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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They call her Nicky.

Her real name is Nicole, but everyone calls her Nicky. I want to tell you her story. She comes from New Jersey, but the family also has a Palm Beach estate where they spend a fair amount of time. Her family brought her to my office, and in that first appointment I spoke with all of them together to gather as much background as possible. She was 24, the baby of the family, with a brother named Vinnie and sister named Sasha. Nicky and her sister Sasha took after their mother; they were all beautiful, with dark hair, light eyes, and tan skin, but Nicky had a more striking exotic appearance that was unique among the three of them. The family is Italian, very wealthy, with the father owning several large car dealerships and car washes all over the place in Jersey. Nicky’s siblings Vinnie and Sasha both work for their father. He runs dealerships while she manages human resources. And then, there is Nicky. Nicky had her share of issues, but not everything was her fault. She came from a home where her mother stayed home with the kids, doing everything for them, while her father worked a lot and wasn’t home much. When he was home, he was drinking wine. Her mom also drank wine. Nicky had few memories of either parent without a wine glass in hand. They were alcoholics, but wine was where it began and ended for them, and it didn’t seem to be an obvious source of family strife. Her brother Vinnie was a bit of a partier, drinking more than he should and smoking marijuana, but he showed up at work everyday and did a great job running his assigned dealerships and making big profits for the family business. Her sister Sasha was an exercise fanatic; she worked out every day, and was in great shape. And then, there was Nicky.  

Now, you’re reading a story written by a psychiatrist who works with a lot of patients with addiction, so you probably know where this is going, but I’d like you to go on the ride anyway. Based on information I gathered from speaking with her parents and siblings, and of course Nicky herself, I learned that Nicky was an extremely precocious kid, both physically and in mind set and attitude. The journey that brought her to where she was now seemed to begin when she was 10 years old. Nicky at 10 was already obsessed with herself. She was into internet porn and pay-for-play live camera peep shows. She was fascinated by those and the people in them, and even thought the live camera show was something she could set up and operate for herself. She never even considered the thought that her very young age should stand in the way of her doing something she wanted to do, so she didn’t let it. She was also very preoccupied with social media, always posting inappropriate pictures and cyber-courting older men with provocative messages. She would get tons of likes and messages and friend requests, and she revelled in the attention, needing it as the very oxygen she breathed. Her mother showed me pictures of Nicky circa age 10, and I was somewhat disturbed by what I saw. The 10 year old in the picture was striking. Nicky certainly didn’t look 10….she looked closer to 15 or 16. Her hair was the blackest black, her green eyes were impossibly bright, and her skin was tanned. She had the kind of looks that could cause unwanted attention for any female, much less one that was only 10 years old. But then again, I knew that the attention she got was not unwanted…it was by design. 

As Nicky got older, her behavior and habits only got more concerning. In a picture taken of her at age 12, she absolutely looked over 18. As a result, she was able to buy cigarettes, so at 12 she started smoking on a daily basis. She was also drinking on weekends, courtesy of the creepy dude that worked at the liquor store….he wanted her and she knew it, so she did whatever with him, and in return, he let her buy booze and beer. In doing so, he also reinforced her notion that she could use her looks to get things in life that she wanted, a tactic that would serve her purposes well and often in the coming years. 

By 13, she expanded her repertoire by picking up marijuana and drinking more frequently, almost on a daily basis. She had no use for her very expensive private Catholic school. There is no question in my mind that she had undiagnosed attention deficit disorder. When she went to classes, she could not sit still. She was always hyper. At 13, she had a habit of smoking in the school bathrooms because she said it helped her to calm down. She was always getting in trouble, always acting out in her classes. Her parents were constantly getting called to school because she was impulsive, talking out of turn, always causing trouble, disturbing her classmates, and acting sexually provocative. 

At ages 14 and 15, she was still skipping classes to hang out with the wrong crowd, drinking every day and smoking marijuana. She was honing the art of how to exploit her own sexuality for her benefit and became even more impulsive, especially with spending money. She was spoiled, and had several of her father’s credit cards. She put these to good use, ordering thousands of dollars of merchandise online, whatever her heart desired. As she maxed out all of the cards, her father would pay them down and she would be back in the saddle again. 

By 16, she graduated to having sex on a regular basis. I’m not certain, but I strongly suspect that she was turning tricks for money. I hate to say these things of a 16 year old, but she was dressing far too provocatively; a lot like a prostitute, and she was acted like a prostitute, hitching her hip, smiling and waving at men in cars. What came to mind was, ‘if it looks like a duck and walks like a duck….’ Anyway, at this point, she would easily pass for 21, so her weekends and many weeknights as well were spent smoking marijuana and getting drunk in a dark and nasty local bar. One night, another bar fly introduced her to cocaine, and taught her how to line it up and snort it. And suprise suprise, she liked it. 

Her 17th year looked a lot like the one before, just with more of everything. She was now smoking cigarettes and marijuana every day, drinking every day, and snorting cocaine on weekends. She wasn’t hiding things as well at this point, and was barely passing her classes at school. But private schools are in business to make money, and evidently they were fine with keeping her barely passing….as long as daddy wrote them a check each semester. 

Once again, Nicky’s 18th year was a lot like the one before, with regular abuse of alcohol, marijuana, and cocaine. The big news was that Nicky somehow managed to graduate from high school, despite almost never going to class in her senior year. It was a Catholic school, so I guess her graduating could’ve been considered a miracle. More likely her father made a substantial “donation” for Nicky to walk across that stage to get her diploma. After graduating, she decided she wanted a change, so she moved into her family’s Palm Beach house. She supposedly had decided that she was going to get her act together and take some college courses at a nearby university. At least that’s what she told her father. Apparently she was convincing, and he gave his blessing, along with one of his credit cards and his first support check for $4,000.00. They had made a deal that he would send her that check every month, as long as she was getting her crap together. It was a pretty sweet offer, especially since she’d also have his credit card. That meant that his monthly check for $4 grand was pretty much gravy. A lot of gravy. And when she arrived at the Palm Beach house, guess what awaited in the driveway. A brand new car! She was spoiled, but that wasn’t really her fault. It was just the way her folks rolled. And surprise suprise, she liked it. 

She had time and money on her hands and wasn’t really working to get her life together, though she gave her father glowing narratives on how well she was doing. In reality, she had found a source for cocaine and marijuana and was still drinking all the time. She started dating a guy of like mind and similar habits and he introduced her to his friends. At a party shortly thereafter, somebody gave her some 10mg oxycodone tablets, Percocet, aka percs and told her to take two, so she did. And surprise suprise, she liked it. 

In no time, she was taking 4 to 5 percs a day, then after a month, 8 to 10 a day. She was spending a lot of cash buying as many as she could from the original guy that gave them to her as well as other drug-using acquaintances. One day while driving high, she wrecked her new BMW and was taken by ambulance to the hospital. She wasn’t seriously injured, but she complained of pain and flirted with the ER doc and managed to get a scrip for 60 percs. That lasted her all of about 5 days. Now she had an opiate habit, she was totally addicted to the percs. But then it became impossible to get scrips because Florida shut down pill-peddling docs and adopted super strict opiate guidelines. Nicky was out of choices. She talked to her friends and various contacts and hooked up with another opiate addict that was in the same boat. Unfortunately, his solution to his inability to supply his opiate pill addiction was to do heroin. **Please see the comment on this subject at the end of this blog.** 

Now back to Nicky. She was then officially introduced to heroin….how to buy it, the amount it takes to get high, its price, how to snort it, how to cook it, how to load a syringe and shoot it, the whole nine yards. And suprise suprise, she liked it. 

Nicky had only been in Florida for about four months. Her father had replaced the car she had wrecked and had it delivered. She wasn’t working or going to school, but she was drinking, smoking cigarettes and marijuana like a chimney and doing coke everyday. She was also thoroughly hooked on heroin, buying and using at least 10 bags a day. And her appetite for heroin was only growing with each passing week. 

It wasn’t long before her father’s $4,000 a month wasn’t sufficient to cover the cost of her booze at the bars, her 2 packs of cigarettes a day, marijuana, cocaine, and the newest addition, heroin. After only two months of using the heroin, she was doing tricks on the street to get more money, because the cost of her various addictions exceeded the $4,000 check her father sent every month. But that didn’t stop her. She just used more. And the more she used, the more she wanted to use, then the more she needed to use. She was up to 15 to 20 bags a day now. So, she was having to prostitute on the side even more frequently to get the money to support her ever-growing habits. She had also had a drug using friend move in with her in exchange for $750 a month, which she always used promptly after getting it. Then one Friday night after finishing with her “clients,” Nicky pointed her car toward home. It was about 3am, and the roads were quiet; traffic was mostly drunks recently kicked out of the bars. And wouldn’t you know it? Boom! Crash! She wrecked the car. She gave a story centering on a drunk guy and it was all his fault, not hers, yada yada. Thankfully, she wasn’t injured. But the car was toast.

She took a cab home and joined her roommate in snorting some heroin. She felt kind of wired, so she may have used a little more than usual. That little more was evidently too much, and she overdosed for the first time. Thankfully, her roommate was there and called 911. At the hospital, she was treated terribly. It was basically like ‘hey, you’re an addict and you overdosed. It’s your fault, so get out of our ER’ and she was discharged very quickly. Unfortunately, the overdose didn’t stop her. She didn’t even consider stepping down on, or getting off of anything she was using.

Nicky said her life at that time was a drug induced blur, reduced to a cycle of drinking, hooking, snorting, smoking, repeat. Before long, she had overdosed twice more and totalled her second and third new cars sent by her father. For the life of me, I cannot understand his thought process, what he was thinking when he kept sending new vehicles to Nicky like lambs to the slaughter.   

So, now, we are into this odyssey for about 14 months or so, these episodes of using, prostituting, crashing her car, overdosing. She was losing weight and started looking a little haggard, worse for wear. Still, she brought guys home from her hangout bar and they paid $300 to $500 for the pleasure. There was one guy that hung out at the bar named Jimmy, and she’d forged just a friendship with him, no business involved. He really had a front row seat to Nicky’s decline and truly wanted to help her. He knew of my practice vis a vis his friend that was a patient, and he begged her to see me. He was pleased when after only a couple of days she agreed. 

He brought her into my office and he said “Doc, please, you’ve got to help get her off all this stuff.” After learning that “this stuff” was alcohol, marijuana, cocaine and heroin, I knew we were going to have an uphill battle, but Nicky was willing to try, and Jimmy was willing to help. I explained that we had to detox her, because she had a $300 a day heroin habit, which was most likely laced with fentanyl. I continued to explain that she had to be off of the heroin for 24 hours before we could start the detox drug, buprenorphine. I could see that both of them were about to freak out, but I assured them that I would give him several prescriptions to dose her with. My plan was to basically knock her out to get her to sleep for most or all of those 24 hours. I gave him scrips for clonidine 0.1mg to give every 3-4 hours, quetiapine 50mg every 4 hours, mirtazapine 30mg every 12 hours, phenergan 25mg every four hours so she doesn’t throw up all these meds, and lorazepam to throw in there every hour if she’s not sleeping and for withdrawl symptoms. I figured the whole combo would knock out a moose, so she should be okay. I gave him my cell number and asked him to call me every four hours and whenever with any questions. I told him to make sure she hydrates and eats, and that I want her zonked out so that she won’t run and use. That was my concern. I explained that the first 24 hours would be the hardest, but that once that’s over, you take the buprenorphine and everything starts to improve. But I also again explained and reiterated not to take the buprenorphine until after the 24 hours. That if it’s taken sooner, it will throw you into an immediate and horrifying withdrawl. Everybody seemed to understand so I sent them to her house to start the process with Jimmy taking care of her. 

Nicky made it through the 24 hours, and she got on the buprenorphine.  She took one, then a couple hours later, another; then three to four hours later, she took a third; then three hours later, a fourth. And tah-daaaaah! She was completely clean of heroin. She still wasn’t happy, but I think that also coming off of cocaine, marijuana and alcohol at the same time was giving her a hard time. She continued with the buprenorphine the next day and the day after. On that third day, I saw her in the office. She had just barely started to clear cognitively, and that chaotic thinking, erratic behavior, and impulsiveness, it was starting to simmer down a bit, and she was just beginning to get real. She said that she didn’t want to be addicted to the buprenorphine. I always worry when newly detoxed patients want to go off the buprenorphine, because it may be a sign that they want to use, and they don’t want the buprenorphine to block the opiate so they can’t get high. I explained that it is not like heroin at all in terms of addiction potential. And I said that her life had been so unsettled since the age of 10, but especially in the last few years or so, her life was total chaos, fueled by drugs, heroin, cocaine, heavy alcohol use and marijuana. I told her she should just stay on the buprenorphine for a little while to stabilize her behavior and get into a healthy, clean and sober daily routine. Her neurotransmitters needed a vacation off of dope, and she would need time to see what life looks like when she isn’t gorked out of her mind, going without sleep for days on end. I told her that once we got her into a ritualized life where her behavior was more routine, then I would consider getting her off the buprenorphine. I convinced her to stay on it. I don’t do this with everyone. For people who only relapse for say a month, I would give them a week detox and they’d be fine. Maybe, if they got regular cravings over the next 10 days, I’d have them take a little of it here and there if needed. But with someone who has lived a chaotic lifestyle for nearly their whole lives and had been living a very heavily drug-addicted and dependant lifestyle for the past few years, there is no way I’d take them off right after detox. So, I followed Nicky for the next two or three months, and Jimmy was her strength and support; I don’t know that she could’ve come that far without him. She came for one visit in a month, then a second visit, but just before her third visit, Jimmy told me she was out and using again. She was back to the whole enchilada- heroin and coke and weed and booze and prostitution to help pay for them. Four months later, Jimmy brought her back in, just out of the big blue sky. We went through the whole detox shebang all over again. Unfortunately, this is not unusual. I got her back on the buprenorphine,16mg twice a day.  Again, I told her she had to stay on it to block the cravings and stabilize her lifestyle after the detox. 

On this second run, she followed up for six months, but then relapsed again, went out drinking, and that lead her back to the marijuana, heroin, coke, and prostitution. She was snorting heroin and she ended up overdosing. She was in the hospital for like five days, on a respirator for three of them, because she had aspiration pneumonia, which happens when you’re so gorked out that you puke up stomach contents and then inhale them into your lungs. It’s an easy way to die. She came back to my office about three weeks after she was discharged. She grudgingly said that the hospital stay was sort of beneficial because she obviously wasn’t doing any drugs while in there, but she also added that the doctors had told her that she had major lung damage and needed to quit smoking if she wanted to live to reach normal life expectancy. 

I think that this was the first time where Nicky saw that her behavior, her extreme drug and alcohol abuse, had serious physical consequences and repercussions. I told her point blank that if she wanted a life, it would have to be a clean and sober one. To this she just nodded. She went back on the buprenorphine once again; this time she would stay on it for two years. She started to build a normal life, and she wound up taking a job at a local dealership here owned by a friend of her father’s. She was actually very intelligent, very capable, and she did a good job for him, though she complained about the pay. I told her to keep the job regardless, at least for a couple of years while she was still settling her clean and sober life. At this point, she did not smoke, drink, take any illicit drugs, or prostitute. She kept the dealership job for two years, almost to the day. I started tapering her off of the buprenorphine, and at that point, I put her on something called modafinil for her attention deficit disorder and as a pre-emptive strike against the fatigue she would likely experience when I stopped the buprenorphine. As it turned out, she got so fatigued that she could not drag herself out of bed. Once on 200mg of the modafinil each day, her focus and energy improved a great deal. She was much more alert and active on the modafinil. 

Nicky moved back to New Jersey a while back, but I still see her in Facetime visits every month. She takes the modafinil everyday. She followed her brother and sister’s cue and now she’s working in one of her father’s car dealerships, and she’s training to become a manager. All in all, she seems to be doing well. She’s not dating because she thinks it’s too risky to go to the bars and such. She says she spends time with her “crazy, loud, obnoxious Italian family” her words, not mine. She eats a healthy diet, and goes to spin classes with her sister Sasha. She learned that she enjoys yoga, and practices it often. This is the part where I’d like to say that Nicky lives happily ever after, but unfortunately, I can’t right now. For the past several months, Nicky has told me that she goes through the motions of life, but she cannot enjoy life anymore. She said that after doing so many drugs, and so much of them, that she can’t be happy. Nothing lifts her spirits. I’ve tried antidepressants, and nothing seems to work. She feels like her life while drinking and drugging was so crazy, so chaotic, that now her sober life is so boring, monotonous, and mundane. And I can imagine that that’s true. She wasn’t just addicted to the drugs and alcohol, she was also addicted to the life and lifestyle that came along with them. In addition to our monthly Facetime visits, she also has a therapist she sees in New Jersey, but so far there has been no resolution to her problem with her boring life. After watching her struggle so hard to get clean and sober, it’s such a bummer when she tells me how she doesn’t enjoy life now. It’s kind of like when you were a kid and you could hardly wait to finish the whole box of cereal so you could get the prize they promised on the front of the box, only to find that they didn’t put one in your box….you got gypped. That’s how I feel about Nicky. She got gypped, and that sucks. But, she takes care of herself and keeps to her routine, dull as it may be to her. I’ll keep following her, and I think that with time, she’ll find a new normal and new happiness. That’s what I hope for Nicky. 

For more patient stories, check out my book, Tales from the Couch. It’s available in the office and on Amazon.com. 

**Comment from above

As most people know, this country is in the grip of an opiate crisis. Staggering numbers of people are dying of opiate overdose every day. Very often it’s from heroin, often laced with fentanyl. People that were addicted to pills found they couldn’t get pills anymore, so they started doing heroin. Please, if you are addicted to opiate pills, do not turn to heroin to replace the pills. And if you’re hooked on heroin, stop. Go to detox and get off of opiates entirely. I detox people all the time, and I assure you that with the medications I utilize, it is far safer and easier to do than you think. 

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Digital Addiction Disorder

Time to Log Off?

