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.
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.
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!
Can you blueberry your way out of depression? The evidence on dietary supplements
By Nicole Mori, RN, MSN, APRN-BC
Research Advanced Practice Nurse, Lindner Center of HOPE
Depression is a common mental health complaint. Although there are effective treatments available, many patients fail to experience satisfactory improvement. There has been increased interest in nutritional supplements as an adjunct or alternative to medications in the treatment of depression. This has contributed to the growth of the dietary supplement industry (projected to reach 230 billion by 2026). Let’s examine the evidence for the dietary supplements that have generated interest in recent years.
Omega-3 fatty acids (EPA/DHA)
A systematic review shows mild-moderate improvement in depressive symptoms, with the best outcomes in studies where omega-3 supplementation is concomitant to standard antidepressant therapy. There is a great deal of heterogeneity in dosing, duration of treatment and EPA/DHA content. Products with a high EPA content appear to be more efficacious than other omega-3 supplements. However, quality of evidence is low due to methodological flaws. Differences in study design and methodology makes it difficult to analyze data across studies. Omega-3 supplements have a favorable safety profile and are well tolerated.
B group vitamins
Folate- Possible dose dependent response in depression but level of evidence is low. Although folate is well tolerated, it has been associated with risk for proliferation of carcinogenic cells in the colon.
L-methylfolate-Available as pharmaceutical product FDA approved for depression. Data shows efficacy at 15mg/d. Some studies show efficacy as augmentation strategy for depression as comparable to lithium and atypical antipsychotics. Usually well tolerated with lower risk for proliferation of cancerous cells than folate.
A 2019 systematic review of clinical trials showed improvement in depression ratings associated with supplementation. Findings remain tentative due to paucity of studies and methodologic bias. Vitamin D is a fat-soluble vitamin commonly found in multivitamins and other commercially available products. In the absence of a deficiency, the recommended dose is not to exceed 600IU/day.
SAM-E (S-Adenosyl methionine)
Clinical trials show mixed results. A 2016 systematic review suggested SAM-E was no better than placebo. The low quality of evidence makes it difficult to draw conclusions about efficacy. There is a need for randomized clinical trials with antidepressant comparators. SAM-E usually well tolerated but there is a possible risk for inducing mania in patients with bipolar depression.
There are few high quality studies of 5-HTP. Two depression studies suggest 5-HTP is superior to placebo. Overall, level of evidence is low. Possible risk for serotonin syndrome when administered concurrently with SSRI antidepressants. Maximum recommended dose is 50mg/kg/day.
Magnesium and Zinc
There is some positive data from animal studies but evidence for efficacy in humans is low quality. There is no conclusive data on the efficacy of magnesium and zinc as coadjutant therapy in depression. Zinc and magnesium are common micronutrients and usually well tolerated.
Depression has been associated with poor diet and altered intestinal flora. Research has shown a relationship between gut health and mental health. A 2016 metaanalysis of probiotics showed an effect in reducing risk of depression in normal subjects and reduced symptoms in subjects with depression. The effect was limited to subjects under age 60. Clinical studies vary greatly in terms of bacterial species, dose, duration of treatment as well as the method of measuring of depressive symptoms. Probiotic supplements are vastly heterogeneous in terms of species composition and dosage.
There is a need for further research to determine optimal composition, dosage, duration of treatment for efficacy. Furthermore, it is important to remember that quality of diet is a major determinant in the composition of gut flora.
In conclusion, evidence for the efficacy of dietary supplements in depression remains limited. Commercially available dietary supplements vary significantly in terms of composition and bioavailability. Although supplements are well tolerated, it is important to be aware of increased risks for adverse events in some patients. Supplementation with omega-3 fatty acids as an adjunct to standard antidepressant therapy seems to hold the most promise. Further research in the area of dietary supplements is needed to determine their role in the management of depression.
For more information about Depression research studies at the Lindner Center of HOPE
call 513-536-0707 or visit https://lindnercenterofhope.org/research/
Firth J, Teasdale SB, Allott K, et al. The efficacy and safety of nutrient supplements in the treatment of mental disorders: a meta-review of meta-analyses of randomized controlled trials. World Psychiatry. 2019;18(3):308-324. doi:10.1002/wps.20672
Martínez-Cengotitabengoa M, González-Pinto A. Nutritional supplements in depressive disorders. Actas Esp Psiquiatr. 2017;45(Supplement):8-15.
