Category: Mental Illness

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Obsessive-Compulsive Disorder (OCD) is a debilitating psychiatric disorder that presents in many forms. OCD is comprised of obsessions, which are persistent and unwanted intrusive thoughts, images, or urges. In OCD, these intrusive thoughts are considered ego-dystonic, meaning they are inconsistent with someone’s self-image, beliefs, and values. Therefore, these obsessions cause significant distress, anxiety, and worry and can greatly interfere with one’s life. To reduce or eliminate this distress or discomfort, OCD sufferers begin to engage in compulsions, which are ritualized behaviors or mental acts that serve to reduce their discomfort and anxiety. Unfortunately, engaging in compulsions reinforces obsessive thinking. Some subtypes of OCD include fears related to contamination, scrupulosity (religious-based fears)/morality, fear of harming others (aggressive or sexual), ordering and arranging, repeating, and checking. It should be noted that not all compulsions are outwardly observable and may include avoidance of triggers or mental compulsions.

Recommended Questions for Assessing OCD

Exposure and Response Prevention (ERP) is a type of Cognitive-Behavior Therapy (CBT). Cognitive-Behavior Therapy varies from other types of talk therapy in that it is focused on changing thinking patterns and behaviors. It tends to be directed at the present, rather than the past and is goal-oriented and solution-focused. ERP aims to change behavioral patterns, allowing someone to confront their fears and therefore, reduce their OCD symptoms. ERP is widely considered to be the “gold standard” therapy for Obsessive-Compulsive Disorder.

Exposure refers to the direct confrontation of one’s fear through voluntarily taking steps towards their fears and triggers. Response Prevention refers to someone voluntarily agreeing to reduce their usual rituals and compulsions. It is very important for someone that is working on doing exposures to simultaneously refrain from engaging in compulsions. Without reducing or refraining from the related compulsions, the person cannot learn that they can tolerate the exposure or that the compulsion is unnecessary.

How is ERP done? 

ERP is done by working with a therapist to examine the person’s specific obsessions and compulsions, generate a fear hierarchy, and begin to work on exposures while limiting engagement in compulsive rituals. A fear hierarchy is a personalized list of exposures. This list is created collaboratively by the person with OCD and their therapist. Exposures include situations, stimuli, or thoughts that evoke a strong, negative emotional response and to which the person has a fear or an aversion. Exposures on the fear hierarchy list should be very specific and can include variations of the same exposure (such as touching several different places on an object and for varying amounts of time). People with OCD often engage in avoidance of triggering stimuli to prevent unwanted distress as well. Much of the fear hierarchy can be generated by examining situations and stimuli that the person avoids. A Yale-Brown Obsessive-Compulsive Symptom (Y-BOCS) Checklist may be completed to help generate ideas. It can also be helpful to gather ideas from family members as well. The goal of exposure work is to slowly and carefully work to approach each of these triggers in a strategic manner.

In vivo exposures refer to confronting one’s fears “in life” or through direct confrontation. This type of exposure is appropriate for things that can be directly approached or confronted. Imaginal exposures refer to mentally imagining being exposed to one’s fears. This type of exposure is utilized for exposures not appropriate for direct confrontation (fear of hitting someone with one’s car). Similarly to in vivo exposures, imaginal exposures are done in a gradual manner and should always be done voluntarily. A SUDS (Subjective Units of Distress Scale) is used to communicate the person’s perceived level of distress, generated by engaging in exposures while refraining from compulsions. The fear hierarchy is arranged to allow someone to work from lower-level exposures to higher-level exposures.

The central premise of OCD is intolerance of uncertainty, with the goal of ERP being to increase the level of tolerance to uncertainty, rather than working to disprove the fear or find ways to become certain. Although it is very common for families to accommodate compulsive behavior or give reassurance when they see a loved one in distress, accommodation and reassurance exacerbate OCD by not allowing the person to learn to tolerate their discomfort. Instead, it is helpful to allow the person to gradually learn how to tolerate their distress with the help of a trained therapist.

How does ERP help with OCD symptoms? 

Exposure and Response Prevention is accomplished through gradual behavioral change, which occurs in the form of habituation and extinction. Habituation occurs with repeated exposure to a particular stimulus. This happens when we become numb or desensitized to things that we see, hear, or do on a regular basis. For example, if we live next to a noisy highway, we might initially be very aware of the noise. However, after living there for a while, we become accustomed to this constant sound, and we learn how to “drown it out.” Habituation in ERP works in a similar manner by repeatedly exposing a person to their feared triggers. Over time they habituate to those triggers and the strong emotions associated with their fears disappear. Extinction occurs when a reinforcer (something that influences behavior) is no longer effective at bringing pleasure or reducing distress. In the case of ERP, by reducing the compulsive behavior that reinforces the anxiety or distress, the obsessive thoughts decrease over time.

If you believe that you or someone you know might be suffering from OCD symptoms, it’s important to reach out to a professional with specialized training in OCD treatment. With the proper treatment, OCD can be a very manageable condition.

By: Jennifer B. Wilcox, PsyD

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by: Ronald Freudenberg, Jr., MA, LPCC-S
Outpatient Therapist, Lindner Center of HOPE

Anxiety can take many forms.  Anxiety is also one of the most common reasons one might seek out mental health treatment.  In this blog, we will explore some of the most frequently occurring anxiety disorders, as well as panic attacks, which can be part of a Panic Disorder (but do not have to be, as will be discussed later).  We will also look at effective strategies for preventing, treating, and managing anxiety disorders and symptoms of anxiety.

