All Posts in Category: General Mental Health

Why Words Are so Important in Psychiatry

Why Words Are so Important in Psychiatry

As reviewed in a past article, the field of Psychiatry is unique among medical specialties. At present, medical technology has yet to provide adequate imaging or laboratory testing that would allow for more objective assessment of a patient’s symptoms and concerns. A person with chest pain, fatigue and a racing heartbeat can rest assured that a carefully designed testing protocol will clarify the nature of the problem. Cardiac enzymes, electrocardiogram, chest x-ray and even cardiac catheterization will provide objective evidence to either rule-in or rule-out a cardiac event. Or the severe sore throat that makes swallowing difficult can be objectively clarified by obtaining a throat culture and consequently help the physician chose an antibiotic if indicated.

So how to proceed with such limited biomedical test resources? The art of listening is the answer. Listening will not be successful unless the patient knows that he/she can freely tell their story. First, the patient needs to hear a simple question. “How can I be of help?” After their reply the telling of their story is most important. For this to be successful there needs to be an open and accepting attitude that promotes this storytelling.

Once the story begins to unfold it is often necessary to backtrack and clarify aspects of the story. The words that the patient use become critical. What one individual means by the word “anxiety” may be quite different from that of others. I have discovered that behind the initial complaint of “I am anxious” will often be a core depressive illness that has an anxiety component. It is not uncommon for major depressive illnesses to contain a whole host of anxiety symptoms.

What of the individual with a true primary anxiety disorder. It is not sufficient to accept the word anxiety at face value. That is because anxiety is a more complex disorder and cannot be explained by a single word. Simply speaking, anxiety can be best understood by two of its components. One is best described as “somatic” or physical. Symptoms can include rapid heartbeat, sweating, gurgling stomach, headaches, tight muscles, shortness of breath etc. This individual is persistently or episodically physically uncomfortable and restless. They feel like they do not have control over their bodily sensations.

The other major component of anxiety is more mental or “psychic”. Such individuals spend excessive time with non-stop worrying. They get stuck with “what if this and what if that” thinking. They ruminate. They cannot turn off their brains. Sleep becomes difficult because of a busy head, Their thinking often is catastrophic, taking their worries down a path much farther than would be based on the current situation. Catastrophic thinking fuels the rumination and a vicious cycle ensues.

I am making a big deal of such language because treatment is often influenced by the specific type of anxiety. There are different medications to address somatic anxiety than that of psychic anxiety. Psychotherapies also differ depending upon the clarification of the anxiety explanation. So this is much more than a semantic intellectual exercise.

It is then most important to clarify the context of the individual’s symptoms. The goal is to try to determine how much the person’s difficulties are due to a reaction to a life situation. I have reviewed in past articles the difference between a core biologically-based psychiatric problem that definitely requires medication, a life based problem that would benefit from talking therapy and the hybrid situation in which a life stress induced problem triggers an underlying biological response that would require a combination of both types of treatment. One cannot get answers to such questions unless the dialog between physician and patient allows for a careful analysis of their story.

I have found that there is an added benefit of this approach. When a patient clearly knows that their physician is carefully listening and actively asking questions to clarify the specific aspects of their problem, a stronger therapeutic alliance develops. All too often I hear patients tell me that they were frustrated in the past with their doctor because they felt that he/she was not listening to them. This is so unfortunate because listening is a fundamental and easy process. Teasing apart the meaning of the words used in the story can be more challenging. Once the patient understands the importance of words, they can better appreciate the treatment plan and thus actively participate as a partner in the therapeutic process.

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Not All Addicts Are Alike

Not All Addicts Are Alike

Since the cocaine scourge of the ’70s and ’80s and the ongoing tragedy of the opiate epidemic, the American public has become painfully aware of the societal impact of addiction. Because of the prevalence and lethality of fentanyl-laced opiate overdoses almost everyone knows of a family that has lost a loved one. And despite all the time, effort and money invested in eradicating tobacco we now have to confront the growing addiction to nicotine through the expanding use of nicotine vape pens.

So what is this societal menace we call addiction? It’s standard definition requires the presence of four components:

  1. The substance is used to elicit a positive reward state.
  2. Physical dependence develops so that when ongoing use is not possible a withdrawal state ensues.
  3. Tolerance to the substance develops over time so that increasingly higher dosages are required to both impart the “high” as well as avoid the development of active withdrawal.
  4. Ongoing substance abuse occurs despite the dangers present. Most addicts will tell you that they are aware of the risks involved, including arrest, incarceration, the dangers of the environments visited to get the drug, fatal overdose or other non-fatal medical complications (like heart attacks from cocaine, liver disease from alcohol, HIV from intravenous use) and the deleterious impact on family, job, relationships and quality of life. It is as if there is a disconnection between the logical part of the brain and the addicted centers of the brain. More on this later.

