Fortunately, our culture has recently seen a gradual erosion of the stigma regarding emotional disorders, along with an increased understanding of such conditions. However, a less well-understood aspect of emotional disorders is the impact that they have on the cognitive functioning of those who are afflicted. Disorders such as Major Depression, Bipolar Disorder, Generalized Anxiety Disorder, Obsessive-Compulsive Disorder, and Schizophrenia all tend to interfere with one’s ability to access the full extent of their cognitive abilities, adding to the burden that these conditions create.

Regarding Major Depression, it is the one disorder that the DSM-V lists cognitive difficulties as one of the diagnostic criteria (diminished ability to think or concentrate, or indecisiveness, nearly every day). As a neuropsychologist, I routinely encounter patients who are all too aware that their depression impacts their ability to think clearly, to focus, and to recall everyday interactions. Part of the reason for this is that depression causes a reduction in processing speed, as well as the energy that it takes to attend to conversations and events. Difficulties with maintaining attention, and “keeping up” with things going on around them, these patients experience troubles recalling information, sometimes so profoundly that they begin to fear that they may have dementia. However, as their depression is more effectively treated, they regain full access to their cognitive skills and abilities.

Anxiety disorders also are accompanied by significant cognitive difficulties, for a couple of reasons. First, when the mind is anxious, most of the brain’s resources (blood flow, oxygen, glucose, etc.) are redirected to the emotional centers of the brain (the limbic system), and away from parts of our brain that mediate higher-level thinking and logic. Secondly, those who are anxious tend to be rather “internally-oriented” in their thinking, and so they are not as attentive to external events. In other words, because they become preoccupied with their fears and worries, the ordinary events of the external world can be largely overlooked. As a result, these ordinary events are not well-encoded into the memories of anxious patients, and therefore they cannot easily be recalled. As with depression, as anxiety becomes better managed, these cognitive issues largely resolve.

Two other diagnoses have profound implications for cognitive functioning. Bipolar disorder has a well-established pattern of cognitive difficulties, including diminished attention, verbal memory, and executive functioning abilities (planning, anticipating, problem-solving, emotional regulation, staying focused and attentive to personal goals, etc.) These difficulties, fortunately, are typically limited to times that these patients are actively experiencing a mood episode, whether it be depression or mania. Regarding those with schizophrenia, they experience similar cognitive difficulties. However, they often continue to experience such cognitive difficulties even when their symptoms of schizophrenia have been well-controlled with treatment. This is why the DSM-V lists “associated features” of schizophrenia specific to these difficulties, explaining that, “Cognitive deficits in schizophrenia are common and are strongly linked to vocational and functional impairments.”

Fortunately, over the past 20 years there have been treatments and interventions to address such cognitive difficulties. Cognitive Enhancement Therapy, or CET, has been developed and implemented for the mentally ill for whom cognitive problems are getting in the way of living independently, maintaining employment, and sustaining meaningful relationships. It has proven to be an effective means to address such difficulties, and for providing a much higher quality of life. It is anticipated that, as the benefits of CET become more evident to those working with the mentally ill, its positive impact will widen in both its breadth and depth.

Thomas A. Schweinberg, PsyD Staff Psychologist Lindner Center of HOPE

Times are uncertain. The world feels scary. Our normal day to day life has been turned upside down. Let me just start by saying this, if you are feeling anxious, scared, overwhelmed, frustrated… you are allowed to feel these emotions, it makes total sense why you feel this way, you are not alone, and you are not weak. Remember, pain in life is unavoidable, but suffering is a choice. Meaning, we are going to experience stress in our life, every person on this planet will, but it is ultimately how we respond to that stress that influences exactly how much pain we will experience. Let’s walk through some ways we can live with anxiety during times of stress.

Mindfulness of Emotions. When it comes to managing our anxiety during times of stress, an important first step that we tend to overlook is mindfulness. In order to reduce anxiety, we must first acknowledge that it is there. Allow yourself to pause and put a name on what you are feeling, notice if you feel it physically in your body, observe what thoughts are running through your mind. Try using the stem “I am aware of the emotion of ______, I am aware of the thought that _______.”  By bringing mindful awareness to our anxiety in this way, we are bravely choosing to face our discomfort while also seeing it as something that we are experiencing in that given moment, not who we are or the way things will always be.