Regardless of how anxiety may present for one person, the various anxiety disorders all have at least one thing in common…fear.  Whether it is described as worry, nervousness, feeling “on edge,” or something else, the basic emotion of anxiety is fear.  We all experience some anxiety sometimes, and in fact, you may have heard that a little bit of anxiety can be a good thing from time to time.  It serves a protective purpose when it tells us to avoid people, things, or situations which could be dangerous.  Anxiety can also help us by keeping us on our toes and motivating us to perform well under pressure, such as when pulling an all-nighter before an exam, giving a big presentation at work, or playing in the championship game.  Yet, as with any negative emotion, anxiety can become problematic when it becomes too frequent, too intense, lasts for too long, or interferes with our lives and our ability to function well, as can happen in the context of the following types of anxiety disorders.

Types of Anxiety Disorders

Adjustment Disorder

Sometimes, one may feel excessively stressed or anxious about a certain thing or things in one’s life.  People often describe this as “situational”, and the clinical term is an Adjustment Disorder with Anxiety.  (It can also present with depression, or other emotional/behavioral responses.)  An example might be if one would experience something stressful like the loss of a job.  Of course, most people would likely feel some anxiety about this.  However, an adjustment disorder is thought of as when one’s response is out of proportion with what may be typically expected.  With this type of anxiety, once the stressor has resolved, so will the anxiety.  So, when that same individual lands a new job, he/she/they will feel better, simply put.

Generalized Anxiety Disorder

Generalized Anxiety Disorder is very much like it sounds.  This is when a person feels generally anxious, worried, and nervous much of the time (more than half of their days) about any number of different subjects.  In order to meet criteria for the diagnosis, one must experience this type of anxiety for at least six months, find it difficult to control the worry, and present with at least some of the following additional symptoms: restlessness, trouble concentrating, irritability, muscle tension, sleep difficulties, and/or trouble concentrating.  Although every person is unique, classically, a person with GAD may tend toward long-term anxiousness, worry excessively about many things (such as finances, family, work, health, world events, etc.), and lay awake in bed at night doing so.

Phobias

Specific Phobias are another type of anxiety disorder in which a person experiences strong fear and anxiety about a specific thing (object or situation), and actively avoids that thing or endures exposure to it with intense discomfort.  In this writer’s experience it is relatively rare for this to be a person’s main reason for seeking treatment, at least in outpatient settings.  Perhaps that may be because many anxiety-provoking subjects can be pretty easy to avoid.  (When was the last time you unexpectedly came across a snake?)

Social Anxiety Disorder

An exception to anxiety that is easily avoided, is Social Phobia, also known as Social Anxiety Disorder.  Social Phobia exists when the source of a person’s fear is social or performance situations in which one may feel subject to scrutiny or judgment by others.  Social anxiety may arise when one feels uncomfortable mingling with new people at a party, walking through halls of (seemingly) glaring eyes at school, or giving a speech.  From an evolutionary perspective, if anxiety helps us to avoid dangerous things which threaten our survival, being ostracized from one’s tribe and forced to try to survive alone in the wilderness is near the top of that list.  With this in mind, it is little wonder that public speaking is often cited as people’s number one fear.

 

 

 

 

 

Panic Disorder and Attacks

Finally, let us explore the issue of panic.  So, what is a panic attack? Panic Attacks, according to the DSM-5, occur when a person experiences an “abrupt surge” of anxiety which reaches a peak within minutes and includes (at least four of) the following symptoms.

Symptoms of Panic Disorder and Attacks

  • Racing/pounding heart
  • Sweating
  • Shaking
  • Shortness of breath
  • Choking sensations
  • Chest pain
  • Nausea
  • Dizziness or feeling light-headed
  • Chills or heat sensations
  • Numbness/tingling
  • Feeling of unreality or detachment from one’s self
  • Fear of losing control, “going crazy,” or dying

When one develops a fear of having additional panic attacks and exhibits maladaptive behaviors designed to avoid or limit the likelihood of them, this is called a Panic Disorder.  Further, if one’s fear and avoidance includes public situations away from home, open or enclosed crowded spaces from which it would be difficult to escape should panic-like symptoms arise, that is called Agoraphobia (which may, but does not have to, co-occur with Panic Disorder).  Also, according to the most recent edition of the DSM, panic attacks are now thought to be a feature which may occur in the context of a spectrum of other mental health disorders, substance use disorders, and some medical conditions.

Treatment of Anxiety, including Treatment for Panic Disorder and Attacks

When it comes to treatment of anxiety, it is unrealistic for one to expect to live out the rest of their days, anxiety-free.  One can no more be “cured” from anxiety, than from happiness, sadness, or anger.  These are basic human emotions, and there are reasons why we have them.  However, the good news is that anxiety symptoms, whether mild or debilitating, can be effectively prevented, treated and managed, usually by a multi-faceted approach.

How to Manage Anxiety, including Managing Panic Disorder and Attacks

Medications can often be a very helpful part of a person’s treatment plan.  Antidepressants, such as SSRIs, and some SNRIs, are commonly used to treat ongoing symptoms of anxiety, while benzodiazepines (such as Xanax, Klonopin, Valium, or Ativan) are sometimes used on a shorter-term or as-needed basis to alleviate acute anxiety or panic.  (Caution is usually advised with the latter due to their addictive potential.)  Some antihistamines, beta-blockers, and anticonvulsants have been shown to be helpful for anxiety as well.

Various forms of talk therapy can be beneficial by providing a safe, supportive experience in which a person can process fears and learn to implement rational coping thoughts to overcome them.  Therapy can also assist one to form new behaviors to mitigate symptoms of anxiety.  Regardless of the specific therapy used, a common element is learning to approach, rather than avoid, that which causes one’s anxiety.  Anxiety and fear lead to avoidance by definition, while summoning the courage to face and overcome our fears cuts them down to size (this is commonly referred to as “exposure”).  Cognitive-Behavioral Therapies (CBT), Dialectical Behavioral Therapy (DBT, as well as Radically Open DBT), and mindfulness-based psychotherapies are common effective treatment approaches.  Mindfulness can help one learn to be in and accept the present, increasing one’s capacity to tolerate feelings of discomfort while reducing anxious thoughts about the future.