On a practical level it is often helpful to restate the problem from another vantage point. Consider the traditional definition of alcoholism. Included in this definition is the need to consume alcoholic beverages upon awakening in ever increasing amounts to avoid alcohol withdrawal, continued imbibing despite the havoc created in one’s life and the rationalization and/or denial employed when loved ones try to talk sense into the alcoholic. This understanding is important but I also contend that one can have an alcohol problem without meeting the alcoholism criteria. Consider the individual who comes home from work every day to consume several beers or a couple of hard liquor drinks. When asked about this custom one will often hear that it is a way to “unwind” and shake off the stress of the day. Why? What about identifying the stressors and attempt to minimize them. Eradicating the source of stress may not always be possible but learning how to more effectively cope with life stress is. Why not substitute time with loved ones/friends, go for a run, meditate, listen to music or see a mental health clinician? All too often in our society we reach for a pill, a drink or an illicit substance to relieve our discomfort. The individual identified here may not meet addict criteria but can be viewed as having a substance related problem. Because of the impact of this problem on one’s life course and life quality, failure to address it becomes unfortunate. Societal acceptance of such maladaptive coping behavior is a big part of the problem, not too different from the common usage of sleeping pills in individuals who should instead directly address their insomnia.

The modern approach to addiction treatment began in the mid 1930’s after meetings between Bill W. and a surgeon now known as Dr. Bob. Dr. Bob recognized alcoholism as a disease process and not merely a social or moral weakness. Out of this came Alcoholics Anonymous whose tenets, Big Book and twelve steps comprise the bulwark of addiction treatment to this day. The twelve step model is an important component in the clinical approach to the addict but it would be unfair to suggest that “one size fits all”.

Classic AA considers the use of any mind-altering medication as taboo to the process of recovery. This is an understandable concept during AA’s early years. However, as addiction science has advanced a more balanced approach is needed. Brain imaging, genetic advances and careful epidemiologic research have all contributed to a more holistic systems approach to recovery. We now know that there are individuals whose addiction has been the direct result of their genetic makeup. As suggested in a previous paper on a systems approach I suggested that there are some individuals whose genetic predisposition only results in clinical pathology when interacting with situational stressors that subsequently activates the biologic psychopathology.

This discussion would not be complete if we did not review the concept of addiction as self-medication. This refers to individuals who discover that the illicit drug or alcoholic beverage serves to reduce or eradicate painful or troublesome mental state symptoms. A classic example is that of social anxiety. Social anxiety disorders can be devastating to say the least and often start in the teenage years. So when a teen discovers at a party that an alcoholic beverage successfully controls the anxiety and for the first time allows the individual to socially interact without emotional constraints, alcohol becomes a necessary ingredient for future social endeavors. Unfortunately, dependence and tolerance ensue and leads to a whole host of new difficulties. Opiates and marijuana similarly modulate social anxiety or panic attacks. Attention Deficit Hyperactivity Disorder (ADHD) represents another example. When the impulsive, terribly restless and hyperactive young person with an inability to focus and control a busy head finds these symptoms almost normalized upon to exposure to recreational cocaine. In fact, cocaine might represent an effective ADHD treatment modality if it were not for its horrendous addiction potential, it’s very short duration of action as well as to say the least, its illegality.

The above discussion introduces the concept of self-medication. Self-medication must be considered in all cases of addiction because once the core psychiatric problem is identified a more definitive treatment becomes possible. By stabilizing the underlying disorder the addictive process has a better chance of entering into an enduring recovery. This does not suggest that the twelve step approach is unnecessary. In fact, the combination of treatment addressing the non-substance abuse psychiatric disorder in conjunction with traditional recovery methods maximizes the outcome.

We now understand that the biology of addiction involves brain regions that get reprogrammed. As a consequence, these brain areas begins to act independently from the healthy rational parts of the brain that under normal circumstances keep us out of harm’s way. These addiction centers are essentially highjacked by the drug and can successfully pathologically influence healthy brain areas. A critical goal of addiction treatment is to help the individual develop coping skills and capabilities that subsequently allow for ability to recover control over previously all powerful addiction centers.

