Monday, April 14, 2008

Depression and Acting Out

Without a doubt, a major issue that contributes to an individual’s acting out cycle is depression. The various ways depression is identified in daily living is through recognizing a variety of symptoms. In non-technical terms, depression might be expressed in statements such as “I’m sad” or “I don’t have any energy.” Some behavioral indicators might be simply not eating or getting out of bed. It is easy to see how sexual compulsive behavior can occur in response to feeling depressed.

Professionals talk about depression in a formal manner. The standard language is defined by the Diagnostic and Statistical Manual for Mental Health Disorders, Fourth Edition, Text Revised. If you are interested in learning more about the details, please feel free to search online for more information. The goal in this topic is to review depression in such a way that you might recognize how depression and sexual compulsivity are related in your life. You may recognize that it is an issue; at that point I strongly recommend that you seek additional support.

Depression also exists on a continuum. Professionals use multiple terms to describe the continuum. I offer these terms for your review. If you hear these terms, please ask your provider to identify additional informatiPublish Poston.

This range of depression diagnoses include the following:

  • Major Depressive Disorder
  • Major Depressive Episode
  • Dysthymia (aka Dysthymic) disorder
  • Minor Depressive Episode
  • Adjustment Disorder with Depressed mood.
  • Bereavement
  • Seasonal Affective Disorder (SAD).

One of the difficulties in recognizing the presence of depression is that sometimes depression may be part of a bigger issue. For example, in later topics I will cover bi-polar disorder, manic episodes and post-traumatic stress disorders. In each of these issues, depression is present as well. It may take some time for an accurate assessment of the right label that describes all of your symptoms. I’ve listed a number of symptoms below which are listed according to what is my opinion of the most severe symptoms. In my opinion, I’d suggest that if 3-5 of these symptoms are present, I strongly request that you seek additional help to help you to get a more accurate understanding.

Please note, that if you are experiencing suicidal thoughts, or feelings, I want you to get immediate help. You can get help at or call 1-800-273-TALK or call 911 or visit your local emergency room. Suicidal thoughts are the most severe symptoms are all clinicians are trained to respond respectively and immediately.


  • A suicide attempt
  • A specific plan for committing suicide
  • Recurrent suicidal ideation without a specific plan
  • Recurrent thoughts of death (not just fear of dying).
  • Depressed mood most of the day, nearly every day.
  • People reporting to you that you look depressed .
  • Expression of feelings of irritability
  • Fatigue or loss of energy nearly every day
  • Feelings of worthlessness or excessive or inappropriate guilt
  • Loss of pleasure or interest in daily activities.
  • Significant weight loss when not dieting (e.g., a change of more than 5% of body weight in a month),
  • Decrease or increase in appetite nearly every day.
  • Sleeping too much (can’t get out of bed)
  • Sleeping too little (can’t fall asleep)
  • Feelings of agitation/body is restless
  • No energy/Body feels weary.
  • Difficulty making decisions
  • Difficulty thinking or concentrating


Now there are some issues that are disqualifiers of a mental health diagnosis. Sometimes a more important/severe diagnosis takes priority. Or, if you’ve taken drugs or chemicals (i.e., alcohol) you might have a different diagnosis. In some cases, a medical condition might be a cause of some of the symptoms. In my opinion, the key is to seek the advice of a professional if 3-5 of these symptoms are present.

Treatment for depression can vary. I’d encourage you to go online as review what suggests exist. Here a few possible treatment approaches. If you are working with a counselor, please talk with him and her regarding their expertise and comfort with these types of therapy. If you want to try something on the list before, it is your right to ask for a referral if your primary counselor cannot provide those resources.

Medication Management.

The number and type of medications are constantly changing. I am not an expert in this area, please consult with a trained professional. Many individuals are not interested in this treatment approach because of fears and stigma regarding medications. I use a metaphor to help explain how medications might be helpful is the following. Consider that you broke your leg, for a while you will need crutches as you heal. In the same way, medications can be a support while you address the issues related to the depression. In another way, some people manage diabetes through diet and exercise, but for some, long term insulin is required to stay healthy. In some cases, long-term use of depression medications is needed for health.

