Catatonia: The Forgotten Syndrome

CATATONIA: The Forgotten Syndrome

Mr. Jones was a 56-year-old husband of three children and a successful CEO. He was brought to the hospital by his wife who was concerned about her husband’s sudden change in behavior. “I woke up yesterday and found him lying in bed staring at the ceiling. He wouldn’t make eye contact with me and has spoken only three words in the past 24 hours. He makes odd noises and repeats phrases that don’t make any sense. Could he have suffered a stroke?” Mr. Jones suffers from post-traumatic stress disorder and bipolar disorder and has been adherent with his medications. He appeared disheveled and has not eaten in over 24 hours.
On examination, Mr. Jones was not responsive. He did not make eye contact, but his eyes were open, and he appeared awake. His eyes blink to threats which suggests he is not blind. He resists any attempts to move his upper and lower extremities. Neuroimaging of his brain appears normal, electroencephalography (EEG) shows no signs of epileptic foci (i.e., no seizure activity), and his labs are all normal. The astute clinician suggests an intravenous (IV) Lorazepam (Ativan) challenge for suspected Catatonia. After just two doses, Mr. Jones begins to respond normally, moves spontaneously, and asks why he was brought to the hospital.

What is Catatonia?

Catatonia is a psychomotor disorder whereby affected individuals display abnormal behaviors and movements. Catatonic behaviors can be categorized as withdrawn or excited, with the withdrawn state more common.
Symptoms of catatonia may include mutism or impoverished/quiet speech, reduced interaction with the environment (i.e., stupor), negativism (i.e., resisting movement by others), increased motor tone/rigidity, posturing and grimacing, automatic obedience, ambitendency, echolalia (i.e., repeating or mimicking others’ words), stereotypy (repetitive movements or speech), verbigeration (i.e., An obsessive repetition of meaningless words and phrases, especially as a symptom of mental illness), echopraxia (i.e., mimicking others’ movements), extreme anxiety/fear, and impulsive/bizarre behavior. 
Although the signs and symptoms of Catatonia have been described in the literature for hundreds of years, it wasn’t until the 1870s that Karl Kahlbaum characterized catatonia as a distinct syndrome.
In an effort to establish a nosology for mental disorders, Emil Kraepelin further expanded upon Kahlbaum’s work and classified catatonia, hebephrenia and dementia paranoides as a single entity he termed “dementia praecox” (dementia of the young).
Eugen Bleuler (1907), inspired by Kraepelin, adopted the view that catatonia was part of a group of severe idiopathic deteriorating psychoses, which he renamed the “schizophrenias.”
It is important to mention that Kraepelin and Bleuler both recognized catatonic symptoms could emerge from mood disorders, but it wasn’t added as a specifier until many years later. Today, we recognize catatonia as a syndrome associated with psychotic disorders, mood disorders, neurological diseases (e.g., stroke, multiple sclerosis, Parkinson’s disease, epilepsy), toxic-metabolic states (i.e., illicit drugs, withdrawal states, liver failure), infections, medications (i.e., immunosuppressants, antipsychotics, steroids, antibiotics), and other medical problems (e.g., post-operative delirium, liver transplant, cardiac surgery, orthopedic surgery).  

Quick Stats about Catatonia

  • The prevalence of catatonia in acute medical settings is about 1.6-6.3%
  • Incidence of catatonia during acute psychosis is about 7-17%
  • Incidence of catatonia during a mood episode is about 13-31%
  • The cause of catatonia is idiopathic/unknown in about 4-46% of cases

The diagnosis of Catatonia can be made when three or more of the following symptoms occur together

  • Stupor
  • Catalepsy (muscle rigidity)
  • Waxy flexibility
  • Mutism
  • Negativism (i.e., resisting movement by others)
  • Posturing
  • Mannerisms
  • Stereotypy (i.e., repetitive movements or speech)
  • Agitation/Impulsive/Bizarre behavior
  • Grimacing
  • Echolalia (i.e., repeating or mimicking others’ words)
  • Echopraxia (i.e., mimicking others’ movements)
In addition, there must be evidence from history, labs, and/or imaging studies that symptoms are from a medical cause and are not better explained by another mental disorder.
Controversially, the Diagnostic and Statistical Manual 5th Edition (DSM-5) precludes the diagnosis of Catatonia if it occurs exclusively during a period of delirium. The controversy exists because Catatonia and Delirium can present simultaneously. In fact, a recent study reported a 12-37% incidence of catatonia in patients with delirium.
Below is a photo of a man with catatonia. As you can see, he is posturing–a classic catatonic sign. Some patients may remain in the same position for many hours. Although we typically associate catatonia with this classic sign, in most cases posturing isn’t a prominent sign or symptom.

