Kaila Busken, Lindner Center of HOPE, Licensed Independent Social Worker

One moment you are bursting at the seams with overwhelming joy. Every fiber of your being is filled with love for this tiny human being in your arms. Looking in your baby’s eyes, you feel like you have found your life’s purpose. And still, motherhood is really hard. New motherhood is sitting in the messy middle of seemingly opposite feelings. You can feel a mixed bag of emotions: sad and happy, overwhelmed, and peaceful, grief and joy, lost and found.

The transition to motherhood and its ambivalence has its own name: matrescence (pronounced like adolescence). The term was first developed by medical anthropologist Dana Raphael in 1973. This term is used to describe the bio-psycho-social- spiritual change that occurs when a woman makes the transition to motherhood. Like in adolescence, matrescence is a physical, hormonal, and emotional change all happening at the same time. Matrescence recognizes the large shift in identity that occurs when a woman becomes a mother and helps to normalize what it feels like to be in the middle of a whirlwind of emotions. Motherhood is a magical metamorphosis, because once you have a baby, nothing will ever be the same. And that is both beautiful and sad.

Around 15-20% of women who birth a child will experience postpartum mood disorders such as depression and anxiety. But matrescence is a normal part of motherhood and it is normal to feel ambivalence in this season of life.

Here are some helpful tips for coping in this new season of life:

1. Let go of expectations.
From the time a woman decides she is going to have children she hears an influx of information about what it means to be a mom and how to care for her baby. One of the biggest things a mom may hear is “you don’t have time for yourself anymore.” An important thing to remember is that you are a person worth caring for. You deserve to eat. You deserve a hot shower. You deserve to hydrate yourself. And you deserve love. You may even have a “Pinterest” perfect image in your head of what motherhood would be like. You may have pictured a blissful bubble in which you only feel complete happiness, but it is important to allow yourself to embrace the messiness and imperfection that is motherhood.

2.  Build your support system.
Just as a baby was born, you as a mother were born too. It is okay to ask for help and it is important to find a group of people who will help care for you. Look for people who will help support you emotionally while you adapt to your new role. Also look for people who will provide practical support like doing that pile of dirty dishes in your sink or the endless pile of laundry that babies create. Babies are tiny but they certainly require a village.

3.  Practice self-compassion.
Being a new mother is difficult. Suddenly this new little life is depending on you day and night and it can be exhausting.  It can be easy in this new vulnerable state to be harsh and self-critical. During this time, it is especially important to practice self-compassion and remind ourselves of our own worth. It can be easy to believe that you are a “bad” mother and that you are not providing what your baby needs. An important self-compassionate reminder is that “you are the best mother for your baby”. The goal is not for you to be a perfect mother but rather to be a “good enough” mother and embrace all the imperfection that comes with raising a baby. Perfection in motherhood is not possible and practicing self-compassion can help in remaining resilient in the face of this new role.

4.  Embrace the ambivalence.
Motherhood is embracing so much of the messy middle between seemingly opposing emotions. It can be uncomfortable to be in this place, where you want to spend every moment with your precious newborn and to crave the independence and space you had prior to having a baby. Motherhood is about the “both/and”, knowing that good and bad can exist in the same place. It is possible for you to embrace them both at the same time. You can love your baby with every fiber of your being and miss a time when you were able to sleep through the night or drink a hot cup of coffee.

5.  Allow yourself to grieve.
It is okay to grieve in this new phase of life. We tend to believe that grief is only reserved for death, but we can grieve many things in this new phase of motherhood. You may grieve your old life, previous relationship dynamics, your body and how it may have worked before, your time, your envisioned birth plan, your envisioned feeding plan, or your expectation of what you thought motherhood would be like. Allowing yourself to feel the sadness in some of these losses will help you to move on and embrace your new role as a mother.

BY: Anna Guerdjikova, PhD, LISW, CCRC, Lindner Center of HOPE, Director of Administrative Services, Harold C. Schott Foundation Eating Disorders Program University of Cincinnati, Department of Psychiatry, Research Assistant Professor

 

An estimated 45 million Americans diet each year and spend $33 billion annually on weight loss products. WebMD lists over 100 different diets, starting with the African Mango diet, moving on to the South Beach and Mediterranean diets and ending up with the Zone. Most diets, regardless of their particular nature, result in short-term weight loss that is not sustainable. Weight cycling or recurrent weight loss through dieting and subsequent weight gain (yo-yo effect) can be harmful for mental and physical health for both healthy weight and overweight individuals. Furthermore, weight fluctuations have been related to increased risk of development of cardiovascular disease, Type 2 diabetes, and high blood pressure.

What is Dieting

The word “diet” originates from the Greek word “diaita”, literally meaning “manner of living”. In the contemporary language, dieting is synonymous with a quick fix solution for an overwhelming obesity epidemic. Dieting implies restriction, limitation of pleasurable foods and drinks, and despite of having no benefits, the omnipresent dieting mentality remains to be the norm.

Most diets fail most of the time. Repeated diet failure is a negative predictor for successful long term weight loss. Chronic dieters consistently report guilt and self-blame, irritability, anxiety and depression, difficulty concentrating and fatigue. Their self-esteem is decreased by continuous feelings of failure related to “messing my diet up again”, leading to feelings of lack of control over one’s food choices and further … life in general. Dieting can be particularly problematic in adolescents and it remains a major precursor to disordered eating, with moderate dieters being five times more likely to develop an eating disorder than those who do not diet at all.

Diets imply restriction. Psychologically, dietary restraint can lead to greater reactivity to food cues, increased cravings and disinhibition, and overeating and binge eating. Biologically, dieting can lead to unhealthy changes in body composition, hormonal changes, reduced bone density, menstrual disturbances, and lower resting energy expenditure.

