N-acetyl Cysteine…New Miracle for Bipolar

N-acetyl Cysteine… New Miracle for Bipolar?

Hello, people… hope everyone is well! In last week’s blog, I introduced you to N-acetyl cysteine, or NAC, an amino acid supplement that’s garnering some serious attention in shrinky circles, as it has shown major potential to help treat multiple psych conditions. Recall from last week that NAC is most renowned for its ability to replenish levels of the body’s strongest antioxidant, glutathione, while it also regulates the very important neurotransmitter, glutamate, acta as an anti-inflammatory, and assists the body’s detoxification system.

The rationale for administering NAC for psych conditions is based on those roles: being a precursor of glutathione, as well as its action as a modulating agent of glutamatergic, dopaminergic, neurotropic, and inflammatory pathways. Those are the mechanics of NAC, the how and why it’s beneficial for brain function: NAC helps to produce glutathione, which, being the chief free radical scavenger, takes up all those nasties, reducing cellular damage. NAC also acts as an anti-inflammatory, so it decreases the blood levels of molecules that cause inflammation in the body and brain, such as interleukin-6, which incidentally may play a role in the pathogenesis of schizophrenia, bipolar disorder, and depressed mood. A third mechanism of action that has been proposed for NAC involves the stimulation, increased synthesis, and release of the neurotransmitters glutamate and dopamine. Let’s talk about those two for a moment.

As the most abundant neurotransmitter in the brain and CNS, glutamate plays an important role during brain development, as well as helping with learning and memory. Glutamate is an excitatory neurotransmitter. What is that? Excitatory neurotransmitters have excitatory effects on the neuron, meaning that they increase the likelihood that the neuron will fire a signal- called an action potential- in the receiving neuron. Because neurotransmitters can increase action potential, you can then probably imagine why neurotransmitter levels are very important. At high concentrations, glutamate can overexcitenerve cells and cause more neuronal firing. Prolonged excitation is toxic to nerve cells, and causes damage over time. So having excess glutamate, as an excitatory neurotransmitter, causes more neuronal firing, and you can actually damage cells this way. In fact, you can excite cells to death… a process referred to as “excitotoxicity.” Having too much glutamate in the brain has been associated with neurological diseases such as Parkinson’s disease, multiple sclerosis, Alzheimer’s disease, stroke, and ALS, amyotrophic lateral sclerosis or Lou Gehrig’s disease. Problems in making or using glutamate have also been linked to a number of mental health disorders, including autism, schizophrenia, depression, and obsessive-compulsive disorder, OCD. Glutamate is also a metabolic precursor for another neurotransmitter called GABA, gamma-aminobutyric acid. GABA is the main inhibitory neurotransmitter in the central nervous system- the flip-side of the coin- which decreases the likelihood that the neuron it acts upon will fire. That’s why glutamate is so important, it’s the dominant neurotransmitter used for neural circuit communication, and it’s estimated that well over half of all synapses in the brain release glutamate. 

Dopamine is the “feel good” neurotransmitter that’s strongly associated with pleasure and reward. It’s a contributing factor in motor function, mood, and decision making, and is also associated with some movement and psychiatric disorders. Dopamine is released when your brain is expecting a reward; when you come to associate a certain activity with pleasure, just the anticipation alone can be enough to raise dopamine levels. It could be a specific food, sex, shopping, or just about anything else that you enjoy. If your go-to comfort food is homemade chocolate chip cookies, your brain may increase dopamine levels when you smell them baking or see them come out of the oven. Then when you eat them, the flood of dopamine you receive acts to reinforce the craving, causing you to focus on satisfying it in the future. Dopamine is all about the cycle of motivation, reward, and reinforcement. Now imagine that you’ve been jonesing for those cookies all day, but your co-workers scarfed them all down while you were sidetracked by a conference call. Your disappointment might well lower your dopamine levels and dampen your mood. It might also intensify your desire for chocolate chip cookies, making you want them even more. Dopamine plays the main role in all of that, but keep in mind that dopamine doesn’t act alone. It works with other neurotransmitters and hormones, things like serotonin and adrenaline. Aside from its “feel good” function, dopamine is involved in many body functions, including blood flow, digestion, memory and focus, mood and emotions, motor control, pain processing, sleep, stress response, heart and kidney function, pancreatic function, and insulin regulation. Once again, as with all neurotransmitters, levels are important… theright amount of dopamine generally equates to a good mood. Ultimately, dopamine contributes to feelings of alertness, focus, motivation, and happiness, and a flood of dopamine can produce temporary feelings of total euphoria.

Those mechanisms I mentioned- glutathione reducing cellular damage, anti-inflammatory action, and the stimulation, increased synthesis, and release of the neurotransmitters glutamate and dopamine- are the proposed how NAC works, but why does NAC help people with varying psych diagnoses? Why might it work across so many conditions? This is the most intriguing thing to me. First and foremost, it seems to target biological pathways that are common across many mental disorders. For example, we know that patients with bipolar disorder have significantly higher levels of oxidative stress, and higher glutamate concentrations in their brains, especially during acute mania. It’s been suggested that people with schizophrenia may have the same, and that this may predispose them to changes in neuronal cell membranes and mitochondrial function that later manifest as symptoms of schizophrenia. It appears that NAC supplementation, by increasing CNS glutamate levels and reducing overall oxidative stress, may reduce the severity of these psychotic symptoms. 

A meta-analysis and systematic review of placebo-controlled studies on NAC as a stand-alone treatment of depressed mood in people diagnosed with major depressive disorder, bipolar disorder, and other psychiatric disorders, found evidence for “moderately improved” depressed mood and improved global functioning. In a four-month, double-blind study, individuals treated with NAC plus their usual antidepressant improved more than individuals taking a placebo with their antidepressant medication. 

In a large, six-month, double-blind study, individuals with schizophrenia who had failed to respond to multiple trials on antipsychotics were treated with 1,000 mg NAC twice daily versus a placebo, while also taking their usual antipsychotic medication. Those taking NAC experienced moderate improvements in symptoms of apathy and social withdrawal, the so-called “negative” symptoms of schizophrenia, as well as improvements in day-to-day functioning, and fewer of the abnormal involuntary movements that are commonly caused by some antipsychotic meds. 

NAC has also been investigated as a treatment for substance use disorders, with promising results. The findings of small, placebo-controlled studies suggest that NAC helped heavy Cannabis users to reduce their use, and that it may reduce the intensity of withdrawal and cravings in people in early stages of cocaine recovery. As in mood disorders, the beneficial effects of the NAC may be related to its role in restoring neurotransmitter activity that has been affected by chronic substance abuse. 

In addition to its mood-enhancing benefits, there is evidence that NAC may reduce trichotillomania (compulsive hair pulling) and other impulse control disorders, like nail-biting, skin picking, and pathological gambling. There was one eight-week, open-label study on pathological gamblers, and over 80 percent of them responded to NAC. They were then subsequently enrolled in a six-week, placebo-controlled trial, and continued to report “significant reductions” in gambling.

As for potential treatment targets, a systematic review of all of the evidence suggests that NAC may be effective at treating major depressive disorder, bipolar disorder, drug addiction, obsessive-compulsive disorder, impulse control disorders, autism, schizophrenia, Alzheimer’s disease, and even certain forms of epilepsy, specifically progressive myoclonic seizures. NAC has also been shown to potentially reduce the severity of mild traumatic brain injury in soldiers, and animal studies show that it can improve cognition after moderate traumatic brain injury. Other disorders such as anxiety and ADHD have some interesting preliminary evidence, but require larger studies.

The jury’s still out as to the mechanism, whether NAC’s benefits are the result of glutathione reducing cellular damage, the anti-inflammatory action, or the actions on glutamate and dopamine. Even though we don’t know exactly why yet, on a clinical level, NAC seems to help with ruminations, the difficult to control, extreme negative self-thoughts. These thoughts are very common in depression and anxiety disorders, and also in eating disorders, schizophrenia, and OCD. NAC seems to help some patients when other modalities, even meds and psychotherapy, haven’t helped much. It doesn’t always work, but when it does, irrational thoughts seem to gradually decrease in intensity and frequency. Negative thoughts, like “I’m a bad person,” “Nobody likes me,” or ruminations about other people or other issues that can’t seem to be quieted by reasonable evidence to the contrary- those really pesky negative thoughts that keep intruding on someone’s awareness, hour after hour, day after day, despite all efforts to control them- seem to decrease with NAC. If they do continue to occur, they’re less distressing, and can be observed from more of a distance, and are less likely to trigger depression or other negative effects.

Overall, NAC seems pretty special. Its ability to successfully cross the blood-brain-barrier to increase CNS glutathione levels, while reducing glutamate and overall oxidative stress, in addition to its anti-inflammatory properties- all conditions linked to depression and other mental health disorders- makes it an interesting treatment candidate for many psych conditions. If you take NAC, you’re basically giving your body an efficient way to soak up excess glutamate, an excitatory neurotransmitter that’s not good in excess concentrations. You’re also reducing oxidative stress and inflammation by giving it glutathione. As a result, this seems to help alleviate a number of different mental health conditions: depressed mood, schizophrenia, impulse control disorders, and substance use disorders. Studies indicate that people benefit from taking anywhere between 250 mg to 500 mg daily. Lower doses are better because high doses of NAC can sometimes redistribute heavy metals into the brain… this is not a good thing, so you obviously want to avoid that. You can take NAC with leucine, another amino acid, as taking leucine with it prevents mercury from being reabsorbed into the central nervous system. As always, please bear in mind that large placebo-controlled studies are needed to confirm the beneficial effects of NAC in mental health care, and to determine safe, optimal dosages for standalone or adjunctive treatment. But if you think it might be helpful, talk to your physician to determine if NAC is a good supplement choice for you. 

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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N-ACETYL CYSTEINE

N-Acetyl Cysteine

Hello, people! Last week, we finished up our discussion on the darker side of OCD and talked about the most difficult subtype to deal with, the pure hell of pure obsession OCD, aka Pure O. As promised, we’re back this week with a new topic, N-acetyl Cysteine, or NAC. NAC is an amino acid used by the body to build antioxidants. Antioxidants are vitamins, minerals, and other nutrients that protect and repair the body’s cells from damage, usually referred to as oxidative stress. Historically, NAC has been used mainly in emergency rooms to treat people who overdose on acetaminophen… I’ve ordered it innumerable times for this very purpose. These days, it can be purchased as a supplement OTC, and new studies have begun investigating its effectiveness as both a stand-alone and adjunctive treatment for depressed mood associated with depression, bipolar disorder, schizophrenia, OCD, and trichotillomania, as well as abuse and dependence on nicotine, Cannabis, and cocaine. And it has shown some promising results. 

Before we get to that, let’s talk about some things NAC does in the body. 

1. NAC is essential for making the body’s most powerful antioxidant, glutathione. Along with two other amino acids- glutamine and glycine- NAC is needed to make and replenish glutathione, which helps neutralize free radicals that can cause oxidative stress- damage to cells and tissues in your body. It’s essential for immune health and for fighting cellular damage, and some researchers believe it may even contribute to longevity. Its antioxidant properties are also important for combatting numerous other ailments caused by oxidative stress, such as heart disease, infertility, and some psychiatric conditions. More on those later.

2. NAC helps detoxify the body to prevent or diminish kidney and liver damage, helping to prevent deleterious side effects of drugs and environmental toxins. This is why doctors regularly give intravenous NAC to people with acetaminophen overdose. It’s usually organ failure that gets you in acetaminophen overdose, and NAC helps to prevent or reduce damage to the kidneys and liver, increasing the chances of survival. NAC also has applications for other liver diseases due to its antioxidant and anti-inflammatory benefits.

