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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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When someone is suffering from depression, a family member is often called upon to help make important treatment decisions.  In the midst of a major depression, your loved one may be too disturbed to make practical decisions about his or her care.

One of the most important decisions to make is the selection of the right depression treatment center to meet your loved one’s needs.  During the screening process, we recommend that you ask the following questions to potential providers:

1. Is the inpatient depression treatment program individualized?

No one wants a cookie-cutter approach to a loved one’s care.  For depression treatment, one size does not fit all. Varying levels of care and types of treatment modalities should be available. Individuals with imminent suicidal risk may require inpatient care, while others may be treated on an outpatient basis. Some patients may respond well to counseling, while others may also need antidepressant medications. The availability of a full treatment menu, with an individualized approach to care, is critical to finding the best treatment options for your loved one.

2. How involved are the patient and family with the inpatient depression treatment program?

Effective treatment programs tend to be ones that actively engage the patient and family in the assessment, planning, and treatment process. Terms like “person-centered” and “family involvement” mean that a center understands the importance of including everyone in the process – not just the professionals.  Even though they are troubled, patients with depression can contribute to an understanding of their illness and are better motivate if they are actively involved in treatment.  Family members can learn ways to better support a loved one coping with a depressive disorder, and they can also benefit from support for their own concerns and frustrations.

3.  What are the depression treatment center staff qualifications?

A professional’s best treatment tools come from a combination of training and experience.  Check the credentials of professional staff on your loved one’s treatment team.  Generally, you should look for clinical staff to have licensure in a professional field such as psychiatry, psychology, social work, marriage and family therapy, or counseling.

4.  What types of counseling and therapy for depression are provided?

When most lay people think about psychology, the first name that comes to mind is Sigmund Freud.  While he may have been a pioneer in the treatment of mental disorders, counseling and therapy have come a long way in the past century.  Many counseling techniques developed in the last few decades are designed to work with the negative feelings and self-defeating individuals with depression often have. Current therapeutic approaches considered the most effective with depression include:

  • Cognitive behavioral therapy (CBT);
  • Dialectical behavioral therapy (DBT);
  • Insight oriented therapy (IOT).

Beware of any provider that considers medication to be the sole method for treating a loved one’s depression. While modern antidepressants can have a very beneficial effect upon resistant depression, treatment should usually include other modalities such as counseling, training, or peer supports.

5.  What is the inpatient depression treatment program’s overall treatment philosophy?

A treatment center should have a clear philosophy about appropriate treatment. In discussing a program’s treatment approach, listen for terms such as the following:

  • Person-centered or patient-centered planning and care (see above);
  • Family involvement (see above);
  • Symptom management – provides patients with tools to help manage their own feelings and behaviors;
  • Least restrictive environment – provides the least intensive level of treatment necessary, while respecting the patient’s freedom;
  • Wellness and recovery – focuses on a total wellness approach to healthy living and a belief that recovery is possible.

Getting the right answers to the above questions can be a productive step in setting your own loved one on a journey to recovery.

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Women appear to be particularly vulnerable to depression during the perimenopause years and in the years immediately after menopause. An estimated 8 – 15% of all women experience menopausal depression symptoms.  Unfortunately, problems are often misdiagnosed, because many menopausal depression symptoms mimic those of normal menopause. The causes of menopausal depression are mostly tied to estrogen levels. Symptom management tends to be the focus of menopausal depression treatment and can include hormone replacement, antidepressants and psychotherapy.

Menopausal Depression Symptoms

Increased fatigue, appetite and sleep disturbance, difficulty concentrating, and increased irritability are symptoms of both clinical depression and peri-menopause (the 8-10 years prior to full menopause) or menopause.

Extended periods of sadness or melancholy, accompanied by feelings of hopelessness or helplessness, call for medical intervention, as clinical depression may be present.  Untreated, depression can lead to a host of emotional and physical problems, and, in extreme cases, even suicide. Several recent studies point to an increased risk of depression in menopausal women, even those without any history of the disorder.  One study, published in the Archives of General Psychiatry, found that women were four times more likely to develop depressive symptoms in peri-menopause than prior to its onset.