The Potential Harmful Effects of Dieting

Aggressive dieting lowers the base metabolic rate, meaning one burns less energy when resting, resulting in significantly lower daily needs in order to sustain achieved weight after the diet is over. Returning to normalized eating habits at this lower base metabolic rate results in commonly seen post dieting weight gain. Biologically, dieting is perceived as harmful and physiology readjusts trying to get back to initial weight even after years since the initial rapid weight loss. Recent data examining 14 participants in the “Biggest Loser” contest showed they lost on average 128 pounds and their baseline resting metabolic rates dropped from 2,607 +/-649 kilocalories/ day to 1,996 +/- 358 kcal/day at the end of the 30 weeks contest. Those that lost the most weight saw the biggest drops in their metabolic rate. Six years after the show, only one of the 14 contestants weighed less than they did after the competition; five contestants regained almost all of or more than the weight they lost, but despite the weight gain, their metabolic rates stayed low, with a mean of 1,903 +/- 466 kcal/day. Proportional to their individual weights the contestants were burning a mean of ~500 fewer kilocalories a day than would be expected of people their sizes leading to steady weight gain over the years. Metabolic adaptation related to rapid weight loss thus persisted over time suggesting a proportional, but incomplete, response to contemporaneous efforts to reduce body weight from its defined “set point”.

Dieting emphasizes food as “good” or “bad”, as a reward or punishment, and increases food obsessions. It does not teach healthy eating habits and rarely focuses on the nutritional value of foods and the benefit of regulated eating. Unsatisfied hunger increases mood swings and risk of overeating. Restricting food, despite drinking enough fluids, can leads to dehydration and further complications, like constipation. Dieting and chronic hunger tend to exacerbate dysfunctional behaviors like smoking cigarettes or drinking alcohol.

Complex entities like health and wellness cannot be reduced to the one isolated number of what we weigh or to what body mass index (BMI) is. Purpose and worth cannot be measured in weight. Dieting mentality tempts us into “If I am thin- I will be happy” or “If I am not thin-I am a failure” way of thinking but only provides a short term fictitious solution with long term harmful physical and mental consequences. Focusing on sustainable long term strategies for implementing regulated eating habits with a variety of food choices without unnecessary restrictions will make a comprehensive diet and maintaining healthy weight a true part of our “manner of living”.

 

Reference: Obesity (Silver Spring). 2016 May ;Persistent metabolic adaptation 6 years after “The Biggest Loser” competition.; Fothergill E, Guo J, Howard L, Kerns JC, Knuth ND, Brychta R, Chen KY, Skarulis MC, Walter M, Walter PJ, Hall KD.

 

 

 

 

 

 

 

 

Sidney Hays, MSW, LISW, DARTT, Outpatient Therapist, Lindner Center of HOPE

“Trauma” has been a buzzword in recent years. Accompanying it has been discourse around what counts as trauma. From the extreme of exaggerating minor inconveniences as trauma to the opposite end of the spectrum which attempts to gatekeep this term, reserving it for life threatening events only.

These extremes create confusion around not only the definition of the term and related concepts, but unnecessarily polarizes an already sensitive topic. As people debate the validity of traumas, it often reinforces the harmful self-judgements adopted by those who have experienced trauma. This reinforcement is often what keeps people stuck in self-blame and blocks actual healing.

It is common for those who have experienced trauma to blame themselves. This occurs for many reasons. One of the most obvious reasons lies in cultural messaging related to victim blaming, exaggerated self-reliance, and toxic positivity. The messaging of victim blaming often sounds like: What were you wearing? Were you drunk? Why didn’t you leave? Why didn’t you fight back? Why were you there in the first place? Are you really going to talk about your mom like that? Rather than holding those who caused the damage accountable, the responsibility gets shifted to the person who experienced it. This causes significant shame, often keeping people stuck in trauma responses and unhelpful patterns.

The worlds of toxic positivity and “just do it” often dismiss the significance of trauma, which impedes the ability to process and heal from trauma. It can sound something like: But you have so much to be grateful for. Your parents weren’t that bad. Other people have it much worse. Just count your blessings. Just decide to change and make it happen. You just need to (insert unhelpful platitude here). These responses encourage us to ignore the impacts of our trauma, which leads to trauma being stored in the body.

Another explanation of the self-blame that often accompanies trauma is that it gives the person who experienced it a false sense of control. If it was my fault, that means I should have just done better. If it was my fault, I can control the situation. If it was my fault, I can make sure it never happens again. Our brains are often much more comfortable with the notion that we messed up than the reality that other people and many events are outside our control.

Like with most debates and continuums, the surrounding discourse usually harms those who live a life of less privilege. Expanding our understanding of trauma and its impacts creates space for healing and growth.

The problem with many definitions of trauma lies in the focus of the definition. Most center around the event that occurred. However, this focus is incorrect and shortsighted. The most important factor in defining trauma is actually related to how a person experiences a moment, event, or series of events. Because of this, what is experienced as trauma will vary between person to person and moment to moment, which impacts how the body physiologically responds to a perceived threat.

Dr. Peter Levine, the developer of Somatic Experiencing, states that “trauma lives in the body, not the event.” When our nervous system perceives something as a threat, it reacts in kind, regardless of whether or not there is an objective threat. Most of us have heard of the fight (yelling, hitting, approaching), flight (running away from, avoiding), and freeze (immobilization, dissociation, disconnection) responses to a threat without fully understanding how these reactions come to be… These are states of our autonomic nervous system, which controls the automatic functions of the body (blood pressure, heart rate, breathing, digestion, hormones, immune response). This means that these reactions are unconscious, automatic, and the result of our nervous system attempting to protect us from a perceived threat.

When our brains perceive something as a threat, our nervous system does not always choose the most effective response. Our responses are informed by a lifetime’s cycles of threat and response. Because of this, the response of our autonomic nervous system is often the one we’ve used most in the past, or the response we wish we could have used then but didn’t have access or ability to use. This can explain many confusing patterns in our lives, such as a person who experienced emotional neglect as a child might struggle to share their emotions and needs even with a partner in a safe, healthy relationship down the line. These patterns require intentional work to mend to get our nervous system on board with responding in ways that may be more effective, or better in line with our values. In order to do this, we need adequate resources to increase our capacity to tolerate threats and distress.

