Personality and Behavior: DISC Model

Personality and Behavior: DISC Model

Wikipedia defines personality as the “characteristic set of behaviors, cognitions, and emotional patterns that evolve from biological and environmental factors.” I’m sure they probably go on to list those factors in the third through fifth paragraphs, so this short definition seems neat and tidy without really committing to much. But as we all know, when you’re dealing with humans, things aren’t ever simple. In reality, there’s no formal or universal definition, but that’s okay, because it gives psych nerds something to argue about. Because there’s no universally accepted meaning, all definitions are essentially theories, most of which center somewhere around an individual’s psychological motivations and resulting interactions with their environment. Alternatively, people can refer to it as character, temperament, or disposition, but in my opinion, no matter what you call it, the bottom line is that each person has a unique combination of characteristics or qualities that form a distinctive set, and these govern their perspectives, motivations, and behaviors. 

Now, before I really get into this week’s topic, this is a good place for me to add a disclaimer: When addressing concepts like personalities and behaviors with a large group of people, I have to simplify and generalize, because these are nuanced subjects with far too many influential and individual factors than I could ever address in a blog. So if there are any psych police out there on patrol, please don’t write me a ticket for simplifications and generalizations. 

Now that that’s out of the way, I’ll start with a question: have you ever noticed at times how different the judgement and behaviors of your family and friends can be from your own? My profession means that I literally spend the majority of my life examining what someone does, their behavior(s), and why they do it, their motivation(s). I’m sure you’ve been in many situations where you’ve asked yourself, “Why did he/ she dothat?” or “What were they thinking?” While sometimes it can be frustrating to have a difference of opinion with people, the truth is that life would be boring if we all thought and acted the same way. 

So how do you understand and reconcile these differences? Believe it or not, the starting point of understanding people is actually pretty simple; accept just one fact: that while I’m sure you’re fabulous, everyone is not like you. In point of fact, everyone is not like everyone else, either. If you search for a definition of the word personality, you’ll invariably find the words “characteristic” and “unique” included, along with other synonyms. These are all evidence of, and pretty words to convey, one fact: that we’re all different. We all carry our life experiences and opinions with us, and we filter everything we see, hear, and experience through them, so they color our perceptions and motivations; and these in turn influence our behaviors. I believe the saying goes something like “different isn’t bad, it’s just different,” and I can roll with that. Each of us is unique; we think differently, and therefore behave differently. It’s really a good thing; far, far better than the alternative.

But behavior and personality can be easily misunderstood, and if that becomes chronic, these repeated misunderstandings tend to become areas of stress that affect a person’s happiness, which in turn affects motivation and productivity in every aspect of life. If you’ve ever been in a situation where you felt like you couldn’t “get along” with someone, on some fundamental level, you probably just don’t understand them. A lack of understanding and acceptance of differences can lead to tension, disappointment, and miscommunication. When issues like these go unresolved, they tend to build, and ultimately, can lead to resentment. Resentments can be notoriously difficult to untangle, so in the end, it’s far better to avoid the original problem if you can. Admittedly, that’s often easier said than done, especially if you don’t have a clue what on earth is going on inside the mind of another person. I’ll shed some light on that, so that hopefully by the end of this blog, you’ll have more insight on what that may be.  

If the problem is associated with misunderstanding(s), then it only follows that the solution to that problem probably has a lot to do with understanding. When I say that, I’m not talking about holding hands and singing kumbaya with everybody… I’m saying that accepting that people have different opinions from yours, and then making reasonable attempts at understanding where they’re coming from, will serve you better than being obstinate and absolutely refusing to do so. That said, the success of nearly every solution is in its application, so how exactly do we better understand people? There is a relatively simple visual model that can serve as a key to understanding the basics on how people behave. It’s called The DISC Model of Human Behavior, aka DISC model. It can be applied to loosely categorize a person’s personality traits and extrapolate their motivating factors and behavioral styles. More on that later.

Before I get into the DISC model, time for another disclaimer: Because personality and behavior are such diverse and nuanced human attributes, and since the DISC model is a theoretical one, it isn’t used for diagnostic or clinical applications. In other words, when you come into my office and tell me your life story, I’m not running through it in my head looking to categorize you as one of four types. People are complex and DISC is by nature more simple and general; and rarely, if ever, does anyone fall perfectly into any one type. That said, I’m covering this model today in blog form because I think it’s an interesting and practical way for everyday non-clinical people to better understand themselves and others, and to apply that in an effort to communicate more effectively with people who have differing perspectives… which is basically everyone! 

Why Personality Traits and Behavior Matter

Why should you care to learn about behavior and personality or the DISC model? Believe it or not, personality and people skills are important aspects of life: personal, social, and workplace. If you can’t work in cooperation with other people, it can be really tough to make it in this world. It can affect your ability to keep a job or advance your position, to make friends, and to keep peace with partners, family, and friends. We’re all familiar with IQ, our intelligence quotient, and we spend years in school developing and learning how to effectively use our minds. But developing your personality to effectively use behavior is also vital to successful living. Studies have shown that technical skill, beginning with intelligence and developed through education and experience, accounts for only 15% of success in the workplace; the other 85% has been shown to actually come from people skills. These skills are developed through learning better ways to behave, communicate, and interact with others. The DISC model is commonly applied as a tool to increase your ability to understand yourself and others, and communicate more effectively with everyone.  

History of the DISC Model

Even if it sounds like one, this isn’t a new age, hippy-dippy-trippy idea. Au contraire. Let’s get in the waaay-back-machineand go to Greece, around about 300 B.C.-ish. Why? To see Hippocrates. Whenever I hear his name I can’t help but smile despite myself, because it always makes me think of Bill & Ted’s Excellent Adventure. When they met Hippocrates, they mispronounced his name like the murderous mammal + crates, pronounced like it rhymed with plates, and in their characteristic burner dude affectations. And now the memory of that movie quote is inextricably linked to his name in my mind.. I hear them say it every time. Anyway, back to the topic at hand. Hippocrates was a physician, but also a rebel! And thankfully so. At a time when most of his fellow Greeks were attributing sickness to The Fates, superstition, and the wrath of the gods, Hippocrates espoused the firm belief that all forms of illness had a natural cause. Which, believe me, is a far better alternative than worrying about appeasing The Fates, the witches, and the gods. At any rate, perhaps in pondering the natural basis of illness, or maybe ways to prove his theory to his colleagues, Hippocrates began to recognize that the behaviors of individuals seemed to follow distinct patterns, and he began to loosely categorize the differences in these behaviors. 

While Hippocrates had the original notions on behavioral patterns, many psychologists and scientists continued to explore and expand on his theory. In 1928, Dr. William Marston wrote The Emotions of Normal People, in which he theorized that people are motivated by four intrinsic characteristics or factors that direct predictable behavioral patterns, and described these four factors as personality types. He then created a visual model that utilized a circle divided into quadrants to represent these four personality types. In his original work, he labelled them as D, I, S, C: Dominance, Inducement, Submission, and Compliance. And poof… the DISC model was born.

From what I’ve read, Marston was kind of a freaky guy, and the slightly(?) deviant undertones of his word choices “dominance, inducement, submission, and compliance” seem to confirm this. Even though he was a well respected psychologist by day, he was also a surprisingly successful comic book author by night, and is in fact credited for creating the comic book character “Wonder Woman.” She’s an Amazonian, a race of female warriors from an island where men were not allowed. This actually isn’t too much of a stretch, because Marston was also a champion of women’s rights. Despite this, he seemed to have had more than his fair share of female-centric scandal in his life. I found several references that said that he invented the first lie detector test, but also found some that credit someone else with this feat. Regardless, apparently he wasn’t exactly always on a first name basis with the truth, because he lied to the public about being a bigamist. Evidently, after he married his second wife (who was also a former student) and she moved in with him and his first wife, he told the public she was just a relative staying with them… and they fell for it. So during his bigamist marriage, they all lived together in a ménage à trois, and he actually fathered children with both women. But in spite of the scandal he caused with his colorful private life, Marston’s theories of human behavior are still widely accepted today. 

What is DISC Used For?

The DISC model is applied as a personal assessment tool designed to ascertain a person’s personality traits and behavioral styles. It’s essentially a series of questions that evaluate human behavior in various situations. For example, it looks at how you respond to challenges, rules, and procedures, how you influence others, and what your preferred pace is. 

While Marston’s theories and DISC model were generally well received, some organizations later modified it and created a negative tool used by organizations and employers to weed out undesirables. But in later years, to reflect a change in attitudes, it has since seen several iterations. Now all existing forms of it are used exclusively as positive tools of inclusion rather than being negative and judgemental. DISC assessments are used to foster understanding and respect, improve people skills, build better teams, increase productivity, reduce conflict, and relate and communicate with others more effectively; all of this is meant to translate to increased cooperation and the creation of better working relationships. In fact, the DISC model is widely accepted in the business community; so much so that many organizations and employers incorporate it into all associate training programs, but it is especially used in fields and positions related to sales, marketing, customer service, and management.

I was surprised to learn that DISC assessments have confirmed use in 70% of the Fortune 500 companies, including Exxon/Mobile, General Electric, Chevron, and Walmart. Pretty impressive, as these are strong companies with good management; and according to what I read, that’s where most of them focus their DISC utilization. 

But you can also apply the model to your personal life, to learn more about yourself and grow as a person, increase people skills, illuminate your own motivations, and uncover your strengths and blind spots, some of which you may not even be aware of. As a bonus, you’ll then be better prepared to answer certain questions that may come up in life; for example, when a prospective employer asks “What would you say your strengths are?” or even better, when your spouse or partner looks at you exasperatedly and asks, “Why the *bleep* do you do that?” Wouldn’t it be nice to have a handy answer to that one?! 

In the end, despite its generalizations, the model is sort of like “personalities for dummies”- not that I’m saying you’re dummies- I’m just saying it’s a simple and useful way for non-clinical people to better understand themselves and their own motivations, and apply that knowledge to relationships and everyday interactions, both in and out of the workplace. 

DISC Terminology: Four Behavioral Patterns

Since Marston’s time, while the general concept surrounding the DISC model has remained the same, some of the terminology has changed several times. Some publishers and reference models use a lowercase i in DISC as a way of distinguishing between different models and for trademarking assessments and reports (read: as a way of making money). DISC with a capital I can’t be trademarked, so I’ve used that form for our purposes. The terms used to convey the DISC personality/ behavioral types have also changed for several reasons: to reflect a change in attitudes and more positivity, as a way of distinguishing between different models, and for trademarking purposes; so now there are a few different versions that vary slightly. Different companies and publishers determine and apply their various terms, and I’ve listed the most popular ones, in an order with the ones that I find most applicable first and Marston’s being last.

D: Dominant / Dominance 

I: Inspiring / Interactive / Inducement

S: Supportive / Steadiness / Submission

C: Cautious/ Conscientious / Compliance

No matter what term is used, the basic traits and behavioral styles are essentially the same; I’ll cover those later.

I should note that now some publishers have apparently modified assessments to further extrapolate personality traits and behavioral styles; I’ve seen some that will describe up to twelve types, and even an article that referenced exactly 41 personality types. I didn’t fact-check or verify that, but just wanted to mention it as kind of an outlier. 

DISC Basics

This model is based on two fundamental observations about what drives people to behave the way they do, which are essentially their motivators. I want to emphasize something to keep in mind: as you look at fundamental behaviors, you’re looking at tendencies, not absolutes. Most people will tend to behave more one way than the other, but will behave both ways, to greater and lesser degrees, depending on the situation they find themselves in. Also, behaviors are fluid; they can and do change over time and vary by situation.

DISC: Two Fundamental Observations

(Internal) Motor and (External) Focus

-Some people are more outgoing, while others are more reserved. This is each person’s “pace,” or “internal motor.” It is sometimes simply referred to as the “motor” drive. Some people engage quickly and always seem ready to go, and these are considered outgoing types. Others engage more slowly or more cautiously, and these are considered reserved types.

-Some people are more task-oriented, while others are more people-oriented. This is each person’s “external focus” or “priority” that guides them; sometimes simply referred to as “focus.” Some people are more focused on getting things done, and these are considered task-oriented types. Others are more attuned to the people around them and their feelings, and these are considered to be people-oriented types.

Visualizing the DISC Model

As I mentioned, DISC is a visual model, and it utilizes a circle to represent the range of “normal” human behaviors. You can imagine it as a clock face.

To illustrate the application of the first fundamental observation, aka motor drive, imagine you divide a circle in half horizontally, as from 9 o’clock to 3 o’clock on a clock face. The upper half then represents Outgoing (or fast-paced) people, while the lower half represents Reserved (or slower-paced) people.

To illustrate the application of the second fundamental observation, aka focus drive, imagine you divide a circle in half vertically, as from 12 o’clock to 6 o’clock on a clock face. The left half then represents Task-Oriented people, while the right half represents those who are more People-Oriented.

When the two motor and focus circles are superimposed to combine them, you end up with four behavioral tendencies to help characterize people: Outgoing, Reserved, Task-Oriented, and People-Oriented. The balance of these four tendencies shapes the way each person sees life and those around them. 

To illustrate the incorporation of the two drives (motor and focus) you can imagine one clock face with two divisions (horizontal and vertical) and therefore in four quadrants. Starting at 12 o’ clock and moving clockwise, you would then see Outgoing at 12 o’clock, People-Oriented at 3 o’clock, Reserved at 6 o’clock, and Task-Oriented at 9 o’clock. 

By combining the two drives, you now have four total behavioral tendencies: from the upper left quadrant, moving clockwise, those tendencies are then: 

Outgoing and Task-Oriented (upper left quadrant)

Outgoing and People-Oriented (upper right quadrant) 

Reserved and People-Oriented (lower right quadrant)

Reserved and Task-Oriented (lower left quadrant).

