Kratom:Panecea or poison?

Kratom: Panacea or Poison?

What is Kratom?

Kratom (scientific name: Mitragyna speciosa) is a tropical evergreen tree in the coffee family that is native to the jungles of Southeast Asia; specifically found in Thailand, Myanmar, and Malaysia. It is also found in Papua New Guinea. Other names for kratom include thang, kakuam, thom, ketum, and biak. Whatever it’s called and wherever it may be found, this tree, or at least the leaves on it, has been causing quite a commotion in recent years.

The Scientific Scoop

Mitragyna speciosa leaves contain multiple active components, referred to as alkaloids, with properties ranging from stimulant-like energizing and uplifting to opiate-like drowsiness and euphoria, so this makes it difficult to characterize kratom as one particular type of drug, i.e. as “stimulant” or “opiate.” Kratom’s two main alkaloids are mitragynine and its active metabolite, 7-hydroxymitragynine, which has strong activity at the µ-opioid receptors (where µ is pronounced like ‘you’ but with an m: mu). This is the main opioid receptor, the same one that is the primary binding target of opioids like heroin and oxycodone. Why is this so important? Why do we need to know exactly where kratom binds and what effect that has? Well, so we know how it may be used. Here in America, the government isn’t so good with just accepting that this ancient Asian secret does xyz just because they said so. Because kratom binds to µ-opioid receptors just like heroin etc, opponents say that it must be categorized as a narcotic and therefore, it must be addictive just like heroin etc. But Narcan/ naloxone is also categorized the same way, and obviously it’s not addictive; in fact, it’s used to save people in cases of opioid overdose. 

There is a great deal of supportive scientific evidence from many independent laboratory studies using mouse models and multiple human cell lines that confirms that kratom’s alkaloid metabolite 7-Hydroxymitragynine is in fact a key mediator of the analgesic effects of kratom, through its agonistic binding to the µ-opioid receptor. This has also been confirmed by the finding that in the presence of the opioid receptor antagonist naloxone, the pharmacological blockade of the analgesic effect will occur. In plain language: they’ve clearly shown that kratom binds specifically to the µ-opioid receptor in human cell lines, and demonstrated that this binding produces analgesic effects by giving it to a specific type of live mouse that essentially models the human system. So after the mice were given kratom, they exhibited analgesic effects from it– through previously established and accepted behaviors that I’m totally not going into here– just trust people. And then, as if that’s not enough, to further prove that this analgesic effect the mice were having was definitely the result of kratom’s binding to the µ-opioid receptor, they then gave the kratom-dosed mice Narcan, aka naloxone, which is a µ-opioid receptor antagonist. What does that mean? Think of it this way: the Narcan “antagonizes” the µ-opioid receptor; it basically bullies anything already bound to that µ-opioid receptor, pushes it off, and then it binds to it and blocks it so that as long as it’s parked there, nothing’s getting by it to bind to those µ-opioid receptors. That’s how and why Narcan saves people from overdose: it pushes all the opioids off all of the µ-opioid receptors and then sits on them, and hopefully that happens soon enough that the person survives the overdose. If they do, and if they then ingest more opioids for several hours after being given the Narcan, they won’t feel the effects of the drugs for as long as the Narcan is present there on those receptors, because the drug’s opioids won’t be able to bind to the µ-opioid receptors, as the Narcan will be sitting there. So there’s been a lot of work done in various labs all over the globe to elucidate kratom’s form and function. But despite all of this work, there’s much more to be done! I’ll talk more about that later.

None of kratom’s uses are clinically proven, as it has not been studied in the human clinical trials that the FDA requires to allow a drug compound to be legally available on the open market. Clinical studies are very important for the development of new drugs, as they help to identify consistently harmful effects, harmful interactions with other drugs, and dosages that are effective, yet not dangerous. That said, there have been many legitimate published laboratory studies with clear demonstrable findings in mouse models and human cell lines that do allow us to at least extrapolate the effects of kratom in humans with some accuracy and relative safety. Most findings have been positive, and there is a large vocal community of kratom supporters with numerous anecdotal testimonials of kratom’s effectiveness in treating various conditions. But despite this, because treatment practices using kratom have not been rigorously studied as either safe or effective, the DEA staunchly maintains that it has no valid medical uses or benefits. In fact, several years ago, the FDA threatened to make kratom a Schedule 1 narcotic, meaning it would be grouped with marijuana, LSD, and ecstasy, among others, and this elicited a huge backlash… tens of thousands of kratom proponents complained vociferously, signed endless petitions and all that yada yada, and the FDA caved, dropping the issue, at least for the time being. But that’s not going to be the end of that story people… not when the government’s involved. So for now, kratom’s status should be listed as “to be continued.”

What is Kratom Used For?

In its native regions of Southeast Asia, kratom has been known to be used as a traditional medicine for more than a century, but has likely been used for multiple centuries. There in Southeast Asia, the leaves of the kratom tree are typically chewed directly from the tree or consumed as a tea, and they induce stimulant and opioid-like analgesic effects, depending on the amount used. This is because the effects felt from ingesting kratom have been found to be dose-dependent: at low doses, which is generally considered 1 to 5 grams, kratom has been reported to work like a stimulant, imparting feelings of being more energetic, more alert, and more sociable. At higher doses, considered to be 10 to 15 grams, kratom has been reported as being more sedating, dulling emotions and sensations while producing euphoric effects. Anything over 15 grams is considered risky.

The stimulant type effects have traditionally made kratom popular among Southeast Asian agricultural workers especially, who use it to aid them in their long hours of hard labor. But for generations there, kratom has also been used successfully in its native regions for several other purposes: as an aphrodisiac to increase sexual desire, as an energy booster, to ameliorate withdrawal symptoms following cessation of opioid use, and for treating cough, diarrhea, and chronic pain. More recently, here in the US, there has been an uptick in the use of kratom by people who are self-treating chronic pain and managing acute withdrawal from opiates, while seeking alternatives to prescription medications. While some people claim to have success using kratom to treat depression and anxiety, and others say that kratom can also be used to treat muscle aches, fatigue, high blood pressure, diarrhea, and post-traumatic stress disorder (PTSD). Some studies report that kratom possesses anti-inflammatory, immunity-enhancing, and appetite-suppressing properties, but obviously more research is needed to confirm these benefits.

Kratom: Processing and Forms

The psychoactive compound referred to as kratom is found in the leaves of Mitragyna speciosa, and the processing seems pretty straightforward: after the plant’s large dark green leaves are harvested, they can be prepared in several ways: fresh leaf, dried leaf that is pulverized and powdered, dried leaf that is simply crushed, and concentrated liquid leaf extract. Kratom can typically be purchased in multiple forms, including paste, capsule, tablet, gum, tincture, and extract. In certain forms it is often combined with added sweetener to overcome its harsh bitterness. Kratom can be brewed into a tea as well, a form that is offered in kratom tea houses present in a few US states. Kratom can also be smoked or vaporized, though this is not very common.

While the use of Mitragyna speciosa is certainly not new, the alkaloid extraction and refinement methods to turn the alkaloids from the plant into kratom has certainly evolved, and now purity is said to be higher. I’ve read that now there are also fortified kratom powders available, and these contain extracts from other plants in a nod to the nutraceutical angle. In the United States, kratom is usually marketed as an alternative medicine, and often found in stores that sell supplements. Kratom can also be found in gas stations and paraphernalia shops in most parts of the US, except in the handful of states and cities that have banned it. Many people purchase kratom over the Internet, where it may be sold for “soap-making and aromatherapy,” a lot like what happened with synthetic marijuana or spice; that’s in an effort to circumvent the FDA’s 2014 ruling that made it illegal to import or manufacture kratom as a dietary supplement in the US.

Is Kratom Legal?

Although kratom is technically legal at the federal level, some US states and municipalities have chosen to ban it, making it illegal to sell, possess, grow, or use it. Other states have imposed age restrictions. In the states of Alabama, Arkansas, Indiana, Rhode Island, Vermont, and Wisconsin, kratom is illegal to buy, sell, possess or use. There are special cases in some states: while kratom is legal in California, it is banned in San Diego. While it’s legal in Colorado, in Denver it’s considered illegal for human consumption. Kratom is legal in Florida, except for Sarasota Country, where it’s banned. Kratom is legal in Illinois for those over the age of 18, except in the city of Jerseyville, where it is banned. Kratom is legal to use in Mississippi, except in Union County, where it’s banned. In New Hampshire, kratom is only legal for those over the age of 18. Please don’t quote me on these people- make sure to double check if you’re wanting to purchase- not that I’m encouraging that or even saying it’s acceptable btw. 

As far as countries around the globe go, kratom is illegal in: Australia, Denmark, Finland, Israel, Japan, Latvia, Lithuania, Myanmar, Malaysia, New Zealand (unless prescribed by a doctor), Poland, Romania, Russia, Singapore, South Korea, Sweden, Thailand, and Vietnam. Note that most places where native Mitragyna speciosa grows, it’s illegal… funny! Speaking of that, the country of Thailand has recently reconsidered the status of some illegal substances, so kratom might not remain illegal there.

In countries like Ireland, Italy, and the United Kingdom, the rules may vary from one city to the next. It’s also important to note that the status of kratom legality isn’t widely known for some countries. For example, it isn’t clear whether it is legal in China, or in many of the African nations. However, as the drug kratom becomes more widely known, countries, counties, and cities that don’t currently ban kratom may choose to do so at any point.

Is Kratom Safe?

Proponents say kratom is an amazing compound, a game-changer and lifesaver. Opponents, like the FDA, say it has no viable medicinal properties. How the US DEA, medical professionals, and millions of regular kratom users can have such divergent views of the same plant is hard to fathom. The overarching “company line” seems to answer this question “No!!” They state that kratom is considered addictive, that people can develop a physical dependence on it, and that in and of itself indicates that it’s not safe. There are some anecdotal reports of people becoming dependent on kratom, but there are more reports of people successfully using it to recover from opioid addiction; not to mention successfully treating chronic pain, fibromyalgia, anxiety, depression, on and on. So in my book, the jury’s out people. 

The question of kratom’s safety comes down to two factors: the lack of regulation and the interactions with other drugs or substances, whether endogenous or exogenous. 

Lack of Regulation

Any time a substance, including herbal supplements, isn’t regulated by the FDA, there are potential safety hazards. This is because there is no standardization when a substance isn’t regulated. That means that companies, particularly if they’re operating online, can market the product however they want. There are no official drug warning labels for kratom, and people may take it without knowing what other substances it contains. A buyer never knows what level of potency a kratom product could have or whether it’s pure. In addition, the active ingredient in kratom varies widely by plant species. As with marijuana strains, different kratom strains have slightly different effects; there are multiple species of the tree, so this makes kratom’s effects unpredictable. This unpredictable nature leads to a risk of overdose and other serious side-effects, including seizures, hallucinations, chills, vomiting, liver damage, or even death.

Kratom Interactions

Because there is little research currently available on how kratom interacts with other substances, the breadth and severity of effects are yet unknown. This unpredictability adds to the dangers of using kratom in combination with something else, because you’ll have little idea what it could do to you. Potentially negative effects can be even more severe when kratom is combined with other drugs and prescription medicines. Some of the kratom chemicals have been shown to interact with how the liver metabolizes other drugs, which can lead to dangerous interactions. Another risk is presented when people buy commercial versions of kratom that have been combined with other drugs or substances, especially if they too work on the same opioid receptors. The potential consequences of many drug interactions can range from seizures to liver damage.

Various Points on the Kratom Controversy

Depending on what you read and who you believe, kratom is a dangerous, addictive drug with no medical utility and severely deleterious side effects that include overdose and death, or it is an accessible pathway out of undertreated chronic pain and opiate withdrawal, as well as being useful in treating many other health issues. There are great physicians and impressive institutions with interesting facts on both sides of this issue.

Recent increased kratom use in the United States, combined with concerns that kratom represents an uncontrolled drug with abuse potential, has highlighted the need for more careful study of its pharmacological activity. The major active alkaloid found in kratom, mitragynine, has been reported to have opioid agonist and analgesic activity in vitro and in animal models that are consistent with the purported effects of kratom leaf in humans. However, preliminary research has provided some evidence that mitragynine and related compounds may act as atypical opioid agonists, meaning they induce their therapeutic effects like analgesia, while also limiting the negative side effects that often accompany classical opioids. One such side effect that is absent in kratom is constipation. A chronic pain medication like kratom that doesn’t cause constipation like current opioids all do sounds like a good thing, but as I said before, it’s a long way from here to there, especially considering the FDA’s current opinion. And something tells me they won’t be changing their collective mind any time soon. 

As it stands now, there is little to no control or reliable information on growth, processing, packaging, and/ or labeling of the kratom currently sold in the US; and all of this adds to the already considerable uncertainty of its health risks. In 2018, the FDA instituted a mandatory recall of all kratom containing compounds over concerns about Salmonella contamination in these products. More recently, the DEA placed kratom on its “Drugs and Chemicals of Concern” list, but as I mentioned before, it has not yet labeled it as a controlled substance, though not for lack of trying. Time will tell how long that lasts.

Kratom can be addictive due to its opiate-like qualities, and a small minority of users may end up requiring addiction treatment. The CDC claims that between 2016 and 2017, there were 91 deaths due to kratom; but this claim should be met with healthy skepticism, as all but seven of these casualties had other drugs in their system at the time of their deaths, and that makes it totally impossible to uniquely implicate kratom.

A patient wishing to use kratom to treat chronic pain or to mitigate opioid withdrawal symptoms could expect to encounter several problems with doing so, not all of which even have anything to do with the intrinsic properties of the kratom itself.

A patient that wants to use kratom to treat a legitimate illness or condition will likely face four problems for the foreseeable future:

-The first problem is that the DEA still occasionally threatens to make it a Schedule 1 controlled substance, along with drugs like heroin and ecstasy. This would make kratom very difficult to access, and would likely make the supply as a whole even more dangerous than it is now. Generally, it’s not a good idea to use something to treat chronic pain or addiction that may soon become less available and less safe: you want to know it’s going to be readily available, and that as a cure, it won’t cause more problems than the illness it’s being used to treat!

-The second problem is that the complete lack of oversight and quality control in the production and sale of kratom makes its use potentially dangerous.

-The third problem is that kratom has not been well studied for any of the uses its proponents claim it has an affinity in treating! Maybe the FDA hasn’t heard the saying that goes, “Absence of evidence of benefit isn’t evidence of absence of benefit.”

-The fourth and final problem is that kratom doesn’t show up on drug screens. I like kratom’s potential, but I can argue that adding another potentially addictive opiate-like substance while an opiate epidemic is already going on may not be the best course of action. 

Is there a sensible path forward with kratom?

I’m not sure that anyone has the answer to that question, but at a bare minimum, the safety of kratom could be improved through:

-Regulation: it would be safer if people knew the exact dosage of kratom they were truly consuming, and that it was totally free of contamination.

-Education: educated consumers who know all of the potential benefits and dangers of the compound they are consuming are far less vulnerable to misleading claims.

-Research: if kratom does in fact have the benefits that have been demonstrated in the laboratory for treating either addiction or chronic pain, we should absolutely know it and make it known: accurately defining the risks of using kratom is critical, as is making all medical personnel and laypersons informed.

If all four of these points could somehow be accomplished by scientists and public health specialists, without: overdue distortion from corporate interests, anti-drug ideology, and romanticism by kratom enthusiasts, then we should have enough clarity to answer the basic questions about kratom, including the most important question of all…is it harmful or helpful?

Effects of Kratom: Good, Bad, Ugly

The Good

Recall that the expected effects from kratom are dose-dependent: that smaller doses will produce a stimulant-like effect, while larger doses will produce sedative or opioid-like effects. 

A small dose of kratom to produce stimulant effects would be up to just a few grams, and these effects would be felt within 10 minutes after ingestion and can last up to 90 minutes. These expected stimulant effects include increased energy, alertness, and sociability, increased sex drive, decreased appetite, and giddiness.

A larger dose of kratom, between 10 and 25 grams, can have a sedative effect, imparting feelings of sedation, calmness, euphoria, pain reduction, and cough suppression, which last for much longer periods of time, potentially up to six hours.

The Bad

Potential unsafe and negative effects of regular kratom use, even at low doses, can include: agitation, tachycardia, drowsiness, vomiting, confusion, anxiety, tremors, itching, sweating, insomnia, lack of appetite, tremor, coordination problems, and withdrawal symptoms.

There can also be negative effects of high dose kratom, including: addiction, nausea, itching, constipation, and withdrawal symptoms of tremor and sweating.

There can be negative side effects of taking any dose of kratom at irregular times or random intervals as well. Many users of kratom have reported something called “The Kratom Hangover” the day after taking it, the symptoms of which can include irritability, anxiety, nausea, and headaches.

Because kratom can cause problems with coordination and sleepiness, it’s dangerous to drive or operate machinery while using it. For this same reason, pregnant women are also advised never to use kratom. 

The Ugly

There can be grave side effects from taking kratom, which can include seizures and respiratory and/ or cardiac arrest.

If a person takes a high dose of kratom and falls asleep, they may vomit and choke while asleep.

Kratom Overdose

There are numerous calls into the CDC poison centers for kratom overdose every year.

The risk of overdose increases when kratom is taken with another substance, especially opioids.

Recent studies have found evidence of fatal kratom-only overdoses involving severe and negative side effects that can occur when someone takes too much. Some of the symptoms of taking too much kratom can include: impaired motor skills, lethargy, slurred speech, either shallow or very heavy breathing, tremors, listlessness, aggression, delusions, and hallucinations.

Long-term and heavy use of kratom can lead to liver problems, as kratom tends to make it more difficult for the liver and kidneys to process and filter toxins out, contributing to the potential for this type of organ damage.

Signs of liver damage include dark-colored urine and yellow skin and eyes.

Kratom: Necessary Evil or Just Plain Evil?

Kratom is currently considered a dietary supplement, as it is not approved nor regulated by the US FDA. That said, there are anecdotal reports of beneficial effects of kratom use, though there is no clinical evidence yet to support them. In the future, with the proper supporting research, kratom may indeed have proven potential. 

But without this research, there are a lot of unknowns with kratom, such as effective and safe dosage, possible interactions, and possible harmful effects, including death. These are all things that you should weigh before taking any drug, but for kratom, they’re all question marks. In the final analysis, going by laboratory findings, kratom holds great potential. But if you’re thinking about using kratom to treat chronic pain or opioid addiction, or anything else… exercise extreme caution people.

I hope you enjoyed this blog and found it to be interesting and educational. Sharing means caring, so please feel free to share it with family and friends. Be sure to check out my YouTube channel with all of my videos, and I’d appreciate it if you would like, subscribe, leave comments, and share those vids! As always, my book Tales from the Couch has more educational topics and patient stories, and is available in office and on Amazon. 

Thank you and be well people!

MGA

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Sadomasochism

Since it’s pretty clear you people really like reading about all things tangential to sex, I don’t mind indulging your secret freaky sides every once in a while. Hey, far be it from me to deny you! So in that spirit, this week’s topic is…. 

wait for it….

Sadomasochism. 

The Oxford Dictionary has this to say:

[sey-doh-mas-uh-kiz-uhm]

noun

interaction, especially in sexual activity, in which a person enjoys or derives pleasure from inflicting or receiving physical or mental suffering upon or from another person.

Abbreviation: S&M, S and M

The shrinky dink version from the American Psychological Association Dictionary version:

1. sexual activity between consenting partners in which one partner enjoys inflicting pain (see sexual sadism) and the other enjoys experiencing pain (see sexual masochism).

2. a paraphilia in which a person is both sadistic and masochistic, deriving sexual arousal from both giving and receiving pain. —sadomasochist n. —sadomasochistic adj.

The Mark G. Agresti version:

deriving pleasure or gratification from inflicting or experiencing pain.

It’s important to note that both the pain and pleasure given and/ or received in sadomasochism can be physical, emotional, or both. In addition, when it exists in the strictest definition, it is considered a mental illness, but there are all sorts of conditions and considerations- and controversy- that go along with that. I’ll elaborate a little on that later. No matter who you listen to or what you believe, sadomasochism tends to be a rather delicate topic, and strictly speaking, not exactly one you’d discuss in “polite society.” Whatevs. I’m all about taking deep dives into that kind of stuff- it’s actually one of my missions in life- and in fact, my entire profession centers on helping people with delicate issues that aren’t talked about in “polite society.” Despite not being coffee talk, there’s a lot to be said about sadomasochism… including the fact that many people exhibit sadomasochistic tendencies, which is not to say they regularly wear black leather gear or want to tie their partners up and beat them btw. I’d even venture to say that most people, eapecially when in romantic love relationships, exhibit characteristics of sadomasochists. How does that grab you? If you’re thinking Ineed my head examined right about now, then keep reading about the psychology of sadomasochism. 

But first, I have to get into where the term sadomasochism comes from, break it down (pun intended), look at its nominal derivation, and how it’s been viewed and analyzed throughout the ages. Let’s just say that shrinky dinks have had a lot to say on the subject. 

Captain Obvious says that sadomasochism is the mashup of sadism and masochism, terms coined in the late 1800’s by an Austrian psychiatrist dude named Richard von Krafft-Ebing, who believed that the natural tendency of the male was toward sadism, while the natural tendency of the female bent toward masochism. What!Everrr! In reality, studies show that sadistic fantasies are just as likely to occur in females as they are males, though the masochistic bend definitely develop earlier in males. We now know that, like many things, sadomasochism knows no gender. When you break it down, sadism is defined as pleasure or gratification gained from the infliction of pain and suffering upon another person, while the counterpart, masochism, is the pleasure or gratification of having pain or suffering inflicted upon the self. At the simplest, most basic level, you could say that sadists get off on dishing it out and masochists on taking it. Now, how often are things that simple? Like never, people. And believe me, that’s the case here. But this generalization works just in terms of remembering which is which. That said, there are no clear lines dividing the two, and in practice, they’re often interchangeable and may even coexist in the same individual at different times.

Krafft-Ebing named sadism after the 18th century Marquis de Sade, a French nobleman, revolutionary politician, philosopher, and writer. He is most famous for his libertine sexuality, and he ‘graced the world’ with novels, short stories, plays, and dialogues, including Justine, which is basically about a woman with the same name who travels around the world getting the crap beaten out of her as she goes, and Les prospérités du vice, which roughly translates to something like the pleasures of vice, in which he said: 

How delightful are the pleasures of the imagination! In those delectable moments, the whole world is ours; not a single creature resists us, we devastate the world, we repopulate it with new objects which, in turn, we immolate. The means to every crime is ours, and we employ them all, we multiply the horror a hundredfold. 

Two of his most commonly annotated quotes:

“It is always by way of pain one arrives at pleasure.“

“I’ve already told you: the only way to a woman’s heart is along the path of torment. I know none other as sure.“

Sounds like a great guy, right? Evidently, his current day ancestors have been very busy trying to rehabilitate their great great great whatever’s image by creating a line of gourmand treats: wine, pâté, cheeses and such; and supposedly had pitched a Sade line of lingerie to Victoria’s Secret. Another fun fact, the film Quills, starring Geoffrey Rush, Kate Winslet, and Michael Caine, is inspired by the story of Sade.

