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By Tracy S. Cummings, MD, Associate Chief Medical Officer for Clinical Excellence and Chief of Child and Adolescent Psychiatry, Lindner Center of HOPE

Medical school was an intense experience filled with mass information consumption regarding physiological health, followed by residency and fellowship focused on mental health care amounting to nine years of training to be a Child & Adolescent Psychiatrist. So much knowledge was amassed over those years, and what topic do I find myself talking about most nearly each day at work? The use of electronics (phone, tablet, computer) by teens. Now, the irony is not lost on me that most readers will be viewing this article online. Ever-present digital media is a reality in our society, and the complicated relationship with it in our lives has become clearer in recent years. Particularly, concerns regarding the impact of the use of electronics on the lives of young people with developing brains have been raised in the literature, by treatment providers, in schools, by families, and even by teens themselves. According to a 2019 Pew Research Center report, “nearly all US teens (95%) say they have access to a smartphone, and 45% say they are ‘almost constantly’ on the internet”. Taking the good with the bad, the need to recharge the proverbial battery in our youth has never been so necessary.

A 2020 estimate by the American Academy of Child and Adolescent Psychiatry noted 4-6 hours/day of screen time for 8-12-year-olds in the US and around 9 hours/day for teens. With a traditional school day lasting 7 hours, it seems the electronics are winning out on capturing the attention of our adolescents. While not all use is problematic, several studies have found associations between the amount of time spent online (and the number of social media platforms utilized) with symptoms of depression, anxiety, obesity, headaches, musculoskeletal pain, decreased levels of physical activity, and problems with sleep (delayed bedtime and/or decreased total sleep time). A growing number of teens sleep with the phone next to them and feel the need to check it multiple times a night with a sense of urgency to respond to any and all notifications immediately. It is striking how many families will report their child has sleep issues leading to irritability and trouble focusing, but often no type of boundary or limitation on phone use, particularly at night, exists. Nomophobia continues to rise globally (and this pertains to adults and youth alike).

Most tweens/teens use their devices to pass the time, and it has become the preferred method for many to interact with their peers. As fewer households have landlines, caregivers like the idea of their child being able to reach them if needed, therefore the age at which a child is receiving their own smartphone has decreased, with approximately 20% of 8-year-olds now having one. Considering the plethora of items one can stumble upon online, even as an adult, the use of the internet by children and adolescents carries significant risk. Frequently, caregivers are unaware of the viewing history on the device, and there is always the potential for exposure to violence, sexual content, substance use, cyberbullying, predators, diet culture, negative stereotypes, and misinformation.

Similar to other household rules, phone/electronic use needs to have parameters. As families consider how phone/internet use will be consumed in their homes, an AACAP Fact For Families Guideline on Screen Time suggests the following:

• For ages 6 and older, encourage healthy habits and limit activities that include screens
• Turn off all screens during family meals and outings
• Learn about and use parental controls
• Turn off screens and remove them from bedrooms 30-60min before bedtime

Healthy screen habits will need to include discussions about what is appropriate to view and share. Kids need to be taught about privacy and safety. Honest discussions about family expectations regarding accounts, passwords, and data usage is helpful (though not always liked by the teen). Looking up information and gaming together are ways to ensure valid resources and monitoring while online. The ability to use the electronic device as a tool to learn new things and connect positively with others can be encouraged and should ideally be modeled by the adults in the home. Consistency with setting this good example will establish a healthy foundation in the youth while holding the adult accountable at the same time. The Business Insider quotes analyst Ben Bajarin’s data about how iPhone users unlock their phones on average 80 times/day. For comparison, adults laugh about 15 times/day. This might be a good time for families to consider which one of those activities would bring us more joy so we can recharge together.

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

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

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

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

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

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

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

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

-Your child begins to misbehave at school.

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

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

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

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

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

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

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

References:

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

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

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

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

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

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By: Angela Couch, RN, MSN, PMHNP-BC,
Psychiatric Nurse Practitioner

The research is in, and it’s clear. Exercise can help with depression, anxiety and cognitive decline, not to mention the physical benefits which we are all probably familiar with already. Physical inactivity can also be a risk factor for depression and anxiety.

What are the ways exercise can benefit us?

