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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24/7 news Is Stressing Us Out

THIS JUST IN!

24/7 NEWS CAUSES ANXIETY! 

READ ALL ABOUT IT!

I remember when I was a kid, my family used to eat dinner after the news. The news used to be thirty minutes. People tuned in and heard about the church bake sale, the plumbing problem being fixed at the elementary school, road closings, and the weather for the next day, and then they moved on with their lives. In this modern age, we are instead constantly inundated with information. We are bombarded with news, 24/7 – 365. News from CNN, ABC, NBC, CBS, MSNBC, FOX, CNBC, Facebook, Twitter, Instagram, on and on. Even when you go to your email inbox it’s in your face. And it’s mainly negative. Why is this? Because negative gets a reaction. Positive news does not get a lot of attention, but negative news does. People react to it, so the news organizations push negative news. They sensationalize the negative, make it bigger, more fearful, more imposing. Until it raises the hairs at the backs of our necks. News that offends, insults, and shocks our sensabilities…that’s sensationalism.  This kind of news- sensationalism- lures viewers. This sensationalism sells. That equals ratings, which then equals advertisers. It’s a big circle. And you, the watchers, the viewers, you’re the target smack dab at the center of that circle. 

Today, when you turn on the news, you hear about more gun violence, another act of terrorism, a missing child, or a scary health epidemic, and it seems as if the world is getting smaller, but growing ever more frightening at the same time. I’m hearing more and more people tell me they’re finding it harder to feel calm in their day-to-day lives. They feel beleaguered by the never-ending cycle of bad news, and this changes them, changes how they feel about life; these changes range from having a constant low level sense of uneasiness all the way to having full-blown anxiety disorders. The persistent sense of worry is joy-robbing at the very least, and debilitating at worst. This news cycle-related anxiety has become particularly obvious in the 21st century, a time that has been packed with global events that live and breathe on the news cycle, the internet, and social media. 

There have been studies on who is at risk for negative impacts from the news cycle. These show that women are more at risk, because they are better than men at remembering negative news for longer periods, and they also have more persistent physiological reactions to the stress caused by such news. The news makes many women feel personally devalued, unseen, unheard, and unsafe, resulting in them having a sense of dread and mistrust about the future. Age is also a big factor: millennials are the age group most upset by the news cycle, with 3 in 5 millennials saying that they want to stay informed, but that following the news causes them undue stress. That’s compared with 1 in 3 older adults saying the same. But these older adults are more apt to deal with this issue by avoiding the news, with 2 in 5 adults reporting that they have taken steps over the past year to reduce their news consumption in response to the stress and anxiety caused by it. 

Our highly connected culture can exacerbate these feelings of anxiety. The internet and social media add to the illusion that the whole world is right outside your door, ready to get you. It used to be that danger from man-made or natural disasters seemed far away. In some cases, you never heard about it in the first place. Today, we have headlines in the 24-hour news cycle that detail the most horrendous crimes and tragedies, from those that touch a few individuals to those that affect thousands. The saying goes “there’s nothing new under the sun” but in fact, now in the last week of February 2020, there is a new thing under the sun: ‘coronavirus anxiety.’ It’s now a real thing in the psych world. The response to the coronavirus illustrates a point about response to the constant news cycle and the fear it breeds. In the last week of February 2020, the global coronavirus outbreak dominated headlines as it entered the political debate and sent stock markets tumbling. In response, Americans did what they always do when confronted with something new and scary: they hit the internet search bar…and the bar bar, and not necessarily in that order. Aside from “coronavirus,” among the most popular topics searched over the past week was “Lysol,” “dog coronavirus,” and “social isolation.” 

Don’t misunderstand me, some anxiety is a good thing. Low levels of it enables awareness and proactive problem-solving. It motivates you to take sensible steps to protect yourself and your loved ones. News serves to inform us about things that are important to us, and at times to warn us about possible health dangers and empower us to avoid them. But too much news and some types of news content, especially when sensationalized, may lead to worry and anxiety. And when anxiety becomes more than a constructive concern, that’s when we need to slow down, when things need to change. So what can you do if what seems like a constant cycle of negative news throughout every media outlet is getting you down and interfering with your well-being? There are some measures you can take to control how much the news negativity affects your everyday routine and outlook. I have ten suggestions below. 

1. When the news is first reported- there has been a bombing, there has been a shooting, war has been declared, there is a new coronavirus outbreak- turn it off, blow it off immediately. This may seem counter intuitive, but initial news, the first news to be reported, is notoriously inaccurate. Numbers are over-inflated. So wait until the news is organized, fully formulated, until they have multiple sources and they can accurately assess the situation. You’ll typically find that, no, it was not 500 people killed, it was 50. It was not 50 people shot, it was 15 people wounded. So just take a step back. When you hear breaking news, put it down, wait, and look at it in a few hours or the next morning, when the news organizations have multiple accurate reports.  

2. Look for good news. Bad news comes your way free and easy, while you have to look for good news. So look for good news. Dig for it. If you look for positive things, you will find them. The whole world isn’t all bad, there are good things happening, positive things. Look for positive things things that interest you, on social media, on YouTube, on television, on the internet. Literally put ‘positive news’ in the search bar and read what you find. 

3. Don’t leave a news channel on all day long, TV or radio, even if it is just for background noise. Some is bound to permeate your brain. Limit the amount of news you watch each day: 20 to 30 minutes a day is enough. You don’t need to be getting news all day long. Be strategic about news exposure. Maybe check the most recent headlines first thing in the morning and then disconnect for the rest of the day. It may be tempting to read every update of a breaking news story throughout the day, but your mind has a way of thinking that the longer a story goes on, the more you are actually involved in the event, even though it may not even directly affect you. And you don’t need to be checking texts, Facebook, Twitter, YouTube, etc multiple times each day either.  

4. I recommend not getting your news from Facebook, Twitter, Instagram, etc because what they say doesn’t have to be true, and what you see will often be a raw emotional response to something that they just saw, which may or may not even be accurate. Get your news from newspapers, either online or in actual print format. News in newspapers, the printed word, tends to be more accurate. The information has been digested and scrutinized by multiple people, so it is a little more fair and presents a more well-rounded perspective.  

5. Prioritize your sleep. Worry often interrupts sleep, and sleep deprivation increases worry. Short-circuit the vicious cycle by avoiding your television, iPad, laptop, and cell phone for at least an hour before bedtime. That means no more late-night scrolling through Instagram or Facebook, where you might find reminders of heavy topics. Pick a before-bed pastime that doesn’t involve a screen, like reading a book. Get your news dose in the morning or maybe a little bit when you first come home from work. Do not do it before bed, because you will not sleep. Murder, treachery, and deceit make for bad bedtime stories.

6. If you find that social media affects you negatively in any way, delete it. Facebook, Twitter, Pinterest, you really don’t need it, especially if it causes you stress or anxiety. Contrary to popular belief, you can live without it…likely better than you can with it. So just delete it.

7. Give yourself a minimum of two hours per day where you are cut off from text messaging, emails, posting, TV, and radio. Spend that time doing something body-positive, like exercise. Physical activity reduces stress and anxiety in the moment and long-term. Practice mindfulness while you exercise by tuning in to your breathing and the physical movement your body is experiencing. This way you’ll have a conscious train of thought that doesn’t involve worry. Or distract yourself some other way. You can preoccupy your brain with relaxing activities: take a warm bath, listen to music, or meditate. If these low-key methods don’t block out the anxiety, try something more engaging, like playing a card game, or catching up with a friend. Whatever you choose, the idea is to give your mind a break.

8. Do not catastrophize, meaning thinking that because one thing is wrong, the whole world is falling apart. Just because there is a terrible stabbing of a little girl in another state does not mean that everyone is unsafe. If there is a shooting in a church in Georgia, that does not mean that all churches are unsafe. Just because there is a strike by the NY City subway workers does not mean that all subway systems across the country are falling apart. Just because there is a viral outbreak in one country does not mean that the whole world is unsafe and that we should shut ourselves in our homes.   

9. Stop querying fear. When fear first strikes, ask yourself once, “What can I do to solve this problem?” If you have an answer, make a plan and implement that plan as best you can. But if you can’t think of a plan or solution that is logical and realistic, then move on. If you continue to worry and rack your brain, resist those thoughts. Distract yourself. See my #7 above. Eventually, the questions will lose their power, and your mind will stop asking them. 

10. Practice eternal optimism. When you start the day in a positive way, the rest of the day will fall in line. And continuing to go about your life with some degree of positivity and optimism is an important cue to your family and friends, reinforcing the message that you- and they- are okay.

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Mental Health Benefits of Dogs

Mental Health Benefits of Pets

The bond between humans and animals is a powerful one, so much so that there have been numerous books written and movies made centering on the relationships between them. Dogs were the first animals domesticated and kept as pets, as much as 45,000 years ago.Regardless of when pet ownership got started, our long attachment to these animals is still going strong. Americans own some 78 million dogs, 85 million cats, 14 million birds, 12 million small mammals, and 9 million reptiles, according to pet industry statistics. 

Studies have scientifically explored the benefits of the human-animal bond, and a positive correlation between pets and mental health is undeniable. According to a recent poll, 95% of pet owners consider their pet a member of the family. Children, adolescents, adults, and seniors all find joy in their pets, so it follows that pets and mental health go hand in hand.

Pets provide companionship, ease loneliness, bring us joy, and give us unconditional love. They also help decrease depression, anxiety, and stress. While the word “pet” usually conjers up thoughts of dogs and cats, a pet doesn’t necessarily have to be a dog or a cat. Even watching fish in an aquarium has been shown to reduce muscle tension and lower pulse rate. A pet can be a horse, parrot, turtle, rabbit, skunk, lizard, chicken, snake…whatever you love and take care of.

Pets have evolved to become acutely attuned to humans. Dogs, for example, are about as intelligent as a two-year-old human child. Some more doggie fun facts: They are able to understand about 150 human words and most are even capable of following a count of five. They understand spatial relationships and are able to use them to navigate obstacles quickly. Although they can’t see the same color spectrum we can, they can see black, white, blue, and yellow; they can’t see red and green- those just look gray to them. A dog’s smell is like 10 million times better than yours. Dogs can sense if you’re going to have a seizure, they know if your blood sugar is low, and some say they can even sniff out cancer. While they understand many of our words, dogs are even better at interpreting our tone of voice, body language, and gestures. And like any good human friend, a loyal dog will look into your eyes to gauge your emotional state and try to understand what you’re thinking and feeling (and to use their special psychic powers to get you to give them treats and throw their ball, of course). I think dogs have psychic powers. My dog Beluga used to use her psychic powers to get me to do stuff all the time.  

Pets, especially dogs and cats, can reduce stress, anxiety, and depression, ease loneliness, encourage exercise and playfulness, and even improve cardiovascular health. Caring for an animal can help children grow up feeling more secure and being more active. Pets also provide good companionship for older adults. Perhaps most importantly, a pet can add real joy and unconditional love to your life.

Early researchers had discovered physical evidence of the mental health benefits of having pets. They found that pets could fulfill the human need for touch, so when hugging or stroking a pet, the human subject’s blood pressure went down, their heart rate slowed, their breathing became more regular, and their muscle tension relaxed. All of these physical changes are signs of reduced stress, which is indicative of a positive psychological impact. 

Since then, scientists have learned much more about the connection between pets and mental health. As a result, animal-assisted therapy programs have become an important part of mental health treatment. But, by owning a pet, you can experience pet therapy benefits every day in your own home. Below are several ways in which pets support good mental health and how pets are beneficial to people with mental health issues.

Interacting with Pets Lowers Stress and Decreases Anxiety:

Just the sensory act of stroking a pet lowers blood pressure, which reduces stress. Petting and playing with animals also reduces levels of the stress hormone cortisol while stimulating endorphin production and release of the happy hormones serotonin and dopamine, which calm and relax the nervous system. It also increases the production of oxytocin, another chemical that naturally reduces stress. Having the companionship of an animal can offer comfort, help ease anxiety, and build self-confidence for people anxious about going out into the world.

Pets Make Us Feel Needed:

The act of caretaking has mental health benefits. Caring for another living thing gives us a sense of purpose and meaning, so people feel more needed and wanted when they have a pet to care for. This is true even when the pets don’t interact very much with their caregivers. In a very interesting 2016 study about pets and mental health, elderly people were given five crickets in a cage to care for. Researchers monitored their mood over eight weeks and compared them to a control group that was not caring for crickets or other pets. They found that participants that were given the crickets became less depressed after eight weeks than those in the control group, so researchers concluded that caring for living creatures produced the mental health benefits they saw. Simply put, doing things for the good of others reduces depression and loneliness.

Pets Increase Well-Being:

Pet owners lives are enriched and generally better in several areas. They have better self-esteem, they are more physically fit, they are less lonely, they are more conscientious and less preoccupied, they are more extroverted, and they are less fearful. Put simply, pet owners are happier, healthier, and better adjusted than non-owners.

Pets Provide Companionship:

Companionship can help prevent illness and even add years to your life, while isolation and loneliness can trigger symptoms of depression. Caring for a live animal can help you shift your focus away from your problems, especially if you live alone. Most dog and cat owners talk to their pets, and some even use them as a sounding board to work through their troubles. And nothing beats loneliness like coming home to a wagging tail or a purring cat.

Cats and Dogs Are Great Examples:  Because pets live in the moment- not worrying about what happened yesterday or what might happen tomorrow- they can help you appreciate life’s simple joys and help you to be more mindful. Mindfulness is a psychological technique, the process of bringing one’s attention to the present moment. This can help distract you from what might be bothering you and help remind you to try to be more carefree and playful. In people diagnosed with mental illnesses like depression, schizophrenia, bipolar disorder, or post-traumatic stress disorder, pets can be among the most supportive connections they have. They provide a unique form of validation through unconditional support, which they may not have in other relationships.   Patients report that pets help them manage their illness, navigate everyday life, and give them a strong sense of identity, self-worth, and meaning. Caring for a pet gave owners a feeling of being in control as well as a sense of security and routine. Most said that their pets helped them manage their emotions and distract them from their symptoms like hearing voices, habitual rumination, and even suicidal thoughts, because they felt needed by their pet.

Pets Help Us Build Healthy Habits:
Pets need to be taken care of every day, and as a result, they help us build healthy habits and routines and add structure to the day. Many pets, especially dogs, require a regular feeding and exercise schedule. Having a consistent routine keeps an animal balanced and calm, and it’s good for people too. No matter your mood, one plaintive look from your pet and you’ll have to get out of bed to care for them. Caring for a pet can help you adopt healthy lifestyle changes, which play an important role in easing symptoms of depression, anxiety, stress, bipolar disorder, and PTSD. Some examples of these healthy lifestyle changes include:
Physical activity: Dog owners need to take their pets for walks, runs, and/ or hikes regularly, and owners receive the benefits of that exercise. Studies show that dog owners are more likely to meet recommended daily exercise requirements.
Time in nature: Walking a dog or riding a horse gets us outside, so we experience the many mental health benefits of being outdoors.
Getting up in the morning: Dogs and cats need to be fed on a regular schedule. As a result, pet owners need to get up and take care of them, no matter what mood they are in. So in this way, pets give people a reason to get up and start the day.
Pet care leads to self-care: Caring for a dog, horse, or cat reminds us that we must take care of ourselves as well.

Pets Support Social Connection: Pets can be a great social lubricant for their owners, helping to start and maintain new friendships. Pets are able to counteract social isolation and promote social connection by relieving social anxiety, because they provide a common topic to talk about. For example, walking a dog or playing in a dog park often leads to conversations with other dog owners. As a result, dog owners tend to be more socially connected and less isolated. This improves the owners’ mental health, because people who have more social relationships and friendships tend to be mentally healthier. The benefits of having social connections include better self-esteem, lower rates of anxiety and depression, a happier, more optimistic outlook, stronger emotional regulation skills, improved cognitive functioning, and having more empathy and feelings of trust toward others.

Pets Give Us Unconditional Love:
This one is best of all! Dogs and cats and pets of all kinds love their owners no matter what. That’s unconditional love. Pets don’t care how your presentation went, how you did on a test, or if you sold a house. Pets don’t judge you based on what you look like, if you are popular, or if you’re super athletic. They’re simply happy to see you, and they want to spend time with you, no matter what! This kind of unconditional love is good for mental health. It stimulates the brain to release dopamine, the chemical involved in sensing pleasure.

To summarize, the link between pets and mental health is clear. So if you don’t have a pet, think about getting one. For a dog or cat, go to a shelter or humane society and adopt somebody, take them home and make them a member of the family. Or maybe talk to a doctor about finding an emotional support animal. Either way, it’ll do you good and you’ll feel good for it. 

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How Cocaine kills You

How Cocaine Kills

Cocaine is a potent, illegal stimulant that affects the body’s central nervous system. It is extracted from the green leaves of the coca plant, and people in South and Central America have chewed these leaves and used them in teas medicinally and as a mild stimulant for thousands of years. But somewhere along the line, these people learned that this humble leaf could be processed in a way that extracted and concentrated its active components to create a substance called cocaine, a white powder stimulant that is anything but mild. 

Cocaine goes by a lot of different slang terms and street names, mostly based on its appearance, effects, or drug culture: C, blow, coke, base, flake, nose candy, and snow are some examples. At the peak of its use here in the 1970’s and 1980’s, cocaine began to influence many aspects of American culture. Glamorized in songs, movies, and throughout the disco music culture, cocaine became a very popular recreational drug. It seemed everyone was using it, from celebrities to college students to suburban moms looking to turn up at the disco on Saturday night. It was so popular in the disco scene that people openly snorted it on the dance floor at Studio 54. But powder cocaine would soon take a back seat to its trashy cousin from the wrong side of the tracks: crack cocaine, or crack. Crack is an off-white crystalline rock made by cooking down powder cocaine with God knows what else for bulk, and the crack rock is then smoked in a pipe. This form of cocaine created a scourge of epidemic proportions and ruled the streets throughout the 1980’s and early 1990’s. Crack is whack and crack was king then, and it’s still around today. It’s actually named for the cracking sound the crack rock makes when it’s smoked. While it’s the same drug as powder cocaine and has the same effects, smoking crack gives a more immediate high than snorting powder cocaine. But it doesn’t last long, so to stay high, crack users have to “hit” the pipe over and over, constantly, 24/7, for hours and ultimately days on end. Crack also has street names: rock, gravel, sleet, and nuggets to name a few. And combined drugs also have street terms, like speedballs, which are a mixture of cocaine with heroin or other opiate. Every illegal drug and drug combination you can imagine has a list of street names…Cocoa Puffs, Bolivian Marching Powder, Devil’s Dandruff…Every time I think I’ve heard them all, a patient uses one that’s new to me.

So, what’s the attraction? What does cocaine do for you? Captain Obvious says… it gets you high. Cocaine creates a strong sense of exhilaration. You feel invincible, carefree, alert, and euphoric, and have seemingly endless energy. It makes you more sensitive to light, sound, and touch. It makes you feel confident, competent, and increases performance and output. For intense Type A individuals, cocaine is a requirement, on par with oxygen. These individuals want maximum performance, maximum fun, maximum sales…maximum everything. Period. And cocaine delivers. It works by increasing the  feel good neurotransmitters dopamine, serotonin, and norepinephrine by blocking their reuptake. No reuptake equals more feel good neurotransmitters equals more feeling good. To be candid, when just starting to use, and in small amounts, people can actually do fairly well using cocaine. They feel great and are more productive, and that’s how smart people get involved with it. At first, it seems there’s no down side, it’s up up up….on top of the world. But as they say, what goes up must come down. Whether you snort, smoke, shoot, or suck on it, using cocaine is a very sharp double-edged sword. I’ve seen people go six, eight months, using every day, and for a short time, for all appearances it works for them; they feel great, they’re focused, performing well. But then without warning, they’re not. They crash, their performance sinks into the abyss. They go into an impaired state, a mental fog, and their neurotransmitters betray them. They become paranoid, confused, disorganized, hopeless, and lost. 

