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Cuties and the Oversexualization of Children in Our Culture
Netflix has recently come under fire for its release of the French film "Cuties." While critics have praised the movie for exploring themes of the oversexualization of children, audience members are consistently appalled at the provocative situations that the 11-year-old characters are put through. In this episode, I discuss our culture's saturation with the oversexulization of children in media with Maddie Ulrich B.S., Randy Stinnett, Psy.D., ABPP, and Caroline Osorio M.D.
|Sep 22, 2020|
Forensic Pedophilia with Dr. Cummings
In this episode, Dr. Cummings and I discuss forensic pedophilia and the sexualization of children in our society.
|Sep 20, 2020|
The Big Five: Neuroticism Part 1
In today’s podcast, we discuss the Big Five personality traits, focusing on neuroticism and how it fits into this set. We then explore each of the six domains of neuroticism and the research of how it manifests in other parts of one’s life and affects relationships.
|Sep 17, 2020|
Nortriptyline and the Tricyclic Antidepressants with Dr. Cummings
In today’s episode of the podcast, we’ll be doing a deep-dive into nortriptyline, a lesser-talked about medication in psychopharmacology. We’ll cover a little about the history of tricyclic antidepressants (TCAs) as well as the characteristics, side-effects, and indications to consider when prescribing this class of medication.
|Sep 15, 2020|
Covid increasing Suicidality
The COVID-19 pandemic and subsequent lockdowns have seemed to foster a “sub-epidemic” of suicidality and deteriorating mental health. Suicidal thoughts have spiked across every demographic due to the loss of connection to usual psychosocial supports, normal activities, and in a lot of cases, jobs, leading to significant financial stress. These stressors compound and massively impact the mental resiliency of everyone reached by this pandemic.
|Sep 13, 2020|
The USMLE: How To Rock It
If you are a medical student or someone studying for a big exam, this episode is for you. We will first discuss the mental roadblocks that prevent students from performing at their top potential for exams. We also break down and outline some effective study strategies, and provide a sample day-by-day study plan for any 2nd year medical student preparing for the USMLE Step 1 exam. Finally, we have also created a 3-step challenge all students can follow.
|Sep 01, 2020|
How to Retire Happy with Dr. Osorio
On this episode of the Psychiatry and Psychotherapy Podcast, we continue our conversation with geriatric psychiatrist, Dr. Osorio, to talk about retirement—specifically, how to retire well and happy. She recently published a book for people in this transition: Stop Freaking Out About Retirement
|Aug 16, 2020|
Disorganized Attachment: Fear Without Solution Part 2
Understanding disorganized attachment as medical professionals is important because some patients have experienced trauma, or 2nd generation influences of trauma, which leads to this issue. As we continue to explore disorganized attachment and how we can help patients with this attachment style, it’s important to remember that this information provides the foundation for why empathy, connection, and emotion mirroring is vital in psychotherapy and psychiatry.
|Aug 08, 2020|
Disorganized Attachment: Fear without Solution
When people dissociate, it means they feel disconnected from their body. They feel fear and dread, sometimes feeling completely frozen. As mental health professionals, understanding disorganized attachment gives us appreciation and understanding for the necessity of empathy, attunement and deeply understanding the experience of another.
|Jul 25, 2020|
Free Will In Psychiatry & Psychotherapy Part 3
In this final part of the free will series, we take a look at the relationship between the concept of free will and mental health. Is free will altered in those suffering from schizophrenia? How is well-being related to free will? Thinking about these questions and the rise of neuroessentialism within psychiatry allows us to recognize the influence of our environment on our decision-making. The debate is far from settled, but a belief in free will clearly affects daily life and the practice of psychiatry.
|Jul 23, 2020|
Free Will in Psychiatry & Psychotherapy Part 2
This is the second episode in our Free will series. In this episode, we will describe some definitions of free will, explore determinism (the opposite of free will), cover some quotes by famous authors on the topic, and break down some statistics, and studies about it.
|Jul 09, 2020|
Free Will In Psychiatry & Psychotherapy Part 1
On this episode of the Psychiatry and Psychotherapy Podcast I have a conversation with Matthew Hagele, a soon to be 4th year medical student with a masters in bioethics. We will talk about the history, the why, and the cultural importance of free will. We will examine the implications of free will on mental health.
This is the first of a three part series. We hope they provide interesting application information for your own practice.
|Jun 17, 2020|
Racism & Trauma: Discussion with Danielle Hairston M.D.
Join Dr. Danielle Hairston and Dr. Puder on a discussion of recent events. Dr. Hairston has served as the Black Psychiatrists of America Scientific Program Chair since 2016. She is also the American Psychiatric Association Black Caucus’ Early Career Representative. She is the residency director at Howard University. She has a Consultation-Liaison Psychiatry Fellowship. Dr. Hairston has also had the opportunity to speak nationally and internationally about the impact of racial trauma and culture on mental health. She is a contributing author to the recently published book, Racism and Psychiatry: Contemporary Issues and Interventions. Her interests include consultation-liaison psychiatry, resident education, minority mental health, cultural psychiatry, and collaborative care.
|Jun 06, 2020|
How Does Mental Pain, Meaning in Life & Locus of Control Influence Suicidality?
On this episode of the Psychiatry and Psychotherapy Podcast, we talk about meaning, and how it relates to suicide.
This is part 3 of a series of podcasts on suicide. If you haven’t listened to the first two episodes, they are here:
|May 22, 2020|
The Link Between Unemployment, Depression and Suicide in the COVID-19 Pandemic
As the economy continues to shut down during COVID-19, people are growing more concerned about work and finances. Even if the virus is miraculously contained in the next few months, the economy will still be reeling from the damage of the lockdown.
As psychiatrists, we are concerned about the increases in mental illness from the lack of employment and a potential increase in suicides. In this episode, we begin to look at past studies on the links between economic disaster and the subsequent rates of depression and suicide, and what we might be able to do to help.
|May 02, 2020|
Meaning and Decision Making in Times of Crisis
On this week’s episode of the Psychiatry and Psychotherapy Podcast, I interview Dr. Daved Van-Stralen. During this season of COVID-19, Van-Stralen is focusing on the unique stresses on the healthcare system. How can the healthcare system improve the way that things are currently being done? How can people handle stress and the stress of seeing multiple deaths, exposure to the disease, and increased hours?
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|Apr 22, 2020|
Courage to have the tough conversations in the COVID-19 Pandemic
In the US, people do not talk about death often or even acknowledge their own mortality. Instead, we act as if we just work hard enough we can do anything, even refuse the grim reaper.
In this episode, we wrestle with the current issues created by COVID-19. Join us as we think more about death and the necessity to have conversations around it.
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|Apr 16, 2020|
COVID-19 and the Brain: Delirium & Viral Encephalitis
In a previous episode, we covered COVID-19 and its effect on mental health. In today’s episode of the podcast, we will be covering COVID-19 from the medical perspective with regards to its effect on the brain as well as treatment options, their side effects and special considerations.
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|Apr 04, 2020|
Getting Better Results from Your Patients as a Psychotherapist
On this week’s episode of the Psychiatry and Psychotherapy podcast, I interview Scott D. Miller, Ph.D. and Daryl Chow, Ph.D., authors (along with Mark A. Hubble, Ph.D.) of Better Results. Better Results is a book that sums up thirty years of research to demonstrate what clinicians can reliably do to improve therapy results by personal and professional development.
|Mar 19, 2020|
COVID-19: Dealing with panic, anxiety, delirium, and mental health.
Stress and anxiety are going to be very common during this time. In one study of Wang et al, 2020 they found that in China, 53.8% of the respondents to a survey rated their psychological impact as moderate-to-severe and 28.8% had moderate to severe anxiety, 16.5% had moderate to severe depressive symptoms, 8.1% had moderate to severe stress levels.
|Mar 17, 2020|
Cancer: Depression, Anxiety, And Hypoactive Delirium - A Dive Into Psycho-Oncology with Mona Mojtahedzadeh, M.D.
In this week’s episode, we sat down with four guests and discussed different aspects of mental health in humans bravely facing cancer. Below is a link to the notes which go beyond the podcast episode in content and depth and hopefully equips you to have more empathy, compassion and knowledge.
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|Mar 05, 2020|
This week I interviewed Dr. Joel Weinberger and Dr. Valentina Stoycheva who recently published the book “The Unconscious: Theory, Research, and Clinical Implications .” We discussed their book and even their unconscious reasons for writing a thrilling, deep dive into the unconscious. This book was graduate level in detail, deep, thoughtful, articulate, sometimes very theoretical, and definitely worthy of reading and contemplating.
|Feb 22, 2020|
Catatonia: Diagnosis and Treatment
Catatonia is a severe motor syndrome. It is a secondary response to an underlying illness that requires quick diagnosis and treatment. There are many different things that lead to catatonia, so finding out the underlying cause is very important. In this episode, Dr. Cummings and I discuss the history, diagnosis, and treatment of catatonia.
Link to resource library.
|Feb 15, 2020|
How Much Violence Is Due To Mental Illness?
In this short episode of The Psychiatry and Psychotherapy Podcast, I interview Dr. Cummings, a forensic psychiatrist, on the topic of the correlation of mental illness and violent crime, and what causes violent crime. I start out with reviewing some studies and then subsequently interview Dr. Cummings, a leading psychiatrist at one of the largest forensic psychiatric hospitals in the United States.
Link to Resource Library
|Feb 08, 2020|
Valproic Acid: History, Mechanism, Treatment in Bipolar, Schizophrenia, Aggression and Side Effects with Dr. Cummings
In this episode, David Puder, M.D. and Michael Cummings, M.D. discuss the history, uses, and side effects of Valproic Acid which is a mood stabilizer for various conditions including: Bipolar Disorder, Schizophrenia, and Borderline Personality Disorder.
|Jan 16, 2020|
Connecting with the Psychotic Patient, Therapeutic Alliance Part 7
In this episode, Dr. Puder talks about the importance of therapeutic alliance in the psychiatric interview, emphasizing the need for a strong therapeutic alliance in order to help patients with psychosis continue their medication.
|Jan 11, 2020|
Therapeutic Alliance Part 6: Attachment Types and Application
Therapy is an intensely focused relationship that involves acceptance, trust, unconditional positive regard, hope, attunement, tolerance, and mending empathic strains and ruptures. There is also emotional contagion between a therapist and patient, with transference and countertransference.
On this week’s episode, I talk about how attachment theory can be a powerful predictor in helping someone move forward past trauma and develop attachment to their therapist in a healthy and therapeutic way.
Link to resource library
|Dec 12, 2019|
IQ: Predictability, Influences, Genes, Environment, & Trauma
What is intelligence? Why is IQ controversial? In this week's episode Nelson Horsley (a 4th year medical student) and David Puder, M.D. discuss the IQ - if it is a predictor for a successful life, and what things can predict or influence IQ.
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|Dec 08, 2019|
Joker: An In Depth Character Analysis
Joaquin Phoenix stars in "Joker" which has divided critics and movie goers alike. Surprisingly, it has divided mental health professionals as well. Some say Phoenix's performance shines a light on the misunderstandings of mental illness while others believe it promotes a falsehood that mental illness is responsible for violence. In this episode, David Puder, M.D. and Hans von Walter, M.D. discuss Joker's cinematic and mental health themes.
|Nov 23, 2019|
The Fentanyl Epidemic
Fentanyl is a highly addictive drug which has led to the deaths of countless people including several well known celebrities. Fentanyl is being used to strengthen the potency of other drugs, such as cocaine, which means that people are being exposed to it without their knowledge. In this episode, David Puder, M.D. discusses the history, impact, and statistical analysis pertaining to the dangers of Fentanyl.
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|Nov 14, 2019|
Is Social Media Good for Mental Health?
Since its introduction in the early 2000’s, social media has become an integral part of our daily lives. It influences culture, current affairs, and connects us to the world like never before. As people spend more and more of their lives online, it's important for us to consider how this new online world is changing us. After all, healthy social connection is one of the key factors in good mental health and well-being. It’s time to check in and find out: how does social media affect mental health?
Link to Resource Library
|Nov 07, 2019|
Does Cannabis Use Increase Schizophrenia and Psychosis?
In this episode, David Puder, M.D., and Victoria Agee discuss possible links between marijuana use and psychosis. There a multiple studies which reveal links in genetics and marijuana potency that can lead to an increase in schizophrenia and psychosis.
Link to resource library
|Oct 24, 2019|
Interviewing Well For Residency & Beyond
On this week’s episode we will be covering a special topic-interviewing well-for psychiatry residency, and even in other interviews post residency. I am interviewing Neal Christopher, a 4th year, chief resident and the host of a podcast for the APA, The American Journal of Psychiatry Residents’ Journal Podcast.
Link to Resource Library
|Oct 16, 2019|
Therapeutic Alliance Part 5: Emotion
People often think of emotions as ethereal, complicated depths that are difficult to explore. They are actually adaptive physical reactions to stimuli. There are a few main categories, and as we will discover, they are concrete, identifiable, and usually in a healthy therapeutic alliance, they can be discussed and even when emotions are painful to express or come with shame or linked with traumatic memories, can be disarmed and understood.
Link to Resource Library.
|Oct 03, 2019|
Deciding for Others: Involuntary Holds and Decision Making Capacity
This week on the Psychiatry and Psychotherapy Podcast, I am joined by Dr. Mark Ard, a chief resident physician at Loma Linda University’s Psychiatry program, to talk about holds and capacity evaluations as it relates to medicine and psychiatry.
Link to Resource Library.
|Sep 28, 2019|
Genetics and Environmental Factors in Suicide
In the previous episode on Suicide, we discussed epidemiology, general risk factors, and associations of suicide with various mental health disorders. Now, in this second part of this series, we will focus on genetic and environmental factors associated with suicide. The data here might be cold and distant, and so is the nature of suicide. It cuts at the core of families that have struggled with it. I have had many patients who have had family members commit suicide, and it devastates them forever.
Link to resource library
|Sep 19, 2019|
Which Foods are Good for Mental Health?
On this week’s episode of the podcast, I interview Dr. Drew Ramsey, a nutritional psychiatrist. When I was a resident, I saw him give a lecture on diet and how it affects our mood, and I’ve been wanting to interview him for a long time. He is the author of several books about diet and health.
Link to full article
|Sep 12, 2019|
Lithium Indications, Mechanism, Monitoring, & Side Effects
Lithium is indicated for a number of things. Most clearly, as a mood stabilizer in bipolar spectrum disorders. It is unique among mood stabilizers in that it is very robustly anti-manic. The medication treats and prevents manic episodes from occurring, providing fairly robust prophylaxis against mood cycling. Lithium is also effective in treating bipolar depression, though not as effectively. Very few of the other mood stabilizers are effective for the depressed pole of bipolar illness.
Link to full article with details on up to date research and more: here
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|Sep 05, 2019|
Why Lithium is a Good Option for Treating Bipolar, with Dr. Walter A. Brown
This week the Psychiatry and Psychotherapy Podcast is joined by Dr. Walter A. Brown, Clinical Professor Emeritus in the Department of Psychiatry and Human Behavior at Brown University, author of the brand new book “Lithium: A Doctor, a Drug, and a Breakthrough”. In order to capture the full experience of this week’s episode, I’ve posted a transcript of my interview with Dr. Brown which you can access in the article link below.
Link to full article with details on up to date research and more: here
Support the podcast, blogs and video: on Patreon
|Aug 29, 2019|
IS ELON MUSK’S NEURALINK A SCIENCE FICTION HORROR SHOW OR THE SALVATION OF HUMANITY?
One of the more controversial components of the Neuralink presentation was Musk’s inclusion of his beliefs about the future of humanity and artificial intelligence. During the press release he stated one of his goals was to create the ability to achieve a “full symbiosis with artificial intelligence,” essentially removing the “existential threat of AI” which he believes will one day “leave us behind” (Neuralink, 2019). This goal has been met with a bit more skepticism, especially by the national media, than the medical applications of Neuralink’s BMI. Forbes describes it as “a bit more fantastical” than the company’s primary goal of treating brain disorders (Knapp, 2019). Other publications have been far less kind, such as The Atlantic, which published its coverage of the Neuralink press release with the title: “Elon Musk’s Next Wild Promise: If someone is going to revolutionize what it means to be human, do we want it to be a tech titan?” (Mull, 2019). Although the New York Times surmised that “one of the biggest challenges may be for his scientists to match his grand vision,” (Markoff, 2019), it serves as a good example of what most major media outlets have chosen to do: stick to the facts.
Link to full article with details on up to date research and more: here
Support the podcast, blogs and video: on Patreon
|Aug 21, 2019|
How To Pick A Good Therapist
Working with a good therapist often requires fewer sessions than other therapists to see improvement; in contrast, working with a therapist you don’t connect with, or with inadequate training, may require an extended number of sessions (Okiishi et al. 2003). People that see effective therapists are more likely to recover or partially recover, whereas those that work with a “bad” therapist are more likely to see no change or an increase in symptoms (Okiishi et al. 2006).
Link to full article/blog
|Aug 10, 2019|
Suicide Epidemiology, Risk Factors, and Treatments
On this week’s episode of the podcast, I interview Jaeger Ackerman, 4th year medical student about suicide risk factors and treatments.
As a therapist, attempt to closely approximate their reality of feeling suicidal with words. When I first hear their thoughts and feelings, I try to clarify with the patient to make sure I’m understanding their feelings. I usually try to put it into other words, and echo back to them. I’ll say something like, “I hear that you feel like there’s no other way out, that you feel lost and like it’s a very dark time for you.” I ask myself continually how to be present with them in their feelings, in the moment.
Link to full episode: notes
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|Aug 03, 2019|
Frontal Lobe Damage: Treating Patients through Grief, Acceptance and Growth
In this episode of the podcast, I interview Steven, one of my patients who had a rare form of a stroke—in the right orbital frontal cortex. He participated in a psychiatric program that I run. He tells his story of how his function and emotions changed, and how he dealt with it. At the end of the episode, I talk more with Jaeger Ackerman (a 4th year medical student) about the science and neurology of his case so other mental health professionals can have a basis for how to think about approaching brain injury with these psychiatric specifics. Steven was a former hotel executive, actor and certified professional accountant (CPA).
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|Jul 25, 2019|
An Introduction to Psychodermatology: "The Mind-Skin Connection"
What is Psychodermatology?
At the most basic level, Psychodermatology encompasses the interaction between mind and skin. It is the marriage between the two disciplines of psychiatry and dermatology, uniting both an internal focus on the non-visible disease, as well as an external focus on the visible disease. This tight interconnection between mind and skin is maintained at the embryological level of the ectoderm throughout life.
According to this article, although the history of psychodermatology dates back to ancient times, the field has only recently gained popularity in the United States. More specifically, Hippocrates (460-377 BC) reported the relationship between stress and its effects on skin in his writings, citing cases of people who tore their hair out in response to emotional stress.
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|Jul 20, 2019|
An Inside Look At Eating Disorders: Anorexia, Bulimia, & Orthorexia
What is an eating disorder?
One of the most important things about anorexia and bulimia is understanding that they are caused by a complex interplay of genetics, epigenetics, early development, and current stressors. They can lead to dangerous outcomes because of how the eating disorder changes both the body and the brain. Many therapists and nutritionists, as you’ll hear in my conversation with Sarah Bradley, don’t treat from multiple angles, and often lack empathy into this condition.
There are three main types of eating disorders we will cover here:
Anorexia is the practice of cutting calories to an extreme deficit or refusing to eat.
Bulimia involves purging, or vomiting, the food that has been eaten.
Orthorexia is a fixation and obsession on eating healthy food (like only eating green vegetables with lemon juice).
Anorexia traditionally lasts for an average of eight years.
Bulimia traditionally lasts for an average of five years.
Approximately 46% of anorexia patients fully recover, 33% improve, and 20% remain chronically ill.
Approximately 45% of those with bulimia make a full recovery, 27% improve, and 23% continue to suffer.
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|Jul 13, 2019|
The Process of Grief
Grief is the multifaceted response—emotional, behavioral, social—to a loss or major life adjustment (like a divorce, loss of a job, etc.). Bereavement is the process of grieving specific to the loss of affection or bond to a person or animal (Parkes & Prigerson, 2013; Shear, Ghesquiere & Glickman, 2013; Shear, 2015).
Some of the signs and symptoms of grief are:
-somatic symptoms (e.g. choking or tightness in the throat, abdominal pain or feeling of emptiness, chest pain)
-physiological changes (e.g. increased heart rate and blood pressure, increased cortisol levels)
-sleep disruption and changes in mood (e.g. dysphoria, anxiety, depression, anger)
Medical and psychiatric complications can also arise due to grief and include:
-An increased risk for myocardial infarction
-Takotsubo cardiomyopathy (Broken Heart Syndrome)
Acute grief begins after a person has learned of the passing of a loved one (Shear, 2015). During acute grief, a person may experience immense sadness, yearning for the deceased, and persistent thoughts of the decreased (Maciejewski, Zhang, Block & Prigerson, 2007; Shear, 2015). Auditory and visual hallucinations are benign hallucinations commonly found in acute grief and involve the person seeing, talking to or hearing the voice of the deceased (Grimby, 1993).
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|Jul 04, 2019|
Clozapine for Treatment Resistant Schizophrenia
What is clozapine?
Not only is clozapine the gold standard medication for treatment-resistant schizophrenia, it is also one of the most unique drugs used in psychiatry.
It was synthesized 1958, only eight years after chlorpromazine, the first antipsychotic drug, was created. At that time, researchers tested for antipsychotic properties by taking various compounds and testing to see if lab mice developed dystonia and catalepsy. When researchers tested clozapine, they found that it did not cause dystonia, but instead made the mice sleepy. Because of this, clozapine was almost missed entirely as an antipsychotic medication. Eventually, however, clozapine was found to be more successful than other antipsychotic drugs.
By the 1970s, Austria, Germany, and Finland had produced positive data on clozapine proving its efficacy. However, clozapine was also found to have caused severe neutropenia in sixteen patients in Finland, and even caused the death of eight of those patients. For this reason, clozapine did not enter the United States until it was approved by the FDA in 1989.
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|Jun 20, 2019|
The Unspeakable Mind: Stories of Trauma and Healing from the Frontline of PTSD Science
PTSD, or Post Traumatic Stress Disorder, occurs when someone experiences or subjectively experiences a near death or psychologically overwhelming event and then goes on to develop specific symptoms. Different types of trauma/stressors that can lead to PTSD include sexual violence, combat experience, medical conditions (e.g. myocardial infarction), and natural disasters (e.g. hurricane) (Chivers-Wilson, 2006; Edmondson et. al, 2012; Grieger et al., 2006; Hussain, Weisaeth & Heir, 2011).
It is characterized by:
Direct exposure or witnessing of trauma/stressor
Presence of intrusive symptoms post-traumatic experience
Avoidance of traumatic stimuli
Negative changes in mood and cognition
Hyperarousal (APA, 2013).
Here are a few stats about PTSD:
In 2017, over 47,000 Americans died by suicide (CDC, 2019). This number has been climbing about 1,000 new cases per year from 31,000 American deaths by suicide in 2000 (CDC, 2019). One contributor to this statistic are people with Post-traumatic stress disorder (PTSD), who are at increased risk of suicide (Wilcox, Storr & Breslau, 2009).
The lifetime prevalence of PTSD in the general population of the US was found to be 6.1% in one national epidemiologic study with certain populations at higher risk for PTSD (e.g. female sex, low socioeconomic status, previously married status, experienced trauma at a young age, African Americans, Native Americans, refugees or immigrants from countries with conflicts) (Alegría et al., 2013; Brewin, Andrews & Valentine, 2000; Goldstein et al., 2017; Kisely et al., 2017; Marshall, Schell, Elliott, Berthold & Chun, 2005).
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|Jun 13, 2019|
Schizophrenia Differential Diagnosis & DSM5
Schizophrenia is a diagnosis of exclusion. Doctors and therapists need to be able to rule everything else out before they can land on schizophrenia as an official diagnosis. There are specific symptoms are known as “first-rank symptoms,” which we will cover later in the article, that will help with diagnosing patients (Schneider, 1959). Eighty-five percent of people with schizophrenia endorse these symptoms, but be wary of jumping to conclusions because they are not specific to schizophrenia and, in some studies, are also endorsed by bipolar manic patients (Andreasen, 1991).
DSM5 (Diagnostic and Statistical Manual of Mental Disorders 5th ed.)
Schizophrenia is a clinical diagnosis made through observation of the patient and the patient’s history.
There must be 2 or more of the characteristic symptoms below (Criterion A) with at least one symptom being items 1, 2 or 3. These symptoms must be present for a significant portion of time during a 1 month period (or less, if successfully treated).
The patient must have continuous, persistent signs of disturbance for at least 6 months, which includes the 1 month period of symptoms (or less, if successfully treated) and may include prodromal or residual periods.
For a significant portion of the time since the onset of the disturbance, one or more major areas of functioning such as work, interpersonal relations, or self-care are markedly below the level achieved prior to the onset.
If the onset is in childhood or adolescence, there is failure to achieve expected level of interpersonal, academic, or occupational achievement.
A. Positive symptoms (presence of abnormal behavior)
3. Disorganized speech (eg, frequent derailment or incoherence)
4. Grossly disorganized or catatonic behavior
B. Negative symptoms (absence or disruption of normal behavior)
5. Negative symptoms include affective flattening, alogia, avolition, anhedonia, asociality.
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|Jun 06, 2019|
Do I have Schizophrenia?
Many people worry that they have schizophrenia. I receive messages or inquires often of people asking about symptoms and manifestations. If you have those types of questions, or if you’re a mental health professional who needs to brush up on symptoms and medications, this article should help you.
There are many clinical observations of how schizophrenia presents itself. Cognitive impairments usually precede the onset of the main symptoms, while social and occupational impairments follow those main symptoms.
Here are the main symptoms of schizophrenia:
Hallucinations: a perception of a sensory process in the absence of an external source. They can be auditory, visual, somatic, olfactory, or gustatory reactions.
Most common for men “you are gay”
Most common for women “you are a slut or whore”
Delusions: having a fixed, false belief. They can be bizarre or non-bizarre and their content can often be categorized as grandiose, paranoid, nihilistic, or erotomanic
Erotomania = an uncommon paranoid delusion that is typified by someone having the delusion that another person is infatuated with them.
This is a common symptom, approximately 80% of people with schizophrenia experience delusions.
Often we only see this from their changed behavior, they don’t tell us this directly.
Disorganization: present in both behavior and speech.
Speech disorganization can be described in the following ways:
Tangential speech – The person gets increasingly further off the topic without appropriately answering a question.
Circumstantial speech – The person will eventually answer a question, but in a markedly roundabout manner.
Derailment – The person suddenly switches topic without any logic or segue.
Neologisms – The creation of new, idiosyncratic words.
Word salad – Words are thrown together without any sensible meaning.
Verbigeration – Seemingly meaningless repetition of words, sentences, or associations
To note, the most commonly observed forms of abnormal speech are tangentiality and circumstantiality, while derailment, neologisms, and word salad are considered more severe.
Different processing speeds
Verbal learning and memory issues
Visual learning and memory issues
Reasoning/executive functioning (including attention and working memory) issues
Verbal comprehension problems
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|May 27, 2019|
Schizophrenia in Film and History
In today’s episode of the podcast, Ariana Cunningham and I talk about schizophrenia. Ariana is a psychiatry resident who is also on my research team.
David Puder, M.D., Ariana Cunningham, M.D.
What is schizophrenia?
It is a psychotic disorder that typically results in hallucinations and delusions, leaving a person with impeded daily functioning. The word schizophrenia translates roughly as the "splitting of the mind," and comes from the Greek roots schizein ( "to split") and phren- ( "mind").
The onset of the disease typically occurs in young adulthood; for males, around 21 years of age, for females, around 25 years of age.
We don’t know exactly what causes schizophrenia. There are certain predictors for it, and as I discussed the basics and pharmacology a previous podcast, frequent marijuana use can increase the risk of a psychotic or schizophrenic illness to about 4 times what it would be without THC use.
History of schizophrenia
Sometimes, in ancient literature, it can be difficult to distinguish between the different psychotic disorders, but as far as we know, the oldest available description of an illness resembling schizophrenia is thought to have existed in in the Ebers papyrus from Egypt, around 1550 BC. Throughout history, in groups with religious beliefs, the misunderstanding of the psychopathologies caused people to paint those with mental health disorders as receiving divine punishments. This theme of divine punishment continues today in some parts of the world.
It wasn’t until Emil Kraeplin, a german psychiatrist (1856-1926) that schizophrenia was suggested to be more biological and genetic in origin. In around 1887, Kraeplin differentiated what we call schizophrenia today from other forms of psychosis. At that time he described schizophrenia as dementia of early life.
In 1911, Eugen Bleuler introduced schizophrenia as a word in a lecture at a psychiatric conference in Berlin (Kuhn, 2004). Bleuler also identified the positive and negative symptoms of schizophrenia which we use today.
Kurt Schneider, a german psychiatrist, coined the difference between endogenous depression and reactive depression. He also improved the diagnosis of schizophrenia by creating a list of psychotic symptoms typical in schizophrenia that were termed “first rank symptoms.”
His list was:
Sigmund Freud furthered the research, believing that psychiatric illnesses may result from unconscious conflicts originating in childhood. His work eventually affected how the psychiatric world and society generally viewed the disease.
The history and lack of understanding of the disease is a dark history, and it is still deeply stigmatized, but psychiatry has made massive leaps in understanding schizophrenia and changing how it is viewed in modern society.
Nazi germany, the United States, and other Scandinavian countries (Allen, 1997) used to sterilize individuals with schizophrenia. In the Action T4 program in Nazi Germany, there was involuntary euthanasia of the mentally unwell, including people with schizophrenia. The euthanasia started in 1939, and officially discontinued in 1941 but didn’t actual stop until military defeat of Nazi Germany in 1945 (Lifton, 1988). Dr. Karl Brandt and the chancellery chief Philipp Bouhler expanded the authority for doctors so they could grant anyone considered incurable a mercy killing. In reading about this event, it seems that This caused approximately 200,000 deaths.
In the 1970’s, psychiatrists Robins and Guze introduced new criteria for deciding on the validity of a diagnostic category (Kendell, 2003). By the 1980’s, so much was understood about the disease that the DSM (Diagnostic and Statistical Manual of Mental Disorders) was revised. Now, schizophrenia is ranked by World Health Organization as one of the top 10 illnesses contributing to global burden of disease (Murray, 1996).
Unfortunately, it is still largely stigmatized, leading to an increased schizophrenia in the homeless population, some estimates showing up to 20% vs the less than 1% incidence in the US average population.
On the podcast episode, we discuss the media’s portrayal of schizophrenia. Although media paints mentally ill as often violent, on average people with mental illness only cause 5% of violent episodes. This is just one example of how the stigma is furthered.
The more we understand about this disorder—what causes it, how we can help, how we can provide therapy and medicate and treat patients—the better. Getting rid of the stigma by learning the history and also moving beyond preconceived ideas to the newest science will also help de-isolate people with schizophrenia and help support them in communities, giving them a chance at a normal, healthy life.
|May 16, 2019|
Marijuana and Mental Health
On today’s episode of of the podcast, I will discuss marijuana use and how it affects mental health with Daniel Binus, the chief psychiatrist at Beautiful Minds, near Sacramento, California. Also joining us is a third-year medical student, Victoria Agee.
Why are we even talking about marijuana?
There are a few reasons we believe this is important to talk about. First, as medical professionals, we often see patients who want help with their anxiety, depression, ADD and suicidality. They say they use cannabis, and that they need cannabis, to help calm those symptoms. When we explain the research to them, it still takes them awhile to let go of their habits and embrace other forms of therapy and medication that is a better long-term option.
Also, we head into a time when marijuana is being legalized, there are tons of THC companies that will benefit from suppressing this information and even suppress these studies we will reference here. Hiding this information could be detrimental to society’s mental health. While there are some potential benefits to one component of marijuana (CBD), something I will review in the future (evidence is fairly young in that field), the THC component can be highly damaging to mental health.
Whether or not people are willing to admit it, cannabis is actually highly addictive. One of the symptoms of addiction is intellectualizing reasons for use. Not only does it change the way the brain functions, it changes the way we see and perceive the world. It also changes our visual and spatial abilities. If you’re an architect or use math in your job, it deeply affects those abilities as well. THC stays in your brain a long time—it can be weeks (or even a month) before people get the full function of their brain back and the fog has cleared.
