Languishing

How have you felt lately? Really?

Good? I am happy for you. Depressed and hopeless? I sincerely hope that you are seeking help and on the road to recovery. The rest of you? My hunch is that you may be feeling a little flat, not motivated, and “meh”. This is weird, right? Vaccines are here, many of us are back to work, things are opening up a little bit, and the warm sunshine of spring and the promise of summertime should be brightening our days. Why then, do we still feel a lack of motivation, have trouble concentrating and find it challenging to focus on the things that matter to us?

Adam Grant, an organizational psychologist at Wharton, addressed all this in his April 19, 2021 article There’s a Name for the Blah You’re Feeling: It’s Called Languishing. He pointed out that we are not depressed or hopeless. We are not impaired. We are functioning daily. We are not burned out. There is just little joy and we feel aimless at times. We lack anticipation for the good things that we used to look forward to.

According to Grant, languishing is a sense of stagnation and emptiness. We are muddling through, and as some of my patients have said in the past “existing but not really living”. Many of us who have had COVID and recovered or those who have not had the illness at all are struggling not with long COVID syndrome, but with “the emotional long haul of the pandemic”.

Think back to early spring 2020. We were all a bit frightened, unsure of what was happening in the world around us that was heading our way. Back then, according to Grant, our natural threat detection system was “on high alert for fight or flight”. We learned that masks were helpful, but we were still scrubbing surfaces and sanitizing our groceries. We developed crude routines that “helped ease our sense of dread”. The problem is that as time has gone by, our acute state of anguish “has given way to a chronic condition of languish”. As languishing is squarely between depression and flourishing, we don’t feel bad but neither do we feel back to our pre-pandemic good either. Grant says that “you’re not functioning at full capacity. Languishing dulls your motivation, disrupts your ability to focus, and triples the odds that you’ll cut back on work”.

The term was coined by a sociologist named Corey Keyes. According to the article, his research suggests that these who are languishing today are going to be at much higher risk of developing depression and anxiety over the next decade. That second great pandemic wave you’ve heard about? It may be psychological, not purely medical. Grant also says something about languishing that hit me: “You’re indifferent to your indifference.” You may not even realize how slowly you are sliding into the malaise.

So, what do we do with all of this? Grant says that one of the best ways to handle emotions is to name them. In the spring of 2020, we were all obviously experiencing acute grief, from loss of loved ones to loss of freedoms to loss of routine to loss of income. So many losses. Now, we learn that we are languishing, and naming it may be the first step in battling our way out of it. Languishing is “common and shared” and just knowing that may give us the ability to bestow a little grace not only on others but on ourselves.

What next? Focus. Relearn, if you must, how to pay attention to the things that are important to you. I am the worst when it comes to this, so believe me when I say I am not preaching to you. Grant says in his article that “computers are made for parallel processing, but humans are better off serial processing”. Simply put this means do not try to multitask! Again, I have five or ten or fifteen things that I must do, want to do, love to do, and I delude myself into thinking that I can do five of them at a time extremely well, but this is simply not true. Pick something, make it realistic and doable, and put your whole focus into it. You’ll feel much more accomplished and maybe even happy if you do!

Set boundaries and block out time for yourself. A colleague and I were talking about this by email just this morning. We need processing time, thinking time, planning time. I know it is hard to come by when you are working from home, taking care of the kids and responding to emails and Zoom invitations all day, but it is worth aiming for.

Grant tells us to focus on small goals. “Try starting with small wins”, because the pandemic was such a big loss to us all. Don’t be too easy on yourself though. Pick something moderately challenging sometimes. “The most important factor in daily joy an motivation is a sense of progress.” Do things that matter to you.

The article finishes up by acknowledging that “languishing is not merely in our heads-it’s in our circumstances”. “Not depressed doesn’t mean you are not struggling.” As one of my patients told me that other day (I told him I would steal this and he agreed), “Just because I am smart and can articulate what is going on with me does not mean that I can fix it.” Don’t let yourself languish, isolate and fall into the pandemic abyss. Use the tools outlined in this article, use your support systems, and get professional help if you need it. We are so close, and we will get there together.

Closure

When one door closes, another opens.”

Alexander Graham Bell

 I have heard it so many times in the past.

