Calming An Overactive Brain–My Day In Pacifica

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Today I am taking a seminar with William Sieber calling Calming an Overactive Brain. He’s an excellent presenter, with a good sense of humor, a down to earth speaker. He’s got a nice balance of enough confidence to be a an excellent speaker without being arrogant. This is quite rare in the seminar business. Even though there’s a lot of stuff I already know I’ve learned a number of  interesting things. The seminar is on the ocean in Pacifica, and outside the windows of the meeting hall I can see the waves crashing on the sand.

One funny thing happened at lunch. I had hurried out to the next door cafe so I could get a table before the crowds hit. Dr. Sieber showed up, looking for a table. I invited him to join me at my table. We started talking and discovered some remarkable commonalities! Both of us had attended Yale for training, me for undergrad, and he for graduate school. He had worked closely with Judith Rodin and Peter Salovey while there. Judy Rodin had been my first psychology professor, and probably the one that influenced me to go into psychology. Peter I had known while teaching at the Bridge, Stanford’s peer counseling center, many years before, and in whose book I have a chapter on Listening Skills. Eventually he went on to teach at Yale, and now is Yale’s president. More surprisingly, Dr. Sieber and I both interned at the Palo Alto Veterans Hospital, in different years! We had a fun lunch reminiscing.

About the seminar. He spoke at length about sleep and it’s impacts on health and wellness. For instance, one study showed that those who got less than 6 hours of sleep were 42% more likely to get diabetes. Or that those with the most disturbed sleep were 97% more likely to die in the next 20 years. Poor sleep makes you more prone to pre-diabetes, anxiety, upsetting emotions, not to mention lowering overall mood and vitality.

Less sleep also affects appetite and eating. Leptin is the hormone that lowers our appetite, and ghrelin is the hormone that increases appetite. With sleep deprivation our leptin goes down, and our ghrelin goes up, and on average we consume 250 calories more on days after a bad night’s sleep. This doesn’t sound like much, but it adds up to about 25 pounds of extra weight per year if you chronically sleep poorly.

I also learned how to assess sleep. The key metric is “sleep efficiency”. This means what percent of the time you are in  bed trying to sleep are you actually asleep. A good number is 90-95%. This is hard.  It means if I am in bed for 8 hours a night, I am asleep 95% of the time, or all except 24 minutes. What is your sleep efficiency? He went over how to use the sleep efficiency log to diagnose sleep problems and guide treatment.

One other interesting factoid for all of you pet lovers. Fifty-three percent of pet owners have disturbed sleep due to their pets.  Maybe we should all shut the door at night and train our pets to sleep somewhere else other than in bed with us.

He discussed how to fix common sleep problems. One such pattern is mine, the delayed sleep cycle. This is the night-owl pattern, going to bed late and getting up late. To fix it, he suggested a short term use of sleep aids to shift the cycle to earlier bedtimes, combined with bright light in the mornings, and no screen light for an hour before bedtime. Cutting back on caffeine use is also helpful.

Others suffer the early phase shift, those who fall asleep too early, and get up too early. To shift these people he recommended getting bright light exposure in the early evening so the melatonin production is suppressed until later in the evening.

In the afternoon we got into discussion of moods and control. Discussing anxiety, he explained the key role that perceived control over situations plays in creating or ameliorating anxiety. Exercise turns out to be a strong treatment for anxiety. Most people with anxiety disorders do not exercise more than once a week, and those who exercise 3 or more times a week rarely have anxiety disorders.

Then he turned to relaxation training for anxiety. He made a great point—that even if you train people to relax deeply, the probability of them continuing to practice even four weeks later is very low. So instead, he shared a 20 second relaxation. Take two deep and slow belly breaths, exhaling for longer than you inhale. While doing that go somewhere relaxing in your mind, and experience that place (ie the beach) in the sensory modality of your preference—seeing, hearing, smelling, or feeling. Make up a two word description of that sensory experience, i.e. “Warm sun”. Repeat that phrase as you take your 2 deep breaths, during the exhale.

He suggested pairing this relaxation practice with something you do multiple times a day. So for instance, pair it with hitting the Send button on your email. That way you will remember to practice a quick relaxation many times a day.

He also shared James Pennebaker’s work, which I often use with patients. Pennebaker found that writing about traumatic events for just 30 minutes a day for 4 days in a row had a fairly profound impact on future emotional and physical health. Interestingly, the initial impact was negative, more anxiety and upset, and more susceptibility to illness. But after three to six months, the pattern reversed, with people showing less upset and anxiety, and better health.

