Category: Anxiety Disorder

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By: Laurie Little, PsyD
Chief Patient Experience Officer and Staff Psychologist,
Lindner Center of HOPE

In recent years, there has been a growing interest in exploring alternative and innovative treatments for mental illness. Among these novel approaches, ketamine has emerged as a promising treatment for various mental health disorders. Traditionally known as an anesthetic and pain-relieving medication, ketamine has shown potential in treating mental health disorders such as depression and anxiety.

History of Ketamine

Ketamine was originally discovered by chemist Calvin Stevens in 1962 for Parke Davis Company and was Food & Drug Administration (FDA)- approved for medical use as an analgesic and anesthetic in 1970.  It is considered a “Dissociative Anesthetic” with different dosages leading to differing effects. Lower dosages can lead to a psychedelic experience and higher dosages can lead to complete dissociation or analgesia. When using Ketamine as an analgesic, researchers noticed an intriguing off-label effect: a rapid and pronounced improvement in mood and depressive symptoms in some patients. This discovery sparked interest in exploring ketamine’s potential as a novel treatment for mental health disorders.

To curb its illicit and recreational use, the United States categorized Ketamine as a Schedule III federally controlled substance in 1999, however research into its mental health benefits continued to flourish. In 2019, the FDA approved the first ketamine derived therapy, called Esketamine, as a therapy for treatment-resistant depression.

Ketamine and Depression

Ketamine’s antidepressant effects are unique compared to traditional antidepressant medications, which typically take several weeks to produce noticeable results. Ketamine often provides immediate relief to patients who are suffering. Ketamine promotes the release of Glutamate, an essential neurotransmitter that is related to cognition, memory and mood.  Traditional antidepressants often affect neurotransmitters such as Serotonin and Dopamine and take longer to notice an improvement in symptoms.

A recently published large, systematic review of published journal articles on Ketamine treatment found “support for robust, rapid and transient antidepressant and anti-suicidal effects of ketamine. Evidence for other indications is less robust but suggests similarly positive and short-lived effects.“ The findings suggest that ketamine facilitates rapid improvements in symptoms among patients with major depressive disorder (MDD), bipolar disorder and suicidality, lasting up to 7-14 days after treatment. In some cases, effects last up to four weeks, depending on the number of ketamine sessions and the underlying mental health conditions.

There is also preliminary but growing evidence base supporting the efficacy of ketamine therapy for substance use disorders, anxiety disorders (generalized, social, OCD, PTSD)  and eating disorders.  However, just like its antidepressant effects, ketamine’s reductions in anxiety are also short-lived, and symptom recurrence is common after several weeks.

Patients who receive adjunctive psychotherapy appear to achieve the most long-lasting benefit compared with ketamine administration alone.

Ketamine Assisted Psychotherapy

Research shows that Ketamine is most beneficial when it is combined with psychotherapy. There is no current standard for how therapy and Ketamine should be combined. Some practitioners combine lower doses of Ketamine and engage in therapy during the treatment. Other practitioners use higher doses of Ketamine and have the patient engage in therapy either the following day or later in the week. Since patients notice an immediate improvement in their mood, they are more able to benefit from therapy and are more open and receptive to thinking about their current circumstances in a new, helpful way.

The Benefits and Challenges of Ketamine Treatment

The most notable benefit of ketamine treatment is its rapid and profound antidepressant effect. Unlike traditional medications, ketamine can provide relief within hours. This immediate response is particularly crucial for patients in crisis, who are suicidal or those struggling with treatment-resistant mental health conditions.

Moreover, ketamine treatment may benefit individuals who cannot tolerate or have not responded well to other standard treatments. Unfortunately, a significant percentage of patients do not find relief from standard therapies and it is important to have multiple treatment options available.

However, ketamine treatment does come with its challenges and risks.

  • Long-Term Data. One major obstacle is the lack of long-term data on the safety and efficacy of ketamine as a mental health treatment. While research has shown short-term benefits, the question of how long the benefits last requires additional investigation.
  • Misuse. Due to its powerful impact, Ketamine is also often misused. Research is still needed on the abuse potential of Ketamine. Interestingly, there is some evidence to suggest that Ketamine itself can be effective in the treatment of other substance use disorders such as alcohol and heroin. There is still much more to be learned
  • Insurance Coverage. Ketamine treatment is often not covered by insurance for mental health conditions, making it financially inaccessible for many patients. The cost of treatment, coupled with the need for repeated administrations to maintain benefits, raises concerns about equitable access to this innovative therapy.

Ketamine treatment represents a groundbreaking shift in the approach to mental health treatment. Its rapid and transformative effects on depression, anxiety and other mental health conditions have sparked hope for those who have exhausted conventional therapies. While ketamine shows immense promise, ongoing research is needed to fully understand its long-term safety and efficacy.