“I had so much more to say”, the grieving mother tells me. “I didn’t know that we were drifting apart”, the middle-aged man says. “I didn’t know that it was going to turn out this way. “

We have witnessed a terrible year of political unrest, a raging pandemic, and social upheaval. With the conviction of Derek Chauvin in the George Floyd murder trial this last week, many said that they felt they could finally sleep, rest, and feel more at ease with the completion of a long, arduous year of pain and wondering. What did all these people have in common?

They needed closure. They needed to know that all that should have been said had been said. They needed to understand the division and come to terms with the reasons for it. They needed to come to grips with how it actually came out in the end. They needed a verdict to know what to do, how to feel, and how to act next.

What is closure?

Abigail Brenner MD writes about closure in her article 5 Ways to Find Closure From the Past in Psychology Today. She says that “closure means finality; a letting go of what once was. Finding closure implies a complete acceptance of what has happened and an honoring of the transition away from what’s finished to something new. In other words, closure describes the ability to go beyond imposed limitations in order to find different possibilities.”

What does it take to achieve that state of closure that we all long for after a particularly tough situation or problem? We must navigate many sometimes conflicting emotions such as sadness, grief, anger, fear or hate. We may literally lose sleep over it. We may not eat. Our usual routines and comforting daily activities may not be enough to keep us on an even keel any more. We may delay going on with our lives because we simply cannot let go of the past and close the door on what was painful.

If we have lost a job, experienced an assault, had significant family issues, had financial setbacks or myriad other stresses, we may feel that there has been an absolute lack of resolution and that we simply cannot process what happened all the way to its logical end.

What does closure do for us then? It helps us to put a marker down, to delineate the before and the after so that we can decide from which point we actually need to move forward. It closes a chapter on what may have been a very painful part of our lives, but it never closes the entire book. There is always more to be written. Closure allows emotions to pour out, to be expressed and laid bare and dealt with where they are, how they are, for what they are. It allows us to make peace with something, move forward, and to go on with life.

Dr. Brenner states in her article that the ways to go about seeking closure include the following five things: taking responsibility for yourself; grieving the loss; gathering your strengths; making a plan for the immediate future, and creating a ritual that helps you move forward.  

Most people have heard the quote I began this column with, but many do not know the quote in its entirety. Bell supposedly said, “When one door closes, another opens,  but we so often look so long and so regretfully upon the closed door, that we do not see the ones which open for us.”

Do you need to seek closure today? If you find it, will you be able to look for the open doors that beckon?

Suffer the Little Children

We are all happy that with the arrival of three vaccines against COVID-19, the end of this long, stressful pandemic might finally be in sight. However, I read two articles recently that gave me pause. I wanted to share them with you .

The first, entitled Kids’ Mental Health is Still Pediatricians’ Greatest Concern, was in the Sunday, March 7, 2021 edition of the Augusta Chronicle. In it, Steven Shapiro, Chair, Department of Pediatrics, Abington Hospital, Philadelphia, PA, stated that “20% of calls are now to put kids on more medications for panic attacks and anxiety.” He was quite concerned that the uncertainty and anxiety spurred by the pandemic, coupled with a lack of social contact, may be having lasting effects on the mental health of children and teens. As we have all seen, children seem to be less likely to have serious physical illness from COVID-19, but the emotional toll of this ongoing pandemic may be affecting them more than we know. Vaccines are super and many of us have already had at least one dose, but they are not yet available for children. Moderna began testing its vaccine for young children just recently, so there is hope that this age group may soon be part of the more fully protected when a vaccine is deemed safe for them to take.

What kind of emotional affects does the pandemic have on kids? For one, they worry about somehow getting infected, then making their parents, grandparents, and teachers sick, according to Stephanie Ewing, Assistant Professor in Counseling and Family Treatment at Drexel University College of Nursing and Health Professions. Routine health appointments and follow up visits for well checks and vaccinations, among other things, fell drastically in the first few months after the pandemic was discovered and stay at home orders became more common. According to a November 2020 Blue Cross/Blue Shield report, vaccinations for measles and whooping cough fell 26% compared to the same time in 2019. On the positive side, there has been a decrease in the number of cases of strep throat, flu, and ear infections due to social distancing, says Jonathan Miller, a pediatrician at Nemours/Alfred duPont Hospital for Children. Dr. Miller also notes that children have been much more inactive, they have had an increase in screen time, and they have been home for a much longer period of time than pre-pandemic times. He wonders about the impact of these on overall wellbeing. There has been an increase in depression and anxiety symptoms in his practice as well, and he has shifted to a more proactive stance and an emphasis on preventative care when dealing with behavioral and mental health issues.

