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.

Fake It Until You Make It

I have been talking with friends, family members, and patients over the last several months about our lives in 2020. We continue to try to describe what it feels like for each of us to live in the middle of the biggest pandemic in the last hundred years. We talk about the things that we have all been feeling: the sense of loss, grief over the changes in our normal lives, the lack of social interactions with others, the inability to participate in things that used to give us joy, and the lack of certainty that pervades every aspect of our lives. We talk about how these stressors have changed the way we work, play and interact with others. We talk of the longing for things to get back to the normal, the predictable, and the reassuring. Almost everyone I know feels less confident, less powerful and less able to influence his environment since the start of this pandemic. We have been shrinking into ourselves, staying at home more and shunning the very social interactions that make us fully human.

There is a phrase that I am sure you’ve heard before. Fake it until you make it. This idea probably goes back to at least Alfred Adler in the 1920s. According to Wikipedia, Adler developed a therapeutic technique that he called “acting as if”, which allowed his clients to practice alternative behaviors that would help them to change dysfunctional patterns. You may know this technique by its more modern name still used today, “role play”.  Fake it until you make it leads us to imitate confidence, competence and a positive optimistic mindset until we can actually achieve these things in our real lives.

Wikipedia offers another way to look at this, attributed to William James:

“Action seems to follow feeling, but really action and feeling go together; and by regulating the action, which is under the more direct control of the will, we can indirectly regulate the feeling, which is not.

Thus the sovereign voluntary path to cheerfulness, if our spontaneous cheerfulness be lost, is to sit up cheerfully, to look round cheerfully, and to act and speak as if cheerfulness were already there. If such conduct does not make you soon feel cheerful, nothing else on that occasion can. So to feel brave, act as if we were brave, use all our will to that end, and a courage-fit will very likely replace the fit of fear.”

— William James, “The Gospel of Relaxation”, On Vital Reserves (1922)

Another place that I have recently found reference to this ability to fake it until we make it is in the 2016 TED talk given by Amy Cuddy. In it, she describes how body language visually telegraphs our mood and state of confidence, and how our nonvisuals impact not only those around us, but ourselves as well.

One of her main points in her talk is that we can fake it until we become it, until we can tell ourselves, “I’m really doing this!” Tiny tweaks in our behaviors can lead to big changes in our lives.

We are living in very stressful times. We are dealing on a daily basis with social upheaval, political unrest and the possibility that we might contract a deadly illness. Even without being told, we have felt ourselves shrink from daily encounters with others, decrease our normal social interactions, and forfeit many activities that give us joy. We may not feel overtly afraid, depressed and defeated, but our body language and our actions may telegraph otherwise, both to others and to ourselves.

Can we fake it until we all make it? Yes, I believe we can. Listen to and act on the recommendations by the CDC. Wash your hands. Wear a mask when you leave your home. Observe social distancing recommendations. Be smart about how and when you interact with others both indoors and out. This pandemic is fueled by the spread of a tiny virus that will stop spreading when it is deprived of new hosts. Our behaviors, coupled with the eventual development of viable, effective, safe and reliable vaccines that we all choose to receive, will stop it in its tracks, and this medical nightmare will finally be history. Until then, even if you feel deprived, depressed and distanced from the people and things that make life worth living, fake it until you make it.