Gratitude During a Pandemic
Tuning into the news can be a stressful and anxiety provoking experience, even in the best of times. During a pandemic, it can be downright frightening. If all of this negativity is wreaking havoc on your emotions, maybe it’s time to put your energy into building a Gratitude Practice.
Gratitude is the conscious decision to focus attention on the positive aspects of a situation and to notice feelings of joy, appreciation and thankfulness. It is a mindset that celebrates all of the wonderful, special, and unique gifts that life has to offer every day, no matter how simple.
When the world pressures us to pay attention to things that are hurtful, dangerous or missing in our lives, it can be especially challenging to maintain a mindset of gratitude and appreciation. This year especially has brought many unforeseen challenges to us all. Cultivating a mindset of gratitude can be accomplished even in these difficult times.
Over the last several decades there have been numerous studies that have shown countless positive effects of practicing gratitude on our emotional, social and physical health. Practicing gratitude has been shown to improve mood, and help reduce depression, anxiety and irritability. Regular practitioners of gratitude are likely to feel happier, more peaceful and do kinder things for others.
Those who practice gratitude may have stronger social relationships. Couples who regularly express gratitude to each other feel their partners are more responsive to their needs and are overall more satisfied with their relationship. This extends to the workplace as well. When gratitude is expressed at work, employees improve their felt sense of self-worth and confidence, leading to an increase in trust between colleagues and more initiative to help one another out.
Physically, people who practice gratitude regularly have a host of positive effects including improved sleep, stronger immune systems, more consistent exercise habits, fewer physical symptoms and better progress towards achieving personal goals. This is especially important in the current climate.
The act of being grateful creates a chain reaction: the more positive things you notice and give thanks for, the better you feel. As you feel better, you are likely to seek out more positive experiences for which to be thankful.
Building a Gratitude Practice
There are many ways that you can begin to incorporate more gratitude into your life. Remember that when making any change in behavior, it is best to start small and gradually build over time.
If you are just starting out, try choosing one or two times per day that you devote to being grateful. You might consider as you are falling asleep each night to think of three things that happened during that day that you are thankful for. You could also try to think of the one thing you are most grateful for. Try to be as specific as possible. Instead of saying to yourself “I am grateful for my family” think …“I am grateful my husband cleaned up the kitchen after dinner.” Or “I am grateful that my son gave me a hug before bed.”
Once you have practiced that, you might want to upgrade to a Gratitude Journal. You can spend 5-10 minutes each night or first thing in the morning, reflecting on all of the things in your life you appreciate. The act of writing it down helps to solidify in your mind the memories and experiences.
Consider incorporating your family into the practice. When sitting down to meals, ask your family members one thing that happened today that they each feel grateful for. We tend to do this before Thanksgiving dinner, but we can also do this as we sit down with our take-out pizza. Before falling asleep, tell your partner something about him or her that you value and appreciate.
Lastly, find opportunities in your day to express your appreciation for others. Consider sending an email to a colleague when you overhear a positive comment or compliment about them. A text with a thank you or heart emoji only takes five seconds but can brighten someone’s morning.
Remember that gratitude is not the same as denial or wearing rose colored glasses. It does not dismiss or deny the very real things that are not ‘ok’ in our society. Instead, gratitude helps us to collectively notice and appreciate the beauty, the kindness, the love that surrounds us every day. Sharing our gratitude allows us to work together to find solutions and to maintain hope in the face of adversity.
Practicing a grateful mindset can be challenging at first, especially when there are so many messages of negativity around us. Over time and with intention, building your gratitude practice can bring just a little more peace and joy to your world.
By Laurie Little, PsyD, Director of Therapeutic Services, Residential, Lindner Center of HOPE
Recent advances in the neuroscience of youth’s brain development and screen time exposure
Screen time recommendations vary by the child’s age. Presently, the American Academy of Pediatrics (AAP) recommends that for children younger than 18 months of age, the use of screen media other than video-chatting should mostly be discouraged. For children 2 to 5 years of age screens are acceptable for no more than one hour per day thus allowing them ample time to engage in other activities promoting growth. For older children, current guidelines encourage proactive development of an individualized Family Media Use Plan (www.healthychildren.org/MediaUsePlan) that takes in consideration the particular child’s maturation and needs. This article will focus on a few recent neurobiological findings addressing the effects of excessive screen time exposure on the growing brain in youth to help us be better informed as parents, educators and healthcare workers.