Then to further define and describe these four behavioral tendencies, the DISC terms are added, one letter per quadrant: Dominant, Inspiring, Supportive, and Cautious. 

Illustratively, these are added to each of the four corners of the diagram, again starting with the upper left quadrant and moving in a clockwise direction: Dominant in upper left quadrant, Inspiring in upper right quadrant, Supportive in lower right quadrant, and Cautious in lower left quadrant.

Once added, starting with the upper left quadrant and moving in a clockwise direction, each DISC term correlates with the four behavioral tendencies such that:

Dominant types are Outgoing and Task-Oriented (upper left quadrant)

Inspiring types are Outgoing and People-Oriented (upper right quadrant) 

Supportive types are Reserved and People-Oriented (lower right quadrant)

Cautious types are Reserved and Task-Oriented (lower left quadrant).

What emerges is the full graphical description of the complete DISC model. 

Interpreting DISC

To make the quadrants easier to discuss, we typically call each quadrant a behavioral style or type, though some people use the phrase personality type. I’ll spare you the specifics as to why, but technically speaking, it’s not really accurate to use the word “personality” type or style with the DISC model, because it’s actually a behavioral model. While I tend to refer to it as a behavioral style, either term- personality or behavior- is generally acceptable for a colloquial discussion or a blog. 

DISCussion: Four Primary Behavioral Styles

While DISC refers to placement within four primary behavioral styles, always keep in mind that each individual person can, and usually will, display some of all four behavioral styles depending on the situation. The resultant blending of behavioral tendencies is often called a style blend, and each individual’s style blend will have more of some traits and less of others. 

The Dominant “D” Style

An outgoing, task-oriented individual will be focused on getting things done, solving problems, making things happen, and getting to the bottom line, usually as quickly as possible. They can sometimes be blunt, outspoken, and somewhat demanding. The key insights in understanding and developing a relationship with this type of person are respect and results.  

The Inspiring “I” Style

An outgoing, people-oriented individual is generally enthusiastic, optimistic, open, and trusting. They thrive on interaction and love to socialize and have fun. This person places emphasis on persuading others and is usually focused more on what others may think of them. The key insights in understanding and developing a relationship with this type of person are admiration and recognition.

The Supportive “S” Style

A reserved, people-oriented individual will place an emphasis on cooperation, sincerity, loyalty, and dependability. They enjoy working together as a team and thrive on helping or supporting others. They usually focus on creating and/ or preserving relationships and on maintaining peace and harmony. The key insights in understanding and developing a relationship with this type of person are friendliness and sincere appreciation.

The Cautious “C” Style

A reserved, task-oriented individual enjoys independence, and often fears being wrong. They will seek value, consistency, and quality information, and will usually focus on details, facts, rules, accuracy, and being correct. The key insights in understanding and developing a relationship with this type of person are trust and integrity.

I should also note that some organizations use a shortcut in discussing the different behavioral types, where the dominant type is also known as High D, the inspiring type is also known as High I, the supportive type is also known as High S, and the cautious type is also known as High C.

Behavioral Styles: Elevator Test

As you’ll see, this is a pun meant to give you an idea of your own behavioral style and to help you identify others. Captain Obvious says it’s not meant to be scientifically or clinically valid, people, it’s just to illustrate the four behavioral styles in a relatable, “everyday situation” kind of way.

The doors are about to close on a person who is eager to get on an elevator, which already has four people inside. One of the four people already inside glances at their watch, because they’re in a hurry and would prefer not to wait. But also inside is the bubbly, smiling, energetic second passenger who actually holds the door open while encouraging the newcomer to climb aboard. The third rider doesn’t mind if the new person gets on, and they simply step back to make room while patiently waiting for them to do so. The fourth passenger barely looks at the new guy, as they’re busily calculating the sum of everyone’s weight in their head while also looking around to estimate the age of the elevator. 

Did you see yourself in this scenario? Did you recognize the behavioral styles of the other elevator passengers? Read on to find out if you’ve got it.

This scenario demonstrates behavior of the Dominant (outgoing / task-oriented) person who wouldn’t really mind if the elevator door closes before the new guy can get on, because they’re just focused on getting where they need to be as quickly as possible. But that possibility is dashed by the Inspiring (outgoing / people-oriented) person who feels energized by the addition of yet another positive interaction to their day. The Supportive (reserved / people-oriented) person just calmly steps back to make room for the new guy because they empathize with him and are willing to be accommodating. All of this while the Cautious (reserved / task-oriented) person almost can’t help but make sure the added person doesn’t exceed the weight limit of the old elevator and potentially cause them all to get stuck… or worse. 

Notice that there were four different people who responded to the same exact event in very different ways? People are motivated differently, and therefore think differently, so they behave differently. 

Takeaways

Every individual person has a unique combination of characteristics and qualities that form a distinctive set, and these govern their perspectives, motivations, and behaviors. 

The DISC model developed by Marston is used as the basis for varying assessments of personality traits and behavioral styles.

While it is simplified and generalized, it can be an effective and empowering tool to examine motivating factors, to uncover and address blind spots, and to identify, highlight, and articulate strengths.

It can be used by people to better understand themselves and others, and to apply that understanding in an effort to improve people skills and to communicate more effectively with people who have differing perspectives.

It is commonly used in the professional arena, especially in Fortune 500 companies. Employers often use it for determining placement of new employees, to build better teams, increase productivity and communication, reduce and resolve conflict, and foster acceptance and understanding. 

Each person has a unique blend of all of the major personality traits and behavioral styles to a greater or lesser extent.

Behavioral patterns are fluid and dynamic, and can change over time or as a person adapts to his or her environment.

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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The Skinny on Psychostimulants, Part 3:Modafinil

The Skinny on Psychostimulants, Part 3: Modafinil

Over the past two weeks, we’ve been discussing the psychostimulants amphetamines and methylphenidate, which stimulate the central nervous system by increasing synaptic concentrations of the neurotransmitters dopamine and norepinephrine to varying degrees, and are used in pharmaceutical preparations primarily for treating ADHD, narcolepsy, obesity, and binge eating disorders. They are also used off label to treat cognitive dysfunction and depression in cancer patients and as part of a regimen in chronic pain patients, as well as being used recreationally to get high, study, take tests, improve focus, and/ or stay awake for extended periods of time. In this last installment on psychostimulants today, I’ll discuss a popular drug called modafinil.

While modafinil isn’t technically a psychostimulant, it acts “stimulant-ish,” and ultimately elicits similar effects as its stimulant brethren. It actually belongs to a class of drugs called eugeroics, which are wakefulness-promoting agents, and is also considered a nootropic. Nootropics are “smart drugs,” substances that can enhance brain performance or focus. Strictly speaking, the term nootropic is generally reserved for prescription and over the counter (OTC) pharmaceuticals and supplements that are not taken therapeutically to treat a particular illness, but rather to enhance cognitive function in healthy individuals beyond what is usually considered “normal” in humans. Nootropics or smart drugs can alternatively be referred to as performance enhancers or pharmacological cognitive enhancers (PCE’s). To cover all the bases and avoid ticking off the biohackers, I suppose you could call modafinil a nootropic eugeroic. Whatever! 

Originally synthesized in France in the 1970’s, modafinil was approved by the FDA in 1998 and is used primarily to treat sleep disorders, including narcolepsy, shift-work sleep disorder, and residual/ excessive sleepiness in obstructive sleep apnea despite continuous positive airway pressure (CPAP). 

It is used recreationally to increase focus and learning, for cognitive and physical performance enhancement, and to stay awake for extended periods of time. Modafinil is taken by mouth, usually once a day. Most people who work during the day take it in the morning on either a full or empty stomach, but shift workers who take it to promote wakefulness do so before their shifts begin. Modafinil is marketed under the trade name Provigil, while its R-enantiomer armodafinil is marketed under the name Nuvigil. If you recall, enantiomers are mirror image molecules, like left and right hands, that generally induce similar pharmacological effects. Indeed, the two are used to treat the same disorders, but armodafinil is a newer compound and has a slightly different side effect profile than its older sibling modafinil. More on that in a moment.

Both forms are Schedule IV drugs, which defines them as having a low potential for abuse and low risk of dependence. Some other examples of Schedule IV drugs are benzodiazepines like diazepam and alprazolam. That said, while I concur that (ar)modafinil has a low risk of abuse and dependence, I beg to differ on the risk of abuse and dependence being comparable to benzos. In my experience, benzos are far more commonly abused, and the incidence of dependence on benzos far exceeds that of modafinil. However, while studies have not shown any significant withdrawal effects from discontinuation of modafinil, any drug that provides stimulant effects to the brain can enforce drug taking to some extent, and thus carry the potential for dependency, which could lead to withdrawal symptoms upon cessation. Anecdotally, people have reported reduced energy, lack of motivation, and depression following discontinuation of modafinil; therefore, modafinil should always be tapered when discontinued if it has been used for a long period of time. 

I’ve found that modafinil carries a very low risk of side effects, and a very mild profile when present, one that may be comparable to having an extra cup of coffee. The most common side effects are potentially occasional minor headaches, possibly some jitters, and sometimes trouble sleeping, which is usually related to the time of dosing being too late. But the official list of side effects also includes: dizziness, upper respiratory tract infection, nausea, diarrhea, nervousness, anxiety, agitation, and dry mouth. For armodafinil, you can add upset stomach to the list and take away upper respiratory tract infection. Something you have to be aware of when taking modafinil are the synergistic effects of other stimulants. If you consume coffee, energy drinks, or anything with caffeine, you’re likely to have much stronger stimulating effects, and these may include jitters or anxiety. It is wise to avoid anything else meant to make you or keep you awake when taking modafinil, at least until you are aware of its effects on your system, and even then you should still use great caution. As with any medication, if you take other prescription or OTC medications, be sure to disclose them with your prescribing physician to discuss potential interactions. Modafinil has a half-life of 12 hours, meaning that after 12 hours, the effects will start to wear off, but half of the drug will still remain in your system.

Modafinil’s off label and “lifestyle” use in healthy individuals to stay awake for extended periods of time and increase cognitive alertness and physical performance is well documented and likely exceeds its therapeutic utility as far as numbers go. In some professional groups such as pilots, academics, and scientists, modafinil use is reported in the ballpark of 20 to 30 percent; but I’d like to note that that is the reported use, not actual use, which I think is significantly higher, given how available it is on the internet. Modafinil’s popularity among college students, athletes, and the Silicon Valley techie set isn’t exactly a state secret, but its use among the military literally was until confirmed relatively recently. The US Armed Forces tested modafinil in improving performance despite sleep deprivation and in combating pilot fatigue; in fact, at one point, we led the world in military research on modafinil. I happened to catch part of a television show over the holidays that mentioned modafinil studies in Air Force fighter pilots. The show stated that it induced vigilance (aka kept them awake) for 40 hours, which, the show mentioned, is apparently a desired effect during times that necessitate flying to Iraq quickly. Now, I’ve never flown to Iraq, much less in a fighter jet, but I can’t imagine that it takes 40 hours to get there… but you get the point. If you were exhausted, but needed to get to Iraq all quick like, modafinil may be the compound of choice. 

Of course, I had to look into these studies. Captain Obvious says that Uncle Sam has been “officially” dosing our Armed Forces for years, so modafinil is just another in a long line of compounds. I’ve had many patients that were/ are members of the US military, and I’ve been told of the sanctioned use of various drug combinations in all branches of it: hypnotics to induce them to sleep before a mission, followed by stimulants (in the form of dextroamphetamine) “go pills” to switch them back on just before, at “go time.” As far as modafinil is concerned, the experiments relating to sleep deprivation seem pretty ambitious, testing for 40, 60, or even 90 hours without sleep. In some journal articles, scientists speculated that with modafinil, troops might function for weeks(!) on as little as four hours of sleep a night. 

Back to fighter pilots: in the study I looked at, Air Force scientists looked at the effects of being awake for 37 hours on pilot alertness and flight performance; this was evaluated through simulator tests repeated every five hours to track the pilots’ level of fatigue. The same experiment was conducted with and without modafinil, and also in a rested state without modafinil for comparison. What did they find? While on modafinil, the pilots’ performance significantly improved, especially at time points after 25 hours without sleep, and the pilots sustained brain activity at almost normal levels despite their sleep deprivation. Further, while under the influence of modafinil, flight performance degraded by 15 to 30 percent. Now that doesn’t sound great, until you consider that performance by pilots without modafinil (and without sleep) degraded by 60 to 100 percent (hell-ooo!!) as compared to rested levels. All of the findings led researchers to conclude that modafinil “significantly” reduced the effects and impacts of fatigue during flight maneuvers, even though sleep deprived pilots on modafinil were unable to maintain the same performance as they exhibited during a rested state off of modafinil. I’ll say… Degraded by 60 to 100 percent?! Bottom line: clearly, if a pilot can’t get sleep, they should get modafinil. Ultimately, they stated that until more research is done, a 100 mg dose of modafinil is viewed as an option to, but not a replacement for, a 10 mg dose of dextroamphetamine.   

All of that said, most of us are not fighter pilots, much less operating a complicated machine at mach speed and 50,000 feet, under stress, and sleep deprived… and thankfully so. Most of the people that ask me about modafinil are everyday people looking to focus better at work, get excellent scores on SAT’s to get into a great school, win a medal or a pro poker tournament (pro poker players love modafinil) or maybe beat out somebody at work for a promotion. In my experience, for all of those things and more, modafinil is a safe and effective tool, and lots of folks want it in their tool box. It’s been around long enough to have some significant studies done; all findings echo my experience, and one another: it works well and nobody’s dropping dead at their desks. 

