How To Determine If Someone Is Suicidal

A Coronavirus PSA

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

Suicide Assessment

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

Facts and Figures

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

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

Suicide Risk Factors

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

–  Family history of completed suicide in first-degree relatives

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

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

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

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

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

Mental Illness and Suicidality

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

–  Depression

–  Bipolar disorder

–  Mania

–  Schizoaffective disorder 

–  Schizophrenia

–  Post-traumatic stress disorder

–  Substance abuse 

Suicidal Ideation

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

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

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

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

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

–  The degree of planning 

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

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

–  Access to the place to commit

–  Note: presence, timing, content

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

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

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

What is a Suicide Plan?

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

–  Timing of the suicide event

–  Access to the method and setting of suicide event

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

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

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

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

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

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

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

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

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

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

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

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

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Mental Health Benefits of Dogs

Mental Health Benefits of Pets

The bond between humans and animals is a powerful one, so much so that there have been numerous books written and movies made centering on the relationships between them. Dogs were the first animals domesticated and kept as pets, as much as 45,000 years ago.Regardless of when pet ownership got started, our long attachment to these animals is still going strong. Americans own some 78 million dogs, 85 million cats, 14 million birds, 12 million small mammals, and 9 million reptiles, according to pet industry statistics. 

Studies have scientifically explored the benefits of the human-animal bond, and a positive correlation between pets and mental health is undeniable. According to a recent poll, 95% of pet owners consider their pet a member of the family. Children, adolescents, adults, and seniors all find joy in their pets, so it follows that pets and mental health go hand in hand.

Pets provide companionship, ease loneliness, bring us joy, and give us unconditional love. They also help decrease depression, anxiety, and stress. While the word “pet” usually conjers up thoughts of dogs and cats, a pet doesn’t necessarily have to be a dog or a cat. Even watching fish in an aquarium has been shown to reduce muscle tension and lower pulse rate. A pet can be a horse, parrot, turtle, rabbit, skunk, lizard, chicken, snake…whatever you love and take care of.

Pets have evolved to become acutely attuned to humans. Dogs, for example, are about as intelligent as a two-year-old human child. Some more doggie fun facts: They are able to understand about 150 human words and most are even capable of following a count of five. They understand spatial relationships and are able to use them to navigate obstacles quickly. Although they can’t see the same color spectrum we can, they can see black, white, blue, and yellow; they can’t see red and green- those just look gray to them. A dog’s smell is like 10 million times better than yours. Dogs can sense if you’re going to have a seizure, they know if your blood sugar is low, and some say they can even sniff out cancer. While they understand many of our words, dogs are even better at interpreting our tone of voice, body language, and gestures. And like any good human friend, a loyal dog will look into your eyes to gauge your emotional state and try to understand what you’re thinking and feeling (and to use their special psychic powers to get you to give them treats and throw their ball, of course). I think dogs have psychic powers. My dog Beluga used to use her psychic powers to get me to do stuff all the time.  

Pets, especially dogs and cats, can reduce stress, anxiety, and depression, ease loneliness, encourage exercise and playfulness, and even improve cardiovascular health. Caring for an animal can help children grow up feeling more secure and being more active. Pets also provide good companionship for older adults. Perhaps most importantly, a pet can add real joy and unconditional love to your life.

Early researchers had discovered physical evidence of the mental health benefits of having pets. They found that pets could fulfill the human need for touch, so when hugging or stroking a pet, the human subject’s blood pressure went down, their heart rate slowed, their breathing became more regular, and their muscle tension relaxed. All of these physical changes are signs of reduced stress, which is indicative of a positive psychological impact. 

Since then, scientists have learned much more about the connection between pets and mental health. As a result, animal-assisted therapy programs have become an important part of mental health treatment. But, by owning a pet, you can experience pet therapy benefits every day in your own home. Below are several ways in which pets support good mental health and how pets are beneficial to people with mental health issues.

Interacting with Pets Lowers Stress and Decreases Anxiety:

Just the sensory act of stroking a pet lowers blood pressure, which reduces stress. Petting and playing with animals also reduces levels of the stress hormone cortisol while stimulating endorphin production and release of the happy hormones serotonin and dopamine, which calm and relax the nervous system. It also increases the production of oxytocin, another chemical that naturally reduces stress. Having the companionship of an animal can offer comfort, help ease anxiety, and build self-confidence for people anxious about going out into the world.