The second article, MUSC Doctor Says Pediatric Suicide , Suicide Attempts “unprecedented” Amid Pandemic, appeared in the Post and Courier on 2-19-21. It continued to look at the issues we’ve already outlined but went a step further to drill down on the issues of suicidal ideation, suicide attempts and completed suicides. It also made this issue much more real for me, as these doctors live and work on the South Carolina coast in the Charleston area.

Dr. Elizabeth Mack, Chief of Pediatric Critical Care at MUSC, says that the number of these suicidal kids has reached a crisis in Charleston during the pandemic. What they are seeing inside the pediatric intensive care unit is much higher than normal and unprecedented. “We’re seeing a twin pandemic in many different ways. The isolation is really amplifying the inequities that have been laid bare for us.”

What are some of the factors that are contributing to the rise in pediatric suicide attempts and suicides? Isolation, grief secondary to the loss of loved ones, and financial insecurity are just three. Delayed return to school, which of course may be rectified in the coming months for many students, has lead to increased anxiety and depression. Schools are also safety nets for kids who don’t have enough food, who get most of their social needs met there, who have better access to physical and mental health care in school, and who sometimes are rescued from various kinds of abuse when a teacher or counselor sees warning signs and investigates further. Even when they are in school, some children worry about getting infected with COVID-19 themselves. Plexiglass barriers, mask wearing and social distancing also lead to odd emotional reactions in some children.

What can we all do to help?

Parents, teachers and counselors can be as open as possible with kids, including sharing some of their own healthy emotional responses to the pandemic and how they dealt with them. Focusing on the future can be very helpful. All of us can be vigilant, and if a child acts or sounds or interacts differently than usual, taking them to their pediatrician is a good first step. One more potentially lifesaving thing we can all pay attention to? Gun safety.

Dr. Annie Andrews, Director of Advocacy in the Department of Pediatrics at MUSC, noted that pre-COVID-19, thirteen million children lived in homes with firearms present, and four million of these in homes where the firearms were not secured. Children in homes with guns are three times more likely to die from suicide. Eighty per cent of children who attempt suicide with a gun will die. Only 2% of those who attempt to kill themselves by ingestion/overdose will die. Gun safety means unloading, locking up, and separating ammunition from firearms. As many as five children a week have been brought to MUSC with self-inflicted gunshot wounds, either accidental or intentional, and many of these kids die.

As Dr. Andrews and others in these articles said, these data are still anecdotal, but more data will be forthcoming as we go forward. As I started this column by saying, we are very happy that one pandemic seems to be heading towards its latter stages. Unfortunately for our children and teens, another pandemic may just be beginning, and we will be wise to watch for it and confront it wherever it arises.

The Right Thing to Do

I was walking back to my car from the pay station in the public parking lot when she pulled into the adjacent space. The front of her white Honda Civic, which she guided too widely into the space, scraped and clipped the front wheel of the car to her left. I saw it and cringed, and I am quite sure she saw me see it. I also saw that there were already scrapes on her bumper from previous encounters. I walked on to my car. I watched,

She did not get out for quite some time. When she did, she glanced my way. She got back into her car. The owners of the adjacent car arrived, got in, and prepared to leave. She did not get out. She did not tell them what had happened. She did not apologize for the assault on their vehicle in their absence. They backed out and left.

She got out of her car again, looked back my way, then walked over and paid her parking fee. She walked away.

If one is dishonest or irresponsible in small things, how does one expect to be honest and responsible in larger, important things? This is a lesson that bears learning and relearning daily.

All Shook Up

Oh, well my hand is shaky and my knees are weak

I can’t seem to stand on my own two feet.

Who do you thank when you have such luck

I’m in love, I’m all shook up.

All Shook Up, by Elvis Presley

One year ago, it was still very common for us to walk up to a friend or business associate, put out our right hand in a gesture of friendship, grasp their hand, and pump it a few times enthusiastically. This handshake, though not the way everyone greets others around the world, is one of the most common ways of doing so worldwide.

