steroids:Seductive Today,Sinister Tomorrow

Steroids: Seductive Today, Sinister Tomorrow

An Appointment and Cautionary Tale

I got a new patient who came into my office- we’ll call him Rocky- and he said to me, “Ya know, I’m here because I’ve been having trouble with rage.” And then he just looks at me expectantly. After eleven words, he’s waiting for me to open my desk drawer and take out my magic wand. Bing! You’re cured! He’s clearly never been to a shrink. We talk here. 

In all honesty, I didn’t even need a magic wand at that point, because between those eleven words and my eyes, I had already diagnosed him. I should’ve waved my pen at him like a wand and said “Stop using steroids. You’re cured.” Instead, I said, “Let’s explore this a bit.”  

He says “I’m worried, I might be bipolar….” How did I just know he was going to say that? It is so typical. At 32 years of age, Rocky’s a big boy, unnaturally bulky, looks like he’s been lifting a lot of weights. Compared to his trunk, his head looks like somebody washed it in hot water. His face is oily, pock-marked with acne and scars. I’m noting all these things, jotting them down on my pad, jot jot, as he goes on. “…and I like to go to the gym to blow off some steam…” Rages jot. Acne jot. Oily skin jot jot. Bacne jot. Receding hairline jot jot. “…and lately everybody just pisses me off and I can’t…” Angry jot jot.“…I mean, I can bench a lot. So the other day, I was with my buddy and I finally figured it out; I realized that he’s jealous; that’s his problem with me…” Paranoia jot jot. “…and I know I’m his competition. I undercut him all the time. He would love to see me fail and close up shop, but…” Ah ha. Psychotic? jot jot. All of this is very typical with steroid use and abuse. “…so anyway, I can push harder, lift more, ya know? I work at it! The steroids help, but the work is all me.” Bingo! Finally! Now we’re getting somewhere. 

So tell me about that…the steroids. Who’s prescribing? “Oh no, I am buying it at the gym.” Well, how much are you using? “I’m doing 200mg every two days.” Injecting testosterone cypionate, 200mg Q 2 days jot jot jot jot jot. Buys at gym jot jot. And how long have you been using them? “Uhh, maybe about three years?” Times 3+ years jot jot jot. Do you think maybe you have a problem? “Oh, no. No.” Denies problem jot jot. I explain that he’s at a max dose for someone who has virtually no gonad function. Confusion jot. I explain that means someone who produces no natural testosterone. I spell it out. You’re taking the max dose that a person with no gonad function, zero testosterone would take, and that’s on top of your normal testosterone levels. Or I should say your natural testosterone levels. So you would be way above normal- ten times normal levels or more. And you’re wondering why you’ve been having these rages? Losing control? Loses control jot jot. Banging on s÷=%t at home jot jot jot. Screaming at wife jot jot. Have you ever hit her? “No. I haven’t hit her. But I’ve wanted to hit something. My fists are clenched and I want to tear something apart with my bare hands.” Denies hitting wife jot jot. Clenched fists jot jot jot. Believes he’s bipolar jot jot. I tell him that he’s not bipolar. Steroids are the problem here. He says, “No, it’s not. Can’t be.” No. It’s the steroids, I’m sure. Rocky says, “Ya know, I’ve been reading, and I’m saying it’s probably bipolar.” He’s just holding on to the bipolar excuse. Addicted jot jot. I mean, he would rather be bipolar- actually fight to be bipolar- than admit that his precious steroids are the sole root of his many issues. Denial jot. Steroids don’t cause a typical high, it’s more of an exhilarating positive feeling, an energized, almost super power feeling. For dudes like Rocky, with his temperment, he is all about that musclebound feeling of power. 

Have you noticed your hairline is receding. “Oh. You can tell?” Umm, yeah, I can tell- it’s like three inches back from where it should be- that’s why I mentioned it. That’s what steroids do. “Really?” Really. Bipolar doesn’t do that. Have you noticed your oily skin and acne on your back? “Yeah, I have.” Yeah. Bipolar doesn’t do that either. Guess what does. You get really argumentative and pissy. Some people actually become psychotic. “Oh, I’m not psychotic, man.” Really?  But, you know, in our conversation, you said you’re always worried about people at the gym being jealous and giving you side eye and you said people are trying to destroy your business. You know, maybe you’re getting a little paranoid. “Oh, I am not paranoid.” Uh huh, yeah. I tried to explain. When you’re getting paranoid, you don’t know you’re getting paranoid. He saw all these deep meanings and he was making these deep connections, why people would be tracking him and why government agencies would be interested in monitoring his business. Rocky is in the nursing home business. He’s not even actually running a nursing home, he just provides services to nursing homes. It’s not like he’s involved with any government agencies. He’s contracted to bring in ancillary services to nursing homes. It’s a fairly big business and he’s been pretty successful financially, but there was no root in reality for the paranoia he was demonstrating. 

I asked him if he noticed anything else, like maybe breast enlargement? “Ahh, maybe a little bit, but no big deal.” Mmm hmm. + breast development jot jot jot. He says, “You know, my muscles got bigger, I got leaner, and my endurance increased. I felt trimmer, more energetic.”   You said your endurance went up, how much cardio do you do, Rocky? He says, “Well, I used to do more, but man, I’ve gotten so much bigger that it’s hard to breathe when I do heavy cardio, you know?” No, I don’t know, because I don’t abuse steroids. Androgenic erythrocytosis jot jot jot. That means that you have increased the number of red blood cells in your blood, so your blood becomes thick and viscous like oil. You have so many red blood cells, it’s tough for your heart to beat, it’s tough for your lungs to get oxygen, because there’s drag from the increased viscosity, so when you do cardio, you can’t breathe. “Yeah, yeah. I can barely run. I used to do triathlons. I can’t do them anymore, but I can lift way more weight.” Yeah, because not only are the steroids making your blood thick like oil with RBCs, the thick blood makes the left heart ventricle- the one that does most of the pumping of the blood- thick. It’s a muscle, so the thick viscous blood overworks it as it tries to pump that thick gross blood through, so it makes that left ventricle wall thick, really thick. So instead of having a thin elastic pump that pumps blood in and out easily, you get this thick, wide left ventricle wall that cannot pump effectively. It enlarges the left ventricle wall, so you can’t pump good oxygen rich blood through. It’s called hypertrophy. With all those factors going on, it’ll cause hypertension. “Oh, yeah, I take medicine for that.” Like no, big deal. Aah, I just take medicine for the damage that I’m causing myself. Duh! + hypertension jot jot jot. + medication jot jot. And did you tell the doctor that prescribes that med that you’re using steroids? “No.” Nice. Prescribing Dr. unaware of illicit steroid use jot jot jot jot jot. Do you know that hypertension leads to kidney disease? “Really? My kidneys work good I think.” I’m thinking ‘maybe for now’ to myself. You think you look good on the outside, although you’re balding, your skin is oily, you have pitted acne scars on your face and acne on your back and you’re growing boobs like a teenage girl and your testicles are microscopic and you have low to no sperm and your penis doesn’t work… and you can’t breathe with any amount of exertion because your blood is thick and gross so your heart is all enlarged and your blood pressure is so high you have to take medication like a man more than twice your age. And you’re causing all of it! Through your steroid addiction. And as if the physical side isn’t bad enough, now it’s affecting you mentally. You’re paranoid, on the verge of psychosis…really you’ve got a toe or two over that line if you want the truth. So no matter how big your muscles are, no matter how good you think you look (and my raised eyebrows were clearly saying that was debatable) you are destroying your body. “Um, like what? How?” Now he’s really listening. I continued. Do you understand what hypertension actually is and does? Cause and effect? How about atherosclerotic plaques. What are those? What do they mean? The arteries in your heart become lined with plaques that are basically made of fat. These fat plaques are sticky, so as your thick gross blood slogs through the arteries, the fat plaques gather and narrow the arteries, so you cannot push blood through the arteries. Eventually, they clog off. It’s like a tunnel being filled with more and more muck, so there’s not enough room for blood to flow through and you get a heart attack and die. But before that happens, you’re incapacitated with high blood pressure because your thick oversized left ventricle is trying to push your thick gross blood through arteries that are filled with fatty muck, athersclerotic plaque filled arteries. “I didn’t know all that.” I’m sure you don’t, but I’m not done educating you yet. It gets better. Well, actually worse. 

Education jot. Steroids decrease HDL, which is the good cholesterol that helps keep your arteries open. And it also raises the LDL, which is the bad cholesterol that causes the fatty plaque to build up. So lowers the good while raising the bad. Got that? “Yep. Got it.” So that causes hypertension, and makes you prone to heart attacks and strokes. Did you know that hypertension also makes your kidneys malfunction? I didn’t think so. Right now, your kidneys are trying to pump under hypertension, and that kills them. The gross viscous blood thick with red blood cells kills them. So your kidneys shut down. Do you like to be able to take a piss? To be able to clean your thick slaggy blood of all the toxins you make? He nodded that yes, he rather liked to be able to take a piss and clear his thick slaggy blood of all the toxins he makes. I thought so. Enjoy it while it lasts. Before long, a machine will do that for you: four hour sessions, three times a week…if you’re lucky enough to live that long. If the massive heart attack doesn’t kill you first. Honestly, Rocky looked like he was about to have a heart attack right now. I know I’m hitting him pretty hard with all of this at once, but this guy was in a romantic relationship with his precious steroids, and I need him to break it off, clean and quick like. But wait, there’s more!

Now, with all this bad stuff going on, the little vessels throughout your body do not pump blood as well because they are clogged and they are hypertensive. So all those tissues, joints, and bones are starved of nutrients and oxygen. You get something called avascular necrosis. Avascular means without vasculature- blood vessels- and necrosis means death. It’s everywhere, but especially in the hips, with the ball and socket joint. The little vessels that feed the balls of your hip joints, where the femur meets your hip? Hello, the blood supply gets occluded- it gets starved- and then it gets dead. So you can recognize all the steroid abusers out there: they’re the 40 year olds using wheelchairs and walkers, whining about the pain in their hips. Balding, acne, boobs, erectile dysfunction, heart problems, kidney issues, disability, chronic pain. On and on. Oh yeah, it’s pretty bad, but it gets worse. His face fell. I couldn’t let up now. You enjoy being able to lift weights? You enjoy being physically capable? Like a zombie, he mumbled on a sigh “Yes…” I’m glad you do. But don’t get too used to it. Because if you keep this crap up, keep injecting that garbage, you’ll build your muscles up beyond what your body can handle. You’ll build them up- your muscles will get bigger- but your ligaments and tendons can’t be built up, and they can’t support these unnaturally large muscles. Do you know what muscles without ligaments and tendons do? Not much. Without healthy ligaments and tendons, big muscles are useless for anything but causing pain, debilitating pain. When you’re pumping iron, lifting really heavy weights, your ligaments and tendons get damaged. In no time, the muscle size supercedes the ability of the damaged ligaments and tendons, so you get irreversible chronic muscle pain. Sounds great, right Rocky? Oh, wait, and to top it all off, now you’re having psychological effects. You’re having rages. You want to tear something apart with your bare hands. You said that. What’s scary is that right now, at this moment, you have the physical ability to do that. If somebody pushed you too far on a bad day, you might go there. You could kill someone. I’ve seen it happen to a patient. A guy a lot like you. He came in here young and dumb and I explained everything to him, just like I’ve done with you. For several years, I begged him to stop. He refused to listen; didn’t believe me. Ultimate in denial. He’s in prison now for the next 30 years; that equals a life sentence for him. It’s scary. What’s even scarier is that if you keep this crap up, keep sticking yourself with that needle, you won’t be able to tear somebody apart for long. You might want to, but you’ll be too debilitated. That guy in prison? He’s in a wheelchair now 90% of the time. He uses a walker sometimes- when he can stand the pain- which isn’t often. 

I’ll make this very plain. You are addicted to steroids. They are physically wrecking your body, the body you seem to worship. Oily skin, acne, bacne, boobs, receding hairline, balding, teeny tiny testicles, a penis that you can’t get up…and no sperm to come out of it anyway. And that’s just the stuff on the outside that people can see! Your insides get wrecked too. Thick slaggy gross blood, hypertension, atherosclerosis, heart attack, stroke, kidney dysfunction, erectile dysfunction, avascular necrosis, chronic pain. And now you’re raging, scaring the crap out of your wife, you’re paranoid, becoming psychotic. You have nothing positive happening in your life. So it’s your call, Rocky. I can help get you off the train here before it runs your ass over. He was nodding very slowly, but clearly shell-shocked. Look, how about this. Don’t use for two weeks and see me again. You’ll have some time to digest all of this. Can you do it? If you can’t- if you feel like you’re gonna hit that needle- I’ll see you sooner. Here’s my cell number. Call me anytime, but especially if and when you’re tempted to use. Deal? “Deal.” We shook on it.  

Dx: steroid addiction, assoc features jot jot jot jot

Pt agrees to d/c use jot jot jot

F/up 2 weeks, will call/ see sooner prn jot jot jot jot jot

Here’s the bottom line on steroids people. Your body just does not like these drugs in excess. There may be some use for them in people with anemia, in people who have wound healing problems, a temporary use in people with HIV or cancer who do not want to eat, and in muscle wasting diseases for short periods of time and in very regulated doses, okay…fine.  

But, for my Olympic athlete patients, my professional athlete patients: you all know who you are. All of my Rocky’s out there: cut it out! You’re sterile, can’t get it up, scared everyone’s gonna see your breasts, hello, they are! I know you’re saying ‘but I cycle them on and off, doc!’ I say bullshit. No, it causes permanent damage to heart, kidneys, tendons, and ligaments. Not to mention the cosmetic aspects: the oily skin, the acne on your face and back, the balding, receding hairline… and you say ‘oh, but to minimize the breasts I use an estradiol’ (an anti-estrogen, because testosterone breaks down to estrogen, so if you use an anti-estrogen in someone who is abusing testosterone or testosterone-like drugs, you will not get the breast enlargement) Yes, that’s true. I’ll give you that. But, you still get all that other crap, guys! Hellllo!! All my elite athletes, you all whine like ‘No, no, no, I need it to stay competitive, because everybody else is doping!’ Whatever! You are addicted to the high, the performance, and the cosmetic enhancement. You get big muscles, tiny balls, and tinier brains. You also get limp and sterile, permanent damage to the ventricles, the heart, and the kidneys, hypertension, and its host of other problems. You are predisposing yourself to coronary disease, heart attack, and stroke. You become delusional, and you fly into rages when the wind blows.  

As you are my patients, I’ve probably told you about other patient stories. For those that haven’t heard them: one steroid abuser was very paranoid and psychotic, but of course didn’t know it, because you will not see yourself becoming psychotic. He was stopped at red light. I don’t know what he was doing, but when the light changed green, he didn’t go right away. So the car behind him honked. He started ticking like a time bomb, and the car kept honking, but for whatever reason, he still didn’t go. Instead, with the light still green, he got out of his car. With a golf club. He went off, banging on the guy’s car with the golf club, and he just didn’t stop. Eventually, they called the police.  The police came and they had to subdue him with a tazer because he was out of control. When he was transported to the emergency room, he continued there, even continuing to spit and scream, even after being put in four-point restraints. Finally, he had to be pharmacologically restrained with a freaking rhino dart. Unbelievable. I mean, he was all black and blue, like he had been beaten, but he did it by thrashing, all by himself. His whole affect was totally inappropriate. I know that some people are beaten by police for no reason; they don’t deserve it, but this maniac was taking every opportunity to hit the police officers for absolutely no reason. In the hospital, he was arguing with nurses, disturbing the entire emergency department for no reason. His wife finally came in, but even she couldn’t calm him. He just lost it, in every sense. He was (or had been) on the road to being Mr. Olympia or some such title. He was 190 pounds, and bench pressing over 450 pounds. It was just crazy. Eventually, but not long after, he went into kidney failure. But it wasn’t from the steroids. Yeah, right. Denial!! jot jot

You know, it also causes immune suppression, so you don’t fight off pathogens like viruses, like COVID-19, like any bacteria. I had someone who had a heart attack and died. He was 25. Another stroked out in his late 30’s. These patients are Olympians, professional athletes, and really elite level people. They’re so hyper-disciplined about their diets and their training and supplements and sleep patterns and all of that. But they’re abusing steroids. It’s a crazy dichotomy. Some have made it. Big success stories that stopped and then did it the right way. But many don’t. Right now I have a 45-year-old man who is just going into kidney failure. And the one with psychosis that killed the guy that set him off. He’ll die in prison. Now I have Rocky. I hope I opened his eyes. 

Remember, people… just because you cannot see what’s going on doesn’t mean the steroids aren’t destroying you. They are. But you can get there without them. And PS, for those that are wondering, there is a steroid withdrawal: headaches, drowsiness, decreased appetite, weight loss, fatigue, depression, dizziness. It’s a mess when I get them off, especially when they do high dose. It takes two to four weeks, and they are miserable, cranky, irritable, and obnoxious people to deal with when they are in withdrawal. I use benzodiazepines, things to help them sleep; I sometimes add anti-psychotics because they can’t see themselves drifting to the psychotic lane, sometimes hearing voices and seeing things. It’s a spectrum. And lots of misreading events in reality… “Those people are talking about me. They’re plotting against me. Those police officers are here to get me, or that group of people talking over there are planning something against me or these workers are not working because they are all in a grand plot against me. They are very faint signs and forms of psychosis. Hearing voices and seeing things, disorganized speech and behavior is the extreme. But there can be the unextreme, the misreading, the over-emotional abnormal response to normal events, thinking people are plotting.  

Probably from age 10 to 30 is when most people started and abused the steroids. And too often, it’s a one way trip, once they start, they get lost in it. You know, “I am superman now” and they don’t stop, and then they stroll into my office and then I deal with them when they are 45 to 50 and that’s when their kidneys shut down, when they get a heart attack, when they are debilitated with degenerative disk disease from lifting too heavy weights, their ligaments and tendons go, they become sterile, they cannot have kids, they’re in constant horrible chronic pain. They have heart problems and kidney problems, and that’s what gets them. If they have heart and kidney failure, to the point where the organs have just given up, that’s what kills them.

Hopefully not Rocky jot jot jot

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Sociopath or A-hole How To Tell The Difference

Sociopath or A-hole?

How to Tell the Difference

When you think of a sociopath, you probably picture someone like Dr. Hannibal Lecter in Silence of the Lambs, or Annie Wilkes in Stephen King’s Misery. But like most mental health conditions, sociopathy- otherwise known as antisocial personality disorder, or ASPD for short- exists on a spectrum. And clearly, kidnapping and hobbling your favorite author or enjoying a cannibalistic dinner with a nice chianti would be pretty out there on that spectrum. 

Before I get started on the details of recognizing sociopathy, I want to quickly remind you about last week’s blog topic, the differences between sociopathy and psychopathy. Both disorders are considered ASPD’s, but people tend to use the terms sociopath and psychopath interchangeably, though they mean different things. Typically, sociopaths are a product of their childhood environment or upbringing. Disturbed and unhinged, they’re not always big planners, so they’re more prone to impulsive behavior. They’re very likely to break rules and/ or laws without thinking twice, but as for going on a murderous rampage? Not so much. On the other hand, psychopaths are essentially born, and have an innate disdain for others coupled with a compulsive need for violence. They are cold and calculating, and can even be charming when it suits their purposes, a la Ted Bundy. Psychopaths are at the most extreme end of the antisocial personality disorder spectrum, and while all psychopaths are antisocial, not all antisocials are psychopaths. 

There are many people with difficult personalities out there, all of which can impact your life to varying degrees. These are your garden variety a-holes, and they’re usually pretty simple-minded and relatively harmless if you don’t pay them much attention. But sociopaths have one of the most hidden personality disorders, as well as one of the most dangerous. They often slip under the radar because they put so much energy into deceiving people. In my vast experience with sociopaths, most people don’t know what to watch out for, and they’re generally shocked at how easily they can be manipulated. In truth, anyone can be a target. The point of this week’s blog is to explain sociopathic behavior, help you identify potential sociopaths in your life, and share how to deal with them once you do. 

Sociopathy occurs in nearly 4 percent of the U.S. population, which works out to about one in 20-ish people. There is a clear link between ASPD and sex. You are 3 to 5 times more likely to be a sociopath if you own a Y chromosome; and only 25% of sociopaths are female. Obvi not all men are sociopaths, but being male can be one clue in identifying them.

Whether someone has intentionally deceived you for their own perverse pleasure, or you’ve had a college roommate eat the last of your mom’s famous homemade lasagna without asking before or apologizing after, you’ve experienced sociopathic behavior. Fortunately, your selfish roommate’s sociopathic behavior probably doesn’t make him an actual sociopath… it just makes him rude AF. 

So that begs the question: how can you differentiate between an a-hole and a sociopath? It’s not always as easy as it seems, because sociopaths can be masters of deception, and some traits might be hidden by their frequent lies. Remember too that they can be intelligent and good at manipulating people into doing what they want, so they may come across as friendly and outgoing when it’s really all a ruse.

That said, here are some of the general themes to be on the lookout for:

Sociopaths can be highly effective at getting you to overlook any warning signs you see or sense. That’s why they’re called con artists: they take you into their confidence, and you trust them. You will doubt yourself before you doubt them. They are narcissistic, believing they are better, smarter, cuter, funnier, and more interesting than anyone else. 

In a dating relationship, a sociopath may be the most loving, charming, affectionate, and giving person you have ever met. But, if it seems too good to be true, it usually is. They are likely to be secretly dating several other people. They can be very promiscuous and are loyal to no one. They’re also very quick to anger. If you dare to question them, their anger response is totally outside the scope of what would be considered ‘normal’.

They can be fast talkers and bull$#&t artists. They’ll say anything to cover up their secret activities, no matter how ridiculous it sounds. I have a patient that was actually living with 3 different women in 3 different houses, at the same time- and the women were happy and had no clue about his deception. I actually had him bring each of them (in separate appointments, of course) for a couple’s session, because I had to see it for myself. Get this…he would tell them that he did contract work for the CIA, so he couldn’t give them any details about it. When he would leave a woman to be with one of the others, he’d just say that he’d be gone all the next week on a secret mission. And then he would lament about how much he wished he could tell them all about it, but he just couldn’t, so they must never askhim about it. And they bought it, hook, line, and sinker! 

They quickly lose interest in a girl-/ boy- friend, but they’ll keep them hanging on with a few words of love, so that they can still have sex with them, borrow money from them (which is never returned) and maintain access to their house or car. They have no empathy, so they’ll use them until they’re not useful anymore, and then leave, feeling no remorse for any damage they’ve left in their wake.

They are secretive. They may pretend they are going to work at the office everyday, when they’re actually going out to deal drugs. Or gambling away their paycheck, then saying they were robbed. They’re often impulsive and irresponsible, and unable to maintain a job, so they don’t have money and need to find a reason to cover that up. They like to see how far they can control a situation, what they can get away with. Everything is done for their personal gain, and they have a greatly exaggerated sense of self-worth.  

Sociopaths love to play the victim. They’ll tell you a story about how someone else took advantage of them, or how life circumstances treated them very badly. This is a calculated tactic to get you to feel sorry for them, so that you’ll want to help them. This ploy works, because normal, healthy people naturally care about others, even strangers. Ted Bundy tore a page out of the sociopath’s play book and used to put a fake cast on his arm or leg, then drop a bunch of books near an isolated young woman on a college campus. Then he would ask her to help him carry his books back to his car, and when they leaned into his car to put the books in the back seat, he would shove them inside. And the rest was history.

I’ve seen firsthand how all of these kinds of activities have gone on under the radar for so many people in relationships with sociopaths. The targets are always shocked, because the sociopath was so good at living a lie. But as I tell the victims, that’s what they do. 

Officially diagnosing someone as a sociopath using the DSM-IV isn’t always as simple as you might think. But, if someone has three or more of the tendencies listed below, as Jeff Foxworthy would say, they might be a sociopath:

-Failure to conform to social norms (i.e, they break the law)

-Repeatedly lie or con others for profit or pleasure

-Fail to plan ahead or exhibit impulsive behavior

-Repeated irritability or aggression (i.e, they always get into fights)

-Reckless disregard for the safety of themselves or others

-Consistent irresponsibility (i.e, they can’t hold down a job or meet financial obligations)

-Lack remorse (i.e., they rationalize their actions or are indifferent to other people’s feelings)

Following is more information on some of the red flag symptoms of sociopaths to watch out for, based on criteria listed in the DSM-IV.

Symptom: Lack of empathy

Perhaps one of the most well-known signs of a sociopath is a lack of empathy, particularly an inability to feel remorse for their actions. When you don’t experience remorse, you’re basically free to do any horrible thing that comes to your sick mind. That’s a problem. 

Symptom: Difficult relationships

Sociopaths find it hard to form emotional bonds, so their relationships are often unstable and chaotic. Rather than forge connections with the people in their lives, they might try to exploit them for their own benefit through deceit, coercion, and intimidation.

Symptom: Manipulativeness

Sociopaths tend to try to seduce people and ingratiate themselves with the people around them for their own gain, or just for sheer entertainment. While some are charming, this doesn’t mean they’re all exceptionally charismatic. I’ve seen plenty that I would not call charming in any way, shape, or form. But they think they are of course; this can be an important distinction. 

Symptom: Deceitfulness

Sociopaths have a reputation for being dishonest and deceitful. They often feel comfortable lying to get their own way, or to get themselves out of trouble, whatever motivation they may come up with. They also have a tendency to embellish the truth when it suits them. 

Symptom: Callousness

Some sociopaths can be openly violent and aggressive. Others will cut people down verbally. Either way, they tend to show a cruel disregard for other people’s feelings.

Symptom: Hostility

Sociopaths are not only hostile themselves, but they’re more likely to interpret others’ behavior as hostile, which drives them to seek revenge. Revenge is a primary goal when a sociopath feels wronged.

Symptom: Irresponsibility

Sociopaths often have a deep disregard for financial and social obligations. Ignoring responsibilities is extremely common, which can include not paying child support when it’s due, allowing bills to pile up, and regularly taking time off work. Their needs and wants supersede everyone else’s, no matter who they are, even including their children. 

Symptom: Impulsivity

We all have our impulsive moments: a last minute road trip, a drastic new hairstyle, or a new pair of shoes you just have to have. But for sociopaths, making spur of the moment decisions with no thought for the consequences is part of everyday life. They find it extremely difficult to even make a plan, much less stick to it.

Symptom: Risky behavior

Combine irresponsibility, impulsivity, and a need for instant gratification, and you get risky behavior. It’s not surprising that sociopaths get involved in risky behavior, because they tend to have little concern for themselves, let alone the safety of others. This means that excessive alcohol consumption, drug abuse, compulsive gambling, unsafe sex, dangerous hobbies, and criminal activities are all on the sociopath’s to-do list.

Can sociopathy be cured or treated?

There’s no cure for sociopathy, and there isn’t a lot of evidence that it can be successfully treated. Typically, the main issue in treating it is that it’s unusual for a sociopath to seek professional help. One of the curious things about this disorder is a general lack of insight on the sociopath’s part. They may recognize that they have problems, might notice that they get into trouble on the job, and may recognize that their spouses are not happy with them. But they tend to blame other people, and other circumstances, for the trouble; this is part and parcel of the diagnosis. The good news is that symptoms of sociopathy and other ASPD’s seem to recede with age, especially among milder cases and in people that don’t do drugs or drink to excess. Cognitive behavioral therapy isn’t very helpful for treating the disorder itself, but it can help people to stop certain devious behaviors. Sociopaths might not really develop actual empathy or learn to feel badly about their actions, but they could possibly learn to stop eating their roommate’s lasagna.

So now you know the symptoms of sociopathy to look for and you’re better prepared to recognize a sociopath. But if you suspect that you’re dealing with a sociopath, what should you do?

The best and simplest answer is to get far away from them, to permanently extricate them from your life. If you don’t, they will seriously complicate that life. Unfortunately, that isn’t always possible. If it’s your boss or a relative, you might not be able to just cut ties and bolt, but you can learn how to deal with their sociopathic behavior and still remain true to yourself and your own mental health.

First, trust your instincts. A person doesn’t need a DSM diagnosis to be a manipulative a-hole who’s causing you harm. If they don’t care about your feelings, repeatedly lie to you, and manipulate your emotions for their pleasure, they aren’t someone you should be around, sociopath or not.

Secondly, remember that you cannot change this person. They may not realize that what they’re doing is abnormal, and they definitely don’t give a flip if it hurts you. You must let go of any illusions that you can fix them or get them to be a better person.

As you distance yourself from them, the sociopath might try to make deals with you. Do not go along with it! They don’t care about your feelings and they don’t obey any rules, so they will never honor any deal they offer. And even worse, when it fails (because it will) they will say that you were the one that ruined the deal; they’ll try anything to put any and all blame on you. So your best bet is to just avoid that crap all together.

If you’re not sure how to distance yourself from this person, or you need other tools to deal with them, talk to a therapist. They’re far better able to spot the true tendencies of a sociopath, and they can help you learn how to set boundaries or remove yourself from the situation. They can also help you cope with the harm the sociopath inflicted and the damage they left in their wake.

If the person seems like they’ll cause extreme harm to themselves or others, you can call an emergency mental health line. SAMHSA (Substance Abuse and Mental Health Services Administration 1-800-662-4357) is a good one. And If you are, or anyone else is, ever in any physical danger, call 911 immediately.

Now you know all the hallmark behaviors of a sociopath and what to do when you realize there’s one squirming around in your life. There are a bunch of sociopaths out there, so by all means, share the knowledge with your friends and family. 

For more information and patient stories on sociopathy and other personality disorders, you can read my book, Tales from the Couch, available on Amazon. And you can also check out my lectures and subscribe to my YouTube channel by searching under Mark Agresti. 

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Psychopaths and sociopaths Tomato Tomato or Tomato Potato

That dude in the little blue speedster flying down I-95 and using all three lanes to cut everyone off and pass them… what a total psycho! The captain of the high school cheerleading squad who’s demanding that her boyfriend work extra hours to pay for her hair and nails to get done every week… that chick is such a self-centered sociopath! We pin these labels on people easily, and often jokingly, but psychopathy and sociopathy are pretty serious states of being, sometimes far from a joking matter. 

Do you know someone who seems to have no understanding of what it means to show empathy or concern for others, someone who has no regard for right or wrong, or someone who actually seems to derive pleasure from hurting others? To you, this behavior and personality seem calloused and unreal, maybe even impossible to believe; but believe it…if the above characteristics sound familiar to you, you’ve probably crossed paths with a psychopath or sociopath. 

A lot of people use the labels psychopath and sociopath interchangeably when referring to a person who exhibits a wide array of creepy, odd, or dangerous behaviors. But while the two do share some common traits, there are other points that separate them as well. Both sociopaths and psychopaths have a patent disregard for the safety and rights of others, and manipulation and deceit are central features to both personalities. Contrary to popular belief and what you see in the movies, psychopaths and sociopaths are not necessarily bloodthirsty or violent. Surprised? Violence is actually not a necessary requirement for a diagnosis of psychopathy— but it is often present. In this blog, I’ll shed some light on sociopathic and psychopathic traits, go over why they’re grouped together, and also what sets them apart from one another.  

In actuality, neither psychopathy and sociopathy are official diagnoses on their own, but The Diagnostic and Statistical Manual of Mental Illness puts them under the heading of antisocial personality disorders, meaning that people with psychopathy and sociopathy have a diagnosis of antisocial personality disorder, hereafter ASPD. 

ASPD is a mental health diagnosis characterized by a lack of empathy, ie an inability to care about the needs or feelings of others. Approximately 3 percent of the US population qualifies for a diagnosis of antisocial personality disorder. It is more common among males and more often seen in people with an alcohol or substance abuse problem, or in forensic settings such as prisons. People with antisocial personality disorder are usually master manipulators and absent of moral conscience. The exact cause of ASPD is not currently known, but environmental factors, genetics, and possible changes in the function and structure of the brain are believed to be factors that contribute to its development. Other contributing factors may include having a family history of mental health disorders or a history of living in an unstable or violent family in an abusive or neglectful environment. In both cases, some signs or symptoms are nearly always present in a person before the age of 15, so that by the time that person is an adult, they are well on their way to becoming a full fledged psychopath or sociopath.

The common features of a psychopath and sociopath lie in their shared diagnosis and key characteristics of ASPD:

Lack of empathy toward others

Constant deceitful or manipulative behavior

Little regard for the safety of others

Difficulty with all relationship types

Aggression or irritability

Criminal history

Lack of remorse or guilt for actions

Reckless and/or dangerous behavior

Laws/ Rules don’t apply to them

Regularly breaks or flouts the law

Impulsive and doesn’t plan ahead

Prone to fighting and aggression

Irresponsible, can’t meet financial obligations

As with many things in life, there are different levels of both psychopaths and sociopaths.

Some might be thieves or cheaters, while others could be actual killers. The most concerning difference between psychopaths and sociopaths is that when someone is a psychopath, you’ll probably never know it, never have the faintest idea… which is what makes them even more dangerous.

You’re probably familiar with some famous fictional psychopaths and sociopaths. How about psychopath Hannibal Lecter from Silence of the Lambs, or the psychopathic detective Dexter from the primetime crime drama of the same name. Or sociopathic pop culture hero, King Joffrey from Game of Thrones, and the sociopathic Joker in The Dark Knight. These characters all had ASPD and lacked empathy, broke laws and disregarded rules, ignored others’ rights, exhibited violent tendencies, and never felt an iota of guilt for their behavior, if they even knew they behaved badly and hurt people in the first place. Which they probably didn’t.