  1. Increases our energy and motivation levels
  2. Releases “feel good” endorphins, and endogenous cannabinoids that enhance our sense of well-being
  3. Reduces the inflammatory activities of immune cells that can harm us
  4. Has positive impacts on brain derived neurotrophic factor (BDNF) which can increase the growth of new neurons (cells) in the brain
  5. Enhances the ability to fall asleep and stay asleep
  6. Improves self-esteem
  7. In the immediate time frame, exercise helps reduce feelings of anxiety, drops our blood pressure, enhances alertness, and can help break the cycle of negative thoughts
  8. With time, exercise reduces feelings of depression, increases motivation, and helps with executive functioning
  9. With time, it reduces the risk of mild cognitive impairment and dementia in older adults

But lifestyle changes are hard to begin with, right?  How do I do it when I’m feeling depressed or anxious, or otherwise unmotivated?

  1. Don’t wait to have the motivation. We can always find an excuse to do it another day, or wait for the “right” time when we feel “better”, and hours can become days, days can become weeks, you get the picture.  However, choosing to do it now is choosing to do something that might make us feel better. “I’ll go for a walk now to help me feel better” instead of “I’ll go for a walk when I feel better.” Motivation levels increase when we’re in a good routine of activity.
  2. Start small, and set reasonable goals. If the idea of “exercise” is too intimidating or unpleasant to consider, shoot for increasing physical activity to start.  Just getting off the couch and moving around is a great start.  Physical activity can include working in the yard or garden for a few minutes, doing some stretching, parking further away from the grocery or the office, vacuuming the house, or walking to the end of the street and back. Don’t think of exercise as another chore on the to-do list, but as a wellness activity and part of treatment.
  3. Make it easier. Set the time, date, and activity on the calendar.  Lay your clothing out the night before, or sleep in it when you’re shooting for activity first thing in the morning.  Set your sneakers by the door.  If you need help getting out of bed for a morning workout, set the alarm on the other side of the room so you cannot lay in bed and hit the snooze button.  If mornings aren’t your thing, choose the time of day when you feel the most energy, or tend to be in the brightest mood, for getting started.
  4. Use an app or a video if you’re not sure what to do, don’t want to pay for a gym membership, or don’t particularly want to be around people. You can get lots of ideas for things you can do at home, if the gym is not your thing, by looking on Pinterest, YouTube, or the internet.  There are often options for mild, short workouts for beginners available.  Make sure to start slow, don’t do anything that causes pain, make the duration short to start, and don’t expect to master the move right away. Consult with your primary care provider, especially if you have some physical limitations or challenges.
  5. Find activities you know you’ll enjoy, or try new things. We’re much more likely to follow through on activities we enjoy. If walking on a treadmill in the basement seems boring, go for a walk or bike ride outside, or hit the local mall and “window shop” while you walk. Take the dog to the local dog park with a tennis ball for play time.  Listen to fun music, or an interesting pod cast, to make the activity more enjoyable.
  6. Enlist help. Work with your therapist or provider to come up with a viable plan to get you moving.  Set up physical activities or exercise to do with a friend,  to make it more enjoyable and  increase the likelihood of follow through. Signing up for a fitness class, or for sessions with a personal trainer, may increase the likelihood of follow through because of sense of accountability.
  7. Be kind to yourself. Reward yourself sometimes for doing the hard thing. Track your victories, even ones you feel are small, and review them when you’re feeling low or discouraged.  Allow yourself to take a break when you need to.

Exercise and physical activity are two tools we can use to help improve our well-being, which can be cost-effective and don’t require a prescription.

Toups, M., Carmody, T., Greer, T., Rethorst, C., Grannemann, B., & Trivedi, M. H. (2017). Exercise is an effective treatment for positive valence symptoms in major depression. Journal of affective disorders, 209, 188–194. https://doi.org/10.1016/j.jad.2016.08.058

Kandola A, Vancampfort D, Herring M, et al. Moving to Beat Anxiety: Epidemiology and Therapeutic Issues with Physical Activity for Anxiety. Curr Psychiatry Rep. 2018;20(8):63. Published 2018 Jul 24. doi:10.1007/s11920-018-0923-x

Stubbs B, Vancampfort D, Rosenbaum S, Firth J, Cosco T, Veronese N, Salum GA, Schuch FB. An examination of the anxiolytic effects of exercise for people with anxiety and stress-related disorders: A meta-analysis. Psychiatry Res. 2017 Mar;249:102-108. doi: 10.1016/j.psychres.2016.12.020. Epub 2017 Jan 6. PMID: 28088704.