As you can see, successful addiction treatment requires a careful multi-system and bio-psycho-social evaluation and treatment planning that serves as the foundation for a future free of drug abuse. Each person with the scourge of addiction deserves an individualized open-minded approach. Despite all the negative media attention that addiction has garnered, the future has never been brighter for treatment. Prevention remains the ultimate goal and an ongoing challenge.

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There’s Something Rotten In…

From the desk of Dr. Gross…

I consider myself a well-trained mental health professional and as such an expert on human behavior. These days however, I find myself more and more at a loss pondering the amount of violence and hate visible in our world. This week I attended an interfaith vigil united to protest hate crimes and violence. It was uplifting to share in the community expression of mutual support, love and the need to heal. However, I left feeling that there still were no answers to the existence of such evil.

What motivates individuals to slaughter innocent people in “soft targets” like schools, theaters or houses of worship? Could it be genes at play? Family of origin pathology? Traumatic life situations? It is too simplistic to blame such behavior on a psychiatric disorder. Instead, I believe that we need to more closely example the societal influence that could spawn such tragic community events.

There appear to be some common factors among such violent individuals. They tend to be loners, self-absorbed, isolated, emotionally empty and socially estranged. They wrestle with an absence of self-worth and meaningfulness. Their antisocial actions often represent a rageful attempt to make a political point or express unmitigated bigotry. These are individuals who for the most part feel marginalized by society.

Emile Durkheim was a French social scientist who many believe was the father of modern sociology. Towards the end of the 19th century he was concerned about the prevalence of completed suicides in Paris. His carefully designed research uncovered some basic components inherent in these tragic events. He coined the term anomie that describes the sense of namelessness, lack of belonging and loss of identity often present in these individuals.

It is my belief that similar factors can be found in the murderous actions of the perpetrators of hate crimes. In many respects, the personality factors that create the self hate and negativity can be redirected outwards to others, whether it be religious beliefs, skin color or political ideology. The net result is violent acting out and tragic loss of life.

Trying to tackle the problem of preventing the development of such individuals may be an almost impossible task. However, I am most concerned about a societal development that has contributed to this process. I am referring to the explosive intrusion of social media and the internet. Don’t get me wrong, there are numerous societal benefits of the internet and social networks. But there is a major downside and that is what I would like to clarify.

Social media has contributed to the development of anomie in many of its participants primarily because of the degree to which it interferes with natural face to face social interactions. Teens are losing the natural ability to maintain eye contact due to their preoccupation with screen contact. Group social interplay suffers as well. Sure, one will sees group of teens together but they are often preoccupied with their phone screens. To make matters worse, as I have written in the past, the wanton spread of traumatic life events on all  aspects of media has profound impact on the psychological health of its innocent witnesses. We all know what it is like to watch the news on television, non-stop mayhem, murder and expressions of negative like events. When was the last time that you saw a program devoted primarily to positive heart-warming news or life events? Daily exposure to such negative stimulation does have an impact on our psyche and can lead to what I have labeled media- related post traumatic stress disorder.

So what is one to do? I think that it is beholden on parents to limit screen time of all kinds and promote exposure to healthy and emotionally uplifting media experiences. It is time to reinforce the value of books. Family mealtime should be for conversation and not for watching the screen. Screen preoccupation in restaurants should become restricted. We need to educate parents about the negative impact of social media addiction. To be successful, grown-ups must also recognize that they are vulnerable to the pathological effects of negative media exposure and therefore need to adjust their behavior as well.

I know this is a tall order. But I truly believe that in the 21st century this is a major societal challenge that cannot be ignore. Thank you for taking the time to read this commentary.

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Mental Health and a Slice of Pizza

Mental Health and a Slice of Pizza

I am sure you are wondering what pizza has to do with mental health. It is much more than enjoying a tasty slice or two. A slice of pizza represents a part of a whole and introduces us to the concept of systems theory. The systems concept helps us process a lot of information in a more orderly way, to be able to go back and forth between the whole and its parts, understanding the interaction between the forest and its trees. We can examine the individual trees while at the same time taking in the picture of the entire forest.