Preschoolers – if the content is educational, that’s all that matters, not how it is presented, right? Wrong!
In a 2019 study by Cincinnati Children’s Hospital researchers documented associations between higher screen use and lower measures of brain structure and skills in preschool-aged children. The team examined the screen time habits and cognitive skills of 47 children, 3 to 5 years of age and conducted brain scans on each child. Prior to the scans, the kids took a cognitive test and the parents filled out a questionnaire regarding their child’s screen time habits. The final score, called the ScreenQ score, was based on a number of criteria focusing on AAP recommendations, including whether the child was exposed to screens before 18 months of age, if they had a television in their room, and how much time they spend in front of screens. Scores ranged from zero to 26 and the higher scores represented less of an adherence to general screen time recommendations from the AAP. It was observed that higher ScreenQ scores were associated with lower brain white matter integrity, poorer expressive language and poorer cognitive skills suggesting that excessive time in front of a screen, even if the content is considered educational, might decrease cognitive skills in preschoolers. (1)
Elementary School Age and tweens -Reading is all good, right? Wrong!
A 2018 study from Cincinnati Children’s Hospital explored the time spent using screen-based media versus reading an actual book on the functional connectivity of the reading-related brain regions in children aged 8-12. Time spent on screens might be linked to impaired shifts in brain connectivity, while reading a book is linked to more beneficial neurobiological changes. The researchers had families rate how much time their children spent on various screens and how much time they spent reading actual books. The children’s brains were scanned, to assess how regions involved in language were connected, and it turned out that screen time was linked to poorer connectivity in areas that govern language and cognitive control. Reading a physical book, on the other hand, was linked to better connectivity in these regions. These findings underscore the importance of children reading real books to support healthy brain development and literacy and to consider limiting excessive screen time, even if some of the content presented through screens might be related to reading and considered educational. (2)
Tweens- screens are all bad, right? Wrong!
A 2019 study published in NeuroImage explored the effect of screen media activity on structural brain changes and how this might affect specific behaviors in 9-11 year olds. Structural scans of the brains of 4277 participants were correlated to screen activity like watching television, playing video games, or using social media. Some finding were expected, like individuals with significant exposure to activities engaging the visual system (watching TV or video) showing structural patterns suggestive of greater maturation in the visual system (i.e., thinner cortex). Some structural brain changes related to increased screen exposure were associated with more psychological issues and poorer performance on cognitive tests, while other latent variables did not show such relationship. The authors summarized that it remains difficult to conclude that brain structural characteristics related to screen media activity have uniformly negative consequences. Moreover, while some media activity associated brain structural changes were related to poorer cognitive performance, others were related to better cognitive performance suggesting that screen media activity can not be simplified as overarchingly “bad for the brain or for brain related functioning”.
Regardless of the age group discussed, one strategy to mitigate the potential risks associated with excessive exposure to screens is to ensure that the child has an overall well balanced and healthy lifestyle. This includes reinforcing proper eating and sleeping habits adequate for the age of the child, sufficient and diverse physical activity and providing plenty of opportunities for not screen related social interactions. Establishing a flexible family matrix of screen rated “rules” which dynamically adapts to the growing child would ensure that parents and educators factor in screen time exposure as one of the determinants when raising a healthy kid.
- John S. Hutton, Jonathan Dudley, Tzipi Horowitz-Kraus, Tom DeWitt, Scott K. Holland.
Associations Between Screen-Based Media Use and Brain White Matter Integrity in
Preschool-Aged Children. JAMA Pediatrics, 2019.
- Horowitz-Kraus T, Hutton JS. Brain connectivity in children is increased by the time they spend reading books and decreased by the length of exposure to screen-based media. Acta Paediatr. 2018;107(4):685-693.