Cooney GM, Dwan K, Greig CA, et al. Exercise for depression. Cochrane Database Syst Rev. 2013;(9):CD004366. Published 2013 Sep 12. doi:10.1002/14651858.CD004366.pub6

Tan ZS, Spartano NL, Beiser AS, et al. Physical Activity, Brain Volume, and Dementia Risk: The Framingham Study. J Gerontol A Biol Sci Med Sci. 2017;72(6):789-795. doi:10.1093/gerona/glw130

Nuzum H, Stickel A, Corona M, Zeller M, Melrose RJ, Wilkins SS. Potential Benefits of Physical Activity in MCI and Dementia. Behav Neurol. 2020;2020:7807856. Published 2020 Feb 12. doi:10.1155/2020/7807856

Physical Activity Guidelines for Americans, 2nd edition | 2018 U.S. Department of Health and Human Services

 

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By: Jen Milau, APRN, PMHNP-BC

When I started my career as a nurse practitioner in 2017, I couldn’t have guessed that I’d end up where I am today – a psychiatric provider treating children, adolescents, and adults with a largely misunderstood and relatively controversial diagnosis that causes severe neuropsychiatric symptoms due to a misdirected immune response.

Pediatric Acute-Onset Neuropsychiatric Syndrome (PANS), considered by expert consortiums to be a type of Autoimmune Encephalitis (AE), is characterized by a dramatic onset of severe obsessive-compulsive symptoms or food restriction that presents along with two or more of the following which cause impairment to functioning:

  • Behavioral/developmental regression (immature play, “baby talk,” afraid of the dark, wanting to sleep in parents’ bed, etc)
  • Abnormal movements such as tics, jerking/involuntary muscle spasms, stereotyped movements
  • Severe mood swings and depression
  • Out of character rage, aggression, tantrums with or without self-injurious behavior or suicidal/homicidal ideation or gestures
  • Changes to executive functioning (poor memory, impaired concentration/focus, slowed processing speed)
  • Separation anxiety and panic attacks
  • Psychosis
  • Sensory amplification (aversion to certain textures, sensitivity to noise, lights, or repetitive sounds)
  • Insomnia or other sleep disturbance (nightmares/night terrors)
  • Changes to fine motor skills or muscle strength (for example, difficulty opening doors, using utensils or holding a pencil; changes to handwriting or drawing abilities)
  • Urinary changes (bedwetting, daytime accidents, urgency/frequency of urination)

So what causes this?

While originally believed to be an unusual response to a Group A Strep infection (Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcus, or PANDAS), we now understand that in susceptible individuals, PANS can be triggered by anything that activates the immune response – this can include infection, allergies, certain cancers, inflammatory conditions or injuries, and exposure to toxins. Like other autoimmune diseases, PANS occurs when the immune system mistakes our own cells and healthy tissue as foreign pathogens that need to be eradicated. More commonly-identified autoimmune diseases, such as rheumatoid arthritis, lupus, hashimoto’s thyroiditis, etc., present with primary physical symptoms that are associated with the type of cell that is mistakenly targeted by the inflammatory response. In the case of PANS/Autoimmune Encephalitis, however, it’s healthy tissue in certain areas of the brain that is the target of this autoimmune attack – the result being the array of severe neuropsychiatric symptoms described above.

Interestingly, since the start of the COVID19 pandemic, PANS/AE clinicians across the country have seen a significant increase in cases. In some instances, this is clearly related to infection with the COVID19 virus, itself; however, often the trigger is not straightforward, and while many theories currently center around the impact of extreme stress (which subsequently can increase inflammation and suppress the immune response which elevates the risk of reactivation of latent infection or acquiring illness from exposure), the overall etiology is not clear.

How is it diagnosed & treated?

PANS symptoms exist on a spectrum of severity that impacts the approach to a diagnostic work-up and treatment recommendations. For individuals with mild to moderate symptoms who are otherwise functioning fairly well overall, I often recommend “traditional” psychiatric treatment with the appropriate psychotherapy interventions along with low-dose medications to target their psychiatric symptoms, with the plan to keep PANS on my differential should their presentation abruptly change in the future.

Typically, however, the patients that I see have a much more severe and impairing set of neurological and psychiatric symptoms that warrants a diagnostic assessment to look for underlying infectious, inflammatory, or immunological abnormalities that might be impacting their clinical presentation. This typically consists of blood work and urine studies though can sometimes include imaging when clinically indicated. In rare and severe cases, a lumbar puncture might be considered. Collaboration with clinicians in other specialty areas such as immunology, rheumatology, and neurology, is necessary in more complex case presentations.