The University of Oxford and Harvard Medical School conducted a formal review of all research papers on cognitive enhancement with modafinil in non-sleep-deprived individuals, dated from January 1990 to December 2014. They found and evaluated 24 studies, which included more than 700 participants total, dealing with different benefits associated with taking modafinil, including planning and decision making, flexibility, creativity, and learning and memory. They also surveyed overall performance enhancing capabilities and side effect reporting. Findings were as follows:

Modafinil made no apparent difference to working memory or flexibility of thought, but did improve executive function, the ability to sift through new information and make plans based on it. 

As to side effects: (70 percent the of 24 studies looked at the effects of modafinil on mood and the side effects of modafinil) In those where side effects were studied, there were very few side effects overall, although a very small number reported insomnia, headache, stomach ache, or nausea, but these were also reported in the placebo group, meaning those who were unwittingly given a “sugar pill” with no biological action. 

As to overall performance enhancing capacity of modafinil: this was found to vary according to the task; the longer and more complex the task tested, the more consistently modafinil conferred cognitive benefits.

Modafinil clearly and reliably enhanced cognition, especially in higher brain functions that rely on contribution from multiple simple cognitive processes. 

Some snippets of findings from other studies:

“It has been shown to increase resistance to fatigue and improve mood.”

In healthy adults, modafinil improves “fatigue levels, motivation, reaction time and vigilance.”

Modafinil is effective at reducing “impulse response,” meaning it reduced the incidence of poor decision making.

Modafinil “…improved brain function in sleep deprived doctors.”

Modafinil “enhanced the ability to pay attention, learn, and remember.”

There is some evidence that modafinil only helps people with lower IQ, but I read validated accounts of years of use associated with validated corresponding increases in IQ, though this could theoretically be due to other unrelated factors. 

How Does Modafinil Work?

Scientists haven’t gotten it all figured out quite yet, but like the psychostimulants we’ve already discussed, modafinil increases the production of norepinephrine and dopamine in the CNS, the neurotransmitters linked to emotional well being, motivation, memory, and focus. At the same time, modafinil may also reduce the production of neurotransmitters that are known for blocking communication between neurons. It also increases the production of histamine, which increases the oxygen concentrations travelling to the brain, making you more awake, or so it’s theorized. Just as the anti-histamine Benadryl dampens histamine and puts some people to sleep, modafinil boosts histamine levels, which has a tendency to wake you up and increase alertness. If you’ve ever had an acute allergy, especially an anaphylactic reaction, and experienced the typical increase in heart rate and blood pressure associated with it (which is also associated with wakefulness and alertness) then you’ve felt the acute effects of excess histamine production. Obviously, modafinil doesn’t cause this level of histamine release, that’s just an explanation of how the release of histamines from taking modafinil are thought to cause a feeling of wakefulness or alertness: from the increase in heart rate and blood pressure associated with their release. Though scientists aren’t exactly sure how it works, they have elucidated that modafinil also enhances several other CNS neurotransmitters, including serotonin, glutamate, and GABA.

The Ethics of Modafinil Use

Pharmacological cognitive enhancers (PCE’s) like modafinil may be used to treat cognitive impairments in patients, but they are more commonly used by healthy individuals in an effort to improve focus, stay awake and alert for extended periods of time, and boost mental and physical performance. This lifestyle use of modafinil by healthy people is increasing, and in fact, it appears that it far exceeds the therapeutic use of modafinil for cognitive impairment and sleep abnormalities. As it enhances cognition and has effects on attention, learning, memory, planning, and problem solving, this lifestyle use raises a number of ethical issues. 

In societies and populations that foster or encourage academic and professional competition, access to knowledge about how to gain a competitive edge and how to perform better in the workplace is a valuable commodity, but not one that tends to be equally distributed across all social groups. As modafinil rises in popularity, will we soon be locked in a productivity arms race, pounding out after-hours spreadsheets with one hand while Googling “latest nootropic advancements” with the other? Some sports organizations already ban the use of prescription psychostimulant drugs- including methylphenidate- without an official ADHD diagnosis, for the same reasons they ban steroids and other performance enhancing drugs. Will employer drug screens soon test for off label modafinil use in an effort to avoid its presence in the workplace? Or will the opposite be the case; will CEOs welcome super sharp workers who never need sleep? Think about the Bezos’ and the Musk’s of the world… will they be adding modafinil to the water coolers? 

Considering modafinil’s popularity, you can be sure that more cognitive enhancing drugs are right around the corner. Will everyone be able to compete? What if you can’t get access to a cognitive enhancer, can’t afford it, or can’t take it due to negative interactions or side effects… are you destined to be stuck in a dead end job or hit an impenetrable corporate ceiling while you watch your friends and co-workers climb the corporate ladder? How about your kids? If you think things are competitive now… just wait ten years. Will they be able to get into a good pre-school without putting modafinil or some other enhancer in their kool-aid, or juice, or whatever you’ll put in their sippy cups? Seriously, will they be able to compete… to get into a good school without cognitive enhancement? In a cognitively enhanced society, what happens to the benefits and self-satisfaction of earning something by the sweat of the brow… especially when that’s just. not. good. enough? Could this lead to a devaluation of hard work and generate less engagement with the world? And if so, what happens to a society where few people see the value of civic work or doing something for the greater good rather than getting ahead? These won’t be hypothetical questions for very long. How about things less under our direct control? Will the FDA save us by prioritizing drugs that preserve lives, or will they bow to pressures from big pharma to prioritize drugs that will undoubtedly be more popular among healthy individuals, have a far larger market, and make more money? 

Hey people… these are things to think about. Don’t shoot the messenger. 

In situations where there is a deficit in performance due to sleep deprivation or fatigue, a medical diagnosis, or learning disorder, there’s no doubt that modafinil can even the playing field. But what about in “normal” healthy individuals? Proponents of modafinil use in healthy individuals argue that it reduces fatigue-related and work-related accidents and improves learning outcomes; in other words, it’s a good thing, so use it. But when it comes to “enhancement” or “optimization” of performance, do the ends always justify the means? To use a sports analogy, does enhancement corrupt the “rules of the game”? If so, does it make the game pointless? Or is enhancement or optimization a slippery slope that leads to the desire to “perfect” human beings? The increase in medical options available to affect human characteristics and abilities over recent decades certainly offers more options to do so, but the desire to want to do so is hardly novel. The difference is that now we’re getting much closer to being able to actually do it. The door is open, and people are walking through it. Some people are running through it. But can we ever turn around to get back to where we were if/ when we find we don’t like what’s on the other side? What happens when average abilities become less the norm, and more of a negative exception… would average people feel fundamentally inadequate?

The ethical implications of the use of modafinil in particular, and smart drugs in general, has become one of the biggest issues in neuroethics and bioethics; it’s got ethics nerds everywhere red faced and arguing, and it’s certainly a favorite topic in the popular media as well, with tons of hype. What about the ethics of biohacking, using any and all, drug and non-drug technologies to improve cognition; ie training and nutrition to boost brainpower, and/ or the application of transcranial magnetic stimulation (TMS), deep brain stimulation (DBS), or brain-computer interfaces (BCI)? There are plenty of biohackers out there- do they have an unfair competitive advantage, or is it mostly acceptable, because a lot of it requires at least more effort and dedication than just swallowing a pill? If most people biohack themselves in order to become cognitively superior, when is superior… superior enough? There could be serious ramifications concerning attitudes towards conventional human abilities in the long term. 

I certainly don’t suppose that I have the answers to these questions, but I know that I’m not the only one asking them. The last question I’ll pose that is still unanswered is: when will we be forced to confront all of the above questions… and then some? Because that day is coming. Of that, I have no doubt.

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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Thank you and be well people!

MGA

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The Skinny on Psychostimulants,Part 2:Methylphenidate Stimulants

The Skinny on Psychostimulants, Part 2: Methylphenidate Stimulants

Last week I introduced a class of drugs called psychostimulants, or central nervous system (CNS) stimulants. As the name states, psychostimulants are “uppers” that stimulate the central nervous system when consumed in varying ways. This class includes the illicit drugs cocaine, ecstasy, and crystal meth, nicotine found in tobacco, and the most commonly consumed drug in the world, caffeine, which is a highly addictive compound that occurs naturally in more than 60 plant species, including the various beans brewed to make the most widely consumed beverage in the world, coffee. Other recognizable sources of caffeine include cocoa beans, tea leaves, and kola nuts. Caffeine is also chemically synthesized for handy inclusion in energy drinks, sodas, and various medications. This class also includes two types of stimulant medications, amphetamines and methylphenidate, which can be found as the bases in a myriad of pharmaceutical products.

In last week’s blog I introduced amphetamines; this week I’ll discuss methylphenidate stimulants. Like amphetamines, methylphenidate stimulants are tightly controlled Schedule II central nervous system (CNS) stimulants that work by stimulating the chemical messengers dopamine and norepinephrine, the neurotransmitters associated with control, attention, fight or flight response, and the pleasure/ reward system in the brain.

While these two types of drugs induce similar effects when taken, the way that they induce those responses, their mechanisms of action, are actually different. Both work to increase levels of dopamine and norepinephrine in the synapses between neurons, which helps messages move from one neuron to the next. Recall from last week that amphetamines have three mechanisms for increasing these levels: 1) they reverse the direction of the transporter pumps that would normally divert dopamine and norepinephrine away from the synaptic cleft, 2) they disrupt cellular vesicles, thereby preventing the storage of excess dopamine and norepinephrine, which frees them up for use in the cleft, and 3) they also promote the release of dopamine and norepinephrine at nerve cell terminals, making them more readily available in the synaptic cleft. Amphetamines’ three mechanisms combined ensure that there are very high concentrations of dopamine and norepinephrine in the synapses of the central nervous system and result in the very strong psychostimulant effects that amphetamines produce. 

In contrast, methylphenidate affects the levels of dopamine and norepinephrine in the synaptic cleft through a single mechanism: by shutting down the transporter pumps that would usually take up excess neurotransmitters. It does not reverse these pumps to cause a flood of neurotransmitters to be released, and does not work to increase neurotransmitter levels through any other actions the way that amphetamines do. As a result, amphetamines are slightly more stimulating than methylphenidate-based stimulants. For this reason, I typically use methylphenidate-based stimulants for children and adolescents and generally reserve amphetamines for use in adults. 

Both amphetamines and methylphenidate are used to treat and control symptoms of narcolepsy, obesity, binge eating disorders, and most commonly, attention deficit hyperactivity disorder (ADHD). Off-label indications, meaning potential uses that are not strictly approved by the FDA, include using either to treat major depressive disorder and in cancer patients to treat weakness, fatigue, and depression. There are also some relatively recent studies that indicate success in using psychostimulants off-label to decrease pain levels as part of a regimen in treating chronic pain patients. 

All stimulants can be prone to misuse, and may be used recreationally in certain populations via oral route, smoking, injecting, or snorting, to get high and/ or to stay awake for long periods of time. And their ability to improve concentration means some people use them to boost cognitive ability, to improve focus, and to study for and/ or take exams. This is a relatively common practice among some college students. 

The two types of medications are available as short-acting medications and in longer acting preparations. Both are essentially equally effective, and have the same benefits, risk(s), and side effect profiles, only varying mainly in their severity, with the profiles associated with amphetamines sometimes being slightly stronger than with methylphenidate. And while I’ve found that most patients respond equally well to either medication, adults to amphetamines and children to methylphenidate, some may respond better to one versus the other. But that’s certainly not a unique feature; that’s always the case with medications, as different bodies respond differently to varying formulations. 

Methylphenidate is most commonly used for treating ADHD, and is FDA approved first line therapy for ADHD patients age 6 and up. While it may seem counterintuitive to treat hyperactivity with a stimulant, this class of drugs have been shown to be the most effective treatment for reducing the symptoms of ADHD. This is because CNS neurotransmitter concentrations are lower in the ADHD brain, sometimes markedly so, and the addition of a stimulant raises the neurotransmitter levels to equal those comparable to the “normal” levels found in the non-ADHD brain. 

Attention deficit hyperactivity disorder (ADHD) is one of the most common neurodevelopmental disorders in childhood, and is associated with impaired functioning and negative developmental outcomes. Children with ADHD find it unusually difficult to concentrate on tasks, to pay attention, to sit still, and to control impulsive behavior. They generally have more difficulty focusing, controlling actions, and remaining still or quiet, as compared to classmates or other people the same age. The American Academy of Pediatrics (AAP) recommends behavior therapy and medication for children 6 years of age and older, preferably both together. The end result in up to 90 percent of cases is that methylphenidate-based stimulant medication helps children with ADHD become more focused, improve their approach to schoolwork, get better organized, think before acting, get along better with others, conform better to societal norms, and break fewer rules. They do better socially, academically, and in terms of self esteem. As a result, they, and their other family members, are happier. In my experience, as the chaos in the patient’s mind is decreased, the chaos that usually follows and surrounds them is also decreased, and that makes for better harmony in the home as well. To put the success of methylphenidate in treating ADHD into perspective, there is no other medication for a psychiatric condition that has such a high response rate. 

In contrast, children with untreated ADHD don’t do as well comparatively speaking. Generally, if the symptoms of ADHD are negatively impacting any area of their life, they are impacting every area of their life, because ADHD is not just an academic problem, it’s a neurobehavioral problem that permeates every aspect of life and affects them academically, emotionally, and socially. Studies have shown that unchecked ADHD symptoms hinder childhood progress, causing a tendency to suffer in school and in social relationships. This negatively affects self-esteem, which causes feelings of anxiety and depression, not only at the time, but as lifelong consequences. The long term implications of low self esteem are well documented and extensive, and nearly always include fairly pervasive anxiety and depression. Low self esteem and all of its many consequences is common in adults with undiagnosed childhood ADHD, as well as from other sources, and it’s a common source of issues that I treat on a daily basis. 