What is the origin of the handshake? Wikipedia tells us that as early as the 5th century BCE in Greece, handshakes were seen as symbols of peace, and most importantly showed that the parties doing the greeting were not carrying any weapons. The Romans took the lowly handshake a step further grasping the entire forearm, once again to look for hidden knives or other weapons. The knights of medieval Europe did the same thing, shaking the hand and arm of challengers vigorously to loosen anything deadly. Another word for handshake is dexiosis, if you’re into Scrabble. Another bit of trivia for you. Stephen Potter of St. Albans shook 19,550 hands at the St. Albans Carnival in August 1987, breaking the world record. As the famed Guinness Book retired that particular category, the record has since been broken, but Potter holds the European record.

What did a handshake mean to us in the days before March 2020, the pre-pandemic times? I don’t think we were often looking for weapons when we greeted a friend with a good fist pump, but we certainly wanted to convey closeness, warmth, sincerity and greeting. You normally shake hands with someone you trust, or at least can respect. (Remember all those celebrated Middle East peace accords, with two opposing leaders shaking hands on a podium, a beaming United States President standing in the middle?) Handshakes can seal a deal, signify a completed contract, and show that it is okay to move closer. Unfortunately, these days we are doing fewer in person deals, and we have very little reason to want to get within arm’s reach of anyone that has a different last name than we do. Handshakes help us meet and greet, say goodbye, congratulate, and express our gratitude.

Are there other ways to do all those things that do not involve grasping hands? Of course. Again, Wikipedia tells us that The New Zealand Maori touch noses, and Ethiopian men touch shoulders. In the Congo friends touch foreheads. In Asian countries, bowing is an acceptable form of greeting though they will shake hands with Americans and others if they think that is expected.

Why might this be important now, in 2021? Handshakes spread germs. Cold germs. Flu germs. Coronavirus germs. With the 2009 H1N1 flu pandemic, as well as with the pandemic we are now living through, alternative ways of greeting one another have been strongly encouraged. Elbow bumps, head nods, bows, and fist bumps can all be seen across the land. Having traveled to Japan and also having seen how South Korea and other Asian countries approach this dilemma, I am partial to their solutions. Wash your hands, wear a mask anytime you are outside in the public, stay several feet apart, and bow to greet one another. Safe, easy, respectful and not conducive to viral spread. Why do you think that many of us have adopted the elbow bump over other methods of saying hello? Because we crave human contact. We crave touch. We are hardwired that way. This last year has been so very stressful in so very many ways, not the least of which is its toll on our emotional and physical connections with each other, individually and within our social institutions.

Is there a post-pandemic future for the handshake? Some, like Dr. Anthony Fauci, said early on in the pandemic last year that he thought maybe we should never shake hands ever again. I’m not sure how realistic that will turn out to be. However, I know that when the all clear is given, there will be smiling, laughing, tears, hugs and kisses, and I don’t see how a few handshakes can be far behind. In the meantime, think like a Roman or a Medieval knight, assume there are deadly weapons in that outstretched hand, and bow instead.

(Un) Comfortably Numb

“Hello? Is anybody in there?”

“I have become comfortably numb.”

Pink Floyd

We are being bombarded with numbers. Numbingly numerous numbers. Allow me to share some familiar, and maybe not so familiar ones with you.

When I first wrote this piece, there had been one hundred ten million, thirteen thousand eight hundred forty-one cases of COVID-19 across the world. Global deaths were two million, four hundred thirty-two thousand six hundred ninety-five. In the United States, we had twenty-seven million, eight hundred twenty-eight thousand one hundred fifty of these cases, and four hundred ninety thousand, seven hundred eighteen deaths. Of course, the numbers have only grown since that time.

The monster winter storm that engulfed the United States from Texas to the northeast resulted in four million without power in Texas alone, and forty deaths across the land. By Thursday of that week, FEMA had already distributed seven hundred twenty-nine thousand liters of water, fifty thousand cotton blankets and two hundred twenty-five thousand meals.

During the COVID-19 pandemic, forty one percent of adults surveyed in January 2021 had some degree of anxiety and depression, up from 11 per cent in January through June of 2019. Thirty six percent of those questioned related poor sleep, and thirty-two had appetite changes. Up to fifty-six per cent of young adults ages 18-24 had been battling depression and anxiety.

Did you see how I wrote all these numbers out in words? Why? Because it takes you longer to read out each word, to really process what the sheer numbers mean, than if you see another in a long string of mind-blowingly large figures. The numbers do not lie. We see them, day after day after day, but my fear is that we are becoming more and more (un) comfortably numb to them.