Self-Compassion. Now that you are observing your anxious mind in action, practice some self-compassion by normalizing the experience, validating its’ presence, being “kind to your mind.” We tend to create more suffering for ourselves when we judge ourselves for our emotions, when we tell ourselves we should not be feeling that way, or try to just “suck it up.” You are an amazing human doing the best you can with some really hard human things right now!

Changing Emotional Response. While part of our goal is accepting the anxiety through mindfulness and self-compassion, we also have the ability to create change in our emotional state and our response to it. First, we need to “check the facts” and get a good look at what our mind is telling us. Our minds tend to be great storytellers, mind readers, and fortune tellers. While these seem like super powers, these are actually mind tricks and traps that create more suffering. Checking the facts is seeing if your emotion and its’ intensity actually match reality (i.e., are valid), or if you are responding to a mind trick.

Next, ask yourself if the action urge associated with the emotion you are feeling is effective? For example, is being angry with your partner because they did not clean the house then throwing a shoe at them actually helpful here??  If the emotion is invalid and/or ineffective, we want to act opposite to what the emotion is telling us to do. So instead of avoiding work responsibilities because we are stressed, make a specific schedule to complete tasks. Instead of spending hours reading the news because we are scared, watch one news program then spend the rest of the day playing with the kids or watching movies.

Acceptance. Consider what is and what is not in your control. If there is a stressor that is in your control, practice problem solving. For stressors we cannot control, accept that we cannot change that reality and focus instead on what in the here and now is in your power. Remember, rejecting reality does not change reality. Instead of dwelling on how terrible it is to be stuck at home, make plans for a game night, clean out that room you have been avoiding, soak up the springtime outdoors.

Practice Gratitude. Lastly, practice gratitude every day. Spend some time thinking about what you have that you are grateful for rather than hyper-focusing on what you don’t have or what has been taken away, which tends to just create more stress. Be specific, instead of just saying you are grateful for your family, say “I am grateful that today my kids helped clean the kitchen and cuddled with me on the couch.”

We as humans are under an incredible amount of stress right now, but remember, as humans we are also incredibly strong and resilient.  Importantly, please know you do not have to struggle with this alone. Sometimes the strongest thing we can do is ask for help. If your anxiety is persistent and intense and/or is significantly interfering with your life, please reach out to a mental health therapist. Telehealth services are being offered across the region, including at the Lindner Center of HOPE, who has a whole team of providers eager to help guide you through this.

By Allison Mecca, PsyD
Lindner Center of HOPE, Staff Psychologist, Harold C. Schott Foundation Eating Disorders Program

 

Peter White, M.A., LPCC
Lindner Center of HOPE, Addictions Counselor

Due to the COVID-19 pandemic, this is a period of unprecedented changes marked by great uncertainty shared by literally everyone. One of the complex realities of dealing with this much uncertainty is that we should feel a wide variety of difficult emotions – confusion, fear, disorientation, sadness, and anger to name a few. In a way, it is healthy to not feel okay at this time. But at the same time, it is important for us to acknowledge that we want to manage these difficult emotions in a healthy way. One common vulnerability in managing difficult emotions is depression. Although challenging, we can get good at identifying and countering the presence of depression during difficult times. We can effectively treat and manage depression so that it does not make our coping less effective.

Depression is a condition involving thoughts, emotions and physical reactions. It is opportunistic in periods of uncertainty expanding its ability to disempower and disquiet ourselves and our relationships. Depression’s biggest advantage is its negative judgement – hopelessness, helplessness, worthlessness and guilt are all hallmarks of depressive thought process. “It’s not going to get better. There is nothing I can do to make it better. I don’t deserve to have it be better,” are all examples of depressive distortions that can plague the mind and divorce us from our natural capacities to endure and thrive. In a way, depression fills the mind with judgements that are fundamentally untrue. There is always hope. Things can always improve. We always have some options to improve our situations, or at least find how to endure with as much forbearance and gratitude as possible. And of course, we all deserve to have our suffering relieved. They may seem like simple reframes, but they are the fundamental effort of successfully countering depression so that we can move forward with all our strengths and resources. Fear is appropriate and understandable in times like this with major uncertainties and potential pending losses of security and predictability. I always encourage clients to honor their fear, comfort themselves with the many blessings of their lives that help them endure and rebound from loss, and resist the power of depression to convince them that they are alone and without options