In general, the treatment of PANS entails a three-pronged approach:

  • Initiate appropriate psychiatric interventions including psychotherapy and medications to target specific symptoms (SSRIs/SNRIs, Non-stimulant ADHD medication, Antipsychotics).
  • Treat any underlying infection with appropriate antimicrobial medication, keeping in mind the importance of balancing this with pre/probiotics to ensure that gut flora is adequately maintained during therapy.
  • Treat immune system dysregulation with anti-inflammatory medication and/or immunomodulatory therapy if indicated.

Once someone has gotten through the most severe part of their flare-up, we often transition to a “maintenance” phase of treatment which includes lifestyle and dietary changes along with selective use of supplements to support immune health and manage systemic inflammation. Psychiatric treatment is also maintained for as long as clinically indicated. These efforts, along with quick identification and treatment of signs/symptoms of future flare-ups, help to minimize the frequency/intensity of subsequent flares and can ultimately improve long-term prognosis.

What makes this such a controversial diagnosis?

Our understanding of PANS and other neuroinflammatory conditions is still somewhat in its infancy. This means that much of the existing literature is based on empirical evidence gathered by expert consensus groups and clinicians with experience in assessing, diagnosing, and treating this special patient population. As with any emerging field of science or medicine, new research and expanded awareness of the disease have led to modifications to the original diagnostic criteria and theories associated with PANS/PANDAS – however, these updates (namely, that PANS/AE may not present as “acute” onset, but rather, as sub-acute or insidious; not limited to pediatrics – can also occur in adolescence and adulthood) are largely underrecognized, and as a result, the condition is prematurely “ruled out” in individuals who otherwise meet criteria based on their clinical presentation.

The complex and variable presentation of symptoms and potential triggers associated with PANS leads many clinicians to refute the connection between infection/immune dysfunction and psychiatric symptoms. Unfortunately, when seeking care, families often face judgment and experience repeated invalidation when they attempt to bring up their concerns for possible PANS/AE, as individual providers and occasionally even entire organizations maintain a firm stance against the assessment/diagnosis and treatment of PANS/PANDAS as a whole.

Final thoughts and resources:

PANS/AE can be a significant source of suffering not only for the individual impacted by the illness, but the entire family who is involved with their care. It’s important to strengthen your own support systems and build in time for self-care when faced with a loved one’s intense cognitive and behavioral manifestations of the disease.

Regardless of the underlying etiology, psychiatric treatment with psychotherapy and appropriate medication management is imperative for individuals with this diagnosis.

Below are a few of my favorite resources for patients, families, and clinicians who want to learn more about PANS/PANDAS/AE:

https://pandasnetwork.org/

https://www.pandasppn.org/

https://aspire.care/

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OCD is a common disorder and affects 1 in 40 people, it is also the 3rd most common psychiatric condition. This disorder can be very tricky and tries to tell lies to keep people trapped in anxiety. Below are the 10 common tricks it tries to use to keep the anxiety lingering as well as how to combat them.

The most common trick is OCD trying to convince you that “this time it is not OCD.” It is important to educate patients how to spot the difference and it’s helpful to emphasize that OCD tends to feel like an emergency and needs to be attended to immediately. One way to treat this lie is to do the “public service announcement” test which is basically challenging the patient to call the radio and request to make a public service announcement to warn people about their fear (i.e., please inform everyone they should not wipe less than 20 times when going to the bathroom, it is not safe to do less than this). This strategy helps them test out their belief and helps them realize they need to accept uncertainty but increase willingness to bet that is OCD and not give in to the compulsion.

The second most common trick is that OCD convinces you that “only crazy, bad, dangerous people have these thoughts.” It is important to teach patients that the content of one’s thoughts is the maker of “crazy, bad, dangerous.” Also educating patients that everyone has intrusive thoughts and how we cannot control our thoughts helps normalize this.

The third most common trick is “if only I knew why I had these thoughts I could stop my OCD.” Many patients have found the why, but actually only have recovered once applying evidence-based CBT skills. Teaching patients that finding the why will not solve their OCD is important.

The fourth most common trick is thinking “you’ll never beat me (OCD), so don’t even bother trying.” Teaching patients that short-term comfort will only lead to worse OCD and more discomfort overall, but short-term discomfort will actually lead to a more free and comfortable life is important for this trick.

