Who is Roseanne Dobkin?

Dr. Dobkin is an Associate Professor of Psychiatry at Robert Wood Johnson Medical School; Rutgers, The State University of New Jersey. Piscataway, NJ United States

Dr. Dobkin completed her PhD in clinical psychology at the Medical College of Pennsylvania-Hahnemann University (2002) and a postdoctoral fellowship in clinical psychopharmacology at Robert Wood Johnson Medical School (2003).

She has been conducting mental health research in Parkinson’s disease (PD) for the past 13 years. To date, her research has addressed the efficacy of face-to-face cognitive-behavioral treatment (CBT) for depression in PD (dPD) in a randomized controlled trial, and the development and pilot-testing of telephone-based CBT interventions for dPD. She has systematically examined barriers to mental health care utilization in PD and the use of telemedicine to leverage access to specialized mental health care in the PD community.

Dr. Dobkin is also a practicing psychologist and the mental health lead for the University of Delaware’s Parkinson’s Disease Telemedicine Clinic. Her prior work has been funded by the National Institutes of Health and the Patterson Trust Awards Program in Clinical Research.

What is Cognitive Behavioral Therapy?

Cognitive-Behavioral Therapy (or CBT as it’s popularly known) is an effective type of talk therapy used by mental health professionals to help people become aware of unhealthy, inaccurate and negative patterns of thinking so that they can view challenging situations more clearly. This newfound clarity allows individuals to respond to life’s opportunities in more effective and meaningful ways. As we’ll explore together, we have developed a specialized CBT program to help persons diagnosed with Parkinson’s disease (PD) to overcome depressive symptoms, to become more proactive and empowered with respect to their own self-care and to work towards living a more fulfilling life. The extensive benefits of this approach for the PD community has been supported by the results of three randomized-controlled trials 1-3. Research suggests that daily practice of the skills and techniques described below is associated with large reductions in depression and anxiety and significant improvements in quality of life. Below, we outline and describe all of the unique ingredients that will help to you cook up the “secret sauce” for optimizing your mood, so that you can live life to the fullest, each and every day. Just “getting by” is not good enough. We want you to thrive; not just survive.

What can CBT help in the mood realm?

Click here for the free video with Drs Subramanian and Dhobkin to discuss PD, Depression and CBT.

Depression and Parkinson’s

As we all know, PD is not just a “movement disorder”. Non-motor symptoms like depression are common and have far reaching negative effects on both people with PD (PwP) and their family members. Unfortunately, at least 50% of PwP will experience depression at some point over the course of the medical condition. And, when it comes to mood, it is important to recognize that there is more than one actor in the play. While this high rate of depression is at least partially due to the neurobiological changes inherent in the disease process, the ways in which an individual copes (e.g., thoughts, feelings, behaviors) with the PD diagnosis, and it’s associated challenges, also influences the development of depression, providing ripe opportunity for intervention.

How does CBT helps treat Depression in people with

PD?

In our program, the cognitive-behavioral treatment of depression in PD is offered over the course of 10 weeks in one-hour, individual (1:1) sessions with a therapist (either in-person, over the phone, or via secure web-based videoconferencing). This type of therapy treats depression by first identifying, and then changing, the behaviors and thinking patterns that lead to low mood. CBT focuses on a PwP present, here-and-now thoughts and behaviors that impede effective coping with the day-to-day challenges associated with living with PD. A brief overview of each of the 10 sessions is provided below. Please note that any of the strategies described below may help you to optimize your health and live the best possible life with PD, even if depression is not a concern at the current time.

What Therapy Looks Like – Week 1

Secret Sauce Ingredient 1: Increase involvement

in meaningful and pleasurable activities.

The first hour-long session is spent learning more about what depression looks like for each individual person with PD (this is called psychoeducation) and setting personalized goals for treatment. The clinician spends intentional time learning what motivates each PwP and what brings them pleasure. These treatment goals are more than the SMART goals (Specific, Measurable, Achievable, Realistic, and Timely) PwP may have worked with in other settings as they incorporate another key component: meaning.