As noted, depression infects both the mind and the body. Depression disrupts our metabolism, so we might experience fatigue, sleep disruption, changes in our appetites, difficulty in concentrating and decision making. Given that depression has a corrosive effect on body, mind and spirit, it is most effective to counter it with body, mind and spirit. Keep moving, maintain a wholesome routine mixing both work and pleasure. An easy acronym to remember is GRAPES. G. stands for gentleness and gratitude in thought. R. stands for relaxation, even for brief moments. A. stands for the recognition of our accomplishments, especially the simple ones-caring for ourselves and our loved ones is always an accomplishment. P. stands for pleasure, again especially the simple ones- food, music, reading, nature, or whatever there is that reminds you that life has its joys. E. stand for exercise, or if not rigorous physical activity, any movement that brings the reward of the body moving through space. And S. stands for remaining social. All of the above are anti-depressive activities – effective reminders that hopelessness, helplessness and especially worthlessness are untruths to be dispelled during our moments of fear and doubt.

Let me end just highlighting the social. All humans, especially so right now, share the experience of fear and doubt related to uncertainty. Near invariably, we are all comforted when these fears are shared amongst our loved ones and our fellows in a spirit of honor and trust. Nearly all of us have experienced a darkness of spirit that is quickly dispelled by kind words from friends. If nothing else, resist the power of depression to convince you that you are alone and do not deserve the fellowship of loved ones and peers. Clearly now, our experience of uncertainty is a deeply shared experience. I encourage you to become robustly social, so that within the shared uncertainty, we can all experience the power of ourselves and others to endure and overcome this frightening time strengthened in our spirit of togetherness.

Chris Tuell Ed.D., LPCC-S, LICDC-CS, Clinical Director of Addiction Services

As feelings of anxiety, depression, or sheer boredom mount due to the growing pandemic of the coronavirus, the desire to turn to drugs and alcohol as a coping mechanism could become more problematic. Experts warn against self-medicating during these stressful times for a multitude of reasons. For many people who struggle with mental illness and/or substance use disorders, there is an unfortunate tendency to withdraw or isolate from others. So when we are told to practice social distancing, remain in our homes, isolate from one another, this can feed into a further deepening of an individual’s struggles and isolation with depression, anxiety, trauma or loss.

According to SAMHSA, (Substance Abuse Mental Health Services Administration), 84% of individuals who experience a substance use disorder, also experience a co-occurring mental health issue as well. During times of stress, many of us seek relief, in any way we can find it. The use of substances is not a healthy way of coping. Substance use is frequently used as a means to escape or numb-out from life’s problems. Substance use will often exacerbate a previous existing problem, making it worse.

In cities across the country, people are increasingly living under “shelter-in-place” or lockdown mandates that have closed businesses, limited social gatherings, and urged self-quarantine. These added stressors have resulted in increased levels of alcohol consumption. According to the Republic National Distributing Company, a wine and spirits distribution company, sales of spirits jumped by 50% for the week ending March 21, 2020. Nationally, the overall increase for the week according to Nielsen data, saw a 55% spike in alcohol sales.

Each of us experiences stress from time to time. However, recent events of the past few months have been unprecedented. Stress can feel overwhelming. There are different types of stress – all of which carry physical and mental health risks. A stressor may be a one-time or short-term occurrence, or it can happen repeatedly over a long time. Some people may cope with stress more effectively and recover from stressful events more quickly than others. Unfortunately for some, substance use becomes an unhealthy way to self-medicate one’s stress, mood and/or anxiety.