Krafft-Ebing was a busy guy, naming masochism for a contemporary of his, 19th century Austrian nobleman, writer, and journalist Leopold von Sacher-Masoch, who gained renown for his romantic stories of Galician life. He also authored Venus in Furs, in which he wrote:

Man is the one who desires, woman the one who is desired. This is woman’s entire but decisive advantage. Through man’s passions, nature has given man into woman’s hands, and the woman who does not know how to make him her subject, her slave, her toy, and how to betray him with a smile in the end is not wise.

Interestingly, evidently Masoch did not approve of this use of his name. Bummer that somebody names something after you and you don’t approve of it. My suspicion is that it’s more likely that he didn’t approve what it was used for, as Krafft-Ebing essentially outed the guy as a masochist. Sadly, no word on a lingerie line for Sacher-Masoch, but I’ll keep you posted. 

Sadomasochism as a mashup term was actually coined by none other than Freud, the mother-loving, father-hating Austrian neurologist and psychologist who is widely regarded as the father of psychoanalysis, a therapeutic process designed to make the subconscious conscious by releasing repressed emotions and experiences. 

Even The Kama Sutra, which dates back to second century India, includes an entire chapter devoted to “blows and cries.” According to the Hindu text, “sexual relations can be conceived as a kind of combat… For successful intercourse, a show of cruelty is essential.” Seriously? 

Now that you’re good to go for the daily double on historical literary references to sadomasochism…

Most of the time, for obvious reasons, we think of sadomasochism and it’s nominal components in terms of sexual behavior only, but they can have broader applications, and this is especially the case in sadism. The quality of being sadistic is most applicable to some notable autocrats of the past and present, and these are actually the first thing that comes to mind when I hear the word. When no other single word could possibly encompass the horror of their being, sadist just works. Think Stalin, Pol Pot, Hitler, Saddam Hussein, and the Kims. I was surprised to even see our 45th President’s name included while looking up a statistic. Hmmm… wonder who submitted that? (Dr. Mark Agresti is not making a statement about any person’s sexual inclination or mental status and is not claiming any political affiliation; this advertisement is brought to you by the equal opportunity offender party.) 

Okay, I have no clue how that dude got in here, but you get the idea about sadism. On the other hand, masochists enjoy receiving pain, which, again, may or may not be sexual. Strangely (?) I couldn’t find much in terms of famous or known masochists. The best I could do was a British artist I actually remember from some required art “appreciation” class freshman year, a painter named Keith Vaughan. Evidently, he purpose built some kind of gizmo contraption to electrocute his own genitals. They definitely didn’t cover that part in my class though, I’m pretty sure I’d remember that. 

Sexual sadism and masochism can actually be considered to be psychological disorders, as each are categorized by the Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV) as paraphilias, which are sexual disorders that are characterized by socially unacceptable preoccupations or behaviors. Some other examples of paraphilias include voyeurism, exhibitionism, and fetishism, to name just a few. There’s a great deal of controversy on this topic, and at first glance, I generally think of sexual sadism and masochism as quasi-disorders at best. Proponents of the ‘disorder theory’ claim that because sadism involves causing physical or psychological pain or suffering to another human being, anyone who enjoys it is mentally ill. Opponents say that it doesn’t involve pain or suffering in the ‘classic sense,’ (say whaaat??) and that as long as it occurs with a consenting partner, it should be argued that it is not a psychological disorder. 

I say that there are many factors to take into account, but that it should definitely be considered a psychological disorder in certain cases: if and/ or when it causes anxiety or depression to that individual, causes problems that interfere with work, social setting, or family, and obviously when it poses, or is likely to pose, a potential danger to another individual person or group. And in fact, more recent versions of the DSM back me up, asserting that it must “cause clinically significant distress or impairment in social, occupational, or other important areas of functioning” in order for sexual sadism or masochism to be considered a disorder. I’ll spare you the markers that must be considered to establish that distinction. And you’re welcome for that. 

When applied to sexual relationships, sadomasochism is generally termed BDSM, or Bondage and Discipline, Dominance and Submission, and Sadism and Masochism. BDSM is generally considered to be an “alternate” sexual preference that includes a variety of sexual identities and activities. Mainstream culture often represents it as reckless, dangerous, and unhealthy; a dark, non-normal kind of sexual preference which typically forces its players to retreat into carefully curated communities alienated from the majority of society. If you actually paid attention to Fifty Shades of Grey, you might have understood that Christian Grey’s reasons for enjoying kink stem from a childhood filled with abuse. Television crime dramas often portray fetishists as seedy, unethical lawbreakers, and that’s probably as a result of the psychological disorder theory more than anything else. Participants or “kinks” often make the argument that dominance and submission are more a power dynamic than a punisher-punishee relationship; and they usually identify themselves in one of three main ways: dominant, submissive, and switch, though the identities are fluid and continuous, and can change depending on the participants’ mood or partner. But if you consider the fact that the terms sadism, masochism, and sadomasochism were coined in the late 1800’s, pop culture wasn’t responsible for making kink the latest fad… it seems some humans have long had a penchant for adventurous sex. Even way back in 1956, when the ​Kinsey Institute was in its heyday, a study revealed that 50% of men and 55% of women enjoyed erotic biting, evidently as racy as they got when describing kinky sex. Considering all of the historical evidence taken together, I can only surmise that we’re not necessarily having more kinky sex than we always were, but we’re just talking about it- or admitting it- more than before. 

BDSM Components

Bondage: A form of restricting a sexual player’s movement, ie by ropes or handcuffs, to increase pleasure.

Discipline: A series of rules and punishments typically used by a dominant partner to exert control over their submissive partner.

Dominance: The act of dominating a sexual partner, during or outside of sex. This can include dictating sexual behavior, food habits, and even sleep patterns.

Submission: The act of a submissive partner following a dominant’s actions or dictates. 

Consensual sadomasochism should not be confused with acts of sexual aggression. While sadomasochists do seek out pain in the context of love and sex, they do not do so in other situations, and typically abhor uninvited aggression or abuse as much as the next person. Generally speaking, sadomasochists are not psychopaths, and thankfully, the opposite is usually true as well. Also contrary to popular belief, evidently submissives have just as much control over deciding what happens to them as their dominant partner does, and sometimes even more so. Communication between the dominant and submissive is of utmost importance, as that’s where boundaries are set, desires are shared, and permission is given. Consent, in the form of a formal contract, a verbal agreement, or a casual conversation, is the key to healthy expression of BDSM and sadomasochism. There is typically an understanding between all partners that activity could stop at any moment should they be uncomfortable with the intensity of play; this can be done through the use of previously agreed upon safe words that signal others to stop when uttered. I’ve seen references to layers of safe words that are like a traffic light: green means good to go, yellow means proceed with caution, and red means get the hell away from me. That’s sure different than the “red light-green light” we played as kids. 

Speaking of games….

Maybe you think that this sort of stuff only applies to a small number of “deviants,” but the truth is that many people, if not most, do actually harbor sadomasochistic tendencies. For example, many casual, “normal” behaviors, like infantilizing, tickling, and love-biting, could be considered as containing traces and elements of sadomasochism. In addition, sadomasochism can play out on a more psychological level- sadomasochism on the DL if you will. Consider the fact that in almost every relationship, one partner is more attached than the other. This phenomenon is just accepted as fact without much discourse, so commonly that it has even been the subject of poetry and philosophy, with the more attached partner being referred to as “the one who waits.”

In 1977, A Lover’s Discourse: Fragments philosopher Roland Barthes writes:

Am I in love? —yes, since I am waiting. The other one never waits. Sometimes I want to play the part of the one who doesn’t wait; I try to busy myself elsewhere, to arrive late; but I always lose at this game. Whatever I do, I find myself there, with nothing to do, punctual, even ahead of time. The lover’s fatal identity is precisely this: I am the one who waits.

When this asymmetry is examined, the less attached partner (A) grows dominant, while the more attached partner (B) becomes infantilized and submissive in a bid to please, coax, and seduce them. Sooner or later, (A) feels stifled and distances themselves, but if he or she moves too far away, (B) feels threatened and may go cold or give up. That in turn prompts (A) to flip and, for a while, to become the more enthusiastic of the two. But the original dynamic soon re-establishes itself, until it is upset again, and so on, ad nauseum. Domination and submission are elements of every relationship (or nearly so) but that does not mean that they are not tedious, sterile, and immature, as Freud points out…endlessly I might add.

Rather than playing cat and mouse, couples need to have the confidence and the courage to rise above the game playing. True love is about trusting, respecting, nurturing, and (healthy) enabling, but not everyone has the capacity and maturity for this kind of love. I see this domination-submission phenoma nd game playing a lot…like a lot a lot, and it can be quite the mess to rectify, as people get comfortable in their roles, whetjer they’re conscious of them or not. 

Sadomasochism, BDSM, kink…they aren’t really my thing. Then again, neither is sociopathy, but I can still effectively diagnose and treat patients with it. That said, sadomasochism as a practice is definitely harder to understand than just grasping it as a general concept. I classify it as one of those great mysteries of the human condition that give me a headache when I try to completely untangle them. I’ve of course had patients into all kinds of kink and BDSM, and then again, I’ve also had some who are more “classic” practicing sadomasochists, who can be more challenging to treat. Everybody’s got a backstory that I may or may not be privy to, so I don’t judge and I think I do a pretty good job of treating everybody fairly. I figure that understanding, or at least the most earnest attempt at it, is the best way to deal with anything we may not ascribe to, even as we wish to respect the person who does. Along that same vein, if you’re curious about BDSM and kink, there are websites galore with tips and tricks, even online “academies” where you can learn to be a dom or a sub, or BDSM groups for the over 50 set…you name it, it’s there for your perusal. If you do decide to partake, I can only suggest to communicate, communicate, communicate; be safe, establish a safe word and safe boundaries, and have fun people. 

I hope you enjoyed this blog and found it to be interesting and educational. If you did, let me know. If you didn’t, let me know that too! 

Be sure to check out my YouTube channel with all of my videos, and I’d appreciate it if you would like, subscribe, and remember… sharing means caring! Please feel free to share the love! Share blogs and YouTube videos with family and friends. 

And if you like what you see and want more of it, or if you want a specific topic, leave it in the comments- I love reading them. As always, my book, Tales from the Couch has more educational topics and patient stories, and is available in the office and on Amazon. 

Thank you and be well people!

MGA

Learn More

Blog Part 3:The Future Of Sex Toys

Hey people!

MGA here. I’m writing this closing after finishing today’s blog, but it’s weird that I’m sticking it at the top of it, but there’s a method to my madness. I’m switching things up today and talking to you first because I might just have an announcement! And maybe even a favor to ask of all of you. So please read on. 

I think you guys have liked these sex toy blogs, no? Well, I have to tell you, this series has been a lot of work, but really great fun, too. So even though today’s sex toy blog is the last in the series (wahn waaahnn waaahhhhnnnnn) I don’t want you to be sad. 

Months ago, when I stumbled across some health benefits of orgasms that I didn’t know or hadn’t thought about, I started thinking that if I didn’t know or think about these things, maybe some of you didn’t either. Once I started looking at all the material online about orgasms, that led me directly to the point (underlined in bold letters) that they’re not the automatic foregone conclusion to any and every sexual event that all the movies and all the… propaganda is really the only accurate word… makes them out to be. In fact, nothing could be further from the truth. Especially for women. This singular fact- that there is more bs and shame shrouding the real reality of sex and orgasm- made me want to expose it. And of course do so in my very own unique (maybe slightly weird and slightly more irreverent) way. My shrinky senses were on alert, and the rest of it, the sex toys and all, was just a natural progression. I had a mission. Present all of it in an approachable way, no shame, no bs, no flinching. 

There’s sooo much material on the great interwebs on all things sex, orgasm, toys, and sex psych… it’s actually overwhelming. I knew that I couldn’t possibly do the subject any justice in one blog, so I decided to do the series. And while I was researching and reading, I saw so much evidence that made it crystal clear that sex, orgasm, and sexual health and wellness are such huge and integral components of the human condition, yet… Shhhh!Keep your voice down! What is wrong with you?! Why do you have to talk about this stuff anyway? Helll-ooo… such huge and integral components of the human condition, yet WE DON’T TALK ABOUT THEM!!

Because the fact that we don’t talk about it is just patently dumb. Look, I’m all for discretion, though you couldn’t be blamed if you’re having a hard time believing that, rolling your eyes right about now and thinking “seriously?” Yep. Seriously. I understand that it’s not an easy topic, but the fact that there’s so much shame and confusion and bs obscuring the topic of sex, all things that do real damage to real people in real life, I knew that propagating those things by continuing to not talk about it just wasn’t going to happen. 

Once I had put up the first sex toy blog, a patient asked me what the hell was I… ‘a psychiatrist of all people, doing writing about sex (very quietly) and dildos (almost whispered, as though she was concerned that the morality police were hiding behind my desk waiting to bust her) and how some people can and some people… can’t… be… satisfied?‘ she almost spit it out, she was so happy to have found the word, any word. Then she quickly added, ‘It’s just too… too personal!‘ she said with a shake of her head and a tsk tsk expression. For any of you that are thinking ‘Yeah, riiight? Exactly!’ right now, my answer to why is pretty simple: I am a psychiatrist, so people come to me seeking help for their problems. Right? I’m dealing with their minds and all the things that happen in them and to them. So any and every “thing” that creates a barrier to their happiness- to the point that they’re sitting in my office- is fair game. And many times, the tallest, widest, and strongest barrier I see in that office is shame. And shame is shame, no matter what it arises from, and so it is my sworn enemy, and I like to make it a point to wipe it out where it lives at every opportunity. And the fact that this patient who wanted to know why I was doing these blogs had to barely whisper the word dildos as it stuck in her throat, and because I could literally see her search frantically for any word to say butorgasm is exactly why I was doing them. How’s that for irony? 

I don’t claim to be a sex therapist, so it doesn’t fall to me to cleanly and concisely educate about it in an academic way, every impact that sexual health and wellness has on people’s lives. That’s not why I wanted to do it. Do I want you to learn something? Definitely. By the time you’ve read these blogs, do I want you to be able to recite the six principles of sexual health and explain the genesis of their inclusion? No. In fact, I don’t even go over all of that technical stuff, because that’s not what this is about. What this is all about is just getting the real deal info out there. Relax the stigma. Show that the subject is not too taboo, which was why I made that the subtitle of the first sex toy blog. 

So during the countless hours I spent putting these last three blogs together, I had an epiphany. Okay, maybe it was part epiphany, part hallucination brought on by a lack of sleep, but the end result remained the same: with all of the things that have to be brought to the light, these were going to be some really. long. blogs. people. In fact, I could totally fill an entire book with this stuff. So I’m going to. That’s the announcement: I’m doing another book…my third. But it’s going to be very different from my first two, and not just because of the subject matter. It’s going to be different because I’m writing with a co-author, something I’ve never done. Her name is Dawn, and she’s kind of got degrees like a thermometer: biology, molecular biology, chemistry, microbio… there could be more, but my point is that she’s not a moron at all, yet despite that, she doesn’t take herself too seriously, and I think you’ll like her writing style, because I do… and it’s a lot like mine to be honest. I think that having both the male and female perspectives will make it a better, more balanced book. It’s going to be good, people!

Which brings me to my next point. Actually, my next question. And it’s for you. Yes… you. And you. All of you! I need a favor. Well, we- Dawn and I- need one. We need you to help us. Will you help us write this book? I promise it’ll be super easy. Here’s the scoop: given the general topic of sex and orgasm, we’re going to be doing a simple, anonymous sex survey in the not-too-distant future, and we’re hoping that you’ll agree to participate in it. And in order to get a statistically significant sample size (say that five times fast) and draw conclusions from the survey, it’s got to get into the hands of a lot of people. So I’m asking everyone to please share this blog with at least five people, but if you can share it with more than that, even better! So I guess that’s two favors I’m asking: one, that all of you will agree to be contacted to take the survey, and two: that each of you will share this blog to pass that same request on to at least five others. I really appreciate it people! 

For you to agree to be contacted to take the survey, you just have to leave a comment on the blog saying so. If you’re familiar with the site, at the end of each blog there’s a little blue link that says “LEARN MORE” Click on that and it’ll take you directly to a reply box. Type in “Contact me to take the survey” fill in your info, check save my info for future, check if you wish to get notifications and submit. Voila!

If you’re like me, you like to ‘copy paste edit’ to save time, so here’s a message you can do that with to send along with the blog to explain everything to your people, people! FYI: I assumed that the people you send to won’t be familiar with the blog, so the instructions on how to leave a comment that I give in the following pre-fab message are different than those I gave you above- they’re faster, as they don’t require they read the whole blog to see the “learn more” link located at the end of each blog. They can just click on the small grey comment link just before the blog. 

Feel free to ‘copy paste edit’ this paragraph to send when you share the blog. Thanks!

Dr. Mark Agresti, a psychiatrist I know, has a weekly blog https://dragresti.com/blog/ and he just mentioned that he will be doing a simple anonymous sex survey sometime in the not-too-distant future, and in order to get a statistically significant sample size of completed surveys to draw conclusions from, he’s requesting that people agree to be contacted to take the survey, and that we please pass that same request on to at least five other people. So great news… you’re one of my people! So please click on the link https://dragresti.com/blog/ and you’ll be able to see and read all of his weekly blogs anytime. To agree to be contacted to take the survey, you have to leave a comment saying so. There are lots of places to do that, but the fastest is to look where it announces that week’s blog title and in small grey letters you’ll see the authorship, date, category and a [> 1 comment] link. Click on that little comment link and it’ll take you directly to a reply box. Please type in “contact for survey” then fill in your details, check the box that says ‘Save my name, etc for next time’ and if you wish to receive future notifications and submit. Voila! And please feel free to pass the request along to as many people as you’d like. Dr. Agresti appreciates it and so do I! 

Housekeeping is almost done here people. 

I hope you’ll enjoy this final blog in the three part sex toy series: The Future of Sex Toys 

Please don’t forget to leave a “Contact for survey” comment and share the blog to pass it along to as many people as possible. The more people that take the survey, the more meaningful the data gathered from it will be- and the better the book based on that will be! 

I really appreciate it.

And if you have other comments about any of my blogs, if you like what you’re reading or you have suggestions, please leave those too. I’m always down for comments! 

Be sure to check out my YouTube channel with all of my videos, and I’d appreciate it if you would like, subscribe, share, and comment on those vids too! And my book Tales from the Couchhas more educational topics and patient stories, and it’s available in the office and on Amazon. 

Thank you and be well people!

MGA

Now without further ado, this week’s blog…

Part Trois du Trois: 

The Future of Sex Toys

Throughout the course of history, humans have experimented with numerous ways to derive sexual satisfaction: ancient dildos, Ben Wa Balls, Cleopatra’s bee vibrator… We’ve already explored how our ancestors got off in the history of sex toys, so now we’ll look ahead. What does the future of sex toys hold?

Imagine a world where you can strap on your VR headset, crank up your smart bodysuit, and have virtual sex with someone on the other side of the globe. It sounds like the setting for a sci-fi porn flick, but fully remote VR sex is closer than you think.

Sex Tech

The marriage of sex and innovative technologies is known today as “sex tech.” And just like every innovative business linked to sex, it’s BIG business: the sex tech industry is currently valued at more than $30 billion dollars. But unlike some businesses linked to sex, the sex tech market specifically is set to explode, and this value is predicted to climax at over $124 billion by 2024… quadruple in four years people! I can’t think of another industry that has, or ever could, accomplish this growth rate expectation. 

Remember that total geek that sat in front of you in eighth grade math class? The guy with the pocket protector and ultra thick glasses that couldn’t get a human date so he was really into robots? Yeah, him. This is what he grew up to do: sex tech. And just fyi… he’s a billionaire now.

From Sex Industry to Sex Tech

While sex toys in their primitive form have existed for literally ages, the last few decades have allowed civilization to explore an unprecedented level of freedom in the sexual health and wellness arena, and this has led to a proliferation of sophisticated technology and innovation in sex tech. A perfect example of this is the novel intersection of sex and Artificial Intelligence (AI), a pairing that was once thought to be inconceivable, but now holds great promise for the most immersive sex experiences ever possible.

Sex Tech Defined

As defined by FutureofSex.net: “Sex tech is technology and technology-driven ventures designed to enhance, innovate, and disrupt in every area of human sexuality and human sexual experience. Sex tech is important because sex and sexuality lie at the heart of everything we are and everything we do.”

Now that we’ve cleared that up…

What Will Sex Toys Look Like In The Future?

Where do you currently keep your sex toys? In the sock drawer? A dedicated goodie box? 

Let’s explore some data:

The world’s largest masturbation study (yup, that’s a real thing) published that 78 percent of adults in the world masturbate, including: 96 percent of British men, 93 percent of German men, and 92 percent of American men; and 78 percent of British women, 76 percent of German women, and 76 percent of American women.

A survey from UK sex toy creator Lovehoney found that three in four Americans own at least one dildo. That means roughly 70 percent of Americans have a dildo in their homes (or cars, or cubicles… no judgement) While the majority, 78 percent, are women, 64 percent of men that answered also said they own a “phallic sex toy;” guess they couldn’t say d i l – d o… dildo.

One safe conclusion we can draw from this data is that there are a lot of dildos floating around out there people. If we round down the current US population to 328 million, and assume that each respondent has just one dildo (which would be highly unusual- most people that use them definitely have more) that means there are more than 229 million dildos in the US. And given that number, as compared to the number of people that freely talk about using them or admit to it, we can also see clear evidence that many people still feel embarrassment and/ or shame to admit to masturbating, much less using toys. So even though the tech has advanced, it’s pretty clear that society’s acceptance has not come nearly far enough. It’s especially true in the non-male founded sex tech companies. There is a definitive double standard, so read on for details on that.

In 2017, one sex tech company self-named by its founder, Lora DiCarlo introduced the Osé, a dual massager for blended orgasms that introduced the world to “sex tech inspired by human movement.” For the very first time, a “smart toy” employed very complex mechanics and robotics that spoke to actual female anatomy and vaginal physiology. This founder and her company actually did a ton of work to develop this. They took countless measurements and made molds of thousands of vaginas to create a natural feeling toy with robotics that perfectly mimicked human movement, specifically a “come hither” motion for G-spot massage. The end result was apparently worth it- it was so unique and the movement so human and life-like that it actually won a highly coveted robotics innovation award from the Consumer Technology Association (CTA) in that same year. 

