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.
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 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 10th 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:
– Bipolar disorder
– Schizoaffective disorder
– Post-traumatic stress disorder
– Substance abuse
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 AgrestiLearn More
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:
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.Learn More
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!Learn More
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.
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.Learn More
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.Learn More
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.Learn More
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.Learn More
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.”Learn More
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.Learn More
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:
Feelings of guilt
Feelings of euphoria when indulging
Inability to prioritize tasks
Problems with keeping schedules
No sense of time
Avoidance of work
Boredom with routine tasks
Physical symptoms may include:
Carpal tunnel syndrome
Poor nutrition: not eating or junk food
Poor or zero personal hygiene
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.Learn More
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
Inability to live independently
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.Learn More
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
– Loss of appetite
– Impaired vision
– Slow breathing rates
– Muscle cramps
– Allergic reactions
– Memory loss
– Inability to concentrate
– Emotional blunting
– Depression and/or suicidal thoughts
– Back pain
– Diarrhea or constipation
– Sinusitis (sinus infection)
– Pharyngitis (sore throat)
– Dry mouth
– Flu-like symptoms
– Breathing difficulties
– Palpitations (irregular heartbeat)
– 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
– Impaired judgment
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.Learn More
A woman named Marianne messaged me wanting to know how to get off of Klonopin, which is a benzodiazepine, or benzo for short. She has been taking them regularly for more than twenty years, which is a very long time to be on a benzo. That will certainly complicate things. Before I go into how to stop taking benzos, I want to tell you what they are and what they do.
What are they?
Benzos are medications designed to treat anxiety, panic disorders, seizures, muscle tension, and insomnia. Some of the most commonly prescribed benzos include: Xanax (alprazolam), Klonopin (clonazepam),Valium (diazepam), Restoril (temazepam),
Librium (chlordiazepoxide), and Ativan (lorazepam). A 2013 survey found that Xanax and its generic form alprazolam is one of the most prescribed psychiatric drugs in the United States, with approximately 50 million prescriptions written that year. Unfortunately, this class of drug is also highly abused. Another 2013 survey found that 1.7 million Americans aged 12 and older were considered current abusers of tranquilizer medications like benzos. When abused, benzos produce a high in addition to the calm and relaxed sensations individuals feel when they take them.
How do they work?
Benzos increase the levels of a chemical in the brain called GABA. Meaningless trivia: GABA stands for gamma amino-butyric acid. GABA works as a kind of naturally occurring tranquilizer, and it calms down the nerve firings related to stress and the stress reaction. Benzos also work to enhance levels of dopamine in the brain. Dopamine is the feel good chemical, the chemical messenger involved in reward and pleasure in the brain. In simple terms, benzos slow down nerve activity in the brain and central nervous system, which decreases stress and its physical and emotional side effects.
Why can using them be problematic?
Benzos have multiple side effects that are both physical and psychological in nature, and these can cause harm with both short-term and extended usage. Some potential short-term side effects of benzos include, but are not limited to: drowsiness, mental confusion, trouble concentrating, short-term memory loss, blurred vision, slurred speech, lack of motor control, slow breathing, and muscle weakness. Long-term use of benzos also causes all of the above, but can also cause changes to the brain as well as mental health symptoms like mood swings, hallucinations, and depression. Fortunately, some of the changes made by benzos to the different regions of the brain after prolonged use may be reversible after being free from benzos for an extended period of time. On the scarier flip side of that coin, benzos may in fact predispose you to memory and cognitive disorders like dementia and Alzheimer’s. They’re many studies currently focusing on these predispositions. A recent study published by the British Medical Journal (BMJ) found a definitive link between benzo usage and Alzheimer’s disease. People taking benzos for more than six months had an 84% higher risk of developing Alzheimer’s dementia, versus those who didn’t take benzos. Long-acting benzos like Valium were more likely to increase these risks than shorter-acting benzos like Ativan or Xanax. Further, they found that these changes may not be reversible, and that the risk increased with age. Speaking of age, there are increased concerns in the elderly population when it comes to benzo usage. Benzos are increasingly being prescribed to the elderly population, many of which are used long-term, which increases the potential for cognitive and memory deficits. As people age, metabolism slows down. Since benzos are stored in fat cells, they remain active in an older person’s body for longer than in a younger person’s body, which increases the drug effects and risks due to the higher drug concentrations, like falls and car accidents. For all of these reasons, benzos should be used with caution in the elderly population.