Finally, he shared some info about new findings about heart rate variability (HRV). HRV is the change in the rate of your heartbeat over each beat and each several seconds. It turns out that having MORE HRV is better for both mental and physical health. People with anxiety disorders have less HRV. And it turns out the the three factors that most predict low HRV are: sedentary lifestyle, a cynical and hostile view of life, and anxiety.

Can you retrain your heart rate variability? Yes, with both breathing retraining, and with biofeedback. And it turns out that when you learn to increase your HRV, your anxiety goes down. Very interesting and cool stuff.

The final part of the workshop was about mindfulness. I won’t even try to summarize this part of the seminar, as it was very detailed, and even profound. Perhaps I’ll blog about it later.

Overall, it was a good learning experience, with a wonderful view of the ocean the whole time!

Now I need to go to sleep early….

Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

SSRI Antidepressants Given in High Doses May More than Double the Risk of Suicide in Adolescents and Young Adults Under 25

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So you’ve got a teenage child who’s depressed. What do you do? A new study published in the Journal JAMA Internal Medicine suggests what NOT to do. In this study, conducted at Harvard, the authors looked at 162,625 people from ages of 10 to 64 years old who took selective serotonin reuptake inhibitors (SSRIs) for depression. (These are drugs like Paxil, Prozac, Celexa, Zoloft, Lexapro, and Luvox, and their generic equivalents.)

The researchers looked at the relationship between initial starting dose and the rate of deliberate self harm and suicidal behavior. What they found was shocking. They found that for people under the age of 25 starting SSRI medication at a higher than normal dose more than doubled the risk of self harm behavior! This translated into one additional occurrence of self harm behavior for every 136 patients who were treated with high-dose SSRIs. This is a lot of additional suicide attempts!

Interestingly enough, for adults 25 to 64 years old, there was only a very small increase in self harm behavior with high-dose SSRI treatment, and the overall risk of self harm behavior was much lower.

Delving more deeply into the data is interesting. In the under 25-year-old range, 142 patients attempted suicide within one year. The rate was 14.7 suicide events per 1000 person-years for those who started SSRIs at average doses, and 31.5 suicide events per 1000 person-years in those who started at high doses. For the older adults the rates were 2.8 per 1000 person-years for average doses, and 3.2 suicide events per 1000 person-years for those who started at high doses.  These numbers translated into seven more suicide events per 1000 for patients under 25 during the first 90 days of treatment with high dose SSRIs.

Also, disturbingly, the study found that 18% of all patients were started on high initial doses of antidepressants, despite clinical guidelines that specifically recommend starting at a low dose and titrating the dose upwards slowly.  The typical doses of common antidepressants are 20 mg for Prozac, 20 mg for Paxil, 20 mg for Celexa, 50 mg for Zoloft, and 10 mg for Lexapro. For unknown reasons, almost one in five patients were started at higher doses than these.

Why were almost one in five patients started at higher doses than these? I suspect I know the answer, although it wasn’t discussed in the study. Unfortunately, the vast majority of patients are given antidepressants by their internist or family physician or pediatrician. In contrast to psychiatrists, these practitioners do not have the time or bandwidth see patients every week. So they are more likely to start the patient at a higher dose.

Most psychiatrists will start patients at subclinical doses and gradually increase the dosage to avoid side effects. It certainly has been my clinical experience that some general medicine doctors do not do a very good job of administering antidepressants. That is why with most of my patients, especially if they can afford it or have good insurance coverage, I suggest that they seek the advice of a psychopharmacologist or psychiatrist for psychoactive drugs.

The authors of this paper point out that recent research suggests that antidepressant medication is at best only slightly effective in young people and that the dosage of antidepressants are typically unrelated to their effectiveness. Given these two research findings, it certainly does not make any sense to start antidepressant treatment at a higher than average dose.

But I would go one step further. I would argue more strongly that in most cases it does not make sense to use antidepressant medications in young people at all. Why expose a young person to the heightened risk of suicide for what is at best a relatively modest improvement in mood?

This is even more relevant when you consider that there is an alternative treatment that has no side effects and has been shown to be effective. That is cognitive behavioral therapy (CBT) for depression. And there is even a specific cognitive behavioral therapy for suicide prevention that has been developed. (CBT-SP). This is a 12 week focused CBT program that in one study demonstrated that it significantly lowered the probability of a suicide event in suicidal adolescents.