Pets Make Us Feel Needed:

The act of caretaking has mental health benefits. Caring for another living thing gives us a sense of purpose and meaning, so people feel more needed and wanted when they have a pet to care for. This is true even when the pets don’t interact very much with their caregivers. In a very interesting 2016 study about pets and mental health, elderly people were given five crickets in a cage to care for. Researchers monitored their mood over eight weeks and compared them to a control group that was not caring for crickets or other pets. They found that participants that were given the crickets became less depressed after eight weeks than those in the control group, so researchers concluded that caring for living creatures produced the mental health benefits they saw. Simply put, doing things for the good of others reduces depression and loneliness.

Pets Increase Well-Being:

Pet owners lives are enriched and generally better in several areas. They have better self-esteem, they are more physically fit, they are less lonely, they are more conscientious and less preoccupied, they are more extroverted, and they are less fearful. Put simply, pet owners are happier, healthier, and better adjusted than non-owners.

Pets Provide Companionship:

Companionship can help prevent illness and even add years to your life, while isolation and loneliness can trigger symptoms of depression. Caring for a live animal can help you shift your focus away from your problems, especially if you live alone. Most dog and cat owners talk to their pets, and some even use them as a sounding board to work through their troubles. And nothing beats loneliness like coming home to a wagging tail or a purring cat.

Cats and Dogs Are Great Examples:  Because pets live in the moment- not worrying about what happened yesterday or what might happen tomorrow- they can help you appreciate life’s simple joys and help you to be more mindful. Mindfulness is a psychological technique, the process of bringing one’s attention to the present moment. This can help distract you from what might be bothering you and help remind you to try to be more carefree and playful. In people diagnosed with mental illnesses like depression, schizophrenia, bipolar disorder, or post-traumatic stress disorder, pets can be among the most supportive connections they have. They provide a unique form of validation through unconditional support, which they may not have in other relationships.   Patients report that pets help them manage their illness, navigate everyday life, and give them a strong sense of identity, self-worth, and meaning. Caring for a pet gave owners a feeling of being in control as well as a sense of security and routine. Most said that their pets helped them manage their emotions and distract them from their symptoms like hearing voices, habitual rumination, and even suicidal thoughts, because they felt needed by their pet.

Pets Help Us Build Healthy Habits:
Pets need to be taken care of every day, and as a result, they help us build healthy habits and routines and add structure to the day. Many pets, especially dogs, require a regular feeding and exercise schedule. Having a consistent routine keeps an animal balanced and calm, and it’s good for people too. No matter your mood, one plaintive look from your pet and you’ll have to get out of bed to care for them. Caring for a pet can help you adopt healthy lifestyle changes, which play an important role in easing symptoms of depression, anxiety, stress, bipolar disorder, and PTSD. Some examples of these healthy lifestyle changes include:
Physical activity: Dog owners need to take their pets for walks, runs, and/ or hikes regularly, and owners receive the benefits of that exercise. Studies show that dog owners are more likely to meet recommended daily exercise requirements.
Time in nature: Walking a dog or riding a horse gets us outside, so we experience the many mental health benefits of being outdoors.
Getting up in the morning: Dogs and cats need to be fed on a regular schedule. As a result, pet owners need to get up and take care of them, no matter what mood they are in. So in this way, pets give people a reason to get up and start the day.
Pet care leads to self-care: Caring for a dog, horse, or cat reminds us that we must take care of ourselves as well.

Pets Support Social Connection: Pets can be a great social lubricant for their owners, helping to start and maintain new friendships. Pets are able to counteract social isolation and promote social connection by relieving social anxiety, because they provide a common topic to talk about. For example, walking a dog or playing in a dog park often leads to conversations with other dog owners. As a result, dog owners tend to be more socially connected and less isolated. This improves the owners’ mental health, because people who have more social relationships and friendships tend to be mentally healthier. The benefits of having social connections include better self-esteem, lower rates of anxiety and depression, a happier, more optimistic outlook, stronger emotional regulation skills, improved cognitive functioning, and having more empathy and feelings of trust toward others.