A big problem with taking benzos for an extended period is tolerance and dependency. Benzos are widely considered to be highly addictive. Remember that benzos work by increasing GABA and dopamine in the central nervous system, calming and pleasing the brain, giving it the feel goods. After even just a few weeks of taking benzos regularly, the brain may learn to expect the regular dose of benzos and stop working to produce these feel good chemicals on its own without them. Your brain figures, “why do the work if it’s done for me?” You really can’t blame the brain for that! It has become dependent on the benzo. But as you continue to use benzos, you develop higher and higher tolerance, meaning that it takes more and more of the drug to produce the regular desired effect. This tolerance and dependence stuff really ticks off your brain. It’s screaming “why aren’t these pills working anymore?!” The answer is that it has become dependent and tolerant, so it needs more. Just to prove its point, it makes you feel anxious, restless, and irritable as it screams “gimme gimme more more more!!!” The problem is that the body is metabolizing the benzo more quickly, essentially causing withdrawl symptoms, and a higher dose is needed. The longer you’re on a benzo, the more you’ll need. It’s a vicious cycle and it’s sometimes tough to manage clinically.
The most severe form of physical harm caused by benzos is overdose. This occurs when a person takes too much of the drug at once and overloads the brain and body. The Centers for Disease Control and Prevention (CDC) cites drug overdose as the number one cause of injury death in the United States. A 2013 survey reported that nearly 7,000 people died from a benzo overdose in that year. Since benzos are tranquilizers and sedatives, they depress the central nervous system, lowering heart rate, core body temperature, blood pressure, and respiration. Generally, in the case of an overdose, these vital life functions simply get too low.
When combining other drugs with benzos, obviously the risk of overdose or other negative outcome increases exponentially. But mixing benzos with alcohol is a special case, deserving of a strong warning as it is life-threatening. BENZOS + ALCOHOL = DEAD. One of the most common and successful unintentional and intentional suicide acts in my patient population is mixing benzos with alcohol. The combo is lethal, plain and simple. The body actually forgets to breathe. People pass out and just never wake up. If you’re reading this and you take benzos with alcohol and you’re thinking that you don’t know what the big deal is, you do it all the time and have never had a problem, then my response to you is that you’re living on borrowed time, and I strongly suggest you stop one of the two, the booze or the benzos, take your pick.
What about withdrawl from benzos?
Benzo withdrawal can be notoriously difficult. It is actually about the hardest group of drugs to get off of. The level of difficulty is based on what benzo you’ve been taking, how much you’ve been taking, and how long you’ve been taking it. Obviously, if you’ve been on benzos for 25 years, it’s not going to be a walk in the park. To be honest, it’s going to be a rough road. Sorry Marianne. But it can be done. The first and most important thing is that you should never just stop benzos on your own, as it can be very dangerous and can include long or multiple grand mal seizures. Withdrawal from benzos should be done slowly through medical detox with a professional. It is best done with an addiction specialist like myself, because a specialist has the most current knowledge and experience. This is the safest way to purge the drugs from the brain and body while decreasing and managing withdrawal symptoms and drug cravings. As for the symptoms of withdrawl, these can include mood swings, short-term memory loss, seizure, nausea, vomiting, diarrhea, depression, suppressed appetite, hallucinations, and cognitive difficulties. Stopping benzos after dependency may also lead to a rebound effect. This is a sort of overexcitement of the nerves that have been suppressed for so long by the benzos, and symptoms can include an elevated heart rate, blood pressure, and body temperature. There may also be a return of the issues that lead you to take the benzos in the first place, insomnia, anxiety, and panic symptoms, and they can possibly be even worse than before.