Many factors impact our ability to cope with perceived threats such as: resources, support, physical health, and the level to which our needs are met. When these factors are well resourced, we have increased capacity to tolerate threat and distress. However, the inverse is also true. When lacking in any of these areas, our capacity drops.

Linda Thai brilliantly defines trauma as, “too sudden, too little, or too much of something for too long or not long enough without adequate time, space, permission, protection, or resources.” This inclusive definition accounts for the many nuances of the human experience, including generational trauma, and trauma resulting from racism, sexism, homophobia, fat phobia, colonization, and other various systems of oppression. Mindfulness of these nuances creates space for the full spectrum of human suffering to be seen, processed, and healed.

When we create this kind of space, increase access to resources, validate, and protect one another, we can be agents of healing in a world severely lacking at.

“If you want to improve the world, start by making people feel safer.”

-Dr. Stephen Porges

Heather Melena, APRN, PMHNP-BC,

Psychiatric Nurse Practitioner, Lindner Center of HOPE

 

 

 

 

 

Living with a chronic illness can be difficult to manage not only physically but also emotionally and mentally as well. The challenges that can come with chronic illness include learning to cope with the symptoms of that diagnosis, figuring out ways to alleviate your symptoms, doctor’s appointments and strain to financial responsibilities and interpersonal relationships. On top of trying to figure out new ways to handle everything that comes with chronic illness, the emotional and mental strain can feel overwhelming and paralyzing.  Psychological distress has been shown to increase with chronic disease and its accompanying treatment protocols as well as the many other areas affected in one’s life. It has also been well documented that continued stress and/or distress can lead to poor health outcomes and mental illness (Sheth et al, 2023). Thus, finding ways to find acceptance, cope with the feelings of powerlessness, and learning to live within the limitations caused by one’s chronic illness is imperative to finding relief from the mental and emotional turmoil brought on by physiological changes of illness.

Seeking help from a mental health provider (with or without the use of medications), engaging in individual and group therapy, attending support groups are all ways to tackle the mental and emotional aspects of chronic illness. Studies have shown that engaging in acceptance and commitment therapy as well as learning mindfulness techniques can reduce pain intensity, depression, and anxiety with increased self-management and physical wellbeing for those living with chronic health conditions (Wallace-Boyd et al, 2023). Learning strategies such as active coping skills, planning, positive reframing, and emotional support will all be of value to learning to live with the changes experienced by persistent illness. In practice, discussion is had about learning how to live within these new limitations, being patient and kind to oneself, setting realistic expectations, and acknowledging that the way you feel physically may change from day to day- which can be extremely beneficial for someone experiencing chronic illness. Powerlessness is a tough emotional and mental barrier when struggling day to day, where much uncertainty feels uncomfortable. By practicing acceptance and self-love, we can learn to live in the present and move away from dwelling on what our bodies were once capable of or fearing what the future may hold.

The American Psychological Association (2023) defines self-efficacy as an individual’s belief in his or her capacity to engage in behaviors to achieve personal goals. This is reflected in the confidence one has to exert control over their own motivation, behavior, and social environment. Studies have shown that greater self-efficacy can increase one’s control (or belief of) over health outcomes (Sheth et al, 2023).  By learning more positive coping mechanisms and increasing self-efficacy, one can gain confidence in their ability to self-manage their illness and improve their quality of life.

While it may be a difficult task, especially for those that struggle with chronic health problems, engaging in physical activity three to five days a week can be extremely beneficial. There has been endless research on the benefits of physical activity including higher quality of life, lower mortality, reduction of pain, and improved mental health. It has been shown that physical activity can positively impact the overall relationship between inflammation and mental health symptoms, thus reducing inflammation will likely improve depression and anxiety symptoms (Sheth et al, 2023). Physical activity can also improve energy, mental clarity, cognitive ability, and reduce stress and anxiety. It has been shown to improve mood, sleep, and circulation (Sheth et al, 2023).. With that being said, be patient with yourself and listen to your body- if physical activity isn’t what your body needs- rest or try low-intensity activities such as yoga or swimming.

Self-care is something we hear about all the time now- but what does that look like in practice? Self-care is the action or behaviors we incorporate into our daily lives that help not only our physical health but overall mental wellness. Incorporating self-care into our daily lives will not only improve our mood, reduce the toll stress can have on our bodies (ie inflammation, fatigue, sadness), but improve our outlook on the constantly changing physical symptoms of chronic illness. Self-care should be personalized to your needs. In practice we often discuss what someone’s “life worth living” looks like and how to achieve this. Incorporating daily self-care is a step towards learning to live within the new limitation set by illness and reframing our thought processes to think more positively which will enable us to continue moving forward despite our body’s shortcomings. Self-care includes:

  • Seeking out professional help: Whether a therapist, mental health provider, nutritionist, personal trainer- all of which can help you navigate treating the many facets of chronic illness, including depression, anxiety, and stress.
  • Finding support: Joining a group of people or talking with others who suffer with similar conditions can be cathartic, oftentimes lowering distress levels, and offering ways to coping with the diagnosis.
  • Stress Reduction: Identifying sources of stress, finding ways to cut stress out of your life, and ways to better manage stress.
  • Physical activity
  • Eating well:  looking for ways to add foods to your diet that will be beneficial in reducing inflammation, improving immune function, and overall wellbeing. Learning moderation in the foods we eat rather than trying “crash” diets. When we eat foods aimed at healing our bodies, we find that our mood and mental health can improve.
  • Sleep: Adequate and restorative sleep is so important for everyone. Our bodies are in a reparative phase while sleeping- which is needed to heal! Try incorporating good sleep hygiene practices including going to bed around the same time each night, avoiding screens prior to sleep, meditation before bed.
  • Hobbies: Find things that make you feel fulfilled, and make you feel joy/bring joy to your life- whether they are the same hobbies or activities prior to your diagnosis- it is important to do things that make you feel good!