Treating and Managing Panic Disorder and Attacks

In the case of panic attacks, it is advised to first rule-out any medical causes of the symptoms which can mimic other medical issues, specifically heart disease.  If another person is present during a panic attack, they provide support and reassurance, helping the person to talk through it or asking what they need that may be helpful.  In addition to medication, there are other helpful strategies for panic symptoms.

Strategies for Managing Symptoms of Panic Disorder and Attacks

  • Breathing or relaxation exercises
  • Physical exercise
  • Mindfulness/grounding exercises (such as a sensory check-in)

Coping Skills for Anxiety, including Panic Disorder and Attacks

Therapy can also help a person develop effective coping skills for preventing and managing anxiety.  These may vary depending on personal preferences, but can include increasing social supports, problem-solving for stressors, journaling, exploring spirituality, exercise/movement, etc.  Practicing healthy self-care habits (such as getting regular exercise and restful sleep, managing health conditions, and minimizing/avoiding alcohol, caffeine and other drugs) and generally trying to live a balanced lifestyle can simultaneously help to reduce the stress one may experience in life, while increasing one’s ability to effectively cope with anxiety.

Summary:  Anxiety is a common human experience, but persistent and debilitating anxiety, is often what causes people to seek treatment. There are a variety of types of anxiety. Panic or Panic Attacks are among the types of anxiety. Learn what are panic attacks, symptoms and causes and treatments for panic attacks and other anxiety disorders.

Learn more about panic attacks and anxiety.

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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

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By Jennifer Farley, PsyD,
Lindner Center of HOPE, Staff Psychologist

There are a number of reasons someone may undergo a psychological evaluation or assessment. The type of testing that is done depends on the individual’s functioning and the setting in which testing may be pursued. This article will look at the different settings of mental health assessments.

Types of Mental Health Assessment Settings

  • Outpatient
  • Inpatient
  • Residential
  • Children’s Assessments

Psychological Assessment in an Outpatient Setting

Testing from a clinical psychologist in a clinical outpatient setting can be pursued on their own or they may be referred from another clinician (such as a primary care physician or psychiatrist). This type of assessment is for patients with non-immediate mental health concerns. In this case, testing is pursued with the referral question in mind (such as whether someone has Attention Deficit/Hyperactivity Disorder, depression, anxiety, a learning disorder, dementia, cognitive problems due to a medical condition, etc). The psychologist tailors the tests to help determine the person’s functioning in the areas that could be affected by a cognitive or emotional disorder. Tests can range from intellectual assessments to personality measures to behavioral questionnaires (which can be completed by the patient themselves, parents, and/or teachers) to academic achievement measures. Clinicians such as neuropsychologists and developmental psychologists can do all these tests and then add additional measures specific to their specialization (such as when documenting problems related to a head injury or when evaluating for Autism Spectrum Disorder). The psychologist can use this information to make a diagnosis and provide recommendations for treatment of the condition. Often, such as for school-age or college-age patients, recommendations for academic accommodations are also provided.

Psychological Assessment In An Acute Inpatient Unit

Sometimes, psychological testing is completed for patients during an acute inpatient psychiatric hospitalization (when the patient is in a mentally unstable condition). In these cases, testing is often used for diagnostic elucidation to help guide decisions about types of medication to use. Recommendations may also be made about additional assessments or resources to pursue following one’s discharge from the hospital. The clinical psychologist completes these evaluations within a short time, since these acute hospitalizations last (on average) about 7 days, and there are usually just a few measures that are administered. Tests are specific to the question about the individual’s diagnosis and may only include emotional/personality measures.

Psychological Assessment in a Residential Setting

Another setting in which psychological testing may occur is within a residential psychiatric setting. This setting is for patients who are experiencing psychological distress that is not severe enough to warrant an acute inpatient hospitalization. Length of stay in a residential setting can vary from 10 days to several months, depending on the purpose of the stay (i.e., evaluation and/or treatment). The purpose of testing in a residential setting is to help comprehensively understand – by way of several different measures – one’s personality functioning, cognitive functioning (which can include neurocognitive skills such as attention, memory, and executive functioning), and other factors (such as external stressors, substance use, medical conditions, etc.) that have contributed to the patient’s condition(s). The patient’s internal strengths and weaknesses are explored, with the intention of making recommendations for how treatment can be tailored to work with the patient’s strengths to compensate for their weaknesses. The clinical psychologist works closely with the other members of the treatment team (such as the psychiatrist, social worker, and the therapists) to understand the patient, develop a treatment plan, and (if a longer stay) to begin implementing the recommendations. The patient’s progress is then monitored and, if needed, further testing can be done to help assess changes in the patient’s functioning as a result of the treatment.

Psychological Assessment in Childhood

In childhood, early observations of potential problems may come from teachers. Teachers may observe struggles in behavior such as impulsivity, talking or interrupting others during times when there is an age-appropriate expectation of silence, and/or oppositional behaviors towards others. Teachers may also be the first to wonder if a child has an underlying learning or attention disorder. If the teacher’s attempts to help the child are unsuccessful, the teacher may recommend testing in the form of a Multi-Factored Evaluation (MFE). Psychological testing may be part of this evaluation and can include intellectual testing and academic achievement testing by a school psychologist. Parent and teacher questionnaires may also be included in the MFE. Depending on the nature of the child’s observed difficulties, others (such as speech and language therapists and physical therapists) may do their own screening. If findings reveal that the student experiences problems that would make learning difficult, accommodations are then recommended and interventions and/or accommodations are then put in place through a 504 Plan or an Individualized Education Plan. It is noteworthy that clinical diagnoses are NOT made from this type of evaluation and findings and recommendations are specific to helping the child learn better.