I’m sure that just about everyone currently taking benzos is thinking “I’m NEVER stopping!” right about now. It is not easy to do, but there is a way to manage all of this, to come off of the benzo and deal with all of the physical and cognitive aspects of withdrawl. I do it everyday. I set up a tapering schedule to lessen the specific benzo dosage over time, sometimes over a period of months. I will also often add or switch to a long acting benzo, which can be very helpful. I use several drugs to deal with the withdrawl symptoms: clonidine for tremor and high blood pressure, neurontin for pain and to help prevent seizures, anti-psychotic like seroquel for sleep, and an anti-depressant for depression, thank you Captain Obvious. The drug regimen varies from patient to patient. I also utilize psychotherapy to help work out the psychological kinks associated with withdrawl and rebound effect symptoms. Another trick I strongly recommend to many of my patients, not just those withdrawing from alcohol or any drugs, is transcranial magnetic stimulation or TMS. This is a non-invasive procedure done in the office that uses magnetic fields to stimulate nerve cells in the brain to improve symptoms of depression and anxiety, and I’ve found that it seems to calm the nerves and offer relief to some people in withdrawl. Electrodes are placed on the forehead and behind the ears and painless stimuli are passed into certain regions of the brain for 40 minutes in each daily session for about a month. Many patients say it’s the best 40 minutes of their day.
I’d like to wish Marianne good luck. Please feel free to call me at the office at 561-842-9950 if you have any questions.
To everyone else: If you can avoid ever having to take benzos, I strongly suggest that you do. If you’re currently taking them, give some serious thought to finding an alternative medication. I can help with that. For more information and stories about benzos, other drugs, and the process of medical detox, check out my book Tales from the Couch on Amazon.com.Learn More
As an addiction specialist, I see patients abusing substances of all kinds. Today I’d like to talk about alcohol. It is so ingrained and accepted in our society. Pop culture would have you believe that you can’t have any fun or lead a fulfilling life without alcohol. During nearly every commercial break on television, there is an advertisement for alcohol, full of smiling people having the time of their lives like they’re on a permanent vacation. As a matter of fact, as I write this, I have a television on in the background, and there was just a commercial for a Mexican beer. It was a fiesta, with women in bright costumes dancing around and people cheering and cheersing with cold cervezas. The message: you’re clearly missing out if your life doesn’t resemble the lives of these people, but if you drink their beer, your life can be as awesome as theirs.
Fermented grain, fruit juice and honey have been used to make alcohol for thousands of years. Even early Greek writings warned of the perils of alcohol. In our modern world, the dangers of alcohol are well studied and well known. Despite this fact, alcohol is the most common drug used and abused by people. Here are some sobering facts and figures: an estimated 15 million Americans suffer from alcoholism, and nearly 90,000 people die from alcohol-related causes annually, making alcohol the third leading preventable cause of death in the United States. 40% of all car accident deaths in the United States involve alcohol, claiming approximately 10,000 lives a year. According to the Institute of Alcohol Studies, consuming larger amounts of alcohol can cause more than 60 different health issues and hundreds of physical conditions.
Day in and day out, I witness the ravages of alcoholism, and it’s not pretty. Alcohol in any amount affects every part of a person, inside and out. It’s just a matter of degrees.
What are these effects? Let’s start with the outward appearance. While drinking moderately may not have immediate disadvantages, over time you’ll start to notice them- especially when you look in the mirror. Drinking alcohol dehydrates you, which makes hair follicles dry and brittle and more likely to cause hair to fall out. What hair you have will look crispy with split ends. Heavy alcohol use can lead to permanent damage to the health of your hair. It can also cause hormonal issues like increased estrogen, which can cause problems with hair growth and loss, particularly in men.
Drinking too much also dehydrates and deprives the skin of vital vitamins and nutrients. Instead of being soft and hydrated, your skin will begin to look cracked and wrinkled. This will leave others thinking you may be older than you actually are. Excess alcohol also alters blood flow to the skin, leaving an unhealthy appearance for days.Alcohol can also cause your face to look pale, bloated and puffy.Sometimes the blood vessels on your face burst and the capillaries break, causing a chapped look. Not only can your face become red, but the tiny blood vessels in your eyes become irritated and rupture, causing bloodshot eyes. Not cute.