Screening Tools

The Bush Francis Catatonia Rating Scale (BFCRS) is the most widely used screening tool for Catatonia.

Diagnostic Tests

Electroencephalography (EEG) is typically normal in catatonia but may show generalized slowing if there is a medically related cause. Brain imaging such as Magnetic Resonance Imaging (MRI) and Computed Tomography (CT) studies are typically normal if not medically related. Lumbar Puncture (LP) may be performed to rule out encephalitis or other central nervous system inflammatory, infectious, or autoimmune processes.

Treatment and Management of Catatonia

Catatonia is a medical emergency and should be treated in a medical hospital.
The treatment of the catatonic patient begins with investigating potential underlying causes and treating them appropriately. This includes discontinuation of any offending medications. Medical conditions and medications associated with catatonia are tabulated below. 
MEDICAL CONDITIONS MEDICATIONS | DRUGS
  • Anti-NMDA-receptor Encephalitis (ANRE)
  • Paraneoplastic Limbic Encephalitis
  • Systemic Lupus Erythematous (SLE)
  • Seizures
  • Brain infections
  • Intracranial Mass Lesions (e.g., tumors)
  • Multiple Sclerosis
  • Delirium (Encephalopathy)
  • Glucose-6-phosphate dehydrogenase (G6PD) Deficiency
  • Vitamin B12 Deficiency
  • Hyponatremia
  • Stroke, Dementia, and Other Brain Degeneration Disorders
  • Takotsubo Cardiomyopathy
  • Wilson’s Disease
  • Ferropenia (low iron)
  • Post Liver Transplant
  • Post Cardiac Surgery
  • Post Orthopedic Surgery
  • Hepatic Encephalopathy (elevated ammonia)
  • Uremia
  • Sepsis
  • Tacrolimus
  • Cyclosporine
  • 3,4-methylenedioxy-N-methylamphetamine (MDMA)
  • Corticosteroids (prednisone, methylprednisolone)
  • Fluoroquinolone antibiotics (ciprofloxacin, levofloxacin)
  • Beta-lactam antibiotics (Cephalosporins)
  • Macrolide antibiotics (clarithromycin, erythromycin)
  • Disulfiram
  • Benzodiazepines and Barbiturates (withdrawal)
  • Baclofen
  • Cocaine (wuithdrawal)
  • Phencyclidine (PCP)
  • Ketamine
  • Antipsychotics
  • Withdrawal from dopamine agonists
In general, antipsychotics should be discontinued and/or avoided. An immediate trial of intravenous (IV) lorazepam at a dose of 2mg-3mg should be administered. The patient should be monitored for a response to this “lorazepam challenge.”  If no response within 60 minutes, consider administering a second lorazepam dose. If still no response, consider adding either a dopamine agonist (e.g., Amantadine, bromocriptine, L-dopa), memantine (Namenda), or zolpidem (Ambien). In cases of malignant catatonia, electroconvulsive therapy (ECT) is strongly recommended and potentially lifesaving. 
If a response to Lorazepam occurs, lorazepam should be administered at a dose of 3mg-20mg per day in divided doses. Usually, patients will require a few weeks of oral lorazepam before slowly tapering.
In addition to Lorazepam, supportive measures are important. These include reversing hyperthermia (if present) and intravenous hydration to prevent kidney injury. Providing adequate nutrition, monitoring oxygenation, and preventing deep vein thrombosis (i.e., compression stockings or anticoagulation), pressure ulcers (i.e., constantly change the patient’s position), muscle contractures, and aspiration are important.
Of note, Electroconvulsive Therapy (ECT) has a 90% response rate and is considered a first line treatment for malignant catatonia, severe malnutrition from refusing to eat, or partial response from medication trials.
For more information about Catatonia, click here.