Using cocaine even once can lead to addiction. As with many drugs, the more you use it, the more your body gets used to it, and that creates the need for a larger dose and/or using the drug more often in order to get the same effect. Cocaine is a potent chemical, and both the short-term and long-term effects of using are dangerous to physical and mental health. Riddle me this: how many old crack addicts are out there? I can tell you, not too many. Why? Because they’re all dead of heart attack, stroke, arrhythmia, respiratory failure, seizures, and sudden death. Whether you use cocaine once, use on occasion, or you’re a habitual user, the risk of seizure, stroke, cardiac arrest, respiratory failure, and even sudden death, is equal. Equal. No matter how little you use or how rarely you use. And the first time you use can also be your last chance.

So exactly how can you kill yourself with cocaine? Let us count the ways….cocaine’s potency and molecular makeup causes serious physiological consequences. No matter what form you use it in, it increases your blood pressure, increases your heart rate (aka your pulse), and it constricts the arteries that supply blood to your heart, all at the same time. So now, you’re asking the heart to pump faster and harder (because it has to pump against your increased blood pressure), and without as much blood flow (and therefore not as much oxygen and energy) as it was getting before the cocaine was in your system, and tah-dah! What can you get? Arrhythmias. Simply put, that’s when your heart can’t keep good time, it beats erratically and sporadically. Without conversion, you have a heart attack. Your heart basically stops beating and you die. And just remember, as you get older, your body is not as resilient. You may or may not have a lethal heart attack at 20, but you sure will at 50. How else can you kill yourself with cocaine? Using can cause you to go into a state where you’re unable to control your temperature, so it gets very high, you get restless, have tremors, dilated pupils, nausea, vomiting, complete disorientation, and mental confusion. If the fever gets too high, you can have seizures, which can lead to death. It happens every day. You also have to take into account potential accidents resulting just from being high, without your normal faculties, and being unable to take care of yourself. Freak accidents while high can be deadly. Remember too that cocaine is cut with crazy stuff- ground glass can cause internal bleeding, and diuretics and laxatives can cause electrolyte imbalance, both of which can kill you. And these days, cocaine is often cut with fentanyl- an opiate 50 times more powerful than pure heroin- which causes hundreds of overdose deaths each day. If you freebase cocaine or smoke crack, the chemicals used to cut it can cause sudden acute respiratory failure where you stop breathing and die, or they can damage the lungs over time and cause respiratory failure and the same result- death. If you use IV (intravenous needle injection) and share needles, you expose yourself to all sorts of potentially lethal infections, including Hepatitis, HIV and AIDS. If you choose to suck on crack, the chemicals used to cut it may be caustic and potentially damage the throat and/ or stomach and cause bleeding, or they may cause intestinal death and decay; these can potentially lead to death. 

So in the beginning of your cocaine career, you’ll feel great- super powerful, confident and competent. High. But shortly into your cocaine career, you’ll find that the magic is gone. The genie is out of the bottle. The high just isn’t the same, no matter how much you use or how you use it. So you chase that high…and you’ll chase it for the rest of your life, but to no avail. The high is replaced with the craving for the high. I’ve never seen a drug with cravings as powerful as cocaine. They’re just unbearable cravings, and they can last indefinitely. I’ve seen many, many cases where they last for years. I see patients now who have had these horrendous cravings for years, and I expect they’ll have them for the rest of their lives. They were lured in by the shiny bauble that is cocaine, and cocaine showed them a great time. Then cocaine turned on them, closed the door and threw the bolt, leaving them to want/need/crave what they had, likely forever. It’s just not worth it. I treat addictions of all kinds: heroin, alcohol, marijuana, benzodiazepines, you name it. For the most part, people with these addictions comply with treatment and come to their follow-up appointments. But cocaine addicts are a different story. They’ll come to my office once, all committed to stopping the cocaine, but you never see them again. They vanish…poof! They don’t do well in treatment, because the cravings are so strong that they can’t resist, so they take off and use again. The cocaine cravings are bar none the strongest I’ve ever seen. Now, the withdrawal from cocaine isn’t bad at all. It’s not like an alcohol withdrawal or withdrawing from Xanax or heroin. Those are gnarly, even potentially dangerous. With cocaine withdrawal, you can get depressed, you sleep a lot, you get vivid dreams, you want to eat a lot, you can’t think super clearly for let’s say three to seven days, but there is no real treatment needed for it, just comfort measures- keep the person cool, keep them hydrated, keep them fed, and allow them to rest- and they’ll bounce back. Now, one thing that sure does come up is that, because the cravings for cocaine are so intense, as soon as they’ve slept and ate and they’re back on their feet, it’s sayonara sucka! They bolt. They’re out again, they’re using, they’re smoking, they’re shooting, they’re shoving it up their nose, they’re putting it in their mouth, wherever and however they can use it. If they had a decent time period of not using, they may get that first super awesome high; but then they’ll inevitably spend the rest of the binge chasing that high, but they won’t find it.   

Now, you might ask how intelligent, successful, type A people get involved with cocaine when they know it will lead to their eventual mental and physical collapse and  possible death? Because these people know that in the short term it will increase their work performance, their ability to think, their social acumen, and their confidence. I always ask my patients what price they’re willing to pay for this temporary condition. Most don’t have an answer. I think that’s because they think nothing bad will come of their using, but I know different because I’ve seen different.

A true story from when I worked in the emergency department at Roosevelt Hospital: there was some sort of summer festival in Central Park, and evidently a guy locked himself in a portajohn so he could smoke crack. It’s summer, there’s no ventilation in the portajohn, and crack causes an increase in body temperature, so this guy had to be hot. But he was also high, so he was confused as to where he was and how to get out. People reported hearing him freaking out in the portajohn, kicking the walls and pounding on the door, but they couldn’t get past the locked door and he couldn’t follow their instructions to unlock the door and open it. So he was all worked up on top of being overheated, so his muscles heated his body up even more. Eventually, NYFD came and got him out of the portajohn, and he was brought to the ER, where I saw him. He was very hot and very dehydrated and very high. I started cool IV fluids and ordered an alcohol bath, but the damage was done. In short order, he developed something called rhabdomyolysis, where the muscles begin wasting away and all the muscle fibers enter the blood stream and shut the kidneys down. Despite our best efforts, he died. The family was very upset. They knew he was smoking crack, but couldn’t stop them. Every attempt to put him in treatment ended with him running away to use. And he was no slouch, no crack bum; he was a regional manager for Ace Hardware, in charge of like 20 stores. And he wound up basically killing himself in a portajohn. What a waste.

When I think about the stereotypical Type A individual doing cocaine to excel in the workplace, I think of a  Wall Street broker. I had a patient, a broker who worked on the Exchange floor. This guy was 40 when he first came to me, said he was on the fast track, that he wasn’t going to make $700,000K a year for much longer. He said he had to be sharp, had to be quick at all times and at all hours, no complacency, so he’d been using cocaine. I warned him about the potential dangers of piling cocaine on top of such a high stress job, but no matter what I said, he wouldn’t give it up. His motto was “Damn the torpedoes- full speed ahead!” He was getting away with using. Six months, seven, gaining on eight, he worked constantly, but he was the man, top trader, taking home fat 6-figure bonuses. After just over eight months on the cocaine, the piper insisted on his payment. He had a heart attack at 41, and when the ER doctor took his history, he readily admitted to using cocaine for eight months. With further questioning, he also reported having periods of confusion over the previous six months. His solution was to use more cocaine in an attempt to regain the sharpness it had once brought him in the beginning, but it didn’t work. What the cocaine did do was really keep him up at night. His solution for this was to drink four martinis every night in order to come down and get some sleep. He was doing this every day of the week for about seven months: cocaine throughout the day and martinis in the night. The cardiologist ordered a whole bunch of tests and it soon became clear that the heart attack that sent him to the ER was not his first. And unfortunately it wouldn’t be his last. His heart muscle was quite damaged from the ups and downs of the cocaine and alcohol fueled roller coaster he had boarded months before. I suspect that he never totally got off that ride, despite having another three heart attacks. Each one was progressively worse and made more obvious his mental and physical decline. At the age of 43, a massive fourth heart attack punctuated his life with a period. The man that burned the candle at both ends had burned himself out. 

No tales of caution would be complete without mentioning the models and the housewives. They like cocaine because it helps them lose weight and stay thin. And because the cocaine stimulates them, they like to take Xanax and drink alcohol at night to come down. I can spot the cocaine/alcohol/Xanax Barbies at 50 yards, because they actually turn gray. I’m serious- their skin turns gray and they get too thin. The whole program makes them look like victims of concentration camps. And they wind up forgetting normal daily activities- forgetting to pick the kids up, forgetting when dinnertime is, forgetting how to do the homework with the kids, forgetting how to accomplish simple banking transactions- everything gets screwed up. In my career, I have lost count how many husbands have sincerely asked me if I think that their cocaine/alcohol/Xanax Barbie wives are: A. Going crazy, B. Exhibiting symptoms of early onset Alzheimer’s disease or dementia, or C. Showing signs of having a brain tumor.

I’ll tell you this one last quick story about a patient I saw a few days ago. Her name is Julia, and she is a 33-year-old out, loud and proud lesbian. She’s very intelligent, a paralegal, and lives with her girlfriend of several years, Paola. She was introduced to cocaine after coming out and getting involved in the lesbian scene at age 21. She used cocaine daily- and in increasing amounts- for ten years, because she said it stimulated her libido and helped her reach orgasm. She stopped using cocaine when she had a heart attack at age 31. Unfortunately, the heart muscle was significantly damaged, and now she is unable to tolerate even mild exertion, such as that which happens during sex. So…the cocaine she used for ten years to increase her libido and help her reach orgasm has caused her current inability to have passionate sex with her girlfriend. How’s that for cruel irony? 

Cocaine is relentless and seductive…initially it can feel amazing, a ladder that lets you climb to the top of the world. Then cocaine is vicious, it sinks its hooks into you, which very few people manage to completely free themselves from. The perceived benefits aren’t worth the cost, which, as with some of my former patients, can be your life. It’s simply not worth it. I hope you get the take home message of all the many ways that cocaine can kill you, and that you understand how smart people find themselves tangled up in using cocaine, but also how even smarter people manage to stop using cocaine. 

For more details and stories about addictive drugs like cocaine, check out my book, Tales from the Couch, available in my office and on Amazon.com.

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Obesity:What Causes it and How to Combat it

We’re nearly six weeks into the new year, and this is right about the time that most people toss their new year’s resolutions out the window. Many of them had resolved to lose weight: surveys have shown that, of the people who make new year’s resolutions, an average of 45% of them resolve to lose weight and get in better shape. So that means that nearly half of resolution-makers are overweight at least. That number seems high, but given that obesity has reached epidemic status, I guess it’s not that surprising. 

Obesity is broadly defined as the state of being well above one’s normal weight. Obesity often results from taking in more calories than are burned by exercise and normal daily activities, aka ‘eating too much and moving too little.’ A person has traditionally been considered to be obese if they are more than 20% over their ideal weight. That ideal weight must take into account the person’s height, age, sex, and build. Obesity has been more precisely defined by the National Institutes of Health (NIH) by utilizing a person’s BMI, body mass index. The BMI is a key index for relating body weight to height, and it is formulaic. The imperial BMI formula is weight (in pounds) multiplied by 703, then divided by height (in inches²). If you don’t feel like dealing with the math, you can google a BMI calculator. Having a BMI of 30 and above is considered obesity. Over 70 million adults (35 million men and 35 million women) in the U.S. are obese, while 99 million (45 million women and 54 million men) are overweight and at risk for becoming obese.

What are the causes of obesity? Obesity can be complex, going beyond eating too much and moving too little. Following are some other factors that cause or contribute to obesity.   

Genetics

Obesity has a strong genetic component. Genetic predisposition means that children of obese parents are much more likely to become obese than are children of lean parents. Genetics also affect the rate at which the body uses energy (burns calories) when at rest, which is called the basal metabolic rate. People with higher basal metabolic rates naturally burn more calories than other people, so they are less likely to gain weight. The opposite is also true: people with lower basal metabolic rates burn fewer calories, so they are more likely to gain weight. But these facts don’t mean that obesity is completely predetermined, that there’s no way to change it. What you eat can have a major effect on which genes are expressed and which are not. This is demonstrated when people of non-industrialized societies come to the U.S., begin a western diet, and then rapidly become obese. Obviously, their genes didn’t change, but their diet did; that changed the signals they sent to their genes, which then changed the expression of the genes. Changing the expression of the genes resulted in obesity. The bottom line is that genetics do play a key role in determining susceptibility to gaining weight and obesity, but that is only one factor of many; it is not all genetically predetermined. 

Diet: What and How You Eat

Obviously, eating an unhealthy diet is a major contributing factor in obesity. Overeating at meals and snacking throughout the day can also lead to obesity. An unhealthy diet would be high in complex carbohydrates, bad fats, and sugar, and low in fresh fruits, vegetables, and high protein lean meats. There are social factors that affect diet and therefore weight. If you spend a lot of time with overweight friends and family who eat too much of an unhealthy diet, the odds are that you’ll be overweight as well. Economic factors also play a role in obesity. If you can only afford cheap, ready-made packaged foods or fast foods from the dollar menu, you are much more likely to be obese. Economics may force you to eat a diet high in complex carbs like pastas, breads, potatoes and rice just to fill yourself up, because that is all you can afford. That type of diet greatly increases the risk of obesity. Unfortunately, eating unhealthy foods and overeating are easy in our culture today. Many things influence eating behavior, including time with family and friends, the low cost of unhealthy but filling foods, and the access to and expense of healthy foods.  

Lifestyle

If you have a lifestyle that centers on eating and/ or drinking, this can contribute to excess weight. A chef, bartender, or baker, something that requires tasting various dishes and trying new recipes for example. Also, someone who travels a lot for their job so always eats at restaurants, which are notorious for hidden calories and fat; they are more likely to be overweight and at risk for obesity. A sedentary lifestyle, where there is little to no activity or exercise is a huge contributing factor in being overweight or obese. Our modern conveniences- elevators, cars, remote controls- have cut activity out of our lives. The problem is that the less you move, the less active you are, the more likely you are to be obese. Being active helps you stay fit. And when you’re fit, you burn more calories, even when you’re resting, so you’re less likely to be overweight or at risk for obesity. 

Medical Conditions

There are a host of medical issues that can cause or contribute to significant weight gain. Some examples are hypothyroidism, diabetes, Cushing syndrome, polycystic ovarian syndrome (PCOS), menopause, depression, and endocrine dysfunction. Some medical issues don’t cause weight gain in and of themselves, but make weight gain more likely because they limit the person’s activity. Some examples would include conditions like osteoarthritis, uncontrolled rheumatoid arthritis, and chronic pain syndromes.

Medications

The list of medications that can cause weight gain is a long one. Everyday medications like corticosteroids (Prednisone, Celestone), diphenhydramine (Benadryl), hormone replacements/ birth control, and even insulin are among the culprits. Sometimes it’s not the drug itself causing weight gain, it’s a side-effect from the drug. Some drugs stimulate your appetite, and as a result, you eat more. Others may affect how your body absorbs and stores glucose, which can lead to fat deposits in your body. Some cause calories to be burned more slowly by altering your body’s metabolism. Others cause shortness of breath and fatigue, making it difficult to exercise, while some drugs cause you to retain water, which adds weight but not necessarily fat. Some medications don’t cause you to gain weight outright, they just make it more difficult to lose excess weight you may already carry. A lot of psychiatric medicines cause weight gain. The worst offenders generally include mirtazapine (Remeron), paroxetine (Paxil), risperidone (Risperdal), aripiprazole (Abilify), and quetiapine (Seroquel). With the exception of Wellbutrin, essentially all classes of psychiatric meds can be associated with serious weight gain. As a psychiatrist, I have to prescribe meds that may cause an unwanted side effect like weight gain. I have to weigh the cost to benefit with each patient. Unfortunately, I have patients who are trapped; they must take certain medicines to remain stable, so they have to severely alter their food intake and diet every day of their lives in an effort to avoid weight gain if possible. That’s the cost to benefit ratio- they pay the cost of a severe diet in order to get the benefit of being stable psychologically.   

Why should you care about your weight? What health issues does being overweight cause? The answer is many. Obesity leads to type 2 diabetes. It causes high blood pressure, which can cause strokes. Obesity can increase cholesterol levels and cause coronary artery disease, which is where deposits line the blood vessels that feed the heart and partially or totally block them, so the heart does not get adequate blood supply; this results in a heart attack, aka a “coronary” and this can easily be fatal. Being overweight puts excess weight on the human body, and this commonly causes osteoarthritis of major joints like the knees, the hips, and the ankles. All parts of the body are stressed and strained because they are not designed to carry around that much weight, and this limits the range of motion, mobility, and ability to walk. Obesity increases the risk of cancer to several organs and body parts: the breast, colon, gallbladder, pancreas, kidney, prostate, uterus, cervix, endometrium, and ovaries.  Another common medical issue from being overweight is sleep apnea. All the weight on the chest and throat causes you to temporarily stop breathing when sleeping, until you finally noisily gasp for air. Sleep apnea is serious, and very disturbing for anyone that you share your bed with. Obesity causes a fatty liver, which then leads to liver disease and the potential to cause the liver to shut down. Obesity can cause gallstones as well as kidney disease, which can cause your kidneys to stop functioning. Obesity can also cause fertility problems in both men and women. As a psychiatrist, I get obese patients referred to me because obesity can directly cause, or indirectly lead to, various syndromes and other issues, including chronic pain syndromes, depression syndromes, isolation syndromes, social problems, self esteem issues, and difficulty dating. People who develop obesity, especially when it is the result of something beyond their control, like from a medical issue such as hypothyroidism, have all sorts of social interaction issues and work problems, and I can treat them and help walk them through it with psychotherapy. 

We defined obesity, discussed the risk factors and what can cause it, and then the issues it can cause. Now let’s discuss how we can lose weight and prevent obesity.  

Food Diary

To offset weight gain or to help work off excess weight, consider keeping a food diary tracking what you eat and when you eat. Becoming a mindful and aware eater is a great first step to managing weight. 

Eat Slowly

Another factor which helps with weight loss is eating slowly. It takes some time for your stomach to tell your brain that you’ve had enough to eat. If you mindlessly shovel huge amounts of food into your mouth, you’ll miss your cue and overeat, and that obvi will cause you to put on weight and increase the risk of obesity. Eating slowly also has the added benefit of reducing the chances of having indigestion. 

Get Physical

Become more active whenever possible. Instead of meeting someone for coffee or a movie, meet them at a park, beach, or green space and go for a walk. Ideally, you want aerobic activity; that means getting your heart rate up, when it’s harder to breathe. Aerobic activities mean constant motion, like running, biking, swimming, soccer, basketball, anything where you’re moving constantly. Constant activity is aerobic activity, and daily aerobic activity will raise your basal metabolic rate and you’ll burn more calories, even when you’re at rest.  

Resist It

Resistance training is good for targeting fatty areas on the body. Resistance training involves moving a specific muscle against resistance, either using your own body weight or using standard weights. Other activities like lifting weights, doing push-ups, and doing squats are good for reducing body fat. 

