Obesity:What Causes it and How to Combat it

We’re nearly six weeks into the new year, and this is right about the time that most people toss their new year’s resolutions out the window. Many of them had resolved to lose weight: surveys have shown that, of the people who make new year’s resolutions, an average of 45% of them resolve to lose weight and get in better shape. So that means that nearly half of resolution-makers are overweight at least. That number seems high, but given that obesity has reached epidemic status, I guess it’s not that surprising. 

Obesity is broadly defined as the state of being well above one’s normal weight. Obesity often results from taking in more calories than are burned by exercise and normal daily activities, aka ‘eating too much and moving too little.’ A person has traditionally been considered to be obese if they are more than 20% over their ideal weight. That ideal weight must take into account the person’s height, age, sex, and build. Obesity has been more precisely defined by the National Institutes of Health (NIH) by utilizing a person’s BMI, body mass index. The BMI is a key index for relating body weight to height, and it is formulaic. The imperial BMI formula is weight (in pounds) multiplied by 703, then divided by height (in inches²). If you don’t feel like dealing with the math, you can google a BMI calculator. Having a BMI of 30 and above is considered obesity. Over 70 million adults (35 million men and 35 million women) in the U.S. are obese, while 99 million (45 million women and 54 million men) are overweight and at risk for becoming obese.

What are the causes of obesity? Obesity can be complex, going beyond eating too much and moving too little. Following are some other factors that cause or contribute to obesity.   

Genetics

Obesity has a strong genetic component. Genetic predisposition means that children of obese parents are much more likely to become obese than are children of lean parents. Genetics also affect the rate at which the body uses energy (burns calories) when at rest, which is called the basal metabolic rate. People with higher basal metabolic rates naturally burn more calories than other people, so they are less likely to gain weight. The opposite is also true: people with lower basal metabolic rates burn fewer calories, so they are more likely to gain weight. But these facts don’t mean that obesity is completely predetermined, that there’s no way to change it. What you eat can have a major effect on which genes are expressed and which are not. This is demonstrated when people of non-industrialized societies come to the U.S., begin a western diet, and then rapidly become obese. Obviously, their genes didn’t change, but their diet did; that changed the signals they sent to their genes, which then changed the expression of the genes. Changing the expression of the genes resulted in obesity. The bottom line is that genetics do play a key role in determining susceptibility to gaining weight and obesity, but that is only one factor of many; it is not all genetically predetermined. 

Diet: What and How You Eat

Obviously, eating an unhealthy diet is a major contributing factor in obesity. Overeating at meals and snacking throughout the day can also lead to obesity. An unhealthy diet would be high in complex carbohydrates, bad fats, and sugar, and low in fresh fruits, vegetables, and high protein lean meats. There are social factors that affect diet and therefore weight. If you spend a lot of time with overweight friends and family who eat too much of an unhealthy diet, the odds are that you’ll be overweight as well. Economic factors also play a role in obesity. If you can only afford cheap, ready-made packaged foods or fast foods from the dollar menu, you are much more likely to be obese. Economics may force you to eat a diet high in complex carbs like pastas, breads, potatoes and rice just to fill yourself up, because that is all you can afford. That type of diet greatly increases the risk of obesity. Unfortunately, eating unhealthy foods and overeating are easy in our culture today. Many things influence eating behavior, including time with family and friends, the low cost of unhealthy but filling foods, and the access to and expense of healthy foods.  

Lifestyle

If you have a lifestyle that centers on eating and/ or drinking, this can contribute to excess weight. A chef, bartender, or baker, something that requires tasting various dishes and trying new recipes for example. Also, someone who travels a lot for their job so always eats at restaurants, which are notorious for hidden calories and fat; they are more likely to be overweight and at risk for obesity. A sedentary lifestyle, where there is little to no activity or exercise is a huge contributing factor in being overweight or obese. Our modern conveniences- elevators, cars, remote controls- have cut activity out of our lives. The problem is that the less you move, the less active you are, the more likely you are to be obese. Being active helps you stay fit. And when you’re fit, you burn more calories, even when you’re resting, so you’re less likely to be overweight or at risk for obesity. 

Medical Conditions

There are a host of medical issues that can cause or contribute to significant weight gain. Some examples are hypothyroidism, diabetes, Cushing syndrome, polycystic ovarian syndrome (PCOS), menopause, depression, and endocrine dysfunction. Some medical issues don’t cause weight gain in and of themselves, but make weight gain more likely because they limit the person’s activity. Some examples would include conditions like osteoarthritis, uncontrolled rheumatoid arthritis, and chronic pain syndromes.

Medications

The list of medications that can cause weight gain is a long one. Everyday medications like corticosteroids (Prednisone, Celestone), diphenhydramine (Benadryl), hormone replacements/ birth control, and even insulin are among the culprits. Sometimes it’s not the drug itself causing weight gain, it’s a side-effect from the drug. Some drugs stimulate your appetite, and as a result, you eat more. Others may affect how your body absorbs and stores glucose, which can lead to fat deposits in your body. Some cause calories to be burned more slowly by altering your body’s metabolism. Others cause shortness of breath and fatigue, making it difficult to exercise, while some drugs cause you to retain water, which adds weight but not necessarily fat. Some medications don’t cause you to gain weight outright, they just make it more difficult to lose excess weight you may already carry. A lot of psychiatric medicines cause weight gain. The worst offenders generally include mirtazapine (Remeron), paroxetine (Paxil), risperidone (Risperdal), aripiprazole (Abilify), and quetiapine (Seroquel). With the exception of Wellbutrin, essentially all classes of psychiatric meds can be associated with serious weight gain. As a psychiatrist, I have to prescribe meds that may cause an unwanted side effect like weight gain. I have to weigh the cost to benefit with each patient. Unfortunately, I have patients who are trapped; they must take certain medicines to remain stable, so they have to severely alter their food intake and diet every day of their lives in an effort to avoid weight gain if possible. That’s the cost to benefit ratio- they pay the cost of a severe diet in order to get the benefit of being stable psychologically.   

Why should you care about your weight? What health issues does being overweight cause? The answer is many. Obesity leads to type 2 diabetes. It causes high blood pressure, which can cause strokes. Obesity can increase cholesterol levels and cause coronary artery disease, which is where deposits line the blood vessels that feed the heart and partially or totally block them, so the heart does not get adequate blood supply; this results in a heart attack, aka a “coronary” and this can easily be fatal. Being overweight puts excess weight on the human body, and this commonly causes osteoarthritis of major joints like the knees, the hips, and the ankles. All parts of the body are stressed and strained because they are not designed to carry around that much weight, and this limits the range of motion, mobility, and ability to walk. Obesity increases the risk of cancer to several organs and body parts: the breast, colon, gallbladder, pancreas, kidney, prostate, uterus, cervix, endometrium, and ovaries.  Another common medical issue from being overweight is sleep apnea. All the weight on the chest and throat causes you to temporarily stop breathing when sleeping, until you finally noisily gasp for air. Sleep apnea is serious, and very disturbing for anyone that you share your bed with. Obesity causes a fatty liver, which then leads to liver disease and the potential to cause the liver to shut down. Obesity can cause gallstones as well as kidney disease, which can cause your kidneys to stop functioning. Obesity can also cause fertility problems in both men and women. As a psychiatrist, I get obese patients referred to me because obesity can directly cause, or indirectly lead to, various syndromes and other issues, including chronic pain syndromes, depression syndromes, isolation syndromes, social problems, self esteem issues, and difficulty dating. People who develop obesity, especially when it is the result of something beyond their control, like from a medical issue such as hypothyroidism, have all sorts of social interaction issues and work problems, and I can treat them and help walk them through it with psychotherapy. 

We defined obesity, discussed the risk factors and what can cause it, and then the issues it can cause. Now let’s discuss how we can lose weight and prevent obesity.  

Food Diary

To offset weight gain or to help work off excess weight, consider keeping a food diary tracking what you eat and when you eat. Becoming a mindful and aware eater is a great first step to managing weight. 

Eat Slowly

Another factor which helps with weight loss is eating slowly. It takes some time for your stomach to tell your brain that you’ve had enough to eat. If you mindlessly shovel huge amounts of food into your mouth, you’ll miss your cue and overeat, and that obvi will cause you to put on weight and increase the risk of obesity. Eating slowly also has the added benefit of reducing the chances of having indigestion. 

Get Physical

Become more active whenever possible. Instead of meeting someone for coffee or a movie, meet them at a park, beach, or green space and go for a walk. Ideally, you want aerobic activity; that means getting your heart rate up, when it’s harder to breathe. Aerobic activities mean constant motion, like running, biking, swimming, soccer, basketball, anything where you’re moving constantly. Constant activity is aerobic activity, and daily aerobic activity will raise your basal metabolic rate and you’ll burn more calories, even when you’re at rest.  

Resist It

Resistance training is good for targeting fatty areas on the body. Resistance training involves moving a specific muscle against resistance, either using your own body weight or using standard weights. Other activities like lifting weights, doing push-ups, and doing squats are good for reducing body fat. 

READ LABELS! 

…and make sure you understand them. If you don’t understand them, do some research, get a library book on nutrition, ask a friend if they understand, or ask your doctor what the values all mean and how much of the various components should be included in a healthy balanced diet or when dieting in an effort to lose weight. Pay close attention to calorie count, fat grams, protein grams, sugar grams, and carbohydrate count. Just because something says “light” doesn’t mean it should be included in your diet. So many people are ignorant about nutrition information on food packaging. Be sure to know what those values mean and how much you should have of each every day.

Know the Fats

Trans fats- Bad fats!

Historically, trans fats are an evil on par with Satan himself, to be avoided at all costs. The worst type of dietary fat, trans fat is a byproduct of the industrial process of hydrogenation, which turns healthy oils into solids to prevent them from becoming rancid. Eating foods rich in trans fats increases the amount of harmful LDL cholesterol in the bloodstream while reducing the amount of beneficial HDL cholesterol. Trans fats create inflammation, which is linked to heart disease, stroke, diabetes, and other chronic conditions. They contribute to insulin resistance, which increases the risk of developing type 2 diabetes. Even small amounts of trans fats can harm health: for every 2% of calories from trans fat consumed daily, the risk of heart disease rises by 23%. Mind blowing. Though they have no known health benefits, trans fats were found in most pre-packaged garbage foods and were the main component in margarine type spreads. I say ‘were’ because recent science found there is no safe level of consumption of trans fats, and as a result, trans fats have been officially banned in the United States and several other countries.

Monounsaturated fat- Good fats!
Evidence has shown that consuming monounsaturated fats has several health benefits, including reducing general inflammation in the body. Studies have also shown that a high intake of monounsaturated fats can reduce triglycerides, decrease the risk of heart disease, and lower bad LDL blood cholesterol while increasing good HDL cholesterol. A diet with moderate-to-high amounts of monounsaturated fats can also help with weight loss, as long as you aren’t eating more calories than you’re burning. These fats are liquid at room temperature. Good sources of monounsaturated fat include avocados, almonds, cashews, peanuts, cooking oils made from plants or seeds like canola, olive, peanut, soybean, rice bran, sesame, and high oleic safflower and sunflower oils.

Polyunsaturated fat- Good fats! 

The two types of polyunsaturated fats (omega-3 and omega-6) are essential fats, meaning they’re required for normal bodily functions, but your body can’t make them, so you must get them from food. 

Omega-3 fats are a type of polyunsaturated fat that, like other dietary polyunsaturated fats, can help to reduce your risk of heart disease. Omega-3s can lower heart rate and improve heart rhythm, decrease the risk of clotting, lower triglycerides, reduce blood pressure, improve blood vessel function and delay the build-up of plaque in coronary arteries.

Omega-6 is a polyunsaturated fat that lowers bad LDL cholesterol. Eating foods with unsaturated fat, including omega-6, instead of foods high in saturated fats helps to get the right balance for your blood cholesterol (ie lower bad LDL and increase good HDL). Sources of polyunsaturated fats include oily fish (like salmon, mackerel, sardines), tahini (a sesame seed spread),
linseed (flaxseed) and chia seeds,
soybean, sunflower, safflower, and canola oil, margarine spreads made from those oils, pine nuts, walnuts, and Brazil nuts.

Follow these easy ideas for getting the balance of blood cholesterol (LDL and HDL) right.

– Go nuts! Nuts are an important part of a heart-healthy eating pattern. They’re a good source of healthier fats, and regular consumption of nuts is linked to lower levels of bad (LDL) and total blood cholesterol. So, include a handful (30g) every day! Add them to salads, yogurt, or your morning cereal. Choose unsalted, dry roasted or raw varieties.

– Go fish! Include fish or seafood in your family meals 2 – 3 times a week. Fish are great sources of the good omega-3 fats. If you don’t eat fish, you can take an omega-3 supplement.

– Use healthier oils! Choose a healthier oil for cooking. For salad dressings and low temperature cooking, choose olive, peanut, canola, safflower, sunflower, avocado or sesame oils. For high temperature cooking, especially frying, choose olive oil or high oleic canola oil, as they are more stable at high temperatures. Store oils away from direct light and heat and don’t ever re-use oils that have been heated before.

Eating polyunsaturated fats in place of saturated fats or highly refined carbohydrates reduces blood pressure, raises good HDL cholesterol, reduces harmful LDL cholesterol, lowers triglycerides, and may even help prevent lethal heart rhythms.

Saturated fat- OK in strict moderation

Saturated fats are common in the American diet, and they are solid at room temperature- think along the lines of cooled bacon grease. Common sources of saturated fat include red meat, whole milk and other whole-milk dairy foods, cheese, coconut oil, and many commercially prepared baked goods and other foods. A diet rich in saturated fats can drive up total cholesterol and tip the balance toward more harmful LDL cholesterol, which can prompt heart disease from blockages formed in arteries in the heart and elsewhere in the body. For that reason, most nutrition experts recommend limiting saturated fat to under 10% of calories a day. Replacing excess saturated fat with polyunsaturated fats like vegetable oils or high-fiber carbohydrates is the best bet for reducing the risk of heart disease. 

Diet Do’s

– Eat plenty of fiber. Fiber fights belly fat. When ingested, fiber goes into your system, binds to and then forms a sort of gel with the food, which slows down the absorption of food in the gut.  

– Eat a high-protein diet. Eggs are eggsellent…high in protein and low in fat. Avoid red meat. All meats should be lean and high in protein, like chicken or turkey. Nuts are also good for a protein snack.

– Eat fish, as often as 2-3 times per week for good omega-3’s. As discussed above, oily fish like salmon, mackerel, and sardines are high in omega-3’s which are good for the brain, help to decrease weight, and have numerous other health benefits. If you don’t eat fish, take a good omega-3 supplement.

– Drink green tea; there are reports that it helps with weight loss, and it’s generally just good for you.    

Diet Don’ts

– Don’t eat sugary foods or anything with sugar in it: sodas, candies, cakes, cookies, doughnuts; those are the main culprits. It’s a major bummer, but to avoid weight gain in your life, much less to try to lose weight if you’re already overweight, you must avoid sugar like the plague. Wah wah wah… 

– Cut out the carbs! To lose weight or just to avoid putting weight on, anything with white flour must go, so say syonara to pasta and most breads. You have to cut way down on starches, if you’re allowed them at all, so there goes rice and potatoes. And while most people consider corn a vegetable, you must count it as a starch when dieting. 