3. NAC helps regulate levels of glutamate, the most important neurotransmitter in your brain, and this may improve some psych disorders and addictive behavior. While glutamate is required for normal brain function, excess glutamate paired with glutathione depletion can cause brain damage. This state- excess glutamate with glutathione depletion- is commonly seen in certain psych disorders; specifically, it’s thought to contribute to bipolar disorder, schizophrenia, obsessive-compulsive disorder, and addictive behavior.

For people with bipolar disease and depression, NAC may help decrease symptoms and improve overall ability to function, and research suggests that it may also play a role in treating moderate to severe OCD. In addition, an animal study implied that NAC may minimize the so-called negative effects of schizophrenia, such as social withdrawal, apathy, and reduced attention span. NAC supplements can also help decrease withdrawal symptoms and prevent relapse in cocaine addicts, and preliminary studies show that NAC may decrease marijuana and nicotine use and cravings. Many of these disorders currently have limited or ineffective treatment options, so NAC may be an effective option for individuals with these conditions. More on this in a moment.

4. NAC can help relieve symptoms of respiratory conditions by acting as an antioxidant and expectorant, loosening mucus in the air passageways. As an antioxidant, NAC helps replenish glutathione levels in your lungs, and reduces inflammation in the bronchial tubes and lung tissue. People with chronic obstructive pulmonary disease (COPD) experience long-term oxidative damage and inflammation of lung tissue, which causes airways to constrict, leading to shortness of breath and coughing. NAC supplements have been used to improve these COPD symptoms, leading to fewer exacerbations and less overall lung decline. In a one-year study, 600 mg of NAC twice a day significantly improved lung function and symptoms in people with stable COPD. But those with chronic bronchitis can also benefit from NAC. Bronchitis is the term for when the mucous membranes in your lungs’ bronchial passageways become inflamed, restricting airflow to the lungs. Not much fun. By thinning the mucus in the bronchial tubes, while also boosting glutathione levels, NAC may help decrease the severity and frequency of wheezing and coughing in respiratory attacks. In addition to relieving COPD and bronchitis, NAC may improve other lung and respiratory tract conditions like cystic fibrosis, asthma, and pulmonary fibrosis, as well as symptoms of garden variety nasal and sinus congestion due to allergies or infections. Ultimately, NAC’s antioxidant and expectorant capacity can improve lung function in everyone by decreasing inflammation and breaking up and clearing out mucus.

5. NAC boosts brain health by regulating glutamate and replenishing glutathione. The neurotransmitter glutamate is involved in a broad range of learning, behavior, and memory actions, while the antioxidant glutathione helps reduce oxidative damage to brain cells associated with aging. Glutamate levels are subject to the three bears law: you need some, but too much isn’t good, as it’s an excitatory neurotransmitter. Because NAC helps regulate glutamate levels and replenish glutathione, it may benefit those with brain and memory ailments. The neurological disorder Alzheimer’s disease slows down a person’s learning and memory capacity, and animal studies suggest that NAC may slow the loss of cognitive ability in people with it. Another brain condition, Parkinson’s disease, is characterized by the deterioration of cells that generate the neurotransmitter dopamine. Oxidative damage to cells, and a decrease in antioxidant ability, contribute to this disease, and NAC supplements appear to improve dopamine function as well as disease symptoms, such as tremor.

6. NAC may improve fertility in both men and women. Approximately 15% of all couples trying to conceive are affected by infertility, and in nearly half of these cases, male infertility is the main contributing factor. Many male infertility issues increase when antioxidant levels are insufficient to combat free radical formation in the male reproductive system, leading to oxidative stress and cell death, culminating in reduced fertility. In some cases, NAC has been shown to combat this, improving male fertility. One condition that contributes to male infertility is varicocele. This is when veins inside the scrotum become enlarged due to free radical damage; surgery is currently the primary treatment. In one study, 35 men with varicocele were given 600 mg of NAC per day for three months post-surgery. The combination of surgery and NAC supplement improved semen integrity and partner pregnancy rate by 22% as compared to the control group with surgery alone. Another study in 468 men with infertility found that supplementing with 600 mg of NAC and 200 mcg of selenium for 26 weeks improved semen quality. Researchers suggested that this combined NAC/ selenium supplement should be considered as a treatment option for male infertility. In addition, NAC may improve fertility in women with polycystic ovary syndrome (PCOS) by inducing or augmenting the ovulation cycle which is altered by the condition. 

7. NAC may stabilize blood sugar by decreasing inflammation in fat cells. High blood sugar and obesity contribute to inflammation in fat tissue. This can lead to damage or destruction of insulin receptors, which puts you at a much higher risk of type 2 diabetes. When insulin receptors are intact and healthy, they properly remove sugar from your blood, keeping levels within normal limits. When the insulin receptors are damaged, blood sugar levels are more difficult to control. Animal studies show that NAC may stabilize blood sugar by decreasing inflammation in fat cells, keeping receptors happy, and thereby improving insulin resistance. That said, human research on NAC is needed to confirm these effects on blood sugar control.

8. NAC may reduce heart disease risk by preventing oxidative damage. Oxidative damage is caused by free radicals, and this type of damage to heart tissue often leads to heart disease, causing strokes, heart attacks, and other serious cardiovascular conditions.

NAC may reduce heart disease risk by reducing oxidative damage to tissues in the heart. It has also been shown to increase nitric oxide production, which helps veins dilate, improving blood flow. This expedites circulation and blood transit back to your heart, and this can lower the risk of heart attack. Interestingly, a test-tube study showed that when combined with green tea, another well recognized antioxidant, NAC appears to reduce damage from oxidized “bad” LDL cholesterol, another bigtime contributor to heart disease.

9. NAC and its ability to boost glutathione levels appears to increase immune function, boosting immune health. Research on certain diseases associated with NAC and glutathione deficiency suggests that immune function might be improved, and potentially even restored, by supplementing with NAC. 

This has been studied mostly in people with human immunodeficiency virus (HIV). In two studies, supplementing with NAC resulted in a significant increase in immune function, with an almost complete restoration of natural killer cells, the main patrol cells. High levels of NAC in the body may also suppress HIV-1 reproduction. A test-tube study indicated that in other immune-compromised situations, such as the flu, NAC may hamper the virus’s ability to replicate; this could potentially reduce the symptoms and lifespan of the associated viral illness. Other test-tube studies have similarly linked NAC to cancer cell death and blocked cancer cell replication. Great news, but more human studies are needed. 

This is a short blog, but that’s a good place to stop for this week. Next week, we’ll talk about how NAC may alleviate the symptoms of multiple psychiatric disorders, as well as reduce addictive behavior; and we’ll talk about some preliminary study findings as well. 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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Dark Side of OCD (Part 4)

The Dark Side of OCD

Hello, people~ welcome back to the blog! The last few installments, we’ve been talking about some of the more unusual subtypes or presentations of OCD. Last week, I told you about POCD, pedophilia OCD. This is a devastating harm based subtype that causes people to worry that they might be attracted to children, and could potentially act on that attraction. To reiterate, these are not predators that actually want to harm or molest children. They are simply- or not so simply- obsessed with the idea that they could. Somewhere along the line, that becomes locked in their brain due to the OCD, and they worry about it incessantly. As a result, they avoid all contact with children, and this can have a huge impact on family dynamics. It causes a great deal of shame and guilt for the person who has it, as they fear being judged by others, while always judging themselves very harshly. And it can also be very damaging to the children in that person’s life, since they miss out on the time and affection that person would have otherwise devoted to them. As you can imagine, all of these things often lead to a great deal of anxiety and depression, and many times, people with POCD suffer through it alone. This week, we’ll be continuing the series with a look at perfectionism. 

Perfectionism is a pretty self-explanatory subtype, the obsession with appearing and being “perfect.” Perfectionism is kind of an unusual trait. It isn’t unique to OCD; not all perfectionists have OCD, and not all people with OCD are obsessed with being perfect. But perfectionism underlies many OCD subtypes, as it can contribute to the need to do a ritual perfectly, or have things arranged just right. But when it’s extreme, perfectionism can really be thought of as its own OCD subtype; when it’s rooted in obsession(s), followed by compulsion(s), and causes dysfunction in the person’s life, it falls into a class of its own. 

Perfectionism can look very different from person to person, but there are some common overarching themes. Perfectionists feel the need to follow rules very rigidly. I’m sure you’ve heard the addage “Anything worth doing is worth doing right.” Some versions end with “well,” but this isn’t strictly true for perfectionists, it must be right. Things must be done in a certain way- perfectly- or not at all. This is tough to live up to at best, and the pressure to achieve this standard can become so great, that at times it’s far easier to give up on doing something altogether. In addition, perfectionists generally need to feel that they are in control of a situation at all times. By definition, they are excessively concerned with making mistakes, especially when other people could potentially see those mistakes. Ultimately, they think that these errors have some bearing on their overall value as a person, that they define them. They also tend to have an overwhelming need to please others. As a result, relationships with authority figures- people like bosses and parents- can be fraught with anxiety. Perfectionists also have trouble with prioritizing. They can’t make a list of five things they want to accomplish, and then decide which to give 100 percent effort to, 80 percent, and 50 percent. That doesn’t work for them, it’s very all or nothing. Every time they came across a task, whether it’s a strength of theirs or a weakness, whether they have expertise in it or not, they always feel like they must perform it at a high level.

There’s nothing wrong with doing things well, or with being very diligent and detail oriented. These are great qualities, and they work well for people, when they’re functional qualities. But when it gets in the way of getting things done- when it becomes dysfunctional- it’s a problem. I had a patient that was a student, a freshman in college, and he loved school. He was all about it, very intelligent, studied a lot, and worked so hard on papers and projects. Too hard as it turns out. He would begin a lab write up or a paper, but would edit as he wrote. He would then write more, then edit that; then he’d try to stitch them together and get frustrated. Ultimately, he’d have to start all over again. It just went on and on in this way, and it took him forever to do a very simple write up. Something that took his peers maybe a couple of hours tops would take him days of work, because it was nearly impossible for him to write it start to finish, then edit start to finish, a reasonable number of times. There was never an end point- he always felt it needed to be better- and was compelled to improve on it, so sometimes he simply couldn’t finish things. His brain just didn’t want to let him. 

Many years ago, I worked with young children in a hospital setting, with a wide array of diagnoses. One young girl, about nine years old, would undoubtedly have a diagnosis of perfectionism. I remember her very well, but her parents made an especially unique impression. When I gave them my assessment, it was quite clear that her being a perfectionist wasn’t a problem for them- this was written all over their faces. The mother especially, she had a little smile, almost of satisfaction or even pride. It was like I was telling them it was a good thing, or maybe too much of a good thing, like having too much money. She was a great student, very precocious, and a great kid, very meticulous. But if she did something imperfectly, if it didn’t meet her standards- which I suspect she may have learned from her mom, or her mom had a hand in planting- it was a problem. She would begin something with such enthusiasm, which was so great to see given her anxiety; but once she realized the task wasn’t going to be up to par, she would just give up and shut down. It was like watching a bright beautiful flower wilt and wither right in front of you. A sad thing at nine years of age.

This is basically a form of avoidance, which is a common compulsion for perfectionists. Better to totally blow something off than to not do it perfectly. Another example of this is something my student patient would do. If he was late for class, he couldn’t bring himself to go in. If he could see from the window that the professor had already started lecturing, and the students were all sitting there, facing front and listening, he would imagine how it would feel to open the door, and have all those heads turn to look at him. He couldn’t take that, everyone seeing his screw up, so he just wouldn’t go, he’d skip class. Then the next class, he was so concerned about showing his face after missing the previous one, it had a tendency to snowball. Even though he was smart and worked very hard, between his lack of participation in class and his issues in completing tasks, he ended up receiving poor grades, or even failing classes, with shocking regularity. 