Prior to any psychological testing, the patient (and/or his/ her family) should understand the purpose of psychological assessment and how it can be useful for guiding treatment and other recommendations.

Find out more information on what psychological assessment is here and why it is a critical step of the process towards finding a diagnosis and treatment plan.

Finding Help and HOPE

If you, or someone you know, is experiencing a mental health crisis, there is help available. The first step would be to consult with a health care provider or mental health care specialist. To see how Lindner Center of HOPE can help you decide on the best mental health assessment setting, reach out to us today. We can help you take the next steps. 

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By: Laurie Little, PsyD 

Lindner Center of HOPE, Staff Psychologist

Plants that have psychedelic properties have been used across all continents for centuries to aid in rituals, recreation and in healing. Over time, researchers have found that psychedelic medicines can also be profoundly effective in treating mental illnesses such as depression and anxiety and in ameliorating the effects of trauma.

Although a psychedelic medicine can be derived from a plant or created in a lab, the user will experience what can be described Laurie Little, PsyD as non-ordinary or altered states of consciousness. These states may include hallucinations, unusual perceptual or sensory experiences or an altered sense of space and time. Many users of psychedelic medicines also report profound experiences of inner peace, compassion towards themselves and others and deeply meaningful spiritual realizations. When combined with psychotherapy, psychedelic medicines have the potential to heal in ways often not seen with traditional therapies.

The psychedelic medicines that are most often being studied with mental health conditions are psilocybin (derived from mushrooms), LSD, Ketamine, Ayahuasca and MDMA. There have been numerous studies showing the effectiveness of psychedelic medicines on treatment resistant depression, end of life anxiety, Obsessive Compulsive Disorder, eating disorders and substance use disorders.

One of the most rigorously studied medicine is MDMA for the treatment of Post-Traumatic Stress Disorder (PTSD). In studies conducted by the Multidisciplinary Association for Psychedelic Studies (MAPS), 88% of participants with severe PTSD experienced a significant reduction in their symptoms and 67% no longer met criteria for PTSD only two months after their treatment.

The question remains, why is the treatment so effective? What is it about the combination of psychedelic medicine and psychotherapy that is so profoundly healing?

One possible theory is that psychedelic medicines offer the user an opportunity to look at difficult or traumatic experiences through a new lens that they have never had before. A psychedelic experience can potentially slow down the experience of time, engender feelings of safety and compassion, provide profound experiences of meaning and purpose and foster or deepen a connection to a higher power. Many of these experiences when applied to processing an old wound or trauma can have a profoundly healing impact.

Case Vignette:

John Doe is a veteran who has seen horrors that most of us cannot imagine. He has spent the better part of his adult years struggling with recurring nightmares, intrusive thoughts and strong feelings of survivor guilt and shame. He lives alone, avoids most people when he can and spends most of his time ruminating about what he should have done differently in his life.

At the behest of his family, John has tried traditional psychotherapy, but has gotten so overwhelmed by symptoms of panic and flashbacks, that he quits. It is too painful to talk about and he assumes it won’t help.

However, when John was given the opportunity to participate in an MDMA assisted therapy session, he was intrigued. He had been hearing more and more about how psychedelics could help with trauma but was afraid to feel hopeful. He had been resigned to feeling this way for so long. He agreed to give it a try.

While taking MDMA, John felt an alert state of consciousness, yet he felt calm and safe in a way that he had not felt for years. He felt at peace and relaxed. When he was gently guided to recall aspects of his past, he did not resist or feel panic like he had before. He was able to recall the events with a certain kind of distance. He could understand now that he was just doing what he could to survive. He could see now for the first time in his life that his so called “enemies” were also doing what they could to survive. He began to realize how true that was for all of the world. After that initial session of MDMA assisted therapy, John was then able to engage in traditional therapy in a way he never could before.

Although many researchers and therapists are aware of how profoundly helpful these medicines can be, there is still a great deal of stigma associated with these medicines. Because these medicines are still illegal in the United States, desperate patients are either travelling to other countries or are finding therapists who are privately using these medicines through “word of mouth”.

The Food and Drug Administration gave approval for certain psychedelic medicines to be researched, as long as they were held to the same standards as other pharmaceutical medications. This has led to a resurgence of new studies showing the safety and efficacy of psychedelic medicines for a multitude of mental health conditions. It is projected that several psychedelic medicines (including psilocybin and MDMA) will become legal and available for therapeutic use within the next one to two years.

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By: Jennifer B. Wilcox, PsyD
Staff Psychologist, OCD and Anxiety Disorders Program

 

 

 

 

What is compulsive hoarding?

Hoarding Disorder is a psychiatric illness and is considered to be a subtype of Obsessive-Compulsive and Related Disorders. The Diagnostic and Statistical Manual of Mental Disorders – 5th Edition (DSM-5) defines Hoarding Disorder (HD) as:

Persistent difficulty discarding or parting with possessions, regardless of their actual value. This difficulty is due to a perceived need to save the items and to the distress associated with discarding them.

The difficulty of discarding possessions results in the accumulation of possessions that congest and clutter active living areas and substantially compromises their intended use.

The hoarding causes clinically significant distress or impairment in social, occupational, or other important areas of functioning (including maintaining a safe environment for self and others).

The hoarding is not attributable to another medical condition and is not better explained by another mental disorder.

 

 

 

 

 

 

How is compulsive hoarding different from normal clutter or collections?