So the lesson is that when weighing risks of treating ADHD with methylphenidate stimulants, recognize that making the decision not to medicate a child with notable ADHD symptoms has its own risks that must be considered. When you take into account that childhood is meant to be a building block and a time to learn, not just math and grammar, but how to make friends and function in the world, what the decision encompasses is a whole person and a whole life, and all that entails. As a psychiatrist, my opinion might be biased, but I might never understand why the decision to treat disorders affecting mental health are made so differently from ones that affect physical health, as if good mental health isn’t as important, or as necessary, as good physical health. I wonder, if a child had diabetes that was negatively impacting their life, would you suggest that child be treated for it, or would you withhold medication from them? Why is mental health treated so differently?

While it has been used safely and effectively for decades, there’s still a great deal of angst and controversy surrounding using stimulants in children with ADHD, one that begs further discussion. I’ll start with some fast facts on ADHD.

ADHD: By the Numbers

Incidence and prevalence statistics always vary according to sources and sampling methods, but the following are the 2020 numbers quoted by the Centers for Disease Control and Prevention.

The number of children ever diagnosed with ADHD is 6.1 million, or 9.4 percent. 

This includes: 

388,000 (2.4 percent) young children, aged 2 to 5 

2.4 million (9.6 percent) of school-age children, aged 6 to 11

3.3 million (13.6 percent) of adolescents, aged 12 to 17

Symptoms of ADHD typically first appear between the ages of 3 and 6.

The average age of ADHD diagnosis is 7 years old.

Males are more than twice as likely to be diagnosed with ADHD than females (12.9% compared to 5.6%).

Despite that fact, the incidence of ADHD diagnosis in girls has increased in recent years. Historically, diagnosis and incidence reporting had been low in girls, but new research indicates how ADHD symptoms manifest differently in boys and girls, leading to better recognition in girls.

ADHD isn’t just a childhood disorder. About 60 percent of children with ADHD in the United States become adults with ADHD, which is about 4 percent of the adult population. 

ADHD severity is generally based on the age at diagnosis:

Mild: Average age of diagnosis is 8

Moderate: Average age of diagnosis is 7

Severe: Average age of diagnosis is 5

Roughly two-thirds of children with ADHD diagnosis have/ have had/ will have at least one other mental, emotional, or learning disorder: most common are depression and/ or anxiety and other behavioral or conduct disorders, but other conditions such as autism spectrum disorder and Tourette syndrome/ tic disorder may also affect children with ADHD.

ADHD On the Rise

Cases and diagnoses of ADHD have been increasing dramatically in the past few years. The American Psychiatric Association (APA) says that roughly 8.4 percent of American children have ADHD, which differs significantly from the statistic quoted by the Centers for Disease Control and Prevention. The numbers vary depending on sampling methods and reference, but they all do indicate one thing: that ADHD diagnoses are on the rise. 

To account for the differences in statistics, there may be an implication that ADHD is being commonly mis-diagnosed, that children are being diagnosed with ADHD when they don’t actually have it. In reality, while ADHD isn’t a fast, easy diagnosis to make, there are strict and clear cut guidelines for diagnosis that make mis-diagnosis fairly rare. There must be a comprehensive evaluation using multiple collaborative sources (including interviews with the child, the parent(s), and typically the teacher), established symptom rating scales, observation by a physician, and cognitive and/ or academic assessments. A valid diagnostic appraisal takes time, so while mis-diagnosis certainly occurs in a very small percentage, it is certainly not responsible for the rise in numbers. 

What is responsible? The answer is multi-faceted, and includes: the increase in research and development in making the diagnosis, the decrease in the stigma associated with seeking help and/ or being evaluated for and/ or potentially having the diagnosis, and the increase in public awareness of ADHD. Many of today’s ADHD patients would have been yesterday’s “problem children.” In other words, we simply know better now, so we do better. Physicians are better trained in how ADHD manifests itself, especially in girls, since it’s stereotypically been a “boy disorder,” and everyone involved, including physicians, parents, and teachers, are more alert and pay closer attention to the disruption that behavioral issues cause in the classroom to everyone, not just the student with ADHD. 

The question then may be asked if more kids are actually experiencing ADHD today than they were before, and if so, why? We now know that ADHD is caused by a mix of genetic and environmental factors, and current best estimates indicate that about 70 to 80 percent of the risk for ADHD is genetic. But it’s not very clear cut or simple, where you either have an “ADHD gene” or you don’t, and there’s no single marker to look for or confirm a diagnosis. Instead, each gene involved in the condition contributes a certain amount of risk for developing it. The genetic component is complicated, but we really know even less about the environmental component, which makes up the other 20 to 30 percent of the risk of developing ADHD. The environmental risk factors we are fairly sure of- the ones we have the strongest and clearest evidence for- appear to be preterm birth and low birth weight. We also know that it is likely that if in fact we are seeing a true rise in ADHD cases over the last 20 years or so, as we believe we are, environmental factors must play an important role in it, simply because genetics don’t change that quickly. Some studies have suggested that exposure to toxins (ie lead exposure, smoking during pregnancy) may play a role, and that traumatic brain injuries may also play a role in increasing risk of developing ADHD. In the end, the rise in the number of cases is most likely to be a combination or interaction of all of the above factors, and that some environmental factors interact with certain genetics to increase a child’s risk of developing ADHD. What else do we know about increasing numbers of ADHD cases? That we always need and want to know more. 

Methylphenidate Medications

There are several methylphenidate product formulations, including oral tablets and capsules in immediate release/ short-acting, extended release/ long acting, chewables, liquid, and patches to be applied to the skin. There’s even a formulation called Jornay PM, which is taken at night, but only becomes active in the morning. All are derived from essentially the same basic methylphenidate compound. Immediate release or short-acting formulations typically begin to work about 30-45 minutes after ingestion and last about 3-4 hours, while extended release generally last about 6-8 hours, though there are of course exceptions that may release even more slowly and last longer.

Ritalin is a short-acting formulation of methylphenidate that lasts about 3-4 hours. Focalin is another form of methylphenidate that also lasts about 4 hours. Both of these medications begin to work about 30-45 minutes after taking them. For children who have trouble swallowing pills, this medication can be crushed and mixed with foods. There is also a liquid and a chewable tablet form of the short-acting methylphenidate.

Other preparations of methylphenidate have been created to release the medication over a greater period of time, extending the duration of the effect of the medication. This is of great benefit when trying to provide a response that lasts through a school day, typically 6-8 hours. Some of these compounds take effect as quickly as the short-acting forms of these medications. 

Concerta is one of the longest-acting methylphenidate medications on the market, lasting 8-12 hours. Concerta can’t be chewed or opened. It has to be swallowed whole in order for it to work the way it was designed. This can be a problem for some kids.

Ritalin-LA and Metadate CD are capsules that are filled with medication. These medications are very similar in that they both last about 6-8 hours. These are better for kids who can’t swallow pills, because you can open up the capsule and sprinkle it on foods like yogurt, applesauce, peanut butter, etc.

Aptensio XR and Focalin XR are also capsules filled with medication that can be opened and mixed with food. They typically work longer than Ritalin LA or Metadate CD.

Quillivant XR is a long-acting formulation of methylphenidate in liquid form, which makes it a good alternative for kids who have trouble swallowing capsules and can’t tolerate beads on food items either.

Quillichew ER is a chewable long–acting formulation of methylphenidate that can last up to 8 hours.

Daytrana is a methylphenidate patch. It’s another good option for kids who can’t swallow pills. You can wear the patch for up to 9 hours, and often get another hour’s worth of response after the patch is removed. But if using the patch, understand that it can often take 1-2 hours from application to the skin to start working.

Potential Benefits of Methylphenidate

In truth, the benefits of treating ADHD with stimulants are too vast to really list when you consider long term implications, but for our purposes, I’m only dealing with direct observed benefits when treating ADHD with methylphenidate stimulants here. 

Methylphenidate based medications have been proven to reduce the disruptive and troublesome symptoms of ADHD, making kids less hyperactive, less impulsive, more focused, and less distractible, with few side effects, if any, when the medications work properly. However, it’s important to note that these medications cannot treat or correct learned behaviors or other types of learning disorders.

The Benefits of Methylphenidate on ADHD Brains: What Science Says

Much of the controversy that surrounds treating childhood ADHD with  methylphenidate stimulants has to do with concerns about long term implications, mainly regarding brain development. Recent research on the neurobiological and anatomical underpinnings of ADHD has shed some light on this subject. 

Several years ago, neuroimaging work confirmed that there are neuroanatomic, or structural differences, in the brains of people with ADHD versus those without ADHD, especially in the frontal cortex, which is involved with attention, organization, abstract thinking, and keeping track of things. It was also confirmed that total brain volume, made up of gray and white matter, also differs.

Regarding anatomical brain differences, specifically, children with ADHD had overall smaller brain volumes, by about 3 percent, than children without ADHD, though it is important to note that intelligence is not linked to or affected by brain size. In addition, five of the regional areas in the deep brain that pertain to regulating emotion, motivation, and emotional problems- the caudate nucleus, putamen, nucleus accumbens, amygdala, and hippocampus- were smaller in people with ADHD; and some showed structural deformations as well. The brains of children with ADHD showed decreased cortical thickness in the prefrontal cortex, and less white and gray matter. 

White matter affects learning and brain functions, and acts as a relay to coordinate communication between different brain regions. White matter consists of axons, or nerve fibers, which have a myelin sheath whose color gives the area its name. Think of these myelinated nerve fibers of the white matter as the wiring of the brain- where information is carried from one point to the next- and these are insulated, so that the information is conserved, ie doesn’t “leak out” as it’s carried. Grey matter is the more outward layer of the brain that serves to process information in the brain and directs sensory stimuli to nerve cells in the central nervous system where the synapses induce the response to that stimuli. The grey matter has more connections than white matter, but isn’t as insulated as myelinated white matter; so this area relates more to memories and facts which are used every day to help a person function optimally.

In fact, further studies have shown that the structural differences in ADHD brains tended to be most observed in the brains of children with ADHD and not as much in ADHD adult brains. This is likely an indication that childhood is an important time to treat ADHD, which seems to be confirmed by further research. All in all, the findings led researchers to state that ADHD is a function of atypical brain structure and atypical chemical development. A few years ago, a research group took these findings a step further. Given the success of methylphenidate in treating the symptoms of ADHD, which is basically correcting the atypical chemical differences in neurotransmitter levels, they looked at the effects of methylphenidate on brain structure. 

The study found that childhood psychostimulant medication (methylphenidate) led to volume normalizations in several areas where volume levels were known to be reduced in the ADHD brain. Normalization means that where they were previously reduced prior to treatment with methylphenidate psychostimulant medication, they were increased to the point of reaching levels found in “normal” non-ADHD brains after being treated with the psychostimulant methylphenidate.

These studies found that specifically, overall white matter volume and grey matter volume normalized, or “resolved” after childhood treatment with psychostimulant, as did anterior cingulate cortex (ACC) volume, which is implicated in several complex cognitive functions, such as empathy, impulse control, emotion, and decision-making. When they looked at the largest part of the brain, the cerebral cortex, which is the ultimate control and information processing center, responsible for higher-order brain functions of sensation, perception, memory, association, thought, and voluntary physical action, they found that the ADHD-related thinning that had been present, was moderated by childhood psychostimulant treatment. The ADHD-related size reduction of the deep brain structures, which are key to learning, memory, reward, motivation, and emotion, normalized after psychostimulant treatment, as did deformations of the caudate nuclei, when present. 

One hypothesis that they had looked to prove or disprove was that methylphenidate treatment of ADHD during childhood and adolescence, but not during adulthood, would stimulate white matter, striatal, and frontal cortical development, resulting in more adult-like values. And in fact, their findings did prove this. This is important, because it is an age-related treatment response. It essentially means that when you treat childhood ADHD with methylphenidate in childhood, the methylphenidate stimulates a response that normalizes most of the abnormalities found in the brain of the child with ADHD such that they are comparable to normal adult values later. That’s a good thing.

Another study looked at behavioral changes associated with using methylphenidate, and found that, relative to periods off medication, ADHD patients on medication have fewer motor vehicle accidents, have a lower risk of traumatic brain injury, are less likely to engage in criminal activity, have lower rates of suicidal behavior, and have lower rates of substance abuse. Why? Because it seems that when neurotransmitter levels are normalized, behavior is normalized as well, which makes behavior when on medication safer, more risk averse, ie less risky. The authors end the report of their findings with this: “Thus the answer to the question ‘Is there long-term benefit from stimulant treatment for ADHD” is a definite “Yes!'”

Potential Negative Side Effects of ADHD Stimulant Medications/ Methylphenidate

Most side effects associated with methylphenidate are very mild and temporary, but if they exist, are likely to be dose or formulation related, as it can take some time to find the appropriate medication and dose. If you find that any side effects are intolerable or persist, it’s important that you inform the prescribing physician. In addition, the dose should be re-evaluated each year, even if there are no issues, as the medication needs can change over time, especially in growing children. 

Decreased Appetite

This is the most common side effect of stimulant medications. The loss of appetite may happen just while the medication is effective, and then wear off, as the benefits of the medication do. Children may be very hungry once the medication wears off, and if they haven’t eaten, they may also be irritable, aka hangry. This is typically a manageable problem, but the issue should be discussed with the physician who prescribes the medication if it persists or is intolerable.