Perfectionism is difficult for those with it to gain insight about, because it’s so engrained within their personality. They like to be focused, discerning, fastidious, and detail oriented. Sometimes it works well for them, but when it works against them, it takes much longer to realize it. All of this makes it hard to treat. Despite the suffering it causes, many times, patients initially resist the idea of abandoning their ways completely. And I get that. Some elements of perfectionism backfire, but there are parts that are beneficial, that help people reach their goals. You don’t want to necessarily eradicate it from their lives altogether, throw the baby out with the bathwater. I understand the hesitation. Somewhere in the dysfunction is function. In my student patient’s case, there were times he got A’s on papers. It took him 40 hours instead of two, but the end result was good, no argument there. So how do you find the happy medium, how do you eliminate the dys- from the functional in treatment? We want people to work hard, to be attentive, accurate, and competent. In treating it, and designing exposures, we don’t want to make a person act stupidly or underperform- proofing and editing is good if you don’t want to send out a paper to your professor, or letter to your boss, filled with typos. That would be nearly impossible to get them to do anyway, even if it was designed as an exposure to treat them. We don’t want to weed out the good parts, or necessarily challenge the outcome or the goal, but we need to challenge how they’re getting there. In the case of my student patient, the exposure would be to write without editing, start to finish, one draft, even if there were mistakes. Other ideas would be to show assignments to other people before they’re turned in, as well as to put max time limits on how long a project can take. Practice doing things well, instead of perfectly, to help them see that they can in fact deal with imperfection. That’s the true reality anyway- nothing is ever perfect. If you want perfection, to the point that you reject anything less than that, you’re going to end up rejecting things you shouldn’t, and missing out on a lot in the bargain.  

That makes me think of a book about OCD by Judith Rapoport called The Boy Who Couldn’t Stop Washing. It’s about a law school student with contamination obsessions that agonized over cleaning his apartment. He obsessed about how long the cleaning would take, and especially about how quickly it would get dirty again. He eventually started to avoid going home, so that its cleanliness would be maintained; it wouldn’t be disturbed by the messiness of his living in it. This escalated to the point that he wound up sleeping on a park bench, willingly homeless, all to avoid his apartment. This might seem radically counterintuitive. How could a person with contamination obsessions- who’s afraid of germs- stand to sleep outside, in a park, with all the dirt that goes with it, all for the sake of cleanliness? This is the dark side of OCD when you have perfectionism. 

I was thinking about positive perfectionism, and out of curiosity, read about the top career choices for perfectionists. Clearly, positive perfectionism can give a person a set of traits that can help them excel in life, especially in certain careers. Accuracy, attention to detail, persistence, conscientiousness, and organization lend themselves well to roles where design, math, and very complex procedures are essential to their tasks. Mechanics, inspectors, accountants, surveyors, tailors, and engineers would be top choices. Artists and creative types seem to suffer the most from perfectionism. Claude Monet, the highly celebrated French Impressionist, was a perfectionist… the perfectionist impressionist! I read that he was set for an exhibition in May of 1908, featuring his newest works, the result of three years of work. But when he took his final look, he decided the paintings weren’t good enough. Amid great protests, he took a knife and a paint brush to the paintings- worth $100,000 at the time- defacing them irrevocably. Today, they would be priceless. His actions prompted all sorts of ethics discussions; should an artist have the right to destroy his own work? Evidently at least one expert thought so, and actually praised him for being a true “arteest” and told the New York Times, “It is a pity, perhaps, that some other painters do not do the same.” A similar, but more tragic story is told in a book from 1886 called L’œuvre, translated as The Masterpiece. It tells the story of another artist who becomes obsessed with creating a large canvas that he worked on incessantly, but it never satisfies him. He kept painting on more and more layers, to the point that the canvas was destroyed. Then he would start over, again and again. He became so distraught and depressed that eventually, he went insane.

So how do you tell the difference between healthy and unhealthy perfectionism? The difference is when you move from a detail oriented, conscientious place, to a rigid and controlling one. When the ideas of perfection prevent you from doing anything at all, a healthy sense of perfectionism has been taken over by a dysfunctional one; putting you in a place where mistakes are catastrophic, where they say something about you, where you have to live up to other people’s expectations. This induces such anxiety that it becomes crippling, because eventually everything needs to be perfect- even things that other people would never even notice start needing to be perfect. Once again, the pressure from that becomes so intense, it’s easier to just forget it, to give in altogether. But in my view, the only way to truly fail at something is to not try at all. If you fail at something, it’s not because you’re not perfect, but because you didn’t try. Most perfectionists don’t subscribe to this; they seem to mostly have a fear of being average. They want to succeed perfectly, but if they’re going to fail, they’re going to do so spectacularly. A healthier point of view is to accept that nothing is ever perfect… but it won’t be anything if you don’t do it in the first place.

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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OBSESSIVE COMPULSIVE DISORDER (Darker Subtypes)

Hello, people! Welcome back to the blog, where we’re continuing our discussion of some darker OCD subtypes. Last week we talked about emotional contamination OCD, which is when people become obsessed with the idea that they may become “infected” by the thoughts or beliefs of another person. This can happen any number of ways; through air, electronic media, by touch, by talking about them, or even by being in the presence of someone who’s been in their presence. It’s difficult to deal with- trying to avoid this influence can become so consuming that it completely alters the course of a person’s life. This week, we’re going to talk about a particularly devastating subtype called pedophilia OCD, which features an obsession with the idea that you might be attracted to children, and could potentially act on that attraction. 

Before we get started, I want to make a very important distinction. People with pedophilia OCD or POCD are not people you need to hide your children from. They are not predators, and have no actual desire to molest children. They have an unusual form of OCD where an idea basically gets trapped in their brain, and because of the OCD, it gets twisted in such a way that they worry they may act on it. Maybe they see a news segment that gives details on a molestation case, or they read an article, or participate in a discussion; that may be all it takes. The idea of harming a child is as horrifying to them as it is to you and to me, but unfortunately, the OCD allows the possibility to take root. They wonder if their worry about pedophilia means they have desire. They fear they could act, and they obsess about the fear. It can be very debilitating. I’ve had patients that were so afraid of what they “could” do that they were often unable to get out of bed in the morning. They think these thoughts must mean something… why would they have them otherwise? It can be a real mind screw. 

Pedophilia OCD is an example of harm based OCD, and there may be many variations on that general theme. It may be a fear that they may hurt or kill strangers, or even parents or siblings. For any person with harm based OCD, the biggest fear is that they are dangerous. The object of harm can remain the same for years, or may change for no obvious reason. A patient I consulted on, a 20-something named Heidi, obsessed about harming her boyfriend. She would find herself worrying she might push him down the stairs, stab him with the carrot peeler, or run him over with her car. She worried about it for three years before she admitted it to anyone… three years! Can you imagine? Once she initiated therapy for that, the focus shifted to a pedophilia based fear; she worried she might molest her baby nephew. It was her first time as an aunt, and she loved the little guy. She didn’t want to hurt him, it was just her OCD talking to her, filling her head with nonsense. She constantly wondered ‘Am I attracted to this; do I want to molest him? Why did I have this thought? This must mean something about me…. this must be who I am.’

It was a nightmare for her. She couldn’t trust herself to be alone with her new nephew, and yet was understandably afraid to tell her sister she was having these thoughts. She wasn’t able to sleep at night, worried she would do something to him while everyone was sleeping. Eventually, she confessed what she was thinking to her mother. With her support, she was then able to talk to her sister, and then her whole family, who all supported her. Sadly, not all do; but she was able to turn to them to seek reassurance. This is a fairly common compulsion for people with stereotypical OCD- they compulsively need another person to tell them what they’re obsessing about isn’t true. Heidi would call her sister or mom and tell them when she was having these scary thoughts, and they would reassure her that she was a good person, she wasn’t going to molest him. It helped take the edge off, but only for about ten seconds. Then it was back to worrying. Remember that OCD is a disorder of doubt. Even after she was diagnosed with OCD, at the back of her mind, Heidi was even unsure if her thoughts came from that, or if it was truly something darker. 

Sometimes pedophilia OCD thoughts first center on a parent. People with it may wonder if perhaps they’re attracted to a parent, and/ or if they were molested as children, if something was done to them to cause the thoughts. That’s never happened in any of the cases I’ve been involved in, it’s simply the obsessive mind looking for reason. These thoughts torment people with pedophilia OCD, and many say that they thought they were going crazy before they were diagnosed with OCD. If their fears revolve around molesting children, they will do all they can to avoid them, and not even talk about them. When they can’t avoid the topic, their anxiety and uncertainty is multiplied. They will desperately review every movement they made around a child to help them figure out whether their actions were inappropriate, and they’ll constantly seek reassurance from loved ones, provided they’re aware of it. If not, they suffer alone. They know they would never hurt a child, but they can’t trust themselves, so they really need to hear it from someone else. Self-compassion is often non-existent, self-loathing is more the rule. They believe they should be able to control their thoughts. Since they can’t, they constantly judge themselves, and that often leads to depression. 

As you can imagine, it’s hard for them to seek treatment, because they’re afraid of being judged. They live in fear that family and friends will find out the “true” nature of their thoughts, and they’ll be ostracized, labeled as a pedophile, as disgusting or evil. People with POCD feel extreme shame and guilt for their thoughts. Most people don’t understand that pedophilia OCD is not the same as pedophilia. Imagine this: you see a kid and you’re like, ‘Awww, so cute!’ If you have POCD, your next thought is something like, ‘Oh, my god. Does that mean I’m a pedophile?’ Clearly, babies are cute, everyone knows that, nothing wrong with it. But the POCD tries to spin it, so if you have it, it makes you worry that you’re a deviant. 

Last week, I talked about exposure therapy for OCD, and POCD is treated the same way- it requires putting the person face to face with the ideas and “temptations” of pedophilia. Just reassuring them that they’re not a pedophile doesn’t work; they don’t believe it. Instead, people with POCD have to become comfortable with the uncertainty, with the risk that their very worst fears are true. Then they have to figure out how to live their lives despite that risk. POCD exposures might include going to a park where children are playing, or to a children’s store, maybe handling clothing. They could watch that pageant show with the nutty parents- might as well try to get a laugh while working on it. At some point, exposures might re-introduce behaviors the person has been avoiding- like having someone who has been avoiding changing a diaper or giving a bath start doing so again- even if it makes them anxious and fearful. As scary as it can be for them, not doing these things can be much more damaging to the children in that person’s life, since people with POCD often avoid giving affection, spending time, or caring for children because of their fears. Ideally, as exposures continue, the person begins to understand that what they’re afraid of isn’t true. The goal is for them to learn that they can trust themselves to do these things without molesting a child or hurting them in any way. As hard as it may be to get there, every patient I’ve worked with has been willing to do whatever it took to reach that realization. It may not make 100% of the obsessive thoughts stop, but it gives them the ability to call bs on them and keep it moving. 

Speaking of, that’s it for this week. Next week, another OCD subtype, perfectionism. 

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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Dark Side of OCD

Dark Side of OCD

Hello, people! Thanks for checking out the blog. Last week, I introduced a new series on unusual OCD subtypes, the darker side of OCD, with compulsions that go beyond the stereotypical examples most people think of. While doubt is still the core issue, people with these obsessions aren’t arranging their colored pencils, checking the light switches, or washing their hands until they’re red and raw. These obsessive thoughts often center more on function- am I swallowing correctly? Can I still blink? Those are examples of the first subtype we covered last week, hyperawareness OCD, also called sensorimotor or somatic OCD. This is an obsession with a part of the body, or with an involuntary bodily function. Breathing, blinking, and swallowing are the top three obsessions, but it can involve the location of a mole or freckle, placement of hands, or even how the skin feels, if it’s itchy, for example. This week, I’m going to cover another subtype, called emotional contamination OCD.