Pets Give Us Unconditional Love:
This one is best of all! Dogs and cats and pets of all kinds love their owners no matter what. That’s unconditional love. Pets don’t care how your presentation went, how you did on a test, or if you sold a house. Pets don’t judge you based on what you look like, if you are popular, or if you’re super athletic. They’re simply happy to see you, and they want to spend time with you, no matter what! This kind of unconditional love is good for mental health. It stimulates the brain to release dopamine, the chemical involved in sensing pleasure.

To summarize, the link between pets and mental health is clear. So if you don’t have a pet, think about getting one. For a dog or cat, go to a shelter or humane society and adopt somebody, take them home and make them a member of the family. Or maybe talk to a doctor about finding an emotional support animal. Either way, it’ll do you good and you’ll feel good for it. 

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Digital Addiction Disorder

Time to Log Off?

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

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

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

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

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

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

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

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

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

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

Emotional symptoms may include:

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

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

Physical symptoms may include:

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

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

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

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

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

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

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

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

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Warning Signs Of Bipolar

As a psychiatrist practicing in Palm Beach Florida, I come across a lot of bipolar patients.  What are the warning signs of bipolar disorder? How can you recognize if someone you love or even yourself has bipolar disorder? You can’t get through an hour television program without at least 2 commercials for bipolar medications, so I thought it would be a good idea to talk about it. 

First, what is bipolar? Bipolar disorder is a mental health disorder more commonly found in women that can cause dramatic changes in mood and energy levels. The term bipolar refers to the two poles of the disorder, the extremes of mood. Those two extremes of mood are mania and depression. The symptoms of bipolar can affect a person’s daily life severely as their mood can range from feelings of elation and high energy to depression. There are two types of bipolar, type 1 and type 2. Type 1 is more serious and disruptive than type 2, which can also be called hypomania. 

Bipolar is sort of the Jekyl and Hyde of psychiatric disorders, with cycling of mania and depression. Manic episodes and depressive episodes have very specific signs and symptoms associated with them.

When someone is manic, they do not just feel very happy. They feel euphoric. Key features of mania include, but are not limited to:

– irritability 

– having a lot of energy
– feeling able to achieve anything
– having difficulty sleeping
– using rapid speech that jumps between topics.
– inability to follow through with ideas or tasks

– feeling agitated, jumpy, or wired
– engaging in risky behaviors, such as reckless sex, spending a lot of money, dangerous driving, or unwise consumption of alcohol and other substances
– believing that they are more important than others or have important connections
– exhibiting anger, aggression, or violence if others challenge their views or behavior
– in severe cases, mania can involve psychosis, with hallucinations that can cause them to see, hear, or feel things that are not there.

People in a manic state may also  have delusions and distorted thinking that cause them to believe that certain things are true when they are not. While I have many patients that get delusions of grandeur, I have one patient that comes to mind. Her name is Felicia. Felicia is a 32-year-old receptionist. She was diagnosed with bipolar type 1 when she was 25, which happens to be the typical age of diagnosis. Felicia is on two medications for her bipolar with mixed results. She still cycles occasionally to a manic state. Sometimes that’s a clue that she may not be compliant with her meds. Like many bipolar people, Felicia loves loves loves her manic state. When Felicia is manic, she is on top of the world. Her house is pristinely clean, the meals she makes for her family are total gourmet, and her appearance is perfect. Sounds great, right? You may be thinking ‘Where’s the downside, Dr. A?’ Well, in this manic state, Felicia absolutely positively believes that she is descended from “the true” royalty. She believes that the father of the current Queen of England, the previous King George VI, actually stole the monarchy and the crown from her father. As a result, she believes that she should be the rightful current monarch. In reality, her father is a semi-retired urban planner living just outside of Topeka Kansas. Regardless, when Felicia is super manic, she will relay this story with a voice full of indignation and a perfectly straight face. She will tell anyone this story, so people think she’s totally nuts. 

