination, sleepiness, trouble sleeping, tremor, de- depression, anxiety,
irritability, seizures, speech problems, memory difficulties, runny nose, rashes,
itching, double vi- vision, blurred vision, vaginal infections, and others. LamoLamotrigine also has a number of interactions with other drugs because it is
Lamotrigine also has a number of interactions with other drugs because it is
metabolized by the liver. Because it has many side effects, including some
dangerous ones, lamotrigine must be used with great caution. Until we learn
more about it, it should probably be reserved for patients who have
FEELING GOOD 659 failed to respond to the better-established mood
stabilizers discussed above. What If My Antidepressant Does Not Work? As I
have emphasized, I would recommend taking a mood test like the one in Chapter
2 to monitor your re- response to any treatment, including medications or
psycho- psychotherapy. You can take the test once a week or even more
frequently, and keep track of your scores. Your scores will show whether and to
what extent the treatment is working. The goal of treatment is to get these scores
reduced sub- substantially. Ultimately, you want your scores to be in the range
considered normal and ideally in the range considered happy. If a drug doesn't
help, or helps only somewhat, what should you do? 1. Make sure you have given
the drug a fair trial. Ask yourself: • Is the dose adequate? • Have you taken the
drug for an adequate period of time? 2. Make sure there are no drug interactions
that are pre- preventing the antidepressant from being effective. Re- Remember
that some other drugs can cause your blood level of an antidepressant to fall,
even if you are tak- taking the correct dose of the antidepressant. Inform your
doctor about any other drugs you are taking. 3. You and your doctor may want to
consider one of the augmentation strategies discussed below. 4. If these
procedures are not successful, you and your doctor can discontinue the
medication and try another type of antidepressant.
660 David D. Burns, M.D. 5. Psychotherapy along the lines described in this
book, either alone or in combination with an antidepressant, can often be far
more effective than treatment with drugs alone. Let's examine each of these
principles. First, you need to be certain the dose is sufficient. If for any reason
your blood level of an antidepressant is too low, then the prob- probability of a
positive drug response will be diminished. How- However, a dose that is too
high might also be less effective. This is because the side effects at excessively
high doses may counteract the antidepressant effects. Concerns about the doses
of antidepressant drugs are important because dif- different people can
metabolize these drugs quite differently. In other words, given a particular drug
at a particular dose, different people can have dramatically different levels of the
drug in their blood. In fact, the levels of a tricyclic antidepressant may differ by
as much as thirty times in two different people who both receive comparable
doses of the same drug. This can happen even if the two people are the same sex,
height, and weight. These differences in blood levels can result from differdifferences in the ways people absorb a drug from their gastro- gastrointestinal
differences in the ways people absorb a drug from their gastro- gastrointestinal
tracts and from differences in how fast people get rid of a drug from their blood.
Genetics can play a role. For example, approximately 5 percent to 10 percent of
the Caucasian population in western Europe and the United States lack the liver
enzyme called CYP2D6 (in the P450 family), and 20 percent of the Asian
population lack the enzyme called CYP2C19.23 These enzymes help to metametabolize a wide variety of drugs including many antidepres- sants. Individuals
who lack either of these enzymes may develop dramatically higher blood levels
of certain antide- pressants because their liver enzymes cannot get rid of these
drugs nearly as rapidly as the average individual. Medical conditions such as
liver, kidney, or heart disease can have an impact on the blood level of
antidepressants. Age can also be important. On the average, children and
FEELING GOOD 661 elderly individuals require lower doses of most
medications including antidepressants. You may recall, for example, that
individuals over sixty-five may develop blood levels of sev- several SSRIs,
citalopram (Celexa), fluoxetine (Prozac) and pa- roxetine (Paxil), that are
approximately 100 percent greater than the blood levels of younger individuals
taking identical doses. Sometimes gender can play a role as well. As noted
previously, men may develop blood levels of fluoxetine (Prozac) or sertraline
(Zoloft) that are 30 percent to 50 per- percent lower than women taking similar
doses of these med- medications. Weather, your personal habits, or other
medications you are taking can sometimes influence blood levels of antideantidepressants or mood stabilizers. For example, if you are sweating a great
deal during the summer, your blood level of lithium may rise, so your doctor
may need to reduce the dose. If you are a smoker, your body will break down tricyclic antidepressants more rapidly because of the effects of the nicotine.
Consequently, you may need a higher dose of these antidepressants. Many other
drugs that can also cause a rapid breakdown of tricyclic antidepressants are listed
in Table 20-5. In contrast, some drugs on this table can slow the metabolism of
tricyclic antidepressant drugs by the liver, leading to excessively high blood
levels of the antidepressants. Remember that these drug interactions can work
both ways: an antidepressant or mood stabilizer may affect the level or activity
of other drugs you are taking, and vice versa. Before you and your doctor decide
that a particular drug is not working, make sure that you review the dose with
him or her. Ask about the possibility of drug interactions if you are taking more
than one drug. Your doctor may want to order a blood test to ensure that the
level in your blood is adequate. Blood-level testing is more commonly done for
the mood stabilizers and for the tricyclic and te- tracyclic drugs than for other
types of antidepressants listed in Table 20-1.
types of antidepressants listed in Table 20-1.
662 David D. Burns, M.D. If the blood level is adequate and you have been
taking the medication for a sufficient period of time but your an- antidepressant
is still not working, your doctor may try switching you to a different type of
antidepressant or may try an augmentation strategy. This involves adding a small
dose of a different drug to try to boost the effect of the antidepressant. Several
kinds of augmentation strategies currently in vogue are listed in Table 20-16 on
pages 664- 669. A complete discussion is beyond the scope of this book; I will
describe just a couple of them to give you a feel for this approach. Interested
readers may want to con- consult the excellent reference by Schatzberg and his
col- colleagues.1 Two drugs commonly used for antidepressant augmenaugmentation are lithium, a drug you've learned about in this chap- chapter, and
a thyroid hormone called liothyronine (also known as Cytomel, or T3). Your
doctor may add 600 mg to 1,200 mg per day of lithium carbonate or 25 to 50
micrograms per day of liothyronine to your antidepressant for several weeks if
the antidepressant has not been working ade- adequately. As noted above,
lithium is usually used to treat bipolar (manic-depressive) illness, and
liothyronine is used to treat people with underactive thyroid glands. However, in
this case, the goal is different—the purpose of adding a small dose of lithium or
liothyronine is to make the anti- antidepressant more effective. It is not clear
why lithium and liothyronine sometimes have this effect of boosting the efeffectiveness of antidepressants. A liothyronine trial will usually last for one to
four weeks. If you respond positively, your physician may con- continue the
liothyronine for two more months. Then she or he will probably taper you off the
augmentation medication over one to two weeks. The dose of lithium used for
augmentation will be ad- adjusted with a blood test so that your blood level will
remain in the range of around 0.5 to 0.8 mEq per L. These levels are a little
lower than the levels used to treat patients who
FEELING GOOD 663 are experiencing mania. The lower levels have the advanadvantage of having fewer side effects. The lithium augmentation trial will
generally last for two weeks. Positive results have been reported when lithium
was combined with tricyclics, SSRIs, and MAOIs. Research studies suggest that
as many as 50 to 70 percent of patients who do not respond to an antidepressant
will respond more favorably when lithium is added. If there is no improvement
in your depression, your doctor will probably discontinue the lithium as well as
the antidepressant and try another medication. Some doctors use antidepressant
combination therapy for patients with difficult depressions. For example, one
new approach is to add an SSRI when a tricyclic does not work, or to add a
new approach is to add an SSRI when a tricyclic does not work, or to add a
tricyclic when an SSRI does not work. This combination can cause large
increases in the blood level of the tricyclic medication, and so your doctor may
decrease the tricyclic first and then check your tricyclic level with a blood test
after you start the SSRI. Your doctor may also order an ECG to make sure there
are no adverse effects on your heart. An MAOI might also be combined with a
tricyclic an- antidepressant as a combination antidepressant strategy. This is an
advanced form of treatment for the specialist and re- requires careful teamwork
between you and your doctor. You will recall that dangerous reactions can result
from com- combining MAOIs with other antidepressant drugs or with lithlithium. Although the Physician's Desk Reference advises against such drug
combinations, Schatzberg and colleagues report that the combination can be safe
and helpful to some patients who fail to respond to single medications.1 To maxmaximize safety, these investigators recommend: A) the MAOI and tricyclic
should be started at the same time; B) clom- ipramine should be avoided; C) the
safest tricyclics to use in combination with MAOIs appear to be amitriptyline
(Elavil) and trimipramine (Surmontil); D) among the two commonly prescribed
MAOIs, phenelzine (Nardil) appears to be safer than tranylcypromine (Parnate)
to use in com- combination with a tricyclic.