References

  • Oldham, Mark A., and Hochang B. Lee. “Catatonia Vis-Ã -vis Delirium: The Significance of Recognizing Catatonia in Altered Mental Status.” General Hospital Psychiatry 37.6 (2015): 554-59. Web.
  • Tandon, Rajiv, Stephan Heckers, Juan Bustillo, Deanna M. Barch, Wolfgang Gaebel, Raquel E. Gur, Dolores Malaspina, Michael J. Owen, Susan Schultz, Ming Tsuang, Jim Van Os, and William Carpenter. “Catatonia in DSM-5.” Schizophrenia Research 150.1 (2013): 26-30. Web.
  • Fink, Max, and Michael Alan Taylor. “Catatonia: A History.” Catatonia (n.d.): 1-18. Web.
  • Jaimes-AlbornozW, Serra-Mestres J. Prevalence and clinical correlations of catatonia in older adults referred to a liaison psychiatry service in a general hospital. Gen Hosp Psychiatry 2013;35:512–6.
  • Grover S, Ghosh A, Ghormode D. Do patients of delirium have catatonic features? An exploratory study. Psychiatry Clin Neurosci 2014;68:644–51.
  • Valproic Acid for Treatment of Hyperactive or Mixed Delirium: Rationale and Literature Review Sher, Yelizaveta et al. Psychosomatics , Volume 56 , Issue 6 , 615 – 625
  • Catatonia in Medically Ill Patients An Evidence-Based Medicine (EBM) Monograph for Psychosomatic Medicine Practice. Academy of psychosomatic medicine
  • Levenson, James L. Essentials of Psychosomatic Medicine. Washington, DC: American Psychiatric Pub., 2007. Print.
  • Kirkhart, Rob et al. “The Detection and Measurement of Catatonia.” Psychiatry (Edgmont) 4.9 (2007): 52–56. Print.
  • J. Ferrando, J. L. Levenson, & J. A. Owen (Eds.), Clinical manual of psychopharmacology in the medically ill(pp. 3-38). Arlington, VA, US: American Psychiatric Publishing, Inc.
  • McCarron, Robert M., et al. Lippincotts Primary Care Psychiatry: for Primary Care Clinicians and Trainees, Medical Specialists, Neurologists, Emergency Medical Professionals, Mental Health Providers, and Trainees. Wolters Kluwer Health/Lippincott Williams & Wilkins, 2009.
  • American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC.
  • Arciniegas, Yudofsky, Hales (editors). The American Psychiatric Association Publishing Textbook Of Neuropsychiatry And Clinical Neurosciences. Sixth Edition.
  • Levenson, J. L. (2019). The American Psychiatric Association Publishing textbook of psychosomatic medicine and consultation-liaison psychiatry. Washington, D.C.: American Psychiatric Association Publishing.
  • Schatzberg, A. F., & Nemeroff, C. B. (2017). The American Psychiatric Association Publishing textbook of psychopharmacology. Arlington, VA: American Psychiatric Association Publishing.
  • Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY, US: Cambridge University Press.
  • Stern, T. A., Freudenreich, O., Fricchione, G., Rosenbaum, J. F., & Smith, F. A. (2018). Massachusetts General Hospital handbook of general hospital psychiatry. Edinburgh: Elsevier.
  • Hales et al. The American Psychiatric Association Publishing Textbook of Psychiatry. 6th
  • Benjamin J. Sadock, Virginia A. Sadock. Kaplan & Sadock’s Comprehensive Textbook of Psychiatry. Philadelphia :Lippincott Williams & Wilkins, 2000.
  • Ebenezer, Ivor. Neuropsychopharmacology and Therapeutics. John Wiley & Sons, Ltd. 2015.
  • Meyer, Jerrold, and Quenzer, Linda. Psychopharmacology: Drugs, the Brain, and Behavior. Sinauer Associates. 2018

Letters All Day Challenge

Letters All Day

Welcome to your 24 hour challenge

What You’ll Need:

INSTRUCTIONS

Pick a day (24 hours) and clear your schedule that day.
Set a timer for 24 hours. Doesn’t matter what time you start.

You’ve been challenged to complete the six (6) tasks below. After completing the 6 tasks, complete the survey below. Do NOT click the button to see the tasks ahead of time.

DISCLAIMER: This is for educational and therapeutic purposes only. By completing this exercise, you are taking responsibility for anything that occurs during the exercise. Take the challenge at your own risk. Please be sure to check with a mental health professional before completing this challenge. 
 CHOOSE A LETTER FROM THE ALPHABET

WRITE THE LETTER DOWN SOMEWHERE.

TASKS

Tap each task to view the instructions.

After completing the task, move to the next one.

TASK 1

The WALK

THE WALK

Begin by going on a walk in an area densely populated with people, shops, and stores. You can pick the starting point and direction to walk. Find the first store, shop, or business you see that begins or ends with the letter you chose. Go into the store, shop, or business and look around for at least 10 minutes. Before you leave, you must ask someone who works there the following question: What does "living your best life" mean to you? Write down their response.