It is easy to develop compassion fatigue in times like these. There is so much hurt and fear and pain and need and stress in our world right now that it is easy for us to develop emotional numbness to these massive threats to our daily way of life. Compassion fatigue is that indifference to charitable appeals on behalf of those who are suffering, experienced as a result of the frequency or number of such appeals. It comes in no small part from actually absorbing into ourselves the trauma and emotional stress of others, leading to a vicarious pain and discomfort that become a secondary trauma to the caregiver or helper.

How does it manifest? Physical and emotional exhaustion, depersonalization, irritability (raising my hand here), self-contempt, decreased sleep, weight loss (or gain in some), and headaches are just a few of the signs and symptoms you might find yourself experiencing during these very troubled times.

How might it affect your ability to function at your best daily? You might be trying harder but find yourself helping less. You might give up, feeling that the stresses in the world are so huge right now that there is nothing one person can do. You might find yourself coping by using alcohol, drugs, or food to self soothe. Small, nagging physical symptoms might worsen into actual illness.

How do you decrease emotional numbness?

Reconnect with the world, with your world. Find a way to reach out and connect locally, nationally or internationally as you feel might be most helpful.

Practice good self-care. This is not the time to back off good pandemic hygiene, good patterns of eating and sleeping, or your usual exercise routine. It is time to double down on these things that make us healthy and keep us happy. I have recently started meditating, having never done it and knowing absolutely nothing about it. I have been amazed at how a brief ten-to-twenty-minute meditation practice session can put me back in the game. Learn something new. I recently listened to a chapter in Dr. Sanjay Gupta’s book Keep Sharp that talked about learning a new language or something equally as challenging. I was heartened to hear him say that it is not impossible to learn these difficult new things as we age, though it might take a little longer than when we were younger. Give yourself the grace to try, to do, and to succeed. We are making history just by surviving in this one-hundred-year pandemic!

Take time with family and friends when you can do so safely and practically. We need social interaction, as discussed here before. We just need to realize that continued vigilance is necessary until we can see the true end of the pandemic approaching.

Write in a journal. As you know if you have been reading my columns and blog posts for long, I love to write. I write in small notebooks, large notebooks, software programs, on Post-It notes, and on the back of envelopes. Our thoughts jotted down on paper or converted to ones and zeros in an app somewhere will be the primary sources for someone who one day writes the definitive history of this pandemic. Think about that and contribute.

I’ve borrowed from Mother Teresa before, and I will do it again to close these thoughts for the week.

“We cannot all do great things. But we can do small things with great love.”

Pandemic Pitfalls

I read a good article on the physical effects of the coronavirus pandemic on our physical health recently. Yes, the Pandemic Is Ruining Your Body was written by Amanda Mull and published on January 14, 2021 in the Atlantic. In it, she addressed many of the ways that living in the middle of the worst worldwide health crisis in a century affect us as human beings who are struggling to be brave, squash fear, stay productive, and thrive, all without the help of our usual social institutions and personal interactions.

She acknowledges that for some of us, myself included, sitting at home virtually all the time, even when working hard, is a situation of relative comfort and incredible luck. We have jobs that allow us to use computers, faxes, cell phones, scanners, email, and videoconferencing to meet, greet, schmooze and therapize to our hearts’ content, just not in person. But at what cost? She says that in her own experience of working from home, she began to experience decreased hip mobility, low grade headaches, sore shoulders, a stiff neck, and dry skin. At first, she and her ailments felt isolated, because she was isolated. She could not see that her coworkers were doing the same things, stretching the same tired muscles and “gobbling up ibuprofen” as she was. Many have been sickened or even died from COVID-19. Those who have avoided those fates, says Mull,  are living through an extended disaster that at the least is painful, but at its worst can be catastrophic.

What are doctors and others seeing? Aches and pains come up for seemingly no reason and then stick around. People who work from home found themselves setting up what they thought would be a temporary home workstation that they might need to use for a few weeks at best, a few months at worst. I did this myself. Over the last year, as pandemic reality set in, I have changed my equipment configuration, furniture and workflow more times than I can even remember. Sitting in front of a too short table, shoulders hunched, laptop screen too low, keyboard at the wrong height, and normal implements not easily reached, makes work tough. This, as Mull says, “all while sitting in a chair meant to support a human for the duration of a meal, not a workday”.