- Paulus MP, Squeglia LM, Bagot K, et al. Screen media activity and brain structure in youth:
Evidence for diverse structural correlation networks from the ABCD study. Neuroimage. 2019;
Anna Guerdjikova, PHD, LISW, CCRC
Director of Administrative Services, Harold C. Schott Foundation Eating Disorders Program, Lindner Center of HOPE, University of Cincinnati, Department of Psychiatry, Research Assistant Professor
Binge eating disorder in primary care: Why should I screen my patients?
Binge eating disorder (BED) is the most common eating disorder, with an estimated prevalence of 3% in the US population. It is also the most common eating disorder among men. BED is characterized by regularly recurrent episodes of eating unusual amounts of food within a discrete time frame (usually <2hrs), which are associated with loss of control and significant psychological distress. Unlike people with Bulimia nervosa, those with BED do not engage in purging behaviors (such as fasting, driven exercise or self-induced vomiting). Untreated BED is a risk factor for obesity, metabolic disorders, mental health problems and poor quality of life. Although psychotherapy and medications have demonstrated effectiveness in treating BED symptoms, the vast majority of patients with BED remain undiagnosed and untreated.
Patients with BED face significant barriers to evaluation and treatment. First, there are patient-related barriers such as lack of awareness of BED as a medical condition, where the patient may attribute their loss of control to having no willpower. Moreover, patients may be reluctant to discuss their eating behavior and weight out of shame or fear of being judged. Finally, past experience may lead patients to assume that their primary care provider is unwilling or unable to address their disordered eating. Providers also face challenges in identifying BED in the primary care setting: Some patients with BED may have a normal BMI, which makes providers assume that they do not have an eating disorder. In addition, BED often co-occurs with psychiatric disorders such as depression and anxiety, which can lead to attributing the BED symptoms to the patient’s mental health diagnosis or the effects of psychotropic medications. Finally, lack of knowledge about treatment options and underestimation of the impact of BED on medical conditions, leads many primary care providers to overlook BED as a target for evaluation and treatment.
The reality is that primary care providers have much to offer patients with BED. Screening, education, self-management tools and in some cases, referrals to specialty care or medication. Screening for and treating BED can be advantageous when managing patients with diabetes, where decreasing the frequency of binges can lead to significant improvement in metabolic parameters. A BED diagnosis is useful when selecting psychotropic medications with lesser potential to aggravate binge eating. Finally, diagnosing a patient with BED can alleviate the patient’s distress and stigma. Patients who struggle with BED are often relieved and thankful that they have a treatable medical condition rather than attributing their bingeing to a character flaw and feel empowered and thankful for any help in managing their disorder. Since untreated BED poses a challenge in treating conditions such as diabetes and dyslipidemia, diagnosing and managing BED can benefit all areas of patient health.
Although there are still significant barriers to screening, diagnosis and treatment, primary care providers have the means to improve health outcomes among their patients with binge eating. Primary care is the ideal setting for raising awareness of the problem of binge eating among the general population, to address patient’s disorder eating concerns and start patients on their journey to recovery. First of all, routine procedures such as weighing patients, offer opportunities to ask patients whether they have any concerns about their weight or eating patterns. These questions can also be added to the medical history updates hat patients complete prior to office visits. Routine screening of special populations such as patients with diabetes, those attempting weight loss or receiving psychotropic medication is of great help in managing those comorbidities. The SCOFF questionnaire is a brief screen for eating disorders suitable for primary care*. Providers interested in providing medication management for BED should also screen for psychiatric comorbidities and substance use disorders to guide their medication choices.
In summary, patients with BED are largely undiagnosed and untreated, which complicates the management of their medical and mental health issues. Although access to specialty continues to be a challenge, primary care providers have the means to start patients on their road to recovery and improve overall health outcomes and quality of life.
The Research Institute at the Lindner Center of HOPE is a world leader in Binge eating disorder research. For more information about our current studies, call 513-536-0710.
*The SCOFF questionnaire is available at:
Chao AM, Rajagopalan AV, Tronieri JS, Walsh O, Wadden TA.
Nurs Scholarsh. 2019 Jul;51(4):399-407. doi: 10.1111/jnu.12468. Epub 2019 Mar 1.