Insomnia/ Sleep Problems

There may be issues with falling asleep associated with methylphenidate. This is usually fairly mild, and it tends to occur more in younger children who might have already had issues with falling asleep before they started the medication. There are many things that can interfere with falling asleep or manifest as sleep issues, so it’s important to determine if any external causes (other than medication) may be present. These can include poor or irregular sleep schedule, excess screen time/ blue light exposure right before bed, academic concerns/ worrying about school tests, or social issues with friends. Again, problems falling asleep are likely to improve over time, but may also be overcome by changing either the time or type of the medication that is given. For example, if a second or third dose of a short-acting formula is taken too late in the day, it may not have worn off by bedtime, which could cause the issue. This can be addressed by the physician with formula or dosing changes.

Mood Changes

There is a small subset of children with ADHD who may seem moody and irritable when they take stimulant medications, even if they are taking the best possible dose. If this is going to happen, it usually happens right away, as soon as they start taking the medication, and goes away immediately when they stop taking it. If this happens, it may help to switch to a different formulation or dose, so inform the prescribing physician right away to discuss potential alterations. Sometimes when a stimulant dose is too high, especially in children, they may begin to look tired or experience irritation. If this happens, the prescribing physician may opt to adjust the dose until the right dose is found: one in which the child gets the most benefit from the medication with the least possible side effects.

“Wear-Off” Effects

While this isn’t technically a side effect, a very small minority of children experience behavioral changes as their ADHD medication wears off, which typically occurs at the end of the school day. Some parents call it “rebound” but that term can be a bit misleading. They can seem more irritable or emotional, but it is usually a mild transient finding. Sometimes it’s related to being hangry or overtired, but it can be connected to the medication level dropping, and strategies that create a more gradual decrease in the medication level may help relieve it. Obviously, discuss with the prescribing physician if you notice it and believe it’s due to the medication levels. 

Tics

About 10% of kids with ADHD will have concomitant tics, whether or not they take methylphenidate, so that translates to a fair number of children. Tics usually start between 6 and 8 years of age, which is often when kids also first start taking a medication for ADHD. Tics may also be transient, and may come and go over time. The best we know from a series of studies, is that stimulants don’t cause tics, but if tics are present, sometimes methylphenidate can aggravate them. Despite this, methylphenidate may possibly still be used, but treatment should be more closely monitored if this is the case. If tics increase significantly during treatment, there may be an option to use a non-stimulant medication that affects the brain in a different way. 

Non-Stimulant Medications for ADHD

There are two types of non-stimulant medications that can help to alleviate some symptoms of ADHD. While they don’t have the efficacy that stimulants do, and they have very different side effect profiles, they may be an option worth trying if stimulants aren’t a viable option due to concomitant disorders like tics. Just as with stimulants, it may take several attempts to find the right medication and dosage, with the least side effects.

Clonidine (Catapres, Kapvay) and guanfacine (Tenex, Intuniv) are called alpha-adrenergic agonists, and these medications were developed to lower high blood pressure in patients with hypertension. But they are also prescribed in adjusted doses for children with ADHD who don’t tolerate stimulants well, and are sometimes also used to treat tics. These medications can cause fatigue related to low blood pressure, so blood pressure and heart rate must be regularly monitored while taking these medications. These are typically short-acting medications that require several doses each day, but they come in longer acting versions, Kapvay and Intuniv.

Atomoxetine (Strattera) is in a class of drugs called norepinephrine reuptake inhibitors. Norepinephrine is one of the CNS neurotransmitters needed to control behavior.

Unlike stimulants, Atomoxetine can take 4-6 weeks to take effect and has to be taken daily.

Busting Myth-information

There’s a great deal of false information out there on ADHD and stimulants. 

Does using stimulants stunt growth?

In spite of concerns that have been voiced regarding growth and stimulants, a recent well-validated clinical study showed that neither ADHD, nor treatment with stimulants, was associated with a decrease in growth rate during the maximum growth period in childhood, or a change in final adult height. Combined with other studies, it is clear that treatment with stimulants has no impact on growth rate or final adult height.

Are psychostimulants addicting?

Provided they are taken via the prescribed route, at the level they are prescribed for ADHD, methylphenidate medications do not raise the dopamine level high enough to produce euphoria, and they are not considered addictive.

Does using stimulants make children prone to addiction later in life?

Observational studies conclude that stimulant medication to treat young children with ADHD does not affect- neither in an increasing nor decreasing way- the risk for substance abuse in adulthood.

Does using stimulants change a child’s personality?

ADHD medications should not change a child’s personality. If a child taking a stimulant seems sedated or zombie-like, or tearful and irritable, it usually means that the dose is too high and the clinician needs to adjust the prescription to find the right dose.

Does using stimulants have negative long term effects?

In over 50 years of using stimulant medications to counteract the symptoms of ADHD, and hundreds of studies, no negative effects of taking the medication over a period of years have been observed. On the contrary, using methylphenidate to treat childhood ADHD especially, is associated with the positive effects and benefits of normalization of neurotransmitter levels and structural brain differences.

Using Methylphenidate for ADHD in Children:

Parental Considerations

As a parent, making a decision to place a child on a stimulant for ADHD isn’t to be taken lightly. As a physician, it’s certainly one I take very seriously. The following are things to keep in mind when weighing the decision.

All research studies indicate that stimulants are the most effective treatment for symptom reduction in ADHD. 

Methylphenidate has been used for decades, and is considered safe and generally well tolerated by most people, including children and adolescents, with low side effect profiles. 

Do a risk/ benefit analysis. You have to weigh the risks associated with treating ADHD with a safe and effective stimulant with a good track record versus not treating the ADHD, and all of the areas of the person’s life that decision impacts, including the well documented academic and social implications. In the total analysis, the risks associated with living with untreated ADHD are generally greater than treating with a methylphenidate stimulant that has an excellent safety profile and actually has the benefits of normalization of neurobiological and structural brain anomalies associated with ADHD. 

When the symptoms of ADHD are negatively affecting every aspect of a child’s life, medication is a better and safer alternative than allowing that negative impact to persist throughout school age years and beyond.

Methylphenidate, like all medications, may cause some side effects, but most are mild, temporary, and/ or can be relieved by a change in formulation or dosing. It may take some trial and error to find the prescription and dosage that works well with the least side effects. While this may take time and patience, it’s time well spent. 

Deficiencies in neurotransmitters such as those in ADHD also underlie many common disorders, including anxiety, mood disorders, anger-control problems, and OCD, obsessive-compulsive disorder. As a result, ADHD often occurs concomitantly with other disorders. In other words, ADHD may not be the only thing going on with an ADHD brain. At least two-thirds of people diagnosed with ADHD are also diagnosed with at least one other mental health or learning disorder in their lifetime, according to the American Academy of Child and Adolescent Psychiatry. Some of the more common accompaniments, especially in children, include anxiety disorders, depression, and learning and language disorders. As a parent, you may find you’re looking for the right mix of medications or treatments for multiple issues.

Granted, there are a lot of issues to consider, but hopefully I’ve managed to cover most of them here. My opinion is clear, and it is that overall, given the high efficacy, the track record, the safety, and the many well proven benefits of its use, methylphenidate treatment for ADHD far outweigh the risks associated with not treating it. 

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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The Skinny On Psychostimulants

The Skinny on Psychostimulants

Happy 2021 people! Are you as happy as I am that 2020 is finally in the rearview?! Weirdest. Longest. Year. Ever. 

That actually makes me think of a new and hilarious commercial I just saw for a big online dating site. It starts out with Satan bored out of his mind in hell, and then he gets a text message from the site saying he’s been matched with a girl, and he’s very intrigued. When they meet, it’s obvious that they’re both instantly smitten. Then the starry-eyed girl introduces herself as 2020. They fall in love. And they live happily (?) ever after… apparently in hell. Unless they stay at her place I guess. Anyway, 2020 is over, even though unfortunately, we’re still schlepping some of its covid baggage, but hopefully not for much longer. 

Considering the euphoria surrounding the new year and the stimulation of resolutions, I thought it very fitting that I start with a three part blog series on pharmacological central nervous system stimulants, aka psychostimulants. One of the main compounds in this class of drugs are the amphetamines, and that will be today’s blog topic. 

As psychostimulants go, amphetamines are very strong ones; they are a group of very tightly controlled and well monitored schedule II drugs. Add a little carbon atom, bind some hydrogens to it, and you’ve got a methyl group; and that makes it methamphetamine, which everyone’s heard of. When prescription methamphetamine is (very) illegally altered…tah-dah…you’ve got crystal meth, aka speed, ice, crank, etc. Other examples of psychostimulants include caffeine, nicotine, cocaine, and other prescription compounds that I’ll cover next week. 

Because of their stimulant activity within the central nervous system, prescription amphetamines are used in the treatment of several disorders, including narcolepsy, obesity, binge eating disorders, and very commonly, ADHD, or attention deficit hyperactivity disorder. They can also be used recreationally in certain populations to get high, to stay awake for long periods of time, and/ or to improve focus and study for exams. In fact, it’s those last two that make amphetamines very popular party favors among college students.

Structurally speaking, amphetamines are drugs that are related to catecholamines, which are chemical messengers that help transmit a message or signal across neural synapses in the central nervous system, from the terminal end of a transmitting nerve cell to the receiving end of a target nerve cell. In an over-simplified explanation, when a signal gets to the end of one neuron, catecholamines help the signal jump to the beginning of the next neuron, hence the name “neurotransmitter.” That message is repeated billions upon billions of times, as there are billions upon billions of neurons in the central nervous system. These neural signals activate emotional responses in the amygdala of the brain, such as fear in a “fight or flight” situation. At the same time, catecholamines also have effects on attention and other cognitive brain functions. Examples of catecholamines include the neurotransmitters dopamine, epinephrine, and norepinephrine. Pharmacologically speaking, amphetamines increase levels of the specific neurotransmitters dopamine and norepinephrine in the neural synapses, which helps the message to make the jump from one neuron to the next. In a way of thinking, amphetamines “speed” the transmission of the message by increasing the levels of these neurotransmitters. Amphetamines increase these dopamine and norepinephrine levels through three different mechanisms of action, at least that we know of: 1) they reverse the direction of the transporter pumps that would normally divert dopamine and norepinephrine away, 2) they disrupt cellular vesicles, thereby preventing the storage of excess dopamine and norepinephrine, which frees them up, and 3) they also promote the release of dopamine and norepinephrine at nerve cell terminals, making them readily available in the synaptic cleft. These three mechanisms combined ensure that there are very high concentrations of dopamine and norepinephrine in the synapses of the central nervous system. The “catecholaminergic” (try that one next time you play scrabble) actions of increasing the levels of dopamine and norepinephrine result in the very strong psychostimulant effects that amphetamines produce.

You’ll notice that I keep saying amphetamines, plural. Why? Because like the neurotransmitters dopamine and norepinephrine it effects, amphetamines are chiral molecules; this is a fancy way of saying that in their three dimensional world, they can exist in different forms called enantomers (more scrabble points!) that are mirror images of each other. I know this sounds complicated, but it’s really not. Think of it as “handedness.” Your left and right hands are mirror images of one another: they look similar, except the placement of the fingers and thumbs are mirror images, and they can do pretty much the same things, like hold a fork or a pencil, but the way they do so differs slightly. The same is true of amphetamines. The two enantiomers of amphetamines are usually referred to as dextroamphetamine (also denoted as d-amphetamine) and levoamphetamine (also denoted as l-amphetamine). All prescription amphetamines boil down to four variations of the amphetamine molecule, which have markedly similar, but potentially slightly variable effects: dextroamphetamine, aka dexadrine; lisdexamphetamine, which is a precursor or pro-drug of dextroamphetamine; methamphetamine, aka methamphetamine HCL, which has that methyl group I mentioned before; and mixed amphetamine, which is essentially a mixture of dextroamphetamine and levoamphetamine at a specific ratio. 

Of those four active forms of amphetamines, there are several brand name drugs on the market, some of which have generic forms available. They are all oral formulations that may be immediate-release, which are typically taken twice a day, or extended-release, which are obviously released more slowly and taken once a day. 

Adderall XR (generic available)

Dexedrine (generic available)

Dyanavel XR

Evekeo

ProCentra (generic available)

Vyvanse

Methamphetamine (Desoxyn)

The desired effects of amphetamines include: stimulation (thank you Captain Obvious), increased alertness, cognitive enhancement, euphoria, and mood lift. Amphetamines have been around for a long time and when taken as prescribed, they’re fairly safe, but there are potential negative side effects. These can include insomnia, hyperfocus, GI irritation, headache, anxiety, slight increase in heart rate and blood pressure, and anorexia. There is addiction potential associated with amphetamines, and there is a short and fairly mild associated withdrawal period where one might feel some fatigue, sleep a lot, and experience strange dreams. 

When taken as directed, and by mouth, usually 20mg – 40mg per day, amphetamines are fairly safe. However, when smoked, injected, or snorted, they are decidedly UNsafe; especially in large doses. I’ve seen people take up to 1000mg per day… though not for long. Why? Because they usually end up dead of overdose. What happens if you choose to use amphetamines in large quantities and/ or via routes other than oral? Hallucinations, delusions, psychosis, seizures, cardiovascular collapse/ arrest, stroke… the bottom line is it ain’t pretty, people, so don’t do it. 

Because amphetamines have multiple mechanisms of action and thereby are very strong psychostimulants, I generally restrict their use to adults only, and choose to use another type of psychostimulant in children called methylphenidate. And that will be the topic next week in psychostimulants part 2 of 3. 

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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Blog Part 3:The Future Of Sex Toys

Hey people!

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

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

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

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

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

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

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

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

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

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

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

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

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

Housekeeping is almost done here people. 

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

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

I really appreciate it.

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

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

Thank you and be well people!

MGA

Now without further ado, this week’s blog…

Part Trois du Trois: 

The Future of Sex Toys

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

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

Sex Tech

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

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

From Sex Industry to Sex Tech

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

Sex Tech Defined

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

Now that we’ve cleared that up…

What Will Sex Toys Look Like In The Future?