Technology addiction, electronic addiction, digital addiction, social media addiction, internet addiction, mobile phone addiction…. No matter the name, the common thread in these addictions is that they’re all impulse control disorders that involve the obsessive use of mobile phones, internet, and/or video games, despite the negative consequences to the user of the technology. For simplicity, I’ll combine all of the above names together and refer to the phenomena as a digital addiction.

*** A new special called “Digital Addiction” will air on the A&E Network (Comcast HD ch 410 / SD ch 54) on Tuesday, September 17th at 9pm. There will be stories of people addicted to video games and social media and discussion on how people are trying to recover from digital addiction. It should be very interesting, so check it out. 

Do you play video games in excess? Are you compulsively shopping or gambling online? Do you spend hours taking the perfect picture to post or ‘Gram or tweet? Do you feel a need to constantly monitor all of your social media outlets to look for likes and loves and to track people to see what they’re up to? Is your excessive use of all of these things interfering with your daily life- family, relationships, work, school? If you answered yes to any of these questions above, you may be suffering from a digital addiction disorder. These disorders have been rapidly gaining ground as they are more recognized as truly debilitating, and as a result, they are recently receiving serious attention from many researchers, mental health counselors and doctors. The prevalence statistics vary wildly, with some reports stating that the addiction disorder affects up to 8.2% of the general population, but others state it affects up to a whopping 38%. In my opinion, it affects far more than 8.2%, but not quite 38%, so my educated guess is about 20%. That’s one-fifth of the population… a staggering number of people. And we have the explosion of the digital age to thank. Advancing technology is the ultimate double-edged sword. One of the most troubling things about this disorder is that we are endlessly surrounded by technology. Most of what we do is done through the internet. And we’re enticed to do things online. Take Papa John’s as an example- if you place your order online, you get an extra discount or a free small pizza. Lots of company sites offer similar discounts. And if you do buy online, most companies then include you in their email blasts with info on sales and discounts. Even if you’re just doing research on something online, not shopping, you’ll get little photo pop-ups from online stores you’ve ordered from before. Gamers make up a huge subset of the digitally addicted. Ask any mother of a male child aged 10 and up if she and her son argue about his spending too much time playing games, and chances are she’ll tell you that it happens all the time. Of course, to the developers of these games, that’s a total eargasm! These game developers have a strategy to keep people, especially kids, glued to their seats with eyes on the screen. Many games, especially the huge multiplayer roleplaying games like World of Warcraft and Everquest, may lead to a gaming addiction because as players play together, they spur each other on. In addition, these games have limitless levels, so in effect, they never end.

Just because you use the internet a lot, watch a lot of YouTube videos, shop online frequently, or like to check social media often does not mean you suffer from a digital addiction disorder. It only crosses over into the trouble zone when these digital activities start to interfere with, or even negate, your daily life activities. Every tweet, every phone alert DING! is an interruption in your thoughts, your psyche, and your day. I have a handful of patients that struggle with just turning their phones off during a session with me. They literally get anxious being without it, being unable to check it. They have to hold it, have it in their hands. I have one patient that couldn’t turn it off but agreed to put it in her purse. That stupid thing dinged and blipped and bleated every freaking 5 – 10 minutes, I swear. And every time, I could see her leave the appointment….it interrupted her train of thought with every stupid, annoying noise it made. I told her that next time, and for every time thereafter, the phone would be off and in my drawer. She grudgingly agreed, but she regularly panicked without it, so I had to begin every session by talking her off the edge.

Like many disorders, it can be difficult to pinpoint an exact cause of digital addiction disorder, but there have been some risk factors identified. These include physical impairments, social impairments, functional impairments, emotional impairments, impulsive internet use, and dependence on the internet. The digital world can be an escape for people with various impairments, so they are at higher risk. 

Digital addiction disorder has multiple contributing factors. Some evidence suggests that if you have it, your brain makeup may be similar to those of people that have a chemical dependency, such as drugs or alcohol. Some studies even report a potential link between digital addiction disorder and brain structure- that the disorder may physically change the amount of gray and white matter in a region of the brain associated with attention, remembering details, and planning and prioritizing tasks. As a result, the affected person is rendered unable to prioritize their life, so the digital technology takes precedence over necessary life tasks.

Digital addiction disorder, as in other dependency disorders, affects the pleasure center of the brain. The addictive behavior triggers a release of dopamine, which is the happy, feel good chemical. Note the name dopamine. Drugs of all sorts are often referred to as dope, and this is not happenstance; they are called dope because drugs elicit the release of dopamine as well, causing the pleasurable high. So chemically speaking, the high that gamers or internet surfers or Facebook hyper-checkers get from indulging their addiction is exactly the same as when a drug addict takes drugs. Win a game or get a like or love on Fakebook, get a dopamine hit. And, just like with drugs, people develop a tolerance over time, so more and more of the activity is needed to induce the same pleasurable response that they had in the beginning. Ultimately, this creates a dependency. 

There are also some biological predispositions to digital addiction disorder. If you have this disorder, your levels of dopamine and serotonin may be naturally deficient as compared to the general population. This chemical deficiency may require you to engage in more behaviors to receive the same pleasurable response that individuals without the addiction have naturally. 

Another predisposition to digital addiction disorder is anxiety and/or depression. If you already have anxiety or depression, you may turn to the internet or social media to fill a void or find relief, maybe in the form of online retail therapy for example. In the same way, people who are very shy or socially awkward may turn to the internet to make electronic friends because it doesn’t require actual personal interaction.  

The signs and symptoms of digital addiction disorder can present themselves in both physical and emotional manifestations. 

Emotional symptoms may include:

Depression
Dishonesty
Feelings of guilt
Anxiety
Feelings of euphoria when indulging 
Inability to prioritize tasks

Problems with keeping schedules
Isolation
No sense of time
Defensiveness
Avoidance of work
Agitation
Mood swings
Fear
Loneliness
Boredom with routine tasks
Procrastination

Physical symptoms may include:

Backache
Carpal tunnel syndrome
Headaches
Insomnia
Poor nutrition: not eating or junk food

Poor or zero personal hygiene 
Neck pain
Dry eyes and other vision problems
Weight gain or loss

Digital addiction disorder impacts life in many ways. It affects personal relationships, work life, finances, and school life. Individuals with it often hide themselves away from others and spend a long time in this self-imposed social isolation, and this negatively impacts all personal relationships. Trust issues may also come up due to the addicts trying to hide, or lying to deny, the amount of time they spend online. Sometimes, these individuals may create alternate personas online in an attempt to mask their online behaviors. Serious financial troubles may also result from the avoidance of work, as well as bankruptcy due to continued online shopping, online gaming, or online gambling. They may also have trouble developing new relationships, and they often withdraw socially, because they feel more at ease in an online environment than an actual physical one.

One of the overarching problems with the internet is that there is often no accountability and no limits. You are hidden behind a screen, so you may say or do some things online that you would never consider doing in person. To some, that can be a very attractive proposition. One iissue that happens in digital addiction is that people who may be shy or awkward or lonely may create a new identity for themselves. They find that on the internet, they can be the person that they can’t be in real life. They develop this perfect fantasy world where everything goes their way. The problem is that the more they get into that fantasy wotld, the more distant they become from the real world. The results can be a disaster emotionally when they’re forced into the real world; they find they can’t function there and desperately need help. There’s a flip side to a created persona, where it’s done to intentionally hurt others. By now, I’m sure most people are familiar with “catfishing” from the eponymous movie and television program. For those who are not familiar, catfishing is the purposeful act of luring someone into a relationship by means of a fictional online persona. Catfish steal pictures of an attractive person, usually from that person’s social media, and they create a fictional persona and post it online with the stolen pictures to see who bites. If they get an attractive bite, they message that target to begin a relationship for their own devious purposes, which is usually just to get their rocks off, to hurt someone because they hurt, to get nude pictures, or to weasel people out of money. Catfish often do this with multiple people, leading them on, and are usually pretty proud of themselves for it. I think they’re lowlife cowards. My point is that the internet is full of people that feel brave online but who cower in real life. Online and social media digital addicts are more likely to be targeted, simply because they spend so much time on their devices, on the internet, or monitoring their social media. 

As for diagnosis, because it was only very recently added to the Diagnostic and Statistical Manual of Mental Disorders as a disorder that needs more research, a standardized diagnosis of digital addiction disorder has not been developed. This is likely due to the variability of the different digital applications that people may become addicted to, as well as the fact that digital addicts can have anxiety and/or depression as well, and therefore would have difficulty, or may be averse to, seeking help.  

As to treatment options for digital addiction disorder, the first step in treatment is the recognition that a problem exists. If you don’t believe you have a problem, you’re not likely to seek treatment. 

Developing a compulsive need to use digital devices, to the extent that it interferes with your life and stops you from doing things you need to do, is the hallmark of an addiction. If you think you or a loved one may have a digital addiction, you should definitely see a psychiatrist, because there may be an underlying issue like anxiety and/or depression that is treatable with talk therapy and/or medication. I specialize in addiction, and I work with many patients with digital addiction with a great deal of success. There is a right way to utilize technology without it running and ruining your life, so please seek help.  

Digital addiction disorder has become such a common theme in my practice that I cover this topic in several stories in my book, so check out Tales from the Couch, available on Amazon.com if you’d like to read patient stories and get more information on the digital addiction phenomenon.

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How To Sleep Better At Night

In this blog, I want to talk about sleep. One of the most common complaints I hear from patients in my practice is that they can’t sleep, and they ask what they can do to sleep better at night. It’s brought up so often that I’ve created a list of rules to follow to get better sleep at night. But first, some facts about sleep… and the lack thereof. 

While sleep requirements vary slightly from person to person, most healthy adults need between 7 to 9 hours of sleep per night to function at their best. Children and teens need even more. And despite the notion that our sleep needs decrease with age, most older people still need at least 7 hours of sleep per night for optimal functioning. 

We all know that good sleep is important. But why? I mean, if we don’t get enough sleep, we’ll be tired, but other than that, it really doesn’t matter, right? Wrong. In terms of importance, getting good sleep, and enough of it, is actually right up there with eating a healthy diet and exercising regularly. Poor or not enough sleep is known to have negative consequences on hormone levels and brain function, and can cause weight gain and increase the risk of obesity and diseases like diabetes and heart disease. On the flip side, adequate or good sleep can keep you healthier, help you maintain physical fitness, and think more clearly and concisely. Unfortunately, sleep quality and quantity have both decreased in recent years, and millions of people battle chronic insomnia for their entire lifetimes. Because it plays such a key role in your health, getting good sleep should be a priority in your life. Toward that end, below are my fourteen rules for good sleep.

Rule 1: Get bright light during the day. Natural sunlight is preferable, but artificial light works too. Your body’s natural clock is called your circadian rhythm; it links your body, brain and hormones, keeping you awake during the day when appropriate and telling you when it’s time to sleep at night. Daytime light exposure keeps your rhythm happy and in sync, improving daytime energy and alertness as well as nighttime sleep quality and duration. 

Rule 2: Avoid blue light in evenings and at night. What is blue light?  Blue light is what is emitted from your computer, laptop, iPad and smartphone. While daytime light exposure is beneficial, nighttime light exposure is not. This is because of its impact on your circadian rhythm; it tricks your brain into thinking that it’s daytime, and this reduces natural hormones like melatonin, hindering sleep. The more blue light you expose yourself to, the more disruption you’ll have in your sleep. There is a solution for this; there’s an app for your smartphone that filters out the blue light. There’s also something called “F.Lux” that you can put on your computer or iPad which will block out the blue light in those devices as well. So remember, blue light is a serious factor. If you are on your iPad or your computer at night, you’re not going to sleep well.  

Rule 3: Avoid caffeine, Captain Obvious. 90% of the US population consumes caffeine on a daily basis, mostly in coffee and energy drinks/ shots. Here are some approximate caffeine counts: an 8 ounce cup of coffee has 95mg of caffeine, a 5-hour energy shot has 75mg and a Red Bull drink has 120mg of caffeine. While caffeine can enhance energy and focus, it can also wreck your sleep. Caffeine stimulates the nervous system, and this can prevent the mind and body from relaxing and falling into a deep sleep. Caffeine can remain elevated in the blood for 6 – 8 hours after ingestion, so consuming caffeine after 2pm is not the best idea, especially if you’re sensitive to it or already have trouble sleeping. In addition, regardless of when you consume it, you should limit caffeine intake to 200mg per day or risk losing sleep over it. 

Rule 4: Watch naps during the day. While short power naps can be beneficial for some, taking long naps during the day can negatively impact  your sleep. How? That wiley circadian rhythm again! Napping during the day confuses your internal clock, disrupting your sleep-wake cycle and potentially leaving you with problems falling asleep at night. 

Rule 5: Try Melatonin. Melatonin is a naturally produced sleep hormone that tells your brain when it’s time to relax and head to bed. Melatonin supplements are an extremely popular over-the-counter sleep aid, helping people to fall asleep more quickly. I usually recommend between 2 and 4mg of melatonin at (or shortly before) bedtime. I find that some patients get daytime hangover from it, so be aware of that and possibly decrease the dose to see if that minimizes the hangover. 

Rule 6: Regulate your sleep-wake cycle. How? By getting up at the same time every day and going to bed at the same time every day…. even on weekends. I know, that last bit is a bummer. Our old friend circadian rhythm is at work again here. The circadian rhythm is basically a loop, and irregular sleep patterns disrupt it and alter the melatonin levels that tell your body to sleep. The result? Not sleeping. I recommend that you go to bed at the same time every night and that you set an alarm to get up at the same time every day, no matter how tired you may be. After some time, you will probably find that you wake up on your own without the alarm and that the consistency of your schedule will give you better sleep quality. 

7. Try additional supplements for sleep. There are a few dietary supplements that have been found to induce relaxation and help you sleep. 

   Glycine: This is a naturally produced amino acid shown to improve sleep quality. I recommend 3 grams at night. 

   Magnesium: This is an important mineral found in the body; it is responsible for over 600 biochemical reactions within the body, and it can improve relaxation and enhance sleep quality. I recommend 100-350mg daily; start at the lower dose and increase gradually if necessary. 

   L-theanine: Another amino acid, L-theanine can induce relaxation and sleep. I recommend 100–200mg before bed. 

   Lavender: A powerful herb with many health benefits, lavender can induce a calming effect on anxiety and help induce sleep. I recommend 160mg at night.   

Rule 8: No alcohol. I’m sure we’ve all heard people say that a nightcap “helps them sleep better.” Don’t ever believe it…it’s total crap. Downing even one drink at night can negatively alter hormone levels like melatonin, disrupting the circadian rhythm and therefore sleep. In addition, alcohol is known to increase, or even cause, the symptoms of sleep apnea such as snoring, which also disrupts sleep patterns and causes poor sleep quality.  

Rule 9: Create a cool, dark and quiet bedroom environment. Minimize external noise and light with heavy blackout curtains and remove devices that emanate artificial light like digital alarm clocks. Make sure your bedroom is a relaxing, clean, calm and enjoyable place. Keep the temperature very cool, I usually recommend 70 – 72 degrees, because the weight of blankets is very comforting. You can even buy weighted blankets for adults and children; I’ve heard many patients say they really relax the body which in turn helps them fall asleep.  

Rule 10: No eating late at night. Late-night eating may negatively impact the natural release of HGH (human growth hormone) and melatonin, which leads to difficulty falling asleep. Also, I think that most of the time, people eat bad things late at night, things with a lot of sugar and things high in fat, like chips, candies, and cereal. These all interfere with sleep. Generally, when the body goes into a digestive mood, as it does after eating, it doesn’t want to sleep.  

Rule 11: Relax and clear your mind.  Many people have a pre-sleep routine that helps them relax to prepare for sleep. Commonly suggested for people with insomnia, pre-sleep relaxation techniques have been shown to improve sleep quality. Strategies can include listening to relaxing music, reading a book, taking a hot bath, meditating, deep breathing and visualization. Stress is a common reason for trouble falling asleep and poor sleep quality and quantity. If your problems are keeping you up at night, you have to come to some resolution on how you’re going to handle those issues in your life so that you can put them to rest, go to bed, and get some sleep.  

Rule 12:  Spend money on a good quality, comfortable mattress, good pillows and good linens. You’re going to spend a third of your life in your bed…don’t cheap out when it comes to the matress and bedding; spend the money. Make sure your mattress is large enough, comfortable and high quality. Studies have shown that quality mattresses significantly reduce back and shoulder pain. And buy good quality, high thread count (800 thread count minimum, but higher if you can) cotton sheets…they’ll get softer with every wash. Find pillows that feel most comfortable and supportive for you. You may have to try multiple pillows before finding the perfect one, but the search and cost are necessary, and your neck will thank you for it. A quality mattress and pillows and great linens can be an investment, but well worth it. You’ll have them for some time and you’ll be happier for it when you get in bed at night and go “Aaaaahhhh.” 

Rule 13: No exercising at night. While daily exercise is key for a good night’s sleep, doing it too late in the day may cause sleep problems. This is because exercise acts like a stimulant, increasing hormones like epinephrine and adrenaline, which increase alertness. Alertness is the antithesis of the relaxation you need to fall asleep. Basically, exercise hypes you up, making it difficult or impossible to fall asleep. 

Rule 14: No fluids before bed. While hydration is an absolute necessity for health, it’s best to restrict fluids for one to two hours before bed. You should also use the bathroom right before going to bed, as this may decrease your chances of waking in the night. The reason for this rule is fairly obvious: a full or partially full bladder will wake you up in the middle of the night to go to the bathroom, and that’s a total drag for you and likely for whomever shares your bed. 

So those are my 14 rules for better sleep. And now I’ll say goodnight, sleep tight, and don’t let the bedbugs bite!

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Lithium The Good The Bad The Ugly

Element 3: Better for Batteries or Brains…or Beverages???