Table 20-16. Antidepressant Augmentation Chart. Note: The first and second
columns list several types of drugs that have been added in small doses to
antidepressants in attempts to make the antidepressants more effective. The next
three columns list three major classes of antidepressants. A check mark (/)
indicates that at least some favorable research regarding this augmentation
strategy has been published in psychiatric journals. Some combinations are
dangerous and best administered by experts in research settings. Information in
this table was obtained in part from the Manual of Clinical
Psychopharmacology} Augmentation Drug I Augmentation Dose Type of
Antidepressant TCAs I SSRIs I MAOIs Comments Amino acids inositol Ltryptophan Phenylalanine 6 gm twice daily 2-6 gm per day 500 mg-5 gm per day
see comment / / see comment see comment Inositol is the precursor of the
phosphatidylinisotol (PI) system in the brain. There are no reports yet using
inositol as an augmentation drug, but it appears to have antidepressant properties
and will probably soon be used for augmentation.25 Tryptophan is the precursor
of serotonin in the brain. L-tryptophan plus MAOIs or SSRIs could cause the
serotonin syndrome. Phenylalanine is the precursor of dopamine and
norepinephrine in the brain. At least one authority has not been impressed with
the effects of this drug in augmenting antidepressants.1
Antidepressants bupropion (Wellbutrin) buspirone (BuSpar) MAOIs low doses
Antidepressants bupropion (Wellbutrin) buspirone (BuSpar) MAOIs low doses
usually, but doses up to 300 mg per day have been used.1 15 mg-45 mg per day
15 mg (or more) of phenelzine (Nardil) daily and 150 mg (or more) of
amitriptyline (Elavil) Bupropion may be used in an attempt to combat the sexual
side effects of SSRIs. There are anecdotal reports it may enhance the SSRIs, but
no controlled studies.1 There is at least one documented case of seizures from
bupropion plus fluoxetine (Prozac). Buspirone (BuSpar) has been shown to
enhance the effects of fluoxetine (Prozac) in an open trial.26 However, doubleblind studies have not confirmed this.1 Buspirone may also be used in an attempt
to combat the sexual side effects of SSRIs. The PDR states that the combination
of an MAOI and a trycyclic is prohibited, but the combination can be relatively
safe in the hands of experts. Double-blind studies have not documented the
effectiveness of this combination. Both drugs should be started at the same time.
Amitriptyline (Elavil) and trimipramine (Surmontil) appear to be the safest
TCAs to combine with MAOIs, and phenelzine (Nardil) and isocarboxazid
(Marplan) appear to be the safest MAOIs.1
Augmentation Drug I Augmentation Dose Type of Antidepressant TCAs I SSRIs
I MAOIs Comments Antidepressants cont. SSRIs TCAs trazodone (Desyrel)
First 4 dose of TCA; 30 mg per day of nortriptyline or 50-75 mg of imipramine
recommended1 when adding a TCA and patient is on an SSRI, start with 25 mg
nortriptyline or 50 mg of imipramine; increase by 25 mg after 3 days1 25 mg300 mg per day See comments on TCAs below See note on MAOI and TCA
combinations above. Several reports suggest that desipramine (Norpramin) will
enhance the effects of SSRIs.27'28 TCA blood level testing must be done
because the SSRI may cause a large f in desipramine levels, side effects, and
toxicity. ECGs must be monitored closely during TCA and SSRI combinations.
Trazodone A00 mg HS) is often added to fluoxetine (Prozac) or bupropion
(Wellbutrin) to help with sleep, since these two drugs may cause insomnia.
However, trazodone (Desyrel) may also enhance the effects of SSRIs.129
Appetite Suppressants fenfluramine (Pondimin) 20 mg-40 mg per day1 This is
an amphetamine-like drug that may enhance serotonin release in the brain. Some
patients become overly stimulated. Hormones estrogen liothyronine (Cytomel;
T3) 12.5 mg-25 mg per day; slowly f to 50 mg per day Estrogen has been used
for years, alone or in combination with other antidepressants, to treat depressed
women. The evidence for effectiveness is shaky at best, and the combination is
unwarranted.1 Some studies have reported positive results with TCAs30 but
other studies have reported negative results.1 May be more effective for women
than men. Case reports also suggest augmentation of SSRIs and MAOIs.1
than men. Case reports also suggest augmentation of SSRIs and MAOIs.1
Responses should be seen within one to four weeks. If the response is positive,
you can continue for two more months. Should be used with caution in patients
with heart disease or high blood pressure.
Augmentation Drug I Augmentation Dose I TCAs I SSRIs I MAOIs Comments
Mood Stabilizers lithium 600 mg-1,200 mg per day in divided doses Several
open studies and double-blind studies suggest that lithium in small doses may
enhance the effects of antidepressants about 50% of the time. The trial will last
about two or three weeks, but the combination may be continued if effective The
combination may also help prevent relapses. Lithium may also be combined with
either carbamazepine (Tegretol) or valproic acid (Depakene) in patients with
difficult cases of bipolar manic-depressive illness, especially those with *'rapid
cycling" (many episodes per year). Stimulants amphetamine (Dexedrine) start at
5 mg per day In one study, amphetamine or pemoline (see below) was added to
an MAOI in patients with severe, treatment-refractory depressions.31 Some
patients responded, but 1 in 5 developed symptoms of mania (abnormal
euphoria). Such combinations are potentially dangerous and could trigger
hypertensive crises. Also see comment on methamphetamine.
methamphetamine (Desoxyn) methylphenidate (Ritalin) pemoline (Cylert) start
at 5 mg per day start at 5 mg per day start at 37.5 mg per day or at 18.75 mg per
day Any stimulant can be addictive. This drug is intensely addictive and
potentially dangerous in combination with antidepressants. Its use in any other
psychiatric disorders, alone or in combination with other drugs, is controversial.
Large doses over prolonged periods can produce rage and a psychosis
resembling paranoid schizophrenia. This combination causes an f in TCA blood
levels, so blood level testing should be done. Also see comment on
methamphetamine. See comment on methamphetamine. Beta-Blockers pindolol
(Visken) 2.5 mg twice daily for 1 week; then ] to 5 mg twice daily; continue for
3 weeks1 Pindolol blocks beta receptors and stimulates 5- HT1A receptors. It is
used to treat hypertension, so blood pressure should be monitored. Side effects
include dizziness, fatigue, and activation, with anxiety, irritability, and insomnia.
670 David D. Burns, M.D. You will see quite a number of additional
augmentation strategies listed in Table 20-16. My experience with these
antidepressant combination and augmentation strategies has been limited, but I
have not been impressed with the results. I have tried lithium or thyroid
augmentation with a number of patients but none of them seemed to improve. I
was not encouraged to continue with this approach. However, if a depressed
patient has failed to respond to an adequate trial of several antidepressants, one
patient has failed to respond to an adequate trial of several antidepressants, one
at a time, from different chemical classes, then a combination of antidepressants
or an augmentation strategy might be worth a try. If you have received an
adequate dose of an antidepres- antidepressant for an appropriate period of time
and you are not re- responding, what antidepressant should you try next? Many
physicians will switch you to an antidepressant of a com- completely different
class to maximize the chance of a positive response. This idea makes good
sense, since the different antidepressants have slightly different effects on the
brain. If you have failed to respond to an SSRI such as fluoxetine (Prozac), your
doctor may want to try a tricyclic such as imipramine (Tofranil), for example.
Prozac selectively ac- activates the serotonin systems in the brain, whereas
imipra- imipramine has effects on many different systems. If you switch to
another drug, you will usually need to taper off your current drug slowly so as to
prevent any withdrawal effects. Antidepressants are not addictive and they do
not cause craving when you stop taking them. However, they need to be
discontinued slowly to prevent uncomfortable withdrawal reactions. For
example, the tri- cyclics can cause insomnia and upset stomach if you go off
them abruptly, as noted previously. Further, as noted above, there may be a
mandatory wait- waiting period when you are switching from one drug to ananother. This is because the two drugs might be dangerous if mixed together,
and the effects of the first drug may persist for a while after you have stopped
taking it. The classic example would be switching from an SSRI, such as fluoxfluoxetine (Prozac), to an MAOI, such as tranylcypromine (Par- nate). The
combination of these two drugs can cause the
FEELING GOOD 67 1 previously described serotonin syndrome, which is occaoccasionally fatal. In addition, both types of drugs clear out of the body slowly,
and so a drug-free period is necessary before switching from one to the other.
When switching from Pro- Prozac, an SSRI, to Parnate, an MAOI, this waiting
period may be five weeks or more. When switching from Parnate to Pro- Prozac,
the waiting period will be at least two weeks. With some combinations of drugs,
however, a waiting period is not nec- necessary. Check with your doctor about
this. Suppose that all these strategies fail to bring about an optimal
antidepressant response. What then? In my expe- experience this is not unusual.
I have seen lots of patients who were treated for years with all kinds of
medications and yet they were still severely depressed. Early in my career, I
realized that drugs did not provide the answer for many people. That is why I
devoted so much of my career to the development of new psychotherapeutic
techniques, such as those described in this book. I wanted to have more tools
available than just drugs. In my experience, the idea that a pill alone will solve
available than just drugs. In my experience, the idea that a pill alone will solve
your problems and bring you joy is not productive. In contrast, the willingness to
use these cognitive therapy tools, often in combination with a compassionate,
persistent, and creative therapist will often lead to substantial improvement.
Other Drugs Your Doctor May Prescribe The various types of antidepressants I
have described are the ones that in my opinion have a clear-cut indication in the
treatment of depression. I will describe several types of drugs that you might
want to avoid, although there are ex- exceptions to this rule. Minor Tranquilizers
(Benzodiazepines). Some doctors use minor tranquilizers (called
benzodiazepines) or seda- sedatives to treat nervousness and anxiety. The
benzodiazepines include many familiar drugs such as alprazolam (Xanax),
chlordiazepoxide (Librium), clonazepam (Klonopin), clor672 David D. Burns, M.D. azepate (Tranxene), diazepam (Valium), lorazepam
(Ati- van), oxazepam (Serax) and prazepam (Centrax). Minor tranquilizers may
be added to the mix of drugs your doctor prescribes if you are depressed.