Fatigue

Words are interesting, aren’t they? I love to use words to convey meaning, to educate, to enlighten and to try to persuade. We all use words that we are familiar with, that we understand and that are part of our normal vernacular. We get used to these words as ways to express a familiar thought or idea that we hold dear or that comforts us. The interesting thing about the English language is that many of our words have nuanced definitions and can be used to express many similar or related meanings.
Fatigue is one of the words that comes to mind for me lately. When we look to the Merriam Webster Collegiate Dictionary definition of fatigue, we find several aspects of this word that pertain to our current situation as we struggle with pandemic life.
First, a definition that was certainly not top of mind for me. “Manual or menial work, such as the cleaning up of a camp area, performed by military personnel.” There is also a corollary definition that goes with this, being “the uniform or work clothing worn on fatigue and in the field”. Think about many households now as young families struggle with educating their children at home, cooking and eating many more meals at home than usual, and having one or more adults working from home at the same time. This scenario has created home landscapes akin to domestic camp areas, staging areas for vocational, culinary and educational missions that were often outsourced and performed far away from the home just a few months ago. We are constantly “cleaning up the camp area” while wearing the new uniform of 2020, shorts, tees, sweats, and Allbirds, trying our best to be efficient and productive while staying as comfortable and low key as possible. For the most part, I think we are succeeding admirably in spite of all the odds against us.
The second definition is more the traditional one that we think of when we think of fatigue. “Weariness of exhaustion from labor, exertion, or stress.” We have all felt this in one way or another over the last seven months. We are working hard, sometimes in vastly different ways or in different places than we are used to. We are caring for families, our coworkers, and others at the expense of caring for ourselves. Some of us have fallen ill with COVID-19 and that has given an entirely new meaning to fatigue for us. Physical weariness that precludes meaningful activity and productivity wears on one’s body, mind and soul. Even if you want to get up and actively engage the world, sometimes a physical illness like COVID-19 stops you in your tracks and says, “not today”. This fatigue, unlike the camp that can be tidied and cleaned, must be managed until it has passed. It is insidious, long lasting and debilitating.
The third definition that caught my eye was the one describing “a state or attitude of indifference or apathy brought on by overexposure (as to a repeated series of similar events or appeals)”. Now, this definition encompasses several different aspects of our current lives in the time of COVID-19. Not only are we feeling extremely overwhelmed by the pandemic and how it has disrupted our daily lives for months now, but we have been dealing with racial tensions, economic stresses and political dissent and strife as we approach one of the most contentious presidential elections our country has held in our lifetimes. When there were fifteen cases of COVID-19, the threat felt small. When there were one thousand deaths, we felt that this was something terrible. Fifty thousand deaths were almost unfathomable. One hundred thousand deaths were unbelievable. Now, we have had eight million cases of COVID-19 in our country and well over two hundred thousand deaths. We have been seeing and hearing these numbers for so long now, and in such quantities, that we are numb to them. We are fatigued. It is harder and harder to muster compassion, much less hope that things will eventually get better. On top of the ongoing pandemic and its stresses, add the civil unrest, the political intrigues and countless ads on television and in the news, and we are simply bombarded with negativity that further numbs and chastens us.
What to do?
See things as they are. We have already found that one cannot wish away a viral pandemic. It will run its course, relentlessly, until we either achieve immunity overall or we have a workable vaccine. We cannot make the government attend to our financial needs. We have had to be creative to find work and put food on the table. We cannot fix racial unrest and social inequalities overnight. These changes can come, but it will take much time and much work by all.
Limit negative exposure. Keep up with the news, but only in prescribed amounts and at certain times. Constant exposure to negativity and stress will only increase social, emotional and physical fatigue.
Act. Plan. Work. Vote. Talk. Collaborate.

One final definition of fatigue that Webster’s offers us? “The tendency of a material to break under repeated stress.” We do not want to let ourselves get to that point, do we?