What is the research on cannabis?
Ganja is from the cut tops of leaves (5-8% THC content) and hashish is from the resin and is therefore more potent (10-20% THC content) Delta-9-tetrahydrocannabinol (THC) is the most commonly used substance worldwide.
It causes long-term changes in the brain
Recent research shows that consistent cannabis use will change the way your DNA is expressed in the brain. It will upregulate and downregulate proteins in the brain, and can change the morphology of the way it works. Marijuana, in fact, leads to changes in our genes over time, called epigenetic changes. So the initial effect may be pleasure or fun, but long term, it can create changes that take months to develop in a way that people don’t understand why they are having new issues that pop up. Basically, it’s not changing your gene structure, but it is changing the expression of those genes. Anytime you make positive food choices or develop a consistent exercise routine or make physical changes, epigenetic changes occur that are healthy for long term change (see my episode on diet and exercise)
It’s not surprising that marijuana also causes similar changes in the brain, but not in a healthy way.
When people use cannabis heavily, it causes our endogenous cannabinoids that naturally occur within the body to shift, which can create a disruption in our natural release of cannabinoids. This actually creates a direct correlation between heavy cannabis use and lower IQs.
It lowers intelligence
Studies show that over 20 year cannabis use, people lose an average of 6-8 IQ points. That means you could go from intelligent to average, or even average to below average.
It affects men’s sexual health
In a survey of 8,650 people, women had no association with any of the sexual problems from marijuana use. Men, however, had significant associations between daily cannabis use and reporting an inability to reach orgasm (OR 3.94), reaching orgasm too quickly (OR 2.68), and reaching orgasm too slowly (OR. 2.05).
Among the 424 men who reported reaching orgasm too quickly, there was an association between frequency of cannabis use and the extent to which reaching orgasm too quickly was experienced as problematic (F- 2.85, P <0.01) (Smith, 2010)
Routine usage of cannabis (more than once per week) was also associated with a nearly 30% reduction in median sperm concentration and total sperm count after adjustment (Gunderson, 2015).
It increases risk for psychotic disorders
Multiple studies have shown a link between marijuana use and psychotic effects that demonstrate that it is definitely causal in contributing to psychotic disorders.
A meta-analysis of 66,000 individuals showed that heavy cannabis and average cannabis users were 4x and 2x, respectively, as likely to develop schizophrenia or other psychosis-related symptoms compared to nonusers.
In a study that came out this year (2019), young adults who used cannabis were about 1.5x more likely to develop depression and suicidal ideation and 3.5x more likely to attempt suicide.
It has negative effects at any age
Cannabis exposure during gestational development has a direct correlation to drug-seeking behavior later in life. Early life cannabis exposure (adolescents) upregulates expression of Penk mRNA, an opioid neuropeptide in mesocorticolimbic system, which has direct causal link to enhanced behavioral susceptibility to heroin use as an adult.
Studies also show that in teens, even a few uses of marijuana makes them predisposed to depression, psychotic disorders and suicidal ideation.
It causes impaired social functioning
It increases the amount of impulsivity and hostility in daily life. It increased hostile behaviors and also paranoia of others being hostile. It also deadens the ability to detect microexpressions and create social connection so that it may remove appear to improve social anxiety. However, it's not an actual solution, because it prevents someone from presenting their real self.
It doesn’t help pain relief
The pain relief effect for people was found to be minimal. And in the long run, studies show that it didn’t help physical pain or decrease the use of opioids.
How to help a patient who uses cannabis
Cannabis can potentially help the symptoms of anxiety, ADD, depression, and a whole host of mental health issues initially. The problem is that cannabis fundamentally changes the brain in a way that causes long-term damage. Not only that, but if people are using cannabis as a coping mechanism for their mental health issues instead of therapy, they will not deal with the underlying issues, only medicate the symptoms.
When a new patient comes in and reports regular marijuana use, I highly recommend for them to get off of it, for at least the course of therapy. However, it also is important to mention that the first stance to take with every patient is empathy. I tell them there is no shame in their marijuana use. I liken it to them using a log when they’re in an ocean—it helped them keep their head above water because it floated. But when a rescue boat comes along, if they try to heft the log into the boat, it won’t work. With proper therapy, with the boat, they won’t need the log for survival any longer.
I even tell them they can get back on it after the therapy if it hasn’t helped them. When they are off of marijuana, they have the ability to be present and really process what they will need to process in therapy in order to get over anxiety and depression.
When they do take the symptom suppressor of marijuana away, often they will experience a flood of emotions and memories. Maybe cannabis was the best thing our patients could find in the moment, but there are obviously better ways of helping them deal with their pain.
I have a very extensive worksheet of all of the research about cannabis in my Free Resources Page. It’s important to understand the depth of the ways THC can affect our patients lives and mental health.
Download Free Marijuana Research Sheet
|May 02, 2019|
How to Help Patients With Sexual Abuse
On today’s episode of the podcast, I interview Ginger Simonton, a PhD student finishing her dissertation. We will cover her in-depth research on alleviating the symptomology of childhood sexual abuse.
We will specifically be talking about the link between women who have been sexually abused, never given a chance to heal, and how it has affected their mental and physical health, and programs that can benefit them.
What is childhood sexual abuse?
“The CDC defines the act of CSA as “inducing or coercing a child to engage in sexual acts” that include “fondling, penetration, and exposing a child to other sexual activities” (2017).”
How does it affect health?
Statistics show that 20-40% of survivors have no negative effects later in life. This is dependent on the response of caregivers. If someone was supported, protected, validated and responded to in a therapeutic way, the child has a higher chance of resiliency, which occurs through secure attachment. If the child has secure attachment, they can usually move forward with their lives.
What Simonton’s study shows is that women who were silenced, shamed or not given a voice to resolve those childhood sexual trauma issues have more mental and physical health issues than normal. If a woman was in a multi-dimensionally unstable family—drug use, no structural stability, alcoholism, revictimization—they are less likely to have resiliency.
Bodily representations of chronic stress:
Women who experienced childhood sexual abuse that was never recognized by a loving caregiver demonstrate biopsychosocial health problems both in childhood and later on in life. Sexual abuse causes intensive stress, and there are many subsequent health issues that stem from it.
What we see is the body begin to break down in the face of cortisol and other stress-related hormones that are released over years of unresolved trauma. One of the first indicators that drives them to seek medical help is usually a physical ailment. Often the patient experiences a few health issues, and ends up medicating the physical things, but the underlying cause is never treated.
These show up in many different ways, but there are some predominant issues such as:
If your patient does have a chronic illness, that does not mean they have experienced childhood sexual trauma. However, if they are retaining stress from childhood sexual abuse, they are more likely to develop comorbid mental and physical health issues later on.
Helping patients who have experienced sexual abuse
Because we are meaning-making creatures, we assign values to situations in our lives. If something good happens, we assign positive meanings to it—we are good people, we are highly valued, we are loved, etc. If something bad happens, we assign meaning to it—we are gross, we are worthless, we are disgusting. As we internalize these beliefs, we begin to act according to those meanings in ways that further damage our bodies and minds.
So how do we help our patients revisit the meaning they’ve assigned to these traumatic experiences? Simonton’s research shows different programs and therapies that can help patients cope with the trauma and relief their symptomology.
Ask them their story
It’s important for a patient to feel they are revealing their story slowly and gradually if that’s what makes them most comfortable. Simply asking for them to tell their story, then helping them unpack the information if they mention sexual abuse, is the best way to go about it.
|Apr 18, 2019|
The science behind forgiveness and how it affects our mental health
What is forgiveness?
On this week’s episode of the podcast, I talk about the power of forgiveness. It’s scientifically proven that forgiveness can affect our health. As mental health professionals, this has important impacts both personally and professionally. I have also included a downloadable PDF for you to give your patients to help you walk them through the act of forgiving.
As a therapist, when I say the word “forgiveness,” my patients can shut down if I don’t explain it properly. Why? Because just the need for forgiveness is proof that they have been wronged. When we are wronged, it can be hard to let go of that hurt. That’s why I wanted to start out by saying what forgiveness (and this episode) is not about.
Forgiveness is not:
So what is forgiveness?
The Definition of Forgiveness:
Forgiveness is a process. It involves allowing yourself to feel the negative emotions you justly have towards an offense, and really putting the wrong into words in a congruent and authentic truthful way. Then choosing to release it, either giving it to a higher power, or letting it go to a cosmic sense of justice, or earthly legal justice system, and then continuing the process until negative affect is replaced with peace, empathy and compassion. When someone forgives they no longer have a portion of their daily life consumed in negative feelings towards the person or situation.
“People, on rationally determining that they have been unfairly treated, forgive when they willfully abandon resentment and related responses (to which they have a right) and endeavor to respond to the wrongdoer based on the moral principle of beneficence, which may include compassion, unconditional worth, generosity, and moral love (to which the wrongdoer, by nature of the harmful act or acts, has no right)” (Enright, 2015).
Elliot (2010) cited Enright and Fitzgibbons (2000) and came up with two types of forgiveness:
Decisional forgiveness: the experience of granting forgiveness without eliminating the emotion, but in this, resentment may continue. It involves a cognitive model where therapist works with the client one time to make decision to forgive.
Emotional forgiveness: the patient must demonstrate changes in emotion and motivation toward their offender.
Studies show that:
Decisional forgiveness can reduce hostility, but it is only marginally effective in improving stress levels or emotional health (Elliot 2010 citing Baskin and Enright 2004, Worthington 2007). This means that emotional forgiveness is the goal of all forgiveness therapy.
What’s the most effective way to help our patients forgive?
Individual therapy that accomplishes Enright’s 4 phases over 20 encounters is “clearly most effective” way to actually accomplish forgiveness. (Elliot 2010 citing Lundahl 2008)
Why should we care about forgiveness?
Forgiveness isn’t a “nice thing to do,” it has real health ramifications that have been thoroughly studied, and it’s a fact that the act of forgiving can be a real change agent in therapy and long term health.
Here are the studies:
Specifically, in chronic low back pain, a preliminary study of 61 adult patients with chronic low back pain (31 recruited from pain and palliative clinic, and 30 recruited from community) showed patients with higher scores on forgiveness-related variables (‘current level of forgiveness’ as measured by Enright Forgiveness Inventory and ‘forgiveness self efficacy’ as measured by the Forgiveness Self-Efficacy Scale) reported lower levels of pain, anger, and psychological distress.
Patients who scored (Carson 2005) analysis revealed that “state anger largely mediated associations between forgiveness variables and sensory pain, whereas the association between current forgiveness and affective pain was mostly independent of state anger.”
What is bitterness?
When someone continues to hold on to unforgiveness, they can become what we would call “bitter.” Bitter people are exactly like that word describes—so steeped in resentment that they become unpalatable.
Clues that someone may be bitter:
* Recurrent resentment affects all relationships and takes up room in one’s emotional life.
What does research say about bitterness?
How can someone forgive?
If the previous studies about the negative effects of not forgiving aren’t enough, let’s look at some of the positive effects of forgiving.
Personal health results of forgiving:
Some patients highly value their higher power. You can ask them to turn to their spiritual power and ask for the grace to have the willingness to forgive. They can give the spiritual power the opportunity to work in their lives in that way. Some have had powerful forgiveness experiences with their higher power.
Steps in the process of forgiveness:
How can we help our patients forgive those who have wronged them? Sometimes our patients have experienced things that can hurt to even hear about. Helping them move from trauma and anger into a place of forgiveness so they can live a healthy emotional life can be difficult to navigate. But, it is a worthy journey to pursue.
Here are the steps I walk through with my patients using a workbook sheets I have created. I have included a FREE DOWNLOADABLE PDF below that you can give to your patients to fill out. It walks them through the steps in detail, giving them a drawing to fill out and journaling exercises with specific questions to answer that will help them process their trauma and grief.Download Free Patient Worksheet
Further Reading on Forgiveness:
“Forgiveness is a Choice” Enright
Bradley, L. A., McKendree-Smith, N. L., Alberts, K. R., Alarcón, G. S., Mountz, J. M., & Deutsch, G. (2000). Use of neuroimaging to understand abnormal pain sensitivity in fibromyalgia. Current Rheumatology Reports, 2, 141–148.
Brand BL, Alexander PC. “Coping with incest: the relationship between recollections of childhood coping and adult functioning in female survivors of incest.” J Trauma Stress. (2003):185–93.
Enright, R. D. Forgiveness is a choice. (2001) Washington, DC: American Psychological Association.
Fernandez, Ephrem, and Dennis C. Turk. "The Scope and Significance of Anger in the Experience of Chronic Pain." Pain (1995) 61(2):165-75.
Greenwood K, Thurston R, Rumble R, Waters S, Keefe F. Anger and persistent pain: Current status and future directions. Pain. (2003);103:1–5.
Knight JR, Hugenberger GP. On Forgiveness. Southern Medical Journal. (2007). 100(4):420-421.
Larsen BA, Darby RS, Harris CR, Nelkin DK, Milam PE, Christenfeld NJ. The immediate and delayed cardiovascular benefits of forgiving. Psychosom Med. (2012) Sep;74(7):745-50.
Lawler, K. A., Jarred W. Y., Rachel L. Piferi, Rebecca L. Jobe, Kimberley A. E, and Warren H. J. The Unique Effects of Forgiveness on Health: An Exploration of Pathways. J Behav Med Journal of Behavioral Medicine (2005). 28(2): 157-67. Web.
Lee YR, Enright RD. “A Forgiveness Intervention for Women With Fibromyalgia Who Were Abused in Childhood: A Pilot Study.” Sprituality in Clinical Practice. (2014). 1(3):203–217
Lichtenfeld S, Buechner VL, Maier MA, Fernandez-Capo M. Forgive and Forget: Differences between Decisional and Emotional Forgiveness.PLoS One. (2015) May 6;10(5):e0125561.
Moons, Wesley G., Naomi I. Eisenberger, and Shelley E. Taylor. "Anger and Fear Responses to Stress Have Different Biological Profiles." Brain, Behavior, and Immunity (2010) 24(2):215-19.
Muscatello MR, Bruno A, Scimeca G, Pandolfo G, Zoccali RA. “Role of negative affects in pathophysiology and clinical expression of irritable bowel syndrome.” World J Gastroenterol.2014;20:7570–7586.
Okifuji A, Turk DC, Curran SL. Anger in chronic pain: investigations of anger targets and intensity. J Psychosom Res. 1999;47(1):1–12.
Reed GL, Enright RD. The Effects of Forgiveness Therapy on Depression, Anxiety, and Posttraumatic Stress for Women After Spousal Emotional Abuse. Journal of Consulting and Clinical Psychology. (2006). 74(5):920 –929.
Schmidt S, Grossman P, Schwarzer B, Jena S, Naumann J, Walach H. “Treating fibromyalgia with mindfulness-based stress reduction: results from a 3-armed randomized controlled trial.” Pain. (2011).152(2):361–9.
Strang S., Utikal V., Fischbacher U., Weber B., Falk A. “Neural correlates of receiving an apology and active forgiveness: an fMRI study.” PLoS ONE. 9:e87654 (2014). 10.137.
White, JM. “Pleasure Into Pain: The consequences of long-term opioid use.” Addictive Behaviors. (2004). 29:(1311-1324).
Winfield JB. Psychological determinants of fibromyalgia and related syndromes. Curr Rev Pain. 2000. 4(4):276-86.
Witvliet CVO, Phipps KA, Feldman ME. Beckham JC. “Posttraumatic mental and physical health correlates of forgiveness and religious coping in military veterans.” J. Trauma Stress. (2004) 17:269–273.
|Apr 11, 2019|
What is Transference and Countertransference?
On this week’s episode of the podcast, I talk about transference and countertransference. It’s the fourth episode in my four-part therapeutic alliance series where I discuss best practices on dealing with the doctor - patient relationship.
Here are the three previous episodes:
What is transference?
Historically the term “transference” refers to the feelings, fantasies, beliefs, assumptions and experiences unconsciously displaced on the therapist that originate in the patients’ past relationships. More recently, transference is seen as the here and now, valid experience the patient has of the therapist.
It is “a mixture of real characteristics of the therapist and aspects of the patient’s figures from the past—in effect, it’s a combination of old and new relationships.” (Gabbard)
How does transference work?
The patient’s early experiences develop organizing principles, constructing a framework for future interpersonal interactions. (Maybe their dad was an abuser, so they project that you will abuse them.) Transference is the continuing influence of these ways of organizing and giving meaning to experiences. They crystallized in the past, but they continue in an ongoing way in the here and now. The therapist’s actual behavior is always influencing the patient’s experience of the therapist because of this.
When a patient visits a therapist, they seek a new developmentally needed experience, but they expect the old, repetitive experience.
There is often misattunement to painful circumstances that can't be integrated into a person’s emotional world. For example—a child who can’t demonstrate his emotion in a way that his parents can handle causes the parents to move away from the child, creating distance. The child then subdues the emotion and creates a new “ideal self” so they can interact with others and no be rejected. The child then doesn’t know how to deal with strong emotion, even moving into adulthood.
Unintegrated affects become lifelong emotional conflicts and vulnerabilities to traumatic states. To handle the difficult situation, they develop defense mechanisms. Those defenses against affects become necessary to maintain psychological organization.
That “ideal self” will stay in place with others until you come along. If they see you as a safe person, they will express their emotions—anger and all—towards you.
When we understand transference is happening, we can listen from the patient's world, acknowledge their subjective perspective, resonate with them, look for their meanings, and form and alliance with the patient's expressed experience.
Of course we must expect their hesitations to trust us, avoid us, have feelings of shame, guilt, and embarrassment...it is uncomfortable to share what one feels.
Negative transference isn’t the only type of transference—there is also positive transference, where you remind the patient of a positive relationship they had, so they feel deeply connected to you. People with borderline personality disorder are very quick to attach, usually commenting that they have never felt so close to a therapist before. When someone does say very positive things to me, especially in the first few sessions, I let them know that it’s also okay to express negative feelings towards me as well.
Kernberg wrote about transference focused psychotherapy. He hypothesized about the developmental birth of borderline personality disorder. By exploring and integrating these “split-off” cognitive-affective units of self and other representations, patients will be able to think more coherently and reflectively. They will be more realistic and accurate in their thoughts, feelings, intentions and desires about themselves and others. Integration will allow for increased modulation of affect, coherence of identity, increased capacity for intimacy, and improved functioning (Kernberg 2008).
Levy (2006) studied transference focused psychotherapy (TFP) vs dialectical behavior therapy (DBT) vs supportive psychodynamic psychotherapy for borderline personality disorder. He found that TFP had increased secure attachments (whereas the other 2 did not change it), with increased narrative coherence. It also improved reflective function—the ability to mentalize the thoughts, feelings, goals of another person.
What are some common transferences?
How do deal with transference in therapy:
Here is the main, overarching principle when dealing with transference: have empathy. Be empathic. Be open to their feedback. Don’t take things personally. Be connected with your patient. Developing a therapeutic alliance requires you being connected, and being connected requires you to allow your patient to explore their emotional world with you. That requires psychological safety.
When you are a safe place, they will hopefully be able to connect, and you can help them identify their transferences so they have a chance at developing healthy relationships in the future without bringing their past with them.
If my patient had a previous therapist, I always ask them, “What went well and what did not go well in your past therapy relationship?”
Other questions I ask are:
When I can tell they don’t want to come to therapy. I normalize their feelings so they feel like they can share with me.
When you sense an empathic strain, mending it is priority number 1. I might say, “Help me understand what I might not have understood here.” Or, “If I said something that makes you feel worse about yourself then let’s talk about it now.” Try to prevent an empathic strain from progressing to an empathic rupture in your relationship by catching the strains early on.
Here are a few tips to handle when patients exhibit strong emotions towards you:
When we are young, we are unable to metabolize emotions correctly, especially in the face of trauma or an unsafe caregiver. When we age, we transfer those patterns of belief onto every other relationship in our life, trying to recreate that. When you, as a therapist, offer a safe environment for a patient to experience those strong emotions, you are helping them rewire their belief system around those emotions. It allows them to interact with every other person in a new way.
The original and narrower definition of countertransference centered around the therapist unconsciously experiencing the patient as someone from their past (similar to transference). Now, countertransference is seen as the therapists’ total reaction to the patient.
First, it’s important to note that therapists need to practice what they preach: do the work in your own therapy so you can identify your own transferences. The less clouded your vision is of what’s happening in sessions, the better. For example, one therapist saw nearly every patient as a trauma victim, and occasionally led them to believe they’d been traumatized as well in the same way.
Countertransference is seen as a source of important information about the patient: it can be a major diagnostic and therapeutic tool. “Countertransference is an instrument of research into the patient’s unconscious.” (Paula Heimann)
Now it is seen as a jointly created reaction in the clinician (some reactions from the therapist's past, some induced by the client's behavior).
There are continuously fluctuating levels of influencing the transference and countertransference by contributions from both patient and therapist during all their interactions. My mentor, Dr. Tarr, said, "To every relationship we bring learned expectations from past encounters.”
One way to handle countertransference to make sure you are coming from a healthy place is to use your left brain to integrate with, and therefore dampen, the right brain. Learn from what you are feeling during the session, but observe yourself with curiosity.
Another form of possible transference is sexual attraction towards a patient. Studies show that 85% of male therapists at some point have erotic arousal towards a female patients. Obviously, it is important to not act on or tell your patient about those feelings.
You should also allow yourself to mirror the patient’s emotions, as to follow the patient’s emotional movements and unconscious content.
Before a patient enters the room, check in with yourself. How are you feeling? What are you feeling?
Here is a checklist I like to use before my sessions with patients. It is based on 7 basic emotions:
It is completely normal to have feelings—both good and bad—towards patients. We are humans, not robots! Sometimes it might seem like you’re supposed to be perfect or void of feelings towards your patient, but that doesn’t allow a living, growing, healthy therapeutic alliance towards them. The important thing is to notice how you feel, without self judgement. Then, deal with those feelings in a healthy manner, like through seeking out your own therapy, getting a mentor, etc. However, sometimes merely allowing yourself to notice the feelings and owning up to the feeling of anger, attraction, boredom, or sadness, is enough to dissipate it.
It’s easy to be busy after a session. It’s better to practice noting your feelings. After all, how can we help our patients express and normalize their feelings if we cannot do it for ourselves?
If you are a mental health professional, I would love for this to be your community. We are in these trenches together, and it’s pretty common for therapists to feel totally exhausted and burned out from all of the countertransference. I hope that through this community, we can develop better practices, help each other, and grow together.
If any of you have any questions or listen to the podcast, I’m active on social media. I’d welcome any feedback you have. My social handles are: Instagram @Dr.DavidPuder, Facebook: @DrDavidPuder, or Twitter @DavidPuder
|Apr 01, 2019|
Reducing Inpatient Violence in a Psychiatric Hospital
Violent aggression in the inpatient psychiatric setting has developed into an important issue that negatively affects patients and staff. There are some simple and surprising treatments different clinics are taking to prevent violent aggression. It’s time we paid attention to this issue so we can prevent injury of both patients and hospital staff.
|Mar 07, 2019|
Depression and Anxiety in Geriatric Patients
On this week’s episode of the podcast, I am joined by Dr. Carolina Osorio, a geriatric psychiatrist (and one of my favorite people). After she finished her psychiatry residency, she also went on to finish a fellowship in geriatric psychiatry to take care of her favorite people. Dr. Osorio runs a special program that treats elderly people with depression and anxiety.
Mental health in the elderly
Sylvia Yu (MS3), David Puder, M.D.
As many people age, their health declines, and their needs increase. At the same time, we can experience loss of spouses because of aging, loss of friends and fear of death. We can lose eyesight, hearing, and subsequently, our drivers licenses and autonomy. It can be an incredibly stressful and lonely time.
At this time in history, like no other time before, we are experiencing a wave of baby boomers that will put a new strain on our already waning mental health facilities. Baby boomers are also more likely to stigmatize using mental health services.
Dr. Osario noticed these problems and she took steps to create a program that is helping her local aging population in a way that makes them feel comfortable.
If you are a primary care physician, psychiatrist, or a family member that is a caretaker for the elderly, this article will have takeaways from Dr. Osorio’s program that can help clarify how we can best help the aging population.
When Dr. Osorio was a resident, she noticed that in mixed-age groups, older adults didn’t get the treatment that they needed. A general outpatient partial program wasn’t benefiting them, and sometimes it would make them worse because older adults tend to become parents to their younger peers in their group. She noticed that the older adults ended up taking care of their younger counterparts and not getting the individualized help they needed.
She started building a program to help the elderly in the way that they needed to be helped—through diet, exercise, therapy, medication management and stress reduction.
Medically, older adults have comorbidities, or more than one medical issue that needs to be treated. Because of this, having a geriatric therapist, group therapy session, or a geriatric mental health program can keep them happier, healthier and independent for longer.
If you run an outpatient group for the elderly, if you’re suggesting one for your patient, or if you are looking for one for an elderly friend or relative, here are a few things to consider:
Medications for aging adults
Unfortunately, many elderly patients are prescribed benzodiazepines—drugs used to treat anxiety. Many primary care doctors have busy schedules with short appointment times. When the patient has hypertension, diabetes and osteoporosis, mental health can take a back seat to managing the more urgent health issues. The primary care doctor will usually just prescribe a benzodiazepine to deal with the anxiety issues.
There are several problems with giving benzodiazepines to the elderly. With time, the body gets used to the benzodiazepine, and the doctor starts to increase the dose. Then, the patient typically becomes even more depressed, more lethargic. This, in turn, increases other health issues.
That is why special consideration should be given when prescribing “benzos” to the elderly. It is also why Dr. Osorio’s goal in her outpatient program is to taper them off of their benzodiazepine medications. She says many of the patients she sees have been on them for 20-30 years.
Tapering a patient off of a benzo should be done very, very slowly in order to avoid delirium or worsening of anxiety.
For example, if the patient is on 4mg of Xanax a day, Dr. Osario will convert them to Klonopin. Because of the half-life of the medication, the patient will have fewer symptoms of withdrawal when they start coming off of it. Then, she would reduce the dosage to 3mg of Klonopin over the next six months to a year.
As we age, our brain changes and there are parts of the brain that are going to have synapses that decrease. Acetylcholine actually decreases with age. But, if you add a medication that is anticholinergic, you are putting a bigger burden into that normal process. Then, there can be bad side effects such as confusion and dementia.
Because of that, Dr. Osorio says she will typically taper off or replace any medication with an anticholinergic burden. For example, the antidepressant Paroxetine is a no-go drug in the elderly population because it is very anticholinergic. The tricyclic antidepressants are also very anticholinergic. Nortriptyline, however, is one that Dr. Osorio would prescribe because it has much less of the anticholinergic burden at lower doses.
(I will put a list up on my website in my resource library of the different medications that are anticholinergic. Along with “Beers list,” medications that are contraindicated in older adults.)
Physicians don't often think about lithium. Lithium is brain-protective (Forlenza, 2014). It has many functions that are very healthy and it actually produces neurogenesis in some patients. Consider, if you have a patient on an SSRI that isn’t responding how you’d like, adding a tiny dose of lithium (usually about 150-300mg).
Medication management for the elderly
Psychiatrists must work very closely with the patient’s primary care doctors. There are primary care doctors who also have a fellowship in geriatrics, but most do not have the specialized training needed to maximize mental health and minimize side effects. Sometimes it is helpful to have a conversation on behalf of the patient and guide them in certain medications. Every doctor should think about the whole body in general, and working with a primary care doctor can help psychiatrists do that.
A lot of older adults start feeling better when you start decreasing their meds. This indicates they were just depressed and did not have Major Depressive Disorder that required a heavy load of medications to manage it. It also shows that the depression was a side effect of medications. That, really, is the first thing you want to think about when you have a new patient and you see a very large list of medications that they are taking—are the symptoms because of the medication or is the medication helping alleviate symptoms? Should they be taking every single medication on the list?
There are a couple of studies that have talked about serotonin in older, depressed patients and how that can delay the progression of mild cognitive impairment of Alzheimer’s (Smith, 2017). One study showed that SSRIs are the best medications for it—Wellbutrin, SNRIs, tricyclics. There is actually another study done with older adults who had mild cognitive impairment and a history of depression (Bartels, 2018). Those who were taking SSRIs delayed progression of mild cognitive impairment by three years. But, in those patients who were put on another type of antidepressant, the progression was faster.
However, it is important to note that putting an elderly patient on an SSRI does not deal with the root of the issue. Therapy in conjunction with medication has been shown to be more powerful and sometimes eliminate the need for medication. If the patient is lonely, eating poorly, and has no life activities to look forward to, changing those factors can decrease the need for medication. Always consider therapy in addition to any psychiatric medication.
No matter what you prescribe, the patients have to take the medication for it to be helpful. Make sure to write down the medication, dosage, and times in clear language. Help the elderly patient understand what to take and when. When necessary, get helpful family members involved to remind the patient as well.
Therapy for the elderly
Another component of aging healthfully is receiving therapy. The cognitive load of aging alone, including the sum total of traumatic experiences, is often enough to require therapy to help with life transitions.
There are many forms of therapy available that can help the elderly experience a fuller life, deal with trauma safely, manage their depression and anxiety, and even stay mentally sharper for longer.
Problem solving therapy for the elderly
Problem-solving therapy is a way of teaching the elderly how to find ways to solve the particular problems that are unique to them. These problems cause anxiety and depression, so teaching them how to think about them, how to solve problems themselves, can give them a sense of autonomy and control. Sometimes, in therapy, you cannot solve the actual problem, per se, but the process of working through it together gives them different options that they can utilize if their anxiety starts to spike when they are alone.
For example, one elderly lady Dr. Osorio works with struggles with terrible anxiety. She recently broke her arm. She couldn’t clean her home, and her family would come over to help. She felt like a burden to them and was very anxious about this. During problem solving therapy, they made a list of all of the things that needed to be done around the house, and then they marked the three things she could do, even with her broken arm, to help. She felt better knowing she could help her family while they were helping her. Even though we couldn’t fix the problem, we made it manageable, and gave her some autonomy back.
Reminiscence therapy for the elderly
In reminiscence therapy, you focus on reminiscing about good things. For example, Dr. Osorio will bring her elderly patients a picture of a turkey. She will ask them what it reminds them of. Everyone starts talking about Thanksgiving with their families. They discuss memories, smells, and they walk through the senses of what it was like for them at a happy time. This alone starts to fire up positive emotions in their brains and can change their moods instantly.
The cool thing about reminiscence therapy is that it even works with patients who have dementia, because their long-term memory is pretty solid. They can dip into their past and they immediately start brightening up. Their whole countenance changes.
It is a simple therapy to use, and it can be very helpful when dealing with depressed patients. They often feel alone, but when they begin to talk about the good times and share memories, it connects them to others in their group, and helps them make positive social connections.
Cognitive behavioral therapy for the elderly
There are also behavioral activations we can implement to help the elderly. The elderly patient typically has a hard time with scheduling routines. As their therapist, it can be helpful to get them to schedule a solid routine they can stick with because we have to break the cycle of depression and anxiety. For example, if you're depressed, you want to be in bed, you stay in bed, you get more depressed. This is damaging to an elderly person because it is much harder to get them to start scheduling and moving around again once they slow down. Activating their schedule can be a first step in keeping them independent for longer.
For elderly cognitive behavioral therapy, first, we do education on this process and then start helping them find ways in which they can break that lethargic routine. We want to help them choose an activity that they want to do so that it’s easier to break that cycle. Maybe that is going every Sunday to visit their grandkids. Maybe they can join a card game club, join a church, a quilting group, a storytelling group or take a community educational class. That one simple thing can break their cycle of depression, ease loneliness, and keep them engaged for longer.
Aging and brain health
The evidence for maintaining brain health while aging says there are several things we can do to stay healthy: physical activity, socialization, nutrition and stress management.
Dr. Osorio’s favorite exercise to recommend for the elderly is tai chi. Tai chi decreases the risks of falls in older adults (Lomas-Vega, 2017). There are even insurances that are starting to pay for tai chi for older adults because it is cheaper than fixing a broken hip. It’s a very easy, very smooth exercise.