– Get on the wagon! If you drink alcohol, you won’t lose weight and keep it off. Won’t happen. When you consume booze of any sort- beer, wine, liquor- the alcohol is immediately converted to sugar, and if you’ve forgotten, see Diet Don’t 1 above. There’s no point in restricting calories, fats, etc by following a diet and also drinking alcohol at the same time, even a small amount.  

Go to Bed!

Sleep is critical if you want to lose weight, so aim to sleep at least 7-8 hours each night. If you do not get proper sleep, it will be very difficult (if not impossible) to lose weight, and you will likely gain weight. This is all thanks to brain chemistry and hormones, which get all fouled up with sleep deprivation. 

Stress Less!

You have to reduce stress if you want to lose weight. When you are stressed, your body produces the stress hormone cortisol, and cortisol increases appetite and increases belly fat by selectively placing fat deposits around the stomach and middle of the body.  

A Fast Fast

We’ve always been told that starving ourselves will not result in weight loss, and that it will even result in weight gain because the body goes into ‘starvation mode.’ Well, there are some recent studies out there that conclude that intermittent fasting, 24 hours without eating, once or twice a week, actually helps with weight loss. Very interesting. 

So that’s all about obesity: what causes it, what it causes, and how to combat it. We are a fat society, and the number of cases of obesity goes up every day. It’s disturbing because it’s essentially a preventable issue. 

For more information and interesting stories on other diagnoses, check out my book, Tales from the Couch, available in my office and on

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Is Marijuana For You

Given the legalization of marijuana in many states, I wanted to have an open discussion on the ramifications and repercussions of its legalization, and why choosing to use might not be the best choice for everyone.

Marijuana is so readily accepted everywhere now, in both legal and illegal states and in any and every social circle; regardless of its legal status, its use is suggested by so many people for everyone and everything under the sun…it’s a revolution that makes Woodstock look like a quilting circle. Grandmas and grandpas, CEO’s, lawyers, actors, the butcher, the baker, and the candlestick maker….everyone’s using marijuana, legal or not, and they’re not afraid to tell the world. And the marijuana of today ain’t yo mama’s marijuana…today many people prefer to smoke marijuana wax rather than the green herbacious stuff, because wax is a minimum of 90% pure THC, miles away from the 15% green stuff.

The legalization of marijuana has created a slippery slope. Now it’s basically off the radar for police, meaning that most officers will give a pass for possessing up to a certain amount of it, even in illegal states. The police officers have discretion in the field, and most just confiscate it and maybe write a fine ticket for it, or maybe not…it’s not worth the time or effort for them to fight it any further, even in illegal states. If they just wrote every possessor a fine ticket for marijuana possession, they’d be buried in tickets, so imagine the paperwork if they arrested them all. I watch a live police program on weekends, and the first question an officer asks the driver they’ve pulled over is if they have any weapons or drugs in the car. They then emphasize that “honesty goes a long way” when it comes to their decision-making process in drug possession. Sometimes they’ll employ a K-9 officer to find drugs, and I swear that at least 85% of the cars they pull over contain drugs of some sort. And most times (after the officer makes it clear that they can’t get in trouble for it) a driver will readily admit that they have smoked within the last hour or minutes before getting behind the wheel, or even just smoked while driving. This is apparently due to a general consensus that marijuana doesn’t cause impairment, which is debatable; more recent studies are suggesting otherwise.   

Because marijuana has essentially vacated its spot in the illegal drug hierarchy, the next “least worse” drugs, meaning cocaine and methamphetamine, have moved up, becoming “less illegal” in a way. Now officers even have some discretion when it comes to the possession of cocaine and meth; if the possessor only has a small amount, they may not necessarily go to jail. As hard as it is to believe, I have seen it on the live police program, people issued a ticket for possessing a small amount of coke or meth. The only difference is the type of ticket issued: while a marijuana ticket is just for a steep monetary fine, the ticket for coke or meth possession is essentially an order to appear before a judge, who then decides if the offender goes to jail or gets off with just a steep monetary fine and/ or probation, community service, etc. I wonder if lawmakers ever imagined that the legalization of marijuana in some states would lead to the near decriminalization of even minute amounts of drugs like coke and meth, but it seems it has. Similar to marijuana, I think it’s likely due to the amount of time and effort it takes to haul every coke and/ or meth possessor to jail: small amounts are permissible when weighed in the face of 100% rule of law…it’s certainly faster, easier, and more profitable to fine someone through the nose (no pun intended) than to house them in our overcrowded and expensive jails.  

Enough of the legal ramifications. Of course as a physician, I see the more personal, medical side of the legalization of marijuana. I am literally asked about it by patients every day, and I am a medical marijuana prescribing physician- I jumped through all of the state’s many hoops so that I can prescribe marijuana. I believe that used properly, marijuana has definite value as a drug. The key is for whom. I think it’s good for someone with cancer, with brain tumors, for AIDS, for neurologic disease like ALS (Amyotrophic Lateral Sclerosis), for Crohn’s disease, irritable bowel syndrome, for post-traumatic stress disorder, for specific types of chronic pain, and for certain seizure types. While I don’t prescribe marijuana willy-nilly, I definitely do prefer prescribing marijuana over other controlled drugs like opiates. But as I tell patients, just because it’s legal doesn’t mean it’s useful for everyone or even reasonable for everyone to use it. In fact, I think that for a subset of the population, up to age 30-ish, marijuana is counterproductive at best and damaging at worst. I call marijuana “the nothing drug.” If you give marijuana to a young developing mind, let’s say someone aged 14, the person belonging to that mind has their life course altered. From the day they start smoking marijuana, nothing happens. Their motivation drops off. They think a lot of good thoughts about what they can do or would like to do, but they do nothing. So nothing gets done. That’s what alters their life course. Dreams are great, but the key is to act on them. I tell my patients that when they use marijuana, nothing happens. Nothing bad, but nothing good. Nothing scary, but nothing awesome. Just nothing. Users do nothing, and if they continue to use habitually, they may amount to nothing. They may not fail, but they definitely will not excel. When you ask that marijuana-smoking 14-year-old what they’ve been up to, they’ll say ‘’nothing.’’ When you ask what they did in school that week, they’ll say ‘’nothing.’ When you ask them what they did over the weekend, they’ll say ‘’nothing.’ When you ask them what happened at the football game, they’ll say ‘’nothing.’’ When you ask them what they do when they get high, they’ll say ‘’nothing.’ Now you get the picture. Marijuana… The Nothing Drug. There’s a PSA campaign for ya’.

Using marijuana is mostly about being alone, being high, and being out of touch. You cause no problems. As a matter of fact, the last thing you want is conflict…it would harsh the mellow. My patients who smoke tell me that when they use it, they just want to keep using it, because it makes them feel so good. But there are qualities to marijuana that make people prone to isolation, where they don’t communicate with others as much. Think about it. When was the last time you went to a wild, raging party with people smoking only marijuana? Do you hear a lot of meeting and greeting, talking and laughing? Nope. But you do hear the sounds of lots of lighters striking and water bongs gurgling. And some muffled coughing- that wierd upper throat/ nasal cough that comes from people holding their breath and trying hard not to cough up the hit they just took. You may hear a woo-hoo or two, but that’ll come from the direction of the couch, which will be replete with reclining stoners. In my experience, people who smoke pot waste a lot of time doing so. It’s the kind of drug that can be used constantly, for hours and days on end, because there’s no concern of overdose. There’s a lot of time wasted, no pun intended, on thoughts not thought through and things left undone. When I warn patients about isolation, I often hear back from them that they do spend time with people, that in fact, they get high with people. I tell them that they may think they’re spending time with friends, getting high with their buddies, but that most of the time they’re getting high and playing video games or listlessly bobbing their heads to music and they just happen to all be in the same room. There’s no real interaction…it’s a very solitary pursuit, but in the presence of others, a mental masturbation marathon.

Obvi, I have many patients that complain that their lives aren’t going well, that they’re depressed and generally unhappy, and many of them smoke marijuana to “relax.” When I ask the marijuana users why they’re unhappy, they seem completely devoid of any insight as to what’s going on. I have a list of questions I ask, and it starts with “How much do you smoke?” I can probably count on one hand the number of people who tell me the truth, that they smoke a lot of marijuana; they always say they smoke “a little” marijuana. When I ask what form they use and how much “a little” is, some admit to using wax, and many tell me they use “only at night, never during the day” like that makes all the difference in the world, given that there are basically 12 hours of night in a 24 hour day.  

The best “medicine” I can dispense to these marijuana-using patients is education. I have given a version of the same talk at least a thousand times, tailored to the patient’s age and condition. It basically goes something like this: “You’re unhappy because marijuana alters you. It makes it so you’re just going through the motions of life; when you’re directed to do something, you can do it, but you never do anything of your own volition. You have no original thoughts or ideas or insight into your life, because you don’t bother to examine it. You don’t have any meaningful interactions with other people. You spend your time playing video games and eating junk food. You never see the sun, unless you have to venture out in daylight for a marijuana-related errand. You’re lacking a creative outlet, because marijuana isn’t conducive to creativity. Marijuana is robbing you of motivation, memory, ambition, desire, and energy. It blunts your emotions so that you feel nothing, so you smoke more to feel high because that’s better than feeling nothing. It’s a vicious cycle. You’re just like a rat on a wheel in a cage.” These facts are why marijuana is most damaging for people up to about age 30, because by this time at the latest they should be expending great effort trying to establish themselves and their lives, deciding where they want to go and setting goals to get there. Instead, they use marijuana and all that goes out the window. For an 80-year-old woman with cancer or rheumatoid arthritis, marijuana isn’t going to affect her life nearly as much as a 20-something-year-old looking for a job or deciding what career path they want to take.

As an example to show that using marijuana is not exclusively for the young, take my patient Frederick, who is 68 years old. He started smoked marijuana at ten and basically smoked all day, every day since. Consequently, he did nothing his whole life, so 58 years. That’s 58 years completely wasted, again no pun intended. Somehow he got on disability years ago. As far as I could tell, his only disability was that he wanted to smoke all day, that he liked to be high. I have another patient, a 23- year-old named Skylar. He’s basically a trust fund baby, living in his parents’ Palm Beach mansion full time while they spend 48 weeks of the year living up in Massachusetts. Skylar’s “job” as caretaker of the mansion, supposedly overseeing a staff of six, has always left him with more than ample time to do, well, nothing…except smoke wax. And he was a hard case, because he was able to afford the strongest wax and he smoked a lot of it- one of the handful that admitted to doing so. I saw him in my office a couple of months ago, and he told me he had wasted enough time using marijuana, he wanted off, and would I help him? Once I recovered from the shock and picked myself up off the floor, I of course told him that I’d be glad to, and I explained the deal. Most people think there’s no withdrawl from marijuana, but that’s not true. There is about a ten day withdrawl period that typically includes insomnia, restlessness, and irritability. It then takes six weeks for green marijuana to eight weeks for wax for all traces of THC to leave the body. I use medications like clonidine and trazodone to minimize the effects of withdrawal, and they make it much easier. At the two-week mark, the four-week mark, the six-week mark and the eight-week mark, patients are amazed at how they feel clearer and clearer at each point. They’re able to see how impaired marijuana was actually making them- they were totally unaware of their impairment at the time, how slow they were, how dopey and lazy. Once it’s completely out of their systems, they tell me how they’re more active, how they’re getting up in the morning and showering and getting dressed, how they’re going outside and exercising, and how things are happening in their lives. I’m happy to report that Skylar was no exception. His withdrawl from marijuana wax was uneventful, and after eight weeks, he was shocked at how different he felt, describing it as like being awake after years of being asleep. For the first time in recent memory, he was thinking, he was weighing his options (now that he had some) and he was planning his future. When I asked his greatest revelations, he said, “I have to make things happen. I have to be proactive. I have to look for and seize opportunities. No one can do that for me.” I really couldn’t have said it better than that. 

Re-reading this, I noticed that I said that marijuana is ‘robbing you’ of this and ‘taking away’ that, but really, marijuana doesn’t take things away from you, you give those things away when you choose to use. Marijuana has its place in treating certain illnesses and diseases; but remember that just because something is legal to use doesn’t make it reasonable to use it. If you’re faced with a choice to use, just think about Frederick, with 58 years wasted, no pun intended, and Skylar, who got a late start in adulting but has an unlimited future…now that he’s no longer letting marijuana limit his present.  

For lots more entertaining stories and information about marijuana and other drugs, check out my book, Tales from the Couch, available on Amazon.com. It makes for a great read and an ever better gift!

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You Might Be An Addict

(And by ‘Might Be’ I mean ‘Are’)

The “Opioid Crisis” is all over the news these days, thanks to cheap heroin cut with fentanyl and heaven-knows-what-else that’s filling up morgue drawers throughout the country. If you think the numbers of overdose deaths are staggering now, medical examiners would be up to their elbows in bodies without Narcan, a drug that scrubs opioids off of the brain’s receptors during overdose, literally snatching people from the grip of the Grim Reaper. Many people that have stopped breathing and whose hearts have stopped beating are only on this side of the grass because of tthis wonder drug. While addiction has recently become a hot topic, it’s certainly not like it’s new, though we do seem to find plenty of novel substances to become addicted to all the time. Also not new is the stigma and overwhelming shame attached to addiction, attached to being an addict. It elicits such a strong negative response that we’re not even supposed to use the word ‘addiction’ anymore- it’s too derogatory- so now we’re to refer to it as ‘substance use disorder,’ lest we offend anyone. That said, to save myself some aggrevation, I am still going to use the word addiction in all of its various forms (shhh!) so I apologize in advance if anyone takes offense. I’ll also be using the term ‘using’ when referring to the use and abuse of drugs and alcohol.  I’m actually amazed that the word addiction is so stigmatizing that even physicians aren’t supposed to dare utter the term. That just goes to show that no matter how we raise awareness about addiction, about how it affects people in every walk of life, and that anyone can become an addict, nobody wants to be labeled as one….especially an addict in denial. It ain’t just a river in Egypt.

I’ve been listening to people’s deepest and darkest thoughts for over 30 years, and in that time I’ve heard people rationalize every behavior and habit under the sun, but none as vehemently as the abuse of alcohol and drugs. The way these rationalizations percolate through people’s minds is interesting. They’ll say, “I’m not an addict because I don’t use that much” or “I’m not an alcoholic; I only drink a little here and there.” To this I tell them that it’s not how much they do or don’t use that makes them an addict. That’s generally when they say, “Well, I know I’m not an addict because I don’t have withdrawls, I don’t get tremors and I don’t shake, even when I don’t use for weeks.” Hmmm. I think they think that one stumps me. But it doesn’t. “Nope, I hate to tell you, that’s not at issue either. Just because you don’t have withdrawals does not mean you don’t have an addiction.” To this they say, “But, but, I only use in certain situations, like at weddings, or funerals…” Blah, blah, blah, blah.  Doesn’t matter- where you use or how often- it just doesn’t matter in terms of whether you’re an addict or not. And then there’s the flotsam and jetsam of rationalizations: “I would never shoot up, I just wouldn’t do that; I never drink shots, I only drink beer; I don’t use marijuana wax, I only smoke a joint every now and again; I would never take pills, I only drink.” The list goes on. The truth is that the amount you use, when you use, how often you use, where you use, whether you withdraw or not, and the means by which you get the drug into your system does not factor into determining if you’re an addict; those things matter not. Right now you may be wondering, ‘So what does matter?’ How do you tell if someone’s an addict? There are behavioral, physical, and psychological factors that can be examined to make the determination. First, I’m going to cover the behavioral stuff, and then I’ll get to the physical and psychological stuff. There are essentially five general behavioral criteria to consider if You Might Be an Addict (And by ‘Might Be’ I mean ‘Are’).