A person in a manic state may not realize that their behavior is unusual, but others may notice a change in behavior. Some people may see the person’s outlook as eccentric or sociable and fun-loving, while others may find it unusual or bizarre. The individual may not realize that they are acting inappropriately or be aware of the potential consequences of their behavior. In some cases, they may need help in staying safe when they are completely out of touch with reality. Bipolar type 1 patients can be some of the most dangerous patients in my practice, as they can be violent, prone to rage and acting out on that rage. They are chaotic. If you have an untreated or ineffectively treated bipolar 1 person in the household, you will know. One big problem is that patients enjoy the manic state of their disorder. They feel such increased energy and euphoria that they are prone to stop taking their meds. Once that happens, all hell breaks loose. 

But eventually, that mania will cycle into deep depression with all of the symptoms that go with it, and may end with suicidal thoughts or acts. Key features of depressive episodes may include, but are not limited to:

– feeling down or sad
– having very little energy
– having trouble sleeping or sleeping a lot more than usual
– thinking of death or suicide
– forgetting things
– feeling tired
– losing enjoyment in daily activities
– having a flatness of emotion that may show in the person’s facial expression
– In very severe cases, a person may experience psychosis or a catatonic depression, in which they are unable to move, talk, or take any action.

Bipolar type 2, also called hypomania, is a disorder which is sort of like type 1-light. It features episodes of depression and hypomania. Symptoms of hypomania are similar to those of mania, but the behaviors are less extreme, and people can often function well in their daily life. But if a person does not address the signs of hypomania, it can progress into the more severe form of the condition at a later time. I see type 2 patients more often in my practice, and I see them as generally being much calmer than type 1 patients. They do not get as violent, do not hear voices, do not have hallucinations, and are not disorganized in their speech or behavior. However, they are usually irritable. They talk quickly. They have trouble sleeping. They have trouble concentrating. They have trouble getting things done. They have relationship issues. They have trouble sleeping. These periods of hypomania can last anywhere between minutes to days to weeks.

So what can be done for a patient suffering from bipolar disorder, whether type 1 or 2? There are multiple drugs which can be used to balance the patient. I find my go-to drug would be lamotrigine, as it is minimal in its side effect profile, is mood stabilizing, does not put on weight, does not make you drowsy, and does not have many drug interactions. There are other drugs which can be used,  oxcarbazepine and divalproex, which are antiseizure mood stabilizers. These have some effectiveness and have various side effect profiles. In some cases, antipsychotic drugs like lurasidone are useful. Many times I put patients on at least two drugs, one to treat mania and one to treat depression. I can prescribe all the drugs in the world, but they won’t do any good if patients are non-compliant in taking them. So the biggest and most important key feature in treating bipolar is having a relationship with the patient and making sure they are compliant with medicine, because the manic state is so enjoyable to them that they may choose non-compliance. That’s really the biggest barrier to treatment. I always explain to my manic patients that while they may like the mania, they will have to pay the piper, because guess what? Next they’ll be hopelessly depressed and unable to get out of bed.

In my practice, I see many female patients with mood disorders. The way I approach treatment is to find the best tolerated drug. This may not be the best drug on the market, but may be the best drug for that patient because it is better tolerated and has a better side effect profile for that patient. If the drugs cause weight gain, make them drowsy, or cause sexual dysfunction, they won’t take them. And who would blame them? So I work very hard to explore all available pharmaceutical treatment options for each patient as an individual. The goal is to have a drug regimen which is the least invasive in that person’s life and to combine that with psychotherapy. Because bipolar disorder is a lifelong disease, treatment should also be lifelong. If you suspect that you have bipolar or a loved one has bipolar, contact a physician for referral to a mental health professional like myself. For more information, check out my book, Tales from the Couch, available on Amazon.com. 

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Depression…What can you do to help yourself?

Let’s talk about depression. First, understand that like most things in life, depression is a spectrum; it is not black and white. Some people have situational depression or very mild depression and do really well with therapy and making some simple life changes. Others might need medication to assist them. Some unfortunately suffer from major depression and find it hard to cope with life.

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Depression – What Can You do to Help Yourself?