If medication is going to be used, one recommendation that follows from all of this research is that it is good idea for doctors to follow the guideline of “start low and slow” when prescribing antidepressant medications to people under 25. Start at lower than typical doses, and very slowly and gradually increase the doses. While this is happening the patient should be followed on a weekly basis.

If the prescribing doctor is not a psychiatrist who sees the young person weekly, it’s a good idea to pair this with weekly psychotherapy sessions. The weekly psychotherapy session, especially when conducted by someone skilled in cognitive behavioral therapy who evaluates mood and suicidal ideation at every session, can be an essential safety measure when prescribing antidepressants to young people. Or consider treating with CBT alone,  which may very well be just as effective.

Because this is so important, I am listing some references below.

No jokes today, as suicide is not a laughing matter…

References

http://www.clinicalpsychiatrynews.com/home/article/suicide-doubles-in-young-patients-starting-high-dose-ssris/3c57e41e724244599c16d5a565ac8ce3.html

https://archinte.jamanetwork.com/article.aspx?articleid=1863925

http://www.intechopen.com/books/mental-disorders-theoretical-and-empirical-perspectives/cognitive-behavioral-therapy-approach-for-suicidal-thinking-and-behaviors-in-depression

http://www.texassuicideprevention.org/wp-content/uploads/2013/06/AdolescentSuicideAttemptersLatestResearchPromisingInterventionsCharlotteHaleyJenniferHughes.pdf  (CBT-SP)

http://www.nimh.nih.gov/news/science-news/2009/new-approach-to-reducing-suicide-attempts-among-depressed-teens.shtml

http://www.clinicalpsychiatrynews.com/home/article/suicide-doubles-in-young-patients-starting-high-dose-ssris/3c57e41e724244599c16d5a565ac8ce3.html

Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

How to Forgive: A Cognitive Behavioral Model for Forgiveness and Letting Go of Anger and Frustration

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What is forgiveness?

Here’s what it is not. It is not for anyone else, only for you. It doesn’t imply reconciliation with the person who hurt you nor does it imply that you approve of their actions. It does not mean forgetting what happened.

What is forgiveness?

It is only for you, in order to help you feel better. As one well-known researcher said, “failing to forgive is like taking poison and waiting for the other person to die.”

Forgiveness means understanding what is causing your current distress. It is not what offended you or hurt you years ago or even a few minutes ago. The primary cause of your suffering is from your thoughts, feelings, and physical sensations in response to your thoughts about the event.

This is a subtle concept. Most of us believe the reason we are angry is because someone has done us wrong. And it’s true, that if we could erase the event, we would stop being angry. But none of us own a time machine so we can not erase the events.

What makes us suffer is each moment that we think about the offending person or event. And how we think about these events. It is as if you own a DVD collection of movies of different events in your life. If you were to choose to only watch the upsetting movies, your overall level of happiness would greatly diminish. Choosing to forgive is choosing the DVDs of your life that are positive and full of joy.

There is another component of how people think about grudges. We often have a magical belief that our anger at someone else causes them to suffer. We imagine them feeling guilty about their behavior and suffering even when we are not present. We think of ways to hurt them in return – the silent treatment, constant criticism, reminding them of their offenses. But the reality is that most people are very good at blocking out guilt and punishment. Whenever they’re not around us they tend to think about other things. And they develop good ways of avoiding our punishment. So really the one who suffers is the person who’s angry and who fails to forgive, not the offender. And if the person we take out our anger on is someone we are still in relationship with, it damages the relationship and makes it even less likely we will get what we want.

Another trigger for resentment and anger is holding onto what the anger and forgiveness researchers call “unenforceable rules”. These are what most cognitive behavioral therapists call “Shoulds”. They are the demands we make on the world and on people around us. You can’t force anyone to do something they don’t choose to do, and you can’t require people to give you things they choose not to.

For instance, you might want fidelity in your romantic partner. You certainly have every right to want that. But you can’t demand or enforce fidelity. If your partner chooses to go outside the relationship, you can’t really change it. The only options you have are how to react to this. You have choices to make about the relationship and about your future relationships.

The research on forgiveness is very interesting. It reduces blood pressure, stress, anger, depression and hurt while increasing optimism and hope. The primary researcher on forgiveness, Dr. Fred Luskin at Stanford, has even done forgiveness research with women in Northern Ireland whose husbands were murdered. Even with these extreme cases people have found the forgiveness model very helpful at easing the pain.

I’ve written about how to conquer anger using the S A P model. In this model you change your shoulds into preferences rather than demands, you place into perspective the events that have caused your anger, and you shift out of the blame model and depersonalize most events.