The first criteria centers on relationships with the people around you. Does a significant other- a lover, partner, spouse, parent, sibling, grandparent, etc- complain about your using? Do they say you change when you use…that you’re a different person? Sound familiar? Do you blow off responsibilities to use? Does finding the money for the drug, getting the drug, and using the drug occupy your mind above all else? Does it change the priorities in your life? Do people in your life complain you’re irritable or that you’re no fun anymore? Do you withdraw and isolate yourself to use or while high? The complaints of family, friends and loved ones are signals that using is impacting significant relationships. This is a definite sign that addiction is present. I have patients say, “I get up and go to work every day, blah blah blah blah; I make money to support my family; I’m a good provider; I do this, I do that; I still go to the gym every day, yada yada yada…” Yeah, but you come home and drink three martinis and yell and scream at your children and your wife. Yeah, but you spend all day Saturday locked in your study in an Oxycontin haze. Those things are problematic! If using impacts significant relationships, You Might Be an Addict (And by ‘Might Be’ I mean ‘Are’).

The second factor to consider is the use of drugs and/ or alcohol in spite of physical, emotional or personal damage; damage to mind and body. Some examples: the alcoholic who is gaining weight and having liver failure. The woman who smokes tobacco but needs oxygen to breathe. The man who smokes marijuana who can’t think clearly, has memory deficits and thought and decision-making issues. The woman who’s smoking meth even though it’s killing her lungs and rotting out her teeth with meth mouth. The guy who’s injecting heroin even though he’s got gnarly scabs and infected abcesses all over his arms and legs. The man who has a cocaine problem but continues to use in spite of arrhythmias and strokes. If using causes physical and/ or mental issues but you still use regardless, You Might Be an Addict (And by ‘Might Be’ I mean ‘Are’).

The third factor focuses on work, your employment. Problems at work, starting to miss work, starting to come in late, making mistakes at work, poor relationships with co-workers, lacking follow-through, becoming lackadaisical or flippant at work, and not excelling/ achieving at work, especially if the behavior is new or recent. These are all drug-related signs. People say, “Oh, for 23 years I’ve gotten up and gone to work every single day and I’ve done fine.” Sure. Okay, but in that 23 years, how many times have you been promoted? Have your reviews and evaluations shown consistent improvement? Or does your boss complain about your personality, how you don’t have a good attitude, how you’re forgetful of things, how you seem to have no energy, how it seems like you’re not enjoying your work? If using affects your work performance in any way, You Might Be an Addict (And by ‘Might Be’ I mean ‘Are’).  

Factor number four is pretty simple: legal issues and their consequences. DUIs come to mind, but any legal problems stemming from the use or abuse of drugs and alcohol count here. That might include anything from charges for possession of drugs, fighting in public, assault, disorderly conduct, disturbing the peace or domestic violence all the way to charges associated with vehicular collisions, even manslaughter. If using has put your attorney’s kids through private school, You Might Be an Addict (And by ‘Might Be’ I mean ‘Are’). 

The fifth and final criteria is a two-fer; it’s super important because the first part is the one thing you can never get back once it’s gone, and the second part is something very hard to get back once it’s gone. Any guesses? Give up? They are time and money. Time spent using is wasted; (no pun intended) it’s time gone from your day, your week, your month, your year, and ultimately gone from your life for good. That time could’ve been better spent being productive, doing literally anything but using. As for money, Captain Obvious says that money spent on drugs or alcohol is also wasted; it too could’ve been better spent on literally anything but drugs or alcohol. The amount of time and money spent using may prevent you from making more money, because the time you might have spent on a money-making opportunity is spent on using. What’s more, time and money act as a barometer for the severity of addiction…when one goes up, so does the other, and the more of both spent, the more severe the addiction. If you waste your time and money buying and using drugs and alcohol, You Might Be an Addict (And by ‘Might Be’ I mean ‘Are’).

So just to review, what are the five behavioral criteria to help determine if You Might Be an Addict? If friends and family complain; if there are physical and psychological issues from using drugs and alcohol but use continues regardless; if there are job-related problems from using drugs and alcohol; and if there is time and money misspent and opportunities lost to using…You Might Be an Addict (And by ‘Might Be’ I mean ‘Are’).

Family members, friends, and co-workers are usually in the best position to recognize a drug problem as they are familiar with the person’s habits and behavior, but considering the weight of the word addiction, you can’t just point an accusatory finger at someone. You must educate yourself on the signs of drug abuse. Above we discussed five behavioral factors that can signal drug addiction, but there are also physical and psychological signs to be aware of as well. Recognizing the signs of addiction is the first step to ending addiction, so I want to give some practical information on the physical signs of addiction, overdose, and withdrawl. These signs are the body’s physical manifestations resulting from the presence of drugs or alcohol in the body. 

General physical signs of addiction include, but are not limited to:

– Enlarged or small pupils (opiate use often causes pinpoint pupils)
– Sudden weight loss or gain
– Bloodshot eyes
– Insomnia
– Unusual body odors
– Poor physical coordination
– Looking unkempt
– Slurred speech

Overdose is a medical emergency. In case of overdose, please seek immediate emergency care. Typical signs of an overdose may include, but are not limited to:

– Drowsiness or trouble walking
– Agitation
– Aggression or violent behavior
– Difficult/ labored/ ceased breathing
– Nausea and vomiting
– Hallucinations
– Delusions
– Loss of consciousness

Withdrawl can be a medical emergency. Please consult a physician during withdrawl events. Typical signs of withdrawl may include, but are not limited to:

– Shakiness, trembling, jumpiness
– Loss of appetite
– Nausea and vomiting
– Depression
– Insomnia and fatigue
– Headaches and fever
– Confusion and hallucinations
– Seizures (lasting over 5 minutes is immediate emergency)

In addition to behavioral and physical signs of addiction, drug abuse also impacts a person’s psychological state. When they’re in the grip of active addiction, the person might not realize or recognize these changes. The psychological signs of drug addiction may include, but are not limited to:

– Anxiousness
– Inattentiveness
– Lack of motivation
– Irritability or angry outbursts
– Changes in personality or attitude
– Emotional/ mental withdrawl
– Sudden mood swings
– Unexplained paranoia

We’ve covered the behavioral, physical, and psychological criteria that indicate You Might Be an Addict (And by ‘Might Be’ I mean ‘Are’). Or should I say You Might Have Substance Use Disorder (And by ‘Might Have’ I mean ‘Have’). I like the first better. No matter what you call it, you don’t have to live life in addiction. Actually, that’s an oxymoron- there is no living life in addiction. And if you do oxy, are you a moron? An existential question to ponder. 

For more information and stories about addiction, check out my book, Tales from the Couch, available on Amazon.com.

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How To Learn With ADD

How to Learn Best with ADD/ ADHD

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Why Are People Going Crazy

Why are people going crazy?

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

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

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

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

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

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

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Car Wash psychiatrist

So I’m at the carwash. My car was a little dirty, and I like to keep it clean, preserve that new car scent. I’m no stranger to this place and I know my mission is the inside-out wash and hand wax. Actually, my mission is to manage to sit through it; I’ve been exiled to the waiting area for two hours. Two freaking hours! It’s a Saturday…don’t all these people have better things to do? As I sit down, my mind roams my subconscious, and I realize that the carwash is one of the few errands that I actually do myself. Thankfully, my amazing wife Debbie handles all the errands and other household stuff with great aplomb; good thing too, because waiting anywhere, for anything, transforms me into a sixteen year old with severe, untreated ADHD. I look at my watch. That little self exploration on errands took a whole 1 minute, 48 seconds. As I continue to sit, bored out of my  freaking mind, I look at the other poor saps waiting with me. Most are on their phones, probably ‘gramming about being bored AF at the carwash, and in my best UK-accented-newscaster-voice-in-my-head, I have a running commentary going on about how this is what modern society has come to. About how there’s really very little reason for us to leave our homes, how we can order everything online for delivery and blah, blah, blah, I’d talked about all of that so many times that even I couldn’t take any more of it. Time check, 11 minutes, 22 seconds gone. Insert long loud sigh here… 

I started watching people getting out of their cars and handing over their keys- I noted what they were wearing and how they carried themselves, how they reacted to the news that they’d be imprisoned here for more than two hours- and I thought this was a great example of how the vehicles we each choose to drive say something about us. They project a mindset or act as a status symbol. The hippie girl in the Prius, the midlife crisis dude in the Corvette, the family man in the Tahoe wrestling with the kid’s car seat. Watching him get red faced and frustrated with it reminded me of all the crap you have to bring with you for an outing with a baby. I remember it being like preparing for a paramilitary exercise. That’s probably why God made babies so cute…to help you overlook what a pain it is to do anything with them. It’s so much easier when they get older and you can just throw ‘em in the car and go. Those days were long gone for me. Man, tempus fugit! Am I old? Do people who people-watch me see me as old? I don’t feel old. Hmm. As I pondered this disturbing thought, a big bronze Hummer drove up and a dude got out. This guy was destined by God to drive a Hummer. He was a little over six feet tall. From what I could see, his appearance was pretty average, save for one attribute…he was built, huge. Like a freaking mountain. His head was perched atop a neck that was the girth of an old banyon tree trunk, with his trapezoid muscles as the roots on either side. When he came into the waiting area, everyone looked at him. This guy needed a theme song to follow him as he moved. I got the feeling he was used to turning heads. There weren’t many free seats, but two of them flanked me, and he took the one to my left, dwarfing the chair as he sat. I glanced at my watch. Only 20 minutes 3 seconds gone; a lot of time left to be insanely, hopelessly, mercilessly, miserably bored….

I don’t usually hit people up in public, but when a giant sits right next to you in a confined space, it is more awkward to ignore them than it is to start a conversation. God knew I had the time, so I turned to acknowledge him, saying, “Hi, you clearly spend a lot of time working out. What do you do? Are you a personal trainer?” Even as I asked, I was assessing him….occupational hazard. He was in his very early thirties and had short blondish hair that was thinning and balding, kind of oily broken-out skin with little deep red pimples, and maybe a day’s worth of stubble on his chin. He was wearing cargo shorts and a tank top that didn’t cover much of his expansive chest, with muscle bound arms attached to broad shoulders. I noticed that he had the same acne on his back, shoulders and chest as he had on his face. With these signs, it took me all of 3 milliseconds to conclude that this dude used a lot of anabolic steroids. To my questions, he answered with a smile “I spend so much time at the gym that I probably should be a trainer, but I’m actually a police officer. My name is Roger. What do you do?” With that, he extended his hand. As I shook it, I said, “My name is Mark Agresti. I’m a psychiatrist. My office is on the island.” I’m always a little reluctant to tell people what I do because I know where it’s usually going next, but as we exchanged some social pleasantries, I learned that he wasn’t from Florida, that his family has a vacation house here on the island and he’s down because he’s really just been overwhelmed lately, he’s had some family drama and wanted to get away. More often than not, this is what happens when I tell people what I do…It’s like I’ve issued an invitation for a free session. So here’s the dilemma: he’s laid it all out that he’s troubled, having family issues, so do I ask what’s troubling him or do I not? Time check, 35 minutes, 12 seconds gone. I’d be bored to tears without this exchange, so it’s a pretty good time to hit me up for advice and to ask me questions, so we kept talking. Before too long, the topic of weight lifting and bodybuilding came up, I mean duh, it had to happen. I felt pathetic talking to Lou freaking Forrigno the Incredible Hulk about my workout routine, but I told him I lift weights and work out, that I run to and from the gym everyday, about five miles. Then apropos of nothing, he says “I’m on steroids.” and I’m thinking like well, yeah, duh, but instead I said, “You look really muscular.” At that point he said, “Yeah, but I’m a little upset because now I’m growing tits.” People tend to unburden themselves in conversations like these, even though they aren’t patients so there is no expectation of cofidentiality. I replied simply, “That’s to be expected; taking testosterone makes dudes grow tits.” He bravely forged on, saying that his scrotal sack has shrunk and oh by the way, that he’s now impotent. He said it like ‘Nice day today, wish I could get it up!’ like BOOM! Knowledge bomb! I could clearly see that this dude had more issues than National Geographic, but he’s not a patient and this is obvi not my office, it is a carwash. I didn’t want to get too deep with him. He didn’t share that reservation, and he continued on, telling me that he has been depressed lately. Now, I could’ve just made some non-committal comment and shut him, and the conversation, down, but then again….time check: only 49 minutes, 5 seconds gone. So I said, “Steroids are a bad idea. They are without a doubt the root cause of all of the issues you’re having.” To this he replied, “Oh, I know you’re right. I know all about it, but I can’t stop. I like the juice, the rush of it.”  I thought to myself, in for a penny, in for a pound, and I dove in. I said, “Look, me, moi, if it caused impotence, if it in any way affected my drive or ability to have sex, I wouldn’t take it. I mean, if something turned my nuts into raisins, I’d avoid that something like the plague. But that’s just me.” He laughed, and flexing his arm to pop his biceps, he asked, “Not even for these?” I replied, pointing at my lap, “Nope, I’d rather have this.” 

