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Caught in the weeds: The impact of cannabis on mental health

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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Can the COVID-19 Vaccine Improve Your Mental Health?

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.

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Mental Health and the Environment of Connection

By Chris J. Tuell, EdD, LPCC-S, LICDC-CS
Lindner Center of HOPE, Clinical Director of Addiction Services; Assistant Professor, Department of Psychiatry & Behavioral Neuroscience
University of Cincinnati College of Medicine

At the end of the Vietnam War in 1975, 1 out of 5 soldiers (20%), returning to the United States from Southeast Asia, was addicted to heroin. It was estimated that approximately 100,000 American soldiers would be returning home, addicted to this destructive drug. Experts projected a drug epidemic, which would destroy countless lives and communities. It never happened.

Once soldiers returned home to families, friends and communities, the destructive nature of a hardcore drug, like heroin, failed to materialize. In fact, 95% of the soldiers who were once addicted to heroin, stopped using the drug almost immediately once they returned home.

For many years, our understanding of addiction was based on early research conducted in the first half of the 20th century. These studies involved rats and consisted of placing a rat in a solitary cage, providing the rat with a choice of water: plain water or water laced with cocaine or heroin. The study found that all the rats preferred the drug-laced water to the plain water. All the rats overdosed on the drug. The majority of the rats died in the study. This became our model of addiction for many years. The accepted belief became, if you are exposed to a drug, you will become addicted, and you may overdose and die.

Several years later, this original study was replicated, but with a significant difference. Researcher Bruce Alexander from the University of Vancouver, created, what was referred to as: a “rat park.” This park consisted of tunnels, multiple levels, toys, and other rat companions. Similar to the original study, all rats were given the same choice of water: plain water or water laced with heroin or cocaine. In Alexander’s study, rats preferred the plain water. Rates of overdose and death to the rats were significantly lower when compared to the initial study. How do we explain this difference in results? Perhaps, it is about the cage. Perhaps, it is about the environment.

Upon their return home, the soldiers from Vietnam who were struggling with a heroin addiction were able to re-connect with loved ones and community. A change in environment allowed for a change in connection, resulting in health, wellness and sobriety. Likewise, the environment of the rat in a solitary cage, as compared to the environment of the rat park, provided the rat with a “connection” with other rats, an environment which allowed the rat…to be a rat.

Individuals, who experience issues of mental illness and/or substance use disorders, have a natural tendency to withdraw and isolate from others. Depression, anxiety and addiction, greatly affect an individual’s ability to connect with others, let alone with one’s environment. This past year we have seen the devastating impact of COVID-19. We know that in order to maintain health and wellness, we need to maintain social distance and disconnect from one another. For now, this has and continues to be, what we need to do. It remains challenging for many of us to continue to avoid contact with loved ones and friends. We are separated from the very individuals who love us, support us, and are our sources of connection.

We have seen the rise of mental health issues during the past year. Nearly 20 percent of COVID-19 patients have developed a mental health issue (i.e., depression, anxiety) within three months of their diagnosis. During the past year, 4 in 10 adults in the U.S. have reported symptoms of anxiety or depression. Within the general population, rates of mental health issues and substance use have significantly increased across the board. In addition, the disconnection that we have witnessed has fragmented our society in general by harboring increased levels of fear, anger and animosity towards one another.

Hope on the horizon

Once “herd immunity” is achieved, the importance of re-connecting with one another becomes vital and essential to our health and mental wellness. We are social beings and need connection with one another. History has shown that the mental health impact of disasters outlasts the physical impact, suggesting today’s elevated mental health needs will continue well beyond the coronavirus outbreak.  Like the moth that needs to struggle out of the cocoon in order to develop the strength that it needs to survive in the world, we too are developing the strength that we need from the struggles we have endured.  Re-connecting with one another is an answer.  It gives us strength and it gives us hope.

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Grief During the Holidays

By Danielle J. Johnson, MD, FAPA

Lindner Center of HOPE, Chief Medical Officer

Many people have experienced loss of several types during the COVID-19 pandemic – employment, financial security, social connections, a sense of safety, and loved ones.  The way we grieve has changed because we cannot rely on our support systems to be physically there for us due to restrictions with social distancing.  With the increasing number of COVID-19 cases, the holiday season will be different this year – no holiday parties, large family gatherings, or other traditions.  It is difficult to be physically separated from loved ones, but even more difficult for those who may be experiencing their first holiday season after the loss of a loved one.

 

What are some ways that we can manage grief during this unprecedented holiday season?