The fifth most common trick is to convince you that you must control your thoughts. Teaching patients it is impossible to control their thoughts will be helpful for beating this trick. The more you try to control them the worse they get. Having patients use meditation like leaves on a stream to allow them to practice observing their thoughts is helpful for this.

The sixth most common trick is trying to convince you that compulsions must be done perfectly. To combat this helping the patient complete the compulsions imperfectly is helpful, such as changing the language of compulsions, or changing the preferred hand to complete the compulsion.

The seventh most common trick is convincing you that rituals will help give you the comfort of certainty. This is a common trick and one that patients spend a lot of time trying to obtain. Teaching patients that there is never certainty in anything is key here. Helping the patient see all the ways they are able to tolerate uncertainty in other areas of their life is helpful: while driving, while eating, when going to bed, going to the grocery store, etc.

The eight most common trick is that you will feel better with reassurance. Helping them reduce reassurances is helpful here, which can be done by tracking reassurances and reducing them by 20% each day to week.

The ninth most common trick is thinking you have a great responsibility to keep everyone safe. One cool technique for this trick is to have patients actually try to make something happen to you by thinking “I hope you break leg tomorrow” or “I hope you get a flat tire on your way home.” This helps the patient see that they don’t actually have control over things.

Finally, the tenth most common trick is thinking” if you don’t do this ritual, something bad will happen to you or your family.” To combat this last trick it can be helpful to change the way you do the ritual as mentioned previously, and to also purposefully wish for bad things to happen, which directly targets the fear.

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The sympathetic nervous system (SNS) is responsible for our “fight, flight or freeze” response and has been essential to our survival since beginning of our existence. In the case of traumatic, threatening emotional, mental and physical experiences, this fear response can become altered.  Connection between the amygdala and hypothalamus causes change to the hypothalamic-pituitary-adrenal axis (HPA), increasing cortisol levels and increased HR, increase respiratory rate, hypervigilance, and sleep disturbance. There are several neural connections and neurotransmitters acting on the amygdala contributing to fear response, and medication management has its risks. In hopes to improve overall outcomes of patients, many people and practitioners have utilized complementary and alternative medicines (CAM).

Yoga is probably the most known and utilized form of CAM in the united states. Yoga has been practiced for thousands of years to heal both physical and mental ailments. Philosophically, Yoga is defined as “Union”, and often interpreted as “union to the divine within”. Union is achieved through pranayama- breathing and asanas- postures.  This ancient Eastern tradition has gained popularity due to the awareness of the mind-body-spirit, holistic approaches in America and Europe. There is now a fair scientific understanding and body of research validating its potential benefit as an integrative intervention.

There are several benefits to incorporating yoga that could benefit people with trauma. It is important to assess one’s state of stability prior to introducing yoga therapy. In yoga philosophy, the concept of krama means “in the correct order” and can reduce risk of additional pain and suffering caused by the treatment. Just as establishing a sense of safety prior to other trauma therapies is essential, it is also to do so with yoga.

Controlling the length of inhale and exhale and manipulating the diaphragm stimulates the Vagus nerve or CN X and parasympathetic response to “rest and digest”. This effectively promotes cardiac relaxation, decreases contractility in the atria and ventricles (less-so). Primarily, it reduces conduction speed through the atrioventricular node. CN X can lower cortisol levels via modulating the hypothalamic-pituitary-adrenal-axis. Which is thought to be hyperactive in people with trauma and stress disorders.

Vagal tone is the body’s ability to successfully respond to stress. One study, by a team in Boston University School of Medicine (Streeter et al, 2012), hypothesized that Yoga effected the autonomic nervous system to improve stress response in PTSD. Using ujjayi pranayama (form of resistance breathing popular in Hatha yoga)  they found “increased relaxation response and increased heart rate variability” thus resilience to effects of stressors It is well understood that yoga has a calming action on the nervous system and is valuable as an adjunct treatment for those with trauma and stress related disorders.

In yoga there are two major concepts that can have psychological benefit. Chitta is the inner processes and capacity of attention and focus inward; and samskaras- the storehouse of past actions, self-beliefs/messages. In yoga the use of asanas, pranayamaand meditative practice- one works towards awareness and letting go of these unhelpful attachments that are stuck in the mind and body. As we know in people who have survived trauma, emotional scars can be felt throughout the body and leave scars of psychological destruction. Yoga offers a loving message of positive, self-compassion and promotes a gentle, non-judgmental environment.  Letting go of negative self-beliefs has many benefits psychologically.