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

Let’s explore some data:

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

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

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

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

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

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

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

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

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

Back to the Future… of Sex Toys

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

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

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

More Options, More Orgasms

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

Alexa… Oh Yeah, Right There Alexa!

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

Integration Innovation

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

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

VR and LDR

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

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

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

Teledildonics, Cyberdildonics, Digisexuality… Oh My!

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

No Partner? No Problem! 

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

Sick of People? Date a Robot!

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

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

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

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

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

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

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

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

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

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

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

#1: Remote Long Distance Sex

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

#2: Virtual Sex, Cybersex

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

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

#3: Robot Sex

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

#4: Immersive Entertainment

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

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

#5: Augmentation

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Embracing Sex Tech: Problems & Solutions

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

…Very Different from Embracing Sexbots!

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

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

Issues: Sex Dolls and Bots

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

Monetary Costs of Sex Dolls and Bots

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

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

And this was a new one on moi…

Enter the Slutbot Sexting Tutors

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

The True Future of Sex Toys Is Non-Binary

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

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

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

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

A Victorian Take on Remote Sex

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

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

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

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

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

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

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

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

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

Potential Real World Ramifications of Sex Tech

Teledildonics Biggest Winners: Sex Workers

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

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

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

Teledildonics’ Biggest Losers: Women Who Abhor Porn and Snoops

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

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

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

Sex Tech Psychology

The End of the World as We Know It?

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

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

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

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

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

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

Thanks- be well, people!

MGA

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Postpartum Depression,Signs,Symptoms,and Treatment

Postpartum Depression: o

Signs, Symptoms, New Treatment?

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

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

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

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

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

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

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

Postpartum Signs & Symptoms

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

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

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

Beyond the Blues

Common Red Flags for Postpartum:

-Mom withdraws from partner

-Mom’s unable to bond well with baby

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

-Mom feels guilty, worthless, useless, overwhelmed

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

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

Postpartum Causes/ Triggers

Hormonal changes after childbirth cause fatigue and depression:

 -Progesterone/ estrogen levels drop

 -Thyroid levels can drop

 -Changes in blood pressure, immune system functioning, metabolism

Numerous physical/ emotional changes after delivery: 

 -Physical delivery pain

 -Difficulty losing baby weight

 -Insecurity, especially in physical/ sexual attractiveness

Significant stress of caring for a newborn:

 -Mom is sleep deprived

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

 -Mom has difficulty adjusting

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

Postpartum Risk Factors

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

  -History of postpartum depression

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

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

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

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

Postpartum Psychosis

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

Postpartum Psychosis Symptoms

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

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

  -Delusions: paranoid, irrational beliefs

  -Extreme agitation and anxiety

  -Suicidal thoughts or actions

  -Confusion and disorientation

  -Rapid mood swings

  -Bizarre behavior

  -Inability or refusal to eat or sleep

  -Thoughts of harming or killing baby

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

Coping with Postpartum Depression

Four Tips for Moms:

1) Create a secure attachment with baby.

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

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

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

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

2) Lean on others for help and support.

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

Ideas to better connect with others:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Treatment for Postpartum Depression

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

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

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

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

Helping New Moms with Postpartum

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

Tips for Partners:

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

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

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

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

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

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

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

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

Edinburgh Postnatal Depression Scale

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

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

____  As much as I always could

____  Not quite so much now

____  Definitely not so much now

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

____  As much as I ever did

____  Rather less than I used to

____  Definitely less than I used to

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

____  Yes, most of the time

____  Yes, some of the time

____  Not very often

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

____  No not at all

____  Hardly ever

____  Yes, sometimes

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

____  Yes, quite a lot

____  Yes, sometimes

____  No, not much

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

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

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

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

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

____  Yes, most of the time

____  Yes, sometimes

____  Not very often

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

____  Yes, most of the time

____  Yes, sometimes

____  Not very often

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

____  Yes, most of the time

____  Yes, quite often

____  Only occasionally

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

____  Yes, quite often

____  Sometimes

____  Hardly ever

____  Never

SCORING VALUES AND GUIDE

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

0 As much as I always could

1 Not quite so much now 

2 Definitely not so much now 

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

0 As much as I ever did 

1 Rather less than I used to 

2 Definitely less than I used to 

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

3 Yes, most of the time 

2 Yes, some of the time 

1 Not very often 

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

0 No, not at all 

1 Hardly ever 

2 Yes, sometimes 

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

3 Yes, quite a lot 

2 Yes, sometimes 

1 No, not much 

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

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

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

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

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

3 Yes, most of the time 

2 Yes, sometimes 

1 Not very often 

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

3 Yes, most of the time 

2 Yes, quite often 

1 Not very often 

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

3 Yes, most of the time 

2 Yes, quite often 

1 Only occasionally 

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

3 Yes, quite often 

2 Sometimes 

1 Hardly ever 

0 Never 

EPDS Score Interpretation/ Action

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

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

Score of 12 to 13: fairly high possibility 

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

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

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

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

MGA

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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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How To Interact With The Mentally Ill

How to Interact with the Mentally Ill

The purpose of this piece is to help the reader how to interact, both verbally and nonverbally, with people with mental illness; and as a corollary, how to get them the help they need. It’s basically a list of do’s and don’ts that I have compiled in my head over many years of seeing patients and dealing with their loved ones… becomes sometimes the former are far easier to deal with than the latter. Anyway, I’m constantly asked, “What do I do? What do I say?” Well, here is the answer to those.

Look, I understand that it’s very difficult when a loved one has a mental illness. A lot of issues come into play; a lot of balls in the air. So learn to juggle. Please understand that in some cases, logic no longer applies here, because when the mentally ill person is your child, your sister, your brother, your mother, your father, the rules don’t apply anymore; the book is out the window. But yet without it, you still have to figure out how you can help them while also respecting them, maintaining their dignity, and helping them to seek effective treatment. There are always degrees of everything. Some patients may be very independent and autonomous and need little help, and some may require a lot of help to get through their days. For the tougher cases, it may be easy to say, “Oh, just send them away to the hospital,” but that’s not how it this works. If you love them, that’s exactly what you don’t do. No finger snap and off they go, no fuss, no muss. Do be prepared to get appropriately fussy and mussy when, and if, necessary. It may not be necessary. But it may be. 

Denial. Nope. You no longer have this luxury. Don’t pretend that they don’t have an illness. This is one of the most common issues that I see, families and friends sticking their heads in the proverbial sand. “He’s just eccentric!” Ugh, how I hate that word. No. Running naked across the Brooklyn Bridge while chased by half of the NYPD is not eccentricity. It is not a statement. It is not a personality quirk. And turning a blind eye is nothelpful. Loved ones that continuously make excuses for unusual, inappropriate, and/ or dangerous behaviors just allow the illness to flourish, a pretty word for get waaaay worse. I’ve seen too many depressed people make multiple suicide attempts and still not get the help they desperately need. Psychotic people walking around the neighborhood arguing with people only they see, and still the families don’t intervene, because it’s their loved one. They don’t want to interfere or take away that individual’s rights. In the United States, sometimes it’s not until the police finally arrest the person that they are offered help. But a lot of times, not even then. Families make excuses for a lot; too much, really. We live in a system where it is very difficult to give treatment to someone who doesn’t want it. The laws are very weak in terms of forcing people into treatment. So what happens far too often is that these people end up self-medicating with illicit drugs, living on the street, and suffering all of the consequences of being mentally ill without a place to turn to. And if you’re thinking that couldn’t happen to your loved one, you’d be taking a gamble there. Sadly, I’ve had patients belonging to some very wealthy Palm Beach families that managed to find their way from society to sidewalk, just because people were in denial, turned a blind eye, didn’t want to infringe, made excuses, whatever the case was… the end was still the same. If the person in question is a friend, or for some reason you don’t feel it’s your place to discuss treatment with them, then find out who you should talk to, and do so. Also, consider that you might be the only person in a place to see or know what’s really going on. You may be the one who has to make the difference for them, the one standing between them and help. So no denial, no blind eye, no excuses. If you love them, you have to face the issue head on in the appropriate way. It’s the only compassionate thing to do, and the most compassionate thing you can do. 

Get some stick-to-it-itiveness and give some hope. Tell your loved one that they can get better, that treatment is available, and that better days will come. And once you do establish a treatment regime, good follow through is very important. Dounderstand that treatment can take years. It could even be a lifelong kind of deal. It won’t always be hectic and scary, a rollercoaster of loop de loops. Truthfully, it might even get monotonous, this appointment, then that one; this med, then that one. But I can tell you that once you find the right regime, if you stick to it, it will be rewarding. Just be supportive and keep standing by them. It may not always be the easiest thing ever, but it may well be the most rewarding thing ever. 

Education is more than a do, it is a must. Everyone, the primary caregivers, ancillary caregivers, friends, families, associates, everyone should become educated. And as I said above, always instill hope and be supportive. This can and does get better. Be willing to help this person from A to Z, whether these things are obvious or not: to seek help, to help make their appointments, to make their appointments if they can’t for any reason (and yes, sometimes this is hard for them to do), to get to their appointments, to get to the hospital, to get to the day program, to get to the intensive outpatient program, to get to detox, to get to the treatment center, to the ER, wherever or whatever or whenever they need help.  

Always express genuine concern.  It is critical. They have mental illness, but that doesn’t mean they are stupid.  They see through bull#%*£ as easily as you do. If they sense fake concern, they will assume that they’re a burden, you just want to get rid of them, or just want to shut them up. Captain Obvious says that this will be a blockade to their progress. I say that this could be the last blockade of their lives, and not in a good way. You never know when someone is at a tipping point. If you love them, do be honest, caring, and honestly caring. 

Share “simple” insights. I use quotation marks, because sometimes what is simple to you may not be so simple to the person with mental illness. Depressed people may not be able to discern what’s good for them, or may not care what’s good for them. Daily activities tend to fall by the wayside when a human brain is contemplating if it’s worth it to live to see tomorrow, so they may not care what they’ll smell like tomorrow, or if their hair is combed and teeth are brushed tomorrow. It’s not uncommon for ADL’s (activities of daily living) to not make the to-do list. If you note this, do address it, but it’s important to do so in a specific way. Always be gentle. You don’t want to be mean or make them feel any shame. You can say “Maybe you want to take a shower today?” or “Would you like me to run a bubble bath for you? I bet you would feel great after you relax in a hot bath; I know I always do.” Do this in as gentle and open a tone as you can. Or if they’ve made a big mistake on something consequential, “Maybe it’s best to check your oil levels every few months, just to avoid any problems. We could even put it on the calendar if you want” or “I understand you’re upset that you failed your test (or burned the cookies, broke a vase, lost a jacket) but it’s not the end of the world and you’ll do better/ know better next time. Don’t make a mountain out of a molehill, and don’t ever yell or chide them. They have feelings just like you do, but they may not have the capacity to take things on the chin like you do. Obvi they don’t want their car to be overheating, or a failed test, or burned cookies, and they’re probably already giving themselves a hard enough time as it is. There may be situations where inappropriate behavior related to their illness might have consequences from others, ie they may accuse someone of acting against them due to paranoia, eliciting a negative response. Or, maybe they’ve dressed a certain way and they’re made fun of or bullied in some way. Firstly, this can be a teaching moment, where you can educate that other person about mental illness or how all people are different. But then when you discuss it with your loved one, you can say “Maybe next time, try not to be so direct” or “…try to be less accusatory” or “…should dress more appropriately” or “If you were a little more open, it might be easier to make friends.” Whatever the case may be. Don’t demand this or that. Do just make suggestions, easy breezey lemon squeezey. Don’tmake a federal case out of stuff. “You know what, I understand that you believe that there are little aliens in the wall shooting you with energy beam guns, but people would disagree with you, so I don’t think that you should share those thoughts with people, because they may judge you in a negative way if you do.” Don’t put them on the defensive. Always find common ground and let them know that it’s safe to tell you anything and everything through encouragement. If they say, “The CIA have me under surveillance, and they’re reporting me to the president. They’re coming to take me to jail.” The safe common ground is usually that you know they think or believe whatever the thought is, ie “I know that you believe that, and it could happen, but I think it’s unlikely, so I wouldn’t worry too much about it.” You can also add “Do you think you should mention that to Dr. Psychiatrist next time? I think he/ she would like to know that, don’t you?” Do make them feel safe to tell you whatever it is they may be feeling by not being judgemental. Do keep an open mind and once again, remember that mental illness has nothing to do with one’s intelligence.  

Be aware of expressed emotion. It is exactly what it sounds like… how you express your emotion. You’re not a saint or an angel, you’re human, and you’ll have normal emotions like anger and frustration. But do pay attention to how you express it. Do take a breath, take a moment before you respond so that you can control how you express yourself. By the way, this is actually a good idea for everyone, no matter who you are or aren’t dealing with. Don’t ever raise your voice. Doalways speak in a relaxed and calm manner. Don’ttalk quickly. Don’t ever back them into a corner. Do speak in a calm and even tone in a quiet area without distractions. Do communicate in a very straightforward way, addressing one issue at a time. Do be apathetic, compassionate, and respectful. 

Have a reflective listening policy. Do always listen to what they have to say.  Even if you think what they’re saying is totally inappropriate, listen to what they have to say. And yes, I realize that this can be very difficult sometimes, but take a breath and listen. You can even tell them that you have a reflective listening policy, and that means that you will always listen to them before you respond. Then back it up by listening respectfully. Then if they have difficulty listening to you and respecting what you say, you can remind them of your policy and ask them for the same courtesy. It’s honestly just a better way to run your life; it makes it so much simpler. My wife and I told our son about this policy, and followed through and raised him with it, since before he could say the word policy, and it turned out just fine and saved a lot of headaches. I can’t stress how important it is to be a good listener.  