READ LABELS! 

…and make sure you understand them. If you don’t understand them, do some research, get a library book on nutrition, ask a friend if they understand, or ask your doctor what the values all mean and how much of the various components should be included in a healthy balanced diet or when dieting in an effort to lose weight. Pay close attention to calorie count, fat grams, protein grams, sugar grams, and carbohydrate count. Just because something says “light” doesn’t mean it should be included in your diet. So many people are ignorant about nutrition information on food packaging. Be sure to know what those values mean and how much you should have of each every day.

Know the Fats

Trans fats- Bad fats!

Historically, trans fats are an evil on par with Satan himself, to be avoided at all costs. The worst type of dietary fat, trans fat is a byproduct of the industrial process of hydrogenation, which turns healthy oils into solids to prevent them from becoming rancid. Eating foods rich in trans fats increases the amount of harmful LDL cholesterol in the bloodstream while reducing the amount of beneficial HDL cholesterol. Trans fats create inflammation, which is linked to heart disease, stroke, diabetes, and other chronic conditions. They contribute to insulin resistance, which increases the risk of developing type 2 diabetes. Even small amounts of trans fats can harm health: for every 2% of calories from trans fat consumed daily, the risk of heart disease rises by 23%. Mind blowing. Though they have no known health benefits, trans fats were found in most pre-packaged garbage foods and were the main component in margarine type spreads. I say ‘were’ because recent science found there is no safe level of consumption of trans fats, and as a result, trans fats have been officially banned in the United States and several other countries.

Monounsaturated fat- Good fats!
Evidence has shown that consuming monounsaturated fats has several health benefits, including reducing general inflammation in the body. Studies have also shown that a high intake of monounsaturated fats can reduce triglycerides, decrease the risk of heart disease, and lower bad LDL blood cholesterol while increasing good HDL cholesterol. A diet with moderate-to-high amounts of monounsaturated fats can also help with weight loss, as long as you aren’t eating more calories than you’re burning. These fats are liquid at room temperature. Good sources of monounsaturated fat include avocados, almonds, cashews, peanuts, cooking oils made from plants or seeds like canola, olive, peanut, soybean, rice bran, sesame, and high oleic safflower and sunflower oils.

Polyunsaturated fat- Good fats! 

The two types of polyunsaturated fats (omega-3 and omega-6) are essential fats, meaning they’re required for normal bodily functions, but your body can’t make them, so you must get them from food. 

Omega-3 fats are a type of polyunsaturated fat that, like other dietary polyunsaturated fats, can help to reduce your risk of heart disease. Omega-3s can lower heart rate and improve heart rhythm, decrease the risk of clotting, lower triglycerides, reduce blood pressure, improve blood vessel function and delay the build-up of plaque in coronary arteries.

Omega-6 is a polyunsaturated fat that lowers bad LDL cholesterol. Eating foods with unsaturated fat, including omega-6, instead of foods high in saturated fats helps to get the right balance for your blood cholesterol (ie lower bad LDL and increase good HDL). Sources of polyunsaturated fats include oily fish (like salmon, mackerel, sardines), tahini (a sesame seed spread),
linseed (flaxseed) and chia seeds,
soybean, sunflower, safflower, and canola oil, margarine spreads made from those oils, pine nuts, walnuts, and Brazil nuts.

Follow these easy ideas for getting the balance of blood cholesterol (LDL and HDL) right.

– Go nuts! Nuts are an important part of a heart-healthy eating pattern. They’re a good source of healthier fats, and regular consumption of nuts is linked to lower levels of bad (LDL) and total blood cholesterol. So, include a handful (30g) every day! Add them to salads, yogurt, or your morning cereal. Choose unsalted, dry roasted or raw varieties.

– Go fish! Include fish or seafood in your family meals 2 – 3 times a week. Fish are great sources of the good omega-3 fats. If you don’t eat fish, you can take an omega-3 supplement.

– Use healthier oils! Choose a healthier oil for cooking. For salad dressings and low temperature cooking, choose olive, peanut, canola, safflower, sunflower, avocado or sesame oils. For high temperature cooking, especially frying, choose olive oil or high oleic canola oil, as they are more stable at high temperatures. Store oils away from direct light and heat and don’t ever re-use oils that have been heated before.

Eating polyunsaturated fats in place of saturated fats or highly refined carbohydrates reduces blood pressure, raises good HDL cholesterol, reduces harmful LDL cholesterol, lowers triglycerides, and may even help prevent lethal heart rhythms.

Saturated fat- OK in strict moderation

Saturated fats are common in the American diet, and they are solid at room temperature- think along the lines of cooled bacon grease. Common sources of saturated fat include red meat, whole milk and other whole-milk dairy foods, cheese, coconut oil, and many commercially prepared baked goods and other foods. A diet rich in saturated fats can drive up total cholesterol and tip the balance toward more harmful LDL cholesterol, which can prompt heart disease from blockages formed in arteries in the heart and elsewhere in the body. For that reason, most nutrition experts recommend limiting saturated fat to under 10% of calories a day. Replacing excess saturated fat with polyunsaturated fats like vegetable oils or high-fiber carbohydrates is the best bet for reducing the risk of heart disease. 

Diet Do’s

– Eat plenty of fiber. Fiber fights belly fat. When ingested, fiber goes into your system, binds to and then forms a sort of gel with the food, which slows down the absorption of food in the gut.  

– Eat a high-protein diet. Eggs are eggsellent…high in protein and low in fat. Avoid red meat. All meats should be lean and high in protein, like chicken or turkey. Nuts are also good for a protein snack.

– Eat fish, as often as 2-3 times per week for good omega-3’s. As discussed above, oily fish like salmon, mackerel, and sardines are high in omega-3’s which are good for the brain, help to decrease weight, and have numerous other health benefits. If you don’t eat fish, take a good omega-3 supplement.

– Drink green tea; there are reports that it helps with weight loss, and it’s generally just good for you.    

Diet Don’ts

– Don’t eat sugary foods or anything with sugar in it: sodas, candies, cakes, cookies, doughnuts; those are the main culprits. It’s a major bummer, but to avoid weight gain in your life, much less to try to lose weight if you’re already overweight, you must avoid sugar like the plague. Wah wah wah… 

– Cut out the carbs! To lose weight or just to avoid putting weight on, anything with white flour must go, so say syonara to pasta and most breads. You have to cut way down on starches, if you’re allowed them at all, so there goes rice and potatoes. And while most people consider corn a vegetable, you must count it as a starch when dieting. 

– Get on the wagon! If you drink alcohol, you won’t lose weight and keep it off. Won’t happen. When you consume booze of any sort- beer, wine, liquor- the alcohol is immediately converted to sugar, and if you’ve forgotten, see Diet Don’t 1 above. There’s no point in restricting calories, fats, etc by following a diet and also drinking alcohol at the same time, even a small amount.  

Go to Bed!

Sleep is critical if you want to lose weight, so aim to sleep at least 7-8 hours each night. If you do not get proper sleep, it will be very difficult (if not impossible) to lose weight, and you will likely gain weight. This is all thanks to brain chemistry and hormones, which get all fouled up with sleep deprivation. 

Stress Less!

You have to reduce stress if you want to lose weight. When you are stressed, your body produces the stress hormone cortisol, and cortisol increases appetite and increases belly fat by selectively placing fat deposits around the stomach and middle of the body.  

A Fast Fast

We’ve always been told that starving ourselves will not result in weight loss, and that it will even result in weight gain because the body goes into ‘starvation mode.’ Well, there are some recent studies out there that conclude that intermittent fasting, 24 hours without eating, once or twice a week, actually helps with weight loss. Very interesting. 

So that’s all about obesity: what causes it, what it causes, and how to combat it. We are a fat society, and the number of cases of obesity goes up every day. It’s disturbing because it’s essentially a preventable issue. 

For more information and interesting stories on other diagnoses, check out my book, Tales from the Couch, available in my office and on

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Electronics Are awesome! Right

Electronics are awesome! Right?

Home computers became available in the early to mid-80’s, but didn’t gain major popularity until about 1990. Home computers were mainly for word processing and games until the advent of the world wide web. Originally unleashed in 1989, the www was developed chiefly to facilitate the exchange of information among professionals on medical and scientific studies, technical blah blah blah and protocols for building nerdy thingamabobbers. All super tres importante stuff. It wasn’t long before the www came into its own, evolving to revolutionize life as 

we knew it in the dawn of the 90’s. And it hasn’t stopped evolving, it literally grows exponentially every minute of every day, 24/7-365. The obvious potential of the www sparked a sort of resurgence of the electronic age. Suddenly everyone wanted, no, needed a computer at home….desktop at first, then laptop once they got them to weigh less than 20 pounds and cost less than $9k. For a little while, the laptop was the most portable window to the www, but then around the mid-2000’s the first smart phones hit the market, followed by the first iPad in 2010, and now we even have watches to wear the www around our wrists. 

So roughly 30 years ago, our world changed, solidifying our entry into a realm where electronics rule. That means that people who are currently age 30 and under were raised in this electronic world. They had nearly limitless access to computers, video games, smart phones, iPads, on and on. When he was 13 years old, my son had an innate knowledge for all things electronic. If I didn’t know how to unlock this code or clear those cookies, I could hand the device to my kid and he would fix it with zero hesitation. I know I’m not the only one that’s experienced this slightly annoying/disturbing phenomena. The other day, my patient EmLea told me she hired her 15-year-old neighbor to hook up her new TV/DVR/Blu-Ray setup she had given herself for Christmas. He didn’t even look at a single word in any of the manuals. And to top that off, he knew what every button on the various remote controls meant and how to switch to the different components, etc. It took him way longer to teach EmLea that stuff than it took for him to unpack and set the TV and all the components up. Our children of the “www era” entertained themselves with computers, games, text messaging, emails, computer card games, social media like Instagram and Facebook, then YouTube and WhatsApp, on and on. They grew up on electronics and have zero fear that they might break something or permanently damage it if they pressed the wrong button the way that many of us “old folks” do. I can’t talk about the advent of the www and social media without mentioning dating apps. Talk about limitless! There are dating sites for every sexual proclivity, hookup sites like Tinder and Grindr, and social sites of all sorts. People spend unbelievable amounts of time on dating apps. They tell me about it and it blows me away. And kids have access to these sites, because parents don’t bother to block them. Then again, maybe they don’t know how to or even know it’s possible to do so. The kids have the upper hand here- they’re far more savvy than their parents, so they get quite the education from those dating and social sites, believe me.  

Speaking of education, the www really allowed people to start educating themselves independently. For someone of my, ahem, maturity level, it was incredible! I mean, when I was in college and I needed to research a topic for a paper, I went to something called a library, where there were infinite rows of shelves with books of all sorts. Technology of the day was microfiche! I can practically hear the millennials asking google or Alexa what that is at this moment. A little help: it’s pronounced micro-feesh. And once I gathered all the information I needed, I had to type my papers. Not type on a computer and print, but type on a typewriter or maybe a word processor, which back then didn’t refer to software- a word processor then was basically a high tech typewriter. Again the millennials are like, “huh?” I have to compare that to my son’s situation again- during his high school years, he was required to use a laptop in all of his classes. Every kid was, and everything had to be done on the school’s network- every project and assignment. A far cry from my day.  

But I have to say, the information available and the ease and speed of access on the www was and is almost incomprehensible. Unless it’s novel, something that a PhD candidate has studied for two years can be learned in very short order, minutes even. The www also allowed us to start finding old friends and then making new ones. It allows us to live in an alternate reality of our own creation, a place where we tune in and get likes and collect friends and build reputations and online brands. And if we come across something we don’t like, we just go someplace else, another screen, another site. Just consider this: a boy, born in 1990, growing up, all he knew was to come home from school, play videogames, hit up social media, surf the internet, kill some brain cells on YouTube, watch Netflix, shop Amazon Prime, install different apps, upload videos… why go out? Why interact with actual people when you can watch them? Same diff, right? 

Today, the socialization, the entertainment, and the information all come to you. Everything is immediate gratification. Everything is online. There is no frustration. The minute you don’t like something, you move, you uninstall, you block, you end notifications, you unfollow, you flip an electronic switch and whatever you don’t like goes away. So naturally, what happens is that you only follow what you like. That’s human nature. The world is your oyster. You create a world where online, everything is just what you like. You never have to deal with people, people who have different opinions, people who you don’t like, people who have negative things to say. You create your own world…the world according to you. That’s all you see. Everything else fades to black, ceases to exist.

It sounds great, right? You have this world where all the information you could ever need is at your fingertips. You can talk to anyone you want in the whole wide world. You can buy anything that’s for sale…and even some things that aren’t. You can collect friends that are of like mind.You can get dates when you want to. When you think about it, it’s awesome, in the strictest definition of the word, deserving of awe. The www is arguably mankind’s greatest feat to date, maybe even greater than the dawn of civilization. It’s changed us in many ways, and for the better. Huge advances in medicine, technology, science, you name it are owed to the www and what it facilitates. It has brought people together and allowed the exchange of ideas and information to and from everywhere on the planet, and it has advanced our society. 

What could ever be wrong with this? It sounds great, right? Well, as with many things, if you scratch the surface, if you look harder, go deeper, there are problems created by the www, human problems. First, it’s not real. The electronic world on the www is not reality. I’m sure some of you are like ‘duh Dr. Agresti’ but I see people in my office every day who forget that. Sane people for whom the line between real reality and the electronic world they created has blurred. When you talk to someone online, you’re not talking to someone who is sitting in front of you. It is not a human interaction- it is an electronic one, a string of 1’s and 0’s. You can’t trust it. For all you know, it could be a bot or some form of artificial intelligence. This will be the issue of the not-distant future. As it is, we humans have to prove our human condition to a computer so it will allow us to log on to secure sites these days, typing in those crazy sideways upside down wierd scrawled letter/number codes. So who’s controlling who? 

Depending on the communication medium, there is some element of reality in that it could be another person, but you don’t know who that person really is. Catfishing runs rampant online, a 22-year-old woman is often an 80-year-old man. Without meeting in person, you can’t know who you’re “talking” to, so you can’t trust. And if you can’t trust, you have to have walls up, and you can’t have a true connection through those walls. On social media you can have a thousand friends, but when life goes sideways, when you need someone, you’ll likely find there’s no one you can really talk to. And meeting real people in real life during a lifetime mostly spent in an electronic world and zoning out to your own alternate reality can be problematic. You lack the social skills, you lack the speech skills, you lack the emotional skills, and you lack the ability to tolerate frustration because these aren’t necessary in the electronic world. When you do manage to meet new people, you lack the social creativity to know how to interact, how to hold your body, how to use voice inflection, and how to read body language- these skills are missing. And in the real world, as you come across random people, you are bound to find opinions that differ from yours. This will cause anxiety, frustration, and even anger, because all of a sudden, you can’t log off, uninstall, block or unfriend…it’s in your face and you have to deal with it. I call this the “frustration phenomenon,” and this occurs frequently and consistently when people who choose to live in an electronic world of their own creation are forced to dip their toes in the deep end of the real world.

Because I mostly treat people under age 30, when I’m out and about, I find that I pay attention to what people of this age group are up to. When I notice something interesting, sometimes I’ll even approach them, introduce myself, and ask them about it. I was recently at lunch with some of my office staff and we were chatting about this and that. Next to us was a table of four mid-twenty-somethings. Even though they were less than five feet away for the best part of an hour, I couldn’t have picked a single one of them out of a lineup. Why? Because their faces were all buried in their phones. The table was silent, save for the light clickity click sound of typing. Aside from placing their orders, they didn’t speak at all. I had to know more. With my staff rolling their eyes, I cleared my throat, introduced myself as a psychiatrist and asked them why they didn’t speak to each other. They all kind of looked at each other and back at me and gingerly set their phones down, as if asked to do so by a parent. Obligatory. Some mumblings of ‘I don’t know’s’ and shrugged shoulders followed. One brave one said they just always took lunchtime to catch up on social and check comments and see what friends were up to. I went around the table and asked each how long they spent doing anything online in a given 24 hour period. Their answers shocked me: 14, 13, 11 and 12. But even more on weekends. They laughed when I commented about it being a full time job. But I wasn’t kidding. 

Another offshoot of the frustration phenomenon occurs in these age-30-and-unders. Because they surround themselves only with music, things, and opinions they like, they have little to no tolerance for anything else. I call it the “other annoyance.” I noticed this while talking to a patient named Stu. He always wore earbuds, even in appointments. When I asked him about it, he said that he had to have them because when he had to be out in public, his music helped him drown everything out. He said he found other music, other people and their voices, and even random everyday noise to be annoying, so he avoided it all whenever possible. Stu was so immersed in a virtual world he created and filled only with things he liked that he had no tolerance for anything outside of that. Anything ‘other than’ was annoyance, and I presume that my presence and voice was included. Another issue with the generation raised on an electronics diet is that they never learned how to entertain themselves. Every time that there’s nothing to do, whenever boredom rears its head, they look to the electronic devices to entertain rather than trying a new activity or trying to meet new people. So social skills suffer further, and the disconnect from the real world becomes wider. There is detachment from the real world. Everything is the same in the electronic world, no matter where in the world you might be. The scenery remains unchanged.

Because this is a new problem, we have to learn to view and solve it in a novel way. As I see it so often, I have some suggestions for parents. When raising a child, the majority of their day must be totally electronic device free. This time should be spent interacting and talking with parents, siblings, and friends. Some time should also be spent doing something independently but device free- coloring, reading, playing with pets, etc. There must be strict limits on how much time is spent on electronics, whether that’s TV, iPad, phone, or games. We’re now realizing the true impact of electronics and how critical this issue is during a child’s developmental years. I’m convinced that the human brain will not develop appropriately if we don’t have significant ‘off time.’ And I’m concerned that we humans are beginning to evolve around electronics rather than the other way around. Even adults must have large blocks of time off electronics. Addiction is a real problem. This is illustrated by the fact that we now even have detox protocols and treatment centers for electronic addiction. 

Don’t quote me on it, but I think we’re headed towards a society where we actually have electronic implants in our brain. Think about it.  They could put an electronic device in your brain, some circuitry or device where you could access the www by utilizing the chip in your brain. I think it’s coming. And I think there will come a day in the future where we may have to wonder if we’re dealing with or “talking” to a robotic device or a real person. Ultimately, I think we’ll use the power and the resources of the electronic world to our best advantage, but we just can’t be caught off guard. Through the wonder of the www, the electronic world has evolved so quickly and has become such a dominant part of our lives, but now we’re learning that we need to exercise some restraint with it. The moral of the story? We can’t be dependent on the electronic world if we also want to control it. 

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Your Brain On The Holidays

Your Brain on the Holidays

Your brain is always busy, but it feels busier during the holidays, and rightly so. There’s a lot for it to think about during the holiday season: what to buy, for whom, and how much to spend, how to make time to visit family as well as friends, how to dodge certain co-workers at the office Christmas party, and hopefully how to squeeze in holiday naps in between eating some good home cooking. Because holiday time tends to pile on the stress, researchers are fascinated with the subject of what is happening in our brains while we’re trading time wrapping presents and plastering on a smile to spread genuine holiday cheer. 