Coping with the impact of chronic stress can be challenging. Because the source of long-term stress is more constant than acute stress, the body never receives a clear signal to return to normal functioning. With chronic stress, those same lifesaving reactions in the body can disturb the immune, digestive, cardiovascular, sleep, and reproductive systems. Some people may experience mainly digestive symptoms, while others may have headaches, sleeplessness, sadness, anger, or irritability. Over time, continued strain on the body from stress may contribute to serious health problems, such as heart disease, high blood pressure, diabetes, and other illnesses, including mental health issues such as depression or anxiety. For some, substance abuse only adds insult to injury.

When does one’s consumption of a substance (i.e., alcohol, drugs, gambling, Internet, gaming) become
problematic? Addictive behaviors consists of the following three behavioral questions (The Three C’s).
• Is there a loss of Control? (I am unable to manage the behavior.)
• Is the behavior Compulsive? (I cannot stop doing the behavior.)
• Do I continue to engage in the behavior, despite the negative Consequences?

Coping with life stressors by the use of alcohol or any other substance, is a bad idea. If you take practical
steps to manage your stress, you may reduce the risk of negative mental and physical health effects. Rather
than reaching for that adult beverage, below are tips that may be helpful in coping with stress:

Be observant. Recognize the signs of your body’s response to stress, such as increased alcohol and other
substance use, difficulty sleeping, , being easily angered, feeling depressed, and having low energy.

Talk to a health professional. Don’t wait for your health care provider to ask about your stress. Start the
conversation and get proper health care for existing or new health problems. Effective treatments can help
if your stress is affecting your relationships or ability to work.

Get regular exercise. Just 30 minutes per day of walking can help boost your mood and improve your
health.

Pursue calming activities. Explore relaxation or wellness programs which may incorporate meditation,
imagery, muscle relaxation, or breathing exercises. Schedule regular times for these and other healthy and
relaxing activities.

Set goals and priorities. Decide what must get done now and what can wait. Learn to say “no” to new
tasks if you start to feel like you are taking on too much. Try to be mindful of what you have accomplished at
the end of the day, not what you have been unable to do.

Stay connected. Even though this may be a challenge, given our current social distancing, we need to remain
connected with one another. You are not alone. Keep in touch with people who can provide emotional
support and practical help. To reduce stress, ask for help from friends, family, and community or religious
organizations. Many community support groups (AA, NA, GA, SMART Recovery) are available online. Stay
healthy, stay connected.

 

Susan L. McElroy, MD

Lindner Center of HOPE, Chief Research Officer and Consultant to Eating Disorders Team

Borderline personality disorder (BPD) is a mental disorder consisting of a pervasive pattern of instability in regulation of emotions, impulses, interpersonal relationships, and self-image. Symptoms of BPD include frequent mood changes and excessive anger; feelings of worthlessness, insecurity, loneliness, and emptiness; periodic distortion of reality; and unhealthy social relationships.  Individuals with BPD are prone to self-harm (including suicidal ideation and behavior, self-cutting, and completed suicide), aggression, problematic alcohol and drug use, and other dangerous behaviors. The cause of BPD is unknown but thought to involve both genetic and environmental factors. Diagnosis is made clinically based on symptoms.

BPD is very common. It occurs in up to 5.9% of the general population and represents 15% to 29% of patients in psychiatric clinics and hospitals. Because the personality of children and adolescents is developing, the features of BPD do not become recognizable until late adolescence or early adulthood. Once the disorder appears, its course is often chronic. Though BPD is more common in women, a substantial number of men have the disorder as well.  There is a high comorbidity of BPD with other psychiatric disorders (approximately 85%), including anxiety disorders, mood disorders, impulse-control disorders, substance-use disorder, and eating disorders.

The present standard of treatment of BPD is psychotherapy, especially a form of psychotherapy called dialectical behavior therapy, to help individuals with tolerating distress and managing mood changes, impulses to self-harm, and relationships.  Most patients with BPD also receive psychiatric medication to target mood instability and excessive anger, impulsive and self-harming behavior, and cognitive and perceptual distortions. Small studies suggest medications that affect the dopamine and serotonin systems, particularly atypical (or second generation) antipsychotics (such as aripiprazole, quetiapine, and olanzapine), can be helpful for these symptoms. However, no medication has been approved by the United States Food and Drug Administration for the treatment of individuals with BPD.