Causes of Menopausal Depression

The most frequent culprit in the development of women’s midlife depression is the significant drop in estrogen levels that accompanies the onset of menopause.   Emotional changes associated with low estrogen levels include depression, anxiety, and increased irritability. With the loss of estrogen, other hormones and neurochemicals become imbalanced as well.  In particular, those affecting stress and mood, such as cortisol and serotonin, may be disrupted.  Low serotonin levels are frequently associated with the development of depression.

The stress caused by other menopausal symptoms can also contribute to feelings of depression.  Insomnia, night sweats, mood swings – symptoms such as these can make the most emotionally balanced person feel out of kilter.  An individual who is biologically more prone to depression may find such menopausal symptoms to be a trigger for a depressive episode.

Finally, age-related stressful life changes and events may coincide with menopause, such as the loss of fertility, “empty nest” syndrome, occupational changes, parental care giving, and marital strife.  These stressors may contribute to feelings of depression.

Women more likely to suffer menopausal depression include those with a history of depression and those who experience a surgical menopause, due to the sudden loss of estrogen.

Menopausal Depression Treatment

Menopausal depression can be treated successfully, with significant symptom management. The most common form of treatment is hormone replacement therapy.  Often used to manage menopausal symptoms such as hot flashes, estrogen therapy has also been found to reduce depressive symptoms. A study reported in the American Journal of Obstetrics and Gynecology found that 80% of menopausal women reported positive mood changes as the result of oral estrogen doses.

Antidepressants can also provide benefit to women with menopausal depression.  Those which help the body raise its serotonin levels are particularly effective.

Psychotherapy has also been found to be an effective treatment method. Trained professionals can assist individuals in learning how to re-frame negative thoughts and reduce stress levels.

A focus on appropriate self-care is helpful for any woman facing menopause. Many symptoms can be managed through practicing such strategies as vigorous physical activity, stress management exercises, good sleep habits, and healthy eating.

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

 

 

 

 

 

 

 

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

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

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

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

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

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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.

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

 

 

 

 

 

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

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

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

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

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

Issue: What if I need this later?

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

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

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

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

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

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

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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. The type of testing that is done depends on the individual’s functioning and the setting in which testing may be pursued.

The Purpose of 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.

The Purpose of Psychological Assessment in a Outpatient Setting

Others may seek testing from a clinical psychologist in a clinical outpatient setting, and this can be pursued on their own or they may be referred from another clinician (such as a primary care physician or psychiatrist). In this type of evaluation, 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). Testing in this type of evaluation is designed with the referral question in mind; 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.

The Uses of 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 so as 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.

The Purpose of 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.

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.

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By Nicole Mori, RN, MSN, APRN-BC, Psychiatric Mental Health Curse Practitioner, Lindner Center of HOPE

Bipolar disorder (BD) is a complex, chronic, progressive and ranks among the leading causes of disability worldwide.  The underlying feature of BPD is mood instability, with alternation of manic/hypomanic and depressive episodes and, commonly, significant subsyndromal symptoms between distinct mood episodes.  Depressive episodes (and residual depressive symptoms in times of remission) are responsible for much of the disability, suicidal behaviors, and exacerbation of comorbid conditions in BD.  Although depression is the predominant presentation and the leading cause of morbidity in BD, it is poorly understood, and the treatment options are limited.  Inadequate treatment of bipolar depression leads to residual symptoms which may drive relapse.  Effective treatment is of great importance, but it depends on accurate diagnosis and appropriate pharmacotherapy.  However, barriers to prompt diagnosis and treatment persist.

Research data suggest that BD is not uncommon among patients with a diagnosis of depression.  In a primary care clinic, 21% of patients screened positive for BD and among these, 2/3 had not received a diagnosis of BD before.  The frequency of BD is believed to be even higher among patients receiving specialty psychiatric care.  In a NIMH study which followed clinical course for at least a year, 25% of participants initially diagnosed with MDD experienced a manic/hypomanic episode which led to a revision in diagnosis to BPD.  These findings suggest that figures may be underestimating true prevalence of BD in the population.  Differentiating between unipolar and bipolar depression is difficult for both primary care and psychiatric providers.  There are no substantial differences in the presentation of depressive episodes between individuals with bipolar disorder and those with unipolar depression.  Misdiagnosis is common due to lack of thorough screening and comprehensive evaluation and history to rule out BD in patients presenting with depression.