Think back to chemistry class, when you studied the periodic table of the elements. You may remember it as being just a confusing jumble of letters and numbers. But our daily lives would be very different without element number 3. It’s a key component in the batteries that power our smartphones, laptops, and even fancy-schmancy Teslas. But that same element also happens to be one of the most effective treatments ever discovered for bipolar disorder and mania, as well as other mental illnesses like depression, schizophrenia, and eating disorders. It is especially effective for treating suicidal ideation. Through the years it’s also been used to treat anemia, headaches, alcoholism, epilepsy, and diabetes. But it’s very scary, because it has some serious and potentially lethal short and long term side effects, and there is a very narrow window between the dose where it’s effective and the dose where it’s deadly. It’s so scary that I literally have only one patient out of my entire practice on it. The element I’m talking about is lithium. Let’s consider the good, the bad, and the ugly of lithium. 

The good: it’s effective as all get out. I would call it one of the most effective drugs in the treatment of mania. It treats the high of the manic episode, the irritability, the agitation, disorganization, hallucinations, delusions, rapid speech, insomnia, racing thoughts, grandiosity, and impulsivity of mania. It prevents the mood cycling of bipolar, and it also treats the suicidality associated with mania and depression. 

The bad: it has a nasty side effect profile. It causes a host of issues. Sedation is a big one. It makes people tired and causes obvious mental slowing. I say obvious because it becomes obvious to everyone. The person appears dull and medicated. It slows the mind down. Thoughts don’t process at normal speed, and speech and reactions are slow. It also affects kidney function, causing frequent urination, as well as nausea and diarrhea. It also can be very disabling because lithium commonly causes fine tremor. When all of the side effects are looked at together, they can easily be mistaken for alcoholism or drug abuse, so it can affect people’s opinions at work and have other huge social and personal consequences. It can cause a great deal of weight gain, as well as disfiguring acne on the face and back, as well as psoriasis, red scaly patches of skin on the body. On top of all of that, it can also affect the heart, potentially causing sick sinus syndrome, which is an arrhythmia where the heart’s natrual pacemeker, the sinus node, doesn’t work properly.  

As for the ugly; let’s just say that lithium wouldn’t be winning any molecular beauty pageants… it is uuuu-uuu-gly! Lithium can cause nephrogenic diabetes insipidus and interstitial nephritis. Those are big words that simply mean it shuts the kidneys down. Like dunzo down. Patients on long term lithium therapy regularly have chronic renal failure. One of my patients that used to be on lithium is currently on a kidney transplant list. Another ugly component of lithium is that it shuts down the thyroid. You kind of need your thyroid to maintain metabolic processes in your body. It’s pretty important…without it, you become ill with all sorts of terrible issues and you must take another drug to kick it back into gear.  

There are other issues with taking lithium. There are some commonly used medications that don’t play well with it. You cannot take diuretics, and you can’t take NSAIDs ibuprofen or naproxen for pain, because these can cause dangerously high levels. Lithium is unusual in that it has that small window of operation I mentioned. You have to have levels checked to make sure they’re between 0.6 and 1.2 mEq/L. If you get toxic by taking thiazide diuretics or NSAIDs or by getting dehydrated, lithium can cause permanent brain damage, nausea, vomiting, diarrhea, and death. So, it is extremely problematic in that it has that narrow window between efficacy and death. In addition, certain drugs lower lithium levels. A big one is caffeine; people have to be very careful with caffeine intake. Even drinking too much water can lower lithium levels, because you can literally dilute it in your system. 

All things considered, I say lithium is a last line drug. Yes, it works, but it’s like using a sledgehammer to nail a one penny nail into the wall…there’s going to be collateral damage to the structure of the wall. As good as the good is, the bad is too bad and the ugly too ugly. There are so many other drugs now to try first. Lamotrigine, oxcarbazepine, valproic acid, lurasidone, aripiprazole, and quetiapine to name some. Some psychiatrists would argue with me because these other choices may not be as effective, but they won’t cause the mental slowing, acne, tremor, frquent urination, kidney failure, and hypothyroidism. I treat a patient as a whole, I don’t treat just the mental illness. If my treatment of the mental illness damages or destroys other parts of a patient’s life, is that proper treatment? I say no, but some physicians say yes. It’s a philosophical issue, a quality of life issue, that won’t be solved until somebody develops a drug that works as well but without the terrible side effects. As I mentioned above, I have only one patient in my entire practice on lithium, and I’m currently trying to get him off of it. Why? Well, he’s experiencing sedation, cognitive slowing, frequent urination, tremor, nausea, acne, and weight gain; surprise, surprise…it is making his life miserable. So we’ll continue to try other drugs and hopefully find some success elsewhere.

We’ve talked about the use of lithium in batteries and in brains, but in beverages? Believe it or not, it’s true. 

Lithium was once a key ingredient in 7 Up soda. This is a 7 Up ad in a 1948 issue of Ladies’ Home Journal magazine. Look how happy everybody is, and notice all the open bottles of liquid lithium everywhere. The father is like “These crazy kids, drinking all this 7 Up. They’re going to drive me to the poor house!” And the son is like “It’s okay, dad! Have another sip of your 7 Up!” And the daughter is like “Wheeee! I LOVE 7 Up!” And the mom is like “I hope I have enough 7 Up to keep me from murdering my entire family.” And the tagline just kills me… “You like it- it likes you!” 

7 Up debuted in 1929, and before 7 Up became it’s name, it was called “Bib-Label Lithiated Lemon-Lime Soda,” (really catchy name) and its original ingredients included a “healthy dose” of lithium citrate. Apparently there were more than 500 lemon-lime soft drinks on the market at the time, which is yet another fact that blows my mind. Anyway, to make their product stand out, Cadbury Beverages North America touted in their ads the “positive health effects” of the lithium in the soda, which interestingly was released just a few months before the 1929 stock market crash and the onset of the Great Depression….things that make you go hmmm….Apparently the recipe had some appeal, because in the 1940s, 7 Up was the third best-selling soft drink in the world. But alas, somebody got wise, and lithium was removed from the recipe in 1950. Just a little fun fact: there is a precedent for the addition of “pharmacologically active” ingredients in soft drinks. Coca Cola added a lot of coca leaves (from which cocaine is derived) to it’s original 1886 formulation, giving it it’s name. Another fun fact: the guy that formulated it was an alcoholic and opium addict who was looking for a cure for his affliction. Evidently it contained a great deal of the cocaine molecule, a fact that undoubtedly led to it’s popularity in those olden days. I’m sure lots of folks were bummed out when it was removed from the formulation in 1903. Didn’t matter to the formulator/owner, because he’d been found dead long before on his office floor with an opium stick in his hand. 

For more interesting stories on psychiatric conditions and the medications that treat them, check out my book, Tales from the Couch, available in my office or on Amazon.

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Drugs with Bizarre Side Affects

You’re in your favorite recliner watching the game, and then comes a “word from our sponsors.” You may not bet on the game, but you can bet there’ll be a commercial for a pharmaceutical drug during that break. For today’s purposes, I’ll refer to a fantasy medication named ‘Druguall.’ The Druguall commercial shows a couple at the beach, walking hand in hand along the shore as the announcer explains the indications for Druguall, ending with the requisite side effect statement “…Druguall may be habit forming, and has been shown to cause an inability to make a left turn, an impulse to chew toenails, and a compulsion to repeatedly beat your head against a wall. If symptoms worsen or become problematic, contact your physician immediately. If you are allergic to Druguall, do not take Druguall.” Duh! That last one always kills me. Does the American public need to be told to not take a drug they’re allergic to? Apparently so, because pharma companies have been held liable for idiots taking their drug (despite being allergic to it) in numbers sufficient enough to spend the extra commercial time and money to make the statement to cover their corporate posteriors. But enough of the woes of big pharma. What am I writing about today? Side effects! Every drug’s got ‘em, and they range from comical to serious…even downright deadly. The point of this is so that you’ll ask your doctor when he or she starts you on a new med, especially if you’re already taking other meds…you need to know if they’ll play nice together. 

Here’s the ugly truth that your doctor probably doesn’t want you to know. When it comes to taking most drugs, it’s a crap shoot. He or she can know the side effects, but there’s no way to predict if you’ll experience any of those side effects, what they may be, and if they will have a minor/major affect on your life. When it comes to prescribing, there’s a lot of ‘throw this out there and see if it sticks’ going on. Granted, good physicians know the published side effects of the drugs they prescribe. I certainly do. But even though I know these drugs inside and out, there’s still some trial and error, because everyone reacts to different medications differently. If you’ve ever seen the PDR, the Physician’s Desk Reference, it is chockablock full of side effects. And it’s big enough to be used as a weapon. Nowadays it’s really just for show…everyone just checks the internet. Anyway, when a drug is tried in humans, everything that happens is noted. If the test subject happens to fart ten minutes after taking a trial medication, that medication is labeled with a side effect of flatulence, even though the guy probably just had broccoli for dinner. So if you look at any given drug, there are multitudes of side effects. Today, I want to talk about some of the weirder and wilder ones. 

Lots of medications get a bad rap for having yucky and unpleasant side effects, and most have earned them. Almost every drug on the market has side effects of upset stomach, dizziness, and headache. Borrrring!!! Instead, I want to look at some not-so-common side effects. The big note here is that just because a certain medication can cause a certain side effect doesn’t mean it will cause that side effect.

Hallucinations happen when you sense something that’s not actually there. I’m talking little green men here, people. But hallucinations can be seen, felt, heard, and even smelled. They are some freaky and frightening side effects. Most people associate them with illegal psychadelic drugs like shrooms and acid, but prescription drugs can also cause hallucinations. The sleep aid eszopiclone and a common medication for depression called escitalopram have been known to cause hallucinations. Even a drug to treat malaria called mefloquine can cause hallucinations. I’ve seen more cases of people hallucinating than I could ever count and ordered lots of four-point restraints. I’ve seen super heroes with broken bones they received learning that they actually  couldn’t fly from multi-story buildings. I’ve seen lots of people who say they’re God, and lots who say they’re Satan, but no proof from any of them. 

Now we’ll go from freaky to funny. There are plenty of meds that will turn your urine different colors. Even some non-drug food items can do it…beets can turn it pink, asparagus can turn it green (and stinky!) and carrots can turn it bright yellow. As for meds that change pee color, every woman probably knows that pyridium for UTIs makes it bright Tang orange. Even OTC Azo will do that too. But can you imagine seeing your urine turn green or bright blue? This can be a side effect of taking the antidepressant amitriptyline or the common pain reliever indomethacin. An antibiotic called metronidazole can even cause your urine to turn black. That would freak me out. The anesthetic drug propofol can also make your urine turn blue. Michael Jackson could’ve told you about that one. Well, if he weren’t dead from abusing it.    

Big word alert for the Scrabble set: anosmia; the loss of smell. This side effect actually has a huge impact on a patient’s life, because the loss of smell goes along with the loss of taste, so patients have no desire to eat, and that becomes a problem. Sometimes patients even have to be put on IV feeds. Some examples of drugs that can cause this side effect include the blood pressure drug enalapril, the antipsychotic drugs chlorpromazine and prochlorperazine, and the antibiotic metronidazole. And just a side note, prolonged use of OTC decongestants like Sudafed can also cause loss of smell.

Sexual side effects are always of interest to patients. The most common sexual side effect is the loss of the ability to either perform during sex or the ability to enjoy sex. The usual culprits of these types of sexual side effects are certain drugs that treat depression. These medications are called selective serotonin reuptake inhibitors (SSRIs), and they include common drugs like Prozac (fluoxetine), Celexa (citalopram), and Zoloft (sertraline). I always consider this side effect when choosing what to prescribe. I find that men aren’t willing to trade mental health for sexual satisfaction, but interestingly, women are more willing to do so. 

On the flip side of the sexual side effect coin is priaprism, which is a painful, permanent erection. A variety of medications can lead to this condition, one which patients who’ve experienced it will never forget. This unfortunate side effect lasts for more than four to six hours and may be caused by antidepressants like trazodone, fluoxetine, sertraline and lithium. An anti-anxiety medication called vistaril and the blood thinner coumadin are also known offenders. Priapism due to a medication side effect (as opposed to from taking a little blue pill) often goes away without treatment, though putting ice packs on the affected area might help speed up recovery. Cringing.

This one sort of goes along with the above discussion. There are several medications that cause the side effects of unusual urges for sex and gambling, though hopefully not at the same time. Common culprits include Requip, which is a medication for restless legs, and the antidepressant Abilify. These meds may cause uncontrollable urges to gamble, binge eat, shop, and have sex. Interestingly, a Parkinson’s medication called carbidopa/levodopa also carries a warning of intense urges for gambling and sex. I’ve had cases where men don’t want to leave their homes because they want to masturbate, as well as cases where they’re caught masterbating in public. As for the gambling…I’ve had patients lose a lot of money gambling in casinos, betting on horses, and even at the dog track. The sexual and/or gambling compulsions just drive them.

It’s common knowledge that drugs affect dreams, but not always in a good way. Medications that affect neurotransmitters in the brain commonly cause bad dreams and nightmares. The Alzheimer’s medications donepezil and rivastigmine, as well as the Parkinson’s medication amantadine, are all reported to cause vivid dreams, often being of a sexual nature. Nightmares are also a commonly reported adverse effect of blood pressure medications called beta-blockers. These include propranolol, atenolol and labetalol. There are also reports of steroids like methylprednisolone and prednisone causing nightmares. Varenicline, the medication often prescribed to help people stop smoking, is known to cause dreams that are super strange and very vivid. Not only does varenecline cause bad vivd dreams, I’ve seen patienta think it’s okay to stab themselves repeatedly or to kill themselves. Varenicline is a scary strange drug. Even stranger? The prescription sleep aid zolpidem doesn’t keep many users sleeping in bed. In fact, many who take it have been known to get up at night and go for a drive, maybe talk on the phone, or even have sex…all without remembering anything in the morning. You can ask Elon Musk about zolpidem. He tweeted that he was going for an IPO for $423 a share after taking it. His advisors had a fit the next morning, but he found it amusing and shrugged it off. But Roseanne Barr wasn’t laughing when she lost her eponymous show after a discriminating tweet. She apologized, but the damage was done. Maybe she should’ve called Elon for help.

Another big word for the Scrabble set: Akathisia. The word comes from the Greek for “inability to sit,” so this side effect invokes feelings of unease and an inner restlessness.  Unfortunately, this is another adverse reaction that folks who experience it never forget. They describe it as wanting to crawl out of their skin. The triggers for this horrible sensation are the anti-nausea medications prochlorperazine and metoclopramide, as well as some SSRI antidepressants, and an anti-anxiety medication called buspirone. Thankfully, this terrible feeling goes away when the medication wears off.

What if taking a medication made you pack on the pounds? How about if it caused you to gain 20 plus pounds in only three months? Some people who take the medication olanzapine for bipolar disorder have done just that. Some common medications used to treat depression, like paroxetine, can also cause unintended weight gain. Weight gain is enough to cause depression in and of itself, so I’m always cognizant of that when I prescribe. Other drugs that can pack on the pounds include steroids, birth control pills, hormone replacement therapies, and some diabetes medications. The bottom line on that is that if you must take one of these drugs, you also must watch what you eat.

File this under the creepy side effect column. And yet another big word for the Scrabble set: Onycholysis. This is the medical term to describe when nails separate from the nail bed. You may not think that’s so bad, but trust and believe that patients who experience it do, and you would too if you had it. It can be super painful and may result in infections under the nails. Believe it or not, there are quite a few meds that can cause this: acne treatments tetracycline and fluoroquinolone, antibiotics like ciprofloxacin and levofloxacin, oral contraceptives, and some chemotherapy medications…all may cause your nails to separate from the nail beds. 

Visual disturbances can also be a side effect of certain meds. These disturbances can include blind spots, distorted vision, blurred vision, or halos around lights. Medications that can affect your vision include antihistamines, high blood pressure medications, and medications taken for malaria or tuberculosis. For men on the little blue pill, a truly weird and whacky side effect can be tinting of the vision, as through tinted glasses. And of course it tints the vision blue. I wonder if that might be a promotional idea…to see blue like their little pill. 

Most people are familiar with the hair loss that goes along with some types of cancer treatments, but there are also several other common medications that cause hair loss, including blood thinners, birth control pills, antidepressants, and medication used to treat gout. But hair growth can also be a drug side effect. Women may experience unwanted hair growth from steroid medications and from the drug danazol, which is used to treat endometriosis.

Have you ever torn a tendon? It isn’t always just from a sports injury. Believe it or not, a common medication used to treat urinary tract infections could cause you to rupture your Achilles tendon. The U.S. Food and Drug Administration (FDA) has issued a warning for just that for the class of antibiotics called fluoroquinolones. According to the FDA, pain, swelling, and tears of tendons in the heel, shoulder, and hand are more likely to occur when taking these drugs. Common medications in this class include the often prescribed antibiotics ciprofloxacin and levofloxacin. So maybe it’s best to warm the bench when you’re taking these antibiotics. 

All jokes aside on this one. No list of side effects would be complete without mentioning side effects causing birth defects. Obviously, birth defects are a very serious medication side effect, and this is why pregnant women are told not to take any drugs before checking with their doctor first. Types of drugs that can cause birth defects include high dose vitamin A, some blood pressure medications, and some antibiotics. Two drugs that are especially dangerous and potentially fatal for developing babies are Accutane (isotretinoin) and Thalomid (thalidomide). Accutane is used to treat severe acne and Thalomid is used to treat a type of white blood cell cancer. When pregnant, all side effects are serious. But pregnant or not, isotretinoin is a nasty, scary, dangerous drug. It’s used most commonly by dermatologists for severe acne. I’ve heard of patients flying planes into buildings, thinking they’re invincible and jumping from buildings, and just acting in an exceedingly dangerous way. It’s like they’re without fear.