Boredom

We have been in this pandemic for months that feel like years. Have you reread all the books from your childhood and college years? Have you put together every jigsaw puzzle from the storage closet under the stairs? Have you binge-watched every Netflix series that caught your fancy? If you have, then you have probably hit that emotional, physical and temporal wall that is boredom. I don’t have anything to do. I just want to go to sleep. Maybe I can find a snack in the kitchen. I should be cleaning or cooking or…
I think we’ve all felt it, experienced it, and dreaded it, but boredom is not something that is to be feared or even endured. I read a January 4, 2019 Time article by Jamie Ducharme recently called Being Bored Can Be Good For You-If You Do It Right. Here’s How. It made some good points and made me think more about how we can embrace boredom and even use it as a jumping off point for creativity and productivity if we just open ourselves up a bit.
Why is boredom, and the act of being bored every once in a while, so important? According to the Time article, boredom “is a search for neural stimulation that isn’t satisfied”. I believe that we sometimes panic when we have nothing to occupy our minds or stimulate us or provide novelty, but being bored pushes our own brains to create the novelty and stimulation from nothing. It forces us to be creative. I love to write, and some of my best ideas to explore have to come to me in such unlikely places as the hot shower on a cold morning, on a steamy trail walk by the river, or when sitting drowsily in the early summer sun in my front porch rocking chair. These down times can be a resting period, a respite from the daily grind that we sometimes do not realize we need. They can happen spontaneously. That being said, can one plan to be bored?
Absolutely. Now, I should say here, as did the author of the Time article, that one should not confuse boredom with relaxation. Acts that require concentration like yoga, meditation, or even putting together a puzzle, do not lead to boredom, even if they are relaxing. Boredom requires that one let the mind wander. No stimulation is necessary. Another crucial aspect of allowing yourself time to be bored is that you must unplug. Having a phone in your hand keeps you from ever reaching true boredom, while it paradoxically fails to truly entertain most of the time. What do I mean by this? Endless scrolling keeps our brains from working out their boredom and coming up with novel stimulation and creative thoughts. At the same time, the quality of entertainment we get from such unstructured time is nowhere near the quality of entertainment that we might get from diving into a good book with characters we truly care about and invest in.
Sandi Mann, a senior psychology lecturer at the University of Central Lancashire in the UK, says that we can become addicted to the tiny dopamine hits we get every time we pick up our devices. “Our tolerance for boredom just changes completely, and we need more and more to stop being bored.”
Planning for times that you will be bored may lead to increased creativity, new ideas to explore, and thoughtful reflection about the things that are important to you but that get pushed back by technology and busy schedules. Being bored may help you become more resilient. You may even find that this new creativity and idea generation gets you outside your own head and thinking about doing something that might benefit others. Read, doodle, listen to familiar music, doze in the sun, anything that will free your brain to be quiet, attentive and open to new things. You may be amazed at what you come up with.

Can You Hear Me Now?

“I feel like a little girl at Christmas!” my almost eighty-five year old mother said, from an appropriate social distance, after she received her new iPad earlier this month.
My middle daughter, ever the organizer and planner, asked if her grandmother knew how to FaceTime or otherwise communicate by video in this new world of COVID-19 and social distancing. Her great-granddaughter is growing up in Colorado and she, like the rest of us, has not been able to see the little one, or any of her other great grandkids, for some time now. Something needed to be done to remedy that. My daughter had the marvelous idea that we should get her Grandma an iPad and teach her how to use it. I agreed and ordered one right away.
The look on her face when I saw my mother talking to me by video on the tablet was simply priceless. She quickly learned how to use this wonderful little piece of tech, and connected swiftly with her grandchildren and great grandchildren in Denver and Chattanooga. Something so simple lead to almost immediate joy. A silver lining in this dark gray Coronavirus cloud for sure.
We have found that we can all stay connected pretty easily to friends and family in this time of social connection crisis, but what about connections between patients and providers? What do you do when you have physical symptoms and have been told to stay away from doctors’ offices and emergency rooms? What happens when your depression deepens, your anxiety flares and the voices that were under pretty good control start to scream at you again? What happens when your resolve to stay sober is dashed by the fact that AA meetings are not meeting at all? How do you connect when mental health centers, doctors’ offices and clinics are not seeing people physically due to the worry about coronavirus transmission?
We have found that there are several very good apps and services that help us to do just that. Most of us in the local mental health center world are now working from home the majority of the time but we still have full schedules of people to assess, check for medications, and to do counseling sessions with. I thought I would share some generalities and specifics of this new world with you. It might help as you pursue your own mental health treatment, and you might find that it also goes for other medical care that you might receive as we navigate this new normal.
We communicate with you by phone call or by video calls of several kinds. This is a wonderful addition to our therapeutic arsenal, but it does come with some caveats. First and foremost, you must understand that while these ways of communicating with your doctor or therapist are quite private and secure, they may not be considered 100% HIPAA compliant. As you might remember, one of the primary jobs of the Health Insurance Portability and Accountability Act of 1996 is to safeguard your private personal and healthcare related information. Speaking with me in my office with the door closed and no one else around is about as safe as we can make things. Talking to me on our iPhones via FaceTime not so much, though it is a wonderfully vivid way to see and talk with each other in real time. You see the tradeoff there.
What are some of the other options for communicating in this new way that are being used by the local mental health community? Doxy.me is a video or audio telemedicine platform that is free to use, though it does have a paid tier with a little more functionality. I can send you a link that allows you to be in my “waiting room” until I call you for the session, which can be video or audio only. This service works well but the quality seems to be a little spotty at times, with freezes and restarts and other issues. If you have a Google or Android phone and have Google Duo, I have found that both the audio and video quality with that app are quite good. Google Voice is my go to for regular phone calls, as the connection is usually quite good and the quality of the call is quite nice as well. I have already mentioned FaceTime above, and some folks specifically asked to be contacted via that platform since they have an iPhone and trust it to be secure.
When we see you using these apps and services, we make sure that we tell you why we are doing this, that it is not the same as being seen in the office and that you give us permission to speak with you using these platforms. Most everyone I have seen over the last two or three weeks has been completely fine with these new ways of having a mental health visit. Some of the upsides? Patients do not have to waste time, gas money or effort getting to the clinic from their homes, paramount during this time of social distancing. When I call and you answer, we can get right to the point, cutting out much of the time walking to and from the waiting room, gathering paperwork for labs, etc (I can do most all of that electronically, as well as electronically prescribing most of your medication right from my laptop keyboard as well) and actually finishing many of these sessions in less time than at the center in person.
Lastly, may I leave you with some tips to help make this a smooth process on both ends of the phone screen? Understand that video or phone appointments are still appointments. They are set at specific times, and we expect to “see” you at those times. These are not casual or social calls. That means that you should be set up and ready to receive the call at the time specified, so that everyone may be seen on time for that day. I have called some patients this week, only to have a parent roust them from bed to speak with me, or having to wait for them to complete a task in the kitchen or bathroom before they can come to the phone. Consider your surroundings, as I do. I have had virtual tours of many backyards and decks, and met several cats and dogs on screen this week, which is certainly fun but may make it harder for us to really hear each other well enough to get our business together completed. Find a quiet, private spot for us to talk, just as we would if we were in the mental health center. One more thing. Remember to dress like you are going to talk to your doctor or counselor. I have been quite surprised and frankly startled a couple of times these last few weeks by what folks will wear while FaceTiming on the phone.
We are very unlucky in that we are all living through the first world pandemic in the last one hundred years. We are also quite fortunate to have at our disposal some of the most useful, easy to master technological tools for communication in our history. I am so glad that we still get to carry our work forward, maintaining our mental health even as we strive to stay physically healthy in these challenging times. Stay safe and thanks as always for reading.