For the wheelchair-bound, she recommends chair exercises. A physical therapist can help the patient move their arms, their torso, their necks. Maybe some of them can lift their legs from the knee up. Even if they can’t, they can still get a good exercise in and get some positive movement going.
When the elderly patient is doing really well in exercise they can start to add weights. Weights are very important because when they use weights their muscles are contracting and they’re positively impacting those bones. This is a good way to decrease osteoporosis. Even with the elderly, muscles can get stronger and their strength can increase. Studies even show that exercise in the elderly pretty much halts the dementia progression.
Socialization is also very important. One study showed that the higher risk factor for morbidity and mortality was related to isolation (Holt-Lunstad, 2015). Isolation is actually toxic for our brains. If someone is home alone, they will usually die faster.
Being with friends and family and maintaining a social life helps the brain because it uses visuospatial skills, social skills and cognition. A simple conversation, a regular visit with a loved one or a new person can help an elderly person maintain positive brain health.
Human connection is necessary throughout all of life, and to have close, connected friends makes a huge difference. As part of her program, Dr. Osorio notices if they're having issues making friends, and she helps them create some behavioral activation to get them to places where there is a potential of making friends.
As far as nutrition goes, we have to take into account that the elderly population is pretty diverse. There are 60 year olds who are very fragile because of many health problems and there are 90 year olds who are pretty healthy.
Dr. Osorio personally recommends the Mediterranean diet. The Mediterranean diet is a diet that consists of grains, fish, olive oil, avocado, fruits and vegetables. The Mediterranean diet offers omega-3 fatty acids in the fish, high poly and monounsaturated fats in the olive oil and in the nuts. There is also a lower amount of sugar then the average American diet. If elderly patients are struggling with making the big change in their diets, it’s best to merely suggest they don’t consume processed foods.
The Mediterranean diet has been associated with a reduced risk of developing mild cognitive impairment (MCI) or progressing to Alzheimer disease from MCI (Scarmeas, 2009). This year it was the number one diet recommended by the medical field.
Stress reduction also adds to positive brain health. Mindfulness and visualization are both helpful practices to reduce stress. Stress reduction is not a one-time fix all. It is something that has to be practiced every single day in order to work.
Ask the patient to download a meditation app if they are technologically savvy, or even join a meditation group for seniors to increase their socialization. If neither of those works, getting them to quietly rest and close their eyes for even five minutes with the intention of relaxing, not just to nap or sleep, can have positive benefits.
If you work with the elderly, or know someone who is elderly, if they struggle with mental health issues such as anxiety and depression, or have comorbidity with other health issues, consider suggesting an outpatient group therapy for the elderly. It can be extremely helpful when paired with nutrition, exercise, and a cohesive plan with their primary care physician.
Other episodes I HIGHLY recommend if you are interested in treating elderly people:
Questions, comments, thoughts? Please comment on the picture that corresponds to this post on my instagram: @Dr.DavidPuder
|Feb 28, 2019|
The Dark Triad (Psychopathy, Narcissism, Machiavellianism), sexually violent predators, Ted Bundy, and porn.
On this week’s episode of the podcast, I interview...quite a few people! We are covering Ted Bundy, America’s most infamous serial killer, and since the world has been fascinated by him lately, I figured I’d get a group of mental health professionals in a room to talk about him. His horrific acts made the news and have scared people for decades now, and rightfully so. Did media and pornography cause this? What was his diagnosis and was it correct? We have so many questions...
As my special guests and panel of experts, I invited Dr. Tony Angelo, who is head of services for a local prison and in charge of prisoners transitioning into normal life. I also invited Dr. Randy Stinnett, a clinical psychologist who co-manages an outpatient behavioral health department in a local community health clinic. Also with me is Nathan Hoyt and Adam Borecky, 4th year medical students who will be going into psychiatry.
Traits of psychopathic antisocial behavior
Criminals like Ted Bundy are skilled manipulators. They often scope their environment to see who will be the easiest to manipulate. They will treat you like you are their long, lost friend, but everything they do is an attempt to pull you in. They “hook” you so that they can get you to do something for them.
Ted Bundy came off as friendly and charming, described as “one of us.” A friend of his from Washington State even said, “He’s the kind of person you’d want your sister to marry.” As disturbing as this is, it is a common trait of psychopathic antisocial behavior.
Ted Bundy displayed many traits of psychopathic antisocial behavior. Some of the most recognizable traits were:
Someone with low affective empathy will not feel your emotions or know your emotions from a mirror neuron experience. Rather he can only read facial expressions and body language without allowing cognitive but not affective empathy.
In episode 2 of the Ted Bundy documentary on Netflix, Confessions with a Serial Killer, in his first arrest Ted Bundy said, “A funny thing happened to me on the way to labor law class. I got two weeks on the spa on the labor floor here. And, a yes, I intend to complete my legal education to become a lawyer, and be a damn good lawyer. Uh, I think things are going to work out, thats about all I can say.”
When he said this, he had a right sided smile and outwardly looked fairly happy and calm. According to studies done about microexpressions, the right sided smile is usually demonstrating contempt, but for him does not look as negative, and because in so many of his videos he has it on his face, he likely thought highly of himself and looked down on others.
I have noted that very good liars look positive, but often still leak microexpressions of very subtle negative emotion. Bundy seems to have expressed anger when he felt thwarted. In his statement, he makes a joke, yet showed a flash of fear or sadness while doing so. Bundy’s emotions of fear, anger, sadness, and pain leaked out through the microexpressions on his face, which are always a truth-telling mechanism.
Below is the quote with my inserted microexpressions in it:
“[contempt] A funny [anger] thing happened to me on the way to labor law class. I got two weeks on the spa on the labor floor here [fear or sadness]. And, a yes [contempt, sadness or fear], I intend to complete my legal education to become a lawyer, and [contempt] be a damn good lawyer [anger]. Uh [pain], I think things are going to work out [fear], thats about all I can say.”
*Note it is hard to determine exact expressions from the poor quality of this video- but my microexpression research team discussed the above and this was our consensus. The fear or sadness comment comes from the eyebrows going up in the middle, but it is hard to determine if there is fear or sadness due to the poor quality of film.
It is believed psychopaths feel little or no fear. Did Ted Bundy feel afraid?
Most of the video of Ted Bundy did not show a physiological reaction to stress. But it is likely to some degree (although much less than others) that he experienced fear. It is thought that those with primary psychopathy have dysfunctional emotional processing due to issues in their amygdala. Studies show they have less fear then control groups and secondary psychopaths (more the sociopath or baked ones) which have more trait anxiety or fear (Skeem, 2007).
What was Ted Bundy’s possible diagnosis?
Primary psychopathy: These typically have low affective empathy and low fear, however not all that are primary psychopaths become criminals. They are sometimes able to still follow the rules while not having any fear or empathy and can even be prosocial.
Sociopath (or secondary psychopathy): These are typically “baked” into being anti-social. Sociopaths are typically “made” to be the way they are, often resulting from a traumatic childhood. Abuse and trauma may influence their later life ability to attach to others. They have higher trait fear, more borderline traits and more mental disorders.
Antisocial Personality Disorder: This is how the DSM classifies people who have a history of illegal behaviors, deceit, impulsivity, failure to plan ahead, aggressiveness, reckless disregard for safety, irresponsibility and lack of remorse. This is usually a criminal psychopath or sociopath with repetitive crimes. They display low empathy and low connection with others. Their behavior usually results in crimes against others.
Ted Bundy’s bipolar diagnosis:
When Ted Bundy was assessed while awaiting his death sentence, he was given a diagnosis of bipolar disorder. However, most depressed people become less violent and don’t have much of a desire to have sex. It is also interesting to note that out of all of the violent events that happen in the US, only 5% of them are due to mental illness (Stuart, 2003). Therefore, we can conclude that most violent acts are not done by people with mental illness.
Could he have been in a manic state?
Most manic states end in death, jail or psychiatric hospitalization. Ted Bundy had no record of being hospitalized in a psychiatric hospital and was only put in jail after he was caught. Bundy was also capable of living a “normal” life. He was an active citizen, joined a church, was married and involved in politics. He played these roles for years.
With mania, this would not have been possible. Those who are manic cannot stop their mania. Also, Ted Bundy displayed reason in the midst of his crimes. He covered his tracks and could pretend to be something he wasn’t. Those who are manic do not have the ability to pretend to be something they are not, nor have the ability to plan and cover up.
DSM 5 antisocial disorder:
Ted Bundy would fall more in line with a DSM 5 antisocial disorder leaning more towards primary psychopathy. With this disorder, you must be 18 years or older and have commited conduct disorder before age 15. Also prevalent is a pervasive pattern of disregard for the rights of others since the age of 15 and psychopathic manifestations. Additionally, they must meet 3 or more of the following behaviors:
Nearly all of these traits were displayed in Ted Bundy’s pattern of behavior. Even when he was young he showed predatory aggression (which I discuss in a prior episode) when he set up tiger traps at camp and injured a young girl. Although he prayed with people before his death, Ted Bundy’s memorable quote, “I am in the enviable position of not having to feel any guilt,” showed he was wired with some primary psychopathy.
Although Ted Bundy has been referred to as a criminal “mastermind,” he may have had a average or only slightly above average IQ. The article by Ceci, 1996, found that cognitive ability tends to be a good predictor of academic performance; measures of academic achievement (LSAT, GRE, SAT) correlate very highly with measures of cognitive ability.
Although we do not know Bundy’s actual LSAT score, only that he believed it was “mediocre,” there is certainly no evidence that states he was a genius. Rather than a genius, I would say he was not impulsive, very calculated, and often planned and put a lot of energy into his criminal actions.
Ted Bundy often referenced hearing voices that told him to do bad things. However, it is not believed he had schizophrenia. Occasionally antisocials will use this as a way to avoid responsibility for their behaviors.
We call it MBD: minimize, blame and deny
Was pornography to blame?
Ted Bundy blamed his behaviors on pornography. However, pornography is not viewed as a cause of sexual violence. In persons who have preexisting conditions for sexual violence, it is a viewed as a contributing factor.
In Episode 4 of the documentary, he is quoted as saying, “I never said (pornography) made me do it. I said that to get them to help me. I did (murder) because I wanted to do it.”
The research confluence theory states men with hyper masculinity that also involves psychopathic tendencies have low agreeableness, abuse, hostility towards women, impersonal sexuality combined with sexual permissiveness. When you have a confluence of those two things and violent pornography it may be a contributing factor to Ted Bundy’s violent, abhorrent behavior.
It is important to note that pornography has not been present in our society for very long. Yet, crimes against women have been happening since the beginning of time. It is because of this fact that many doubt that pornography is to blame for crimes of this nature.
Hald, 2010, found that the correlation between violent pornography and attitudes supporting violence against women (r=0.24) was significantly higher (P< 0.001) than the correlation between nonviolent pornography and attitudes supporting violence against women (r=0.13): however these are still low correlations.
Antisocial personality disorder and psychopathy as a mental illness:
Just because antisocial personality disorder is in the DSM, it doesn’t mean it should be viewed the same way we view schizophrenia, bipolar, major depressive disorder, etc. Largely, antisocial personality disorder is not something that is treated by psychiatrists. There is no medication for it and most with this disorder are not interested in help. If they come to see a psychiatrist, it is typically because they want something from you.
Ted Bundy had traits of narcissism as displayed in the DSM 5 criteria: a pervasive pattern of grandiosity, lack of empathy and a need for admiration which begins by early adulthood. To meet the criteria, 5 or more of the following behavioral features must be met:
I would add that some narcissists are low-self esteem, but I believe he was a high self-esteem psychopathic narcissist.
Machiavellianism overlaps with narcissism and antisocial disorders. They are more likely to deceive and manipulate others for their own personal gain. They see people as objects for use and manipulation. They will have normal amounts of empathy unless they have traits of psychopathy.
The opposite of machiavellianism are people who display honesty and altruism.
In viewing Ted Bundy, it is highly probable that he displayed high Machiavellianism with traits of psychopathy and narcissism—thus having all the dark triad.
How did Ted Bundy come to be this way?
Home-grown sociopaths don’t necessarily have a need to be seen and appreciated by others. They often have been made the way they are due to horrific abuse, and usually prefer to be left alone. But, psychopaths who are born with low physiological arousal, have more of the predatory aggression which we see in Ted Bundy.
A person with primary psychopathy can either choose to live in society and do things to help, although without empathy and with difficulty attaching to others. Or they can choose to do illegal things to get their drives met. Whichever one they choose will write their brain and pattern of behavior that they will follow. These people can be incredibly helpful to society or incredibly harmful.
Determinism versus free will
It often comes down to determinism versus free will. In other words, did he make the choices or did his mental illness cause them? Ted Bundy went to prison for the choices he made, not the psychological predisposition that he had. However, when one goes into determinism, they will blame others for the choices that they made.
It is important to remember these people do have a choice. Because, ultimately, there is another dimension here, which is the moral dimension. We all have the responsibility to others and to society.
However, there are people who have less choice than others. For example, a person with a frontal lobe injury will have less “choice” than someone who does not. Ultimately, choice must be in line with responsibility. But I have known people to “check themselves in” for desires to do bad things, and get help. Sometimes we only have a small choice to change our environment.
With the Ted Bundy type of psychopath, therapy will most likely not benefit them. This type of person should be put in prison for life.
Therapists must be especially on guard with someone like this, which can be uncomfortable for therapists and clinicians. You must view your interactions with them like a chess match. Because, everything about your interactions is a game to them.
Towards their therapists, they may exhibit these types of behaviors:
However, the “baked” sociopaths, or those with features of antisocial behaviors, can benefit from therapy. Clients will very rarely be as healthy and whole as you want them to when they leave therapy.
However, the goal is for them to leave with better connection to people, not use sex as a coping strategy, be more intimate (non-sexually) with humans, and relate better to authority. This will lower their risk of sexual violence, and help them on a track to be able to fit into society.
You can give all the tests you want, but one of the most valid tests of psychopathy is the “hair on the back of your neck” test. You just know it when you’re in the presence of psychopathy. It will alarm your body’s natural detection mechanisms. You can just “feel” it. I know that isn’t technical jargon, but it’s so true.
The goal in therapy should be to change their mindset away from objectifying people. It is suggested that you get access to their large criminal history in order to learn what they have done and use that strategically in their treatment. This will arm you with the knowledge of what they have done and what they are capable of.
Approaching them with the idea that they are likely to continue their cycle of behavior unless they do something to change it is an ideal approach. Discussing the importance of change itself and how change occurs can be helpful.
Focus primarily on the dynamic risk factors or “stable factors”:
Targeting those aspects one by one and digging into each one is a strategic approach. Improvement in each of these areas will lessen their risk of continuing their behaviors significantly.
There will always be that one in a million person who will use their predisposition to harm others and create a life of criminal behavior.
However, the glamorization of criminals like Ted Bundy from the media tend to breed a culture focused on the fear of these one in a million criminals.
It is important to remember that the media carries a bi-directional quality. Where the consumer drives what the media will pay attention to. Limiting the attention we give these types of criminals will lessen their need to be publicized and noticed.
|Feb 06, 2019|
How to treat violent and aggressive patients
On this week’s episode of the podcast, I interview Dr. Michael Cummings. Dr. Cummings works at a state psychiatric hospital for the criminally insane, so he has extensive experience in treating patients for aggression and violence.
The different types of aggression
The words “aggression” and “violence” are sometimes used synonymously, but in reality, aggression can be physical or non-physical, and directed either against others or oneself. Violence is more of a use of force with an intent to inflict damage.
One study looked at the principle types of aggression and violence that occur in psychiatric patients, and broke it down into three categories:
Within 5 state hospitals, 88 chronically or persistently violent patients with 839 assaults, the rate of impulsive violence was 54%, and predatory violence was 29%. Psychotically driven patients logged 17% of total violence (Meyers, M. Cummings et al., 2013). Studies show psychotically driven violence decreases the longer the patients are in care and medicated.
Predatory violence is what people typically think of when they think of psychopathy, or someone with antisocial personality disorder. It is violence with a purpose, and that purpose is usually to gain something. They typically show a lack of fear and very little autonomic arousal even when they are being violent. The amygdala and the temporal lobe is underactive and the communication between them has a weak signal. People with predatory violence also have lower affective empathy.
Some of the early research done by Adrian Reign measured blood pressure, galvanic skin response and heart rate when showing neutral, frightening or peaceful pictures to children. Of those who lacked effective response or autonomic response to those pictures, 75% percent of those individuals became violent criminals by age 18. Interestingly, 25% of them became prosocial and entered jobs as police officers, bomb disposal experts, and so forth.
True psychopaths are a very tiny part of the population. About 2% of women score significantly on the psychopathy checklist. About 2-4% of men have elevated scores on the psychopathy checklist. Not all of those individuals, however, are violent, and many persons who are psychopathic are more interested in profit. Some become the crime bosses (not actually doing the violence themselves) and others end up in politics.
Impulsive violence or aggression is actually the most common, and in many ways the most complex, form of violence that occurs in a variety of mental illnesses, including:
It is essentially an imbalance in impulse generation and a failure of the prefrontal cortex to evaluate the impulse and weigh the consequences. All of us generate a variety of impulses, some good and some bad, including impulses driven by our irritability and anger.
In predatory aggression there is increased medial prefrontal cortex activity whereas in reactive aggression there is decreased activity.
What can cause impulsive violence to be an issue:
Psychotically driven aggression is most often a result of delusional ideation or the belief the person holds that they are in some way being persecuted and being taken advantage of. Psychotic or mentally ill people do have an increased rate of violence compared to the general population. The mentally ill are responsible for around 5% violent crimes, meaning non mentally ill people are responsible for 95%.
Psychotic Delusions leading to violence
Ones study looking specifically at the first episodes of psychosis found that in about 458 patients, anger was associated with certain types of delusions that led to the violence (Coid, 2013).
The underpinnings of delusion-driven violence usually stems from when people have delusional beliefs that are persecutory in nature. When they believe that someone is out to get them, it removes inhibitions against acting out violently, because that person’s view is they are protecting themselves. Typically, this violence comes from the belief they are being spied on or persecuted.
Persecutory delusions associated with a command hallucination is a particularly potent precursor to violent behavior. If your delusion tells you your neighbor is the devil, and your command auditory hallucination is that God is telling you to “kill him and save the world from destruction” it can lead to a very bad outcome.
IQ and aggression
There is also an association between the IQ and aggression (Huesmann, 1987).
A recent study in state hospitals looked at what correlated with persisting violence, and across all of the types of violent behavior, cognitive deficits (particularly impairments and executive functioning) were associated with elevated rates of violence.
Men are more violent than women
Men are likely more violent than women because they have historically been the hunters, which involves violence. Women were gatherers more often than not, and consequently, men have a standing evolutionary tendency toward more frequent use of violence. Women can be violent, but if you look at the rates of violence between men and women, men are clearly more violent.
The purpose of aggression
You could say the healthiest outcome for our aggressive and violent impulses is when we use our innate ability to be aggressive to engage in things like a healthy competition. Or even to provide motivation and drive to achieve.
In the beginning, humanity formed tribes, and aggression allowed someone to climb up the dominance hierarchy within the tribe. It also allowed them to protect themselves from other tribes. It was basic for survival.
If we look at animal psychology, there is a lot we can learn about the aggression and dominance hierarchy, like how apes interact with each other, or form alliances. As a way of creating alliances, often an alpha ape will groom other males. The violence comes out when the clans come against each other. When one ape is wandering from its clan, two apes from another clan may attack one single ape viciously.
In other circumstances, if a dominant ape is taken away from his clan for a couple of days and brought back into the clan, a couple of other apes may have formed a new alliance against the prior leader and attack him.
As human beings, we are also like this. Many of our social interactions and group structures have the same kinds of alliances and effects of absence can play out similarly. Of course as humans, we do have higher verbal centers, and philosophy or spirituality, that allows an individual to be less violent and to transcend their base instincts.
Aggression and autism
People with intellectual challenges most often exhibit impulsive violence, particularly those on the autistic spectrum. The person may have a greater difficulty processing or understanding their own emotions if there are significant intellectual deficits. They may also have elements of not being able to judge a response or to moderate a response. The general pathophysiology of the autistic spectrum disorder suggests that the connections between neurons and the autistic brain is not what it should be, and they are not differentiated so that information processing can be fragmented.
Treatment of aggression
Psychotic aggression treatment
Treating with an antipsychotic medication is helpful and decreases violent episodes. In one study, clozapine helped psychotic aggressive patients with executive dysfunction more, compared to using haldol or olanzapine (Krakowski, 2011).
Psychopathic aggression treatment
A predatory-violent individual needs to be contained in prison if there is a demonstrated past of persistent violence.
There is evidence that by enhancing intellectual empathy, psychopaths will be less violent. There is also interesting research that by giving oxytocin, the hormone that increases affiliation and collaboration, may have a moderating effect on some psychopathic individuals.
However, in terms of psychopharmacology, we don’t have any specific medications to control that behavior. Some medications, such as clozapine, can affect the underlying issues behind psychotic behavior and thereby reduce it, but there is no direct treatment for psychopathic violence pharmacologically.
Impulsive aggression treatment
Dr. Cummings discussed the use of Mood stabilizers helping in persons with borderline personality disorder, SSRIs and trazodone helping in dementing illness in the elderly and alpha 2 agonists in people with things like autism or TBI. Alpha 2 agonists (clonidine) can fool the brain stem into thinking enough norepinephrine has been released, then less norepinephrine is secreted, making the brain stem calm down.
Essentially, in an emotional disorder, if you change the affective (limbic) tone, you can decrease the likelihood of emotionally reactive aggression, for example, by using mood stabilizers lithium and divalproex.
Using an antipsychotic, and not just a mood stabilizer, doesn’t show any benefit for traumatic brain injury patients. Antipsychotics have been used for people with autism spectrum disorder, and some evidence shows that drugs like risperidone can be helpful to control outburst issues. If there is evidence of sexual aggression (or aggression occurring at women after puberty), using an GnRH agonist—antiandrogen treatment—can sometimes be necessary).
Psychotherapy for aggression
There have been a number of anger management therapies that have been used over time. Therapists can help people be aware of their anger and manage their impulses, or push their anger and aggression toward a more prosocial response.
For people with borderline personality disorder, dialectical behavioral therapy, mentalization based therapy or transference therapy are important. For schizophrenic patients, a good therapeutic alliance is important to create medication compliance. I have touched on how to process anger in my microexpression series and will have future episodes focusing more on the psychotherapy approaches to anger.
Overall in therapy, we must assume that our patients will lie to us sometimes because they are afraid, and double check to insure they are following our prescribed protocol. We must also work hard to build trust and a therapeutic alliance.
Violence and aggression deserve much more attention as a specialty than we have given it in the past. It is a major burden for family members and friends.
Please submit any questions you have and we will submit them to Dr. Cummings and to answer.
(In the podcast details about specific medications are discussed for psychiatrists who are interested in advanced psychopharmacology.)
Link to Ideal blood levels are found in Resource Library
|Jan 23, 2019|
How Empathy Works And How To Improve It
What is empathy?
Empathy is the ability to understand another’s state of mind or emotions. It is also is being able to feel, understand and share with someone else in what they are saying, their meaning of life, their motivations and values.
In research there are 3 types of empathy that are commonly described: cognitive, affective, and compassionate.
Cognitive empathy is also known as perspective taking, and it can help someone understand another’s personal experience. It also tends to reduce interpersonal aggression. Cognitive empathy is exactly what it sounds like—cognitively understanding someone’s situation, emotions, and motivations. When we understand someone else, we are more likely to view their behavior as similar to our own.
Affective empathy is about a shared emotional experience, one of feeling together. It uses the mirror neuron system, which I will discuss later on in the article. Affective empathy forms powerful emotional relationships.
The third form of empathy is compassionate empathy, which is also called empathic motivation, prosocial concern, or sympathy. This is when you feel moved to help another from how to experience their reality.
The science of empathy
Mirror Neurons are sharing neurons
Our brain has neurons solely designed to mirror other people. From birth, when we focus on another's movements, emotions and intentions, our brain lights up automatically, and largely unconsciously, around 10% the same way. Our own body-state can be derived from someone else outside of us. We can therefore understand and map out the mind of others by placing ourselves in a comparable body state. This process is important for empathy, intuition, transference, countertransference, enactment, projection, internalization and intersubjectivity.
The discovery of mirror neurons:
In 1992, while studying a monkey's brain with electrodes attached to the motor area (the area that lights up when movements by the body are made), researchers accidentally discovered that not only would the neurons become activated by the monkey reaching out to pick up a piece of food, but also when the researchers made a similar movement. Later, the same team published a paper that showed that there were mirror neurons responding to mouth actions and facial expressions. Further studies confirmed that around 10% of neurons in certain areas of a monkey's brain had mirror abilities. Later, these studies were expanded to humans.
A recent study summarizing the data of 125 fMRI studies of humans (brain imaging that shows what is active), found that there were many areas of the brain with this capacity. (Molenberghs, 2012) Beyond seeing actions performed by others and having them represented in our brain, there are 3 other areas of the brain that are activated in a similar fashion:
Now researchers are saying that the mirror neuron system is involved with:
Non-empathic types—the Dark Triad
The “Dark Triad” refers to three types of disorders that cause people to have low empathy for others. The big common denominator for these people is a deficit in affective empathy, but after matching for primary psychopathy, the others are no longer predictors of low affective empathy (Wai 2012). The Dark Triad consists of: narcissists, Machiavellians and psychopaths. People who have narcissistic traits and machiavellian traits often have some primary psychopathy traits as well.
Individuals high in narcissism had positive feelings when looking at sad faces and were accurate at recognizing anger (higher cognitive empathy may be bias at grandiose self reporting). Individuals higher in primary psychopathy (they can usually maintain cool composure and carefully execute planned behaviors with a lack of morality, whereas those with secondary psychopathy respond to their negative emotion when they harm others) felt positive when looking at sad, angry or fearful images and more negative when looking at happy images, and were rather inaccurate at identifying all emotions.
Machiavellians felt negatively with happy images and positively with sad images, while they tended to inaccurately identify happy or sad emotions.
Empathy and the medical field
Research on “Therapist Effect”
Can we improve our empathy?
Studies show that we can. Here are some things that can improve your ability to empathize:
Can therapists lose our empathy?
Studies show we can experience empathic strain and rupture. Empathic failure may lead to aggression. It is hard to empathize when we feel subjected to powerful influences from patients: complaints, requests, accusations, subtle seductions, bits of blackmail, challenges. Throughout history, rulers have decreased empathy in their warriors and people by stirring up disgust towards those they seek to kill.
We are more likely to empathize with those we interact with frequently, find similar to us, or find thoughtful and kind. We need to humanize people’s actions and see them like us, to not lose the part of us that could consider that we too could be in their situation.
Consider the stages of empathy:
I think of empathy in terms of 3 categories: the moment to moment emotional experience, the meaning and context of the emotion in their life, and the subjective experience evoked and created by the unique connection I am having in the here and now with the person.
Level 1: There are moment to moment flashes of emotion on someone’s face, changes in body language, and current distress. Empathy can be experienced by just witnessing a flash of emotion and allowing the person to know you see it and that you hear them. During this, we can try to understand the person’s emotions, and ask them to verify what they are feeling, if we are correct in our questions, such as if they are feeling sad or angry about something.
Tuning into their experiential state and then asking if you are on the right track: (note if the patient gives a different word then do not contradict) can be helpful.
Level 2: This is where we try to know the context of the flash of emotion, the distress either in the distant past (how early relationships informed it) or recent life situations. Sometimes the quantity of distress is only as high as it is because it is linked to prior loss or prior trauma. We can find the context of the emotion by matching their emotionality, their demonstration of emotions on a level that we feel is appropriate. We can look at the meaning of the emotion and the context of the meaning of that emotion in their lives. We can also empathize with the meaning of the emotion once they’ve identified its context.
Even if they flash anger towards themselves, but maybe they in doing that are not accomplishing the energy of the emotion, and they are missing how the anger can help them accomplish their goals. Thus when the anger is pointed at themselves, we can explain that the anger should be pointed outward, and give energy to action.
Level 3: This level is when the person is having emotion that occurs because of their relationship with you. It is the interpersonal, and commenting and empathizing with any distress (or positive emotion) that your relationship is creating is a level 3 empathic statement. When a patient demonstrates anger towards their therapist, it’s helpful to ask if they are feeling anger towards you and if they feel comfortable talking about that emotion.
We can create psychological safety for a patient to give feedback to us by telling them we like to hear what they are feeling towards us. For example, my mentor, Dr. Tarr, tells his patients:
“I very much want to hear your positive and negative feelings, particularly about me, and particularly negative ones. It will be helpful for you to share any feelings of disappointment, feelings of not being understood, feelings of not being responded to or criticized, or mannerisms or things I say that affect you undesirably. I hope you can understand that this is not a usual social situation, where you don’t tell people negative thoughts, here I hope you have the courage to say them out loud. It will be very helpful to say it has it is happening; we can learn much more than if it comes out later; we know it’ll be hard—but this kind of a laboratory where we discover what goes on between us.”
|Jan 08, 2019|
ADHD: Diagnosis, Symptoms & Treatment
Link to show on: iTunes, Google Play, Stitcher, Overcast, PlayerFM, PodBean, TuneIn, Podtail, Blubrry, Podfanatic
What is ADHD?
ADHD is a brain neurotransmitter disorder that affects a person’s ability to concentrate, their social interactivity, and their impulsivity.
People who truly have ADHD typically experience inattentive and hyper symptoms across all areas of their life. For example, if they are in a job that requires periods of attention to complete or organize a project, it will be inherently more difficult for people with ADHD.
One of the things that’s important in diagnosing people (particularly younger people) is their collateral history. People around the person with suspected ADHD are often more aware of the person’s deficits than the person themselves. When they reach adulthood, the problems might be made more obvious when they integrate into normal society and notice they struggle with symptoms of ADHD (compared to other people).
Although not required for diagnosis, PhD level psychologists can do psychological testing, along with ADD/ADHD testing and IQ testing, to get a full idea of the patient’s symptoms. It helps confirm the diagnosis because these tests are widely used among the entire population, which provides a large sample mean to compare with. It’s also helpful to get a benchmark of performance before beginning treatment and then follow it up with later testing to see how effective the treatment has been.
Myths about ADHD
If a child is hyper, he or she has ADHD.
ADHD diagnosis has, at times, been a fad in the public, leading to many misdiagnoses and overmedicating, especially in children. Children are inherently hyperactive and less attentive than adults are. Doctors who are performing diagnostic tests must really pay attention to the criteria in children to make sure that the magnitude of the problems truly cause stress and social dysfunction before they try to diagnose or medicate a child.
For example, the LA times published an article that ⅓ of the children in Orange County suffered from ADHD. Real studies show that prevalence in children is around 6-8%, in adolescence about 2.8%, and in adults about 2.5% of the population.
ADHD disappears with the onset of puberty.
Attentional deficits sometimes remains into adulthood, while hyperactivity may disappear as a child matures.
We are giving people methamphetamines as medication.
Methamphetamines and amphetamines are completely different drugs on a molecular level. The methyl group paired with amphetamines increases its absorption and effect on the brain. The amphetamines that are used to treat ADHD are essentially variants of dextroamphetamines.
There are even versions that are difficult to abuse, such as with vyvanse, where lysine (the amino acid) is bound to the amphetamine. The lysine make the amphetamines unabsorbable unless it’s in the GI tract. It cannot be inhaled or injected and still be effective. Similarly, some of the slow-release versions are encapsulated in pills that won’t release the drug easily, except very slowly in the GI tract, making it difficult to divert or abuse those formulations.
Dopamine stimulants are the only treatments for ADHD.
There are other drugs that are useful for ADHD symptoms. They are (for the most part) drugs that increase brain norepinephrine. They can be used for people who don’t tolerate increases in dopamine, or for other reasons cannot be treated with dopaminergic agents.
The most common side effect from amphetamines are increased anxiety, insomnia, increased sweating, hypertension, heart rate and blood pressure. These are things that can be overcome by titrating the drug more gradually, or being very attentive to the overall dosing of the drug.
Amphetamines are likely the first line of treatment, unless a person has anorexia, is still growing, or still has strong family genetics with a history of addictions.
What are true warning signs of child ADHD?