Rather than a condition, this one is about a drug called Interferon. Interferon is used to treat certain cancers, leukemias, and Hodgkin’s Disease. I’ve seen some pretty bizarre things with Interferon. People become suicidal, openly so. They’ll talk about suicide like it’s an acceptable option. Sometimes they cut themselves and make themselves bleed. It’s very odd and very scary. Interferon can also cause bizarre thoughts, and people become psychotic. Also, they can have anosmia. Remember that? That’s the loss of smell that I discussed above. Interferon can be useful in cancer treatments, but people have to be closely monitored for side effects.

I’ve saved the weirdest of the weird, the most bizarre side effect I’ve ever seen, for last. At the time, I was in medical school but working in the ER. What I saw looked straight out of The Exorcist. The side effect is called an extra-pyramidal oculogyric crisis. Oculo- refers to eyes, which fix upward and to the side during the crisis. In severe attacks, there can also be involvement of the head and neck and structures within the neck. There are several drugs that cause it, and the crises or attacks can happen in varying degrees, from minor reactions to major emergencies requiring intubation for airway control. Oculogyric reactions are caused by neuroleptic drugs,  antipsychotics, antiemetics (anti-nausea drugs), and antidepressants. Cases involving other drugs have been reported, including methylphenidate and carbamazepine. In this case, the patient’s head was turned sideways and backward at an impossible angle, with her eyes fixed very strongly to the opposite side. Her face was frozen in a grimace and her neck was so flexed that she was unable to speak and her airway was compromised. She needed to be intubated for airway support, but doctors were unable to straighten her neck to insert the tube. They were considering a tracheostomy, making a hole in her throat, to buy some time because they didn’t know what was happening.  Because she was unable to speak, she couldn’t tell the ER doctor that she had taken an antiemetic, a medication for nausea, which had caused the episode. The doctors were puzzled as to what was happening because of how extreme the episode was, and several were gathered around her bed in the ER. A nurse just happened to stick her head in the room to see what the commotion was, and she mentioned in passing that she had seen something similar in someone who had taken compazine. At that word, compazine, the patient snapped her fingers and pointed at the nurse; the doctors asked if she had taken compazine and she snapped her fingers again and the mystery was solved. They gave her IV Benadryl and five minutes later her neck and eyes relaxed to midline and in another five minutes, she was able to speak. I’ve seen oculogyric crises since, but none like that. The whole Exorcist thing is the craziest side effect I’ve ever seen, but I will forever remember extra-pyramidal oculogyric crises.

After working in psychiatry for the past 30 years, I’ve seen time and time again that when you put a drug in the human body, you don’t know what you’re going to get. It’s like Forrest Gump’s box of chocolates,  but not as tasty. For more patient stories, be sure to read my book Tales from the Couch, available on Amazon.com.

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How To Know If Someone Is Schizophrenic

A man named Eugene Bleuler coined the term schizophrenia. If you break the word down to its parts, “schizo” and “phrenia,” it literally means split personality. But that’s not what schizophrenia is. There are so many misconceptions about schizophrenia that I want to explain more about it.  

Schizophrenia is a psychotic disorder, a severe and often debilitating brain and behavior disorder. It  affects how a person thinks, feels, and acts, because they have breaks from reality. Basically, that means they have hallucinations and delusions, and can have trouble telling the difference between reality and fantasy. Their thought processes, behavior, and speech can become disorganized. Disorganized basically means abnormal. Disorganized speech is generally gurgly speech, it makes no sense. Disorganized behavior is basically a decline in daily functioning. This can range from a person not taking care of their hygeine, not bathing or brushing their teeth, to catatonia, where they are unable to move at all. They freeze and look like a statue, and this is called posturing. There can be something called “waxy flexibility” which is where their body can be placed in any shape in a fixed position, like a wax figure, hence the name. Disorganized thinking is basically when someone cannot “think straight.” They are unable to connect thoughts into logical sequences, so their thoughts become disorganized and fragmented. They often have unpredictable or inappropriate emotional responses, and hear imaginary voices and believe others are reading their minds, controlling their thoughts, or plotting to harm them. These are delusions and hallucinations; the two are very different. A delusion is a false fixed belief, often involving thoughts of others monitoring or threatening them or reading their thoughts. The most common type of delusion is a paranoid delusion. “The CIA is tracking me,”  “The FBI is coming to get me,” “My neighbor is watching me.”  These are common delusions in people with schizophrenia. Hallucinations cause a patient to hear, see, feel or smell something that is not there. The most common type of hallucination is an auditory hallucination, meaning the person hears something not actually there. These auditory hallucinations can be dangerous if they are what are called “command hallucinations,” because they can tell the person to kill themselves or someone else. Obviously, this is not good, and must be taken very seriously. Anytime you have someone experiencing hallucinations, it is in your best interest to explore these with a mental health practicioner to find out what they are and take appropriate measures. 

Schizophrenia can be cyclical. There can be remission and relapse cycles; a person can get better, worse, and then better again repeatedly over time.
As a result, people with schizophrenia suffer from symptoms either continuously or intermittently throughout their entire lives, and they are often severely stigmatized by people who do not understand the disease. Contrary to popular belief, people with schizophrenia do not have “split” personalities or multiple personalities, and as long as they receive appropriate treatment and are compliant with medications, most pose no threat to others. However, the symptoms are sometimes so terrifying to those experiencing them that they can become agitated, withdrawn, and depressed. Sadly, people with schizophrenia attempt suicide more often than people in the general population, and it is estimated that up to 10 percent of people with schizophrenia will complete a suicidal act at some point within the first 10 years of the illness. This is particularly true in young men with schizophrenia. While schizophrenia is a chronic disorder, it can be treated with medication and psychological counseling, and this can substantially improve the lives of people with the condition.

Schizophrenia can have very different symptoms in different people. The way the disease manifests itself and progresses in a person depends on the age of onset and the severity and duration of symptoms, which are categorized as positive, negative, and cognitive. Positive symptoms don’t mean symptoms that are good, they mean symptoms or actions which are added to the person’s behavior. Examples of positive symptoms are delusions and hallucinations, and these can be severe or mild. Negative symptoms don’t mean they are especially bad, they mean symptoms or actions which are taken away from the person’s behavior. They reflect a loss of functioning in areas such as emotion or motivation. Examples of negative symptoms are loss of motivation, aimlessness, poverty of speech, a blunted or flat affect, and inability to express emotion or find pleasure in life.  They often lead to social withdrawl and apathy, and can be mistaken for laziness or depression. Cognitive symptoms involve problems with attention and memory, especially in planning and organizing to achieve a goal. These cognitive deficits are often the most disabling for patients trying to lead a normal life, as they make it very difficult to keep up with peers in the big wide world. All three types of symptoms- positive, negative, and cognitive- reflect problems in brain function. 

Schizophrenia affects men and women equally. Symptoms such as hallucinations and delusions usually start between the ages of 16 and 30, though men tend to experience schizophrenia symptoms earlier than women. Schizophrenia rarely occurs in children, but awareness of childhood onset schizophrenia is increasing in the psychiatric community. It can be difficult to diagnose schizophrenia in teens. This is because the first signs can include behaviors commonly exhibited by normal teenagers, such as a change in friends, a drop in grades, sleep problems, and irritability. Despite this, there are a combination of factors that can predict schizophrenia in up to 80 percent of youth who are at high risk of developing the illness. These factors include isolation, withdrawing from others, an increase in unusual thoughts, paranoia and unusual suspicions, and a family history of psychosis. 

Currently, schizophrenia is diagnosed by the presence of symptoms or their precursors for a proscribed period of time. There must be at least six months of deteriorating function where the illness is present. Additionally, two or more positive symptoms, such as hallucinations, delusions, and/or disorganized speech, as well as negative symptoms, must be significant and last for at least one month to make a diagnosis. In some cases, only one symptom is required for diagnosis if the delusions are bizarre enough or if dangerous auditory command hallucinations are present, or if there are two or more voices “conversing.” Social or occupational problems can also be taken into account in diagnosis. 

What causes schizophrenia is still unknown. Scientists are working to understand the genetic and environmental mechanisms that combine to cause schizophrenia. It is not purely genetic, because one of a pair of identical twins may have it while the other does not. In terms of environmental issues, when a baby is in utero, it can be exposed to bacteria, viruses, environmental toxins, poisons, and contaminants, which may also play a role. Trauma at birth and decreased oxygenation may play a role. Some psychological and social issues may also contribute. Sexual abuse, physical abuse, a neglectful family, a stressful life, parents that have died, people raised or living in rough urban areas, and people who move from their home country- are more prone to schizophrenia. As more is discovered about chemical circuitry and structure of the brains of people with the disease, better diagnostic tools and early intervention techniques can be developed. This is crucial for schizophrenia, as it is believed that with every psychotic episode, increased damage is done to the brain. It doesn’t go back to it’s previous place. Speaking of the brain, their can be some differences in the schizophrenic brain. In general, but not always, people with schizophrenia may have less intracranial volume, which basically means their brains are small. They have less white matter and their grey matter decreases over time. There is an increase in ventricular volume, meaning that the ventricles that house the brain get larger, but the actual brain itself gets smaller. 

As mentioned before, schizophrenia can be cyclical, with periods of remission and relapse, but no cure exists for schizophrenia. However, it is treatable and manageable with medication and behavioral therapy, especially if diagnosed early and treated continuously. Those with acute symptoms, severe delusions or hallucinations, suicidal thoughts, or the inability to care for themselves may require hospitalization. Schizophrenia treatments typically include antipsychotic drugs as the primary medication to reduce the symptoms of schizophrenia. They relieve the positive schizophrenia symptoms by impacting the brain’s neurotransmitters. Other treatments for schizophrenia include cognitive and behavioral therapy that can then help “retrain” the brain. These approaches improve communication and motivation, and can teach coping mechanisms so that individuals with schizophrenia may attend school, hold down a job, and socialize properly. Obviously, patients who are compliant with medications and therapy do better than those who are not. Social networks and family member support have also been shown to be helpful.

Unfortunately, there are sad cases, people that for whatever reason(s) don’t do well. Life is difficult for them. You may have seen them, wandering the streets aimlessly, making bizarre movements, having an argument with someone who is not there. It is very hard to treat these people who are socially withdrawn. They’re going nowhere in life. They usually live in an assisted living facility, if they’re lucky. Many live on the street. They are sedentary. They usually neglect their hygiene. They don’t eat a healthy diet. They chain smoke cigarettes. Believe it or not, nicotine may be helpful for the treatment of schizophrenia. It sort of calms them down. They drink soda and eat sugary foods. They eat too much and very poorly. They’re prone to developing diabetes because the treatments, the medications, on top of the smoking and the sedentary lifestyle can cause coronary artery disease, diabetes, and fatty liver. They do not live healthy lives due to their illness.

In general, schizophrenics live an abbreviated life, about 20 years less than the norm. The most common issues are delusional beliefs and command hallucinations to kill themselves. Disorganized behavior in public may result in them being victims of crime. They usually have violent ends because they are victims of crime.  Substance abuse is often rampant in schizophrenics seeking an escape from the chaos inside their heads. Non-compliance with treatment is another factor. Also, the much higher incidence of smoking cigarettes, poor diet, poor exercise habits, and poor self-care contribute. All of these separately or together in some form or fashion is what usually causes their longevity to be dramatically decreased.

But with full compliance, patients can have a good life. There are famous people with schizophrenia. John Nash, the Nobel Prize winning mathematician. The great author Jack Kerouac. Peter Green, guitarist for Fleetwood Mac. Syd Barrett founder and member of Pink Floyd, and Beach Boy Brian Wilson.

For case studies of schizophrenia as well as other psychiatric diagnoses, check out my book, Tales from the Couch,

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Millennials:The Blame Game

Most of the patient population in my practice are millennials. There are varying opinions on the age of this group, but for my purposes, I go with 40 and under. It seems like all I hear about these days is that this group, these people, have ruined EVERYTHING, and frankly, I’m sick of it. Listen, the older generation blaming problems on the younger generation is certainly not new; it’s always been that way. But for some reason, millennials are taking a far bigger rap for the problems in the world today than any other generation has in the past. They should be called the “Scapegoat Generation.” Sure, millennials have different priorities, values, and goals than their parents’ generation. No argument there. In general, they value healthy eating habits, spending their money on experiences rather than on physical possessions, and working their butts off to pay down their astronomical student loan debt. And of course, you have to remember that they grew up with the internet, the world at their fingertips. Contrast that with the older generation that had to go to a libraryand check out actual books. And the older generation had to actually drive to a store to buy things, but millennials just order it and it shows up on their doorstop two days later. So the older generation thinks millennials have it too easy. But au contraire, they have to suffer the consequences for the actions of previous generations and take the blame for ruining everything to boot. It drives me so crazy that I just have to talk about it. So below I want to go through some of the things that millennials are blamed for annihilating, some of which are absolutely patently ridiculous. But that’s just my opinion. Read on and decide for yourself.

Restaurant Chain Gangs
Dummy’s Yummies, Fooligan’s, Thank God It’s Fattie’s, yada yada. “Casual dining” restaurants are losing business and having to close stores left and right because those damn millennials don’t want to eat the high cal, high fat, high cholesterol foods that have been expanding waistlines for years. To the “All you can eat all fried everything appetizer!!” they say no. They much prefer to cook healthy and at home so that they actually know what’s in their food. Shame on you, millennials!

Lucy in the Sky With(out) Diamonds 
Remember the De Beers’ ad from years ago that said a reasonable guideline to spend on an engagement ring was six month’s salary?! That might have flown then, but times have changed. Shockingly, De Beers now reports that diamond sales have been steadily dropping, from 32% in 1990 to 27% in 2015, and that sales continue to follow this downward trend. Why? Well, the obvious reason is money money money. Millennials are having a hard enough time making ends meet without adding pricey ice to their already tight budget. A less obvious reason that they’re not buying diamonds is an ethical one…they’re actually concerned with how and where diamonds are mined. It’s very popular now to choose a non-diamond gemstone for engagement ring bling. Silly millennials…thinking independently.

Tears for (Crappy) Beers
Bud, Coors, Natty Light…millennials don’t care for the cheapo pee water that passed for beer that their parents and grandparents drank by the gallon. Instead, they prefer unique craft beers, the smaller the batch the better. They enjoy beer flights with lagers and IPAs that actually taste like something. Expanding your horizons and daring to break beer tradition…bad millennials!  

Bar Soap is Bad Soap?
No, I’m not kidding. Millennials are destroying the bar soap industry. Marketwatch surveys reports that millennials think bar soap is “gross,” and that they prefer to wash up with liquid soap instead. Their statement of findings said, “Almost half (48%) of all U.S. consumers believe bar soaps are covered in germs after use, a feeling that is particularly strong among consumers aged 18-24 (60%), as opposed to just 31% of older consumers aged 65+.”
So nearly twice as many millennials are grossed out by germy bar soap than old people. Pesky millennials, preferring not to wash your hands with germy, gunky, dirty old bars of soap.

Endangered Species: Paper Napkins
These cheap millennials are even killing paper napkins. How do they carry out this dastardly deed? They buy paper towels! And get this…they not only use them for their intended use, they also use them as napkins! Oh, the horror! And why, why, why would they do this?!?! They say it’s because “it’s just one less thing to buy,” but I’m sure it’s a grand conspiracy. 

Boxed Cereal
Seriously? Paper napkins yesterday, boxed cereal today. It’s a very slippery slope, people! What is the world coming to? Evidently, cereal sales have fallen almost 30% in recent years, and it’s all the millennials’ faults. Reports state that “Almost 40 percent of millennials surveyed said cereal was an inconvenient breakfast choice because they had to clean up after eating it.” I assume this clean up involves washing a bowl and a spoon. Painful though it is, I have to side with the old folks on this one….40% of you are lazy millennials!

No “Fore!” Play
Millennials don’t play “the sport of kings,” aka golf, nor do they watch it on TV or waste time thinking about hitting a little white ball into a hole with a metal stick. A very expensive metal stick. They also don’t have respect for the people that hit that little white ball for a living…a very lucrative living. It makes no sense to them. Their apathy is real and ever-growing, so much so that fans of the sport fear that within the next 52 years, millennials will succeed in finally killing golf, making it (poof!) disappear entirely. Don’t ask me how they figured exactly 52 years…I have no clue.

Workin’ 9 to 5…Not the Way to Make a Livin’?
The days of clocking in at 9 AM and out at 5 PM are long gone, but not because millennials are lazy. In fact, thanks to technology, millennials are changing the way the American work force gets stuff done. With technology, they’re working from home more and demanding more work flexibility from employers. Instead of being unreachable and shutting the computer down at the end of the day, employees are never out of touch. That’s great for employers, but not so much for millennial employees. No fun when your boss interupts your binge-watch.

Vacay…Yay or Nay?
Speaking of always working….Travel & Leisure has decided that millennials have destroyed the American vacation, not because they’re poor or lazy as some believe, but because they’re obsessed with work! They say that work pressure and an always-on attitude have increasingly caused many Americans to abandon their vacation days. In 2015, it’s estimated that 55% of working Americans didn’t use all of their vacation days, leaving behind 658 million days of unused PTO on the table. Silly millennials…take your PTO!!!

Movie Madness
You only need one word when it comes to how millennials and their evil technology have destroyed movie theaters…Netflix! Since its advent, the movie industry has been flailing, struggling to justify their own existence. Why spend $12 to sit shoulder to shoulder with loud, popcorn-munching strangers in a crowded, sticky-floored theater when you can Netflix and chill at home in your pajamas? The answer? You wouldn’t! Now who thinks like a millennial? 

Super-Duper Home Improvement Stores
We’ve established that millennials are generally broke. If they aren’t living with mom and dad, most of them rent, meaning they don’t own a home. So they have no use for a home improvement store to buy a bunch of stuff to improve a home they don’t have. As a result, millennials are apparently killing Lowe’s and Home Depot, both of which have reported a huge dip in sales. Naturally, that’s all your fault, millennials!!