Javaras KN, Pope HG, Lalonde JK, et al. Co-occurrence of binge eating disorder with psychiatric and medical disorders. J Clin Psychiatry. 2008;69(2):266-273. doi:10.4088/jcp.v69n021
Nicole Mori RN, MSN, APRN-BC
Nurse Practitioner, Lindner Center of HOPE Disorder Services
An Introduction to Radically Open Dialectical Behavioral Therapy
Radically Open Dialectical Behavioral Therapy (RO DBT) is a treatment developed by Thomas Lynch for those who develop disorders associated with an overcontrolled (OC) personality. OC individuals are often described as reserved and cautious, not very expressive with their emotions, and great at delaying gratification. OC individuals tend to be strong rule followers and feel a high sense of obligation in their lives (i.e., go to a birthday party because they feel they have to rather than wanting to do so). However, at times, they may experience “emotional leakage,” or emotionally breaking down once they are in private after holding it all together all day in public. An OC personality can be really helpful in some ways. These are the people that get their work done no matter what, show up to work on time every day, work through all the nitty, gritty details of a project, and follow through on their word. They can be very organized and methodical, and they are great at planning for long-term gains (i.e., saving to buy a house). However, they can be rigid and inflexible at time (i.e., get very upset if a restaurant lost a dinner reservation and struggle with figuring out where else to go to eat) and may have difficulty receiving feedback. Patients that may benefit from this treatment include those with chronic depression and anxiety, autism spectrum disorders, Obsessive-Compulsive Personality Disorder, and Anorexia Nervosa.
The biosocial theory behind RO DBT explains that OC individuals have brains that zoom in on the negative or threatening aspects of a situation before seeing the positives. This predisposition interacts with being raised in an environment that encourages or praises high levels of self-control in one’s life (i.e., doing homework without one’s parents needing to remind them to do so), performing at a high level (i.e., getting good grades, doing well in sports, receiving accolades), and avoiding making errors. These individuals end up avoiding uncertain situations, hold back their emotions out of fear that others may see them as being out of control, and become guarded in social situations, appearing to others as withdrawn. Their lack of vulnerability and difficulty expressing what they are really feeling leads others to struggle to relate to them, so they end up feeling lonely and isolated. Thus, RO DBT operates under the assumption that increasing connectedness to others can improve psychological functioning, thus targeting emotional expression. Additionally, RO DBT encourages being open to hearing other points of view so that one can learn as well as learning to be flexible in responding to varying situations.
Thomas Lynch describes that the five main behavioral targets of RO DBT include 1) being socially distant or reserved, 2) inflexible, rule-governed behaviors, 3) focusing on the details rather than the big picture of a situation and being overly cautious, 4) demonstrating emotional expressions that are inconsistent with how one is really feeling, and 5) comparing oneself to others, leading to resentment and envy. In RO DBT, patients work with their therapists on identifying personal goals consistent with these behavioral targets, connecting these goals to the problems that brought them into treatment. For instance, a patient may bring up that he/she would like to deepen relationships with others, be more flexible when things don’t go according to plan, or let go of past grudges to help fight depression and anxiety.
Many incorrectly assume that RO DBT and Dialectical Behavior Therapy (DBT) are the same thing. While RO DBT has some similarities with DBT, these are two very different treatments. DBT primarily benefits those who have an undercontrolled (UC) personality. UC traits include being impulsive, sensation-seeking, wearing one’s heart on one’s sleeve, and acting in the here and now. Thus, DBT can be helpful for those that have impulsive control problems, such as those with borderline personality disorder, bulimia nervosa, binge eating disorder, and substance abuse disorders. Both RO DBT and DBT combine individual therapy with skills training classes, involve tracking emotions and behaviors via diary cards, allow for telephone consultation with the individual therapist, and involve consultation teams for the group and individual therapists. However, DBT has a stronger focus on self-regulation to target emotion dysregulation whereas RO DBT is much more focused on helping individuals address social signaling and connectedness with others.
Lynch, T. R. (2018). Radically Open Dialectical Behavior Therapy. New Harbinger Publications.
Lynch, T. R. (2018). The Skills Training Manual for Radically Open Dialectical Behavior Therapy. New Harbinger Publications.
Lindner Center of HOPE, Psychologist and Clinical Director of Partial Hospitalization/Intensive Outpatient Adult Eating Disorder Services
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.