When the child is struggling socially, has attention deficit, is struggling academically, and the problems are noted by the educators and parents alike, it may be time to seek out a diagnosis. Most teachers get pretty good at recognizing the one or two children in the class that are most impulsive, most hyperactive, and less attentive, so it can be helpful to ask them first if they’ve noticed something disruptive about the child.
Often, boys with ADHD are easier to spot, because they tend to act out more. Girls tend to more often fall into the inattentive subtype, but may not be hyperactive or disruptive. They may not do as well academically, though intelligent, and that is a cue that they should be tested for the inattentive subtype. The problem is that unlike many disorders that have clear markers, attention—and the ability to modulate attention—always varies.
One of the characteristics of people with ADHD is that they tend to be impulsive, often acting without thinking through the consequences of their behavior, which can lead them in some cases to do things that will get them in trouble in school or in their social group. It can become a self-reinforcing phenomenon. If a child is often in trouble and begins to take on the “troublemaker” attitude, the behavior can continue as part of their identity. There is even an association between ADHD and the development of conduct disorder and/or antisocial personality disorder.
ADHD in adults
Sometimes I treat young adults who were high functioning enough in high school to be able to get by academically, but they noticed a major difference in college when the coursework became more difficult. They’d procrastinate as long as they could, and only get things finished at the last minute when adrenaline kicked in and stimulated their brain to do the work.
ADHD has been recognized as a failure of the reticular activating system to adequately stimulate the portions of the brain stem (the cortex and basal ganglia) in a way that it works for non-ADHD people. It can feel a little like the brain is drowsy all of the time.
Another characteristic of ADHD is that patients tend to be more able to concentrate on subjects they are interested in. For example, medical students who prefer higher-risk, fast paced environments tend to not need their medication when they are in emergency room rotations. When they are in a subject matter that is not as interesting to them, they might need to take their medication to function at a higher level and retain the information. I try to help my ADHD patients increase the meaning in what they are doing on a daily basis as a form of treatment.
People with ADHD have a higher rate of injury than the general population. There are many circumstances in which not paying attention to your environment is dangerous.
One study shows that there is even a correlation between car accidents and ADHD. Driving requires attention and responses, and if people are prone to do impulsive things, but are not prone to pay attention, it can increase their rate of accidents.
There is a noted decrease in risk of drug abuse when someone is treated appropriately with dopaminergic drugs, than there is if someone with ADHD is untreated. One of the things that occurs in people who don’t receive appropriate treatment and education (but they have ADHD) is that the first time a person takes a stimulant medication, maybe experimenting in college, illegally borrowing some for a test from a friend, they will report it as being the “first time they ever felt normal.” It can be a powerful lure to revisit the experience of feeling more normal, and being able to pay attention (I am in saying this, not recommending you ever share your ADHD medications, but nevertheless it is commonly reported to me on history as how they found out they might need treatment.)
Without guidance and education, it can be a pathway to drug abuse rather than an appropriate treatment. Proper treatment can greatly enhance quality of life.
I once had a patient in the emergency room that told me she put a little bit of methamphetamines in her coffee every morning. She wasn’t getting high off of it, but I did wonder if she was self-treating something she had naturally noticed was a problem for her—inattention.
People with ADHD should also be receiving a broad spectrum of psychosocial treatment and therapy, not just medication. If a child is under the age of 6, he or she should be given behavioral therapy as a first line treatment. The initial approach of diagnosis should be made carefully. If the person does have ADHD, the first treatment should be psychosocial interventions, afterwards, if that does not work, they can try medication.
The main category for pharmacological treatment of ADHD are dopaminergic stimulants. These drugs essentially serve to stimulate the production of dopamine (amphetamines) or to block its reuptake (with drugs like methylphenidate). Amphetamines increase and release proper neurotransmitters and block reuptake, while methylphenidate is more purely just a reuptake inhibitor for dopamine.
Medications that contain amphetamines will stimulate motor activity in healthy people, while it will actually return a hyperactive person to a calmer state as the dopamine regulates in their brain.
For those who don't respond to dopamine increasing drugs, the other approach has been to increase norepinephrine with drugs like atomoxetine or some of the noradrenergic antidepressants, thereby increasing the person’s alertness. About 70% of people respond to dopaminergic agents, and 30% don’t respond, or can’t tolerate the increase in dopamine because of either insomnia or increased restlessness.
Sometimes people with ADHD can also have comorbid anxiety. One professor explained that there is a survival advantage of both having ADHD and being willing to do high-fear tasks, but they also can have comorbidity with anxiety that keeps them from taking too high of risks and killing themselves.
Often, when a patient comes to see Dr. Cummings that has both ADHD and anxiety, his first line of defense is to try and increase serotonin through SSRIs, along with the drug they are taking for ADHD. Some could take an antidepressant as well. Most children and adolescents with ADHD do best with a dopaminergic agent, although those are also problematic in some people.
Exercise also has a positive effect on ADHD, specifically anaerobic exercise. It can aid several neurotransmitters, including norepinephrine and dopamine.
Issues with ADHD medication
Sometimes children who are on ADHD medication can experience a loss of proper growth hormone, causing different issues. If someone chronically takes a stimulant, they will be about an inch or an inch and a half shorter than if they did not take a dopamine stimulant. If that’s a problem for them will depend on the inherent genetic makeup of the person. If the child comes from a family of very tall people, it might not be a problem to lose an inch or two. If the family is short, losing an inch or two might be more of an issue socially and culturally.
Also, anorexia can be an issue, because dopaminergic medications can decrease appetite. It occurs to some extent in everyone who takes a dopaminergic drug, definitely enough to cause widespread clinical concern. However, there are approaches, such as taking drug holidays from the medication, that can help regulate the decreased appetite. Whether someone should take a drug holiday, or break from taking their medication, will depend on how disruptive the person will become when they are not on a stimulant. If it will cost the person social interactions and friendships, it is usually better to keep them on the medication.
Other abuses of ADHD drugs are very similar to the abuse or appropriate use of any molecule. The person who is using a stimulant appropriately is using it to improve their functionality—they are using it to pay attention and have a normal life. The person who is abusing a stimulant is taking it for the purpose of getting high. They are seeking the euphoric effects of the stimulants rather than positive life change. Someone who is trying to get a “speed run” will take a gram of medication, while someone who is trying to medicate for ADHD will take 20,30, or 50mg of methylphenidate in order to maintain their ability to concentrate.
The true identification of abuse of amphetamine medication is a person’s deterioration in their ability to function in a balanced manor. Not sleeping for days because of stimulants, even if someone is able to get A’s on tests, is not improving their functionality and may hurt them long term.
As a whole, doctors need to be more careful when diagnosing ADHD. There is a tendency to over-diagnose, leading to over-medicating. Even if you receive a diagnosis, there are also several cognitive behavioral therapies that have been developed to help people deal with the psychosocial components of having ADHD. These can be self-administered through computers. There are also mindfulness practices to help the person monitor themselves so they are better at social interactions. Exercise should also be optimized. Repeat psychological tests can help guide effective treatment. Patients who have had ADHD untreated for years might have subsequent low self esteem. Approaching the uniqueness of the patient and their presentation will help the patient thrive!
|Dec 15, 2018|
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On this week’s episode of the Psychiatry and Psychotherapy podcast, I interview Mark Ard, M.D., a third year psychiatry resident at Loma Linda University. On the state level, he works towards developing means of access to care, in-patient psychiatric care, affordability of care, and further access to mental health.
Mark is also the person who encouraged me to start pursuing weight training through Starting Strength, which we will link in this article.
Link to show on: iTunes, Google Play, Stitcher, Overcast, PlayerFM, PodBean, TuneIn, Podtail, Blubrry, Podfanatic
David Puder, M.D., Mikyla Cho, Mark Ard, M.D.
What is placebo?
The original meaning of the word placebo is, “I will please.” That statement comes from a time when doctors didn’t have our modern code of ethics, and they would prescribe whatever would make the person feel better. They probably had the best intentions, but they also would have known that whatever they were prescribing might not have been a real medication for the symptoms the patient was experiencing.
Doctors, even then, knew that suggestion was powerful, sometimes more powerful than the medicine they were prescribing.
Laypeople who hear the word “placebo” automatically think of sugar pills. They may think only that it’s something a doctor gives to placate and make people feel better when they aren’t getting the active medication. Placebos have long been used as a comparison arm for clinical trials. Usually it is in the form of an inert sugar pill or sham-procedure. Researchers can observe a psychobiological response known as the placebo effect.
But when thinking about the word “placebo,” we must think of the entire effect of it, and it is perhaps better termed “the meaning effect.” As I discussed in last week’s episode of the podcast, the meaning we give something creates belief, and belief is a potent change mechanism, even when it comes to our physical health. It is especially potent when it comes to mental health.
The placebo effect encompasses the therapeutic alliance, expectations, natural healing of the body and mind, and the environment of therapy. It involves the power of suggestion, mood, and the beliefs behind even one positive or negative interaction with a doctor. It also, as we will see, involves studies involving heavy-hitting medication.
When there is an increased ritual, there is an increased placebo effect. During a hospital stay, the surgery preparation, meetings with doctors, nurses and therapists can have an incredibly therapeutic effect on a patient. It is possible to see biological mechanisms triggered by psychosocial context and attribute it to a placebo effect.
What is the power of suggestion, the meaning effect, placebo effect, and how do we use it or avoid it in our practices and when testing new medical treatments?
Why do we study placebo?
We study placebos because we need to understand how meaning works, how belief works, and on the other side, if a medicine actually works.
As doctors, we need to be able to read studies critically, with an eye for placebo. We need to see what actually works and what the study was controlling the treatment group to. We also need to know if there parts of the treatment that are working only because of the placebo effect, and if so, how do we use that to heal people.
How does the placebo effect work?
The efficacy of the placebo goes up because of the expectation and meaning we give to placebo.
In one study, half of the patients got the actual medication, half got the placebo. In the same study, in another group, 25% of the patients got the placebo, and 75% of them got the actual medication. In both of these studies, the participants were told the percentage chance they would get the real medication. In the study where only 25% of patients received the placebo, more people experienced positive changes from the treatment, whether they received the placebo or not. Most people believed, because of hearing the percentages, that they would probably get the medicine. That belief increased the placebo effect.
In groups with lower percentages receiving the actual medication, the response is lower, even with real medication.
Researchers think placebo effect works because of expectation and classical conditioning mechanisms. Such understanding may be an oversimplification of a very complex phenomenon but it provides a useful framework. Expectation is how much the patient believes in the therapy. Higher expectation leads to hope and positive outlook, which results in better outcomes. Exactly how this works is still under investigation. There are multiple theories as to the underlying mechanism, but overall, we can say that there is a bidirectional interaction between expectations and emotions, and we respond better when expectations are high and our mood is good.
Classical conditioning contributes to the placebo effect by modulating conscious expectation and non-conscious learning. The white coat effect is a classic example of how our body responds to a conditioned stimulus. Also, when a patient feels better after taking a pill, it becomes a conditioned stimulus, and the body may respond positively even after taking a placebo medication because of its conditioned response.
Expectation can be shaped by many factors. Broadly, these factors can be grouped into patient effect, clinician effect and study design effect. Patient effect refers to patient characteristics such as beliefs, values, cultures, and the meanings associated with the illness and the treatment.
In a study of IBS patients, Vase et al found that expected pain levels and desire for pain relief accounted for up to 81% in the variance in visceral pain intensity. There is also a greater dopamine release in patients who had higher expectation. (De la Fuente-Fernández). Conversely, pessimists were more likely to have negative side effects (when compared to optimists’ responses) when told a placebo would make them feel bad.(Geers)
How a patient interprets and generates meaning in a given treatment condition is widely variable and difficult to control for. A similarity in demographic characteristics would not account for all of them. Direct-to-consumer (DTC) advertising of antidepressants is an example of how a society can shape one’s view and expectation of the illness and the treatment. The promotion of antidepressants inherently depends on the biological model of depression. By simplifying depression as serotonin deficiency, antidepressants were promoted as a simple solution to a complicated problem. These advertisements are designed to convey that “psychopharmaceuticals have an obvious, objective, and scientific relationship to the symptoms they are supposed to treat”(Greenslit, 2012). The reality is more complex and difficult to understand than the advertising, but the narrative is believed and shapes decision making.
An interaction with a clinician can shape the expectation of outcomes as well, especially if there is a strong alliance. Warmth, empathy, duration of interaction, and communication of positive expectation may significantly affect clinical outcome (Kaptchuk).
One article (Verhulst et al., 2013) deconstructed the correlation between the medical alliance and placebo. The placebo effect encompasses the beliefs, values, and expectations that patients have about a treatment. We can help shape a patient’s belief and expectations by giving realistic illustrations of the treatment, which are more valuable than false hopes; this is the medical alliance that we as healthcare providers can utilize. Part of the medical alliance is the idea of concordance between the physician and patient. There is both narrative concordance, the shared understanding of the patient’s condition, and the relational concordance, the shared relationship structured based on scripts, boundaries, and interactional rules. Ultimately, by utilizing the idea of concordance and a strong alliance with the patient we can influence how they view a treatment and better the outcomes via the placebo effect.
Study design can also change expectation. Having a higher chance of being assigned to the treatment group and having a choice (Rose 2012) increases the expectation. The degree to which placebo resembles the treatment is another important consideration, because unblinding can lead to decreased expectation. (Some studies utilize active placebo to make unblinding more difficult.) In pharmacological studies, active placebo usually contains some real medication that contains some of the expected side effects to imitate the expected treatment.
The mechanisms that control placebo effect:
This system bolsters a lot of the evidence for pain relievers—you have more of a placebo effect on the patient if they know they're getting the medication than if it’s snuck into an IV. The opioid system in the brain begins to work as a pain reliever before any actual medication sets in, if it’s even administered.
Dopamine signaling is involved in expectation and response. Our brains will respond as if something is happening if it believes it will happen. This pathway is also involved in habit formation and novelty seeking. The brain lights up in the same way to a placebo as it does to an active intervention. There is a fascinating link between dopamine deficiency and Parkinson’s disease; placebos can induce dopamine release, leading to improvement in Parkinson’s disease motor dysfunction.
In another study, people were told they were getting either a cheap medication or an expensive medication. Even though they both received placebos, the group who was told they were getting the more expensive medication experienced a greater placebo effect.
Even the color of medication can affect a person’s response. Brand names can affect a person’s response. A person who is told they are receiving an anti anxiety medication will calm down, even if it’s a placebo.
The third “system” is prefrontal cortex, which is involved in associations and meaning. This is also one of the main areas involved in improvement of depression (Murray, 2013).
What is the effect of placebos on the medical profession?
Is placebo testing accurate?
Some industries fail to examine things with an accurate and rigorous placebo. For example, in a recent study on Botox used for depression, ¾ of the subjects knew if they had received the placebo or not (Finzi & Rosenthal, 2014). Some studies also neglected that placebos can actually change brain chemistry, and activate or deactivate different areas of the brain.
We often think that the patient who is administered a placebo, in taking the medication, thinks it is real and thus the whole placebo response is merely from taking the pill. But in those results we neglect the human factors that come into play when a person meets with a psychiatrist that is doing the patient interview, and how it could be the therapeutic alliance and feeling cared for that influences outcomes and spontaneous remission of symptoms.
For the medical field to determine that it’s not only the placebo effect taking place, that the medicine or treatment actually works, many factors come into play.
Discussing negative side effects with patients
How do you talk about medication as a doctor without scaring the patients with a side effect list? Studies show that by listing side effects, people are more likely to experience the side effects.
I usually discuss the side effects with patients if they occur in more than 1% of patients or if the side effect is life threatening. Also, if the patient feels like they need to stop the medication, I tell them to call or email me. Even knowing they can reach out of they are experiencing problems gives patients a sense of peace, and could decrease negative placebo effects of the medicine, and increase positive effects of it.
In medical education at large, there seems to be a loss of the science of connection and a focus on medicine rather than being able to emotionally connect to people, and mental health is part of the human experience.
Therapy and the placebo effect
Placebo and psychiatry have an interesting and complicated relationship—both are concerned with the mind-body connection. Using placebo in psychiatriatric research is, therefore, more challenging. It is more difficult to tease out the true effect of a treatment since mental illnesses have significant psychosocial components.
Higher therapeutic alliance, higher empathy, and higher interpersonal skills all have better outcomes. Beyond the model of therapy, each therapist’s kind of connection to their patients deeply affects a patient's’ response.
The value of the therapeutic alliance can be as powerful as medication, and also bolster the effectiveness as the medication itself.
In their paper Wampold, Frost, and Yulish (2016) reviewed the history of how placebo was used in randomized control trials for testing the efficacy of psychotherapies. They found that when poorly designed placebo therapies were used as controls, the psychotherapy treatment group had superior results. It is difficult to have a truly controlled placebo. For example, it can be obvious whether a therapy is a placebo or a true psychotherapy and the providers administering the treatments would also know which was the true treatment. People have advocated that different psychotherapies are beneficial because of their common factors such as the therapeutic alliance, discussing expectations, and instilling hope. These and other factors common to the variety of psychotherapies can also be found in the placebo effect, which facilitates the argument that placebo psychotherapies are not inert. Therefore when we look at studies that compare psychotherapies to a placebo therapy, we must be aware that the comparisons may not be completely accurate.
In therapy practice there are no effective placebos to be given to compare, so effect size with therapy is very different than effect size with medication vs placebo. A broader and more nuanced understanding of the placebo effect is important in two ways. First, it allows a clinician to critically evaluate studies that compare the treatment with placebo. Placebo should be evaluated within the framework of mental illnesses. Secondly, understanding placebo allows a clinician to maximize the clinical outcome by focusing on factors such as alliance. Placebo teaches us about the complexity of the mind body connection, and calls for a more integrated approach in treating mental illnesses.
The effect size in double blind studies, however, does not tell the whole story of the effectiveness of the psychiatric relationship, because it does not take into account the part of the placebo response that actually came from a psychiatrist’s relationship with the patient.
Even since the beginning of psychopharmacology, in the 1940’s, placebo effect has increased. In part, I believe that’s because we’ve reduced mental illness to a few symptoms and then say those can be helped or fixed by a pill. For example, there is commonly believed language around depression that says it’s a serotonin deficiency. So, patients take medicines to boost their serotonin (SSRI medication). That is not the only thing going on in depression, and it’s not necessarily true. So SSRI medications have a large placebo effect.
Further, different psychiatrists will have different effectiveness with patients (McKay, 2006). The authors analyzed data from the Treatment of Depression Collaborative Research Program (TDCRP) that compared imipramine hydrochloride with clinical management vs. placebo with clinical management and found that 7% to 9% of outcome variabilities depended on the psychiatrist providing the treatment. When using BDI, the results were statistically significant (p < 0.05) and when using the HAM-D the results were marginally significant (p = 0.053). Therefore the authors concluded that the psychiatrist effect was at least equal to or greater than the treatment effects. The effectiveness of a psychiatrist is also critical in proving optimal treatment.
Non-therapeutic medical fields and doctor-patient relationships
Even the awareness that the placebo effect exists should make medical workers understand that we need to consider people’s outside lives, not just the psychopharmacological effects of the medication. If little things have a placebo effect, and that is directly related to meaning and belief, what are the patients experiencing outside of the medical office that is influencing them?
Our brains were made to create meaning out of things, and this meaning can change the very nature of the brain. When we understand placebo we become better guides to our patients, steering them away from things that don’t do anything, and towards things like having a connected relationship with a caring person, which can be the treatment itself. We also look not only at how powerful a medication was compared to the placebo, but also if the patients thought they were taking the real medication or not. We also learn that belief is powerful and can understand how people get swayed into cults and taking things which have been proven to only be harmful.
|Nov 29, 2018|
Perinatal Mood and Anxiety Disorders
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In this podcast and article Dr. Kelly Rivinius, a licensed clinical psychologist who helps women suffering from PMAD, gives her insights about PMAD, its risk factors, prevention, and her own experience with perinatal OCD and anxiety.
David Puder, M.D. and Kelly Rivinius, Psy.D. have no conflicts of interest to report.
Article the accompanies this episode go: here
|Nov 15, 2018|
Therapeutic Alliance Part 2: Meaning and Viktor Frankl’s Logotherapy
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In this week’s episode of the podcast, I’m going to be emphasizing the meaning that I, as a therapist, can help draw out of other people’s experience through a therapeutic alliance.
David Puder, M.D., Kristen Bishop, Brooke Haubenstricker, Mikyla Cho
In the celebrated book Man’s Search for Meaning, author Viktor Frankl wrote about his intimate and horrific Holocaust experience. He found that meaning often came from the prisoners’ small choices—to maintain belief in human dignity in the midst of being tortured and starved and bravely face these hardships together.
“The way in which a man accepts his fate and all the suffering it entails, the way in which he takes up his cross, gives him ample opportunity—even under the most difficult circumstances—to add a deeper meaning to his life. It may remain brave, dignified and unselfish. Or in the bitter fight for self-preservation he may forget his human dignity and become no more than an animal.” - Viktor Frankl
“We who lived in concentration camps can remember the men who walked through the huts comforting others, giving away their last piece of bread. They may have been few in number, but they offer sufficient proof that everything can be taken from a man but one thing: the last of the human freedoms—to choose one’s attitude in any given set of circumstances, to choose one’s own way.” - Viktor Frankl
Frankl argued that the ultimate human drive is the “will to meaning,” which could be described as the meaning to be found in the present and in the future. For example, I have had patients who are suicidal, yet they would not kill themselves, despite part of them desiring death, because they would not get to see their grandkids grow up. The meaning of the future moments and being able to help their grandkids in some small way empowers them to keep going to treatment.
People’s meaning keeps them going, even when other drives, like sex or desire for power, are completely gone. In this way, Frankl noted, “Focus on the future, that is on the meaning to be fulfilled by the patient in his future…I speak of a will to meaning in contrast to the pleasure principle (or, as we could speak also term it, the will to pleasure) on which Freudian psychoanalysis is centered, as well as in contrast to the will to power on which Adlerian psychology, using the term ‘striving for superiority,’ is focused.”
This idea led to the beginning of a new type of therapy—logotherapy.
Helping a patient find meaning
Being unable to find personal meaning in our lives can lead to depression, hopelessness, anxiety, and suicidality. As a physician, I see this often, and I try to help my patients find meaning in their lives. However, the approach I have learned from Dr. Tarr (my mentor), and from my studies, is different than the normal approach of just asking people, “What is your purpose?” or, “What is your vision for the future?” The technique I use is based on another principle called “psychic determinism,” which means that everything has meaning. There is nothing that a person says, no flash of emotion, no change in body posture that is meaningless.
When you believe this, you view the patients’ words differently. The meaning may not be readily apparent; it may be expressed in primary process mentations and have an unconscious-type meaning like dreams, which may be difficult to understand. Suffice to know at this point that the mindset we have when we approach people is that everything they say has meaning; every sequence of thoughts that they say is deep and valuable.
We start from small moments of meaning that are coming from their words, their body language, their microexpressions, your experience of them in the moment, and we take those small moments of meaningfulness and start to verbalize what we find meaningful. Listening to our patients and helping them to understand the hidden meaning in their lives, even in the midst of work or difficult times, can help them withstand trauma, stress, and hardships.
No rambling is random
Sometimes patients will talk for awhile, changing subjects rapidly, and we may think it is random, but it isn’t. Even when schizophrenic patients talk, there is meaning behind what they’re saying. When we allow for free association, we can derive a sense of meaning from the commonalities in topics that come up.
For example, a patient might be talking about how they are angry at their significant other, then immediately report that when they were young their mother would often yell at their father, and their father would cower in his room in silence. How is their current anger related to how they felt as a child watching this drama? How might the two be linked? What about the microexpression of disgust that flashed as they reported both topics.
As you look deeper, the meaning becomes more evident. In this particular situation, the disgust or revulsion they experience recollecting their father’s cowardice magnified the disgust they felt toward their significant other. Understanding the link and the uncovered meaning helped them tolerate the intensity of that negative feeling, and helped them develop new meanings about their current and past experiences.
Even hallucinations and delusions generated by some mental illnesses have meaning. When I’ve given patients antipsychotics and they’ve adapted to the medicine, we explored their hallucinations and they were able to see why they wanted to believe in an alternate reality—it gave them a sense of power or control, or related to a deep underlying fear in some way. As we developed meaning in their real lives, they felt more comfortable in their actual reality.
When we sincerely believe that everything the patients say has meaning, the patients themselves feel meaningful. Ascribing meaning enhances the patient’s esteem tremendously and makes them feel safe enough to continue to freely associate. Incredible progress can be made with patients in this way.
To get people to free associate, you need to reduce the shame enough to get people to feel safe enough to be able to share their uncensored thoughts and feelings.
Empathize with the meaning
“Men are not moved by events but by their interpretations.” - Stoic Epictetus
Relationships can allow for deeper understanding and meaning to develop in life. To strengthen our relationship with our patients, we must understand what they’re saying and then empathize with that meaning.
We often think in the context of our own lives, and as therapists or physicians we need to allow people to be the experts of their own lives. A word or phrase may mean something completely different to our patients than it does to us, so we must ask the patients to help us understand their interpretations and the meanings they assign to the events they’ve experienced. It is important that the patient communicates their meanings and that assumptions aren’t made. Misunderstandings can cause feelings of isolation, leading to strains or ruptures in the relationship. If this happens, try to reconnect, as this conveys respect.
Try to deeply connect with the patient emotionally through empathy and listening. Listen to what is said, what is not said, and what makes the patient defensive. We can listen to the rhythm, the sound, their vocal cadence, and watch their face for emotional cues.
Even if we believe the patient isn’t entitled to the emotions they are experiencing, we have to search for the meaning they’ve assigned to their pain. That meaning is what we can empathize with, no matter the circumstance. When we empathize, we can join them in their distress or enjoyment, and we can develop a deeper therapeutic alliance that is patient-centered and emotion-centered.
“To feel with a patient and share distress and hopelessness and mistrust of the future, is therapy. You are an observer in taking history, but you’re a participant as a therapist. To share together, is therapy.” - Dr. Tarr
Meaning develops emotional endurance
People who have chronic pain who believe they are enduring it for a deeper meaning report feeling far less physical pain compared to those who do not report a deeper meaning. Even in birthing units, women report the highest amount of pain, but also often the highest amount of satisfaction. The child being born gives meaning to the pain, and this meaning is so powerful that some women choose to endure the pain instead of accepting medication.
Help patients find meaning in their symptoms. Most symptoms are adaptive, even eating disorders, cutting, and other harmful behaviors. These things have helped people cope with the realities of their lives in some way. We don’t want them to judge their symptoms, but we want them to identify what the meaning behind them.
To really connect with a patient, we must convey to them through our words and actions that they mean something to us, and that we empathize with the meanings they’ve assigned to their lives.
Here are a few phrases I like to use that convey to the patient that I want to connect with them:
Logotherapy, created by Viktor Frankl, helps patients understand and develop meaning in their lives.
Viktor Frankl’s book not only chronicles how the principles of logotherapy helped Frankl survive the Holocaust, it also recounts his observations of how others used meaning to retain their human dignity during times of great suffering. So what is this “logotherapy” that helped people survive?
Essentially, logotherapy is a meaning-centered approach to psychotherapy. Frankl first published his ideas on logotherapy in 1938, and it is now known as the “Third Viennese School of Psychotherapy.”
The Viktor Frankl Institute lists the three principles that are the basis for logotherapy:
The core tenants can also be elaborated in another way, as done by the Viktor Frankl Institute of Logotherapy in Texas:
Frankl noted that there are a variety of ways in which we can find meaning, such as by our actions, our experiences, our relationships, and our attitude toward suffering. Indeed, logotherapy has been utilized to help treat a variety of psychiatric illnesses, such as anxiety, depression, obsessive-compulsive disorder, and even schizophrenia. Currently, there are several logotherapy institutes around the world in Africa, Asia, Europe, and North America that focus on educating the public about logotherapy and applying it to find meaning in people’s lives.
Here are some studies about logotherapy:
By focusing on what is said by our patients and those we care about and by believing that everything that is said has meaning, we can increase our connectedness with them. We can also slowly find the deeper sources of meaning and purpose which can help make sense of suffering and physical and emotional pain.
|Oct 30, 2018|
Psychiatric Approach to Delirium
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This week on the podcast, I am joined by Dr. Timothy Lee, the Loma Linda residency program director and the head of medical consult and liaison services. One of his specialities is delirium, so this week we will be discussing both hypoactive and hyperactive delirium.
What is delirium?
Delirium is an acute change in a person’s sensorium (the perception of one’s environment or understanding of one’s situation). It can include confusion about their orientation, cognition or mental thinking.
With hyperactive delirium, a patient can become aggressive, violent and agitated with those around them. A patient experiencing delirium can have hallucinations and hear things, they can become paranoid, and they are overall confused. A family, or non-psychiatric medical staff, might be concerned that the patient is experiencing something like schizophrenia.
Hyperactive delirium symptoms in patients:
Hypoactive delirium is much more common than hyperactive delirium (based on research studies), but it is often missed because the presentation is much less dramatic. People with hypoactive delirium are confused and disoriented, but they do not express their confusion verbally or physically.
Hypoactive delirium symptoms:
Often, nurses and physicians can miss the fact that the patient has the typical confusion that denotes delirium because the patient is quieter, so it doesn’t come to the attention of the medical team or psychiatrist consult service.
Delirium can even be confused for depression. One Mayo Clinic study showed that when consulting a doctor about their depression, 67% of the time, the patient ended up having delirium.
Why does delirium happen?
Often we see it happen, even to relatively healthy people, in physically stressful situations—post surgery, during an acute illness, or even just being stuck in the hospital for a few days. This does not mean it is indicative of a sudden onset of a long term mental illness, such as schizophrenia.
To consider what can cause delirium, I like to think systematically from the top of the body and work my way down. This is by no means exhaustive, but it can be helpful.
Many things can cause delirium. I like to think about starting at the top of the body and going down, as a way to not miss the cause. Here are a few we would consider as we go down the body:
How do we identify delirium in a patient?
Asking certain questions to the patient and/or medical team and family can help us understand if the patient is experiencing delirium. Often, a patient experiencing delirium will still know where they are, what they are doing, and who they are. The main test to really determine if it’s delirium is the “clock drawing” where we ask the patient to draw a clock with the hands showing 11:10.
Here are some questions and tasks we ask the patient to answer and perform to test for delirium:
Some tests that are common to determine delirium are:
How to help
It is important, if the patient has loved ones with them, to educate the family about delirium, because both hypoactive and hyperactive delirium can be terrifying to watch.
When it comes to giving medications, it’s important to follow a few rules, Dr. Lee says. Giving medications with anticholinergic side effects can make the patient more agitated. When prescribing meds, be careful not to switch from a hyperactive delirium presentation to a hypoactive delirium presentation by just sedating the patient but maintaining confusion. Medications like benzodiazepine, barbiturates, sedatives and pain medications (beyond what is needed for pain) can all cause worsening of delirium.
If the confusion is from an infection, an antibiotic should eventually help the cause of the delirium, however it may take a few days for the confusion to improve after the cause is eliminated. At times antipsychotic medications are used to help the delirium and reduce the time needed to stay in the hospital.
Even after the cause of the delirium is gone, and the delirium seems to have improved very quickly, a person may still have lingering cognitive issues. It’s important to be conservative in terms of how quickly you taper them off of the antipsychotic medication used to treat the delirium.
|Oct 08, 2018|
Ketamine and Psychedelics with Dr. Michael Cummings
Blog by David Puder, M.D., Mark Ard, M.D., Mikyla Cho,
On this week’s episode of the podcast, I interview Dr. Cummings, a reputable psychopharmacologist, about ketamine. We talk about psychedelics, the research behind it, both the positives and the negatives. We will look at how it is or is not helpful in psychiatric treatments.
(Disclaimer: There are no conflicts of interest to report. Neither Dr. Puder or Cummings is affiliated with any companies in favor of ketamine and other drug companies.)
Although ketamine has recently become a medication of great interest in psychiatry, it actually is a fairly old medication. It was first synthesized in 1962 and began human trials for anesthesia in 1964. It was finally approved by the FDA as a dissociative anesthetic in 1970.
What has piqued interest in psychiatry is that infusion of a smaller dose of ketamine produces a rapid response in terms of reversal of depressed mood, suicidality, and some treatment-resistant depressed patients.