Talk Therapy

  • Talk therapy takes a range of approaches. The number and type of interventions are simply too many to list. But some of these include:
  • Cognitive-Behavioral Therapy (CBT)
  • Dialectical and Behavioral Therapy (DBT) Skills
  • Supportive and Affirming Talk Therapy.
  • Eye Movement Desensitization and Reprocessing (EMDR)
  • Relationship Therapy

Alternative Therapies (a catch all category)

  • Exercise and Diet Plans
  • Recreational Therapy Activities (Challenge Courses, Outward Bound, etc)
  • Easter approaches such as Acupuncture, Yoga, and Massage.

Healthy Daily Activities

  • Talk with someone every day, preferably face to face. Though you feel like withdrawing, ask trusted friends and acquaintances to spend time with you.
  • Spend time with people who aren't depressed. This can lift you up and make you feel better.
  • Wait until you are feeling better before doing t hings you find difficult or unpleasant.
  • Make a written schedule for yourself every day and stick to it, no matter what.
  • Don't skip meals
  • Get at least eight hours of sleep each night.
  • Get out in the sun or into nature for at least 30-minutes a day.
  • Make time for things that bring you joy.

(adapted from located at

Sunday, April 13, 2008

Behavioral Analysis of the Acting out Cycle

A helpful tool in identifying thinking errors, feeling triggers and high risk situations is the completion of a behavioral analysis. This is a step-by-step examination of what happened. The level of detail is on the minutia. The goal is to help identify additional relevant issues to be addressed. I often challenged my clients to tell me how to drive a car. As they do, I will playfully trip them up by asking questions about this or that. What they come to realize is that driving a car is a remarkable complex task, with multiple cognitions, and items to be aware of. psychology the term is automaticity: the ability to complete complex behaviors without active cognitive thinking. Much of the ritual in sexual compulsivity is automatic. The behavioral analysis is a process to slow down and uncover the contributing factors. The following table is helpful.

What happened



High Risk Situation

Woke up tired/Didn’t sleep well

Frustrated that I’m not sleeping well


Not Sleeping Well

Went to work


Boss angry (and not even at me)

Better be careful or she’ll turn on me.

I better not screw up


Fearful that someone is angry

I make a mistake

Oh no. I’m in trouble now.

I should know better. I can’t tell anyone.

I’m going to get fired.


Made a mistake

Not talking with others

Not being honest

I hide the mistake

Maybe they won’t find out

Paranoid/Fearful again


Boss mad at me

I can’t do anything right.


I shut down

Can’t talk to no one.

I’m alone

Sad, depressed, lonely, tired


I head over to the bar after work

Maybe I can meet some of my friends

Lonely, tired. Sad

Bar setting

Drink too much

At least I won’t feel anything for a while



Start Cruising at the bar.

Maybe I can connect with someone.

Lonely. Excited

Cruising behaviors

Bring someone home.

Unsafe Sexual contact (no condom).

Wow. He/she is attractive. Sex will be great.

Excited. Happy. Numb


Unsafe Sex

Not establishing boundaries.

Wake up tired

Frustrated that I did it again

Summary of the analysis



I can’t make a mistake

I’m in trouble

I can’t tell anyone

I’m going to get fired

I’m alone










Not sleeping well

Making a mistake


Being in a bar



Unsafe Sex

In the process of completing the analysis, you now have a number of places to start intervening to stop or interrupt the cycle. Learning to recognize and then contradict thinking errors is part of this process. Challenging negative thinking through corrected thoughts, or affirmations if you’re familiar with the 12-step tradition is a start.

Addressing the feelings are important. Identifying ways that you can connect with others in a healthy way allows you to help address feeling lonely. Perhaps if the sadness and depression is significant enough, and long term enough, medications or therapy might be helpful. Finding ways to engage in healthy “sober” fun is another way to intervene on the cycle.

In each of the high risk behaviors, I talk about an escalating pattern of behaviors that sets the stage for the next trip through the cycle. Working with clients, I call this a “micro-cycle” which suggests that the whole day can be a cycle, but in each attempt to cope or failure to cope, I engaged in a pattern of unhealthy behaviors. The key then is to identify ways that you can interrupt any and all of the aspects of the cycle addressed in this chart.