(Mended Hearts, 2023)

References

American Psychological Association (2023). Teaching tip sheet: Self-efficacy. https://www.apa.org/pi/aids/resources/education/self-efficacy

Ciotti, S. (2023). “I Get It, I’m Sick Too”: An Autoethnographic Study of One Researcher/Practitioner/Patient With Chronic Illness. Qualitative Health Research33(14), 1305–1321. https://doi-org.northernkentuckyuniversity.idm.oclc.org/10.1177/10497323231201027

MedlinePlus (2022). Living with a chronic illness- dealing with feelings. National Library of Medicine. https://medlineplus.gov/copingwithchronicillness.html

MendedHearts(2023). Chronic illness and mental health blog. https://mendedhearts.org/chronic-illness-and-mental-health-9-tips-for-self-care/

Sheth, M. S., Castle, D. J., Wang, W., Lee, A., Jenkins, Z. M., & Hawke, L. D. (2023). Changes to coping and its relationship to improved wellbeing in the optimal health program for chronic disease. SSM Mental Health3. https://doi-org.northernkentuckyuniversity.idm.oclc.org/10.1016/j.ssmmh.2023.100190

Wallace-Boyd, K., Boggiss, A. L., Ellett, S., Booth, R., Slykerman, R., & Serlachius, A. S. (2023). ACT2COPE: A pilot randomised trial of a brief online acceptance and commitment therapy intervention for people living with chronic health conditions during the COVID-19 pandemic. Cogent Psychology10(1). https://doi-org.northernkentuckyuniversity.idm.oclc.org/10.1080/23311908.2023.2208916

By Danielle Beltz, MSN, PMHNP-BC, Psychiatric Nurse Practitioner, Lindner Center of HOPE

Pregnancy and childbirth can be one of the most rewarding and fulfilling things a woman can do in her
lifetime but can hand in hand be one of most challenging and emotionally taxing times.
A female goes through not only physical changes throughout pregnancy but also hormonal, emotional,
and psychological changes. In addition, a pregnancy can bring stress and emotional hardship to their
interpersonal dynamics.

A lot of new moms experience postpartum “baby blues” after giving birth which differentiates from
postpartum depression. Symptoms usually include sadness, irritability, moodiness, crying spells, and
decreased concentration. Baby blues usually begin within 2 to 35 days after childbirth and can persist up
to 2 weeks. When these symptoms last longer than 2 weeks this is when the mother should consider talking
to a healthcare provider.

About one in seven women develop postpartum depression. It most commonly occurs 6 weeks after delivery but can begin prior to
delivery as well. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) a major depressive episode with the onset
of pregnancy or within 4 weeks of delivery is considered postpartum depression. Five of the nine symptoms must be present nearly every
day for at least two weeks and constitute a change from previous functioning to be diagnosed. Depression or loss of interest in addition
to the following symptoms must be present:

• Depressed mood (subjective or observed) most of the day
• Diminished interest or pleasure in all or most activities
• Insomnia or hypersomnia
• Psychomotor agitation or retardation
• Feelings of worthlessness or guilt
• Loss of energy or fatigue
• Recurrent suicidal ideation, thoughts of death or attempts
• Diminished concentration or indecisiveness
• Change in weight or appetite (5% weight change over 1 month)

Fifty percent of postpartum major depressive episodes begin before
delivery so collectively these episodes are described as peripartum
episodes. Mothers with peripartum major depressive episodes commonly have severe anxiety and panic attacks.

The exact etiology of postpartum depression is unknown. Several factors have been reported to contribute to the development of
postpartum depression. The physical and hormonal fluctuations resulting from pregnancy influence postpartum women to develop
depression when stressful and emotional events coincide with childbirth. Some of these factors include the stress of motherhood, difficult
labor, poor financial and family support, and harmful health outcomes of childbirth. Lower socioeconomic demographic, personal or
family history of depression, anxiety, or postpartum depression, PMDD, complications in pregnancy and birth, and mothers who have
gone through infertility treatments have also all been suggested to be strong contributors.

Postpartum depression not only affects the mother’s health but also the relationship the mother has with her infant and that child’s
development. Studies have shown that children are at a greater probability of developing behavioral, cognitive, and interpersonal problems
whose mothers have postpartum depression. It can also lead to inability to breastfeed and marital conflict.

Postpartum psychosis is another severe kind of depression but is not the same thing as postpartum depression. Around 1 in 500 or 1 in
1,000 women has postpartum psychosis after delivering a baby. It commonly starts the first 2 weeks after giving birth. Women who are
also diagnosed with bipolar disorder or schizoaffective disorder are more prone to have postpartum psychosis than women who are not
diagnosed with other mental health conditions.

Postpartum psychosis is considered a psychiatric emergency with a capacity of suicide and infanticidal threat. Some symptoms include
delusions, hallucinations, unusual behavior, paranoia, and sleep disturbances. If postpartum psychosis is suspected help should be sought
immediately.

Psychotherapy and antidepressant medications are the first line treatments for postpartum depression. Psychotherapy is considered first
line for women with mild to moderate depression or if they have concerns of starting a medication while breastfeeding. For moderate to
severe depression therapy and antidepressant medications are recommended. The most common medication for postpartum depression is
an SSRI or selective serotonin reuptake inhibitor. Once an efficacious dose is reached, treatment should persist for 6-12 months to prevent
relapse of symptoms. Risk versus benefits of treated versus untreated depression while breastfeeding or pregnant should be discussed.
Transcranial Magnetic Stimulation (TMS) is an alternate therapy that can be used for women who have concerns about their child being
exposed to a medication. Although, the risk of taking an SSRI while breastfeeding is relatively low. ECT is another option for women with
severe postpartum depression who do not respond to traditional treatment. It can be particularly helpful with psychotic depression.

Zurzuvae (zuranolone) is the first oral medication approved by the FDA specifically for the treatment of postpartum depression in adults.
Until August 2023, treatment for PPD was only available as an IV (Brexanolone) and was only available at certified healthcare facilities.