As the field of mental health continues to evolve, ketamine treatment has the potential to offer a lifeline to those who struggle with treatment-resistant conditions. It is crucial for the medical community, researchers, clinicians, policymakers, and insurers to collaborate in ensuring equitable access to this promising therapy.

Ketamine Therapy & Treatment in Cincinnati

If you’re seeking Ketamine Therapy in Cincinnati, the Lindner Center of HOPE is an excellent place to begin your mental health care journey. Reach out to explore your available options.

 

References

Banoff, MD, Young, JR, Dunn, T and Szabo, T. (2020). Efficacy and safety of ketamine in the management of anxiety and anxiety spectrum disorders: A review of the literature. CNS spectrums, 25(3), 331-342.

Berman, R. M., Cappiello, A., Anand, A., Oren, D. A., Heninger, R., Charney, D. S., & Krystal, J. H. (2000). Antidepressant effects of ketamine in depressed patients. Biological Psychiatry, 47(4), 351-354.

Feder, A., Rutter, S. B., Schiller, D., & Charney, D. S. (2020). The emergence of ketamine as a novel treatment for posttraumatic stress disorder. Advances in Pharmacology, 89, 261-286.

Krupitsky, E. M., & Grinenko, A. Y. (1997). Ketamine psychedelic therapy (KPT): A review of the results of ten years of research. Journal of Psychoactive Drugs, 29(2), 165-183.

Mia, M. (2021) Glutamate: The Master Neurotransmitter and Its Implications in Chronic Stress and Mood Disorders. Front Hum Neurosci. 15: 722323.

Murrough JW, Iosifescu DV, Chang LC, Al Jurdi RK, Green CE, Perez AM, Iqbal S, Pillemer S, Foulkes A, Shah A, Charney DS, Mathew SJ. (2013). Antidepressant efficacy of ketamine in treatment-resistant major depression: a two-site randomized controlled trial. Am J Psychiatry. 2013 Oct;170(10):1134-42. doi: 10.1176/appi.ajp.2013.13030392. PMID: 23982301; PMCID: PMC3992936.

Chadi G. Abdallah and Lynnette A. Averil

Ragnhildstveit, A., Roscoe, J., Bass, L., Averill, C., Abdallah, C. and Averillhe, L.. (2023). Potential of Ketamine for Posttraumatic Stress Disorder: A Review of Clinical Evidence. Ther Adv Psychopharmacol, Vol. 13: 1–22, DOI: 10.1177/.

Reznikov L. R., Fadel J. R., Reagan L. P. (2011). “Glutamate-mediated neuroplasticity deficits in mood disorders,” in Neuroplasticity, eds Costa e Silva J. A., Macher J. P., Olié J. P. (Tarporley: Springer; ), 13–26. 10.1007/978-1-908517-18-0_2

Walsh, Z., Mollaahmetoglu, O., Rootman, J., Golsof, S., Keeler, J., Marsh, B., Nutt, D., and Morgan, C. (2022). Ketamine for the treatment of mental health and substance use disorders: comprehensive systematic review. BJPsych Open (2022) 8, e19, 1–12. doi: 10.1192/bjo.2021.1061

Witt K, Potts J, Hubers A, et al. Ketamine for suicidal ideation in adults with psychiatric disorders: A systematic review and meta-analysis of treatment trials. Australian & New Zealand Journal of Psychiatry. 2020;54(1):29-45. doi:10.1177/0004867419883341

Wolfson, P., & Hartelius, G. (Eds.). (2016). The ketamine papers: Science, therapy, and transformation. Multidisciplinary Association for Psychedelic Studies.

Zarate, C. A., Singh, J. B., Carlson, P. J., Brutsche, N. E., Ameli, R.,

Luckenbaugh, D. A., … & Manji, H. K. (2006). A randomized trial of an N-methyl-D-aspartate antagonist in treatment-resistant major depression. Archives of General Psychiatry, 63(8), 856-864.

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by Jessica Kraft, MSN, PMHNP-BC

 

 

 

 

Anxiety and mood disorders are amongst the most commonly diagnosed mental health conditions in the United States. While many find successful treatment through various psychotherapies or medications targeted at managing anxiety and depression, no medication will magically take away all anxiety or life stressors and it is not uncommon to experience breakthrough anxiety or symptoms of depression even while under the care of mental health professionals.  In today’s hectic world it can be challenging to juggle daily responsibilities and find ways and time to take a step back and practice mindfulness or focus on self-care. This article explores different mindfulness activities and alternative therapies, some of the benefits they illustrate, and how to include them in our day-to-day routines.

Meditation: Meditation has been practiced for thousands of years and is considered one of the oldest spiritual practices in ancient India and China. While it can be challenging to find an agreed upon definition for meditation, in general it is agreed upon that meditation is a practice and form of mental training with the goal of calming the mind (Wang et al., 2022). Meditation can look different to different people and can be practiced in as little as a few minutes every day.