F5s

F5
Incredible tornado.
261-318 mph.
Strong frame houses lifted off foundations and carried considerable distances to disintegrate; automobile sized missiles fly through the air in excess of 100 meters; trees debarked; steel reinforced concrete structures badly damaged.

tornadoproject.com

 

We had a strong storm front come through the southeastern United States last week. Of course, this was not the first time this happened, and it will certainly not be the last. It was fascinating to watch it march inexorably across the country, showing up on my weather app as a ragged green diagonal slash from Gulf to heartland to northeast, moving slowly and relentlessly across the landscape. In the center of the ragged slash was a well defined hard bright yellow-orange-red line of destruction. Pretty on the screen, destructive on the ground. Destroyer of worlds.

Texts began to trickle in from my daughter, who lives in Spartanburg, of an apparent tornado that touched down not five miles from her house and destroyed a shopping center. A coworker who sees patients at the mental health center by telehealth connection also reported frightening noises that drove her to her basement to hunker down until all warnings were lifted later in the day. Both reported the loud, surreal wail of tornado warning sirens, something that I have never heard in real life, but that I am sure must be quite distressing in the midst of gray skies, howling winds,  pouring rain and lightning flashes. Not an F-5, but terrifying nonetheless.

When I hear about such stressful situations and see evidence of the destruction they bring,  I think of my friends, family, acquaintances and patients have who struggled with cancer, financial stress, persecution for various reasons, and other stresses that lead to anxiety, fear and emotional upheaval. My aunt who succumbed to ovarian cancer when I was a boy. My mother, who is a breast cancer survivor. My friend, who tragically committed suicide. My patients, who tell me stories of unbelievable trauma, neglect, abuse and hopelessness. Like an F-5 monster tornado, these life circumstances can drop on any of us unexpectedly from the sky. Pretty colored X-rays and scans reveal the destructive power of the cancer underneath. Sirens go off. The mind screams take cover, take cover! The body sometimes is only grazed, shrapnel cutting but not killing. Other times, the impact is devastating. Nothing looks as it did before the storm. The landscape is flattened and only rubble is left. We return to a place, time or set of circumstances that we expect to be familiar, only to realize that all of our old landmarks are gone, destroyed. We do not know whether to drop to our knees and cry, run headlong into the pile of rubble, or turn and walk away.