  • Take charge of your holiday season: Anticipating anxiety about the holiday, especially if it is the first one without a loved one, can be worse than the actual holiday. Taking control of your plans and deciding how you will spend your time can relieve anxiety.  Do not spend time where you do not feel emotionally safe or comfortable.
  • Find nourishment for the soul: Your faith community may offer resources. Look for a support group for people who have suffered a similar loss or for those who are alone.  Due to the pandemic, many support groups are online.
  • Give yourself permission to change your holiday traditions: Some traditions may be a comfort, while others may be painful. Some traditions will have to change due to the pandemic.  It is ok to start new traditions.  Many families are finding ways to celebrate virtually.
  • Change how you give: Give a gift on behalf of your loved one to someone else or donate to a charity in memory of your loved one.  If you are spending less due to not spending the holidays with loved ones, consider giving more to charitable organizations.
  • Do not let guilt overtake you: You can enjoy the holiday without your loved one.  Celebrating does not mean you do not miss or have forgotten about your loved one.
  • Be gentle with yourself: Realize that familiar traditions, sights, smells and even tastes, may be comforting, or may trigger strong emotions. Be careful with your emotions and listen to yourself.
  • Do not pretend you have not experienced a loss: Imagining that nothing has happened does not make the pain of losing a loved one go away or make the holidays easier to withstand. It is ok to talk with others about what you have lost and what the holidays mean to you.
  • Pay attention to your health: It is often difficult for people who have experienced a recent loss to sleep. Make sure you get regular rest.  If you feel overwhelmed, talk with your health care provider.
  • Experience both joy and sadness: Give yourself permission to feel happiness and pain. Do not feel like you must be a certain way because of your loss or because it is the holidays.
  • Express your feelings: Suppressing your feelings may add to distress. To express your feelings, talk with a supportive friend or journal.
  • How can support persons help those who are grieving during this holidays season if we cannot physically be there? Be available to listen. Send cards, gift cards for meals, offer to help shop, or decorate the outside of the home.  If you are concerned about their mental wellbeing, offer to help them find a support group or encourage them to reach out to their health care provider for help.

Resources

https://www.griefshare.org/holidays

https://whatsyourgrief.com/alone-together-14-ideas-for-a-virtual-holiday/

https://coronavirus.ohio.gov/wps/portal/gov/covid-19/families-and-individuals/resources-for-parents-and-families/holiday-celebrations

Crisis Text Line, text CONNECT to 741741 for 24/7 help from a crisis counselor.

Ohio Care Line, call 1-800-720-9616 for 24/7 support from behavioral health professionals.

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When To Seek Treatment For Anxiety

 

By Angela Couch, RN, MSN, PMHNP-BC

Psychiatric Nurse Practitioner, Lindner Center of HOPE

Anxiety is a common symptom. Anxiety is a part of everyone’s lives, we have all experienced it to one degree or another. Believe it not, anxiety serves some useful purposes. Anxiety can help give you the drive to make a change, or complete task on time.Anxiety can activate the fight or flight instinct, in a “potentially” dangerous situation, giving you the drive to get out of there, or do something to prevent harm. Anxiety can occur when you are enduring multiple stressors, or there is uncertainty, and it’s not entirely unexpected.

For instance, say you hear layoffs are coming in the company, and you’re not sure if your department will be affected. You may experience physical symptoms of anxiety (which could include racing heart, nervous stomach, sweating, tremor, nausea, shortness of breath, and more), and you might also experience worry. COVID-19…yup, that can cause some anxiety, or worry, too! Situational anxiety is a part of life, and often can be managed by rational self-talk, problem-solving, and various positive self-care strategies. (For more on that, see some of our other recent blog articles, for lots of helpful ideas!) So how do we know when the anxiety is more than just “normal” or to be expected, and when to seek help?

According to the National Comorbidity Study Replication, about 19.1% of U.S. adults will have had an anxiety disorder in the past year, and 31.1% experience an anxiety disorder in their lifetime. In other words, it’s pretty common! There are various types of anxiety disorders, and most have an underlying common thread– difficulty in accepting uncertainty in some form. So how do you know if you may need to seek further assessment or help for anxiety, if it’s really so common? If everyone gets it, is it really a problem that requires treatment? The answer is yes, it might. Some symptoms that may indicate problematic anxiety include:

* Feeling “paralyzed” by fear.

* Anxiety is causing you to avoid things you used to be able to do without anxiety, or things that are important to you (this could include social activities, leaving your house, going to your job, driving, engaging in spiritual activities, etc.).

* You have difficulty staying present “in the moment”, which may repeatedly distract you from attending to conversations, being able to complete work or school tasks because of lack of focus.

* You are having difficulty with sleep or eating due to excessive worry or anxiety.

Anxiety is causing significant physical symptoms.

* You cannot determine a cause for the anxiety and the symptoms are persistent or very bothersome.

* You worry about “everything” or “all the time”.

* The anxiety/worry you are experiencing about situations seem excessive.

* You need to engage in compulsive or repetitive behaviors, or do things in a certain way, in order to avoid significant anxiety/worry.