But then, when the CTA considered that the company was founded by a woman, they actually rescinded the award! Apparently because in their estimation, a female engineer/ founder creating robotic tech ‘inspired by human movement’ for the purposes of creating ‘a dual massager with come hither G-spot massage and clitoral stimulation’ for the specific purpose of ‘achieving a blended orgasm’ was lewd, and as such, the CTA could not be associated with the device in any way; which btw in their policies, that made it comparable to hard core pornography. That means they were actually saying that a woman creating robotic tech to theoretically pleasure herself and other women is pornographic. Saaay whaaat?! I’m a guy, so I don’t even have a horse in this race, but I’m still offended! They made it quite evident that if it had been developed by a man, it would have been a different story. A male founder of the product would have kept the award. Can you believe that bullshit, people? And PS, they also refused to let her company, and all other female founded sex tech companies, to even attend the event in the future! 

As you can imagine, Lora DiCarlo was mad as hell, but not surprised at all. She and all of the other female sex techies were used to having Facebook and other social media platforms censor them, PayPal refuse to offer their payment platform for their websites, or to be associated with them in any way. They got nothing but doors slammed in their collective faces. Just another Tuesday.

Well, Captain Obvious says that Ms. Lora DiCarlo had some things to say to the CTA about that. She started a critical public conversation about gender equity in tech, demanded that CTA issue a public apology and re-award her the award that she earned, and publicly demanded that any and all female-founded sex tech companies be invited to all future CTA events. And CTA in fact got smart and capitulated to her demands. Since that time, Lora DiCarlo and her company have continued to champion the cause of women’s sexual health in as open and public a way as possible. In addition, she and her fellow female techies have also formed Women of Sex Tech, which the New York Times said is “a tech-savvy and female-led women’s sexuality movement that has made its home in New York, instead of, say, Silicon Valley. Women, many of them under 40, are updating sex toys and related products with their own needs in mind, and leading the companies that sell them.”

And in fact, there are many more female founded sex tech co’s than male- it’s not even close, and Facebook and some other social platforms still censor them, so some specifically create vanilla campaigns to slip past the censors to be allowed on them. I don’t know about PayPal, but any person or company with three brain cells to spark off each other should be rolling out the red carpet to welcome these previously wrongly censored companies. I can feel her pain with Facebook… they refuse to boost my blog ever since I said that social media was problematic because devotees spent too much time in their artificial, anti-social social media platform. They need to get with the times and realize that just because they don’t appreciate a product or comment or statement, that doesn’t automatically invalidate it. 

Anyway, the moral of that story is that today, women are kicking butt and leading the charge in the women’s sexual wellness arena and the robotics and AI that go with it…a fact that offends the nerdy guys in their Silicone (Valley) Prisms. 

Back to the Future… of Sex Toys

We all know what yesterday’s dildos look like- mostly veiny, flesh-toned, realistic penis replicas (designed by men- I can believe that) or brightly colored carnival-prize-looking things that apparently didn’t excel in form or function. Both of those are relegated to under the bed to gather dust and dog hair (eeeww) or under the socks in the top drawer. 

Now contrast that to an insta-worthy living room with a coffee table proudly displaying an artsy magazine, a glass succulent cactus terrarium, and a beautiful, artisanal, teal-colored dildo…

According to sexperts, advances in sex tech will continue to be accompanied by a more open and accepting attitude towards sexuality. As a result, sex toy designs are moving away from products that need to be hidden away under a bed or in a drawer like a dirty secret. Now designers are embracing sleek and aesthetically pleasing designs that are meant to be noticed and begging to be on display in (almost) every home in the country. Ornamental dildos? Sure, why not?!

More Options, More Orgasms

As society becomes more open-minded and accepting of trans, non-binary people, and just all people, we can expect to see more gender neutral toys in a range of sizes, colors, and designs. In fact, as you’ll read later, this is already the case. 

Alexa… Oh Yeah, Right There Alexa!

The future isn’t just about high tech gadgets, it’s about having greater control over them. Imagine a vibrator with a range of personalized settings: slow and sensual or a hit it and quit it quickie for lunch breaks. Voice recognition and AI technology will play an increasing role in realizing this future. Voice activated toys that respond when asked to change strength, speed, or force will make Alexa look like a boring prude by comparison. And in fact, this is another example of ‘the future is now’ deal, as Vibease, the company that introduced the world’s first app controlled vibrator has now developed the world’s first AI integrated, voice activated vibrator. And it actually looks like a designer lipstick, so they clearly created it with an eye toward it going with when the user heads out to work or play. As Vibease says, their “goal is simple: bring out your inner glow…” Pretty catchy, huh people? Right now, I believe the AI enabled voice activated lipstick vibrator (say that four times fast) is actually available on Kickstarter for half price; they’re evidently selling it at a discount as a means of funding future techie toys. If anybody maybe needs a handy excuse for buying and trying…

Integration Innovation

How about sex toys that become integrated into our bodies? The founder of media and research company Future of Sex believes that in 30 years we might not even see sex toys as separate entities. I don’t know about that exactly, but it’s quite a concept, and as you’ll read later, Elon Musk is already working on what I might categorize as similar tech. A male sex techie named Rich Lee has developed the LoveTron9000. How stereotypical does that sound? I can hear some dulcet baritone celeb like Morgan Freeman or James Earl Jones, or best yet, Barry White, voicing the commercial… “The LoooveTronnn9thouusaaannd… Oh yeaaahhh, you neeeeddd thiiss, mennn.” So what is it? It’s an implant that’s embedded behind the pubic bone, and it vibrates so that it makes the penis vibrate. If you’re into that, then the good news is that innovation in bio-hacking and body modification means that similar tech innovations will become more common. Just had a thought: is Barry White dead? If he is, sorry and may he RIP, baaabbbyyyy.

If vibrating penises aren’t your thing, how about a smart bed that can hug you, whisper sweet nothings in your ear, and stimulate your nether regions… all at the same time. That tech is on the not-too-distant horizon too, people. 

VR and LDR

If you’re in a long distance relationship and/ or living in The Time of Corona, futuristic sex toys could bring you closer together, even if you’re social distancing. VR, sex robots, and teledildonics (sex toys controlled remotely over an internet connection via apps) are combined to allow your sex doll to be controlled remotely by your partner while you’re wearing a VR headset, with… say, Fiji as the 3D backdrop. The tech is coming soon, people. Teledildonics has already been around long enough to be slightly goosed by the newer competition. While it’s not obsolete by any means, there have been tech advancements that necessitated a new and equally advanced term: cyberdildonics. While some references seem to mistakenly use the two terms interchangeably, cyberdildonics is actually distinctively different. Both are technologies for participants to have remote sex via electronic data link and/ or smart applications, but cyberdildonics is tech in which tactile sensations (which is also called haptic tech) specifically are also able to be communicated between the participants via a data link and/ or smart applications.

Here’s how cyberdildonics work. The dildo lover/ female/ pronoun of your choosing/ yourself/ them: they have a high-tech dildo embedded with touch sensors. The person who enjoys penis attention has an advanced penis sleeve that’s capable of pulsating and contracting. First step: the two lovers connect their sex toys to the interfacing app. Second step: both then connect to a video call, which can be through the same toy interface app (some companies have this ability included) or through another exogenous app like FaceTime, What’s App, or Duo. Third step: have some fun! When they stroke or suck or insert the dildo into themselves, the other sees it on the video call screen and in response, their sleeve pulses and squeezes, delivering sensations that are said to be remarkably close to actual sex.

And/ or… switch ’em up! For the person who would usually be enjoying the sleeve’s pulsations on their penis, give them a smart vagina, replete with vulva and clitoris and embedded with touch sensors. Then give their lover an app-enabled vibrator. As one strokes or licks the smart vagina, their lover’s vibrator will react so they can feel their touch with every move made. With tech advances, new smart toy types have been, and will be continued to be, released. So if variety is the spice of life, get the vibrating cock ring, butt plug, vibrator egg, or whatever strikes your fancy and eat it up!

Teledildonics, Cyberdildonics, Digisexuality… Oh My!

Here’s a neologism for ya: digisexuality. What is it? A digisexual is a person who is sexually attracted to robots or other forms of sexuality that are technologically-mediated. Like the geek in my eighth grade math class with his thick glasses and pocket protector… the one who’s bound to be a billionaire by now. He’s a digisexual for sure. But whatever floats your boats people. No judgement, just saying.

No Partner? No Problem! 

According to sexperts, it’s just a matter of time before celebrities hop on the digisexual and cyberdildonic bandwagon and license the use of their faces for sex dolls or VR scenes, so one day soon, you’ll be able to have a simulated sexperience with your favorite celebrity! Honestly, this one rates kinda high on my creep-o-meter people.

Sick of People? Date a Robot!

Wouldn’t it be great if you could program your boyfriend and/ or girlfriend to do and say whatever you wanted? Well, sex robots are not a sci-fi fantasy anymore: they’re already among us. Harmony 3.0 (and by now maybe even 4.0 and 5.0) is a lifesize doll which can be programmed via the Realbotix app. And of course it comes with 18 personality types, 42 nipple designs, and 14 dishwasher-friendly labias to choose from, don’tcha know. These AI drive sex toys are transforming the way people view- and feel- sex. One benefit associated with them would be that if you wish to fulfill any sexual fetish that a regular human partner might not want to engage in, you can access various quick sex scenarios on your bot partner and indulge in the experience that way. And Captain Obvious says that another benefit of utilizing this technology is that the risk of STD is completely eliminated. Remember Ryan Gosling in the movie Lars and the Real Girl? I mentioned it in a previous blog. If you’re into this, dolls and bots can be programmed to tell jokes and recite poetry, whatever you’re willing to teach them, they’re willing to learn. Just think: she will always remember your birthday. And never bitch when you leave the toilet seat up. Now that is technology I can get behind people!

If bionic penises are more your speed, sexbot company RealDoll also has a fully customizable male doll… Though it looks like they literally have one, while the rest of their site is absolutely overrun with different female versions: classic, petite, and wicked, in dizzying arrays of features, along with interchangeable heads and toros too, for the Jeffrey Dahmer set I suppose. And if you like penises but could care less what it’s attached to… or if it’s actually attached to anything, they also sell the RealPenis, which at first glance is shockingly realistic. And it may also be at second glance too, but I couldn’t look again.

The Future of Sex Toy Tech is Coming… Are You?

The expiration of the original teledildonics patent a few years ago is the driving force behind the rapid expansion in the field of smart sex toys. That’s why we’ve come so far in such a short period of time and have an array of smart toys. It’s been a wild ride, but we haven’t even hit the loop de loops yet! Where there once were only app controlled panty vibes where you turned control over to your partner so they could zing you out of the clear blue sky just to say hi, now there are teledildonic couple toy sets: an app controlled toy for vaginal/ G-spot/ clitoral stimulation is sold in a set with a vibrating penis sleeve, or vibrating butt plug, or vibrating cock ring. They’re meant to be used simultaneously via app control by your partner. 

There are a few really unique smart app controlled vibrating toys that are worth an honorable mention. If you can’t sleep unless you can hear and/ or feel the beat of your partner’s heart, Little Riot’s Pillow Talk might be the ticket. It lets you hear the heartbeat of your loved one in real time via a mobile app, wristband, and speaker, as if you have laid your head on their chest, even when they’re on the other side of the world. And haptic touch advancements in combination with VR have also made smart toy prototypes that make virtual hugs and even remote kissing possible. Now I don’t know about you, but I’m going to have to see that to believe people.

What could possibly go wrong? Well, since you asked… as anyone who’s argued helplessly with Alexa or Siri about just turning on a damn light has discovered, the reality of an ‘Internet of Things’ is sometimes closer to an ‘Internet of Shit.’ If you think it’s irritating when your own doorbell decides you’re an intruder because you’re wearing your favorite Batman shirt, wait until tech companies start using your genitals to beta-test their cutting edge tech. And the quality of your sexual experience in using these is based on the quality of internet connections and the app/ software interface between the devices. But I imagine the up-side is that time will only lead to better connectivity. Regardless, this tech is not without risk. In reality, it’s possible that people can be hurt, technologically and maybe even physically by this tech. Companies could possibly leak data that identifies users, even without malicious intent mind you. Remember the Ashley Madison hack in 2015? When “The Impact Team” stole the user data of Ashley Madison, the commercial website that billed itself as an enabler of extramarital affairs? At least two suicides are directly attributed to having been identified in that data breach. 

Breaches of that order happen all the time. I got a letter from an e-commerce, or “shopping cart” company about a year ago. They’re basically responsible for presenting you an online store’s stuff, enabling you to select the stuff you want and put it in your cart, write reviews, seek faq’s, make modifications, and eventually pay for your crap in order to receive it. Well, the letter informed me that this gigantic e-commerce site had a security breach, and that my card information was among the data that was extracted. The kicker? The breach had taken place like 16 months before! Yet this was the first I’d heard of it. I don’t know if they dragged their feet during an investigation and that’s why they didn’t inform me sooner, or if maybe they didn’t even know about the breach until long after it was done. Frankly both are disturbing. They say that cyber thieves or their network rings usually just hold on to the data they steal for a while, lulling you into believing that your info must be safe, because surely they would’ve robbed me blind by now, right? Right? Anyway, you see the issue. If you’re employing an app to facilitate intimacy, use protection… and I don’t mean condoms.

Poor security could also allow malicious hackers to view the GPS coordinates of users, or take control of devices remotely. We’ve known for years that cars can be hacked, as can heart implants and webcams. Similar invasions could possibly be coming soon to your erogenous zones, too. But I have noted that some sex techs are very serious about security, as Bluetooth can also be hacked. And the almighty cloud. In an attempt to thwart this, I know that sex tech co Vibease allows only one linked device to control the toy at any given time so that any hacker will just be impotent. You set it up with your partner with a password and they also suggest a fingerprint-required complete phone lock to keep pick-pocketing smartphone thieves from availing themselves of your partner’s pleasure. Maybe the sex toy app itself should require a penis or nipple print as a unique identifier to access it too. 

While there are always cons against pretty much anything in life, the same goes for pros. In addition to providing a viable outlet for sexual intimacy in long distance relationships, as well as the same during A Time of Corona, there are some other fascinating opportunities. For example, sex tech can provide people with an anonymized and untraceable alternative to a physical encounter in countries where gay sex is against the law. In a situation like that, teledildonics could provide physical pleasure with far less risk than what would be involved with an actual encounter. And as we’re already seeing with cyberdildonics, as sex tech advances, it will continue to incorporate other emerging technologies. Combining VR is on the not-too-distant horizon, so in combining VR and toys, you’re more fully immersed in the sexual experience, since you can see it, hear it, feel it, and get physical stimulation based on what you’re seeing in the chosen scene. Morning sex in Maui, a nooner floating along on the Nile, and for delicious dessert, go to Dubai.

Another cool thing about sex tech is the definitive opportunities to create hardware for disabled people to have sex. Historically, most toy controllers have been touch-based. There hasn’t been a lot of time and/ or effort dedicated to voice interfaces or eye tracking capabilities that would allow people who can’t reliably manipulate a phone to control toys. Through hands free utilization, tactile capabilities, and voice recognition AI, sex tech can be developed as a more sexually gratifying experience for people with disabilities. Also, for those people, or any people who may find it difficult to reach orgasm, many tech toys already can, or will be able to “learn” what gets their user off, so that the patterns and combinations that are the E ticket ride can be recalled, accessed, and re-played anytime.   

Whether you consider yourself to be a visionary on the cutting edge or a total dinosaur in technology adoption, one thing is for sure… sex tech literally moves at cyberspeed. A report from Future of Sex offers insightful information and predictions on technological transformation in 5 areas:

#1: Remote Long Distance Sex

Internet of thing (IoT) system that enables the safe connection of device(s) to the Internet. Obvi this technology of teledildonics and cyberdildonics is already here and expanding, and there doesn’t seem to be an end in sight. 

#2: Virtual Sex, Cybersex

Virtual sex or cybersex would entail the electronic transmission of sexually explicit or obscene messages via text, voice, or video. Historically, cybersex has utilized chatroom(s) and/ or online games, but believe it or not, good old fashioned phone sex and sexting are some of the most common forms of virtual sex. 

Virtual sex via online games allow fantasies to run wild. Online multiplayer virtual games allow users to adopt different roles to see what they like best. The game Red Light Center allows you to design your own avatar to experience virtual interactions and even sex with other players in real time. The role playing, customization of avatars, and the virtual environment allows fantasies that are erotic and outrageous, and everything in-between. Some 3D sex games even support virtual reality headsets and interactive sex toys, all of which can deeply intensify the immersive cybersex experience.

#3: Robot Sex

Robots aid humans in various tasks; robotics are actually integrated into so many everyday objects that we take them for granted… we don’t even think about them. But sex tech robots are designed to be noticed; and many “online adult forums” utilize erotic chatbots to help moderate and facilitate racey group chats or private room activities. So it should come as no surprise that sex robots have been a popular sex tech trend, and they’re getting better all the time, as I mentioned near the beginning of this blog. Sexbots are basically very expensive and very lifelike, fully customizable silicone dolls. Tech advancements give them increasingly sophisticated movement and features to make them look, feel, and act like real girls. As they do closely mimic human movement and behavior, when you consider the potential to learn constantly, get smarter in communication on every topic (humor, speech, friend’s preferences/ likes/ dislikes) and with every interaction their human friend has with them, they offer very realistic and responsive experiences when it comes to sex and intimacy. Different doll techies/ creators offer multiple dolls with varying levels of virtual reality, artificial intelligence, physical characteristics, capabilities, and external feature realism, such as skin qualities: how it feels to the touch, it’s warmth, and the presence of responsive touch sensors. 

#4: Immersive Entertainment

In order to have an immersive experience and heighten the end user’s intimacy, it is common to see many adult entertainment providers embrace and incorporate virtual reality (VR) technology with teledildonics and cyberdildonics. For example, CAM4VR offers live streaming with a VR sex camera and voice capability, so users can engage directly with adult performers. Put it all together and it makes for a very up-close and personal experience. Meanwhile, CamSoda includes 3D holograms to explore and even incorporates a release of various scents through a sensory mask in order to provide a multi-sensory play.

Aside from the adult industry, VR is utilized in  an immersive sex education experience in an effort to create a safer environment for people to learn about their sexuality. Emory University and Georgia Tech plan to develop a high-engagement VR sex education program focusing on safer sex practices for young women to minimize instances of STD infection and transmission, HIV infection and transmission, and unintended pregnancy. VR is also utilized in therapeutic applications as well. BaDoinkVR is one example of such a program; their complementary VR tool is provided to singles and couples to help them discover their own sexual pleasure preferences and those of their partner, as well as methods to enhance both sexual pleasure and performance in real world sexual intimacy. And what’s coming soon may have you doing the same… on the not too distant horizon, VR will be applied to haptic (touch sensation) tech for users to indulge in thoroughly immersive acts of sexual intimacy.

#5: Augmentation

Human augmentation typically refers to the notion of improving on or building upon the capabilities of the human body. But being human, we’re constantly wanting more and better, so augmentation also refers to theoretical methodologies to push the envelope on the human body’s capabilities and use methods that could, would, or will (!) include augmented reality through implantables or wearables. 

The future is now, and many recent medical breakthroughs have demonstrated marked success in human augmentation; these have opened our eyes to many possibilities we once believed impossible. 

Some success stories include: the first US penis transplant in 2016. A penile cancer patient required an amputation of his penis in order to have a chance of survival. Following this at a later date, his surgeons at Massachusetts General Hospital successfully completed the 15 hour transplant operation using a complete organ taken from a deceased donor. The operation was ultimately deemed a success after the 64-year-old man regained sexual function and the ability to urinate normally once again. This procedure has been adapted and procedure time significantly decreased to apply the surgical technology to US soldiers who sustained severe bodily damage and amputations from bombs and IED explosions during overseas wars, and thus far with great success, as they have regained sexual function and the ability to urinate normally post-operatively.  

Another example of augmentation success as Swedish doctor Mats Brannstrom completed the world’s first “womb” transplant, which I assume they mean is a uterine or total vaginal transplant. Since then, many procedures involving varying iterations of vaginal transplants have been successful in countries around the globe, some of which were reproductively successful with patients carrying pregnancies to full term and delivering normally with the transplanted organs. 

Yet another example of successful human augmentation was made possible by doctors at Wake Forest Baptist Medical Center when they succeeded in building and implanting a lab-grown vagina derived from the patient’s own cells, ultimately allowing her to resume normal vaginal function. The same group was also responsible for bio-engineering penile erectile tissue followed by successful implantation on laboratory rabbits. 

Augmentation methodology has been used to overcome sexual dysfunction and/ or injury through the re-engineering of human tissues and organs which are then transplanted to help restore normal function. Moreover, this technology offers the potential for future body modification and customization in an effort for humans to enhance their individual sexual aesthetic and increase their enjoyment of sexual intimacy.

Clearly, augmentation is yet another technology where the future is now, as it has already been successfully employed numerous times around the world to repair the body and its organs after the ravages of disease and war. But what if feelings of orgasmic pleasure or heroin-like bliss were accessible through augmentation and made available to you as easily as you could push a button? Would you push it?

Elon Musk is betting you will. His company Neuralink has recently made quite a stir with the claim that their products can directly stimulate the pleasure centers in the brain. The company is dedicated to creating “Brain Computer Interfaces” (BCIs) which are devices that communicate directly with the brain at the synapse level. Basically, they want to put microchips inside people’s skulls, people… microchips that would elicit a chemical release as a response to their communication with the brain.

Musk has introduced a pig named Gertrude to the world, and she has a coin-sized chip implanted in her brain. Interesting timing, as the BBC states that Neuralink applied for approval to begin human testing on their BCI microchips last year.

So what is this brain chip anyway? Musk calls it a “digital superintelligence layer” that mediates communication between the limbic system and the brain’s cortex. The limbic system mainly deals with emotions, how we feel about things, while the cortex is more involved with the experiences of consciousness, perception, and thought which are far more important to human homeostasis.

Musk has stated that the initial use of BCIs will be aimed at brain-related diseases, claiming that neurological conditions like Obsessive Compulsive Disorder (OCD), Amyotrophic Lateral Sclerosis (ALS), and autism could all potentially be “solved’ or cured with Neuralink’s microchip. Basically, brain signals release chemicals, and those chemicals make us feel the way we do about things. So if Musk’s chip can tap into our sexual pleasure centers, it can cause a release of chemicals that make us feel an orgasm without the physical actions and scenarios that we would usually undertake in order to reach it. In a nutshell, he says that the chip will allow the wearer to bypass the requisite physical activity and get straight to the reward. I’m going to use the example of Tourette Syndrome, which is a disorder whereby affected people are compelled to make repetitive disruptive noises and sudden movements called tics. Like OCD, Tourette Syndrome is a neurological disorder that is totally out of a person’s conscious control; if they make attempts to deny the tics or hold them back for any length of time, eventually they will literally explode with tics, to the point where they are unable to function until the tics are expressed, which then sort of puts them back at baseline, almost like they’ve been reset. Affected people say that the mental feeling of needing to tic is like the need to scratch an itch, and that the feeling will build and multiply until they must finally “scratch it,” meaning they express the tics. This causes them to expel the tics that have built up in a sort of fit, after which the “itch” is vanquished… for a short time. It will build again and the whole cycle starts over. This feeling of being purged of tics must be mediated by the release of a chemical in the brain…. Just as the all-encompassing feeling of ‘I need to tic, I must tic’ is mediated by a chemical released by the brain when affected people resist their tics. That bit is basic science people, it’s like a for-sure deal that different chemicals released by the brain are what tells the person’s nervous system ‘hey, you haven’t tic’d, you can’t deny me, you must tic now now now…’ And also after having tics, then ‘hey, it’s okay, chill out, you’re good… for now.’