People with depression especially new mothers and postpartum mothers may not identify or accept that they’re depressed. They also
may be unaware of the signs and symptoms of depression. If you are questioning whether a friend or family member has postpartum
depression or is developing signs of postpartum psychosis, assist them in pursuing medical treatment and recognize that help is accessible.
References:
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Commissioner, O. of the. (n.d.). FDA approves first oral treatment for postpartum depression. U.S. Food and Drug Administration. https://www.fda.
gov/news-events/press-announcements/fda-approves-first-oral-treatment-postpartum-depression#:~:text=Today%2C%20the%20U.S.%20Food%20
and,the%20later%20stages%20of%20pregnancy
Guo, L. , Zhang, J. , Mu, L. & Ye, Z. (2020). Preventing Postpartum Depression With Mindful Self-Compassion Intervention. The Journal of Nervous and
Mental Disease, 208 (2), 101-107. doi: 10.1097/NMD.0000000000001096.
Mayo Foundation for Medical Education and Research. (2023, April 14). “I’m happy to be a new mom. but why am I feeling
so sad?” Mayo Clinic. https://mcpress.mayoclinic.org/mental-health/im-happy-to-be-a-new-mom-but-why-am-i-feeling-sosad/?
mc_id=global&utm_source=webpage&utm_medium=l&utm_content=epsmentalhealth&utm_
campaign=mayoclinic&geo=global&placementsite=enterprise&invsrc=other&cauid=177193
Miller, L. J. (2002). Postpartum depression. JAMA : The Journal of the American Medical Association, 287(6), 762-765. https://doi.org/10.1001/jama.287.6.762
Mughal S, Azhar Y, Siddiqui W. Postpartum Depression. [Updated 2022 Oct 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023
Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519070/
Postpartum depression. March of Dimes. (n.d.). https://www.marchofdimes.org/find-support/topics/postpartum/postpartum-depression?gad_
source=1&gclid=EAIaIQobChMIqKLemfTfggMVq0VyCh3ouwGDEAAYBCAAEgKxjPD_BwE
Silverman, M. E., Reichenberg, A., Savitz, D. A., Cnattingius, S., Lichtenstein, P., Hultman, C. M., Larsson, H., & Sandin, S. (2017). The risk factors for postpartum
depression: A population-based study. Depression and Anxiety, 34(2), 178–187. https://doi-org.uc.idm.oclc.org/10.1002/da.22597
Stewart, D. E., & Vigod, S. (2016). Postpartum depression. The New England Journal of Medicine, 375(22), 2177-2186. https://doi.org/10.1056/NEJMcp1607649

 

by Dawn Anderson, LPCCS

Humans are a very resilient species. We have overcome generations of burdens to accomplish family unity, and yet this effort renews with new barriers and challenges each year. A vital component of a thriving family unit is the ability to co-regulate. Co-regulation describes the process in which a parent can identify their child’s need for help, recognize their own emotional reaction, and then help themselves cope to share that gift with their child.

Just like the airplane metaphor- you must put on your own oxygen mask before you can help others. As a parent, we are bombarded with requests for our time, resources, and attention. We have a certain amount of emotional energy in the day, and this is a renewable resource! Taking the time to take care of your own emotional health allows you to be more responsive in the ways we’d like to show up with our children. Another huge burden on parents is the one we place there ourselves- guilt. We fret about the choices to be made, the amount we’re able to give our children, and the perpetual feeling we aren’t enough. The reality is we all bring different types and amounts of skills and talents to the table.

Some of us have different capacities for stress, and that doesn’t make us good or bad. Sometimes it’s helpful to think of your stress tolerance as a cup- is yours a 12 oz picnic cup? A 2 oz bathroom water cup? An Olympic swimming pool? Whatever the size, we must take ownership of knowing where we are throughout the day, and how we are showing up in interactions with our children. We also need to be intentional about emptying said cup proactively throughout the day, so it doesn’t overflow. Overflow here is where we see the unintentional screaming at our precious ones, storming off, or being unable to play with them after our long day.

Lastly in explanation, its valuable to consider the way language impacts our thoughts, feelings, and behavior. In common language, we say things about children such as “they’re a mess,” “they’re not listening to me,” “they’re being a brat.” In all humans, we have a system in our brain that takes in information and decides if it’s safe or not, and then sends it to either the thinking part or the survival part of our brain. What our brains decide as safe depends on the person. Some of us have different themes that activate the threat systems in our own bodies, and with careful observation, you might be able to pin these down for your loved ones. If this feels difficult, a licensed clinical therapist can help.

Once the “threat center” of your brain decides something isn’t safe, we have survival reactions: our heart rate picks up, heavy breathing, we feel shaky, and/or we have a hard time thinking clearly due to the process where your brain diverts power from the thinking brain to the survival brain. That said, that’s part of why it’s hard to talk to someone who doesn’t feel safe. It’s hard for them to hear you, and hard for them to express how they feel in words. If we use compassionate language, it removes blame from the driver seat. Try “they look like they need help” or “they are having some big feelings” You and your child are a team, and teams are stronger when they work from the operating point that we win when we work together with our strengths.

That said, here are some helpful tips to regulate with your child:

  1. When you identify that your child needs help, first check in with yourself on what you need to be best able to respond to them. Its valuable to practice the breathing skills when you don’t need them, so you can use them in the moment when you do. Trying to only use them in a moment of crisis is like expecting yourself to learn to swim in the choppy ocean.
  2. Get on their level. Kneel, squat, or sit down if necessary. Looking up at someone activates the “threat” center of our brain and makes it harder to calm down.
  3. Use a low, consistent tone. If I want someone to hear me, I need to be quieter, not louder. Especially if they are yelling. Keep your messages concise and direct, such as “I want to hear you, and it’s easier when you’re at a level 2” or “Let’s take a deep breath together then we can put your toy back together.”
  4. Take a full, deep breath in your nose and exhale slowly out your mouth. Imagine feeling like you’re smelling something super pleasant and trying to cool off hot cocoa with the exhale. Even if they are not in the place to participate because they’re too dysregulated, their body will unconsciously mirror yours.
  5. If you’re not able to offer your child 1:1 proximity, or their bodies are not safe for you (i.e. hitting) consider regulating in the room by counting items together. Redirection is a powerful tool for the right moment. Again, a licensed therapist can help you catch these windows of opportunity.
  6. If appropriate, leave the room and regulate yourself before returning. Use your words to announce the intention “I need two minutes to regulate myself and I will be back to work on this with you.” Stepping away from the situation is a tool that can give teenage parents the break we need to not ground our child for the next 100 years when we’re both stuck in an argument.
  7. With any strategy, it’s important to come back together and process Use the compliment sandwich: Identify one thing that went well, offer constructive feedback, and close with another positive thing you noticed or future oriented reconnection point. “I’m proud of you for breathing with me. Next time, do you think it would help if we used the feelings chart? I’m glad I have you.”