Researchers believe that not only does the brain actually change over the holidays, but that they even know what culprit is: nostalgia. Essentially, nostalgia is that bittersweet feeling of love for what is gone, and the longing we feel to return to the past. The holidays lead to a special feeling of nostalgia that is unlike any other. Reminiscing with family, watching old holiday movies, eating favorite dishes, smelling the familiar smell of your grandparent’s house, and maybe even sleeping in your childhood bed….the holidays are a heady mix that induce nostalgia on steroids. But even more than this, therapists actually say that we should basically “expect to regress” during the holiday season. Who doesn’t want to be a kid again, to look forward to going home for the holidays? While “home” means different things to different people, I think even Ebenezer Scrooge can relate to the notion that when we celebrate the holidays with loved ones, something in us changes; it feels different. There is a child-like nostalgia, a forward-looking feeling of anticipation. Research suggests that’s because there are some serious changes in our brains during the holidays. Here are some examples of things that you might experience as a result of nostalgia:

1. You Want to Eat All of the Food

That’s pretty much what happens when you’re back in your mom’s or grandma’s kitchen, eating a meal with your siblings, is it not? You’re not just eating a meal, you’re living a memory, so you want it all! Eating a lot during the holidays is totally a real thing, and science says it’s largely because aromas trigger vivid memories, just like the smell of your grandparent’s house takes you right back to being seven years old. And socially, the same thing happens. Just because you and your siblings or cousins are grown-ups doesn’t mean you’ll act that way. Remember, if you’re regressing over the holidays, so are they. But just remember to be an adult and use your manners around the dinner table.

2. You Want to Drink All the Alcohol

There are many reasons that people drink more during the holidays. Studies have shown that the average American sees a 100% increase in their alcoholic drinking habits between Thanksgiving and New Year’s. Along with the holly jolly holidays comes an increase in social functions, holiday parties and dinners out, which inevitably leads to more alcohol consumption for most adults. Many of us look forward to celebrations during the holidays, but it’s amatuer hour when it comes to drinking… a time when some people who don’t normally drink actually drink far beyond their limits. Some of these people will suffer adverse consequences that range from fights and falls to traffic crashes and deaths. Sadly, people often put themselves and others at great risk just for an evening of celebratory drinking. So please, get a clue and get an uber. There is no reason to drive after drinking…remember: more than two means an uber for you!

3. You Want to Buy All of the Things

Holiday shopping, for most of us, feels pretty miserable. The music is loud, the mall is crowded, and you’re half way to the checkout before you realize you don’t actually know your uncle’s shirt size and you didn’t double check if your office Secret Santa recipient has any allergies. What’s worse? Apparently, shopping during the holiday season changes our brain, and even the most self-controlled shoppers can fall victim to marketing masters. That cheerful holiday music? Those festive colors? Those free samples around every corner? The bright cheery lights? Marketing. Allllll marketing. And, all pretty much intended to get you to relax, have a good time…and loosen that hold on your wallet and kiss that money goodbye. And not even any misteltoe!

4. Maybe You Don’t Want to Get Out of Bed

Not everyone enjoys the holidays. For some people, it can trigger serious battles with mental health, depression and anxiety. Between 4 and 20 percent of people experience a form of Seasonal Affective Disorder, otherwise known as SAD, which is a depression that generally sets in during early winter and fades by spring or early summer. Even people who are not diagnosed specifically with SAD may still experience depression and anxiety over the holidays. Why? Well, we postulate that people’s desire for perfection can become crippling during holiday time. People see more of each other and have more than the usual amount of time to compare themselves to others during the holiday season, in terms of what they can or cannot afford to spend on gifts or where they may travel for vacation. People often try to do too much and end up over-extending themselves. 

The holidays are meaningful to people for many different reasons. For some it is a religious holiday, for others a time to spend with family and friends, and even a time of sadness and loneliness for some. Whatever the holidays mean to you, you really need to make it a point to take good care of yourself during this busy season…it’s the best gift you can give yourself.  

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Is Marijuana For You

Given the legalization of marijuana in many states, I wanted to have an open discussion on the ramifications and repercussions of its legalization, and why choosing to use might not be the best choice for everyone.

Marijuana is so readily accepted everywhere now, in both legal and illegal states and in any and every social circle; regardless of its legal status, its use is suggested by so many people for everyone and everything under the sun…it’s a revolution that makes Woodstock look like a quilting circle. Grandmas and grandpas, CEO’s, lawyers, actors, the butcher, the baker, and the candlestick maker….everyone’s using marijuana, legal or not, and they’re not afraid to tell the world. And the marijuana of today ain’t yo mama’s marijuana…today many people prefer to smoke marijuana wax rather than the green herbacious stuff, because wax is a minimum of 90% pure THC, miles away from the 15% green stuff.

The legalization of marijuana has created a slippery slope. Now it’s basically off the radar for police, meaning that most officers will give a pass for possessing up to a certain amount of it, even in illegal states. The police officers have discretion in the field, and most just confiscate it and maybe write a fine ticket for it, or maybe not…it’s not worth the time or effort for them to fight it any further, even in illegal states. If they just wrote every possessor a fine ticket for marijuana possession, they’d be buried in tickets, so imagine the paperwork if they arrested them all. I watch a live police program on weekends, and the first question an officer asks the driver they’ve pulled over is if they have any weapons or drugs in the car. They then emphasize that “honesty goes a long way” when it comes to their decision-making process in drug possession. Sometimes they’ll employ a K-9 officer to find drugs, and I swear that at least 85% of the cars they pull over contain drugs of some sort. And most times (after the officer makes it clear that they can’t get in trouble for it) a driver will readily admit that they have smoked within the last hour or minutes before getting behind the wheel, or even just smoked while driving. This is apparently due to a general consensus that marijuana doesn’t cause impairment, which is debatable; more recent studies are suggesting otherwise.   

Because marijuana has essentially vacated its spot in the illegal drug hierarchy, the next “least worse” drugs, meaning cocaine and methamphetamine, have moved up, becoming “less illegal” in a way. Now officers even have some discretion when it comes to the possession of cocaine and meth; if the possessor only has a small amount, they may not necessarily go to jail. As hard as it is to believe, I have seen it on the live police program, people issued a ticket for possessing a small amount of coke or meth. The only difference is the type of ticket issued: while a marijuana ticket is just for a steep monetary fine, the ticket for coke or meth possession is essentially an order to appear before a judge, who then decides if the offender goes to jail or gets off with just a steep monetary fine and/ or probation, community service, etc. I wonder if lawmakers ever imagined that the legalization of marijuana in some states would lead to the near decriminalization of even minute amounts of drugs like coke and meth, but it seems it has. Similar to marijuana, I think it’s likely due to the amount of time and effort it takes to haul every coke and/ or meth possessor to jail: small amounts are permissible when weighed in the face of 100% rule of law…it’s certainly faster, easier, and more profitable to fine someone through the nose (no pun intended) than to house them in our overcrowded and expensive jails.  

Enough of the legal ramifications. Of course as a physician, I see the more personal, medical side of the legalization of marijuana. I am literally asked about it by patients every day, and I am a medical marijuana prescribing physician- I jumped through all of the state’s many hoops so that I can prescribe marijuana. I believe that used properly, marijuana has definite value as a drug. The key is for whom. I think it’s good for someone with cancer, with brain tumors, for AIDS, for neurologic disease like ALS (Amyotrophic Lateral Sclerosis), for Crohn’s disease, irritable bowel syndrome, for post-traumatic stress disorder, for specific types of chronic pain, and for certain seizure types. While I don’t prescribe marijuana willy-nilly, I definitely do prefer prescribing marijuana over other controlled drugs like opiates. But as I tell patients, just because it’s legal doesn’t mean it’s useful for everyone or even reasonable for everyone to use it. In fact, I think that for a subset of the population, up to age 30-ish, marijuana is counterproductive at best and damaging at worst. I call marijuana “the nothing drug.” If you give marijuana to a young developing mind, let’s say someone aged 14, the person belonging to that mind has their life course altered. From the day they start smoking marijuana, nothing happens. Their motivation drops off. They think a lot of good thoughts about what they can do or would like to do, but they do nothing. So nothing gets done. That’s what alters their life course. Dreams are great, but the key is to act on them. I tell my patients that when they use marijuana, nothing happens. Nothing bad, but nothing good. Nothing scary, but nothing awesome. Just nothing. Users do nothing, and if they continue to use habitually, they may amount to nothing. They may not fail, but they definitely will not excel. When you ask that marijuana-smoking 14-year-old what they’ve been up to, they’ll say ‘’nothing.’’ When you ask what they did in school that week, they’ll say ‘’nothing.’ When you ask them what they did over the weekend, they’ll say ‘’nothing.’ When you ask them what happened at the football game, they’ll say ‘’nothing.’’ When you ask them what they do when they get high, they’ll say ‘’nothing.’ Now you get the picture. Marijuana… The Nothing Drug. There’s a PSA campaign for ya’.

Using marijuana is mostly about being alone, being high, and being out of touch. You cause no problems. As a matter of fact, the last thing you want is conflict…it would harsh the mellow. My patients who smoke tell me that when they use it, they just want to keep using it, because it makes them feel so good. But there are qualities to marijuana that make people prone to isolation, where they don’t communicate with others as much. Think about it. When was the last time you went to a wild, raging party with people smoking only marijuana? Do you hear a lot of meeting and greeting, talking and laughing? Nope. But you do hear the sounds of lots of lighters striking and water bongs gurgling. And some muffled coughing- that wierd upper throat/ nasal cough that comes from people holding their breath and trying hard not to cough up the hit they just took. You may hear a woo-hoo or two, but that’ll come from the direction of the couch, which will be replete with reclining stoners. In my experience, people who smoke pot waste a lot of time doing so. It’s the kind of drug that can be used constantly, for hours and days on end, because there’s no concern of overdose. There’s a lot of time wasted, no pun intended, on thoughts not thought through and things left undone. When I warn patients about isolation, I often hear back from them that they do spend time with people, that in fact, they get high with people. I tell them that they may think they’re spending time with friends, getting high with their buddies, but that most of the time they’re getting high and playing video games or listlessly bobbing their heads to music and they just happen to all be in the same room. There’s no real interaction…it’s a very solitary pursuit, but in the presence of others, a mental masturbation marathon.

Obvi, I have many patients that complain that their lives aren’t going well, that they’re depressed and generally unhappy, and many of them smoke marijuana to “relax.” When I ask the marijuana users why they’re unhappy, they seem completely devoid of any insight as to what’s going on. I have a list of questions I ask, and it starts with “How much do you smoke?” I can probably count on one hand the number of people who tell me the truth, that they smoke a lot of marijuana; they always say they smoke “a little” marijuana. When I ask what form they use and how much “a little” is, some admit to using wax, and many tell me they use “only at night, never during the day” like that makes all the difference in the world, given that there are basically 12 hours of night in a 24 hour day.  

The best “medicine” I can dispense to these marijuana-using patients is education. I have given a version of the same talk at least a thousand times, tailored to the patient’s age and condition. It basically goes something like this: “You’re unhappy because marijuana alters you. It makes it so you’re just going through the motions of life; when you’re directed to do something, you can do it, but you never do anything of your own volition. You have no original thoughts or ideas or insight into your life, because you don’t bother to examine it. You don’t have any meaningful interactions with other people. You spend your time playing video games and eating junk food. You never see the sun, unless you have to venture out in daylight for a marijuana-related errand. You’re lacking a creative outlet, because marijuana isn’t conducive to creativity. Marijuana is robbing you of motivation, memory, ambition, desire, and energy. It blunts your emotions so that you feel nothing, so you smoke more to feel high because that’s better than feeling nothing. It’s a vicious cycle. You’re just like a rat on a wheel in a cage.” These facts are why marijuana is most damaging for people up to about age 30, because by this time at the latest they should be expending great effort trying to establish themselves and their lives, deciding where they want to go and setting goals to get there. Instead, they use marijuana and all that goes out the window. For an 80-year-old woman with cancer or rheumatoid arthritis, marijuana isn’t going to affect her life nearly as much as a 20-something-year-old looking for a job or deciding what career path they want to take.

As an example to show that using marijuana is not exclusively for the young, take my patient Frederick, who is 68 years old. He started smoked marijuana at ten and basically smoked all day, every day since. Consequently, he did nothing his whole life, so 58 years. That’s 58 years completely wasted, again no pun intended. Somehow he got on disability years ago. As far as I could tell, his only disability was that he wanted to smoke all day, that he liked to be high. I have another patient, a 23- year-old named Skylar. He’s basically a trust fund baby, living in his parents’ Palm Beach mansion full time while they spend 48 weeks of the year living up in Massachusetts. Skylar’s “job” as caretaker of the mansion, supposedly overseeing a staff of six, has always left him with more than ample time to do, well, nothing…except smoke wax. And he was a hard case, because he was able to afford the strongest wax and he smoked a lot of it- one of the handful that admitted to doing so. I saw him in my office a couple of months ago, and he told me he had wasted enough time using marijuana, he wanted off, and would I help him? Once I recovered from the shock and picked myself up off the floor, I of course told him that I’d be glad to, and I explained the deal. Most people think there’s no withdrawl from marijuana, but that’s not true. There is about a ten day withdrawl period that typically includes insomnia, restlessness, and irritability. It then takes six weeks for green marijuana to eight weeks for wax for all traces of THC to leave the body. I use medications like clonidine and trazodone to minimize the effects of withdrawal, and they make it much easier. At the two-week mark, the four-week mark, the six-week mark and the eight-week mark, patients are amazed at how they feel clearer and clearer at each point. They’re able to see how impaired marijuana was actually making them- they were totally unaware of their impairment at the time, how slow they were, how dopey and lazy. Once it’s completely out of their systems, they tell me how they’re more active, how they’re getting up in the morning and showering and getting dressed, how they’re going outside and exercising, and how things are happening in their lives. I’m happy to report that Skylar was no exception. His withdrawl from marijuana wax was uneventful, and after eight weeks, he was shocked at how different he felt, describing it as like being awake after years of being asleep. For the first time in recent memory, he was thinking, he was weighing his options (now that he had some) and he was planning his future. When I asked his greatest revelations, he said, “I have to make things happen. I have to be proactive. I have to look for and seize opportunities. No one can do that for me.” I really couldn’t have said it better than that. 

Re-reading this, I noticed that I said that marijuana is ‘robbing you’ of this and ‘taking away’ that, but really, marijuana doesn’t take things away from you, you give those things away when you choose to use. Marijuana has its place in treating certain illnesses and diseases; but remember that just because something is legal to use doesn’t make it reasonable to use it. If you’re faced with a choice to use, just think about Frederick, with 58 years wasted, no pun intended, and Skylar, who got a late start in adulting but has an unlimited future…now that he’s no longer letting marijuana limit his present.  

For lots more entertaining stories and information about marijuana and other drugs, check out my book, Tales from the Couch, available on Amazon.com. It makes for a great read and an ever better gift!

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Secrets For Surviving Panic Attacks

Well, it’s another Saturday. My avid blog readers might know what that means…I’m at the carwash again for my Inside-Out Wash and Hand Wax. And yes, I know I’m pretty particular about the state of my car, thank you very much, but in my professional opinion there’s no pathology there whatsoever. Anyway, I’m stuck for a minimum two hour sentence at this joint. It’s always the longest two hours of my life, and if I don’t find something to occupy my mind I might just lose it. I usuallly sit inside for the A/C, but the weather was beautiful, so I sat outside on what barely passed as a patio: two of those round concrete table jobbies with the rough curved benches encircling them, surrounded by tall but sparse hedges on three sides. I wasn’t the only one with the bright idea to sit outside- Floridians get very excited in November when the temperature dips below 75 for a second and the cooler breezes make it onshore- we flock to outdoor spaces like Aztecs worshipping the sun. I spied a concrete bench that was empty and sat down with my coffee from my fave place on US-1. There was a dude at my table on the bench across from me, and he didn’t so much as acknowledge my presence when I sat, so engrossed in his phone was he. Fine by me. As I surveyed my company, what struck me was that there were literally zero words being exchanged among the other waiters, even those that were clearly there together. It was like a freaking monestary- if the monestary was right next to a carwash with its particular “music” of Inside-Out Washes and Hand Waxes in the background. I don’t know why I still find the lack of communication, especially in the very most basic sense, to be so alarming, almost disturbing even. I know I’ve gotten into this in so many different blogs and videos, and of course in my book, but it seems like no one talks to anyone anymore. People talk more to Alexa and Siri these days than other people. Anyway, what were my fellow waiters doing while they weren’t talking? They were of course on their phones, just like everyone always is, always on freaking cell phones. I wasn’t the least bit shocked to see what looked like a ten-year-old girl buried in a phone. These days, young kids, I’m talking like age three and up, have phones to play games on, because moms can’t bear to give up their phones to allow the kids to play on them, and if the kids don’t have phones to play on, they’ll drive their moms crazy and make it impossible for the moms to be on their phones. So the obvious solution, nay, the only solution, is to get your four-year-old a phone. I wonder what Dr. Spock or Mr. Rogers or Bert and Ernie would say about the Romper Room set having phones, or even worse, needing phones. 

Anyway, as I sat on the hard and scratchy concrete bench on the “patio” surrounded by the sparse hedges, a woman entered the scene. She walked up and asked if anyone was sitting next to me, to which I said no. The way these benches are curved and situated, it makes it a little awkward to sit at one with a stranger, but she smiled and took a seat next to me. She looked about 40 or so, medium height and weight,  with jet black hair. I guessed she had more than a little Latin blood in her. She was not dressed Saturday casual like the rest of us waiters: she wore a nice black skirt suit with a bright pink blouse, and I assumed she was on her way to work. At where or doing what I had no clue, but realtor was at the top of my guess list. I noticed she wore no wedding ring, though that doesn’t really mean anything these days. She looked like a woman of means, and she was fairly attractive, but something was off. She looked kind of shocked for lack of a better term, like psyche shocked, and she nearly visibly vibrated, like she was plugged into a light socket. She was clearly very unsettled by something, or maybe several somethings, and it or they were simmering just below the surface. I could see she was accustomed to the valiant effort to keep them there, but they were clear as the day to me. Your average person on the street wouldn’t see any of this in her, but I’ve made my living watching and listening to people as they lay bare their pain and fear, and this woman had plenty of both. 

She said her name was Pilar, and that and her slight accent confirmed my previous guess that she was of Latin descent. I knew damn well that something was wrong with Pilar, something that I might be of help with, but also that I might not. My mental machinations continued. She could be in denial, and she could be offended if I offered an opinion. I mean, how many people want to be analyzed by a shrink they just met while waiting at the carwash? I decided that I would not open Pandora’s box. Not going there. I’m just going to sit here in the sun and be polite, but be surface. Mind my own business. Polite, surface. After a moment sitting at the little concrete table, she asked me how long the carwash takes. I dutifully explained that the Inside-Out Wash and Hand Wax took a bare minimum of two hours, especially on a Saturday morning, but that it was well worth the wait. At this, she blew her bangs out on a long resigned sigh. Then motioning to my cup, she asked where she could get good coffee. I gave her directions to my fave spot, which was just up the street on US-1 and told her to ask for “Bailey the Barista, the best barista in the Easta” I had given this name to a barista named Bailey at my fave place because she really is the best barista ever in the vast history of baristas. (ADD side note: what the hell did we call the people who made our coffee prior to the advent of Starbucks?) Pilar laughed and said she’d be back; right after she left, even the guy across from me stood up and said that with my glowing recommendation, he just had to go for a cup as well. How to win friends and influence people…with coffee…who knew, I mused. Maybe the next book? I filed that under ‘Later’ in the grey matter. 