TASK 2

THE TALK

THE TALK

Call or text a close friend or family member whose name contains the letter you chose. Ask that person the following question: How would you describe me to someone who has never met me? Write down their response.

TASK 3

THE TASTE

The TASTE

Find a bakery, coffee shop, food truck, deli, ice cream shop, or restaurant whose name begins with the letter you chose. Order something to eat or drink that begins with the letter you chose. If there is no item that begins with that letter, continue to the next letter until you see something on the menu that begins with that letter. NOTE: A is after Z. Describe, in detail, what you taste.

TASK 4

THE SIGHT & SMELL

THE SIGHT

Find the closest object that begins with the letter you chose. Describe, in detail, what the object looks like without stating what the object is. Write down your description.

TASK 5

The SOUND

The Sound

Pick a song with a title that begins with the letter you chose. Listen to the entire song and pay attention to your feelings while you are listening. After listening to the song, sit/stand where you are for one minute and pay attention to the sounds around you.

TASK 6

THE VOICES

The Voices

Find a quiet place to sit and be alone. For 5 minutes, simply listen to your internal dialogue as if an outside observer. Listen with curiosity and try to avoid judgments. What do you hear? Write it down.

Mental Disorders

MENTAL DISORDERS

The Benefits of Journaling

The Benefits of
Journaling

Why is journaling important?

Journaling is a simple activity that most people overlook. Journaling has been shown to have significant mental and physical health benefits and to improve a person’s overall quality of life.

Here are five (5) evidence-based benefits to journaling.

(1) Journaling Can Reduce Depression and Anxiety Symptoms

A 2006 study by Stice, Burton, Bearman, & Rohde showed that writing in a journal can be as effective as cognitive-behavioral therapy in reducing depression risk in young adults. Other studies have shown that journaling can reduce the frequency of intrusive and depressive thoughts in those diagnosed with a Major Depressive Disorder.
Hasanzadeh, Khoshknab, & Norozi found that the simple act of journaling reduced anxiety in women with multiple sclerosis. Another study found that journaling could help students effectively manage stress and anxiety, as well as improve overall classroom engagement.
How does journaling help with depression and anxiety?
Both depression and anxiety are often accompanied by negative thoughts. Journaling allows you to get these thoughts down on paper, process them in a more analytical, non-emotional way, and then respond appropriately to them.
Social psychologist and researcher James Pennebaker puts it this way:
Emotional upheavals touch every part of our lives. You don’t just lose a job, you don’t just get divorced. These things affect all aspects of who we are — our financial situation, our relationships with others, our views of ourselves. … Writing helps us focus and organize the experience.
Instead of simply letting negative thoughts run rampant in your mind, journaling for anxiety allows you to engage with your thoughts and determine whether they are true or false.

(2) Journaling Can Help Boost Immune Function

Surprisingly, journaling has been proven to improve overall immune function and decrease your risk of illness. Karen A. Baikie and Kay Wilhelm found that those who journaled regularly had fewer stress-related visits to the doctor, had improved immune system functioning, reductions in blood pressure, and improved lung and liver function.
Journaling allows a person to develop a “coherent narrative” of their life. It enables a person to take the events they experience and integrate them into their overall perspective on life. This, in turn, enables a person to think more positively about their life and create a holistic picture of themselves in relation to the rest of the world. It follows that a person with a positive, holistic view of themselves is less prone to things like depression and anxiety, both of which can cause a variety of physical health problems.

(3) Journaling Helps Cultivate Gratitude

It is well known that practicing gratitude has health benefits. Gratitude is directly tied to things like increased exercise and improved quality of sleep, both of which promote long-term well-being. It has been shown to significantly increase optimism, which indirectly affects both your happiness and your health.
Gratitude is tied to reduced levels of depression, making progress toward goals, and making a person more sociable and friendly. Journaling allows you to reflect on all the good things in your life, which, in turn, enables you to be grateful. When you don’t journal, it’s easy to forget about all the good things happening in your life…

(4) Journaling Can Help With Recovery From Traumatic Events

It has also been shown that journaling can help a person recover more quickly from traumatic events. Writing things down allows you to process what has occurred and see the good side of life, even when things are difficult. Journaling also allows you to directly confront the things you’ve experienced instead of avoiding them and not taking the time to process them.
If you’ve experienced the death of a loved one, journaling can enable you to effectively grieve in a manner that’s both healthy and healing. As you journal, you can take the necessary time to remember your loved one, process the loss, and begin to move forward.
A 2002 study by researchers Provencher, Gregg, Mead, & Mueser also found that journaling can speed the recovery of those who are struggling with various psychiatric conditions. Psychiatric conditions are often accompanied by repetitive, intrusive thoughts that can be difficult to process. Journaling allows you to get those thoughts down on paper, process them effectively, and finally let them pass through.