It is not uncommon for people to acquire a few extra possessions from time to time, resulting in occasional clutter. However, while normal clutter or collecting doesn’t usually interfere with a person’s daily functioning, compulsive hoarding often does. Compulsive hoarding also differs from normal clutter or collecting as it tends to become unmanageable, overwhelming, and causes significant distress or family discord. Though collections usually bring people joy and fill them with pride, hoarding often comes with shame and embarrassment.

Why do people hoard things?

Compulsive hoarding is thought to result from a combination of factors including genetics, environmental factors, life experiences, and learned behaviors. The reason one person hoards may not be the same as the reason someone else hoards. Some people who hoard are compulsive shoppers and acquire more things than they need or have room to accommodate. Others may have difficulty categorizing or making decisions about what to do with particular items. Sometimes they can’t remember what they own or where it is, leading to the purchase of duplicate items. Other times people hold on to possessions for emotional or sentimental reasons or get anxious when they discard things. Some people believe that the hoarded items may be useful someday and keep the items despite not needing them currently. The level of insight a person has about their struggles in these areas can vary widely from completely absent insight to good insight.

What types of things do people hoard?

The types of items a person hoards vary based on factors such as the reason they are hoarding and how severe their hoarding issues have become. Some commonly hoarded items include books, newspapers, magazines, boxes, bottles, clothes, food, items purchased in bulk, collectibles or vintage items, furniture, animals, or digital media.

How many people suffer from Hoarding Disorder and who does it affect?

While the exact prevalence of people who suffer from Hoarding Disorder is not certain, it is estimated that it affects approximately 2.5% of the general population. Studies have shown that prevalence rates in men and women are nearly equal and appear to be consistent across developed countries. Most studies report onset between 15 and 19 years of age and show a chronic course over the lifespan.

What is the treatment for Hoarding Disorder?

Hoarding Disorder is treated using Cognitive-Behavioral Therapy (CBT), a type of therapy that allows someone to work with a therapist to shift their thinking patterns and change their behavioral patterns to healthier ones. Randomized controlled trials have shown this to be an effective treatment for hoarding. While the data on the efficacy of medication for Hoarding Disorder is limited, there is some evidence to support the use of medication in the treatment of this disorder. For those hoarders who have limited insight, a Motivational Interviewing (MI) approach can help to foster their motivation and confidence. Finally, working on skills that improve the hoarder’s ability to maintain attention and focus, categorize items, and decision-making can be beneficial in treating Hoarding Disorder.

What can I do to help a loved one who seems to have issues with compulsive hoarding?

It is generally not recommended for family and friends to discard hoarded items without the hoarder’s permission. This can be extremely distressing for a compulsive hoarder and tends to make them upset, anxious, or angry. Instead, it is recommended that friends and family talk to their loved ones about their concerns and help them to seek professional treatment. Additional resources are available at the International Obsessive-Compulsive Disorder Foundation (IOCDF) and the Anxiety and Depression Association of America (ADAA).

Resources:

American Psychiatric Association, 2013. Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. American Psychiatric Association Publishing, Arlington, VA.

Treatment of Hoarding Disorder

https://instituteofliving.org/programs-services/anxiety-disorders-center/what-we-treat-at-the-adc/compulsive-hoarding

https://www.psychiatry.org/patients-families/hoarding-disorder/what-is-hoarding-disorder

Postlethwaite, A., Kellett, S., Mataix-Cols, D., 2019. Prevalence of Hoarding Disorder: A systematic review and meta-analysis. Journal of Affective Disorders 256, 309-316.

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The Difference Between CBT and DBT (Cognitive and Dialectical Behavioral Therapies)

Stacey L. Spencer, Ed.D.
Clinical Neuropsychologist, Lindner Center of HOPE
EMDR Trained therapist
Assistant Professor, Department of Psychiatry & Behavioral Neuroscience

 

There are many, many possible types of psychotherapy. Psychotherapy is an optimal treatment method for mental illnesses.  Cognitive Behavioral Therapy (CBT) and Dialectical Behavioral Therapy (DBT) are among the most common psychotherapies.

CBT vs DBT

What is Cognitive Behavioral Therapy?

One that has been in the public sector for decades, and that you’ve likely heard of, is Cognitive Behavioral Therapy (CBT). If you’ve ever gone to therapy, it’s very likely that the therapist you saw practiced CBT. This therapy, also called talk therapy, helps people better understand how thoughts influence our feelings. The goal of CBT is to talk through problems and help frame thoughts differently. CBT is typically time-limited and there are specific goals and homework provided. You might start out with a situation that troubles you, or one you may find troubling. With the guidance of the therapist, you identify the thoughts around the situation and work on finding alternatives and ultimately changing the behaviors in order to feel better. So, it’s thought-feeling-action-focused. Some mental flexibility is involved given that most of these thoughts are automatic and can become engrained.

Cognitive Distortions are often discussed in CBT.  CBT helps us to break up negative thought patterns or “thought traps” that can lead to feelings of anxiety, depression and cause us to avoid. A technique to help one move away from this type of thinking and often employed in CBT is “cognitive shifting”. With the help of awareness in what a person focuses on (in this case, often the negative cognition/thought/belief) the idea is that this helps us learn to shift our focus to something more helpful or innovative. There are many Cognitive Distortions under this umbrella. Examples of catastrophizing could be magnifying or minimizing. I read a good description once of this being a “billowing cloud of everything can go wrong” and believing it inevitably will.  Or in Minimizing when we downplay our successes.

A CBT-oriented therapist might give someone who tends to catastrophize events in their lives, leading to anxiety, for instance, a worksheet and walk through the process with them. This is hypothesized to have evolved as a way to help us survive during the immediate crisis. Now that we have developed higher-level reasoning skills, this can turn against us, as these negative thoughts can turn sticky.