Is there anything good about F-5s, cancer, abuse, trauma, and destruction?  What an odd question, I hear you asking me.

These scourges, while leaving city blocks, body parts, and psyches in absolute ruin, are often coldly surgical in their devastation. That is, a few hundred yards away, or a few inches outside the margins, or in some other part of the emotional us, the sun is shining, the tissue is healthy, the coping is reasonably good and life goes on. Friends rush to help. Prayers go up. Communities, wonderful , supportive, dynamic communities form. Support is not only offered but insisted upon. Rebuilding begins immediately in the aftermath of the siren’s wail, the surgeon’s knife, and the abuser’s fist.

When the horror and the shock and the denial and the anger and the tears and all of it subsides, victims become empowered survivors.

Strong!

The chorus goes up.

We will rebuild.

Life will go on.

We’re still here.

A Milieu of Unfriendliness?

As we had our all agency meeting at work the other day, involving mental health employees from all three of our sites and from all types of job descriptions, I was struck by something that come up as we discussed issues of cultural diversity. We had had a good presentation on diversity and how it was germane to the people that we serve everyday. Then, a few folks made observations that made me understand immediately that they felt misunderstood, unappreciated, and unacknowledged in the positive ways that they obviously felt were important.

How could that be, I thought? I started working for the local mental health center in Aiken part time in 1991 and came on full time in 1993 for the specific reasons that I loved the patients, the clinical environment, and most of all the people that I worked with. I have stayed at the center for almost twenty nine years for those same reasons. Now, I know that we are not perfect, but I do get the sense that the folks I see and work with every day are basically good people, caring people and people who care about my wellbeing as well as their own. For the most part, we cooperate, we commiserate, we collaborate and we celebrate, all important parts of being on a team that pulls in the same direction for positive changes and outcomes. I was a bit saddened to hear that some of my coworkers do not seem to feel respected, genuinely valued or appropriately acknowledged.

How did we get from 1991 to 2020 and this angst? I have a few ideas about what might have changed.

We work in a culture of fear-driven productivity at the expense of much else. Being a part of the management team as medical director, I understand this from a purely operational viewpoint, in that we must do a certain amount of business, bill a certain amount, collect a certain amount of money and constantly push for provision of appropriate services to keep our doors open. Otherwise, we would not be much good or be able to provide services to anyone at all. I get that. But it does seem to me that a lot of our staff feel pressured by the numbers, the spreadsheets and the bottom line, regardless of the emotional toll that this pressure takes on them daily. In this twenty first century world, we have perfected the art of cranking out widgets, but we have sometimes lost our drive to connect in meaningful ways with each other in the bargain.

As a corollary to that, the time that we spend with each other, WITH each other, is minimal.  I have noted, as have others, that sometimes we can pass each other in the hallways and not even acknowledge the other with a smile or a kind word of greeting. Now, there are some of us who are excellent at that kind of connection, bright rays of sunshine in an otherwise clinical gray haze, but I’m afraid many of  us, myself included, can easily fall short at times. We need to connect emotionally and model that behavior that we often try to teach our patients about.

I began to think, we have lots of folks working here, lots of people like me and not like me, with different values and priorities and hopes and dreams and ways to act and dress and walk and talk and interact with others. We preach acknowledging these differences, even elevating and celebrating them in our patients, but are we failing to do the same with those who work in the offices next to us? Based on what I heard at our meeting, I’m afraid that might be the case.

Are we fostering a workplace culture of exclusion? A milieu of unfriendliness?

There is enough stress in the world right now to go around, and then some. There are social, cultural, political and class stresses that make us wonder how we will ever get through some days. In spite of those stresses, we do get through each day.

We need to be consciously  aware at home, at work, at play, wherever we are, that there are those who feel marginalized, unappreciated, unloved, unseen and disconnected.