The literature is rich (in one sense) as the most recent consensus statement (Sanacora, 2017) looked at seven randomized controlled trials, all of which support a robust antidepressant response and anti-suicide response. The difficulty with those trials is the majority of them lasted only one week. A few of the later trials lasted two to three weeks with two to three infusions per week. So, what’s lacking at this point is adequate data regarding long term treatment response and data about transitions to more traditional antidepressant treatments.
This area is of great interest, largely because of the limitations of our current antidepressants. In the STAR D antidepressant trials, 48.6% of people got a 50% reduction in depressive signs and symptoms with the first antidepressant, whereas only 37% of depressed patients achieved remission with the first medication.
Limitations of ketamine in Psychiatry
People receive low-dose infusions of ketamine for depression and suicidality, and there seems to be short term response to this, though the long term effects have not been measured.
The decrease in depression and suicidality is typically robust, but short lived. There is a fairly rapid decay of the antidepressant response following infusion. The infusions are done over 40 minutes. About thirty percent of the patients will become fairly unresponsive to light verbal stimulation. They then recover, but within a few days their mood will begin to deteriorate.
The study comparing 2 days/week to 3 days/week showed fairly equivalent effectiveness of ketamine for the several weeks it was studied. The other limitation of ketamine in terms of an ongoing treatment for depression is like all NMDA antagonists, these drugs are psychotomimetic and cause dissociation. They can induce psychotic signs and symptoms, and those do begin to become more prevalent with repeated infusions.
Currently adverse effects are known for chronic abusers, and can include cognition problems and bladder issues and we don’t have adequate data telling us how long it would be safe to continue ketamine infusions and how to make a transition from ketamine to a more stable, longer lasting treatment.
Ketamine and Dissociative States
Those who described their experiences during the ketamine infusion note a loss of sense of personal boundaries and a sense of union with the universe. There are fairly dramatic changes in their thinking.
Ketamine inhibits the brain’s primary activating receptor, the N-methyl-D-aspartatic receptor, blocking the effects of glutamate, which transiently enhances plasticity. Ketamine blocks presymptic inhibitor interneurons, blocking glutamate, leading to more glutamate overall in the brain. This “glutamate surge” leads is what is thought to lead to a rapid release of BDNF which is a growth factor for the brain. This may be responsible for the short term improvement in depressive symptoms.
People also use ketamine as a recreational drug because of its ability to induce a dissociative state. It has been a drug of abuse for a number of years since its introduction in the 1970s. It goes by “Special K,” and a number of other names. Many people abuse it after drinking and at raves. If they take a high enough dose, they can lose their ability to hear and see and become stuck in a “frozen state.”
It can produce delirium, which can be either stuporous or agitated. The related drug, phencyclidine (PCP, aka angel dust), causes more severe dissociation and psychosis. However, the effect of ketamine and phencyclidine are in the same direction and by the same mechanism.
People refer to Ketamine’s dissociative state as the “K Hole,” when one can’t move and experiences this depersonalization. Ketamine is sometimes used as a “date rape drug” because the person can be in a very vulnerable state.
Side effects/risks of ketamine infusion
When people are recovering from the antidepressant infusion, there is still a risk. They may become agitated, confused, or hallucinate, which is why one of the recommendations for treatment centers using ketamine is that they have adequate expertise in controlling psychomotor agitation and confusion if those things occur.
During ketamine infusion, about one-third of patients also exhibit a fairly pronounced sympathetic arousal during the initial portion of the infusion.
Mechanism of action
In many cases of treatment-resistant depression, it is necessary to alter the plasticity of the brain to get a response. Ketamine, perhaps via the blockade of glutamate at NMDA receptors, and perhaps via downstream mechanisms from that, seems to do this.
This correlates to some extent with how we know antidepressants and electroconvulsive therapy works. They have looked at CT scans for what is important in gaining a response, and for decades, it was thought that it was the seizure. Now, it may actually be the postictal neuronal suppression period that accounts for the therapeutic benefit because that is associated with turning on rapid response genes.
One small study looked at simply exposing people repeatedly to isoflurane, an anesthetic agent, causing repeated neuronal suppression. They also received an antidepressant response from that. So it may be that turning neurons off transiently can be beneficial in terms of resetting them at the DNA level and making them more plastic. Ketamine may not be the only anesthetic agent that alters longer term functioning of neural circuits.
Although ketamine has become popular, the major risk is not that the drug may not have psychiatric utility, but that we are still fairly early on in using it. The risk is that the use will outrun the data we have available to guide us. This may already be happening, as evidenced by the surge of new ketamine clinics.
Often, the clinics are started by anesthesiologists, and there is no clear psychiatric evaluation that may precede patients starting ketamine.
Currently, the data we have now essentially points to ketamine as treatment for major depression, refractory to other treatments. In many ketamine clinics, they’re using it to treat all complaints, but the data on this ranges from slim to none at all.
There may be a lucrative pull toward these clinics as they are usually cash pay since insurances don’t currently cover this.
Advice to Those Considering Ketamine Clinics
One should first get a very careful psychiatric evaluation, including a diagnosis of their mental disorder and a careful review of their treatment history to be sure that they have received optimal treatment in terms of established long term treatment options.
If one does decide to pursue ketamine treatment, then they should work with a psychiatrist who is well-versed in not only using ketamine, but is also knowledgeable in using other means to address depression, such as more traditional antidepressant medications and psychotherapies (especially day treatment programs).
Other Concerns with Ketamine
According to existing literature, ketamine is not a cure all for major depression. It may help “jolt” a brain that has become resistant to treatment into being more plastic and transiently being less depressed, but it is not a cure for the underlying condition.
Another concern is that we don’t know what the patient will be like after long-term treatment with ketamine. Will they have had a full recovery? Experience persistent issues or treatment complications? Cognitive issues? Bladder issues?
Ketamine may be most helpful for patients who have failed multiple treatment modalities, such as full doses of antidepressants or even ECT. It may provide a means to enhance treatment response to get the person out of the immediate danger of severe depression and suicidality. However, at this point it is not a standalone treatment.
|Sep 25, 2018|
What is psychodynamic theory?
On this week’s episode of the podcast, I interviewed Allison Maxwell-Johnson, a social worker and PhD student of clinical social work. I refer patients to her regularly for psychoanalysis, and she has had a wonderful impact on their mental health journey.
Psychodynamic therapy is a form of talk therapy where the practitioner work focuses on the patient’s emotion, fantasies, dreams, unconscious drives and wishes, early and current life relationships, and the relationship that is forming between the patient and therapist.
The history of psychodynamic therapy
Sigmund Freud is known as the father of psychodynamic therapy. He practiced in the late 1800’s and early 1900’s. Some psychiatrists and therapists think that Freud has been debunked because he is a controversial figure. But my colleague, Allison Maxwell, and I, think his impact on furthering the mental health field has been positive.
Historically, people with borderline personality disorder, somatic disorder and post traumatic stress disorder (PTSD) were all grouped under the title of “hysteria.” A few hundred years ago, these people would have been killed as witches, put in asylums, and there wasn’t much ability to, or interest in, digging into their psyche. There was certainly no warmth or empathy given to them.
Freud began to grapple with those deeper, tougher issues, claiming it wasn’t just a medical disorder. He gave empathy, and a level of connectedness to his patients that hadn’t been done before. As the first psychoanalyst, he was a pioneer in his field, and he figured out that having an emotionally connected relationship with his patients (he would even have is patients over for dinner and go for walks with them) could actually heal the patient.
Affect is something therapists need to pay attention to when it comes to each individual patient. It’s about noting the facial and emotional state of the person. Is the patient emotionally flat or expressive? Are they depressed or happy? Are they peaceful or agitated?
We focus on their emotional state and try to lean in to understand what a patient is feeling during a session. As the doctor or therapist, what is the emotional reaction you're having to the patient, in the moment? Analyze the situation—both your feelings and theirs. Ask them for clarification on their feelings, then ask yourself how you can use that information to understand and connect with the patient emotionally.
There are multiple emotions going on which can be conflicting. We need to ask ourselves if we can empathize with the distress that is in the room.
It’s not only about intellectually understanding what’s happening with a patient, or diagnosis. It’s about understanding how to create an emotional connection and help someone.
A therapist applies the principle of transference when we pay attention to the emotional state the patient has towards them. If the therapist reminds them of their abusive father, and they react emotionally, it’s a classic transference situation.
Understanding transference can help a therapist remain empathic and curious, even when a patient is angry at them. Transference can be seen in their complete reaction towards you, both from their past, and how you are interacting with them.
As therapists, we are also humans. We will have reactions to the patients we work with. Countertransference is the complete reaction we have towards our patients, both coming from how the patient reminds us of people from our past, and our reaction towards the things that the patient is uniquely doing.
The unconscious exists both in our patients and in us. If we can keep countertransference in our awareness as therapists, we can try to understand what is happening interpersonally—why we do or don’t like our patient, and why we feel angry or upset with our patients.
As therapists, we should not react to our patients out of direct emotion, but understand that countertransference is happening, and be curious about the meanings behind our feelings, and their feelings towards us.
Studies that show psychodynamic theory works:
Mentalization therapy is an emotion-focused therapy for people with borderline personality disorder. It helps them question whether they are accurately mentalizing, or understanding, their own experiences and their therapists emotional experiences. The positive effect of mentalization-based therapy is measurable. It has a mean effect size of 1-2, meaning it is 1-2 standard deviations from the control group—it works.
People who were in and out of psychiatric hospitals with suicide attempts, after mentalization therapy, can have great success in achieving a normal life.
Transference Based Therapy:
As therapists, including psychodynamic principles can help us connect with our patients. It will protect us from burnout, and give our patients the chance to feel emotionally connected with someone, in a corrective and healing way. It can be incredibly rewarding, rather than draining, when we feel connected, and our patients usually express gratitude as they heal.
|Sep 20, 2018|
Advice for medical students applying to psychiatric residency
Timothy Lee has talked to thousands of medical students about how to applying for residency programs, and here, he gives us a few tips on how to make it through the gauntlet, and how to have your best chance at landing the program you want.
Here is what Timothy Lee says:
Many students have been fine tuning their personal statements, and trying to get their resume just right, or hurrying to press the faculty to write letters of recommendation. It can be very stressful.
It’s okay to turn in information a little bit later, in order to have all of the paperwork you need. It’s even okay to review your statement after you’ve already turned it in. No one will lower their opinion based on that. You will need to have applied for the majority of the programs you are interested in by early or mid-October, otherwise the program director might wonder if you’re applying to them later as a backup plan.
What matters in a personal statement?
Every program director will have different opinions on what you write, and every program director will be looking for different things from your personal statement. For some people, it’s a chance to get to know the applicant a little bit. For others, it doesn’t really matter that much.
As long as your grammar and syntax are competent, you should be fine. Some people don’t worry about the format, and others are more particular. To be on the safe side, if you have access to a good mentor, run it by them. Also, don’t be too wordy—stick to a page and a half.
Do step scores matter?
Step scores are a very convenient screening tool for what matters, but there are studies that show that step scores are not directly correlated to success in residency performance. They are helpful, but are not the end-all-be-all. It’s only one part of the picture of an applicant. However, if you are going for a highly-competitive school, you might need to worry about step scores a bit more.
Apply to the right number of programs
The number of programs is not the only way to increase your chance of success of getting in. Pay attention to the types of programs you are applying to as well. If you are applying for a good number of programs, make sure at least half of them are are ones you are a solid and potentially attractive candidate for.
Keep a good perspective
Ultimately, you are more than your CV, step score, or personal statement. If patients like you, that’s going to go a long ways. Your patients won’t know your scores, or where you graduated from medical school. They will know if you were competent, caring and connected. That is ultimately what matters.
|Sep 16, 2018|
Therapeutic Alliance Part 1
What is a therapeutic alliance?
The therapeutic alliance is a collaborative relationship between the physician and the patient. Together, you jointly establish goals, desires, and expectations of your working partnership.
Every interview with a patient, whether it’s for diagnostic, intake, evaluative, or psychopharmacology purposes, has therapeutic potential. The treatment starts from your first greeting—how you listen, empathize, and even how you say goodbye.
It’s built from a partnership and dialogue, like any other relationship. It’s not built from medical interrogation. It’s not about pulling medical information to be able to make a diagnosis. We have to make it a positive experience for patient, so they can begin to talk about what's negative in their lives.
The therapeutic alliance is full of meaning, and it uses every emotional transaction therapeutically. If they get angry, sad, or have fear you will abandon them, as a therapist, it’s our job to figure out how to help them through that feeling within the relationship. The doctor can express desire for the patient to share, in real time, how the patient is feeling, even about his or her relationship with the doctor.
Why do we care?
We all know that some talk therapists have better outcomes than other talk therapists. What’s interesting though, is that some some psychiatrists’ placebos worked better than other psychiatrists’ active drugs. One study of NIMH data of 112 depressed patients treated by 9 psychiatrists with placebo or imipramine, found that variance in BDI score (a score that measures depression) due to medication, was 3.4% and variance due to psychiatrist was 9.1%. One-third of psychiatrists had better outcomes with the placebo than one-third had with imipramine.
Another book argues that the therapist is more important to outcome than theory or technique. Many other studies have shown that therapeutic alliance directly correlates to success rates.
What builds a therapeutic alliance?
Research shows there are a few things that grow therapeutic alliance:
Maintenance of the therapeutic frame
Empathy, attunement, positive regard
Foundational concepts of the therapeutic alliance
Our profession gives us a privileged glimpse into the human heart and mind. Each patient is idiosyncratic, unique, precious. Each patient has unique strengths which we should place focus on. Some therapists can be in a hurry to find out what's wrong, but we should also want to find out what's right with our patients.
Our own feelings, as therapists, about the session are not intrusions but clues. If you are experiencing boredom, perhaps you are not understanding the main point the patient is trying to explain. Be curious for what you are missing. If you start feeling something different than you did at the beginning of the encounter, notice it. Try to empathize for the patient with what changed.
Our goal is for the patient to feel understood, heard, accepted, felt. To be understood is to be accepted.
A strong alliance will provide a "Corrective Emotional Experience" (Franz Alexander), which means past relational pain and difficulties are worked out in a new relationship. When your subjectivity (your feelings, thoughts, goals) come into contact with the patient's subjectivity, a unique "intersubjective relationship" is formed from your mutual influencing of each other. A new dyad (2 coming together) is formed by looking at new meanings, understandings and connectedness. As a therapist, you are a “participant observer” as you observe the patient’s behavior and also become a “significant other” in their life through your interactions (Harry Stack Sullivan).
Here are some things to consider on a first encounter with a patient:
The patient will feel: examined, fear being seen as crazy, fear of not being liked, discouraged, hopeless, helplessness, needy, fear you are a mind reader, or even fear that you sleep with your patients.
In developing this relationship, it’s important to understand they can formulate defenses that are adaptive. Try to empathize with that underlying emotion. Starting with what's an adaptive response and solves something, looking for what’s maladaptive does not.
The patient may question your competence. They might say you look very young to be a doctor. The appropriate response would be to dig down and see why they are feeling what they are feeling. Say something like,"Perhaps you were looking for someone who looks older; of course you’re entitled to worry about how competent I am and how much I may be able to help you."
Therapists are always worried about being ineffectual. It's very natural to feel like an impostor in our position. It’s also normal to feel—when someone's angry at us, our mirror neurons lead us to be angry back.
Always face the patient, without desks between you, lean slightly forward, give appropriate eye contact, and do not do excessive note taking (you should be observing at least 90% of the time). Ideally, a clock is positioned behind the patient which can easily be seen by you without making obvious movements.
On Listening: An Active Process
Connection is non-verbal, and is equally as important as verbal communication, sometimes more so.
Listen to the patient’s goals, purposes, aspirations, fears, hopes, values, meanings.
How do you create and maintain a working alliance:
Be sensitive to empathic strains and prevent them from developing into empathic ruptures.
Ask for feedback. Reflect on the "we" aspect of the encounter. If the intervention/participation failed to have the desired result then look at what went wrong with the communication.
Be able to define and predict interpersonal conflicts that may cause a disruption of the shared empathic relationship. Set the groundwork for openness.
Doctor: "Tell me about your past psychiatrist? “What worked and what were your disappointments with your past psychiatrist?"
Patient: "He was kind of a jerk."
Doctor: "Can you tell me more about that?"
Patient: "He always would just stare at this computer, and often answered his pager during sessions."
Doctor: "Thank you for sharing that, I will stop typing and finish this later, I hope that if you ever have any feedback for me you will know that I will want to hear it, even if it is negative, and will appreciate knowing your experience of things."
Patient: “Ooo I was not talking about you.”
Doctor: “Ok, nevertheless it is a good reminder to not be focused on the computer, but if you are bothered by things or frustrated it will be helpful to know.”
The therapeutic alliance is an incredibly powerful relationship, and if it is managed with care, it can affect positive change in a patient’s life.
In future episodes on therapeutic alliance I will dig deeper into specifics of it, and pull upon the depth of my mentorship from Dr. John Tarr.
|Sep 06, 2018|
How to Treat Emotional Trauma
This week on the podcast I spoke with fellow therapist, Randy Stinnett Psy. D, about how trauma works, and how we can help our patients overcome it.
What is trauma?
Emotional trauma comes from stress that is overwhelms a person’s neurological system. Some stress can be good and formative, or it can be bad and get stuck in the brain, causing someone deep emotional pain.
Think of climbing Mount Everest. Some people choose to do that, and it’s easily one of the most stressful situations you can put yourself in on purpose. That’s good stress if you have trained for years and are ready for it. If someone forced you to climb Mount Everest, it would register in the brain as a trauma.
Trauma is too big for the mind, brain, and nervous system to assimilate. It’s a memory, or experience, that gets stuck because the person believed it would result in their death, or at least serious injury.
The brain has several mechanisms to keep something stuck so that the person will remember it, and try to avoid getting hurt in the same way in the future. It is a survival instinct.
People commonly demonstrate symptoms of trauma when they’ve:
People who have PTSD, or post traumatic stress disorder, have experienced a soul-level of brokenness, and even talking about the event, or having a memory of it, can bring it back with the same force that occured in the actual accident. They often have recurring nightmares, or repetitive symptoms that continue long after the event.
Typical PTSD symptoms alternate between chronic shut down and fight and flight
Body movement and trauma
We’ve all heard the reference to Pavlov’s dogs—the bell rings and the dogs salivate because they know it is dinnertime. Pavlov discovered many more things than that dogs drool. Once, his lab was flooded with freezing water that nearly filled the cages of the dogs. When they were finally able to get the dogs free, the dogs interacted differently with the world around them. They seemed hopeless.
Humans work the same way.
PTSD rates were 16% for survivors of 911, and 33% for survivors of Hurricane Katrina. Why? Traumatologists speculate it was because during 911, survivors were running away from the catastrophe to save their lives. In Katrina, the victims were airlifted out and placed in gyms, for sometimes months at a time. Those in lower socioeconomic levels had no money, no home, and nowhere to go—they were trapped.
The body is designed to move away from danger, but if the body can’t move, trauma can set in.
Attachment based trauma
Having a negative attachment with parents often sets people up for later traumas in life to be a bigger assault on the nervous system and psychological functioning, than it would have been as a standalone event.
Patients who experience unhealthy attachments often struggle with emotional regulation and boundaries.
Many people, as children, were not heard and mirrored in their emotions and experiences. When they discussed their problems with their parent, and it was met with disdain or shut down, the patient has most likely developed the idea that they have no voice. The stress was not contained and thus all the raw emotion is still there and unprocessed. This leads something to continue to be traumatic in the brain.
This follows the same pattern as polyvagal theory. When we are in connection mode, we are open hearted and happy. When we feel stress, or lack of connection, our sympathetic nervous system kicks in and we switch into fight or flight mode. If that disconnection continues, our parathetic nervous system takes over and we go into full-on shutdown. When children are repeatedly ignored or abused, they switch in and out of shutdown mode, causing trauma.
Polyvagal theory and attachment theory, and how they affect children (and adults too), are demonstrated best in the Still Face Experiment video (link to prior article I wrote on that experiment).
Attachment trauma is repeated trauma. It can occur in childhood, or any other time throughout our lives within relationships.
Notes to therapists on dealing with PTSD
Studies show that having an emotionally connected therapist, while someone is reprocessing their traumatic memories, can help heal the emotional damage of those memories.
Displaying emotional stability
Patients often superimpose all of their abusers onto their therapists. As therapists, we need to realize this, and stay steady during the entire course of therapy. Remaining calm, safe and empathic is one of the most healing things we can do for them.
It is a way of being, not just an action, or a reaction, towards our patients.
As therapists, it’s important to be able to receive feedback from our patients about what is working for them without it being an adversarial situation.
We must respond in a way that allows the patient to have their own voice. First, validate their emotional experience of the patient. Next, thank them for being honest with you. Ask for the whole story behind their feedback.
I am not saying this as some sort of technique, but rather this should come out of the belief that 1) their emotional experience is valid and needs a voice 2) it takes courage to voice any feedback and this is important for their growth and success.
When these things are truly believed, we are empathizing and thanking them, out of the core of our being, and not just as a technique.
Where they were expecting rejection, you end up validating their experience. Finally, ask them how it feels, in the moment, to be heard and to be able to safely express their opinion. Allow them to experience a felt difference between you and their abusers. This provides a corrective emotional experience!
Know when to limit the stress
Understanding the different nervous system’s functions will help you know when enough is enough for your patient.
Study the symptoms of the activation of the somatic, autonomic, sympathetic, and parasympathetic nervous systems. This is imperative, and if you cannot slowly uncover the stressful situations in a way that the patient can manage it without engaging shutdown mode, you will end up doing more damage than good.
One psychiatry resident asked my mentor, Dr. John D Tarr, if it was better to keep inpatient people at an emotional distance, so the patient would not get attached and want to continue to stay in the hospital. My mentor responded that we always want to be connected to our patients, to be empathic. When we feel they are getting attached and don’t want to leave, we need to open up that dialogue to how we can help them experience connection outside of the hospital.
Studies show that patients who feel connected to their doctor are more engaged in treatment—they go to therapy, take their medications, and continue their mental health journey.
Trauma-based memories are different from normal memories, like knowing what you ate for breakfast this morning. Trauma-based memory has a sensory aspect to it. They are stored in a different part of the brain than where we function for our daily, normal connection mode.
As therapists, when we access those memories with patients, the patient begins to switch to a different part of their mind, and demonstrate symptoms of trauma physically. They may tremble, sweat, and sometimes even their voice changes—it can be hard to get the words out, they whisper, they sound child-like.
To understand how people respond to trauma, we have to know that emotions have primacy, or first dibs, on our reactions. Our brain deems them more important than our executive functioning—our ability to reason and plan our lives’ daily tasks.
If the patient is open to it and we have established a good, trusted attachment and connection, we will talk about their traumatic memories. If we do not have a connection in that way, I will not explore deep traumatic memories with them. It is more important to build a safe, secure relationship first.
Trauma gets stuck in the non-analytical parts of the brain—our emotions, creativity, experiences, art. It’s image-based, somatic (physical body), it’s non-verbal. Parts of the left hemisphere of the brain deals with logic, reasoning and language. To integrate this part of the brain, the patient will have to access the emotional parts and then put words to their experiences.
In that conversation, these are some of the questions I will ask:
Allow for freedom
Also, when we require our patients to do anything, even to stay for the whole hour of therapy if they do not want to, we are reinforcing the trapped feeling. Keep an open dialogue about what your patient is feeling throughout the therapy session.
If the patient is suicidal with a plan and intent, they likely need a safe place to get through the intense time. I will tell them, “My goal is to not keep you here indefinitely. We will come up with a plan to get you out of here, and for you to be healthy.”
In general, try to give your patients, especially the PTSD ones, choices. Create boundaries and give guidance, but allow them to have freedom in their choices.
In this first discussion with Dr. Stinnett, I wanted to highlight some introductory understanding on trauma. We discussed how trauma is stored differently in the brain and how the polyvagal theory is connected with this journey. We highlighted the importance of emotion, connection and feedback. Please leave comments below on your thoughts regarding this blog and podcast!
|Aug 23, 2018|
Setting Boundaries in Relationships
What are boundaries?
When we refer to boundaries, we are talking about emotional walls that are healthy. Boundaries are meant to keep us in relationship with the people that we love.
Think of them as your property lines around your house. You know where your lines are, where your property ends and your neighbors begins. Therefore you know what you are supposed to take care of and what your neighbor is supposed to take care of.
A boundary defines our self. Within ourselves, our “property” consists of our physical body, our desires, our intellect, and our ability to make decisions. It gives us a sense of defining what is “me” and what is “not me.”
We are not supposed to take on too much of other people’s emotional experiences. When I was a newly practicing psychiatrist, I didn’t know that, and I felt depressed after meeting with a depressed patient. It is possible to have an understanding of what is happening in someone’s emotional world, but not take it on yourself.
There is a psychological principle that is common among people who struggle with having good boundaries with others. It’s called “siding with the aggressor.” For example, if someone grows up in a home where the father is constantly displaying angry behavior, a child might learn to develop a sense of humor if he or she learns that will diffuse the situation. Rather than running away from, or fighting back, these people joined with the aggressors, paying attention to them, calming them, helping them.
Early on in childhood, people who side with the aggressor understand how to make others happy. This continues into adulthood and is formative in new relationships in how the person would choose to interact with others.
I don’t think of it as a weakness, I think of it almost as a superpower—these people are incredibly skilled interpersonally when they get older. They know how to react to others, how to make others happy, and how to make angry people calm down. They are great peacemakers, therapists, and psychiatrists. It was an adaptive feature for them in childhood.
But as they grow into adulthood, they need to learn to choose when to use this superpower, or when to have a boundary.
My wife, Lindsay, first began learning about boundaries when she was experiencing burnout as a young, working woman. She never said no, always went above and beyond the requirements of her job. And at the end of the night, she was exhausted. After awhile, she started to become upset—upset at herself, and even a her situation.
Within the Big 5 personality types test, Lindsay scores high in Trait Agreeableness. People who are high in that trait value relationships, are empathic and helpful. They will do things they don’t want to, merely to maintain their relationships. Women typically test higher in the trait than men.
I see many women come into my practice who have high markers of agreeableness—they haven’t found (or been able to express) their boundaries. They have issues with chronic pain, problems with expressing anger, either within themselves, or towards others.
It’s also common that these people have no idea that their “helpfulness” is causing them huge amounts of physical pain. People who are caretakers, who feel looped in to being someone’s source for happiness, life, wellbeing, often get looped into these types of situations if they don’t have a strong sense of self. Obviously, many people are caretakers for their relatives. I’m not talking about being a nice person versus being selfish, or being a caretaker versus letting someone you love be alone.
I’m talking about the emotional position of your heart during those situations. Are you able to say no when you need to? Are you asking for help when you need to? Are you taking time for yourself? Are you in pain? What is your emotional state when someone calls and asks for help? Do you check in with yourself before you say yes?
How do you know when you need to start establishing boundaries?
Typically, with people who have no boundaries, the resentment will build and build, and they will do something drastic to relieve their pain—cut off the relationship, quit caretaking altogether, stop being friends with the person, get a divorce. Or the resentment will build up in their body, causing either depression (as the anger is turned inward) or body pain (as the body carries the burden).
The truth is though, that when someone with no boundaries says yes, it might be ingenuine. They are saying yes out of guilt and obligation, not out of a true desire to say yes.
When we do things out of obligation or compulsion, we lose passion for that task, and begin to build resentment. If we aren’t making the choice to say yes, we are thus protecting our ability to say yes to our passions, joys and desires.
Good fences make good neighbors
As you’re setting up your “fence,” you want to keep the bad out, but it will also keep the good in.
When we talk to people about boundaries, they are often scared of beginning to say no.
When you learn to say no, and you begin to make new friendships with people, you will tend to set higher standards for how you want to be treated during those relationships.
How to set up healthy boundaries
Parenting and boundaries
Children are difficult to have boundaries with. It can be because we love them and want to give them the world, because we know they aren’t fully emotionally developed, or because we want to ease some of our own exhaustion by giving in!
One key to holding our boundaries when our kids throw temper tantrums is to respond to tears with empathy, not just say “yes” to ease our discomfort. If we resonate with them, it will help both us and them. For example, if your child is screaming and crying about leaving the park early, try saying, “I know it must feel hard for you to leave something that is so fun. We will come back again. Nevertheless right now, it’s time to go. At home, you have toys too and can play with them.” This offers empathy, hope and it keeps a boundary.
If we give in and let them stay, we are teaching them a bad habit. We should never set a boundary that we aren’t willing to follow through on. It helped Lindsay and I to remember the statistic that even giving in to 1 out of every 8 tantrums taught the child that tantrums worked, and they would win. It reinforced their negative behavior.
If we make them leave and don’t care that they are upset, we aren’t recognizing their emotions and are being unempathic.
Letting children feel stress, and being empathic and reassuring when they’ve completed the task, is more helpful for them as they grow. If you step in every time and relieve the stress (such as not making them go to school when they don’t want to), you’re not preparing them for adulthood.
Keep your boundaries, and express empathy.
Boundaries in romantic relationships
Dating is hard work. There are several boundaries to navigate during dating. When you have talks about boundaries in dating, if they don’t respond appropriately, you definitely need to evaluate whether you want to continue dating them or not.
Be honest and open right from the start.
This is a hot topic in society today—consent, verbal consent, being able to talk and have conversations. Many of my patients do not want to follow through with physical relationships with people, but they have a hard time saying the actual word “no” when they are in the moment. Define what you want and don’t want, long before you get into another relationship. If someone does not respect your “no” that should be a deal breaker.
Define what you want and don’t want, what you believe spiritually. What are your worldview deal breakers? Defining your deal breakers and writing them down, and asking your friends to help keep you accountable, is important.
If you are Muslim, Jewish, or Christian, make sure that you know what you want in a partner, and that you aren’t letting go of boundaries that will one day matter to you again, just so you can date someone.
Part of dating now is “ghosting,” or shutting down communications when you don’t want to have real conversations about how you’re experiencing someone. I believe this has developed unhealthy communication patterns in society.
When Lindsay and I were dating, she almost broke up with me because I demonstrated some anxious behaviors during our dinners together. I would shake my leg, or eat three loaves of bread in ten minutes! She nearly ended it without telling me why—she just thought I was odd.
But when she talked to her friends, they urged her to communicate how she was experiencing me. When she told me what she was feeling, and I told her I was behaving that way becuase I was nervous—I was so into her! She was pleasantly surprised and we continued dating. Now, we have been married for 6 years and have two children together.
When you’re dating, make it a point to not shut down just because you’re having a negative experience of someone (if that experience isn’t too bad, of course). Try communicating to the person what you’re feeling. This will go a long way in setting up the relationship (and changing your personal habits) to developing positive communication patterns.
Dealing with relationships and change
People view consistency as a positive. That means that as humans, we are wired to strive for create an equilibrium in our relationships. And agreeable, boundary-less people strive for consistency in behavior more than others.
When someone that didn’t have boundaries starts saying “no,” the people in their lives start to sit up and notice what they would deem “inconsistency.” The first time you say you cannot help with that thing you’ve helped with every week, they may be nice about it. But the second and third time, they’ll start to say that sentence we all fear…”you’ve changed…”
When you grow in your boundaries, there will be people who don’t like them. They will shame you, yell at you, push every button that they can to get you to comply in the way that you used to.
Understand that by saying no, you may not be as helpful in relationships, volunteer organizations, or work situations as you used to be.
But, by saying no, you will also free up your time to be able to accomplish what only you can accomplish in your life. Saying no to trivial things that are daily time-vampires will free you up to do the things you are passionate about. That passion will grow, your freedom will grow, and you’ll be able to really start to feel in control of your own life and schedule again. People will respect you.
|Aug 11, 2018|
The History and Nuances of Bipolar Illness
Below is a detailed review of the podcast episode, with most of the content that Dr. Michael Cummings and I (Dr. Puder) discussed. Special thanks to Arvy Wuysang (MS4) for his work in the initial transcription and organization.
The history & nuances of bipolar illness
Bipolar Illness was first discovered by Emil Kraepelin, who was also the first to describe schizophrenia in the 19th century.