Now, you would think that there was no way this conversation could get deeper or more personal, but you’d be wrong. The saying goes that you shouldn’t discuss religion or politics in polite society, but evidently Roger had never heard that saying. He proceeds to tell me that he’s a Christian; he was raised in a Christian home, went to a Christian college, he’s very active in his church, that it’s the focal point of his life. Now, as I said before, when I tell people I’m a psychiatrist, most invite themselves to an on-the-spot free session. The flip side of that coin is that it’s almost like my profession is a free pass for me to find out what’s going on with virtually anyone, anytime- I can choose anyone I want, and I’m able to just walk up and say, “Hello, Dr. Mark Agresti. I’m a psychiatrist. What’s up? What’s going on in your life?” It’s a strange thing. I’ve been a psychiatrist for a long time, since 1988, so 31, almost 32 years I guess. Anyway, at this point in my conversation with Roger, I basically said ‘What’s up?’ At least metaphorically, anyway. I was now invested. So Roger is a Christian and his faith is of utmost importance to him, but he’d said he had problems lately. So I’m thinking okay, maybe he’s got a girlfriend, maybe she’s married or something. Or, being a big muscular cop, maybe it’s a brutality thing, he got into a fight and beat someone up. Or maybe he took a bribe, or he has a drinking problem or he’s addicted to drugs. But I was floored with the real problem. He began, “My father…..” He told me his father’s name, and it turns out that he’s a fairly well-known individual in politics, a highly respected pillar of his community. I won’t say his name or what he was and where; it doesn’t matter for the story anyway. He tells me that one month ago, his father sat him and his sister down and told them that after 36 years of marriage, he was leaving their mother. He had filed the divorce papers a few months ago and expected it would be finalized in the next few weeks. I said, “That’s a shame…” and then stuck my foot in my mouth, asking my assumption, “…Girlfriend?” With a wry chuckle, he said, “Nope. Boyfriend. My father came out of the closet; he told us he was gay and that he’s going to move in with his lover. Then he said he was sorry, and told us what for, then begged us to not say a word of it to anyone.” Shocked, I said, “Wow, that’s pretty intense.” He said, “Yeah. My entire life has been fake. Everything up until now, the relationship I thought they had, the family I thought we had, growing up in the church in a normal American family. My father as a well-known political figure, lying to the constituents, all the people who made him. All these years, I thought that my life was one thing, and now I find out it’s another thing, all fake. Like gold plated bullshit.” I was lucky enough to have been born into a family that had never seen a divorce for generations, since it’s inception really. But I imagine that divorce would shake anyone to the core, regardless of how old they may be at the time it happens. I mean, your parents are always your parents, and you want the nest to always be there, even if you’re no longer living in it. All I could say was, “Man, that’s pretty rough.” He went on to say that with this new perspective of his father being gay, he’s reliving his entire life, reviewing every moment of it for clues, trying to understand if he should have, or even could have possibly seen that his father was gay. He used his father’s admission like a prism, and looking at his life through it, things started to slowly fall into place and make sense. He saw the reason that his father was always working so much, why he had a separate apartment in town and only came home on weekends, and why when he was little his mother used to cry a lot, but how her tears had dried the older he got and eventually just stopped falling. It all started to make sense to him. He came to believe that every part of his childhood, everything he did with his father, and therefore with his mother, was counterfeit, tinged with deceit. He told me that now things are very awkward with his father, because he’s realizing that he doesn’t know who his father really is anymore, and this new revelation of him being gay and moving in with a man he didn’t know anything about is super awkward. On the flip side, he feels deep sadness, because he realizes that his father had lived most of his life as a lie; he had sacrificed his wants and squelched his true desire to be with men, instead exchanging it for a false life, presumably out of love for his children and even for his wife. It was a lie of a life built of love and guilt and regret….a tangled mess. So Roger felt sorry for his father and for his mother, but for very different reasons. Despite feeling sorry for his father, he also felt angry. Regardless of his motivation, everything his father did was total manipulation. He was a practiced liar. He lied to his mother, he lied to his sister, and he lied to him. His feelings toward his father were complicated, but not mutually exclusive. He was angry at him for being a liar, but he sympathized with him at the same time, because he thought his father’s motives were pure. It was a mixed bag to be sure. 

To further complicate matters, his father was also prominent in the church, and their position has always been, and likely will always be, quite clear: homosexuality is unacceptable. But divorce? That’s okay. Ironic, right? Anyway, the family had to disclose the pending divorce and carefully craft the “reasons” behind it, and that was of course a very sticky wicket. Ultimately, fearing a news leak in the parish as to the full truth of the matter, they decided to leave their church. Leaving that church vacated a huge component of Roger’s life, and ultimately left him questioning his Christian values. Those values are intolerant of being gay, and they disallow homosexual relationships, the type his father is in, so if he supports his father, it’s in direct conflict with the Christian values of the church, a church in which he had always placed his faith. All of this left Roger very confused, and rightfully, it was very upsetting to him. He told me, “On one hand, I feel like I can’t really trust my father ever again. On the other hand, he’s always been a good father; he put me through college, he supported my choice to go into law enforcement, and he helped me become the man I am today. But, my mom was amazing, too. She baked cookies, kissed boo boos, packed lunches, drove my sis and I to soccer, boyscouts and dance, and made our house a home. And she was so hurt by his affair, gay or not. It destroyed her, and that pissed me off. It still pisses me off. She was totally devoted to him, and he repaid her by cheating and lying.” I could see his point. Not only did he have to deal with his feelings about his dad and the family strife, but he also had an obligation to help his poor mother heal from them as well. She was leaning on him and his sister a lot as they all tried to get over it in their own way. And the more his mom leaned on him, the more resentful he became of his father. It was unfair to his father, but it was impossible for him to stay objective when his mother was so needy, holding sway over him. When he finally asked me, “So, what do you think, doc?” I paused to formulate my response, how to couch it, if to couch it. I went with the direct approach, saying, “Well, the whole resentment thing will not work. It will not serve anyone. Whatever has happened, has happened. You can only look forward to what is ahead. The only way you will find any peace is to forgive your father and accept his choice to love whomever he loves. And you may not like this, but bear in mind that your mother must’ve known. This situation is not solely your father’s fault, and he should not get all of the blame. Your mother has some degree of complicity as well; some responsibility falls on her head. I know it probably sounds bizarre to you, but at some level she knew, and I think she was part of the big lie, the cover-up. I watched his face as he took that on board, then realization dawned. He said, “You know, thinking about it now, I think I remember something about a letter he wrote her many years ago, when my sis and I were just kids. There was a big blow out fight because mom found a videotape in the house. I never saw it, but now I assume it was gay porn. She was angry, I think maybe because it wasn’t well concealed, my sister and I could’ve found it and taken it or told somebody, something to that effect. I think he wrote a letter to her apologizing and saying he was scared because he thought he might be gay. It was a big fight, but it blew over; it seemed the coast was clear as far as us kids were concerned. Barely a blip on the radar.” I had to call him on that, and I said, “I’m sure there were other signs, other pieces of the puzzle, you just weren’t aware of them. It wasn’t just one letter that was the be all, end all. There are some issues between a man and woman in their marriage that are hidden beneath the surface, yet they bring to light facts that both, for their own reasons, would prefer to remain in the dark. The husband being gay is most definitely one of those kinds of facts. I’m certain that both of your parents knew the fact, but one of them, your mother, wanted to deny it, so she shoved it deep down into a dusty corner of her brain. So both were complicit in making and keeping it a secret. Your father finally could not, or would not continue the lie, and when he took a stand and told your mother that he was gay, wanted a divorce, and was moving in with his lover, the truth shattered your mother’s denial. But on some level, whether he had told her or not, somewhere deep down, she always knew he was gay. There’s a level of intimacy and sexuality that a gay man cannot reach being with a woman, and I’m sure that a woman would pick up on it. Women’s intuition is legendary, not cliche or an old wive’s tale. Regardless, it takes two to tango. It was a marriage and both played their parts. Although he did lie, you can’t place all the blame on your father, just as you can’t place it all on your mother. But for the sake of your own serenity, hold them both accountable, accept them, warts and all, and then forgive them both. That’s your only path to peace, man.” Roger had been nodding periodically as I went through all of this, and now when I finished, he said, “You know, I get it. I think you’re right on all counts. I’ve been racking my brain, trying to divide up the blame, like dad gets 90%, mom gets 10%; then I think, well, maybe I’m being too hard on dad, so I decrease his and increase mom’s. I’ve literally been doing that in my head, and I think it’s been driving me crazy. Like I’m the freaking blame police, parceling it out and assigning it to one or the other. So stupid and pointless! From now on, I’m not going to blame either one or be angry at either one. Nobody’s perfect nor blameless and I have to concentrate on the future and my relationship with them.” Happy that he got the idea, I said, “That’s a good start. You should make the effort to repair your relationship with your father. You must first accept his choice to love someone other than your mom, then accept that it happens to be a man. It will be awkward at first, but your love for him needs to outweigh the awkwardness. When you feel less awkward, he will too, and eventually it will all dissolve with time. Make the decision to forgive both your parents, and with time and patience, your relationships will grow together and be stronger than ever. Anger, resentment, shame, guilt, culpability, blaming this one, blaming that one, it doesn’t help at the end of the day. It’s just a mind screw.” He said, “I totally get it. I walked in here blaming my dad for everything, sure I was right about it, with no solution or path to move forward. You turned everything on its ear and made me see it all in a different light, and you gave me suggestions for how to move forward with my family. And for the first time since this all started, I feel hopeful when I think about my relationship with my dad, instead of feeling anxious, with my stomach in knots like I’m going to puke.” As he clapped me on the shoulder with one hand and shook my hand with the other, he said, “I feel like a huge weight has been lifted off my shoulders, and I am so grateful to you for that. To be honest, I never would’ve actually thought to see a psychiatrist for the things that happened with my family and the way I felt about it, but you’ve changed my mind on that too. I see why people come to you….it’s really cool to talk things through and hear an objective point of view.” 

Just then, the carwash announcer guy shouted “Agresti!” I said, “Here!” as I stood up. I extended my hand to Roger and told him it was good to meet him. He shook my hand and said, “Thanks again, doc.” I went outside to my inside-out washed and hand waxed vehicle and I got in, inhaling the new car scent. As I drove out, I caught a glimpse of my watch: 77 minutes, 46 seconds. That’s how long it had been since I’d last checked my watch.…. I’d spent all of that time speaking to Roger, and I didn’t regret a single second of being a carwash psychiatrist. That’s the whole story, nuts (or raisins) and all.

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How To Get People To Like you In Ten Minutes

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

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

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

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

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

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

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

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

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

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

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

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

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Find out How Technology is changing You.

Can we Talk?

We live in a world that is constantly changing technologically, and as it does so, it is changing how we as people interact. In previous generations, in order to obtain anything- food, shelter, clothing, information- you had to speak to another person. All of these transactions required interactions. And that meant you would have to converse with people. But things have evolved, and are continuing to evolve, every day. Obtaining those normal life needs I mentioned above has been revolutionized to the point that they no longer require person to person interactions. I talk to and listen to people all day, everyday, and I have seen some repercussions from the decline of personal interactions. These days, people really suck at the art of conversation. And it is an art. But now that the advent of technology has made it unnecessary to converse, it’s clear that its gone downhill. Look at texting. Most people choose to communicate by text rather than by voice/ phone whenever possible. The problem with that is that when people actually do talk to others, it sounds sort of like a text, with all the appropriate jargon and acronyms. Even the way we entertain ourselves has changed. You can entertain yourself alone now. You don’t even need a friend to play a game. For that matter, you don’t even need to make friends in person. You can have electronic friends to play video games with. If you’re in school and you need to do research, you can do it all online. There is no seeking out of experts and sitting down in person for a discussion. You don’t comb through giant reference texts; hell, you don’t even need to go to a library, you just need a laptop. When I tell millennial patients that I spent a lot of time in the library when I was in school, they’re amazed. They can’t wrap their minds around using microfiche (“Duuuude, like what is that microfish Doc?”) to look at newspaper articles from years past. They don’t even understand what the Dewey Decimal system is, and would have absolutely no clue as to how to find and check out a book. While today’s ability to get all the information you need online sounds totally fantastic, there are some pitfalls to be aware of. For all the information on the superhighway, there is a lot of misinformation. You have to be able to weed that out, which can be difficult. There are plenty of people with their own nefarious agendas posting crap online and taking no accountability. There is no monopoly on information.  Good, bad, or indifferent, everything is shared online. Social media has radically changed interactions between people. It used to be that to find a date, you actually had to leave your house. Not so anymore. Now you can find dates and vet them without even getting off your couch, and that first awkward conversation is had in text rather than in person. Facebook, Instagram, Twitter, Tinder, Match, JDate, Farmer’s Only, DateUrDog, yada yada- there are crazy sites for every segment of the population- these sites allow people to share information and give the illusion of socialization. 

What about some basics of just feeding yourself? When going “out to dinner,” people would normally socialize. But that does not happen anymore. Uber Eats, Delivery Dudes, DoorDash, you can get virtually any restaurant food delivered, whatever you want, whenever you want it. As a result, there are no more random interactions where you would meet people for dinner or run into people you know while you’re out. Money management is another area that has drastically changed. Banking, stock trading/ dealing, investment management, everything has gone online. There is no more going to the bank, gossiping with a teller friend, or running into people at the bank. Doesn’t happen much any more. I remember when I was a kid, people used to say that a banking job had good security, because people would always need money. I wonder what they think now, when everything is done electronically. Another major shift has been online shopping. I hate making comparisons that start with “When I was a kid…” but when I was a kid, a teenager, a big place to hang out and see cute girls was the mall. That’s where most people bought their clothes and it was the place to be seen wearing them. But now, shopping is done online…Amazon, Walmart, Rakuten, Wish, on and on. Every store has a website; it’s a virtual mall to buy clothes, shoes, decor, jewelry, whatever you could possibly want. You don’t need to go out every week to grocery shop either. Now you can join Amazon Prime and get Whole Foods groceries delivered to your doorstep. These days, we don’t have to do many of the errands that our mothers and grandmothers did. Dry cleaners pick up dirty laundry and deliver everything perfectly pressed the next day, dog food is delivered, pharmacies deliver medications, groceries are delivered with the frozen goods still frozen, and there is even an increasing trend of doctors doing more telemedicine. I have one patient, Eileen, who tells me she leaves the house just twice a month- to get her hair done, her nails done, spa treatments, or to see a doctor or dentist. That’s all she’ll leave the house for. She even gets her dog groomed from a mobile dog groomer that comes to her house.  Since everything we need can be delivered to the home, there is very limited interaction where we see others, and social interactions are even more limited. There becomes only one reason to interact, and that is that we as humans need to socialize or risk damage to our psyche. Think about what you hear about most serial killers…they were quiet, they were loners, never seen with others. Socialization is healthy. But now, instead of making and nurturing all these relationships through the chores we used to do, we have to create a social world, a place in which we choose to make time to socialize, where we choose to interact with people. It’s like socialization by appointment.

This information applies to all generations. I have talked a lot about millennial this, millennial that, but this is all generations. Yes, our young people have been raised on a diet of electronics and have not learned to communicate with one another, but our older generations that were taught and practiced social skills are now losing those skills as they age. I’ll put it this way…with any learned skill, if you do not use that skill for seven years, you will lose that skill. I have elderly clients who never leave their homes; everything is ordered in and delivered. Their social skills are inadequate. One of my long time patients, Albert, comes to mind. He was a vastly different person when he was going out to dinner with friends, when he went grocery shopping or played cards with friends. Now he doesn’t get out much and his social skills suffer for that. I feel very strongly about the need for socialization; I would say if we do not socialize, we do not exist.  I think we need to come to the point where we recognize that a lack of interaction between people is a problem. Not just not socializing with people but also “electronic friends” from social media that are not real friends. People whose lives revolve around these “friends” on social media and videogames have to see that these virtual relationships aren’t fulfilling. There is no intimacy in those relationships. And when I say intimacy, I’m referring to physical and emotional intimacy. You can’t see a facial expression, read body language, or touch, feel, or smell over the internet or through text or anything other than an in-person interaction. Another problem with electronic online relationships is that there are no checks and balances on behavior. You can say or do whatever you want, and you can dress, smell, and look any way you want and it really doesn’t matter. You can even be a predator or a catfish trolling online…or you could be a victim of those people when you are interacting on the internet. There is no one to say hey, that was dumb, or that was funny, or that was great, or you are pretty, or you are dressed inappropriately. So, without outside interaction, behaviors can become more bizarre in the technological vacuum. You also limit group interactions that nurture skills that are good, as in leadership, speech,skills of social interaction, the ability to make a case for yourself and sway opinion. These are critical in terms of group behaviors.