Yoga: Yoga is an ancient spiritual practice with roots in Indian culture and is an alternative therapy often combined with meditation that focuses on breathwork and the adoption of physical postures.  There are multiple style of yoga that differ in intensity and length of time, but multiple individual studies and systematic reviews have concluded that yoga can benefit those struggling with depression with symptom reduction seen with 60-minute sessions per week (Saeed et al., 2019).

Exercise: There are numerous studies and clinical trials showing the benefits of exercise related to mental health, particularly for those who struggle with anxiety and depression. A meta-review examining the relationship between anxiety disorders and physical activity (especially aerobic and resistance exercises) with over 69,000 participants showed that on average participants reported significantly reduced anxiety over a 3-year period when engaging in physical activity on a regular basis. Analysis examining sedentary behavior showed an increased risk of depression over time compared to those who engaged in more physical lifestyle activities (Firth et al., 2020). While there can be limitations in studies related to exercise types, additional therapies, and other variables there is one thing that remains consistent: no trials have shown that physical activity worsens anxiety or depression (Saeed et al., 2019).

While mindfulness activities and alternative therapies sound great on paper, they can be challenging to practice regularly. Below are some tips for squeezing in mindfulness activities into a hectic schedule:

  • Utilizing meditation apps. Most popular meditation apps (Calm, Headspace, Healthy Minds Program) have lengthy daily meditations, but they also include quick 1-3 minute meditations/deep breathing exercises that can easily be practiced before going to bed, before starting the work day, or to take a time out when feeling overwhelmed
  • Find exercise you enjoy doing. Motivation to exercise can be challenging enough, but when it is for an activity you don’t even enjoy this can be even more challenging. Find an activity or sport that you actually enjoy or look forward to doing and this will help with consistency, especially if you are able to engage in the activity with friends or family and turn it into a social or group event
  • Make slow, incremental changes to routine. It’s not uncommon to make a self-care plan including things like exercising daily, meditating daily, and making dietary changes. When we try to make multiple changes like this overnight it is easy to get discouraged if we miss a day and sometimes, we don’t even get back to it. Focusing on one change at a time and incorporating it into your routine more slowly helps with habit changing
  • In short, set yourself up for success with the four laws of behavior change. 1) make it obvious – if you want to go to the gym after work every day pack your bag the night before, 2) make it attractive – get yourself a new pair of shoes or a new workout outfit, 3) make it easy – start with a few minutes per day, and 4) make it satisfying – set up incentives to motivate yourself and keep it going (Clear, 2022)

Sources:

Clear, J. (2022). Atomic habits: An easy & proven way to build Good Habits & Break Bad Ones: Tiny Changes, remarkable results. Cornerstone Press.

Firth, J., Solmi, M., Wootton, R.E., Vancampfort, D., Schuch, F.B., Hoare, E., Gilbody, S., Torous, J., Teasdale, S.B., Jackson, S.E., Smith, L., Eaton, M., Jacka, F.N., Veronese, N., Marx, W., Ashdown-Franks, G., Siskind, D., Sarris, J., Rosenbaum, S., Carvalho, A.F. and Stubbs, B. (2020), A meta-review of “lifestyle psychiatry”: the role of exercise, smoking, diet and sleep in the prevention and treatment of mental disorders. World Psychiatry, 19: 360-380. https://doi.org/10.1002/wps.20773

Saeed SA, Cunningham K, Bloch RM. Depression and Anxiety Disorders: Benefits of Exercise, Yoga, and Meditation. Am Fam Physician. 2019 May 15;99(10):620-627. PMID: 31083878.

Wang, Zanyi1,; Rawat, Vikas1; Yu, Xinli2; Panda, Ramesh Chandra3. Meditation and its practice in Vedic scriptures and early Taoism scriptures. Yoga Mimamsa 54(1):p 41-46, Jan–Jun 2022. | DOI: 10.4103/ym.ym_48_22 (https://journals.lww.com/yomi/fulltext/2022/54010/Meditation_and_its_practice_in_Vedic_scriptures.8.aspx)

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By: Dr. Nicole Bosse, PsyD, Lindner Center of HOPE

 

OCD is a disorder that responds very well to a form of Cognitive Behavioral Therapy called Exposure and Response Prevention. Brain imaging studies found that people with OCD have excessive levels of activity in the orbital cortex, the caudate nucleus, the cingulate gyrus, and the thalamus. Differences are unrelated to intelligence and most other cognitive abilities. These studies also show that the brain changes in response to Exposure and Response Prevention. The overactive parts of the brain become less active and similar to others without OCD after engaging in Exposure and Response Prevention.

Exposure and Response Prevention consists of confronting what you are afraid and abstaining from the related compulsions. Specifically, exposures are purposeful and gradual confronting and maintaining contact with feared objects, thoughts, or images to allow the anxiety to rise, peak, and subside. Response Prevention is the halting of neutralizing actions and/or thoughts (i.e., compulsions) to allow habituation to a feared stimulus (e.g., not washing after touching a doorknob). This is done with the help of a trained therapist. It is a form of therapy that is collaborative and the individual works with the therapist to brainstorm various exposure ideas to start forming a hierarchy.