Contamination OCD generally revolves around the classic “feeling germy” or disease obsession. I have patients with this that may take 8 to 10 showers a day, sometimes more if they’re really “in it.” Others have to wear cotton gloves because they’ve washed their hands so much the skin has deep, angry cracks that bleed, yet they still worry they aren’t clean. But with emotional contamination OCD, the obsessive thoughts center on “catching” more abstract things from others, like ideas, values, and traits, as if they are infectious. They constantly ask themselves, what if being near this person causes me to lose my values and assimilate theirs… what if I start believing in what they believe in, instead of what I believe in? It’s a scary thought, right? Imagine having to worry that if you sit next to someone on a train to work, when you arrive, you might not think like you any longer, you might be infected with their thoughts. Will you even still know how to do your job? Yikes! What if you meet someone who’s immoral or a criminal? If you stand near them, touch them inadvertently, or sit in a chair they once sat in, those immoral thoughts may transfer to you, like a virus. You might start stealing things, or cheating on your wife. People with emotional contamination doubt the authenticity and stability of their thoughts. If a thought pops into their heads, it’s ‘did I think that? Or did I catch it from that person?’ And once the thought of contamination begins, it’s so hard to stop. 

The obsessive trigger may be a person, a geographical location, or an object, and by touching it, sitting near it, or even going to a place associated with it, people with emotional contamination OCD think they’ll somehow become contaminated with its essence. I had a patient we’ll call John. Great guy- a kid, really- who developed terrible emotional contamination. He was in college on a scholarship, and lived with a roommate, a guy named Mike, who was pretty successful academically as well. They were both business majors, so it sounded like a great setup. Well, as it turns out, Mike was successful because he was entitled and ruthless, and always took advantage of people that offered to help him. This didn’t sit well with John at all, he was a sensitive kind of guy, and he began to worry that he would start to think and act like Mike. He didn’t know why, but he found himself thinking about it constantly, obsessing about it. He was terrified that if he kept living with Mike, or even came into contact with him, that he’d become a ruthless user too. So he started avoiding him, and any friends who interacted with him. He stopped going to the coffee shop where he studied, the bars he frequented, and the restaurants where he ate. He even switched his major so that he and Mike wouldn’t have any crossover. If someone in one of his classes had taken a course in the business building- where Mike took classes- John would have to drop out of that class. Not only that, but he felt so contaminated that he had to throw away the books and study materials, and even the clothes he was wearing when he saw that person. Like many people with emotional contamination OCD, John felt that the traits could also spread through the air, through an association with other people, and even through the internet, so that anything and everything could really become contaminated at any time. 

Before long, John had to give up his scholarship and drop out of school. He continued to get rid of his belongings repeatedly- books, computer, clothes- it had to go if it had any prior affiliation with Mike. He had to move into a room above his parent’s garage, he couldn’t go into the main house because Mike’s name had been mentioned there. But Mike had never been discussed in that room, so that was a “Mike free” zone. When he tried to take classes online, he found that even the internet was contaminated by Mike, because his social media profiles were also on the web. When he reached the point where he was getting ready to move into another apartment in a town fifteen miles from his parents, and he was about to buy his fifth computer, he finally decided to get help, and came to see me. 

People with emotional contamination OCD feel compelled to avoid the person or idea that’s contaminating them, and that quickly becomes a gargantuan task. Not only does it spread through air, people, objects, and the internet, it can spread through language, so even hearing a word or phrase that sounds like the obsession can trigger the fear and feelings of danger. People end up avoiding television, newspapers, radio, the internet, computers- a constantly expanding circle of people, places, and things- completely isolating themselves to avoid any risk of a potential reminder of their obsession. Eventually, that circle can make it nearly impossible to function. 

Imagine you develop emotional contamination around Hershey, Pennsylvania. Very quickly, it wouldn’t be enough to just avoid that town; you wouldn’t be able to go to any towns surrounding it, either. Then you wouldn’t be able to eat Hershey’s chocolate bars, because they share the same name. Then, you’d have to avoid parts of the grocery store, because you’d see the chocolate bars. Then you realize, much to your horror, that Hershey’s makes other food products too, and you need to avoid them. Then you’re stuck in the grocery store for hours, reading labels to make sure you don’t have any contact with Hershey’s products. You can see how it swiftly becomes a big problem. And who knows when and where else you might randomly be triggered. Maybe you go to grandma’s and she asks you to get her favorite hot cocoa from the cabinet, and you discover it comes in a tin that says… you guessed it. You don’t think about the connections between things in life, until they cause you anxiety. When you have emotional contamination, you’re constantly thinking about exactly that, because you have to avoid certain things. But it’s difficult to completely avoid being triggered, even when you’re trying to.

Emotional contamination is rooted in what’s called magical thinking, a psychological concept that your thoughts, imagination, or beliefs will lead to something actually happening in the real world. The phenomenon is present in many subtypes of OCD, but is especially prevalent in emotional contamination. Sometimes people’s thinking can become so “magical” that emotional contamination OCD can even be misdiagnosed as psychosis if a therapist hasn’t dealt with it before. It can be difficult to get a handle on because it’s so nebulous, but the good news is that, like all types of OCD compulsions, emotional contamination can be treated using ERP therapy- exposure and response prevention therapy- which is considered the gold standard for OCD treatment. 

If you’ve ever tried to not think about something, you know how hard it is to control your thoughts. If I tell you don’t think about that dumb purple dinosaur Barney, and definitely don’t sing his silly song in your head. What are you doing right now? Are you singing “I love you, you love me, we’re a happy family…” Exactly. So ERP therapy takes the opposite approach; instead of trying to make yourself stop your obsessive thoughts, you welcome them, and deal with them. The concept behind it is that repeated exposure to the obsessive thoughts, and thus the discomfort that comes with them, affords you the best chance to avoid the compulsion and alleviate that discomfort. When you continually submit to the urge to do compulsions, it only strengthens the need to engage in them. But on the flip side, when you prevent yourself from engaging in your compulsions, you teach yourself a new way to deal with them, and that generally leads to a reduction in anxiety. 

Because doubt and uncertainty are at the core of the obsessions, ERP gives you a chance to live with it, to experience it and get through it another way. During ERP therapy, you discuss and track your obsessions and compulsions, and develop a list of alternative ways to face your fears. A therapist then designs exposures, which slowly put you into situations that bring on your obsessions, and cause anxiety or discomfort. You respond, eventually, hopefully in a way that is not compulsory, and this reduces or eliminates the anxiety. In other words, you regain some control, so you prevent yourself from performing whatever compulsion you normally do, be it a physical or mental compulsion, and that eliminates the anxiety or discomfort. Get it? Exposure and response prevention. It can take time, but with continued exposures, you build toward reaching whatever goal you’ve set. ERP therapy can make a huge difference in an OCD patient’s life, and it has a decent success rate, about 80 percent. 

That’s a good place to stop for this week. Next week, another OCD subtype, one you won’t want to miss. 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 officeand on Amazon. 

Thank you and be well people!

MGA

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OCD SUBTYPES PART 1

The Darker Side of OCD

Hello, people! Last week we finished up our discussion on the importance of vitamin D, so I hope everyone spent a few minutes in the sun over the weekend to get a dose… gotta have it! This week, we’re starting another series on OCD, Obsessive Compulsive Disorder. What’s the first thing that comes to mind when you hear about OCD? It’s probably neatness, everything in its exact place, like making sure all the edges of the silverware are perfectly aligned in the drawer. Or maybe it’s repetitive hand washing, counting steps, or checking the locks on all the doors in the house. While those stereotypical obsessions are definitely common symptoms, in reality, OCD can involve any persistent, intrusive, obsessive thought that causes anxiety; it’s then generally paired with a behavior that attempts to quell that anxiety. But the scope of it can reach much further than worry over germs or counting and checking, as it is limited only by the person’s mind. Some obsessions are much darker, incorporating a person’s deepest darkest fears and worries. How about obsessing about killing your mother? All of your thoughts center on how you’d go about it, how it would feel. While these types of obsessions may be less common, they can clearly be much harder to talk about, and for that reason, can remain undiagnosed for years, even if a person seeks help. In the best case scenario, it can take an average of 14 to 17 years for people to find treatment, even though OCD usually emerges in childhood.

Think about having an obsession centering on a bodily function, let’s say swallowing. How many times do you swallow in a day, whether eating or drinking or not… ever noticed? Probably not, unless that happens to be an obsessive thought for you. Do you ever worry about the ability to swallow when you need to… do you doubt it? Can you imagine how debilitating something like that could be? And most people have more than one obsession that draws their focus. I did have a patient with OCD who thought he was Jesus, so all of his obsessions centered on that. He dressed like Jesus, wore his hair and beard like Jesus, and acted like Jesus- or how I imagine Jesus would act- with this “peace, brother” persona that he never dropped. He was court ordered, but totally harmless. The total effect was, well… honestly, kinda eerie. That could’ve been me- for some reason, it gave me flashbacks to confirmation classes as a kid. Anyhoo, he was so sure of his true identity that he would only date women named Mary. Yep. Sometimes in OCD, all of the obsessions are present in the mind at once, competing for attention, while at other times, one will take center stage, while the others wait in the wings. Depending on the year, the day, or even the minute, OCD can look completely different, even within one individual.

At its core, OCD is a disorder of doubt. A person can’t be sure that their thoughts aren’t indicative of something that may happen in real life. They can’t be sure of their safety, their intentions, their motives, or even their true realities. And yet, most people with OCD are completely, and usually painfully, aware that what they’re thinking isn’t true. For example, a person with a contamination obsession knows deep down that they don’t need to wash their hands for the 100th time, but they cannot get past the possibility that there could be germs lingering there. They’re haunted by the reality that there could be. Are those germs dangerous… could they make them sick, even kill them? That doubt is what they obsess over. So they continue to wash. When people find out what I do, at cocktail parties and the like, they’ll sometimes ask me, what’s the weirdest/ worst/ scariest symptom or diagnosis you see? Well, when it comes to OCD, there’s really no hierarchy to suffering- one obsession isn’t necessarily inherently worse than another- the worst obsession is the one that’s right now. Still, some forms of OCD are more challenging to deal with, diagnose, and treat. To start with, the content of some obsessions are so taboo that people simply won’t divulge it, so they suffer without finding the help they need. Sometimes they don’t even know that they have OCD, that that’s what’s driving these obsessive thoughts. So this week we’ll be talking about the darker side of OCD, examining some lesser known types you may have never heard of. 

Before we start, a note on these subtypes. Although all forms of OCD have symptoms in common, the way these symptoms present themselves in daily life differs a lot from person to person. Usually, OCD fixates around one or more themes, and some of the most common themes are contamination, harm, checking, and perfection. The content of a person’s obsessions isn’t ultimately the important part, though it’s certainly what feels important in the moment. Someone’s subtype is really just their manifestation of symptoms- the particular way their OCD affects them. What does the mind focus on, and what thoughts and actions result from this focus? Psych geeks like me call a condition like OCD “heterogeneous” because it varies so much from one person to the next, but there are a few common “clusters” of symptoms. There’s a lot of discussion about these symptom clusters, and even more debate about whether or not they should be classified as more specific categories or subtypes. But there are clear groups of obsessions and compulsions that pop up regularly in people with OCD. Many clinicians try not to talk about subtypes because there isn’t any real research backing them. They’re not perfect categories or neat little boxes you’re supposed to fit into, so if you have OCD, it’s not worth spending too much time trying to figure out which subtype you fit into if it’s not immediately apparent. That said, for lots of folks with OCD, the immediate recognition of their own experience in a list of subtypes is a powerful thing, and may actually be the start of the treatment process. 