Because most depressed patients also experience anxiety, this practice is
unfortu- unfortunately quite common. I usually do not recommend minor
tranquilizers because they can be addictive, and the sedation they produce might
make your depression worse. In my experience, anxiety can nearly always be
treated successfully without using these drugs. Two highly esteemed colleagues
from Canada, Dr. Henny A. Westra from the Queen Elizabeth II Health SciSciences Center, and Dr. Sherry H. Stewart from Dalhousie University, recently
reviewed the world literature on the treatment of anxiety disorders with
cognitive behavioral therapy versus medications. Based on their careful review
of many clinical outcome studies, the authors recommended treatment of anxiety
disorders with cognitive behavior ther- therapy instead of medications.1 The
authors concluded that cognitive behavioral therapy without drugs is a highly efeffective and long lasting treatment for anxiety. In compari- comparison, they
emphasize that benzodiazepines may give some limited relief but only for a short
period of time, tend to lose their effectiveness over time, and are very difficult to
discontinue. If you have a serious interest in this topic, the scholarly article by
Drs. Westra and Stewart would be worth reading. Although the benzodiazepines
such as Ativan, Librium, Ritrovil (available in Canada), Valium, Xanax, and
others can have wonderfully calming effects almost immediately after you take
them, the main problem is that these relaxing effects do not last. As soon as the
drug leaves your body a few hours later, there is a high likelihood you will feel
nervous again. In addition, if you take these drugs daily for more than a few
weeks, you may experience withdrawal effects when you try to go off them. The
most common withdrawal symptoms are anxiety, nervousness and trouble
most common withdrawal symptoms are anxiety, nervousness and trouble
sleeping. Ironically, these are the exact reasons you started taking the drug in the
first place. These withdrawal sympFEELING GOOD 673 toms trick you into thinking you still need the drug, and
so you start taking it again. This is how the pattern of drug dependency develops.
Fortunately, antidepressants are also effective in treating anxiety, as are the
cognitive and be- behavioral therapy techniques described in this book, and these
treatments are not addictive. This is why I avoid the benzodiazepines in the
treatment of depressed or anxious individuals. , There are other reasons to avoid
minor tranquilizers in the treatment of anxiety. One of the cardinal treatment
prin- principles is that anxious individuals must face their fears and surrender to
their fears in order to overcome them. For ex- example, if you have a fear of
heights, you may have to climb to the top of a ladder and stand there until the
anxiety goes away. I could give you dozens of examples of patients who have
experienced dramatic improvements or even complete recoveries when they
faced their fears in this way. Anxious individuals who face their fears often feel
tremendous relief because they discover their fears were not realistic in the first
place. This realization may not occur if you are simply taking tranquilizers and
not facing your fears. Even if you do manage to face your fears with the help of
tranquilizers, the medication will tend to reduce the effectiveness of your efforts.
In fact, when doctors prescribe tranquilizers for anxious patients, there is the
danger that this will reinforce the idea that the fears really are dangerous and
must be avoided and that the uncomfortable symptoms must be sup- suppressed.
These messages are the very antithesis of the newer exposure therapies that have
shown so much promise in the treatment of anxiety. If your doctor has been
prescribing a benzodiazepine, or suggests this type of medication, a discussion
of the pros and cons would be indicated. Remember that you are the conconsumer, and your doctor is working for you. You have every right to discuss
your treatment in a frank and respectful way. This sense of teamwork and
collaboration is quite important. Sedatives. Many prescription sleeping pills can
also be ad- addictive and are easily abused: They can lose their effectiveness
674 David D. Burns, M.D. after only a few days of regular use. Then greater and
greater doses may be required to put you to sleep. This can lead to a pattern of
drug tolerance and dependency. If you take them daily, these pills can disrupt
your normal sleep pattern. Severe insomnia is a withdrawal symptom from
sleeping pills, and so every time you try to stop taking the pills you will falsely
conclude that you need them even more. Thus they can greatly worsen your
sleeping difficulties. In contrast, there are several sedative medications that
sleeping difficulties. In contrast, there are several sedative medications that
enhance sleep without requiring increased doses. In my opinion, these drugs
represent a superior approach to treat- treating insomnia in depressed
individuals. Three that are often prescribed for this purpose are 25 to 100 mg of
trazodone (Desyrel) or doxepin (Sinequan) or 25 to 50 mg of diphen- hydr^mine
(Benadryl). The first two are antidepressants that require a prescription.
Benadryl is an antiallergy medication that is now sold without a prescription.
Make sure that you consult with your doctor before taking any medication, even
one that is sold over the counter, to make sure there are no dangerous drug
interactions with other medications you are taking. Remember that many overthe-counter drugs, like Benadryl, were once available only on prescripprescription, so they can be just as dangerous as prescription drugs. The new
anticonvulsant, gabapentin, also has sedative and antianxiety effects without
being habit-forming, and some doctors are prescribing it for this purpose. If you
are having trouble sleeping, you may have personal problems that make it hard
to get to sleep. It could be any- anything—a problem at school or work, or a
conflict with a fam- family member or friend. Some people sweep these
problems under the carpet so they won't have to deal with them. Then they
develop a variety of symptoms instead. Some people become anxious, others
have trouble sleeping, and some de- develop aches and pains that have no
organic causes. I have always felt it is better to try to identify and solve the
problem rather than masking it with tranquilizers or sleeping pills. In our culture,
the idea of a quick cure is
FEELING GOOD 675 tremendously appealing to patients and physicians alike.
It is easy to prescribe a drug that will make the problem go away. This
contributes greatly to the enormous popularity of sleeping pills and minor
tranquilizers. Stimulants. How about the "pep pills" (stimulants) such as
methylphenidate (Ritalin) and the amphetamines that used to be so commonly
prescribed for weight loss? It is true that these drugs can produce a temporary
stimulation or elation (much like cocaine), but they can also be dan- dangerously
habit-forming. When you come down from the temporary high state, you may
tend to crash and experience an even more profound sense of despair. When
given chronically, these drugs can sometimes produce an aggres- aggressive,
violent, paranoid reaction resembling schizophrenia. I have not prescribed
stimulants for depressed patients (or for any other problem) because of my
concerns about these drugs, but this is clearly an area of controversy. Some psypsychiatrists do prescribe stimulants for elderly depressed pa- patients under
certain circumstances, and they are quite popular for treating hyperactive
children and adolescents. If your doctor recommends taking such pills, you
should certainly discuss the pros and cons. You might also want to obtain a
should certainly discuss the pros and cons. You might also want to obtain a
second opinion if you feel uncomfortable about the treat- treatment. There are
exceptions to this rule, like any. Because of its energizing properties, some
doctors add methylphenidate (Ritalin) to a tricyclic antidepressant. This
combination may be helpful for some patients who are very sluggish and
unmotivated. However, methylphenidate also inhibits the breakdown of most
tricyclic antidepressants by the liver, and so the blood level of these other
antidepressants will increase. This may lead to greater side effects and may
require a reduction in the dose of the antidepressant. Antipsychotic Medications
(Neuroleptics). What about the antipsychotic medications (also called
neuroleptics or "major tranquilizers")? Some of the older drugs in this
676 David D. Burns, M.D. category include chlorpromazine (Thorazine),
chlorprothix- ene (Taractan), haloperidol (Haldol), fluphenazine (Pro- lixin),
loxapine (Loxitane), mesoridazine (Serentil), molindone (Moban), perphenazine
(Trilafon), pimozide (Orap), thiothixene (Navane), thioridazine (Mellaril), and
trifluoperazine (Stelazine). Some of the newer drugs include clozapine
(Clozaril), olanzapine (Zyprexa), quetiapine (Ser- oquel), risperidone
(Risperdal), sertindole (Serlect), and zi- prasidone (trade name not yet available).
These agents are usually reserved for patients with schizophrenia, mania, or
other psychotic disorders. They do not play a major role in the treatment of most
depressed or anxious patients. Pills that combined an antidepressant with an
antipsychotic med- medication were marketed and promoted in the past, but
most clinical studies have not documented any superior efficacy of such
preparations in the treatment of depression. Only a minority of depressed
individuals benefits from antipsychotic agents. These include depressed patients
who are delusional—that is, patients who draw false and highly unrealistic
conclusions about external reality. For example, a depressed patient might have
the delusion that there are worms in his or her body or that there is a conspiracy
against him or her. Elderly depressed patients seem more likely to develop
paranoid delusions. Depressed patients who are extremely agitated and cannot
stop pacing some- sometimes benefit from the antipsychotic agents as well.
How- However, the major tranquilizers may also cause a worsening of the
depression because of their tendency to cause sleep- sleepiness and fatigue. In
addition, unlike most antidepressants, many of the an- antipsychotic medications
carry the risk of an irreversible side effect called tardive dyskinesia. Tardive
dyskinesia is an abnormality of the face, lips, and tongue; it involves reperepetitious, involuntary movements, such as smacking the lips over and over or
grimacing. The abnormal movements can also sometimes include the arms, legs,
and torso. The major tranquilizers can also cause a number of other alarming but
and torso. The major tranquilizers can also cause a number of other alarming but
FEELING GOOD 677 reversible side effects. Therefore, these drugs should be
used only when they are clearly needed so that their poten- potential benefit
outweighs the potential risk. Polypharmacy Polypharmacy refers to the practice
of prescribing more than one psychiatric drug at a time to a particular patient.
The idea is that if one drug is good, two, three, or more will be even better.
Doctors may combine antidepressant drugs with other types of antidepressants as
well as with other types of drugs, such as minor and major tranquilizers. The
patient ends up taking a cocktail of many different types of drugs. Polypharmacy
used to be frowned upon. Now the prac- practice has become more accepted, and
many psychiatrists rou- routinely prescribe two or more drugs for many of their
psychiatric patients. In contrast, if a family physician is treating your depression,
then it is much less likely that she or he will prescribe more than one psychiatric
medication at a time. This is because a family doctor is usually more concerned
with your medical problems and much less ag- aggressive in the treatment of
emotional problems. In some instances, polypharmacy can be helpful in the
treatment of mood disorders. For example, I have described several
augmentation strategies that might boost the effect- effectiveness of an
antidepressant. I have also described how the occasional use of a second
medication can combat a drug side effect. Rational polypharmacy might also be
helpful when a patient has separate disorders that both require treat- treatment.