Managing Suicidality During Isolation
In the United States, suicide is the 10th leading cause of death. The rate increased 33% from 1999 through 2017 according to the Centers for Disease Control and Prevention. The American Foundation for Suicide Prevention states that “suicide most often occurs when stressors and health issues converge to create an experience of hopelessness and despair.” For some, the COVID-19 pandemic could create this experience. The pandemic has produced a condition that has increased many of the risk factors for suicide: feelings of depression and anxiety, increased alcohol and substance use, serious physical health conditions, unemployment, financial crisis, illness or death of a loved one, isolation, and decreased access to care.
Social distancing and isolating at home have limited access to coping skills and reduced suicide protective factors. People no longer have in person contact with behavioral health providers, there is decreased connectedness to support systems, and no access to gyms, art studios, massage therapy, beauty salons, barbers, etc. With fewer physical and creative outlets, healing therapies, and self-care that improves self-esteem, people can feel lost. They also no longer have physical access to places of worship where the social connection was as important as the message or music. It important to remember that we need to maintain physical distancing rather than social distancing – it is necessary to maintain physical separation to not contract the virus but other ways of maintaining social connections are still very important.
Another risk factor that staying at home can bring is closer proximity to abusers. Children of abusive parents who are no longer in school are now with their abusers all day and adults with abusive partners are also with their abusers more often. Adverse childhood experiences are associated with 2 to 3 times more suicide attempts later in life and victims of intimate partner violence are twice as likely to attempt suicide.
Staying at home also increases access to lethal means so it is imperative to either remove guns from the home or ensure they are locked securely and reduce access to other lethal means (such as large amounts of extra medications, excess amounts of alcohol, ropes/cords) in the home for people who are high risk for suicide. For homes with large amounts of prescription medications due to multiple health conditions, a medication safe is recommended.
For people with loved ones who have risk factors for suicide, it is important to know the warning signs. Warning signs include talk of: killing themselves, feeling hopeless, having no reason to live, being a burden, feeling trapped, and unbearable pain; behavior: increase use of alcohol and drugs, looking for a way to end their lives (including internet searches), withdrawing from activities, isolation from family and friends, too much or too little sleep, saying goodbye to people, giving away possessions, aggression, and fatigue; and mood: depression, anxiety, loss of interest, irritability, humiliation/shame, agitation/anger, and relief/sudden improvement. If you notice these warning signs, it is important to ask a person directly if they are having thoughts of suicide and if they are, get them help by contacting their mental health providers, calling a crisis line, taking them to an emergency department, or calling 911. Visit take5tosavelives.org or bethe1to.com to learn how to talk to your loved ones about suicide. Due to COVID-19, people have tried to avoid emergency departments and hospitals but if someone you love is unsafe do not hesitate to get them the help they need.
What are ways to increase coping skills and protective factors in our current climate? Take advantage of telephone or video appointments offered by your mental health providers. If you do not already have mental health providers, now is a good time to seek treatment – practices are still accepting new patients and insurances are covering telephone and video appointments. To reduce worry and fear, limit media consumption about COVID-19. Stick to a routine, stay physically active, get outside with appropriate physical distancing, get enough sleep, limit alcohol, and eat healthy. If you feel you have a problem with alcohol, substances, overeating, or other addictive behaviors – there are online support groups. Connect with loved ones by phone, social media apps, video apps, or writing. Consider safe altruistic ways to connect with others – making masks, running errands for vulnerable loved ones, donations, etc.
How can you get help? Crisis Text Line: text HOME to 741741, they can also be messaged on Facebook messenger.
National Suicide Prevention Lifeline 1-800-273-8255
YouthLine answered by trained teen peer support from 4 pm – 10 pm and by adults from NSPL during other hours 877-968-8491 or text teen2teen to 839863
Childhelp National Child Abuse Hotline text or call 1-800-422-4453
National Domestic Violence Hotline 1-800-799-7233 or text LOVEIS to 22522
Mental Health America Support Group Directory www.mhanational.org/find-support-groups
Lindner Center of HOPE 513-536-HOPE
Danielle J. Johnson, MD, FAPA Lindner Center of HOPE, Chief Medical Officer
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