Traits of a Psychopath

Psychology researchers generally believe that people are born psychopaths, as it’s likely associated with genetic predisposition. The flip side is that sociopaths tend to be a product of their environment, perhaps as a result of abuse. But that’s not to say that psychopaths may not also suffer from some sort of childhood trauma. 

Research has shown that psychopathy might be related to physiological brain differences, as psychopaths often have underdeveloped areas of the brain in regions that are responsible for emotion regulation and impulse control.

Generally speaking, psychopaths are superficial, egocentric, and emotionally shallow. They’re practiced and smooth operators, and they will compliment you, make you feel good, and say all of the right things, until you find out later they’ve been playing you for their own purposes, using you, stealing money from you, or plotting some kind of crime…like your murder. 

They’re extremely manipulative and pros at gaining others’ trust. They have a hard time forming real emotional attachments with others, so they intentionally form shallow, artificial relationships designed to be manipulated in a way that most benefits them. They see people as pawns to be used to forward their own goals and agendas, and rarely, if ever, feel any guilt regarding how they treat others or how much they hurt them. 

Psychopaths can often be seen by others as being charming and trustworthy, as they hold steady, normal jobs. They tend to be very successful and well liked, much like master con artists. They may even have families and seemingly-loving relationships with a partner. And while they tend to be well-educated, they may also have learned a great deal on their own, living in and experiencing the real world. They are the princes most charming of all…until they aren’t anymore. Legendary psychopath Ted Bundy comes to mind here. Women found him smart and attractive, and they took him at face value; and that was their undoing.

When a psychopath engages in criminal behavior, they tend to do so in a way that minimizes risk to themselves. If that means they must implicate an innocent party in the behavior, so be it. They will carefully, and even obsessively, plan criminal activity to ensure they don’t get caught, having contingency plans in place for any and every possibility.

While psychopaths are like chameleons, seamlessly blending into their environment, sociopaths are easier to spot. The cool, calm psycho attitude is replaced by the hot-headed sociopathic one. They are rage-prone, and if things don’t go their way, they’ll get angry and aggressive, with emotional outbursts.

Traits of a Sociopath

Researchers tend to believe that sociopathy is the result of environmental factors, such as a child or teen’s upbringing in a very negative household; or in any situation that resulted in physical abuse, emotional abuse, or childhood trauma.

In general, sociopaths tend to be more impulsive and erratic in their behavior than their psychopath counterparts. While they also have difficulties forming attachments to others, some sociopaths may find it easier to form an attachment to a like-minded group. Unlike psychopaths, most sociopaths have a difficult time holding down a long-term job, fitting in properly with some social situations, and presenting a normal family life to the outside world.   

When a sociopath engages in criminal behavior, they may do so in an impulsive and largely unplanned manner, with little regard for the risks or consequences of their actions. They may become agitated and angered easily, sometimes resulting in violent outbursts. These kinds of behaviors increase a sociopath’s chances of being apprehended.

Who is More Dangerous?

As with many things in life, there are different degrees of severity in psychopaths and sociopaths. In reality, both pose risks to society, because they must constantly, 24/7-365, find ways to cope with a way of thinking and a way of life that is different from society’s accepted norm, and this can make them edgy. But, that said, psychopathy is the more dangerous disorder, because people with it experience far less guilt connected to their actions. Also, a psychopath is better able to dissociate from their actions, meaning they can easily separate emotional feelings from any actions they undertake. Without this emotional involvement, any pain that other people suffer is completely meaningless to a psychopath. All of the most famous serial killers have been psychopaths.

Psychopath v Sociopath: Childhood Clues

Clues indicative of later psychopathy and sociopathy are usually available in childhood. Most people who are diagnosed with sociopathy or psychopathy have had a previous pattern of behavior in which they violated the basic rights of others or endangered their safety. They also often have a childhood history of breaking rules and laws, as well as societal norms too. These kinds of childhood behaviors are recognized as a conduct disorder. 

Conduct Disorders:

Four categories of problem behavior

Aggression to people and animals

Destruction of property

Deceitfulness or theft

Serious violations of rules or laws

If you recognize any of the above four symptoms or any of the specific childhood clues of conduct in a child or young teen, they’re at much greater risk for having antisocial personality disorder. We’ll talk about what to do with that next week. Also next week, we’ll get deeper into how to spot a sociopath. 

Check out my website for more blogs at dragresti.com/blog/ and pass them around to friends. Search my name on YouTube to see all of my lectures there and subscribe to my channel, people. And share with your friends! Also, as always, my book Tales from the Couch is available on Amazon.com.

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Pedophilia:Predators in Your Back Yard

*Sensitive Content*

*Reader Discretion/ Age Advisory*

Pedophilia: Predators in Your Back Yard

Pedophilia has become a topic of increased interest, awareness, and concern for both the medical community and the public at large. In my nearly thirty years of practice, I am sad to say that I have treated far too many victims of pedophilia and sexual predation of every unimaginably horrific kind; those narratives are indelibly etched into my memory. In the last decade or so, increased media exposure, new sexual offender disclosure laws, web sites listing the names and addresses of convicted sexual offenders, and increased investigations of sexual acts with children have increased public awareness about pedophilia. That’s definitely a good thing. The passing of laws, like Megan’s Law in 1996, authorizes local law enforcement agencies to notify the public about convicted sex offenders living, working, or visiting their communities, and has helped expose pedophiles living amongst us, and this allows parents to better protect their children.

But in the age of the internet, cyber predators can stalk their victims from a safe distance before ever suggesting they meet. They can be very cunning, and they often lie about their age/ gender/ status/ likes/ dislikes; they play online team video games to attract children, and they make up customized stories, tailor made to lure specific victims. Because of these realities, it’s important for everyone to understand pedophilia, its rate of occurrence, and the characteristics of both pedophiles and sexually abused children. 

In recent years, the law has taken a tougher stance on dealing with pedophiles and sexual predators, and exposure is often the order of the day for the media, as these cases play out in the wide open. You need only note the allegations of sexual predation in the priesthood or in the Boy Scouts to realize that predators are everywhere, even in some unlikely places. Who can forget Jared Fogle, the smiley faced Subway spokesman who lost 200-plus pounds, supposedly by eating only sub sandwiches? Who would’ve ever guessed that he was actually a predator, targeting children of middle school age, a demographic he often found himself in the company of during his well paid and nation wide lectures about healthy eating habits. That age group was his preference, but he wasn’t discriminatory by any stretch of the imagination. He made that quite clear in the surreptitiously taped conversations he had with a “friend” who was actually working undercover for the FBI. I was physically repulsed when I heard those recordings, and even as I remember them now, I can actually taste and feel the bile rising in my throat. Ultimately, in 2015, Fogle was adjudicated as guilty of charges of child pornography and having sex with minors, and was sentenced to more than 15 years in prison. He apparently passes the time by filing frivolous lawsuits against the Feds and Donald Trump, all without the aid of his attorney. 

A name synonymous with sexual predation since the millennium, especially here in Palm Beach County, is of course Jeffrey Epstein. This multimillionaire financier dirtbag was a predator incarnate, who, over a period of at least 15 years, lured a procession of girls as young as 14 to his Palm Beach mansion to perform nude bedroom massages for money; massages that often ended with Epstein groping or sexually assaulting the girls. All told, investigators found evidence that Epstein preyed on at least 80 girls total, here and in New York. 

One of my patients, I’ll call her Dominique, was one of at least 15 girls from Royal Palm Beach High School alone, who Epstein sexually exploited in that aforementioned bedroom 15 years ago, and she will live with those memories forever. At the time, it was a not-so-well-kept secret among RPBHS students, teachers, and administrators that girls were being sexually exploited in return for gifts of cash, expensive cars, trips, and shopping sprees courtesy of their Sugar Daddy; but nobody reported their concerns to authorities at the time. Epstein masterminded an underage sexual assault scheme, paying girls $200 for each new victim they recruited, instructing them to target vulnerable girls, often on the verge of homelessness and desperately needing money, and “the younger the better.” 

Dominique drove a convertible Mercedes, courtesy of Epstein, flew in his jet to travel on trips with him to Mexico and the US Virgin Islands, and met some very famous and influential people, including a former POTUS, a ridiculously wealthy computer nerd, and one particularly slimy smarmy one that calls Britain’s monarch “Mummy.” Dominique told me that she and the other girls would skip school, hang out at his house, float around in the pool, go out on the boat, or head to Worth Ave for lunch, followed by black card shopping. The girls also drank alcohol and did drugs, made available by Epstein, of course. Consumption of alcohol and drugs is a way that predators groom their targets, to seduce them, make them more comfortable and less inhibited, and hamper their ability to resist. 

The girls traded sexual favors in exchange for all of the cash and material gifts he gave them, and Dominique said that oral sex and intercourse were just an acceptable part of the deal; it was very much a simple transaction. The better the girls were, the more they pleased him, the more money and gifts he would give them. It was a calculated and infinitely alluring arrangement, all by Epstein’s diabolical design, and before she knew it, Dominique was in over her head, but yet unable to cut ties. Thankfully, the law intervened and cut those ties for her, for once and for all. Now she’s moving on with her life and looking forward to the future, all while still dealing with the extreme damage done in the past.

When any of his girls became nervous or ever questioned activities, Epstein had a remedy for those circumstances as well. He used his “assistant” Ghislaine Maxwell as a beard to make the girls feel more comfortable; sort of an older sister vibe, a figure for them to look up to and emulate. She played a key role in the scheme, and she’s currently awaiting trial on sex trafficking charges and who knows what else. In his first two charges here in Palm Beach County (soliciting a minor for prostitution and procuring minors for prostitution) Epstein made a sweetheart deal with the Florida DA’s office, spending 13 months (of an 18 month sentence) in a private wing of the Palm Beach County Jail on Gun Club Road, but he was still allowed to go to “work” on Palm Beach Island six days a week for twelve hours each day. I consider that incomprehensible. Then after he served his tiny time here, he was facing more charges in New York for sex trafficking of girls as young as 14 and conspiracy to commit sex trafficking. Apparently, the Feds also had a lot more charges up their sleeves, and were investigating every single thing in his life. At his arraignment in New York, Epstein pleaded not guilty to all charges. If convicted, he would have faced up to 45 years in prison. But, evidently, he couldn’t take the heat. He was found hanging in his cell by the guard that may have been too busy sleeping to guard him. The coroner’s manner of death was listed as suicide, but his family and other conspiracy theorists say he was murdered. Either way, he’s gone, as is the opportunity for his victims to face him in open court and tell their truths. 

Below, I define pedophilia and associated terms, and discuss a generalized profile of a typical pedophile or sexual predator, and go over what you can do to protect children from such predators. 

Pedophile, Hebephile, Ephebophile, Predator, or Child Molester?

I want to clarify some terms related to pedophilia. A pedophile is a person who is primarily attracted to prepubescent children, usually defined as under the age of 12. A common mistake is to define a pedophile as anyone attracted to another person that is below the age of majority; but this definition would include people attracted to teens, which is incorrect. Even a late adolescent (like 15 or 16 years old) can be a pedophile, if they have sexual interest in prepubescent children. A hebephile is a person who is primarily attracted to others in their young to mid-teens, while an ephebophile is a person who is primarily attracted to others in their mid-to-late adolescence. Captain Obvious says that a child molester is anyone who molests a child, but without regard to their sexual attractions or preferences. Their act of molestation is not typically linked to sexual desire or interest. In the interest of time for this blog, I will not divide or differentiate the term predator into hebephile or ephebophile, and the terms pedophile, predator, and molester will be used interchangeably.  

Pedophilia is a psychiatric disorder in which an adult or an older adolescent is sexually attracted to young children. Pedophiles can be anyone: rich or poor, young or old, of any race/ creed/ color, educated or not, and professional or not. Despite this wide array of potentially inclusive characteristics, pedophiles do often demonstrate similar attributes. Please note that these are just possible indicators, and you should never automatically assume that individuals with these indicators or characteristics are pedophiles. But noticing these characteristics in a person, in combination with questionable behavior, could be a red flag that someone may be a pedophile or sexual predator.

All parents want to protect their children from predators, but how do you do that when you don’t know how to spot one? Anyone can be a pedophile/ predator/ child molester, so identifying one can be difficult, especially because most of them are initially trusted by the children they abuse. Below, I’ll go over which behaviors and traits are red flags, what situations to avoid, and how to deter predators from targeting your child.

Understand that there is no one physical characteristic, appearance, profession, or personality type that all child predators share. They may appear to be charming, loving, and totally good-natured, while also adept at harboring predatory thoughts. That means that you can’t just dismiss out of hand the idea that someone you know could be a child predator. Anyone can turn out to be a pedophile or predator.

Most pedophiles are known to the children they abuse. Thirty percent of children who have been sexually abused were abused by a family member; that can include mother, father, grandmother, grandfather, aunts, uncles, cousins, stepparents, and so on. Sixty percent of children who have been sexually abused were abused by an adult that they knew, but who was not a family member. That means that only ten percent of sexually abused children were targeted by a total stranger. In most cases, the child predator turns out to be someone known to the child through school or some other common everyday activity, such as a neighbor, teacher, coach, clergy member, tutor, music instructor, or babysitter.

Traits of Pedophiles or Sexual Predators

-Majority are men over 30 years of age, regardless if victims are male or female

-Heterosexual and homosexual men are equally likely to be child molesters

-Notion that homosexual men are more likely to be child molesters is completely false

-Female child predators are more likely to abuse boys than girls

-Often single and/ or with few friends 

-Some have mental illness, such as a mood or personality disorder

-Many have a history of physical and/ or sexual abuse in their own past

Behaviors of Pedophiles or Sexual Predators

-Display more interest in children than adults -May have a job or volunteer in a position allowing them unsupervised access to a child 

-Will contrive other ways to spend time with children (act as helpful neighbor or coach)

-Tend to talk about or treat children as though they are adults 

-May refer to a child as they would refer to an adult friend or lover

-Often say they love all children or feel as though they are still children

-May prefer children nearing puberty who are curious about sex but sexually inexperienced

-Common for the pedophile to be developing a long list of potential victims at any one time

-Many believe their proclivities aren’t wrong: it’s healthy for the child to have sex with them

-Almost all pedophiles have a pornography collection, which they protect at all costs

-Many predators also collect “souvenirs” from their victims, which are also very cherished 

Other Noteworthy Characteristics

Look for signs of grooming. The term “grooming” refers to the process that the child predator undertakes in order to gain a child’s trust, and sometimes the parents’ trust as well. Over the course of months, or even years, a pedophile will become an increasingly trusted friend of the family; they will likely offer to babysit, take the child shopping or on trips, or spend time with the child in any number of ways. Many child predators won’t actually begin abusing a child until full trust has been gained; this exhibition of patience and restraint is unnerving in the grand scheme of things. 

Child predators look for children who are most vulnerable to their tactics, whether they are shy, withdrawn, handicapped, lacking emotional support, come from a broken, dysfunctional, and/ or underprivileged home, come from a single parent home lacking supervision, or just aren’t getting enough attention at home. Pedophiles work to master their manipulative skills and unleash them on these vulnerable children by first becoming their friend; this quickly builds the child’s sense of self-esteem and brings them closer to the predator. The pedophile may refer to the child as special or mature, which appeals to their need to be heard and understood. They basically strive to give the child whatever is lacking in their home. This sounds altruistic, but in reality, it’s just another empty ploy, used by the predator to distance the victim from their family and draw them nearer to them. Often, the next step is to entice them with adult activities, like looking at sexually explicit pictures and magazines and watching x-rated movies. 

Pedophiles and predators don’t only need to earn the trust of their mark; they must also work very hard to convince parents that they are a nice, responsible person and capable of supervising their child or children in their absence. They may make it seem like they’re doing the parent(s) a favor by watching them or taking them out, “Oh, I don’t mind taking little Johnny to get an ice cream cone and then to the park, that way you can just relax and put your feet up for awhile.” This is how a child predator manipulates parents, instills a false sense of security, and gains their trust. Pedophiles will foster a close relationship, and even forge a friendship, with the parent(s) of a mark in order to get close to that child. That friendship with the parent(s) is just the ticket to get the predator through that front door. Once inside the home, they have many opportunities to manipulate the children and use guilt, fear, and love to confuse them. If the child’s parent(s) works, they may offer after school babysitting or tutoring, and this gives them the private time needed to abuse the child.

Pedophiles often refer to children in angelic terms; they use descriptive words like innocent, heavenly, divine, angel, pure, and other words that may describe children, but seem inappropriate and/ or exaggerated. They may also fixate on a specific feature on a child’s face or body, and talk incessantly about it, making unusual and age inappropriate comments like, “Oh, that baby girl has the prettiest lips I’ve ever seen, they look so soft, and they’re the perfect shade of pink,” or “Wow…she’s going to be really hot when she grows up and fills out,” or “I’ll bet she’s going to grow up to be a real tease, ya know what I mean?” These are examples of how pedophiles and predators sexually objectify children, by speaking to or about them in a way that is not age appropriate and is not acceptable. 

A pedophile will often use a range of games, tricks, and activities to gain the trust of and/ or deceive a child. One of the predator’s main goals is to make sure the child won’t tell anyone about the inappropriate contact. What they do or say to ensure this silence depends on the age of the victim. For younger children, they may suggest a pact of secrecy; secrets are valuable to most kids, because they’re seen as something very “grown up” or “adult” and a source of power as well. For older children, the predator may threaten their victim, warning them that nobody would believe them if they told, and that people would make fun of them, and that they would lose all their friends if they told. In rare cases, the predator may even threaten bodily harm. Some predators just don’t care if the world knows what they’re doing; they feel above everyone else, like nobody and nothing can touch them, a la Jeffrey Epstein. As the relationship progresses, they incorporate some sexually explicit games and activities like tickling, fondling, kissing, and touching. The predator will behave in a sexually suggestive way, and have no issue exposing a child to pornographic material, bribing the target child, flattering them, and then worst of all, showing them affection and love. Be aware that all of these tactics are ultimately used to confuse your child and isolate them from you. 

Now that you know some general traits of pedophiles and predators as well as some behaviors to be aware of and look out for, let’s move on to protecting your child from predators.

How to Protect your Child(ren)

One of the first things you can and should do is find out if, and how many, sex offenders live in your neighborhood. There are subscription services that show you everything about the offenders and then send you updates with alerts when new sex offenders are released from jail and/ or if a registered sex offender moves near you. But, unless you need all the bells and whistles for some reason, you can always go to one of several free sites that will allow you to search a sex offender database by zip code, neighborhood, and by offender name if you suspect someone specific of being a sex offender. Here is my disclaimer: while it’s good to be aware of potential predators, realize that it is illegal to endeavor to take any kind of action against registered sex offenders.

Dru Sjodin National Sex Offender Website

https://www.nsopw.gov/

The Florida Department of Law Enforcement Sexual Offenders and Predators Search https://offender.fdle.state.fl.us/offender/sops/home.jsf

Another way to protect your child is to supervise their extracurricular activities. Being as involved as possible in your child’s life is the best way to guard against child predators. They will look for a child who is vulnerable and who isn’t getting a lot of attention from his or her parents, and they will cozy up to them, and then will do everything in their power to convince the parents that they are of no danger to their child. Show up at sporting games, practices and rehearsals, chaperone field trips and all other trips out, and spend time getting to know the adults in your child’s life. Make it obvious to everyone that you’re an involved and present parent. If for some reason you can’t be there for a trip or other outing, make sure that at least two adults you know well will be chaperoning the trip. Don’t ever leave your child alone with adults that you don’t know well. Remember that rule even goes for relatives too, as they can also pose a threat. The key here is to be as present as possible.

Set up a nanny cam if you hire a babysitter. Obviously, there will be times when you won’t be able to be present, so use other tools to make sure your child is safe. Set up hidden cameras in your home so that inappropriate activity will be detected. No matter how well you think you know someone, you always need to take precautions for your child’s safety.

Teach your child about staying safe online. Make sure your child knows that predators often pose as children or teenagers in order to lure children in. Monitor your child’s use of the internet, keeping rules in place to limit their “chat” time. Have regular discussions with your child about whom he or she is communicating with online. Be sure your child knows to never ever give out your address or phone number, or send any pictures to a person they met online; and that they must not ever meet someone in real life that they’ve only communicated online with. As a parent, you must know that children are often very sneaky and secretive about online behavior, especially when encouraged by others to keep secrets, so you’ll need to be vigilant about staying involved in your child’s online activity.

Make sure your child is feeling emotionally supported. Since children who don’t get a lot of attention are especially vulnerable to predators, make sure you are spending a lot of time with your child and that he or she feels supported. Take the time to talk to your child every day and work toward building an open, trusting relationship. Child predators will always ask, or demand, that their marks keep their secrets from their parents. Ensure that your children understand that if a person has asked them to keep a secret from you, it’s because they know what they’re doing is wrong. Express ongoing interest in all of your child’s activities, including schoolwork, extracurriculars, and hobbies; and let your child know that he or she can tell you anything, and that you’re always willing to talk.

Teach your child to recognize inappropriate touching. Many parents use the “good touch, bad touch, secret touch” method. It involves teaching your child that there are some appropriate touches, like pats on the back or high fives; there are some unwelcome or “bad’ touches, like hits or kicks; and there are also secret touches, which are touches that the child is told to keep a secret. Use this method to teach your child that two types of touches aren’t good, and if and when these touches happen, he or she should tell you immediately, even if the person touching them tells them that they can’t or shouldn’t tell. Teach your child that no one is allowed to touch him or her in private areas, and that they are not to touch anyone in their private areas. Many parents define private areas as those that would be covered by a bathing suit. Children also need to know that an adult should never ask a child to touch their own private areas or to touch anyone else’s private areas, and if someone tries to touch them or tells them to touch someone else, tell your child to say “no” and walk away. And again, reinforce the directive of telling them to come to you immediately if someone touches them the wrong way.

Recognize when something is out of sync with your child. If you notice that your child is acting differently for no obvious reason, pursue the issue to find out what’s wrong. Regularly asking your child questions about their day, including asking whether any “good,” “bad,” or “secret” touches happened that day, will help open the lines of communication and create an important daily dialog. If your child tells you that he or she was touched inappropriately or doesn’t trust an adult, never summarily dismiss it. Always trust your child first. Along those same lines, never dismiss a child’s claims just because the adult in question is a valued member of society or appears incapable of such things. That’s exactly what a predator or pedophile wants, it’s their stock in trade. They’re counting on adults not listening to child victims so that they can continue to get away with molesting them. 

By age 12, kids should already have gotten basic sex education explained by their parents, including what everything is called, what it does, and how it works. Parents explaining it all to their kids themselves will prevent a predatory teacher or friend from misleading them about sex for their own nefarious purposes. Make sure your child already knows everything they need to know about what’s what and what is and isn’t acceptable behavior, before they are taught very different lessons and definitions through rumor and innuendo discussed on the monkey bars or over ham and cheese sandwiches in the cafeteria. 

A child aged 14 and under may not recognize that there’s a difference between a grumpy teacher giving extra homework and a strange acting teacher that insists on kissing them on the cheek before leaving the room. They can’t really differentiate, because at this age, they simply file both of these things in their brain under ‘annoying.’ So if your child tells you vague stories about the teacher making sex jokes or touching them, or being ‘annoying’ and asking all kinds of ‘private stuff,’ you must consider the possibility that there might be something hinky going on. When and if a child mentions that their teacher is acting strangely, asking about their family and siblings, making them uncomfortable by grilling them for private information, and/ or is pushing for pictures, you must guide that child, and tell them how to react to, and deal with, these ‘annoying’ things. 

But I cannot stress enough that you must be realistic in your approach! Telling your kids to run away screaming bloody murder if the teacher touches their back, or telling them to yell ‘no!!’ and smack the teacher’s hand away if an innocent touch grazes a shoulder as the teacher walks down the rows of desks in the classroom. Those reactions will not help the situation for several reasons. First of all, chances are that they won’t hit a teacher under any circumstances, but they surely won’t do so if that teacher is actually and truly grooming them, all while filling their head with smooth assurances that they’re a good guy, on their side, and only there to help them. 

So, what’s a parent to do if they suspect something’s hinky, but have no concrete proof? If the child is age 14 and under, there are a couple of possibilities to consider. The first one is to instruct the child that if this person touches them, or asks questions or makes suggestions that makes them feel uncomfortable, that they should tell this person that they have told their parents about this issue (of inappropriate touching or making them uncomfortable with questions or whatever the case may be) and that their parents weren’t happy to hear about it. This would definitely take some serious chutzpah on the child’s part, but I think it would also empower them, and that’s never a bad thing. The second option would be to have the child deliver a message to the person that touches them, or asks questions and makes suggestions that makes them feel uncomfortable. One of the parents would create the message by getting a piece of paper and jotting a quick note on it; it should simply say ‘Stop touching my son/ daughter, Johnny Smith/ Jenny Smith’ or ‘Please stop asking my son/ daughter, Johnny Smith/ Jenny Smith so many questions, as they make him/ her very uncomfortable’ or whatever the issue may be. Then finish the note with the date and the parent’s autograph. Then the parent can put the signed note in an envelope and give it to their child, and instruct them that they are to give the envelope to the person who is touching them inappropriately, at the time they are touching them inappropriately, despite being asked to stop; or give the envelope to the person who is asking them questions and making suggestions that make them uncomfortable, at the time they are making them uncomfortable, despite being asked to stop. It is important to make sure the child gives the note to this person when they are red handedly doing what they have asked them to stop doing. This can be a very tricky situation, so make sure to give this a lot of thought. Keep in mind that employing one of these two tactics will only have a positive effect if you are absolutely sure that this person is ignoring a child’s personal boundaries and going too far with touching inappropriately or asking questions and making suggestions that make the child uncomfortable, all despite being asked to stop. You must be sure that this is a deliberate act of a magnitude that is unacceptable. One impulsive hand on the shoulder doesn’t meet the criteria to qualify here. 

Remember that the most important thing you can do to protect your child is to pay attention to them and really listen when they speak. Keep the lines of communication open, let them know you’re on their side, assess their needs and desires, talk to them, and basically, just be the best parent you can possibly be. The bottom line is that if you don’t pay attention to your child, someone else will.

These days, it seems like pedophiles and predators really have the odds stacked in their favor; they get away too easily due to lack of evidence, and even when they are caught and jailed, they get out early for good behavior. One factor that works against the pedophile is that eventually, the children they molested will grow up and recall the events that occurred, and hopefully they will report them. Often, pedophiles and predators are not brought to justice until such time occurs, and even then, they get off far too lightly. That makes victims even angrier, as they feel like they are victimized twice- first by the predator, and then again by the justice system. More than anything, victims of pedophiles and sexual predators want to protect other children from the same fate that befell them. 

Don’t forget to check out my YouTube channel for tons of interesting lectures, and be sure to hit that subscribe button. If you liked this blog and found it insightful, please pass it along to family and friends, especially if they care for children. And as always, my book, Tales from the Couch has lots of patient stories and great information; you can find it on Amazon.com.

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The 15 Scariest Mental Disorders of All Time

The 15 Scariest Mental Disorders of All Time

Imagine having a mental disorder that makes you believe that you are a cow; or another that you’ve somehow become the walking dead. Pretty freaking scary, eh? Well, while relatively rare, these disorders are all too real.

Worldwide, 450 million people suffer from mental illness, with one in four families affected in the United States alone. While some mental disorders, like depression and anxiety, can occur organically, others are the result of brain trauma or other degenerative neurological or mental processes. Look, having any mental illness can be scary, but there are some disorders that are especially terrifying. Below, I’ve described the 15 scariest mental disorders of all time.

‘Alice in Wonderland’ Syndrome

In 1865, English author Lewis Carroll wrote the novel Alice’s Adventures in Wonderland, commonly shortened to ‘Alice in Wonderland.’ Considered to be one of the best examples of the literary nonsense genre, (seriously, who knew they even had a nonsense genre?) it is the tale of an unfortunate young girl named Alice, who falls through a rabbit hole into a subterranean fantasy world populated by odd, anthropomorphic creatures. That’s your vocabulary word for the week… anthropormorphic. Popular belief is that Carroll was tripping when he penned it. Regardless if that’s true or not, what is true is that one of Alice’s more bizarre experiences shares its characteristics with a very scary mental disorder. Also known as Todd Syndrome, ‘Alice in Wonderland’ Syndrome causes one’s surroundings to appear distorted. Remember when Alice suddenly grows taller and then finds she’s too tall for the house she’s standing in? In an eerily similar fashion, people with ‘Alice in Wonderland’ Syndrome will hear sounds either quieter or louder than they actually are, see objects larger or smaller than what they are in reality, and even lose sense of accurate velocity or textures they touch. Described as an LSD trip without the euphoria, this terrifying disorder alters one’s perception of their own body image and proportions. Fortunately, this syndrome is extremely rare, and in most cases affects people in their 20’s who have a brain tumor or history of drug use. If you need yet another reason to not do drugs… well, there ya go. 

Alien Hand Syndrome

While most likely familiar from cheesy horror flicks, Alien Hand Syndrome isn’t limited to the fictional world of drive-in B movies. Those with this very scary, but equally rare mental disorder experience a complete loss of control of a hand or limb. The uncontrollable body part takes on a mind and will of its own, causing sufferers’ “alien” limbs to choke themselves or others, rip clothing off, or to viciously scratch themselves, to the point of drawing blood. Alien Hand Syndrome most often appears in patients suffering from Alzheimer’s Disease or Creutzfeldt-Jakob Disease, a degenerative brain disorder that leads to dementia and death, or as a result of brain surgery separating the brain’s two hemispheres. Unfortunately, no cure exists for Alien Hand Syndrome, and those affected by it are often left to keep their hands constantly occupied or use their other hand to control the alien hand. That last one actually sounds even worse- one unaffected arm fighting against the affected arm that’s trying to tear into the person’s own flesh. Yikes. 

Apotemnophilia

Also known as Body Integrity Disorder and Amputee Identity Disorder, Apotemnophilia is a neurological disorder characterized by the overwhelming desire to amputate or damage healthy parts of the body. I recall a woman with Apotemnophilia making worldwide news ages ago when she fought with her HMO to cover the amputation of one of her otherwise healthy legs. Good luck; they don’t even cover flu shots. I remember I was pretty shocked that she found a surgeon to agree to do the amputation in the first place, as it seemed to me that might violate that little thing called the Hippocratic Oath us docs took when we got our medical degrees, specifically that part about ‘do no harm’… and sparked a debate about the ethical dilemma of treating or “curing” a psychiatric disorder by creating what is essentially a physical disability. Though not a whole heck of a lot is known about this strangely terrifying disorder, it is believed to be associated with damage to the right parietal lobe of the brain. Because the vast majority of surgeons will not amputate healthy limbs based purely upon patient request, some sufferers of Apotemnophilia feel forced to amputate on their own, which of course is a horrifying scenario. Of those who have convinced a surgeon to amputate the affected limb, most say they are quite happy with their decision even after the fact.

Boanthropy

Those who suffer from the very rare- but very scary- mental disorder Boanthropy believe they are cows, and usually even go so far as to behave as such. Sometimes people with Boanthropy are even found in fields with cows, walking on all fours and chewing grass as if they were a true member of the herd. When found in the company of real cows, and doing what real cows do, people with Boanthropy don’t seem to know what they’re doing when they’re doing it. This apparently universal finding has led researchers in the know to believe that this odd mental disorder is brought on by possible post-hypnotic suggestion, or that it is a consequence of dreaming or a sleep disturbance, sort of kin to somnambulism, aka sleepwalking. I can buy the sleepwalking thing. I have a patient that is a lifelong sleepwalker who sleep-eats, sleep-cleans, sleep-cooks, sleep-destroys, sleep-online-shops, sleep-everythings. Some mornings she wakes up to very unpleasant findings of the house in total disarray, electronics dismantled and improperly and ridiculously fashioned together, every piece of furniture moved or a sink full of dishes and pots and pans with dried up food in them. Before setting up prevention measures, she even had single episodes of adult sleep-driving, and even sleep-biking at (eek!) age 9. In the middle of the night, her mother awoke to what she thought was the big garage door opening, and when she went to check, she saw her coasting out of the driveway on her bright yellow bike, heading right toward a very busy highway. She always has zero recall of the events afterwards. If she can do all of that while essentially sleeping, it would be comparatively easy to wander out to a pasture on all fours and stick around to munch on some grass. Curiously, it is believed that Boanthropy is even referred to in the Bible, as King Nebuchadnezzar is described as being “driven from men and did eat grass as oxen.” Or was it King Nemoochadnezzar? No? Okay, moooving on…

Capgras Delusion

Named after Joseph Capgras, a French psychiatrist who was fascinated by the effective illusion of doubles, Capras Delusion is a debilitating mental disorder in which a person believes that the people around them have been replaced by imposters. As if that’s not bad enough, these imposters are usually thought to be planning to harm the sufferer. It really sounds like a bad Tom Cruise movie. Oh, wait; that’s redundant. Anyhoo, in one case, a 74-year-old woman with Capgras Delusion began to believe that her husband had been replaced with an identical looking imposter who was out to hurt her. Fortunately, Capgras Delusion is relatively rare, and is most often seen after trauma to the brain, or in those who have been diagnosed with dementia, schizophrenia, or severe epilepsy.