One of the greatest challenges in the treatment of bipolar disorder (BD) is the significant weight gain associated with psychotropic medications.  Mood stabilizer medications with antimanic activity, which include lithium, valproate as well as atypical antipsychotics, remain the mainstay of treatment despite being associated with different degrees of significant weight gain.  This is particularly notable for antipsychotic medications, which are furthermore associated with metabolic disturbances.  Accelerated weight gain is concerning because it is associated with increased cardiovascular risk, and particularly important in patients with BD because of their increased risk for cardiac and metabolic disease.  Furthermore, excessive weight gain is distressing and often plays a role in dissatisfaction with treatment and early discontinuation.  A growing body of evidence suggests that weight gain, weight cycling, and central obesity are linked with exacerbation of bipolar symptoms and less favorable course of illness.  A comprehensive treatment plan for bipolar disorder should include interventions to prevent or mitigate excessive weight gain.  Let’s examine the available options and identify areas for further research.

Until recently, interventions for weight gain were mostly limited to lifestyle interventions.  Inactivity and dietary choices are significant contributors to metabolic abnormalities seen in patients with BD, and although dietary and lifestyle changes have the potential for improving the overall quality of life, the results from these interventions often fail to keep up with the accelerated weight gain seen with psychotropics.  Clinicians have also attempted to select medications with lesser potential for metabolic dysfunction and increased appetite, but this is not always a viable option.  Bariatric surgery has the greatest potential impact as an intervention for obesity in BD.  Although there is evidence that weight loss resulting from bariatric surgery is associated with improvements in mood, there is no data specific to patients with BD and this is only an option for stable, euthymic patients.

The use of off-label adjunctive medications for mitigating weight gain has had mixed results:  Weight mitigation has been modest, efficacious medications have produced significant adverse events leading to discontinuation or the cost to the patient has been prohibitive. Topiramate and zonisamide are antiepileptic drugs with data suggesting efficacy in weight mitigation.  Topiramate has shown significant efficacy in weight mitigation (3.1kg over 6-26 week, according to a meta-analysis), but it is poorly tolerated and is associated with significant cognitive adverse events and paresthesia.  The estimated cost for a month’s supply of topiramate ranges from $40-$250.  Data suggest that zonisamide also has a significant effect on weight gain mitigation with similar, but milder adverse events.  Opioid receptor antagonists like naltrexone and samidorphan have demonstrated modest efficacy in mitigating weight gain associated with olanzapine.  Samidorphan, the best-studied opioid antagonist, is associated with modest weight mitigation (1kg with olanzapine), is well-tolerated and is available on the market as part of a proprietary combination with olanzapine with an estimated cost of $1000/month.

Antidiabetic drugs like metformin and glucagon-like peptide-1(GLP-1 RA) receptor agonists have  potential for weight mitigation and improvement of metabolic parameters such as dyslipidemia and insulin resistance.  Metformin is a popular option for medication-induced weight gain.  In patients treated with atypical antipsychotics, the estimated weight mitigation with metformin is 2-3kg and it is generally, well-tolerated.  The average estimated monthly cost of Metformin ER 2000mg/daily ranges from $27 to $50.  GLP-1 RAs and similar drugs have the potential for significant mitigation of weight gain associated with psychotropics, and in some cases, weight loss.  These drugs are better tolerated than topiramate but additional research on the effects of these drugs on patients with BD is needed to determine efficacy and safety.  GLP-1 RAs decrease glucagon secretion, have the potential for decreasing insulin resistance and delay gastric emptying, therefore decreasing appetite.  In addition, GLP-1 RAs have been shown to improve glucose regulation, lipid levels, and reduce cardiovascular risk.  Although GLP-1 agonists have demonstrated effectiveness in inducing weight loss and improving metabolic parameters in type 2 diabetes mellitus and obesity, data shows that only 10% patients eligible for treatment do not take these medications due to the high cost.

As we have seen, there are a few options for treatment of excessive weight gain associated with psychotropics, which can be used in addition to lifestyle interventions.  Limitations the modest results seen with some interventions, intolerable adverse events with more effective options or high cost.  Additional, affordable treatment options are needed.

For more information about Bipolar Disorder research at the Lindner Center of HOPE:

https://lindnercenterofhope.org/research/clinical-trials/#1619574722103-ad16b647-fc35

Works consulted:

Laguado SA, Saklad SR. Opioid antagonists to prevent olanzapine-induced weight gain: A systematic review. Ment Health Clin. 2022 Aug 23;12(4):254-262. doi: 10.9740/mhc.2022.08.254. PMID: 36071739; PMCID: PMC9405627.

Mangge H, Bengesser S, Dalkner N, Birner A, Fellendorf F, Platzer M, Queissner R, Pilz R, Maget A, Reininghaus B, Hamm C, Bauer K, Rieger A, Zelzer S, Fuchs D, Reininghaus E. Weight Gain During Treatment of Bipolar Disorder (BD)-Facts and Therapeutic Options. Front Nutr. 2019 Jun 11;6:76. doi: 10.3389/fnut.2019.00076. PMID: 31245376; PMCID: PMC6579840.

Wang Y, Wang D, Cheng J, Fang X, Chen Y, Yu L, Ren J, Tian Y, Zhang C. Efficacy and tolerability of pharmacological interventions on metabolic disturbance induced by atypical antipsychotics in adults: A systematic review and network meta-analysis. J Psychopharmacol. 2021 Sep;35(9):1111-1119. doi: 10.1177/02698811211035391. Epub 2021 Jul 27. PMID: 34311625.

