Why Is Sleep Important? Part Deux

Why is Sleep Important? Part Deux

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Why Is Sleep So Important

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

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

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

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

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

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

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

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

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

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

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

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

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Why Are young Americans So Unhappy

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

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

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

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

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

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

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

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

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

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

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

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

Dear Young Americans,

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

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

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

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

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

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

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

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

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

Good luck. Make yourself proud of yourself.

Mark Agresti M.D.

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The Truth About Gender Dysphoria

The Truth About Gender Dysphoria

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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What Are Personalty Disorders

What are Personality Disorders?

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

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

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

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

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

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

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

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

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

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

Ten Types of Personality Disorders

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


10. Obsessive-Compulsive Personality Disorder

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

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

Personality Disorders: Treatment and Outlook

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

Sociopathy Test

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

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

Narcissist Test

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

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

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

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Caplyta(lumateperone):NEW Treatment Schizoprenia and Bipolar Disorder

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

6) The first symptoms of schizophrenia can include…

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

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

8) Many schizophrenics believe that _______ eases their symptoms.

Correct answer: Smoking

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

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

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

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

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

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

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

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

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

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

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

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

– Caplyta (lumateperone) for schizophrenia

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

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

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

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

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

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

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

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

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

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

– Utilizes CYP3A4: lumateperone is contraindicated in patients taking 

drug(s) which block CYP3A4 enzyme.

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

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

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

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

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10 Secrets to Sleeping Better

10 Secrets to sleeping Better

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

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

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

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

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

6.) No sugar 2 hours before bedtime.

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

8.) Calm your mind before sleep.

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

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

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How To Determine If Someone Is Suicidal

A Coronavirus PSA

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

Suicide Assessment

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

Facts and Figures

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

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

Suicide Risk Factors

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

–  Family history of completed suicide in first-degree relatives

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

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

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

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

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

Mental Illness and Suicidality

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

–  Depression

–  Bipolar disorder

–  Mania

–  Schizoaffective disorder 

–  Schizophrenia

–  Post-traumatic stress disorder

–  Substance abuse 

Suicidal Ideation

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

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

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

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

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

–  The degree of planning 

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

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

–  Access to the place to commit

–  Note: presence, timing, content

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

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

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

What is a Suicide Plan?

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

–  Timing of the suicide event

–  Access to the method and setting of suicide event

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

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

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

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

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

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

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

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

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

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

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

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

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Obsessive Compulsive Disorder:Signs,Symptoms,and Treatment

Obsessive Compulsive Disorder: Signs, Symptoms, and Treatment

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Be well, everyone.

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HOW TO BEAT FEAR OF CORONA VIRUS

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

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

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

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

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

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

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

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

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

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

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

3. Do seek support, but do so wisely.

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

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

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

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

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24/7 news Is Stressing Us Out

THIS JUST IN!

24/7 NEWS CAUSES ANXIETY! 

READ ALL ABOUT IT!

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Mental Health Benefits of Dogs

Mental Health Benefits of Pets

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

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

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

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

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

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

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

Interacting with Pets Lowers Stress and Decreases Anxiety:

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

Pets Make Us Feel Needed:

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

Pets Increase Well-Being:

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

Pets Provide Companionship:

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

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

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

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

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

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

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Electronics Are awesome! Right

Electronics are awesome! Right?

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

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

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

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

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

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

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

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

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

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

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

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

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

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Your Brain On The Holidays

Your Brain on the Holidays

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

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

1. You Want to Eat All of the Food

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

2. You Want to Drink All the Alcohol

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

3. You Want to Buy All of the Things

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

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

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

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

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Secrets For Surviving Panic Attacks

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

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

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

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

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

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

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

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

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

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

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Why Are People Going Crazy

Why are people going crazy?

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

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

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

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

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

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

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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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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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