Kraepelin noticed another major mental illness in which people had episodic disturbances of mood. He saw either elevation of mood and increased energy, along with a decreased need for sleep, and often impulsive or psychotically related behaviors.
Then, the same patient would experience the opposite, sleeping through the day, demonstrating lowered energy and depression. These patients were noted to have normal function in-between these episodes.
Nuances of the bipolar illness diagnosis
The Diagnostic Statistical Manual of Mental Disorders (DSM) identifies bipolar illness primarily by the presence of at least one episode of mood elevation to help distinguish it from unipolar or major depressive disorder.
Here are some defining symptoms:
Bipolar and the limbic system
Underlying pathophysiology is centered around the limbic system. Involves the temporal lobes and and structures which swings upward into the mamillary bodies into the anterior cingulate gyrus, which then projects forward into the frontal lobe. That circuit goes through periods of hypo-activity or depression in people who are bipolar. They have depressed metabolic rates of the system upto 30 to 40 % below normal. During periods of mood elevation, there is an increase in metabolic activity and instability in that limbic circuit. The mood is an element of that, but the person’s overall activity, sleep-wake cycle, circadian rhythms, along with all the things related to the functioning of the limbic system are disturbed in bipolar illness.
Bipolar illness and sleep patterns
There are some models of the illness that suggest that perhaps the core of the pathophysiology of bipolar illness is an abnormally regulated biological clock.
In most of us, the nerve cells, the neurons that make up the biological clock, are very tightly linked to each other in terms of their operation. They literally form two pacemakers or oscillators in a very small structure that sits right on top of the optic chiasm called the supraoptic nucleus.
Normally all of our circadian rhythms are regulated by this master clock. In healthy people, it’s very difficult to get the two oscillators to separate from each other. In bipolar people, those oscillators drift apart relatively easily. Something as simple as loss of sleep during the latter half of the night will cause them to diverge from each other.
When that begins to happen, the overall functioning of the limbic system begins to oscillate in an unstable manner.
People have looked at things like disturbed sleep as being a very common precipitous of a mood episode. If somebody has a difficult day or disturbing event, and they’re genetically vulnerable to being bipolar, they may not sleep well at night, and the next night they may not need to sleep as much. The night after that, they really don’t sleep, and then their mood begins to elevate and another episode is initiated.
Genetic markers of bipolar illness.
Bipolar is typically passed on genetically, and can be linked with other similar markers of illness. Around 100 genetic markers have been linked to bipolar illness.
They overlap with schizophrenia in part, but not entirely. People with bipolar illness have a much more normal brain in terms of development then do people with schizophrenia. But, there appears to be an inherent defect in the operation of the limbic system elements with these periodic repeating of overactivity and underactivity, plausibly related to the core biological clock.
Mood stabilizers have an effect in terms of decreasing and stabilizing the activity of the limbic system. They tend to push that clock back toward being phase-linked or operating together as a single oscillator, rather than as divergent oscillators.
History of Lithium
The very first mood stabilizer discovered was lithium. It was very popular in the 19th century for the treatment of gout because it decreases uric acid crystals.
In the 1940s, a psychiatrist named John Cade (1912-1980) served in World War II and was a prisoner of war for three years. After the war, he worked in a repatriation hospital in Australia and became fascinated with bipolar illness. At the time, he looked at the earlier history and thought that uric acid somehow caused bipolar illness. That turned out to be a wrong hypothesis. But, it led him to use lithium urate, a soluble form of uric acid, in hamsters, to see what would happen. The hamsters got lethargic and sleepy upon administration.
He decided to give his lithium compound to ten patients—six of them were bipolar, four of them were schizophrenic. They all became less agitated, though the schizophrenics didn’t change all that much. However, all of the bipolar patients’ moods stabilized.
It’s amazing how he didn’t kill any of these patients in spite of giving them gigantic doses of lithium. His initial dose was 1300 mg, three times a day. Most of the patients got ill with that. If you give somebody too much lithium, they develop nausea, tremor, and diarrhea. You can make them very seriously ill with lithium because it has a very narrow therapeutic index. The distance between therapeutic and toxic is not very far. Optimal dose for most patients 0.6 - 1.0 mmol/L. Toxicity usually begins at about 1.5 mmol/L, serious toxicity begins at about 2.0 mmol/L.
At Loma Linda and at patton State Hospital, most patients start at 900 mg at night, obtain a plasma concentration five to seven days later, and then adjust the dose.
Lithium should never be given in divided doses.
The kidneys is spared by having a long trough period between lithium doses, so it is best to give it at bedtime.
Lithium tends to decrease urine concentrating capacity. Almost everyone who takes lithium, their urine output will increase by about 20%, and their water intake will correspondingly increase by about 20% to compensate. There are a few people who get much more severe diabetes insipidus, an insensitivity to anti-diuretic hormone in the kidney.
Over the course of many years, about 5% of people who take lithium will develop mild to moderate degrees of renal failure or insufficiency. That risk is minimized by keeping the lithium level < 1.0 meq/L and also by giving Lithium only once a day.
Lithium and suicidality
It’s clear that lithium reduces suicidality, which may be a product of its ability to inhibit impulsivity. Suicide rates are substantially lower when people take lithium.
In the healthy population, when they’ve done studies in areas with very low concentrations of lithium in the groundwater, rates of suicide and rates of homicide are lower in areas with lithium in the groundwater compared to areas that don’t have lithium in the groundwater.
The amount of lithium that people are getting from the groundwater would be roughly the equivalent of taking 3 milligrams of lithium a day. This means that in the healthy non-bipolar non-mood disordered brain, it doesn’t take very much lithium to make people somewhat less violent.
When would you take someone off Lithium?
History of other mood stabilizers
The reason we have other treatments for bipolar illness, is largely the result of the work of Robert Post.
Post was a psychiatrist who worked at NIMH and was doing an unrelated experiment. He was looking at kindling, or increased sensitivity of the limbic system, by putting electrodes into mouse temporal lobes and giving them a one second electrical stimulus once a day.
Initially, when you do that, nothing happens.
But about day two or three, the mouse will have a complex partial seizure, a temporal lobe seizure. If you keep doing it pretty soon the mouse will start having spontaneous seizures. Robert Post looked at that and thought that the nerve cells of the limbic system can become more and more sensitive, more and more hyperactive, less and less well-controlled. He thought that he could block that effect, in terms of seizures, with anticonvulsants. He then, made a leap in logic, thought that perhaps mood episodes are acting like electrical stimulus causing kindling in the limbic system for people with recurrent mood episodes, like in bipolar patients.
He decided to treat some bipolar patients with an anti-epileptic.
The first medicine he used was Carbamazepine (Tegretol). Tegretol is a very difficult drug to use because it induces its own metabolism, so the level keeps falling. It also is fairly toxic with respect to the bone marrow. So, you have to watch out for loss of white cells, red cells, platelets.
He fairly soon turned to another anti-epileptic, valproic acid, which is a branched-chain fatty acid. He found that it was also effective in treating bipolar illness. Turned out that compared to lithium, valproic acid was more effective if the person was a rapid-cycling bipolar patient having more than four episodes a year. (Although lithium remain superior if the person is a classic type I bipolar patient.)
In young women in general, valproic acid it can be problematic because it can cause Polycystic Ovary Disease.
Psychiatry has pretty much examined every anti-epileptic introduced since to see if it had mood stabilizing properties.
Lamotrigine (Lamictal) for example, does treat bipolar depression and does stabilize mood cycling, but has almost no benefit with respect to mood elevation. In fact, Lamotrigine as a monotherapy may actually cause switches into mania in some patients.
People have looked at Topiramate and found that it may have some prophylactic capability but doesn’t seem very effective at all if the person is already manic or depressed. If their mood is already stable, and you’re just trying to decrease the cycling, it may have some benefit.
Lamictal, used as a mood stabilizer, may have gotten more use than it should because although it does have antidepressant properties in bipolar illness, it is certainly not a benign drug.
People were initially attracted to it because there’s not a lot of laboratory monitoring involved. The plasma concentrations of lamotrigine don’t correlate very well with its efficacy because it is very rapidly cleared from the blood compartment and taken into tissue. It’s easy to administer and when you’re not using it for seizures, usually can be dosed all at bedtime.
It does carry a risk of Stevens-Johnson Syndrome, which is severe malignant rash, and which the person winds up looking like a burn victim because their skin literally dies and falls off.
It also can cause lymphohistiocytosis, which is a similar autoimmune process, but involving the blood vessels and internal organs. Luckily, that is rare, but it's also typically a life threatening response to the drug
The risk of the side effects above are increased by titrating the drug to rapidly. They discovered the side effects when they were using the drug initially for seizures. They were often increasing the dose by a hundred milligrams a day starting at 100 mg, and by day four, the person was on 400 milligrams. They found a 9% increased rate of malignant rash. If you slow down and don’t go faster than around 25 to 50 milligrams a week in the titration, the risk is reduced, but it’s still not zero. It’s probably less than one half of 1%, but it is a caution.
The other caution with the drug of course in bipolar patients is it sometimes is not a very good monotherapy because it doesn’t provide any protection against mood elevation. It seems to be effective in treating the depressed phase of the illness, but not the manic or hypomanic phase.
Oxcarbazepine has flunked multiple trials as a mood stabilizer. Oxcarbazepine differs from Carbamazepine in only one bond. In carbamazepine the bond between carbons 10 and 11 is an epoxide bond, while in oxcarbazepine that same bond is an ester bond.
It appears, however, that the mood stabilizing properties of carbamazepine result from the epoxide metabolite, and of course oxcarbamazepine does not produce that metabolite.
Oxcarbazepine can, in some individuals, reduce impulsivity, which seems to be a truism across the anti-epileptic drugs, but it’s not an effective bipolar treatment.
There was only one study looking at it in forensic settings for impulsive or violent patients. It was a self-funded single investigator study and it’s been the only study that was ever produced, never replicated. It was suspicious in that the patients were all outpatients, self-recruited via newspaper ad. It’s database even for impulsivity and so forth is pretty limited. It does have some application in that regard, but it is not as good as people hoped.
People became enamored with it simply because it was easier to use than carbamazepine, which isn’t to say that it’s benign. It induces hepatic enzymes, it causes dangerous hyponatremia in about 2.5% of the people who take it.
There haven’t been any really good studies identifying it as an anxiolytic. Like most anti-epileptics, it can be sedating and somewhat calming, but you could get the same effect from literally any of the anti-epileptic drugs, probably safer would be gabapentin.
Antipsychotic use as mood stabilizer
Some of the second generation antipsychotics have also shown mood stabilizing properties, albeit as an addon to a primary or classic mood stabilizer. This include drugs like Aripiprazole, Brexpiprazole, Cariprazine, Olanzapine, and Quetiapine. Quetiapine in particular is effective in treating bipolar depression, as is Lurasidone.
Antidepressants as mood stabilizers
Do not give an antidepressant to a bipolar depressed patient!
There are now a host of studies suggesting that antidepressants offer little or no benefit with respect to depression in bipolar illness. It serves only to increase the rate of mood cycling and to risk a switch into mania.
Cognitive side effects of mood stabilizers
Lithium typically causes cognitive impairment only if the plasma concentration is too high, in which case it can cause decreased brain function all the way up to coma if the concentration is high enough. However, lithium used at therapeutic concentrations actually is neurotrophic.
It’s been used now in some demented patients with modest results. MRI scans will show a thickening of the cortex if you put somebody on lithium.
In contrast to lithium, antiepileptic drugs almost universally tend to dull cognitive performance. For example, one of the tip-offs that you’re giving the person too much topiramate is they start to lose the ability to find nouns, they become anomic.
Barbiturate and Benzodiazepine use in bipolar illness
Barbiturates were introduced in 1903. At that time, they were essentially the only psychiatric medication available. They treated literally everything that involved mood elevation or agitation with a barbiturate.
In the middle ages, individuals that seemed to have manic episodes as we understand it today, were considered witches. They were given doses of sedation that would bring a normal person down. These manic individuals, however, would not be sedated with those doses.
This is described in the book The Witches’ Hammer. Most of these tests were designed so that if you were the accused, you most likely won’t pass them. For example, one of the tests was being tied up and thrown into a mill pond. If you drowned, you were concluded not to be a witch, but of course you were dead. If you manage to float and you survived, you were concluded to have done so via witchcraft, in which case they retrieved you from the water and subsequently burned you.
Frankly, psychiatry has come a long way!
Importance of sleep hygiene in bipolar illness
One of the most important things to teach bipolar patients is to emphasize the importance of sleep hygiene. They should go to bed at the same time every night. It’s dangerous for them to casually stay up to watch tv or a movie etc. That may be a setup for them to have the next episode of mood disturbance.
If they’re having difficulty sleeping, this is a group in which long term use of one of the Z drugs may be appropriate.
Dr. Cummings’ personal favorite in that group is Eszopiclone (Lunesta), because it has a longer half-life. It’s half-life is around 4-6 hours, so it’s long enough that the person will actually stay asleep. It also has a broad dose range, 1 mg - 8 mg at night.
It’s been used to treat primary insomnia in some individuals for up to decades without development of complete tolerance, or resulting in any withdrawal syndrome if the medication is stopped.
Education for bipolar patients
Patients and families need to realize that the more episodes of illness they have, the more resistant to treatment the illness will become, and the less responsive the illness will become to medications. This idea goes back to Robert Post’s study on kindling.
Additionally, when people have more episodes, the cycle tends to become progressively shorter. If they were initially having an episode every two or three years, it may suddenly occur every year, to having multiple episodes for a year.
One of the major costs for both families and individuals who are bipolar is that severe depression or severe mania is incredibly disruptive to the individual’s life. It can destroy their marriage, their job, and cause large setbacks.
I (Dr. Puder) will bring patient's families in, get them on board with a plan to identify early symptoms such as decreased sleep, increased energy, and change in physical activity. I want the family to keep in close contact with me if these things are developing, and I will alway get them in within the week.
Role of psychotherapy in bipolar illness
|Aug 02, 2018|
The History, Mechanism and Use of Antidepressants
In this week’s episode of the podcast, Dr. Michael Cummings and I talk about the history of antidepressants, and their use in overcoming depression and anxiety disorders. Below is a short blog on the topic to complement the podcast and subsequently I you can find detailed notes on the topic further below.
What is depression?
The overarching term “depression” is characterized by feelings of sadness and hopelessness, anxiety, and loss of pleasure.
But there are many different types of depression and depressive disorders:
Some symptoms of depression are:
Major depression is characterized by a continuous feeling of sadness—it does not lift for long periods of time. The average length of an episode of major depression, if not treated, last around 11 months. People with major depressive disorder often had an average of four to eight episodes during their lifetime.
Each episode of major depression usually makes the next episode more likely.
The annual prevalence rate for major depression estimated in the US and in Europe ranges from 2-7%. But, if somebody has an episode of major depression, the odds that they have a second episode at some point in their life rises to almost 50%. Then, for each episode they have after that, the probability of the next one becomes more likely.
For people who had recurrent episodes of major depression, by the time they were in their 50s, 60s, or 70s, they had often become chronically depressed or apathetic; their life had deteriorated significantly.
Melancholic depression is at the severe end of the depressive spectrum.
These people have a severe loss of enjoyment, and they usually lack energy. They often develop mood congruent psychotic symptoms, such as delusions that they are guilty for everything in the world.
This tends to be the most resistant form of depression. When severe. people who suffer with melancholic depression sometimes require electroconvulsive therapy to snap them out of a depressive state.
Is depression a chemical imbalance?
People with recurring bouts of major depression can actually experience anatomical damage to the cortex and the spine, because depression is caused by, and can also cause further, chemical changes in the brain. How does this work?
The history of antidepressants
Doctors used to believe depression was norepinephrine or serotonin deficiency. We now view depression as the inability of the limbic system to be modulated by the neurotransmitters.
Antidepressant medications target this problem by increasing the ability of these molecules that deal with our emotions, motivations and memory to do what they need to do.
Prior to the discovery of antipsychotics and and antidepressants, depressed and anxious patients were sent to restful places, or asylums. In the late 19th century, the number of asylums surged.
They used psychoanalysis and psychotherapy to treat patients, but there was no medicinal treatment for psychiatric issues. They sometimes used chemically induced convulsive therapy to induce a grand mal seizure two to three times a week, and it was quite a brutal treatment.
Electrical induction of convulsive therapy came about in the 1940s. It was widely used in both mood disorders and psychosis.
As a result of these two treatments, people had broken bones and muscle damage. Because of that, electroconvulsive therapy developed a horrible reputation.
The treatment was later reformed in terms of paralyzing people and using anesthesia prior to treatment. These steps made electroconvulsive therapy much more humane than it originally was. Now people don’t experience the side effects they would have back then. It still remains the most effective treatment there is for severe melancholic or catatonic depression.
As I discussed in a previous blog on psychopharmacology, in 1940 the original antipsychotic was originally an antihistamine. When doctors noticed the sedative effect it had, they started prescribing it for pre-surgery anxiety. It was the first time doctors prescribed a medication to treat mood.
In 1951, Dr. Roland Kuhn discovered that imipramine, a drug originally tried for psychosis, was not in fact effective in treating psychosis. He did found that imipramine was effective in improving mood and anxiety symptoms.
First generation antidepressants
After World War II, there was a surplus of hydrazine missile fuel leftover. People began experimenting with hydrazine as a base compound for development of drugs.
One of the first drugs that came out of that endeavor was Isocarboxazid, which was initially used to treat tuberculosis.
It turned out that a few people who were being treated for tuberculosis happened to be bipolar and became manic while taking isocarboxazid, which led to the discovery of monoamine oxidase inhibitors (MAOIs).
MAOIs stop the breakdown of serotonin, dopamine and norepinephrine in the brain. MAOIs stop that enzyme from removing those chemicals from the brain. The result is more balanced neurotransmitters—and a lack of depression.
Still, the possible side effects including incredibly high blood pressure when eating certain foods made scientists keep searching for better alternatives.
Selective serotonin reuptake inhibitors were introduced to the market in 1987, with the introduction of Fluoxetine. The SSRIs were almost instantly popular because they were much safer.
These drugs increase the amount of serotonin available in the brain.
The SSRI became very widely used very quickly for treatment of depression.
They have even been found useful because the increased serotonin input to the limbic system they create (the part of our brain that deals with motivation, learning, emotions and memory) decreases the amount of anxiety and vigilance that the person has.
SSRI was also found to be effective for:
If someone was still resistant to SSRI medication and is still depressed, electroconvulsive therapy is still the best option available.
When do you prescribe antidepressants?
If the initial episode of depression is not severe to the point that it’s inducing suicidal ideation or impairing their ability to engage in activities of daily living, then psychotherapy and exercise should be the first treatment.
If the following statements are true, antidepressants could be prescribed:
Overall, about 40% of the probability of becoming depressed is genetically determined, the other 60% arising from the environment.
There are also important gender differences, women during their reproductive years have about twice the rate of major depression compared to men.
If somebody has recurrent episodes of depression, an antidepressant should be considered, and possibly continued indefinitely. However I often recommend for these patients a combination of treatments including exercise, diet, effective therapy, and over time can get them on lower doses or less medications.
Below is a detailed review of the episode, with most of the content. Thanks Arvy Wuysang (MS4) for your help with this!
|Jul 24, 2018|
Emotional Shutdown—Understanding Polyvagal Theory
“Polyvagal Theory Simplified”
By David Puder, M.D.
Polyvagal theory explains three different parts of our nervous system and their responses to stressful situations. Once we understand those three parts, we can see why and how we react to high amounts of stress.
If polyvagal theory sounds as exciting as watching paint dry, stick around, trust me. It’s a fascinating explanation of how our body handles emotional stress, and how we can use different therapies it to rewrite the effect of trauma.
Why is polyvagal theory important?
For therapists, and pop-psychology enthusiast alike, understanding polyvagal theory can help with:
We like to think of our emotions as ethereal, complex, and difficult to categorize and identify.
The truth is that emotions are responses to a stimulus (internal or external). Often they happen out of our awareness, especially if we are out of touch, or incongruent, with our inner emotional life.
Our primal desire to stay alive is more important to our body than even our ability to think about staying alive. That’s where polyvagal theory comes in to play.
The nervous system is always running in the background, controlling our body functions so we can think about other things—like what kind of ice cream we’d like to order, or how to get that A in med school. The entire nervous system works in tandem with the brain, and can take over our emotional experience, even if we don’t want it to.
A story about a gazelle...
Animals are a great example of how we handle stress, because they react primally, without awareness. They do what we would, if we weren't so well tamed.
If you have ever watched a National Geographic Africa special, you’ve seen a lioness chase a gazelle. A group of gazelles is grazing, and suddenly one looks up, hyper aware of what is happening around him. The whole group notices and pays attention.
After a moment, the lioness starts her chase. The gazelle she’s singled out runs as fast as he can (sympathetic nervous system), until he is caught. When he is caught, he instantly goes limp (parasympathetic nervous system).
The lioness drags the gazelle back to her cubs, where they begin to play with it before they go in for the kill. If the lioness gets distracted, and the gazelle sees a moment of opportunity, he’s up and sprinting off again, looking like he suddenly came back to life (back into sympathetic nervous system response).
When the gazelle was caught, with fangs around his neck, his shutdown response kicked in—he froze. When he saw the opportunity to run, his fight or flight kicked in, and he ran.
Poyvagal theory covers those three states—connection, fight or flight, or shutdown.
Here's how they work...
or...rest and relaxation...or myelinated vagus nerve of the parasympathetic nervous system coming from the nucleus ambiguus response
During non-stressful situations, if we are emotionally healthy, our bodies stay in a social engagement state, or a happy, normal, non-freak-out state.
I like to call it “connection.” By connection, I mean that we are capable of a “connected” interaction with another human being. We are walking around, unafraid, enjoying our day, eating with friends and family and our body and emotions feel normal.
It’s also called ventral vagal response, because that’s the part of the brain that is activated during connection mode. It’s like a green light for normal life.
How does this look and feel?
Freeze, Flight, Fight, or Puff Up
...or the sympathetic nervous system response
The sympathetic nervous system is our immediate reaction to stress that affects nearly every organ in the body.
The sympathetic nervous system causes that “fight or flight” state we have all heard of. It gives us those cues so that it can keep us alive.
How does this happen? How does this look and feel?
In fight or flight, at some level we believe we can still survive whatever threat we think is dangerous.
...or the Unmyelinated Vagus of the Parasympathetic Nervous System coming from the Dorsal Motor Nucleus
What’s interesting about this part of the parasympathetic nervous system? Its function is to keep us frozen as an adaptive mechanism to help us survive to either fight or flight again.
When David Livingston was attacked by a lion, he later reported, “it caused a sort of dreaminess in which there was no sense of pain nor feeling of terror, though quite conscious of all that was happening.”
When our sympathetic nervous system has kicked into overdrive, and we still can’t escape and feel impending death the dorsal vagal parasympathetic nervous system takes control.
It causes freezing or shutdown, as a form self preservation. (Think of someone who passes out under extreme stress.)
How does this look and feel?
In shutdown mode, at some level our nervous system believes we are in a life-threatening situation, and it tries to keep us alive through keeping our body still.
Some people who have had both attachment trauma and subsequent trauma can have chronic suicidality, and dissociation episodes that last days to months. Research shows that long term solutions include:
How trauma affects the nervous system
As humans, we do the same thing as that gazelle when we perceive emotional or physical danger. We alternate between peaceful grazing (parasympathetic - connection mode), fight or flight (sympathetic system- fight and flight) or shutdown (parasympathetic- shut down mode).
Our response is all in our perception of the event. Maybe someone was just playing a game when they jumped out to scare us, but we fainted. Whatever the reason, whether the incident was intentional or not, our body shifted into shutdown mode, we registered it as a trauma. our body shifted into shutdown mode.
Or maybe the trauma event was really, life threatening, and our nervous system responded appropriately to the stimuli.
No matter what the cause was, our brain believed what was happening was life threatening enough that it caused our body to go into flight, flight, or shutdown mode.
If someone has been through such a traumatic event that their body tips into shutdown response, any event that reminds the person of that life-threatening occurrence can trigger them into disconnection or dissociation again.
People can even live in a state of disconnection or shutdown for days or months at a time.
Veterans often experience this during loud, sudden noises such as fireworks or thunderstorms. A woman who was raped might quickly switch into hypervigilant or dissociated response if she feels someone is following her. Someone who was abused might be triggered when even another person starts yelling.
The problem occurs when we haven’t processed the original trauma in such a way that the original trauma is resolved.
That’s what PTSD (post-traumatic stress disorder) is—our body’s overreaction to a small response, and either stuck in fight and flight or shut down.
People who experience trauma and the shutdown response usually feel shame around their inability to act, when their body did not move. They often wish they would have fought more during those moments.
A Vietnam vet may feel they failed their companions who died around them while they stood, frozen in fear. A rape victim may feel he or she didn’t fight off their rapist because they froze. A victim of abuse may feel they quit trying to escape their abuser, and that they are weak or failed.
Much of “stress” training, which trains people to continue to remain in fight and flight mode, aims to keep people out of dissociation during real life or death situations. Unfortunately, these practices aren’t common beyond elite sports teams or special forces. The right amount of stress, with good recovery, can lead our nervous systems into higher levels of adaptation.
Coming out of shutdown mode
So how do we climb back out of shutdown mode?
The opposite of the dorsal vagal system is the social engagement system.
So, in short, what fixes shutdown mode is bringing someone into healthy social engagement, or proper attachment.
Getting down into the nuts and bolts of how this works in our body can help us understand why we feel the way we do physically when your body is in fight, flight, or shut down mode.
When we understand why our body reacts the way it does, like a string of clues and some basic science about the brain, we can understand how to switch states. We can begin to move out of the fight or flight state, out of the shutdown mode, and back into the social engagement state.
As therapists, whether we are just establishing a connection with a new, anxious patient, or helping them deal with their deepest traumatic memories, knowing how to navigate the polyvagal states is important.
It can also be helpful if you have just identified yourself in some of these symptoms. Such as, “When I’m with my parents, even as an adult, and they start fighting, I feel lightheaded and disconnected.”
If you’ve seen some of these things in yourself, hopefully through therapy, and even understanding how this works, you can pull yourself out of a disconnected state.
Studies show that some parts of the brain shut down during the recall of traumatic events, including the verbal centers and the reasoning centers of the brain (Van Der Kolk, 2006).
This is why it’s important to conduct therapy, or coming out of shutdown mode, in a safe, healthy way, in a safe, healthy environment. This is why positive attachment is imperative. Otherwise, you run the risk of retraumatizing the patient.
Because I am a psychiatrist, I am going to write this to demonstrate how to help a patient switch out of shutdown mode.
However, these tips still apply to those who are just understanding how shutdown mode works. And it can even help those who feel shut down to begin to know how to try and attain a healthy social engagement mode again.
Further, as a dissociative memory is explored, finding anger and reducing shame allows for the memory to fundamentally change. Anger brings them out of dissociation, even if it is anger at you, the therapist!
|Jul 10, 2018|
The Psychology of Procrastination
My podcast guest this week, Dr. Jackson Brammer, says he used to be an expert procrastinator.
But after some research into why people procrastinate, he found a few tricks and tips to help him on his journey to live a more balanced life.
Dr. Brammer started this path by investigating Impostor Syndrome. Impostor Syndrome involves feeling like you're not the person people think you are—as if you’re deceiving everyone. People with Imposter Syndrome believe if someone knew the real them, they would never receive the same level of trust or responsibility.
People who deal with Impostor Syndrome take negative statements and magnify them, adding them to the pile of proof that they aren’t as capable as people believe them to be.
For Dr. Brammer, Imposter Syndrome came from his ability to excel in school, despite consistently cramming for assignments and tests. He felt that someday he would be “caught” and everyone would know that he had “faked” competence.
Recognizing this link led to the revelation that fighting procrastination might help him stop feeling like he didn’t deserve to be in his position.
The Psychology of Procrastination
Jackson Brammer, M.D., David Puder, M.D.
What is procrastination?
Procrastination is the act of avoiding something through delay or postponement.
You might be procrastinating when:
It usually brings about feelings of:
Why do we procrastinate?
We procrastinate because our brains receive a reward for avoidance. Avoidance brings immediate relief from the distress associated with the task. Although we may experience discomfort in the final moments before a task is due, we rarely think about the past or future when procrastinating.
This creates a problematic cycle, one that erodes at our self-confidence. It also causes us to keep up a steady stream of “I should be…” in our subconscious minds.
The ingredients for procrastination
|Jul 03, 2018|
How to Fix Emotional Detachment
What is congruence?
Psychological congruence is someone’s ability to feel and express their inner emotions in a consistent manner with their outer world—their speech and body language.
As an example, have you ever smiled when you’re talking about something sad? Or felt very emotional, yet had a flat face and still posture? Have you ever felt angry, but pushed it down and developed a headache? These are incongruent speech and behavior patterns.
Incongruence happens when we’ve lost touch with our inner world, our emotions that are represented with bodily sensations. Many of my patients experience emotions, but have a hard time expressing them with words, so they shove them out of their experience.
Emotions are unavoidable.
We experience them all the time, whether we know it or not. Common terms for pushing them out of our awareness are suppression, denial, repression, and other defense mechanisms. We may think we can suppress our emotions, but they will come out in one way or another—sometimes through physical pain and illness.
There is extensive research on how the body processes emotion, and how that affects us physically. One of my favorite books on this subject is The Body Keeps the Score, by Bessel van der Kolk and The Feeling of What Happens by Antonio Damasio. I have spoken about the science of emotion in part 1, part 2, part 3 on microexpression and a popular episode on the polyvagal theory which give the science and application of understanding emotion.
As psychotherapists, our job is to help people reconnect to those emotions, and be able to experience them in healthy ways. People bury so many of our psychological problems in our bodies that we don’t even feel comfortable in our bodies anymore, and we prefer to be numb.
People further push unwanted emotions out of their experience through use of drugs, alcohol, and other addictions like porn, gambling, movie binging, or mindlessly scrolling forever on social media.
How do we develop incongruence?
But we don’t start out as emotionally disconnected, or incongruent. As children, we express our emotions as we feel them. If we are happy, we giggle, smile, or stick out our tongue as we work on a project. If we are sad, we cry. If we are angry, we bite, yell, spit or claw. If we have disgust we spit things out, push things away and protest against putting things in our mouth!
If our emotions are mirrored back, and our caretaker acknowledges them verbally, them we optimally will be connected to our bodily responses from a young age. This is why I always recommend starting any discipline or high emotional moment with kids by empathically mirroring their emotions in words, and adding meaning to why they might feel such a way.
To get along with others, most kids, over time, develop a normal adaptive way to conceal emotions, which helps function in family and friendships. We learn that there is a context for truly sharing what is going on, and this is a good thing. Sometimes suppressing strong emotion until later is helpful!
Stronger issues develop when repeated messages invalidate or shame our experience, or trauma moves us away from being congruent with our inner experience. It is also possible that there is no one who an individual connects with enough to be congruent around.
For example, if everyone you know would shame or attack you, it might not be a good idea to bring out your deepest thoughts and emotions. These kinds of households often have heavy drugs or alcohol, severe mental illness, or predators.
We are meaning-making creatures. We assign meaning to events in our lives, and that meaning becomes our guiding belief and principle, especially in key developmental periods in childhood.
These meanings shape how we are going to interact with the world. Although unconscious and out of our awareness most of the time, when we live out of congruence without ourselves, it leads us to form these earlier, shaping meanings. (click here for more on the science of meaning)
How incongruence develops:
The response to a healthy therapeutic relationship and subsequent changes in behavior can be astounding. To deal with it, it is necessary to both find new ways of connecting with others but also not be able to use the incongruent way of being for an adaptive means.
How do we fix incongruence?
Our goal as we progress in life is to connect our physical body, emotional experience and verbal communication. The best public speakers seem to speak from the core of their being. The most powerful messages come from getting in touch with ourselves and integrating it.
We can introduce the concept of reconnecting with the self in several ways:
Art helps people bypass the logical areas of the brain and produce something raw and congruent to their inner experience. Painting, drawing, working with clay, or other forms of art help us connect with things deep down in our inner experience. Sometimes we ask people to make a self portrait or a picture of their home to discover new things and access something true.
Then we ask for people to describe their pictures and link the congruent space of the art with what they share.