There are other things that are lost without an in-person social interaction. It is tough to have humor online. It’s hard to convey certain thoughts, without voice inflection and facial expression. In effect, you lose your sense of humor and the ability to make people laugh. It’s also difficult to have or convey empathy. You can’t understand what is going on in other peoples’ heads or what they’re feeling or thinking. The internet can cater to people looking to hurt others, bully people, and be mean; they can say what they want while remaining anonymous. Social etiquette is lost.  The ability to speak and interact using your voice, your speech and your body language to communicate a message is lost in electronic interactions, as is understanding nonverbal cues, group dynamics, and the art of conversation, as I mentioned above. You actually become dulled when you have limited true life interactions, so you lose the ability to pick up on social cues. Another thing lost to limited true life interactions are shared experiences. You are always alone with only electronics, no personal interactions, so there’s no one to motivate you or challenge you. By severely limiting real life interactions, you lose exposure to everything outside of you. There are no new things, new tastes, smells, places, people, and travel…you just don’t get that from your electronic internet- bubble life. 

Whenever I present a problem, I like to present a solution as well. So, if you’re living an electronic/ internet existence, what can you do about it?  It sounds cliche, but the first thing is to recognize that there is a problem, and that you want to change your reliance on electronics and improve your social skills. This is big, because most people do not even realize there’s a problem. They don’t realize how much they are depending on electronics/ social media to communicate. 

Then two, once you realize the problem, you have to commit to doing everything possible to increase interactions with real people in the real world. To do this, you’ll have to begin to desensitize yourself, because there may be anxiety early on when interacting with other people. But don’t let the anxiety prevent you from doing it. Go out and talk to people, same or opposite sex, maintain a conversation, and try being funny. Definitely make sure to be appropriately dressed in something you feel good about wearing, and make sure your hair and/or makeup is on point. Be aware of non-verbal cues like your body posture and your natural facial expression. If you have Resting Bitch Face, find and frequently practice a more open expression in the mirror. Essentially, you want to enhance your positives and interact appropriately. Before you know it, you’ll be less terrified by personal face to face interactions. Another way to meet people and increase real social skills is by doing errands, especially if you previously had them done and delivered for you. If you like certain products, go where they sell them and interact with salespeople or other customers and buy them. If you see someone buying something you haven’t tried before, tell them that and ask them what they think of it. Also, make it a point to expand your world by involving yourself with hobbies, your family, sports, academics, whatever piques your interest. Make an effort to seek out new things and try them. As you go to new places, the goal is to make new friends, to start real relationships in the real world. You can do this by starting a conversation based around whatever activity you’re both doing. For example, if you’re taking a cooking class, ask someone in the class what dish they really want to learn to cook or what restaurants they go to when the dinner they make is inedible. A common denominator is a great place to start a conversation. It may take a minute to psych yourself up to start a conversation, but don’t get stuck there- It’s not a big deal to start a conversation, so don’t spaz out and make it into one.

If you want to have real relationships,function properly in the real world, and learn how to interact appropriately and carry on a conversation- with co-workers, bosses, friends, family- the key thing you have to do is to put down the electronics, the phone. Turn it off and don’t carry it for a day and see how your social interactions change. 

So, you’ve admitted there’s a problem with your social interactions, that you have trouble making in person friends and starting real relationships with real people, and that you really only interact with people electronically on the phone. And you’ve said that you’ll do whatever it takes to learn how to make real friends in real life and stop relying on electronic friends; that you will put the phone down and get hobbies or try sports or whatever you can find to meet people in person and not online. That’s all great. But I have a couple of tips for you. First tip: when you go out now to wherever and whatever it might be and you’re making efforts to interact with people, observe successful people and copy them. When I say successful, I don’t necessarily mean someone who has money (though that doesn’t hurt lol) I just mean successful in that they are clearly holding people’s interest, or it could be someone who oozes charisma to you, someone that you’d like to be or hang out with. So locate that person and look at how they interact with others and pick and choose the qualities you like and can integrate with your unique personality. You don’t have to  reinvent how to interact with people, you just have to find someone you think is successful at it and copy it into your personality. And the second tip is that it’s perfectly fine to talk to people about how to meet people, and it’s okay to ask for help. No one is born knowing everything there is to know about everything. So while you will be better at some things, there will be some people who could be role models or instructors for you who are maybe wiser or more capable in this communication area, and you could learn skills from them on how to break the ice, how to interact face to face, and how to hold conversations. 

When I asked ‘Can we Talk?’ I asked it literally, because every day I see that the spoken word is being usurped and replaced by the texted/ transmitted word, a fact that I find unsettling at best.

As technology advances, I’m certain that robotics will continue to take over an ever-expanding pool of tasks that require skilled labor, jobs that are currently filled by humans. In the future, we will have to learn to live with robots, to interact with them on a daily basis. I wonder what that will be like, if they will have the ability to have real conversations given that they would not have hearts and souls. I worry that artificial intelligence will take over and possibly eliminate human intelligence, human feelings and interactions, just as many human jobs will surely be eliminated. Even after robots, life will continue to evolve, it has no choice…but I think it’s going to be a bumpy ride. 

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They call her Nicky.

Her real name is Nicole, but everyone calls her Nicky. I want to tell you her story. She comes from New Jersey, but the family also has a Palm Beach estate where they spend a fair amount of time. Her family brought her to my office, and in that first appointment I spoke with all of them together to gather as much background as possible. She was 24, the baby of the family, with a brother named Vinnie and sister named Sasha. Nicky and her sister Sasha took after their mother; they were all beautiful, with dark hair, light eyes, and tan skin, but Nicky had a more striking exotic appearance that was unique among the three of them. The family is Italian, very wealthy, with the father owning several large car dealerships and car washes all over the place in Jersey. Nicky’s siblings Vinnie and Sasha both work for their father. He runs dealerships while she manages human resources. And then, there is Nicky. Nicky had her share of issues, but not everything was her fault. She came from a home where her mother stayed home with the kids, doing everything for them, while her father worked a lot and wasn’t home much. When he was home, he was drinking wine. Her mom also drank wine. Nicky had few memories of either parent without a wine glass in hand. They were alcoholics, but wine was where it began and ended for them, and it didn’t seem to be an obvious source of family strife. Her brother Vinnie was a bit of a partier, drinking more than he should and smoking marijuana, but he showed up at work everyday and did a great job running his assigned dealerships and making big profits for the family business. Her sister Sasha was an exercise fanatic; she worked out every day, and was in great shape. And then, there was Nicky.  

Now, you’re reading a story written by a psychiatrist who works with a lot of patients with addiction, so you probably know where this is going, but I’d like you to go on the ride anyway. Based on information I gathered from speaking with her parents and siblings, and of course Nicky herself, I learned that Nicky was an extremely precocious kid, both physically and in mind set and attitude. The journey that brought her to where she was now seemed to begin when she was 10 years old. Nicky at 10 was already obsessed with herself. She was into internet porn and pay-for-play live camera peep shows. She was fascinated by those and the people in them, and even thought the live camera show was something she could set up and operate for herself. She never even considered the thought that her very young age should stand in the way of her doing something she wanted to do, so she didn’t let it. She was also very preoccupied with social media, always posting inappropriate pictures and cyber-courting older men with provocative messages. She would get tons of likes and messages and friend requests, and she revelled in the attention, needing it as the very oxygen she breathed. Her mother showed me pictures of Nicky circa age 10, and I was somewhat disturbed by what I saw. The 10 year old in the picture was striking. Nicky certainly didn’t look 10….she looked closer to 15 or 16. Her hair was the blackest black, her green eyes were impossibly bright, and her skin was tanned. She had the kind of looks that could cause unwanted attention for any female, much less one that was only 10 years old. But then again, I knew that the attention she got was not unwanted…it was by design. 

As Nicky got older, her behavior and habits only got more concerning. In a picture taken of her at age 12, she absolutely looked over 18. As a result, she was able to buy cigarettes, so at 12 she started smoking on a daily basis. She was also drinking on weekends, courtesy of the creepy dude that worked at the liquor store….he wanted her and she knew it, so she did whatever with him, and in return, he let her buy booze and beer. In doing so, he also reinforced her notion that she could use her looks to get things in life that she wanted, a tactic that would serve her purposes well and often in the coming years. 

By 13, she expanded her repertoire by picking up marijuana and drinking more frequently, almost on a daily basis. She had no use for her very expensive private Catholic school. There is no question in my mind that she had undiagnosed attention deficit disorder. When she went to classes, she could not sit still. She was always hyper. At 13, she had a habit of smoking in the school bathrooms because she said it helped her to calm down. She was always getting in trouble, always acting out in her classes. Her parents were constantly getting called to school because she was impulsive, talking out of turn, always causing trouble, disturbing her classmates, and acting sexually provocative. 

At ages 14 and 15, she was still skipping classes to hang out with the wrong crowd, drinking every day and smoking marijuana. She was honing the art of how to exploit her own sexuality for her benefit and became even more impulsive, especially with spending money. She was spoiled, and had several of her father’s credit cards. She put these to good use, ordering thousands of dollars of merchandise online, whatever her heart desired. As she maxed out all of the cards, her father would pay them down and she would be back in the saddle again. 

By 16, she graduated to having sex on a regular basis. I’m not certain, but I strongly suspect that she was turning tricks for money. I hate to say these things of a 16 year old, but she was dressing far too provocatively; a lot like a prostitute, and she was acted like a prostitute, hitching her hip, smiling and waving at men in cars. What came to mind was, ‘if it looks like a duck and walks like a duck….’ Anyway, at this point, she would easily pass for 21, so her weekends and many weeknights as well were spent smoking marijuana and getting drunk in a dark and nasty local bar. One night, another bar fly introduced her to cocaine, and taught her how to line it up and snort it. And suprise suprise, she liked it. 

Her 17th year looked a lot like the one before, just with more of everything. She was now smoking cigarettes and marijuana every day, drinking every day, and snorting cocaine on weekends. She wasn’t hiding things as well at this point, and was barely passing her classes at school. But private schools are in business to make money, and evidently they were fine with keeping her barely passing….as long as daddy wrote them a check each semester. 

Once again, Nicky’s 18th year was a lot like the one before, with regular abuse of alcohol, marijuana, and cocaine. The big news was that Nicky somehow managed to graduate from high school, despite almost never going to class in her senior year. It was a Catholic school, so I guess her graduating could’ve been considered a miracle. More likely her father made a substantial “donation” for Nicky to walk across that stage to get her diploma. After graduating, she decided she wanted a change, so she moved into her family’s Palm Beach house. She supposedly had decided that she was going to get her act together and take some college courses at a nearby university. At least that’s what she told her father. Apparently she was convincing, and he gave his blessing, along with one of his credit cards and his first support check for $4,000.00. They had made a deal that he would send her that check every month, as long as she was getting her crap together. It was a pretty sweet offer, especially since she’d also have his credit card. That meant that his monthly check for $4 grand was pretty much gravy. A lot of gravy. And when she arrived at the Palm Beach house, guess what awaited in the driveway. A brand new car! She was spoiled, but that wasn’t really her fault. It was just the way her folks rolled. And surprise suprise, she liked it. 

She had time and money on her hands and wasn’t really working to get her life together, though she gave her father glowing narratives on how well she was doing. In reality, she had found a source for cocaine and marijuana and was still drinking all the time. She started dating a guy of like mind and similar habits and he introduced her to his friends. At a party shortly thereafter, somebody gave her some 10mg oxycodone tablets, Percocet, aka percs and told her to take two, so she did. And surprise suprise, she liked it. 

In no time, she was taking 4 to 5 percs a day, then after a month, 8 to 10 a day. She was spending a lot of cash buying as many as she could from the original guy that gave them to her as well as other drug-using acquaintances. One day while driving high, she wrecked her new BMW and was taken by ambulance to the hospital. She wasn’t seriously injured, but she complained of pain and flirted with the ER doc and managed to get a scrip for 60 percs. That lasted her all of about 5 days. Now she had an opiate habit, she was totally addicted to the percs. But then it became impossible to get scrips because Florida shut down pill-peddling docs and adopted super strict opiate guidelines. Nicky was out of choices. She talked to her friends and various contacts and hooked up with another opiate addict that was in the same boat. Unfortunately, his solution to his inability to supply his opiate pill addiction was to do heroin. **Please see the comment on this subject at the end of this blog.** 

Now back to Nicky. She was then officially introduced to heroin….how to buy it, the amount it takes to get high, its price, how to snort it, how to cook it, how to load a syringe and shoot it, the whole nine yards. And suprise suprise, she liked it. 

Nicky had only been in Florida for about four months. Her father had replaced the car she had wrecked and had it delivered. She wasn’t working or going to school, but she was drinking, smoking cigarettes and marijuana like a chimney and doing coke everyday. She was also thoroughly hooked on heroin, buying and using at least 10 bags a day. And her appetite for heroin was only growing with each passing week. 

It wasn’t long before her father’s $4,000 a month wasn’t sufficient to cover the cost of her booze at the bars, her 2 packs of cigarettes a day, marijuana, cocaine, and the newest addition, heroin. After only two months of using the heroin, she was doing tricks on the street to get more money, because the cost of her various addictions exceeded the $4,000 check her father sent every month. But that didn’t stop her. She just used more. And the more she used, the more she wanted to use, then the more she needed to use. She was up to 15 to 20 bags a day now. So, she was having to prostitute on the side even more frequently to get the money to support her ever-growing habits. She had also had a drug using friend move in with her in exchange for $750 a month, which she always used promptly after getting it. Then one Friday night after finishing with her “clients,” Nicky pointed her car toward home. It was about 3am, and the roads were quiet; traffic was mostly drunks recently kicked out of the bars. And wouldn’t you know it? Boom! Crash! She wrecked the car. She gave a story centering on a drunk guy and it was all his fault, not hers, yada yada. Thankfully, she wasn’t injured. But the car was toast.

She took a cab home and joined her roommate in snorting some heroin. She felt kind of wired, so she may have used a little more than usual. That little more was evidently too much, and she overdosed for the first time. Thankfully, her roommate was there and called 911. At the hospital, she was treated terribly. It was basically like ‘hey, you’re an addict and you overdosed. It’s your fault, so get out of our ER’ and she was discharged very quickly. Unfortunately, the overdose didn’t stop her. She didn’t even consider stepping down on, or getting off of anything she was using.

Nicky said her life at that time was a drug induced blur, reduced to a cycle of drinking, hooking, snorting, smoking, repeat. Before long, she had overdosed twice more and totalled her second and third new cars sent by her father. For the life of me, I cannot understand his thought process, what he was thinking when he kept sending new vehicles to Nicky like lambs to the slaughter.   