One way to start is to help the client identify what they are currently most worried/anxious about. The client might start by specifying what they imagine will occur without using “what if” statements. Instead, the focus is on the client’s own predictions, e.g., “ I will fail the exam and get kicked out of school.” You ask the client to rate how much they believe this to be true from 0-100%. Next, the client is asked to take a step back and consider the likelihood of the catastrophe to occur. By helping the client to take a step back and assess the fear from a different perspective and re-interpret their concerns, this is called “reframing”.

Working on ways to cope with and manage these fears/anxieties by not diving into them is a strategy that CBT therapists employ. It takes practice and yet studies have shown that finding more balanced ways of managing these types of thoughts can lead to better mental and physical health outcomes. By helping the client to explore the underlying thoughts, emotions and beliefs and problematic thinking, they can work towards a more balanced view of themselves. The hope is that by helping the client change their perception to support more positive thinking, they will reduce distress and suffering and lead a more fulfilling life.

To recap, CBT features the following:

  • Treats emotional response
  • Is time-limited
  • Works best with solid therapist-patient relationship
  • Relies on the application of logic and reason
  • Employs structure to guide tailored treatment

What is Dialectical Behavioral Therapy?

Dialectical Behavioral Therapy (DBT) comes from dialectical theory and is actually a type of CBT.  DBT posits balance; not leaning too hard in one direction or another. This modality was originally created by Dr. Marsha Linehan in her work with people with chronic life-interfering behaviors, like self-harm and chronic suicidal thoughts. It has expanded to help with many other issues. Dialectical Behavioral Therapy techniques utilize individual therapy, group skills class and coaching. Groups emphasize learning specific DBT coping skills and there is homework given in-between to reinforce what was learned.

DBT Coping Skills

The four pillars of DBT coping skills include:

Mindfulness

Emotion Regulation

Distress Tolerance

Interpersonal Effectiveness

Mindfulness is a DBT coping skill that involves living with intentional awareness of the present moment. This includes not trying to push away or reject the moment but to notice it and not attach ourselves to it. As Dr. Linehan describes, this is by “Attending to the experience of each new moment, rather than ignoring the present by clinging to the past or grabbing for the future.” This takes practice and patience and can take many forms. Some examples of mindfulness include meditation in the form of noticing by either opening or focusing the mind. Contemplative prayer (in any spiritual form) is another mindfulness practice along with mindful movement such as yoga, martial arts, hiking, tai chi.

Emotion Regulation involves understanding and naming one’s emotions. By helping to learn to identify emotions, one can hope to gain an understanding of what they do for us. Goals of this are to decrease the frequency of unwanted emotions, the vulnerability to them and decrease emotional suffering.

Distress Tolerance are DBT coping skills for when involved in a crisis situation and the goal is to not make the crisis worse. By utilizing skills of Radical Acceptance, one can achieve freedom from suffering and being “stuck”. This can help by reducing acting on intense emotions and tolerating painful events. These are only utilized in a crisis situation, where the event or experience is highly stressful and short-term.

Lastly, Interpersonal Effectiveness skills are to help assist with either strengthening current relationships or end destructive ones, to learn to say yes/no effectively, resolve conflicts before they get overwhelming and create and maintain balance in relationships.

The Difference Between CBT vs DBT in Treating Certain Illnesses

Not all mental illnesses respond to treatment in the same way.  The difference between CBT and DBT must be taken into consideration when determining the optimal treatment method for an individual. CBT has been shown to be effective when treating depression, anxiety, obsessive compulsive disorder (OCD), phobias, panic disorder and post-traumatic stress disorder. DBT was created to help people who might be easily dysregulated and tend benefit from learning ways to self-soothe, communicate more effectively with others and find ways to reduce significant distress.

The Difference Between CBT and DBT Treatment Methods

The difference between CBT and DBT are defined. CBT focuses on the connection between thoughts, feelings and behaviors and how they influence each other. DBT emphasizes regulating emotions, being mindful and tolerating the uncomfortable. CBT guides patients to recognize troubling thoughts and redirect them, while DBT helps patients accept themselves, feel safe and manage emotions to avoid harmful behaviors.

When comparing CBT vs DBT, both therapies have aspects of how our thinking influences our emotions and behaviors but are different in their approaches and structure of the therapeutic process. Both modalities are evidenced-based, that is, much research has gone into showing whether they are effective.  When choosing a therapist, as important as it is to find someone in-network or with openings, it’s equally so to know what treatments are most effective for the reasons you’re seeking therapy in the first place. Therefore, asking about CBT vs DBT and which one might work best for you, would be an important next step in this process.  This is the best way to determine if CBT vs DBT are right for you.

Knowing your diagnosis is key to determining what therapy will be most effective for you. However, many people have more than one diagnosis, and sometimes people use a blend of therapy elements to best manage symptoms.

It can be confusing to know what techniques will best help you. CBT and DBT are some of the more common therapy practices, and have been shown to help individuals suffering from a number of mental illnesses.

Choosing to take care of your mental health is just as important as your physical health and finding providers that utilize evidence-based practices will provide you with the best outcomes possible.

For more information about DBT skills group at Lindner Center of HOPE.

 

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By: Jessica Kraft, APRN, PMHNP-BC
Lindner Center of HOPE, Psychiatric Nurse Practitioner

Seasonal affective disorder (SAD) is a type of depression that is more isolated to the changing of the seasons. It can happen in the spring and summer but occurs most commonly in the fall and winter months. We know that everyone is going to have a bad day from time to time, and it’s not uncommon for some to face more challenges in the winter months when the weather is colder and the days are shorter. But when does this become a problem that requires intervention?

What are some of the common symptoms of SAD? 