 

By Nicole Mori, RN, MSN, APRN-BC, Lindner Center of HOPE Psychiatric Nurse Practitioner

By Thomas Schweinberg, PsyD, Staff Psychologist, Lindner Center of HOPE 

 

 

 

 

 

 

 

Over the last few years, cannabis has clearly become much more prevalent and accepted in this country, both for medical and recreational purposes. This is in stark contrast to the demonization of cannabis that existed from the 1950’s through the 1970’s. The pendulum has swung radically in the opposite direction as cannabis is now viewed as not only benign, but also a panacea for a multitude of ills. In fact, in the state of Ohio, as of the end of 2022, marijuana has been approved to treat 25 medical conditions. I am not aware of any other medication that is approved to treat over two dozen conditions. It would appear that cannabis is a very powerful medication capable of relieving many symptoms and conditions. Accordingly, shouldn’t we be asking what side effects we might experience from such a powerful substance? Yet, this information is not freely offered up as it is during every pharmaceutical commercial that we see on television. Instead, cannabis is generally portrayed as a substance with considerable upside and very little, if any, downside. Of course, this cannot accurately reflect reality.

Cannabis does have a number of benefits to its users, and I am actually in favor of its legalization. However, a great deal more needs to be done to inform and caution users about the potential side effects, some of which can be extremely disruptive, even life altering. Obviously, cannabis directly impacts the central nervous system when actively using, but what about over the long term? The National Institute of Health reported that chronic cannabis exposure, particularly during the period of brain development (up to 26 years old), “can cause long-term or possibly permanent adverse changes in the brain.” To begin with, animal studies have shown that exposure to cannabis is associated with structural and functional changes in the hippocampus, the brain structure responsible for consolidating and recalling new information, i.e., memory. Memory difficulties are likely experienced by the majority of those who use cannabis regularly, which is typically accompanied by poorer attention and slowed response time. What is less clear is how persistent these memory problems are after an individual stops using.

In addition to this, there is the potential for cannabis to globally impact a developing brain. As young brains develop, the connections between our brain cells, or neurons (via branch-like structures called “dendrites”) are either strengthened (because that connection is often used or adaptive), or they are pruned away (because that connection is seldom used or is maladaptive). Animal studies have revealed that exposure to cannabis during adolescence can provoke premature pruning of dendrites in the developing brain. The “before and after” images that come from these studies are very clear and compelling. While some of these neuronal connections may have eventually been pruned away anyway, it seems clear that some of these connections that are lost could have been strengthened and put to functional use during adulthood. This neurological impact may help to explain research findings which indicate that those who use cannabis chronically, particularly during adolescent brain development, are less likely to complete high school or obtain a college degree, have a lower income, experience greater unemployment, and report diminished life satisfaction. Certainly, this is not true for all who use, but those are the statistics.

Perhaps one of the most life-altering risks of using cannabis is the increased risk of experiencing psychosis that can become prolonged, or even life-long. There is considerable controversy about whether cannabis simply provokes psychotic symptoms in those who were already genetically predisposed to schizophrenia, or whether cannabis could cause a prolonged psychotic state which resembles schizophrenia. While the majority of users will not encounter psychotic symptoms, it does appear to be a sizeable minority, perhaps 10-15% of chronic users. Clinically, my colleagues and I have repeatedly seen the connection between cannabis misuse and psychotic disorders, enough that it is difficult to believe that it is merely coincidental. The association between cannabis and the onset of psychosis is great enough that the Canadian government has attached a warning label to its medicinal marijuana which reads, “Warning: Regular use of cannabis can increase the risk of psychosis and schizophrenia.” They added, “Young people are especially at risk.” Unfortunately, you will not find a comparable warning label in the United States.

While this article appears to generally denounce the use of cannabis, I should state again that I am in favor of its legalization as there are a number of potential benefits for those attempting to manage certain physical or emotional disorders. However, if cannabis is legalized without clearly reporting the potential side effects and adverse outcomes, we are being reckless and irresponsible. Those who produce and distribute legal cannabis should be held to the same standard as pharmaceutical companies who are compelled to advertise the potential risks of their products. While many or most who use cannabis can do so safely, there are those for whom cannabis presents a substantial risk for a number of cognitive and psychological difficulties. These potential risks should be clearly and responsibly communicated to the public as cannabis use becomes much more widely available. Otherwise, cannabis users could be misled into believing that its use is entirely safe and benign, unwittingly opening themselves up to possible long-term cognitive, psychological and functioning difficulties.

Continue to explore the relationship between cannabis and mental health

Radically Open Dialectical Behavioral Therapy (RO DBT) is a treatment developed by Thomas Lynch for those who develop disorders associated with an overcontrolled (OC) personality.  OC individuals are often described as reserved and cautious, not very expressive with their emotions, and great at delaying gratification. OC individuals tend to be strong rule followers and feel a high sense of obligation in their lives (i.e., go to a birthday party because they feel they have to rather than wanting to do so). However, at times, they may experience “emotional leakage,” or emotionally breaking down once they are in private after holding it all together all day in public. An OC personality can be really helpful in some ways. These are the people that get their work done no matter what, show up to work on time every day, work through all the nitty, gritty details of a project, and follow through on their word. They can be very organized and methodical, and they are great at planning for long-term gains (i.e., saving to buy a house). However, they can be rigid and inflexible at time (i.e., get very upset if a restaurant lost a dinner reservation and struggle with figuring out where else to go to eat) and may have difficulty receiving feedback. Patients that may benefit from this treatment include those with chronic depression and anxiety, autism spectrum disorders, Obsessive-Compulsive Personality Disorder, and Anorexia Nervosa.