Over time, drinking heavily can have other, more permanent, detrimental effects on your skin. Rosacea, a skin disorder that starts with a tendency to blush and flush easily is linked to alcohol consumption. Continued alcohol consumption can eventually lead to a condition called rhinophyma, a facial disfigurment that is a subtype of rosacea, where large, red, pus-filled bumps develop on the face, commonly on the cheeks, chin, and especially the nose, where it can cause severe bulbous distortion. If you have rosacea, I strongly urge that you google rhinophyma and that you don’t drink.
Let’s not forget that alcohol is fattening, high in empty calories. A couple of gin and tonics and a pint of beer equal about the same calories as a big fast food burger. You might be surprised to find out what the junk food calorie equivalents are for your favorite drinks. Alcohol also bloats your stomach. “Beer belly” is real people, but not only caused by beer. And then there’s cellulite; many believe the toxins in alcohol contribute to its build up.
A less often discussed result of drinking heavily is B.O. Yes, the bad odor emanating from the body after a long night of drinking is directly related to the alcohol seeping from it. According to the Institute of Alcohol Studies, over 10 percent of alcohol consumed leaves the body unused through your sweat, breath, and urine. While pretty much everyone can smell it, non-drinkers are generally especially susceptible to the odor. And it is gross. Keep that in mind the next time you wake up after a bender. Your body odor could leave a lasting impression.
Let’s move from external effects of alcohol and go inside the body, starting with the brain. Obviously, when you’re drunk, your brain is impaired. There is loss of inhibitions, confused or abnormal thinking, and poor decision-making. But I want you to understand the chronic effects of alcohol on the brain and cognition, the long term effects. So, how does alcohol impact cognitive ability? Clearly, the impact is directly related to the frequency and quantity of alcohol consumed.
Occasional and moderate drinkers:
– Memory impairment
– Impaired decision-making
Heavy and/or chronic drinkers:
– Diminished gray matter in the brain
– Inability to think abstractly
– Loss of visuospatial abilities
-Loss of attention span
In general, heavy alcohol use causes the brain to shrink. Any alcohol use causes clouded thinking, slow thought process or delays in cognition. If you drink at night – even two drinks – the next day, your thoughts aren’t as fluid, you’re not as clear, you’re not as creative. Alcohol use changes behavior. You may develop psychological issues, personality issues. It is well established in the mental health field that alcohol consumption can exacerbate underlying mental health disorders. People become more irritable, anxious, and depressed when they drink. So why do it? People use it as a coping skill. It lowers inhibitions, gives “liquid courage” and allows us to do things we wouldn’t normally do. Some people use it to keep a job they hate, or to stay in a miserable marriage. It numbs pain, it’s an escape hatch for the psyche. It becomes a solution to a problem, or a way to mask the problem. Just as we are all different, the way alcohol affects us all differently.
The following factors have been shown to influence how alcohol impacts a person’s brain functioning over time:
-The volume a person drinks
-How often a person drinks
-The age at which drinking began
-The number of years a person has been drinking
-The person’s sex, age, and genetic factors
-Whether the person’s family has a history of alcoholism
-Whether the person was exposed to alcohol as a fetus
-The person’s general health
One of the biggest problems with alcohol that I see is trauma, people getting hurt. When you drink alcohol, your decision making is impaired. The brain that usually protects you is suddenly impaired, so you fall, you fight, you drive a car recklessly, and your coordination is off. You’re going to fall or make a bad decision and get hurt. So many accidents and deaths are attributed to alcohol. It’s especially disturbing because they’re preventable.