  • Feeling down or depressed for most of the day, almost every day
  • Less interest in hobbies, social activities, or things that have brought you joy in the past
  • Decreased concentration at home and at work
  • Fatigue, sluggishness, or low energy
  • Sleeping too much or too little
  • Changes in appetite (increased craving for carbohydrates) or changes in weight
  • A general feeling of hopelessness
  • Low self-esteem
  • Thoughts of self-harm or suicide

It is hard to estimate the number of people who have SAD, as many do not know they have it. It’s also thought that the number in recent years has been higher due to the COVID-19 pandemic. Women can be at higher risk for developing SAD as well as those who live further north. SAD most commonly develops in young adulthood, it often runs in families, and can often be co-morbid with other mental health conditions including depression, bipolar, anxiety, ADHD, and eating disorders.

It is not entirely understood what causes SAD, but research indicates that people with SAD may have reduced activity of serotonin, too much melatonin production, or even vitamin D deficiency. Changes in these areas may impact the body’s daily rhythm that is tied to the seasonal night-day cycle. Negative thoughts and feelings about the winter and its associated limitations and stresses are common among people with SAD, as well as others. It is unclear whether these are “causes” or “effects” of the mood disorder, but they can be a useful focus of treatment especially when seeking therapy.

If the above symptoms start to interfere with day-to-day life, it may be beneficial to seek out care for SAD. For some it may be ideal to start with their primary care provider in order to rule out other medical conditions that could be responsible for symptoms of SAD including alterations in thyroid hormones, low blood sugar, anemia, or viral infections like mono. If there is not an identifiable medical cause, seeking psychiatric help may be beneficial.

What are some of the common symptoms of SAD?

  • Light therapy – a common approach to SAD since the 1980s. The thought is that exposure of bright light every day can supplement the lack of natural sunlight/sun exposure in the winter months. Sitting in front of a light box of 10,000 lux daily during the winter months in the morning can be a helpful intervention.
  • Talk therapy – the most common type of talk therapy for SAD is cognitive behavioral therapy (CBT).
  • Vitamin D supplementation – there is mixed research on how helpful supplementation of Vitamin D is for SAD but some find it helpful and a good option to try prior to trying a psychiatric medication.
  • Psychiatric medication – for those who haven’t seen much improvement with light therapy or CBT, psychiatric medication can be an option including SSRIs (Prozac, Zoloft, Lexapro, etc.) or Wellbutrin. It is important to keep in mind that treatment with one of these medications may take several weeks in order to be efficacious, for some up to 6-8 weeks.
  • When doing research on this topic I came across many anecdotal stories from those struggling with SAD and what interventions they tried and found helpful. Some examples included going outside more often, taking a trip, caring for something like a plant or a pet, finding a new hobby or interest, staying social, creating new rituals, consistent exercise, quality nutrition, good sleep, and maintaining a consistent schedule.

What are some of the common symptoms of SAD?

One of the helpful things about treating SAD is the predictability of when symptoms set in compared to other sub-types of depression that are much more variable. Unfortunately there is little research answering the question of whether or not this can be prevented or if there is a significant benefit to starting treatment early. Of the limited data available the medication Wellbutrin was found to be the most helpful intervention to start early.

Sources:

https://www.nimh.nih.gov/health/publications/seasonal-affective-disorder/index.shtml 

https://www.psychiatry.org/patients-families/depression/seasonal-affective-disorder 

https://www.yalemedicine.org/news/covid-19-seasonal-affective-disorder-sad 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7302868/ 

https://www.sciencedirect.com/science/article/pii/S2215036620303072 

https://forge.medium.com/advice-for-coping-with-seasonal-depression-from-9-people-who-have-it-a5c04fdfe996

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Nicole Jederlinic, DO
Lindner Center of HOPE Staff Psychiatrist and Medical Director for the Cincinnati Children’s Hospital Acute Unit at Lindner Center of HOPE

As an inpatient and outpatient child / adolescent psychiatrist, I see children and teens, and, consequently, their families facing a wide range of mental health conditions. In the wake of the extensive remote learning related to the COVID-19 pandemic, these challenges have become increasingly common, and can range from social impairments to academic hardship to overt refusal to attend school.

According to the National Alliance on Mental Health, one in six children ages 6-17 experience a mental health disorder each year. Nearly half of all mental health conditions begin by age 14. While schools play a critical role in helping to identify concerns in children, schools are often tremendously (and increasingly) overwhelmed and can only do so much. As such, parents and guardians can play an active role in helping to identify their children’s struggles. Unfortunately, most kids won’t directly tell you they are struggling, so here are some signs to look out for:

-Talking about school becomes off limits, particularly about subjects in which your child may be struggling.

-Your child exhibits a major attitude change toward school. Children and teens may complain of being “bored”, which could also mean they do not understand the material.

-Your child exhibits changes in sleeping or eating patterns. Especially, look out for this on school nights.

-Your child spends too much time on homework. A rough estimate is that a child may have about ten minutes per grade level of homework per night. It’s important to be familiar with the teacher’s homework policy.

-Your child’s teacher explicitly expresses concerns. They see the behavior in school, BUT even they miss things, especially if your child tends to hold things in and is not disruptive.

-Your child begins to misbehave at school.

-Your child receives low grades and these are a drastic change from grades they previously earned.

-Your child spends much of the school day at the nurse with vague physical complaints, missing critical class time and socialization. At an extreme, your child may attempt to avoid going to school altogether.