So ultimately, I’ve chosen to go with calling these subtypes, but you can call them forms of OCD, or whatever you want, really. The point is that the symptoms seem to fall into groups naturally, and the info just needs to be out there so there’s more awareness of what lots of folks with OCD struggle with on a daily basis. Imagine that you’ve thought of yourself as truly- and totally uniquely- messed up for a long time. No way anyone has ever had the thoughts you have, or so you think. All of a sudden, you’re crusing the interwebs and see a list of symptoms that match yours exactly. Recognizing yourself in this OCD subtype, you’re not alone anymore- there are enough people like you out there to have your own type. Maybe you don’t have to feel hopeless anymore, because other people have clearly faced similar struggles, with similar types of obsessions and compulsions. There’s no realization that comes close to that kind of hope. Listing subtypes may be an imperfect way of categorizing OCD, because people may mistakenly think of them as distinct conditions rather than common manifestations of the same diagnosis, but I think it’s the way it should be. All of that said, keep in mind that there are hundreds of different ways OCD can show up in someone’s life- people don’t fit in boxes, they can have more than one subtype, and while the subtypes are relatively stable over time, they can change- new symptoms can appear and old ones might fade. Not a lot of rules when it comes to the brain’s capacity for imagination and change. So now, finally, we’ll begin discussing some unusual OCD subtypes, just to illustrate the mosaic of experiences associated with the diagnosis, and to illuminate some of what goes on in the OCD mind. 

Hyperawareness OCD

Hyperawareness OCD is an obsession with a part of the body, or with an involuntary bodily function. The patient I mentioned earlier, with the swallowing obsession, had hyperawareness OCD. It’s also called sensorimotor or somatic OCD. At any given moment, your brain, through your entire CNS, is sending and receiving signals about what different parts of your body are doing- like where your hands are, what your heart rate is, or if your stomach is empty or full. These are done subconsciously, so most people don’t pay attention to them. Everyone blinks and swallows, but very rarely do you give it any consideration. With sensorimotor OCD, a function like this can become an obsession. A person can get stuck in this place where they become hyperaware of some part of their body, or of the signal controlling it in their brain. I had a patient obsessed with blinking. Every morning, her first thought upon waking was to check to make sure she was still blinking, or still able to blink. And the thought persisted throughout the day… am I blinking now? It was consuming her life, not only was it the first thing she thought about, but also the last. She even kept herself awake with it, because she would close her eyes to sleep and would have to open them and make sure she could still blink. 

When anyone starts to think about things like involuntary processes- even for people without OCD- they can become heightened. If thinking about “it” makes it happen, and if “it” happening makes you think about it… well, you can see how easily this could lead to an obsession in the mind. To make matters worse, a lot of the anxiety in OCD lies in the person’s fear that they’ll never stop thinking about the blinking or swallowing, or whatever the obsession may be. And of course, the more they monitor it, the more they try to control it, the less automatic it feels, the more controlled it feels, and the more it seems like they’re never going to stop thinking about it. It’s a never ending cycle, and it produces a lot of other obsessions like, what if this drives me crazy, what if I never stop, if I’m permanently distracted by it? And in fact, my blinking patient also had a tendency for projection, so she imagined obsessing over blinking for the rest. of. her. life… ife… ife… ife…. I should point out that I make light of it, because one of the ways to combat an obsession is, oddly enough, to examine it in detail, so that includes looking at the futility of obsessing over an automatic bodily process that you cannot control… forever. It sounds counterintuitive, but dealing with it that way is a form of mindfulness- for those of you who read my blog on that many moons ago- examining whatever the thought may be, and the body part it involves, in an effort to soothe and assure. It can’t control it, but it can help lead to acceptance of the thought, which can take away its power. 

While sensorimotor OCD is relatively rare, in addition to blinking, the top three obsessions also include swallowing and breathing; but it can focus on the function of literally any part of the body. It can even involve non-functional parts, like the location of a mole or freckle, or hyperawareness of normal occurrences like itching or heart rate. As you can imagine, it can be very debilitating and isolating. My swallowing patient had a very hard time eating in front of anyone- these obsessions tend to be very self-propagating- and she was too anxious over being anxious about her swallowing. And it’s very difficult to talk about these symptoms, even with a therapist or a shrink, so unfortunately, people really suffer. It’s easier to just keep it simple and tell people that you have OCD and let them think you spend all your time straightening silverware or washing your hands, rather than risk being judged for the other manifestations. It’s a tough situation- while I understand it may be easier, it’s not necessarily better in the end. Some clinicians don’t understand sensorimotor OCD, or recognize that people with it have compulsions. Compulsions are the actions or rituals the person is basically “required” to complete in order to make the obsession, and therefore the resulting anxiety, stop. For instance, in contamination OCD, the obsession is germ exposure, and the compulsion is the continual hand washing. But in sensorimotor OCD, the compulsions are there, but they’re just not obvious. It’s more about the mental rituals taking place in sensorimotor, like reviewing or checking to see how that bodily sensation feels, or maybe trying to actively replace the obsessive thought with another thought. 

Given the lack of understanding, one of the biggest barriers to treatment is the isolation that the patients feel. Meds are helpful, and there are specially licensed therapists for treating serious OCD. Regardless of the subtype, treatment essentially the same. The gold standard of treatment is exposure and response prevention therapy, or ERP, which is sort of a combined approach. I’ll talk more about that later, but as with anything else, acceptance is key. If you’re a person that thinks about blinking, then you’re a person that thinks about blinking. Hopefully treatment stops that, but if it doesn’t, are you going to let it run your life? Once there’s acceptance, that then becomes the question, as opposed to being concerned about it. That’s where mindfulness comes in. If you pay attention to your blinking, then that’s one thing, but if you’re worried about it, that’s kind of pointless. You’ve proven you’re doing it right, and that your blink isn’t broken, about 18 times in the last minute alone. Did you know that that’s the average number of times a person blinks in one minute, 18? Sounds like a lot. Anyway, there’s a difference between watching your behavior in a mindful way, and not trying to change it, versus actively thinking about it and trying to figure out if you’re doing it the “right” way. Personal acceptance of anything means being less judgmental about the internal experience of it. Admittedly, it’s a lot easier said than done. There shouldn’t be any trivializing how upsetting it would be to think about blinking, or swallowing, or where a mole is. These things may seem banal to you, but they may be the center around which another person’s life revolves. When you think about accepting anything, but especially OCD, maybe just ask yourself, what would my patient Jesus do?  

Next week… more OCD subtypes! I hope you enjoyed this blog and found it to be interesting, and of course, 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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Thyroid 2

Welcome back, people! Last week I introduced a new topic- the thyroid- and hopefully you remember that it’s a butterfly shaped endocrine gland that wraps around the windpipe in the forward aspect of the middle throat. It plays a major role in regulating the body’s metabolism, growth, and development by production and release of thyroid hormones, called T3 and T4, into the bloodstream. When it doesn’t work properly, it can have a huge impact on multiple systems throughout the entire body. We also talked about how all of the functions of the endocrine glands are interlinked, and that the thyroid works especially closely with the pituitary gland located in the brain. In order to make the right amount of T3 and T4, the thyroid gland needs the help of the pituitary, to “tell” it- through its own hormone called thyroid stimulating hormone, TSH- when to produce and release more or less hormones into the bloodstream. And we left off with an introduction on the two basic states that result from thyroid disease or dysfunction: hyperthyroidism, when you make too much thyroid hormone, and hypothyroidism, when you make too little. 

This week, we’ll get deeper into thyroid disease and talk about the various symptoms of thyroid imbalance. But I should remind that the endocrine system and the thyroid are very dynamic and can change temporarily in response to normal natural processes other than disease. If and when the body needs more energy in certain situations- if it’s during a growth spurt, time in a very cold environment, or during pregnancy for example- the thyroid gland may temporarily produce more hormones. That increase in T3 and T4 increases the basal metabolic rate, so all of the cells in the body work harder. That causes a faster pulse and stronger heartbeat, a rise in body temperature, and activation of the nervous system and then other systems needed to accomplish whatever the situation may call for. Because the cells are working harder, they need more energy, so energy stored in the liver and body is broken down and utilized faster, and food is used up more quickly as well. When the situation has ended- say the growth phase is over, or mom has the baby- the demand is lessened, the thyroid will produce less T3 and T4, the basal metabolic rate will slow, and energy requirements will reduce to previous levels.  Ultimately, the thyroid and entire endocrine system will return to their previous functional levels, ready to respond next time. 

Thyroid Disease by the Numbers

Thyroid disorders are very common, and very commonly run in families, and affect more than 12 percent of Americans, or an estimated 20 million people. They can occur in anyone- men, women, teens, children, or infants- at any time, meaning they can be present at birth or may develop later. Hypothyroidism is much more common than hyperthyroidism, though the latter is easier to diagnose. About one in 20 people has some kind of thyroid disorder, which may be temporary or permanent, and up to 60 percent of people with thyroid disease are unaware of their condition. While they can occur in anyone, thyroid disease affects 5 to 8 times more women than men, so one woman in 8 will develop some type of thyroid disease at some point in her life. 

When the thyroid is properly balanced, it produces and replaces just the right amount of hormones to keep your metabolism working at the proper rate. When the thyroid makes too much hormone, as in hyperthyroidism, that’s sometimes also called overactive thyroid. And the flip-side of this, when your thyroid makes too little hormone, in hypothyroidism, that’s sometimes called underactive thyroid. These conditions can be standalone or caused by other diseases and conditions that impact the way the thyroid gland works, including genetic and inherited disease.

Hyperthyroidism Causes and Conditions

There are several conditions that can cause overactive thyroid, or hyperthyroidism. The most common cause is an inherited autoimmune disorder that affects 1% of the general population, called Graves’ disease. This causes immune cells attack the thyroid gland, which responds by enlarging and secreting excess thyroid hormone. Immune cells may also go on to attack the muscles and connective tissue of the eyes, causing them to bulge, a state known as exophthalmos, and this eye condition is usually then referred to as thyroid eye disease or Graves’ eye disease. 

Thyroid nodules, which are small, round, usually benign masses present within the thyroid gland tissue, can also cause thyroid overactivity. There may be a single autonomously functioning nodule or a condition called toxic multinodular goiter, where there are multiple nodules within the thyroid which produce too much hormone. As the nodules increase in size and/ or number, it can cause a large, externally obvious swelling called a goiter in the neck. 

Having excess iodine in your body can also stimulate the thyroid to make more hormone than it needs, since iodine is the mineral used to make T3 and T4. Excessive iodine can be found in some cough syrups and other medications like amiodarone, a heart medication. 

An inflammatory process of the thyroid called thyroiditis may also cause hyperthyroidism. The person may or may not be aware of it, as it can be painful or not felt at all. In early stages of some types of thyroiditis, the thyroid may release or leak hormones that were stored there, and this hyperthyroid state can last for a few weeks or months. If it continues, the inflammation will eventually impair the production of thyroid hormone, and this will result in hypothyroidism.

Hypothyroidism Causes and Conditions

Some of the conditions associated with underactive thyroid, or hypothyroidism, include other types of thyroiditis, where the swelling of the thyroid gland impairs hormone production. Hashimoto’s thyroiditis is the most common cause of hypothyroidism. This is an inherited autoimmune disorder whereby the body’s own immune cells attack the thyroid, causing inflammation and damage to the tissue that inhibits or halts production of hormone. 

Postpartum thyroiditis is a usually temporary condition that occurs in 5% to 9% of women after childbirth, whereby the thyroid is temporarily inflamed and underactive as a result. 

An iodine deficiency is a common cause of underactive thyroid, or hypothyroidism, outside of the US. When the body is deficient in iodine, it simply doesn’t have enough to produce a sufficient amount of T3 and T4 hormone. Even today, iodine deficiency affects several million people around the world. 