Clinical Lycanthropy

Like people with Boanthropy, people suffering from Clinical Lycanthropy also believe they are able to turn into animals; but in this case, cows are typically replaced with wolves and werewolves, though occasionally other types of animals are also included. Along with the belief that they can become wolves and werewolves, people with Clinical Lycanthropy also begin to act like the animal, and are often found living or hiding in forests and other wooded areas. Didn’t Tom Cruise play a werewolf in one of his many (vapid) movies? Or was it a vampire? Werewolf, vampire – tomato, potato.

Cotard Delusion

In a case of life imitating art, or life inspiring art, we have Cotard Delusion. In this case, the ‘art’ is zombies, a la The Walking Dead. Oooh, scary! For ages, people have been fascinated by the walking dead. Cotard Delusion is a frightening mental disorder that causes the sufferer to believe that they are literally the walking dead, or in some cases, that they are a ghost, and that their body is decaying and/or they’ve lost all of their internal organs and blood. The feeling of having a rotting body is generally the most prevalent part of the delusion, so it doesn’t come as much of a surprise that most patients with Cotard Delusion also experience severe depression. In some cases, the delusion actually causes sufferers to starve themselves to death. This terrifying disorder was first described in 1880 by neurologist Jules Cotard, but fortunately, Cotard’s Delusion, like good zombie movies, has proven to be extremely rare. The most well-known case of Cotard Delusion actually occurred in Haiti, circa 1980’s, where a man was absolutely convinced that he had previously died of AIDS and was actually sent to hell, and was then damned to forever walk the earth as a zombie in a sort of pennance to atone for his sins. 

Diogenes Syndrome

Diogenes Syndrome is a very exotic name for the mental disorder commonly referred to as simply “hoarding,” and it is one of the most misunderstood mental disorders. Named after the Greek philosopher Diogenes of Sinope (who was, ironically, a minimalist), this syndrome is usually characterized by the overwhelming desire to collect seemingly random items, to which an emotional attachment is rapidly formed. In addition to uncontrollable hoarding, those with Diogenes Syndrome often exhibit extreme self neglect, apathy towards themselves or others, social withdrawal, and no shame for their habits. It is very common among the elderly, those with dementia, and people who have at some point in their lives been abandoned or who have lacked a stable home environment. This is likely because ‘stuff’ never hurts you or leaves you, though most people with the disorder are unlikely to be able to make that connection. Fortunately or unfortunately, depending on how you look at it, this disorder is much more common than some of the others I’ve mentioned here.

Dissociative Identity Disorder

Dissociative Identity Disorder (DID), is the mental disorder that used to be called Multiple Personality Disorder. Another disorder that has inspired a myriad of novels, movies, and television shows, DID is extremely misunderstood. Generally, people who suffer from DID often have 2-3 different identities, but there are more extreme cases where they have double digit numbers of identities. There was a “reality” show a few years ago that centered on a young mother of two that supposedly had like 32 distinct personalities. All of them had names and ranged from a five-year-old child to an old grandpa; and according to her, a few of them were homosexual while the rest were not, so she was required to be bisexual. She claimed that many of the personalities knew everything about all of the others, and they would get mad at or make fun of the others at various times. What’s more, she would “ask” other personalities to come forward so that producers could ask them questions for the camera’s sake, and her voice and mannerisms changed, depending on the different characteristics of the personalities. It was all pretty difficult to buy to be honest, because I’ve seen a lot of people with DID, and none seemed like they were having as much fun with their illness as she did. In true DID cases, sufferers routinely cycle through their personalities, and can remain as one identity for a matter of hours or for as long as multiple years at a time. They can switch identities at any time and without warning, and it’s often nearly impossible to convince someone with DID that they actually have the disorder, and that they need to take medications for it. For all of these reasons, people with Dissociative Identity Disorder are often unable to function appropriately in society or live typical lives, and therefore, many commonly live in psychiatric institutions, where their condition and their requisite medications can be closely monitored. 

Factitious Disorder

Most people cringe at the first sniffle indicating a potential cold or illness, especially these days, but not those with Factitious Disorder. This scary mental disorder is characterized by an obsession with being sick. In fact, most people with Factitious Disorder intentionally make themselves ill in order to receive treatment; and this is what makes it different than hypochondria, a condition where people blow mild symptoms into something they aren’t, kind of like if you cough once and automatically think you have covid-19. Sometimes in Factitious Disorder, people will simply pretend to be ill, a ruse which includes elaborate stories, long lists of symptoms, doctor shopping, and jumping from hospital to hospital. Such an obsession with sickness often stems from past trauma or a previous genuinely serious illness. It affects less than .5% of the general population, and while there’s no cure, psychotherapy is often helpful in limiting the disorder. 

Kluver-Bucy Syndrome

Imagine craving the taste of a book or wanting to have sex with a car. That’s reality for those affected by Kluver-Bucy Syndrome, a mental disorder typically characterized by memory loss, the desire to eat inedible objects, and sexual attraction to inanimate objects such as automobiles. I’ve seen a television documentary that featured people with strange fetishes, and they had two British guys that were sexually attracted to their cars. They gave them names and described their curves in the same manner that some men describe women. While one guy (supposedly) limited it to “just” caressing his car, the other actually also made out with his car; I’m talking about tongue and everything. Talk about different strokes! Because of the memory loss, not surprisingly, people with Kluver-Bucy Syndrome often have trouble recognizing objects or people that should be familiar. They also exhibit symptoms of Pica, which is the compulsion to eat inedible objects. The same wierd fetish documentary featured two young women that were “addicted” to eating weird stuff; one routinely ate her sofa cushions. She actually pulled the foam apart into bite sized pieces and ate them, many times a day. She became so used to doing so that she would get anxious if she went too long without eating it, so she started having to bring pieces of her sofa with her to work. I’m guessing she didn’t have to worry about co-workers stealing her food. She had started eating the cusions so long ago that she was actually on her second couch. Her family was so concerned about the potential medical ramifications of eating couch cushions that they made her see a gastro doc, who thought he was being punked when he asked why she was there. After imaging studies, she was in fact diagnosed with some intestinal issues and told to stop eating couch cushions, but the desire was too great for her to cease. She’s probably on her fourth couch by now. The other girl actually loved eating powder laundry detergent. She described the taste in the same dreamily excited way a foodie describes a chef’s special dish du jour. This terrifyingly odd mental disorder is difficult to diagnose, and seems to be the result of severe injury to the brain’s temporal lobe. Unfortunately, there is not a cure for Kluver-Bucy Syndrome and sufferers are typically affected for the rest of their lives.

Obsessive Compulsive Disorder

Though it’s widely heard of and often mocked, Obsessive Compulsive Disorder (OCD) is rarely well understood. OCD manifests itself in a variety of ways, but is most often characterized by immense fear and anxiety, which is accompanied by recurring thoughts of worry. It’s only through the repetition of tasks, including the well-known obsession with cleanliness, that sufferers of OCD are able to find relief from such overwhelming feelings. To make matters worse, those with OCD are often entirely aware that their fears are irrational, but that realization alone actually brings about a new cycle of anxiety. OCD affects approximately 1% of the population, and though scientists are unsure of the exact cause, it is thought that chemicals in the brain are a major contributing factor. I’ve discussed OCD and recounted OCD patient stories many times in this blog and in my book, Tales from the Couch.

Paris Syndrome

Paris Syndrome is an extremely odd but temporary mental disorder that causes one to become completely overwhelmed while visiting the city of Paris. Stranger still, it seems to be most common among Japanese travelers. Of the approximately 6 million Japanese visitors to Paris each year, one to two dozen of them experience the overwhelming anxiety, depersonalization, derealization, persecutory ideas, hallucinations, and acute delusions that characterize Paris Syndrome. Despite the seriousness of the symptoms, doctors can only guess as to what causes this rare and temporary affliction. Because most people who experience Paris Syndrome do not have a history of mental illness, the leading thought is that this scary neurological disorder is triggered by the language barrier, physical and mental exhaustion, and the reality of Paris as compared to the idealized version. Slam! I’ll bet the Paris Tourism Board hates to hear about this one! Huh houn, wee wee monsieur.

Reduplicative Amnesia

The Reduplicative Amnesia diagnosis was first used in 1903 by neurologist Arnold Pick, when he described a patient with a diagnosis of what we know today as Alzheimer’s Disease. It is actually very similar to Capgras Syndrome, in that it involves duplicates, but instead of believing that people are duplicates, people with Reduplicative Amnesia believe that a location has been duplicated. This belief manifests itself in many ways, but always includes the sufferer being convinced that a location exists in two places at the same time. Today, it is most often seen in patients with tumors, dementia, brain injury, or other psychiatric disorders.

Stendahl Syndrome

Stendahl Syndrome is a very unusual psychosomatic illness; but fortunately, it appears to be only temporary. The syndrome occurs when the sufferer is exposed to a large amount of art in one place, or is spending time immersed in another environment characterized by extreme beauty; probably one of those places that “takes your breath away.” Those who experience this scarily weird mental disorder report sudden onset of rapid heartbeat, overwhelming anxiety, confusion, dizziness, and even hallucinations. It actually sounds a lot like a panic attack to moi. Stendahl Syndrome is named after the 19th century French author who described in detail his experience after an 1817 trip to Florence, which is evidently a beautiful place. I have it on good authority that Stendahl Syndrome has never happened to any visitor to Paris, which, oddly enough is Stendahl’s country of origin. 

So, we’ve learned a lot today: that there is a nonsense literary genre, that there are a bunch of freaky and frightening mental disorders out there, that some people might need to look up the word anthropormorphic, that illicit drugs are bad for yet another reason, that a lot of terrible B movies are actually based on some pretty obscure mental disorders, that people with Boanthropy probably get a lot of fiber in their diet, that the lives of people with Capras Delusion sound a lot like a bad Tom Cruise movie, that the term “bad Tom Cruise movie” is redundant, that Tom Cruise probably has Clinical Lycanthropy, that Tom Cruise is a tool, oops, sorry, everyone already knew that. We also learned that there is no longer such thing as Multiple Personality Disorder; it is now called Dissociative Identity Disorder, that Kluver-Bucy Syndrome is threatening to couches, and that if you have Kluver-Bucy Syndrome, co-workers will never steal your lunch. We learned that Japanese tourists hate Paris, and that Stendahl Syndrome never happens there. And we learned lots of other cool stuff, but that if you have so much stuff that you can’t walk through your house you likely have Diogenes Syndrome, probably because you have a deep seated knowledge that stuff never hurts you or leaves you. 

Please check out my videos on YouTube- better yet, hit that subscribe button, and share them with folks. And as always, my book, Tales from the Couch has lots more information and patient stories on various psychiatric diagnoses and is available on Amazon and in the office. Be well, everyone!

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How To Interact With The Mentally Ill

How to Interact with the Mentally Ill

The purpose of this piece is to help the reader how to interact, both verbally and nonverbally, with people with mental illness; and as a corollary, how to get them the help they need. It’s basically a list of do’s and don’ts that I have compiled in my head over many years of seeing patients and dealing with their loved ones… becomes sometimes the former are far easier to deal with than the latter. Anyway, I’m constantly asked, “What do I do? What do I say?” Well, here is the answer to those.

Look, I understand that it’s very difficult when a loved one has a mental illness. A lot of issues come into play; a lot of balls in the air. So learn to juggle. Please understand that in some cases, logic no longer applies here, because when the mentally ill person is your child, your sister, your brother, your mother, your father, the rules don’t apply anymore; the book is out the window. But yet without it, you still have to figure out how you can help them while also respecting them, maintaining their dignity, and helping them to seek effective treatment. There are always degrees of everything. Some patients may be very independent and autonomous and need little help, and some may require a lot of help to get through their days. For the tougher cases, it may be easy to say, “Oh, just send them away to the hospital,” but that’s not how it this works. If you love them, that’s exactly what you don’t do. No finger snap and off they go, no fuss, no muss. Do be prepared to get appropriately fussy and mussy when, and if, necessary. It may not be necessary. But it may be. 

Denial. Nope. You no longer have this luxury. Don’t pretend that they don’t have an illness. This is one of the most common issues that I see, families and friends sticking their heads in the proverbial sand. “He’s just eccentric!” Ugh, how I hate that word. No. Running naked across the Brooklyn Bridge while chased by half of the NYPD is not eccentricity. It is not a statement. It is not a personality quirk. And turning a blind eye is nothelpful. Loved ones that continuously make excuses for unusual, inappropriate, and/ or dangerous behaviors just allow the illness to flourish, a pretty word for get waaaay worse. I’ve seen too many depressed people make multiple suicide attempts and still not get the help they desperately need. Psychotic people walking around the neighborhood arguing with people only they see, and still the families don’t intervene, because it’s their loved one. They don’t want to interfere or take away that individual’s rights. In the United States, sometimes it’s not until the police finally arrest the person that they are offered help. But a lot of times, not even then. Families make excuses for a lot; too much, really. We live in a system where it is very difficult to give treatment to someone who doesn’t want it. The laws are very weak in terms of forcing people into treatment. So what happens far too often is that these people end up self-medicating with illicit drugs, living on the street, and suffering all of the consequences of being mentally ill without a place to turn to. And if you’re thinking that couldn’t happen to your loved one, you’d be taking a gamble there. Sadly, I’ve had patients belonging to some very wealthy Palm Beach families that managed to find their way from society to sidewalk, just because people were in denial, turned a blind eye, didn’t want to infringe, made excuses, whatever the case was… the end was still the same. If the person in question is a friend, or for some reason you don’t feel it’s your place to discuss treatment with them, then find out who you should talk to, and do so. Also, consider that you might be the only person in a place to see or know what’s really going on. You may be the one who has to make the difference for them, the one standing between them and help. So no denial, no blind eye, no excuses. If you love them, you have to face the issue head on in the appropriate way. It’s the only compassionate thing to do, and the most compassionate thing you can do. 

Get some stick-to-it-itiveness and give some hope. Tell your loved one that they can get better, that treatment is available, and that better days will come. And once you do establish a treatment regime, good follow through is very important. Dounderstand that treatment can take years. It could even be a lifelong kind of deal. It won’t always be hectic and scary, a rollercoaster of loop de loops. Truthfully, it might even get monotonous, this appointment, then that one; this med, then that one. But I can tell you that once you find the right regime, if you stick to it, it will be rewarding. Just be supportive and keep standing by them. It may not always be the easiest thing ever, but it may well be the most rewarding thing ever. 

Education is more than a do, it is a must. Everyone, the primary caregivers, ancillary caregivers, friends, families, associates, everyone should become educated. And as I said above, always instill hope and be supportive. This can and does get better. Be willing to help this person from A to Z, whether these things are obvious or not: to seek help, to help make their appointments, to make their appointments if they can’t for any reason (and yes, sometimes this is hard for them to do), to get to their appointments, to get to the hospital, to get to the day program, to get to the intensive outpatient program, to get to detox, to get to the treatment center, to the ER, wherever or whatever or whenever they need help.  

Always express genuine concern.  It is critical. They have mental illness, but that doesn’t mean they are stupid.  They see through bull#%*£ as easily as you do. If they sense fake concern, they will assume that they’re a burden, you just want to get rid of them, or just want to shut them up. Captain Obvious says that this will be a blockade to their progress. I say that this could be the last blockade of their lives, and not in a good way. You never know when someone is at a tipping point. If you love them, do be honest, caring, and honestly caring. 

Share “simple” insights. I use quotation marks, because sometimes what is simple to you may not be so simple to the person with mental illness. Depressed people may not be able to discern what’s good for them, or may not care what’s good for them. Daily activities tend to fall by the wayside when a human brain is contemplating if it’s worth it to live to see tomorrow, so they may not care what they’ll smell like tomorrow, or if their hair is combed and teeth are brushed tomorrow. It’s not uncommon for ADL’s (activities of daily living) to not make the to-do list. If you note this, do address it, but it’s important to do so in a specific way. Always be gentle. You don’t want to be mean or make them feel any shame. You can say “Maybe you want to take a shower today?” or “Would you like me to run a bubble bath for you? I bet you would feel great after you relax in a hot bath; I know I always do.” Do this in as gentle and open a tone as you can. Or if they’ve made a big mistake on something consequential, “Maybe it’s best to check your oil levels every few months, just to avoid any problems. We could even put it on the calendar if you want” or “I understand you’re upset that you failed your test (or burned the cookies, broke a vase, lost a jacket) but it’s not the end of the world and you’ll do better/ know better next time. Don’t make a mountain out of a molehill, and don’t ever yell or chide them. They have feelings just like you do, but they may not have the capacity to take things on the chin like you do. Obvi they don’t want their car to be overheating, or a failed test, or burned cookies, and they’re probably already giving themselves a hard enough time as it is. There may be situations where inappropriate behavior related to their illness might have consequences from others, ie they may accuse someone of acting against them due to paranoia, eliciting a negative response. Or, maybe they’ve dressed a certain way and they’re made fun of or bullied in some way. Firstly, this can be a teaching moment, where you can educate that other person about mental illness or how all people are different. But then when you discuss it with your loved one, you can say “Maybe next time, try not to be so direct” or “…try to be less accusatory” or “…should dress more appropriately” or “If you were a little more open, it might be easier to make friends.” Whatever the case may be. Don’t demand this or that. Do just make suggestions, easy breezey lemon squeezey. Don’tmake a federal case out of stuff. “You know what, I understand that you believe that there are little aliens in the wall shooting you with energy beam guns, but people would disagree with you, so I don’t think that you should share those thoughts with people, because they may judge you in a negative way if you do.” Don’t put them on the defensive. Always find common ground and let them know that it’s safe to tell you anything and everything through encouragement. If they say, “The CIA have me under surveillance, and they’re reporting me to the president. They’re coming to take me to jail.” The safe common ground is usually that you know they think or believe whatever the thought is, ie “I know that you believe that, and it could happen, but I think it’s unlikely, so I wouldn’t worry too much about it.” You can also add “Do you think you should mention that to Dr. Psychiatrist next time? I think he/ she would like to know that, don’t you?” Do make them feel safe to tell you whatever it is they may be feeling by not being judgemental. Do keep an open mind and once again, remember that mental illness has nothing to do with one’s intelligence.  

Be aware of expressed emotion. It is exactly what it sounds like… how you express your emotion. You’re not a saint or an angel, you’re human, and you’ll have normal emotions like anger and frustration. But do pay attention to how you express it. Do take a breath, take a moment before you respond so that you can control how you express yourself. By the way, this is actually a good idea for everyone, no matter who you are or aren’t dealing with. Don’t ever raise your voice. Doalways speak in a relaxed and calm manner. Don’ttalk quickly. Don’t ever back them into a corner. Do speak in a calm and even tone in a quiet area without distractions. Do communicate in a very straightforward way, addressing one issue at a time. Do be apathetic, compassionate, and respectful. 

Have a reflective listening policy. Do always listen to what they have to say.  Even if you think what they’re saying is totally inappropriate, listen to what they have to say. And yes, I realize that this can be very difficult sometimes, but take a breath and listen. You can even tell them that you have a reflective listening policy, and that means that you will always listen to them before you respond. Then back it up by listening respectfully. Then if they have difficulty listening to you and respecting what you say, you can remind them of your policy and ask them for the same courtesy. It’s honestly just a better way to run your life; it makes it so much simpler. My wife and I told our son about this policy, and followed through and raised him with it, since before he could say the word policy, and it turned out just fine and saved a lot of headaches. I can’t stress how important it is to be a good listener.  

This is a corollary to being a good listener… ask appropriate questions well, appropriately, ie softly or easily. Do ask simple questions: “Did you have breakfast today?” “We aren’t able to find your medicine, is everything okay with your medications?” Don’t say, “Did you take your medicine today?” “Did you eat yet?” It tends to sound accusatory. In a very gentle way, you say, “Everything okay with your medicine? Oh, here’s the bottle. Any problems?”  Let them speak.  Don’t press them.  If they’ve forgotten to eat or take medications, don’t get upset or angry, tale a breath, let them explain. If you have an issue about why they don’t want to take their medication, listen to why. Respect them and let them at least give you an interpretation of the reasons and symptoms. Don’t interpret for them. There may be a side effect that’s intolerable to them, and all of that must be brought to the prescribing physician. It’s all valid information, so do listen. After you have listened, you may then calmly answer “I heard that you don’t like to take your medicine because it makes you xyz, but if you don’t want to take it, we’ll call Dr. Prescriber and explain it and see what he/ she says, okay?” That way they know you listened to what’s going on, they know they’ve been heard, but they also know it’s either take the medication or talk to the doctor.  

I have heard some families make demands, withhold privelleges, make bargains, bark orders, physically intimidate; I’ve heard it all. It makes me a little anxious when I hear things like “Just take your *expletive* medicine!” or “Let’s pray about it.” Don’t get me wrong, I’m all for prayer, but it’s inappropriate in some respects when it comes to should Bobby or Suzie take their medication today, because they don’t feel like it. 

Other don’ts: You need an attitude adjustment. You’ve got a bad attitude. Stop being so negative for once. You need to get a job. Why can’t you do something productive with your life? You need something to do. Your thoughts are totally misguided. Now you’re just being dumb. You really are crazy. Don’t act crazy. 

No. None of those things are appropriate, ever. Especially the word “crazy” or any similar term. That is the ultimate “C word” in my office. Doremove it from your vocabulary, pronto. The goal is to not agitate them. No ultimatums.  No threats.  No punishment. It will get you nowhere except to crisis. Criticizing them or blaming them is a no go. And don’t ever speak rapidly or loudly. And don’tstare at them. It invites defiance. Silence is okay. Pauses are okay. I know you may get frustrated, but any sort of frustration or anger directed at them will not work. Don’t make jokes or be sarcastic, because it’s not funny. I don’t find it funny at all.  Don’t talk at them with a patronizing, condescending tone, as in, “Are you going to take your medicine today, or what?” “Could you shower already, you know you smell?” “Are you going to do anything today besides watch TV and smoke cigarettes?” “Have you gotten a job yet?” “You are so useless” “You don’t work. How about you get a job to pay for things?” “When are you going to stop taking and start giving?” “Do you ever worry about anyone but yourself?” These kinds of comments do not work. If any of my patients report this kind of thing, I always make it a point to correct the situation quickly, because it can be very damaging, especially to an already fragile person. 

You are dealing with a loved one with a mental illness, so do establish rapport, and through that rapport, using some of these do’s and don’ts which I just gave you, try to help them get a psychiatric appointment, get to a psychologist, get to a day program, or at least get them to some medical health practitioner for an evaluation. That may mean making an appointment with primary care for a referral, calling their psychiatrist or mental health therapist, or even taking them to an emergency room if it is an urgent situation. In some cases, it may even be necessary to call 911 and have them taken by police or ambulance if they aren’t willing to go on their own and they’re in crisis. Do be willing to do what it takes. Hopefully you’ll be properly directed to appropriate levels of care, and then do follow through with that. Don’t just let it go. Bottom line is get them somewhere. The most important thing that can happen at that point is that that caregiver establishes a bond with the individual, your loved one, and using that relationship, they can motivate and encourage and direct their care. That’s what you’re looking for: a caregiver (psychiatrist or mental health professional) they trust, that they will be honest and open with. That professional should be able to navigate issues and properly direct them to the appropriate level of care.  

So, you want to do everything in your power to encourage a good relationship between your loved one and that professional. Don’t sabotage that relationship. Work within that relationship. Don’tthreaten that caregiver. Don’t give the caregiver ultimatums. Do everything in your power to maintain a good open relationship between the mental health professional/ caregiver and the patient, your loved one.   

I hope this was helpful to any and all that needed to read it. 

Check out all of my other blogs and feel free to share them. Please check out my YouTube channel (just google YouTube Mark Agresti if all else fails) and hit that subscribe button to get all of my videos. As always, for patient stories and more information, check out my book, “Tales from the Couch” available in my office and on Amazon.com. 

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Why Is Sleep Important? Part Deux

Why is Sleep Important? Part Deux

When we left part one, I had just explained how lack of sleep can make people fat, and was about to explain how it can also make people ugly. First, just a quick review of the cascade that makes you fat. When you don’t sleep, there is an increase in the hormone ghrelin, which causes hunger, and makes you eat everything in sight at 3am. At the same time, levels of leptin, the hormone that makes you feel full, go way down. So you feel like you’re starving, but you can’t feel full, so you eat and eat and eat. Then, the stress hormone cortisol enters the scene since you’re not sleeping. Cortisol is a bully that pushes insulin around, so insulin picks up his toys and goes home, and this means insulin isn’t around to process all the sugary food you just ate courtesy of ghrelin. With all those sugars floating around, they eventually find their way to fat. But that’s not the end. Cortisol is such a bully that when insulin leaves, it starts picking on growth hormone. Fed up, growth hormone is suppressed, and that’s a bummer, because growth hormone is what repairs, restores, and rejuvenates the body. It builds protein, heals bone, and heals cartilage and connective tissue, as well as parts of the body that are very important to the beauty industry. And at long last, here is where I tell you how lack of sleep can make you ugly.  

They did a study centered on determining sleeplessness through imagery. It showed that it took people just four seconds max to look at images and determine which people had not slept. The bottom line is that not sleeping makes you look older. Your skin loses elasticity, making it more wrinkled. Why? Well, remember the 3am date with the Frigidaire? How the stress hormone cortisol crashed the party, bullying insulin and human growth hormone and causing their suppression? Well, without human growth hormone to repair and replenish the cartilage and connective tissue, the skin loses its elastic properties. Without elasticity, the skin wrinkles badly. Also, many restorative and metabolic pathways take place at night. Certain genes present on our chromosomes have specialized jobs. They are involved in creating proteins to restore the skin, connective tissues, cartilage, musculature, and basically to repair the body and fight the aging of the body. The genes that do these jobs turn on at night while sleeping. If you’re not sleeping, those genes can’t do their job normally. All in all, it makes you look old and ugly before your time: your eyes get puffy and bloodshot, your face gets droopy, you have decreased muscle tone and more pronounced wrinkling, and your posture changes, becoming more stooped over. When shown subjects with good sleep patterns, public perception studies show that those subjects are considered more likeable, sexier, more successful, more articulate, healthier, and happier. So now we know, if you don’t sleep, you get fat. If you don’t sleep, you look ugly. And that’s not so good.

Next, let’s talk toxins. In order to be awake with a functioning, metabolizing brain, our body produces waste products, basically like pollution in the brain. These byproducts of metabolism are inflammatory compounds called beta-amyloid and tau proteins, and these are deposited in the brain. These are no bueno; it’s very important that we get rid of these compounds. Why? Both of these proteins are causative factors in Alzheimer’s disease and dementia, and other types of dementia as well. The body has a system, the lymphatic system, and it’s like a garbage disposal system. It coats the entire brain in cerebrospinal fluid and it pushes all the toxins, inflammatory products, beta-amyloid proteins, and tau proteins out and away from the brain, and it takes them away where the liver and the kidney metabolize them and they are ultimately excreted in urine, feces, and sweat. That lymphatic system is critical, but like any system, it can be overloaded. If you don’t sleep, your risk of dementia goes way up, especially if you are chronically sleep deprived. A lot of other things go bad too, but this is a big bad one. You must sleep in order to clear the body of inflammatory products and toxins, and to keep the brain healthy. It is nothing short of critical.

I’ve given you a lot of reasons to give yourself seven to nine hours of sleep each night. During sleep, our bodies undergo transformative changes. Our blood pressure drops, our heart rate drops, our respirations drop. It sets up the conditions that allow us to clear our body of toxins, to heal, to restore, and to grow. But there are plenty more interesting studies related to sleep deprivation that will make you want to give yourself those seven to nine hours. During spring daylight savings time when we lose an hour of an hour of sleep, heart attacks increase by 24 percent. They infer that not sleeping increases the risk of heart attack and stroke, because of hardening of the arteries. If you don’t sleep, arterial repairs aren’t getting done, so there is an increase in blood pressure and heart rate. Couple that with increased levels of uncleared inflammatory products and toxins oozing around the brain and body, and it creates all sorts of problems if it is chronic. 

There are also psychiatric reasons that we need to sleep. Essentially, every psychiatric illness either causes sleep disruption or is exacerbated by sleep disruption. Most schizophrenics have an abnormal circadian rhythm that causes them to sleep during the day rather than the night. Sleep deprivation also causes some issues with psychiatric components. If you don’t get enough sleep, you have less empathy, you cannot recognize the pain and suffering of others. You can also lose the ability to understand facial expressions of pain, suffering, happiness, sadness. You can’t effectively ‘read’ someone’s expression or demeanor. Also, impulsivity increases when you do not sleep, and you’re prone to dangerous behaviors. There is no question that depression, anxiety, psychosis, panic disorder, and a host of other psychiatric problems are dramatically increased when people’s sleep wake cycle is impaired. You also can’t effectively concentrate if you do not sleep. Remember our student from part one, Randy Gardner. He deprived himself of sleep and was nearly a basket case by the third day. Speaking of school, I think that kids should not be starting as early as they do. I have seen that they do not regularly get the proper amount of sleep. They should start school at 9am, not before. As it is now, we make these kids get up so early, they are basically in a state where they cannot concentrate because they are sleep deprived, and that’s a huge problem, because this mimics attention deficit disorder. It’s very likely that many kidsdiagnosed with attention deficit disorder and even medicated for it really were just sleep deprived. Also, many studies on learning and sleep have been done. One was set up to study how well students learned a second language. They taught the same cirriculum to all of them, and the results showed that students with adequate sleep had a higher retention rate than sleep deprived students. From that, and many other studies, researchers have confirmed that memory is impaired by not sleeping. They did a similar study focusing on creativity and showed a three-fold decrease in creativity when sleep deprived. We know that the prefrontal cortex of the brain, which does all the decision making, is impaired by sleep deprivation. Scientists believe that the Challenger explosion and the Chernobyl disaster are both a direct consequence of a lack of sleep. There was a pilot program in some county in Minnesota that started school 90 minutes later in the morning, and the number of car crashes in the driving children under age 20 went down, as did the suicide rate.  

There is some interesting stuff about the immune system as well. They found that natural killer cells go down in people that don’t sleep. What does all that mean? We all have these primordial cancer cells floating around in us, which are basically little tiny cellular precursors to cancer. But we also have specific immune cells called natural killer cells, and they circulate around and their job is to kill those primordial cancer cells. So, this study showed that if we don’t sleep, the number of those natural killer cells goes down, leaving more primordial cancer cells. This supports all of the studies that have shown that chronically sleep deprived people absolutely do have higher instances of breast, prostate, and colon cancer. Recently, the World Health Organization even went so far as to recognize chronic sleep deprivation as a carcinogen. That’s saying a lot, people. Other immune studies centering on immunizations, flu shots, were completed tolook at antibody response. One group of people were sleep deprived, and the other group was well slept. All were given the same flu shot at the same time. The results showed that the people who were sleep deprived had just half the antibody response of those who were well slept. That’s a dramatic finding. So when you’re chronically sleep deprived, cancer incidence goes up and the ability to mount an immune response goes down. That’s like the perfect storm. This is important, because it has a huge impact on your life, especially now with the coronavirus. If you get fewer than five or six hours a night, your immune system is approximately 40 percent less competent than the immune system of someone who is well swept. Also dramatic, people. 

Just a quick review… unless you are among the five percent with a genetic mutation that allows your brain and body to work properly on little sleep, you need to sleep seven to nine hours each night to have optimal health. If you chronically and consistently do not get enough sleep, we have learned that you will overeat and be overweight, you will not be able to learn as well, your concentration and memory will nose dive, you will be less intelligent, and cosmetically, you won’t be very appealing. Basically, fat, dumb, and ugly. That doesn’t sound so great. So you really need to sleep.

Now that you know why you need adequate sleep, here are some tips on how to get it. 

– Get into a routine. Go to bed at the same time every day, and try and get up at the same time every day. 

– Create the proper environment. Sleep in a quiet place to avoid interference. Also sleep in a dark room, as any light throws off your natural melatonin that tells the body it is time to sleep. A cold room is best for sleep, cool enough to require a comforter. It’s very name tells you why: the weight of a comforter is…well, comforting. You can also buy a weighted blanket; these are great for kids too. 

– Situate yourself. Sleep position is important. Many publications say that the best sleep position is on your back with your legs elevated to maintain appropriate spinal cord posture. If you’re unable to sleep that way, then whatever position feels best to you and doesn’t cause pain in the morning is the correct one. 

– Blue light is bad. Blue light is emitted from screens on iPads, computers, kindles, etc. You must not have blue light exposure for a minimum of one hour before sleep, so shut it all down at least an hour before you go to bed. This is really important, as the bluelight is very disruptive to the melatonin cycle; it actually tells your body to get up. Speaking of light, there’s nothing as disruptive as bright light in the middle of the night. So if you must get up to use the bathroom in the night, don’t turn on a bright light. Get a dimmer switch and leave it set very very low and only use that. 

– Wind down. Consider incorporating a period of time to wind down into your pre-sleep routine. Reading from a book by low light is good, but it must be the old school kind written on paper, not on Kindle or in an e-book. Taking a hot bath is good too. It causes the small capillaries at the skin’s surface to open up, getting blood to the skin surface to radiate heat and cool the body. 

– Don’t drink a lot of fluids before sleep, because as your body goes into sleep, if it senses it has to go the bathroom, it wakes the brain, and then you wake up. Your body does have a mechanism for this; the posterior pituitary releases an anti-diuretic hormone to prevent the creation of urine during sleep, but you can override that by drinking too much fluid before sleep. So avoid that. 