Musk didn’t mention my example, but I think it’s the perfect model for explaining the potential of a chip with this technology, assuming it actually does interface with the brain in the way it’s described and that it does elicit the chemical response as it’s described to do. But please understand that those are big assumptions for now.

If this BCI chip causes the release of chemicals in the brain that mediate how we feel about something without having to physically enact the behavior(s) that would usually cause their release, then it should work well in Tourette Syndrome or tic disorder, along with other neurological disorders with the same sort of altered or skewed reward system, where you could get the chemical release without acting out the potentially maladaptive or undesirable behavior of tics or checking and re-checking the locks in OCD, or self-injurious behaviors (like head baging) often exhibited in autism. I can also see the potential for use in psych patients who are cutters: they have an irresistible need or urge to deeply incise the skin and/ or release blood and/ or feel pain. If they could have that insatiable desire quenched chemically in the brain without having to act out the physical cutting action, that’s it… problem solved, cutting cured. That’s pretty incredible to imagine. The potential benefit in ALS patients is a little more complex, so I won’t bother with that here, but on first glance, Musk’s BCI chip has the potential to be a total game changer in treating some of the most difficult neurological and neuropsych disorders on the face of the planet in my opinion. It could hold great promise for disorders where the reward system is somehow perverted or held for ransom by the brain.

Musk says that the advent of his BCI chip will not necessitate the automatic elimination of physical activity, and that the chip’s presence would not override independent human thoughts of performing physical activities as we’re all used to doing now. And dare I add the single qualifier “before…” to the end of that statement? Because when you’re monkeying around with the reward center, the release of chemicals, and the brain, bad things can happen from the jump or they can develop over time. The brain is a powerful organ people, just ask an addict. That said, to me, Musk’s pre-qualifying comment at this very early stage of the game sort of smacks of his intentionally plugging a pacifier into our collective mouths before we even start whimpering about its absence. In any case, Neuralink’s human studies could prove to be an interesting bit of theater. But Musk generally gets what he wants, and he wants this technology- at least the ownership of it. Because I’m pretty dang sure he won’t be getting one of those chips in his skull anytime soon. Still lots to be determined. Stay tuned. 

I do see benefits of the chip in the sexual wellness category. For people who are unable to physically engage in sexual activity due to illness and/ or injury, people who are simply anorgasmic, or people that can perform acts of sexual intimacy, but not to a point of orgasmic release, I see great potential. These are all genuine issues with real life implications. The chip could allow for the stimulation of pleasure centers to heighten arousal and increase the potential for an orgasmic sexual response. Then it could essentially capture and record the pleasure responses of one person and those can be read by some technology within the chip or even some of the independent biofeedback type sex tech devices, and then transmitted (for lack of a better word) to that person’s partner, which would let that partner know what the first person’s sexual pleasure feels like, and that could integrate that desire into their partner’s intimate experience. And also, if there is a specific set of circumstances that arouses someone and makes them more likely to achieve the end goal of reaching orgasm, they could share that feeling with their partner. Say if they like the excitement from the risk of being caught having sex in a public place, or they like the completed idea of getting away with it, the chip could capture what that risky feeling feels like to them and those feelings could then be overlaid onto the partner’s chip or through some other type of independent sex tech, so that the partner also feels the rush or excitement from that risk, and therefore automatically incorporates it into their feelings during the sexual experience. Almost like dimming the lights to set a mood, except this would be setting a mental mood, so that the sexual experience would have a specific mental context that may make both halves of the couple more likely to reach orgasm. That’s a win – win scenario.

Sounds interesting, right? Well, need I say there are risks? Actually, there are RISKS people. I mean, Captain Obvious reminds us that we are talking about having a chip implanted in or near the brain… an electronic component interfacing directly with brain tissue, or at least interacting with another electrical system, which the human brain is. But even if we throw those trivial matters aside, hell, I’ve had my computer hacked- what happens if some homicidal freak hijacks people’s chips? Would they be able to remotely control someone to do their dirty work? Yikes, people! And what about all the data collected from chips? All the random thoughts and/ or feelings, the ‘side data’ if you will. If a private interest group got access and/ or control over everyone’s data and used it to advance a candidate in an election, or influence the government, or squash or advance legislation or alter bill introduction or the passing of laws or affect the governing actions of all of the above? Any group that had access to all that information would basically rule the world- they could control everyone and everything with relative impunity.

But this I know: people could potentially be seriously harmed by overstimulating the brain globally, and overstimulating the pleasure centers of the brain specifically. Helll-ooo… aaa-ddic-cc-tion! If people can have “orgasmic pleasure” or “heroin-like bliss” freely available to them as easily as pushing a button, will they be able to continue functioning everyday without constantly pushing that button? They would be bombarding their neurons with pleasure chemicals… and usually, too much of a good thing… is a really bad thing. 

We’ve all seen sci-fi movies where AI (artificial intelligence) enslaves the entire human race. But Musk has an answer for that too. Sort of. He claims that Neuralink’s devices are actually the very things that will protect us humans from this situation, should it ever arise: that BCIs would give us virtually instant access to information in a way analogous to completely automated systems, which intimates that we would somehow “know” or “understand” everything, even when we’re being tampered with or manipulated. Not so sure about that.

Generally speaking, I like Elon Musk. And admittedly, some of this sounds cool. But I don’t trust his abilities over mine to be certain of potential medical, psychological, and behavioral ramifications of brain neurochemistry. But I assume he’s put the right people in the right places. I have to say that as a psychiatrist, if there was a cure for some of the most destructive and currently incurable neuropsych disorders in existence, that would be amazing. But… in my experience, where Mother Nature or God or a higher power or whatever you believe in puts a check…there’s a balance somewhere, usually in a place you don’t see until it’s too late. Couple that with the potential for addiction issues, the possibility of chip hijacking, and honestly, Musk’s (kinda lame) assertion/ pseudo explanation not to worry, that we would know and/ or anticipate everything would keep us safe, that feels a little too tenuous for moi to step out on… So let’s just say that I won’t be beta testing these BCIs. But, I will follow this issue and read with great interest all about the people who do. 

Embracing Sex Tech: Problems & Solutions

As far as existing sex tech and products coming in the relatively near future, most fall squarely into the “adult entertainment” and “sexual health and wellness” arenas, and I think the latter have been, and will continue to be, better received. It seems that innovations in teledildonics and cyberdildonics aim to improve intimacy and sexual pleasure, and they hold great potential to resolve the age-old problems that revolve around physical, emotional, and geographical constraints of romantic love relationships. I know that with coronavirus, some couples that had to temporarily split for months at a time had difficulty doing so successfully. Long distance relationships are another excellent example. If you’re a young newlywed bride from Great Grits Georgia and your soldier husband is called to serve in some hellhole on the other side of the globe for a year, that’s a real problem- the kind that breeds misery, introversion, distrust, communication issues, and physical/ emotional intimacy problems in both partners- problems that can potentially pave a road to divorce where one never existed before. So if sex tech and couple toys or similar interactive devices allow couples to continue- or even advance- their sexual intimacy, while forging ahead with a difficult situation, then only good healthy things are likely to come of it. 

…Very Different from Embracing Sexbots!

AI-driven sex tech robots are relatively new and their aim is to apply advanced concepts of machine learning to transforming our sexual experience. Thanks to the sensors in the defined “sensitive” zones of the bots’ bodies, these sex robots can experience pleasure and, in turn, reciprocate the favor. Also, they can learn from previous experiences. For example, your habits and moods or what turns you on. 

I was surprised to read a recent survey that said that 1 out of 5 men said they are open to the idea of having sex with a doll. This number is likely to increase when sex dolls become more humanlike and way less expensive. In fact, human/doll (or bot) sexual intercourse might overtake human/human sexual intercourse way faster than we think.

Issues: Sex Dolls and Bots

However, major concerns are arising, not the least of which involve the concept of men having sex with child type sex dolls. With sex dolls, the romance and chit-chat typical of a normal relationship are eliminated, and maybe more importantly, these relationships happen in a strictly private environment. It’s not like you bring your bot ball and chain with you when you go to a buddy’s house to watch the game. So really we’re left to just speculate about the psychological ramifications of a continual and purposeful romantic love relationship with a non-human entity. And boy do we speculate…

Monetary Costs of Sex Dolls and Bots

Currently, these things are freaking E for expensive people. A Realbotix head alone costs about $10,000, but you’ll shell out another $25,000 to $65,000 if you want a body to put it on. And speaking of that body, features such as skin-like materials, self-warming orifices, full-body detailing, and a texturized canal with internal pulsations are only the tip of the iceberg. If a human tells their doll/ bot what they enjoy sexually, they can evidently learn from it; then when it’s applied during physical intimacy, the patterns can be recorded or “remembered” by the doll or bot; I can only assume that they can then be recalled, essentially repeating the exact same experience. This would only be in the most advanced models I’m sure. Doll/ Bot companies claim that today’s most futuristic dolls can learn whatever names you give them, when your birthday is, how to read poetry, and even hold their own during erotic conversations. Plus, they don’t require cab fare when you’re done or a romantic dinner before you even get started. 

In comparison, the “busted up bargain bots” as I lovingly call them only range from $4,000 to $12,000. But with continued advances in technology, the price across the bot board is certain to drop, making this tech more accessible to the average person, which will undoubtedly lead to more dolls and bots, but probably the same scant amount of information about the psychological ramifications of a purposeful romantic love relationship with a non-human entity.

And this was a new one on moi…

Enter the Slutbot Sexting Tutors

Supposedly, these were developed in response to the controversy that has obviously sprung up around the invention of such high-functioning sex bots, with people arguing that such machines will make interpersonal interactions a thing of the past. But the world’s first Slutbot Sexting Tutor has entered the scene and it’s definitely making the conversation more interesting- in more ways than one. This intuitive robot helps users express their sexy, seductive side in a more efficient and flirty way, which serves as not only a relationship booster, but also a terrific add-on to any interactive sex toy you might already own and utilize. So its reason for existence is basically to transform lonely -cis men into slutbox sexters? Alllrrrightyyy thennn…

The True Future of Sex Toys Is Non-Binary

When sex toys became popular in the ‘70s, they were made “by men” and “for women” so it’s no great wonder that they looked like giant towering examples of realistic penises, complete with veins and perfectly sculpted heads, often with an attached set of perfectly sculpted balls, neatly placed where they would be in an anatomy schematic but never in real life. They were typically flesh toned and the focus was placed on the penetrative aspect as opposed to being concerned with stimulation. In short, they missed the mark, and that really set them up to continue to miss it for a very long time. Why? Because that’s what the industry execs assumed women wanted to use. And so began a long enduring disconnect. But fast forward to today, when the sex tech industry is finally focused on inclusion, and actually does include some non-binary-led companies amongst the many powerful female-led companies, all of them seeing that the future of sex tech is truly and unapologetically non-binary. 

Gone are the days of “one size dildo fits all vulvas.” Gone are the days when hot pink phallic contraptions had to be appreciated, just because it was amazing to even have a choice. It’s a good thing that those days are in the rearview mirror. But let’s face it, there’s still a huge amount of phobia surrounding sex in general, no matter the labels or qualifiers. But it’s magnified and multiplied when it’s non-cis, non-hetero sex. Thankfully, more and more companies are working hard to do away with that phobia.

When it comes to sex toys, we now recognize that sexual interests and tastes can be as unique and singular as the bodies that contain them. While there’s nothing wrong with wanting a rainbow glitter dick, lipstick vibrator, or hyper-realistic flesh-colored dildo, many of these products can be alienating to individuals who may identify as gender nonbinary, or people who feel put off by the gender essentialism of toys created “for men” or “for women.” So, in light of the increased cultural awareness of non-binary gender identities, innovative sex toy designs are making pleasure more accessible for everyone. One company striving to make the sex toy industry more inclusive is Wild Flower, a nonbinary sex toy retailer and digital community dedicated to providing sex education to those who have been overlooked by the adult industry. 

What makes purchasing a sex toy so difficult for some individuals are the ideas and labels that automatically come attached to them like baggage. Gender, sex, and bodies are complex topics… acknowledge this and counter it by totally eliminating gender in marketing. While this might make things like search engine optimization difficult, the upside is that newly unlabeled and unlimited genderfluid-friendly toys can open minds and new worlds of sexual expression for everyone, regardless of how they identify, or if they even do at all.  Free the toys!

A Victorian Take on Remote Sex

Today’s blog has been all about the future of sex tech, which at its heart centers around smart sex toys designed for remote sex in one of many forms. But really, remote sex is nothing new. Ever since the dawn of literacy, lovers separated by distance or circumstance have touched each other remotely through erotic letters held and read in one hand… while doing something else with the other. If you’ve got some time, there are many examples of “Victorian sexting” during the civil war era online. Some of it is hilarious and some is pretty mind blowing… but let’s take a quick “wow break” to check out a couple of excerpts from letters between none other than General George Armstrong Custer and his wife Elizabeth “Libbie” Bacon Custer, who was said to be “hotter than a $2 pistol.” We’ll see how they implemented remote sex.

Far from the prudish stereotype of the Victorian woman, Libbie clearly delighted in creative euphemism and double-entendre. In one letter to her husband, she wrote of “a soft place upon somebody’s carpet” and of her desire to “sit Tomboy” (as in astride) for “just one… ride” as they were fond of asking for “just one” which appears to be a reference to an orgasm. Scandalous.

Custer wrote in reply “Oh, I do want one so badly. I know where I would kiss somebody if I was with her tonight.” Shocking.

Nothing could dampen Custer’s ardor for Libbie. During one of his campaigns, he sent her the 19th Century equivalent of a dick pic:

“Good morning my Rosebud. ‘John’ has been making constant and earnest inquiries for his bunkey for a long time, and this morning he seems more persistent than ever, probably due to the fact that he knows he is homeward bound.”

And in one letter to her BFF, Libby told her that she and Custer had had a threesome, and it seems like she wants her to stay! 

She said “Custer, as I, devoted most of our attention … to the selection of a pretty girl… This pretty girl … was held by both of us, and would do more toward furnishing and beautifying our army quarters than any amount of speechless bric-abrac.” 

That Libby was really freaky. And the great General Custer was into it. Who knew?

Now moving away from the Victorian age and through the 20th century, remote sex migrated to the telephone, when even Dear Abby approved of- and even recommended- phone sex for long distance lovers. Of course, any form of remote sex is not the “real thing,” but the body’s sexiest organ is the mind, and remote sex talk excites it just as much now as it did in years past. Teledildonics and cyberdildonics basically combine these excited and sexy thoughts, and therefore the minds, of each half of a couple that are separated, bringing them together virtually, and that extends the potential excitement more than ever before.

Potential Real World Ramifications of Sex Tech

Teledildonics Biggest Winners: Sex Workers

No doubt some long-distance lovers will embrace teledildonics and have big juicy fun. But the largest market for Web-enabled sex devices appears to be sex work. The Web already contains a surfeit of sites whose female (and gay male) employees show their assets, touch themselves, and exhort remote users to masturbate, all in an effort to earn a buck.

Teledildonics not only makes remote sex work more lifelike, it’s also more personal. The phone-Web interface is more one on one, allowing consumers to feel closer to providers. In addition, teledildonics allows sex workers to earn extra money by fulfilling requests. Men can tip to see the sex worker fellate a dildo while they physically feel it by utilizing a device. Tipping is almost too easy: just tap your phone, and voila… the fee is charged to your credit card. No fuss, no muss, no exchange of fluids.

Many sex workers prefer remote sex to the real thing. And why not? The hours are flexible. They can work in the privacy of their homes. And compared to the alternatives: street-walking, massage parlors, hotel calls, and brothels, remote sex is safer… no violent customers, poor hygiene, or sexually transmitted diseases, and no risk of arrest. Police generally focus on street level sex work; they really couldn’t care less what people do on the phone behind closed doors. Teledildonics is also safer for men who regularly pay for sex as well, and for all the same reasons.

Teledildonics’ Biggest Losers: Women Who Abhor Porn and Snoops

While teledildonics may be a boon to long distance lovers, it’s bound to cause consternation among women who feel threatened by their men masturbating to porn. Except instead of the man stroking himself to some random video image, now teledildonics allows him to look at a real live woman who’s stroking, licking, and using a Web-enabled sex toy. Many men are likely to find that more compelling than porn. And I suspect that their wives will not exactly be thrilled about all that. 

By some estimates, as many as 25 percent of coupled individuals have peeked into their partners’ devices looking for evidence of porn use or affairs. I hear about this from patients all the time. They complain that their partner tracks them, or steals their phone to snoop. Some put a screen lock on, but their partners know that sometimes the photos they might be looking for would be on the micro card, so they snag it and plug it into their phone to snoop. Anyway, the evolution of sex tech means that from now until who knows when, jealous and insecure partners will continue to snoop and should now be expected to check for teledildonics apps- after scouring the phone for texts and calls with random women, and tossing the closets and drawers looking for web-enabled sex toys.

As teledildonics and cyberdildonics become more established, I think the news media will treat it breathlessly, with sympathetic profiles of long distance couples who “really enjoy it” followed by hand-wringing from those who consider it a threat. Personally, I find that sex sells… people love to read about it and speculate on it, and app-enabled sex toys are a fascinating new wrinkle in the oldest quest of all time: the search for erotic satisfaction. Especially in my profession, where that search is often tied into self worth. I’m not terribly concerned with what it all means for civilization, since it’s not like commercial phone sex services have led us to the ruins of Sodom and Gomorrah in previous years. We’ll survive. Necessity may be the mother of invention, but lust is often the father of necessity… because don’t forget that a hard prick has no conscience.

Sex Tech Psychology

The End of the World as We Know It?

If the sexbots are already here, what’s next? Will everyone start marrying dolls and sever connections with other human beings? If we get used to programming our partner, how could we ever go back to human beings with free choice? Panic rules the streets!

I’ve read articles and comments online that point to concerns that sexbots and VR pornography could dehumanize sex and warp our perception of consensual relationships, but I’m not convinced of that at all. Even if that’s a possibility in the future, it’s certainly not the case yet, because I think sex robots have yet to seem ‘real’ enough to appeal to a large audience. Until the last couple of years, designers have been very bad at making human-like robots, as technology hasn’t been all that well suited to it, and our brains can easily pick out points where human-like things don’t look like humans, and that’s a buzzkill in every way imaginable. And until recently, after advancements in skin technology to add warmth and feel and the addition of more realistic facial features and movements, sex robots have really just been immobile sex dolls glorified with some animatronics and chat capabilities built in, and I think it’s going to stay niche as long as that’s the case, and that makes it a non-starter in the problem department. I don’t think they treat these dolls like real people.

But some vehemently disagree, claiming that owners become deeply bonded to bots, but also add that even if their use of sex dolls appears to dehumanize real (meaning actually human) women or promotes misogyny, that in reality, bot-owners actually “cherish” their dolls and treat them with respect. That’s a ‘Hmmm maybe’ for moi people. I’m sure that for some people that find it hard to make connections and sustain romantic relationships, sex dolls could be an incredibly useful way to combat loneliness. But I can’t imagine a way that any man could ever convince himself that he is in a real relationship with a doll. Just doesn’t compute for me. But I guess the fact is that it doesn’t have to! In the meantime, it’s an interesting theoretical, but I don’t think I’ll be spending much time worrying about it.

The Future of Sex Toys: For Better or Worse? Utopia or Dystopia?

Should we be excited about all this new technology, or terrified of what the future holds? Are sex robots a threat to human relationships, or a niche invention which can help the lonely without affecting anyone else?

With all of the questions swirling around the future of sex, I think that the answers have everything to do with being human, and little to nothing to do with technology. No matter what “toys” you add, it still comes down to a person’s brain, as that’s what’s ultimately in control. As for the future, I’m just hoping for one that is more open, with less judgement and shame, and more acceptance and equality. I think that’s something we can all get behind. However it goes, the future of sex tech promises to be exciting, and all we can do is wait for it to be revealed and see what it’s about.

Thanks- be well, people!

MGA

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Sex Toys:Not Too taboo

Sex Toys: Not Too Taboo

Usually I write my blogs and record my vids right off the top of my head with basically zero preparation required. Today’s topic is a little outside my usual scope, but I’m man enough to admit that I did some research- and believe me when I tell you that there is a freaking metric ton of info on sex toys out there! As a physician, I’ve seen more than my fair share of kink and way-out-there sex practices in hospital ER’s all over this great country, but I found that toys these days go from “wow…now that sounds interesting” to “they want you to put that there?” to “dammit, why the hell didn’t I think of that??” Some of it is totally blush-worthy, but set aside your hang-ups and preconceived notions, open your minds, and get ready to get really up close and personal here, people! And fair warning: prepare for plenty of innuendo and double entendre – and any time you read something and think to yourself ‘oh wow, did Dr. Agresti realize what he wrote there, what that word choice kinda sounds like in a blog about sex?’ The answer is yes and yes…I did and I do. So I hope you like it and share it.

Sex toys are clearly no longer the taboo subject of generations past, as ever increasing numbers of men and women, cis and trans, L, G, B, and Q, individually, and in couples and fill-in-the-blank-somes, are incorporating toys into their sex lives. As a result, it’s no surprise that the sex toy business is banging. Not a shock if you recall my wildly popular orgasm blog and some of the not-so-fun facts I had to reveal: 

-10% to 15% of all women are anorgasmic, meaning they cannot or do not orgasm…like at all. Bummer days people.

-75% of women will never (Hey, you hear that? Never…ever…ever…ver…ver…err…errr) reach orgasm from straight up intercourse alone, without a toy. Like wow people. 

-Captain Obvious says that means that only 25% of women will reach orgasm from vanilla sexual intercourse alone, ie without a toy.

-Only 29% of women regularly reach orgasm with their partner, while 75% of men will always reach orgasm with their partner (“yeah, or a hole in the wall” as added by someone who will remain nameless that’s giving me the stink eye at this very moment because for some reason she thinks that when I’m typing on my laptop I somehow magically become blind to everything else.) Anyway, the moral of this story is that women are far more likely to orgasm when they’re all by themselves than when they’re with a partner. Ouch people.