I took Pilar’s absence as an opportunity to remind myself not to get involved, to not play the curious shrink role. No matter how bored to tears, how desperately in need of a distraction I became, I would be strong. I would not go there. Be polite, be surface. You may be wondering why I don’t just announce my profession and delve into stuff with people at every opportunity. First, that would mean I’d have to be ‘on’ and wearing my Dr. hat a lot when I’m at social events and such, when I’d really prefer to be chill. But it goes beyond that. Here’s the thing. Unless someone asks me straight up what I do, I don’t usually tell random people I’m a psychiatrist, because invariably I end up spending a lot of time listening to a story about someone’s Aunt Edna from Des Moines who has 53 cats and hasn’t left her home in 12 years because she’s purposely hoarded it with old newspapers, jars full of pee, and her old fossilized poopy diapers, all as an excuse to never leave, and do I think that maybe she’s depressed and can I give her a prescription for Prozac? There’s a lot of that kind of thing. Another issue that can happen is someone tells me their story, and in my opinion they may actually need help, but when I tell them they should seek that help, they get all pissed off at me. Plus, when I talk to people when I’m out and about, they don’t know that they should have no expectation of privacy because they aren’t patients and we aren’t in my office, and they may tell me some deeply private things, and it just gets messy for me that way. So, for those reasons, and a lot more, I don’t generally just announce that I’m a psychiatrist. But there is a flip side. It’s no secret that I hate to do nothing. I hate waiting for my car to have its Inside-Out Wash and Hand Wax because I have nothing to do while I wait. And remember: I hate doing nothing. So sometimes, like during my interminable wait for my car, when I’m bored out of my skull and climbing the walls, I might be less averse to telling people I’m a psychiatrist, because 100% of the time, it starts what might be an interesting conversation, one that might help pass the time until my car is ready. All I have to do is introduce myself and my profession, “Hi, I’m Dr. Mark Agresti, I’m a psychiatrist. What’s up?” and we’re off to the races. People spill their guts. Other times, I don’t use my last name or announce my profession, but I still engage in the conversation. So it’s kind of like the little cartoon with the angel on one shoulder and the devil on the other and do I dive in or mind my own business? It’s an internal tug-of-war I’m familiar with. Earlier, I had simply introduced myself to Pilar as Mark. In this case, I knew that Pilar was genuinely troubled, but if I told her that I was a psychiatrist, I wasn’t sure how she would take it; she seemed fragile to me. All the more reason for me to be polite but be surface. But on that flip side, I did have time to kill, and Pilar seemed very nice, and maybe I could help her just as another human rather than as a physician. So much for polite and surface. Maybe she wouldn’t even want to open up to me. But maybe she would. I had the feeling it could get deep on this carwash patio. Guess I’d find out. 

With time to kill, I decided to be like everyone else and get on my phone to check my Facebook, or Fakebook as I like to call it. They recently refused to boost one of my posted blogs. Interestingly, it was called “Carwash Psychiatrist” and was all about a different Saturday morning conversation with a steroid-raging mountain-sized man. Fakebook refused to boost it citing inappropriate content. I call total bs on that. I thought it was really informative and interesting, if I do say so myself. It’s on my website if anybody wants to read it and decide for themselves. I re-read it again as I sat there, and still I didn’t think it was inappropriate. I wished I could figure a way to get around Fakebook to boost it. As I considered that, Pilar returned and sat down next to me with her cup of coffee. Her expression was more open than it had been. I think she was more comfortable with me because now we had this coffee connection. Somehow, sitting next to each other drinking coffee together set a mood to talk, a vibe like we were old friends catching up. Glancing at my watch, I saw that I still had an hour until my car would be ready. More than enough time for a conversation, if one arose. I had given up the mental jujitsu match and decided to be polite and open. I could feel Pilar’s dis-ease, referring to her uneasiness, not illness, though she always kept it hidden…or tried to. She looked at her watch and sort of tisked the time, saying that she hoped her car would be done soon because she had to get to work. When I asked her what she did and if she usually worked weekends, she said that she designed and sold high end kitchen cabinetry, and that no, she didn’t normally work weekends, but she was behind because she’d missed a lot of days recently because she’d been sick. This was it. This was the turning point. I could be in or out. Polite and surface or open. I know something’s going on with her, maybe there’s something I can do to help her, so I go there, unable to resist the psychiatrist in me, but at this point still unwilling to tell her there was one. So I went there, I asked her the obvious question that her answer had begged: what was wrong?

She answered, “I thought I was dying.” Okay, I’m looking directly at this woman, and while she looks troubled, she is definitely not dying. I’ve seen dying. I know dying. I decided to take the light-side approach and gave a little non-committal laugh as I said she’d have to narrow that down with some details. She began, “A month ago, I had to go to the emergency room.” I expressed surprise and asked what happened to land her in the ER. She replied, “I woke up one morning and I had this tightness in my chest. I couldn’t breathe, and my heart was racing. I was sweating buckets, and I was so uneasy, like something awful was happening. I thought for sure I was having a heart attack. I had this sensation of pins and needles in my fingers. I didn’t know if I was losing my mind or really actually dying, because I felt like I didn’t know who I was or where I was…I felt like it wasn’t real. Crazy, right?” Before she had even finished her second sentence, I knew that Pilar was describing anxiety, maybe a panic attack, so I said, “Let me take a wild guess, when you went to the ER, they took your vitals, started an IV, drew blood for labs, did a chest x-ray and an EKG and when the results came in, they told you everything was normal, that you just had anxiety.” Surprised, she said yes. When I asked if she’d had other similar episodes, she said, “You know, I have been getting these attacks in the middle of the night when I’m sleeping. When it happens, I wake up and I’m sweating, I can’t breathe, my heart’s hammering, and I feel like I’m honestly losing my mind, because I can’t calm down. I really feel like I’m dying, like I’m having a heart attack, and I’m sure I’m going to die.” When she followed up with her family doctor, he repeated the same tests that the emergency room doctor did and came up with the same conclusion of anxiety, so he gave her 2mg Xanax and told her to break them in half and take a half twice a day. She said it helped a lot, but that she had been living on them for the past 3 weeks, and she was very worried about becoming addicted, because she had read that they are very addictive. She was definitely right on that count. Xanax is very effective at treating anxiety and panic disorders, but it’s a dual edged sword at best and not good as a long term solution. Then she told me that about two weeks ago, she had another attack, and she wanted to try to avoid going to the ER if possible, but she wanted to be close in case she needed them. So she decided to drive to the ER but not go in. She parked and sat in the lot for about 90 minutes, waiting for the attack to subside, but she didn’t go in. She did that same thing twice. Then, she said that she had plans to go out with her friends about a week ago, and she had an attack in her house. She was just about to get in her car to meet them, and she had an another attack. She said that this one was the same deal: shortness of breath, sweating like crazy, feeling like she isn’t real, like she is losing her mind, like she’s having a heart attack and that she’s going to die. It seemed that this had been going on for about a month. Then she said that she was living in a constant state of fear, always scared that she was going to have an attack. And that was why she was working this weekend, because she had called out of work so many times in the past 4 weeks that she was really behind on some projects. I asked her how things stood now, and she said she had stopped all social engagements. She was pretty much confined to her house, only leaving for necessities like going to her office, grocery store, and gas station. It seemed like that was pretty much it, and she needed a Xanax just to do those few things. She was living in constant fear of having the attacks, but now that fear had expanded; now she had fear of getting in her car, fear of driving, fear of being out in public, and even fear of meeting up with her friends. She’s pretty much stuck in her home, only leaving if she absolutely must. So a month into her anxiety and panic attacks, that’s where she stood. It wasn’t good. She’d have to get help to get it under control.

Keep in mind, Pilar doesn’t know what I do, but I kind of needed to push the envelope a little. I asked what her family practice doc’s diagnosis was, and she said he had told her that it was just plain old anxiety. That didn’t jive for me; this wasn’t garden variety anxiety. When I told her that I didn’t think it was just anxiety, she kind of freaked out, eyes wide, asking if she could die from it, if she would be like this for the rest of her life, and if there was a cure for it. And only then did she finally think to ask what it was. I told her with a smile, “I think you’re going to live. I’m pretty sure you have something called panic disorder. I’ve read about it. You should see a psychiatrist, because there are ways to treat it without using addictive drugs like Xanax.” She looked relieved as she asked what panic disorder was. I explained that it’s not a physical illness, it’s a psychiatric illness with attacks exactly like she was describing, and that Xanax works, but that there were other medications for it, and that’s why she should see a psychiatrist. When she asked how I knew about all this, I told her that I had read up on it a lot because I had a sister who was diagnosed with panic disorder. I went on to say that her doctor gave her Zoloft, and that seemed to work really well for her. After two weeks on it, her attacks had basically stopped, and it wasn’t addicting at all like Xanax. When she asked if I knew what caused the attacks, I told her that I’d read that the panic attacks were the result of a false alarm going off in the brain, a suffocation alarm. You think you’re suffocating, you think you’re about to die, but you’re really not. She said she never imagined that something in her brain could cause her to feel like she was really dying, but that she was glad that it was treatable. I told her that when she got on the right medicine, the attacks should go away, just like they had for my sister. She thanked me profusely and assured me that she would see a psychiatrist. Then she lifted her coffee cup, took a big sip, and said she was so relieved. I told her that by the way, caffeine wasn’t the best idea, that my sister had to give it up because it encouraged more attacks. She said she understood, but that between waking up with attacks and taking the Xanax, she was exhausted and needed the boost, but that she would make the effort to stop the caffeine. I reiterated that she should get off the Xanax asap, that it was just a very temporary fix, and she smiled and gave me a funny salute and an “Aye aye, Captain!” 

We continued to talk, and she said that she was glad she had sat down next to me. I kind of felt badly about my little white lies, not telling Pilar that I was a psychiatrist while telling her that I knew about anxiety and panic disorder because I’d read up on it when my sister had been diagnosed with it. The next thing I knew, I heard two last names called, mine being one. The other actually turned out to be Pilar’s. We stood up simultaneously, laughed, and then shook hands as she thanked me again. I told her no problem and to be well. And that’s how it was left. As I got into my freshly Inside-Out Washed and Hand Waxed car, I assuaged the bit of guilt I felt by reminding myself that there is risk in telling people you’re a psychiatrist these days. I didn’t tell Pilar. Maybe I should have, I don’t know. I think I helped her despite holding back the truth, and I felt good about that. I was sure that she would see a psychiatrist and make the effort to stop the Xanax. How weird would it be if she actually came to me, to my office to see me? It could happen. If it did, she might be angry. I’d have to cross that bridge when and if I came to it.

Pilar’s panic disorder is not at all uncommon, unfortunately. By some estimates, approximately two million adults in the United States suffer with panic disorder each year. There are two types of panic disorder: with agoraphobic features and without. Agoraphobia is defined as an extreme or irrational fear of entering open or crowded places, of leaving one’s own home, or of being in places from which escape is difficult. Most people with panic disorder start off without agoraphobia, but if the condition persists without adequate treatment, it can progress to include agoraphobia, where people find it almost impossible to leave their homes. It can be very debilitating, but it doesn’t have to be. Emma Stone, Amanda Seyfried, Sarah Silverman, Oprah Winfrey, John Mayer, Kristen Bell, and Caitlyn Jenner… What do these people have in common? They’re just a few of the many notable people that have panic disorder. That just goes to show that having a psychiatric illness like panic disorder isn’t the end of the world, and it doesn’t have to hold you back. You just need to make the choice to seek appropriate treatment if you suspect that you have it or have been told that you have it. Don’t make the mistake of ignoring it with the hope that it’ll just go away, because it won’t…it’ll only progress.

For more “psych stories,” check out my book, Tales from the Couch, available on Amazon.com.

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You Might Be An Addict

(And by ‘Might Be’ I mean ‘Are’)

The “Opioid Crisis” is all over the news these days, thanks to cheap heroin cut with fentanyl and heaven-knows-what-else that’s filling up morgue drawers throughout the country. If you think the numbers of overdose deaths are staggering now, medical examiners would be up to their elbows in bodies without Narcan, a drug that scrubs opioids off of the brain’s receptors during overdose, literally snatching people from the grip of the Grim Reaper. Many people that have stopped breathing and whose hearts have stopped beating are only on this side of the grass because of tthis wonder drug. While addiction has recently become a hot topic, it’s certainly not like it’s new, though we do seem to find plenty of novel substances to become addicted to all the time. Also not new is the stigma and overwhelming shame attached to addiction, attached to being an addict. It elicits such a strong negative response that we’re not even supposed to use the word ‘addiction’ anymore- it’s too derogatory- so now we’re to refer to it as ‘substance use disorder,’ lest we offend anyone. That said, to save myself some aggrevation, I am still going to use the word addiction in all of its various forms (shhh!) so I apologize in advance if anyone takes offense. I’ll also be using the term ‘using’ when referring to the use and abuse of drugs and alcohol.  I’m actually amazed that the word addiction is so stigmatizing that even physicians aren’t supposed to dare utter the term. That just goes to show that no matter how we raise awareness about addiction, about how it affects people in every walk of life, and that anyone can become an addict, nobody wants to be labeled as one….especially an addict in denial. It ain’t just a river in Egypt.

I’ve been listening to people’s deepest and darkest thoughts for over 30 years, and in that time I’ve heard people rationalize every behavior and habit under the sun, but none as vehemently as the abuse of alcohol and drugs. The way these rationalizations percolate through people’s minds is interesting. They’ll say, “I’m not an addict because I don’t use that much” or “I’m not an alcoholic; I only drink a little here and there.” To this I tell them that it’s not how much they do or don’t use that makes them an addict. That’s generally when they say, “Well, I know I’m not an addict because I don’t have withdrawls, I don’t get tremors and I don’t shake, even when I don’t use for weeks.” Hmmm. I think they think that one stumps me. But it doesn’t. “Nope, I hate to tell you, that’s not at issue either. Just because you don’t have withdrawals does not mean you don’t have an addiction.” To this they say, “But, but, I only use in certain situations, like at weddings, or funerals…” Blah, blah, blah, blah.  Doesn’t matter- where you use or how often- it just doesn’t matter in terms of whether you’re an addict or not. And then there’s the flotsam and jetsam of rationalizations: “I would never shoot up, I just wouldn’t do that; I never drink shots, I only drink beer; I don’t use marijuana wax, I only smoke a joint every now and again; I would never take pills, I only drink.” The list goes on. The truth is that the amount you use, when you use, how often you use, where you use, whether you withdraw or not, and the means by which you get the drug into your system does not factor into determining if you’re an addict; those things matter not. Right now you may be wondering, ‘So what does matter?’ How do you tell if someone’s an addict? There are behavioral, physical, and psychological factors that can be examined to make the determination. First, I’m going to cover the behavioral stuff, and then I’ll get to the physical and psychological stuff. There are essentially five general behavioral criteria to consider if You Might Be an Addict (And by ‘Might Be’ I mean ‘Are’).

The first criteria centers on relationships with the people around you. Does a significant other- a lover, partner, spouse, parent, sibling, grandparent, etc- complain about your using? Do they say you change when you use…that you’re a different person? Sound familiar? Do you blow off responsibilities to use? Does finding the money for the drug, getting the drug, and using the drug occupy your mind above all else? Does it change the priorities in your life? Do people in your life complain you’re irritable or that you’re no fun anymore? Do you withdraw and isolate yourself to use or while high? The complaints of family, friends and loved ones are signals that using is impacting significant relationships. This is a definite sign that addiction is present. I have patients say, “I get up and go to work every day, blah blah blah blah; I make money to support my family; I’m a good provider; I do this, I do that; I still go to the gym every day, yada yada yada…” Yeah, but you come home and drink three martinis and yell and scream at your children and your wife. Yeah, but you spend all day Saturday locked in your study in an Oxycontin haze. Those things are problematic! If using impacts significant relationships, You Might Be an Addict (And by ‘Might Be’ I mean ‘Are’).

The second factor to consider is the use of drugs and/ or alcohol in spite of physical, emotional or personal damage; damage to mind and body. Some examples: the alcoholic who is gaining weight and having liver failure. The woman who smokes tobacco but needs oxygen to breathe. The man who smokes marijuana who can’t think clearly, has memory deficits and thought and decision-making issues. The woman who’s smoking meth even though it’s killing her lungs and rotting out her teeth with meth mouth. The guy who’s injecting heroin even though he’s got gnarly scabs and infected abcesses all over his arms and legs. The man who has a cocaine problem but continues to use in spite of arrhythmias and strokes. If using causes physical and/ or mental issues but you still use regardless, You Might Be an Addict (And by ‘Might Be’ I mean ‘Are’).

The third factor focuses on work, your employment. Problems at work, starting to miss work, starting to come in late, making mistakes at work, poor relationships with co-workers, lacking follow-through, becoming lackadaisical or flippant at work, and not excelling/ achieving at work, especially if the behavior is new or recent. These are all drug-related signs. People say, “Oh, for 23 years I’ve gotten up and gone to work every single day and I’ve done fine.” Sure. Okay, but in that 23 years, how many times have you been promoted? Have your reviews and evaluations shown consistent improvement? Or does your boss complain about your personality, how you don’t have a good attitude, how you’re forgetful of things, how you seem to have no energy, how it seems like you’re not enjoying your work? If using affects your work performance in any way, You Might Be an Addict (And by ‘Might Be’ I mean ‘Are’).  

Factor number four is pretty simple: legal issues and their consequences. DUIs come to mind, but any legal problems stemming from the use or abuse of drugs and alcohol count here. That might include anything from charges for possession of drugs, fighting in public, assault, disorderly conduct, disturbing the peace or domestic violence all the way to charges associated with vehicular collisions, even manslaughter. If using has put your attorney’s kids through private school, You Might Be an Addict (And by ‘Might Be’ I mean ‘Are’). 

The fifth and final criteria is a two-fer; it’s super important because the first part is the one thing you can never get back once it’s gone, and the second part is something very hard to get back once it’s gone. Any guesses? Give up? They are time and money. Time spent using is wasted; (no pun intended) it’s time gone from your day, your week, your month, your year, and ultimately gone from your life for good. That time could’ve been better spent being productive, doing literally anything but using. As for money, Captain Obvious says that money spent on drugs or alcohol is also wasted; it too could’ve been better spent on literally anything but drugs or alcohol. The amount of time and money spent using may prevent you from making more money, because the time you might have spent on a money-making opportunity is spent on using. What’s more, time and money act as a barometer for the severity of addiction…when one goes up, so does the other, and the more of both spent, the more severe the addiction. If you waste your time and money buying and using drugs and alcohol, You Might Be an Addict (And by ‘Might Be’ I mean ‘Are’).

So just to review, what are the five behavioral criteria to help determine if You Might Be an Addict? If friends and family complain; if there are physical and psychological issues from using drugs and alcohol but use continues regardless; if there are job-related problems from using drugs and alcohol; and if there is time and money misspent and opportunities lost to using…You Might Be an Addict (And by ‘Might Be’ I mean ‘Are’).

Family members, friends, and co-workers are usually in the best position to recognize a drug problem as they are familiar with the person’s habits and behavior, but considering the weight of the word addiction, you can’t just point an accusatory finger at someone. You must educate yourself on the signs of drug abuse. Above we discussed five behavioral factors that can signal drug addiction, but there are also physical and psychological signs to be aware of as well. Recognizing the signs of addiction is the first step to ending addiction, so I want to give some practical information on the physical signs of addiction, overdose, and withdrawl. These signs are the body’s physical manifestations resulting from the presence of drugs or alcohol in the body. 