So, now, we are into this odyssey for about 14 months or so, these episodes of using, prostituting, crashing her car, overdosing. She was losing weight and started looking a little haggard, worse for wear. Still, she brought guys home from her hangout bar and they paid $300 to $500 for the pleasure. There was one guy that hung out at the bar named Jimmy, and she’d forged just a friendship with him, no business involved. He really had a front row seat to Nicky’s decline and truly wanted to help her. He knew of my practice vis a vis his friend that was a patient, and he begged her to see me. He was pleased when after only a couple of days she agreed. 

He brought her into my office and he said “Doc, please, you’ve got to help get her off all this stuff.” After learning that “this stuff” was alcohol, marijuana, cocaine and heroin, I knew we were going to have an uphill battle, but Nicky was willing to try, and Jimmy was willing to help. I explained that we had to detox her, because she had a $300 a day heroin habit, which was most likely laced with fentanyl. I continued to explain that she had to be off of the heroin for 24 hours before we could start the detox drug, buprenorphine. I could see that both of them were about to freak out, but I assured them that I would give him several prescriptions to dose her with. My plan was to basically knock her out to get her to sleep for most or all of those 24 hours. I gave him scrips for clonidine 0.1mg to give every 3-4 hours, quetiapine 50mg every 4 hours, mirtazapine 30mg every 12 hours, phenergan 25mg every four hours so she doesn’t throw up all these meds, and lorazepam to throw in there every hour if she’s not sleeping and for withdrawl symptoms. I figured the whole combo would knock out a moose, so she should be okay. I gave him my cell number and asked him to call me every four hours and whenever with any questions. I told him to make sure she hydrates and eats, and that I want her zonked out so that she won’t run and use. That was my concern. I explained that the first 24 hours would be the hardest, but that once that’s over, you take the buprenorphine and everything starts to improve. But I also again explained and reiterated not to take the buprenorphine until after the 24 hours. That if it’s taken sooner, it will throw you into an immediate and horrifying withdrawl. Everybody seemed to understand so I sent them to her house to start the process with Jimmy taking care of her. 

Nicky made it through the 24 hours, and she got on the buprenorphine.  She took one, then a couple hours later, another; then three to four hours later, she took a third; then three hours later, a fourth. And tah-daaaaah! She was completely clean of heroin. She still wasn’t happy, but I think that also coming off of cocaine, marijuana and alcohol at the same time was giving her a hard time. She continued with the buprenorphine the next day and the day after. On that third day, I saw her in the office. She had just barely started to clear cognitively, and that chaotic thinking, erratic behavior, and impulsiveness, it was starting to simmer down a bit, and she was just beginning to get real. She said that she didn’t want to be addicted to the buprenorphine. I always worry when newly detoxed patients want to go off the buprenorphine, because it may be a sign that they want to use, and they don’t want the buprenorphine to block the opiate so they can’t get high. I explained that it is not like heroin at all in terms of addiction potential. And I said that her life had been so unsettled since the age of 10, but especially in the last few years or so, her life was total chaos, fueled by drugs, heroin, cocaine, heavy alcohol use and marijuana. I told her she should just stay on the buprenorphine for a little while to stabilize her behavior and get into a healthy, clean and sober daily routine. Her neurotransmitters needed a vacation off of dope, and she would need time to see what life looks like when she isn’t gorked out of her mind, going without sleep for days on end. I told her that once we got her into a ritualized life where her behavior was more routine, then I would consider getting her off the buprenorphine. I convinced her to stay on it. I don’t do this with everyone. For people who only relapse for say a month, I would give them a week detox and they’d be fine. Maybe, if they got regular cravings over the next 10 days, I’d have them take a little of it here and there if needed. But with someone who has lived a chaotic lifestyle for nearly their whole lives and had been living a very heavily drug-addicted and dependant lifestyle for the past few years, there is no way I’d take them off right after detox. So, I followed Nicky for the next two or three months, and Jimmy was her strength and support; I don’t know that she could’ve come that far without him. She came for one visit in a month, then a second visit, but just before her third visit, Jimmy told me she was out and using again. She was back to the whole enchilada- heroin and coke and weed and booze and prostitution to help pay for them. Four months later, Jimmy brought her back in, just out of the big blue sky. We went through the whole detox shebang all over again. Unfortunately, this is not unusual. I got her back on the buprenorphine,16mg twice a day.  Again, I told her she had to stay on it to block the cravings and stabilize her lifestyle after the detox. 

On this second run, she followed up for six months, but then relapsed again, went out drinking, and that lead her back to the marijuana, heroin, coke, and prostitution. She was snorting heroin and she ended up overdosing. She was in the hospital for like five days, on a respirator for three of them, because she had aspiration pneumonia, which happens when you’re so gorked out that you puke up stomach contents and then inhale them into your lungs. It’s an easy way to die. She came back to my office about three weeks after she was discharged. She grudgingly said that the hospital stay was sort of beneficial because she obviously wasn’t doing any drugs while in there, but she also added that the doctors had told her that she had major lung damage and needed to quit smoking if she wanted to live to reach normal life expectancy. 

I think that this was the first time where Nicky saw that her behavior, her extreme drug and alcohol abuse, had serious physical consequences and repercussions. I told her point blank that if she wanted a life, it would have to be a clean and sober one. To this she just nodded. She went back on the buprenorphine once again; this time she would stay on it for two years. She started to build a normal life, and she wound up taking a job at a local dealership here owned by a friend of her father’s. She was actually very intelligent, very capable, and she did a good job for him, though she complained about the pay. I told her to keep the job regardless, at least for a couple of years while she was still settling her clean and sober life. At this point, she did not smoke, drink, take any illicit drugs, or prostitute. She kept the dealership job for two years, almost to the day. I started tapering her off of the buprenorphine, and at that point, I put her on something called modafinil for her attention deficit disorder and as a pre-emptive strike against the fatigue she would likely experience when I stopped the buprenorphine. As it turned out, she got so fatigued that she could not drag herself out of bed. Once on 200mg of the modafinil each day, her focus and energy improved a great deal. She was much more alert and active on the modafinil. 

Nicky moved back to New Jersey a while back, but I still see her in Facetime visits every month. She takes the modafinil everyday. She followed her brother and sister’s cue and now she’s working in one of her father’s car dealerships, and she’s training to become a manager. All in all, she seems to be doing well. She’s not dating because she thinks it’s too risky to go to the bars and such. She says she spends time with her “crazy, loud, obnoxious Italian family” her words, not mine. She eats a healthy diet, and goes to spin classes with her sister Sasha. She learned that she enjoys yoga, and practices it often. This is the part where I’d like to say that Nicky lives happily ever after, but unfortunately, I can’t right now. For the past several months, Nicky has told me that she goes through the motions of life, but she cannot enjoy life anymore. She said that after doing so many drugs, and so much of them, that she can’t be happy. Nothing lifts her spirits. I’ve tried antidepressants, and nothing seems to work. She feels like her life while drinking and drugging was so crazy, so chaotic, that now her sober life is so boring, monotonous, and mundane. And I can imagine that that’s true. She wasn’t just addicted to the drugs and alcohol, she was also addicted to the life and lifestyle that came along with them. In addition to our monthly Facetime visits, she also has a therapist she sees in New Jersey, but so far there has been no resolution to her problem with her boring life. After watching her struggle so hard to get clean and sober, it’s such a bummer when she tells me how she doesn’t enjoy life now. It’s kind of like when you were a kid and you could hardly wait to finish the whole box of cereal so you could get the prize they promised on the front of the box, only to find that they didn’t put one in your box….you got gypped. That’s how I feel about Nicky. She got gypped, and that sucks. But, she takes care of herself and keeps to her routine, dull as it may be to her. I’ll keep following her, and I think that with time, she’ll find a new normal and new happiness. That’s what I hope for Nicky. 

For more patient stories, check out my book, Tales from the Couch. It’s available in the office and on Amazon.com. 

**Comment from above

As most people know, this country is in the grip of an opiate crisis. Staggering numbers of people are dying of opiate overdose every day. Very often it’s from heroin, often laced with fentanyl. People that were addicted to pills found they couldn’t get pills anymore, so they started doing heroin. Please, if you are addicted to opiate pills, do not turn to heroin to replace the pills. And if you’re hooked on heroin, stop. Go to detox and get off of opiates entirely. I detox people all the time, and I assure you that with the medications I utilize, it is far safer and easier to do than you think. 

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Drugs with Bizarre Side Affects

You’re in your favorite recliner watching the game, and then comes a “word from our sponsors.” You may not bet on the game, but you can bet there’ll be a commercial for a pharmaceutical drug during that break. For today’s purposes, I’ll refer to a fantasy medication named ‘Druguall.’ The Druguall commercial shows a couple at the beach, walking hand in hand along the shore as the announcer explains the indications for Druguall, ending with the requisite side effect statement “…Druguall may be habit forming, and has been shown to cause an inability to make a left turn, an impulse to chew toenails, and a compulsion to repeatedly beat your head against a wall. If symptoms worsen or become problematic, contact your physician immediately. If you are allergic to Druguall, do not take Druguall.” Duh! That last one always kills me. Does the American public need to be told to not take a drug they’re allergic to? Apparently so, because pharma companies have been held liable for idiots taking their drug (despite being allergic to it) in numbers sufficient enough to spend the extra commercial time and money to make the statement to cover their corporate posteriors. But enough of the woes of big pharma. What am I writing about today? Side effects! Every drug’s got ‘em, and they range from comical to serious…even downright deadly. The point of this is so that you’ll ask your doctor when he or she starts you on a new med, especially if you’re already taking other meds…you need to know if they’ll play nice together. 

Here’s the ugly truth that your doctor probably doesn’t want you to know. When it comes to taking most drugs, it’s a crap shoot. He or she can know the side effects, but there’s no way to predict if you’ll experience any of those side effects, what they may be, and if they will have a minor/major affect on your life. When it comes to prescribing, there’s a lot of ‘throw this out there and see if it sticks’ going on. Granted, good physicians know the published side effects of the drugs they prescribe. I certainly do. But even though I know these drugs inside and out, there’s still some trial and error, because everyone reacts to different medications differently. If you’ve ever seen the PDR, the Physician’s Desk Reference, it is chockablock full of side effects. And it’s big enough to be used as a weapon. Nowadays it’s really just for show…everyone just checks the internet. Anyway, when a drug is tried in humans, everything that happens is noted. If the test subject happens to fart ten minutes after taking a trial medication, that medication is labeled with a side effect of flatulence, even though the guy probably just had broccoli for dinner. So if you look at any given drug, there are multitudes of side effects. Today, I want to talk about some of the weirder and wilder ones. 

Lots of medications get a bad rap for having yucky and unpleasant side effects, and most have earned them. Almost every drug on the market has side effects of upset stomach, dizziness, and headache. Borrrring!!! Instead, I want to look at some not-so-common side effects. The big note here is that just because a certain medication can cause a certain side effect doesn’t mean it will cause that side effect.

Hallucinations happen when you sense something that’s not actually there. I’m talking little green men here, people. But hallucinations can be seen, felt, heard, and even smelled. They are some freaky and frightening side effects. Most people associate them with illegal psychadelic drugs like shrooms and acid, but prescription drugs can also cause hallucinations. The sleep aid eszopiclone and a common medication for depression called escitalopram have been known to cause hallucinations. Even a drug to treat malaria called mefloquine can cause hallucinations. I’ve seen more cases of people hallucinating than I could ever count and ordered lots of four-point restraints. I’ve seen super heroes with broken bones they received learning that they actually  couldn’t fly from multi-story buildings. I’ve seen lots of people who say they’re God, and lots who say they’re Satan, but no proof from any of them. 

Now we’ll go from freaky to funny. There are plenty of meds that will turn your urine different colors. Even some non-drug food items can do it…beets can turn it pink, asparagus can turn it green (and stinky!) and carrots can turn it bright yellow. As for meds that change pee color, every woman probably knows that pyridium for UTIs makes it bright Tang orange. Even OTC Azo will do that too. But can you imagine seeing your urine turn green or bright blue? This can be a side effect of taking the antidepressant amitriptyline or the common pain reliever indomethacin. An antibiotic called metronidazole can even cause your urine to turn black. That would freak me out. The anesthetic drug propofol can also make your urine turn blue. Michael Jackson could’ve told you about that one. Well, if he weren’t dead from abusing it.    

Big word alert for the Scrabble set: anosmia; the loss of smell. This side effect actually has a huge impact on a patient’s life, because the loss of smell goes along with the loss of taste, so patients have no desire to eat, and that becomes a problem. Sometimes patients even have to be put on IV feeds. Some examples of drugs that can cause this side effect include the blood pressure drug enalapril, the antipsychotic drugs chlorpromazine and prochlorperazine, and the antibiotic metronidazole. And just a side note, prolonged use of OTC decongestants like Sudafed can also cause loss of smell.

Sexual side effects are always of interest to patients. The most common sexual side effect is the loss of the ability to either perform during sex or the ability to enjoy sex. The usual culprits of these types of sexual side effects are certain drugs that treat depression. These medications are called selective serotonin reuptake inhibitors (SSRIs), and they include common drugs like Prozac (fluoxetine), Celexa (citalopram), and Zoloft (sertraline). I always consider this side effect when choosing what to prescribe. I find that men aren’t willing to trade mental health for sexual satisfaction, but interestingly, women are more willing to do so. 

On the flip side of the sexual side effect coin is priaprism, which is a painful, permanent erection. A variety of medications can lead to this condition, one which patients who’ve experienced it will never forget. This unfortunate side effect lasts for more than four to six hours and may be caused by antidepressants like trazodone, fluoxetine, sertraline and lithium. An anti-anxiety medication called vistaril and the blood thinner coumadin are also known offenders. Priapism due to a medication side effect (as opposed to from taking a little blue pill) often goes away without treatment, though putting ice packs on the affected area might help speed up recovery. Cringing.

This one sort of goes along with the above discussion. There are several medications that cause the side effects of unusual urges for sex and gambling, though hopefully not at the same time. Common culprits include Requip, which is a medication for restless legs, and the antidepressant Abilify. These meds may cause uncontrollable urges to gamble, binge eat, shop, and have sex. Interestingly, a Parkinson’s medication called carbidopa/levodopa also carries a warning of intense urges for gambling and sex. I’ve had cases where men don’t want to leave their homes because they want to masturbate, as well as cases where they’re caught masterbating in public. As for the gambling…I’ve had patients lose a lot of money gambling in casinos, betting on horses, and even at the dog track. The sexual and/or gambling compulsions just drive them.

It’s common knowledge that drugs affect dreams, but not always in a good way. Medications that affect neurotransmitters in the brain commonly cause bad dreams and nightmares. The Alzheimer’s medications donepezil and rivastigmine, as well as the Parkinson’s medication amantadine, are all reported to cause vivid dreams, often being of a sexual nature. Nightmares are also a commonly reported adverse effect of blood pressure medications called beta-blockers. These include propranolol, atenolol and labetalol. There are also reports of steroids like methylprednisolone and prednisone causing nightmares. Varenicline, the medication often prescribed to help people stop smoking, is known to cause dreams that are super strange and very vivid. Not only does varenecline cause bad vivd dreams, I’ve seen patienta think it’s okay to stab themselves repeatedly or to kill themselves. Varenicline is a scary strange drug. Even stranger? The prescription sleep aid zolpidem doesn’t keep many users sleeping in bed. In fact, many who take it have been known to get up at night and go for a drive, maybe talk on the phone, or even have sex…all without remembering anything in the morning. You can ask Elon Musk about zolpidem. He tweeted that he was going for an IPO for $423 a share after taking it. His advisors had a fit the next morning, but he found it amusing and shrugged it off. But Roseanne Barr wasn’t laughing when she lost her eponymous show after a discriminating tweet. She apologized, but the damage was done. Maybe she should’ve called Elon for help.