Sometimes, the thyroid gland simply doesn’t work correctly from birth, and for obvious reasons, this can have severe implications. This condition affects about 1 in 4,000 newborns. If left untreated, the child can have both physical and mental issues in the future. Because of the potential consequences, all newborns are given a screening blood test in the hospital to check their thyroid function.

Thyroid Disease Risk Factors

The causes of thyroid dysfunction are largely unknown, but there are several factors that can place you at a higher risk of developing a thyroid disease. The first and most obvious is if you have a family history of thyroid disease, as it is commonly familial. Also, if you have had treatment for a past thyroid condition, such as a partial thyroidectomy, or cancer treatment such as radiation, you are more likely to have thyroid issues later. If you are Caucasian or Asian your risk is slightly higher. If you have prematurely graying hair, your risk for developing thyroid disease is higher. In addition, if you have certain other medical conditions like Down Syndrome, Turner syndrome, and bipolar disorder, it increases your risk. If you have autoimmune or related disorders, you are at especially increased risk: lupus, rheumatoid arthritis, pernicious anemia, celiac disease, type 1 diabetes, primary adrenal insufficiency, Sjögren’s syndrome, Addison’s disease, or vitiligo. If you take a medication that’s high in iodine, such as amiodarone, this excess iodine increases the risk for developing hyperthyroidism. And if you are over 60 years old, your risk increases. This is especially true in women, as their risk is already so much greater than men. 

Thyroid Disease Symptoms 

Because there are such a variety of symptoms associated with thyroid disease, many can be very similar to the signs and symptoms of other medical conditions, as well as general stages of life changes. This can make it difficult to know if your symptoms are related to a thyroid issue or something else entirely. 

Symptoms of Hyperthyroidism

Because the thyroid is overactive, it speeds cellular activity and generally causes the body processes to move faster. This causes the body to use energy too quickly, so people with hyperthyroidism usually have increased appetite, and may feel weak unless they consume more food to keep up with energy demands; and even if they do, they may still lose weight unintentionally. In addition, it may cause them to have trouble sleeping and sleep disturbances, confounding the fatigue they feel. Hyperthyroidism also tends to cause increased heart rate, stronger heart beat, tremors, heat sensitivity, itching, and increased sweating. It often results in feelings of anxiety, irritability, and nervousness, and causes racing thoughts, and difficulty focusing on one task. It may cause an enlarged thyroid gland to the point of goiter, where it is visible externally, as well as problems with vision or eye irritation, including protruding or bulging eyes called exophthalmos. Women with hyperthyroidism will typically have light and irregular menstrual periods. And rarely, men with hyperthyroidism can see some breast development. Be aware that if someone experiences symptoms like irregular heart rate, dizziness, shortness of breath, and/ or loss of consciousness, that requires immediate medical attention. Hyperthyroidism can cause atrial fibrillation, which is a dangerous arrhythmia that can lead to strokes as well as congestive heart failure. This is an extreme medical emergency. 

Symptoms of Hypothyroidism

When the thyroid is underactive, body processes move more slowly, and this causes people to feel extremely tired and fatigued. Because cellular processes move more slowly, less energy is required, so less stored energy is utilized. Because the metabolism is sluggish, less food is required and more is stored, so having hypothyroidism makes someone much more likely to gain weight. Mentally, people commonly experience depression, mental slowness, and forgetfulness. Physically, they commonly experience constipation, puffy face, muscle cramps, dry skin, brittle nails, dry and coarse hair, hair loss, hoarse voice, and intolerance to cold temperatures. They may experience fatigue and shortness of breath with exercise. They are likely to have joint pain, stiffness, and swelling, and even carpal tunnel syndrome. Women with hypothyroidism are likely to have frequent and heavy menstrual periods.

Kids and teens with hypothyroidism can have all of the signs above, but may also have delays in sexual maturity or puberty, growth delays and shorter stature, slow mental development, and slower development of permanent teeth. 

Infants and babies with hypothyroidism may have no symptoms at all. But if symptoms do present, they can include cold hands and feet, constipation, extreme sleepiness, weak or hoarse cry, little or no growth, poor feeding habits, puffy face, stomach bloating, swollen tongue, and umbilical hernia. In addition, you may notice low muscle tone, sometimes called floppy baby, as well as persistent jaundice, which is yellowing of the skin and whites of the eyes. These symptoms require immediate medical attention. 

I think we’ll pick up there next week, with complications and prognosis.

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!

Please feel free to share the love! Share blogs and YouTube videos 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, and share those vids too! 

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

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Xanax Withdrawl

Xanax Withdrawal

Welcome back, people! Last week we continued our foray into all things Xanax and talked about dependence and use disorder. The next step in the chain- withdrawal- can be a special kind of beastie, definitely deserving of its own blog, so this week will be all about Xanax withdrawal.

As I mentioned last week, some folks can take their bit of Xanax a couple of times a day as directed for umpteen years, and never develop a tolerance or pathological dependence. Others start out taking it as directed, but develop a tolerance and maybe start to abuse it- take too much too often- and then begin to develop a more pathological dependency. Others may abuse it recreationally on occasion, to netflix and chill, find they really like it, then develop a severe addiction. It may not sound like these people have much in common, but they do. When they stop taking it, they’re all going to go through withdrawal.

They won’t do so alone, though. In 2017, doctors wrote nearly 45 million prescriptions for Xanax, so it’s no surprise that these prescribing practices have contributed to thousands of cases of abuse and dependence. With those numbers, there has been all sorts of research and stats examined on benzos, and I read that in 2018, an estimated 5.4 million people over the age of 12 misused prescription benzodiazepines like Xanax. That’s a lot of people, people.

To many patients that take their Xanax exactly as prescribed, it seems to come as a surprise that they’re facing a withdrawal experience, but Xanax doesn’t discriminate- so anyone taking enough of it for more than a few weeks will develop a physical dependence. Once you have become physiologically dependent on a drug, you will experience withdrawal symptoms when you stop or reduce your dose. Simple as that.

Withdrawal is different for everyone. Depending on the dose and how often you’ve been using it, the withdrawal experience typically ranges from uncomfortable to very unpleasant, but it can also be medically dangerous. The only safe way to quit is to slowly taper down the dose under the direction of a physician, or in an in-patient treatment center setting, depending on the situation. If you’ve been taking high doses of Xanax several times a day, then quitting is going to take a great deal of time, patience, and determination. Please note that quitting cold turkey can cause extremely dangerous withdrawal symptoms. This can include delirium, which is a state characterized by abrupt, temporary cognitive changes that affect behavior; so you can be irrational, agitated, and disoriented- not a good combo. Sudden withdrawal can also cause potentially lethal grand mal (aka tonic-clonic) seizures. These are like electrical storms in the brain, where you lose consciousness and have violent muscular contractions throughout the body. It’s not a risk you want to take, people- so don’t do this on your own! Even if you’ve been taking Xanax illicitly, that doesn’t mean you have to go it alone. Just fess up to a physician and tell them exactly how much you’ve been taking so they can design a taper schedule for you, or help you find a treatment center. There is a lot of help available if you make the effort.  

Tapering your dose is the best course of action for managing withdrawal symptoms, but that doesn’t mean it’s a picnic in the shade. While you taper down the dose, you’ll likely experience varying degrees of physical and mental discomfort. You may feel surges of anxiety, agitation, and restlessness, along with some unusual physical sensations, like feeling as though your skin is tingling or you’re crawling out of your skin. But keep in mind that these are all temporary. 

Signs and Symptoms

The major signs and symptoms of Xanax withdrawal vary from person to person. Research indicates that roughly 40% of people taking benzodiazepines for more than six months will experience moderate to severe withdrawal symptoms, while the remaining 60% can expect milder symptoms. It’s very common to feel nervous, jumpy, and on edge during your taper. And because Xanax induces a sedative effect, when the dose is reduced, most people will experience a brief increase in their anxiety levels. Depending on the severity of your symptoms, you may experience a level of anxiety that’s actually worse than your pre-treatment level. Support from mental health professionals can be very beneficial during and after withdrawal, as therapy and counseling may help you control and manage the emotional symptoms of benzo withdrawal.

Physical Withdrawal Symptoms

As a central nervous system depressant, Xanax serves to slow down heart rate, blood pressure, and temperature in the body- in addition to minimizing anxiety, stress, and panic. Xanax may also help to reduce the risk of epileptic seizures. Once the brain becomes used to this drug slowing all of these functions down on a regular basis, when it is suddenly removed, these CNS functions generally rebound quickly, and that is the basis for most withdrawal symptoms. Symptoms can start within hours of the last dose, and they can peak in severity within 1 to 4 days. The physical signs of Xanax withdrawal can include: headache, blurred vision, muscle aches, tension in the jaw and/ or teeth pain, tremors, nausea, vomiting, diarrhea, numbness of fingers, tingling in arms and legs, sensitivity to light and sound, alteration in sense of smell, loss of appetite, insomnia, cramps, heart palpitations, hypertension, sweating, fever, delirium, and seizures.

Psychological Withdrawal Symptoms

Xanax, as a benzodiazepine, acts on the reward and motivation regions of the brain, and when a dependency is formed, these parts of the brain will be affected as well. When an individual dependent on Xanax then tries to quit taking the drug, the brain needs some time to return to normal levels of functioning. Captain Obvious says that whenever you stop a benzo, because it acts as an anxiolytic, you’re going to experience a sudden increase in anxiety levels. While there are degrees of everything, the psychological symptoms of Xanax withdrawal can be significant, as the lack of Xanax during withdrawal causes the opposite of a Xanax calm, which is to say something akin to panic. At the very least, that can make you overly sensitive, and less able to deal with any adverse or undesired feelings. Withdrawal can leave people feeling generally out of sorts, irritable, and jumpy, while some individuals have also reported feeling deeply depressed. Unpredictable shifts in mood have been reported as well, such as quickly going from elation to being depressed. Feelings of paranoia can also be associated with Xanax withdrawal.

Nightmares are often reported as a side effect of withdrawal. I included insomnia in physical symptoms, but trouble sleeping can also be a psychological symptom, as it is both mentally and physically taxing. People can be overtaken by anxiety and stress during withdrawal, and that may cause this trouble sleeping at night, which then contributes to feelings of anxiety and agitation, so it’s a cycle that can be tough to break free of. Difficulty concentrating is also reported, and research has found that people can have cognitive problems for weeks after stopping Xanax. Ditto for memory problems. Research shows that long-term Xanax abuse can lead to dementia and memory problems in the short-term, although this is typically restored within a few months of the initial withdrawal. Hallucinations, while rare, are sometimes reported when people suddenly stop using Xanax as well. Suicidal ideation is sometimes reported, as the anxiety, stress, and excessive nervousness that can occur during withdrawal can lead to, or coexist with suicidal thoughts. Finally, though rare, psychosis may occur when a person stops using Xanax cold turkey, rather than being weaned off of it.

Xanax Withdrawal Timeline

Xanax is used so commonly for anxiety and panic disorders because it works quickly, but that also means it stops working quickly and leaves the body quickly. Xanax is considered a short-acting benzodiazepine, with an average half-life of 11 hours. As soon as the drug stops being active in the plasma, usually 6 to 12 hours after the last dose, withdrawal symptoms can start. Withdrawal is generally at its worst on the second day, and improves by the fourth or fifth day, but some symptoms can last significantly longer. If you go cold turkey and don’t taper your dose, your withdrawal symptoms will grow increasingly intense, and there really is no way to predict how bad they may get, or how you’ll be affected. 