* Anxiety is causing you to turn to self-medication with alcohol or substances.

So you’ve determined you should seek help, now what? Psychotherapy can be helpful for anxiety, and is a very important component of treatment. Psychotherapy may include several modalities such as cognitive behavioral therapy, addressing faulty beliefs contributing to anxiety, psychoeducation about anxiety and worry, problem-solving, exercise and wellness activities/lifestyle changes, addressing sleep hygiene, skills for time management and stress reduction, or exposure therapy, just to name a few.

How do you know if psychotherapy is enough to manage the symptoms? Medication can be a helpful component in treatment of anxiety, particularly if symptoms are not improving with other psychotherapeutic interventions mentioned above. Medications alone are rarely enough to treat anxiety disorders adequately. Medication can often make it easier to engage in meaningful psychotherapy, to make those helpful lifestyle changes, or try new ways of coping with the anxiety/worry. If you are experiencing suicidal thinking or significant depression, medication should be a consideration. If the anxiety symptoms are preventing you from being able to work or do other essential tasks, medication may be indicated. If your therapist suggests a medication consultation, you should consider it.

The important things to remember are, everyone has some anxiety, not all anxiety is bad, and when anxiety does become problematic or excessive, there are evidence-based treatments to help, so don’t be afraid to reach out for help!

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Psychological Disorders and Their Impact on Cognition

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

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

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

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

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

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

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Living with Anxiety During Times of Stress

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

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

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

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

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

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

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

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

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

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Isolation and Loneliness During Social Distancing

Quarantine.Isolation . Lockdown.

Who could have ever predicted that these words – so often associated with scary movies or rare, brief safety emergencies – would become so commonplace in our social language? The terms, themselves, being so casually thrown around that we’ve nearly become numb to their actual magnitude? The concept of loneliness is a broad one: certainly, this can describe distance or literal, geographical separation from others; however, it is also quite possible to experience loneliness while physically surrounded by people. This often arises in response to feeling misunderstood or “different” from those around us, or through a belief that we are truly alone in our struggles and suffering.

 

When in this state of mind, it’s easy to inadvertently fall into self-destructive patterns and habits that further worsen the depth of isolation we experience. This tends to be easier to “catch” in the “normal” world – someone is missing days at work or school, not showing up to family events, skipping appointments. However, in the midst of the COVID19 pandemic, this has become more difficult to identify, both in ourselves and in family members or friends. In this strange new reality, maladaptive coping might present through symptoms of depression:

– Withdrawing from others by declining phone calls or choosing not to respond to text messages
– Staying in bed during times when you’re not sleeping or physically in need of rest
– Deferring school assignments or work deadlines in favor of binging on Netflix series for extended periods of time
– Not leaving the house for fresh air when weather permits
– Declining hygiene practices and decreased attention to nutritional needs and physical activity
– Self-medicating through alcohol or drug use

In contrast, some individuals experience severe levels of anxiety when facing loneliness or isolation. Those with pre-existing obsessive-compulsive disorder, anxiety or impulse-control disorders, eating disorders, or traits of perfectionism may attempt to cope with isolation by trying to gain a sense of control over specific aspects of their lives. This could present as:

– Excessive cleaning, organizing, list-making in the home without clear need to do so
– Catastrophic thought processes with over-indulgence in news reports and social media
– Difficulty sleeping or resting due to racing thoughts
– Flare-ups of previous OCD rituals or disordered eating patterns
– Difficulty concentrating on school assignments or work due to preoccupation with above concerns

One of my favorite, go-to methods for combating these negative impulses is an emotion regulation technique called “opposite action,” a concept originating from the skill sets taught in dialectical behavioral therapy (DBT). This technique forces us to identify our emotion and the urges or impulses that go along with it, and to assess their degree of helpfulness or harmfulness by challenging them with facts. If found to be irrational or maladaptive, then we aim to implement the opposite of our emotion-driven impulse. We actually implement opposite action frequently through our lives without necessarily naming it as such. By identifying the technique, though, we
can consciously choose to use this skill when our level of motivation to change is low. Consider this example
(modified content courtesy of PsychPoint.com):

STEP ONE: Identify the emotion you’re looking to change. You’re really anxious about leaving home to go
on vacation.
STEP TWO: Identify the urges/impulses associated with the emotion. You actively avoid booking the
vacation by burying yourself in work and household tasks to subconsciously convince yourself that you simply
do not have the time to take a vacation.
STEP THREE: Assess whether the urge or behavior fits the facts of the situation. You have plenty of unused
vacation time and recognize that your year-end productivity will not be negatively impacted by taking the break.
You’ve taken vacations before and your family has benefited from the escape each time.
STEP FOUR: If the emotion and behavior does not fit the situation, then apply the opposite action.
Create a manageable schedule / timetable to take the steps necessary to search for and secure the logistics
required for booking the trip.
STEP FIVE: Experience the opposite emotion. Experience the excitement involved with planning activities
and excursions or buying a new outfit for the occasion. Go on the trip and enjoy the time with your family while
allowing others at work to keep things running smoothly until you return.