The Research Institute at the Lindner Center of HOPE is participating in two important studies of one such medication, brexpiprazole, for treating BPD (clintrials.gov identifier NCT04100096 and NCT04186403) and is actively seeking individuals with BPD for participation. The first study is a 12-week, double-blind, placebo-controlled trial to evaluate the efficacy and safety of brexpiprazole for the treatment of individuals diagnosed with BPD. The second study is a six-month open-label trial of brexpiprazole in individuals who have completed the first study. (Open-label means all participants will receive brexpiprazole; no one receives placebo).

Otsuka Pharmaceutical Development and Commercialization, Inc., the manufacturers of brexpiprazole, is sponsoring the studies. Of note, brexpiprazole already has approval from the United States Food and Drug Administration for the treatment of schizophrenia and major depressive disorder (the later in combination with an antidepressant).

Please see the following links to get more information about the study:

https://clinicaltrials.gov/ct2/show/NCT04100096?term=Rexulti&cond=Borderline+Personality+Disorder&draw=1&rank=2

https://clinicaltrials.gov/ct2/show/NCT04186403?term=rexulti&draw=1&rank=8

https://lindnercenterofhope.org/research/

You may also contact Morgan Pond at [email protected]  or (513) 536-0704.

For further information on BPD:

https://www.nimh.nih.gov/health/topics/borderline-personality-disorder/index.shtml

 

Jennifer Farley, PsyD

Lindner Center of HOPE, Staff Psychologist

The holiday season can be an enjoyable and peaceful time for many of us. We adults know that this can also be a busy, tense, overstimulating, overindulgent, and overwhelming time. Any of these experiences can be triggered, for example, by holiday memories of the past, our current experiences, or worries about the future. We also may have expectations for how our holidays “should” be, which can bring about even more stress in planning them or sadness or anger if our experiences fall short of what we wanted.

Using mindfulness, or focused attention on the “here and now,” can be helpful in making the holiday season more tolerable and, hopefully, more enjoyable. Mindfulness involves being self-aware of one’s thoughts or feelings or behaviors in the current moment and without judgment. Why the current moment? Because thinking about the past can bring about sadness (and depression) and thinking about the future can bring about worry (and anxiety). Being mindful without judgment is also important – it helps prevent an emotion from being experienced more intensely. For example, telling oneself, “I’m a horrible friend for not giving them a gift,” is far different than, “I have the thought that I am a horrible friend for not giving them a gift.” Similarly, reflecting, “I’m sad that my family member isn’t here,” is experienced differently than “I have the feeling of sadness about my family member not being here.” The without judgment part also comes from not judging oneself or anyone else for having a particular thought, feeling, or behavior. Telling oneself, for example, that they’re “bad” for thinking or feeling a certain way is a judgment – having a thought or feeling simply makes one human. What we do with a thought or feeling is what matters more.

Thoughts about how the holidays “should be” can intensify people’s emotional experiences further. Many people, for instance, experience “shoulds” surrounding holiday traditions. While these can bring comfort to our holidays, “shoulds” can also weigh people down with guilt, burden, or anxiety. Family traditions are important, but so is the consideration of how a specific tradition might be unreasonable to expect – for oneself or others. Letting go of the word “should” allows more flexibility and adaptability to an experience, and as such, can bring about more joy and a lot less tension. Do you really “need” to host Christmas dinner? Or is it that you prefer it but can adapt to having someone else host?

Mindfulness can be practiced by observing and describing one’s current thought(s) or feeling(s). Mindfulness can also involve doing something with intention. Consider how you might – with focused intention – wrap a present, look at Christmas lights, drink your cup of coffee or hot chocolate, hug a loved one, sing a Christmas carol, hang ornaments on your tree, watch a favorite holiday movie, or study the fire in the fireplace. Doing something with intention helps you remain in the present moment. Be aware of how your phone or other distractions prevent you from being fully present with others. If you find yourself diving deeper into a holiday memory, try to catch yourself first, and mindfully reflect if it’s a happy or heartwarming memory or one that could bring about sadness or hurt or anger.