So…why should you care, you ask? Well, numero uno is that you might have a vagina. Duh. And if you’re an owner of said vagina, you are statistically much more likely to be among that 75% that can’t orgasm from vanilla intercourse, or the 71% that don’t orgasm with your partner at all! Or you could even be both. Or, maybe you have a penis, but you care about someone that has a vagina…like you really care, to the point where you want to have sex with them and please them…both at the same time I mean. This would be good intel then, no? Because then you could even introduce a sex toy (surprise, honey!) and explain that you got it just because you’re so concerned that she may be a member of the “no orgasm club.” But don’t call it that- use big words and quote the statistics in an effort to make yourself sound smart- they’ll appreciate that. Oh, and because you’re a giver. Throw that one in there too. No… really, in all seriousness, emotional intimacy and pleasure from physical intimacy are truly very important parts of a love relationship. And emotional intimacy is at its best when everybody involved derives pleasure from engaging in physical intimacy. To simplify: make your partner’s orgasm at least as important as yours. They’ll be much more inclined to like you and give you more opportunities to make their orgasm at least as important as yours… it’s a positive feedback loop.

There are a lot of myths surrounding sex toys, and one of the most ridiculous is that they’re unnatural and unhealthy. In reality, that couldn’t be farther from the truth. Sex is one of the most natural things a body does; it’s a gross comparison, but sex is right up there with peeing and pooping. Anything that promotes sex and pleasure is absolutely natural and completely healthy! In fact, people who abstain tend to have more instances of anxiety and depression. Facts people. Women that use sex toys report greatly increased levels of sexual desire, much more frequent orgasms, far greater sexual satisfaction, and happer, better, and more complete intimate relationships. I can’t find a negative in any of that. 

Why are sex toy sales on the rise?

While they were once seen as depraved and belonging to a certain line of work, these days they are totally socially acceptable. Now there are even more sex toy parties than Tupperware parties, and women enthusiastically compare notes about the latest sex toys in their collection. The hype surrounding the film Fifty Shades of Grey has played a part in this, along with the fact that today’s women are no longer ashamed about satisfying themselves. On the contrary, self-assured modern women are open about their sexuality, and this includes the fact that they don’t necessarily need a man to be sexually satisfied. That said, couples are also incorporating sex toys into their activities at an ever increasing rate. In particular, couples in long-term relationships are using sex toys to spice up their love lives, allowing them to explore new sexual experiences together. I’ll be talking all about this in part three of this sex toy series, and you don’t want to miss it- it is hot stuff people!

But before we get that deep, today I’m going to start with the basics on sex toys: what they are, how they started, and what they’re all about. Then next week in part two, I’ll talk about who’s using sex toys and what you should consider if you decide to join them. As I said before, part three will be about partner toys and ways to spice up long-term relationships. And at the end, I’m going to paste some links to articles and sites where you can find more information about different types of toys, how to choose a first toy, and where you can find and purchase any and every toy you could ever want. Look, if you’re into playing fingerpuppet five-on-one or downstairs DJ and it works for you, I certainly have no objections your honor, but some new toys could put a new smile on your face; so keep reading my blogs and if anything strikes your fancy… be adventurous and go for it!

What are sex toys?

As if you don’t know… Sex toys, aka adult toys, aka “marital aids”… all are terms for objects that people use to have more pleasure during partner sex or masturbation. Sometimes sex toys can also have medical uses, as in cases of sexual dysfunction, although that seems to be something of a point of contention. There are many different types of sex toys, and people use them for any of many different reasons, but the general idea and end goal is basically the same for everyone across the board: to get off. I’m pretty sure that’s the technical term.

Here’s a quick overview of some of the most common categories of sex toys:

Vibrators

AKA vibes or buzzers

AKA “personal massagers” (yeah…riiiight) 

-Objects that vibrate or buzz to stimulate internal and/ or external genitals.

-Most commonly used on the clitoris and/ or other parts of the vulva and vagina, especially the G-spot.

-Can also stimulate the penis, scrotum, testicles, nipples, anus, and the male P-spot. 

-Come in endless shapes and sizes, waterproof or not, for inside the body and/ or out, and for all genders.

Dildos

-Objects that go inside a vagina, anus, or mouth. 

-Come in many shapes and sizes, but they’re often shaped similarly to a penis. 

-Some look realistic, others more abstract.

-Can be slightly curved to help stimulate G-spot or prostate,  the P-spot.

-Can be made out of lots of different materials: silicone, rubber, plastic, metal, or

glass (freaking yikes – not for butterfingers!)

-Dildo Fun Fact #1: Ever wonder where the term dildo came from? Constantly, right? Let’s get in the Wayback Machine to find out!

-Turns out, like so many words, dildo is thought to be a bastardization of terms taken from other languages.

-IMO, the winner is diletto, taken from the Italian which means ‘a woman’s delight.’ This seems a very likely place where the word we know and love today got its start, however there are a couple of other contenders. 

-My next personal choice would be dill-doll, which is the ye olde English translation for the old Norse word ‘dilla,’ a verb meaning ‘to soothe.’ So literally, a dill-doll would be a soothing doll, as in…a penis! Of course! Or an intimidating giant rubbery effigy of one, anyway. 

-Dildo Fun fact #2: Did you know that there’s an actual place called Dildo? I heard that’s where Waldo was… Waldo in Dildo. But seriously, there’s a town in the maritime province of Canada called Dildo, and Dildo Island is located just offshore don’tcha know. The tourism marketing folks there are fighting one hell of an uphill battle. Check out these tags that I came up with: 

‘Dildo~ The Weather is Here…Wish You Were Beautiful!’ 

‘Come to Dildo…See the Sights!’ 

‘The Isle of Dildo…Get On It!’

Anal Toys

-Captain Obvious says these are toys made specifically to stimulate the anus. 

-Includes plugs (aka butt plugs), anal beads, prostate massagers, and wide base/ flared dildos. Yeah people…pay special attention to that wide base/ flared part- if you don’t, these suckers are prone to take an accidental detour waaay up the hershey highway, and then you’ve got to go to an ER to have it pulled out, and that’s not embarassing at all. I’ve seen this all up-close-and-personal-like more times in the ER than my poor brain can block people.

-You must use lube to use anal toys (especially anal toys) safely. An overarching theme on these toy sites is basically this: lube is cheap, so use lots and lots of lube when you play with toys.

Sleeves

-AKA masturbation sleeves

-AKA penis sleeves 

-AKA strokers

-Soft tubes designed to put the penis into.

-Come in all shapes and sizes, and with different textures on the inside for more sensation. 

-Some feature vibration or suction. 

-These are cool because there are strokers specially designed for a larger clitoris or smaller penis, particularly for intersex or trans people.

Penis Rings

AKA cock rings 

AKA erectile dysfunction rings

AKA constriction rings  

-Shockingly, these are rings that go around your scrotum and/ or penis (must be prior to arousal people!)

-Work by slowing the blood flow out of the penis once it’s erect, thereby increasing sensation and/ or making the erection harder and longer-lasting. 

-The safest penis rings are made from soft, flexible materials that can be easily removed in case of emergency: silicone, rubber, or leather with snaps for the biker set. 

-Some penis rings have little vibrators on them to stimulate the wearer and/ or their partner during intercourse. 

-Penis rings restrict blood flow, so don’t wear one for longer than 10 to 30 minutes, and take it off right away if it becomes even slightly painful: kind of defeats the purpose. 

-Talk to a nurse or doctor before using penis rings if you have a bleeding disorder or are on blood-thinning medicine. See, just the fact that they mention that leads me to believe that there could be blood shed associated with using this toy…so for me, this is a pass and a no freaking way, people!

Pumps

AKA penis pumps

AKA vacuum pumps

AKA vacuum erection pumps

-Vacuum-like devices that use a hand or battery-powered pump to create suction around the penis, clitoris, vulva, or nipples. -Pumps drive blood flow to the area, which helps increase sensitivity and sensation. -Penis pumps can help you get an erection, but they won’t make your penis permanently bigger. Sorry people.

-Some pumps are designed to help treat erectile dysfunction, genital arousal disorder, and orgasm disorder. 

-For more information about these pumps, contact a nurse or doctor. You can also go to your local Planned Parenthood health center. -Most of the pumps you buy in sex stores or adult shops are not medical devices, they’re just meant to enhance pleasure during sex and masturbation. 

-Make sure to follow the instructions on the packaging, and don’t pump for longer than the instructions dictate.

-Once again, talk to your doctor before using a pump if you have a blood disorder, or are on blood-thinning medication.

Ben Wa Balls

AKA Kegel balls

AKA Kegel trainers 

AKA Vagina balls

AKA Orgasm balls

-I’m sure you’ll all be shocked to learn this first part: that these are round objects; but maybe a little more surprised by the second part: that they’re designed to be inserted inside the vagina, and definitely shocked by the last part: some women keep them in for an entire day. Like on purpose. Whoa people. Don’t mind me, I’ll just be crying in the fetal position over in the corner. 

-They can assist in exercises that tone and strengthen the Kegel muscles. 

-Kegel balls are usually weighted so that the vagina must be squeezed to keep them inside the body, strengthening the pelvic floor muscles. 

-You don’t need these balls to do Kegel exercises, and not everyone uses them for that purpose; many women just like the way they feel inside the vagina.

-Fun Ben Wa Balls fact: female prisoners could use these to enlarge their “God purse,” which is what they call their vaginal cavities, especially when they hide illegal items from cops and/ or smuggle contraband into jails and prisons. Wonder if a female inmate came up with them… after all, necessity is the mother of invention.

-Some are hollow with smaller balls inside that roll and bounce when you move, making a jiggling sensation. And probably a jingling noise too, right? Can you imagine that? I’ll do it for you: you’re a man in an elevator, you’ve just pushed the button for eleven, and just as the doors are about to close, you hear the familiar sound of jingle bells getting louder as you see a woman is running to catch the elevator, and as she jumps inside at the last second and lands in her spot, there’s one final loud jingle as she smiles and says “five please,” then silence. Internal thoughts as you push five: Hmmm, those were bells. Like jingle bells? Huh. But kind of… quiet-ish… almost muffled (? you ponder this as you clean your right ear with a pinky finger). Funny, it’s May, not December. I don’t see any bells tied to her stilettos. Odd. Well, maybe she’s one of those people that keep that holiday spirit all year long. Freaks. Ugh so annoying! Or, she’s got ’em in that purse. It’s really small; didn’t see that on her other shoulder before. That’s it. They’re in that purse. Gotta be. Mystery solved. Good job. 

Meanwhile, her internal thoughts after you pushed five: Sheese…this ass monkey moron heard my bell balls. Ha! He’s trying to figure it out right now…I can see the gears working overtime in his pea brain. Can practically smell the burning as he’s inspecting me. No moron, they’re not tied to my Manolo’s…what am I, four? Doesn’t he- oh, he just saw my purse. Yep, he thinks I’ve got them in there. Oh yeah, he thinks he’s got it all figured out…he looks so proud of himself. Little does he know this silly little purse won’t even hold my bell balls! But my God purse does…juuust fine. Later loser.

Right after his mental pat on the back, the elevator stops, the door opens, and she’s gone… jingle all the way.

Harnesses

-AKA straps 

-AKA strap-ons

-These are garment systems that hold a packer, dildo, or other sex toy against the body. 

-Some can be worn like underwear or jock straps, while others can go around other parts of the body, such as the thigh.

People still have a hard time talking about sex and orgasm, but make no mistake: these are integral components of life, and even the ancients knew it. The desire for a good, satisfying, old-fashioned orgasm is timeless. Our ancestors, while they were making hair combs out of bone and forming and firing clay pots, they didn’t neglect their sexual needs… quite the opposite actually. Need proof? To date, the oldest dildo recovered is a big curved stone phallus found in Germany. How old was it? 28,000 years old people!

Turns out, historical men (and women, maybe even more so) were light-years ahead of us in the pleasure department; we have proof positive of this, thanks to their inventions, all of which are still used today. Here are the backstories on some of the most recognized sex toys and paraphernalia that’s still out there in one form or another. 

Blow-up Dolls

-Invented in 1904

-“Lady substitutes” are recorded as far back as the seventeenth century, when French sailors devised the Dame de Voyage: a collection of curvaceous rags (say whaaat?) that could only ever resemble a woman to a very homesick and horny Frenchman. But it wasn’t until some time after vulcanized rubber was patented that the more familiar model came about, which was in 1904. Boy, that must’ve been a Goodyear… and a good year! At that time, they marketed them as  “inflatable dolls for discerning gentlemen.” Would’ve been a hell of a lot easier than marketing tourism to Dildo.

-Less than four years later, German sexologist Iwan Bloch was marvelling over mass-manufactured versions that could ‘imitate ejaculation’ for sale in Parisian catalogues. Rating super creepy was a firm that offered a custom doll resembling “Any actual person, living or dead,” which has to be the single most disturbing tagline in the history of marketing and advertising. Except maybe of course for ‘The Isle of Dildo…Get On It!’ 

-Now they make those “real life girls” which are waaay too (sur)real for me, but devotees talk to them, eat with them, and live with them like they’re real humans. Some medical show I saw followed these men that preferred these dolls, and one guy had four of them, and he actually detailed conversations between himself and the “girls,” including arguments between them about how they would get jealous when he chose to “spend time” with someone other than them. And I’ll never forget when they filmed him opening a door with a smile and saying something like “Yeah, the girls hate to be put in the closet,” and the camera focuses on the closet and there are his three other girls all sprawled out haphazardly. Here he was explaining how he loved each of them, combed and styled their hair, shopped for hot outfits for them, and here they were, all crumpled up in some dingy little closet, waiting for their next date with him or whatever. It was patently ridiculous while absolutely hilarious! There was a movie on this same storyline, I think it was called Lars and the Real Girl. I’m sure you could find it if you were so motivated. 

Butt Plugs

-Invented in 1892

-An English dude named Frank E. Young was a man with a vision, and that vision evidently involved things being inserted up other people’s rectums. Because that happens everyday, right? 

-Developed in 1892, but not marketed until the turn of the century, his ‘Rectal Dilator’ was a terrifying 4 1/2-inches of pain, designed to go not just where the sun don’t shine, but where the sun can’t, and won’t ever, shine. At the time, it was billed as a cure for piles, a gussied-up term for hemorrhoids. 

-The devices were hawked to doctors and even advertised in respected journals. And people might well have gone on believing they were medical devices too, were it not for the ridiculously suggestive instruction manual included with each order. 

-For forty years, these Victorian butt plugs managed to jump the pond to be sold all across the US of A, before they fell afoul of the 1938 Federal Food, Drugs, and Cosmetics Act, which banned them for “false advertising.” Given that it looks like it does, I don’t see how that’s possible, but we are talking about our federal government here. 

Vibrators

-Invented in 1869

-That date is the officially accepted one, but legend has it that Cleopatra actually developed the first version of a vibrator. She was said to keep a jar of live bees on her bedside table, and when she was needing some personal attention, she had her servants fill a hollowed-out gourd with them. She then pressed that against her lower Mesopotamia, using the angry vibrations emanating through the gourd to pleasure herself.  

-She had to stimulate her own self after all four of her husbands died… I guess a girl’s gotta do what a girl’s gotta do. And evidently she did, quite regularly.

-Back to the Victorian vibrators of 1869… this period was a different time… a time when “robots” were steam-powered and doctors treated hysterical women by masturbating them to climax. Of course. I also covered this in my orgasm blog.

-Female hysteria was supposedly a genuine illness, and its treatment involved a qualified medical professional rubbing the female patient’s private parts until orgasm was achieved. Because nothing about this practice could be logical, doctors often complained of boredom and pain-in-the-wrist, probably the very first cases of repetitive motion injury. 

-One of said qualified medical professionals, George Taylor, came to the rescue and invented the first steam-powered vibrator. Because what could possibly go wrong with that… a metal device powered by steam… which is hella hot people!

-Although (shock of shocks) that version failed to catch on, J. Granville’s 1880 ‘electrochemical’ design really did, much to the delight of housewives everywhere, as they went bonkers for them. 

-Even Good Housekeeping magazine started running monthly reviews of these marvelous wonders. So what happened? Well, society accepted the ‘massager’ as long as devotees could tell themselves that it was a medical device, rather than a sexual aid. Yeah, riiight…whatever gets ‘ya through the night people. 

-Now, I should note something I learned while doing research for this blog: that supposedly, while this practice of medical professionals using a vibrator to bring women to climax was common, it was not done for a female hysteria diagnosis, as there supposedly was no such animal. So there ‘ya go, now ‘ya know.

-After these vibrators made their debut in the earliest porn films, husbands soon realized what their wives were up to all the time, and they put a stop to it. Of course they did! Because as every man of that era knew, the last thing you wanted was a sexually satisfied wife… total bullshit. 

-Trust me people, I’m a doctor: a partner that’s satisfied in every aspect of life is actually the thing you should want more than anything else in the history of things in the whole wide world. If you’re wondering why, (re-)read my orgasm blog. 

Condoms

-Depends on whose history books you read, but the accepted invention date was around 1560-ish.

-Going by a strictly modern definition, the first reliable record of condom use doesn’t appear until 1564.

-Regardless, in Japan and China, ‘condoms’ made from various animal membranes were in use before the 15th century. I use ‘quotes’ because there’s really no telling what they were called.

-Japan favored tortoiseshell, but then later thin leather, to make them. In China they were made out of oiled paper or lamb intestines. Neither differed much from condoms in later centuries that were made out of linen or animal intestine.

-They were typically one-size-fits-all – sorry “Magnum” men – and they had to be dipped in water before use to make them pliable. Hmmm… pleasure fit.

-In the 16th century, condoms were used primarily to prevent STD’s like syphilis, as it was typically fatal. So whatever they called them, they may have saved some lives. That is until…  Duhn Dun Duuuhhhnnn!!!

-The discovery of spermatozoa in the 17th century changed everything forevermore. -The Church became outraged over the use of any barrier that could impede the progress of men’s little swimmers as they attempted to reach and fertilize a golden egg. 

-As a result, by the 18th century, the condom’s reputation amongst medical professionals had been firmly cemented as a tool for philanderers, prostitutes, and the immoral.

-Despite this condom condemnation, they actually proved to be quite popular among the upper and middle classes of the day. The beleaguered working classes finally gained access to them after the vulcanization of rubber, round about 1839… another Goodyear and good year. And also what undoubtedly led to the ubiquitous term recognized ’round the world… ‘rubbers.’

Penis (Cock) Rings

-Invented in China in about 1200 A.D.

-These have undergone few changes or innovations in their history. If it ain’t broke…

-Evidently, being ancient Chinese nobility was not an easy job. Not only did you have to put up with assassination plots and Mongol invaders, you were also expected to service your wife, mistresses, and concubines… all on a regular basis. 

-While it sounds like fun and games, there was an urgent reason behind it: if you didn’t produce an heir, you could be pretty sure some obscure prince was going to step up to take his shot at a coup. 

-In stressful circumstances, performing can become… well… difficult, people!

-But have no fear – penis rings are here! -First made from the upper and lower eyelid rings of a goat, with the eyelashes still attached (freaking ouch!) it helped the wearer get on with the business of impregnation for hours on end, even if he was secretly crying on the inside. And I’ll bet he was.

-While primarily made for purposes of sexual enhancement, they were later made from carved ivory and jade to also be worn for aesthetic adornment. No matter how pretty it is, I betcha they still hurt like hell.

-For a brief period inspired by sexual repression, these rings were also designed specifically for the purpose of preventingerections and sexual exploits by inflicting pain with constriction or spikes. 

-This is interesting, because it really demonstrates the clear link between pleasure and pain, even waaay back in dynastic China… tres 50 Shades. Interesting though it may be, I’ll take a hard pass on the pain part of that equation, thank you very much people. Debbie and I have no Christian and Anastasia tendencies at all.

-In reality, the basic form and function of these rings have remained quite unchanged, though they are now made in softer, less painful materials and in adjustable models as well. 

Geisha Balls

-AKAs: Ben Wa Balls, Burmese Balls

-Origins are uncertain and incomplete

-What we know: they appeared in the Orient sometime around A.D. 500 and were originally used to pleasure men. 

-Women soon (somehow) caught on to the benefits (?) of the device, and the balls went supernova. 

-Recorded across most Asian cultures, Geisha Balls were the “Rabbit” of their day: a toy that could heighten pleasure during sex, or simply facilitate some good old-fashioned self-pleasure.

Penis Enlargement

-Popularized in Third Century A.D.

-The Kamasutra was many things: a manual for living, a treatise on sex, and likely the earliest recorded scam. Why? I’m glad you asked: because in it, they describe a method for making a penis larger. How? I’m glad you asked: by catching wasps, and- stingers and all- rubbing them all over the penis, being very careful not to crush and kill them before they angrily sting the entire shaft and head of the penis. Or, some people say you could also simply grasp each wasp and apply its stinger to the skin of the penis- and then repeat that action until you’ve managed to cover it completely. Does it work? I’m glad you asked: technically, yes… but the enlargement you get would only be courtesy of the swelling caused by the poison stinger, and I’m quite sure that using the penis for intercourse in that condition would be painful as hell, certainly sufficient enough to prevent you from doing so. In reality, the efficacy of this “treatment” in making the penis larger is questionable at best, and lethal at worst, if that’s how one discovers they happen to have a severe anaphylactic reaction to wasp stings, and would be very temporary in any case… So it would only work about as well as the tub o’ enlargement cream that Junior High boys buy online after sneaking dad’s credit card. 

-There is an alternative of sorts, to increase the girth of a penis. What is it? I’m glad you asked: Apadravyas. What the hell are those? I’m glad you asked: apadravyas are a type of deep penis shaft piercing. *Warning: cross your legs, penis people!* These piercings pass through the penile shaft at certain specific points and apparently function to make the penis feel larger as it enters the vagina – or so devotees claim. 

-These girth piercings come in other forms based on where they are placed through the shaft.

-In addition to apadravyas, other forms of these piercings are called ‘deeply placed ampallangs’ and ‘reverse shaft Prince Alberts.’ Well hell, that clears it right up… not!

-These deep penis shaft piercings are fairly rare piercings due to (helll-ooo!!) their associated pain, difficulty, bleeding, and long healing times. 

-Common placement is directly behind the head of the penis, but they can be placed farther back if the (completely batshit crazy) man so desires.

-In the interest of research (heh heh) I had to ask Debbie if she would have intercourse with a dude with an apadravyas. I can’t describe the look she gave me, because words just can’t go there, and I can’t tell you exactly what she said… but it sounded a lot like “what the muck is a applegravys and what does it have to do with mucking some dude?!” After I enlightened her, I repeated my question: “…so would you have intercourse with a dude with an apadravyas?” I can’t tell you what she said, because she didn’t say anything… she just set her face in an ‘ewww, what the hell stinks?’ expression and shivered… an impressive, full body-length shiver, starting from the blonde hairs on the very top of her pretty head and carrying down to the very tips of her perfectly manicured pink toenails. After this shiver response, she started to turn and walk away, but then turned back to add “Just to be clear… I would never (word that sounds like muck) a dude with an applegravys in his (word that sounds like lick) – not even after a tetanus shot! I love my wife, so it’s my duty to keep her on her toes, however I find it fit to do so. That’s how I see it anyway… can I get an amen?! Anyway, so it was for her own good that I asked (read: yelled after her as she left) in my very best Austin Powers voice “…so you’re saying it really turns you on, huh baby?” And what did I get for all of my concern? A Debbie triple: an eye roll-tongue tisk-whut-everrr! As you can imagine, it’s a classic at my house. 