– Don’t eat big meals before sleep. This also disrupts sleep. A little snack is okay, because you don’t want to go to bed hungry, as that is disruptive as well. Ideally, you really need to have your dinner four to five hours before sleep. Also, along those same lines, don’t have any sugar before bedtime. Sugar tends to inundate the system and then wake you as it’s metabolized, so no sugar before bedtime.  

– Alcohol, caffeine, and nicotine. No, no, and no. All are disruptive to sleep architecture. Alcohol: for every drink, you need four hours before going to sleep to not affect sleep. Caffeine: this has a long half life, so you need at least six hours per caffeinated beverage before going to sleep. Nicotine: ideally, you should have four hours before sleeping. This is a tough one, because people who smoke are commonly awakened by withdrawal from nicotine. So if you’re a smoker and you have trouble sleeping, try to quit smoking. I guarantee you’ll sleep and feel better in a short period of time. 

– Vitamins and supplements. Magnesium is a calming hormone, so it helps you sleep. Calcium is used to manufacture tryptophan, an amino acid which causes drowsiness, so that helps promote sleep. Vitamin D3 and B vitamins help metabolize calcium, so those are good. You need iron, vitamin E, and melatonin.  Also, valerian root is helpful. L-theanine is good, it is another amino acid that has a calming effect.

So now we’ve discussed the risks  and repercussions of not sleeping and some tips tohelp you sleep better. If you find you still can’t sleep, consider seeing a physician, especially if you can see that it is impacting your life in a negative fashion. 

I’d really appreciate people going to my website, dragresti.com and checking out all of my blogs and sharing them. You can also see all of my videos on tons of different topics on my YouTube channel. Please give me some likes and comments- I love reading comments- and most of all, hit that subscribe button, people! As always, if you want funny, informational, and helpful patient stories, you can find my book, Tales from the Couch available on Amazon.com.

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Why Is Sleep So Important

One of the most important things I deal with in my practice is sleep. Sleep is defined as “a naturally recurring state of mind and body characterized by altered consciousness, relatively inhibited sensory activity, reduced muscle activity, inhibition of nearly all voluntary muscles, and lacking interactions with surroundings.” All animals need to sleep. Evolutionarily, in order to survive and successfully pass on genetics to another generation, sleep is a necessity. Humans are animals in this regard; we’re no different, as we require sleep to live too. And while it is a naturally occuring state, for some people, getting sleep is an absolute battle, fought tooth and nail every night.

Just some fun facts about how a few animals sleep… Can you imagine sleeping for as little as 30 minutes a day? How about for only five minutes at a time? Our giraffe friends can, because that’s exactly what they do. For a large animal in the middle of the open savanna, it’s risky to sleep because of predators. They must remain vigilant, so they nap in short intervals, usually standing up so that they are always ready to run. Dolphins and some of their marine mammal cousins are also unusual in that, unlike us, they must consciously think to breathe, even when they’re sleeping. They also have to be on guard 24/7 for predators or other potential dangers. So how do they do this? Well, they shut down only half of their brain at a time while sleeping. This is called unihemispheric sleep. This prevents them from drowning, while at the same time, allowing them to literally sleep with one eye open and remain on the lookout for potential danger or predators. Great Frigatebirds can stay in flight for months at a time, with their feet never touching ground. This is an impressive feat, but even more so when you think about how they sleep: in 7–12 second bursts. They spend approximately a total of 40 minutes sleeping like this per day while also flying. But when they are on land, they do sleep considerably more.  

We humans can’t shut down half of our brains and we can’t fly or sleep underwater, which is a bummer. But really, how important is sleep for humans? Very! Rats are used in research because they accurately portray human systems, and there have been many sleep studies with them. One study showed that rats deprived of sleep for two weeks die. There is even an illness in humans called fatal familial insomnia, where if the people that have it do not sleep, they will eventually die from the cumulative lack of sleep. So let’s talk sleep. Sleep is basically the price we pay for the privilege of being awake, and there’s no way around it. So we have to pay the piper, but what’s the price? How much sleep do we need? The answer is that the vast majority of people need 7 to 9 hours of sleep per night. But, there is an exception. Five percent of the population has a genetic mutation where they only need five hours of sleep per night. Lucky ducks! Fun fact: in the past 50 years, the amount of sleep the average American gets has dropped by about an hour and 15 minutes to an hour and a half each night. That’s actually a lot, and there are consequences in our modern lifestyle. Also, you can’t bank sleep. You can’t say, ‘I slept an extra four hours over the weekend, so I can lose at least four hours of sleep tonight in order to get my big project done at work.” or “I won’t sleep much this week so I can study for a test, but I’ll make up the sleep this weekend.” Nope. It doesn’t work like that. More often than not, you really need to be on a regular sleep schedule, getting about the same number of hours each night. I treat sleep issues more than anything else in my practice. Hands down, every patient who comes in has a problem with sleep. With some people, I can do behavioral management; with others, I use meds or natural supplements. I’ll get to that later. When I’m lecturing, I always get questions about how one spouse gets up early and the other late and is that normal, etc. Yes, that is totally normal. There are certain genetic types, called chronotypes.  There are larks, people who get up early, but then go to bed early. And there are night owls, who go to bed very late, and then wake up very late. Your genetic makeup determines what your chronotype is, whether you are a lark or a night owl, it’s perfectly healthy to be either. It doesn’t matter when you sleep, what matters is that you sleep. Ideally seven to nine hours a night. Adolescents sleep more, up to 12 or 14 hours per night, and newborns sleep for 16 or 17 hours each day, mainly because these are growth stages, and that tires the body. But by the time you reach adulthood, age 20 or so, you need that seven to nine hours. It is a myth that older people need less sleep. In reality, they need just as much sleep. The reasons they don’t sleep well can be because they are in pain, have bladder problems and need to use the bathroom, or all the medicines they are on disrupt the sleep architecture. A lot of neurostimulants, diuretics, and other drugs that make them drowsy during the day make it so they do not sleep well at night. It can be a really frustrating mess that’s difficult to untangle.  

I want to talk about the reasons why we need sleep. Like many things in life, the reasons why are essentially based on the consequences of not getting it. 

The brain makes up just two to three percent of our body mass, but it consumes 25% of the body’s energy. It’s like a car that’s running really fast; as the car burns gas, it makes fumes. Similarly, when the brain is burning calories, it creates waste. That waste is cleaned out when we sleep, and is why most people need 7 to 9 hours per night. Now, some people think they can avoid sleep and just drink coffee or energy drinks, but that’s wrong. One of the byproducts of our brain using all the energy it does is the production of a waste product called adenosine; and it takes sleep to get rid of it. Caffeine blocks the body’s sensors that this toxin is building up, not unlike having a car running in your house. If you ran your car in your garage or house, carbon monoxide would build up and eventually you would die of carbon monoxide poisoning. Caffeine blocks the body’s ability to determine how much adenosine is in it, so the body is tricked into thinking all is well, no need to rest. If it goes on too long, there are consequences to pay, and you eventually collapse. 

A story on this topic that I find interesting is one about Randy Gardner, who holds the world record for sleep deprivation. There is some dispute about that, another dude named Tony Wright claims the record is his, but whatever. Anyway, Randy was a high school student in the 50’s and he had a science fair project to do. After much thought, he decided to study sleep deprivation. Randy decides he wants to prove all of his teachers wrong by showing them that people don’t really need sleep. He was normally a pretty affable guy, but right about day two, he started getting moody. Then he started having major problems concentrating at about third or fourth day. On day five, they tell him to start at 100 and to keep subtracting seven. He said “okay, 100 minus 7 is 93, minus 7 is 86, minus 7 is 79, minus 7 is…is…72, minus 7…no, minus 9 is 79, minus 7…wait…what am I adding? I mean…subtracting?” He was totally lost after just three subtractions. When they asked why he stopped, he couldn’t even tell them what he had been doing. And he was not a dumb kid, he was actually a straight A student. It was clear that missing four nights of sleep was clouding his mind to the point that he couldn’t remember simple directions. His inability to concentrate and his short-term memory loss was due to the fact that his brain and body were severely sleep deprived. But he still carried on with the experiment. Then something bizarre started happening around day six and seven. He started checking the windows in his house, making sure they were locked. Then he started looking for people watching him. He was sure that his friends were conspiring against him, and was constantly checking around corners, pulling down shades, and drawing the curtains on the windows in his house. If his mom opened them, he would freak out and hide in his room. Then he started saying that not only were they watching him, they were plotting against him. These people he was referring to were his best friends, but he was sure they had an evil agenda to get him. He still refused to stop his experiment, but his mother convinced him to see his doctor. It backfired: the doctor wanted to give him a B-12 injection, but when the syringe came out, Randy ran out of the room, convinced that the doctor was trying to poison him. He was going downhill very fast. On the eighth day, he started hallucinating, seeing and hearing things that weren’t there. Then he started having problems with pronunciation of simple words; a straight A student couldn’t pronounce everyday words. All because he had not slept, he had not allowed the brain and body to rest, to rid themselves of toxins. Then he stopped recognizing everyday objects. They would put a fork in his hand, and he couldn’t say what it was or what it was used for. By this time, he was like a zombie, walking dead. By the ninth and tenth day, he lost his sense of smell, and then his vision became progressively more blurry. By the eleventh day, he collapsed. He was emotionally, mentally, and physically done. His brain had given out first, then he started to lose normal bodily function, until his body finally gave up. He went 11 days without sleep. That’s 264 hours. 15,840 minutes. They didn’t say how long he finally slept. I suspect he was actually just unconscious at first. And they didn’t say what he got for a grade on his science fair project. I’d like to think it was an A, since the kid basically risked his life for the stupid thing. He went from a smart, gregarious kid to a babbling idiot in eleven days flat.

Lots of bad things happen when people don’t get enough sleep. In sleep deprived adolescents, the suicide rate goes up dramatically. In all ages, but more so in adolescents, the risk of car accidents also goes up considerably. There is also an increased tendency for moral lapses in people who do not get enough sleep; they do things that are typically out of character for them, like rob people or cheat on their spouses. Sleep deprivation also leads to learning problems, regardless of age; studies have shown that the capacity to learn is reduced by 40% when people are sleep deprived. That’s huge! It also causes an inability to recognize facial expressions. You may ask why that’s a big deal. Well, if you can’t tell that you’ve pissed off the big thug on the subway, you might continue to unwittingly irritate him and get yourself beat up… or worse. Reaction times are greatly affected by sleep deprivation; they’re slowed severely. That’s why car accidents increase. But researchers have thoroughly studied sleep and reaction times in sports. Many studies on sleep deprivation come from basketball players. Their accuracy and their performance metrics all go down relative to the hours of sleep missed. Hockey players’ reaction times, after just one night of missed sleep, were off by 30%. A goalie’s reaction time down by 30% is dramatic when it translates to the other team scoring on him 30% more often. 

It’s all about getting that seven to nine hours. There are lots of physiological consequences of sleep deprivation. Blood pressure goes up, the risk of heart attack goes up, the risk of stroke goes up, you become obese, and often diabetic as a result. There’s actually a mechanism for it that I’ll explain in a moment. A host of psychiatric and mental illnesses can result from lack of sleep, and studies have shown that people who are chronically sleep deprived die much younger.   

Now, let’s talk about your endocrine system. The endocrine system is the collection of glands that produce hormones that regulate metabolism, growth and development, tissue function, sexual function, reproduction, sleep, and mood, among other things. So, it pretty much controls like… everything. In young males, sleep deprivation makes the testosterone levels drop. The ability to produce testosterone is decreased in men who sleep less than six hours a night. What does that mean? Only that their testicles get smaller, they can have erectile dysfunction, and reduced sex drive. In adolescents, it can hamper the development of the bones and muscles, the deepening of the voice, and hair growth; all the stuff that helps boys start to look, sound, and act like men. It has an analagous affect on women, in that fertility goes down and estrogen levels decrease with chronic sleep deprivation. But in a cruel and ironic twist, a decrease in estrogen has been shown to cause insomnia and less productive sleep, or just very poor sleep. So for women, it’s often a vicious cycle. 

What else happens to your hormonal system when you do not sleep? I’m sure you can correlate a lot of this stuff with your real life experiences. When you can’t or don’t sleep, do you notice you crave junk food? It’s 3am and you’re standing in the kitchen, scarfing down cold pizza? Or some other high fat or high sugar thing…a big bowl of cereal or ice cream or a doughnut, or three? Or a cinnabun? I love those and I must have one every time I’m at the airport, those are good. Anyway, that’s a distraction- I didn’t mean to bring that up. Remember earlier when I said that I’d explain why obesity is so much more common in people who are sleep deprived? Here we are. So what happens to you’re endocrine system when you don’t sleep? For one thing, you secrete a hormone called ghrelin. Ghrelin is a gnarly beast of a hormone, high on the list of the most hated hormones ever in the history of hormones. It even sounds like the name of a goblin, right? And not a nice goblin. A bad, mean, evil goblin. Ghrelin the gnarly goblin. Why the shade? Ghrelin is the hormone that makes you hungry…and hangry. So here you are, middle of the night, can’t sleep. And all of a sudden you’re starving! Why? Because not sleeping has triggered the release of a crap load of ghrelin, and it’s coursing through your body, making you crave sugary, fatty foods… whatever doesn’t run away when you reach for it is fair game. Ain’t that a bi-otch? But that’s not the worst of it. Ghrelin the goblin has a goody goody cousin named leptin. Leptin is the hormone that makes you feel full. He’s nowhere to be found when the gnarly goblin ghrelin is out on the prowl. So not only are you starving courtesy of ghrelin, but goody goody leptin is home studying, so you won’t be seeing him or feeling full anytime soon. So before you know it, you’ve eaten all the leftover pizza, a bowl of cereal, and a giant bowl of cookies & cream topped with more cookies and whipped cream! And you’re still eyeing the rest of that baked chicken in the fridge. But wait! The hormonal chemical conspiracy isn’t over friends. Without leptin to make you feel full, ghrelin the goblin has made you eat everything that’s not nailed down, but somebody else is coming to join the party…cortisol. Dahn dun duuuuuhhhnnn! Cortisol is the stress hormone, and he gets produced at higher levels when you don’t sleep. When he gets to the party, he pushes insulin around (they have a terrible history; don’t even ask) so insulin feels emasculated, so his levels go down. Why should you care about insulin levels? Well, remember all the carbs and sugar that ghrelin made you gorge on? Insulin is what helps your body break all that down. But since cortisol came to the party, pushing insulin around, all those sugars have nothing to do. What does that sound like? Begins with a “d”? Diabetes! Obvi you don’t become diabetic from one 3am rendezvous with the Frigidaire, but it sets up a diabetes-like condition that leaves those sugars all dressed up with nowhere to go. If that happens chronically, you can end up with diabetes. So what happens to these loose sugars at 3am? They go to fat. It’s squishy and warm there, a great place to land. It’s a whole cascade, a hormonal conspiracy to make you fat and…and…ugly! For real?! How does that happen? The cascade continues! Growth hormone doesn’t get along with cortisol either, so when cortisol shows up, growth hormone is outta there. When growth hormone leaves the party, that’s really a bummer, because he’s what basically restores the body, especially parts of it that are very important to a certain industry…the beauty industry. You now know that not sleeping can make you fat, but how can it make you ugly? Well, check back next week and I’ll tell you! 

In the meantime, hop on my website dragresti.com and read some other blogs and like and comment on them, and check out my videos and subscribe to my YouTube channel. If you want more great stories that’ll make you sound really smart at your next cocktail party, check out my book, Tales from the Couch available on Amazon.com. 

And people, for better or worse, it seems like the world is re-opening once again, so just please make wise choices. Maintain a little distance, don’t rush out to bars and dance floors to make up for lost time, and if you’re sick, stay home for God’s sake! And bosses, remember the lessons that corona taught us: let your people stay home if they’re sick; don’t make them choose between their health and their livelihood. I’ll now step down off my soapbox. Have a great week!

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Why Are young Americans So Unhappy

The majority of my practice is made up of fairly young people, so I’m very well aware of what makes them tick. Over the past few years, I’ve noticed a definite trend of increasing unhappiness, a dissatisfaction with life. It’s enough to where I’ve begun unofficially gathering data on the phenomenon and formulating some conclusions based on hundreds of hours listening to them, and I’ve come up with a set of circumstances and reasons why I believe they aren’t happy. I’m going to share them with you so that you might better understand them. Why is it important? Why should you care? Well, aside from the fact that they may be your sons, daughters, nephews, nieces, grandchildren, or the friends of same, these are the future leaders of our country, the people who are going to be running things when people of my age are sitting in rocking chairs on porches or rotting away in some old folks home. Sad but true. So, why are young Americans so unhappy? In my opinion, the overarching theme is that the institutions and/ or systems that are meant to guide and give direction are essentially failing to do so, and that leaves this group adrift and rudderless. Below is a listing of these institutions and systems, along with an explanation of the issue(s).

Social media: I have discussed the “evils” of social media many times in other blogs and videos, but there is a definite correlation between the amount of time that the average young American spends on social media and depression and anxiety. Believe it or not, that number is six hours per day. That’s the average amount of time spent on social media daily. Studies have shown that anything north of two hours a day is linked to depression and anxiety. As it pertains to this blog, I think the real issue with social media is that it causes loneliness. When you are only electronically connected with someone, you are not actually with that person…you are actually alone. Loneliness is also a by-product of gaming, web surfing, video watching, video sharing, texting, e-mailing, etc. These are solitary pursuits, often leaving users feeling empty.

Patriotism: We now find ourselves in a position where our confidence in our government and its leaders is in serious decline. We have little to no faith in the powers that be, the officials running our country. As a result, the level of patriotism in our country is nowhere near what it was one generation ago. There is little belief in the “American way” and the power of the “red, white, and blue,” not just in the eyes of many Americans, but even worse, in the eyes of people around the globe. One generation ago, the US used to be respected, even feared, as a superpower. These days, the US is a veritable laughing stock, not respected nor feared. For young Americans, this engenders a sense of chaos, a distinct lack of confidence, and mistrust. The government is not fulfilling its role to help guide us, give us meaning, direction, and purpose; or a sense of belonging to something bigger.

Religion: Today, people are much less involved in organized religion as they used to be. The church used to be a pillar in the community, the place where you saw your neighbors and friends every Sunday morning. Today, churches are often a hotbed of controversy and even scandal. They are no longer sacred places of reverence, no longerinstitutions that establish guiding principles and give people direction. Organized religions and churches are now sources of mistrust and outdated principles in the eyes of many young Americans, a far cry from even the previous generation. Today’s young people have an ingrained sense of mistrust of authority, especially when that authority attempts to dictate the way they “should” live their lives. Many are not willing to “confess” to a stranger that has not proved themselves, or turn their lives over to someone or something they cannot see or challenge. The church used to be a tether of sorts, creating a sense of community. That sense is absent in young Americans, so whether realized or not, they are more adrift than previous generations.

Family: Today, young people are marrying less often. Many don’t even subscribe to the ideology of monogamy for life, it is an archaic notion to them. The previous generation had their sexual revolution, but today’s young Americans are in the midst of a far different sexual revolution, one in which you may not even be the gender you were born into. Having children or being part of a family is no longer predicated on marriage for them; they don’t live their lives for a piece of paper, they live them for themselves and the people they love. Marriages are also happening much later in life, after personal goals like education or travel have been fulfilled. Today, the definition of family has changed drastically from that of the previous generations, and it is a fluid definition, not set in stone as masculine father married to feminine mother that are parents to 2.5 biological offspring. The value of having a family is less than the value of having a fulfilled and accomplished life, whatever that may mean or look like to the individual. Today’s young Americans make their own definitions. Previous generations had faith in the institutions of marriage and family, and that faith grounded them. Many young Americans express to me that they don’t feel anchored or rooted in their personal lives, and I believe it’s because of their negative thoughts about marriage and family. Life is often a team sport, so free agents may be left out in the cold. 

Employment security: Individuals from previous generations expected to establish a secure career path, and invest themselves in a company where the boss knows their name. They would start in one position and expect to work hard to move up through the ranks for forty years, and then get the gold watch and retire with a pension. That is decidedly not the case for young Americans today. For them, it’s all about taking jobs that make money now, not jobs that will make money five, ten, or fifteen years from now. They expect they will likely take a series of jobs; they are willing to follow the money. There is no career path or job security. Why? Technology. It’s a double edged sword. It advances our society, but it also dictates career obsolescence. Young people don’t know who will be able to stay in what kind of particular career for any length of time. So they do what works here and now, and they don’t count on having a future doing that same thing. They know that technology or corporate governance will probably erase that job, so they don’t invest themselves in it. They expect it will be outdated,outsourced, taken away by an algorithm or artificial intelligence, a robot, or novel software or methodology. Young Americans know they must make hay while the sun shines. They have no job security, no employer-employee loyalty, and they definitely don’t expect a gold watch. When I talk to young Americans, it’s almost an automatic ‘I‘m screwed attitude’ that I hear from them. It’s pretty clear that the lack of basic job security can lead to undue anxiety and even anger and depression in this group. 

Heroism: It seems that heroism decreases with every generation. It used to be that people idolized movie stars in Hollywood and heroes in the sporting world; but young Americans see these people as false heroes. They are exposed as such on social media and in courtrooms across the country. They’re people who can memorize and spit back lines in a script, but they are anti-human beings on the inside. They are not real heroes.  They are fabricated by Hollywood or idolized on a field simply because they can run fast, catch a ball, or hit hard. Those things don’t make them heroes, don’t make them deserving of idolatry. Look at O.J. Simpson, he got away with double murder because he was a football hero, and that blinded the jury. Or the recent college admissions scandals, where rich actors believed they were above the law and could afford to pay people to lie, cheat, and steal on their behalf in order to get their kids into a specific college. In reality, they’re dirtbags with more money than scruples. Young Americans see through all of that kind of bs and don’t tolerate it, which is a good thing; but it also makes them jaded, which isn’t such a good thing. 

Technology: As I mentioned before, technology is a double-edged sword. For all of its good, it also makes people outdated very quickly. It causes uncertainty to cloud our futures, and leads to complexity and chaos, because we do not know what’s going to happen next or how our livelihoods will be affected by the advances in technology. If you’re a cashier, a bank teller, a retail worker, a postal worker, a UPS driver…anxiety city. Earlier this month, the drug store CVS had a live test for delivery of medications during the coronavirus pamdemic via drone for a huge senior community in Orlando, a job that had employed humans. Evidently it was a great success. Even the practice of medicine is under threat of being replaced by algorithms. There is even an algorithm for the practice of radiology, which has the highest malpractice insurance rates, along with obstetrics. If radiology becomes algorithmic, then that affects insurance companies too. I guess no career path is an island. Think about Detroit- the car companies that all went automated. People were replaced by robotic machines that never get sick, don’t have unions, don’t take vacations, and don’t complain. It became a ghost town overnight. Young people almost need a crystal ball to make a decision on what to do for work, so they don’t think in the long term future, they take a job to make money now, whether they like it or not. They lack security, and that does affect their psyche. 

News Media: The media used to be a trusted organization. When the news came on, previous generations watched and listened and believed. If it was stated or printed, it was so. Nobody trusts the media anymore, their opinions are bought by the highest bidder. It is so biased that if you watch it you are misinformed, but if you don’t watch it,you are ill-informed, so there’s just no way to win. These days, every news outlet has its own agenda, and damn if you can figure out what it is. Where previous generations believed that if it was in print or on the television it was true, today, young Americans have zero faith in the institution of media and news reporting. They take everything with a grain of salt, because they have to. Facts are no longer factual, and truth is no longer subject to reality.  

University educational system: Young Americans see this for what it is…a biased, outdated system to give people a questionable education in return for saddling them with hundreds of thousands of dollars in debt. They overcharge for an archaic teaching methodology, then pronounce graduates “educated.” Those graduates then enter the job market and find that surprise(!) they aren’t really prepared to work anywhere.

. Two year technical degrees are most definitely more appealing to young Americans these days, because at least they walk out of there certified in a trade, able to do something for someone somewhere. Our educational systems are a failure, in desperate need of an overhaul. They don’t do the vast majority of young Americans any justice at all. 

Do you see a pattern here? All of these organizations and systems that are meant to give us direction, give us purpose, and set us up for the future, seem to be failing, becoming less important, less useful, or not worthy of our trust. We have no confidence that what our leaders are saying is worthwhile or applicable to our real life. As a result, we are generally more cynical. It is a precarious situation for young Americans, and there are no google maps to get from here to there or now to then. So I have some suggestions.

Dear Young Americans,

I’m sorry the world is basically stacked against you. Following are some suggestions on how to deal with the hand you’ve been dealt. 

Be original. Create your own moral codes and live by them. Decide which relationships are most important to you, and build them up so as to make them permanent and impermiable. They are the most valuable things in your life. Treat them as such.   

The place where you sleep at night is your home. The area surrounding it is your community. The area surrounding that is your environment. Your home, your community, and your environment are important. Always endeavour to make them a better place. 

You do not require an organized religion or a brick-and-mortar church to live a spiritual life, to believethat there is something greater than you in the universe, or to be grateful to it.

Only you can decide what your work life will look like or what career direction is for you. The job you’re in does not have to dictate your path, it can be a stepping stone to the work life that you wishto create.

You must decide how to approach politics. Don’t let it entrap or bias you. Don’t deal in generalities, only in specifics. Decide what issues matter to you and work toward improving them.  

Some part of your life must be dedicated to a charity or charities of your choice. It’s a two-for-one…by helping others we help ourselves, enriching our lives at the same time. 

Understand the pitfalls of social media. It is a solitary pursuit, born and bearing of loneliness. In healthy measures, social media is a positive andessential part of life, educating us and expanding our horizons. Optimize the positives and eliminate the negatives, don’t overuse and abuse it. 

Remember that by its very nature, life is constantly changing. As such, it must be reexamined andreevaluated on a continual basis.  

Good luck. Make yourself proud of yourself.

Mark Agresti M.D.

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The Truth About Gender Dysphoria

The Truth About Gender Dysphoria

Gender dysphoria is basically a mismatch between a biological sexual assignment, i.e. the gender one is born into, and what gender they feel they are psychologically and desire to be physically. Until several years ago, it was termed “gender identity disorder,” but, for three reasons, I never liked that nomenclature: first, it was/ is not a disorder, second, the term ‘disorder’ was further stigmatizing to a group of people who frankly were already dealing with such huge stigma by simply existing, and third, the term ‘dysphoria’ is a more accurate term, for reasons I’ll explain shortly. So, good riddance to bad rubbish. 

And speaking of rubbish, we’ve all heard people say how this “phenomena” is a “trend” and how “these young people think it’s cool to say they are something they’re not.” Can I just say, I’ve found that anything following “these young people…” is bound to be crap 99% of the time, and this is just another perfect example. A lot of people also say that “it’s a phase” and that kids will “grow out of it.” To be clear, GD is not acne or puberty or a shoe size. It is not a phase, not a growing pain, not a cool trend, and most certainly not a choice. But what it is, is a very confusing, very painful, very disturbing state of being, especially when first realized and explored. In my experience, the later in life that the realization happens, the greater the pain, ramifications, and complications that will manifest in the person’s life. 

First awareness of gender dysphoria historically begins around the age of four, but can be even earlier. In some people, it might be more into early adolescence, and in a very small percentage, even into young adulthood, though I believe those are likely cases of severe repression and/ or denial. Regardless of the age, it is always very psychologically distressing to the person with GD and their parent(s)/ family, but for very different reasons that are age dependent: if a five-year-old has enough awareness to tell their parents about it, his/ her parents will react very differently than parents of a nineteen-year-old. It’s potentially the difference between the six-year-old maybe being ignored or hopefully going to a physician for discussion, and the nineteen-year-old possibly getting thrown out of the house. And of course the potential parental and/ or family reactions to the news vary widely across a huge spectrum, regardless of the age of awareness or realization; and those reactions can either encourage the process or forbid it, or anything in between. 

Some people find it very difficult to believe (read: don’t) that a child of four could ever have the awareness of GD, or of being in the ‘wrong’ body, but they absolutely can. Let’s be clear, a four-year-old girl doesn’t look in the mirror and think “Gee, I hate this dress; I’d rather wear jeans. Hmmm, I must have gender dysphoria. I’ll tell the parental units, riiiight after I finish my chicken nuggets.” It doesn’t happen that way. GD is also not about little girls refusing tea parties in favor of tonka trucks or little boys preferring their sister’s tutus to GI Joes. If only it were actually that simple and easy to diagnose! In reality, gender dysphoria can be a confusing conglomerate of signs that can be very misleading. Depending on the age and psychological state of the child with GD, it may be less confusing and more acceptable to them, because younger well-adjusted kids typically have greater acceptance of things they feel but haven’t seen or had exposure to…nobody has tainted them, inoculated them with cynicism, self-doubt, or guile; in short, they’re innocent. If they’re of an age that Santa and the Tooth Fairy are real, how much of a stretch is it to honestly feel they belong in a different body? I know all the questions from listening to the parental/ familial perspective for years. They always wonder if their child is lying. The truth is that children under age ten to twelve-ish likely don’t even know about the existence of GD, much less enough to lie about it. And if they’re asking about older children, adolescents, or even young adults lying, I always wonder (and ask) why on earth anyone would want this, or intentionally insert themselves into this situation? Who would relish this scary, confusing, and troublesome state of being? The answer is no one. Parents exploring GD want to know when “it” happened, like it’s the big bang. They wonder aloud when a girl child is more Tom than just tomboy, what are the signs, and how do they recognize and read those signs? The problem is that they’re usually looking for proof in a situation that is inherently difficult to prove without a crystal ball and related accoutrements. I generally tell them to not try to read any signs; that it’s much better to simply listen when a child speaks. Invariably, it comes down to this: “But how does my child know they’re not the gender they were born, or that they’re in the wrong body? How does my daughter know she’s not a female/ my son know he’s not a male?” I always answer that question with a question: “How do you know you are a female/ are a male?” The answer is that you just know. It’s an inherent thing. Children more readily accept it because they don’t have all of the hang-ups that come as standard equipment with adulthood. But please don’t misunderstand, when I say that children more readily “accept” it, I don’t mean that little Johnny realizes he doesn’t belong in the body he was born in and then he skips off in bliss. Not at all. With gender dysphoria, there is plenty of angst to go around, and every person in the family gets a heaping helping. It is difficult on the person with GD because they were born, named, and recognized as one sex, but have always known they were supposed to be the other sex. It is difficult on the parents and on the family system, because someone who was born, named, and recognized as one sex, (seemingly) suddenly wants to be the other sex. And all of them must choose to adapt to it or fight it, neither of which are easy roads to hoe. And what seems to the parents and family to be a snap decision on the gender dysphoric person’s part is actually anything but; this knowledge came only after long and serious consideration and great internal debate, relative to, but regardless of, their age at the time. In any case, it’s an inherently difficult situation to adapt to for everyone, and that’s one of the main reasons why gender confirmation (aka gender reassignment) is a multiple years-long process, not an overnight thing. Incidentally, the preference was changed from gender ‘reassignment’ to gender ‘confirmation’ by leaders in the field because they (and people with GD) say it isn’t reassigning another sex to the person, it is actually and truly confirming the sex the person was meant to have been in the first place. But both terms are still used interchangeably for the most part.

The Harris Institute says 0.3-0.4% of the US population, approximately 1.3 million people, are affected by gender dysphoria. That’s a pretty significant number; certainly high enough to deserve better care than what’s primarily available. There are a couple centers of excellence with a few big-shot surgeons that handle confirmation surgeries currently in the US, but there really should be several more in strategic parts of the country. I treat about three to four patients with gender dysphoria a year, so figure approximately 100 total throughout my career. To put that into perspective, I’ve treated about 20,000 depressed/ bipolar patients and 8,000 to 10,000 schizophrenia patients. It doesn’t come very close comparatively, but it’s enough to say that I’ve definitely seen an increase in the last ten years or so. And as attitudes change and acceptance becomes more widespread, I expect that trend to continue. It may sound strange to say, but I hope those numbers do continue to go up, because the alternative is frightening…it means that more people with GD are suffering silently, being marginalized, either severely in denial or repressed, hopeless and suicidal, mutilating, and ultimately, opting for suicide rather than confronting the issue headlong. And that is simply unacceptable if we are to call ourselves an enlightened society in this day and age.  

As hard as it is on the parents and family, the most difficult path is that of the individual with gender dysphoria. This goes back to my earlier reference of dysphoria being a more accurate term than identity disorder. The reason why is because of the presence of dysphoria in relation to one’s gender. Dysphoria is defined as a state of unease or a generalized feeling of dissatisfaction with life; in gender dysphoria, this state of unease and dissatisfaction is caused by one’s gender, of being born in and living in a body of the wrong gender. 

