My patient, Annie* waited weeks to tell me about it. Then, with tears in her eyes and a shaky voice, she revealed that she thought she might be going crazy. "I have this thing that happens where I don't hear what people are saying. I know they are talking but I just zone out and I feel like I'm not real. They're not real. Time kind of seems to stop, but goes too fast, all at the same time." Assessment revealed that Annie had these experiences during moments of panic due to her intense social anxiety. Depersonalization (feeling detached from one's mind or body) and its related experience, derealization (feeling detached from one's surroundings) are often some of the most disturbing symptoms of Panic Disorder. Many who experience these believe they are losing their minds, and that belief makes anxiety even stronger. In Annie's case, the phenomenon seemed so crazy to her she was afraid to even mention it to me. Depersonalization and derealization can occur in other mental illnesses, such as Dissociative Disorders and PTSD. It is important to get a good assessment and diagnosis by a trained mental health professional. However, the feeling Annie expressed is very common in Panic Attacks. These intense bursts of anxiety carry numerous symptoms including increased heartrate, breathlessness, mind racing, and shakiness, to name just a few. It is estimated that 10%-20% of people will experience panic in their lifetime. And for some, derealization is a part of that picture. There are many tools in the CBT (Cognitive Behavioral Therapy) toolbox, but one of the most important ones is knowledge . Knowing what panic is, and what it isn't, is a key to regaining one's calm. Once the sympathetic nervous (Fight-or-Flight) system is engaged, a number of mental/emotional and physical symptoms are set in motion. These vary by individuals, but can include hyperventilation, increased heartrate, shakiness, even a sensation that the environment is getting too bright. But these are all explainable when you consider that the purpose of this system is to ready you to defend yourself from a threat. The body is primed to run, fight or hide , causing changes in respiration, heartrate, even pupil dilation. The sympathetic nervous system also tends to sharpen focus on these "lifesaving" tasks, while blurring focus on extraneous stimuli. This is likely why Annie couldn't focus on a conversation and felt zoned out. Knowing this is a physiological protective mechanism, rather than the beginnings of schizophrenia, helped Annie to overcome her anxiety. I hope her story helps to encourage others to reveal this symptom in therapy sooner rather than later, so healing can begin. *Annie is a pseudonym. Name changed, along with identifying details, to protect patient confidentiality.

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October is Depression Awareness Month. As such, I hope to highlight the lesser known issue of seasonal depression so that you can protect yourself and your loved ones. Although Seasonal Affective Disorder, or SAD, affects 6-13% of the US population , many people still have not heard of it. Yet many report depression, or a worsening of existing depression, as the days get shorter and there is less intensity to sunlight. By January, it is common for me and my colleagues to have practices full of individuals with this sub-type of depression. Like depression, SAD encompasses low mood, feelings of guilt, low energy, difficulty concentrating, and loss of pleasure in activities. But unlike depression, SAD symptoms begin in fall and remit in spring. Sufferers report decreased energy and oversleeping. Weight gain often occurs, thanks to an increase in cravings, particularly for carbohydrates . It's as if our brains are in hibernation mode! A common misconception about SAD is that some people just don't like the winter. SAD is not about preferences for sunny days and beach vacations. There seems to be neurochemical drivers behind seasonal depression, and many psychiatrists treat it with the same antidepressant drugs used for depression. The reason for these neurochemical changes is unclear. We know that low levels of sunlight can increase melatonin production and cause changes in circadian rhythms, likely accounting for increased sleep, and decreased energy. For this reason, treatment for SAD has focused on medication, CBT (Cognitive Behavioral Therapy), and light therapy. Light therapy utilizes exposure to very bright artificial light (10,000 lux) for 20-60 min a day, preferably in the morning. Interestingly, SAD has been linked to low vitamin D levels, notes this study from UGA . In addition to being detrimental to physical health, low vitamin D levels can affect mental health, since vitamin D (the "sunshine vitamin") is involved in the synthesis of dopamine and serotonin, two neurotransmitters linked to depression . Thus, vitamin D may be an effective treatment. This study concluded that "early detection and vitamin D supplementation can be a simple, convenient, and cost-effective treatment strategy for improving symptoms and mental health outcomes associated with major depression." If you suffer from seasonal depression, its a good idea to get your vitamin D levels checked . Labs can be safely and inexpensively ordered without a doctor's visit through various online platforms, such as Ulta Labs , Walk-in-Labs , or others. Ask your doctor before beginning any supplementation, and be aware that vitamin D dosing is highly individualized. Your ideal dose can only be determined by rechecking labs periodically to determine if your dose brought your levels in range. By the way, if you want more on why this issue is near to my heart personally, click here .

Therapy is a valuable journey to those courageous enough to embark on it. A safe, confidential place to process emotion, and sort through ideas, along with a supportive, objective listener creates a rich experience in which your life can grow and change. However, if you are going to put in the time, effort and finances, you will get more out of therapy with some targeted journaling. Think of your therapy journal as the scrapbook of a deeply personal journey. Whether it is a physical book or electronic file, please be sure to keep your journal in a private place. Then follow the tips below. Bon Voyage! Record your starting point I typically give clients objective assessments of some type - a mood survey, social anxiety checklist, etc. This yields a snapshot of current symptoms and problem areas, and becomes the baseline for goals. Your therapy journal should include some objective data about why you sought help, and what you are hoping to accomplish. Adding detail ("I have become so socially isolated I only leave the house once or twice a week") is important, so paint a picture of your starting point. Later, these initial notes provide a great way to compare how far you've come. Itinerary - Your Session Agenda Research shows that sessions that begin with an agenda accomplish more. Your agenda is a brief "to-do list" for that day's therapy session. One or two words per topic you want to discuss will suffice, such as: 1. Dad's visit, 2. upcoming presentation, 3. confusing text Tell your therapist at the outset of session what these agenda items are before you start. This helps you and your therapist stay on track with what is most important to you. Insta Post - Give it some detail and color! In between sessions, record any time you experience a strong emotion (such as a panic attack), notice a thinking error (such as personalizing, catastrophizing, or all-or-nothing thinking), or have trouble coming up with a logical counter-thought. Bring these to session to process and collaborate. You will begin making connections between concepts discussed in session and your own experience of your thoughts and behaviors. Make a note of those connections! They form the basis of re-training your brain to think more logically, and free yourself from anxiety or self-defeating thinking. Snapshots - Hold on to the significant moments There are the lightbulb, AHA! moments in therapy that seem so significant you will never forget them. However, people forget! In a dark moment of depression, it would be helpful to look back at those lightbulb moment notes and remember when your therapist pointed out that you had to continually reach out to your close friends, even when you didn't feel like it, to turn a corner. Or the significance of realizing that your panic attack was the fear of fear, rather than the fear of a clear and present danger. Bottom line - write down the bottom line! Chronicle the significant learnings from each session, the takeaways that you want to hold on to. Especially if you take copious notes, it helps to color-code or bold those important thoughts in a specific way, so you can find them later when your head is less clear. Has journaling enhanced your therapy experience? Or were there details you wished you'd documented? I'd love to hear from you in the comments section below (for confidentiality reasons, please do not give your full name or identifying information).

Reason and emotion both travel with us through life. Who drives?