For example, a patient with schizophrenia may also be depressed and may
benefit from a combination of an anti- psychotic medication along with an
antidepressant. A bipo- bipolar (manic-depressive) patient may receive an
antideprcssant in addition to the lithium during an episode of depression. During
an episode of mania, the doctor may prescribe a neuroleptic or a benzodiazepine
in addition to lithium lo
678 David D. Burns, M.D. combat the acute symptoms, as described previously.
Although there are specific instances like these when combinations of drugs are
indicated, I am usually not in favor of polypharmacy in the treatment of
depression or anxiety because of the increase in side effects, drug interinteractions, and costs. In addition, polypharmacy has the ten- tendency to
convey the message that all the patient's problems can be dealt with by drugs.
The patient may take one or two drugs for depression, one or two additional
drugs to treat the side effects of the antidepressants, one more drug to treat
anxiety, and so on. And if the patient is angry, she or he may get yet another
drug, such as a mood stabilizer, to treat the anger. The patient may end up in a
rather passive role as a kind of human test tube. You may think I am
rather passive role as a kind of human test tube. You may think I am
exaggerating, but I have seen numerous patients who were in just this posiposition. They were taking lots of drugs with lots of side effects but were
receiving very little benefit from any of them. I have treated many of these
patients successfully with cog- cognitive therapy and no drugs or cognitive
therapy and only one antidepressant. I believe that some psychiatrists rely too
much on drugs. Why is this? One problem is that most psychiatric training
programs strongly emphasize biological theories about de- depression and stress
the importance of drug treatments for depression and other disorders. In
addition, a great many of the continuing education programs for psychiatrists in
practice are sponsored by drug companies, and the focus of these conferences is
nearly always on medications. The psychiatric journals, too, are filled with
expensive drug company advertisements promoting the benefits of the latest
medications for depression or anxiety, but I have never seen an ad promoting the
latest psychotherapy technique. This is because there is simply no money to pay
for such an ad! Drug companies also fund a great deal of the research on
medications that appears in psychiatric journals, and con- concerns have been
voiced about the potential conflict of in- interest inherent in such arrangements.
FEELING GOOD 679 I do not mean to sound like a rabble-rouser! This is not a
black-or-white issue. Clearly, the excellent research con- conducted by the
pharmaceutical industry has been an enor- enormous boon to the psychiatric
profession and to individuals suffering from psychiatric disorders. My concern is
that the emphasis on drugs sometimes seems excessive. Unfortu- Unfortunately,
some psychiatrists do not have good training in the newer forms of
psychotherapy, including cognitive behav- behavioral therapy, which can be so
helpful for individuals suf- suffering from depression and anxiety. When a
patient does not respond to medications, the main response of the psypsychiatrist may be to increase the dose or add another medi- medication
because this is what the psychiatrist has been trained to do. And when a patient
complains of an adverse side effect, the psychiatrist may decide to add some
other ad- additional drug as an antidote—because that is what she or he has been
trained to do. The result in some cases is that patients end up taking more and
more drugs in larger and larger doses—without any real benefits. This is when
polypharmacy can get out of hand. When I was a psychiatric resident, I used to
have the ide£ that if only I could find the right ' 'magic bullet'' (in other words,
the right pill), I could help every patient. In those days, we treated our patients
with pill after pill after pill but very little psychotherapy. My clinical experience
taught me over and over again that this model was not sufficient—too many of
my patients simply did not recover, no matter how many drugs I used, singly or
in combina- combinations. To make things worse, most psychiatrists do not
in combina- combinations. To make things worse, most psychiatrists do not
require patients to take mood tests, like the one in Chapter 2, be- between
therapy sessions to track progress. As a result, the psychiatrist may conclude that
the patient is being "helped" by a drug when the patient has not really imimproved substantially. To my way of thinking, treating patients without
session-by-session assessments is anti- scientific and represents a barrier to good
treatment and progress in the field.
680 David D. Burns, M.D. Some psychiatrists and many patients are almost
exclu- exclusively committed to these biological theories and treatments for
depression. They may discount the value of other ap- approaches, sometimes
with a religious fervor. A number of well-known psychiatrists are quite
outspoken in this regard. The intensity of these debates about psychotherapy
versus drug therapy is sometimes more reminiscent of a power struggle for turf
than an intellectual search for the truth. Fortunately, there is a growing and
healthy trend to rec- recognize that all of our current psychiatric drugs are
limited in their effectiveness. In addition, there is an increasing recognition that a
combination of medication with the newer forms of psychotherapy (including
cognitive behav- behavioral therapy and others) usually provides a more
satisfac- satisfactory outcome than does treatment with drugs alone. It is clear
that antidepressant drugs can help some indi- individuals, but it is also clear that
many patients do not re- respond adequately. When patients do not respond, I
would prefer to switch into a different gear and use cognitive ther- therapy or a
combination of cognitive therapy and one anti- depressant medication at a time.
Most depressed people have real problems in their lives, and nearly all of us
need a compassionate, healing relationship with another human being to talk
things out at times. The idea that drugs alone should work to cure depression and
anxiety may be ap- appealing, but this approach is often ineffective. To be fair,
an exclusive focus on psychotherapy alone can be just as biased. I have seen
patients who did not respond to many psychotherapeutic interventions that I perpersonally administered—week after week their depression scores on the test in
Chapter 2 did not change. Sometimes I prescribed an antidepressant while we
continued working with a variety of psychotherapeutic strategies. Within sevseveral weeks, the depression and anxiety often began to im- improve, and the
psychotherapy suddenly began to work better. In these cases, I was glad to have
the medications available. A final problem contributing to polypharmacy is that
FEELING GOOD 681 many patients are unassertive. Even though they feel ununcomfortable about all the drugs they are taking, they may sometimes assume
that "the doctor knows best.'' This is understandable. The doctor does have a
that "the doctor knows best.'' This is understandable. The doctor does have a
great deal of train- training, and the patient's knowledge is usually limited. In adaddition, the patient often admires the doctor and respects his or her advice. But
in psychiatry and psychology, treatment approaches are far more subjective and
varied than in in- internal medicine, where the treatments are far more precise
and uniform. Your feelings about the treatment are impor- important, and you
have every right to share these feelings with your doctor. This review of drugprescribing practices obviously rep- represents my own approach. Your
physician's ideas might differ. Psychiatry is still a blend of art and science.
Perhaps some day the "art" will no longer be such a prominent ingredient. If you
feel uncertain about your treatment, ask your physician questions. State your
concerns and urge your doctor to explain the treatment in simple terms you
understand. After all, it's your brain and body that are at risk, not the doctor's.
The sense of teamwork and collab- collaboration are important to successful
treatment. As long as the two of you agree to a rational, understandable, and mumutually acceptable strategy for your therapy, you will have an excellent chance
of benefiting from your doctor's efforts to help you.
Notes and References (Chapters 17 to 20) 1. Schatzberg, A. F., Cole, J. O., &
DeBattista, C. A997) Manual of Clinical Psychopharmacology. Third EdiEdition. Washington, DC: American Psychiatric Press. 2. Some psychologists
are lobbying for the right to pre- prescribe drugs, and some psychologists in the
armed services have already been licensed to prescribe drugs. There is intense
controversy about the merits of this proposal. Some psychologists argue that the
right to prescribe drugs is desirable because it will put them on an even footing
to compete with psychiatrists for pa- patients. Other psychologists argue that
drug prescribing requires extensive medical training and that the profesprofession will lose an important part of its identity if psy- psychologists win the
right to prescribe drugs. They also point out that the role of the psychiatrist,
particularly in managed care situations, has become quite unap- unappealing.
Many psychiatrists who work for HMOs are now forced to see huge numbers of
patients for ex- extremely brief visits consisting only of discussions about
medications without any time to do psychotherapy or to learn about the problems
in their patients' lives. 682
Notes and References (Chapters 17 to 20) 683 3. Baxter, L. R., Schwartz, J. M.,
& Bergman, K. S., et al. A992). Caudate glucose metabolic rate changes with
both drug and behavioral therapy for obsessive- compulsive disorders. Archives
of General Psychiatry 49, 681-689. 4. Simons, A. D., Garfield, S. L., & Murphy,
G. E. A984). The process of change in cognitive therapy and pharmacotherapy
G. E. A984). The process of change in cognitive therapy and pharmacotherapy
for depression. Archives of General Psychiatry 41, 45-51. 5. Antonuccio, D. O.,
Danton, W. G., & DeNelsky, G. Y. A995). Psychotherapy versus medication for
depres- depression: Challenging the conventional wisdom with data.
Professional Psychology: Research and Practice 26 F) 574-585. 6. Dobson, K. S.
A989). A meta-analysis of the efficacy of cognitive therapy for depression.
Journal of Con- Consulting and Clinical Psychology, 57C), 414—419. 7. Hollon,
S. D., & Beck, A. T. A994). Cognitive and cognitive behavioral therapies.
Chapter 10 in A. E. Bergin & S. L. Garfield (Eds.), Handbook of PsychoPsychotherapy and Behavioral Change (pp. 428-466). New York: John Wiley &
Sons, Inc. 8. Robinson, L. A., Berman, J. S., & Neimeyer, R. A. A990).
Psychotherapy for the treatment of depression: Comprehensive review of
controlled outcome research. Psychological Bulletin, 108, 30-49. 9. Scogin, F.,
Jamison, C, & Gochneaut, K. A989). The comparative efficacy of cognitive and
behavioral bib- liotherapy for mildly and moderately depressed older adults.
Journal of Consulting and Clinical Psychology 57, 403-407.