Let’s take my patient Thomas, who preferred to be called Tommy. Born male, Tommy was thirteen, and had started puberty several months before his parents brought him to my office. They said they were concerned because he “had stopped eating recently for no reason.” That piqued my interest, because I had a thirteen-year-old son once upon a time, and he never stopped eating “for no reason.” So I performed a stat parentectomy and brought Tommy into my office. Appearance-wise, he looked like any regular thirteen year old, but psychically he looked down, troubled, and on edge. I asked him what was going on with the not eating thing, and at first, he looked like he was running through a list of answer options, i.e. lies, and was trying to decide which would get him out of here with the least fuss. I quickly added, “the truth, Tommy. You’re never going to be done with me until you tell me the truth and we work through it, so you might as well start now. I can assure you that whatever you tell me won’t shock me.” After a long breath, he wisely chose the truth and started talking. For length’s sake, I’ll paraphrase what he said: he had stopped eating because he had hoped to stop puberty, basically to starve it of nutrition to try to prevent it, because it was so painful for him to gain weight and take on male characteristics. He was so distressed to see facial hair, pubic hair, muscles developing, his penis enlarging, and his voice deepening. He said it was wrong, he had known it was wrong since he was three, that this feeling was one of his earliest memories. Obvi, I had a good idea where he was going, but I had to encourage him to be more specific, and I told him that he couldn’t mince words, that he needed to voice it in his own words; so after a couple of beats, he did. With a few tears, he pointed to his lap and told me that he didn’t belong in “this” body. I really felt for this kid. He went on, the words choking him, saying that every morning he gets up for school and goes to the bathroom, and he looks down and has a panic attack. If I live to be 112, I’ll never forget the next thing he said; he tried to just slide it in, but it made my blood run cold. He said that he was going to find a way to cut it off, that he’d cut it with a nail clipper, but he didn’t have the guts to really do it. I had to bite the inside of my cheek. Every once in a very, very, very great while, maybe three times in my career, for a split second, I’ve thought to myself, “I can’t do this right now.” Looking at Tommy, I had that thought right then. It passed quickly, but the mental picture of what he was describing hit me like a ton of bricks. I asked him if he still had those feelings, and he said that he just didn’t know what to do. That was too vague for me, and in any case, it didn’t answer my question. I needed to know if he was going to hurt himself. I told him that I was going to help him, but to do that, he had to be 100% honest with me. When he agreed that he would be, I asked him point blank if he was going to hurt himself, cut himself, or mutilate himself in any way. He said no, and I believed him. Tommy was clearly depressed; it was clear to me that this scared little kid had the weight of the world on his shoulders. In his mind, he was female; his body disagreed, but he knew with every fiber of his being that his body was wrong. He wanted to be female. He wanted a female voice, a female body, a female top and a female bottom, to match his female mind. For Tommy, it was not a trend, not a passing thought, not a stage, not a lie, not a ploy, and nothing he asked for. This female being in a male body was a condition, one he had suffered with his entire life. He said he hadn’t told his parents, that he didn’t know how. When I asked if he needed my help to do that, he said yes. Tommy’s was my last appointment before lunch, so I had some time. When I asked if he wanted to tell them now or next appointment, he said now. I was on board, so I went out to the waiting room and called them into my office. 

Once Tommy’s parents made themselves comfortable, I explained to them everything that Tommy and I had talked about. Suffice it to say there was shock, disbelief, tears, and many questions. Tommy answered some and I took the rest. I explained all about the diagnosis of gender dysphoria and the reason Tommy had stopped eating. There were some protestations and some denial that I did my level best to dissuade, or, if I’m honest, maybe something more akin to shut down. All in all, they took it relatively well, or at least better than some parents have at any rate. I explained that there is a very proscribed path to follow, and I made it very clear that Tommy’s physical and psychological well being was very likely at stake. I told them that he was very anxious and depressed, and that I could treat him for those things, but that I suspected that the only way to make him better was to fix the underlying issue, the gender dysphoria, through hormonal and surgical means. That freaked them out, but they relaxed a little when I said that today’s appointment was only the first of many steps that would be taken before that could happen. I still needed to talk to Tommy a lot more, as well as the entire family, before finalizing any diagnosis. I told them that today was a good start, that I was very proud of Tommy, and that they should be too. I gave them my cell number and told them to call anytime if they needed anything and suggested they go home and keep the dialog going. We made a follow up appointment for two weeks. I shook Tommy’s hand, patted him on the shoulder, gave him my card with my cell number, and looked him in the eye and told him to call me if he needed to talk. He got the message and said he would. He looked like twenty pounds had been lifted off his shoulders. I was hoping that the communication trend would continue when they were back at home. Lots of parents say they’ll do something in my office, but then don’t follow through at home. I didn’t think that would happen in this case. I really hoped for Tommy’s sake that I was right, and that in two weeks they’d say that they were willing to start on the long road to exploring Tommy’s issues, potentially with a view toward gender confirmation surgery. In two weeks, I’d know if they were willing to allow us to explore that potential diagnosis. 

I have had a fair number of patients like Tommy, including genetically male patients of similar age who have been sent to me after attempting suicide and/ or mutilating their penises in a misguided attempt to fix themselves, or at least make life more tolerable. Unfortunately, that is not uncommon. It’s a very sad situation for all of them, but especially heartbreaking for the ones that have no support from their parents; or worse, the ones whose parents chide them, scold them, or do anything within their power to try to “change” them or make them see “the error of their ways,” including horrible and illegal things that make decent people want to vomit. I have had young female patients who, when they get their periods, develop severe anxiety disorders. For eight to ten days a month, they have a painful reminder of everything that is “wrong” with them and the bodies they are trapped in. When they start to narrow at the waist and get the weight distribution of a woman, they become intensely alarmed and anxiety ridden; and when their breasts begin to develop, they band them up or they tie them up so severely that they form a band of deep bruising, connecting continents of black and blue contusions. And sadly, breast mutilation in genetic females with gender dysphoria is nearly as common as penile mutilation in genetic males with gender dysphoria. It’s a devastating fact that most people would rather not consider. 

Most of my practice is young people, so patients with gender issues, unknown psych issues, or even undiagnosed GD come to my office when they’re usually 12-15 years of age, a time when they are doing everything in their power to block puberty because it is so deeply disturbing to them. When I speak to them about it, I find that they are not afraid of changing their sex, they are not afraid of having top surgery, or of having bottom surgery, which is a major procedure, a very painful one with a long recovery period. What they fear is living in the wrong body, disappointing their parents, and feeling the wrath of siblings, strangers, bullies, and anyone who disagrees with their choices or state of being. Gender dysphoria is the only psychiatric condition that can be cured through surgery rather than through psychiatric intervention. My job is to guide them and treat the depression, the anxiety, and the panic of the unchanged being. Once they are on the introduced hormones and have the confirmation surgery, they do much better. It’s the only psychiatric condition that is like a broken bone, once it’s fixed, it’s fixed…it can never be broken in the same place ever again. Once you confirm the patient’s gender with surgery and change their outward appearance to match the sense of self they have always felt inside, they are dramatically better. They are whole, and they will not break in that place ever again. It is an amazing metamorphosis, one I have been privileged to be a part of many times. 

Now, what is involved in this process of diagnosis and surgical intervention of gender dysphoria? I can tell you that it’s a long road, and not an easy one. Basically, there is a long list of criteria required to move forward on the path toward gender confirmation surgery. To meet the psychological criteria, there must be a documented history of gender dysphoria by a psychiatrist for a minimum of six consecutive months. By the time 90% of my GD patients get to my office, they have been tormented by the issue for years, and they are beyond ready to disclose it and take any steps necessary to move forward. I always make sure that the patient’s pediatrician is on board, and that they’ve done labs to look at general blood cell counts and hormone levels, and I also make sure there’s nothing significant in the medical history that might be pertinent to potential diagnosis. Assuming I make a diagnosis of GD, genetic females are put on testosterone, and they develop male characteristics: facial hair, a male weight distribution pattern, increased muscle mass with exercise, and lower voice tone. Then in due time (but never soon enough for them) they start having surgeries. The earlier surgeries are typically mastectomy (aka “top surgery”) and various facial plastic procedures, i.e. mandible (jaw) implants to square off the face and chin implant to accentuate the profile. Some may decide to break from surgery at this point and live this way for a period of time. Eventually, most genetic females undergo “bottom surgery” to complete gender confirmation. This is where female tissue is surgically altered and converted into a penis with varying sensitivity and functionality. Once healed, there can be numerous revisions to improve aesthetics and achieve better function over a period of several years if the person so desires. There can even be surgeries to alter the length of vocal cords to change the pitch and tenor of the voice to sound more characteristically male. 

Post diagnosis, genetic males are put on female hormones estradiol and micronized progesterone, and these decrease the male penis, testes, and the sperm product. There are other drugs that can be used to demasculinize male facial features. Then there is laser hair removal for the face and body, and hair implants to lower the hairline to appear more feminine. There are many plastics procedures to make the face less masculine and more feminine, such as narrowing the nose, shaving down the forehead, reducing the chin, reducing the ears, adding cheek implants, shaving down the Adam’s apple, and all sorts of injections and fillers to feminize the face. Breast implants, various body implants, and liposuction feminize the body shape, and there are millions of different facial peels, laser treatments, and lotions and potions to remove the ruddiness that’s more typical of male skin and feminize skin tone. There are many procedures regardless of gender change direction, so a team approach with everyone on board and on the same page, and with constant communication is critical.  

As with many medical issues, the sooner you can start therapy, the better. Hormonal therapy in gender confirmation is no different. The sooner you put a GD patient on testosterone or on estradiol/ progesterone, the better the result will be. But before that can start, many things have to happen, and those things take time. First, if the patient with GD is sub-adult (which they usually are), the parent has to get them to a doctor, which means that the child has either told them what’s going on, or the parent notices that there’s a problem, as Tommy’s parents did. That all takes time. Then, the next step is either a pediatrician’s office, who runs tests and then sends the patient to me, or the parent brings the child directly to me for evaluation first. More often than not, the entire process begins in earnest in a psychiatrist’s office. My problem as a psychiatrist is that children of age 10, 11, 12 do not yet have fully formed brains, yet they are asking to make permanent changes to their sexual assignment; to go from a genetic boy to a girl, or genetic girl to a boy. It’s best to start hormone therapy at this age, I know that, but what if you’re wrong? The odds of being wrong are pretty low because of exhaustingly thorough therapeutic examination of the issue, and the fact that really no one pretends that they have this problem, it’s not a fad, not a lie, not cool, not fake, etc. That is all plain to see in these patients. They are suffering and in great emotional distress. Their psychiatric problems are not about having the actual sex confirmation surgery or taking on characteristics of the opposite sex. Their problems either surround not being able to tell their parents, or dealing with family issues, of their parents rejecting them, siblings who may reject them, bullies at school, and/ or being isolated and depressed in their skin, thinking about not having friends, etc. These individuals have much higher suicide rates. The rate of depression, anxiety, and panic disorder are dramatically higher as well. So for the patient with GD, we have to intervene with parental counselling, and we have to intervene with family therapy. The whole family, as a unit, needs to process the potential changes in gender assignment. And of course there must be a great deal of individual therapy to help the GD patient navigate the waters of the process. As I mentioned before, the least of their worries is the surgeries; more importantly, they must learn how to tell people about their status if they wish, and learn how to deal with other people’s reactions, and with society’s reactions as a whole. For example, being forced to use the wrong bathroom, one that does not go with their true internal gender. Or dealing with someone using the wrong pronoun, referring to them as sir or mister when they prefer miss or ma’am. Driver’s licenses list the genetic gender that doesn’t match their true gender. These things are all very painful, very traumatizing for a person with gender dysphoria. Every stage or every place where society labels someone male or female is distressing for people with gender dysphoria. Even after they’ve had confirmation surgery, it can be painful. Obviously, Social Security records and birth certificates always list the gender a person was born under. If they want to change it, it’s not easy. They need lawyers for practically everything, they have to threaten to sue to go to the right bathroom, to get records changed, every little thing. But these things are very important to them, so they often choose to do them, no matter the expense or pain involved. And how do they apply for a job? What gender do they check? Because if that job includes health insurance and life insurance, it all has to match up. They can’t have their genetic/ birth gender on one document and confirmed/ inside/ new gender on another one. And speaking of health insurance, you can pretty much forget them paying for any of it, so you better hope somebody is independently wealthy or wins the lottery, because you’re looking at about a quarter million to get through just the basic therapy, testing, meds, and surgeries. Then tack on a lot more for potential revisions and all of the necessary plastics surgeries and other refining procedures and upkeep.

As a psychiatrist, I am usually the first hoop to jump through. I treat GD patients for depression, anxiety, sleep problems, addictions, attempted mutilation trauma, attempted suicides, and the physical/ emotional/ sexual abuse they may go through, as most do have harrowing abuse histories. I give my stamp of approval to move them forward on the gender confirmation pathway, and continue to follow them throughout. As the person that sees them first and last, I have a front row seat to before and after, so I have seen that things get much better for patients as their sexual transition progresses. It sounds like it happens quickly, but it doesn’t; even all the approvals can take years to put together, and then there are often surgical waiting lists, as there are only a few super-specialists who do the most major part of the process. It also has to be a team approach, with every physician trusting each member of the team. On that team, you need psychiatric therapy for the individual, parents, and siblings. You need a pediatrician for general medical, a pediatric endocrinologist to monitor hormonal changes, urology and urology surgery to deal with the plumbing, specialty surgery to do the actual reassignment/ confirmation, along with plastic surgery of all sorts to deal with function and aesthetics, the list is never ending. And again, you have to go to a center of excellence to find all of these surgeons, because these super-specialists don’t grow on trees…you’ve gotta go to them, for every procedure and every follow-up visit. With so few centers and so few super-specialist surgeons, that involves a lot of time in the air…lots of frequent flier miles. We desperately need more surgical centers and more super-specialists, and we have to maintain the team approach to treating GD. Because the psychiatrist is usually the first hoop to jump through, they lead the team. They are the ones to say “I have thoroughly evaluated this patient, and I certify that they have gender dysphoria and believe that they require gender confirmation surgery.” It’s really not so easy; it’s one thing to confirm a diagnosis, but it’s quite another to say “I am going to lead this team, and I am confident that making this permanent surgical transition is the only path to psychological health for this person. I will work with them, their parents and siblings, separately and together, for the duration.” To say that to a group of ten plus physicians, all of whom are counting on that original diagnosis, putting themselves on the line legally and ethically is a big deal, and not one I take lightly. I have to be pretty secure in what I’m saying, and to be honest, it takes me a while before I’m willing to make that play. I am required to certify the circumstances of GD for a period of six months, but it takes me a lot longer than that. I hate to say it, and maybe I should do it in less time, but it takes me over a year of working with that patient before I’m ready to lay it all on the line with a diagnosis of gender dysphoria. And patients get, ironically, well, very…impatient. Whenever I look back at my GD patients, I always think I should’ve pulled the trigger sooner. Sooner really is better in these cases, less traumatic, fewer mutilations borne of frustration, fewer attempted suicides, more effective hormone treatment, and with better final outcomes. I always say I’m going to shorten the time to diagnosis when I get the next case, but then I’m drawn in by an overabundance of caution. It’s not the worst thing ever, but maybe not the best? It’s really hard to say. Next time I have a GD patient, I’ll make a mental note to read this blog, and maybe that will decrease the length of time it takes for me to put my chips down on the GD diagnosis. A lot of it depends on the patient’s age of realization and their willingness, as well as their parent’s willingness, to undergo all of the therapy it takes to come to the diagnosis in the first place. 

I’ve had a bunch of patients undergo these sexual reassignment/ confirmation surgeries, and I’ve had pre-op genetic males end up looking like post-op females and vice versa, and at every stage in between, so when they would come to see me during the process and would be in the waiting room, sometimes my secretaries wouldn’t recognize them. They would see a name they recognized on the chart, but sometimes not the face, which has led to some confusion…so these hormone therapies and procedures, when done well, can be very convincing. Over the years, some of these patients were thrilled when the girls up front didn’t recognize them! One such patient was Tommy. Remember him…the 13-year-old genetic boy I talked about earlier? Well, when her surgeries were all said and done, she looked amazing as a nearly 20-year-old woman. The day finally came when Tommy (she kept the nickname btw) caused a bunch of confusion with my secretaries. When she walked back into my office, she was smiling ear to ear because my secretaries didn’t have a clue who she was. It was pretty awesome to see, and I felt good being a part of something that was so clearly right. Tommy walked that long, and often dark, path to acceptance, and came out the other side beautifully, with all of her familial relationships intact. It doesn’t always happen that way. I’ve had patients who had to wait until they were out of their childhood homes because they were told they couldn’t have the surgery while they lived there. So they left as soon as possible. I recall even helping two GD patients emancipate themselves at 17 years old in order to get started that one year earlier. Ultimately, it comes down to the individual patient and the lengths they are willing and able to go to in order to feel comfortable in their own skin. As with any other aspect of life, we each have our own path to take, and I’m just privileged to be a guide.    

If you like this blog, make a comment, give it a like, and pass it along. From now on, I’ll be doing a video to go with the blogs on dragresti.com. You can also subscribe to my YouTube channel for all of it! And of course, you can always check out my book, Tales from the Couch, available on Amazon.com. 

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What Are Personalty Disorders

What are Personality Disorders?

An individual’s personality is a set of characteristics that defines how they perceive the world around them. It is made up of features that cause them to think, feel, and act in a particular way. Our style of behavior, how we react, our worldview, thoughts, feelings, and the way we interact in relationships are all part of what makes up our personality. Having a healthy personality enables a person to function in daily life. Everyone experiences stress at some time in life, but a healthy personality helps us to face the challenges and move on. Genetic make-up, biological factors, and environmental surroundings all help to shape personality. Personality makes each of us different…makes each of us an individual. 

A personality disorder is officially described as “A deeply ingrained, inflexible pattern of relating, perceiving, and thinking that is serious enough to cause distress or impaired functioning.” In order to receive a diagnosis of a personality disorder, an individual must meet certain criteria, which are discussed below.

For someone with a personality disorder, the features of everyday life that most of us take for granted can become a challenge. When an individual has a personality disorder, it becomes harder for them to respond to the changes and demands of life, and to form and maintain relationships with others. These experiences can lead to distress and social isolation, and can increase the risk of depression and other mental health issues.

There are ten types of personality disorders, and The Psychiatric DSM-5 (Diagnostic and Statistical Manual, 5th edition) groups these ten personality disorders into three broad clusters, referred to as A, B, and C.

Cluster A personality disorders involve behavior that seems unusual and eccentric to others.

They include:
Paranoid personality disorder
Schizoid personality disorder
Schizotypal personality disorder

Cluster B personality disorders feature behavior that is emotional, dramatic, or erratic. 

Examples include:
Antisocial personality disorder
Borderline personality disorder
Histrionic personality disorder
Narcissistic personality disorder

Cluster C personality disorders feature behaviors that are motivated by anxiety and fear. 

Examples include:
Avoidant personality disorder
Dependent personality disorder
Obsessive-Compulsive personality disorders

Ten Types of Personality Disorders

1. Paranoid Personality Disorder
Affects approximately 2% – 4% of the general population. A person with paranoid personality disorder finds it hard to trust others. They might think that people are lying to them or manipulating them, even when there is no evidence of this happening. The inability to trust others can make it hard for people with paranoid PD to maintain relationships with those around them.

People with this may exhibit 
– Mistrust and suspicion
– Hypervigilance
– Fear
– Anxiety about others taking advantage of them
– Anger over perceived abuse
– Concern about hidden meanings or motives

2. Schizoid Personality Disorder
Affects fewer than 1% of the population. A person with schizoid personality disorder may feel more comfortable with a pet than with another person, and in fact may form attachments with objects or animals rather than people, because they feel very uncomfortable when they are required to relate to others. Others may see the person as aloof, detached, cold, or as a “loner.” Note that schizoid personality disorder shares some features with schizophrenia, but they are not the same, as psychosis and hallucinations that are required for the diagnosis of schizophrenia are not part of schizoid personality disorder. However, individuals with schizoid personality disorder may have relatives of with schizophrenia or schizotypal personality disorder.

The person will tend to:
– Avoid close social contact with others
– Have difficulty forming personal relationships
– Seek employment that involves limited personal or social interaction
– React to situations in ways that others consider inappropriate
– Appear withdrawn and isolated

3. Schizotypal Personality Disorder
People with this disorder may have few close relationships outside their own family, because they have difficulty understanding how relationships develop, and how their behavior affects others. They may also find it hard to understand or trust others. A person with this condition has a higher risk of developing schizophrenia in the future.

For diagnosis, the person must exhibit or experience five or more of the following behaviors:
– Ideas of reference; example, when a minor event happens, they believe it has special significance for them.
– Odd beliefs or magical thinking that influences their behavior; such as superstitious thinking, beliefs in telepathy, or bizarre fantasies or preoccupations
– Unusual perceptual experiences, including bodily illusions and odd thinking and speech; example, metaphorical thinking, minute detail, and overelaboration.
– Suspiciousness or paranoia
– Inappropriate or bizarre facial expressions
– Behaviors that seem odd, eccentric, or peculiar
– Lack of close friends or confidants, other than first-degree relatives
– Extreme social anxiety

4. Antisocial Personality Disorder
A person with antisocial personality disorder (ASPD) acts without regard to right or wrong, or without thinking about the consequences of their actions on others. It is more likely to affect men than women. Approximately 1% – 3% of the general population have ASPD, but is found in approximately 40% – 70% of the incarcerated (jailed) population. When found in children under 15, commonly referred to as conduct disorder, which significantly increases the risk of having ASPD later in life. Researchers studied specific genetic features in 543 participants with ASPD. They found similar genetic features, as well as low levels of grey matter in the frontal cortex area of the brain. They determined that genetic, biological, and environmental factors are all likely to play a role.

This can result in:
– Irresponsible/ delinquent behavior
– Novelty-seeking behavior
– Violent behavior
– High risk for criminal activity

5. Borderline Personality Disorder
A person with borderline personality disorder will have trouble controlling their emotions.
They may experience:
– Mood swings
– Shifts in behavior and self-image
– Impulsive behavior
– Periods of intense anxiety, anger, depression, and boredom
These intense feelings can last for only a few hours or for much longer periods, even up to weeks. They can lead to relationship difficulties and other challenges in daily life, resulting in:

– Rapid changes in how the person relates to others, for example: swift  shifts from closeness to anger
– Risky behaviors, ie dangerous driving and spending sprees
– Self-harming behavior
– Poor anger management
– Sense of emptiness
– Difficulty trusting others
– Recurrent suicidal behaviors, gestures, threats, or self-mutilation, such as cutting
– Feelings of apathy, detachment, or dissociation

6. Histrionic Personality Disorder
A person with histrionic personality disorder feels a need for others to notice them and reassure them that they are significant. This can affect the way the person thinks and acts. It is considered to be one of the most ambiguous (ie non-specific) diagnostic categories in mental health. The person may feel a strong need to be loved, and they may also feel as if they are not strong enough to cope with everyday life alone. The person may function well in social and other environments, but they may also experience high levels of stress, and this can lead to them having depression and anxiety. The features of histrionic personality disorder can overlap with, and be similar to, those of narcissistic personality disorder.

It may lead to behavior that appears:
– Self-centered
– Provocative and flirtatious
-Inappropriate
– Excessively emotional or dramatic
– Emotionally shallow
– Insincere, as likes and dislikes shift to suit the people around them at the given moment
– Risky, as the person constantly seeks novelty and excitement

7. Narcissistic Personality Disorder
This disorder features a sense of self-importance and power, but it can also involve feelings of low self-esteem and weakness. These features can make it hard for them to maintain healthy relationships and function in daily life.

A person with this condition may show the following personality traits:
– An inflated sense of their own importance, attractiveness, success, and power
– Craving for admiration and attention
– Lacking regard for others’ feelings
– Overstatement of their talents or achievements
– Expectation of deserving the best of everything
– Experiencing hurt and rejection easily
– Expecting others to go along with all of their plans and ideas
– Experiencing jealousy
– Believing they should have special treatment
– Believing they should only spend time with other people who are as special as they are
– Appearing arrogant or pretentious
– Being prone to impulsive behavior

People with narcissistic PD may also have a higher risk of:
– Mood, substance, and anxiety disorders
– Low self-esteem and fear of not being good enough
– Feelings of shame, helplessness, anger at themselves
– Impulsive behavior
– Using lethal means to attempt suicide

8. Avoidant Personality Disorder This personality disorder can make it hard to form friendships. A person with it avoids social situations and close interpersonal relationships, mainly due to a fear of rejection and the feeling that they are not good enough. There may also be a higher risk of substance abuse, eating disorders, or depression, and the person may think about or attempt suicide. A person with avoidant personality disorder may want to develop close relationships with others, but they lack the confidence and ability to form relationships. They generally appear extremely shy and socially inhibited.

They often exhibit:
– Feelings of inadequacy
– Low self-esteem
– Distrustfulness of others

9. Dependent Personality Disorder
People with dependent PD often lack confidence in themselves and their abilities. It is difficult for them to undertake projects independently or to make decisions without help, and they may find it hard to take personal responsibility. They are especially vulnerable to ill-treatment from others, including emotional, verbal, physical, domestic abuse. Any mistreatment can lead to further complications, such as depression and anxiety.

A person with this condition may have the following characteristics:
– Having an excessive need to be taken care of by others
– Being overly-dependent on others
– Having a deep fear of separation and abandonment
– Investing a lot of energy and resources in trying to please others
– Going to great lengths to avoid disagreement and conflict
– Being vulnerable to manipulation by others.

– A willingness to tolerate mistreatment to keep a relationship
– A preference to not be alone 

Others may see their behavior as:
– Submissive
– Clingy
– Nonassertive
– Passive
– Docile


10. Obsessive-Compulsive Personality Disorder

A person with OCPD can find it difficult to accept when something is not perfect. Obsessive-compulsive personality disorder (OCPD) is not the same as obsessive-compulsive disorder (OCD). OCD relates to everyday tasks, while OCPD focuses specifically on following procedures. In addition, OCD can interfere with the way a person functions in everyday life, whereas OCPD can enhance a person’s professional performance, while also potentially interfering with their personal life outside of work. Some people may experience both OCD and OCPD, and research has shown that there appears to be a link between them. An excessive concern with perfectionism and hard work dominate the life of a person with OCDP. The individual may prioritize these ideals of perfectionism and hard work to the detriment of close personal relationships. In fact, others may see the individual as sanctimonious, stubborn, uncooperative, and obstinate.

A person with OCPD may:
– Appear inflexible
– Feel an overwhelming need to be in control
– Find that concerns about rules and efficiency make it hard to relax
– Find it hard to complete a task for fear that it is not perfect
– Be uncomfortable when things are messy
– Have difficulty delegating tasks to others
– Be extremely frugal, even when it is not necessary
– Hoard items

Personality Disorders: Treatment and Outlook

People with personality disorders often don’t feel there is anything wrong with their behavior, but they may seek help because they are experiencing social isolation and fear. Regardless, depression, anxiety, and other mental health issues can result from living with a personality disorder. For this reason, it is important for them to seek help early. Personality disorders often share features, and it can be hard to distinguish between them, but there are sufficient criteria for an appropriate diagnosis. Following that diagnosis, treatment can help people with the various types of personality disorders. The physician may prescribe medication, and will often recommend therapy or counseling. Individual, group, and family counseling can help. One type of counseling is cognitive behavioral therapy (CBT). CBT helps a person to see their behavior in a new way and to learn alternative ways of reacting to situations. In time, this can make it easier for the person to function in everyday life and to maintain healthy relationships with others. So overall, the outlook is positive if the person with the personality disorder is willing to dedicate themselves to diligent work. 
PsyCom has several online tests you can take for yourself or for someone else in your life, and then submit for results. Just for funsies, below are links to some tests related to this week’s topic, personality disorders.  

Sociopathy Test

Do you have antisocial personality disorder, commonly referred to as sociopathy? Use this quiz to determine whether you or someone you know may be a sociopath.

https://www.psycom.net/antisocial-personality-disorder-sociopath-test/

Narcissist Test

Do you have narcissistic personality disorder? Use this quiz to determine whether you or someone you know may be a narcissist or have a more severe case of Narcissistic Personality Disorder (NPD).

https://www.psycom.net/narcissistic-personality-disorder-test

If you enjoyed this blog, please comment and share. For more information and stories on personality disorders, please check out my book, Tales from the Couch, available on Amazon.com. 

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Caplyta(lumateperone):NEW Treatment Schizoprenia and Bipolar Disorder

Caplyta (lumateperone): New for Schizophrenia…and More? 

Before we talk about Caplyta (lumateperone), I want to announce that I take no remuneration of any kind from any pharmaceutical or healthcare company. I am providing the following information solely for educational purposes. 

Caplyta (lumateperone) has recently been approved by the FDA for the treatment of schizophrenia in adults, and it is expected to be available by prescription by late April 2020. This new drug seems to have a lot of promise, especially for patients who don’t do well on other drugs, or cannot tolerate the side effects of other drugs. This may sound strange, but scientists don’t actually know what the drug’s mechanism of action is, meaning that they don’t know exactly how it works. They have some educated guesses, and I’ll talk about those later. But believe it or not, it’s not that unusual for a drug’s mechanism of action to be partially or poorly understood…it happens frequently. 

They’ll figure it all out in time, but what matters right now is that they do know the drug’s efficacy, which is it’s effectiveness, in treating schizophrenia in adults. I think that this will be a vitally important drug, especially for patients who don’t respond to other drugs and/ or cannot tolerate the side effects of other drugs. And I’ll go into that later as well. But first, I want to go over some general information about schizophrenia. 

Schizophrenia is a very serious, disabling, and complex mental illness impacting approximately 2.4 million adults in the United States. It is most disabling because there is no for schizophrenia, but there are treatments, and it must be treated and monitored for a lifetime. Like many mental illnesses, it not only severely impacts patients, it also majorly impacts patients’ families. The clinical presentation of schizophrenia is very diverse. Acute episodes can be characterized by psychotic symptoms, such as hallucinations and delusions, and these can be so debilitating that these patients require hospitalization.  The disease is chronic and lifelong, and is often accompanied by depression. There can also be a deterioration of social functioning and cognitive abilities. Patients with schizophrenia often discontinue treatment, stop taking their meds, because of major side effects, which can include weight gain, lactation, gynecomastia, and movement disorders. More on these side effects later. For now, suffice it to say that an effective and well tolerated treatment can be game-changing for people living with schizophrenia. 

I thought it might be fun to have a little quiz, just to see what you do or don’t know about schizophrenia, all in an effort to educate and de-stigmatize. If you don’t know them now, you will when you finish. I’ll give you the answers and explanations later. No cheating, people!

1) Schizophrenia is the most disabling of all mental illnesses.
A)   True
B)   False

2) There are 50 million people with schizophrenia in America.
A)   True
B)   False

3) Schizophrenia is often called “split personality disorder.”
A)   True
B)   False

4) Psychosis means that a person…
A)   Has suffered memory loss
B)   Suffers from chronic insomnia
C)   Can’t distinguish imagination from reality
D)   Has a virus that affects the brain

5) The most common hallucination in schizophrenia is…
A)   Visualizing shadows
B)   Smelling smoke
C)   Feeling cold
D)   Hearing voices

6) The first symptoms of schizophrenia can include:
A)   Irrational statements
B)   Excessive crying
C)   Outbursts of anger
D)   All of the above

7) Who has more symptoms at the onset of schizophrenia?
A)   Men
B)   Women
C)   Children
D)   Elderly

8) Many schizophrenics believe that ____ actually eases their symptoms.
A)   Silence
B)   Eating
C)   Screaming
D)   Smoking

Let’s see how many you got right and I’ll explain the correct answers:

1) True/ False: Schizophrenia is the most disabling mental illness.

Correct answer: True
Explanation: Schizophrenia is an incurable, severe, and lifelong disease that is the most disabling of all mental illnesses. Treatments for schizophrenia focus on controlling the symptoms.

2) True/ False: There are 50 million people with schizophrenia in the US. Correct answer: False
Explanation: About 1% of people in the U.S. have schizophrenia, which is just over 2 million people.

3) True/ False: Schizophrenia is often called “split personality disorder”

Correct answer: True
Explanation: Schizophrenia is sometimes confused with other mental illnesses and may be mistakenly referred to as “split personality disorder.” While “schizo” does mean “split,” patients with schizophrenia do not have split personalities. What they do have is psychosis, which is a distorted perception of reality.

4) Psychosis means that a person…
Correct answer: C) Cannot distinguish imagination from reality
Explanation: Experts don’t know what causes schizophrenia. In some people, brain chemistry and brain structure are not normal. Family history may be a factor in some cases. Schizophrenia is never caused by anything a person did, or by any personal weakness, bad choices, or a person’s upbringing.

5) The most common hallucination in schizophrenia is…
Correct answer: D) Hearing voices Explanation: Auditory hallucinations, or “hearing voices” is the most common hallucination in schizophrenia. Voices can seem to be coming from within one’s own mind or externally, as if a person is talking to them. These voices may tell the person with schizophrenia to do things, or they may comment on their behavior. The voices may even talk with one another. It is common for people with schizophrenia to hear voices for a long time before anyone else notices the problem. Other kinds of hallucinations experienced by people with schizophrenia include seeing people or objects that are not there, feeling as if they are being touched by invisible fingers, or smelling odors that no one else can smell.

6) The first symptoms of schizophrenia can include…

Correct answer: All of the above
Explanation: There are numerous early symptoms of schizophrenia. In some cases, family and friends may notice a shift in behavior or sense something is “off” about the person who is schizophrenic. Early signs and symptoms of schizophrenia may include irrational statements, excessive crying or inability to cry, outbursts of anger, social withdrawal, and extreme reactions.

7) Who has more symptoms at the onset of schizophrenia?
Correct answer: Men
Explanation: Schizophrenia affects men and women at equal rates, and symptoms may start suddenly or occur gradually. Men tend to develop schizophrenia slightly earlier, between 16 and 25 years old, while women develop symptoms several years later, in the late 20s to 30s. Schizophrenia symptoms tend to be more severe in men, while women with schizophrenia may have more depressive symptoms and paranoia.

8) Many schizophrenics believe that _______ eases their symptoms.