Family Ties (That Bind)

Millennials are being blamed for destroying the very fabric of society by choosing not to have children. Why? Kids are freaking expensive, potentially putting them in an 18-plus year financial bind. And we’ve established that millennials are mostly broke, struggling with little pay and humongous educational debt. As established above, most don’t own a home with a big backyard and white picket fence. Many work multiple jobs in a gig economy, (which is also their fault) so they don’t have a lot of the time it takes to raise a small human. And many of them don’t see the brightest future when it comes to finance, government leadership, and the environment. And why would they? They went to college with the surety of graduating to find a fabulous job with amazing benefits and instead graduated to the worst economical slump since the great depression of the 40’s, no jobs, dying oceans, drought, family farms closing, and no bright promise on the horizon. Jaded millennials…but I ask, why shouldn’t they be?  

Football?!?!
Millennials are killing football now too?! Looking into this, I see that it’s not so much that millennials don’t like football; it’s more that they don’t want their kids playing the sport. That’s if they even dare to have kids, a topic which I explored above. There is far more information about the danger of football today. Previous generations smacked their kids on the ass and sent ‘em out to the field and cheered as they tackled the other team’s players. Today we understand the cumulative damage of repetetive concussions, and not surprisingly, many parents are prohibiting their kids from playing tackle football. Eventually, this will lead to a dearth in potential professional football stars hired by the NFL, and that will equate to a lot of unhappy people in the fall and January of every year. Apparently millennials are staunchly against repetitive concussive brain injuries in their children. Go figure.

The American Dream…A Nightmare?
Damn it, millennials! Stop the madness! Now you’re killing off the American Dream? How could you…It’s been around for so long!! I’ve told you that millennials are poor, but let’s get specific. Studies have shown that millennials earn 20% less than their parents did at their ages, and they only own half the total assets as the Baby Boomers did at their age. Financial forecasts show that the idea of buying a home is now way out of reach for most young people today. They’re graduating from college with huge amounts of debt, they’re working longer hours than any previous generation, and they’re getting paid less than their parents made…so much for the American Dream. But somehow, the downfall of that American Dream is their fault. Hmmm…

What have we learned about millennials today? What are the takeaways? 

Millennials are:
– Smart and adaptive
– Hardworking but poor
– Debt-ridden with college loans
– Health-conscious
– Hooked on technology
– Clearly ruining everything!

I cover more in a full chapter about millenials in my book Tales from the Couch, which is available on Amazon.com.

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Autism Spectrum disorder

Comedian Dan Aykroyd, children’s author Hans Christian Andersen, movie director Tim Burton, naturalist Charles Darwin, poet Emily Dickinson, scientist and mathematician Albert Einstein, chess grandmaster Bobby Fischer, Microsoft founder Bill Gates, actress Daryl Hannah, late Apple CEO Steve Jobs, painter Michelangelo, music composer/ pianist Amadeus Mozart, and artist and cultural influencer Andy Warhol, just to name a few…  

What do all of the above people have in common? Given their fame and success, I bet you’ll never guess. They all have islands of extreme expertise, but all also have social limitations in terms of their abilites to interact with others and their ability to communicate. What does that sound like? What diagnosis do they share? Autism.

Autism spectrum disorder (ASD) is a condition related to brain development that affects how a person relates to and socializes with others, and which also causes problems in communication and social interactions. Replacing just the single word autism, the term “spectrum” in autism spectrum disorder refers to the wide range of symptoms and potential severity of the disorder of autism.

Autism spectrum disorder is said to be a “developmental disorder” because symptoms generally appear in the first two years of life. The disorder extends into adulthood, causing problems with functioning in society, in school, and at work. Children often show symptoms of autism within the first year of life, though signs may be subtle at first. Sometimes children appear to develop normally in their first year, but then exhibit regression between 18 and 24 months of age as they develop autistic symptoms.

Symptoms of ASD

Children can show signs of autism spectrum disorder in early infancy. These include reduced eye contact, lack of response to their name and/or indifference to caregivers. Some children may develop normally for the first few months or years of life, but then suddenly become withdrawn or aggressive or lose the language skills they’ve already acquired. Fairly definitive signs of ASD are usually seen by age two. 

Each child with ASD will have difficulty with social interactions and will exhibit unique patterns of behavior and levels of severity, from low functioning to high functioning.
Some children with autism spectrum disorder may have difficulty learning, and some have signs of lower than average intelligence. Other children may have normal to high intelligence and learn quickly, but have difficulty communicating and applying what they know. Because of the unique mixture of signs and symptoms exhibited in each child, the severity of ASD can sometimes be difficult to determine. It’s generally based on the level of impairment and how that impairment impacts the ability to function.

A child or adult with ASD may have problems with social interactions and communication skills, including any of these signs:

Failure to respond to his/her name or appearing to not hear you at times

Resists cuddling and holding as child

Lacks facial expression

Prefers playing alone, retreats into his/her own world

Exhibits poor eye contact 

Doesn’t speak/ has delayed speech/  loses previous speech ability 

Can’t initiate or further conversation 

Speaks with abnormal tone or rhythm; may use a singsong voice or robot-like speech

Repeats words or phrases verbatim, but doesn’t understand meaning

Doesn’t appear to understand simple questions or directions

Doesn’t express own emotions/ feelings and is unaware of others’ feelings

Inappropriate aggression or disruption to social interactions of others 

Difficulty recognizing nonverbal cues, interpreting other people’s facial expressions, body postures, or tones of voice

A child or adult with ASD may exhibit limited and repetitive patterns of behavior, including any of these signs:

Performs repetitive movements, such as rocking, spinning or hand flapping

Develops specific routines or rituals, becomes disturbed at the slightest change

Performs self-harming activities, including biting or head-banging

Is unusually sensitive to light, sound, and/or touch, yet can be indifferent to pain or temperature

Has problems with coordination or exhibits odd movement patterns, such as clumsiness, walking on toes, and odd, stiff, or exaggerated body language

Is fascinated by small details of an object without understanding the overall purpose or function of the object. Ex: spinning wheels of a toy car

Doesn’t engage in imaginative or make-believe play

Fixates on an object or activity with abnormal intensity or focus

Has very specific food preferences: eats very few foods/ refuses certain textures

A child or adult with ASD may exhibit other signs and symptoms, such as:

Unusual Touch and Sound Sensitivities: They may recoil when touched, and/or may be extremely hypersensitive to certain sounds

Seizures: Approximately four out of ten people with ASD suffer from seizures; most commonly occurs in childhood or entering teenage years and in those with more severe cognitive impairment.  

Bowel Disorders: People with ASD tend to have more gastrointestinal symptoms such as abdominal pain, constipation, and diarrhea than peers

Placing Inedible Objects in the Mouth: While it is common for babies and toddlers to put toys or other inedible objects in their mouths, older kids with autism may continue to do this even as they age. Some children have been known to put items like soil, chalk, and paints into their mouths, which means supervision is a must to prevent them from eating something toxic or choking on an object.

Sleeping Issues: Getting a child to sleep at an assigned time can be hard, but children with ASD often have different sleep patterns. ASD interferes with the “working clock” that regulates sleep patterns. Many children with ASD with sleep problems will have the problem in adulthood as well. 

As they mature, some children with autism spectrum disorder become more engaged with others and show fewer behavioral disturbances, but some, usually those with the least severe problems, may end up leading normal or near-normal lives. But others continue to have difficulty with language or social skills, and for them, the teen years can bring even worse behavioral and emotional problems.

When to see a doctor

Babies develop at their own pace…they don’t necessarily follow the developmental timelines that Dr. Spock or other parenting book authors lay out. But children with autism spectrum disorder usually show some signs of delayed development before they are two years old. If you’re concerned about your child’s development or suspect that your child may have ASD, discuss your concerns with your pediatrician, as some ASD symptoms can look like other developmental disorders.

Your pediatrician may recommend developmental tests to identify if your child has delays in cognitive, language and social skills, or if your child doesn’t meet certain timelines:

Doesn’t respond with a smile or happy expression by 6 months

Doesn’t mimic sounds or facial expressions by 9 months

Doesn’t babble or coo by 12 months

Doesn’t gesture, point or wave by 14 months

Doesn’t say single words by 16 months

Doesn’t play “make-believe” or pretend by 18 months

Doesn’t say two-word phrases by 24 months

Loses language skills or social skills at any age

Causes of ASD

Autism spectrum disorder has no single known cause. Given the disorder’s complexity and the fact that symptoms and severity vary, there are probably many causes, with genetics and environment likely playing larger roles.

Genetics: Several different genes appear to be involved in ASD. For some children, ASD can be associated with another genetic disorder, such as Rett syndrome or fragile X syndrome. For other children, genetic mutations may increase the risk of autism spectrum disorder. Other genes may affect brain development or the way that brain cells communicate. Some genetic mutations are inherited, but others occur spontaneously.

Environmental factors: Researchers are currently exploring whether factors like viral infections, medications, complications during pregnancy, or air pollutants play a role in triggering autism spectrum disorder.

Not from childhood vaccines: One of the biggest controversies in autism spectrum disorder centers on whether childhood vaccines can cause ASD. Despite extensive research, no reliable study has shown a link between autism spectrum disorder and any vaccines. In fact, the original study that ignited the debate years ago has been retracted due to poor design and questionable research methods. Not only do vaccines not cause ASD, but 
avoiding childhood vaccinations can place your child and others in danger of catching and spreading serious diseases, including whooping cough (pertussis), mumps, and/or measles. So don’t let the fear of ASD keep you from allowing your child to have their vaccines. 

Risk factors for ASD

The number of children diagnosed with autism spectrum disorder is rising. It’s not clear whether this is due to better detection and reporting or a real increase in the number of cases, or a combination of the two.
Autism spectrum disorder affects children of all races and nationalities, but certain factors increase a child’s risk. These risk factors may include:

Your child’s sex: Boys are about four times more likely to develop autism spectrum disorder than girls are.

Family history: Families who have one child with autism spectrum disorder have an increased risk of having another child with the disorder. It’s also fairly common for parents or relatives of a child with autism spectrum disorder to have minor problems with social or communication skills themselves or to engage in certain behaviors typical of the disorder.

Other disorders: Children with certain medical conditions have a higher than normal risk of autism spectrum disorder or autism-like symptoms. Some examples include fragile X syndrome, tuberous sclerosis, and Rett synsyndrome.

Extremely preterm babies: Babies born before 26 weeks of gestation may have a greater risk of autism spectrum disorder.

Parental ages: Children born to older parents may be more likely to develop ASD, but more research is necessary to fully establish this link.

Complications of living with ASD

The problems that come with ASD in terms of social interactions, communication, and behavior can lead to issues in life, including:

Problems in school and successful learning

Employment problems

Inability to live independently

Social isolation

Stress within the family

Victimization and being bullied

Prevention of ASD

There is no way to prevent autism spectrum disorder, but there are some treatment options. Intervention is helpful at any age, but early diagnosis and intervention is the most helpful to improve behavior, skills and language development. While children don’t usually outgrow autism spectrum disorder symptoms, with work, they may learn to function well within their environment.

Diagnosis of ASD

Your child’s doctor will look for signs of developmental delays at regular checkups. If your child shows any symptoms of autism spectrum disorder, you’ll likely be referred for an evaluation to a specialist who treats children with autism spectrum disorder, such as a child psychiatrist/ psychologist, pediatric neurologist or developmental pediatrician.

Because autism spectrum disorder varies widely in symptoms and severity, making a diagnosis may be difficult. There isn’t a specific medical test to definitively diagnose the disorder. Instead, a specialist will make observations. These may include:

Observing your child’s development, social interactions, communication skills and behavior; done over time to determine if there have been changes.  

Give your child tests which will cover hearing, speech, language, developmental level, and social and behavioral issues.

Score your child’s social and communication interactions.

Include other specialists in order to definitively determine a diagnosis.

Recommend genetic testing to determine if your child also has a genetic disorder such as Rett syndrome or fragile X syndrome.

Treatment for ASD

While there is no cure for autism spectrum disorder, early and intensive treatment can make a big difference in the lives of most children with ASD. The goal of treatment is to maximize your child’s ability to function by reducing ASD symptoms while also supporting development and learning. Early intervention during the preschool years can help your child learn critical social, communication, functional, and behavioral skills that will make a huge impact on their adult lives.

The range of ASD “therapies” you’ll find on an internet search can be very overwhelming. If your child is diagnosed with autism spectrum disorder, talk to experts about creating a treatment strategy and build a team of professionals to meet your child’s needs.

Some ASD treatment options may include:

Behavioral and communication therapies: Many programs address the range of social, language, and behavioral difficulties associated with ASD. Some programs focus on reducing problem behaviors and teaching new skills. Other programs focus on teaching children how to act in social situations or how to communicate better with others. Applied behavior analysis (ABA) can help children learn new skills and apply these skills through a reward-based motivation system.

Educational therapies: Children with ASD often respond well to very structured educational programs. Successful programs typically include a team of specialists and a variety of activities to improve social skills, communication and behavior. Earlier intervention is better, and preschool children who receive intensive one on one behavioral intervention show more progress.

Family therapies: Parents and other family members can learn how to play and interact with their children in ways that promote social skills, manage problem behaviors, and teach communication and other daily living skills.

Other therapies: Depending on your child’s needs, they can have speech therapy to improve communication skills, occupational therapy to teach activities of daily living, and physical therapy to improve movement and balance. Any and all of these may be beneficial. Adding a psychologist to address problem behavior is also beneficial.

Medications: There are no specific medications to improve the core signs of autism spectrum disorder, but some medications can help control specific symptoms, including hyperactivity, behavioral issues, and anxiety. Always keep all health care providers updated on all medications or supplements your child is taking, as some can interact and cause dangerous side effects.

Some ASD takeaways

Autism spectrum disorder is a developmental disorder that causes problems with communication and social interactions. There are no specific tests for autism spectrum disorder, the diagnosis is made by observation and process of elimination. There are no one-size-fits-all therapies for autism spectrum disorder. Early detection and intervention are of utmost importance and make a greal deal of difference in determining the person’s likely functional level in adulthood. If your child exhibits some of the characteristics defined above, it is best to see your pediatrician for an evaluation.

For information on other psychiatric diagnoses and patient stories and experiences, please check out my book, Tales from the Couch, available on Amazon.com. 

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Let’s Talk About Ambien

Ambien, generic name zolpidem, is the most commonly prescribed sleep aid, accounting for 85% of prescribed sleeping pills. It also ranks in the top 15 on the list of most frequently prescribed drugs in the country. Its popularity is clearly due to its efficacy. Zolpidem works as a hypnotic drug, meaning that it induces a state of unconsciousness, similar to what occurs during natural sleep. How does it do that? Zolpidem affects chemical messengers in the brain called neurotransmitters, specifically a neurotransmitter called GABA. By affecting GABA, it calms the activity of specific parts of the brain. One of the areas in the brain that is affected is the hippocampus. Along with other regions of the brain, the hippocampus is important in the formation of memory. Because of this hippocampal involvement, 

zolpidem can cause memory loss, especially at higher doses, an effect colloquially referred to as “Ambien Amnesia.” If you take it and do not go to bed immediately as recommended, this is more likely to occur. When you get right in bed after taking it, a loss of memory is inconsequential…it doesn’t matter if you can’t remember lying awake for a few minutes before falling asleep. But there are many reports of people taking it and remaining awake and out of bed, and they commonly experience an inability to recall subsequent events shortly after taking it. Because of its effects on memory, there is some concern that zolpidem could affect long-term memory and contribute to the development of dementia or Alzheimer’s disease, though there has been no research to prove or disprove these possible associations. Zolpidem comes with a host of known side effects that range from weird and wacky to illegal and downright dangerous behaviors. Included are hallucinations, decreased awareness, disinhibition, and changes in behavior. Very serious problems may occur when someone who has taken zolpidem gets up during the night. They may exhibit very complex sleep-related behaviors while under the influence of zolpidem. These might include relatively innocuous sleeptalking, sleepwalking, sleep cleaning and sleep eating, to more disturbing behaviors like sleep cooking and sleep sex, to potentially deadly sleep driving. While in a confused state, a person on zolpidem may act in a way that is different from their normal waking behavior. This can lead to legal consequences, such as driving under the influence (DUI) or potentially even sexual assault charges stemming from disinhibited sexually charged behavior. 

I have a long time patient named Deanna that takes zolpidem and regularly sleepwalks, also known as somnambulation for the Scrabble set. It happens that she has been a sleepwalker ever since she had the ability to walk, so being on the zolpidem now makes her nocturnal activities and behaviors really way out there. Just flipping back through her chart, I see she mentions: taking apart electronics and trying to put them back together with no success. Dumping all of her shoes out of their boxes onto her closet floor. Taking all of her clothes off their hangers and throwing them over her dining room chairs. Gathering all sorts of disparate items together, evidently whatever catches her eye at the time, and putting them in her oven. She said she learned that particular lesson the hard way. This one is whacked. She started “painting” a wall in her house….with a purple sharpie. She showed me a picture of that. She once found several pages of her stationery scrawled in words she knew she didn’t consciously write in a letter to someone, she didn’t know who. She brought that in. She said she would evidently clean in her sleep; she put shower gel all over the tile in her shower and “put things away” in odd places they didn’t belong in. She also sleep eats. Cereal, bread, ice cream, whatever she sees that looks good I guess. She regularly wakes up to a mess in the kitchen and destruction in the house. It used to really freak her out to see the evidence of activities she didn’t remember, but now she just feels unsettled as she surveys the damage from her night time escapades. But since it hasn’t ever been anything dangerous and because zolpidem works well for her, she doesn’t want to change it. 

How is it that a person on zolpidem can achieve these complex behaviors while unconscious and asleep? It’s because the parts of the brain that control movement still function, but inhibition, consciousness, and the ability to create memory is turned off. Because of this, the person is disinhibited, and that can lead to unintentional actions and behaviors as discussed above.