Radically Open Dialectical Behavior Therapy for Overcontrolled Personality

The biosocial theory behind RO DBT explains that OC individuals have brains that zoom in on the negative or threatening aspects of a situation before seeing the positives. This predisposition interacts with being raised in an environment that encourages or praises high levels of self-control in one’s life (i.e., doing homework without one’s parents needing to remind them to do so), performing at a high level (i.e., getting good grades, doing well in sports, receiving accolades), and avoiding making errors. These individuals end up avoiding uncertain situations, hold back their emotions out of fear that others may see them as being out of control, and become guarded in social situations, appearing to others as withdrawn.  Their lack of vulnerability and difficulty expressing what they are really feeling leads others to struggle to relate to them, so they end up feeling lonely and isolated.  Thus, RO DBT operates under the assumption that increasing connectedness to others can improve psychological functioning, thus targeting emotional expression. Additionally, RO DBT encourages being open to hearing other points of view so that one can learn as well as learning to be flexible in responding to varying situations.

Thomas Lynch describes that the five main behavioral targets of RO DBT include 1) being socially distant or reserved, 2) inflexible, rule-governed behaviors, 3) focusing on the details rather than the big picture of a situation and being overly cautious, 4) demonstrating emotional expressions that are inconsistent with how one is really feeling, and 5) comparing oneself to others, leading to resentment and envy. In RO DBT, patients work with their therapists on identifying personal goals consistent with these behavioral targets, connecting these goals to the problems that brought them into treatment. For instance, a patient may bring up that he/she would like to deepen relationships with others, be more flexible when things don’t go according to plan, or let go of past grudges to help fight depression and anxiety.

Radically Open DBT vs DBT

Many incorrectly assume that RO DBT and Dialectical Behavior Therapy (DBT) are the same thing. While RO DBT has some similarities with DBT, these are two very different treatments. DBT primarily benefits those who have an undercontrolled (UC) personality. UC traits include being impulsive, sensation-seeking, wearing one’s heart on one’s sleeve, and acting in the here and now.  Thus, DBT can be helpful for those that have impulsive control problems, such as those with borderline personality disorder, bulimia nervosa, binge eating disorder, and substance abuse disorders. Both RO DBT and DBT combine individual therapy with skills training classes, involve tracking emotions and behaviors via diary cards, allow for telephone consultation with the individual therapist, and involve consultation teams for the group and individual therapists. However, DBT has a stronger focus on self-regulation to target emotion dysregulation whereas RO DBT is much more focused on helping individuals address social signaling and connectedness with others.

For more information see our Comprehensive Guide to RO-DBT.

References:

Lynch, T. R. (2018). Radically Open Dialectical Behavior Therapy. New Harbinger Publications.

Lynch, T. R. (2018). The Skills Training Manual for Radically Open Dialectical Behavior Therapy. New Harbinger Publications.

Elizabeth Mariutto, PsyD

Lindner Center of HOPE, Psychologist and Clinical Director of Partial Hospitalization/Intensive Outpatient Adult Eating Disorder Services

By: Anna Guerdjikova, PhD, LISW, CCRC, Director of Administrative Services, Harold C. Schott Foundation Eating Disorders Program, Lindner Center of HOPE 

 

 

 

 

 

Spring is in the air. More often than not during this time of year, we find ourselves determined to clean, declutter and organize. In a way, spring cleaning is very similar to New Year resolutions and the big hurray at the beginning of the school year in August when everything is new and fresh, big decisions of how we will be better are made…but not for long. We find ourselves hyper-focused on new goals and behaviors to quickly abandon them soon after as it is too hard, too slow, too boring, or life comes in the way of our good intentions. Then the guilt of “look at this mess, I should be decluttering” sets in, we continue to buy things to organize the many things we already have and this cycle continues to perpetuate both the mental anguish and the physical clutter.

To be able to consistently change a behavior, it is helpful to understand why we are resistant to the change, even if we know it will make us feel better in the end. Digging into the barriers and the reasons for our self-sabotage can help us be more self-compassionate and to get us a step closer to actually making the changes we intend and hope for.

Decluttering can be difficult and anxiety provoking. Below we summarize some of the issues and possible ideas on how to approach the solutions to avoid self-blame and feelings of failure and to finally get the ball rolling.

Issue: The job is too huge and you don’t know where to start. It gets to be too overwhelming too quickly. 

Solution: Decide on decluttering small bites – a time period to declutter daily/weekly or one surface, drawer, rack, 1/3 closet at a time and don’t overdo it. Keep a very open mind and avoid rigid agenda (ex. be done with the kitchen by Sunday) no matter how tempting this is, as when the job does not get done for some reason as we have planned, we tend to abandon the whole project.

Issue: What if I need this later?

Solution: If you have not used it in 6 months, you are most probably not going to use it now. Most things in our households can be replaced quickly, thus giving yourself the permission to buy new if needed is the “get out of jail free card” that can help battle this problem. In most cases than not you will not have to use the card/buy the item again.

Issue: The guilt of life not lived. Textbooks we bought to study something we never got to, the hiking shoes to walk the Appalachian trail, the super expensive multicooker and many others representing the life we hoped to have or wished to live but never actually implemented.

Solution: Consider radically accepting yourself for who youare truly at the present moment in life instead of who you wished you were. Get rid of the expensive hiking shoes you have never put on. If you decide to hike the Appalachian trail, you will have to start by hiking the local parks and this can be done in regular sneakers for a while, then if needed you can buy some new fancy hiking shoes.

Issue: Change is hard and decluttering does not solveother issues.

Solution: Take it slow and give your brain and body time to process the change. If you get rid of a rug, the room will feel empty and sad and the most common reaction is to go buy another rug immediately. Try to give the new look time to settle, this will allow you to see the space with new eyes and can spark creativity and true change. If in a while you still feel you need the rug, go for it.

Give approaching decluttering with curiosity and self-compassion a try this spring. It is not fatal if it does not get done and beating yourself over what “should be finished” is not helpful in moving forward. Finally, decluttering our physical and digital spaces might make us more aware and mindful of our habits, but is not the “fix for our lives”. Clutter can be seen as a result of some struggles that we deal with and starting to tackle it might bring to light a plethora of challenges and this is one of the reasons why this process can be so anxiety provoking. Kindness to self, giving it all time and space to unfold and paying attention to the mental load behind the physical possessions might be helpful in promoting sustainable change.