Holiday Spirit: The Highs and Lows -- Srini Pillay, MD. -- 12/10/02

Last Editorial Review: 6/3/2004

WebMD Live Events Transcript

We discussed the emotional ups and downs of the holiday season with our guest, psychiatrist Srini Pillay, MD.

The opinions expressed herein are the guest's alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.

Moderator: Welcome to The WebMD University Student Lounge, and to our "'Tis the Season to be Healthy" course, brought to you by Blue Cross Blue Shield of Massachusetts. Today's lounge guest is Srini Pillay, MD, a psychiatrist at McLean Hospital, affiliated with Harvard Medical School. Dr. Pillay, is it true that most people's anxiety levels go way up in this country around the holidays?

Pillay: Yes, it is. There are many causes for why anxiety levels go up, which includes the fact that people have a lot of expectations, and they have the desire for the perfect holiday. In addition, missing loved ones who are no longer with them can cause a certain amount of distress. Also, financial stresses usually escalate during the holidays. And family conflicts may also seem to be more intense during the holidays. In addition, I think that people tend to over commit during the holidays in many dimensions of their lives. And so they feel that they need to meet not only other people's expectations but their own expectations as well.

Moderator: You work in the field of anxiety and panic disorders. Do you have any advice for those of us who have a friend or family member with such a disorder, to help them make it through the holidays?

Pillay: Sure. I think that the holidays can be a stressful time for anyone without a baseline anxiety, so someone with baseline anxiety would potentially be more vulnerable during that time. I think that talking to people, to family and friends, who have anxiety disorders may be helpful to them, especially if you demonstrate that you have an understanding of what they are going through. In particular, reminding them through reassurance of the many stressful dimensions that may exacerbate their anxiety might help them focus on ways to deal with these anxieties in advance.

For example:

Advising them that they should know their spending limits ahead of time and plan accordingly.
Helping them to remember that organization goes a long way in reducing anxiety.
Making sure that holiday priorities do not interfere with other usual priorities such as exercise and nutrition.
Emphasizing the importance of relaxation so as to not always be on the go.
Remembering to breathe deeply, and remembering that responses do not have to be immediate if faced with an anxious situation.

If it seems that the anxiety is more out of control than it is usually, then it would be important to avoid anxiety provoking situations, so as not to contribute to the already escalating stress. If it seems that these interpersonal interventions are not reassuring enough, then seeking help from a professional either to adjust or start medication or psychotherapy could be helpful.

Moderator: We are inundated with messages that the holidays are "magical" and that good times just naturally occur this time of year, but it's actually a lot of work to get from here through the New Year!

Pillay: I think that that is true. And remembering that the holidays are both a time of good vibes and positive possibilities as well as a highly stressful time when expectations are sky high is important. It is important not to collude with the idea of having to be, feel, or do something that does not seem commensurate with whom one is. Research studies have shown that false expressions such as smiling with a strain may actually adversely impact one's general health.

Probably one of the most stressful notions is that everybody has to feel the same all the time throughout the holiday season. But people are individuals, feel differently, and have different lives. So that any one person's response to a given situation would be expected to be different from another's. It is important to remember that not all people will have the same feelings around the holidays, and if hosting a party, for instance, it is an important sensitivity not to overly pressure someone to join in the tone of celebration that the majority of people may feel.

Member: I'm on Celexa for mild depression. I've been on it for about six months and I've been doing very well, but wonder if I feel the depression taking over again during the holidays, which have always been a melancholy time for me, is that a sign that the meds aren't working, or are dips in mood to be expected?

Pillay: Dips in mood are to be expected if the holiday is usually a melancholy time. Therefore, it is probably not immediately advisable to assume that the medication is not working, since there is an easily identifiable external stressor. However, worsening of depression usually means that more than just mood is affected. Other parameters that may escalate are:

Interest in day-to-day activities
Sluggishness or excitability
Homicidal idealization

If these parameters are affected it is likely that the depression is more severe. In any case, a suspicion of worsening depression should be explored by a consultation with your regular healthcare provider.

Aside from increasing the dose of the medication or changing the medication, it may be possible to handle the heightened sense of depression with either a brief cognitive therapy or a supportive psychotherapy. Therefore, it is also important not to ignore the heightened sense of melancholy especially if there is a history of depression since it is possible that the medication or other treatment modalities may need to be adjusted.

One factor to bear in mind is that the holidays occur through the winter, and that there may be a seasonal component to the depression. In which case, additional treatment modalities such as light therapy may be useful during this time. Recognizing escalating depression is important early on, as it is only earlier on that one can institute measures to prevent any further worsening of the depression. For instance, setting emotional and financial limits may go a long way toward preventing a further downhill course.

Member: I've been feeling stressed and a bit depressed for a while now (Christmas is just one more thing to make me feel overwhelmed and anxious) and I may make a New Year's resolution to see someone about it. What's the difference between a psychologist and a psychiatrist and how do I pick whom to see? Should I talk to my family doctor first?

Pillay: The difference between a psychologist and psychiatrist is essentially in the type of training. Psychologists have a degree in psychology, usually a PhD or an EED, whereas psychiatrists have gone to medical school and have an MD degree. Functionally, this translates to the fact that psychiatrists are able to prescribe medication, whereas psychologists do not. Also many medical conditions can present with psychological symptoms such as depression and anxiety and a good psychiatrist would be more likely to be able to rule these out prior to ongoing treatment for the depression and anxiety. The emphasis of training for psychologists is on psychotherapy, and for psychiatrists the emphasis in training is on all treatment modalities, including psychotherapy. Different psychologists and psychiatrists may have a particular expertise at one or more modalities of therapy.