(5) Journaling can Improve Memory Function

It shouldn’t come as any surprise that journaling can also improve overall memory function.

Neurologist Judy Willis says,

“The practice of writing can enhance the brain’s intake, processing, retaining, and retrieving of information… it promotes the brain’s attentive focus … boosts long-term memory, illuminates patterns, gives the brain time for reflection, and when well-guided, is a source of conceptual development and stimulus of the brain’s highest cognition.”

When you journal, you are both recording and processing the events of a particular time period. As you do this, you are remembering and reflecting upon the details of the events, which then helps you retain those memories for a significantly longer amount of time.
Additionally, journaling allows you to analyze past events for patterns. As you look at your journal over time, you may begin to see particular patterns emerge, whether in your own behavior or in the behavior of others. Once you spot these patterns, you can respond appropriately.
If you aren’t journaling yet, I hope these five reasons encourage you to start. Journaling is incredibly beneficial, both mentally and physically. It enables you to process the events you experience, which leads to a healthy and holistic view of yourself.
It empowers you to work through trauma, bringing healing to past wounds and insight into the way forward. It also improves your memory of events and enhances your ability to see patterns in life.

So take the first step and start journaling with us!

Self-Assessments

Self-Assessments

ADHD

ANXIETY

DEPRESSION

BIPOLAR DISORDER

SELF-CARE

SELF-CARE ASSESSMENT

Self-care activities are the things you do to maintain good health and improve well-being. Many of these activities you do already as part of your normal routine. 

In this assessment you will think about how frequently, or how well, you are performing different self-care activities. This will help you learn about your self-care needs by spotting patterns and recognizing areas of your life that need more attention. Some of these items may not apply to you. 


When completing this assessment, use the following rubric:

(1) I do this poorly; I do this rarely
(2) I do this alright; I do this sometimes
(3) I do this well; I do this often
(0) I would like to improve at this; I would like to do this more frequently

SELF-CARE ASSESSMENT

Your responses WILL NOT be recorded and will be sent to your email only!

Exploring Your Personal Values

EXPLORING YOUR PERSONAL VALUES

WHAT ARE PERSONAL VALUES?

Your values are the things that are important in the way you live and work. They (should) determine your priorities and they’re probably the measures you use to tell if your life is turning out the way you want it to.

A list of common personal values is provided below.

Accountability
Accuracy
Achievement
Adventurousness
Altruism
Ambition
Assertiveness
Balance
Being the best
Belonging
Boldness
Calmness
Carefulness
Challenge
Cheerfulness
Clear-mindedness
Commitment
Community
Compassion
Competitiveness
Consistency
Contentment
Contribution
Control
Cooperation
Correctness
Courtesy
Creativity
Curiosity
Decisiveness
Democraticness
Dependability
Determination
Devoutness
Diligence
Discipline
Discretion
Diversity
Dynamism
Economy
Effectiveness
Efficiency
Elegance
Empathy
Enjoyment
Enthusiasm
Equality
Excellence
Excitement
Expertise
Exploration
Expressiveness
Fairness
Faith
Family-orientedness
Fidelity
Fitness
Fluency
Focus
Freedom
Fun
Generosity
Goodness
Grace
Growth
Health
Helping society
Holiness
Happiness
Hard work
Honesty
Honor
Humility
Improvement
Independence
Ingenuity
Inner harmony
Inquisitiveness
Insightfulness
Intelligence
Intellectual status
Intuition
Joy
Justice
Leadership
Legacy
Love
Loyalty
Making a difference
Mastery
Merit
Obedience
Openness
Order
Originality
Patriotism
Perfection
Piety
Positivity
Practicality
Preparedness
Professionalism
Prudence
Quality-orientation
Reliability
Resourcefulness
Restraint
Results-oriented
Rigor
Security
Self-actualization
Self-control
Selflessness
Self-reliance
Sensitivity
Serenity
Service
Shrewdness
Simplicity
Soundness
Speed
Spontaneity
Stability
Strategic
Strength
Structure
Success
Support
Teamwork
Temperance
Thankfulness
Thoroughness
Thoughtfulness
Timeliness
Tolerance
Traditionalism
Trustworthiness
Truth-seeking
Understanding
Uniqueness
Unity
Usefulness
Vision
Vitality

WHY ARE PERSONAL VALUES IMPORTANT?