This is a corollary to being a good listener… ask appropriate questions well, appropriately, ie softly or easily. Do ask simple questions: “Did you have breakfast today?” “We aren’t able to find your medicine, is everything okay with your medications?” Don’t say, “Did you take your medicine today?” “Did you eat yet?” It tends to sound accusatory. In a very gentle way, you say, “Everything okay with your medicine? Oh, here’s the bottle. Any problems?”  Let them speak.  Don’t press them.  If they’ve forgotten to eat or take medications, don’t get upset or angry, tale a breath, let them explain. If you have an issue about why they don’t want to take their medication, listen to why. Respect them and let them at least give you an interpretation of the reasons and symptoms. Don’t interpret for them. There may be a side effect that’s intolerable to them, and all of that must be brought to the prescribing physician. It’s all valid information, so do listen. After you have listened, you may then calmly answer “I heard that you don’t like to take your medicine because it makes you xyz, but if you don’t want to take it, we’ll call Dr. Prescriber and explain it and see what he/ she says, okay?” That way they know you listened to what’s going on, they know they’ve been heard, but they also know it’s either take the medication or talk to the doctor.  

I have heard some families make demands, withhold privelleges, make bargains, bark orders, physically intimidate; I’ve heard it all. It makes me a little anxious when I hear things like “Just take your *expletive* medicine!” or “Let’s pray about it.” Don’t get me wrong, I’m all for prayer, but it’s inappropriate in some respects when it comes to should Bobby or Suzie take their medication today, because they don’t feel like it. 

Other don’ts: You need an attitude adjustment. You’ve got a bad attitude. Stop being so negative for once. You need to get a job. Why can’t you do something productive with your life? You need something to do. Your thoughts are totally misguided. Now you’re just being dumb. You really are crazy. Don’t act crazy. 

No. None of those things are appropriate, ever. Especially the word “crazy” or any similar term. That is the ultimate “C word” in my office. Doremove it from your vocabulary, pronto. The goal is to not agitate them. No ultimatums.  No threats.  No punishment. It will get you nowhere except to crisis. Criticizing them or blaming them is a no go. And don’t ever speak rapidly or loudly. And don’tstare at them. It invites defiance. Silence is okay. Pauses are okay. I know you may get frustrated, but any sort of frustration or anger directed at them will not work. Don’t make jokes or be sarcastic, because it’s not funny. I don’t find it funny at all.  Don’t talk at them with a patronizing, condescending tone, as in, “Are you going to take your medicine today, or what?” “Could you shower already, you know you smell?” “Are you going to do anything today besides watch TV and smoke cigarettes?” “Have you gotten a job yet?” “You are so useless” “You don’t work. How about you get a job to pay for things?” “When are you going to stop taking and start giving?” “Do you ever worry about anyone but yourself?” These kinds of comments do not work. If any of my patients report this kind of thing, I always make it a point to correct the situation quickly, because it can be very damaging, especially to an already fragile person. 

You are dealing with a loved one with a mental illness, so do establish rapport, and through that rapport, using some of these do’s and don’ts which I just gave you, try to help them get a psychiatric appointment, get to a psychologist, get to a day program, or at least get them to some medical health practitioner for an evaluation. That may mean making an appointment with primary care for a referral, calling their psychiatrist or mental health therapist, or even taking them to an emergency room if it is an urgent situation. In some cases, it may even be necessary to call 911 and have them taken by police or ambulance if they aren’t willing to go on their own and they’re in crisis. Do be willing to do what it takes. Hopefully you’ll be properly directed to appropriate levels of care, and then do follow through with that. Don’t just let it go. Bottom line is get them somewhere. The most important thing that can happen at that point is that that caregiver establishes a bond with the individual, your loved one, and using that relationship, they can motivate and encourage and direct their care. That’s what you’re looking for: a caregiver (psychiatrist or mental health professional) they trust, that they will be honest and open with. That professional should be able to navigate issues and properly direct them to the appropriate level of care.  

So, you want to do everything in your power to encourage a good relationship between your loved one and that professional. Don’t sabotage that relationship. Work within that relationship. Don’tthreaten that caregiver. Don’t give the caregiver ultimatums. Do everything in your power to maintain a good open relationship between the mental health professional/ caregiver and the patient, your loved one.   

I hope this was helpful to any and all that needed to read it. 

Check out all of my other blogs and feel free to share them. Please check out my YouTube channel (just google YouTube Mark Agresti if all else fails) and hit that subscribe button to get all of my videos. As always, for patient stories and more information, check out my book, “Tales from the Couch” available in my office and on Amazon.com. 

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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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In Isolation…Now what

You’re in Isolation… Now What?

I regret that I even have to make this blog. The situation we find ourselves in is so surreal, but here we are, so we have to rock and roll with it. Covid-19 is a respiratory virus, a particularly nasty one. In recent years, scientists have tried to prepare for a long-feared hypothetical pathogenic disaster they called Disease X, and defined it as: any unknown disease that springs suddenly into our species and races ruinously through it. Covid-19 is the first Disease X to arise since the terminology was coined, but it certainly won’t be the last. The climate is warming, we’re hacking down forests, our population is expanding faster than the earth can keep up with, and our skills at waging biological warfare are expanding and improving. The odds that we’ll keep encountering more and more Disease X’s are increasing. We will need all the vaccines we can make for this, and future, Disease X’s. Right now, there are at least 40 research groups around the globe working on Covid-19, and there are 43 Covid-19 vaccines in various stages of development around the world. One potential vaccine has just started a small human trial. While it sounds promising, with Covid-19, both the viral contagion itself and the vaccine type (using novel DNA/ RNA tech) are so new that there’s no telling what human trials will reveal, or how long they will take. Most of the scientists researching Covid-19 say that we’ll be lucky to have a vaccine for human use within 12 – 18 months.    

Yes, we’re in a pretty precarious state, but there are ways to make it less uncomfortable, less disturbing. An ounce of prevention is worth a pound of cure. The best defense is a good offense. These cliches were not popularized by accident, they’re true. In the case of Covid-19, the best preventative measure and the best offense is…stay home! It may not be fun and it may not be easy, but if there’s any possible way to stay home, do so. The only thing worse than isolating to prevent contracting the virus is to be quarantined withthe virus! I want to talk about some things you can and should do to maintain your sanity while waiting Covid-19 out. For general information, I’ve found that Unicef has great intel broken down into manageable units. They detail handwashing, using hand sanitizer, and behavioral ways to help stop the spread of Covid-19. You can navigate through the entire site from:

https://www.unicef.org/coronavirus/everything-you-need-know-about-washing-your-hands-protect-against-coronavirus-Covid-19

After talking with so many patients about Covid-19, listening to their fears and anxiety, I’ve come up with 10 things you should pay attention to while you’re isolating or you’re in quarantine.  

1. Consider anyone who is living with you in isolation, under quarantine, or simply in your shelter, as family. Everyone must function as a family, ie as a group, a “covid family” if you will. A few weeks ago, our world changed forever, and you must work together and be in it for the long haul, because we don’t know how long this is going to last. Make a decision to be good to each other, to respect each other. You must get along, because now we have an enemy that is far greater than us. It is a virus, not a natural disaster like a hurricane, flood, tornado, or fire, nothing that we are accustomed to dealing with. It is not a war, but make no mistake…we are under attack. So you need to treat the people in your “covid family” the way that you want to be treated. Talk to each other (no yelling or demeaning language) in a positive manner; this won’t always be easy, because the uncertainties linked to this pandemic will cause stress, which generally leads to shorter fuses. Decisions have to be made in a thoughtful way; if you have several people in your “covid family,” that may mean voting on important issues. Whatever you do, make every effort to keep the peace in your “covid family.”

2. Hygeine is everything when it comes to transmissible disease, andeveryone living in the house must participate in it. Wash your hands often, and just as important, wash them properly! I’ll discuss ‘the how’ below. First, let’s talk about ‘the when’. Your mama taught you to wash after using the toilet, before and after eating, after changing diapers or helping children use the toilet, after touching animals and pets, after touching garbage, and whenever they are obviously dirty. Those rules still apply of course, but with Covid-19, we’ve stepped it up a bit to include a few more “after’s”:

– After coughing, sneezing, and blowing your nose
– After visiting public spaces/ places: public transportation, markets, banks, drive-thrus, and places of worship
– After touching any of the surfaces outside of the home, including money, ATM machines, credit/debit checkout machines and stylus pens
– Before, during and after caring for a sick person, regardless of their Covid-19status
Those are minimum hand washing requirements. I suggest you wash at least every 1 – 2 hours, even if you haven’t done any of the above things. Ritualize your hand washing, especially if anyone in your “covid family” is high risk and/ or still venturing out of the home. If you touch the doorknob, wash your hands. If you touch a faucet, wash your hands, stove, wash. You get the idea. In this situation, there’s really no such thing as washing too much; you cannot be too careful, because this virus does live on surfaces for an extended period of time. FYI, that includes Amazon boxes. One of my very high risk patients actually “quarantines” her deliveries for five days and then opens the boxes with gloves on. Overkill? Hard to say. We all have to gauge our personal risk level and then behave accordingly.

As promised, here is ‘the how’ of proper handwashing. There are five simple steps to proper handwashing:

 1: Wet hands with running water (water temperature doesn’t matter)

 2: Apply soap liberally- don’t skimp- use enough to thoroughly cover your hands.
 3: Scrub all over the hands for 20 – 30 seconds with lots of sudsy lather: every surface, back and front of hands, between all fingers and under fingernails. Pretend you’re a surgeon. We’ve all seen surgeon’s scrubbing in. Do that vigorous, thorough scrubbing for 20 – 30 seconds. And yes, sing the ‘Happy Birthday’ song twice to ensure you wash for 20 seconds minimum…it’s so easy to stop early if you don’t sing, because 20 seconds is a fair chunk of time. Don’t short yourself! 

 4: Rinse well under running water

 5: Dry with a paper towel or clean cloth. 

IF YOU’RE OUT OR WHERE THERE’S NO SOAP OR RUNNING WATER, USE HAND SANITIZER. Use it basically the way you would soap. Put a generous amount into the palm of one hand and rub briskly but thoroughly all over both hands: front, back, between fingers, and under nails. If necessary, use another dose of it to act as a sort of rinse, especially if your hands have contacted multiple surfaces. 

Some other hygeine tips:

– Do not touch your face.  

– Make hand sanitizer and tissues like the American Express card…don’t leave home without it.

– Sneeze into a tissue. Some say it’s okay to sneeze into the crook of your elbow, but only as a last resort if you don’t have a tissue; your best bet is to keep a tissue handy. 

– If you must leave your home, limit outings to once a day.

– If you do leave your house, when you come back home, go straight to the bathroom and bathe before you interact with the house. Then use pre-moistened antibacterial cleansing cloths or a bleach solution to clean everything you touched on the way in. 

3. Do everything you can to boost your immune system, especially if you are higher risk. Take vitamins, 50 mg Zinc Gluconate per day, 1000 international units of Vitamin D3 per day, and 1000mg Vitamin C each day. If Vitamin C upsets your stomach, look for liposomal Vitamin C, because it is better digested.  

4. Take care of yourself. I’m embarassed to say that I have a friend from Pennsylvania who found ridiculously cheap plane tickets to Florida, $28 round trip, for he and his wife to take a quick trip about a month ago, just before travel was prohibited. Guess who got sick with coronavirus? Both of them! Guess where they are now? Quarantine! I mean, duh! File that under “Don’t be a moron!” I can’t believe I’m friends with someone that stupid. Anyway, back to taking care of yourself. This isn’t rocket science. 

– Eat healthy, limit bad things. You’re likely to have more time on your hands; don’t spend it drinking more alcohol, smoking more cigarettes or more weed, or eating your way through the pandemic. Fresh fruits and vegetables are the best, but you may not have access to them, so frozen fruit and veg are better than no fruit and veg. Every restaurant has delivery now, but try to not give in and order carb, fat, sugar crap delivery. Eating healthy also helps boost your immune system. Google “foods that boost the immune system” and see what you like and what you can get your hands on.    Blueberries, raspberries, nuts, eggs, leafy vegetables, lean meat, fish. 

– You must exercise every day. Obviously you should not visit a gym or use community gym equipment, but it’s fine if you own it and it’s inside your home. If you share gym equipment with your “covid family” be sure to clean it between uses and wash your hands thoroughly after using it. If you don’t use equipment, go for a walk or bike ride. Look On-Demand or YouTube for workout videos to do at home. Move your body everyday. 

– Keep to your regular work day sleep-wake schedule. Go to bed at a certain time, get up at certain time. Sleep deprivation and/ or exhaustion compromises your immune system, so it compromises you.  

– Get dressed. If you dress like a bum, you’re more likely to feel like a bum. Try for the sake of the people that may be in your “covid family”. Don’t wear your pajamas all day, get dressed and look a human being please. Shower, shave, brush your teeth, wash your face, yada yada. Fine, if you’re working from home and want to wear sweats for a day or two, that’s fine, but doing it every day for a long period of time tends to  undermine the sense of self-esteem and degrade the community around you, aka your “covid family” 

– Learn to relax. These are trying times. Do things to help deal with anxiety. Try aromatherapy, music, gardening, yoga, meditation. Google meditation videos, and look on YouTube as well and give it a try. For some people, a pet is the best anxiolytic in the world; think about getting a fish or a little mammal. If that’s not for you, try getting a little plant to take care of, just something you can nurture. It helps a great deal psychologically.  