Correct answer: Smoking

Explanation: Many schizophrenics believe smoking cigarettes eases their symptoms, and up to three times more schizophrenics smoke than in the general population. It is thought that smoking may be a kind of self-medication. The nicotine seems to help with some of the cognitive and sensory symptoms experienced by schizophrenics, and it can ease some of the side effects of medications commonly prescribed. However, it’s important to note that smoking still causes cancer, lung disease, and heart disease.

Now that you probably know a little more about schizophrenia than you did 15 minutes ago, let’s talk about this new drug treatment, Caplyta, generic name lumateperone. Obviously, since it hasn’t been released yet, I haven’t had the opportunity to prescribe it to my patients, but I have been following its development and have read about it extensively. Based on that, I think this drug will be well tolerated, and a valuable drug in the armamentarium for the treatment of schizophrenia. In addition, I think it will be valuable in treating bipolar disorder and could also benefit patients with Alzheimer’s and/ or dementia with agitation. 

Let’s talk turkey. Why is it good to have a new option for treating schizophrenia? Here’s where those side effects I mentioned before come in. The current drugs used to treat schizophrenia are chock full of side effects, some of which are stigmatizing and intolerable to patients. So a new drug, a better tolerated one, is a big deal. Older drugs like Olanzapine cause weight gain, metabolic syndromes, insulin resistant diabetes, increased cholesterol, and increased triglycerides. Other drugs like Risperdal are known to cause elevations in prolactin, which causes lactation, milk production in women, and breast enlargement in men, all of which are very unsetteling to patients, to say the least. Another major factor in older antipsychotic drugs like Aripiprazole, Brexpiprazole, and Haloperidol involve what are termed extrapyramidal symptoms, dystonia and tardive dyskinesia. All those fancy words just mean involuntary muscle contractions that can cause repetitive movements like tics, ie grimacing and eye blinking, muscle spasms, and all sorts of uncontrollable muscular movements that people obviously find very uncomfortable and cosmetically disfiguring. These extrapyramidal symptoms are problematic in terms of compliance, meaning that patients don’t take the drugs, they are not not compliant, because while they are already stigmatized by their illness, they are further stigmatized by these side effects of breast enlargement and lactation, and the disfiguring extrapyramidal muscular movements and motor tics the drugs cause.  

Caplyta, lumateperone is apparently different. And this is where I’ll explain a little about the mechanism of action, how I believe it works. We know from previous accepted research that the undesirable extrapyramidal motor symptoms like tics and spasms associated with antipsychotic medications are the result of a high affinity for a receptor called the D2 receptor. Having a high affinity for a receptor basically means that a drug likes to bind there, and in doing so, it blocks that receptor. That would be a mechanism: the binding of a drug to a receptor and its subsequent blocking of that receptor. So, the older antipsychotic drugs have a high affinity to, they like to bind to, D2 receptors, blocking them. But this new drug, lumateperone, has low affinity for these receptors, the D2 receptors, so they are left unbound and unblocked. As a result, those stigmatizing involuntary muscle movements and tics are absent. Before I go further, here’s a quick and simplified synopsis on the basics of clinical trials: when drugs are tested in clinical trials, they begin with randomly giving the drug being tested to a certain number of subjects, while giving a placebo (an inactive substance, sometimes called a “sugar” pill) to the other people in the trial. The study is randomized, meaning the people in the study don’t know if they’re being given the drug being tested or the placebo. In most studies, even the people running it and those dispensing the study “medications” don’t know which is which or who’s getting what. That way there is no bias, people just honestly report their symptoms. At the end of the study, when the results are tabulated, the drug company hopes to be able to clearly see the difference between the study drug and the placebo in symptoms and efficacy and whatever other traits they want to look at. Then they use those numbers to report the findings of the testing drug versus the placebo. So for this new schizophrenia drug Caplyta (lumateperone), the reported trial numbers shake out to subjects taking the study drug lumateperone reported having extrapyramidal symptoms/ side effects only 0.4% more than reported by subjects taking the placebo, and that is evidently due to its very low affinity for the D2 receptor, so those D2 receptors are mostly open. D2 receptors blocked= extrapyramidal symptoms, involuntary motor tics. D2 receptors open= no extrapyramidal symptoms. Make sense? This is all very simplified, and there are more receptors and pathways in the body than you would ever want to know…and they all do different things depending on if they are open or blocked, presynaptic or postsynaptic, agonistic or antagonistic, upstream or downstream, activated or inactivated, partially or completely and everything in between. It’s complex stuff…I just want you to have an idea of why drugs cause or don’t cause different side effects, because that’s the name of the game when it comes to efficacy and tolerance of drugs, and that’s what determines patient compliance in taking drugs, and that’s what determines how much their mental illness affects them, and that’s what determines their place in this world. Phew! Get it? It’s a big deal. 

So that’s an example of how lumateperone avoids those extrapyramidal side effects. Now you may ask how it works in controlling the hallmark syptoms of schizophrenia: delusions,  hallucinations, disorganized speech, and disorganized behavior. That mainly has to do with its effect on another receptor, the Serotonin 5-HT2A receptor. Lumataperone has a high affinity for this receptor; it binds and blocks it. We know that a drug called Pimavanserin does the same thing, and Pimavanserin is used to treat Parkinson’s disease psychosis, so we can correctly infer that blocking and binding the Serotonin 5-HT2A receptor in lumataperone makes it effective as an antipsychotic drug, controlling delusions, hallucinations, disorganized speech, and disorganized behavior associated with schizophrenia. Along those same lines, lumataperone also affects dopamine receptors in a specific pathway called the mesolimbic pathway. That happens to be the pathway that blocks hallucinations, delusions, disorganized speech, and disorganized behavior. This is all good stuff. 

What else? Lumataperone has decreased muscarinic receptor activity. When activated, muscarinic receptors cause dry mouth, pupil dilation, blurred vision, constipation, and flushing. Because that activity is decreased, those effects are reduced or absent, so no dry mouth, dilated pupils, blurry vision, constipation, or flushing. It also does not cause or lead to any metabolic syndromes, elevation in cholesterol, significant weight gain, and insulin resistance, another big plus.

Lumataperone has decreased effects on the alpha adrenergic receptor, which causes orthostatic hypotension, meaning a drop in blood pressure upon standing that often leads to a fainting episode. Because of lumataperone’s decreased effects on this receptor, this removes this risk.  

Lumataperone also has minimal effects on the endocrine system, and therefore it does not affect prolactin like the older drug Risperdal does, so female patients do not experience lactation and milk production, and men do not get breast enlargement. This is majorly important in drug compliance. Patients are more likely to take the medication if they don’t have to leak milk from existing breasts or grow breasts where they don’t belong.

Lumataperone metabolics and dosing is convenient becuase it does not require titration, meaning patients don’t have to build up to the full dose by taking smaller doses first. Patients start at 42 milligrams, peak plasma level is in 3-4 hours, and it has a half-life of about 13 hours. This is nice, because that means it can be taken just once a day, because the half-life is long enough.  

While lumateperone seems to be far superior to the older schizophrenia drugs in nearly every way, there is no such thing as a perfect drug…yet. It does have some possible side effects, including nausea, dizziness, fatigue, and vomiting. But these appear to be fairly insignificant, not affecting quality of life. It has also been shown to cause drowsiness; I think it must have something called a histaminic effect. This is really its most major side effect, with anywhere between 10% and 24% of people to experience drowsiness. But we can turn that frown upside down…we can use this drowsiness to our advantage by dosing it when it’s time to go nite-nite. And since it’s dosed once a day, it works out great. 

The last important footprint of Lumateperone has to do with it’s metabolism by the Cytochrome P450 3A4 system (I told you this stuff can get a little complicated). Abbreviated CYP3A4, this is a very important enzyme in the body, mainly found in the liver and the intestine. It oxidizes small foreign organic molecules, such as toxins or drugs, so that they can be removed from the body. Patients taking lumateperone should not take any drug which blocks CYP3A4 enzyme concomitantly. This is really the only contraindication at this time.  

So, when we put all of this stuff together, what do we have?

– Caplyta (lumateperone) for schizophrenia

– Dosing: 42 milligrams, once per day, with food, at night if causing drowsiness.

– Works mainly by affecting dopamine, serotonin, and glutamine.

– Binds and blocks Serotonin 5-HT2A receptors, eliminating negative symptoms of schizophrenia: delusions, hallucinations, disorganized thoughts, and disorganized behaviors.

– Low affinity for D2 receptors leaves them unbound and unblocked, eliminating the stigmatizing extrapyramidal symptoms of involuntary muscle movements and tics, dystonia and tardive dyskinesia.

– Minimal endocrine effects, preventing female patients from experiencing lactation, and male patients from breast enlargement, and relieving patients of these stigmatizing side effects.

– Decreased muscarinic receptor activity, eliminating dry mouth, dilated pupils, blurry vision, constipation, and flushing.  

– Elimination of metabolic syndromes: no elevated cholesterol, no significant weight gain, no insulin resistance, no diabetes.

– Decreased effects on the alpha adrenergic receptor, eliminating fainting episodes due to orthostatic hypotension. 

– Possible side effects: nausea, dizziness, fatigue, and vomiting. But these appear to be fairly insignificant, not affecting quality of life. 

– The only significant side effect is drowsiness, 10% to 24%. This can be turned around and used to help insomnia when dosed at night. 

– Utilizes CYP3A4: lumateperone is contraindicated in patients taking 

drug(s) which block CYP3A4 enzyme.

Essentially, that adds up to getting all the good stuff for treating schizophrenia without getting any of the bad stuff, and all it’s going to cost you is maybe some minor nausea, vomiting, and/ or fatigue, all of which will likely go away after two weeks. You might have some drowsiness, but I see that as a plus, as lots of patients complain of insomnia, and it can be taken only at night due to its once a day dosing. 

Schizophrenia for now…what about later? Lumateperone is a weak serotonin transporter pump inhibitor just like SSRI (Selective Serotonin Reuptake Inhibitor) antidepressants are. To simplify the mechanism: serotonin is a happy neurotransmitter regulated by a pump. It’s pumped out, but can be removed by being “uptaken,” if you will, which leads to low serotonin levels commonly found in people with depression. So an SSRI drug, an antidepressant, is given. The SSRI is employed, and the RI, which stands for reuptake inhibitor, stops (inhibits) the reuptake of the serotonin, leaving higher levels of free happy serotonin circulating and thereby increasing mood. It has other antidepressant effects which I think will make it very effective for treating depression and bipolar disorder. And because it has a low affinity for D2 receptors, leaving them open, I think it could control agitation in people with Alzheimer’s and/ or dementia without causing any of those horrible side effects of current antipsychotic medications. When physicians prescribe Caplyta for anything other than schizophrenia, or prescribe any drug for any diagnosis it was not labelled for (ie originally developed for), it is called off-label prescribing, and it is a common practice in psychiatry, as the regulation of receptors and pathways overlap in many different mental illnesses. 

In summary, Caplyta (lumateperone) shows a great deal of promise, and I’m looking forward to being able to offer it to my schizophrenia patients that are having compliance issues due to the stigmatizing side effects of current antipsychotic therapeutics. This could be a game changer and a life changer for them. And then once I really see how it’s tolerated, I’ll give great consideration to using it off-label for bipolar depression and to combat agitation in my Alzheimer’s and dementia patients. It could be a much needed breakthrough for them as well. 

If you liked this blog, please comment and pass it along. Even posting simple comments and sharing information help reduce the stigma of mental illness…and it’s certainly high time for that. If you’re interested in reading more about the subjects discussed here, and a lot more, check out my book, Tales from the Couch, available in my office or on Amazon.com. 

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Covid Comedy

This week, I could write a blog on the psychosocial ramifications of long term isolation, or the effects of fear of contracting coronavirus on people with anxiety disorder, or tips on how to ride this pandemic out. I could do any and all of that, but to be honest, I’m over it. I’m burned out, people. So, this week, the goal for this blog is not to educate you, not to give you tips about taking care of yourself during these trying times, not to regurgitate stuff you’ve heard before. Nay, people. The goal of this week’s blog is a simple one…to make you laugh. That’s it. I just want to make you laugh. But first, I want to say that I mean no disrespect by making light of a very heavy situation, a virus that has claimed many lives. 

Coronavirus itself is no joke, it is serious and even deadly business. What is funny however, is some of the madness going on in the world because of the coronavirus: the toilet paper hoarding, the stockpiling of groceries, and don’t forget the new “Coronavirus Challenge,” where people lick toilet seats. Ewww!! Anyway, I combed the internet and social media for funnies, and even made up some jokes that are all my own. So this week, it’s all about…

Covid Comedy

We’re more than three weeks into the corona isolation, the coronalation. Some folks are under quarantine, the coronatine. Coronalation, coronatine, potato, patato…whatever you want to call it, clearly Mother Nature has put us all on restriction and sent us to our rooms for being buttheads and always destroying her fine work.

Four weeks ago, the most misspelled Google search was “corn and teen.” It was then that I started to slowly lose faith in humanity. Who knew it was that hard to spell Q-U-A-R-A-N-T-I-N-E? Well, apparently it is. Although covid-19 is nothing to joke about, I can’t help but chuckle at some of the hilarious mishaps and behaviors we’re seeing during the country’s “quarantine.” I use that term lightly because some Americans are just not having it. They refuse to bow down to the coronavirus, to allow it to change their lives or make them modify their behaviors, so I call them ‘The Covid Cowboys,’ because these people are pretty reckless. For the rest that do quarantine or isolate, it’s pretty evident that spending a majority of the day indoors can make them do some crazy-funny stuff. Right now, it’s good to laugh on the rare occasions that things tickle your funny bone. For eons, people have used laughter to help deal with bad situations, and it’s really a healthy response, especially in the situation we find ourselves in now.

Remember that different places around the globe had/ have different ways of dealing with this virus…I’m talking about marshall law here people. A lot of countries weren’t quite so polite as our good ole US of A. Our leaders merely “strongly suggested” that we shelter in place or isolate. In some countries, you were locked into your home or apartment building, not permitted to leave for any reason, not even to walk your dog. In all of China, but especially in Wuhan Province where this pandemic started, it was total lockdown. There was no running down to the corner store to get food; if you didn’t have food, you went hungry. People who disobeyed the lockdown order were forcefully dragged off, literally kicking and screaming, and some of them haven’t been seen since. But no matter what patch of green on the globe that you call home, isolation + stress + lack of sleep = temporary insanity!  

Evidently, Spain also had very stringent lockdowns to help flatten the curve. A stir-crazy man from Spain disguised himself as a dog in an attempt to leave his apartment. People in the neighborhood were peering out their windows, freaking out, thinking that they were seeing some sort of corona-crazed bigfoot-bear hybrid monster. The man wasn’t arrested for leaving his home during lockdown, he was arrested for inciting panic. Well, at least he got to a new space with a different view, albeit through bars. 

A 19-year-old woman in Britain was using her newfound free time wisely(?) Don’t quote me on that last qualification. Anyway, she went through her contacts and made a list of all of her exes. She then called each and every one to ask them what went wrong in their relationship, and then shared this new information with her followers on social media. What went wrong? Umm, maybe you lost your mind? Just a guess.

Even though Americans haven’t been forced to stay home, that doesn’t keep them from doing some ridiculous things. I’ve read about and seen videos of people fighting over cases of water, hand sanitizer, and you guessed it…toilet paper. I’m talking about knock down, drag out fights. And who do you figure would punch somebody in the face over 16 ounces of hand sanitizer or 12 rolls of TP? Big biker guys, right? They fight over everything. Well, guess again! Not big burly biker guys, but housewives! Hair-pulling, nose-punching, nail-scratching, pugilistic housewives. And these fights always seem to happen at WalMart. Things that make you go hmm…

File under ‘Silly Social Media’

Thirty days hath September, April, June, and November; all the rest have thirty-one. Except for March, which hath 9,000.

The perfect quarantine schedule, afternoon to evening:
4:00 – Wallow in self pity
4:30 – Stare into the abyss
5:00 – Solve world hunger (tell no one)
5:30 – Jazzercise 
6:30 – Dinner w/ me (can’t cancel again)
7:00 – Wrestle with my self loathing

I’ve been waiting for the perfect time to change my Netflix password so my ex-boyfriend can’t watch it anymore, and it really doesn’t get any more perfect than during a national lockdown. 

In Australia, we had fires, then floods, and then this virus. On January 1, 2020, my husband said he knew that the day was going to be the start of something awesome. Next time he says anything like that, I’ll make some PSA’s so we can all prepare. 

I wouldn’t be surprised if, in nine months, some parents name their newborn kid Covid if it’s a boy and Corona if it’s a girl.

Isolation Menu:

Sunday: Steak

Monday: Burgers

Tuesday: Spaghetti

Wednesday: Ramen

Thursday: Creamed Corn

Friday: Roadkill du Jour

Saturday: Dried Grass & Clover

Day 1 of quarantine: I will use this time as an opportunity to take better care of myself.

Day 2 of quarantine: For personal reasons, I am eating a lasagna in my shower.

A doctor, a nurse, and an epidemiologist walk into a bar, and they said “GET OUT! GO HOME!”

A man and his 15-year-old son are having a talk in 2035:

Son: Hey dad, why did you name my sister Paris?

Father: Well, because we conceived her in Paris France.

Son: Oh, okay…thanks, dad.

Father: No problem, Quarantine.

Side effect of quarantine: it’s really hard to get off the phone. Twice today I said, “okay, I have to run” but then I remembered there’s nowhere to run to.

Due to the quarantine, I’ll only be telling inside jokes. 

Me: Can I have fun?
2020: No
Me: OK

Costco priced an 82 inch Samsung TV for $1,200. I don’t think that was a coincidence.

Fast Funnies

I know a great joke about coronavirus…you probably won’t get it though.

A man walks into a bar and goes up to the bartender and says “I’ll have a Corona please, hold the virus”

If I get quarantined for two weeks with my wife, and I die, I can assure you it was not the virus that killed me.

*Breaking News!* Apparently the first person in Boca Raton has died due to the coronavirus. In his house they found 1,000 cans of soup, 90 pounds of pasta, 80 pounds of rice, 300 rolls of toilet paper, and 50 gallons of hand sanitizer, all of which he had panic purchased from the supermarket to stockpile “just in case.” The “just in case” stockpile collapsed and buried him.

Day 3 without sports. Discovered a lady sitting on my couch yesterday. Apparently she’s my wife. She seems nice enough. 

Since everybody has now started washing their hands, the peanuts at the bar have lost their taste.

The news said that a mask and gloves were good enough to go to the supermarket. They lied, everyone else had clothes on.

Before coronavirus, I used to cough to cover a fart, now I fart to cover a cough.

Definition of Irony – When the Year of the Rat starts with a plague.

People with a cold: “I just want to stay in bed and do nothing, I feel terrible.”
People with coronavirus: “I feel terrible, I think I will go skiing in Austria, visit the Eiffel Tower, and maybe do some white water rafting in Camino de Santiago.”

My body has absorbed so much soap and disinfectant lately, that now when I pee, I clean the toilet.

2020 is a unique leap year. It has 29 days in February, 300 days in March, and 10 years in April.

Back in the day, the only time we started panic buying was when the bartender yelled “last call!”

I think it’s really great that people are finally starting to drink water, wipe their asses, and wash their hands.

Ok, so if the coronavirus isn’t about beer, why do I keep hearing about cases of it?

To the people who bought 20 bottles of soap, leaving none on the shelves for others, you do realize that to stop the spread of coronavirus, you need other people washing their hands too. Duh!

Chinese doctors have confirmed the name of the first person to contract coronavirus. His name is Ah-Chu.

Don’t worry, the coronavirus won’t last long…it was made in China.

To those who are complaining about the quarantine period and curfews, just remember that your grandparents were called to war… you are being called to the couch to Netflix and chill. You can do this.

How come the liquor stores don’t have empty shelves? Don’t people understand that they’ll be quarantined with their spouses and kids?

Mexico is asking Trump to hurry up and build the wall NOW!

Having trouble staying at home? Shave your eyebrows off.

Pet thoughts during isolation:
Dogs: “Oh my gosh, you’re here all day! This is the best: I can love you, see you, be with you, and follow you all day long! I am so excited because you are the greatest person, my person, and I love you so much!”
Cats: “What the hell are you still doing here?”

I don’t know why my fishing buddy is worried about coronavirus, he never catches anything.

Social distancing rule: “If you can smell their fart, move further apart.”

The coronavirus has achieved what no female has ever been able to achieve… It has cancelled sports, closed every bar, and kept all the guys at home!

The science community has figured out that the spread of coronavirus is based solely on two things. 
1. How dense the population is
2. How dense the population is

I hope I made you laugh at least a few times. Be well, people. Don’t go corona crazy during your coronalation! Or your coronatine!

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10 Secrets to Sleeping Better

10 Secrets to sleeping Better

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​1.) Get on a schedule and go to bed at the same time every night. Do the same thing before bed every night.

2.) Sleep in a dark, quiet and cool room.

3.) Sleep on your back with a pillow under your feet.

4.) No eating or drinking 2 hours before bedtime.

5.) No caffeine 14 hours before bedtime. No alcohol or nicotine 4 hours before bedtime.

6.) No sugar 2 hours before bedtime.

7.) No blue light from computer, I pad screens 1 hour before bedtime, no bright light of any kind 1hour before bedtime.

8.) Calm your mind before sleep.

9.) Get enough Vitamin D3, Vitamin E, Magnesium, Iron,  B complex vitamins and calcium.

 10.)      Valerian root, Chamomile, L-Theanine and Lavender ​help you sleep.

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How To Determine If Someone Is Suicidal

A Coronavirus PSA

Before we get to this next blog on suicide, I must say something related to Coronavirus transmission, because I’m tired of yelling it at my television when I see people doing it or talking about it, how “safe” it is. What is it? It’s “elbow love,” bumping elbows with someone to say hello, goodbye, good job, whassup, whatever. Think about this, people: during this viral outbreak, what have we been asking people to do when they sneeze or cough? Ideally, to do so in a tissue, but that’s not realistic, it rarely happens, so we ask them to sneeze or cough into their bent arm, at the elbow. Get the picture? The droplets they expell during that sneeze or cough are deposited everywhere surrounding that area, including the part you bump, so if your “bumpee” has Coronavirus, even if they have no symptoms, you, the “bumper” get those bijillions of virions on your elbow, and you can take them home with you. Then maybe your spouse or partner welcomes you home by putting their hands on your arms to give you a kiss… and now half a bijillion virions may be on one of their hands, just waiting to be deposited everywhere. Bottom line: for as long as this virus is around, use your words, not your body, to say whassup. So pass this knowledge on…not the virus. 

Suicide Assessment

Suicide is always a very difficult topic for every family, and in thirty years as a psychiatrist, it’s never gotten much easier to broach this subject. What motivated me to write this blog is a recent conversation I had with the father of one of my young patients, a fourteen-year-old named Collin, who in fact had just made what I believed was a half-hearted suicide attempt; the proverbial ‘cry for help.’ Understand that half-hearted does not mean it’s totally safe to blow it off, but we’ll get to an explanation about that later. His father, Lawrence, who prefers to be called Law, was a single parent, a widower after metastatic melanoma devastated the family of three about eighteen months before. Shortly after the mother, Sharon, passed away, Law brought Collin to my office. It was clear from the first appointment that Collin was depressed, and had been for some time. Psychotherapy was difficult with him, and it took about five appointments to establish more than a tenuous relationship and for him to begin to open up to me. I had tried him on a couple of medications, but they never seemed to do the job. I strongly suspected that it was due to a compliance issue. Actually, I’m certain that it was. He just didn’t take them regularly or as directed. That always mystifies me, patients who are miserable, anxious and depressed, but they take their meds haphazardly, at best; meds that could turn their worlds around…not because they’re inconvenient, and not because of side effects, just because. So, the tenuous connection made for less than optimal psychotherapy sessions, and that, combined with the absence of appropriate meds, put Collin on a path that led here, my office, 22 hours after his attempt. I was a little shocked by his attempt, but very shocked at how effectively, how deeply, he was able to hide the monumental amount of pain that he had obviously been feeling. His father Law looked exhausted, shellshocked, and was having such difficulty talking about it for a number of reasons, but he told me that one of the main reasons was shame. He was ashamed that Collin was so ill, and even ashamed that he was ashamed of it. He was ashamed that he could do nothing to help him, and ashamed that he had possibly caused or contributed to his son’s illness. I told him repeatedly and in several different ways that I understood, that his feelings weren’t unusual among parents of children like Collin, that he absolutely was helping him, and that while mental illness does have a familial component, he was not responsible in any way for his sons illness or attempt. Unfortunately, I don’t think he really heard a word I said. In my experience, suicidal ideation, thoughts of suicide, suicide attempts, and the actual act of suicide affects everyone it touches in a way that no other psychiatric illness does. But in this situation, I think Law was thinking about what his life would be like if Collin tried again and succeeded. It would be very sad, alone, and lonely.

Facts and Figures

Suicide is the 10^th leading cause of death in the United States, claiming 47,173 lives in 2019. Montana and Alaska have the highest suicide rates, which is interesting because both of those states have very high gun ownership rates. Believe it or not, New Jersey is the lowest. I have no clue why that would be the case. There were 1.4 million suicide attempts last year in the US. Men are 3.54 times more likely than women to commit suicide.  Of all the suicides in the United States last year, 69.67% were white men; they don’t seem to be doing so well. The most common way to commit suicide is by firearm, at about 50%; suffocation is 27.7%, poisoning is 13.9%, and other would be the rest, things like jumping from a tall building or bridge, laying on train tracks or jumping in front of a subway car or a bus. Among US citizens, depression affects 20 to 25% of the population, so at any given point, 20% of the population is a bit more prone to suicide, as obvi people must first be depressed (chronically or acutely) before attempting suicide. There are 24 suicide attempts for every 1 completed suicide. The most disturbing statistic is that suicide rates are up 30% in the past 16 years, with a marked increase in adolescent suicides, and suicide is now the second leading cause of death in people ages 10 to 24.

You would think the US would have the highest suicide rates in the world, but in fact, Russia, China, and Japan are all higher. 

Suicide Risk Factors

What are some factors that may put someone at higher risk of suicide?

–  Family history of completed suicide in first-degree relatives

–  Adverse childhood experiences, ie parental loss, emotional/ physical/ sexual abuse

–  Negative life situations, ie loss of a business, financial issues, job loss

–  Psychosocial stressors, ie death of loved one, separation, divorce, or breakup of relationship, isolation

–  Acute and chronic health issues, illness and/ or incapacity, ie stroke, paralysis, mental illness, diagnoses of conditions like HIV or cancer, chronic pain syndromes

But, understand there’s no rule that someone must have one or more of these factors in order to be suicidal.

Mental Illness and Suicidality

In order to make a thorough suicide risk assessment, mental illness must be considered. There seem to be 6 mental health diagnoses that people who successfully complete suicide have in common: 

–  Depression

–  Bipolar disorder

–  Mania

–  Schizoaffective disorder 

–  Schizophrenia

–  Post-traumatic stress disorder

–  Substance abuse 

Suicidal Ideation

Suicidal ideation refers to the thoughts that a person may have about suicide, or committing suicide. Suicidal ideation must be assessed when it is expressed, as it plays an important role in developing a complete suicide risk assessment. Assessing suicidal ideation includes:

– Determining the extent of the person’s preoccupation with thoughts of suicide, ie continuous? Intermittent? If so, how often?

– Specific plans; if they exist or not; if yes, how detailed or thought out?

– Person’s reason(s) or motivation(s) to attempt suicide

Assessment of Suicide Risk
Assessing suicide risk includes the full examination/ assessment of:

–  The degree of planning 

–  The potential or perceived lethality of the specific suicide method being considered, ie gun versus overdose versus hanging

–  Whether the person has access to the means to carry out the suicide plan, ie a gun, the pills, rope

–  Access to the place to commit

–  Note: presence, timing, content

–  Person’s reason(s) to commit suicide; motivated only by wish to die; highly varied; ie overwhelming emotions, deep philosophical belief

–  Person’s motivation(s) to commit suicide; not motivated only by wish to die; motivated to end suffering, ie from physical pain, terminal illness

–  Person’s motivation(s) to live, not commit suicide

What is a Suicide Plan?

A suicide plan may be written or kept in someone’s head; it generally includes the following elements: 

–  Timing of the suicide event

–  Access to the method and setting of suicide event

–  Actions taken toward carrying out the plan, ie obtaining gun, poison, rope; seeking/ choosing/ inspecting a setting; rehearsing the plan 

The more detailed and specific the suicide plan, the greater the level of risk. The presence of a suicide note suggests more premeditation and typically greater suicidal intent, so an assessment would definitely include an exploration of the timing and content of any suicide note, as well as a thorough discussion of its meaning with its author.

I spent years teaching suicide assessment to other physicians, medical students, nurses, therapists, you name it. It all seems super complicated when you look at all the above factors written out, but as I always taught, it becomes clearer when you put it into practice. What are we doing when we embark on a suicide assessment? We’re determining suicidality, the likelihood that someone will committ suicide. You’re deciding how dangerous someone is to themselves using the factors discussed above. You’re either looking at how lethal they could be, how lethal they are at this time, or how lethal they wereduring a previous episode of suicidal ideation or previous suicide attempt. 

When we put this all into practice, we look at statements and actions to determine how dangerous a person is. Did someone say, ‘if so and so does this, I’ll kill myself’ or, did someone act but just scratched their wrist? Those would be low level lethality, and they would not be very dangerous. Did someone buy a gun, load the ammunition, learn how to shoot it, go to the place where they planned to kill themselves at the time they planned, and then practice putting the gun to their head…essesntially a dry run? That would be the most lethal; that person would be the most dangerous. Those are the two poles of lethality and danger, but there are variant degrees and many shades of gray, so you really have to discuss it very thoroughly with each individual. 

Let’s say a 15-year-old is in the office after taking a big handful of pills in a suicide attempt. I ask him if he realized that taking those pills could have actually killed him, and he says no. He’s not that lethal, not that dangerous, because even though his means (pill overdose) was lethal, he didn’t know it was, so lacking that knowledge mitigates the risk, making him less dangerous. Example: acetominophen is actually extremely lethal. People who truly overdose on it don’t die immediately, but it shuts down the liver, killing them two days later. A person that takes a bunch of it thinking it’s a harmless over the counter drug is not that dangerous, because even though their method was lethal, they didn’t know it. In a similar manner, I’ve had people mix benzos with alcohol, which is another very lethal method. It’s a very successful way to kill yourself, but a lot of people don’t realize it, so it’s not that lethal to them. In the reverse case, people who know about combining alcohol and benzodiazepines, who know how dangerous it is, are dangerous, highly lethal to themselves. 

People who play with guns, like Russian Roulette-type stuff; or people who intentionally try asphyxiating or suffocating themselves, as for sexual pleasure; or people who tie a rope to a rafter and then test their weight…these people are very dangerous, very lethal, very scary to psychiatrists.   

Where someone attempts suicide is also very telling, very instructive in determining their lethality, how suicidal, how dangerous they are. If they do it in a place where there is no chance of being found, of being interrupted, they are very suicidal, very dangerous. Contrast that to doing it in a place where there are people walking by, or in a house where someone is, or could be coming home, then they are not as suicidal, not as dangerous. As an exaple, let’s say someone leaves their car running in a garage when they know that no one will be around for 2 days. That is very dangerous, they are very suicidal. If someone takes an opiate overdose at night when everyone’s in bed so they won’t find them for many hours, they are dangerous. If someone takes the overdose during the day, when people are awake at home, they are less dangerous. 

A change in somone’s behaviors and/ or outlook can also help determine lethality. When people start giving away their possessions, that is a sign that they are very lethal, very dangerous. Another factor that can be informative is if an unnatural calm comes over them, and they say that they have no more problems, and everything is great. That is an indicator of serious lethality, major danger. These people have a sense of ease because they know that they’ll be dead very soon, and they don’t have to worry about things anymore. These are ominous signs.

Giving information about an attempt also informs a person’s level of lethality. If someone makes a statement of intent to commit suicide, they are not very dangerous. For example, a spouse saying ‘if you leave me, I’ll kill myself’ or ‘you broke my heart, I can’t live without you, I’m going to kill myself’ those statements alone do not indicate a very dangerous person. Not telling anyone and hiding when they plan to attempt is much more dangerous. There are many cases when people don’t come out and tell, but they aren’t being very secretive, intentionally or not, possibly even subconsciously. They leave clues, almost giving people a road map. This is very common, and these people are typically discovered. The discovery can either totally abort the act before it’s attempted, or can abort after the attempt, but in enough time to get the person help. This is why for every 1 “successfully” completed suicide, there are 24 failed suicide attempts. Similarly, someone who says ‘if this thing (interview, event) goes my way, I’ll be good, but if it doesn’t, I swear I’ll kill myself’ is not that dangerous, not very suicidal, because they’re bargaining, which means they’re still living in the real world. But, someone who does not want to negotiate, doesn’t care to affect things one way or another, may not be living in the real world, and they’re dangerous, they may be high risk to enter the world of the dead.  

There are a couple other things to be considered in assessing risk of suicide, determining how dangerous someone might be. If someone is impaired, using drugs and/ or alcohol when they attempt or consider suicide, and if they are not suicidal when they’re clean and sober, they are generally not that suicidal, not that dangerous, they just have a drug or alcohol problem. When they get clean and sober for good, the risk is essentially zero, barring anything else. In a similar way, if someone is suffering from a mental illness when they attempt or consider suicide, but when you correct that mental illness they are not suicidal, they are not a huge danger. 