Ginger often uses the phrase “inner child” but I like to describe it as the “true self,” or the core of our being. Living congruently out of the “true self” is when how you imagine yourself lines up with what you do and how you articulate yourself. This is not a new idea, Karen Horney’s Neurosis and Human Growth is my favorite author on this topic.
Learning that we sometimes have hidden this part of ourselves, and then gaining access to it and learning to live by it can be powerful. When we are around people who can give us grace and truth as we progress, we can find this more and more.
Bodyscan (or interception)
Patients who have dealt with trauma often dissociate from their bodies. Even in this era of technology, it’s easy to forget we have bodies. People spend most of their time disconnected, scrolling the internet.
When we experience our body and work through emotions at the same time, it brings us into ourselves and develops congruence.
Ginger likes to ask the following questions when her patient is experiencing a triggering event, to be able to dig down to the root cause of incongruence:
I like to ask as well:
I want to access their bodily memories and the source of their pain.
Taper off of harmful and unhelpful drugs.
It’s easier to medicate incongruence, rather than actually deal with the root of it. It’s quicker. Substances like alcohol and drugs deeply affect people’s emotions. When patients are self medicating, they are usually trying to rid themselves of a symptom of emotional pain.
I like to ask them, “What are you getting out of the substances? Sleep? Peace?” Once we can answer that question, we can get to the bottom of where the anxiety and fear or anger comes from. We can begin to develop congruence, which will in turn, bring peace.
People medicate with illegal, and prescribed, legal drugs, as a way of dealing with emotional pain.
Some doctors and therapists can be symptom based, rather than focused on what is underneath the symptoms. When they see a patient, they can be on a hunt, trying to identify what’s wrong, the bottom line, and then find a medication that will relieve symptoms.
When we do that as therapists, we connect with the patient’s illness narrative, rather than who their core is, before they developed these problems.
Some patients who come to see us are taking 20-33 pills a day for all their different illnesses. If there is so much medication involved, it can become difficult to do psychotherapy as likely the sensorium or total brain function is impaired.
We have found when we establish a secure emotional connection with them, we can get some of these medications off the table, and then our patients can start to develop a range of emotions.
Through an attachment with a a therapist, that is trusting and meaningful, people can start to feel what before they either consciously or unconsciously suppressed. I have spoken about the worst medications here.
How to stay congruent during tough circumstances.
It is tough to apply all that patients have learned through therapy in their everyday lives. Our families and friends love homeostasis—usually, the people around us want us to stay the same. They say, “you’ve changed,” as if that’s a bad thing.
When we’ve been healed, when we are congruent with ourselves, it can be difficult for our friends and family to accept the “new us.” They connect more easily with the old us.
We have noticed that if the patient begins to grow, the whole family system needs to change as well.
To maintain newfound congruence and healthy mental states, patients work to find healthy relationships they can be congruent within. In the future I will talk about how to identify safe people and how to have healthy boundaries that keep us in relationships.
Questions, comments, thoughts? Please comment on the picture that corresponds to this post on my instagram: @Dr.DavidPuder
|Jun 30, 2018|
The History and Use of Antipsychotics
In my last post, Dr. Cummings and I talked about what psychopharmacology is, how medicine works in our body, and what factors affect medicine absorption rates.
In the latest podcast, Dr. Cummings and I talked about antipsychotics, the particular branch of psychopharmacology that deals with medicines that treat psychotic experiences and other mental disorders, such as:
The history of first generation antipsychotics
The use of antipsychotics as medication began in 1933 in France. The research around developing antihistamines evolved into the introduction of promethazine. This drug produced sedative side effects, so doctors started prescribing it before surgeries as a calming agent.
Eventually, a doctor studied the derivatives of promethazine, altered it, and developed chlorpromazine. It was mostly used as a pre-surgery anti-anxiety pill, until psychiatrists took note of the calming effect of the drug and began prescribing it to their patients.
Prior to chlorpromazine, the options for treating psychotic patients were electroconvulsive therapy, hydrotherapy, and putting patients in an insulin coma. None of those are antipsychotic in nature.
When two psychiatrists, Dr. Delay and Dr. Deniker, gave 38 psychotic patients a test round of chlorpromazine, they noticed the patients were calmer, and also less psychotic—they had less delusional thinking, fewer hallucinations, and fewer psychomotor-agitation symptoms. Deniker and Delay began giving talks on the benefits of the drug, and in 1955, chlorpromazine became available in the United States. Chlorpromazine is still used today as a treatment for different mental illnesses and mood disorders.
Once the government saw the positive effects of chlorpromazine, it began to shut down mental health facilities. There was no longer as large of a need to house psychotic patients, and they saw an opportunity to cut costs. However, they did not create adequate sources in the community for ongoing care. California alone is estimated to have 40-60% of homeless people that have a mental disorder.
Once chlorpromazine became a success, pharmaceutical companies rushed to create their own version of an antipsychotic drug. Because chlorpromazine was the grandfather of the first generation of antipsychotic drugs, the rest of that generation can be categorized by their ability to merely block dopamine D2 receptors in the brain.
In repeated studies, dopamine antagonism is responsible for 92% of their effectiveness. It also led to the thought that people were psychotic because they had too much dopamine. Since then we have found that their are much more complex psychopharmacological dynamics going on in psychosis.
Second generation antipsychotics
The next set of antipsychotics that came on the market were clozapine, olanzapine, risperidone, and other related drugs. Those medications had less effects on motor movement than the first generation drugs.
Clozapine is a poor antagonist of dopamine- blocking 30-40% of dopamine receptors but also promotes the activation of glutamate through activation of NMDA receptor, which increases activity in the frontal lobe (which helps with schizophrenia’s negative symptoms).
Clozapine had more system-wide changes than just dopamine suppression, and it had more positive response from patients. It was more effective—40-60% of people who won’t respond to a first generation antipsychotic, do respond to clozapine.
However, in Finland in 1975, 6 people taking clozapine died due to agranulocytosis (lowered white blood cell count, leading to a severe lack of immunity). A lowered neutrophil count (called agranulocytosis) can show potential problems with fighting off normal bacteria we live with all the time. When patients are on clozapine, initially they need weekly blood checks for this reason.
Despite the risks, clozapine can be an incredible drug—I have one patient who was schizophrenic and homeless, and she is now back in school and recently graduated with a perfect GPA! People who had been dysfunctional for decades, who are given clozapine, can become extremely high functioning. Key to success here was her willingness to work with me, despite having to try different things before something worked.
A trial run on a antipsychotic should be done at a minimum of 6 weeks, and blood tests must be conducted to make sure that the concentration of the medicine is at good therapeutic-dose levels. Dosage alone is sometimes not enough because we all metabolise drugs so differently. I have uploaded recommended levels in my resource page.
Third generation antipsychotics
What is deemed the third generation of antipsychotics, aripiprazole and brexpiprazole are partial dopamine receptor agonists. They keep dopamine at a max of 25% in the brain which due to the high affinity to the receptor it does not vary much based on dose.
The good thing about this generation of drugs is that they don’t lower blood pressure, cause insulin resistance, and are not sedating in nature.
It works for some people, it doesn’t for others. But when it does work, it works really well.
Side effects of psychiatric medicines
Akathisia is the inability to stay still, characterized by a feeling of inner busyness. It is a miserable side effect, exhausting to the patient.
If someone is experiencing this, they should immediately call their psychiatrist or go to an emergency room.
One of Dr. Cumming’s patients described it as “ants running up and down the bones of his legs.” It usually involves an anxious feeling, and a desire to move the lower extremities of the legs. Akathisia can be caused by any drug that lowers dopamine (including SSRIs).
This syndrome is so complex because it involves several compounds, including dopamine, norepinephrine, acetylcholine, and serotonin inputs. Options for treatment include: choosing a lower dosage, picking another dopamine antagonist that is less strong (quetiapine or clozaril), or prescribing a drug like amantadine, propranolol, mirtazapine or clonazepam (more nuance in the podcast on this).
It is a harmful disorder, and one to watch out for in patients. If a patient is sent home from the hospital experiencing these symptoms, but is not properly vetted for akathisia, a doctor could be subject to serious legal repercussions.
The questions to test a patient for akathisia are:
Acute dystonia involves muscle spasms and it affects movement, causing the posture to twist abnormally. It can be painful for patients to experience. This occurs because of too little dopamine in the basal ganglia part of the brain.
Parkinsonism involves muscle stiffness and slower movements. It’s usually uncomfortable, but not a miserable side effect. This also occurs because of too little dopamine in the basal ganglia part of the brain.
The future of antipsychotics
With each generation of new medicines, we’ve gotten closer to being able to help people stabilize their psychosis. We haven’t been able to achieve complete wellness.
Dr. Cummings says he has hope that with further advances in the medical field, we will be able to identify who is at risk. There is hopeful data that we may be able to one day prevent the development of schizophrenia.
History of Antipsychotics (notes by Arvy Tj Wuysang).
|Jun 19, 2018|
How Psychiatric Medications Work with Dr. Cummings
This week I interviewed Dr. Cummings, a psychopharmacologist, on the Psychiatry and Psychotherapy Podcast. Below is a brief introduction to the episode. For more detailed notes by Dr. Cummings, go to my resource page.
What is psychopharmacology?
Psychopharmacology is a branch of psychiatry that deals with medications that affect the way the brain works. The medicines used in psychopharmacology treat illnesses whose primary concerns and issues are mood, cognitive processes, behavioral control, and major mental disorders.
It is a unique branch of pharmacology because the illnesses are usually addressed by both medication and psychotherapy.
What makes a drug psychiatric in nature?
What makes a drug labeled as psychotherapeutic, is the intent behind the prescription. Some drugs will serve more than one purpose, so understanding why it was prescribed is important. For example, valproic acid is helpful in treating seizure disorders, and also bipolar disorder. For the seizure disorder, it would not be considered a psychotherapeutic drug. For the bipolar disorder, it would be considered a psychotherapeutic drug.
How do medications work?
All medicines go through the same steps of digestion in our bodies. They are liquified in the stomach, and then absorbed. The drug travels through the liver, and then into the blood supply, which brings it to the organ it was designed to target.
Our bodies have receptor sites, made of protein, that sit on the surface of a neuron, or a nerve cell in the brain. The drug, when it reaches that receptor, either binds to it and blocks it, or it can help the neurotransmitter work to further what it does naturally.
For example, caffeine is an adenosine blocker. Adenosine is a naturally occurring molecule in our bodies that calms us down as the day wears on, preparing us for sleep. Caffeine, as a drug, blocks our natural adenosine from reaching its receptor; it keeps us awake.
Medicines work in the same way—inhibiting or helping certain molecules reach their targeted organs.
How absorption and dosage rates affect medicine
Many things can affect absorption rate, and medications absorb at different rates, and at different potencies.
Things like gastric bypass, (when they take out a part of the stomach and intestines) can affect absorption rate of drugs. One of my patients had a stomach surgery, and afterwards, their depression came back. I told them to start grinding their pills to help with absorption rate of their antidepressant, and their medication started working again.
Our livers play the main part in absorption. Sometimes they are gatekeepers, and they can hinder absorption rates dramatically. Animals and plants have been at war for thousands of years. Plants create toxins to try to discourage animals from eating them. Our livers develop different enzymes to break down those toxins in order to make the plants safe for our bodies. Those same enzymes break down medications. Our bodies are constantly adapting and changing, adjusting to what we consume.
As a psychiatrist, it’s important to pay attention to absorption rates to make sure our patients are getting maximum benefit. Maybe a patient has defected genes that limit absorption rate, or deficient enzymes to break down the medication. Or maybe other medications are interacting and changing absorption rates.
A few times in my practice I have seen patients come in on multiple medications which are interacting poorly. For example, they are on a medication called amitriptyline and also on something that blocks its breakdown like fluoxetine. In our session they complain that they are confused and disoriented. I figure out that the drugs they’ve been prescribed is either inhibiting, interacting with, or increasing the effect of another medication. Once we learn that, we can make changes to their prescriptions, and they return to feeling normal.
When you change the concentration of a medication, you can destroy the entire point of the prescription in the first place. There are numerous computer programs that can help us determine problems with drug interactions. Those programs can sometimes point out what could become a clinical problem, but often point out minor, irrelevant interactions.
Just prescribing medicines, without taking into account the individual ecosystems we each have, is often a practice of trial and error. With properly administered tests and observation, we can move towards an effective dose and effective treatment plan.
Because there are so many things that can change a drug level in the body, taking a plasma concentration may be the best way to assess if the dose is appropriate (check out my resource page for a list of appropriate levels). A high or low blood level might hint that the person is a rapid metabolizer, poor metabolizer, has GI issues with absorption, or has other medications or supplements that are increasing or decreasing the dose.
How to reduce negative side effects
One of the reasons that people develop problems with psychiatric side effects to medications is because they are increased too fast. There is a balance between wanting to get someone to an appropriate dose, and minimizing side effects.
Too often, patients are prescribed a medication at full force and, due to sudden side effects patients will quit taking the medication.
If the medicines were administered in a slower onramp, giving time and attention to their perceived absorption rates and side effects, many problems with those medications would stop.
Is therapy or medication more helpful?
There are many trains of thought on psychotherapy and medication. Some people want a pill to fix everything. However, not everything is a chemical imbalance in the body and can be fixed with a pill.
If someone comes to me with a psychiatric problem, I almost always recommend psychotherapy, and often prescribe medication. Medications help, especially if someone has severe mental illness. If levels are mild to moderate, I find psychotherapy and lifestyle changes (like strength training and diet) are more effective for long term success.
Rates of prescribing medication has increased and use of psychotherapy has decreased. Too many patients are taking medication without psychotherapy or lifestyle changes. One study shows that 73% of antidepressants are prescribed by primary care physicians (Mojtabai, 2008). Antidepressant use has increased from 1996 to 2005 from 6% to 10% while rates of therapy have gone down from 31% to 20% for those on antidepressants (Olfson, 2009).
Because of that, people are not being treated in the most effective way possible. This is especially the case when considering the treatment of psychological trauma, for which talk therapy can cure in ways medications can not.
Through both medications and psychotherapy, we can rewire the brain. In one study on obsessive compulsive disorder (OCD), two groups of people were studied—those who underwent cognitive behavioral therapy, and those that took medication. The therapy was found to be as helpful in eliminating OCD symptoms. However, the OCD symptoms returned when the medication was stopped. The symptoms did not return when the person had received cognitive behavioral therapy.
Dr. Cummings uses a simple guideline to see if someone would benefit from medicine or talk therapy. If what the person is depressed about is something in their lifestyle—their weight, their job, their relationship, lifestyle changes and talk therapy will probably be most effective.
If someone is experiencing neurovegetative symptoms of depression, such as: loss of appetite or increased appetite, severe energy loss, severe sleep disturbance with early morning awakening, physically slowed down, they are suffering from brain disturbances that are helped by medication.
For more notes by Dr. Cummings, go to my resource page.
Mojtabai, R., & Olfson, M. (2008). National patterns in antidepressant treatment by psychiatrists and general medical providers: results from the national comorbidity survey replication. The Journal of clinical psychiatry.
See below for notes on the episode writen by Arvy Tj Wuysang.
Dr. Cummings has recommended these articles to read along with this session (thank you Mona Mojtahedzadeh M.D. for organizing them and adding some notes):
2. Thompson, J., Thomas, N., Singleton, A., Piggott, M., Lloyd, S., Perry, E. K., ... & Ferrier, I. N. (1997). D2 dopamine receptor gene (DRD2) Taq1 A polymorphism: reduced dopamine D2 receptor binding in the human striatum associated with the A1 allele. Pharmacogenetics, 7(6), 479-484.
4. Tracy, T. S., Chaudhry, A. S., Prasad, B., Thummel, K. E., Schuetz, E. G., Zhong, X. B., ... & Tay-Sontheimer, J. (2016). Interindividual Variability in Cytochrome P450–Mediated Drug Metabolism. Drug Metabolism and Disposition, 44(3), 343-351.
6. psychotropic medications: overview seminar core handout
7. McCutcheon, R., Beck, K., Bloomfield, M. A., Marques, T. R., Rogdaki, M., & Howes, O. D. (2015). Treatment resistant or resistant to treatment? Antipsychotic plasma levels in patients with poorly controlled psychotic symptoms. Journal of Psychopharmacology, 29(8), 892-897.
|Jun 12, 2018|
Prescribing Strength Training for Depression
Recent studies show the power of strength training in treating depression. This blog and podcast episode discuss this important treatment of depression.
|May 29, 2018|
Using Microexpressions in Psychotherapy
The last two weeks, we’ve covered using Microexpressions to Make Microconnections and the Microexpressions of Fear, Surprise, Disgust and Creating Connection. We discussed what microexpressions are, what each of the different emotions are, and how they look on the face.
Learning about microexpressions develops a deeper connection with others—whether in therapy, or just in everyday relationships.
Microexpressions are tiny facial movements that give us cues to what someone is feeling. Their eyebrows might twitch down for a moment to display anger. Or the sides of their mouth might stretch horizontally to show they are afraid.
Our goal as therapists is to understand what emotion our patients are feeling, and to develop our empathy towards them through understanding the reason behind that emotion. Understanding microexpressions can lead to micromoments of connection by developing a greater closeness between you and your patient.
Microexpressions happen out of our awareness, and can be great cues to what someone is unconsciously feeling.
Using microexpressions to understand the unconscious
Microexpressions develop our identity
We are always picking up on some level of people’s microexpressions, whether we are trained in it or not. Many people intrinsically understand what others feel. This understanding can become our social mirror as we are growing up.
If we have an ability to make people smile when we are children, we may try to reinforce that reaction from others by building our interactions around humor. Then we are known as the “funny” one. These cues people give us can become a part of our identity.
One of my patients had a facial deformity. She noticed, and internalized, the messaging that she was “disgusting” to look at, based on other people’s facial expressions when they saw her. That led to deep feelings of disgust about herself. She often showed a microexpression of disgust on her face when she was talking about herself. Over time spent in therapy, she was able to create her values, her beliefs, and determine that as a human, she was more than her deformity.
Internalizing people’s microexpressions as feedback about ourselves can be helpful or harmful. When we learn more about microexpressions, we are able to develop techniques to delve deeper into people’s reactions and understand that those reactions are often not about us, but about the other person’s experience.
Through understanding microexpressions, we learn that we do not need to take every reaction and internalize it as part of our identity, either positive or negative. With our patients, seeing microexpressions as they talk about themselves can help us uncover deep seated beliefs—whether it’s disgust, arrogance, or any number of other emotions.
Microexpressions reveal object relations
Object relations is a theory about how we internalize early attachment figures and then subsequently understand future in relationships. For example, if we have a tense relationship with our father, and then we might expect or recreate tense relationships with our male teachers, male boss, and male therapist, as a way to make sense of the world and hope to have a different outcome.
We most often create these emotions towards early developmental relationships, then paint our beliefs about them on others throughout our lives, unless we deal with our feelings towards those people, and begin to be able to distinguish and differentiate, i.e., “not all authority figures are evil.”
In therapy, microexpressions can be helpful to unearth some of these emotions. The relationship between a therapist and a patient can represent, to the patient, many different relationships. Being a safe person for them to discuss their feelings with is the most important part of therapy.
Reading microexpressions can help us understand the emotions still present that the patient feels towards early attachment figures. These may come out as they discuss a current issue, and then express a strong emotion. If you focus in on the part of the story where the emotion was present, then they might start eventually talking about early attachment figures like their emotionally distant dad or angry mother.
The microexpression allows us to know where to focus in, and listen closely in their story. They are not only important to pay attention to when it comes to how a patient feels about others, but also how they feel about us. Knowing how they feel about us, as their doctors, helps to be able to identify what are overarching, negative early life experiences and how we can help them work through those feelings so that they can live more present and thriving in the present.
Talking about Dreams reveals microexpressions
As therapists, listening to dreams can give you a great glimpse into your patient’s inner emotional life. Studies show that memories more easily develop around negative emotions, and those negative moments can form points of organization for our memory. They found that PET scans showed that the parts of the brain that store our memories are also the ones activated during REM sleep.
Dreams usually demonstrate what’s most emotionally relevant to work on during psychotherapy. As patients are telling me their dreams, they will show microexpressions while reporting the narrative of the dream. Through discussing the dream, they can talk about emotions and desires they might not have consciously allowed themselves to have.
For example, if a patient is feeling trapped in a job or relationship, she may have a dream she is trapped in a box, or stuck underwater. She will be able to express her emotions during the description of the dream—her fear, anger, surprise, disgust. She may not be ready to talk about her relationship or job, but she can unearth the unconscious emotions of the dream and feel comfortable talking about that. In the end, her thoughts will go to areas of her life where she feels stuck, and then suddenly realize what the dream might mean.
As psychotherapy progresses and the person unpacks their emotions, the dreams change to be more positive. When a patient feels supported, heard and psychologically safe, they begin to unpack deeper, unconscious emotions they once only felt in dreams.
Psychological Defense and microexpressions
People experience psychological defense as a way of creating an alternative, safe reality for themselves. It’s an adaptive way to defend against their feelings, their reality, and the state of their mental health. Psychological defense is largely an unconscious, adaptive process.
Sometimes a patient will have a thought that is too distressing to pay attention to. Their brain will then send what we call “signal anxiety,” or a message that this thought, emotion, or desire must be suppressed from consciousness. As a result, they might have a psychological defense act as a way to adaptively defend against these thoughts. For example, they might suppress a thought to later deal with, deny that it happened, or go wash the car to get their aggression .
Another example where microexpressions will help is if a patient says they aren’t angry at a person. They may believe that, or may try to believe that. Maybe that person harmed them in a huge way. Prior to saying, “I’m not angry,” their face may have flashed a microexpression of anger, letting you know that perhaps they are denying what is truly going on.
The best thing to know here, is that psychological defenses are there for adaptive reasons, and the patient needs to feel safe enough to have them soften. If you empathize with the distress that comes with the defense you will be helping them get to what is under it.
Warnings about using microexpressions in therapy
When I first started learning about microexpressions, I would tell people, “When you told that story, you flashed an expression of anger.” Then the patient would be angry at me for assuming they were angry. Maybe the patient hadn’t even had the chance to process on their own that they were, in fact, angry. Or maybe I was just wrong about what I was assuming! Either way, I didn’t give them the space to find their own emotions.
It’s important to allow people to mine their own feelings, and even discover the meaning behind the feeling. If they are telling a story and show a microexpression of anger, be curious about their feelings in that moment. Ask them to draw out the emotion and describe it. Be gentle with your word choices.
The danger is when we are wrong about what we think someone is feeling, but we aren’t accurate, and we assume we are still correct.
As we learn about microexpressions, we see that there are hundreds of them being expressed in any one-hour therapy session. It can be overwhelming if we take responsibility for another person’s emotional life. It’s important to know the difference between their feelings and our own feelings, so we don’t own their emotions.
When I first started in my psychiatry rounds in medical school, I didn’t understand emotional contagion. I began to feel depressed after different conversations with suicidal patients. After talking to several mentors about it, I realized I was internalizing my patients’ emotions, and having issues with self/other distinction. Their emotions were contagiously experienced in my head, and I had little defenses against feeling overwhelmed.
Now, before I go into any therapy session with a patient, I take an emotional gauge of myself. I see how I’m feeling, what my natural, resting emotional state is. When I enter the therapy session, I am able to categorize what is additional to my experience—sadness, anxiety, joy, fear, as the other person's, not mine. I am also able to deeper empathize with their feelings because I am not in a confused emotional state.
When we delve too deeply and become emotionally distressed with our patients, it inhibits our ability to offer insight, reflect, or therapeutically help the other person. Feeling deeply can be a tool in therapy for developing connection, but make sure you have healthy boundaries, too.
Being able to understand the patient and their reality can also help us own our own reaction to them. Maybe the patient reminds us of someone we know, and we are putting negative feelings on them.
Rushing the process
Maybe you repeatedly notice anger on your patient’s face during conversations about their father. Here’s the catch—maybe they don’t know they are angry at their father yet. If you rush that revelation, you are taking away their emotional experience of uncovering their feelings.
Letting someone use their words, and not forcing word choice, is important. If they say “frustration” and not anger, you should also say “frustration” and not the word anger. Allow them to have their own process.
People are the experts of their own inner world. Microexpressions, though incredibly helpful, only give us hints. They do not give us a perfect map of someone’s entire emotional experience.
When you express curiosity about what someone is feeling, allow them to correct you if you offer specific word choices or suggestions. Ask them to clarify, and accept their explanations about what they were feeling.
Learn about microexpressions
It is helpful, when implemented correctly, to learn about microexpressions and use that knowledge to develop micromoments of connection.
To learn more about microexpressions, download the Emotion Connection IOS app.
For full PDF of the episode with citations and further notes go here.audio Block Double-click here to upload or link to a .mp3. Learn more
|May 24, 2018|
Microexpressions: Fear, Surprise, Disgust, Empathy, and Creating Connection Part 2
On the last Psychiatry and Psychotherapy podcast and blog, we talked about how Microexpressions make Microconnections, their role in therapy and how learning about them can increase our emotional connection to others.
This week, we will continue uncovering how different microexpressions look on the face and feel in our body, and their corresponding emotions.
Fear is an adaptive emotion—its original goal is to keep us safe and alive. When someone pulls into our lane on the interstate, it’s fear and our ability to quickly jerk the steering wheel straight that saves our lives. When we encounter heights, snakes, or frightening people in a dark alley at night, fear is the emotion we feel.
As children, we have fears of abandonment from our mothers, and at around two years old, we begin to experience stranger anxiety. As we grow, we read our parents and see what they are afraid of, so we can form protective fear patterns. Even different genders receive different messaging about fear. Parents teach male children to be more fearless, empowering and enabling, more courageous. They teach females to be more cautious, careful and more fearful.
Fear, demonstrated on the face in a microexpression, looks like:
Fear can bond people together but also separate us from having an emotional connection. In any emotional interaction, we are experiencing a state of calmness, fight/flight, or disconnection.
Fear and anger come into play in both fight and flight. When we notice someone exhibiting fear when we are interacting with them, it’s important to be curious as to why. Are they fearful because of the interaction with us? Or are they fearful because they are accounting a story about something that scared them?
When someone experiences fear, it’s important to strive for a healthy connection again. That person may experience fear because of vulnerability or shame. Because fear’s goal is to stay safe, it can cause disconnection. Establish a psychologically safe place for them to feel connected, rather than fight or flight.
Dealing with fear
Listen to your voice of courage that’s inside of you. Anytime there is fear, there is also a courageous part of us that is sending different messages too, we just need to focus on it and therefore turn up the volume of the courage signals. When we get stuck, frozen, in a state of fight or flight, we can choose to engage the object of fear anyway. We can choose courage.
Experiencing fear during sporting events or performances is a great way to think about this. Fear can be decreased over time. When we train often enough, or compete often enough, that fear response slowly decreases. After plenty of performances, after plenty of sport competition events, we start to normalize that fear and courage takes over—training gives us confidence in the face of fear.
We can learn how to handle fear without being totally overwhelmed by facing the cause of our fear in slow, small increments. It can create an adaptation, rather than stress. Even cardiovascular health is tied to your emotional ability to handle fight or flight. By training physically, you are actually training for interpersonal stressors as well by spiking your adrenaline, breathing and heart rate.
Beyond behavioral therapy help, you can do mental exercises to regain control of your body during fear. Even simply saying out loud, “I am experiencing fear” can feel normalizing. Also, through meditation and breathing, you can reset your heart rate and breathing, and calm your body’s fear responses.
On the face, the microexpression of surprise looks similar to fear, but where fear affects the face on a more horizontal axis, surprise affects the face on a more vertical axis. Surprise looks like:
Surprise can be awe, curiosity, a revelation. It can be a more transitory emotion—quickly moving on to fear, anger or joy. When someone is exhibiting surprise on their face, be curious about why, ask them if the answer isn’t obvious—such as them arriving at their own surprise party—and you may learn something new about them.
People rarely use the word “disgust.” They’ll talk about happiness, anger or fear or other emotions. But disgust is something that we don’t understand as easily without dipping back into the primal reasons for the emotion, and how it is helpful in modern day interactions.
Originally, disgust was an important emotion for survival. It standardized hygiene and behavioral norms. If a caveman or woman ate something gross, or fell out of line with the accepted hygiene of the day, they were shunned from the group. If they slept with a relative or animal, ate another human, or did not clean food properly, they aroused disgust in their tribe, and were exiled or even killed.
Without disgust, there would be less social norms, less “rules” for relating to each other and maintaining health codes. It’s a powerful emotion that drives behavior.
Disgust as a microexpression looks like:
I feel that people need to be more aware of disgust as a microexpression, and learn what it is trying to communicate to them. It’s not just about a survival mechanism, such as smelling rancid milk and being able to avoid getting sick. It’s also about how our spouse treats us, how we feel when we watch interactions between other people.
The negative effects of disgust, when it is taken too far, can be damaging and horrific. Racism and sexism are examples of disgust gone wrong. It can be dehumanizing. Even listening to Hitler’s conversation at his dinners, experts have analyzed disgust-oriented language. Much of his propaganda was even disgust-provoking propaganda.
People who are an object of someone’s disgust experience deep shame. Sometimes, that is warranted—such as when that person has broken a societal rule like pedophelia. But as a therapist, I have to have a lower threshold of disgust when it comes to hearing people’s secrets.
After awhile, I think that disgust, like fear, can be adaptable. I have heard all manners of secrets, and I rarely feel disgust anymore. Instead, I feel I need to exhibit psychological safety, so the patient feels open to talking about the things they cannot tell anyone. Through talk therapy, hopefully I can help them feel less shame and understand their unique journey and struggles more fully.
Using microexpressions in interactions
The first key to using microexpressions is to pay attention. Look at the person’s face, be interested and curious about what emotional state they are in. Notice the facial movements, and listen to what they are saying. Is what they are expressing maybe outside of their awareness as they talk? Does the emotion they are showing match what they are talking about?
As a therapeutic tool, understanding microexpressions is a way of gathering information about someone else. Use that information to respond in a way that shows the person you are desiring to connect.
Paying attention to microexpressions actually creates empathy. We have mirror neurons—neurons in our brain that are devoted to telling us what someone else is feeling. Those neurons light up when we watch someone else doing something, or feeling something. When we see someone bite into hamburger on a commercial, it might make us hungry, even causing our stomach to rumble or our mouths to make extra saliva. When we see someone cry, it might make us cry. Your brain will light up, to some degree, as if you are experiencing someone else's emotions. We can train ourselves to pay attention to those neurons to better be able to connect with people.
Some people experience either less or more empathy than what is considered normal. This can be because of a disorder, or because of emotional burnout. Even experiencing emotional overload causes a decrease in empathy.
Being able to determine the difference between yourself and the other person is another important part of empathy. Learning about microexpressions can help you do that—you can see their emotions, and recognize they are the one experiencing it, and you can respond to the emotion, but you do not have to own it as your own.
Tune in next week to hear part three of Microexpressions. If you'd like to try out the app that trains people how to read microexpression, go here: IOS Emotion Connection App
For full PDF of the episode with citations and further notes go to: https://psychiatrypodcast.com/resource-page/
|May 15, 2018|
Microexpressions to Make Microconnections Part 1
What are microexpressions?
Microexpressions are brief, involuntary facial expressions that are cues to the true emotions that someone is feeling. We see microexpressions in tiny twitches of the brows, the lips and nose. They can last for as little as 1/15th of a second on the face.
Microexpressions are helpful because they send messages, both to ourselves, and to those we are trying to communicate with. Some are naturally better at sensing what someone else is feeling, but if you want a deeper clue into emotions and emotional connection, start to study microexpressions. We can even begin to understand ourselves a little better when we pay attention to them.
What are emotions?
Emotions are adaptive brain networks, expressed rapidly on the face and in the body. They carry messages about our environment or thoughts, and they have a specific goal or intention.
Although they appear ethereal in nature—fleeting feelings of happiness or sadness—emotions are actually grounded, measurable reactions. Each person, based on their experiences in life, will react differently to each stimuli. With each person, the reaction and meaning of the emotion lies within the lens we have.