One’s mental health represents the forest. The goal of this paper is to better understand the trees, the critical systems that contribute to the whole of our emotional being. We are all aware of the nature versus nurture approach. To what degree can we explain a person’s psychological makeup on genes (nature) or upbringing and life experience (nurture)? I wish it was that simple, just a matter of measuring the degree to which nature and/or nurture matter so we can then direct treatment proportionally to each factor. How does one measure the effect of a problematic childhood or stressful life events? How to quantify the brain-based source of bipolar disorder or schizophrenia? Mental health professionals have some tools to provide these measurements but they are extraordinarily rudimentary. Our technology in not yet at the level to allow for definitive answers. A general systems approach helps us address the biological, psychological and social fields that ultimately contribute to our wellbeing or ill mental health.

The biological field consists of not just our brain but the body systems that ultimately influence brain function such as the cardiovascular, endocrine, pulmonary and gastrointestinal. As an example, chronic obstructive pulmonary disease (COPD) can reduce the availability of oxygen to the brain and consequently alter brain function. A simple experiment decades ago demonstrated that the use of a portable oxygen generator can significantly increase the IQ of a person suffering from COPD. This same individual would subsequently experience less depression and emotional duress. Or the individual on a variety of sedating medications that erroneously creates a clinical picture of memory deficits masquerading as a dementia. Additionally, if one has a medical disorder that will be lifelong, how do we anticipate the psychological toll it will take on the person in the future? Addressing these concerns become an essential part of the treatment team.

The social systems are a bit more difficult to assess due to the subjective nature of data gathering. Family of origin influences are paramount. Negative influences can be mollified by the presence of healthy role models and support systems when young. Interpersonal relations represent an important influence on self concept development. Only recently have we begun to recognize the impact of childhood bullying on the psyche. The goal of a reasonably healthy childhood is to produce a person whose self regard and image is based on their own uniqueness, not necessarily on being good looking, a star athlete, rich of top of their class. This healthy self concept serves as the foundation for the acquisition of future skill, talents and attributes.

To further complicate the impact of social systems on mental health we have to add a time dimension to our study that includes the past, present and the future. A person who comes out of a pathological family of origin can then be exposed to corrective emotional experiences in the present (like good friends and role models) that help dilute the damage already done. Likewise, emerging from a healthy childhood only to be currently traumatized in battle can result in enduring psychological difficulties like post traumatic stress disorder. We must also pay attention to the individual’s expectations of the future. Do they look forward with a cup is half empty approach or with a cup is half full attitude? Are they on a life path that will help ensure future stability (like a career, education, marriage, etc.) or are they proceeding towards the future with limited or confused goals and plans? Or, have they been influenced to pursue a career by their family that they really had no say in and find themselves trapped and helpless? These are several examples of the data that must be gathered by mental health professionals.

Psychological systems are not as easily assessed because they represent concepts that must be deduced and not so easily observed or measured. They include attitudes, belief systems and coping styles. They are the product of one’s journey through childhood and later life representing an ongoing learning process, for good of for bad, a process that can be adaptive or maladaptive for healthy growth. When maladaptive traits are significantly pervasive and persistently interfere with function we raise the clinical possibility of a character or personality disorder. The veracity of this diagnosis is important because treatment of personality disorders can be quite difficult and protracted.

Once we gather systems data it is now necessary to develop a treatment plan. How to determine where to direct treatment? If someone presents with depression, is it adequate to prescribe an antidepressant alone and offer no other treatment recommendations? This is where the systems approach becomes essential. For example, treating the depression alone without attending to address the presence of significant marital discord in an individual with childhood trauma will not result in the desired outcome unless the other areas of dysfunction are addressed. Sometimes it is necessary to create a stepwise approach. Let us assume that the individual with depression is so depressed that full participation in psychotherapy would be unproductive until the depression begins to improve. In this case it would be important to improve the depression with medication before proceeding with psychotherapy.

As I have discussed in past articles it is a challenge to determine if a person’s current symptoms represent a brain-based biological disorder or a reaction to a life situation. We know that all behavior, thought processes and emotional expression emanates from our brains but the difference between a biological disorder and a life reactive state is that the former tends to be long-lasting and persistent while the latter tends to be time-limited. It is important to recognize that there is a middle ground between the biological and the situational states disorders is best described as a hybrid state. The hybrid state occurs when an individual with a biological (possibly genetic) predisposition to depression, anxiety or psychotic disorders interacts with a stressful life situation. The biological predisposition is then activated and resulting in a pathological disorder.