When the things that you do match your values, life is usually good – you’re satisfied and content.
Living a life unaligned with your personal values feels… wrong. And this can be a source of unhappiness. This is why making a conscious effort to identify your values is so important.
Life can be much easier when you make plans and decisions that honor your values. 

When you know your own values, you can use them to make decisions about how to live your life, and you can answer questions like:

  • What job should I pursue?
  • Should I start my own business?
  • Should I compromise, or be firm with my position?
  • Should I follow tradition, or travel down a new path?
Take the time to understand the real priorities in your life, and you’ll be able to determine the best direction for you and your life goals!

VALUES CHANGE AS YOU MOVE THROUGH LIFE

Values remain fairly stable but also don’t have strict limits or boundaries. As you move through life, your values may change. 
For example, when you start your career, success – measured by money, status, and recognition – might be a top priority. But after you have a family, work-life balance may be what you value more.
As your definition of success changes, so do your personal values.
This is why keeping in touch with your values is a lifelong exercise. You should continuously revisit this, especially if you start to feel unbalanced… and you can’t quite figure out why. When you define your personal values, you discover what’s truly important to you.

Next, we will go through six (6) steps that will help you identify your personal values…

RESPONSES WILL BE SAVED UNTIL THE END. DO NOT REFRESH THE PAGE OR EXIT THE BROWSER OR YOUR RESPONSES WILL BE LOST. 

IN SUMMARY

Identifying and understanding your values is a challenging but important exercise. Your personal values are a central part of who you are – and who you want to be.
By becoming more aware of these important factors in your life, you can use them as a guide to make the best choice in any situation. Some of life’s decisions are really about determining what you value most.
When many options seem reasonable, it’s helpful and comforting to rely on your values – and use them as a strong guiding force to point you in the right direction.

What Should I Do With My Life? A Guide to Finding Purpose and Passion

WHAT SHOULD I DO WITH MY LIFE?

A GUIDE TO FINDING PURPOSE AND PASSION

DISCLAIMER: This activity is not for everyone and is not considered personal medical advice.

“I FEEL STUCK. I DON’T KNOW WHAT I SHOULD DO WITH MY LIFE.”

If you’re feeling lost in life and you aren’t sure what you “should” do, join the club. You are NOT alone.
If you think this module is going to tell you the answer, that’s your first problem. Why? Because no one, except you, can answer that question. So, the first step is to recognize and appreciate that seeking answers externally isn’t going to get you very far. To solve this problem requires you to dive into your internal world. It may be uncomfortable, but it’s necessary. And this exercise can help guide you…

THE MAFIA BOSS

If you think back to when you were a kid, you didn’t sit and agonize about how you were going to spend your time. You just did things. You played tag at recess, built Legos, pretended you were a Disney princess, or dug tunnels in the sandbox. Your curiosity and imagination fueled your enthusiasm for doing things. You learned what you enjoyed and what you didn’t enjoy by trying different things. If you liked it, you kept doing it. If you didn’t like it, you stopped doing it. It was that simple. 
Well, guess what? It’s still that simple. The problem is not that you don’t have passions, interests or enthusiasm–it’s that your inner voice is getting in the way. That inner voice is telling you how you “should” or “shouldn’t” live your life. Your inner voice can be a real b****h! It feeds off of, and listens to, outside influences. Your inner voice feeds off the fear of being ridiculed, judged, or perceived negatively. 
If you want to live a meaningful and purposeful life, you have to take accountability for your life. This means you have to be the pioneer of your own adventure–the writer of your own story. And to do that, you need to let go of any resistance to doing so. That is, you have to let go of the stories you’ve been telling yourself. 
So, like a Mafia boss would say, “it’s time to pay that annoying inner voice a visit.”