One classic holiday movie (A Christmas Story) features Ralphie and his myriad of Christmas-related incidents. There are two scenes that highlight mindfulness practice: 1) when Ralphie looks with amazement at the snow-covered scene outside his bedroom window on Christmas morning, and 2) when Ralphie’s parents sit together in the dark and gaze at their Christmas tree. Another movie (Elf) depicts a father making a choice to fully participate in singing a carol with his family. These pop culture references may help highlight ways you might practice mindfulness in your own ways this holiday season. As a result, may your next month or so be experienced with mindful moments that bring self-awareness, peace, and joy.

Michael O’Hearn, MSW, LISW-S

Odum’s Paradigm

Odum’s (1988) Self-Organization, Transformity, and Information is a conceptual framework for this intervention.  It is supported by two traditional pillars of economic theory: (1) the production-consumption model (“supply and demand”), and (2) production-consumption growth equilibrium.  This is a social currency system, not a monetary system; the currency is energy and information.  Odum adds “recycling” to the first component, constituting the following model:

Source > Production > Consumption > Recycle >

The output from production-consumption-recycle iterations is recycled into more concentrated and refined products (components) and by-products (process fractals).  Both are recycled as source input of subsequent iterations, and simultaneously constitutes a control parameter fortifying production (Odum, 1988).  Products and by-products of partner interactions are recycled as source input, control production, and either fortify or inhibit development over time.

Production components are contributions and defections; each generates products and by-products.  Gottman (2012) outlines behavioral correlates that sustain or erode cooperation and trust in relationships.  These are discerned as inventories of contribution products and by-products, and defection products and by-products.

Contributions.  Contribution products and by-products can help regulate autonomic nervous system (ANS) triggering, fortify cooperation, and trust in relationships.  Four advantages of demonstrated trust in relationships are: (1) trust reduces complexity of all transactions, (2) trust permits action with incomplete information (benefit of the doubt), (3) trust minimizes transaction costs, and (4) trust increases relationship resilience as complexity naturally increases over time (Gottman, 2012, p.78).

Some partner contribution products can include: (1) neutral narrative of subjective views, (2) minimum 4:1 positive to negative interaction frequency, (3) soft start to difficult conversations, (4)  accept influence, change behavior to meet partner’s needs, and recognize partner’s change efforts, (5) tolerate partner’s negative emotion, and focus on the problem at hand, (6) set limits on behavioral expression of negative emotions, (7) accept responsibility and apologies, and (8) make positive statements of needs (Gottman, 2012).

Examples of contribution by-products can include: (1) overall positive perspective and “us-ness,” (2) shared meaning, purpose, fondness, and admiration, (3) eye contact and touch are soothing in conflict, (4) prioritize understanding, (7) non-defensive listening to partner’s negative emotion, (8) effective dialogue and problem solving on perpetual issues, (9) offer and accept apologies, and (10) cooperation and trust (Gottman, 2012).

Defections.  Defection products and by-products reinforce elevated and protracted ANS activation, entropy conservation, and erosion of cooperation and trust in relationships.  Criticism, contempt, defensiveness, and stonewalling are correlates of marital dissatisfaction and divorce (Gottman, 2012).

 

By Danielle J. Johnson, MD, FAPA
Lindner Center of HOPE, Chief of Adult Psychiatry

May is Maternal Mental Health Awareness Month.  One in five women will develop a maternal mental health disorder.  They are also referred to as perinatal mood and anxiety disorders (PMADs) to emphasize that women experience more than postpartum depression during pregnancy and after birth.  Women who have symptoms of PMADs might not seek help because of guilt, shame, or embarrassment for feeling something different than the expected norms of motherhood.  Awareness and education are important to reduce stigma so mothers and babies get the help they need.

PMADs can occur during pregnancy or up to one year after giving birth. The most common PMAD is the “baby blues”, affecting up to 80% of new mothers.  Symptoms include sudden mood swings, loneliness, sadness, crying spells, loss of appetite, problems sleeping, irritability, restlessness, and anxiety.  These symptoms are a normal adjustment to changes in hormones and resolve without treatment in two to three weeks.