684 Notes and References (Chapters 17 to 20) 10. Scogin, F., Hamblin, D., &
Beutler, L. A987). Bib- liotherapy for depressed older adults: A self-help alteralternative. The Gerontologist 27, 383-387. 11. Scogin, F., Jamison, C, & Davis,
N. A990). A two- year follow-up of the effects of bibliotherapy for dedepressed older adults. Journal of Consulting and Clinical Psychology 58, 665-
667. 12. Jamison, C, & Scogin, F. A995). Outcome of cogni- cognitive
bibliotherapy with depressed adults. Journal of Consulting and Clinical
Psychology 63, 644-650. 13. Smith, N. M., Floyd, M. R., Jamison, C, & Scogin,
F. A997). Three-year follow-up of bibliotherapy for de- depression. Journal of
Consulting and Clinical Psychol- Psychology 65 B), 324-327. 14. Burns, D. D.,
and Nolen-Hoeksema, S. A991). Coping styles, homework compliance and the
effectiveness of cognitive-behavioral therapy. Journal of Consulting and Clinical
Psychology 59 B), 305-311. 15. Burns, D. D., & Auerbach, A. H. A992). Do
self-help assignments enhance recovery from depression? Psy- Psychiatric
Annals 22 (9), 464-469. 16. Dessain, E. C, Schatzberg, A. F., & Woods, B. T.
A986). Maprotiline treatment in depression: a perspec- perspective on seizures.
Archives of General Psychiatry 43, 86-90. 17. Maxmen, J. S., & Ward, N. G.
A995). Psychotropic Drugs Fast Facts, Second Edition. New York: W. W.
Norton & Company. 18. You will notice that the percentages of patients reportreporting stomach upset in Table 20-5 are a little lower than
Notes and References (Chapters 17 to 20) 685 20 percent to 30 percent on the
average. This is be- because the percentages in the table represent the differdifferences between the rates for the actual drug minus the rates for patients
differences between the rates for the actual drug minus the rates for patients
taking placebo medications. 19. You will learn below that the MAOIs can cause
dan- dangerous blood pressure elevations, but this is only if you take one of the
forbidden foods or medications. Usu- Usually, the MAOIs can cause a mild drop
in blood pres- pressure. 20. A patient with a "difficult'' or "resistant" depression
is simply one who does not readily respond to the usual treatments. If your
doctor tries many antidepressant drugs and you do not improve, your doctor will
natu- naturally conclude that your depression is more difficult than usual to treat.
However, you may respond nicely to another type of treatment. I have treated
large num- numbers of patients who had years and years of unsuc- unsuccessful
treatment with a wide variety of drugs prior to seeing me. Many of these '
'difficult'' patients recov- recovered when I used cognitive therapy techniques
like those described in this book. No single treatment is a panacea for everyone.
That's why \t is important to have lots of approaches avail- available, including
many different kinds of medicines and many different kinds of
psychotherapeutic methods as well. The term, "different strokes for different
folks" is right on target in the context of depression treatment! 21. Arky, R.
(Medical Consultant). A998). Physician's Desk Reference, 52 Edition. Montvale,
NJ: Medical Economics Company, Inc. 22. The telephone number of the
Madison Institute of Med- Medicine is 608-827-2470; their fax is 608-827-2479;
their address is 7617 Mineral Point Road, Suite 300, Mad686 Notes and References (Chapters 17 to 20) ison, Wisconsin, 53717; and their
email is IN- FOCTRS@Healthtechsys.com. They can do literature searches and
supply pamphlets, reprints and other in- information for a modest fee. 23.
Preskorn, S. H. A997). Clinically relevant pharmacol- pharmacology of selective
serotonin reuptake inhibitors. Clinical Pharmacokinetics Suppl. 1, 1-21. 24.
Westra, H. A., & Stewart, S. H. A998). Cognitive be- behavioral therapy and
pharmacotherapy: Complemen- Complementary or contradictory approaches to
the treatment of anxiety? Clinical Psychology Review 18 C), 307-340. 25.
Levine, J., Brak, Y., Gonzales, M., et al. A995). Double-blind controlled trial of
inositol treatment of major depression. American Journal of Psychiatry 152, 792-
794. 26. Joffee, R. T., & Shuller, D. R. A993). An open study of buspirone
augmentation of serotonin reuptake inhib- inhibitors. Journal of Clinical
Psychiatry 54, 269-271. 27. Nelson, J. C, & Price, L. H. A995). Lithium or desipramine augmentation of fluoxetine treatment (letter). American Journal of
Psychiatry 152, 1538-1539. 28. Weilburg, J. B., Rosenbaum, J. F., Biederman,
J., et al. A989). Fluoxetine added to non-MAOI antidepressants converts
nonresponders to responders: a preliminary re- report. Journal of Clinical
Psychiatry 50, 447-449. 29. Nirenberg, A. A., Cole, J. O., & Glass, L. A992).
Psychiatry 50, 447-449. 29. Nirenberg, A. A., Cole, J. O., & Glass, L. A992).
Pos- Possible trazodone potentiation of fluoxetine: a case series. Journal of
Clinical Psychiatry 53, 83-85. 30. Joffee, R. T., Levitt, A. J., Bagby, R. M. et al.
A993). Predictors of response to lithium and triodothyronine:
Notes and References (Chapters 17 to 20) 687 augmentation of antidepressants
in tricycylic non- responders. British Journal of Psychiatry 163, 574- 578. 31.
Fawcett, J., Kravitz, H. M., Zajeda, J. M., et al. A991). CNS stimulant
potentiation of monoamine oxidase in- inhibitors in treatment of refractory
depression. Journal of Clinical Psychopharmacology 11, 127-132.
Suggested Resources Other Books by Dr. Burns The Feeling Good Handbook
(New York: Plume, 1990). Dr. Burns shows how you can use cognitive therapy
to overcome a wide variety of mood problems such as de- depression,
frustration, panic, chronic worry and phobias, as well as personal relationship
problems such as marital con- conflict or difficulties at work. Intimate
Connections (New York: Signet, 1985). Dr. Burns shows you how to flirt, how
to handle people who give you the run-a-round, and how to get people of the
opposite sex (or the same sex, if that is your preference) to pursue you. Ten Days
to Self-Esteem and Ten Days to Self-Esteem: The Leader's Manual (New York:
Quill, 1993). In this ten- step program, Dr. Burns provides a practical, workable
blueprint for breaking out of the bad moods that rob us of self-esteem. He
provides you with clear, easy-to-understand instructions and specific tools
gleaned from twenty years of systematic research and psychiatric practice. The
Leader's Manual shows you how to develop this program in hospi- hospitals,
clinics, schools, and other institutional settings. 688
Suggested Resources 689 Workshops and Lectures by Dr. Burns Dr. Burns
offers workshops and lectures for mental health professionals and for general
public audiences as well. For a list of dates and locations, you are invited to visit
Dr. Burns' Web site at www.FeelingGood.com Audiotapes for the General
Public Burns, The Perfectionist's Script for Self-Defeat. Dr. Burns helps you
identify perfectionistic tendencies and explains how they work against you. He
shows you how to stop setting unrealistically high standards and in- increase
productivity, creativity, and self-satisfaction. Burns, Feeling Good. Dr. Burns
describes ten common self-defeating thinking patterns that lead to depression,
anxiety, frustration, and anger. He explains how to replace them with more
positive and realistic attitudes so you can break out of bad moods and enjoy
greater self-esteem now and in the future. Audiotapes for Mental Health
Professionals Strategies for Therapeutic Success: My Twenty Most EffecEffective Techniques—Volumes I and II. 8 Cassettes In this two-day intensive
Effective Techniques—Volumes I and II. 8 Cassettes In this two-day intensive
workshop, Dr. Burns illustrates the most valuable therapy techniques he has
developed dur- during two decades of clinical practice, training, and research.
Feeling Good: Fast & Effective Treatments for Depression, Anxiety, and
Therapeutic Resistance. 4 Cassettes Dr. Burns describes the basic principles of
CBT and il- illustrates state-of-the-art treatment methods for depression and
anxiety disorders. He also illustrates how to deal with
690 Suggested Resources difficult, angry patients who seem to sabotage the
treatment because they feel mistrustful and unmotivated. Feeling Good
Together: Cognitive Interpersonal Therapy 4 Cassettes In this workshop, Dr.
Burns shows how to modify the attitudes that sabotage intimacy and lead to
anger and mis- mistrust. He also explains how to deal with patients who blame
others for their personal relationship problems. Rapid, Cost-Effective Treatments
for Anxiety Disorders 4 Cassettes In this workshop, Dr. David Burns shows you
how to integrate three powerful models in the treatment of the en- entire
spectrum of anxiety disorders, including generalized anxiety, panic disorder
(with or without agoraphobia), pho- phobias, social anxiety, obsessivecompulsive disorder, and post-traumatic stress disorder (including victims of
child- childhood sexual abuse). You may order the audiotapes for professionals
or for the general public by visiting Dr. Burns' Web page at
www.FeelingGood.com Treatment and Assessment Tools for Mental Health
Professionals Therapist's Toolkit 2000 Includes hundreds of pages of state-ofthe-art assessment and treatment tools for the mental health professional. PurPurchase includes licensure for unlimited reproduction in your clinical practice.
Site licenses are available. Feeling Good Web Site You are invited to visit Dr.
Burns' Web site at www. FeelingGood.com. This Web site contains information
about:
Suggested Resources 691 • dates and locations for upcoming lectures and workworkshops by Dr. Burns • audiotapes for the general public • training tapes for
mental health professionals (includ- (including CE credits) • links for referrals to
cognitive therapists around the country • description of Dr. Burns' new
Therapist's Toolkit • links to other interesting sites • new information of potential
interest to patients, ther- therapists, and researchers • Ask The Guru. You can
submit questions about any mental health topic. Answers to selected questions
are posted in a column format.