General physical signs of addiction include, but are not limited to:

– Enlarged or small pupils (opiate use often causes pinpoint pupils)
– Sudden weight loss or gain
– Bloodshot eyes
– Insomnia
– Unusual body odors
– Poor physical coordination
– Looking unkempt
– Slurred speech

Overdose is a medical emergency. In case of overdose, please seek immediate emergency care. Typical signs of an overdose may include, but are not limited to:

– Drowsiness or trouble walking
– Agitation
– Aggression or violent behavior
– Difficult/ labored/ ceased breathing
– Nausea and vomiting
– Hallucinations
– Delusions
– Loss of consciousness

Withdrawl can be a medical emergency. Please consult a physician during withdrawl events. Typical signs of withdrawl may include, but are not limited to:

– Shakiness, trembling, jumpiness
– Loss of appetite
– Nausea and vomiting
– Depression
– Insomnia and fatigue
– Headaches and fever
– Confusion and hallucinations
– Seizures (lasting over 5 minutes is immediate emergency)

In addition to behavioral and physical signs of addiction, drug abuse also impacts a person’s psychological state. When they’re in the grip of active addiction, the person might not realize or recognize these changes. The psychological signs of drug addiction may include, but are not limited to:

– Anxiousness
– Inattentiveness
– Lack of motivation
– Irritability or angry outbursts
– Changes in personality or attitude
– Emotional/ mental withdrawl
– Sudden mood swings
– Unexplained paranoia

We’ve covered the behavioral, physical, and psychological criteria that indicate You Might Be an Addict (And by ‘Might Be’ I mean ‘Are’). Or should I say You Might Have Substance Use Disorder (And by ‘Might Have’ I mean ‘Have’). I like the first better. No matter what you call it, you don’t have to live life in addiction. Actually, that’s an oxymoron- there is no living life in addiction. And if you do oxy, are you a moron? An existential question to ponder. 

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

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How To Learn With ADD

How to Learn Best with ADD/ ADHD

I want to talk about learning with attention deficit disorder (ADD) or attention deficit hyperactivity disorder (ADHD). I have been working with patients with ADD/ ADHD for over 30 years. In that time, I have helped people pass exams of all sorts: the bar, CPA exam, medical boards, police entrance exam, lieutenant exam, marine captain exam, ACT, SAT, MCAT’s, LSAT’s, marine captain’s license, firefighter exams, pilot exams, GED’s, on and on. It’s a unique situation, because people with ADD/ ADHD have specific study methods that work, but may not be the conventional way. They have a distinct problem with concentrating while sitting. They cannot just sit there and read and incorporate the information they read, it just won’t work. They also do not do well sitting and listening, so sitting in a lecture will do little to no good. Large groups are virtually impossible. Sitting in a group of 500 people listening to a professor during a freshman English lecture is useless for someone with ADD/ ADHD, it’s a waste of time. Studying and learning may be more challenging for those with ADD/ ADHD, but it’s definitely doable, so if you have either of these diagnoses, don’t use it as an excuse! Based on my experience listening to literally thousands of patients with ADD/ ADHD, I’ve come up with 15 guidelines on study methods and the do’s and the don’t’s that will help to process, incorporate and recall information in preparation for any test.

Before I get to those, a quick note. Your diagnosis is your business, but if you do choose to inform your teacher(s) or prof(s), you may find they’re willing to help you by possibly giving you more exam time, giving you extra materials (like questions or even practice tests) or by giving you one-on-one time to guide you as to what topics or ideas are most important. This may not be possible in professional exams or standardized exams, but if it’s a grade 1 to 12 school or even a college situation, it’s very likely they’ll assist you. Often they have policies in place already, so if you do have the diagnosis, don’t be afraid to tell them and ask for help. You certainly can’t be penalized in any way for doing so. If you do feel comfortable disclosing the diagnosis, a guidance counsellor is a great place to start. Now for my guidelines.

1. Do not just sit and read, do not just sit for lectures unless they’re required, and do not just sit (get my drift?) and watch something being done and expect to learn from it the way others might. It won’t necessarily hurt you, but your time might be better spent learning in a different way. If you do go to lectures, maybe use that time to create questions on the material as the teacher or prof drones on about it….insert Charlie Brown teacher soundbite here….wahn wahn waaahhhn waahnn wahhnnn wahn…. More on questions later.

2. With ADD/ ADHD, you will learn best by using interactive methods. Tutorswork very well whether you have ADD/ ADHD or not. Group interaction works well too, so start a study group. Better yet, combine the two- start a study group and have everyone pitch in to pay a tutor to help study for exams. Working with an interactive computer program would be great, a program where it asks you a question and you choose an answer and enter your choice. Some textbooks have those types of study aids online, so check out whatever resources exist at the end of chapters in your textbook, whether it’s online or printed.

3. Never cram for a test! Study over a prolonged period- this will allow you to “sleep on it,” which will help you retain more of the material. During sleep, the brain rehashes the information you’ve learned. Reviewing it over several days will increase the odds that you will better understand the material and remember more of it. And always do a before bed blitz… Studies show that you remember more when you take 10 to 15 minutes to review material you’ve studied or learned just before you go to sleep. Obvi, don’t do all of your studying at bedtime, just do a quick review so the brain processes the information as you sleep. And be sure to catch enough shut eye. Experts say that most people need to sleep eight to nine hours a night to remember what they’ve learned, and teens need even more than that.

4. Study the material, not the clock. When you sit down to study, note the time you start, but do not study by the length of time spent studying. Instead, study by the amount of material you cover; ie decide to cover x number of chapters, and do not stop until you know that material. And while your goal is to cover x amount of material, do try to make your study sessions last as long as the time allotted for the exam. This will start habituating your mind to be active for (and be able to sit for) a 2- or 4-hour exam or whatever the case may be.

5. When you sit down and study, treat it like it is an exam, don’t get lazy and knock off early. When you sit down and study, you sit down and you rock and roll, you pretend like you are in an exam situation. If you’re not willing to sit down and put your mind in an exam situation, then studying is a waste of time. Train your mind to be in the exam. Pretend you are in the exam so that when you do get in the actual exam, you are well practiced, your body is habituated for that situation, and everything comes more easily.

5. Learn to study anywhere, anytime. You don’t know the exam situation: if the person next to you will be coughing, if the clock on the wall will be ticking, ifthere will be noise outside, if you can hear the sound of the street, if the overhead lights are buzzing, if the fan is clicking rhythmically, etc. Break up your study locations or study in different situations so that you learn to adapt. Plus, you can get superstitious if you always study in the same place…I’ve had patients tell me they can only learn in one particular place- their room, kitchen, or the library. Also, you may find that you increase your focus and motivation for studying by seeking out locations outside of your house or room, like a Starbucks. 

6. When you read questions, read very carefully! This is key. If you have study questions, read carefully to prepare yourself to do so in the actual exam, because obvi, that’s where it matters. Remember to pay very close attention to words like yes and no and phrases like the most, the least, which one is, which one is not. Also pay close attention to absolutes in questions, words like never and always. Take it from a physician who is dual board certified: critical reading of the question is the most important thing in exams. Focus! Do notread the question quickly and always read it twice to make sure you understand exactly what is being asked. If some key words in the test question are familiar from studying, you might be inclined to just skim the question when you see the words, assuming it uses those words in the same context as they were in the book or study materials. Don’t make that assumption- pay attention and read the question again, even if you’re sure you got it the first time. Maybe the question only has a minor difference, like ‘is’ instead of ‘is not.’ Sometimes your brain can trick you….and sometimes the test maker can too! 

7. Work out every day. Thirty minutes of aerobic exercise a day improves focus and executive functioning skills, especially in students with ADD/ ADHD. It doesn’t matter what you do: sit ups, pushups, squats, planks, running…do it for half an hour every day.

8. Be mindful with socialization. You can study in a work group, but as for going to parties the day before a test, that’s a negatory! Your brain will not have time to regroup before the exam. Actually, it’s better to rsvp no to all parties during the entire study period- not only do you lose that study time, but you won’t be able to redirect your thought processes back into the study mode the next day. Save the party for after the exam, when you hopefully have something to celebrate…knowing you did well! 

9. Drugs. Caffeine helps bigtime, so have coffee and tea on hand when studying and learn to love it. Caffiene and studying are like an AmEx card- you shouldn’t study without it. Other amphetamine stimulants like Adderall are very helpful. Patients I’ve placed on stimulants see a dramatic difference in their ability to study and retain information. It’s a tool for them, just like a number 2 pencil, which btw, don’t forget to have at least three sharpened number 2 pencils and a good eraser so you can fully erase mistakes. This is especially important in scantron tests! If you’re struggling in exams and school and you haven’t tried a stimulant like Adderall, maybe you should ask your physician about trying it. And on the topic of drugs, Captain Obvious says don’t drink or smoke pot because it makes your brain discombobulated for a looooong time! If you do drink and smoke pot, don’t bother wasting time studying. It would be pointless.

10. Set goals. Tell yourself ‘I will get through x amount of material today,’  ‘I will do so many questions today,’ ‘I will be able to recite so much material today.’ Set goals that challenge you, but are attainable. If you have a tutor or are in a study group, it’s much easier to stay on track and stick to goals like these, so if that’s difficult for you, consider going that route.

11. Never ‘kind of’ know something. If, after you have studied and done questions and practice tests, you can close the book and recite what you have just learned, you should be golden. If you can teach the material to a total stranger, you should be golden. Be careful testing that theory though- it would suck to miss the exam because you’re in jail.

12. Always study with a computer or an iPad next to you so that you can look things up if you don’t know the definition of a word or understand a concept. A question may hinge on the definition of a key word, and it would suck to get it wrong because you thought you knew the definition when you studied so you didn’t bother to look it up. That would be the definition of dumb.

13. Questions, questions, questions! Here it is. I’m all up in your grill with questions because they’re the best way to learn if you have ADD/ ADHD. The best way to create questions is to make a practice test. Try to predict what your teacher may ask on the exam. If they give a review in class, you definitely want to be there, because they’re not giving a review just to hear themselves talk. If they give out a study guide, know it, because they didn’t take the time to make it just for funsies. Study old quizzes, making sure you’re using the right answers, and ask classmates what they think is importantenough to be on the test. And then create a practice test. Obvi, that doesn’t mean you should only know the material you put in your practice test. If you study in a group, which you should, have each person create a practice test, and then make copies and distribute to everyone in the group for a better variety of topics. Then go over every test as a group and study those questions. The very best way to prepare for a test is to get a tutor, join a study group, and do questions. That would be the winning trifecta for exam preparation. 

14. Keep a positive attitude. If you have ADD/ ADHD, chances are you beat yourself up throughout your whole life, and people may have even put you down, saying you’re not that smart blah, blah, blah. Well, screw them. You are smart. Study and get excellent grades as a big F.U. to anyone who ever put you down. Know your stuff and stay positive.

15. You must be determined. Have a can do attitude. You must say ‘I will do this at all cost.’ Make success the only option. Yoda said it best: “No try. Do.”

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Why Are People Going Crazy

Why are people going crazy?

Why do I ask? Well, sadly, because these days, some people like to pick up a weapon or cache of weapons and commit mass murder. The images of the aftermath on CNN have become all too familiar. If you asked the average person on the street to use one word to describe the type of person that commits these mass murders, what word would the majority use? Crazy. Or a smile thereof, like insane or nuts. So, let’s take a look at what the word ‘crazy’ means. The accepted definition is ‘Mentally deranged, especially in a wild or aggressive way.’ It is not a technical term. As a psychiatrist for more than half of my life, I have never diagnosed a single person as crazy. Crazy is not a term for mental illness. Mental illnesses are things like psychosis, bipolar, depression, obsessive compulsive disorders, panic disorders, anxiety disorders and personality disorders, to name a few. These are the illnesses I know and deal with on the daily; they do not generally create an individual who wants to go out and fire upon a random group of people with no intent but to maim and kill. Because doing that, randomly wiping people from the face of the earth, is not in and of itself mental illness. No. Killing a group of people is crazy. So, what is it about our society that creates members that go crazy? 

First, let’s specify who I mean when I say “members of our society.” I have researched this topic, looked at every mass shooting/ killing in the United States, and I’ve come up with some commonalities here. Basically, the shooters are male, they are white, and they are young, under 35 years of age. Oh, and they are absolutely, unequivocally, totally crazy/ insane/ nuts/ cuckoo/ Looney Tunes/ whacko; you get the idea. What else? They spend a lot of time on the internet, typically a minimum of 4 hours a day. Some are on the internet constantly, either playing video games, watching videos or surfing chat rooms, literally every waking moment. A mind boggling 28% of the under 35 crowd spend every waking moment on the internet, and another 45% are on and off it maybe 4 to 5 hours a day.  What does that mean? Keep in mind, being on the internet is not like watching TV or watching Netflix…with TV and movies, there are producers and directors that, to some extent, have decided what content will be shown in the program or movie. On the internet, content cannot be controlled in the same way. A fairly simple search can take you to very specific, very isolated sites that talk about anger, white resentment, white nationalism, and hate groups of every kind. On these sites, you find others of like mind, who agree with you on these distorted views, and as a result, there is a phenomenon of mutual brainwashing. Imagine for a minimum of 16 hours a day, being constantly bombarded by hate, negative thoughts, resentment and feelings of oppression. You fall into groups that encourage the need to lash out, groups where you seek out a singular message and you get back a singular message. The more you seek it out, the more it comes to you, the more you read about it, the more you think about it. The more you talk to people about it, the more people who want to talk to you about it. It just snowballs as it brainwashes, and people become obsessional about hate and killing, perverse topics of all sorts. These negative messages are constantly being broadcast on the internet, and the more someone does, the more they want to do. So, excessive time on the internet, seeking out hate and perversity, that’s the first factor associated with these young white men who go crazy and shoot people. 

Another factor is that these people are constantly getting messages from the media: television, radio, blogs, podcasts, talk shows, that white men are responsible for many of society’s problems. They are responsible for all sorts of racism, oppression, slavery, income inequality, starvation in the third world, climate change… young white men are responsible for everything that is wrong in our society. That is the current message broadcast from the media; the cause, if you will. The effect? Well, the creation of some really pissed off, young white guys that feel like you keep putting them down, keep stepping on them, keep telling them that they’re bad. You rarely hear a good message about white men. It is generally stereotypically negative, negative, negative. If you were to do that in any other group, it would be called racism; but if it’s focused on the white privileged, it passes. Their feelings of oppression have abnormal repercussions, and I think that’s why we get white men lashing out in crazy bizarre ways. So these repercussions from negative messages and perceptions are the second factor associated with these young white men who go crazy and shoot people.

A third factor contributing to the mass shooting phenomenon is the availability of guns, drugs and alcohol. So these guys have the means to kill in all manner of ways, and they are impaired by drugs and alcohol. Gun ownership is up. And have you seen some of the guns that people are legally allowed to own? AK’s, 50 cals, grenade launchers…the type of firepower legally possessable is mind blowing. These weapons are made to kill people, plain and simple. And of course, drug use is also up. Last I checked, there are 30 million Americans abusing drugs, and most are not in the work force. The availability of guns and prolific drug use make up the third factor associated with why these young white men go crazy and shoot people.

Another factor is that these people spend an inordinate amount of time alone. Most do not have jobs and are loners for various reasons, so there are no checks and balances for them, they are not expected to be anywhere. Also, there is no one to positively influence them, to tell them do this, do not do that, that is not appropriate, etc. They are alone.  They are alone with nothing but negative thoughts, on the internet all the time, satisfying perverse needs, being brainwashed, and getting negative messages about white men. Combine that with the availability of drugs and alcohol and weapons, and you have a fire just waiting for a match. These make up the fourth factor associated with why these young white men go crazy and shoot people. 

While those are four factors that these young white men are doing that contribute to the mass shooting phenomenon, there are some things that they are not doing that also contributes to it. They are not making friends, entering relationships or having sex, which would probably tone things down. Also, they are not involved in religious organizations, which would teach ideas of forgiveness, the sanctity of life, to be good to your fellow man, and how to help others. Religion would offer a positive group consciousness. There is not that religious component to our lives like there used to be, or to the extent it used to be. The lack of the positive motivator that religion brings plays a role in the mass shooting phenomenon. Another thing they are not doing is participating in team sports. Why do parents put kids in pee wee football, soccer, or softball? Team sports are where we teach moralities, sportsmanship, working as a team, caring for others, and helping others. As we grow up, team sports reinforce these ideals. Because these guys don’t participate in these things, they are not learning group behavior, team building behavior. What’s more, they are not feeling part of a community.  What they have is the internet and its vague, nebulous, untethered existence. They may play video games with people all over the globe, but there is no sense of community and no checks and balances that community brings. No care of presence or absence. On a more national level, there is less sense of true patriotism. We are not one people. To these young white men, patriotism is twisted at best, and it feels to them like they are not part of America anymore. They are marginalized and spout anti-patriotism. Even at the school level, they are ‘apart from’, they have no school pride, no sense of belonging to a group. Their lives are just a random series of interactions with electronic entities that they do not even know. They don’t know who or what these people really are that they may find on the internet, that they may blindly follow. They have no relationships to positive groups or organizations that help stabilize people and steer them to do appropriate things. These things are not happening. This is what I call the collective consciousness of our society. It has broken down, fragmented, partially by us. So now the common good or the common morality has alluded us. It has been diluted, been made to be a smaller component in our lives. Instead we are fed a diet of negativity. So some people are not being socialized by positive groups. Instead they go to the internet, video and social media. There they find material that appeals to their deepest, darkest negative thoughts; places where those thoughts are promoted and nurtured. I think that these are the reasons why people go crazy, the factors that contribute to the making of mass murderers. I get more into true mental illness in my book, Tales from the Couch, by Dr. Mark Agresti, available on Amazon.com. Please check it out.

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Car Wash psychiatrist

So I’m at the carwash. My car was a little dirty, and I like to keep it clean, preserve that new car scent. I’m no stranger to this place and I know my mission is the inside-out wash and hand wax. Actually, my mission is to manage to sit through it; I’ve been exiled to the waiting area for two hours. Two freaking hours! It’s a Saturday…don’t all these people have better things to do? As I sit down, my mind roams my subconscious, and I realize that the carwash is one of the few errands that I actually do myself. Thankfully, my amazing wife Debbie handles all the errands and other household stuff with great aplomb; good thing too, because waiting anywhere, for anything, transforms me into a sixteen year old with severe, untreated ADHD. I look at my watch. That little self exploration on errands took a whole 1 minute, 48 seconds. As I continue to sit, bored out of my  freaking mind, I look at the other poor saps waiting with me. Most are on their phones, probably ‘gramming about being bored AF at the carwash, and in my best UK-accented-newscaster-voice-in-my-head, I have a running commentary going on about how this is what modern society has come to. About how there’s really very little reason for us to leave our homes, how we can order everything online for delivery and blah, blah, blah, I’d talked about all of that so many times that even I couldn’t take any more of it. Time check, 11 minutes, 22 seconds gone. Insert long loud sigh here… 

I started watching people getting out of their cars and handing over their keys- I noted what they were wearing and how they carried themselves, how they reacted to the news that they’d be imprisoned here for more than two hours- and I thought this was a great example of how the vehicles we each choose to drive say something about us. They project a mindset or act as a status symbol. The hippie girl in the Prius, the midlife crisis dude in the Corvette, the family man in the Tahoe wrestling with the kid’s car seat. Watching him get red faced and frustrated with it reminded me of all the crap you have to bring with you for an outing with a baby. I remember it being like preparing for a paramilitary exercise. That’s probably why God made babies so cute…to help you overlook what a pain it is to do anything with them. It’s so much easier when they get older and you can just throw ‘em in the car and go. Those days were long gone for me. Man, tempus fugit! Am I old? Do people who people-watch me see me as old? I don’t feel old. Hmm. As I pondered this disturbing thought, a big bronze Hummer drove up and a dude got out. This guy was destined by God to drive a Hummer. He was a little over six feet tall. From what I could see, his appearance was pretty average, save for one attribute…he was built, huge. Like a freaking mountain. His head was perched atop a neck that was the girth of an old banyon tree trunk, with his trapezoid muscles as the roots on either side. When he came into the waiting area, everyone looked at him. This guy needed a theme song to follow him as he moved. I got the feeling he was used to turning heads. There weren’t many free seats, but two of them flanked me, and he took the one to my left, dwarfing the chair as he sat. I glanced at my watch. Only 20 minutes 3 seconds gone; a lot of time left to be insanely, hopelessly, mercilessly, miserably bored….