About 10% of women experience depression during pregnancy and about 15% during the first year postpartum.  Feeling sad, hopeless, helpless, or worthless; fatigue, difficulty sleeping or sleeping too much, appetite changes, difficulty concentrating, crying, loss of interest or pleasure; lack of interest in, difficulty bonding with, or excessive anxiety about the baby; feelings of being a bad mother, and fear of harming the baby or self are symptoms of peripartum depression.  Risk factors include poverty, being a teen mother, advanced maternal age; personal or family history of depression, anxiety, or postpartum depression; premenstrual dysphoric disorder, inadequate support, financial stress, relationship stress; complications in pregnancy, birth or breastfeeding; a history of abuse or trauma, a major recent life event, birth of multiples, babies in neonatal intensive care, infertility treatments, thyroid imbalance, and diabetes.

Anxiety can occur alone, or with depression, in 10% of new mothers.  Symptoms include constant worry, racing thoughts, inability to sit still, changes in sleep or appetite, feeling that something bad is going to happen; and physical symptoms like dizziness, hot flashes, and nausea.  Some mothers may also have panic attacks with shortness of breath, chest pain, dizziness, a feeling of losing control, and numbness and tingling.  Risk factors are a personal or family history of anxiety, previous perinatal depression or anxiety, and thyroid imbalance.

Post-traumatic stress disorder (PTSD) can occur in up to 6% of mothers following a traumatic childbirth.  Possible traumas are prolapsed cord, unplanned C-section, use of vacuum extractor or forceps to deliver the baby, baby going to NICU; and feelings of powerlessness, poor communication and/or lack of support and reassurance during the delivery.  Women who have experienced a previous sexual trauma are also at a higher risk for developing postpartum PTSD.  Intrusive re-experiencing of the traumatic event, flashbacks or nightmares; avoidance of stimuli associated with the event; increased arousal (irritability, difficulty sleeping, hypervigilance, exaggerated startle response); anxiety and panic attacks, and feeling a sense of unreality and detachment are symptoms of PTSD.

Obsessive-compulsive disorder (OCD) can occur in 3% to 5% of new mothers.  Obsessions are persistent, repetitive thoughts or mental images, often related to the baby. Obsessions can be so bizarre or disturbing that they can be mistaken as psychosis.  Compulsions are repetitive acts performed to reduce obsessions.   Mothers are distressed by the obsessions which can lead to a fear of being left alone with the baby or hypervigilance in protecting the baby.  Mothers with postpartum OCD know that their thoughts are out of the ordinary and are unlikely to ever act on them.

Postpartum psychosis is the most severe of the PMADs.  It is often associated with an episode of bipolar disorder. It is rare, occurring in 1 to 2 per 1000 women.  The onset is abrupt, within 48 to 72 hours and up to two weeks after delivery. This is a psychiatric emergency, requiring immediate treatment.  Mothers may experience hallucinations (hearing voices or seeing things) and/or delusions (believing things that aren’t true.)  If psychosis occurs as part of a bipolar manic episode, there might be additional symptoms such as irritability, hyperactivity, decreased need for or inability to sleep, paranoia and suspiciousness, rapid mood swings, difficulty communicating, and confusion or memory loss. Risk factors are a personal or family history of bipolar disorder or a psychotic disorder.  Most women with postpartum psychosis do not have violent delusions but there is an up to 5% rate of infanticide or suicide due to acting on delusions or having irrational judgement.

PMADs are the most common complication of pregnancy and childbirth.  They are treatable with psychotherapy and/or medication and early intervention provides relief for the mother and ensures the baby’s wellbeing.

BY: Elizabeth Wassenaar, MS, MD, Lindner Center of HOPE, Staff Psychiatrist and Medical Director of Williams House

 

Life can be overwhelming and we all would like to take a day off every once in a while. Likely, as helping professionals, we don’t take mental health days as often as we could actually benefit from them.  This is one of the reasons why, when a child or adolescent refuses to go to school, we may be initially sympathetic.  Maybe a day or two off will help, we may think.  In too many cases, however, we see that a day or two off turns into something much more problematic as parents and professionals struggle to get a school avoider back to school.  Homework piles up, grades start to fall, and friends wonder what has happened to their classmate.  Parents try many different tactics to try to get their child back to school; bribing, negotiating, punishing, or even carrying a child through the school door.