We are also working longer hours. How can that be, I asked myself after I read this in multiple articles for the fifth or sixth time. If you must get up, get ready, drive to your workplace and then leave at a prescribed time once you are done, there is an eight or nine hour rhythm to your day. If you subtract some of the prep time and all of the commute time, you find yourself (and again, I can attest to this) working an extra hour or even two. As I wrote this, I finished a “normal” ten hour workday that was jam packed with patients, emails, consults, and reviews. It simply feels that work has been busier, more packed with tasks and with much less down time or break time then pre-pandemic. Let’s be honest. Everyone feels just a little twinge of guilt when they work from home. And Mull says, “expectations of productivity have increased” because you are there. Granted, some may be able to outfit a spare bedroom or home office with nicer and more usable equipment, but “for those living in cramped housing with kids who go to Zoom school and other family members who also need space to work, building a personal mini office simply isn’t an option”.

Does any of this bleed over into our emotional wellbeing and ability to cope with the social and mental stresses that this pandemic has caused? Of course it does. In the past year, many months of which I have worked predominantly at home, there has not been a workday that goes by without me hearing about folks who are anxious and can’t sleep. Not a single day. Much like Amanda Mull discussed in her article about the physical stresses that can lead to physical problems, I have seen the psychological toll that the coronavirus has had on our normal psychological and emotional worlds. While staying home, we have lost out physical connection to others. There is no chatter around the coffee pot or in the parking lot before or after work. We have been forced to use different “equipment” to connect with each other. As my rector opined at a recent annual church business meeting, “Well, Zoom gets the job done I guess, but it’s not the same, is it?” Screens are now our “windows on the soul”. Why? Because any time we are face to face with most people we know outside our immediate family, we are wearing masks. Unless you are extremely close to someone, it is hard to read real emotion from just raised eyebrows or crinkling crows feet. Why is this important?

Because stress, anxiety, depression, loneliness, and hopelessness kill. They are not dangerous in themselves just for the misery they cause, and the potential for catastrophic consequences like suicide. As Mull states in her article, depression and anxiety “are enormous risk factors for heart problems, especially among people over 50. Quarantine itself is also a risk factor. Loneliness and social isolation increase the risk of myocardial infarction and stroke by up to 30 per cent”.

What can you do now, today? Connect with others, however you can, however awkward. Call. Zoom. FaceTime. Text. Reach out to the elderly who have little social support. Spend some non-screen time with a child. Cook dinner, and then leave part of it in a basket for the neighbors next door. I know I keep saying this, but it’s true. This pandemic will end. We will get through this together. We just need to make sure that we come out of this ordeal as physically and mentally healthy as we possibly can.

What Kind of Stress?

Over the last pandemic year, I have heard countless stories of people who have lost their jobs, had to move, lost a loved one to COVID-19, or just felt that their entire world had been upended by the restrictions and lockdown that this time in the world has foisted on all of us. These folks are invariably stressed, sometimes to their breaking points. They are not functioning well. They are irritable and depressed and anxious. They can’t eat and they barely sleep. They have little desire to do anything and have lost the joy they used to feel for almost everything. They come to see me, tell me their stories, and then tell me what they think the problem is and what I need to treat them for.

“I have PTSD,” they tell me, sure that this is the diagnosis that this pandemic has saddled them with, and equally sure that a medication or two will fix things and get them on the fast road to recovery and mental health again. But wait, is it really PTSD, or is that simply the diagnosis that most people know is associated with trauma, therefore must be the one they are suffering from?

I would like to talk to you this week about two kinds of stress reactions that are very easily confused. Most of the information that I am about to share with you can be found in UpToDate, a medical resource that pulls together the latest research and knowledge on a wide variety of topics and illnesses.

The first disorder is ASD, or Acute Stress Disorder. ASD is an acute stress reaction that occurs within one month of the traumatic event that causes it. Prevalence for this disorder is between 5-20%. What kinds of trauma can lead to ASD? Thirteen per cent of those who have severe motor vehicle accidents will have it, as will 16% of assault victims and, most horribly notable for all of us over the last month or two, 33% of those who witness mass shootings. Risk factors for developing ASD include being female, having various pre-existing mental health or physical illnesses, having a history of a previous trauma, and being exposed to a more severe trauma in the first place. The trauma experienced by someone may lead to a very transient reaction and no ASD, with a very swift return to normal. On the other hand, it may lead to ASD, then within a month also return to normal, pre-trauma life. One group, however, may go on to develop PTSD, or Post Traumatic Stress Disorder. As we shall see shortly, these folks may suffer long term effects that are life changing.