‘Lube

-Sometime and somewhere – evidently, actually everywhere in Ancient Greece.

-Given their reputed penchant for orifices that don’t naturally lubricate, it should come as no surprise that the Greeks were into lube. 

-While no record exists of its earliest use, we do know that by 350 B.C., olive oil was big business… and it wasn’t just for salads, o-kaaay? 

-Aristotle makes a passing reference to this olive oil love in his History of the Animals, implying that smoother sex was best because it made pregnancy less likely. Suurre…

-Two centuries later, physician Soranus echoed Aristotle’s views on olive oil as lube. Seriously?! A Greek dude named Sore-anusthat’s into olive oil lube? Duh! This has got to be a joke. Albeit a hilarious one!

-Sore-anus’ friends- Herodotus, Plutarch, and Ovid- evidently agreed wholeheartedly, and all maintained that Athens got its name because the goddess Athena herself gifted its founders with an olive tree… that’s how much they loved olive oil.

-Greeks were clearly keen on material innovations. In an effort to upgrade from hard (not to mention dangerous and so very uncomfortable) materials like stone, dried tar, and wood, the Greeks developed olisbokollikes- these were essentially dildos baked out of bread. They basically made breadsticks, people. Breadstick dildos…a whole new take on “food porn.” 

-I don’t know why, but whenever I think about Greeks, I automatically think Romans, so I don’t want to leave them out… the Romans were innovators as well during this time. They’re actually known for creating the double-ended dildo, which was regularly used between partners and friends, but was also even used during certain public ceremonies. Roman exhibitionists… that’s amore, people!

….And speaking of dildos

-Archaeologists discovered an eight inch stone behemoth in Germany, dated at 28,000 years old, people!

-The dildo may well be humanity’s most durable invention, as only fire, weapons, clothing, and beads appear to have been around longer. 

-Evidently, archaeologists find dildos on digs all the time: it’s almost as if people in the prehistoric era found sex to be a natural and enjoyable thing that they didn’t have to be ashamed of. No shame in their game people. 

…And speaking of no shame: Pornography

-Years ago, archaeologists uncovered a decidedly pervy prehistoric statue carved from a mammoth tusk. Who knew that archeology could be so titillating?

-It was basically a female torso with… hmmm- how to put this… ‘exaggerated’ sexual parts on top and bottom. 

-It was a toy- a sex toy- and it was also functional pornography! A two-fer people!

-The exact age of it is uncertain, but the best guess places it at over 35,000 years old. 

-That means it may even pre-date religion. That’s big, people. 

-Obviously, the history of religion is essentially educated guesswork, so lots of eggheads argue about it, but if you assume it’s true- that this pervy porno sex toy pre-dates religion- can you understand the implication of that?

-In case you can’t, I’ll help you out: that would mean that before humans bothered with their ‘trivial’ thoughts on the meaning and creation of life, they had already figured out all the things that turned them on and got them off, and were producing toys and paraphernalia to make it easier and more gratifying to do so. Talk about priorities, people. 

Clearly, human beings have been exploring sexuality since the dawn of time, and as it turns out, sex toys and sex paraphernalia have been around for just as long. The above glimpse at their design histories offers a strange and often hilarious look at humans’ constant quest for innovation and better…. connection, let’s say. 

Okay people, this blog has been a long one, but you hung in there (hahaha I’m on a roll here!!) and I like to reward good behavior. So, speaking of hilarious, I found a page from a UK-based global sex toy company called Lovehoney (Lovehoney.co.uk) where they sell stuff that might blow your mind…but the following will sooner bust your gut: it’s their list of the 101 funniest Lovehoney site searches (look for occasional commentary from me, MGA people!)

101 Funniest Searches on our Sex Toy Site

https://www.lovehoney.com/blog/2018/03/08/101-funny-sex-toys-searches-lovehoney/

Quoted from Lovehoney page:

There have been 6.9 million unique searches on Lovehoney.co.uk in the year to date. Most of the words that are typed into the search box at the top of our site are pretty straightforward: cock rings, vibrators, and all the other types of sex toys we sell. And when customers type in a phrase, we try to present them with the product or page they’re looking for. Simple. But!!! Some of the searches are not quite what you’d expect…

“Anal cockroach”???

Ummm… Sorry, no page for that!

Or any of the below, which are just 101 of the funniest, weirdest, and ‘whoops you’re on the wrong website’ searches we’ve found!

Typos and epic auto-correct fails…

1. make your duck longer

2. election enhancer (MGA: we’ll all need this come November people!)

3. cockfosters extension

4. pension extender (MGA: where can I sign up for this?)

5. masterbakers for male

6. master storyteller sleeves

7. prostate lasagne (MGA: not what your Italian grandma serves for Sunday supper, thank you God) 

8. blowtorch stroker

9. extra quiet clitoris

10. quiet rabbi

11. g spotify

12. large g snot rabbit

13. vibe eating butt plug

14. king clock dildo

15. breaded dildo (MGA: ditto last comment)

16. jelly bilbaos

17. rubber dodos (MGA: and scientists claim they went extinct)

18. nipped pasty

19. nipple gardening cream

20. or gasman creams

21. pies for woman to get horny (MGA: we need to introduce this lady to Mr. 5 ^)

22. parents ribbed and dotted

23. bondage ape (MGA: our ASPCA would never allow those here)

24. lego restraints (MGA: I remember looking for that set. People really snapped ’em up at Christmas time!)

25. clint clamp

26. sexist enhancer (MGA: ‘Ah-hem, I’m afraid I couldn’t purchase these again for you, Mr. President’)

27. £3 sex tits (MGA: that’s only $3.75 USD…can’t be very BIGsex tits)

Somebody’s got the sex toy blues…

28. argue dildo

29. be warned balls

30. begging set

31. bitterly kiss

32. bleak lace lingerie

33. blue worthless knickers

34. fifty shades of greed

35. cock extinction

36. fleshlight insults

37. handcoffins

38. hate based lubricant

39. male sick vibrator

40. male wasterbators (MGA: masturbating stoner guys)

41. vaginal fighting cream

42. ben war balls

43. very berating pants

44. misery bundle

45. pensive sleeve

46. performance kills

47. remorse egg

48. repent rabbit

49. undead wear

50. ruthless panties

51. sorry panties

52. worthless dispenser panties

We do NOT sell these…

53. bishop vibrator

54. barman vibrator

55. cricket vibe

56. turnip vibrator (MGA: for the very strict vegan)

57. parsnip vibrator (MGA: okay, somebody clearly thinks they’re a comedian. I make the jokes here, people!)

58. vibrators with noodles

59. bike saddle dildo

60. pogo stick dildo

61. glasses with testicals snaped to them

62. Darth vader condom

63. extra sting condoms

64. pickled onion condoms

65. chicken tikka masala condoms (MGA: it’s past somebody’s dinnertime)

66. lovehoney wine

67. extra wine vibrator

68. make-up sperm coconut

69. paperami lube

70. Love twiglets

71. family guy sex doll

72. Japanese dancing pants

73. loyal pyjamas

74. machine guns

Going somewhere? You’re on the wrong site… (MGA: if I had captioned this, it would’ve been: “Sorry – we’re all about coming, not going…”)

75. gloucestershire bus timetables

76. london to whitehaven train times

77. meeting point in bangkok airport

78. walking trails in east falmouth

79. bike rack inside caravan

80. staying in a hotel in alton towers

81. is drinking allowed on coaches

82. parrot sale in india

83. North Korea (MGA: there’s a Kim dynasty joke in there somewhere)

Nope, we’re not a grocery store…

84. andrex supreme quilted toilet roll tissue paper

85. fairy non bio pods sensitive skin washing capsules

86. gaviscon double action mint tablets

87. roasted cauliflower with parmesan cheese

88. serrano ham

89. Ragu

90. Absinthe

Just plain weird…

91. Peter from gravesend – timewaster

92. hide your drink in bra

93. mild penis

94. mild vagina

95. outpouring vegan

96. room of priests

97. scrotal parachute (MGA: I know they stretch as we age, but wow…that’s gotta be impressive)

98. the loo of love (MGA: must’ve missed that position in the Kamasutra)

99. Wednesday

100. Dave

And finally this person, who clearly knows exactly what they want…

101. a silicone butt plug for beginer one my wife can leave in her ass n get on with housework shaped without risk of it falling out

(MGA: alert the media people… I’m speechless!!)

   _______________________________

That’s some of the history and background on sex toys. In the next couple of weeks, I’ll be covering more interesting details and specifics on sex toys that you won’t want to miss, so be sure to come on back for more, people. 

I hope you really enjoyed this blog and maybe even found it to be slightly more titillating than the usual fare. If so, please feel free to spread the love and share it with family and friends…. and lovers of course! And be sure to check out my YouTube channel with all of my videos, and I’d appreciate it if you would like, subscribe, leave comments, and share those vids! As always, my book Tales from the Couch has more fabulously educational topics and patient stories, and is available in office and on Amazon. 

Thank you and be well people!

MGA

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Opiates:History,Use,Abuse,Addiction

Opioids: History, Use, Abuse, Addiction

How Did We Get Here?

Anchored in the history, culture, religion, mythology, biology, genetics, and psychology of the earliest civilizations to the societies of present day, humans have long tried to balance the positive medicinal properties of opioids with the euphoric effects that have so often led to their use and abuse.

Before we get into their history, first a quick fyi lesson in the semantics of the terms opiates vs opioids vs narcotics. While the terms are often used interchangeably, they are technically different things. 

The term opiate refers to any drug that is derived from a naturally occurring substance, ie from opium alkaloid compounds found in the poppy plant. Types of opiate drugs include opium, codeine, and morphine. The term opioid is broader, and refers to any synthetic or partially synthetic drug created from an opiate. Examples of opioid drugs include heroin, methadone, oxycodone, and hydrocodone. Narcotics is an older term that originally referred to any mind altering compound with sleep-inducing properties.

For the general public, only the term opioid is really necessary, as it includes all opi- substances. In my practice and in my blogs, I sometimes make a distiction between the terms, but if you’re looking for a safe bet, or maybe a trivia win, the term opioid is the best and most accurate choice. Regardless of the word used, one is not any safer than the other; any opiate or opioid has the potential to treat pain, to be abused, and to cause dependence.

Following are some of the most common opioids and their generic names, listed in order of increasing strength.

Codeine

Hydrocodone (Vicodin, Hycodan)

Morphine (MS Contin, Kadian)

Oxycodone (Oxycontin, Percocet)

Hydromorphone (Dilaudid)

Fentanyl (Duragesic)

Carfentanyl (Wildnyl)

History of Opiates

A long, long time ago, opiate use began with Papaver somniferum, otherwise known as the opium poppy. Native to the Mediterranean, it grew well in subtropical and tropical regions fairly easily, a fact that contributed to its historical popularity. Unripe poppy seed pods were cut, and the milky fluid that seeped from the cuts was scraped off, air-dried, and treated to produce opium. 

In case you’re wondering… today, legal growing of opium poppies for medicinal use primarily takes place in India, Turkey, and Australia. Two thousand tons of opium are produced annually, and this supplies the entire world with the raw material needed to make the medicinal components. Papaver somniferum plants grow from the very same legal and widely available poppy seeds found in today’s many seed catalogues. But, planting these seeds is less legal, with the DEA classifying them as a Schedule II drug, meaning that technically, they can press charges against anyone growing this poppy variety in their backyard. You can ask this one dude in North Carolina about it, as he was busted for having one acre of these big blooming beauties behind his house. At about 9 feet tall and topped with big red blooms, they’re not exactly inconspicuous. Another grow was discovered after an Oregon state patrol officer stopped to look at a field of beautiful “wildflowers,” wanting to cut a bouquet for his wife… a story that I personally find totally hilarious. Evidently, when he cut the first one, he was surprised by the sap that got all over his hands, so instead of taking some home to his wife, he took one to a fellow cop friend that was big on horticulture, and she enlightened him on what it was. Good thing too, because he had even thought about how cool it would be to dry the “wildflowers” to seed and plant them in his side yard! You just can’t make this stuff up.

Archaeologists have found 8,000 year-old Sumerian clay tablets that were really the earliest “prescriptions” for opium. The Sumerians called the opium poppy “Hul Gil,” meaning the “Joy Plant,” which was regularly smoked in opium dens. Around 460-357 B.C. Hippocrates, known as the “Father of Medicine” acknowledged opium’s usefulness as a narcotic, and prescribed drinking the juice of the poppy mixed with nettle seed. Alexander the Great took opium with him as he expanded his empire- it’s surprising that he was so great, because some accounts seem to suggest that he was a raging addict. Arabs, Greeks, and Romans commonly used opium as a sedative, presumably for treating psychiatric disorders. In the 15th and 16th centuries, Arabic traders brought opium to the Far East. From there, opium made its way to Europe, where it was used as a panacea for every malady under the sun, from physical ailments to a wide variety of psych issues. Biblical and literary references, and opium’s use by known and respected writers, leaders, and thinkers throughout history, including Homer, Franklin, Napoleon, Coleridge, Poe, Shelly, Quincy, and many more, made opium use perfectly acceptable, even fashionable. 

19th Century Opiates to Opioids

There was a lot of unrest and violence around the globe throughout the 1800’s. Wounded soldiers from the American Civil War, British Crimean War, and the Prussian French War were basically allowed to abuse opium. And sure enough, beginning in the 1830’s, one-third of all lethal poisoning cases were due to opium and its opiate derivatives, and this really marked the first time that a “medicinal” substance was recognized as a social evil. Yet, most places around the world still really turned a blind eye to opium and opiate use. But, so many soldiers developed a dependency on opiates that the post-war addiction state was commonly known as “soldier’s disease.”

In 1806, German alkaloid chemist Friedrich Wilhelm Adam Sertürner isolated a substance from opium that he named “morphine,” after the god of dreams, Morpheus. The prevailing wisdom for creating morphine was to maintain the useful medicinal properties of opium while also reducing its addictive properties. Uh huh, sure. In the United States, morphine soon became the mainstay of doctors for treating pain, anxiety, and respiratory problems, as well as consumption and “female ailments,” 

(that’s old-timey for tuberculosis and menstrual moodiness/ cramps) In 1853, the hypodermic needle was invented, upon which point morphine began to be used in minor surgical procedures to treat neuralgia (old timey for nerve pain). The combination of morphine and hypodermic needles gave rise to the medicalization of opiates.

Well, morphine turned out to be more addictive than opium, wouldn’t ya know it. So, as with the opium before it, the morphine problem was “solved” by a novel “non-addictive” substitute. Of course… I mean, what could possibly go wrong? Your first clue is that this novel compound was the first opioid, and was called heroin. See where this is going? First manufactured in 1898 by the Bayer Pharmaceutical Company of Germany, heroin was marketed as a cough suppressant, a treatment for tuberculosis, and a remedy for morphine addiction. Well, as you can probably guess, that worked great, until heroin proved to be far more addictive than morphine ever thought of being. So what to do? Hmmm… what…to…do… I know! Let’s make a “non-addictive” substitute for the heroin! That’s the best plan, definitely. 

20th Century: Opiates to Opioids

By the dawning of the 20th century, the United States focused on ending the non-medicinal use of opium. In 1909, Congress finally passed the “Opium Exclusion Act” which barred the importation of opium for purposes of smoking. This legislation is considered by many to be the original and official start of the war on drugs in the United States. Take that, Nancy Reagan! In a similar manner, the “Harrison Narcotics Tax Act of 1914” placed a nominal tax on opiates and required physician and pharmacist registration for its distribution. Effectively, this was a de-facto prohibition of the drug, the first of its kind.

In 1916, a few years after Bayer stopped the mass production of heroin due to the dependence it created, German scientists at the University of Frankfurt developed oxycodone with the hope that it would retain the analgesic effects of morphine and heroin, but with less physical dependence. Of course they did, because this worked out so swimmingly before. What could possibly go wrong? 

Well, we know how this story turns out.

First developed in 1937 by German scientists searching for a surgical painkiller, what we know today as methadone was exported to the U.S. and given the trade name “Dolophine” in 1947. Later renamed methadone, the drug was soon being widely used as a treatment for heroin addiction. But shocker… unfortunately, it too proved to be even more addictive than its predecessor heroin. Captain Obvious says he’s sensing a trend here.  

In the 1990’s, pharmaceutical companies developed some new and especially powerful prescription opioid pain relievers. They then created some equally powerful marketing campaigns that assured the medical community that patients would not become addicted to these drugs. Gleefully, docs started writing for them, and as a result, this class of medications quickly became the most prescribed class in the United States- even exceeding antibiotics and heart medications- an astounding statistic. Well, we now know that the pharma co’s were full of crap: opioids were (and still are) the most addictive class of pharmaceuticals on the planet… and so in the late 90’s, the opioid crisis was born. 

Opioids: True and Freaky Facts

The real fact is that 20% to 30% of all patients who were/ are prescribed opioids for chronic pain will misuse them. Further, studies on heroin addicts report that 80% of them actually began their addiction by first misusing prescription opioids. That’s a big number people, but I think it’s actually higher. Food for thought for all the pill poppers out there saying ‘I’ll never use a street drug like heroin.’ And speaking of that, by the turn of the 21st century, the mortality rate of heroin addicts was estimated to be as high as twenty times greater than the rest of the population. Twenty times, people.

Opioid Addiction and Overdose

Opioids produce a sense of wellbeing or euphoria that can be addictive to some people. Opioids are often regularly and legitimately prescribed by excellent, well-meaning physicians when treating patients for severe pain. The problem is that even when taken properly, many people develop tolerance to these opioids, meaning they need more and more to get the same effect and relieve their pain. That’s just one factor that makes them so insidious. In addition, we cannot predict who will go down this tolerance and potential addiction path, because it can happen to anyone who takes opioids. However, there are some factors that make people more susceptible to addiction, such as the presence/ prevalence of mood disorder(s) and especially a genetic/ familial history of addiction, which contributes to nearly 50% of abuse cases.

When people become addicted to opioids, they begin to obsessively think about ways they can obtain more, and in some cases they engage in illegal activities, such as doctor shopping, stealing prescriptions from friends and family, and/ or procuring them on the street. 

Another insidious facet of tolerance is that the tolerance to the euphoric effect of opioids develops faster than the tolerance to the dangerous physical effects of taking them. This often leads people to accidentally overdose as they chase the high they once felt. In this attempt to get high, they take too much and overdose, dying of cardiac or respiratory arrest. Drug overdose is the leading cause of accidental death in the United States, and there are more drug overdose deaths in America every year than deaths due to guns and car accidents combined. According to the CDC, 2019 drug overdose deaths in the United States went up 4.6% from the previous year, with a total of 70,980 overdose deaths, 50,042 of which were due to opioids. 

There’s a kahuna in Opioidland that’s so big and so bad that it bears a special mention… fentanyl. Referencing the above statistics, of the more than 50,000 opioid overdoses, fentanyl is specifically indicated in more than 20,000 of those fatalities. Again, I think it’s way higher than that. Regardless, I think we can all agree that it’s deadly. Fentanyl is so crazy dangerous because it is 50 to 100 times more potent than morphine, so it takes the teeny tiniest amount to overdose. A lethal dose of fentanyl for adults is about two milligrams- that’s the equivalent of six or seven grains of salt people! 

Obvi, there are tons of chilling statistics about fentanyl, but here’s another one for you: in one-third of fentanyl overdoses, the individual died within seconds of taking it. Get this- they died so quickly that their body didn’t have enough time to even begin to metabolize the drug, so no metabolites of fentanyl were found on toxicology screens at the time of autopsy. The moment you ingest or inject any drug/ pharmaceutical, the body immediately begins to break it down into components called metabolites. After a certain period of time (which varies according to many different factors) the drug is completely metabolized by the body, so a toxicology screen will pick up those metabolites rather than the complete molecule(s) of the drug. Every drug has a known rate of metabolism, so tox tests can tell how long ago a drug was used or ingested. This data is saying that in one-third (33%) of fentanyl overdose deaths, tox screens pick up zero metabolites, because the body had no time to even begin to start the process of making them. The screens detected the presence of the full complete molecule(s), but no breakdown products. It’s a very significant and scary hallmark of fentanyl use/ abuse/ overdose: the fact that you may not live long enough to regret using it.  

How did fentanyl become such a big part of the opioid epidemic? Around 2010, docs were getting smart to the use and abuse of opioids and the ensuing crisis, and many stopped prescribing them. This left a lot of addicted people, including many who legitimately required relief from pain, unable to get prescriptions and SOL. At the same time, buying prescription drugs on the street was crazy expensive due to increased demand and decreased supply. But also, heroin had became so abundant that it suddenly became cheaper than most other drugs, so addicts started to switch to heroin. In one survey, 94% of people in treatment for opioid addiction said they used heroin only because prescription opioids became much more expensive and harder to obtain. 

Next, to make things exponentially worse, drug cartels discovered how to make fentanyl very cheaply, so huge quantities of fentanyl started flooding the market. Because fentanyl is easier to make, more powerful, and more addictive than heroin, drug dealers recognized the opportunity, and began to lace their heroin with fentanyl. People taking fentanyl-laced heroin are more likely to overdose, because they often don’t know they’re taking a much more powerful drug. Fentanyl can be manufactured in powder or liquid forms, and it can be found in many illicit drugs, including cocaine, crack, and methamphetamine. And let’s face it folks, the people making this garbage aren’t exactly rocket scientists, so all of these drugs can (and usually do) contain toxic contaminants and/ or have different levels of fentanyl in each batch, or even varying levels within the same batch. These facts just add to the lethal potential of this stuff. 

Now fentanyl has found its way onto the street in yet another form: pills. When fentanyl pills are created for the street, they’re pressed and dyed to look like oxycodone. Talk about insidious! If you go looking to buy oxy’s on the street and the dealer is selling them dirt cheap because they don’t know any better, or care is probably more accurate, you’ll probably think ‘Wow- these oxy’s are cheap! Let me get those!’ If your body is accustomed to using real oxy’s and you unknowingly take fentanyl, you will absolutely overdose. Like see ya later, bye overdose.

But believe it or not, it gets worse… A new variation of fentanyl is finding its way into the drug trade. Carfentanil is 100 times stronger than fenatanyl, which makes it 10,000 times more potent than morphine. While it was originally developed as an elephant tranquilizer (hel-looo??!!) the powdered form of carfentanil is now commonly used as a cutting agent in illicit drugs like heroin, cocaine, and methamphetamine.

Opioid Withdrawal

Opioid withdrawal can be extremely uncomfortable. But an important thing to remember is that opioid withdrawal is not generally life threatening if you are withdrawing only from opioids and not a combination of drugs. This is because each drug class is pharmacologically different, so withdrawal is different for each one. FYI, the most dangerous withdrawls are from benzodiazepines (Valium, Xanax, etc) and alcohol, even though alcohol isn’t technically a drug, it reacts, is metabolized, and physically withdraws from the body like any drug. Individually, either can be lethal in withdrawl and require medical supervision. 