Misdiagnosis is a significant barrier to recovery because response to treatment and clinical course largely depends on the selection of appropriate pharmacotherapy that addresses the mood instability underlying bipolar depression.  Antidepressant therapy- in the absence of mood stabilizing medication- has not demonstrated efficacy in bipolar depression.  Current treatment guidelines recommend antidepressant use only as an adjunct to mood stabilizing agents.  In general, data show that antidepressants are not particularly effective in bipolar depression (either as single or adjunctive therapy) and there are safety concerns for cycle acceleration and induction of mania among some patients.  In addition, initiation of ineffective treatments can prolong the time the patient is symptomatic, with impaired function and lower quality of life.

The diagnosis of BD in depressed patients presents unique challenges to healthcare providers.  The depressive phase of bipolar disorder presents many similarities with unipolar depression, and the correct diagnosis can only be made after careful screening and history.  Although there are several validated instruments to diagnose major depressive episodes, the options available to primary care providers remain limited.  The Mood Disorder Questionnaire (MDQ) is a screening questionnaire that can be used in combination with a thorough history, can improve the chances of identifying individuals with BD if used in combination with a through history.  Clinicians should be alert to features suggestive of underlying bipolar disorder such as the presence of subthreshold hypomanic symptoms, a history of multiple failed antidepressant trials, symptoms of ADHD, or comorbid substance abuse (particularly when early in onset).  Validating information from the patients’ family members can aid in accurate diagnosis.

Depressed patients with BD have significant unmet needs.  Residual morbidity and symptoms are quite common, even among treated patients. The treatment of BD often requires complex pharmacotherapeutic regimens.  Most effective mood stabilizing medications are associated with challenging adverse events, which limits their tolerability and requires watchful monitoring.  In addition to the burden of adverse events, patients with BD can experience loss of response or depressive symptoms that fail to improve after multiple medication trials.  Additional medication options are needed.  Research for novel pharmacotherapies should focus on developing potential, better-tolerated treatments for Bipolar depression.

Sources

McIntyre RS, Calabrese JR. Bipolar depression: the clinical characteristics and unmet needs of a complex disorder. Curr Med Res Opin. 2019 Nov;35(11):1993-2005. doi: 10.1080/03007995.2019.1636017. Epub 2019 Aug 5. PMID: 31311335.

Stiles BM, Fish AF, Vandermause R, Malik AM. The Compelling and Persistent Problem of Bipolar Disorder Disguised as Major Depression Disorder: An Integrative Review [Formula: see text]. J Am Psychiatr Nurses Assoc. 2018 Sep/Oct;24(5):415-425. doi: 10.1177/1078390318784360. Epub 2018 Jun 28. PMID: 29952230.

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Elizabeth Mariutto, PsyD, CEDS

 

 

 

 

When the average person is asked to describe eating disorders, body image concerns are one of the most identified symptoms.  However, not everyone with an eating disorder struggles with body image.  Those with Avoidant and Restrictive Food Intake Disorder (ARFID) avoid or restrict certain foods, but do not do so out of fear of weight gain, desire to lose weight, or body dissatisfaction. Instead, those with ARFID limit their eating based on sensory features of the food, fear of something bad happening when one eats, or a lack of interest in eating (Thomas & Eddy, 2019).

However, ARFID is more than picky eating. Those with ARFID are highly selective in what they eat, and this selectivity leads to some type of impairment in their lives (American Psychiatric Association, 2013). Children or teenagers may not grow as expected, leading to pediatricians being concerned that they have not followed the typical growth curve that had been evidenced earlier in their lives. Those with ARFID may lose a significant amount of weight unintentionally. Others end up needing to rely on oral supplements or nasogastric tube feedings to get in sufficient energy, and those with ARFID may display nutritional deficiencies.  Additionally, many with ARFID struggle socially (American Psychiatric Association, 2013). Many get-togethers, holidays, and celebrations with family and friends revolve around food, which can be anxiety and shame-inducing for those that eat more selectively, often leading to avoidance of such social gatherings and consequently, problems in relationships.