After a trauma, in my experience and in DSM V criteria, one’s self-perception of negativity as well as negative beliefs about the world can damage spirituality or connection to a power greater than oneself.  In yoga the common ending to a practice is to bow in honor and say “Namaste”. Which translates into “the Divine light within me sees, honors and respects the Divine light within you”. For those with trauma, believing there is light within them that can shine again, can be the key to transformational healing. Yoga is not a religion, and it does not promote worship of any deity, instead “God” is expressed as truth, light, love and energy that is flowing through the universe.  Religious and non-religious can benefit from the spiritual practice of Yoga.

Yoga has proven its place in the holistic approach to mental health treatment, and because the only requirement is to be able to breathe, it is accessible to anyone who can breathe.  It has been said about yoga, by a great teacher… the breath is a wonder drug! I hope you consider utilizing a yoga practice for yourself or recommending it to someone who could benefit.

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Christine Collins, MD, Lindner Center of Hope

By: Christine Collins, MD, Lindner Center of HOPE Addiction Psychiatrist

 

 

 

Legalization of cannabis is rapidly expanding across the world. To date, 17 states (and DC) in the US have legalized marijuana for all uses, and another 19 states have legalized it for medical purposes only. The media tends to portray cannabis and its constituents, as safe, natural items that have potential to provide benefit. As medical marijuana dispensaries and CBD stores seem to be popping up all over, it is important for us to recognize the impact of cannabis on mental health and how it may affect vulnerable populations, such as young people. Clinicians and patients alike should be aware of the current state of scientific evidence and possible risks posed by cannabis use.

Cannabis is a complex plant composed of hundreds of compounds including THC (9delta-tetrahydrocannabinol, the main psychoactive component) and CBD (cannabidiol, purported to offer many health benefits). There are currently several medications approved by the FDA that are cannabis-related: dronabinol and nabilone (synthetic THC containing meds used for chemotherapy-related nausea and for appetite/weight gain in HIV patients), and recently-approved Epidolex (cannabis derived which contains CBD used for the treatment of rare childhood seizure disorders, Dravet syndrome and Lennox-Gastaut syndrome). These were extensively studied and underwent the typical FDA process for approval as effective and safe medications for these purposes. Other uses of cannabis are largely unregulated.

Using “medical” marijuana varies by state and is a much different process from taking an FDA approved medication which has been rigorously studied. Since it is designated DEA schedule I by the federal government, large scale studies on cannabis have been limited in the US. The current scientific evidence on cannabis remains mostly observational data and animal studies, rather than the gold-standard randomized controlled trials in humans. There is an ongoing need for well-designed research in this area to better understand the possible therapeutic benefits and safety profile of cannabis and to differentiate the effects of its constituents. Current evidence suggests that cannabis may help chronic pain, nerve pain, and spasticity in certain patients. There is limited and inconsistent evidence that CBD in particular may have benefit in treatment-resistant anxiety, social anxiety, and insomnia. However, other studies show that whole-plant cannabis worsens existing anxiety and mood. Notably, there IS consistent evidence that cannabis increases the risk for developing a psychotic disorder in vulnerable individuals and exacerbates psychotic symptoms. Cannabis use in anyone with a history of an addictive disorder may trigger another cross addiction or contribute to someone falling back to an old addiction.

Safety considerations must be taken into account regarding cannabis. Today’s whole-plant cannabis is generally more potent (higher levels of THC) than it was historically. How it is consumed also plays an important role—vaping allows for a higher percentage of THC to be absorbed quicker and therefore may be more likely to trigger adverse mental health reactions such as anxiety and paranoia. Edibles can cause problems for users who expect a quicker onset of action leading to higher levels of consumption to achieve a desired effect. Interactions with other medications do occur. For instance, certain psychiatric meds may alter the breakdown and elimination of THC and CBD, and vice versa.

What may be the area of greatest concern is the impact of increasing cannabis acceptance and legalization on young people. A recent study demonstrated that earlier use of all substances including cannabis was associated with increased risk for developing a substance use disorder later in life.  Cannabis use has been shown to have adverse effects on IQ and executive functioning. Moreover, younger onset of marijuana use is associated with lower overall neurocognitive functioning. Youth who engage in marijuana use, also report taking part in other risky behaviors such as using other substances like nicotine and alcohol, and driving after marijuana use. As such, there is grave concern that cannabis use in this age group could lead to significant problems.