I don’t usually hit people up in public, but when a giant sits right next to you in a confined space, it is more awkward to ignore them than it is to start a conversation. God knew I had the time, so I turned to acknowledge him, saying, “Hi, you clearly spend a lot of time working out. What do you do? Are you a personal trainer?” Even as I asked, I was assessing him….occupational hazard. He was in his very early thirties and had short blondish hair that was thinning and balding, kind of oily broken-out skin with little deep red pimples, and maybe a day’s worth of stubble on his chin. He was wearing cargo shorts and a tank top that didn’t cover much of his expansive chest, with muscle bound arms attached to broad shoulders. I noticed that he had the same acne on his back, shoulders and chest as he had on his face. With these signs, it took me all of 3 milliseconds to conclude that this dude used a lot of anabolic steroids. To my questions, he answered with a smile “I spend so much time at the gym that I probably should be a trainer, but I’m actually a police officer. My name is Roger. What do you do?” With that, he extended his hand. As I shook it, I said, “My name is Mark Agresti. I’m a psychiatrist. My office is on the island.” I’m always a little reluctant to tell people what I do because I know where it’s usually going next, but as we exchanged some social pleasantries, I learned that he wasn’t from Florida, that his family has a vacation house here on the island and he’s down because he’s really just been overwhelmed lately, he’s had some family drama and wanted to get away. More often than not, this is what happens when I tell people what I do…It’s like I’ve issued an invitation for a free session. So here’s the dilemma: he’s laid it all out that he’s troubled, having family issues, so do I ask what’s troubling him or do I not? Time check, 35 minutes, 12 seconds gone. I’d be bored to tears without this exchange, so it’s a pretty good time to hit me up for advice and to ask me questions, so we kept talking. Before too long, the topic of weight lifting and bodybuilding came up, I mean duh, it had to happen. I felt pathetic talking to Lou freaking Forrigno the Incredible Hulk about my workout routine, but I told him I lift weights and work out, that I run to and from the gym everyday, about five miles. Then apropos of nothing, he says “I’m on steroids.” and I’m thinking like well, yeah, duh, but instead I said, “You look really muscular.” At that point he said, “Yeah, but I’m a little upset because now I’m growing tits.” People tend to unburden themselves in conversations like these, even though they aren’t patients so there is no expectation of cofidentiality. I replied simply, “That’s to be expected; taking testosterone makes dudes grow tits.” He bravely forged on, saying that his scrotal sack has shrunk and oh by the way, that he’s now impotent. He said it like ‘Nice day today, wish I could get it up!’ like BOOM! Knowledge bomb! I could clearly see that this dude had more issues than National Geographic, but he’s not a patient and this is obvi not my office, it is a carwash. I didn’t want to get too deep with him. He didn’t share that reservation, and he continued on, telling me that he has been depressed lately. Now, I could’ve just made some non-committal comment and shut him, and the conversation, down, but then again….time check: only 49 minutes, 5 seconds gone. So I said, “Steroids are a bad idea. They are without a doubt the root cause of all of the issues you’re having.” To this he replied, “Oh, I know you’re right. I know all about it, but I can’t stop. I like the juice, the rush of it.”  I thought to myself, in for a penny, in for a pound, and I dove in. I said, “Look, me, moi, if it caused impotence, if it in any way affected my drive or ability to have sex, I wouldn’t take it. I mean, if something turned my nuts into raisins, I’d avoid that something like the plague. But that’s just me.” He laughed, and flexing his arm to pop his biceps, he asked, “Not even for these?” I replied, pointing at my lap, “Nope, I’d rather have this.” 

Now, you would think that there was no way this conversation could get deeper or more personal, but you’d be wrong. The saying goes that you shouldn’t discuss religion or politics in polite society, but evidently Roger had never heard that saying. He proceeds to tell me that he’s a Christian; he was raised in a Christian home, went to a Christian college, he’s very active in his church, that it’s the focal point of his life. Now, as I said before, when I tell people I’m a psychiatrist, most invite themselves to an on-the-spot free session. The flip side of that coin is that it’s almost like my profession is a free pass for me to find out what’s going on with virtually anyone, anytime- I can choose anyone I want, and I’m able to just walk up and say, “Hello, Dr. Mark Agresti. I’m a psychiatrist. What’s up? What’s going on in your life?” It’s a strange thing. I’ve been a psychiatrist for a long time, since 1988, so 31, almost 32 years I guess. Anyway, at this point in my conversation with Roger, I basically said ‘What’s up?’ At least metaphorically, anyway. I was now invested. So Roger is a Christian and his faith is of utmost importance to him, but he’d said he had problems lately. So I’m thinking okay, maybe he’s got a girlfriend, maybe she’s married or something. Or, being a big muscular cop, maybe it’s a brutality thing, he got into a fight and beat someone up. Or maybe he took a bribe, or he has a drinking problem or he’s addicted to drugs. But I was floored with the real problem. He began, “My father…..” He told me his father’s name, and it turns out that he’s a fairly well-known individual in politics, a highly respected pillar of his community. I won’t say his name or what he was and where; it doesn’t matter for the story anyway. He tells me that one month ago, his father sat him and his sister down and told them that after 36 years of marriage, he was leaving their mother. He had filed the divorce papers a few months ago and expected it would be finalized in the next few weeks. I said, “That’s a shame…” and then stuck my foot in my mouth, asking my assumption, “…Girlfriend?” With a wry chuckle, he said, “Nope. Boyfriend. My father came out of the closet; he told us he was gay and that he’s going to move in with his lover. Then he said he was sorry, and told us what for, then begged us to not say a word of it to anyone.” Shocked, I said, “Wow, that’s pretty intense.” He said, “Yeah. My entire life has been fake. Everything up until now, the relationship I thought they had, the family I thought we had, growing up in the church in a normal American family. My father as a well-known political figure, lying to the constituents, all the people who made him. All these years, I thought that my life was one thing, and now I find out it’s another thing, all fake. Like gold plated bullshit.” I was lucky enough to have been born into a family that had never seen a divorce for generations, since it’s inception really. But I imagine that divorce would shake anyone to the core, regardless of how old they may be at the time it happens. I mean, your parents are always your parents, and you want the nest to always be there, even if you’re no longer living in it. All I could say was, “Man, that’s pretty rough.” He went on to say that with this new perspective of his father being gay, he’s reliving his entire life, reviewing every moment of it for clues, trying to understand if he should have, or even could have possibly seen that his father was gay. He used his father’s admission like a prism, and looking at his life through it, things started to slowly fall into place and make sense. He saw the reason that his father was always working so much, why he had a separate apartment in town and only came home on weekends, and why when he was little his mother used to cry a lot, but how her tears had dried the older he got and eventually just stopped falling. It all started to make sense to him. He came to believe that every part of his childhood, everything he did with his father, and therefore with his mother, was counterfeit, tinged with deceit. He told me that now things are very awkward with his father, because he’s realizing that he doesn’t know who his father really is anymore, and this new revelation of him being gay and moving in with a man he didn’t know anything about is super awkward. On the flip side, he feels deep sadness, because he realizes that his father had lived most of his life as a lie; he had sacrificed his wants and squelched his true desire to be with men, instead exchanging it for a false life, presumably out of love for his children and even for his wife. It was a lie of a life built of love and guilt and regret….a tangled mess. So Roger felt sorry for his father and for his mother, but for very different reasons. Despite feeling sorry for his father, he also felt angry. Regardless of his motivation, everything his father did was total manipulation. He was a practiced liar. He lied to his mother, he lied to his sister, and he lied to him. His feelings toward his father were complicated, but not mutually exclusive. He was angry at him for being a liar, but he sympathized with him at the same time, because he thought his father’s motives were pure. It was a mixed bag to be sure. 

To further complicate matters, his father was also prominent in the church, and their position has always been, and likely will always be, quite clear: homosexuality is unacceptable. But divorce? That’s okay. Ironic, right? Anyway, the family had to disclose the pending divorce and carefully craft the “reasons” behind it, and that was of course a very sticky wicket. Ultimately, fearing a news leak in the parish as to the full truth of the matter, they decided to leave their church. Leaving that church vacated a huge component of Roger’s life, and ultimately left him questioning his Christian values. Those values are intolerant of being gay, and they disallow homosexual relationships, the type his father is in, so if he supports his father, it’s in direct conflict with the Christian values of the church, a church in which he had always placed his faith. All of this left Roger very confused, and rightfully, it was very upsetting to him. He told me, “On one hand, I feel like I can’t really trust my father ever again. On the other hand, he’s always been a good father; he put me through college, he supported my choice to go into law enforcement, and he helped me become the man I am today. But, my mom was amazing, too. She baked cookies, kissed boo boos, packed lunches, drove my sis and I to soccer, boyscouts and dance, and made our house a home. And she was so hurt by his affair, gay or not. It destroyed her, and that pissed me off. It still pisses me off. She was totally devoted to him, and he repaid her by cheating and lying.” I could see his point. Not only did he have to deal with his feelings about his dad and the family strife, but he also had an obligation to help his poor mother heal from them as well. She was leaning on him and his sister a lot as they all tried to get over it in their own way. And the more his mom leaned on him, the more resentful he became of his father. It was unfair to his father, but it was impossible for him to stay objective when his mother was so needy, holding sway over him. When he finally asked me, “So, what do you think, doc?” I paused to formulate my response, how to couch it, if to couch it. I went with the direct approach, saying, “Well, the whole resentment thing will not work. It will not serve anyone. Whatever has happened, has happened. You can only look forward to what is ahead. The only way you will find any peace is to forgive your father and accept his choice to love whomever he loves. And you may not like this, but bear in mind that your mother must’ve known. This situation is not solely your father’s fault, and he should not get all of the blame. Your mother has some degree of complicity as well; some responsibility falls on her head. I know it probably sounds bizarre to you, but at some level she knew, and I think she was part of the big lie, the cover-up. I watched his face as he took that on board, then realization dawned. He said, “You know, thinking about it now, I think I remember something about a letter he wrote her many years ago, when my sis and I were just kids. There was a big blow out fight because mom found a videotape in the house. I never saw it, but now I assume it was gay porn. She was angry, I think maybe because it wasn’t well concealed, my sister and I could’ve found it and taken it or told somebody, something to that effect. I think he wrote a letter to her apologizing and saying he was scared because he thought he might be gay. It was a big fight, but it blew over; it seemed the coast was clear as far as us kids were concerned. Barely a blip on the radar.” I had to call him on that, and I said, “I’m sure there were other signs, other pieces of the puzzle, you just weren’t aware of them. It wasn’t just one letter that was the be all, end all. There are some issues between a man and woman in their marriage that are hidden beneath the surface, yet they bring to light facts that both, for their own reasons, would prefer to remain in the dark. The husband being gay is most definitely one of those kinds of facts. I’m certain that both of your parents knew the fact, but one of them, your mother, wanted to deny it, so she shoved it deep down into a dusty corner of her brain. So both were complicit in making and keeping it a secret. Your father finally could not, or would not continue the lie, and when he took a stand and told your mother that he was gay, wanted a divorce, and was moving in with his lover, the truth shattered your mother’s denial. But on some level, whether he had told her or not, somewhere deep down, she always knew he was gay. There’s a level of intimacy and sexuality that a gay man cannot reach being with a woman, and I’m sure that a woman would pick up on it. Women’s intuition is legendary, not cliche or an old wive’s tale. Regardless, it takes two to tango. It was a marriage and both played their parts. Although he did lie, you can’t place all the blame on your father, just as you can’t place it all on your mother. But for the sake of your own serenity, hold them both accountable, accept them, warts and all, and then forgive them both. That’s your only path to peace, man.” Roger had been nodding periodically as I went through all of this, and now when I finished, he said, “You know, I get it. I think you’re right on all counts. I’ve been racking my brain, trying to divide up the blame, like dad gets 90%, mom gets 10%; then I think, well, maybe I’m being too hard on dad, so I decrease his and increase mom’s. I’ve literally been doing that in my head, and I think it’s been driving me crazy. Like I’m the freaking blame police, parceling it out and assigning it to one or the other. So stupid and pointless! From now on, I’m not going to blame either one or be angry at either one. Nobody’s perfect nor blameless and I have to concentrate on the future and my relationship with them.” Happy that he got the idea, I said, “That’s a good start. You should make the effort to repair your relationship with your father. You must first accept his choice to love someone other than your mom, then accept that it happens to be a man. It will be awkward at first, but your love for him needs to outweigh the awkwardness. When you feel less awkward, he will too, and eventually it will all dissolve with time. Make the decision to forgive both your parents, and with time and patience, your relationships will grow together and be stronger than ever. Anger, resentment, shame, guilt, culpability, blaming this one, blaming that one, it doesn’t help at the end of the day. It’s just a mind screw.” He said, “I totally get it. I walked in here blaming my dad for everything, sure I was right about it, with no solution or path to move forward. You turned everything on its ear and made me see it all in a different light, and you gave me suggestions for how to move forward with my family. And for the first time since this all started, I feel hopeful when I think about my relationship with my dad, instead of feeling anxious, with my stomach in knots like I’m going to puke.” As he clapped me on the shoulder with one hand and shook my hand with the other, he said, “I feel like a huge weight has been lifted off my shoulders, and I am so grateful to you for that. To be honest, I never would’ve actually thought to see a psychiatrist for the things that happened with my family and the way I felt about it, but you’ve changed my mind on that too. I see why people come to you….it’s really cool to talk things through and hear an objective point of view.” 

Just then, the carwash announcer guy shouted “Agresti!” I said, “Here!” as I stood up. I extended my hand to Roger and told him it was good to meet him. He shook my hand and said, “Thanks again, doc.” I went outside to my inside-out washed and hand waxed vehicle and I got in, inhaling the new car scent. As I drove out, I caught a glimpse of my watch: 77 minutes, 46 seconds. That’s how long it had been since I’d last checked my watch.…. I’d spent all of that time speaking to Roger, and I didn’t regret a single second of being a carwash psychiatrist. That’s the whole story, nuts (or raisins) and all.

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How To Get People To Like you In Ten Minutes

Through the years I’ve had lots of patients ask me how to interact with people and how to be social, the mechanics of it, so I want to give some rules of the road, social skills 101 if you will. First, let’s talk about why social skills are important. Social skills are the foundation for positive relationships with other people: friends, partners, co-workers, bosses, neighbors, on and on. Social skills allow you to connect with other people on a level that is important in life, a level that allows you to have more in-depth relationships with others rather than meaningless surface relationships that have no benefit to anyone. Once you understand the value of having good social skills, you need to want them for yourself and commit to working on them, because that may mean doing new things that may be uncomfortable at first.  So, how would you start to improve social skills? Well, socialization is an interaction, so you need at least one other person to socialize with. So  the first step is to put yourself among other people. Basically, you have to suit up and show up to socialize. You might feel wierd or shy at first, but don’t let anxiety stop you. If you’re not around other people to socialize with, you’re obviously not going to improve your social skills. So take a breath and dive in.

Step number two, put down the electronics. If you’ve put yourself in a social situation, you may be tempted to fiddle with your phone to avoid the awkwardness of just standing there, but when you’re around people, turn the phone off.  You shouldn’t be disrupted, you can’t be distracted, and you can’t be checking email, messages, notifications, etc. Those things will get you to exactly nowhere. When you’re distracted, you won’t pay proper attention to the social setting you’re in, and since that’s kind of the whole point, put it away and keep it there.

So you’re in a room with plenty of folks to socialize with, your phone is tucked away, so what’s next? Well, if you want to interact with people, socialize with people, you have to look like it. You can’t put yourself in a corner with your arms crossed and a disinterested look on your face. Step three is to demonstrate an open, friendly posture. You need to be inviting to others who may want to talk to you. Put on a friendly face – you’ll be surprised at how many people approach you when you look approachable. 

As they say, the eyes are the entries to the mind. Step four is to always maintain good eye contact. This is hugely important when conversing, but fleeting eye contact also comes in handy when you’re just circulating in a room or looking for someone to strike up a conversation with. Eyes can entirely change a facial expression and easily convey mood and interest. Without eye contact, there is limited communication, and social skills are compromised without appropriate eye contact. Eye contact is so integral to communication that some people say they can tell if someone they’re talking to is being honest or lying by their eye contact, or the lack thereof. 

To communicate well, you must pay attention to your equipment…your speech. So step five is remember your speech: the tone, the pitch, the volume, the tempo, the accent. Right or wrong, people will judge and label you by your voice. A man’s voice that’s too loud is a turnoff, he comes off as a blowhard. A woman’s voice that’s too soft is annoying because people have to try too hard to hear her, and people may say she’s a sexpot, a la Marilyn Monroe. If she speaks at too high a pitch, she’s a bimbo. To some, a southern accent means you’re dumb and a northern accent means you’re a hustler. Speaking too slowly or too fast is annoying, too monotone and you’ll put people to sleep. On the flip side, a singer or actor with perfect pitch or an especially unusual or dulcet tone can build a legacy based just on their voice, a voice that will be instantly recognized for all time. When it comes to the way you speak, be aware and make alterations to be distinct and easily understood. Remember voice inflection, because monotone is a tune-out and turnoff. Speech should be like a story, with highs and lows, ups and downs to hold people’s interest.

After reading step five above, you might think that developing good social skills hinges on everything you say, but that leaves out a key factor…listening. Step six on the path to developing good social skills is to be a good listener. Just listen. Eazy peazy lemon squeazy. Now, if you’ve ever in your entire life enjoyed speaking to someone who clearly wasn’t listening to anything you said, raise your hand. Any takers? Anyone? I thought not. It is annoying AF when it’s so obvious that someone’s not listening to you speak. And you don’t want to be annoying AF, do you? I thought not. Social skills aren’t just about what comes out of a person’s mouth, so listen. 

A great way to deal with nerves that may accompany you when you put yourself in a social situation and talk to people is to find commonality, so this is step seven. When you first meet someone, a sense of commonality is a great way to establish a quick rapport with them. Commonality is something you share. It could be something as simple as going to the same school, a shared interest in sports, same places where you’ve lived or hobbies in common. Step seven is to find commonality with someone; something simple to break the ice and establish a conversation. 

Once you’ve begun a conversation with someone and you want to further it, you need to go beyond just commonalities. You need to relate to the person on a deeper level. How do you do that? Through step eight, empathy. Empathy is the ability to relate to someone by putting yourself in their position in order to understand them better. If someone has a dying parent, has just lost their job, if someone is lonely, has ended a relationship, didn’t get a promotion, or experiences anything that elicits an emotional response, being empathetic is the ultimate understanding of their pain, their sorrow, or their disappointment. Step eight in improving social skills is the ability to put yourself in someone else’s shoes in order to have genuine empathy for that person. A key word here is genuine. As a general rule, good social skills are genuine. Lip service is not part of good social skills.