What are the symptoms of ASD? Re-experiencing the traumatic event is common, as is anxiety. Nightmares and vivid dreams may affect sleep. Recurring thoughts and increasing feelings of fear may arise. There is sometimes hypervigilance guarding against further threats. One might avoid people, places or things that remind of the trauma, and emotional numbing with flat features sets in. Dissociation from others, isolation and social avoidance complete the picture of someone who is feeling terrible but has an extremely hard time communicating this or sharing it with others, even those they are the closest to.

The good news? Most people who experience traumatic events of various kinds will have a brief period of symptoms and adjustment, and then will adapt and go back to their previous level of functioning within days to weeks. In some studies, it has been shown that 40-80% of people with ASD will go on to develop PTSD. The bright side of that is of course that almost half will not.

How is the diagnosis of ASD made? Quite simply, one must have several necessary symptoms. The first is exposure to the trauma, either directly, as a witness, or being told of the danger or injury to a loved one, for example. Intrusive symptoms can include dreams, memories and flashbacks. Mood becomes negative. There may be dissociative episodes. Avoidance tries to prevent recurrent trauma. Finally, arousal leads to decreased sleep, irritability, and an increased startle reflex. ASD may begin immediately after a trauma, but is usually best diagnosed three days or more afterwards.

What about PTSD? How is it different? It is diagnosed after four weeks of symptoms following the traumatic event. Two of the most likely types of events to lead to PTSD include sexual trauma at 33% (which may include childhood sexual abuse, rape, or domestic violence) and interpersonal traumatic 30% (which might include the death of your spouse or the serious illness of a child). Lifetime prevalence of PTSD may be as high as 6-9%. In one sample of 5692 adults in the United States, 83% had been exposed to severe traumatic events, but only 8.3% had developed lifetime symptoms of PTSD. Some very specific groups like native Americans and refugees from other countries with endemic abuse and stress are at higher risk for PTSD. Gender, age, educational level, history of previous abuse and poor social support may also lead to a higher risk of developing PTSD. Women are four times more likely to suffer from PTSD than men. A higher severity of symptoms at one month seems to be predictive of more serious PTSD symptoms at six months and onward.

Diagnosis of PTSD is similar to ASD, in that exposure to a traumatic event is necessary, intrusive symptoms such as re-experiencing and flashbacks are often present, and avoidance is present. Depression, decreased interest in activities, guilt, and disconnection from others are often seen. People feel on edge, reckless and irritable, and they tend to engage in risky behavior or make poor decisions. There may more serious depersonalization or derealization, or even amnesia for parts of the traumatic event.

PTSD tends to be a chronic disorder in many. One third recover at one year follow up, but another one third might still have symptoms ten years after the trauma. Some studies have shown that those with PTSD have poor social supports, increasing disability and inability to complete higher educational goals,

Now, what does all of this mean for the dozens if not hundreds of patients who have told me that they have “PTSD” because they feel traumatized and anxious due to pandemic? The very good news is that the vast majority of us will have initial anxiety when traumatized in this way, but most of us will recover in a very short time. We anticipate getting back to our pre-COVID lives one day, and we very much look forward to that. Those who go on to develop more serious anxiety symptoms and the other associated symptoms of PTSD should of course seek treatment as needed for what can turn into a chronic and debilitating illness.

Peekaboo, the ER Sees You!

Peekaboo, I see you!

Any of you who have children have played this game over and over with your young ones. At a certain age, they love to pull a blanket over their heads, or better yet, to have you hide behind that same blanket, and then squeal with joy when you emerge. It’s always as if you went far, far away and then miraculously returned to be with them again, much to their delight. The repetitive interaction teaches your child that you are always there, that if you appear to be gone that you will return and that you are a constant in their lives. They learn that you are there for them, and that you will keep them safe.

In mental health, we try to see and evaluate children in many contexts. We see them for who they are in a family unit, in their school environment, with their friends and in other social settings. In pre-COVID-19 times, we might have seen a child in the office, with input by a therapist, nurse and child psychiatrist. We might have had a school based therapist see the child in his or her natural environment in the classroom, the lunchroom, or the playground. We most likely would have wanted to get collateral information from other family members, several teachers, court systems, pediatricians, probation officers, or anyone else who might know something about that particular child and their presenting problem.