While ongoing high-quality research is needed in this area, current available evidence does NOT show consistent benefit for cannabis (including CBD products) on mental health symptoms and it may instead exacerbate symptoms. Patients should be encouraged to use caution and to have open conversations with their mental health and medical providers about cannabis use in order to understand how this may impact their mental health. Clinicians should be aware of the risks of cannabis use particularly for adolescents and should help prevent use in this specific population.

Sources:

Dharmapuri, S, Miller, K, & Klein, JD. Marijuana and the pediatric population. Pediatrics. 2020; 146(2)279-289

Hill, K. Medical marijuana for treatment of chronic pain and other medical and psychiatric problems, a clinical review. JAMA. 2015; 313(24) 2474-2482

Levinsohn, E & Hill, K. Clinical uses of cannabis and cannabinoids in the United States. Journal of the Neurological Sciences. 2020; 116717

Whiting et al. Cannabinoids for medical use: A systematic review and meta-analysis. JAMA. 2015; 313(24) 2456-2473

 

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Jennifer L. Farley, PsyD
Lindner Center of HOPE, Associate Chief of Psychological Services

Congratulations! Your child graduated from high school!  And now…   what?

Many are busy selecting their fall semester college courses and buying necessities for their dorm room. Others have chosen to delay college and work instead, using time to consider their future. Some opted to focus on a career trade and are doing apprenticeship work. No matter their course, these newly-minted adults can now do 3 main things in America: vote, go to jail for their own actions, and enter into contracts on their own accord.  Yet, there are some contracts for which 18-year-olds are too young, and many lack the financial independence many contracts require. Bottom line: young adults still need support. But things are different, they’re high school graduates now. And most still live at home, at least for a little while.

The length of time it takes for one’s emancipation from home is entirely dependent on the path they’ve chosen and their success with it. For college students, the biggest first leap is when they move into their college dorm. It’s their first space outside of home to call their own.  Yet, the college dorm is still a contained bubble, where rules still dictate what’s expected and complete freedom is not given. Even dorms typically shut down during extended or holiday breaks. Freshman year represents the first of a graduated series of “bubble” expansions, when by their 3rd or 4th year, students have learned how to cook some of their own meals (instead of relying on cafeteria meal plans), they have to navigate roommate tensions without the aid of a dorm resident advisor, and they’ve (hopefully) learned to be self-disciplined and self-accountable. Most college students aren’t fully emancipated from their parents until they function completely independently on their own – when they get a job and make enough money to support themselves. That stage doesn’t mean “without support” of parents, it’s just that the adult child no longer requires parents’ resources to live on their own. For any young adult, this takes time:  time to get a job, time invested in working, and time spent saving money.

Even among the healthiest of families, any young adult’s process of emancipating from home comes with tension. This is par for the course… it’s how young adults develop self-confidence and gumption.  Without “tests” involving interactions with family, without the development of gumption, young adults risk a poor transition into their independent years. Imagine going away to college, working a full-time job, or moving out feeling insecure about yourself, not being able to trust that you can assert yourself or make good decisions. Without gumption, one may be so comfortable at home that they don’t seek more independence. Gumption fuels self-decision-making and serves as a foundation towards independence. Gumption often brings tension, and tension is experienced before big changes or transitions. The changes involved with emancipation are experienced by young adults and their families, alike.

During the months leading up to one’s emancipation from home, tension is often experienced in waves. Parents, realizing the borrowed time they have with their child, may seek more time to spend together with their child. Other times, parents may engage in more activities without their child to prepare themselves for their child to leave home. Adult children do a similar dance; sometimes they may seek their parents in anticipation of being away from them, while much of the time they want to spend time with friends. You can imagine the conflicts that arise when an adult child wants freedom with friends during a time when parents seek quality time with their child. This is all natural, it’s just a matter of recognizing and understanding it. Time spent together can involve some creativity with lessons in laundry, basic cooking, and how to manage money – while times of tension make it easier for everyone to prepare to say “goodbye” and to face the changes ahead.

No matter the transition ahead, practice the cycle of a “submarine parent” – stay offshore, come up for air sometimes to check in with your young adult child, and retreat back down in the water when you see your child is doing just fine.