Step nine is a pretty simple concept, though not so much in practice. Respect. In order to learn good social skills (and have anyone to practice them on) you must respect what other people say. I did not say agree. You can completely disagree with their opinion, but step nine is that you must respect their right to have it and include it in the conversation.  

While in theory you have the right to say anything you want in your social circle, you should watch what you say. Step ten is to consider the content of your conversation. There are certain things that shouldn’t be brought up in some situations. As they say, religion and politics are big no no’s for sure. Gossiping is also on the no list, because it’s really toxic to a conversation and leaves people scratching their heads. If you’re talking about Mary to Connie, Connie’s bound to wonder what you say about her when you’re speaking to Shelly. So it’s best to just not talk about people. But I think it was First Lady Dolly Madison who said “If you don’t have anything nice to say, sit next to me” Some people do like gossip, the jucier the better. But you have to be prepared to pay the piper. A conversation can be like a minefield, with certain subjects as the mines. You have to navigate through the whole conversation without blowing yourself to smithereens.  

In order to have appropriate social skills, you must consider the non-conversational parts of social interaction. If you’re so drunk that you can’t speak or no one can understand what you’re saying, obviously you can’t use good social skills. Same goes for drugs. If you take a Xanax to calm your nerves before the company mixer, you will not have appropriate social skills. You may not think people can tell, but you’d be wrong. Step eleven is  about intoxicants like alcohol, marijuana, benzodiazepines, and Adderall… they all make you act weird and affect your social interactions, and people pick it up right away. They may not know what drug you’re on, but they’ll know you’re on something for sure, because your social interactions will be inappropriate. Rule eleven: you cannot interact appropriately when using drugs or alcohol, so cut both out if you want to have good social skills.

If you follow these steps, you’ll definitely learn better social skills. And a breath mint wouldn’t hurt. Like with anything else, practice makes perfect when it comes to social graces. Be positive, open, honest, empathetic, clear, respectful and sober, and you’ll never be at a loss for people to talk to. You’ll navigate the waters of conversation deftly with give and take, and all included will come out feeling positive about the interaction.

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Find out How Technology is changing You.

Can we Talk?

We live in a world that is constantly changing technologically, and as it does so, it is changing how we as people interact. In previous generations, in order to obtain anything- food, shelter, clothing, information- you had to speak to another person. All of these transactions required interactions. And that meant you would have to converse with people. But things have evolved, and are continuing to evolve, every day. Obtaining those normal life needs I mentioned above has been revolutionized to the point that they no longer require person to person interactions. I talk to and listen to people all day, everyday, and I have seen some repercussions from the decline of personal interactions. These days, people really suck at the art of conversation. And it is an art. But now that the advent of technology has made it unnecessary to converse, it’s clear that its gone downhill. Look at texting. Most people choose to communicate by text rather than by voice/ phone whenever possible. The problem with that is that when people actually do talk to others, it sounds sort of like a text, with all the appropriate jargon and acronyms. Even the way we entertain ourselves has changed. You can entertain yourself alone now. You don’t even need a friend to play a game. For that matter, you don’t even need to make friends in person. You can have electronic friends to play video games with. If you’re in school and you need to do research, you can do it all online. There is no seeking out of experts and sitting down in person for a discussion. You don’t comb through giant reference texts; hell, you don’t even need to go to a library, you just need a laptop. When I tell millennial patients that I spent a lot of time in the library when I was in school, they’re amazed. They can’t wrap their minds around using microfiche (“Duuuude, like what is that microfish Doc?”) to look at newspaper articles from years past. They don’t even understand what the Dewey Decimal system is, and would have absolutely no clue as to how to find and check out a book. While today’s ability to get all the information you need online sounds totally fantastic, there are some pitfalls to be aware of. For all the information on the superhighway, there is a lot of misinformation. You have to be able to weed that out, which can be difficult. There are plenty of people with their own nefarious agendas posting crap online and taking no accountability. There is no monopoly on information.  Good, bad, or indifferent, everything is shared online. Social media has radically changed interactions between people. It used to be that to find a date, you actually had to leave your house. Not so anymore. Now you can find dates and vet them without even getting off your couch, and that first awkward conversation is had in text rather than in person. Facebook, Instagram, Twitter, Tinder, Match, JDate, Farmer’s Only, DateUrDog, yada yada- there are crazy sites for every segment of the population- these sites allow people to share information and give the illusion of socialization. 

What about some basics of just feeding yourself? When going “out to dinner,” people would normally socialize. But that does not happen anymore. Uber Eats, Delivery Dudes, DoorDash, you can get virtually any restaurant food delivered, whatever you want, whenever you want it. As a result, there are no more random interactions where you would meet people for dinner or run into people you know while you’re out. Money management is another area that has drastically changed. Banking, stock trading/ dealing, investment management, everything has gone online. There is no more going to the bank, gossiping with a teller friend, or running into people at the bank. Doesn’t happen much any more. I remember when I was a kid, people used to say that a banking job had good security, because people would always need money. I wonder what they think now, when everything is done electronically. Another major shift has been online shopping. I hate making comparisons that start with “When I was a kid…” but when I was a kid, a teenager, a big place to hang out and see cute girls was the mall. That’s where most people bought their clothes and it was the place to be seen wearing them. But now, shopping is done online…Amazon, Walmart, Rakuten, Wish, on and on. Every store has a website; it’s a virtual mall to buy clothes, shoes, decor, jewelry, whatever you could possibly want. You don’t need to go out every week to grocery shop either. Now you can join Amazon Prime and get Whole Foods groceries delivered to your doorstep. These days, we don’t have to do many of the errands that our mothers and grandmothers did. Dry cleaners pick up dirty laundry and deliver everything perfectly pressed the next day, dog food is delivered, pharmacies deliver medications, groceries are delivered with the frozen goods still frozen, and there is even an increasing trend of doctors doing more telemedicine. I have one patient, Eileen, who tells me she leaves the house just twice a month- to get her hair done, her nails done, spa treatments, or to see a doctor or dentist. That’s all she’ll leave the house for. She even gets her dog groomed from a mobile dog groomer that comes to her house.  Since everything we need can be delivered to the home, there is very limited interaction where we see others, and social interactions are even more limited. There becomes only one reason to interact, and that is that we as humans need to socialize or risk damage to our psyche. Think about what you hear about most serial killers…they were quiet, they were loners, never seen with others. Socialization is healthy. But now, instead of making and nurturing all these relationships through the chores we used to do, we have to create a social world, a place in which we choose to make time to socialize, where we choose to interact with people. It’s like socialization by appointment.

This information applies to all generations. I have talked a lot about millennial this, millennial that, but this is all generations. Yes, our young people have been raised on a diet of electronics and have not learned to communicate with one another, but our older generations that were taught and practiced social skills are now losing those skills as they age. I’ll put it this way…with any learned skill, if you do not use that skill for seven years, you will lose that skill. I have elderly clients who never leave their homes; everything is ordered in and delivered. Their social skills are inadequate. One of my long time patients, Albert, comes to mind. He was a vastly different person when he was going out to dinner with friends, when he went grocery shopping or played cards with friends. Now he doesn’t get out much and his social skills suffer for that. I feel very strongly about the need for socialization; I would say if we do not socialize, we do not exist.  I think we need to come to the point where we recognize that a lack of interaction between people is a problem. Not just not socializing with people but also “electronic friends” from social media that are not real friends. People whose lives revolve around these “friends” on social media and videogames have to see that these virtual relationships aren’t fulfilling. There is no intimacy in those relationships. And when I say intimacy, I’m referring to physical and emotional intimacy. You can’t see a facial expression, read body language, or touch, feel, or smell over the internet or through text or anything other than an in-person interaction. Another problem with electronic online relationships is that there are no checks and balances on behavior. You can say or do whatever you want, and you can dress, smell, and look any way you want and it really doesn’t matter. You can even be a predator or a catfish trolling online…or you could be a victim of those people when you are interacting on the internet. There is no one to say hey, that was dumb, or that was funny, or that was great, or you are pretty, or you are dressed inappropriately. So, without outside interaction, behaviors can become more bizarre in the technological vacuum. You also limit group interactions that nurture skills that are good, as in leadership, speech,skills of social interaction, the ability to make a case for yourself and sway opinion. These are critical in terms of group behaviors.

There are other things that are lost without an in-person social interaction. It is tough to have humor online. It’s hard to convey certain thoughts, without voice inflection and facial expression. In effect, you lose your sense of humor and the ability to make people laugh. It’s also difficult to have or convey empathy. You can’t understand what is going on in other peoples’ heads or what they’re feeling or thinking. The internet can cater to people looking to hurt others, bully people, and be mean; they can say what they want while remaining anonymous. Social etiquette is lost.  The ability to speak and interact using your voice, your speech and your body language to communicate a message is lost in electronic interactions, as is understanding nonverbal cues, group dynamics, and the art of conversation, as I mentioned above. You actually become dulled when you have limited true life interactions, so you lose the ability to pick up on social cues. Another thing lost to limited true life interactions are shared experiences. You are always alone with only electronics, no personal interactions, so there’s no one to motivate you or challenge you. By severely limiting real life interactions, you lose exposure to everything outside of you. There are no new things, new tastes, smells, places, people, and travel…you just don’t get that from your electronic internet- bubble life. 

Whenever I present a problem, I like to present a solution as well. So, if you’re living an electronic/ internet existence, what can you do about it?  It sounds cliche, but the first thing is to recognize that there is a problem, and that you want to change your reliance on electronics and improve your social skills. This is big, because most people do not even realize there’s a problem. They don’t realize how much they are depending on electronics/ social media to communicate. 

Then two, once you realize the problem, you have to commit to doing everything possible to increase interactions with real people in the real world. To do this, you’ll have to begin to desensitize yourself, because there may be anxiety early on when interacting with other people. But don’t let the anxiety prevent you from doing it. Go out and talk to people, same or opposite sex, maintain a conversation, and try being funny. Definitely make sure to be appropriately dressed in something you feel good about wearing, and make sure your hair and/or makeup is on point. Be aware of non-verbal cues like your body posture and your natural facial expression. If you have Resting Bitch Face, find and frequently practice a more open expression in the mirror. Essentially, you want to enhance your positives and interact appropriately. Before you know it, you’ll be less terrified by personal face to face interactions. Another way to meet people and increase real social skills is by doing errands, especially if you previously had them done and delivered for you. If you like certain products, go where they sell them and interact with salespeople or other customers and buy them. If you see someone buying something you haven’t tried before, tell them that and ask them what they think of it. Also, make it a point to expand your world by involving yourself with hobbies, your family, sports, academics, whatever piques your interest. Make an effort to seek out new things and try them. As you go to new places, the goal is to make new friends, to start real relationships in the real world. You can do this by starting a conversation based around whatever activity you’re both doing. For example, if you’re taking a cooking class, ask someone in the class what dish they really want to learn to cook or what restaurants they go to when the dinner they make is inedible. A common denominator is a great place to start a conversation. It may take a minute to psych yourself up to start a conversation, but don’t get stuck there- It’s not a big deal to start a conversation, so don’t spaz out and make it into one.

If you want to have real relationships,function properly in the real world, and learn how to interact appropriately and carry on a conversation- with co-workers, bosses, friends, family- the key thing you have to do is to put down the electronics, the phone. Turn it off and don’t carry it for a day and see how your social interactions change. 

So, you’ve admitted there’s a problem with your social interactions, that you have trouble making in person friends and starting real relationships with real people, and that you really only interact with people electronically on the phone. And you’ve said that you’ll do whatever it takes to learn how to make real friends in real life and stop relying on electronic friends; that you will put the phone down and get hobbies or try sports or whatever you can find to meet people in person and not online. That’s all great. But I have a couple of tips for you. First tip: when you go out now to wherever and whatever it might be and you’re making efforts to interact with people, observe successful people and copy them. When I say successful, I don’t necessarily mean someone who has money (though that doesn’t hurt lol) I just mean successful in that they are clearly holding people’s interest, or it could be someone who oozes charisma to you, someone that you’d like to be or hang out with. So locate that person and look at how they interact with others and pick and choose the qualities you like and can integrate with your unique personality. You don’t have to  reinvent how to interact with people, you just have to find someone you think is successful at it and copy it into your personality. And the second tip is that it’s perfectly fine to talk to people about how to meet people, and it’s okay to ask for help. No one is born knowing everything there is to know about everything. So while you will be better at some things, there will be some people who could be role models or instructors for you who are maybe wiser or more capable in this communication area, and you could learn skills from them on how to break the ice, how to interact face to face, and how to hold conversations. 

When I asked ‘Can we Talk?’ I asked it literally, because every day I see that the spoken word is being usurped and replaced by the texted/ transmitted word, a fact that I find unsettling at best.

As technology advances, I’m certain that robotics will continue to take over an ever-expanding pool of tasks that require skilled labor, jobs that are currently filled by humans. In the future, we will have to learn to live with robots, to interact with them on a daily basis. I wonder what that will be like, if they will have the ability to have real conversations given that they would not have hearts and souls. I worry that artificial intelligence will take over and possibly eliminate human intelligence, human feelings and interactions, just as many human jobs will surely be eliminated. Even after robots, life will continue to evolve, it has no choice…but I think it’s going to be a bumpy ride. 

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Ivan’s Addiction:Alcohol Detox

Ivan’s Addictions: Alcohol Detox

I want to discuss what people can expect when detoxing off of alcohol, inspired by my patient Ivan. He was a long-time patient, though I hadn’t seen him in a while. He was big time addicted to opioids years ago, and he had dragged his sorry butt into my office, barely coherent, begging for help. That’s how we met. I managed to get him clean off of the oxy’s he so dearly loved, but I would learn that Ivan had a very addictive personality…this guy could get addicted to oxygen. Anyway, that’s where it started with Ivan, and over the subsequent years I saw him in the office here and there. Now fast forward twenty years and in walks Ivan. It looked like the years had not exactly been kind to him. He looked like an alcoholic. Red swollen nose, check. Ruddy grey skin, check. Blood shot eyes, check. Balance just slightly off kilter, check. Gaunt frame with distended belly, check. I could go on, but suffice it to say that after so many years of doing what I do, I can spot an alcoholic from 50 yards. He said he was still clean, off opiates, but admitted to drinking in excess for many years. I burst his bubble with a sharp prick of  cold harsh truth: he was an alcoholic. When I said it, he might’ve flinched, but he didn’t argue. 

I asked him what he was doing for work. He said he was rehabing properties. He had inherited some money, bought a bunch of properties, fixed them up and rented them out. He collected the rent paychecks every month from his “magic money mailbox.” That sounded great, but the down side of this equation was that he wasn’t expected to be anywhere at any given time. And that left a lot of time for drinking. When I asked how much he was drinking, he admitted to drinking at least ten of those 2 ounce airline mini bottles a day. He had found some place where they only cost a buck a bottle. I was floored. That is an incredible deal. But I digress. I told him that we would have to do a medical detox, and he was on board. What follows are all of the things I told him.

To start, I explained that he needed to hydrate. Even though alcohol is liquid, it is very dehydrating, so there must be copious amounts of water during detox. As I told Ivan, drink water until you think you’ll burst. Next, start eating healthy foods. This is critical, getting food in your system, because alcohol causes irritation of the walls of the stomach and intestines. Also, you have to kick start the digestive tract, because alcoholics don’t eat well, if they eat at all. Next, start taking an over the counter stomach proton pump inhibitor like Prilosec or Prevacid. This will help to decrease the acid in the stomach as well as heal the stomach wall and the esophagus. Next, start taking B complex vitamin and multivitamin to replenish the system. He said he understood as he dutifully wrote all of this down. 

Next, I explained the important warnings about detox, the reasons why it’s important to medically detox. We have to use a type of drug called a benzodiazepine to prevent severe alcohol withdrawal. Without it, you will start shaking, you can become delirious and confused and have grand mal, full body seizures. There is a possibility of death: up to 25% of people actually die from severe alcohol withdrawl when they don’t use the benzodiazepines. I use medications liberally to prevent the withdrawl and safely detox. My goal is to keep patients comfortable with meds, but never nodding out. I wrote a scrip for 2mg alprazolam and told him to take one 2 or 3 times a day. I also gave him one to take immediately in the office because it had been 16 hours since his last drink and he was really starting to feel it. He had all of his instructions, so I told him I’d call him at 8pm that night as well as every six hours thereafter, and that he could call my cell phone anytime with questions or problems. With that, he left.

That night when I called, he said he was feeling not so great, but that he had eaten, was drinking lots of water, and taking the vitamins. When I called him the next morning, he said he woke up feeling very uneasy, very tense, and with some slight tremor. I told him to take the alprazolam right then and to take another in the afternoon around 2 or sooner if he felt tremulous. He repeated the alprazolam schedule on day 2 and also took it that night. When day 3 came, I explained that this is the most dangerous time. While seizures and delirium can happen at any time, they are most likely to happen on day 3. It’s also the worst day. It was really tough for Ivan. He was sweating. He had tremors. He was a little confused. His girlfriend came over and made him chicken soup, served with some TLC, and checking to be sure he was hydrating and taking the vitamins. He took the alprazolam three times that day, but didn’t sleep much. I gave him a drug called mirtazapine for sleep, and this helped. The fourth day dawned and Ivan saw the light at the end of the tunnel. Day 4 was better than day 3, but he was still feeling tremor, still sweating, and still needed 2 alprazolam that day. On day 5, he had no tremor. The sweating had lessened, but he still felt restless. He took just 1 alprazolam that day. As of the 6th day, he didn’t need the alprazolam at all. The detox was done. I told him to continue the vitamins and the Prilosec stomach meds for 2 months, keep up the improved diet, and keep hydrating. 

Ivan followed all of my instructions and he came out the other side and did pretty darn well. He got in great shape by walking his dog Malcom for a minimum of 3 hours a day, and he felt better every day. In fact, Ivan had dodged some serious bullets in that he had no major organ damage from the alcohol. There are several very common things that go bad with alcoholism. Most didn’t happen to Ivan, but let me caution you what can happen with alcohol abuse. Pancreatic issues are common. The pancreas is the most important organ for blood glucose regulation and digestion. You become a diabetic if your pancreas shuts down.  Gastritis quickly becomes a potentially lethal problem. Gastritis is extremely dangerous, it is irritation or bleeding of the stomach, leading to bleeding ulcers. Aspiration pneumonia is a concern: where you are so drunk that you throw up or cough up stomach contents and you breathe the stomach contents into your lungs, causing a serious and life threatening infection. A very common issue with alcoholics is that they get drunk, fall, and break a bone or hit their head, causing subdural hematomas of their brain. And you can’t forget liver disease. One of the key features of chronic alcohol abuse is liver failure and liver cirrhosis. The liver shuts down and so the body diverts the blood flow around the liver because the liver is so scarred and gnarly that it no longer accepts blood. As a result, you get big vessels forming in the esophagus and rectum, and they explode, causing hemorrhage and death. Ivan was lucky… he didn’t have any of those things. But he didn’t get off scott free. The most common thing I see with alcohol- that no one escapes- is cognitive damage. The brain slows down. It is permanently damaged. As a result, you cannot think straight. You are not as coordinated as you were. You become less active so there can be muscle wasting. These had happened to Ivan. As I said, no one escapes this. So Ivan was little bit slower, a little less coordinated, legs a little weaker. But he’s not drinking, and that’s a major accomplishment. I’ll continue to follow him in his clean and sober life. If you are abusing alcohol, Ivan would advise you to medically detox, as would I. If you would like to read more about alcohol withdrawl, medical detox or more patient stories, check out my book, Tales from the Couch, available on Amazon.com.

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