Meaning-centered goals and activity planning are one key ingredient in the “secret-sauce” of the program and why the first week is so critical. Individuals collaboratively set daily behavioral goals with the clinician in the following areas: exercise, social connections, and activities associated with meaning/joy/pleasure. PwP often experiment with many different activities and observe how mood fluctuates in response to activity change. Behaviors associated with positive emotions are increased; those associated with negative feelings are eliminated. Put simply: The more you are able to act in accordance with your goals and not your feelings, the easier it will become to increase your involvement in meaningful and rewarding activities and the better you will feel! The intention is not to “be busy” but rather to create opportunities to experience joy. So “start low, go slow” and practice making one small change at a time. Old, new, and modified activities are all fair game. Many PwP find it help to schedule their activity goals in their weekly planner, in order to help stay organized and on track.

What Therapy Looks Like – Week 2

Secret Sauce Ingredient 2: Increase awareness of

your internal dialogue

The second week of treatment centers on the construction of a thought log. The thought log is a great introduction to the cognitive component of treatment; it can be used to identify patterns of negative thinking and to connect negative feelings to the negative thoughts that preceded them. PwP can write down thoughts (i.e., meaning, interpretations) about specific situations that are troublesome. Importantly, it’s the place that illustrates the point that it’s a person’s interpretation and/or meaning that they assign to specific events or situations that leads negative feelings—not the situation or event in and of itself. For example, does having an argument with your spouse (situation) mean that you are human (thought 1- healthy and balanced cognition) or unlovable (thought 2- unhealthy and extreme thought).

A thought catalogue allows PwP to obtain an understanding of patterns of thinking, to teach them that their thoughts about a situation can impact how they feel (e.g., frustrated vs. depressed in response to an argument), and teach them that their thoughts about a situation can also influence their behavior (e.g., talk it out with your spouse or withdraw). We all talk to ourselves all of the time; monitoring one’s thoughts provides a close-up of the contents of that inner dialogue. Most of the time, we do not speak to ourselves with the same kind, gentle, compassionate words that we may use to speak with others. “Seeing” our thoughts on paper can help to highlight the need to press “pause” and further reflect on the interpretations we are making in that moment.

What Therapy Looks Like – Week 3

Secret Sauce Ingredient 3: Identify and pause

“red flag thinking patterns”

The third week of therapy leverages the lessons learned from patterns of thinking and goal-directed behaviors in the previous weeks and adds in the concept “red flag thinking patterns”. “Red flag thinking patterns” are common thinking errors that are exhibited by people who are anxious or depressed. Thoughts that fall into these categories are usually much less accurate than they feel and further exacerbate negative mood. It’s important to note that everyone engages in these thinking errors at some point in their lives. However, if these thoughts occur frequently, and are viewed as fact, they can lead to increased depression and anxiety.

“Red flag” thinking patterns may take many different forms. Several common negative patterns are reviewed with PwP, such that they may more easily catch themselves when thinking in this way. Any thought that matches a “red flag thinking pattern”, may need to be “paused”, noted on the thought log, and “more closely examined” (see sessions 4-6 below) prior to accepting it as fact.

Two examples of “red flag thinking patterns” are provided below for illustrative purposes.

Fortunetelling: You predict the future negatively: Things will get worse, or there is danger ahead.

Examples:

My future is bleak.
I have nothing to look forward to.
I will not be able to do anything meaningful with my life.
I will be too tired to enjoy the game.

Mind reading: You assume that you know what people think without having sufficient evidence of their thoughts.

Examples:

People think I’m a freak when I have PD symptoms in public.
My friends are annoyed with me because I’m slower.

What Therapy Looks Like Weeks 4-5

Secret Sauce Ingredient 4: Talk back to negative

thoughts

In weeks 4 & 5, we introduce and practice cognitive restructuring, or the process by which we change and interrupt these problematic ways of automatic thinking. Cognitive restructuring is a tool that will teach you to examine your negative thoughts more closely, to help determine if they are as “true” as they “feel.” It is common for people to accept their thoughts as an absolute truth without taking the time to examine, if in fact, they are really 100% accurate. There are dozens of different ways to examine and evaluate a negative thought.