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The role of the circadian system in obesity and disordered eating

By Nicole Mori Psychiatric Mental Health Nurse Practitioner

The circadian system is the body’s endogenous timekeeper, a network of hierarchically-organized structures (“clocks” or “oscillators”) in nucleated cells, which regulates a variety of biological processes (including the cell cycle, metabolism, growth, development and sleep/activity cycles) by generating outputs in a rhythmical manner. The suprachiasmatic nucleus (SCN) in the hypothalamus acts as the “master” pacemaker by generating periodic outputs targeting clocks in peripheral cells. The endogenous SCN period is greater than 24 hours, but it resets every day in response to environmental signals.  The main  synchronizer for the SCN is the periodical light/dark signal over the course of 24 hours.  Additional environmental synchronizers include feeding and social activity.  The circadian system enables  organisms to adapt to environmental changes and optimize function, playing a central role in the maintenance of health and illness.  Research has linked circadian dysregulation to a variety of disorders including cancer, cardiovascular disease, metabolic abnormalities and obesity in humans and animals.

Recent studies support the role of circadian dysfunction in the development and maintenance of obesity.  Circadian misalignment can manifest as metabolic abnormalities, sleep disturbances, delayed sleep phase (evening preference), abnormalities in daily rest/activity rhythms and disordered eating patterns. Both endogenous (e.g., genetic) and exogenous factors are involved in circadian dysfunction. External factors include decreased sleep duration, jet lag, frequent snacking and nighttime eating and exposure to bright light. Epidemiological data show shift work is an independent risk factor for obesity and increased metabolic risk. Decreased sleep duration is associated with increased risk for obesity and metabolic disease. Among children, sleep loss is associated with the development of obesity and is a predictor of lifelong obesity. The increasing prevalence of obesity in recent decades has coincided with trends such as shortened sleep duration, light pollution, increased nighttime exposure to bright light and increasing shift work.

Sleep pattern changes affect appetite and eating behaviors and vice versa. Sleep restriction has been associated with changes in circadian hormonal patterns, which result in increased appetite, hunger and food choices such as increased preference for sweets.  In turn, alterations in eating patterns have a dysregulating effect on the circadian system. For instance, overeating has been associated with decreased sleep duration, high dietary fat and carbohydrate intake with decreased short wave sleep and high increased nighttime arousal respectively.

The timing of food consumption plays an important role in metabolism and body weight. Nighttime eating leads to increased insulin resistance and worsened glucose tolerance and lipid levels than meals consumed during the daytime. Among bariatric patients, eating late in the day has been associated with less post-operative weight loss.  In addition, irregular eating patterns are associated with abnormal weight gain, increased binge eating and greater eating disorder severity. Conversely, appropriate timing of eating and regularization of meal times appear to have a beneficial effect. Animal studies show that time restricted feeding (limiting feedings to a timeframe appropriate to the species’ diurnal/nocturnal pattern) is associated with decreased obesity. Among humans, an app study showed an association between time-restricted feeding and sustained weight loss.

As we have seen, the regulation of metabolism and body weight appear to depend on the optimal function of the circadian system, which requires appropriately timed exposure to synchronizing stimuli. Interventional studies suggest that manipulation of synchronizers may be beneficial in treating disordered eating behaviors, metabolic abnormalities and obesity. Potential interventions for circadian dysfunction would optimize the timing of synchronizers (such as bright light therapy, timing of food intake and time-restricting feeding), regularize rest/activity circadian rhythms (by increasing regular exercise, maintain a consistent waking up schedule), or the administration of medications according to circadian phase. The treatment of circadian dysfunction promises improved outcomes in the prevention and treatment of obesity, but further research is needed.  New technologies and methods will enable a thorough characterization of circadian function is obesity and eating disorders and determine whether the circadian system is a potential target for chronotherapeutic interventions.

The Lindner Center of HOPE is conducting a comprehensive study of circadian function in adults with obesity with and without binge eating disorder.  For more information, contact Brian or George at (513) 536-0707 or visit http://www.lcoh.info

Bibliography

Broussard, J. L., & Van Cauter, E. (2016). Disturbances of sleep and circadian rhythms: novel risk factors for obesity. Current opinion in endocrinology, diabetes, and obesity, 23(5), 353-359.

Garaulet, M., Gómez-Abellán, P., Alburquerque-Béjar, J. J., Lee, Y. C., Ordovás, J. M., & Scheer, F. A. (2013). Timing of food intake predicts weight loss effectiveness. International journal of obesity, 37(4),
604-611.

self-esteem and self-worth in our youth will bring about numerous long-lasting, positive changes that Cupid’s arrow could only dream of creating.

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

Dr. Paul Crosby, Lindner Center of HOPE

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

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

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

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

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

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