Unfortunately, five days doesn’t signal the end of withdrawal for some people, as some may experience protracted withdrawal. Estimates suggest that about 10% to 25% of long-term benzodiazepine users experience protracted withdrawal, which is essentially a prolonged withdrawal experience marked by drug cravings and waves of psychological symptoms that come and go. Protracted withdrawal can last for several weeks, months, or even years if not addressed by a mental health professional. In fact, these lasting symptoms may lead to relapse if not addressed with continued treatment, such as regular therapy.

Factors Affecting Withdrawal

Withdrawal is different for each individual, and the withdrawal timeline may be affected by several different factors. The more dependent the body and brain are to Xanax, the longer and more intense withdrawal is likely to be. Regular dose, way of ingestion, combination with other drugs or alcohol, age at first use, genetics, and length of time using or abusing Xanax can all contribute to how quickly a dependence is formed and how strong it may be. High stress levels, family or prior history of addiction, mental health issues, underlying medical complications, and environmental factors can also make a difference in how long withdrawal may last for a particular individual and how many side effects are present. 

Coping with Xanax Withdrawal

The best way to avoid a difficult and potentially dangerous withdrawal is to slowly taper down your dose of Xanax, meaning to take progressively smaller doses over the course of up to several weeks. By keeping a small amount of a benzo in the bloodstream, drug cravings and withdrawal may be controlled for a period of time until the drug is weaned out of the system completely. It may sound like designing a taper would be a no-brainer, but it’s definitely not recommended to taper without a physician’s guidance. Why? Because Xanax is a short-acting drug, your body metabolizes it very quickly. Controlling that is challenging because the amount of drug in your system goes up and down with its metabolism. To help you avoid these peaks and valleys, doctors often switch you from Xanax to a longer acting benzo during withdrawal, as it may make the process easier. And believe me, that’s what you want. If the physician goes this switch route, once you’ve stabilized on that med, you’ll slowly taper down from that a little bit at a time, just as you would with Xanax. 

Another reason not to play doctor on this one is if you start to have breakthrough withdrawal symptoms when your dose is reduced, your physician can pause or stretch out your taper. It’s up to him or her, through discussion with you, to design the best tapering schedule for your individual needs. Sometimes it’s a fluid and changing beastie.

In addition, adjunct medications like antidepressants, beta-blockers, or other pharmaceuticals/ nutraceuticals may be effective in treating specific symptoms of Xanax withdrawal, and you’ll need a physician to recommend and/ or prescribe those as well. 

Alleviating Symptoms of Withdrawal

An individual may notice a change in appetite and weight loss during Xanax withdrawal, so it’s important to make every attempt to eat healthy and balanced meals during this time. It may sound obvious, but a multivitamin including vitamin B6, thiamine, and folic acid is especially helpful, as these are often depleted in addiction and withdrawal. There are some herbal remedies that may be helpful during withdrawal, such as valerian root and chamomile for sleep. Meditation and mindfulness are very useful for managing blood pressure and anxiety during withdrawal, so be sure to check out my March 15 blog for more on mindfulness. Considering the insomnia and fatigue that may occur during withdrawal, it may seem counterintuitive to commit to exercise, but it has been shown to have positive effects on mitigating withdrawal symptoms and decreasing cravings. Exercise stimulates the same pleasure and reward systems in the brain, so it stands to reason that it can also help to lift feelings of depression or anxiety that may accompany physical withdrawal symptoms.

Xanax Withdrawal Safety

Some of the things I’ve mentioned are so important they bear repeating. Xanax should not be stopped suddenly, or cold turkey, and vital signs like blood pressure, heart rate, respiration, and temperature need to be closely monitored during withdrawal. This is because these may all go up rapidly during this time, and this can contribute to seizures that can lead to coma and even death. 

People with a history of complicated withdrawal syndromes and people with underlying health issues should work very closely with their physician during withdrawal, as should the elderly and people with cognitive issues, as there can be unique risks involved. If you have acquired your Xanax illicitly, you can still work with a doctor to taper down your dose. Start by visiting a primary care physician or urgent care center and tell them that you are in, or are planning to be in, benzodiazepine withdrawal. If you don’t have insurance, visit a community health center. If you plan to or have become pregnant, you will need to discuss your options with your prescribing physician and OB/GYN about the risks and benefits of continuing versus tapering Xanax or other benzos. Some women continue taking them throughout their pregnancy, while others follow a dose tapering schedule.

The key to achieving the goal of getting off of Xanax is to follow the tapering schedule to the very end. By the end of your taper, you might be cutting pills into halves or quarters. Note that some individuals may be better suited for a harm reduction approach, in which the taper leads to a maintenance dose rather than abstinence. If you’re very concerned about the risks involved in Xanax tapering for any reason, discuss these concerns with your physician, because you may be better suited for inpatient detoxification. While this is more expensive, it is covered by many insurance plans.

No matter how you slice it, quitting Xanax takes time, patience, and determination. If you’ve been using it for longer than a few months, quitting can be hard, and there will be days where you want to give up and give in. But with medical supervision and support, you can be successful, and in the long-term, the health benefits are considerable. Withdrawal isn’t a picnic, but if Xanax is both the alternative to it, and a problem for you, it beats that alternative hands down. 

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!

Please feel free to share the love! Share blogs and YouTube videos 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, and share those vids too! 

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

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Alprazolam Use Disorder

Alprazolam Use Disorder

Helll-ooo people! I hope everyone had a great holiday weekend, maybe bit the head off a big bunny- a chocolate one of course. We’ve been talking about alprazolam, trade name Xanax. Last week I warned you about the dangers of buying it off of the street. If you’ve forgotten why it’s dangerous, it’s because it’s nearly always counterfeit crap made in some moron’s basement with fentanyl and heaven knows what else, and you don’t want that. If you think I have a pretty clear opinion on fake Xanax, or any fake pharmaceutical for that matter, Captain Obvious says you’d be right. 

If you read the first blog in this series a couple of weeks ago, you already know that Xanax, generic name alprazolam, is a member of the class of anxiolytic drugs called benzodiazepines, and very commonly prescribed for anxiety and panic disorders- mainly because it’s very effective and works quickly. But it also has serious addiction potential and is a common drug of abuse, and this is something that patients and their families must be aware of up front. With that in mind, this week’s blog will focus on the signs and symptoms of Xanax abuse, and how that progresses to the diagnosis of sedative use disorder, or more specifically Xanax use disorder. 

Some people who are prescribed Xanax for anxiety or panic disorders can take their prescribed dose twice a day for years and never experience an issue, unless or until they stop taking it. They become dependent upon it, but only in that their body becomes used to having the drug in their system- it’s not a pathological dependence. Upon stopping it, they’ll still experience withdrawal symptoms, but they don’t develop Xanax use disorder, because their use is quite literally not disordered. Incidentally, I’ll be focusing on withdrawal from Xanax next week. In contrast, far too many people develop a pathological dependence upon Xanax. Even if they have a genuine anxiety disorder and start out taking it only as prescribed, they begin to abuse it by taking too much and/ or too often, and they develop a use disorder, which progresses to what we colloquially call an addiction. 

This is a process that generally starts because they begin to develop a tolerance to the drug and require more of it to achieve the desired effect, whether that is to quell their symptoms of anxiety, or to get high. Tolerance is a phenomenon that occurs with many drugs, but it is especially dangerous in a drug like Xanax, as it’s a closed circuit- the more you need, the more you take, and the more you take, the more you need. Ideally, a patient informs their prescribing physician if they feel that their current dose is no longer adequate. But that doesn’t always happen, and patients may choose to increase the dose on their own; and at that point, they’re abusing the drug. 

Some of the most common physical signs and symptoms of Xanax abuse include slurred speech, poor motor coordination, confusion, blurred vision, drowsiness, dizziness, difficulty breathing, loss of consciousness, and an inability to reduce intake without symptoms of withdrawal. Beyond the physical symptoms, when a person begins to abuse Xanax, there will likely be noticeable changes in their behavior as well. Some of the most common behavioral signs of Xanax abuse include the following:

-Taking risks in order to buy Xanax: some people may do things they wouldn’t have previously considered in order to obtain it. For instance, they may steal, often from loved ones, in order to pay for Xanax.

-Losing interest in normal activities: as Xanax abuse takes a firmer hold in a person’s life, they commonly lose interest in activities they formerly enjoyed.

-Risk-taking behaviors: as Xanax abuse continues, the person may become more comfortable taking big risks, such as driving while on Xanax.

-Maintaining stashes of Xanax: to ensure that they will not have to go without Xanax, they will attempt to stockpile it.

-Relationship problems: Xanax abuse invariably leads to interpersonal problems and social issues, but this often isn’t enough to motivate the person to stop.

-Obsessive thoughts and actions: the person will spend an inordinate amount of time and energy obtaining and using Xanax. This may include activities like doctor shopping or looking for alternate sources of it, or asking friends, family, and/ or colleagues for it. 

-Legal issues: this can be related to illegally obtaining Xanax, being arrested/ incarcerated for drugged driving, or for other disturbances as a consequence of use. 

-Solitude and secrecy: when abusing Xanax, it’s very common for people to withdraw from friends and family to protect their use.

-Financial difficulties: to pay for Xanax, a person may drain their financial resources and/ or those of family and friends.

-Denial: this includes setting aside valid concerns about Xanax abuse to protect ongoing use of the drug. For example, minimizing or refusing to recognize the dangers of buying it on the street.

As Xanax abuse progresses, it reaches what most people would term an addiction. But the actual diagnosis recognized in the psych nerd’s bible, the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th edition) is termed use disorder. If the person is using Xanax, we call it sedative use disorder or Xanax use disorder, but there is opioid use disorder as well- essentially anything that is abused can fill in the blank. In order for a person to be diagnosed with a sedative use disorder, they must exhibit a certain number of signs and symptoms within a one year period. The more symptoms that are present, the higher the grading the sedative use disorder will receive, and this places the severity of the disorder on a continuum, be it mild, moderate, or severe.

Paraphrased versions of the assessed symptoms of Xanax use disorder are as follows:

-Repeated problems in meeting obligations in the areas of family, work, or school because of Xanax use.

-Spending a significant amount of time acquiring Xanax, using it, or recovering from side effects of use.

-Continued Xanax use despite hazardous circumstances.

-Continued Xanax use despite the complications it causes with social interactions and interpersonal relationships.

-Continued Xanax use despite experiencing one or more negative personal outcomes.

-Using more Xanax or using it for longer than recommended or intended.

-An inability to stop using Xanax despite an ongoing desire to do so.

-Obsessive craving for Xanax.

-Ceasing or reducing participation in work, social, or family affairs due to Xanax use.

-Building tolerance over time, necessitating the use of increasing amounts of Xanax to achieve desired effect.

-Experiencing withdrawal symptoms upon decreasing the dose of Xanax.

These last two signs- building tolerance that requires continual dosage increases, and experiencing withdrawal symptoms when dosage is decreased- are indicative of physical dependence and ultimately addiction. These are natural body processes that occur when the brain and body habituate to drug use over time. Once the body becomes accustomed to having the drug, a sort of new normal is established in its presence. Thereafter, when the drug use stops, the body will issue its demand for more of the drug in the form of withdrawal symptoms. And that’s exactly where we’ll pick up next week. 

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!

Please feel free to share the love! Share blogs and YouTube videos 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, and share those vids too! 

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

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CounterfeitDrugs:Fake Xanax

Counterfeit Drugs: Fake Xanax

For this week’s alprazolam blog, I want to know if I can fake you out. We’re going to talk about fake Xanax. Look at the picture above. Can you tell which Xanax are fake? Are you certain? Enough to roll the dice with your life on the pass line? Because, make no mistake- if you get your Xanax from anywhere other than a licensed pharmacy, you are absolutely, positively doing so every single time you take it. By the end of this blog, you’ll definitely know the answer to the first question. As to the second, I’d hope you already know the answer, because even Captain Obvious won’t bother with that one, people. 