Index Page numbers in italics refer to figures and tables. A small "n" following a
page number refers to a note on that page. accomplishments, self-esteem and,
page number refers to a note on that page. accomplishments, self-esteem and,
327-30 advantages of, 328 disadvantages of, 328-29 does work equal worth, 331
— 41 accurate empathy, 185-91 achievement DAS test score and, 285 worth
and, 327-41 achievement trap, 346-51 action, motivation and, 125- 27 active
death wish, 387 Adapin, 379 side effects, 531 adaptive anger, 163-64 Adler,
Alfred, lOn adolescent rejection, 301-2 Agras, Stuart, xxii air-traffic controllers,
409 alcohol, 330 all-or-nothing thinking, 32-33, 42 American Psychiatric
Association, xxvi amitriptyline (Elavil, Endep), 448-49, 518 side effects, 499-
500, 530 amoxapine (Asendin), 519 side effects, 536 amphetamines, 330
Anafranil, 484, 518 side effects, 530 anger, 149-97 as adaptive, 163-65 cognitive
therapy and, 153 Freud on, 153 frustration and, 195-96 internalized, 153
irrational statements, 159— 60 labeling, 157 magnification, 158-59 as
maladaptive, 164-94 mind reading, 158 Novaco anger scale, 150-52 as
productive, 163-65 693
694 Index anger (continued) ten things to know about, 194-97 thoughts and,
154-56 Anger Cost-Benefit Analysis, 166 anger hierarchy, 191-93, 192 angry
rejection, 303 Anhedonia, 90 antidepressant drug therapy, 10, 11-17,404, 513n681 cognitive therapy and, 10-18 antidepressant drugs, xxi, 404, 427, 441, 474-
77 augmentation chart, 664-69 augmentation strategy concerning, 662-71 being
treated with, 478 bupropion (Wellbutrin), 605- 7 consumer's guide to, 513n- 681
costs of, 515-24 deciding whether or not to take, 479-80 efficiency of, 483
generic, 516 how to tell if working, 484- 86 how they work, 443-54 ineffective,
659-71 interactions with other drugs, 505-12 length of time for results
concerning, 487 length of time to take, 489- 90 MAO inhibitors, 444-48, 514,
520, 564-98 medical supervision concerning, 480 mirtazapine (Remeron), 615-
17 mood elevation and, 486 mood stabilizers, 575, 522, 617-59 most effective,
483-85 myths concerning, 464-68 names, doses, and costs of, 518-22 preventing
or minimizing side effects of, 501-5 reasons for side effects of, 498-501
serotonin antagonists, 514, 521, 599-605 side effects of, 492-98 simultaneously
taking different, 486-87 SSR inhibitors, 449-50, 514, 520, 547-64 table of, 514-
15 taking on long-term basis, 490-91 tapering off, 491 tetracyclic, 514, 519, 524-
27, 534-47 treatment of suicidal patients, 384 tricyclic, 448-49, 501, 514, 518-
19, 524-34, 538-47 venlafaxine (Effexor), 611- 15 when not working, 487-89
who benefits from, 480-82 see also individual names antiheckler technique, 145
antihistamines, 500 Antiperfectionism Sheet, 357 Antiprocrastination Sheet, 99
antipsychotic medications (neuroleptics), 675-77 Antonuccio, David O., xx, xxi,
463
Index 695 anxiety disorders, 484 cognitive therapy for, xxii symptoms of, 26
approval, 290-310 DAS test score and, 285 independence and self- respect, 296-
approval, 290-310 DAS test score and, 285 independence and self- respect, 296-
309 need for, 290-92 origin of the problem, 293- 96 self, 309-10 Archives of
General Psychiatry, 457 Asendin, 579 side effects, 536 augmentation chart, 664-
69 augmentation strategy, 486, 662-71 Authoritative Guide to Self- Help Books,
xxix autonomy, DAS test score and, 288-89 Aventyl, 579 side effects, 532
averageness, 353 Baxter, Lewis R., Jr., xxi, 457 BDC. See Beck Depression
Checklist BDI. See Beck Depression Inventory Beck, Aaron T., 1 On, 2In, 51,
53n, 115, 367,383,413, 420 preface by, xi-xiii interpreting, 21-27 Beck
Depression Inventory (BDI), xxiv, 46, 67, 250, 386, 391 being alone advantages
of, 321 loneliness and, 313-18 benzodiazepines, 671-73 Bergman, Kenneth S.,
xxii, 457 beta-blockers, 502 bibliotherapy, xxiii-xxix studies concerning, xxiiixxix biological treatments, 460-62 myths concerning, 464-68 vs. psychological
treatments, 456-73 studies concerning, 457-60 bipolar (manic-depressive)
illness, 428-29, 461-62 symptoms of, 430 boosting self-esteem, 53-80 borderline
personality disorder (BPD), 484-85 BPD. See borderline personality disorder
brain biology of, 433-38 research, 453-54 brain chemistry, imbalances in, xxixxii, 431-33, 478 theories concerning, 438-43 Brown, Helen Gurley, 334
bupropion (Wellbutrin), 527, 605-7 doses, 607 drug interactions, 610-11 side
effects, 607, 608 Burns Depression Checklist (BDC), 20-27, 22 BuSpar, 450-51
buspirone (BuSpar), 450-51 But-Rebuttal Method, 107-9, 108 Cade, John, 617
Campbell, Barbara D., xxix ' 'Can't Lose" System, 124- 25, 126
696 Index carbamazepine (Tegretol), 522, 640-41 blood testing, 641-43 doses,
641 drug interactions, 646-51, 648-50 side effects, 643-46 Celexa, 520 Center
for Cognitive Therapy, 13, 22n chemotherapy, 233 citalopram (Celexa), 520
Cleveland Clinic, 463 clomipramine (Anafranil), 484, 518 side effects, 530
coercion, 92, 116-17 cognitive distortions, 201, 238- 39, 393, 402-3 definitions
of, 32-41, 42-43 of suicidal individuals, 392, 394, 401 cognitive rehearsal, 191,
194 cognitive therapy, xvii-xxiiin, 57 anger and, 153 antidepressant drug therapy
and, 13-14 for anxiety disorders, xxii for depression, 13-18, 75 dialogue between
client and therapist, 410-11 for eating disorders, xxiii effectiveness of, xx
helplessness and, 419-20 hostility and, 411-16 ingratitude and, 416-17 moodcontrol techniques of, 10-11 origin of, 9-10 for personality disorders, xxii
principles of, 12-13 self-criticism vs. self- defense, 62-68, 69, 76- 77, 134, 244,
261 studies concerning, xx- xxxi, 18 for suicidal individuals, 383- 84, 393-99,
401-3 theory of, xvii-xix uncertainty and, 419-22 compulsive slowness, 359-60
cooling hot thoughts, 167-69 coping, 70-78 with criticism, 144 with
helplessness, 419-22 with hostility, 411-16 with ingratitude, 416-17 with
uncertainty, 419-23 Cosmopolitan, 334 criticism coping with, 146 fear of, 92
overcoming fear of, 131-44 Daily Activity Schedule, 94- 98,95 Daily Record of
overcoming fear of, 131-44 Daily Activity Schedule, 94- 98,95 Daily Record of
Dysfunctional Thoughts, 65-67,66,100- 4, 101-3, 106-7, 170, 208 Danton,
William G., 463 DAS. See Dysfunctional Attitude Scale death wish, 386-87
defeating guilt, 205-28 antiwhiner technique, 22 Daily Record of Dysfunctional
Thoughts, 208 developing perspective, 225- 26
Index 697 learning to stick to your guns, 218-22 Moorey moaner method, 223-
25 4'should" removal techniques, 208-18 DeNelsky, Gurland Y., xx, 463
Depakene, 522 Depakote, 522 dependency, 311 need for love and, 311, 312- 15,
324-26 depression, xx, xxx-xxxi anti depressant drug therapy and, 13-18
antiheckler technique, 145 BDC scores, evaluating, 24- 25 the Beck Depression
Inventory (BDI), xxiv, 46, 67, 250, 386, 391 brain chemistry imbalance and, xxixxii cognitive therapy as treatment for, 12-18 drugs as treatment for, xx- xxi
effects of, 28 environmental influences role in, 428-31 Freud on, 144 genetic
influences role in, 428-31, 460-62 hopelessness and, 387, 405- 6 identifying
silent assumptions downward- arrow method, 264-88 medical science's approach
to, 403-4 mild chronic, 24 National Institute of Mental Health on, 16-17 negative
self-evaluation, 54- 56 negative thinking and, 28- 29, 47-48, 58-59 physical
symptoms of, 25- 26, 432 prevalency of, 9 as product of mental slippage, 13
psychotherapy for, xxi-xxii realistic, 233 relapses, xxvii-xxviii, 492 sadness and,
231-32 schizophrenia and, 57-58 self-dislike and, 53 sexual drive and, 58 suicide
and, 383 willpower and, 81 see also antidepressant drug therapy; suicidal
individual Depression: Causes and Treatment (Beck), 53, 383n Depression:
Clinical Experimental & Theoretical Aspects (Beck), 53n Descartes, Rene, 455
desipramine (Norpramin, Pertofrane), 518 side effects, 531 Desyrel, 451-52,
484, 527, 599 doses, 600 drug interactions, 603-5 side effects, 600-3, 601
Diagnostic and Statistical Manual (DSM), xxvi disapproval, 301-9 fear of, 290-
92 self-respect and, 301-9
698 Index disarming critics, 137-42 disarming technique, 117-19 disattribution,
225-26 disqualifying the positive, 34- 36,42 divalproex sodium (Depakote), 522
do-nothingism, 81-130 coercion, 92 examples of, 83 fear of disapproval or
criticism, 92 fear of failure, 90-91 fear of success, 91-92 guilt, 93 hopelessness,
82 jumping to conclusions, 89 low frustration tolerance, 92- 93 overwhelming
oneself, 89 perfectionism, 90 resentment, 92 self-activation methods, 94- 130
self-blame, 93 self-labeling, 89-90 undervaluing the rewards, 90 doxepin