Now that you’ve identified the problem, what can you do? Have an open conversation with your child – let them know what you’ve noticed and give them a chance to respond themselves. Try and stay open and really listen to their concerns without trying to assume your own interpretations like “they are lazy” or “they are overdramatic”. Remember, they may be guarded, so it’s important to gather additional information. Connect with your child’s teachers to get their thoughts. If difficulties are in one specific class, you could try tutoring or extra help from the teacher;  if they are more pervasive you may need to be more aggressive in how you address things. Try and determine the nature of the difficulty: is it more social/emotional or cognitive/academic? The school may be able to help distinguish this, and it’s okay to ask for additional help from a pediatrician, therapist or psychiatrist.

At public schools, you may formally request that the school evaluate your child’s needs by submitting a written request. Remember to sign and date the request, have the school sign and date when they receive the request and get a copy upon their acceptance of the letter. They have 30 days to respond and either agree to start an evaluation OR provide parents with a “Prior Written Notice” explaining why they do not think evaluation is warranted. This does not mean families cannot purse additional testing /evaluation on their own, but sometimes this can be costly.

Overt refusal to attend school is not a diagnosis in the psychiatric manual, but can point to a variety of psychological conditions like anxiety, trauma or depression. Approximately 2-5% of school children may experience school refusal. It’s important to remember this is NEVER normal. The failure to attend school has significant short and long-term effects on children’s social, emotional, and educational development. That said, it is a complicated problem and requires a collaborative approach to treat. Parents SHOULD NOT feel they are in this alone! Other members of the team may include a pediatrician, psychiatrist, or therapist. At some extremes, children may even require treatment in an inpatient psychiatric hospital or partial hospitalization program. It’s important to build relationships with the school and possibly others to help develop and plan for getting and keeping a child in school.

Typically, remote learning is not the answer to any school difficulties. Even prior to the pandemic, studies indicated that students who did remote learning were at a disadvantage. In 2015, a study of 158 virtual schools compared with traditional schools indicated virtual students obtained lower results in reading and math. In 2021, an analysis of virtual learning during the pandemic indicated a loss of five to nine months of learning with multiple psycho-social consequences including anxiety, depression, concentration difficulties, social isolation and lower levels of physical activity. In summary, there is little evidence of benefit with complete remote learning. More schools are offering hybrid learning models for students floundering in mainstream programs.

School is central to a child’s development. Parents now should have some tools and resources for identifying signs of struggle in their children. Early intervention is important to foster academic and social development and promote psychological well-being.

References:

NAMI. Mental Health in Schools. https://www.nami.org/Advocacy/Policy-Priorities/Improving-Health/Mental-Health-in-Schools

Linnell-Olsen, Lisa. (2020, May 20). 7 Warning Signs Your Child is Struggling in School. Very Well Family. https://www.verywellfamily.com/warning-signs-your-child-is-struggling-in-school-2601436

Cincinnati Children’s Hospital Inpatient Handouts. SPED Request for Families.

Kawsar, MD S., Yilanli, M and Marwaha, R. (2021, June 11). School Refusal. StatPearls (Internet). https://www.ncbi.nlm.nih.gov/books/NBK534195/

Bissonnette, S and Boyer, C. (2021, July 27). The Effects of Remote Learning on the Progress of Students Before and during the Pandemic. Inciativa Educacao. https://www.iniciativaeducacao.org/en/ed-on/ed-on-articles/the-effects-of-remote-learning-on-the-progress-of-students-before-and-during-the-pandemic

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Thirteen months ago, the world was experiencing the onset of a shared trauma … a pandemic was sweeping over the globe. The actions that were taken to keep people safe included community shut downs, stay at home orders and mandated isolation. Lindner Center of HOPE, like mental health providers around the world, began to see spikes in mental illness and addiction. Individuals who were already struggling with mental illness or a pre-disposition, saw exacerbated symptoms and an increase in severity of illness. People who were managing, saw new onset at higher levels of acuity. As time has passed since the beginning of the pandemic, the trauma has been sustained with higher percentages of people still struggling with mental illnesses and addictions. Additionally, data shows people who have experienced COVID-19 infection are also suffering with co-occurring psychiatric symptoms.

Dr. Paul Crosby, Lindner Center of HOPE

Fortunately, vaccines have been released to protect the population from the physical health threats of COVID-19. However, Lindner Center of HOPE’s President and Chief Operating Officer, Paul R. Crosby, MD, states the vaccine also offers mental health benefits as well.

“The first mental health benefit of the vaccine is simple,” Dr. Crosby said, “since the risk of COVID-19 infection diminishes significantly with vaccination, receiving the vaccine would also protect individuals from co-occurring mental illness that has proven to manifest with COVID-19 infection.”

“The second mental health benefit of the vaccine is the reduction in overall anxiety and stress, as risk and fear of infection is reduced. Vaccinated individuals can lift their isolation from other vaccinated individuals, can begin to see a return to other activities that improve mental health, like more exercise, improved sleep, new experiences through travel and more. A return to these healthier activities can hopefully also lead to a reduction in substance use, overeating or lack of participation in other things that bring joy.”

“The COVID-19 vaccine has significant potential in improving your mental health.”

For individuals experiencing symptoms of mental illness, it is critical to access help. Mental illnesses are common and treatable and no one should struggle alone.

Lindner Center of HOPE in Mason is a comprehensive mental health center providing excellent, patient-centered, scientifically-advanced care for individuals suffering with mental illness. A state-of-the-science, mental health center and charter member of the National Network of Depression Centers, the Center provides psychiatric hospitalization and partial hospitalization for individuals age 12-years-old and older, outpatient services for all ages, diagnostic services for all ages and short-term residential services for adults, and research. The Center is enhanced by its partnership with UC Health as its clinicians are ranked among the best providers locally, nationally and internationally. Together Lindner Center of HOPE and UC Health offer a true system of mental health care in the Greater Cincinnati area and across the country. The Center is also affiliated with the University of Cincinnati (UC) College of Medicine.