Our pizza pie model of mental healthcare would not be complete without a discussion about the importance of assembling a team of professionals to provide both evaluation and treatment. The ideal team is composed of multidisciplinary licensed mental health professionals with multimodality evaluation and treatment capabilities. The ability to provide a comprehensive psychological test battery, perform a focused psychological trauma assessment or obtain a medical neuropsychiatric evaluation makes it possible to identify which slices of our pizza pie need to be addressed in the treatment plan. Most importantly, the presence of this team under one roof allows for ongoing treatment meetings and consultations among the professionals. Being able to share clinical information in realtime is essential to the management of complex mental health problems. Teamwork also provides mutual support for the clinicians and promotes professional growth.

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What is Self Harm?

Self harm or self-injury is the intentional wounding of one’s own body. Most commonly, a person who self harms will cut themselves with a sharp object.

Self harm can also include:

  • burning or branding (using cigarettes, lit matches or lighters, or other hot objects)
  • severely scratching
  • hair pulling (trichotillomania)
  • biting themselves
  • excessively picking at their skin (dermatillomania) or wounds
  • punching or hitting themselves
  • head banging
  • carving words or patterns into their skin
  • excessive skin-piercing or tattooing, which may also be indicators of self harm

Generally, a person who self-harms does so in private. They often follow a ritual. For example, they may use a favorite object to cut themselves or play certain music while they self injure.

Any area of the body may be targeted, however the arms, legs, or front of the torso are the most commonly selected. These areas are easy to reach and easy to cover up so the person can hide their wounds away from judgmental eyes.

In addition, self harming can also include actions that don’t seem so obvious. Behaviors like binge drinking or excessive substance abuse, having unsafe sex, or driving recklessly can be signs of self harm.

Self Harm Causes

There isn’t a simple answer for what causes people to self-injure. Although this extreme behavior may seem like a suicide attempt on the surface, it’s really an unhealthy coping mechanism.

People cut or hurt themselves to release intolerable mental distress or to distract themselves from painful emotions. Often, the self-mutilator may have difficulty expressing or understanding their emotions. People who self harm report feelings of loneliness or isolation, worthlessness and rejection, self-hatred, guilt, and anger.

When they attack themselves, they are looking for:

  • a sense of control over their feelings, their body, or their lives
  • a physical diversion from emotional pain or emotional “numbness”
  • relief from anxiety and distress
  • punishment of supposed faults

People who self harm often describe an intense yearning to injure themselves. Completing the act of mutilation and feeling the resulting pain releases their distress and anxiety. This is only temporary, however, until their guilt, shame, and emotional pain triggers them to injure themselves again.

Who is At Risk for Self Injury?

Self harm occurs in all walks of life. It is not restricted to a certain age group, nor to a particular race, educational, or socioeconomic background.

It does occur more often in:

  • people with a background of childhood trauma, such as verbal, physical, or sexual abuse
  • those without a strong social support network or, conversely, in those who have friends who self harm
  • those who have difficulty expressing their emotions
  • people who also have eating disorders, post traumatic stress disorder (PTSD), obsessive compulsive disorder (OCD), borderline personality disorder, or those who engage in substance abuse

Although anyone may self harm, the behavior happens most frequently in teens and young adults. Females tend to engage in cutting and other forms of self-mutilation at an earlier age than males, but adolescent boys have the highest incidence of non-suicidal self injury.

Self-Harming Symptoms

Physical signs of self harm may include:

  • unexplained scars, often on wrists, arms, chest, or thighs
  • fresh bruises, scratches or cuts
  • covering up arms or legs with long pants or long-sleeved shirts, even in very hot weather
  • telling others they are clumsy and have frequent “accidents” as a way to explain their injuries
  • keeping sharp objects (knives, razors, needles) either on their person or nearby
  • blood stains on tissues, towels, or bed sheets

Emotional signs of self harm may include:

  • isolation and withdrawal
  • making statements of feeling hopeless, worthless, or helpless
  • impulsivity
  • emotional unpredictability
  • problems with personal relationships

Help for Self Harm

The first step in getting help for self harm is to tell someone that you are injuring yourself. Make sure the person is someone you trust, like a parent, your significant other, or a close friend. If you feel uncomfortable telling someone close to you, seek out a teacher, counselor, religious or spiritual advisor, or a mental health professional.

 Professional treatment for self injury depends on your specific case and whether or not there are any related mental health concerns. For example, if you are self harming but also have depression, the underlying mood disorder will need to be addressed as well.