Opioid Withdrawal Symptoms

Withdrawal typically includes the following symptoms to varying degrees:

Low energy

Irritability

Anxiety

Agitation

Insomnia

Runny nose

Teary eyes

Hot and cold sweats 

Goose bumps

Yawning

Muscle aches and pains

Abdominal cramping

Nausea

Vomiting

Diarrhea

Stages of Opioid Withdrawal

-The first phase (called acute withdrawal) begins about 12 hours after the last opioid use. It peaks at around 3 – 5 days, and lasts for approximately 1 – 4 weeks. This acute stage has mostly physical symptoms.

-The second phase (post-acute withdrawal) can last for a long time, with some references documenting up to two years. The symptoms during this phase are mostly emotional, and while they are considered less severe, they last longer.

Symptoms include mood swings, anxiety, variable energy, low enthusiasm, variable concentration, and disturbed sleep.

But, don’t let concern over withdrawl symptoms keep you from getting off of opioids. There are medications that can significantly decrease all of these. Two of the most common are methadone and buprenorphine. Being that drug detox is one of my specialties, in next week’s blog, I’ll outline both of these and tell you my reccommendations.

Until then…

Now that we’ve covered the history and background on opioids, if you think you might have an opioid addiction, I have a separate quiz that will bring some clarity to you on that question. I will upload a more detailed assessment as a separate blog, but for now, here’s a short generalized screen to take first. 

Do You Have an Opioid Addiction?

Answer yes or no to each of the following questions. If you answer yes to at least three of these questions, then you are likely addicted to opioids and should definitely take the detailed addiction self-assessment test which follows. I also suggest that you print the assessment and answers and take them with you for a professional evaluation.

Addiction: Basic Screen1) Has your use of opioids increased over time?2) Do you experience withdrawal symptoms when you stop using?3) Do you use more than you would like, or more than is prescribed?4) Have you experienced negative consequences to your using?5) Have you put off doing things because of your drug use?6) Do you find yourself thinking obsessively about getting or using your drug?7) Have you made unsuccessful attempts at cutting down your drug use?

Again, if you answered yes to at least three of these questions, then you are likely addicted to opioids and should take the detailed addiction self-assessment test which follows as a separate blog. Be sure to print both with you for a professional evaluation. 

I hope you enjoyed this blog and found it to be interesting and educational. Please feel free to share it with family and friends. Be sure to check out my YouTube channel with all of my videos, and I’d appreciate it if you would like, subscribe, leave comments, and share those vids! As always, my book Tales from the Couch has more educational topics and patient stories, and is available in office and on Amazon. 

Thank you and be well people!

MGA

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Postpartum Depression,Signs,Symptoms,and Treatment

Postpartum Depression: o

Signs, Symptoms, New Treatment?

Last week, we talked about sex and orgasms, so it seems only fitting that this week, I talk about the potential ‘homework’ that may come after the sex and orgasms: pregnancy… and the postpartum depression that may accompany it. 

It is one of life’s greatest joys, and for me personally, the proudest moment of my entire life: the birth of a child. But no matter how much you love that baby or how you’ve looked forward to its arrival, having a baby is stressful on both parents for many reasons. However, there are specific reasons that make it more physically and emotionally taxing on mom. Captain Obvious says that there are many physical, emotional, and chemical changes in a woman’s body that allow them to (help) create, carry, and birth these little miracles. And add to that the onset of new responsibilities, sleep deprivation, and lack of time for any personal care, it’s not a big shock that lots of new moms get overwhelmed and feel like they’re on an emotional rollercoaster from hell. In fact, the mild depression and mood swings that are so common in new mothers have earned them a name, “the baby blues.” But how do you know if what mom is feeling goes beyond the blues? What should you look for, and when should you seek help? 

The majority of women experience at least some symptoms of the baby blues immediately after childbirth. Why? It’s all down to female hormones: specifically, progesterone and estrogen, the big kahunas in the female hormone universe.

Progesterone’s role in pregnancy is so vital that it’s referred to as the “pregnancy hormone.” Actually, progesterone comes into play long before pregnancy, as it is one of the hormones secreted by the ovaries that governs ovulation and menstruation in post-pubescent women. Then upon conception, it gets the uterus ready to accept, implant, and maintain a fertilized egg, and it also prevents the uterine muscle contractions that would otherwise cause a woman’s body to reject it. During fetal gestation, it helps create an environment that nurtures the developing baby. It makes it sound like progesterone is in there painting, hanging curtains, and fluffing pillows, but its role goes way beyond that. The placenta, which is the structure inside the uterus that provides oxygen and nutrients to a developing baby, will itself begin to produce progesterone after about 8 to 10 weeks of pregnancy. At this point, the placenta increases progesterone production to a much higher rate than the ovaries ever thought about making. Those high levels of progesterone throughout the pregnancy cause the mom’s body to stop producing more eggs, as well as prepare her breasts to produce milk. 

Also produced by the ovaries when not pregnant, and then later by the placenta during pregnancy, estrogen helps the uterus grow, maintains the uterine lining where the budding baby is nestled, steps up blood circulation, and activates and regulates the production of other key hormones. In early pregnancy, it also helps mom develop her milk-making machinery. And baby benefits too, as estrogen triggers the development of those teeny tiny organs and regulates bone density in those cute little developing arms that wave and legs that kick. 

The increased levels of progesterone and estrogen during pregnancy actually make mom feel good and feel bonded to baby, even though she may be crying her eyes out for virtually no reason (sorry ladies) in the beginning. Levels of both hormones continue to increase as the pregnancy advances, and mom’s body actually gets used to these high levels. Then when the baby is born, there’s no more placenta, so mom’s progesterone and estrogen levels drop suddenly and precipitously, in a matter of hours. So mom goes essentially cold turkey from high hormone levels to comparatively no hormone levels. Sudden hormonal change + stress + isolation + sleep deprivation + fatigue = tearful + overwhelmed + emotionally fragile mom. Generally, these feelings can start within just the first day or so after delivery, peak at around one week, and taper off by the end of the second, third, or maybe up to the fourth week postpartum; that’s if it’s the baby blues. 

These baby blues are perfectly normal, but if symptoms are extreme, don’t go away after a month, or get worse, mom may be suffering from postpartum depression and likely needs help.

Postpartum Signs & Symptoms

Though they share some symptoms, postpartum depression is a much more serious problem than the baby blues, and should never be ignored. Shared symptoms of the two include mood swings, crying jags, sadness, insomnia, and irritability.      

Postpartum depression is the most common complication of childbearing, and it occurs in 10% to 20% of all moms after delivery. It is different from the baby blues in that the symptoms are more severe and longer lasting. It is an issue that can’t be blown off or underestimated, because it begins at a critical time, when mom is caring for a helpless infant and needs to be bonding with them. 

Symptoms of postpartum depression can include suicidal thoughts, an inability to care for the newborn child, and in extreme cases, even thoughts of harming the baby. Postpartum can be extremely debilitating, and certain signs can put the lives of mom and/ or baby in jeopardy.

Beyond the Blues

Common Red Flags for Postpartum:

-Mom withdraws from partner

-Mom’s unable to bond well with baby

-Mom’s anxiety gets out of control, preventing ability to sleep and/ or eat

-Mom feels guilty, worthless, useless, overwhelmed

-Mom seems preoccupied with death or wishing she were no longer alive

There’s no single reason why some new moms develop postpartum depression and others don’t, but a number of interrelated causes and risk factors are generally at play.

Postpartum Causes/ Triggers

Hormonal changes after childbirth cause fatigue and depression:

 -Progesterone/ estrogen levels drop

 -Thyroid levels can drop

 -Changes in blood pressure, immune system functioning, metabolism

Numerous physical/ emotional changes after delivery: 

 -Physical delivery pain

 -Difficulty losing baby weight

 -Insecurity, especially in physical/ sexual attractiveness

Significant stress of caring for a newborn:

 -Mom is sleep deprived

 -Mom is overwhelmed/ anxious about her abilities to properly care for baby

 -Mom has difficulty adjusting

All of the above factors are especially true in first time moms, as they must also get used to an entirely new identity at the same time. 

Postpartum Risk Factors

Several factors can predispose a mom to suffer from postpartum depression:

  -History of postpartum depression

A prior episode can increase the chances of a repeat episode by 30% to 50%.

  -History of non-pregnancy related depression and/ or family history of mood disturbances

  -Social stressors, including lack of emotional support, abusive relationship, and/ or financial uncertainty 

  -Significantly increased risk in women who discontinue medications abruptly for purposes of pregnancy.

Postpartum Psychosis

Postpartum psychosis is an even more rare, and more extremely serious disorder that can also develop after childbirth. Characterized by a loss of contact with reality, postpartum psychosis poses an extremely high risk for suicide or infanticide, and hospitalization is nearly always required to keep both mom and baby safe. Postpartum psychosis develops suddenly, usually within the first two weeks after delivery, and sometimes within a matter of 48 hours. 

Postpartum Psychosis Symptoms

Postpartum psychosis is considered a medical emergency requiring immediate medical attention.

  -Hallucinations: seeing things and/ or hearing voices that aren’t real 

  -Delusions: paranoid, irrational beliefs

  -Extreme agitation and anxiety

  -Suicidal thoughts or actions

  -Confusion and disorientation

  -Rapid mood swings

  -Bizarre behavior

  -Inability or refusal to eat or sleep

  -Thoughts of harming or killing baby

There is a screening tool that can be used to detect postpartum depression, called the Edinburgh Postnatal Depression Scale. I will put the questions and explain the scoring of this scale at the conclusion of this blog. It can be helpful if mom or partner isn’t quite sure if symptoms are the baby blues or true postpartum depression. 

Coping with Postpartum Depression

Four Tips for Moms:

1) Create a secure attachment with baby.

The emotional bonding process between mom and child, known as attachment, is the most important task of infancy. The success of this wordless relationship enables a child to feel secure enough to develop fully, and affects how he or she will interact, communicate, and form relationships throughout their entire lives.

A secure attachment is formed when moms respond warmly and consistently to baby’s physical and emotional needs. When baby cries, quickly soothe them. If baby laughs or smiles, respond in kind. In essence, the goal is for mom and baby to be in synch, and to be able to recognize and respond to each other’s emotional signals.

Postpartum depression can interrupt this bonding. Depressed moms can be loving and attentive at times, but at other times may react negatively or not respond at all. Moms with postpartum depression are generally inconsistent in their care, and tend to interact less with their babies; they are also less likely to breastfeed, play with, and read to them. Postpartum is sinister in this way, as learning to bond with baby not only benefits the child, it also benefits mom by releasing endorphins that make mom feel happier and more confident. By its very presence, postpartum makes the bonding process difficult, and therefore mom is less likely to produce those endorphins that would make her feel better. It’s a vicious cycle.

If mom didn’t experience a secure attachment as an infant, she may not know how to create a secure attachment as a mom. However, this can be learned, as human brains are definitively primed for this kind of nonverbal emotional connection that creates so much pleasure for both mom and baby.

2) Lean on others for help and support.

Human beings are social creatures. Positive social contact relieves stress faster and more efficiently than any other means of stress reduction. Historically, and from an evolutionary perspective, new moms have typically received help from those around them after childbirth. In today’s world, new moms often find themselves alone, exhausted, and lonely for supportive adult contact. 

Ideas to better connect with others:

 -Make relationships a priority. When feeling depressed and vulnerable, it’s more important than ever to stay connected to family and friends, even if you’d rather be alone. Isolating will only make the situation feel even bleaker, so make adult relationships a priority. Let loved ones know your needs and how you wish to be supported.

 -Don’t hide feelings. In addition to the practical help that friends and family can provide, they can also serve as a much-needed emotional outlet. Share experiences- good, bad, and ugly- with at least one other person, and preferably face to face. It doesn’t matter who mom talks to, so long as that person is willing to listen without judgment and offer reassurance and support.

 -Be a joiner. Even if mom has supportive friends, she may want to consider seeking out other women who are dealing with the same transition into motherhood. It’s very reassuring to hear other mothers share the same worries, insecurities, and feelings. Good places to meet other new moms include support groups for new parents or organizations such as ‘Mommy and Me.’ Pediatricians can also be excellent neighborhood resources.

3) Take care of yourself. One of the best things moms can do to relieve or avoid postpartum depression is to take care of themselves. The more moms care for their mental and physical well-being, the better they’ll feel. 

Simple lifestyle changes can go a long way toward helping moms feel more like themselves again.

 -Skip the housework. Make yourself and baby the priority, and give yourself the permission to concentrate on just that. Remember that being a 24/7 mom is far more work than holding down a traditional full-time job.

 -Ease back into exercise. Studies show that exercise may be just as effective as medication when it comes to treating depression, so the sooner moms get back up and moving, the better. No need to overdo it: a 30-minute walk each day will work wonders. Stretching exercises, like those found in yoga, have shown to be especially effective.

 -Practice mindfulness meditation. Research supports the effectiveness of mindfulness for making moms feel calmer and more energized. It can also help moms become more aware of what they feel and need.  

 -Don’t skimp on sleep. A full eight hours may seem like an unattainable luxury when dealing with a newborn, but poor sleep makes depression worse. Moms must do whatever they can to get plenty of rest- from enlisting the help of the partner or family members, to catching naps at every opportunity.

 -Set aside quality time for yourself to relax and take a break from mom duties. Find small ways to pamper yourself, like taking a bubble bath, savoring a hot cup of tea, lighting scented candles, or getting a massage at a day spa, or even calling a masseuse to come to you.

 -Make meals a priority. Nutrition often suffers during depression. What mom eats has an impact on her mood, and also the quality of breast milk the baby requires, so always make the best effort to establish and maintain healthy eating habits, for yourself and baby.

 -Get out in the sunshine. Sunlight lifts the mood, so try to get at least 10 to 15 minutes of sun each day.

4) Make time for your relationship with your partner. More than half of all divorces take place after the birth of a child. For many men and women, the relationship with their partner is their primary source of emotional expression and social connection. The demands and needs of a new baby can get in the way and fracture this relationship, unless couples put time, energy, and thought into preserving their bond.

 -Don’t scapegoat. The stress from nights of no sleep and new or expanded responsibilities can leave parents feeling overwhelmed and exhausted. It’s all too easy to play the blame game and turn frustrations onto your partner. Instead of finger pointing, remember that you’re in this together. If you tackle parenting challenges as a team, you’ll find that you’ll become an even stronger unit.

 -Keep the lines of communication open. Many things change following the birth of a baby, including roles and expectations. For many couples, a key source of strain is the post-baby division of household and childcare responsibilities. It’s important to talk about these issues, rather than letting them fester. Don’t assume your partner has a crystal ball or knows how you feel or what you need, because you’re bound to feel perpetually disappointed and frustrated if you do. 

 -Carve out couple time. It’s essential to make time for just the two of you when you can reconnect. But don’t put pressure on yourself to be romantic or adventurous, unless you’ve discussed it and found you’re both game. And you don’t need to go out on a date to enjoy each other’s company. Just spending even 15 or 20 minutes together, undistracted and focused on each other, can make a big difference in how close you feel to each other.  

Treatment for Postpartum Depression

If, despite self-help and the support of family, mom is still struggling with postpartum depression, it’s best to seek professional treatment.

 -Individual therapy/ marriage counseling A good therapist can help moms deal better with the adjustments of motherhood. If moms or partners are experiencing marital difficulties or are feeling unsupported at home, marriage counseling can also be very beneficial.

 -Antidepressants. In postpartum cases where mom’s ability to function adequately for herself or baby is compromised, antidepressants may be an option, though they are more effective when accompanied with psychotherapy. Obviously, medication must be closely monitored by a physician.

 -Hormone therapy: Estrogen replacement therapy can sometimes be helpful in combating postpartum depression, and is often used in combination with an antidepressant. There are risks that go along with hormone therapy, so moms must be sure to talk to their doctor about what may be best, and safest, for them.

Helping New Moms with Postpartum

If your loved one is a mom experiencing postpartum depression, the best thing you can do is to offer support, give her a break from her childcare duties, provide a listening ear, and always be patient and understanding. But, be sure to take care of yourself too. Dealing with the needs of a new baby is hard for the partner as well as mom. And if your significant other is depressed, that means you are dealing with two major stressors.

Tips for Partners:

 -Encourage mom to talk about her feelings. Listen without judgement and without making demands. Instead of trying to ‘just fix’ things, simply be there for mom to lean on.

 -Offer help around the house. Chip in with the housework and childcare responsibilities, and don’t wait for mom to ask… trust me on this one!

 -Make sure mom takes time for herself. Rest and relaxation are even more important after a new edition. Encourage her to take breaks, hire a babysitter, or schedule some date nights.

 -Be patient if she’s not ready for sex. Depression affects sex drive, so it may be a while before mom’s in the mood. Offer her physical affection, but don’t push it if she’s not up for anything beyond that.

 -Getting exercise can make a big dent in depression, but it’s hard for moms to get motivated when they’re feeling low. So do something simple, like going going for a walk with mom. Better yet, make walks a daily ritual for just the two of you, or for the whole family.  

There is a fairly new breakthrough drug called Zulresso (brexanolone). Approved in 2019, Zulresso is a neuropathic drug, and first in its class. So what is it? Basically, it’s an aqueous (water-based) solution of progesterone products. They have taken the component product of progesterone and put it into solution; it is then administered to a new mom with postpartum depression. And then a miracle happens… seriously! This lifts postpartum depression like a kid does candy. It is a scientific breakthrough; never before have we had a drug that treats postpartum depression faster than any drug for any type of depression, ever. That’s the good news, but guess what comes next… the bad. While we know it works, very well and very quickly, there are some major disadvantages of this drug. The first one is that it can only be administered by IV infusion. So that means that you have to place an IV map into mom’s vein and drip the drug in with IV fluid. That brings me to the next big disadvantage: it can only be administered in a hospital setting. Why is that? Well, studies show that during administration, which takes place over about 60 hours, two and a half days, some moms can become very dizzy and faint, can lose consciousness, and can even stop breathing. For all of these reasons, moms must be medically monitored with an oximeter and telemetry for two and a half days, during which time they must be checked on every two hours. And they cannot be in charge of baby during this hospital stay, because they may be in and out of consciousness and/ or have severe respiratory issues. While that’s no bueno, the last disadvantage is muy loco, people. Are you ready? The drug costs $34,000. Yep. But wait, it gets better, which in this case, actually means worse. That little $34K is just for the drug! The hospitalization and monitoring costs more… a lot more. And to add insult to injury, you have to shell out the cash to pay for a sitter to watch baby, as mom could potentially be very busy losing consciousness and going into respiratory distress.  

Needless to say, Zulresso is not used very much, even though it is an amazing breakthrough product, essentially curing the notoriously difficult-to-treat postpartum depression in a mere 60 hours. There are some other anti-depressants that work pretty well. Effexor (venlafaxine, desvenlafaxine) and Wellbutrin (bupropion) with antipsychotics like Abilify help to speed up the treatment process generally show some progress in about a week. 

So while I’m very impressed with Zulresso as a novel, first-in-class drug, you can see my practical issues with it. Although, I suppose that everything is relative: if my wife were suffering from serious postpartum depression, to the point that she was suicidal, or the baby’s life was in danger, and it was refractory, meaning all other treatment options had been tried and failed, I would find a way to get the Zulresso treatment; I’d make it happen, by contacting the manufacturer for patient support options. Or maybe by selling a kidney. Whatever it took.

Edinburgh Postnatal Depression Scale

This 10-question self-rating scale has proven to be an efficient way of identifying patients at risk for “perinatal” or postpartum depression. While this test was specifically designed to be administered by a medical professional, to a woman who is pregnant or has just had a baby, it can be used as an effective at-home guide to determine if you or someone you care about has postpartum depression. Just make sure to follow all of your score’s corresponding action(s).

For each of the 10 questions, please check mark the answer that comes closest to how you have felt in the past 7 days. Scoring is explained after the questions.1) I have been able to laugh and see the funny side of things.

____  As much as I always could

____  Not quite so much now

____  Definitely not so much now

____  Not at all2) I have looked forward with enjoyment to things.

____  As much as I ever did

____  Rather less than I used to

____  Definitely less than I used to

____  Hardly at all3) I have blamed myself unnecessarily when things went wrong.

____  Yes, most of the time

____  Yes, some of the time

____  Not very often

____  No, never4) I have been anxious or worried for no good reason.

____  No not at all

____  Hardly ever

____  Yes, sometimes

____  Yes, very often5) I have felt scared or panicky for no very good reason.

____  Yes, quite a lot

____  Yes, sometimes

____  No, not much

____  No, not at all6) Things have been getting on top of me.

____  Yes, most of the time I haven’t been able to cope at all

____  Yes, sometimes I haven’t been coping as well as usual

____  No, most of the time I have coped quite well

____  No, I have been coping as well as ever7) I have been so unhappy that I have had difficulty sleeping.

____  Yes, most of the time

____  Yes, sometimes

____  Not very often

____  No, not at all8) I have felt sad or miserable.

____  Yes, most of the time

____  Yes, sometimes

____  Not very often

____  No, not at all9) I have been so unhappy that I have been crying.

____  Yes, most of the time

____  Yes, quite often

____  Only occasionally

____  No, never10) The thought of harming myself has occurred to me.

____  Yes, quite often

____  Sometimes

____  Hardly ever

____  Never

SCORING VALUES AND GUIDE

Grade each of your checked answers with the specifically stated score, then add the scores together. Take that sum and apply to the interpretation/ action scale and follow the stated suggestion.1) I have been able to laugh and see the funny side of things

0 As much as I always could

1 Not quite so much now 

2 Definitely not so much now 

3 Not at all 2) I have looked forward with enjoyment to things

0 As much as I ever did 

1 Rather less than I used to 

2 Definitely less than I used to 

3 Hardly at all 3) I have blamed myself unnecessarily when things went wrong

3 Yes, most of the time 

2 Yes, some of the time 

1 Not very often 

0 No, never 4) I have been anxious or worried for no good reason

0 No, not at all 

1 Hardly ever 

2 Yes, sometimes 

3 Yes, very often 5) I have felt scared or panicky for no very good reason

3 Yes, quite a lot 

2 Yes, sometimes 

1 No, not much 

0 No, not at all 6) Things have been getting on top of me

3 Yes, most of the time I haven’t been able to cope 

2 Yes, sometimes I haven’t been coping as well as usual 

1 No, most of the time I have coped quite well 

0 No, I have been coping as well as ever 7) I have been so unhappy that I have had difficulty sleeping

3 Yes, most of the time 

2 Yes, sometimes 

1 Not very often 

0 No, not at all8) I have felt sad or miserable

3 Yes, most of the time 

2 Yes, quite often 

1 Not very often 

0 No, not at all 9) I have been so unhappy that I have been crying

3 Yes, most of the time 

2 Yes, quite often 

1 Only occasionally 

0 No, never 10) The thought of harming myself has occurred to me 

3 Yes, quite often 

2 Sometimes 

1 Hardly ever 

0 Never 

EPDS Score Interpretation/ Action

Score of 8 or less: depression not likely, but continue to seek support.