Beyond zolpidem’s effects on memory, awareness, and behavior, there may be additional issues associated with its use. Some other common side effects include:

– “Hangover” or carry-over sedation,               especially in women

– Headaches

– Loss of appetite
– Impaired vision
– Slow breathing rates
– Muscle cramps
– Allergic reactions
– Memory loss
– Inability to concentrate
– Disorientation
– Emotional blunting
– Depression and/or suicidal thoughts
– Anxiety
– Nightmares
– Sedation
– Confusion
– Dizziness
– Delirium

– Aggression
– Back pain
– Diarrhea or constipation

– Sinusitis (sinus infection)
– Pharyngitis (sore throat)
– Dry mouth
– Flu-like symptoms
– Seizures

– Breathing difficulties
– Palpitations (irregular heartbeat)
– Rash
– Rebound insomnia

Any of these side effects could be bothersome and may interfere with the continued use of the medication. Sometimes the benefits of zolpidem outweigh the risks and/or side effects. If a symptom is particularly bothersome, discuss this with your prescribing doctor to see if an alternative treatment may be a better option for you.

If you take zolpidem, use it exactly as prescribed and get in bed immediately after taking it. It’s best to allow yourself at least 7 to 8 hours of sleep to help ensure avoidance of morning hangover effects. Keeping a regular sleep-wake schedule will also help. Taking zolpidem with other drugs that depress the central nervous system such as alcohol, opioid pain medications, or tranquilizers intensifies the sedative effects of zolpidem and increases the risk of overdose as a result of respiratory depression. Zolpidem is an abusable drug. Individuals who take it for non-medical reasons or at more than prescribed doses are at risk of experiencing intensification of adverse side effects, including the following:

– Excessive sedation
– Confusion and disorientation
– Lack of motor coordination
– Slow response times
– Delayed reflex reactions
– Dizziness
– Hallucinations
– Impaired judgment
– Aggression
– Seizures

– Withdrawl

Men and women don’t metabolize zolpidem in the same way. Women metabolize it much more slowly, so they often wake up with a zolpidem hang over and feel cloudy in the morning. So an important note for women taking zolpidem is to be extra cautious about allowing at least 8 hours of sleep after taking it and to take lower doses of it due to the potential effects on morning function, especially driving. 

Actor Roseanne Barr had probably taken a little too much when she “Ambien tweeted” a racist statement comparing an Obama aid to an ape. She admitted that she had taken zolpidem shortly before the 2am tweet that caused her eponymous show to be cancelled. Elon Musk, Mr. Tesla, can feel her pain. He shocked investors when he tweeted he was considering taking Tesla private at $420 a share and that funding was secured. He said he sometimes takes zolpidem because it’s either that or no sleep. Good thing he has people to protect him from himself when he’s in a zolpidem daze.

Zolpidem can be a safe and effective medication to treat insomnia, but if it affects your memory or causes sleep behaviors or other adverse side effects, you should probably consider alternative treatments for your insomnia. Hello Roseanne and Elon…that means you!!

I talk more about drugs for sleep like zolpidem and a host of other psychoactive drugs in my book, Tales from the Couch, available on Amazon.com.

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Help and Homeopathy for Anxiety

Anxiety disorders affect 40 million adults in the United States, making it the most common mental health condition in the country. Untreated anxiety can affect every facet of life, making it difficult to relax, to achieve success in a work environment, to have fulfilling hobbies, and to maintain close relationships with family and friends. While there is no cure for anxiety, there are ways to manage it. While there are many prescription anxiolytics, today I want to talk about some behaviors, supplements, vitamins and homeopathic remedies that you can use to help deal with anxiety and release the hold it may have on your life. 

Let’s start with some simple stuff. Some behaviors that you should stop and some you can start to help quell anxiety. 

Behaviors to stop

Alcohol: If you think consuming alcohol would help ease anxiety, you would be wrong. While alcohol relaxes the body, it clouds the mind, and a clouded mind actually increases anxiety. And though you might feel relaxed for an hour or two, once you stop drinking, your mind and body are affected as the alcohol leaves your system, so the other 22 hours of your day will only be filled with more anxiety. Not only that, if you have chronic anxiety and drink in a misguided attempt to help it, you’re going to be consuming alcohol in quantities that can end up in your developing alcoholism. 

Smoking tobacco: Again, you may think that cigarettes might help anxiety. When a smoker gets stressed, they often say they want to smoke to chill out. So why does smoking seem to help smokers relax? Smoking cigarettes interferes with certain chemicals in the brain. When smokers haven’t had a cigarette for a while, the craving for another one makes them feel irritable and anxious. These feelings can be temporarily relieved when they light up a cigarette, so smokers associate the improved mood with smoking. In fact, it’s the effects of smoking that are likely to have caused the anxiety in the first place, as nicotine raises blood pressure. Additionally, many studies have shown that cutting out the cancer sticks improves mood and thereby reduces anxiety.

Caffeine: This one is a no-brainer. Caffeine is actually a psychoactive drug, and like many of its kind, it is a stimulant. When you consume it, caffeine stimulates your “fight or flight” response, and studies show that this not only increases anxiety, it can even trigger an anxiety attack. If you’re anxious, consuming caffeine is pretty much the worst idea ever in the history of ideas.

Poor diet: Like it or not, what you eat can make a difference in how you feel, physically and mentally. You should not be on a first name basis with the Dominos delivery dude and the Mickey D’s drive-thru girl. Fact, Jack! Cut out the high carbs, the high fats, the processed foods and sugars. Remember: garbage in, garbage out.

Electronics: Surfing the net, watching YouTube vids, online shopping, and anything done on a screen can lead to an increase in anxiety by affecting your sleep. How? Exposure to the blue light of a screen anytime within four hours of sleep disrupts the natural circadian rhythm, and may even disrupt the natural production of melatonin, resulting in poor sleep. Functioning normally while tired can increase anxiety. 

No news is good news: If you are anxious or prone to anxiety, stop watching the news. Stop reading the news. Stop listening to the news. Why? The press is categorically tailor-made to incense, aggrevate, enrage, and incite. All of these roads lead to Anxiety City. So think again before feeling guilty for not keeping up with current events. A national survey conducted by (oddly enough) NPR and a bunch of other eggheads found that watching, reading, or listening to the news caused people greater stress and anxiety. It’s like the old saying goes…what you don’t know can’t hurt you. And clearly, what you do know can. 

Anti-Social media: The advent of social media has completely changed the way humans interact on a global scale. Just stop and think about that. It literally changed the entire planet. Now you can interact with anyone on the face of the earth that has a cellphone on a 24/7 basis. It sounds like the greatest thing ever, but it can cause an incredible amount of anxiety in a number of ways. Trust me, I see it day in and day out. So, how does social media cause anxiety? It has brought the concept of keeping up with the Jonses to a whole new level. Used to be the Jonses just lived down the street. Now they’ve moved. To everywhere! There are billions of electronic Jonses to emulate, be jealous of, to love, to hate, and to outdo. From posting the perfect picture that took 2 hours to take on Fakebook to likes and hearts and wow! faces, everyone gets to weigh in and hate on. All of these things are so anxiety producing. But social media can also be addicting. It’s a like-seeking quest, and every like reward is a dopamine hit. Dopamine is a happy chemical. A hit gives a little high, akin to any drug high. And just like with drugs, there can be an actual withdrawl if you separate that person from their source, their cellphone. Some people check social media 20 times or more in a day. They must check for likes, they must see what all their “friends” are doing, what all those electronic Joneses are up to. Keeping up with them and always being on the hunt, all are naturally anxiety producing. If you find that social media becomes stressful, makes you feel jealous, or mad or sad as a result of trolls or the presence or absence of positive comments, silence the alerts, put the damn phone down, and do something more positive with your time. If you feel anxious when you do this, go visit your parents or a friend in real life. You’ll get through the anxiety and be better for it. Then do whatever you have to do to set and stick to limits on your social media use. Be electronically anti-social and personally social. 

There are also tons of behaviors that you can add to your life to help with anxiety.

Behaviors to start

Exercise: You don’t have to turn into a gym rat, just spend at least 15 minutes a day doing something that moves your body.

Meditation: Spend 5 minutes a day centering yourself. Clear your mind and the rest will follow.

Breathing: Dr. Andrew Weil deveoped a breathing exercise called 4-7-8. It goes like this: exhale completely through your mouth, making a whoosh sound. Close your mouth and inhale quietly through your nose to a mental count of 4. Hold your breath for a count of 7. Exhale completely through your mouth, making a whoosh sound to a count of 8. You’ll likely find this is very helpful in reducing anxiety. 

Reading: This is great for distracting yourself from stressors occupying your mind and causing anxiety. Open a book and immerse yourself in someone else’s story.

Routine: Establishing and following a routine forces behavior modification and can be stress reducing.

Positive affirmations: Practice saying all the good things about yourself to yourself.

Connect with nature: Take a walk in the woods or get some sand between your toes. Try to lose your worries and yourself in a place that’s bigger than you. 

Eat healthy: Eat lots of fresh fruit and veggies and eat only lean meats. There are some natural food components that can help with anxiety. Omega-3 fatty acids make up the basic building blocks of the brain and nervous system. They are essential for cognitive functioning and have also been shown to improve symptoms of depression, which is often closely linked with anxiety disorders. These brain-boosting amino acids are found in a wide variety of fish species, including salmon, tuna, mackerel, herring, sardines and anchovies. They are also found in supplement form. Probiotics are also helpful. Probiotics are microorganisms known for their digestive health benefits. But recent research has revealed that probiotics can also have a profound impact on mental health. A healthy balance of bacteria in the body can boost the body’s ability to cope with stress, improve overall mental health, and bolster cognitive functioning. Probiotics can be found in direct supplement form but are also found in a wide variety of foods and drinks. Some of the most common sources include sauerkraut, yogurt, kimchi, kombucha, miso, and pickles. Put good stuff in, get good stuff out.

Talk: Whether to a therapist, friend, family member or clergy, find someone to talk to and share worries and anxiety with. The support of others can do wonders.

Be grateful: Count your blessings; think about the good things in your life: a home, support of family and friends, a place to sleep, food to eat, a vehicle, whatever the positives may be, be happy that you have them.

Take action: If you have something you need to do that’s weighing on your mind, do it. If you have a bunch of things to do, make a priority list and start doing them. As you finish the items, literally cross them off the list. This way the list isn’t overwhelming and it will feel really good to mark things off. 

Sauna: Heat is amazingly relaxing and wonderful in combating anxiety. Relax the body to relax the mind. 

Massage: A great massage is fabulous in reducing tension and anxiety.

Accupuncture: The Chinese haven’t been wrong for thousands of years. Accupuncture is one of the most relaxing, stress and anxiety reducing activities. Don’t be scared of the needles. Almost a must if you have anxiety. 

Spirituality: If you have it, use it. Prayer can be centering, almost meditative. 

Supplements and vitamins: If you live with anxiety, one measure you can take to reduce your symptoms is to include supplements and vitamins for anxiety in your diet. These can be taken directly in an oral pill form and in the consumption of various foods and drinks. Before taking any of these, check with your physician first, especially if you already take any prescription medications. 

Some of the best supplements and vitamins for anxiety include:

B Vitamins: B vitamins are vital to healthy nervous system functioning, so they play an important role in various aspects of mental health. They also have a significant impact on stress management and mood. Because of these benefits, many people with anxiety take B-complex vitamins and/or incorporate B vitamins into their diet through a variety of foods, including wild salmon, shrimp, tuna, halibut, yogurt, eggs, cheese, lamb, venison, turkey, grass-fed beef, carrots and green, leafy vegetables.

L-Theanine: L-theanine is an amino acid that can improve focus, reduce stress and promote relaxation. You pretty much have to take this as an oral supplement because it’s not commonly found in many foods or drinks. You can take 400mg of the supplement three times a day.

Chamomile: Chamomile has been used as a traditional medicine for thousands of years to calm anxiety and settle stomachs. Chamomile is best known as an ingredient in herbal tea, but is also available as capsules, liquid extracts, tinctures, and topical creams. Adults can take it in capsule form, 400 to 1600 mg in divided doses daily; as a liquid extract, 1 to 4 ml three times daily; in a tincture, 15 ml three to four times daily; or as a tea, 1 to 4 cups per day.

Lavender: Lavender is an herb that has been proven effective by leading researchers as a natural remedy for treating signs of anxiety. In one published study, lavender oil was shown to be just as effective as the pharmaceutical drug lorazepam, but without sedative effects or potential for drug abuse or dependence. Other studies have confirmed the anti-anxiety properties of lavender as well as many other medicinal benefits. Lavender oil capsules can be taken by mouth, 800mg three times a day. Tea can also be made by using 1 to 2 tablespoons of whole, dried flowers for each cup of boiling water. Steep for 10 to 15 minutes using a tea infuser or strain before drinking. You can also add six drops of lavender oil extract and 1/2 cup of dried lavender flowers to bath water for a great anxiety relieving soak. 

GABA: Gamma-aminobutyric acid is a neurotransmitter located in the brain that is crucial to serotonin production. Serotonin is one of the nervous system’s most “feel-good” neurotransmitters, so GABA plays a significant role in reducing anxiety, regulating mood and in relaxation, aka “feeling good.” I’m told this is very effective. When I tried it, I noticed that my skin tingled. An unual and somewhat unpleasant side effect.

Passionflower: This is a calming herb commonly used as a household treatment for anxiety. It has been shown to alleviate nervousness, promote positive moods, and improve sleep quality. Passionflower can be consumed as an extract and tablet, or can be added into teas and tinctures.

Valerian Root: This has been used for a variety of medicinal purposes since the time of ancient Greece. While most commonly known as a sleep aid, this herb can also be helpful for reducing anxiety. Valeric acids found within the herb convert to calming, “feel-good” neurotransmitters in the body, regulating stress and relaxing the mind and body. Valerian root extract is available in both capsule and liquid form, as well as a tea.

Licorice Root: This herb carries many health benefits for people with anxiety because of the effects it has on the adrenal glands, which produce the stress hormones adrenaline and cortisol. Licorice helps regulate the production of these hormones, relieving stress and reducing anxiety symptoms. Licorice root can also soothe gastrointestinal upset, which is common in many people with anxiety. Be aware that most drinks and candies that claim to contain licorice only contain flavoring, which has no benefits. It’s best to consume licorice in an extracted, purified form. Deglycyrrhizinated licorice (DGL) is the safest and most effective variety of medicinal licorice root available. DGL is sold in capsule, powder, tea and chewable tablet forms.

Ashwagandha: Ashwagandha is a plant native to India and North Africa that has been used for centuries to reduce anxiety, combat the effects of aging, and improve energy. In natural medicine, the root is considered to be an “adaptogen,” or a compound that helps regulate the body’s natural processes and promote overall wellness and health. Today, many people use Ashwagandha to improve mood and reduce anxiety symptoms. While the benefits of Ashwagandha are gained by eating the fruit, seeds and shoots of the plant it is derived from, Ashwagandha is most commonly consumed in capsule form, 600mg a day.

CBD products: Cannabidiol (CBD) is a type of cannabinoid, a chemical found naturally in marijuana and hemp plants. Unlike THC, tetrahydrocannabinol, another type of cannabinoid, CBD doesn’t cause any feelings of intoxication or the “high” associated with cannabis. Several studies point to the potential benefits of CBD for anxiety. It can be found in many forms: oil, gummies, teas, tinctures, vape pens, and more. As for where to begin, consider trying a sublingual (under the tongue) CBD tincture first. They have high bioavailability, meaning the body easily absorbs them. If you’ve never used CBD before, be sure to do some research and get it from a reputable place…not from the gas station around the corner. Start by taking the dropper and placing the liquid under your tongue and allow it to sit for about 2 minutes so it absorbs into your bloodstream before you swallow it. Figuring your ideal dose is tricky. Most packaging will have guidelines, but dosing is still a guessing game, as CBD affects everyone differently. You can try one dropper full and go from there. You’ll have to see how you feel to determine how much works best for you. 

Rhodiola: Also referred to as “golden root,” Rhodiola has a long history of medicinal use in traditional Chinese and Siberian medicine. Like Ashwagandha, Rhodiola is considered to be an adaptogen, meaning that it promotes physical and mental health while improving mood and resilience to stress. It is typically taken in capsule form, but it is also available in extracts and teas.

While the above homeopathics, supplements, and vitamins can be beneficial for anxiety, it’s important to check with your doctor before adding them to your diet. Taking this precaution can help prevent any potentially dangerous side effects or drug interactions. Keep in mind that while vitamins for anxiety can be helpful, they are not a substitute for prescription medications or doctor-approved therapies. It is especially important to speak to a medical professional if your anxiety co-occurs with another mental health condition. 

The supplements, vitamins and homeopathics discussed above can be found on Amazon. I discuss anxiety and other mental health issues in my book Tales from the Couch, also available on Amazon.

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Marianne asks “how can I get off klonopin’’

A woman named Marianne messaged me wanting to know how to get off of Klonopin, which is a benzodiazepine, or benzo for short. She has been taking them regularly for more than twenty years, which is a very long time to be on a benzo. That will certainly complicate things. Before I go into how to stop taking benzos, I want to tell you what they are and what they do. 

What are they?

Benzos are medications designed to treat anxiety, panic disorders, seizures, muscle tension, and insomnia. Some of the most commonly prescribed benzos include: Xanax (alprazolam), Klonopin (clonazepam),Valium (diazepam), Restoril (temazepam),
Librium (chlordiazepoxide), and Ativan (lorazepam). A 2013 survey found that Xanax and its generic form alprazolam is one of the most prescribed psychiatric drugs in the United States, with approximately 50 million prescriptions written that year. Unfortunately, this class of drug is also highly abused. Another 2013 survey found that 1.7 million Americans aged 12 and older were considered current abusers of tranquilizer medications like benzos. When abused, benzos produce a high in addition to the calm and relaxed sensations individuals feel when they take them. 

How do they work?