Emotion is a survival mechanism that we all have. For example, the purpose of anger is to protect and reconnect. Anger surfaces when we feel threatened—when a lion tries to attack our family—it gives us the physical response we need to attack what is attacking us. Fear is helpful to trigger our body to be able to outrun that lion when we need to—our heart starts pumping, adrenaline rushes in, survival mode turns on. In modern society, we’ve tried to suppress or deny those emotions, but they’re still there, and they’re still helpful. We just have to know what they are, and what to do with them.
What are the different emotions?
Scientists have lumped all of our complex feelings into seven, basic categories.
Emotion: Happy, Joy
Body Sensation: Positive warmth throughout the body, grounded feeling.
Microexpression: Mouth going up symmetrically, cheeks pulling up and change in contour, and eyes contracting (especially on the outside with classic “crows feet”).
Meaning and Goal of Emotion: Heartfully rejoicing, finding pleasure and wanting more of something, noting what brings you pleasure, feeling safe connection, having mutuality with someone, moving towards a goal.
Body Sensation: Heavy feeling in chest, decreased limb activity.
Microexpression: Inner eyebrows rising and outer eyelid dropping, pulling down of the lip corners, chin moving up, and lips showing a pout.
Goal of Emotion: Express loss over connection, an object, or attachment, invite solace and concern.
Body Sensation: Weight on chest, constriction around neck, butterflies in the stomach.
Microexpression: Upper eyelids rising high and longer than surprise, lower eyelids tensing, eyebrows drawing up and together with tension in the forehead, mouth opening horizontally.
Goal of Emotion: Preserve and maintain life, freeze to analyze danger, prepare to run or attack, puff up (to look dangerous).
Body Sensation: Queasy, feeling of wanting to vomit, gag feeling in the throat.
Microexpression: Wrinkling around the nose, upper lip rising, and eyebrows move down without tension (contrast this with anger where the eyebrows are pulled together and the eyelids are raised and tense).
Goal of Emotion: To move away from, avoid, reject, spit out, get away from.
Emotion: Pride, Smug, Contempt
Body Sensation: Increased sensation in the chest and head of euphoria, puffed up feeling in chest
Microexpression: One side of the lips rising faster than the other, or one side coming down slower than the other.
Goal of Emotion: To take pride in another’s success, proud when I succeed, feel superior, or diminish inferiority.
Body Sensation: Startle and jolt to the body
Microexpression: Rising and rounding eyebrows, co-occurring with rising upper eyelid, and sometimes mouth falling open with lips relaxing. Note: rising eyebrows can also be a conversational signal emphasizing something.
Goal of Emotion: Prepare for the next step, achieve familiarity with an object/situation so that you are better prepared when encountering a similar situation in the future.
Emotion: Anger, Frustration
Body Sensation: Tight chest, tension in neck and back, knots or burning in stomach.
Microexpression: A short tightening of the eyelids, eyebrows moving down and together, and sometimes lips pressing together. Rarely, showing of teeth. The tightening of eyelids and eyebrows for an extended period of time can also be seen when a person is concentrating or focusing, so context is important.
Meaning and Goal of Emotion: Overcome obstacle to move towards a particular goal (desire to reconnect with a loved one). Protect self or significant others—set up boundaries, have a voice, or be assertive. Attack when you feel no escape is possible either physically or psychologically.
Why should you learn about microexpressions?
Learning about microexpressions is helpful for emotional connection. Connection is largely based on empathy, and when we know what someone else is feeling, studies show we experience more empathy.
It can help raise the level of connection in personal life, in work, and even for people who have disorders that can cause emotional disconnection, such as schizophrenia.
Therapists and mental health workers, when tested, demonstrated they were no better at reading microexpressions than the average person. Another study also showed that therapists and mental health professionals overestimate how good they are at reading micrexpressions. We believe microexpression training would benefit therapists, and help them build a therapeutic alliance with their patients.
One study of 21,000 patients, showed that those who were under the care of doctors who demonstrated higher empathy, had 40% less life-threatening instances related with their diabetes. Higher empathy = better health outcomes. In another study about psychotherapists, the overall therapeutic connection impacted how well someone responded to both the placebo and the active medication.
Learning about microexpressions will help therapists be able to diagnose or identify depression, anxiety, and find underlying emotional responses to a story a patient is telling.
How do you learn about microexpressions?
Anyone can learn how to read microexpressions, and studies show that it really does help us feel more connected to people, and it helps us develop empathy.
Even when we lean in, and specifically pay attention to someone else’s emotions, we are better able to empathize with that person and connect. That’s a simple way to feel closer to someone, but to really go deeper into the science of emotional connection, you have to study microexpressions.
The most effective way to learn microexpressions is through a training program. I built a training app that can help. The app has over a hundred recorded videos of real facial expression responses. After the video plays, it will prompt you to guess the emotion the person expressed. Once you respond, the app gives you immediate feedback of the correct answer, along with what facial movements are involved in each emotion. Repetition is key in learning microexpressions.
The positive effects of microexpression training
There are incredible benefits to microexpression training, whether you are a healthcare professional or just someone who is interested in emotional connection.
It develops psychological safety.
When we read a microexpression, it shows we are demonstrating an appreciation for the person you are listening to. You are giving time and attention to their feelings. Often, when we recognize a microexpression, we tend to mimic it on our own faces. When someone is sad, we are sad with them. When someone shows anger, we shake our head and demonstrate anger with them. When they feel heard and understood, they feel psychologically safe to give you accurate feedback.
It normalizes emotions.
When we cognitively understand that we are feeling anger or disgust, and not just living in the feeling, it allows us to begin to breakdown the why behind it. When we dig that deep, we can process responses that are out of context. Emotions should happen in the appropriate time, in an appropriate amount. Checking the why can help us untangle complex situations from our past, and help us deal with emotions in healthier ways in the future.
Also, rather than judging emotions, when we learn microexpressions, it brings our brains into the equation, so our responses are rarely trigger-happy. We are able to be curious about the why behind it, which is much more helpful in the long run.
If you’d like to keep learning about microexpressions, download a PDF with more detailed notes from this episode with all citations: https://psychiatrypodcast.com/resource-page/
If you'd like to try out the app that trains people how to read microexpression, go here: IOS Emotion Connection App
|May 08, 2018|
Hormonal Contraceptives & Mental Health
Do Hormonal Contraceptives Cause Depression? How Do Estrogen and Progesterone Influence Behavior and The Brain?
Many women take hormonal contraceptives as a way of preventing pregnancy, or for other health reasons. These contraceptives basically use hormones to stop your body from ovulating.
But do you ever wonder if changing your hormones can affect more than just your chances of getting pregnant?
Birth control has many positive effects too, other than just preventing unwanted pregnancy. It can help with:
How hormones work without the pill
In a woman that’s not on the pill, early in their cycle, they’ll have the least amounts of estrogen and progesterone in their body. Around ovulation, estrogen will rise, which changes their mood, causing them to experience more of the reward hormone, dopamine, and even the happy hormone, serotonin. Later in the cycle, progesterone rises too, changing the emotional state again. The drop in hormones and Progesterone is the depressant hormone, so this is typically what causes the pre-period moodiness that some women feel.
This hormonal shift does not happen, or happens very subtly in women who are on birth control.
Using a hormonal contraceptive changes your body’s chemistry, and alters your hormones. When you change your body chemistry, you may have influences on your mood, desire, all sorts of things we wouldn’t normally consider when we are only looking for the benefits.
Here are some of the things hormone contraceptives can effect:
What women find attractive
Scientists noticed that women who were ovulating, and not on the pill, had an increased attraction to more masculine faces, dominant male behavior, taller men, deeper voices, versus when they were not ovulating. Ovulating women also wanted to go to public events more, and had more sexual fantasies. When they weren’t ovulating, women looked for a man who is more empathic, more fatherly, more compassionate.
One study followed a group of women for a number of years to see if their mood changed. They found that the younger (15-19) contraceptive group was 1.7-1.8 times more at risk of depression and being prescribed antidepressants. Specifically, younger women (15-19), and those who were prescribed progesterone-based pills, were at highest risk of depression. Also, most of these women experienced the depression onset at around 2 months - 1 year.
If you’re older, taking a more estrogen-based hormone, have been on it for awhile, and are not depressed and have been taking hormonal contraceptives for more than one year, I would say you are probably not at risk of developing depression because of contraceptives. Now, that said, there are tons of reasons that people get depressed—life situations, genetics, health—it’s not just related to hormones. If you are concerned about depression, talk to your doctor about it.
Natural fear response
Women who are on hormone contraceptives are more likely to experience anxiety. Natural hormone levels help with fear extinction, or the ability to overcome fears. Birth control can inhibit our ability to regulate fear in stressful situations.
In the part of the natural cycle, before ovulation, when estrogen is higher, women have an increased ability to recognize facial expressions of emotion. Hormonal contraceptives decrease brain responsiveness, making it more difficult to process emotion, and making recognition of negative emotions harder.
Ovulation also causes an increase in estrogen, which increases the brain reward pathways by increasing dopamine, our body’s pleasure response hormone.
If you are on an oral contraceptive, the changes in hormones can cause a dampened reward processing, so there may be a decreased amount of pleasure you can experience through things like food, sex, or even social connectedness.
My conclusion about the pill
Overall, with the positive effects birth control has caused in society, namely, a decrease in teen pregnancy, it can be difficult how to integrate the new details emerging on the influence on mental health.
I know my research into this has led me to be more aware of teens I treat who are taking hormonal contraception. If you’re looking for the benefits of the pill, there are many types of contraceptives, and because every woman is different, there is not a one-size-fits-all option. Talk to your doctor about which one is best for you.
Below are more detailed notes that Dr. Mona Mojtahedzadeh and Dr. David Puder worked on together to provide the scientific foundation to this episode.
Do Hormonal Contraceptives Increase Risk of Depression?
Pathophysiology: How do OCPs work in general compared to natural states of hormonal secretions?
1. Hormonal levels
2. Mode of secretion
3. Feedback mechanisms
Point 2: OCP Have Unique Effects on the Brain
Partner Selection and Relationship:
Citations and Further reading:
Further reading on IUD: article showing how uncommonly IUDs are used in the US
Bobst, C., Sauter, S., Foppa, A., & Lobmaier, J. S. (2014). Early follicular testosterone level predicts preference for masculinity in male faces–But not for women taking hormonal contraception. Psychoneuroendocrinology, 41, 142-150.
Brunton, L. L., Chabner, B., & Knollmann, B. C. (Eds.). (2011). Goodman & Gilman's the pharmacological basis of therapeutics.
Cheslack-Postava, K., Keyes, K. M., Lowe, S. R., & Koenen, K. C. (2015). Oral contraceptive use and psychiatric disorders in a nationally representative sample of women. Archives of women's mental health, 18(1), 103-111.
Lisofsky, N., Riediger, M., Gallinat, J., Lindenberger, U., & Kühn, S. (2016). Hormonal contraceptive use is associated with neural and affective changes in healthy young women. Neuroimage, 134, 597-606.
Osório, F. L., de Paula Cassis, J. M., Machado de Sousa, J. P., Poli-Neto, O., & Martín-Santos, R. (2018). Sex Hormones and Processing of Facial Expressions of Emotion: A Systematic Literature Review. Frontiers in Psychology, 9, 529.
Roberts, S. C., Little, A. C., Burriss, R. P., Cobey, K. D., Klapilová, K., Havlíček, J., ... & Petrie, M. (2014). Partner choice, relationship satisfaction, and oral contraception: The congruency hypothesis. Psychological Science, 25(7), 1497-1503.
Russell, V. M., McNulty, J. K., Baker, L. R., & Meltzer, A. L. (2014). The association between discontinuing hormonal contraceptives and wives’ marital satisfaction depends on husbands’ facial attractiveness. Proceedings of the National Academy of Sciences, 111(48), 17081-17086.
Wegerer, M., Kerschbaum, H., Blechert, J., & Wilhelm, F. H. (2014). Low levels of estradiol are associated with elevated conditioned responding during fear extinction and with intrusive memories in daily life. Neurobiology of learning and memory, 116, 145-154.
World Health Organization, United Nations Population Fund, & Key Centre for Women's Health in Society. (2009). Mental health aspects of women's reproductive health: a global review of the literature. World Health Organization.
Klaiber EL, Broverman DM, Vogel W, Peterson LG, Snyder MB. Individual differences in changes in mood and platelet monoamine oxidase (MAO) activity during hormonal replacement therapy in menopausal women. Psychoneuroendocrinology. 1996;21(7):575-592.
|May 03, 2018|
Postpartum Depression with Dr. Pereau
Dr. Pereau is incredibly honest and vulnerable in this emotional episode as she shares her story. Throughout it, she talks about the symptoms of her postpartum depression, including: * Intrusive thoughts * Emotional disconnection from her baby * Sleep deprivation * Poor focus * Hopelessness * Problems with concentration * Disconnection from passion and joy * Panic attacks and anxiety * Poor self care
|Apr 24, 2018|
Performance Enhancement with Dr. MaryEllen Eller
Our bodies are “wired” to perform. Learning how to consciously modulate your internal sympathetic state is the key to unlocking optimal performance. The autonomic nervous system (ANS) facilitates survival by generating the fight-or-flight response and promotes recovery following activation (the ability to relax). The ANS achieves this by balancing two complementary systems: the sympathetic nervous system (SNS) and the parasympathetic nervous system (PNS). For example, your ANS is currently adjusting your pupillary diameter, respiratory rate, blood pressure, heart rate, skin conductance, sweat production, sphincter tone and postural muscles (just to name a few) to allow you to focus your eyes to read this information without passing out, falling over, overheating or urinating on yourself.
The sympathetic nervous system (SNS) sends signals throughout the body to enhances its ability to respond to a perceived threat. For example, when a cave man encounters a bear, he must be able to rapidly harness enough energy to fight the bear or run away from it. The SNS achieves this by increasing oxygen mobilization, increasing heart rate and optimizing the utilization of stored energy to allow the cave man to quickly sprint away from the bear. If the threat becomes imminent (i.e. “I’m not fast enough”), “freeze” mode prompts the body to immediately enter an extreme state of energy conservation in a final attempt to maintain survival (decreased heart and respiratory rate, loss of muscle tone, etc). The parasympathetic nervous system (PNS) activates through myelinated nerve fibers from the nucleus ambiguus when the perceived threat has been removed and allows the body to rest and refuel. While instinct alone was sufficient to keep our cave man alive, this instinctual response system has not evolved with society’s modernization (not many of us are still being chased by angry bears). This disconnect allows the ANS to be hijacked by perceived threats on a continual basis and is an underlying cause of chronic stress, pathologic anxiety and poor performance.
The “freeze” mode can turn into a third system, with the activation of the unmyelinated dorsal vagal parasympathetic system. This system is “shut down mode” seen in animals that go limp when there is no escape possible. This is the place where public speakers lose their ability to get words out. This is also the place where athletes completely fall apart. This is the space our brain goes when traumatic things occur. We no longer feel our body and may feel light headed. Effective training prevents the performer to enter this place.
Breathing to relax
While the ANS has various “access points,” the most accessible conscious modulating benefit is often achieved through mastery of controlled breathing techniques. The goal of breathing exercises is to consciously create a desired state through stimulating the body’s chemoreceptors (located in the medulla oblongata) and subsequently causing the body to calm down.
The human body achieves maximized PNS activation during sleep. There are 3 major and distinct sleep stages, each with a correlating breath pattern. Relaxation through PNS activation is best achieved by controlled mastery of breathing patterns that replicate the unconscious breathing cycles seen in sleep onset and non-REM sleep. Sleep on-set is best replicated by utilizing “clearing” breaths. To use “clearing” breaths, exhale out fully and hold for as long as you can, which allows for an increase in pCO2. Repeat this 2-5 times before transitioning into 4-8 cycles of relaxed breathing in a 4 second, 7 second, then 8 second pattern.
4-7-8 BREATHING CYCLE:
As your skill and comfort increases with these breathing techniques, you can achieve deeper relaxation when combined with visualization, positive self-talk and guided meditation.
Breathing for activation
Breathing for activation is best achieved by replicating the rapid breathing pattern seen during maximum sympathetic activation. A hallmark feature of panic attacks is rapid, shallow breathing (i.e. hyperventilation). Hyperventilation leads to decreased pCO2 which signals SNS activation, which jumpstarts physiologic shifts that can maximize your stored energy availability. Hyperventilation is followed by 1 or 2 clearing breaths to promote balanced activation of both the SNS and PNS. Without clearing breaths the SNS may become over-activated and lead to decreased performance.
RAPID CYCLING: diaphragmatic nasal breathing with use of accessory breathing muscles
Exhale until you feel a knot in your abdomen
Hold at full expiration for 5-10 sec (the duration will increase with time and practice)
Repeat 1-2 times (~30 secs)
As your skill and comfort increases with these breathing techniques, you can achieve heightened activation by combining focused breathing with visualization, positive self-talk and internal coaching.
CAUTION: Breathing techniques, especially hyperventilation, may trigger lightheadedness, extremity tingling and even loss of consciousness. Due to these risks, these techniques should be practiced in a safe environment with supervision (not in water, while driving, etc.). Additionally, these skills require practice to achieve optimal effectiveness. Start slowly and increase the duration of breathing exercises with your comfort level.
Many athletes struggle with over-activation on performance day. Without proper training, it is easy for the pressure of performance to push even the most highly-trained and physically fit athletes into “freeze” mode. To maintain optimal performance, athletes must be able to monitor and modulate their internal state to maintain optimal activation (see the performance activation curve below). It is also important to note that the level of necessary activation varies from sport to sport.
For athletes who struggle with “freezing” or “choking” on game day, it is helpful to perform a retrospective behavior chain and begin to build a “game day routine” to build confidence and abort future over-activation. This requires focused attention on internal monitoring, effective usage of necessary breathing techniques, visualization, positive self-talk, internal coaching and relaxation techniques. The ultimate goal is to maintain performance within the “target zone” with the ability to implement learned techniques when the athlete catches their internal state trending towards under- or over-activation. The key to success is internal monitoring and prevention.
Many athletes struggle to consistently train at the level they perform. Often athletes report frustration that they can “turn it on” during a performance but feel unable to replicate that level of intensity in daily practice. For these athletes, it is important to understand the “performance activation curve” and learn to identify and replicate game-day performance on a routine basis. This requires focused attention on breathing techniques to achieve activation (rapid cycling and clearing breaths), visualization techniques, pre-performance routine, positive self-talk and internal coaching.
Join Dr. Eller on:
|Apr 17, 2018|
Sensorium: Medications, Drugs (THC, Alcohol), Medical Issues, Sleep, and Free Will
Questions? Look for the posts related to this content on one of my social media sites. I will try my best to answer the questions or plan to answer them in a future episode.
Dr. David Puder
For PDF with citations: https://psychiatrypodcast.com/resource-page
Special thanks to intellectual and research contributions from: Rebeka Sipma, Dr. Amul Shah, Ale-salvo Daniela, Adam Borechy, and Jaime Rudyk
|Apr 05, 2018|
Exercise as a Prescription for Depression, Anxiety, Chronic Stress (like Diabetes) and Sensorium
The most recent podcast on the Psychiatry & Psychotherapy Podcast is on the benefits of exercise for depression and cognitive function. I cover 17 studies on the benefits of different kinds of exercise, most specifically strength training.
Strength training may be underestimated in terms of improving cognitive function and depression. I wrote a blog about this in the past, and it is a passion of mine. Basically, strength makes people harder to kill.
My exercise recommendations:
I use a model called “Starting Strength” and recommend this book and watching these videos on technique:
Do 3 sets of 5 repetitions each to start out.
Consider getting a coach if you live by one, or an online coach if you want to be a garage warrior like I am!
This is a link to online coaching (use the discount code of “courage”)
For PDF with citations with links to articles go here.
|Mar 23, 2018|
Diet on Cognitive Function, Brain Optimization, Sensorium Part 2
How do we optimize our diet for total brain function?
What are the best diets for the brain and cognitive function?
How much does diet influence our sensorium?
What particular foods are important?
How do we change our genes to optimize our brain?
For PDF with citations, detailed notes, (which can be freely shared) go to:
|Mar 15, 2018|
Schizophrenia with Dr. Cummings: Controversies, Brain Science, Crime, History, Exercise, Successful Treatment
In this episode, Dr. Puder addresses the fascinating realm of schizophrenia with Dr. Cummings, a previous guest in the show. Dr. Cummings is a psychiatrist with a wealth of experience from working at Patton State Hospital in California, one of the biggest forensic hospitals in the world.
Gitlin, M., Nuechterlein, K., Subotnik, K. L., Ventura, J., Mintz, J., Fogelson, D. L., ... & Aravagiri, M. (2001). Clinical outcome following neuroleptic discontinuation in patients with remitted recent-onset schizophrenia. American Journal of Psychiatry, 158(11), 1835-1842.
Pajonk, F. G., Wobrock, T., Gruber, O., Scherk, H., Berner, D., Kaizl, I., ... & Backens, M. (2010). Hippocampal plasticity in response to exercise in schizophrenia. Archives of general psychiatry, 67(2), 133-143.
|Mar 06, 2018|
Physicians Receiving Treatment, with Dr. Trenkle
This week I had a discussion with Dr. Darcy Trenkle on the difficulty of providers to get psychiatric treatment, using ourselves as the examples. In a recent article nearly 40% of physicians surveyed said they would be reluctant to seek formal medical care for treatment of a mental health problem because of concern that this may put their medical license in jeopardy. Physicians have three times the national average for suicide and have unique stressors and often a culture not conducive to seeking help. We discussed difficulties we had in contemplating getting care for different issues we faced. Hopefully this will open a discussion regarding the conflicts providers have in engaging needed help. Dr. Trenkle is a psychiatrist in Southern California and is affiliated with Loma Linda University Health. She received her Medical Degree from Loma Linda University School of Medicine. She completed her residency training at Loma Linda University in 2015. She is the Medical Director for Electroconvulsive Therapy as well as Program Development for the Behavioral Medical Center at Loma Linda University. If you are a Medical Student, Resident or Attending listening to this and need help, please reach out to a local provider. We are open to receive emails if you are local, our names are searchable in the Loma Linda email system.
|Feb 28, 2018|
Sensorium: Total Brain Function Optimization Part 1
Sensorium is the total brain capacity for focusing, processing, and interpreting. It is not a static state—it can fluctuate throughout the day.
It can be influenced by sleep, food, stress, exercise, drugs, medications, and long term, through epigenetic phenomenon.
If there is damage to the structure of the brain, it can permanently lowered.
It is a slope, which we all move up and down on, based on our baseline, but then also influenced by many factors.
Figure 1: Line representing how sensorium (total brain function) changes based on positive and negative influences.
In your 20s and 30s you are very far on the left side of the line. If you get stressed, sleep deprived, starving, maybe have a small infection, you may still be able to think, but just less clearly. If you did those same things to an elderly person, they would be sent into a full delirium, hallucinating, throwing things, yelling, seeing spiders on the wall, and looking psychotic. In this way it is common for an elderly person with dementia, they can be more confused in the evening then in the morning, they call this “sundowning”.
We all have a baseline level of brain function, and this can be optimized by several factors like good sleep, good amounts of exercise, good mental functions (like reading), meaningful relationships, good spiritual practice, and meaningful work.
We can also lower our sensorium through certain drugs, excessive alcohol, significant medical issues, poor sleep, poor diet, unrelenting stress, and untreated medical issues (like out of control diabetes or obstructive sleep apnea without treatment).
This applies directly to psychiatry, because we want to think about how to make our patients the most functional human beings possible, with the highest sensorium, so they can engage in meaningful work and life.
This applies directly to psychotherapy, because the chance of significant work taking place in psychotherapy will be lower if your patient is confused, and unable to integrate new memories and new ways of processing information.
I am going to go through some of the science of how sensorium is lowered or strengthened. I am going to hit the categories briefly and in future episodes go through them in more detail. We will start with what delirium is—very, very poor sensorium.
Delirium is defined as an acute confusional state, decreased significantly from baseline. For example, an older person with a urinary tract infection who starts hearing and seeing things with no history of ever having such issues, has what is called hyperactive delirium. There is also something called hypoactive delirium, where someone is confused, down, seems acutely depressed, but is not hallucinating. Delirium has a waxing and waning course, meaning it might be worse at sometimes in the day and then better later. This affects up to 38% of older hospitalized patients. Studying what can cause, or worsen, delirium can also inform our study of lesser severe states of sensorium issues. For example, here are some things that provoke or worsen delirium (Ahmed, 2014; Laurila, 2008):
This led me to be curious about how to optimize sensorium, both in how to decrease dives in sensorium, and also how to increase it long term. I wanted to present this topic early in my podcast because it is a way that I think about psychiatry and psychotherapy and influences many of my decisions. First, I will go into 3 stories, which illustrate the power of treating someone with sensorium in mind. I will change the demographic information to protect their identities.
Jake was a 60 year old man who came into my clinic after being on disability for 10 years. He had lost his daughter, which still weighed heavily on him. He used to be a business executive, having run several companies with over two hundred employees. He was an expert at turning around dysfunctional companies that were about to fail, even to the point of needing to let go of all their staff and facing shutting down. At a certain point 10 years ago he had had a head injury, with loss of consciousness for greater than one hour. He had needed to be hospitalized afterwards. He was put on pain medications and muscle relaxants, and was subsequently unable to control his anger, flying into fits of rage, throwing things, yelling at staff and acting ways that got him fired. Afterwards, Jake ended up on chronic disability with little hope of working again.
Jake had a hard time reading books like he had before, and had general issues with focusing and completing tasks. In my initial assessment, I focused on giving him hope that I thought he could optimize his brain function and improve his sensorium. We started an intensive outpatient program to help him overcome the loss of his daughter, and so I could manage his medication closely. I tapered him off his opioids, benzodiazepine, and baclofen (a muscle relaxant that is centrally acting). We also worked on optimizing positive things, like doing strength and cardiovascular exercise, and diet changes. His concentration returned; he was able to work through his grief, and after the intensive outpatient program we focused each session we had on re-launching his life. He eventually was able to get a position as a CEO of a big company, and within months the profits were up at the company and he was able to do meaningful work.
Another example is a middle aged woman who worked as a therapist. Beth was having issues with memory and reading things. She always felt like she was in a fog. She had a difficult time with keeping her schedule and was frequently missing things. She was worried she might be having dementia. We did several exercises, including helping her give up her chronic anger she had towards an ex. We switched her migraine medication from 2 things that lower sensorium (topiramate and an anticholinergic amitriptyline) to another medications which does not lower sensorium (Cymbalta). We also did some lifestyle changes, like 4 days per week of exercise and eating more healthy food. Her memory and focus came back and she once again found her work meaningful and pleasurable.
Tom was a man in his mid 40s who could not focus and felt like he was depressed. He came to me wanting ADHD medication and something for depression. But on further history he had no history of ADHD in childhood, but only in the last 4 years. He had gained weight into his 30s and 40s and was over 300 pounds. He would wake up with headaches, and he had out of control type 2 diabetes. He ate fast food and drank alcohol 3-4 times per week, usually 3-4 servings per night. I was concerned he had sleep apnea, which he did, and we got him started on wearing a sleep mask and losing some weight for a long term solution. We cut out soda, fast food, and other non-healthy foods. I had Tom focus on working through his marriage conflicts, and his chronic stress from work also decreased with some therapy.
Over the course of 2 years, he lost 50 pounds. His diabetes was under better control. He was also able to increase his strength through strength training. He doubled his strength and now is able to decrease his medications he used for diabetes to only metformin. He had also stopped drinking alcohol, except for maybe one drink per week. He would meal prep and was eating high quality food, mostly in line with a mediterranean diet. He said his focus was the best it had ever been and felt purpose and meaning in his work and life. His relationship had also improved and he enjoyed time with his kids and wife.
In part 2, I will go through more details on things that increase or decrease sensorium.
Ahmed, S., Leurent, B., & Sampson, E. L. (2014). Risk factors for incident delirium among older people in acute hospital medical units: a systematic review and meta-analysis. Age and ageing, 43(3), 326-333.
Laurila, J. V., Laakkonen, M. L., Laurila, J. V., Timo, S. E., & Reijo, T. S. (2008). Predisposing and precipitating factors for delirium in a frail geriatric population. Journal of psychosomatic research, 65(3), 249-254.
Pisani, M. A., Murphy, T. E., Araujo, K. L., Slattum, P., Van Ness, P. H., & Inouye, S. K. (2009). Benzodiazepine and opioid use and the duration of ICU delirium in an older population. Critical care medicine, 37(1), 177.
McLaughlin, K. J., Gomez, J. L., Baran, S. E., & Conrad, C. D. (2007). The effects of chronic stress on hippocampal morphology and function: an evaluation of chronic restraint paradigms. Brain research, 1161, 56-64.
|Feb 19, 2018|
A Journey Learning Psychotherapy, with Randy Stinnett, Psy.D
This week I (David Puder), had a discussion with Randy Stinnett, Psy.D, regarding his journey to become an excellent therapist. Randy shares aspects of his journey and insights. His enthusiasm is contagious. He discusses formative influences including Habib Davanloo, Donald Kalsched, and Todd Burley.
I asked Randy to give a summary of his 5 recommendations for someone aspiring to be an excellent therapist, which compliment the dialogue on this podcast:
|Feb 13, 2018|
Inpatient Child and Adolescent Suicidality, “Culture of death”, “13 Reasons Why” with Dr. Britt
Dr. Britt, an expert with three decades of experience, breaks down the increasing trend in teen suicide.
In this episode I will be interviewing William Britt, PhD level clinical psychologist, an expert in cognitive behavioral therapy, object relations therapy, EMDR and a board certified neuropsychologist. He runs cognitive rehabilitation groups and neuropsychological assessments, and supervises neuropsychological fellows and interns. He also works closely with the psychiatric residents teaching about suicide.
In this episode, Dr. William Britt explores his experiences running an inpatient psychiatric group for 5 to 13 year olds who are being treated for violence or attempted suicide, using uses a method based on Irving Yalom’s inpatient group psychotherapy technique.
We discuss how the trend of teen suicide has increased over the years. We also cover common bullying tactics and how cyber bullying has changed society. We then discuss how to use the group's support to help each other move away from being suicidal. We explore how the Netflix TV series “Thirteen Reasons Why” has influenced young minds and the new terms the patients are using.
In the end, Dr. Britt and Dr. Puder answers how we adapt and recover from trauma, and how we find meaning and value within stress.
13 Reasons Not To Commit Suicide by Dr. Britt
Compiled from insights from adolescent patients in inpatient group therapy.
If you read this and our struggling with thoughts of suicide, please call the National Suicide Prevention Lifeline: 1-800-273-8255
|Feb 06, 2018|
Psychopathy with Michael A. Cummings M.D.
In this episode, Dr. Cummings and I discuss psychopathy: the fearless, empathyless people, who see others as objects, and have the inability to attach within relationships. Dr. Michael Cummings recently contributed to a book called “Violence in Psychiatry,” detailing the biological aspects of psychopathy, edited by Stephen Stahl. Dr. Cummings works at Patton State Hospital, one of the biggest forensic hospitals in the world. He is the Yoda of the psychiatric world, with many other psychiatrists bringing him their most complex and difficult cases.
In this episode we cover:
We also wrestle with how to increase the percentage of psychopaths that end up helping society vs percentage that become criminals.
|Jan 29, 2018|
Cognitive Distortions and Practicing Truth
This week we discussed cognitive distortions with Adam Borechy. Usually cognitive behavioral therapists deal with cognitive distortions by helping their clients identify habitual negative thoughts and and putting those thoughts on trial. We don’t have to accept every thought that passes through our brains as truth. When we have distressing thoughts, it can be helpful to consider if we might be telling ourselves the full truth about a situation.
We refer to common cognitive distortions—depression, anxiety, feelings of failure, negative thoughts when interacting with people, social anxiety—and we see how they are applying to our thought process.
For a PDF of the cognitive distortions and a 8 days journal task towards better identifying them in your life, please see my resource page. In this 8 day journey you will better identify your own troubling thoughts and move towards gratitude.
|Jan 23, 2018|
The Basics of the Psychiatric Interview Part 1
In this first episode I talk about my approach to seeing a new patient for the first time. I go over the importance of empathy and psychological safety in the first interview. I then go into how to do some of the components of a psychiatric history. I go into details on what parts are important and why. Please see my resource page for a full PDF of my notes and also the PDF of the document I give to patients prior to their first appointment with me.
|Jan 16, 2018|