One technique is called “Examining the Evidence.” This technique includes listing out all of the “facts” or “evidence” that supports the thought, but also the evidence that suggests the thought might not be so true. After looking at both the evidence for and against the thought, individuals will come up with a “reframe,” or an alternative or more balanced way of restating the thought, so that it takes into account all of the facts of the situation, not just the most negative ones which typically echo loudest in the mind.

It is important to note that the goal of cognitive restructuring is to help people have more realistic, accurate, and/or balanced thoughts about situations, instead of thoughts that are unduly skewed to the negative and block adaptive coping to life’s ongoing challenges. The goal is NOT to encourage you to see things through "rose colored glasses." Cognitive therapy is about the power of realistic and healthy thinking. Can we learn to speak to ourselves in a way that leads to feelings of control and empowerment vs. despair and helplessness?

What Therapy Looks Like – Week 6

Secret Sauce Ingredient 5: Focus on the most

realistic outcome; not the worst case scenario

In the sixth session, we continue to work on cognitive restructuring, with a specific focus on tools that can be particularly useful for managing thoughts that take the form of “negative predictions” about a specific future event. This is critically important as negative predictions lead to anxiety; anxiety leads to avoidance; avoidance leads to one’s world becoming smaller. We want your world to grow larger and your buckets to overflow with meaning, joy, and satisfaction. This may sometimes require you to experiment with saying “yes”, when you are more inclined to say “no.”

Some helpful questions to consider to guiding your decision making are as follows:

“What’s the worst that could happen (in a given situation)?”
“What’s the best that could happen (in a given situation)?”
“What’s the most realistic outcome (in a given situation)?”

Negative thoughts are like “Miracle Grow” for anxiety. Anxiety “blossoms” when people overestimate the likelihood of the worst possible case scenario taking place (and underestimate their ability to handle it as if something untoward were to happen). Although the “worst case scenario” is always a “possibility”, it is not usually a “probability.” This is a very important distinction that can have a profound impact on your mood and behavior.

Focusing on the most realistic outcome in a given situation will reduce your experience of anxiety and depression, while allowing you to formulate an appropriate action plan to address the circumstances in question.

What Therapy Looks Like – Week 7

Secret Sauce Ingredient 6: Remember to breathe

each day

In week seven, we focus on three relaxation techniques to work in concert with the cognitive and behavioral techniques learned in the previous sessions. The 7th session explores guided imagery, progressive muscle relaxation, and complete natural breathing. Several examples of these, and other similar techniques, are freely available online (e.g., YouTube) as well as on several mobile apps (e.g., Insight Timer). Regular daily practice (at least 20 minutes per day) is recommended to optimize mood.

What Therapy Looks Like – Week 8

Secret Sauce Ingredient 7: Put your worries in

their place

Secret Sauce Ingredient 8: Develop a consistent

sleep routine

In the eighth week of treatment, two topics are explored: worry control and sleep hygiene. Daily worries can easily spiral out of control if not kept in check. Rather than allowing worry to take up valuable space and time in your day, let’s put them in their place. This can be done with two specific steps. Step 1: Schedule Your Worry Time! Yes, you are reading this correctly. Block out 15 minutes, 1-2 times per day, just to worry. Do not do anything else during this 15-minute block. Set a timer. When the alarm goes off, you are done until your next scheduled worry time. If worries flood your mind after your scheduled time, practice “postponing” your focus on the worry, until your next scheduled time. This is the only time you will ever be encouraged to “kick the can down the road.” As you continue to delay your focus on your worries, the intensity of concern will naturally decrease over time.

In addition, disturbances of sleep are one of the most common problems experienced by people with Parkinson’s disease. Depression and anxiety can further worsen sleep disruption in PD. Therefore, healthy sleep behavior is important. Allow yourself at least one hour of “down time” before bed. Work to maintain a consistent sleep schedule, in which you go to bed and get out of bed at approximately the same time each day. If you need a nap, schedule it at around the same time each day and limit it to 90 minutes or less. Keep the bedroom cool, dark and comfortable and avoid consuming excessive amounts of caffeine and alcohol. Daily exercise will also promote higher quality sleep. Similarly, the scheduling of “Worry time” affords many PwP a tool through which to channel nervous energy productively and to separate it from their bedtime rituals.