Most commonly, self harm is treated with a psychotherapy modality, such as:

  • Cognitive behavioral therapy (CBT), which helps you identify negative beliefs and inaccurate thoughts, so you can challenge them and learn to react more positively.
  • Psychodynamic psychotherapy, which helps identify the issues that trigger your self-harming impulses. This therapy will help you develop skills to better manage stress and regulate your emotions.
  • Dialectical behavior therapy (DBT), which helps you learn better ways to tolerate distress. You’ll learn coping skills so you can control your urges to self harm.
  • Mindfulness-based therapies, which can help you develop skills to effectively cope with the myriad of issues that cause distress on a regular basis.

Treatment for self injury may include group therapy or family therapy in addition to individual therapy.

 Self care for self-harming includes:

  • Asking for help from someone whom you can call immediately if you feel the need to self injure.
  • Following your treatment plan by keeping your therapy appointments.
  • Taking any prescribed medicines as directed, for underlying mental health conditions.
  • Identifying the feelings or situations that trigger your need to self harm. When you feel an urge, document what happened before it started. What were you doing? Who was with you? What was said? How did you feel? After a while, you’ll see a pattern, which will help you avoid the trigger. This also allows you to make a plan for ways to soothe or distract yourself when it comes up.
  • Being kind to yourself – eat healthy foods, learn relaxation techniques, and become more physically active.
  • Avoiding websites that idealize self harm.

 If your loved one self-injures:

  • Offer support and don’t criticize or judge. Yelling and arguments may increase the risk that they will self harm.
  • Praise their efforts as they work toward healthier emotional expression.
  • Learn more about self-injuring so you can understand the behavior and be compassionate towards your loved one.
  • Know the plan that the person and their therapist made for preventing relapse, then help them follow these coping strategies if they encounter a trigger.
  • Find support for yourself by joining a local or online support group for those affected by self-injuring behaviors.
  • Let the person know they’re not alone and that you care.

Need More Information?

Are you engaging in self harm or is your loved one self injuring? Don’t wait to seek help – speak to one of our caring, compassionate mental health professionals today. Contact the Center for Treatment of Anxiety and Mood Disorders in Delray Beach, Florida for more information or call us at 561-496-1094.

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On Being A Physician by Dr. Gross

Looking back on my many years as a physician I thought it appropriate to comment on this profession especially in a time when the core values of physician-hood are being tested.

I truly am grateful and honored to continue to serve as a physician to my patients. Unlike other “jobs”, being a physician is a unique calling. Perhaps the best way for me to share with you the special nature of this profession is by relaying an experience from my first year at medical school at the University of Florida. The Chairman of Medicine, Dr. Lee Cluff facilitated a seminar entitled “What has modern medicine contributed to humankind?” Like good medical students we each chose a topic to present; infectious disease, heart disease, etc. Each week several of us presented an in-depth treatise on our topic that covered all the miraculous advances in medicine that aided our patients. When the last medical student presented their topic Dr. Cluff then proceeded with his contribution. He started by telling us that we were all correct in our summaries as to the contributions of modern medicine while at the same time we were also wrong. He went on to state that what has not changed in over one hundred years has been the role of the physician. Our responsibility is to our patients so that at “the end of the day” they can be assured they have someone to call in their time of need. He was emphasizing the critical importance of the physician-patient relationship; the trust, compassion and honesty of communication that must be developed.

I believe that if one replicated this seminar today focusing on the amazing scientific advances in all of medicine we would still fall back on Dr. Cluff’s core premise underlying the importance of the therapeutic alliance between physician and patient. As physicians we function as healer, friend, confidant and at times wise sage. This is quite a tall order which at times can be demanding. Nevertheless I believe that it is essential component of physician-hood. This brings me to the nature of medicine in this 21st century. The stunning advances in the science of medicine have unfortunately placed an undue focus on the science itself, placing the physician-patient covenant somewhere down the priority list. There are a whole host of factors responsible for this shift including the role that modern health insurance and the managed care industry have relegated physician providers to a subservient role. Health insurance in the previous century reimbursed the individual for covered expenses. The last two decades of that century saw the development of provider physician panels that essentially allowed the insurance companies to gain control of the marketplace. Provider physicians suddenly were faced with reduced controlled fee schedules resulting in higher volumes of patients. This then led to what we witness today, patient volume-related reduction in time spent with each patient. As one would imagine, relationships are based on time and experience and as a consequence the relationships of today's medical practice have suffered.