Another big word for the Scrabble set: Akathisia. The word comes from the Greek for “inability to sit,” so this side effect invokes feelings of unease and an inner restlessness.  Unfortunately, this is another adverse reaction that folks who experience it never forget. They describe it as wanting to crawl out of their skin. The triggers for this horrible sensation are the anti-nausea medications prochlorperazine and metoclopramide, as well as some SSRI antidepressants, and an anti-anxiety medication called buspirone. Thankfully, this terrible feeling goes away when the medication wears off.

What if taking a medication made you pack on the pounds? How about if it caused you to gain 20 plus pounds in only three months? Some people who take the medication olanzapine for bipolar disorder have done just that. Some common medications used to treat depression, like paroxetine, can also cause unintended weight gain. Weight gain is enough to cause depression in and of itself, so I’m always cognizant of that when I prescribe. Other drugs that can pack on the pounds include steroids, birth control pills, hormone replacement therapies, and some diabetes medications. The bottom line on that is that if you must take one of these drugs, you also must watch what you eat.

File this under the creepy side effect column. And yet another big word for the Scrabble set: Onycholysis. This is the medical term to describe when nails separate from the nail bed. You may not think that’s so bad, but trust and believe that patients who experience it do, and you would too if you had it. It can be super painful and may result in infections under the nails. Believe it or not, there are quite a few meds that can cause this: acne treatments tetracycline and fluoroquinolone, antibiotics like ciprofloxacin and levofloxacin, oral contraceptives, and some chemotherapy medications…all may cause your nails to separate from the nail beds. 

Visual disturbances can also be a side effect of certain meds. These disturbances can include blind spots, distorted vision, blurred vision, or halos around lights. Medications that can affect your vision include antihistamines, high blood pressure medications, and medications taken for malaria or tuberculosis. For men on the little blue pill, a truly weird and whacky side effect can be tinting of the vision, as through tinted glasses. And of course it tints the vision blue. I wonder if that might be a promotional idea…to see blue like their little pill. 

Most people are familiar with the hair loss that goes along with some types of cancer treatments, but there are also several other common medications that cause hair loss, including blood thinners, birth control pills, antidepressants, and medication used to treat gout. But hair growth can also be a drug side effect. Women may experience unwanted hair growth from steroid medications and from the drug danazol, which is used to treat endometriosis.

Have you ever torn a tendon? It isn’t always just from a sports injury. Believe it or not, a common medication used to treat urinary tract infections could cause you to rupture your Achilles tendon. The U.S. Food and Drug Administration (FDA) has issued a warning for just that for the class of antibiotics called fluoroquinolones. According to the FDA, pain, swelling, and tears of tendons in the heel, shoulder, and hand are more likely to occur when taking these drugs. Common medications in this class include the often prescribed antibiotics ciprofloxacin and levofloxacin. So maybe it’s best to warm the bench when you’re taking these antibiotics. 

All jokes aside on this one. No list of side effects would be complete without mentioning side effects causing birth defects. Obviously, birth defects are a very serious medication side effect, and this is why pregnant women are told not to take any drugs before checking with their doctor first. Types of drugs that can cause birth defects include high dose vitamin A, some blood pressure medications, and some antibiotics. Two drugs that are especially dangerous and potentially fatal for developing babies are Accutane (isotretinoin) and Thalomid (thalidomide). Accutane is used to treat severe acne and Thalomid is used to treat a type of white blood cell cancer. When pregnant, all side effects are serious. But pregnant or not, isotretinoin is a nasty, scary, dangerous drug. It’s used most commonly by dermatologists for severe acne. I’ve heard of patients flying planes into buildings, thinking they’re invincible and jumping from buildings, and just acting in an exceedingly dangerous way. It’s like they’re without fear.

Rather than a condition, this one is about a drug called Interferon. Interferon is used to treat certain cancers, leukemias, and Hodgkin’s Disease. I’ve seen some pretty bizarre things with Interferon. People become suicidal, openly so. They’ll talk about suicide like it’s an acceptable option. Sometimes they cut themselves and make themselves bleed. It’s very odd and very scary. Interferon can also cause bizarre thoughts, and people become psychotic. Also, they can have anosmia. Remember that? That’s the loss of smell that I discussed above. Interferon can be useful in cancer treatments, but people have to be closely monitored for side effects.

I’ve saved the weirdest of the weird, the most bizarre side effect I’ve ever seen, for last. At the time, I was in medical school but working in the ER. What I saw looked straight out of The Exorcist. The side effect is called an extra-pyramidal oculogyric crisis. Oculo- refers to eyes, which fix upward and to the side during the crisis. In severe attacks, there can also be involvement of the head and neck and structures within the neck. There are several drugs that cause it, and the crises or attacks can happen in varying degrees, from minor reactions to major emergencies requiring intubation for airway control. Oculogyric reactions are caused by neuroleptic drugs,  antipsychotics, antiemetics (anti-nausea drugs), and antidepressants. Cases involving other drugs have been reported, including methylphenidate and carbamazepine. In this case, the patient’s head was turned sideways and backward at an impossible angle, with her eyes fixed very strongly to the opposite side. Her face was frozen in a grimace and her neck was so flexed that she was unable to speak and her airway was compromised. She needed to be intubated for airway support, but doctors were unable to straighten her neck to insert the tube. They were considering a tracheostomy, making a hole in her throat, to buy some time because they didn’t know what was happening.  Because she was unable to speak, she couldn’t tell the ER doctor that she had taken an antiemetic, a medication for nausea, which had caused the episode. The doctors were puzzled as to what was happening because of how extreme the episode was, and several were gathered around her bed in the ER. A nurse just happened to stick her head in the room to see what the commotion was, and she mentioned in passing that she had seen something similar in someone who had taken compazine. At that word, compazine, the patient snapped her fingers and pointed at the nurse; the doctors asked if she had taken compazine and she snapped her fingers again and the mystery was solved. They gave her IV Benadryl and five minutes later her neck and eyes relaxed to midline and in another five minutes, she was able to speak. I’ve seen oculogyric crises since, but none like that. The whole Exorcist thing is the craziest side effect I’ve ever seen, but I will forever remember extra-pyramidal oculogyric crises.

After working in psychiatry for the past 30 years, I’ve seen time and time again that when you put a drug in the human body, you don’t know what you’re going to get. It’s like Forrest Gump’s box of chocolates,  but not as tasty. For more patient stories, be sure to read my book Tales from the Couch, available on Amazon.com.

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Autism Spectrum disorder

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

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

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

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

Symptoms of ASD

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

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

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

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

Resists cuddling and holding as child

Lacks facial expression

Prefers playing alone, retreats into his/her own world

Exhibits poor eye contact 

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

Can’t initiate or further conversation 

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

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

Doesn’t appear to understand simple questions or directions

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

Inappropriate aggression or disruption to social interactions of others 

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

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

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

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

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

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

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

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

Doesn’t engage in imaginative or make-believe play

Fixates on an object or activity with abnormal intensity or focus

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

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

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

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

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

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

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

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

When to see a doctor

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

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

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

Doesn’t mimic sounds or facial expressions by 9 months

Doesn’t babble or coo by 12 months

Doesn’t gesture, point or wave by 14 months

Doesn’t say single words by 16 months

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

Doesn’t say two-word phrases by 24 months

Loses language skills or social skills at any age

Causes of ASD

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

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

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

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

Risk factors for ASD

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

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

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

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

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

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

Complications of living with ASD

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

Problems in school and successful learning

Employment problems

Inability to live independently

Social isolation

Stress within the family

Victimization and being bullied

Prevention of ASD

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

Diagnosis of ASD

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

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

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

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

Score your child’s social and communication interactions.

Include other specialists in order to definitively determine a diagnosis.

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

Treatment for ASD

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

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

Some ASD treatment options may include:

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

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

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

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

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

Some ASD takeaways

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

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

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Help and Homeopathy for Anxiety

Anxiety disorders affect 40 million adults in the United States, making it the most common mental health condition in the country. Untreated anxiety can affect every facet of life, making it difficult to relax, to achieve success in a work environment, to have fulfilling hobbies, and to maintain close relationships with family and friends. While there is no cure for anxiety, there are ways to manage it. While there are many prescription anxiolytics, today I want to talk about some behaviors, supplements, vitamins and homeopathic remedies that you can use to help deal with anxiety and release the hold it may have on your life. 

Let’s start with some simple stuff. Some behaviors that you should stop and some you can start to help quell anxiety. 

Behaviors to stop

Alcohol: If you think consuming alcohol would help ease anxiety, you would be wrong. While alcohol relaxes the body, it clouds the mind, and a clouded mind actually increases anxiety. And though you might feel relaxed for an hour or two, once you stop drinking, your mind and body are affected as the alcohol leaves your system, so the other 22 hours of your day will only be filled with more anxiety. Not only that, if you have chronic anxiety and drink in a misguided attempt to help it, you’re going to be consuming alcohol in quantities that can end up in your developing alcoholism. 

Smoking tobacco: Again, you may think that cigarettes might help anxiety. When a smoker gets stressed, they often say they want to smoke to chill out. So why does smoking seem to help smokers relax? Smoking cigarettes interferes with certain chemicals in the brain. When smokers haven’t had a cigarette for a while, the craving for another one makes them feel irritable and anxious. These feelings can be temporarily relieved when they light up a cigarette, so smokers associate the improved mood with smoking. In fact, it’s the effects of smoking that are likely to have caused the anxiety in the first place, as nicotine raises blood pressure. Additionally, many studies have shown that cutting out the cancer sticks improves mood and thereby reduces anxiety.

Caffeine: This one is a no-brainer. Caffeine is actually a psychoactive drug, and like many of its kind, it is a stimulant. When you consume it, caffeine stimulates your “fight or flight” response, and studies show that this not only increases anxiety, it can even trigger an anxiety attack. If you’re anxious, consuming caffeine is pretty much the worst idea ever in the history of ideas.

Poor diet: Like it or not, what you eat can make a difference in how you feel, physically and mentally. You should not be on a first name basis with the Dominos delivery dude and the Mickey D’s drive-thru girl. Fact, Jack! Cut out the high carbs, the high fats, the processed foods and sugars. Remember: garbage in, garbage out.

Electronics: Surfing the net, watching YouTube vids, online shopping, and anything done on a screen can lead to an increase in anxiety by affecting your sleep. How? Exposure to the blue light of a screen anytime within four hours of sleep disrupts the natural circadian rhythm, and may even disrupt the natural production of melatonin, resulting in poor sleep. Functioning normally while tired can increase anxiety. 

No news is good news: If you are anxious or prone to anxiety, stop watching the news. Stop reading the news. Stop listening to the news. Why? The press is categorically tailor-made to incense, aggrevate, enrage, and incite. All of these roads lead to Anxiety City. So think again before feeling guilty for not keeping up with current events. A national survey conducted by (oddly enough) NPR and a bunch of other eggheads found that watching, reading, or listening to the news caused people greater stress and anxiety. It’s like the old saying goes…what you don’t know can’t hurt you. And clearly, what you do know can. 

Anti-Social media: The advent of social media has completely changed the way humans interact on a global scale. Just stop and think about that. It literally changed the entire planet. Now you can interact with anyone on the face of the earth that has a cellphone on a 24/7 basis. It sounds like the greatest thing ever, but it can cause an incredible amount of anxiety in a number of ways. Trust me, I see it day in and day out. So, how does social media cause anxiety? It has brought the concept of keeping up with the Jonses to a whole new level. Used to be the Jonses just lived down the street. Now they’ve moved. To everywhere! There are billions of electronic Jonses to emulate, be jealous of, to love, to hate, and to outdo. From posting the perfect picture that took 2 hours to take on Fakebook to likes and hearts and wow! faces, everyone gets to weigh in and hate on. All of these things are so anxiety producing. But social media can also be addicting. It’s a like-seeking quest, and every like reward is a dopamine hit. Dopamine is a happy chemical. A hit gives a little high, akin to any drug high. And just like with drugs, there can be an actual withdrawl if you separate that person from their source, their cellphone. Some people check social media 20 times or more in a day. They must check for likes, they must see what all their “friends” are doing, what all those electronic Joneses are up to. Keeping up with them and always being on the hunt, all are naturally anxiety producing. If you find that social media becomes stressful, makes you feel jealous, or mad or sad as a result of trolls or the presence or absence of positive comments, silence the alerts, put the damn phone down, and do something more positive with your time. If you feel anxious when you do this, go visit your parents or a friend in real life. You’ll get through the anxiety and be better for it. Then do whatever you have to do to set and stick to limits on your social media use. Be electronically anti-social and personally social. 

There are also tons of behaviors that you can add to your life to help with anxiety.

Behaviors to start

Exercise: You don’t have to turn into a gym rat, just spend at least 15 minutes a day doing something that moves your body.

Meditation: Spend 5 minutes a day centering yourself. Clear your mind and the rest will follow.

Breathing: Dr. Andrew Weil deveoped a breathing exercise called 4-7-8. It goes like this: exhale completely through your mouth, making a whoosh sound. Close your mouth and inhale quietly through your nose to a mental count of 4. Hold your breath for a count of 7. Exhale completely through your mouth, making a whoosh sound to a count of 8. You’ll likely find this is very helpful in reducing anxiety. 

Reading: This is great for distracting yourself from stressors occupying your mind and causing anxiety. Open a book and immerse yourself in someone else’s story.

Routine: Establishing and following a routine forces behavior modification and can be stress reducing.

Positive affirmations: Practice saying all the good things about yourself to yourself.

Connect with nature: Take a walk in the woods or get some sand between your toes. Try to lose your worries and yourself in a place that’s bigger than you. 

Eat healthy: Eat lots of fresh fruit and veggies and eat only lean meats. There are some natural food components that can help with anxiety. Omega-3 fatty acids make up the basic building blocks of the brain and nervous system. They are essential for cognitive functioning and have also been shown to improve symptoms of depression, which is often closely linked with anxiety disorders. These brain-boosting amino acids are found in a wide variety of fish species, including salmon, tuna, mackerel, herring, sardines and anchovies. They are also found in supplement form. Probiotics are also helpful. Probiotics are microorganisms known for their digestive health benefits. But recent research has revealed that probiotics can also have a profound impact on mental health. A healthy balance of bacteria in the body can boost the body’s ability to cope with stress, improve overall mental health, and bolster cognitive functioning. Probiotics can be found in direct supplement form but are also found in a wide variety of foods and drinks. Some of the most common sources include sauerkraut, yogurt, kimchi, kombucha, miso, and pickles. Put good stuff in, get good stuff out.

Talk: Whether to a therapist, friend, family member or clergy, find someone to talk to and share worries and anxiety with. The support of others can do wonders.