The same factors that lead to the onset of ARFID are worsened by its symptoms, which creates a cyclical pattern. Those who develop ARFID may experience more intense sensory experiences (Thomas & Eddy, 2019). They may be more sensitive to textures and/or may be a “supertaster” and pick up on more subtle variations of flavor than others. However, eating the same few foods repeatedly can lead to sensory-specific satiety, leading to those few foods becoming more aversive with time. Furthermore, if nutritional deficiencies develop, the taste of new foods can be altered, thus leaving someone to feel they have very few tolerable options. Others with ARFID may start out simply not having much interest in eating. When they eat less as a natural result, their fullness cues start kicking in prematurely and hunger cues dissipate, leading to eating even less.  Lastly, those who develop ARFID after having some type of aversive experience around food (i.e., choking) start to avoid the food that led to the negative experience hoping to avoid the same event. This expands into avoidance of similar foods as well.  The avoidance of these foods reinforces the fear, as these individuals do not have recent fear-countering experiences to teach them that they can safely consume these foods. Avoidance leads to increased anxiety, making the fear more entrenched.

ARFID treatment approaches resemble those for other forms of eating disorders but may include some modifications that more closely resemble the exposure treatment that is often used for obsessive compulsive disorder and anxiety disorders.  A treatment provider will likely do a thorough evaluation and case formulation of what factors need addressed in treatment.  First and foremost, patients may require medical stabilization to manage any of the acute health concerns that have risen with malnutrition.  Second, to prevent further medical problems from occurring and to begin the process of nutritional stabilization, clients often need to increase the overall volume of food.

There has not been much research on treatment for ARFID, although a modified version of cognitive behavioral therapy, CBT-AR, is being researched for ARFID and is showing promise (Thomas et al., 2020; Thomas et al., 2021). CBT-AR pulls from existing eating disorder, obsessive compulsive disorder, and anxiety disorder treatments and extensively educates the patient on how the disorder develops and is maintained, nutritional deficiencies and the importance of volume and variety, then gradually helps patients expose themselves to the foods that they have been avoiding (Thomas & Eddy, 2019).  Furthermore, Family-Based Treatment, which is a front-line treatment for adolescents with eating disorders, has been recently modified to address ARFID more specifically, also showing promising results (Lock, Sadeh-Sharvit, & L’Insalata, 2019). This treatment, which addresses the eating behaviors directly and conveys the seriousness of the eating disorder, empowers parents to refeed their child, takes a non-blaming approach to the illness, and helps parents and patients separate the illness from their identity (Lock et al., 2018).

Getting professional support can help patients with ARFID improve medically, nutritionally, psychologically, and socially. While therapists can provide support and teach specific techniques, the patient ultimately has a significant say into what foods to incorporate, when, and how.  With persistence, those with ARFID can eat with much greater variety and flexibility.

References

American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Publishing, Inc.

Lock. J., Robinson, A., Sadeh-Sharvit, S., Rosania, K., Osipov, L et al. (2018). Applying family-based treatment (FBT) to three clinical presentations of avoidant/restrictive food intake disorder: Similarities and differences from FBT for anorexia nervosa. International Journal of Eating Disorders, 52, 439-446. doi: 10.1002/eat.22994

Lock, J., Sadeh-Sharvit, S., L’Insalata, A. (2019). Feasibility of conducting a randomized clinical trial using family-based treatment for avoidant/restrictive food intake disorder. International Journal of Eating Disorders, 52, 6, 746-751. doi: 10.1002/eat.23077

Thomas, J. J., Becker, K. R., Kuhnle, M. C., Jo, J. H., Harshman, S. G. et al (2020). Cognitive-behavioral therapy for avoidant/restrictive food intake disorder (CBT-AR): Feasibility, acceptability, and proof-of-concept for children and adolescents. International Journal of Eating Disorders, 53, 10, 1636-1646. doi: 10.1002/eat.23355

Thomas, J. J., Becker, K. R., Breithaupt, L., Burton Murray, H., Jo, J. H., et al. (2021). Cognitive-behavioral therapy for adults with avoidant/restrictive food intake disorder. Journal of Behavioral and Cognitive Therapy, 31, 1, 47-55. doi: 10.1016/j.jbct.2020.10.004

Thomas, J. J., & Eddy, K. T. (2019). Cognitive-Behavioral Therapy for Avoidant/Restrictive Food Intake Disorder: Children, Adolescents, and Adults. Cambridge: University Printing House.