In Psychiatry, the advent of managed care has relegated the Psychiatrist to physician prescriber while non-psychiatrist provider panels provide the psychotherapy due to insurance cost issues. As I have indicated in the past, Psychiatry is no different from other fields of medicine in that the physician Psychiatrist core role is to be able to provide a diagnostic assessment after a comprehensive examination and data gathering. The treatment plan comes next which may include additional testing, psychotherapy and/or medication. I cannot over emphasize the importance of an evaluation that employs a comprehensive medical (bio-psycho-social) model.

Despite the misgivings outlined, I remain proud of my role a physician Psychiatrist and the honor of providing care to my patients. At the end of the day it is essential for all of us to know there is someone to call in our time of need.

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How Do You Know That You Have Received a Comprehensive Psychiatric Evaluation?

As I have discussed in previous blogs on this website, the practice of Psychiatry is challenging. Unlike other medical specialties there are a paucity of laboratory testing or radiologic imaging that will reveal the true nature of the problems being presented at the time of our appointment. Instead of relying on objective data I must process a wealth of subjective information; that is, the words that you use in describing your current emotional state. I view this challenge much like a good detective would tackle a mystery. To help you better understand the complexities of the evaluation I will try to outline the key components.

Firstly, I certainly recognize that a new patient coming into my office will be uneasy and not sure of what to expect. So it is important to reassure the individual that he evaluation process is straightforward and geared to better understanding what brings the individual to my office.

This brings us to what I call the “Chief Complaint”, best expressed by asking “How can I help you?” Quite commonly people present with concerns about being depressed or suffering from anxiety. The problem with the chief complaint is that what people mean by words like depression or anxiety differ tremendously among individuals. So the chief complaint must be clarified with more specific descriptions of what the person means by the words they are using. Often a perceived problem with anxiety represents a symptom of a depressive disorder. I commonly hear individuals come in concerned about “mood swings” with a fear that they could have bipolar disorder (manic depressive illness). However, after clarifying their concerns by getting a more comprehensive description, I often discover that what they are describing I a swing between feeling fine and feeling depressed, a symptom complex that can be part of a core depressive disorder.

Once the chief complaint is determined, the next step is to obtain a “History of Present Illness”. Specifically, this entails finding out how long the difficulties have been present, what does the development of emotional symptoms look like and what was the context in which the difficulties presented themselves. Since a major goal of assessment is to discover if there are underlying biological (that is, brain related) factors causing symptoms,  it is just as important to determine if there are situational factors present during symptom development. Then the challenge is to try to better understand whether there are psychological factors (coping style, attitude and belief systems) influencing or even responsible for producing the current problems bringing the person to my office.

Current problems and symptoms must be understood in the context of any “Past Psychiatric History”. Have these problems and/or symptoms been present in the past? If so, has there been a pattern of episodes? Has there been previous psychiatric treatment and what was the outcome of such treatment? It is always helpful to know if an individual had previous depressive episodes and responded to a particular antidepressant. If there is a history of prior courses of psychotherapy, what type of therapy was it and what was the outcome?

The presence of “Substance Abuse” (another section of the comprehensive evaluation) must be discovered because of the complicating role it may play in the presentation of the individual’s symptoms and concerns. The drugs, amount used and duration of use must be clarified. When substance abuse has been extensive and long term, all bets are off in determining a non-substance abuse primary psychiatric disorder. It is only after months of a brain free of the substance(s) abused can one adequately determine the presence or absence of a core mood or anxiety disorder.

A most important section of this initial assessment consists of the “Family Psychiatric History”. Knowing what the individual’s genetic pedigree is can be very telling. If mood and/or anxiety disorders are prevalent in nuclear and extended family members the possibility of an underlying biological problem must be considered when treatment planning occurs. This does not mean that biological dysfunction is the sole problem. It is quite common to discover that there has been a stress-diathesis interaction; that is, the external situational stressors are interacting with an underlying biological predisposition.

A “Childhood History” is another critical component. To discover that there is a past history of traumatic life experiences raises questions about both the nature of the present problem and aspects of treatment planning. Bullying has unfortunately become recognized as a major factor in the development of future suffering and trauma syndromes. Determining if there was any birth injury, delay in developmental milestones or school related anxiety and avoidance or academic learning difficulties is part of this section. Although a very sensitive area of investigation, learning about a history of abuse, whether it be emotional, physical or sexual, represents important albeit painful information to gather.