Forgiveness is about being happy. Living your life to its fullest is the best revenge you can take on someone who has offended you. Instead of focusing on the hurt or betrayal, focus your energy on getting what you want in your life in a different way other than through the person who has hurt or betrayed you. Take responsibility for your own happiness rather than placing it onto other people and then being disappointed when they don’t provide happiness.

Change your story. Too often we have what is called a grievance story. We tend to tell this story to many people. It always ends with us feeling stuck and angry. Change your story. Change the ending so that it ends with a powerful and strong choice to forgive.

 
So to summarize, here’s how to forgive:

1. Let yourself first feel the pain. Share the experience with a few close and trusted friends.

2. Recognize that your anger is a result of your choices about what thoughts to experience about an event. Decide to forgive so that you can move forward and feel better.

3. Recognize that you probably won’t be able to get rid of your hurt and anger by punishing the other person. All you will accomplish is to damage the relationship or make the other person suffer while you continue to suffer.

4. Recognize the role that your “unenforceable rules” or Shoulds plays in your continued hurt and anger. Change or eliminate these rules.

5. Figure out what you want in your life and how to succeed in achieving those goals even if the other person doesn’t provide the answers. Remember that happiness is the best revenge.

6. Use the S A P model to change your shoulds, eliminate exaggerated awfulizing thinking, and take away blame.

7. Rewrite your script. Tell the new story where you were hurt but recovered and forgave and moved forward. You are a hero!

 

Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

New Hope for Procrastination: Procrastinators are Trying to Repair Their Negative Moods by Avoiding Work According to the Wall Street Journal

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The Wall Street Journal has an intriguing article To Stop Procrastinating, Look to Science of Mood Repair. In the article, they discuss new research that suggests that many of the avoidant behaviors procrastinators use are actually attempts to repair low moods. Procrastinators often feel anxious or worried about the task they are attempting to accomplish, so that go to Facebook, the refrigerator, or to sleep to avoid those feelings. Learning new ways of dealing with negative feelings, and using some acceptance methods so that they can better tolerate the negative emotions are both helpful strategies for overcoming procrastination.

Highly recommended article, check it out! I’d write more, but I’m trying to get to work and stop avoiding by writing about avoidance!

Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

The Treatment of Tinnitus using Cognitive Behavioral Therapy

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Tinnitus is condition where the person hears a ringing in their ears or other sounds when none of these sounds are present. It is a very common problem, especially as people age. According to studies, up to 20% of people over the age of 55 report symptoms.

What causes tinnitus? There can be many causes. The most common cause is noise-induced hearing loss. Other causes include medication side effects, as well as withdrawal from benzodiazepines. In many cases no apparent cause can be found.

For many, tinnitus is a relatively minor problem that they tend to ignore. Almost everyone has momentary tinnitus symptoms. But for other people tinnitus creates a tremendous amount of psychological distress. This includes anxiety and depression. The person fears the loss of their hearing, and tends to focus intensely on their symptoms. They begin to avoid situations where their symptoms are more noticeable. This typically means avoiding quiet locations where there is no sound to mask the tinnitus sounds. Or it may involve avoiding situations where there are loud noises such as movie theaters due to the fear of further hearing loss.

Similar to some forms of obsessive compulsive disorder (OCD), the person may begin to engage in frequent checking behavior. This means that they consciously check the presence and volume of the ringing in their ears. They may also frequently check their hearing.

The person also suffers from constant thinking about causes of the tinnitus. They often blame themselves for exposure to loud noises in earlier life. They think about the music concerts they attended where they didn’t wear earplugs, or even recreational listening to music. They have strong feelings of regret that can blend into depressive symptoms.

Unfortunately there are no terribly effective physical treatments for tinnitus. This leaves psychological treatment as the primary modality for successful reduction of distress.

Cognitive behavioral therapy (CBT) conceptualizes tinnitus much like it conceptualizes the experience of chronic pain. Chronic pain consists of two components. The first component is the physical sensations. The second component is the bother or suffering caused by these physical sensations.

Tinnitus can be conceptualized in the same way. The subjective experience of sounds in the ears is the physical sensation. The interpretations of these sensations lead to the emotional reactions; suffering and bother.

Although CBT cannot directly change the physical sensations of tinnitus, it can change the reactions to these sensations. And changing the reactions can actually lead to a subjective experience of diminishing symptoms.

What are the components of the CBT treatment for tinnitus?