When you think of counterfeit drugs, you may not be too concerned if you consider them to be just weakened copycat versions of the real thing, made with a bunch of essentially harmless junk. Probably the worst that could happen is it won’t work, right? Wrong! Obviously, the main problem with counterfeit drugs in general is that they’re clearly illegal and therefore unregulated, so you don’t know what you’re getting. I mean, with counterfeit drugs, there’s no truth in advertising. And helll-ooo, they’re produced in somebody’s gnarly basement, so there sure as hell isn’t any quality control. While they can be cut with innocuous things like baking soda or baby powder, they can also be laced with extremely harmful substances, things like rat poison, bleach, and formaldehyde. Unfortunately, many drug users don’t know, or don’t care, how dangerous it is to ingest substances like these. But there are cases where counterfeit drugs are especially dangerous, and fake or counterfeit Xanax is at the top of that list. In late 2015, the entire country learned this lesson the hard way when in three months, there were nine documented cases where people in San Francisco suddenly overdosed from “Xanax.” To be clear, it wasn’t Xanax at all. That number included a baby, who had picked a tab of it up off the floor and put it in their mouth. It also included one person who didn’t even get to live to regret it. I think we got off pretty easily in that singular event, but obviously more have followed. 

By the Numbers… Without Numbers (?)

Again, since production and sale of fake Xanax is illegal, underground, and unregulated, there aren’t national or global databases to collect information or statistics as there are with other drugs. But I found some reports from various global sources that were interesting. And by that I mean frightening. Some highlight snippets include a report citing that 25% of 2018 drug overdose deaths in Northern Ireland were caused by counterfeit Xanax. Another report from U.S. Customs and Border Protection stated that in the first four months of 2020, during unspecified smuggling attempts, their CBP officers seized 27 shipments of fake Xanax, totalling over 35 pounds. I also listened to part of a podcast on the subject that featured an officer from Portland, Oregon talking about a spate of teenage overdoses on fake Xanax, and the subsequent investigation. They apparently did a round up of all the street dealers they could find, and busted down doors and did everything they could to clean up the area. The goal was to get every Xanax pill off the street, and he stated that of all the “Xanax” pills they recovered, not a single one was legit. He didn’t say exactly how many that was, but it seemed like a lot. Every pill in the area was fake. That’s huge. And very scary. 

Fake Xanax: Beyond the Obvious

“Good” counterfeit Xanax pills look exactly like the real thing. And clearly, by “good” I don’t mean that in the traditional sense. That means they have the same color, size, shape, and pharmaceutical markings, aka imprints, on the pills as the bonafide prescription versions do. While the difference isn’t obvious to the naked eye, there is one huge difference between real and fake Xanax that makes it especially scary: the latter usually contains fentanyl, an extremely potent opioid that is responsible for countless accidental overdoses in numerous counterfeit and legal preparations. In fact, it’s estimated that many thousands of U.S. citizens ingest a deadly dose of  each year without ever even realizing it. How horribly tragic and senseless is that?  

Fentanyl is a schedule II synthetic opioid that is 50 to 100 times stronger than heroin and morphine, respectively. It is typically prescribed by a specialized physician strictly for patients struggling with severe or chronic pain, and it is such a potent and dangerous drug that the DEA has advised officials to take extra protective precautions, like gloves, even just when handling it, to avoid accidental death. This is because it is easily absorbed through the skin, and takes so little to be lethal. While other opiate doses are measured in milligrams, fentanyl is dosed in micrograms, and an amount equal to two grains of salt is lethal to nearly all individuals. Clearly, a drug that is 100 times stronger than morphine is no joke, and it officially now kills more Americans annually than any drug in history.

People who take fentanyl accidentally will be unaware of what they have taken, or how much, so they face an even higher risk of an opioid overdose. In the case of fake Xanax exposure, if or when a person does overdose on it, in the unlikely event that they’re lucky enough to make it to a hospital, it presents a unique problem. As a physician, I can tell you that when a person’s symptoms present differently from what is expected, it delays treatment, and Xanax overdose and fentanyl overdose present very differently. So when it’s reported that a person took “Xanax,” or some pills are found on their person, but their symptoms don’t look like a benzodiazepine overdose, those few minutes a medic or doc takes to assess the situation may be the few that end up costing them their lives. But that can be the case fake percocet or oxycodone as well, because fentanyl is commonly used in producing counterfeit versions of all of those. Even cocaine- maybe especially so because of the cost differential- fentanyl is so much cheaper that it’s very commonly used to cut it. And talk about presenting differently: cocaine and fentanyl overdose are not even remotely similar to one another. Even if users are aware that fentanyl is in the product, and aren’t that concerned about it, there’s still no way to know how much fentanyl is in it, or exactly how potent that fentanyl is. As a result, it is extremely easy to overdose after consuming any counterfeit product. 

Since the pills look exactly like the real thing, it’s nearly impossible to tell the difference. But, if someone consumes counterfeit Xanax made with fentanyl, there will be noticeable symptoms and side effects that wouldn’t ordinarily be present with genuine Xanax. The side effects of fentanyl include excessive itching, slowed breathing, nausea and vomiting, flushed skin, and constricted pupils. These can quickly progress to overdose, and those signs and symptoms are progressively shallow breathing, usually followed by gurgling or choking sounds, or sounds like “snoring,” pale, blue, cold, or clammy skin, limp body or unresponsiveness, and finally suppressed breathing. People often report that they didn’t recognize that someone was overdosing, even though they literally sat there watching it. They usually think they’ve nodded out and are snoring, and then just stop snoring. In reality, they’re really choking, then their breathing is severely suppressed, and when they stop making noise, they’ve simply stopped breathing. Fentanyl also yields some dangerous psychological effects, such as depression, hallucinations, difficulty sleeping, and nightmares. These are all signs to be aware of if you ever take a drug from a questionable source.

Fake Xanax: How it’s Done

Counterfeit Xanax is made using a pill press, which is exactly what it sounds like: it’s a device that is used to press powders together with a binding agent, to make the substance into a solid pill form. Pill pressing devices can be smaller than the size of a person’s palm, or large enough to need a small room for storage. Pill molds are added to the pill press to press the pills into certain sizes and to make markings or indentations. Sometimes they’re called “stamps,” and manufacturers use these to customize the appearance of the pill and mimic the exact imprint used by the legit pharmaceutical company. Currently, it’s not illegal to own a pill press, and in fact, some people use them to make their own vitamins or supplements at home. But it is illegal to own a pill mold that is used in a pill press. As a result, counterfeit pill molds are usually designed in other countries and sold to the U.S. as “spare parts” or “equipment.” This allows street dealers and manufacturers to purchase their supplies without gaining attention from the police, and continue to make fake drugs in their gnarly basements.

Fake Xanax: Why it’s Done

Helll-oooo! People who sell drugs don’t do so because they enjoy it, they do it to earn a profit. It behooves them to find a way to make their drugs cheaper and more potent, because that’s the best way to generate more profit from a smaller amount of product- that’s just common business sense. Believe it or not, many street-level dealers can get their hands on fentanyl very cheaply, either through theft, or through overseas production of cheap, sketchy fentanyl look-a-likes, so they commonly use it to cut their drugs, and this actually makes their products cheaper and more potent. To be clear, these fake products may not even contain the actual primary component. But in cases of fake Xanax, if it does contain actual alprazolam, the combination makes it even more dangerous-  but the fentanyl alone can just as easily provide or mimic the effects the user is looking for. The result is a product that looks and feels pretty much like real Xanax, but is infinitely more dangerous; sold at a fraction of the price, as compared to the real thing, brought to you by your friendly neighborhood street thug. 

Fake Xanax: How to Avoid It

Clearly, the easiest way to avoid purchasing fake Xanax is to never purchase the drug on the streets in the first place. In fact, the only reason anyone should ever take Xanax in the first place is if they have a prescription for it and are instructed to by their doctor. Unfortunately, some people who are prescribed the medication seek out cheaper ways to fill their prescription, such as purchasing it from shady online pharmacies or from overseas stores. But you’d be surprised how enterprising some dealers are, and a “pharmacy” selling counterfeit drugs is certainly not unheard of. So kids, the take home lesson is that if you have a Xanax prescription, you should always get it filled at a licensed pharmacy.

Fentanyl: The Masked Killer

As a final word of caution, I just wanted to include a short synopsis of three stories I read about counterfeit drugs containing fentanyl. None of them have happy endings. 

A 28-year-old smoked “a powdery substance” at his mother’s home, where he was living at the time. His mother found him unresponsive in the living room, and having no idea of what had happened, called 911. He was pronounced dead on arrival. The death investigation determined that the substance had been given to him by a friend, who stated they both thought it was cocaine. Toxicology confirmed that while he had a non-lethal level of cocaine in his system at the time of death, the cause of death was acute fentanyl intoxication- he died of a fentanyl overdose.

A 20-year-old college student suffering from undiagnosed anxiety was panicking about a test the following day, so consumed a single oxycodone pill he had obtained illegally before going to bed. His roommates found him dead the next morning. Toxicology confirmed that he died from a fentanyl overdose.

A 19-year-old purchased two Percocet from a friend. He consumed both pills and subsequently died from an overdose. His friend confirmed the purchase, but then toxicology showed the presence of lethal levels of fentanyl. His friend swore he didn’t know they were fake and was very distraught. That friend was also later found dead of an overdose. It was confirmed that it was also due to fentanyl, but it wasn’t clear if it was suicide or accidental. 

These are cases where four individuals died of fentanyl overdose, with all of them consuming a different drug, and three of them never even realizing they were consuming fentanyl. On that note, have you decided which group of Xanax in the picture were fake? I’ll tell you now: both are fake. Guess it’s a good thing you couldn’t actually choose. Get my point?

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!

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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

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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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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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How To Determine If Someone Is Suicidal

A Coronavirus PSA

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

Suicide Assessment

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

Facts and Figures

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

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

Suicide Risk Factors

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

–  Family history of completed suicide in first-degree relatives

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

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

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

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

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

Mental Illness and Suicidality

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

–  Depression

–  Bipolar disorder

–  Mania

–  Schizoaffective disorder 

–  Schizophrenia

–  Post-traumatic stress disorder

–  Substance abuse 

Suicidal Ideation

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

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

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

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

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

–  The degree of planning 

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

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

–  Access to the place to commit

–  Note: presence, timing, content

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

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

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

What is a Suicide Plan?

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

–  Timing of the suicide event

–  Access to the method and setting of suicide event

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

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

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

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

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

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

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

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

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

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

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

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

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Obsessive Compulsive Disorder:Signs,Symptoms,and Treatment

Obsessive Compulsive Disorder: Signs, Symptoms, and Treatment

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Be well, everyone.

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HOW TO BEAT FEAR OF CORONA VIRUS

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

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

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

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

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

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

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

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

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

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

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

3. Do seek support, but do so wisely.

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

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

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

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

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24/7 news Is Stressing Us Out

THIS JUST IN!

24/7 NEWS CAUSES ANXIETY! 

READ ALL ABOUT IT!

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Your Brain On The Holidays

Your Brain on the Holidays

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

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

1. You Want to Eat All of the Food

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

2. You Want to Drink All the Alcohol

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

3. You Want to Buy All of the Things

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

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

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

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

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Secrets For Surviving Panic Attacks

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

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

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

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

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

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

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

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

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

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

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How To Get People To Like you In Ten Minutes

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

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

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

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

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

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

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

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

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

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

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

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

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Marianne asks “how can I get off klonopin’’

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

What are they?

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

How do they work?

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

Why can using them be problematic?

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

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

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

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

What about withdrawl from benzos?

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

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

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

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

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