A hierarchy ranges from items that bring about low to high distress/anxiety. An example hierarchy for someone that has a fear of snakes could look like: reading about snakes, looking at pictures of snakes, watching videos of snakes, looking at snakes behind glass, being in the room with someone holding a Gardner snake, being in the room with someone holding a boa constrictor, touching a Gardner snake while someone else is holding it, touching a boa constrictor that someone else is holding, holding a Gardner snake, and being in a bathtub with boa constrictor snakes. The last item can be something that wouldn’t necessarily be done for exposures, it is just used as a something to help scale other exposures.

There are two types of exposures I usually talk about with patients, planned vs. spontaneous. Planned exposures can take various forms, from in vivo to imaginal. In vivo exposures are exposures that are completed in person, for example touching things that could be contaminated with germs or breaking down avoidance of certain people for fear of harming them. Imaginal exposures are usually implemented when it is impossible/unethical to do in person exposures. For example, the individual can be instructed to write sentences about hurting someone or write an imaginal script detailing their worst fear. These exposures can be done over and over in one sitting until it starts to get boring.

Spontaneous exposures are things that happen throughout the day that are unplanned and typically cause significant anxiety. For instance, if someone is afraid of germs and someone sneezes on food etc. With spontaneous exposures, I usually instruct individual to do one of two things, either abstain from the compulsion or do something called ritual weakening. Ritual weakening is completing the compulsion but doing it differently than the OCD desires. For example, postponing washing hands or writing down that you are giving into a compulsion in order to be able to do the compulsion. The idea is it makes it slightly less convenient to do the compulsion, which over time weakens OCD.

In sum, Exposure and Response Prevention is a very successful form of treatment for OCD. To be effective, the individual must be willing and motivated. An individual is never made to do something they are uncomfortable with. It is best to go slow in order for the individual to learn their anxiety will decrease over time.

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By Angela Couch, RN, MSN, PMHNP-BC, Lindner Center of HOPE, Psychiatric Nurse Practitioner

Hypochondriasis has been replaced in the DSM 5 by Somatic Symptom Disorder (SSD) or Illness Anxiety Disorder (IAD), both categorized under Somatic Symptom and Related Disorders.  Previous diagnoses classified under Somatoform Disorders were often interpreted with a negative connotation, implying that the patient’s concerns were not real or valid. However, it is not appropriate to give a person a mental diagnosis for no other reason than no medical cause can be identified, nor does the presence of a medical diagnosis exclude a co-morbid mental disorder.  About 75% of persons previously diagnosed with Hypochondriasis will fall into the category of Somatic Symptom Disorder, while the other 25% will meet criteria for Illness Anxiety Disorder.  Let’s examine the differences.

Somatic Symptom Disorder (SSD)

Somatic Symptom Disorder (SSD), requires the patient to have one or more somatic symptoms (that is to say, pertaining to the body), that are distressing or result in significant disruption of daily life. Excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated health concerns are manifested by at least one of the following: disproportionate and persistent thoughts about the seriousness of one’s symptoms, persistently high level of anxiety about health or symptoms, and excessive time and energy devoted to these symptoms or health concerns.  Although any one somatic symptom may not be continuously present, the state of being symptomatic is persistent, generally more than 6 months duration. Specifiers include predominant pain (formerly pain disorder), persistent, and mild, moderate or severe. High health anxiety can be a symptom of SSD but is not necessary for a diagnosis of SSD. Patients with SSD often seek care from multiple doctors and often feel their assessments were inadequate. Reassurance given does not seem adequate nor to last for these patients. Patients with SSD may worry that excessive physical activity may damage their body and may seem more sensitive to medication side effects.  The prevalence in adults may be 5-7% of the population, likely more common in females. In comparison to Obsessive-Compulsive Disorder (OCD), the recurrent worries are less intrusive and individuals may not exhibit repetitive behaviors aimed at reducing anxiety other than seeking assessment.  Usually in OCD, the obsessions would not be confined to somatic symptoms.

Illness Anxiety Disorder (IAD)