Let’s talk about depression. First, understand that like most things in life, depression is a spectrum; it is not black and white. Some people have situational depression or very mild depression and do really well with therapy and making some simple life changes. Others might need medication to assist them. Some unfortunately suffer from major depression and find it hard to cope with life. No matter where on the spectrum people fall, the following information is helpful to anyone who has experienced depression.

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Depression – Part 6 – Medical Treatment

Dr. Mark Agresti discusses the medical treatment options to help those suffering from depression.

Dr. Mark Agresti, West Palm Beach Drug & Alcohol Detox Specialist, Psychiatrist

Call (561) 842-9550 or email: info@206.189.200.158 Dr. Agresti today to get psychiatric help today.

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Depression – Part 5 – Treatment of Depression

Dr. Mark Agresti talks about the treatment options available for depression.

Dr. Mark Agresti, West Palm Beach Drug & Alcohol Detox Specialist, Psychiatrist

Call (561) 842-9550 or email: info@206.189.200.158 Dr. Agresti today to get psychiatric help.

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Depression – Part 4 – How to Diagnose

Dr. Mark Agresti discusses ways of diagnosing depression and why it is important to get a proper diagnosis.

Dr. Mark Agresti, West Palm Beach Drug & Alcohol Detox Specialist, Psychiatrist

Call (561) 842-9550 or email: info@206.189.200.158 Dr. Agresti today to get psychiatric help.

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Depression – Part 3 – Causes of Depression

Dr. Mark Agresti talks about the different causes of depression.

Dr. Mark Agresti, West Palm Beach Drug & Alcohol Detox Specialist, Psychiatrist

Call (561) 842-9550 or email: info@206.189.200.158 Dr. Agresti today to get psychiatric help.

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Depression – Part 2 – Symptoms of Depression

Dr. Mark Agresti Discusses the many different symptoms of depression.

Dr. Mark Agresti, West Palm Beach Drug & Alcohol Detox Specialist, Psychiatrist

Call (561) 842-9550 or email: info@206.189.200.158 Dr. Agresti today to get psychiatric help.

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Depression – Part 1 – Types of Depression

Dr. Mark Agresti describes the different types of depression.

Dr. Mark Agresti, West Palm Beach Drug & Alcohol Detox Specialist, Psychiatrist

Call (561) 842-9550 or email: info@206.189.200.158 Dr. Agresti today to get psychiatric help.

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Holidays and Stress

www.dragresti.com ~ (561) 842-9550 Dr. Mark Agresti, West Palm Beach Drug & Alcohol Detox Specialist — Psychiatrist, shares how to deal with holiday stress. With the holiday season upon us, let Dr. Agresti give you some tips to survive them.

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Depression is Treatable

Depression usually starts out simple. For my patient, Cindy, for example, it began with down days during her first semester in college, when she wouldn’t get out of bed. She did not leave her apartment, wore sweat pants all the time, stopped doing her hair and makeup, gave up her spin class, and neglected her bathing and hygiene.

As time went on, she became more and more isolated from her friends. Her eating habits deteriorated — Skittles and Chinese food became her staple, and in order to sleep, she took Benadryl with a giant glass of wine.

Symptoms and Treatment of Depression

It was the same thing, day in, day out, and as bad as it sounds, her condition was treatable. It’s important for those battling depression to remember this, which is why I am sharing Cindy’s story. (more…)

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Why do people stop Psychiatric medications?

The biggest reason people stop medication is they don’t like taking pills. Some people just forget. Others start doing well so they say, “I don’t need it anymore”. Side effects that are uncomfortable are another big problem. Dry mouth, constipation, nausea, and dizziness can occur with a lot of medications. People stop medications because they don’t believe that they are sick or that the medication will help. Individuals are in denial about illness. Lately I’m seeing people stop medication because it’s too expensive. Sometimes people stop medication because they like the manic state and don’t want anything to stop.

One patient told me he wanted to use alcohol and didn’t want to take his medication with alcohol. I think that makes sense.

How do we keep people on medication? First education is the key. Educating them on the risks of the mental illness. Psychiatric illness can be damaging to the brain. Untreated mental illness results in breakup of relationships, loss of jobs, legal problems and problems in marriages.