Consultation with the family practitioner is a reasonable way to go, especially if the family practitioner is able to recommend a reliable treater. Also, if a person chooses to work with a psychologist, the family practitioner may be able to prescribe medication, especially in uncomplicated situations. One thing to remember is that psychiatrists usually charge more than psychologists.

Member: I'm happy the holiday season happens in December; otherwise I'd be a real mess, because I hate the cold and darkness. Once January rolls around I go into a deep funk. I'm assuming I have SAD, but I've never been diagnosed with it or any other kind of depression. Is it worth talking to my doctor about? Or is having the winter blues something to just grin and bear?

Pillay: It is worth talking to your doctor about, whether you have seasonal depression or not, since there are other conditions such as bipolar disorder that this may be mimicking. However, having said that I believe that even after visiting with a doctor you should still be involved in choosing whether you want any particular kind of treatment.

Although diagnosis and medication management are highly "fashionable" these days it is important to be wary of labels and treatment that is rushed rather than appropriately contemplated. Also, it is more likely that presenting your sadness to a professional will derive, at least in part, a labeled response. And it's important to assess the value of adopting this label as part of your identity.

Although it is tempting to attribute much of what we feel to biological variables such as chemistry, biology is one of many metaphors for what is going on inside of you. Therefore, I feel that seeing a professional is important but is important only to get a perspective that you can consider in trying to address the amount of discomfort that the seasonal "funk" causes. In all cases, assessing the advantages and disadvantages of treatment and severity of symptoms is crucial.

Member: My child has ADHD. He is always excited, but the holidays send him into orbit. How do we help him enjoy the holidays without totally losing control?

Pillay: If your child has been diagnosed with ADHD I assume that he is in treatment. When you say "into orbit" it seems that his behavior is probably uncontrollable and difficult to manage. As such, he would probably benefit from an additional visit to his treater to see whether there is any need for medication adjustment over this time. In addition, other factors can be modulated in order to make him easier to manage. Some things to consider include decreasing the stimulation. For example, if there were many Christmas presents it might be helpful to spread out when you give them to him rather than giving them to him all at once.

Also, the most effective way to address this clearly would be to prevent it from happening. Basic rules of conduct and behavior in the house should probably be maintained with little compromise around limits, while still allowing a sense of celebration and enjoyment. Also, taking some time off for yourself probably would not be a bad idea, as this will allow you to more effectively cope with his behavior.

Moderator: I get pretty stressed out during the holidays, and my first-grader sees that. I don't want to put on a false smile, but I don't want her to associate the holiday season with stressing out, either. Should I be careful about expressing my stressed-out state around her?

Pillay: I think that your concern about expressing your stressed-out state is well intentioned, but maybe more appropriately addressed initially by yourself in relation to why being stressed out is OK to you but not to your first grader. Modulating the factors that contribute to the stress some of which I mentioned earlier may be helpful in decreasing your stress and therefore what you express to the child. One of the important things to remember is not to transfer the stress that you hold to the child. And one way to do this is to take time to identify where the responsibility lies for the stress that you are feeling.

Having said that, there is also a human side to this that has to do with the fact that it is probably within the context of normal human experience for a child to have some exposure to a parent who is stressed out, provided that this occurs within boundaries that you are comfortable with. If you find that you are reaching the point of extreme frustration to the extent that you are feeling tempted to express your anger inappropriately toward the child this would be an indication to seek help more immediately.

Also, some of the frustration and stress may in fact be related to the child's behavior. Paying attention to limits and rules could go a long way to making the experience more pleasant for everyone.

Member: My teenager doesn't want to participate in any family activities this Christmas. Should I let her sit them out or demand that she participate?

Pillay: I think that if your teenager does not want to participate in any activities, the first approach should be to probably sit down with her and talk to her in an empathetic way about what might be going on.

There are many potential reasons why she might not want to participate in holiday activities. Apart from the usual rebelliousness of adolescence, it's possible that she may be suffering from depression or a social anxiety disorder, and sitting down to talk is the first step toward trying to help her. With regard to this, a professional would be able to contribute a potentially useful opinion.

In sitting down with her, you might want to ask more open-ended questions initially, questions that illustrate and demonstrate your interest in her feeling state. Also, this will give you an opportunity to eventually express some of your feelings in a way that she might be more able to receive. Having a battle over these issues in a confrontational way is rarely helpful to either person.

It is often the case that teenagers or any other person may have an initial reticence that dissolves after being present at occasions for a while. Other potential solutions may also be considered. For example, you may reach a compromise about her attending some but not all occasions; or that she may attend all occasions with an acceptable friend of choice. It is often the case that not wanting to attend family functions stems from feeling uncomfortable at them or being drawn away from something else that seems more pressing. Giving an ear to what these situations may be would be helpful probably to both you and her.

Therefore, neither insisting nor being in authentically lenient is probably a good idea in this case. A step-by-step approach using this as an opportunity to deepen family connections is potentially helpful. Given the amount of negative energy on both sides.

Moderator: Any final thoughts before we wrap up, Dr. Pillay?

Pillay: If the holiday stress does get one down, remember that it's transient and the holidays will pass is often a relief especially when you feel like you are caught in some endless boredom and conflict that seems will never go away.

Moderator: Unfortunately, we are out of time. Thanks for joining us members, and thanks to Srini Pillay, MD, for being our guest.

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