Illness Anxiety Disorder (IAD), requires the patient to have a preoccupation with having or acquiring a serious illness. Somatic symptoms are either not present or are mild in intensity. If another medical condition is present or there is a high likelihood of developing a medical condition, the preoccupation is excessive or disproportionate. There is a high level of anxiety about health and the individual is easily alarmed about their health status. The individual performs excessive health related behaviors, such as body checking, or exhibits maladaptive avoidance, such as avoiding medical assessment.  In IAD, the distress has been present for at least 6 months, though the specific illness targeted may change during that time. The preoccupation is not better explained by another mental disorder such as SSD, panic disorder, generalized anxiety disorder, body dysmorphic disorder, obsessive-compulsive disorder or delusional disorder. In IAD, the distress comes from the distress about the significance, meaning or cause of the complaint, not from a specific physical symptom or sensation. Most commonly, the physical symptoms exhibited are normal type sensations or considered benign or self-limiting dysfunction. Individuals who have IAD may be easily alarmed by reading or hearing about illnesses, and often will seek reassurance about illnesses through internet research or speaking to doctors or friends and family. In a smaller number of cases, the patient may be help avoidant versus help seeking. The reassurance given by medical professionals may potentially heighten the patient’s anxiety. Those who have IAD may avoid activities in order to avoid harming themselves or catching an illness from others.  The prevalence of IAD is possibly between 1.3-10% in the general population, and in ambulatory medical populations the 6-12 month prevalence is between 3-8%, and about equal across the sexes. The prevalence in OCD is also equal across the sexes. Persons with IAD may exhibit the intrusive thoughts about having a disease and may do compulsive behaviors such as reassurance seeking, but the preoccupations are usually focused on having a disease; in OCD, the intrusive thoughts are often about potentially getting a disease in the future or wanting certainty that they do not have one right now. In OCD, the obsessions and compulsions usually extend beyond disease concerns.

One study examined 118 treatment seeking patients with health anxiety, and gave them structured diagnostic interviews to assess for Hypochondriasis, IAD and SSD, as well as co-morbid mental disorders; additionally, the study looked at self-report measures of health anxiety, co-morbid symptoms, cognitions and behaviors, as well as service utilization. 45% of patients were diagnosed with SSD, 47% with IAD, and 8% with co-morbid SSD/IAD.  SSD and IAD were seen to be more reliable diagnoses than Hypochondriasis. Half of the sample group met criteria for Hypochondriasis, and of that sample, 56% met criteria for SSD, 36% for IAD, and 8% for co-morbid SSD/IAD.  SSD was characterized by higher levels of health anxiety, depression, somatic symptoms, and health service utilization, in addition to higher rates of major depression, panic disorder and agoraphobia.

Patients with these diagnoses often present in medical settings initially, and arrive in a mental health care setting via referral from another medical provider. It is important that medical providers validate the individual’s experience of symptoms and their anxiety, but also explain the rationale of supplementing medical interventions with mental health treatment.

Summary of Differences:

IAD                                                                             SSD

Absence/minimal distressing physical                Presence of distressing physical
symptoms                                                                  symptoms

 

High health anxiety not a requirement                 High health anxiety always present

 

Reassurance seeking common, but also             Reassurance/assessment seeking
less frequently can be care avoidant related
to anxiety

Equal across sexes                                                 More common in females

 

May engage in additional compulsions                More frequently associated with co-morbid depression, panic disorder,

higher level of health anxiety, and more utilization of medical services

To learn about anxiety disorders treatment at Linder Center of HOPE, visit https://lindnercenterofhope.org/anxiety-disorders/

References:

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

Newby, J.M., Hobbs, M.J., Mahoney, E.J., Shiu, W. and Andrews, G. DSM-5 illness anxiety disorder and somatic symptom disorder: Comorbidity, correlates, and overlap with DSM-IV hypochondriasis. Journal of Psychosomatic Research, 101, 31-37.

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By Peter White, M.A., LPCC, LICDC, Lindner Center of HOPE Outpatient Therapist

The problem during Bipolar Mood Disorders is a pattern of swings of the essential elements of mood between the two poles, like the North Pole and South Pole, of Mania and Depression. These swings are not moodiness, which are swings of mood throughout a day. A Bipolar swing is a distinct period of at least one week when the full spectrum of mood elements exhibits depressive and/or manic elements.

Although thought of as a subjective experience, mood deeply influences three areas. First is metabolism – sleep, appetite, libido and energy levels. Second, mood influences both motivation as well as the ability to experience pleasure and/or a sense of accomplishment. Thirdly, mood deeply influences interpretations within thoughts from positive to neutral to negative.

So, we can think of this first spectrum of mood disorder along an axis of depression to neutral to manic. Therefore, a depressed mood will depress metabolism. A person will have difficulty with sleep through either excessive or inadequate or disrupted sleep, loss of appetite or excessive eating despite disrupted appetite, loss of libido as well as loss of energy. Depression will hinder motivation making it difficult to experience the drive to initiate activities as well as hinder pleasure or the reward of activity. This is a very difficult cycle when it is hard to get active in the day compounded by not finding any pleasure or reward in the day’s activities. Lastly, depression will darken the flow of thoughts adding many themes of hopelessness, helplessness, worthlessness and guilt into our thought process.

Conversely, mania will elevate the same essentials. It will increase energy levels often in the face of declining sleep hours. It will increase libido, increase excessive and/or absence of appetite. It will increase motivation often leading to excessive engagement of plans or activities and will create a compounding loop of all activity feeling especially pleasurable or rewarding. Again, conversely is will paint thinking with elevated judgements of specialness, invulnerability, and inevitable positive outcomes.