Used consistently, opposite action can help us to change our emotional response to stressors over time. It’s
important, though, to commit to the technique so that you can experience the full benefits of taking control of
your mood and behaviors rather than allowing them to be in control of you.

For a quick video explanation of opposite action, view the following:

If you’re experiencing the above symptoms associated with loneliness and have tried methods for self-help
without benefit, or if you’ve been previously diagnosed with a psychiatric illness or substance use disorder
that has begun to flare up in the midst of these extraordinary times, please know that psychiatric treatment
providers are still open, available, and ready to help you through this – at all levels of care.

Clinicians at the Lindner Center of HOPE are seeing patients every day through Telehealth, with options for
telephone or video sessions for both therapy and medication management. Additionally, our services are open
for emergency intake assessments and inpatient hospitalization, partial hospitalization, intensive outpatient,
residential, and treatment for substance use disorders.

If you or a loved one could benefit from professional help, call the Lindner Center of HOPE at 513-536-
4673 to start the conversation and take the next steps toward healing.

Jen Milau, APRN, PMHNP-BC
Lindner Center of HOPE , Psychiatric Mental-Health Nurse Practitioner

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Managing OCD During a Pandemic

Many who struggle with OCD are probably noticing a spike in their symptoms during these unprecedented times. Stress and uncertainty can often make OCD symptoms flare. Those who struggle with specific types of OCD may be having an even harder time: specifically those with contamination concerns and those concerned with harming others. Another symptom of OCD that may be particularly hard currently are perfectionism tendencies. While it may be harder to fight back against OCD with everything going on right now, it is more important than ever to not give in to compulsions and let them take over your life. One simple step you can take is to stay connected to your therapist, likely via telehealth at the moment. Having regular sessions during this time is key, especially as symptoms flare. Staying connected to others online or through social media options is also important, as the more you are connected to others the less stress you will notice. Another key piece is to continue to do things you enjoy and that bring you pleasure, as this will help lessen stress as well. Keeping a structured routine can be helpful and can help make things to continue to feel more normal. It can be important to try to continue with whatever routine you had going before that you are still able to do, for instance still getting at the same time in the morning and getting ready for work even if you are working from home. Adding consistent exercise into that routine will also be helpful, as this helps create endorphins and naturally lessens anxiety. Lastly, avoid reading the news all day, which will only lead to more stress and anxiety. It is important to limit access to only a couple of trusted sites and not get carried away with reading up on everything all day long.

Some specific OCD related steps you can take will vary depending on the type of OCD you have. For those who struggle with contamination concerns, get familiar with the CDC guidelines for the current pandemic and do not add other steps that are not recommended. For instance, they are recommending only washing hands for 20 seconds after being outside or in public, before eating, after going to the bathroom, and after you’ve coughed/sneezed/blown your nose. If soap and water are not available, they recommend you use hand sanitizer that contains at least 60% alcohol. They also only recommend disinfecting surfaces once per day. This should only take a few minutes per day and they suggest only focusing on the surfaces in your home that are frequently touched. It is also important to think about whether this is truly needed (for example, if you stayed home all day and had no visitors, do you really need to disinfect that doorknob?). It is also important to avoid some news sources that might not offer expert recommendations but rather their own opinions.

For those who struggle with fears of harming others, these symptoms might tackle the current pandemic and cause you to obsess about whether or not you might have infected someone or whether or not you might infect someone in the future. This might be a similar theme to past fears of contamination concerns, but it will still be helpful to alert your therapist to the new content so that new exposures can developed.

For those who struggle with perfectionism tendencies, this might be an especially trying time. The perfectionism could target all of the changes going on and adaptations people are having to make to conduct
their jobs, manage their families etc. It is important to give yourself a break and realize that it is impossible to be perfect in anything we do, but especially now during all of this change and uncertainty. Practice doing one or two things imperfectly on purpose as an exposure.

One important exercise I make sure to encourage all of my patients to do is to keep track of their victories against OCD, whether the victories are big or small. Keeping track of successes and not dwelling on everything that is going wrong is a helpful way to stay on track and to realize everything that you are doing to fight OCD, which is likely a lot. It can sometimes be hard to pick out the successes and often others only notice the failures or slips, but there are victories in there as well that deserve your attention and that can help give you confidence to fight back even harder next time

Nicole Bosse, PsyD
Lindner Center of HOPE, Staff Psychologist

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Managing Depression During Times of Uncertainty

 

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

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

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

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

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