1. Psychoeducation. The first step is to educate the client about how tinnitus works. The model used is that the loss of certain frequencies in the hearing range leads the brain to fill in those frequencies with sounds. It is very much like phantom limb pain, where an amputee may experience pain in the removed extremity.

The nature of hearing loss is explained, and psychoeducation regarding tinnitus and the risk of further hearing loss is discussed. If needed, results of hearing tests can be discussed relative to the actual severity of hearing loss. Although in some cases of tinnitus hearing loss is quite significant and may actually impair functioning, in many cases the hearing loss is relatively minor and does not impair functioning in any way.

2. Cognitive therapy. Here the therapist helps the patient to identify the negative thoughts that are leading to anxiety and/or depression. Typical thoughts for anxiety are: “I can’t live my life anymore with this condition. I will lose my hearing entirely. The sounds will drive me crazy. I’m out of control. If I go into _____ situation I will be troubled by these sounds so I must avoid it. I need to constantly check my hearing to make sure it’s not diminishing. I need to constantly check the tinnitus sounds to make sure they are not getting worse. They are getting worse! They will get worse and worse until they drive me crazy.”

Typical thoughts for depression are: “Life has no meaning if I have these sounds in my ears. I can’t enjoy my life anymore. It’s hopeless. There’s nothing I can do about it. Doctors can’t help me. It will get worse and worse and slowly drive me crazy. I won’t be able to function.”

Once these thoughts are identified then the skills of challenging them and changing them are taught to the client. The client learns how to alter these thoughts to more healthy thoughts. This produces a large reduction in anxiety and depression.

3. Attentional strategies. Because much of the subjective perceived loudness of tinnitus is based on attention, with higher levels of attention leading to higher levels of perceived loudness, developing different attentional strategies will help very much. In this part of the treatment mindfulness training and attentional training is used to help the client learn how to shift their attention away from the tinnitus sounds onto other sounds or other sensations. Often a paradoxical strategy is first used, where the patient is asked to intensely focus only on their tinnitus sensations. This teaches them that attention to tinnitus symptoms increases the perceived severity, and helps motivate them to learn attentional strategies.

Another aspect of attentional retraining is to stop the constant checking of symptoms and hearing. Helpful techniques include thought stopping where the client may snap a rubber band against their wrist each time they notice themselves checking.

4. Behavioral strategies. Tinnitus sufferers typically develop an elaborate pattern of avoidance in their lives. They avoid situations where they perceive tinnitus sounds more loudly. This can include avoiding many quiet situations, including being in quiet natural places such as the woods, or even avoiding going to quiet classical music concerts. They also tend to avoid situations where they might be exposed to any loud noise. This includes movie theaters, concerts, and even noisy office situations.

The behavioral component of CBT encourages an exposure-based treatment whereby the client begins to deliberately go back into all of the avoided situations. In situations where there is actual loud noise exposure at a level potentially damaging to hearing, they are encouraged to use protective earplugs.

The purpose of the behavioral component is to help the person return to their normal life.

5. Emotional strategies. Sometimes it is necessary to help the client go through a short period of grieving for their normal hearing. This allows them to move forward and to accept the fact that they have hearing loss and tinnitus. Acceptance is a key factor in recovering psychologically. This often also includes forgiving themselves for any prior excessive loudness exposures.

Changing the thoughts about the tinnitus symptoms also produces emotional change and a reduction in anxiety and depression.

In summary, cognitive behavioral therapy of tinnitus seeks to reduce the psychological suffering caused by the sensations of tinnitus. Cognitive, emotional, behavioral, and attentional strategies are taught to the client to empower them to no longer suffer psychologically from their tinnitus symptoms. Successful treatment not only reduces the psychological suffering, but because it also changes the attentional focus and lowers the checking of symptoms, people who complete CBT for tinnitus often report that their perceived symptoms have reduced significantly.

Tips:

1. Traditional psychotherapy is typically NOT helpful for tinnitus.

2. Find a practitioner, typically a psychologist, with extensive training in Cognitive Behavioral Therapy. If they have experience treating tinnitus that is even better.

3. Give treatment a little time. You will have to work hard to learn new ways of thinking and reacting, and this won’t happen overnight. You should be doing therapy homework between sessions.

4. Medication treatment such as anti-anxiety or antidepressant medication is typically not very helpful, and in the case of anti-anxiety medications can actually worsen tinnitus especially during withdrawal. First line treatment should be CBT.

5. Get help. Although the actual symptoms of tinnitus have no easy fix, the suffering can be treated and alleviated. Especially if you are experiencing depression symptoms, is is important to seek therapy with a CBT expert.

Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.