The second spectrum of mood disorders, like most other behavioral health problems, is along the spectrum of severity – mild to moderate to severe. If you combine this spectrum of severity along with the first spectrum of depressive to manic, we see how varied and individualized any person’s experience with Bipolar Mood disorders can be.  Most people can relate to some degree of depression during periods of their life with perhaps a few weeks or month of low energy, noticing that they are not getting the same rewards in their regular activity as well as perhaps noticing they are thinking unusually negatively about themselves and their outlook on life. We might call this a mild, brief depressive episode. But the reality is that depression is one of the most disruptive and costly of all health conditions as recognized by the World Health Organization. This mean that depression is often moderate or severe to very severe and can disrupt functioning on every level for weeks to months if not years. A severe depression can make it difficult to get out or bed for days on end both from collapsed energy and motivation. It can destroy the pleasure and rewards of living so that all activity feels like a painful chore at best. Finally, it can turn thoughts dangerously dark with so much hopelessness, helplessness and worthless that suicidal thinking emerges nearly with a sense of relief.

Again conversely, though experienced less often by most people, Manic Episodes can present with mild, moderate, severe and very severe intensity. During a sever episode, a person with manic symptoms is often sleeping little but maintaining very high levels of energy. They are often talking very quickly and sometimes laughing excessively and outside the context of humorous things. Given the very high levels of motivation and the reinforcement of pleasure in all activities, they often initiate an excessive number of activities – starting multiple projects with little awareness of the ability to balance or complete them. They frequently initiate conversations or relationship in an open or disinhibited style very unusual for to their character. With elevated thought patterns, they might believe they have a unique or special purpose, and they are convinced that all their activities will be successful and rewarding. Give the excessive energy, motivation, pleasure and elevated sense of self and success, people in manic states will often engage in behavior patterns much riskier than typical – spending money well beyond their mean, unusually disinhibited sexual decision, reckless driving, shop lifting.

I hope it’s useful to review the way mood symptoms fluctuate along these two spectrums, because like all health care conditions, we are best off when we accurately identify what these behaviors are – symptoms. Mood symptoms are not moral challenges, personality traits or unconsciously desired behaviors. Mood symptoms are symptoms, and fortunately, there are many very effective treatments for all symptoms along both spectrums. Please know if you or a loved one or a client is experiencing any degree of Bipolar mood problems, there will be many ways to help and cope, and experience the satisfaction of effectively treating a behavioral health care condition.

 

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What is Panic Disorder?

Panic Disorder is an anxiety disorder that occurs when someone experiences recurrent, spontaneous, unexpected, and untriggered panic attacks. This leads to preoccupation with and fear of experiencing another attack. Panic attacks occur when there is an intense physical surge of symptoms that quickly reach their peak, usually in a few minutes. A panic attack can be felt very differently from one person to another. A combination of the following symptoms is typically experienced during a panic attack:

  • Heart palpitations, pounding heart, or accelerated heart rate
  • Sweating/perspiration
  • Trembling or shaking
  • Sensations of shortness of breath or feeling smothered
  • Feelings of choking
  • Chest pain or discomfort
  • Nausea or abdominal distress
  • Feeling dizziness, unsteadiness, light-headedness, or faintness
  • Chills or feeling over-heated
  • Numbness or tingling sensations
  • Feelings of depersonalization (unreality)
  • Feelings of derealization (being detached from oneself)
  • Fear of losing control or “going crazy”
  • Fear of death or dying
  • Sense of impending doom or danger

At least one of these panic attacks is followed by one month or more of persistent concern or worry about having another attack and/or a significant change in behavioral pattern (typically avoidance of certain places or situations).

Panic attacks can be viewed as a “false alarm” related to a fight-or-flight response to a mis-perceived threat. Fight-or-flight is a natural human reaction that prepares us to defend ourselves or flee the situation. When someone becomes hyperaware of their body’s sensations, they may interpret a sensation as a threat when there’s not one.

Panic disorder affects 2-3% of Americans and is affects women roughly twice as frequently as it affects men. The onset of Panic Disorder typically occurs in adulthood, but can also affect children and teens.

What is Agoraphobia?

Agoraphobia occurs when someone persistently avoids situations in which they might become embarrassed or have difficulty escaping. This is often the result of fear of having a panic attack in public. This can manifest in fear of using public transportation (such as planes, buses, trains), being in open spaces (such as parking lots, malls, or stadiums), being in enclosed spaces (such as elevators, stores, or cars), being in crowds or standing in line, or even being outside the home alone.

Panic Disorder can be present with or without Agoraphobia, but these disorders commonly present together. When they occur together, Agoraphobia usually develops following an adverse experience, such as having a panic attack in one of these places/situations in which the person feels trapped, embarrassed, or fearful. Over time, avoidance of these situations and places reinforces one’s fear, leading to further avoidance.

How are Panic Disorder and Agoraphobia treated?