We must start somewhere.

Smile. Acknowledge. Say hello. Check in. Look up. Make eye contact. Tear down the wall that surrounds the milieu of unfriendliness and build your own bridge to a culture of appreciation and hope.

It starts with me, and with you.

 

Demograffiti

Way back in the day, when I was going to medical school and my beloved Mac computer was but a gleam in its creator’s eye, we were taught to think about and to present medical cases in a very circumscribed and conventional way. After reviewing all of the pertinent medical records (which were all written down on paper and required transport from nursing station to workroom on small but sturdy wheeled carts, of course), we proceeded to the patient’s room (if hospitalized) or to the clinic exam room if outpatient and proceeded to take a history. Yes, my friends, we actually sat down, SAT DOWN, I tell you, and spent minutes if not an hour or two with the sick person at hand and actually talked to them, a la William Osler, giving them ample opportunity to tell us what was wrong with them, and then to gregariously yet sanctimoniously let them in on the secret, as if we had actually figured it out ourselves. (Most of the time, it is quite true, patients have a pretty good idea what is wrong with them and will tell us of we will only take the time to listen) Yes, the whole review and history taking process could be as long…as that last sentence was.

Now, after that was done, we of course did the requisite physical examination, which might include judicious use of a reflex hammer to the knee and a sticky wheel to test for sensation and a tongue blade applied at just the right angle to view whatever was lurking down the gullet. We came. We looked. We saw. We diagnosed.

Then we reported. To the chart. To our attending. To the nurses. To our less bright counterparts who were slow on the uptake and couldn’t tell the difference between a whiteout from pneumonia on chest X-ray and Aspen, Colorado in a February snowstorm. Our discourse almost always began as follows.

“This forty-two-year-old alcoholic white male presented to the emergency room with acute chest
pain of two hours duration accompanied by nausea, diaphoresis and pain radiating down his left arm.”

“This sixteen-year-old sexually active white female presents with new onset abdominal and pelvic pain and a moderate fever, with elevated white count and a left shift.”

“This fifty-year-old obese black female presents with abdominal pain, anorexia, listlessness and depression over the past three weeks.”

“This eighty-five-year-old male, a former aerospace engineer, presents with irritability, forgetfulness, wandering behavior, and inability to find words or name routine everyday objects.”

Now it is funny to me that in this day and age, when Google knows our whereabouts and Amazon can deliver things to us in two hours before we even knew we needed to order them, some folks take great exception to the routine practice of calling attention to one’s age, sex, race, color, creed, sexual proclivities or activity, body habitus, or other defining personal parameters and characteristics. Somehow, this is seen as invasion of a person’s privacy or is knowing too much about a person’s private information.

Really.

Well, when I was taught medicine, it was very important for me to know your sex, your age, whether or not you were HAVING sex, your weight, your alcohol and drug use habits (including the use of needles), your eating habits, your stress level, what kind of job you did, how much time off you took, your complete family history, and so forth. I needed to know those things, because in order to differentiate heartburn from heart attack, ectopic pregnancy from eructation, psychosis from neurosis and flatulence from petulance, I needed all the information I could gather, and then some. I might even have to speak with your spouse (with your permission, of course) or (God forbid) your mother to find out the things that you conveniently left out and did not want me to know.

Yes, today we who work in the healthcare industry are in the business of safeguarding privacy, and I am all for that. HIPAA (a 1996 Federal law called the Health Insurance Portability and Accountability Act that restricts access to your private health information) is king. However, I am not the enemy. Your other doctors are not the enemy. Your physician assistants, nurse practitioners, counselors, psychologists, nurses, phlebotomists, and lab techs are not the enemy. We are not Facebook. We are not Google. We are not Alexa. Okay, I think you get the point. We need to know these things because we know that dementia rarely strikes eight-year-old girls and sarcoidosis might be a little more common in a middle aged African American woman. An overweight man with chest pain who tries to keep his case of beer a day habit from me when I admit him to the hospital for depression will make treatment of his ensuing alcohol withdrawal that much more difficult as we work him up for his third heart attack.

In order to give you the excellent care that you deserve, we need to know everything that pertains to your health, including habits, mental health issues, and pattern of substance use. Please help us. Because you know, some of your demographics are written all over your history and physical and are easy for me to see. Other bits of vital information are hidden in your head. Unless you let them out, that is where they shall stay.