There is no bodily system that alcohol does not affect. What are other physical dangers of alcohol? Drinking alcohol increases the risk of cancers of the mouth, esophagus, pharynx, larynx, liver, and breast. The common thing that everyone understands is liver damage with alcohol. It causes fatty liver and cirrhosis of the liver which eventually kills you. There are a host of digestive problems with alcohol consumption: peptic ulcers, bleeding ulcers, diarrhea, pancreatic cysts/disease/failure. Alcohol can lead to diabetes, a compromised immune system, lung infections, stroke, and heart disease. It can be associated with memory issues, learning disorders, and neurological problems, where you have numbness in your arms and legs, lack of coordination, and slurred speech.
Alcohol plays a role in other issues as well. Family problems, legal problems, and social problems. One of the biggest concerns with drinking frequently is (or should be) dependency, becoming an alcoholic. Right now, I’m sure almost 100% of you are thinking ‘I‘d never become an alcoholic.’ There’s a television show called Intervention that documents the trials, tribulations, lifestyles, and consequences of alcoholics and drug addicts. None of them planned on becoming alcoholics back when they drank socially or just had a few drinks at night. The great news is that if you never make alcohol a part of your life, guess what? You’ll NEVER have to be an alcoholic or deal with all of the issues that come with it. I can’t stress enough how strongly you should take this to heart.
By now I’m certain that you understand the ravages and damages of alcohol use and abuse. But the dangers are minimized and we’re desensitized to it by pop culture; it’s so ubiquitous that we accept it as a part of life. If you tell someone that you don’t drink, they look at you like you have three heads. It is ingrained in every aspect of our society in terms of weddings, funerals, bars, restaurants, hotels, public events, private events, and clubs.
Have you ever noticed how glorified alcohol is? They put it in these beautiful bottles. I admire alcohol bottles. The artistry and sculpture of the bottles…they’re just beautiful. They look like there must be something very good inside, so you want to find out. When you go to a restaurant, the first question is always, “Would you like a drink?” Now, children’s birthday parties even serve drinks to the adults. If it’s so safe, why don’t we serve it to children? It’s because we know it’s poison, we know it’s dangerous, but it’s minimized. It’s socially acceptable. I’m not for prohibition; I think there is a place for alcohol in our society, but it shouldn’t be so glorified and so easily accessible. We need to acknowledge it’s dangers and be more restrictive with it. Take all-you-can drink mimosa or bloody mary brunches or happy hours for example, where drinks are two-for-one. These things encourage drunkenness, and then people leave with alcohol-induced poor decision skills and car keys in hand. These sorts of events need to be seriously restricted. There should be no event where we encourage people to get drunk. We should not condone its overuse or extoll its virtues.
With all of that said, how does an individual stop drinking alcohol? It’s a simple theory. You make a decision to stop, and then you stop. There is no other way. If you’re not in control of stopping, then who is? I’ve spent more than thirty years medically detoxing and working with people with alcohol and drug addictions, and I assure you that there is no other way to stop other than the person making the decision to stop and living with it. I’m not saying it is easy, especially with alcohol all around us in grocery stores, restaurants, on television, on billboards…it is everywhere. But it can be done. I see it every day, people living fulfilling lives without alcohol. If you want to be one of those people living without alcohol, make an appointment. I can help you. I talk more about this in my books, A Chance to Change and Tales from the Couch, both available on Amazon.Learn More
Attention Deficit Disorder
ADD, Attention Defecit Disorder is a chronic condition marked by issues with attention. It is most often seen in childhood, but can persist into adulthood, and there are 3 million US cases per year. Due to it’s high prevalence, I want to take the opportunity to discuss the diagnosis, symptoms, and treatment of ADD.
ADD has a sister disorder called ADHD, Attention Defecit Hyperactivity Disorder. What’s the difference between them? It’s pretty simple. ADHD includes the symptom of physical hyperactivity or excessive restlessness. That’s what the “H” is for. In ADD, the symptom of hyperactivity is absent.
What are the hallmarks of this disorder? Basically, it is a disorder of concentration, marked by problems concentrating and the inability to stay on task. These individuals are easily distracted and readily bored. They move from project to project without finishing and start projects without all of the appropriate tools needed to complete them. This all leaves them very anxious. In cases of ADHD, they are also impulsive, intrusive, disruptive, and hyperactive, often constantly fidgeting.