Be grateful: Count your blessings; think about the good things in your life: a home, support of family and friends, a place to sleep, food to eat, a vehicle, whatever the positives may be, be happy that you have them.

Take action: If you have something you need to do that’s weighing on your mind, do it. If you have a bunch of things to do, make a priority list and start doing them. As you finish the items, literally cross them off the list. This way the list isn’t overwhelming and it will feel really good to mark things off. 

Sauna: Heat is amazingly relaxing and wonderful in combating anxiety. Relax the body to relax the mind. 

Massage: A great massage is fabulous in reducing tension and anxiety.

Accupuncture: The Chinese haven’t been wrong for thousands of years. Accupuncture is one of the most relaxing, stress and anxiety reducing activities. Don’t be scared of the needles. Almost a must if you have anxiety. 

Spirituality: If you have it, use it. Prayer can be centering, almost meditative. 

Supplements and vitamins: If you live with anxiety, one measure you can take to reduce your symptoms is to include supplements and vitamins for anxiety in your diet. These can be taken directly in an oral pill form and in the consumption of various foods and drinks. Before taking any of these, check with your physician first, especially if you already take any prescription medications. 

Some of the best supplements and vitamins for anxiety include:

B Vitamins: B vitamins are vital to healthy nervous system functioning, so they play an important role in various aspects of mental health. They also have a significant impact on stress management and mood. Because of these benefits, many people with anxiety take B-complex vitamins and/or incorporate B vitamins into their diet through a variety of foods, including wild salmon, shrimp, tuna, halibut, yogurt, eggs, cheese, lamb, venison, turkey, grass-fed beef, carrots and green, leafy vegetables.

L-Theanine: L-theanine is an amino acid that can improve focus, reduce stress and promote relaxation. You pretty much have to take this as an oral supplement because it’s not commonly found in many foods or drinks. You can take 400mg of the supplement three times a day.

Chamomile: Chamomile has been used as a traditional medicine for thousands of years to calm anxiety and settle stomachs. Chamomile is best known as an ingredient in herbal tea, but is also available as capsules, liquid extracts, tinctures, and topical creams. Adults can take it in capsule form, 400 to 1600 mg in divided doses daily; as a liquid extract, 1 to 4 ml three times daily; in a tincture, 15 ml three to four times daily; or as a tea, 1 to 4 cups per day.

Lavender: Lavender is an herb that has been proven effective by leading researchers as a natural remedy for treating signs of anxiety. In one published study, lavender oil was shown to be just as effective as the pharmaceutical drug lorazepam, but without sedative effects or potential for drug abuse or dependence. Other studies have confirmed the anti-anxiety properties of lavender as well as many other medicinal benefits. Lavender oil capsules can be taken by mouth, 800mg three times a day. Tea can also be made by using 1 to 2 tablespoons of whole, dried flowers for each cup of boiling water. Steep for 10 to 15 minutes using a tea infuser or strain before drinking. You can also add six drops of lavender oil extract and 1/2 cup of dried lavender flowers to bath water for a great anxiety relieving soak. 

GABA: Gamma-aminobutyric acid is a neurotransmitter located in the brain that is crucial to serotonin production. Serotonin is one of the nervous system’s most “feel-good” neurotransmitters, so GABA plays a significant role in reducing anxiety, regulating mood and in relaxation, aka “feeling good.” I’m told this is very effective. When I tried it, I noticed that my skin tingled. An unual and somewhat unpleasant side effect.

Passionflower: This is a calming herb commonly used as a household treatment for anxiety. It has been shown to alleviate nervousness, promote positive moods, and improve sleep quality. Passionflower can be consumed as an extract and tablet, or can be added into teas and tinctures.

Valerian Root: This has been used for a variety of medicinal purposes since the time of ancient Greece. While most commonly known as a sleep aid, this herb can also be helpful for reducing anxiety. Valeric acids found within the herb convert to calming, “feel-good” neurotransmitters in the body, regulating stress and relaxing the mind and body. Valerian root extract is available in both capsule and liquid form, as well as a tea.

Licorice Root: This herb carries many health benefits for people with anxiety because of the effects it has on the adrenal glands, which produce the stress hormones adrenaline and cortisol. Licorice helps regulate the production of these hormones, relieving stress and reducing anxiety symptoms. Licorice root can also soothe gastrointestinal upset, which is common in many people with anxiety. Be aware that most drinks and candies that claim to contain licorice only contain flavoring, which has no benefits. It’s best to consume licorice in an extracted, purified form. Deglycyrrhizinated licorice (DGL) is the safest and most effective variety of medicinal licorice root available. DGL is sold in capsule, powder, tea and chewable tablet forms.

Ashwagandha: Ashwagandha is a plant native to India and North Africa that has been used for centuries to reduce anxiety, combat the effects of aging, and improve energy. In natural medicine, the root is considered to be an “adaptogen,” or a compound that helps regulate the body’s natural processes and promote overall wellness and health. Today, many people use Ashwagandha to improve mood and reduce anxiety symptoms. While the benefits of Ashwagandha are gained by eating the fruit, seeds and shoots of the plant it is derived from, Ashwagandha is most commonly consumed in capsule form, 600mg a day.

CBD products: Cannabidiol (CBD) is a type of cannabinoid, a chemical found naturally in marijuana and hemp plants. Unlike THC, tetrahydrocannabinol, another type of cannabinoid, CBD doesn’t cause any feelings of intoxication or the “high” associated with cannabis. Several studies point to the potential benefits of CBD for anxiety. It can be found in many forms: oil, gummies, teas, tinctures, vape pens, and more. As for where to begin, consider trying a sublingual (under the tongue) CBD tincture first. They have high bioavailability, meaning the body easily absorbs them. If you’ve never used CBD before, be sure to do some research and get it from a reputable place…not from the gas station around the corner. Start by taking the dropper and placing the liquid under your tongue and allow it to sit for about 2 minutes so it absorbs into your bloodstream before you swallow it. Figuring your ideal dose is tricky. Most packaging will have guidelines, but dosing is still a guessing game, as CBD affects everyone differently. You can try one dropper full and go from there. You’ll have to see how you feel to determine how much works best for you. 

Rhodiola: Also referred to as “golden root,” Rhodiola has a long history of medicinal use in traditional Chinese and Siberian medicine. Like Ashwagandha, Rhodiola is considered to be an adaptogen, meaning that it promotes physical and mental health while improving mood and resilience to stress. It is typically taken in capsule form, but it is also available in extracts and teas.

While the above homeopathics, supplements, and vitamins can be beneficial for anxiety, it’s important to check with your doctor before adding them to your diet. Taking this precaution can help prevent any potentially dangerous side effects or drug interactions. Keep in mind that while vitamins for anxiety can be helpful, they are not a substitute for prescription medications or doctor-approved therapies. It is especially important to speak to a medical professional if your anxiety co-occurs with another mental health condition. 

The supplements, vitamins and homeopathics discussed above can be found on Amazon. I discuss anxiety and other mental health issues in my book Tales from the Couch, also available on Amazon.

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COUPLES AND CONFLICT

Couples and Conflict

One of my foremost jobs as a psychotherapist is to be a listener. All day, every day people come to me to talk about their problems. As you can imagine, many times patients want to talk about their spouses, specifically how they fight with them. So I want to talk a little bit about couples and fighting. Whether it’s about money, children, career, housework, all couples fight. Nobody gets along 100% of the time without some conflict. It’s all a matter of how you resolve that conflict. I had a patient named Roxanne come in for her session yesterday, and she told me that she and her husband Bill fight all the time. One yells at the other and the other yells back louder until it reaches a terrible crescendo and both storm off in opposite directions. She said she had no choice in this, he just made her so angry and they just didn’t get along. I told her that the first thing that had to happen for the relationship to move forward was to decide that it wasn’t his fault and wasn’t her fault, it was both of them. She immediately recoiled and told me I was dead wrong. That it was all Bill’s fault. He was never home, he didn’t want to be a part of the family, he this, he that, ad nauseum. I asked her about how they fight, her yelling and screaming…was it working? Was it resolving anything? She launched in again, saying it wasn’t her fault, it was his fault because he made her yell. He antagonized her. I told her that she didn’t have to go to every fight he invited her to, she had the choice. This is a point that I think a lot of couples miss. Just because your spouse may be baiting you, looking for a fight, it doesn’t mean you have to give them what they’re looking for. You don’t have to respond at all. You have a choice in how you behave.

I explained to Roxanne that the only way to start to resolve an issue is to not yell and scream, not raise a voice. Once you express anger, you’ve made the situation worse. I suggested to her that the only way to make the situation better when Bill is yelling and screaming is to fall silent. Until the yelling stops, nothing productive can be accomplished. A conflict cannot be resolved through warfare. Once people raise their voice, no interaction happens. For instance, if you raise your voice at a child, they shut down. They will hear nothing you say. The same happens in couples. If one raises their voice at the other, from that moment forward, nothing constructive happens. So, if you’re married or in a relationship and you find you are having problems or there is fighting, and yelling, you are responsible for your response, and your response should be to not yell back, fall back. All yelling does is put fuel on the fire. If you fall silent, eventually they will stop yelling, and once the yelling stops, resolution can start. You can begin a conversation by discussing what the problem is, why you keep arguing, and what you can each do to make things better. That’s the only way these things will really be resolved. But you have to be willing to change how you respond to conflict and how you fight. Learn to fall back if baited. Talk should replace screaming matches. 

I hear so often in my office “it’s not me, it’s him, it’s her, they’ll never change, we tried that” blah, blah, blah, blah. If you really want to effect change in your relationship, change your own behavior and then the reaction you get back from your spouse or partner will change. Stop yelling and start conversing. Focus on what you can each do to make the relationship better. To resolve conflict, cooler heads should always prevail over heated emotions.

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January 6, 2018 THE RIGHT APPROACH TO THE OPIOD CRISIS

As a practicing doctor with certification in psychiatry and having worked in Palm Beach County for the past 25 years, my views on the current opioid epidemic are the result of my daily contact with addicts, their families, the medical community, law enforcement and the judicial system. My work has taken me from the E.R. to the inpatient treatment centers and rehabs to the courts to our psychiatric hospitals and to our coroners offices. I have watched this epidemic from its earliest stages to its current existential threat status. As a result I have come to the following conclusions about this tragic situation our community and communities across the country find themselves faced with. WE MUST CHANGE THE WAY WE THINK ABOUT THIS AND TREAT THIS PLAGUE.
1.) Move away from the concept of a war on drugs. Move towards providing an aid package for these vulnerable and impaired individuals.
2.) Move away from concepts of criminalization, imprisonment, and that they are deserving of severe punishment. Move towards treatment and therapeutic interventions. View individuals with OUD as impaired and of need of help.
3.) The concept of opiate-dependent individuals as merely addicts that are weak, self-indulgent, hedonistic, and who are scorned by all is not helpful in resolving this national issue. There certainly is a volitional component to this illness. While personal responsibility and accountability is the only path to a healthy life, opiate-dependent individuals need a support system and tools to help get them on that path. Individuals suffering from OUD hate themselves, the behaviors in which they engage, and the resulting consequences. People with OUD are reckless with their lives because they feel their lives have little or no value. The mind-set of the opiate-dependent individual is one in which it doesn’t matter if they live or die. These vulnerable individuals are also prone to abuse and exploitation.
4.) Society must track these individuals and intervene when necessary.
5.) Society as a whole must be educated about opiates and all aspects of drug dependency, starting in grade school. Opiates come in pill form, patches, lollipops, and can be snorted and inhaled. Drug dependency can begin after one dose. Five days of continued use of opiates can result in drug dependency. Individuals who are genetically predisposed to dependency are more affected.

Like many drugs, over time the same amount of opiates has less and less affect which results in individuals increasing the drug dose and decreasing time between doses. This is the concept of drug tolerance. People spend more time getting the drug and doing the drug, and it becomes a vicious cycle. OUD individuals start to live a life of lies to cover their drug use. They spend a majority of their time planning to get money and make time to use drugs. They become psychologically consumed by thoughts of procuring opiates, using opiates, and disregarding everything else, including family, friends, job, health, and finances. All that matters to them now is getting high. When in withdrawal, these individuals can become very desperate and dangerous. They will go to great lengths to get high.

What can we do in terms of how society should deal with the problem? When treating an OUD patient, both incentives and consequences need to be geared towards keeping them off the drug of abuse. These five areas are conceptual changes needed towards resolving the national opiate use crisis and treating patients with Opiate Use Disorder:

1.) There needs to be a massive education campaign similar to the education campaign against tobacco including the danger of opiates and treatment options for OUD individuals. Explain the dangers of opiates, what opiates are, how they affect our brains, and, importantly, how easily it is to become dependent. The potential of overdose and death needs to be underscored. For example, the opiate called fentanyl, in amounts barely visible to the human eye, can cause individuals to stop breathing. Fentanyl is measured in micrograms. There are 100 milligrams in a gram. There are 1000 micrograms in a milligram. There are 100,000 micrograms in a gram. Two hundred micrograms or maybe less is lethal, which hardly covers the tip of a needle.
2.) The streets must be flooded with Narcan inhalers. One to three sprays in a nostril can revive an opiate overdose.
3.) The streets must be flooded with test kits to determine what is in the drugs and how much is in them. People make better decisions when they know what is in the drug they are taking. For example, if someone makes a street purchase of a drug with fentanyl or methadone in it, they need to be extra careful because those drugs can easily kill you. Methadone is dangerous not only because it is so potent but because it lasts so long. There is an even more dangerous drug on the street called carfentanyl which is 100 times more potent than fentanyl! Note: methadone has been useful in the treatment of OUD, however, it is so dangerous that the dose must be given out on a daily basis. While methadone blocks cravings, it provides a high so can still be abused and lead to an overdose. Buprenorphine is another drug used in treating OUD, and it has been found to be safe enough to prescribe on a monthly basis. The negatives and stigma associated with methadone should not be associated with buprenorphine.
4.) Laws need to be changed. Instead of charging people with accessory to murder when a friend overdoses and dies, give them immunity. Give complete immunity to people in the presence of someone who overdoses if they call 911 during the overdose. Encourage people to call 911 and save lives, not run and hide fearing prosecution.
5.) The court system for individuals with OUD must change. Once in the system, these individuals must be tracked with drug testing and given treatment when needed. Criminal records for possession or use can be wiped away if the individual stays sober. Incarceration should be a last resort. Charging people with felonies for drug possession scars people for life. Once labeled a felon, re-entering society becomes very difficult. OUD individuals are not sociopaths or criminals, they are ill with a disease. Treat the illness and there are no criminal problems.
This perspective demands basic changes in our societal and individual thinking about opioid dependency. Equally as important is the way the established medical community regards and treats this diagnosis and it is just that….a medical condition.

I have many thoughts for my peers and given the opportunity, I would welcome the chance to share them.

No matter what our circumstances in life, we are all touched by this epidemic in some way. We all have skin in this game. Time is precious, costly and limited. Soon may become later and it is already too late to wait.
More comprehensive explanations about how to deal with addictions in my book Tales From The Couch on amazon.com

Mark Agresti, M.D.

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