What Therapy Looks Like – Week 9

Secret Sauce Ingredient 9: “Knock Out” negative

thoughts with a “1-2 punch”

During the ninth week of treatment, a technique called “Simplified Restructuring” is introduced. It is done by moving immediately from a negative thought to a revised thought (i.e., a more rational response). Note that this is only impactful because individuals now understand the process behind cognitive restructuring (i.e., not the power of positive thinking but rather a meaningful change in your thought processes based on a systematic examination of the “facts”), and they may be able to move straight from the negative thought to a revised thought, without going through all of the in-between steps. It is important to work to increase the speed and efficiency with which you are able to put your negative thoughts in their place…and crush them like a bug…

Some examples of simplified restructuring:

Negative Thought Revised Thought

I am rapidly deteriorating. The neurologist said that my motor exam is the same as it was 6 months ago; exercise is helping to keep my symptoms stable

Nobody at the party will talk to me. At least some people at the party will talk to me. It is highly unlikely that I will be completely ignored.

What Therapy Looks Like – Week 10

Secret Sauce Ingredient 10: Develop a plan for

regular practice of new coping skill

The final week of treatment is about reflection and the future. Together both therapist and the PwP create a plan to maintain regular practice of newly acquired coping skills. The techniques described in this blog only work if they are practiced on a regular and consistent basis. It is also important to consider challenges that may interfere with your continued practice and to develop a plan to overcome these obstacles if they were to arise. Long-term success is not determined by the experience of heightened less of stress or mood fluctuations; this is part of life. Victory is yours when you are able to respond to these emotional challenges in a healthier and more constructive way.

It’s normal to experience mood fluctuations. Do not get derailed by this. Mood fluctuations don’t mean you are relapsing – they mean you are human. Brief periods of low mood are great opportunities to practice all of the skills you have learned to optimize your health.

What Does This Mean for Me Today?

YOUR MOOD IS ONE CRITICAL ASPECT OF YOUR MEDICAL CONDITION THAT YOU CAN CONTROL! DON’T SUFFER IN SILENCE! EFFECTIVE TREATMENTS ARE AVAILABLE! If your mood is not as good as you would like it to be, speak with your movement disorder specialist or primary care physician about local mental health referrals. Psychotherapy is fully covered by most insurance plans and can be incredibly beneficial, if delivered in the office or via telemedicine. Just like PT, OT, and Speech, early and effective treatment of depression and anxiety is a critical part of your overall PD management plan.

To read more books and articles by Michael S. Okun MD check on Twitter @MichaelOkun and these websites with blogs and information on his books and http://parkinsonsecrets.com/ #Livingwith Parkinson’s #EndingPD #Parkinsonsecrets #LessonsFromTheBedside

He also serves as the Medical Advisor for the Parkinson’s Foundation.

To see more on Dr. Indu Subramanian she does live interviews of experts in Parkinson’s for the PMD Alliance.

The blog artist is Jonny Acheson.

References:

1. Dobkin RD, Menza M, Allen LA, Gara M, Mark MH, Tiu J, Bienfait KL, Friedman J. Cognitive-behavioral therapy for depression in Parkinson’s disease: a randomized controlled trial. Am J Psychiatry. 2011;168(10):1066-1074

2. Dobkin, RD, Mann, S. L., Gara, M. A., Interian, A., Rodriguez, K. M., & Menza, M. Telephone-based cognitive behavioral therapy for depression in Parkinson disease: A randomized controlled trial. Neurology. 2020; 94: e1764-e1773.

3. Dobkin RD, Mann SL, Weintraub D, Rodriguez KM, Miller RB, St Hill L, King A, Gara MA, Interian A. Innovating Parkinson's Care: A Randomized Controlled Trial of Telemedicine Depression Treatment. Mov Disord. 2021 Mar 12. doi: 10.1002/mds.28548. Epub ahead of print.

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The 10 secret sauce ingredients to treat depression in Parkinson's