– Meals become a bigger deal now, because it will probably be the most face to face interaction you’ll have, assuming you’re not going out. I suggest you schedule one big meal a day- usually dinner- and everyone pitches in. Some people prep, some cook, and some clean up. Working together is good for the mind and the soul, because it gives everyone a sense of belonging. 

5. Be frugal. If that is foreign to you, learn to stop spending. Figure it out. You must conserve all resources and manage the resources you have in the most efficient way, so you are not wasting food, goods, or money. You don’t know how long this is going to last, or the effect on the economy once it’s gone, so think before you spend a penny. 

6. Limit news exposure. You’ll go crazy watching it all day. Don’t leave the news station on as white noise either. Remember that some people, like politicians (ahem), have a secondary agenda that you can’t even begin to imagine, so you can’t really believe everything you’re hearing. Take everything with a grain of salt until you hear the same news from multiple sources who have conflicting interests. Then you can put more stock into what you’re being told.

7. How to entertain yourself or others in your “covid family”? The key here is to keep changing it up. Movies, binge watching tv shows, virtual reality systems, Gameboys, puzzles, board games, cards, reading, art. Try some hobbies you’ve never had the time to try before: planting a garden, sewing, knitting, painting, drawing, writing, tie-dye, whatever rocks your boat. You’re not going to be able to do the same thing day after day, because you’ll be bored out of your skull; remember that we’re probably looking at months before it’ll be safe to return to life, but likely a year minimum before things even start to get back to normal. Months to a year is a long time to be bored. 

8. You must maintain a high level of socialization. Use Facetime rather than just phone calls. Email or text, however you can stay in touch with people. Anyone who’s read my book, Tales from the Couch, available on Amazon (shameless plug) or reads/ watches my blogs/ vlogs, will laugh at this next bit. I suggest that you use social media, Facebook, Instagram, etc to facilitate interactions with people and get ideas from the outside world and really stay in tune with what’s going on. Normally I harp on the evils of social media, but it’s a brand new world people! Try very hard to stay in touch with friends and family during this isolated state.

9. Have structure, especially if there are kids in the house. You must establish special rules for the special circumstances we are in. If you have school-aged kids, are they “out of school?” This isn’t summer, and most schools have a curriculum for students during this time at home. So, the kids must wake up in the morning, shower, have breakfast, brush the teeth, and boom…school is in session! Make a schedule for them for every day, Monday to Friday, and stickto it religiously. I ran a school for 10 years, and I know how important this is. This isn’t punishing or being mean to the kids; kids are happier on a schedule, because they know exactly what to expect and when to expect it. The key here is to break the day up into separate topics/ sessions: reading time (or lecture, depending on age), discussion/ questions on the reading or lecture, outside activity, snack time, art, creative play time, lunch time, nap time (if applicable), puzzle time, special project time. The key to success is tailoring the subjects, activities, and the length of each session to the age of the kids. Young kids have a short attention span, so spend no more than 20 minutes on each session. Older children can usually handle 45 minutes, but adjust the time according to your child. Special projects could include maybe making homemade kites and racing them, or having a cookie day, where you make cookies and talk about the origin of ingredients and/ or their purpose in the recipe. For instance, when you add the chocolate chips, explain that chocolate actually starts as a big pod grown on a tree, called cacao (pronounced ka-kow), and google a picture of it along with how the process goes, from the pod to the chocolate chips in the cookies. As for lecture subjects, you can google lectures or ‘educational topics for ____ graders’ and find cirriculum and lesson plans. And it really is worth it for you to order stuff online to keep them entertained and learning and productive. You can even get topic or lecture ideas from everyone sitting around the dinner table. Understand that kids feel the stress of this situation too, so engaging them in positive and productive activities will take their minds off the fear and uncertainty while improving their skills and expanding their education. The bottom line is that if you don’t engage the kids, they’ll be idle and bored, a perfect prescription for the house to descend into chaotic madness.

10. Think! Think really hard before doing anything. Ask yourself, ‘Is it worth my money?’ and ‘Do I need it?’ Stop with the panic buying! Really, how much toilet paper do you actually need? Buy the things you need, but think before you do in order to conserve your resources.  Think wisely about what your family will eat, and what items will last for a long time: rice, pasta, jarred sauces, frozen fruit and veg, granola, protein bars, shelf stable milk, etc. Don’t do anything stupid like my friend in Pennsylvania did, taking a quick vacay to Florida…now he and his wife are on a Covid-19 quarantine vacay, a bummer place to be. And think how idiotic they’ll look when they have to answer friends and family’s questions on how and where they got the virus! Also, don’t panic. There’s really nothing to panic about. Prepare the best you can, take good care of yourself, be smart, and wait it out. Always keep your wits about you. 

Do you know the answer to the question ‘How long can you do this?’ I’ll tell you. The answer is… as long as we need to. Look, this will surely pass, but probably a lot like a kidney stone. That is to say, it’s going to be a long, rough ride that will involve some pain. But we’ll get through it, because we are nothing if not resilient. One day, hopefully sooner than later, we’ll have a treatment and even a vaccine for Covid-19, and eventually this virus will only exist in the perpetually frozen and hermetically sealed specimen libraries of the CDC, WHO, NIH, and whatever other acronym’d organizations keep stuff like that, filed under V– not for Virus- but for Vanquished.

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HOW TO BEAT FEAR OF CORONA VIRUS

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

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

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

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

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

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

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

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

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

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

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

3. Do seek support, but do so wisely.

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

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

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

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

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Attention-Deficit/Hyperactive Disorder : Signs, Symptoms, and Treatments

Attention-Deficit/Hyperactivity Disorder: Signs, Symptoms, and Treatments

ADHD is a disorder that makes it difficult for a person to pay attention and control impulsive behaviors. They may also be restless and seem to be active constantly. Contrary to some beliefs, ADHD is not just a childhood disorder. While the symptoms of ADHD often begin in childhood, ADHD can continue through adolescence and into adulthood. While hyperactivity generally improves as a child ages, other problems with inattention, disorganization, and poor impulse control often continue through the teen years and into adulthood.

Causes of ADHD

Current research suggests that ADHD may be caused by a combination of genetic and non-genetic factors. These factors include genetics, cigarette smoking, alcohol, or drug use during pregnancy, exposure to environmental toxins at a young age (ex: lead), low birth weight, and brain injuries.

Warning Signs of ADHD
People with ADHD typically have a pattern of three different types of symptoms:

1. Difficulty paying attention (ie inattention) 
2. Being overactive (ie hyperactivity)
3. Acting without thinking (ie impulsivity)

These symptoms get in the way of development and functioning. The way these three symptoms are manifested varies by person. 

Problems with paying attention (ie inattention) may manifest in:

– Overlooking or missing details, making careless mistakes on schoolwork, work projects, or during other activities
– Having problems sustaining attention during tasks or while playing, including conversations, lectures, or lengthy reading
– Seeming to not listen when spoken to directly
– Failure to follow through on instructions, failure to finish schoolwork, chores, or duties in the workplace, or starting tasks but quickly losing focus and getting easily sidetracked
– Having problems organizing tasks and activities, such as doing tasks in sequence, keeping materials and belongings in order, keeping work organized, managing time, and meeting deadlines
– Avoiding tasks that require sustained mental effort, such as schoolwork or homework, or for teens and older adults, preparing reports, completing forms, or reviewing lengthy papers
– Losing things necessary for tasks or activities, such as school supplies, pencils, books, tools, wallets, keys, paperwork, eyeglasses, and cell phones
– Becoming easily distracted by unrelated thoughts or stimuli
– Being forgetful in daily activities, such as chores, errands, returning calls, and keeping appointments

Problems being overactive (ie hyperactivity) and acting without thinking (ie impulsivity) manifest in:

– Fidgeting and squirming while seated
– Getting up and moving around in situations when staying seated is expected, such as in the classroom or in the office
– Running or dashing around or climbing in situations where it is inappropriate; or, in teens and adults, often feeling restless
– Being unable to play or engage in hobbies quietly
– Being constantly in motion or “on the go,” or acting as if “driven by a motor”
– Talking nonstop
– Blurting out an answer before a question has been completed, finishing other people’s sentences, or speaking without waiting for a turn in conversation
– Interrupting or intruding on others during conversations, games, or activities

Showing these signs and symptoms does not necessarily mean a person has ADHD. Many other problems, like anxiety, depression, and certain types of learning disabilities, can have similar symptoms.

Treating ADHD
Although there is no cure for ADHD, there are some treatments that may help to reduce symptoms and improve functioning. Today, ADHD is commonly treated with medication, education or training, therapy, or a combination of these treatments.

Medication for ADHD

Many people with ADHD find that medications reduce their negative symptoms of hyperactivity and impulsivity while helping to improve their ability to focus, work, and learn. 

There are many different types and brands of ADHD medications, and all have potential benefits and side effects. Sometimes several different medications or dosages must be tried before finding the one that works well for an individual person. Anyone taking medication(s) for ADHD must be monitored closely and carefully by their prescribing doctor.

Stimulants: The first line treatment for ADHD is the stimulant class of medications, and stimulants are the most common type of medication prescribed for ADHD. While it may seem unusual to treat someone that has a hyperactivity disorder with a stimulant, they have shown great efficacy in boosting concentration and reducing impulsivity and hyperactivity. The stimulant class of medication includes widely used drugs such as Ritalin, Adderall, and Dexedrine. Researchers believe that stimulants are effective because they increase the brain chemical dopamine, which plays an essential role in thinking and attention.

Non-Stimulants: These medications take longer than stimulants to start working, but they can also improve focus, attention, and impulsivity in a person with ADHD. A non-stimulant may be prescribed if a person had negative side effects from  a stimulant, if a stimulant was not effective, or if the combination of a non-stimulant with a stimulant increases effectiveness. Two examples of non-stimulant medications include atomoxetine and guanfacine.

Antidepressants: Although antidepressants are not approved by the U.S. Food and Drug Administration specifically for the treatment of ADHD, antidepressants are sometimes used to treat adults with ADHD. Older antidepressants are sometimes used because they affect brain chemicals dopamine and norepinephrine, just as stimulants do.

Therapy for ADHD: There are different types of therapy that have been tried for ADHD, but research shows that therapy alone may not be effective in treating ADHD symptoms. However, adding therapy to an ADHD medication treatment plan may help patients and families better cope with the daily challenges posed by ADHD.

Help for children and teens with ADHD: Parents and teachers can help children and teens with ADHD to stay organized and follow directions with tools such as keeping a routine and a daily schedule, organizing everyday items, using homework and notebook organizers, and giving praise or rewards when rules are followed.

Help for adults with ADHD: A licensed mental health provider or therapist can help an adult with ADHD learn how to organize his or her life with tools such as keeping routines and breaking down large tasks into smaller, more manageable tasks.

Children and adults with ADHD need guidance and understanding from their parents, families, and teachers to set goals for success and reach their full potential. Mental health professionals can educate the parents and family of a child or adult with ADHD about the condition and how it affects them. They can also help them develop new skills, attitudes, and ways of relating to each other.

If you are concerned about whether you or your child might have ADHD, the first step is to talk with a healthcare professional to find out if the symptoms fit the diagnosis. The diagnosis of ADHD can be made by a mental health professional, like a psychiatrist or clinical psychologist, primary care provider, or pediatrician.

For more on ADHD and other similar diagnoses, check out my book, Tales from the Couch, available on Amazon.com.

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How Cocaine kills You

How Cocaine Kills

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

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

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

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

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

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

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

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

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

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

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

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

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

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Electronics Are awesome! Right

Electronics are awesome! Right?

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

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

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

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

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

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

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

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

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

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

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

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

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

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Your Brain On The Holidays

Your Brain on the Holidays

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

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

1. You Want to Eat All of the Food

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

2. You Want to Drink All the Alcohol

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

3. You Want to Buy All of the Things

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

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

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

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

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How To Learn With ADD

How to Learn Best with ADD/ ADHD

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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How To Get People To Like you In Ten Minutes

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

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

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

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

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

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

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

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

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

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

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

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

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Digital Addiction Disorder

Time to Log Off?

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

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

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

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

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

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

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

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

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

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

Emotional symptoms may include:

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

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

Physical symptoms may include:

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

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

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

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

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

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

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

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

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Autism Spectrum disorder

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

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

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

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

Symptoms of ASD

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

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

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

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

Resists cuddling and holding as child

Lacks facial expression

Prefers playing alone, retreats into his/her own world

Exhibits poor eye contact 

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

Can’t initiate or further conversation 

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

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

Doesn’t appear to understand simple questions or directions

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

Inappropriate aggression or disruption to social interactions of others 

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

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

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

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

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

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

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

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

Doesn’t engage in imaginative or make-believe play

Fixates on an object or activity with abnormal intensity or focus

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

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

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

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

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

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

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

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

When to see a doctor

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

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

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

Doesn’t mimic sounds or facial expressions by 9 months

Doesn’t babble or coo by 12 months

Doesn’t gesture, point or wave by 14 months

Doesn’t say single words by 16 months

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

Doesn’t say two-word phrases by 24 months

Loses language skills or social skills at any age

Causes of ASD

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

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

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

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

Risk factors for ASD

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

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

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

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

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

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

Complications of living with ASD

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

Problems in school and successful learning

Employment problems

Inability to live independently

Social isolation

Stress within the family

Victimization and being bullied

Prevention of ASD

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

Diagnosis of ASD

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

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

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

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

Score your child’s social and communication interactions.

Include other specialists in order to definitively determine a diagnosis.

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

Treatment for ASD

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

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

Some ASD treatment options may include:

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

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

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

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

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

Some ASD takeaways

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

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

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Let’s Talk About Ambien

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

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

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

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

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

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

– Headaches

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

– Aggression
– Back pain
– Diarrhea or constipation

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

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

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

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

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

– Withdrawl

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

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

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

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

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