People with Panic Disorder often present to emergency departments or their physician’s office due to their uncomfortable physical sensations (often fearing that they are suffering from a heart attack). While it is important to rule out any physical cause for these symptoms, repeated trips to the ER and doctor visits can also reinforce the symptoms. Instead, it is important to receive appropriate mental health treatment for Panic Disorder and Agoraphobia.

Treatment for Panic Disorder and Agoraphobia typically includes of a combination of medication and psychotherapy. Medications commonly used to treat Panic Disorder and Agoraphobia include selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs), beta blockers, and benzodiazepines. SSRIs and SNRIs are a category of antidepressants that are also useful in treating anxiety disorders such as Panic Disorder and Agoraphobia. Beta blockers can be used to help control some of the physical symptoms of panic attacks such as a rapid heart rate. Benzodiazepines are useful to provide temporary relief of acute anxiety symptoms. These medications can be very helpful, but they should be used with caution due to their potential for dependence. Benzodiazepines can also interfere with the ability to habituate or learn that situations are safe. Only your health care provider should determine whether these medications are appropriate for use and you should not discontinue any medications without consulting with your provider.

Cognitive-Behavioral Therapy (CBT) is an evidence-based type of psychotherapy that is helpful in treating Panic Disorder and Agoraphobia. This therapy helps people to change their behavior and their way of thinking. Various CBT techniques are useful in treatment of these anxiety disorders. Interoceptive exposures involve purposely provoking uncomfortable physical sensations (heart pounding, shortness of breath, dizziness) to desensitize oneself to them. This should be done with the guidance of a trained mental health professional to ensure that it is done correctly. Similarly, gradually limiting avoidance of circumstances and places (such as driving or going into stores) that are typically avoided allows someone to become comfortable and gain confidence in these situations. Breathing and relaxation exercises can help to lower someone’s overall level of anxiety to prevent them from having a panic attack. And finally challenging faulty beliefs, such shifting from thinking “I’m in danger” to “my body is telling me that I’m in danger, but I’m actually safe” can be helpful in lowering related anxiety. Other helpful interventions include biofeedback and mindfulness. Additional lifestyle changes such as reducing one’s intake of caffeine, sugar, nicotine, regular exercise and sleep, and limiting checking vital signs can be helpful in lowering anxiety.

If you believe that you or someone you know is suffering from Panic Disorder and/or Agoraphobia, it is important to seek the help of a mental health provider. These disorders can become debilitating without proper treatment but can become manageable if properly treated.

by Jennifer B. Wilcox, PsyD
Staff Psychologist, Lindner Center of HOPE

 

 

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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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By: Sidney Hays, MSW, LISW, DARTT,

Lindner Center of HOPE Professional Associates, Outpatient Therapist

From wild parties in the massive frat houses to stories finding your soulmate in movies and television, many enter college with bright eyes and big dreams. There are expectations of melting into a friend group, dating, gaining experience, and finding your passion as soon as you get to college. All of this, stepping-stones to graduating with the dream job lined up, a group of best friends you’ll vacation with every summer, and that special someone you just might spend the rest of your life with. You’ve heard about the glory days and the football games and the spring break trips. But, what happens when you get to college and the classes are hard, friendships are complicated, partying comes with consequences, and heartbreak hits you?

Many young adults enter college with high hopes and expectations that seem reasonable Unfortunately, the movies and glory day memories from loved ones miss crucial struggles and obligations that come with college. This often leaves college students feeling like they’re “missing something” or failing, which contributes to poor mental health in an environment already rife with challenges. The struggles of large class sizes, living with strangers, easier access to drugs and alcohol, financial stress, being away from home, and lack of structure tend to tax the delicate wellbeing of young adults who have not been adequately equipped with needed skills and whose brains are not fully developed.

Most 18-year-olds step onto a college campus and it’s the first time they will be spending the majority of their time living away from home. Suddenly they are responsible for most every aspect of their life, with minimal adult supervision. Out from the safety net of coming home to parents and the guidance of coaches and teachers, college freshmen spend the majority of their time exclusively with others their same age, facing the same struggles. They navigate friendships, romantic relationships, and living with strangers as best they can, often struggling with codependency, lack of boundaries, and the pervasive anonymity and distance offered by the internet. This group tends to struggle with interpersonal skills and ability to regulate their own emotions, with little guidance on effective skills to use. Many find themselves feeling lonely and in cycles of unhealthy or unfulfilling relationships.

Accountability is a new concept for many college students. The looser structure of college settings requires more self-determination and discipline than high school. College is a place where students are generally free to make most of their decisions. While this can be liberating and a time of beautiful self-discovery, it can also lead to poor attendance, study habits, and moderation of substances and sleep. The negative physical, academic, and emotional effects of these choices tend to pile up, which is why so many college students begin to struggle with anxiety and depression.

What to tell a college student who isn’t having the best time of their life:

Know that you are not alone.