THAT INNER VOICE

You know that annoying voice in your head that won’t shut up? If you haven’t met that voice yet, it’s time to introduce yourself.
If you’re having trouble identifying that voice, simply stop reading and close your eyes. If you asked yourself “is this the voice?” then you found it. This is the voice that won’t shut up. This annoying inner voice puts you down, questions your decisions, and complains about EVERYTHING. It’s helpful recognize this annoying inner voice that’s constantly trying to take you out of the present moment.
Here are some examples of what that voice sounds like: Is it going to be this way forever? What are they going to think of me? What if I fail? If _____, then _______. Is this even going to help? I can’t do this. I’m so stupid. Does this mean I’m lazy? Where do I even start? I look so fat in the mirror. I’m so scrawny. I’m ugly. I’ll do it tomorrow. I don’t deserve to enjoy that. I should work harder. This is pointless. Am I sure that was the best idea? What if they find out I’m a fraud?
Remember that this inner voice is just a sequence of thoughts. This inner voice is your mind’s creation based on whatever input it receives from your brain. Therefore, this inner voice isn’t truly YOU. Let me explain…

YOUR BRAIN, YOUR MIND, AND YOU

For a moment, consider your reality as involving three entities: your brain, your mind, and you.

YOUR BRAIN: Your brain is a physical entity–a collection of organic matter that sits within your skull. Your brain sends “raw data” to a processor, also known as your mind.
YOUR MIND: Your mind receives this “raw data” and filters it, edits it, and manipulates it so you can understand it. 
YOU: You are just you. You are the one observing and experiencing what your mind does with the raw data it receives. This concept is essential to understand. You are the one who is aware of your thoughts, but you are NOT your thoughts.
That inner voice is just a sequence of thoughts. And we experience thoughts…but we aren’t the thoughts themselves.

So… that inner voice…isn’t truly you.

This is a different way of framing reality than believing you are the content of the thoughts themselves. Most of us struggle to separate ourselves from the mind. If we don’t separate ourselves from our minds, then we run the risk of feeling personally responsible for our thoughts and the analysis of our thoughts.
Mindfulness means observing what your mind is doing and deciding for yourself how involved you want to be in that process. Whether or not you believe the mind is part of the brain or part of something else isn’t relevant because we are most interested in what the mind DOES, not what it is. Recognizing that inner voice is ESSENTIAL as you begin asking yourself important questions about your life and your future.

PASSIONS

According to Merriam Webster, “passion” refers to a strong feeling of enthusiasm or excitement either for something or about doing something. Passions are often something you would love to do constantly. 
Sometimes our passion is something we would love to do for work. Sometimes we only think that’s what we want. Having passion for our work is more specific than being excited or enthusiastic about something.
“Worker passion” is something that motivates us to dig into the tough problems and sustains us through challenges and setbacks. This type of passion brings out our desire to figure something out, to learn faster, to make an impact. 
One of the biggest mistakes people make is believing that the answer to “What should I do with my life?” is all about the career you choose. A career is ONE factor.
Yes, you’ll need to work to make a living and you’ll likely be working for a good chunk of your life….so…yes…it is a very important factor. But living a meaningful and purposeful life requires more than just a career–even if it’s the career of your dreams. The important lesson is that you don’t need to choose a life goal or career path you’re passionate about at the outset…that’s something that develops over time. And maybe your job will just be a job to pay the bills. That’s okay. That doesn’t mean you can’t live a meaningful and purposeful life.

STOP THINKING AND START EXPERIENCING

“Find what your passion is and look for ways to make money doing that.” This is TERRIBLE advice for many reasons.  Who said that living a meaningful and purposeful life requires that you find a career doing something your passionate about? A job is a job. It makes work-life more enjoyable if you’re passionate about it, but it isn’t a requirement.
Even if you are passionate about something, the day-to-day requirements of a career may zap the passion right out of it. If you think the goal is to be doing something you’re passionate about 100% of the time, you’re going to be disappointed. Passions are important, but they are not the IMMEDIATE “goal.”
“Finding a passion” requires that we “try-on” different life experiences (like when you were a kid and you tried different sports or extracurricular activities). This means passions evolve and develop over time. They can even change over time. It’s true that finding your passion is often interlinked with happiness and fulfillment on a more personal level and that finding a passion is necessary to living a fulfilling life. But, as I said above, it takes time.
Discovering and uncovering your passions requires engaging in different types of work and other pursuits. It is rare to have a passion for something we know nothing about. You have to get to know the problems and challenges of a pursuit to fall in love with it. 
The interesting thing about pursuing your passions is that doing something you care about on an emotional and intellectual level will result in you wanting to do more of it. This means there’s a direct link between discovering and developing your passions and achieving growth in your career and personal development.
This isn’t a one-time process that happens in a single day. Your passions may change throughout your whole life. That’s okay. In fact, that’s part of living a purposeful and meaningful life. The process of cultivating and developing your passions is part of what makes life worth living. 
But the end-goal isn’t always as clear as finding a way to get paid for doing the thing you love to do in your spare time. 