Score of 9 to 11: depression is possible, continue seeking support and re-screen in 2 to 4 weeks. Seriously consider appointment with primary care provider or established mental health professional.

Score of 12 to 13: fairly high possibility 

of depression. Continue to monitor and seek support. Make appointment to see primary care provider or established mental health professional.

Score of 14 and higher: this is a positive screen for probable postpartum depression. Diagnostic assessment is required to determine appropriate treatment. See mental health specialist or primary care provider for referral to same. 

Note: if there is any positive score (a rating of 1, 2, or 3) on question 10 (suicidality risk) definite immediate discussion and possible emergency management is required. Refer to primary care provider, mental health specialist, or emergency resource for further assessment and intervention as appropriate. The urgency of the referral will depend on several factors, including: whether suicidal ideation is accompanied by a plan, whether there has been a history of suicide attempt(s), whether symptoms of a psychotic disorder are present, and/ or if there is concern about harm to the baby.

So that’s all the news on postpartum depression. If you liked this, please share with friends and family. Look for new blogs here every Monday, and check out my book, Tales from the Couch, for more education and patient stories, available on Amazon.com. See my YouTube channel for new lectures- I post them all the time. And I’d appreciate it if you hit that subscribe button, people! Thanks everybody, be well. 

MGA

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Double your Pleasure:the Health Benefits of the Magical Mystical Orgasm

Double your Pleasure: the Health Benefits of the Magical Mystical Orgasm

Once a topic strictly relegated to hushed conversations, research has taken the orgasm from bedroom to clinic, elucidating the many positive benefits of these happy endings. Great news, right? But before I get into that, I want to talk about the definition and history of the orgasm. What you don’t know might surprise you. 

Because it’s hilarious, my favorite clinical description of orgasm is ‘a temporary state of neuromuscular euphoria and paroxysmal climax, often accompanied by vocalization, and generally with the ejaculation of semen in the male and vaginal contractions in the female.’ 

If you’ve ever wondered, the sensation of an orgasm is basically the same for men and women. This is because the penis and clitoris are homologous organs, meaning they arise from the same tissue in a developing embryo. Whichever part you have is connected to the spinal cord, and hence the brain, through a pair of nerves called the pudendal nerves. It’s a horrible name for the same nerves in males and females, so it makes perfect sense that we have the same perfect sensations of pleasure.

From fascination to repulsion and everything in between, orgasm has been the subject of speculation and debate since the Big Bang. Aristotle actually wrote about orgasm and female ejaculation in the first-century BC… and you thought he was just into philosophy! By the way, that’s not a typo: women can ejaculate, though research estimates that only 10% to 50% of women do; actually a small number considering that the woman must reach orgasm in the first place in order to ejaculate. The moral of that story? Don’t let the pornos fool you- it’s a pretty rare event whose presence or absence says nothing of a male’s or female’s sexual prowess. 

In ancient times in Western Europe, women could be medically diagnosed with a disorder called “female hysteria,” during which they exhibited symptoms of nervousness, insomnia, irritability, loss of appetite for food/ sex, and “a tendency to cause trouble.” (this elicited a what-ever! and an eye roll from my wife Debbie) Women diagnosed with the condition would sometimes undergo the proscribed treatment of “pelvic massage” by a medical professional until they experienced “hysterical paroxysm,” which immediately, but not permanently, “cured” them. Captain Obvious says that this diagnosis is no longer recognized as a medical condition. In the early 1900’s, the first electric vibrators hit the market- a decade before vacuum cleaners and electric clothes irons! Evidently, women had gotten their priorities straight. And the rest, as they say, is history. 

Thankfully, we’ve clearly come a long way in narrowing the orgasm perception gap. But questions persist: how long does it last, does a woman need one to get pregnant, can all women have them, can men/ women have multiples, what’s the G-spot, where’s the G-spot, do women fake it and how to tell??? Time for answers.

I’ll just get the less pleasant news out of the way first. 10% to 15% of all women are anorgasmic, meaning they cannot orgasm… at all. It can be global, meaning there is no means by which she can orgasm, or it can be situational, meaning she can only orgasm under certain circumstances. In some cases, age and circumstance are factors in the ability to orgasm for both women and men. (Un)Fun fact: Marilyn Monroe was actually anorgasmic until the age of 36, when she reported to her psychiatrist that she had finally had her first orgasm. A sadly ironic circumstance for America’s biggest sex symbol was that her first orgasm, and possibly last, had been just months before her death. In men, anorgasmia typically manifests in an inability to ejaculate, called anejaculation, and usually occurs as part of erectile dysfunction, which can be organic or a side effect of medication.

Fast facts from peer-reviewed studies:

-75% of women never reach orgasm from intercourse alone. 

-75% of men and 29% of women always reach orgasm with their partner. 

-Women are far more likely to orgasm alone than with a partner. Ouch.

Are orgasms like potato chips? Experts say that if women can have one, they can have more than one. In fact, studies have shown that most women are not only capable of multiples, but they are actually capable of two different types of multiples: sequential and serial multiples. Sequential multiples are a series of orgasms that come fairly close together. Usually from 2 to 10 minutes apart, sequential orgasms have a drop-off in arousal in between; they’re like a roller coaster, with a dip after the first hill before a climb back up the next. According to studies, women report that the most common scenario for sequential multiples is an oral sex orgasm followed by another orgasm during intercourse. In contrast, serial multiples are orgasms that come one after another and are separated by just seconds; with no interruption in arousal, serial orgasms are more like a set of waves breaking on a beach. It’s a different story for men, who have what’s called a refractory period. This is the time needed for a break- and sometimes a nap- between orgasms, but given the right amount of time, male multiples aren’t entirely unusual.

The average length of a man’s orgasm is approximately 10 seconds, though it is possible for them to last up to 30 seconds. A woman’s orgasm may last slightly longer or much longer than a man’s, with an average length of 20 seconds, but possibly up to 30 seconds or more. There is a very rare and misunderstood disorder called Persistent Genital Arousal Disorder (PGAD) found in women. PGAD is spontaneous, persistent, unwanted, and uncontrollable genital arousal in the absence of sexual stimulation or sexual desire, and which is typically not relieved by orgasm. Women with this disorder report feeling constantly and uncomfortably on the brink of orgasm for weeks or months at a time. If you’re thinking that would be cool, you’re wrong; for the sufferer, it is a very debilitating and embarrassing disorder with no cure and little potential for future therapeutic intervention. There is concern that the word ‘arousal’ in the title may be misleading, because it connotes pleasure, and having PGAD is the polar opposite of pleasure. Though vastly more common in women, PGAD is considered an analogous version of priapism, and is called such; this is when men have persistent and often painful erections for various reasons, the most well known being a side effect of the ‘little purple pill’ Viagra.

According to a published study, straight women only have orgasms 62% of the time they have sex, while lesbians orgasm 75% of the time they have sex. I guess there’s something to be said about being familiar with the tools you’re working with.  

G-whiz! There’s much ado about the female G-spot, and most people don’t even have a clue what the G in G-spot stands for. The Gräfenberg Spot was named for German gynecologist Ernst Gräfenberg, who unknowingly started a furor when he characterized an erogenous area of the vagina that, when stimulated, can lead to strong sexual arousal, powerful orgasms, and potential female ejaculation. While some people think the G-spot is as real as a unicorn, most say that every woman has one, but that it’s not necessarily the magical button of fable and lore. So for reals, what is it? The G-spot is a quarter-sized area in the vagina that swells with blood when women are aroused, and some “experts” say it is directly connected to the ‘orgasm center’ in the brain. For the record, I call bullshit on this ‘orgasm center’ stuff- it sounds like it comes from a Cosmo article. Being board certified in psychiatry and neurology, I know a few things about the brain, and there isn’t an ‘orgasm center.’ In reality, orgasms are not localized, discrete events. Researchers have used PET-scans and functional-MRI’s to show that up to 30 major brain systems are activated during orgasm, so it’s more like a wave that washes over the brain in a global manner. There is an analogous male G-spot called the P-spot, where P stands for prostate. This organ is located internally, between the base of the penis and the rectum, and produces pleasant sensations on stimulation.  

Though an orgasm isn’t strictly necessary to feel pleasure, most people will admit that reaching the big “O” with a partner or ‘Han Solo’ is a great added bonus. But beyond just feeling great, an orgasm also brings with it a host of unexpected health benefits, from lowering stress levels and heart attack risk to giving skin a fabulous natural glow. Read on to learn all the good stuff that comes from the fun stuff.

Several hormones are released during orgasm in both males and females, including oxytocin and DHEA. Studies suggest that these hormones could have protective qualities against cancers and heart disease. Oxytocin and other endorphins released during male and female orgasm have also been found to work as relaxants, in both a physical sense and psychological sense, as a mood elevator. Oxytocin is the bonding and cuddling chemical, aka the ‘tend and befriend’ chemical, and makes both sexes feel a desire to be closer to their partner during and after sex. Women actually release four times the normal amount of oxytocin on orgasm. In fact, evidence shows that the bonding and cuddling mechanism is so reliable and predictable that if a woman doesn’t feel cuddly after sex, it is strongly suggestive that she faked her orgasm. Whoa, people.

Orgasms can help lower the risk of prostate cancer in older men. Ward off prostate cancer by having sex? True story! A decade-long and well-reviewed study demonstrated that regular and frequent ejaculation (defined as at least four times per week) in men over age 50 can lower the risk for prostate cancer by up to 30%. One of the authors of the study said, “We know that having sex and orgasms is beneficial for every aspect of male health. The male reproductive system fares best with regular use, and the prostate belongs to that system. The more ejaculations, the better off he’ll be.” Hey, no argument here. 

Orgasms can help regulate the female menstrual cycle, even during times when women are not actively on their periods. According to a published and peer-reviewed scientific journal, the mechanism is linked to the apparent circadian rhythm of ovaries and their response to inflammation. Regular orgasms in females lower inflammation, improving immune health, mental health, and circadian health, which fosters regular cycles.

Orgasms can also help boost female fertility.

Regular sexual activity triggers physiological changes in the body that increase a woman’s chances of getting pregnant, even outside the window of ovulation, meaning that orgasms bring benefits at any and all points in the fertility cycle.

An associated concept is that female orgasm appears to improve the odds of conception. Now, I’ve been surprised and frightened by the prevailing ignorance on this topic, so let me be clear here: a female orgasm is not required for a woman to get pregnant; all that is required is the male’s sperm (part of the ejaculate) to meet the female’s egg(s), which is/ are released automatically and independently each month during ovulation. The basic premise of orgasm improving the odds of conception centers on the vaginal and cervical contractions during orgasm. It is believed that the ligaments involved in the muscular pulsations and contractions from the female orgasm cause the cervix to dip down and pull in any semen pooled in the vagina. That brings in more sperm, and more sperm means it’s more likely for one or more of those wiley guys to win the race to any unsuspecting egg that may be hanging out up there. This is all borne out by findings in women who have had intercourse with orgasm having more sperm in their cervical mucus than women who have had intercourse without orgasm. The moral of this story is that orgasmic pulsations are some next-level shit, and those baby-making parts have minds of their own, grabbing around in the dark to continue the genetic line. Science, people! 

Orgasms as the next homeopathic treatment for colds and flu? Consider going to the bedroom instead of the drugstore. Orgasms are killer for your immune system, no pun intended. A small German study found that immediately after sexual arousal and masturbation to climax, men showed increased levels of leukocytes, which are the white blood cells that help protect the body from illness and infectious disease. But the ladies haven’t been left out here. Another study demonstrated a correlation between female sexual activity, and therefore female orgasm, and levels of Helper T cells, which help to activate the cells the body needs to fight off foreign invaders that cause disease and illness. In addition, orgasm in both males and females releases those feel-good hormones called endorphins, and these are known to reduce general inflammation, the arch enemy of the immune system and other biological pathways. Reduction of inflammation, wherever it may be, does a body good. 

In both men and women, orgasm is shown to help alleviate pain and increase one’s threshold for pain. This is also due to the release of those feel-good endorphins and their ability to reduce inflammation. Studies have shown a direct link between sexual activity and migraines, with 60% of participants reporting some improvement of their migraine attack, and 70% reporting moderate to complete relief. It is believed that orgasm impacts perceived pain through the down-regulation of pain sensitization pathways and by modulating the immune system to reduce levels of inflammation, thus reducing pain levels. Orgasm as an anti-inflammatory once again… O-lieve?

Evidently, orgasm is also useful for relieving the pain of menstrual cramps. In addition to the reduction of inflammation for general pain relief, the pleasurable muscular pulsations and contractions of the female orgasm also use up specific lipid compounds called prostaglandins, which are the cause of menstrual cramps. Lower concentrations of free prostaglandins translates to less cramping-type muscle pain, which is a very good thing.   

Orgasms can help keep your brain sharp. The flood of hormones released in both male and female orgasm sends a ton of messages throughout the body, increasing brain activity. This is particularly true in women. An imaging study of brain function and orgasm showed that while masturbating and upon orgasm, women’s brains light up with activity in the cortical, subcortical, and brainstem regions. The researchers stated that these benefits are more powerful than doing challenging crossword puzzles. Hmmm… Sunday New York Times puzzle, roll in the hay; New York Times, roll in the hay… Frustration, satiation… Duh- this one’s what you call a no-brainer. At least, that’s the technical term.

Orgasm reduces levels of stress and anxiety in males and females. Though an orgasm initially releases a flood of stress hormones, studies have shown that the end-game effect is stress reduction. Experts have long agreed that the post-coital payoff in terms of anxiety reduction is also major, as during an orgasm, the parts of the brain that process fear shut down. All of this is thanks to our friend oxytocin, the bonding, snuggling, tend and befriend chemical.  

What makes for a happy heart can also make for a healthy heart. Since any sort of physical activity helps your heart pump more efficiently, it’s no surprise that sex can too. But published studies indicate that regular sexual activity seriously benefits heart health, helping to lower cardiovascular risk in older men and women. More specifically, they demonstrated that frequent sex and orgasms reduced instances of cardiovascular disease, hypertension, and rapid heart rate among those over age 65, especially in comparison to those that don’t have frequent sex and orgasms. This study didn’t define “frequent,” so take away from that what you will. Or what you can get away with.

Orgasm as the mystical fountain of youth? That radiant flushed look is post-coital glow; it’s for reals, and all thanks to the increased blood flow from your orgasm. The skin is the body’s largest organ, and also the biggest tell. If you’re under stress, it shows by way of a sallow, stressed out complexion. But when men and women climax, blood vessels throughout the body open up, allowing them to carry greater quantities of blood, which is the source of the flushed and blushed look. The increased blood flow also helps to stimulate the production of collagen, a protein that keeps skin looking plumped and youthful, which is why orgasms may be the quickest- and cheapest- way to gorgeous skin. Some British shrink did a survey of 3,500 people, including both men and women, and determined that regular orgasms were the second most common factor/ cause for people looking younger, the first being regular exercise. Nobody called me, so I don’t know who appointed this guy the chief judge of orgasm and youngness, but it is what it is. 

Orgasms can help boost your self-esteem and well-being. When your desires are being satiated, it makes sense that you would feel better about yourself, but it turns out that there’s a proven and demonstrable link between sexual health and self-esteem. So say researchers at Johns Hopkins (well…la tee da) as they found that sexual pleasure among young adults (ages 18-26, both male and female) is linked to healthy psychological and social development. They specifically looked at measures of self-esteem, autonomy, and empathy, and found that sexual pleasure increased all three of these measures in both males and females. However, they also found that the level of increase was not uniform: measures of self-esteem increased the most in young women particularly, while young men showed higher levels of empathy. The explanatory hypotheses for these findings are similar: that the effect of a female’s orgasm on self-esteem is circular, so the ability to easily achieve orgasm increases a woman’s self-esteem, which, in turn, better facilitates her achieving orgasm, which again feeds her self-esteem, and so on. In an analogous way, empathetic males are more responsive to their partner’s needs, and this initiates a positive feedback cycle: being more responsive to their partner’s needs increases the male partner’s ability to reach orgasm, which feeds the male’s empathetic nature and makes them more responsive to their partner’s needs, and so on… Now, I can’t say that I’m calling bullshit on this, but it seems to me that this is back-asswards: while I totally buy that orgasm in both men and women would lead to increases in all three measures, I would think that levels of self-esteem would be more increased in men, resulting from a sort of evolutionary caveman pride ‘look what I can do’ kind of thing. And I would think that greater empathy levels would be higher in women, because of the super intensive release of oxytocin that results in the huggy cuddly ‘oh how I love this person’ feelings. Then again, maybe it’s that women have a higher increase in self-esteem because their orgasm assures them that they are sexually attractive, and men have a higher increase in empathy because their partner has had a simultaneous orgasm? I’m not sure, and you probably don’t care, so we’ll just step away from this one for now.

Orgasms can help you live longer, so say some experts. Additionally, the health benefits of orgasm increase with age, and extend throughout a person’s life. Some Brits studied men between the ages of 45 and 59, and found that those with “high orgasmic frequency” lowered their mortality risk by as much as 50%. The men that had two or more orgasms a week died at a rate that was half the rate of the men who had orgasms less than once a month; in other (less confusing) words, the men that had fewer than one orgasm per month died twice as fast as the men that had eight or more orgasms per month. Like wow, people! These findings prove that sexual activity and orgasm have a protective effect on men’s health. As for the ladies: over the course of an eight-decade study on married, heterosexual couples, researchers found a demonstrable link between orgasms, health, and longevity: specifically, results indicated that women who orgasmed frequently lived longer than their female counterparts who didn’t, though they did not disclose a longevity estimation or definitive ratio of the number of orgasms required to attain greater longevity. 

Orgasms aren’t exactly a miraculous method for weight loss, but getting there might be a different story. Sex is an aerobic activity; it gets your heart rate up, and there’s no better way to burn calories than when your heart is pumping. Beats a treadmill, stairclimber, or pilates any day of the week. Researchers have attempted to measure the number of calories burned during sex for many years and on numerous occasions, but the results have varied wildly. Accepted averages indicate that most people burn about 150 to 200 calories each time they have sex, but there are some really fun ways to set that number on fi’ya… a heated make-out session can burn as many as 85 calories per hour in a 150-pound person, while 15 minutes of heavy foreplay will burn about 25 calories. So, figure you make-out for 15 minutes, then another 15 minutes of foreplay, followed by intercourse, will burn about 250 calories- that’s the same number burned in a 30-minute run, but it’s way more fun than a run. If that’s not enough burn for you, add in a sensual and arousing massage at a burn rate of 80 calories per hour. Or, employ the magic of multiples: reaching a second orgasm can burn an additional 60 to 100 calories, depending on the amount of work required to get there; and since it’s a bonus score, why stop after just one? The ultimate formula for burning more calories during sex is fairly simple: just pour on more heat and more passion for a longer period of time. 

You have probably always known that orgasms are awesome, but now you know the why and how of everything orgasmic, and are all set to impress and amaze your friends with your dazzling sexual intellect at the next cocktail party.

And even though I wrote this blog on the benefits of orgasm, I don’t want to contribute to society’s historical relationship with sex and orgasm: typically seen as goal-based, a skill to be practiced and reward to be achieved, rather than something to explore, experience and enjoy. So go forth, explore, experience, enjoy, orgasm, and spread the word, people! 

But first, google ‘Dr. Mark Agresti YouTube’ to check out my videos, leave comments, like, and subscribe to my YouTube channel. As always, you can find tons of content and patient stories in my book, Tales from the Couch, available in office or on Amazon. Thanks people.

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steroids:Seductive Today,Sinister Tomorrow

Steroids: Seductive Today, Sinister Tomorrow

An Appointment and Cautionary Tale

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

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

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

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

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

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

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

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

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

Dx: steroid addiction, assoc features jot jot jot jot

Pt agrees to d/c use jot jot jot

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

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

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

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

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

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

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

Hopefully not Rocky jot jot jot

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Sociopath or A-hole How To Tell The Difference

Sociopath or A-hole?

How to Tell the Difference

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

-Repeatedly lie or con others for profit or pleasure

-Fail to plan ahead or exhibit impulsive behavior

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

-Reckless disregard for the safety of themselves or others

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

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

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

Symptom: Lack of empathy

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

Symptom: Difficult relationships

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

Symptom: Manipulativeness

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

Symptom: Deceitfulness

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

Symptom: Callousness

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

Symptom: Hostility

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

Symptom: Irresponsibility

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

Symptom: Impulsivity

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

Symptom: Risky behavior

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

Can sociopathy be cured or treated?

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

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

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

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

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

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

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

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

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

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

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Psychopaths and sociopaths Tomato Tomato or Tomato Potato

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

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

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

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

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

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

Lack of empathy toward others

Constant deceitful or manipulative behavior

Little regard for the safety of others

Difficulty with all relationship types

Aggression or irritability

Criminal history

Lack of remorse or guilt for actions

Reckless and/or dangerous behavior

Laws/ Rules don’t apply to them

Regularly breaks or flouts the law

Impulsive and doesn’t plan ahead

Prone to fighting and aggression

Irresponsible, can’t meet financial obligations

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

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

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

Traits of a Psychopath

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

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

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

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

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

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

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

Traits of a Sociopath

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

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

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

Who is More Dangerous?

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

Psychopath v Sociopath: Childhood Clues

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

Conduct Disorders:

Four categories of problem behavior

Aggression to people and animals

Destruction of property

Deceitfulness or theft

Serious violations of rules or laws

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

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

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Pedophilia:Predators in Your Back Yard

*Sensitive Content*

*Reader Discretion/ Age Advisory*

Pedophilia: Predators in Your Back Yard

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Traits of Pedophiles or Sexual Predators

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

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

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

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

-Often single and/ or with few friends 

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

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

Behaviors of Pedophiles or Sexual Predators

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

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

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

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

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

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

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

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

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

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

Other Noteworthy Characteristics

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

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

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

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

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

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

How to Protect your Child(ren)

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

Dru Sjodin National Sex Offender Website

https://www.nsopw.gov/

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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The 15 Scariest Mental Disorders of All Time

The 15 Scariest Mental Disorders of All Time

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

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

‘Alice in Wonderland’ Syndrome

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

Alien Hand Syndrome

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

Apotemnophilia

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

Boanthropy

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

Capgras Delusion

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

Clinical Lycanthropy

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

Cotard Delusion

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

Diogenes Syndrome

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

Dissociative Identity Disorder

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

Factitious Disorder

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

Kluver-Bucy Syndrome

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

Obsessive Compulsive Disorder

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

Paris Syndrome

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

Reduplicative Amnesia

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

Stendahl Syndrome

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

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

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

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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

​

​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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