Benzos increase the levels of a chemical in the brain called GABA. Meaningless trivia: GABA stands for gamma amino-butyric acid. GABA works as a kind of naturally occurring tranquilizer, and it calms down the nerve firings related to stress and the stress reaction. Benzos also work to enhance levels of dopamine in the brain. Dopamine is the feel good chemical, the chemical messenger involved in reward and pleasure in the brain. In simple terms, benzos slow down nerve activity in the brain and central nervous system, which decreases stress and its physical and emotional side effects.  

Why can using them be problematic?

Benzos have multiple side effects that are both physical and psychological in nature, and these can cause harm with both short-term  and extended usage. Some potential short-term side effects of benzos include, but are not limited to: drowsiness, mental confusion, trouble concentrating, short-term memory loss, blurred vision, slurred speech, lack of motor control, slow breathing, and muscle weakness. Long-term use of benzos also causes all of the above, but can also cause changes to the brain as well as mental health symptoms like mood swings, hallucinations, and depression. Fortunately, some of the changes made by benzos to the different regions of the brain after prolonged use may be reversible after being free from benzos for an extended period of time. On the scarier flip side of that coin, benzos may in fact predispose you to memory and cognitive disorders like dementia and Alzheimer’s. They’re many studies currently focusing on these predispositions. A recent study published by the British Medical Journal (BMJ) found a definitive link between benzo usage and Alzheimer’s disease. People taking benzos for more than six months had an 84% higher risk of developing Alzheimer’s dementia, versus those who didn’t take benzos. Long-acting benzos like Valium were more likely to increase these risks than shorter-acting benzos like Ativan or Xanax. Further, they found that these changes may not be reversible, and that the risk increased with age. Speaking of age, there are increased concerns in the elderly population when it comes to benzo usage. Benzos are increasingly being prescribed to the elderly population, many of which are used long-term, which increases the potential for cognitive and memory deficits. As people age, metabolism slows down. Since benzos are stored in fat cells, they remain active in an older person’s body for longer than in a younger person’s body, which increases the drug effects and risks due to the higher drug concentrations, like falls and car accidents. For all of these reasons, benzos should be used with caution in the elderly population. 

A big problem with taking benzos for an extended period is tolerance and dependency. Benzos are widely considered to be highly addictive. Remember that benzos work by increasing GABA and dopamine in the central nervous system, calming and pleasing the brain, giving it the feel goods. After even just a few weeks of taking benzos regularly, the brain may learn to expect the regular dose of benzos and stop working to produce these feel good chemicals on its own without them. Your brain figures, “why do the work if it’s done for me?” You really can’t blame the brain for that! It has become dependent on the benzo. But as you continue to use benzos, you develop higher and higher tolerance, meaning that it takes more and more of the drug to produce the regular desired effect. This tolerance and dependence stuff really ticks off your brain. It’s screaming “why aren’t these pills working anymore?!” The answer is that it has become dependent and tolerant, so it needs more. Just to prove its point, it makes you feel anxious, restless, and irritable as it screams “gimme gimme more more more!!!” The problem is that the body is metabolizing the benzo more quickly, essentially causing withdrawl symptoms, and a higher dose is needed. The longer you’re on a benzo, the more you’ll need. It’s a vicious cycle and it’s sometimes tough to manage clinically. 

The most severe form of physical harm caused by benzos is overdose. This occurs when a person takes too much of the drug at once and overloads the brain and body. The Centers for Disease Control and Prevention (CDC) cites drug overdose as the number one cause of injury death in the United States. A 2013 survey reported that nearly 7,000 people died from a benzo overdose in that year. Since benzos are tranquilizers and sedatives, they depress the central nervous system, lowering heart rate, core body temperature, blood pressure, and respiration. Generally, in the case of an overdose, these vital life functions simply get too low.  

When combining other drugs with benzos, obviously the risk of overdose or other negative outcome increases exponentially. But mixing benzos with alcohol is a special case, deserving of a strong warning as it is life-threatening. BENZOS + ALCOHOL = DEAD. One of the most common and successful unintentional and intentional suicide acts in my patient population is mixing benzos with alcohol. The combo is lethal, plain and simple. The body actually forgets to breathe. People pass out and just never wake up. If you’re reading this and you take benzos with alcohol and you’re thinking that you don’t know what the big deal is, you do it all the time and have never had a problem, then my response to you is that you’re living on borrowed time, and I strongly suggest you stop one of the two, the booze or the benzos, take your pick. 

What about withdrawl from benzos?

Benzo withdrawal can be notoriously difficult. It is actually about the hardest group of drugs to get off of. The level of difficulty is based on what benzo you’ve been taking, how much you’ve been taking, and how long you’ve been taking it. Obviously, if you’ve been on benzos for 25 years, it’s not going to be a walk in the park. To be honest, it’s going to be a rough road. Sorry Marianne. But it can be done. The first and most important thing is that you should never just stop benzos on your own, as it can be very dangerous and can include long or multiple grand mal seizures. Withdrawal from benzos should be done slowly through medical detox with a professional. It is best done with an addiction specialist like myself, because a specialist has the most current knowledge and experience. This is the safest way to purge the drugs from the brain and body while decreasing and managing withdrawal symptoms and drug cravings. As for the symptoms of withdrawl, these can include mood swings, short-term memory loss, seizure, nausea, vomiting, diarrhea, depression, suppressed appetite, hallucinations, and cognitive difficulties. Stopping benzos after dependency may also lead to a rebound effect. This is a sort of overexcitement of the nerves that have been suppressed for so long by the benzos, and symptoms can include an elevated heart rate, blood pressure, and body temperature. There may also be a return of the issues that lead you to take the benzos in the first place, insomnia, anxiety, and panic symptoms, and they can possibly be even worse than before. 

I’m sure that just about everyone currently taking benzos is thinking “I’m NEVER stopping!” right about now. It is not easy to do, but there is a way to manage all of this, to come off of the benzo and deal with all of the physical and cognitive aspects of withdrawl. I do it everyday. I set up a tapering schedule to lessen the specific benzo dosage over time, sometimes over a period of months. I will also often add or switch to a long acting benzo, which can be very helpful. I use several drugs to deal with the withdrawl symptoms: clonidine for tremor and high blood pressure, neurontin for pain and to help prevent seizures, anti-psychotic like seroquel for sleep, and an anti-depressant for depression, thank you Captain Obvious. The drug regimen varies from patient to patient. I also utilize psychotherapy to help work out the psychological kinks associated with withdrawl and rebound effect symptoms. Another trick I strongly recommend to many of my patients, not just those withdrawing from alcohol or any drugs, is transcranial magnetic stimulation or TMS. This is a non-invasive procedure done in the office that uses magnetic fields to stimulate nerve cells in the brain to improve symptoms of depression and anxiety, and I’ve found that it seems to calm the nerves and offer relief to some people in withdrawl. Electrodes are placed on the forehead and behind the ears and painless stimuli are passed into certain regions of the brain for 40 minutes in each daily session for about a month. Many patients say it’s the best 40 minutes of their day.

I’d like to wish Marianne good luck. Please feel free to call me at the office at 561-842-9950 if you have any questions. 

To everyone else: If you can avoid ever having to take benzos, I strongly suggest that you do. If you’re currently taking them, give some serious thought to finding an alternative medication. I can help with that. For more information and stories about benzos, other drugs, and the process of medical detox, check out my book Tales from the Couch on Amazon.com.

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The Dangers Of Alcohol

As an addiction specialist, I see patients abusing substances of all kinds. Today I’d like to talk about alcohol. It is so ingrained and accepted in our society. Pop culture would have you believe that you can’t have any fun or lead a fulfilling life without alcohol. During nearly every commercial break on television, there is an advertisement for alcohol, full of smiling people having the time of their lives like they’re on a permanent vacation. As a matter of fact, as I write this, I have a television on in the background, and there was just a commercial for a Mexican beer. It was a fiesta, with women in bright costumes dancing around and people cheering and cheersing with cold cervezas. The message: you’re clearly missing out if your life doesn’t resemble the lives of these people, but if you drink their beer, your life can be as awesome as theirs.  

Fermented grain, fruit juice and honey have been used to make alcohol for thousands of years. Even early Greek writings warned of the perils of alcohol. In our modern world, the dangers of alcohol are well studied and well known. Despite this fact, alcohol is the most common drug used and abused by people. Here are some sobering facts and figures: an estimated 15 million Americans suffer from alcoholism, and nearly 90,000 people die from alcohol-related causes annually, making alcohol the third leading preventable cause of death in the United States. 40% of all car accident deaths in the United States involve alcohol, claiming approximately 10,000 lives a year. According to the Institute of Alcohol Studies, consuming larger amounts of alcohol can cause more than 60 different health issues and hundreds of physical conditions.

Day in and day out, I witness the ravages of alcoholism, and it’s not pretty. Alcohol in any amount affects every part of a person, inside and out. It’s just a matter of degrees. 

What are these effects? Let’s start with the outward appearance. While drinking moderately may not have immediate disadvantages, over time you’ll start to notice them- especially when you look in the mirror. Drinking alcohol dehydrates you, which makes hair follicles dry and brittle and more likely to cause hair to fall out. What hair you have will look crispy with split ends. Heavy alcohol use can lead to permanent damage to the health of your hair. It can also cause hormonal issues like increased estrogen, which can cause problems with hair growth and loss, particularly in men.   

Drinking too much also dehydrates and deprives the skin of vital vitamins and nutrients. Instead of being soft and hydrated, your skin will begin to look cracked and wrinkled. This will leave others thinking you may be older than you actually are. Excess alcohol also alters blood flow to the skin, leaving an unhealthy appearance for days.Alcohol can also cause your face to look pale, bloated and puffy.Sometimes the blood vessels on your face burst and the capillaries break, causing a chapped look. Not only can your face become red, but the tiny blood vessels in your eyes become irritated and rupture, causing bloodshot eyes. Not cute. 

Over time, drinking heavily can have other, more permanent, detrimental effects on your skin. Rosacea, a skin disorder that starts with a tendency to blush and flush easily is linked to alcohol consumption. Continued alcohol consumption can eventually lead to a condition called rhinophyma, a facial disfigurment that is a subtype of rosacea, where large, red, pus-filled bumps develop on the face, commonly on the cheeks, chin, and especially the nose, where it can cause severe bulbous distortion. If you have rosacea, I strongly urge that you google rhinophyma and that you don’t drink. 

Let’s not forget that alcohol is fattening, high in empty calories. A couple of gin and tonics and a pint of beer equal about the same calories as a big fast food burger. You might be surprised to find out what the junk food calorie equivalents are for your favorite drinks. Alcohol also bloats your stomach. “Beer belly” is real people, but not only caused by beer. And then there’s cellulite; many believe the toxins in alcohol contribute to its build up. 

A less often discussed result of drinking heavily is B.O. Yes, the bad odor emanating from the body after a long night of drinking is directly related to the alcohol seeping from it. According to the Institute of Alcohol Studies, over 10 percent of alcohol consumed leaves the body unused through your sweat, breath, and urine. While pretty much everyone can smell it, non-drinkers are generally especially susceptible to the odor. And it is gross. Keep that in mind the next time you wake up after a bender. Your body odor could leave a lasting impression.

Let’s move from external effects of alcohol and go inside the body, starting with the brain. Obviously, when you’re drunk, your brain is impaired. There is loss of inhibitions, confused or abnormal thinking, and poor decision-making. But I want you to understand the chronic effects of alcohol on the brain and cognition, the long term effects. So, how does alcohol impact cognitive ability? Clearly, the impact is directly related to the frequency and quantity of alcohol consumed. 

Occasional and moderate drinkers:
– Memory impairment
– Blackout
– Recklessness
– Impaired decision-making

Heavy and/or chronic drinkers:
– Diminished gray matter in the brain
– Inability to think abstractly
– Loss of visuospatial abilities

-Memory loss

-Loss of attention span

In general, heavy alcohol use causes the brain to shrink. Any alcohol use causes clouded thinking, slow thought process or delays in cognition. If you drink at night – even two drinks – the next day, your thoughts aren’t as fluid, you’re not as clear, you’re not as creative. Alcohol use changes behavior. You may develop psychological issues,  personality issues. It is well established in the mental health field that alcohol consumption can exacerbate underlying mental health disorders. People become more irritable, anxious, and depressed when they drink. So why do it? People use it as a coping skill. It lowers inhibitions, gives “liquid courage” and allows us to do things we wouldn’t normally do. Some people use it to keep a job they hate, or to stay in a miserable marriage. It numbs pain, it’s an escape hatch for the psyche. It becomes a solution to a problem, or a way to mask the problem. Just as we are all different, the way alcohol affects us all differently. 

The following factors have been shown to influence how alcohol impacts a person’s brain functioning over time:
-The volume a person drinks
-How often a person drinks
-The age at which drinking began
-The number of years a person has been drinking
-The person’s sex, age, and genetic factors
-Whether the person’s family has a history of alcoholism
-Whether the person was exposed to alcohol as a fetus
-The person’s general health 

One of the biggest problems with alcohol that I see is trauma, people getting hurt. When you drink alcohol, your decision making is impaired. The brain that usually protects you is suddenly impaired, so you fall, you fight, you drive a car recklessly, and your coordination is off. You’re going to fall or make a bad decision and get hurt. So many accidents and deaths are attributed to alcohol. It’s especially disturbing because they’re preventable.

There is no bodily system that alcohol does not affect. What are other physical dangers of alcohol? Drinking alcohol increases the risk of cancers of the mouth, esophagus, pharynx, larynx, liver, and breast. The common thing that everyone understands is liver damage with alcohol. It causes fatty liver and cirrhosis of the liver which eventually kills you. There are a host of digestive problems with alcohol consumption: peptic ulcers, bleeding ulcers, diarrhea, pancreatic cysts/disease/failure. Alcohol can lead to diabetes, a compromised immune system, lung infections, stroke, and heart disease. It can be associated with memory issues, learning disorders, and neurological problems, where you have numbness in your arms and legs, lack of coordination, and slurred speech.   

Alcohol plays a role in other issues as well. Family problems, legal problems, and social problems. One of the biggest concerns with drinking frequently is (or should be) dependency, becoming an alcoholic. Right now, I’m sure almost 100% of you are thinking ‘I‘d never become an alcoholic.’ There’s a television show called Intervention that documents the trials, tribulations, lifestyles, and consequences of alcoholics and drug addicts. None of them planned on becoming alcoholics back when they drank socially or just had a few drinks at night. The great news is that if you never make alcohol a part of your life, guess what? You’ll NEVER have to be an alcoholic or deal with all of the issues that come with it. I can’t stress enough how strongly you should take this to heart. 

By now I’m certain that you understand the ravages and damages of alcohol use and abuse. But the dangers are minimized and we’re desensitized to it by pop culture; it’s so ubiquitous that we accept it as a part of life. If you tell someone that you don’t drink, they look at you like you have three heads. It is ingrained in every aspect of our society in terms of weddings, funerals, bars, restaurants, hotels, public events, private events, and clubs.  

Have you ever noticed how glorified alcohol is? They put it in these beautiful bottles. I admire alcohol bottles. The artistry and sculpture of the bottles…they’re just beautiful. They look like there must be something very good inside, so you want to find out. When you go to a restaurant, the first question is always, “Would you like a drink?”  Now, children’s birthday parties even serve drinks to the adults. If it’s so safe, why don’t we serve it to children? It’s because we know it’s poison, we know it’s dangerous, but it’s minimized. It’s socially acceptable. I’m not for prohibition; I think there is a place for alcohol in our society, but it shouldn’t be so glorified and so easily accessible. We need to acknowledge it’s dangers and be more restrictive with it. Take all-you-can drink mimosa or bloody mary brunches or happy hours for example, where drinks are two-for-one. These things encourage drunkenness, and then people leave with alcohol-induced poor decision skills and car keys in hand. These sorts of events need to be seriously restricted. There should be no event where we encourage people to get drunk. We should not condone its overuse or extoll its virtues. 

With all of that said, how does an individual stop drinking alcohol? It’s a simple theory. You make a decision to stop, and then you stop. There is no other way. If you’re not in control of stopping, then who is? I’ve spent more than thirty years medically detoxing and working with people with alcohol and drug addictions, and I assure you that there is no other way to stop other than the person making the decision to stop and living with it. I’m not saying it is easy, especially with alcohol all around us in grocery stores, restaurants, on television, on billboards…it is everywhere. But it can be done. I see it every day, people living fulfilling lives without alcohol. If you want to be one of those people living without alcohol, make an appointment. I can help you. I talk more about this in my books, A Chance to Change and Tales from the Couch, both available on Amazon.

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COUPLES AND CONFLICT

Couples and Conflict

One of my foremost jobs as a psychotherapist is to be a listener. All day, every day people come to me to talk about their problems. As you can imagine, many times patients want to talk about their spouses, specifically how they fight with them. So I want to talk a little bit about couples and fighting. Whether it’s about money, children, career, housework, all couples fight. Nobody gets along 100% of the time without some conflict. It’s all a matter of how you resolve that conflict. I had a patient named Roxanne come in for her session yesterday, and she told me that she and her husband Bill fight all the time. One yells at the other and the other yells back louder until it reaches a terrible crescendo and both storm off in opposite directions. She said she had no choice in this, he just made her so angry and they just didn’t get along. I told her that the first thing that had to happen for the relationship to move forward was to decide that it wasn’t his fault and wasn’t her fault, it was both of them. She immediately recoiled and told me I was dead wrong. That it was all Bill’s fault. He was never home, he didn’t want to be a part of the family, he this, he that, ad nauseum. I asked her about how they fight, her yelling and screaming…was it working? Was it resolving anything? She launched in again, saying it wasn’t her fault, it was his fault because he made her yell. He antagonized her. I told her that she didn’t have to go to every fight he invited her to, she had the choice. This is a point that I think a lot of couples miss. Just because your spouse may be baiting you, looking for a fight, it doesn’t mean you have to give them what they’re looking for. You don’t have to respond at all. You have a choice in how you behave.