WHAT IS AFFECTIVE FORECASTING?

In psychology, affective forecasting, also known as hedonic forecasting, is predicting how you will feel in the future. Researchers had long examined the idea of making predictions about the future, but psychologists Timothy Wilson and Daniel Gilbert investigated it further. They looked into whether a person can estimate their future feelings. For example, would marrying a certain person bring you happiness? Or would moving to a new city boost your mood? It turns out that humans are terrible at this…
In Wilson and Gilbert’s research, they found that people misjudge what will make them happy and have trouble seeing through the filter of the present. Because of this, affective forecasting is unreliable in decision-making.
People tend to be inaccurate in forecasting how they might feel later. They also tend to overestimate how positive or negative they would feel about future situations. An example might be wishing to purchase a luxury car. You might anticipate immense and extended joy when you finally buy that car, but over time, the joy of owning that car will dissipate.

How does affective forecasting relate to procrastination?

Our present self thinks that our future self will be more motivated. Therefore, our present self is eager to procrastinate and put off being productive. Staying with an exercise or fitness program is a good example of this thinking. Why bother working out now when you’ll be more inclined to do so tomorrow? This is why you need to shift your mindset away from believing the IMMEDIATE GOAL is to find a job or experience that will make you the happiest in the future.
Instead, we need to explore what we know to be true RIGHT NOW and we need to take action RIGHT NOW…because RIGHT NOW is all we really have…

SAYING GOODBYE TO THE SHOULDS

It is tempting to tell ourselves that we “should” or “shouldn’t” do something.
Although this “self-advice” comes from good intentions, it’s just another trick used by that annoying inner voice to hijack your present moment.
The “Shoulds” and “Shouldn’ts” need to take a walk…off a cliff.

IDENTIFYING YOUR PERSONAL VALUES

Your values are the things that you believe are important in the way you live and work. They (should) determine your priorities, and, deep down, they’re probably the measures you use to tell if your life is turning out the way you want it to. When the things that you do match your values, life is usually good – you’re satisfied and content.
Living a life that isn’t aligned with your personal values feels… wrong. And this can be a source of unhappiness. This is why making a conscious effort to identify your values is so important.
Take a few minutes to complete the module below…

IKIGAI

Ikigai is a Japanese term meaning “one’s purpose.” Take a look at the diagram below. The long-term goal is to reach a place in the center…But again, this takes life experiences and time…

What follows are a series of questions that will help get the juices flowing so you can start taking action RIGHT NOW to get you to that center spot.

LIFE GOALS AND WHY THEY’RE IMPORTANT

Living a meaningful and purposeful life requires that we have goals and structure. For many people, schedules, routines, and structure generate discomfort, frustration, and fear. This is to be expected.
Holding ourselves accountable and setting expectations generate fear and anxiety because it means there is potential for failure and disappointment.
The fear associated with taking initiative and accountability is another sneaky tactic used by that annoying inner voice that’s constantly trying to “protect” you from anything that might result in failure, embarrassment, or disappointment. In doing so, the inner voice is preventing you from achieving your dreams. That’s because achieving your dreams requires you to take risks.
When you learned how to ride a bike, you took a risk. When you learned how to drive, you took a risk. When you learned how to beat a level in a video game, you took a risk. When Jeff Bezos created Amazon, he took a risk. When our ancient ancestors hunted for food to survive, they took a risk. 
And sometimes they failed. And that’s okay. Actually, it was necessary…it provided them an opportunity to learn and grow. 

Remember, failure is an event, not a person.

Don’t get discouraged by that inner voice in your head that’s probably screaming right now. It’s probably saying something like: Where do I start? How do I start? What is the first step? Will this even help me? What do I do first? How many times should I do it? How long should I do it? Do I have to do this? I don’t know who I am anymore. I don’t know what I want Why is this so difficult?
That annoying inner voice is trying to taunt you and stall you from achieving any forward movement. It’s trying to get you to compulsively seek certainty instead of leaning directly into your fears.
The simplest strategy is to remember that every act of embracing uncertainty is an act of defiance against that voice.
And embracing uncertainty means taking that first step.
Let’s explore your goals. Don’t worry if you struggle with this a bit…just get some goals written down. The module below will help you…
Now that we have the basics down, we need to put all of this into action. 

Try the two-week commitment to get you started!

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