So during suicide risk assessment, you can be looking at someone having a nebulous thought and/ or making a statement that a lot of people may have or make, and you know that they’re not very dangerous; or looking all the way to the opposite side, someone who thinks about it, formulates a thorough plan, picks the place and time, aquires all the things needed to commit the act, writes a suicide letter, and practices the complete act soup to nuts, and you know that they are very, very dangerous. And all the shades in between. 

So that’s my primer on suicidal thinking and assessing suicide risk. There are lots of factors to keep in mind, and sometimes it’s a little like reading minds, but you get more proficient as the years go by…it’s easier to tell when someone is misleading or being honest and open. If you enjoy a humorous approach to character studies in all sorts of diagnoses, you would enjoy my book, Tales from the Couch, available on Amazon. I mean, most of you are isolating, sheltering in place anyway, right? Might as well entertain yourself! Check it out. – Dr. Mark Agresti

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Obsessive Compulsive Disorder:Signs,Symptoms,and Treatment

Obsessive Compulsive Disorder: Signs, Symptoms, and Treatment

Today I want to thoroughly explain obsessive compulsive disorder, because it is a seriously life altering condition that is frequently misunderstood. We have all heard people refer to friends or family as “OCD” in a joking manner. An example may be if you’re at a party at a friend’s house and the second someone puts their drink on the coffee table, the host runs to grab a coaster and quickly puts it under the drink, prompting a partygoer to say, ‘Oh my gawwwd, Pam, you’re so OCD!” This casual and off-handed way that OCD is referred to in everyday conversation may make it seem that the obsessions and/ or compulsions are just something annoying or amusing that a person can just “get over.” But for people with OCD, it’s not just a simple annoyance, it is a complex, frustrating, and anxiety inducing disorder. OCD is fairly common, affecting roughly 3% of the population. The age of onset is typically during the childhood years, and it is equally distributed between males and females. I have many patients with OCD, and unfortunately, I have diagnosed and treated many children with OCD throughout my career. One of the factors I always think about when assessing and diagnosing children with any disease or disorder is how much they may or may not be able to understand the symptoms they’re having. In cases of OCD, it concerns me even more, because it’s clear that these symptoms are very disturbing to children, especially because they don’t know what the heck’s going on. They don’t know why they get fixated on things or what their ritualistic behaviors are about, like why they have to turn their bedroom light off and on exactly 29 times before they can turn it off for good at night. They don’t understand why they get so upset and angry when they cannot perform their compulsive rituals, or why they constantly get stuck in intrusive, obsessive thoughts. Even adults with OCD don’t understand these things, but they are better equipped to recognize that something isn’t right, and better able to communicate the need to seek help. Obviously, children cannot simply drive themselves to a physician’s office, they rely on parents who may mislable the symptoms as a behavioral problem, not even notice the symptoms, or notice them but not realize there is a problem.

At its root, OCD is an anxiety disorder, marked by the presence of  obsessions, compulsions, or a combination of the two. Obsessions are essentially intrusive thoughts that come up for no obvious reason and that just don’t go away. Compulsions are behaviors they feel they must perform, otherwise they become very anxious and very distressed; for some, almost to the point where they are paralyzed if they don’t do them. But, people with OCD do not want to do these compulsive things; they know they aren’t right, know they aren’t normal, and that means that they are not psychotic. A psychotic individual would say they do these things because aliens told them to, or for any reason. The point is that psychotic people believe they have a reason. Contrast that to people with OCD; they have no reason, no explanation. It occurs because a switch in their minds malfunctions. It doesn’t shut off, it doesn’t ever tell them that checking the lock once before bed is enough, that when they see that the lock is engaged, it will stay that way until they unlock it the next morning. 

There are four criteria to consider in diagnosing OCD: – The presence of obsessions, compulsions, or a combination of the two. – These obsessions and/ or compulsions cause a significant amount of distress, to the point that they get in the way of a normal life.  – The obsessions and/ or compulsions are not the result of taking any pharmaceutical or street drugs.- The obsessions and/ or compulsions cannot be explained by the presence of another illness; for example,being obsessed with body image as a result of body dysmorphic disorder, or being obsessed with food as a result of having anorexia nervosa.  

So, what is an obsession? An obsession is an intrusive thought that an individual cannot expel from their conscious thinking, a thought that randomly pops into their head and will not leave. Now, understand that everyone, even people without OCD, will sometimes have some sort of obsessive thoughts; it’s entirely normal, so this is a matter of degrees. For example: if a student has a big important exam the next day, they may check their phone alarm or alarm clock 3 or 4 times the night before. This is not indicative of obsessive or compulsive behavior. But, someone with obsessive compulsive disorder will check the alarm so often, over and over, to the point that they get no sleep. A person basically crosses the bridge from normal, cautious behavior to pathologic obsessive and/ or compulsive behavior when these behaviors interfere with, and prevent them from living full lives. 

Obsessive subtypes in OCD sort of loosely fall into five categories, but don’t forget that there’s always something new under the sun.

1. Counting/ math/ calculations/ numbers: they exhibit a ritualization involving numerical calculations in the brain. They have to count something- it may be steps, times turning switches off and on, locking and unlocking a deadbolt, etc. Some have to add or subtract numbers of steps involved in completing a certain action, and they must get the same number each time they perform that action. If they take three steps forward, they must take that many backward. While these things don’t make any rational sense, they actually create order for them. You might think, well, they aren’t hurting anyone, so whatever floats their boat. But they are actually hurting themselves. These people count so much and do and redo so many times that they can’t get to work on time, they can’t live their lives normally. It can have a devastatingly negative impact on every aspect of their lives. Sometimes they literally get stuck somewhere, because ‘the numbers don’t work.’ One of my long time OCD patients, Bruce, does pretty well for the most part, he takes his meds, keeps his appointments, and earnestly works on himself. He’s pretty much a model OCD patient, but every once in a while, the train jumps the tracks, and I get an emergency call from him saying he’s stuck somewhere. The last time was just a few weeks ago; he was inside a bank, and had just realized that there were separate entrance and exit doors, so he knew that the number of steps he had taken to get from his car and into the bank were going to be fewer than the number of steps it would take for him to walk out of the bank and back to his car. I explained that yes, Bruce, it would take more steps to walk out of the bank and back to your car, simply because you parked closer to the entrance door when you drove in. I told him that was normal, and it was to be expected. But he was really stuck, incredibly anxious, evidently pacing back and forth in the bank lobby. He said the tellers and bank manager were seriously eyeing him. They were probably thinking that he had some nefarious scheme in mind and that his constant frantic pacing was his way of plucking up the courage to enact his plan. Thankfully, I was able to talk him down off the ledge that day. It wasn’t easy, and it wasn’t quick, but eventually I convinced him that the difference in the number of steps was expected, that it had to be that way, so it was okay, and that he would see that I was right, that it was true, as soon as he left the bank and got in his car. I stayed on the phone as he walked out of that bank, certainly with great trepidation, and I could hear him counting steps just under his breath, until he got in his car. When I heard him exhale loudly and close the car door, I knew we were home free. He thanked me profusely, I said it was cool, no prob, and I went  back to my patient. That’s Bruce!

2. Catastrophic Fears: aptly named, these are fears of major proportions, absolute worst case scenarios on steroids, and taken to the n’th degree. These are not like, ‘oh, I forgot my presentation was scheduled today.’ These are more like, ‘did I leave something on? Oh my, I just know I left the stove on. Oh no, the house is going to burn down to the ground! It’s going to burn! And we’ll never afford to rebuild! Oh God, what will I do?!’ 

Or, it can be a fear that you will harm someone, even someone you love. That you’ll suddenly take a hammer and bash someone’s head in, or that you’ll take an assault rifle and gun them down in their backyard. I’ve had lots of OCD patients of both kinds, the doom and gloom Negative Nancy types, and the head-smashing-hammer-weilders and assault-rifle-gunners. When I think of the latter type, I always think of a patient named Hillary. She was just twenty when she first came to see me, and she came with her mother, whose name was Alain or Alaina or something like that. I do recall that she had a very french accent. When I asked Hillary why she had come to see me, she didn’t answer right away, so eventually, her mother said in her thick accent, ‘she’s worried that she wants to kill me, to slit my throat.’ I have to say, I was taken aback. I looked across my desk at this whisp of a girl, not looking at me, but at her hands, which she knotted and unknotted, like she was washing them. I asked her if that was true, and still not looking at me, she nodded. I asked her mother, “So you brought her in because you’re worried that she’s going to kill you?” She looked at me and replied, “No, doctor. I brought her because she is worried that she’s going to kill me. I am not worried about that, only about her. She talks about it incessantly. She says she doesn’t think she wants to do it, but she’s still afraid she’s going to.” I asked Hillary how often she thought about it, about killing her mother, and she simply said, “All the time.” I will never forget how heavy that room was. You could feel the oppression, for lack of a better word. Matricide, the killing of a mother by her child is pretty uncommon, especially at the hands of a daughter. I could see clear OCD tendencies, but her pathology really hinged on her obsessive, catastrophic fear, which was undoubtedly 100% genuine. Without any rhyme or reason, apropos of nothing, the thought of killing her mother would randomly pop into her head. Imagine that for a moment. Imagine the first time it popped into Hillary’s head at age thirteen. Then imagine it constantly popping into her head, all the time. But, you know you love your mother, right? Right? But yet you think you might kill her. At twelve. How confusing would that be? I knew that we had a long road ahead, but I wanted to help Hillary. With OCD, one of the main treatments is exposure therapy. For example, if someone had to touch the faucet 37 times before they could turn it on, the exposure therapy would be to push them into walking into a bathroom and simply turning on the faucet without touching it beforehand. You expose them to the thing they obsess about, the thing they perform their compulsion on. It’s very difficult at first, but it can be very effective. There really was no way to try exposure therapy for Hillary’s particular obsessive thoughts of catastrophic fear…I couldn’t give her a knife to hold at her mother’s throat as I tell her to resist slitting her throat. Captain Obvious says that might be traumatic. Nonetheless, we met at least every two weeks, and more often when she was in a tough spot, which happened a lot. We tried drug therapies and eventually hit on a combination that seemed to work well, and we did some serious psychotherapy over several years. And ever so very slowly, she improved. She wasn’t OCD free, but it was possible that it would never be totally gone. There were still times when her obsessive thoughts were exacerbated for no obvious reason, but those have been fewer and farther between as she’s gotten older. I attribute a lot of that to her mother. She is a strong woman, and she could have chosen to dismiss Hillary’s fears because she didn’t understand them or believe them. You have to admit, it would feel weird to hear your child speak obsessively about slitting your throat. But Hillary’s mother didn’t turn a blind eye or distance herself, she actually did the opposite: she drew her daughter closer and sought help. There isn’t always that kind of family support, so it was very reassuring to all three of us. The depth of Hillary’s beliefs in her obsessive fears was significant, especially for a girl of her age. She was sure that she was going to kill her mother, whether she wanted to or not. But please know that just because someone in the family has OCD, it does not mean they’re out to get you.  

3. Fear and Hypermorality:  hypermorality is essentially taking manners and consideration for others to an unnatural degree. The fear these people have is that they said the wrong thing, did the wrong thing, made a mistake or misstatement to a friend or family member, or sent an email or text or made a comment on social media that may have hurt someone else’s feelings or made them upset. They will go over and over a previous interaction in their mind, obsessively searching for anything they may have said that could have possibly slighted someone, because they’re sure they did, they just aren’t certain when. For example, if they say hello, they will immediately begin thinking ‘did I say hello in the right way, in the right tone? Did I walk away too quickly after I said hello? And I only said hello, I didn’t ask how they were, should I have asked how they were?’ This is not an exaggeration. Can you imagine what these people go through, when the simple act of saying hello causes tremendous amounts of anxiety and endless rounds of second guessing everything! That’s how this disorder interferes with people’s lives; it gets in the way of their daily operations, and they simply cannot get anything accomplished because they are so consumed with these obsessions.

4. Religion: some people have religious obsessions, where they believe they must say specific prayers in a certain order for a multiple of times, and that each round must be perfect; if not, they must start again. This can take up hours upon hours on end. These prayer rituals are compulsive, and are required in an attempt to quell the obsessive thoughts about how to love God perfectly, or how to be worthy, how to ask His forgiveness or how to live a righteous life…whatever obsessive beliefs they affix themselves to. Commonly involved in religious obsessions and related compulsive behaviors involve acts of supplication, kneeling or bowing before God or whatever religious idol they obsess about, because they must do so. Some religions incorporate other compulsory activities like fasting, so OCD people may believe they must also do that to show their devotion. When religious activities are taken to a level of obsession, they are likely to be much harsher and far more restricting than the original religion actually proscribes. Ritualistic self-mutilation and pain is encouraged by some radical religions to prove one’s worthiness, and people with extreme religion-oriented OCD obsessions feel a compulsive draw to these behaviors. They can see that they are different, that others do not take their beliefs to the same levels, but they cannot stop. Whenever I think of OCD cases involving religious obsessions and associated radical compulsions, I have one patient that comes to mind. I’ve seen him over a span of probaby ten years…a long time. His name is Benigno, and he is originally from Peru, but he’s lived on Palm Beach for a long time, and he’s done well for himself. He first came to see me (reluctantly) at the request of his family. They were concerned that his religious beliefs and activities had become far too radical in recent years. They reported that he was now totally consumed by his religion, and that they believed it was endangering his life. That’s all the background his family gave me. When he sat down for his first appointment, I started by asking Benigno to tell me about his upbringing. He said he was raised in a traditional Catholic home in Peru, but he always saw his beliefs as very different from his siblings, even though they were raised in the same home. He said that even his family noticed that from the very early age of seven, he took his relationship with God to an unusual level for such a young child. Even at that age, he spoke endlessly about God, he would fast for days, he would kneel on rocks in the backyard as he prayed for 15 hours straight, he would deny himself sleep in favor of praying the rosary until his voice was hoarse. As he grew and advanced in school, rather than playing sports or making friends, he spent time in a radical religious group, with people far older than he was. They clearly saw his unusually zealous behavior and encouraged it, telling him that he must do more to demonstrate his worthiness to God. It was really the only time I can recall hearing that anyone actually encouraged another person’s obsessive thoughts and destructive compulsions. It was disturbing, to say the least. Benigno definitely had OCD, but it was a little atypical in it’s origins. I think that when it started in his childhood, the religious belief system he was raised in may have contributed to its genesis. Perhaps a nun at his school said that he should pray more, or ask God’s forgiveness for something or else risk eternal damnation, who knows. He didn’t like the OCD label, and wasn’t always sure that his obsessive thoughts and compulsive behaviors were preventing him from having a fulfilling life. He always vacillated on that point, but he did concede that his behaviors weren’t normal. Over time, he’s eased up a little on his compulsions, but he’s uncomfortable during those times, because his obsessive thoughts are telling him that he needs to do certain actions to lead a life that pleases God or to be worthy of His love, whatever thought is screaming the loudest in his brain. I just started him on medication recently, because he had refused it until then. I think that will really help him, but we will continue on with psychotherapy. Benigno is a work in progress. 

5. Symmetry/ Order: symmetry and ordering obsessions and compulsions are among the most prevalent OCD symptom subtypes. These people are compelled to make everything line up, to make things equal on two sides, and/ or to arrange things into equal groups. Many times, I’ve seen frazzled parents in my office very concerned, because little Johnny must have his toy trucks in a perfect line, grouped by color, and arranged from largest to smallest. They are amazed and more than a little frightened by his precision. If one truck is accidentally moved a fraction of an inch out of place when Fido runs through to bark at the old lady next door as she heads into her garden, little Johnny loses his mind. And even if mommy runs like a cheetah to put it back perfectly in its place a mere millisecond later, it doesn’t assuage his outrage. This is actually a pretty typical presentation in a child of little Johnny’s age. But these obsessive thoughts on order and symmetry will change as he ages. He may need his third grade class to have an exactly equal number of boys and girls, or else he cannot be in that classroom, and he demonstrates that in all sorts of destructive behaviors…screaming, kicking, biting, throwing books, tearing down posters, and generally throwing a monstrous tantrum. Why? Because little Johnny is pissed off. His brain is telling him that everything is wrong in his world right now, because there are four more boys than girls, and that’s unacceptable. So his brain just fizzes, like when you put pop rocks in a pepsi…it overwhelms him. It’s a difficult OCD subtype to manage because it’s so persistent. Little Johnny will need a lot of time in therapy, but ultimately, I think he’ll be okay. 

As for compulsions…these can be as numerous and diverse as anything that people’s brains can come up with, which is to say they’re pretty much unlimited. The ones that often spring to mind are like checking to make sure the stove is off, checking to make sure the garage door is shut, checking to make sure the locks are locked, the alarm is on, the gas is off, the fire in the fireplace is dead, the faucet is off, the grill cover is on, the car has gas, the tires have air, the lights are off…and then checking them again. And again. Maybe locking and unlocking and locking the front door, over and over, until they’re satisfied it’s locked, which is almost never. Their brain never says STOP! THE DOOR IS LOCKED. GO TO BED. That box doesn’t get ticked; it does not happen quickly. 

They may be obsessed with cleanliness, either of themselves or their possessions: home, car, clothes. So they ritualistically clean them over and over, it must be perfect. I have a fairly new patient named Launa, and she is obsessed with cleanliness, and she ritualistically cleans…very, very thoroughly. She cleans and cleans and cleans again. She will cover the house seven or eight times in a day, or all through the night instead of sleeping, whenever her obsession moves her. And she doesn’t just sweep, wash, and wax her floors. She gets a roll of scotch tape and gets on the floor, placing her head perpendicular to the floor so that she can see the profile of a microscopic bit of sand, or some flotsam, real or imagined, against the flat surface of the floor. Once she has it in her sites, she takes a piece of the scotch tape and sticks it on top of the speck, pulling it off the floor, trapping it on the tape, then putting the bit of tape with the offending speck in her pocket for safe keeping. She does every square inch of her floors that way, on her hands and knees, moving specifically from her back kitchen door, into each of her two guest bedrooms, and finally finishing at the far wall of her bedroom. She goes through a minimum of six rolls of scotch tape at a time, and she will do this every single day. Often, she gets to that far wall of her bedroom and starts over again immediately. Her knees are perpetually black and blue, and her hands are often swollen and painful from overuse, but that’s more tolerable than trying to deny the compulsive behavior that her obsession demands. It’s sad, because this smart, funny, gentle woman has no life, and she knows it, sees it, hates it, but feels powerless to change it. But I am committed to helping her do just that, and I know she’ll get there.  

By the time most of my OCD patients get to me, they’re pretty stuck in their compulsions. There’s the engineer that must spend precisely eight minutes in the shower- no more, no less. He sets an alarm in the bathroom for seven minutes and fifty-two seconds, and when it goes off, he has exactly eight seconds to open the door and step out of the shower. If for some reason something delays his exit, like having to pick up a dropped washcloth, he must start another shower. He will do this until he gets it perfect. I would hate to have his water bill. In a similar fashion, he allows himself four minutes to brush and floss his teeth and use mouthwash…which he must do in a certain pattern…swish quickly in left cheek three times, then right cheek three times, then around his front teeth three times, then tilt head back to gargle three seconds, and spit. 

There’s the recent suma cum laud college grad that lost her dream job because she was always late. Why? Because she spent anywhere from twenty minutes to an hour each morning when she was to leave her house to go to work, locking and unlocking her front door over and over until she had to leave. But she was never satisfied that it was locked, so she often went home on her lunch hour, spending it standing at her front door, turning the key, unlocking, locking, unlocking, locking…Losing her job was an eye-opener, and that’s what brought her to me.

Another OCD patient, a 13-year-old boy named Andrew, was consumed with a very detailed and very peculiar eating ritual. The food on his plate could not be touching. His mother had to make sure of this. The meat could not touch the rice, which could not touch the broccoli, which could not touch the roll. If a catastrophe happened and any of the food touched, it had to be thrown out and his mother would have to make him a new plate. But that wasn’t all. When his mother set his plate in front of him, she had to arrange it so that the meat was top left, the veg top right, the starch bottom left, and the roll at the bottom right of the plate. Then, before he could begin eating, he had to hold his fork in his left hand and his knife in his right, each positioned tines and blades up just so, and flanking the sides of his plate. Then he would simultaneously raise the utensils and touch them to the table three times, and then put them together above the center of his plate and touch once there, then put them together again below the center of his plate and touch once there. Only then could he eat his food, but just as the food couldn’t touch on the plate, it couldn’t touch in his mouth either. He ate each part separately, always in order. First the meat, then the veg, then the starch, and then the roll. Well, unfortunately, one day Andrew was riding in a friend’s mothers car, and they were in a terrible car accident, and he was paralyzed, so his mother had to do everything for him, including feeding him. His ritualistic compulsions were still so consuming, so powerful, that before he could eat, his mother had to perform his rituals. Every single one of them. And she had to do them over and over and over, until they were perfect…or else he would totally lose it, scream and spit and curse her for being stupid. She told me that in the beginning, she would be sitting at that table for hours and hours, tears streaming down her face, repeating his knife and fork touching rituals, to the point where she would literally be nodding off, only to be snapped awake by his belittling venom. I told him that everyone understood that he couldn’t help it, that he wasn’t in control of his compulsions, but that it was unacceptable to treat his mother the way he did, screaming at her, calling her names, and spitting at her. I told him that she was the only person even willing to try to put up with his behaviors. His father had zero patience for it, and he didn’t dare speak to him with the words he used with his mother. With time, meds, a lot of therapy, and the acceptance of his paralysis, he mellowed out a little and things have improved. But Andrew needs more work, and his mother is completely devoted to helping him. I honestly don’t know how she does it, but for his sake, I’m glad she does.

I had a nine-year-old boy with OCD come into the office. His mother had to wear gloves and a mask to prepare his food, because otherwise she would contaminate it. She had to serve it on a paper plate, and when she set the food in front of him, he would spend 15 minutes scrutinizing it, like he was looking for germs, as though he could see them. He had to eat with disposable plastic utensils and use only paper napkins. Everything was always single use, so as not to take the chance that old food could stay on ceramic plates or steel utensils even after being washed. 

Another patient, a 42-year-old man named Gary, was obsessed with perfectly pristine white sneakers. If he got so much as a speck of dirt on them, they were ruined. He would buy a new pair and burn the offending pair. 

Another patient, a man originally from Jamaica, had a ritual of tracing a cross on his chest with his finger every time he felt he had said anything contrary to anyone. He dis this so often, to the point that he wore through the skin, literally down to the sternum bone in the middle of his chest.

I had another patient, a physical therapy tech that had an odd compulsion. While driving, if he went over a speed bump, he had to turn the car around to check to make sure he hadn’t run over a person. He knew on some level that it was just a speed bump, that he had even seen the speed bump as he’d driven ober it, but his obsession told him that it might possibly have been a person, so the compulsion was for him to turn around to make sure. Luckily, it hasn’t been a person a single time. 

A young woman came in for her first appointment, and she arrived looking totally exhausted. She had dark circles and huge bags under her eyes, her hair was all messy, and she looked like she was waaay out there. I told her that she looked very tired and she agreed. I asked her why, and she said she had been up all night. That begged the question of why once again, and she said that she had recently moved to a new apartment, and she had been trying to hang a picture. To which I raised an eyebrow and said, and?…. She smiled, blushed, and said that she just couldn’t get it level, so it took ‘a while.’ I said, “Are you telling me that you spent all night hanging that one picture?” Embarassed, she quietly answered yes. I suggested wryly that she buy a level at Home Depot. Still embarassed, she said, “I have one. I didn’t trust it.” Despite myself, all I could do is laugh. Then I suggested that she might have OCD. And I swear, with a straight face, she said, “Really? Do you really think so?” Oh boy…seriously?! She was actually surprised…I’m telling you, never a dull moment.  

Late one afternoon not long ago, I finished with a patient, the last one of the day, so I said I’d walk out with him, and I went and turned the AC up, shut the lights off, and walked out the door, never breaking stride. As I locked the office door behind us, I saw that he was looking at me, incredulous. Startled, I said “What?” He said, “Oh my God, how did you just do that?!” Totally confused, I was like ‘what?’ and he said, “How can you just close up and walk out of your office like that, that fast? I spend at least an hour a day getting out of my office, checking everything over and over before I can walk out, then at least another 15 minutes locking and unlocking the front door before I can head to the car.” I told him, “Next appointment, you and I are going to discuss that, man.”  

And now of course, I have lots of patients freaking out about coronavirus. I have a specific woman who does not ever leave her home, and even though she’s home alone, never exposed to anything or anyone, she cannot touch anything bare handed inside her own home. So, her solution is to wear surgical gloves, 24-7. We had a facetime appointment recently and I commented on the gloves, and she told me she wore them all the time, even to bed, but that the skin on her hands was getting irritated. I talked her into taking the gloves off for a minute so I could see her hands. They were so pruney, reddish purple, and deeply wrinkled all over, like they had been covered in water for a loooong time…which I mentioned to her. But, she said it wasn’t water, it was sweat. I said, “Ewwww!” and she was like, “Yeah, I should probably let them dry off, maybe air them out a little bit.” Ya think?! 

All kidding aside, you can imagine how strong these obsessions can be, and how debilitating all the ritualistic checking, rechecking, doing, undoing can be. Many people with OCD have a very strict schedule. They have a routine that they follow religiously, day in and day out, that helps them to be somewhat functional. They get up at the same time everyday, eat the same breakfast, wear the same color shirt, same color tie, same shoes, drive the same route to work, park in the same space, eat the same lunch, drive the same route home, watch the same television shows, eat the same dinner, on and on and on. For these people, every single day of their lives is groundhog day. They have no room in their lives for spontaneity, no opportunities for joy…not without help.

These are anxious people, stressed out to the max. OCD is a distressing illness at best. But it’s not all doom and gloom. Treatment does work for those willing to put in the work, and they can go on to live healthy lives. The commonly accepted treatments involve psychotherapy and exposure response coupled with cognitive behavioral therapy. What does that mean? Basically, the therapist must coach the patient on what to do with the obsessive thoughts. Explain that they must accept that they cannot control the thoughts. That they must not engage with the thoughts, not feed the thoughts, because once they do, the thoughts will get stuck in their head, with no way to get rid of them. So they must let them just float away, do not address them, just let them float away. Let them drift away, and the further they drift, the more they can replace them with healthy thoughts. Explain that if the thoughts do come, it’s okay, but they should respond to the thoughts in a way that does not escalate anxiety, so not focusing on the thoughts, not feeding the thoughts, but redirecting the thoughts to other thoughts that are healthy, this is the best way to deal with them. There are also drug treatments, SSRI medications, selective serotonin reuptake inhibitors, like Prozac and Paxil. Luvox and Zoloft can also be used to treat OCD. Whenever possible, I like to employ a combination of meds, plenty of psychotherapy, and the exposure response coupled with cognitive behavioral therapy. When an OCD patient is willing to work and sticks to the plan, it’s truly life changing. Need proof? Well, maybe ask soccer star David Beckham, comedian Howie Mandel, actor Leonardo DiCaprio, singer Justin Timberlake, or his ex-girlfriend, actress Cameron Diaz. Or maybe actress and entreprenuer Jessica Alba, Shock Jock Howard Stern, or actor Nicolas Cage. They all seem to have done pretty well for themselves, and I’m pretty sure they’d tell you that treatment works.  

If you’re interested in more stories of OCD patients, or other psychiatric diagnoses, you can check out my book, Tales from the Couch, on Amazon.com. It’s a great read, entertaining and informative, and a really awesome way to spend a no- fun quarantine, if I do say so myself.

Be well, everyone.

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In Isolation…Now what

You’re in Isolation… Now What?

I regret that I even have to make this blog. The situation we find ourselves in is so surreal, but here we are, so we have to rock and roll with it. Covid-19 is a respiratory virus, a particularly nasty one. In recent years, scientists have tried to prepare for a long-feared hypothetical pathogenic disaster they called Disease X, and defined it as: any unknown disease that springs suddenly into our species and races ruinously through it. Covid-19 is the first Disease X to arise since the terminology was coined, but it certainly won’t be the last. The climate is warming, we’re hacking down forests, our population is expanding faster than the earth can keep up with, and our skills at waging biological warfare are expanding and improving. The odds that we’ll keep encountering more and more Disease X’s are increasing. We will need all the vaccines we can make for this, and future, Disease X’s. Right now, there are at least 40 research groups around the globe working on Covid-19, and there are 43 Covid-19 vaccines in various stages of development around the world. One potential vaccine has just started a small human trial. While it sounds promising, with Covid-19, both the viral contagion itself and the vaccine type (using novel DNA/ RNA tech) are so new that there’s no telling what human trials will reveal, or how long they will take. Most of the scientists researching Covid-19 say that we’ll be lucky to have a vaccine for human use within 12 – 18 months.    

Yes, we’re in a pretty precarious state, but there are ways to make it less uncomfortable, less disturbing. An ounce of prevention is worth a pound of cure. The best defense is a good offense. These cliches were not popularized by accident, they’re true. In the case of Covid-19, the best preventative measure and the best offense is…stay home! It may not be fun and it may not be easy, but if there’s any possible way to stay home, do so. The only thing worse than isolating to prevent contracting the virus is to be quarantined withthe virus! I want to talk about some things you can and should do to maintain your sanity while waiting Covid-19 out. For general information, I’ve found that Unicef has great intel broken down into manageable units. They detail handwashing, using hand sanitizer, and behavioral ways to help stop the spread of Covid-19. You can navigate through the entire site from:

https://www.unicef.org/coronavirus/everything-you-need-know-about-washing-your-hands-protect-against-coronavirus-Covid-19

After talking with so many patients about Covid-19, listening to their fears and anxiety, I’ve come up with 10 things you should pay attention to while you’re isolating or you’re in quarantine.  

1. Consider anyone who is living with you in isolation, under quarantine, or simply in your shelter, as family. Everyone must function as a family, ie as a group, a “covid family” if you will. A few weeks ago, our world changed forever, and you must work together and be in it for the long haul, because we don’t know how long this is going to last. Make a decision to be good to each other, to respect each other. You must get along, because now we have an enemy that is far greater than us. It is a virus, not a natural disaster like a hurricane, flood, tornado, or fire, nothing that we are accustomed to dealing with. It is not a war, but make no mistake…we are under attack. So you need to treat the people in your “covid family” the way that you want to be treated. Talk to each other (no yelling or demeaning language) in a positive manner; this won’t always be easy, because the uncertainties linked to this pandemic will cause stress, which generally leads to shorter fuses. Decisions have to be made in a thoughtful way; if you have several people in your “covid family,” that may mean voting on important issues. Whatever you do, make every effort to keep the peace in your “covid family.”

2. Hygeine is everything when it comes to transmissible disease, andeveryone living in the house must participate in it. Wash your hands often, and just as important, wash them properly! I’ll discuss ‘the how’ below. First, let’s talk about ‘the when’. Your mama taught you to wash after using the toilet, before and after eating, after changing diapers or helping children use the toilet, after touching animals and pets, after touching garbage, and whenever they are obviously dirty. Those rules still apply of course, but with Covid-19, we’ve stepped it up a bit to include a few more “after’s”:

– After coughing, sneezing, and blowing your nose
– After visiting public spaces/ places: public transportation, markets, banks, drive-thrus, and places of worship
– After touching any of the surfaces outside of the home, including money, ATM machines, credit/debit checkout machines and stylus pens
– Before, during and after caring for a sick person, regardless of their Covid-19status
Those are minimum hand washing requirements. I suggest you wash at least every 1 – 2 hours, even if you haven’t done any of the above things. Ritualize your hand washing, especially if anyone in your “covid family” is high risk and/ or still venturing out of the home. If you touch the doorknob, wash your hands. If you touch a faucet, wash your hands, stove, wash. You get the idea. In this situation, there’s really no such thing as washing too much; you cannot be too careful, because this virus does live on surfaces for an extended period of time. FYI, that includes Amazon boxes. One of my very high risk patients actually “quarantines” her deliveries for five days and then opens the boxes with gloves on. Overkill? Hard to say. We all have to gauge our personal risk level and then behave accordingly.

As promised, here is ‘the how’ of proper handwashing. There are five simple steps to proper handwashing:

 1: Wet hands with running water (water temperature doesn’t matter)

 2: Apply soap liberally- don’t skimp- use enough to thoroughly cover your hands.
 3: Scrub all over the hands for 20 – 30 seconds with lots of sudsy lather: every surface, back and front of hands, between all fingers and under fingernails. Pretend you’re a surgeon. We’ve all seen surgeon’s scrubbing in. Do that vigorous, thorough scrubbing for 20 – 30 seconds. And yes, sing the ‘Happy Birthday’ song twice to ensure you wash for 20 seconds minimum…it’s so easy to stop early if you don’t sing, because 20 seconds is a fair chunk of time. Don’t short yourself! 

 4: Rinse well under running water

 5: Dry with a paper towel or clean cloth. 

IF YOU’RE OUT OR WHERE THERE’S NO SOAP OR RUNNING WATER, USE HAND SANITIZER. Use it basically the way you would soap. Put a generous amount into the palm of one hand and rub briskly but thoroughly all over both hands: front, back, between fingers, and under nails. If necessary, use another dose of it to act as a sort of rinse, especially if your hands have contacted multiple surfaces. 

Some other hygeine tips:

– Do not touch your face.  

– Make hand sanitizer and tissues like the American Express card…don’t leave home without it.