(Adapin, Sinequan), 484, 518 side effects, 531 DSIVL See Diagnostic and
Statistical Manual Dunton, William G., xx Dyer, Wayne, 162-63 Dysfunctional
Attitude Scale (DAS), 270-89, 296 interpreting your score, 285- 89 scoring, 281-
84 Dysfunctional Thoughts, Daily Record of, 65-67, 66, 100-4, 101-3, 106-7,
84 Dysfunctional Thoughts, Daily Record of, 65-67, 66, 100-4, 101-3, 106-7,
170, 208 dysthymic disorder, 24 eating disorders, cognitive therapy for, xxiii
Effexor, 450, 527, 611-12 doses, 612-14 drug interactions, 614-15 side effects,
608, 614 Einstein, Albert, 160, 163 Elavil, 448-49, 518 side effects, 499-500,
530 Eldepryl, 444 side effects, 573 Ellis, Albert, lOn, 116 emotional reasoning,
38, 42, 79 empathy, 135-37, 207 accurate, 184-85 empathy method, 304-6
Endep, side effects, 530 endorsing yourself, 109-10 enlightened manipulation,
177- 80 entitlement, DAS test score and, 287-88 environmental influences, role
in depression, 428-31 Eskalith, 522 facts, feelings and, 47^48 failure, fear of, 90-
91 fairness, relativity of, 160-62 fear of criticism, 92 overcoming, 131—44 fear
of disapproval, 92, 290- 92 fear of failure, 90-91 fear of success, 91-92 feedback,
141-44 Feeling Good (Burns), xxix- xxx
Index 699 Feeling Good Handbook (Burns), xxix feelings, facts and, 47^-8
Floyd, Mark, xxviii fluoxetine (Prozac), 449-50, 484, 520 side effects, 503-4
fluvoxamine (Luvox), 484, 520 fortune teller error, 37, 42 Freud, Sigmund, 55-
56, 144, 153, 198 frustration, 195-96 gabapentin (Neurontin), 522, 651-53 doses,
653-54 drug interactions, 655-58 side effects, 654-55, 656- 57 Gabitril, 651-52
Garfield, Sol L., 459 generic drugs, 516 genetic influences, role in depression,
428-31, 460- 62 The Gerontologist, xxiii Goldstein, Mark K., 178 gratification,
316-18 "grieving" method, 308-9 guilt, 93-94, 198-228 cycle of, 203-4
defeating, 207-28 distortions causing, 199 inappropriate "should" statements,
201-3 irresponsibility of, 204-7 thoughts leading to, 198-99 habit management,
122 Hamilton Rating Scale for Depression (HRSD), xxi v- xxvii happiness,
success and, 329- 30 healthy sadness, 254-55 helplessness, 88 coping with, 419-
22 heroin, 330 Hitler, Adolf, 292, 331 hopelessness, 88, 472-73 depression and,
387-88, 404-5 suicidal individuals and, 386-87, 400, 404-5 Horney, Karen, lOn
hostility, coping with, 411-16, 415 HRSD. See Hamilton Rating Scale for
Depression human worth scale, 235 hyperpyretic crisis, 575-77 how to avoid,
577-79 medications and drugs to avoid concerning, 583-99 hypertensive crisis,
575-77 foods to avoid concerning, 579-82 how to avoid, 577-79 medications and
drugs to avoid concerning, 583-98 illusions, 31-32 imaging techniques, 169-72
imipramine (Tofranil), 13,448- 49, 519 vs. Prozac, 516 side effects, 531
imipramine pamoate (Tofranil PM), 519 independence, 296-309 cost-benefit
analysis, 296- 98
700 Index independence (continued) disapproval and, 301-8 need for love, 312-
13, 314, 324-26 rejection and, 301-9 self-respect blueprint, 298- 300 verbal
techniques, 300-1 Inderal, 502 ingratitude, coping with, 416- 19, 418 internal
dialogue, 30 internalized anger, 153 iproniazid, 443-44 irrational statements,
159-60 Irritability Quotient, 149 calculating, 152-53 isocarboxazid (Marplan),
159-60 Irritability Quotient, 149 calculating, 152-53 isocarboxazid (Marplan),
572 Jamison, Christine, xxiii, xxviii Jews, 292 job, loss of, 240-50 Journal of
Consulting and Clinical Psychology, xxiii jumping to conclusions, 36, 42, 89
Kaiser facility, 22n labeling, 39-40, 43, 157 Lamictal, 522, 658-59 lamotrigine
(Lamictal), 522, 658-59 Lazarus, Arnold, lOn learning to expect craziness, 176-
77 Lethargy Cycle, 86, 87 life, loss of, 233-36 malignant attitudes toward, 234
limb, loss of, 237-39 distorted attitudes toward, 237-38 lithium (Eskalith), 26,
522, 617-20 blood testing, 621-22 doses, 620-21 drug interactions, 629-34, 630-
31 medical tests prior to treatment with, 621-22 side effects, 502, 623-29
loneliness, being alone and, 313-18 loss of job, 240-50 loss of life, 233-36
malignant attitude toward, 233-34 loss of limb, 237^0 distorted attitudes toward,
234 loss of a loved one, 251-54 love, 286-87 DAS test score and, 285 need for,
311-26 love junkie, analysis of the presumed ' 'advantages" of being a, 314-15
loved one, loss of, 251-54 low frustration tolerance, 92- 93 Ludiomil, 519 side
effects, 536 Luvox, 484, 520 magnification, 37-38, 42, 158 maladaptive anger,
164 mania, symptoms of, 26-27 manipulative rejection, 303-4 Manson, Charles,
292 MAO, 438 MAO inhibitors, 444-48, 514, 520, 564-67
Index 701 doses, 567-69 foods to avoid when taking, 579-82, 580-81
medications and drugs to avoid when taking, 583- 98, 584-90 names, doses, and
costs, 520 side effects, 569-75, 572- 73 toxic reactions caused by, 575-79
maprotiline (Ludiomil), 579 side effects, 536 Marplan, 572 Marshall, E., 18n
medical science approaches to depressive illness, 403-4 mental disorders, major,
symptoms of, 26 mental filter, 34, 42 mid-life crisis, 400-3 mind reading, 36, 42,
143 minimization, 38, 42 Minnet, Ann M., xxix minor tranquilizers
(benzodiazepines), 671- 73 mirtazapine (Remeron), 452, 527, 615 doses, 615-16
drug interactions, 617 side effects, 609, 616-17 mislabeling, 38-39, 43
monoamine oxidase. See MAO monoamine oxidase inhibitors. See MAO
inhibitors Monroe, Marilyn, 57 Mood Clinic (University of Pennsylvania), 10,
lOn, 13, 412, 413 mood-control techniques of cognitive therapy, 11 mood
stabilizers, 575 carbamazepine (Tegretol), 640-51 gabapentin (Neurontin), 651-
58 lithium (Eskalith), 617-34 names, doses, and costs, 522 side effects, 624-25
tiagabine (Gabitril), 651-52 valproic acid, 634-40 vigabatrin (Sabril), 651-52
mood swings, 263, 385, 399 Moorey, Stirling, 223 Moorey moaner method, 223-
24 motivation action and, 125-27 coercion and, 92, 116-17 motivational
paralysis, 86 "Mourning and Melancholia'' (Freud), 56 Murphy, George E., 459
rawsterbation, 39, 116 Nardil, 444, 520 side effects, 572 National Institute of
Mental Health, 17-18 need for love, 311-26 attitude modification, 320- 26
dependency and, 311, 312- 15, 324-25 independence and, 313-14, 324-25
Pleasure-Predicting Sheet, 318-24 nefazodone (Serzone), 451-52, 527, 599
Pleasure-Predicting Sheet, 318-24 nefazodone (Serzone), 451-52, 527, 599
702 Index nefazodone (continued) doses, 600 drug interactions, 603-5 side
effects, 600-3, 601 negative self-evaluation, 53- 54 negative thinking, 244
depression and, 28-29, 48- 49, 57-58 negotiation, 142-44, 182-84 neuroleptics,
675-76 Neurontin, 522, 651-53 doses, 653-54 drug interactions, 655-58 side
effects, 654-55, 656-57 nihilism, 394 nondirective therapy, 60 Norpramin, 518
side effects, 531 nortriptyline (Aventyl), 519 side effects, 532 Novaco, Raymond
W., 150n Novaco anger scale, 150-52 obsessive-compulsive disorder (OCD),
484 OCD. See obsessive- compulsive disorder Oedipal incestuous fantasies, 198
omnipotence, DAS test score and, 288 operationalization, 339 original sin, 198
overcoming perfectionism, 352-80 absurdity of all-or-nothing thinking, 372
advantages and disadvantages, 354 Antiperfectionism Sheet, 356-58 benefiting
from failure, 361- 66 developing process orientation, 367-69 focusing on happy
memories, 378-79 focusing on positive side, 372 learning to make mistakes,
370-71 learning from mistakes, 380 lowering one's standards, 354, 379 personal
disclosure, 374-78 as a realistic goal, 358 Response-Prevention Form, 361-62
the role of fear, 360 setting time limits on one's activities, 370
overgeneralization, 33-34, 42 overwhelming yourself, 89 Parnate, 444, 484 side
effects, 573 paroxetine (Paxil), 520 passive-aggressive type, 85 passive death
wish, 386 Paxil, 520 PDR. See Physician's Desk Reference perfectionism, 90
DAS test score and, 285 overcoming, 352-80 personal inadequacy, 53-55
personality disorders, cognitive therapy for, xxii personalization, 40-41, 200
Pertofrane, side effects, 531 PET scanning. See positron emission tomography
Index 703 phenelzine (Nardil), 444, 520 side effects, 572 physical handicaps,
237-40 Physician's Desk Reference (PDR), 512 Pleasure-Predicting Sheet, 104-
7, 105, 318-22, 579, 349, 350 polypharmacy, 476-77, 677- 81 positive, the,
disqualifying, 34- 35,42 positron emission tomography (PET scanning), xxii
pregnant women, antidepressants and, 480 Prinze, Freddie, 57 procrastination,
38, 83-84, 86 productive anger, 163-64 productivity scale, 235 propranolol
(Inderal), 502 protriptyline (Vivactil), 519 side effects, 532 Prozac, 427, 449-50,
484, 501,520 vs. imipramine, 516 side effects, 503-4 psychotherapy, 12, 403 vs.