Going off medications may result in withdrawal syndromes. Stopping medications can make a lot of things worse. Depressive disorders, anxiety disorders and psychiatric disorders become worse. Untreated mental illness may predispose people to addiction and self medication with drugs of abuse. (more…)

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What is Bipolar Disorder?

http://206.189.200.158 ~ (561) 842-9550

Dr. Agresti, West Palm Beach Mental Health Specialist – Psychiatrist, explains what Bipolar Disorder is.  He explains the manic side and the depressive side of bipolar disorder.  Learn the extremes of the two different behaviors and some of the medications used to treat bipolar disorder.  Bipolar disorder medications and treatments should be ones that work with you, the patient, as an individual and suite your life.

Call Dr. Agresti today to get help with Bipolar Disorder.

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Depression: The use of Medication for Depression

http://206.189.200.158 ~ (561) 842-9550

Dr. Agresti, Psychiatrist in West Palm Beach, Florida, talks about his preferred medications for treating depression.  Depression is more that just feeling sad for a few days.  Psychological symptoms of depression are sadness, lack of desire for fun, hopelessness helplessness, despair, worthlessness, guilt, thoughts of death and dying.  The physical symptoms of depression are changes in appetite and changes in weight. Problems with sleeping develop with people who suffer from depression.  Depression medications start working in a week or two and may take up to two months.  Anti-depressants commonly used are Wellbutrin, Prozac, Zoloft, Lexapro, Paxil, Remeron, Effexor and Pristiq.

Call Dr. Agresti today to get help for your depression.

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Depression: What Can I Do For Depression?

The first step is identifying the illness.  Depression is more that just feeling sad for a few days.  Depression means weeks of being so sad, you start having trouble working or going to school.  You start having problems in relationships.  Problems develop in just taking care of you.

People with depression have two types of symptoms.  The first type is psychological.  The second type is physical.  Psychological symptoms are sadness, lack of desire for fun, hopelessness helplessness, despair, worthlessness, guilt, thoughts of death and dying.  The physical symptoms are changes in appetite and changes in weight.  Problems with sleeping develop.  Usually individuals wake from sleep easily.  Problems with concentration and cognition develop.  Individuals become agitated or irritable.  Problems dealing with stressors and making decisions.

That’s enough about symptoms.  Once you see you or a loved one has depression help is crucial.  See a mental health professional.  Things can be done right away if you are depressed.  One important thing is to start exercising everyday.  Stop drinking alcohol or using non prescribed sleep aids.  Start eating a healthy diet.  That means lean meats, fresh chicken, fruits, vegetables and nuts.  No sugar, salt or complex carbs.  Complex carbs are anything from a bakery.  You know cakes, cookies, candies, breads and processed foods.  That’s what individuals can do for themselves.  Then it might be helpful to see a psychotherapist.  That’s where you sit and talk to someone.  Seeing a psychiatrist is also helpful. (more…)

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Opiate Detox: What Do Opiates Do To People?

By Dr Mark Agresti

Treating opiate addiction (Oxycodone, Roxycodone dependency) since 1988 has taught me a few things.  Opiate dependency is all consuming.  Individuals become consumed with getting money for opiates, obtaining opiates and having time to use opiates.  All this mental energy is pulled from other activities.  Resources are taken from loved ones, leisure activities and business.  Individuals using opiates spend discretionary income on opiates (i.e. oxycontin), instead of going out to dinners, dating and playing.  Once on opiates the range of activities that individual engages in decrease.  Hobbies and sports fall to the side.  These individuals lack time and money to do fun things, but also lack desire to have fun.  There is no desire to have sex and desire to socialize decrease.  These individuals can maintain jobs and relations with a few close others.

They usually become depressed, crave sugar, and gain weight.  Their complexion changes to a grayscale cancer looking color.  They develop strange eating habits and sleeping habits.  Their sense of self worth and self-esteem decline.  They have feeling of emptiness and detachment from others.  One patient said she looked in the mirror and she saw a skeleton.  She no longer existed.  The opiate becomes everything.

The opiate becomes an individual’s lover and family.  The fear of going into withdrawal is so powerful.  When the possibility that the individual may be cut off from drugs, the beast comes out. (more…)

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