I’m a psychiatrist, but I’m not a mind reader.

CBD

One question I get asked a lot lately is this.

“Is it okay for me to use CBD oil?”

I thought it would be a good idea to address this general question in Mind Matters this week.

First of all, CBD oil and associated preparations are types of alternative medications, medicines that might not be mainstream or readily prescribed by doctors , but are nevertheless used by many people on their own. Alcohol and marijuana are two substances that are often used as “medicines” by those that think they function better with them than without them. Many people self-treat medical as well as psychological symptoms with nonstandard therapies.

Some of these agents, like CBD oil, do not currently have FDA approval for treatment of specific psychiatric illnesses. If you choose to use them, either alone or in combination with standard therapies, you must understand that there are several things to consider. First, they may have unexpected side effects. Secondly, they may interact with other foods or drugs that you already use. And lastly, they may or may not be legal for general public use. I will address some of these issues in the rest of this column.

According to WebMD, cannabidiol is found in the cannabis sativa or marijuana plant. There are eighty similar chemicals in these plants. THC is the major active ingredient, but cannabidiol makes up forty per cent of overall cannabis extracts. Cannabidiol may have antipsychotic properties, but we are not sure why. It might also actively block some of the effects of THC. There is really insufficient evidence for use of cannabidiol in bipolar disorder, dystonia, epilepsy, Parkinson’s Disease, schizophrenia, or social anxiety. Side effects due to cannabidiol use might include dry mouth, decreased blood pressure, light headedness and drowsiness. There is no good data on the use of cannabidiol in pregnancy or breast feeding, nor for many specific drug-drug interactions.

Some of these concerns were addressed in a recent interview on Medscape where Columbia University Chief Resident Angela Coombs, MD, interviewed Diana Martinez, MD, Professor of Psychiatry at Columbia and an addiction expert. Dr. Martinez stated that there is really very little known about how CBD affects humans and why. It may have some legitimate medicinal effects, but the jury is still out on some of these. She stated that if you buy CBD at stores, the advertised doses may not be realistic or true. Some websites of companies that manufacture CBD and have their products tested by legitimate outside companies will more likely list the actual amount of CBD available in their products. It might be very important to know about the presence or absence of contaminants as well. Some states like Colorado may do a better job at this point in testing products for factual labelling and overall safety.

CBD may be effective in treating seizures in some children with specific illnesses such as Dravet Syndrome or Lennox Gastaut Syndrome, obviously a very small group of people. If they do not respond to more traditional medication therapies, high doses of CBD in the neighborhood of 1000 mg might be effective.

The positive symptoms of schizophrenia (such as hallucinations) may be reduced with the use of CBD, but this is in the presence of traditional antipsychotics, not in place of them.

There is not much research to address the use of CBD oil in the treatment of anxiety or social anxiety. Dosing is largely unknown. 300-600 mg seems to be helpful for anxiety.

Dr. Martinez also addressed the drug-drug interactions that might occur when CBD is added to other, more traditional therapies. When the enzyme systems in the liver are affected by substances such as CBD, metabolism of other drugs might be sped up or slowed down, affecting the amount of those medications available in the bloodstream. This might lead to compromised treatment with seizure medications or antipsychotics. She also was not able to clearly answer the question about the legality of CBD at this time. Because of various bills, the DEA, the FDA and other regulators, there is not one specific answer as to the legality of buying, possessing and using these agents. Will it be regulated anytime soon? She was also not able to directly answer that question.

So, if you are thinking about using alternative therapies like cannabidiol, what are some of the things that you might need to consider?

1) It the substance an additive, food, plant, chemical, alcohol preparation or other kind of substance?

2) Is it approved by the US Food and Drug Administration?

3) Is it regulated by the FDA, DEA or other agencies?

4) Is it checked for safety by an independent lab or company for purity, quality, concentration, adulterants, etc?

5) Is it expensive or affordable?

6) Is it legal in your state or nationwide?

7) Does it interact with food, alcohol or other drugs? Are any of these interactions life threatening?

There is no hard and fast advice on the use of CBD oil yet, and much more research is needed.