I explained to Roxanne that the only way to start to resolve an issue is to not yell and scream, not raise a voice. Once you express anger, you’ve made the situation worse. I suggested to her that the only way to make the situation better when Bill is yelling and screaming is to fall silent. Until the yelling stops, nothing productive can be accomplished. A conflict cannot be resolved through warfare. Once people raise their voice, no interaction happens. For instance, if you raise your voice at a child, they shut down. They will hear nothing you say. The same happens in couples. If one raises their voice at the other, from that moment forward, nothing constructive happens. So, if you’re married or in a relationship and you find you are having problems or there is fighting, and yelling, you are responsible for your response, and your response should be to not yell back, fall back. All yelling does is put fuel on the fire. If you fall silent, eventually they will stop yelling, and once the yelling stops, resolution can start. You can begin a conversation by discussing what the problem is, why you keep arguing, and what you can each do to make things better. That’s the only way these things will really be resolved. But you have to be willing to change how you respond to conflict and how you fight. Learn to fall back if baited. Talk should replace screaming matches. 

I hear so often in my office “it’s not me, it’s him, it’s her, they’ll never change, we tried that” blah, blah, blah, blah. If you really want to effect change in your relationship, change your own behavior and then the reaction you get back from your spouse or partner will change. Stop yelling and start conversing. Focus on what you can each do to make the relationship better. To resolve conflict, cooler heads should always prevail over heated emotions.

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Attention Deficit Disorder and Attention Deficit Hyperactive disorder

Attention Deficit Disorder

ADD, Attention Defecit Disorder is a chronic condition marked by issues with attention. It is most often seen in childhood, but can persist into adulthood, and there are 3 million US cases per year. Due to it’s high prevalence, I want to take the opportunity to discuss the diagnosis, symptoms, and treatment of ADD.   

ADD has a sister disorder called ADHD, Attention Defecit Hyperactivity Disorder. What’s the difference between them? It’s pretty simple. ADHD includes the symptom of physical hyperactivity or excessive restlessness. That’s what the “H” is for. In ADD, the symptom of hyperactivity is absent. 

What are the hallmarks of this disorder?  Basically, it is a disorder of concentration, marked by problems concentrating and the inability to stay on task. These individuals are easily distracted and readily bored. They move from project to project without finishing and start projects without all of the appropriate tools needed to complete them. This all leaves them very anxious. In cases of ADHD, they are also impulsive, intrusive, disruptive, and hyperactive, often constantly fidgeting. 

What percent on the population are we dealing with here?  Roughly 20% of boys and 11% of girls have some type of attention deficit disorder. 

What are the causes of attention deficit disorder? While we don’t know exactly, there are several suspects. Maternal use of alcohol or cocaine while in utero is an extremely common finding. Brain infections when pregnant or during early childhood, head trauma, and any birth defects that affect child development are also suspected. Exposure to enviromental toxins and pesticides are suspect. Excessive video games alter brain chemistry, as does a diet of processed foods and sugar, and these are also suspected causes for attention deficit disorder. I would say the number one cause of ADD is most likely genetic, inherited from mother or father. 

What is the result of having attention deficit disorder? How does it affect one’s life? It results in having problems fitting into the academic world or the job world. People with attention deficit disorder don’t fit into a regimented or organized educational or work environment. They can be very intelligent and productive people, but they don’t fit into what we would consider the stereotypical or standard type of academic setting or work setting. Also, due to their impulsivity and their disorderly conduct, they can wind up getting in trouble in school and in trouble with the law. They can be unsuccessful at work, not because they aren’t smart enough, but because they cannot stay focused. In terms of lifestyle, they also have a much higher rate of obesity. This is likely due to lack of impulse control, causing them to overeat. They have problems in relationships, and their divorce rates are much higher. Their propensity toward domestic violence may also be higher. They may also be more prone to Alzheimer’s disease. Because of all of these failures and shortcomings in the stereotypical organized worlds of education and career, they have much lower self-esteem. There are studies that report that up to 52% of people with attention deficit disorder have drug or alcohol problems. 

So how can we help these people? How do we treat these illnesses? The number one treatment is behavioral training with a mental health professional. The gist of that is educating them to focus on one thing at a time. They are not able to handle instructions with multiple levels at once, but they can focus on one thing at a time and have success with that. Pharmacologically, ADD and ADHD are generally treated with amphetamine stimulants. Some antidepressantants may also benefit people with attention deficit disorder. Essentially, a combination of behavioral therapies, special education programs and medications show the most promise in the treatment of attention deficit disorder. But a diagnosis of ADD or ADHD isn’t all future doom and gloom. Eventually, people find their niche in the world and can become successful. The actor Ryan Gosling takes medication for his ADD and says that it may take him longer to read his scrips than other actors, but he manages to get the job done. Uber successful comedian Howie Mandel has successfully done just about all there is to do in Hollywood. I have met a lot of CEO’s with ADD, and they function well because they have people around them to take care of all the boring mundane tasks, giving them the chance to think freely and create business opportunities. They are creative and capable people. They are another example of why you can’t judge a book by it’s cover…you can’t assume that someone with a psych diagnosis will never make it in the world. Ask Richard Branson. I think he’s done pretty well for himself in the corporate world despite his ADD. Justin Bieber has ADHD and has managed to record a few hit songs. Olympian Michael Phelps has ADD, depression and anxiety, and that hasn’t stopped him.These are some examples of people that have adapted and overcome their diagnoses rather than be labeled by them. If you have ADD or any psych diagnosis, I’d suggest you follow their lead. 

For more patient stories, check out my book Tales from the Couch, on Amazon.com.  

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How To Manage Stress

Rather than just introducing you to today’s topic, I want to play a little game of ‘Who am I?’ I’ll give you ten clues and let’s see if you can guess who I am. And no looking down below and cheating!

1. Everyone has me, either intermittently or constantly.

2. I am an unwelcome guest.

3. Some people deal with me better than others do.

4. I keep lots of people up at night.

5. I make some people physically ill.

6. I can shrink your brain. 

7. Some people take drugs to deal with me.

8. I can make some people binge, purge, or starve themselves.

9. I can cause a whole host of medical problems.

10. I have a good side, but nobody ever gives me credit for it!

Last clue: 

I am defined as “a physical, mental, or emotional factor that causes bodily or mental tension.”

So who am I? 

I am STRESS! 

I see so many stressed out people every day that I thought I’d do a little educational primer on stress.

Stress is a normal psychological and physical reaction to life’s everyday demands. A small amount of stress can be good. Positive stress is officially called eustress, and it can motivate you to perform well. But multiple challenges throughout the day such as sitting in traffic, meeting deadlines, managing children, and paying bills can push you beyond your ability to cope.

What’s going on in your brain when you feel stress? Your brain comes hard-wired with an alarm system for your protection. When your brain perceives a threat or a stressor, it signals your body to release a burst of hormones, especially cortisol, that increase your heart rate and raise your blood pressure. This is part of the fight or flight mechanism. But once the threat or stressor is gone, your body is meant to return to a normal, relaxed state. Unfortunately,some people’s alarm systems rarely shut off, causing chronic stress. When chronic stress is experienced, the body makes more cortisol than it has a chance to release. This has been shown to kill brain cells and even reduce the size of the brain. Chronic stress has a shrinking effect on the prefrontal cortex, the area of the brain responsible for memory and learning. So it’s very important to find effective ways to deal with stress. Stress management gives you a range of tools to reset your brain’s alarm system. Without managing stress, your body might always be on high alert, and over time, this can lead to serious health problems and contribute to mental disorders such as anxiety, depression and post-traumatic stress disorder. So don’t wait until stress damages your health, relationships, or quality of life…start practicing some stress management techniques. 

To help combat the negative effects of stress and anxiety, here are five tips to help manage stress in your daily life…

1. Follow a Regular Sleep Routine
It may seem like simple advice, but often the simplest advice is the best advice. Following a regular sleep routine can help you decompress, recharge, and rejuvenate your body and mind after a stressful day. Try going to bed at the same time every night and aim for 7 to 8 hours of sleep. Resist the urge to stay up late watching TV. In fact, avoid screen time altogether before bed, including tablets and smart phones. Studies have proven that reading on a backlit device before bed interrupts the body’s natural process of falling asleep. These devices also impact how sleepy and alert you are the following day.

2. Use Exercise to Combat Stress
Exercising regularly can have an enormous impact on how your body deals with stress, and it is one of the most recommended ways doctors instruct patients to reduce stress. The endorphins released while exercising can help improve your overall health, reduce stress levels, regulate sleep pattern, and improve mood. The key to exercising is to choose something that you truly enjoy. Whether it’s going for a walk, taking an exercise class at the gym, going for a swim, or lifting weights, exercise keeps us healthy. Make sure to mix up your exercise routine to prevent boredom and stay motivated. 

3. Learn How to Meditate
One of the simplest ways to help alleviate stress is to practice deep breathing and meditation. There’s no secret to this, and you don’t have to chant and burn incense or any of that. It’s just about finding a quiet space without distractions. It only takes a few minutes every day, either before bed or first thing in the morning. Breathe in through your nose, letting your abdomen expand. Hold your breath for a count of three, then breathe out slowly through your mouth. Repeat this three times. Focus on your breathing and your heart beat to prevent thinking about everything that you need to do. If doing it in the morning allows stressful thoughts of the upcoming day to intrude, try it at night. Deep breathing is especially important when your stress levels are high. Aim for meditating for at least 15 to 20 minutes, but if you’re feeling pressured during the day, a quick 5-minute meditation session can help you chill out.

4. Take Care of Your Skin
It may not seem like skin care and stress prevention are linked, but they are. Have you ever noticed that your skin is more prone to break out when you’re stressed out? How many times have you gotten up for work all stressed out about a presentation and looked in the mirror only to see a big zit on your nose? For crying out loud…why the heck is that?!!? How does your skin know you have a big presentation? Well, stress causes a chemical response that makes your skin more sensitive. And as we discussed, your body produces more cortisol when stressed, which causes your sebaceous glands to produce more oil. More oil means oily skin that is prone to acne. So it’s important not to neglect your skin care routine, especially when you’re stressed out. This goes for both guys and girls. You may be exhausted at night and want to go straight to bed, but taking an extra few minutes to wash your face and remove daily dirt and any facial products or makeup you’ve worn during the day will make a world of difference. And if you’re prone to oily or dry skin, always choose skin care products that are specifically designed for your skin type. Your skin will thank you for it by surprising you with big red zits less often. 

5. Ask For Help When You Need it
Asking for help may not always be easy, but when you need a shoulder to cry on or someone to listen, it can help put things into perspective.  Seeking support from family and friends or a professional isn’t a sign of weakness. In fact, it takes courage to admit you need help. Many patients that I see for the first time have been needlessly suffering for so long. I feel terrible for them. There is no reason not to seek help for any ailment affecting your health, especially your mental health. Patients who wait until they start to develop multiple physical and psychiatric issues before seeking help have a much harder time recovering than those who seek help sooner. Remember that friends and family are great support, but if you develop any signs of anxiety or depression or other mental health issues, get help from a licensed mental health professional immediately. In my experience, some patients may need medication, but some do not, they find relief through simple talk therapy with me. It’s very much an individualized assessment. While not a replacement for professional help, you can also look for online support groups for stress management. You’re not the only person who’s ever dealt with a specific stressful situation, so why not discover how other people managed their stress and overcame a potentially frustrating situation.

Hopefully after reading this you have a better understanding of what stress is, how it can impact your physical and mental health, and what you can do to start dealing with it effectively to minimize its role in your life. If you feel you need help, call my office for an appointment. I can help you. For more mental health topics and stories, check out my book Tales from the Couch, available on Amazon.com or for purchase in my Palm Beach office. 

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How To Sleep Better At Night

Slumber, shuteye, repose, siesta, snooze…Sometimes we have a love-hate relationship with it…we love it when it’s good and curse it when it’s bad, but we all need it. Whatever you call it, one complaint I hear from patients day in and day out is that they have difficulty sleeping. It’s so prevalent that I want to discuss how to  get better sleep. In my 30 years of practice, I’ve compiled a list of 14 things in no specific order that you can do that should have you snoozing at night night in no time. 

Rule 1: Bright light during the day.  Your body has to have bright light during the day; sunshine is best, but even sitting in a bright room, like by a window, is helpful. Bright light tells your brain that it is day time, time to be awake. Darkness or the absence of bright light tells the brain it is night time, time to sleep. If you’re in a dark room all day, you probably won’t sleep well at night. So remember, in the day time, bright light is right. 

Rule 2: Limit blue light. What is blue light? Blue light is what is emitted from your computer, laptop, and smartphone. The more blue light you are exposed to, especially at night, the more disruption you’ll have in sleep, as it disrupts circadian rhythm. Lots of people climb into bed with their cell phone or iPad, and that’s the worst thing to do. You should avoid looking at bright screens beginning two to three hours before bed. There are apps you can install on your phone that filter out the blue light. There’s also something called “F. Lux” that you can put on your computer or iPad which will block out the blue light. You never hear about it, but blue light exposure, especially at night, is a major factor in hindering sleep. 

Rule 3: Captain Obvious here with a newsflash. Caffeine will keep you up at night. Don’t think you’re going to have coffee or tea after dinner or before bed and expect to sleep. And if you’re drinking sodas, coffee, or iced tea all day, it’ll still disrupt your sleep. I tell patients to limit caffeine consumption to under 250 – 300mg a day. As a guide, an 8oz cup of coffee has about 100mg caffeine, the same amount of tea has 24mg, a 12oz can of soda has 34mg, and those gnarly energy shots have 200mg of caffeine! I strongly advise against consuming caffeine after lunch if you plan on a bedtime between 10pm and midnight.  

Rule 4: No naps! Boo! Hiss! Why is it that as kids, just the word nap sent us into a tizzy tantrum, but as adults we love naps? If anyone has an answer, please let me know. Anyway, as satisfying as it is, napping disrupts your sleep-wake cycle, temporarily resetting it to where you’re not likely to be able to go to bed between 10pm and midnight. Bummer. 

Rule 5: Melatonin. I recommend 2 to 4mg of melatonin at bedtime; it really seems to help a lot of my patients. I do find that some patients get daytime hangover from it though, so you’ll have to see where you fall on that one. But it’s definitely worth a shot if you’re suffering from insomnia. 

Rule 6: Get up at the same time every day, and go to bed at the same time every day. Yeah, it’s kind of a drag not sleeping in on weekends, but a sleep routine can make a big difference in your relationship with Mr. Sandman. You can’t regulate when you’ll fall asleep, but you can regulate when you wake up. So set your alarm and get up at the same time every day, no matter how tired you are. Don’t nap and go to sleep between 10pm and midnight, and you should fall asleep. If sleep still eludes you, stick to the same plan, and you should surely sleep the second night. You can’t decide when you’ll fall asleep at night, but you can regulate your sleep-wake cycle by deciding when you wake up. Stick to setting your alarm for the same time every day, and hopefully your brain will get the idea. 

Rule 7: I recommend taking a glycine or magnesium supplement at night as well as L-theanine and lavender. They don’t make lavender teas, pillow sprays, lotions, and sachets for nothing. I have heard from people that swear by lavender as part of their wind down routine before bed. You can find these supplements on Amazon.com. Shameless plug: handily enough, you can also find my book, Tales from the Couch for sale there too. Check it out. 

Rule 8: This is the Mac Daddy, numero uno, absolute, not-to-be-broken rule. Alcohol. If you consume alcohol before sleep, you will not sleep. Why? As the body metabolizes the alcohol, it goes into a withdrawl-like reaction and disrupts sleep. I know what you’re thinking. You’re thinking that a little nightcap helps you sleep. Wrong. Some people will tell you differently, but trust me…alcohol and sleep do not play well together. 

Rule 9: A comfortable bedroom. Your bedroom should be an oasis of calm serenity. There should be no office or desk in the bedroom. It should be uncluttered. Anything not conducive to sleep should be out. Make sure it’s dark and quiet at bedtime. The weight of multiple blankets can help sleep. You can even purchase weighted blankets expressly for this purpose. The weight is comforting and relaxing to the body. 

Rule 10: This sort of goes hand in hand with #9 above. Try a low temperature in the bedroom. I personally make sure my bedroom is at 70 degrees. The blankets from rule number 9 come into play here too. There’s something very comforting about burrowing under fluffy blankets to go to sleep. I mean, they’re called comforters for a good reason. 

Rule 10: No eating late at night. People seem to mostly make terrible food choices at night, all in the name of snacks…chips, candies, baked goods. Sugary foods are especially bad. When you eat, the body goes into digestive mode, not sleep mode; it is very interfering to sleep. Sugars especially are no bueno. Evening or night snacking is one of the worst things you can do If you want to sleep.  

Rule 11: Relax and clear your mind. There’s an older pop song that has a lyric, Free your mind and the rest will follow. It’s true. We all have problems and stresses throughout the day, and they seem to pop up when your head hits the pillow. You have to come to some resolution on how you’re going to handle the problems in your life and put them to bed so that you can put the rest of you to bed.  

Rule 12: Spend money on a comfortable quality mattress. You’re going to spend a third of your life in your bed. Just suck it up and spend the money on the mattress. Don’t cheap out. Another place to spend money is on good linens. Few things are as inviting as a comfortable mattress covered in minimum 1,000 thread count all-cotton sheets. If you’ve never had nice linens, try them.You can pick them up on a white sale or online. You can thank me later. 

Rule 13: No exercising late at night.  When you exercise late at night, you raise blood pressure and heart rate, which will hype up the body, which is the antithesis of what you want when it’s time to sleep.  

Rule 14: No liquids prior to sleeping. No rocket science here. If you put liquids in, you’re going to need to get liquids out. In other words, you’re going to have to get up in the middle of the night to pee. And you’re probably going to stub your toe. Not good. 

This is my handy dandy guide on the do’s and don’ts when it comes to sleep. Anything is better than counting sheep. I don’t know who came up with that, but I would like to inform them that I have never in 30 years heard of it working. I’ve never before wanted people to fall asleep as a result of reading something I wrote, so this is a first! I hope you’ve learned some things here that will put you out like a light.

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