The person’s “Past Medical History” cannot be ignored. This section includes the presence or absence of medical system problems (involving heart/vascular, lungs, kidney. Liver, thyroid, gastrointestinal, other hormonal, and brain) that may be impacting on the individual’s current complaints. An accurate and detailed list of current medications and dosages taken is essential for treatment planning due to the varied effects of medication on mental state as well as the risk of drug to drug interactions when psychiatric medications need to be prescribed. Obtaining a history of medication-related or other allergies, surgeries, head injuries or concussions rounds out this section.

The “Psychosocial History” explores childhood specifics, religious background, educational level, job history, marital status and special interests or hobbies. It helps to fill in the context of the present illness.

The “Mental Status Examination” is the psychiatrist’s equivalent of the internist’s physical examination. This examination evaluates the behavior and demeanor of the individual. Emotional experience and expression is assessed. Thinking content and process along with speech characteristics are components as well. A formal assessment of memory, attention/concentration, abstract language use, fund of knowledge and perceptual/sensory disturbances are an integral part of mental status.

Because severe mental disorders can lead to self or other destructive thoughts and urges, an evaluation of dangerousness risks is an important aspect of a comprehensive evaluation.

After all this information is obtained, a preliminary psychiatric assessment is provided. This diagnostic section utilizes the American Psychiatric Association Diagnostic and Statistical Manual, Edition V to aid in evidence-based diagnostic consistency.

The initial plan of treatment may include medication, lifestyle recommendations and psychotherapy. It is important to recognize that both diagnostic impressions and treatment recommendations need to be flexible because as the therapeutic relationship unfolds additional information becomes available which may alter treatment planning.  

 

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13 Reasons Why

13 REASONS WHY

Following the Netflix release of 13 Reasons Why in 2017, many mental health, suicide prevention, and education experts from around the world expressed a common concern about the series’ graphic content and portrayal of difficult issues facing youth. Resources and tools to address these concerns were quickly and widely disseminated in an effort to help parents, educators, clinical professionals and other adults engage in conversations with youth about the themes found in the show.

In advance of the release of season 2, SAVE (Suicide Awareness Voices of Education) brought together a group of 75 leading experts in mental health, suicide prevention and education as well as healthcare professionals (see full list below) to develop tools to help encourage positive responses to the series. In just a few short months, this group has developed a toolkit providing practical guidance and reliable resources for parents, educators, clinicians, youth and media related to the content of the series (suicide, school violence, sexual assault, bullying, substance abuse, etc.).

Using the toolkit and resources developed will help to encourage conversations, identify those at risk and prevent unexpected tragedies. Hopefully, it will also help those in need get the appropriate level of support and professional care to ensure that youth are protected, nurtured and our communities are stronger.

Dan Reidenberg

Executive Director – SAVE

SAVE especially thanks the following sub-group leaders in this effort:

Katherine C. Cowan

Christopher Drapeau

Frances Gonzalez

Sansea Jacobson

Matthew Wintersteen

ABOUT

The organizations listed below represent thousands of mental health and suicide prevention, education experts and healthcare professionals from around the world with decades of experience working with youth, parents, schools and communities.

SAVE thanks the following organizations for their participation in this effort:

  • American Academy of Child and Adolescent Psychiatry
  • American Association for Emergency Psychiatry
  • American Association of Suicidology
  • American Psychiatric Association
  • Australian Institute for Suicide Research and Prevention
  • Befrienders Worldwide
  • British Psychological Society
  • Danish Research Institute for Suicide Prevention
  • International Association for Suicide Prevention
  • International Academy for Suicide Research
  • Medical University of Vienna, Center for Public Health, Dept of Social and Preventive Medicine
  • Mental Health Foundation of New Zealand
  • National Association of School Psychologists
  • National Council for Behavioral Health
  • National Suicide Prevention Lifeline (USA)
  • National Suicide Research Foundation (Ireland)
  • Orygen, The National Centre of Excellence in Youth Mental Health, Australia
  • Prevention Communities
  • Samaritans UK
  • Stanford Psychiatry’s Center for Youth Mental Health and Wellbeing
  • School of Public Health, University College Cork, Ireland
  • Society for the Prevention of Teen Suicide
  • Suicidal Behaviour Research Laboratory, University of Glasgow, Scotland
  • Suicide Awareness Voices of Education
  • The Jason Foundation
  • The Jed Foundation (JED)
  • The Lancet Psychiatry
  • The Trevor Project
  • University of Michigan Psychiatric Emergency Services

https://www.13reasonswhytoolkit.org/

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