Since the pandemic began and lockdowns of various types began to be commonplace last spring, a lot of this normal information gathering has been curtailed. Clinics are closed and onsite, face to face interaction with mental health professionals is severely curtailed. School based therapists have been deprived of their most fertile diagnostic and therapeutic ground, the school itself, because so many children have been placed in virtual learning environments, often from home. If mental health providers cannot see the kids, they cannot do an adequate assessment and provide timely treatment. The result is the very real possibility that more depression, academic failure, physical, mental, or sexual abuse or neglect may be happening but never seen. Where do children and their parents turn when care is needed, but normal avenues of assistance are cut off?

The CDC tells us in their Morbidity and Mortality Weekly Report (MMWR) for the week of November 13, 2020, that emergency departments are often the first point of care for children’s mental health emergencies. As a community telepsychiatrist who has seen folks in the emergency rooms of South Carolina for the last ten years, I can attest to the truth of that statement. An interesting point here: during the first few months of the pandemic last spring, ER visits for all sorts of problems for adults and children actually went down, not up, at least at first. Why? Everyone was so afraid that they would contract COVID-19 at the ER that they stayed away, even if they had legitimate emergency health issues that needed to be attended to right away. Starting in April 2020, the CDC tells us, the proportion of children’s mental health related visits among all pediatric ER visits increased and remained high through October. Compared with 2019, the proportion of mental health related visits for children aged 5-11 and 12-17 years increased 24% and 31%, respectively.

We know that the coronavirus pandemic has had a negative effect on the mental health of children. If other services as outlined above are not available, children end up in ERs. These resources are invaluable when the going gets tough and there is no other option, but by virtue of their very nature, rapid assessment and evaluation of the sickest among us and triage to admission or discharge to further outpatient assessment, it is impossible for ER staffs to do a really thorough assessment of a child with serious mental health needs, even with telemedicine and other services there to assist.

Monitoring indicators of children’s mental health, the CDC tells us, promoting coping and resilience, and expanding access to services to support children’s mental health are absolutely critical during the COVID-19 pandemic. With the launch of vaccinations and continued use of masks, handwashing and physical distancing, we will get through this pandemic and back to some semblance of normal. In the meantime, we must not let even one child who needs us slip through the cracks and suffer from mental illness that can be assessed, diagnosed and treated.

Peekaboo, we see you.

Multiverse

I bought a Leatherman tool a few months back, thinking that having one multi tool in my bag or fishing tackle box would solve all the problems of finding that perfect screwdriver or pry or opener that always seems to hide itself from you when you need it the most. I have already used it to cut down cardboard boxes for recycling, to put together a pair of Adirondack chairs for the porch upstairs and to fetch an embedded hook from the throat of a largemouth bass. It is built well, it’s rugged and it’s complete. What more could you need, right?

I have also used other multi tools, including a laptop and desktop computer, an iPad, a multi pen, and others that claim to make life easier by having everything you could possibly need in hand at any time. They deliver on their promises,but are they as satisfying to use as single tools made for a single job?

Back when I was in medical school and residency, pens and paper were the lifeblood of medical charts and orders and notes. Cross pens (remember those?) were easily recognized in pockets and hands. They were given as gifts, singly or in little blue felted lined boxes with equally silvery shiny mechanical pencils. Mont Blancs were a step up, and of course I had a maroon one that I loved. Perfectly weighted, felt good in the hand, wrote smoothly. What more could you ask for, right?

Reading used to be accomplished by holding things called books, (You remember those too, right?), a single target use device that was made to entertain, impart knowledge or provide in hand research after rifling throughout wonderfully musty card catalogues at your local library. More recently, we have iPads, Kindles and a host of other electronic reading devices that may or may not do fifteen other things that distract you from that primary goal of reading. (Check Twitter! Check email! Order from Amazon.com!) Better, or not?

I often had a good natured argument with several friends and coworkers about the actual existence of multitasking and whether or not it could actually be accomplished in any meaningful and productive way. Our brains are made to focus on one thing at a time, and we do not do multiple tasks well all at one time. Is it better to be a jack of all trades and a master of none, or…

So, now that I have had access to laptops, iPads, multi use audio devices, multipens, and multi tools, I have come to the realization that I love the thought, feel and process of using one tool at a time for one job at a time most of the time.

Give me my book, my superbly weighted pocketknife, a throwaway Uniball Signo DX pen, and a good notebook anytime. I will be satisfied, productive, and happy.