What percent on the population are we dealing with here? Roughly 20% of boys and 11% of girls have some type of attention deficit disorder.
What are the causes of attention deficit disorder? While we don’t know exactly, there are several suspects. Maternal use of alcohol or cocaine while in utero is an extremely common finding. Brain infections when pregnant or during early childhood, head trauma, and any birth defects that affect child development are also suspected. Exposure to enviromental toxins and pesticides are suspect. Excessive video games alter brain chemistry, as does a diet of processed foods and sugar, and these are also suspected causes for attention deficit disorder. I would say the number one cause of ADD is most likely genetic, inherited from mother or father.
What is the result of having attention deficit disorder? How does it affect one’s life? It results in having problems fitting into the academic world or the job world. People with attention deficit disorder don’t fit into a regimented or organized educational or work environment. They can be very intelligent and productive people, but they don’t fit into what we would consider the stereotypical or standard type of academic setting or work setting. Also, due to their impulsivity and their disorderly conduct, they can wind up getting in trouble in school and in trouble with the law. They can be unsuccessful at work, not because they aren’t smart enough, but because they cannot stay focused. In terms of lifestyle, they also have a much higher rate of obesity. This is likely due to lack of impulse control, causing them to overeat. They have problems in relationships, and their divorce rates are much higher. Their propensity toward domestic violence may also be higher. They may also be more prone to Alzheimer’s disease. Because of all of these failures and shortcomings in the stereotypical organized worlds of education and career, they have much lower self-esteem. There are studies that report that up to 52% of people with attention deficit disorder have drug or alcohol problems.
So how can we help these people? How do we treat these illnesses? The number one treatment is behavioral training with a mental health professional. The gist of that is educating them to focus on one thing at a time. They are not able to handle instructions with multiple levels at once, but they can focus on one thing at a time and have success with that. Pharmacologically, ADD and ADHD are generally treated with amphetamine stimulants. Some antidepressantants may also benefit people with attention deficit disorder. Essentially, a combination of behavioral therapies, special education programs and medications show the most promise in the treatment of attention deficit disorder. But a diagnosis of ADD or ADHD isn’t all future doom and gloom. Eventually, people find their niche in the world and can become successful. The actor Ryan Gosling takes medication for his ADD and says that it may take him longer to read his scrips than other actors, but he manages to get the job done. Uber successful comedian Howie Mandel has successfully done just about all there is to do in Hollywood. I have met a lot of CEO’s with ADD, and they function well because they have people around them to take care of all the boring mundane tasks, giving them the chance to think freely and create business opportunities. They are creative and capable people. They are another example of why you can’t judge a book by it’s cover…you can’t assume that someone with a psych diagnosis will never make it in the world. Ask Richard Branson. I think he’s done pretty well for himself in the corporate world despite his ADD. Justin Bieber has ADHD and has managed to record a few hit songs. Olympian Michael Phelps has ADD, depression and anxiety, and that hasn’t stopped him.These are some examples of people that have adapted and overcome their diagnoses rather than be labeled by them. If you have ADD or any psych diagnosis, I’d suggest you follow their lead.
For more patient stories, check out my book Tales from the Couch, on Amazon.com.Learn More
Let’s talk about depression. First, understand that like most things in life, depression is a spectrum; it is not black and white. Some people have situational depression or very mild depression and do really well with therapy and making some simple life changes. Others might need medication to assist them. Some unfortunately suffer from major depression and find it hard to cope with life.Learn More
Let’s talk about depression. First, understand that like most things in life, depression is a spectrum; it is not black and white. Some people have situational depression or very mild depression and do really well with therapy and making some simple life changes. Others might need medication to assist them. Some unfortunately suffer from major depression and find it hard to cope with life. No matter where on the spectrum people fall, the following information is helpful to anyone who has experienced depression.Learn More
Individuals often speak of feeling depressed. Indeed, it is common to feel periodic sadness due to life’s
disappointments. Clinical depression, on the other hand, is quite different from those times when we experience
unhappiness or despair.