Children want to not go to school for many reasonable causes: kids can be cruel; learning can be difficult; anxiety about performance can be overwhelming; health concerns can require special privileges that feel too identifying; and getting up early in the morning is harder for some more than others. Furthermore, mental illness can make school attendance difficult for many additional reasons.  There are good reasons to keep children home from school – physical illnesses can be contagious, some stages of mental illness are better treated with mental rest, and in some cases of bullying the safest way to deal with an unsafe situation is to remove the child.

Nevertheless, school refusal is avoidance, and anxiety loves avoidance. Nothing is more reinforcing that one cannot handle something than not doing it.  So, after one has checked on physical health and for other explanations, how can professionals support parents to keep their children in school or break the cycle of school avoidance and school refusal?

  1. Help parents identify the behaviors of avoidance and link that to anxiety.

Avoidance is a coping mechanism for dealing with anxiety, which can become maladaptive when avoidance becomes the only options. Avoidance can look a lot of different ways –tantrums, tearfulness, vague physical symptoms, negotiation (more on that later), chaos, and so on.  Parents may not be able to recognize all of the forms avoidance can take. Helping them objectify avoidance will help them strategize on how to deal with it.

  1. We have to truly believe that avoiding school will not make it better.

It can be tempting to collude with anxiety that the precipitant needs to be avoided for all the reasons laid out in this article and we need to be internally convinced that anxiety is not correctly assessing the situation. As difficult as school can be, school occupies a unique place in a child’s life.  It is the place of work, play, and love.  Learning and playing are the main jobs of childhood.  Playing looks both like playing at recess and like experimenting in relationships with both friendship and love. Identity is formed and reformed through our work, play, and love.  When a child is not in school for an extended length of time, they are abrupting their opportunity for this developmental process to proceed.

  1. Negotiation is another way of avoiding and is a dangerous game.

Many of my patients have used a variety of negotiating tactics with their parent: “Let me go in later and then I’ll go, I promise” or “Let me catch up on my work today and I’ll go in tomorrow”. Small avoidances add up to large avoidance and are not moving towards your goal.  Reverse the negotiation and set up conditions that will allow an out as long one starts the day at school.  Often, once anxiety has lost its argument that one cannot handle going to school, staying in school through the day is easier to manage.

  1. Encourage parents to work with the school

Parents and school are on the same side of this concern – both parties want the child to be successful in school. For parents, this may be the first time dealing with school refusal, but it is most certainly not the first time the school has dealt with school refusal.  Most schools have a variety of plans to help keep a child in school.  Have parents reach out to the school and let them know what is going on.

  1. Set small goals that lead to the victory

The ultimate goal of full school participation is an overwhelming prospect. Depending on how severe the school refusal is, reintroducing school can be an extended process of gradually introducing larger and larger challenges.  Perhaps, on the first day, one can only walk through the school doors.  Maybe a student will be able to be in the school building, but not in classes.  Parents can engage trusted friends to provide motivation and encouragement through social interaction and distraction while at school.

  1. School has many different forms

Many families choose alternative school arrangements including home schooling, virtual schooling, and others, for a variety of reasons and this article is not meant to convict choices that do not have a child in a classroom every day. There are many viable options for school that provide an environment that promote healthy development.  When a family is making a decision to change the way school is delivered, help them examine what factors are involved in their decision.  If they are making the decision from a place of believing that the anxiety that drives school avoidance cannot be defeated then, help them with all the ways described above.

School is a venerable and sometimes dreaded rite of passage. A great deal rides on academic and social success in school which increases anxiety and can lead to school refusal.  As a team, parents, professionals, and schools can help keep children and adolescents in school and accomplishing their goals.

On October 28, 2015, Dr. Elizabeth Wassenaar, Lindner Center of HOPE Psychiatrist and Williams House Medical Director, joined Lon Woodbury on the Woodbury Report radio show.  Their discussion focused on outlining the benefits of a residential assessment for mental health concerns in adolescents.

Click here to listen.