Mayo Health Clinic reported in July 22 that up to 44% of college students reported symptoms of depression and anxiety. The stressors faced by college students are underplayed and the good times overly glorified. It often takes time to make friends and friend groups naturally change; that’s okay. People are trying to understand what they want to do with the rest of their lives, becoming independent adults, and learning about the world. This will likely lead to many shifts in relationships as well.

Manage expectations.

You are in school to get a degree, learn about yourself, create relationships, and prepare yourself for the workforce. You may not find a group of friends during welcome week or even freshman year. The romantic relationships may not work out. You may not graduate with your dream job lined up. This is a step towards your goals and can still be part of a life worth living, even if you don’t get exactly what you want by graduation.

Get support and develop lasting relationship skills.

College is a great time to connect with a therapist to process the changes and have a support to help you identify your goals and live within your values. Learning skills to set boundaries, prioritize your time, communicate effectively, and regulate your emotions will make a world of difference in college and will carry on through your life.

A great option for learning these skills is Dialectical Behavior Therapy (DBT). DBT is a treatment that helps participants learn and practice skills to regulate emotions, tolerate distress, and effectively navigate interpersonal relationships.

If you are interested in learning more, for yourself or someone else, about DBT or individual therapy to help navigate this beautiful and challenging season, contact the Lindner Center of HOPE.

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For many families, the start of the school year means the start of activities, socialization, and helpful structure. For others, it signals the start of anxiety – anxiety about grades, socializing, separation from loved ones, and the like. Anxiety is very common in childhood and adolescence and often does not require mental health intervention.

Common childhood fears include:

  • loud noises
  • costume characters
  • the dark
  • separation from parents
  • social anxiety

However, some children may develop clinical levels of anxiety, warranting attention from a mental health provider. It is estimated that 9% of youth ages 3-17 have had an anxiety disorder. The prevalence rises as children move into adolescence.

If mild anxiety is normal and expected, how do you know when it is a problem?

It might be a problem if anxiety is…

…getting in the way of school.

…getting in the way of friendships or personal goals.

…negatively impacting their mood.

…causing significant strain on the family.

So, what can I do as a parent?

It can be highly distressing to witness a child suffering. Parents may also find it frustrating if their child cannot or will not engage in developmentally appropriate activities due to anxiety (e.g., go to school, complete chores, sit at the dinner table). This can make it hard to know what to do to help

First, identify whether the fear is based on a true threat. Use your judgment here, but if there is clearly a threat or the anxiety is in proportion to the situation, validate and support your child. And just because a fear is valid, it is not always solvable or preventable. Encourage your child to tolerate the anxiety and convey your confidence in their ability to cope.

For anxiety that seems out of proportion to the actual threat, it can be helpful to educate your child. Many young children are still learning about what is dangerous and what isn’t. However, if your child comes to you repeatedly to get reminded or reassured that they are okay, this may no longer be helpful.

Encourage approach coping. Research tells us that overtime, with repeated exposure to feared situations, anxiety will reduce. Avoidance can reinforce anxiety in the long run. Try encouraging your child to engage in activities that they are avoiding. Don’t allow them to avoid doing what is expected in your house or given their developmental level.

This may involve facing your own distress. When you see your child in distress repeatedly, it is normal to become overprotective. You may start anticipating what they fearand protect them. Parents do this because seeing your child in distress is HARD, and it can feel cruel to maintain expectations (e.g., child to sleep alone in their own bedroom) when they are visibly upset.

Just remember that overprotectiveness is NOT helpful because:

  • it can promote avoidance
  • it reinforces the belief that the world is dangerous
  • it reinforces the belief that your child is not capable of managing distress

Positive reinforcement. Acknowledge how difficult it is to be brave and praise your child when they go outside of their comfort zone. Implementing tangible rewards can also be helpful in motivating children to face their fears.

Differential attention. Sometimes, families can get into a pattern where the anxious child gets more attention when fearful. This can inadvertently reinforce anxiety and dependency. By providing relatively more attention when children are engaging in brave or expected behavior, you can help to reverse this pattern.

Modeling. Children learn by watching you, so keep an eye on what you are teaching them through your actions. When you can, demonstrate bravery and willingness to mess up.

Scaffolding. Scaffolding can be a very useful technique when the behavior change needed is too challenging to be expected all at once. It involves providing enough support for your child to engage in a desired behavior (e.g., school) and then slowly reducing that support overtime.

If you think your child may have an anxiety disorder, talk to your pediatrician or a mental health provider. And if you need extra help, seek advice from a professional. Many providers also offer tailored education and parenting support.

 

Lindsey Collins, Lindner Center of Hope new studio portraits. UC/ Joseph Fuqua IIBy: Lindsey Collins Conover, PhD
Lindner Center of HOPE, Staff Psychologist

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By: Laurie Little, PsyD 

Lindner Center of HOPE, Staff Psychologist

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

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

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

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

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

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

Case Vignette:

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

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

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

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

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

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