– Sneeze into a tissue. Some say it’s okay to sneeze into the crook of your elbow, but only as a last resort if you don’t have a tissue; your best bet is to keep a tissue handy. 

– If you must leave your home, limit outings to once a day.

– If you do leave your house, when you come back home, go straight to the bathroom and bathe before you interact with the house. Then use pre-moistened antibacterial cleansing cloths or a bleach solution to clean everything you touched on the way in. 

3. Do everything you can to boost your immune system, especially if you are higher risk. Take vitamins, 50 mg Zinc Gluconate per day, 1000 international units of Vitamin D3 per day, and 1000mg Vitamin C each day. If Vitamin C upsets your stomach, look for liposomal Vitamin C, because it is better digested.  

4. Take care of yourself. I’m embarassed to say that I have a friend from Pennsylvania who found ridiculously cheap plane tickets to Florida, $28 round trip, for he and his wife to take a quick trip about a month ago, just before travel was prohibited. Guess who got sick with coronavirus? Both of them! Guess where they are now? Quarantine! I mean, duh! File that under “Don’t be a moron!” I can’t believe I’m friends with someone that stupid. Anyway, back to taking care of yourself. This isn’t rocket science. 

– Eat healthy, limit bad things. You’re likely to have more time on your hands; don’t spend it drinking more alcohol, smoking more cigarettes or more weed, or eating your way through the pandemic. Fresh fruits and vegetables are the best, but you may not have access to them, so frozen fruit and veg are better than no fruit and veg. Every restaurant has delivery now, but try to not give in and order carb, fat, sugar crap delivery. Eating healthy also helps boost your immune system. Google “foods that boost the immune system” and see what you like and what you can get your hands on.    Blueberries, raspberries, nuts, eggs, leafy vegetables, lean meat, fish. 

– You must exercise every day. Obviously you should not visit a gym or use community gym equipment, but it’s fine if you own it and it’s inside your home. If you share gym equipment with your “covid family” be sure to clean it between uses and wash your hands thoroughly after using it. If you don’t use equipment, go for a walk or bike ride. Look On-Demand or YouTube for workout videos to do at home. Move your body everyday. 

– Keep to your regular work day sleep-wake schedule. Go to bed at a certain time, get up at certain time. Sleep deprivation and/ or exhaustion compromises your immune system, so it compromises you.  

– Get dressed. If you dress like a bum, you’re more likely to feel like a bum. Try for the sake of the people that may be in your “covid family”. Don’t wear your pajamas all day, get dressed and look a human being please. Shower, shave, brush your teeth, wash your face, yada yada. Fine, if you’re working from home and want to wear sweats for a day or two, that’s fine, but doing it every day for a long period of time tends to  undermine the sense of self-esteem and degrade the community around you, aka your “covid family” 

– Learn to relax. These are trying times. Do things to help deal with anxiety. Try aromatherapy, music, gardening, yoga, meditation. Google meditation videos, and look on YouTube as well and give it a try. For some people, a pet is the best anxiolytic in the world; think about getting a fish or a little mammal. If that’s not for you, try getting a little plant to take care of, just something you can nurture. It helps a great deal psychologically.  

– Meals become a bigger deal now, because it will probably be the most face to face interaction you’ll have, assuming you’re not going out. I suggest you schedule one big meal a day- usually dinner- and everyone pitches in. Some people prep, some cook, and some clean up. Working together is good for the mind and the soul, because it gives everyone a sense of belonging. 

5. Be frugal. If that is foreign to you, learn to stop spending. Figure it out. You must conserve all resources and manage the resources you have in the most efficient way, so you are not wasting food, goods, or money. You don’t know how long this is going to last, or the effect on the economy once it’s gone, so think before you spend a penny. 

6. Limit news exposure. You’ll go crazy watching it all day. Don’t leave the news station on as white noise either. Remember that some people, like politicians (ahem), have a secondary agenda that you can’t even begin to imagine, so you can’t really believe everything you’re hearing. Take everything with a grain of salt until you hear the same news from multiple sources who have conflicting interests. Then you can put more stock into what you’re being told.

7. How to entertain yourself or others in your “covid family”? The key here is to keep changing it up. Movies, binge watching tv shows, virtual reality systems, Gameboys, puzzles, board games, cards, reading, art. Try some hobbies you’ve never had the time to try before: planting a garden, sewing, knitting, painting, drawing, writing, tie-dye, whatever rocks your boat. You’re not going to be able to do the same thing day after day, because you’ll be bored out of your skull; remember that we’re probably looking at months before it’ll be safe to return to life, but likely a year minimum before things even start to get back to normal. Months to a year is a long time to be bored. 

8. You must maintain a high level of socialization. Use Facetime rather than just phone calls. Email or text, however you can stay in touch with people. Anyone who’s read my book, Tales from the Couch, available on Amazon (shameless plug) or reads/ watches my blogs/ vlogs, will laugh at this next bit. I suggest that you use social media, Facebook, Instagram, etc to facilitate interactions with people and get ideas from the outside world and really stay in tune with what’s going on. Normally I harp on the evils of social media, but it’s a brand new world people! Try very hard to stay in touch with friends and family during this isolated state.

9. Have structure, especially if there are kids in the house. You must establish special rules for the special circumstances we are in. If you have school-aged kids, are they “out of school?” This isn’t summer, and most schools have a curriculum for students during this time at home. So, the kids must wake up in the morning, shower, have breakfast, brush the teeth, and boom…school is in session! Make a schedule for them for every day, Monday to Friday, and stickto it religiously. I ran a school for 10 years, and I know how important this is. This isn’t punishing or being mean to the kids; kids are happier on a schedule, because they know exactly what to expect and when to expect it. The key here is to break the day up into separate topics/ sessions: reading time (or lecture, depending on age), discussion/ questions on the reading or lecture, outside activity, snack time, art, creative play time, lunch time, nap time (if applicable), puzzle time, special project time. The key to success is tailoring the subjects, activities, and the length of each session to the age of the kids. Young kids have a short attention span, so spend no more than 20 minutes on each session. Older children can usually handle 45 minutes, but adjust the time according to your child. Special projects could include maybe making homemade kites and racing them, or having a cookie day, where you make cookies and talk about the origin of ingredients and/ or their purpose in the recipe. For instance, when you add the chocolate chips, explain that chocolate actually starts as a big pod grown on a tree, called cacao (pronounced ka-kow), and google a picture of it along with how the process goes, from the pod to the chocolate chips in the cookies. As for lecture subjects, you can google lectures or ‘educational topics for ____ graders’ and find cirriculum and lesson plans. And it really is worth it for you to order stuff online to keep them entertained and learning and productive. You can even get topic or lecture ideas from everyone sitting around the dinner table. Understand that kids feel the stress of this situation too, so engaging them in positive and productive activities will take their minds off the fear and uncertainty while improving their skills and expanding their education. The bottom line is that if you don’t engage the kids, they’ll be idle and bored, a perfect prescription for the house to descend into chaotic madness.

10. Think! Think really hard before doing anything. Ask yourself, ‘Is it worth my money?’ and ‘Do I need it?’ Stop with the panic buying! Really, how much toilet paper do you actually need? Buy the things you need, but think before you do in order to conserve your resources.  Think wisely about what your family will eat, and what items will last for a long time: rice, pasta, jarred sauces, frozen fruit and veg, granola, protein bars, shelf stable milk, etc. Don’t do anything stupid like my friend in Pennsylvania did, taking a quick vacay to Florida…now he and his wife are on a Covid-19 quarantine vacay, a bummer place to be. And think how idiotic they’ll look when they have to answer friends and family’s questions on how and where they got the virus! Also, don’t panic. There’s really nothing to panic about. Prepare the best you can, take good care of yourself, be smart, and wait it out. Always keep your wits about you. 

Do you know the answer to the question ‘How long can you do this?’ I’ll tell you. The answer is… as long as we need to. Look, this will surely pass, but probably a lot like a kidney stone. That is to say, it’s going to be a long, rough ride that will involve some pain. But we’ll get through it, because we are nothing if not resilient. One day, hopefully sooner than later, we’ll have a treatment and even a vaccine for Covid-19, and eventually this virus will only exist in the perpetually frozen and hermetically sealed specimen libraries of the CDC, WHO, NIH, and whatever other acronym’d organizations keep stuff like that, filed under V– not for Virus- but for Vanquished.

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HOW TO BEAT FEAR OF CORONA VIRUS

Coronavirus, covid-19…the mere mention of these names strikes fear into the hearts of people that have one thing in common: they live on planet earth. It’s pretty sad that it takes a virus to bring us all together, working on a common goal. 

It’s that fear that I want to talk about. Fear of the coronavirus is the one thing that spreads more rapidly and is more contagious than the virus itself. That’s really thanks to the media. This is one of the most sensationalized topics I have ever seen in the media. Their choice of verbage and the names of their reports, it’s all to get people’s attention; it’s unnerving and inflammatory. A great deal of the intel that we’re fed is misleading at best. I think the virulence has been overstated, along with the way they calculate the percentage of deaths resulting from the virus. 

Consider that 50% of the people infected have no symptoms at all, 30% have mild symptoms. They eat some chicken soup and take some acetominophen and they’re fine. Many don’t seek treatment. Maybe 20% have moderate-to-severe symptoms and require treatment. Very few, most high risk cases, go on to pneumonia and organ failure. Now consider how many people actually get sick with the virus but don’t report it. Why? Because they don’t want to be ostracized, treated like a leper, a modern day Typhoid Mary. They don’t inform anybody. That’s why the death rate is so high right now, because the number of confirmed cases is so low. If everyone that got sick from the virus actually reported and sought treatment, we would be able to accurately assess the death rate and it would be far lower than what is reported. That’s just one example of how some things are up for interpretation and one reason why you can’t allow these statistics to freak you out. 

The media should learn to dispense accurate information without being sensational, and it should avoid exploiting people’s fears. For example, they call it a “deadly virus,” but that can be misleading, because for most people, the virus is not deadly at all. Don’t get me wrong, this situation is deserving of our vigilance and attention, and I’m all for being prepared and doing everything you can to help flatten the exposure/ infection curve, but there’s a thin line between being aware and informed and living in a state of constant fear and anxiety. 

But understand that constant worry may make people more susceptible to the very thing they fear…as long-term stress is known to weaken the immune system. So ultimately, the more worried we are, the more vulnerable we are to the coronavirus.

Look, it has to be said…there isn’t any real, practical (read: sane) reason to stock up on toilet paper, but it may make people feel a little more in control of a situation that embodies the very definition of the word unknown. The less worried they are because they bought toilet paper, as ridiculous as that seems, the more they’ve reduced their fear, and in turn, minimized the effects on their immune system. So, if buying 8 year’s worth of toilet paper gets you through the night, or the pandemic, then go for it.

The good news is, there is a happy medium between ignoring the biggest story in the world right now and going into a full-on panic. Here are some tips. Think of it like hand-washing and self-isolation, but for your brain.

How not to lose your s÷&t over coronavirus: Do’s and Don’t’s

1. Do pare down your sources of information. There is a ton of information out there, which means you have to decide who to believe and wilfully ignore everyone and everything else. You can control your intel intake with the following steps:
– Do find a few sources you trust and stick with them. Choose one national or international source like the CDC, and one local, non-national source; this way you can know what’s going on in the country or world as well as your community. 

Don’t sit in front of your tv for hours on end flicking channels between CNN, FoxNews, CNBC, etc.
– Do limit the frequency of your news updates. Things may be changing rapidly, but they don’t change every 15 minutes. And even if they did, do you really need to know the very minute that 4 new people are infected? No, you don’t. Look at it this way: if there’s a tornado coming toward you, you need info asap and in a hurry. HINT: The coronavirus is not a tornado. Don’t leave the tv on all day as white noise, because some of that crap gets in your brain. Doget the information you need and keep it moving.
– Do hang it up! Get some social media self discipline. Put the phone away. For a lot of my patients, this is their biggest hurdle. It may not be easy to limit time on social media, but commentary from friends and acquaintances on your Facebook feed is worse than actual updates from news organizations. Don’tever count on recirculated, dubiously-sourced posts on Facebook, because all they’ll give you is a panic attack.

2. Do define your fears, it makes them less scary. A ‘pandemic’ is such a nebulous threat. It can be very helpful to sit down and really consider what specific threats worry you. Do you think you will catch the coronavirus and die? That’s where the brain is more likely to go, because the fear of death taps into an evolutionary core fear, but how realistic is that? Do consider your personal risk and think how likely it is that you will actually come in contact with the virus. And, if the worst happens and you or someone you love does contract the virus, plan for what happens next. In all likelihood,hope is not lost. Don’t overestimate the likelihood of the bad thing happening while underestimating your ability to deal with it. Being prepared for your fears will help keep them in check. Do everything you can to prepare; once you’ve done that, you’re done… just take care of yourself.

3. Do seek support, but do so wisely.

Don’t talk to Chicken Little…the sky is not falling! It’s natural to talk to people, even strangers, about something so pervasive as coronavirus. But choose your counsel wisely. If you’re afraid, it’s not the best idea to talk to someone else who’s freaking out, you’d just create an echo chamber. Don’t talk to the doomsday preppers about your coronavirus fears. Do talk to a more glass-half-full type, someone that’s handling it well, they can check your anxiety and pointless fears. Do seek professional help if you can’t get a handle on your thoughts. It doesn’t have to be long term, just situational assistance. 

4. Do continue to pay attention to your basic needs. In times of stress, we tend to minimize the importance of the basic practices of our ‘normal’ lives when we really should be paying more attention to them. Don’t get so wrapped up in thinking about the coronavirus that you forget the essential, healthy practices that affect your wellbeing every day. Do make sure you are getting adequate sleep, keeping up with proper nutrition, getting outside as much as possible, and engaging in regular physical activity. Practicing mindfulness, meditation, or yoga can also help center you in routines and awareness, and keep your mind from wandering into the dark and often irrational unknown.

I give the media and the government a hard time, but I think they’re panicking a little, because we’ve never seen a worldwide pandemic, it’s awesome. I don’t mean like awesome yay great, I mean awesome like wow, we’re in awe of this crazy pandemic. We never expected this, there’s no road map, but here we are, our collective pants around our ankles. All we can do now is the best we can. I don’t think the US has seen the worst of it yet, but I still see a bright future. In the next months, our detection, our means to stop the spread of it, and our treatment of this will dramatically improve. They will start using antiviral drugs already on the market, like Kaletra that’s used in AIDS cases, and that will likely stop coronavirus in its tracks. The only people that I think may need to worry are people who are immunocompromised or of advanced age. My projection is by the end of April 2020 this will max out, and by end of May the cases will start declining, and by August this will be a bad memory. It will just be another flu virus; and we will have the vaccine for it within 18 months, it will be under control, just another vanquished virus in the CDC archive. It will not overwhelm our system, will not destroy our economy; it will be resolved. My money’s on that.

Be well, everyone. Wash your hands with soap and hot water. Avoid crowds. Flatten that curve, people!

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How Alcohol Kills You

How Alcohol Kills

Too much of anything, no matter how pleasurable it may be in the beginning, can lead to harmful effects. Anything that you might enjoy- eating chocolate, shopping, playing cards, even exercising- may cause harm if it is overindulged in. The negative effects or the consequences of overindulgence are well known- obesity, bankruptcy, harm to the body, etc. The same can certainly be said about alcohol. Ethyl alcohol is a highly toxic substance that can cause serious damage, both physically to the body and psychologically to the mind. An occasional drink is not the issue. But if drinking takes on a substantial role in one’s life, the effects can ultimately be devastating. You drive recklessly, you have poor coordination so you fall on your head, your inhibitions are down, so you get mouthy in a bar and get yourself stabbed or shot. 

Let’s talk numbers. Excessive drinking remains a leading cause of premature mortality nationwide. Alcoholism is a widespread problem in the US, with nearly 90,000 deaths attributed to alcohol each year, according to the Centers for Disease Control. They have established guidelines to help determine what constitutes excessive drinking.

First: A “drink” is defined as a 12-ounce beer, 8 ounces of malt liquor, 5 ounces or wine, or 1½ ounces of liquor. Remember that some cocktails contain multiple types of liquor, so they may have more than 

1½ ounces each.

Excessive drinking is considered 8 or more drinks in a week for women, and 15 or more drinks in a week for men.

Binge drinking is considered 4 or more drinks in a single occasion for women, and 5 or more drinks in a single occasion for men.

Binge drinking is the most common form of excessive alcohol consumption, and is responsible for more than 50% of the deaths from excessive drinking. Binge drinking is a major cause of alcohol poisoning, and is a pattern of heavy drinking: in males, binge drinking is the rapid consumption of five or more alcoholic drinks within two hours; in females, binge drinking is the rapid consumption of four or more alcoholic drinks within two hours. These numbers may be lower, depending on a person’s weight and body composition. An alcohol binge can occur over a period of hours or last up to several days.

Binge drinking can cause alcohol poisoning. Alcohol poisoning is a very serious- and sometimes deadly- consequence of drinking large amounts of alcohol in a short period of time. Drinking too much too quickly can affect your breathing, heart rate, body temperature, and gag reflex, and potentially lead to coma and death.

Most people can easily consume a fatal dose of alcohol before passing out. Even after losing consciousness, or after stopping drinking for the night, alcohol continues to be released from your stomach and intestines into your bloodstream, and the level of alcohol in your body continues to rise. Unlike food, which can take hours to digest, alcohol is absorbed quickly by your body- long before nutrients are. Most alcohol is processed or metabolized by your liver, and that’s why the liver is so damaged by alcohol. 

Captain Obvious says that the more you drink, especially in a short period of time, the greater your risk of alcohol poisoning. There are several ways thatbinge drinking and alcohol poisoning kill you: 

Choking: Alcohol may cause vomiting. And because it depresses your gag reflex, the risk of choking on vomit if you’ve passed out is very high. If you don’t die from that directly, you can also die from aspiration pneumonia. Aspiration pneumonia often results when you breathe in vomit, and you are not able to cough up this aspirated material, so bacteria grow in your lungs and cause an infection. Yucky! And deadly!

Stopping breathing: Accidentally inhaling vomit into your lungs can also lead to a dangerous, fatal interruption of breathing, called asphyxiation.

Severe dehydration: Vomiting can result in severe dehydration, leading to dangerously low blood pressure and fast heart rate.

Seizures: Heavy alcohol consumption can lead to seizure in multiple ways, including trauma to the head from falling or auto accident, a sudden drop in blood sugar, and even upon withdrawl from heavy drinking. 

Hypothermia: Your body temperature may drop so low that you become hypothermic, leading to cardiac arrest.

Irregular heartbeat: Alcohol poisoning can cause the heart to beat irregularly, called arrhythmia, or even stop, called cardiac arrest.

Brain damage: Heavy drinking may cause irreversible brain damage. This can happen intrinsically or as a result of head trauma from falling or car accident, etc. 

Death: Any of the issues above can lead to death.

If right now you’re thinking you’re safe because you don’t binge drink, think again. If you have “just a few” drinks every night, that is considered excessive consumption, so those few drinks each night are killing you, make no mistake. 

When you think about the ways alcohol kills, some obvious ways spring to mind: trauma from car accidents, trauma from falls from being drunk, and general stupidity from being drunk, such as things that happen when alcohol lowers inhibitions to the point that you pick a fight you can’t hope to win (and you don’t) or you get lost and walk drunkenly into a bad neighborhood and get yourself killed. For the lucky people that avoid a trauma-related death from alcohol, the negative effects of excessive alcohol consumption may not be apparent for some time, but at some point there will be obvious signs that alcohol is killing them.

Ways Alcohol is Kills

It is mind boggling just how destructive alcohol is to the brain and body. The signs alcohol is killing you may creep up slowly, with a symptom here or there, or hit you all at once with a liver that has stopped functioning, as happens in late stage alcoholism. 

Signs and ways alcohol kills:

Cardiac issues: Long-term heavy drinking takes a heavy toll on the heart. Signs of serious cardiac issues that could result in death include atrial fibrillation and ventricular tachycardia, two signs of heart arrhythmia, ie abnormal heart beat. Alcohol can also lead to a heart condition called alcoholic cardiomyopathy, which is when the heart muscle weakens and cannot pump enough blood to the organs. This can result in organ damage or heart failure.

Cognitive dysfunction: Alcohol use can lead to brain damage, which shows up first as a reduction in cognitive functioning and problems with memory. Alcohol use often leads to Thiamine (B1) deficiency, which leads to significant brain damage. Alcohol also destroys the   hippocampus, the part of your brain involving memory and reasoning.  You get confusion, memory loss, and muscle coordination problems. You also interfere with the body’s ability to repair and build new nerve cells, called neurogenesis; it is much less effective. So without a sober brain, without a clear memory, and without thinking clearly, you will put yourself in very dangerous situations that may end with you dying. Or maybe you have so much confusion and memory loss that you take the wrong dose of medication or the wrong medication completely? Or you have such impairment that you drive and cause an accident or drive and get lost. It happens every day. I had a long time patient named Rona. She was a severe alcoholic; I don’t even remember how many times she went to detox and/ or treatment. She tried to quit drinking so hard and so many times. Back then, my office was in West Palm. One day she had an appointment with me, and I could tell she had been drinking, but she didn’t seem wasted. I told her for the eighteenth million time that she had to quit drinking, and Rona dutifully replied that she knew. I made sure that she hadn’t driven to the office and she said she would be taking the bus home, so I let her go. The next day I got a visit from two sheriff’s detectives, and they told me that  Rona was dead, and did I think that she had been suicidal. I told them she had not been suicidal and explained my assessment and protocol for suicidal patients asked how she had died. They said that she was downtown and walked out into the street and right in front of a car. Her whole left side and head were destroyed by the hood of the car, and she was Trauma Hawk’d to the trauma center. Unfortunately, she had massive internal injuries and severe head trauma and she died about 3 hours later. Rona’s story is an example of the kind of trauma that happens when people drink. I had another patient, a 36 year old man named Jennings, that had very poor coordination from drinking, but he didn’t think so. Jennings had this false illusion that he was as capable as everyone else, if not more so, and when he drank he thought he was invincible. His wife had divorced him about a year earlier so he lived alone. He either did really well for himself or had family money. I always suspected a combination of the two. One Saturday afternoon, he was sitting on his porch, drinking of course, looking at his boat at the end of the dock. While continuing to drink, he apparently got the bright idea that he wanted to take the boat out. He went and got it down from the lift and into the water, and then stepped from the dock into the boat to crank the engine. Then he got out and walked inside to get a cooler together, and he stepped again from the dock to the boat to load it in. He then evidently got out of the boat to get something else, and once he got it, he was stepping from the dock into the boat for the third time. But then his run of luck ran out. That third time, he didn’t quite make that step from the dock into the boat, and he slipped, hit his head on the side of the boat, and slipped unconscious into the water, where he drowned. It was a sad end to his life. 

Gastrointestinal problems: Alcoholism can cause acid reflux and excess acid in the stomach, which can lead to gastritis. It also causes irritation and inflammation of the stomach lining, which can cause painful ulcers and internal bleeding. Alcohol hampers blood clotting, so the loss of blood from these can be extreme, leading to anemia and causing extreme fatigue, or worse. Excessive drinking can also lead to stomach pain that may indicate chronic cholecystitis, a very serious gallbladder condition. 

Liver disease: Alcohol is incredibly toxic to the liver. The problem with liver disease is that the signs of it may not be detected until later stages, such as when cirrhosis occurs. At that point, the eyes will appear yellow, along with other signs of jaundice. Also, one loses their appetite so there will be sudden weight loss, as well as intense itching, weakness, and fatigue, and easy bruising. Cirrhosis of the liver, which often begins as fatty liver disease, is ultimately fatal, unless a liver transplant is successful. But before you die of cirrhosis, you are prone to die of fun things like esophogeal varices. These varices are abnormally dilated veins that develop beneath the lining of the esophagus as a result of the pressure from cirrhosis. The more severe the liver disease, the more likely esophageal varices are to bleed, and alcohol further thins the lining of the esophagus, which contributes to variceal growth, but also makes the varices more likely to bleed. And to top it off, alcohol thins the blood by wrecking clotting factors. So what does that mean? Ruptured varices. Which means all of a sudden, with no warning, blood gushes deep in the throat from all directions, choking you as you breathe it in and cough it up and eventually, you die. It is a painful, bloody, and terrible death, I promise. I have had many patients with very sick livers over the years succumb to esophageal varices. 

Pancreatitis: Alcohol causes severe pancreas issues and pancreatitis. The pancreas controls blood sugar by producing natural insulin. Alcohol interrupts this process, so the pancreas doesn’t secrete the insulin. Without the pancreas secreting insulin, your blood sugar sky rockets and you get diabetic ketoacidosis. This means that you have sugar in your blood, but you cannot get it into your cells without the insulin, and that leads to a host of metabolic issues and could easily end in you dead. 

Cancer: Excessive alcohol causes inflammation of the tissues, and this inflammation predisposes you to cancer. Types of cancer associated with heavy alcohol consumption include oral, throat, esophageal and voice box cancers, colon cancer, rectal cancer, pancreatic cancer, liver cancer, and breast cancer. The symptoms that may indicate cancer vary depending on the type of cancer, but symptoms generally begin with weight loss, fatigue, and pain in some area in the body. 

Absorbtion Syndromes: Alcohol also causes absorption syndromes. A big one is B12. Alcohol prevents you from absorbing B12 in your small intestines, and that leads to all sorts of muscular, brain, and central nervous system issues, causing confusion, memory problems, and eventually death. Alcohol also prevents you from absorbing folate. Folate is a neuroprotectant, so lacking folate causes memory issues. There are also anemias associated with lacking folate. 

Poor/ Lacking Sleep: Alcohol causes sleep disturbances. It causes snoring and sleep apnea, so you don’t sleep well and have inadequate sleep. And guess what? People who do not sleep have a shortened life span and a much higher incidence of accidental death. I had a patient named Richard. I don’t know if I would label him as an alcoholic, but he did drink at night and was a heavier weekend drinker. He had a really good job driving heavy machinery on construction sites. One day, there was an accident on the site. Richard had actually fallen asleep and he somehow hit a guy working on site. The injured guy was actually a friend of Richard’s. He was injured with a compound tibial fracture and was going to be fine after surgery, but Richard was sick about it. As a matter of course, the company tested Richard and found no drugs or alcohol in his system. After he told me about it, he admitted that he had fallen asleep on the job and that’s how the accident had happened. I asked him how he slept and he said he thought okay, but je was always tired during the day. I explained how drinking can interrupt sleep and the consequences of that and that I had the cure. He was excited until I told him the cure was to quit drinking. I told him that this time, he’d “only” hurt a friend and co-worker, that next time it might be worse. He said he’d think about it and left. Three days later, he was back, asking me to detox him. Hallelujah! That was almost three years ago, and Richard is doing well. He managed to keep his job and his friendship, and he’s a much happier guy, proud to look in the mirror again. So not sleeping can kill you, or maime you…or someone you care about.

Infections: Alcohol suppresses your immune system, which predisposes you to infections. These may be viral or bacterial infections. Both can kill you, especially if you’re in a physically weakened state from excessive alcohol consumption.

In addition to physical effects and consequences of alcoholism, life-altering impairment can be caused in many other ways as well. There are psychosocial issues, and these include legal problems due to DUIs, loss of a job, divorce, custody battles, and financial problems. There are so many signs…physical, mental, and psychosocial…that alcohol is devastating a person’s life. Make no mistake- the most devastating way alcohol affects lives is to end lives. If you drink, be aware and beware…it happens in far more ways than you could ever imagine. 

For more information and stories about alcohol use and abuse, please check out my book, Tales from the Couch, available on Amazon.com.

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Attention-Deficit/Hyperactive Disorder : Signs, Symptoms, and Treatments

Attention-Deficit/Hyperactivity Disorder: Signs, Symptoms, and Treatments

ADHD is a disorder that makes it difficult for a person to pay attention and control impulsive behaviors. They may also be restless and seem to be active constantly. Contrary to some beliefs, ADHD is not just a childhood disorder. While the symptoms of ADHD often begin in childhood, ADHD can continue through adolescence and into adulthood. While hyperactivity generally improves as a child ages, other problems with inattention, disorganization, and poor impulse control often continue through the teen years and into adulthood.

Causes of ADHD

Current research suggests that ADHD may be caused by a combination of genetic and non-genetic factors. These factors include genetics, cigarette smoking, alcohol, or drug use during pregnancy, exposure to environmental toxins at a young age (ex: lead), low birth weight, and brain injuries.

Warning Signs of ADHD
People with ADHD typically have a pattern of three different types of symptoms:

1. Difficulty paying attention (ie inattention) 
2. Being overactive (ie hyperactivity)
3. Acting without thinking (ie impulsivity)

These symptoms get in the way of development and functioning. The way these three symptoms are manifested varies by person. 

Problems with paying attention (ie inattention) may manifest in:

– Overlooking or missing details, making careless mistakes on schoolwork, work projects, or during other activities
– Having problems sustaining attention during tasks or while playing, including conversations, lectures, or lengthy reading
– Seeming to not listen when spoken to directly
– Failure to follow through on instructions, failure to finish schoolwork, chores, or duties in the workplace, or starting tasks but quickly losing focus and getting easily sidetracked
– Having problems organizing tasks and activities, such as doing tasks in sequence, keeping materials and belongings in order, keeping work organized, managing time, and meeting deadlines
– Avoiding tasks that require sustained mental effort, such as schoolwork or homework, or for teens and older adults, preparing reports, completing forms, or reviewing lengthy papers
– Losing things necessary for tasks or activities, such as school supplies, pencils, books, tools, wallets, keys, paperwork, eyeglasses, and cell phones
– Becoming easily distracted by unrelated thoughts or stimuli
– Being forgetful in daily activities, such as chores, errands, returning calls, and keeping appointments

Problems being overactive (ie hyperactivity) and acting without thinking (ie impulsivity) manifest in:

– Fidgeting and squirming while seated
– Getting up and moving around in situations when staying seated is expected, such as in the classroom or in the office
– Running or dashing around or climbing in situations where it is inappropriate; or, in teens and adults, often feeling restless
– Being unable to play or engage in hobbies quietly
– Being constantly in motion or “on the go,” or acting as if “driven by a motor”
– Talking nonstop
– Blurting out an answer before a question has been completed, finishing other people’s sentences, or speaking without waiting for a turn in conversation
– Interrupting or intruding on others during conversations, games, or activities

Showing these signs and symptoms does not necessarily mean a person has ADHD. Many other problems, like anxiety, depression, and certain types of learning disabilities, can have similar symptoms.

Treating ADHD
Although there is no cure for ADHD, there are some treatments that may help to reduce symptoms and improve functioning. Today, ADHD is commonly treated with medication, education or training, therapy, or a combination of these treatments.

Medication for ADHD

Many people with ADHD find that medications reduce their negative symptoms of hyperactivity and impulsivity while helping to improve their ability to focus, work, and learn. 

There are many different types and brands of ADHD medications, and all have potential benefits and side effects. Sometimes several different medications or dosages must be tried before finding the one that works well for an individual person. Anyone taking medication(s) for ADHD must be monitored closely and carefully by their prescribing doctor.

Stimulants: The first line treatment for ADHD is the stimulant class of medications, and stimulants are the most common type of medication prescribed for ADHD. While it may seem unusual to treat someone that has a hyperactivity disorder with a stimulant, they have shown great efficacy in boosting concentration and reducing impulsivity and hyperactivity. The stimulant class of medication includes widely used drugs such as Ritalin, Adderall, and Dexedrine. Researchers believe that stimulants are effective because they increase the brain chemical dopamine, which plays an essential role in thinking and attention.

Non-Stimulants: These medications take longer than stimulants to start working, but they can also improve focus, attention, and impulsivity in a person with ADHD. A non-stimulant may be prescribed if a person had negative side effects from  a stimulant, if a stimulant was not effective, or if the combination of a non-stimulant with a stimulant increases effectiveness. Two examples of non-stimulant medications include atomoxetine and guanfacine.

Antidepressants: Although antidepressants are not approved by the U.S. Food and Drug Administration specifically for the treatment of ADHD, antidepressants are sometimes used to treat adults with ADHD. Older antidepressants are sometimes used because they affect brain chemicals dopamine and norepinephrine, just as stimulants do.

Therapy for ADHD: There are different types of therapy that have been tried for ADHD, but research shows that therapy alone may not be effective in treating ADHD symptoms. However, adding therapy to an ADHD medication treatment plan may help patients and families better cope with the daily challenges posed by ADHD.

Help for children and teens with ADHD: Parents and teachers can help children and teens with ADHD to stay organized and follow directions with tools such as keeping a routine and a daily schedule, organizing everyday items, using homework and notebook organizers, and giving praise or rewards when rules are followed.

Help for adults with ADHD: A licensed mental health provider or therapist can help an adult with ADHD learn how to organize his or her life with tools such as keeping routines and breaking down large tasks into smaller, more manageable tasks.

Children and adults with ADHD need guidance and understanding from their parents, families, and teachers to set goals for success and reach their full potential. Mental health professionals can educate the parents and family of a child or adult with ADHD about the condition and how it affects them. They can also help them develop new skills, attitudes, and ways of relating to each other.

If you are concerned about whether you or your child might have ADHD, the first step is to talk with a healthcare professional to find out if the symptoms fit the diagnosis. The diagnosis of ADHD can be made by a mental health professional, like a psychiatrist or clinical psychologist, primary care provider, or pediatrician.

For more on ADHD and other similar diagnoses, check out my book, Tales from the Couch, available on Amazon.com.

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