Clinical depression is a serious disease caused by a brain disorder, and its effects on the individual’s ability
to perform in daily situations is profound. The condition can impact moods, thoughts, habits, and physical
According to the National Institute of Mental Health (NIMH), depression strikes about 17 million American adults
every year. This is more than the amount of cases related to cancer, AIDS, or coronary heart disease. What makes
it even worse is that an estimated 15 percent of people dealing with depression ends in suicide.
Dealing with depression could appear like a daunting task. Some people don’t even comprehend the real nature of
the disease. “Many people still believe that depression is a character defect, or caused by bad parenting”, says
Mary Rappaport, a spokeswoman for the National Alliance for the Mentally Ill. It needs to be noted that taking
care of depression does not merely involve willpower. It requires proper medical attention.
The good news is that depression is treatable. In fact, among the initial steps of taking care of depression,
consists of making use of either of the two major treatment options available; medication or therapy. First, a
proper medical diagnosis must be obtained before one can go on with dealing with depression.
When identifying and dealing with depression, it is necessary to keep in mind that that there are three primary
classifications of the condition. These are major depression, dysthymia, and bipolar depression (otherwise known
as manic depression).
The symptoms for each category of depression can differ, depending upon the person. And there are numerous
factors that serve to increase the risk of depression. According to the American Psychiatric Association’s
Diagnostic and Statistical Manual, the following are the typical symptoms of depression as noted in the DSM-IV:
depressed mood, loss of interest or pleasure in nearly all activities, changes in appetite or weight,
interrupted sleeping patterns, slowed or restless movements, fatigue, loss of energy, feelings of worthlessness
or extreme guilt, difficulty thinking, focusing, or making decisions, and even recurrent thoughts of death or
Antidepressant medicines are often prescribed as a step in dealing with depression. These medicines, such as
tricyclic antidepressants, monoamine oxidase inhibitors, and selective serotonin re-uptake inhibitors, work by
modifying particular chemicals in the brain, such as serotonin. This leads to improved symptoms of depression,
and can assist in taking care of depression.
Alternatively, persons dealing with severe depressive episodes may not be responsive to medication alone. In
order to offer long term relief, psychiatric therapy is required.
At some point in our lives we might experience depression. Depression is described as a feeling of unhappiness,
dissatisfaction, loneliness, or having negative thoughts towards oneself or to other people. Nonetheless, if the
feelings become overwhelming and continue to appear, which can substantially impact your health and your
everyday routine, immediate care and attention needs to be sought.
In fact, the level of depression that every person experiences might range from mild, moderate, to serious,
depending upon the symptoms related with each condition and the degree the condition disrupts everyday
activities. Managing depression is also, like the level of depression, different from one person to another.
Some individuals might realize the condition to be really disabling, and that they cannot seem to overcome it,
while others manage to undergo effective treatment. It is very difficult to comprehend exactly how extreme the
feelings of a depression sufferer.
We may be able to understand if we know what the possible causes are, and the symptoms of the depression.
Dealing with depression might not be as easy as you think, but, we can offer help to depressive individuals by
letting them know that we always have an ear to listen to their problems. Loss of something or somebody
essential. Loss of control over your own life or things around you.
Most likely, the person who feels this, in some way, senses that nothing can be done to alter the undesirable
events in life, and that handling depression is an impossible job. I should state this one is a great factor why
an individual feels depressed in the first place, as a negative attitude can cause self-defeat.
Here are some of the typical symptoms of depression, mostly grumbled by depression victims. A person with
depression might feel a strong sense of unhappiness, anxiety, guilt, anger, hopelessness, mood swings, and
An individual having depression might commonly sleep too much or too little, experience loss of hunger or
overeating, constipation, irregular monthly period, lose interest in sex, and experience weight loss or gain.
Considering that a depressive person deals with down feelings, crying without reason can occur. Also, withdrawal
from other people or the world in general, irritability, loss of interest in activities, and loss of interest in
physical appearance, no set objectives, and resorting to abuse via drugs and alcohol are simply some of the
things you’ll notice with a depressive person.