biological treatments, 456-73 myths concerning, 468-73 studies concerning,
457-60 "Psychotherapy vs. Medication for Depression/' xx 4'Psychotherapy
Works, but for Whom?'' (Marshall), 18n rational responses (self- defense), 244
realistic depressions, 232-33 reasoning, emotional, 38, 42, 79 reducing anger,
methods of accurate empathy, 184-91 anger hierarchy, 191-92 cognitive
rehearsal, 191-94 cooling hot thoughts, 167— 69 develop the desire, 165-67
enlightened manipulation, 177-80 imaging techniques, 169-72 learn to expect
enlightened manipulation, 177-80 imaging techniques, 169-72 learn to expect
craziness, 176-77 negotiating strategies, 182— 84 putting it all together, 191- 94
rewrite the rules, 172-74 "should" reduction, 180 thought stoppage, 172
rejection, 301-7 recovering from, 308-9 relativity of fairness, 160-62 Remeron,
452, 527, 615 doses, 615-16 drug interactions, 617 side effects, 609, 616-17
remorse, 199 resentment, 92 response prevention, 360 Response-Prevention
Form, 361 revenge, developing desire for, 165-67 rewriting the rules, 172-74
Rothko, Mark, 57 Sabril, 651-52 sadness depression and, 231-32 without
suffering, 254-55
704 Index Santrock, John W., xxix Schatzberg, Alan F., 574, 598, 627, 640, 643,
658, 662, 663 schizophrenia, depression and, 57 Schwartz, Jeffrey M., xxi- xxii,
457 Science, 18n Scogin, Forest, xxiii, xxiv, xxviii sedatives, 673-75 selective
serotonin reuptake inhibitors. See SSR inhibitors selegiline (Eldepryl), 444 side
effects, 573 Self-Activation Methods, synopsis of, 128-30 self-approval, 309-10
self-blame, 93 self-criticism, 62-67, 68, 76- 77, 134, 243, 261 triple-column
technique concerning, 63 self-defeating behavior, 84-85 self-defense, 62-67, 68,
76- 77, 134, 141, 244, 248- 49 self-dislike, 53 self-esteem, 235, 261-62
accomplishments and, 327- 40 the achievement trap, 345- 51 boosting, 53-80
four paths to, 341-45 Pleasure-Predicting Sheet, 349-50 specific methods for,
62-80 self-evaluation, negative, 55- 56 self-labeling, 89-90 self-respect, 296-309
blueprint for, 298-300 cost-benefit analysis, 296- 98, 297-98 disapproval and,
301-9 rejection and, 301-9 verbal techniques, 300-1 sense of worthlessness,
overcoming, 59-61 serotonin, 440-41 serotonin antagonists, 514, 599 doses, 599
drug interactions, 603-5 names, doses, and costs, 527 side effects, 601 sertraline
(Zoloft), 520 Serzone, 451-52, 527, 599 doses, 600 drug interactions, 603-5 side
effects, 600-3, 601 sexual drive, depression and, 58-59 4'should" statements, 39,
42, 775, 787,208-11 side effects, antidepressant drugs, 492-98 checklist, 494-96
preventing or minimizing, 501-5 reasons for, 498-501 silent assumptions, 262-63
cost-benefit method for evaluating, 297-98 downward-arrow technique, 264-70
Dysfunctional Attitude Scale, 270-89, 296 vertical-arrow technique, 263-70
Simons, Anne D., 459 Sinequan, 484, 518 side effects, 557
Index 705 slowness, compulsive, 315-17 Smith, Nancy, xxviii SSR inhibitors,
449-50, 501, 514, 541-49 doses, 549-52 drug interactions, 559-64, 560-63
names, doses, and costs, 520 side effects, 552-59, 553- 54 Stanford University
Medical Center, 255 stimulants, 675 success fear of, 91-92 happiness and, 330
visualizing, 119 suicidal impulses, assessing, 386-88 suicidal individual
antidepressant drugs in treatment of, 383-85 assessing impulses of, 386- bleak
outlook of, 384-85 cognitive distortions of, 393- 94, 402-3 cognitive therapy
treatment of, 384, 393-400, 401-4 conviction of insoluble dilemmas, 400 degree
treatment of, 384, 393-400, 401-4 conviction of insoluble dilemmas, 400 degree
of hopelessness of, 387-88, 404-5 desire for self-mutilation, 389-90 illogic of
suicide, 389-401 mid-life crisis and, 400-3 nihilistic theory of, 394-99 suicide,
251-57 depression and, 383 illogic of, 389-401 rate among general population,
383 unrealistic sense of hopelessness and, 385-86 youngsters and, 383
superachievers, 329 Surmontil, 519 side effects, 532 Task-Interfering Cognitions
(TICs), 112-13 Task-Oriented Cognitions (TOCs), 112-13 Tegretol, 522, 640-41
blood testing, 641-43 drug interactions, 646-51, 648-50 side effects, 643-46 Ten
Commandments, 161 testing your "can'ts," 123-24 tetracyclic antidepressants,
5149 524-26 doses, 525-27 drug interactions, 538-47, 540-47 names, doses, and
costs, 519 side effects, 534-38, 536 thought stoppage, 172 tiagabine (Gabitril),
651-52 TICs. See Task-Interfering Cognitions TIC-TOC Technique, 110-11,
112-13 TOCs. See Task-Oriented Cognitions Tofranil, 13, 448-49, 519 side
effects, 531 Tofranil PM, 579 tranquilizers, 9 minor (benzodiazepines), 671-73
706 Index tranylcypromine (Parnate), 444,484 side effects, 573 trazodone
(Desyrel), 451-52, 484, 527, 599 doses, 600 drug interactions, 603-5 side effects,
600-3, 607 tricyclic antidepressants, 448- 49, 501, 514, 524-25 doses, 525-27
drug interactions, 538-47, 540-47 names, doses, and costs, 518-19 side effects,
527-34, 530-32 trimipramine (Surmontil), 519 side effects, 532 Tuskegee
Veterans Affairs Medical Center, xxviii UCLA School of Medicine, 457
uncertainty, coping with, 419- 23, 421-22 undervaluing rewards, 90 University
of Alabama, xxiii, xxviii University of California (Irvine), 150 University of
Nevada, xx, 463 University of Pennsylvania School of Medicine, 9, 10, 241, 390
University of Texas (Dallas), xxix valproic acid (Depakene), 522, 634 blood
testing, 635-36 doses, 634-35 drug interactions, 638—40 side effects, 636-38
venlafaxine (Effexor), 450, 527, 611-12 doses, 612-14 drug interactions, 614-15
side effects, 608, 614 vertical-arrow technique for identifying silent assumptions,
263-70, 296 vigabatrin (Sabril), 651-52 visualizing success, 108-9 Vivactil, 579
side effects, 532 Washington University School of Medicine (St. Louis), 459
weekend/holiday blues, 97 Weissman, Arlene, 271-79 Wellbutrin, 527, 605-7
doses, 607 drug interactions, 610-11 side effects, 607, 608 willpower, depression
and, 81 work, worth and, 331-40 workaholics, 328 worth achievement and, 327-
30 four paths to self, 345-51 as only a concept, 341-43 Pleasure-Predicting
Sheet, 349, 350 work and, 331-40 worthless as a concept, 341- 44 worthlessness,
sense of overcoming, 59-61 youngsters, suicide and, 383 Your Erroneous Zones
(Dyer), 163 Zoloft, 520
David D. Burns, M.D., graduated magna cum laude from Amherst College,
receive his M.D. degree from Stanford University School of Medicin rind
receive his M.D. degree from Stanford University School of Medicin rind
completed his psychiatric residency at the University , Pennsylvania. He has
served as Acting Chief of Psychiatry < Ihe Presbyterian/University of
Pennsylvania Medical Cent* <md as Visiting Scholar at the Harvard Medical
School. In 199 Dr. Burns and his family returned to California. He is curren? ly
Clinical Associate Professor of Psychiatry and Behavior Sc icnces at his alma
mater, the Stanford University School , Medicine, where he is actively involved
in research and teac ing. Dr. Burns is certified by the National Board of
Psychiatr ,»nd Neurology. Di. Burns has received numerous awards, including
the A.I Hinnett Award from the Society for Biological Psychiatry fc his research
on brain chemistry and the Distinguishe < ontribution to Psychology through the
Media Award fro^ I lu* Association of Applied and Preventive Psychology. I he
received the Teacher of the Year Award from the grad psychiatric residents at
Stanford.